Carlos Sainz (Jr.) and Sochi

While hoping to be forgiven for the long delay, I do need to address the issue of Carlos Sainz’s return to competition after his accident in Sochi. Here’s my slant on the question.

Carlos’ accident was very violent; certainly it would be normal to expect at least some concussive symptoms (given that other physical injuries were ruled out). The short observation period followed by a quick release from the hospital were reassuring of course, but even concussed patients are not kept hospitalised (unless there’s another reason) just for these symptoms.

Once he (and the team) made clear that he wanted to race on Sunday, he had to be examined by both the circuit’s Chief Medical Officer and the FIA Medical Delegate. (Unfortunately, it would have been better to have had to have his accident in Austin, where the CMO is Dr. Steve Olvey, a world expert on concussion, especially in the motorsports environment.) This examination would include a thorough history, looking for subjective symptoms of concussion, as well as a detailed neurologic examination.

Carlos would also have had to re-take the ImPACT test, a computer-based neurocognitive battery specifically designed to detect concussion. All the drivers get tested pre-season (to supply baseline data); they are retested whenever concussion is suspected.

The ImPACT test consists of a number of subtests, each of which looks at a different aspect of brain function (visual memory, executive function, pattern recognition, etc). It’s crucial to note that the test starts with a review of SUBJECTIVE symptoms – a series of true false questions (“I slept well last night”, “I have a headache”).

My conclusion? I find it odd that Carlos failed to mention his dizziness pre-race to ANY MEDICAL STAFF AT THE CIRCUIT, including the CMO and the Medical Delegate, who unquestionably asked that specific question. And that he blabbed about it to the press almost immediately after alighting from his car. Let me repeat this: this kid denied symptoms to the people responsible for his care, got into his car, raced, then complained about not being well-taken care of.

HOW STUPID IS THAT?

One of the biggest problems with concussion is that many of its symptoms are subjective. That means they can be denied. As in all other walks of life, ultimate responsibility for one’s health and safety lie with oneself. If you’re stupid (or competitive, or just ignorant) enough to deny your symptoms when specifically asked by your doctor, you’d best have the maturity to deal with the consequences.

As much as the Medical Delegate’s lack of experience enrages me (and I can only assume that the Russian CMO was equally inexperienced, I give him a pass on this one. He was clearly dealing with a patient who was not mature (or honest) enough to respond accurately to the questions he was asked by his doctors.

35 thoughts on “Carlos Sainz (Jr.) and Sochi

  1. Thank you so much for writing about this! I am a rural family doc and the more adults act like grown ups, the more likely it is that our high school football players and wrestlers and soccer players will take it seriously….

    • Excellent question! In fact, numerous medical associations have indeed called for boxing to be banned. Let’s remember that this is a sport whose goal is to inflict a head injury on one’s opponent. That in itself should be reason to make it illegal.

      Interestingly, well before the long-term consequences of head trauma on brain structure and function were called Chronic Traumatic Encephalopathy, the constellation of clinical findings in these patients was called DEMENTIA PUGILISTICA.

      Guess that about says it all.

  2. Other news: It is a pity some large conglomerate can’t wade in and pay for a seat for Suzie Wolff to become the first woman driver in formula one racing for many a year – the last female starter of a F1 race was in 1976 (according to Wikipedia).
    Suzie Wolff retiring from F1
    http://www.bbc.co.uk/sport/0/formula1/34714704
    List of female F1 drivers
    https://en.wikipedia.org/wiki/List_of_female_Formula_One_drivers#Official_drivers
    Sponsored drivers:
    http://www.bbc.co.uk/sport/formula1/21194933

