INTERNATIONAL JOURNAL OF MOTOR SPORT MEDICINE ISSUE#10, APRIL 2017

SCIENCE OF CIRCUIT DESIGN Predictive modelling has become a key tool for modern circuit designers P24 ON SITE AT RALLY SWEDEN Examination of the medical facilities at 2017 Rally Sweden WRC event P32 KAZUKI NAKAJIMA The WEC racer recounts his crash at Spa and rapid recovery from injury P36

GETTING PHYSICAL How F1 drivers have prepared for the increased physical demands of the 2017 cars 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. I am delighted as a member of the publication’s editorial board to present this edition.

LETTERS/ In our cover story we examine how drivers are P4 The best letters and emails received from readers around the world dealing with the physical demands of the new, faster cars. The higher G-Forces GLOBAL NEWS/ will certainly test them physically this year and P6 NASCAR appoints official medical team those that trained well in pre-season will reap P7 Earnhardt Jr returns from major concussion the benefits during the season. P7 Dr Brent May named FIA Doctor of the Season P8 Paralympian wins first Keep Fighting Award P9 Pascal Wehrlein misses F1 races after back injury We also speak to Dr Brent May, who has just P10 ICMS 2016 round-up and review helped to deliver the medical provisions and cover for the first race of the 2017 F1 season in FEATURES/ his capacity as Chief Medical Officer for the P12 GETTING PHYSICAL . We also look at how F1 drivers have been working with doctors and trainers to ensure simulation and data analysis programmes have they are physically up for the fight in the 2017 season become key tools for modern circuit designers, P20 CMO PROFILE: DR BRENT MAY espcially when it comes to safety. Australian Grand Prix CMO Dr Brent May on his career, the challenges he faces and improving motor sport medicine P24 PREDICTING THE UNPREDICTABLE In our regular Road Back feature we speak to An examination of the simulation software and data analysis World Endurance Championship driver programmes used by modern motor sport circuit designers Kazuki Nakajima, who broke a vertebra at a P32 INSIDE RALLY SWEDEN’S MEDICAL OPERATION race in Spa in 2015. He explains how he A complete breakdown of the medical equipment and facilities used returned to compete at Le Mans an astonishing at the 2017 edition of Rally Sweden six weeks later. P36 THE ROAD BACK: KAZUKI NAKAJIMA The Toyota World Endurance Championship driver discusses his high-speed crash at Spa in 2015 and his rapid recovery from injury Our scientific article looks at the on‑scene treatment of spinal injuries in motor sport. STUDY/ P42 ON‑SCENE TREATMENT OF SPINAL INJURIES IN MOTOR SPORTS I hope you enjoy the latest issue. A detailed analysis regarding prehospital treatment of spinal injuries, particularly focussed on race car drivers

Editor: Marc Cutler Deputy Editor: Alex Kalinauckas Designer: Cara Furman Dr Kelvin Chew

We welcome your feedback: [email protected] Chief Medical Officer,

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experience in motor sport behind them, there is I recommend for anyone involved in medical the opportunity to hear detailed reviews of the care in motor sport to please strongly consider previous two years’ incidents in FIA-organised and attending the next seminar. You will not regret it. other events. You also have a chance to contribute to the discussions to improve safety for the future. Dr Rowley Cottingham MB BS BSc FRCS(Ed) The Summit was invaluable; firstly to keep abreast FRCEM of change, secondly to revise previous knowledge Consultant in Emergency Medicine, Brighton and In this section, we print the best letters and emails received from readers around the and finally to network with colleagues facing the Sussex University Hospitals NHS Trust world. We welcome comments on articles as well as suggestions for future content. If same issues as I do in my motor sport practice Medical Director, BodyChillz Ltd you wish to send in a letter or email, please direct it to: [email protected] around the world. Many people contributed to this Honorary Research Fellow, University of Brighton excellent conference but one person who does Honorary Treasurer, BASICS (www.basics.org.uk) deserve praise for the impressive organisation is Dear Editor, there are three speakers per side, a limited the FIA Medical Affairs co-ordinator, Magali Louis, Editor: Thanks for your comments. The positive In company with many friends and colleagues, time for each speaker’s presentation (which has who made sure everything happened when and feedback is appreciated by all of those involved with I had the pleasure of attending the biennial FIA been previously prepared) and a moderator where it should. Thank you, Magali. the event. Medical Summit at the Hofburg Palace, Vienna in who controls the debate and sums up at its December last year. conclusion. As usual the programme for the Summit was Controversy, evolution and change are a mixed bag of lectures, round table discussions inevitable in medicine and indeed motor sport. and workshops. We all should recognise and embrace that fact Somewhat surprisingly, for what some might and be able to take part in discussions on various describe as a rather dry subject, by far the best topics without fear or favour. workshop was that presented by Sandra Silveira I can remember when I was a medical student Camargo and Magali Louis on anti-doping. being told that 50 per cent of what I was learning The format used was one of discussing “real” at that time would be obsolete within the next 10 cases, what had happened and how this might years. be investigated and what penalty (if any) should The problem was, of course, that no one told be applied to the competitor concerned. They me which 50 per cent! had put a lot of work in to their presentation and I thank them sincerely for that. Dr Rik Hagen That led me to wonder if that type of format FIA WRC Regional Medical Delegate for Asia and might be applied more widely to the Seminar as Oceania a whole? Member of FIA Anti-Doping Disciplinary The types of presentations that I have seen Committee work well in the past include: - Editor: Thanks for your comments on the FIA Medical Scenario based presentations Summit. The FIA Medical Commission received Where there is a panel with assigned roles positive and constructive feedback from many of the such as Clerk of Course, CMO, Ambulance delegates at the event. All of this will be considered Coordinator, Chief Marshal, Fire Chief and Police when it begins planning for the next one. Commander. The moderator starts the scenario narrative, pauses for input from the panel members and then progressively reveals more Dear Editor information for further comment etc. I was a delegate at the excellent Medical Summit The 2016 Medical Summit welcomed 2016 in Vienna. This is the third Summit I have motor sport doctors Debates on Controversial Subjects attended, and I have been impressed by each. from across the world Where there are two opposing sides (e.g. the Not only is there the chance to network with merits or otherwise of Cervical Collars!) and colleagues and other experts with years of 4 5 AUTO+MEDICAL GLOBAL NEWS AUTO+MEDICAL GLOBAL NEWS

EARNHARDT JR Garry Connelly RETURNS FROM presented May MAJOR CONCUSSION with the award GLOBAL NASCAR driver Dale Earnhardt Jr says he is approaching a new era of his career after missing much of the 2016 season with concussion. The American driver crashed heavily at the Michigan NASCAR round last June and although he NEWS participated in the next three events, he sat out the rest of the season after being diagnosed with concussion – his AMR will send second in four years. DR BRENT MAY NAMED FIA staff to all Earnhardt was cleared to return to NASCAR events racing at the end of 2016 and made DOCTOR OF THE SEASON his return at the 2017 season-opening race in Daytona. “I do feel like this is a new chapter, Australian Grand Prix chief Chairman Garry Connelly handed for whatever reason,” he said. “I don’t medical officer Dr Brent May has the award to May, who is also the have a vision for what’s going to won the FIA Best Doctor of the Chief Medical Officer for happen. I don’t know how to explain Season award for 2016. Motorcycling Australia and it, but it feels like a new me.” The honour is one of seven FIA Karting Australia. During his recovery, Earnhardt was awards that are presented each May described the award as open about his diagnosis in year to officials working in motor “an amazing honour to receive”. interviews and on social media, an sport, such as doctors, stewards He added: “It was wonderful to approach that he believes helped to and marshals. be recognised for the work I do reduce his anxiety and stress-levels. May was presented with the for CAMS as well as in my role as He said: “To heal from the award at the Confederation of CMO for Karting Australia and concussion, I needed to be stress- Australian Motor Sport’s annual Motorcycling Australia.” free, to get that stress as low as gala in February 2017. During the Turn to page 18 to read a full possible,” he said. “I worried a ton event, FIA Formula One Stewards interview with Dr May. about people’s perception about what my problem was. I didn’t want any guesses out there. That’s the reason I NASCAR INTRODUCES OFFICIAL MEDICAL TEAM was so transparent." MEKIES DELIVERS SAFETY LECTURE FIA Safety Direcor Laurent Formula E seat belt tension Mekies outlined the FIA’s measuring device. The NASCAR series has made the American Medical established, medical response system even better. AMR approach to safety research as Mekies described the feeling Response (AMR) company its official emergency medical is a leader in the emergency services sector, and its he delivered the 2017 Watkins of pride he felt while delivering services partner. doctors and paramedics add another layer of expertise Lecture at the Autosport Show the lecture, which is named AMR will send a doctor and paramedic to all of the to the immediate response team.” in Birmingham, England. after safety pioneer Professor events on the 2017 NASCAR schedule and they will be Edward Van Horne, president and chief executive Mekies discussed the Sid Watkins. situated in an on-track response vehicle alongside two officer of AMR, described how his operation would seek forensic approach of the FIA’s He said: “We are trying of the championship’s Track Services staff members. to collaboratively improve medical intervention practices safety department and every year to contribute to The doctor and paramedic will be called on to provide with NASCAR. presented several studies this effort and to try and make medical intervention at the scene of an incident. He said: “We’re excited about this partnership with carried out by the FIA's sure the sport remains safe. Steve O’Donnell, NASCAR’s executive vice president NASCAR. We’re going to work collaboratively with research partner, the Global I’m particularly honoured to and chief racing development officer, described how the NASCAR and local teams to share best EMS practices Institute for Motor Sport be here because I think it is new deal would strengthen the stock car championship’s and ensure the highest quality of care," Safety. These studies included one of the best, if not the best medical arrangements. AMR is a subsidiary of Envision Healthcare and is the the single-seater cockpit examples of paying tribute to He said: “This partnership further strengthens NASCAR’s largest provider of emergency medical transportation safety device research and the Sid Watkins.” medical response capability, making our well- services in the USA.

