INTERNATIONAL JOURNAL OF MOTOR SPORT MEDICINE ISSUE#8, SEPTEMBER 2016

VIDEO LARYNGOSCOPES An examination of the equipment used to visualise a patient's larynx P26 INSIDE THE WEC MEDICAL A new car carries the medical kit in the World Endurance Championship P30 NICK HEIDFELD The racer describes a recent injury and his recovery process P34

MAN VS MACHINE Land records are being broken at record pace and the FIA is ensuring that medical provisions for drivers keep up AUTO+MEDICAL AUTO+MEDICAL

Welcome to the new issue of AUTO+Medical, which features the latest news and reports from the world of motor sport medicine. As a member of the publication’s editorial board, I am pleased to present this edition. In our cover story we hear how the FIA is LETTERS/ applying universal standards to the medical P4 The best letters and emails received from readers around the world provisions for land attempts and we then introduce a new series of features that GLOBAL NEWS/ will study specific pieces of kit often used by P6 ICMS set to host 26th Annual Congress medical motor sport personnel, with the first P8 Grand Prix Trust renamed to broaden motor sport reach focusing on video laryngoscopes. P9 Injured IndyCar star praised after victory Elsewhere in this issue we speak with P9 MDD named FIA's official medical products supplier P10 Vienna set to host FIA medical summit Dr Kelvin Chew, the CMO of the Singapore Grand P11 Williams brings F1 skills to neonatal care Prix, about the challenges of running the medical team at ’s only full night race. We FEATURES/ then take a look inside the World Endurance P12 MAN VS MACHINE Championship’s new medical car, and hear from The FIA’s Land Speed Records Commission sets out to ensure Nick Heidfeld about his recovery from injuries minimum medical provisions are in place for speed challenges sustained in a Formula E race last season. P20 CMO PROFILE: DR KELVIN CHEW Our scientific paper examines the latest theories Dr Kelvin Chew on organising the Singapore Grand Prix, challenges he has faced and how he would improve motor sport medicine and practices applied to resuscitation P26 VIDEO LARYNGOSCOPES techniques, while discussing how these ideas An in-depth examination of the equipment used to visualise a could be best applied to motor sport medicine. patient's larynx that is used by medical motor sport personnel Finally, I would like to express my condolences to P30 INSIDE THE WEC MEDICAL CAR the family of Dr Phil Rayner, the FIA Formula E The World Endurance Championship has introduced a new medical Medical Delegate who sadly passed away in May. car that carries the kit to help drivers from multiple racing classes You can read our full obituary to Phil on page P34 THE ROAD BACK: NICK HEIDFELD The Formula E racer shares his thoughts and memories on the wrist seven of this issue. injury he sustained at the 2015 Putrajaya ePrix I hope you enjoy the latest issue. STUDY/ P40 MOTOR SPORT RESUSCITATION REVIEW Dr Matthew Mac Partlin discusses the latest resuscitation techniques and explains how these can be applied to motor sport

Editor: Marc Cutler Dr Matthew Mac Partlin Deputy Editor: Alex Kalinauckas Designer: Cara Furman Critical care physician, , Deputy CMO WRC Rally Australia, Assistant CMO Formula One We welcome your feedback: [email protected] Grand Prix Australia, CAMS NMAC

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Teams practice on the extrication simulator at a training event at the Le Mans circuit

In this section, we print the best letters and emails received from readers around the world. We welcome comments on articles as well as suggestions for future content. If you wish to send in a letter or email, please direct it to: [email protected]

Dear Editor, their countries, doctors should work hard to acquire I would like to share my thoughts about the motor knowledge by themselves. Moreover, a doctor trained sport medical training available to doctors, especially in pre-hospital care in a developing country should in developing countries, and the value of publications not hesitate to begin practicing but they should always like AUTO+Medical to help prepare doctors for keep in mind to pursue the highest standards of motor motor sport events. It is essential that doctors in all sport safety possible. AUTO+Medical is a publication developing countries realise their role is much more that allows doctors at all levels to keep in touch with important than just taking care of injured drivers. the latest developments and see how others are By highlighting the range of motor sport medicine working in the sport. activities we can understand our duties may cover Dino Altmann many different areas. Chief Medical Officer or the Brazilian GP First, comes preventive measures concerning drivers, circuit and car safety. It is possible to keep up with the Dear Editor highest standards of motor sport safety by working We would like to buy a Formula One training together with organizers, engineers and drivers. chassis, like the one the FIA Institute developed to Second, comes the medical organisation itself. practice for our extrication teams. Could you help Despite having access to the FIA International Medical me and I’m sure other events by detailing where Regulations, the budget is not always available to can we find one and how can we arrange it? follow them and there may be a need to adapt to Thanks a lot, the reality in the best possible way. Doctors should Laszlo Gorove MD not be afraid not to follow the highest standards. Chief Medical Officer of the Hungarian GP Therefore, I suggest they should begin with the best they can achieve and try to pursue the ideal scenario. Editor: Thanks for your question. The F1 extrication Experience, time and their commitment will convince simulators, an FIA Institute initiative, are used for other people to invest in ones’ proposals. Training has training and practice at Grand Prix circuits around always been a very important part of best practice. the world. Built from fibre-glass, these simulators Third item to tackle is the anti-doping program which (pictured right) are replicas of F1 from the is not an easy one but as important as any other bulkhead behind the driver to the nosecone. They medical practice. It makes competition fairer and safer. offer the chance for track teams to practice before Fourth comes recovery and reintegration of an injured and during the event weekend. They can be purchased driver back into to competition. The final decision may from the FIA Institute by contacting the FIA, the FIA be the result of a medical panel of physicians from Institute’s education partner. For further information, different specialties and other medical disciplines. please contact Kate Robson ([email protected]) from In conclusion, there is no other way to work in motor the FIA Development Department, with a copy to sport other than beginning to practice. Not having Jacques Berger ([email protected]) from the FIA Safety other experienced doctors in motor sport from Department. 4 5 AUTO+MEDICAL GLOBAL NEWS AUTO+MEDICAL GLOBAL NEWS

DR PHIL RAYNER, 1950-2016

Dr Phil Rayner, Chief Medical Officer for the MSA and a long-serving member of the FIA Medical Commission, passed away suddenly at home on 4 May 2016. GLOBAL A Consultant in Anaesthesia and Intensive Care in Chesterfield Hospital for many years, he recently retired from the NHS only to take on the role of FIA Medical Delegate for the newly formed FIA Formula E championship. Dr Rayner was the Chief Medical Officer for Wales Rally GB for over 20 years, equally at home working as NEWS CMO with the rally as he was on circuits sitting in the Formula One chase car alongside Professor Sid Watkins. He was also Chairman of the MSA Medical Advisory The 26th ICMS annual congress Panel and a member of the FIA Anti-Doping takes place on Disciplinary Committee since its formation. 7-8 December Dr Paul Trafford, who worked with Dr Rayner for many years, said: “Phil was totally unflappable, always having a sense of humour but always being a total professional. He will be missed by all those who worked with him and knew him and our sincere sympathies go out to his wife Pauline and the family.” Professor Gérard Saillant, FIA Institute President, said: “Phil was a leading member of the motor sport medical community with a great amount of knowledge and experience. I would like to express our sincere condolences on behalf of everyone at the FIA and our thoughts are with his family, friends and colleagues.”

The medical cen- tre at the 2016 London ePrix was named in memo- ry of Dr Rayner

ICMS SET TO HOST 26TH ANNUAL CONGRESS

The 26th International Council of Motorsport Sciences’ drivers,” read a PRI statement. (ICMS) Annual Congress will take place on 7 – 8 The second annual Race Track Safety Program (RTSP) December 2016. will also take place on 9 December 2016. This seminar, The event, which takes place alongside the which is presented in conjunction with the ICMS Performance Racing Industry (PRI) Trade Show at the congress, includes educational and practical Indiana Convention Center (ICC), will present and discuss demonstrations of safety techniques to be used by the latest scientific, medical and educational research on-track medical and safety teams working at motor across all forms of motor racing. sport events. “The ICMS’ 26th Annual Congress will educate and After the RTSP has concluded, a Race Track Safety inform international motorsports personnel, scientific Team Demonstration will be given by “some of the and medical stakeholders, sanctioning body personnel, world’s most experienced safety response teams”, who car designers and constructors, race team managers will offer their own personal insights and experience of and drivers, and industry organizations on improving on-track safety initiatives. This event will be open to all safety and performance for racers as well as highway those who attended the PRI Show at no extra charge.

