Out of surgery? (speculation)

It has been reported, but NOT by the hospital itself, that Jules is out of surgery and “breathing on his own”.

When a patient is brought emergently to the neurosurgical theatre for evacuation of a hematoma, the decision on how to manage the end of the surgery is a collaborative one, between the neurosurgeon, the anaesthetist, and perhaps the intensivist who will subsequently be charged with the patient’s care.

The decision basically involves: do we wake the patient up, or do we keep him or her asleep, intubated, ventilated mechanically, and do the wake-up later.

Factors that would tend to lead us to awaken after surgery would be:

  • relatively decent neuro status pre-op (meaning a GCS more like 8-10 or so)
  • a pre-op CT scan that doesn’t suggest widespread damage, intense swelling, or multiple hematomas (that kind of patient usually won’t make the preceding criteria, anyway)
  • a brain that doesn’t appear to swell when opened during surgery, and that doesn’t seem to have significant damage other than the hematoma
  • stable vitals and ICP during awakening
  • high quality surveillance and immediate availability of neurosurgical and anaesthetic resources

If indeed Jules is out of the OR, and if indeed he has been extubated and is breathing spontaneously by himself, then what is significant (in the absence of other specific medical information) is that this indicates how confident his surgeons and intensivists are that his neurological status is sufficiently stable to allow him that “luxury”. That would be really superb news.

#ForzaJules

55 thoughts on “Out of surgery? (speculation)

  1. WARNING… THIS IS FROM TWITTER:

    Statement from Bianchi’s family via Marussia says he has “suffered a diffuse axonal injury and is in a critical but stable condition”

    • Eric,
      I went to http://www.brainandspinalcord.org/traumatic-brain-injury-types/diffuse-axonal-injury/index.html for information and found this:
      “Prognosis of Diffuse Axonal Injury
      It is thought that diffuse axonal injury can occur in just about every level of severity, with concussion thought to be one of the milder forms. In mild to moderate forms of diffuse axonal injury, recovery is possible, with the mildest forms of diffuse axonal injury often resulting in few if any long-term issues.

      About 90% of survivors with severe diffuse axonal injury remain unconscious. The 10% that regain consciousness are often severely impaired.”
      lm

      • What we call “axonal” could properly be replaced by “cellular” or “metabolic”. A spectrum of dysfunction that probably has an impact on how the cell makes energy, how it synthesises, packages and releases neurotransmitters, and on the connections with other cells. Mild enough and self repair mechanisms are sufficient. More severe and cell death can result. And if the anatomy is disrupted, sometimes the framework remains and plasticity takes care of the rest. Other times not . . .

        Let’s remember here that this is why I insisted so much in the Michael posts on EARLY SATISFACTORY airway control. The unconscious patient not only doesn’t breathe adequately (quantitatively, leading to lower oxygen and higher CO2, which are really not good for an injured brain), but he or she is not capable of PROTECTING his air passages either. From saliva, blood, vomit or any of the other gross things that we handle every day without them “going down the wrong pipe”.

      • Gary,
        You joined my husband and me at breakfast this morning. He’d read a reference to you re Bianchi, at about the time your comment to me came through, so I put my Chromebook on the breakfast table with your response on the screen and we discussed you, your blog, and the impact one clear voice can have amidst the larger cacophony of voices.
        Welcome to our family!
        lm

  2. I wonder why they’ve called Saillant in, now. Isn’t he an orthopaedic? I understand he was involved in Michael’s care process, since the two are close friends, but now? What would consultation with him be useful for?

  3. Dear dr. Gary,

    First of all, I would like to ask- am I right if I say that Jules accident is very simillar to accident of Schumacher? Or from Your opinion and point of view is a little bit easier (if we can use this word).

    Also, Mr. Jeand Todt visited Michael at his home, and said that Michael will be back at ”normal life again” but he ”wont be able to drive na F1 car again”. Is that mean that he spoke with him, that Michael made a big progress and will be able to walk again, etc…? From my personall point of view, maybe his family didn’t want to give us real information, maye he was in better shape and they always gave us later information- for example maybe he was out of coma in february or march already, but they told us this in June, and they will wait for Michael couple of months and then he will go to public.
    Please comment both topics (my questions).

    Thanks in advance.
    Best regards from Croatia

  4. Dr Hartstein, just wanted to say thanks for your comments on this horrific incident. Both as a huge fan of F1 and also as a doctor myself as well, it’s great to have a colleague who has been intimately involved in F1 to interpret the media reports and provide some expert opinion.

    As an Orthopaedic surgical trainee, it’s been a long time since I’ve directly looked after anyone with a head injury but I have (unfortunately) been involved in a fair bit of spinal trauma. Having seen the footage now, I would be very worried about a cervical spinal injury with that mechanism.

