From Cryonics, October 1990

The Cryonic Suspension of A-1242

by Mike Darwin and Steve Bridge

First Call

On the evening of May 8, 1990 a telephone call came in from an Alcor associate member notifying us that his wife was hospitalized and likely to deanimate. This member and his wife, whom we'll call Dr. and Mrs. Graham, had visited the Alcor facility in October of 1989 and had decided at that time to pursue suspension arrangements. They were in the early stages of the sign-up process when Mrs. Graham experienced unexpected complications from a long-standing cancer and was rushed to the hospital. Dr. Graham informed us that Mrs. Graham's physicians felt that she was unlikely to survive this admission and that she had apparently experienced irreversible damage to her lungs as a result of chemotherapy.

Mike Darwin suggested that an Alcor team be dispatched immediately (since the Grahams lived a few hours away in a coastal city we'll call Seaside) and that Dr. Graham fill out the Alcor suspension paperwork that night. Owing to his fatigue, and shock at his wife's sudden turn for the worse, Dr. Graham indicated that he was in no condition to execute paperwork and, in any event, expected his wife to last for several more days. He suggested that we come the following day, once his wife was on a respirator and her condition and prognosis could be better assessed. Despite severe anxiety on the part of Mike Darwin that we get there as soon as possible, Dr. Graham was firm. As Mrs. Graham's blood gases were reasonable and not deteriorating, it was hard to argue otherwise.

Unprepared

There were already many complications in this situation. Dr. Graham had been involved in cryonics to various degrees for over 20 years, and he had been in the process of beginning to prepare suspension arrangements for himself, his mother, and his wife; but he had not completed these arrangements. Apparently Dr. Graham did not realize how serious his wife's condition was, since he had not previously told Alcor personnel that Mrs. Graham had had breast cancer for four years. Now, her death was suddenly approaching and he was not prepared. Thus, we were not adequately prepared. We knew that when we got to Seaside, before we performed any suspension procedures, we would have to get Dr. Graham to read, understand, and sign the appropriate cryonic suspension documents, including the Cryonic Suspension Agreement, the Consent for Cryonic Suspension, and the Authorization of Anatomical Donation. He would also have to provide the minimum Suspension Funding.

The next morning (May 9), we further delayed in leaving while Dr. Graham and Mrs. Graham's doctor debated the propriety of putting the patient on a respirator. Finally, Mrs. Graham was placed on a respirator and we started on final preparations, under the assumption that this would buy her a few more days.

A Suspension Begins

This assumption turned out to be entirely incorrect, and Mrs. Graham's condition steadily worsened. We again increased the speed of our preparations. Michael Darwin, Steve Bridge, and Arthur McCombs prepared themselves and the equipment so we could take both the Alcor ambulance and Jerry Leaf's Cryovita van to Seaside to stand by for the time when Mrs. Graham would be declared legally dead. When it became clear that we would be leaving soon but that we could be in Seaside overnight, Arthur McCombs left for his house to pick up a change of clothes. Unfortunately, shortly after he left the facility, the call came in from Mrs. Graham's physician advising us that Mrs. Graham was in cardiac arrest. Mike Darwin had previously advised the physician on how to proceed if that should occur, and the physician followed his instructions and administered the Abbreviated Instructions for Stabilization of Alcor Biostasis Patients. Within minutes Mike Darwin and Steve Bridge were on their way out the door to respond to the emergency.

Just as we were leaving, Alcor Treasurer Dave Pizer pulled into the parking lot, presumably on some errand that had nothing to do with this suspension. Mike Darwin commandeered Dave Pizer to drive the ambulance and the three of us left almost immediately, with Steve Bridge driving Jerry Leaf's van.

We left the facility sometime around 3:15 P.M. and went east on 91, to pick up 200 pounds of ice at the ice house just off of 14th St. We left the ice house at approximately 3:40 — right into the heart of rush hour traffic. With Steve fresh from Indiana, Dave fresh from Phoenix, and Mike not very familiar with the route we were to travel, this was not the best of situations. Other people later gave us better suggestions for getting to Seaside, but we were forced to take main highways to prevent getting lost. This delayed us about 20 minutes, perhaps.

It was extremely fortunate for us that we had the CB radios installed and working. We lost visual track of each other several times, but the radios kept us in touch. They also allowed us to confirm the route and exits without having to stop. (We have since added a cellular phone, so we can now keep in touch with Alcor as well.)

