From Cryonics, March 1991
by Ralph Whelan
Day five of the Busy Week was slated to be the final day of the Transport Protocol Training Course, in which eleven cryonicists would strive for the accolade of Transport Technician. We'd trained for four straight days, taking our final exam on day four to leave day five open for hands-on training.
Things were going well. After four days of training, we'd only lost one cryonicist. (Okay, down with the melodrama: Joe Tennant had to return to work, it being Monday. The rest of us were playing hooky.) Remaining were: Fred and Linda Chamberlain, Arel Lucas, Arthur McCombs, Carlos Mondragon, Mike Perry, Naomi Reynolds, Mark Voelker, Ralph Whelan, and Russ Whitaker. Mike Darwin was directing the course, and Hugh Hixon was filming it for distribution to all the major networks. (Not really.)
New Year's Eve, 1990, circa 10:00 AM:
Meet Miss Piggy. One hundred and five pounds of enthusiastic volunteer. (She'd seen the Donahue Show, and given a choice between Oscar Mayer and Alcor... well, there was no turning back.) Miss Piggy, with only minimal cajoling, stood up and took her thorazine like a pig. The rest of us donned our scrub gear and began prepping the Operating Room. The effects of the thorazine would be a few minutes yet.
But a lot can happen in a very few minutes. With the final preparations underway, Carlos stepped out to take a phone call from the son of a suspension member. He returned after a couple of minutes with the news: an elderly suspension member at a local hospital had developed a serious abdominal aneurysm, an ominous prognosis for someone of her advanced age and weakened state.
This put us in an awkward position. With the deanimation of a member likely to occur within the next day or two, did we dare begin our work on the pig? The concern was not supplies and personnel so much as it was facility readiness. That is, performing the transport protocol on a pig was sure to contaminate the facility and some of the equipment that we would want to use if there was a suspension. But, on the other hand, we hadn't yet heard from the member's physician, and family members in distress could inadvertently exaggerate the situation.
Just after Mike and Carlos agreed that the pig transport should be called off, the member's physician called and informed us that the aneurysm had started to leak badly and her blood pressure was down to about 60 mmHg. He and Mike spoke in detail about the member's condition, with the doctor making it quite clear that she was almost certain to deanimate very soon no matter what he did, but that he would operate and attempt to surgically remove the rupturing aneurysm and replace it with a Gortex graft, in hopes of maintaining the patency of her circulatory system.
It seemed that, given the situation, we were extremely fortunate. The doctor was not just willing to cooperate, he was eager. He described in detail her condition and what he wanted to do, and asked if there was anything we wanted him to do. Mike recommended that he proceed with the operation as soon as possible, and informed him that our transport team would roll within minutes.
Then, with things starting to pick up speed, we hit a snag. Jerry Leaf, the only person fully capable of setting up the heart-lung machine (changes to the circuit had been made recently) and performing the actual surgery, was vacationing in Hawaii. The paging system beeper that he wears does not function outside of the Southern California area, and he couldn't be reached at his hotel. We left messages with the hotel staff to the effect that Jerry was desperately needed to perform surgical techniques that no one else could perform.
Meanwhile, Mike rallied the team and the equipment, much of which had been diverted for use on the pig. About 20 minutes after the call came in, seven people (the Chamberlains, Carlos, Mike, Russ, Arel, and Mark) left for the hospital in the ambulance and Carlos' car. Since I—along with Naomi, Arthur, Hugh, and Mike Perry—remained behind to prep the lab and the operating room (which I'll describe in a little bit), I'm going to beg off narrating the transport and let you have it first-hand.
by Fred and Linda Chamberlain
We rapidly moved equipment into the ambulance, since much of it had been taken into the operating room for the training course. One piece of critical gear (the remote-sensing thermometer) was left behind, but we noticed this before reaching the freeway, so a hasty turnaround sufficed.
Mike Darwin drove the rescue vehicle and Fred, Mark, and Russell began drawing up medications en route; Carlos and Linda followed in a "chase car." It was difficult—careening along freeways—to get sterile containers opened properly, penetrate them with needles, and extract just the right amounts of pharmaceuticals needed, but most of this work was done (without any accidental sticks) before we reached the hospital.
