Ask the Doc: How did this happen?


A little while back, Lance revisited the death of Moto2 racer Luis Salom in the somber context of two other unrelated motorcyclist deaths. 

Salom crashed during a practice session at the Catalunya MotoGP round. Despite track improvements that followed the 2011 death of Marco Simonelli in Malaysia, and Salom’s donning of appropriate gear, he could not be resuscitated from cardiac arrest. How is it that a 24-year-old wearing appropriate gear died in a solo crash?

Let's look at the care on scene, en route and in the hospital. Note that care in the United States versus outside the United States is often different in terms of approach. In the United States, Emergency Medical Services (EMS) personnel generally spend as little time as possible at the scene of injury, using a “scoop and run” approach. Many other countries instead pursue additional time on the scene rendering care regardless of the kind of illness or injury. Both teams use the same techniques (CPR isn’t different in Catalunya, after all), but don’t always have the same team members. It is uncommon to have a physician riding with an EMS crew in the United States, but commonplace elsewhere. Remember Princess Diana anyone?

Salom was in cardiac arrest with no pulse and no blood pressure after a high-speed, high-kinetic-energy blunt injury. Energy increases as the square of velocity (Energy = 0.5MV2, where M = mass and V = velocity). Resuscitative efforts after blunt injury are so unsuccessful that many U.S. states enable EMS crews to declare death on scene. Victims with penetrating injuries are managed differently if they are reached in a short time frame, or lose their heartbeat on the way to the hospital. Why? Penetrating injury care leads to survival in many cases, while the same intense set of therapies fails for victims of blunt injury like Salom, except in certain very unique circumstances (unfortunately, he appeared to have had none of them).

Back to the scene: A doctor was on site and participated in care. Salom’s helmet was removed, a neck brace to protect his spinal cord was applied, and chest compressions as well as resuscitative medications were administered. While not specifically stated, he likely also had a breathing tube placed to aid in oxygen delivery and to clear carbon dioxide (waste product). Catheters were inserted into each side of his chest to relieve any pressure from gas that escaped his lungs and filled the space between his lungs and chest wall (pneumothorax). The same catheter can also be a pop-off valve for chest bleeding (hemothorax). Neither gas nor blood appeared to be present. CPR continued on scene for 18 minutes.

While a helicopter was available, ground transport was chosen to allow the team to continue care. Providing care in a helicopter is challenging due to space limitations, as well as motion. He arrived at the Hospital General de Catalunya at 4:10 p.m. and was taken into the Operating Room for abdominal exploration, according to MotoGP Medical Director Dr. Angel Charte. While operative details are not available, Salom was pronounced dead at 4:55 p.m., 45 minutes after hospital arrival.

What was the cause of death?

Since his belly and not his chest was opened, a few assumptions (careful, as you know what happens when you assume) are reasonable: 1) there was blood in his belly, 2) he had a solid organ injury.  Solid organs are principally made of tissue and blood (liver, spleen, pancreas, kidneys) as opposed to being filled with gas (stomach, small or large bowel) or liquid (bladder). When injured, solid organs can bleed a lot, but generally less than gas- or fluid-filled ones. They can also bleed from where blood vessels enter and exit. Remember, while we tend to think of organs as being mostly in one place in your body, they are quite mobile with points of attachment (like where arteries and veins enter and exit).  Salom hit the barrier and his motorcycle hit him. The forces of crashing to a rapid stop and being hit by the motorcycle cause those vessels and organs to flex around one another and can tear the organ off of its blood supply, and can also cause organ damage as the soft structures compress and rebound. 

An organ like your liver can bleed up to 1.5 liters per minute if torn off of its blood supply — and people generally have only five liters of blood in total. This is a big part of why blunt injury leading to cardiac arrest is so difficult to treat — many simply bleed to death before help can arrive. Other injuries can also occur, such as those of the brain, spinal cord, and aorta (main blood vessel in your chest and belly), but appear not to have been the issue for Salom.

If gear did not save him, why wear it?

Glad you asked! This is not a gear failure, but is instead a testament to the frailty of the human body. Gear provides you with the potential to survive either unscathed or with a reduced injury, but most importantly, provides you time to be reached and helped after serious injury.  It does so by reducing transmitted forces (soft armor, helmet), or protecting you from penetrating injury when off road (hard armor). If you bleed less or have a less extensive fracture or brain injury, it is easier for EMS and then a trauma team to care for you.

All the gear in the world won't always protect you from high-speed injuries, anymore than it would protect you from jumping off a bridge and reaching terminal velocity (118 mph) prior to crashing. MotoGP top speeds are even higher and range from 175 to 225 mph, according to Brembo data. To understand how effective protective gear is, think about how many times riders crash every race weekend and walk away unhurt.

Would a U.S.-style approach have been better?

The answer is, I believe, a resounding no. Whether less time was spent on scene, air ambulance evacuation was used, or more rapid hospital arrival occurred, massive blood loss leading to cardiac arrest is nearly always fatal. Some cutting-edge techniques and technologies for bleeding control are being deployed to help save victims of blunt or penetrating injury.  At present, these are limited to the hospital — for now.

Despite the very long odds against them, the medical team in Catalunya tried heroically to restore that most precious of all gifts — life.

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