Raman Chawla, Sudeep R. Nayak
The socio-economic & infrastructural growth of India exhibited increased vulnerabilities in terms of road incidences, public health and asymmetric distribution of urban: rural health resources. The emergency medical responsive ability significantly differs in urban and rural set ups. The non-organic evolution of bike ambulances (Type A under AIS -125 Part 1) in naxal affected areas exhibited a major increase in institutional deliveries of new babies, reducing both infant and mother’s mortality rates. DRDO’s Rakshita, a casualty evacuation seat fitted ambulance evolved as a value added response specialized vehicle to save lives in difficult terrain during rescue missions. Despite such success stories, the regulatory framework is yet to evolve to use bike ambulances as a special purpose vehicle for saving life (both in sitting and supine position) as being done with bikes for fire management using AIS-167 standard.
The present review systematically analyzed various requirements and their scientifically evident solutions. It includes revision of definitions of categorization, types, functionalities with their intended outcome and site of usage. The restriction of width up to 1.5 m and aerodynamic designs with its relative impact on manoeuvring in narrow lanes was analyzed. A detailed scientific analysis of Brake Horse Power (BP) and Cubic Capacity (cc) was conducted involving coefficient of air drag, frontal area of ambulance to evaluate speed range limitations with respect to permissible loaded weight. This criterion allows selection of appropriate bike with minimum of 249 cc having higher or equal to 18 BHP to evacuate critical victims in supine position. It is recommended to select a bike with minimum ground clearance of 165 mm for multi-terrain usage ability. The patient’s safety in terms of real time monitoring of vital parameters, telemedicine support capability, GPS linked tracing, sanitization measures to prevent air and surface transmission of pathogens, puncture resistant tyres ensuring no delays in response, wireless and innovative medical devices for saving lives, new life saving solutions for trauma care and contaminated patient management are essential. Standards should include space optimization provisions to accommodate such technologies.
The novel DRDO and other commercial technologies are now available for providing such edge to bike ambulances. It include UltraswachhTM– Vayu Swachh aka Air Sanitization Unit (ASU); Anti-microbial coatings; Tapas Aasan (pressure dispersive sheet); ProtectonTM (multi-use PPE with NFPA 1999: 2018 compliance); Third Eye; Wireless Electro Cardio Gram (ECG) and other devices. An approach is being adopted by Start ups to innovate a composite ecosystem for evolving regulatory compliant development for life saving 2-wheeler based ambulances. These standardized pieces of innovations will not only fulfil domestic requirement(s) while exported to countries of Global South requiring cost-effective high quality ambulances.
India being the fastest growing economy, exhibited 59% increase in length of National Highways, expected to be doubled by 2047. Ironically, the country also loses 18 persons per hour due to road crashes. Further, the South East Asian Region is expected to observe an increase of 11.4% mortality rate due to injuries with 10.4% increased disease burden in India (as per 2016 data). Among major causes of trauma related mortality, 23% are contributed by transportation incidences.
The comprehensive study on emergency and injury care including 100 hospitals from all across India was conducted to analyse gaps & submitted to Niti Aayog in 2021. 91% of these hospitals have in house 148 advance, 97 Basic and 70 transport ambulances (total : 378) in addition to 17,000 ambulances fleet offered by ‘102’ & ‘108’ ambulance network to manage the burden of 1.5 million road traffic related deaths. However, 34% have trained paramedics, 98.5% ambulances are used for transporting dead bodies, only 18% hospitals are equipped with pre-hospital notification care and 3-5% of total beds dedicated to emergency department(s) are flooded with junior doctors rather than specialists. The lack of essential medicines for resuscitation (~restricted to 11%), non-availability of dedicated blood banks, bulk transfusion protocols & delay in emergency care are attributing reasons for high mortality incidences. Only one of the hospitals at Chandigarh has 2 functional bike ambulances which were used for patient transport. The studies recommended increase in emergency beds, optimal use of emergency medical resources inclusive of ambulances with specific focus on training aspects.
Non-organic evolution of Bike Ambulance(s)
The country has visualized a non-organic evolution of bike ambulances restricted to local regions, yet showed impressive social outcome(s). An example of deployment at Maoist-affected Gadchiroli district of Maharashtra under Integrated Tribal Development Project (ITDP) showed increase in institutional deliveries of babies and reduced neonatal or maternal mortality rates among tribal population. Similar efforts by local NGOs, with the support of UNICEF, deployed at Narayanpur district of Chhattisgarh showed nearly 27% of institutional deliveries supported by bike ambulances. ‘108’ ambulance fleet also added a bike ambulance with side carriage to their fleet for evacuation of patients from narrow lanes of remote areas. All these Type ‘A’ ambulances are restricted to transfer patients in supine position. Systematic efforts supported by a regulatory framework with an ecosystem are still lacking with an exception of DRDO’s effort for support of Paramilitary Forces.