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DRIVERS TOLD TO MDD NAMED FIA'S OFFICIAL COVER UP BY NEW FIA REGULATION MEDICAL PRODUCTS SUPPLIER

A new FIA regulation will The FIA has appointed MDD services regardless of motor sport require all competitors Europe Ltd (MDD) as its official level and recognition by the FIA of in circuit events, hill- supplier for medical products. our commitment to continual climbs, special stages MDD, which has been the development, quality of rallies and selected medical and safety team provider improvement and service sections of cross-country for the FIA Formula E series since it provision is well received. We aim competitions to make began in 2014, produces a range to continue to build on its success sure their neck, wrists of medical equipment from small by working in collaboration with and ankles are doubly tools to full medical centre the FIA to develop and improve the protected against fire. refurbishment or new buildings. safety provision at all levels of The latest rule The company also provides motor sport”. was included in the clinical and safety personnel, as Laurent Mekies, FIA Safety governing body’s 2016 well as specific training packages. Director, added: “The FIA is pleased update of Appendix L Its Director Peter Schroeder hopes to extend its partnership with of the International INJURED INDYCAR STAR that the new deal will “develop and MDD, in several FIA Drivers’ Licences, PRAISED AFTER VICTORY improve” medical and safety Championships. We look forward Medical Examinations, considerations in motor sport. to developing further medical Driver’s Equipment and He said: “We are delighted to technologies with them. It is also Conduct requirements. IndyCar safety consultant Dr Terry have been selected as the official crucial for us to provide our teams The regulation states: The Grand Prix Trammell has hailed Josef Newgarden’s supplier of the FIA in providing our on the ground with the highest “The neck, wrists and Trust was established return to racing after suffering a broken range of services to the motor standards of medical equipment in 1987 ankles shall always be hand as “remarkable.” sport industry. We pride ourselves and we know that MDD will covered by at least two The Ed Carpenter driver fractured his on our drive for high quality deliver.” articles of protective right clavicle and right hand in a major clothing. The balaclava crash at the Texas Speedway on 12 June and underwear shall but he climbed back into the cockpit for GRAND PRIX TRUST RENAMED TO overlap by a minimum the next race at just 12 of three cm around the days after the accident. BROADEN MOTOR SPORT REACH driver’s neck, except at The American driver finished eighth the front central line on his return to action and then won the where they shall overlap following event in Iowa. The Grand Prix Mechanics Trust The support offered by the by at least eight cm.” “The kid is amazing,” said Trammell. has been renamed as the Grand Trust today ranges from financial “A week after surgery he’s back in the Prix Trust as part of a drive to help assistance, to specialist medical car and a couple of weeks later he’s more people involved in motor advice, rehabilitation or back in victory lane. For all my years sport. repatriation, and guidance he wins the prize for the fastest guy The Trust, which was relating to rights and benefits. back in competition and, frankly, it’s established 29 years ago by Sir Each case is treated confidentially remarkable.” Jackie Stewart, provides support, and mechanics from many eras of “I watched his steering input on a help, and advice to current and F1 have been helped. computer [at Road America] and he was former employees of Grand Prix A Grand Prix Trust statement so precise. Turning left all day with those teams and their families if said: “For 2016 we will be G forces and he never turned the wheel something goes wrong. renamed the Grand Prix Trust to more than one or two inches all day. Stewart created the Trust after recognise the broader reach and And his hand was still plenty weak, so becoming aware that many teams scope of those whom we can help, that made it even more impressive. He and mechanics competing in his as Formula One roles evolve. Our drove like a man possessed and never era, and before, often did not aim is to be there for those made a mistake and it was remarkable have insurance, pensions or coming into the sport tomorrow to watch." financial comfort to provide as well as those who served it with support in the event of fatal or honour in the past, and we See p34 for Formula E driver Nick serious incident. appreciate your support.” Heidfeld on returning from wrist injury.

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INDYCAR STAR RACES USING WEARABLE TECHNOLOGY

IndyCar driver Tony Kanaan has used biometric monitoring technology woven into his race suit to monitor his body during races in 2016. The Brazilian driver has sampled the Hitoe shirt, which is produced by NTT Data, and measures heart rate, respiratory rate intervals, and muscle activity in the form of electrocardiogram (ECG) and electromyogram (EMG) waves. Kanaan said: “The shirt is allowing me to see in great detail what is happening to my body when I’m in the car.” The Hitoe technology works by applying an electro- conductive polymer to nanofibers, which turns the VIENNA SET TO HOST FIA shirt fabric into a collector of physiological electrical data. MEDICAL SUMMIT “As a medical doctor, I saw people experiencing complications that could have The 2016 FIA medical summit will take Laurent Mekies will provide an update been avoided if diagnosed place in Vienna on 28–29 November. on developments for frontal protection and treated sooner,” said Dr. The event, which will take place at on single seater cars. The day will end Tsukada, the NTT researcher WILLIAMS BRINGS F1 SKILLS TO NEONATAL CARE the Hofburg Palace, will bring together with a welcome cocktail at City Hall. who invented the Hitoe leading medical motor sport personnel The second day of the summit wearable technology. “I from around the world. features a workshop session on wanted to provide doctors The Williams Formula One team has offered its expertise “Analogous with the requirements of an effective FIA President Jean Todt will open the intraosseous infusion and hands-on with the ability to monitor in delivering rapid pitstop times to help improve care for pitstop, we have worked with the Williams team to summit with a welcome speech airway management on track (both ECG and EMG on a consistent neonatal patients at the University Hospital of Wales implement Formula One techniques and processes to alongside Professor Gérard Saillant, surgical & non- surgical) by Dr Harald basis, allowing them to (UHW) in Cardiff. augment neonatal resuscitative care”. the President of the FIA Institute. Hertz and Dr Amjad Obeid. The second proactively treat conditions The British team, which achieved the quickest pitstop Claire Williams, deputy team principal of the Williams The itinerary for the first day of the workshop session will cover “Halo and before they become worse.” at 11 out of the first 13 Formula One races held this squad, added: “If some of the advice we have passed on conference includes a round table Extrication with FIA training chassis season, sent members of its operations crew to UHW to helps to save a young life then this would have been an discussion on concussion and the and technique to open a visor without discuss ways that the hospital could develop its practices extremely worthy endeavour.” wider issues surrounding the subject, moving the head”. Dr Jean Duby and when it came to resuscitating newborn babies. UHW is also developing a plan to get its staff to use with contributions from Professor Dr Theodoros Voukidis will then give a The hospital has since audited and streamlined its more hand signals, an F1-style radio-check before each Jean-Charles Piette, Professor Peter demonstration on the use of a motor equipment trolley to make locating it faster in emergency resuscitation, and apply video analysis and debrief Hutchinson and Dr Dino Altmann. sport survival kit. scenarios and has mapped out the floor space in its delivery sessions following every procedure it completes. A second round table will examine Papers will be presented on topics theatres to clearly show the area where its team will work, Other F1 teams have also worked with hospitals in the use of cervical collars for trauma such as consistency issues for much like Williams’ pit crew does at each Grand Prix. recent years. McLaren repurposed its Electronic Control patients, with contributions from Dr extrication training, and simulator Speaking about the arrangement, Dr Rachel Hayward, Unit to monitor young patients' vital signs at the Michael Scholtz and Dr Jean Duby. training of medical car and extrication specialist registrar in Neonates at the University Hospital Birmingham Children’s Hospital, while invited Papers will be presented on topics teams. Professor Saillant will then of Wales, said: “There is a growing amount of evidence to staff from London’s Great Ormond Street Hospital such as video laryngoscopes and the deliver the closing remarks. support a systematic approach to resuscitative care, to its Maranello base to learn how choreographed responsibilities of CMOs at motor To register for the Summit, visit: which is time-critical and dependent upon optimal team pitstop teamwork could improve their procedures sport events, and FIA Safety Director www.bit.ly/medsummit16 dynamics and clear communication. during surgery.

10 11 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES FEATURES MAN VS MACHINE Land speed records continue to be rapidly broken and Formula One’s Dr Ian Roberts has been appointed to the FIA’s Land Speed Records Commission to ensure that the medical provisions for drivers keep up

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Racing across a barren desert for mile-after- mile at more associated with aerospace missions is what land speed records are all about. Despite the lack of visual reference points, the roar from the engine and the blur of distance markers confirms one thing: you are pushing the boundaries of what man and machine are capable of. Such events need careful planning with medical and safety concerns high on the agenda. This is why the FIA’s Land Speed Records Commission appointed Formula One medical rescue co-ordinator Dr Ian Roberts to its ranks at the end of 2015. “The reason for the appointment was that specifically the Commission wanted some medical input into the Appendix D safety plan,” says Roberts. The safety plan is an addition to the FIA’s International Sporting Code that focuses on attempts and the Medical Intervention section sets out exactly what medical equipment and personnel need to be

BLOODHOUND IS VERY HIGH PROFILE BUT INDIVIDUALS WITH The Bloodhound SSC “ machine will attempt to LOW FINANCES ARE PUSHING THE break the outright land BARRIERS SIGNIFICANTLY” speed record in 2017 in place before a high-speed run takes place. One of the most commonly referenced outright record but there have been other Bloodhound is very high profile there are also “This is all to codify what is put into place,” land speed record attempts is the upcoming records set by diesel and even steam powered records being attempted by individuals who says Roberts. “There are obviously medical Bloodhound SSC project, which will try to break cars over the years. In August 2015, the have very low finances and they are actually resources put into place for any attempt but outright record and the 1,000mph barrier electric vehicle company broke a land speed pushing the barriers quite significantly.” they have not necessarily been to an official in October 2017. But there are many more record for EV machines with its Buckeye Bullet The Appendix D regulations state that during or regulation level. Certainly some would have automotive speed records that the Land Speed car, which was built in conjunction with the event racing operations two radio equipped been above what was necessary and some Records Commission is required to adjudicate. Ohio State University. ambulances are required, one that is located necessarily below. But it’s really just to ensure The Thrust SSC car, which travelled 763.035 “The Commission is looking across the at the pit entrance and one at the venue’s that there is a minimum standard.” over one mile in 1997, holds the current board,” explains Roberts. “Although the control tower, but it is up to the event safety