Arrival

We arrived in Seaside at approximately 6:50 P.M. and found the hospital quickly. We decided to wait to refill the gas tanks until after we had taken possession of the patient.

When we arrived at the waiting room of the hospital, we discovered that, much to our amazement, Dr. Graham had gone home to eat. We also discovered that, while Mike's instructions were otherwise followed cornpletely, only the patient's head had been packed in ice, instead of the entire body. This may be a result of the way the instructions are usually given; i.e., 'Pack the patient in ice, especially the head." Under pressure, the other party may hear, "Pack the patient's head in ice."

The hospital personnel were ready for us and the nurse in charge of the Intensive Care Unit (ICU) allowed us (encouraged us, really) to get the patient into the Portable Ice Bath (PIB) as soon as possible. Once we had reached Dr. Graham and established that he would come right back over, Mike and Steve took the ice and the PIB to the patient's room. We quickly moved her into the PIB, placed rectal and esophageal thermocouple probes to monitor her temperature descent, and covered her with ice.

Due to the long ischemic time delay (4 hours and 48 minutes), no attempt was made to restore circulation with CPR. The hospital had done CPR for approximately 15 minutes while transport medications were given, but owing to staff limitations were unable to provide extended support. We were incredibly fortunate to have had any support at all; usually the treating physician and hospital staff will decline to take any action in support of suspension because they are concerned about liability, ethics, and their competence and legal authority to act.

All we could do in this situation, where there had been prolonged ischemia and minimal stabilization, was quickly cover the patient in ice in direct contact with the skin and reduce her temperature by external cooling. Even though Mrs. Graham's head and neck had been completely packed in plastic bags filled with ice, her pharyngeal temperature had only dropped to 15.8C (60F)!

Doing The Paperwork

We then left the ICU and returned to the hospital lobby to discuss the paperwork with Dr. Graham. He appeared a bit dazed by everything and confessed that he hadn't really examined the paperwork to any great degree. He kept saying that he trusted us and wanted to get this going as soon as possible. Steve explained carefully to him that, since he had not previously signed up and was not fully familiar with the legal documents, we had no authority to proceed until we could establish informed consent and full authorization. Obviously we were all under a great deal of pressure to get the patient back to the Alcor facility. However, it is critical that full and informed consent be established in any suspension, and this is especially necessary in a case like this for the protection of the patient, the family, and for Alcor.

When understanding and informed consent was established (and Dr. Graham's long history of cryonics knowledge and involvement was taken into consideration here), the three core documents were signed by Dr. Graham and witnessed by two hospital security guards. Dr. Graham then gave us a check to cover the cost of a neurosuspension (as a down-payment) and agreed to pay the balance for whole body suspension within a few days.

Dr. Graham also filled out the first page of the Cryonic Suspension Application and was told that we would be contacting him for the rest of that information. At this time, Dr. Graham also filled out a consent form for Alcor to receive a copy of the patient's medical records.

Mike and Steve went back to the ICU, picked up the completed death certificate, discussed the patient's last few hours with the nurses, left some Alcor information for the physician and the head nurse, and went into the patient's room. We rapidly wheeled the patient out of the room and through the hallways to the mortuary pickup exit, accompanied by one of the very helpful and courteous security guards.

In fact, all of the hospital personnel we dealt with were polite and professional. Any hostility was kept concealed, and several people were quite friendly. We are not sure why this was so (although we feel that our own constant efforts to be polite and professional give us some advantage in this regard), but it is usually the case and we hope it will continue.

Return To Alcor

We left the hospital about 9:30 P.M. and drove to a nearby gas station to fill up both vehicles. On the return trip, Dave Pizer drove Jerry Leaf's van and Steve drove the Alcor ambulance.

One good aspect of the trip was what Steve could only describe as the "Curtis Henderson pioneering kind of feeling" we got driving along the Pacific coast with a suspension patient in the back and the moon glowing brightly on the ocean. It was sort of thrilling, surreal, and heroic all at the same time. The trip back was fairly smooth, since traffic was light, although the ambulance does have an alarming tendency to oversteer badly when fully loaded.

At 1:10 A.M. we arrived at the facility with the patient. Others present at the lab included Carlos Mondragon, Jerry Leaf, Dr. Thomas Munson, Scott Greene, Arel Lucas and Naomi Reynolds (both of whom had flown in from Alcor Northern California), Arthur McCombs, Laurence Gale, Saul Kent, Hugh Hixon, and Michael Perry.

