A (nother) fantastic save! (long, a bit technical, surprise ending)

First of all, it’s fantastic to see James Hinchcliffe on the mend. As the story developed, we slowly were made aware of just how bad things had actually been. And now we’re told that he received 14 units of blood. This deserves some background, in order to fully understand just how well things worked for James . . . and draw some conclusions about how things are.

Even intuitively, hearing the number FOURTEEN PINTS is massive. Remember, James’ normal blood volume is probably (to simplify a bit) about 5 liters (for the english unit addicts, a quart is just about a liter). And a unit of red blood cells is about 400 ml. That means that his entire blood volume (5.6 liters to be exact) was replaced, presumably in the first 24 hours after admission. In trauma circles, that’s the standard definition of “massive transfusion”; this definition is not sterile, as it has important implications for management.

First, a few details.

Unlike what was headlined in some of the posts, the 14 units of blood were not administered BEFORE arriving at the hospital. There are several reasons for this (we will see the most medically relevant below), but the most practical is that this quantity of blood is NEVER available before getting to a hospital. The infield medical center at the IMS almost certainly has two to four units of blood (O negative, more later), but from there to the hospital, no blood would be available. More importantly, early transfusion of significant amounts of fluid are no longer standard protocol for massive bleeding.

The lovely tradition of drivers having their blood groups on their overalls is just that – a lovely tradition. No one, repeat NO ONE, will EVER EVER EVER be transfused based on some embroidered letters on his overalls. Ever. Period.

Let’s talk in some depth about just what and why the Holmatro team, and then the evac team who took James to the hospital did and didn’t do. First, some background.

Until very recently, the dogma in terms of taking care of trauma victims was to follow the “A B C” sequence. Life-threatening problems were dealt with in a very specific order. Problems with maintaining an open Airway were managed before problems with the Breathing, and only then were Circulatory derangements dealt with.

In terms of the circulation, by far the most common problem in trauma patients is hemorrhage. Blood loss causes a drop in the heart’s output, which in turn causes the various tissues of the body to be hypoperfused. This means that they receive too little oxygen and nutrients to maintain normal function. If this situation lasts, it is called hypovolemic (too little volume) shock. If this shock state lasts too long, it becomes irreversible; at that stage all attempts to save the patient are futile.

Advances in military medicine, notably during the Vietnam war, led to the idea of early and aggressive fluid replacement in shocked trauma patients. Intuitively this made perfect sense – since the primary problem was a deficit in circulating volume, restoring that volume (initially with relatively cheap and easy to store salt solutions) should allow cardiac output to trend upward, providing tissues with better nutritive perfusion.

This, in fact, is what is still taught in most mainstream trauma courses. After attending to the A and B parts of the protocol, we are told to rapidly begin infusing large quantities of fluid into shocked trauma victims.

The problem is, not only does this not work, but it actually makes things worse.


Once again, some visionary physicians, working in almost war-zone conditions (ok, Houston, Texas to be exact), followed by the conflicts of the 2000s, have taken the received wisdom and turned it on its head.

First of all, the A B C sequence is being, slowly but surely, revised. It is clear that with certain injuries (think IEDs, think suspension elements ripping up a major artery in the thigh), massive arterial bleeding will kill a patient within scarce minutes, usually even faster than loss of airway opening. This has led some to propose a newer, more time-relevant acryonym: MARCH. This corresponds to Massive hemorrhage, Airway, Respiration, Circulation, Head injury.

Remember Alex Zanardi’s horrible accident in Lausitz in 2001? Well when i title this post “another”, that’s the other save to which I’m referring. Both in Germany (kudos again to Terry Trammell and Steve Olvey), and at Indy last month, the rescue teams concentrated basically all their efforts on what we call “exsanguinating hemorrhage” – commonly known as the patient bleeding out.

The second reversal of “standard” trauma care is rather less intuitive, but incredibly important.

While the idea of rapidly restoring a normal circulating volume (again, using clear fluids) would appear to make physiologic sense, studies done both in civilian penetrating trauma, as well as the military’s amazing database show that it is plain wrong (the lessons from this database will save tens of thousands of lives over the next decades; this being one of the most significant and lasting legacies of the conflicts in Iraq and Afghanistan).

When we look at two groups of trauma victims in hemorrhagic shock, one of which receives early and aggressive fluid resuscitation, while the other receives almost no fluid (UNTIL THE SURGEON HAS STOPPED THE BLEEDING, meaning that resuscitation is not ignored but delayed), we see a very significant difference in outcome. And surprisingly, it’s the group who is “allowed” to remain shocked (again, and crucially, until surgical bleeding control is obtained) who do considerably better.

Why would this be?

