BY JUSTIN J. BOUTILIER
Poor access to emergency medical care is a major barrier in the treatment of time-sensitive medical emergencies such as cardiac arrests and motor vehicle accidents. In this article, Justin J. Boutilier of the University of Toronto explores the potential of drone technology to be a transformative innovation for the provision of emergency medical services, despite a host of new technological, regulatory and operational challenges.
Time-sensitive medical emergencies are responsible for over one-third of deaths worldwide, according to recent data from the World Health Assembly. Emergency medical services (EMS) are responsible for handling time-sensitive medical emergencies such as cardiac arrest, road traffic accidents, and maternal health issues such as childbirth, and often act as the first point of contact for the provision of healthcare services to the public. There is widespread empirical evidence that shows that emergency medical services can save lives. Despite such evidence, however, poor access to and availability of emergency medical care continues to be a widespread problem.
Drones, or unmanned aerial vehicles, have the potential to be a transformative innovation for providing emergency medical services in a variety of settings. Drones are broadly defined as a class of aircraft without a human on board. In recent years, drone technology has exploded, with significant advancements occurring in computer vision, autonomous flight and avoidance measures. Drones have the potential to be a disruptive innovation in the consumer delivery market. The use of drones for consumer goods delivery is currently being vigorously developed by major corporations including Amazon, Google, Alibaba, FedEx, DHL and the United States Postal Service. Companies have proposed drones to deliver everything from pizza, to official government documents, to medical supplies. The use of drones to deliver consumer goods poses various new operational problems that have generated a growing body of operations research and management science literature.
A Matter of Operations: Drones Save Lives
In the past year, various research studies and media articles have highlighted the plethora of high-impact healthcare applications for drones. Initial research noted the potential for drones to deliver medical supplies to remote and rural areas. Zipline, a medical drone delivery company, realised this potential and has been delivering blood and medical supplies throughout Rwanda since October 2016.
More recently, a growing body of research has focussed on using a drone to deliver an automated external defibrillator (AED) for use at the scene of an out-of-hospital cardiac arrest (OHCA). OHCA claims over eight million lives across the world each year and is one of the most time-sensitive medical emergencies. Survival is estimated to decrease by 10% for each minute without treatment.
An AED is one of the only effective methods for the treatment of OHCA. Research has demonstrated that the probability of survival increases by 40-70% with prompt defibrillation. Improving AED access and reducing the time to defibrillation are critical for improving OHCA survival. A drone network that can deliver AEDs has the potential to significantly improve the survival rate from OHCA, especially in remote and rural areas.
A growing body of research has focussed on using drones to deliver an automated external defibrillator (AED) for use at the scene of an out-of-hospital cardiac arrest (OCHA). OHCA claims over eight million lives across the world each year and is one of the most time-sensitive medical emergencies.
Specialised drone technology has been developed to deliver AEDs. The most unique AED drone prototype does not attempt to deliver the AED as a separate package, but rather integrates the AED into the drone itself. This integrated AED drone was developed by Alec Momont at Delft University of Technology in the Netherlands and can fly at speeds of over 100 kilometres per hour. The drone weighs only four kilogrammes and includes both a microphone and camera, so that the emergency response dispatcher can survey the scene and provide assistance to bystanders. Other prototype AED drones take a more traditional delivery approach and either drop the AED via parachute or land at the scene so that the AED can be removed from the drone by a bystander.
Much like consumer drone deliveries, the delivery of AEDs poses various new operational challenges including regulation, geographical deployment strategy, and integration into current EMS systems. Thus far, the scientific literature has focussed on the second challenge − the geographical deployment strategy. For example, in a 2017 paper, using data from over 50,000 historical OHCAs from 26,000 square kilometres around Toronto, Canada, this author and collaborators demonstrated that an optimised drone network has the potential to significantly reduce the AED delivery time for bystander use. In particular, drones were found to reduce the median AED delivery time by three minutes while simultaneously reducing the 90th percentile delivery time by over 10 minutes. To accomplish these gains, the authors predicted that 81 drone bases and 100 drones would be needed. However, if the various regional providers are able to coordinate their response through an integrated EMS system, then the number of bases and drones can be reduced by 30-40%.
