Last week’s Jules update

First of all, as many of you have pointed out, we once again owe a deep and sincere thank you to Jules’ parents.

Obviously this is good news, at a few levels. Being closer to home, to friends and family, is immensely important.

Knowing that Jules is breathing on his own is also very good news. Not so much prognostically; rather because it’s one less open door to potentially life-threatening infections.

The press release also says that the “medically induced coma” has been ended. Remember, ALL patients with severe head injury are anesthetised. This is to allow them to be ventilated by a respirator, and to better control many of the patient’s parameters during the first crucial days.

During the acute phase (roughly speaking from ICU admission until the intracranial pressure/brain swelling was brought under control) if the intracranial pressure rises too high, and the usual means fail to bring it down, this anesthesia (itself a medically induced coma) is deepened significantly, as a last-ditch effort to control the pressure. This was done, as you remember, for Michael Schumacher. It was also almost certainly carried out for Jules. This deep anesthetic is usually only used for a few days up to a week or two (rarely more). Then the background “routine” anesthetic is also slowly weaned. The speed of this process depends on the patient’s circumstances and how withdrawal of sedation is tolerated. This was presumably done prior to Jules being transferred back to Nice.

But he is still unconscious.

The fact that Jules is no longer being sedated, is no longer receiving anesthetic drugs to maintain a state of PHARMACOLOGIC coma, but remains unconscious at almost two months post injury, is obviously of great concern. But his is perfectly compatible with the clinical course of a patient with severe diffuse axonal injury who was unconscious on hospital admission.

While statistically the situation is fairly dire, statistics are just that – numbers. Let’s wait, support the Bianchis in any way we can, and constantly hope things get better.

Sorry for the delay in posting this. Lots of things going on, and just could not find time to write.

72 thoughts on “Last week’s Jules update

  1. Now that the FIA report has concluded that Jules was sadly driving too fast (just as you said) and that he hit the 6,500kg crane at a speed of 126kph (78mph) I wonder if you might be able to comment on the detail of his injury below.
    “Bianchi’s helmet struck the sloping underside of the crane,” read the report.
    “The magnitude of the blow and the glancing nature of it caused massive head deceleration and angular acceleration, leading to his severe injuries.
    “All rescue and medical procedures were followed, and their expediency are considered to have contributed significantly to the saving of Bianchi’s life.”
    Thanks.

    • A graphic and distressing explanation of what happened which confirms what both Gary and others said at the time and flies in the face of Marussia’s at the time suspiciously strident outrage and anger at the suggestion Bianchi didn’t slow down.
      It still remains to be found out exactly why he didn’t. Upon instruction (active or tacit) from his pit or of his own decision? In any event I feel Marussia don’t come out of this terribly well.
      A head colliding with the underside of a tractor at 126 kph. Given what we know already, I don’t think it takes much imagination to see what the future holds for Jules and his family. I feel desperately sorry for them.
      And as for his life being “saved”? I wonder.

      • Peter, I thought the same thing about his “life being saved”:. Saved for what? A lifetime of misery for him and his family. Sometimes I don’t understand this higher power.
        This morning my daughter told me that one of her daughter’s friend’s mother passed away. What kind of God takes a mother away from two young children??
        Sorry, for this but this kind shit really upsets me….and makes me question my faith…whatever is left of it.

      • “What kind of God takes a mother away from two young children??”

        He giveth and He taketh. One can either be of an appreciative frame of mind or of a disparaging frame of mind. If you find God helpful, then keep the faith. If you find the notion of God unhelpful then embrace agnosticism or atheism.

      • Given the choice Pyotr (I had to scroll down to see how to spell your new name … have you recently embraced Rachmaninov or something!!) …. I’ll go with atheism … the rest, in this context, is complete nonsense!

      • If there is a God (I’m very agnostic on this) I can’t think that people being left in a vegetative state was part of his plan for this world. I’ve always liked Gary’s comment somewhere way back on this blog that we are all angels and demons and the belief that both God and Satan are fighting for control in us all is the only thing which has ever made sense to me. Sorry about the children who lost their mother Mimi, but I don’t think God can be blamed for every single bad thing which happens in the world. I like to think of a weak God who quickly lost control but needs our help to fight back.

    • When you have been driving at 200 mph plus 78 mph must seem like a snails pace, When driving in town you get a sense of speed of 30 mph. Then drive on the motorway for two hours – when you get back on town roads 30 mph seems like a snails pace.