‘RAKSHITA’ Bike Ambulance: DRDO’s Rescue System
Rakshita, a chair conformation based bike ambulance, was evolved as a ‘rescue’ vehicle to operate in difficult terrain especially for responders care by INMAS, DRDO.. The patient chair on the rear seat of the bike is directly deployable as well as easily removable as a wheel chair ensuring no delays during response. The system is fitted with multi-channel vital parameter analyzer; sirens, beacons and even driver can visualize these parameters via front LED display. The space management while driving was managed by extended front guards and all electric operational switches within reach of the driver. Herein, drivers act as emergency medical technician, first responder or paramedic. The suitable immobilization systems are designed on chair conformation ensuring safety of patients during transit. DRDO’s ‘Rakshita’ had undergone field trials at difficult terrains of naxal’s affected areas by the Central Reserve Police Force (CRPF) and was undergoing a transition process to add a complete fleet. The only limitation of such types of ambulances is that these are not equipped to evacuate to surgically traumatized victims/ responders (with spinal injuries). Under combat / confrontations/ road traffic injuries, surgical injuries also constitute a significant percentage and cannot be ignored.
An investigatory study was conducted by All India Institute of Medical Sciences (AIIMS), Patna reviewed the concept of bike ambulances and their ground status in India. The group recommended a special guideline manual for the “first responder” bike with all engineering specifications should be developed and standardized for the future benefits. The present investigation is undertaken to review the existing regulatory framework of 2-Wheeled first responder vehicles to evolve guiding principle(s) for engineering for road worthiness, patient safety and other related aspects.
RAKSHITATM– a product of Institute of Nuclear Medicine and Allied Sciences (INMAS), Defence Research & Development Organization (DRDO) for deployment of emergency rescue vehicle
(Presently deployed with Central Reserve Police Force, handed over to CRPF on January 18, 2021).
Investigatory review of AIS -125 (Part 1) and AIS-167 standard as guiding regulatory framework & optimization of requirements for usage of Two-Wheelers as special purpose vehicle i.e. bike ambulance with an ability to manage and transfer patients both in sitting and supine positions i.e. medical & surgically traumatized patients respectively. Best practices evolved in the country or globally that can be useful in integrated models are also reviewed.
llustrative design of evacuation of surgically traumatized patient (with/ without spinal injury) in supine position in side-stretcher mounted bike having ability to load AIS-125 Part 1 compliant stretcher (Left) & fast rescue of medical emergency patient (with no spinal injury) in sitting position on modified wheel chair (from wheel chair complying with AIS-125 part 1) mounted on pillion seat (Right) as systematic evolution of Two-Wheel Ambulance(s)
Existing Regulatory Framework
The existing regulatory framework includes AIS-125 (Part 1) that guides development of ambulances inclusive of type A, B, C and D category in regards to their specialization, advancement & stringent regulatory requirement(s) in addition to their function utility as Basic or Advance Life Support Ambulances (BLS/ ALS) respectively. The scope of functionality as BLS /ALS is also linked to medical equipment(s) provisioned along with trained manpower which was evolved in AIS 125 Part 2.2-Wheeler based first responder ambulances available within country are either Type A for On-Site response but not transferring of patient or otherwise if evacuated only in sitting position restricting its usage for some aspects of preventive health care only. Figure 2 provides an illustration of how existing ambulances with modified pillion seats can be governed by Type A ambulance of AIS-125 Part 1.
A substantial increase in fire fighting vehicles between 2006-2023 with an average of 21,000 units/ month supporting 3926 fire stations was observed across the country. However, managing fire emergencies in narrow access lanes was still a major challenge. In 2020, AIS 167 standard was notified by Government of India standardizing usage of Two-wheeler as Special Purpose Vehicle (SPV) for First Response to Fire emergencies in systematic manner leading to addition of such fleet in fire brigades. The designing and improvisation has been undertaken by youth to re-modify equipment(s) to provide maximum ability to manage fire incidence.
A similar evolution is required as part of evolving 2-Wheelers as ambulances to manage all types of emergencies in terms of stabilizing and evacuation of patients in the earliest possible manner.. Accordingly, Government of India has undertaken this task and presently evolving regulatory standards for the same.
