Practice Makes Perfect

INTERNATIONAL JOURNAL OF MOTOR SPORT MEDICINE: ISSUE #5 ISSUE#5, AUGUST 2015

RACING RE-VISION Researchers are using simulators to see how impaired vision affects driving P24 CONCUSSION FOCUS A scientific examination of concussion and how it affects performanceP36 ANDREAS MIKKELSEN The World Rally Championship star looks back on a major accident P32

The FIA has developed a PRACTICE portable medical extrication vehicle for closed cars to help MAKES teams practice worldwide PERFECT AUTO+MEDICAL AUTO+MEDICAL

Following the tragic passing of two drivers from major championships in recent weeks - Jules Bianchi and Justin Wilson - it is more important than ever that we continue to research and Contents LETTERS/ develop ways to improve safety and medical care P4 The best letters and emails received from readers around the world across motor sport. In this issue of AUTO+Medical we take a look at two of our latest projects. GLOBAL NEWS/ The first is the development of a new P6 Qatar to Host Regional Medical Seminar extrication simulator for closed car P7 F1 Tech Might Help People Live Longer championships. It is a portable and low-cost P7 'Race with Restraint' Debuts P8 Justin Wilson 1978-2015 piece of equipment designed to help extrication P9 ASNs Start Using FIA Motor Sport Accident Database teams practice their duties and hone the craft. P10 FIA Sport Plenary Discusses Motor Sport Medicine The second is an ongoing study to learn more P11 NASCAR Drivers Educate Themselves on Safety about the nature of vision and how it affects a FEATURES/ driver’s ability to race safely. These projects are examples of the different P12 PRACTICE MAKES PERFECT ways we are trying to improve our sport and we A look at the new equipment developed to help extrication teams practice their craft in a realistic environment believe they will be of great importance for the P18 CMO PROFILE: DR MICHAEL SCHOLZ development of motor sport medicine. Dr Michael Scholz on his career, the challenges he faces and how he Elsewhere in this issue we speak with wants to improve motor sport medicine Dr Michael Scholz, the Medical Chairman of the P24 RACING RE-VISION DMSB and CMO of the German GP, whose keen An overview of the work being undertaken to study the affects and eye for preparation and communication makes limitations of a racing driver's vision his interview a fascinating read. P28 INSIDE THE FORMULA E MEDICAL CAR The medical crew at the London ePrix explains the unique Our scientific study examines one of the most equipment inside the Formula E medical car important issues in the sport – driver concussion. P32 THE ROAD BACK: ANDREAS MIKKELSEN The Norwegian rally ace shares his thoughts and memories on the I hope you enjoy the latest issue. 2012 crash that left him with a concussion

SCIENCE/

P36 CONCUSSION IN MOTOR SPORT Prof. Peter Hutchinson and Prof. Steve Olvey explore the diagnosis and treatment of concussion in motor sport

Professor Gérard Saillant Editor: Marc Cutler FIA Institute President Designer: Cara Furman We welcome your feedback: [email protected] FIA Medical Commission President

2 3 AUTO+MEDICAL LETTERS AUTO+MEDICAL LETTERS

In this section, we print the best letters and emails received from readers around the STAR LETTER world. We welcome comments on articles as well as suggestions for future content or insight into an area of motor sport medicine you feel would be relevant. If you wish to send in a letter or email, please direct it to: [email protected] Dear Editor,

First of all, I would like to thank you for the excellent idea of creating the AUTO+ Medical journal. Even though I am a junior doctor in motor sport, I think I Dear Editor, Dear Editor, share the same feelings and challenges as every one of us. We all are people with oil running through our veins and we live for our work in motor racing with a great I was curious what the process for submitting On behalf of the Board of Directors and the passion. articles for publication in AUTO+Medical. I am Curriculum Committee of the International Council working on a paper regarding "track noise levels" of Motorsport Sciences (ICMS), we would like Luckily, we have got used to fewer and fewer lethal incidents due to the that includes some original research I did at the to invite motor sport medicine professionals to improvements in safety and security items, and the training and professionalisation Circuit of the Americas last year. Let me know if join us at the ICMS Annual Congress. This year's of teams throughout motor sport. However, we can't forget that our pilots risk their you think that is a topic you would be interested congress will be held from December 9-11, 2015 in lives everyday and they put their health in our hands. in reviewing for publication and how it should be Indianapolis, in conjunction with the Performance submitted. Racing Industry (PRI) Trade Show that draws over Ways of communicating between each other such as this journal, or the biannual 45,000 participants from around the world. FIA meeting, helps us to share and improve our weak points or doubts, and keeps Best regards, us from thinking that we are the only ones with these problems. Twenty-six ICMS Congresses (annual general

John P. Sabra, MD meeting + scientific sessions) have been held since I enjoyed Dr.Steve Olvey's article about the traumatic brain injury (see AUTO+ CMO-Circuit of the Americas 1988. They have served as a site and environment Medical #4) and was able to speak thoroughly with Professor Hutchinson in Doha Assistant Professor- Dell Medical School for discussion, collaboration and vetting of thoughts about the same matter. Department of Surgery and Trauma and ideas related to the world of motorsport Austin, Texas medicine and safety. Previous congresses have This type of lesson and its management are extremely difficult in our world, not been held in Canada, Italy, England, Mexico and only because it is difficult to prove whether the pilot is completely out of risk and Editor: We would be delighted to receive your article France as well as the United States can drive again, but also because of the the high pressure the pilot, team and for publication. medical team all have to get along with it. Sincerely, All articles should be relevant to Motor Sport I encourage the whole medical community to discuss and try to reach a protocol Medicine and follow the accepted guidelines for any Hugh Scully. MD, MSc, FRCS(C), FACS. about this important matter. I look forward to the next journal and congratulate medical articles submitted for publication, be they Chairman Emeritus; Chair, Curriculum Committee you again for the initiative, the quality and the variety of the articles. an overview of a topic or original research being Toronto, Canada presented; briefly they should include Title, Authors, Yours, Images and references. Rob Seal, MD, FRCP(C) Chair, Education Committee Dr. Anna Carreras Castañer You should also confirm that the submission is not Edmonton, Canada Trauma and Orthopedic Surgeon, Hospital Quiron Teknon (Barcelona) subject to copyright elsewhere and is an original work. Authors are accountable for all aspects of Editor: This is a great event for medical professionals. Member of Barcelona-Catalunya Circuit Medical Team the work and should ensure that it is accurate and For those that are unble to attend we’ll be reporting on representative. the highlights in a future issue.