More recently, Claesson et al. (2017) conducted 18 AED drone test flights in the fjords north of Stockholm, Sweden to demonstrate that it is possible to autonomously deliver an AED using a drone. The authors found that, on average, the drone arrived on the scene 16 minutes ahead of EMS. Due to the overwhelming potential for drone-delivered AEDs to save lives, EMS providers all over the world have begun conducting test flights, including emergency services in Stockholm, Sweden; Mississauga, Canada; and Reno, United States.
It is important to note that this is only one example of the potential for drone technology to transform EMS. According to the World Health Organisation, childbirth, another time-sensitive medical emergency, kills over 300,000 women each year due to complications. The lack of access to emergency medical care is viewed as the main obstacle to better health for mothers during childbirth. Although drones cannot yet transport trained professionals, they can deliver pregnancy kits and provide remote assistance to mothers via the camera and microphone embedded in the drone.
Road traffic accidents, a third time-sensitive medical emergency, kill over 1.3 million people each year and are the leading cause of death of people between the ages of 15 and 29. For example, in India, motor vehicle accidents are responsible for one death every four minutes. Over 60% of the patients die before reaching the hospital, a 2014 study showed. Drones have the potential to quickly deliver trauma kits to the scene of the accident, while traditional EMS responders are en route. Road traffic accidents are a particularly promising application for drones because they are almost always witnessed by a bystander who can initiate the EMS response and help the patient using the drone-delivered trauma kits.
In India, motor vehicle accidents are responsible for one death every four minutes. Over 60% of the patients die before reaching the hospital. Drones have the potential to quickly deliver trauma kits to the scene of the accident, while traditional EMS responders are en route.
Drones in the Developing World
All three time-sensitive medical emergencies discussed so far disproportionally affect people living in lowand-middle income countries (LMICs). Emergency patients in LMICs typically face slow response times and limited access to emergency care because, until recently, EMS systems have not been a major priority for many LMICs, according to a 2012 analysis by the International Federation for Emergency Medicine (IFEM) Task Force on access and availability of emergency care.
Designing an EMS system in LMIC conditions comes with unique challenges that are not present in high-income countries. For example, traffic is typically much worse and route disruptions occur far more regularly. Moreover, it is not the norm to yield for emergency response vehicles, which can easily become stuck in traffic. However, many LMICs can leapfrog high-income countries by learning from their mistakes and quickly adopting promising new technologies. Drones, which can avoid all road traffic, have an even greater potential to impact timesensitive medical emergencies in LMICs compared to high-income countries.
Aside from emergency medical services, drone technology has an important role to play in search and rescue as well as disaster relief efforts. Drones equipped with high-resolution or infrared cameras allow responders to quickly search large areas in real time. Drones can also be used as part of a coordinated disaster relief effort to deliver supplies to remote and/or inaccessible areas.
Similarly, drones can be used to reach patients in areas that may otherwise be considered too dangerous for first responders. Various countries such as Canada have already tested and implemented drones for search and rescue purposes. Many drone companies are developing technology specifically designed for search and rescue applications, including the ability for drones to fly for long periods of time or autonomously coordinate fleets to search large areas.
Regulating Drone Technology
Although the potential for drone technology is overwhelming, there are still many practical challenges associated with implementing and realising medical drone deliveries. Currently, regulatory hurdles are the most significant challenge. Some countries like India have completely banned drone flights, while many others like the US or Canada limit drone use to operator line of sight. In other words, drones cannot be flown autonomously and must be flown where a human operator can see them. Obviously, these are major limitations for both commercial and medical drone delivery applications. By contrast, more progressive countries such as the United Kingdom, Sweden and Rwanda have relaxed regulations and are issuing drone delivery permits on a case-by-case basis.