Perfusate preparation had been delayed until paperwork was executed and the patient was in our legal custody. As a consequence of this, plus some technical delays [setting up for a perfusion seems to be nearly as complex as setting up for a Space Shuttle launch, if the reduced scale is taken into account —SB], perfusate and other preparations were not completed until 8:30 A.M.

Naomi Reynolds and Scott Greene stayed up all night filtering the perfusate and Jerry Leaf and Laurence Gale also stayed awake making final preparations. Laurence also drove to pick up additional dry ice. The rest of the staff took naps at the lab, at home, or at Saul Kent's home.

Surgery Begins

Surgical Team Duties:

  • Thoracic Surgery: Jerry Leaf, Thomas Munson, assisted by Arthur McCombs
  • Cranial Surgery: Mike Darwin
  • Chemical Analysis and Silicone Fluid preparation: Hugh Hixon
  • Technical Recording: Naomi Reynolds; later, Arel Lucas
  • Narrative Recording: Steve Bridge
  • Photography: Saul Kent
  • Assistants and Circulators: Arel Lucas, Scott Greene, Carlos Mondragon, Laurence Gale

At 9:49 A.M. on May 10, Mike Darwin began the scalp incision to drill the "burr hole," exposing a 3-5 mm area of Mrs. Graham's brain. The burr hole allows for dynamic monitoring of brain volume and blood washout during the suspension. Patients (such as Mrs. Graham) who have suffered ischemic injury invariably develop brain swelling (edema), and edema of other tissues as well, during circulation of cryoprotective agents (perfusion). To prevent the brain from being severely injured by this swelling, it is carefully monitored during perfusion. If too much edema occurs, as evidenced by the brain bulging into the burr hole opening in the bone, perfusion can be modified or stopped.

At 9:51 A.M. Jerry Leaf began the midline incision to open the chest and connect the patient to the heart-lung machine so that cryoprotective drugs could be circulated through the patient's tissues to minimize freezing damage.


Notetaking during the suspension. Left: Mike Darwin, center: Arel Lucas, right: Naomi Reynolds.


Surgery underway on the patient's chest to place cannulae (tubes) which will allow the patient to be connected to the heart-lung machine for the circulation of cryoprotectant. Left to right: Suspension Team Leader Jerry Leaf, Thomas Munson, M.D., and Surgical Assistant Arthur McCombs.


Venous and arterial cannula in place in the patient's aorta and right heart.

By 11:58 A.M. all surgery was completed and total body washout (displacement of the patient's blood with perfusate) was begun. This was the first time the Abbreviated Protocol had even been used, and we were concerned about whether or not the patient would be clotted. When the scalp incision was made to open the burr hole, a fair amount of bleeding was noted and there was no sign of either blood clotting or agglutination (clumping of red cells upon cooling). At 12:04 P.M. the first venous sample was taken and the pH was 6.41, very acid compared to the normal pH of 7.4, but not unexpected considering the circumstances.

Absence of clotting was confirmed as the blood washout proceeded smoothly. Much to our relief, the area of the cerebral cortex surface that was exposed by the burr hole showed excellent blood washout and complete clearing of pial (brain surface) vessels by 12:25 P.M.

Cryoprotective Perfusion

Perfusion Duties:

  • Perfusion Supervision: Jerry Leaf
  • Staff Monitoring and Cranial Monitoring: Mike Darwin
  • Pump Monitor: Naomi Reynolds
  • Chemical Analysis: Hugh Hixon
  • Computer Analysis of Glycerolization: Michael Perry
  • Blood Samples: Scott Greene
  • Suction and Chest Monitoring: Arthur McCombs
  • Technical Notes: Arel Lucas
  • Narrative Notes and Outflow Monitoring: Steve Bridge
  • Silicone fluid preparation and monitoring: Laurence Gale
  • Photography: Saul Kent

The start of the "cryoprotective ramp" occurred at 12:13 P.M. We begin blood washout perfusion with a 5% (w/v) glycerol concentration whenever we have a patient who is ischemic. Normally, if we are doing a blood washout under optimum conditions in the field, we do not have cryoprotectant present. Because of the long warm ischemic time in this case, we used nitrogen gas to supply the oxygenator instead of oxygen. This is done to limit reperfusion injury; tissue damage would likely occur upon the reintroduction of oxygen during the restart of circulation. The perfusate also contains a free radical buffer (glutathione) to help minimize reperfusion injury.


