Luca di M’s statement

I have no idea at all what, exactly, Luca di Montezemolo means when he says that the news is not good. I’ve read speculation that actually he said something like “there’s no good news”, and that this has been mis-translated into “news that is not good”.

I assume that had Michael died, it would not be a furtive comment by a relatively distant ex-friend that would reveal this to the world.

We are now over two years since the injury. Despite the family’s silence, one can safely assume that were there to have been ANY good news, we’d have gotten it. After all, the family “allows” close friends to make statements (e.g. “he’s still fighting”, etc).

What we know is that two years after a severe head injury, a patient’s clinical status is (with near statistical certainty) not going to change. Given that the family’s own statements define what we call a “minimally conscious state”, this obviously is about as bad as news can be. What else can go wrong?

Because patients in a minimally conscious state have lost many of the body’s built-in “maintenance” functions, their life expectancies are significantly shortened compared to age-matched controls. Highly skilled and motivated nursing and medical care can forestall many or most of these, but they remain constant threats. The kind of things that happen to people in this situation are:

  • muscle loss. This is both an expression of the effects of lack of activity, as well as a key factor in several other complications
  • pneumonias. MCS is often associated with difficulties swallowing, and ineffective coughing to clear the normal secretions that our bronchi constantly produce. The loss of coordinated swallowing places the patient at risk of inhalation of oral and gastric contents, leading to repeated bouts of bronchopneumonia. This is a near constant in this group of patients, so much so that it’s virtually certain that Michael is fed through a tube inserted directly into his stomach or small intestine (a gastrostomy or jejunostomy tube).
  • urinary stones. These are also extremely frequent, and can lead to repeated urinary infections. These infections can lead to septicaemia, and are a frequent cause of hospitalisation.
  • pressure sores. Because these patients usually do not move much spontaneously, long-duration pressure on various parts of the body (back of the head, sacrum, heels) can compress the capillaries and lead to tissue breakdown and sore formation. No doubt the extraordinary care that Michael is receiving goes a long way to avoiding this problem.

Long story short? It’s possible that Luca di M is talking about one of the above complications. Anything worse? Could be, but I suspect that should this be a REALLY significant turn for the worse, the family might actually consider the millions of people who pray every day for Michael and say something.

 

 

Sh*t’s gonna hit the fan…

After a series of heart wrenching Facebook posts, PhilIppe Bianchi has posted this today:

Que chacun sache que si depuis un certain temps la Famille Bianchi est resté bien calme il n’en est rien notre petit jules nous donne chaque jour sa force et de belles actions vont etre menées jamais on ne l’oubliera et vous ces fans ces amis vous vous ferez toujours partis de son histoire rendez vous en Janvier pour la riposte

Here is my translation:

“Just so everyone knows, if for some time the Bianchi family has been serene, this is just an impression. Our little Jules gives us strength every day, and notable action will be taken. We will never forget him, and you his fans will always be part of his story. Rendezvous in January for our response”

We obviously don’t know what action is meant, but what is intriguing is the use of the word “riposte”.

 

Carlos Sainz (Jr.) and Sochi

While hoping to be forgiven for the long delay, I do need to address the issue of Carlos Sainz’s return to competition after his accident in Sochi. Here’s my slant on the question.

Carlos’ accident was very violent; certainly it would be normal to expect at least some concussive symptoms (given that other physical injuries were ruled out). The short observation period followed by a quick release from the hospital were reassuring of course, but even concussed patients are not kept hospitalised (unless there’s another reason) just for these symptoms.

Once he (and the team) made clear that he wanted to race on Sunday, he had to be examined by both the circuit’s Chief Medical Officer and the FIA Medical Delegate. (Unfortunately, it would have been better to have had to have his accident in Austin, where the CMO is Dr. Steve Olvey, a world expert on concussion, especially in the motorsports environment.) This examination would include a thorough history, looking for subjective symptoms of concussion, as well as a detailed neurologic examination.

Carlos would also have had to re-take the ImPACT test, a computer-based neurocognitive battery specifically designed to detect concussion. All the drivers get tested pre-season (to supply baseline data); they are retested whenever concussion is suspected.

The ImPACT test consists of a number of subtests, each of which looks at a different aspect of brain function (visual memory, executive function, pattern recognition, etc). It’s crucial to note that the test starts with a review of SUBJECTIVE symptoms – a series of true false questions (“I slept well last night”, “I have a headache”).

