“Medical car on scene”: first medical contact (2)

Before we consider the approach to the driver still in his (or her – my use of the masculine pronoun is purely for simplicity!) car, I wanted to briefly consider what we do when the driver is out of the car on arrival on-scene.

First, the relatively rare situation of a driver out of his car, but not feeling well. The best and most interesting example of our approach in this case would be Fernando Alonso’s accident in Brazil in 2003:

When we arrived on-scene, Fernando was half sitting, leaning back against the base of the grandstand wall. He was pale, sweaty, and clearly not in top form. I’d seen the accident on the screens in the Medical Car, and knew it had been huge. I told Fernando that we were going to place him on a gurney, load him onto the ambulance that had already arrived on-scene.

“I’m not going on a stretcher, I’m going to stand up” he said stubbornly. I was annoyed, but not surprised. This is how these guys are. I thought about it for a moment.

Happily, Dino, the Chief Medical Officer in Brazil has teamed us with Dr. Fernando Novo for years. Fernando is one of the pillars of the PHTLS (Prehospital Trauma Life Support) course in Brazil, and this brilliant skill set, as you’ll see in a moment, came in incredibly handy here. I told Dr. Fernando that we were going to do a “two man takedown”.

I told Fernando (the F1 version), still sitting against the wall, what was going to happen. I said we’d let him stand up and wave to the crowd. I insisted that if he felt unwell standing, he was to just whisper that to me, and we’d get him lying down pronto. I told him that before we let him stand up, we were going to place a rigid cervical collar before he stood up. And that as soon as he’d waved to the crowd and acknowledged their applause, he was to remain quite still as we prepared him to be put on the gurney and loaded onto the ambulance. I told him this was non-negociable.

Fernando (Novo, my colleague) stood on Fernando (Alonso)’s right, and I at his left. Standing up was uneventful. Good. Step one successful. Now picture this: Fernando Novo and I apply a long spine board (held vertically of course) to Alonso’s back (while he’s standing), holding it there with my right, and Fernando Novo’s left hands, placed under Alonso’s armpits on each side and grabbing the handles on each side of the board. We each place our free hands (my left hand and Dr. Fernando’s right) on either side of Alonso’s head, to provide additional stabilisation beyond that of the collar. My left (and Novo’s right) feet are blocking the bottom of the board. Ready? On the count of three, we tip Fernando back, the ambulance crew grab the bottom of the board, and waving to the crowd, Alonso is placed on a gurney and loaded onto an ambulance while the crowd cheers.

This is an excellent example of the complementarity between the local team (here represented by Fernando Novo in the medical car) and the FIA. It also eloquently speaks to how important it is to have everyone reading from the same page in terms of medical knowledge and technique. Here, Fernando Novo and I shared knowledge of the PHTLS course, with obviously highly satisfactory results. Now we need to hope the FIA actually does move ahead with worldwide implementation of a motorsport medicine course. Yeah, the one they’ve been talking about for ten years now.

When the driver is out of the car and not complaining, we’ll almost always take him in the medical car. I would use this time to check for any subtle complaints that only start to appear when the adrenaline of the accident starts to fade away. It’s also a great opportunity to look for subtle symptoms of concussion. So I’ll ask about who he was following when the accident happened, and other questions looking for anything . . . not right. If there are symptoms, complaints, or if the medical warning light of the car was triggered, we drop the driver off at the medical centre.

Some important science on disorders of consciousness – part 2

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An MRI scanner

Imagine this: You’ve volunteered for a brain imaging experiment to help study consciousness. You come to the MRI suite, and lie down. The researchers put an IV drip in place, and then infuse a form of glucose that “lights up” the brain areas that are activated at any given moment. So far so good.

You’re told to close your eyes and imagine hitting a tennis ball back and forth with a partner. Sure enough, this consistently activates an area related to preparing the brain for motor activity (called the Supplementary Motor Area, SMA, in yellow below). Then you’re asked to imagine walking around your house, and to visualise all the things you’d see as you navigated like this. And once again, the corresponding area, called the Parahippocampal Gyrus, (PG, in green below) lights up. Here’s roughly what the images look like:

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Nothing unusual or unexpected here. But now let’s go a bit further with the technique.

Let’s now take a series of patients (54 to be exact) who have been diagnosed with either vegetative state (remember – that’s eye opening without any signs of conscious interaction with the environment) or a minimally conscious state (awake, but with fluctuating but consistent signs of consciousness), and let’s try the same experiment.

Incredibly, FIVE of these patients  (10%!) could manipulate brain activity in response to the researchers’ requests. These people were, in fact, obeying commands (“think about tennis”, “think about navigating”), but their response wasn’t behavioural, it was . . . metabolic; what’s crucial is that they clearly showed signs of consciousness.

This was an amazing finding, but the investigators took the work further still, and, using a very ingenious trick, what they revealed shocked the world of medicine.

Let’s quickly put you back into the fMRI machine. This time, here’s what I’m going to do. I’m going to ask you a simple, unambiguous question (like, do you have a brother?). I’m going to tell you to think “tennis” for YES, think “navigation” for NO. (Rather like using fMRI activation as a “blink once for yes, twice for no” kind of communication tool.) Turns out this works fine, with 100% accuracy with normal subjects.

I guess you see where I’m going with this. Let’s take one of the patients diagnosed as vegetative but who has shown the ability to “light up” his or her supplemental motor area or parahippocampal gyrus on demand. Let’s do the same thing with him. Let’s ask him or her questions – tennis if yes, navigation if no. What happens? Let me quote the researchers: “. . . for those five questions, the pattern (of activation) produced ALWAYS matched the factually correct answer.” 

I’ll let that soak in for a moment.

These scientists just took a patient who’d been diagnosed as vegetative (and again, I’ll insist that this means NO CONSCIOUSNESS) and not only TALKED TO HIM, but actually got answers!