Overview of the patient and heart-lung machine/perfusion circuit. The patient is on the operating table packed in ice and the heart-lung machine is in the foreground.

In order to help minimize cerebral edema during perfusion, we used pulsatile perfusion on Mrs. Graham. Pulsatile flow, unlike the normal steady flow output from a heart-lung machine roller pump, mimics the natural pulsatile flow generated by the heart. This has been shown to help prevent cerebral edema during heart bypass surgery and has been especially effective in controlling cerebral edema in ischemically injured suspension patients.

Almost from the start of perfusion, Mrs. Graham began to develop edema and experience increasing perfusion pressure. Her pressure during blood washout was 100/50 to 100/60 but rose to 150/90 within about an hour and forty-five minutes of the start of the cryoprotective ramp, and finally to 190/110 near the end of perfusion. At 2:21 P.M., perfusion was stopped due to increasing vascular resistance (as evidenced by rising perfusion pressure) and the development of cerebral edema as evidenced by the cortical surface bulging into the burr hole about 1 mm. Typically, in a properly stabilized and transported patient, we reach a terminal glycerol concentration of 4M glycerol (37% w/v glycerol). Our terminal glycerol concentration (as measured in the final venous effluent) in Mrs. Graham was 3.65 M glycerol (33.6% (w/v)). Considering the lack of adequate transport, we did surprisingly well.

At 2:26 the burr hole incision was closed, and at 2:55 the chest wound was closed. By 3:15 the patient was cleaned up, placed inside two plastic bags, and prepared for placement in the silicone oil bath for cooling to -79C.


The patient being placed in protective plastic bags prior to placement in the silicone oil cooling bath for freezing to -79C.


The patient after placement in the silicone oil bath. The plastic jugs being added contain sand and are used as "space takers" to reduce the need for the (expensive) silicone oil.

The temperature of the silicone oil bath had previously been reduced to -9.5C, and at 3:29 P.M. the patient was placed in the oil bath and the freezing process started.

From 3:40 P.M. on May 10 until 10:00 A.M. on May 11, Mrs. Graham was cooled at a controlled rate of about 2C per hour in the silicone oil bath. On May 19, 1990 at 3:50 P.M., Mrs. Graham was transferred from the silicone oil bath into two heavy-duty sleeping bags and affixed to a stretcher prior to insertion into the Bigfoot dewar for vapor cooling to liquid nitrogen temperature. On May 20 at 11:45 P.M., after completion of cooling to -196C, Mrs. Graham was transferred to a dual patient dewar and submerged in liquid nitrogen. On July 11 she was moved back into the Bigfoot unit with two other Alcor patients, where she is currently being maintained in long-term storage.


The cover of the October 1990 issue of Cryonics depicts Mrs. Graham being hoisted for placement in a Bigfoot dewar.

Legal Fallout

The morning of May 10th, while perfusion was still in progress, Carlos Mondragon received a call from a nephew of Mrs. Graham. The gentleman said he was "assisting the family" and he needed a certified copy of the death certificate in order to access certain bank accounts which Mrs. Graham held jointly with his mother. Carlos explained that there was little chance of getting a certified death certificate and why. (The California Department of Health Service's ongoing refusal to give us a permit for disposition of human remains meant that one line on the death certificate could not be completed.) He also explained what would likely be necessary to deal with the bank in the absence of one and offered help in that regard. Over the next few days there were more calls of a similar nature.

A few weeks after the suspension, we were told by Dr. Graham that his wife's sister was attempting to probate a photocopy of a will which Mrs. Graham had signed in 1986. This will gave substantially all of Mrs. Graham's estate to her sister. It also contained a rather shocking provision stating specifically that she did not want to be frozen or cremated after death and directing that she have a "Christian burial."

Dr. Graham said he had not known of the existence of this will, but had since determined that his wife had destroyed the original in the process of implementing a new estate plan. Fortunately, Mrs. Graham's new estate plan left quite a paper trail, all of it in contradiction to the terms of the will. Mrs. Graham had put the assets she wanted her sister to have into joint tenancy accounts. She did the same with property meant for her husband. According to Dr. Graham, objections to cryonics which his wife had had in the past were religious in nature and had been overcome in recent months. Mike Darwin and Carlos Mondragon heard this directly from her when the Grahams visited the facility.

Dr. Graham has challenged the validity of the will and he plans to vigorously defend his wife's suspension. That process has just begun, and no quick resolution is expected.

