Cryonics, June 1992
You know it is going to be a rough day when you start by looking up from the bottom of a Pizer tank. -- Anon.
At a recent cryonics meeting one of us (Arel) talked to two Alcor members who were considering taking Emergency Medical Technician (EMT) training as a step in the direction of becoming Alcor Transport Technicians. Both of them in separate conversations made statements to the effect that they thought EMT training would not be very useful because (paraphrasing) "what could you do wrong? The people they would be working on for Alcor would already be dead."
A prominent cryobiology researcher was horrified when he happened to overhear one of these conversations. I (Keith) was assured that one of these two came away from the resulting conversation with a very different viewpoint from the one that he started with. However, in the press of the meeting, one of them got away. While the one who got away seems to have been joking, there may be others out there in the membership with similar ideas. Since we certainly want such views corrected before any of them work on us, we decided to describe medical ethics and practice as it has been adopted by Alcor.
In spite of the "legal death" requirement, Alcor suspension patients are not dead in any meaningful sense of the word. Consider the last suspension. Our patient underwent an (almost certainly) reversible cardiac arrest as a result of dehydration. When that happened, the transport team restored circulation (mechanically) and breathing and forced IV fluids into him. This process would have a good chance of restoring consciousness if it were not combined with drugs which greatly reduce brain metabolism. After that, we cooled him and did a blood washout. Is this irreversible? Hardly: Alcor has recovered dogs after many hours of cold bloodless perfusion. All it takes is to warm them up and replace their blood.
Is the cryoprotective perfusion step irreversible? No again. The people working on organ preservation routinely load and unload organs with cryoprotectant levels similar to what we are using, and the organs resume functioning when they are unloaded and reperfused with blood. How about cooling? Dr. Suda (see Dr. Perry's article in the April Cryonics) found that cooling to -20°C for 5 days does not damage a cat brain beyond its ability to produce nearly normal brain waves after rewarming. So, at least until a patient goes below -20°C, the evidence is strong that all steps could be reversed and the patient could recover consciousness. (Doing this to a terminal patient would, of course, be a cruel and meaningless extension of pain and misery.)
It is certainly true that our patients are badly injured. So badly injured (by disease usually) that current medical practice has no way to extend their lives (at least with any quality of life). But this is far from saying that a patient is beyond sustaining further injury. In fact, by the very nature of the process, our patients are uniquely vulnerable to injury, especially to ischemic injury during the earliest stages of the suspension process when their metabolic rate is still high. (The colder a patient gets, the more time you have to correct a situation as it develops.) Mechanically taking over ordinary life-sustaining processes -- oxygenating and pumping blood, controlling temperature, pH, glucose, and electrolytes -- is a difficult task, and if it goes wrong, the patient can be seriously damaged. A functioning organism maintains these automatically. I (Keith) got a sample of just how intense a task it is to maintain the correct levels on the last patient when I was in charge of sustaining him on intermittent flow on the MALSS (Mobile Advanced Life Support System) cart for several hours.
What happens if we fail a patient? It depends on how much damage we do -- and we do not know exactly where the damage limits are. Like Humpty Dumpty, all the king's nanotechnology will not bring back a patient's memories and personality beyond some point. We try to do as little damage to the patient as possible, guided by our experience in recovering total body washout animals. If you take EMT training you will learn that any time patients receive IV fluids they can be damaged by air entering a vein through the IV set. Air blocks blood flow through the smallest capillaries, so some section of the blood-flow path gets clogged when a patient is given air. Air in the arterial side of the flow is even more serious. (The lungs filter out bubbles in a vein before it gets to the brain.) A bubble of air into the brain from a mistake in operating the perfusion machine is known to cause multiple strokes and seizures in experimental animals and heart bypass patients. It blocks brain perfusion in suspension patients wherever the bubbles lodge. We are unhappy to report that two of the last three patients have been given IV air (fortunately in small amounts), and it's possible that the last patient received arterial micro-bubbles toward the end of his cryoprotective perfusion, if any got through the filter. (Though the filter producers assure us that this is vanishingly unlikely.)
In addition, there is a complex regimen of medications Alcor gives to reduce/reverse tissue damage from low or absent blood flow and to keep the patients' blood from clotting and closing off the circulatory system. Failure to give these medications in the proper amounts at the proper time may cause tissue injury or result in blood clotting. Tissue injury or failure to keep the circulatory system open seriously compromises our ability to introduce cryoprotectants. This damages the patient because freezing injury is a lot worse if we cannot reach the desired cryoprotectant levels. A procedural error by the surgeon on the last suspension prevented us from reaching the target cryoprotectant level (though we came very close).
In short, we are performing a very critical service for patients who are inherently unstable. We are attempting to stabilize them in the same way that emergency medical technicians do their best to stabilize accident or disease victims in what is known as the "prehospital setting." Alcor Transport Technicians are expected to use EMT and paramedic methods to stabilize a critically ill patient in a presuspension setting. After watching patients stop breathing and be pronounced legally dead, we can tell you for certain that no visible transition takes place in that person at cessation of breathing and heartbeat. There is a slow process during which these vital functions slow to a stop, a gradual, damaging decline which team members itch to block, but in which we can not intervene until what EMTs call "crossover" is accomplished.
Crossover is a transfer of care based on medical ethics. Medical ethics and the practice of those ethics has a history going back to the Greeks. It has generated a hierarchy of medical authority, directly related to the level of education and experience of the practitioners. This hierarchy, the specialties of the practitioners, and the needs of the patient determine (without argument) who is in charge of the patient's care. Two doctors may have training and experience that is equal in length, but in different specialties. An endocrinologist would be expected to hand over a diabetic patient normally in his care to an orthopedic surgeon (or even a resident) for treatment of a broken limb.