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officer to determine if there are more suitable cockpit, which will transmit a lot of acoustic locations. These ambulances must be crewed energy into the vehicle.” by staff trained to a level that meets the local To counter this, Bloodhound’s cockpit laws and rules for public first responders. There has some very high quality soundproofing must be a minimum of two Emergency Medical that utilises ‘Basotect’ foam, a material that Technicians in each ambulance and these is used on space to protect their vehicles must be at their stations before any satellites during launch. Underneath the racing operations can get underway. full-face FIA-spec helmet, Green will be A doctor proficient in resuscitation and wearing moulded earplugs complete with experienced in the management of trauma microphones built inside to enable two-way victims is required for absolute and outright voice communications. land speed record attempts, although this is Dr Andy Timperley, Chair of the Aerospace strongly recommended for all other challenges. Medicine Group at the Royal Aeronautical Society, explains that the potential danger for PREPARING TO LAUNCH But there are further overall medical considerations for any land speed record FROM A MEDICAL POINT OF mission. In a project such as Bloodhound, VIEW,“ IT’S ABOUT ENDURANCE with its ambitious targets, the driver will face PHYSIOLOGY. THE DRIVER HAS problems from the heat and noise generated Head movement is kept TO BE PREPARED FOR ADVERSE to a minimum in Venturi's by running a car at such high speeds across the CONDITIONS record breaking ground. Often he will be subjected to speeds and forces more commonly associated with ” aerospace missions. a land speed driver is not the high-speed itself Heat is another factor. “There’s an enormous “It is our aim to deliver the Golden Hour on- So it’s a good thing that Bloodhound’s but the acceleration required to get there, as amount of heat not just in the car but also in site: stabilisation and promotion of recovery, designated driver, , is already an there will be high G-forces acting on the body. the area that they run the attempt [usually a before transporting to an appropriate experienced RAF pilot, as well as the current There are also other factors to consider, such desert]," he continues. "So from a medical point secondary care facility,” he says. land speed holder with Thrust. as vision problems caused by the acceleration: of view, it’s actually an endurance physiology In the 14 months leading up the record “The body is quite good at detecting “During rapid acceleration and to a lesser extent, point of view really. The driver has to be attempt, the development of Bloodhound’s acceleration, which is significant for when travelling at constant high speed, it may prepared for those adverse conditions.” safety plan will need to take into account Bloodhound,” he explains. “And the noise is be difficult for the driver to see in detail their Bloodhound’s operations and medical crews the remoteness of Hakskeenpan, the South another matter. The airflow into the jet intake surrounds, which may become a blur; this may have been working closely to prepare for any African desert site where the run will take is shaped and compressed by the ‘pre-entry be aggravated by vibration of the car and driver.” safety scenario from a problem with the car, place, from the established primary and ramp’, which is the top of the cockpit. This It is also important for a driver to be fully fit to crush injuries to physical extremities, or secondary care facilities. The project’s shape is designed to slow the relative airflow to deal with the unique acceleration of a record puncture wounds from mishandled tools in main safety precautions have already been from 1000 mph to about 600 mph, as jet attempt. Roberts adds: “Getting up to speed, its on-site workshop. If something were to go considered and applied to the design of the engines don’t like supersonic airflow. That’s a it’s the G-Forces that will be acting upon the wrong, critical care would be administered car, support equipment, team training and speed reduction of 400 mph over a distance of body, which have various consequences for immediately by engaging both its ground and operational processes. “It is our aspiration less than two metres, or in time terms about his cardiovascular physiology in terms of blood air paramedic capabilities to help the team to train all team members to typical airline two milliseconds. This will generate some very pressure, conscious levels, and those sorts doctor, Charan Naidoo, who is registered with cabin crew standards,” says Martyn Davidson, powerful standing shockwaves on top of the of things.” the South African Health Professionals Council. Bloodhounds's Operations Director. “All

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SAFETY STANDARDS FOR ALL attempted, they vary enormously from single Land speed record attempts such as the driver operated small teams, right the way up Bloodhound project will attract headlines to the outright record attempt,” he says. “So and interest given the incredible speeds you’ve got a huge range of people and teams they are attempting to reach. By putting in all the way down to teams where they are place the minimum medical requirements not running on a great deal of financial input. for all teams, including those producing So we also have to be very conscious that we vehicles to try and break other categories of can’t be too prohibitive in terms of saying: ‘you speed records, the FIA Land Speed Records need major trauma teams on alert and if that’s Commission is aiming to make the sport safer no good the record attempt simply will not for everyone involved. But it does not want happen’.” to be prohibitive and that is a fine , All sorts of vehicles from lorries to production according to Roberts. cars are undertaking these record-breaking “The land speed records that are being missions, so it is essential to be flexible and supportive of all attempts not just the most THEY ARE THE UNSUNG high profile, according to Roberts. “I think they are the unsung heroes of land HEROES“ OF LAND SPEED speed records really, upon which everything The Venturi Buck- RECORD ATTEMPTS, UPON else is built. The FIA Land Speed Records eye Bullet is built Commission is well placed to make sure that around a modified WHICH EVERYTHING IndyCar tub ELSE IS BUILT their attempts are recorded and done under ” the best possible safety rules.” vehicles and workshops will be equipped with Inside the car, driver Roger Schroer wears medical response equipment appropriate to a helmet fitted with a bladder that can be their role.” inflated to aid its removal after a crash, as well as a HANS device and a nine-pointed COCKPIT PROTECTION harness to keep him secure in the cockpit. “I A record-breaking machine also requires also have to force my head back into a tight additional protection for the driver. The Venturi cockpit surround area,” he says. “I literally Buckeye Bullet, which last year set the record can’t move my head from side-to-side or up of 212.615mph in the sub-class for electric or down in the event of a situation where vehicles over 3.5 tonnes, uses an adapted the forces would be such that it would really IndyCar survival tub to add strength to the shake your head. The idea is to restrain your chassis and features master switches that head as much as possible.” safety crews can use to shut off the electricity in Schroer explains that mandatory arm the event of a crash. Given the electrical nature restraints work better if sewn into the sleeves of the car, which Venturi will again use to try of a fireproof suit than those that are just and break the outright EV record later this fitted around the outside. “You can’t be month, the team briefs the safety personnel too careful out there,” he says “but paying that work during its record attempts on how to attention to all of the little details could save react to an incident, such as an electrical fire. your life.” IMAGE: A4GPA (FLICKR)

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the temporary track medical centre. An of the team. The briefings include reminders on DR KELVIN CHEW agreement with the event’s primary receiving personal safety and overall safety of the team, hospital is subsequently worked out, ensuring as well as team responsibilities. Chief Medical Officer, Singapore Grand Prix all of the required specialist services will be on The teams are subsequently deployed Dr Kelvin Chew became the Chief Medical Officer of the Singapore Grand Prix in standby during race days. throughout the circuit and this is followed by a We then get confirmation of the ambulance medical inspection. This will ensure that 2009, one year after helping to organise the medical aspects of the inaugural event. service and medical vehicles, as well as an placements of the various medical teams are He tells AUTO+ Medical about the challenges of running the medical team at Formula update of medical equipment and supplies. optimal and safe. Other track service teams or One’s only full night race and how he would improve motor sport medicine. Meetings with the national security and structures could hamper an emergency emergency agencies then take place to plan response and such situations will need to be both track and spectator emergency sorted out before the start of the race. Thereafter, I will be stationed at Race Control to AUTO+Medical: How did you become CMO of co-ordinate medical responses to any incidents the Singapore Grand Prix? DURING THE EARLY YEARS at the circuit. In between sessions, if the Kelvin Chew: I was shortlisted to assist in OF THE SINGAPORE GRAND schedule permits, I make my way on foot to organising medical support for the 2008 event PRIX“ FROM 2008 TO 2009, THE various track positions to check on various because of my background as a sports LEARNING CURVE WAS INDEED teams. At the end of the day’s events, a debrief medicine physician organising medical support is conducted. Through this, we get feedback for various sporting events. I had no experience STEEP from the ground as well as ensure that all in motor sport but within a year, I learnt about ” personnel are accounted for. It is close to motor sport and picked up the intricacies contingencies. Training sessions occur months midnight at this point. involved in organising medical coverage for this before with a series of lectures and hands-on sports discipline. sessions, with medical simulations and A+M: Can you describe the biggest challenge I had to immerse myself in various roles that extrication practice leading up to the you have faced as a motor sport doctor? year at various circuits and races. Credit has to event week. KC: To me the biggest challenge was to take on go to my mentor, Dr Carl Le who was the The track medical centre only gets completed the leadership role and responsibility for the medical delegate for V8 Supercars, an one month before the event, when we will start Singapore Grand Prix during its inception. Australian race series, at that time. Within a furnishing and equipping the place. The full Given that motor racing at such a scale before year, he had systematically imparted all his circuit gets locked down only on the 2008 had taken a 35-year hiatus in the city, we knowledge on race administration, volunteer Wednesday of race week. had to work from scratch. recruitment, logistics and training. Dr Le was One of my responsibilities was to recruit and CMO for the inaugural Formula One Singapore A+M: What is your role during an actual train up a medical team with no motor sport Grand Prix in 2008, but in 2009, I had to take it race weekend? experience. My apprehension was that of on as the CMO. So the learning curve was race organisation meetings to discuss matters KC: A typical day during race weekend would fielding a team that was unfamiliar with indeed steep. pertaining to the circuit, such as volunteer involve arriving early at the circuit with a operating in a motor sport environment. The recruitment, training, logistics, as well as meeting for senior race officials in race team needed to be familiar with extrication, A+M: What does your work as CMO at the security. Typically, we would start volunteer organisation. We are updated on potential communications, race operations and Singapore Grand Prix involve in the period recruitment some 6-8 months before the event. situations and any changes to the event terminology. And most important of all was the leading up to the race? Thereafter, we would make modifications to schedule, as well as track and weather issue of safety. Maximum efforts were placed KC: The following sequence occurs in the medical deployment if needed to meet any conditions, manpower and logistical issues. on track craft and how to manoeuver safely in period leading up to the race: work first starts changes in requirement of the circuit. This Such information is disseminated to the this high-speed environment. nine months before the event with monthly would also include the placement and layout of medical team in the daily brief for the members The event also needed the involvement of

