Discussion

This study examines the use of motorcycles in the sustainable development of public health policies. There are two main objectives: firstly, compare the duration of access to emergency patients between motorcycles with the traditional ambulance model; and second, analyze the use of the AED on the motorlance to reach emergency patients in areas without accessible AEDs in public places.

In the emergency operations with motorcycles, it was found that the population studied was similar in number of males and females. This is consistent with previous studies that found that emergency patients, for the most part, had no gender differences. ^{Reference Soares-Oliveira, Egipto, Costa and Cunha-Ribeiro3,Reference Kiefe and Soares-Oliveira5,Reference Riley7,Reference Pons, Haukoos, Bludworth, Cribley, Pons and Markovchick8,Reference Apiratwarakul, Ienghong, Mitsungnern, Kotruchin, Phungoen and Bhudhisawasdi16}

In terms of the age groups who use motorlance services, it was found that the group that primarily used them was mostly over 60 years old, followed by the 50-to-59-year age group, which may be caused by data gathering between the years 2019-2020. It was during the outbreak of the coronavirus disease 2019 (COVID-19) virus. Most of the elderly did not want to go to the hospital or were restricted to travel by government policies and may be lacking regular medications, loss of follow-up, and waited until the service was needed through EMS. ^{Reference Thornton33,Reference Apiratwarakul, Kongudom, Kotruchin and Phungoen34} Another reason may be from the hospital policy to send a motorlance out to first check emergency patients in case there was a risk of contracting COVID-19, in which case they would arrange an ambulance with appropriate protective equipment to continue to take care of those patients. ^{Reference Apiratwarakul, Ienghong, Mitsungnern, Kotruchin, Phungoen and Bhudhisawasdi16}

As for the operating shifts, most of the operations took place in the afternoon shift. This is consistent with previous studies. ^{Reference Faramand, Frisch and Martin-Gill35–Reference Croda and Garcia37} The main reason for this is the pattern of family relationships in Thai society that dictates that normally people of working age will go to work outside the accommodation, while their older parents will stay at home and take care of their grandchildren. ^{Reference Thanapop and Thanapop38–Reference Bhuanantanondh, Buchholz, Arphorn, Kongtip and Woskie40} This kind of pattern results in the elderly having symptoms of illness and having to wait for the parents to return to meet their children at home, and after that request assistance in the EMS setting. Therefore, most operations take place in the afternoon shift, which is the time after work.

For Thailand’s EMS, there are personnel in operation consisting of a doctor, a nurse, a paramedic, AEMTs, and EMTs. The operation has two levels including advanced and basic. In the advanced operation level, there must be a doctor or nurse participating in the operation. An advanced-level deployment will occur when the patient’s symptoms are notified and initial assessment is of critically ill patients; the command center will order the advanced operation. In the case of urgent symptoms or when immediate treatment is not necessary, they will be ordered to operate at the basic level of operations. ^{Reference Pattanarattanamolee, Sanglun and Nakahara41–Reference Riyapan, Chantanakomes and Ruangsomboon44}

It was also found that when comparing the time in EMS from motorlance with the traditional ambulance in all shifts, activation time of the motorlance was shorter than the ambulance, which is consistent with previous studies. ^{Reference Alanazy, Fraser and Wark45,Reference Kelker, Yoder and Musey46} In this study, ambulance and motorlance parking spots were in the same area. Therefore, the shorter activation time of motorlance is due to the lower number of operational personnel (only two operational personnel), unlike an ambulance which requires four to five personnel to operate, thus making the length of time it takes for personnel to arrive at the vehicle different. However, according to EMS standards, the proper activation time should be less than two minutes, which shows the readiness of personnel to carry out operations with both models of emergency vehicles using less than two minutes. In terms of response time, motorlances took a shorter time to arrive at the scene than an ambulance. This is consistent with previous studies which point out one of the main benefits of a motorlance in that it is better able to move in a small street or in traffic jams. ^{Reference Kiefe and Soares-Oliveira5,Reference Riley7,Reference Chinprasatsak, Satthapong, Kotruchin and Maporn9,Reference Apiratwarakul, Ienghong, Mitsungnern, Kotruchin, Phungoen and Bhudhisawasdi16,Reference Alassaf, Al Hamid, Kentab, Al Otaibi and Al Mufareh47,Reference Walker, Jiarpakdee and Loupis48} Most of the areas in this study were conducted within the university campus and surroundings which have different conditions of traffic routes. The university road has two to four traffic lanes, but in rush hour, there will be a lot of vehicles. In areas around the university, small alleyways and unmarked one-lane roads make up a majority of the grid, which in turn makes direction giving and routes to the patient complicated. Motorlances are clearly more advantageous in these types of environments. However, the period of EMS time (activation and response time) of motorlances and ambulances were shorter than the previous study, ^{Reference Apiratwarakul, Ienghong, Mitsungnern, Kotruchin, Phungoen and Bhudhisawasdi16} possibly due to the study period during the epidemic of the COVID-19 virus when traffic conditions were more flexible than usual, along with a number of students and staff working from home, causing the number of vehicles on the traffic route to decrease, resulting in access to patients faster than normal operations. ^{Reference Suratana, Tamornpark and Apidechkul39,Reference Prommoon, Phibalsak, Netwachirakul, Mekthat, Jitpiboon and Sangthong42,Reference Alanazy, Fraser and Wark45}

