From Cryonics June 1988
by Mike Darwin
On May 8, 1988, a long-time cryonicist and Alcor member was placed into whole-body cryonic suspension at Alcor's Riverside, California facility. The patient was a 72-year-old man with a long history of arteriosclerosis and congestive heart failure. In order to protect the privacy of the member's family, he will be referred to in this article by his first name only, which is Bob. What follows is a non-technical account of the suspension, and then an article about some of the political consequences of it.
It had been a long week and it was turning into a long weekend. Alcor Florida Emergency Response Team member Bill Faloon hadn't slept for over 24 hours when at 12:10 AM on the morning of May 8th his phone rang. On the other end of the line was Bob's 17-year-old son Steve, who informed Bill that his father had suffered a cardiac arrest a few minutes prior to his placing the call. Steve told Bill that the paramedics had been called and that he had already packed his father's head in ice from a supply he had purchased in anticipation of his father's impending ischemic coma (so-called "clinical death").
Bob had been in and out of the hospital for congestive heart failure a number of times during the preceding months, and had been hospitalized three times in the preceding week for discomfort and chest pain secondary to end-stage heart failure. He wanted no heroic resuscitative efforts, and in fact made the decision to experience legal death at home with his family in a nonmedical setting, fully aware of the risks that would expose him to. In the weeks prior to his ischemic coma, I had repeatedly spoken with Bob and explained the risks involved. Bob lived over an hour and a half by freeway from the nearest cryonicist with rescue equipment and skills.
Bob wanted very much to be with his family until the "end," since this was the last opportunity he would likely have to be with them (they are not cryonicists). Bob thus was willing to accept the virtual certainty that he would suffer a long period of ischemia.
I first met Bob in April of 1980, and I had repeatedly urged him to establish a professional relationship with a local physician -- someone who would be able and willing to sign a death certificate or speak to the medical examiner (ME) about Bob's prior history of severe heart disease and thus prevent Bob from becoming a "coroner's case" (and as a result being subject to the risk of autopsy and the certainty of a long delay until suspension could begin).
Bob didn't do this. No doubt part of the reason was that he had been assured by the hospital where he was being treated that the outpatient physician who was seeing him would sign the death certificate. . . .
Unfortunately, Bob experienced cardiac arrest on a Sunday morning. The physician who had seen him last could not be reached and the Emergency Room physician refused to sign the death certificate. The paramedics contacted the police and Bob became a medical examiner's (ME) case (i.e., coroner's case; Dade County uses a medical examiner rather than a coroner).
When the police arrived they instructed Steve to take the ice off his father's head, which he refused to do. They also told Bob's wife Deborah that there would be an autopsy. Despite badgering from the police, Steve steadfastly refused to remove the ice and Deborah told the detectives in no uncertain terms that there would be no autopsy. The police left things as they were until the ME's people arrived a few minutes later.
Fortunately, Bill Faloon had met with the Dade County Medical Examiner some weeks in advance of Bob's ischemic coma and explained the situation with respect to Bob's terminal condition and his wish to be placed into suspension -- and succeeded in enlisting the ME's cooperation.
Thus Bill was on the phone to the ME within 10 minutes of the time he was notified that the ER physician was refusing to sign the death certificate. The ME agreed to get out of bed and be at the county morgue by 6:30 AM to meet with Bob's family and arrange his release. Meanwhile, Bob was transported to the ME's office with his head packed in ice, and he was then placed under refrigeration at 4°C.
Cooperation from the ME's office was excellent. They performed an intracardiac puncture on Bob (to draw blood for a toxicology screen), briefly questioned Deborah and Steve, contacted the hospital for a sign-off on Bob's medical records, and released Bob to the Alcor transport team at 10:00 AM.
The transport team, consisting of Bill Faloon, Greg Strom, and Glen, Marc, and David Tupler, placed Bob in a specially prepared shipping container and packed him in water ice. At 2:00 PM Florida time, less than 14 hours after the start of his ischemic coma, Bob was a plane headed for Los Angeles International Airport (LAX), accompanied by his wife and daughter.
