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.

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Just a short one, then i’m done . . . really . . . no really

There’s one thing I totally forgot to say, and that’s congrats to NASCAR for this initiative. Another of Sid’s legacies is smashing through what was was for a long time an impenetrable barrier – the Atlantic. It’s so reassuring to see everybody on the same page in terms of offering the safest environment possible to motorsports participants. Both before AND after something happens.

People disagree about things that seem no-brainers, and they do so sincerely and often for very profound reasons. Stuff that has to do with fundamental conceptions of autonomy etc. So it’s also normal that those visions can clash . . . but at the end of the day all you can do is talk it out. 

Once again, the concussion prevention and management program NASCAR is putting together is a HUGE step forward for everybody. Thanks so much.

What about return to competition?

If you’ve read Brad Keselowski’s comments about concussion testing, he raises the point of objectivity.

Quite a number of years ago, Sid pulled someone from a race weekend, and was lambasted in that driver’s national press for “manipulating the championship”. When I became Medical Delegate, I wanted to construct the best firewall possible between return to competition (RTC) decision-making and that kind of accusation.

Now of course, medicine is never perfectly objective. Neither for that matter is race engineering! But in an effort to provide the most reproducible, predictable and transparent return-to-competition criteria, I met with several authorities on concussion, and the medical directors of the top US open-wheel series. This resulted in an algorithm for RTC that reflected current best practice. The document was given to the Stewards, and they would be informed whenever a driver was to be reintegrated after an accident involving concussion. 

Here’s a copy of the RTC criteria I used. I have no idea whether Jean-Charles Piette (the current Medical Delegate and close mate of Jean Todt) uses these criteria. 

The decision to return a driver to competition after a head injury will be based on the following criteria:

Return to participation at the same event is possible if:

  • no loss of consciousness has occurred
  • amnesia has lasted < 15 minutes
  • neurological examination is normal with no overt post-concussive symptoms
  • CT and/or MRI scanning is negative
  • ImPACT testing reveals no significant decrement from baseline or from age-matched controls
  • if above criteria not met then

 

Return to participation in the NEXT event is possible if:

  • neurological examination performed before start of competition is normal with no overt post-concussive symptoms
  • ImPACT testing reveals no significant decrement from baseline or from age-matched controls
  • CT and/or MRI scanning is negative
  • if above criteria not met then

 

Return to participation requires:

  • neurological examination performed before start of competition is normal with no overt post-concussive symptoms
  • CT and/or MRI scanning is negative
  • normal electroencephalogram (EEG) off antiepileptic medications
  • ImPACT testing reveals no significant decrement from baseline or from age-matched controls
  • satisfactory performance on testing observed by a qualified observer
  • These drivers are considered to be under probation for the first practice session after return to competition.

 

A second episode of MTBI within 1 month of the first (as documented by a significant fall in ImPACT scores or clinical criteria):

  • one month out-of-competition
  • neurological examination performed before start of competition must be normal with no overt post-concussive symptoms
  • ImPACT testing reveals no significant decrement from baseline or from age-matched controls
  • CT and/or MRI scanning is negative

 

A third episode of MTBI during the same season eliminates the driver from further competition that season. The above criteria are then applied at the start of the next season.

 

Decline in baseline performance over several seasons in a driver suffering from multiple episodes of MTBI over time (even with strict adherence to the above) will result in discussion with the driver as to continuation of his career.

We really need to have a word about baseline concussion testing

It’s funny, but I’d been feeling like writing about concussion (or MTBI, mild traumatic brain injury) for a few days now. Mr. Keselowski’s comments have given me a reason to.

As an emergency physician I see lots of concussions. This is a pathology that interests me personally, because it has long been underdiagnosed, undertreated, and, well, minimised. So from now on, I want you to promise me that when you read “mIld traumatic brain injury“,  you’ll see it like this:

xxxx traumatic FREAKIN’ BRAIN INJURY!!!! 