      Of course this isn’t the whole story, different parts of the track will be driven at different speeds and I think the “78 mph” is the speed at collision rather than speed where he lost control of the car. What would be useful is knowing by how much Bianchi (& others) slowed down at that point in the track (compared to “normal” speed).

  2. Phillip Hughes is being buried. I am wondering whether this is the biggest outpouring of emotion Australia has faced in recent times for a death of an individual. I am thinking of the death of Princess Diana as having a similar effect on a nation. There was the death of Steve Irwin (crocodile hunter) but I can’t quite recall it having the same emotional impact as Phillip Hughes.

    • Heartbreaking images of Phil’s funeral on the news this morning. I love that people are showing respect by placing cricket bats outside. There is a snooker tournament in the UK at the moment and Aussie Neil Robertson carried a bat into the auditorium and kept it by his seat. Lovely gesture.

    • I like it that they made a point of including the bowler Sean Abbott in the ceremony. A terrible thing to live with – like killing someone in a road accident and having to live with the guilt all your life.

      • that’s ended up in the wrong place, so to be clear I find the exaggeratedly public outpouring of grief bizarre not that they included Sean Abbott in the proceedings …

      • I tend to agree with you, Peter. Don’t even try anyone to compare this kid to Princess Diana. Diana was an icon….I had never heard of this kid. And cricket?????

      • Mimi, cricket is fine if you only watch the highlights and something happens every ball. But if you watch it live…..well, you fall asleep!!

      • I loved your comments about cricket Peter. Having grown up as the only girl in a family obsessed with football, cricket and golf (which really is the most boring sport in the world) I refused to play with the nasty hard ball although I always enjoyed getting sixes with a tennis ball and making the others run to field it.

        This was in the Gary Sobers days and my Dad strongly disapproved of Kerry Packer, bouncers and what he calls the pyjama cricket they play today. My Dad’s dream cricket is so boring that watching paint dry is more exciting.

  3. Hi Gary, in the UK we have High Dependency Units where patients like Jules can go once they can breathe by themselves – this is because we have a limited number of intensive care beds and people have to be moved on to make way for other patients. I just wonder why Jules is still in intensive care. Do they have similar facilities in France and Belgium?

    In the UK I don’t think people stay on ventilators very long due to health rationing. Brain injured patients seem to have tracheostomies early and can’t go to rehab until they are breathing wihout a ventilator in most cases. I think Belgium may have more intensive care beds – I found out recently that Germany has even more intensive care beds than the US which amazed me!

  4. Mark Webber is reported by the BBC in saying “correct angle of impact saved me” but a few sentences down the report says “The Australian, who said he had no recollection of the accident or how it happened”. So I guess he must have been told this by those who saw it happen. It looked like a huge accident, the outer shell of the Porsche was ripped apart leaving some form of protective “space capsule” remaining – but it was difficult to tell – it looked like a complete wreck from a different angle. Presumably advanced engineering save him.

    http://www.bbc.co.uk/sport/0/motorsport/30271784

    • Don’t want to know better here but I’m afraid there has been the usual press manipulation here too.
      The crash was a heavy one but Mark ended up going into the (final) wall backwards. If you look at all the photos you will see the front of the car, and thus the survival cell, was largely (with a capital L) intact which is why he survived relatively unscathed.
      The press chose to mainly show photos of the wreck from the back which of course made it look much worse. Big crash though … goodness me, he HAS had his fair share over the years. @aussiegrit

  5. Read that Marussia auctioned all of their cars, equipment, parts etc. Not include were the engines. I guess this means that the engines are returned to whomever? Not sure how that works.

    • Strange. I would have given good money that Marussia rather than Caterham would be the ones who would eventually find a buyer.
      Mind you it would have been someone else’s money, I would have borrowed it at an inflated rate of interest and I would eventually have discovered it to have been severely leveraged … but money I would have given.
      Actually I wouldn’t have ‘given’ it … I would have lent it and then taken it back because the receivers were called into to tend to my affairs weeks ago … but the thought was there, and it’s the thought that counts ….!

  6. Gary, there’s an interesting story on Will Buxton’s blog (titled “Hope”) from the father of a survivor of injuries similar to Jules. We can hope for Jules (&MS).

    On the side topic of “virtual safety cars”, has a (raised?) pit lane speed limiter idea been dismissed? The tech is there already.

