Good news?

As my mom always said, “You make your bed, you gotta sleep in it”. So even though I was sure I’d written my last post having anything to do directly with the Michael Schumacher tragedy, I just want to answer the hundreds of questions I’ve already gotten as to the import of todays statement.

1) It is obviously good news that Michael has left the hospital. Because of the length of time since Michael’s injury, and of the specific role of an Intensive Care Unit (ICU) in supporting and monitoring the function of the body’s major systems, it’s almost certain that Michael has not simply been discharged from the ICU to a rehab, without having “transitioned” by a stay on the regular wards. I have never seen a head injury patient with a 5 month ICU admission be transferred directly to a rehab facility . . . but anything’s possible. 

Remember that there are lots of rehab facilities that can handle ventilated patients, so this transfer also says nothing about whether or not Michael is breathing spontaneously.

2) The moment Sabine announced that Michael had moments of eye opening, we knew he was no longer in a coma. BY DEFINITION. Coma = no consciousness, no eye opening. Open your eyes but unconscious, it’s a vegetative state. Add fluctuating signs of interaction with the environment, it’s a minimally conscious state.

So what does that mean? Sabine is a professional. At the beginning of April, she told us Michael had moments of awakening AND of consciousness. Once again, by saying this, she told us in almost clinically perfect language that Michael was no longer in a coma. She used two terms that only specialists actually distinguish; for laymen being awake and being conscious are the same thing. This language, then, clearly was used based on discussions with Michael’s care team, and reflected a highly accurate description of his minimally conscious state.

Now, we’re told, with what appears to be a bit of a triumphal air, that Michael is no longer in a coma. As stated above, THIS IS NOT NEWS. I cannot help but think that this is a highly cynical use of language, using the truth to convey an impression that is almost certainly false. I cannot but think that if Michael had emerged AT ALL from the minimally conscious state that Sabine so accurately described in April, we’d be told that Michael is leaving for rehab, that he is having problems expressing himself and will work hard to get better. Or that he’s having to learn to walk,read, write, etc all over again. But no, we’re told what we already know, and pretty much told to not ever expect further updates. Kinda like what I was thinking.

This all leaves a very bad taste in my mouth. And a huge space of sadness for Michael’s family, and for you, his fans.

Some REAL expert reading!

Here’s a reference to an excellent and VERY recent (May 29th issue) review of the what, how, and why of traumatic intracranial hypertension. Online it’s subscribers only, but if this is a subject that interests you, it’s worth trying to get a copy of the article.

Traumatic Intracranial Hypertension

Stocchetti N, Maas A

New England Journal of Medicine, 2014: 370(22); 2121-2130

Oh and if management of near-lethal trauma interests you (I’ll get into some of this in future posts), then check this article in today’s New York Times out:

http://www.nytimes.com/2014/06/10/health/a-chilling-medical-trial.html?hpw&rref=health

 

“Medical car on scene”: first medical contact (2)

Before we consider the approach to the driver still in his (or her – my use of the masculine pronoun is purely for simplicity!) car, I wanted to briefly consider what we do when the driver is out of the car on arrival on-scene.

First, the relatively rare situation of a driver out of his car, but not feeling well. The best and most interesting example of our approach in this case would be Fernando Alonso’s accident in Brazil in 2003:

When we arrived on-scene, Fernando was half sitting, leaning back against the base of the grandstand wall. He was pale, sweaty, and clearly not in top form. I’d seen the accident on the screens in the Medical Car, and knew it had been huge. I told Fernando that we were going to place him on a gurney, load him onto the ambulance that had already arrived on-scene.

“I’m not going on a stretcher, I’m going to stand up” he said stubbornly. I was annoyed, but not surprised. This is how these guys are. I thought about it for a moment.

Happily, Dino, the Chief Medical Officer in Brazil has teamed us with Dr. Fernando Novo for years. Fernando is one of the pillars of the PHTLS (Prehospital Trauma Life Support) course in Brazil, and this brilliant skill set, as you’ll see in a moment, came in incredibly handy here. I told Dr. Fernando that we were going to do a “two man takedown”.

I told Fernando (the F1 version), still sitting against the wall, what was going to happen. I said we’d let him stand up and wave to the crowd. I insisted that if he felt unwell standing, he was to just whisper that to me, and we’d get him lying down pronto. I told him that before we let him stand up, we were going to place a rigid cervical collar before he stood up. And that as soon as he’d waved to the crowd and acknowledged their applause, he was to remain quite still as we prepared him to be put on the gurney and loaded onto the ambulance. I told him this was non-negociable.

Fernando (Novo, my colleague) stood on Fernando (Alonso)’s right, and I at his left. Standing up was uneventful. Good. Step one successful. Now picture this: Fernando Novo and I apply a long spine board (held vertically of course) to Alonso’s back (while he’s standing), holding it there with my right, and Fernando Novo’s left hands, placed under Alonso’s armpits on each side and grabbing the handles on each side of the board. We each place our free hands (my left hand and Dr. Fernando’s right) on either side of Alonso’s head, to provide additional stabilisation beyond that of the collar. My left (and Novo’s right) feet are blocking the bottom of the board. Ready? On the count of three, we tip Fernando back, the ambulance crew grab the bottom of the board, and waving to the crowd, Alonso is placed on a gurney and loaded onto an ambulance while the crowd cheers.

