American Journal of Emergency Medicine 66 (2023) 40–44

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Drones reduce the treatment-free interval in search and rescue

operations with telemedical support – A randomized controlled trial
Michiel Jan van Veelen a,b, Giulia Roveri a, Anna Voegele a, Tomas Dal Cappello a, Michela Masè a,c,
Marika Falla a,d,e, Ivo Beat Regli a,f, Abraham Mejia-Aguilar g, Sebastian Mayrgündter h,i, Giacomo Strapazzon a,i,⁎
a
Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
b
Department of Sport Science, Medical Section, University of Innsbruck, Innsbruck, Austria
c
Department of Cellular, Computational and Integrative Biology, University of Trento, Trento, Italy
d
Center for Mind/Brain Sciences - CIMeC, University of Trento, Rovereto, Italy
e
Department of Neurology/Stroke Unit, General Hospital of Bolzano, Italy
f
Department of Internal and Emergency Medicine, Buergerspital, Solothurn, Switzerland
g
Center for Sensing Solutions, Eurac Research, Bolzano, Italy
h
NOI Techpark, Bolzano, Italy
i
Corpo Nazionale Soccorso Alpino e Speleologico - CNSAS, Milano, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Response to medical incidents in mountainous areas is delayed due to the remote and challenging
Received 3 January 2023 terrain. Drones could assist in a quicker search for patients and can facilitate earlier treatment through delivery of
Accepted 8 January 2023 medical equipment. We aim to assess the effects of using drones in search and rescue (SAR) operations in chal-
Available online xxxx lenging terrain. We hypothesize that drones can reduce the search time and treatment-free interval of patients by
delivering an emergency kit and telemedical support.
Keywords:
Methods: In this randomized controlled trial with a cross-over design two methods of searching for and initiating
Unmanned aircraft
Drone
treatment of a patient were compared. The primary outcome was a comparison of the times for locating a patient
Mountain rescue through visual contact and starting treatment on-site between the drone-assisted intervention arm and the con-
Search and rescue ventional ground-rescue control arm. A linear mixed model (LMM) was used to evaluate the effect of using a
Emergency medical services drone on search and start of treatment times.
Results: Twenty-four SAR missions, performed by six SAR teams each with four team members, were analyzed.
The mean time to locate the patient was 14.6 min (95% CI 11.3–17.9) in the drone-assisted intervention arm
and 20.6 min (95% CI 17.3–23.9) in the control arm. The mean time to start treatment was 15.7 min (95% CI
12.4–19.0) in the drone-assisted arm and 22.4 min (95% CI 19.1–25.7) in the control arm (p < 0.01 for both com-
parisons).
Conclusion: The successful use of drones in SAR operations leads to a reduction in search time and treatment-free
interval of patients in challenging terrain, which could improve outcomes in patients suffering from traumatic
injuries, the most commonly occurring incident requiring mountain rescue operations.
© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Incidents in remote and mountainous areas can result in an injury or
medical condition requiring urgent medical attention. Trauma is the
most commonly occurring incident, and initiation of treatment can be
delayed due to search and approach in challenging terrain [1,2].
Reaching a patient is commonly done on foot or by helicopter (including
⁎ Corresponding author at: Institute of Mountain Emergency Medicine, Eurac Research,
Via Ipazia 2, 39100 Bolzano, Italy.
E-mail address: giacomo.strapazzon@eurac.edu (G. Strapazzon).
winch operation) [1,2]. Any delay in treatment could impact the out-
come negatively, especially in time-sensitive conditions, such as uncon-
trolled bleeding or an impaired airway. Prolonged environmental
exposure of a trauma patient is associated with a higher injury severity
score (ISS), a higher risk of accidental hypothermia, and more fre-
quently occurring hypotension at hospital admission [3].
Unmanned aerial aircraft, or drones, can accelerate the search for pa-
tients in remote areas [4,5]. Drones can also facilitate an earlier start of
medical treatment by delivering emergency medical equipment, such
as an automated external defibrillator (AED), as shown in an experi-
mental setting [6,7], and recently demonstrated in clinical practice [8].

https://doi.org/10.1016/j.ajem.2023.01.020
0735-6757/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M.J. van Veelen, G. Roveri, A. Voegele et al.
