California concussion incident raises questions, but what could have been done differently?

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It’s difficult, and perhaps meaningless, to assess blame over what happened in the moments that followed Toms Skujins’ high-speed descent crash at the bottom of Quimby Road on Stage 2 of the Amgen Tour of California.

Clearly struggling to maintain his balance, the Cannondale-Drapac rider — who crashed from the lead breakaway group with 22km remaining — attempted twice, to get back on his bike, ultimately re-mounting and riding for several kilometers before he was pulled from the race. It would be unfair to lay blame on a rider who has just suffered a brain injury, and that’s beside the point; getting back on the bike and continuing on after a crash is what bike racers do. For better or worse, it’s how they are hard wired.

The neutral support mechanic — Jasper Matson working for SRAM from the back of a motorcycle — helped Skujins back onto his bike, twice, even though to those watching on television, Skujins was clearly concussed.

Yet Matson, a neutral support veteran, was doing his job. A neutral support mechanic is not a trained medical provider. Assessing concussions, no matter how obvious it might seem, is not in the job description. Neutral service applies to bicycles, not bodies.

It’s also worth pointing out that during a few critical seconds of Skujins’ disorientation, Matson’s eyes were focused on his bike, not on what was happening with the rider.

Matson referred all questions to SRAM Senior Public Relations Manager Michael Zellmann, who said the Chicago-based components group would not identify the mechanic by name, but that he had done everything in accordance with his role as a neutral support.

“From the SRAM perspective, and more specifically, from the neutral race perspective, his job is to protect the rider from other riders and race traffic, and to get him back on a safe machine. He is not there to make medical assessments of the rider,” Zellmann said.

“In the confusion that was that moment, you see a lot of activity, he was bringing wheels out, grabbing the bike, directing the rider away from danger… our mechanic accomplishes a lot in that moment. [The mechanic] was focused on the bike, and did not have the chance to pay great attention to the rider’s reaction. He was concerned with other riders, other cars, race traffic, the wheels in his hand, the rider’s bicycle, and making a number of quick decisions. When a rider demands to get back on his bike, which [Skujins] did multiple times, the mechanic’s job is to make sure the machine is safe and to help the rider back to his bike.”

Every UCI race has several doctors on course; in this case, the head race doctor, Ramin Modabber, was in the caravan, behind the peloton, which at that point was spread out across several miles due to the punishing pace over the climb of Mt. Hamilton.

There was another doctor, with the breakaway, however all cars with the break had been pulled forward of the riders to avoid excessive vehicles mixed among the riders on the extremely technical descent of Quimby Road; cars cannot keep up with cyclists on technical descents, and would only get in the way.

Ramin Modabber, head race doctor at the 2017 Amgen Tour of California.

Most teams in the race also have a team doctor, who often rides in the second follow car, behind the peloton, essentially in a sweeper role. On Monday, Cannondale-Drapac medical staff was at the finish, in San Jose.

Like the medical staff, Cannondale-Drapac team director Tom Southam was stuck behind the riders on the descent, with no in-car TV images and no cell reception; all the information coming to him was via race radio.

“It was a high-speed crash and unfortunately it happened at a time when the race was fragmented, which delays information and makes these situations extremely hard,” Southam said. “Toms instinctively continued riding but it was clear that he couldn’t go on.”

Kristin Klein, president of the Amgen Tour of California for AEG, pointed questions back to the UCI; AEG owns the event, however, as with all race organizers, the event is held under UCI rules and regulations. What happens in the peloton is under the jurisdiction of the sport’s governing body, regardless of which sponsor race organizers choose to provide neutral support.

Essentially, in the first moments following his crash, there was no doctor or team director immediately available to assess Skujins. The net result was no shortage of outrage, but no clear answer as to where it should be directed.

Ultimately, the Cannondale-Drapac team car caught up with Skujins, and he was pulled from the race. At a local hospital he was diagnosed with a concussion and a broken collarbone.

“I don’t remember the crash, or say the next 15 minutes,” Skujins said. “After the descent, my next memories are of me riding in a group realizing I’d lost time, realizing my collarbone was broken, and then my team rolling up to me and putting me in the car, and that was clearly the right call. At the same time, teams don’t have video footage all the time, they couldn’t have known I had a concussion. By the time that information got to them, I was already in the car.”

