We are pleased that the thought leaders and originators of this line of research consider our articleReference Hupert, Hollingsworth and Xiong1 to be a useful contribution to ongoing discussions about improving mass casualty trauma care. Our approach focused on the tripartite, dynamic relationship among patient selection resulting from triage decisions, trauma system treatment capability, and time-dependent mortality. Our main finding is that, for most mass casualty incidents, triage accuracy has less impact on outcomes than does the relative proportion of critical casualties to treatment capability, with the corollary that focusing on the rate of overtriage (ie, getting triage “wrong” in the direction of overcrowding) may obscure other drivers of critical outcomes.

As noted by Armstrong et alReference Armstrong, Hammond, Hirshberg and Frykberg2 in this issue, our model did produce “a positive correlation between overtriage and critical mortality when the number of noncritical casualties increases” but this relationship is both nonlinear and dependent on the ratio of critical casualties to treatment bays. For all of its limitations, this model represents a conceptual framework that begins to reflect the complex relationships among actions, resources, and patient outcomes, and we will continue our efforts to improve its fidelity to the realities of trauma care in both the field and hospital settings.