There are a number of hypotheses, all of which certainly contribute to the better outcome:

  • Restoring circulating volume with clear fluids does not contribute to the oxygen carrying capacity of blood, and, importantly, dilutes the clotting factors so vital to stem the bleeding by natural means
  • Increasing the blood pressure likely makes the tenuous blood clots that DO form less likely to stay in place, increasing bleeding
  • Even when using warmed fluids (and this can be quite hard to do, especially in the pre-hospital environment) massive infusion of clear fluids will usually make the patient hypothermic. The thing is, our coagulation system is exquisitely temperature sensitive. It begins to fail, miserably, when temperature gets below around 35°C, a temperature that is all too “normal” in shocked trauma patients.

Another crucially important element that has come from study of the military’s experience in recent conflicts has to do with not just WHEN we replace lost volume (as soon as surgical control is obtained), but WHAT we replace it with.

When a blood donor give a pint of blood, that pint is almost immediately fractionated. The red blood cells are packaged separately (this is the fraction most often needed by patients who are anemic from various causes), with the plasma (it’s here that we find most of the coagulation factors) and platelets (tiny cell fragments vital in the coagulation process) packaged separately.

Until recently, it was felt that shocked trauma patients mainly needed red blood cell transfusions; it was thought that the need for plasma and platelets was relatively rare. In fact, when I did my residency, we were taught specifically that plasma was NEVER to be used “simply” to restore circulating volume…ever.

Well once again, what seems clear and logical turns out to be wrong. In fact, hemorrhagic shock almost immediately induces problems with the coagulation system. And the faster and more aggressively these problems are treated, the better the patient does. So much so that in state of the art facilities, the policy is that in the shocked trauma patient, the FLUID OF CHOICE for restoring volume is . . . you guessed it . . . plasma.

Enough background. Lets look at what the Holmatro team no doubt did, and how they kept Hinch alive long enough for the surgeons to save him.

There is no doubt that at the scene they were confronted with exsanguinating hemorrhage. Their first priority then was to get James out of the car, and to stop the bleeding, even temporarily. If the site of the bleeding was far enough down the thigh to allow use of a tourniquet, they certainly applied one, high and tight. If it was higher, precluding use of a tourniquet, they used modern wound dressings that contain substances that induce a powerful local formation of blood clots (called “hemostatic dressings”). In fact, they likely used both.

(This is another reversal in “standard” practice. It is still taught that tourniquets are last resort items. In fact, with exsanguinating extremity bleeding, they are the FIRST resort. Terry understood this intuitively with Alex in Germany, but it has not -yet – become the new normal. Once again, thanks to the military trauma docs for this.)

The Holmatro guys no doubt put in a few fat IV lines, but only infused enough fluid to keep Hinch (barely) alive, for fear of creating the situation I referred to above. They also probably gave him any of the O neg (universal donor) blood available from the infield med center. In addition, they certainly administered tranexamic acid, an old drug that “boosts” the coagluation system and has been shown to dramatically reduce mortality from hemorrhagic shock.

Then then prioritised evacuating Hinch to the hospital, and, crucially, made sure that there was an operating room ready for him, and that the necessary blood products were prepared. Once admitted, once the surgeons got control of the bleeding, the anesthesiologists began to transfuse. Not just red blood cells, but also massive amounts of plasma and platelets too. In fact, the ratio was probably pretty close to 1:1:1.

Make no mistake about it – only the knowledge, skill and teamwork of the Holmatro team at the scene made it possible for Hinch to get evacuated alive. They deserve massive credit for this. I sure take my hat off to them.

Now for the surprise.

American racing is organised more along the lines of just a few teams, who travel with their respective championships and thereby gain tremendous experience working with each other, training with each other, and staying current with best practice guidelines.

In F1, for a number of reasons, each circuit fields what should be an autonomous team. The FIA Medical Delegate and Medical Rescue Coordinator are only there, nominally, to provide liaison, coordination, and to confirm that regs are followed.

Long story short? Of the 20 races of the season, at best five to seven of these “autonomous” teams would be capable of saving James, had that accident happened at an F1 event. These are the teams that are mature, stable, experienced, and well led. And it’s not always the ones you’d think of that are up to the task.

There are a number of reasons for this, not least of which are high turnover in teams, lack of training, and lack of team member participation in prehospital trauma care in the “real world”. This is not new. When I was involved in F1 I continually trumpeted this fact to the hierarchy. Given that a permanent FIA team attending all races is just not realistic, I constantly pushed for more intensive simulation based training. The hierarchy found it politically inexpedient to deal harshly with the local Chief Medical Officers whose lack of leadership contributed to this. Remember, it’s the national federations who go on to vote for the FIA president.

Don’t get me wrong – the Medical Rescue Coordinator is present at every race, and is a massively experienced trauma doctor, fully equipped both in terms of knowledge, skills, equipment and leadership. And even at the majority of circuits where the local team would not be able to handle an accident as dramatic as James’, he has at his disposal sufficient “manual labor” to get the job done. That said, one must not labor under any illusions. If we imagine the same accident at every race of the season, the outcome will vary, sometimes dramatically, depending on where we are.

