The Motorsport Medicine and Rescue Mastery Podcast - Season 1, Episode 4

Initial Assessment and Communication



Everything is going smoothly so far and you're at the side of the crashed race car looking at the driver. The race has been brought under the control, nothing is burning and the car's electrics have been disabled. The focus is now largely on the clinical needs of the potentially injured competitor and there are several parts that go into the next few decisions that need to be made.

This section will be about general principles. Specific clinical conditions will be covered in later articles and podcasts.

Setting the tempo early on


The tempo of the rescue is often set during the first few seconds of the competitor evaluation. A competitor found to be unconscious would focus the extrication specialists on creating the fastest access possible with additional resources being deployed to the scene, while an uninjured conscious competitor with only minor complaints may result in a de-escalation in the incident response and trigger the track to begin preparations to return to racing as soon as possible. Answering several critical questions can help to set the appropriate tempo for the first few minutes.

  1. Does the competitor have an immediately detectable life threatening injury for which there is immediate management available?

  2. Is it likely that the competitor has a time critical injury that is not immediately detectable however could cause death or significant harm if it is not addressed immediately?

  3. What additional clinical and rescue needs will the competitor have during the extrication from the vehicle and evacuation to a more appropriate care location and are the currently on scene assets sufficient to provide them? (i.e. track medical centre, trauma centre, local hospital)?

  4. What information needs to be provided to the other phases of the rescue to allow them to complete their goals? (Information to the extrication specialists, track management, care facilities, security, etc. Usually communicated either directly to personnel on site or via race control).


There is usually a degree of pressure to get back to racing as soon as possible. While this is a practical issue, the clinical needs of the patient take precedence and working with the race director and clerk of course is always better than working against them. Fostering a good relationship helps with this, which is easier if you have time prior to the event.

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Example of the “Rescue Ballet” at a closed cockpit circuit event

  • The vehicle had hit the barrier at the end of the fastest section of the track.

  • Race control advised that the vehicle had taken a hard impact with significant damage and an engine on fire.

  • First on scene rescue teams began extinguishing the fire and evaluated that the driver was trapped and unconscious but breathing.

  • The MIV arrived on scene and a doctor was deployed to the vehicle to treat the driver.

  • Immediately on entering the vehicle the fire scene commander moved within hearing distance of the doctor.

  • The extrication team chief, already close to the scene commander, asked if roof should be removed from the vehicle.

  • The doctor heard this question and advised the scene commander the driver was still unconscious.

  • In training it had been decided that in this situation the roof would be removed from the vehicle and the competitor would be lifted out. The scene commander told the extrication chief to remove the roof.

  • At the same time the doctor had advised race control that the driver was “Code 1” – the track code for an unconscious but breathing competitor. This caused the on-scene helicopter to power up and prepare for launch.

  • The driver was cut out of the vehicle and lifted to the responding ambulance. He was transferred to the helicopter and evacuated to the local trauma center.

Total time of incident from impact until helicopter departure from the scene – 4 minutes 31 seconds

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Priority-based minimum necessary intervention

From a clinical perspective the objective of a medical track response is to minimise the time used to effect a safe transfer to definitive care that will result in a meaningful outcome for the patient. This is not a stay-and-play versus load-and-go dichotomy. Rather it means forming a rapid prioritisation of clinical, rescue and logistic needs against the resources that can be made available.


Needs-Resources balance


A critical part of this is determining how much needs to be done on scene or during transport in order to create the best chance of delivering a live patient to definitive care who is likely to survive ongoing interventions.



Efficient on-scene communication

Communication becomes critical in this situation, particularly at a remote incident such as during a rally or off-road event. The intervention vehicle is limited by space and weight as to what it can carry so the sooner you can get what you need the better the likely outcome for the patient. Using a code system can efficiently transmit your needs to race control who can then act on this information. This provides everyone with the information in a clear and concise fashion where there is no room for doubt on what has occurred.

