A Jules update, and some wishes

Once again, I find myself moved by Mr. and Ms. Bianchi’s openness. It’s wonderful that they understand how important Jules is for us, and how we just don’t forget. Remarkable people.

I’m pretty sure I speak for a lot of us if I say that Jules is never very far from any of our thoughts. And prayers.

Rehabilitation after severe head injury means a few things. Most importantly, it’s the rehab people who make sure that Jules’ limbs stay flexible, and that his muscles stay as toned as possible. Remember, a good part of our flexibility, and an even bigger part of our muscular health, are due to impulses from the brain that help maintain their growth and metabolic status. When those impulses aren’t incoming, a program of externally applied movement is important. Avoiding pressure sores is also close to a full-time job in anyone with restricted movement.

Respiratory rehab, especially since Jules is breathing on his own (brilliant news, as it’s one less machine to fail dangerously!), can be necessary, to help him cough and clear secretions.

As for brain-specific rehab, I’m at a total loss here. While the other aspects of rehab would presumably feed back body information (“proprioception”) to the brain (gotta help with maintaing plasticity), I don’t know if there are any effective and evidence-based techniques that improve outcome in this phase of severe head injury. It’d be fascinating if any specialists out there commented with info about this.

Lastly, and most importantly, I want to wish you all, EVERY ONE OF YOU, health and joy and warmth. Comfort for those who comfort. Calm after turmoil. You have all been part of this becoming something I had no idea would become as important to me as it has (ok, that sentence sucked. Forgive me, Ms. Dahlberg). Happy New Year to all of you, and let’s really make 2015 amazing!

69 thoughts on “A Jules update, and some wishes

  1. RIP Jules.

    In response to the latest sad news re: Jules, I was re-reading about DAI … and found the wikipedia article: https://en.wikipedia.org/wiki/Diffuse_axonal_injury#Histological_characteristics

    I’m in no way a doctor or medical professional, but this paragraph leapt out at me: “While it was once thought that the main cause of axonal separation was tearing due to mechanical forces during the trauma, it is now understood that axons are not typically torn upon impact; rather, secondary biochemical cascades, which occur in response to the primary injury (which occurs as the result of mechanical forces at the moment of trauma) and take place hours to days after the initial injury, are largely responsible for the damage to axons.”

    I have no doubt that these details have been obvious to you since the accident, Doc … but it just highlights for me, the critical impact that the delay in medivac due to lack of available helicopter, likely caused.

    It’s all very sad, and my thoughts are with Jules’ family.

    • Indeed. With head injury, the primary lesion (the initial trauma) is always followed, on a variable timescale for the various elements, by a “secondary” lesion (or more properly, lesions), which all worsen the condition of the brain and aggravate the damage caused in the first place. Secondary injuries are all the factors that worsen the brain’s physiologic, metabolic, and anatomic “milieu”. One example in a multiply injured patient would be the decrease in brain perfusion caused by low blood pressure from blood loss. Another would be the decreased oxygen and increased carbon dioxide provoked by the breathing irregularities often associated with severe head injury.

      Because of the rapidity with which these secondary lesions can amplify the initial damage, it is, as you so correctly point out, extremely important to ensure quality neurosurgical care as rapidly as possible after a head injury.

  2. If Michael is now showing some emotion and Gary’s theory about the brain trying to rewire itself is true, I think that this would be the ideal time for the Schumachers to invest in some device which might allow him to communicate in some way. At the very least someone ought to be able to devise a simple device he could operate with eye movement so that he could get some kind of reward – it could be something like listening to music, family voices or even F1 cockpit recordings.

    As he is probably still fed by PEG tube it’s a bit early for food rewards but long term I hope he will be able to eat as I’m trying to think what are the basic pleasures which make life worth living.

  3. IF these reports were true would Michael be classed as between a Minimally Conscious State and a confusional state? nobody seems to remember what Dr. Jean-Francois Payen said about Michael that it could take between 1 and 3 years and that the little bits of insider rumours that have been coming out is very positive and is making progress just like reports on severe brain injuries state,that he is going through the stages of recovery.

  4. Even allowing for hyperbole and total ignorance of brain injury, the general consensus in the press now seems to be that Michael Schumacher is rather better than their stories of a month or so ago, as they have now forgotten the ventilator and most stories now put him in a wheelchair. Maybe in this strange way some kind of agreement of his likely state is evolving despite the lack of any official statements.

