You guys are pretty amazing

Wow – if I was amazed before at your comments, I’m totally staggered by all the feedback from the previous post. I’m staggered by the depth of your thought and reflection, by your eloquence, and by your willingness to sit down and join the conversation.

You’ve made me realise I was certainly too strong in my criticism of the current comms policy. You’ve probably noticed this is a bit of a character trait! I’m exquisitely sensitive to the unimaginable situation Michael’s family and friends are in, and if I could think of how giving us SOME information would make their lives in any way worse, I would reverse position immediately.

I do feel strongly that there’s an implicit contract, whose terms are negotiated in real time, between celebrities and their public. Paparazzi can take and publish pictures of celebrities during “private” moments that they can’t take of any of us. That’s been established as a legal principle. The line they and others either respect or step over is also defined in real time, by judges, juries, and by societal mores. But it seems a bit one-sided to want the benefits of celebrity yet retain all the perquisites of a full private citizen outside of, say, the circuit. Once again, I don’t mean this to say that all discretion, all privacy, are sacrificed to the altar of the public’s obsession to “know”, but simply that there’s a line, a very squiggly changing line, that needs to be plotted.

Once again, thanks so much for taking the time to write. I’ve learned so much, and been forced to think so much, from your input. That’s exciting and sobering, and is an immense privilege.

Frank – you’re gone coz no matter how strongly you feel about anything, this isn’t the place for vitriol. Tone it down, and read these comments before writing – smart, well thought out, passionate. You can call ME whatever you want; I’ve heard it before and will certainly hear it again. But don’t even THINK about insulting my readers.

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Perplexity

I’ll admit to being perplexed.

First, about the silence from Grenoble.

If you’re not in the habit of reading the comments section after each post (I do, of course – it’s wonderful to see what those of you who read me think, and a source of wonder that you’d actually take the time to write), it’s worth a look (in chronological order) at the comments to my last entry.

It’s pretty clear that Michael’s fans are beginning to feel like their devotion, commitment, and passion for someone they’ve elevated to hero status over many years means nothing. I see strains of anger, disappointment, frustration. Others, with considerable self-abnegation, are hewing to “respect for Michael’s privacy” and accepting the lack of information with equanimity . . . but even here there is an undertone of frustration at being asked to do so.

I’m not a journalist, and I’m not a PR/communications professional. But I totally fail to see how the current comms policy helps either Michael or his family. I fail to see how talking to us about the significant ups and downs of this long hard process damages Michael’s privacy or makes Corinna and the kids’ journey more difficult. I cannot possibly understand the reasons for any of this. I’ve said it before, and I’ll repeat it. This is totally unfair to the people who made Michael the celebrity he is. The people who vibrated to his victories, and were saddened by his defeats. They deserve to be told something. I didn’t say it’s their right to know (although jurisprudence places looser limits on celebrities’ “privacy” than on that of “normal” citizens); rather I said they DESERVE to know. Why on earth is their pain not being considered? How is keeping the millions of fans in the dark helping ANYTHING?

I’m also a bit perplexed about this latest thing in FOCUS.DE about re-starting the sedation. First of all, the article is rather remarkably poorly written. That, plus a singular lack of content make it useless, and surely not even worth wasting one’s time reading.

With no knowledge of Michael’s current clinical condition, it’s impossible to say why he would be re-sedated at this stage. Generically, any situation requiring a still, tranquil patient might raise consideration of reinstating sedation. This could be, for example, respiratory deterioration that requires a new period of mechanical ventilation. It could mean that there has been a change in his neurological status, with perhaps some signs of agitation, or a systemic infection originating in one of the several catheters still present. Again, we have absolutely no idea.

Right now I’ve really only one question (that predates the re-sedation issue). Has Michael been weaned from the ventilator?

As I’ve mentioned, once the sedation was stopped, the next big step physiologically speaking was respiratory weaning. This appears to me to be a piece of news that is unequivocally good, and therefore I cannot imagine it being held from the public. Imagine having heard Sabine say “I’m happy to say Michael is now breathing on his own”. Once again, if he HAS been weaned and we’ve not been told, then this is a shameful and arrogant neglect of his fan base and the public.