Categorization, Type & Functionality
The regulatory framework defining Type A-D category (basic / advance) with range of equipment(s) & trained manpower treat 4-Wheeler as a base vehicle. The evolution of 2/3- wheeler based ambulances needs to be treated with their utility scores and accordingly categories & functionality should be evolved. In an analysis of existing models of bike ambulances, it could be either ‘chair’ type or ‘side carriage’ type and should be evolved as an ‘ambulance accessory’ definition in scope of newly evolving standards for Two-Wheel ambulance. In terms of functional categorization, ‘chair’ type can be used as (a) first response, feeder; (b) medical emergencies and; (c) fast evacuation from difficult terrains (as being RAKSHITA). On the other hand, ‘stretcher’ type calls for (a) universal response; (b) emergency trauma; (c) preventive health care; (d) resuscitation & urgent evacuation. These categories will evolve a concept of medium life support, if supported by the right choice of medical equipment(s).
Aerodynamics & Manoeuvring
The aerodynamic design is inversely related to coefficient of drag. Another target of Two- Wheeler ambulance is the ability to turn via narrow lanes. Hence, the width is required to be limited and lesser than 4- wheeler counterparts (generally > 80” width) yet minimum enough to accommodate patients in supine position. This is linked to medical grade stretchers foldable and transformable into wheel chairs, in turn, applicable for different types of bike ambulances. Such medical grade stretchers conforming to AIS 125 Part 15 should have a minimum width of 480 mm. The total width needs to accommodate a side carriage able to hold such a stretcher, fitted with a wheel and connected to the bike via connectors. Keeping these variables in consideration, the width should remain within 60” or 1.5 m as being envisaged by the Department of Health, Government of Jharkhand12. However, the maximum limit for 2/3 wheel based vehicles the maximum permissible width is 2.0 m as per existing regulations thus to accommodate creativity of innovators, the same shall be considered in regulatory evolution. This width restriction allows ease of manoeuvring via narrow lanes thus for consideration of the ideal model, 1.5 m shall be taken into consideration in estimation of their speed requirement(s).
Brake Horse Power (BHP) & Cubic Capacity (cc)
Lightweight motorcycles with 50-300 cc (displacement) exhibit an average range of 3-40 Horse Power (HP). The analysis of Indian e-Rikshaws with their loading range (total capacity), maximum permissible speed & peak power revealed that > 10 HP is sufficiently enough to manage 750 Kg at maximum permissible speed of 45 Km/h. The analysis indicated that cc/BHP of motorcycles should support > 10 HP (minimal basis) & accordingly, 149-249 cc bikes were compared. The analysis of 28 commercially available two-wheelers showed 150, 200 & 250 cc bikes corresponds to an average range of 12-14 HP; 18-24 HP and; 16-30 HP respectively (herein 1 BHP = 0.9863HP). It indicated that a minimum 150 cc engine is required fitting all bike ambulances into L2 category vehicles as per existing standards. The next step is to evaluate maximum permissible speed with respect to total expected range of loaded weight. The other two variables include: (a) coefficient of drag and; (b) frontal area of ambulance inclusive of side carriage.
Coefficient of drag ranges from 0.5, 0.9 and 1.0 for low, medium and high air resistance offered by two-wheeler vehicle(s). For removing any impact of aerodynamic designing, 1.0 as higher air resistance is taken for estimation purposes. The average weight of 2-wheelers is nearly 150-200 Kg, if we add weight of one pillion and patient as well as side carriage etc., the total weight range might be taken as 500 Kg (1102.31 lbs); 750 Kg (1653.46 lbs) and; 1000 Kg (2204.62 lbs) as ’03 point weight range’ for estimation purposes. The frontal area is calculated by:
Frontal Area = Width (w) of front of vehicle (inclusive of side carriage)
X Height of length from ground till helmet of driver
The width was restricted to 1.5 m (= 59” or ~ 60” i.e. 5’) as for effective manoeuvring ability as discussed above and keeping overall area lesser than any 4- wheeler being deployed for ambulance purposes at present. Height was considered with a maximum limit of 7’. Hence Maximum Area = 7 X 5 =35 sq ft. The estimation with ‘03 point weight range’ vs speed range of 40-60 Km/ h at frontal area of 35 sq ft and maximum coefficient of drag (~1.0) exhibited range of HP requisite for safe selection of motorcycles for bike ambulances as special purpose vehicles (Table-1).
