Some important science on disorders of consciousness – part 2

An MRI scanner

Imagine this: You’ve volunteered for a brain imaging experiment to help study consciousness. You come to the MRI suite, and lie down. The researchers put an IV drip in place, and then infuse a form of glucose that “lights up” the brain areas that are activated at any given moment. So far so good.

You’re told to close your eyes and imagine hitting a tennis ball back and forth with a partner. Sure enough, this consistently activates an area related to preparing the brain for motor activity (called the Supplementary Motor Area, SMA, in yellow below). Then you’re asked to imagine walking around your house, and to visualise all the things you’d see as you navigated like this. And once again, the corresponding area, called the Parahippocampal Gyrus, (PG, in green below) lights up. Here’s roughly what the images look like:

Nothing unusual or unexpected here. But now let’s go a bit further with the technique.

Let’s now take a series of patients (54 to be exact) who have been diagnosed with either vegetative state (remember – that’s eye opening without any signs of conscious interaction with the environment) or a minimally conscious state (awake, but with fluctuating but consistent signs of consciousness), and let’s try the same experiment.

Incredibly, FIVE of these patients  (10%!) could manipulate brain activity in response to the researchers’ requests. These people were, in fact, obeying commands (“think about tennis”, “think about navigating”), but their response wasn’t behavioural, it was . . . metabolic; what’s crucial is that they clearly showed signs of consciousness.

This was an amazing finding, but the investigators took the work further still, and, using a very ingenious trick, what they revealed shocked the world of medicine.

Let’s quickly put you back into the fMRI machine. This time, here’s what I’m going to do. I’m going to ask you a simple, unambiguous question (like, do you have a brother?). I’m going to tell you to think “tennis” for YES, think “navigation” for NO. (Rather like using fMRI activation as a “blink once for yes, twice for no” kind of communication tool.) Turns out this works fine, with 100% accuracy with normal subjects.

I guess you see where I’m going with this. Let’s take one of the patients diagnosed as vegetative but who has shown the ability to “light up” his or her supplemental motor area or parahippocampal gyrus on demand. Let’s do the same thing with him. Let’s ask him or her questions – tennis if yes, navigation if no. What happens? Let me quote the researchers: “. . . for those five questions, the pattern (of activation) produced ALWAYS matched the factually correct answer.” 

I’ll let that soak in for a moment.

These scientists just took a patient who’d been diagnosed as vegetative (and again, I’ll insist that this means NO CONSCIOUSNESS) and not only TALKED TO HIM, but actually got answers!

What are the implications? First of all, this study shows how hard it actually is to make a proper diagnosis of the vegetative state. Until now, this diagnosis relied on confidently stating that there is evidence of absence of consciousness, based on detailed and lengthy observation of the patient’s behavioural responses. But remember, these patients have severely damaged brains; the behavioural repertory of responses that they can show may often be so limited that none will be found. But this study emphasises that absence of (behavioural) evidence is NOT necessarily evidence of absence (of consciousness). The infinitely more sensitive “behavioural” response of metabolic brain activation could allow, in the future, clinicians to make this diagnosis with much more confidence. This obviously has enormous implications in terms of medical and ethical decision-making as concerns any given patient.

More importantly for us, this tool would appear to open up the possibility of actually communicating with some of these patients (a small minority at best, but still . . .). The current procedure is much too cumbersome, difficult, and expensive to use routinely, but it’s not too much of a stretch to imagine a future where helmet-sized mini-MRI machines are placed on the heads of patients with prolonged disorders of consciousness to allow their care team and loved ones to communicate with them.

There is a huge amount of fascinating and useful research being done on consciousness – both normal and disordered. Functional imaging is one of the most powerful tools in this quest for knowledge. As they say, watch this space.

Here’s a link to the original NY Times article about this research. The second contains a video by Liege’s own Steve Laureys (the lead researcher), explaining the technique. And the third is to a pdf of the original article, published in the New England Journal of Medicine.

http://www.nytimes.com/2010/02/04/health/04brain.html

http://thelede.blogs.nytimes.com/2010/02/04/doctor-demonstrates-method-of-speaking-with-vegetative-patients/?_php=true&_type=blogs&action=click&module=Search&region=searchResults&mabReward=csesort%3As&url=http%3A%2F%2Fquery.nytimes.com%2Fsearch%2Fsitesearch%2F%3Faction%3Dclick%26region%3DMasthead%26pgtype%3DHomepage%26module%3DSearchSubmit%26contentCollection%3DHomepage%26t%3Dqry575%23%2Flaureys&_r=0

http://www.nejm.org/doi/pdf/10.1056/NEJMoa0905370

Sid, my friend, 20 years after Imola

Nürburgring, watching tennis before a session

It’s 1992. Summer, but it’s cool enough in the Ardennes morning to be happy to put on the long underwear and overalls. Now we’re sitting over that first, anticipation-laced coffee:

“Professor?”

“Yes old boy?”

“Do you think it’d be ok if I called you Sid?”

