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!

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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.

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. . .

Some important science on disorders of consciousness – part 2

Image

An MRI scanner

Imagine this: You’ve volunteered for a brain imaging experiment to help study consciousness. You come to the MRI suite, and lie down. The researchers put an IV drip in place, and then infuse a form of glucose that “lights up” the brain areas that are activated at any given moment. So far so good.

You’re told to close your eyes and imagine hitting a tennis ball back and forth with a partner. Sure enough, this consistently activates an area related to preparing the brain for motor activity (called the Supplementary Motor Area, SMA, in yellow below). Then you’re asked to imagine walking around your house, and to visualise all the things you’d see as you navigated like this. And once again, the corresponding area, called the Parahippocampal Gyrus, (PG, in green below) lights up. Here’s roughly what the images look like:

Image

Nothing unusual or unexpected here. But now let’s go a bit further with the technique.

Let’s now take a series of patients (54 to be exact) who have been diagnosed with either vegetative state (remember – that’s eye opening without any signs of conscious interaction with the environment) or a minimally conscious state (awake, but with fluctuating but consistent signs of consciousness), and let’s try the same experiment.

Incredibly, FIVE of these patients  (10%!) could manipulate brain activity in response to the researchers’ requests. These people were, in fact, obeying commands (“think about tennis”, “think about navigating”), but their response wasn’t behavioural, it was . . . metabolic; what’s crucial is that they clearly showed signs of consciousness.

This was an amazing finding, but the investigators took the work further still, and, using a very ingenious trick, what they revealed shocked the world of medicine.

Let’s quickly put you back into the fMRI machine. This time, here’s what I’m going to do. I’m going to ask you a simple, unambiguous question (like, do you have a brother?). I’m going to tell you to think “tennis” for YES, think “navigation” for NO. (Rather like using fMRI activation as a “blink once for yes, twice for no” kind of communication tool.) Turns out this works fine, with 100% accuracy with normal subjects.

I guess you see where I’m going with this. Let’s take one of the patients diagnosed as vegetative but who has shown the ability to “light up” his or her supplemental motor area or parahippocampal gyrus on demand. Let’s do the same thing with him. Let’s ask him or her questions – tennis if yes, navigation if no. What happens? Let me quote the researchers: “. . . for those five questions, the pattern (of activation) produced ALWAYS matched the factually correct answer.” 

I’ll let that soak in for a moment.

These scientists just took a patient who’d been diagnosed as vegetative (and again, I’ll insist that this means NO CONSCIOUSNESS) and not only TALKED TO HIM, but actually got answers!

What are the implications? First of all, this study shows how hard it actually is to make a proper diagnosis of the vegetative state. Until now, this diagnosis relied on confidently stating that there is evidence of absence of consciousness, based on detailed and lengthy observation of the patient’s behavioural responses. But remember, these patients have severely damaged brains; the behavioural repertory of responses that they can show may often be so limited that none will be found. But this study emphasises that absence of (behavioural) evidence is NOT necessarily evidence of absence (of consciousness). The infinitely more sensitive “behavioural” response of metabolic brain activation could allow, in the future, clinicians to make this diagnosis with much more confidence. This obviously has enormous implications in terms of medical and ethical decision-making as concerns any given patient.

More importantly for us, this tool would appear to open up the possibility of actually communicating with some of these patients (a small minority at best, but still . . .). The current procedure is much too cumbersome, difficult, and expensive to use routinely, but it’s not too much of a stretch to imagine a future where helmet-sized mini-MRI machines are placed on the heads of patients with prolonged disorders of consciousness to allow their care team and loved ones to communicate with them.

There is a huge amount of fascinating and useful research being done on consciousness – both normal and disordered. Functional imaging is one of the most powerful tools in this quest for knowledge. As they say, watch this space.

Here’s a link to the original NY Times article about this research. The second contains a video by Liege’s own Steve Laureys (the lead researcher), explaining the technique. And the third is to a pdf of the original article, published in the New England Journal of Medicine.

http://www.nytimes.com/2010/02/04/health/04brain.html

http://thelede.blogs.nytimes.com/2010/02/04/doctor-demonstrates-method-of-speaking-with-vegetative-patients/?_php=true&_type=blogs&action=click&module=Search&region=searchResults&mabReward=csesort%3As&url=http%3A%2F%2Fquery.nytimes.com%2Fsearch%2Fsitesearch%2F%3Faction%3Dclick%26region%3DMasthead%26pgtype%3DHomepage%26module%3DSearchSubmit%26contentCollection%3DHomepage%26t%3Dqry575%23%2Flaureys&_r=0

http://www.nejm.org/doi/pdf/10.1056/NEJMoa0905370

Some important science on disorders of consciousness – part 1

Well Liège has made it into the news again!