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‘RACE WITH RESTRAINT’ DEBUTS

The Motorsport Safety Foundation (MSF), a GLOBAL US organisation established to help improve safety standards, introduced its ‘Race with Restraint’ initiative at the 24 Hours of LeMons at Autobahn Country Club in Illinois providing grassroots racers with high-end safety equipment for rent at low prices. Hiring out HANS devices and helmets to NEWS drivers for just $30 a day each, MSF provided the gear to competitors for a much lower cost than buying the QATAR TO HOST REGIONAL MEDICAL SEMINAR equipment outright. Scot Elkins, MSF CEO, underlined the fact The Qatar Motor and Motorcycle Federation will host Throughout the various interactive sessions, footage that hiring a helmet and a HANS device, “for the 2015 FIA Middle East and North Africa (MENA) from real life incidents will be played to trigger points of F1 TECHNOLOGY MIGHT $60 a day total, a driver got $1,600 worth of Medical Seminar on 7-8 October in Doha, where the discussion. safety equipment.” focus will be on rallying and off-road events. During the practical exercises those in attendance HELP PEOPLE LIVE LONGER The initiative aims to provide affordable Chief Medical Officers (CMOs) and their deputies from will participate in workshops covering a wide range of safety equipment to competitors at the region will meet to partake in theoretical discussions issues from extrication and resuscitation to practicing grassroots levels, where the majority of the and practical exercises. responses to incidents with multiple casualties and/or The McLaren Formula One team gauging the human body and drivers’ budgets are preoccupied with The delegates will discuss general topics such as technical difficulties. is confident that it can adapt its developing the ability to monitor buying and tuning their cars. organisational structures, training and selection of staff, Leading figures from the motor sport medical technology from Formula One to it via sensors. Elkins says that due to the success of the as well as covering areas specific to rallying and off- communicty will be speaking at the event, including help people live longer and it is McGrath explained: “After concept, they intend to take it to national road racing including logistical issues, spectator safety, German Grand Prix CMO Dr Michael Scholz, FIA WRC developing a range of wearable working with the England Rugby level, with plans to have up to 20 stalls at accident management and how to overcome weather Permanent Medical Delegate Jean Duby, and Bahrain tech to help it do so. team and analysing their various race tracks around the USA. related problems. Motor Federation CMO Dr Amjad Obeid. Geoff McGrath, the team’s Vice performance, we formed a President of Applied strategical alliance with the MSF chose the 24 Hours of LeMons to Technologies, wants to measure largest pharmaceutical company debut the programme as, in Elkin’s mind, it Rallying events, people in the same way that the in the world, Glaxosmithkline. epitomised the grassroots level of the sport. such as the 2015 team measures the cars driven “Working on mobility and The series is an ultra-low budget category Qatar International by Jenson Button and Fernando diseases such as Parkinson’s and that restricts competitors to the use of cars Rally, will be a focus Alonso. ALS, clinical trials took place with that cost no more than $500. of the seminar Speaking at the Wired Health our team putting simple sensors “This type of racing works perfectly for us 2015 event, McGrath said: “If we and microchips on their bodies because these guys only participate two or can measure the health of an and we found the optimum three times a year and it doesn’t justify engine then why can’t we position on the body to them to go out and spend a lot of money on measure the well-being of a understand the context of safety equipment,” he said. machine or the person operating whether somebody is walking, that machine – that is our sitting, sleeping, etc. philosophy. “We then used deep learning “As we do in Formula One, we techniques to try and spot tiny can feed intelligence into a anonyms which would provide a model and aim for the predictive pre-systematic warning if intelligence. We will then use someone was trending towards a simulations so that we can start problem. It’s not pure medical to support our decision-making science but it is great bio- capabilities and understand how mechanic insight that an the product is being operated.” intervention or a check-up may In the same way as the cars be necessary.” can relay information being sent McLaren plans to have its first through thousands of sensors in wearable technology on sale by real time, Applied Technologies is 2016.

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that can be analysed with the aim “It is difficult to talk about ASN'S START of informing future research and a particular occurrence or a safety innovations. change in safety procedures and USING FIA The full launch follows an initial technology from a hypothetical two-year trial of the system. With point of view. It is an easier MOTOR SPORT a larger amount of data at its task to develop procedures and ACCIDENT disposal, the FIA can identify where technology based on actual data.” to focus research and development While stressing that it is DATABASE projects to improve safety across unrealistic to prevent accidents a wide spectrum of motor sport from occurring altogether, disciplines. President Todt remains confident FIA National Sporting Authorities FIA President Jean Todt said: that with the assistance of (ASNs) have started to use a new “The introduction of the database the database being open to database that collates data from will open up an opportunity for other nations, the safety risks racing accidents the world over. the world of motorsport to provide when incidents do happen are In May, individual usernames detailed information on any minimised. and passwords were sent to a serious accidents that occur. “You cannot remove accidents correspondent at every ASN to “A significant number of the from motorsport,” he explained. permit access to the portal and major safety improvements made "But the primary goal of the FIA data entry. throughout motorsport have been is to minimise, as much as we The idea behind the initiative is predicated by fatal or serious possibly can, the harm that occurs to have a database of accidents accidents. when they do happen.”

JUSTIN WILSON 1978-2015

The global racing community has been mourning the Raceway, Andretti Autosport, and the Verizon IndyCar loss of British driver Justin Wilson, who passed away Series as well as the entire racing community for the after suffering a head injury when he was struck by amazing outpouring of support from fans around the debris from a crashed car during an IndyCar race at world.” Pocono Raceway on Sunday 23 August. Wilson spent the majority of his career racing in The nose section of Sage Karam’s car hit Wilson on open-wheel championships in America, after winning the helmet after the American driver had crashed on a number of titles on the European scene during his lap 180 of the 200-lap race. IndyCar medical staff were junior career. He won the inaugural Formula Palmer on the scene within moments, with Wilson quickly Audi title in 1998 and drove on the Formula One support extricated from his car and airlifted to the Lehigh Valley bill for three seasons in Formula 3000, winning the Health Network Cedar Crest Hospital in Allentown, championship in 2001. Pennsylvania, where he arrived in a critical condition. He made his F1 debut for Minardi in 2003 and But he did not regain consciousness and IndyCar contested 11 races with the Italian squad before officials announced he had died on the evening of completing the final five rounds of the year with Jaguar. Monday 24 August. He switched to Champ Car in 2004 and took four A statement released on behalf of Wilson’s family said: victories over four seasons, finishing as series runner up “Justin was a loving father and devoted husband, as well in 2006 and 2007. National Sporting Authorities as a highly competitive racing driver who was respected After Champ Car merged with IndyCar in 2008, will enter data from serious by his peers. Wilson went on to make 120 IndyCar starts and claimed accidents across the world “The family would like to thank the staff at the Lehigh four victories. He is survived by his wife, Julia, and two Valley Health Network Cedar Crest Hospital, Pocono daughters, aged five and seven.

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FIA SPORT CONFERENCE Dr Steve Olvey PLENARY DISCUSSES MOTOR SPORT MEDICINE