My conclusion? I find it odd that Carlos failed to mention his dizziness pre-race to ANY MEDICAL STAFF AT THE CIRCUIT, including the CMO and the Medical Delegate, who unquestionably asked that specific question. And that he blabbed about it to the press almost immediately after alighting from his car. Let me repeat this: this kid denied symptoms to the people responsible for his care, got into his car, raced, then complained about not being well-taken care of.

HOW STUPID IS THAT?

One of the biggest problems with concussion is that many of its symptoms are subjective. That means they can be denied. As in all other walks of life, ultimate responsibility for one’s health and safety lie with oneself. If you’re stupid (or competitive, or just ignorant) enough to deny your symptoms when specifically asked by your doctor, you’d best have the maturity to deal with the consequences.

As much as the Medical Delegate’s lack of experience enrages me (and I can only assume that the Russian CMO was equally inexperienced, I give him a pass on this one. He was clearly dealing with a patient who was not mature (or honest) enough to respond accurately to the questions he was asked by his doctors.

Congratulations (again) Lewis

Well Lewis, you’re a triple world champion. Congratulations. An incredible achievement, making you one of history’s great sportsmen. But you won this one months ago. I think you understand what I mean.

Seen from the outside, you’ve evolved, staying on the path we glimpsed at last season. And for me, this has been the most wonderful part of your championship.

The way you feel blessed to be able to do what you do, the marvel and fun you take to your personal life, and the way you’ve worked to find who and how and why you are . . . you, are incredibly inspiring. More than that, you’ve become a model for millions of people of what true success really means.

Your message is incredibly important – humility and joy, hard work and real relaxation, the importance of finding oneself. If you stay true to this, Lewis, I have no doubt that your influence and power will go way beyond your collection of F1 Championships. It has been a privilege watching your career, and I am honored to have known you.

Once again, congratulations Champ!

 

 

Round 2 of Get Gary! (Jean’s after me again)

I guess I must have again touched a raw nerve at Place de la Concorde. After trying to get me fired with an FIA-funded trip to my former employer, I have just received the following letter from the “lawyer for the FIA”:

Letter to Gary Hartstein 24 08 2015

For information, I have responded:

Email response to FIA lawyer

Over the past year or so, lots of very influential journalists have been highly critical of the FIA’s current administration, without eliciting anything near these kinds of attempts at intimidation. I suppose it’s clear that not only does this speak to the kind of people we’re dealing with, but more importantly indicates just how nervous I make them. And I needn’t point out the proximate cause of their worry, as it’s mentioned specifically in Mr. Martel’s letter.

I was, and am, sickened by the tragedy that has befallen Jules Bianchi and his family. My only motivation is, and has been, to highlight how far we’ve strayed from the path so brilliantly plotted by Sid Watkins, Max Mosley, and all the others who worked so hard to make, and keep, this sport safe.

Once again, I can only wonder who authorised the use of FIA funds for such an adventure, and whether or not the various internal structures tasked with determining FIA policy were consulted about this.

Let’s be clear:

  • this will play out VERY publicly
  • if necessary, I will crowdsource my defence, relying on the thousands of fans of our sport to help me defend myself against those whose major objective would appear to be not the safety and wellbeing of the participants in motorsport, but rather their own safety and wellbeing.

Thanks for your time and attention. As they say in French . . . à suivre.

A (nother) fantastic save! (long, a bit technical, surprise ending)

First of all, it’s fantastic to see James Hinchcliffe on the mend. As the story developed, we slowly were made aware of just how bad things had actually been. And now we’re told that he received 14 units of blood. This deserves some background, in order to fully understand just how well things worked for James . . . and draw some conclusions about how things are.

Even intuitively, hearing the number FOURTEEN PINTS is massive. Remember, James’ normal blood volume is probably (to simplify a bit) about 5 liters (for the english unit addicts, a quart is just about a liter). And a unit of red blood cells is about 400 ml. That means that his entire blood volume (5.6 liters to be exact) was replaced, presumably in the first 24 hours after admission. In trauma circles, that’s the standard definition of “massive transfusion”; this definition is not sterile, as it has important implications for management.

First, a few details.

