RIP Luis

It is always a tragedy to lose young, active healthy people to trauma – and the pain is of course shared even more widely when the victim is a sportsman in the public eye. I would therefore like to extend my deepest condolences to the family and friends, teammates and fans, of Luis Salom.

I have read the statement that was released detailing the medical management of this tragedy. I know Dr. Angel Charte, and have worked with him. His statement reads like a textbook of management of severe traumatic injury.

As to the use of ground transport as opposed to helicopter transfer to the receiving hospital, I think one crucial point must be kept in mind. Luis was in cardiac arrest on arrival of rescue services, and remained so during the intervention.

Angel no doubt had the helicopter moved to the scene to facilitate the most rapid transport possible IN THE EVENT THAT THE CARDIAC ARREST WAS RAPIDLY REVERSIBLE (airway obstruction, severe hypovolemia, etc). When Dr. Charte realised that the quality of CPR on the way to the hospital was going to be the determinant factor in Luis’ eventual survival, he astutely elected for an ambulance, where the availability of more space makes high quality CPR (a team effort) possible. This was an exceptionally mature decision by an experienced and unflappable clinician. Unfortunately, it was not to be…

It is reassuring to see that from a medical point of view, these guys are in very good hands.

Good bye Luis.

An open letter to the Bianchis

Today’s news (opens in new window/tab)

Dear Mr. and Mrs. Bianchi,

Forgive me for (once again) intruding into your lives.

Once again,  allow me to tell you that you have been examples of dignity and humanity in the face of unthinkable tragedy. While I cannot possibly understand the depth of the tragedy you have faced, as a father I can understand its immensity. And through it all, you have remained open and full of love and respect. You are marvellous people and you are forever in the minds and hearts of hundreds of thousands of Jules’ fans .

While it is not for me to judge “correctness” or propriety, I believe you are doing the right thing in seeking legal redress for the tragedy that has befallen you. It goes without saying that nothing will re-kindle the light that Jules brought us, but it goes without saying that your reasons lie elsewhere.

Most importantly, multiple components of the safety structure of current race practice must be reviewed and reformed. Your action will no doubt catalyse that long overdue process.

The issue closest to me is that of the medical and rescue services, the medical regulations, and the level of competence and experience of the Medical Delegate. Please do not misunderstand me. I have done my time in motorsports medicine. I have given what I can to improve how we take care of our boys and girls when they get into trouble. I am no longer angry about no longer being involved, and do not seek to once again travel the world in that position.

I am, however, bitter at the glaring lack of consideration for the quality, experience and competence of the person who has ultimate responsibility for medical and rescue decision making for the FIA’s flagship series.

This is not a “vanity” position. And while thankfully the need for medical and rescue services has become astonishingly rare, the weight of this responsibility is enormous. The decisions that must be made by the Medical Delegate often have dramatic consequences…as you have so horribly and painfully experienced.

As I’ve mentioned before (limiting myself to that with which I am intimately familiar) the crucial element as concerns the tragedy of Suzuka lies in the fact that meteorologic conditions precluded use of the medical helicopter. As the minutes of numerous meetings of the FIA Medical Commission will confirm, helicopter regulations are a constant subject of debate and concern.

According to the current regulations (authored by the Medical Delegate himself), under the conditions at Suzuka that day, with the medevac helicopter grounded, the only way that racing could have continued is if it had been demonstrated that ground evacuation to the designated receiving hospital took 20 minutes or less. I needn’t remind you that, in fact, this transfer actually took 45 minutes, more than double the allowable time.

I am not a lawyer but I think your legal team should, in their efforts to uncover contributory elements to your tragic loss, explore the following issues:

  • was there a simulated evacuation to the receiving hospital, and if so what was the time of the transport?
  • if there was a simulation, was it carried out under “real world” conditions of race day traffic, and what if any allowance was made for the atrocious meteorologic conditions present on Sunday?
  • if there was no simulation, how was a predicted ground transport time calculated? All experienced pre-hospital care providers know to use an average ambulance transport speed of 30 km/h AT BEST. Even this is often optimistic, especially under the conditions mentioned above.

