What may be going on now, and where this might be going (long, speculative and detailed)

The Daily Mail has done it again. With today’s headline they’ve “forced” me to take to my blog to help clarify some of what’s being said.

As with everything that I’ve said, tweeted or written since Michael’s accident, I need to make clear that I have not seen Michael, not seen his scans, and not had any contact with the medical team caring for him. I’m going to base the following on what has been said by his care team, on the things that have not been said (by anyone), and on my clinical experience (and that of colleagues) with similarly injured patients.

What is likely happening now? Michael is almost certainly still in the Intensive Care Unit (ICU). I say this primarily because it is rather likely that he still requires this level of care given his injuries, but also because had he been moved from the ICU to a normal room, this would have been sufficiently newsworthy to have almost certainly been announced. If Michael’s breathing is still handled by a respirator, he will almost certainly have had a tracheostomy done. This is more comfortable for the patient, spares the patient from potential damage to the vocal cords, and can make weaning from the respirator easier. It can also be easily closed later, when appropriate.

More importantly is the question of the “artificial coma”. Now those of you who’ve been reading me since the beginning have no doubt noticed that I HATE the term “artificial coma”. It’s confusing and doesn’t transmit any useful information. Initially Michael was no doubt maintained at a VERY deep level of sedation, deep enough to virtually suppress most electric activity in the cerebral cortex (the outer layer of the brain, responsible for higher intellectual functioning). This was done to help manage what were extremely high and dangerous levels of intracranial pressure (ICP, see previous blog entries).

Now that the acute phase of the injury has largely passed, it is almost certain that ICP is no longer problematic. The swelling and bruising are being resorbed. This means that the sedation will certainly have been lightened. Remember that having a tube in the windpipe is a pretty significant and painful stimulus. So sedation is almost always needed to help the patient tolerate the tube, to allow mechanical ventilation, and permit all the other “aggressions” that are part of day-to-day ICU routine. If this is the case, then the care team will be repeatedly, and considerably, lightening the sedation, in order to start weaning Michael from the ventilator, and to allow neurologic evaluation.

This would be good – if the sedation is light, and if respiratory weaning (getting Michael to breathe by himself) is progressing, with a neurological status that allows this, then we can relax for a few weeks, and see how the situation evolves. This situation would mean progress has been made, and renders further prognostication impossible. Progress will continue at an unknown and unknowable speed, and will stop at an unknown and unknowable level of function.

It is also conceivable, at the other end of the “goodness” spectrum, that the sedation has been turned off, that Michael is tolerating the tube, but is neither breathing adequately on his own nor showing significant signs of emerging. You understand that tolerating a tube with no sedation implies rather severe problems with deep levels of the brain, as does the lack of adequate breathing despite stopping the sedatives. At three weeks post injury, this is the worst outcome we could hope for, as it would indicate a rather high probability that normal consciousness will not be regained.

A brief word about the terms “critical” and “stable”. First of all, as used with respect to the condition of hospitalised patients, neither is precisely defined. So it’s important to see them rather more like an impressionistic image than as an accurate statement of  physiology. Critical means imminent life threat or threat to a vital system. Stable means that something is not changing, and is usually being maintained within normal limits. So Michael is no longer CRITICAL (the ICP has normalised), and STABLE, as his physiological parameters are now acceptably “constant”.

Ok let’s get down to the hard stuff here. What are the possible outcomes? I’ll look at some of them, mostly with an eye to defining terms we’re likely to see thrown about in the near future, so that we can be precise ourselves, and be critical when faced with imprecise, ambiguous, or misleading information from others (are you listening Daily Mail?).

Now remember, all we know with certainty about Michael’s injuries comes from the press conferences given by his care team. After explaining the how and why of evacuating the right-side extradural hematoma (on the Sunday) and then the left-sided intracerebral hematoma (on the Monday), the neurosurgeon let slip a VERY telling statement.

I’m almost quoting him here, translating from the French. He said “don’t think that we evacuated two hematomas and that’s it”. “Michael has lots of hematomas in his brain, on the left, on the right, and in the middle”.

Damn. See, the “middle” is where all the important stuff happens – awareness, arousal, control of blood pressure, respiration, swallowing etc. And the left – well that’s usually language. Etc etc. The neurosurgeon, intentionally or not, painted a rather catastrophic neurologic picture.

First off let me say that it is EXTREMELY unlikely (I’d honestly say virtually impossible) that the Michael we knew prior to this fall will ever be back.

I think that it will have to be considered to be a triumph of human physical resiliency, and of modern neurointensive care, if Michael is able to walk, feed himself, dress himself, and if he retains significant elements of his previous personality. If recovery proceeds to this point (which is totally POSSIBLE, if perhaps rather improbable), it is an open question as to how well the “higher functions” (memory, concentration, reading, planning, etc) will recover. Please note, I would love to be proven wrong about this! 

