From Cryonics, February 1992
by H. Keith Henson
[The patient's name and his wife's are pseudonyms.]
The first indication that our patient was in imminent trouble came less than two weeks before his suspension. "Dennis" had metastasized gastric cancer which had spread into the liver before it was discovered about 5 months ago. He had been out of the country for most of that time in an experimental program which seemed to be having positive results.
On December 4, word reached Alcor that Dennis was in the early stages of liver failure. The patient's wife ("Cynthia") was advised of the near impossibility of doing an overseas transport in his situation, and he was advised to get back if possible. They arrived back on Dec. 7 and checked Dennis into one of the University of California at San Francisco hospitals for evaluation.
The next day (December 8) we moved the transport kit from my place in San Jose, where it is usually stored, to the coordinator's house in Palo Alto (closer to San Francisco). There was a regular monthly meeting scheduled that day, so the local transport team members (Naomi Reynolds, Arel Lucas, Joe Tennant, Leonard Zubkoff, Keith Henson) came early to check out the equipment and review operational procedures. During the inspection/ review session, we found that the fittings on our high impulse heart-lung resuscitator (HLR) were incompatible with the oxygen-supply fittings (something which had been known for some time, but not fixed). Leonard and I did some running around to get it fixed. (The manufacturer — Michigan Instruments — happens to use "M" type air chucks, male on the machine.) We got the correct air chuck from a local hardware store, and that was the one actually used for the stabilization. The next day, Leonard picked up enough of the green Hanson fittings for us to have used those as well.
Tuesday, December 10, I was out getting a second "H" cylinder of oxygen when Arel got the word that our patient was in trouble — serious enough for the team to assemble at the hospital. (Michigan Instrument HLRs use up two "H" cylinders during a stabilization. More oxygen may be needed if some gets used up for pre-stabilization supplemental oxygen, or if no washout is possible. In this stabilization, we emptied one of them and used about 1400 psi from the other one in an hour and 45 minutes of HLR operation.)
When I got home, we transferred some materials into the car — including the nimodipine which had been missed in the first load — threw in our RONKs (specialized Alcor "Remain OverNight Kits") dropped our daughter Amber with (designated childcare people) Laura and Johan, and headed off to San Francisco.
The hospital was fairly easy to find with the directions we had been given, but directions were about all the correct information we had. The initial call to Alcor central had hit when both Mike and Carlos were out of the office (Mike was in a dentist's chair!). Alcor alerted Naomi (our local coordinator) who got in contact with the nurse who had originated the call. The nurse asked what they should do if the patient should die before Alcor arrived, so Naomi read her the abbreviated transport protocol. The Nurse, perhaps in consult with a resident, told Naomi that they could not do this, so Alcor should bring their own medications, which Naomi took to imply that we could administer the transport medications if we brought them. When we got to the hospital, Naomi determined that the hospital would not let us do any of the initial transport protocol within their walls. We would have to remove Dennis and frantically administer the medications in the parking lot. There is a lesson here in knowing who can speak for a hospital; and neither nurses nor doctors can do that. We were allowed to move our portable ice bath into the room along with ice in chests.
About 7 p.m., an Alcor transport team consisting of Mike Darwin, Tanya Jones, and Carlos Mondragon left Riverside in the Alcor ambulance and a rented back-up van. They had a rough time of it going up the central valley in dense fog (Stephen King grade). During a discussion with Cynthia about Dennis's condition (over a cellular phone link) Mike commented that if they drove any faster, our patient was more likely to live through the night than the transport team.
Dennis, while somewhat disoriented and hard to understand, did not seem to be in much danger that evening. He was up to hosting a popsicle party (the humor of this hit days later) and near midnight (trailing oxygen and feeding tube lines) insisted on getting out of bed and into a chair. The reason we had been called was that his condition was deteriorating very rapidly (he had been completely lucid the previous day). His family was worried that the team's presence would distress him, but since he understood his condition, we seemed to be a comfort instead. When he saw the lab coats with the Alcor insignia stitched onto them, he began asking, "Thirty years, true or false?" in accordance with the latest local speculations that cell-repair machines might be available for rescue in that time period.
Discussions in the hospital and over the cellular phone about what we could do in the hospital led to the conclusion that having our patient pronounced there would result in a lot of delay and very serious ischemic injury. The doctors were cooperative, but the administration was not willing to let us do any of the initial procedures in the hospital. We could have put the Alcor legal team on the case, but getting him out of there seemed like a much better idea. There were attempts to get Dennis out of the hospital that night, but it was impossible to make the proper connections and make the complex arrangements needed. The most important part—which couldn't be done late at night—was finding 24-hour hospice-nursing care for quick pronouncement of legal death. In the meantime, the team socialized with Dennis's family and friends, and (using a rough floor plan of the house chalked up on a conference-room board by a friend) decided how to deploy equipment at the patient's home.
