Institute of Transportation Studies
UC Berkeley Traffic Safety Center
( University of California, Berkeley)
Year 2004 Paper UCB - TSC - RR - 2004 - 18
Pre- hospital Care of Road Traffic Injuries
in Chiang Mai, Thailand
Ted R. Brown Judy A. Geyer Azita Taghavy
U. C. Berkeley U. C. Berkeley U. C. Berkeley
Brian P. Mitchell David R. Ragland
University of Utah U. C. Berkeley
This paper is posted at the eScholarship Repository, University of California.
http:// repositories. cdlib. org/ its/ tsc/ UCB- TSC- RR- 2004- 18
Copyright  c 2004 by the authors.
Pre- hospital Care of Road Traffic Injuries
in Chiang Mai, Thailand
Abstract
In many developing countries, transportation infrastructure development
lags behind the tremendous growth in motorization. Road traffic injuries cause
enormous morbidity and mortality worldwide, placing heavy burdens on global
and national economies. . Underdeveloped transportation infrastructures crit-ical
to traffic safety include roadway improvement, occupant protection laws,
traffic law enforcement, and emergency medical services ( EMS). Highlighting
one important aspect of lagging infrastructure, this article focuses on emer-gency
medical services. This research study offers a descriptive evaluation of
the existing pre- hospital care system in Chiang Mai, Thailand. The research
objectives were ( a) to describe how emergency rescue services are organized in
Chiang Mai, ( b) to examine ongoing public health efforts to improve emergency
services, and ( c) to document the training, certification, employment, and med-ical
use of pre- hospital personnel. Thailand’s national and local pre- hospital
services ( i. e., services designed to transfer persons with traffic injuries into the
country’s hospital infrastructure) are both insufficient and inefficient. The Thai
National Government has promised funding to create a national EMS network by
2006. Research recommendations for Thailand EMS include more professional
training for emergency workers, standardization of equipment, centralization of
communications, and further analysis of competitive services.
Brown, Geyer, Mitchell, Taghavy, and Ragland 1
Pre- hospital Care of Road Traffic Injuries in Chiang Mai, Thailand
November 15, 2004
Ted R. Brown, MD, MPH
MS Hub Medical Group
1100 Olive Way, Suite 150
Seattle, WA 98101
Phone: 1- 888- 634- 6778
Fax: 206- 685- 3244
berktocm@ yahoo. com
Judy A. Geyer, MSE
Traffic Safety Center
University of California
140 Warren Hall # 7360
Berkeley, CA 94720
Phone: 510- 643- 5659
Fax: 510- 643- 9922
jgeyer@ berkeley. edu
Azita Taghavy, MD
Traffic Safety Center
University of California
140 Warren Hall # 7360
Berkeley, CA 94720
Phone: 510- 642- 4456
Fax: 510- 643- 9922
azita@ berkeley. edu
Brian P. Mitchell, MPH, MSc
University of Utah, School of Medicine
35 F Street, # 423
Salt Lake City, Utah 84103
Phone: 801- 364- 6899
Fax: 801- 581- 2931
mitch4brian@ hotmail. com
Corresponding Author:
David R. Ragland, PhD, MPH
Traffic Safety Center
University of California
140 Warren Hall # 7360
Berkeley, CA 94720
Brown, Geyer, Mitchell, Taghavy, and Ragland 2
Phone: 510- 642- 0566
Fax: 510- 643- 9922
davidr@ berkeley. edu
Brown, Geyer, Mitchell, Taghavy, and Ragland 3
ABSTRACT
In many developing countries, transportation infrastructure development lags behind the tremendous growth in
motorization. Road traffic injuries cause enormous morbidity and mortality worldwide, placing heavy burdens on
global and national economies. . Underdeveloped transportation infrastructures critical to traffic safety include
roadway improvement, occupant protection laws, traffic law enforcement, and emergency medical services ( EMS).
Highlighting one important aspect of lagging infrastructure, this article focuses on emergency medical services.
This research study offers a descriptive evaluation of the existing pre- hospital care system in Chiang Mai, Thailand.
