INTERNATIONAL JOURNAL OF MOTOR SPORT MEDICINE ISSUE#14, AUGUST 2018

MOTORSPORT MONITORS A focus on what technology is available to medical teams trackside P24 TIAGO MONTEIRO The WTCR star recounts his remarkable recovery from a big crash in testing P38 INSIDE THE F1 SAFETY CAR A look at the equipment inside 's fastest ever safety car P32

SEATING PAINS How new medical research is improving seat design to prevent driver discomfort and injury AUTO+MEDICAL AUTO+MEDICAL

I am thrilled to join the editorial board of this prestigious publication that reaches the medical community dedicated to motorsport around the world. The cover of this edition draws our attention GLOBAL NEWS/ to the seats of racing cars, discussing their importance concerning safety and how P4 Award for lifesaving SAFER Barrier P5 GP3 driver achieves podium with broken collarbone technology is being used for this purpose. We P5 FIA Medical Summit set for St Petersburg must bear in mind that the current concept P5 IndyCar introduces concussion test of safety in racing cars must come from P6 FIA launches ultra-protective helmet for F1 inside out, that is, it should focus on the P6 NASCAR makes concussion baseline test mandatory P7 New FIA Medical Commission members padding around the driver and the seat, so P7 Pirelli F1 boss reveals role as ambulance driver that the energy dissipation generated during P7 Safari Rally utilises WRC medical equipment an accident is transferred as little as possible to the driver, mitigating the injuries caused. VIEW FROM THE GROUND/ In the case of prototypes competing in P8 Dr José Cuartero gives his view on grassroots motor sport in Spain endurance events, as mentioned by Alex Wurz, shorter drivers have their safety compromised FEATURES/ with the insertion of foams which allow a P10 SEATING PAINS better position for driving, but do not We examine the issue of seat-releated injuries and how new maintain the same restrictive protection of technologies are being used to solve the problem the trunk, pelvis, shoulders and sometimes P18 BIG INTERVIEW: DR NAOMI DEAKIN even of the lateral protection of the head. In We speak to Dr Deakin about her work in motor sport and how winning short, an article that raises many questions the Watkins Scholarship will contribute to her research into concussion that are being investigated to improve P24 MOTOR SPORTS MONITORS An examiniation of the ideal medical monitor for motor sport drivers’ safety. P32 INSIDE THE SAFETY CAR Dr Naomi Deakin sets an example for all the A look inside the fastest Safety Car ever to be used in F1 doctors working in motorsport, for her P38 THE ROAD BACK: TIAGO MONTEIRO dedication and perseverance, joining her The World Touring Car driver discusses the injuries he sustained in a medical training to her recreational interests, crash during testing at Barcelona last year thus adding value to the safety of our sport. It STUDY/ is with great merit that Dr Deakin was awarded the Watkins Scholarship, giving a P44 RACE DRIVER FATIGUE IN ENDURANCE RACING sequel to a work initiated by Prof Sid Watkins A literary review of race driver fatigue measurement in Endurance who sought to understand and minimize Motor Sport. severe traumatic brain injuries. Editor: Marc Cutler Enjoy this edition. Deputy Editor: Rory Mitchell Designer: Cara Furman Dr Dino Altmann We welcome your feedback: [email protected] Deputy President, FIA Medical Commission

2 AUTO+MEDICAL GLOBAL NEWS AUTO+MEDICAL GLOBAL NEWS

GP3 DRIVER ACHIEVES PODIUM FIA MEDICAL SUMMIT SET WITH BROKEN COLLARBONE FOR ST PETERSBURG

GP3 driver Alessio Lorandi But the adrenaline, when you The next FIA Medical Summit and Chief GLOBAL achieved a podium in the get in that zone, you could have Medical Officers’ Seminar will take place Formula One support series race an arm bleeding and you in St Petersburg, Russia on 2-3 December. in Austria, despite racing with a wouldn’t even realise. At the Professor Gérard Saillant, President broken collarbone. end of the race when I got out of the FIA Medical Commission, will The incident happened a of the car, I had to wait a bit open the summit with a welcome month ago when Lorandi was because of the pain.” speech on the Sunday. This will be testing in a go-kart and it “It could have been a win but followed by an overview of the latest NEWS flipped over. After being taken it’s good that we are there after developments in FIA championships. to hospital, doctors advised the injury, hopefully we can keep In the afternoon, among other him not to race for the next this up,” said Lorandi. “I want to presentations, there will be one that three months. try and grab poles and race wins draws on the experience from the “It happened in Germany a now.” French Air Force which looks at month ago,” Lorandi said after improving the efficiency of the the race. “I was testing with my extrication and medical team by using kart to stay in shape and I crew resource management. flipped.” On Monday there will be four Fearing that he could miss workshops; one that will focus on races through staying in hospital, extrication for rally cars and single Lorandi managed to make a seaters that use the Halo, and another recovery after just 10 days. He will focus on the safety hazards that now races with a steel plate in his come with electrical cars and how it is shoulder that helps heal his standardized across different disciplines. broken bones, and enables him There will be a round table to make movements in the discussion led by Dr Dino Altmann and cockpit while driving. Matteo Piraccini, based around the “It will stay in for a year and a prevention of injuries in motor sport. half,” explains Lorandi. “When The summit will be rounded off with you get in the car, it hurts a lot. a discussion of the day’s topics.

SAFER barriers have been a key safety feature at ovals Neuro Kinetics, I-PAS gives medical professionals a INDYCAR INTRODUCES series of 14 tests to determine whether a driver has a concussion, migraines or BPPV (benign paroxysmal CONCUSSION TEST positional vertigo). AWARD FOR LIFESAVING SAFER BARRIER “That was a game-changer for us,” said Dr Terry IndyCar has introduced a Trammell, safety consultant to IndyCar. "I-PAS has A team of researchers behind the Alabama Department of Mechanical circuits in the US, and is designed to new eye-tracking proven to be an important part of the decision-making Steel and Foam Energy Reduction Engineering. “Dr Melvin was a long absorb and reduce the kinetic computer test as a process as to if and when a driver may return to (SAFER) barrier has been honoured time mentor of mine starting when I energy during the impact of a high- requirement for its competition.” with the Dr John Melvin Motor Sport was a graduate student. His speed crash. concussion evaluation. The I-PAS system was first brought to IndyCar’s Safety Award. leadership and expertise in The project was initially funded by The new ‘I-Portal attention back in 2016, when Will Power crashed Leading figures in highway safety occupant kinematics and injury Tony George of the Indy Racing Portable Assessment heavily into the wall during a practice session. research collected the award on causation influenced the next 30 League and the Indianapolis Motor System’ (I-PAS) uses a Initially, IndyCar doctors determined that he had a behalf of the Midwest Road Safety years of careers.” Speedway, and was developed portable virtual reality headset and is able to gauge concussion and ruled him out of the race, however Facility Team (MwRSF), who helped Over the last decade the SAFER following the deaths of Adam Petty the ocular motion of the eyeballs and measure the further evaluation using I-PAS helped determine that develop the SAFER barrier. Barrier has been a key safety feature in 2000 and in 2001. whites, pupils and iris of a driver’s eyes, enabling he was in fact suffering from an inner ear infection. “It is an honour to receive this for NASCAR and IndyCar circuits, and That led to a push in safety doctors to observe movement of eye muscles. IndyCar has now made the test mandatory for each national award recognizing safety some European circuits. It is usually modifications, and since circuits Developed by Pittsburgh-based eye-tracking experts driver to complete. innovations in racing,” said Dean found on oval racetracks and high- adopted the barrier in 2005 there Sicking, professor at University of speed sections of road on street have been no fatal wall crashes.