(and i want you to see it with the exclamation points)

There’s nothing mild about interacting with someone who’s concussed. Thought power reduced dramatically, asking the same question over and over again. The blank stare. The nausea. The vomiting. The total inability to string together a rational train of thought. Not sure that one needs to be a doctor (even a race-ignorant one!) to want to know, despite SUBJECTIVE denials (yes you racers SURE do want to get back into your cars), if this brain is still capable of information processing at over 200 mph. If I was sitting in the stands, I’d like to figure SOMEONE would take you out of your car if you couldn’t remember anything that happened a few minutes ago.

It doesn’t stop there actually. Yeah, this is regularly followed by days, or more typically weeks, of altered sleep-wake cycles. Not ideal for students, or pretty much anyone intent on any kind of productive life. Emotional lability. Head splitting headaches. Inappropriate laughter, or crying. Atypical morosity, or euphoria. Difficulty concentrating on anything, and in retaining information for any period of time.

I suppose it’s not surprising. With 100 TRILLION synapses, the brain is functioning at a rather sophisticated level of integration. Go ahead and kick a coke machine, Mr. Keselowski, and then see if it works. Not surprising it doesn’t, at least not how it did before, right? How about your brains inside your helmet after hitting the wall? Get the picture?

Funny thing is, until that brain, that kicked-100-trillion-synapse-coke-machine inside your helmet gets better (and remember how easy it is to deny symptoms), it’s exquisitely sensitive to a second concussion. Do you REALLY think Dale Jr.’s second concussion was a coincidence? And it’s even scarier. We know from other sports that when that still-recovering brain gets a mild hit, it can sometimes, and unpredictably, swell. This causes a coma, and is often, all too often, associated with a persistent vegetative state, or even death. We call it the second impact syndrome. Ever hear about it? It’s why we like to diagnose concussions, and then make sure they’re GONE before letting you guys back in the cockpit. Better for everybody.

I don’t resent being told, generically, that “doctors don’t understand our sport”. But let me tell you something. Very very clearly. READ THE ABOVE MR. KESELOWSKI. That’s medicine, and it’s sport, and it’s people getting their heads knocked. Do people in YOUR sport get their heads knocked Mr. Keselowski? See? We’re starting to understand each other.

We really do understand concussion, or at least how to do the best we can with concussed patients in 2013.

I’ll suppose, Mr. Keselowski, that you’re too . . . busy . . . to be following all the stories in the lay press about the epidemic of chronic traumatic encephalopathy (CTE). Anyway, I’m sure I’ve no need to remind you Brad (can I call you Brad?, you can call me Gary), CTE is caused by numerous episodes of, yes you guessed it (you’re a SHARPIE!) concussion. And with CTE, the terrible, treatment-resistant depression. The almost constant descent into alcohol and/or drug dependency. The dementia. The death in the late 40s or early 50s. The ruined families that started with such promise.

You say you racers are risk takers. That’s certainly true. I’ve known my share.  They, however, would appear not to be willing to risk CTE. I’m pretty sure no one would blame them.

ImPACT, the test NASCAR is going to use, uses OBJECTIVE criteria. That’s what makes it beautiful. Compared to baseline, it allows the clinician to judge the severity of cognitive dysfunction . . . OBJECTIVELY. Beyond a well described, objective threshold, a concussion is present. Until those scores are back to baseline, the concussion isn’t healed. This is one more, objective, tool (and not the only tool) in the arsenal of the physician taking care of you guys.

Just when we’re making into inroads on getting concussion taken seriously, in high schools, in colleges, and pretty much everywhere people are getting them, you come along and discredit what is virtually a major public health initiative. Dude, you’re a risk taker? Go bungee jumping. But when you’re behind the wheel of that car, you’re a sportsman, and you’re doing it in front of thousands of people sitting there. And for millions sitting in front of their TV sets. You can hurt the ones at the track. Kill them even. Getting behind the wheel when you’re concussed puts them at risk. Do you REALLY want to criticise a tool that can prevent that from happening?

Read a bit, DM me, we’ll talk. I want you to understand why we do this. It’s really not to bother you guys, just to make it all safer.

Now THIS is interesting

Now THIS is interesting

Just been sent this link to an article in today’s Telegraph. It concerns a letter sent by the RAC to the FIA back in July.

