Riders, race doctors and the rules

Sunday, 10 July 2011

Porte + Jalabert

Many fans were distressed to see the video of Chris Horner from Friday. He crashed late in the stage, the same move that took out FDJ’s Rémi Pauriol and Sky’s Bradley Wiggins but whilst these two were holding their arms in the tell-tale sign of a broken collarbone, the Radioshack rider was apparently unconcious in the roadside ditch. He came to and finished the stage but crossed the finish line unaware of where he was and what was going on around him, seemingly riding the last part of the race on instinct alone.

There was a related story with Tom Boonen. He crashed hard on Stage 5, sustaining head injuries but carrying on. Boonen quit on Stage 7, telling cyclingnews.com:

I’ve got a huge headache… Every kilometre was one too many. I was wondering, ‘who am I pleasing by continuing?’ Not myself, that’s for sure. I was a danger for the other riders, too. I think I suffered a concussion. Noise, colours… I couldn’t stand them. A honking car that passed was echoing a thousand times in my head. Yesterday was a dark day – due to the rain – and maybe that’s why it went better.”

Now I’m no medic but it sounds like he was in bad way since the crash, the symptoms Boonen describes sound just like brain trauma, also known as concussion. Whether he should have stayed in the race is beyond my knowledge, concussion supposedly passes with time but often bed rest is recommended; but riders often do things that others don’t.

But this raises the question of who decides on a rider’s health? Do they have the final say? Is it the team doctor in charge? What about the race doctor? Here are the relevant UCI rules:

13.1.008 The Team shall not oblige or allow any cyclist to participate in cycling events if he has been judged unfit by the Team doctor or if it learns in any other way that he is unfit.
13.1.011 In the event that the Team doctor learns of any facts that in his view render the cyclist (even temporarily) unfit to participate in cycling events, he shall declare the cyclist unfit and shall inform the Team Manager. The duration of the period for which a rider shall be deemed unfit shall be determined by the Team doctor. This decision and the declaration of unfitness shall be made in writing and added to the rider’s medical file.

In other words the team has a duty of care to the rider and the buck stops with the team doctor. It’d be interesting to see what went into Tom Boonen’s medical file last week. For me 13.1.008 isn’t worded quite right as “oblige or allow” is a little contradictory, if a rider is not allowed to start they cannot be obliged! But it makes clear that the team should not let a rider start if it learns that the rider is “unfit”.

I don’t want to make this about individuals although obviously the tales of Boonen and Horner have made me ask aloud what’s involved. It’s worth noting that these two riders are influential riders and valuable riders on their teams. It’s more the lesser rider I might worry about, the one who is worried about their contract coming to an end and “soldiering on” for the sake of the team but at the risk of their health.

Porte book

Dr Porte's medical notes

The role of the “race doctor” has retreated. In the 1950s Doctor Pierre Dumas was the Tour de France doctor and was involved every day in treating the riders, whether at the roadside or in their hotel. Dumas was an early crusader against doping, calling a press conference to denounce the actions of some in the entourage of French rider Jean Malléjac as “attempted murder” after the rider almost died in the race.

More recently Dr Gérard Porte was the “Tour doctor” until ASO ended his contract but in recent times this role has meant heading up a staff of fellow medics, including a nurse and an osteopath. But the visible role of the race doctor is primarily concerned with first aid during the course of a stage. They will intervene if there’s an accident or if a rider requests help and they note any rider visiting hospital after the race. But they can’t give every rider a check-up before each stage.

Summary
The teams and in particular the their appointed doctor are in charge of monitoring a rider’s health. This can include declaring them unfit to race. Note the potential for a conflict of interest here, a doctor is paid by the team and the team’s interest are not always those of the rider.

The official “race doctor” you see in the Tour de France and other race is more available for first aid and to help riders cope with incidents during the stage.