Unlike what was headlined in some of the posts, the 14 units of blood were not administered BEFORE arriving at the hospital. There are several reasons for this (we will see the most medically relevant below), but the most practical is that this quantity of blood is NEVER available before getting to a hospital. The infield medical center at the IMS almost certainly has two to four units of blood (O negative, more later), but from there to the hospital, no blood would be available. More importantly, early transfusion of significant amounts of fluid are no longer standard protocol for massive bleeding.

The lovely tradition of drivers having their blood groups on their overalls is just that – a lovely tradition. No one, repeat NO ONE, will EVER EVER EVER be transfused based on some embroidered letters on his overalls. Ever. Period.

Let’s talk in some depth about just what and why the Holmatro team, and then the evac team who took James to the hospital did and didn’t do. First, some background.

Until very recently, the dogma in terms of taking care of trauma victims was to follow the “A B C” sequence. Life-threatening problems were dealt with in a very specific order. Problems with maintaining an open Airway were managed before problems with the Breathing, and only then were Circulatory derangements dealt with.

In terms of the circulation, by far the most common problem in trauma patients is hemorrhage. Blood loss causes a drop in the heart’s output, which in turn causes the various tissues of the body to be hypoperfused. This means that they receive too little oxygen and nutrients to maintain normal function. If this situation lasts, it is called hypovolemic (too little volume) shock. If this shock state lasts too long, it becomes irreversible; at that stage all attempts to save the patient are futile.

Advances in military medicine, notably during the Vietnam war, led to the idea of early and aggressive fluid replacement in shocked trauma patients. Intuitively this made perfect sense – since the primary problem was a deficit in circulating volume, restoring that volume (initially with relatively cheap and easy to store salt solutions) should allow cardiac output to trend upward, providing tissues with better nutritive perfusion.

This, in fact, is what is still taught in most mainstream trauma courses. After attending to the A and B parts of the protocol, we are told to rapidly begin infusing large quantities of fluid into shocked trauma victims.

The problem is, not only does this not work, but it actually makes things worse.

Huh?

Once again, some visionary physicians, working in almost war-zone conditions (ok, Houston, Texas to be exact), followed by the conflicts of the 2000s, have taken the received wisdom and turned it on its head.

First of all, the A B C sequence is being, slowly but surely, revised. It is clear that with certain injuries (think IEDs, think suspension elements ripping up a major artery in the thigh), massive arterial bleeding will kill a patient within scarce minutes, usually even faster than loss of airway opening. This has led some to propose a newer, more time-relevant acryonym: MARCH. This corresponds to Massive hemorrhage, Airway, Respiration, Circulation, Head injury.

Remember Alex Zanardi’s horrible accident in Lausitz in 2001? Well when i title this post “another”, that’s the other save to which I’m referring. Both in Germany (kudos again to Terry Trammell and Steve Olvey), and at Indy last month, the rescue teams concentrated basically all their efforts on what we call “exsanguinating hemorrhage” – commonly known as the patient bleeding out.

The second reversal of “standard” trauma care is rather less intuitive, but incredibly important.

While the idea of rapidly restoring a normal circulating volume (again, using clear fluids) would appear to make physiologic sense, studies done both in civilian penetrating trauma, as well as the military’s amazing database show that it is plain wrong (the lessons from this database will save tens of thousands of lives over the next decades; this being one of the most significant and lasting legacies of the conflicts in Iraq and Afghanistan).

When we look at two groups of trauma victims in hemorrhagic shock, one of which receives early and aggressive fluid resuscitation, while the other receives almost no fluid (UNTIL THE SURGEON HAS STOPPED THE BLEEDING, meaning that resuscitation is not ignored but delayed), we see a very significant difference in outcome. And surprisingly, it’s the group who is “allowed” to remain shocked (again, and crucially, until surgical bleeding control is obtained) who do considerably better.

Why would this be?

There are a number of hypotheses, all of which certainly contribute to the better outcome:

  • Restoring circulating volume with clear fluids does not contribute to the oxygen carrying capacity of blood, and, importantly, dilutes the clotting factors so vital to stem the bleeding by natural means
  • Increasing the blood pressure likely makes the tenuous blood clots that DO form less likely to stay in place, increasing bleeding
  • Even when using warmed fluids (and this can be quite hard to do, especially in the pre-hospital environment) massive infusion of clear fluids will usually make the patient hypothermic. The thing is, our coagulation system is exquisitely temperature sensitive. It begins to fail, miserably, when temperature gets below around 35°C, a temperature that is all too “normal” in shocked trauma patients.

