Rollcage Medic Podcast

Feast your ears and eyes on podcast and vodcast goodness, as I pick the brains of the leading lights of the motor sport medicine and rescue community.

Some will be well known, others working in the background, but all are experts in their field with acres of experience that they are willing to share.

So tune in, turn on and absorb the goodness.

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Podcast 26 and 27 - Concussion in Sport with Prof David Hughes (AIS)

May 30, 2018

David Hughes is a sports physician. He's a professor too. And he got together with two of his colleagues, Lisa Elkington and Silvia Manzanero, to sift through the joint consensus statement on concussion in sport that went through its most recent update in Berlin in 2016 and come up with a position statement on concussion in sport for Australia. The position statement was a collaboration between the Australian Institute of Sport (AIS) and the Australian Medical Association (AMA); so this is big stuff. 

The three authors thought a bit more about it and penned an update to the AIS-AMA position statement on concussion in sport and published it in the Medical Journal of Australia in April. I read it. And I quite liked it because it not only outlined the what of concussion management but also the how and why.

This is really important because there is a lot of back and forth discussion about how to implement the various concussion management guidelines and it can often seem like only professional sports people with the backing of a full team will be able to access the resources needed to effect a safe return to competitive sport.
Not so.

In fact it is all quite achievable.

It is also good to read their acknowledgement and addressing of some of the concerns that many clinicians and clinical support professionals have about some of the diagnostic and therapeutic modalities for concussion.

So it seemed a good idea to track these authors down and put them on the podcast. I managed to get hold of Prof Hughes, in between busy lectures, clinical appointments and academic commitments.

Now go and read the 2016 joint consensus statement on concussion: 

Then go and read the update article. It's here:

Now you are ready for the podcast. Actually, it's two podcasts, as despite only tackling about three-quarters of the material, we still went for over an hour and after editing I've had to split it into two episodes for ease of downloading.

Here are the key items that we address....
1) Who makes up this expert panel that issues the joint consensus statement every couple of years? It's quite a broad range, drawn largely from contact and field sports. There's no motorsport representation, but then there is no representative for snooker either and to date we haven't generated much hard data to get ourselves invited to the party.

2) Why are we hearing more and more about concussion over the past 6 years or so? Are we unmasking it by fixing other problems or have we just admitted its presence and started to look at it properly?

3) There seems to be pathophysiological differences in the manifestation of concussion in men and women, and between adults and children. Women and children take longer to recover, but we don't know why really. This is an evolving area and management guidelines may change as more data is unearthed.

4) Not everyone needs a CT, MRI or formal clinic based neuro-psychological assessment. Thank Christ for that. Triggers to think about referral include:
  • The usual head injury red flags; e.g. Canadian Head CT Rules 
  • Prolonged symptom duration: adults > 14 days, children > 4 weeks; though this may yet evolve further.
  • Significant symptom burden
  • Consideration of a prolonged break or a career end because of concussion

5) Trackside tests like SCAT, ImPACT and K-D are good screening tests, though their results should not be used in isolation to determine the presence or absence of concussion. Clinical judgement is part of the process. Knowing the athlete (e.g. team physician) helps. Additionally, it seems that between athlete gaming, ceiling effects and a degradation in utility over only 3 to 5 days (for SCAT anyway), it is not yet recommended practice to use these tests to determine fitness to return to sport. This is interesting as this does happen around the world and it may also have impact upon some of the studies that are being run to determine the validity of a variety of diagnostic modalities.

6) There are biomarkers of brain injury. They are not yet ready for real time clinical use. They've been covered on the Rollcage Medic site here - Concussion biomarkers, the new brain troponins. There may be more up to date information now as this piece was written 4 years ago.

7) There are a handful of devices that are being developed as expertise-independant trackside diagnostic tests, most of which have little or no publicly available peer reviewed evidence to support their widespread adoption yet. I admit that I really hope the iPAS system works out. It does have some evidence behind it though this is not publicly available (personal communication with developer), however a number of its component tests have received FDA approval. The iPAS system is currently undergoing trials through IndyCar in the USA and the MSA-UK with Naomi Deakin and Peter Hutchinson. So, fingers crossed.

8) Second impact syndrome is still very controversial with strong opinions (and little hard evidence) on both sides. It may be a moot issue as David argues that if a concussion episode is managed correctly, we should never see an acute second hit because the competitor should already have been removed and be under clinical supervision.

9) Chronic traumatic encephalopathy. What a hot potato! Still. Decide for yourself about this but make sure you have appraised the available evidence. Maybe the Boston and now also Sydney-based brain bank will be able to shed some light. Here's the JAMA article with the two videos that David mentions in the podcast: Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football

10) Complete physical and cognitive rest for the immediate 24 hours after a concussion is no longer recommended. Woo hoo! Try getting anyone to comply with that bit of advice. It is now recommended that deliberate rest for 24 to 48 hours should be the aim, accepting light exertion and cognitive activity that does not worsen the concussion symptom profile. Beyond 48 hours, the evidence does not support complete rest and a graded return to full activity is the main strategy.

