From Cryonics, November 1988

THE CRYONIC SUSPENSION OF ALICE BLACK

[Note: At the request of the participants, "Alice Black," "Jim Black" and "Carol Black" are pseudonyms.]

Part I: Initial Stabilization And Transport Of The Patient

By Stephen Bridge

Introduction

So at last I am a "real" cryonicist. I've been part of cryonics for more than eleven years; but for the first time, I can now say I've been part of a suspension. With all of the stories I have heard from Mike Darwin, Jerry Leaf, and others over the years, I was afraid it might be the worst experience of my life. Instead, in many ways, it was one of the best.

If you have never been on a suspension team, and especially if you are new to cryonics, that statement might seem peculiar to you. Someone dies and I'm excited about it? But death is nothing new, certainly not to me. People die every minute, and I went through the deaths of three grand-parents, an uncle, and my mother during a three-year period a decade ago. I could do nothing about them; my favorite people simply disappeared from my life and, as far as I know, from existence. But now the mother of a good friend was near death, and I had part of the responsibility to see that she would be suspended instead of being allowed to disappear. The fact that we were able to accomplish this gives me a deep sense of satisfaction.

Being a cryonicist outside of California is a completely different experience. Here in the Midwest, we have no 5,000 square foot cryonics facility, no ambulance, and no Mobile Advanced Life Support Cart. We also don't have a twelve-person suspension team ready to jump into action. This summer there were just four of us in Indianapolis to take care of each other -- Jim and Carol Black, Angalee Shepherd, and myself. I had the benefit of training as an Emergency Medical Technician (EMT); but they don't spend much time on cryonic suspension techniques in EMT classes. Besides, I'm a librarian by profession and actually use my EMT training very little. But because I had that basic training and because we did have four members within close proximity, Alcor had felt it was important to provide me with a remote standby kit a couple of years ago. We had never worked out time for me to come to California and take the full training course, and Mike Darwin had not been able to come here to give me the training. However, I did have a heart-lung resuscitator (HLR) which I knew how to use, oxygen tanks for it, a medicine kit, and a suitcase full of miscellania. The intent was that in the event of an emergency, I had the materials to take an Alcor member who had been declared legally dead, put that patient on the HLR, put in an IV, administer a range of medications such as heparin (to prevent clotting) and mannitol (to prevent brain swelling and ischemic injury), to pack that patient in ice, and to ship him or her out to Riverside.

A High Risk New Member

During the summer, Jim told me he felt that his mother, Alice, who was 78 years old and in a nursing home with emphysema, was becoming interested in cryonics. When it became clear that Alice was not only interested but very much wanted to be suspended, and that she probably would not live through the winter, Jim and I had to do a lot of scrambling. Funding in cash had to be arranged (insurance companies being understandably reluctant to insure someone with a few weeks or months to live), a will and other documents had to be drawn up and signed while Alice's mental health was still good, other relatives had to be consulted, and her doctor and other people involved had to be told.

None of this was easy, but Jim and Carol are amazingly persistent people and they refused to accept the roadblocks that that were thrown at them. The biggest roadblock came from a relative who appeared to be so upset by the idea of cryonics that he refused to even discuss it with Jim and Carol or with me. After repeated attempts at communication failed, Alice signed a form which gave Jim the sole responsibility of determining her medical care and the disposition of her remains. (I realize that most of us consider suspension to be a continuation of medical care; but the law sees it differently, so we continue to use terms like "remains.")

Getting Cooperation

We were amazed to discover how cooperative Alice's nursing home and physician were. We got some temporary hostility from the head nurse at the nursing home, but her staff were unfailingly helpful. The administrator of the facility tried to help us in many ways, although he did tell us that we could not put an intravenous line into Alice until declaration of death, since the nursing home was not licensed to provide IV therapy. (This restriction caused no problems.) The physician also pledged to aid us in any way legally possible, including coming to the nursing home immediately if clinical death was imminent, and he made sure his office staff and answering service knew to notify him without delay.

We also were fortunate enough to have a cooperating mortician who was located through the persistent efforts of Angalee Shepherd. He agreed to pick up the patient at the nursing home, transport her to his mortuary, let us use his facility for whatever preparations were necessary, and transport her to the airport for a flight to California. He also took care of filing the death certificate, obtaining the necessary transport permits, and making the flight reservation for the insulated transport container. He was paid fairly well for this, but he did not seem to be concerned about the money.