In addition, the use of an AED on motorlances will be used in the event of a notification that there is an emergency patient who is unconscious, collapses, or stops breathing. Due to limitations of the installation of AEDs in public places, this study applied the new health policy of bringing an AED to be installed on a motorlance to solve two problems. Firstly, the lack of publicly installed AEDs, and secondly, the lack of expertise in using the equipment. It was found that the length of time to reach the patient is less than eight minutes, which is the standard assigned to the emergency medical unit to reach out-of-hospital cardiac arrest patients to increase the chance of survival. ^{Reference Milewski, Sokołowska, Jankowiak, Kowalewska, Milewski and Lewko22,Reference Smith, Griffiths, Fothergill, Vlaev and Perkins24,Reference Post, Schaefer and Biese27} The study also found that almost all areas that reach emergency patients do not have AED equipment installed in public places, which corresponds to the nature of residence. Most of them live in one house or in an allotted village, which is far from the areas where an AED is located, such as a bus station or shopping mall. The modification of health policy will increase chances of survival of the people in the community. ^{Reference Sekendiz49,Reference Pemberton, Bosley, Franklin and Watt50} As can clearly be seen from the study, almost all of the patients that are accessed with an AED-equipped motorlance have a chance to continue cardiopulmonary resuscitation (CPR) at the hospital. The health sustainable development policy with the use of a motorlance plays an important role in reducing access time to patients. In addition, the installation of the AED on the motorlance increases the chance of survival, which is considered a worthwhile investment. ^{Reference Abelairas-Gómez, Schroeder and Carballo-Fazanes51,Reference Nakagawa, Oliveira and Lockey52} In countries with limited budgets, installing AEDs in public areas is an important policy that both the government and private sectors should pay attention to and jointly develop, but during the waiting period for development, the application of available resources by bringing a motorlance to install an AED would be beneficial to people in the community, especially patients with out-of-hospital cardiac arrest. In addition, the role of motorlances differs depending on the context of each country, such as in European countries, a motorlance will be used for assessment of disaster situations to assess if the area is safe. This includes early access to assess the resources needed at the scene. In Korea, a motorlance was used to reach out-of-hospital cardiac arrest patients to increase chances of survival. In African countries, motorlances were used to bring pregnant women to undergo antenatal care at community health centers, including taking pregnant women to deliver their babies at the hospital. Not surprisingly, motorlances are significantly cheaper to acquire and operate when compared with ambulances in the form of regular cars. Therefore, it is a new challenge in applying motorcycles to perform duties in the development of public health policies, especially in large urban areas with traffic congestion.

There may be some modifications to the vehicle configuration from a motorcycle to another form of three-wheel vehicle (Tuk Tuk) which is unique to Thailand, larger than a motorcycle but smaller than a car. The Tuk Tuk can solve emergency situations that motorcycles cannot, such as operating during heavy rain or strong winds. The Tuk Tuk can install rainproof plastic to prevent rain, resulting in a greater ability to perform and create a better environment for the operator and the emergency patients. Further developments such as telemedicine systems may be installed, such as a real-time camera recording so EMS members or doctors who are stationed at the hospital can see the patient’s condition to be assessed promptly and deliver a timelier treatment, including possibly installing a navigation system from the hospital to the scene by using the shortest travel time.