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F1 world INDIAN STUDENT WINS Wehrlein NEW COORDINATOR FOR champion WATKINS SCHOLARSHIP missed the first ANTI-DOPING INITIATIVE gave the award races of 2017 to Low Indian student Nikil Abraham has won the 2017 Watkins Scholarship, a funded The FIA’s Medical Department has appointed Prisca position in motor sport safety research. Mauriello as its new Medical Affairs Coordinator. Named after motor sport safety Mauriello, who previously worked as a lawyer for ten pioneer Professor Sid Watkins, the years in the areas of sports and commercial law, and scholarship offers a one-year position intellectual property, joined the FIA’s Development with the Global Institute for Motor Department as a Sporting Coordinator in 2016. With a Sport Safety, the research partner of specific focus on anti-doping matters, Mauriello will the FIA, and is jointly funded by the FIA, now joinSandra Silveira Camargo, Head of Medical FIA Foundation and the Global Institute. Affairs, and Magali Louis, Medical Affairs Coordinator, Abraham, who holds a Masters who concentrates on the department’s medical Degree in Automotive Engineering from programmes. the FH Aachen University of Applied The FIA’s anti-doping programme, Race True, aims to Sciences, was selected by a panel of protect clean drivers through testing and education. It experts that consisted of Formula One also informs and educates driver support personnel Managing Director , German and officials on anti-doping, which is considered a Motor Sport Federation Medical PASCAL WEHRLEIN priority by the FIA. Director Michael Scholz and Global MISSES F1 RACES AFTER A booklet named “Anti-doping Key Facts”, which Institute General Manager Research WINTER BACK INJURY summarises what the drivers and their entourages Laurent Mekies. must know about anti-doping, was launched in 2016 Abraham said: “I am delighted to win and is now available in seven languages. It is being the 2017 Watkins Scholarship and take Sauber Formula One driver Pascal widely distributed both by the FIA and national up this role at the Global Institute. It is Wehrlein missed the 2017 Australian governing bodies. going to be a challenging but very Grand Prix due to concerns over his fitness Race True also provides a ten-language online course interesting year and I look forward to levels following a back injury he sustained to go into more depth on the different aspects of continuing the legacy of Professor during the winter break. anti-doping, including topics such as the prohibited list, Watkins and making a real difference to The German driver will also miss this therapeutic use exemptions, dietary supplements, the world of motor sport safety.” weekend’s Chinese Grand Prix and will be doping control process, and disciplinary procedures. PARALYMPIAN WINS FIRST Luc Argand, the Global Institute replaced by Antonio Giovinazzi, who stood Last year, drivers competing in all FIA World Chairman, said: “We are pleased to in for him in Melbourne. Championships, Formula E and European Formula 3 KEEP FIGHTING AWARD welcome Nikil to the Global Institute as Wehrlein suffered the injury when he series received anti-doping group training based on the our second Watkins Scholarship crashed towards the end of the Race of principles of the Race True programme. This training recipient. He will be a true asset to our Champions event in January. The 22-year- Paralympic champion Vanessa Schumacher family for their will be extended to the FIA European Championships team as we continue our research to old subsequently missed the first F1 Low has been presented with the courageous step. I am completely this year. improve motor sport safety worldwide.” winter test and was forced to pause his inaugural Keep Fighting Award, behind the values that this Prisca The inaugural winner of the Watkins winter training regime. which has been established award represents and I am very Mauriello Scholarship, Sameer Patel, worked on Although he was cleared by the FIA to through a charity initiative happy to help spread them. I was has been several high-profile projects in Formula race in Australia, the training delay left him launched by the family of seven very surprised on first learning I appointed One, World Rally and other FIA questioning his ability to complete a race times Formula One world was the winner, I am very proud I Medical championships, and has now taken up distance in the new-for-2017 F1 cars, champion Michael Schumacher. have been selected and I would Affairs a full-time role with the FIA as a which require drivers to have increased Low lost both of her legs in an like to thank them for it.” Coordinator research engineer. physical abilities due to their higher levels accident at the age of 15 but has Speaking on behalf of the of downforce. since gone on to win a number of Schumacher family, Speaking as Sauber confirmed he would ParaAthletics titles in long jump spokesperson Sabine Kehm not race in China to allow him to rebuild and 100m events, including a explained why Low had been his fitness levels, Wehrlein said: “For me long jump gold at the 2016 chosen as the first winner of the the most important [thing] is that I can Paralympics in Rio de Janeiro. Keep Fighting Award: “[She] train intensively to ensure a 100 per cent As she accepted the award, embodies and conveys the values performance from my side as soon as which was presented by FIA that this prize wants to promote: possible. I will then be well prepared for President Jean Todt and 2016 F1 to never give up and; despite my first complete Grand Prix weekend for world champion Nico Rosberg, setbacks to positively shape the Sauber F1 Team.” Low said: “I admire the the future.”

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and to stay loyal to that squad. “What’s best for the team is usually Extrication teams ETHICS AND EXTRICATION – LOOKING BACK ON ICMS what’s best for each member of the demonstrated the latest techniques team,” he explained. The International Council for ETHICAL CONSIDERATIONS FOR considerations for motor sport Olvey also explained that Motorsport Sciences held its annual MEDICAL DIRECTORS AND TEAM physicians cover four areas: fairness, medical officers should be aware three-day congress on 7-9 December PHYSICIANS integrity, responsibility and respect. of participants abusing the system, 2016, where a number of medical and DR STEVE OLVEY He then covered the problem of doping amongst the competitors, safety topics were covered. dual agency – and the accompanying non-unified reporting to the media, These included the role of Dr Steve Olvey, Associate Professor of responsibility problems this creates entanglement with a participant’s biomarkers in the diagnosis of Clinical Neurology and Neurosurgery for medical directors – and examples personal issues, and any potential concussion by Dr Alain Ptito, how to and Bioethics Consultant for the of preventative ethics. These include traps placed to cast doubt on the build bridges in motorsports safety University of Miami, discussed the arranging local providers to medically medical systems in place. by Dr Matthew Mac Partlin, and ethics that motor sport medical cover an event, ensuring the “The Medical Director has an an explanation of damage control personnel should consider. competency of the medical and safety obligation to provide for the general resuscitation for catastrophic bleeding He began by outlining examples teams, developing a satisfactory mass well-being of all those involved in the by Dr Timothy Pohlman, which of the best ethical practices for casualty plan, designating appropriate event,” he said in summation. featured an in-depth analysis of James physicians: “[These are] beneficence, local hospitals, maintaining accurate Hinchcliffe’s near fatal IndyCar accident do no harm, confidentiality, and medical records, and being alert for SPINAL MOTION DURING RACE in 2015. Hinchcliffe also stepped up to honesty.” extreme environmental and other CAR DRIVER EXTRICATION the stage to talk about his experiences. Then, using six case studies – unexpected all-encompassing issues. DR TARA T. AMENSON trauma being fitted with a string fires – and Hulschoff explained that AUTO+Medical takes a closer look at from a hypothetical young karting When it comes to medical of six tri-axial accelerometers and the company’s interests are driven three presentations, which covered prodigy who has suffered numerous personnel working for motor sport Dr Tara Amenson, a Biomedical tilt sensors, data was collected at to “bring people home safe”. ethics, fire simulation training and head injuries, to a fictional marshal teams, Olvey explained that it is Technical Consultant at the SEA 20Hz with sensors using associated To apply its fire simulation spinal motion during driver extrication reporting defective safety barriers important to respect the established systems software company, gave software. The data was recorded technology to motor sport, Bullex procedures. – Olvey explained how the ethical hierarchy, be aware of favouritism, a presentation that explained the preliminary results of her study that as tilt angles relative to gravity and Haagen has built a replica Formula assessed spinal motion during the regional ROM, which is the relative One car prop, which it has dubbed Indycar star James process of driver extrication. motion between adjacent distal and the ‘Sapeurs Pompiers de ’. Hinchcliffe praised The purpose of Amenson’s study proximal sensors. “Accuracy of the The model, which is 4.47m long the work of the was to “measure the spinal motion sensor string has previously been and 1.7m wide, is fitted with an medical staff that of conscious human subjects with investigated within high precision, engine fire, cockpit fire, smoke saved his life stable spines during simulated such as yaw, pitch, and generator, extinguisher filler, remote extrication, investigate the effect roll movements,” said Amenson. control operating system, and a fire of immobilisation techniques Amenson's report suggested that resistant training manikin. on cervical spine motion, and to one sensor, fitted on the C3 Hulschoff also described how investigate the effect of extrication vertebra during the study, the pit lane area of motor sport and transfer techniques on spinal measured movement of between events presents a distinct danger motion,” she said. four and minus four degrees of fire due to the presence of After explaining the existing during the time period of 700 and refueling equipment and other literature and the practice of 1600 seconds during a practice associated kit, as well as the large immobilising the cervical spine extrication exercise. number of people working in a during management of traumatically confined area. He explained that injured drivers, Amenson described BENEFITS OF DIGITAL FIRE one of the benefits of fire simulation how “neurological injuries can SIMULATORS IN MOTOR SPORT software is that these personnel can be caused or exacerbated by FRANK HULSCHOFF be trained how to safely intervene if techniques used during extrication, a blaze breaks out. yet some spinal motion is inevitable Frank Hulschoff, the marketing “In the pit lane is arguably where [in that process].” director of the Bullex Haagen fire there is the highest chance of a fire Her study therefore looked at fighting training company, delivered related incident,” he said. spinal motion limits during the his presentation on the benefits of “This means the persons who are extrication process, and applied digital fire simulation products for first to respond to a fire are instruments to human subjects teaching motor sport safety crews usually not trained fire fighters during practice rescue sessions. and team members. but team members such as During the study, which involved Bullex Haagen provides fire safety mechanics. Training methods a 5ft7inch, 160lbs adult male training tools – such as advanced live until now needed real fire and this is with no history of spinal pain or fire set-ups, smart props and digital far too risky in the pit environment.”

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Formula One cars are fast, but in 2017, for the tone can reduce injury severity to the joints first time in a generation, they have been built and bones that they serve, but if the forces to go faster through corners. This has and will are sufficient, injury can still result. Weak THE DRIVERS TRIED TO have a major effect on the drivers throughout muscles in the neck, for example, support the MAXIMISE NEURAL AND the season as they face some daunting physical head poorly as the G-forces act upon it, and STRENGTH“ ADAPTATIONS challenges ahead. consequently soft tissue and ligaments can be WITHOUT INDUCING The cars are up to 40km/h quicker through torn.” high-speed corners as a result of the increased When the updates to the F1 regulations MUSCULAR HYPERTROPHY levels of downforce created by the new were announced in 2016, it soon became ” chassis regulations and the bigger tyres the apparent to the sports medicine personnel and saw a substantial increase in commitment from championship has introduced. This means the trainers employed by the teams and drivers all of our drivers and coaches this winter based drivers have significantly higher G-forces acting that existing fitness regimes would have to be on the assumption that the cars would be upon them as they race through F1’s fastest adapted. much more physical to drive.” corners. “We knew that cornering speeds would The push to increase fitness levels for 2017 – Any increase in cornering speed also adds to increase substantially and would make the with greater focus on head and neck strength Hintsa Performance’s the potential for the drivers to get hurt if they cars more physical to drive than they had been – led to F1 drivers starting their winter training Dr Luke Bennett have not sufficiently trained their neck and for over a decade,” says Hintsa Performance earlier than they had done in previous years. shoulder muscles to cope with higher G-forces. Medical and Sports Performance Director, Dr They used to focus on keeping their weight to a According to F1 Medical Rescue Coordinator, Luke Bennett, who is the F1 team doctor for minimum, a consideration that they still had to to train harder with more strength-focused Dr Ian Roberts: “Good muscle bulk and both Mercedes and McLaren squads. “So we bear in mind for this season, as the new chassis training rather than just long cardio sessions.” regulations have not made the cars any lighter. Toro Rosso’s Carlos Sainz revealed that But strengthening was the key consideration his winter fitness regime doubled in length Carlos Sainz doubled the length this year. to incorporate all of the additional strength of his workouts “The specific programmes required vary exercises the drivers put in before the start of ahead of 2017 considerably with the baseline weight, interests, pre-season testing. strengths and weaknesses of each driver,” “Our fitness levels of 2016 won’t be any good explains Bennett. “But it’s fair to say that they for this year, so for that reason we needed all took significantly less time off in December to step it up even more,” he says. “Instead of and added much more dedicated time in the sessions of 50 minutes, which is normal, mine gym this winter.” were between 1.5 and two hours – the length To increase strength, instead of focusing on of a GP – and we were working at around 180- long sessions of cycling or running to work on 190bpm heart rate. It also included boxing and their cardiovascular systems as they did in the cardio work, it was relentless and we never past, the drivers have had to balance those stopped working during the entire session. It pursuits with the need to increase the amount was full-on physically.” of weight training they did to build stronger Sainz also explains the ways he trained his muscles in the neck and shoulders. neck to cope with the higher G-force levels. “Before you were designing your training These ranged from specific weight sessions in programme to not gain any weight,” explains the gym to driving a go-kart with a weighted Haas F1’s new driver Kevin Magnussen. “Now helmet to simulate the new conditions on the we’ve relaxed that a little bit and we’re able track.