Once the Alcor and other legal paperwork was finalized, Alice began to go downhill rapidly. Her quality of life had been terrible for many months. She was constantly "air hungry" and on supplemental oxygen, she was also confined to bed from painful osteoporosis and arthritis, and she was frequently in agony from post-herpetic neuropathy; an excruciatingly painful complication of shingles. Once her affairs were in order and cryonics arrangement were in place, she quite understandably appeared to have stopped fighting to stay alive. Jim and I got pagers for ourselves and stayed in close contact with Alcor.

Unexpected Help

Up until this point, Jim and I had assumed that we would have to pull this off by ourselves. We were deeply relieved to have Mike tell us that, as long as there was some warning, he and Jerry Leaf had decided to fly to Indianapolis to assist us. If at all possible, they intended to do a blood washout at the mortuary before transport to Riverside for cryoprotective perfusion and freezing. To help with this, Mike sent out a specially insulated shipping case for transporting Alice and six large containers of the necessary equipment and chemicals (Alcor's full remote standby kit).

It was obvious that the suspension would occur within a few weeks at most, and there were still several items to prepare. While Angalee and Carol were locked into tight work schedules, Jim is self-employed and I have a comparatively flexible situation at the library. One bonus of my being open about cryonics for many years is that my co-workers at the library understood the emergency nature of what I was doing and graciously agreed to cover for me when I had to be gone.

Unexpected Reprieve

We found out the hours and prices for bagged ice at various places in town, and made sure we had plenty of cash and change available in case of a middle-of-the-night suspension. We rented three large oxygen cylinders, placing one at the nursing home and two at the mortuary. I spoke to friends who were EMT's in case we needed emergency assistance. We prepared an exact table of medications to be administered after Alcor (meaning Jim and I!) took over patient care. Jim and Carol took turns being with Alice as many hours as possible.

We did not have long to wait. A few days later (Wednesday, October 5), after an injection of demerol (a pain reliever) to help ease unbearable pain and air hunger, Alice's blood pressure dropped to 40/0. Alcor was called, and Mike Darwin and Jerry Leaf left for the airport. By the time they arrived in Indianapolis, Alice had rallied and had regained a tolerable BP, although it was clear to everyone that the end would not be long in coming. She was extremely weak and was refusing all food and fluids.

The Suspension Begins

After assessing the situation, Mike and Jerry got some rest. They spent Thursday at the nursing home making preparations and talking with the physician and nursing home administrator. On Friday morning (October 7), the patient's pressure dropped again, with all indications that cardiac arrest was near. That arrest occurred at approximately 1:25 p.m. and the patient was pronounced by the R.N. at the nursing home.

Mike and Jerry immediately began CPR with a bag-valve mask, and Jim and I began filling ice bags. As soon as we got ice around the patient's head and other vital areas, I relieved Mike on CPR so he could began setting up for the IV, medications, and HLR. The physician was immediately notified and left his office right away, but was unfortunately delayed (we found out later) by a delivery van blocking his parked car. He arrived at 2:05, and asked us to stop CPR while he examined the patient. At 2:08 he declared legal death, and allowed us to restart CPR. (Causes of death were listed as: "1. Respiratory failure; 2. Chronic obstructive pulmonary disease [of which emphysema is a type]; 3. Coronary pulmonade; 4. Tobacco abuse.")

The Heart Lung Resuscitator was applied at 2:12 and the IV line was in place at 2:18. Mike and Jerry immediately began administering THAM (tromethamine) to combat acidosis and heparin to prevent clotting. Desferal, verapamil, mannitol, and potassium chloride were given to reduce ischemic damage to the brain. All medications had been started by 2:23 (the mannitol drip was still in progress), and we began putting things away and preparing to transport the patient.

The mortician had also been called at 1:25; but our actual cooperating mortician had taken the day off, and the mortician who was taking call for him was caught 20 miles away in heavy traffic. He finally arrived about 3:00, at which point the patient was quickly loaded and transported on the 25-minute drive to the mortuary. We arrived at the mortuary about 3:30 and immediately began setting up for the wash-out. Jim went to a nearby ice company for 400 pounds of ice.

The late arrival of the physician and the mortician very likely caused some ischemic damage; but when you are dependent on others, such things are probably unavoidable. At least the patient was cooled rapidly and given cardiopulmonary support the entire time. Another delay could have been avoided if we had one more experienced person to stay with the patient while Jerry and/or Mike could have gone back to the mortuary to mix up the wash-out solution and set up the pump-oxygenator circuit.

