From Cryonics, June, 1993
Easter Sunday (April 11th), a day usually associated with the death and resurrection of a prominent religious figure, saw the deanimation of Alcor member A-1399, a man who may now have one of the better chances at "resurrection" of the cryonics patient population. The suspension of "Edward Davis" was significant for more than one reason: it was Alcor's first suspension in over eight months to require stand-by, transport, and cryoprotective perfusion; it was our first ever without the skills of either Jerry Leaf or Michael Darwin; and it was our first opportunity to test an unproven emergency response capability, and an equally unproven Suspension Team Leader.
It's difficult for me to find a place to begin. Part of my initial speechlessness stems from my desire to accurately convey the events of this suspension and its four day stand-by in conjunction with the emotions that prevailed, everything from the constant nervousness of inexperience and indecision, to the quiet swell of triumph felt when we realized that we'd done it, despite our insecurities.
To begin at the beginning, Edward called Alcor for information a year ago. After receiving our information, Edward followed up his call with a heartfelt letter which thanked us for simply existing and doing business. His letter was accompanied by a completed application, the sign-up initiation fee and the sad news that Edward had AIDS and lymphoma and suspected that he would be needing our services relatively soon. Doctors gave him 24 months, best case. Nine months, worst. Splitting the difference, Edward's suspension occurred just thirteen months after his diagnosis.
We had received sporadic reports from Edward during the progression of his illness. In December, he'd spoken with his oncologist about his cryonics arrangements, and his oncologist was willing to help ensure that things proceeded smoothly. Little did we know the scope of this doctor's "help." When we arrived at the hospital in response to Edward's calls, we were surprised to find that the oncologist had already discussed Edward's case with the hospital administrators, and had provided them with erroneous information about Alcor's procedures and requirements. It is conceivable that this misinformation was a contributing factor to the ultimate level of cooperation we received from the hospital. Some of the statements attributed to the oncologist would have made me nervous, too. (S/He told them that because Edward was a neurosuspension patient, we would have to remove his head before we left the hospital.)
We were aware that Edward had entered the hospital for treatment during the first week of April, and that he wasn't optimistic about his chances. Earlier this year, Keith Henson and Naomi Reynolds, of the Northern California Transport Team, had spent some time at Edward's condominium, discussing the logistics of performing a transport from his second-story apartment. Although the logistics were less than ideal, we were willing to work around the nasty staircase, but emphasized that carrying an 800-pound gurney up and down a narrow flight of stairs with a patient inside was a very risky maneuver for the patient, our equipment, and the team members.
Our concerns about the staircase at his condominium turned out to be unnecessary, as Edward later decided to remain in the hospital. He felt that remaining at home under the care of a hospice service would be too much of a hardship on his family. Edward was being cared for by his lover and several friends. His brother had flown in from the East Coast, and his sister was due in a few days. During the time following his admission to the hospital, we received several calls from Edward's brother, "Charles." Charles asked numerous questions about cryonics, stating that he wasn't interested for himself, but that he wanted to ensure that his brother was going to get the best possible cryonic suspension available.
Unfortunately, Charles had to return home on April 8th. Edward wasn't left without family however, since his sister "Anne" had arrived a couple of days earlier, and she wouldn't be leaving. She echoed Charles' attitude with respect to cryonics and her brother's impending suspension. Anne is a critical care nurse, so we were very happy to have her constantly watching over her brother's condition. Her expertise in dealing with critically ill patients afforded us some reassurance that Edward's condition wouldn't deteriorate without Alcor hearing about it. Based on Anne's assessment that Edward probably wouldn't last through the next night (April 8th), the ambulance was deployed on the evening of April 7th. Scant hours before the sun was due to rise, Hugh, Steve Bridge, and I arrived at a much appreciated resting point after a long, dark drive: Keith Henson's home. We stayed long enough to catch a few hours sleep and a shower, and to get an update on the patient's condition before continuing on to the hospital.
Our arrival at the hospital wasn't particularly well-timed, as far as making administrative arrangements were concerned; we arrived in the early afternoon of the Thursday preceding a major religious holiday weekend — Good Friday and Easter Sunday, to be more specific. Administrators like to take holidays off. Arriving on Thursday afternoon left us with little time to locate and interact with the people making the decisions regarding this impending cryonic suspension.