Drones have also been used in particularly challenging mountainous
areas to rescue hikers or climbers (e.g., a canyon, ice cliff, or high
altitude) [9-11].
Equipping a search and rescue (SAR) team with a drone could both
accelerate the search of a patient in challenging terrain and simulta-
neously deliver medical equipment to facilitate earlier treatment. How-
ever, drone capability for these tasks and the implications in terms of
rescue-mission times have not been assessed so far. In this study we
aimed to compare the time required to locate and start treatment of a
patient in a challenging environment by SAR teams equipped versus
not equipped with a drone.
2. Methods
2.1. Design and study setting
This is a randomized controlled trial with a cross-over design that
compared two methods of searching for a patient, reported according
to the CONSORT guidelines. Six rescue teams performed four simulated
missions in a random order, two with the assistance of a drone (inter-
vention arm) and two without (control arm), as shown in Fig. 1. The pri-
mary outcome was a comparison between intervention and control
arms in terms of time for: (i) locating a patient through visual contact
and (ii) starting treatment on-site.
The ethics committee review board of Bolzano, Italy, approved the
study (protocol number 0105095-BZ). We conducted the trial under
the principles of the Declaration of Helsinki. Written informed consent
was obtained in all the participants. The trial took place in the
GEOPARC Bletterbach canyon, South Tyrol, Italy, a site characterized
by challenging and uneven terrain, poor accessibility through limited
access points, and poor Global Positioning System (GPS) and cellular re-
ception, complicating communication and drone flight control (Fig. 2).
We conducted the trial over six days in autumn 2020 and spring 2021.
Twenty-four members of the Italian Mountain Rescue, Corpo
Nazionale Soccorso Alpino e Speleologico (CNSAS), were included and
assigned to six teams. Age younger than 18 years was an exclusion
criteria. We excluded rescuers if they had COVID-19 symptoms, a
Fig. 1. Study design with randomization order of interventions for each SAR team (from A
to F). For each team, the number of members is reported in brackets and the allocation of
control (C) and intervention (I) missions are displayed in colored squares.
41
American Journal of Emergency Medicine 66 (2023) 40–44
positive test for SARS-CoV-2, or unprotected contact with COVID-19 pa-
tients. The task was to locate a patient as early as possible and start
treatment. Six locations were chosen based on historical SAR locations
in the canyon. Scenarios were standardized and consisted of a stable
adult patient, immobile after an extremity injury, and accompanied by
a bystander that initiated an emergency call indicating an approximate
location to restrict the search area. All scenarios started at the headquar-
ters (HQ) of the Bletterbach area. A team leader determined the search
approach, and a drone operator was responsible for drone movements
and for reviewing live the drone high-definition footage shot. Vehicles
were available for the rescue team to navigate to the trailhead or a suit-
able drone take-off point. During each mission, the rescuers covered 2–4
km in rough terrain, including descending and scrambling on the can-
yon floor. We instructed the bystander to display the international al-
pine ground-to-air distress signal raising both arms and forming the
letter Y. After visual confirmation, an emergency kit (weighing approx-
imately 500 g, see next paragraph) was dropped with a parachute at the
patient's site. The team leader maintained and coordinated radio com-
munication between all rescue team members throughout the scenario.
The treatment consisted of assessing the patient and preventing further
heat loss by deploying a thermal cover, as instructed over the radio in
the case of a drone-assisted scenario, and splinting an extremity as
soon as the rescue team was on site. We used telemedical support
via the radio in the kit to instruct the bystander to initiate medical
treatment.
2.2. Materials
The drone used (Q4X, MAVTech, Italy) was equipped with an RGB
camera (FS700, Sony, Japan) or a custom bracket for carrying cargo
and remote release of the emergency kit. The kit was in a polystyrene
box where there were a radio, first aid material (pressure bandages, res-
cue foil, disinfectant solution), and personal protective equipment
(PPE), such as gloves and a filtering facepiece 2 (FFP2) mask (similar
to an N95 mask).