Still, how much more obvious could it have been that Skujins was in no condition to continue? At the finish line atop Metcalf Road, a crowd of a few thousand people watching on a large screen television yelled “No!” seemingly in unison, urging Matson not to put Skujins back on his bike. Television commentators in the U.S. and France did the same. It was a horrifying sight to see, akin to watching someone hand car keys to a drunk person and then sit them behind the wheel.

But Skujins did remount his bike, after nearly causing riders in the chase group to crash as he stumbled across the road. Once back on the bike, he nearly crashed again, into a curb. What transpired over a minute or two felt like hours, Skujins falling over repeatedly, a danger not only to himself, but to other riders.

Yet the rider wanted to get back on his bike, and the mechanic did his job in helping the rider by servicing his equipment.

“Neutral support always wants to get you back on the bike, and if he hadn’t, I would have probably gotten pissed off and angry,” Skujins said. “Even though I don’t remember the crash, I’m guessing that would have been my reaction. I know I would have been unhappy with him not letting me back on the bike.

“I’m not sure what more we can do in these situations, I think there’s really nothing more you can do,” Skujins continued. “I understand that people watching may have been getting frustrated, but I wasn’t thinking clearly, and everyone was just doing their jobs. It’s easy to say, ‘he should have done that, he shouldn’t have done that,’ but that’s all in retrospect.”

By the time the race doctor caught up to Skujins, he was coherent enough to have a conversation, and was no longer swerving.

“I was in the medical car behind the peloton,” Modabber told CyclingTips. “We got to him after he was up and riding, about two minutes after his crash. He was with it, and recalled the details of the descent right up until the crash and didn’t want to receive treatment from the car, but said he would wait for his team car and then come by the medical tent at the finish. He asked us how far the group was behind us, and we told him one to two minutes.

“Then his team car came behind us, and could tell he was pretty banged up, and he abandoned. The team brought him to the tent where he and I chatted for a while we cleaned up extensive road rash, and upon evaluation we noticed he clearly had a clavicle fracture. He went to the local hospital with the team chiropractor. I went to the TV truck and watched his crash, and the nearly two minutes that followed. It was… not pretty.”

The good news, of course, is that Skujins was not seriously injured, and that no other riders were injured in the aftermath.

In the end, what is more constructive than assigning blame is to consider what might be done to to minimize the likelihood of these events repeating themselves.

But how?

Many questions, few solid answers

One of the biggest hurdles cycling faces when it comes to concussion protocol is its lack of stoppage time, and the inherent challenge of a rolling enclosure on a moving field of play.

Pro cycling is a hardman’s game, and enduring through the pain is ingrained to the fabric of the sport. Assessing a serious injury on the fly is tricky, and most riders (and team managers) are hardwired to instinctively encourage pushing through the pain.

Current UCI protocol leaves the final decision as to whether a rider should continue in a race — a decision made either on the spot, during a race, or in the event of a stage race, in the hours after the finish — to the official race doctor, supplied by the race organizer.

Modabber pointed out that race owner AEG has made every effort to keep experienced doctors despite pressures to use race-sponsored medical practices or hospitals. “We see medical sponsors often at bike races,” he said, “but thankfully the organization has used my group of doctors, which has more days in the pro peloton than any other in the country.”

The UCI requires race doctors to adhere to SCAT 3 (Standardized Assessment of Concussion) guidelines established at the fourth International Conference on Concussion in Sport, held in Zurich in November 2012. A standardized tool for evaluating injured athletes for concussion, the SCAT 3 calculates a score from a range of 22 symptoms.

In 2012, Medicine in Cycling, a group consisting of U.S. cycling doctors and other medical professionals, developed an in-race assessment “pocket card” with input from national governing bodies, athletes and other experts in the field. And while it’s a helpful tool, it’s not universally accepted or enforced by any governing body.

Perhaps it should be.

Since 2013, the UCI has required anyone driving in the race caravan to be certified. Earlier this year, the federation tightened up safety procedures and instructions for the movement of vehicles in the race convoy. Neither of these measures, of course, prevented what we saw Monday in San Jose.

One option is to increase the number of doctors in the race caravan. That’s problematic, however, in a sport where there are already too many incidents between motos and riders. Adding more motos, as a safety measure, seems counter intuitive. One cannot call for rider safety measures and insist that additional motos on course is the solution.

Another option might be to require that those in the caravan receive basic first-responder training. Given that the UCI is already requiring certification of anyone driving in the caravan, should that also include basic first-responder training such as CPR and basic concussion protocol?