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“We had two ways of training the neck,” he to their training needs,” says Bennett. “One each racer has their own attention span and explains. “The first was with weights in the gym, particular contemporary issue has been the interests that need to be accounted for when which helped prepare for the G-forces we’ll SEVERAL DRIVERS HAVE HAD requirement to monitor heavy metal ingestion it comes to designing a wellbeing regimen. have to face in the car. The second was with a TO“ MODIFY OR REDUCE THEIR - several drivers have had to modify or reduce Even during the off-season, it can be difficult specific method when karting. These weights INTAKE OF LARGE FISH IN THE their intake of large fish in the context of an for them to manage a week of consistent, made the helmet around 1.5-2kg heavier than CONTEXT OF AN OTHERWISE otherwise very healthy diet.” uninterrupted physical training due to the normal, which corresponds to the kind of extra VERY HEALTHY DIET number of commitments placed on them by weight the G-forces feel in F1. This, together STAYING IN SHAPE COME RAIN OR SHINE their teams, sponsors and outside demands. with other specialised exercises, gave the neck ” Health and fitness concerns were not just a “Once the first pre-season test begins in muscles a very good workout.” the weight that accompanies muscle gain pre-season problem for the F1 drivers heading February, the coaches and drivers more or But as is the case in so many areas of F1, stems from a constant source of debate into the 2017 season, as the demanding 20- less enter a maintenance phase with respect it was not just about improving one specific between their trainers and race engineers, race calendar requires a lot of effort from to training, with perhaps a handful of further area. The drivers also built up strength in other who want to keep the overall weight of car them to stay at their maximum performance opportunities to top up fitness through the areas of their bodies to improve their overall and driver to a minimum. As a result the capabilities. year,’ explains Bennett. “The late season performance. drivers tried to maximise neural and strength Incorporating the strict training regimes and fly-away schedule from mid-September is “Core abdominal, back and pelvic muscle adaptations without inducing muscular diets into a driver’s busy schedule is a real art both brutal and decisive for championship strength is always of huge benefit in open- hypertrophy. for F1 doctors and trainers every season. As outcomes, so the mandatory summer cockpit motor sport categories,” says Bennett. Some of the ways they achieved the well as the long calendar, this is also because shutdown each August can be a fine balance “Together with building a better cardiovascular desired balance included completing lower endurance base, these have been additional numbers of repetitions with heavier weights, Sainz used a weighted priorities. Explosive braking forces are giving increased attention to more technical helmet during go-kart demanding, so leg strength is also a more measures like plyometric training, having training over the winter focussed adjunct to this core stability.” longer recovery intervals and undertaking Less time off and more fitness training might more explosive lifting when working out. not have sounded appealing to a young F1 Strict, healthy diets also play a key role in driver, but Sainz’s Toro Rosso teammate Daniil helping drivers to keep their weight down, a Kvyat saw it differently: the better prepared a focus that became particularly important in driver was for the new season, the more they F1 when the V6 turbo regulations were first would enjoy driving the new cars over the introduced for the 2014 season and the overall course of the year. weight of the cars increased significantly. While “I’d rather be training than partying,” he says, eating balanced and nutritious foodstuffs is “as the end result is I get to drive an F1 car. So not a new revelation for professional athletes, it’s always a pleasure to work towards good there have been recent discoveries about results. When you know you have done your certain foods that mean they are no longer preparation work as well as possible, suitable for drivers to consume in large then you can approach everything in a calm quantities. state of mind.” “Weight minimisation is an issue for many F1 drivers and there is an unsurprising focus EVERY LITTLE HELPS on eating whole foods of high nutritional The balance the drivers faced of adding as value, eliminating junk carbohydrates and much strength as possible whilst minimising balancing macronutrient intake appropriate

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impacts can be significant. As always, good car engineering and track safety measures make a significant difference to the outcome.”

THE PAY-OFF From the very first test of 2017, the drivers discovered how physically challenging this season will be. Mercedes F1 star Lewis Hamilton says: “It doesn’t matter how fit you are and how hard you trained, you get in that car and it beats the crap out of you. It just does, there’s just no simulation for it. So whether you feel it in the neck – there’ll be a muscle you

Higher levels of didn’t even know you had, deep down under downforce from new aero your rib cage, and you’re like ‘what the hell?’ parts have increased – through those testing days you figure those speeds and G-forces Magnussen weak areas out.” swapped long cardio The British driver, who uses the demands of sessions between prioritising mental recovery with a reckons the increased cornering speeds could cross-country skiing to boost his cardiovascular for strength good holiday, and squeezing in a few more lead to a driver suffering a sudden loss in and physical fitness levels, described the training physical training sessions.” performance capabilities at any race if they sensations of driving the new faster F1 cars The current F1 calendar includes back-to- have not sufficiently kept their strength high for the first time. “I definitely put my body to significantly faster, and as the season develops back events in Singapore and Malaysia, which throughout the year. the test. It was good to feel the wider, beefier the current crop of F1 drivers will be hoping are regularly described as the championship’s “For racing, any increased G-force with higher car. You’ve got to drive it a bit differently, [but] the hard work of their winter training will pay toughest races due to their hot and humid cornering speeds will affect the whole body, it’s so much better than last year’s cars. The off by allowing them to produce consistent climates. The higher G-force levels will make but the extra forces placed on the head require G-Forces are definitely higher. It’s faster, more performances throughout the year, despite things even tougher for the drivers during good strength and endurance from the neck physical, it’s a beast.” the greater demands the higher G-forces are these events in 2017, but their fitness advisors and shoulder muscles,” he explains. “Rapid The new cars were designed to be placing on their bodies. have worked out ways to help them adapt to driver fatigue, countered by good preparation, the heat. can certainly be an issue over the duration of “Cooling and hydration protocols on race the race.” MOST DEMANDING F1 RACES weekends are the mainstay of managing these When it comes to potential crashes, however, conditions,” says Bennett. “But for specific the risk of drivers getting hurt in crashes drivers and where the schedule allows, we may has not been increased with the new cars, SINGAPORE GP MALAYSIA GP MEXICO GP acclimatise in the weeks beforehand using a according to Roberts. F1’s night race takes place The race at the Sepang The Mexican race takes period of training in Asia or a dedicated heat “Deceleration injury, plainly, is not simply at the Marina Bay circuit, circuit takes place in place at 2,229m above sea chamber closer to home in Europe.” a result of increased car speeds but of which has the highest sweltering conditions, with level - the highest altitude all uncontrolled deceleration,” says Roberts. number of corners of any on track temperatures season - and as a result the STRONG DRIVERS, STRONG CARS “Rapid deceleration, its vector and rotation are F1 track (23). It also has the hitting 56 degrees in 2016. cars also record the fastest Although the hotter races on the F1 calendar all very important in the mechanism of injury, second highest average It is also the longest race at speeds (372.5km/h) at any require special preparation, Dr Ian Roberts and that is why some apparently more trivial monthly temperature. 310.4km. track on the F1 schedule.

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training simulation on the day prior to the proximity of the track to a Major Trauma DR BRENT MAY event to make sure we have consistency Centre – 90 seconds from gate to door – we despite the varied backgrounds of everyone have special dispensation to work without a Chief Medical Officer, Australian Grand Prix involved. medical helicopter. MBBS, FANZCA, MSc (Trauma) Specialist Our medical centre is also geared much Anaesthetist and Prehospital Physician A+M: What is your role during an actual F1 more to orthopaedic and minor injuries but race weekend? still has resources and personnel to deal with Dr Brent May is the Chief Medical Officer BM: Like most CMO’s for F1, my role is any serious trauma or medical condition. for the Australian Grand Prix. Ahead of the oversight and governance. I sit in race control 2017 event he tells AUTO+Medical about with the FIA medical delegate and my medical A+M: Does the temporary nature of the the challenges of running the medical communicator. We make sure the on-track Albert Park paddock influence the set-up team at what has become Formula One’s responses are appropriate – applying my of the medical facilities? traditional season opener and how he experience in motor sport and making risk BM: We have a specific area that the medical assessments based on that. I also make centre is located in each year. I think this is would improve motor sport medicine. decisions on the fitness of a driver to compete important because the medical centre is in conjunction with the FIA medical delegate. easily accessible from the track and to external roads. Plus all drivers and officials AUTO+Medical: How did you first get A+M: What medical and safety facilities do know where it is, as do the international involved in motor sport? you use during the Australian Grand Prix? travellers. This reduces the risk of errors in Brent May: I have always loved watching BM: We have a temporary circuit at Albert Park finding the medical centre by those looking motor sport and even met my wife at a race in Melbourne. We run a team that includes five for it and also means that we minimise meeting, but not as a patient. My first medical cars and six ambulances. Due to the transport times. experience was at Phillip Island after a friend I HAVE ALWAYS LOVED invited me down to the track as a junior doctor. The Albert I arrived at the track and met an amazing group WATCHING MOTOR SPORT Park race “ takes place of people who I am still friends with to this day. AND I EVEN MET MY WIFE on a At that event, a V8 Supercar crashed no more temporary AT A RACE MEETING, BUT circuit than 30 metres from us at high speed. We NOT AS A PATIENT responded straight away and from that moment on I was hooked. I am still with the ” same volunteer medical team, Team Medical A+M: What does your work as CMO involve Australia, more than 10 years later. in the period leading up to the race? BM: I think the hardest thing about being a A+M: How did you become CMO of the CMO is losing most of the clinical and on-track Australian Grand Prix? work and moving to more administrative tasks BM: To be honest, it was like any other job and logistics. All the lead-up to the race is interview with a CV, panel interviews and a recruitment, administration and making sure tense wait. The Confederation of Australian that the service is consistent with the Motor Sport (CAMS) has a pretty formal and regulations. open approach to this stuff to make sure it gets I also spend significant time building the best candidates. I was extremely pleased to redundancy into our system and organising all receive the call confirming that I was successful. the equipment and resources. We run a full day

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A+M: What has been your greatest A+M: In what ways would you improve Alonso's accident at the 2016 Australian achievement in motor sport medicine? motor sport medicine? Grand Prix was the BM: My recent award as the FIA Doctor of the BM: I think education and research are the keys biggest crash May has witnessed Season was an amazing honour to receive. It to improving motor sport medicine. I have been was wonderful to be recognised for the work I fortunate to travel internationally and help do for CAMS as well as in my role as CMO for spread contemporary, relevant and evidence- Karting Australia and Motorcycling Australia. based education programmes to the motor sport community. I think the time has come A+M: Can you give any examples of when we can use technology to make these incidents you have responded to during programs more pervasive so that many can your time as a motor sport doctor? benefit. BM: With almost 20 weekends of motor sport a With regard to research, we sorely need a year over more than 10 years, there are many. minimum recommended data set that can be From high-speed rollovers, start line incidents easily collected in each country. Collaboration with multiple wrecks to heavy impacts into the between organisations using the same data wall and trapped drivers. sets allows for rapid comparison and much I have also seen some strange accidents bigger numbers to get meaningful results. The including riders trapped in motorcycles and use of apps and technology will greatly assist drivers trapped in karts. The biggest incident in these programmes. recent memory was watching Alonso walk away from his crash at the 2016 Australian Grand May was given A+M: The 2017 Australian Grand Prix was A+M: Can you explain how the medical Prix. It just showed me that you need to be the 2016 FIA Doctor of the the first race with the new, higher-speed F1 facilities for spectators are arranged in prepared for everything. Medical teams need Season award cars – how did you prepare for that? Albert Park? standardised communication and operating BM: We are very used to being the first Grand BM: We have both a first aid service and procedures so that when ‘it’ hits the fan, you Prix of the season and have experienced minor ambulance response service dedicated to the can rely on your training as a team. and major changes to the cars in the past. The spectators. Given the proximity of the circuit to introduction of the Kinetic Energy Recovery Melbourne’s Alfred Hospital, any injury or A+M: What is the most rewarding part of Systems in 2009 and then the 2014-spec ERS, illness of any significance is rapidly transported your work in motor sport medicine? as well as changes in engines, have meant that there. BM: It used to be good outcomes from each we spend a lot of time researching the cars and incident I attended, but these days, it is the educating our team prior to the event. A+M: Can you describe the biggest challenge education and training I do. Travelling I don’t think the increase in speed will place you have faced as a motor sport doctor? internationally is very rewarding and reinforced any significant pressure on our medical service BM: A death at the circuit is always the hardest by the emails I receive from those I have shared although we may see some more incidents. We to deal with. The memory stays with you knowledge with. are prepared for anything that happens but the forever and you always think about the causes, Locally, it is sitting on committees and Formula One cars are extremely safe as we saw safety aspects, management and what could commissions to improve standards and with ’s crash last year. I am have been done to prevent the outcome. medical responses in motor sports across awaiting the possible introduction of the Halo Fortunately, fatalities are rare in Australian CAMS, Motorcycling Australia and Karting system and the issues that may present for our motor sport but the few I have been involved Australia. extrication teams in 2018. with still stay with me.