A big grin. “You know, the tramps sleeping under the stairs of my hospital call me Sid. Don’t see why you couldn’t.”

There. That was easy. Only took two years.

Although I was a lifelong fan of Formula 1, I’d never heard of Sid Watkins when the Chief Medical Officer at Spa-Francorchamps decided to make me the “local guy”, riding in the back of Sid’s FIA Medical Car in 1990. I was a 35 year-old anaesthetist, and had been told, by everyone involved, how important, imposing, and difficult the English gent was.

We found some common ground. Not difficult, you’d say, what with motor racing, medicine and cigars as shared starting points. Worked out fine. At least one big accident each weekend too, so we actually WORKED together.

This is the start of my third Grand Prix weekend. As usual, we’ve met at the medical centre, and hitched a ride to the paddock. I’ve screwed up the courage to ask. Cool. From now on it’s “Sid”.

1994. Two years later, twenty years ago, and I’m seeing Sid for the first time since Imola. Don’t know what to say. I know he loved Ayrton. He seems fine. Say nothing? We’d gotten to the medical car a few moments early, and were standing inside “la triangle” of La Source hairpin, which was (and is) our standby position.

“You ok?”

He leans against the door of the car and says, “We ran some fluid in, and got a pulse. Then the clouds moved a bit, and his face was in the sun. That’s when I knew . . .”

And that was it. We didn’t need to talk about medical care, about ambulances and extrications. This brilliant professor, this locomotive of a man, had lost a great friend.

It was remarkable to see, in the coming months and years, how Sid steered the steady, relentless progress of this “second revolution” in safety (the first, I’d say, was from when Sid came on board as FOCA surgeon in 1978 until the mid 80s). And how brilliantly it was all set up.

That’s what Sid was like – extraordinarily multifaceted. Nothing was done half way. Personality? The most charismatic person I’ve ever seen. Sid drew you in and held you there with his stories, his intelligence, and his heart. Intelligence? Just look where he brought our sport! But he also read voraciously – historical biographies were a particular favourite. And of course, a sense of humour that just didn’t stop.

Jerez 1997. In the hotel lobby with a several of Sid’s “kids”, waiting for him so we can leave for dinner. He’s a bit late. That’s unusual. The inevitable round of “You go get him”. “No, YOU go get him.” “Sorry, not gonna happen, YOU go get him.”

I’m the new guy on the block, so I’m elected. I know after this first season with Sid that if he’s been napping he’s likely to be a bit . . . curt. Oh well, here goes. KNOCK KNOCK KNOCK. Gulp.

The door flies open. And there he is, huge grin on his face . . . and nothing else on . . . anywhere.

Gulp.

“Hello old boy! Come right in!!! I’ll be ready in a moment.”

I love you Sid, but I think I’ll wait in the lobby, thanks.

“Medical car rolling”: en route and approach to the accident

So there’s been an incident, and race control has red flagged the session (or activated the Safety Car, if this is a race), and asked us to deploy. We’ve instantly switched from being the spectators with the coolest seats around to being the people to whom everyone turns when the bad stuff happens. How exactly do we roll up our sleeves and get to work?

We usually, but not always, have a good idea of where the incident has occurred. This is either from having seen the accident and understood where it is on the screens in the car, or because we’ve been told by race control. In any event, the tower quickly lets us know where we need to go – and when it’s important, where the car has come to rest, whether at the entrance to, mid corner of, or at the exit of a corner, left side or right side of the circuit, etc.

A parenthetic anecdote to lighten the atmosphere

(When Olivier Panis had his accident in Montreal, race control cleared us to deploy. Sid and I had gloves on and were ready to go when we realised the car hadn’t budged. Sid assumed there was a linguistic problem with our French-speaking driver. He told the driver, in an appropriately assertive way “We need to go!”. A quizzical look came over the driver’s face. “Now?”, he asked, “in the middle of the race?” Sid hid his frustration well. “Yes old boy, there’s been an accident we need to attend.” Our driver, a lovely fellow named Pierre, stated the obvious – “But we don’t know where the accident is!” At this point I heard the reassuring tones of Sid’s angry voice “LET’S JUST DRIVE AROUND THE FUCKING CIRCUIT AND WE’LL PROBABLY FIND IT SOMEWHERE!”)

Back to the serious stuff

The second we see an incident that might require a response, Alan puts the car in gear (the motor is running through all sessions), and we start putting on our medical gloves. Alan has already verified that we can exit our standby position safely, and this verification is repeated until we get clearance to roll.

As you can imagine, this is a fairly active moment for us all. Our first order of business is to get to the accident scene safely. That’s a tall order. There will almost always be racing cars on the circuit and even when they’ve slowed dramatically for a red flag (and are therefore heading back to the pit lane) or safety car, they’re still going VERY VERY fast.

