by Mike Darwin
“Recent theorists have argued that humans are genetically programmed to think in story form: stories, they say, are how we best remember the important events in our own lives, how we interpret meaning in the lives of those around us, and how we best remember world events.” – Richard Jewell
Prologue: Let Me Tell You a Story…
The terror in the voice on the other end of the phone was so intense it seemed as though the caller was in the room with me, not over a thousand miles away. I had never spoken with him before, and it had taken extraordinary effort and cleverness on his part to find my phone number. It was 0100; the middle of the night, and his mother was dying. He had emailed me several times in the past with technical questions about cryonics, but other than that, we had had no prior contact. His situation was desperate because, like me, he lived in a small town over an hour away from the nearest Wal-Mart – a pretty good gauge of how far removed you are from the amenities of civilization – and there was little in the way of meaningful help from his cryonics organization.
He wanted my advice and my help on what he could do to improve the odds for his mother, given that she was going to die sometime within the next 12-24 hours. He was fortunate, unusually so, in fact, in that he had two other family members and several close friends who were willing to do just about anything within reason to help him. He, his mother and his sister had been signed up with a cryonics organization for several years and all of them enjoyed reasonable health and seemed in no imminent danger of dying. The fly in the ointment was that his mother had a history of congestive heart failure and neither he, nor anyone else he relied on for advice, understood that that diagnosis in a frail elderly lady is as lethal as any disseminated cancer. With the added twist that decompensation, flooding of the lungs with fluid, and death could occur with little or no warning. It was 1 o’clock in the morning and this man, his sister, and his mother were utterly alone, and utterly unprepared for the emergency that was unfolding in their lives.
He and his sister were unable to reach his mother’s cardiologist, but they did get the family physician out of bed and, as is so often the case in small rural communities, he assessed the situation by phone and offered to come over to see the patient since he was certain to arrive before the ambulance which had been dispatched from yet another small community located 15 minutes further out from the neighboring city (and that could be expected to take at least an hour and a half to arrive). (Both of the neighboring city’s fire department paramedic-staffed ambulances were engaged in other long-distance emergency calls and were unavailable to respond.)
The physician was there within 20 minutes of the call and his assessment was as blunt as it was honest. Their mother was dying, and hospitalization would make no difference in either the duration of the dying process, or its certain outcome. She had suffered another heart attack and now had massive pulmonary edema with large airway flooding, as well as frank hemoptysis (bleeding into her lungs). In medical parlance she was actively dying, and the only realistic course of action was to administer palliative oxygen and morphine and wait for the inevitable. A call was made to the EMT in the ambulance that was en route (who was also head of the volunteer fire department that provided the ambulance service) to ask whether they could leave one of their large oxygen tanks and a portable suction unit for the night, with the physician’s assurance it would be returned in the next few days. The answer was “yes.”
Figure 1: Homemade active compression-decompression CPR device (L) and the Ambu CardioPump (R). The CardioPump costs ~$400.00 US, and is technically illegal to sell in the US. The homemade version (L) costs ~16.00 US, and can be easily made from off the shelf pumping parts available at most hardware stores.
The next six hours of frantic phone calls (including to a funeral home in a neighboring town) and two trips to Wal-Mart did much to remedy the lack of the basics. The funeral director sent his son out with a metal air shipping case (universally and erroneously referred to as “Ziegler cases”). I had asked the son to see if the mortuary could loan him a transport gurney; unfortunately they only had one. I then spoke briefly with the mortician and asked if he had an extra “church cart” which is a scissor-action, horizontally collapsible cart used to move caskets in and out of churches and around the funeral home. He had an extra church cart and agreed to bring it.
Figure 2: A very serviceable expedient portable ice bath (PIB) can be quickly put together using a metal mortuary air shipping container (L), a mortuary “church cart” (R) and ratchet-type nylon tie down straps used to secure motorcycles, or cargo during shipment. The shipper should be lined with a double layer of water-tight plastic sheeting because the shippers frequently leak at the seams!
Upon arrival, the air shipper and the church cart were then paired up using nylon “cargo-style” ratchet straps with S-hooks; converting the air shipper and the cart into an expedient portable ice bath (EPIB) (Figure 2). The trips to Wal-Mart were for an inexpensive, throw-away-type expanded polystyrene (EPS) cooler, half a dozen more rugged picnic chests filled with water ice, two Accu-Rite electronic indoor-outdoor digital thermometers (the kind with the temperature sensor on a long lead wire that is normally placed outdoors), a small submersible-type water sump pump, three yellow plastic Green Thumb (6-1/2”diameter) yellow plastic lawn sprinkler rings, a roll of garden hosing, a large selection of garden hose quick disconnects, assorted other garden and plumbing fittings and connectors, and every garden hose repair kit Wal-Mart had on their shelves. Also on the list were several packages of disposable nitrile rubber gloves from the pharmacy section of the store and a toilet plunger
The patient’s son said he was “good with his hands,” and in fact one of the one of the reasons he had originally sought me out over the Internet was to ask about the feasibility of making his own version of the Ambu CardioPump for active compression-decompression CPR (ACD-CPR). He had already made a prototype handle for the device, but the type of toilet plunger “suction cup” he had selected would not form a good seal with the chest wall.