Some of the leading practitioners crash, but lived and Dr Olvey said in the field of motor sport that this would not have been medicine gathered to discuss possible without the medical issues at the FIA Sport communication between Conference in Mexico in July. engineers, organisers and The panel touched on a wide doctors and the subsequent range of subjects, highlighting improvements they led to. how research and He stated that the future communication continue to progress of motor sport improve standards in motor medicine relies upon continued Dr Manuela sport. cooperation and learning Alberro Prof. Gérard Saillant, President between these parties. of the FIA Institute and FIA Dr Manuela Alberro, the WRC Medical Commission, spoke Medical Delegate in Mexico and about how current initiatives Argentina, spoke of the logistical focused on research can have a medical challenges specific to positive effect: “The FIA database rallying and how she and her and the accident data recorders team tackle them. are fantastic improvements to try “Obviously the environment of to collect all the accidents in the the WRC is extremely challenging world and learn what is the not just because of the mechanical aspect and what is geographical situation but often the medical consequence [of because the rally control is a long these events]”. way away from the point of the Dr Steve Olvey, a Founding accident and it can even be Fellow of the FIA Institute and hundreds of kilometres former medical director at sometimes. IndyCar, highlighted how “We have a very large number communication has and of vehicles that we call 'medical Prof. Gérard NASCAR DRIVERS EDUCATE THEMSELVES ON SAFETY continues to improve medical intervention cars' and they have Saillant practices: “In 1990 we began to state of the art medical see doctors speaking with equipment. They are located NASCAR drivers have been taking the happens in a medical situation and how the doctors were chosen, engineers and with time we knew around the course so that they opportunity to educate themselves trackside, but also who is involved [it] was definitely kind of eye-opening we had the same goals in mind can guarantee medical care in a on the safety procedures and policies in providing a duty of care to those as to how much money and time and we began to understand maximum of 10 minutes. This in place at NASCAR events. who are injured. NASCAR utilises a was spent to make sure they had the each others’ language.” means that on average we have In the wake of Kyle Busch’s Febru- travelling team of medical, safety right people at every race track, and, He believes that this sharing of 12 to 15 medical vehicles for ary crash at the Daytona Interna- and trackside coordinators, but also really, the longevity of the staff and ideas and information marked an rallies.” tional Speedway in which the Joe makes use of each of the track’s some of the people who have been important point in the history of The panel also included Gibbs driver broke his leg and ankle, medical teams and the teams work a part of our community for such a safety development and gave an leading safety experts such as a handful of drivers from the series together to implement procedures long time. example of how it had an impact NASCAR Safety Director Thomas gathered a week later to learn more well in advance of each race. “Some of it is just now knowing on racing. “The crash that Alex Gideon, Formula One Race about the specific mechanisms in Harvick admitted that he felt more about it and I don’t think anybody is Zanardi had in Germany in 2001, Director and Safety Delegate place in the event of an accident. comfortable with the systems in saying that it can’t always be better. [was] until that time considered Charlie Whiting and COO of the Senior competitors, such as cur- place once he had taken the time But I feel pretty confident in what the non-survivable.” Motorsport Safety Foundation, rent Sprint Cup champion Kevin to avail himself of it, commenting: process is and in the medical staff Zanardi lost his legs in the Scot Elkins. Harvick, learnt not only what “Once they explained the process, that we have at the tracks.”

10 11 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES FEATURES PRACTICE MAKES PERFECT To help extrication teams hone their skills, the FIA has developed a portable and cost-efficient medical extrication vehicle for closed car championships.

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One of the key specifications of the project THE DRIVING PRINCIPLE BE- was that it helps provide the most realistic HIND IT IS TO HAVE A CAR THAT training scenarios possible for the teams to “ practice with, so the car has been designed to IS COMPLETELY REPRESENTATIVE be compliant with real-life safety standards and OF A REAL RACING CAR technical regulations. ” “The driving principle behind it is to have a car that is completely representative of a real fitted with seats (that are optional), a steering racing car, be it a rally car or closed circuit car,” wheel, a tunnel, a console, pedal box, footrest, says Mekies. gearstick and a handbrake – all of which are When folded, the entire unit can fit into a used to simulate realistic extrication scenarios square box, around 1.5m across and 0.5m high. that the teams could face. It also weighs just 80kg with the steering wheel, “It is made out of the proper steel that you console and bodywork. This makes it easy to would normally find on the roll cage. Actually, transport around the world for use at specific it is stronger than on the race cars because events and for delivery to customers. you want the extrication team to be able to cut Mekies stresses how important it is to have through the strongest materials.” a finished product that is transportable, as he

Simulating realistic scenarios in which extrica- accident is a crucial aspect of motor sport tion teams can practice is expensive and logis- medicine, especially in closed-cockpit cars tically challenging. But the FIA hopes to have where the driver might remain trapped for an solved this issue with the development of a extended period of time. Practicing for these reusable and portable medical extrication car. scenarios is essential and so with the ultimate An exact replica of the roll cage and interior aim of the project to improve the training that of a modern closed car, the unit has been extrication teams receive, the car has been built designed to be an easily transportable and to be as realistic to work on as possible. cost-effective device for National Sporting Au- “It is an exact replica of a current racing or thorities (ASNs) and other stakeholders to use rally car,” says Mekies. “It’s just a roll cage, but when training their personnel. it includes the key elements of the cockpit “It is very much a project driven by the FIA environment. There are also some very basic Medical Commission,” says FIA Safety Director bodywork panels that have been incorporated. Laurent Mekies. “Professor Saillant [Commis- At the end of the day, the conditions that the sion President] had this idea in his mind for extrication teams face are representative of quite a while, so we worked with doctors and what can happen at the race track or stage.” the Chief Medical Officers of the medical The car uses replaceable steel tubes that can commissions to produce a practical solution.” be cut during training exercises and Extricating a driver safely following a serious subsequently switched at a very low cost. It is

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and his colleagues intend for the car to be as harnesses, steering wheels, cameras, seats and convenient to use as possible. “It has to be able other paraphernalia to contend with. to be shipped very easily around the world. In First used for training at the 2014 Abu Dhabi the past you would spend more in shipping the Grand Prix, the F1 simulator was hailed as a car because of volume and weight. But this only success by the organisers and has since been weighs around 95kg in total with everything at- distributed to other venues in order for their tached.” teams to practice with. As well as providing a realistic training simu- This success is what the FIA wants to replicate lation and transportable equipment, the FIA with the closed extrication car and Mekies is wants to make the car cost-effective to use over confident it will achieve that. and over again. “I think it will be a great step forward for “A big advantage of this car is that the safety. The side benefits are that you can roll it, extrication teams, including fire forces, can and put it upside down to simulate real life rally come and cut half of the roll cage off and or circuit accidents. It enables you to simulate a replace it for a very cheap price, which you variety of possible outcomes.” couldn’t do on a real car.” Showcased at the FIA Sport Conference in Mekies sees no reason why this will not help Mexico in July, the extrication car is expected improve the overall training that extrication to be unveiled at a variety of events in the near teams receive, reflecting on past projects that future. Ensuring that the equipment is kept in have had similar success. the public domain, Mekies would like to see it “If you look at how key the open cockpit transported around the world to various extrication car was and how it helped train seminars and conferences, thus further pro- teams all over the world, then I think you could moting itself as a safety product. expect the same success with the closed car.” “I think that the National Sporting Authorities Developed in 2013, the F1 extrication simu- would probably like to have use of one to train lator has proved to be a very useful tool for their teams and I think there are many ways in training teams who would not otherwise have which the FIA can help,” says Mekies. had access to such equipment. By giving these “Like I said we can ship our car to all of the personnel access to a replica of the cockpit, seminars to help train people. Those with they could train in the specifics of extrication, bigger needs will be buying them as practicing the safe removal of a driver with real there are different monetary mechanisms that the ASNs can utilise in the name of safety. I’m sure that some of them might want to explore A BIG ADVANTAGE OF THIS that and create a finance deal for buying the CAR IS THAT THE EXTRICATION car.” “ Currently only one extrication car has been TEAMS CAN CUT HALF THE produced, but the feedback Mekies and his ROLL-CAGE AND REPLACE IT FOR colleagues have received has made them con- A VERY CHEAP PRICE. fident that they will be producing a lot more in ” the near future. 16 17 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

DR MICHAEL SCHOLZ Chief Medical Officer, German Grand Prix; Medical Chairman, Deutscher Motor Sport Bund

Dr Michael Scholz has been involved in motor sport medicine since 1996, when he started working as a trackside physician at the Motorsport Arena Oschersleben. He has since gone on to work across a large range of racing disciplines, including sports cars, superbikes, touring cars and Formula One. He is currently Medical Chairman of Germany’s National Sporting Authority and CMO of the German Grand Prix.