What are the implications? First of all, this study shows how hard it actually is to make a proper diagnosis of the vegetative state. Until now, this diagnosis relied on confidently stating that there is evidence of absence of consciousness, based on detailed and lengthy observation of the patient’s behavioural responses. But remember, these patients have severely damaged brains; the behavioural repertory of responses that they can show may often be so limited that none will be found. But this study emphasises that absence of (behavioural) evidence is NOT necessarily evidence of absence (of consciousness). The infinitely more sensitive “behavioural” response of metabolic brain activation could allow, in the future, clinicians to make this diagnosis with much more confidence. This obviously has enormous implications in terms of medical and ethical decision-making as concerns any given patient.

More importantly for us, this tool would appear to open up the possibility of actually communicating with some of these patients (a small minority at best, but still . . .). The current procedure is much too cumbersome, difficult, and expensive to use routinely, but it’s not too much of a stretch to imagine a future where helmet-sized mini-MRI machines are placed on the heads of patients with prolonged disorders of consciousness to allow their care team and loved ones to communicate with them.

There is a huge amount of fascinating and useful research being done on consciousness – both normal and disordered. Functional imaging is one of the most powerful tools in this quest for knowledge. As they say, watch this space.

Here’s a link to the original NY Times article about this research. The second contains a video by Liege’s own Steve Laureys (the lead researcher), explaining the technique. And the third is to a pdf of the original article, published in the New England Journal of Medicine.

http://www.nytimes.com/2010/02/04/health/04brain.html

http://thelede.blogs.nytimes.com/2010/02/04/doctor-demonstrates-method-of-speaking-with-vegetative-patients/?_php=true&_type=blogs&action=click&module=Search&region=searchResults&mabReward=csesort%3As&url=http%3A%2F%2Fquery.nytimes.com%2Fsearch%2Fsitesearch%2F%3Faction%3Dclick%26region%3DMasthead%26pgtype%3DHomepage%26module%3DSearchSubmit%26contentCollection%3DHomepage%26t%3Dqry575%23%2Flaureys&_r=0

http://www.nejm.org/doi/pdf/10.1056/NEJMoa0905370

Sid, my friend, 20 years after Imola

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Nürburgring, watching tennis before a session

It’s 1992. Summer, but it’s cool enough in the Ardennes morning to be happy to put on the long underwear and overalls. Now we’re sitting over that first, anticipation-laced coffee:

“Professor?”

“Yes old boy?”

“Do you think it’d be ok if I called you Sid?”

A big grin. “You know, the tramps sleeping under the stairs of my hospital call me Sid. Don’t see why you couldn’t.”

There. That was easy. Only took two years.

Although I was a lifelong fan of Formula 1, I’d never heard of Sid Watkins when the Chief Medical Officer at Spa-Francorchamps decided to make me the “local guy”, riding in the back of Sid’s FIA Medical Car in 1990. I was a 35 year-old anaesthetist, and had been told, by everyone involved, how important, imposing, and difficult the English gent was.

We found some common ground. Not difficult, you’d say, what with motor racing, medicine and cigars as shared starting points. Worked out fine. At least one big accident each weekend too, so we actually WORKED together.

This is the start of my third Grand Prix weekend. As usual, we’ve met at the medical centre, and hitched a ride to the paddock. I’ve screwed up the courage to ask. Cool. From now on it’s “Sid”.

1994. Two years later, twenty years ago, and I’m seeing Sid for the first time since Imola. Don’t know what to say. I know he loved Ayrton. He seems fine. Say nothing? We’d gotten to the medical car a few moments early, and were standing inside “la triangle” of La Source hairpin, which was (and is) our standby position.

“You ok?”

He leans against the door of the car and says, “We ran some fluid in, and got a pulse. Then the clouds moved a bit, and his face was in the sun. That’s when I knew . . .”

And that was it. We didn’t need to talk about medical care, about ambulances and extrications. This brilliant professor, this locomotive of a man, had lost a great friend.

It was remarkable to see, in the coming months and years, how Sid steered the steady, relentless progress of this “second revolution” in safety (the first, I’d say, was from when Sid came on board as FOCA surgeon in 1978 until the mid 80s). And how brilliantly it was all set up.

That’s what Sid was like – extraordinarily multifaceted. Nothing was done half way. Personality? The most charismatic person I’ve ever seen. Sid drew you in and held you there with his stories, his intelligence, and his heart. Intelligence? Just look where he brought our sport! But he also read voraciously – historical biographies were a particular favourite. And of course, a sense of humour that just didn’t stop.

Jerez 1997. In the hotel lobby with a several of Sid’s “kids”, waiting for him so we can leave for dinner. He’s a bit late. That’s unusual. The inevitable round of “You go get him”. “No, YOU go get him.” “Sorry, not gonna happen, YOU go get him.”

I’m the new guy on the block, so I’m elected. I know after this first season with Sid that if he’s been napping he’s likely to be a bit . . . curt. Oh well, here goes. KNOCK KNOCK KNOCK. Gulp.

The door flies open. And there he is, huge grin on his face . . . and nothing else on . . . anywhere.

Gulp.

“Hello old boy! Come right in!!! I’ll be ready in a moment.”

I love you Sid, but I think I’ll wait in the lobby, thanks.

“Medical car rolling”: en route and approach to the accident

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So there’s been an incident, and race control has red flagged the session (or activated the Safety Car, if this is a race), and asked us to deploy. We’ve instantly switched from being the spectators with the coolest seats around to being the people to whom everyone turns when the bad stuff happens. How exactly do we roll up our sleeves and get to work?

We usually, but not always, have a good idea of where the incident has occurred. This is either from having seen the accident and understood where it is on the screens in the car, or because we’ve been told by race control. In any event, the tower quickly lets us know where we need to go – and when it’s important, where the car has come to rest, whether at the entrance to, mid corner of, or at the exit of a corner, left side or right side of the circuit, etc.