4 5 AUTO+MEDICAL GLOBAL NEWS AUTO+MEDICAL GLOBAL NEWS

FIA LAUNCHES Dale Earnhardt Jr retired ULTRA-PROTECTIVE at the end of the 2017 NEW FIA MEDICAL HELMET FOR F1 season following a series of concussions COMMISSION MEMBERS A new ultra-protective helmet standard that will be adopted by Formula One in Two new members have joined Scully and Dr Robert Scarlot 2019 was officially launched by the FIA at the FIA's Medical Comission, Dr respectively, both of whom its Sport Conference in Manila. Jacques Bouchard from Canada have retired from the Medical The latest standard, called FIA 8860- and Dr Brigitte Pasquier from Commission, but will remain 2018, outlines the construction and Monaco. active in Motor Sport. testing requirements that the helmet Dr Bouchard has been This has been part of a new manufacturers must achieve to provide SAFARI RALLY involved in the Canadian Grand age limit of 75 that has been equipment for the FIA’s top series. It will Prix since the race began in placed on all members of FIA UTILISES WRC be mandatory for Formula One from 1978, as the Director of the commissions from this year MEDICAL EQUIPMENT 2019 and in other championships. Track Medical Centre and then onwards. These new helmets will offer a number Chief Medical Officer. He has Dr Scarlot was a key player of safety benefits, including advanced A round of the African Rally been a key figure in advancing in developing the extrication ballistic protection, increased energy Championship utilised World Rally the field of the delivery of health process and is also one of the absorption and an extended area of Championship medical equipment care at motor sport events in Vice Presidents for the protection for drivers. earlier this year. Canada and around the world. Automobile Club De Monaco. “Six months after the FIA approved the The Safari Rally Project was given Dr Pasquier joins the Medical Professor Scully has worked new standard we have a prototype cutting edge medical tools, to be used Commission having been part in motor sport medicine since helmet,” said FIA Safety Commission in emergencies during the 2018 ARC of the Medical Commission and 1968, having previously worked President Peter Wright. “This is the result Safari Rally. Local stewards operated a senior member of the as Medical Director for the of a collaboration over a number of years the safety equipment, and were Automobile Club de Monaco. at between the FIA, the helmet trained by FIA-appointed experts Dr Bouchard and Dr Pasquier Mosport and subsequently manufacturers and test laboratories. from South Africa. have replaced Professor Hugh Montreal. That is the way safety research and NASCAR MAKES CONCUSSION Supplies included the Thomas development should happen.” BASELINE TEST MANDATORY Advanced Trauma Support Kit, which is Throughout the research programme, considered to be the standard in FIA researchers worked closely with F1 life-saving situations around the world. helmet manufacturers such as Stilo, Bell PIRELLI F1 BOSS REVEALS ROLE They also had access to an advanced NASCAR has confirmed that it will received while racing, including Racing and Arai. AS AMBULANCE DRIVER hydraulic extrication device, which can be using the King-Devick test, as one that caused him to miss the Stephane Cohen, Bell Racing Helmets Pirelli Formula One boss cut through metal and peel off glass. part of its process to diagnose a second half of the 2016 season. Chairman, said: “The area of testing will Mario Isola has revealed Having this equipment enabled the concussion in a driver after an “The field of concussions is be expanded compared to what we that he works night Safari Rally Project to put on a WRC- accident. constantly evolving, and we work currently enjoy, which means that the shifts as an ambulance style event, which is key to a planned Developed in association with with experts across the country in overall protection of those helmets could driver. return to world championship status Mayo Clinic, the King-Devick (K-D) maintaining a proactive approach be considered better and as usual the FIA Having started out as after losing it in 2002. test measures a person’s eye to prevention and assessment,’’ will be at the forefront of helmet a for Pirelli’s With a 1.8m boost in funding from movement, while they are asked said a NASCAR statement. “At protection technology.” road car division, Isola the Kenyan Government, the Safari to read out numbers from left to those experts’ recommendation, uses this experience to Rally Project could utilise the right as quickly as possible we are implementing the K-D test help his local town as a equipment delivered by Medisurge, a without making any errors. as part of a basic neurological volunteer for their Malawi-based company involved in the The times required to complete exam for drivers in the IFCC.” ambulance service on distribution of medical tools. each card are recorded and it All drivers were required to non-race weekends. Dr Alex Gikandi, a director of captures impairment of eye complete a baseline test by 8th "People with a normal day job are obliged to volunteer and drive Medisurge, said that it could handle movements, attention, and July, for the tool to be used in one night shift a week," he explained to F1 Racing. “At weekends, any sort of emergency put in front of it language, to determine if a infield care centres on race 90% of the ambulance service is made up of volunteers. We start at and was even used during a visit by person has a concussion. weekends. 7pm and finish at 5am. There's enough time afterwards to go former US President Barrack Obama. NASCAR’s introduction of the NASCAR joins the ranks of other home, take a shower and go to work." “We are not taking anything to Around 80 to 90 per- K-D test follows the retirement of professional worldwide sporting His role in the local ambulance service extends to designing the chances,” said Chief Safety Officer Nazir cent of decisions Dale Earnhardt Jr, who put his exit organisations that utilise the K-D course that trains ambulance drivers in the Lombardy region of Yakub, who thanked Medisurge for come from the eyes from the series down to the test, including NHL and Rugby Italy. This is now used by 100 instructors, and has seen over 5,000 donating first aid kits for every car in number of concussions he Football Union. drivers come through the programme. the Safari for free.

6 7 AUTO+ MEDICAL VIEW FROM THE GROUND AUTO+ MEDICAL VIEW FROM THE GROUND

The most frequent injuries in Karting It would be interesting to promote at VIEW FROM THE GROUND: are cervical whiplash and fractures of University level a specific training in the the fingers, wrist (ulna and radius), ankle initial care of trauma in our sport. Currently (tibial malleolus and peroneus) and ribs. it is not usual in Schools of Medicine and DR JOSÉ CUARTERO There are frequently dermal lesions and other University Schools, but the few In the first of a new column from the frontlines of grass roots motor microfractures of ribs at the level of the initiatives that are made in this regard sport, Dr José Cuartero gives his views from the ground in Spain. edge of the seat. get much interest among students.

There have been many improvements in In grass roots motor sport you learn to Karting safety in recent years. At the work as a team, especially as resources can I have been involved in motor RFEdA level, the rules of Medical Services be limited. The doctor must know the sport for more than 45 years. for Karting have been published (Annex 1 Regulations, the Safety Plan of the First as a racing driver, and then as medical of Medical Services for Testing), and some championship and the available means at his chief of the Federación Aragonesa de intervention protocols have been drawn up fingertips. He must be aware of his Automovilismo (FADA), and then as (Circuito Internacional de Zuera). But the responsibility and, therefore, he must be President of the Medical Commission at the lack of evolution in safety matters for the involved together with the Organizer in the Real Federación Española de driver is worrying. More studies and new hiring of the medical means, and in the alert Automovilismo (RFEdA). I have worked as designs are needed to protect the body of communication with the Emergency Services Medical Chief or Rescue Doctor, in all types the driver especially in case of rollover. in the area and the knowledge of the of motor sport both cars and motorbikes. appropriate hospitals for transfers. It is also It is necessary to require from the Circuits important to know the functions of the other In Spain there are five karting circuits the application of a Safety Regulation that race meeting Officials, especially those of the with FIA homologation: Zuera, Motorland, must be agreed on a National level, following Race Director and Track Marshals. , Lucas Guerrero and the standards already established by other This is essential for the coordination Campillos. The Spanish Championship Federations. This Regulation must of the interventions (team work).” (RFEdA) is celebrated in them, in the contemplate the requirement that the medical different categories (alevin, cadete, junior, and paramedical personnel be properly senior and senior KZ2). trained for the initial care of the injured/ traumatized driver. In the case of Karting, the conditions are not always ideal, as the events are In general, it is not difficult to recruit organised by clubs and promoters with volunteer doctors. What is difficult is finding fewer resources that may lead to cost doctors with the right training for the needs of cutting in safety matters. Another problem our sport. That means experts in the initial is the hiring of medical personnel with attention to the injured. When there is a adequate training. In our sport, it is traumatized driver, the important thing is the essential that both doctors and paramedics initial care that includes cardiopulmonary Dr Cuartero has worked have adequate training in the initial care of resuscitation, adequate immobilization, with both cars the injured driver. stabilization and transfer to an appropriate and motorbikes Center, and this cannot be done by any doctor.

8 9 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES FEATURES

SEATING PAINS AUTO+ Medical examines the latest medical advice around seat design and how new technologies are being used to help prevent driver injury.