2.3. Statistical analysis
We analyzed the time needed to locate the patient and the time to
start treatment for both arms. We used a linear mixed model (LMM)
to evaluate the effect of using a drone on search and start of treatment
times. Other factors inserted in the LMM were the location and the in-
teraction effect between the method of searching (with and without
drone) and the location. We also inserted in the LMM the consecutive
mission number of each team as a covariate to consider a possible train-
ing effect. The team was treated as a random effect. We used SPSS
version 27 (IBM Corp., Armonk, NY, USA). We considered p < 0.05
(two-sided) statistically significant. We reported values as median
(interquartile range, IQR), except the estimated means of the LMM as
mean (95% confidence interval, CI).
3. Results
Twenty-eight search and rescue missions were performed. Four
drone missions were unsuccessful because the drone experienced tech-
nical difficulties (due to camera live-image transmission failure) and re-
peated with the same team. Twenty-four missions were included in
data analysis.
Search and start of treatment times are shown in Fig. 3. The time to
locate the patient was shorter in the intervention than in the control
arm [14.6 (95% CI 11.3–17.9) min versus 20.6 (95% CI 17.3–23.9) min,
p = 0.008]. The time to start treatment was shorter in the intervention
than in the control arm [15.7 (95% CI 12.4–19.0) min versus 22.4 (95% CI
19.1–25.7) min, p = 0.005). An effect of the location was detected on
the time to start treatment (p = 0.033), while on the time to locate
the patient was close to statistical significance (p = 0.067).
M.J. van Veelen, G. Roveri, A. Voegele et al.
Fig. 2. A. Overview of the study area with an indication of distance scale (1 km), search and rescue headquarters (SAR HQ), landing and take-off zones (LZ1–3), and scenario locations
(V1–6). B. Take-off procedure of the drone at LZ1. C. View of the dropped emergency kit and drone in mid-air from below. D. Retrieval of the emergency kit by the bystander (pictures
courtesy of Michiel Jan van Veelen and Giacomo Strapazzon).
In the intervention arm the median time taken for the drone to be
transported and set up at the take-off spot was 9.7 (IQR 7.1–10.2) min
and the median search flight time was 6.5 (IQR 4.0–9.5) min. A median
time of 0.6 (IQR 0.4–1.4) min was needed in the intervention arm to
drop the emergency kit and for this to be retrieved by the bystander
to initiate treatment at the patient's side. The emergency kit was
dropped via parachute and landed at a median distance of 18 (IQR
8–34) m from the patient.
4. Discussion
This study demonstrates that the use of drones in SAR missions in
challenging terrain leads to a significant reduction of the time to locate
and start the treatment of a patient, although there can be limitations in
their use due to technical failure. The time saved is clinically relevant in
trauma patients with a massive hemorrhage, impaired airway, or
patients with medical conditions, such as cardiac arrest.
We used a drone to locate a patient rapidly and start treatment ear-
lier through a drone-delivered medical and communication kit in the in-
tervention arm. This combined approach resulted in a reduction of the
treatment-free interval. The delivery of medical equipment with
telemedical support could enable life-saving procedures to be per-
formed by a bystander even before the arrival of the emergency medical
services, such as the delivery of an AED or a tourniquet [6, 7]. Bystanders
could initiate these procedures coached by a telemedical support [12].
Drones can also facilitate triage procedures by combining visual and his-
tory details [13,14], as well as intervention for anticipation of pain re-
duction procedures (from immobilization to oral/sublingual drug
administration) and hypothermia prevention (application of a rescue
42
American Journal of Emergency Medicine 66 (2023) 40–44
foil) [1,9,15]. Previous studies showed that drones allowed a quicker
search of the patient in remote areas, but they did not test the potential
impact on time-to-treatment and were performed in areas easy to nav-
igate and oversee, such as exposed snow fields or shallow water at a
coastline [4,5]. Mountainous areas are more challenging terrain to
pilot and oversee due to changing weather conditions, obstacles, and
vegetation, and they frequently have poor cellular and GPS coverage.
We run our tests in a realistic setting with a randomized cross-over ex-
perimental design, and we included, in our evaluation of the time in the
intervention arm, the delay of transporting and setting up a drone on a
suitable take-off point instead of measuring only the flight time as in
previous studies [4,5]. Our data confirm the findings from case reports
and feasibility studies that showed the successful use of drones in chal-
lenging environments like high-altitude SAR missions in the Himalayas
and in a canyon [9,10,13,16]. However, the failure of four tests due to
technical difficulties highlights the need of a thorough test of the drones
under the required operating conditions, before they are used in mis-
sions.