The Coma Science Group here at our hospital, working with other centres,

has published another significant study of persistent disorders of consciousness. It’s worth having a look at this; in a subsequent post we’ll look at another very important paper by these researchers. I’ll also  place these reports into some kind of context in terms of Michael Schumacher’s situation (or more correctly, presumed situation).

First a link to an article about today’s study:

http://www.nytimes.com/2014/04/16/health/pet-scans-found-to-clarify-vegetative-state.html?hp

And a link to the article itself:

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673614600428.pdf?id=baaFobxDfjPxxfydMxPvu

The background

Remember how we said that the vegetative state is defined as a state where the patient shows signs of wakefulness (notably open eyes) without behavioural responsiveness (as a marker of consciousness or awareness). Because of the emotionally laden and ambiguous nature of the word “vegetative”, some, including the Coma Science Group, prefer to use the term “unresponsive wakefulness syndrome” (henceforth UWS) for this state.

The key in differentiating a patient with unresponsive wakefulness syndrome from a minimally conscious state is the presence in the latter of fluctuating signs of awareness, with consistent but intermittent appropriate responses to stimuli.

Distinguishing these states can be difficult, but is absolutely crucial, medically, socially, ethically and therapeutically. A patient who is genuinely in a UWS, has, by definition, no self awareness. No voices are recognised, no sensation of hunger, none of pain, none of thirst. This is why clinicians caring for patients in a UWS are authorised almost everywhere to withdraw medical support, if and when appropriate, (including food and water – remember this is not cruel because there is no hunger or thirst perceived) from UWS patients. This is not the case once the patient has demonstrated any consciousness at all. Prognostically, as we’ve mentioned previously, persistence of a clinically correctly diagnosed (and that’s the point here) UWS for one year after the inciting trauma pretty much means any meaningful recovery is impossible. On the other hand, a minimally conscious state raises the possibility of continued progress.

Unfortunately, it can sometimes be remarkably difficult to show conclusively what state the patient is in. The problem is double.

First of all, there is the fluctuating nature of awareness. Episodes of interaction can appear randomly, or might be associated with a certain time of day, the presence of certain people, etc. The key is to do sufficient evaluations, sufficiently often, to reliably ascertain what the patient’s best level of awareness is.

Second, let’s remember that these patients have suffered devastating brain damage, whether caused by trauma (as is the case with Michael), infections, massive strokes, global anoxia, etc. This means that these patients will almost always have severe restrictions in their ability to show their responses to external (and internal) stimuli – spastic limbs which preclude reliable movements, visual or auditory deficits, etc.

Because of this, current guidelines for the management of patients with prolonged disorders of consciousness are becoming more and more insistent as to the FREQUENCY and QUALITY of the evaluations that are done. Standardised measurement scales are used, and the training necessary to administer them are well defined. Despite this, doubt remains at the edges between the diagnoses. Help is clearly needed to reliably diagnose the presence of these difficult-to-demonstrate degrees of awareness.

The study published today is an attempt to validate the use of imaging techniques, in addition to clinical evaluation, to help determine whether a patient is or is not AWARE.

The study

Steve’s study looked at the ability of two imaging techniques, FDG PET scanning and fMRI imaging, to help distinguish between UWS and minimally conscious states. FDG PET images show brain areas that are actively using glucose. This is known to correlate with activity in those same areas. FDG PET images show the pattern of brain activity at rest. On the other hand, fMRI images look for use of oxygen in the brain. It is particularly useful to do when asking the subject to do a mental task – whether visualising something, imagining something, or DOING something moving fingers, pressing buttons, etc).

It is also known with high confidence that certain brain areas show normal activity in normally conscious patients, essentially no activity in UWS patients, and intermediate (but significantly reduced) activity in patients who are minimally conscious.

This study looked at the reliability of using activity in these areas to help confirm the diagnosis made clinically, and to help determine the patient’s prognosis.

