A Randomized Controlled Trial of ABCD-IN-BARS Drone-Assisted Emergency Assessments
, Fabian Ling Ngai Tung 1, Shuk Yin Joey Ho 1, Jeff Yip 2, Zoe Tsui 3 and Alice Yip 3,*
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsFix ethical approval inconsistency: Two different ethics approval codes are given (HRE210101 vs. HRE230218). Choose the correct one and make it consistent throughout. Clarify if trial registration (ChiCTR2500104207) was prospective or retrospective.
Remove redundancy in Methods: The sentence “ABCD-IN-BARS checklist is available in Supplementary File 1…” is repeated in almost every subsection. Keep it once, then go directly into the details.
Improve Results presentation: Table 3 is too dense; convert key findings into simpler figures/graphs ( bar chart for injury detection improvement, line graph for assessment times). Emphasize effect sizes ( partial η² = 0.114) along with p-values.
Language and Grammar corrections Correct awkward phrases: “Participants voluntary participant” - “Participants voluntarily participated.” “Participants praising the protocol’s workflow efficiency…” - “Participants praised the protocol’s workflow efficiency…” General English editing for clarity and conciseness.
Highlight key limitations more strongly: The sample was mainly medically trained volunteers, which limits generalizability to laypeople. Technical barriers (camera alignment, drone maneuvering) need deeper discussion and possible solutions (Like AI-guided stabilization).
Strengthen the Conclusion: Explicitly stress applicability in real-world, non-specialist, rural, and disaster settings. Recommend multicenter validation studies to generalize findings.
Author Response
Point 1: As methods adequately described. Can be improved.
Response 1: Thank you for your comment. Our research team has revised this concern in the methods section. [Line 75-85]
Point 2: Are the results clearly presented. Can be improved.
Response 2: Thank for your comment. We have revised this concern in the results section.
[Line 254-313]
Point 3: Are all figures and tables clear and well-presented? Must be improved.
Response 3: Thank you for your advice. Our research team revise all related figures and tables.
[Line 108-109, 260-268, 294-295]
Point 4: Fix ethical approval inconsistency: Two different ethics approval codes are given (HRE210101 vs. HRE230218). Choose the correct one and make it consistent throughout. Clarify if trial registration (ChiCTR2500104207) was prospective or retrospective.
Response 4: Thank you for your comment. Our apologize for mixed the Grant number and the ethics approval number. [Line 391]
Point 5: Remove redundancy in Methods: The sentence “ABCD-IN-BARS checklist is available in Supplementary File 1…” is repeated in almost every subsection. Keep it once, then go directly into the details.
Response 5: Agree. We removed this sentence.
Point 6: Improve Results presentation: Table 3 is too dense; convert key findings into simpler figures/graphs (bar chart for injury detection improvement, line graph for assessment times). Emphasize effect sizes (partial η² = 0.114) along with p-values.
Response 6: Thank you for your comment. We have revised the line bar (no matter standalone bar cumulative, the effect is poor than a table). Therefore, we keep as table. Cohen benchmarking added. [Line 283-284]
Point 7: Language and Grammar corrections Correct awkward phrases: “Participants voluntary participant” - “Participants voluntarily participated.” “Participants praising the protocol’s workflow efficiency…” - “Participants praised the protocol’s workflow efficiency…” General English editing for clarity and conciseness.
Response 7: Agree. That sentence moved.
Point 8: Highlight key limitations more strongly: The sample was mainly medically trained volunteers, which limits generalizability to laypeople. Technical barriers (camera alignment, drone maneuvering) need deeper discussion and possible solutions (Like AI-guided stabilization).
Response 8: Agree. We have revised this concern in the issue. [Line 351-362]
Point 9: Strengthen the Conclusion: Explicitly stress applicability in real-world, non-specialist, rural, and disaster settings. Recommend multicenter validation studies to generalize findings.
Response 9: Thank you for your comment. Our research team has revised this concern in the methods section. [Line 374-380]
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors proposed the research on"
: A Randomized Controlled Trial of ABCD-IN-BARS Drone-Assisted Emergency Assessments.
