Merci, Monsieur

No one who has read even parts of Philippe Bianchi’s words could be other than deeply moved, or help feeling almost unbearably close to fellow humans’ suffering. More than a “press release”, Jules’ father spoke with us, shared with us thoughts and information that is usually, and rightfully, intensely private.

And I can only hope Jules, and his parents, have an idea of just how many people feel connected to them now.

It says something about people that here, now, discussing medicine feels wildly inappropriate. What is happening behind the doors of the ICU in Mie Hospital is not for us. Because we are connected with Jules’ family now, because that’s what’s important.

I don’t think we can talk about better or worse media “strategies”. Michael’s early course was about head injury. This isn’t.

This is about people. Jules’ family. And their humanity and dignity are staggering.

#ForzaJules

Somebody put a sock in his mouth

http://www.bbc.com/sport/0/formula1/29551563

OMFG. One of his colleagues is in hospital in a coma, and he’s spouting some of the stupidest comments I’ve heard in a VERY long time. I’m shaking with rage.

Leaving aside the way he races, which often leaves a lot to be desired, let’s just take a look at some of the implications of what Sergio says, some of the contradictions, and use it as a “bullshit gauge” for statements by EVERYONE in the future.

“The Mexican says drivers will be asking governing body the FIA for “explanations of what happened and what are we going to change going forward”.”

Fair enough. The FIA is, after all, the regulatory body, tasked with ensuring safety. So tell us, Serge old boy, what about the safety measures in place?

” “You know you have to show a lift of the throttle to the FIA,” Perez said. “

Hold on a second – you mean the same FIA you’re counting on for answers to your problem? So, lemme see if I understand this.

When YOU’RE racing, it’s fine for YOU to basically thumb your nose at rules that have been developed to protect the poor shmucks who take care of you guys when you go off. Rules that say, black on white, to be prepared to stop.  Because there are people, and cranes, and stuff, RIGHT THERE. Around the bend. Holy shit! How could I have known?

You see, Sergio, the rules that you’re trying hard to ignore actually not only do something about safety, they really work remarkably well. What sucks is that for that to happen, you have to OBEY them. First thing to change Sergio my friend? Read the fucking international sporting code – YOUR rulebook, dude – and think about what the fuck you do out there.

” “But if we are honest we know we want to lift as little as possible and go as fast as possible. “

See, I must be overtired, coz I don’t follow you. We kinda understand that you need to go fast. Actually that’s why we watch this stuff! A lot of us like to drive fast too. But we follow the rules. When we’re late for work. Or to pick up the kids. Things that are a FUCK of a lot more important than your job, our entertainment.

But guess what happens when I consider that my kids, my job, allow me to skirt the rules? Yep, same thing as when your double waved yellows are just something to “show a lift” for! I know, right! People wind up with two broken legs. Or in comas. Or dead.

So let me ask again – you want change, you want more safety, but you also want to go as fast as possible through a double yellow zone?  That seems mutually exclusive to me. In fact, it sounds like something a third grader would say – someone so impossibly unthinking that he’s not even aware of the internal contradictions. Why didn’t you say, “we at the gpda understand that we need to look at how we drive, as well as all other factors contributing to these incidents”? Why can none of you take any responsibility for anything? Grow up. Think.

Do you think that Charlie hasn’t spend enormous amounts of his time already looking at making trackside vehicles compatible with yours (bet he’s already talked to the engineers at the Institute)? That he isn’t ALREADY doing a feasibility study of behind-the-armco cranes everywhere?

YOU are the guys out there taking the risks, not us – not Charlie, not Herbie, not any of us. That said, we’ve proved ourselves incredibly capable of protecting you from almost everything.

But if you don’t start thinking a bit, it’s gonna be hard to protect you from yourselves.

Two remarkable folks

I just drove two hours into France, and of course had time to think. One thing kept coming back very powerfully.

I kept thinking how much I hope Jules’ parents know and feel the support and energy of what are certainly hundreds of thousands, if not millions, of fans worldwide. That’s a lot of parallel processing. Sure can’t hurt.

And I kept thinking that I hope they understand how grateful we are for their courage in talking to us through an simple honest press release.

 

Diffuse axonal injury

When we talk about “severe” head injury, as I mentioned Sunday, we’re talking about a classification that’s done CLINICALLY. That means the Glasgow score is assigned without taking into account exactly what the injuries are. Eyes, verbal, motor. That’s it.

We’ve spoken quite a bit about hematomas – collections of blood either outside of the membranes protecting the brain (“extradural” hematoma), within those membranes (“subdural”), under them (“subarachnoid”) or in the brain substance itself (“intracerebral”). Hematomas cause damage by compressing and displacing brain tissue, but also by increasing the intracranial pressure (see earlier posts about this).