11) We didn't get into this in the podcast but a predominance of vestibular features appear to be associated with a more prolonged course and worse outcome and there is increasing focus on using occulo-vestibular retraining exercises in the management of concussion. The keen-eyed among you will spot that this is a key target of the King-Devick and iPAS testing systems, as well as the BESS test component of SCAT

12) What if you do need to sit an athlete down and discuss the future of their chosen professional sport? How does one approach that difficult conversation? There is no hard evidence to guide you, according to David and we are not the sports police, so we can only offer the best advice that we have. For those who do step down permanently, assistance with readjustment to life outside of professional sport will be critical. Watch this SBS panel discussion on "Life after sport": 

Here are the podcasts with David

Here's Part I - Concussion and its assessment

Here's Part II - Consequences of concussion and concussion management: 

Attribution: The intro sound clip is the opening bars from Soundgarden's track "Head injury" from their 2017 re-issued album "Ultramega OK". The outro is my own recording of a rally car starting a stage of the National Capital Rally of Canberra in NSW, Australia.

References and resources
Dario Franchitti's videos on retiring from motorsport due to concussion

Podcast 25 - Crew Resource Management in Motorsport Rescue and Safety - David Hakim

April 4, 2018

David Hakim is an anaesthetist (anesthesiologist) who lives, works and chases race cars in Canada. He gave one of the talks at last year's ICMS annual general congress in Indianapolis. The topic he chose was one that he has spent some time exploring in order to try to streamline how motorsport rescue and safety is practiced by the team that he works with. 

This exploration led him to learning more about how we think and behave in certain situations and, more importantly, what we can do about i...

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Podcast 24 - ICMS ACG 2017 Day 2

January 12, 2018

And so to the final day of the ICMS annual congress. Following on from day 1, today covered:

  • A description of the Billy Monger / Patrick Pasma Formula 4 crash at Donnington Park along with the interventions and follow up thereafter.
  • An overview of and updates to the FIA's RaceTrue anti-doping program
  • The Dan Q Marisi Lecture
  • A panel presentation on developments in occulovestibular reflex testing and its application to concussion assessment in motor sport
  • A presentation on the physical and physiolo...

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Podcast 23 - ICMS ACG 2017 Day 1 Part 2

December 30, 2017

This is the second part of a three-part series of summaries that cover the two days of the ICMS Annual General Congress in earlier in December.

The topics covered included human factors, situational awareness and race resource management, research in driver physiology and safety in powerboat racing. Vincenzo Tota wasn't able to come and present his talk on concussion attributed to rigid race seat headrests in DTM cars (you can read about this in an earlier Rollcage Medic article - ) and was re...

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Podcast 22 - ICMS Annual Congress 2017 Day 1 Part 1

December 19, 2017

At the beginning of this month I made the long trip to early winter Indianapolis (yes, it snowed) for the International Council for Motorsport Science (ICMS) Annual General Congress. This is the second time that I have attended this particular conference, the first time having been this time last year. It was good to be able to attend for a second consecutive year and good to catch up with colleagues and friends. 

As it was in 2016, the ICMS AGC was embedded within the much larger Performance ...

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Podcast 21 - Concussion in Motor Sport - A literature review

November 4, 2017

Concussion is an ongoing issue in sport. It has gained a lot of attention over the past few years in turn driving attempts to improve diagnostic and therapeutic strategies. Have a look through the “References and resources” section below for previous posts and podcasts concerning concussion on this website.

Most of the work done on sports-related concussion has occurred in field and contact sports, such as rugby, gridiron and horse events. Predictably, there is an increasing awareness of t...

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Podcast 20 - David Dalrymple and Fire - Part II

September 20, 2017
Motorsport championships are heating up. As is the approaching Australian summer. So let's crack on with the second half of the podcast that I recorded with Fire Specialist and Motorsport Rescue Technician, David Dalrymple.

In Part 2 we cover:
  • Fire suppression and extinguishing agents.
  • Standards, recommendations and regulations.
  • The NFPA 610 regulations for fire response at motorsport events.
  • David's forthcoming article on two new mask respirators for fire management safety. David's First Res...

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Podcast 19 - David Dalrymple and Fire - Part 1

September 1, 2017

The speed, the heat, the fumes .... motorsport is great!

Unless the heat and fumes are the cause of a fire and the speed refers to the rate at which the flames are spreading. Then it's really bad.

There are a lot of reasons why a fire can get going during a motorsport event, whether at the scene of a crash or somewhere in the paddock or service park. We rely on the presence of knowledgeable and experienced fire marshals to have our backs (and fronts, sides, tops and underparts), but wouldn't i...
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Podcast 18 - The competitor's perspective with Karl Reindler

July 10, 2017

What's it like to crash at over 150kph? What's it like to be crashed into? What about being engulfed in a fireball while strapped into your seat by a combination of a 6-point harness, communications wiring, ventilation and drinks tubing and a window safety net? And what is it like to have a medical response team haul you out of your broken car and start working on you right there?

If you race for long enough and push hard enough there is a statistical likelihood that this will happen at some p...

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Podcast 17 - Naomi Deakin and Research in Motorsport Medicine

May 20, 2017

Naomi Deakin is a trauma fellow pursuing a PhD in England. No strange thing amongst doctors who are trying to carve out a place and career for themselves. Except that few choose motorsport medicine as an area to chase down that higher qualification. And yet why not? It's a fertile area full of possible aspects to explore.

Yet if you go looking for clinical advancement topics in motorsport your search will not take too long. There's just not that much too be found. This is odd for a profession ...
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