10 11 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

While this year’s Spanish Grand Prix might a driver will face. So it can be a challenge to Wurz has Comfort is an have been a straightforward lights-to-flag helped the ensure that the seat works in conjunction increasing focus victory for , Williams driver FIA and with the other safety systems on the car. of modern Sergey Sirotkin described it as “the toughest with research “When you just sit in an empty monocoque technology race” of his life. your body is not protected left and right, and After threading his way through the that means your spine is not in the correct wreckage of Romain Grosjean’s opening-lap shape,” says Wurz. “So I can only recommend crash, he started to feel discomfort from to all the young professional drivers out his seat. “I was really struggling with seat there to be extremely accurate, and go into comfort and just staying in the car,” he said great detail when you are making your seat. after the race. “It was a very painful feeling Make sure it’s your seat and not just some I was getting.” foam insert, and that it’s a really good seating Sirotkin was in fact struggling with position in relation to the seat belts, the REPLICATING THE COCKPIT posture-related problems in the cockpit of HANS device, safety points like the headrest To help prevent these issues some teams his Williams, particularly with the angle of and so on.” are consulting experts to ensure that the the shoulder pads that go towards his SOMETIMES EVEN IN A This is especially important for lower- seating position of a driver does not create HANS device. Rather than holding him in SMALL ACCIDENT, A BAD SEAT level single seater racing where there may unnecessary strain on his body. place, they were pushing him down into the “ not be a budget for a specially-moulded UK-based consultancy F1 Spinal Solutions, seat, which caused significant discomfort CAN ACTUALLY CAUSE A LOT OF seat for the driver. which works with the Mercedes F1 team, through the corners. DAMAGE IN RELATION TO THE “I see drivers sitting in a Formula 3 or uses a special upright MRI scanner to scan “Seating position is one of the most CRASH OR OFF ITSELF car with just foam all around them a driver’s spine and muscles whilst sitting in underestimated performance and safety and they aren’t sitting in the proper seat,” adds the race position. This offers greater insight items,” says Grand Prix Drivers Association ” Wurz. “You will hardly be able to feel what the rather than using a conventional tunnel-type chairman Alex Wurz. “Sometimes even in said at the time. The team made changes car does and if you have an impact, all of the MRI scan, and gives them the opportunity to a small accident, a bad seat can actually to put his back in a more neutral position, safety devices which are designed around the advise drivers and teams on how to mitigate cause a lot of damage in relation to the which put less pressure on his discs and this seat will then work with much less efficiency.” for potential issues. crash or off itself.” solved the issue. However, Bottas admits “The MRI machine is clever enough that it It is not an uncommon problem. Over the he was surprised to have the problem in can pick up the driver, the skin, the muscles, years, a number of drivers have suffered due Australia, with no signs that his seat position and the shape of the spine,” says radiologist to seat-related issues and often the correct wasn’t right.“I’ve never had any problems Dr Steven Morgan, one of the founders of the posture within a seat can be the difference before with the lower back. That kind of thing company. “The upright scanner is essentially between getting injured in an accident and normally takes a bit of time to build up. But weight bearing and we can load a driver escaping unscathed. there was no warning, it just went suddenly.” sitting, bending forwards and backwards, Finnish driver had a similar This is not just an issue in F1 but across which allows us to tell if the (spinal) disc issue in 2015 when he missed the Australian motor racing – single seaters, sports cars is stable and physiological as opposed to Grand Prix because of a back injury he and . normal loading where they are lying down.” sustained during qualifying. He traced the Since launching the company two years problem back to his seat position in the CONTROLLING FORCE ago, Morgan has worked with a number of F1 Teams often Williams car, with the bumpy nature of the When making a race seat, a team’s main goal use foam padding drivers, including one who was suffering from track in Melbourne compounding the injury. is to replicate the driver’s body shape in the on their seats for pain during rapid decelerations. By analyzing extra comfort “It was the seat and pedal position,” he car but it is difficult to replicate the G-Forces an MRI scan with the driver in his normal

12 13 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

racing position, they were able to identify the cause of the problem. They found that when the muscle groups were working hard, the blood flow increased dramatically, resulting in muscle WITH THE RECURRENT engorgement. In a tight-fitting seat, there G-FORCE DRIVERS USE A FOAM was no space to accommodate this swelling, “INSERT TO GIVE THEM MORE which therefore resulted in pain. So the seat design, which seemed to fit the driver PADDING. THAT'S OFTEN NOT IN perfectly when the car was stationary, had to THE CORRECT PLACE. be changed to allow for muscle changes in a racing environment. ” Quite often teams will put padding in the driver’s cockpit, which is designed to help with any discomfort and stop the driver ‘submarining’ under braking. But these can be misplaced or not the right type of material, meaning it could be subjected to increased degradation over time due to the high temperature and G-Forces that drivers are subjected to. “You can easily tell by looking at the seat that the padding is in the wrong place,” says Morgan. “With the drivers’ recurrent (G-Force) loading they often put a foam insert down the center of the seat to give them a little bit of padding. That’s often not in the correct place, or offline. There are different kinds of cushions for different kinds of spines, and we try to glean most of what their problems are and how to fix them.” Morgan explains how they were able to see this information after conducting a series of experiments when drivers still complained they found back pain returned, even when they were happy with the inserts. “From this we could infer that there was significant foam degradation within the hostile driving Regulations on seating position environment,” says Morgan. “We advised are set to change the teams to fit new inserts every 2-3 races, for LMP1 in 2020/21 solving the issue.”

14 15 4-3 ACCIDENT RECONSTRUCTION -SIMULATION RESULTS- Case01 Case02 Case03 Even minimal compression of foam inserts Maria Lopez’s accident during the 2017 can make a huge difference to the driver. “We Silverstone race where he sustained can go down to a millimeter if we need to “minor damage” to two vertebrae, and see how different foams compress under and Daniel De Jong’s crash at Spa weight bearing,” adds Morgan. “If you have Francorchamps in which he fractured a two-centimeter foam insert for the driver the T6 vertebra during a GP2 race after Without Muscle and tell them it compresses to 50 per cent, Without Muscle With Muscle colliding with Pierre Gasly and slamming Activation Activation Activation that’s quite important even in the virgin state into the barrier, head-on at high speed. of the foam because it will incur quite a lot of “This is actually resulting in a rule degradation over a few races.” change, because we had a few accidents where we had broken spines from SCOPE FOR EVOLUTION compression break” explained Wurz, Whereas drivers in F1 have the luxury of referring to the next LMP1 regulations Accident Simulation Accident Simulation Accident Simulation making seats to suit their body shape, in that will be introduced in 2020/21. “We will Spinal fracture No No Spinal fracture T12, L1 T12 Spinal fracture T6 T6 sportscar racing it is a different affair. They have a slightly different seating position Helmet Contact Yes Yes Helmet Contact -- No Helmet Contact -- No often have to share the car with two other to ensure that the pressure between each drivers, with the seat itself changing every vertebra is spread out as equal as possible Confidential Reconstructions of Lopez (Case 2) time they do a driver change. and De Jong's (Case 03) crash injuries to not have one weak link in your back. “In my case, because I’m the tallest I have This will help to prevent injuries that we’ve the carbon seat, which is shaped to me and seen in the past where either a rearwards then the smaller team mates will have the Following ’s heavy crash From there, they were able to recreate or forwards impact compression breaks foam inserts,” says Wurz. “It’s the same story during the 2012 running of Le Mans, when Davidson’s crash and compare it to Wurz in the vertebrae.” for the foam inserts, but also for the safety he crushed two vertebrae in his lower back the same scenario for a smaller and taller It is all part of a move to ensure that of the positioning of the steering, that has after his LMP1 car was launched into the driver. They found that the smaller driver teams take a safety first (rather than to be the best compromise possible where air, the FIA conducted an investigation into (Davidson) ended up moving around in the performance first) approach when always the number one priority is safety, two how he was injured. cockpit more during an impact, whereas for designing drivers’ seats. The FIA and its is performance and three is comfort.” While it was not clear whether it was the taller driver (Wurz) there is less distance safety research partner the Global Institute the vertical landing or frontal impact with for them to travel because they are rested are one year into a four-year research the barriers that caused the injury, it was against the monocoque. project using Toyota’s THUMS software to a concern for the FIA, which was already This technology has been used to analyze further improve this aspect of motor sport. investigating ’s head-on other impacts such as Toyota driver Jose The joint project covers research on crash in an LMP2 car at the Le Mans Test Day, collisions across motor sport disciplines, when he also sustained an injured vertebra. and will include analysis of safety elements As such, the FIA teamed up with Toyota such as seat structures and seatbelt Motor Company to use its Total Human IT HAS TO BE THE BEST positioning, with a focus on minimising Model For Safety (THUMS) software, which COMPROMISE POSSIBLE WHERE spinal injury. The results will be used to put is a computer model that represents the “THE NUMBER ONE PRIORITY IS forward proposals to update motor sport An MRI of human body. This enabled them to recreate SAFETY, TWO IS PERFORMANCE regulations and safety equipment. a spine in a body parts using their Finite Element Drivers can rest assured that motor load-bearing AND THREE IS COMFORT position modelling and simulate how individual bones sport safety researchers are not sitting still and organs react in the event of an accident. ” on this important issue. 17 16 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