To the extent possible ALL of us (meaning Alan, myself, and the doc-in-back) have our eyes on the circuit. Ideally Alan is freed up to drive, but obviously he’s also in the mirrors. When a race car approaches us (I wish you could appreciate the closure rates; we’ve usually got some speed going, but the racing cars make us look, and feel, like we’re standing still), Alan will tell me when to activate our green light. This is the same as on the light bar of the Safety Car, and signals to the oncoming racing car that we’ve seen him, and that it’s ok to pass us.

The racing cars pose some hazard to us; much more dangerous still are the local medical intervention cars, ambulances, and extrication units. These can be expected to join the circuit from their respective standby positions without looking, to immediately take to the racing line, and also to drive two or three abreast. Often no attention is paid by our colleagues to those low, loud and fast cars covered with advertising stickers and big rear wings. The ones driven by helmeted people. You only need search for YouTube videos of Safety- and Medical Car accidents to see the kind of stuff that we just CANNOT let happen. Coordination of this deployment is one of the important reasons behind my insistence in the first post of this series that the FIA team and the local resources be in real communication with each other.

As we head to the accident, Alan is pushing quite hard. I’d say (my impression) that he’s somewhere around 80 -85% of the car’s possibilites. This depends on a lot of things, among which are the situation and how “chaotic” things seem (higher chances of a marshal randomly losing focus and stepping in front of us), the weather, etc. Race control will be giving us information (status at the site, info relayed from the marshals, etc). 

This is also the time for a final quick review of the sequence of our intervention with my colleague in back. Scene survey, driver survey, determine the extrication strategy and need for care on-site. Who will do what. I always insist, en route, that my colleague will manage the scene and I’ll assist as necessary . . . if he or she is comfortable with that. If not, I have no problem assuming that role. There can’t be ambiguity about any of that once we start working.

On approaching the scene, we are thinking about three things: vehicle placement, scene safety, and indicators of mechanisms and severity of injury.

Vehicle placement

When arriving at the scene of an accident, it’s important to think about where each vehicle should be stopped. The accident scene, although covered by flag marshals, can be more clearly delineated using the intervention vehicles, especially as they are almost always equipped with flashers. The scene also needs to be protected from any oncoming traffic. Finally, vehicle placement should facilitate, rather than hamper, the functioning of the intervention.

Of course, every accident is different, and for most situations there’s no one right way to do this. The point is to take into consideration the following factors:

• has the race been stopped, and if so is the circuit already clear, or are we under yellows and the Safety Car?
• how far off or on the circuit is the accident?
• visibility on approach
• relation of the accident scene to the racing line
• the width of the track

In general, the first intervention car on site (MIC in the diagram) should park upstream of the accident, off the racing line, and in a “fend-off” position. This means the car is slightly angled away from the circuit with the wheels also turned towards the edge of the track. This way, if the car is struck, it will move further from the circuit. This will often, but not always, be the FIA Medical Car.

Next to arrive will be the extraction team (EXT) (when requested) and/or the local MIC. This vehicle covers the rear of the scene, Fire teams stop ahead of the intervention cars, abeam of the accident, and the ambulance in front of the scene. Remember, the ambulance is rear-loading, so this position facilitates expeditious access to the cabin.

Scene safety

This step is usually not apparent when viewed from the outside. On arrival at an accident scene, all our instincts are screaming “GET OUT OF THE CAR AND GO HELP THIS GUY!!!”. This is the wrong thing to do. All medical rescue personnel need to always have in mind how dangerous a circuit is, and that their overriding priority is actually TO AVOID SECONDARY ACCIDENTS. This means verifying implicitly (most incidents), or explicitly (special situations) with the chief incident marshal at an accident scene that it’s safe to approach. Our reflex to help must never trump the order of safety priorities: first protect one’s team, then scene personnel, and only then the victim.

Scene analysis

I don’t think most people realise how important anticipation is when taking care of trauma victims. Trauma is caused by the application of FORCE to the body. So as we approach the patient, and in fact all through that initial management phase, we’re constantly asking ourselves –  what was the DIRECTION of the forces involved, and what was their MAGNITUDE. We’ll talk more about this next time, but for now one of the key things we’ll be doing as we get close to the accident scene is closely looking at signs of exactly what happened. 

Early clues to it being big are things like a long debris trail, the stress audible in radio communications, the vigour and intensity of flag waving on approach, and crowd movement towards the scene.

If we’ve not seen the accident on our in-car screens, as we get to work I try to find out from the incident marshals exactly what they saw.

Well we’re out of the car, heading to the accident itself. Time to take a breather.

Next time: initial assessment and management

 

Some important science on disorders of consciousness – part 1

Well Liège has made it into the news again!

The Coma Science Group here at our hospital, working with other centres,

has published another significant study of persistent disorders of consciousness. It’s worth having a look at this; in a subsequent post we’ll look at another very important paper by these researchers. I’ll also  place these reports into some kind of context in terms of Michael Schumacher’s situation (or more correctly, presumed situation).