In it, the RAC poses some important and unsettling questions about the lack of financial transparency of the FIA. Among other things, it specifically points out Jean Todt’s “Personnel expenses of €6.1m and €8.3m for travel, missions and conferences.” I’ve already mentioned that most if not all of the President’s travel is by private jet (among other things, we were issued with team itineraries for races with flights for all team members, including the president, when he attended a race). Presumably so is that of the “ambassadors” for the Action for Road Safety. If this program has one concrete achievement, it’s certainly that of allowing the participants to see the world comfortably.

In an era of economic crisis, when we on the inside were subject to constant cost pressures, it is reassuring to see a major ASN questioning the old club style of governance, potentially playing fast and loose with members’ money.

That said, almost more important than the issue it raises (which also forms a key part of David Ward’s manifesto) is that this letter indicates a crumbling of Todt’s internal support structure. Remember, Graham Stoker (UK RAC and MSA) is one of Todt’s Deputy Presidents and a key member of his slate. Certainly this letter would not have been sent without Mr. Stoker’s approval. When we see the rumors of a possible opposition candidacy from another key member of the slate, I think it safe to say that Mr. Todt might do well to begin to do some post-presidential career planning. 

For info, the dates for the introduction of candidates are from 26/10 to 15/11.

Extrication in 2013

I talked last time about introducing the concept of “cockpit-out design” as one of the ways I think motorsport safety can progress. It’s important to realise that this is a further application of the system put into place by Max Mosley and Sid Watkins. After acceptance and adaptation of the concept, the essential element is the research, in order to develop a consensus among experts as to exactly WHAT current best practice is.

While I’m firmly convinced that “cockpit-out design” will further reduce injuries, in terms of the actual practice of motorsport medicine (that is, after the accident has happened), I think one of the major priorities to be addressed by the coming administration is EXTRICATION. Extrication is quite simply the process by which an accident victim is removed from his vehicle.

First, a bit of background, then I’ll make some suggestions (why is this not a surprise!) as to one way forward.

After Philippe Streiff’s accident in Brazil in 1989, Sid Watkins charged one of his associates with looking at the process of extrication. (Ironically, extrication had absolutely nothing to do with the devastating injuries Philippe suffered, but that’s not the subject here). Thus were born the “KED teams” seen since 1990 at all F1 races. These are physician-led six man teams trained in the use of the KED, a device originally used for extricating accident victims from road cars. (Here’s the Wikipedia article: http://en.wikipedia.org/wiki/Kendrick_Extrication_Device). Interestingly, the first time an extrication team was used in anger was at MY first Formula 1 race, at Spa in 1990. The victim was Luca Badoer, who incidentally had just said some pretty nasty things about my mother after I placed a rather huge catheter in a rather small vein on his hand. In his defence, he was concussed. And in the interest of truth, my mother is a TEACHER, and she’s not filthy.

It rapidly became clear that while the KED was useful, it was hardly ideal. Among other difficulties, placing it in position required manipulating the driver, which is precisely what we try NOT to do. This led Sid to push for extricable seats, which are now in use in all major single-seater championships. The idea behind this is intuitively brilliant: the seat itself acts as a spinal splint and the driver is removed from the car still in his seat.

Under the influence of Sid’s associate (who also was a motorsports medicine pioneer but had zero experience with real accident victims), training in use of the KED and extricable seat became the be-all and end-all of “medical” training for FIA championships. To this day, there is an official extrication exercise on the Thursday before every race weekend; it is only recently (and totally unofficially) that the rest of the medical competencies necessary at the track are examined with an integrated accident simulation scenario . . . including extrication.

Spinal injuries are devastating, and it is clear that every measure possible must be taken in order to avoid aggravating the injury caused by the accident, notably by moving the victim inappropriately. This is the “raison d’être” of extrication teams.

The problem is, in 2013 we have no real idea of what spinal injuries are occurring, and what mechanisms of injury are causing these lesions. We know they’ve become extremely rare in motorsports (a wonderful result in itself, but one that singularly complicates our job in a statistical sense!), but beyond that, we just don’t know if what we’re doing is the best way to do it, if the tools at our disposal are the right tools for the job, and if the apportionment of training (currently 99% extrication 1% everything else!) is correct.

Obviously, we should have answers to all these questions . . . before the next spinal injury! How do we go about getting those answers?

