1. Medical Services in Rallies
Cem Boneval, MD
FIA Medical Commission Member
Chief Medical Officer
F1 Turkish GP, WRC Rally of Turkey

2. Special circumstances, risk factors & definition of the problem
CONTENTS
Special circumstances, risk factors & definition of the problem
Preventive safety features
Principal elements of medical support, tasks & providers
Organization before, during & after the event
Questions & comments
If we look at the ID Pass cards or tickets of motorsport events we will see a remark in small print which says that “motorsport is dangerous”

3. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

4. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

5. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

6. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

7. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

8. Motorsport is Dangerous
Performance vehicles optimized for speed
High top speeds, cornering speeds, G forces
Slippery, rough and difficult terrain
Changing circumstances due to weather & weather related conditions: Heat exhaustion, impaired visibility in rain, snow, fog
Ambitious drivers determined to win
High adrenalin levels during competition - “superman” effect
Effect of revenues!?
Motorsport is dangerous because it is performed with very high performance cars, with top speeds exceeding 350 km/h and having under 1 kg of weight per HP

9. What to Do Make the racing environment safer Stages Race car
Driver outfit
Provide adequate/efficient medical support
Attitude (wishful thinking?):
Safety comes before performance !!!
What can be done?
We have to make the racing environment safer
We have to provide efficient medical support
But something which is of outmost importance:
We need a consciousness between teams, drivers and even spectators that safety comes before performance.
Any team will willingly spend any penny for more performance than for more safety

10. Stage safety
???
While in closed cars a roll cage protects the cockpit against deformations
Special seats with 6 point seat belts hold the driver tight and in place
Fire triggered extinguishing systems protect against fire
Telemetry is widely used in monitoring the status of the car and radio communication is possible between team, driver and race control

11. Racing car safety Roll cages Special seats 6 point seat belts
Fire extinguishing systems
Remote monitoring and telecommunications
While in closed cars a roll cage protects the cockpit against deformations
Special seats with 6 point seat belts hold the driver tight and in place
Fire triggered extinguishing systems protect against fire
Telemetry is widely used in monitoring the status of the car and radio communication is possible between team, driver and race control

12. Driver safety Fire proof outfit Helmet
Head and Neck Restraint System (HANS)
Top physical condition
The driver wears a highly effective fire proof outfit, a helmet equipped with the HANS head and neck restraint system.
And as my colleague already has mentioned they are high level athletes in top condition.

13. FACT: Despite all precautions and safety measures accidents happen with morbidity & mortality
Nevertheless despite all precautions and safety measures accidents happen.
The good thing is that we have not seen any fatality in the Formula One since Senna and Ratzenberger’s death in 1994

14. Fatal WRC Accidents

15. Medical support, on site, now!
What now?
Medical support, on site, now!

16. International Sporting Code Appendix H
Medical support guidelines are outlined in
International Sporting Code
Appendix H
 Sport  Regulations  Medical
The medical support guidelines are outlined in the FIA International Sporting Code Appendix H
Which is published on their website open to public

17. The medical support guidelines are outlined in the FIA International Sporting Code Appendix H
Which is published on their website open to public

18. The medical support guidelines are outlined in the FIA International Sporting Code Appendix H
Which is published on their website open to public

19. “Medicine in Motor Sport” – The Book Excellent Reference for Physicians

20. Medical Support - Principal Elements
Chief Medical Officer (CMO)
Approved by the ASN, under the authority of the CoC
Name must appear in the Supplementary Regulations
Responsible for the recruitment, implementation, operation and running of the medical services and evacuation.
All the medical and paramedical personnel, including those recruited by the ASN, are concerned by his decisions.
Remains at rally control in dialogue and collaboration with the CoC in the event of an accident.
It should be always possible to contact him.
The organisers are obliged to provide him with all the material and administrative means necessary for the performance of his duties.
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.

21. Medical Support - Principal Elements
Chief Medical Officer (CMO)
Before the event:
Medical Safety Plan, with the CoC and the Safety Officer.
Check all special stages well ahead of the rally, with the Safety Officer and/or the Clerk of the Course, in a car similar to the medical intervention car to establish the right position for the start and intermediate points
Ensure the viability and quality of the ambulances, the medical helicopter and fire vehicles.
Ensure that the equipment and supplies in the medical and rescue cars are in perfect working order.
He is responsible for the capacity and the quality of the hospitals designated to cover the rally.
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.