A Caution

We would like to add a brief but important caution to current and prospective Alcor members, especially to members who may wish to assist relatives in last minute suspensions. California law specifically requires that a person's instructions concerning disposition of his or her human remains following legal death must be followed, assuming that those instructions have been financially provided for and that they are not a threat to public health.

Alcor has successfully used this law to defend the rights of suspension patients. But if a person has stated that they do not wish cryonic suspension, that wish must also be respected. (Some of us feel that this is a moral obligation, as well as a legal one.) It is in your own best interests to make sure that your instructions for cryonic suspension are clearly known to all significant members of your family and that they are clearly written down in your will and in other documents (not ONLY in your will — wills can "disappear"). And — especially in California — be very cautious about attempting to suspend relatives who have stated they do not wish this procedure. Alcor will not endanger the suspensions of other patients in order to defend the suspension of someone who specifically did not want the procedure.

 

PAPERWORK COUNTS!
Alcor is Forced to Surrender a Body for Burial

by Carlos Mondragon
From Cryonics, 3rd Quarter, 1994

In April the California Supreme Court refused to hear an appeal of lower court rulings which had mooted the anatomical donation of the body of "Sylvia Graham" to Alcor for cryonic suspension (see the report above of the whole body suspension of A-1242, Oct. 1990 Cryonics). The effect was to let stand a court order directing that Mrs. Graham's next-of-kin arrange a "Christian burial."

This disposition of this case underscores the immense importance of executing for oneself the "onerous" paperwork which is required for Suspension Membership. Although we have from time to time reported on the progress of this case in Cryonics, here is a brief review.

Mrs. Graham had not executed any Alcor paperwork bythe time she became critically ill and unable to do so. The suspension was arranged by her husband, Dr. "Marvin Graham." This was not the first or last of Alcor's "last minute cases" (those suspensions arranged by persons other than the patient). Under California law and the Uniform Anatomical Gift Act, a decedent's next-of-kin has the legal authority to arrange for disposition of remains, including anatomical donations, in the absence of other written instructions by the decedent.

The litigation which ensued did not dispute the legality of cryonics or the right of the patient to have chosen cryonics. Rather, the issue was the patient's intent. About two months after the suspension, the patient's sister produced a photocopy of an old will signed by Sylvia Graham which explicitly stated that she wanted a Christian burial, and did not want to be "frozen or cremated"! The sister brought suit to force execution of that will. No original of the will was ever found, and it was Dr. Graham's contention that Sylvia had resolved her religious reservations regarding cryonic suspension and had, in fact, decided to sign up with Alcor several months prior to her death. The sign-up process had been delayed due to difficulties in arranging funding. Evidence supporting the fact that the other, primarily monetary provisions ofthe will had been rendered invalid by changes to her estate which Sylvia had made in the last two years of her life. Mike Darwin and I gave testimony (by deposition and at trial) that Sylvia had apparently already changed her mind on cryonics when she and Dr. Graham visited Alcor a few months prior to her suspension.

The trial court ruled that notwithstanding any evidence of Sylvia Graham's acceptance of cryonic suspension, she could not have given informed consent to the procedure. And since the judge accepted the legal status of cryonics as scientific research (that status having been established by an appellate court in Alcor's litigation with the California Department of Health) he went further: the standard of informed consent applied was equal to what would be required for medical experimentation on legally living patients.

Alcor never did intervene or participate in this litigation. We had fought in the courts long, hard, and successfully to defend and firmly establish the legal right to choose disposition of one's remains. Since this case presumed the right to choose, our role was to provide moral support and hope for the best.

Ultimately, when Dr. Graham was forced to carry out the court order, our only choice was to demur. (An attorney assured us, meanwhile, that our move to another state did not change our legal status in this matter.) The court had ruled that Sylvia's will and lack of informed consent had sufficiently revoked her husband's authority to have made an anatomical donation of her body. But as next-of-kin he was still obligated and empowered to arrange a final disposition within the guidelines set by the will: no freezing and no cremation. Dr. Graham and Alcor complied with the letter of the law. At the end of May, Sylvia's body was transported back to California for burial, the first time such an incident has happened in the history of Alcor.

If there is any good news here, it is that you can expect the judiciary of the State of California to upholdyour direction regarding disposition of your human remains after legal death. The caveat is that we had better be damned swift about making those directives. Even if full suspension membership has not been completed (for whatever reason), I believe that a signature on any two of the three core documents which comprise Alcor's core paperwork package would be sufficient to produce a different outcome in circumstances similar to those described above.