The use of drones can reduce the exposure to dangers associated
with steep terrain, swift water, or avalanches, and allow to operate in
smaller teams [10]. Wankmüller et al. conducted eleven usability tests
with mountain rescue teams and found that drones contributed to in-
creased safety and higher performance of rescue teams [11]. McRae
et al. showed that drones successfully maintained radio communication
between deployed rescuers and a central command in ten different re-
mote areas in Utah [17]. In our trial, the ground SAR team and the
drone operator coordinated their efforts during the mission and re-
duced time-to-locate and the time-to-treatment interval compared to
the control tests.
M.J. van Veelen, G. Roveri, A. Voegele et al.
Fig. 3. Boxplots of time to locate the patient (A) and time to start treatment (B) for the conventional rescue teams (n = 12 missions) versus the drone-assisted teams (n = 12 missions).
4.1. Limitations
Our study has some limitations. The simulated scenario might not
reflect the actual use in real rescues as it does not fully represent the va-
riety of conditions experienced (e.g., all scenarios took place in favorable
meteorological conditions). Due to technical limitations of the specific
drone model available during the trial, which either had a powerful
zoom-enabled camera or a bracket for cargo release, we had to operate
two drones consecutively and to compute the time needed to start the
treatment of the patient. However, it would technically be achievable
to combine the required characteristics in one drone.
5. Conclusions
The successful use of drones in SAR operations leads to a reduced
treatment-free interval of patients in challenging terrain, which could
improve outcomes in patients suffering from traumatic injuries, the
most commonly occurring incident requiring mountain rescue opera-
tions. Treatment can be started earlier through a quicker search and
43
American Journal of Emergency Medicine 66 (2023) 40–44
the delivery of medical equipment. Bystanders can be guided/supported
under telemedical coaching. Widespread implementation of drones in
SAR operations is currently limited by the availability of skilled drone op-
erators and existing regulations ensuring civil and aviation safety during
flight and equipment drop. Limitations of flight in extreme environmen-
tal conditions, as well as a lack of robustness, remain limiting technolog-
ical factors, as demonstrated by four failed aborted missions in this trial.
Funding
This work was supported by the European Regional Development
Fund under the Cooperation Programme Interreg V-A Italia Austria
2014–2020, ITAT3023, Smart Test for Alpine Rescue Technology
(START).
Availability of data and materials
The datasets collected and analyzed in the current study are avail-
able from the corresponding author on reasonable request.
M.J. van Veelen, G. Roveri, A. Voegele et al.
CRediT authorship contribution statement
Michiel Jan van Veelen: Conceptualization, Data curation, Method-
ology, Project administration, Resources, Visualization, Formal analysis,
Investigation, Writing - original draft, Writing - review & editing. Giulia
Roveri: Data curation, Resources, Investigation, Writing - review &
editing. Anna Voegele: Conceptualization, Methodology, Writing –
review & editing. Tomas Dal Cappello: Conceptualization, Methodol-
ogy, Visualization, Data curation, Formal analysis, Writing - review &
editing. Michela Masè: Data curation, Formal analysis, Investigation,
Writing - review & editing. Marika Falla: Conceptualization, Resources,
Investigation, Methodology, Writing - review & editing. Ivo Regli: Data
curation, Investigation, Writing - review & editing. Abraham Mejia-
Aguilar: Data curation, Project administration, Funding acquisition,
Investigation, Methodology, Resources, Writing - review & editing.
Sebastian Mayrgündter: Project administration, Funding acquisition,
Resources, Writing - review & editing. Giacomo Strapazzon: Conceptu-
alization, Data curation, Formal analysis, Funding acquisition, Method-
ology, Supervision, Investigation, Project administration, Resources,
Writing - original draft, Writing - review & editing.
Declaration of Competing Interest
None.
Acknowledgments
We thank Tamara Herbst and all other members of the Italian moun-
tain rescue services Corpo Nazionale Soccorso Alpino e Speleologico -
CNSAS who participated in this trial. We thank Christian Weber and
his colleagues at the GEOPARC Bletterbach for their hospitality and sup-
port. The authors thank the Department of Innovation, Research, Uni-
versity and Museums of the Autonomous Province of Bozen/Bolzano,
Italy for covering the Open Access publication costs.
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