DR NAOMI DEAKIN

PhD candidate (Clinical Neurosciences), University of Cambridge

Naomi Deakin is the first doctor to win the Watkins Scholarship, a funded research position with the Global Institute for Motor Sport Safety. She has been involved in motor sport medicine for a number of years, having worked with the and the British Touring Car Championship. AUTO+ Medical spoke to Deakin about her ambitions to lead a global study of concussion in motor sport and also use those results to benefit road safety

AUTO+ Medical: You’re the first doctor to win the Watkins Scholarship, how does it feel? Naomi Deakin: Fantastic! When the Watkins Scholarship was first released three years ago I thought it was an incredible opportunity. It was great to see the work that the engineers have completed over the years, and with Sid (Watkins) being a doctor and a neurosurgeon himself I hope I can do him justice by being the first doctor to receive the award. Deakin works with the A+M: Have you always been a follower of Silverstone medical team for events like the World motor sport? Endurance Championship ND: From quite an early age yes. My dad was a road mechanic and so I was always

1818 19 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

patients in it and looked at who was coming sort of forces, be it their magnitude, or their to the circuit, how they were injured, and direction, or the rotation, actually cause the where they were injured on track. We injury. So the fantastic thing that the Watkins changed some of the marshal posts and Scholarship can do is have some insight into where the medical cars were stationed. Later that engineering data and link it up to that I started a project in my real area of medical data that we collect in Cambridge. academic interest which is developmental One of the things we are doing in Cambridge neuroscience and head injury at a very early is some very detailed, functional MRI imaging age. I was working with Prof Hutchinson and where you see the structure of the brain and we found that there was a real gap in terms you see the connections between different of concussion, so actually I moved on then regions that are . If we can match that and started working with him for the British up to the forces that we are able to collect in Touring Car Championship and things have the car, either in the drivers’ ears or on the really moved on from there. chassis itself, it will help us to understand how that injury has occurred. A+M: Will the Watkins Scholarship help Deakin conducted a major study with drivers with your research? A+M: Could this be a case where in the British Touring ND: So what we are doing now is putting motorsport research can really benefit Car Championship together a two-year concussion research road safety? programme which will be based in ND: Exactly. My ultimate goal would be to Cambridge. We are in the process of setting correlate motorsport data to the injuries that interested in cars, but medicine very or even globally, and I think that largely stems up a concussion clinic, which is being we see in road traffic accidents. We are in a quickly became what I was focusing on. I from the fact that a lot of the doctors who attended by some international drivers, but very privileged position in motor sport as we never dreamed that I would be able to provide care at motor sport circuits have we also have it open to other semi- bring the two together. It was only another day job. So you find that each professional sports participants. But what the through meeting Professor Peter individual provides medical care in a different Watkins (Scholarship) will do is allow me to Hutchinson, who is the Chief Medical way and at very high quality, but that is quite create a vital bridge between motor sport Officer for Silverstone as well as Professor ad-hoc. The first thing I found when I looked medicine and the engineering aspects, of Neurosurgery at the University of at Silverstone was that we needed to start to because one of the things we really don’t Cambridge, that I got the opportunity to standardise how we care for the drivers and understand is what the threshold value is for do some motorsport medical research, really create a good evidence base for what concussion. There is some excellent work in which I wasn’t really aware of at the time! we are doing, which was really exciting for me terms of frontal head protection systems and It’s fairly unbelievable that I’ve been in because it means there is almost a blank helmet design which has happened in recent such a fortunate position really. sheet of paper. We have got a fantastic years. But what we have seen in terms of foundation but also scope to improve on the injuries is that we have moved from very A+M: When you started with the motor things we do. severe traumatic brain injuries where drivers sport research, what did you think have died, and we have sort of shifted drivers about it? A+M: What have been the results of your on the spectrum towards the mild brain Deakin did her ND: Well the first thing I found was that in research so far? injury which is where we find concussion. As pilot study on terms of medical motor sport research ND: The first study I did was on injuries in we are moving towards that lower end of the injuries in motor racing there isn’t that much happening in the UK competitive racing. The pilot study had 10,000 spectrum, we really don’t understand what

20 21 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURESDeakin will continue to work at the race track throughout her research have our medical teams on site and we also know exactly what has happened in the accident; we have the video footage and all of MY ULTIMATE GOAL IS TO this other engineering data. If we can use “MARRY THE DATA WE GATHER, what we learn in that environment to TO INJURIES WE SEE IN ROAD translate it to road safety, I think it has some TRAFFIC ACCIDENTS really outstanding possibilities for improving care for patients after road traffic accidents. ”

A+M: Previous Watkins Scholars have been based at the Global Institute’s office in baseline and post-injury concussion Geneva, is that something you are going testing for touring cars, Formula 4, and the to do? - all of the series that ND: Actually it will be fairly different from are associated with TOCA. I’ll continue to how the Watkins has worked previously. With travel around the UK with them, but the way medical licensing works I am a doctor hopefully in light of the Watkins in the UK but as soon as you leave that isn’t Scholarship I will have more of a role transferrable unless you get a licence from a reviewing the accident and the ADR data different country. That is why we have the from Formula 4 for example, and also permanent medical delegates for the FIA providing a point of contact. championships and the local doctors too because they have the medical certificate A+M: What are your ambitions in motor valid in each country. For the 2018 Sid sport medicine? Watkins Scholarship, I will be based here in ND: They’re evolving all the time! In Cambridge to enable me to complete the general, motor sport medicine is creating concussion research project and to support its own area of expertise; my personal the sports concussion clinic with Prof experience is that we are a very small Hutchinson, but then I will travel to the community that is producing some Global Institute or the Research Working fantastic pockets of work around the Group meetings and the Scientific Advisory world. There are a few conferences and Committee meetings in Paris, and also seminars happening that make sharing whenever I need to spend some time to learn that knowledge easier and there is a some new skills, with the Accident Data growing social media movement which Recorders (ADR) for example, so it is sort of facilitates the sharing of our professional shared between the two locations. knowledge on Twitter. Specifically there are a couple of groups in the US and in A+M: Will you continue with your other Canada and Australia, so I can see motor work on motor sport? sport medicine really evolving as an ND: I’ll continue the relationship I have with international entity over the next few touring cars (TOCA), where nominally I am years and the Watkins Scholarship will their concussion expert, so I do all of their hugely help that I think.

22 23 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

INSIGHT: MEDICAL MONITORS IN MOTOR SPORT Medical monitors are essential for assessing driver injury after an accident. Dr Paul Trafford analyses the best options for the motor sport environment.

Additional research: Dr Robert Seal and Dr Matthew Mac Partlin

Motor Sport medicine pre-hospital applied to everyone at the track. emergency care has its own unique demands The FIA Appendix H mentions the use of and challenges, requiring special expertise a heart monitor, a defibrillator and a device and equipment. One of the most important for measuring oxygen saturation, leaving requirements is the ability to monitor the the choice of how this is achieved to the physiological parameters of any injured, or individual; yet the choice of what to use potentially injured competitor, both in their and how to comply with not only the FIA vehicle during rescue and extrication, and regulations but also the requirements of during transfer by whatever means to a what any physician would deem necessary, is definitive medical facility. both complex and varies around the world. In recent years there have been significant With this in mind, AUTO+ Medical has advances in technology, battery life and the explored what is available, who is using parameters that can be monitored, along what, and what an ideal monitor might have. with better packaging to make the monitors It may be that you use different items of more user friendly, reliable and smaller. equipment to monitor each parameter, so There are also minimum standards for a Non-Invasive Blood Pressure machine, a monitoring laid down by various medical separate ECG, perhaps integrated with an bodies, such as the Royal College of AED and a separate pulse oximeter, but it is Anaesthetists in the UK, but whatever your much easier and practical to have everything specialty, there is a standard of care that in one portable monitor and that’s what is should be provided in motor sport and being considered here.