22. Medical Support - Principal Elements
Chief Medical Officer (CMO)
During the event:
Each evening he must examine all drivers and co-drivers who had an accident during the day, even if no medical intervention was necessary, to be sure that they can start the next day
After the event:
During the two weeks following the rally, he must send the FIA, for the attention of the Medical Delegate and the Medical Commission, a report on all the medical interventions on drivers, officials and spectators. This report must explain the circumstances of the incident or accident, the timing of the interventions, the initial medical status, the treatment and the medical follow-up.
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.

23. Medical Support - Principal Elements
Chief Medical Officer (CMO)
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.

24. Medical Support - Principal Elements
Clerk of the Course
Chief Medical Officer (CMO)
Chief Safety Officer
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.

25. Medical Support - Principal Elements
Clerk of the Course
Chief Medical Officer (CMO)
Chief Safety Officer
Medical Intervention Vehicle (MIV)
Extrication/
Rescue Team
Resuscitation Ambulances
Ambulance Helicopter
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.
Service Park Medical Unit

26. Medical Support - Principal Elements
Clerk of the Course
Chief Medical Officer (CMO)
Chief Safety Officer
Medical Intervention Vehicle (MIV)
Extrication/
Rescue Team
Resuscitation Ambulances
Ambulance Helicopter
What are the principal elements of medical support?
Firstly we need rapid intervention by a qualified doctor at the accident scene, which is done by the teams in the medical intervention car
If the victim is injured and/or unconscious he has to be helped out of the cockpit, which is done by a trained extrication team
Quick and safe transport is provided either by road ambulances or helicopter.
Primary or life saving therapeutic interventions can be made in the adequately equipped track medical center.
But in the end the victim has to be transported to the reference hospital for definitive treatment.
Service Park Medical Unit
Referral Hospital

27. Running of the event

28. Principal Elements of Medical Support Pre-event preparations
Drive through the stages with the safety officer
Evaluate and prepare the medical plan
Points of placement for medical cars
Efficiency of radio contact
Evacuation roads
Helicopter landing points
Porperties of terrain for selection of proper vehicles
Referral hospitals in the area
Implement the medical plan into the safety plan
Collect & train his medical team
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

29. Highly skilled driver with rally experience
Principal Elements of Medical Support Medical Intervention Vehicle/Team
Doctor and/or paramedic competent in ATLS (Advanced Trauma Life Support) and pre-hospital trauma care
Highly skilled driver with rally experience
All necessary equipment for ATLS and field intervention (App H Suppl 3)
On standby at road side at stage starts and at midpoints for stages exceeding 15 kms
Targeted approach time <10 min on rally stages
May be combined medical + rescue
Light desincarceration equipment if solely medical
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

30. Principal Elements of Medical Support Stage Setup at Rallies

31. Principal Elements of Medical Support Stage Setup at Rallies

32. Principal Elements of Medical Support Stage Setup at Rallies

33. Approach and evaluate the scene
Principal Elements of Medical Support Medical Intervention Vehicle/Team
Approach and evaluate the scene
The team is responsible for the safety of:
1st - themselves
2nd - the scene
3rd - the patient(s)
Evaluate the victim
Begin care immediately – in car if necessary
Take the victim out of the car…
CAVEAT: Spinal injuries are not rare and preventive immobilization is of outmost importance.
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

34. All elements of safety are also an obstacle for the medical team!
Nonremovable steering wheel
Position of seat vs. B pillar
Seat head support
Seat shape
Bars of the roll-cage
How shall we get the victim out?

