LAUSR

In this issue of JAMA Surgery, Lale and coauthors1 are to be congratulated on their attempts to quantify and categorize the extent and outcomes of undertriage of patients with firearmrelated injuries in Chicago. The study's strengths include the size of the databases and the use of geographic information systems to map the most affected areas of the city. The authors conclude that undertriage is a problem, given that nearly one-third of patients were treated at facilities that were not designated as trauma centers and that many patients met national anatomic triage criteria. While the authors acknowledge that some of this apparent undertriage may be caused by the acceptable practice of civilians transporting injured patients or patients in extremis to the nearest facility, there are a few other considerations that might influence the authors’ conclusions. First, it is unclear how the authors ascertained the “anatomic triage criteria” cited in the article’s Methods section. The International Classification of Diseases, Ninth Revision, Clinical Modification codes are frequently nonspecific and do not distinguish between elbow and forearm or knee and lower leg, which are important distinctions in trauma triage. A gunshot wound to the ankle would not be a trauma activation but a wound to the knee would be because proximal injuries are more likely to be associated with lifeor limb-threatening vascular injuries. Patients with injuries below the elbow or knee could be treated at non–trauma centers and would not need to be transferred to a higher level of care. Firearm-related injuries are very common inChicago,andthespectrumofinjuriesalonemaylargelyexplain the apparent triage disparity. Because the authors did not provide a list of codes, it is impossible to know if injury location alone explains most of the presumed undertriage. Second, the maps provided seem to demonstrate a high prevalence of undertriage on the south and west sides of the city. However, the undertriage does not appear to be normalized by the denominator of firearm-related injuries or patient injury severity in each community. It may be that 200 people walked into area hospitals after being shot in the hands or feet and were treated locally, which would be completely appropriate in the Chicago trauma care system. In summary, this article provides an important first look at whether patients with firearm-related injuries in Chicago have appropriate access to trauma care. However, more work needs to be done before conclusions can be drawn or action plans can be discussed about undertriage.