From Cryonics, September 1991
by Mike Darwin
Foreword: A Special Thanks to Jerry Leaf and to Alcor, by Linda and Fred Chamberlain (from Cryonics November 1991).
When we first heard that Jerry Leaf was being suspended, we experienced the same disbelief, shock, dismay, and personal loss all cryonicists, and particularly Alcorians, have felt. We knew Jerry for nearly two decades. The tributes in the September issue of Cryonics were moving and appropriate. What more can be said? The loss of a good friend is never easy to express.
To us, the greatest enigma in the tragic ischemic time Jerry suffered was the fact that he had made such tremendous contributions toward building an unequaled organization and procedures designed to eliminate ischemic damage. The suspension of Linda's mother (Arlene Fried) is at this time considered the "gold standard." Suspension was started within seconds of her deanimation. Her kidney, nearly 48 hours after her deanimation, was considered to have been in transplantable condition. It is tragic that one of the people who did so much both to formulate the procedures used, who spent days of his own life on standby at Arlene's home, and used his expert skills to give her that unparalleled suspension, should fall victim to circumstances which resulted in prolonged ischemia.
In spite of this, [as the story below shows,] the support of Judge Munoz in freeing Jerry from the bureaucratic grip which might have extended that ischemic time devastatingly longer, and the courage of the Alcor suspension team during that time of personal loss and shock are inspiring. The legal battles of the past few years have been costly and bloody. We have all wondered whether the costs could be justified. We now know they were.
And the strength of Alcor is clear. One of the Generals will be gone from our midst for a while. But the rest of the soldiers have shown they will pick up his shield and they will continue with the inspiration he gave us all. Not only to carry Jerry from the jungle, but also to see that the Jerry Leaf tradition (of standing by any Alcor member who may be in danger) continues within Alcor.
Jerry would have been proud if he could have watched his own suspension. And he would be happy to know that Alcor is strong enough to withstand his loss and continue to grow. His own survival depends on that, and he helped to make it so. The resolve to make Alcor strong, for Jerry and for all of us, can be heard in your voices and seen in your faces. Although the pain of our loss seems blinding at times, we must not lose sight of the courage of the rest of the Alcor staff. Thank you for being there so completely for Jerry, and for the strength and resolve you are now pouring into building Alcor to make it even stronger....
... and thank you, Jerry, for all that you did to build the organization which now protects both you and all the rest of us.
See also: Interview with Jerry Leaf
Mike Darwin, Transport Team Leader
Ralph Whelan, Driver, Team Member
Tanya Jones, Medications, Scribe
Carlos Mondragon, Legal/Executive
Mike Darwin, Suspension Team Leader, Circulator, Housekeeping
Hugh Hixon, Laboratory Analysis, Perfusate Preparation
Tanya Jones, Physiological Monitoring, Scribe
Carlos Mondragon, Administrative, Photographer
Thomas Munson, M.D. Assistant Surgeon
Paul Genteman, O.R. Nurse
Scott Greene, O.R. Nurse
Russell Whitaker, Perfusionist
Naomi Reynolds, Perfusion Assistant, Housekeeping
Ralph Whelan, Perfusion Assistant
Bill Jameson, Samples, Perfusion Assistant, Housekeeping
Fred and Linda Chamberlain, Cool-Down Technicians
David Christiansen, Logistics Support
Lawrence Gale, Logistics Support
Crew for Transfer Dry Ice to Liquid Nitrogen Cooling
Hugh Hixon, Crew Leader, Engineer, LN2 Cooldown Tech.
Max More, Strong back
Ralph Whelan, Strong back
Carlos Mondragon, Strong back
Mike Darwin, Strong back
Fred Chamberlain, Strong back
Lawrence Gale, Strong back
David Christiansen, Probe Wrangler
Bill Seidel, Video Recording
Linda Chamberlain, Video Recording
Tanya Jones, Photographer
At approximately 23:15 on 10 July, 1991 Alcor Suspension Team Leader Jerry D. Leaf experienced cardiac arrest in his home in Downey, California. His wife Kathy, who is a Registered Nurse, began CPR immediately and summoned the paramedics. After an unsuccessful attempt to establish an IV and re-start his heart with defibrillation, Jerry was transported to the Emergency Room of Downey Community Hospital, where he arrived at 23:41.