First a link to an article about today’s study:

http://www.nytimes.com/2014/04/16/health/pet-scans-found-to-clarify-vegetative-state.html?hp

And a link to the article itself:

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673614600428.pdf?id=baaFobxDfjPxxfydMxPvu

The background

Remember how we said that the vegetative state is defined as a state where the patient shows signs of wakefulness (notably open eyes) without behavioural responsiveness (as a marker of consciousness or awareness). Because of the emotionally laden and ambiguous nature of the word “vegetative”, some, including the Coma Science Group, prefer to use the term “unresponsive wakefulness syndrome” (henceforth UWS) for this state.

The key in differentiating a patient with unresponsive wakefulness syndrome from a minimally conscious state is the presence in the latter of fluctuating signs of awareness, with consistent but intermittent appropriate responses to stimuli.

Distinguishing these states can be difficult, but is absolutely crucial, medically, socially, ethically and therapeutically. A patient who is genuinely in a UWS, has, by definition, no self awareness. No voices are recognised, no sensation of hunger, none of pain, none of thirst. This is why clinicians caring for patients in a UWS are authorised almost everywhere to withdraw medical support, if and when appropriate, (including food and water – remember this is not cruel because there is no hunger or thirst perceived) from UWS patients. This is not the case once the patient has demonstrated any consciousness at all. Prognostically, as we’ve mentioned previously, persistence of a clinically correctly diagnosed (and that’s the point here) UWS for one year after the inciting trauma pretty much means any meaningful recovery is impossible. On the other hand, a minimally conscious state raises the possibility of continued progress.

Unfortunately, it can sometimes be remarkably difficult to show conclusively what state the patient is in. The problem is double.

First of all, there is the fluctuating nature of awareness. Episodes of interaction can appear randomly, or might be associated with a certain time of day, the presence of certain people, etc. The key is to do sufficient evaluations, sufficiently often, to reliably ascertain what the patient’s best level of awareness is.

Second, let’s remember that these patients have suffered devastating brain damage, whether caused by trauma (as is the case with Michael), infections, massive strokes, global anoxia, etc. This means that these patients will almost always have severe restrictions in their ability to show their responses to external (and internal) stimuli – spastic limbs which preclude reliable movements, visual or auditory deficits, etc.

Because of this, current guidelines for the management of patients with prolonged disorders of consciousness are becoming more and more insistent as to the FREQUENCY and QUALITY of the evaluations that are done. Standardised measurement scales are used, and the training necessary to administer them are well defined. Despite this, doubt remains at the edges between the diagnoses. Help is clearly needed to reliably diagnose the presence of these difficult-to-demonstrate degrees of awareness.

The study published today is an attempt to validate the use of imaging techniques, in addition to clinical evaluation, to help determine whether a patient is or is not AWARE.

The study

Steve’s study looked at the ability of two imaging techniques, FDG PET scanning and fMRI imaging, to help distinguish between UWS and minimally conscious states. FDG PET images show brain areas that are actively using glucose. This is known to correlate with activity in those same areas. FDG PET images show the pattern of brain activity at rest. On the other hand, fMRI images look for use of oxygen in the brain. It is particularly useful to do when asking the subject to do a mental task – whether visualising something, imagining something, or DOING something moving fingers, pressing buttons, etc).

It is also known with high confidence that certain brain areas show normal activity in normally conscious patients, essentially no activity in UWS patients, and intermediate (but significantly reduced) activity in patients who are minimally conscious.

This study looked at the reliability of using activity in these areas to help confirm the diagnosis made clinically, and to help determine the patient’s prognosis.

Briefly, the study showed that FDG PET imaging is highly correlated with a previously validated (and widely if not universally used) clinical scoring scale. Importantly, one third of patients (13 of 41) diagnosed clinically as being in a UWS were shown by FDG PET to have activity in centres associated with awareness. Over the next year, nine of these 13 patients (remember, they were classified clinically as UWS!) had moved “up” to a clinical diagnosis of minimal consciousness or better, while of those with an imaging “confirmation” of UWS had terribly dismal outcomes. Of these 26 patients, 35% were still unconscious after one year . . . and 56% were dead. This shows that these images may well sensitively show the possibility of awareness, and seem to contain the same prognostic information that a clinical diagnosis of minimally conscious state contains. Further the numbers track what I’ve said in previous posts in terms of prognosis.

It is absolutely vital that we understand what the study didn’t show. It did NOT show that these 32% of patients were aware, or conscious. It showed that these patients, who clinically were felt to be unconscious, “had cerebral activity compatible with consciousness” (the authors’ words). But importantly, these patients had significantly better CLINICAL courses subsequently than those in whom PET confirmed an absence of activity compatible with consciousness.

Conclusion: it’s looking like at some point in the not distant future FDG PET imaging may well be a standard test in addition to clinical scoring, to determine whether awareness is or is not present in patients with disorders of consciousness. Remember: 1) it’s not yet fully validated, meaning more research is necessary before making this a standard tool with fully accepted statistical notions of reliability and validity; 2) until it IS validated, it remains a research tool.

