January 18, 2007

By Rebecca Gladden

Rebecca Gladden

2006 NASCAR champion Jimmie Johnson won the 2006 Brickyard 400 at Indianapolis Motor Speedway, but he narrowly escaped serious injury in the same race just one year earlier.

In August 2005, Johnson sustained a vicious hit in turn four after blowing a tire late in the race.

As Johnson pulled his mangled Chevrolet into his pit stall, the engine caught fire. Crew chief Chad Knaus quickly pulled Johnson out of the driver's window.

Johnson said he hit the wall "head first" and had no idea at the time that the car was on fire. In fact, he didn't even remember how he got to pit road. "I don't really remember coming from turn four to the pits," said Johnson. "I just remember kind of waking up on pit road and the guys pulling me out of the car."

Johnson sat on the pit wall for several minutes after the incident and Knaus, who observed that his driver was "definitely dizzy" and had "definitely blacked out", was livid about the emergency medical care Johnson received at the scene.

"There's a driver that's sitting on pit wall out there in need of an ambulance, and NASCAR doesn't even send an ambulance down there. What happens to them?" Knaus asked. "I think it's ridiculous. We walked all the way from 39th pit stall into the garage area before we had any medical attention whatsoever."

Johnson was eventually airlifted to a nearby hospital, where he was diagnosed with a concussion, treated and released.

At the time, NASCAR spokesman Ramsey Poston defended the emergency medical procedures. "Here's what we know," said Poston. "There were two EMT personnel on site and they spoke with Jimmie, and Jimmie declined treatment - said he was fine. The EMTs called up to the tower and said he was declining to be seen, so then no other further medical assistance was sent."

"However, after he was sitting there a while, an official did walk him to the infield medical center for further treatment - once they realized he needed to be seen."

The incident as described left many unanswered questions, chief among them: Is it ever safe or prudent to let a driver involved in a high speed crash refuse treatment?

While I don't advocate second guessing the EMS crew, many fans who watched Johnson's interview on TV just after the wreck noted that he seemed foggy and dazed. His car had been on fire while he was still in the cockpit, and Johnson himself could not recall driving from turn four to his pit stall.

This frightening scenario was almost duplicated last month, except there were no television cameras on hand to capture the crash or the driver's post-accident comments.

Cup driver Greg Biffle was participating in a Goodyear tire test at Las Vegas Motor Speedway in December, traveling 204 miles per hour when he blew a tire.

Biffle, who sustained a concussion and a dislocated shoulder, commented, "I don't know what happened. The guys heard the tire blow in the pits, in the garage. Boom! - they heard it. Then four seconds later they heard it hit the fence, and I went all the way around the corner unconscious before I woke up. I woke up on the backstretch. I crashed in turn one you know, so it was big."

As in Johnson's crash, Biffle's car also burst into flames after coming to a stop. Kyle Busch, following behind Biffle at the time of the accident, helped pull him from the burning machine.

Subsequently Biffle criticized the emergency medical responders, stating that he was not taken to either an infield care center or a hospital. He drove his own car from the speedway and flew home to North Carolina, where his doctor diagnosed his injuries and advised him that flying could have been dangerous because of the concussion.

According to a track spokesman, Biffle was evaluated by paramedics at the scene but refused treatment, writing, "I feel fine," on a refusal form.

Chris Powell, General Manager of the speedway, stated that Biffle's, "recollection of the event is in gross error."

That statement could in fact indicate that Biffle was not thinking clearly at the time.

Emergency medical personnel, whether at a NASCAR race or elsewhere, face a difficult conundrum when patients refuse treatment or transport. In the March 2003 issue of the Journal of Emergency Medical Services (JEMS) magazine, paramedic and attorney Jay Weaver wrote: (*)

"For EMS administrators, the most problematic patients are sometimes those who do not want an ambulance at all. EMS providers who transport a patient involuntarily may face allegations of assault, battery or false imprisonment. Conversely, those who leave a patient behind may be accused of negligence. Because an employer may be held liable for the on-duty actions of employees, their EMS agency or system stands a good chance of getting sued as well."

Due to the risk of litigation, and in the interest of patient welfare, many state legislatures and EMS agencies have created strict guidelines regarding patient refusals. However, Weaver writes, "Unfortunately, most of these policies prove woefully inadequate. Some rely on inappropriate criteria. Others are too abbreviated. A few actually increase the likelihood of litigation by recommending action that violates accepted legal principles. As a result, EMS administrators who rely on these policies as a shield from liability often fall victim to a false sense of security."

There is no question that mentally competent adults have the right to refuse care. The problem arises when a normally competent patient's judgment is temporarily altered. Writes Weaver: "This right of refusal is by no means absolute, however. In a medical emergency, EMTs and paramedics may force a patient rendered mentally incompetent by illness, injury or intoxication to accept life-saving care, no matter how strongly the patient objects. The challenge for EMS administrators is to define for field personnel the circumstances under which a patient should be presumed incompetent."