  7. Richard Hammond has been in the UK media a lot this week talking about his accident again. This is a tiny bit relevant to Jules as people keep saying he had DAI which is possible, although it must have been very much milder as he was only actually completely unconscious for a day or two. He is now fully recovered but has been talking frankly about how the knock on effects of his brain injury meant that he had a pretty tricky few years as he was susceptible to depression, obsession, compulsion and paranoia, although he wasn’t aware of it at the time. it’s all about the emotional effects of traumatic brain injury, which is something I hope you might be able to post about in future Gary as I think it is much more common after TBI than the devastating effects Jules and Michael have suffered..

    What is interesting is that all the papers are now reporting that he was in a coma for 2 weeks which I know is wrong as I followed the story at the time. The reason they are quoting 2 weeks is that he can’t remember 2 weeks – he was actually talking a couple of days after the accident but had post-traumatic amnesia for a couple of weeks. I hope you might also be able to post about PTA and how it is a good measure of how severe TBI is.

    Thanks – just feel that the more knowledge everyone has of TBI the better.

  8. Hey Gary, With the recent and sad death of the cricketer Phillip, He seemed to die so suddenly, like they expected him to regain consciousness almost suddenly? How long does it take for them to declare him unable to regain consciousness? I don’t know. He obviously wasn’t brain dead at the time they did the surgery i think. Can you please clear this up possibly in a blog post?

  9. “Michael Schumacher” was the second highest term searched for on Yahoo in 2014.
    Shows the interest and concern people have for him. Those close to him should take note.

      • Haha! Yahoo has apparently 4% of market share though I agree, but one assumes the statistics translate up to a point to Google and the other search engines.
        The message though is clear … people love and take an interest in Michael Schumacher. they want information about him that is reliable.
        Simples!

  10. My husband saved a man’s life today using the Heimlich maneuver – he was in a restaurant and this man started choking.

    I only once saw a man die – it was a horrible slow death in and out of intensive care, bleeding to death into a bottle at his side. He was a chronic alcoholic and had been in hospital for a month – he had oesophageal haemorrhage.

    Life is very fragile and precious – thanks to everyone like Gary who must witness death all the time.

  11. “He sits in the sun”. Have any of you seen the German magazine with the misleading cover shot of MS?
    The picture was taken well over a year and half ago and is a total fraud.
    This is what happens when information from the family is not forthcoming. Magazines, people, photographers etc are left to speculate and make things up.
    One photo of Schumacher and one brief statement of truth coming from his wife would go a long way in shutting down all the guessing.

    • One photo of Schumacher and one brief statement of truth coming from his wife would go a long way in shutting down all the guessing.

      Given that folks have been making just this observation since the beginning, only for Kehm to ignore that route suggests we’re in for a bull market in MS BS from the bottom-feeding media.

  12. With regard Phil Hughes and helmet issues – it seems the ball hit him high up on the neck. So it is not clear a change in helmet design could have prevented this particular incident. A batsman needs to have an unobstructed vision and to be able to move his head and neck to be able to bat properly.

  13. Not ashamed to admit that I shed a tear this morning at the news of Phil Hughes death. Not because I was particularly a fan but simply because head injury is now close to the hearts of all of us who follow this blog. His family and friends are devastated but a part of me can’t help but wonder whether this outcome is preferable to a family sitting by the bedside week after week, month after month while their loved one wastes away and they hope against hope for a miracle that just isn’t going to happen. Just a thought.

    • Very sad news Sue – I’ve just heard the tearful announcement on Radio 4 but Gary was right. I don’t think this was a survivable injury as some of the horrific footage made clear. It reminds me of the death of Sarah Burke, extreme skiier who tore a verebral artery and went into cardiac arrest.

      Regarding your other point – I’ve heard people whose sons have ended up in a vegetative state agree with you that the ones who die quickly may well be the lucky ones …….

    • The family have no choice in the outcome whether preferable or not. The so called cards are dealt and everyone has to get on with it. People looking after a parent or partner who are suffering from some incurable condition are under no illusion. Duty and compassion are important elements in all of this. With this happening with someone so young there is a sense of unfulfilled possibility. But it happens.

      • Absolutely right and correct. However, I am pretty sure that in the old days experienced doctors in the UK at least used to avoid treating patients when they knew the likely outcome was virtually hopeless and I am not not convinced that their decision to play God was necessarily the wrong one…….