AUTO+ Medical: How did you first become CMO. It happened on a Saturday and the involved in motor sport? Race Directors had to react to this situation Michael Scholz: I first became involved immediately. As a result of the circumstances during the mid-nineties thanks to and after discussions with senior construction of the third permanent circuit in management, I was appointed CMO for that Germany near my hometown. However, it weekend. Everything went really well and as a was difficult at first to get involved as a huge consequence I was appointed as CMO for the number of my colleagues were also rest of the season. interested in doing so. But, due to fortuitous Due to a huge number of high-level national circumstances, I got a chance. I met a and international motor sport events at the paramedic who worked at the circuit in my circuit, I came into the focus of the ASN hospital and was working with me in the officials. We met and discussed ideas and operation theatre. He was the one who ways to implement them. From there I had connected me with the Chief Medical Officer more and more involvement and ultimately of the Motorsport Arena in Oschersleben. progressed to the role of Medical Chairman of the DMSB. A+M: How did you come to be Medical Furthermore, as the result of the high Chairman of the DMSB and CMO of the frequency of FIA events in Germany, the ASN German GP? got a number of positive Medical Reports MS: I started out working as a doctor all from the FIA Medical Delegates. I presume around the circuit: in the pit lane, on foot, in a these positive reports were one piece in the trackside ambulance, as part of the medical decision making of the ASN to approve me as team and in the medical car. This gave me an CMO of the German GP. in-depth knowledge of many of the areas of I would like to mention that my mentor in the specific issues we face at motor races. numerous matters was the current FFSA At the circuit in Oschersleben a wide range of Medical Commission President and international races took place, and over the permanent Medical Delegate for the FIA course of one of these events there was a World Endurance Championship and FIA vacant space related to the position of the World Touring Car Championship, Dr Alain

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are the basic principles of creating an immediate action, to inform security to get Chantegret. He is a good friend and most Delegate and the F1 Medical Rescue efficient system, especially in the instance of them access, for the racing team to arrange things I know I learned from him. Coordinator and afterwards the show begins. serious accidents. If all is prepared well then the way of transport across the garage, and Now is the time your system has to run anything that happens feels like it has been then to inform the FIA Medical Delegate and A+M: As CMO of the German GP, what smoothly. planned for and you can start the event with the Race Director what was going on and how are your day-to-day activities on a race It is absolutely crucial to start planning as a sense of well-being. much time it would take. weekend? early as possible for a GP in order to be well Day-to-day I believe that the daily update of The result of this was that we found a fast MS: The work starts on Monday. I check all prepared. Consequently your medical team is information is a crucial part of my role. We way to transport the patient without barriers of the medical equipment, the track and the aware of its responsibilities, is well trained must ensure the capabilities and contact to the Medical Centre, with no consequences emergency routes, the way to the hospitals, and the atmosphere is relaxed yet focused. details for the hospitals, people in charge and for the proceeding of the race. the duty roster and the best place for the No less important is prior communication the different teams and personnel are It was also important we communicated with individuals related to their medical skills. I with the hospitals and the clarification of correct. I make sure I inform the team of all the hospital to arrange all details and to get in touch with the hospitals and the procedures and communication channels changes and that I have explained all the update the clinical team accurately. To police department to clarify details and with all involved. From my point of view these relevant issues and instructions regarding achieve objectives like this you have to clarify methods of communication. Wednesday is ERS, self protection, extrication, scenario procedures beforehand, and you need good the time for the official hospital visit if management etc. Another issue is dealing command structure and communication as necessary, Thursday for all extrication MARK WEBBER’S RED BULL with complex paperwork and data access. I well as clear operating principles in race exercises and medical scenarios. Friday LOST A TYRE AND IT HIT A try to provide the FIA Medical Delegate and control, with the teams around the circuit and morning the medical briefing takes place CAMERAMAN“ IN THE PIT LANE. Medical Rescue Coordinator with all needs. with the medical centre, and reliable with a warm welcome for the FIA Medical And last but not least, it is crucial to clarify structures and people in the hospitals. ” beforehand with all other services and via a common briefing the operating principles on A+M: You’ve worked across many different scene at an accident. motor sport disciplines, which ones pose the biggest medical challenges and why? A+M: Can you give an example of an MS: All disciplines of motor sport pose incident you have responded to? different challenges. In motorcycling we see a MS: One remarkable incident occurred whole range of accidents and injuries. In during the German GP at the Nürburgring in historic racing we are faced with an 2013. After changing tyres in the race, Mark imbalance between the high speed of the Webber’s Red Bull lost one of them and it hit cars, their safety features and the mostly a cameraman in the pit lane. He was seriously elderly drivers. injured in the incident, which poses several But for me ensuring the medical care at a challenges to overcome such as traffic, a rally is the biggest challenge. Firstly we have large number of people, noise, limitation of two passengers in a rally car. space, access and transport methods. Furthermore we often have to go long Consequently if we needed an ambulance in distances to reach the car after an accident. the pit lane, the Race Director had to deploy Special circumstances are caused by the the Safety Car. The solution was a different terrain, environment and the cooperation between the medical pit lane potentially difficult positions of the car. Good The pitlane during the team and a team that was sent by the cooperation and interaction of extrication, 2013 German GP Medical Centre and came from the other side rescue and medical teams are essential if we across the garage. It was necessary to take are to be effective. The methods of transport

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and communication are further issues as well education programmes for the special as the big task to ensure spectator safety. medical teams such as the extrication team topic includes quite a number of interesting and the team in the medical centre. The aspects such as data access immediately A+M: What changes would you like to see concept of the medical car, the medical after an accident occurs, evaluation of to motorsport medical standards / expertise of the crew, as well as the training, performance data, particularly related to long procedures / policies? were completely redefined. The idea was distance races, as well as performance and MS: Firstly it would be great to have a born to offer an education concept for all safety aspects relating to the best time for universal approach to medicine in motor medical staff at the circuit to create an driver changes and so on. sport and see programmes designed to approach for this special environment. The improve the quality of medical service. feedback was really good and we discovered A+M: What would you like to achieve in Therefore it is necessary to reflect on the resources and potential for improvement by the rest of your motorsport career? cultural and political environment, the making interactive training scenarios with all MS: My national focus is to stabilise the economic basis, the focus of motor sport other services. existing structures and promote further disciplines, and the experiences of the To establish all of these ideas and development to ensure progress. I would like medical team in the region. We are working programmes and to have motivated and to step up cooperation between the circuits on a new basic medical course as well as a professional colleagues and team members and the hospitals as I think such cooperation guide for electronic devices. behind me are my greatest achievements. will give our colleagues in hospitals To create sustainability we like to build One more is the really great collaboration interesting educational opportunities, as well regional networks to train colleagues and between the different ASNs and medical as give our medical teams similar chances to teams directly. Other points are regional and teams in Austria and the Netherlands. learn. My international focus is to launch and international networks to illustrate problems I was aware that it would be a long-term goal establish regional education to improve the and solutions, to share experiences and to and this was the biggest challenge as well - at level of medical service in general, whilst highlight different ways of thinking. the beginning we only had the support of considering economic resources and Data access after accidents is on our focus as some circuits, so we worked enthusiastically IT IS ABSOLUTELY CRUCIAL TO experiences. An important goal must be to well. The medical car crew can use a tablet but without real economic resources. It was a START PLANNING AS EARLY AS offer a good quality of medical service not with an electronic accident protocol. This long process and as a consequence of “POSSIBLE FOR A GRAND PRIX. just at high-level motor sport events, but also protocol is linked with the medical centre and positive feedback from the participants, as for grassroots races. I would appreciate we have the option to provide the emergency well as the drivers after some big accidents, ” regional and international networks - because unit in the hospital with the relevant data too. we could move forward. Now we have a well- and more difficult. Modifications like hatch- of the opportunity they present to effectively defined structure, cooperation with the DMSB roof, removable parts of the seat and share experiences and ideas, different points A+M: During your career in motorsport Academy and the status as an FIA Institute movable seat are helpful. Another approach of view and thinking - to be updated. medicine, what have been your greatest Medical Regional Training Provider. is the development of new devices, so we In general I would like to achieve a closer link achievements and what have been your have focused on research aspects like how to the technical and safety personnel in terms biggest challenges? A+M: Are you working on any interesting stable is a fracture of the spine after the first of safety and rescue as it is important that we MS: When I started to deal with motorsport medical research projects at the moment? impact, how intensive is the manipulative give manufacturers feedback after serious medicine I saw a good running system. As I MS: There are two main issues of interest at treatment by using the classical KED, what accidents on how improvements could be have mentioned I was in touch with several the moment. The first is the status and forces are affecting the patient, does it make made regarding safety as well as feedback to different series, hence I got different development of extrication procedures, sense to continue to use these devices or will the drivers and teams in terms of influences and ideas related to possible especially in closed cars. With such vehicles it be better to look for other solutions with understanding rescue procedures. changes to improve some parts, especially there is a compromise of safety of the driver new and smaller ones, especially in closed cars? The overall goal of all we do must be to issues like interaction, tasks and education. and limitation of space - to work with the The second area of research is the field of achieve the best outcome for the driver in the We launched several pilot projects, like classic KED system or similar devices is more stress-level monitoring and data access. This event of a serious accident.