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PREDICTING THE UNPREDICTABLE Simulation and data analysis programmes are key tools for modern circuit designers. AUTO+Medical examines how they are used to create exciting and safe motor racing tracks.

The 2016 FIA WTCC Race of Argentina at the Termas de Rio Hondo track, built using prediction tools

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Motor sport is dangerous, and crashes designers to understand the angle of any have always been part of the thrill of the Jarno Zaffelli, Clive Bowen, impacts that may occur at corners, which they founder of competition. But technology is now capable founder of can adapt to make sure the crash occurs at an the Dromo Apex circuit of taking the unpredictable elements of circuit design design angle of 30 degrees or less to try and ensure racing and looking for patterns in the chaos company that the accident is less severe. with the aim of improving circuit design, as “You can mitigate risk and you can design well as the positioning of safety staff and the corners so that the impacts are going to be equipment. Crashing just got a little 30 degrees or less, which is a known angle less random. where if you are 30 degrees or less it will be a When it comes to designing circuits or glancing blow rather than a sudden stop,” improving existing venues, simulation and explains Bowen. “So what you can do is data analysis software have become vital. deflect the trajectory of the vehicle, Jarno Zaffelli, the founder of the Dromo and it then dissipates its speed on circuit design company, spent 11 years a different trajectory.” gathering data – crash figures, on-track events, and general circuit statistics – that CRASH PREPARATION he converted into a programme that he programme,” he explains. “Some are use the criteria for different media along that Zafelli relies more on a crash prediction believed would aid circuit design. predictable and we focused on collecting trajectory whether it be grass, gravel or model for his track designs. In 2012, he “I always aim to do what is possible to these by examining, understanding and asphalt, and we have an idea of speed worked on an overhaul of the Termas de Rio improve circuits,” says Zaffelli. “That doesn’t looking for evidence. Everywhere, we looked decay as you cross those different surfaces,” Hondo circuit in Argentina, which had first mean to take away crashes, incidents, and at a wide spectrum to find possible says Bowen. opened in 2007. clashes, but to try to take away the correlations to build a model robust enough Simulation software also enables circuit The track was rebuilt with Dromo’s safety predictable ones and leave the racers to to be deployed. Statistics cannot be used to enjoy the tracks for our own enjoyment. predict the future, but they can be used to try The FIA is working on safety improvements to understand what happened in the past, and regulations, promoters work on race and react.” formats and media appeal, and I’m helping to bring the objective tools I use to support SIMULATION SAFETY my experience in race track design.” Another important tool for circuit designers is After a few months of research and simulation software. For Clive Bowen, development, Zaffelli produced Dromo’s founder and director of the Apex circuit first prediction model, which used artificial design, it is an essential part of the design intelligence algorithms based on the data process as it can predict potential hazards he had collected during his track study. The and accident zones. first instance of the crash calculation Apex’s simulation software takes raw data software used the geometry data, crash from the on-board recorders of various statistics, and images captured on the categories – from touring cars to FIA Formula Software predicts the video feeds from the CCTV cameras 3 to Formula One – and creates a ‘best fit’ likelihood of accidents in each corner installed around the courses. model for new corners and runoff areas. and recommends “Using a simple classification we “We have developed that simulator with ambulance placements determined the classes for the new data and better analysis, so now we can

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recommendations incorporated into the new layout, which brought it up to the top level of THE PROCESS OF CIRCUIT safety standards required by the governing DESIGN IS AS MUCH ART AS bodies of international automobile and “ motorcycle racing. IT IS SCIENCE, INNOVATION “We designed the new track on the basis of REQUIRES ORIGINAL the existing one, to receive FIA Grade 1 and THOUGHT FIM Grade A homologation, so all the track and runoffs were designed for both world ” championship events,” explains Zaffelli. After the race, Dromo compared its crash At that stage, Dromo’s software – the first prediction software with the events that “public prediction algorithm available” happened at the track that weekend. Across according to Zaffelli – was tuned for motor the three days of on-track action, 36 crashes bike racing and one of the company’s occurred with 93 per cent of them happening engineers had individually analysed all 865 in an area of the circuit that the programme crashes from the 2013 Moto GP had determined that 90 per cent would championship. From that study, Dromo occur. There was a single injury, which produced a report marking the location of happened at the track’s Turn 5, where an the incidents and logging any injuries ambulance was positioned. sustained by riders during those crashes. Ahead of the 2014 Argentina motorcycle ALTERNATIVES TO ALGORITHMS Grand Prix, the first premier class motor bike But relying solely on crash prediction race event to be held at the Termas de Rio software is not always an approach favoured Hondo circuit since it had been rebuilt, by all circuit designers. For Bowen, when it Dromo showed its crash prediction software comes to producing a new track it is to FIM’s then chief medical officer, Dr Michele important to combine a scientific approach Macchiagodena. Working together they with creativity. planned where to situate rescue and medical “The process of circuit design is as much art personnel based on the areas of the track as it is science,” he says. “It is a design where accidents were likely to occur process where innovation requires original according to the programme. thought. If you were to apply an algorithm “We discussed the results of the model,” that designs a track, you’ll end up with the says Zaffelli, “and we began to think about same thing coming out each time, which is how to deploy the medical teams around the not going to challenge the drivers or impress track. Macchiagodena’s idea was to put the the visitors or the spectators and will rescue teams and ambulances where the ultimately make the whole process anodyne. model was indicating the most likely number You want to have some kind of quirkiness to of crashes, coupled with their magnitude. The start of the 2014 create an identity for a different location Moto GP Argentina Nobody had experience on the track, as it Grand Prix at the Termas compared to another.” was brand new, and this was the only de Rio Hondo Another consideration is the landscape of information available in addition to his own that location, which is usually incorporated career experience.” into the design of the circuit, particularly with

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street circuits where the presence of drivers have a clear view of the marshals’ DROMO'S CRASH PREDICTION MODEL CLASSIFICATION buildings and walls heavily influences posts so they are forewarned of any the layout. YOU ALSO NEED TO upcoming danger. EVENT TYPE CAR BIKES “You identify what you can fit within your ACCOMMODATE THE FIA’S The topography of the venue and other Total loss of control Predictable Predictable site and you seek to achieve a particular “GUIDELINES, SO WE’VE elements of proposed circuit infrastructure Water crossing Predictable Predictable Spin (High side) Predictable Predictable criteria depending on whether you’re aiming GOT SOME PRETTY GOOD are all factored into the simulation to ensure for something that is like a Formula One track they do not impede visibility. Understeer (Low side) Predictable Predictable STANDARDS TO MEET Mechanical failure Unpredictable Unpredictable or the other end of the scale where you’re “We have a means by which we can identify Aerodynamic failure Unpredictable Unpredictable looking at club racing,” says Bowen, who what is visible and what is not to the eyeball,” ” Electronic failure Unpredictable Unpredictable worked on the Dubai Autodrome and the says Bowen. “So if we locate a marshal post, Partial loss of control Part. Predictable Rare Kuala Lumpur street circuit. “You also need to we then run, almost like a radar sweep, a Contact between Unpredictable Unpredictable accommodate the FIA’s guidelines and the simulation that we’ve established that looks competitors various appendices to the sporting code, at the 3D model we’ve created and takes into so we’ve got some pretty good standards consideration barrier locations, and, if you’ve crews at race events, another important to meet.” got them, lighting mast locations. We always consideration when building a new track try to ensure that before we’ve even asked a is access to the course for recovery and VISIBILITY AND TRACK ACCESS circuit inspector that you can see from one other safety vehicles. Another aspect of track design is visibility marshal post upstream to the next, and These are usually placed at the analysis, which is an important safety Visibilty is downstream to the previous one. And we juxtaposition of where the straight consideration for circuit designers. Designers crucial for ensure that the view to the circuit is boundaries of the circuits meet the side on motor sport need to make sure safety staff can clearly see safety workers unencumbered for that section between areas. A corner such as Silverstone’s Copse each other around the track and ensure the marshal posts because that by definition would have a ‘snatch gap’ facing the barrier means if you can see it, it can see you. So so a recovery vehicle could quickly move to therefore the racing driver is going to be able pick a stranded car and then reverse off. to see the marshals posts and therefore the “Logically you would have an access point flag being waved.” at that deepest point in a corner runoff While event and championship chief area, and depending on the size of the medical officers often work with circuit circuit and the length of the arc and the designers to plan the location of medical likelihood of an incident, you would have at least one, possibly two, more access points to that runoff area,” says Bowen. “These may not necessarily have a recovery vehicle parked there but may allow one parked elsewhere to be able to manoeuvre around and go through the other access gap.” The use of simulation software and data analysis has become more and more Safety barriers and track access points Silverstone's Copse commonplace in many areas of motor are major factors corner (here in 2015) sport. To circuit designers, these for circuit designers has a 'snatch gap' for safety vehicles programmes are vital tools for creating and improving racing venues around the world.

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Providing medical coverage for a doctor working alone or with a World Rally Championship event nurse. The centre also has an INSIDE RALLY that covers over 14,000km is no ambulance waiting on standby easy task. Combine that with a ready to transport patients to the SWEDEN’S setting in a snow-packed forest designated emergency hospital, in the middle of a Scandinavian which is just five minutes away winter and it is clear that Rally from the service park. MEDICAL Sweden requires a unique As well as taking care of the approach. drivers and team staff competing OPERATION To keep World Rally in the event, Rally Sweden’s Championship competitors and medical team is responsible AUTO+Medical examines the medical spectators safe, Rally Sweden for helping the spectators that employs 11 doctors, one come to watch the cars. They are equipment and facilities used at Rally paramedic, one anaesthesiology supported by a team of Red Cross Sweden 2017 nurse, and two fire fighters workers that are located near the working across eight medical event's specific viewing areas. intervention cars. AUTO+Medical takes a detailed The event has a main medical look at some of the other facilities centre based at the rally service used by the Rally Sweden medical park, which is manned by one team.

MEDICAL INTERVENTION CARS All eight of Rally Sweden’s medical intervention cars are equipped especially for the event according to the FIA’s regulations for the WRC. There is a medical vehicle stationed at the starting point on every stage but for the longer runs a second car is positioned at an intermediate point, which is to ensure that there is no more than 10 minutes transport time to the scene of an accident. Ahead of the rally, the event’s CMO is required to travel with the Safety Officer or Clerk of the Course to establish the correct positions for the medical vehicles along the route.