About 2 a.m. we split the team, leaving Naomi and Joe at the hospital. Arel, Leonard, and I went over to a motel to get a little sleep. We arranged for a place for Mike, Tanya, and Carlos to stay when they got in. They rolled into the hospital parking lot shortly after 4 am. After checking that Dennis's condition seemed stable for the moment, they went off for a few hours' sleep. After an uneventful night where I slept and Arel did not, we went back over to the hospital at 8 a.m. to relieve Joe and Naomi. The team from Riverside came back from the motel about 11 am.
As soon as she arrived back at the hospital, Arel began to seek out the discharge coordinators who had already made plans to move Dennis to his home. It is hard to say enough about the usefulness of hospital social workers. One of them, Bill Rosenfeld, found hospice nurses, arranged for commercial ambulance service to transport Dennis home, and took care of many critical items that no one else considered. It still took from 8 am to about 2 p.m. to get everything ready.
The hospital asked us to move the ambulance from their tiny parking lot at about 11 a.m. I moved it across the street, and stayed with it parked in a taxi zone so it would not be towed away. If any of you ever get drafted to drive that beast, read the instruction book first. There are ways you can immobilize it, and do several hundred dollars of damage by flipping the battery switch at the wrong time.
Come 2 p.m., the rest of the team, friends and family cleared out of the patient's room and loaded the Pizer tank (portable ice bath, or PIB), ice chests, and some other equipment into the van. Dennis traveled in a regular ambulance with a paramedic crew, his wife, and Mike. Since I have driven trucks before, I was left to drive the Alcor ambulance.
About halfway between the hospital and Dennis's home I ran out of gas. We later determined that this was caused by a stuck valve, which should switch between tanks. Even with the switch in the (full) auxiliary tank position, it was trying to take fuel from the (empty) main tank. On the advice of a mechanic, Carlos banged the valve with a mallet later, but we did not trust that valve for the remainder of the transport. Carlos was behind me in the van, and stopped. Naomi was behind him, and stopped. Naomi went down to the next gas station to pick up some gas, while Carlos left the van parked behind the ambulance to partly shield it from fast freeway traffic. Sitting beside a freeway with cars whizzing by is not my idea of a fun time! Arel came by, and we sent her off to get gas as well, since our car had a gas can in it, and we figured Naomi might have problems getting one (she did not). Naomi came back with a can and we got the ambulance started, after I took off the air cleaner and poured a little gas into the carburetor. Arel locked her keys in the car when she got to the gas station, but we located her because it was the same gas station where Naomi had picked up gas. Naomi and Arel, driving the two station wagons, took off ahead. After filling up, Carlos and I drove the van and ambulance to the patient's home. When we got there, the transfer ambulance was just about to leave, having been held up by the lack of bed padding which was in one of the two cars. It took us nearly two hours to make what should have been a half-hour trip.
Cynthia had had Bill order several cots for us as well as a hospital bed for her husband. Once the padding arrived, Dennis was put in bed in the living room, where (as had been planned at the hospital) the furniture had been pushed back to the walls or moved out of the room. It was the best place available, and gave us adequate room to put the MALSS (Mobile Advanced Life Support System) cart next to his bed when the time came. Some of his friends managed to get a plastic sheet down to protect the carpet. Plastic sheeting and masking tape are going to be added to our stabilization kit. We certainly would have ruined the carpet without it. His friends also acquired pitchers for spreading ice, and 5 gallon buckets for catching blood washout. These should be standard kit items as well. One of his friends also made an airport run to pick up items not brought up with the Alcor South team.
With Dennis in bed, and the MALSS cart unloaded from the ambulance and brought into the dining room, the team and the first of the hospice nurses got together for a briefing from Mike. Either we were very lucky, or the quality of hospice nurses in this area is very high. They were all surprised by the complexity (and evident effectiveness) of the MALSS cart, and the concern that the team members showed for our patient. The nurses were on an eight-hour rotating shift, which brought the first one back the next afternoon. They were all interested in what we were going to do. As our briefing and preparations continued, the first of many visitors began to arrive. Our patient was a well-known and highly-respected figure in Silicon Valley, and had been out of town for some time, so a lot of people came through that night, perhaps as many as 50 people over several hours. The last prominent Silicon Valley figure came through, his latest amour on his arm, about midnight.