At the other end of the spectrum would be continued coma. Coma is defined as a state where there is neither wakefulness nor awareness (the patient cannot be woken by stimuli), no meaningful interaction with the environment, and no voluntary actions. This is obviously catastrophic. This outcome is entirely possible based on what we know about the brain’s primary injuries (the fall, the hematomas, bruises, etc) as well as the relatively long period with high ICP.

It happens that patients in coma emerge sufficiently to show spontaneous eye-opening, and even sleep-wake cycles (demonstrating wakefulness or arousal), but show no interaction with the environment, and no signs of any higher function (thought, speech, etc). This is called a vegetative state. Definitions vary somewhat, but usually after four weeks it is termed a persistent vegetative state, and after one year it is called a permanent vegetative state. Very roughly speaking, about 50% of head trauma patients who are in a vegetative state one month after injury become conscious, often with significant neurologic impairment. If the vegetative state persists for six months, this falls to roughly 20%, usually with severe impairment. After one year, resumption of normal consciousness is very rare, and, when it happens, function is usually gravely altered.

Whereas a patient in a vegetative state shows no signs of awareness, a patient in a minimally conscious state will show definite signs of awareness of either self and/or of the environment. This may include obeying simple orders, some intelligible language use, or other behaviors that seem “goal directed”. Examples would be appropriate emotional responses, appropriate eye tracking, consistent and appropriate movement or vocalisation in response to language (not just sounds). These signs usually fluctuate through the day, and over time. Importantly, the chances of meaningful recovery from a minimally conscious state are higher than from a vegetative state. They are however, still disappointingly low.

There is certainly reason for worry – lot’s of worry. But no reason to lose hope. Everyone who works with head-injured patients has seen VERY severely injured patients (who were not expected to do well) recover acceptably. All we can do is wait, pray, and be behind Michael and his loved ones.

 

 

36 thoughts on “What may be going on now, and where this might be going (long, speculative and detailed)

  1. Pingback: Comment va Michael Schumacher, un mois après son accident ? - Direct.cd

  2. Thanks for this blog – the reports in the daily mail are somewhat upsetting to read :-( praying for a miracle for Michael and his family as are millions of his fans. I work with a wide range of people, some of which have sustained brain injuries that have gone on to make a reasonable recovery (just look at Richard Hammond). Come on Michael you can do this xx

  3. I’m not a “fan” of F1 or even an avid MS watcher but I simply feel caught up in the evolving human tragedy of a great sportsman and his family. The absence of news from the hospital is telling and the crass comments by the press such as the Daily Mail are really unhelpful. Thank you for your blog posting … it’s very helpful albeit bleak.

  4. Excellent blog, Dr. Hartstein. Thanks for telling it like it is.

    For anybody wanting to learn more about traumatic brain injuries and their long-term effects, watch this excellent documentary:

    http://thecrashreel.com/store/?index.php

    Sadly, the Schumi we all knew and loved died on Dec 29th. If there is a recovery (and that’s a very big “if”, at this stage), the man that will emerge will be a distant memory of the version we all knew. Praying to his recovery and that someday I have to eat my words.

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  6. Hi Gary,
    Very much appreciating your articles. We all hope for Michael’s full recovery, but there is talk about a severely brain-injured person getting a changed personality. How is this? Is it like “a completely new personality” or is the person really the same, but has difficulties “getting through” to others and the outside world?

  7. I hope you are wrong too Glenn but I do agree with you. What we get from Dr. Hartstein is first hand … what we get from the Press is second hand, but we cannot just ignore the stated opinion of specialists in this area of medicine who seem to be beginning to say the same thing. ‘The longer this goes on ….’ etc.
    Eminent neurosurgeons Jean-Marc Orgogozo of Bordeaux, Dr Richard Greenwood of University College and one other eminent specialist whose name escapes me have all commented on Michael’s condition, and even allowing for Daily Mail type hyperbole, the situation is beginning to look pretty grim. The ‘DAMN’ paragraph in Dr Hartstein’s piece doesn’t leave much to the imagination either. I too feel we sense where this is going …. but just don’t want to take it in all at once.
    I too remember the Senna wait … I remember the Ronnie Peterson wait and going further back the Jochen Rindt wait (made worse as I was at Monza having been invited to the pits) .. what makes this so much worse is that I fear this will be a very different kind of wait. A wait that could take many years.