As this research stands now, the following major revisions and minor revisions are to be completed so that the research can be appropriately reviewed:
- Abstract first senses “Emergency medical services struggle to deliver timely assessments in remote areas or difficult” looks incomplete, leading to confusion.
- Authors must importantly explain what the ABCD-IN-BARS protocol is about in the abstract and entire manuscript.
- The authors made this assertion in the introduction, which is based on lines 50-51. To what justification is this true? I have investigated the methodology to see any derivation of how this gap determination in the research proposed is true, but found none: “Despite accelerated telehealth adoption during the COVID-19 pandemic [7], structured methodologies for drone-mediated emergency interactions are critically underexplored “
- The comparison result of the author's method used is not clear in the abstract, as it does not relate to the literature.
- The whole introduction is not detailed, whilst it lacks many appropriate research components, making it poorly developed.
- In the introduction, the authors mentioned a few literature authors and relate them to describing the problem of drones' effective delivery during emergency situations in remote areas, but do not state any clear methodologies in which the literature relates to their proposed ABCD-IN-BARS protocol, which is not even fully explained in the entire research.
- The challenges of the proposed technology should be detailed and show how the authors solved the problem well.
- No clear contribution of the research were clearly outline, and there is no clear outlined developed structure.
- The authors have not clearly developed any literature studies or reviews and relate that to how their method is useful in solving the pending drone issues.
- There is no mathematical analysis or algorithms derived to show that the authors' survey with patients, and with regard to how the measurements are valid. No relevant software was mentioned or indicated in the research as to how all the table results were derived.
- If the research study is empirical, there is still more to be done to show with valid proof about drones concepts analysis and equations to validate results well.
"
Author Response
Point 1: Does the introduction provide sufficient background and include all relevant references? Must be improved.
Response 1: Thank you for your comment. Our research team has revised this concern in the introduction section. [Line 45-71]
Point 2: Is the research design appropriate? Can be improved.
Response 2: Thank for your comment. We have revised this concern in the methods section.
[Line 75-86]
Point 3: Are the methods adequately described? Must be improved.
Response 3: Thank you for your advice. Our research team revise this concern in the methods section.
[Line 75-85]
Point 4: Are the results clearly presented? Must be improved.
Response 4: Thank you for your comment. Our research team revise the results section. [Line 253-313]
Point 5: Are the conclusions supported by the results? Can be improved.
Response 5: Agree. Our research team revise the conclusion section. [Line 366-379]
Point 6: Are all figures and tables clear and well-presented? Can be improved.
Response 6: Thank you for your comment. We have revised all figures and tables. [Line 108-109, 260-268, 294-295]
Point 7: Abstract first senses “Emergency medical services struggle to deliver timely assessments in remote areas or difficult” looks incomplete, leading to confusion.
Response 7: Thank you for your advice. Our research team revised this concern. [Line 13]
Point 8: Authors must importantly explain what the ABCD-IN-BARS protocol is about in the abstract and entire manuscript.
Response 8: Thank you for your comment. Please see session 2.2.4 and there is supplementary file mentioned in Line 126.
Point 9: The authors made this assertion in the introduction, which is based on lines 50-51. To what justification is this true? I have investigated the methodology to see any derivation of how this gap determination in the research proposed is true, but found none: “Despite accelerated telehealth adoption during the COVID-19 pandemic [7], structured methodologies for drone-mediated emergency interactions are critically underexplored”
Response 9: Thank you for your comment. The gap: no drone-based human-robotic protocol. This manuscript, design and validate it. [Line 57]
Point 10: The comparison results of the author’s method used is not clear in the abstract, as it does not relate to the literature.
Response 10: Thank you for your advice. Our research team revised the abstract is about the design and primary result by ANOVA and TAM. [Line 26-31]
Point 11: The whole introduction is not detailed, whilst it lacks many appropriate research components, making it poorly developed.
