Alcor Case Report for Patient A-2061

By Aaron Drake, NREMT-P, CCT
Alcor Transport Coordinator
July 8, 2009

Member A-2061:

Member A-2061, age 86, born on April 6th, 1923, a retired computer programming school owner from Colorado Springs, CO, was legally pronounced on June 7th, 2009, of Cerebral Anoxia and Parkinson's disease.

A-2061 started his paperwork for cryopreservation on January 11th, 2003 and was officially approved on January 28th, 2004. He elected for a neuro-cryopreservation and was funded through a life insurance policy through North American LIC.

Background:

Family:

Sons: Peter, Matthew and Andrew.

Alcor Personnel:

Jennifer Chapman, Executive Director
Aaron Drake, Transport Coordinator
Hugh Hixon, Research Fellow
Todd Huffman, Contractor
Nancy McEachern, Contract Surgeon
Regina Pancake, Readiness Coordinator

Known medical history:

Parkinson's disease, Thrombocytosis, Melanoma, Chronic Kidney Disease, Functional Decline.

In the care of Life Care Solutions of Colorado Springs providing 24/7 home health care.

Circumstances of legal death:

Clinical death occurred at A-2061's private residence. Witnesses included Thomas Barton of Life Care Solutions, his sons Peter and Matthew, and employees of Black Forest Fire and Rescue.

Notification of Alcor:

TeleMed received a call at 09:26 am on June 7th, 2009 and dispatched a text message to the Alcor notification list at 09:30 am Arizona time. The information read:
"45)9:26 AM STAT (719-488-XXXX) thomas barton RE Pt A-2061 RE:HUMAN STATUS: DECEASED [ID#:82061][REASON::pt is passing away now, unable to get pulse][LOC".

Narrative:

Note: All times are Arizona time, unless otherwise indicated.

History:

In the fall of 2006, A-2061 became a patient of Select Long Term Care Hospital of Colorado Springs, CO. An agreement among Select, Alcor and A-2061 was executed to comply with the wishes of our member. This consisted of pre-deploying a mini-medication kit with instructions for administration in the event ofA-2061's clinical death. The kit consisted of five medications: Propofol; Streptokinase; Heparin; Epinephrine; and Gentamicin. In 2008, care was transferred to Life Care Solutions for 24/7 home health care and the medication kit was also sent toA-2061's personal residence. On July 8th of 2008, Regina Pancake sent an updated kit that contained non-expired medications along with administration instructions to Becky Birch, the coordinator of the program. In May of 2009, Aaron Drake had spoken with Becky regarding their willingness and comfort level in administering the medications in the event of an emergency. This conversation was initiated during Aaron's routine calls to members considered to be at an elevated level of risk.

Pre-Deployment:

On the morning of Sunday June 7th, 2009, Thomas Barton, CNA for Life Care Solutions was at A-2061's home in Colorado Springs, CO, providing routine home health assistance. A-2061 was awake and at the breakfast table having toast and something to drink, however he had consumed very little that morning. Thomas also noticed that he had difficulty holding his head up. There had been a perceptible decline in A-2061's activity level over the previous two weeks and he had become especially lethargic since the previous Thursday, June 4th. When Thomas noticed that he was beginning to have some difficulty breathing, possibly due to his body's position, he moved A-2061 from the chair to the floor and laid him supine. He then called Alcor's emergency 800 number to give a "head's up". He phoned his office who subsequently called the son, Peter to notify him of his father's condition. Thomas claimed that A-2061 was still breathing however he eventually became unresponsive and Thomas was unable to detect a pulse; so he called 911. When paramedics from Black Forest Fire and Rescue arrived, A-2061 exhibited a couple of agonal respirations before he went into full arrest. The paramedics began to work the code.

During this time, TeleMed sent out a text to the Alcor notification list at 9:30 am. Jennifer Chapman (at home) called Hugh Hixon (at Alcor) to review A-2061's file and determine his Alcor status. TeleMed contacted Jennifer to confirm receipt of the text. Both Jennifer and Aaron (who was out on a bicycle ride at the time) repeatedly called the number listed on the text and it was initially busy. Jennifer directed Hugh to prepare Alcor's operating room and contact Nancy McEachern to determine her availability for surgery, as Jose Kanshepolsky was out of town. Regina was in the hospital with a personal medical issue and was unavailable for deployment. Aaron arrived home in 10 minutes and began to pack and prepare in case he was sent.