A parenthetic anecdote to lighten the atmosphere

(When Olivier Panis had his accident in Montreal, race control cleared us to deploy. Sid and I had gloves on and were ready to go when we realised the car hadn’t budged. Sid assumed there was a linguistic problem with our French-speaking driver. He told the driver, in an appropriately assertive way “We need to go!”. A quizzical look came over the driver’s face. “Now?”, he asked, “in the middle of the race?” Sid hid his frustration well. “Yes old boy, there’s been an accident we need to attend.” Our driver, a lovely fellow named Pierre, stated the obvious – “But we don’t know where the accident is!” At this point I heard the reassuring tones of Sid’s angry voice “LET’S JUST DRIVE AROUND THE FUCKING CIRCUIT AND WE’LL PROBABLY FIND IT SOMEWHERE!”)

Back to the serious stuff

The second we see an incident that might require a response, Alan puts the car in gear (the motor is running through all sessions), and we start putting on our medical gloves. Alan has already verified that we can exit our standby position safely, and this verification is repeated until we get clearance to roll.

As you can imagine, this is a fairly active moment for us all. Our first order of business is to get to the accident scene safely. That’s a tall order. There will almost always be racing cars on the circuit and even when they’ve slowed dramatically for a red flag (and are therefore heading back to the pit lane) or safety car, they’re still going VERY VERY fast.

To the extent possible ALL of us (meaning Alan, myself, and the doc-in-back) have our eyes on the circuit. Ideally Alan is freed up to drive, but obviously he’s also in the mirrors. When a race car approaches us (I wish you could appreciate the closure rates; we’ve usually got some speed going, but the racing cars make us look, and feel, like we’re standing still), Alan will tell me when to activate our green light. This is the same as on the light bar of the Safety Car, and signals to the oncoming racing car that we’ve seen him, and that it’s ok to pass us.

The racing cars pose some hazard to us; much more dangerous still are the local medical intervention cars, ambulances, and extrication units. These can be expected to join the circuit from their respective standby positions without looking, to immediately take to the racing line, and also to drive two or three abreast. Often no attention is paid by our colleagues to those low, loud and fast cars covered with advertising stickers and big rear wings. The ones driven by helmeted people. You only need search for YouTube videos of Safety- and Medical Car accidents to see the kind of stuff that we just CANNOT let happen. Coordination of this deployment is one of the important reasons behind my insistence in the first post of this series that the FIA team and the local resources be in real communication with each other.

As we head to the accident, Alan is pushing quite hard. I’d say (my impression) that he’s somewhere around 80 -85% of the car’s possibilites. This depends on a lot of things, among which are the situation and how “chaotic” things seem (higher chances of a marshal randomly losing focus and stepping in front of us), the weather, etc. Race control will be giving us information (status at the site, info relayed from the marshals, etc). 

This is also the time for a final quick review of the sequence of our intervention with my colleague in back. Scene survey, driver survey, determine the extrication strategy and need for care on-site. Who will do what. I always insist, en routethat my colleague will manage the scene and I’ll assist as necessary . . . if he or she is comfortable with that. If not, I have no problem assuming that role. There can’t be ambiguity about any of that once we start working.

On approaching the scene, we are thinking about three things: vehicle placement, scene safety, and indicators of mechanisms and severity of injury.

Vehicle placement

When arriving at the scene of an accident, it’s important to think about where each vehicle should be stopped. The accident scene, although covered by flag marshals, can be more clearly delineated using the intervention vehicles, especially as they are almost always equipped with flashers. The scene also needs to be protected from any oncoming traffic. Finally, vehicle placement should facilitate, rather than hamper, the functioning of the intervention.

Of course, every accident is different, and for most situations there’s no one right way to do this. The point is to take into consideration the following factors:

  • has the race been stopped, and if so is the circuit already clear, or are we under yellows and the Safety Car?
  • how far off or on the circuit is the accident?
  • visibility on approach
  • relation of the accident scene to the racing line
  • the width of the track

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In general, the first intervention car on site (MIC in the diagram) should park upstream of the accident, off the racing line, and in a “fend-off” position. This means the car is slightly angled away from the circuit with the wheels also turned towards the edge of the track. This way, if the car is struck, it will move further from the circuit. This will often, but not always, be the FIA Medical Car.

Next to arrive will be the extraction team (EXT) (when requested) and/or the local MIC. This vehicle covers the rear of the scene, Fire teams stop ahead of the intervention cars, abeam of the accident, and the ambulance in front of the scene. Remember, the ambulance is rear-loading, so this position facilitates expeditious access to the cabin.

Scene safety

This step is usually not apparent when viewed from the outside. On arrival at an accident scene, all our instincts are screaming “GET OUT OF THE CAR AND GO HELP THIS GUY!!!”. This is the wrong thing to do. All medical rescue personnel need to always have in mind how dangerous a circuit is, and that their overriding priority is actually TO AVOID SECONDARY ACCIDENTS. This means verifying implicitly (most incidents), or explicitly (special situations) with the chief incident marshal at an accident scene that it’s safe to approach. Our reflex to help must never trump the order of safety priorities: first protect one’s team, then scene personnel, and only then the victim.

Scene analysis

I don’t think most people realise how important anticipation is when taking care of trauma victims. Trauma is caused by the application of FORCE to the body. So as we approach the patient, and in fact all through that initial management phase, we’re constantly asking ourselves -  what was the DIRECTION of the forces involved, and what was their MAGNITUDE. We’ll talk more about this next time, but for now one of the key things we’ll be doing as we get close to the accident scene is closely looking at signs of exactly what happened. 

Early clues to it being big are things like a long debris trail, the stress audible in radio communications, the vigour and intensity of flag waving on approach, and crowd movement towards the scene.

If we’ve not seen the accident on our in-car screens, as we get to work I try to find out from the incident marshals exactly what they saw.

Well we’re out of the car, heading to the accident itself. Time to take a breather.