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RACING RE-VISION

Through a series of simulator tests, the FIA Institute is examining how impaired vision affects driving standards in racing.

In an effort to learn precisely how a driver’s vision affects their ability to race safely, the FIA Institute is undertaking a programme testing the nature of eyesight in motor sport. “The aim is to better understand what aspect of vision is the most important for drivers”, says Julien Adrian, who is leading the project for Streetlab Vision, the company in- structed by the FIA Institute to perform these tests in partnership with the Institut de la Vision. As simplistic as it might seem to say that good vision is an important part of safety, deciphering exactly which aspects of vision are most important and how they effect a driver’s performance can help to develop safety features, regulations and tests. “We’re trying to find out what are the most important parts of vision in terms of safety. We are collecting data on the aspects of vision used when racing and also trying to determine limits and rules for licensing drivers to race,” explains Adrian. Together with French simulator manufac- turer Oktal, Adrian and his team have created a platform through which they are testing

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eight racing drivers’ abilities with artificially altered vision. Using a simulator with screens that provide a 100-degree field of vision and glasses with vision-altering filters, they are as- sessing drivers’ ability to identify, process and react to danger when their vision is obscured. Before they begin the experiments, the drivers are tested to determine their capabilities with unimpeded sight, thus setting a standard against which to measure the subsequent tests. They are then given a pair of glasses that completely blocks vision from one of their eyes and are tested against their initial run. “The first objective of this test is simply to discover if it is possible to drive a race car WE’RE TRYING TO FIND with only one eye. Then we assess the level to OUT“ WHAT ARE THE MOST IM- which they can drive with that impediment”. PORTANT PARTS OF VISION IN While the premise of these initial tests is TERMS OF SAFETY. fairly straightforward, the project has not been without its issues. Adrian reports that ” some of the ‘more experienced’ drivers have The next phase of the tests will focus on suffered from motion sickness from using the endurance driving. For a long-distance races simulators, “but it is not a problem for the such as the Le Mans 24 Hours, a driver’s vi- younger drivers,” he says. “We went to the sion can be affected by the long stints behind FFSA (Fédération Française du Sport Automo- the wheel, changing light and lack of sleep. bile) to use their young academy drivers to first, we put an obstruction in the way of the car covering the driver's left eye and having an The researchers will look at exactly how test the simulators and everything was OK, and see how they react, if they can escape it. obstruction approach from the left.” eyesight is affected and how long it takes to the simulator was very good.” “The second scenario is in three separate This process is repeated 10 to 15 times for deteriorate in these circumstances, creating a After the primary set of tests, the drivers parts. In the first part we have an object ap- each participant, with steadily decreasing lev- platform from which guidelines and potential are set a series of tasks on the simulator proach the car from the periphery of the els of vision in each eye, until ultimately safety features can be developed. with varying artificial visual impairments. The screen and record if and how quickly the driv- vision from either the left or right is “We have the drivers testing until October- purpose of these tests is to identify how much er avoids it with perfect vision. Next, we place completely obscured. These tests should help November time,” says Adrian, "so once all the vision from each eye is necessary to race and a filter on their right eye and have an obstacle to identify if it is possible for a driver to race tests have been conducted and the data col- how it affects the drivers’ abilities. approach from the left, again recording how safely with just one eye and exactly how that lated, we hope to present our findings to the “There are three separate scenarios. For the well they do. The final part of this section is ailment affects their ability. FIA Institute by the end of 2015.”

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INSIDE THE FORMULA E Formula E Incident Commander Jonathan Webber and Dr Gareth Davies take us inside the Formula E medical car at the 3 RESPIRATORS “These are standard MEDICAL CAR London ePrix and the specialist equipment at their disposal. respirators with filters and bilateral filters. If there was a battery fire, it’s not actually 1 THE BMW I3 a smoke and flame “It’s a totally electric fire that you might be car provided by BMW used to seeing with which obviously fits in a race car. A battery with the series. What’s fire is actually known interesting about 2 as thermal runaway, Formula E is that the where there’s a medical car is not just chemical exchange a medical car, it is an taking place in the incident vehicle so it battery, where the carries equipment to 3 battery overheats and enable the medical releases a very toxic crew and the safety fume. If we go to a teams to help the 4 driver who is injured drivers and to protect in a car with a battery themselves and carry all fire, or indeed in of the additional safety the pit lane or in the equipment.” garage, then we have Jonathan Webber to be able to protect 1 ourselves from the fumes that come out. The occupants of the 2 THE TEAM medical car have been “The four-strong team face-fitted for these that rides in the medical respirators.” car consists of a doctor, Jonathan Webber paramedic, incident commander and a battery specialist from Williams whose job it 4 OXYGEN is to help manage any “There is oxygen, battery-related issues which is fairly they might have at the standard medical car scene of an incident. equipment. There is “The occupants all wear also a cylinder with a open face helmets and standard mask and electrically insulating high-flow oxygen gloves with leather and with this you can outer protectors and treat anybody with standard footwear.” breathing difficulties.” Jonathan Webber Jonathan Webber

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5 THE ‘HOOK’ 8 INTUBATION KIT “The idea of the hook is that if you touch a “In this particular pack we have just about car that is electrically live, because it is direct everything that you have in an emergency current, then muscular contraction occurs department in a hospital so it allows us to meaning you end up almost being glued to address problems with breathing and you can the car and you can’t release. If somebody be intubated. tries to touch you or pull you away then they “This particular pack is used if the patient will also get electrocuted. So the insulated has got a serious head injury. We use the hook is designed to give you a reach so there equipment in here, plus some drugs, to will be no transfer of the electricity moving anesthetise the patient and we can pass a tube down. The small portable one is carried in the down into the lungs, and then using this device medical car and there are much longer hooks we can take over the breathing of the patient. available in the other rescue resources.” That’s connected to oxygen so we can make Dr Gareth Davies sure the patient is breathing properly.” Dr Gareth Davies

