Trauma systems in high socioeconomic index countries in 2050

It is expected that by 2050 20% of high SDI populations will be aged 70 years and older, compared to the current rate of 14% [28]. Several systems report an increasing shift in the median age of trauma patients [29, 30] and low energy mechanisms such as falls are predominating and will continue to increase [31]. Current population level falls that prevent programs are effective, comprising awareness, muscle and proprioceptive training and environmental hazard control, yet are workforce intensive [32‐34]. Scientific and technological innovation is required to improve on this to meet the needs of aging populations.

While the proportion of elderly will increase, the patterns of aging and roles will evolve [35, 36]. Many older people will pursue dynamic social, economic and cultural roles, and increased physical activity. This physical activity will maintain and improve their physiological and cognitive reserve in response to injury yet at the same time increase their exposure to risk and more high energy trauma mechanisms such as sports, cycling and motorbikes. These changes mandate an individualized approach to elderly trauma patient where triage and assessment focus on physiological age and frailty rather than chronological age [37, 38]. Sensitive triage will facilitate pathways for non-frail, healthy elderly patients with good physiological reserve to high-level centers for aggressive management by specialized teams. The existing Geriatric Trauma Outcome Score does not account for frailty and preexisting levels of autonomy [39] despite recent evidence highlighting the need for robust, valid, geriatric trauma triage tools which incorporate physiological aging and frailty [40, 41]. Geriatric trauma pathways integrating decision support tools for prognostication, palliation and patient choice should also be part of every trauma program. Dedicated multidisciplinary management and early rehabilitation teams improve outcome in trauma patients [42]. The trauma community will need to decrease the aging-related knowledge gap and intensify research into triage, management, prognostication and rehabilitation in the older trauma patient. Considerable agency leadership and institutional efforts will be required to make this transition happen.

Deaths from transportation in high SDI countries decreased from 20 to 11/per 100,000 over the last 30 years [1]. Improved vehicle safety design has reduced mortality in crashes over the last 20 years [24, 43, 44]. Future prevention strategies, including automatic breaks, speed and collision control, automatic vehicle deactivation triggered by sleep or drug-induced driving patterns, may improve safety further. Self-driving cars are expected to reduce road traffic accidents, although not supported by current evidence; and incidents with self-driving vehicles may increase before the technology reaches maturity [45]. Injuries from electric scooters comparable to those seen with motorbikes illustrate the difficulty to predict the epidemiological effects of new technology [46‐49]. The prevention of transportation incidents is not only restricted to new technologies. Despite a comparable SDI, the USA accounts for more than twice the mortality rate of pedestrians than Australia, namely 12.5 versus 5.3 deaths/100,000 per year [50]. Pedestrian deaths in the USA increased for the first time in 41 years according to the State Highway Safety Office in 2022 [51], demonstrating considerable uncertainty in our understanding of how road safety evolves, to provide projections and determine the most efficient prevention policies [52]. Programs with a consistent beneficial impact adopted proactive system approaches, where human behavior is considered an integral dimension to improve traffic safety [52]. Prospective monitoring of emerging trends in transportation injuries shared by researchers, epidemiologists and policymakers will be crucial to assess the effect and efficacy of preventive policies and enhance adjustment to risk patterns. Trauma systems, transportation industries, lead agencies and policy makers must intensify coordination and cooperation in future years and decades.

Injuries caused by self-harm have had a stable incidence of 15 deaths/10,000 per year across high SDI countries since 1990, with some countries even reporting significant reductions, such as Finland by 50% [1]. Similar to violence, circumstances with social and economic instability, including natural disaster, increase the risk of suicide [53‐56], and in the future, the risk should be reduced by prioritizing social stability and providing equitable access to mental health.

In high SDI countries, deaths from interpersonal violence decreased from 4.2 to 2.5 deaths/10,000 per year [1]. Yet despite this small decrease in absolute numbers, interpersonal violence generates substantial societal and psychological impacts. Patterns of violence are similar across most high SDI countries, except for mass shootings (defined as > 4 fatalities per incident) in the USA, with an increase from 272 in 2014 to 651 in 2023 [57]. The sociology and economics of violence are well understood [58, 59], where social instability, limited access to mental health support, availability of drugs/alcohol, economic deprivation, gender and social inequalities are among the numerous risk factors. There are, however, considerable discrepancies within and among countries, where access to firearms increases the risk of death and injury at population level, such as the 7.5 times higher homicide rate in the USA than in comparable high SDI settings [60]. The increased domestic assaults reported during the COVID-19 pandemic also illustrates the potential for future increases in interpersonal violence [61]. The most promising avenue for violence prevention is described within a Public Health Approach [62] (Fig. 1). This approach requires intensive multilayer cooperation from the community (anti-violence training, employment, education, policing) to legislative bodies (access to weapons, social rehabilitation, poverty prevention) [63]. Advocacy and monitoring through healthcare providers such as Hospital Based Violence Intervention Programs reduce violence (https://​www.​thehavi.​org/​what-is-an-hvip); and numerous public health initiatives report dramatic reductions [64]. An important consideration remains the long-term support of victims of violence, with need for improvement in many countries according to the WHO [65].

Apart from the aforementioned factors, migration and climate change, civil disorder and armed conflict will probably affect how we provide trauma care in high SDI. The trajectories associated with these factors are difficult to predict and their impact may destabilize or destroy the current socioeconomic framework of high SDI countries [66‐68]. The trauma community should prepare for these scenarios and learn how to make our trauma systems resilient in a challenged or failing socioeconomic environment. Some examples of political turbulence have generated high levels of civil unrest while the overall social and economic order remains intact. For example, during the mass terrorist events witnessed, existing trauma provision appeared to cope with the scale of unrest. A recent international follow-up survey conducted in 22 hospitals exposed to mass attacks identified the many elements of crucial lessons learned, even years after the event. These included the need for re-triage at hospital arrival, need for coordination roles, flexibility and large-scale training exercises. The organization of human response, rather than consumption of physical supplies, emerged as the key finding [69], and this emphasizes the need to prioritize this during training now and in the future. Innovative tools for mass casualty management have been developed by an international consortium [70], yet these innovations rely on high levels of technicality, creating dependency and increasing the risk of reduced resilience and adaptation. A multi-casualty crisis is first and foremost a cognitive challenge and large-scale training, including civilians, appears to offer the most cost-efficient preparation. The Ukraine conflict may provide useful lessons on how to prepare a civil society for crisis and recruit civilians into crisis management roles [71] with a possible first lesson on tourniquet use [72]. In the future, this type of preparation could be combined with the training and deployment of highly skilled medical teams able to provide advanced trauma care even in hostile civil environments, comparable to the experience of US and UK forces [73].