Appendix F5 - CMO questionnaire - Rally-Raid /Six Days'of Enduro

This questionnaire must be completed by the Chief Medical Officer (CMO) and returned to the FIM: cmi@fim.ch 2 months prior to the event

A copy of this form has to be handed over before the first track inspection to the FIM Medical Director, if present.

Included:

1) EVENT INFORMATION

2) CHIEF MEDICAL OFFICER

3) MEDICAL SERVICES

Rows	YES	NO
Are all medical services under the control of the Chief Medical Officer (CSM)

3a) NUMBER OF MEDICAL PERSONNEL

4) NUMBER OF VEHICLES TYPE A1

4a)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Doctor as per Medical Code
Second doctor, nurses, paramedic or equivalent as per Medical Code
Driver as per Medical Code

4b) NUMBER OF VEHICLES TYPE A2

4c)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Doctor as per Medical Code
Nurses, paramedic or equivalent as per Medical Code
Driver as per Medical Code

4d) MEDICAL EQUIPMENT

Rows	YES	NO
Portable oxygen supply
Manual ventilator
Intubation equipment
Suction equipment
Intravenous infusion equipment
Equipment to immobilise limbs and spine (incl. cervical spine)
Sterile dressings
ECG monitor and defibrillator
Drugs for resuscitation and analgesia/IV fluids
Sphygmomanometer and stethoscope

4e) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio Communication with Race Director and CMO
Visible and audible signals
Equipment to remove suits and helmets

4f) TYPE OF VEHICLES

4g) OTHER EQUIPMENT

Rows	YES	NO
Protective canvas/Tarpaulins

5) NUMBER OF VEHICLES TYPE B1

5a)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Doctor as per Medical Code
Personnel as per Medical Code

5b) NUMBER OF VEHICLES TYPE B2

5c)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Doctor as per Merdical Code
Personnel as per Medical Code

5d) MEDICAL EQUIPMENT

Rows	YES	NO
Portable oxygen supply
Manual and automatic ventilator
Intubation equipment
Suction equipment
Intravenous infusion equipment
Equipment to immobilise limbs and spine (incl. cervical spine)
Sterile dressings
Thoracic drainage equipment/chest decompression equipment
Tracheostomy equipment / Surgical airway equipment
Sphygmomanometer and stethoscope
Stretcher
ECG monitor and defibrillator
Pulse oximeter
Drugs for resuscitation and analgesia/IV fluids

5e) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio Communication with Race Director and CMO
Visible and audible signals
Equipment to remove suits and helmets
Air conditioning and refrigerator (recommended)

5f) TYPE OF VEHICLE

6) NUMBER OF VEHICLES TYPE C

6a)

Rows	YES	NO
Do positions conform to map of circuit/posts?
Personnel as per Medical Code

6b) MEDICAL EQUIPMENT

Rows	YES	NO
Stretcher
Oxygen supply
Equipment to immobilise limbs and spine
First aid medicaments and materials

6c) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio Communication
Visible and audible signals

6d) TYPE OF VEHICLE

7) PERSONNEL

Rows	YES	NO
Doctor/paramedic or equivalent experienced in emergency care
Stretcher bearer

7a) MEDICAL EQUIPMENT

Rows	YES	NO
Equipment for initiating resuscitation and emergency treatment including initial airway
Cervical collar
Scoop stretcher

7b) TECHNICAL EQUIPMENT

Rows	YES	NO
Radio Communication with Race Control and CMO

8) MEDICAL CENTRE

Rows	YES	NO
Is a medical centre available as per Medical Code?
Secure enivronment from which media and public can be excluded
Area easily accessible by first aid vehicles
Helicopter landing area nearby
A room large enough to treat more than one rider with minor injuries simultaneously
Temporary separation in this area, e.g. curtains or screens
Radio communication with Race Control, CMO, ambulances & ground posts
If the Medical Centre is fed by normal power electric supply, it must also be permanently conncected to its own U.P.S. (Uninterruptible Power Supply)
Water supply, heating, air-conditioning and sanitation appropriate to the country
Office facilities
Dirty utility container
Equipment storage
Parking for ambulances