Table -1 Estimated Horse Power requirement(s) for SPVs$
| Total Weight of SPVs(all inclusive) | Speed Range | ||||
| 40 kmph(24.85 mph) | 45 kmph(27.96 mph) | 50 kmph(31.06 mph) | 55 kmph(34.17 mph) | 60 kmph(37.28) | |
| 500 Kg (1102.31 lbs) | 4.62 | 6.29 | 8.35 | 10.84 | 13.80 |
| 750 Kg(1653.46 lbs) | 5.09 | 6.83 | 8.94 | 11.49 | 14.52 |
| 1000 Kg(2204.62 lbs) | 5.57 | 7.36 | 9.53 | 12.14 | 15.23 |
Constant(s) used for calculation of HP: Maximum Frontal Area of Special Purpose Vehicle: 35 sqft; Maximum coefficient of drag: 1.00
The analysis revealed that 2-wheelers with minimum of 249 cc with higher or equal to 18 BHP will provide significant boost and ability to provide necessary support to stabilize and evacuate a single patient in supine position. The same can be realized for electric power to accommodate electric bikes in future too. It is important to evolve electric bikes with significant power, faster charging ability and silent mode of operations to make it even effective for usage in combat zones too.
Ground Clearance
Another aspect of design is ground clearance that if higher it makes a comfortable on bumpy or steep terrain roads while if lower improves handling and stability on the highways as well as steering more responsive to the reflexes of the driver. The optimization is linked to the number of persons loaded and in case of bike ambulance(s), the side carriage needs to match it with the primary base vehicle. For effective movement from gravel, mud and sand tracks, it requires a minimum of 6.6 inches (~ 167 mm). In the analysis of 28 commercially available Indian Motorcycles with effective cc/BHP requirement, it is ideal to select a bike with minimum ground clearance of 165 mm, optimizing all variables together.
Patient’s Safety & Safe Evacuation
The patient’s safety is linked to breathing air/ oxygen, least time to evacuate, immobilization to prevent secondary injuries, spinal alignment, and stabilization and live monitoring of vital parameters during transit, resuscitation ability if required, on-site airway, breathing & circulation management using regulatory approved medical devices. Sanitization measures for preventing air & surface transmission of pathogens is an essential requisite based on lessons learnt during recent pandemics. Safe evacuation is linked to a comfortable and safest ride (puncture resistant) in minimum possible time. The contrasting factor is time delay with respect to restrictive speed limits for road safety against secondary disasters. The latter supported by GPS mapping and navigation adds value to ambulances. The bike ambulance shall accommodate maximum permissible resources to be evolved as a special purpose vehicle that can save lives. Some of the new devices/ technologies that are now available for integration into such vehicles & their impact are summarized in Table-2. Standard should evolve to provide space for accommodation of the same, wherever applicable as recommended earlier. The next generation model of DRDO’s combat ambulance shall accommodate such characteristics with respect to combat requirements of Defence Forces with dual usage in the civilian sector too.
Table 2: Novel Technologies/ Devices available for integration into Ambulances (realized as next generation model in Figure 3).
| Name of Device | Function & Impact | Source(s) |
| Vayu Swachh aka Air Sanitization Unit | Mutli-layered air sanitization inclusive of purification, microbial neutralization to provide medical grade air. It will provide a safe environment for evacuees while transit from contaminated, infected or polluted environments. Similar technology is being used by the US Air Force with ozone free bi-polar ionization supported by HEPA filters at their installations. An advanced unit with HEPA equivalent nano-filtration (reusable) is available as part of UltraswachhTM initiative. | DRDO’s Ultraswachh Technology |
| Covid Coat+ aka Anti-microbial coating | Sustainable anti-microbial coating tested against prevalent hospital pathogens prevents microbial build up for nearly 03 months. Alshebi and coworkers (2023) reviewed the need for infection control in ambulances by using appropriate interventions against contact precautions. This technology will aid surface protection against transfer of infection between subsequent evacuees or to paramedics. | DRDO’s Ultraswachh Technology or commercial counterparts like Hydra guard Plus;Germ shield pro etc. |
| Tapas Aasan (Pressure Dispersion Device) | Pressure dispersive gel sheets that distribute pressure exerted from ground to the patient’s body into all directions significantly reducing its impact, even used for Operation Theatre Positioning Devices. Safe transfer of patients from difficult terrains with multiple obstacles. | DRDO’s Ultraswachh Technology or commercial counterparts |
| Multi-use Protective Clothing (NFPA 1999: 2018 compliant) | Protective clothing for driver and pillion (aka paramedic) to protect them against cross infection/ contamination while dealing with patients in terms of stabilization / resuscitation protocol. Advance and cost-effective options as can be used multiple times being washable & prevent bio-penetration of pathogens. | DRDO’s Protection Technology or imported counterparts |