Implications for Michael Schumacher

Actually, to the extent that Michael has been reliably shown clinically to have signs of awareness/consciousness (this would appear to be the case based on direct quotes of Sabine Kehm), this type of imaging would have no real utility, as a diagnosis of minimally conscious state would then have been made clinically.  On the other hand, my next post will deal with another paper by our Coma Science Group, one with fascinating clinical and even philosophical implications.

 

 

“Deploy Medical Car”: decision-making and roll-out

We all know that sinking feeling we get when the cameras covering practice, qualifying, or the race cut to an accident. The marshals scramble to the scene, the commentators comment, and everyone waits to see how the driver is. Sometimes, within moments, the television shows us the Medical Car heading to the accident. Let’s look at what happens from the moment of the accident until the medical and rescue system is activated.

First, a word about the FIA Medical Car. 

I’m pretty sure that as far as race fans go, there aren’t many cars in the world as well known as the AMG C63 wagon in service as the Medical Car. It’s loud, powerful, superbly capable, and very fast. It’s not an easy car to drive, in an environment for which it was not made, but Alan van der Merwe makes it look easy. The car “belongs” to Allsport Management, the outfit that centralises much of F1 logistics, and also owns and operates the Paddock Club; AMG has two full-time technicians who travel to each race with the necessary kit (pic below). There are two MC’s (and two Safety Cars) at every race. And no, I don’t know what AMG does with them when they’re retired. The medical car has served since 2008 (if I’m not mistaken), with impressive reliability given how high a percentage of its mileage is flat out. Fuel economy? I remember once calculating it and came to something like 40-50 l/100 km, or 4.7-6 mpg.

In terms of medical equipment, the MC is stocked with basically the same stuff as the other MICs around the circuit. This consists of the material we need to make sure that an accident victim’s airway is open and secure, that breathing is effective (either by the patient or by us!), and to access, and if necessary treat, the circulatory system. In fact, we’ve usually got two full sets of equipment on board – my kit as well as that of the local doctor assigned to ride in the FIA car. We do that for a few reasons. First of all, during the stress of an intervention, it’s better that the local doctor have his own kit, knows what’s where, etc. Secondly, since we have two doctors, we may as well be able to manage two victims, should we be be first on scene! 

The car has four Recaro race seats and full harnesses front and back. Interestingly, we have 5-point harnesses in front, and 4-points in back. It was always reassuring to see what good care AMG took of . . . um  . . . well you get the idea. Alan and I are plugged into the car’s intercom/radio base station, so we speak to each other through our helmet boom mics and hear each other through our moulded earpieces (these double as noise attenuators when on scene). We each have a push-to-talk button for the main (digital) radio, and another for the backup (analog) set. Once we get out of the car, we need to unplug our earpiece/mic cable from the car and plug into our handsets. (I hear the ever so slight murmur – “he’s speaking in the present tense…”. He is. Indulge me. It just sounds weird and heavy using the correct tense).

The car also has three screens – two up front and one on the back of the central console. The rear screen is for our local colleague, whose weekend can be a bit lonely if language is a problem (especially with the front seat guys speaking in mere whispers over the intercom). The rear screen is “slaved” to the upper front; they can all receive the international TV feed (no sound, and usually on the top screen), the first timing screen (sectors and gaps, usually on the lower screen), the third timing screen (messages to teams), and the real-time gps locations of the cars around the circuit. This is obviously useful en route to an incident. At least in theory, because as you’ll see next time, we’re pretty busy when that happens, and switching screens is not the first priority.

(By the way, this is us following Bernd in the Safety Car exiting Suzuka’s Spoon Corner, one of the most thrilling moments one can have in a car, as quite significant velocity is involved. In fact, my laps around Suzuka with Alan are certainly my favourite car moments ever.)

The Medical Car is on standby for all F1, GP2 and GP3 sessions and races. The standby position varies from circuit to circuit, but is usually at the pit exit. We’ll always have scouted out any shortcuts through the circuit using secured inner roads (not all circuits have them). These can allow us to cut off up to half the length of some circuits, with a huge time gain.

There’s been an accident

When something happens on the circuit, we usually see it at the same time you folks do. Not surprising, given that we get the same TV feed you do. Obviously, race control has seen things in rather more detail, because of the coverage of the circuit by CCTV. 

If we look at how the actual decision to deploy medical resources is made, it really occurs in one of three ways. (Remember, I grew up in a medical car, not in race control!) The first would be “by sight”. It’s a big accident, there are bits everywhere, gut feeling: fair likelihood of needing some sort of medical presence. I’d include in this category a good number of the bigger incidents we see, fully aware that most of the time there are no injuries. Obviously if the driver is immediately on the radio (and they usually are) speaking appropriately about, well, just about anything, this is good evidence for the absence of significant injury, at that moment anyway. I feel pretty strongly that if it looks big, secure the circuit and deploy. Sure, the MC would be deployed a bit more often, but these types of incident are relatively rare. A practice session or qualifying  can be restarted after a red flag; admittedly a higher threshold needs to be used for the race. On the other hand, if there are time-critical injuries, if a “by sight” deployment isn’t used, then race control will have to rely on the report of marshals. Now I’m never been convinced that this kind of non-medical evaluation of the victim is any more valid than that of a first, visual, impression from the cameras by an experienced crew in race control. If the driver gets out of the car, has no complaints, walks and talks, then the medical car, deployed “by sight”, can be told that fact, and would either continue back to its standby position, or, more likely, pick up the driver. This would allow the medical team in the car to evaluate the victim for concussive symptoms and decide on the appropriate followup. Again, this should not be a common occurrence, but the 15-20 seconds saved by NOT waiting for word from the marshals WILL come in very handy some day.