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The Singapore Grand various ministries and national emergency Prix is Formula One's agencies to plan and possibly execute various THE AMOUNT OF only full night race contingencies for both track and spectator PLANNING AND TABLE incidents at various scales. The amount of TOP“ EXERCISES THAT WENT planning and table top exercises that went into the event was unfathomable. But INTO THE 2008 EVENT WAS fortunately, we made it through that UNFATHOMABLE inaugural event. ” A+M: What has been your greatest A+M: Can you give any examples of achievement in motor sport medicine? incidents you have responded to during KC: I don’t believe I have achieved anything your time as a motor sport doctor? great in motorsport medicine yet. But pulling KC: What comes to mind was a pit lane through that first event with a brand new incident, where [ in 2008] was medical team was probably my greatest released too early before the fuel hose was achievement. disconnected injuring a mechanic. We had just

Nico Rosberg battles for the lead of the 2015 Singapore Grand Prix talked through various scenarios that could Other static medical elements include track happen at the pit lane in the weeks before and posts at strategic turns and the pit lane medical were devising strategies to swiftly and safely teams. The dynamic medical elements include manage such situations and then it really medical intervention cars, extrication vehicles happened. Within minutes, together with the and ambulances. pit lane medical team, we stabilised and On average, the Marina Bay Street Circuit also evacuated him to the medical centre via a pre- has approximately 86,000 spectators within the arranged route through the paddock. This Circuit Park daily, so there are also multiple first incident impressed on me the importance of aid posts to service the spectators throughout contingency planning and simulation training. that area. This was how we were able to react and execute plans effectively in that scenario. A+M: Have there been many changes to the medical facilities and services since the A+M: What medical and safety facilities do Singapore Grand Prix began in 2008? you use during the Singapore Grand Prix? KC: Yes. We started out having the medical KC: The Singapore Grand Prix is held in the centre at the pit entry in 2008, but due to the heart of the city. The street circuit setting space constraints of the street circuit, the means we are limited for space. The compact medical centre is now situated in a compound track medical centre is constructed on a plot of close to the pit exit. This meant making changes parkland and is completed one month before to ambulance movement protocols to and from the event. the medical centre and there were some pros

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and cons to this. While this location may prove to see our volunteers come back year-after- training and education for medical marginally less disruptive to the race, it is a year. I find that it is important to provide them professionals involved in motor sport. Secondly, slightly longer hike from the paddock. with a positive volunteer experience. This improvements in volunteer management. includes providing effective training, It is difficult to standardise a training A+M: Does the street circuit layout in engagement all year round, and listening to programme as culture and motor sport Singapore affect the protocols for the their feedback. Volunteering for motor sport is disciplines vary widely. One approach is with medical team? not an easy task. The hours are long and the customised programmes that ensure that KC: Yes. The Singapore circuit is very conditions are not always the most teams perform at a suitable standard. These challenging as some parts of the track are comfortable. Sometimes little things like programmes should include not only narrow with a lack of run-off areas, which lollipops or ice cream in between sessions can theoretical knowledge, but also practical skills means a smaller margin of error for the drivers. be comforting. Most important of all is to keep and team-based simulation exercises focused The medical team will need to be on their toes our volunteers engaged throughout the event. on challenges in motor sport environments. at all times, ready to respond to any incidents. We keep our medical volunteer retention rate In many aspects of motor sport, volunteers The street circuit layout means deployment IT IS REWARDING TO SEE at around 75 per cent and aim to improve that. make up the majority of race officials and are of medical elements and vehicles is tricky. essential for a successful event. Efforts must be Access is mainly from the track. Once a medical OUR“ MEDICAL VOLUNTEERS A+M: In what ways would you improve taken to ensure adequate training, safety and vehicle is being deployed for an incident, it COME BACK TO THE motor sport medicine? welfare of volunteers. Regular volunteer would be an intricate exercise to reset or cover SINGAPORE GRAND PRIX YEAR- KC: There are two things I would like to see engagement, team-building efforts and seeking that sector with another medical element AFTER-YEAR. being more done. Firstly, improvements in feedback are important. without disrupting the race. So it is like a balancing act of static and vehicular ” medical elements. keep a small team at the medical centre past leads the start of opening hours, so the medical centre is running the 2015 Singapore race A+M: Are there any extra considerations for for 24 hours every day. I remember in one year safety and medical protocols due to the I had to stay up with a driver who needed Singapore race taking place at night? specialist medical attention in the wee hours of KC: We were apprehensive for the inaugural the morning because he kept European timing. race in 2008 and made several contingencies. But once we saw the track lit, our fears were A+M: Do you have to train your medical and allayed, as the lighting was four times brighter safety team differently due to the Singapore than a fully lit stadium. Grand Prix taking place at night? The downside was that each day would end KC: As the circuit is so brightly lit, protocols in really late at night, which meant the medical terms of track craft and safety are similar to any team would only get to leave the circuit past other race during the day. It is only in areas midnight and get home in the wee hours of the beyond the run-offs that we had to cater for morning. Fatigue is a potential problem we are extra lighting. keeping an eye on. A+M: What is the most rewarding part of A+M: Does the unique timing approach of F1 your work in motor sport medicine? teams to the Singapore race create any KC: Having seen through a successful event additional health and safety concerns? and having provided the volunteers with a

KC: Maybe it’s more for the standby team. We meaningful and engaging time. It is rewarding IMAGES: SINGAPORE GP PTE LTD

24 25 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES IN FOCUS: VIDEO LARYNGOSCOPES

AUTO+ Medical responds to a request for information about video laryngoscopes, equipment carried by anaesthetists working in motor sport series around the world Contributors: Dr Paul Trafford, Dr Rob Seal and Dr Ian Roberts

Maintaining an airway is something that any are best left to the anaesthetic specialists doctor or paramedic may be required to do. and are not something to be added to the Motor Sport provides some unique challenges, routine emergency medical bag,” says Dr Paul but basic airway manoeuvres should always be Trafford. “We also hope to consider basic deployed first, with often a simple jaw thrust airway management in a future edition of this or clearing of the airway being adequate along publication as this is something very important with the use of an oxygen mask. Where further to all of us whatever our specialty.” intervention is necessary, simple devices such The classic Macintosh laryngoscope has a as the oropharyngeal or nasopharyngeal handle containing a battery, to which various airways should be used and if appropriate the designs of blades can be attached depending i-gel or laryngeal mask. on the circumstances that it is required for. A Medical cars in Visualisation of the larynx, also known as light source is usually situated at the end of the Formula One and laryngoscopy, facilitates the insertion of an blade to illuminate the pharynx, epiglottis, vocal other series carry a large bag for endotracheal tube into the airway – a practice cords and tracheal opening, although in some equipment that is routinely carried out by anaesthetic cases the light source is actually located in the specialists in hospitals, but this is something handle with fibre optics being used to deliver all doctors attending motor sport events in an the light to the end of the blade. “In recent The large medical bag has a foldout design emergency capacity should be familiar with. times many countries have made the blades, and contains a wealth Yet even in the hands of a skilled anaesthetist and in some cases the entire laryngoscope, of equipment, including this is not always an easy procedure. Rarely disposable and they are thrown away after a a small portable automatic ventilator necessary on-track or in a stage of a rally, single use because of concerns over infection and all the airway intubation is best performed under controlled control,” explains Trafford. equipment, such as the tubes to the video conditions in a medical centre and where The laryngoscope is held in the left hand, laryngoscope. possible by a skilled anaesthetist with inserted into the mouth and used to push the The Glidescope Ranger appropriate assistance. tongue to the left side and lift the epiglottis, video laryngoscope We were asked for information on video which obstructs the view of the vocal cords. (far right) is used in laryngoscopes following publication of a recent To achieve this, the correct positioning of the Formula One and by other medical personnel paper in the British Journal of Anaesthesiology patient’s head and neck is essential – the neck involved in motor sport and whilst we are pleased to discuss the needs to be flexed forward with the head worldwide. subject we want to point out that such devices extended backwards in a position often called

