From Cryonics, August 1992
by Mike Darwin
Photos by Carlos Mondragon
"Jack Arbeitzin" [a pseudonym] is a 64-year-old long-time Alcor member whose involvement dates back to the late 1970's when he worked with Jerry Leaf and others in helping to promote and facilitate cryonics research. He had retired several years ago and relocated to the greater San Diego area where he was not as active in cryonics, but still kept in touch.
A few weeks prior to his suspension we were notified that Jack had terminal, metastatic colon cancer and that he had been given only a few weeks to live. An assessment team was sent down from Alcor to visit with Jack and evaluate his condition.
On June 16th we received a call from Jack's wife that his conditioned had deteriorated sharply and that he might die at any moment. Fortunately most of the transport team was at the lab and the Alcor ambulance rolled for Jack's home within about 30 minutes of receiving the call. When the team arrived Jack's condition was found to have stabilized (in no small measure due to vigorous action taken by Jack's wife Jolene, who is also a nurse).
After assessing the situation it was determined that Alcor staff would remain on site and standing by for the patient. After the second day of standby a decision was made to post staff at a nearby motel since Jack's home did not have extra sleeping quarters and was, additionally, filled with relatives who were assisting Jolene with Jack's care. It should also be pointed out that Jack's family were not cryonicists and we were intruding on their privacy during a very difficult time. Despite this, they were very supportive of us and welcomed the transport team into their home.
Since Jack's condition, while grave, was more or less stable, it was anticipated that Jack would "shock" before experiencing cardiac arrest, giving us plenty of time to arrive on site from the motel, which was about a 4-minute drive from Jack and Jolene's home. With Jolene being a nurse and Jack's vital signs being monitored and recorded frequently, it was felt there was little risk in this maneuver. Also, there were others in the home who were available to sit up with Jack and provide relief for Jolene. Consequently, we again decided to pull back to the local motel and await a call notifying us of any change in Jack's condition. Additionally, several staff members were sent back to Alcor so that they could continue to work productively.
On June 18th the standby team received a call from Jolene alerting us of another crisis. Additional Alcor staffers were called in; however, Jack stabilized again and that evening the team left the home to standby at two local motels (the first one being full and second one at which a room was found being about 12 minutes away from the home) with Jolene and others in the household standing watch.
At 6:15 AM on the 19th, Jolene's sister called the transport team notified them that the patient had experienced an unwitnessed cardiac arrest sometime during the preceding 30-minute interval when Jolene had inadvertently dozed off to sleep. The first part of the team, consisting of Naomi Reynolds and myself arrived approximately 10 minutes after receiving the call. Jolene was doing CPR and Naomi and I quickly took over this task and awaited the hospice's nurse's arrival so that Jack could be pronounced and the administration of transport medications be started. Within approximately five minutes of the arrival of Naomi and myself, the second part of the team arrived consisting of Carlos Mondragon, Paul Wakfer, and Tanya Jones. Paul took over chest compressions and Naomi continued ventilation while Carlos, Tanya, and I moved the MALSS into position and got the medications set up to administer pending arrival of the hospice nurse.
At 6:50 AM the hospice nurse arrived and pronounced Jack, and he was moved into the MALSS, placed on Thumper support, covered in crushed ice, and given transport medications. The latter required that a cutdown be performed on the external jugular vein since the low-flow IV had infiltrated (Jack had no central venous catheter in place and Jolene had been giving him IV glucose through a small needle in a very small and fragile vein at his wrist). This delayed the start of transport medication until 7:07 AM.
A further complication occurred when the venous reservoir on the bypass circuit was found to have been damaged (presumably as a result of hastily moving it into the home from the ambulance) and going on bypass in the home was deemed impossible. Consequently, Jack was moved on Thumper support to Alcor with the drive taking one hour and 13 minutes. Unfortunately, due to Jack's severe pulmonary edema (fluid accumulation in the lungs), he did not oxygenate during Thumper support. The only good thing in this was that Jack's temperature had dropped by approximately 17°C to 20.4°C by the time he arrived at Alcor.
Jack was then moved into the operating room and connected to the heart-lung machine circuit of the Mobile Advanced Life Support System (MALSS). Surgery to connect Jack to the MALSS was complicated by heavy tumor involvement over and around the femoral vessels, slowing the pace of surgery and forcing me to switch from Jack's left to right groin. The tumor had apparently spread from adjacent lymph nodes.
The MALSS uses a blood pump and heat exchanger-oxygenator to rapidly cool the patient to a few degrees above freezing while maintaining delivery of oxygen and nutrients to the tissues. By 11:41 blood washout was completed and continuous perfusion with Viaspan organ preservation solution was commenced. Viaspan perfusion was continued intermittently until 4:00 P.M. when chest surgery was begun to connect Jack to the heart-lung machine in the Alcor operating room and begin the introduction of cryoprotectant.
Cryoprotective perfusion was completed at 7:35 P.M. with a terminal concentration of about 5M glycerol having been reached in the venous effluent. To what extent cryoprotection of Jack's brain was achieved is unknown since he experienced some brain swelling during the course of perfusion. However this swelling was modest compared to that observed in some other cases. By 8:35 P.M. Jack was transferred to the Silicone oil bath for cooling to dry ice temperature (-79°C).