Next time: initial assessment and management

 

“Deploy Medical Car”: decision-making and roll-out

We all know that sinking feeling we get when the cameras covering practice, qualifying, or the race cut to an accident. The marshals scramble to the scene, the commentators comment, and everyone waits to see how the driver is. Sometimes, within moments, the television shows us the Medical Car heading to the accident. Let’s look at what happens from the moment of the accident until the medical and rescue system is activated.

First, a word about the FIA Medical Car. 

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I’m pretty sure that as far as race fans go, there aren’t many cars in the world as well known as the AMG C63 wagon in service as the Medical Car. It’s loud, powerful, superbly capable, and very fast. It’s not an easy car to drive, in an environment for which it was not made, but Alan van der Merwe makes it look easy. The car “belongs” to Allsport Management, the outfit that centralises much of F1 logistics, and also owns and operates the Paddock Club; AMG has two full-time technicians who travel to each race with the necessary kit (pic below). There are two MC’s (and two Safety Cars) at every race. And no, I don’t know what AMG does with them when they’re retired. The medical car has served since 2008 (if I’m not mistaken), with impressive reliability given how high a percentage of its mileage is flat out. Fuel economy? I remember once calculating it and came to something like 40-50 l/100 km, or 4.7-6 mpg.

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In terms of medical equipment, the MC is stocked with basically the same stuff as the other MICs around the circuit. This consists of the material we need to make sure that an accident victim’s airway is open and secure, that breathing is effective (either by the patient or by us!), and to access, and if necessary treat, the circulatory system. In fact, we’ve usually got two full sets of equipment on board – my kit as well as that of the local doctor assigned to ride in the FIA car. We do that for a few reasons. First of all, during the stress of an intervention, it’s better that the local doctor have his own kit, knows what’s where, etc. Secondly, since we have two doctors, we may as well be able to manage two victims, should we be be first on scene! 

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The car has four Recaro race seats and full harnesses front and back. Interestingly, we have 5-point harnesses in front, and 4-points in back. It was always reassuring to see what good care AMG took of . . . um  . . . well you get the idea. Alan and I are plugged into the car’s intercom/radio base station, so we speak to each other through our helmet boom mics and hear each other through our moulded earpieces (these double as noise attenuators when on scene). We each have a push-to-talk button for the main (digital) radio, and another for the backup (analog) set. Once we get out of the car, we need to unplug our earpiece/mic cable from the car and plug into our handsets. (I hear the ever so slight murmur – “he’s speaking in the present tense…”. He is. Indulge me. It just sounds weird and heavy using the correct tense).

The car also has three screens – two up front and one on the back of the central console. The rear screen is for our local colleague, whose weekend can be a bit lonely if language is a problem (especially with the front seat guys speaking in mere whispers over the intercom). The rear screen is “slaved” to the upper front; they can all receive the international TV feed (no sound, and usually on the top screen), the first timing screen (sectors and gaps, usually on the lower screen), the third timing screen (messages to teams), and the real-time gps locations of the cars around the circuit. This is obviously useful en route to an incident. At least in theory, because as you’ll see next time, we’re pretty busy when that happens, and switching screens is not the first priority.

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(By the way, this is us following Bernd in the Safety Car exiting Suzuka’s Spoon Corner, one of the most thrilling moments one can have in a car, as quite significant velocity is involved. In fact, my laps around Suzuka with Alan are certainly my favourite car moments ever.)

The Medical Car is on standby for all F1, GP2 and GP3 sessions and races. The standby position varies from circuit to circuit, but is usually at the pit exit. We’ll always have scouted out any shortcuts through the circuit using secured inner roads (not all circuits have them). These can allow us to cut off up to half the length of some circuits, with a huge time gain.

There’s been an accident

When something happens on the circuit, we usually see it at the same time you folks do. Not surprising, given that we get the same TV feed you do. Obviously, race control has seen things in rather more detail, because of the coverage of the circuit by CCTV. 

If we look at how the actual decision to deploy medical resources is made, it really occurs in one of three ways. (Remember, I grew up in a medical car, not in race control!) The first would be “by sight”. It’s a big accident, there are bits everywhere, gut feeling: fair likelihood of needing some sort of medical presence. I’d include in this category a good number of the bigger incidents we see, fully aware that most of the time there are no injuries. Obviously if the driver is immediately on the radio (and they usually are) speaking appropriately about, well, just about anything, this is good evidence for the absence of significant injury, at that moment anyway. I feel pretty strongly that if it looks big, secure the circuit and deploy. Sure, the MC would be deployed a bit more often, but these types of incident are relatively rare. A practice session or qualifying  can be restarted after a red flag; admittedly a higher threshold needs to be used for the race. On the other hand, if there are time-critical injuries, if a “by sight” deployment isn’t used, then race control will have to rely on the report of marshals. Now I’m never been convinced that this kind of non-medical evaluation of the victim is any more valid than that of a first, visual, impression from the cameras by an experienced crew in race control. If the driver gets out of the car, has no complaints, walks and talks, then the medical car, deployed “by sight”, can be told that fact, and would either continue back to its standby position, or, more likely, pick up the driver. This would allow the medical team in the car to evaluate the victim for concussive symptoms and decide on the appropriate followup. Again, this should not be a common occurrence, but the 15-20 seconds saved by NOT waiting for word from the marshals WILL come in very handy some day.

As I just said, a request by marshals for medical assistance, or a report of driver complaints (other than about his colleagues) while he or she is still in the car, will elicit a medical response.

Lastly, race control can decide to send us out based on triggering of the medical warning light.

This light equips every F1 car. It’s located on the top surface of the car, just in front of the “windscreen”. Wired to the car’s data logger, it is always on, with a slowly oscillating bright-dark cycle, to show it’s operational. But when it is triggered by a force of > 15 g (front to back, side to side), or > 20 g vertical (to take into account running over curbs) for over 5 msec, it shines VERY bright blue. It’s a reliable indicator of high energy transfer, and it also activates a warning lamp in race control. Activation of the MWL will often lead to race control ordering a response.