The research objectives were ( a) to describe how emergency rescue services are organized in Chiang Mai, ( b) to
examine ongoing public health efforts to improve emergency services, and ( c) to document the training,
certification, employment, and medical use of pre- hospital personnel. Thailand’s national and local pre- hospital
services ( i. e., services designed to transfer persons with traffic injuries into the country’s hospital infrastructure) are
both insufficient and inefficient. The Thai National Government has promised funding to create a national EMS
network by 2006. Research recommendations for Thailand EMS include more professional training for emergency
workers, standardization of equipment, centralization of communications, and further analysis of competitive
services.
Brown, Geyer, Mitchell, Taghavy, and Ragland 4
INTRODUCTION
Road traffic injuries cause enormous morbidity and mortality worldwide and place heavy burdens on global and
national economies. Worldwide in 2000, traffic injuries were the ninth leading cause of disability- adjusted life years
lost ( or, global burden of disease) ( 1). By the year 2020, traffic injuries are projected to be the third leading cause of
the global burden of disease ( 1). Ninety percent of disability- adjusted life years due to road traffic accidents are in
developing countries ( 2).
In developing countries, rapidly increasing motorization is outpacing the development of transportation
infrastructure. This fact is the primary reason for the increasing numbers and rates of motor vehicle injuries in
developing countries. The lagging transportation infrastructure includes roadway improvement, occupant protection
laws, traffic law enforcement, and emergency medical services. This article focuses on one aspect of the developing
world’s transportation infrastructure: emergency medical services. Because the majority of trauma deaths in
developing nations occur in the pre- hospital setting, it is imperative that emergency medical systems be established
and improved in such countries. ( 3)( 4) The countries of Asia are making progress in organizing emergency medical
systems, but much work remains to be done.
This article describes emergency medical services ( EMS) as well as a cross- sectional field survey of rescue
workers in Chiang Mai, Thailand, the second largest province of Thailand. Chiang Mai Province, which is located
in northern Thailand, has a population of 1.47 million, of whom 248,000 live in the municipal district, and about
200,000 live in its immediate suburbs. There are 45 hospitals in the province, and more than half of these are in the
vicinity of the city. In Chiang Mai, there are high morbidity and mortality rates due to traffic injuries. In particular,
one survey of the EMS providers in Chiang Mai indicates that about 70% of their emergency cases are for
motorcycle crash victims.
In Thailand, injuries ( including poisonings) are the second leading cause of death overall. Thailand is one
of many developing countries that is experiencing rising traffic fatality rates at a time when rates are steadily falling
in highly developed countries. The rate of accidental deaths peaks between the ages of 15 to 34. In this age group,
the male to female ratio is at least 4: 1. ( 2)( 5)( 6)( 7)( 8) Many factors contribute to the rising traffic fatality rates in
Thailand. Urbanization and economic growth have been accompanied by rapid motorization. Road infrastructure
and traffic safety have not developed as quickly.
In developing countries like Thailand, the percentage of vulnerable road users ( pedestrians, motorcyclists,
and bicyclists) is relatively high. Although helmet use is legally mandated for motorcyclists, it is not strictly
enforced. Motorcycle crashes account for most ( 72%) of all hospital admissions related to traffic injuries in
Thailand compared to only 1.8% in the US.
The goal of this article is to describe the current national and local efforts to improve emergency medical
service. The following section summarizes the investigative methods used to research this topic. Next, there is a
summary of national efforts, followed by a summary of local efforts. To close, we offer a discussion and conclusion
that outline possible improvements to Thailand’s developing emergency medical service system.
METHODS
This article is a descriptive study of the management of road traffic injuries in Chiang Mai and Bangkok, Thailand,
between May and June 2003. The data stem from oral interviews and written questionnaires administered to
emergency rescue workers. Additional data were collected from publications of The Narenthorn EMS Center of the
Ministry of Health and unpublished documents of the Chiang Mai Health Department Office of Emergency Care.
Officials at the Ministry of Health, private rescue foundations, the Chiang Mai Provincial Hospital and two
private hospitals were contacted prior to the study to arrange preliminary interviews. Interviewee referrals were
used to arrange subsequent interviews with emergency responders at the Chiang Mai Health Department Office of
Emergency Medicine, the police and fire departments of Chiang Mai, hospital- based and foundation- based
emergency services and one rescue club. Oral interviews were conducted in the Thai language by the investigator
based on a prepared list of key questions specific for each interviewee. Interview information was recorded in
written notes that were subsequently analyzed.