Response 11: Thank you for your comment. Further enhanced as NIH structure. Research Problem, Problem of statement. [Line 46-70]
Point 12: The challenges of the proposed technology should be detailed and show how the authors solved the problem well.
Response 12: Thank you for your advice. This is not a technology; this is a novel patient assessment method via drone for the special issue – Drone SAR.
Point 13: No clear contribution of the research was clearly outline, and there is no clear outlined developed structure.
Response 13: Thank you for your advice. Our research team revised this issue in the manuscript. [Line 351-380]
Point 14: The authors have not clearly developed any literature studies or reviews and relate that to how their method is useful in solving the pending drone issues.
Response 14: Thank you for your advice. First, this is not a literature view. Second, there are no such research about using drone for patient assessment via telemedicine. The most close would be Japan ART disaster Triage training while that is for overall quick triage and no interaction with the patient.
Point 15: There is no mathematical analysis or algorithms derived to show that the authors' survey with patients, and with regard to how the measurements are valid. No relevant software was mentioned or indicated in the research as to how all the table results were derived.
Response 15: Thank you for your advice. Line 200–208 indicate how the sample size calculate with G power software. Line 223 –241 indicated SPSS version 30 for ANOVA GLM.
Point 16: 10. If the research study is empirical, there is still more to be done to show with valid proof about drones concepts analysis and equations to validate results well.
Response 16: Thank you for your time and suggestion to make this manuscript more robust. This is not a lab or AI model study, there are no equations.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsThis study addresses the critical gap in standardized protocols for drone-assisted emergency assessments. The proposed ABCD-IN-BARS protocol demonstrates clear innovation through its integration of patient-assisted maneuvers and structured workflows. However, the manuscript contains several fundamental flaws pertaining to the depth of technical validation and objectivity in result interpretation, necessitating substantial revisions for publication suitability.
​​1, The manuscript’s core objective is to validate the protocol’s value in standardizing emergency assessments, the study design conflates "assessment process completion efficiency" with "clinical reliability of diagnostic outcomes." The research fails to adequately separate these distinct concepts, undermining claims about the protocol’s clinical utility.
2, The manuscript emphasizes the protocol’s advantages in "standardized workflow" but inadequately addresses the mitigation of environmental interference. For instance, low-altitude wind shear—a likely factor in the study location—would induce camera instability. This instability directly compromises vision-dependent steps such as respiratory rate counting and wound dimension measurement. Critically, the manuscript does not analyze the misjudgment rates for key indicators (e.g., respiratory distress assessment) caused by video jitter, nor does it discuss the applicability of existing drone image stabilization technologies to mitigate this issue.
3, The designation of the non-injury scenario as the "control group" is fundamentally flawed. Both groups utilized the identical ABCD-IN-BARS protocol; the sole difference was whether patients simulated an injury. This represents a variable of "injury complexity," not a true intervention vs. control comparison. A scientifically valid control group should have employed traditional, non-protocol-guided drone assessment to demonstrate the incremental value of ABCD-IN-BARS.
4， The statistical analysis and interpretation of results exhibit misleading tendencies. For example, the high score for "Perceived Usefulness" (PU) likely stems from the question design itself (e.g., leading questions like "Use of drones is important in patient assessment"), which lacked counterbalancing negative items (e.g., "The protocol increases cognitive load"). This potentially biases the acceptance findings optimistically. It is recommended to clarify the clinical significance of effect sizes, rigorously distinguish between "short-term training fluctuations" and the "protocol's true benefit," and revise the TAM questionnaire to incorporate balanced question design.
5， The manuscript’s primary research contribution lies in evaluating the effectiveness of a structured diagnostic method/protocol. It does not sufficiently engage with the core scientific or technological domains relevant to this journal (Drones), particularly concerning drone-specific technical innovations, sensor integration, or flight dynamics challenges in medical applications. The findings pertain more to telemedicine protocol validation than to advancing drone technology itself.
Author Response
Point 1: Does the introduction provide sufficient background and include all relevant references? Can be improved.