Mark Rushton July 10, 2011 at 11:29 am

Might be worth getting a comment from @drdavehulse as he now works with Sky and was the ToB doctor as well. He can prob. give a good account of the races from his point of view

john fotheringham July 10, 2011 at 12:51 pm

I am a medic and mainly deal with rugby, concussion is common and we have a well thought out strategy using the SCAT system alluded to by the Radioshack Dr on cycling news- unfortunately Chris Horner did not appear to have been assessed with SCAT. We also use Cogsport, a computer based testing system in which the athlete is “baselined” at the beginning of each season and is then tested after a head injury. This system tests cognition, reasoning and reaction times all of which become impaired after a significant TBI/concussion. If the score deviates from baseline the athlete is stood down from EVERYTHING until he returns to normal. This includes reading, play station and TV as well as all sports and training.
In many ways cycling is so gladitorial it is frightening! it doesn’t seem to have moved on since the fifties in some respects, in others- mainly bike technology and doping it is cutting edge.

What you allude to in the end of your post regarding the conflict of interest that the Dr faces is true in all sports, however if the Dr is doing his job his first priority is to his patient. Given the scale of doping on the continent it appears that a different set of ethics may apply however..
I am really pleased by the rise of the British, American Australian and other new world riders- maybe we can sweep out the corruption and omerta that still corrodes the sport we all love.

Kris July 10, 2011 at 1:39 pm

Dr Fotheringham,

I am a little astonished you seem to believe that the “continent” has lower ethics than the Anglosaxon world, and that it is time the so-called new world riders get rid of all the bad things that occur in cycling. Ever heard of a team called US Postal and its renowned leader at the time? Omerta restricted to the continent? The scale of doping higher on the continent? What about BALCO and all the other steroid-scandals that have plagued all US top sports since many years? I don’t see many reasons to regard the anglosaxons as white knights as opposed to the continental dark forces of evil, sorry.

TdF Lanterne Rouge July 10, 2011 at 2:07 pm

Thanks for this, @inrng. This isn’t about doping.

Is the team doctor in the team car on the course every minute of every stage? If not, this isn’t a responsibility that should be assigned to them.

The rules need to be strengthened and clarified to identify the individual with the responsibility and authority for making decisions on behalf of the rider’s health when he has failed diagnostic criteria for head injury out on the course. If any rider has been knocked unconscious on course (and it seems both Boonen and Horner were) they should not be permitted to continue, and any rider suspected of cranial trauma should be tested on course before being allowed to rejoin the peloton.

Luc Prévost July 10, 2011 at 3:53 pm

Bonjour tout le monde!

Is it not ironic that we are discussing the role of doctors and their responsabilities when, at the same time, simple civilians, like UCI staff, take away their professional privileges, like using a needle to treat a human being …

Maybe cyclists are not human after all.
Just fallen gods who do not deserve what all of us consider normal medical treatments.

luc

Cyclemaine July 10, 2011 at 6:25 pm

Cycling seems to be catching up to the trend we have seen here in the US for the last year or two regarding head injuries. Notably, American Football and NHL hockey are two sports that are struggling with tHESE types of injuries in the face of the fact that they are a natural consequence of violent collisions. Cycling has a more nuance problem in that the event that causes the injury is not a planned (legal) part of the sport, but rather a mistake that often triggers an event involving innocent riders in the wrong place at the wrong time.

Personally, I am impressed with the authority given to the team doctors to protect rider safety. Conflicts abound between athletes and team physicians in every sport. The key is to set the expectation that doctors will ensure safety first. This problem is not dissimilar (indeed it is probably closely linked) to the doping debate. Compliance will only result from a cultural shift recognizing the importance of long-term rider health and safety.

TdF Lanterne Rouge raises a good point: where are these doctors during the race? Baseline tests are easy to administer and can be invaluable for on-scene analysis of a head injury. I would like to see riders mandated to be cleared for head injuries anytime they are suspected and certainly anytime they have been rendered unconscious. However, this only works if the the doctors are present and involved with each accident (a difficult propositio depending on where the accident happens).