6 MATS 9 BANDAGES “The electrical mats are of the minimum of “Here we’ve got bandages. These are the same class zero-electrical conductivity, there’s a sort of bandages that the military use that are drape mat that goes over the top of the car impregnated with special chemicals to make the covering the monocoque and driver’s shroud blood clot to put around a limb if there is major area. There are two floor mats for the doctor, 7 8 haemorrhage from a blood vessel that has been paramedic and rescue staff to stand on so torn.” that the car and the floor are insulated in 10 Dr Gareth Davies order that there isn’t any electrical contact. It’s quite basic but it’s very critical in terms of such an unusual and potentially catastrophic situation.” Jonathan Webber 5 9 10 WATERJEL PACKS “One of the major issues we have to be careful of is the small battery, the 12v that sits underneath the driver seat. At a couple of races we’ve been 7 DRUGS too, that 12v battery has become a problem “In here again is a pretty comprehensive and could short circuit or explode, so we have selection of medications, so quite an array to be able to deal with the potential for burns of different drugs that are anaesthetic very quickly. In the medical car we carry a water agents. Some of these drugs help stimulate gel critical-burn kit, 1which enables us to quickly the heart beat and control your heart rate, smother the injured person in water gel material, some of them are for anti-sickness, some 7 which is a special material that aids cooling, of them are for sedation - and these ones 8 but also is recommended to help with burn are also to support circulation so it’s quite a injuries. That’s kept in the medical car and all of comprehensive selection.” 9 the medical units and ambulances around the Dr Gareth Davies circuit.” Dr Gareth Davies

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THE ROAD BACK: ANDREAS MIKKELSEN World Rally Championship star Andreas Mikkelsen looks back at his accident during the 2012 Intercontinental Rally Challenge’s Circuit of Ireland Rally and gives his thoughts on concussion and safety.

Following a heavy front-on collision during the Q: But you managed to finish the stage 2012 Circuit of Ireland Rally, Norway's Andreas without any further incident? Mikkelsen found he was able to continue the AM: Yeah, we finished that stage and I also event, eventually finishing second. It was not finished the next two stages and we finished until afterwards that he realised he did not the rally. Of course I went to the hospital after remember any of the stages following the that but I just tried to finish the rally. I was accident and was later diagnosed with knocked out for a little bit, but I felt fine and concussion, spending the night in hospital. He just suffered the memory loss. spoke to AUTO+ Medical about his experience and his thoughts on rally safety. Q: At the time you didn’t realise that this was a concussion? Question: What do you remember about AM: Well of course I had hit my head, I didn’t the accident? feel 100 per cent but I felt well enough just to Andreas Mikkelsen: I don’t remember too finish the rally, take it carefully and seek much, I remember starting the stage and medical help after that. losing control of the car because it started to rain. I remember the impact after that, that’s Q: So what do you remember of the post- all. The next thing I recall was being at the race events? stage finish. Basically I was knocked out for AM: At first we went to the finish ramp and like 15 seconds and then the stage finished. then I went to the prize-giving, and because I felt my eardrums weren’t right, my hearing Q: Did you have medical attention after was really strange, I went to the hospital after you were knocked out? the prize-giving and stayed there overnight. AM: Well no, not really. Because we had to get They kept me in for observation and they took to the next stage and at that time it was so some scans and all that, nothing was really important for me to get points from that rally wrong, just a normal concussion. so I was just trying to focus on finishing and I had two or three stages to go. After that crash Q: Looking back on it now, if there had I finished that stage, but I didn’t know exactly been a doctor examining you straight after which country I was in! I knew I was in a rally the incident, do you think you should have because I was sitting in a rally car, but I was been allowed to carry on? sitting there wondering where I was. AM: Probably not. I mean it is hard to say

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when you are not qualified, when you are just rally procedures and then decided to check it safety wise. Of course it’ll never be perfect but Q: How do you and your fellow drivers feel driving a car in a stage and I mean crashes out just to be sure. It is definitely better be it is hard to make the sport 100 per cent safe about the current levels of safety in happen so often in a rally. So it’s really hard to safe than sorry, so I should not have waited so and I don’t think that is really possible. rallying? control but for me I didn’t even tell my co- long to check it out. With my concussion, I remember talking to the AM: It’s different from rally to rally I have to driver that I didn’t know which country I was rally radio after just finishing that stage and say. In some rallies it is much better than in in, because if I told him then I probably would Q: So have you suffered any other they could clearly see I was out of it because I others, but the real safety issue, which I have had to stop and it was really important concussions since that accident? was strange in that interview, I didn’t really believe all the drivers think, is that we are for me to get those points. It is probably not AM: No, I have stayed out of trouble after that. know what was going on. Maybe in future we coming into certain rallies like Poland where if really correct what I did, but yeah, that’s the I have had accidents but nothing where I have should have a doctor at each stage end, you make one slight mistake you hit a lot of way I chose to be. But looking back now, doing been knocked out or feel really dizzy maybe that can solve things a bit? people. So we need to make sure they are the rest of the rally in not 100 per cent afterwards. As a young rally driver you want to compete standing in the secure areas and to control the condition is probably not the correct choice. no matter what, so maybe it is best that you spectators in the correct way. Q: Did that crash change the way you think do not make the decision. With my accident I That is where rallying needs to improve. There Q: What advice would you give to other or your approach? was fighting for first position, and after that was a moment when I went off in Poland, I drivers who have suffered a suspected AM: Not really, I think that we’re in really safe stage I remember my co-driver saying that ‘it is went off the road and I almost hit three concussion during a race or rally? cars and you see also the accidents we have over now because we have lost 40 seconds’ spectators. I drove over some chairs and AM: Luckily in my case there was nothing now, like I have just had in Finland [Mikkelsen’s and I was a little bit angry with him as I luckily people were not in them, so that was a really wrong, except for the loss of memory event ended early when he rolled his couldn’t understand why he said that we have really close one. Basically I’m not too worried and the fact that there is concussion, but you Volkswagen after taking a bend too quickly]. lost time because I didn’t remember I had about our safety but all the spectators and know I waited a long time to check it out. I You see what the cars look like and yet we’re crashed! I said ‘what are you talking about’, I how they are controlled, this needs to be finished and went through all the usual post- just walking around. We’ve come a long way just couldn’t remember. looked at even more.

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CONCUSSION IN MOTOR SPORT

The diagnosis and treatment of concussions are issues that have been widely debated throughout the sporting world. Dr Peter Hutchinson and Dr Steve Olvey explore the subject in relation to motor sport.