At 9:46 am, the deployment committee of Jennifer, Aaron and Dr. Steve Harris conferred over the phone and decided that they did not have enough information at this time to make a deployment determination. Another text and call from TeleMed indicated that Thomas Barton called again, saying that he was on the phone with 911 when we were trying to reach him.

Aaron tried the number again and this time talked to Thomas to better understand the situation and probable outcome. Thomas confirmed that the patient was still alive when the ambulance arrived. The paramedics were working the code, however they were not making any progress as the patient was in Pulseless V-Tach and was not responding to treatment protocols. They were considering discontinuing supportive measures as they believed their efforts to be futile. The paramedics asked if the family preferred to discontinue supportive measures at home and leave the patient for the Coroner to declare or to transport the patient to the hospital and let the Emergency Physician, Dr. Hooker, declare the patient. After consulting with Steve Harris, Aaron told Thomas that Alcor would prefer leaving the patient at home with the idea that pronouncement would be quicker. The theory behind this was that a Coroner would respond quickly to the home because the Sheriff or Paramedics that remained with the patient, to maintain the chain of custody, would need to return to service, where at a hospital, there might not be any sense of urgency to respond. In addition, the home health provider and family were willing to initiate medication administration and cooling procedures immediately following pronouncement. Aaron was able to speak to the son, Peter, about the situation. Although it was emotionally difficult for Peter to talk, he said he was aware of his father's intent to be cryopreserved and he confirmed that he wanted to help honor those wishes.

Jennifer was advised of the situation and she directed Aaron to begin looking for the next available flight. Hugh began to promote a scenario where no deployment would be made and that the mortuary would just send out the patient directly to Alcor. His justification was that it might take too long before we could get to Colorado Springs and gain access to the patient. This option was considered as well but the fact that this was occurring over the weekend made having someone on the ground to help facilitate expediency more attractive.

When Aaron checked the flight status online, he found there were only four seats available on a direct flight to Colorado Springs with US Airways; however he did not book them prior to leaving home as he did not have confirmation that the final decision was to deploy. At 10:45 am, Aaron departed for the airport just in case. While en-route to the airport, Jennifer confirmed with Aaron that the decision was for him to go and that he should go ahead and book the next available flight. Aaron requested that Hugh bring the Medication Kit and meet him at the airport in an attempt to make the next flight.

Upon arrival at the airport, Aaron checked with the ticket counter and all seats on the original flight were now sold out. The next flight was to Denver two and half hours later. As this was the next best option, Aaron booked the flight and planned to rent a car to drive from Denver to Colorado Springs. Hugh arrived with the medication kit at 11:35 am and Aaron checked the kit through as baggage.

It was considered whether to contract with Suspended Animation, particularly to perform a field washout. An Alcor technical advisor was consulted. Based on the fact that cardiac arrest had already occurred, and that transporting a washout team from Florida to Colorado would add hours more of ischemic time, Alcor was advised to just ship the patient from Colorado to Arizona as soon as possible.

Jennifer spoke to Peter and Steve Harris. The Coroner had been contacted and the Sheriff's office was there. He confirmed that the IV had been left in his arm and that they had the mini-med kit. Steve was asked by Jennifer to handle instructions for the family to draw up the meds and Peter was advised to get ice, if possible.

At 11:40 am, Steve walked one son (who had had some experience with syringes in doing farm work) through IV admin of 1) all heparin, 2) 1 dose Streptokinase (mixed and given though the filter), and 3) Epinephrine, which Steve asked to be given only in a 5 mL dose. This was followed with 10 cc of saline to flush all meds into the line (an arm line, apparently). Clamp valve to the bag was turned off the whole time. Due to circumstances, Steve had them omit the Gentamicin and Propofol. They also had another dose of Streptokinase which Steve had them hold in reserve. This process took about 15 minutes.

After the meds were in, Steve had them start chest compressions, 30 - 60 a minute, for 10 minutes. They were comfortable doing this and understood the reason for it. Steve heard on the phone as they started the compressions and seemed satisfied they were going well. They had sent another son to get ice and would pack the head after finishing compressions.

