The Dronization of Combat Medical Support
Drones have already revolutionized warfare. This revolution will extend to medical support of military and disaster relief operations soon. The lack of air superiority in recent wars makes air medical evacuations extremely challenging: the "golden hour" is becoming the "prolonged casualty care". In the civilian world, the rise of telemedicine supported by artificial intelligence and distant collection of patients' physiological parameters mean that patients could be cared for remotely. These three concomitant developments are leading military medical services to develop combat medical support within high intensity combat using drones associated with remote medicine. The Ukrainian forces have just evacuated (first time ever) a casualty from the front to a surgical team using a cargo drone.
These medical drones performing combat medical support will be: medical cargo-drones (the first generation); ambulance-drones (the Holy Grail); medical robot-drones (the second generation), and these two generations adapted to CBRN environments.
This dronization will dramatically modify the combat medical support and disaster relief organization and implementation. Healthcare workers will implement medical activities remotely, using fleets of specialized and cooperating drones with first-aiders on the spot. This technological and doctrinal revolution cannot take place without taking into account robustness and resilience.
Drones, aka Unmanned Aerial Vehicles (UAV) or Unmanned Aerial Systems (UAS), have already revolutionized military operations (1). The Nagorno-Karabakh war between Azerbaijan and Armenia in 2020, and even more the current fighting in Ukraine, have demonstrated that the use of drones has become fundamental to land and sea combat. This revolution will extend to medical support. Especially as the lack of air superiority makes air medical evacuations extremely challenging, if not impossible. The expeditionary wars waged since 2001 in Afghanistan, Middle East and Africa have led to major medical progresses in the survival of combat casualties by implementing the "golden hour" which has saved many wounded soldier's life (2). This means handing over a combat casualty to a surgical team in less than an hour, after having immediately administered first aid (e.g. controlling bleeding with a tourniquet). This “golden hour” has saved lots of wounded soldier's lives, thanks to the training of military personnel in combat rescue (known as TCCC: Tactical Combat Casualty Care) and medical evacuation by helicopter.
In high-intensity warfare, the lack of air superiority prevents such evacuations using helicopters. A new way of caring for combat casualties was therefore developed. First called "delayed casualty care", then "prolonged casualty care", the aim is now to keep the wounded alive long enough (i.e. several hours) to be able to reach a surgical team by any available ways of medical evacuation. Obviously, under these conditions, casualty survival rates cannot remain as gratifying for medical teams.
Meanwhile in the civilian world, the rise of telemedicine supported by artificial intelligence and the remote collection of patients' physiological parameters (body temperature, heart rate, oxygen saturation of haemoglobin, etc.), mean that patients can be cared for without physical contact with healthcare professional.
These three concomitant developments are naturally leading military medical services to develop combat medical support using drones with vertical take-off and landing and remote medicine (3).
Worldwide, several experiments have already been carried out using drones to deliver blood bags, medications or evacuate (fake) patients (4,5). But war is a gas pedal of medical progress, as the Ukrainian forces have just demonstrated by carrying out the first evacuation of a combat casualty from the front to a surgical team using a cargo drone (6).
The dronization of combat medical support is going to happen soon, as it solves some of the challenges presented by longer and more complex medical evacuations within high-intensity combat and shortages of healthcare personnel.
1- Medical cargo-drones
A first generation of medical drones will be designed to transport a load from point A to point B. This load could be medical supply (pharmaceuticals at room temperature or refrigerated/frozen, blood products and oxygen cylinders) from the rear to the front, and medical waste in the opposite direction.
The load could also be biological or environmental samples taken by an epidemiological investigation team in an epidemic zone, or by a SIBCRA (Sampling and Identification of Biological, Chemical and Radioactive Agents) team in a CBRN (Chemical, Biological, Radiological and Nuclear)-contaminated zone, and sent to a laboratory (7). These first-generation drones will also be used to transport casualties to the nearest surgical team, as demonstrated by Ukrainian defence (6).
In technical terms, this first-generation of medical drones should be able to meet operational requirements in terms of range of action, autonomy, payload, agility and ability to fit into an already very dense battlefield without risk to on-going operations, automatic or remote piloting by a human operator, robustness and resistance to jamming. As demonstrated in Ukraine by the Russian jamming systems Pole-21 or Zhitel, all drones can be hampered until dozens kilometres from the front (8). The field of research and development is already immense for manufacturers. The use of these drones will also generate radical changes in the organization and doctrine of medical support, as well as the need for new human resources to operate and support drone fleets (9). This use will also raise dizzying questions about medical ethics, rules of war (the International Humanitarian Law) and the protection of these non-human medical resources under the Geneva Conventions (10).
2- The Holy Grail: the ambulance-drone
Anyone who has seen photos of heliborne medical evacuation during the Korean War, or who remembers the opening minutes of Robert Altman's film MASH, would have been horrified to imagine themselves in the shoes of the casualty strapped outside of a Bell 47 (Figure 1). However, this is a development avenue being pursued by many in the industry: a crate with propellers transporting casualty alone over the battlefield to the nearest surgical team (5). Because health personnel are and will remain scarce, especially in high-intensity combat where needs will be immense, they will not be on-board. Especially when helicopters, even those displaying a Red Cross or Crescent, cannot fly safely. Therefore, these ambulance-drones will be for unaccompanied patients, i.e. stabilized, breathing spontaneously, conscious. They will offer the worst possible experience to casualties, and will join the museum of medical abominations along with the high-containment isolators for highly contagious patient in soft plastic, preventing the casualty from seeing clearly outside for hours on end. Nevertheless, it is conceivable that in medium term, a transparent drone ambulance flying at ground level could reduce the anxiety of the transported patient. For the time being, only desperate situations will justify unaccompanied medical evacuation by cargo drone over a combat zone.
