Reality Training: Does this IndyCar driver need a backboard?

Spinal immobilization is based on exam findings and patient complaints, not the mechanism of injury


Incident Date: May 13, 2015

Department: Indianapolis Motor Speedway EMS professionals and Track Safety Crew

What happened: During practice laps at the Indianapolis Motor Speedway IndyCar driver Helio Castroneves goes airborne.

Watch the video of the car flipping upside down in the air, bouncing hard on the asphalt, and then landing upright. The video shows the crash from several different angles, including two on-board cameras.

Discussion: Is spinal immobilization indicated?

There is no doubt that this was a blunt force trauma mechanism, but is there evidence of spinal injury? Castroneves, like many vehicle drivers that have been in a collision, walked away from the crash.

As you watch the video ask yourself or discuss with your partner, company, or squad the criteria for use of a cervical collar and long spine board based on either your local protocols or the Marion County (Ind.) Advanced and Basic Life Support protocol:

EMS response in and around the track is managed by several agencies and this specific protocol may not apply to a driver on the race track surface. “Indianapolis EMS is responsible for anything outside of the track gates/fences and supports interior operations as needed/requested. A private service handles all calls inside the track for medical and traumatic injury needs, excepting the track surface and drivers. The track surface itself, including drivers is handled by another layer of EMS professionals and Physicians.”[1]

The Marion County protocol for EMS Out-of-Hospital Spinal Clearing/Immobilization[2], and many like it, starts with “Spinal immobilization is to be provided to blunt trauma patients only if significant evidence of spinal injury exists.”

A cervical collar is indicated if the patient has any of the following:

  • Presence of midline bony tenderness of c-spine to palpation or with movement
  • Focal neurologic deficit present or reported
  • Age <8 or >65
  • Intoxication
  • Distracting injury present
  • High risk injury/mechanism of injury or medic discretion

Palpation for midline bony tenderness was either not performed or not shown in the video. We also have no knowledge of Castroneves, 40, reporting neurological deficit. There is no reason to believe or suspect he was intoxicated. No other injuries are shown or reported.

The most interesting criteria for discussion is the “high risk injury/mechanism of injury or medic discretion.” An aerial flip and upside down landing is arguably a high risk mechanism and suspicion of injury is warranted, even though, an IndyCar  is designed with multiple features to protect the driver from the forces of the collision. What is your judgement or discretion? What are the implications of applying a cervical collar and backboard to this otherwise healthy patient and transporting him to a hospital?

The protocol continues with criteria for immobilization of a patient with a cervical collar on a long spine board if any of the following criteria are met:

  • Unconscious or altered mental status on exam
  • Neurologic deficit present or reported
  • Midline spinal tenderness or deformity
  • Intoxication

According to the the Indy Channel trackside coverage Castroneves was uninjured. No injuries and no complaints equals no cervical collar and no long spine board immobilization.

But the mechanism…

Treat the patient. Not the mechanism. The IndyCar medical team evaluated the safety of self-extrication by comparing it with drivers that received full spinal immobilization and subsequent X-ray imaging (radiation exposure). The paper, published in the Journal of Emergency Medicine concluded, “In our IndyCar racing experience, a protocol-led self-extrication system resulted in neither a mismanagement of an unstable spinal fracture nor neurological deficit, and reduced radiation exposure.[3]”

References

1. Indianapolis Metropolitan Area EMS Protocols 2014 Version. Out-of-Hospital Spinal Clearing/Immobilization. Page 72.  http://mobile.indianapolisems.org/docs/Final_2014_V3.03_IEMS%20%282%29.pdf

2. Email correspondence with Carl A. Rochelle III, Chief of Communications and Stakeholder Relations at Indianapolis EMS. May 14, 2015

3. Radiation Exposure as a Consequence of Spinal Immobilization and Extrication. http://www.jem-journal.com/article/S0736-4679%2814%2900750-1/abstract

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