Structured questionnaires were prepared for emergency rescue workers in consultation with two North
American physicians, a paramedic who oversees emergency medical technician ( EMT) certification for a California
county, and an EMT textbook. ( 9) The questions were pre- tested with twenty American EMTs ( two basic level and
eighteen intermediate level), translated into Thai, and then pre- tested again with two Thai nurses and one Thai
emergency rescue worker. The questionnaires were administered by a Thai research assistant who was trained by
the principal investigator. The questionnaire included four sections: ( 1) demographic information ( sixteen closed-ended
questions), ( 2) quality of training, job satisfaction and seatbelt use ( using Likert scale questions), ( 3) decision
Brown, Geyer, Mitchell, Taghavy, and Ragland 5
making during triage, work- related problems, suggested improvements and barriers to change ( eight open- ended
questions), and ( 4) emergency equipment knowledge and use ( battery of questions).
All aspects of the emergency rescue worker survey were done according to the protocol approved by the
Human Subjects Committee at U. C. Berkeley. Subjects were recruited by written invitations that were distributed
by the subjects’ employers. For all participants, written informed consent was obtained before study participation.
All participants were full- time emergency rescue workers in the Chiang Mai municipal area.
RESULTS
National Efforts by Thai Government
In Thailand, progress on road safety has been slow. Two national departments, the Department of Transportation
and Communication and the Ministry of Health, are poised to improve emergency medical response services. The
former has been drafting, but has not fully implemented, a plan to create an agency governing road traffic safety.
( 10) This effort, four years in the making, is only part of the Department of Transportation and Communications’
20- year effort to establish EMS services. These efforts are plagued by a lack of coordination with other
departments, limited national funding, and/ or lasting results.
More promising progress has come in the past five to ten years under the auspices of the Ministry of
Health. ( 11) Under Thailand’s Ninth National Plan for Economic and Social Development, the Narenthorn EMS
Center, an EMS Center in Bangkok and a division of the Ministry of Health, aims to make EMS available
throughout the country by 2006. Narenthorn defined the project goals to include:
• Hitting a target response- time of ten minutes or less
• Field stabilization by EMT basic and intermediate personnel.
• Providing pre- hospital services through this program for 25% of all emergency cases in the participating
provinces.
The plan is predicated upon promoting the existing loose network of provincial emergency rescue providers,
rather than replacing them with a uniform workforce. Under this plan, hospital- based services shall be responsible
for pre- hospital care for life- threatening, neurological, vascular and severe orthopedic injuries. Payment for EMS
services shall be accounted on a case- by- case basis. Triage decisions shall be made at an EMS radio control room
located at the provincial health office, police station or provincial hospital, depending upon the requirements of each
province. Participating hospitals and rescue foundations shall be required to have annual vehicle inspections and
staff- training courses. The inspecting committee would include provincial health nurses and emergency room
doctors.
According to the Narenthorn plan, EMS providers will receive government payments based on the number
and seriousness of cases that they retrieve, rather than on the size or comprehensiveness of the pre- hospital service
that they maintain. This approach is in contrast to the national health insurance scheme, which reimburses hospitals
based on the number of persons that they enroll, not based on the actual number of patients seen. All accredited
hospitals in Thailand are required to maintain ambulances with features approximating Western standards. Only a
few large urban hospitals have full 24- hour staffing for ambulances. Most hospitals send ambulances in response to
phone requests or police radio requests, but the primary use of hospital ambulances is non- emergency patient
transportation.
There are also emergency transport services provided by philanthropic organizations and hospitals, each
maintaining its own workforce and emergency vehicles. The foundations’ emergency vehicles are typically
operated by teams of two or three men paid small salaries. The vehicles are simplified ambulances: that is, most are
a pick- up truck with a covered cabin over the bed in the rear. These volunteer patrols park at street- side locations
where they wait for a command from their communication unit. When an emergency message is received, they
hasten to traffic crash sites and transport injured persons to public or private hospitals. In Chiang Mai, two private
hospitals and one public hospital have EMS programs. The hospitals have between two and nine full- time rescue
workers and between one and four 24- hour rescue units. ( Statistics for 2002 could not be obtained from the private
hospitals.)