24 25 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

So, what monitoring parameters ZOLL, which produces the Zoll series X with So, besides the actual monitoring what and medical providers from various would an ideal medical monitor in monitor and defibrillator in one unit. else is important? backgrounds, so it is unlikely everyone will motor sport have? be familiar with the same equipment. Some The minimal level of basic monitoring SIZE AND WEIGHT degree of training and familiarity is very available for a driver who may be trapped in The actual size and weight of the monitor are important along with a device that is intuitive a car or injured or ventilated should include: extremely important. The monitor must be and user friendly with easy to use menus and small enough to fit into a closed car if there is rapid starting and set up. ECG with pulse rate - three leads, ideally an injured driver who is trapped. Using long with the option of five or 12 leads cables having them trailing outside and trying SCREEN Pulse Oximetry SaO2 to position the screen so it can be seen by the A large colour screen is essential, which can End Tidal CO2 waveform display rescue and medical workers inside the car be seen in bright sunlight and from an angle Non-Invasive Blood Pressure are both difficult and can lead to cables being as well as straight on. Defibrillation using external paddles tangled and the monitor being unable to be or pads PHYSIO CONTROL Lifepack SERIES 15 with seen. It’s not unusual for someone to have to

monitor and defibrillator in one unit. hold the monitor for long periods so it can be Any monitor Alongside this there are other parameters seen so we don’t want something so heavy it must be able to that may be desirable: becomes unmanageable. A small footprint is work in a range of conditions useful allowing the monitor to be positioned 12 lead ECG in smaller places. Temperature monitoring Carbon Monoxide monitoring BATTERY using Masimo’s rainbow sensors Any monitor has to be able to run on ST analysis of the ECG batteries as mains power is not an option. Sausset is the first Arrhythmia monitoring quadruple amputee to A long battery life with rapid charge facility The ability to externally pace compete at Le Mans and the ability to replace the battery without using the defibrillator pads Remote Diagnostic Technologies RDT, a losing monitoring or data is vital. It’s also Invasive Pressure monitoring small company that has just been bought by important to know if the battery can be Philips. It has one of the smallest monitors charged in the monitor or has to be removed It’s not unusual to find many of these on the market, the Tempus Pro designed and and charged in a separate unit. physiological parameters available in one built for military use, which links by Bluetooth monitor and several devices are available, with a separate small stand-alone defibrillator ENVIRONMENTAL CHALLENGES with the top three providers probably being: which can be used by itself or in conjunction Motor Sport and pre-hospital care are harsh with the monitor as the Tempus ALS. environments with often exacting conditions involving heat, snow and ice, rain and dust. IN RECENT YEARS THERE Any monitor must be able to withstand these HAVE BEEN ADVANCES IN extremes and continue working at a range of “TECHNOLOGY, BATTERY LIFE, temperatures, not lose the battery charge or allow water and dust to enter. At some point, AND THE PARAMETERS THAT any monitor will be dropped so it has to be CAN BE MONITORED able to stand some hard use. Many motor ” sport events rely on the loan of equipment 26 27 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

ALARMS Some monitors are These are important and must be audible as able to incorporate well as visual as it may not be easy to hear voice recording with still and video cameras alarms if an event is continuing and you are trackside. They should however be easy to silence and the thresholds simple to adjust.

MEDIA Some monitors now incorporate voice recording as well as still and video camera that can store this media alongside the physiological data; this can provide a very useful record for any receiving hospital and prove invaluable for reviewing the care that was provided.

COST All the monitors are expensive sophisticated devices and can cost up to €25,000 with all the options. The companies often help with purchase or may help with loan equipment for big meetings such as F1.

ADDITIONAL FUNCTIONS The RDT Tempus monitor has the ability to incorporate a video laryngoscope and ultrasound probe, but these are of course available as stand-alone devices

So who uses what? In the USA at the , on track Zoll X series is used, and at the medical centre Lifepack 15. In Australia Zoll M series and Lifepack 20 with options ETCO2 and the Tempus Pro are used. In Singapore the Zoll X series is used in the medical centre and for transfer, and Lifepack 15 or Zoll X in the medical cars. In Germany the Lifepack 15 is used, and in the UK Philips provide the monitoring. In the UK, Zoll, Lifepack and Tempus are used, with Tempus increasingly being used by various Ambulance services.

28 29 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

MONITOR / DEFIBS Physio-Control Inc. ZOLL Medical Corporation Remote Diagnostic GS Elektromed. Geräte G. Philips Medical Inc. Schiller AG Technologies Ltd. Stemple GmbH Product Likepak 15 X Series Tempus ALS Corpuls³ HeartStart MRx Defigard Touch7 GENERAL Fully featured monitor-defib; Yes Yes Yes with built in cameracamera Yes Yes No - no pacing Manual / AED / Cardioversion / and optional ultrasound and fibre- Pacing optic laryngoscope

Weight fully configured with 9.1 kg 5.3 kg 5 kg (2 modules) 6.3 kg (3 modules) 6 kg 3.2kg (2.4 kg monitor battery, without accessories or plus 0.6 kg printer) saddle bags

ENVIRONMENT Ingress Protection - total product IP44 IP55 IP66 IPX4 IP24 IP55 BATTERY Rechargeable batteries 2 batteries - Lithium-ion 1 battery - Lithium-Ion 2 batteries - Lithium-Ion 3 batteries - Lithium-Ion 2 batteries - Lithium-ion 1 battery - Lithium-Ion Capacity - A/h 5.7 Amp hours 6.6 Amp hours 10.2 Amp hours / 5.8 Amp hours 4,4 Amp hours 5.8 Amp hours Capacity - Nb of shocks 420 shocks at 360J 300 at 200J 300 at 200J 200 at 200J Every 15/min 20 200J discharges Capacity - Monitoring only 6 hours 6 hours 10-14 hours (monitor) / 10 hours 4 hours 9 hours (defib in monitor mode) Charge Time of an empty battery 4.25 hours 4 hours 4 hours (monitor) / 2 hours (defib) 2 hours 3 hours

DISPLAY Size 8.4 inches (21.6 cm) diagonal 6.5 in (16.56 cm) diagonal “6.5 in (16.56 cm) diagonal - 8.4 inches (21.6 cm) diagonal 8.4˝ diagonal (128 mm x 171 mm) 7 inches (17.8 cm) diagonal monitor 5.7 inch (16.5 cm) diagonal - defib” 8.4 inches (21.6 cm) diagonal 8.4˝ diagonal (128 mm x 171 mm) 7 inches (17.8 cm) diagonal

DEFIBRILLATION Charge time on Battery at 200J <10 seconds 7 seconds 8 seconds <10 seconds 5 seconds Time to first shock at full power 15 seconds 20 seconds 13.8 seconds from switch-on

MONITORING OPTIONS 12 Lead ECG Monitoring and re- Yes Yes Yes Yes Yes Yes cording Co-oximetry e.g. SpMet, SpCO, Yes Yes Yes Yes No No, SpMet & SpCO only SpHb NIBP Yes Yes Yes Yes Yes Yes Temperature Either IBP or temp Yes - 2 channels Yes - 2 channels Yes - 2 channels Yes - 2 channels Yes - 1 channel only Not both together Pacemaker Yes Yes Yes Yes Yes No Patient record feature No No Yes No No No

ADDITIONAL FEATURES: ST monitoring is provided by Lifepack and Tempus with QT monitoring on the Tempus and Phillips. Impedance respiration is only on Zoll and Tempus. All include invasive pressure monitoring to varying degrees but the Lifepack can only monitor temperature or invasive NOTE: The author uses a variety of monitors in his clinical practice and BTCC has purchased a number of Tempus pressure, not both together. All have built in Bluetooth Zoll and Tempus having USB and WiFi connectivity. Only Tempus provides built in 4G mobile monitors. A+M has no relationship with any of the manufacturers in this article. connectivity, although Corpuls has 3G available. Both Tempus and Corpuls can provide real time data streaming allowing remote monitoring, however Tempus also allows remote voice communication. The tempus is also cyber secure as it was developed for military use.

30 31 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

INSIDE THE 2018 F1 SAFETY CAR AUTO+ Medical takes a look at the new Formula One Safety Car, the most powerful ever produced.