When we arrived at the hospital and began interfacing with the staff, our first contact was with Anne and a hospital social worker, who had no real authority, but who knew some of the right people. The social worker introduced us to the head nurse. Steve Bridge and I then sat down with Anne, the social worker, and the head nurse to explain our procedures and to establish a common ground for determining the level of cooperation we were going to receive from the hospital. Our requests were relayed (one example of on-duty personnel tracking down critical off-duty personnel for decision-making) to the Director of Administration. While we were engaged in these conversations, it was looking unlikely that Edward would survive the night, according to the hospital staff and Anne. Because of this, we were well-motivated to resolve the administrative issues as quickly as possible.
The head nurse returned with the verdict: Hospital policy dictated that we were not authorized to do anything to the patient on the premises. No CPR, no medications, nothing. Further meetings, later that day and the next, proved fruitless. A concession we were able to get was that our special "gurney" could be brought into the hospital and stored across from the patient's room. With that, we brought in the Mobile Advanced Life Support System (MALSS) and several coolers full of ice and placed them in a room directly opposite Edward's. By bringing the ice into the hospital, we were technically defying the hospital's policy; however, none of the hospital staff challenged our ice, and we didn't quite get around to bringing it up ourselves. Our team, now consisting of Naomi Reynolds, Keith Henson, Leonard Zubkoff, Joe Tennant, Hugh Hixon, Steve Bridge, and myself, set up shop in a lounge down the hall and began our wait.
Finding a place to park the ambulance was a challenge, as the hospital was located between streets filled with parking meters and numerous tow-away zones. A nearby paint supply store allowed us to put the ambulance in their parking lot until we completed the suspension. Still, that was only the ambulance, and the team members accumulated several hours of driving time by simply moving their cars between various tow-away zones.
While we were attempting to arrange things with the hospital, Naomi was working on another complication. The mortuary with which we'd contracted for prep room space and removal services had fourteen steps leading down to their prep room. No elevator and no ramp. As with the stairs at Edward's condo, we were reluctant to commit ourselves to any logistics which would require carrying an 800-pound MALSS (with patient) up and down any flights of stairs.
Our dilemma was resolved when we discovered that the mortuary had a garage. Hugh and Steve had driven to the mortuary to discuss the transport preparations with the mortician when they noticed the garage and asked if the mortician would lease garage space instead of the prep room. He would and did, and he even reduced the rental charges. After all, it was a garage that we were renting. Edward Davis became the second Alcor patient whose washout was performed in a garage turned-field-operating-room. (Patient A-1260 was the first.)
On the night of April 8th, Edward was placed on oxygen as a comfort measure to augment the morphine he'd been receiving. He was exhibiting many agonal signs (including air-hunger), and Anne expressed the opinion that Edward's death might occur within hours. The hospital requirements demanded that we have a state-licensed mortician sign the regulatory transfer and transport documents, despite Alcor's (as an organization) legal authorization to execute this paperwork in order to receive and transport our patients. To minimize the time it would take us to clear the hospital bureaucracy after pronouncement, we contracted with the mortician to sit the stand-by with us. At 3:30 am on April 9th, the mortician was called in to join in the wait. Naturally, his arrival was the impetus Edward needed to hang on.
That day (Friday), Steve continued to lobby for better cooperation from the hospital. He and I later met with an ad ministrative assistant and provided her with copies of our standard legal documents, and copies of the California injunction which states that Alcor has the right to put a pronounced patient on the heart-lung resuscitator (HLR) in the hospital. Not even this judgment was sufficient to sway the Director of Administration, to whom copies were relayed, and neither was the assurance of written, comprehensive releases of liability for the hospital and its staff. The administrator stood her shaky ground of "hospital policy," and it was up to Steve and myself to decide whether legal intervention was prudent in this situation. Although the staff members with whom we were dealing were courteous, they were very closed-mouthed, which complicated the situation. They refused to supply us with the names of the hospital's legal council, or give us direct access to the administrator who was reportedly making all of the decisions.