    What I do believe is the difference between the two families is that even if the prognosis proves bleak for Bianchi we won’t have to put up with this kind of absurd guesswork and that they will give the fans a genuine chance to share in their pain if things don’t go as well as we all hope and pray that they do. I believe that real sharing of bad news might actually help the family as well as help the fans to feel respected and included.

  5. I read that MS is unable to move or speak but that he shows some emotion with tears when he sometimes hears his wife’s voice and his kid’s voice. “He looks into a void”. Doc, is he “locked in” in your opinion? Sure sounds like it.

    • 1) we’ve no idea if this is, indeed, true. 2) If it IS true, we’ve no idea if this response represents an actual emotional response. That would require more investigation. It would appear possible (no idea of likelihood) that this also could be a case of mixed up wiring, and that rather than representing genuine sadness, frustration, anger, these tears may simple be the result of the brain’s plasticity finding an outlet to express SOMETHING, given that other routes of expression may be damaged or destroyed. If I were a neurologist, I would move heaven and earth to attempt to ascertain Michael’s inner state and his subjective level of “wellbeing” with his current state. As mentioned here before, a surprising number of severely handicapped patients express general satisfaction with their quality of life.

      The term “locked in” generally refers to a rather specific set of lesions that leave the brain essentially intact, but with virtually no outlet for expression (eye movements, especially up-down) tend to be spared. While severe problems with expression ARE a consistent feature of minimally conscious states, the brain here has undergone widespread damage. Without detailed and sophisticated exploration, we’ve no idea of residual processing ability.

      • I just wondered when I read this if it might be like babies who cry before they smile. Just wondered if you have any experience of this Gary?

      • Dear Doc:

        Once again you are a beacon of knowledge and understanding in this fog of assumption and conjecture.
        This bit of information gives rise to so many questions and observations. Firstly on the topic of Michael’s recovery process, one has to ask how one can interpret the shedding of tears from the damaged brain as having the same meaning, as that of a healthy one. I am also astonished by the assumption of emotions,and cognitive functions. Your explanation cleared that up pretty well. None of the assumptions can be made by journalists. Secondly, I can’t help but ask myself why you have been so admonished for your writing on this blog, when so many others, dissimulate so much false information, with impunity. Thirdly, after discrediting Strieffe so thoroughly, how can stated “reliable sources”, come out and say exactly the same thing a couple of weeks later and be more credible? Its all very bizarre.

      • The horrible thing about this is that it might possibly be true – I watched a coma documentary months ago via a link someone posted here and it included footage of someone who had been in a vegetative state for over a year crying like this. It was something which really upset the family to watch and I think it is a very upsetting detail.

        Gary – I salute you for coming up with the best possible explanation for this. I can’t believe they tried to slience you and Strieff and yet allow a horrible story like this to spread round the world without any attempt to give a balanced and restrained medical explanation.

      • Would higher level cognitive abilities tend to go before lower level emotional responses? Emotions tend to be linked to hormonal levels so one wonders how well would these hormones are “controlled” when the brain is injured. In addition having an emotional response without knowing why one is having an emotional response can occur with people with normally functioning brains, e.g. I am sad but I don’t know why I am sad.

      • Good question about the endocrine effects of persistent disorders of consciousness. There is some, but not a lot, of scientific articles about this. But since the hypothalamus and pituitary tend to control the hormonal system, certain derangements are relatively frequent.

        The limbic system, where the emotional charge is assigned to events, has very few anatomic connections with the cortex and subcortex, where higher level intellectual processing takes place. This may help explain why it’s so hard to get rid of fears by intellectualising them, and why phobias are so powerful.

      • Excuse my grammar in my previous comment I think the middle sentence are should be be.

        In addition to my previous comment: the human face is remarkable for its signally ability: there are about 43 muscles in the face that together form a combinatorial explosion of possible facial expressions – which express human emotion. I believe (?) the control of these muscles are primarily involuntary (w/ voluntary over layer) and controlled by “lower level” parts of the brain and hence (perhaps) less likely to be affected than higher level cognitive functions.