Response 1: Thank you for your comment. Our research team has revised this concern in the introduction section. [Line 45-71]
Point 2: Is the research design appropriate? Must be improved.
Response 2: Thank for your comment. We have revised this concern in the methods section.
[Line 75-86]
Point 3: Are the methods adequately described? Can be improved.
Response 3: Thank you for your advice. Our research team revise this concern in the methods section.
[Line 75-85]
Point 4: Are the results clearly presented? Must be improved.
Response 4: Thank you for your comment. Our research team revise the results section. [Line 253-313]
Point 5: Are the conclusions supported by the results? Must be improved.
Response 5: Agree. Our research team revise the conclusion section. [Line 366-379]
Point 6: Are all figures and tables clear and well-presented? Can be improved.
Response 6: Thank you for your comment. We have revised all figures and tables. [Line 108-109, 260-268, 294-295]
Point 7: The manuscript’s core objective is to validate the protocol’s value in standardizing emergency assessments, the study design conflates "assessment process completion efficiency" with "clinical reliability of diagnostic outcomes." The research fails to adequately separate these distinct concepts, undermining claims about the protocol’s clinical utility.
Response 7: Thank you for your advice. Our research team sincerely thank Reviewer 3 for raising this. To address this concern, we have undertaken the following modifications to the manuscript: Separate Analysis and Reporting: In the Results section, we have separated the data and analysis for efficiency metrics (e.g., average completion time) Revised Discussion: We have revised the Discussion to interpret the findings for efficiency separately, and to acknowledge that while our protocol demonstrates improvements in both aspects, they provide distinct forms of evidence for its utility. We have also added a sentence on this as a limitation for future research to address more directly.
As mentioned in this text, this is a simulated patient research mentioned in the text, and therefore we do not examinate the reliability.
Point 8: The manuscript emphasizes the protocol’s advantages in "standardized workflow" but inadequately addresses the mitigation of environmental interference. For instance, low-altitude wind shear—a likely factor in the study location—would induce camera instability. This instability directly compromises vision-dependent steps such as respiratory rate counting and wound dimension measurement. Critically, the manuscript does not analyze the misjudgment rates for key indicators (e.g., respiratory distress assessment) caused by video jitter, nor does it discuss the applicability of existing drone image stabilization technologies to mitigate this issue.
Response 8: Thank you for your comment. (a) This is a feasibility study at an outdoor campsite, similar as real world environment, which mentioned in Line 95; (b) The DJI Mini4pro gimbal are very stable, addition text added to Line 104. [Line 95, 104]
Point 9: The designation of the non-injury scenario as the "control group" is fundamentally flawed. Both groups utilized the identical ABCD-IN-BARS protocol; the sole difference was whether patients simulated an injury. This represents a variable of "injury complexity," not a true intervention vs. control comparison. A scientifically valid control group should have employed traditional, non-protocol-guided drone assessment to demonstrate the incremental value of ABCD-IN-BARS.
Response 9: Thank you for your comment. Our research team have more clearly explained how 2 randomizations. (a) Wait list control (as your suggestion a clear control group and how the people serve as their own control in T0. T1. T2); (b) Injury or not scenario also randomized.
The baseline duration results already the non-protocol guided drone assessment as requested.
Point 10: The statistical analysis and interpretation of results exhibit misleading tendencies. For example, the high score for "Perceived Usefulness" (PU) likely stems from the question design itself (e.g., leading questions like "Use of drones is important in patient assessment"), which lacked counterbalancing negative items (e.g., "The protocol increases cognitive load"). This potentially biases the acceptance findings optimistically. It is recommended to clarify the clinical significance of effect sizes, rigorously distinguish between "short-term training fluctuations" and the "protocol's true benefit," and revise the TAM questionnaire to incorporate balanced question design.
Response 10: Thank you for your comment. The study was conducted and hence we cannot modify the questionnaire. The question is the standard of TAM and there is no counterbalance requirement. We have reference to another TAM research, go through expert panel. We published the question in a table to enhance the transparent and we will listen to you and enhance in next drone usability research.