Readying Alcor Riverside
Members of the Los Angeles Area Suspension Team were scattered across the Los Angeles basin when the call came in at 9:44 PM PDT. Within minutes of Bob's cardiac arrest, I was reached at a wedding reception I was attending in Pasadena, and other members of the team were quickly contacted thereafter. As soon as it was clear that Bob was going to be an ME case, a decision was made to carry out his perfusion here in Southern California. This decision was made so that while efforts were being made to obtain his release from the ME, the suspension team could assemble in Riverside to begin mixing perfusate and preparing the facility for a suspension. Thus no additional time would be lost flying California team members to Florida: critical team members who would arrive in Florida without sleep and still have to confront the 12 to 18 hours of preparation that would be required to get the facility ready for a suspension.
By the time Bob's plane arrived at LAX, preparations at Alcor Riverside were well underway. Most of the staff had arrived and approximately half of the 120 liters of perfusate required for a whole body suspension had been prepared. Meanwhile, at LAX Arthur McCombs and I were standing by to meet Bob's wife and daughter and pick Bob up from the air freight office as soon as he was removed from the cargo hold of the plane.
As soon as Arthur and I had Bob situated in the Cryovita van, we opened the transport container and established that the ice packs refrigerating Bob did not need to be replenished with the fresh supply of ice we had brought with us. Very little of the transport ice had melted, which indicated that Bob had cooled a substantial part of the way towards 0°C in the ME's morgue before being released to the Alcor Florida team -- a good sign!
Bob was then driven to Riverside for cryoprotective perfusion and deep cooling. His deep pharyngeal temperature was a reassuring 2.1°C when he rolled in the door at 8:55 PM PDT. Bob was then almost immediately positioned on our bed scale and a preprocedure weight of 65.3 kg was obtained. For several years the utility of being able to weigh suspension patients during perfusion has been discussed. A decision had been made some months prior to Bob's ischemic coma to use our hydraulically adjustable bed scale as an operating table and to carry out the entire perfusion on the bed scale.
Bob arrives at the facility and the shipping container is opened in preparation for his transfer to the bed scale for weighing and perfusion.
Bob is lifted from the ice-filled shipping container for transfer to the bed scale/operating table.
After his transfer to the bed scale/operating table, Bob is repacked in ice and prepared for surgery.
During Bob's initial assessment when he was being weighed, prepped for surgery, and temperature probes were being placed, a truly remarkable observation was made. Bob's head, neck, biceps, and forearm muscles were not in rigor mortis, while his leg and abdominal muscles were in full rigor. This was surprising because it is the smaller muscles of the head, neck, and arms which are normally the first to go into rigor and the larger muscles of the thigh and calf which are the last. Muscles enter rigor as a result of metabolic exhaustion -- in other words, when they use up all of their available energy stores. Smaller muscles have less metabolic reserve and so enter rigor sooner. Typically, rigor starts with the muscles of the eyes and proceeds in a wave-like action down the body. Apparently Steve's aggressive efforts at packing Bob's head and neck in ice (and his prompt refrigeration thereafter) had protected these tissues (and probably to a great extent the brain as well) from metabolic exhaustion. Complete absence of rigor in the head and neck after 24 hours of cold ischemia is nothing short of incredible! Steve deserves tremendous thanks for his efforts.
An hour and 25 minutes after his arrival in the facility, surgery to open Bob's chest and connect him to the heart-lung machine was begun. The surgery to cannulate Bob's aorta and right heart for blood washout and cryoprotective perfusion proved enormously difficult. Bob's chest was a mass of adhesions and scars from two previous bypass operations. It took chief surgeon Jerry Leaf and assistant surgeon Brenda Peters over three hours of painstaking and careful dissection to even reach and identify major anatomical structures such as the heart, aorta, and superior and inferior vena cava. Bob's wife later remarked that it took the team that operated on him for his second bypass surgery even longer to clear his heart of scar tissue in preparation for his second set of bypass grafts.
Working in parallel with Jerry Leaf, I opened a burr hole in Bob's head to allow for visualization of the cerebral cortex surface to facilitate verification of blood washout and adequate cerebral perfusion during the introduction of cryoprotectant.
Surgery to open Bob's chest and connect him to the heart-lung machine begins.
Mike Darwin, with assistance from Carlos Mondragon, begins surgery to open the burr hole in Bob's skull.
Difficulties are encountered in identifying critical anatomical structures due to extensive scarring from two bypass operations.