  8. Please go to bleacherreport.com and read the F1 article “media too intrusive and speculative”. This article praises Gary and the information he shares with us and derives the speculative and sensationalized reports that some of the tabloids feel we needs to read

  9. Pingback: Fernandes joins critics of double points plan | F1 Fanatic Round-up | Formula 1 News

  10. Pingback: Michael Schumacher brain injured - Page 3 - Pirate4x4.Com : 4x4 and Off-Road Forum

  11. What you need to know may not be what you want to hear. So said an engineer friend of mine. Exactly how I feel right now. I was in the Tribuna Verde behind Tosa almost 20 years ago when Ayrton Senna crashed. Michael Schumacher went on to win the race and become the driver we all remember. I’m feeling the same emotions since the accident that I felt on that long walk from Tosa to the train station. Many of the Italians had portable radios, they were giving us updates but I think we all knew what had happened. Hope I’m wrong.

  12. Miracles do happen. Although it might be difficult to compare cases
    I know of a speedway rider named Ricky Ashworth who was in a coma for
    3 months following a critical head injury sustained in a motorcycle crash.

    Hopefully the same miracle will happen to Schumi.

  13. Pingback: F1 Fanatic round-up: Fernandes joins critics of double points plan

  14. Forget the racing, achievements and all the ‘greatness’ stuff we know already. What comes across from so many of these posts is what a ‘good’ man Michael is. I speak German and so have been able to watch some of the interviews he gives in his own language, and yes, he comes across as a ‘good’, articulate, considerate, thoughtful, kindly man .. especially since his first retirement. He was approachable at Mercedes, even funny .. a real personally had been born in the time he was away from the sport. It is now clear we won’t get the Michael we know now back … as the truth slowly dawns that is in itself almost unbearable, but whatever we do get let’s not forget what a ‘good’ man he is.

    • Hi Peter – Beautifully stated. All hope is not yet lost. We must remember that miracles occur. Frankly, I am praying and holding good thoughts for Michael Schumacher. I really don’t give a darn about “Joe Bloggs.”

      Again, eloquent post.

  15. Thanks so much gary for sharing your knowledge with us….I can hardly bear the thought of the Michael we know and love against the Michael he may become. He is such a good man I pray that the man above will grant a miracle and bring him back to us. My love and respect to his brave family and wish them the strength to carry on.

  16. Hi Gary, not a lot more to say other than what has been said here already. It’s so desperately sad to see this wonderful and oft misunderstood human being reduced to a few paragraphs of sensationalist sh*t. I feel cold, numb and scared for what the future holds but am trying to cling on to the best possible outcome. I pray daily for his family to find the strength to carry on and truly hope they know just how much their pain is shared, how close to millions of people’s hearts they are and that one day they can take comfort in that fact. I know it won’t be easy. My thanks to you for being the voice of reason in this difficult time – it is VERY appreciated.

  17. I echo the sentiments of all here whilst I have to admit shedding a few tears reading your article & Eliza’s comments. I truly pray that Michael will be able to shake your hand after all this. I don’t think Michael would fight on for anything less than the best scenario you mention or better than doctors would reasonably expect, something akin to a miracle. If anyone can do this The Schumi can!

  18. Thanks for the explanations. I confess that comprehending the level of care that Michael is receiving leaves me with a severe case of culture shock. Without any doubt whatsoever no one would survive his injuries in the UK county where I Iive. If one should watch “House” the number of tests performed for diagnosis is breathtaking. Here, A&E have about 5 possible tests, if you do not show positive, you are not ill, you are discharged regardless.

  19. Thank you for being a voice of sanity amidst the frenzied, unfounded speculation. We appreciate your taking the time to keep us all informed and to guide our expectations for the future.

  20. Gary once again thank you for thinking of us fans, which the majority of the press are completely failing to do never mind Michael’s family and close friends who are having a hard enough time of it as it is. Some of what you have written is difficult reading but until we know the facts we just have to prepare for anything whilst hoping for the best possible outcome.