Problems: Encountered and Overcome

Some problems with preparation of the perfusate (wash-out solution) and the measurement of the patient's temperature show some of the problems with doing a suspension "on the road." Some hasty packing at Alcor (due to look- alike bottles and sacks) caused some components of the perfusate to be left in Riverside. Fortunately a combination of other chemicals which were brought, along with some items I had in my kit, still allowed us to deliver the proper solution. The only significant difference from the "ideal" was that we were short 30% on the amount of potassium chloride desired. This was made up for by the addition of a liter of Plasmalyte electrolyte solution.

The temperature problem was partly my fault, based on a lack of understanding. We had three telethermometers on hand; but only one of them had working batteries. The instrument which Mike brought from California was found to be "Dead On Arrival" and required an odd size of mercury battery which was available nowhere in the city. The standby thermometer was out of order. We were thus stuck with using an instrument which had been sent along by the Chamberlains some months before but which only registered temperature down to 20øC -- the top of the temperature range we would actually need. Packed with this telethermometer was an odd little blue box, with no instructions. It turned out to be an adapter to allow use of the telethermometer to measure temperatures down to 0øC. So in the middle of preparations at the mortuary I was on the phone to California with Fred Chamberlain, the man who designed the blue box, trying to figure out how it worked.

Once this problem was solved, we were able to start taking pharyngeal (throat) temperature readings on the patient. The first temperature was 12.5°C at 5:28 p.m. By this time the 20 liters of perfusate solution were mixed and in place, the blood pump/oxygenator circuitry was set up, and Jerry Leaf was preparing for surgery. At 5:55, the "femoral cut-down" was started. This procedure consists of making an incision in the groin exposing the femoral artery and vein. A tube is then connected to the artery and to the vein so that a blood pump can take over the patient's circulation and oxygenation. Before entering the patient, the solution passes through an oxygenator to provide oxygen to the cells, and also through a heat exchanger connected to an ice water bath to cool the solution and more rapidly reduce the patient's temperature. The perfusate is pumped through the arteries and veins, washing the blood out of the vessels. The actual perfusion began at 6:43 PM and was completed at 7:03, the patient's temperature having been reduced to 6°C by the end of perfusion.

During this procedure, Jerry Leaf acted as surgeon, with Mike Darwin as surgical assistant. I functioned as "circulator," handing over tools, adjusting the blood pump, and "gophering" as needed. Jim recorded temperature readings and took notes.

Preparation For Air Transport

After completion of perfusion, the incision was closed and the circuitry taken down. As rapidly as possible, the patient was placed in a heavy plastic body bag and lifted into the shipping container. This container consisted of a steel Ziegler case (shipping coffin), placed inside a sealed and painted 1/2" plywood crate lined with styrofoam and fiberglass insulation. By this time, Angalee and her son, David, had arrived to help load the ice bags. About 300 pounds of ice were loaded into Ziploc bags and placed inside the Ziegler case with the patient. An insulating mat was laid over the ice and the lid on the Ziegler case was then sealed with silicone caulk and securely screwed on. The wooden lid to the crate was then screwed down, with the entire operation being completed at about 8:00 p.m. These preparations seemed to have worked extremely well, since by the time the patient arrived at the Alcor facility in Riverside over 14 hours later, only 10% of the ice had melted and her temperature had dropped to 1°C.

After cleaning up and repacking, hunger and exhaustion begin to take their toll. We realized that we had had virtually nothing to eat or drink all day long! It was decided to adjourn for a late night pizza. A day of food deprivation mixed with adrenalin jumpiness and a certain exhausted elation, made that the best pizza I ever remember eating. Then it was off to bed for a brief four hours of sleep.

The only non-stop flight available to transport Alice was at 9:30 the next morning (Saturday). That flight was fully booked for passengers, so we had to put Mike and Jerry on a flight leaving a couple of hours earlier. It made Mike nervous not to be on the same flight with the patient; but it did allow him and Jerry to direct preparations at the Alcor facility before the patient's arrival.

The cooperating mortician had stopped in during the evening to make sure things were going all right and to handle the various permits and airline arrangements. On Saturday, after Mike and Jerry left, the mortician and I transported the patient in the shipping container to the airport. I then waited at the passenger gate to watch the case being loaded on the plane before going home. Our part was over; the rest was up to our comrades in California.