It would be normal to ask the question as to whether this could have changed things in Jules’ case. While this is of course impossible to know with any certainty, I would encourage your legal team to speak widely to experts in the acute care of head-injured patients to ask the following question;

Could a difference between a 20 minute transport time and a 45 minute transport time to definitive care have been important in contributing to the outcome of a deeply comatose victim of a head injury?

Other facts can be raised, not directly relevant to this case, but rather to hammer home the lack of experience with modern pre-hospital trauma care. One of the most important of these would be the extrication strategy of the FIA. This strategy is so out of touch with current practice that several Chief Medical Officers of circuits of the F1 season worry that by following the FIA’s own regulations they are putting themselves at risk of malpractice because of deviations from standards of care. This is so critical that some have even gone on record with their concerns.

I fully expect a vicious response from certain elements at the FIA. After attempting to have my employment at my previous hospital terminated, and after threatening (almost comically were they not actually “serious”) legal action against me, I now expect worse. But no matter – I devoted a large part of my career to caring for our drivers, and I will continue to do everything I can to make sure that the legacy of my mentor Sid Watkins is not sullied.

I am available to you for any assistance or expert testimony I can provide to help you on your painful and courageous quest for answers, and more importantly, changes, to make sure that others do not suffer as you have.

With all my respect, sympathy, and love,

-Gary Hartstein

 

It’s not you, it’s me . . .

It’s over. We’re officially on a break. It’s gotten to the point where there’s less pain separating than staying together. I never, ever, thought it’d get to this. But what’s going on just makes no sense, seems perfectly conceived to drive us all away, and is shameful and embarrassing. Maybe we’ll get back. But it’s not possible to think of that now. Good bye. Good luck.

No need to rehash the past, but let me just put some of the why’s on “paper” – it’ll make me feel better about this, help ME to put my thoughts in order. Maybe to convince myself that I’m doing the right thing by walking away. It might be a bit disjointed, a bit rambling. Sorry for that. I’m pretty emotional about this.

It started for me in 2008, with my demotion and replacement by someone who not only had never cared for an accident victim of any sort, but had only ever attended two or three races . . . as a spectator. At the time, I was told by the president of the FIA Medical Commission, “We still need your knowledge and experience, though. You’re our life insurance policy.” Can’t be clearer than that, eh? We need to wait a few years for the consequences to play out, but they do, and the price is awful. A grievously injured driver, barely clinging to life, spends three quarters of an hour on soggy roads in a creaking ambulance, before receiving proper care. It still sickens me.

Here’s a scoop: there will soon be published, in an international peer-reviewed journal, a scientific paper demolishing the current system of extrication that has not been changed in over 20 years, despite dramatic advances in this field. The lack of knowledge and experience at the medical lead is so blatant that several Chief Medical Officers of the F1 season are worried that by following existent FIA protocol they are making themselves vulnerable to medico-legal consequences by failing to follow current standards of care. Read that again. This from a sport that purports to be at the leading edge of everything.

I’ve ranted about this before, and stayed faithful to the sport. But there’s more.

The qualifying debacle currently playing out to the shame of all concerned is the proximate cause. Think back – the problem years ago was an empty circuit when meteorologic conditions were such that running wasn’t advantageous. True to F1 form, complication was chosen over simplicity. Rather than a simple rule constraining teams to get their cars out there or be penalised, all manner of contrivances were instituted. Only to wind up with . . . an empty circuit at the end of quals, arguably what should be the most exciting moments of all. I can’t say who gains by this, but I sure know who loses.

What about safety car procedures? I’ve never understood the delta times, never understood keeping the car out there for two or three extra laps so that “lapped cars may unlap themselves” All I know is that under conditions that by definition are some of the most dangerous, when the entire circuit is covered by yellow flags (need I quote again the regulation concerning driving under yellows?) we have guys driving flat out. Remember Fernando’s accident at Brazil? He used the first of his thankfully many lives there . . . under the safety car. And it’s only gotten worse. Once again, why do simple when we can do complicated. And the public (who want racing once the accident has been cleared, not cars unlapping themselves) be damned.