If on the other hand Michael is still dependent on the ventilator, it’s important to look at why. In this case, that of a young and (remarkably) healthy man with a high probability of brainstem lesions, damage to the respiratory centres would be high on the list of reasons.

Damage to the brainstem can be associated with numerous clinical presentations. It is where breathing is controlled. As important, the brainstem contains structures that play a vital role in waking the brain and maintaining wakefulness and attention. It’s also where the nerves to and from the face (for hearing, sight, taste, feeling and movement) enter the brain.

With sufficiently widespread damage to the brainstem, the patient shows no sign of awakening, and remains ventilator dependent. This is obviously a devastating situation. Brainstem injury is suspected based on the clinical status of the patient, and is then sought using imaging, especially MRI scanning. The actual function of the brainstem can be interrogated using several techniques, including what are called “brainstem auditory evoked potentials”. This involves placing headphones on the patient and playing a series of several thousand clicks through them. Then, sophisticated software is used to detect, embedded within the electroencephalogram, the passage of the sound information through the brainstem (where it enters and undergoes initial processing).

Let’s cut to the chase.

If Michael is not breathing on his own, and is (as we suspect) not showing signs of purposeful interaction with his environment (I am ignoring the mouth movements of which Felipe Massa spoke), AND if there is imaging and functional evidence of extensive and irreversible brainstem damage, Michael’s doctors will discuss withdrawing treatment with the family, as under these circumstances there is essentially no chance of recovery. It is possible that this discussion has already happened.

If Michael is breathing on his own but still not showing purposeful interaction with his environment, then patience is still very much in order. Remember that at one month post-sedation, persistence of this state means roughly a 50% chance of awakening, with the quality of that awakening an open question. This falls to 20% at six weeks (three weeks from now), with a larger portion of these patients having severe functional handicaps. And at one year, essentially no one still comatose wakes up.

Lastly, if Michael is breathing on his own AND showing signs of meaningful interaction with his environment (I very much hope, but very much doubt that this is the situation), then a certain number of people should be ashamed of themselves for denying this good news to his fans. If there is indeed progress and good news ready to be told, then the current comms strategy will go down in the annals as among the most ill-guided, unprofessional, and hurtful in the history of Formula 1 PR.

What should we be thinking now?

It’s just about two weeks since the team caring for Michael Schumacher stopped administering sedatives in order to allow him to emerge from the pharmacologic part of his depressed consciousness. Where are we now?

As usual, a few caveats. I am not receiving medical information from Grenoble. I am basing most of what I say on experience-related conjecture, as well as cautious interpretation of whatever is leaking from the hospital. This obviously means that it all needs to be taken with a rather large grain of salt!

I’m assuming, taking as axiomatic, that if there was significant good news we would be told. Despite the totally understandable need of Michael’s family for privacy and “space”, Michael is a public figure, admired and revered throughout the world. It’s the public who largely made Michael the hero he is to so many. If my assumption is wrong, if there has been a decision to effectively embargo all news, then I think this is somewhat unjust, unfair, and maybe even a strategic error in terms of communications. What’s more, it automatically means the only “information” we get is from leaks.

I’ve heard that the hospital staff is warned every day about protecting confidentiality. This is normal – but so is a passing comment made by a staff member to a friend or family member (prefaced of course by “you mustn’t tell anyone” and relayed in turn to another, trusted person, but still preceded by “you mustn’t tell anyone”) that then gets relayed to a journalist, hungry for anything to write. This is usually a tabloid, as only they would publish such unconfirmed stuff. So in the current state of affairs, I’m somewhat inclined to accord Bild’s latest output “there’s rarely smoke without fire” status. For what it’s worth.

First, as to the “gradual” reduction in the sedation.

In terms of the pharmacology of ICU sedation, we tend to use drugs that are eliminated quickly. This is to allow rapid adjustments in the level of sedation. Several drugs fit the bill; the actual choice depends on local practice, patient characteristics, and the objective of the sedation. 

I’ve seen one article that implies that Michael was sedated using anaesthetic gases. It correctly points out that after prolonged administration these agents take considerable time to be eliminated. It is almost certain that these were NOT used. While some ICUs (as opposed of course to operating rooms) use anaesthetic gases, it is rare, requires special equipment, and has numerous drawbacks. And IF anaesthetic gases were turned off two weeks ago, well there’s none left ANYWHERE in Michael’s body, for over a week now. So much for “coaxing the last molecules” from his body, as I saw written somewhere!