Conclusion, Or The End Of The Beginning

In all of this stress and hectic activity, the four of us have been sincerely grateful for the advice, encouragement, and deep caring offered by Mike, Jerry, and other Alcor personnel. I am proud to be a member of Alcor, proud to have helped with this suspension, and proud to be part of the reality that we are a mutual aid society that really cares about each of its members. This experience has given me even more confidence that my friends in this organization will also be there when I need them, to give me my chance at the future. I really think the world a century from now will be a fascinating place, and I hope Alice will find it to be so. Because I want to be there when she awakens, so I can greet her; "Hello, Alice. Welcome to Wonderland."

Part II: Cryoprotective Perfusion And Cooling

by Mike Darwin

Introduction

On the evening of Tuesday, October 4th, Steve Bridge and I had a short phone conversation about cryonics-related matters. The issue of Mrs. Black's health came up, but was not a major topic for discussion. She was reported to be "doing about the same as before." It had been rough week for us here (what week in recent memory hasn't been!) and we were, as usual, very behind on the magazine. With two potential suspensions staring us in the face I decided to tough it out and simply work through the night to complete the writing job for the front end of the October issue of Cryonics. It was a long night. As I was putting the finishing touches on the last article, the phone rang. It was 6:30 AM PST. It was Steve Bridge: "What are you doing there at this hour?" he said.

"I haven't been home yet, I worked through the night." I replied.

His next words were not what I wanted to hear: "Alice Black is near death. Could you and Jerry please get on a plane for Indiana at once."

Much to my surprise Steve was calm. He informed me that he was on his way to get to the heart-lung resuscitator and other emergency equipment (it was 9:30 AM in Indiana and he was already at work) and get over to the nursing home. Judging from her reported condition, we expected to find Mrs. Black at the mortuary, already in cardiac arrest and in deep hypothermia on the heart-lung resuscitator by the time we arrived.

Fortunately, we were given a respite and allowed the time required to get things better prepared for her transport. Steve has done a fine job of chronicling what happened during Alice's initial stabilization and transport, so I won't cover that ground again.

But I will take some time here to make some observations about the people in Indiana and how things went in general. Now, nearly two months later, I am still trying to absorb the fact that the "very theoretical" Alcor Coordinator Program actually worked. Jerry Leaf and I walked into a practically turnkey situation in Indiana, and that was in no small measure due to the preparation provided by the Coordinator program and the will and determination of Steve, Jim, Angalee, and Carol. Steve and Jim had practiced with the HLR and knew how to operate it with confidence. Steve's prior EMT training served him very well. Aside from logistic problems with transportation and the physician which were beyond our control, the operation in Indiana went incredibly smoothly.

The entire crew of Alcor members in Indiana deserve more credit than we can put into words. Not only did they facilitate a member's cryonic suspension under good conditions, they demonstrated that the Coordinator program can work, and work well.

Arrival In California

Jerry Leaf and I arrived at the facility about two hours prior to Alice's scheduled arrival. Phone calls were made to verify the arrival time of the flight Alice was on, and final preparation of the facility in Riverside was begun for cryoprotective perfusion. Most of the staff had already assembled and the facility was in a high state of readiness. Perfusate preparation was in the final stages and the operating room had been set-up by the rest of the team under the direction of Hugh Hixon.

However, sweaty-palms times were not completely behind us. The call to the airport revealed that the freight offices of the airline Alice was coming in on were closed on Saturdays and would not reopen till Monday. We might have to wait till Monday, we were told. After some quick and to-the- point negotiations by Alcor President Carlos Mondragon, it was decided we wouldn't have to wait. When the Alcor pick-up crew arrived at the freight office with the Cryovita van, the transport container with Alice inside was on its way over to the freight office on a baggage ramp (all the freight company's personnel capable of operating fork lifts had the weekend off!).

By 1:40 PM PST Alice had arrived in the facility and by 2:20 PM, the shipping container had been opened and her pharyngeal temperature measured to be 1°C. A preliminary examination revealed the typical degree of rigor observed in remotely cooled and transported patients: the muscles of the neck and forearms were not in rigor and the large muscles of the thighs were also not in rigor. With the exception of the fingers and wrist of one hand, the rest of Alice's small muscles were in rigor.