AUTHORS:

PETER HUTCHINSON Professor of Neurosurgery, Uni- versity of Cambridge Chief Medical Officer for the Formula One British Grand Prix

STEPHEN OLVEY Associate Professor in the Department of Neurological Surgery at the University of Miami, Miller School of Medicine

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BACKGROUND MANAGEMENT One of the most challenging aspects of OVERVIEW OF MANAGEMENT medicine in motor sport is the evaluation of The first stage in the management of patients drivers with suspected concussion and mild with concussion is to establish the diagnosis traumatic brain injury. from the history, examination findings and This applies both to establishing the initial the potential application of assessment tests. diagnosis and decision-making in terms of The second stage is to remove the participant return to both practice and competitive from the action and monitor for driving. deterioration. Referral to an emergency Definitions of concussion vary and include mechanistic, pathophysiological and clinical criteria. The classical definition of concussion ONE OF THE MOST is a “traumatically induced, usually transient, CHALLENGING ASPECTS OF disturbance of brain function that involves “MEDICINE IN MOTOR SPORT complex pathophysiological processes.” Such IS THE EVALUATION OF processes are thought to include derangements in the metabolism of DRIVERS WITH SUSPECTED neurotransmitters. CONCUSSION AND MILD In practice, patients with concussion TRAUMATIC BRAIN INJURY. experience a period of confusion, headache, nausea or vomiting, or visual disturbance of ” variable duration. Loss of consciousness is department may be required and imaging not required for a diagnosis of concussion, performed as indicated from guidelines e.g. medical event; whether there is retrograde helmet should also be examined for signs of and concussion can be sustained with no the UK NICE head injury guidelines (1). In and / or post-traumatic amnesia; whether impact damage. Examination of the cervical period of retrograde or post-traumatic terms of acute imaging, CT is the investigation there was loss of consciousness; and initial spine should also be performed in patients amnesia. of choice but with MRI being increasingly and on-going symptoms. Relevant symptoms with a suspected head injury. In pathophysiological terms, there is a applied, including classic structural MRI and include headache, nausea, vomiting, continuum of diffuse brain injury, which newer sequencing techniques such as dizziness, visual disturbance, speech ASSESSMENT TOOLS extends from the mild end of the spectrum, diffusion MR and spectroscopy. In patients disturbance, hearing disturbance, memory Several tools are available for the sideline of which concussion is a subset, to more with a mild head injury and a normal CT scan, and concentration impairment. assessment of sports concussion, each with severe diffuse injuries. Rotational forces 25% have an abnormal MRI scan. The third its own sensitivity and specificity. The time to leading to transient distortion of stage is the decision to return to EXAMINATION FINDINGS administer these tests is of importance which intracerebral tissues seem an important participation. Examination findings should include standard varies from less than one to 10 minutes, element of the injury mechanism that and neurological observations (including rendering many impractical for on-field or explains why concussion may occur with HISTORY pulse, blood pressure, pupil reactivity), track use. They may aid decision making but rotational injuries even where there is no The history should include past medical assessment of the three parts of the Glasgow overall the clinical experience of the impact to the head. Imaging is usually normal history including previous history of head Coma Score and a neurological examination healthcare professional remains paramount. in patients with concussion. injury and neurological symptoms. The of both the cranial nerves and peripheral The ImPACT test (2) is regarded as the gold In terms of prognosis, symptoms resolve in circumstances of the impact should be nervous system. The scalp and face should be standard for rapid neuro-psychiatric testing. 80% of patients in 7-10 days. explored: whether there was a precipitating examined for bruising and swelling. The It has a long period of administration (40

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minutes) and requires a certified examiner, SUSPICION OF MORE SEVERE INJURY Patients with symptoms lasting more than but has the advantage of no learning, If more severe injury is suspected, the patient PATIENTS WITH SYMPTOMS one-three weeks should be referred to normalisation to baseline indicative of should be referred to an emergency specialist services for clinical assessment and, healing, and is repeatable. The King-Devik department for further assessment and “LASTING MORE THAN ONE-THREE if needed, formal neuropsychological input test and SCAT tests 2 and 3 have the imaging. Indictors of more severe injury are WEEKS SHOULD BE REFERRED and consideration for more advanced advantage of rapid administration, are GCS <14 immediately, GCS <15 by two hours TO SPECIALIST SERVICES FOR imaging (MRI scan). sensitive without requiring a baseline and can after injury, deteriorating mental state, CLINICAL ASSESSMENT The long-term prognosis for concussion is be administered by a non-certified examiner. potential spinal injury and neurological signs generally good, with most patients recovering SCAT3 (3) assesses the Glasgow Coma on examination. ” completely given time. However, certain Score, orientation, patient reported headache return on increasing exertion, then patients may develop the post-concussion concussive symptoms (including headaches, INDICATION FOR CT SCAN extension of the period of rest and reduction syndrome of persistent symptoms that can dizziness, visual disturbance, slowed thought Guidance for the indications for CT scanning in level of activity are recommended. last weeks or months but even this is self- processes), cognition, a rudimentary neck is available form the UK NICE head injury Participants, managers, and family members limiting in most patients. The post-concussion examination and balance and coordination. guidelines. For adults who have sustained a need to know that important symptoms can syndrome is often associated with minor Given the advantages and disadvantages of head injury and have any of the risk factors, a be present even when the patient seems head injuries and comprises a number of these tests, a combination of testing is one CT head scan should be performed within “normal.” symptoms including physical (headache, option using ImPACT for baseline testing and one hour of the risk factor being identified to signal recovery and return to competition, (table 1). and the SCAT3 or King-Devik for initial Driver's helmets should diagnosis and removal from competition. ON-GOING MANAGEMENT be examined for signs Overall neurocognitive testing, whether by On-going management of concussion of impact damage paper or automated test protocols, has been requires firstly early recognition of the shown to be more valid, effective, and condition, secondly rest until cerebral reliable than imaging for diagnosing and recovery and thirdly graduated return to managing most concussed sportspeople. cognitive and physical activity. While However, consideration needs to be given formalised protocols exist, a personalised to the practicalities of introducing these tests approach is needed, based on the participant, across all types of motor sport in terms of the level of performance, and the rules and high level professional driving compared to practicalities of the sport. amateur competition. If symptoms such as excessive tiredness or

TABLE 1

GCS less than 13 on initial assessment in the emergency department GCS less than 15 at 2 hours after the injury on assessment in the emergency department INDICATIONS FOR CT Suspected open or depressed skull fracture SCANNING TO BE PERFORMED WITHIN Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage ONE HOUR OF THE from the ear or nose, Battle’s sign). RISK FACTOR BEING IDENTIFIED (4) Post-traumatic seizure Focal neurological deficit More than one episode of vomiting

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TABLE 2 GRADUATED RETURN TO PLAY PROTOCOL

REHABILITATION STAGE FUNCTIONAL EXERCISE AT EACH STAGE OF OBJECTIVE OF EACH STAGE REHABILITATION 1 NO ACTIVITY Symptom limited physical and cognitive rest Recovery 2 LIGHT AEROBIC Walking, swimming or stationary cycling keeping Increase HR EXERCISE intensity <70% maximum permitted heart rate No resistance training 3 SPORT-SPECIFIC Skating drills in ice hockey, running drills in soccer. Add movement EXERCISE No head impact activities 4 NON-CONTACT Progression to more complex training drills, eg, Exercise, coordination and cognitive TRAINING DRILLS passing drills in football and ice hockey load May start progressive resistance training 5 FULL-CONTACT Following medical clearance participate in normal Restore confidence and assess PRACTICE training activities functional skills by coaching staff 6 RETURN TO PLAY Normal game play