  14. We’ve spent much time hearing about the state of the art F1 medical response and facilities – heres what happens when a sport gets it critically wrong; Phillip Hughes, Australian Cricketer hit in the head this week by a ball, collapses instantly and yet there are no facilities on site and it takes over 23minutes for an ambulance to arrive. Reports indicate CPR and defibulation used in the time it took for ambulance to arrive.

    I think I am surprised that players are quick to say the design of the helmet was not an issue, but acknowledge that people have been injured through the helmet, albeit not seriously, before. So we have a situation where a properly designed helmet could have avoided a known risk, and any kind of medical response plan for injuries more serious than a broken finger could have resulted in better treatment earlier.

    I suppose we are somewhat spoiled with the world class facilities and responses maintained in F1 bit I can’t help but think this young man will pay the price for complacency in a sport not traditionally considered as a risk.

    • At the very least, an injured athlete should be able to expect to enter the emergency medical system AT LEAST in similar time to a similarly injured person in “the real world”. I’d like to think that a head injury in a major city would be sorted and in an A & E dept 23 min post injury.

      When even that rather low setting of the bar isn’t satisfied, the system in place not only is not efficient, but actually acts detrimentally, as a hindrance to other more effective systems.

    • I think the surprise isn’t so much what happened to Hughes, but the fact that it happens so rarely. For those who don’t know there are many broken fingers that can attest to the hardness of a cricket ball, and it comes at you at just under 100mph. It is also not uncommon for the ball to be aimed so it bounces directly at the batsman’s head to intimidate him, this is called a ‘bouncer’.
      It’s miraculous this kind of injury isn’t happening every week.
      The question is how far do you go? Do you keep an ambulance on standby at cricket matches? If so, at state level or only international? What about junior games? Football? Golf? What level of medical presence is needed in sport across the board?

      • In this case, I think proper initial care for Mr. Hughes actually seemed to have been hindered by his being at a top flight cricket match, as opposed to this happening on any random street corner. At the very least, providing a seamless and efficient interface with the emergency medical services covering the general population would appear to be the least one can do!

      • The Australians tend to deal with these sort of things in a more matter of fact and sensible manner than has become the norm over here in the UK, where litigations and the ‘blame game’ would be the first thing on peoples’ mind and I would by no means rule out the British press taking this and running with it for days to come in the dreary search for someone to pin some blame on.
        But there is also a second victim in this and that it the bowler Sean Abbot who seems to be, understandably, struggling with the outcome of his actions. Poor man … what a dreadful situation to be in.
        I find cricket the most singly boring pastime on the planet to both play (At school they used to put me at longstop or somewhere and I’d cry my eyes out out of utter boredom standing alone and seemingly friendless on some distant boundary !!) and particularly to watch after soccer but it has always struck me as strange and cynical that to deliver a ‘bouncer’ is nothing more than an excuse to launch a ball at about 100mph directly and unerringly at the batsman’s head with all the obvious risks that entails.
        There seems little chance of getting the batsman ‘out’ (either by LBW or by hitting his wicket) as things are all happening at head height, and so it strikes me that after this sad experience a review of the ‘bouncer’ might be in order instead of trying to find someone in the medical profession to blame for something that has never happened in the game before.
        My suggestion would be that we look at the game and see if there is anything that can be changed rather than to try and put knee jerk measures in place to anticipate this sort of thing happening again as it probably won’t, but what WILL happen is something else which we haven’t anticipated either!

      • Many people seem to see cricket as a sport that is not especially dangerous. But wasn’t an umpire killed by a cricket ball just a few years ago? Or am I wrong?

      • A 72 year old umpire died after being hit on the head by a cricket ball. If he hadn’t have been “exercising” on the cricket field he may have been overweight with a heart condition. Swings and balances – life is risky – extending to 100% after 130 years. Riding a bicycle is risky. Crossing the road is risky. We need to take a balanced view of risk and recognise risk and probabilities translate to individual events.

      • Yes, an umpire was called by a ball in an amateur game a few years back, another freak event as it’s the only such case I’ve ever heard of. Being a game in which participants can keep playing well into late middle age, there are far, far more deaths from heart attacks brought on by exertion than by the game itself.

      • I’d be surprised to find that there wasn’t some kind of medical response team there, if only due to the scale of the public event i.e. a big crowd. I’d wait a while until the full picture emerges before concluding.

        But, in this sport, what’s happened is a genuine black swan event. Off hand I can only think of one, maybe two other such deaths in 150-odd years of professional cricket. Fatal heart attacks in the crowd would be far more common, so the level of medical response will be set around that, if anything.

