The Christmas and New Year holidays are over and having spent some enjoyable time with the family poncing about, it's time to get back to work. Here is my summary of Day 2 of the FIA Institute Medicine in Motorsport CMO seminar held as part of the FIA AGA in Vienna at the beginning of December.

The first half of the day was composed of an opening speech by Jean Todt (which I missed) and four workshops. After lunch there were five free papers presented followed by the closing speech. After a somewhat lively first day it seemed that delegates arrived to the second day with their discrepancy-radars turned up to 11. Good job too.

The morning workshops

These are presented in the order in which the group that I was in was allocated to attend.

Halo-equipped open cockpit extrication workshop

First up was the chance to get our hands on and heads around the proposed Halo frontal impact protection device for open cockpit race cars. The expectation is that whatever device is finally selected (though it will most likely be the Halo) it will be introduced into Formula 1, Formula E and Formula 3 in 2018 and Formula 4 in 2019 once the requisite chassis reinforcements are in place.




While the workshop used only the FIA open cockpit training tub with a Halo bolted on, it was quite useful to sit in the car and get a feel for the driver's perspective, even though the dimensions of the 2018 car will probably be a bit different. It was also useful to see a programmed and rapid extrication demonstrated by the Austrian Red Bull Ring rescue response team.

Programmed extrication took 3min 25s from "Go" to placement on the Vacuum Mattress .
Rapid extrication took 35s.


Afterwards I had a chat with the Red Bull Ring rescue team doctor for a perspective on the challenges of working around the Halo device. He admitted that it was tricky to get used to. Most of the extrication team were able to work around the Halo structure to access clips and hook points for both the programmed and rapid extrication. However, maintaining manual in line stabilisation (MILS) of the driver's neck meant either:
  1. Reaching between the Halo struts below the hoop for direct access but then having to change around when it came to lifting the driver out, or,
  2. Reaching down through the Halo loop from above to apply MILS either by manufacturing a new joint in his own forearms or grasping the lower edge of the helmet with his hands and getting his fingertips along the driver's jaw.

Neither was perfect, but even after a few weeks of practice, this was the best that he could do within the physical limits of the Halo.

An additional issue that he identified was trying to maintain some form of MILS during rapid extrication without getting tangled up in the Halo elements when it came to lifting the driver out and transferring him to the ground beside the car. Clearly these will be issues for the various response teams at circuits around the globe to troubleshoot, unless the FIA find a solution between now and then.

I also had a chat with FIA Institute (now Global Institute) safety director, Laurent Mekies, about the Halo. It 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.

As a safety measure a test of cutting the Halo struts with a battery-driven Holmatro GCU 5050 EVO which has a maximum working pressure of 720bar, 72MPa or 10443psi. The left rear hoop strut took 5 seconds to cut through (The cutting tool operator admits to being a bit nervous about how the strut would react and so was cautious for the first cut) while the right rear and front struts took 2 seconds each.

More important to be aware of than the time taken to cut is that the titanium strut is not actually cut but compressed to a point that it fractures. This has two implications. First, there is a loud bang when the material integrity gives way and fractures, which in the context of a motorsport rescue could be suddenly very distracting. Secondly, given the strength of the titanium struts, should the safety cell be bent out of shape there is a potential for load release upon cutting the strut resulting in a chassis element springing and injuring the driver or the rescuer. This has not yet been tested.

An additional item that was noted was the redesign of the Lear seat base. The crotch strap clasps almost always get caught up in the central hole between the driver's legs. Now there are two larger holes at either side for the straps.


Cross country rally competitor survival pack workshop

This was a workshop provided by recently appointed FIA medical and rescue equipment provider MDD. The concept was laudable, that of the provision of a lightweight, compact, easily stored pack that could be opened in the event of a crash during a long distance cross country (Dakar-style) rally which would provide the essential tools for the stricken competitors to look after themselves for the subsequent 3 to 6 hours until assistance arrives.