When we take a patient to the CT scanner to see what the injuries are, we’re sometimes surprised to see that our (very) comatose patient has a shockingly “normal” looking scan. When the scan shows essentially generalised swelling with no significant focal neurosurgical lesions (i.e., bruises and hematomas), we talk about diffuse axonal injury, or DAI. We HATE when this happens. We have a scan that’s remarkably . . . pristine, with a patient who is seriously comatose.

Let’s look at the terms just a bit:

DIFFUSE: unlike hematomas, which by definition occur at a given location, using conventional imaging, DAI doesn’t show any SPECIFIC location for damage. This obviously isn’t particularly good news, because it precludes systematisation of the patient’s symptoms, makes rehabbing harder, etc.

AXONAL: the axons are the cable part of the nerve cell. They’re insulated cables, to conduct nerve impulses faster, so they’re covered in a fatty membrane, making them whitish. When you group lots of axons together you get white matter. The cell bodies of the nerve cells (neurons) are greyish . . . so when you put a bunch of nerve cell bodies together, yep, there it is, grey matter.

DAI seems to damage the white matter of the brain. The cabling. Once again, this isn’t really great, as the cabling is what allows higher-level information processing by hooking up the various brain areas (e.g., visual and auditory. I SEE you talking, HEAR your words, but actually it’s associative areas  of my brain that fuse the information and integrates it into my experience of YOU TALKING. That kind of processing is easily interrupted with DAI.

This will often be associated with brain swelling, at least initially.

I’m totally gutted, sickened, by having to ask you to go back to December and January’s posts for more about ICP if you’re interested. I don’t have the heart to go through this again. Not for another of our guys. Jeez.

DAI is usually associated with a somber prognosis. Jules is young, strong, and is being cared for by a superb team. C’mon Jules. Go for it.

Before the reform frenzy starts

We’re just over 48 hours since Jules’ accident. Still hoping and praying for a good outcome. And of course, by now, the dust is settling, and discourse becomes less emotional, less intense, and more reasoned. I thought I’d take advantage of this period of relative calm to put a few thoughts out there.

The first thing I want to point out is that the three most severe accidents we’ve had since 1994 have all occurred through mechanisms that are not easily predictable. I’ll not go so far as to use the expression “freak accidents”, but being hit in the head with an 800 gm spring, driving into the lifting tailgate of a lorry, or aquaplaning into the exact spot a recovery unit is working are not your standard scenarios.

I say this because we need to have a bit of perspective here. Virtually every weekend we see, often with a quiet “ho hum”, accidents that in a not distant past would no doubt have been fatal. Basically, the things that used to kill and maim drivers have almost been engineered out of the system. Fire? (Williamson, Courage, Bandini to name a few)? We just don’t see it anymore (yes we had a few, but none with any significant consequences). Frontal collisions? (Rindt) We shrug off the most spectacular. Side impacts (Senna)? Ehhhhh… Flying rollovers? Shaken, but not stirred.

Not only do we almost have to invent bizarre ways to get hurt, but when someone DOES fall victim to an unusual accident, the governing body has shown itself fairly adept at acting appropriately. Felipe’s accident? Zylon visor reinforcements. Etc etc.

Jules’ accident was INCREDIBLY violent. It is a miracle he is alive, purely and simply. And this is a testimony to the entire system. Where should we look if we want to find out if there actually IS anything to change?

To start with, I’ll harken back to one of my pet peeves.

Those of you who saw the video no doubt were impressed by just how fast that Marussia was winging it as it streaked through the runoff area into the JCB. I surely was. And I was all the more impressed that:

  • Jules was certainly aware of the risk at that point of aquaplaning (and was no doubt told of SUT’s off)
  • there were double yellow flags displayed at one, and possibly two, upstream marshal posts.

For the sake of my sanity, I’ll point out again that double yellows mean that the track might be obstructed, that there are HUMAN BEINGS WORKING trackside of the Armco, and to BE PREPARED TO STOP.

I’ve been a passenger in an F1 car, and can confirm that the brakes are phenomenal. That said, given the water on the circuit, given the loading on the car through corners 6 and 7, and given the speed of that Marussia, it is indisputable that Jules carried MUCH TOO MUCH speed into that corner. By definition. He is instructed (by the flags) to slow enough to be able to stop, yet he was fast enough to aquaplane. Those are mutually exclusive options. Period.

I’ve been saying since 2010 that flag discipline is deteriorating, and it’s deteriorating fast. And no one is making properly vigorous efforts to re-establish it.

At every F1 drivers briefing, the drivers hound Charlie for a number – “how fast can i go under yellows?” or “how fast under double yellows?”. Or even, “will I be penalised if I do 0.2 sec less than the last time thru that sector…”

THEY’RE MISSING THE POINT. AND BECAUSE WE’RE NOT INSISTING ENOUGH ON THE RIGHT ANSWER, BAD THINGS HAPPEN.

The point is that the speed that’s appropriate under double yellows is variable. It’s not a speed limit, it’s a warning. Just ahead you might have nowhere to go. Or, just ahead someone’s uncle, brother, father is pushing one of your colleague’s cars off the circuit (remember the marshal whose legs you broke in Monaco Pastor? When you kept your foot in it through double yellows into Casino? I do).