Jennifer called Steve Rude. He advised that Colorado is a sign-and-file state. When the funeral director arrives, he will get necessary vitals so everything can be expedited. He instructed National Shipping that we want the patient sent cold. They briefly discussed the logistics of shipping and the need for a direct flight. The family also expressed concern about having a memorial service and that the patient's wish was for the remainder of his body to be cremated. Steve Rude said he would call and talk to the family regarding this.

Springs Funeral Home arrived at the home at 12:30 pm (1:30 MDT). They loaded and transported the patient, packed in ice, to the mortuary where the gurney was placed into a 34 degree F. walk-in cooler at 1:00 pm (2:00 MDT). The ice was removed from around the patient to allow for the cold air flow.

Hugh and Jennifer discussed the possible candidates for the surgical team and made calls to determine availability.

Deployment:

At 2:55 pm, US Airways flight #490 departed for Denver and arrived at 5:42 pm. After collecting the medications kit from the baggage terminal, Aaron rented a car and began the two-hour drive to Colorado Springs. Along the way he spoke with Jennifer and Hugh to confirm the plans for the evening and tomorrow. He also called and spoke briefly with the son, Peter, to alert him of his arrival. Peter kept the phone call brief as family had just arrived and he needed to tend to them. They agreed to speak early in the morning to obtain the remaining vital statistics needed for the death certificate.

Aaron arrived at the Springs Funeral Home at 8 pm (9 pm - MDT). He met with Paul Wood, the funeral director who had spoken with Steve Rude earlier in the day. They spoke about cryonics for around 15 minutes and covered what processes he would need to perform at his facility. Paul was very willing to help and said he would be available no matter what time of day or night it was. They viewed the patient that was kept in the cooler. No ice was currently around the patient but cold air was blowing across the surface. Paul said they had removed the ice upon arrival as they thought the cold moving air would cool the body temperature quicker than if the ice bags were blocking air movement. The patient felt very cold to the touch and was sufficiently stiff. The right arm was bent and cocked in a 90 degree position. The IV tubing was visible however upon further examination it revealed that it was not intact in the patient's arm as originally thought. Even at 10+ hours after clinical death coupled with the sufficiently cold storage, the blood still flowed profusely from the patients IV wound when the arm was straightened, due to the administration of our medications. 4X4s gauze pads and Coban wrap had to be used to stop the bleeding.

The mortuary's storage cooler was only tall enough to accommodate rolling cots with bodies on top and was not feasible for someone to stand inside. Aaron decided to build a makeshift ice bath out of an inverted air shipper box. This way, ice could be placed around the patient to maintain the cold temperature and then be moved to another room where medications could be administered. The patient was returned to the cooler while Aaron began the process of drawing up the medications. At Aaron's direction, Paul left to purchase 20 bags of ice and 2.5 gallon zipper style plastic bags.

It took around 45 minutes to draw up the medications. Steve Harris had advised to give all of the meds that had not been administered by the family, with the exception of the Propofol. Alcor keeps the components of its med kits in three different locations based upon the different levels of temperatures needed for storage. Because of this, it is possible for someone to not obtain all the meds needed, especially if done in a hurry. While drawing up the medications, it was determined that the Mannitol, which is stored separately, was not in the kit.

The temporary ice bath was constructed on top of a cot and held together with duct tape. The patient was moved into the box and then surrounded with bagged ice, which had been placed into zip lock bags. This entire unit was then moved into another room for Aaron to work.

After donning the necessary Personal Protective Equipment, Aaron established a peripheral IV in the vein of the antecubital fossa of the left arm on the first attempt. Due to the position and height of the box surrounding the patient, the IV had to be started left handed. An 18 gauge over-the-needle catheter with a saline lock was used and secured with Tegaderm. Blood return was observed and flushed with saline. No redness, swelling or signs of infiltration was noted and patency was determined to be intact. Coban wrap was applied to further secure the IV site. The medications were systematically administered in the proper order per protocol. There was difficulty in introducing the Nasal Gastric tube supplied due to its thickness. However, it was eventually placed. After delivering around 60 cc's of the Maalox, blood started to return up the tube and had to be clamped using hemostats. Aaron called Hugh to inquire about the unexpected events and Hugh said that due to the elapsed time from clinical death, the buffering agent was not needed and that he could discontinue that medication. The tube was extubated and a pool of blood was noted in the oral pharynx. There were no thermo couples in the Med Kit to develop a temperature profile in the field.