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EQUIPMENT Each medical intervention car is equipped with a full set of airway stabilisation equipment, specific drugs, neck stabilisation kit and IV fluids. However, IV fluids, which are usually provided to seriously injured patients to help them avoid hypothermia, AMBULANCE may freeze in cold environments. Alongside the medical intervention cars, an ambulance Each car is also required to have is stationed at the start of each stage, as well as in the two 4kg fire extinguishers, a service park. The vehicle is equipped for treating vital warning siren, and a kit of basic distress symptoms, whether neurological, respiratory rescue equipment determined or circulatory, and the crew is comprised of a driver, by the CMO in collaboration a doctor proficient in resuscitation or a paramedic, with the event’s chief scrutineer. who may also be the driver, according to the FIA’s The cars must have suitable WRC regulations. Along with the rest of the medical communications equipment team stationed around the course, ambulance staff to maintain contact with Rally members are required to communicate with the CMO HQ, which is where the CMO either through the general radio network or through a is stationed to co-ordinate the dedicated network radio channel. response to an incident.

STUDDED TYRES The cold climate of Rally Sweden, and the snow and ice the drivers have to compete on, also presents a challenge for the medical intervention teams and their vehicles. Each medical car is a dedicated all-terrain vehicle and is fitted with distinct winter tyres. This means each tyre has special studs attached STAGE START to provide extra grip, which is an Around 100,000 spectators attended the four days of the 2017 essential requirement for crews Rally Sweden, and although many issues that arise from the responding to an accident on crowds are dealt with by the Red Cross staff, the event’s fully icy roads. “All of Rally Sweden’s medically equipped rescue helicopter, which has a doctor medical response teams are stationed on-board, is available to provide assistance in case mobile rescue units that are of a serious incident. “This year three people got injured in a well trained for extrication and snowmobile accident on their way to the stage,” explains Dr medical first aid,” explains CMO Maria Lannerås, the event’s CMO. “Two of them had fractures to Dr Maria Lannerås. the femur and one had an arm fracture. In a separate incident, one spectator got treated for a severe allergic reaction.”

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THE ROAD BACK: Nakajima returned to action just six weeks after his KAZUKI NAKAJIMA crash at Spa. The Toyota World Endurance Championship driver looks back at his high-speed crash at Spa in 2015, his rapid recovery from injury and return to racing

During the opening practice session for A+M: Were you aware that you had hurt the 2015 World Endurance Championship your back immediately? event at Spa-Francorchamps, Toyota’s KN: I had a big crash and straightaway I could Kazuki Nakajima slammed into the back feel the back pain. The car was not in a good of an Audi car being driven by Oliver enough condition to drive back to the pits so I Jarvis after being unsighted in heavy just coasted down to the next corner and I spray caused by wet weather. The stopped there. Because I felt the pain in my Japanese racer immediately felt pain in back I thought I should stay in the car until the his back that was quickly diagnosed as a marshals came to me. broken vertebra. Despite being told the injury would take three months to heal, A+M: What did they do when they reached Nakajima returned to race at the Le Mans you? 24 Hours just six weeks after his accident. KN: As part of the normal procedure they He spoke to AUTO+Medical about the asked me if I was ok and I told them that I had incident and his recovery. back pain. Then they just followed the normal extrication procedure, which was done well – I AUTO+Medical: How did the crash occur? didn’t suffer from any additional pain at all Kazuki Nakajima: It happened in the from that at least – and then I was put in an opening practice session and the conditions ambulance and went to the circuit’s medical were quite wet. I was going along the centre. Then I went straight to the hospital straight after Eau Rouge and was almost after that. next to one of the Audi cars. Because he was in front of me I went to the side of him to A+M: What happened at the hospital? avoid the water screen and I think there KN: First I was given a bit of medication to were a couple of LMP2 cars in front of us reduce the pain, then I went for a CT scan and and the other Audi, car eight [driven by might have had an X-ray as well – I don’t Jarvis] was there too. remember exactly. They found the damage I I think car eight was probably trying to let had sustained on the vertebra and I had to its sister car by so he was not going at full stay there for a week or so. speed. But I couldn’t see him because of the water screen and I basically just hit him from A+M: What did the doctors tell you about right behind without noticing he was there your injuries and recovery time? until I hit him. I couldn’t brake or even get KN: Initially they told me that I had damaged prepared for the impact. the vertebra and it would take maybe three

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months to recover. They basically told me I underwent the operation. myself and for the team to check that I A+M: Was this the first injury that you had had to stay still, as the damage was not too could drive normally. So we did all of suffered in your career? bad so their recommendation was to keep it A+M: So what was your recovery process those procedures on the Le Mans test day. KN: Yes, it was the first big injury. Of course like that for three months and then they said it between the operation and racing at there was some small ones or maybe I had a would be fine. Le Mans? A+M: What did it feel like when you got bit of pain on the odd occasion, but this was KN: I left the hospital the day after the back in the car for the first time? the first proper injury in my career. A+M: But didn’t you come back after just operation, which was already quite impressive. KN: Initially it was kind of strange; maybe a six weeks to race at Le Mans? Then I went to Italy to stay with our team little bit of a scary feeling, but mostly it was A+M: How would you rate the medical care KN: Yes, because I had Le Mans coming in six physio and team trainer and there I did quite a excitement. It was a mixed feeling but soon given to you at Spa and later in hospital? weeks, three months was a bit too long for lot of rehabilitation processes. This was mainly afterwards I could see that I could drive KN: It was good because it was all clear to me me. Thanks to our team doctor, he knew training together with those guys and I also normally and without pain. After two or what they were trying to do, so the another doctor who could do a cementoplasty went to a rehabilitation place for a week. After three laps I started to get the rhythm communication between me and all the procedure – where they put material into the that I went to a team camp together with my back and I felt quite relieved after that. marshals and doctors was clear all the time. bone and this can stick the bone together teammates for another week. All of these When I understood the injury I was a little bit straightaway. processes helped me to recover quickly from A+M: Did you have any problems from the anxious but all the explanations I received and So I went for the operation, but of course I the operation. injury during the 24-hour race? the result was clear, so it was quite good. had to think about it because with an KN: Not really. Of course because of the injury operation there is always a bit of a risk. But for A+M: What happened when you got to I think I had not only damaged the vertebra A+M: Is there anything that motor sport me to race in Le Mans was the number one Le Mans? but also the muscles around it. medics can learn from your situation? priority so in the end we decided to go for it at KN: Before driving I had to see a doctor and Compared to normal or compared to now KN: It’s difficult to say because there were no a hospital in Nice in France. One week after they checked me. I also had to give them an it was a little bit more difficult – my back was mistakes and everything went quite well. The the crash I moved out from the hospital in X-ray photo before driving to show them that getting tired more easily. But apart from only lesson I can say is that all the preparation Belgium and went to the hospital in France. the bone was ok. So they checked me and that everything was ok and I managed to they are doing was quite useful in the end as Then after being there for two or three days I gave me a go, but of course I had to test for finish Le Mans [in eighth place] without they did it correctly and in a good way. So I just a big issue. appreciate that very much.

A+M: So what happened after Le Mans? Did A+M: What advice would you give to other you have to do more rehabilitation? drivers when it comes to recovering from KN: Not really because after that I was an injury? concentrating more on training rather KN: I think every driver has their own priorities than rehabilitation to get the muscles – taking part in some race or whatever. So around the vertebra back to normal. So I was they just need to think about their own training more than I would usually have priorities and do their best to recover. done but apart from that I didn’t do I think I was lucky to recover quickly and anything special. without any after effects and I could race in I had the X-ray checked one year after Le Mans without any problems. But after the the crash just to make sure that it was shunt I think I was ready to accept what still fine, and it was completely fine. happened to me and then think about Nakajima was All those muscle issues went away what to do afterwards. It was a good lesson unsighted by the spray kicked up three or four months later so after that for me and I believe it can be a good one for by other cars I was completely back in shape. other drivers too.

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SCIENCE ON ‑SCENE TREATMENT OF SPINAL INJURIES IN MOTOR SPORT Spinal injuries are common consequences of accidents at motor sport events. This article explains the correct procedures that motor sport safety workers and medics need to follow when dealing with patients suffering with damage to their spines.

Authors: Dr Michael Kreinest, Dr Michael Scholz, Dr Paul Trafford

(Article republished with full permission from the European Journal of Trauma and Emergency Surgery)

ABSTRACT Spinal cord injuries can have fatal consequences for injured race car drivers, so prehospital treatment of spinal injuries is therefore a major concern in motor sport. A structured procedure for assessing trauma patients and their treatment should follow established Airway/cervical spine protection, Breathing, Circulation, Disability, Exposure/ environment (ABCDE) principles. Only then, a stable patient could be further examined and appropriate measures can be undertaken. For patients in an acute life-threatening condition, rapid transport must be initiated and should not be delayed by measures that are not indicated. If a competitor must first be extricated from the racing vehicle, the correct method of extrication must be chosen.

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To avoid secondary injury to the spine after a Sustainability [68] and more recently by the METHODS Fig. 2 The head racing accident, in-line extrication from the Global Institute for Motor Sport Safety, the new A structured literature search of the United and neck vehicle and immobilisation of the patient are research partner of the FIA. States National Library of Medicine and the support (HANS) is a frontal head standard procedures in motor sport and have In general, the effects of spinal cord injuries National Institutes of Health database was restraint device been used for decades. Since immobilisation can have severe and extensive consequences for performed using MEDLINE through Pub-Med. consisting of a be associated with disadvantages and the patients. To avoid secondary injury, The search terms used are listed in Table 1. We shoulder corset (1) and two complications, the need for immobilisation of extrication from the race vehicle with the considered the literature from 1980 to 2016 straps (2) that trauma patients outside of motor sport medicine patient in-line and immobilisation of the cervical and additional articles listed in the reference are fixed at the helmet (3) has become the subject of an increasing number spine or the entire spine has been standard sections of these articles were also included. of reports in the scientific literature. procedures in motor sport for decades. Original articles as well as review articles and Even in motor sport, where specific safety However, evidence to support these procedures articles about current guidelines were included. RESULTS systems that offer spinal protection are is lacking [1, 23, 43, 66]. For trauma patients All articles found by the literature search were The literature search, carried out as described present, the indications for spinal outside of motor sport, the questions of read in full text by the authors. above, yielded 181 articles after removing immobilisation need to be carefully considered immobilisation in general and the choice A new protocol that supports on-scene duplicates. A reference analysis found additional rather than being blindly adopted as a matter among various techniques for implementing decision making for indications for spinal 53 articles. Thus, a total of 234 articles were of course. this measure in particular have become the immobilisation after a motor sport accident included and read in full text. The key The aim of this article is to use recent subject of increasing controversy in the was developed based on the data and conclusions were summarised in table format. literature to present an overview about the scientific literature. protocols found in the literature. Many criteria treatment of spinal injuries in motor sport. The aim of this article is to use recent found in the literature are intentionally not SPINAL INJURIES IN MOTOR SPORT Further, we present a new protocol for literature to present an overview about the included in the new protocol as they are An analysis of injuries with race cars on Fuji indications for immobilising the spine in motor treatment of spinal injuries in motor sport. usually not applicable in motor sport or Speedway in Japan in the years from 1996 to sport that is based on the ABCDE principles and Further, we present a new protocol for indications because they do not consider circumstances in 2000 showed that injuries to the spine are the takes into account the condition of the patient. for immobilising the spine in motor sport that is particular to motor sport. most frequent injuries in auto motor sport based on the ABCDE principles and takes into [61]. Spine injuries are especially common INTRODUCTION account the current condition of the patient. when trauma is the result of excessive impact Fig. 1 Seating Injury to the spine occurs in only about 1–2 per positions in race force. There are many classification systems cent of trauma patients [71]; close to 20 per cars. Upright for injuries to vertebral bodies; however, TABLE 1 seating position cent of these suffer damage to the spinal cord in closed touring differentiation due to the mechanism that [71]. When multiple injuries are involved, the Search terms utilised in PubMed or rally cars (a). involves either compression, distraction or proportion including spine injuries jumps to Reclined seating rotation is widely recognised [69]. Thus, position with almost 34 per cent due to the forces impacting Motor AND (sport OR racing) high legs and analysis of the sequence of events feet in a formula the victim more widely [68]. The percentage of Cervical spine immobilisation characterising the accident can provide key car (b) and patients with spinal cord injuries is also Spine AND motion IndyCar (c) evidence about the mechanism of the injury. significantly higher among polytraumatised Spine AND protocol Hence, impact of the head against the patients and is stated in the current literature Spine AND [(prehospital) OR (out-of-hospital)] windshield with axial compression may lead to as approximately 8 per cent [1]. a compression injury in the spine. When an (Spine AND injury) AND [(prehospital) OR (out-of-hospital)] In auto motor sport, injuries to the spine are accident occurs in a vehicle with no or with (Spine immobilisation) AND [(prehospital) OR (out-of-hospital)] mostly feared by the race drivers [31]. The improperly installed head supports, (Spine immobilisation) AND [(prehospital) OR (out-of-hospital)] frequency of spine or spinal cord injuries in hyperextension may result in a distraction [(Spine injury) OR (spine trauma)] AND the context of motor sport accidents is not injury. In cases of high-speed trauma with a exactly known and was the subject of research [(prehospital) OR (out-ofhospital)] range of different forces acting in different by the FIA Institute for Motor Sport Safety and directions (e.g., a car accident with a rollover,