Briefly, the study showed that FDG PET imaging is highly correlated with a previously validated (and widely if not universally used) clinical scoring scale. Importantly, one third of patients (13 of 41) diagnosed clinically as being in a UWS were shown by FDG PET to have activity in centres associated with awareness. Over the next year, nine of these 13 patients (remember, they were classified clinically as UWS!) had moved “up” to a clinical diagnosis of minimal consciousness or better, while of those with an imaging “confirmation” of UWS had terribly dismal outcomes. Of these 26 patients, 35% were still unconscious after one year . . . and 56% were dead. This shows that these images may well sensitively show the possibility of awareness, and seem to contain the same prognostic information that a clinical diagnosis of minimally conscious state contains. Further the numbers track what I’ve said in previous posts in terms of prognosis.

It is absolutely vital that we understand what the study didn’t show. It did NOT show that these 32% of patients were aware, or conscious. It showed that these patients, who clinically were felt to be unconscious, “had cerebral activity compatible with consciousness” (the authors’ words). But importantly, these patients had significantly better CLINICAL courses subsequently than those in whom PET confirmed an absence of activity compatible with consciousness.

Conclusion: it’s looking like at some point in the not distant future FDG PET imaging may well be a standard test in addition to clinical scoring, to determine whether awareness is or is not present in patients with disorders of consciousness. Remember: 1) it’s not yet fully validated, meaning more research is necessary before making this a standard tool with fully accepted statistical notions of reliability and validity; 2) until it IS validated, it remains a research tool.

Implications for Michael Schumacher

Actually, to the extent that Michael has been reliably shown clinically to have signs of awareness/consciousness (this would appear to be the case based on direct quotes of Sabine Kehm), this type of imaging would have no real utility, as a diagnosis of minimally conscious state would then have been made clinically.  On the other hand, my next post will deal with another paper by our Coma Science Group, one with fascinating clinical and even philosophical implications.

 

 

“Moments of consciousness and awakening”!!!

Well today is a superb day.

Sabine has told us two incredibly important things, things that not only inform us as to where we are, but open up rather more optimistic possibilities than some of the darker options we’ve considered until now, based on not knowing.

I want to repeat, because it’s important to fully understand what will follow, that while “wakefulness” and “consciousness” usually are pretty much one and the same, after the brain is injured, the two can be dissociated. What do I mean?

Assuming that the terms are being used and translated correctly (and Sabine is a consummate professional and wouldn’t get this wrong), awakening refers to (at least) the appearance of . . . being awake. Basically that means eyes open. And as I mentioned before, this eye opening can even be cyclic, following what looks just like a sleep-wake cycle (even if not synchronised to real day-night hours).

Wakefulness WITHOUT consciousness is the definition of a vegetative state. The eyes are open, but there’s no interaction with the environment. If Sabine had “only” said that Michael was showing wakefulness, it would mean that he is not comatose. That in itself is a damned sight “better” than persistent coma, not just in terms of life expectancy, but in terms of the chances of neurologic improvement.

But Sabine has also told us that Michael is showing signs of consciousness. My lord, the brain is an amazing organ. And Michael a remarkable man. What does this consciousness probably look like? It consists of episodes of clear, purposeful interaction with the environment, and/or clear signs of awareness of self, even if these signs are not constantly present. For example, if Michael smiles when a member of his entourage talks to him – reproducibly and consistently on at least a few occasions. Or following people with his eyes. Or trying to communicate, or obeying simple commands. Any of this constitutes objective signs of contact between the “outside” and the “inside”. This then would be a minimally conscious state. And that is about the best news we could possibly get right now.

Why? Because of what it means for everyone – Michael himself, his loved ones, and his fans. It means that Michael may well see, hear, and feel the love that’s around him. That he is, in some very real way, HERE. It means his life expectancy has now improved VERY significantly. And last, but perhaps most important, it opens up a very real chance for further improvement. This would mean spending more time “in touch” with his surroundings, and also improvement in the quality of the interaction. How incredibly positive!

This means rehab, lots of rehab. Michael is used to working hard. Getting that brain to learn new ways of doing things, stimulating it, forcing it to handle data, and all the while working hard to build him up again physically. All very exciting. And very good.

Don’t get me wrong – this is a very important step, but we don’t want Michael to stay like this. But this is a very very very big step.

We all need to thank the team taking care of Michael as well as the people around him, for their devotion and patience. Everyone is going to need to be patient – for weeks, months, maybe years.

But if you’re even the slightest bit spiritual, it’s time cast a look upwards and mouth the words “thank you”.