All medications were flushed with saline and chest compressions were applied to promote circulation throughout the patient. After completion of this procedure the patient was returned to the cooler. Aaron cleaned up and spoke to Paul about the plans for the following morning. Paul was planning on contacting the physician of the health care service to determine the cause of death, get the Coroners signature (office open at 9:00 am MDT) and finally to obtain a health department permit. The contingency plan was to be granted a deferred death certificate. This is a certificate that allows for transport but is incomplete for some reason. In this case, it may take too much time to determine the cause of death as no one may be available to make an immediate determination. The mortuary felt very comfortable that they could obtain this if needed. Paul also provided Aaron with a list of questions for Peter so they could complete the death certificate paperwork.

Aaron had just checked in to a motel at around 12:30 am (MDT) when Jennifer called to review the actions of the evening and to determine a possible timeline of events for the next day. To promote expediency, it was decided to only allow for a short window of time to obtain a "cause of death" from a physician before attempting to obtain the deferred death certificate.

At 6:00 am the next morning, Jennifer called Aaron to discuss the logistics of preparing the shipping container and keeping the patient cold. A Ziegler case had to be obtained from Denver and the mortuary had someone assigned to starting on that early in the morning.

Aaron called Peter to collect the remaining vital statistics of his father and explained the plan to ship the patient to Alcor, in Scottsdale, later that same day. Aaron provided this information to the mortuary when he arrived. By 9:30 am it was decided to obtain a deferred death certificate from the Coroner. National Shipping was coordinating the flight arrangements and was experiencing difficulty in finding an airline that would accommodate a "wet-ice" shipment.

Eventually, United Airlines was selected and a 4:00 pm flight was booked. There was a push for an earlier flight but it just was not feasible. The mortuary needed to get a Ziegler case from Denver, construct the shipper, load the patient, load the Ziegler, transport back to Denver (up to 2 hours) and deliver to United Cargo two plus hours prior to departure. It appeared that a 4:00 pm flight would be the earliest that could be achieved. If we pushed a lot harder we could maybe gain an hour but we could also get pushback which might greatly delay the process. Aaron booked a seat on the same flight as the patient was scheduled to take.

Aaron directed the mortuary to send someone out to purchase 2X4 pieces of wood and insulation to complete the construction of the ice shipper. Aaron supervised the construction of the shipper to ensure that it met our guidelines to provide the best possibility to maintain cold temperatures during travel. During this process, the mortuary received notification that the Health department had issued the permit and all the paperwork was prepared. The Ziegler case had arrived and the patient was placed and packaged with ice on all sides. This was then secured into the Air tray, labeled and the paperwork was secured in a document holder on the outside of the shipper. By 12:00 pm they were putting the finishing touches on the box and getting it loaded into their hearse. They departed at 12:15 pm for the Denver airport.

Aaron obtained copies of all of the paperwork, everything that the mortuary had as well as what was being shipped with the container. He said his goodbyes and gave thanks for their assistance. They provided feedback that they felt they would have been the only funeral home in the city that could have pulled this project off as quickly as they had accomplished it. Most local mortuaries would not have even have accepted a cryonics case and it could possibly have taken numerous days to complete if we had used someone else. So they thought the selection process that we used to find them, National Shipping through Steve Rude, was very good.

Aaron traveled to Denver and called Paul to confirm that the shipment had arrived at the Cargo desk as planned. Paul said that he had received confirmation from the airline that the shipment had arrived prior to the two hour deadline required. United flight #523 departed at 4:03 pm MDT and arrived at 4:54 pm Arizona time.