Both rescue foundations and hospital- based EMS programs are geared toward the management of traffic
injuries and not toward transporting people with illness from home to the hospital. Unlike traffic injury services,
which are free, hospitals charge a fee to pick up a patient from home.
In the US, there is generally only one ambulance company responsible for EMS in a given county. In
Chiang Mai Province, the central government and provincial government have had only minimal involvement in
developing EMS until the last few years. Although much has been done to coordinate communications between the
emergency networks, there are still a half- dozen or more emergency hotlines to choose from. Emergency calls are
Brown, Geyer, Mitchell, Taghavy, and Ragland 6
also made directly to hospitals. Finally, there are three rescue foundations with their own emergency hotlines and
radio bands.
As the number of pre- hospital providers and emergency hotlines grew during the 1990’ s, the EMS system
became disjointed and competitive. Until 2002, there was no registry of emergency rescue workers in Chiang Mai.
The Health Department had no control over the staffing of rescue vehicles, and the only way that it could enforce
standards for emergency worker pre- hospital training was by sponsoring voluntary courses and encouraging
emergency rescue service providers to send their regular workers for training.
Local Efforts in Chiang Mai
The Provincial Health Department’s Office of Emergency Medicine launched its effort to bring organized EMS to
Chiang Mai in 2002. It convened a series of meetings attended by officials of most of the local EMS private
organizations and major hospitals to devise an EMS referral plan for metropolitan Chiang Mai. Modeled after the
Ministry of Health plan, rescue foundations were granted responsibility for management of emergency cases with
only Basic Life Support ( BLS) requirements. Hospital- based EMS units were given charge of emergency cases with
Advanced Life Support ( ALS) requirements. There were originally nine hospitals that offered to provide EMS.
Each was to operate EMS units only within their designated EMS zone ( within ten kilometers of the hospital).
Triage of patients with the most acute critical care needs was organized separately. Overseeing the pre- hospital
triage process was a central radio communication center, the Wiang Ping Rescue Center, which had already been
established within the provincial hospital.
The 2002 meetings set a blueprint for the orderly conduct of emergency dispatch and triage to hospital.
Emergency calls in Chiang Mai reach EMS providers through a range of channels and most calls were acted upon
without clearance through the Health Department’s communication system, especially by rescue foundation
respondents. To date, the attempt to dispatch hospital and foundation EMS units based on the severity of the injury
has not been very successful. Rescue foundations often go beyond their designated responsibility for BLS cases and
also manage ALS cases. Some hospitals are providing emergency services for ALS cases as planned, but are also
competing with the rescue foundations for BLS cases and sending units outside of their own catchments areas,
bypassing other hospitals that may be nearer to the crash scene. Most decisions about hospital referral are made by
the EMS units without much input from the Health Department’s communication center. Meanwhile, most of the
hospitals that agreed to provide EMS within their zones have not gotten their programs started and are serving only
as receiving hospitals. In short, operations are much the same as before the EMS plan was introduced.
In practice, rural district hospital ambulances rarely give ALS to road traffic accident victims. Most often,
they are utilized for inter- hospital patient transportation. Routine ambulance equipment is limited to a stretcher with
an intravenous stand, an oxygen tank, bag- mouth breathing apparatus and a basic first aid kit. Hospitals providing
EMS services in the city of Chiang Mai have the best- equipped ambulances in the province. Even so, they are
generally not equipped with defibrillators, ventilators or equipment for intubations.
Equipment in the rescue foundation vehicles is limited by the small space available in the back of a pick- up
truck. Typically, they contain a stretcher, home made spinal board and splints for arms and legs. Cervical collars,
first- aid kits, gloves and bag- mouth apparatus are not uniformly provided. Meanwhile, the rescue workers have
limited knowledge about emergency equipment. Table 1 contains the results of an equipment survey of 40
emergency rescue workers in Chiang Mai.