| Medical Grade Foldable Stretcher (AIS 125 Part 1 compliant) | AIS 125 Part 1 compliant medical grade stretcher with minimum dimensions of LXBXH in mm (1800 X 480 X 380 from loading holding assembly to unladed lying part) and transformable into chair. Robust, regulatory compliant and useful for both designs of bike ambulances provide quality control for bike ambulances on similar lines to 4- wheeler ambulances. It is illustrated in Figure 2. | Available commercially by multiple manufacturers. |
| Geo-location & Navigation Support Device | Devices that provide both GPS location and back end supported by a team that is monitoring movement, stationary time, parking time, inventory of devices, maintenance systems/ alerts, time of loading/ unloading of patients to decipher performance and ensured safety enroute. Such systems ensure safe deployment and usage of bike ambulances in remote regions to mitigate impact of secondary disasters. NavIC is an emerging indigenous technology to enable accuracy to 3 meters within the Indian sub-continent. | Global Positioning System (GPS) enabled devices with on line support or Navigation with Indian Constellations (NavIC) enabled devices by ISRO technology |
| Integrated Live Monitoring / Telemedicine & Pre-hospital notification system | 5/6- channel vital parameters monitor keeping vigil on the health of patients and relaying live information to hospitals to whom being evacuated fitted with a pre-hospital notification system. Aid in emergency resuscitation during transit by experts. Telemedicine support is a growing essential for all emergency health care systems with systematic convergence of information technology and medical service. Such a facility is being maintained by AIIMS, Delhi linked with 54 centres. | Shall be worked out from the site of deployment & impact radius. |
| Blue Tooth enabled Monitoring Device for Safe Transit | Bluetooth enabled feed of vital parameters of patients by 5/6-channel parameters being displayed continuously to driver/ pillion (aka paramedics) to assess the situation and if required, can stop vehicles to provide support to patients. It ensures early warning for paramedics to manage patients effectively ensuring safe evacuation. | Customizable by manufacturer or retrofitter to match requirements |
| Wireless ECG & other vital parameters monitoring systems | Wireless Electro Cardio Gram (ECG) with manifold applications is available for integration in advanced bike ambulances and similarly explores wireless options for other devices ensuring ease of installation and usage. All these devices lead to added safety for the patient per se. | Commercially available technology that can easily be integrated into the Ambulance system. |
| Puncture Resistant Tyres | Emerging technology with pressure resistant polymeric material inside tyres resistant escape of air when sharp/ pointed material is removed from tyre, able to cause puncturing of tyre. It will provide value added protection against delay of bike ambulances in case of puncturing of tyres. | Rhinoplex Gel (USA); CEAT Zoom RadX 1 tyres & Viscoelastic Gel (India) |
Futuristic Hybrid Bike Ambulance: Evolution Strategy (i) to (iv): (i) Transformation of Pillion Seat such that modified wheel chair model is able to accommodate medical victim with telemedicine compatibility; (ii) Transformation to wheel chair (AIS-125 part 1 compliant) transformable into stretcher with (iii) Taaran (Safe Passage) Patient Transfer system capability; (iv) Wheel Chair-cum-Stretcher with Taaran & Telemedicine capacities equipped for Bike with advance features: (a) Next generation (able to sanitize exhaled air of patient fits as pillion seat or (b) transformable open stretcher directly fits as side attachment with mini Vayuswachh+ capability; (c) Paramedic using multi-use Protecton (NFPA 1999:2018 compliant); (d) e bike L2 vehicle or (e) fuel bike L2 vehicle; (f) silencing assembly to silent mode operations (g) complete immobilization and pressure dispersion Tapas Aasan assembly; (h) NAVIC equipped system for continuous monitoring; (i) Siren/ PA system with infra-red light and; (j) Puncture Resistant Tyre technology. Design developed for bike with mountain terrain accessibility requisite for combat scenarios.
India’s economy is booming though its health care structure is yet to be evolved. The evacuation vehicles (aka ambulances) are an important component of such a structure. The time has come to systematically evolve standards for bike ambulances followed by its implementation to save lives. These standardized pieces of innovations will not only fulfil domestic requirement(s) while exported to countries of Global South requiring cost-effective high quality ambulances.
Acknowledgement: Author(s) are grateful to Director, INMAS for facilitation and support given to R&D work of “RAKSHITA”- specialized rescue vehicle & policy research to evolve regulatory framework for 2-Wheeler special purpose vehicle(s) in the country. Author(s) also acknowledge(s) significant contribution of Dr. Prem Chand Gupta, Ex-Scientist, INMAS, DRDO & his team who has developed ‘RAKSHITA’ that is being used by CRPF, at present.
Authors Biography
Dr. Raman Chawla , Scientist F & Dr. Sudeep Ranjan Nayak, Scientist E of Institute of Nuclear Medicine & Allied Sciences (INMAS) DRDO.