Once the decision is made to activate the medical service, the circuit is secured. For practices and qualifying this is by a red flag. The Medical car is informed by the FIA that the red flag is coming out, and we’re either then deployed immediately or put on a brief standby. During the race, we’re put on standby with the safety car. When we’re given the “GO”, we follow Bernd out; Bernd will show us his green light and move over usually within a corner or two of deployment. In any event, when we need to go, we always know there are likely to be race cars on the circuit at least for some of the time we’re out there. More on this next in the next post.

Remember that last time we spoke about the distribution of medical cars and extrication teams around the circuit. And we talked about the CCTV screens in race control. In order to reduce response times to a maximum, race control has a chart like this for each circuit (this example is from Malaysia, 2005):

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Each cell in the table corresponds to a screen in race control. An incident on any screen, referred back to this chart, immediately indicates the local units to deploy. Because traffic NEVER goes the wrong way ’round a circuit, each car and each extrication unit, covers a sector from their respective position to that of the next downstream unit.

When we get told to go, everybody on board the Medical Car needs to be ready for just about anything. In the next post, we’ll look at what happens en route to the incident, and what happens on arrival.

 

 

“Standby Medical Car”: the system

Another season is underway, and watching Pastor scooping up and flipping Esteban Guttierez over in Bahrain, I thought it might be interesting to go over the steps involved in the response to an accident at a race. I did this when I first started using Twitter, but we’ll go over the concepts a bit more in detail. This way, you’ll have a pretty good idea of what’s going on if there’s a rescue response to an incident on the circuit. I’ll do this in a series of posts, and we’ll culminate with the race weekend in Shanghai next week.

As a travel companion through these posts, those interested could pick op a free pdf copy of the Medicine in Motorsport manual:

http://medicineinmotersport.fiainstitute.com

First, let’s understand how things are set up from a medical/rescue standpoint.

COMMAND, CONTROL, COMMUNICATIONS

The eyes, ears and brain of the operation are, of course, located in race control.

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For Formula 1 events, the FIA Race Director, his Deputy, and the ops coordinator are up here, along with the Medical Delegate. The local circuit command is also here – the Clerk of the Course (CoC, the guy who is usually the Race director when we’re not in town), Chief Marshal, Chief Medical Officer, etc. Every inch of the circuit is covered by cameras that can pan, tilt and zoom. The locals, at least at the more “mature” circuits, know which cameras cover the usual problem areas, and have them pre-set to cover precisely those zones. Remember that depending on the circuit, these local race control guys might be doing this every two weeks for years now (Spa, Silverstone, Hockenheim, etc). Also remember that each camera is connected to a DVR, so every second of every camera gets recorded . . . just in case.

Nothing, but nothing happens on track without it being decided, approved, and ordered by race control. From the moment the circuit is made active (usually by a red flag being displayed on a course car driven around the circuit) until circuit discipline is “relaxed” (yep, by a green flag “opening” the circuit), trackside personnel are behind the rail, vehicles are in standby position, engines running, and no one moves unless race control says so. The only exception is the flag marshal, signalling events in his or her sector – but even these events are immediately reported to race control. Here’s what happens when that rule isn’t obeyed:

The FIA team is in radio contact with the Medical Car and the Safety Car (which is not used during practices and qualifying, of course). They also have private comms to each team’s pitwall, and listen to all driver comms during a session. The local circuit team is in radio contact with all local resources through their own dedicated radios.

As you can see, from a systems standpoint, one of the potential barriers to seamless function in race control lies in the parallel nature of the FIA and local systems. There just aren’t a lot of built-in connection points between Charlie/Herbie (FIA) and the Clerk of the Course (local). Failure of timely and high quality crossovers between the systems can lead to deployment of local resources before the circuit is properly secured on the one hand, or a delay in the arrival of necessary reinforcements if the FIA “network” is activated without this happening with local resources.

In terms of this “connection node” between the FIA and the local team, Charlie, Herbie and the CoC are usually sitting in very close proximity, each with big headphones on (very isolating in terms of real conversations). The most important interface obviously depends very strongly on Charlie and Herbie’s rapport, confidence and ease of interaction with the CoC.

Note to self: this node needs to be STRUCTURAL and as independent as possible of human foibles. Like the structures that govern relations between aircrew members – predefined, unambiguous, etc.

Another note to self: since each CCTV screen in race control has its own DVR, these could be used to PLAY recordings of accidents back onto the screens. Race control could be used as a giant simulator. This could even be integrated with the medical/rescue simulation we do every Thursday afternoon of every Grand Prix weekend.

THE RESPONDERS

Because of the international nature of Formula 1, the response to an incident at a Grand Prix has, since being organised by “the Prof”, Sid Watkins, is based on a fully manned, equipped and competent local medical team. Let’s take a bit of time to look at the elements of this local team, and to introduce the FIA Medical Car.

The regulations governing all of this are found in Appendix H of the FIA’s International Sporting Code. This includes organisational details as well as the equipment required for the various components of the medical/rescue response system. Here’s a link to the regs:

http://www.fia.com/sites/default/files/regulation/file/14.01.02_ANNEXE%20H%202014_publié%20le%2002.01.2014.pdf

Medical intervention cars (MICs)

MIC brazil

The first properly medical contact the victim of an accident will have will be with the crew of a medical intervention car. These vehicles will carry a doctor and a nurse or paramedic and be driven by a driver experienced at the circuit and with high performance driving. The MIC carries sufficient equipment to expeditiously handle problems with the airway, with breathing, and with circulation. Just what you need to keep things from getting worse in moving from the accident site to the medical centre. Details on this in a subsequent post.

