Two weeks ago I was sitting in an apartment in the middle of the Vienna Naschmarkt, having flown in at 6am that morning from Australia to attend the biennial FIA Institute Medicine in Motorsport Chief Medical Officer's seminar. Traditionally, while there are a handful of exceptions, this is a fairly passive affair consisting of a series of talks and a couple of fairly didactic workshops (SMACC it is not).

Two years ago a small bonfire was lit when Dr Sean Petherbridge (CMO for the Abu Dhabi F1GP and the Abu Dhabi Desert Challenge) suggested that having dedicated extrication teams at circuit events might not be necessary and cross-trained intervention vehicle crews might be more efficient. That statement caused a brief stir and then it was back to normal operations. (If you want to know a bit more about Sean's opinions on this you can read his co-authored article in Trauma: The case against extrication in motorsport: Reforming the deployment method.)

This year there was a bit more fire in the audience than perhaps was anticipated, which made proceedings and particularly the post-talk Q&A sessions more spicy than usual.

Here is a run down of Day One.


Videolaryngoscopy (VL) in motorsport - Rob Seal

The question being addressed in Rob's presentation was whether VL should be a mandatory piece of equipment for the medical response team. A wide variety of VL devices were reviewed which unfortunately led to the core message being somewhat buried in the content. It was, however, thrashed out during the Q&A session afterwards.

The majority opinion was that while VL is a useful tool, it is more important to ensure that trackside medics (doctors and paramedics) have solid basic airway skills sufficient to ensure the safe delivery of a patient to either the medical centre or the receiving hospital. There was concern over mandating a piece of equipment that members of the response team may have little day-to-day familiarity with.

Limitations of VL in the pre-hospital environment are important for users to be aware of. Here is a review paper on the pre-hospital use of VL: What is the role of video laryngoscopy in pre-hospital care?


The role of the chief medical officer (CMO) – Hugh Scully

This is a topic that has been covered before at FIA Institute seminars but it hadn't previously been subjected to such push back from the audience. There were several points that delegates took issue with.

First was the assertion that the CMO should have their base career as a qualified trauma specialist in one of emergency medicine, intensive care, surgery or anaesthetics. There are many good motorsport CMOs who are in general practice and in-hospital medical and non-trauma surgical specialties. Pre-hospital and retrieval medicine was not even mentioned. It was suggested by several delegates in the audience that while knowledge of trauma processes is certainly important, the skills that mattered to an effective CMO are those of a competent, confident manager who is able to cope well with stressful situations and communicate well with a wide variety of people in other roles.

It was also suggested by the audience that an effective CMO need not necessarily be a doctor when it comes to directing rescue efforts on the race track and a good paramedic could make the same decisions in race control and perhaps do it better.

No specific agreement or recommendations came out of all of this debate, but it did imply that there was a reluctance to unquestioningly accept the status quo as delivered.

It was also stated in the presentation that included in the safety plan should be the details of each member of the medical and rescue response team, including name, address, phone number and blood group. This raised concerns of confidentiality and practicality, as the safety plan is a public document. It was also pointed out that recording the blood groups of individual response team members would be rendered irrelevant as any hospital would send a sample to the lab for typing regardless. Let's face it, we stopped printing competitor's blood groups on their car windows years ago.

The last bone of contention was a statement that in order for on track fatalities to be better understood in context, the local coroner should be invited by the CMO to attend events. This was wholeheartedly rejected by delegates in the audience as the event rate is uncommon, it would not reduce any responsibility for proper procedure and documentation and the coroner is unlikely to have the time to attend every local motorsport event on the chance that a fatality might occur.


Concussion in motorsport – Steve Olvey

This topic featured several times during the two day seminar. During this presentation, the challenges of diagnosing concussion at motorsport events was reviewed along with some of the current diagnostic tests and their limitations. Importantly, it was pointed out that concussion features can evolve over time so that a single assessment very soon after the injury event may not be enough to catch the diagnosis. The difficulties around determining return to play suitability were also highlighted.