  3. Hi Gary,
    Thanks for this, I was quite worried about Carlos apparently wanting to get back in the car when it looked like he had a concussion – although I suspect that most people competing in sports have a tendency to ignore their injuries – pro cyclists as an example getting back on the bike with broken legs, wrists and even a broken pelvis!
    I’m currently suffering from post-concussive syndrome myself after a high-speed accident on my bike in June. I had a whole bunch of interesting issues after a severe concussion from problems with visual processing to difficultly reading – but dizziness was a constant symptom for the first 10 to 12 weeks. Finally I didn’t have it all the time – but now my symptoms regress under conditions of high-cognitive load – the higher the load, the higher the amount of dizziness. Coupled with that when I feel dizzy my brain also seems to ‘slow down’ and I have more difficulty with higher functions such as constructing sentences and ‘thinking’. I guess my thought was that perhaps Carlos didn’t feel dizzy but tracking movement in the car and what must be a huge cognitive challenge of driving the car brought the symptoms back. But given that, I agree it was dangerous for him and everyone else to continue – perhaps the drivers need to be educated better – not only about the risks but about not feeling bad about saying no. I really admired Perez when he said he wasn’t fit to drive after his Monaco accident.

    • Thanks so much for your comment! Especially for pointing out how the natural time course of recovery often proceeds from near constant symptoms to symptoms only under progressively higher cognitive loads. The same is true for PHYSICAL exertion, which is often used as a “gauge” of recovery.

  4. This was so obviously stupid that I wonder if it demonstrates lack of frontal lobe maturity in a young driver. I wonder if the system takes into account that the frontal lobe is the last to develop and if there is any way of protecting drivers from their own immaturity until their brains are fully mature. I’m sure that I’ve read somewhere that the young brain may be more vulnerable to concussions as it is still developing. At least it demonstrates that Alonso’s brain must be fully mature now.

  5. Hello Gary,

    I recall a few years ago in NASCAR Dale Earnhardt Jr. had a bad crash and suffered a concussion. He then had another which sidelined him for a while. This raised the issue that having a crash while the brain has not fully recovered from a concussion is very dangerous. Do you feel this notion has not fully reached formula one yet? Or am I talking non sense?

    • Hi Dennis, and thanks for writing. Dale Earnhardt’s consecutive concussions illustrate an extremely important and well-documented fact: until the FIRST concussion is completely healed, a patient is at EXTREMELY high risk of a second. This is likely because of concussion’s effects on cognitive function as well as on strength, reaction times and balance. The problem is that a second concussion, in addition to the fact of the cumulative long-term damage from multiple concussions, can cause catastrophic brain swelling (often leading to prolonged coma and/or death), even with relatively minor impacts (called the second impact syndrome).

      Sid and I have been proactive about ALL aspects of concussion management since 1998, including using neurocognitive testing, obtaining pre-season baselines, and strict return-to-comptetion criteria. In fact, not only have these notions reached F1, but they reached it 15 years before almost every other sport.

  6. Hey Dr. Hartsein. Nice to see you back. The entire Sainz accident is extremely worrisome to me.
    The way I see it, either Carlos lied through omission to his team and the medical staff, or the medical staff was aware of Carlos’s condition and let him race anyway. Either situation is frightening. If Carlos failed to tell anyone about his dizziness prior to or during the race, he should be banned from racing forever. He put his life, the lives of every other diver, and the lives of the marshalls & spectators in jeopardy.
    If the team/FIA/medical staff were aware and let him drive anyway, I shudder to think of what the potential consequences could be in the future.

    • It is worrisome. Not sure what, if any, sanctions should apply, but if I were the Medical Delegate I’d surely delve deeper into what exactly happened. If indeed Carlos wilfully denied symptoms at the very least he should be warned and sternly lectured!

  7. Thanks for the reply, Gary. No problems on any delays.
    I agree 100% on the stupidity comment, at the very least it was stupid of him not to say something, or pull off the track. That he has said something, and no action or reaction from the powers that be, or anyone in a position of authority including his team (from what I’ve seen), is worrying. In fact, the whole event is disturbing. To my mind, its symptomatic of F1 increasingly paying lip service to safety.

    • Rather than safety becoming a less important objective, I think that what you’re seeing is the FIA keeping the Medical Delegate out of the spotlight, and this for a number of reasons. He speaks English poorly, and under proper journalistic questioning his lack of experience would be immediately apparent. They are also deathly afraid of him being asked questions about helicopter operations and the decision-making around that at Suzuka in 2014; I still think that they are at high risk of a law suit and then at high risk of loosing, and keeping Piette out of the spotlight would help reduce that risk.