8a) EQUIPMENT FOR RESUSCITATION AREAS

Rows	YES	NO
Equipment for endotracheal intubation, tracheostomy and ventilaton support including suction, oxygen and anaesthetic agents?
Equipment for intravenous access including cut down and central venous cannulation
Fuids including colloid plasma expanders and crystalloid solutions
Intercostal drainage equipment
Equipment for cardiac monitoring and resuscitation, including ECG monitoring, defibrillation and blood pressure measurement
Equipment for immobilising the spine at all levels
Equipment for the splinting of limb fractures
Drugs/IV fluids including analgesia, sedating agents, anticonvulsants, paralysing and aneasthetic agents, cardiac resuscitation drugs/IV fluids

8b) EQUIPMENT FOR MINOR INJURIES

Rows	YES	NO
The area must have beds, dressings, suture equipment and fluids to treat up to three riders with minor injuries simultaneously
Sufficient stocks to replenish the area during the event must be available and sufficient doctors, nurses and paramedics or equivalent experienced in treating trauma must be available.

8c) NUMBER OF MEDICAL PERSONNEL

8d) SPECIALISTS AT MEDICAL CENTRE

Rows	YES	NO
1. Surgeon experienced in trauma
2. Trauma resuscitation specialist

8e) OTHER SPECIALISTS

Rows	SPECIALITY
3.
4.
5.
6.
7.

9) NUMBER OF VEHICLES FOR TRANSPORT TO HOSPITAL

10) NUMBER OF HELICOPTER WITH MEDICAL EQUIPMENT

10a)

Rows	YES	NO
Fluids and drugs
Respirator
Oxygen
ECG/defibrillator

10b) NUMBER OF MEDICAL PERSONNEL

11) CLOTHING OF MEDICAL PERSONNEL AS PER MEDICAL CODE

Rows	YES	NO
Doctor
Nurses or paramedics or equivalent

12) MEDICAL SERVICE FOR SPECTATORS

Rows	YES	NO
Is there separate medical personnel for spectators?

13) ANTI-DOPING

Rows	YES	NO
Are there anti-doping facilities

13a) PLEASE DESCRIBE THE LOCATION OF THE DOPING CONTROL STATION

13b)

Rows	YES	NO
Are chaperones available on site for the doping control officers?
Is a waiting area with seating available for riders?
Are sealed bottles of still water available for the riders?

14a) HOSPITALS

Rows	Name of the hospitals (local, general, Ortho-trauma, etc) & Tel. N°
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoraci surgery
Burns/plastic surgery
Vascular surgery
Micro surgery

14b) HOSPITALS

Rows	Address/GPS coordinates-Google map
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoraci surgery
Burns/plastic surgery
Vascular surgery
Micro surgery

14c) HOSPITALS

Rows	Distance in km	Time to hospital by road (min.)	Time to hospital by air (min)
Local hospital
General surgery
Orthopaedic/trauma surgery
Neurosurgery
Spinal injuries
Cardio/thoraci surgery
Burns/plastic surgery
Vascular surgery
Micro surgery

For 15 below: Please enter for every doctor (CMO, 2, 3...) where he/she will be stationed. Remember to enter only one x in ach column (except where there is an asterix (Type A1 and B1), please enter the post n°)

15) TRACKSIDE POSITIONS OF DOCTORS

Rows	CMO	2	3	4	5	6	7	8	9	10
Doctor (number)
Race Control
Other place
Type A1*
Type B1*
Medical centre /Art. 7d)

16) MAPS

Rows	YES	NO
A route map is enclosed

17) CIRCUIT CMO QUESTIONNAIRE

Rows	YES	NO
This questionnaire has been completed by the CMO

18) REMARKS

19) FILE UPLOADS (maps, etc.)

20) DATE

Date

21) SIGNATURE OF THE CMO

Rows	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Doctor (CMO incl.)
Nurse
Paramedic or equivalent
Other medical personnel
Stretch bearer
Driver
Other (e.g. Pilot)
Total medical personnel

Rows	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Doctor
Nurse
Paramedic or equivalent
Stretch bearer
Driver
Other
Total medical personnel

Rows	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Doctor
Nurse, paramedic or equivalent
Pilot
Total medical personnel