      • Emotional expressions tend to be organised somewhat automatically (below the cortical level), as the brain is processing emotional information. Along with other “automatic” responses (e.g. swinging the arms alternately when walking), these can be abolished (for example) with Parkinson’s disease, where a masklike face, devoid of the fleeting expressions of emotion, is very frequent.

      • I think Gary’s theory is particularly good because even if the face muscles are frozen in Michael’s case (as in Parkinsons and locked in state) and smiling is impossible it might mean that he isn’t actually unhappy. I know that in locked in state people report often report happiness but a bit of googling has established that they often can’t smile and so it is perfectly possible that the expression of emotion is different to the internal feeling.

        I’ve decided to believe this because the alternative that only fear and pain is left is unbearable. I know people talk about the reptilian brain and say that fear comes first. I’ve had two babies and know what a relief it is when babies first smile. It’s something to do with the reward system deep in the limbic system. Fear is supposed to be the primary motivation and the reward is escaping from danger and hence the smile. I just hope so much for Michael’s family that he will be able to smile soon.

  6. Gary, when is your book coming out? Don’t even think about saying that you aren’t writing one. With your ability to convey complex issues (in a really important and interesting field) to laymen without ever being patronising, coupled with your obvious knowledge and humane compassion make you perfect for the job.
    Keep up the good work and all the best for 2015.
    Richard

  7. Happy New Year, doc and huge thanks for what you’re doing here!
    Eventhough sometimes my opinion doesn’t match yours in full, I appreciate your honesty and efforts. Keep up the great work and have the magnificent 2015!
    Andy

  8. Happy New Year to you as well Gary. I hope 2015 finds you healthy. I work as an Advanced Care Paramedic at Canadian Tire Motorsports Park. You might remember it as Mosport?! I was going through some old correspondence and came across a training memo from our former Medical Director, Hugh Scully. The training was related to closed head injuries and treatment modalities. It was written by you. Take about 6 points of separation! I and all my coworkers wish you well with this irritating issue with the FIA and their attempts to cause you some personal distress over your PRIVATE blog. I for one value the info. As a race fan, a health care professional, and as a human being.
    Thanks!
    Chris Bayards

  9. I came across your blog via a link from a comment on Joe Saward’s blog. Two beacons in the fog of rubbish fed to us via the PR driven news media – yes, even some of the specialised press. The blogs will be essential reading for 2015 and wishing you a successful New Year and no more harrassment from the maFIA!

  10. Gary, knowing you through having worked with you at the FIA, I feel compelled to add my note to what has been a tremendously difficult year in the world of F1. I mean, who the Hell would have thought this all would happen???

    I’ve read everything published; your blog, the press, the comments – the good, the bad and the ugly, but you alone have been the one source I’ve consistently turned to to get regular, to-the-point, factual updates about both MS’s and JB’s conditions. For that I’d like to truly thank you as these posts really helped when I’ve been so darn worried about them both, and I have re-posted them on my FB page for others to read too.

    Dont give up on your great blog; many of us reading your posts are so grateful to you for taking the time to write them (know how long this takes!) and practically rely on your thoughts to cut through the other written c**p.

    Thank you Gary, and may 2015 be an awesome year for you.

    Lucy C (ex B!)

  11. Happy New Year Gary to you and your family.

    I’ve just caught up on your updates since a week or so before Christmas and wanted to express that no matter what happens regarding the rather underhand approach to your employer, that your blog has been invaluable to me and people just like me, who have little understanding of the many medical terms and their implications to the patient. Thank you for your clarity and taking the time to explain complex situations to us all in such a fascinating way.

    Finally, I would also like to express my gratitude and support to the families of Jules Bianchi and Michael Schumacher and I hope 2015 brings them real and tangible improvements.

    Have a fantastic 2015, Gary.

    Steve

  12. Extremely thankful and amazed at the continued warmth and openness of Philippe and Christine Bianchi after the latest Jules update. They really are remarkable people, focused not only on their son and the heartbreaking ordeal they suffer but also thinking about his fans and keeping everyone connected.
    Wishing you a very happy New year Gary and thank you for provided a wonderful place that people can come to for information and insights. X

  13. Hi Gary, hi folks.
    Late but early enough: I wish you all a peaceful, lucky and healthy new year. May the bright light of kindness, compassion and clear thoughts be with you, even when some think that others are making mistakes. It is their way to master an insane situation.