The rest of the presentation focused on work being done on occulovestibular reaction time (OVRT) tests being used as diagnostic modalities for concussion. These tests evaluate a number of occulovestibular reactions that include:

  • Saccades
  • Smooth pursuit
  • Vergence movements
  • Occulovestibular movements
  • Optokinetic reflex

A US military trial that tracked these eye movements of mild head injured patients seated in what amounted to a wobble-chair found a high discrimination value (AUC 0.97) for the diagnosis of concussion against a gold standard (Oculomotor, Vestibular, and Reaction Time Tests in Mild Traumatic Brain Injury). The test takes just under an hour and requires fairly bulky equipment, so it is not practical to run at a motorsport event.

A subsequent similar trial was run to pre-test over 250 high school, college and professional athletes this time using headgear similar to augmented reality (AR) goggles instead of a bulky moving chair. The equipment is fairly compact and the test can be performed without specialist medical training taking about 5 minutes.

 
For instance, one of the tests consists of the goggle wearer being shown a series of white dots that appear at various positions in front of them. The person's eye movements are measured via computer tracking and the speed and accuracy with which the white dot is located is recorded. It results in objective data which is measured against a population average. Measurements falling outside a set standard deviation are deemed abnormal.

There are several appealing aspects to this strategy:
- apparent ease of performance.
- interpretation is based on objective measurements that requires little training. 
- return to play metrics built in.

It will be interesting to see the research data made available so we can assess calibration and validation. If this modality is proven to have both internal and external validity it could represent a significant advance in concussion diagnosis and management.

Here is the manufacturer's website for currently available information: Neuro Kinetics iPortal PAS


Steve's presentation was followed by a concussion panel session. It included a discussion by Dino Altman on concussion biomarkers (Read about these on an earlier Rollcage Medic post here). Newer biomakers have been studied, including GFAP and UCH-L1. A study in JAMA Neurology May 2016 looked at the dynamics of several potential concussion biomarkers in 584 subjects with mild to moderate traumatic brain injury (TBI) with respect to time to first detection, peak level, time to return to baseline and correlation with concussion symptoms and severity. This is interesting stuff, however it is probably early days still and there is a lot more work to be done before we are measuring point of care concussion biomarkers at motorsport events.

Dr. Olvey spoke about the role of in-car and in-ear accelerometer measurements in unpicking the pathophysiology of concussion and signals for its likelihood of occurrence. It appears that angular acceleration rather than linear is what matters most, something that has shown up previously. In a small sample size study looked at by Steve's group it appeared that vehicle accelerometry measurements correlate poorly with the occurrence and severity of concussion compared to in-ear accelerometry data.

Return to play was discussed as this causes significant difficulty. It was generally agreed that graduated return to play algorithms, while flawed, are probably the best strategy we have at the moment. We are still early in the exploration of brain injury biomarkers. Occulovestibular reaction time (OVRT) testing may ultimately prove useful.


One of the most useful statements of the seminar was made during this session by Peter Hutchinson when he said

“Motorsport is uniquely placed to produce high quality research in concussion and trauma generally.”


The role of cervical collars in motorsport - Panel discussion

 

This was always likely to be a fiery session. Semirigid collars have a folkloric place in the equipment packs of motorsport rescue teams. Here is a previous Rollcage Medic post on the topic: C-spine collar glory days.

Despite a shifting evidence base that has resulted in a softening of international recommendations, there is an unwillingness to change practice among some motorsport rescue groups. This reluctance is somewhat understandable given the challenges of extrapolating civilian data to a motorsport context which mixes higher speeds and deceleration forces with better safety equipment. There is additionally the conflict of high immediate visibility through spectator and media presence. So some leadership from peak bodies in the form of a systematic evidence review followed by a set of recommendations seems to be in order. This has already been done for civilian practice. Motorsport practice should be no different and not doing so risks falling out of step with current practice. And with a room full of clinical and motorsport medical experts present there should have been no reason not to.

Paul Trafford outlined a small motorsport context trial run by the FIA Institute that replicated Dixon et al's trial of methods of extrication from a car to assess cervical spine motion. Trafford's trial used goniometers placed on the skin along volunteers' spines to measure movement and similar to the Dixon trial found that self extrication resulted in the least amount of cervical spine movement. Unfortunately, the paper is not yet publicly available.