I think the first step needs to be to convene an expert conference. This needs to look at both road accidents as well as motorsports-related accidents. The epidemiology needs to be obtained – who’s getting injured, how, and how are these injuries evolving from time-of-impact to definitive care. Then the experts need to look at this data and determine how best to take people out of cars in different situations. Are the vast majority of lesions stable in flexion but unstable in extension? Is rotation to be avoided at all costs? This kind of knowledge will place bounds on how we extricate and on what tools we can use to get that job done.

Once this is done (and this is no small job), we need to look at the tools available, both for paramedics, EMTs and docs working in the streets, as well as in the motorsports environment. And we need to remember that “the motorsports environment” means single seaters, dragsters, rally cars, GT cars, etc! If the proper tools don’t exist, we need to develop them. The full resources of the FIA, FIA Institute and FIA Foundation can and should be used for this, especially by forming ties with industry.

Who better than the FIA Institute and Foundation to organise this kind of conference? A  global commitment to arriving at an evidence-based updating of extrication procedures for both road accidents as well as those occurring in motorsports would bring potentially massive benefits. To my way of thinking, this is one of the ways to really bring home the “Action for Road Safety”, and to start to make the FIA a deservedly household word!

An open letter to the future President

Dear Mr. President,

Today we learned of the death of Sean Edwards. It’s been a rough season. You know that at least as well as any of us. The fact that we know you share our deep sadness and sense of loss is important to every fan of motorsports – it is true that tragedy draws us together. And this sense of connection can and should be leveraged to make our sport better – safer, cleaner, more popular and accessible. This is why I’m writing.

In what will no doubt be a flood of comments, criticisms and suggestions, I would like to discuss an initiative that may be a fruitful way forward as concerns driver safety. I refer to it as “Cockpit-out design”. Let me explain.

When designing a racing car for any given formula or series, I believe that the starting point for the engineer should logically be a set of “best practice” guidelines for creating the safest environment currently possible for the driver. Only when this is done should the engineer begin the process of “surrounding” the driver with the highest performance vehicle allowed by the regulations. This is what I mean by “cockpit-out design”. As you fully understand, this is pretty much the opposite of the historic way of creating a race car. Only a more or less limited set of regulatory requirements (depending on the formula or series) need be incorporated, often as “engineering afterthoughts” into a car entirely conceived for performance, at least as concerns the driver’s immediate environment.

Several steps will be necessary before instituting this kind of process. These are of several orders – philosophical, scientific, logistical and administrative.

Philosophically, it appears to me (admittedly not the most objective observer) logical that in the design and construction of a racing car in the second decade of the 21st century, the driver would be provided with a workspace that is the fruit of current knowledge as concerns safety. Discussion of the concept widely, with an emphasis that this should in no way (quite the contrary!) compromise performance. The various relevant FIA Commissions must discuss these ideas until the concept becomes engrained at all levels of the sport.

In terms of science, let’s be perfectly clear. When using current best practices, and following modern engineering principles the modern racing car is a remarkably safe and well constructed vehicle considering the energies involved. That said, the current set of regulations have been arrived at individually, piecemeal. Again, the ensemble (collapsible steering columns, foam head surrounds, etc) is remarkably effective; most of these steps have been arrived at as the fruit of research.

What is needed is a fully international consensus as to exactly WHAT constitutes the safest cockpit possible . . . today. All aspects must be considered, thinking both structurally (e.g. the safest seat) as well as functionally (what are the injuries and what must we do to prevent them?). A major conference, calling on experts from relevant fields should be called with an aim to coordinating working groups. The goal would be the creation of a series of medical-rescue regulations for FIA formulae, and which could be copy/pasted by ASNs and other series.

Administratively, prior to presentation to the World Motor Sport Council, such regulations would need to be “bounced” back and forth among the various Commissions, ideally shepherded forward by a group of wise men, to avoid the initiative being lost in commission politics and/or deviating too far from original intentions.

Logistically, this need take account of the significant amount of time for each cycle of conception, design and fabrication of a series or formula car. Cars in the pipeline must be the last cars made before universal application of “cockpit-out design”.

I’m at your disposal to discuss any or all of this at your best convenience.

And congratulations.

-Gary