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motorcycle accident), the spine may be subject the skull and of the cervical spine resulting in can be used to assess the position or height of to complex rotation injuries. reduction of basilar skull fractures and cervical TABLE 2 a known injury approximately: cricoid cartilage The ABCDE concept for treating trauma patients In addition, in motor sport the seating fractures in auto motor sport [69]. (at the third cervical vertebra, C3), navel (at the position of the driver must be taken into In addition, there are also general safety tenth thoracic vertebra, T10), and the iliac crest A Airway/cervical spine protection consideration. In closed cars (e.g., touring or features including the roll cage and the (at the fourth lumbar vertebra, L4). In addition, B Breathing rally cars), the driver is sitting almost up right requirement for helmets, as well as special limitations in mobility or sensitivity C Circulation in an anatomical position (Fig. 1a) and the construction features on the raceway [52] that disturbances such as numbness or paresthesia D Disability spine is relatively stable with the facet joints have significant impact on the severity of E Exposure/environment may point to additional spinal cord damage. engaged. When the driver is in a more reclined injuries in the event of high velocity accidents. These symptoms may not be present seating position, as found in formula cars (Fig. Experience shows that because of these immediately after the event and may vary in 1b) or IndyCars (Fig. 1c), the seating position TABLE 3 precautions, the severity of injuries in motor Motor function of the key muscles to assess intensity over time. As a part of the initial induces a flexed spine. Here, the natural sport must be adjusted compared to the spinal cord injury (SCI) assessment following the ABCDE principles, a anatomical curvature of the spine is severity of injuries in road cars. targeted neurological evaluation of the motor compromised by an artificial kyphosis with The same is true for motorcycle sports [17] LEVEL OF SCI IMPAIRED MOTOR FUNCTION and sensory systems is then performed. If the reversal of the physiological lumbar lordosis. due to especially designed run-off areas and C4 Breathing patient’s condition is stable and a spinal cord This extra anatomical setting of the spine special spine protector systems that are in use. C5 Elbow flexion injury is suspected, the key reference muscles seems to be a significant factor for fractures of C7 Elbow extension (Table 3) can then be assessed. In addition, the thoracic spine becoming more evident in ASSESSMENT OF TRAUMA PATIENTS WITH L3 Knee extensors sensory system deficits can be documented rearward direct impacts seen in IndyCars [68] SPINAL INJURIES IN MOTOR SPORT L4 Ankle dorsiflexors using the most caudal intact dermatome (e.g., or open-wheel open cockpit race cars [70]. If the preliminary diagnoses made in a L5 Long toe extensors paraplegia sub T12). If the trauma has affected Furthermore, landing impacts after launching prehospital setting are compared with the spinal nerves or the spinal cord, there may be effects in formula cars can lead to thoracic or reliable diagnoses confirmed in the hospital, it been established in motor sport [74]. Even if functional impairment or even complete loss of lumbar spine fractures by compression. is apparent that spine injuries are often there is strong suspicion of spine trauma, the all motor, sensory and autonomic functions Stabilisation of the cervical spine is also underestimated, particularly if there are examination should always follow and and reflexes (spinal shock) in all regions beyond subject to normal flexion and thus influenced multiple injuries [35]. Due to limited options in complete the ABCDE system. this point of damage to the spine. by seating position (Fig. 1). diagnostics in a prehospital setting, only Evidence of spinal trauma can be found even Finally, it is important to note that a patient To minimize the risk of spine injuries, motor guiding criteria for assessing the possibility of as early as during the assessment of the injured with a spine injury can exhibit a highly variable sport has a number of additional safety spinal injury can be detected. driver according to the ABCDE system, clinical presentation. Hence, even patients who systems in place [60], such as specially First, the mechanisms of the accident should however. For example, approximately 45 per are capable of walking after a traffic accident designed seats, moulded back supports and be analysed. If not directly observed and not cent of spine injuries are present with relevant may have a spine injury [57]. Whether the injury head restraints with absorbing foam inserts. witnessed by the race control monitors, in most concomitant injuries [55]. In particular if there is to the spine is stable or unstable can only be There are also special harness restraint cases wreckage reading and interpreting the injury to the head, injury to the cervical spine determined using imaging diagnostics within systems with up to nine points of fixation to surroundings can be informative. Often the should also be considered [36], which is why a the hospital. firmly hold the competitor and prevent race marshals can also provide details about spine trauma is initially assumed for any movement in the seat. Head and neck devices, the events and the mechanisms of the accident. accident victim with reduced consciousness [48]. such as the Head and Neck Support device To ensure a structured, focused and prompt Typical symptoms also include pain in the IT IS IMPORTANT TO NOTE (HANS, Fig. 2), are a widespread protection assessment of a trauma patient, the initial area of the spine, which the patient indicates THAT A PATIENT WITH A system [49]. HANS reduces neck loading, neck examination should follow the established either at rest or when moved. The entire spine “SPINE INJURY CAN EXHIBIT A tension and shear forces [49] by transferring ABCDE system (Table 2). The sequence of can be inspected and palpated for pain; force via two straps (Fig. 2, 2) that are fixed to measures in the ABCDE system follows a strict deformities or stepping during a log roll HIGHLY VARIABLE CLINICAL the helmet (Fig. 2, 3) to a shoulder corset (Fig. order to break through the cascade of manoeuvre that is performed while the patient PRESENTATION 2, 1). Thus, HANS prevents sudden flexion of pathophysiological reactions [26] and has also is in-line. The following anatomical landmarks ” 45 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

MANAGEMENT OF TRAUMA PATIENTS B—Breathing: If there is suspected injury to WITH SPINAL INJURIES IN MOTOR SPORT Fig. 3 Immobilisation the cervical and upper thoracic spine with protocol for adult Like the assessment itself, treatment of a trauma patients in involvement of the cervical spinal cord, ti≠mely trauma patient injured in motor sport follows motor sports. The preparation for ventilation should be made, as the ABCDE principles [74]. If the patient is still ABCDE principles are respiratory disturbances can arise either as a the central elements of in the vehicle, once the patient’s condition has this decision-support result of disrupted innervation of the been evaluated, a decision about the urgency tool. Depending on the diaphragm (C3–C5) or damage to the auxiliary status of the patient, of rescuing and thus about the mode of differentiated respiratory muscles. extrication must be made. A patient’s indications for various C—Circulation: If the assessment of a crashed condition can deteriorate at any point moving options for spinal race driver indicates unstable circulation, immobilisation are them into a more urgent category. In motor addressed. For stable priority for transportation is high. In the event sport, extrication is a standard procedure that patients, the indication of blunt trauma, immobilisation may be is based on the ESCAPE has been refined over many years, with criteria, after the minimised using just a cervical collar (Fig. 3). extrication seats developed [35] to facilitate assessment of the Although the use of a cervical collar alone patient has been in-line extrication in many instances. evaluated as does not adequately restrict the mobility of If the patient requires resuscitation or if appropriate (ICP the cervical spine [16, 44, 45], the residual there is an acute external danger for the intracranial pressure) mobility is accepted in this case, taking into patient and the rescue team (e.g., vehicle on account that complete immobilisation would fire), an emergency extrication without regard result in delayed transport. According to the for axis symmetry (e.g., using a Rautek grip) is literature, trauma patients with unstable necessary. In safer situations, the initial circulation following penetrating trauma are assessment using the ABCDE system is not immobilised (Fig. 3). On the other hand, if completed in situ [74]. If the patient’s the assessment of circulation indicates condition is deemed critical, an urgent hypotension and bradycardia due to isolated extrication takes place with the cervical spine neurogenic shock associated with injury to the immobilised (typically on a spine board). Full cervical or thoracic spinal cord with no other spine immobilisation during the extrication signs of hemorrhagic shock, then treatment process cannot be ensured in this case and with a parasympathetic drug or must not take priority because of the patient’s catecholamines can be administered. Vagus condition. A patient who is in stable condition area, treatment follows using the ABCDE and treatment of the trauma patient. nerve stimulation (e.g., from suctioning or and in a safe situation and for whom there is system. The following details should be noted Whenever possible, all procedures performed intubation) can magnify bradycardia even to indication for spine immobilisation is retrieved with respect to a spine injury: on a trauma patient (airway management, the extent of cardiac arrest. In such cases, using an elective extrication with the fullest A—Airway: If possible, immobilisation of the turning manoeuvres, etc.) should be carried temporary use of a pacemaker may be immobilisation of the spine that is possible cervical spine should always take place out with a minimum of further manipulation of indicated. In contrast to the situation when (e.g., with the aid of technical rescue). Patients immediately after arriving at a trauma patient the spine in general and of the cervical spine in there are multiple injuries (target systolic in stable condition can also be introduced to [24, 74]. To avoid delay caused by positioning particular. Both manual immobilisation and blood pressure is 90 mmHg [24]), if the spinal leave the car on their own. This kind of self- a cervical collar prior to assessing the patient positioning of the cervical collar should not cord is the only injury then normotension extrication leads to less movement of the using the ABCDE principles, immobilisation apply any traction on the cervical spine, as this should be strived for. cervical spine as many other extrication can be achieved by restraining the head using could cause damage to the medulla oblongata D—Disability: Assessment of a trauma patient methods in civil cars [26] but is not yet manual immobilisation (Fig. 3). The so-called (the control centre for the heart and lungs) if for neurological deficit should include evaluated for race cars. manual in-line stabilisation is sustained there is atlanto-occipital dislocation, for checking for signs of severe brain injury or As soon as the accident victim is in a safer throughout the complete ABCDE assessment example [9]. craniocerebral trauma with increased