Dennis had markedly deteriorated since the previous night and was now in a coma from liver and kidney failure, but there seemed to be no immediate danger of cardiac arrest. We had no idea how long this state might continue; estimates ranged up to a week. Arel and I left for a couple of hours, collecting a small refrigerator from home which could keep some of the ice frozen. When we got back, we sent Joe home. He only had a few hours before being recalled about 1:30 am.
After getting things set up as well as it seemed we could, I went to bed around 1 a.m. Carlos and Tanya set up cots behind the MALSS cart in the dining room. Mike had intended to check into a nearby motel, but Dennis's vital signs kept dropping so he borrowed a sleeping bag and some foam, and slept on the floor of the garage. Arel stayed up watching somewhat longer (not entirely trusting the people who were watching Dennis to call us if he were to quit breathing). I found it impossible to sleep, being on edge and expecting to be called out at any moment. Our patient continued to deteriorate all night, and we were called about 7 am to get ready. There was a frantic effort to get the medications drawn up and to get the Viaspan (washout solution) injected with heparin, insulin, garamycin, and dexamethasone (supplied from our kit, since it had not been sent with the Viaspan). We also primed the MALSS cart and moved it next to Dennis' bed. But we had underestimated the strength of Dennis' heart.
At 11 a.m. we were still waiting. At 11:12 Dennis' blood pressure hit an undetectable low, seemingly 0/0, and then to our amazement he rallied, with color coming back into his fingernail beds. We stood down for a few hours, and managed to send out for some food. There was another crisis which he got through in the early afternoon. We were beginning to worry about the life of the drawn up meds, bacteria growing in the ECMO (Extracorporeal Membrane Oxygenator) circuit, and about the life of the oxygenator. Mike injected some antibiotic into the circuit to extend its life, and was starting to think about what we had available to tear it down and set it up again. About 4 p.m. Dennis began to experience very irregular bradycardia and a falling respiratory rate. Still, he lasted about an hour longer. He was pronounced at 5:03 p.m.
In addition to the transport team, we had several helpers available to move Dennis from the bed to the PIB. Dennis was a large guy (215 lb.), and while he was wasted in the upper body, he was really edematous (full of fluid) in the legs, with a massive abdomen from his cancer-invaded liver. Moving a person of that size can be nearly impossible. We did it by the sheet-pickup method, and lots of helpers; I seem to remember 4 on each side. (A week later, at a memorial at our patient's house, an old friend of mine repeated the aphorism that a friend is someone you call to help you move, and that a real friend is someone you call to help move a body. We had lots of real friends that day.) Moves of this type need to be carefully planned out in advance, with everyone told exactly how it is to be done. In this case, he went out over the end of his bed, and back over the end of the Pizer tank. I removed the IV pole from the MALSS so it would not be in the way, and stuck it back on when they had him placed. The HLR was on Dennis about 2.2 minutes from the time he was pronounced.
Transport team members (L to R) Keith Henson, Tanya Jones, Naomi Reynolds (partially obscured), and Joe Tennant make last minute preparations.
Minutes after "legal death," Heart-Lung Resuscitator support has begun and airway work is underway. Left to right: Naomi Reynolds, Mike Darwi, Leonard Zubkoff, Keith Henson, Tanya Jones.
Afterwards Leonard recommended that we measure our patients and adjust the HLR base to fit. We had significant problems with the HLR plunger moving out of position during use — partly because the massive liver and ascites made the chest slope toward the neck. As a result, the plunger walked upwards and twisted sideways, requiring frequent readjustment.
In a matter of seconds, ice and water were dumped into the portable ice bath on top of the MALSS cart, and the transport medicines were administrated through an indwelling Quinton catheter which had been left in place for us. Shortly after we started the HLR, the hose blew off the plunger. I put a cable-tie on it after Leonard stuck the hose back on. Arel had trouble keeping the airway open, but she learned that when she could hear a death rattle (raspy breathing) the end-tidal CO2 monitor showed good oxygenation, and the only way she could keep the airway open was by hyperextending the neck. This had to be done regularly to avoid poor ventilation. After a couple of these adjustments, a lap pad was rolled up and placed under the patient's neck as a bolster. To augment Arel's suggestion that a bolster should be included with the ice bath, Tanya made a better suggestion of an adjustable strap on the PIB to correctly hyperextend the neck for better ventilation.