    I understand that HANS devices have been mandated for some time now, but I just wanted to ask what kind of support does a HANS give and would it withstand this kind of force?

    Also (if you have time) how would you extract a driver protecting their c-spine? Are the seats extractable from the cars with the drivers in them?

    Thanks, Simon (Sydney, AU)

  5. There are obvious comparisons which will be drawn between Bianchi’s injury and Schumacher’s. The one thing that stands out for me is Michael was awake in the moments following the accident before the (I believe) brain swelling caused him to lose consciousness. Bianchi seems to have lost consciousness immediately. Does this difference tell us anything about a possible difference in the injuries?

    • I guess this is really deserving of an answer. Extremely interesting point; additionally, we consider comparison with Massa’s impact with the spring, too. Massa’s accident was clearly less harmful than Schumacher’s. Why did the former lose consciousness right away, while the latter retained some capacity to speak and understand his environment for a while? Does Bianchi follow-up plunging into a coma necessarily mean he sustained heavier damages?

      • The existence of a lucid interval depends on the rapidity with which damage occurs. In Michael’s case, it’s classic that this kind of hematoma takes a bit of time to form, and then there’s a sudden degradation as it does. Not many other conclusions to be drawn from the interval between injury and neurologic deterioration. But really a good point!

  6. Pingback: Suzuka Review - Bianchi's crash - Matt Meir

  7. There was a camera on the accident itself and the footage has now been uploaded to Youtube. I shall not however provide the link here as it would be wholly inappropriate.
    It was however an appalling accident … quite dreadful.
    For as long as I can remember tractor cranes have been used to move cars which have crashed to a place of safety. This was no different. Mr Bianchi and the crane in question were unfortunately in the wrong place at the wrong time.
    My thoughts and sympathies to Mr Bianchi, his family and also to his charming and clearly utterly distraught young girlfriend.

  8. Hi Gary
    Thanks for all your concise views, have you seen the video of the actual impact ? I have been involved in Motorsport safety for over 40 years, worst impact I have seen, huge impact to move a multi ton digger off the ground, he is lucky to have survived thus far.

    smellmyclutch.com

  9. Just saw the horrific clip of the accident on bild.de. FIA is muffling the news for obvious reasons. Prayers with Jules.

  10. Dear Doc,

    While watching the appalling images of Jules’ unfortunate crash, I searched for the Martin Brundle’s Suzuka crash, 20 years ago, and eventually found it:

    Fading light, heavy rain – heavier, probably, than in 2014 but I’m assuming everyone was on “full wets” which wasn’t the case at all yesterday – and a vehicle removing a race car from the runoff of a difficult corner… And soon after, another incident with a car aquaplaning onto the armco.

    I really struggled while writing this. I do not wish to speculate at such a delicate time, but the similarities are so many that I cannot help asking if, in your opinion, wasn’t there a lesson (or more) to be taken from the 1994 situation?
    How do you see this situation, bearing in mind earlier issues this season on SC being released for supposedly less dangerous occasions, and the criticism these decisions generated?

    Going from anxious to angry, really. It’s hard to watch such a talented kid menaced by such a stupid, freakish accident, crashing against something that is not supposed to be an obstacle or part of a race. Then again, probably we all feel the same…

    #ForzaJules

    Thanks for everything, Doc.

  11. Keep fighting, Jules! Sending my prayers. Dr. Hartstein, thank you very much for your help in explaining things to us.

    I hope they give fans access to medical updates. Sometimes they don’t seem to get the fact that fans REALLY care. The handling of the Schumacher information was torturous.

  12. Hi Gary
    I didn’t think it was very likely that he was breathing alone after surgery but started to believe it when BBC reported it. Disappointed that this now seems very unlikely.

    Latest statements
    http://www.bbc.co.uk/sport/0/formula1/29503730
    http://www.marussiaf1team.com/news/1034/#V2m8q7hUZrvtmgVK.99

    It reminds me too much of the early days after Michael Schumacher accident as latest is that information will only be released when agreed by family, who are travelling to Japan and likely to be delayed by bad weather.

    I hear that Jean Todt has seen Michael Schumacher at home and latest news sounds very downbeat. I think we should be very cautious about unlikely positive stories.

    • I don’t know where you heard that about Michael’s condition, Jane. The latest news I have – today in fact – is here: http://news.playf1.net/special/schumacher-can-live-normal-life-again-todt and it sounds cautiously upbeat. However, as usual, take any reports with a grain of salt unless officially confirmed. There has been more misinformation on Michael’s condition published than on any issue that I can remember outside of politics and war.