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The Glidescope Ranger in in the medical cars for Formula One and the results of the study, those without a channel action. A small electronic BTCC as well as other series where there are guide proved more effective. screen similar to those fitted on smart phones is used to medical professionals familiar with their use, The paper also included a note that explained show the view of the Larynx however evidence of their use in the difficult how previous studies using in-line stabilisation airway pre-hospital setting is limited, and we of the cervical spine had a success rate for certainly aren’t recommending them as an intubation that was far higher than when essential addition to the medical bag. intubation was attempted in the presence of a The image shown on the screen of a video hard cervical collar. laryngoscope can be difficult to see in bright “We feel that if faced with the situation of light and it may be necessary to use a shield having to intubate a competitor in a hard that is held over the person performing the collar, the accepted procedure would be to intubation. Some models have a channel for loosen or remove the collar during intubation guiding the endotracheal tube placement, to allow mouth opening and have a colleague but in those that do not it is necessary to use stabilise the neck and hold the head in line, a ‘stylet’, or insert, to stiffen the ET tube and replacing the collar after the procedure was allow it to be bent into position, something complete,” says Trafford. “This of course many users may not be familiar with. would not allow flexing of the neck or any A paper recently published in the British extending of the head, but by allowing the Journal of Anaesthesia has reviewed the use mouth to open fully, the procedure would be of a video laryngoscope in a simulated difficult made easier.” ‘sniffing the morning air’. The field of view with not suitable. A small electronic screen similar airway setting. Patients were fitted with a hard a laryngoscope is very limited even in ideal to those fitted on smart phones is used to cervical collar that limited mouth opening REFERENCES conditions and “this makes it difficult to show show the view at the tip of the laryngoscope from an average of 46mm without the collar, others what you are looking at,” adds Trafford. blade, which may not be visible via direct sight. to 23mm with the collar. Attempts were made • British Journal of Anaesthesia, 116 (5): 670–9 Where the anatomy is distorted, or in “In skilled hands these devices can assist with using a range of six different laryngoscopes (2016) cases where mouth opening, head and neck correct placement of an endotracheal tube (three with a channel to guide the ET tube • Evaluation of six videolaryngoscopes in 720 mobility or prominent teeth cause issues through the vocal cords and into the trachea,” into position and three without) in a total of patients with a simulated difficult airway: a with the visualisation of the pharynx and explains Trafford. 720 patients. The success rate during the multicentre randomised controlled trial tracheal opening, it may become difficult and “Video laryngoscopes are now available first attempt was 85-90 percent, although the • M. Kleine-Brueggeney, R. Greif, P. Schoettker, in some cases impossible to see what is going in disposable form and are produced by a success differed markedly with the type of G. L. Savoldelli, S. Nabecker and L. G. Theiler on. For this reason, when a difficult airway is number of suppliers at reasonable cost,” he video laryngoscope used. According to the encountered, anaesthetists have a series of continues. “They can be a useful tool for alternative methods available to them, most of those familiar with its use.” The devices are which are confined to the specialist in a hospital available in hospitals as part of the difficult CALL FOR LETTERS In future articles we will be looking at setting. Some, such as the use of the laryngeal airway protocol, and can be used for teaching If you have an opinion on the use of video new advances in equipment as well as mask (for example the i-gel), are commonly the anatomy and learning intubation skills. laryngoscopes in motor sport, whether existing medical items, so if you are aware used in emergency pre-hospital care. “Where the intubating conditions are difficult you have used one as part of your of any new developments used in motor The video laryngoscope is a device that allows and the user is familiar with its use, a video emergency equipment or have sport medicine or want to see a review of the user to demonstrate the anatomy to others laryngoscope in the pre-hospital setting can experience using them, please write to: something you use, please write in and let as well as allowing visualisation of the pharynx be really helpful in securing the airway,” says [email protected]. us know your thoughts on the topic. and vocal cords where direct laryngoscopy is Trafford. “To my knowledge they are carried

28 29 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES INSIDE THE WEC MEDICAL CAR AUTO+ Medical takes a look inside the World Endurance Championship’s brand new Audi A6 medical car

The Audi A6 Avant 3.0 TDI competition quattro tiptronic made its debut as the World Endurance Championship medical car at the first race of the 2016 season, the Silverstone Six Hours. The car can accelerate from 0-100km/h in 5.2 seconds and has a top speed of 250km/h. It is manned by three crewmembers – a driver, a doctor and a paramedic. At tracks like the Nürburgring, which hosted the fourth round of the 2016 WEC season, there were three A6 medical cars stationed around the circuit in addition to the main car, which is located in the pitlane. At each WEC race, the car’s medical equipment is brought to the track by the race organisers and Audi employees from quattro GmbH fix the kit in place in the car’s boot. The equipment, which is similar to that used in Formula One and Formula E due to its electrical components, requires additional kit, such as gloves and a hook for the intervention teams. The WEC A6 is fitted with a blue roof beam lighting system and an aerial, which connects to a radio system installed in the armrest between the two front seats. The car’s engines are permanently running during every WEC race to let the drivers instantly react to a problem.

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3 MONITOR AND 4 INTRA-OSSEOUS DEFIBRILLATOR: VASCULAR ACCESS 7 A monitor and SYSTEM: defibrillator are The WEC medical car present in all WEC is fitted with an intra- medical cars alongside osseous vascular one or more collars access system, which and a fire extinguisher. can be useful in certain circumstances, such as if a driver is stuck 3 in a car making other approaches difficult. 4

6 5 INTERVENTION BAG: 1 The WEC medical crews will carry a small bag for intervention that holds a lamp, catheter, oximeter and fluid, as 5 well as a cervical collar and resuscitator for the doctor to use when attending to a patient outside of the car.

1 EMERGENCY BAG: 2 HELMETS: The emergency The helmets worn bag includes by all the crew of the 7 KENDRICK 6 ELECTRICAL SAFETY substances to ensure medical car have a 2 EXTRICATION DEVICE: EQUIPMENT: cardio-respiratory radio link to the on-site A green Kendrick A rubber mat and a resuscitation, analgesic resuscitator and they Extrication Device hook are used to help and an anesthetic, must communicate is used in the WEC the medical team as well as intubation directly with the event to assist medical extricate the driver hardware, infusion sets, chief medical officer personnel when dealing without touching the infusion fluids, O2, and and medical delegate with crashes involving car. These are used a small portable suction when attending to any GTE cars, although this to ensure medical apparatus. It also holds serious incident. is not adaptable for personnel are not hurt bandages, antiseptic, LMP1 or LMP2, and it from the electrical masks, gloves, a blood sits at the bottom of the systems used in some pressure monitor, medical car’s boot. WEC cars. ventilation equipment, tourniquets and splints.

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Heidfeld finished THE ROAD BACK: tenth in the second Formula E season NICK HEIDFELD The former Formula One driver and current Mahindra Formula E racer looks back on the injury he sustained at last season’s Putrajaya ePrix and offers his thoughts on when it is right to return to the cockpit

During the close stages of last season’s a proper scan it was impossible to know. We Putrajaya ePrix, Nick Heidfeld’s Mahindra were all sure there was nothing really too steering wheel jerked unexpectedly out of bad. But the next morning it got worse and his hand. Although he was able to finish the then as soon as I was home in Switzerland I race and was not aware of any serious injury, had it checked by a scan with some injections he had snapped a ligament in his wrist and to see where all the fluid goes and then they was forced to miss the following race in could see that there was a scapholunate Punta del Este. He spoke to AUTO+Medical ligament that was cut through. This meant about the incident and his recovery process. that we needed to organise an operation quickly because if we waited too long it goes AUTO+Medical: What happened during the back by itself and then it’s too late to fix, so I Putrajaya ePrix that caused the damage to got an operation date a week later in Zurich your wrist? and it was operated on. Nick Heidfeld: I had a big oversteer moment and I also brushed the wall, but it had nothing A+M: And how did that operation go? to do with the small impact. I think it was just NH: The operation was longer than initially the fact that I put a lot of opposite lock on planned and as my scar shows, they wanted and as the oversteer was quite huge and with to do it a bit smaller but they had to open it a this steering compared to other racing cars, bit more as it’s quite complicated to get to you can actually turn the steering wheel quite the damaged part. I think the operation time far. You can nearly turn the car on the spot was about 50 minutes long or something and the radius is very small. like that. So I was turning as much as I could and then the arms locked out. I assume that I had A+M: Did you know then that you would lot of force on all the muscles, but then as I miss some Formula E races? couldn’t turn my hand further it just dropped NH: Yes. Initially, from my understanding, it out of the steering wheel and I think this is was like ‘maybe I will miss one race’ but then when it snapped. the more I spoke to the doctor and the Afterwards it didn’t hurt much, just a little physiotherapist and it was more like ‘you will bit, so I went to the doctors at the circuit. definitely miss one and very likely two, or They put some ice on it and I thought it would even more races.’ So this was quite tough be ok. They obviously looked at it but without to hear.

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The most important thing was that the doctor A+M: What did they tell you to do to aid had assured me that I might feel it and it might your recovery process? hurt, but it was not dangerous. On top of that, NH: First of all I had two nails inserted into my wrist strength wasn’t at 100 per cent, and my wrist to immobilise the hand. On top of the doctors have said it will never be the same that I had something that covered the hand as before. Still now it’s not as good as it was so I couldn’t move it up and down. Those before and I’m still working on it. things were to stop it moving because they I told Mahindra I was not sure if I would do told me it was crucial not to move the hand at the race in Buenos Aires because I was not all for it to recover well. I had to wear the sure if my strength would be enough. I said, “I cover for like six weeks and when it was can try it, it’s very sensible to try it but I’m not eventually taken off I had the two nails inside 100 per cent sure’. The good thing was that removed as well. Adrian Campos [boss of Mahindra's partner, My physiotherapist told me all the time that ] was there as well and he told I would surely miss two races. But I was me that he also had some injuries in his career always like ‘yeah, maybe, but we can do it’ and he said that once you get into the rhythm and she said, ‘no, it’s not going to work’. They had warned me before that when the immobilising stuff was taken away, all the THIS WAS PROBABLY THE muscles had started to disappear after 48 hours as all the tendons and everything sort BIGGEST ACHIEVEMENT THAT I FACED“ IN MY RACING CAREER of fall asleep. So at the beginning I could The Putrajaya barely move my hand. I remember on the race is held in DURING THE COURSE OF THE first day I was not even able to push a button Malaysia's federal capital city 2016 SEASON on the bottom of my phone with my left hand. Then when I was at the physiotherapist ” again she told me ‘now you understand that want me to take a decision now if I can do the asked if it was feasible for them to let me the adrenaline comes and it will be ok. you will not be able to do the next race!’ But I next race at Buenos Aires and I don’t test drive the shakedown in Buenos Aires and So we decided together that I would do the still said, ‘no, let's try.’ anything before, I will say ‘no’. This was have another driver on hand to take over if I race on the Saturday in Buenos Aires, but I Then it was a long process. With the because I had doubts and I could not be sure couldn’t do the race. Again, luckily, they still told them I was not 100 per cent sure I therapist in the beginning I saw her twice per at all without a test. agreed to do that because they definitely would not have any pain and I might not week and she warmed it up, stretched it very So it was arranged and I did a test in an old wanted to have me back in the car, which was have enough strength, and the end of the lightly and I had to do a lot of exercises at GP2 car and it worked out better than a nice feeling to have the team pushing very race would be poor because of that. But home by constantly moving the fingers with expected. I only did four or five laps not hard and giving me every to together we decided to try it and then the different things and trying to move the wrist. pushing flat out but I could see that maybe in maybe make it. Then, after the shakedown, it race went relatively ok, just in the last couple ten days time I could do Buenos Aires. But was still not an easy decision to start the race. of laps I missed a bit of strength and in the A+M: What happened after you missed the again I told them I was not sure if I was able high-speed chicane I couldn’t push flat out Punta del Este ePrix? to do it because on the day of the test I would A+M: What did the wrist feel like when you there, but I didn’t lose much time. NH: Luckily then it started to go a bit quicker not have been able to complete a full race. got back in the car? For me this was probably the biggest than expected and I had a test organised with I needed to foresee what would happen, NH: On certain movements it would still hurt, achievement I had in my racing career this Mahindra in Valencia, which was not with a which is very difficult with an injury like this not on all the movements but if I had any year because getting my hand working again , because I told them if you and I’ve never had anything like this before. I sudden oversteer to react to, it would hurt. was by far the most difficult part.