It took a lot of strength from Joe or Leonard to keep the mask sealed to the patient's face because of facial wasting (which was also the case with Arlene Fried, whom we stabilized two years ago). Taping the mask on didn't work because Arel had failed to put the tape all the way around the head, and because the water soaked it off. But an elastic or Velcro strap such as that used earlier on the patient's oxygen mask might have helped. We should have intubated him, but what we did worked okay, and Mike, the only person who could have done it, was otherwise fully occupied. (We discovered during the glycerol perfusion the next day that the patient's head had been bruised, probably by being pressed against ice in the bottom of the bath because of the pressure needed to seal the mask.) About an hour into the stabilization the first cylinder ran out of oxygen. There was a quick change of cylinders, and everyone vowed next time to put a regulator on the second cylinder before the first one runs out.
While Leonard, Joe, and Arel were busy at the head end, Naomi was injecting the transport meds. It was not until after the suspension that Naomi realized that she had forgotten to continue to add medications after the initial boluses and continuous infusions were set up. During this Mike and I were doing a cutdown. (Tanya was taking notes, and Carlos was videotaping.) Dennis was very edematous, and his vessels were deep, over two inches below the skin. We used up every gauze sponge we had in the kit and the ambulance trying to keep the operating field dry, and had use for the suction when we had a bleed. The night before, one of the nurses and Mike had spent a lot of time trying to find a pulse from these vessels, and had failed. We tried on the side which had been used for chemotherapy infusions, and gave up. (In retrospect, we almost certainly did not go deep enough). We cut into the other side, and eventually located a vessel with a clot in it, but no artery. After enlarging the incision in both directions, and cutting down to muscle in some spots, we finally found the femoral vein. Cutting through tissue that edematous was a real problem.
The cover photo for this issue of Cryonics illustrates Mike and Keith beginning the femoral cutdown that will enable a field Viaspan flush.
Once we exposed the vessels, Mike had to tie off a number of small branches to get down to the femoral artery. After tying off the distal ends, ligating the vessels and putting a small clamp on the proximal end, Mike clipped partway into the vessels (one at a time) with scissors. He cut the vein first, and then the artery. The cannulas went in with each of us holding one side of the vein or artery. I managed to screw up and backed out the arterial cannula in error. Cannulas need to be securely tied down, because having one come out is very, very hard on the patient. (i.e., in about a minute all their blood is gone.)
Operating an ECMO circuit is tricky; for one thing, you have to be sure to get all the bubbles out of the circuit where the tubing splices into the cannulas. This is done by filling the end of the tubes and the cannulas from a syringe filled with saline. When we finally did get things hooked up, it was a relief to see that the arterial blood and even the venous blood was well oxygenated. Hats off to the head-end crew!
The nurse who pronounced stayed and helped as scrub nurse. It is impossible to say enough good things about her. She was a welcome and valuable asset to Mike. (I was green as grass as a surgical assistant.)
When we got the ECMO circuit hooked up, the patient's temperature was still rather high. He went on bypass after an hour and forty-five minutes, with an arterial temperature of 23.2°C. (Far too much time to do a cutdown, but about the same as Arlene because of the time it took to transport her to a mortuary for the cutdown and washout.) Arlene's smaller mass had cooled much further in that time. Bypass greatly increased the cooling rate, though we could have used a larger heat exchanger.
During the surgery I noticed a few problems with the squid (ice-water circulator). Dennis, being such a large guy, took up the entire tank from side to side. This caused the water to pile up at the head end, and not flow fast enough to the foot end where the pump intake was located, so the pump tended to suck air while the head end of the tank flooded. Two lengths of 2-inch plastic pipe about 4.5 feet long placed in the bottom of the tank would help get the water back to the foot of the tank and the pump.
The heat sink for the blood heat exchanger is water in the Pizer tank. This works, but you need to watch and be sure there is plenty of ice where the water is flowing. A lot of ice was melted between the intake and outlets. I suspect that the heat transfer water was not as cold as it could have been, i.e., it was above 0°C part of the time.
Another improvement for getting heat out of the patient would be to put a grid of small pipes in the bottom of the PIB, and draw or release water through them. This would allow water to flow beneath the patient for much-improved heat-exchange. Large people just cool slowly from the surface. By the time we had completed the cutdown on Arlene Fried she was at the washout temperature. It took about the same time to get Dennis hooked up, but it took considerable additional time recirculating blood to get him down to washout temperature. It just takes longer for a person with three times Arlene's weight.
When the patient was cooled to about 12 degrees, Mike started dumping treated Viaspan into the bag reservoir on the MALSS cart, and opened the venous return line to begin the Viaspan flush. He had hooked up an additional large-bore dump, but the special Viaspan spike broke off in the first bag. We jury-rigged an IV spike replacement (which leaked some Viaspan on the floor) and used a small-gauge port as well. The Viaspan flow rate was very slow, and Mike had to keep turning the pump on and off. At one point he got distracted, and air was sucked into the system, but fortunately none got into the patient. A cross-connect line at the patient end (to take the patient out of the loop temporarily) would have been a blessing to get the bubbles back in the reservoir. In spite of all our troubles, which included blowing the tubing off the oxygenator and putting more Viaspan on the plastic sheet, we got all but one or two of the Viaspan bags into the patient. Mike saved these for buffer for the trip to Riverside.