As I’ve mentioned, it’s quite possible (in fact highly likely) that a long-acting agent (a barbiturate) was used as a sedative during the period with what appears to have been dangerously high and resistant intracranial pressure. These agents would almost certainly NOT have been administered for more than 5-10 days at the beginning of Michael’s care. They would simply have been stopped, not weaned, and another agent (or agents) with much shorter actions would be started. In a young fit patient with normal liver and kidney function (certainly the case with Michael), the barbiturates would have been cleared within three to five days – but remember, shorter acting agents were started when the barbiturate phase stopped. These agents have such a fast on/off that they have to be administered continuously (by carefully calibrated pumps). This phase of sedation would be based around either propofol or a cousin of valium (a benzodiazpine), usually with a low-dose infusion of a morphine relative.

When the time has come to stop the sedation, it is usually just . . . stopped. I mentioned this in my previous blog post. Any problems along the way are usually cause to re-start the sedation, and make another attempt at stopping later. It is very rare that the first attempt succeeds. That said, it is two weeks since we were told that the sedation was being stopped. I think it’s a very fair assumption at this point that sedation has been stopped sufficiently long for there to be no residual pharmacologic effects.

Still with me? I never fail to amaze myself with just how wordy i am . . .

If my assumption is correct as to sedation, the next question I’d ask would be about ventilatory support. I hope Michael is breathing unassisted at this point, through the tracheostomy that has no doubt been placed two or so weeks ago. This qualifies as some of the good news I spoke about above. If Michael is indeed autonomous from a respiratory point of view, it’s a milestone. And one about which I think you deserve to be told. Again, I assume that this has been accomplished. If on the other hand Michael cannot be weaned from the respirator, especially if this is because of lack of ventilatory drive, this is more than ominous. At this phase post injury and post sedation, this kind of strong evidence of severe brainstem dysfunction (especially if corroborated by other testing) would likely prompt discussion with the family about withdrawing support. I do not think that this is the situation. At least I truly hope not.

If ventilatory weaning has been successful, the next question one asks is what is Michael’s level of reactivity with the environment. It’s here that we need to think about the Bild report. 

The motor response of a head injured patient is one of the most important prognostic indicators. People involved in caring for head injured patients use a standardised scoring system (called the Glasgow Coma Score, or GCS) in order to do this. The motor component of the GCS has six steps. These range from obeying simple commands (stick out your tongue, put your thumb up, etc) down to no reaction at all. In between, on the way “down” from obeying, one sees progressively less organisation in the response. Makes sense.

So IF what Bild says is true (and I looked on their site summarily, but didn’t see where this was said), we need to figure out what they meant by “no reaction to external stimulus”. If there is no response at all to painful stimulation, not even archaic stereotypical responses organised deep within ancient parts of the brain, then this is very bad news indeed. This would likely imply extensive damage to the brainstem, and at this stage post injury would, I think, be associated with a patient who was also dependent on the ventilator, as mentioned above. I would simply note, as one of those things I wish I had never heard, that when the neurosurgeon spoke about hematomas “left, right and centre”, this is what I feared. The brainstem is one of those things in the centre… 

If the motor response to external stimulation is one of the primitive stereotypical responses, this is bad news but leaves hope of some level of recovery. Numbers? Well, this level of response would indicate the persistence of a vegetative state, but roughly 50% of these patients emerge, usually with some level of residual dysfunction.

To be honest, based on Bild I don’t think any other reactions (all of which are MORE organised than what I mentioned) would lead someone familiar with the care of these patients to say he’s not reacting.

Upshot: not good. Starting to be really not good.

Lastly, I spent three days last week teaching on a trauma course with a bunch of motorsport medicine mates. One of them is a professional neurointensivist. He works in one of England’s regional neurointensive care centres. They get 600 PATIENTS LIKE MICHAEL A YEAR. One regional centre. That means that we’re all just 2 or so degrees of separation from someone affected by this. So I really hope that more than just provide “information” about Michael’s condition, I hope my “head injury” blog entries sensitise us to this devastating society-wide plague.