Figure 1: Medical evacuation with Bell 47 (H-13G).
(Source: Wikimedia Commons [Internet]. [cited 2023 Sep 8]. Available from: https://commons.wikimedia.org/wiki/File:Bell_47_(H-13G)_medevac_inflight_bw.jpg)
The emergence of these ambulance-drones will transform the processes of medical support. Their development should be accompanied by doctrinal reflection starting today, in order to channel the initiatives of manufacturers who are currently proposing solutions that are not always relevant to the armed forces.
3- Medical robot-drones:
A second generation of medical drones is already on the drawing board: these will be flying robots, interacting with patients, first aid or rescue teams.
With no contact with the patient, and equipped with all the attributes of a medical teleconsultation (steerable camera with zoom, microphone and loudspeaker), silent enough to allow a good quality close dialogue with casualties and battle-buddies in all possible languages (instant translation by artificial intelligence), they will be able to assess the state of consciousness, make a visual assessment of lesions and collect infra-red data on body temperature. Soon, thanks to technologies currently under development, it will be able to measure heart and respiratory rates, as well as haemoglobin oxygen saturation, without contact (11). Combined with biometric sensors worn by combatants, it will be able to collect more medical data, such as the cardiac electrical activity, and refine the parameters measured remotely (12). This robotic drone will be able to assess and monitor the clinical condition of a casualty, either on its own assisted with medical artificial intelligence or with the help of remote medical personnel, and to advise or steer a rescue team already on site. A drone of this kind will revolutionize field care for battle injuries, but also for victims of natural or accidental disasters (13). In the event of a MASCAL (Mass Casualty), drones flying within a meter or two of casualties can triage them, categorizing them in seconds as high or low priority, and other drones will guide them to the right place, or guide rescue teams to them (14).
This second generation of medical robot-drones will be equipped with articulated arms. Initially, they will be able to carry out their own environmental sampling (water, soil, plants, small corpses, etc.) or even biological sampling, with a drop of blood taken by a needle from a casualty who will be hopefully consenting or at least unconscious. These samples will be brought as fast as possible to the most appropriate laboratory, and in a few years time, the drop of blood will probably be analysed by the robot-drone itself: it will then only transmit the results to the medical team.
4-CBRN (Chemical, Biological, Radiological, Nuclear) drones
In the context of a zone contaminated by radioactive particles, chemical agents or toxins, several uses could already be envisaged.
The first generation will be used to bring back biological or environmental samples taken by investigation teams in the red zone to a competent laboratory in the green zone. Already at this stage, a host of challenges are posed. For example, in the case of surface contamination only, two-layers drones will be indispensable: an upper, locomotive part, which will remain clean, and a lower part to be contaminated by the samples. This second part will need to be far enough apart so that the drone propellers don't aerosolize the contaminant. A toxic cloud will prevent the use of these drones. Single-use or decontaminable cargo-drones will be needed.
For the second generation, drones capable of sampling air, water, soil and surfaces on their own in contaminated zones, and bringing back plants (a very good chemical sensor) or animal corpses, will emerge. And other drones, either alone or remotely piloted by health and CBRN personnel, will also triage contaminated people, guiding them to decontamination chains, or conversely guiding rescue teams to immobile casualties, for whom other drones will already have assessed the clinical condition, taken biological samples and will remain on site to monitor the clinical evolution and reassure the patient. All these drones will have to operate as a coherent, synergistic fleet, and be adapted to CBRN conditions.
5- Maritime and land drones
The compromise between speed and safety for transporting casualties, samples or urgent supply will always be better by air. Therefore the development of medical cargo- or robot- drones, whether sea- or land-based, does not seem relevant today. The exception will be underwater drones capable of evacuating a submarine crew in deep water: these will also need to be capable of evacuating lying casualty.
Other medical drones will be part of medical support, but will not be involved in battlefield. It will be for example drones able to detect and assess mosquitoes or ticks population, and to guide pest and vector control actions in support of force health protection operations. Or it will be fixed-wing ambulance drone, able to evacuate casualties from role 2/3 medical treatment facility with an airfield to a role 4 with an airport, and airlift medical supply on the way back.
These descriptions are not science fiction, but anticipation. Most of the technological parts for these medical robot-drones already exist, but their integration into a system is still to be done. In the future, the medical drone revolution will turn the organization and implementation of medical support for military and disaster relief operations upside down. Medical teams, made up of increasingly scarce and valuable healthcare personnel, will no longer be in combat zones, but will implement medical activities (triage, care, investigation of epidemics or CBRN events) remotely, using fleets of specialized, cooperating drones, and possibly guiding and advising first-aiders on the spot. In the absence of air superiority, medical care for combat casualties could still be provided rapidly; and the implementation of "prolonged casualty care", steered remotely or by AI, could enable stabilized patients to be evacuated by road or sea. Realistic medical evacuation by drone remains to be invented. Of course, this technological revolution cannot take place without taking into account the robustness and resilience essential to these high-tech systems: medical drones activity will be surely impacted by satellite connection jamming (15). Finally, this revolution will impose a major update on medical ethics, rules of war and the protection of these non-human medical resources under the Geneva Conventions.
Dr. Benjamin Queyriaux, MD, MPH, FFPH
Medical director at HIPS Agency, Munich, Germany
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