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Heidfeld has raced in Formula E since the series began

Heidfeld managed to finish ninth in the 2015 Putrajaya race

A+M: Was this the first injury you have about the doctor getting the correct suffered in your career? findings – and I was very sure with the NH: Yes, it was the first big one. I had some doctors I had that they were right. I’ve had small concussions but not something that put it before and there is a saying in , me on the sidelines for too long, so this was ‘three doctors, three different points of view’, the biggest I ever had. Not only in racing, but so you have to make sure that you know also in general. exactly what is going on and that you’re fully behind what action you are going to take – A+M: Did the nature of the Formula E car’s whether you ultimately need to have an steering play a part in your injury? operation or not. NH: I’m not sure. What probably made it Just try to get the best people possible and more difficult is that we don’t have power then I think, as in anything, it is important to steering and in most other cars we do. So it’s believe in yourself. For me, if I hadn’t pushed quite hard to turn and it puts quite a lot of flat out on my recovery I would have missed stress on your arms, shoulders and wrists. more races. It is a hard job and a lot of work but it was kind of easy because I love racing A+M: What advice would you give to other – like all other racing drivers do – so it comes drivers who are recovering from an injury? easy to you to try everything you possibly can NH: First of all you have to be absolutely sure to recover as quickly as possible.

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Formula One driver Carlos Sainz is placed in an ambulance following his crash in practice for the 2015 SCIENCE Russian Grand Prix MOTOR SPORT RESUSCITATION REVIEW

Dr Matthew Mac Partlin discusses the latest theories and practices in resuscitation techniques and explains how these ideas can be applied to motor sport

Author: Dr Matthew Mac Partlin, critical care physician, Australia, Deputy CMO WRC Rally Australia, Assistant CMO F1GP Australia, CAMS NMAC.

Contributor: Dr Carl L Gwinnutt FRCA, Emeritus Consultant, Salford Royal Hospitals NHS Foundation Trust, & President, Resuscitation Council (UK)

INTRODUCTION All healthcare professionals have an ethical and statutory responsibility to be familiar with developments that occur within their own speciality. There are a host of resources available which allow us to achieve this; through attendance at meetings organised by colleges and associations, peer reviewed journals, face- to-face courses and internet articles. These resources allow professional development using an evidenced-based approach to ensure that we provide the most up-to-date

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care. For those of us involved with motor immediate, following unsurvivable injuries The medical sport medicine, the same responsibilities e.g. thoracic aortic disruption, helicopter at the apply. The vast majority of available within the first hour from airway, breathing Circuit of the information, however, is based upon public or circulatory problems, Americas practice. There are some instances of after days or weeks from sepsis or military practice, but very few which multiorgan failure. address the specifics of event medicine and more specifically motor sport medicine. ATLS was based upon recognising and Consequently, most healthcare treating the problems that caused deaths in professionals and indeed others who the first hour, many of which were regarded provide care at motor sport events e.g. fire as avoidable, hence the term “Golden Hour”. and rescue, extrapolate from our day-to- This resulted in a misplaced assumption that day professional abilities and experience to a practitioner had up to 60 minutes to try and identify what is likely to be intervene in a major trauma victim, which is applicable, what might need some now recognised as an oversimplification. It adaptation and how this may be achieved. also resulted in inaccurate measures of However, it is important to keep in mind quality of care. many of the differences between motor Clearly, some victims need intervention sport and general public incidents, the key much sooner (e.g. tension pneumothorax, ones of which are the high speeds involved, impact brain apnoea) while others might ultra-rapid medical and rescue attendance progress over a much longer time (e.g. at the scene and the variety of safety subdural haematoma, pelvic venous plexus (BLS) interventions, followed by a dash for the tried to repair all injuries, leading to devices employed. bleeding) (1). What is more important than nearest major trauma centre (2). Once again, prolonged surgery and disappointing The aim of this article is to review a assuming a window of one hour in which to many experts consider this apparent mutual outcomes, due in part to the triad of selection of recent changes in hospital and provide care is the appreciation that a major exclusivity to be an oversimplification. hypothermia, acidosis and coagulopathy (3). pre-hospital based acute care and explore trauma patient is at high risk immediately Factors such as the injuries sustained, skills Initial trauma surgery has evolved to: how these may be utilised within motor and requires a systematic approach at each of those responding, and transport time/ Treating rapidly any immediately life- sport rescue and medicine. stage of care in order not to miss life- distance all have an effect on the outcome of threatening injuries e.g. haemorrhage from threatening injuries. This is particularly true the individual. This is reflected in motor sport a hepatic laceration, pelvic fractures PRACTICE (R)EVOLUTIONS for circuit motor sport where the medical whereby it may be perfectly reasonable to Transfer to the ICU to manage any response team will be rapidly on scene after provide basic life support interventions physiological derangement and prevent THE GOLDEN HOUR FALLACY an incident and signs and symptoms of the followed by a two minute journey to the subsequent complications The concept of the ‘Golden Hour’was injuries may be only beginning to develop, nearby trauma centre to a circuit competitor, Definitive surgery then takes place when developed by the American Trauma which may lead to an underestimation of a similarly injured Dakar competitor may the patient is stable, which may be several surgeon, Dr. R. Adams Cowley and was the severity of injury unless those in attendance require roadside decompression of the days later. basis for the Advanced Trauma Life understand the dynamics of the incident. haemothorax or placement of an advanced Support (ATLS) course. You can read more The concept of a ‘fixed’ period in which to airway to ensure their survival of the much This process is referred to as ‘Damage about his story here: About Advanced deliver care also led to the presumed longer transfer to definitive care. Control Surgery’ and has resulted in Trauma Life Support. He described a dichotomy of ‘stay and play’, providing improved outcomes and reduced trimodal distribution of deaths after advanced life support (ALS) skills at scene or DAMAGE CONTROL RESUSCITATION complications. Further evolution of practice, major trauma: ‘scoop and run’ providing basic life support In early trauma practice, the surgical team influenced by military practice in recent

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conflicts, has led to the concept of ‘Damage necessary to ensure that the person much more likely in victims of trauma in BLOOD AND BLOOD PRODUCTS Control Resuscitation’, of which damage survives to reach the Emergency motor sport and although permissive Alongside work on damage control control surgery is a part alongside targeted Department or operating theatre of the hypotension has been extrapolated to blunt resuscitation, there has been an evolution in permissive hypotension and haemostatic receiving hospital; e.g. decompressing a chest trauma, there is currently less the understanding of the haematological resuscitation. For a full review of the history tension pneumothorax, application of a evidence to support it, though it is not consequences of major trauma and its and components of damage control pelvic splint, insertion of an advanced physiologically unreasonable. associated therapeutic interventions, in resuscitation read Damage control airway. Performing a pre-hospital When there is an isolated head injury, the particular the risk of developing a resuscitation: history, theory and technique resuscitative thoracotomy is controversial current recommendations are for a target coagulopathy in major trauma victims, in the Canadian Journal of Surgery (4) and and is dealt with below. systolic BP of >110 mmHg (mean arterial usually referred to as the Acute Coagulopathy Damage control surgery in the era of damage Where there is evidence of or a high index blood pressure > 90 mmHg) (7). of Trauma (ACoT or ACT). An understanding control resuscitation in the British Journal of of suspicion of ongoing, uncontrollable A big problem here is the trauma victim of this condition has been part of the drive to Anaesthesia (5). haemorrhage i.e. intrathoracic or with both ongoing blood loss and a head minimise the large volumes of crystalloid and How do these changes integrate into the abdominal, consider permissive injury. There are mixed expert opinions on colloid fluids previously given in trauma in management of trauma at motorsport hypotension. For penetrating major trauma, preference for blood and blood products; i.e. events? which is relatively uncommon in motor platelets, fresh frozen plasma (FFP) and Clearly in nearly all cases surgery is not sport, there is (moderate quality) evidence PERFORMING A PRE- packed red blood cells (PRBC) and within performed within the motor sport environment, (6) to support accepting a systolic blood HOSPITAL RESUSCITATIVE military practice, fresh whole blood. However, but some key principles can be applied: pressure of 90mmHg. Blunt trauma to “THORACOTOMY IS the use of such products is rare within motor Perform the minimum interventions either or both the thorax and abdomen is CONTROVERSIAL sport practice as the need for cross-matching, appropriate storage and reconstitution of ” these products and limited ‘shelf-life’ makes it the best approach to this situation. For an impractical for most venues. The search for a The medical overview of the controversies read Permissive reliable synthetic haemoglobin is ongoing. team at the Silverstone Hypotension on the Critical Care FFP and clotting factor preparations are an circuit Compendium of the Life In The Fast Lane blog. interesting area, with work being done on What is clear is that estimating the BP based lyophilised, freeze-dried FFP and clotting on presence or absence of the radial pulse factor fractions, which have long shelf lives, or which pulse is palpable, is not valid. In can be quickly reconstituted and have no motor sports, blood pressure and perfusion compatibility issues (9,10,11). should be measured using clinical estimates of perfusion and a non-invasive device, which is quicker and requires less equipment than invasive monitoring. Recognising the device limitations is important. Ensure that patient hypothermia is prevented, or even treated if the prehospital phase is prolonged. Minimise prolonged body surface exposure and the use of cold intravenous fluids. Blood and blood product strategies will be dealt with in the next section.