At the hospital vigorous attempts to resuscitate him were carried out for over 45 minutes, but to no avail. Alcor was notified of the situation by the ER staff at approximately 00:15. At 00:35 Jerry was pronounced legally dead by the ER physician. The ER was staff incredibly cooperative (it should be noted that Jerry's wife Kathy is head of Nursing at the hospital) and continued CPR for another 45 minutes and administered some transport drugs.
Transport Team Dispatched
A transport team consisting of Ralph Whelan, CRT, Carlos Mondragon, Tanya Jones CRT, and Mike Darwin, CRT, departed the Alcor facility at 00:50. When consideration is given to the fact that with one exception all personnel responding needed to be wakened and summoned from home (Mike Darwin was home, but awake) this response time is excellent. (Nevertheless we are working on ways to improve it further.)
When the Transport Team arrived at the hospital, CPR had been discontinued and Jerry's head had been incompletely packed in ice in plastic bags and he had been placed on a cooling blanket. His rectal temperature was 35°C.
Since Jerry experienced cardiac arrest suddenly and without a prior history of heart disease, he was automatically a Medical Examiner's (ME) case. Initially it was hoped that the ME would waive the case and give an ME's release number, enabling Alcor to take immediate custody and begin administering transport medications and continue external cooling.
However, when the Los Angeles County ME's office was reached by the ER physician they refused to issue a release number and ordered that no further transport medications be given. However, they did allow Alcor personnel to transfer Jerry to the portable ice bath (PIB) and begin cooling him with crushed ice in direct contact with his skin. The Transport Team was further informed that it would be sometime after 09:00 before an investigator could be sent out to determine if the ME was going to take custody and/or perform a partial or complete autopsy. This meant at least seven additional hours of ischemia (no blood flow).
Thus at 02:13 Jerry was transferred onto a bed of crushed ice in the PIB on the Mobile Advanced Life Support System (MALSS) cart and covered over with additional ice. He was then moved to the hospital morgue walk-in cooler for refrigeration until the ME investigator arrived.
Throughout this interval Saul Kent was hard at work on the phone making arrangements to fly in our back-up surgeon and handle other logistic details. When it was determined that the ME was not going to release Jerry, Saul was apprised of this and he began an effort to reach Alcor attorney Chris Ashworth. Chris had recently moved and we did not have his new home phone. By an incredible stroke of luck Chris was working late and when Saul (in a last-ditched effort) called the law office at about 02:00, Chris answered the phone!
Once Chris was told of the situation he went into high gear and placed a phone call to Judge Aurelio Munoz and explained the circumstances. Judge Munoz then offered to issue a court order ordering Jerry's immediate release to the Alcor Transport Team. After some quick discussion Carlos decided to take this course of action and within a short time Judge Munoz contacted the Administrator of Downey Community Hospital and ordered Jerry's immediate release. The ME was also notified of this court order. The ME then contacted Carlos and a compromise was worked out wherein the ME would have an investigator on the scene within 40 minutes and the ER physician would draw blood via a femoral stick for the ME so that a toxicology screen could be done to rule out foul play via poisoning. The ME investigators arrived in slightly under 40 minutes, carried out an external exam (to rule out trauma) and made a photographic record.
We felt it important to make this compromise even though it resulted in another hour's delay. Our reasons for this decision were that 1) given Jerry's condition an added (relatively) short period of time was not going to make much difference: with such a long down-time most of the up-front injury had already occurred and there was not much we could do to hasten cooling or improve the situation beyond external cooling which was already underway, 2) The ME was being reasonable and friendly and, considering the circumstances and the delicate nature of the situation we felt it was prudent to be reasonable in return. We know we will have to work with the LA ME's Office in the future, and creating a bad situation will not make this any easier, 3) We wanted to reduce the chances that there might later be questions regarding the cause and mode of death by allowing the ME to do the modest examination they requested and to take the toxicology sample they needed.
By 04:12, Jerry had been loaded into the ambulance and transport to Alcor was underway. His temperature at this time was measured at 19.8°C via a thermocouple probe placed in his pharynx (throat). At 04:19 cardiopulmonary support (CPS) was briefly established to circulate transport medications and facilitate cooling. External cooling using a water circulating pump and perforated hose array (SQUID) was also begun at this time.