Steve discussed the matter with other Board members, including Carlos Mondragon, who has extensive experience in dealing with hospital bureaucrats. Together they concluded that calling in the attorneys would probably compromise the suspension more than just abiding by the restrictions imposed by the hospital. The final, compromised list of do's and don'ts: we could keep the MALSS very near the patient; we could pack him in ice after pronouncement; our patient would receive a prompt pronouncement (within a few minutes); hospital staff would leave all lines (including an IV) in the patient; the ambulance could use the service entrance for loading; the team could wait in a lounge on the same floor; the team members could not administer any medications on the hospital premises; and we were not allowed to provide cardiac support in the hospital.
By this time, Edward's condition appeared stable, so Keith located a nearby motel, and some of us went to get some rest and a shower. The mortician had been sent home even earlier. For the next 36 hours or so, Edward's condition remained stable. On Saturday (April 10th), Anne admitted to having given up predicting when pronouncement was likely to occur. Despite her nursing background, the reality of Edward's survival was consistently disproving her professional assessments of his condition. I explained to her that this resistance to death had been the case for every patient transport I've participated in. A common thread in cryonicists appears to be stubbornness in hanging on to life. Some of the nurses had even expressed the opinion that Edward could last for another week or two, in his (then) current condition. They'd seen it before: many individuals seem to exhibit strong attachment to life as it leaves them.
As we later discovered, the time we spent waiting around might have been used more productively. While I knew how the ambulance was stocked and where the supplies and equipment were located, Hugh was the only other team member who was familiar with its organization. Our time would have been well spent acquainting the team with the ambulance, the transport procedures, and each individual's specific role. Also, Steve should have been more familiar with the transport procedures, as in my absence he would be expected to lead the team. All of this is, of course, a fine example of the clarity of hindsight. Next time, we will do better.
At 4:00pm on April 11th, Naomi and I went to get some sleep at the hotel. A few hours later, a nurse pointed out to Steve that Edward's right foot was mottled and blue. This is an indication of very poor circulation, and usually a reliable sign of impending death. At this point, Steve or Hugh should have called the motel to waken Naomi and myself. Just to reiterate, proper briefing of what danger signs to expect and under what circumstances to have the entire team assembled would have been beneficial in this case. It wasn't until I was reading Steve's typed notes from the suspension, a full three weeks after the transport, that I discovered the extent of the cyanosis which the nurse, Steve, and Hugh had observed. Had I been informed when the nurse discovered the foot, Naomi and I would have been present at pronouncement.
Naomi and I had planned to return to the hospital at 10:00pm to relieve Steve and Hugh. At 8:55pm I was about to step into the shower when my pager sounded, indicating that Edward had deanimated. (We have a pre-arranged set of codes for the pagers which indicate the nature and urgency level of any page.) Naomi and I rushed to the hospital and arrived twelve minutes after being notified of Edward's deanimation. When we got there, we were able to transfer Edward to the MALSS and pack him in ice. At the same time that Edward was being loaded for transport, the mortician was completing the necessary transfer and transport documents. We were thus able to leave the hospital almost immediately upon completing the transfer to the MALSS. Hugh had brought the ambulance to the loading area and set the lift gate for a quick-load and departure.
Those team members who hadn't been near the hospital at pronouncement were dispatched directly to the mortuary. Keith was on his way, having returned home for a brief while. Joe Tennant had also been sent home, and he too responded immediately. Leonard had remained at the hospital and assisted with moving the patient. Once Edward was out of the hospital doors, Leonard started the Heart-Lung Resuscitator and began administering oxygen to the patient through manual-bagging. (This was our first opportunity to initiate these transport procedures, given our arrangements with the hospital.) As soon as the patient was secured inside the ambulance, I performed a tracheotomy to open a secure airway to allow for mechanically ventilating the patient with the HLR. This was the first use of this technique in a field situation, and it proved much more efficient than even my practice attempts on canines had indicated. In about thirty seconds, we had our airway. Placing any other sort of airway would have taken me, or any other team member, several minutes at least, if it could have been placed at all. Placing airways in patients is a difficult skill to master if you don't have many patients to practice on. By performing a tracheotomy, I was able to avert potentially longer ischemic episodes. The tracheotomy proved its worth in our protocol almost immediately. It's simple, effective, and fast.