At 2:14 AM PDT on the morning of May 9, blood washout commenced. Washout proceeded with extreme difficulty due to the massive clotting that was present. Initially the right atrium was left open to allow large clots to be vented into the operative field and sucked out (along with draining venous perfusate) with a wide-bore suction line. Once the largest of these clots were expelled, a standard venous return cannula was placed in the right heart and perfusion was continued. Clotting was so severe that only with extensive manipulation of the venous catheter was it possible to obtain any venous flow whatsoever. Early venous drainage was a semisolid mass of viscous and partially clotted blood. Blood washout took nearly two hours of low flow, stop and go perfusion.
At 4:37 AM cryoprotective perfusion began using a 5% glycerol solution in the new sucrose-HEPES perfusate. Hydroxyethyl starch was present in 5% concentration as the colloid (used to minimize fluid accumulation (edema) between cells). The cryoprotective ramp was begun at 4:41 AM using the connected reservoir system developed by cryobiologist Dr. Gregory Fahy. This system allows for very smooth "linear" increase in glycerol concentration and eliminates much of the inefficiency experienced with the previous system. An adjunct to this system was a "predictive" interactive computer program written by mathematician Dr. Mike Perry. The program is a model of the patient and perfusion system and allows a range of variables to be plugged in and dynamically altered, such as the patient's weight, the desired terminal glycerol concentration, the perfusate flow rate, glycerol concentration in the reservoir, and so on. . . .
Dr. Fahy's system and Dr. Perry's program both functioned flawlessly. The patient's glycerol introduction ramp was smoothly duplicated by Mike Perry's program. All who saw it were impressed with the ability of Mike's program to predict the course of the perfusion. The final proof of this is that 80 liters of perfusate were mixed (using Mike's program and the patient's preperfusion weight) in anticipation of reaching a terminal concentration of 3.5 M glycerol. Bob's actual terminal glycerol concentration (as measured in the venous effluent) was 3.6 M (excellent!) and only 10 liters of glycerol concentrate remained at the termination of perfusion.
Reagent-grade glycerol, which is used to minimize freezing injury.
The extensive ischemic clotting which Bob had experienced prior to his arrival proved a major barrier to good systemic perfusion. Bob's heart, lungs, brain, head and arms perfused well, but his external abdomen and lower extremities did not perfuse at all. A major complicating factor was probably Bob's extensive femoral atherosclerosis. The femoral arteries which supplied Bob's legs were severely narrowed prior to his ischemic coma (by 70% on the right leg and 50% on the left) and these badly atherosclerotic vessels were probably further occluded by clots which effectively prevented perfusion of his lower extremities. To what degree, if any, perfusion of Bob's abdominal viscera occurred we have no way of knowing as we did not perform a laparotomy.
Good Brain Perfusion
At 8:55 AM on Sunday morning perfusion was discontinued. Bob's face was markedly edematous and he had experienced a perfusion-associated weight gain of 8.5 kilos (18.7 pounds). Despite his fulminating pulmonary edema (several liters of fluid were suctioned from Bob's lungs during perfusion) and peripheral edema, Bob's brain had remained relatively constant in volume throughout the procedure -- with the cortical surface bulging only slightly against the burr hole at the conclusion of perfusion. Blood washout of the brain was judged to be excellent and the cortical surface was a uniform pearly white at the conclusion of perfusion. Perfusion of the face and neck was also judged to be very uniform as evidenced by both the glycerol induced ambering of his skin and the uniformity of the edema. [Note: Patients without a long period of ischemia complicated by clotting do not experience edema during glycerol perfusion. However, in both human and animal models post-ischemic perfusion complicated by clotting results in massive edema.]
Cooling To -79°C
At 10:15 AM, ice packs were removed from Bob and he was placed inside two large plastic bags. He was then submerged in a tank of silicone oil (Silcool) which had been precooled to -10°C. His rectal and pharyngeal temperatures were 6°C and his brain surface temperature was 9.0°C at the start of cooling to dry ice temperature. The Silcool bath was outfitted with four small centrifugal circulating pumps to increase the efficiency of heat exchange. By maintaining a 10°C to 15°C differential between surface and core temperatures, Bob was slowly cooled to -79°C over the next 35 hours by gradual addition of dry ice to the Silcool bath.
Protected by two plastic bags, Bob is submerged in the Silcool bath for cooling to -79°C.
Bob in the Silcool bath. The bath was precooled to -10°C, and dry ice (in the cloth bag) is added to begin cooling to -79°C.
Mike Perry and Arthur McCombs (background) begin monitoring Bob's descent to dry ice temperature as Mike darwin (left) looks on.
