An illustrative anecdote

I’m always going on about the inexperience of the current leadership of the medical arm of the FIA. I think it’s important, especially in view of the issue of intentional water/calorie restriction (which may well need regulatory input from the Medical Commission), that people understand that this is not (only) residual anger and bitterness because I was fired. So here’s a small example of what happens when important decisions are left to people without the background, experience or knowledge to carry them out appropriately.

At a 2012 meeting of the Medical Commission (I was still an observer), the president (Gérard Saillant) and vice president (Jean-Charles Piette, also the Formula 1 Medical Delegate) presented a draft regulation to the commission members, for what they expected to be rubber-stamp approval. In essence the regulation said the following:

In closed cockpit series, if the cockpit of the car is too small to allow either expeditious extrication of the driver or prompt removal of the helmet, drivers are REQUIRED to wear open face helmets.

Sounds simple, eh? Maybe even logical, right? They were happy that the cause of driver safety was being advanced. Interestingly, neither of the authors of this regulation have ever, in any way, managed an airway.

The intention of this regulation was laudable – to allow airway access rapidly under conditions of difficult extrication. But beneath the face of it, this proposition illustrated everything that is wrong with the current leadership.

The reading of the reg was met by silence around the table. I need to point out that the members of the medical commission are massively experienced, massively motivated, and massively frustrated. The president, until he was appointed by his friend Jean Todt, never had direct involvement in motorsport medicine. Same with the vice president, until he was named F1 Delegate, for the same reason.

Just as this proposition was about to be put to a vote, I raised four questions.

Question 1: How many drivers have suffered an adverse outcome due to failure to access/control the airway in a closed car? The answer is rather simple – ZERO. Although this is the nightmare situation of every motorsport doc, IT JUST HASN’T HAPPENED.

Question 2: How many drivers have suffered catastrophic head and/or maxilla-facial injuries due to contact with cockpit elements WHILE WEARING FULL-FACE HELMETS? The answer – well, I can name 4 or 5 off the top of my head. And I’m pretty sure had they been wearing open-face helmets, things would NOT have been better.

Question 3: How will the FIA answer the lawyers representing the family of a driver killed as a result of head injury wearing a mandatory open-face helmet?

Question 4: Why just accept that there are FIA-homogolgated cars still racing, with cockpits so small and roofs so low as to preclude satisfactory rescue operations? As the FIA body responsible for medical regulations, when the Medical Commission gets it wrong, lives are at stake. Why, I asked, has the Med Comm not gone on record with the relevant OTHER commissions to demand a say in cockpit design, before closing the technical regs for each series? This is the concept of cockpit-out design that I blogged about some months ago.

The reg was immediately withdrawn. I needn’t point out the eye-rolling among the membership at having been presented such a . . . silly proposition.

This is why I’m a bit fearful of knee-jerk, symptomatic responses to the weight control issue. This is why I’m enraged by the stagnation in medical progress in motorsport – it’s not down to nothing left to do, or to obstacles to advancement being thrown up. Rather, it’s down to a total lack of vision, perspective and knowledge of the ins and outs of this field, resulting from nepotistic, incestuous appointments. Again, Jean, you can give your mates titles, but that doesn’t mean you’ve made them competent.

36 thoughts on “An illustrative anecdote

  1. Dr. Hartstein –

    Another aspect of the (current) minimum weight rule that I am seriously concerned about (a concern reinforced by anecdotal evidence, experience and indirect observation + interaction) is its potential to encourage doping in violation of WADA Code, which may already have occurred.

    Previously F1 was nowhere near as high-risk a sport for this kind of body-composition-altering-doping as professional cycling, for example.

    You know as well as I do that there are countless “experimental” peptide hormones available for easy purchase online that athletes have been experimenting with (on themselves!) for several years already to improve/enhance body composition. And it’s foolish and naive to think that in a sport decided by thousandths of a second and awash in hundreds of millions of dollars like F1, where some drivers are presently restricting caloric intake to obtain as little of an advantage over their teammate as 200g of body mass, and where some of these drivers have long-established personal and professional connections to athletes, trainers, managers and doctors from pro cycling, that (WADA Code notwithstanding), doping is not now more of a risk as a result of this rule than it was at any time before 2014…

    How many OOC controls is FIA even performing on current F1 and reserve drivers?

  2. Gary, this might interest you.
    German magazine Bild (compare with The Sun, Daily Mail, Daily Mirror et al.) mentions your name in their article when criticizing remote diagnosis by doctors, e.g. you.