Of course, medical assessment also costs significant time and can dash the hopes of a race contender. Perhaps one solution would be to allow motor pacing for some period of time equivalent to the time needed for assessment. Another option would be to “stop the clock” for an individual rider while cognitive testing takes place. There is obviously room for abuse of such a rule, but considering the long-term effect of head injuries, making sure riders are cleared before they proceed should be paramount.

Q July 10, 2011 at 6:48 pm

The previous poster mentioned ways to make the necessary time for proper cognitive testing. Another option would be allowing for exceptions to time cuts. The incentive to continue in a race after a serious injury is much higher in a stage race where the rider has the hope of recovering and racing another day.

By the way, there was a very good post about all of these issues yesterday by the guys at sportsscientists.com

brew July 10, 2011 at 6:55 pm

The Garmin-Cervelo doc mentions using a version of SCAT (and having the relevant questionnaires in each team car) in this recent cyclingnews piece: http://www.cyclingnews.com/news/pro-cycling-plagued-by-head-injuries

martin hardie July 11, 2011 at 12:51 am

The July International Network of Humanistic Doping Research Editorial which I wrote hours before the Horner incident discusses these matters. Concussion is not as common in cycling – although it does happen; as in Australian or American football for example. Chronic Fatigue does happen much more often. http://doping.au.dk/fileadmin/www.doping.au.dk/Editorials/Martin_Hardie_-_July_2011_-_INHDR_editorial.pdf

I am not sure the esteemed Garmin Dr is the right person to be giving advice on complying with the rules mentioned by Inrng. he has admitted in the media that he sees no reason in complying with them.

I am sure this is an issue which won’t be going away and given the tardy way in which many teams fail to comply with the rules it is about time the UCI took some action against them – to send a signal as we say.

The buck actually stops with the team manager who faces a ban of up to 10 years. The doctor is responsible for the medical aspects but the team manger is ultimately responsible to see that the program in the UCI regs is properly complied with – the ten year penalty for a manger is a sign of the fact that in the end that it is the manager who needs to ensure his employees’s health and safety is properly looked after.

martin hardie July 11, 2011 at 12:55 am

I just watched the Horner video for the first time. It is clear from what Bruyneel said it was obvious Horner should not have continued after the crash and he should be charged under the UCI rules

Oli Brooke-White July 11, 2011 at 3:17 am

Could you please elaborate on Dr Porte’s contract being ended? I hadn’t heard this and am curious as to why, if you know. Cheers, Oli

Elissa July 11, 2011 at 7:08 am

Frankly, I am shocked and disturbed at the decisions this doctor made with Horner. I’m a certified athletic trainer (health professional, not personal trainer) and have worked with sports teams for 15 years. I evaluate and manage about 30-40 concussions per year and can’t believe that he was allowed to finish the race. I don’t give rats a** if he insisted on getting back on his bike. He was clearly unconscious when found (and he later reported this). When an athlete is unconscious, you immediately assume a spinal cord injury, stabilize and get them on a stretcher. Aside from monitoring vitals, the evaluation is done. Game over. The doctor even tried to say it was impossible to tell how bad his head injury was until he got back on the bike and finished the race. Excuse me?? I could tell from watching on tv that he had a concussion. Hello…he was unconscious!! I watched in horror that not only did the staff move him immediately, but then put him on his bike holding on the to car?!? With head injuries, there is a significant risk of passing out…what if he would have passed out riding next to that car? He could’ve died!! That doctor should not only get some serious backlash for this, but be fired from the tour. He clearly does not prioritize safety with the athletes and is unfit to work a sporting event.

martin hardie July 11, 2011 at 7:37 am

I don´t think The Radionshack team doctor (Dr Celaya) was at the accident. The race doctor might have been present. But from the video Bruyneel obviously thought there was a problem but didn’t take any action. In the finial instance it is his call and he has responsibility for the management of the riders health and safety program under the rules. He should be sanctioned.

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