In spite of fears that the patient might not survive until we arrived, surgery was still underway as we pulled up. Fortunately for us, a heroic effort to sustain the patient's life went hand-in-hand with facilitating a good cryonic suspension, since without the operation the patient would not have had a viable circulatory system. But our good fortune went beyond mere serendipity; throughout the standby, the medical staff was helpful and cooperative. Many of them were plainly intrigued with the efforts put forth by Alcor on the patient's behalf.
After arrival, we continued to prepare and cross-check the many medications that we would use to protect the patient from damage after deanimation. Mike and Carlos spoke with the patient's nurses and doctors to assess the situation. After all the medications were prepared and taped to a shelf on the MALSS (Mobile Advanced Life Support System) Cart, we all felt that the initial crisis was contained. It might be hours or it might be days... but now we were ready!
One member of the standby team stayed near the operating room at all times to keep abreast of changes in the patient's condition. This person was relieved every half hour by another team member. The patient's son had rented an apartment in a building adjacent to the hospital. While we waited tensely to learn how the patient would respond to surgery, he graciously invited us to his apartment for fresh fruit, muffins, sandwiches, and other life-saving staples. Many of us had not eaten since breakfast and evening was fast approaching.
The patient's son had equipped the apartment for his mother with a hospital bed, heart monitor, and (among many other things supportive of cryonics objectives) a small freezer filled with crushed ice. He (the son) had not slept well for some time and was now finding it very hard to relax, even though a full standby team was on hand. We could empathize with that. Barely six months before, the two of us (Linda and Fred) had gone through much the same experience with Linda's Mom (see Linda's article "Her Blue Eyes Will Sparkle" in the December 1990 issue of Cryonics).
Back at the hospital, doctors now informed Mike and Carlos that the patient had survived surgery and might live a day or so more. Her prognosis was clouded, due to age and poor health, but there was a relief from the feeling she might go at any moment. We discussed renting a nearby motel room so team members might sleep in shifts.
In expectation of a more drawn out operation, Carlos and Fred departed for Alcor, with instructions for Carlos to be paged if the situation should change. Ten minutes later we were informed that the patient was going into shock. She was losing blood very rapidly due to a condition called Disseminated Intravascular Coagulation (DIC), and it seemed that she might die suddenly. In DIC the patient develops countless microscopic clots in the small vessels and this results in the consumption of all of the patient's clotting capacity resulting, paradoxically, in bleeding. We were back in crisis mode. Mike phoned the lab and had Ralph page Carlos, with instructions for Carlos and Fred to return.
Mike then assigned specific responsibilities to all the remaining team members. The MALSS was lowered from the ambulance on the ambulance lift gate and moved—together with several ice chests—toward the emergency room entrance, close to the ICU in which the patient lay in a maze of monitoring equipment. Fifteen minutes after being paged, Fred and Carlos were back. There was the sense that we might be called on any moment.
Many moments passed. As is common with surgical crises, the patient clung to life. Better than an hour came and went with the patient in deep shock with a blood pressure of 50 mmHg or less. Some of the hospital staff came out and looked at the MALSS cart, asking questions. We were told that the patient's condition was worsening, so the cart was moved to a closed waiting room even closer to the ICU.
Then came the most agonizing wait of all. The hospital staff informed us that the patient had deanimated. But since the patient had just undergone surgery, the Los Angeles County Coroner had to be called to waive autopsy and provide the hospital with a "release number." This call cannot be made until after the death occurs. (The Coroner does not waive autopsy in "anticipation" of death. That's not how the system works!) Even though the Los Angeles Coroner's Office is staffed twenty-four hours a day, we couldn't help worrying. After all, it was New Year's Eve!
Every moment of this wait was torture for us, knowing oxygen levels were dropping in the patient's tissues, calcium was flooding into her cells, blood pH was dropping. The very structure of her being, of her potential to-be-restored life, was being eroded. But finally, after seventeen agonizing minutes, the waiting came to an end. The call came through, and the hospital staff gave us the go-ahead.
The ICU seemed to be packed with hospital personnel as the MALSS Cart rolled in. The medical people stood and watched, fascinated with our urgency in supporting circulation and respiration, in preparing to administer protective medications, in removing the patient from their facility as if we were paramedics coming upon a dying person on a street corner. Did they see us as people on a life-saving mission, or something else? We don't know, but it makes us wonder, sometimes. Can it be so obscure, what we are trying to accomplish?