  21. Pingback: Daily #F1 News and Comment: Wednesday 22nd January 2014 | thejudge13

  22. Good day Mr. Hartstein. Firstly although you know how grateful we are for all of your reassuring statements and advice, I am going to express my deepest and most heartfelt gratitude to you. Needless to say, that everything since that fateful day in December has been heartbreaking, devastating, worrying and terrifying, but even in the toughest storms, there’s always a light that shines through and that light is YOU. To describe what Michael means to me would be a task deemed impossible. Michael is like a part of me and will always be. Life has lost its color and fairness since his accident and every second of everyday it seems is spent on thinking and praying for a miracle recovery. I’m still in incredible shock and still even after this long, can’t believe that this tragedy is real. So stating all of that, your advice and expertise has definitely been the CALM in this STORM. I honestly ask myself- What would we do without you? Your presence exudes serenity and even when reading these UNTRUE and HIDEOUS reports on our beloved Michael- we know that we have a “safe place” to adequately and respectively gain information regarding his condition. You may never truly understand how precious that is to all of his fans that are frantic whilst awaiting credited news. While all these “OTHER” specialists provide their unwanted doom and gloom, you provide the gift of knowledge in a gentle manner. I hope that you receive all the blessings that’s owed to you Sir and one day hopefully soon Michael will thank you himself for looking after the fans that love him with all their hearts. As always prayers with his amazingly resilient Family. They are so beautiful and I respect them to no end. May GOD look into our hearts and see our wishes and relinquish Michaels suffering and that of his families, friends & fans. Lastly to you Sir- all that’s left to say is THANK YOU & GOD BLESS and may our hero SCHUMI come back. Kindest regards-Eliza.

  23. Gary, Lucy (Bonser) here. Hope you’re well? Good to read your excellent, clear posts. So very worried about MS; avidly following any information I can find but only believing in yours. Keep them coming, it does helps fill the silence. Thank you.

  24. Thank you for this. As fans, we are devastated by Michael’s accident, but also want to support Michael’s family in their decision to reduce press interest so that they are not continually hassled during access & egress to the hospital during this difficult time. That the press are releasing such sensationalist and frightening reports helps nobody, not Michael, not his family, nor us who love him also. I believe in Michael, I believe in the doctors and I believe he would not be here now following this horrendous accident if he were not still fighting… and I believe in not following sensationalist press reports. To read your explanation both scares me what Michael and his family face, but also helps me understand. I continue to pray for Michael, for Corinna and his children, his brother and father, and hope desperately that Michael is able to make a recovery. X x

  25. Thank you for the clarification and your honesty. All in all, the current situation and the possible outcomes sound very discouraging to me, but who knows: Never give up on a miracle.

    • Sabine – I am quite new at this and so I ask that you forward the following to Gary after you have had an opportunity to do your own research.

      There are many studies taking place in the U.S. regarding TBI and Pharmaceutical Quality of Fish Oil. You can Google Fish Oil and TBI to substantiate that statement.

      Thanking you in advance for forwarding this to Gary and it is my prayer as well that Michael receives every opportunity available to recover and be Michael Schumacher rather than “Joe Bloggs.”

      Thank you for your help

      KC Fisher

      What follows below is found on CNN: http://www.cnn.com/2014/01/18/health/fish-oil-recovery/

      The story is about Grant Virgin and what his parents did when the doctors said that there was no hope left for their son.

      “Grant’s mother got in touch with one of the foremost omega-3 experts, Dr. Barry Sears, who had consulted on the first-ever case of high-dose fish oil for traumatic brain injury in 2006.

      It involved a miner, Randal McCloy, who was involved in a deadly explosion in West Virginia. His brain had been badly damaged by carbon monoxide, and his team of doctors was trying desperately to keep him alive.

      McCloy’s neurosurgeon at the time, Dr. Julian Bailes, describes considering high-dose fish oil in this case, as akin to “throw(ing) the kitchen sink at him.”

      “There is no known solution, there’s no known drug, there’s nothing that we have really to offer these sorts of patients,” said Bailes, co-director of NorthShore Neurological Institute in Evanston, Illinois, during a previous interview with CNN.

      The theory behind fish oil as a therapeutic intervention for traumatic brain injury is at once simple and complex.

      Simply stated, the brain’s cell wall is, in part, composed of omega-3 fatty acids.
      “If you have a brick wall and it gets damaged, wouldn’t you want to use bricks to repair it?” said Dr. Michael Lewis, founder of the Brain Health Education and Research Institute. “By supplementing using (omega-3 fatty acids) in substantial doses, you provide the foundation for the brain to repair itself.”

      More complicated is how omega-3 fatty acids might control inflammation — or damage — in the brain. Sears likens it to quelling a metaphorical fire in the brain.

      That “fire” begins when the brain is traumatized — as with a profound injury like Grant Virgin’s, or milder insults like concussions suffered on a soccer field. Neurons snap, setting off a wave of inflammation in the brain that can smolder for long periods of time — sometimes weeks or months after the injury has occurred.

      “That (inflammation) will continue over and over unless there’s a second response that turns it off,” said Sears, president of the Inflammation Research Foundation.
      The fatty acid that Sears says can effectively “turn off” that inflammatory fire is a metabolite (what remains after the body breaks something down) of eicosapentaenoic acid, or EPA, called resolvin.

      EPA is found in fish oil.

      “What we think is happening is, high levels of EPA coursing in the brain metabolize into resolvins, turning down and turning off inflammatory process,” said Sears.”

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