    “Nur die Fachärzte in Grenoble wissen, was in Schumis Kopf wirklich passiert ist. Und genau deshalb sind Ferndiagnosen (z.B. von Ex-Formel-1-Arzt Gary Hartstein) in den seltensten Fällen angemessen und richtig.”
    http://www.bild.de/sport/motorsport/michael-schumacher-skiunfall/michael-schumachers-zustand-verbessert-sich-35342152.bild.html

    In this article, first the journalist writes that “Michael is obviously not awake”, then Sabine Kehm herself states that “Michael is not in a vegetative state”. What is then left? Death, coma, minimally conscious state, awareness (and responsiveness). Obviously the only option is coma since Sabine Kehm would have informed of death and of wakefullness (she promised to notify of any significant change). Please note that Sabine Kehm gave an interview/statement to Bild (Nicola Pohl).

  3. Sabine Kehm gives out information that is authorised by Michael’s family.
    Whilst I numbered myself amongst those who questioned her/their motives in the beginning (solely because we are used to the continual rubbish other PR people and thus the press put out) I am now of the opinion that the way the family/Sabine have handled the whole PR issue since Michaels accident has been nothing short of brilliant and should be studied by other PR ‘gurus”
    Did ANYONE take any notice of the absurd idea of Corinna ‘building an intensive care facility in the grounds of their (£25 MILLION!!!!) pound estate.
    How do we think that happens?
    You phone up “Intensive-care-centres-R’-us” and order one in blue and yellow, delivered within 2 weeks and costing £10MILLION!!! pounds!! “And yes, we can build you 2 at our special offer price of £15MILLION!!! so you can bring all your injured ‘pals’ along? Absolutely ridiculous.
    It would take months and months to build, not taking into account the planning issues such a building would need, especially in Switzerland.
    Michael Schumacher and his family are telling us, via the redoubtable Sabine, just exactly what they want us to know and when, which is their inalienable right.
    Why do we have to constantly question their motives …. as if somehow we either know better or that we inhabit some moral high-ground which confers on us the right to know more?

  4. Times, They Are a-Changin´ … (Bob Dylan)

    Sabine Kehm´s new statement/interview:
    -Family, doctors and friends optimistically minded towards Michael waking up.
    -No private hospital being built in Schumacher´s premises.
    -Next move would be to some rehabilitation center.
    -Encouraging signs (not defined though).

    Bild:
    -Possibly Rolf Schumacher, Michael´s father to move to the estate, therefore building activities on premices.

    Source: Bild.de at http://www.bild.de/sport/motorsport/michael-schumacher-skiunfall/michael-schumachers-zustand-verbessert-sich-35342152.bild.html

    Why so late, dear Sabine Kehm?

    • I just wish they would tell us what these encouraging signs are. I don’t want to get my hopes up over something that is much smaller than I imagine – we all want to imagine the best case scenario. I know they clearly don’t want to give anything to the press / public, I just don’t see what the harm is in giving the fans the information that is giving them cause for optimism….

  5. Jason, I (think) meant this: Diaphragm (anatomy) In mammals, a sheet of muscle separating the thorax from the abdomen, contracted and relaxed in respiration to draw air into and expel air from the lungs; also called thoracic diaphragm.

    Thanks for teaching me new words (had to look up in dictionary) like intercostal, diaphragm, bronchioles, aetiology, supine.

    My sequitur is, that there perchance be extant other perusers who are engrossed to fathom florilegia of Gary or just obiter dictums of other expositors, who are not so cognizant of argot enunciated in colloquy inter pares dexterous confreres, quod erat demonstrantum.

    Thanks anyhow for your comment. Hope you got my point & do not feel offended!

    • Silly me!
      Of course the plural form of “obiter dictum” is “obiter dicta” and not “obiter dictums” as I wrote. No wonder nobody understood nor riposted my comment. Hope this helps. Sorry for writing so incomprehensibly in the first place.

      • Hi you are in general perfectly clear. On my part I don’t reply to a particular comment when I have nothing to add to it. So the function of this comment is to say that on my part I find you comprehensible. 🙂

  6. Jason (and Gary et.al.), I do not possess any medical education nor training whatsoever, for which reason my questions are not accurate, precise nor am I using correct medical terms and jargon.

    Let me rephrase my question since you do not, nor any other anaesthetist nor neurosurgeon does not want to nor even is able to give any accurate predictions regarding Michael Schumacher recovery and future status, especially since the information provided this far is very limited.

    So, here is my question. On the basis of historical medical data, what is statistically speaking the possible outcome of a head trauma patient after 1 year and 5 years after the accident did occur, provided the patient has been comatose for 90+ days and is still being ventilated mechanically? Possibilities are, death, coma, vegetative state, minimal conscious state, wakefulness, recovery to somewhat normal state and full recovery.

    For the sake of clarification I want to ask whether possible overdose of barbiturates can cause coma or whether the only possible result from overdosing barbiturates is only death.

