Silverstone was a blast (2)

What about the folks in the front seat, the folks doing what I did?

The first thing to say is that there is a fundamental difference in how the medical service is organised in MotoGP, as compared to F1. With F1, the governing body, the guys who write the rules, also supply the people to liaise, coordinate and if need be work with the local team providing medical cover. The COMMERCIAL rights holder, has NOTHING to do with things.

In MotoGP, the FIM writes the regulations, and presumably has mechanisms to verify compliance. But the people at the circuit, sitting in the medical cars, work for Dorna, the commercial rights holder.  Now I’ve not thought through the implications and complications of this (not sure it’s better or worse than the set-up in F1, just different), so I’ll simply point out the difference.

In the “old days”, that is up until shockingly recently, medical care for this championship was supervised by “Dr. Costa” and his Clinica Mobile. Usually described as a legend and a demi-god by non-medical people, he was certainly his own greatest admirer. If I had lawyers, and I don’t, they’d be waving their arms madly to prevent me from writing exactly what I think of the Clinica Mobile. So I won’t. Not even to say that – what’s that? – I can’t even say THAT? Ok forget it. You all get the message, right. Wink wink? Wink wink!

The death of Simoncelli was the catalyst for Dorna to bring in a group of people who were tasked with bringing medical cover and response from the Renaissance to the 21st century.

The team is 100% Spanish, which is normal given that Dorna is too. They’re a small, friendly and highly motivated group of doctors and paramedics. They’re on a very steep learning curve, given what would appear to be total neglect over years (either that or total, severely misplaced, faith in many of the local teams!) of medical and rescue training and standards at many of the circuits visited top-flight motorcycle racing.

Interestingly, from what I can see, they’ve been “parachuted” into this environment without having followed the “usual” path we all follow. That is, junior doc/nurse/paramedic paired with an experienced person for a season or so, then years of accumulating experience and knowledge about race procedures, the clinical epidemiology of the injuries seen, etc. Then being the senior person mentoring the junior. Then deputy chief, etc etc.

This is important.

Not having that shared background “in the trenches” has a number of consequences that will make their jobs a bit harder.

Credibility: it’s hard to realise just how important this is. The shared database of shivers and full bladders, snoozes and cold sweats, of radio failures and aborted starts is almost REQUIRED before most motorsport rescue people will take your comments on board.

Real-world experience: what’s an Incident Officer? What’s the blue flag mean? Knowing that leaning on or over the Armco is dangerous. At an accident scene, knowing (and loving) that edge of chaos and the need to improvise every time.

And most important? Passion. If these folks are passionate about the sport, and about doing everything they can to make the care offered to the riders as good as it can possibly be, they’ll succeed. If they approach this as a job, they’re going to struggle. That’s because for US, the one word on all our lists of why we do this is passion.

If they’ll have me again, I’d love to work at another MotoGP race. I just won’t make it a habit!

Silverstone was a blast! (1)

Being at Silverstone this weekend, after 21 months O.O.O. (out-of-overalls), brought home to me just how true it is that I came forthe racing, but I stayed for the people. I had a blast. Here, again in a totally random fashion, my thoughts and feelings about working at my first MotoGP race.

I rediscovered that draw-dropping wonder at watching these lunatics riders on those stunning little jewels of machines. Yes, F1 holds me in thrall, but over the years I’d lost much of that very young boyish feeling of . . . Almost not believing I’m seeing what I’m seeing. In fact, I spent the weekend saying “awesome” constantly. Our standby position allowed us to watch them apexing and accelerating out of Copse. It is a seriously thrilling sight.

The open-face helmet. When I worked with Sid, we donned helmets for race laps only. After Sid retired, all the car-borne personnel agreed that we should always be lidded.