My nervousness was evidenced when I tried to place an end-tidal CO2 detector between the oxygen line and the tracheotomy tube. I could not make the detector fit. After the suspension, I went back and tried to connect them, and found that they fit well. Logic had told me, during the transport, that they should fit given their standardization, but my hands were uncooperative. I was wasting precious time, and left the detector out of the loop. In the future, I'll be sure to calm down a bit if I find that things aren't fitting.
While I was occupied with the airway, Naomi was administering the medications with Leonard's assistance, Steve was taking notes, and Hugh was driving. Despite hilly streets which made us grab the sides of the MALSS in order to remain upright as we worked frantically, we managed to administer all of the medications (or at least begin the administration, in the case of large volume medications) and even place a rectal temperature probe. We arrived at the mortuary in what felt like no time at all, but was actually a full fourteen minutes.
Upon our arrival, we muscled the equipment which was being stored at the mortuary into position, including an operating room light we'd brought from Riverside. For once, adequate lighting was available for surgery. At 10:15pm I was able to begin the femoral cutdown on the right side. Keith, who was to be my assistant, hadn't yet arrived, so I began the surgery without him. Joe Tennant arrived and began photographing the setup. Hugh began setting up the perfusion circuit. Naomi, Leonard, and Steve were still manning their respective stations of medications, HLR/oxygen support, and documentation.
Shortly after I began the surgery, Keith arrived and began assisting. Conversation, even between Keith and myself across the top of the MALSS, was strained. When in operation, the HLR emits loud noises, which alone may successfully prevent conversation. Face shields and face masks were also not entirely conducive to the propagation of sound waves. In any case, it was very difficult to hear. We've encountered this before, however, and found the AIDS precautions (specifically, the face shields) added the benefit of a layer of personal protection far out-weighing the sound-propagation inadequacies. The femoral cutdown proceeded smoothly until it came time to place the venous cannula. When we attempted to place the cannula, we found a large clot blocking our passage. I was still able to drive the cannula through the clot and get flow, without performing a cutdown on the other side. There were no other significant developments during the surgery and the connection of the bypass circuit.
Keith arrives to assist with the surgery.
All hands occupied: Naomi's with preparing the washout solution. Hugh's with setting up the perfusion circuit. And the surgery also progressing.
Despite the inconvenience of having to repeat every instruction or comment for the notes two or three times, Edward was on bypass one hour and ten minutes after the initial surgical incision, a time which compares favorably to the recent average of one hour and nineteen minutes to begin the bypass (times compiled from the last four transports requiring field washout).
We washed out the patient's blood and replaced it with Viaspan (an organ preservation solution). By 1:45am, we had completed the washout, secured the patient and equipment in the ambulance for the drive to Riverside, and tidied up the garage so that it was cleaner than we'd found it upon our arrival.
One complication which may have affected the perfusion involved was a result of (surprise!) bleach. Bleach has been shown to neutralize the AIDS virus within thirty seconds of undiluted exposure. As a result, we have incorporated it into our AIDS precautions. Chlorine bleach was poured into the ice bath of the MALSS, because many excretions, including blood from the surgery, flow into the bath. Unfortunately, much more bleach was poured into the bath than was necessary to chlorinate 5-10 gallons of water. The ice-water from the MALSS is used in the perfusion circuit to provide cooling, and the massive amount of bleach may have corroded the heat exchanger, causing it to rust. Corrosion of the heat exchanger/ oxygenator might then have contaminated the patient circuitry with cooling water. We are still awaiting test results which will give us the information necessary to determine the extent of the damage (if any). Irrespective of what the test results are, this sort of damage must be prevented, and without compromising the health/ safety precautions for the team members. In the future, the correct amount of bleach crystals will be pre-packaged.
Hugh drove the ambulance, while I monitored the patient and maintained in termittent low-flow perfusion for the next nine hours. Steve and Naomi drove in Steve's car as our "chase" vehicle. The other transport team members went home to recuperate, i.e., sleep.
