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.

15 thoughts on “We really need to have a word about baseline concussion testing

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  3. it’s rather funny to think, that u wrote this article about concussion a.k.a traumatic brain injury, and just a few days later a certain F1 living legend will have a brain injury & now fighting for his life.. well we are all praying that he will get through it..

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  5. Brad Keslowski has some valid concerns but made the wrong way and possibly for the wrong reasons.

    Gary Hartstein’s reply is probably closer to the truth and outlines a lot of the concerns that clinicians who deal with these injuries have, but there are still some points that need clarification.

    Concussion is not mild traumatic brain injury (TBI). Concussion is one of a number of potential consequences of TBI; mild, moderate and severe (though you first have to survive your severe TBI to be in with a chance of suffering concussion). Typically lasting 2 – 4 weeks from the time of onset, features of concussion may be delayed in their appearance and may be prolonged in their course.

    The consequences of concussion are where most of the concerns lie

    1) Immediate consequences – impaired concentration, impaired decision making, impaired coordination, distracting symptoms such as blurred vision, headache and nausea. Potential for further injury (not just further head injury) to self, but in the context of motorsport also to others such as other competitors, track officials and spectators.
    2) Second hit syndrome – feared by anyone who claims to have seen it occur, but evidence for it is largely anecdotal and hard data is questionable (for more info, go to Concussion and the ‘Second Impact Syndrome’ at http://asmmr.yolasite.com/news/concussion-and-the-second-impact-syndrome-)
    3) Chronic Traumatic Encephalopathy (CTE) – anecdotal, based on poor quality observational studies, but creates a lot of anxiety amongst clinicians and solicitors (For more info, go to Compensation for Chronic Traumatic Encephalopathy at http://asmmr.yolasite.com/news/compensation-for-chronic-traumatic-encephalopathy)

    Even if only one of these 3 main consequences of concussion are valid entities, concussion is worth approaching with due caution and concern.

    Yes, doctors are cautious when it comes to the well-being of their patients. That is what we do. And why should it be treated as a lesser concern then that of your cheif mechanic or engineer. Trust between a driver and their chief mechanic is essential to the race season. What driver would head out knowing that the mechanic had serious concerns about the brakes or the alternator or the radiator? Would a driver be happy to race a wet track on slick tyres, or a bone dry track on full wets? The chief mechanic’s job is to ensure that the car performs in peak condition and safely. So it is with doctors who work in motorsport.

    There are, however, concerns amongst clinicians regarding the validity of concussion assessment methods and the implications of their results, including those of the available sideline concussion assessment tools. This was most recently reflected in the updated American Academy of Neurology guidelines (http://www.neurology.org/content/early/2013/03/15/WNL.0b013e31828d57dd.full.pdf+html), which revised their stance on the use of sideline concussion tools, stating that they remain an option for the treating clinician to use when assessing concussion but should not be used in isolation. While stepping someone down from competition following a head injury with a suspicion of concussion is relatively straightforward, it remains unclear as to the role the tests should play in determining a competitor’s fitness to return to competition; which might be the centre of Brad Keslowski’s concerns. (For more information on this, watch this podcast of a presentation that I gave at last year’s FIA Medicine in Motorsport summit – http://asmmr.yolasite.com/news/concussion-in-motor-sports-assessment-and-controversies)

    The point being made is that these sideline tools might be able to independantly help us to determine the impact of concussion on a competitor, we just don’t have the evidence to back that up yet. So mandating baseline ImPACT assessment at the start of every racing season might be the correct thing to do, but the data to support this is thin. And that’s where a potential problem and also an opportunity presents itself.

    There are many instances in medicine where a proposed therapy made good sense and was introduced before being properly studied. Those treatments have become so ingrained as “standards of care” that it now proves very difficult to go back and study their true benefits (e.g. adrenalin in cardiac arrest, leukodepletion in blood product transfusion).

    So if the mandating of baseline ImPACT testing is going ahead, let’s do it properly and make sure it is achieving its proposed benefits. The ICMS (http://www.icmsmotorsportsafety.org/) has a good history of analysing race data and making suitable interventions (e.g. the SAFER barrier, driver seating position), so why not set up a trial of some sort to answer this question. A large randomised control trial may not be feasible and a before-and-after trial has immediate flaws, but it should be possible to work something out. Then we should be able to address the concerns of competitors like Mr Keslowski and those of clinicians treating these competitors, in an objective way.