    Gary, I hope that you will continue to share your insights with us. Keep going!

    Frank

  14. The positive nature of your blog posts means that they are truly a pleasure to read. Thanks for contributing so much this year.

    Happy New Year Doc.

  15. Happy New Year! (I’m in Asia so i get to say it first!)
    Having just read about a certain person who cries when he hears his family members’ voices, I can only imagine the nightmare of being trapped inside.
    I do wish the comments that I had read were never published, as it feels like a serious violation of their privacy.
    I pray that they both improve dramatically in 2015, that God gives their families strength and comfort, and that you enjoy a less stressful year.
    Chris

    • Just read that story in the Italian press.
      What a load of complete, utter and total rubbish.
      The raving fantasy of a man deluded by his own opinions and thus the worst possible kind of Italian gutter journalism, but which only adds more weight to the argument that the Schumachers really should give out some sort of detailed update.
      But they won’t …. and so this absurd situation continues unabated.

      • I shouldn’t have googled it but did so thought I would atone by quoting an article I printed out months ago on ‘Recovery of patients after four months or more in the persistent state’ about patients in the Royal Hospital and Home, Putney, London by Keith Andrews. This states that even the most profoundly disabled patients were able to take pleasure in their surroundings and expressed happiness when they saw their family. Why do journalists always have to make things worse than they are? Some sort of emotional response would be a good thing and everyone feels like crying sometimes especially when they read this kind of garbage.

      • My objection is not so much the fact that what he writes is feasible but more the tear jerking tosh about Michael ‘sitting with the lake in front of him and the snow covered Alps behind” and a “small tear rolling down his cheeks” when his children approach him etc etc.
        The hack in question clearly hasn’t been near Schumacher and what he writes is no more than a flight of Barbara Cartland’esque fantasy which people who don’t know better misinterpret as gospel.
        The comments at the bottom, many of which wish Michael a “speedy” and above all “complete” recovery seem just to reinforce the chasm of misinformation and misunderstanding about Michael’s true situation which can only be laid at the door of his spokesperson.
        What with this and what Phillippe Streiff has seen fit to put about, Michael’s situation is becoming a scenario even Kafka couldn’t have envisioned!

  16. Best wishes for the new year.

    Now for an aside: In academia and learning institutions there is something called outreach and community impact, this is when experts in their padded ivory towers mix with the riff-raff (just kidding). Given many of these institutions are publicly funded there is increasing demands for public communication and justification. So more and more academics and experts are setting up blogs as one mechanism for this outreach and public dissemination of knowledge and learning – either linked to the institution or independent from it (academics & experts used to be an independent lot – certainly independence of thought is a much cherished entity). So this is an additional factor to add to the melting pot if ever one needs to justify outreach activities such as an experts blog.

  17. Hi Gary, I’ve read your posts with great interest and together with what I’ve read elsewhere believe I have a pretty good understanding of where both Michael and Jules are at and what their families are going through. As someone who’s personally been impacted from a loved one recovering from an anoxic/hypoxic traumatic brain injury the incidents with Michael and Jules have very much hit home with me. The physical injuries, 4th degree burns in my wife’s case, are something that you can see and directly address through incredibly skilled surgeons, nurses, and others in the medical field such as yourself. The brain however is not something you can easily touch and fix and that can be an incredibly frustrating experience for the families. The brain does continue to heal and change however, contrary to what some might tell you, so you never know what tomorrow might bring and for us the differences between 7 years ago and today are dramatic.

    It’s great to read that Jules is breathing on his own, removing the ventilator is a huge step and not to be taken lightly. Our doctors would have a daily anesthesia holiday and stop the meds to see if she would start to wake and she was off them after 10 days so it is concerning that Jules is still unconscious after being off sedation. You are correct that there will be much physical therapy and rehab including what most of us assume to be such simple things as how to swallow and it’s amazing how some of those simple things are actually quite complex when you really look at them.