  15. Hi everybody.
    Living in Nice, I can say that all doctors and all medical people that are close to Jules Bianchi are very good. One of the best neurosurgical professor follow him from another service.
    And as Gary says, all his family can see him and talk to him, even Jules is unconscious.
    Let’s pray, let’s hope.

      • Gary, how would you compare European brain specialists to American brain specialists? I’ve wondered why an American was not consulted in the MS case. Is this guy Saillant the big dog in the world?

      • I will avoid the obvious response. But only barely.

        I think that there’s expertise a-plenty in Europe. This is neurosurgery and neuro-intensive care, not quantum gravity.

        Saillant WAS an orthopedic surgeon. NOT a neurosurgeon. He was no doubt a large fromage in the world of french orthopedics. Not particularly outside of that small world.

  16. Gary, I’ve read that Jules’ father Philippe says some days are better than others. With an injury of this magnitude, what kinds of things would he mean by that? Could it be that the scans of his head look better on some days as opposed to others, or would he be speaking about things like blood pressure, heart rate, oxygen saturation, or things like that?

    • Depending on when in Jules’ clinical course this statement was made, it most likely referred to intracranial pressure, synchronisation with ventilators, etc.

      At this stage, I have no idea to what it might refer.

    • Does Saillant like to see his name in lights? It seems like he is front and center whenever a celebrity has a brain injury. First Schumacher and now Bianchi. Why would you want to consult an orthopedic guy for a brain injury? Makes no sense.
      .

      • He is also, despite never ever ever EVER having worked in any capacity at a race, and with no knowledge or experience of acute trauma care (except for fixing broken bones), the president of the FIA Medical Commission. Remember, he’s best mates with todt.

      • Hi Mimi

        There was a risky operation in Philippe Streiff’s story which Saillant was involved in. He was never a neurosurgeon but he must have been top of his field years ago. I think the problem is he is too old now (like many in F1) and doesn’t know when it is time to hand over to the next generation of experts.

        ‘In a rare stroke of fortune, one of the doctors at the hospital in Rio had studied under Saillant in Europe and they talked through an initial surgery over the phone. By now, 10 hours had passed while medical consultants deliberated and specialists were brought in from Sao Paulo.

        “Renee called Gerard and told him what had been happening and he immediately decided to come over to Rio,” recalls Streiff. “He was there the day after the accident and immediately saved my life twice when my heart started to fail. He is a true lifesaver. I am so grateful that Renee called him to come over. Without him I would have died in 1989, for sure.”

  17. Gary, I’ve been meaning to say thank you. Thank you to you, and to Sid [1]. Sid’s autobiography and your blog together gave me a background understanding of head-injury, ICP, sedation, intubation and various parameters of critical care. This knowledge was then invaluable in the early days following my brother’s accident 3 months ago (bike vs car), in that far less was completely new to me (and therefore scary) than it would otherwise have been. My brother was lucky – 10 days in ICU, home within the month, diplopia yet but otherwise pretty good. Meanwhile, Forza Jules…

    [1] – Of course, Sid may not have internet access where he is – but one likes to think he’d read your blog!

    • Thanks so much for writing, Richard. It’s amazing to think that what I wrote/write actually HELPS. Really glad your brother is doing well!

      I suspect Sid may be having an occasional chuckle, perhaps surprised at how many of his stories are still right there in my memory!

  18. Great to see that you’re back on posting!

    Gary, what are the prognosis and treatment of a DAI? WIll the severity and prognosis depend solely on how much and which region of white matter was injuried in the crash?

    • The prognosis depends, among other things, on the patient’s presentation (how deeply comatose he or she is) on arrival to the hospital. Patients who are comatose at the scene tend to have a fairly dismal prognosis.

      In terms of treatment, it’s largely supportive. Maintaining hydration and nutrition, avoiding infections and muscle contractures are key. Nothing specific for the injured brain exists . . . yet.

      As to the anatomy of the lesion, that requires specialised imagining, and I’m not at all sure that those correlations have been established yet.

  19. Scarcely believable to be reading this for a second time this year. And today, in the other sport I follow, a freak head injury to Phil Hughes which sounds as bad. What is going on?

    • You’re right. And then there are the (tens or hundreds of) thousands with MTBI, or concussion. Head injury is something that, unfortunately, is never more than two or so degrees of separation away.

      • Yes, Dr. H, I think I recall you writing that 55 cases of TBI enter the system in Great Britain. A DAY! We are all only a traffic mishap away.

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