While the solutions to this are not simple (or cheap, no doubt), they do exist. All that’s necessary is the will and leadership to get the job done, and to improve the standards everywhere. And of course, the “knock-on” effects of such a commitment, both in terms of “lower” series as well as in trauma care in general, can’t be ignored.

Thanks for your patience.

The Bianchi accident investigation panel

We’ve been given a summary of the Bianchi investigation, and the 300-some-odd page report has been condensed to what looks approximately like 1.5 A4 pages.

Over 300 pages to less than 2. Holy crap. Either there are a hell of a lot of wasted words in the full text, or someone has really mastered the art of the resumé.

I can’t say much about the reasons behind not releasing the full text of the report, but it is clear that the credibility of the conclusions, such as they are, is not helped by the absence of corroborating background.

In addition, when we look at the composition of the panel, we realise that fully HALF the members have a clear and unambiguous conflict of interest in any investigation. The current positions, and indeed future careers in motorsport, of those panel members who are not dear personal friends of the FIA president depend intimately on remaining in his good graces. Mind you, I am not impugning the integrity of anyone. That’s what’s so insidious with conflicts of interest. They only have to appear to exist to have their negative effects.

This of course rang alarm bells when the panel was formed, but courtesy, decorum and respect no doubt calmed the chuckling at the idea of a body investigating itself. I fear that chuckling was perfectly appropriate.

Let’s get a bit more specific.

The primary conclusion, that Jules was driving too fast, is, as I’ve said before, true by definition. I’m surprised at the reactions of those who feel that this is somehow unfair, unjust, or unkind. It is none of these. Young men make mistakes of judgement all the time, and some pay a grievous price for it. That is the case here. The technical details of BBW and FailSafe are just that – details.

I smiled when I read:

It is considered fundamentally wrong to try and make an impact between a racing car and a large and heavy vehicle survivable. It is imperative to prevent a car ever hitting the crane and/or the marshals working near it.

Suppose they’d said that 60 years ago about Armco? We’d not have developed the know-how that led to 6-row tire barriers with conveyor belting, and we’d certainly not have Techpro. I wonder what would’ve happened to my friend Perez in Monaco a few years ago? Actually, I KNOW what would have happened to him. Ironic, isn’t it? Somehow both goals stated in that quote seem worthy of pursuit; neither do they appear mutually exclusive.

Now it gets a bit complicated. You see, the entire summary (and therefore presumably the report itself, but we have no way of knowing that) is focused on the events leading up to the accident. There would appear to be no attempt to look at those elements of the response that are there to mitigate the consequences AFTER the event has occurred. And now I start to get rather uncomfortable.

We are told:

All rescue and medical procedures were followed, and their expediency are considered to have contributed significantly to the saving of Bianchi’s life.

The first part of this statement is patently untrue. Egregiously. The self congratulatory second part, while certainly true, is inappropriate.

Bear with me, and struggle through this excerpt from the Appendix H of the FIA’s own International Sporting Code (that concerned with “Supervision of the Road and Rescue Services”).

An evacuation under intensive care by medically equipped ambulance (equipment and presence of a doctor proficient in resuscitation on board) with an escort may, however, be carried out, provided that the receiving hospital has been approved beforehand for the treatment presumed necessary according to the casualty’s condition and that it can be reached in approximately 20 minutes (except for serious burns), regardless of the weather and road traffic conditions (except in a case of force majeure). If these conditions are not satisfied, the timed session must be interrupted.

d) Unforseen circumstances, especially the weather, may prevent the arrival, departure or return of the helicopter. In such a case, and after consultation between:

– the Chief Medical Officer;
– the Race Director; and
– the FIA Medical Delegate;
an ongoing or interrupted timed session may perhaps continue or be resumed depending on the conditions of evacuation of a casualty under intensive care to one of the hospitals mentioned in the medical questionnaire for the event and approved by the FIA Medical Delegate.

We were told at the Sochi press conference that the evacuation took 40 minutes. Twice the 20 minute upper boundary that THE FORMULA ONE MEDICAL DELEGATE HIMSELF HAD WRITTEN INTO THE REGS.

We were also told at Sochi that Jules’ condition at the end of that waterlogged siren-punctuated ambulance ride to the hospital was exactly the same as when he left the circuit. Are you kidding me?

Don’t get me wrong. I have no doubt that my Japanese colleagues were indeed able to make sure that Jules’ blood pressure, heart rate, oxygen saturation, expired carbon dioxide, etc (the EXTERNAL parameters, the ones we measure easily) were unchanged over 40 minutes.

But find the nearest neurosurgeon and ask him if the brain of a patient who’s had a head injury with immediate coma is the same after 40 minutes of transport as after 20 minutes, and he’ll look at you like you were nuts. Because you are.