    I can only hope that both Michael and Jules and their families are able to enjoy each others company again and celebrate the holiday season next year and beyond. My wife is thankfully as physically healed and more ambulatory than we originally had hoped for and while she will never be the person she was prior to her incident to have her with us is incredibly important to me and our daughter. Each family has reacted in their own way to sharing updates and that’s okay with me, they’ve earned that right. I truly appreciate Jules families openness but also understand Michaels family being very protective. I do hope that they understand there are many thousands of people interested however and don’t take that interest the wrong way. They have a difficult road to walk even with the best of support and as interested as I am in details I certainly don’t want to pry and my hope is for the best of all possible outcomes for both of them.

    Eric

  18. Happy and peaceful New Year to you too. I am very relieved to see you back posting as you have been a source of so much understandable information during the last traumatic year. Thank you
    Fran

  19. Thanks for a Brilliant 2014! Only found your blog recently (Actually during the Medical car series on Extraction and accessing patients etc) And I found those very insightful as I do with the MS and JB posts. What kind of track side car would Ian Roberts and other medical teams been able to provide? Would he had to preform CPR or an On site tracheotomy? And How could he deal with an un Conscious servere injured driver possibly not breathing.

  20. We’re always told NOT to compare, because it’s no good to compare, be it children, careers, love lives, intelectual abilities, cars, sticks, wallets, diamonds, whatever. Because there’ll always be someone else who’s got it better/bigger/shinier/richer/whatever. And this is simply self-inflicted frustration. Which is bad, they say. Eh, whatever.
    I think comparing is mostly good, because it makes one’s situation more obvious, offers a point of referrence, sort of speak. One is either on the shiny side of the fence, or the other one. If it’s shiny, one remembers to enjoy that. If it’s darker, one can find the motivation to change that state of fact.
    All this long digression to point out, in my own words, the huge difference between the handling of a situation by two different sets of people. And the Bianchis have proven to be such nice, down to earth people, when they could have been aloof, hide behind their grief and claim for privacy, say nothing to the public, or just a couple of vague things. I do not pretend to understand what the MS family and team go through, but I know they are wrong when they don’t say anything to the public. Sure, he got where he was due to his own talent, but the public also helped, for example to get advertisment, which I am sure was a fairly important factor in the equation. His fans don’t claim to have paid not even one bill of his medical expenses, even though that is arguable, but they deserve to know more. The Bianchis know that even if the fans are far away, it does not mean they do not care. Or are not grateful.
    And the last part applies to you as well, doc. We are all far away, we don’t know much about you, or one another, but what we do know, we like, and made us care, and be grateful for you taking the time to interact.
    Sometimes bad things happen to good people. Sometimes good luck is all that makes the entire difference. Sometimes life is just a whimsical bitch playing russian roulette. But always, always, good people are appreciated and cared for. Have the best 2015 you could ever wish for, doc!

    • To say that your comment is dumb would be an understatement – the decisions whether to announce publicly medical or general health information about someone is strictly personal and you can’t just say this is the right way and the other is not the right way to handle things. You are not a Bianchi and not a Schumacher. You don’t walk those men’s relatives’ path and you can’t know. That you get frustrated that you’re not getting details about either of them is YOUR problem, not theirs. You can’t compare an active F1 driver who was injured doing his job and fulfilling his contract with a RETIRED driver who fell while skiing. Your statement reads as if Jules’ family care about fans because fans give them money and make them rich. You realise this is absolute bullshit, right? Jules is not married and doesn’t have kids and his parents take decisions, very different than Michael. You can’t know what Michael’s wish could be regarding such incidents. Jules is younger and he most probably didn’t think of these things. Calling people you don’t personally know “aloof” shows that you’re an ignorant hypocrite. Obviously a lot of people who are not fans for example show respect, when they don’t have to. As I said how you react shows what kind of person you are. No one “deserves” to know anyone else’s medical info no matter if they spent $$ millions. It was your problem you spent money. You did it willingly. Not everything in this world is down to money.

      • Hey, were it not for the fans buying tickets, buying memorabilia, buying crap that he huckstered.etc. etc MS wouldn’t have a very big pot to p*** in. Where would F1 be without the fans? So, for you to say that to these folks is the real bullshit. You don’t accumulate a half a billion dollars without a little help. And now, he gets to spend it all on himself.

  21. Thanks for your fascinating blog and your entertaining commentary and antics during the year (your Ice bucket challenge vid was awesome). Look forward to reading your blog in 2015 and hope you have an fabulous and productive year.