The emergency equipment knowledge battery revealed that a large majority of the rescue workers are
familiar with spinal boards and cervical collars ( Table 1). Workers who had such equipment in their vehicles
reported that they put them to use. However, 22% of the workers stated that their vehicles did not have spinal
boards or cervical collars, and limited inspection of the vehicles by the investigators confirm their assertion. Low-cost
spinal boards and cervical collars are now manufactured in Thailand.
In addition to equipment deficiencies, EMS programs lack well- trained workers. The results of interviews
with 40 emergency rescue workers ( all males, n= 40) are contained in Table 2. Generally, this occupation is
reserved for young men with low education ( a ninth- grade education is mandatory and the average education in this
survey was 9.7 years). A large majority of the participants have been employed as rescue workers for more than one
year, suggesting that job turnover is fairly slow. This may be explained by the high ratings for job satisfaction. That
almost all participants rated their job satisfaction as good or excellent is somewhat surprising, considering their poor
salaries, especially when calculated on an hourly wage basis. On average, the rescue workers receive about 25%
less monthly wage than do nurse’s aides at hospitals, but work about 30 hours more per week. The average work
week was 76 hours, the average hourly wage was $ 0.28 ( USD). One occupational safety concern is the use of seat
belts. Also as part of this survey, the respondents were asked to report the frequency with which they wear seatbelts
Brown, Geyer, Mitchell, Taghavy, and Ragland 7
while riding in their rescue vehicles. Sixteen ( 40%) responded “ never,” 21 ( 52.5%) responded “ sometimes,” and 3
( 7.5%) responded “ always.”
The training of emergency medical responders is often minimal. 35 of the 40 emergency workers
interviewed had obtained less than 24 hours of pre- employment training. Only four of the 40 emergency workers
had obtained Emergency Medical Technician Certification. In Chiang Mai, new recruits at the rescue foundations
start out paired with a more experienced rescue worker and gradually learn while on the job. The foundations have
periodic in- service trainings, conducted monthly to quarterly by different organizations. It is hoped that the basic
Trauma Life Support course that was conducted in 2002 at the Health Department will be followed by annual
refresher rescue courses for the emergency workers.
For comparison, in the US EMT training and licensing requirements vary by location but are much more
rigorous. EMT programs are taught at two- year colleges and private trade schools. In California, the EMT
curriculum averages 130 hours, including 8 hours of clinical experience. To become a paramedic, one must
complete an EMT training program and do additional training ( 1040 hours in California). Both EMT’s and
paramedics are awarded two- year licenses. A lack of large training programs continues to be an educational issue
for Thailand. In Thailand in the year 2002, only 60 health professionals graduated from EMT programs ( Table 3).
In Thailand, the lack of trained personnel has been cited by the Narenthorn Center as one of the chief
impediments to developing a national EMS network. Police officers are usually the first personnel to arrive at
accident scenes. Their emergency medical training is, however, limited to a few lectures on emergency medicine
during their year at police academy. The police play only a supporting role in treatment of injury victims. In
addition, firefighters receive BLS training, but their focus is on extrication and they usually defer pre- hospital care
to others.
Khon Kaen University in Thailand’s Northeast, has had a two- year EMT- intermediate vocational program
for several years. Two other universities are starting similar programs. The graduates are capable of some ALS
procedures ( starting intravenous fluids, resuscitation, giving injections), but not intubations or operation of a
defibrillator. The Narenthorn EMS Center in Bangkok has a six- month EMS training course that produces EMS
intermediates, but it only accepts a few students per term.
Generally, it is understood that the National Health Insurance program is placing great demands on the
teaching hospitals in Chiang Mai. Therefore, at the moment, the additional work in starting, funding, and
maintaining an EMS program is thought to be an insurmountable task. It will likely be several years before such a
program is begun.
DISCUSSION AND RECOMMENDATIONS
In Thailand, the number of registered passenger cars and motorcycles grew by over 1300% in the last two decades
of the 20th century. Associated with this motorization was a marked increase in the traffic mortality rate. Currently,
about 500,000 people out of a population of 61 million experience traffic injuries annually at an economic cost of
2.5 billion dollars ( USD). Causes include poor traffic engineering design, limited enforcement of traffic safety laws,
unsafe driving habits, and a high percentage of vulnerable road users. Thailand has created a system of hospitals
covering every district in the country and has instituted universal health care coverage. There is a high rate of road
traffic accidents ( the highest rate in Southeast Asia) and a good hospital infrastructure to manage these events.