Back in the separate waiting area near the hospital entrance, intravenous medications began stabilizing cell membranes, blocking and chelating calcium, feeding cells hungry for energy to maintain homeostasis, inhibiting blood clotting, protecting the digestive tract from acidosis, and maintaining the circulatory system. With antibiotics, foreign organisms were suppressed. Scavengers of free radicals were infused, to further limit cellular damage. And of course, concurrent with all of the foregoing, we had also completely packed her in ice/water to begin dropping her core temperature as quickly as possible. We were beginning to do what we'd come to do.
As soon as the initial medications were administered, we were out of the hospital and into the ambulance, with the heart-lung resuscitator thumping away and the patient's son waving and imploring that we drive safely. Then we were on our way back to Alcor.
An hour later, as the MALSS was unloaded, transport came to an end. The rest of this story is about the suspension operation itself, and Ralph will unfold it in his inimitable style.
Fred Chamberlain. Photo by Saul Kent.
Linda Chamberlain. Photo by Saul Kent.
by Ralph Whelan
Once the transport team rolled, the real preparations began. Arthur hunkered down to the most onerous task: the mixing of the perfusate. Naomi began prepping the operating room. Hugh Hixon made a dry ice run, and Mike Perry began organizing and labeling the myriad sample tubes that would be filled during the suspension. I began ringing Jerry's hotel in Hawaii every ten minutes, and helping out on odd tasks between times.
By the time the team arrived at the hospital (about an hour after they left the lab), the patient reports coming back to us had become sufficiently pessimistic about her prognosis that we felt certain the suspension would begin within the next few minutes to couple of hours. So we started to worry just a little bit. Setting up the perfusion tubing system was a task for which no one but Jerry was completely prepared. Jerry, however, was still unreachable. Hugh had returned from his dry ice run and had begun studying the perfusion schematics, but he was not optimistic.
Word came back that the team had arrived at the hospital and the operation had begun. As we waited, the news came in bits and pieces: the patient survived the operation, then she was fading fast, then she was stabilizing and likely to hang on for a few days. As we all let ourselves relax just a little bit, a call came in from Jerry in Hawaii. He said that he'd be catching the next available flight, but that he wouldn't be reaching Los Angeles International Airport until about 1:00 AM. Since it was already early evening and the patient seemed to be holding her own, the crisis seemed past.
Then she deanimated. Things kicked back into the fast lane. Suddenly there was no end of things to do and no time to do them. Ninety minutes later—the quickest 90 minutes of my life—the transport team was back with the patient. The news was: while the transport meds were given OK, the patient had lost so much blood volume that CPS (Cardiopulmonary Support) was not effective at restoring adequate circulation, and everything that was administered to support her "volume" was just as quickly lost through the bleeding incisions. We began to wonder how thoroughly she'd been perfused with the transport medications. Thankfully, later laboratory analysis of Transport blood and effluent samples disclosed that her serum tissue-specific enzymes levels were much lower than expected, and certainly far lower than would have been the case if adequate distribution of transport medications had not occurred (unfortunately, we have "controls" in the form of patients with whom transport was not possible due to circumstances beyond Alcor's control).
The cooldown, though, was going very well. We dropped her temperature very quickly considering the lack of adequate circulation, and shortly after she arrived we switched her from the now heavily contaminated Patient Ice Bath on the MALSS to a fresh ice pack in a fresh Patient Ice Bath. By the time we did this, her temperature was down to 16.3C (a drop of 21.7C in 104 minutes) and her circulation was poor enough that we felt comfortable discontinuing use of the Thumper.
While some of us worked hard to clean up the facility contamination and others continued preparation of the perfusate, Mike Darwin and Carlos moved the patient into the operating room and began work on a femoral cutdown. This was a daunting task for several reasons. First of all, her femoral artery was almost completely occluded with atherosclerotic plaque and had been bypassed with the Goretex graft. This meant that Mike had to reopen the surgical wound, cannulate the graft and locate the femoral vein under very adverse circumstances. Mike managed to cannulate the graft and the vein and flush the patient with six liters of Viaspan, the solution used to store organs for transplant. The Viaspan perfused very well, cheering us and encouraging us to believe that the transport medications per- fused well also. This also bought us some time, since, with the Viaspan substituting for blood, the patient could be maintained on ice with little deterioration for many hours.
Arthur McCombs begins preparation of the perfusate. Photo: Saul Kent.
Just after arrival: adjusting the "squid." Photo: Saul Kent.
More perfusate preparation. Photo: Saul Kent.
Mike cannulates the Gortex graft with Carlos' assistance. Photo: Saul Kent.