Long Term Storage
On Thursday, May 12, a team of Alcor members consisting of Hugh Hixon, Max O'Connor, Mike Perry, Jerry Leaf, Scott Greene, Arthur McCombs, and myself assembled at the facility to transfer Bob from dry ice to liquid nitrogen storage. Saul Kent and Steve Harris acted as photographers, and Bill Seidel videotaped portions of the transfer. The Alcor dual-patient cryogenic dewar was rocked into horizontal position after being precooled to approximately -100°C. The metal tank used for Silcool/dry ice cooling (and now drained of Silcool and completely filled with dry ice) was lifted out of its insulating container and transferred to two rolling dollies so that it could be wheeled into position in the central work area of the facility.
The bed scale, with the sleeping bag in position, is readied to receive Bob. Mike Darwin (R) and Hugh Hixon (L).
The storage dewar is rocked down to load Bob in.
The stretcher and sleeping bag which were to receive Bob were then positioned on the bed scale and were pre-cooled with liquid nitrogen. When everything was ready, the dry ice surrounding Bob was very rapidly removed by the seven transfer team members working in parallel. The outer oil-soaked plastic bag surrounding Bob was then slit lengthwise, exposing the dry (i.e., oil-free) inner plastic bag and the pick-up straps which had been placed on Bob prior to his cooling to - 79°C. Arthur, Scott, Max, Mike, Hugh, and I then lifted Bob from the bed of dry ice and hoisted him smoothly onto the stretcher and into the sleeping bag. Jerry Leaf trimmed away excess plastic bag at Bob's head (and managed the mare's nest of thermocouple leads) while a standard precooled neurocan was slipped over Bob's head for additional thermal and mechanical protection during long-term storage.
The sleeping bag and stretcher are precooled with liquid nitrogen.
Max O'Conner (R) and Arthur McCombs (L) discuss the strategy for lifting the dry ice filled tank holding Bob out of its insulated chest and onto dollies.
Bob is lifted from the dry ice cooling tank onto the bed scale platform for final weighing and insertion in the sleeping bag.
The sleeping bag was then completely closed and Bob was carried over to the storage dewar and slid inside until his stretcher docked with the tabbed base plate at the far end of the unit. The entire assembly was then rocked into an upright position using Hugh Hixon's dewar rocker (a design idea originated by Trans Time's John Day). Once the dewar was upright, it was loaded with four aluminum cylinders each 4" in diameter and 6'6" tall. Two of these cylinders were filled with liquid nitrogen and a specially fabricated lid with a built-in circulating fan was used to close the unit. The total temperature rise Bob experienced during the entire transfer operation was 1°C, measured by two external probes.
In the sleeping bag, Bob is secured to the stretcher prior to being placed in the Dewar.
Mike Darwin hitches a ride on the rocker as the dewar containing Bob is rocked upright.
Reservoir pipes in the dewar are filled with liquid nitrogen by Mike Darwin.
By controlling the rate of addition of liquid nitrogen and the fan speed a reasonably homogeneous and controlled temperature descent to -196°C was carried out over the next four days. While this system worked far better than the previous one of just slowly filling the unit with liquid nitrogen (which results in a very large head-to-toe temperature difference), it was far from satisfactory. The fan unit repeatedly overheated, and the seal between the lid and the dewar was inadequate (resulting in excessive heat loss and ice pumping as the fan introduced warm room air into the dewar).
However, the worst drawback was the lack of automation. Since control of temperature descent was completely active this meant that someone had to sit there and operate the system every minute for eight days! This was a difficult burden and it was borne most heavily by Dr. Perry, and to a lesser but very significant extent by Max O'Connor, Hugh Hixon, and Scott Greene. An urgent priority for the future is an active process controller which both dynamically controls the temperature descent while monitoring and logging that descent. Such units are reasonably inexpensive and they are now almost off-the-shelf items (costing about $2,000). One nightmarish experience with round-the-clock, minute-by-minute active control of cooling a patient extending over an eight-day period is enough to try the resolve of the hardest of men! The boredom alone is incredible.
On May 17th, the dewar housing Bob was filled to the top with liquid nitrogen and Bob entered long term cryogenic storage. He remains submerged in liquid nitrogen in the Alcor facility in Riverside -- waiting. Bob's problems with cryonics are probably now virtually over. The rest is up to us. Now we're the ones with problems to worry about.