  6. Brilliant response. And necessary. I am a Neuroradiologist — a radiologist that specializing in brain/spine imaging. TBI is a complex interplay of myriad pathology that is still being elucidated. We have much more to do in terms of understanding it’s natural course. NEVERTHELESS, what we do know [at present] is substantial. And baseline testing for motor racing is critical. Racing has evolved over the decades and fortunately has become much, much safer. And in terms of safety and protecting all those involved, there is no such thing as overkill.

  7. Pingback: Former F1 Doctor Replies to Brad Keselowski's "Doctors don't Understand Our Sport." | I-am-bored.hu

  8. A few years back at the the F1 FOTA Forum in Manhattan, I asked Sergio Perez if there was an FIA baseline test for concussion and, if not, how did he (and Sauber) determine when it was safe to come back to race after a MTBI. My question came a few races after Perez suffered a heavy crash in 2011 when he lost control of his Sauber exiting the tunnel in Monaco, impacting the barrier at the chicane.

    Perez explained it was up to a driver and the team to determine fitness to race and that no FIA concussion testing/clearance existed. At the subsequent CanadianGP, Perez recalled how he simply could not drive the car in a safe manner at race speed whatsoever and that he would be a danger to himself, other drivers, his pit crew, etc… had he just stuck it out and raced the whole weekend.

    Since an F1 driver faces more G’s and more threat to his well being (i.e. crashing at high speeds at more acute angles with more force in an open cockpit), he cannot rely on rubbin’ the adjacent car nor the somewhat forgiving nature inherent to oval track racing (yes, not completely safe I know) to mitigate the effect concussion might have on his race craft. Maybe Brad’s opinion toward this issue would be different if he races in a different car and series.

    I’m guessing Brad’s complaint against baseline testing will be have the same impact as Michael Schumacher’s gripe about how uncomfortable Michael felt the HANS device was and how he hated to race with the device.

    • This is an interesting comment, and an interesting anecdote about Sergio.

      I initiated use of ImPACT testing when I was still working with Sid, and it is still used now. All drivers have baseline testing, including Sergio.

      Interestingly, after his accident in Monaco the current Medical Delegate re-tested Sergio and passed him fit to race in Montreal. After a few laps in FP1, he parked the car and informed the team that he was not sufficiently recovered to continue driving. (The team principles and Sergio himself came to me to ask me what they should do, and were most concerned about the decision-making capabilities of the Medical Delegate). This was, for a young driver with everything to prove, an exceptionally mature and wise decision, but it also illustrates a comment I made on Twitter – ImPACT is just one useful tool available to evaluate concussion and recovery from concussion. These tools must be used by a clinician experienced in the management and followup of patients with MTBI. The Delegate has none of this experience, either in the “real world” of medical practice (he’s a rheumatologist), nor in the world of racing.

      Sergio’s example is one of the most flagrant of the consequences of placing unqualified people in positions of undeserved authority. Had Sergio been less mature and continued banging out laps, this decision could have had disastrous and tragic consequences.

      Being personal friends with Jean Todt should not be considered to be sufficient qualifications to make life or death decisions in one of the most widely watched high performance sports in the world. The lives of the drivers, pit crews, and crowd depend in part on this person’s knowledge and experience.

  9. Pingback: Former F1 Doctor Gary Hartstein’s Rebuttal to Keselowski’s Comments on Concussions

  10. Failing any other reasoning hitting home…

    Dude, your job depends on the MENTAL part. Lots of people can do the steering wheel thing, but a champion knows how to RACE — which is mental — not just drive, which is physical.

    Even off of the track, your job is mental. Your salary, and the bills for your team, and in fact everything else in your sports world, is paid for by SPONSORS. You know, like Miller Beer? And Miller needs you to be a corporate spokesman just as much as they need you to drive fast.

    But if you scramble your brain — go talk to Ernie Irvan if you get a chance — you can’t do that very well. Not to mention that you can’t be nearlys as sharp with your comments to your team about the car, or for that matter, even remember which race you’re at this week. Both on and off of the track

  11. Few years ago I worked in motorsport, not at your level Gary, just a spanner monkey!

    I lost a very good friend and a driver that would have gone on to be very special. He died, partly, because he was testing at a circuit without any medical back up.

    I also had a step son that had a road car accident that resulted in a brain injury.
    The doctors in intensive care told me that they know very little about the brain.
    But I’ll bet they know a hell of a lot more than Brad!

    Gary I thank you (and Sid) for for all you have done to make motorsport safer.
    I sometimes help out with club race cars at race circuits in the UK and due to you the medical facilities and medical personal present are so much better.

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