There’s been near constant press coverage of concussion (or MTBI) lately. Here are the three things you need to follow – for yourself and for your loved ones. Thanks to Arslan Visuals (email@example.com)!
Since it’s pretty clear that the message of Michael’s tragedy hasn’t been picked up by those with the wherewithal to actually DO something, I’ve created a petition asking Jean Todt to commit the FIA to taking the lead on improving helmet safety.
Let’s get this done, so that when people strap helmets on, they can actually be confident they’re being protected!
Thanks so much!
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.
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:
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.
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:
“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.
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.
“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.
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 route, that 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.
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
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.
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.
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
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.
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.
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!
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.
(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):
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.