I emailed him a set of Transport Data Collection sheets from my BioPreservation, Inc. (BPI) days, as well as some simple and very basic instructions in 16 point type. I pasted in photographs where appropriate, and I also sent along sections from the last version of the BPI Transport Manual. I then spoke at length with the family physician who, while not enthused about cryonics, was genuinely caring, and who agreed to stay with the patient until she experienced cardiac arrest, and then pronounce medico-legal death, and sign the death certificate. He explained that while he was “off” for the next two days with no office duties or hospital rounds, he would need to go home briefly to gather some supplies, and he agreed to give the patient some Lasix (furosemide, a potent diuretic) in the hope that it might buy a little more time by slowing the progression of the pulmonary edema. While he was unwilling to start a TKO (to keep open) IV, he did agree to place a “heparin-loc” catheter in the median cubital vein of the patient’s right arm, and to assist her son and daughter with starting an IV after legal death was pronounced. Of note was that one of his major concerns would be the need to use less morphine for palliation than he was comfortable with, lest the patient arrest almost immediately. He said that the only reason he was willing to do this was his prior knowledge of the patient’s strong desire to be cryopreserved.
One problem that seemed insurmountable was access to heparin in sufficient quantity and concentration to serve as an anticoagulant. The other medications that I suggested be given intravenously post-pronouncement were ones that the physician kept on hand in his office: chloropromazine, Toradol (ketorlac tromethamine), Minocin (IV minocycline), five 50 ml vials of 50 mEq sodium bicarbonate and a 1-liter bag of normal saline. Uncharacteristically, the hospital pharmacy in the small city nearby refused to dispense any injectable medications except to inpatients in their facility, despite the fact that this physician had practice privileges there.
In desperation I began searching the Internet for hemodialysis (artificial kidney) centers in the area and found one located just a few blocks from the Wal-Mart. These facilities invariably have heparin in large quantities and they also have 23% sodium chloride in 30 ml vials. That was critically important because it could be added to the liter of normal saline to create a 3% hypertonic saline solution – arguably one of the better things that could be given to improve microcirculatory flow; thus facilitating better distribution of the other medications, and possibly helping to directly reduce ischemia-reperfusion injury. The recording on the dialysis center’s phone line indicated that they would open for business at 0500. On the chance that they might be willing to dispense heparin and hypertonic saline with a prescription from the physician, one of the family’s close friends set out again to wait until 0500.
An added advantage to this trip was that he could pick up a number of items from the Wal-Mart which we had forgotten on the first trip, including half a dozen boxes of Ziploc bags, two 2-quart plastic pitchers to scoop ice with, two 5-gallon plastic pails for adding and removing water from the makeshift PIB, and several heavy duty tarpaulins to line the air shipper cum PIB to guard against possible leaks.
Figure 3: Consumer household-type indoor/outdoor thermometer available at many discount retail outlets.
At around 0545 the registered nurse (RN) in charge of the commercial dialysis center contacted the facility’s medical director who had no objection to providing heparin and hypertonic saline on the condition that it was expressly not for medical or veterinary use (i.e., not for use on a legally alive patient). Graciously, there was no charge for these items and they were on hand at the patient’s bedside when she arrested later that day.
The patient’s son and another family member worked diligently to turn the sump pump, garden hose and lawn sprinkling parts into a working surface convection cooling device (SCCD). They then went on to attach the toilet plunger to the T-handle which had been previously fabricated from 1” plastic plumbing parts. Fortunately, the thread on the butt of the wooden dowel which had been both epoxied in place and secured with screws inside the piece of 1” PVC plastic pipe (that constituted the upright section of the T-handle), was compatible with the newly acquired rubber plunger head.
Figure 3: A simple, expedient head ice positioner (HIP) fabricated from a plastic garment storage box and a piece of foam pipe insulation. The thermoplastic typically used to manufacture these materials is notoriously liable to fracture during cutting and drilling. The cutout in the HIP pictured above was made using a (repeatedly) heated disposable box-cutting knife. A less satisfactory but easier to fabricate alternative is to use a disposable expanded polystyrene ice chest. However, in many areas these are season items, and are not available in the winter months.
A U-shaped cut out was made on one side of the EPS ice chest and this was placed at the head end of EPIB to serve as a reservoir for ice and water around the patient’s head. One of the lawn sprinkler rings was positioned between the crown of the patient’s head and the wall of the EPS cooler opposite the U-cutout. This allowed a constantly replenished reservoir of ice and stirred water to accumulate around the patient’s head providing effective cooling without splashing and spraying the water. The other sprinkler rings were distributed over the patient’s body and covered with bath towels to prevent water spraying out of the EPIB, and to more evenly distribute the ice water as a smooth sheet of cooling fluid over the patient’s body.