      • Thanks Mike – this is new and different to the accounts I read at the weekend.
        It does mention RTL as Belgian broadcaster in the latest report so Gary should have heard this if it is true …….. What I read at the weekend was that he was ‘struggling’ and recovery would be long and hard. This latest news sounds suspiciously upbeat to me but would be wonderful if it turned out to be true.

        Gary – have you heard anything on Belgium radio?

        Precious little is known about Schumacher’s health condition, but Todt has reportedly now delivered an upbeat report to the Belgian broadcaster RTL.

        “We may assume that Schumacher can live a relatively normal life within a short period of time,” said the FIA president.

        “What we can say is that he will probably never again drive a Formula One car.”

      • I’ve heard nothing. I’m also a bit sceptical of jean todt’s ability to prognosticate about the recovery (both in time and in quality) of a patient in a minimally conscious state at almost a year post injury. Qualified neurologists and neurosurgeons don’t say things this stupid. True enough, he’s neither, so might be excused . . .

        This statement is devoid of content, devoid of value, and devoid of sense. It should rightfully be ignored.

      • Wouldn’t it be the case to STOP thinking for a while he’s still is in a MCS? You’re the one to still assume it, Dr Hartstein. People around him’s statements seem to point in a different direction.
        Uh, I have to add that I’m also pretty darn skeptical about the ability of anyone to prognosticate/diagnose anything directly from his living room couch. But I guess you already know this.

      • I’ve no idea what condition Michael is in. The last description of Michael’s status by his press staff was a textbook definition of an MCS. I’m therefore not diagnosing anyone. Michael could be preparing for next season’s Dancing with the Stars as far as any of us know, but it’s not likely. I’m not prognosticating. I’m just pointing out how worthless statements by unqualified people are.

      • Okay, I understand what you mean, doctor. I ask you to excuse me for the way I harshly and pointlessly criticized you, it’s just that I strongly disagreed of your way of reporting opinions/speculations a bit as they were facts.
        And, uh, really thank you for your insights. Since the beginning.

      • Thanks for your comment Roberto, but there’s no need to excuse yourself! We’re all adults here, and we’re passionate and involved! That makes it interesting.

        I try very hard to NOT report my opinions and speculations as fact. If I sometimes slip up with that, I apologise. It’s extremely important to me that I retain some credibility, and NOT reporting stuff as fact is one way to do that.

        Thanks again!

      • Have no fear, Dr Gary, your credibility is secure so far as we readers are concerned (at least in the majority of cases, I can’t speak for everybody). I agree that the statement should be viewed with suspicion, but I posted the link because it didn’t seem to be in keeping with the reported tenor of what Jane had been hearing, and because hope should never be abandoned – just filtered through a prism of realism. And that’s what you do for us – provide realistic assessments of these situations so that we have a context for the interpretation of reports that is grounded in reality.

  13. Hello Gary,

    Heard you speak on BBC Radio 5 Live here in the UK this morning and give a few brief explanations, about medical and safety procedures, live on air. Thank you for explaining the technical side to the safety of the sport. Much appreciated.

    Wishing the best for Jules Bianchi and everybody concerned.

    Mark.

  14. I dunno why, but I remember some news reporting that Jules was robbed in front of his hotel few years ago. What got my attention was the fact that he was out for a smoke when this happened. Of course I do not know if he is a regular smoker. But if he is, isn’t that a big negative factor for a pacient suffering from any hemorrhagic condition Dr. Gary?

    • I have no idea if Jules is a smoker, but I’d be surprised if he was. As you say, cigarette smoking is a risk factor for adverse outcome in lots of unexpected situations. I’m not sure that head injury is one of them, but wouldn’t be surprised if it was.

      • I know from personal experience that Michael Schumacher was a avid fan of a nice cigar, he seemed to manage OK with them, but I would treat all reports regarding progress with scepticism until they are “official” as others have commented, we’ve been here historically.

  15. From Sky Sports Online. Last Updated: 06/10/14 5:44am

    “Sky Sports News HQ’s Craig Slater, reporting from Japan, says that the initial surgery has now been completed.

    Bianchi has been moved to intensive care where his condition remains ‘critical’. Contrary to some reports, he is not breathing unaided.”

    • This, while obviously not as upbeat as those initial reports, would be much more in keeping with the type of lesion one would expect from a high-speed drive-under, with what we were told was a patient who was unconscious on-scene and throughout transport (the FIA told us this, so it’s reliable), and with the kind of clinical management one would expect.