Point 11: The manuscript’s primary research contribution lies in evaluating the effectiveness of a structured diagnostic method/protocol. It does not sufficiently engage with the core scientific or technological domains relevant to this journal (Drones), particularly concerning drone-specific technical innovations, sensor integration, or flight dynamics challenges in medical applications. The findings pertain more to telemedicine protocol validation than to advancing drone technology itself.
Response 11: Thank you for your comment. This submission is for the special issue: https://www.mdpi.com/journal/drones/special_issues/4NQK38927W
which aligned with “showcasing innovative UAV-based SAR strategies,”, “Manned-Unmanned teaming” theme, “enhance responder safety. Interdisciplinary contributions” … etc.
This manuscript is design for all SAR partitioner, and this journal is their usual reading. Not doctors and nurses that they have their medical journals. therefore, I would like to have your favour consideration. As the motto of SAR: We do something that’s other may live!
Author Response File: Author Response.pdf
Reviewer 4 Report
Comments and Suggestions for AuthorsA very interesting article in the field of UAV applications in medicine. In order for the article to be accepted, the following revisions should be made:
1. Literature review. The authors cite a number of sources concerning the use of drones in medicine and telemedicine; however, a more systematic analysis is missing that would demonstrate precisely how previous studies fail to meet the requirements of clinical practice. The current review is descriptive rather than critical. There is also a lack of analysis of potential implementation barriers, such as legal regulations, network infrastructure, or cultural differences in the acceptance of technology.
2. Application of the proposed solution. The choice of the ankle sprain scenario should be justified rather than focusing on more critical conditions (e.g., head trauma, polytrauma). Is this due to the limitations of the developed solution? The effectiveness of the protocol has not been compared to the classical one used in telemedicine (without drones). Without such a comparison, it is difficult to assess the advantage of the proposed approach.
3. Research methodology. It would be valuable to indicate what organizational and training changes would be necessary to implement the protocol within EMS systems. Why did the authors choose “emergency medical volunteers” as study participants? The participants may have “played” patients in a way that aligned with the researchers’ expectations, since they understood the protocol and knew what answers were clinically “correct.” This could inflate the apparent effectiveness of the protocol under experimental conditions. Why were the studies not conducted on patients without medical training? In practice, such patients may not always be able to follow instructions correctly, may not understand the terminology, or may present inconsistent symptoms. A research-based discussion should be included in this section to justify the choice of “emergency medical volunteers.”
Author Response
Point 1: Is the research design appropriate? Must be improved.
Response 1: Thank for your comment. We have revised this concern in the methods section.
[Line 75-86]
Point 2: Are the results clearly presented? Must be improved.
Response 2: Thank you for your comment. Our research team revise the results section. [Line 253-313]
Point 3: Are the conclusions supported by the results? Must be improved.
Response 3: Agree. Our research team revise the conclusion section. [Line 366-379]
Point 4: Literature review. The authors cite a number of sources concerning the use of drones in medicine and telemedicine; however, a more systematic analysis is missing that would demonstrate precisely how previous studies fail to meet the requirements of clinical practice. The current review is descriptive rather than critical. There is also a lack of analysis of potential implementation barriers, such as legal regulations, network infrastructure, or cultural differences in the acceptance of technology.
Response 4: Thank you for your advice. Our research team explained the literature of telemedicine assessment and this study is very important that assignment via drone camera in Line 124-188. This study shows the first aid trained lay people can complete a patient assessment team up with drone and with brief training. [Line 124-188]
Point 5: Application of the proposed solution. The choice of the ankle sprain scenario should be justified rather than focusing on more critical conditions (e.g., head trauma, polytrauma). Is this due to the limitations of the developed solution? The effectiveness of the protocol has not been compared to the classical one used in telemedicine (without drones). Without such a comparison, it is difficult to assess the advantage of the proposed approach.