Surgery to access the aorta and right heart was begun at 6:20 PM. At 8:40 PM cryoprotective perfusion was begun. The degree of blood washout achieved in Indiana had been excellent and perfusion proceeded very smoothly. Due to minimal funding and supply problems, a decision had been made in consultation with Alice and her son to reduce costs wherever possible. For this reason, we used Dextran 40 instead of hydroxyethyl starch (HES). It was anticipated that the Dextran 40 would protect the brain against edema about as well as HES (although Dextran 40 does not protect the lungs against edema and they will rapidly accumulate fluid during perfusion with solutions employing Dextran 40 as the colloid). Since Alice was a neuropatient, this was not an issue.

The heart-lung machine and gradient maker. Scott Greene observes, Arthur McCombs takes notes, and Bill Jameson monitors the machine.

Mike Darwin makes a burr hole in the skull to observe perfusion of the brain.

A computer in the operating room. Mike Perry's program models the course of the perfusion.

Surgery in progress. Chief Surgeon Jerry Leaf is assisted by Brenda Peters.

One immediately apparent difference that was observed with the use of Dextran 40 during blood washout in Indiana was that there was none of the cold agglutination (clumping together) of red cells that has been previously observed. A corollary of this was that glycerolization of the skin was observed to proceed with absolute uniformity during cryoprotective perfusion. We did not observe the usual patchy areas of unglycerolized skin which take long periods of time to resolve.

Unfortunately, the Dextran 40 did not provide the degree of oncotic support to the brain that we had hoped for. Alice developed moderate cerebral edema early in the perfusion, and it persisted throughout the two hours of cryoprotective perfusion. Alice's cerebral edema did not preclude a complete perfusion, but it did limit flow rates and we suspect from a preliminary analysis of the data that terminal glycerol concentration in the brain may have been 2 M to 2.5 M as opposed to the 3 M to 3.5 M concentration we like to see at the end of perfusion. Terminal glycerol concentration in the venous effluent was 5.03 M. However, we are not sure that the brain was being well circulated near the end of perfusion due to cerebral edema.

In the future we intend to use HES or HES-Dextran 40 mixtures. It was apparent from this experience that Dextran 40 simply does not stay in injured brain capillaries well enough to be used in patients who have experienced ischemic (i.e., no blood flow induced) injury.

Control of pH was excellent during perfusion and our terminal venous pH was 7.73 -- higher than we have achieved in any previous suspension.

Cooling to -79°C

Alice had elected for neurosuspension, and cephalic isolation was carried out without difficulty. At 11:20 PM Alice was placed inside two plastic bags and transferred to a silicone oil cooling bath which had been precooled to -12°C. An hour later, at 12:20 AM on the morning of October 9th, Alice's oral temperature had dropped from 7°C to 5°C and she was well on her way to dry ice temperature.

Dry ice cooling. Silicone heat exchange fluid is circulated with a small pump.

Dry ice cooling was completed at 4:45 PM the same day and at 12:25 AM on the morning of October 11, Alice was transferred to a neurocan surrounded by dry ice nested inside a Linde LR-35 cryogenic dewar. The LR- 35 dewar was then lowered by power hoist into a liquid nitrogen bath inside the Alcor pediatric dewar. Cooling to liquid nitrogen temperature took 11 days and was achieved in the usual way by allowing heat to slowly leak out of the superinsulated dewar containing the patient. At 7:40 PM on October 25th Alice was placed into long-term storage in the vault containing five of the seven other Alcor neuropatients.

Conclusion

No cryonic suspension is ever routine. Each patient is different, every situation somewhat unique. And yet, given the fact that Alcor has averaged one suspension every four months over the last 17 months, they are beginning to seem commonplace. The positive side to this is that we are rapidly becoming very professional and skilled at doing suspensions.

It is reassuring to know that support such as was demonstrated by the Alcor members in Indiana is possible. It should be a shining example of what's possible to Alcor members everywhere.

Finally, on behalf of Jerry Leaf, myself and Alcor, I would like to offer thanks to my parents, Michael and Ella Federowicz, who were kind enough to shuttle us around during our four days in Indiana and who opened their home to us during our first exhausted night in town. Not only did your hospitality go a long way towards containing costs, it helped immeasurably in facilitating Alice's suspension by two rested, reasonably relaxed Southern Californians.

As with the other Alcor patients now in suspension, Alice is on her way. She remained lucid to the very end, and she was aware that it was an incredible journey against enormous odds that she was undertaking. I did not know her well. We exchanged only a few words that long night before her ischemic coma began. I admire tremendously her love of life and the wonderful flexibility and courage it must have taken for a 78 year old woman to confront an unknown future far removed from this time and place.

Good luck, Alice, and safe traveling.