As Formula One gets faster safety has to developed on the famous Nurburgring circuit. on Michelin Pilot Sport Cup 2s. and radio system buttons for both on the keep up. This is why Mercedes have this It is the 23rd consecutive year that Inside the cockpit there are two integrated centre console. year launched the most powerful F1 Safety Mercedes has provided such a crucial iPads; the left is used to display the In the boot there is enough space for the Car ever, with 585bhp and a top speed element to F1 weekends, and this year it is international TV broadcast and the right can telemetry units, a Wi-Fi router which links to of 318km/h. again driven by Bernd Maylander alongside feature either an animated display of the the iPads, onboard camera and timing This power is important as the safety car co-driver Richard Darker who maintains radio current positions of cars or show current lap system unit, siren control unit, marshalling must maintain a minimum speed level to contact with race control. times. On the dashboard there are the system unit, FIA SDR (software defined radio) prevent the tyres, brakes and engine of an F1 It has a fully redesigned suspension, active marshalling system LEDs (flag signals), unit, car data logger, and the Safety Car car from excessive cooling and overheating. aerodynamics, extra supports to boost control LEDs for the Light Bar and Flashing Systems fuse and relays box. That is why the all-new 2018 AMG GT R torsional rigidity, nine-position traction Lights, and switches for the Light Bar, All of this equipment ensures that it is not features the driving components carried over control, adjustable coil over spring/damper Flashing Lights and Siren. There is also a just the fastest safety car ever produced, but from its AMG GT3 racing car that was units, and will drive F1 tracks around the world secondary rear-view mirror for the co-driver, the safest one too.

32 33 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

Switches for Light Bar, Flash Lights and Siren

Control LEDs for Light Bar and Flash Lights

Co-Driver Rear View Monitor Marshalling System LEDs (Flag Signals)

Onboard Interior Camera Second one behind Driver Seat

Radio System Control Buttons iPad TV Feed Timing Page Positioning Map Information Page

34 35 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

Onboard Camera and Timing System Telemetry Units

Radio Systems (Digital and Analog) + Intercom

Wi-Fi Router FIA SDR unit Marshalling System Unit (Link to iPads)

Safety Car Systems Fuse and Relays Box

Siren Control Unit Car Data Logger

36 37 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

THE ROAD BACK: TIAGO MONTEIRO

The driver reveals his remarkable road to recovery following serious injuries sustained in a heavy crash in September 2017.

During the closing stages of a three-day test at the Circuit de Catalunya last year, Tiago Monteiro lost control of his World Touring Car after the brakes failed at 255kph. Heading into the first corner, the car spun and went backwards into the wall. The impact resulted in him sustaining two head traumas, a dislocated shoulder, and a brief loss of vision in his eyes. But after spending months recovering and consulting doctors around the world, Monteiro tested with Honda again this year with plans to return to racing in 2019. He spoke to AUTO+ Medical about his injuries and on-going recovery.

AUTO+ Medical: What can you tell us about the accident itself? Tiago Monteiro: I had a mechanical failure with the brakes and went off the road at Monteiro spun 255kph. I tried to avoid hitting the wall head off at 255kph while testing with Honda on at Barcelona into the first corner. This is a at Barcelona very high-speed place with not a lot of run

38 39 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

off, and I tried to avoid that and go to corner from the time it took to get me out of the A+M: What caused that? number two. But at that speed obviously you car until I got to the hospital, it was TM: The extension of the Cranial Sixth R, I COULDN’T TALK, MOVE don’t have a lot of control, so I turned and probably like 15 or 18 minutes max. I did which is the nerve that puts your eyes to the MY RIGHT SIDE, FEEL MY went onto the grass and spun. Then I hit the a lot of (medical) exams and side. So it was like as if my eyes came out of “RIGHT LEG, I HAD NO SPEECH, wall, slower but still at 170kph and 44G observations, and then I woke up in the my sockets and it extended the nerve, and COULDN’T SWALLOW LIQUIDS, acceleration, which knocked me unconscious. bed with a huge headache. I couldn’t talk, then in the lateral impact I scratched and move my right side, feel my right leg, I squeezed C1 and C2 cervical, which then AND I COULDN’T SEE A+M: How long were you unconscious for? had no speech, couldn’t swallow liquids, I squeezed the canal where the nerve goes ” Obviously you weren’t awake for this couldn’t see because I had 85 per-cent into your spine. So not only was it squeezed, point, but do you know what happened in strabismus. but it was also stretched. A lot of times you recovered faster, the right one took longer terms of the extraction from the track? don’t recover from it, but thank god and this is the one that is taking a little bit TM: It was towards the end of the day, all of sometimes you do recover from it. I also longer still. the stewards were getting ready to go so they dislocated my shoulder, which tore a lot of were quite fast. But because I wasn’t tendons and muscles around there. My back A+M: So when did you change your breathing properly and was unconscious they was scratched, I tore my biceps, bruised four mindset? At four weeks was it ‘I just want were a little bit worried to touch me and ribs, and my toes and knees were completely to get better’ or ‘I want to return to extract me, and my pulse was very low. In the in blood because I destroyed the pedals and racing?’ meantime my team manager and mechanics everything inside the car with the lateral TM: My first thoughts were to go back racing! arrived and were also quite worried. Then the impact. There was a lot of injuries, but the It was crazy. In some cases I know that some medical staff arrived, but it was not easy to Monteiro had to wear a most concerning was my neck and two people think ‘I’ve had enough’ and that ‘this patch over his eye to prevent get me out of the car. I was put into a feelings of dizzyness traumas in the head, that’s why I was under is a sign, lets stop it’ - I didn’t take it like this, I hammock, then into a medical helicopter, so observation in intensive care. wanted to go back racing from day one. But that’s also what helped me go through all the A+M: Which hospital was this and what work and treatments. We did a lot of travel Honda gave sort of treatment did they give you? and went to a lot of doctors, and I think that Monteiro a test at Monza last TM: That was Barcelona initially, Martorell so was the motivation behind all of that. I was month it’s near Barcelona. That was for a week and leading the championship at the time and I two days, and then they evacuated me to had that goal in my mind that I wanted to go Portugal, where I stayed in for another week. to the next race, even though most people So it was about a week and a half of intensive thought it was impossible. So to have these care and then one week in a regular hospital. goals, they were really unrealistic but that’s Only after three weeks I stood up and started what was giving me the energy to keep on to move, then having this big, big conversion moving. of the eyes meant I threw up a lot, and had severe headaches. That, plus the trauma was A+M: What kind of things were you doing very painful and very hard to go through. to help? Every hour I would need to change a patch, TM: From the basic osteopathy’s we then did because otherwise you would just feel sick forty or sixty hours of hyperbaric chamber, like you were drunk all the time. Then you get breathing pure oxygen for two hours a day used to it like anything, but for six months I to help regenerate cells. We did a lot of work was seeing double, and then only a month with the eyes, with some machines and also ago I started to recover. The left eye with some basic tools to help exercise the

40 41 AUTO+MEDICAL FEATURES AUTO+MEDICAL FEATURES

eyes. I went to the USA in San Diego for sent videos from people in the motor sport TM: Well one thing is get good insurance. A head traumas, where six-to-eight hours a world who I hadn’t seen in 10 years or 15 lot of drivers that I know, if they don’t have day you would be on a drip sitting there and years. It was really, really strong support to work contracts they won’t get insurance. getting these two litres of vitamins and help me move forward. That’s really stupid and dangerous because amino acids and stuff like that. I also went to it’s so easy to have an accident. But the main Florida to get an injection in my spine with A+M: So then you’ve finally made it back advice, apart from physical pain, is that it will like a super, kind of anti-inflammatory to the point where you would go back in be very, very psychologically difficult to Monteiro underwent product. It makes it regenerate faster and I numerous tests on the car, how did that feel? accept that you’re not driving. I didn’t know if did also therapy in my blood, so I got a his eyesight TM: The first time it was way too early, I I was going to be driving again, but the main blood transfusion almost. We also did all of couldn’t see so it was really bad. It felt as if I thing is to never, ever give up. You always the physical training a lot, but the eyes and had double and blurry vision so it was not need to be thinking that whatever happens, brain were the most important things. possible, then a month later I did another test you will find a way to overcome it. It feels in Monza, which was much better. I would get easy to say it now, but that’s what I’ve been A+M: Were there any particular doctors to a certain lap time because I would get the through. I didn’t ever think about not coming or physios that you worked with during feeling for it and I could see very well. back, that was my strength I think. So even this time? when you can’t talk and can’t swallow water TM: The team physio helped me put Monteiro A+M: What advice would you give to other or liquids or solids, you still need to think, in a together a good group of specialists, but was determined drivers who go through tough injuries? few weeks or months, I will be there. to make a full then I was also lucky to get the doctor who recovery is in charge of the Portuguese hospitals to choose the best neurological doctors. Then I went to the USA and stayed in two different places. I went to Japan, Germany, and Spain SUPPORT IS REALLY where I saw one of the best optometrists IMPORTANT BECAUSE YOU’RE doctors in the world. [MotoGP rider] Marc “IN SUCH A WEAK STATE OF MIND Marquez gave me his name, because he had a similar thing but just in one eye, so I went THAT YOU CAN EASILY GO INTO to see him. I was really in good hands, in my A DOWNWARD SPIRAL head I was like ‘Even if I don’t race again, I don’t want to leave with the thought that I ” haven’t done everything I could, so I’m lucky that I’m in this situation and had a great group of people. Then you have the nurses who took care of me, some of them were really helpful – not just the way that they talk to you but the way they treat you. Support is really important because you’re in such a weak state of mind, that you can easily go into a downward spiral, Monteiro spent After sitting out the psychologically just get depressed and lose 40 to 60 hours 2018 season, Monteiro motivation. The amount of messages I in a hyperbaric plans to return in 2019 chamber received, it was such a motivation, getting