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TABLE 4 intracranial pressure. In this case, avoiding the assessed. Adequate assessment is not Criteria PRO and CONTRA spinal immobilisation and use of a cervical collar is recommended (Fig. 3), possible in the event that there are language integration into the protocol for adult trauma patients as a cervical collar may cause further barriers or severe distractions (e.g., distracting in motor sport significant increases to intracranial pressure injuries, states of anxiety, as well as seriously [20, 46, 62]. However, because cervical spine injured or deceased persons at the scene). In Pro/Con References injuries often coincide with craniocerebral such cases, the indication is for complete Criteria included in the protocol trauma [25], immobilisation using the vacuum immobilisation. Age >65 years PRO [4, 30, 65] mattress is suggested [40]. Even without a If assessment of the patient is not limited, State of acute anxiety PRO [30] cervical collar, a modern vacuum mattress with factors that are associated with higher risk of Language barrier PRO [30] Acute stress reaction PRO [13] lateral headrests can achieve excellent spine injury can be evaluated via the ESCAPE Distracting injury PRO [4, 13, 59] immobilisation. Moreover, a supine position criteria (Fig. 3). According to these criteria, MVA ejection PRO [4, 27, 65] with the upper body elevated 30° is possible, full-body immobilisation should take place if at Altered/loss of consciousness PRO [2, 13, 28–30, 63, 72] which is also recommended for patients with least one of the following criteria is confirmed: Spine pain/tenderness PRO [4, 13, 29, 30, 37, 63, 72] craniocerebral trauma [40]. Alternatively, the effect on sensibility or motor function, Abnormal sensory/motor PRO [4, 28–30, 53, 63, 72] exam patient may be immobilised on a spine board, supraclavicular injuries (injuries to the neck or Significant head or facial injury PRO [2, 37, 72] with which it has been shown that complete the head), collision of a biker, age greater than Supraclavicular lesions PRO [53] immobilisation is possible even without the STABILITY AND COMFORT 65 years, pain on palpation or during active No neurological abnormalities CONTRA [40, 41] use of a cervical collar [18]. DURING IMMOBILISATION 45° neck rotation (as well as cervical midline No midline C-spine tenderness CONTRA [40, 41] “ No distracting injury CONTRA [40, 41, 64] E—Exposure/environment: Removing the ARE BETTER WHEN A VACUUM pain at rest), ejection from vehicle. If all Able to actively rotate neck CONTRA [4, 65] race overalls or other clothing and searching MATTRESS IS USED ESCAPE criteria can be positively excluded, Functional range-of-motion CONTRA [3] for further injuries may be performed later on immobilisation is not necessary (Fig. 3). Since Criteria not included in the protocol necessitated by the situation. This should ” the isolated use of a cervical collar does not involve inspection and palpation of the spine. If of motor sport. The resulting criteria are provide adequate immobilisation of the Rigid vertebral disease PRO [72] Intoxication PRO [13, 28, 29, 72] trauma to the spine is present or suspected, summarized in the ESCAPE criteria and cervical spine [20, 46, 62], the given protocol Fall from >1 m PRO [4, 65] the procedure that follows depends on the included in the aforementioned protocol for does not distinguish between immobilisation Fall from large animal PRO [27] patient’s condition: if there is an acute and spinal immobilisation of adult trauma of the cervical spine and the remainder of the High speed accident PRO [4, 65, 72] life-threatening status, high priority for patients in motor sport (Fig. 3). Many criteria spine for stable patients. Full-body MVA or pedestrian vs. train PRO [27] transport is given and only minimal found in the literature are intentionally not immobilisation is recommended in stable Vehicle rollover PRO [4, 65] Bicycle collision PRO [4, 65] immobilisation of the cervical spine should be included in the ESCAPE criteria as they are patients if there are indications of spine injury Road traffic collision PRO [38] performed using a cervical collar (Fig. 3). If the usually not applicable in motor sport (e.g., fall for the reasons given above. Reduced Significant intrusion of vehicle PRO [4] patient is stable, further neurological from height, collision with train or bicycle, immobilisation using a cervical collar on its Axial load to head PRO [4, 65] examination could be ruled out. In stable diving accident, intoxication) or because they own and positioning the patient inline on the Diving accident PRO [72] Sport injuries PRO [38] patients without any symptoms of neurological do not consider circumstances particular to stretcher is only acceptable for patients in Shooting PRO [38] or motor dysfunction, it is necessary to decide motor sport (e.g., high speed accident) or the critical condition and with high priority for Death at scene PRO [11, 37] on the indication for complete immobilisation wording for the criteria was too generalised transport, where ensuring rapid transport is Other spine fractures PRO [72] using a spine board or vacuum mattress or (e.g., road traffic collision, significant intrusion essential (Fig. 3). Stability and comfort during Severe injuries to other body PRO [2, 28, 29, 37, 72] systems whether the manual immobilisation that was of vehicle, sport injuries) or in some cases, the full-body immobilisation are better when a No evidence of intoxication CONTRA [40, 41, 64] maintained to this point can be discontinued. criteria are difficult to identify in a prehospital vacuum mattress is used compared to a spine Penetrating trauma CONTRA [73] To provide a decision tool for stable patients, setting (e.g., other spine fractures). board [36, 48, 55]. However, it is reported that literature-based criteria when there is Following the given protocol (Fig. 3), the first full-body immobilisation on a spine board is increased risk for spinal injuries (Table 4) were assessment to be made with a stable patient less time consuming [57]. gathered and adapted to the special concerns is whether the patient can be adequately Additional treatment for spine injuries

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includes adequate analgesia, because spinal Surgeons [67]. Even though adequate motor sport scene, have done them for years. cord lesions, fractures of the spine and any treatment of spinal injuries has been a major The special structure of the provided protocol accompanying injuries can cause severe pain. concern in motor sport for decades, there are, allows the integration in the assessment of There is no specific drug treatment used in the to our knowledge, no decision tools or injured competitors following the ABCDE prehospital setting for spine injuries. treatment protocols for prehospital spinal care principles established in motor sport [22, 54]. Administration of cortisone is no longer available in motor sport. The same is true for the decision of extrication recommended [24]. According to the current literature, the FIA methods that should also be based on the The destination hospital of choice is started a major research project in 2014 ABCDE principles [32]. Besides the generally specified in advance at racing events. looking at incidence, mechanisms and retrospective analysis about assessment and When there are spinal injuries, the most gentle treatment options of spinal injuries [68] since treatment of injured competitors as currently mode of transport and providing adequate there has only been a little research published done at Silverstone Race Circuit [22] and analgesia must be ensured. Rescue by air on treatment of injured competitors in motor coming up for some German Race Circuits, ambulance typically has a shorter transport sport [4]. A number of decision-support tools prospective studies have to prove the benefit time and is smoother [35]. The destination that have been described in the literature are of using standardised procedures in hospital should be equipped with specialists in subject to many limitations. These traditional emergency care of competitors with spinal the treatment of acute spine trauma, as this 50, 62]. Even complete immobilisation, for decision tools were developed for conscious trauma as it has been done for trauma has a direct influence on the outcome of the example on a spine board, is not without risk. and oriented patients [40, 65]. Many decision patients apart from motor sport [6]. patient [56]. In healthy young men, full immobilisation was tools preclude penetrating [12, 33, 59] or blunt Depending on the local facilities, these associated with restrictive effects on injuries [7]. The current status of the patient CONCLUSION specialists may be posted in different pulmonary function [8]. Furthermore, (stable or unstable) is not considered [4, 12, Spinal injuries are common in severely injured competence centres (trauma surgery, immobilisation on a spine board may also 40] or the tool is only applicable if the trauma patients as well as in race drivers. neurosurgery or orthopedics). In case of spinal cause pain [14, 15, 19] and may result in circulation is already stabilised [65]. Even Assessment and management of all trauma cord injury, transport to a centre for paraplegic pressure ulcers [10]. Additionally, mouth though a new protocol for spinal patients in motor sport should follow the patients is often secondary. However, both the opening is reduced [42] and airway immobilisation has been currently provided ABCDE concept of emergency trauma care. choice of mode of transport and the management is more complicated in [51], this decision-support tool could also not Following the ABCDE principles, spinal injuries destination hospital are initially made immobilised patients [34, 42]. As the severity be thoughtlessly applied to trauma patients in are not addressed until any acute life- exclusively on the basis of the current of patient injury increases, the likelihood of an motors sport, since the mechanisms of threatening events are handled. Afterwards, condition of the patient and the overall associated spinal injury also increases [25]. accidents as well as the protection systems further assessment and treatment of spinal pattern of injuries. However, clear prioritisation of all procedures differ from typical settings in ordinary road injuries and spinal cord injuries may be is strictly recommended in such patients, as traffic accidents. To our knowledge, there is no performed in a stable patient. DISCUSSION full immobilisation of trauma patients can also applicable protocol for indications for spinal Furthermore, the decision about the correct The use of a cervical collar on its own does not be associated with delays [18] and even immobilisation that consider the patient’s mode of extrication must be made and the provide full immobilisation of the cervical increase mortality, for example in patients current status and are valid for all adult indication for spinal immobilisation in general spine, as there is still obvious mobility who have suffered a penetrating trauma [39]. trauma patients in motor sport. and the immobilisation method in particular remaining. This residual mobility is evident in Because of these potential complications, In this article, a decision tool for indication of has to be provided. Remembering that all models of spinal collars that have been the indication for immobilisation needs to be spinal immobilisation based on the current immobilisation of trauma patients is not tested [5, 47, 58]. Thus, to protect the spinal thoughtful, for motor sport accident victims as literature and guidelines and adapted to without complications according to numerous column, full immobilisation of the head and well [68]. The use of decision-support tools for motor sport specialties is provided. reports. Therefore, this article presents a new trunk is necessary [16, 44, 45]. Furthermore, a indication is also recommended by current Furthermore, clear indications for the decision protocol to be considered for immobilisation cervical collar may compress the jugular veins guidelines, such as those by the German S3 of the method of extrication are given. Thus, of adult trauma patients in motor sport, based [8] and, hence, can lead to a significant Polytrauma Guideline [24] or the Guideline of standardised procedures can be performed as on the ABCDE principles and oriented to the increase in intracranial pressure [20, 21, 46, the American Association of Neurological emergency care providers, apart from the patient’s current status. AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