However, insufficient pre- hospital services make it difficult to get patients safely to the hospital. Improvement in
EMS is a critical component of transportation infrastructure.
The Chiang Mai Health Department’s initiatives have moved the EMS providers toward cooperation and
established a means to enforce educational requirements and competency standards for emergency rescue workers.
Both local efforts and national efforts still have room for improvement. Following is a list of recommendations
resulting from this article’s summary of EMS in Chiang Mai.
Training
Basic improvement would result from improved training and employment conditions for emergency medical service
responders. Emergency rescue workers receive minimal pre- employment training, and must learn on the job. They
work long hours and receive small wages. Their vehicles often lack essential equipment for the safety of their
patient’s, let alone the driver’s or the medical technician’s.
Little attention is given to the safety of the drivers and other rescue workers during patient transportation.
Training seminars should place greater emphasis on safe driving and seat belt usage in emergency vehicles. The
absence of female emergency rescue workers, perhaps a result of sexual discrimination by employers or well-defined
social roles, reduces the pool of potential rescue worker applicants. Moreover, it may be a cause of friction
Brown, Geyer, Mitchell, Taghavy, and Ragland 8
between male rescue workers and female nurses who lead some hospital- based ALS ambulance units. Therefore,
the Health Department should encourage EMS providers to actively recruit females to the field.
Equipment
The Ministry of Health and local health departments should act quickly to provide all emergency rescue vehicles
with spinal boards and other essential emergency medical equipment. Even the more modern ambulance units have
deficiencies in equipment. The rescue foundation units, as opposed to the hospitals, are the least well equipped.
Vehicle inspections are conducted at the Provincial Health Office, creating an opportunity for EMS providers to
pool emergency equipment from several units to put together a complete array of what is required for the inspection.
Spot inspections would allow a much more accurate assessment of compliance with ambulance equipment
standards. Basic life support courses are conducted at the Provincial Health Office using Health Office equipment
that in some cases is not generally available. For example, scoop stretchers are used in practicing transfers at the
office, but most stretchers used in the field are simple boards covered with foam. If the trainees brought and used
their own equipment in training seminars, it would benefit their emergency techniques in the field.
Improved Hospital, Police, and EMS Coordination and Communication
Even in Bangkok, where EMS is most prevalent and most advanced, less than half of emergency cases are brought
to the hospital by EMS. Once the national plan to support EMS services is instituted, the annual budget will be
limited to $ 10.7 million ( USD), which many believe is not a sufficient sum.
There is an array of EMS providers, including private rescue organizations supported by donations and
hospital- based providers supported by hospital budgets. It is fair to say that local governments, hospitals, and
citizen groups are leading the effort to establish systems for pre- hospital care, however funding for EMS is not well
coordinated by government. In 2002, the Health Department attempted to organize an EMS system by ( 1)
delegating responsibilities to various EMS providers according to their neighborhood zones and according to
severity of injury, ( 2) promoting an emergency dispatch communication center, and ( 3) providing BTLS training
courses for rescue workers and creating a formal emergency rescue worker registry. However, efforts still prove to
be uncoordinated. For example, non- hospital- based EMS workers are responding to emergency radio transmissions
from the police radio network without waiting for instructions from the emergency medical dispatch center. As long
as this continues, pre- hospital care will remain haphazard. To coordinate EMS providers, it may be necessary to
protect police radio signals and hire a few more workers at the emergency medical dispatch center to achieve more
effective communications
Plan for Expansion
Currently, the EMS programs of hospitals and foundations in Chiang Mai focus on road traffic injury management,
both in training and in the scope of operations. There is an unmet need for EMS in illness and injury occurring at
homes and workplaces. As the EMS system matures, it should assume more responsibility for more diverse
emergency settings, including stroke, asphyxiation, drug overdose, falls, and firearms injuries. Appropriate training
and additional equipment, such as defibrillators, should be provided.