Another crucially important element that has come from study of the military’s experience in recent conflicts has to do with not just WHEN we replace lost volume (as soon as surgical control is obtained), but WHAT we replace it with.

When a blood donor give a pint of blood, that pint is almost immediately fractionated. The red blood cells are packaged separately (this is the fraction most often needed by patients who are anemic from various causes), with the plasma (it’s here that we find most of the coagulation factors) and platelets (tiny cell fragments vital in the coagulation process) packaged separately.

Until recently, it was felt that shocked trauma patients mainly needed red blood cell transfusions; it was thought that the need for plasma and platelets was relatively rare. In fact, when I did my residency, we were taught specifically that plasma was NEVER to be used “simply” to restore circulating volume…ever.

Well once again, what seems clear and logical turns out to be wrong. In fact, hemorrhagic shock almost immediately induces problems with the coagulation system. And the faster and more aggressively these problems are treated, the better the patient does. So much so that in state of the art facilities, the policy is that in the shocked trauma patient, the FLUID OF CHOICE for restoring volume is . . . you guessed it . . . plasma.

Enough background. Lets look at what the Holmatro team no doubt did, and how they kept Hinch alive long enough for the surgeons to save him.

There is no doubt that at the scene they were confronted with exsanguinating hemorrhage. Their first priority then was to get James out of the car, and to stop the bleeding, even temporarily. If the site of the bleeding was far enough down the thigh to allow use of a tourniquet, they certainly applied one, high and tight. If it was higher, precluding use of a tourniquet, they used modern wound dressings that contain substances that induce a powerful local formation of blood clots (called “hemostatic dressings”). In fact, they likely used both.

(This is another reversal in “standard” practice. It is still taught that tourniquets are last resort items. In fact, with exsanguinating extremity bleeding, they are the FIRST resort. Terry understood this intuitively with Alex in Germany, but it has not -yet – become the new normal. Once again, thanks to the military trauma docs for this.)

The Holmatro guys no doubt put in a few fat IV lines, but only infused enough fluid to keep Hinch (barely) alive, for fear of creating the situation I referred to above. They also probably gave him any of the O neg (universal donor) blood available from the infield med center. In addition, they certainly administered tranexamic acid, an old drug that “boosts” the coagluation system and has been shown to dramatically reduce mortality from hemorrhagic shock.

Then then prioritised evacuating Hinch to the hospital, and, crucially, made sure that there was an operating room ready for him, and that the necessary blood products were prepared. Once admitted, once the surgeons got control of the bleeding, the anesthesiologists began to transfuse. Not just red blood cells, but also massive amounts of plasma and platelets too. In fact, the ratio was probably pretty close to 1:1:1.

Make no mistake about it – only the knowledge, skill and teamwork of the Holmatro team at the scene made it possible for Hinch to get evacuated alive. They deserve massive credit for this. I sure take my hat off to them.

Now for the surprise.

American racing is organised more along the lines of just a few teams, who travel with their respective championships and thereby gain tremendous experience working with each other, training with each other, and staying current with best practice guidelines.

In F1, for a number of reasons, each circuit fields what should be an autonomous team. The FIA Medical Delegate and Medical Rescue Coordinator are only there, nominally, to provide liaison, coordination, and to confirm that regs are followed.

Long story short? Of the 20 races of the season, at best five to seven of these “autonomous” teams would be capable of saving James, had that accident happened at an F1 event. These are the teams that are mature, stable, experienced, and well led. And it’s not always the ones you’d think of that are up to the task.

There are a number of reasons for this, not least of which are high turnover in teams, lack of training, and lack of team member participation in prehospital trauma care in the “real world”. This is not new. When I was involved in F1 I continually trumpeted this fact to the hierarchy. Given that a permanent FIA team attending all races is just not realistic, I constantly pushed for more intensive simulation based training. The hierarchy found it politically inexpedient to deal harshly with the local Chief Medical Officers whose lack of leadership contributed to this. Remember, it’s the national federations who go on to vote for the FIA president.