Applications are currently being accepted for roles in "Alcor: The Movie."
During the drive to Riverside, we were out of contact with the lab for about seven hours of the nine hour drive. This was the result of problems with the cellular phone, which made it inoperable outside of a very limited southern California range. The phone company had neglected to activate a switch in their offices which would allow us greater range. Additionally, the batteries in my country-wide pager failed, and the replacement batteries failed shortly thereafter. Ralph Whelan, who'd been left to prepare the facility for the cryoprotective perfusion, found himself unable to contact us with his questions about some of the preparations which were beyond his experience (tasks which Hugh and I would usually perform). However, Ralph wasn't without things to do, and all of the preparations Ralph had the knowledge to address were completed before our arrival.
When we were about two hours away from the facility, Steve found that the cellular phone was finally within range and called the lab. Ralph had assembled the suspension team, and the surgeon was scheduled to arrive within an hour of the patient. Many of the pre-suspension tasks were done, and there were just a few tasks (like mixing the perfusate) that remained. (Based on recent recommendations made by Dr. Steve Harris and Mike Darwin about some unexpected physiological properties of sucrose, we elected to use mannitol rather than sucrose as the osmotic agent for this cryoprotective perfusion.) Ralph had used my standard operating procedures and checklists while preparing the facility, and in some cases, was able to determine that certain sections of these procedures must be re-written for clarity.
Recently certified team members participated in their first cryonic suspension. Brian Murdock, Regina Pancake, and Jay Skeer (the three new technicians) joined Derek Ryan, Trudy Pizer, Nancy McEachern, Mike Perry, Thomas Munson, and Bill Seidel for the suspension. Everyone, except Trudy and Nancy, was already at the facility when we arrived with the patient. Brian sat in the ambulance and monitored the patient during the final preparations. He maintained the perfusion cycle that had been implemented in Northern California, while awaiting the transfer of the patient inside for the open-heart surgery. With the able assistance of the remaining volunteers and staff, the open-heart surgery was begun within a few hours of our arrival.
Dr. McEachern began the surgery, with me assisting and Naomi handing off instruments, while maintaining the order of the surgical trays. Ralph was the perfusionist, and he'd drafted Jay to assist him. Regina took notes; Bill videotaped the proceedings. Once the surgery began, Trudy, Derek, and Brian circulated throughout the operating room, completing any non-sterile tasks that scrubbed-in surgical personnel needed done. Mike Perry ran the computer program which would provide us with projected efficacy and cryoprotectant administration information about the perfusion.
During the surgery, a few significant things happened. For the first time ever, we tied off the pulmonary artery, taking the lungs out of the perfusion loop, and thereby creating a more efficient circuit. Also, Edward had a paper-thin right auricle, which made placing the purse-string sutures required for cannulation difficult, but we were careful, and placing the sutures was uneventful. At 4:51pm, we began the cryoprotective perfusion. A few minutes later, we stopped the perfusion, upon finding that the clamp on the descending aorta was no longer in position, for reasons which still are unclear. Luckily, we had tied the descending aorta with suture (in addition to clamping it) and were able to stop the leakage quickly and restore the clamp.
Brewing bourbon? No, just a cryoprotectant cocktail.
Dr. McEachern preparing to connect the perfusion circuitry.
Naomi and Tanya assist Dr. McEachern with the open heart surgery. Brian Murdock observes closely.
Double-checking the connections and flow patterns before beginning the cryoprotective perfusion.
Hugh had prepared a burr hole, through which we were able to view the brain for signs of edema. What we saw was heartening: The brain not only receded from the opening (a good sign of cryoprotectants removing water from the system and causing shrinkage), it receded more than in any other patient I've ever seen — nearly 25 millimeters by the end of the perfusion!