anterior pituitary dysfunction in symptomatic slowed protective reactions risks further patients attending a neurotrauma clinic. injury and exacerbation of concussive Hypogonadic hypopituitarism is most symptoms. frequent finding. Specific to motor sport is whether to return Also for patients with ongoing symptoms, the same day at the same meeting, or the Headway (5), the brain injury association, next meeting. Drivers who are diagnosed provides excellent practical advice for with concussion should absolutely not return recovery after brain injury. to driving the same day nor during the same race meeting. Drivers should also not drive RETURN TO “PLAY” themselves home on the public roads after a The decision to return to sport, including concussion sustained during a race. blurring of vision, dizziness, tinnitus, poor competitive motor sport, is often difficult. The Guidance exists in terms of return to play balance and fatigue), psychological THE SECOND IMPACT over-riding factor is clinical recovery but for from the International Conference on (impairment of memory, concentration and more severe injuries with CT scan Concussion in Sport (6) which was initially executive function), psychiatric (frustration, “SYNDROME IS A RARE BUT VERY abnormalities, the risk of post-traumatic aimed at pitch sports but can be sensibly anxiety and depression) and social (job loss, SERIOUS CONDITION THAT CAN seizure also needs to be considered. Motor applied to motor sport (table 2). This advises divorce). Treatment is generally supportive OCCUR FOLLOWING A SECOND sport differs from other sports, notably pitch a stepwise progression. The competitor and includes medication, e.g. analgesics for TRAUMATIC BRAIN INJURY. sports, where return to play may be possible should continue to proceed to the next level headache (of variable efficacy) and after assessment. Australian rules and rugby if asymptomatic at the current level. antidepressants, and therapy, e.g. cognitive ” allow rolling substitutions to enable players Generally, each step should take 24 hours so behavioral therapy. to be assessed pitch-side. that a competitor would take approximately Patients with ongoing symptoms including It is essential that people with symptoms one week to proceed through the full fatigue and depression should also be and signs of concussion should not continue rehabilitation protocol once they are assessed for pituitary dysfunction. Our own or return to sport until the symptoms resolve. asymptomatic at rest and with provocative series show at 6 months, 12% incidence of Early return to play with symptoms and exercise. If any post concussion symptoms

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resumption of activity, with specialist assessment of persisting symptoms. THE PROBLEM OF SUMMARY OF RECOMMENDATIONS “ACCURATELY DIAGNOSING The diagnosis of concussion should be based CONCUSSION AND SUBSEQUENT on the history and examination findings. DECISION REPRESENTS A MAJOR Assessment tools are an adjunct. The SCAT ON-GOING CHALLENGE FOR or King-Devik tests may be applied to assist in MOTOR SPORT MEDICINE. the initial diagnosis and removal from competition. ImPACT may be applied for ” baseline testing and to signal recovery and questionnaires (SF-36, QOLIBRI) and more return to competition. formal neuropsychological assessment. Patients with a diagnosis of concussion should not compete again in the meeting. CONCLUSION A graduated return to driving should be The problem of accurately diagnosing implemented. This may require specialist concussion and subsequent decision assessment by a doctor experienced in the represents a major on-going challenge for management of traumatic brain injury. motor sport medicine. The key points in the occur while in the stepwise program then an individual, and expert opinion is management of competitors with concussion ACKNOWLEDGEMENT they should drop back to the previous recommended. and mild traumatic brain injury are firstly to Peter Hutchinson is supported by a UK NIHR asymptomatic level and try to progress again exclude severe intracranial injury, secondly to Research Professorship and the Cambridge after a further 24 hour period of rest passes. SECOND IMPACT SYNDROME monitor recovery with appropriate return to NIHR BRC. Steve Olvey receives For patients with more severe injury The second impact syndrome is a rare but play, and thirdly ensure that patients are compensation as a member of the Scientific (particular in the presence of CT abnormality) very serious condition that can occur counseled about the need for gradual Advisory Committee, NOCSAE. the risk of seizure needs to be considered following a second traumatic brain injury. It is and should be less than 2% per annum to be more common in children and young adults considered fit to return to competition, this is and characterised by aggressive brain the baseline rate of seizure risk in the general swelling possibly of vascular origin. The REFERENCES AND FURTHER READING 5. Headway - www.headway.org.uk 6. Consensus statement on Concussion in population. Head injury is a risk factor for second impact may be minor but is usually 1. NICE head injury guidelines - https:// Sport - The 4th International Conference seizures and TBI is a prevalent cause of followed by rapid collapse (within a minute), www.nice.org.uk/guidance/cg176 on Concussion in Sport held in Zurich, No- acquired epilepsy in the general population, intractable brain swelling and a mortality of 2. ImPACT test - https://www.impacttest.com vember 2012. McCrory P, Meeuwisse W, particularly amongst young adults. Post- 50%. Urgent treatment is required. 3. SCAT3 - http://bjsm.bmj.com/con- Aubry M, Cantu B, Dvořák J, Echemendia traumatic seizures have profound tent/47/5/259.full.pdf R, Engebretsen L, Johnston K, Kutcher J, implications for patients’ quality of life and ASSESSMENT OF OUTCOME FOLLOWING 4. The Canadian CT Head Rule for patients Raftery M, Sills A, Benson B, Davis G, Ellen- socioeconomic status, e.g. driving, TRAUMATIC BRAIN INJURY with minor head injury. bogen R, Guskiewicz K, Herring SA, Iverson employment, and can onset suddenly several There are various methods by which outcome Ian G Stiell et al. The Lancet, Volume 357, G, Jordan B, Kissick J, McCrea M, McIntosh years after a latent period without seizures. may be assessed following the diagnosis of No. 9266, p1391–1396, 5 May 2001 A, Maddocks D, Makdissi M, Purcell L, Pu- Population studies can assist in determining traumatic brain injury. These include the http://www.thelancet.com/pdfs/journals/ tukian M, Schneider K, Tator C, Turner M. the risk of seizure and decision making but Glasgow Outcome Score, the Extended lancet/PIIS014067360004561X.pdf Phys Ther Sport. 2013 May. cannot be absolute in determining the risk for Glasgow Outcome Score, Quality of life

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SURVEY ON CONCUSSION An important survey on concussion for motor sport medical professionals

AUTO+ MEDICAL EDITORIAL BOARD “Many of you involved in motor sport have to deal with competitors who are involved in accidents, relying on your skills Dr Paul Trafford and experience in dealing with trauma to provide a high standard (Chairman) of care. More difficult for the majority of us is the driver with no physical injuries but exhibiting the symptoms of concussion. Dr Robert Seal “Not only challenging to diagnose trackside, we are also faced (Medical Director, with the decision of should we allow a competitor to continue? Do Canadian Motorsports they need to go to hospital? Do they need imaging? Response Team) “If we do send a competitor to hospital and they send them back to the track, what do we do then? Dr Matthew “Some of us have the benefit of being able to refer competitors MacPartlin with concussion to leading experts in this specialty in motor sport, (Assistant Chief Medical but not all of us have an experienced motor sport expert in Officer, Australian GP) neurosurgery available to us. “Professor Peter Hutchinson, along with Professor Steve Olvey, Dr Pedro Esteban both leading experts in concussion and both with vast experience (FIA Medical Delegate, in motor Sport as well as being Chief Medical Officers have written World Rallycross the comprehensive review in this issue of AUTO+Medical on the Championship) subject which we think will be valuable to all of you involved in the sport. Dr Jean Duby “In an effort to find out more about how we all deal with (FIA Medical Delegate, concussion and get more information on the subject we have World Rally included a survey, which we urge you all to complete. This is Championship) entirely confidential and can be completed online. Dr Kelvin Chew Click here to take the survey (Chief Medical Officer, Singapore GP) “We look forward to hearing any comments you may have.” Dr Jean-Charles Piette AUTO+ Medical Editorial Board (FIA Medical Delegate, Formula One)