I bet that the “appropriate” speed through T6-7 Sunday was probably something like 80-100 km/h – something like pit lane speed. Had drivers done that, the absurdity would have rapidly become apparent, and race control would have had little choice but to deploy the SC.

Disrespect for flag discipline is not a minor issue. It kills and injures people. If flags are respected, things get remarkably safer. If these flags had been respected, it is hard to imagine this accident happening, at least with this kind of energy.

Before we start changing everything, wrapping JCB’s in tech pro, putting SC’s out every time someone’s in the armco, let’s correctly apply the spectacularly effective safety system already in place. And let’s start by making sure drivers actually respect the SPIRIT (“be prepared to stop”) and not the LETTER (“how many tenths down do I have to be to not get a stop-go penalty?”) of the safety regulations.

Oh and one last thing: please Jules, get better fast.

 

Out of surgery? (speculation)

It has been reported, but NOT by the hospital itself, that Jules is out of surgery and “breathing on his own”.

When a patient is brought emergently to the neurosurgical theatre for evacuation of a hematoma, the decision on how to manage the end of the surgery is a collaborative one, between the neurosurgeon, the anaesthetist, and perhaps the intensivist who will subsequently be charged with the patient’s care.

The decision basically involves: do we wake the patient up, or do we keep him or her asleep, intubated, ventilated mechanically, and do the wake-up later.

Factors that would tend to lead us to awaken after surgery would be:

  • relatively decent neuro status pre-op (meaning a GCS more like 8-10 or so)
  • a pre-op CT scan that doesn’t suggest widespread damage, intense swelling, or multiple hematomas (that kind of patient usually won’t make the preceding criteria, anyway)
  • a brain that doesn’t appear to swell when opened during surgery, and that doesn’t seem to have significant damage other than the hematoma
  • stable vitals and ICP during awakening
  • high quality surveillance and immediate availability of neurosurgical and anaesthetic resources

If indeed Jules is out of the OR, and if indeed he has been extubated and is breathing spontaneously by himself, then what is significant (in the absence of other specific medical information) is that this indicates how confident his surgeons and intensivists are that his neurological status is sufficiently stable to allow him that “luxury”. That would be really superb news.

#ForzaJules

Suzuka background information: head injury definitions

Head injury is often divided into mild, moderate and severe. These definitions depend on a classification system that I’ve mentioned some time ago (under equally stressful circumstances) called the GLASGOW COMA SCORE (GCS). This is a standardised score used worldwide that gauges the depth of coma, and allows tracking of a patient’s condition.

The immediate approach to a patient with evidence of (or suspected of having) a head injury (and once the airway is opened and secured, oxygen provided, and circulatory status verified) involves assessment of the pupils. Normally, pupils are mid-open, and react to light.

Under some circumstances, that changes. When we remember that the diameter of the pupils is controlled in the brainstem, where most other vital functions are handled, we realise that the pupils can be a marker of significant things happening neurologically.

Dilated pupils that do not constrict with light worry us. A lot. I mean seriously a lot.

One dilated pupil means the brainstem is getting squished to one side by asymmetric pressure above. Not good at all. VERY rapid action is indicated.

There are other pupillary signs – details for us here. Let’s move on.

The next thing that’s assessed is the GCS. Scores run from a minimum of 3 to a maximum of 8. Scoring allows classification into MILD (GCS 13-15), MODERATE (GCS 9-12) and SEVERE (≤8) head injury. This determines initial management.

When the rescuer looks at the pupils, she’s also looking at the eyes. There are four possibilities, and these are given points:

  • eyes open spontaneously: 4 points
  • eyes open when you talk to the victim: 3 points
  • eyes open when the victim receives a painful stimulus: 2 points
  • no eye opening: 1 point

The patient’s vocalisation is next assessed. The verbal score is done like this:

  • oriented: 5 points
  • confused: 4 points
  • inappropriate, but stil words: 3 points
  • sounds only: 2 points
  • no verbalisation at all: 1 point

Then the patient’s movements are considered (the best side if there’s a difference):

  • obeys simple commands: 6 points
  • pushes away an “annoying” hand: 5 points
  • vague mass reaction to noxious stimulation: 4 points
  • highly abnormal generalised flexion response: 3 points
  • highly abnormal generalised extension response: 2 points
  • no movement at all: 1 point

Mild head injury (13-15) is usually what we call concussion. They lose a point because when you leave them alone they shut their eyes, and another because they’re confused.

Severe head injury patients lose points with their eyes – usually at best a 2, more often a 1. They lose points on verbal. When we get to these folks fast, they might be speaking. That rapidly becomes mumbles, moans, etc. One point gone each step. And lastly, severe head injury patients often initially show those frightening abnormal responses, which often indicate pressure on the brain from a hematoma.

Enough for now.

#ForzaJules