Don’t get me wrong – the Medical Rescue Coordinator is present at every race, and is a massively experienced trauma doctor, fully equipped both in terms of knowledge, skills, equipment and leadership. And even at the majority of circuits where the local team would not be able to handle an accident as dramatic as James’, he has at his disposal sufficient “manual labor” to get the job done. That said, one must not labor under any illusions. If we imagine the same accident at every race of the season, the outcome will vary, sometimes dramatically, depending on where we are.

While the solutions to this are not simple (or cheap, no doubt), they do exist. All that’s necessary is the will and leadership to get the job done, and to improve the standards everywhere. And of course, the “knock-on” effects of such a commitment, both in terms of “lower” series as well as in trauma care in general, can’t be ignored.

Thanks for your patience.

For all future F1 docs

I’m constantly contacted by medical students and young doctors who wish to devote their lives and careers to Formula 1. They seek advice as to what the best path to follow to actualise that desire. Here in a nutshell is my answer.

First of all, I know almost no one in motorsports medicine for whom it is a full-time job.This includes some of the most well-known and important guys doing this. There are a number of reasons for this, including the weekend nature of the sport, the fact that to maintain any level of competency one needs constant clinical exposure, and the fact that very few (non corrupt) motorsport associations can afford to pay doctors a full-time salary for what is basically a hobby. A time-consuming, passionately engaging, and extremely serious and rewarding hobby to be sure, but a hobby nonetheless.

DO NOT ENTER THE FIELD OF MEDICINE BECAUSE YOU WANT TO BE A “F1 DOC”. Become a doctor because you want, need, cannot BUT, be a doctor. If what keeps you going, through the long grueling years of studying, through the 100 hour weeks, the emotional and physical hardships of training, is the ultimate goal of being in the front seat of the medical car, GET OUT NOW. Not just because of the extreme statistical unlikelihood that it will happen, but because the motivation needs to come from the day to day practice of medicine, not from what or where you want to be . . . years later.

In terms of the skill set you need to work in motorsports, pick the field of medicine you love. The one that fulfils you. The specialty that fits your personality. It doesnt matter if it’s dermatology, ob/gyn, anesthesia, emergency medicine, or endocrinology. Remember, you need to wake up every day and go to work. And if your first thought is “shit, another day in the clinic seeing diabetics” or some such negativity, you’re going to be miserable.

To be effective at a circuit, at a rally, drag strip, etc, you of course will need total mastery of the basics of trauma care. Taking and passing courses such as PHTLS, ATLS (or perhaps more usefully the European Trauma Course) is obligatory. And only then can you start to take these certificates and turn them into real, reflexively available, psychomotor skills. I know psychiatrists, dermatologists, etc, who are marvellous motosports docs – because they’ve taken the time to learn what they need.

Get involved with the sport you love early. Start hanging out at your local venue, whether it be a hill climb, rally, circuit … Get exposed to the work, the environment, the organisation. Start to meet and know the people, and to let them know you. It’s a pretty small world, and by the time you’re ready to get out there, you’ll have built up a circle of friends, mentors, and colleagues.

Work as much as you can. I remember when i first met Sid. I’d been a consultant anesthesiologist for years, but had been doing motorsports for only a few months. I remember he turned to me on the Sunday and said “you know old boy, in five or ten years, you’re going to have figured this thing out, and you might be pretty good”.  I was, of course, shocked. But, of course, he was right. It takes a long time to figure things out. In every way. Be patient, keep your eyes and ears open. Find a mentor, and engrave everything he or she says in your memory. And be safe, right from the get-go. It’s a dangerous environment, and mistakes get paid for in cash. Protect your ears from the beginning. Thresholds are such that ANY exposure will immediately start killing your sensory cells. They don’t grow back, and you won’t notice it until it’s too late. I’ve been extremely careful since the beginning, and I’m the only person I know in any position with fully intact, audiogram-proven, hearing. Everybody else is well on their way to becoming functionally deaf.

If your personality, your medical orientation, and your needs point you to a more “acute” specialty, then the obvious constitute fantastic preparation for prehospital trauma care. Emergency Medicine and Anesthesiology – nothing like them to give you the knowledge, technical skills and reflexes necessary for immediate, life-saving decision making. Then go on and learn the principles of mass casualty management.

Hope this helps. Post your questions to the comments, and I’ll get to them as I can.