42 43 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

LITERATURE REVIEW OF RACE DRIVER FATIGUE MEASUREMENT SCIENCE IN ENDURANCE MOTOR SPORT Fatigue is a common issue amongst sports car drivers who race Authors: Nick Owen, for long hours without breaks. This literature review explores Horace King, Matthew Lamb - Victoria University that and the solutions that could be implemented in the future. Research Group

45 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

ABSTRACT

Australia's circuits Driver fatigue in endurance motor racing has have environmental been problematic for driver safety and factors that demand optimal performance. Historically the focus in more from drivers this sport has been primarily on improving mechanical performance; making the racecar light, faster and improving grip (aerodynamics and suspension geometry). Driver safety has come secondary. A series of fatal accidents that were attributed to fatigue have led to rule changes; however, these were made with little understanding of the driver fatigue (type/level). As the literature indicates, few publicly available studies into driver fatigue take into account all of the identified stresses for endurance motor racing. Technology has progressed where it is now easier to self quantify with the use of appropriately selected and placed sensors. This literature review aims to highlight the need for sports engineers to develop a new electronic system for fatigue measurement in endurance racing and is the first part of a major research project in the development of a system for race driver fatigue measurement.

INTRODUCTION Motor racing has evolved well beyond being a recreational pursuit; it is now a multi-million dollar sport demanding the highest level of physical and mental fitness similar to that of any other athlete. Endurance drivers, like the cars they drive, are complex from a physiological perspective. However, unlike the cars they drive, driver-athletes have not been comprehensively examined, evaluated, and tuned to the same degree. Wearable health- monitoring systems are becoming very popular, especially in enabling the non- invasive diagnosis of vital functions on the

46 47 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

human body [1]. The purpose of this review is A 24 hour kart to present literature relevant to driver fatigue race at Le Mans in endurance motor sport and state the was examined to design direction towards the development of measure fatigue a new type of electronics system to be used in the quantification of driver fatigue.

REVIEWED LITERATURE In this section a review of the most relevant literature to racing driver fatigue, monitoring and detection is presented.

2.1 The case for driver science in motor sport: a review and recommendations A review carried out by Potkanowicz and Mendel has shown that the influence of stress and strains exerted on race drivers is not well understood or the combined effect is not known [2]. While trainers and sports scientists try to simulate the racecar and race event environment with their training regimens (e.g. hot yoga, loaded steering wheel resistance training, reaction testing, and training), without quantifiable data of the driver’s experience, these regimens do not take full advantage of the training principle of specificity [3]. Providing quantifiable data through additional research will help to validate the driver as an athlete. In uncovering this information, the scientific community has an opportunity to contribute to racing becoming that much safer, that much more competitive, and that much more when the drivers are highly trained and fatigue, which may cause crashes [4]. Durand comprehensive for the driver, the team, and FATIGUE CAUSED BY adapted to the condition, fatigue is known to studied heart rate (HR) over the course of a the sport [2]. EXTENDED HOURS OF DRIVING compromise final performance by lowering 24-hour go-kart race at Le Mans, France. The “ anticipation movements affecting force research aimed to statistically correlate driver 2.2 Bioenergetical and cardiac adaptions A CAR HAS CONSIDERABLE exerted to control vehicle trajectory [4]. HR with energy expenditure (EE) of the driver. of pilots to a 24h-team kart race INFLUENCES ON ALERTNESS Furthermore, the lack of precise The research concluded that driving a kart for Fatigue along with excessive speed and AND PERFORMANCE recommendations on maximal driver 45 minutes before driver change at around alcohol is the main factor in road accidents in duration in relation to vehicle type, exposes 60 km/hr resulted in a 300 kcal EE, the general community. In motor racing, ” the driver to potentially dangerous levels of corresponding to a 5.6 Mets (Metabolic

48 49 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

Equivalent of Task, energy cost of physical a seat that was mounted to a vibration shaker activities). This effort is responsible for 73+ table that was configured to vibrate in a beats per minute (BPM) increase in HR, frequency range of 1-15Hz, with vibrations reaching 82% HR maximum intensity (157 intensity levels limited to 0.3 m/s, 2 Root BPM). These high values were repeatable Mean Square (RMS). An electroencephalogram between each successive driving instance, (EEG) headband was placed on the test but not statistical enough to prove that subjects. Beta and theta brain activity was increased HR induced physiological fatigue. observed in the frequency domain utilising The research also reported they did not Fast Fourier transformation (FFT) and power take into account effects of vibration on spectral density (PSD) within each of the brain the whole. The researchers did not activity bands. The results of the study for all evaluate the combined effects or the ten subjects found that the measured beta frequency of vibrations the driver reported, brainwave activity, which indicates alertness and a role for this factor on EE elevation level, decreased in both random and and fatigue development cannot be sinusoidal excitation. However, the eliminated [4]. drowsiness effect in sinusoidal vibration was more pronounced compared to random 2.3 Influence of vibration on vehicle vibration condition. The test methodology occupant fatigue was a good indication that vibration is a Fatigue caused by extended hours of contributing factor to drowsiness and mental driving a car has considerable influences fatigue. However, the environment protocol on driver alertness and performance, was not realistic as the test participants were which therefore can lead to a compromise not stimulated in the same way a driver in transportation safety. However, fatigue would be operating a motor vehicle (the caused by vibration is not well investigated participants were asked to sit comfortably or reported in the available literature. The with their back on the backrest and hands on relationship between vibration magnitude their laps) [5]. As the environment was not and vibration frequency of vehicle replicated then it would be difficult to deduce occupant and associated fatigue has been if the effects of fatigue were induced by established without sufficient research. vibration or lack of mental stimulation. This is because fatigue is a complex phenomenon, and there is little 2.4 The Clipsal 500 Studies; (CO), quantitative data in existence characterised dehydration and heat stress specifically to motor racing [5]. Research by Australia’s race circuits such as the Adelaide Amzar and Fard proposed that low- Street Circuit include environmental factors frequency vibration might induce such as high temperature, high solar drowsiness and cause a reduction in radiation, and low wind which when Excessive exposure alertness [5]. To test the hypotheses an combined with Carbon Monoxide (CO) from to Carbon Monoxide experiment was conducted where ten race car exhaust gases, exert unique can increase sweat rate and dehydration individuals, one by one, were secured into physiological demands on motor sport