No definitive conclusion was reached at the end of this panel session and neither was there a clear commitment to develop a recommendation for motorsport practice; which is a bit disappointing given the expertise available in the room. The likelihood of a definitive trial in this area is slim, but what was encouraging here was that we were finally having this debate openly. There are sometimes conflicts between imposed recommendations trying to cover for the lowest common denominator, the fear of litigation and the daily practice of knowledgeable and experienced clinicians. It is important that whatever we decide to do that we are able to justify our clinical decisions and have the flexibility to engage in up to date and evidence influenced practice.


Doping in motorsport – Sandra Camargo

WADA regulations, therapeutic use exemption (TUE) and doping control processes were outlined. Anyone who wants to find out more about anti-doping in motorsport can paricitpate in the e-learning program at https://racetrue.fia.com


Frontal protection structures for open cockpit single seaters – Laurent Mekies

 

Laurent is an engineer and the FIA Institute (now GIMMS) Safety Director. He spoke about the selection of the Halo design over the Aeroscreen based on better performance characteristics during a tyre projectile test. While the Halo has not been confirmed as the final design it does appear likely to be.

The Halo is currently constructed from titanium, though it can also be steel or carbon fibre. It is apparently the strongest part of the entire race car and can withstand 12 tonnes of mass and 15 times the weight of the F1 car. The design intent is to deflect large objects. Smaller objects such as the spring that struck Felipe Massa will not be deflected by the Halo but the argument is that the homologated driver's helmet construction will perform this role and so the helmet and Halo together provide an integrated protection system.

This has not yet been directly tested in a full crash and the only functional assessments conducted so far have been lab-based projectile simulations on partial safety cell mock ups and a retrospective review of F1 crash videos with consideration of whether the Halo device could potentially have been beneficial (Not exactly robust science).

Some of the F1 drivers have had a chance to drive with a Halo device to get a feel for any visibility restrictions. Reportedly the F1 drivers are positive regarding visibility and egress. The acceptable self-extrication time has been extended slightly to 7 seconds. 

 
The proposed introduction dates for the Halo are 2018 for F1, Formula E and Formula 3 and 2019 for Formula 4. This is largely because the chassis needs to be reinforced to support the Halo so that it is not simply ripped away in the event of a major collision.

In the event that assisted extrication is required, a normal programmed Lear seat extrication process (https://youtu.be/uMObyoBEkWc) can occur and a rapid extrication needs a bit of dexterity due to the need to work around the Halo struts.

 


So Day 1 was interesting. At previous seminars presentations have been given largely unchallenged. Today was different as delegates robustly challenged speaker statements during question time. Resource limited situations were acknowledged and evidence based practice evolutions were highlighted in contrast to practice based on tradition and anecdote. While there were few definitive resolutions, it was evident that there are some topics at least where it is no longer felt by many to be appropriate to continue as we have without questioning whether it really reflects current best practice, at the same time recognising that motorsport is a niche pre-hospital area with difficulties in extrapolating from civilian literature.

Day 2 will be reviewed in the next post. Please leave any comments below.


References and resources

The case against extrication in motorsport: Reforming the deployment method. Sean Petherbridge and Mansoor Khan. Trauma 18(4) · April 2016. DOI: 10.1177/1460408616640804.

What is the role of video laryngoscopy in pre-hospital care? Wolfgang G Voelckel. Scand J Trauma Resusc Emerg Med. 2014; 22(Suppl 1): A6.

Video Laryngoscopy in the Prehospital Setting. Lars P. Bjoernsen, MD; Bruce Lindsay, MD. Prehospital and Disaster Medicine,  June 2009.

Oculomotor, Vestibular, and Reaction Time Tests in Mild Traumatic Brain Injury. Balaban, Hoffer et al. PLoS ONE 11(9): e0162168, September 21, 2016.

Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury. Papa, Brophy, Walsh et al. JAMA Neurol. 2016;73(5):551-560.

C Spine Collars. The Emergency Care Institute NSW. October 2016.

Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study. Mark Dixon, Joseph O'Halloran, Niamh M Cummins. Emerg Med J doi:10.1136/emermed-2013-202500.