Editor's Note: As this article neared completion, a significant change occurred in open wheel racing in the United States. On February 22, 2008, The Champ Car World Series ceased operations and merged with the Indy Racing League (IRL). Due to this merger, The Champ Car World Series medical safety team described in this article was eliminated. Although this model does not currently exist, we feel that the model presented provides valuable information for our readers.
Motorsports is one of the largest amateur and professional sports in developed nations, and each year many participants die or are seriously injured. In addition, drivers and support personnel are subject to personal injury or illness not related to on-track incidents. Access to consistent medical care can be difficult if there is not a well-planned medical program with experienced staff available. Discussed here is how medical care is provided by the Champ Car World Series, a U.S.-based open wheel racing series where competition is held on both street and open terrain courses.
The Champ Car World Series supports its drivers, crewmembers, and support staff with a unique onsite medical program. At each event, a highly trained and experienced staff of physicians, nurses, athletic trainers, and rescue personnel provide medical care to anyone associated with the series. A special emphasis is placed on driver extrication, stabilization, and treatment after an incident on track. Currently, events are held in the United States, Canada, Mexico, Europe, and Australia. At this time there is no other racing series in the world that incorporates such a comprehensive medical and safety program.
Grange and Cotton (1) published an excellent article in 2005 that summarizes why a specialized medical program is so important in motorsports and some of the background regarding planning for events. The purpose of this article is to relate specifically how medical care is delivered by the Champ Car World Series.
Champ Car was previously known as Championship Auto Racing Teams (CART), founded in 1979. In 2003, the series was purchased by new owners and renamed The Champ Car World Series. Although several chassis and engine configurations have been used in the past, current Champ Cars are single-seat, open wheel cars using a carbon fiber Panoz DP01 chassis. Power is supplied by Cosworth turbocharged 2.65 L V8s capable of producing approximately 800 horsepower on methanol fuel. As configured, speeds approaching 195 MPH are attainable on current racing circuits. Currently, Champ Car does not race on high-speed oval courses.
Champ Car also sanctions the Mazda Atlantics Series, which serves as the driver development series for Champ Car. Carbon fiber, single-seat chassis are used and constructed by Swift Engineering. Power is supplied by Mazda MZR 2.3-L, four-cylinder, non-turbocharged engines engineered by Cosworth. Using racing gasoline, these cars are capable of reaching speeds up to 175 MPH.
Race events are typically 3 d in duration. Practice and qualifying occur on Friday and Saturday, with the race on Sunday. Events are run in dry or wet weather, but activities will be suspended if there is standing water on the track or lightning in the area.
In 1979, Steve Olvey, M.D., then the medical director for the United States Auto Club (USAC) was asked by team owners to oversee the medical care provided by a new racing series known as CART, sanctioned by USAC. Initially he and Dr. Edwards provided onsite medical care at each event using a local ambulance in addition to medical equipment they personally brought to each race. Consistent onsite medical care was found to improve driver outcome after crashes, and paddock efficiency increased by treating support staff illness and injury onsite. Therefore, in 1985 a specially equipped ambulance was constructed, which served as the first series medical center. Future generations included a highly customized fifth wheel trailer and large bus-type motor home. In 1996, a uniquely designed and custom-built semi-trailer was put into service and serves as the current Champ Car Medical Center.
Consistent on-track rescue and stabilization was also identified as critically important. In 1984, the CART Safety Team was formed, consisting of firefighter/paramedics that traveled to each event. Through the use of training, unique extrication techniques, experience, and specialized vehicles, driver outcome after incidents was maximized and on-scene time was reduced. The CART Safety Team became the first in the world to incorporate physician presence with the first responders at every serious on-track incident. Average response time was less than 30 sec on high-speed ovals and less than 60 sec on road courses.
Medical care at each event is provided by two physicians, one nurse, one athletic trainer, and 13 safety team members. All are required to be actively practicing and properly licensed in their respective professions. Currently, physicians are board-certified in either emergency medicine or general surgery. All nurses are actively engaged in emergency or critical care nursing. Athletic trainers have all been involved in top-level sports, including the National Football League, National Hockey League, NASCAR, or the American Lemans Series. Each safety team member is a firefighter/paramedic. A medical center coordinator is responsible for the day to day operation of the medical unit and transporting it to events. Each member of the medical staff has had an average of 15 yr experience with the series. Safety team members have an average of 10 yr.
At the center of on-site medical care is the Champ Car Medical Center, a specialty-built, climate-controlled Freightliner semi-trailer completed in 1995 (Fig. 1). By incorporating double slide-out sides, a total of 850 square feet of space is available for use (Fig. 2). The unit is divided into three main areas: a minor treatment area, major treatment area, and an athletic training area (Figs. 3-5). Two patients can be treated in each area simultaneously. In the front of the unit, there is a reception/office area that serves as the communication center for the medical center. Several TV monitors are available with direct track video feed in order to view any incident from different angles.