When cardiac arrest occurred, the physician remained on hand to assist with giving the medications and insuring that the disposable bag-valve resuscitator left by the ambulance crew at the son’s request was used correctly, since the patient was not intubated. To his credit as a human being, which also served as a testament to his competence as a physician, without any request or discussion that he do so, or that it would even be desirable, he also administered two additional doses of morphine after pronouncement during the hour and a half that cardiopulmonary support (CPS) was continued. CPS was discontinued when the AccuRite thermometer, the probe of which was placed deep in the oropharynx, registered a temperature of 17 degrees C.
Stupidity, Insanity, or Something Else?
The story above has been repeated with variations several times over the last five years, usually with a much less favorable ending. The patient in this story was lucky to have a son who understood the importance and the urgency of good care for his mother and who also had the intelligence and manual skills to make it happen. She was also fortunate to have a physician, family and friends who were willing to extend themselves so far in order to help her achieve something that most of them did not consider a priority, or even a worthwhile thing to do.
This story will mean different things to different people. Some will see it as an interesting adventure of sorts, others as a lesson in how decent and caring people can be, and still others as an exercise in technological expediency in a trying situation. All of these interpretations are valid, but alas, none of them addresses the most important issue this story raises for cryonicists, and that is how to avoid it happening again, and even more importantly, how to avoid it happening to you.
A critical reading of the various case reports published by cryonics organizations makes it clear that there are truly horrible problems that are recurring over and over again in patient transport. Patients routinely arrest before the Standby Team arrives (http://www.alcor.org/Library/html/casesummary1831.html, http://www.alcor.org/Library/html/casesummary2340.html, http://www.alcor.org/Library/html/casesummary1356.html, ), after the team has stood down (http://www.alcor.org/Library/html/casesummary1356.html) or they arrest with no help on the horizon beyond a mortician who will come, with no particular sense of urgency, and more or less pack the patient’s head in ice http://www.cryonics.org/reports/CI72.html, http://www.cryonics.org/reports/CI79.html,. Cryopatients routinely experience many minutes or even hours of ischemia not only absent cardiopulmonary support, but absent cooling of any kind. In one recent case, a patient went for 4-hours post-arrest with no ice or other refrigerant applied to her head http://www.cryonics.org/reports/CI82.html. This story is in no way remarkable, except that in this case both the patient and her spouse were committed, signed up cryonicists! How could this happen?
The answer is that it happened because of lack of information, lack of education, lack of preparation, and the complete absence of even the most basic tools to cope with an emergency that was not just a remote possibility, but an absolute certainty. Over the years, people in medicine (outside of cryonics) who have read some of these case reports online have remarked to me, “What is the matter with these people? Are they stupid, or do they just not care?” Perhaps Benjamin Franklin comes closer to the truth with his observation that “the definition of insanity is doing the same thing over and over and expecting different results.” Are we cryonicists stupid, insane, or are we just not paying attention?
The “Big Fix”
Cryonicists tend to be focused on major technological advances and “big fixes” when they think of what is likely to be of benefit in improving the quality of their own cryonics care. There is also an understandable tendency to rely on their cryonics organization to provide the critically important instructions, supplies and hands-on care they will need in an emergency. Unfortunately, the world we live in is not one where cryonics organizations’ facilities are as commonplace as fire stations – with paramedics and ambulances no more than a phone call and three to five minutes away. In fact, as the story above illustrates, depending upon where you live, paramedics and even emergency medical technicians, may be 15 minutes or even an hour or more away. Not all cryonicists in the United States (US) live in urban areas (or even in rural areas) with good emergency services. So, if you want to improve your chances in a cryonics emergency, depending upon the breaks, it is going to be largely up to you. This will be especially true if you experience sudden or unexpected cardiac arrest.
If you live outside the contiguous 48 US states and Canada (North America), the definition of “sudden” will often be any arrest that occurs with less than 48 hours notice, or that doesn’t occur within 72 hours from when the Standby Team was deployed.
The cryonics organizations† have failed miserably in providing the education, instructions, and hardware that would go a long way towards remedying this situation. Having said this, it should also be duly noted that cryonics organizations are created and run by and for cryonicists. The contingent of the dissatisfied who rail and complain on various cryonics list serves certainly have a point, but they just as certainly are doing nothing concrete or positive to fix the problems. Cryonics has a 40+ year history of people with big ideas they’ll talk about endlessly – and never act on, as well as people who have a never ending litany of complaints and criticisms, but nary a solution to offer or act upon. Both of these approaches result in lack of progress, and worse, demoralization and loss of credibility.
That has to change, starting now.
End of Part I
† I note with bleak humor that there is actually an organization with a very slick website called the The Cryonics Society (http://www.cryonicssociety.org/mission.html) which “aims to foster support for the emerging science of cryonics by educating the public, advocating for more research, and by providing objective and unbiased information about cryonics and its benefits to everyone.” How is this to be done? Well, they advise that “to make those compassionate and humane goals a reality, human beings need to come together and to work together to achieve that end.” How? “By joining the Cryonics Society.” Sure, give us your money and we’ll tell you what you already know, namely that cryonics could save your life and lots of others. Could, that is, if it were really an attractive and practical option not encumbered with many hours of warm and cold ischemia and a generally miserable level of care.