Per his request, the Riverside County Coroner was notified as soon as Bob entered Riverside County. In fact, the Riverside County Coroner's Office had been notified of Bob's impending suspension several months prior to his ischemic coma.
On Tuesday, the 10th of May, the Coroner's office was provided with a copy of Bob's death certificate (per Alcor's policy) and I attempted to obtain a permit for disposition of human remains (known as the VS-9) from the Vital Statistics Division of the California Department of Health Services. I was informed by Virginia Whitney of Vital Statistics' Riverside office that as of 1981 her office had received instructions not to issue VS-9's for cryonics patients. "Why not?" I asked. Her answer was that we were "...not a licensed bank or storage facility, not a cemetery, and not a mortuary and therefore were not entitled to have or hold human remains."
When I asked how Alcor could become licensed (something cryonicists have been asking the PHS for over 10 years!) I was curtly told by Ms. Whitney that she didn't know. Her abrupt manner told me something else: she didn't care, either. She then ended the conversation by abruptly strolling off to her office.
We later learned that the American Cryonics Society (ACS) and Trans Time (TT) were having similar problems with their suspension of ACS member Violet Jones in Northern California.
For two weeks following Bob's suspension there was relative quiet. Then reporters began calling wanting to know about the "illegal" suspension we had just done and if we knew about the District Attorney being handed fresh misdemeanor charges against us for prosecution by the Riverside PHS (failure to have a VS-9 on a body is a misdemeanor). Calls to the County of Riverside and State of California PHS confirmed the press reports. There was then a round of nasty stories in the press -- none of which told our side of it or pointed out that museums with mummies, tissue banks, and a plethora of physician's and chiropractor's offices have human bodies or body parts and do not have VS-9's.
Calls to ACS/TT lawyer Jim Bianchi and a contact we have in the Orange County PHS confirmed the 1981 memo date and also the reason for it. To our surprise it was not the Dora Kent case but the Chatsworth debacle that resulted in the current "crisis". It seems that after Chatsworth the PHS decided to issue no more VS-9's for cryonics. If a public health menace like abandoned, rotting bodies via cryonics was going to occur, (as it did in Chatsworth) it was going to do so without the "blessing" of the California PHS in the form of a VS-9. No egg on their faces, thank you ma'am.
Don Cavallo of the Riverside PHS and David Mitchell of the State PHS both insisted that Alcor was breaking the law by suspending people and that cryonics is not a permitted form of disposition under California law. This is interesting since it isn't prohibited anywhere in California law either.
To clarify all this, the PHS argument goes something like this:
1) The law says you must have a VS-9 on any human remains (including "parts" of people like neuropatients) within a 5-day period of either death or the arrival of the remains in the state of California.
2) The law does not specify cryonic suspension as a form of "interment" or "disposition" which a VS-9 can be issued for (in bureaucratic parlance: there is no box on the form for them to check). Since the law was last amended in 1965, two years prior to the first cryonic suspension, this is not surprising.
3) Since there is no box for them to check off and no law which allows them to regulate cryonics (which is neither disposition or interment and which the California State Attorney General's opinion says isn't a tissue bank either) they cannot issue a VS- 9.
4) Since they cannot issue a VS-9 we are breaking the law.
5) Since we are breaking the law we are criminals engaged in an illegal act and we must stop engaging in it.
As Dr. Betty Keiswetter of the PHS licensing staff points out: "there is no class of licensing which a cryonics facility would qualify for." Dr. Keiswetter also pointed out that tissue banks are not licensed in the State of California nor are they regulated and they have human remains and tissues too. They are not required to file VS-9's and they are not accused of lawless conduct for failing to have them! As the accompanying newspaper articles point out -- no such luck for us cryonicists.
Naturally we placed some calls to our attorney, and followed it up with a meeting. He tells us these folks are "up in the night". He got a nasty glow in his eyes. This reassured us somewhat.
We have not been charged yet with failure to have a VS-9(s) (or with anything, for that matter) nor have we been ordered to turn over our patients for conventional interment. Nevertheless, something is going to happen.
A call from the PHS to the Riverside Zoning Board destroyed our chances for quick issuance of our Conditional Use Permit (CUP) and caused the Zoning Board to move for a 90-day continuance on our request.
Life in cryonics continues to be interesting in Riverside and elsewhere.... Some days, Bob, I think you're the lucky one.