As I just said, a request by marshals for medical assistance, or a report of driver complaints (other than about his colleagues) while he or she is still in the car, will elicit a medical response.

Lastly, race control can decide to send us out based on triggering of the medical warning light.

This light equips every F1 car. It’s located on the top surface of the car, just in front of the “windscreen”. Wired to the car’s data logger, it is always on, with a slowly oscillating bright-dark cycle, to show it’s operational. But when it is triggered by a force of > 15 g (front to back, side to side), or > 20 g vertical (to take into account running over curbs) for over 5 msec, it shines VERY bright blue. It’s a reliable indicator of high energy transfer, and it also activates a warning lamp in race control. Activation of the MWL will often lead to race control ordering a response.

Once the decision is made to activate the medical service, the circuit is secured. For practices and qualifying this is by a red flag. The Medical car is informed by the FIA that the red flag is coming out, and we’re either then deployed immediately or put on a brief standby. During the race, we’re put on standby with the safety car. When we’re given the “GO”, we follow Bernd out; Bernd will show us his green light and move over usually within a corner or two of deployment. In any event, when we need to go, we always know there are likely to be race cars on the circuit at least for some of the time we’re out there. More on this next in the next post.

Remember that last time we spoke about the distribution of medical cars and extrication teams around the circuit. And we talked about the CCTV screens in race control. In order to reduce response times to a maximum, race control has a chart like this for each circuit (this example is from Malaysia, 2005):

 

Each cell in the table corresponds to a screen in race control. An incident on any screen, referred back to this chart, immediately indicates the local units to deploy. Because traffic NEVER goes the wrong way ’round a circuit, each car and each extrication unit, covers a sector from their respective position to that of the next downstream unit.

When we get told to go, everybody on board the Medical Car needs to be ready for just about anything. In the next post, we’ll look at what happens en route to the incident, and what happens on arrival.

 

 

“Standby Medical Car”: the system

Another season is underway, and watching Pastor scooping up and flipping Esteban Guttierez over in Bahrain, I thought it might be interesting to go over the steps involved in the response to an accident at a race. I did this when I first started using Twitter, but we’ll go over the concepts a bit more in detail. This way, you’ll have a pretty good idea of what’s going on if there’s a rescue response to an incident on the circuit. I’ll do this in a series of posts, and we’ll culminate with the race weekend in Shanghai next week.

As a travel companion through these posts, those interested could pick op a free pdf copy of the Medicine in Motorsport manual:

http://medicineinmotersport.fiainstitute.com

First, let’s understand how things are set up from a medical/rescue standpoint.

COMMAND, CONTROL, COMMUNICATIONS

The eyes, ears and brain of the operation are, of course, located in race control.

For Formula 1 events, the FIA Race Director, his Deputy, and the ops coordinator are up here, along with the Medical Delegate. The local circuit command is also here – the Clerk of the Course (CoC, the guy who is usually the Race director when we’re not in town), Chief Marshal, Chief Medical Officer, etc. Every inch of the circuit is covered by cameras that can pan, tilt and zoom. The locals, at least at the more “mature” circuits, know which cameras cover the usual problem areas, and have them pre-set to cover precisely those zones. Remember that depending on the circuit, these local race control guys might be doing this every two weeks for years now (Spa, Silverstone, Hockenheim, etc). Also remember that each camera is connected to a DVR, so every second of every camera gets recorded . . . just in case.

Nothing, but nothing happens on track without it being decided, approved, and ordered by race control. From the moment the circuit is made active (usually by a red flag being displayed on a course car driven around the circuit) until circuit discipline is “relaxed” (yep, by a green flag “opening” the circuit), trackside personnel are behind the rail, vehicles are in standby position, engines running, and no one moves unless race control says so. The only exception is the flag marshal, signalling events in his or her sector – but even these events are immediately reported to race control. Here’s what happens when that rule isn’t obeyed:

The FIA team is in radio contact with the Medical Car and the Safety Car (which is not used during practices and qualifying, of course). They also have private comms to each team’s pitwall, and listen to all driver comms during a session. The local circuit team is in radio contact with all local resources through their own dedicated radios.

As you can see, from a systems standpoint, one of the potential barriers to seamless function in race control lies in the parallel nature of the FIA and local systems. There just aren’t a lot of built-in connection points between Charlie/Herbie (FIA) and the Clerk of the Course (local). Failure of timely and high quality crossovers between the systems can lead to deployment of local resources before the circuit is properly secured on the one hand, or a delay in the arrival of necessary reinforcements if the FIA “network” is activated without this happening with local resources.