A circuit will usually have between 3 (for VERY short circuits) to 6 MICs. They are arranged around the circuit in order to divide it into sectors that take roughly the same amount of time for the vehicles to cover. So a sector that’s got a lot of corners, and is therefore slower, will be shorter than the sector of an MIC that covers mainly straights and fast curves. Remember that the Prime Directive at a circuit is: no one EVER goes the “wrong way” on a circuit. EVER. EVER. As an example of a med team’s deployment map, here’s the circuit diagram for Abu Dhabi, from a few years ago:

Abu Dhabi circuit diagram

Let’s also note that the FIA Medical Car always has a local doctor on board. Because he is in radio contact with the CoC, the Med Car is another connection point between the FIA network and the local team. In my experience this functions extremely well when the following conditions are met:

  • both docs are experienced in prehospital medicine AND comfortable in the motorsports environment
  • both docs have explicitly considered their responses to a range of possible situations
  • language is not a problem

As you can imagine, these conditions are not always met; in addition, remember that the medical car intervenes AFTER deployment is decided. The upstream processes are therefore still vulnerable to “parallel functioning”.

Extrication units

Extric team

FIA-spec extrication units are physician led six-man teams whose task is to remove an incapacitated driver, or one in whom spinal injury is considered to be a possibility, from a car with a minimum of motion of the vertebral column and spinal cord. They are highly trained in the various techniques of extrication (more on this in subsequent posts, of course), and carry the necessary equipment to carry out their mission. There are at least two, and often three, extrication units at a Formula 1 circuit, depending again on the length of the circuit.

Ambulances

For a Formula 1 event, there is at least one ambulance at each MIC location. In addition to transport from the scene to the Medical Centre, the ambulance also can serve as a covered work area if the victim needs “packaging” after extrication but prior to transport to the medical centre.

Medical Centre

The medical centre is the headquarters of the medical team. It’s where they meet, stand down, relax, and practice. It is also where “routine” medical care is initiated during the race weekend, for all race and associated personnel. And of course, it’s where accident victims are first transported, before being evac’d to the receiving hospital. Medically the goal is to rapidly figure out just how injured the victim is, and what resources he or she is likely to need to stabilise the situation. This then determines the urgency of evac. The med centre is staffed and equipped to be able to apply a series of sophisticated life-saving diagnostic and therapeutic techniques.

Medical centres range from the rudimentary but functional to the virtually opulent. Here’s a typical “Tilke” centre, and a typical resuscitation area:

Korea exterior 1Nurburgring resus area

We may have looked at the various elements of the mandated medical/rescue structure separately, but in fact each is a link in the sequence of care. The overall quality of an intervention will depend not on the STRENGTH of each link, but rather on the quality of the weakest link. That’s why we/I insist so much on education and (simulation-based) training. More in a few days!

Next post: “DEPLOY MEDICAL CAR!”

An illustrative anecdote

I’m always going on about the inexperience of the current leadership of the medical arm of the FIA. I think it’s important, especially in view of the issue of intentional water/calorie restriction (which may well need regulatory input from the Medical Commission), that people understand that this is not (only) residual anger and bitterness because I was fired. So here’s a small example of what happens when important decisions are left to people without the background, experience or knowledge to carry them out appropriately.

At a 2012 meeting of the Medical Commission (I was still an observer), the president (Gérard Saillant) and vice president (Jean-Charles Piette, also the Formula 1 Medical Delegate) presented a draft regulation to the commission members, for what they expected to be rubber-stamp approval. In essence the regulation said the following:

In closed cockpit series, if the cockpit of the car is too small to allow either expeditious extrication of the driver or prompt removal of the helmet, drivers are REQUIRED to wear open face helmets.

Sounds simple, eh? Maybe even logical, right? They were happy that the cause of driver safety was being advanced. Interestingly, neither of the authors of this regulation have ever, in any way, managed an airway.

The intention of this regulation was laudable – to allow airway access rapidly under conditions of difficult extrication. But beneath the face of it, this proposition illustrated everything that is wrong with the current leadership.

The reading of the reg was met by silence around the table. I need to point out that the members of the medical commission are massively experienced, massively motivated, and massively frustrated. The president, until he was appointed by his friend Jean Todt, never had direct involvement in motorsport medicine. Same with the vice president, until he was named F1 Delegate, for the same reason.

Just as this proposition was about to be put to a vote, I raised four questions.

Question 1: How many drivers have suffered an adverse outcome due to failure to access/control the airway in a closed car? The answer is rather simple – ZERO. Although this is the nightmare situation of every motorsport doc, IT JUST HASN’T HAPPENED.

Question 2: How many drivers have suffered catastrophic head and/or maxilla-facial injuries due to contact with cockpit elements WHILE WEARING FULL-FACE HELMETS? The answer – well, I can name 4 or 5 off the top of my head. And I’m pretty sure had they been wearing open-face helmets, things would NOT have been better.

Question 3: How will the FIA answer the lawyers representing the family of a driver killed as a result of head injury wearing a mandatory open-face helmet?

Question 4: Why just accept that there are FIA-homogolgated cars still racing, with cockpits so small and roofs so low as to preclude satisfactory rescue operations? As the FIA body responsible for medical regulations, when the Medical Commission gets it wrong, lives are at stake. Why, I asked, has the Med Comm not gone on record with the relevant OTHER commissions to demand a say in cockpit design, before closing the technical regs for each series? This is the concept of cockpit-out design that I blogged about some months ago.

The reg was immediately withdrawn. I needn’t point out the eye-rolling among the membership at having been presented such a . . . silly proposition.

This is why I’m a bit fearful of knee-jerk, symptomatic responses to the weight control issue. This is why I’m enraged by the stagnation in medical progress in motorsport – it’s not down to nothing left to do, or to obstacles to advancement being thrown up. Rather, it’s down to a total lack of vision, perspective and knowledge of the ins and outs of this field, resulting from nepotistic, incestuous appointments. Again, Jean, you can give your mates titles, but that doesn’t mean you’ve made them competent.

Something NOT about head injury!

No seriously, are you guys KIDDING?