Unfortunately the workshop did not come across terribly well. The contents have not been finalised and the presenter asked for delegates to write down suggestions for additional or better equipment, which sort of came across as a market research session. It turns out that the packs won't be provided as such, but may cost in the region of EU200-300 (again, this is uncertain given that the contents are not yet agreed upon).

Some of the issues raised about the current contents included:
  • The medical gloves are latex, allergy to which is a problem for a lot of people
  • The compass as provided didn't work. There is no map provided with the compass. Most competitors will have a mobile and GPS device, though battery life and signal strength were acknowledged issues.
  • A mirror was provided in the pack to signal with. Not so useful at night and there are at least two and up to four already available depending on the vehicle (bike, quad, car, truck).
  • There were two gel burns dressings in the pack which, based on the packaging, would have been enough to cover a 2% BSA burn.
  • A numbered medication pack that competitors could be given advice over the phone or radio to take based on reported symptoms - "Open pot 2 and swallow the contents." A lot of people felt uncomfortable with this approach.

Quite apart from the contents, it was also pointed out that any equipment provided to competitors would need to be accompanied with the requisite training; especially for items such as the resus tourniquet and the haemostatic dressing.


Doping in motorsport workshop

This was the only workshop not presented by doctors and was actually quite useful. Sandra Camargo and Magali Louis led a two case based discussion on the reporting responsibilities and sources of conflicts of interest of team doctors and event CMOs. There was no particular new info but it provoked lively discussion.



For more FIA information on doping in motorsport check out these two web pages:

 
Airway management workshop

Disappointingly, this was very basic. Practitioners who's day to day job included airway management on a regular basis gained little and those who's regular job did not include airway management were unlikely to have learned a skill that could be maintained between the point of learning and having to perform it for real.

The workshop was also held out of context, in a pleasant, quiet, cosy palace room on a few tables lined along one wall. Perhaps this session would have benefited from some in-situ simulation. Even better might have been a simulated incident during which trackside and race control decision making could have been appraised and improved rather than the technical skill of intubation, especially as this was billed as a CMO Seminar, most of whom work from race control rather than trackside at the higher level events.


The afternoon Free Papers session


Simulator training in motorsport medicine


Presented by German Airforce Tornado pilot and air crash investigator Fabian Berger, this was one of my favourite presentations of the conference. So much so that I cornered him for a podcast afterwards, which you can listen to here:

Podcast 15 - Fabian Berger, tornado jets and human factors training

Human factors and Crew Resource Management awareness and training have been popular topics in critical care circles in recent years and have been themed presentations and workshops at medical conferences. There is a bunch of good material on this topic:


 


Fabian spoke about how he took his training and experience in aviation to the DMSB and started a Race Resource Management and Simulation program for the rescue response teams. He used in-situ simulation with audio and video recording of the performance to facilitate constructive debriefing. This is repeated periodically to reinforce learning points and, importantly, crew member relationships.




Unfortunately the equipment used is quite expensive (approximately EU10,000), though there are cheaper ways to achieve these aims.

 
This model of training has been evolving in hospital and pre-hospital based trainee programs and has similar applicability to motorsport response team training. Some of the advantages of this could be the provision of standardised training format and content, which in turn may facilitate cross-recognition of regional, national and perhaps even international certification. It may even enhance recruitment and retention. 

Of note, this topic was also presented at the ICMS annual congress in Indianapolis a week later by Las Vegas Speedway assistant medical director Dr Tressa Naik during her talk on team dynamics.


Medical and safety issues for historic racing

Essentially a summary of motorsport regulations as they apply to historic racing by Theo Voukidis.
Nothing new.


Percutaneous vertebroplasty for compression fractures without SCI

This was a presentation by Bruno Franceschini on a 20 year experience of this procedure in motorsport competitors. It is employed for ongoing pain that interferes with driving, facilitating a faster return to training (as early as 3 days) and to competition (2-3 weeks). Some genuine experts in the room felt this is too soon and that while the surgical recovery may be fast the structural integrity may not have fully settled, but acknowledged that individual experience may vary.