In terms of this “connection node” between the FIA and the local team, Charlie, Herbie and the CoC are usually sitting in very close proximity, each with big headphones on (very isolating in terms of real conversations). The most important interface obviously depends very strongly on Charlie and Herbie’s rapport, confidence and ease of interaction with the CoC.

Note to self: this node needs to be STRUCTURAL and as independent as possible of human foibles. Like the structures that govern relations between aircrew members – predefined, unambiguous, etc.

Another note to self: since each CCTV screen in race control has its own DVR, these could be used to PLAY recordings of accidents back onto the screens. Race control could be used as a giant simulator. This could even be integrated with the medical/rescue simulation we do every Thursday afternoon of every Grand Prix weekend.

THE RESPONDERS

Because of the international nature of Formula 1, the response to an incident at a Grand Prix has, since being organised by “the Prof”, Sid Watkins, is based on a fully manned, equipped and competent local medical team. Let’s take a bit of time to look at the elements of this local team, and to introduce the FIA Medical Car.

The regulations governing all of this are found in Appendix H of the FIA’s International Sporting Code. This includes organisational details as well as the equipment required for the various components of the medical/rescue response system. Here’s a link to the regs:

Click to access 14.01.02_ANNEXE%20H%202014_publié%20le%2002.01.2014.pdf

Medical intervention cars (MICs)

The first properly medical contact the victim of an accident will have will be with the crew of a medical intervention car. These vehicles will carry a doctor and a nurse or paramedic and be driven by a driver experienced at the circuit and with high performance driving. The MIC carries sufficient equipment to expeditiously handle problems with the airway, with breathing, and with circulation. Just what you need to keep things from getting worse in moving from the accident site to the medical centre. Details on this in a subsequent post.

A circuit will usually have between 3 (for VERY short circuits) to 6 MICs. They are arranged around the circuit in order to divide it into sectors that take roughly the same amount of time for the vehicles to cover. So a sector that’s got a lot of corners, and is therefore slower, will be shorter than the sector of an MIC that covers mainly straights and fast curves. Remember that the Prime Directive at a circuit is: no one EVER goes the “wrong way” on a circuit. EVER. EVER. As an example of a med team’s deployment map, here’s the circuit diagram for Abu Dhabi, from a few years ago:

Let’s also note that the FIA Medical Car always has a local doctor on board. Because he is in radio contact with the CoC, the Med Car is another connection point between the FIA network and the local team. In my experience this functions extremely well when the following conditions are met:

• both docs are experienced in prehospital medicine AND comfortable in the motorsports environment
• both docs have explicitly considered their responses to a range of possible situations
• language is not a problem

As you can imagine, these conditions are not always met; in addition, remember that the medical car intervenes AFTER deployment is decided. The upstream processes are therefore still vulnerable to “parallel functioning”.

Extrication units

FIA-spec extrication units are physician led six-man teams whose task is to remove an incapacitated driver, or one in whom spinal injury is considered to be a possibility, from a car with a minimum of motion of the vertebral column and spinal cord. They are highly trained in the various techniques of extrication (more on this in subsequent posts, of course), and carry the necessary equipment to carry out their mission. There are at least two, and often three, extrication units at a Formula 1 circuit, depending again on the length of the circuit.

Ambulances

For a Formula 1 event, there is at least one ambulance at each MIC location. In addition to transport from the scene to the Medical Centre, the ambulance also can serve as a covered work area if the victim needs “packaging” after extrication but prior to transport to the medical centre.

Medical Centre

The medical centre is the headquarters of the medical team. It’s where they meet, stand down, relax, and practice. It is also where “routine” medical care is initiated during the race weekend, for all race and associated personnel. And of course, it’s where accident victims are first transported, before being evac’d to the receiving hospital. Medically the goal is to rapidly figure out just how injured the victim is, and what resources he or she is likely to need to stabilise the situation. This then determines the urgency of evac. The med centre is staffed and equipped to be able to apply a series of sophisticated life-saving diagnostic and therapeutic techniques.

Medical centres range from the rudimentary but functional to the virtually opulent. Here’s a typical “Tilke” centre, and a typical resuscitation area:

We may have looked at the various elements of the mandated medical/rescue structure separately, but in fact each is a link in the sequence of care. The overall quality of an intervention will depend not on the STRENGTH of each link, but rather on the quality of the weakest link. That’s why we/I insist so much on education and (simulation-based) training. More in a few days!

Next post: “DEPLOY MEDICAL CAR!”

A comment about comments

As you’ve all noticed, I don’t get very involved with the comments on my blogs. I get an email when each comment is posted, and make a point to read every one. I’ll say something when a comment has been particularly vicious, gratuitous, and personal. My theory being that if they stab you, you shoot them, if they shoot you, you burn their house down . . . that kind of idea. Or I’ll say something when there’s a clear misinterpretation of what I’d posted, or a clear need for some medical information.