35. Principal Elements of Medical Support Extrication
Extrication is the procedure of removing the victim from the racing vehicle
The goals of extrication are:
to remove the victim from the vehicle as rapidly as his or her condition allows
to allow care to continue
to avoid creating or aggravating injuries - mainly, but not only, to the spine
Extrication is an important step of the flow of medical care, never consider extrication to be an aim in itself!
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

36. Principal Elements of Medical Support Extrication
Types of extrication:
Emergency
Urgent/Rapid
Elective
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

37. Principal Elements of Medical Support Emergency Extrication
First choice when victim is in a life threatening situation (e.g. CP arrest or presence of fire etc)
“Take him out or let him die"
Fast manual extrication with bare hands
Mostly without any time for immobilization
Beware:
Trauma to the spine may be aggravated and the rescuer has to deal with this responsibility
Very rarely used
A quick modified Rautek maneuver may be applied if the chassis does permit it
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

38. Principal Elements of Medical Support Emergency Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

39. Principal Elements of Medical Support Emergency Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

40. Principal Elements of Medical Support Emergency Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

41. Principal Elements of Medical Support Elective Extrication
Victim is in relatively stable condition
Several options of spinal immobilization and desincarceration:
KED,
with seat,
with back of seat removed,
from the back,
from the top,
……????
The chassis may be cut clean
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

42. Principal Elements of Medical Support Elective Extrication
Kendrick’s Extrication Device
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

43. Principal Elements of Medical Support Elective Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

44. Principal Elements of Medical Support Elective Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

45. Principal Elements of Medical Support Urgent Extrication
Somewhere in between the preceeding two modalities
The victim is stable at first sight but shows rapid detoriation
Time has to be used as effective as possible:
Manual inline immobilization,
Removal of helmet & HANS,
Rapid application of a cervical collar
Take-out on a spinal board
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

46. Principal Elements of Medical Support Urgent Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

47. Principal Elements of Medical Support Urgent Extrication
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

48. Principal Elements of Medical Support Extrication
Video excerpts form FIA Extrication Training Seminar performed in Zlín with the Medical Rescue service of Zlín Region
Comprehensive Booklet available at
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

49. Principal Elements of Medical Support After Extrication
Stabilize patient(s)
Call-in ambulance (air/road)
Refer to hospital
using ambulance on evacuation roads
using helicopter
using both
Let us now look closer at the principal elements of medical support:
First we have the medical intervention team on standby at track or stage side
A doctor qualified in ATLS and pre-hospital trauma care is driven by a skilled driver to the incident site when necessary

50. Principal Elements of Medical Support Ambulances

51. Principal Elements of Medical Support Ambulances
Medically equipped to treat vital distress
Able to provide intensive care standarts during transport either by air or land.

52. Principal Elements of Medical Support Referral Hospital
Trauma Management Center
Reserved ICU Beds
Trauma Team on standby
Easy access by road/air (Heliport)
Familiar to media management protocols

53. Principal Elements of Medical Support Rally Control - WRC
Vehicle Tracking System
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

54. Principal Elements of Medical Support Rally Control - WRC
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.
Clerk of the Course
Chief Safety Officer
Chief Medical Officer
(((((((
Radio contact with all teams on the field

55. Principal Elements of Medical Support Problems & Shortcomings
Up to 10 min arrival time
Difficult terrain, delay in approach inevitable
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

56. Principal Elements of Medical Support Problems & Shortcomings
Many/long stages = Many Teams
Every team consists of only 2-3 persons (driver, doctor, paramedic)
Difficulties in management, especially during extrication
Close collaboration with rescue teams is needed – use of disincarceration equipment
Training (Accreditation of Extrication Teams?)
Coordinated extrication in cooperation w/rescue teams & Marshalls
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

57. Principal Elements of Medical Support Problems & Shortcomings
High-tech safety cars, great obstacle for intervention
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

58. Principal Elements of Medical Support Problems & Shortcomings
Recruitement
Many teams
Up to 4 days
Inadequate payment?
Liability issues
Malpractice not defined
Professional liability insurance
Who
How
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

59. Principal Elements of Medical Support Problems & Shortcomings
Coverage of crowded spectator areas
Mass casualities –colloboration with local authorities
Normal stages (spectator rally!)
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

60. Principal Elements of Medical Support Problems & Shortcomings
Consider:
Who is first at accident site?
The following rally car
Train rally teams for emergency extrication and basic life support
Basic Life Support Training for Marshalls???
A similar control room is used in WRC events. The main difference is that while direct TV monitoring is not possible every rally car has a radio transmitting signal unit which is seen on the map. Hence ID, speed, position and situation is closely monitored. Green means everything is OK, red means emergency help needed. Malfunction is not rare, so marshall confirmation is seeked for.

61. Medical Questionnaire
Universal
Medical Questionnaire

64. Thank You for Your Attention Questions? Comments?