As we neared a molar concentration of glycerol equivalent to the previous best case (Jim Glennie, 6.0M), we began to get nervous about the potential toxicity of higher glycerol concentration levels. When I called a cryobiologist for advice, I received better news than I had expected. He was momentarily astounded at our achievement of these glycerol concentrations and was elated at our potential for even higher concentrations! During this conversation, the cryobiologist not only confirmed the efficacy of the perfusion (based on his pioneering work in the field of vitrification), but even encouraged us to take the glycerol concentration as high as it would go. He indicated that toxicity damage was outweighed by the benefits of the cellular protection resulting from higher concentrations. This encouragement to aim for the moon was later amended somewhat, and we were advised to stop at 8.0 Molar levels, just in case. We achieved equilibrated venous and arterial concentrations equal to 7.9M, which calculates to only 14% of the water in the brain being converted to ice! A record!
We took samples of the spinal cord for later analysis, with the expectation that they will give us a better idea of how well the brain perfused. These samples will be good indicators, as nerves typically perfuse poorly, when compared to other organs. If we are able to determine the glycerol concentration in the spinal column, we will know that the brain reached that concentration or better.
The subsequent cephalic isolation and cooling proceeded without incident, and we were able to test the new automated cool-down and data-collection system developed and implemented by Scott Herman, Hugh Hixon, Keith Henson, and Mike Perry. It performed admirably, and for once, the only cool-down tasks that Mike had to do were monitoring the system for failure and adding dry ice at appropriate intervals. Cooling to liquid nitrogen temperature and placement into permanent storage were completed by April 25th.
A closer look at the new automated neuro-cooler.
One of the tasks involved in a cryonic suspension which rarely has been been publicly addressed is the cleaning of the facility, after the cryoprotective perfusion. This generally has been done by exhausted team members who want little more than to go home and sleep for a few weeks. When these tired individuals must perform the thousand-and-one tasks which are necessary to restore the suspension capability, we risk something critical being overlooked. Again with this suspension, the exhausted Transport and Suspension Team Members were called upon to clean up. We hope to address this by lining up a fresh and rested "clean-up team" to take over, next time.
In the past, it has taken as long as a week to fully re-establish our suspension capability. Far too long! That interval has already been reduced with overstocking the ambulance and remote kits with consumables (like medications), however, on a limited budget, there are restrictions on how much we can afford in providing redundancy. Still, many of the preparations can be done by volunteers, and in the future, volunteers will be solicited for this less-glorious aspect of cryonics.
Returning to the specific suspension at hand, Edward Davis was perfused to nearly the glycerol concentrations required for complete vitrification (9.3M). Achieving these levels in the future is well within our capabilities.
With this suspension, Alcor's cryonic suspension capability has been clearly demonstrated. In some respects, it has even been shown to be improved beyond previous levels. During this suspension, the atmosphere in the field and in the operating room was much less stressful than for any other I've experienced. This doesn't indicate inattentiveness, it indicates a reduction in the performance-limiting pressures. And there was an increase in the development of mutual cooperation, respect, and self-confidence, on both individual and group levels. The team is inexperienced, with some exceptions; however, that inexperience is not hindering the process of performing and improving the quality of cryonic suspensions for Alcor members. Improvements to the suspension procedures, as the result of the imperfections evidenced by this case, are well underway.
This suspension was not perfect. However, the deficiencies are specific and reparable: we need more technicians familiar with the layout of the ambulance; we need further redundancy in all positions, far beyond the little we have now; we must solicit volunteers to assist with the post-suspension recovery period; we must adhere to our infectious disease protocol more stringently. The good news is that primary improvements now lie in the direction of training, acquiring more knowledgeable personnel, and improving the mechanics and physiologic understanding of a cryoprotective perfusion. Much of this training requires on-going exposure to cryonic suspensions and cannot be obtained except through trials-by-fire. However, having a team with the confidence to succeed and the desire to do what is best for the patient is an excellent start. The rest will come.
I wish to thank everyone who participated in this suspension. Your assistance, enthusiasm, and confidence was (and is) inspiring: Stephen Bridge, Keith Henson, Hugh Hixon, Dr. Nancy McEachern, Dr. Thomas Munson, Brian Murdock, Regina Pancake, Dr. Michael Perry, Trudy Pizer, Naomi Reynolds, Derek Ryan, Bill Seidel, Jay Skeer, Joe Tennant, Ralph Whelan, and Leonard Zubko ff. And come the next suspension: expect a call.