Suggested code system (but not prescriptive):

With any of the first three codes it is worth explicitly stating additional needs with regards to extrication and ambulance assistance.

“Driver is Code 3, request Echo assistance and will need Alpha on scene for transport.”

(Echo = extrication. Alpha = ambulance)


Determining a priority code

So how is a code determined?

For that we can fall back on a primary survey as employed by ATLS (https://www.facs.org/quality-programs/trauma/atls/about), EMST (https://www.surgeons.org/education/skills-training-courses/early-management-of-severe-trauma-emst), ETM (https://etmcourse.com/) or TCCC (https://www.naemt.org/education/naemt-tccc).


As a rough guide, anything that would require primary survey intervention within the next few minutes to prevent loss of life would qualify as a Code 1. Equally, a competitor who is unconscious and not responding (the current BLS trigger – https://www.ilcor.org/publications/publications/) would also be a Code 1.

If the injury is significant but you figure that there is enough time to conduct a controlled move of the patient from their vehicle to the ambulance, then it's probably a Code 2, but watch for deterioration and be prepared to upgrade the code if necessary. If intervention is not life, limb or sight saving or an injury is suspected but not yet proven then it's a Code 3.

If you have assessed that there is a serious injury that requires intervention, as a clinician it can be difficult to resist diving straight in. However getting some extra help to the scene may pay off, particularly at events like rally and off-road where the cavalry may be a significant distance away. So communicating your needs to race control early and efficiently gets those resources mobilised to you.

Often there is a separate and clearly different code for a driver death. However, there are several reasons why the choice to transport the person off site before declaring death, though it may not always be possible to do so. The main reason to defer declaring a death on scene is respect for the person's family as news tends to get out very quickly and in an uncontrolled way which can be devastating.


The self extricated competitor

Not infrequently, the driver will have self extricated. And most will know enough to get behind a barrier so that they are safe from other cars ending up where their car is; so you might have to chase them down there or after the race to do an assessment. Do not assume that if they are walking away, that they are uninjured. A lot of competitors will be looking at the damage and wondering how much it will cost them or how mad the team manager will be at them. Additionally, the adrenalin effect may not yet have worn off, particularly at circuits where the responsding team is on site within seconds. However you still need to make a clinical assessment.

Get face to face and ask them to remove their helmet and balaclava, if not already done. Any interaction is helpful in making a mental state/concussion assessment. Just ask them for 30 second of their time. Some will not be happy to see you but this is usually not personal. Have them squeeze your fingers, palpate their chest, spine, abdomen and limbs, even while standing. Screen for concussion if you can. They should be able to focus for you at least for a short while during your assessment and even get in some motorsport-modified Maddock's questions. While this is not a definitive examination it may give you enough of a feel to want to conduct a more formal assessment.


Modified Maddock's Questions for motorsport
(From the Motorsport Australia Concussion Guidelines, Feb 2020)


Even if they won't hang around, look at how they are walking or standing. Is their gait steady? Are they limping? If you have concerns, alert race control who can often contact the competitor through their team.

If you are satisfied, try to get them into a vehicle (preferably your MIV) which will return them to their pit or paddock via the circuit medical centre. If you are not sure about their ability to drive for whatever reason, send them to the care centre with someone who knows about the trackside assessment (This will help guide the medical personnel in the med centre).


Summary

The general aim of the first contact assessment is to rapidly determine the clinical, extrication and logistical priorities, set the tempo and to communicate a code to race control within a minute or two of arriving at the scene. This will give everyone who needs to know a fair picture of what resources need to be mobilised and what logistical elements are likely to play out over the next few minutes.


Assess-Intervention-Communication cycle


Following the initial code, it is good practice to reassess and update the on scene response crews and race control every five minutes or so along with an estimate of how much longer you anticipate you'll be on scene. In the meantime, race control, via the event chief medical officer or the emergency co-ordinator, should be keeping the radio communications to the minimum necessary, controlling race proceedings, clearing any access needed for emergency service access and egress and alerting either the medical centre or receiving hospital as needed.

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