It was getting on into the evening now (about 9:30 PM, I believe), the patient was very cool (about 2C), completely packed in ice, and well-perfused with Viaspan, so we turned our attention to what final preparations for surgery remained. We were also still hard at work on final preparation of the perfusate; principally it was still being slowly filtered. The filtration process would continue even after Jerry's arrival and set-up of the perfusion circuit, so as it turned out, his absence did not really delay cryoprotective perfusion at all. As most tasks were wrapped up and the clock was mere minutes from the New Year's countdown, we sent most of the team off to bed. (Naomi and I utilized the lull to process the 80-or-so suspension sign-up letters that had arrived during the transport training course!)
Saul returned from LAX with Jerry at about 2 AM. Jerry spent a few hours setting up the heart-lung machine and supervising the last part of the perfusate filtering while most of the team slept. Russ and I spent the night watchdogging the filtering (the tubing likes to leak if you increase the pressure too much) and assisting Jerry.
At about 7:00 AM the sleepers were called in and the surgical team—consisting of Jerry, Thomas Munson, M.D., and Arthur—scrubbed in while the patient was prepped and the rest of the team asked for straight IV infusions of 50% caffeine solution (but had to settle for coffee instead). Somebody mumbled "happy new year," I'm not sure who.
The surgery in preparation for perfusion took about one and a half hours. Mike made a burr hole in the skull, which disclosed that blood washout with Viaspan was good; much better than expected considering the DIC. As cryoprotective perfusion proceeded she developed some brain swelling and the microscopic clots from the Disseminated Intravascular Coagulation caused very patchy perfusion in her tissues. Nevertheless, her terminal venous glycerol concentration was measured at 3.98 M, a very respectable number considering her adverse pre-deanimation medical complications. After the perfusion and the closing procedures were completed, the final preparations begin cool-down were completed and we prepared to transfer her into the silicone oil bath for gradual cooling to -79C.
In the heat of surgery. Photo: Saul Kent.
Carlos and Ralph monitor the cooldown to dry ice temperature. Photo: Saul Kent.
The transfer (taking place a little after noon) went very well. We placed the patient on to a specially fabricated stretcher of tubular aluminum and expanded aluminum metal devised by Mike Darwin and constructed by Hugh to allow the silicone oil—which is circulated by a pump—to easily flow beneath the patient. That done, the patient's temperature was lowered to -79C at a slow and controlled rate. A new cooling protocol was used on this patient for the first time, and this resulted in far more effective and rapid temperature descent during the entire procedure. This task fell to Dr. Mike Perry, who endured nearly 24 additional hours without sleep.
This is not to say that there were not other tasks in need of doing. We had to C-L-E-A-N U-P. While most of the team departed for their respective and (for some) distant homes or jobs (yes a couple people actually went into to work at their regular jobs after leaving Alcor), a few of us (Mike, Hugh, Jerry, Mark, myself, am I missing anyone?) remained to restore the facility to some semblance of order and decorum. Things came out of overdrive at last; the adrenalin wells ran dry.
I think that the cryonic suspension of A-1268 went about as well as it could have, which was in fact rather well. The ischemic insult time was an artifact of the medical red tape (despite the unprecedented cooperation), rather than our response time (which was good) or the delay in Jerry's arrival (which really didn't interfere at all).
The transfer to LN2, a few days later, was relatively smooth and uneventful. This was the first time that we used the new Alcor pod system and the new pod performed well. Many of the bugs we have observed with competing organizations' pod systems were missing from the unit Hugh had fabricated (our thanks to our competitors for the reservoir of experience). The fastener system Hugh developed allowed rapid, reliable closure of the pod and a reliable rapidly applied system of immobilizing and protecting the patient within it; two major problems with the other systems we've observed. Cooling to liquid nitrogen temperature was uneventful and was completed in a little over 24 hours.
Currently, the patient rests in a dual patient storage dewar. However, she will soon be transferred to a new Bigfoot unit.
Another cryonaut joins the ranks of the hopeful.
Coming out of the silicone oil bath. Photo: Steve Harris.
Preparing to close off the pod. Photo: Steve Harris.
Cover of Cryonics, March 1991: Patient A-1268's pod is readied for transfer to a dewar for vapor cooling. Standing (L-R): Jerry Leaf, Ralph Whelan. Crouching (L-R): Carlos Mondragon, Max More, Arthur McCombs, Mike Darwin. Photo: Steve Harris.