I guess we shouldn’t be surprised about Jenson and Lewis’ “revelations” about drivers intentionally compromising their health and well-being to minimise their weight. This is a sport that requires total commitment, and pressure to do anything to shave a tenth or so off one’s lap time. Millions are spent on aero tweaks, on salaries for the best designers around, etc. Remember that in the 80s we had a spate of drivers passing out post-race, because they were all taking beta-blockers. These were felt to improve performance under stress. Not.

I’m shocked and very very concerned about this development. I’m almost equally apprehensive of the potential reaction of the FIA in an attempt to mitigate this insanity. Oh and I think we need to be grateful to Louis and Jenson for their forthrightness about this.

So let’s start with a stable of drivers who are collectively some of the fittest athletes around, whose fitness regimens, 120 km bike rides, triathlons, etc, are the stuff of tweets, newspaper articles and tv reports. Everyone understands that the price of success in Formula 1 requires total physical condition. Only that will allow one to handle the physical stress of driving the cars and to maintain concentration despite physical discomfort. Only NOW we get to watch these guys starve and dehydrate themselves in order to minimise their weight. These are the same guys who never went ANYWHERE without their drinks bottles. I’ve been next to drivers who were tooting away on their bottles WHILE THEY WERE PEEING. Presumably McLaren has issued their drivers carbon fibre “peristalsis reversal devices”. They look just like spoons, and reliably induce vomiting. Jeez. Hey guys – nicotine activates the brain somewhat reliably. Maybe you should all take up smoking?

This is insane, and most worrisome. Obviously the implications of an unwell driver at the helm of a terrestrial cruise missile are huge – for themselves, for their fellow drivers, and for others. And the message this sends to the public, and to every young driver from go karts to GP2 is obvious – train for the week after a race, then totally fuck yourselves up for a week before the next one. Yeah, that’s the message you should be sending. Brilliant.

I needn’t go into ANY detail about why this regimen of starvation and dehydration is ridiculous from a medical point of view.

This has got to stop. And it’s got to stop now. And given the competitive pressures of the sport, this will not be easy. And given the implications for the safety of the public, track workers, and other drivers, it won’t be sufficient to issue some lame statement encouraging the drivers not to act like 90s heroin-chic supermodels.

Problem is, I fear that given the lack of experience of the current medical leadership (I’ll give an example of the absurdity this can lead to in a subsequent post), the solution will be more ridiculous than the problem. Let me make it clear – it is folly to try to paternalistically control nutrition or hydration of mentally competent adults by regulation. Any solutions must be legally acceptable, enforceable, and actually serve to discourage the behaviour in question.

So what’s to be done?

I’ve spend a bit of time thinking about this and pending something better, I think:

1) a statement highlighting the FIA’s concerns about this behaviour should be released

2) it should be stated that the nature of the problem of any driver who is unwell enough at the end of the race to require medical assistance will be investigated. The points of any points-finisher requiring medical assistance after the race will be provisional to the results of this investigation. A driver found to be intentionally dehydrating or starving (go ahead, think of a better word – Jenson said some of them eat NO CARBS for a week pre race!!!!!) will have his points cancelled and will receive a grid penalty for the next race. A second violation will lead to suspension of his or her super license. Forever.

These guys want to win, and as we can see, they’re willing to do anything for that to happen. We can question their sanity, intelligence, and wisdom, but not their motivation. But this also has ethical implications for those around the drivers with a duty to care, notably team physicians and the physios. If they are allowing this to happen, and worse, encouraging this, they are violating the cardinal rule of ANY caring profession: PRIMUM NON NOCERE. First, do no harm.

Some fascinating calculations, and one conclusion

Lots of people have asked me about the kind of forces involved in producing injuries similar to those Michael has suffered. It’s an interesting question, and after doing some calculations, it’s emphasised to me something that I think must be done relatively urgently. More of this later.

Let’s make a few assumptions as to baseline conditions. This means any results are at best approximations of the real world, but they allow us to “ballpark” the forces in question, and to perhaps compare with other mechanisms. And while I’m on the qualifiers, I’m SO not a physicist!

I’m assuming that the mechanism of injury is a near vertical fall onto the head, after Michael was “launched” by contact with a rock. I’ll assume his head was at 2.5 meters, not unreasonable for this kind of mechanism (and only slightly higher than one’s own height), that there was only a vertical component to his movement, and that he weighs 70 kg. This results in an energy of 1715 joules. Never mind the units for the moment – we’ll just generate some more energy data and then compare.

How about Felipe Massa’s accident? We know the spring weighed 800 gm (0.8 kg), and that Felipe was moving at 260 km/h (the spring is considered to have no horizontal velocity). This gives an energy of 2085 joules.

The same kind of calculation shows us that the bullet from a Kalashnikov (7.9 gm, muzzle velocity of 715 m/s, thanks Wikipedia!) has . . . 2019 joules!

To compare some other energies, let’s look at a soccer player heading the ball. Just to simplify, I’ll assume the player has no vertical speed when he heads the ball, and that the ball is falling from, say, 20 meters. This gives a “measly” 86 joules. Nothing, eh? (The actual value will be higher because of the player’s vertical momentum, and also if the ball falls from higher). Well how about this: there is a direct correlation between a the number of heads a soccer player has in his career and his cognitive function. So even this relatively tiny force, repeated many times, will likely damage a brain!

What about American football, where we read every day about cases of chronic traumatic encephalopathy (the damage done by years of hits)? Again, a few assumptions. Defensive lineman, 100 kg. Offensive lineman, 150 kg. Speed of each at impact? 1.2 meters/sec. What does this give? This gives us 180 joules combined. Again, doesn’t sound like much, but repeated over a career from high school, through college, to the pros, it seems often to result in very significant damage to the brain.

But back to the object of our concern. What explains the dramatic difference in outcomes between Michael and Felipe?

The obvious first (and perhaps only significant) answer is their helmets. Felipe was wearing the latest spec full face carbon kevlar racing helmet. Michael was wearing a . . . ski helmet.