  22. Doc;
    While I usually disagree with your take on American social issues, yours has become one of the most important, unbiased, factual, least strewn with bullshit voices on the vast innerwebs regarding not only non-patient specific medical info, but the entire inner world of Formula 1. No wonder a bunch of little men are desperately afraid of you.

    So Thank You for sharing general insights and rest assured that if push were to come to shove, there would be an awful lot of us willing to stand up and fight for your defense.

    Happy New Year

  23. Warmest wishes and hugs, Gary, to you and your family. Keep talking to us all, whatever the responses, since F1 is sterile without a human voice. Phillie x

  24. I came across this recently and thought you might find it interesting. (Motor Racing fans might find the segment from 7:35 onward fun.) The question arises in my mind whether this could be used in recovery, especially with younger patients or those with ingrained skills that the games simulate (eg Driving)? I was just reminded of this by a comment from Quickybaby (the guy in the video) made on his live stream – he is thinking of doing a fund-raiser where he plays the game he makes his money from, and at which he is one of the worlds best players, using just facial and eye movement.

    Lets hope next year is a better one for everyone, including yourself.

  25. Thanks Doc, for communicating with those of us outside the medical realm and making the words and meanings understandable. Wishing you a stress-less 2015 and wishing peace and nothing but good news for you, the Bianchi and Schumacher families – and all of us touched by those that have suffered brain injury.

  26. Dear Gary. For all the time you have given us over the past year, I thank you.

    After being a Michael Schumacher fan for 20 years my allegiance move to Jules when he retired. While the internet is rightly or wrongly blamed for every failing in the modern world, your blog and the community that has developed around it has been a much needed source of information and hope.

    I wish you and all your readers a very happy new year.

    Paul

  27. Thanks for all the information you have provided us with over the past 12 months.
    I for one have never contributed to any blog before and cannot think that I would do so again …. yours however was somehow different and has made me feel connected in some way to what has befallen a man I have always admired.
    Good wishes for the year ahead to you, your family, to Jules, his family and to Michael and his and of course to all the people on this blog …. yes … even to her…! 😉

  28. Thanks Gary – and all of that right back at you. I hope you have some exciting stuff planned for yourself in 2015 (if exciting is what you want it to be).

    At 5:45am that is about the best I can do but I am sure we will converse further in the New Year.

    Now, Doctor – about this pain in my shoulder that has kept me up all night…..

    Happy New Year to you and yours.

    Eric

  29. Hi Gary and many thanks for your blog. It’s a great pleasure for me to read a medical professional’s view on F1

    You asked for an effective and evidence-based therapy for someone like Jules Bianchi who is recovering from severe head injury. Can I repeat my previous comment about zolpidem? There is considerable evidence that it reverses brain damage, as reported in some detail on this website: https://sites.google.com/site/zolpidemtherapy/home

    We do not know the percentage of responders and it could be 1% or even less but even if it is that low the effects are so remarkable and the risks so negligible that it is well worth a trial in each person. It’s worth repeating that the evidence includes objective brain scans ( SPECT and 1 case of magneto-encephalography at Aston University) showing that there is new activity within infarctions when zolpidem is present. I think this is quite revolutionary considering that we all believed infarcts to be beyond recovery until now. Clinically there have been awakenings from vegetative states, recoveries from post-stroke aphasia and many more … They are all on the references page of the website.

    It’s my fond hope that Jules and Michael are responders …

    All the best
    Andy Sutton

  30. If ever a family deserved a better 2015 it’s this one. I send my very best wishes to them and to everyone who watches and waits by the bedsides of similar patients all across the world.

  31. Happy new year to you to Gary. You’ve been a reliable source of information for many this past year and an important part of my days and weeks. Thanks for being there with a calm and considered ‘take’ on events. Forza Michael and jules!! Best wishes to all for 2015.
    mandy

  32. Gary, you have been a voice of reason, calm and logic during a very uncertain time for many in the racing community. You have my deep appreciation and I join with everyone in wishing you and yours a wonderful 2015.
    -Brian in NJ

  33. Cheers to you, as well, Doc! You’ve been an important part of the past year for me, as I’m sure you have been for many. All of my best wishes to you for 2015!

    -Tony

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