First of all, I assume that any of you who know anything about me realise that I’m pretty serious about head injury and its prevention/mitigation. Our requirements were relatively simple, and after due consideration we opted for high quality open faced helmets. In the case of the medical car crew, we felt that the most likely mechanisms of head injury ON SCENE would be falls and flying debris. (That’s why in most pictures of me ready for work I’m wearing ballistic eyewear also). It was clear that both to maintain protection as well as to foster the most professional image possible, we would not remove our lids while working. This essentially eliminated full face helmets from consideration.

Remember, we’re in a huge road-ready Merc that’s been reinforced just where you’d want it to be. We’ve got 6-point harnesses in front and we’re on a circuit that is purpose built to make sure that decelerations are as gentle as possible. Yes, of COURSE we’re travelling a bit . . . swiftly . . . but Alan and I felt utterly protected with our helmets on.

The local team providing medical cover for the Silverstone leg of the MotoGP championship is the team that covers the British Superbike championship. These guys are spectacularly devoted, utterly professional, and really are a model of efficiency, good humor and passion. They take their JOBS, not themselves, seriously.

They didn’t assume I knew nothing about doctoring for bikes, but nor did they assume I knew everything. So I learned TONS. How can that not be fun?

Interestingly, and this came as a huge surprise, there’s almost no intersection between the medical/rescue people doing cars and those doing bikes. My non-random sampling indicates that a large proportion of them are actualy bikers. But the passion, the commitment, and the willingness to tolerate hours of boredom/discomfort/heat/cold/wet/mosquitos etc, is the same as everybody out on a corner or in an intervention car, whether it’s bikes, cars, boats, airplanes or trucks out there.

Hey this is getting long. I’ll finish up tomorrow, and talk a bit about the people sitting in the front seats of the medical cars.

 

Back at Silverstone

For the past longer-than-I-can-remember, I’ve been coming to Silverstone every February to join the faculty of a three day trauma course we teach at the Medical Center. The instructors are a fabulous group, with massive cumulative motorsport medicine experience. Ian Roberts, the current F1 Rescue Coordinator is there every year, as is the Chief Medical Officer of the British Superbike series.

This past February, perhaps more as a dare, Heike (the Superbike CMO) asked if I’d come up for MotoGP at the end of August.

So here I am.

My thoughts so far?

In no certain order, and with scant attention to the importance or lack thereof of any of this drivel, here goes:

  • I’m sure it’s a total coincidence but I’m riding in Chase 1. The previously mentioned (Twitter) M550d. The power comes on so linearly that one can be fooled. It’s very quiet and quite comfortable. Not as agile as the Merc, but BMW has not yet tried. It needs to shed a hundred or so kg. Or better, 200.  A no drama mama.
  • The medical folks are a totally charming group. They really seem to be committed to getting it right, and have not been there long. Closer relations between these guys and some of the FIA medical people would benefit everyone, and help these guys move up their learning curve even faster.
  • I am staggered by the amount of time I have spend getting to, shitting around at, and queueing to leave, circuits all over the world for the past 17 years.
  • I am staggered by the amount of time I have spent sitting in medical cars over the past 24 years. I am actively avoiding thinking about the opportunity costs of this passion.
  • I had a fantastic day, learning about bikes, talking to the team in the car, and soaking up being at a circuit again.

For info, I did NOT go to the race at Spa. It’s massively nice of Mr. E. to have approved a pass for me, but stuff kept coming up that totally prevented me from actually  getting there.  Interestingly (for me at least), this was accompanied by none of the angst, drama, or panic that one would think normal under these conditions (my home GP, first race in a year, first Belgian GP not attended in 24 years, etc).

I think this means nothing more and nothing less than that “it” is officially out of my system. Yes, here I am at Silverstone, but besides this being a 6 month old commitment, it’s FUN, and it’s my choice.

I love this racing thing. I’ll certainly work at events in the future. But right now I’m working on some super exciting possibilities for the near future, and besides keeping me busy, it feels like starting to prepare for a journey, and I’ve always loved that feeling…

A petition for action on helmets

Link: Tell Jean Todt – Help Make Helmets Safer for Everyone

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!

“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