Equipment in the medical center is similar to that which can be found in most emergency departments. Two Hill Rom power columns with oxygen, air, and suction outlets are mounted in the center of the unit. Cardiac monitoring is provided by two Zoll Critical Care Transport monitor/defibrillators with 12 lead EKG capabilities. Available airway control measures items include oral airways, ET tubes, King Tubes, combitubes, LMAs, and cricothyrotomy kits. Resuscitation supplies include complete advanced cardiac life support medications, chest tubes, central lines, and a thoracotomy tray. Adequate sized equipment is available to care for newborn through adult patients. Two Hill Rom General Procedure Stretchers are utilized for patient placement in the critical care area.
Approximately 90 medications are stocked in the inventory, enabling the medical staff to treat most conditions that may be encountered. Included are cough and cold preparations, non steroidal anti-inflammatory drugs, antihypertensives, antiemetics, antidiarrheals, antacids, antivirals, steroids, dermatological preparations, antibiotics, local anesthetics, otics, ophthalmics, anxiolytics, vasopressors, and neuromuscular blockers. Controlled substances include opiate pain medication and benzodiazepines. Propofol is available for conscious sedation. If a medication is needed that is not stocked, most may be obtained from a track-sponsored medical center, local pharmacy, or hospital by prescription.
Due to weight and space limitations, the medical unit does not have a dedicated x-ray suite or computed tomography (CT) scanner. Since most orthopedic injuries seen are in the peripheral small bones and joints, a small Xi-Scan C-arm is used for imaging those areas. Printouts of obtained image are available to send with the patient. If injury to a long bone, spine, pelvis, or intracranial injury is suspected, transport to an appropriate facility is warranted.
Miscellaneous items available include suture supplies, splints, casting material, crutches, bandages, IV fluids and supplies, syringes, Dermabond, nasal packing, cautery, surgical scrub, gloves, masks, gowns, biohazard disposal containers, specialty tape, ace wraps, and various supplies used by the athletic trainers.
The Champ Car safety vehicles are highly modified Mazda MX 6 sport utility vehicles. All carry communication radios, fire suppression equipment, extrication tools, airway management supplies, an automatic external defibrillator, track cleanup supplies, and towing hardware. Two are staffed with four firefighter paramedics; one has three firefighter/paramedics and one physician. Additionally, a two member Pit Safety crew uses a highly modified Club Car Carryall to provide emergency services for any pit incidents.
To provide on site medical care at such a wide variety of events in multiple countries, considerable preplanning is necessary. Beginning immediately after the conclusion of a racing season, advanced planning for the following year begins. The first task is obtaining a firm race schedule and creating a roster of personnel to staff each event. Currently, all events are staffed by two physicians, one nurse, and one athletic trainer. The only exceptions are open tests that are staffed by one physician, one nurse and eight Safety Team members.
All medication use for the previous year is reviewed, and all currently stocked medications are discarded. Because the medical center is frequently subjected to temperature extremes, medications are likely exposed to temperatures outside of the recommended range; therefore, yearly replacement is mandatory. Based on the medication review, a new medication list is created incorporating any changes deemed necessary by the medical director. A similar review also is conducted for all supplies. Once complete, the updated lists are submitted to the pharmacy, central supply, and sterile processing departments at Methodist Hospital in Indianapolis where replacement items are purchased. Delivery of the new stock is immediately prior to the first pre-season open test session the following year. Resupply is based upon usage and occurs as needed throughout the season.
Attention is then turned to pre-event planning. Champ Car is unique in worldwide motorsports as it is the only series in the world that brings a complete safety team, medical staff, and medical center to every event. Other series have variations, but none are as comprehensive. For example, the American LeMans Series brings a Safety Team, one physician, and staffs a small medical trailer at times for minor medical issues. The Indy Racing League brings a safety team, physicians, and nurses, but no medical center. NASCAR has a traveling nurse but uses primarily track-supplied rescue and medical services. Formula One has a chief medical officer but uses track-supplied medical and rescue personnel.
Because Champ Car brings such a comprehensive system to each event, extensive communication is necessary in order to integrate our program into established safety and medical programs at each venue. This is accomplished by having a personal relationship with the local medical director and local medical personnel. Even though Champ Car medical and safety teams provide comprehensive onsite care, significant onsite and all offsite care must come from local medical personnel. The Champ Car Director of Medical Affairs works closely with local medical directors so a coordinated team approach is in place to maximize access through resolution of medical issues.
Pre-event planning for established events with adequate medical support require little more than phone contact prior to an event to assure there are no significant changes in the onsite or local medical system. Event disaster plans are reviewed yearly. Newer events will frequently need minor changes based on the previous year's experience. Examples may include positioning of the medical center or ambulances and receiving hospital changes. Domestically, as emergency departments become busier and overcrowded, designation of a single receiving institution has become increasingly difficult. In some cities, several hospitals are designated as receiving hospitals. The particular one chosen will depend upon medical need and institutional volume at time of system access.