A modified version of the usual Alcor Transport Protocol was given. When the gastric tube was placed to give the Maalox, it immediately became filled with blood. The Maalox was given and continuous suction established. Over the 40 minutes of HLR operation, over 1500 cc of blood was suctioned from the stomach; a not unexpected result of the delay in establishing good cardiopulmonary support and the inability to neutralize corrosive stomach acid with Maalox shortly after cardiac arrest. Administration of transport medications was completed by 04:52 and CPS was stopped at 05:22 because of inadequate blood circulation.
Jerry arrived at Alcor at 05:26 and was moved from the ambulance to the central work area to continue external cooling while final preparations were made for surgery and cryoprotective perfusion. Our back-up surgeon arrived a few minutes later.
Jerry in the Portable Ice Bath atop the MALSS cart shortly after arriving at the facility.
Because of his weight (approx. 90 kg) and lack of blood circulation (a third of his blood volume had been suctioned from his stomach!) Jerry cooled very slowly; his temperature upon arrival at the facility was 18.6°C pharyngeally and 28.0°C rectally.
By this time the entire suspension team had assembled. We were very fortunate that Russell Whitaker, whom Jerry had just completed training to set-up the heart-lung machine, was available. Russ had received an unexpected job offer and was scheduled to leave for Switzerland the morning of the day Jerry had his heart attack. A last-minute change in plans delayed Russ' departure. Russ had planned on training Alcor staffer Ralph Whelan before he left; however this had not proved possible. Russ' presence was especially important since Jerry had trained him on using a new circuit which only Jerry and Russ had familiarity with. Ralph thus got some unexpected on-the-job training in setting up the circuit.
Scott Greene looks on (seated) as Ralph Whelan (center) and Russell Whitaker (right) set up the heart-lung machine.
At 08:49 the heart-lung machine was primed and ready and Jerry was moved onto the operating table. Prep for surgery began at 09:13 and surgery itself was begun 09:25. A burr hole over the frontal lobe was made to allow visualization of the brain surface. Access to the circulatory system for circulation of cryoprotective drugs (perfusion) was through the great vessels of the chest (via division of the breast-bone). Blood washout and cryoprotective perfusion were begun at 10:40. Blood washout was excellent with no sign of clotting. This was apparently as a result of heparinization by the hospital staff during the period of CPR following the pronouncement of legal death.
Repacking Jerry in ice after transfering him from the PIB onto the operating table.
Surgery underway to connect Jerry to the heart-lung machine for cryoprotective perfusion.
Shortly after the start of perfusion, brain swelling began to develop. The rate of addition of glycerol (the cryoprotectant used to minimize freezing damage) was increased to try to counter the swelling and pulsatile flow was also used in an attempt to minimize its progression. Neither of these maneuvers was particularly successful, and brain swelling continued throughout the remainder of cryoprotective perfusion.
Twenty-five minutes into perfusion: most of the Suspension Team going full tilt.
At 12:06 brain swelling was sufficiently severe that a decision was made to terminate perfusion pending evaluation of the glycerol concentration in the venous perfusate (which should reflect the true tissue concentration of the drug). Glycerol concentration was determined to be 1.62 M and perfusion was discontinued at 12:23. The final venous glycerol concentration was 2.36 M. However, it is doubtful that the terminal brain glycerol concentration was much over 1.5 M since cerebral edema (swelling) was so severe.
After removal of the perfusion cannulae, the heart was examined for evidence of infarct. The posterior and left inferior walls of the heart were edematous and discolored and a dark 3 cm long clot was noted in what appeared to be a coronary vein. It appeared that the cause of cardiac arrest was a massive myocardial infarction.
All wounds had been closed by 13:16 and Jerry was cleaned up, placed inside a heavy plastic bag and transferred to the cooling stretcher for loading into the Silcool silicon oil bath for cooling to -79°C. Jerry was positioned in the Silcool bath at 13:37 and cooling was begun at an average rate of 5°C per hour. Cooling to -79°C (as measured by the pharyngeal probe) was completed on 12 July. Cooling was monitored and controlled by Fred and Linda Chamberlain who drove down from Northern California and then marathoned through till about 07:00 on the 12th!
Jerry is hoisted up and into the Silcool bath for cooling to dry ice temperature (-79°C).