    Thanks in advance.

  7. “Rather, it’s down to a total lack of vision, perspective and knowledge of the ins and outs of this field, resulting from nepotistic, incestuous appointments.”
    Gary,
    When you speak truth to power you quickly find yourself marginalized and/or shown the door. Last week you had the cheek to bring your knowledge and experience to an assessment of Schumacher’s condition and were met by a personal attack from Sabine Kehm questioning your competence because you were fired.
    I winced because of my personal experience. I worked for an east coast US newspaper in the mid-1990’s and apparently I was the only one aware of the impact the nascent Internet would have on print publishing.
    While the power and scope of personal computers grew exponentially, this publishing company poured millions into a larger printing building, thinking if they could only speed the printing process they could . . .what? I never heard the end of their argument. In the meantime I’m talking to everyone from advertising to department heads to the president telling them they need to get online. No-one had email in 1996! I told them the big national and international news will come via the ‘net and the only market they will really own is local news. Knowing I was in dangerous territory I offered plans for a new approach whereupon I was “let go” because my “vision” did not “align” with that of the company and was replaced by someone who was prepared to “work within the system”.
    Hang in there. I just hope you never have occasion to say “I told you so”.

    • Hi! Thanks for the comment. I heard that Sabine mentioned that I actually didn’t know Michael THAT well, and that I wasn’t involved in his care.

      Could you let me know where I can see exactly what might have been said about my being fired and my competence? I’d be most interested if the family is making this adversarial.

      • I’ll do some research and find the quote. I’ve followed the PR managing of Schumacher’s accident quite closely these several weeks. Quite fascinating.

    • We are a disliked breed Lulumoretti, ones who speak the truth when folk around don’t want it to be heard or revealed, usually because it doesn’t suit their agenda. Truth and political correctness very often clash I’m afraid but I know which one my morals steer me in the direction of, even at my own expense in terms of environmental wellbeing if you get my drift.

      • “Respect those who seek the truth, be wary of those who claim to have found it.” reported to be a quote from Mark Twain.

        The issue is not truth. The issue is evasiveness & secrecy. Certain matters need to be discussed and debated openly.

      • Your quite right Jason, openness is the meaning. I don’t profess to be the font of all knowledge but what I say comes from my heart. I don’t equate truth to correctness just to “saying it as it is”.

  8. Hi everybody, hello from France. and sorry for my English… Maybe some faults…

    To speak about the initial subject, it is always the same.
    Important decisions are taken by people who are not users, pilots in this case.
    The theory of the open face helmet could be acceptable, but not the implementation. So, why pilots are not admitted in these meetings to help people to take decisions?

    What would have said Stewart, Senna or Prost about that idea if they were at the meeting…?

    • People who are going to use something or bear the conseqenses of a decision, seldom have a direct say in making the decision.

      Maybe economic interests (helmet manufacturers or something ) can be behind a suggestion such as this one. Or somebody’s interests and carreer interests (going together). This is just a thought, I do not know anything.

      Excuse my English, if there are errors.

  9. How would you comment my prediction of possible state of Michael Schumacher after 5 years from now? Presuming he is now not breathing autonomously AND it has elapsed 94 days since the accident AND assuming he has been comatose the whole time and still is.

    10-20% Death (=due to inflammation in lungs, urinal canal/organs, brains etc.)
    40-60% Permanent coma
    20-25% Vegetative state or minimal conscious state
    0-5% Somewhat normal life (= able to eat, able to dress/undress himself etc.)
    0% Full recovery

  10. Another question to you Gary (or to any other with medical competence to answer my question).

    If the palleatic i.e. respiratory muscles have weakened/atrophied so much that autonomic respiration is thus impossible, what are the means to stimulate/strenghten them in order to get the muscles to start working again?

    • Hi Jussi. I don’t know what the sedative/anesthetic drugs are used preferentially in French ICUs. That said, for “routine” sedation of neurosurgical patients, propofol is almost always the drug of choice, largely because of its rapid reversibility. This makes it easy to do frequent neuro checks on the patient.

      When the ICP remains critically elevated and DEEP sedation is needed (so deep that almost all electrical activity in the brain is suppressed), barbiturates remain the drug of choice. This is true despite the numerous drawbacks of this drug (hemodynamic depression, long duration of action, immune suppression, etc). If sedation was withdrawn when the announcement was made, there has been no trace of any sedative molecule in Michael’s body since at latest 5 days to 1 wk after stopping it. When one talks of Michael still being in a “wake up phase”, this does NOT mean that sedation is still being tapered off!

      If Michael is still being ventilated mechanically, it is virtually certainly not because of RESPIRATORY problems such as respiratory muscle atrophy. If he is not breathing spontaneously, it is almost certainly because the brain centres that command ventilation are damaged and not functioning.