What about grid penalties? These were treated with humour last season, but seriously? Hundreds of places of grid penalties with a grid you can count on two hands and two feet? Who is kidding whom here? Who is mocking whom? I’m sick of being mocked.

What about engine tokens? With a brilliant and potentially transferable technological formula for energy recovery, we institute a byzantine system in a half-assed attempt to control costs. Complicated, when simple would do.

We’re not complicated, we the fans. We just want good racing. We want to see the skill and cleverness and bravery of drivers battling for position. We’ve all known for years that sophisticated aerodynamics makes for incredible cornering speeds, but makes overtaking more and more difficult. Everyone smart and savvy has been clamouring for years for less aero and more mechanical grip. Huge slicks and small wings – and let the drivers do the rest. What do we get? More aero in the next version of the tech regs, and a promised 4 to 5 second fall in lap times. Do any of us care about fast processional laps? That’s what I thought. The sport is not only not listening to us, but like a petulant child it’s thumbing its nose at us. How long must we endure that?

Should I mention tires? And the absurdly complicated allotment system, the engineered degradation “to make the racing more interesting”?

In a way, these are details, but they are telling. More importantly, MUCH more importantly, is what is going on with the circuits. The circuits are where it all plays out. Where we are reminded, season after season, of the glorious history of the sport. Where, depending on the stroke of the architect’s pen, we are either treated to almost two hours of thrills, or relegated to 305 kilometres of boredom. What about the circuits?

They are being strangled. They are being charged money, much too much money, for the privilege of hosting this soon-to-be farcical spectacle. They are signing contracts that guarantee multi-million dollar losses, and this despite often fantastic attendance. They are forced each year to beg, cap in hand, for a pittance to keep functioning, to continue to host a sport where BILLIONS are earned and distributed. And finally, one after another of the temples of this sport are throwing in the towel. Now Monza is under dire threat and may not be on the calendar in 2017. The only places who can meet the current levels of parasitic pricing are those with governments that are either flush with petrodollars (not sustainable anyway in the current market) or flush with corruption.Or both. Bernie and todt getting touchy-feely with Putin was and is an abidingly nauseating spectacle. Who are they kidding? And who is losing out here? Yep – we the fans. I’m sick of it.

todt has proven that, since becoming FIA president, he either has no idea how to make sure his flagship championship flourishes, or just doesn’t care. Either way, his term has been a shameful example of (almost laughably ineffective) self-promotion. Of blatant abdication of his roles and responsibilities. Of cowardly acquiescense to others.

Bernie, a man I love(d) and respect(ed), has apparently lost the plot. Or lost the ability to influence the plot. The man who created the modern sport of F1 can find nothing better to do than to slag off on it publicly. Can anyone remember the last constructive idea he has had, the last time we actually said “Thank God he’s around”? I sure can’t.

His business model, with floats and bonds and all manner of other financial manoeuvring too complicated for someone like me to understand, has created a monster. A monster whose driving force is profit . . . to the detriment of the fans. I’m not one to bemoan the role of money in global sport. Tennis, golf, football, etc are all multibillion dollar enterprises. BUT THEY CONSISTENTLY ACT IN THE INTEREST OF THEIR FANS BECAUSE THAT’S WHAT KEEPS THE DOLLARS COMING IN. Not F1. Soooo not F1. And I for one am sick of yacht-owning, Gulfstream-flying, Maybach-riding preadolescents bickering and yapping while the sport that made them rich burns. And while the fans who made them rich cry.

There you go. I’m out. Maybe if enough of us do the same they’ll realise where the true power is. But I have no intention of trying to start a movement. I just can’t keep investing emotionally in a sport that has no concern, demonstrably none at all, for us.

I’ll continue to follow all my F1 related twitter feeds.I’ll continue to love Lewis and Jenson and Fernando and Max and all of them. Continue to respect and admire their skill and courage. Continue to pray for them to be safe. But I won’t watch. I can’t. Not unless things change.

 

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!