The Bianchi accident investigation panel

We’ve been given a summary of the Bianchi investigation, and the 300-some-odd page report has been condensed to what looks approximately like 1.5 A4 pages.

Over 300 pages to less than 2. Holy crap. Either there are a hell of a lot of wasted words in the full text, or someone has really mastered the art of the resumé.

I can’t say much about the reasons behind not releasing the full text of the report, but it is clear that the credibility of the conclusions, such as they are, is not helped by the absence of corroborating background.

In addition, when we look at the composition of the panel, we realise that fully HALF the members have a clear and unambiguous conflict of interest in any investigation. The current positions, and indeed future careers in motorsport, of those panel members who are not dear personal friends of the FIA president depend intimately on remaining in his good graces. Mind you, I am not impugning the integrity of anyone. That’s what’s so insidious with conflicts of interest. They only have to appear to exist to have their negative effects.

This of course rang alarm bells when the panel was formed, but courtesy, decorum and respect no doubt calmed the chuckling at the idea of a body investigating itself. I fear that chuckling was perfectly appropriate.

Let’s get a bit more specific.

The primary conclusion, that Jules was driving too fast, is, as I’ve said before, true by definition. I’m surprised at the reactions of those who feel that this is somehow unfair, unjust, or unkind. It is none of these. Young men make mistakes of judgement all the time, and some pay a grievous price for it. That is the case here. The technical details of BBW and FailSafe are just that – details.

I smiled when I read:

It is considered fundamentally wrong to try and make an impact between a racing car and a large and heavy vehicle survivable. It is imperative to prevent a car ever hitting the crane and/or the marshals working near it.

Suppose they’d said that 60 years ago about Armco? We’d not have developed the know-how that led to 6-row tire barriers with conveyor belting, and we’d certainly not have Techpro. I wonder what would’ve happened to my friend Perez in Monaco a few years ago? Actually, I KNOW what would have happened to him. Ironic, isn’t it? Somehow both goals stated in that quote seem worthy of pursuit; neither do they appear mutually exclusive.

Now it gets a bit complicated. You see, the entire summary (and therefore presumably the report itself, but we have no way of knowing that) is focused on the events leading up to the accident. There would appear to be no attempt to look at those elements of the response that are there to mitigate the consequences AFTER the event has occurred. And now I start to get rather uncomfortable.

We are told:

All rescue and medical procedures were followed, and their expediency are considered to have contributed significantly to the saving of Bianchi’s life.

The first part of this statement is patently untrue. Egregiously. The self congratulatory second part, while certainly true, is inappropriate.

Bear with me, and struggle through this excerpt from the Appendix H of the FIA’s own International Sporting Code (that concerned with “Supervision of the Road and Rescue Services”).

An evacuation under intensive care by medically equipped ambulance (equipment and presence of a doctor proficient in resuscitation on board) with an escort may, however, be carried out, provided that the receiving hospital has been approved beforehand for the treatment presumed necessary according to the casualty’s condition and that it can be reached in approximately 20 minutes (except for serious burns), regardless of the weather and road traffic conditions (except in a case of force majeure). If these conditions are not satisfied, the timed session must be interrupted.

d) Unforseen circumstances, especially the weather, may prevent the arrival, departure or return of the helicopter. In such a case, and after consultation between:

– the Chief Medical Officer;
– the Race Director; and
– the FIA Medical Delegate;
an ongoing or interrupted timed session may perhaps continue or be resumed depending on the conditions of evacuation of a casualty under intensive care to one of the hospitals mentioned in the medical questionnaire for the event and approved by the FIA Medical Delegate.

We were told at the Sochi press conference that the evacuation took 40 minutes. Twice the 20 minute upper boundary that THE FORMULA ONE MEDICAL DELEGATE HIMSELF HAD WRITTEN INTO THE REGS.

We were also told at Sochi that Jules’ condition at the end of that waterlogged siren-punctuated ambulance ride to the hospital was exactly the same as when he left the circuit. Are you kidding me?

Don’t get me wrong. I have no doubt that my Japanese colleagues were indeed able to make sure that Jules’ blood pressure, heart rate, oxygen saturation, expired carbon dioxide, etc (the EXTERNAL parameters, the ones we measure easily) were unchanged over 40 minutes.

But find the nearest neurosurgeon and ask him if the brain of a patient who’s had a head injury with immediate coma is the same after 40 minutes of transport as after 20 minutes, and he’ll look at you like you were nuts. Because you are.

Why did Dr. Saillant not address the question of EXACTLY when the Medical Delegate (his personal appointee) knew that the helicopter could not land at the receiving hospital? Under difficult circumstances this often requires near real time communication with the helicopter crew. The delegate is up in race control with nothing else to do during the race. That’s why he’s there. Why was racing not stopped? This is far from a trivial issue, and is all the more dramatic that the FIA’s own regulations would appear to have been ignored by their author, the Medical Delegate.

This is a potentially grievous error, and it is all the more shocking that the question is not even addressed. And unfortunately this is precisely the kind of result one would expect with a panel studded with insiders.

 

 

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A petition for action on helmets

Link: Tell Jean Todt – Help Make Helmets Safer for Everyone

Since it’s pretty clear that the message of Michael’s tragedy hasn’t been picked up by those with the wherewithal to actually DO something, I’ve created a petition asking Jean Todt to commit the FIA to taking the lead on improving helmet safety.

Let’s get this done, so that when people strap helmets on, they can actually be confident they’re being protected!

Thanks so much!

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

 

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:

Image

On the graph, we’ve got time (in months) along the bottom, and percent of patients along the yaxis. 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. . .