Remember that force is not the only factor – we have to consider the area over which the force is spread. When a 70 kg man steps on your foot with his loafers, it hurts, but nowhere NEAR as much as when a 70 kg woman does the same with a stiletto heel. In one case, the force is spread over a much larger AREA, giving a lower pressure. And it’s pressure that actually does the damage. One of a helmet’s main roles is to distribute a force over a (much) larger area, dramatically reducing the pressures generated.

Now, the FIA Institute has done remarkable applied research in helmet design, and the helmet Felipe was wearing reflects that research. This helmet was designed specifically with very demanding requirements for impacts with objects having rounded edges as well as those having sharp edges, and equally for penetration resistance. These requirements were based on known mechanisms of injury in the sport concerned, and the levels of energy seen.

Ski helmets, on the other hand, are designed and homologated (WHEN they’re homologated) almost solely to prevent skull fractures. While this provides an easy method of evaluation in testing labs, we know that this has VERY little (if anything) to do with the actual mechanisms of brain injury. And unfortunately, Michael is a living demonstration of this.

Therefore, I’d like to throw a few ideas out there:

  • the Federations responsible for skiing, from recreational to competitive, should convene a working group of experts to look at the epidemiology of head injury in the sport
  • conclusions should be drawn about the kind of head protection likely to mitigate the injuries ACTUALLY SEEN
  • Jean Todt should offer the full resources of the FIA Institute (data, expertise, etc) to help design this helmet, to make it affordable, and to make sure it is used as widely as possible.

Michael’s injury is no more tragic than those of every patient who suffers severe head trauma. If, however, his public persona spurs action that goes on to significantly improve the safety of skiing, it will be another of his many remarkable accomplishments!

Antidoping

Funny, just after considering writing about concussion and finding a cool reason to do so, I started thinking that I should perhaps write a bit about the antidoping efforts underway. And, again, no sooner do I think that then I start to see a series of my tweets from mid-August resurfacing, this time inserted into “debates” with various other actors.

Now I don’t need to point out that “journalistically” speaking (I’m not a journalist but I maintain a strict and copious diet of good journalism daily) this is methodologically atrocious. Had the points in question (more on this momentarily) actually been discussed among those quoted, the outcome, impact and implications would likely be entirely different. So in the interest of making my slant on things clear, here goes.

In August an “authority” spoke to the press about doping in F1, mentioning specifically use of a drug called “tacrine” to help drivers memorise circuits. He said it’d been going on for years.

In typical (wiseguy) fashion, I responded on twitter. In essence I said that having done a few laps with a few decent drivers on circuits they’d not driven before, and spoken with a fair number of others, I never found that the rate-limiting-step in performance was (after the first 5 or so laps) memorising the circuit.

In addition, the drug mentioned was only (barely) effective in its specific target group (patients with mild-moderate dementia of the Alzheimer type), and had a fairly significant side effect profile. Making it rather . . . improbable that it would be used routinely, over the years, by otherwise fit young men.

Lastly, and most significantly, tacrine is not nor has ever been, on the World Anti-Doping Agency’s Prohibited List. Now the FIA follows this list, and has for years. In fact, it recently became a fully participating Federation in the WADA community. In essence, if a substance or technique isn’t on this list (revised annually by expert scientific and medical consensus), then taking it or doing it isn’t doping. That’s by definition, and with a drug that’s been around for years (meaning it is reviewed over and over again based on new data) it reflects a general agreement that that specific drug does not  enhance performance.

In that series of tweets, I expressed my rather strong feeling that Formula 1 does not have a particular problem with doping. Those tweets have now been resurrected in an entirely different context. So I’ll use this opportunity to clarify and nuance my remarks just a tad.

I think it useful to separate two aspects of driver performance enhancement. Let’s first consider strength and muscle mass, especially of the upper body.

This is obviously an area where pharmacology can intervene, to accelerate and intensify gains made through “classical” strength and resistance training. But remember, in essence ALL known anabolic substances are on the prohibited list both in and out of competition. And as the “bad guys” develop new compounds, they’re added to the list. This kind of doping would likely take place mostly during the off season, and would logically be most prevalent among drivers just coming into the championship. The out-of-competition ban is why the FIA requires whereabouts notification for just about all of a driver’s free time. And they are regularly targeted for random, out of competition testing. Knock-knock, 6 AM, bathrobe, wtf kind of testing. They hate it, we love it, it works.

I don’t need to point out of course, that while drivers are extraordinarily fit, their schedules are often almost built around the several hours per day they need to be doing fitness activities. This is LARGELY enough to develop the strength and mass necessary … with neither the physical, legal, or sporting risks of anabolic substances. Oh, and we’ve not yet had a positive test in F1.

Now let’s look on-track.

I think we can pretty much agree that once in the car, any pharmacological enhancement of performance is going to come from what we might call “vigilance enhancers”. There are a number of these, all of which are on the prohibited list, and all but one class of which are associated with rather dramatic side effects. These are certainly consistent enough and significant enough to NOT go unnoticed – by anyone around anyone taking this stuff. And of course, they’re all tested for during each in-competition test.

Those of you who follow me know I’m not naive. At all. And while Jean-Charles Piette is correct in pointing out that pole position sometimes comes down to a few thousandths of a second, I’m quite confident that our guys are not finding them in prohibited substances – the side effects and risks to their health and careers are just too severe to risk.

That said, I agree with Mark (Webber) – the more you test, the more credible you are. Testing is EXTREMELY expensive (think how strict things must be legally, in terms of evidentiary quality, to risk depriving people of their livelihood!). And the Medical Commission has consistently pushed for as much testing as possible.

The FIA has put in place an effective and credible system to help guarantee that its championships are clean. I have no doubt that the pool of Formula 1 drivers consists of a VERY low risk pool for doping violations, largely because of the specificities of the sport. I think we’re all gonna wait quite a while before there’s a doping scandal in F1.