Many of these regulations are based on safety concerns. For example, drones have been caught attempting to deliver drugs into prison and have crash landed in sensitive areas, such as the White House lawn. It is imperative that drone flight be regulated to respect traditional airspace rules and avoid areas such as airports and military bases. To date, there have been multiple incidents involving drones and traditional aircraft. Aside from flight collisions, drone crashes represent another safety concern, especially near highly populated urban areas. Historically, the crash rate for drones has been much higher than traditional aircraft and there have already been dronerelated deaths in both the US and UK.
However, significant lobbying efforts by major corporations and appeals to more progressive international legislation are likely to pave the way for further drone delivery operations. At the same time, continued advancements in drone technology will help to reduce safety concerns. For example, many drone experts believe that autonomous flight is significantly safer than human-piloted flight, due to an increase in reaction time. Further technological advancements in collision avoidance and self-stabilisation measures are likely to reduce the chances of a crash.
The Future for Drones
Aside from technological advancements, more operational research is needed to develop mathematical models and decision support tools that can help EMS providers determine how to best implement a medical drone network. Research is also needed to investigate the economic feasibility of drones and determine their cost-effectiveness for various medical applications. After implementing medical drone projects, large-scale medical trials will be required to prove that drones can truly impact population-level survival for time-sensitive medical emergencies like OHCAs and road traffic accidents. Lastly, research is needed to determine how to best integrate drones within the current EMS framework. Surprisingly, there is almost no scientific literature on any of these topics.
Aside from technological or scientific advancements, widespread educational and awareness campaigns should accompany drone projects. These campaigns need to inform people that medical drones, indicated perhaps via lights, sirens, or colour, are life-saving devices and should not be tampered with. For example, in the US, there have already been multiple incidents where citizens have shot down drones flying over their property.
Although the potential for drone technology is overwhelming, there are still many practical challenges associated with implementing and realising medical drone deliveries. Currently, regulatory hurdles are the most significant challenge.
In LMICs, where it is not the cultural norm to call for emergency services, education campaigns are even more important: drones are not useful if no one initiates the EMS response. However, the high-profile and exciting nature of drone technology may provide the additional awareness needed to successfully conduct a large-scale educational campaign.
Looking ahead, all of these challenges are within our control and provide new avenues for scientific discovery, especially in fields related to drone technology and operational implementation. It is crucial that the research community focus on medical drone applications so that EMS organisations are well-prepared to take advantage of this technology when it becomes a reality. Drones may hold the key to solving many of the 21st century’s most pressing health challenges. The future of drone technology will be limited only by our imagination.
For Further Reading
Anderson, P D, R E Suter, R Mulligan, G Bodiwala, J A Razzak, and C Mock (2012). World Health Assembly Resolution 60.22 and Its Importance as a Health Care Policy Tool for Improving Emergency Care Access and Availability Globally. International Federation for Emergency Medicine (IFEM) Task Force on Access and Availability of Emergency Care. Annals of Emergency Medicine, 60: 35-44.
Boutilier, J J, S C Brooks, A Janmohamed, A Byers, C Zhan, J E Buick, A P Schoellig, S Cheskes, L J Morrison, and T C Y Chan (2017). “Optimizing a Drone Network to Deliver Automated External Defibrillators.” Circulation, 135 (25): 2454-2465.
Levine, A C, S Gadiraju, A Goel, S Johar, R King, and K Arnold (2007). “International Emergency Medicine: A Review of the Literature.” Academic Emergency Medicine, 14: 182-1833.
World Health Organisation (2016). Maternal Mortality Fact Sheet. Retrieved from http://www.who.int/mediacentre/factsheets/ fs348/en/.
Morgan, D and D Seetharaman (2015). “Industry Lobbyists Take Aim at Proposed FAA Drone Rules.” Reuters. Retrieved from https://www.reuters.com/article/us-usa-drones-lobbying/ industry-lobbyists-take-aim-at-proposed-faa-drone-rulesidUSKBN0LS04R2015022