Analysis of Effects of Competition
The National Government’s proposed fee- for- service payment program ties reimbursement to the quantity of service
provided, i. e. the number of patients delivered to the hospital, and the severity of their condition. Competition,
instead of cooperation, might decrease the pre- hospital travel time, but with the current state of communication, it
also results in a lack of communication between police, EMS teams, and the hospitals. Given the widespread lack of
adequate training, this reimbursement system may also prompt EMS providers to respond to very severe injury cases
that exceed their knowledge of pre- hospital care. A better payment system might be based on quality standards
( e. g., maintenance of 24- hour coverage with ALS capabilities within a specific district). Further economic analysis
of possible reimbursement strategies would help reveal the most appropriate payment scheme.
CONCLUSION
Injuries are the leading cause of hospital admissions in Chiang Mai, and traffic injury is the leading subcategory.
Motorcyclists comprise about 70% of traffic injuries. There is increasing awareness of the need for improved pre-hospital
services to respond to traffic injuries. The Department of Transportation and Communications and the
Ministry of Health have launched programs to coordinate EMS services and register emergency rescue workers. By
2006, the Thai National Government plans to fully support local Health Departments and EMS programs and to
Brown, Geyer, Mitchell, Taghavy, and Ragland 9
integrate them into an effective system. Before then, areas of improvement that could benefit the current system
include sufficient supply of emergency equipment, training of emergency responders and centralizing
communication between hospitals and emergency responders. Throughout this expansion in medical services,
coordinators must carefully weigh the effects of competition and reimbursement programs in providing quality
services. Finally, in addition to traffic safety, these efforts could be combined with a goal to provide emergency
medical service for a vast array of medical emergencies.
This report summarized emergency medical services in Thailand. EMS is only one component of
transportation infrastructure than can reduce the severity of motor vehicle collisions. Understanding the barriers to a
comprehensive EMS system in Chiang Mai provides insight into the struggles of many developing nations as they
seek to improve transportation safety.
Brown, Geyer, Mitchell, Taghavy, and Ragland 10
ACKNOWLEDGEMENTS
The investigators thank Prawit Wongpeng for field work, Dr. Richard Gosselin for research assistance and Theresa
Gray for help in manuscript preparation. Dr. Somchai Kanchanasut and Dr. Verawat Muttarak provided insights
about Thai Government policies. The principal investigator received financial support from the David Boren
Graduate Research Fellowship Program and the Wellness Educational Fund. Preparation of this report was
supported by the Traffic Safety Center at U. C. Berkeley, whose funding is provided by the California Office of
Traffic Safety through the Business, Transportation, and Housing Agency.
Brown, Geyer, Mitchell, Taghavy, and Ragland 11
REFERENCES
1. Mohan D, Tiwari G. Road safety in less motorized countries- relevance of international vehicle and highway
safety standards. Proceedings of the International Conference on Vehicle Safety 2000. June 7- 9 2000, pg. 155-
165
2. Arreola- Risa C, Mock CN, Lojero- Wheatly L, de la Cruz O, Garcia C, Canavati- Ayub F, Jurkovich GJ. Low-cost
improvements in pre- hospital trauma care in a Latin American city. J Trauma. 2000 Jan; 48( 1): 119- 24.
3. Mock CN, Jurkovich GJ, nii- Amon- Kotei D, Arreola- Risa C, Maier RV. Trauma mortality patterns in three
nations at different economic levels: implications for global trauma system development. J Trauma. 1998
May; 44( 5): 804- 12; discussion 812- 4.
4. Pozner CN, Bayleygne TM, Davis MA, Benin- Goren O, Noble VE, Halpern P. Emergency Medical Services
Capacities in the Developing World: Preliminary Evaluation and Training in Addis Ababa, Ethiopia. Pre-hospital
Emergency Care 2003 7: 392- 396.
5. Public Health Statistics A. D. 1999. Ministry of Public Health, Bangkok, 2001. pg. 71,89,105,126- 133,179- 180.
6. Thailand Health Profile 1997- 98. Chapter Five: Health Service Systems in Thailand. Ministry of Public Health,
Nonthaburi. 1998 URL: http:// eng. moph. go. th/ profile97- 98/ chapter51. htm ( Accessed 3/ 1/ 03)
7. Traffic Safety Facts 2000. U. S. Dept. of Transportation, National Highway Traffic Safety Administration, DOT
HS 809329.