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Managing ACT has also led to the penetrating wound resulting in a tension Most trauma experts take the view that the A competitor is reconfigured role for Tranexamic Acid (TXA), pneumo- or haemothorax which majority of traumatic cardiac arrests are given treatment an antifibrinolytic. There is increasing subsequently causes a PEA (EMD) arrest can secondary to hypovolaemia from during the remote Dakar Rally evidence for the use of TXA for major be addressed rapidly with restoration of the haemorrhage and that CPR therefore only haemorrhage in trauma (CRASH-II trial (12) circulation. Blunt trauma, a mechanism much serves to enhance exsanguination, and the MATTERS trial (13)), and the fact that more likely in motor sport, was considered to interfere with other resuscitative efforts it is cheap, easily stored, transported and have a much worse prognosis, due to there and delay transport to definitive care (19). reconstituted makes it attractive for use being less likelihood of a readily correctible Although this is probably true, as either trackside or in the medical centre. The lesion. However, recent evidence questions mentioned above, in those cases where dosing is simple and giving the initial dose of this premise (18). cardiac arrest is the cause of the trauma, 1g of TXA once the trackside basics have been There are two main controversies in the and the resulting trauma itself has not led attended to is well within the remit of the management of traumatic cardiac arrest; the to major blood loss, CPR may still be of motor sport medical team. Some motor sport role of CPR and the role of the resuscitative benefit. Additionally although rare, a direct medical response teams now carry TXA as thoracotomy. blow to the precordium can precipitate a part of their pharmaceutical stock. ventricular fibrillation (VF) cardiac arrest, a There is a good overview of the TXA condition called comotio cordis (20). This controversies in this article in the Medical THERE IS INCREASING should always be considered a possibility Journal of Australia - Trauma and tranexamic EVIDENCE FOR THE USE OF TXA where the victim is young and there is no acid (14). The CRASH-III trial (15) plans to “ immediate evidence of other injuries and evaluate the use of TXA in the subset of FOR MAJOR HAEMORRHAGE mandates rapid ECG monitoring and where trauma patients with head injury while the IN TRAUMA appropriate, defibrillation. PATCH Trauma trial is being conducted to evaluate the role of TXA in mature trauma ” RESUSCITATIVE THORACOTOMY In recent years there has been evolution with systems (16). CARDIOPULMONARY RESUSCITATION Performing a resuscitative thoracotomy this particular intervention, and although it (CPR) involves opening the chest cavity rapidly in has previously been considered a hospital CARDIAC ARREST IN THE TRAUMA VICTIM The cardiac arrest may be the result or order to identify and temporise a limited procedure because of its complexity and high Cardiac arrest in the setting of trauma the precipitant of the trauma. Where it is number of injuries; a tamponading risk of complications, it has been performed (traumatic cardiac arrest, TCA) (17) has the precipitant it is likely to have an haemopericardium, an exsanguinating lung with increasing confidence by leading traditionally prompted a bleak response from underlying medical cause and laceration, intercostal artery disruption and prehospital services such as the UK HEMS medics with a tendency to cease resuscitation management should be based upon cross-clamping the descending aorta. It has and Sydney HEMS services. Both efforts on the presumed basis of futility. This standard basic and advanced life largely been the domain of the organisations have doctors as part of the in turn has led to some conflict, including support interventions. Clues that the cardiothoracic or trauma surgeon in the response crews and have published criticism for commencing resuscitative event may have a cardiac cause include: resuscitation bay of a major trauma guidelines for performing a pre-hospital efforts. In the pre-hospital setting, there may older age of the victim, hospital and typically only performed when resuscitative thoracotomy, which are be pressure to be seen to provide treatment, a relative lack of other significant the TCA had occurred within the preceding embedded into their traumatic cardiac arrest especially in the highly visibile circumstances injuries 5 to 10 minutes following a penetrating policies (Sydney HEMS Traumatic Cardiac of a major motor sport event when there are evidence of loss of consciousness prior chest or upper abdominal injury. Arrest operating procedure). It would large crowds or the event is televised. to impact; e.g. absence of crash There have been survivors of blunt chest therefore seem appropriate that a member When cardiac arrest is caused by trauma, avoidance indicators such as witness injury TCA where a resuscitative of the medical team at motor sports events the mechanism, whether it is penetrating or accounts or lack of braking tyre marks thoracotomy has been performed, though should understand the principles of how to blunt has until recently been a key crash in an unusual location such as a the rates of neurologically intact survival perform a resuscitative thoracotomy and determinant of resuscitative action. A straight or an easy turn. while not zero are very low (<1%). preferably have ‘hands on’ experience by

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Guidelines. This algorithm focusses on the mechanisms resuscitative thoracotomy, would be an At the same time, control any external of TCA that will kill quickly and yet, with the uncommon occurrence, especially in the haemorrhage, check for and treat a correct intervention they can at least be absence of the appropriate skills and tension pneumothorax and apply a pelvic temporised to buy time to transfer the equipment. binder device. injured person to a facility that can provide Step 9, the decision to cease efforts, should If commotio cordis is suspected, treat as definitive care (ideally the receiving trauma be made by the most senior member of the per ALS. Early defibrillation is critical. Use hospital rather than the event medical team and only after discussion with all other trauma interventions as needed. centre). However, there will be situations members. In the highly visible environment 5. If a traumatic cause of cardiac arrest is where it will not be possible to follow exactly of a motor sport event, this may prove very suspected: the components of this algorithm, for difficult. However, provided that accepted Perform bilateral thoracostomies for example in the case of a competitor trapped guidelines have been followed and full tension pneumo/haemothoraces. Use of documentation of interventions, responses attendance at a critical care workshop (23). a scalpel-finger technique is preferred to and reasons for the decision have been At the end of last year the International needle decompression(33). ILCOR UPDATE INCLUDED made, it is defensible. Liaison Committee on Resuscitation (ILCOR) Compress any obvious external AN ALGORITHM FOR This algorithm, or some agreed version of it published its five year update on the haemorrhage. Use a tourniquet on “MANAGING A TRAUMATIC should be included in the event’s Medical International Concensus on Cardiopulmonary limbs. Topical haemostatic agents or CARDIAC ARREST Response Plan and be addressed at the Resuscitation and Emergency Cardiovascular dressings are an option for some medical briefing as this offers clarity and a Care with Treatment Recommendations (29). haemorrhaging wounds. ” degree or protection for members of the Having previously focussed mainly on medical Apply a pelvic splint. in the vehicle. In such cases, the steps should medical team should they be faced with a causes of cardiac arrest, this latest document 6. Gain secure IV or IO access. Once a be applied according to the circumstances. traumatic cardiac arrest situation. It is also clear included an algorithm for the management of spontaneous circulation is established, The majority of competitors in this scenario that a successful outcome will be enhanced by traumatic cardiac arrest. The recommended give judicious fluid volumes aiming for a who are going to survive will respond to steps clear communication, streamlined transport algorithm has been adopted with some local systolic BP of 90mmHg unless a significant 1 to 7. Step 8, the decision to perform a processes and regular education and training. inflections by theEuropean , American, head injury is suspected (see above). Australian and Resuscitation Blood products are preferable but again Councils (the Resuscitation Council of Asia is there are often logistical barriers to their yet to publish their full set of updated availability at motor sport events. guidelines). 7. Secure the airway. Below is a suggested version for how this 8. If there is no response to the above algorithm might be applied to a motor sport interventions in the setting of penetrating competitor: or blunt chest injury, perform a 1. Arrive at scene and assess. Victim resuscitative thoracotomy, if there is the unconscious and showing no signs of life. skill set and equipment available. A 2. Open the airway and commence assisted bilateral clamshell incision is preferred ventilation with supplementary high flow over an initial unilateral incision. oxygen. 9. When the cause of the TCA is major trauma 3. In out of hospital TCA, only life-saving and a medical cause is unlikely, most interventions are performed, so as not agencies and associations suggest that delay transfer. after any reversible causes have been dealt Motor sport medics practice with a 4. If a medical cause is suspected: with, it is reasonable to consider ceasing spine board Start treatment according to ALS resuscitation efforts after 10 minutes.

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Editors Note The subject of the use of cervical collars and immobilisation is on the agenda to be discussed at the Biannual CMO conference in Vienna. We hope to report on the discussions in a future issue.