Credit also needs to be given to the new Barnant automated temperature monitor. This new device (purchased by Jerry via Cryovita a few months before) performed spectacularly. The unit automatically scans up to 12 probes at intervals from as low as three seconds (due to printer constraints our minimum scan interval is 15 seconds) to a maximum interval of 90 minutes. The unit can be interfaced with a computer to allow for direct dump of data to disk and, more important, to serve as the data collection end of an active temperature descent controller. The unit also has alarm features.
It is hard to understate how much effort this unit saves and how much more data it allows to be collected (a mixed blessing). In the past a human had to log temperatures by hand every 15 minutes over a period of 24 to 36 hours. While a human is still needed to control refrigerant additions and to supervise, not having to log temperatures every 15 minutes is a godsend. We hope to automate the cooling system even further in the near future using the Barnant unit as the monitor/controller of the system and a PC as the recorder.
On the afternoon of Monday the 15th, Jerry was removed from the Silcool bath and transferred to a heavy-duty mummy-type sleeping bag inside an aluminum pod. The pod was then hoisted through the skylight in the patient care bay and lowered into Bigfoot dewar #3 for cooling to liquid nitrogen temperature. Cooling to -196°C was commenced at 21:00 and completed (measured pharyngeally) at 06:00 on 17 July. Cooling to liquid nitrogen temperature was at a rate of approximately 6°C per hour.
Closed up in the sleeping bag, Jerry is secured to the pod by Hugh Hixon. Mike Darwin stands ready with an LN2 sprayer to hold the line on temperatures while Carlos Mondragon and Dave Christiansen sort out the temperature monitoring probes.
Hugh Hixon closes the pod in preparation for hoisting it into the Bogfoot for cooldown to -196°C.
Reflections On The Suspension
There are at least two ways to evaluate any cryonic suspension: by absolute criteria and by relative criteria. By relative criteria Jerry's suspension went phenomenally well. Personnel responded promptly and in a reasonably organized fashion, although there were a couple of oversights: the transport data logging sheets were left behind and the nimodipine was left in the freezer (and thus was unavailable for administration). The unavailability of the nimodipine is not considered significant due to the long period of CPR time in the ER and the long ischemic (no blood flow) period; nimodipine is likely to be of benefit only if administered at the very beginning of cardiopulmonary support (CPS). Data was logged on regular paper and was very complete.
The availability of Chris Ashworth, his vigorous efforts and good judgment, and the willingness of Judge Munoz to issue a court order to release Jerry after being wakened in the middle of the night leave us speechless with both amazement and gratitude. There was much good luck in the unfolding of these events!
Similarly, cryoprotective perfusion and dry ice and liquid nitrogen cooling proceeded more or less routinely. It is true that Mike Darwin was extremely busy and unable to give the usual supervisory attention and that this resulted in minor problems such as data being recorded in the wrong column on the data sheet and some data regarding perfusate reservoir levels being lost, but these errors were not significant and did not effect the outcome of perfusion. Relatively speaking, the suspension went very, very well.
From an absolute point of view the suspension was far less than optimum. There was a prolonged period of warm and cold ischemia in the absence of either cardiopulmonary support or blood substitution with an appropriate tissue preservative solution. There was obvious injury to the brain capillary bed as evidenced by the development of cerebral edema and probably injury to the brain cell membranes from autolytic degradation by phospholipases. While these injuries in and of themselves are not likely to be insurmountable in terms of repair, they are complicated by the fact that their presence prevented the introduction of the high concentrations of glycerol (3.5 M to 4 M) required to protect against mechanical injury during freezing. Only time will tell as to what price has been paid in terms of loss of information encoded on an ultrastructural level.
It is more than a little ironic that much of the effort exerted by Jerry during his career in both medicine and cryonics was unavailable to him personally when the need arose. His professional career, which spanned 15 years of work at the UCLA Medical Center, was focused on the development of techniques for treating heart attack: especially controlling "reperfusion injury" to the heart after a clot in a coronary vessel was removed or bypassed and circulation was re-started.
Similarly, much of Jerry's work in cryonics concerned itself with eliminating ischemic injury to patients and improving transport techniques. Sadly, his benefit from these advances was also minimal.
Nevertheless, Jerry did make it into suspension and some degree of cryoprotection was achieved; certainly significant membrane cryoprotection was achieved with both sucrose and 1.5M glycerol. Considering the circumstances, this in and of itself is nothing less than amazing.