International events present unique challenges. These may include language barriers, licensing issues, cultural differences, communication difficulties, equipment and supply transportation, and payment for services used at local hospitals. An onsite visit is compulsory for any event outside the United States, Canada, or Mexico to address each issue. Formal presentations are made that explain our medical and safety programs and how local personnel and equipment will be used. With the circuit medical director present, the local receiving hospital is inspected, and transport time from the circuit to hospital is documented. Services such as magnetic resonance imaging that frequently are not routinely available on weekends will be specially arranged. Particularly important is assuring that English-speaking personnel are available at all times in each rescue vehicle, ambulance, and in the medical center in non-English speaking countries.
Transporting the Champ Car Medical Center overseas is not practical; therefore, an equivalent facility is required on-site. Venues at permanent terrain courses usually have a permanent on-site medical facility. In the event one is not available or not acceptable due to location, a temporary medical center is required. Usually a large mobile office trailer will suffice when properly equipped. Because of preplanning and a highly detailed list of requirements, the Champ Car medical staff is able to bring a minimal amount of supplies and function normally at events overseas.
Events are typically scheduled Friday through Sunday. The medical center coordinator assures that the medical center arrives and is set up by Thursday afternoon. Set-up takes 1 d and involves parking the unit, extending the slide-out sides, connecting telephones, cable, water, and electricity, interior set-up, and pre-event cleaning. Operations begin on Friday morning 1 hr before the first and ends 1 hr after the last on-track activity. All Champ Car-credentialed personnel may be seen for any medical issues, event-related or not. There is no charge for any service obtained at the medical center.
During any on-track activity, one physician rides in a safety team vehicle and is dressed in a standard three-layer nomex fire suit. The physician's main responsibility is attending to a driver after an incident and determining what, if any, medical intervention is needed. Upon arrival to the scene and after determining that the scene is safe, the physician typically straddles the front of the car to have direct access to the driver's face. Airway patency and level of consciousness are assessed first, followed by a brief physical assessment. At times, initial assessment can be difficult due to car position, driver position in the car, and outside ambient noise. Any necessary airway control or other medical intervention will be performed on-scene immediately as needed.
Next, a driver code is communicated to race control to inform them of the seriousness of the situation. In Champ Car, codes are used as follows: Code 1: no injury, Code 2: unclear injury, need more time to assess, Code 3: injury, not life threatening, Code 5: severe injury including loss of consciousness, Code 10: death. If an ambulance will be needed for transport, the closest one is dispatched to the scene.
Once a driver exits or is removed from the car, a driver disposition is made. Options include release from the scene, transport to medical center via ambulance without spine precautions, transport to medical center after extrication from car using spine precautions, and finally extrication with direct transport from the scene to the hospital via ground ambulance or air. This sometimes is the most difficult determination because symptoms on the scene may be vague, transient, or tainted by driver anger or adrenaline surge during the incident. If the physician determines there is a reasonable risk of significant injury, transport to the medical center is mandated. All decisions are made exclusively by the on-track physician, and drivers must comply with that decision.
Most injured drivers can be managed onsite by the Champ Car medical staff. After a driver is transported to the medical center, a detailed physical exam is performed with specific attention to recurring injuries specific to Champ Car. Although infrequent, the most common injuries are concussions, compression fractures of the spine, contusions, and injuries to the hands and wrists. Significant intrathoracic or intraabdominal injuries are rare and have not occurred in over 15 yr. Any driver who experiences a significant concussion or is thought to be at risk for spine injury is transferred to the local receiving institution for further evaluation. Any further stabilization required will be performed before transport.
Once the decision is made to transport offsite, either ground ambulances or helicopters may be used, depending upon severity of condition and local logistics. At time of transport, all ongoing medical care is transferred to local personnel. Before each transfer is made, contact with a physician at the receiving hospital is made to relay proper information regarding an incident, medical condition, and injury pattern information associated with the series. The race medical director also becomes involved to assist in communications locally. Although the proceeding references driver management, transfer of any Champ Car personnel from the medical center would occur in a similar fashion.
Follow-up assistance is provided as needed. Depending on the injury or illness, follow-up is arranged via the medical center, specialist, or personal physician. If an extended hospital admission is needed, the Champ Car Director of Medical Affairs maintains frequent contact with physicians, family, and officials to ensure proper communication and coordination of care. Continued involvement is continued should any rehabilitation services be necessary after discharge from an acute care institution. In the case of driver injury, return to competition may occur only after approval by the Champ Car medical director.
The Champ Car World Series provides the most comprehensive safety and medical system available in motorsports. This article gives a brief overview of how medical care was delivered at one of the top-level racing series in the United States.