“Certainly if you want to put a greater umbrella of safety over the peloton, everyone in the bike race should understand what sort of things to look for,” Modabber said. “If you watched what happened today, it was not ideal. Someone is helping [Skujins] to get back on his bike when he’s having trouble just walking. But we also can’t hold a neutral support person to a medical standard, that’s just not fair.

“It’s the same analogy as CPR training, we don’t only train medical professionals in CPR, we certify the average person as a first responder, but we can’t hold a person liable or responsible because they don’t know CPR. It’s just unfortunate that sometimes in a bike race, the first responder is a non-medical person.”

At the very least, it would seem that team managers, commissaires, and support staff should be instructed on how to assess a head injury. But what authority would they be given to act on an assessment? And what happens the first time a race official holds up an athlete who is perfectly fine, costing them a race win? What if it is a manager from one team, holding up an athlete from another team — or if the official is a SRAM neutral support mechanic, holding up a Shimano-sponsored rider?

The more one runs through the scenarios, the more difficult it gets to imagine a scenario that makes sense.

Zellmann, the PR manager at SRAM, said they would abide by any ruling the UCI makes, but declined to comment as to whether he felt it was an appropriate measure.

“If the UCI required concussion training for neutral support mechanics, we would participate as a neutral race provider,” he said. “We would honor the request of the governing body and the race itself, to be educated on any situation as they see fit. The question of more training, or more doctors in the caravan, is for the governing body to determine.”

Asked how he might respond to being told by a caravan driver or race marshal to sit tight and wait for the race doctor before remounting his bike, Skujins’ teammate Nathan Brown said he would be okay with it. “Concussions are something you don’t want to mess around with, and I think if anyone saw someone in that state they should ask questions and see if they are okay to keep riding,” he said. “At the end of the day it’s our safety that matters. If you lose the race because of it I mean, oh well. I’d rather our riders be safe than that.”

Cannondale-Drapac’s Taylor Phinney recently abandoned the Tour of Flanders with a concussion, and said he would have appreciated more care than he got from the race officials — which was none.

“The post-concussion stuff that I did, it was all memory related, and they are kind of strange questions, but that would be something that I think could be implemented,” he said. “In my personal case, at Flanders, the race just left me behind, they left me to fend for myself. So yeah, there could be some improvement.”

Yet Ben King (Dimension Data) points out that various caravan officials, even if trained, stopping injured riders to administer an in-race assessment from a pocket card is problematic.

“Unless there’s a very standardized process then it could be a very subjective situation,” King said. “I mean, you have to know the baseline as well. Half the time [at a stage race] I wake up in the morning and don’t know what day of the week it is, what city I’m in, or anything like that, so I don’t know. I know that riders are hard-wired and conditioned to push through anything. I didn’t have a concussion today, but I suffered like a dog and just a normal stage like today is more painful than a lot of serious injuries that you can sustain, so sometimes it’s hard to tell the difference between good pain and bad pain.”

Modabber agrees, saying that the only definitive line that can be drawn is at a “witnessed loss of consciousness.”

“It’s not even a black and white decision for seasoned medical professionals to assess a head injury in the initial seconds, or even minutes, after a crash,” Modabber said. “Medical professionals from a variety of specialties have discussed this challenge at length and even these ‘experts’ are challenged with this unique situation in our sport. Medical professionals caring for cyclists need to make a quick decision regarding this condition, which all agree is unique in that it does not even declare its full extent in the first minutes after an injury. Specific principles can be applied, and judgment and experience can help, but all experts agree that science does not offer a clear answer. So we are left with an imperfect situation which leaves doctors, athletes, and all those involved with our sport a certain level of discomfort.

“Head injuries are so unique, they are so nebulous, and at an international race like this, there’s a language issue. Half of these riders, you can’t just ask the questions and know their normal state. The language barrier creates an additional challenge, which further complicates a quick roadside assessment of mental status, and these are huge issues. You can’t really conduct a coordination test with someone standing in cleats — someone who just crashed, with a heart rate of 180 beats per minute, with abrasions all over the place, their bike is all twisted. Oftentimes they are not really very pleasant or cooperative in that moment. Even a trained doctor has to stand back and watch and use their judgment. It is very complicated.”

It is complicated. Yet for those watching Stage 2 of the Amgen Tour of California, it seemed simple enough — Skujins should not have been back on his bike. Seemingly everyone who witnessed the incident was terrified of the outcome, and can only hope that steps will be taken to ensure nothing like it happens again. Yes, crashes are inevitable, but all parties must agree that further steps must be taken to minimize further damage whenever possible.

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