Mike strives to achieve an acceptable flow rate.
Even with all the cold Viaspan, the patient was still at a slightly higher temperature (4.1°C) than is desirable for transport, but we had to go. Fortunately we still had plenty of people around, because we used them to move the MALSS cart down a step, and take much of the weight off the overloaded wheels as we moved it to the ambulance. (The MALSS cart started life as a gurney.) We bailed out the PIB and removed much of the ice for the short move to the ambulance; still, the MALSS cart and Dennis weighed about 800 pounds. The lift gate on the ambulance worked great; whatever was paid for it, it was well worth it.
During the transfer to the ambulance and for almost the entire drive to Riverside, Dennis was maintained on low-flow circulation. The MALSS cart has two large deep-cycle batteries and a charger built in. We kept the cart hooked up to AC power until we left the house. That left enough power in the batteries to run the cart for many hours. Dennis arrived with no rigor, an indication of adequate metabolic support all the way.
We (Mike, Carlos, Tanya, Arel, Keith, and Naomi) managed to get on the road at 9:16 p.m. I drove the ambulance from Dennis' house to Stockton. After getting out of the Bay Area we hit a solid wall of fog. What with the lack of sleep, I was fading and felt my competence to drive fast into dense fog was lacking, so I swapped with Carlos and drove the van (following lights on the ambulance) for a while. At a gas stop Arel took over driving, and she lost the ambulance in dense fog. (The unholy rush down Interstate 5 was to get the patient to Alcor before the contract surgeon had to leave — although Arel didn't know this.) We drove on for a while, then swapped again after picking up gas at Kettleman City. The fog was so dense at Kettleman City that you could only see one of the gas stations at a time. I made it almost to the Grapevine before deciding that going any further was going to result in a wrecked van. We pulled off the road, called Alcor from a phone, and got a nap between 4 and 5 a.m. The cold woke us up and we reached Alcor close to 8 a.m., an hour and a half behind the ambulance, and just as Saul was rushing the contract surgeon to the airport. He had only managed to get most of the perfusion "plumbing" in place, and Mike was able to take over and complete the job. I know we may have to make do with contract personnel, but I sure am not happy about it. Arel had the shakes from lack of sleep and sheer terror, and since there were plenty of OR people available, she appropriated one of the beds in the crew room for the next three hours.
Setting up for cardiac surgery.
Ralph Whelan (left) assists Alcor's contract surgeon in placing cannulas in the heart.
Closing the circuit is tricky. Mike (right) works bubbles out of the line, with Ralph's assistance.
Wasted as I was, I felt I could not go to sleep, so I scrubbed and dried the PIB on the MALSS cart, and got the cooling set-up together and down to temperature. Later I had to get into scrubs and help Mike, Hugh, and Arel with the cephalic isolation.
During the part of the operation that Mike took over, he had a serious problem with the aorta tearing, but he was able to clamp off the tear. How well our patient had been supported was apparent from the complete lack of brain swelling. All three of the last well-supported patients have lost a large amount of fluid from the burr hole (used to see how the brain is perfusing). Almost the entire perfusion circuit withdrawal amount (which sets the rate at which cryoprotective glycerol is introduced) was exiting through the burr hole. We almost certainly did not transect a blood vessel on the brain or in the dura. Possibly this behavior is just normal for uninjured brains.
Dennis perfused beautifully to a 4.5 molar glycerol concentration with no brain swelling; in fact, X-rays indicated at least four millimeters of shrinkage. Such good perfusion was the result of a number of factors: Cynthia's complete cooperation, Dennis' personal physician (who wrote pre-mortem prescriptions to limit ischemia damage), an incredibly cooperative nurse, relatives who started out semi-hostile and became supporters, a number of friends, a team which could recover from glitches minor and major, and a large amount of luck.
Perfusion underway, Hugh and Tanya monitor the Heart-Lung Machine and various temperature readouts.
After a suspension I always take time to reflect on how things went and how we might improve them. This one, coming right before Mike Darwin's resignation became effective, has more the flavor of "Can we ever do this well again?" I think we can, but it is very clear to me that a lot of hard work (and money) will be required to even partly replace the skills and leadership that we have lost with Mike and Jerry.