Why did Dr. Saillant not address the question of EXACTLY when the Medical Delegate (his personal appointee) knew that the helicopter could not land at the receiving hospital? Under difficult circumstances this often requires near real time communication with the helicopter crew. The delegate is up in race control with nothing else to do during the race. That’s why he’s there. Why was racing not stopped? This is far from a trivial issue, and is all the more dramatic that the FIA’s own regulations would appear to have been ignored by their author, the Medical Delegate.

This is a potentially grievous error, and it is all the more shocking that the question is not even addressed. And unfortunately this is precisely the kind of result one would expect with a panel studded with insiders.



Before the reform frenzy starts

We’re just over 48 hours since Jules’ accident. Still hoping and praying for a good outcome. And of course, by now, the dust is settling, and discourse becomes less emotional, less intense, and more reasoned. I thought I’d take advantage of this period of relative calm to put a few thoughts out there.

The first thing I want to point out is that the three most severe accidents we’ve had since 1994 have all occurred through mechanisms that are not easily predictable. I’ll not go so far as to use the expression “freak accidents”, but being hit in the head with an 800 gm spring, driving into the lifting tailgate of a lorry, or aquaplaning into the exact spot a recovery unit is working are not your standard scenarios.

I say this because we need to have a bit of perspective here. Virtually every weekend we see, often with a quiet “ho hum”, accidents that in a not distant past would no doubt have been fatal. Basically, the things that used to kill and maim drivers have almost been engineered out of the system. Fire? (Williamson, Courage, Bandini to name a few)? We just don’t see it anymore (yes we had a few, but none with any significant consequences). Frontal collisions? (Rindt) We shrug off the most spectacular. Side impacts (Senna)? Ehhhhh… Flying rollovers? Shaken, but not stirred.

Not only do we almost have to invent bizarre ways to get hurt, but when someone DOES fall victim to an unusual accident, the governing body has shown itself fairly adept at acting appropriately. Felipe’s accident? Zylon visor reinforcements. Etc etc.

Jules’ accident was INCREDIBLY violent. It is a miracle he is alive, purely and simply. And this is a testimony to the entire system. Where should we look if we want to find out if there actually IS anything to change?

To start with, I’ll harken back to one of my pet peeves.

Those of you who saw the video no doubt were impressed by just how fast that Marussia was winging it as it streaked through the runoff area into the JCB. I surely was. And I was all the more impressed that:

  • Jules was certainly aware of the risk at that point of aquaplaning (and was no doubt told of SUT’s off)
  • there were double yellow flags displayed at one, and possibly two, upstream marshal posts.

For the sake of my sanity, I’ll point out again that double yellows mean that the track might be obstructed, that there are HUMAN BEINGS WORKING trackside of the Armco, and to BE PREPARED TO STOP.

I’ve been a passenger in an F1 car, and can confirm that the brakes are phenomenal. That said, given the water on the circuit, given the loading on the car through corners 6 and 7, and given the speed of that Marussia, it is indisputable that Jules carried MUCH TOO MUCH speed into that corner. By definition. He is instructed (by the flags) to slow enough to be able to stop, yet he was fast enough to aquaplane. Those are mutually exclusive options. Period.

I’ve been saying since 2010 that flag discipline is deteriorating, and it’s deteriorating fast. And no one is making properly vigorous efforts to re-establish it.

At every F1 drivers briefing, the drivers hound Charlie for a number – “how fast can i go under yellows?” or “how fast under double yellows?”. Or even, “will I be penalised if I do 0.2 sec less than the last time thru that sector…”


The point is that the speed that’s appropriate under double yellows is variable. It’s not a speed limit, it’s a warning. Just ahead you might have nowhere to go. Or, just ahead someone’s uncle, brother, father is pushing one of your colleague’s cars off the circuit (remember the marshal whose legs you broke in Monaco Pastor? When you kept your foot in it through double yellows into Casino? I do).

I bet that the “appropriate” speed through T6-7 Sunday was probably something like 80-100 km/h – something like pit lane speed. Had drivers done that, the absurdity would have rapidly become apparent, and race control would have had little choice but to deploy the SC.

Disrespect for flag discipline is not a minor issue. It kills and injures people. If flags are respected, things get remarkably safer. If these flags had been respected, it is hard to imagine this accident happening, at least with this kind of energy.

Before we start changing everything, wrapping JCB’s in tech pro, putting SC’s out every time someone’s in the armco, let’s correctly apply the spectacularly effective safety system already in place. And let’s start by making sure drivers actually respect the SPIRIT (“be prepared to stop”) and not the LETTER (“how many tenths down do I have to be to not get a stop-go penalty?”) of the safety regulations.

Oh and one last thing: please Jules, get better fast.


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


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.