Still in the preparation stage, Dan Spitzer (left) and Ralph Whelan — perfusionists for this case — discuss set-up of Heart-Lung Machine.
Mike Darwin and Carlos Mondragon perform the femoral cutdown necessary for the introduction of Viaspan, an organ preservation solution.
Mike Darwin (left), Keith Henson, and Paul Wakfer (obscured) check an IV line, shortly after completion of the femoral cutdown.
Arel Lucas, by far one of Alcor's most dedicated and competent volunteers, monitors the femoral bypass circuit.
Mike Perry (left) — Alcor's Patient Caretaker, Computer Scientist, and Resident Historian — calculates the settings critical to a proper glycerolization ramp, with input from Ralph Whelan.
Hugh Hixon and Keith Henson — another of Alcor's stalwart volunteers— perform the perfusate analyses essential to ongoing revision of the perfusate ramp rate.
Clearly the fact that this patient experienced an unwitnessed cardiac arrest resulting in many minutes of ischemia and inadequate perfusion is completely unacceptable. I made a serious error in judgment when I sent the team to local motels to rest for the night. At least one and preferably two skilled people should have been left standing by — one of them in the bedroom with Jack and Jolene.
The use of cardiac monitors is not desirable in slowly dying patients because once their use is begun they cannot be disconnected without a physician's order. The downside to this is that very often the nervous system of the heart will produce an EKG even though the heart is no longer beating or pumping blood. This is known as electro-mechanical disassociation (EMD). Unfortunately, under California law if a cardiac monitor is in place the patient cannot be pronounced until the monitor shows no coherent EKG activity even if only EMD is present.
The alternative of having an Alcor team member sit in the bedroom of a dying patient "invading" the last moments of family with the patient is also often not tenable. Jack and Jolene were very close and Jolene would lie next to Jack holding him. In such a setting it is in questionable taste for Alcor staff to be lurking like vultures in a chair nearby. It is also quite possible that the Alcor staffer could either fall asleep or fail to notice that the patient has experienced cardiac arrest. This is in part why hospital patients are monitored in the ICU even when they are extremely unstable and have a one-on-one nurse. A moment's inattention is all it takes for someone to slip away.
So what is the solution to this problem? What can we do to insure that this situation never happens again? First, Alcor should quickly acquire a pulse oximeter. Pulse oximeters are noninvasive devices which have a sensor which can be slipped onto an ear lobe or finger tip to monitor the degree of blood oxygenation (measured as the mixed arterial and venous oxygen saturation). As the patient becomes agonal (declines toward death), blood oxygen saturation deteriorates, and when it drops below 80% the patient generally loses consciousness. Cardiac arrest has usually occurred by the time the patient's oxygen saturation has dropped to 60%. Current pulse oximeters are quite sophisticated devices which have alarm capability and which can be preset to alarm at any predetermined blood oxygen saturation level. Usually a slowly dying patient's "sats" will start to decline in a steady downward trend hours before cardiac arrest occurs.
Had we had a pulse oximeter on Jack that evening we probably never would have left, since his blood gases were almost certainly deteriorating due to his developing pulmonary edema even then (although we had no way of telling that this was so). When the transport team arrived, Jack was in fulminating pulmonary edema and his lungs had "blown:" they had massively filled with fluid which was welling up out of his mouth as his wife performed CPR. This relatively "sudden" filling of the air space in his lungs was the proximate cause of cardiac arrest. Before the lungs "blow," and the air spaces fill with fluid, pulmonary edema can be notoriously difficult to diagnose. A chest X-ray is the only sure way. Just a few hours before Jack arrested, Mike Darwin had consulted a physician on-call to Alcor about Jack's condition and had specifically discussed the possibility of pulmonary edema. For a variety of reasons this diagnosis was not considered probable and this was a material factor in standing down from a full-tilt standby. (Another consideration was the need to have rested staff so that when cardiac arrest did occur the transport team would not have been reduced to a crew of sleep-deprived zombies.)
Achieving good oxygenation during transport of a patient with fulminating pulmonary edema is almost impossible, and the presence of a pulse oximeter would not have prevented this from happening. But it would have shaved off quite a few minutes of ischemic and hypoxic time before we were able to start cooling and medicating Jack. It also would have allowed us to carefully move the MALSS into the crowded bedroom, set up the perfusion circuit and avoid damaging the venous reservoir, thus allowing us to go on MALSS support at least an hour sooner and perhaps several hours sooner than we did.
Instrumentation in an of itself is never the complete answer to a problem. In the future, even with the use of pulse oximetery, it will be Alcor policy to leave a staff member in the home (where possible) to respond to alarms and to monitor the patient's condition. The problems with this patient's suspension have provided a costly lesson. We must always put a monitor of some kind on Alcor members during critical illness, and we must, where possible, keep at least a core of skilled quick-response staff on-site to deal with any unexpected changes in the patient's condition.