Remember, this is my first, and only, blog. Having comments at all was a surprise. That people would take the time to think about what they wanted to say, then actually TYPE it and send it was quite amazing to me. And of course, I had to think carefully about how was I going to deal with this unexpected phenomenon – was I going to be interactive, chatty, available, or rather a bit removed.

As you can tell, I chose the latter attitude. Besides not having the time to continually interact, the great majority of comments express opinions, or ask questions, that either just need to be stated, or don’t require answers, or are answered by subsequent commenters.

Stepping back just a tad, in order to grab some perspective, I think it’s useful to point out that what brought the vast majority of my readers here is my slant on what’s been happening with Michael. So it’s pretty inevitable that sooner or later this kind of situation would lead to people, already very involved emotionally with the shock and unexpectedness of this tragedy, to express their thoughts about some VERY deeply personal issues. The nature and limits of privacy, the meaning of respecting a grieving family’s wishes, the nature of fandom and how that exchange works when it’s not all about fireworks and Ferrari tee shirts anymore, right down to advanced directives and end-of-life decisions. At risk of sounding trite, what we have in common is our humanity, our concern for all victims of seemingly random life-changing events, and a desire to learn and understand more. This has sure pushed me into exploring an area of medicine with which I was only indirectly involved (persistent disorders of consciousness; I’m usually only really involved in the acute phase of head injury, not this less “medical” phase).

It’s normal and expected that the powerfully held, deeply felt, and strongly expressed opinions jostle each other, bang against each other, sometimes even crash into each other.

Now don’t get me wrong – I’m as cynical, sarcastic, and “noir” as anyone I know. Actually a damned sight more than most people I know. That said, I’d love it if we could get back to making the comments section an enriching, respectful place, where opinions can be challenged without the holder being attacked. A place where even the most seemingly difficult statements are considered in their context, and if necessary, clarification sought . . . before the Uzis come out. By trying to keep in mind everything we have in common we might just be able to take the edge off the things that make us each unique.

I’m going to start a series of posts reprising something I did when I first started tweeting – the sequence of events starting with an accident and ending with the patient being evac’d from the circuit Medical Centre. This format (a blog) gives me the possibility to do so with a few more than 140 characters! Aiming at a first installment later today, but that depends on how wrathful the Gods of the ER prove to be.

 

“Moments of consciousness and awakening”!!!

Well today is a superb day.

Sabine has told us two incredibly important things, things that not only inform us as to where we are, but open up rather more optimistic possibilities than some of the darker options we’ve considered until now, based on not knowing.

I want to repeat, because it’s important to fully understand what will follow, that while “wakefulness” and “consciousness” usually are pretty much one and the same, after the brain is injured, the two can be dissociated. What do I mean?

Assuming that the terms are being used and translated correctly (and Sabine is a consummate professional and wouldn’t get this wrong), awakening refers to (at least) the appearance of . . . being awake. Basically that means eyes open. And as I mentioned before, this eye opening can even be cyclic, following what looks just like a sleep-wake cycle (even if not synchronised to real day-night hours).

Wakefulness WITHOUT consciousness is the definition of a vegetative state. The eyes are open, but there’s no interaction with the environment. If Sabine had “only” said that Michael was showing wakefulness, it would mean that he is not comatose. That in itself is a damned sight “better” than persistent coma, not just in terms of life expectancy, but in terms of the chances of neurologic improvement.

But Sabine has also told us that Michael is showing signs of consciousness. My lord, the brain is an amazing organ. And Michael a remarkable man. What does this consciousness probably look like? It consists of episodes of clear, purposeful interaction with the environment, and/or clear signs of awareness of self, even if these signs are not constantly present. For example, if Michael smiles when a member of his entourage talks to him – reproducibly and consistently on at least a few occasions. Or following people with his eyes. Or trying to communicate, or obeying simple commands. Any of this constitutes objective signs of contact between the “outside” and the “inside”. This then would be a minimally conscious state. And that is about the best news we could possibly get right now.

Why? Because of what it means for everyone – Michael himself, his loved ones, and his fans. It means that Michael may well see, hear, and feel the love that’s around him. That he is, in some very real way, HERE. It means his life expectancy has now improved VERY significantly. And last, but perhaps most important, it opens up a very real chance for further improvement. This would mean spending more time “in touch” with his surroundings, and also improvement in the quality of the interaction. How incredibly positive!

This means rehab, lots of rehab. Michael is used to working hard. Getting that brain to learn new ways of doing things, stimulating it, forcing it to handle data, and all the while working hard to build him up again physically. All very exciting. And very good.

Don’t get me wrong – this is a very important step, but we don’t want Michael to stay like this. But this is a very very very big step.

We all need to thank the team taking care of Michael as well as the people around him, for their devotion and patience. Everyone is going to need to be patient – for weeks, months, maybe years.

But if you’re even the slightest bit spiritual, it’s time cast a look upwards and mouth the words “thank you”.