In Reply We thank Lt Col Reade for his thoughtful and most pertinent comments, which highlight some very important points. We agree that the Injury Severity Score (ISS) is an imperfect tool for controlling for case mix in combat injury because it may underestimate complex battlefield wounds,1 and even more imperfect is the Abbreviated Injury Scale (AIS), with more than 2000 codes, on which the ISS is based. Recognizing this, a group of military surgeons convened to create AIS 2005-Military2 (AIS 2005.mil, since updated to AIS 2008.mil) in an effort to compensate for the inability to code large soft-tissue and complex multisystem injuries. This provided some improvement but was still inadequate, and after many years of tri-service efforts, the Military Combat Injury Scale and the Military Functional Incapacity Scale were created in 2013.3 The Military Combat Injury Scale is simpler, with only 269 codes, and it has been extensively validated on combat data; however, AIS 2005.mil and ISS were used in our study1 because they were the only consistently used tools available. The coding was performed by a small group of individuals, but the uniformity of the shortcomings obviated extensive recoding of a large number of cases. Numerous other publications, including many we cited, have been burdened with the same frailty, but the point is well taken.
Kotwal RS, Champion HR, Gross KR. A Military-Specific Injury Scoring System to Aid in Understanding the Golden Hour—Reply. JAMA Surg. 2016;151(5):491-492. doi:10.1001/jamasurg.2015.4895