This is an excellent example of the complementarity between the local team (here represented by Fernando Novo in the medical car) and the FIA. It also eloquently speaks to how important it is to have everyone reading from the same page in terms of medical knowledge and technique. Here, Fernando Novo and I shared knowledge of the PHTLS course, with obviously highly satisfactory results. Now we need to hope the FIA actually does move ahead with worldwide implementation of a motorsport medicine course. Yeah, the one they’ve been talking about for ten years now.

When the driver is out of the car and not complaining, we’ll almost always take him in the medical car. I would use this time to check for any subtle complaints that only start to appear when the adrenaline of the accident starts to fade away. It’s also a great opportunity to look for subtle symptoms of concussion. So I’ll ask about who he was following when the accident happened, and other questions looking for anything . . . not right. If there are symptoms, complaints, or if the medical warning light of the car was triggered, we drop the driver off at the medical centre.

A brief announcement

I’ve decided that I’m going to stop writing about Michael Schumacher, about his accident, and about what his situation may or may not be.

There’s not much more really to say. It leaves me with a leaden feeling in my gut that Michael is in his sickbed, and that more words aren’t going to help anybody with anything. And in terms of my blog, I think I’ve pretty much covered it all.

I’ll read all your comments as I’ve always done. Forgive the odd deletion – the criteria are fluid, and are highly dependent on whether they’re the first comments I read upon awakening, or rather in the near-euphoria of returning home after a long day at the hospital! Bear with me about that, and if a given deletion SEEMS illogical, trust me, it is. I in no way intend disrespect for your thoughts and for the fact that you actually WRITE stuff here. It still blows me away. But I’ll try to maintain a bit of decorum (totally arbitrary I know) in the comments, and will rely mostly on YOU to keep things civil. Or at least make the incivility so good that we all are dying to use it somewhere else. THAT would be worth it. And no, I’m not going to have an incivility contest. Hmm…

My interest in head injury, and in concussion in particular, remains, and will be a source of posts. The POTUS just had people to the White House to discuss this issue – there is a HUGE, almost evidence-based cultural tsunami going on, and its ramifications are enormous.

Anyway, see all of you soon.

Michael – five months on

First of all, I want to thank you all for your comments and questions since last week. We’ve got lots to talk about – today it’ll be a bit about Michael Schumacher’s situation, but I’m also going to be writing about the fascinating duel between Lewis and Nico . . . AND continue the series about trackside medical intervention.

I’m also looking at starting a video blog, as a way to better interact with you all. This will probably be through a YouTube channel; one of the things I want to do there is answer your questions in a more comfortable format. (If you’ve got questions you want answered, send them here to comments, and I’ll get to them once the v-log is up and running.

Tons of you have asked about Michael’s current status. Obviously I have no direct information. And I’m STILL considering that if there were good news to be had, we’d have been told. I can conceive of no possible reason that Michael’s entourage, understandably extremely protective of his (and their) privacy, would NOT tell his fans if significantly good things have happened. So as always, I’m speaking based essentially on the published and consensus epidemiology concerning outcome in severe head injury. And of course, as always, a reminder. Every caregiver working with a significant number of head injured patients has seen surprising and unexpected emergences. But these are rare, achingly rare.

Let’s take a look at what’s called a “survival curve” for patients in a persistent vegetative state (PVS) after trauma:

On the graph, we’ve got time (in months) along the bottom, and percent of patients along the y–axis. At time 0 (the day of injury), we’ve got 100% of the study population of patients in PVS. Just as a reminder, PVS means apparent wakefulness (eye opening, something resembling a sleep-wake cycle, etc) without signs of consciousness (awareness of self and/or the environment).

As we move left to right, we see three sub-populations opening up – from top to bottom, there are those who regain consciousness, those who die, and those who remain in a vegetative state. Michael is now 5 months post-injury, but for the sake of simplicity, let’s look at the 6 month mark. Look at the line indicated by the arrows. Notice how at 6 months, this line becomes very nearly horizontal.

This horizontal line says, in the most eloquent and desperately sad way, that after 6 months only a tiny tiny fraction of patients in PVS regain consciousness. In essence, persistence of the vegetative state or death are the primary outcomes remaining. The slope of the line separating “dead” from “persistent vegetative state” shows the approximate death rate of these patients – roughly 25-30% per year. And just to repeat what I’d said in an earlier post, essentially no one in a persistent vegetative state at ONE YEAR will ever regain consciousness.

If Michael is in a minimally conscious state (MCS, defined as the presence of objective, but fluctuating and inconsistently reproducible signs of either self-awareness or interaction with the environment), the outcomes are slightly better. There would then be a low, but real, possibility of improvement in the quality of consciousness over the next several months to years. That said, agonisingly few patients in an MCS at six months ever wind up speaking, walking, dressing themselves, etc.

As to the rumours of Michael being at home, they could easily be true, but I have no way of knowing. This would be the kind of information I’d assume would be EXTREMELY closely held, for obvious reasons.

There is no reason why this shouldn’t be possible. If Michael is still ventilator-dependent, taking Michael home would require a certain amount of equipment and the round-the-clock presence of a significant level of care, but thousands of ventilator-dependent patients are cared for at home. If Michael is breathing on his own, home care becomes even more feasible. As you can imagine, patients with prolonged severe disorders of consciousness require a high level of care, but this would be something that Michael’s family could organise with no major problems.

I’m quite afraid (and virtually certain) we will never have any good news about Michael. At this point, I rather dread seeing that the family has put out a press release. . .