This does not break what is called the "standard of care." But if the endocrinologist called in someone with a first aid certificate from the waiting room and told him to take care of the patient's fracture, that would break standard of care. Why? Because patients are always handed over (crossover) to those more skilled in caring for the patient's current needs. It would be an exceptional doctor of any specialty who did not know more about treating a broken bone than someone with a first aid card. Individual care in critical situations may be "handed off" to those less skilled only if the caregiver cannot meet all the patient's needs, and the skill or skills being handed off can be explained and done on a transient basis. For instance, an EMT can ask a bystander to put pressure on a bleeding wound while she attends to more skilled functions. The same EMT could not ask a bystander to spike an IV bottle or place a splint without breaking standard of care or even being judged to have abandoned her patient.
Does this apply to cryonics? It does at Alcor. When we are needed (after pronouncement of legal death), our skilled specialty Transport Technicians jump to the top of the heap of the medical hierarchy for that patient. The attending doctor (or pronouncing nurse), whether he or she recognizes it or not, is performing a crossover, as though from paramedic to emergency-room staff, or from general practitioner to specialist. Although the law regards us as experimenting on dead bodies, as far as we are concerned we are the critical-care, trauma-center specialists who take over when all other medical authority has given up. We should add that doctors very often do recognize our sudden authority. This was why they stood back in awe as an Alcor trained Transport Technician started CPR and administered transport medications to his mother. The doctors were impressed enough in the professionalism they saw to refer to her continuing treatment as cryonic therapy in their discharge summary.
Just like first-on-the-scene EMTs, Transport Technicians have to stabilize a critical patient whose heart and breathing have stopped. We do it by paramedic methods -- giving oxygen, cardiac support, and intravenous fluids. At that point we have only bought time, and not much of it. Pounding on the chest with a cardiac thumper cannot be done for long. In tens of minutes the lungs will fill with fluid and lose the ability to absorb oxygen. As quickly as possible we must accomplish a femoral cutdown and put our patient on cardiac bypass.
This is a skilled procedure by any medical standards, well beyond anything EMTs do. There are lots of places to make serious errors which may result in great damage to our patient. Besides the lungs filling with fluid, there are other reasons to put a patient on cardiac bypass as quickly as possible. Poor blood flow results in ischemic injury and breakdown of the patient's tissues. The best mechanical CPR does a comparatively poor job of providing blood flow, and even emaciated patients cool slower than we would like despite being immersed in flowing ice water.
There is a major crossover in patient care when the patient is put on bypass. The "head end" crew turns off the HLR and is released from their critical job of providing blood flow and oxygen to the patient's tissues. These functions are taken over by a blood pump/oxygenator/heat exchanger circuit which now requires monitoring as closely as a similar circuit being used on a heart bypass patient. The cooling rate greatly increases with ice-cold blood flowing in the circuit and through the patient. When the patient reaches 12-15°C, blood (essential to this point) becomes a liability. The red cells start to stick together and clog the smallest capillaries. Fortunately, the reduction in metabolism caused by cooling, coupled with the fact that cold water holds more oxygen, allows a blood washout (with Viaspan or similar fluids) to be done. At the end of washout it is possible to pack the patient in ice and ship to Alcor, though we get better results by maintaining patients on low flow if the patient deanimates within the area we can service by MALSS/ambulance. The patient is still critical, but deterioration has been slowed so we now have up to a day to get him/her to the next stage of care. Our patient is still quite vulnerable. Being lost in airline freight would be a disaster.
Crossover happens again when this critical patient is delivered to Alcor, cold and (ideally) on artificial circulation. The patient is still unstable, but with each transition she has gone to a lower plateau of urgency, becoming more stable, less subject to rapid tissue damage. Notice that in Alcor, as in medical circles, care of the patient is being handed to more and more skilled practitioners, with the first stage stabilizing technicians (like EMTs) handing over care to technicians trained in surgery and bypass perfusion (like emergency-room personnel), who hand over care to those who do the complex cardiac surgery and cryoprotective perfusion in Alcor's operating room (like hospital personnel).
Cryoprotective perfusion completed, the patient is monitored over a period of a day or two to reach the temperature of dry ice, and over several days to a week to reach final temperature, -196°C. Eventually, care of the cold, now stable patient (at liquid nitrogen temperature) is handed over to personnel skilled in cryogenic management for the remainder of the patient's trip to the future.
While the level of effort required to maintain a patient is greatly reduced when he or she reaches final temperature and is placed in storage, the responsibility is truly that of life and death. Everybody recognizes that a patient warming up to room temperature would be lost -- and as Dr. Perry discussed in his recent articles on the subject, a number of them have been lost at this stage (though none of these were Alcor patients).
In medicine, as a patient becomes more critical, standard of care always goes up, not down. Crossover goes from less skilled to more skilled -- although this may include transferring the patient to care which takes less training, but is specialized for the patient's needs at that time. (For example, a stable patient may be sent to a nursing home, which is a less skilled facility than a hospital, but better suited to the patient's needs at that time. The same is true for a critical patient who is sent home to die -- at some point a hospital may become the wrong place to take care of a patient.)
That puts Alcor personnel in the position of being the most skilled and specialized, the most critical people in a terminal patient's care. It puts us in the position of being able to do ultimate harm -- or (if this whole business works) a near ultimate amount of good. If you decide to take EMT training as a preliminary to Alcor transport training, pay close attention to the medical ethics in the course. If the responsibility you are undertaking does not wake you up in the middle of the night, you just don't understand.