  16. In the latest BBC report dated “5 Oct 2014 Last updated 18:06”
    “Earlier reports in the French media said Bianchi was breathing on his own following surgery. However there are now conflicting accounts. BBC Sport is seeking clarification on his condition. “

  17. Dr Hartstein,

    Could the comment that Bianchi is “breathing on his own” (notably, yet to be confirmed) reflect merely the presence of spontaneous respiratory drive (e.g., breathing over the ventilator)? I would never expect an intensivist to be so casual in describing the clinical condition of a patient, but these are media reports, not progress notes.

    Thanks for your efforts to help us better understand the world of motorsport medicine.

    • I have no idea what was meant. Were it to be (have been) true, it would have been (would be) good news, if unexpected. I think we really need to wait for what is now a long overdue FIA announcement.

  18. Gary, why is the green flag out. Video upper left tower. I believe there are now two cars involved, medical crew at scene (blue dungarees). The steward is still showing green.

    • Because that marks the end of the caution sector. That marshal is downstream of the accident, and is therefore telling oncoming drivers that from that point on, normal track discipline is operant. Doesn’t matter that the accident is just a few meters up circuit from him or halfway towards the nearest upstream marshal post – this guy shows green.

      The double yellows, telling the drivers that there is an intervention and to be prepared to stop, were displayed at the immediately upstream post.

      • Was wondering about this too, thanks for the explanation.

        Is it possible that due to the bad weather, Jules didn’t see the double yellows? Massa was saying a few laps before that he couldn’t see anything.

        Terrible accident.
        #ForzaJules

  19. Thank you for the explanations of the rumours circulating as to his condition. Somehow it is more reassuring to read from a medical professional with experience in motor sports.

  20. We should be very careful here. After both Massa and Schumacher’s accidents, false rumours circulated suggesting they were OK. This was probably just wishful thinking, which at some point became reported as fact. We could be seeing the same thing here. Let’s keep our fingers crossed for an official announcement of positive news.

  21. As far as the race goes, I think the racing drivers themselves believed the decision to allow the race to go ahead was correct – there was a gap in the weather and most of the time the conditions necessitated intermediate tyres – not full wet weather tyres.

    There are at least two issues I see 1) the deteriorating conditions at the end. For example Felipe Massa was saying the safety car should have been put out five laps before it did. The conditions worsened rapidly during the end of the day with rapidly deteriorating light. Massa said the conditions became ridiculous for some – those with not enough downforce, rapidly increasing risk of aquaplaning. The second issue at least for me is 2) why was the recovery tractor allowed onto the track while the conditions were getting rapidly worse, at a position where a car had aquaplaned off into the barriers, while the cars were still racing or at least travelling at race pace. Acceptable risk … I am not sure. The barriers were doing their job, the formula 1 cars are designed for minimising safety … but bringing a lump of hard metal into the run off zone under those conditions … it makes me worry.

  22. They say that Jules was taken to hospital by ambulance because the helicopter couldn’t fly in the conditions. I thought the medical helicopter being able to fly was a prerequisite of a session going ahead? I know I have been at an event, possibly a DTM quali at Brands Hatch, where action was delayed until the helicopter could fly. I’m not suggesting that this in any way contributed to Jules’ condition but have things changed? Or does that rule vary from circuit to circuit or event to event?
    There seem now to be conflicting reports about whether he is breathing independently post-surgery. Praying for the best outcome for him.

    • I’ve tweeted about this a bit. There are regulations concerning this. Remains to be seen if the Medical Delegate followed them, and if not, why not. Plenty of time for those determinations, though.

  23. At the beginning of the race, while the field was led by the safety car, BBC live stream said that FIA officials had tried to persuade the Suzuka organizing committee to run the race two hours earlier and avoid the brunt of the typhoon. The FIA did not prevail and the race ran on time.

  24. Gary, perhaps you clarify a point for me since it’s a long time since I did neuro. Re: Medical evacuation, what is the policy to transferring unstable patients via helicopter say if they are still unstable cardiovascular. I know this might be standard practice in the military but how easy is it to achieve that in the confines of the standard air ambulance.
    I was taught airway with online neck stabilisation, breathing, circulation and disability. With a heavy emphasis on maintaining normal blood pressure since only then will any expanding mass lesion become apparent.

  25. You a\re my go-to person to enable me to interpret/intuit the sparse medical bulletins, Gary, thank you. I take on board all your caveats about you’re not having more information than us to go on, but I appreciate you can read between the lines better than us. Thank you

  26. Thanks Gary – as you say if this is confirmed by the hospital it sounds very encouraging to me. I have no medical expertise and can only base my observation on having gone through my other half being in ICU, ventilated & kept asleep for several days following a RTA (multiple fractures of his body and a head injury) which he came through. My thoughts are with his family, friends and team at this time as this is simply the worst time for them..the waiting..I will keep everything crossed that the hospital do confirm this to be the case. Keep Fighting Jules!

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