8. World Health Organization South- East Asia Regional Office Disability Injury Prevention and Rehabilitation
Work Plan for 2002- 2003 # ICP DPR 001- II URL: http:// w3. whosea. org/ drd/ mainf. htm. Accessed February
25, 2004
9. McSwain NE, White RD, Paturas JL, Metcalf WR. The Basic EMT: Comprehensive Pre- hospital Patient Care.
Mosby Lifeline, St. Louis, 1996, pg. 43.
10. Bangkok Post: Road Safety. Nov. 9, 2002. URL: bangkokpost. co. th/ bkkpost/ 2002/ nov2002/ bp20021109/ news/
( and) bangkokpost. co. th/ bkkpost/ 1998/ bp98_ sep/ bp19980919/ 190998_ news10. html ( Accessed 3/ 1/ 03)
11. Kanchanasut S, Emergency Medical Services System for Thailand. Linked to Narenthorn Center URL:
http:// www. narenthorn. or. th ( Accessed 3/ 10/ 03)
Brown, Geyer, Mitchell, Taghavy, and Ragland 12
LIST OF TABLES
TABLE 1 Emergency Equipment Questionnaire Conducted with 40 Emergency Rescue Workers in Chiang Mai.
TABLE 2 Survey of 40 Emergency Workers in Chiang Mai.
TABLE 3 Graduating Health Professionals in Thailand.
Brown, Geyer, Mitchell, Taghavy, and Ragland 13
TABLE 1
Emergency Equipment Questionnaire Conducted with 40 Emergency Rescue Workers in Chiang Mai.
Equipment Item
Number and percentage of the
equipment being present in the
vehicle
If present, frequency that the
equipment is actually used
Medical gloves 40 ( 100%) 100%
Leg splint 40 ( 100%) 100%
Compressive dressing 35 ( 87.5%) 100%
Oxygen tank 35 ( 87.5%) 94%
Bag valve mask 33 ( 82.5%) 97%
Spinal board 31 ( 77.5%) 100%
Cervical collar/ immobilizer 31 ( 77.5%) 100%
Sphygmomanometer 30 ( 75%) 70%
Oral airway 26 ( 65%) 96%
Stethoscope 16 ( 40%) 100%
Brown, Geyer, Mitchell, Taghavy, and Ragland 14
TABLE 2
Survey of 40 Emergency Workers in Chiang Mai.
Variable Findings Comments
Site of employment:
Hospital n = 9
Rescue Foundation N = 27
Rescue Club n = 4
Gender Male = 40, Female = 0
Age Mean = 27 Range = 18 - 46
Years of Education Mean = 9.7 Range = 6- 14
Pre- employment training: Range = 3 hours- 2 years
≤ 24 hours N = 25
25 – 80 hours n = 6
81 – 160 hours n = 6
161 – 320 hours n = 1
≥ 320 hours n = 2
Certification for Basic Trauma Life
Support
Yes = 35 ( 88%)
No = 5 ( 12%)
Certification for Emergency Medical
Technician
Yes = 4 ( 10%)
No = 36 ( 90%)
Time employed in emergency rescue:
< 1 year n = 6
1 - 2 years N = 16
≥ 3 years N = 18
Hours worked per week Mean = 76 Range = 60 - 96
Number of workers per rescue unit
( including driver) Mean = 2.6 Range = 2 - 3
Monthly salary ( U. S.$) Mean = $ 84 Range = $ 73 - $ 153
Hourly wage ( U. S.$) Mean = $ 0.28 Range = $ 0.19 - $ 0.81
Self- reported case- load per 12- hour shift Mean = 3.0 Range = 1- 7
Job satisfaction:
Poor n = 0
Fair n = 1
Good n = 19
Excellent n = 20
* All results are self- reported and unverified.
Brown, Geyer, Mitchell, Taghavy, and Ragland 15
TABLE 3
Graduating Health Professionals in Thailand.
Professionals Graduating Health Professionals in Thailand
Physicians 960/ yr ( 1998)
Nurses 3393/ yr ( 1998)
EMT’s 60/ yr ( 2002)
Paramedics none
*( 6) ( 11)