No significant complications were reported to have occurred, such as cement embolism, nerve impingement or allergy.

While interesting, this was quite a niche topic. This is not a published paper at this stage.


Monoccular risk

Bahram Bogdaghi presented a small unpublished pilot study of simulated monoccular deficit and demonstrated a 1.8 to 3 times greater risk of accident. Greater risk occurred when approaching a lead car compared to being overtaken from behind. And there was a delayed reaction time.



However, there was one fairly significant limitation to this trial, amongst several lesser ones. Healthy binoccular drivers were studied and monoccular vision was simulated by placing a piece of card or a patch over one eye; ie simulated monoccularity rather than actual monoccular competitors. Chronic monoccularity is associated with adaptation over time to compensate for loss of stereoscopic vision, so the true accident rate may actually be lower.

The set up was not tested for an open cockpit with the Halo protection structure. Whether this matters or not will be determined by the filtering down of the Halo from F1, F-E, F3 and F4 to categories that could include monoccular drivers.


Headrest impact causing concussion

I liked this paper. It raised a potentially important question.

Presented by Vincenzo Tota, who is the Audi Sport medical doctor, he talked about how his position gave him close relationships with the team drivers and how several had brought up an issue of their heads repeatedly hitting against the headrests of the seat, albeit while wearing a helmet. Some had mentioned symptoms that struck Tota as suggestive of concussion.


Luckily, cameras had been installed inside the cars facing the drivers and being a closed cockpit format they tended to leave their helmet visors at least partially open. He also had access to the car telemetry through one of the team engineers. When they reviewed the video footage of one of the prominent drivers, following a corner kerb strike the driver was noted to close his eyes and appear unresponsive for 1.5 seconds!! That's massive given the speeds and the distance travelled that it translates to.

So he then performed a similar review of a crash incident in which the car left the track crossed a gravel trap and had a moderate 45degree impact with the tyre wall. On the video playback there was no loss of consiousness for the driver. There were also no abnormal findings on examination at scene by an experienced medic, nor subsequently in the medical centre. However, later on Vincenzo noted a short term memory deficit on repeated questioning, suggesting a concussion event. Two MRIs were normal, on Day 1 and Day 28.

Vincenzo and the engineer postulated that repeated head impacts with an overly rigid carbon fibre headrest during racing was possibly causing a concussive injury. So they collaborated with design engineers to modify the headrest design and structure, ultimately testing a Nomex cover versus kevlar cover with a reconfigured CONFOR foam composition headrest in a lab test. The results demonstrated the same peak G but a slower time in milliseconds to achieve the peak with the Nomex cover.

Now this is hardly rigorous science, but it raised some very interesting ideas and possibilities. It would seem that the occurrence of repeated micro-concussion events during a racing season may need to be looked at properly and if demonstrated to be a genuine entity then strategies to mitigate it will need to be explored.

What I particularly took from this case study was the:

  • Value of team doctor relationship with competitors
  • Value of collaboration between medics and engineers to identify, characterise and solve a problem
  • Value of being able to access competitor and vehicle telemetry data and link it to in-car video playback.


And that brought to an end the 2016 FIA Institute CMO Seminar. It was encouraging to see an audience that demanded evidence for statements and recommendations and who questioned opinons and dictums. This is how we will advance the way that we practice and avoid falling behind the rest of the critical care and prehospital community.


Yes, motorsport has a specific cohort of patients with different characteristics to the general public. The same can be said of military medicine or extreme environment and wilderness medicine, yet they are proactive in conducting research to better serve their populations. So let's challenge dogma and tradition and maybe in two years time we will see a progressive, enthusiastic seminar that can lead motorsport medical and rescue practice. It is worth once more quoting Peter Hutchinson:
 
"Motorsport is uniquely placed to produce high quality research in concussion and trauma generally"