Response 5: Thank you for your comment. Our research team have revised this issue. Sprain Ankle is the most common case seen in SAR operation. [Line 99]
Point 6: Research methodology. It would be valuable to indicate what organizational and training changes would be necessary to implement the protocol within EMS systems. Why did the authors choose “emergency medical volunteers” as study participants? The participants may have “played” patients in a way that aligned with the researchers’ expectations, since they understood the protocol and knew what answers were clinically “correct.” This could inflate the apparent effectiveness of the protocol under experimental conditions. Why were the studies not conducted on patients without medical training? In practice, such patients may not always be able to follow instructions correctly, may not understand the terminology, or may present inconsistent symptoms. A research-based discussion should be included in this section to justify the choice of “emergency medical volunteers.”
Response 6: Thank you for your comment. Our research team have modified the wording from emergency medical to first aid training in order to prevent mis understanding, this protocol aims to support first aid trained SAR Personnel and that why the people without medical training were selected. Related text revised in Line 84.
The terminology used in the protocol alignment with MPDS which mentioned in Line 113. MPDS system is the 911 system wording.
The Line 110-188 clearly indicated the development and the related patient assessment and telemedicine literature.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe corrections are addressed
Author Response
Point 1: Figures and tables must be improved.
Response 1: Thank you for your comment. Our research team has revised them and in manuscript and supplementary file 1.
Reviewer 2 Report
Comments and Suggestions for AuthorsAuthors have addressed some more concerns but some of them which are major are still not appropriately resolved:
Authors are required to show clear contributions in the introductions when advised to do in the first revision, as below, but references to other sections in the manuscript, as below, should be complied:
Point 13: No clear contribution of the research was clearly outlined, and there is no clear
An outlined developed structure.
Response 13: Thank you for your advice. Our research team revised this issue in the
manuscript. [Line 351-380] ?
Author Response
Point 1: Does the introduction provide sufficient background and include all relevant references? Must be improved.
Response 1: Thank you for your comment. Our research team has revised this concern in the introduction section. [Line 49-72]
Point 2: Is the research design appropriate? Can be improved.
Response 2: Thank for your comment. We have revised this concern in the methods section.
[Line 76-87]
Point 3: Are the methods adequately described? Can be improved.
Response 3: Thank you for your advice. Our research team revise this concern in the methods section.
[Line 76-87]
Point 4: Are the results clearly presented? Can be improved.
Response 4: Thank you for your comment. Our research team revise the results section. [Line 253-310]
Point 5: Are the conclusions supported by the results? Can be improved.
Response 5: Agree. Our research team revise the conclusion section. [Line 361-373]
Point 6: Authors have addressed some more concerns but some of them which are major are still not appropriately resolved. Authors are required to show clear contributions in the introductions when advised to do in the first revision, as below, but references to other sections in the manuscript, as below, should be complied:
Point 13: No clear contribution of the research was clearly outlined, and there is no clear an outlined developed structure.
Response 6: Thank you for your comments and take your advice. Our research team revised the introduction section. Further restructure Line 50 - 60 and then line 67 – 72. by referencing 360 – 372 as suggested:
Included:
- Restructure to highlight gap and the news.
- Added hypothesis
- Line 67 - 70 added feasibility, accuracy and efficiency, scalable, reproducible wordings
to highlight the contribution of this study.
[Line 49-72, 360-372]
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsBefore formal publication, the manuscript requires layout adjustments and unification of table styles according to the journal's requirements.
Author Response
Point 1: Before formal publication, the manuscript requires layout adjustments and unification of table styles according to the journal’s requirements.
Response 1: Thank you for your comment. Our research team has adjusted in the manuscript.
Author Response File: Author Response.pdf
Reviewer 4 Report
Comments and Suggestions for AuthorsThe authors have carefully addressed all of my previous comments and suggestions. The revisions have significantly improved the clarity, structure, and overall quality of the manuscript. The arguments are now more coherent, the data is better contextualized, and the conclusions are well supported. In its current form, the article presents a valuable and well-crafted contribution to the field.
Author Response
Thank you for your comment.