REFERENCES AND RESOURCES 1. Abram S, Bulstrode C. Routine spinal of a dissociative injury. J Trauma. immobilization. Ann Emerg Med. evaluation for potential spinal injury immobilization in trauma patients: 2010;69:447–50. 1992;21:1185–8. is not affected by the mechanism of what are the advantages and 10. Berg G, Nyberg S, Harrison P, et 17. Chapman MA, Oni J. Motor racing injury. Prehospital Emerg Care Off J Natl disadvantages? Surg J Royal Coll Surg al. Near-infrared spectroscopy accidents at , 1988/9. Br J Assoc EMS Phys Natl Assoc State EMS Edinb Irel. 2010;8:218–22. measurement of sacral tissue oxygen Sports Med. 1991;25:121–3. Dir. 1999;3:332–7. 2. Agrawal A. Cervical spine clearance: saturation in healthy volunteers 18. Connor D, Greaves I, Porter K, et al. Pre- 28. Domeier RM, Evans RW, Swor RA, et al. a review and understanding of the immobilized on rigid spine boards. hospital spinal immobilisation: an initial Prehospital clinical findings associated concepts. JNMA J Nepal Med Assoc. Prehospital Emerg Care Off J Natl consensus statement. Emerg Med J EMJ. with spinal injury. Prehospital Emerg 2008;47:244–50. Assoc EMS Phys Natl Assoc State EMS 2013;30:1067–9. Care Off J Natl Assoc EMS Phys Natl 3. Anderson PA, Muchow RD, Munoz A, Dir. 2010;14:419–24. 19. Cordell WH, Hollingsworth JC, Olinger ML, Assoc State EMS Dir. 1997;1:11–5. et al. Clearance of the asymptomatic 11. Bortsov AV, Platts-Mills TF, Peak et al. Pain and tissue-interface pressures 29. Domeier RM, Frederiksen SM, Welch K. cervical spine: a meta-analysis. J Orthop DA, et al. Pain distribution and during spine-board immobilization. Ann Prospective performance assessment of Trauma. 2010;24:100–6. predictors of widespread pain in Emerg Med. 1995;26:31–6. an out-of-hospital protocol for selective 4. Armstrong BP, Simpson HK, Crouch the immediate aftermath of motor 20. Craig GR, Nielsen MS. Rigid cervical collars spine immobilization using clinical spine R, et al. Prehospital clearance of the vehicle collision. Eur J Pain (London, and intracranial pressure. Intensive Care clearance criteria. Ann Emerg Med. cervical spine: does it need to be a England).2013;17:1243–1251. Med. 1991;17:504–5. 2005;46:123–31. pain in the neck? Emerg Med J EMJ. 12. Burton JH, Dunn MG, Harmon 21. Davies G, Deakin C, Wilson A. The effect 30. Dunn TM, Dalton A, Dorfman T, et al. 2007;24:501–3. NR, et al. A statewide, prehospital of a rigid collar on intracranial pressure. Are emergency medical technician- 5. Askins V, Eismont FJ. Efficacy of five emergency medical service selective Injury. 1996;27:647–9. basics able to use a selective cervical orthoses in restricting cervical patient spine immobilization 22. Deakin ND, Roberts I, Collett A, et al. immobilization of the cervical spine motion. A comparison study. Spine. protocol. J Trauma. 2006;61:161–7. Keeping competitors safe: a four-qear protocol?: a preliminary report. 1997;22:1193–8. 13. Burton JH, Harmon NR, Dunn MG, study. Auto + Med. 2015;38–51. Prehospital Emerg Care Off J Natl Assoc 6. Bandiera G, Stiell IG, Wells GA, et al. The et al. EMS provider findings and 23. Deasy C, Cameron P. Routine application EMS Phys Natl Assoc State EMS Dir. Canadian C-spine rule performs better interventions with a statewide of cervical collars — what is the evidence? 2004;8:207–11. than unstructured physician judgment. EMS spine-assessment protocol. Injury. 2011;42:841–2. 31. Ebben WP, Suchomel TJ. Physical Ann Emerg Med. 2003;42:395–402. Prehospital Emerg Care Off J Natl 24. Deutsche Gesellschaft Für demands, injuries, and conditioning 7. Barkana Y, Stein M, Scope A, et Assoc EMS Phys Natl Assoc State EMS Unfallchirurgie. S3—Leitlinie Polytrauma/ practices of stock car drivers. J Strength al. Prehospital stabilization of the Dir. 2005;9:303–9. Schwerverletzten-Behandlung AWMF- Condition Res Natl Strength Condition cervical spine for penetrating injuries 14. Chan D, Goldberg R, Tascone A, et al. Register Nr.012/019. 2011. Assoc. 2012;26:1188–98. of the neck—is it necessary? Injury. The effect of spinal immobilization on 25. Deutsche Gesellschaft Für Unfallchirurgie 32. Floß FM, Balbach P, Scholz M. 2000;31:305–9. healthy volunteers. Ann Emerg Med. (Dgu); Sektion Intensiv- & Notfallmedizin Extrication. In: Kreinest M, editor. 8. Bauer D, Kowalski R. Effect of spinal 1994;23:48–51. SNa-aDUG. TraumaRegister DGU— Schwerverletztenversorgung im immobilization devices on pulmonary 15. Chan D, Goldberg RM, Mason J, et Jahresbericht 2014. 2014. Motorsport—Das RTTLSKonzept. Berlin: function in the healthy, nonsmoking al. Backboard versus mattress splint 26. Dixon M, O’halloran J, Hannigan A, et al. MWV; 2013. man. Ann Emerg Med. 1988;17:915–8. immobilization: a comparison of Confirmation of suboptimal protocols 33. Goldberg W, Mueller C, Panacek E, et 9. Ben-Galim P, Dreiangel N, Mattox symptoms generated. J Emerg Med. in spinal immobilisation? Emerg Med J al. Distribution and patterns of blunt KL, et al. Extrication collars can 1996;14:293–8. EMJ.2015. traumatic cervical spine injury. Ann result in abnormal separation 16. Chandler DR, Nemejc C, Adkins 27. Domeier RM, Evans RW, Swor RA, et Emerg Med.2001;38:17–21. between vertebrae in the presence RH, et al. Emergency cervicalspine al. The reliability of prehospital clinical 34. Goutcher CM, Lochhead V. Reduction in AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

mouth opening with semi-rigid cervical 42. Holla M. Value of a rigid collar in addition collars. Br J Anaesth. 2005;95:344–8. to head blocks: a proof of principle study. 35. Grohs T, Archer S. Design of an Emerg Med J EMJ. 2012;29:104–7. extractable safety seat for the F1 43. Hood N, Considine J. Spinal immobilisaton Cockpit. SAE Technical Paper 2000-01- in pre-hospital and emergency care: 3540. 2000. A systematic review of the literature. 36. Hamilton RS, Pons PT. The efficacy and Australas Emerg Nurs J AENJ. 2015;18:118– comfort of full-body vacuum splints for 37. cervical-spine immobilization. J Emerg 44. Horodyski M, Dipaola CP, Conrad BP, Med.1996;14:553–9. et al. Cervical collars are insufficient for 37. Hanson JA, Blackmore CC, Mann FA, immobilizing an unstable cervical spine et al. Cervical spine injury: a clinical injury. J Emerg Med. 2011;41:513–9. decision rule to identify high-risk 45. Hostler D, Colburn D, Seitz SR. patients forhelical CT screening. AJR Am A comparison of three cervical J Roentgenol. 2000;174:713–7. immobilization devices. Prehospital Emerg 38. Hasler RM, Exadaktylos AK, Bouamra Care Off J Natl Assoc EMS Phys Natl Assoc O, et al. Epidemiology and predictors State EMS Dir. 2009;13:256–60. of spinal injury in adult major trauma 46. Hunt K, Hallworth S, Smith M. The effects patients: European cohort study. Eur of rigid collar placement on intracranial Spine J Off Publ Eur Spine Soc Eur Spinal and cerebral perfusion pressures. Deform Soc Eur Sect Cervical Spine Res Anaesthesia. 2001;56:511–3. Soc. 2011;20:2174–80. 47. James CY, Riemann BL, Munkasy BA, 39. Haut ER, Kalish BT, Efron DT, et al. et al. Comparison of Cervical Spine 51. Kreinest M, Gliwitzky B, Schuler S, et al. Race Track Trauma Life Support— Spine immobilization in penetrating Motion During Application Among 4 al. Development of a new Emergency ein Konzept für die präklinische trauma: more harm than good? J Rigid Immobilization Collars. J Athl Train. Medicine Spinal Immobilization Protocol Behandlung von Schwerverletzten Trauma.2010;68:115–20. 2004;39:138–45. for trauma patients and a test of im Motorsport. Dtsch Z Sportmed. 40. Hoffman JR, Mower WR, Wolfson 48. Johnson DR, Hauswald M, Stockhoff C. applicability by German emergency care 2014;65:160–5. AB, et al. Validity of a set of clinical Comparison of a vacuum splint device to a providers. Scand J Trauma Resusc Emerg 55. Luscombe MD, Williams JL. Comparison criteria to rule out injury to the cervical rigid backboard for spinal immobilization. Med. 2016;24:71. of a long spinal board and vacuum spine in patients with blunt trauma. Am J Emerg Med. 1996;14:369–72. 52. Leonard L, Lim A, Chesser TJ, et al. Does mattress for spinal immobilisation. National Emergency X-Radiography 49. Kaul A, Abbas A, Smith G, et al. changing the configuration of a motor Emerg Med J EMJ. 2003;20:476–8. Utilization Study Group. N Engl J Med. A revolution in preventing fatal racing circuit make it safer? Br J Sports 56. Macias CA, Rosengart MR, Puyana JC, 2000;343:94–9. craniovertebral junction injuries: lessons Med. 2005;39:159–61. et al. The effects of trauma center care, 41. Hoffman JR, Wolfson AB, Todd K, et al. learned from the Head and Neck Support 53. Lin HL, Lee WC, Chen CW, et al. Neck admission volume, and surgical volume Selective cervical spine radiography device in professional auto racing. J collar used in treatment of victims of on paralysis after traumatic spinal cord in blunt trauma: methodology of the Neurosurg Spine. 2016;1–6. urban motorcycle accidents: over- or injury. Ann Surg. 2009;249:10–7. National Emergency X-Radiography 50. Kolb JC, Summers RL, Galli RL. Cervical underprotection? Am J Emerg Med. 57 Mahshidfar B, Mofidi M, Yari AR, et Utilization Study (NEXUS). Ann collar-induced changes in intracranial 2011;29:1028–33. al. Long backboard versus vacuum EmergMed. 1998;32:461–9. pressure. Am J Emerg Med. 1999;17:135–7. 54. Lingner M, Scholz B, Kammermayer T, et mattress splint to immobilize whole AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

spine in trauma victims in the field: a KL, et al. The Canadian C-spine rule for randomized clinical trial. Prehospital radiography in alert and stable trauma Disaster Med. 2013;28:462–5. patients.JAMA. 2001;286:1841–8. 58. Mccabe JB, Nolan DJ. Comparison of 66. Sundstrom T, Asbjornsen H, Habiba S, the effectiveness of different cervical et al. Prehospital use of cervical collars immobilization collars. Ann Emerg in trauma patients: a critical review. J Med. 1986;15:50–3. Neurotrauma.2014;31:531–40. 59. Meldon SW, Brant TA, Cydulka RK, 67. Theodore N, Hadley MN, Aarabi B, et al. et al. Out-of-hospital cervical spine Prehospital cervical spinal immobilization clearance: agreement between after trauma. Neurosurgery. emergency medical technicians and 2013;72(Suppl 2):22–34. emergency physicians. J Trauma. 68. Trafford P, Henderson M, Trammell T. 1998;45:1058–61. Spinal injuries and motor sport. Auto + 60. Melvin JW, Begeman PC, Faller RK, et Med. 2014;30–41. al. Crash protection of stock car racing 69. Trammell T, Hubbard R. Medical and drivers—application of biomechanical Technical Outcomes of HANS® Use in analysis of Indy car crash research. CART. SAE Technical Paper 2002-01- Stapp Car Crash J. 2006;50:415–28. 3350.2002. 61. Minoyama O, Tsuchida H. Injuries in 70. Trammell TF, K. Spine fractures in drivers professional motor car racing drivers of open-wheeled open cockpit race cars. at a racing circuit between 1996 and ASPETAR Sports Med J. 2012;1:196–202. 2000. Br J Sports Med. 2004;38:613–6. 71. Vaillancourt C, Stiell IG, Beaudoin T, et 62. Mobbs RJ, Stoodley MA, Fuller J. Effect al. The out-of-hospital validation of the of cervical hard collar on intracranial Canadian C-Spine Rule by paramedics. pressure after head injury. ANZ J Ann Emerg Med. 2009;54(663–671):e661. Surg.2002;72:389–91. 72. Vandemark RM. Radiology of the cervical 63. Muhr MD, Seabrook DL, Wittwer spine in trauma patients: practice pitfalls LK. Paramedic use of a spinal injury and recommendations for improving clearance algorithm reduces spinal efficiency and communication. AJR Am J immobilization in the out-of-hospital Roentgenol.1990;155:465–72. setting. Prehospital Emerg Care Off J 73. Walters BC, Hadley MN, Hurlbert RJ, et al. Natl AssocEMS Phys Natl Assoc State Guidelines for the management of acute EMS Dir. 1999;3:1–6. cervical spine and spinal cord injuries:2013 64. Myers LA, Russi CS, Hankins DG, update. Neurosurgery. 2013;60(Suppl et al. Efficacy and compliance of a 1):82–91. prehospital spinal immobilization 74. Wölfl CG, Bouillon B, Lackner CK, et guideline. Int J Emerg Med. 2009;2:13–7. al. Prehospital Trauma Life Support® 65. Stiell IG, Wells GA, Vandemheen (PHTLS®). Unfallchirurg. 2008;111:688–94. AUTO+MEDICAL SCIENCE

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 future contact information. Dr Paul Trafford issues of AUTO+ Medical, (Chairman) please send it to: The editorial board will [email protected] 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 Special Medical Delegate)

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