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. . .