The term competent is more legal than medical, however, and judging a patient's mental competence in the field is by no means a precise science. In addition, guidelines vary greatly by state and even by jurisdiction. As Weaver states, "Historically, many EMS systems have relied on an orientation standard, permitting a patient who has demonstrated an awareness of person, time and place to refuse care."

However, the orientation standard, though still used, is now considered inadequate by many experts. More often than not, paramedics are being asked to assess a patient's ability to comprehend the nature of his medical condition, as well as the risks and benefits of receiving and refusing treatment.

This is no easy task in an often confusing and fluctuating field setting.

Further complicating the issue is the behavioral temperament of multimillion dollar athletes, many of whom are somewhat accustomed to calling their own shots and getting their own way.

But in the case of Johnson and Biffle, there are important lingering questions regarding whether either driver should have been permitted to refuse treatment or transport.

The mechanism of injury of both crashes, the fact that both drivers had a brief loss of consciousness and both had to be pulled from burning vehicles, and the fact that neither of them remembered driving from the accident site to the location where their cars came to rest - all suggest that their judgment may have been temporarily clouded regarding the emergent medical situation.

In retrospect we know that both drivers were, in fact, diagnosed with a concussion, indicating that they sustained a blow to the head with force sufficient to "jar or shake the brain inside the skull, interrupting the brain's normal activities." (definition courtesy of WebMD.com)

Symptoms of concussion may be mild to severe but include confusion, disorientation and amnesia, all of which may temporarily affect one's ability to make reasoned judgments.

Some of these symptoms, including loss of consciousness, could be indicative of more serious brain injuries, which should be ruled out.

Part of the problem in Johnson's case is a quirky NASCAR policy which states that if a driver's wrecked car comes to rest on the track, he must make a mandatory visit to the infield care center by ambulance to be cleared by a physician. But if he is able to drive back to the pits or the garage, that trip is optional.

If this is still the policy, as was reported at the time of Johnson's wreck, it is an illogical rule which needs to be changed.

Biffle's wreck was a little more complicated since it occurred during an off-season tire test. NASCAR analyst and former crew chief Jeff Hammond was asked who should have been responsible for seeing to it that Biffle was checked by a doctor: "That's a great question," Hammond wrote in an article at FOXSports.com. "Who is responsible? I wish somebody would step up and tell me. If I put the onus back on NASCAR in this instance, they would tell me it was not a NASCAR-sanctioned test. It was a track test by Goodyear. If you go to the track, I think you'd find that somebody is going to pass the buck."

As a former paramedic and certified emergency nurse myself, I know there is a certain degree of strong persuasion which can be exerted on patient's who initially refuse care. It often helps to involve the patients friends or family. Hammond writes, "I really believe you'd have a hard time finding anybody to fess up to who's in charge, but I feel like the crew chief should step up and say, 'Greg, let's go to the hospital. You and I should go somewhere where we can get a second opinion.' "

Clearly, the issue of head injuries is a complex one, made more so by the fact that the circuit travels to many different states and racetracks, each one providing its own EMS squads, and with each state and jurisdiction having its own guidelines regarding refusal of care issues. Couple this with the noise and confusion of a race, the incredible g-forces involved in high-speed crashes, the temperament of high-profile athletes, and the sometimes puzzling NASCAR rules regarding crashes, and you have a disaster waiting to happen.

One frequently proposed solution is a traveling medical team that would tour the NASCAR circuit all season. Veteran driver Bill Elliott has long been an advocate of such a solution. In his autobiography, "Awesome Bill from Dawsonville: My Life in NASCAR," Elliott wrote:

"Fans would be shocked to know how poor basic first aid is at many NASCAR tracks. I've been in so-called safety meetings where all it is, is a Joe Blow local EMT who works that particular race because he gets a (garage) hot pass. This is a true story: I had a guy after a wreck one time, a paramedic, who was riding with me in the ambulance. On the way to the hospital he actually asked me to autograph my oxygen mask for him."

NASCAR should be commended for all of its recent safety initiatives - the safer barriers, the HANS device, eliminating racing back to the caution, and so on. But as hard as the sport has lobbied for the Car of Tomorrow - in large part because of its safety advances - it should also reevaluate the entire issue of trackside emergency medical care.

A simple measure would be to insist that all drivers involved in serious collisions get examined by a physician, whether at a test session or in a race, and regardless of whether the car comes to rest on the track, in the infield, in a pit stall or in the garage. As Jay Weaver wrote in the JEMS article, "Although a physician generally has no greater right than an EMT to force unwanted care on a competent patient, a doctor may prove useful in convincing the patient to accept transport. In case of a bad outcome, a physician's testimony may later support the field providers' contentions that they handled the situation properly."

This initiative should be instituted immediately. It is a logical first step to insure the welfare of all drivers until more advanced policies can be evaluated and implemented.

* Weaver, Jay. “Beware Patient Refusals.” Journal of Emergency Medical Services, March 2003, Volume 28, Issue 3.

The thoughts and ideas expressed by this writer or any other writer on Insider Racing News, are not necessarily the views of the staff and/or management of IRN.