      Hope this helps.

      • Yes, thanks, it helped.

        You wrote “it is almost certainly because the brain centres that command ventilation are damaged and not functioning”. This is bad.

        Please correct if I am wrong. So the need for ventilation is not due to atrophy of lung muscles, but due to trauma in the brain (brain stem)? Can you confirm?

        PS Wrote another question at the same time you answered my previous ones!

      • Interesting questions & interesting answers. With regard to “lung muscle” I assume you mean the intercostal muscles & the diaphragm. As far as I am aware the lungs don’t have any muscles (apart from the smooth muscle of the bronchioles – it is contraction of those muscles that is part of the aetiology of asthma). With regard to breathing since MS is supine & inactive there doesn’t need to be much muscle strength to effect a base tidal flow. Hence I would guess issues with signal generation and transmission rather than muscular atrophy.

        Ps In terms of the “official” information released there is no way of determining whether MS is still on the ventilator or not. All we can do is to draw less than 100% inferences. The reports of the MS family planning to build a multimillions of pounds facility for MS care at home, suggests that significant medical equipment is required …

  11. Gary, one (or two) question to you – any other professional may also comment.

    Do you have any knowledge of Michael Schumacher being sedated using barbiturates or was he sedated using more modern sedatives e.g. Propofol, benzodiazepines together with opioids or with dexmetetomidines (Dextor, Dextomidor, Precedex)?

    If not, do you have knowledge of what sedatives are commonly used in French university hospitals at intensive care units when medically induced coma is a necessary procedure to relieve brain pressure?

    I have read that in Finland for example barbiturates are being discouraged from use as sedatives due to high risk of overdosage, longevity of its effectiveness (Biros ja Heegaard 2001), harms to liver, accumulation and addiction.

    Therefore, I am referring to the risk of overdose and accumulation in the body as ONE possible cause of long, still prevailing coma status with regard to Michael Schumacher´s case.

    Thanks for your answer in advance.

  12. WOW! I can’t applaud you more than right now, once again having the guts to put this on record. This type of appointment is so typical of many organisations. I’ve been trying to get this point across for SOOO long about senior managers making themselves fully aware & understanding of what they ask and expect their employees to do and as to what their employees actually face in practice in carrying out the duties imposed on them. How else can a senior manager manage??? It also helps them to understand just how much their employees can copy with.

    Simple innit? But I wonder how many more of your readers can relate to this type of situation including the absolute lack of competency of crucial appointees in a similar manner to that you mention.

    Competency is THE key to good H&S practice!

  13. I read the part of this post about open-face helmets open-mouthed. Had to check the date of the post to make sure it wasn’t April 1st. I mean, I have no medical experience, but surely anyone who’s followed motor racing for the last couple of decades knows why open face helmets were replaced with full face helmets. The last top line driver I recall wearing an open face helmet was Dale Earnhardt… Maybe the FIA Medical Commission’s next recommendation will be for drivers of open cockpit cars to not wear seatbelts, so they can jump out of the vehicle in the event of a crash! Problem is, Gary won’t be around this time to tell them it’s a bad idea.

  14. We should start a petition to get you back in there!! I fearlives are at stake at the moment if I read this level of stupidity!

  15. It is scary how willing Jean Todt has been to promote via the Peter Principal (i.e. promote someone until just beyond their level of competence). Especially when people’s lives are at stake. And I don’t just mean the drivers – what about the team members around them, and all the unpaid volunteers around the tracks (most marshalls are paid very little, if at all) and even the spectators that actually pay for the privilege to be in these risky circuses of sport!

  16. Of course! Totally unreasonable, and equally inexplicable.

    But seriously, I’m fine where I am. I’d have done another 2 seasons – and this year (what would have been my last) I’d have asked to have someone with me, as Sid did with me, to make the proper introductions, know the particularities of the CMOs and teams, etc. Since that didn’t happen, and since it’s not just a change of faces, I kinda think it’s useful for people to get a glimpse behind the curtain at the little men shouting “We are the great wizards . . .”

    • I rather suspected a perfectly logical and reasonable reply would follow ! (A smiley would be appropriate at this point, but this isn’t Facebook!)
      I just wanted to ask the question in an unobtrusive way, before someone else did it differently.
      Thanks for the answer!

  17. This will undoubtedly elicit a strong backlash, but to suggest the repeated criticism of the FIA in general and Jean Todt in particular could be interpreted by some as a mild case of sour grapes would be regarded as heresy and quite unreasonable? Yes, I suppose it would.

  18. Thanks Gary for this short insight into the subject matter. You could continue on this subject of criticism towards FIA and present status of motorsport medicine and “total lack of leadership” within FIA.

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