50 51 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

Fatigue can impair sweat loss, other were not [8]. This suggests braking or steering inputs. Fatigue impairs perception and that there is a need to capture driver fluid perception and the ability to make the reaction times intake, to better understand the relationship decision to react, and it also degrades the between hydration and the fore mentioned performance of the action(s). stresses. Additionally the study above totally neglects the contribution of whole body VW summaries the effects of vibration, as the study was focused on the psychological fatigue into four categories: effects of CO, hydration and temperature awareness. Physiological (regulation of the vegetative and nervous system) 2.5 Don’t sleep and drive – VW’s fatigue detection technology Cognitive (perception and information Fatigue in general is a very complex processing) phenomenon; the resulting micro-sleeps are merely a subset of the potential causes of Motor (behavior) accidents, which can be traced to a lack of fitness or performance capability on the part Subjective (experience) of the driver. Around 20% of fatal road

accidents involve driver fatigue. According to Table 1. Classification of fatigue category and effects VicRoads, around 30% of severe single participants [6]. AIMSS researchers made rate and temperature rise, thus increasing vehicle crashes in rural areas involve the CATEGORY FATIGUE EFFECTS observation of a control group of drivers at the effects of hyperthermia and dehydration driver being fatigued [9]. In an attempt to Physiological Reduced psycho-physiological the Australian V8 Supercar championship on psychomotor performance. Dehydration is tackle this problem automotive simulation (Clipsal 500, Feb 2008). Measurements were fluid loss due to the normal functioning of the manufacturers have developed driver fatigue Cognitive Reduction in alertness made in cabin temperatures, CO levels and body, mainly via perspiration and breathing. monitoring systems for consumer vehicles and vigilance driver specific effects, such as fluid loss due to It increases susceptibility to fatigue and [10]. An example of such a system is the Informed processing dehydration and body core temperature. muscle cramps. Inadequate fluid replacement Driver State Monitoring System developed by and decision-making Driver cabin CO levels were above 100ppm before, during and after physical activity Volkswagen (VW). VW researchers identified takes longer for significant periods of time (up to 15mins). causes dehydration, which may lead to human error to be a casual factor in many Motor Reaction time increases when Although the research indicates several fatigue, heat exhaustion or heat stroke. public road accidents. Human error is critical event occurs metrics for evaluation, it falls short on Optimal hydration levels are vital, not just for explained by shortcomings in perception, Control reactions are more quantifying how each of the metric (CO, body motor sport participants to perform at their interpretation of information, decision- variable and less effective temperature, hydration) affects the driver. best physically and to maintain mental making, information recall and direct Reduced preparedness Excessive exposure to CO can cause acute function; they also help ensure safety and performance of an action. However, general to react disturbances highly relevant to the task of maintain long-term general health [6]. Driver physical and cognitive aspects such as controlling a racing car, including impaired weight changes for Race 1 and 2 showed attention and fatigue also play an important coordination, reduced accuracy in mean losses of 1.5% and 1.8% of body mass, role, because they affect other cognitive There are difficulties with the methods that determining a vehicle's position, slower respectively [7]. There was considerable processes [11]. When drivers are tired, they are used to assess the drivers’ state and reaction times and impaired ability to attend variation, which indicates some drivers were fail to take action to avoid an accident. This is fatigue level in particular. This in turn creates to multiple tasks. CO also increases sweat drinking sufficiently during the race to match especially the case of incidents requiring a problem when an attempt is made to test

52 53 AUTO+MEDICAL SCIENCE AUTO+MEDICAL SCIENCE

the suitability of fatigue recognition understand the complex relation of driver technology. The VW Driver State Monitoring fatigue in endurance motor sport. What REFERENCES System implements a non-intrusive makes an effective and efficient system for 1. G. A. V. M. M. D. M.-P. S. Ping Jack v8_supercars. [Accessed 16 Decemeber observational approach: blink rate, head consumer vehicles, does not necessarily Soh, “Wearable Wireless Health 2014]. movement (nodding) and eye pupil position. translate to the world of endurance motor Monitoring,” IEEE Microwave Magazine, 8. Australian Institute of Motor sport The system uses two dashboard-mounted racing. Understanding the athlete and the vol. 16, no. 6, pp. 55-70, 2015. Safety, “Fast facts about dehydration:,” cameras focused toward the driver's face; a environment is of vital importance, and the 2. R. W. M. Edward S. Potkanowicz, “The 2013. [Online]. Available: http://aimss. detection algorithm processes the data to differentiating factors of how an Case for Driver Science in Motor sport: com.au/wp- content/uploads/2012/12/ determine the likelyhood of the occurrence of endurance racing fatigue monitoring A Review and Recommendations,” Clear_to_Steer-Hydration_Booklet.pdf. a micro-sleep or abnormal driver distraction. system shall operate and what should be Sports Medicine , vol. 43, no. 7, pp. [Accessed 15 December 2014]. If the system detects any of the three the inputs for fatigue detection algorithms 565-574 , 2013. 9. Roads Corporation (Vic.), “Road accident indicators of fatigue, then it will alert the [13]. By examining the literature, it 3. A. J. Klarica, “Performance in motor facts, Victoria / VicRoads.,” in Road driver with audible / visual alarms [11]. The becomes evident that heart rate, sports,” British journal of sports accident facts, Victoria / VicRoads., VW type system is an effective and efficient respiration, carbon monoxide levels, medicine, vol. 5, no. 35, pp. 290-291, Melbourne, Roads Corporation (Vic.), tool in combating fatigue in medium to long hydration, temperature, and whole body 2001. 1999. road trips in consumer motoring. In motor vibration are contributors to a driver’s 4. S. Durand, M. Ripamonti, A. Rahmani 10. Y. G. G. R. D. F. C.D. Katsisa, “A wearable sport the driver is a trained athlete and the physical and mental fatigue in motor and B. Beaune, “Bioenergetical system for the affective monitoring likelihood of the driver experiencing the same racing. Despite this no studies have and cardiac adaptations of pilots of car racing drivers during simulated type of fatigue, or pre-fatigue such as lack of implemented an approach that allows the to a 24h-team kart race.,” Journal conditions,” Transportation Research sleep or stimulation, is minimised if not combined effects of all the stressors to be of Strength & Conditioning Research:, Part C: Emerging Technologies, vol. 19, eliminated by professional athletic established. Ongoing work conducted by the 2014. no. 3, p. 541–551, 2011. preparation, as the stressors and strains authors focused on the development of an 5. M. A. &. F. M. Azizan, “The Influence 11. T. K. T. S. K. H. J. &. Z. R. Von Jan, “Don’t placed on the driver in motor racing are electronic system, which integrates and logs of Vibrations on Vehicle Occupant sleep and drive-VW’s fatigue detection caused by environment, rather than sleep relevant sensory input, designed specifically Fatigue.,” INTER-NOISE and NOISE-CON technology.,” in In Proceedings of 19th debt. Additionally the driver’s race safety for the driver and the environment. It is Congress and Conference Proceedings International Conference on Enhanced equipment, such as helmet, head restraints hoped that the research will lead to the , vol. 249, no. 6, pp. 1767-1777, 2014. Safety of Vehicles, Washington, DC., and fire retardant balaclava, render optical development of a tool that can be used to 6. D. T. J. A. &. D. A. C. White., “Study: 2005. tracking and facial feature recognition allow for further research towards (CO), Dehydration and Heat Stress 12. P. Marks, “Dawn of motor sport’s inoperable. developing an understanding of the complex – Full Story,” Australian Institute of electric dream,” New Scientist, vol. 211, relationship between the stressors and Motor sport Safety (AIMSS), 2013. no. 2831, pp. 26-27, 2011. LITERATURE CONCLUSION driver fatigue. [Online]. Available: http://aimss.com. 13. L. D. Adrian H. Taylor, “Stress, fatigue, Endurance motor racing is a team sport that au/study-co-dehydration-and-heat- health, and risk of road traffic accidents requires the driver, the car and the team to ACKNOWLEDGEMENTS stress/. [Accessed 15 December 2014]. among professional drivers: The be at the peak performance [12]. The *The author would like to mention that the 7. AIS Sports Nutrition, “V8 Supercars; Contribution of Physical Inactivity,” technology currently used in motor racing is field of wearable wireless health Characteristics of the Sport,” Australian Annual Review of Public Health (Impact well suited to measuring electro-mechanical monitoring is new and the role that this Sports Commission. , 2013. [Online]. Factor: 6.63), no. 27, pp. 1-20, 2006. phenomenon of the car and logging the data technology would play in motor racing is Available: http://www.ausport.gov. for further analysis, but is not designed to yet to be defined. Competitive edge in this au/ais/nutrition/factsheets/sports/ specifically interface with the driver or sport has limited the amount of public identify the occurrence of driver fatigue. domain information as the reference More research is required to further list reflects.

54 55 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 Championship)

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

Dr Kelvin Chew (Chief Medical Officer, Singapore GP)

Dr Dino Altmann (Deputy President, FIA Medical Commission)

56