REFERENCES AND RESOURCES 1. Emergency Medical Services Intervals (AANS), Congress of Neurological and Survival in Trauma: Assessment of Surgeons (CNS), AANS/CNS Joint the “Golden Hour” in a North American Section on Neurotrauma and Critical Prospective Cohort. Ann Emerg Med. Care. Guidelines for the management 2010 Mar;55(3):235-246 - http://www. of severe traumatic brain injury, 3rd ncbi.nlm.nih.gov/pubmed/19783323 edition. J Neurotrauma. 2007;24:S1– 2. Pro/con debate: Is the scoop and 106. - http://www.ncbi.nlm.nih.gov/ run approach the best approach to pubmed/17511535 trauma services organization? Barbara 8. Acute traumatic coagulopathy. Curr Haas and Avery B Nathens. Critical Opin Anaesthesiol. Frith D, Davenport Care200812:224. - http://www.ncbi. R, Brohi K. 2012 Apr;25(2):229- IMPACT BRAIN APNOEA SUMMARY nlm.nih.gov/pmc/articles/PMC2592727/ 34. - http://www.ncbi.nlm.nih.gov/ Another trauma condition that has gained This review has been an attempt to explore 3. Damage control surgery–new concept pubmed/22270921 increased recognition is the syndrome of some of the evolutions in in-hospital and or reenacting of a classical idea? 9. Development and testing of freeze- Impact Brain Apnoea (21). In this situation a pre-hospital trauma management and how Beuran M, Iordache FM. J Med Life. dried plasma for the treatment of direct or indirect blow to the head is they might influence that care in a motor 2008 Jul-Sep;1(3):247-53. - http://www. trauma-associated coagulopathy. thought to disrupt brainstem function sport context; but by its very nature can ncbi.nlm.nih.gov/pubmed/20108501 Shuja F, Shults C, et al. J Trauma. transiently causing apnoea and a only provide but the briefest glimpse of all 4. Damage control resuscitation: history, 2008;65:975–985. - http://www.ncbi. catecholamine surge that results in the information available through a variety theory and technique. Ball CG. Can J nlm.nih.gov/pubmed/19001961 cardiovascular collapse, which may be of media. There are a number of other Surg. 2014;57:(1)55-60. - http://www. 10. Lyophilized plasma for resuscitation misinterpreted as hypovolaemia. This aspects of trauma practice that have not ncbi.nlm.nih.gov/pubmed/24461267 in a swine model of severe injury. phenomenon has been described in motor been included in this review, such as 5. Damage control surgery in the era of Spoerke N, Zink K, et al. Arch Surg. sport, mostly at motorbike races. Typically, concussion management and spinal damage control resuscitation. C. M. 2009;144:829–834. - http://www.ncbi. on arrival at scene the competitor is immobilisation practice, which are no less Lamb, P. MacGoey, A. P. Navarro and nlm.nih.gov/pubmed/19797107 unconscious, pale and apnoeic with dilated (r)evolutionary and will hopefully be A. J. Brooks. BJA, Volume 113, Issue 2, 11. Freeze dried plasma and fresh red and sluggishly reactive pupils, but addressed in a future issue of this Pg. 242-249. - http://bja.oxfordjournals. blood cells for civilian pre-hospital otherwise appears minimally injured. publication. org/content/113/2/242.full hemorrhagic shock resuscitation. Hypoxia occurs rapidly in motor sport With time, experience and research, 6. Immediate versus delayed fluid Sunde GA, Vikenes B et al. J Trauma competitors due to their increased oxygen clinical practices evolve and hopefully resuscitation for hypotensive Acute Care Surg. 2015 Jun;78(6 Suppl demand. The key resuscitation intervention improve. In order to provide optimal care patients with penetrating torso 1):S26-30 is support of ventilation and oxygenation. for our patients, whether on or off the race injuries. Bickell et al. N Engl J Med. 12. The CRASH-2 trial: a randomised These victims can and should make a full track, we must endeavour to keep our 1994 Oct 27;331(17):1105-9 - http:// controlled trial and economic recovery as the condition is transient. For knowledge and skills as current as possible www.nejm.org/doi/full/10.1056/ evaluation of the effects of more on this topic listen to neurosurgeon, using the resources that are available to us. NEJM199410273311701 tranexamic acid on death, vascular prehospitalist and motorsport enthusiast We should also endeavour to maintain 7. Brain Trauma Foundation, American occlusive events and transfusion Dr Mark Wilson - Impact Brain Apnoea with professional contact with each other and to Association of Neurological Surgeons requirement in bleeding trauma Mark Wilson (22). keep discussions open and progressive.

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patients. Roberts I. et al. Health Technol Guidelines/Adult-ALS/ANZCOR- slideshare.net/canicaveronica/ european-resuscitation-council- Assess. 2013 Mar;17(10):1-79. - http:// Guideline-11.10.1-Trauma-Apr16.pdf advancedtraumalifesupportatls9thedition guidelines-resuscitation-2015- www.ncbi.nlm.nih.gov/pubmed/23477634 20. Commotio Cordis: Ventricular Fibrillation 27. ATLS 9th Edition review by Dr Kenji Inaba section-4-cardiac-arrest- 13. Military Application of Tranexamic Acid Triggered by Chest Impact–Induced - https://youtu.be/nB8mNNmjCZg special#ASPECIALCAUSES in Trauma Emergency Resuscitation Abnormalities in Repolarization. 28. ATLS Evolving on ScanCrit (May 24, 2016) 32. Australian and New Zealand (MATTERs) Study. Morrison JJ, Dubose JJ, Mark S. Link. Circulation: Arrhythmia - http://www.scancrit.com/2016/05/24/atls- Resuscitation Council Guidelines on Rasmussen TE, Midwinter MJ. Arch Surg. and Electrophysiology. 2012; 5: 425- evolving/ Traumatic Cardiac Arrest 2016 2012 Feb;147(2):113-9. - http://www.ncbi. 432. - http://circep.ahajournals.org/ 29. ILCOR 2015 Updated Guidelines: ILCOR (Guideline 11.10.1) - http://resus.org. nlm.nih.gov/pubmed/22006852 content/5/2/425.full CoSTR 2015 - http://www.ilcor.org/ au/guidelines/ 14. Trauma and tranexamic acid. Russell 21. Impact brain apnoea - A forgotten cause consensus-2015/costr-2015-documents/ 33. Simple Thoracostomy: Moving L Gruen, Ian G Jacobs and Michael C of cardiovascular collapse in trauma. 30. ILCOR 2015: Does it matter for motorsports? Beyond Needle Decompression in Reade, on behalf of the PATCH-Trauma Wilson MH, Hinds J, Grier G, Burns B, - http://rollcagemedic.com/news-and- Traumatic Cardiac Arrest. MEA study investigators. Med J Aust 2013; Carley S, Davies G. Resuscitation. 2016 reviews/ilcor-2015-does-it-matter-for- Escott. JEMS 2014, Vol 39 (4) - http:// 199 (5): 310-311. - https://www.mja.com. May 20;105:52-58. - http://www.ncbi. motorsports- www.jems.com/articles/print/ au/journal/2013/199/5/trauma-and- nlm.nih.gov/pubmed/27211834 31. European Resuscitation Council Guidelines volume-39/issue-4/features/simple- tranexamic-acid 22. Podcast 12 - Impact Brain Apnoea with on Traumatic Cardiac Arrest 2015 – http:// thoracostomy-moving-beyond- 15. Clinical Randomisation of an Mark Wilson on Rollcage Medic - http:// ercguidelines.elsevierresource.com/ needle.html Antifibrinolytic in Significant Head Injury rollcagemedic.com/podcasts/podcast- (CRASH-3). ClinicalTrials.gov. - https:// 12-impact-brain-apnoea-with-mark- clinicaltrials.gov/ct2/show/NCT01402882 wilson 16. Pre-hospital Anti-fibrinolytics for 23. Fitzgerald, M. et.al. (2010). Emergency Traumatic Coagulopathy and physician credentialing for resuscitative Haemorrhage (The PATCH Study). thoracotomy for trauma. Emergency ClinicalTrials.gov. - https://clinicaltrials.gov/ Medicine Australasia. 22, 332- ct2/show/NCT02187120 336. - http://www.ncbi.nlm.nih.gov/ 17. Traumatic cardiac arrest. EM Docs. - http:// pubmed/20629696 www.emdocs.net/traumatic-cardiac- 24. Hunt, P. Greaves, I. & Owens, W. arrest/ (2006). Emergency thoracotomy in 18. Traumatic cardiac arrest: should thoracic trauma-a review. Injury. 37, advanced life support be initiated? Leis 1-19. - http://www.ncbi.nlm.nih.gov/ CC, Hernández CC, Blanco MJ, Paterna pubmed/16410079 PC, Hernández Rde E, Torres EC. J Trauma 25. Emergency Department Thoracotomy. Acute Care Surg. 2013 Feb;74(2):634- EAST Guidelines, Published 2015. 8. - http://www.ncbi.nlm.nih.gov/ J Trauma. July 2015 79(1):159–173 pubmed/23354262 - https://www.east.org/education/ 19. Management of Cardiac Arrest due to practice-management-guidelines/ Trauma. ANZCOR Guideline 11.10.1. - emergency-department-thoracotomy http://www.nzrc.org.nz/assets/Uploads/ 26. ATLS 9th Edition - http://www.

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CALL FOR SUBMISSIONS Every issue of AUTO+Medical contains a scientific research paper that looks at the various medical issues that surround motor sport.

All submissions are welcome For each submission please AUTO+ MEDICAL so if you have a study that include a summary of the EDITORIAL BOARD you feel would be suitable research and all necessary for publication in the future contact information. Dr Paul Trafford issues of AUTO+Medical, (Chairman) please send it to: The editorial board will medical@fiainstitute evaluate each submission Dr Robert Seal before it is accepted for use (Medical Director, in the magazine. Canadian Motorsports Response Team)

Dr Matthew Mac Partlin (Assistant Chief Medical Officer, Australian GP)

Dr Pedro Esteban (FIA Medical Delegate, World Rallycross Championship)

Dr Jean Duby (FIA Medical Delegate, World Rally Championship)

Dr Kelvin Chew (Chief Medical Officer, Singapore GP)

Dr Jean-Charles Piette (FIA Medical Delegate, Formula One)

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