  8. Wouldn’t it be better to say if a driver was exposed to xxG forces in a crash to not only have a mandatory hospital visit (as is now) but also a mandatory 2 week (or whatever is sensible) ‘cool off’ period to recover? Take the drivers feelings out of the equation and err on the safe side?

    • I think that the current system isn’t bad, but does indeed require just a tad of maturity on the part of the drivers. When I was Medical Delegate I was prepared for drivers to refuse to take a baseline ImPACT test (none refused) – I’d have told them that without a baseline I’d be forced to keep them out of the cockpit for FOUR weeks if I even suspected a concussion. When they understood that the testing might actually get them back racing faster than without objective data, all resistance melted away.

      • In a discussion on this very subject last weekend someone posed the question “what if someone deliberately (and cynically) underperforms in their baseline tests at the start of the year thus guaranteeing thry won’t fail to match up to them in the event if a concussion?” Obviously I have no specific knowledge of the baseline tests but it’s an interesting point – what do you make of the suggestion that it could happen Gary?

      • Good question. I remember walking Jacques Villeneuve from his motorhome to the place where I was doing baseline testing. He was not happy. He told me that he was going to do “poorly” intentionally. I told him that 1) we have extensive data on the scores of age- and education-matched subjects, and that if his score deviated significantly I’d invalidate the test and keep him out of the car for a month in case of suspected concussion.

        Secondly, these guys are SO competitive, no matter what their intention is when STARTING the ImPACT test, they get caught in “doing well” and obviously try to do great.

      • Setting low baseline scores is something that’s talked about in the world of rugby, and was one of the things that Dr. Barry O’Driscoll was critical of after he resigned from his post with the IRB (http://www.planetrugby.com/news/irb-must-tackle-concussion-head-on/). Things are getting slowly better, with the introduction last season of a protocol for a ten-minute mandatory “Head Injury Assessment”, but there’s always more work to be done

      • As I’d mentioned, we have normative data on a HUGE population of age- and education-matched subjects. This allows us to “ballpark” test results if we doubt the good faith of the test taker. This, plus the ultra competitive nature of the drivers (they go crazy when they get a “wrong” answer, every single time!) means we were lucky enough to never have had this problem.

  9. It certainly felt rushed to see him racing so soon after such an impact and media comments that he must be fine because he didn’t pass out were ill informed and worse, dangerous.

  10. I could imagine a scenario where the driver feels “okay” but then a few laps pulling 2-3-4-5 G’s, with vibration and noise and lots of visual stimulation, might “disclose” other symptoms. I recall such a case a few years ago in IndyCar — driver thought she was okay, tried to drive, quickly abandoned the effort.

    • You are totally right. This happened to Perez in Montreal on Friday after his huge accident at Monaco at the previous race. He was cleared but was massively symptomatic and boxed. So if this is what happened, he should have done the mature thing and parked it.

      • But obviously now we’re dealing with F1 driver / team culture. Putting it mildly, it is said to be ruthless, and any sign of injury or weakness — or unwillingness to “play hurt” — is seen as reason to give a call to the next driver?

      • On the part of a young, relatively inexperienced driver, I could understand it. But it’s obviously foolish and in an era of liability phobia is clearly not an attitude to be accepted.

  11. People recover from concussions differently. If you ignore symptoms and in doing so jeopardize the lives of hundreds, as in racing that’s one story. A tennis player from Canada fell and hit her head on the locker room floor and got a concussion. She may have ignored her symptoms and played again much too soon but in doing so no lives were put in danger. She is now suing the USTA for millions. And that is another story.

    My point being….there are different motivations for people doing what they do in competitive sports. There is the motivation of money, points, publicity etc.
    The only problem I have with someone ignoring symptoms is when by doing so they put the lives of others in jeopardy.

    I hope I made a little sense here….;)

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