Upon arrival in Phoenix, Aaron traveled directly to Alcor to prepare for surgery as Rude Family Mortuary was on site to receive the shipment. Steve Rude called at 5:54 pm to say that the patient was not on the scheduled flight as expected. He has no idea why and found it unacceptable. The patient was at the airport on time and the air bill said "express". Regardless of the circumstances, the patient was now on United flight #329 and was scheduled to arrive at 7:28 pm Arizona time. They will unload immediately as soon as the plane touches down. His representative is at the airport and they plan on filing a grievance and/or claim.

Surgery

Back at Alcor, the surgical team had been assembled and was awaiting the arrival of the patient. On hand were Nancy McEachern, D.V.M., as Surgeon, Hugh Hixon as Perfusionist, Todd Huffman and Bruce Cohen as general help, and Aaron Drake representing patient transportation.

Rude Family Mortuary arrived to Alcor with the patient at 8:40 pm and the shipping container was transferred into the surgery bay. There was some condensation noted on the exterior of the Ziegler case after removing it from the shipping container. Examination showed that the patient was packed very well with ice and was still completely covered. The patient was removed from the container and placed onto the surgical table and repacked with bags of ice.

By 8:48 pm, Todd began to prep the head and initiated shaving. He noted that a small nick to the scalp produced substantial blood flow. He also noted some blood in the oropharynx. Aaron confirmed that he had noticed this after inserting the nasal gastric tube in Colorado Springs, and he relayed his experience, as described previously in this report. At 8:59 pm the patient was repositioned so that the head was closer to the edge of the surgical table.

Dr. McEachern sterilized the freshly shaven head with isopropyl alcohol and made two incisions in to the scalp to prepare for the bur holes. She commented that the patient was bleeding out of the incision and that apparently the anti-coagulants did a very good job at keeping clots from forming. After the second incision was made, spreaders were used to open an area for the craniotome perforator. Todd held the head while Bruce starting on making the first bur hole. Todd took over the craniotome when Bruce had difficulty in advancing the perforator all the way. Todd finished the first bur hole and then completed the second bur hole. Hugh and Dr. McEachern cleaned up both holes with a Sperling Kerrison rongeur. It was noted that it was difficult to see the membrane due to a substantial amount of blood which raised the possibility that the patient may have had an aneurysm, which may have contributed to his clinical death.

Hugh stated that the crackphone was not currently functioning so we would be placing a thermocouple only. Dr. McEachern placed the right thermocouple and secured it with bone wax, however it was later removed for observation purposes. The patient was repositioned so that Dr. McEachern could access the patient's neck, utilizing ice bags to prop the shoulders and head. She felt she was still too low for optimal access so a step stool was brought in to increase her height and angle. She also requested repositioning of the surgical lights and to lower the ambient temperature of the surgical bay. At 9:30 pm, she made the first incision into the left side of the neck and worked towards identifying the left carotid artery. At 9:41 pm it was identified and clamped off. The patient was then repositioned to expose the right side of the neck and an incision was made to search for the right carotid artery. After 15 minutes, the artery was identified and clamped at 10:05 pm. Over the next six minutes the process of cutting the skin and tissue around the neck was completed. Todd then used an osteotome to separate the cranium from the body. At 10:15 pm, cephalic isolation was complete.

Todd moved the head to the neuro isolation enclosure and it was fastened into place. Hugh inserted the right cannula into the right carotid artery and Nancy sewed the cannula into place. Todd, who was at the perfusion unit, noted that the pressure reading was 154 however the reservoir was running low. Adjustments were made in the speed to 70 and pressure to 60 and the reservoir began to refill. The left cannula was inserted and secured. Perfusate was observed to flow from both vertebral arteries, indicating a functional Circle of Willis and so the vertebral arteries were clamped off. A nasopharyngeal thermocouple and jugular thermocouple were placed to monitor temperature. The Lab View system was started and Hugh noted that they were getting really good flow. At 10:56 pm, Hugh switched over to a closed circuit; the top of the cephelon enclosure was placed; and the cryoprotective ramp was started.

Over the next five hours, the cryoprotectant concentration in the head was increased and monitored by manual refractometry. At 3:54 am, effluent from both jugulars had been over the desired terminal concentration for 1/2 hour; and the cryoprotection was ended. At 4:15 am the patient was transferred to intermediate storage.

Conclusions and Findings:

Present:
Aaron Drake, Hugh Hixon, Regina Pancake, Jennifer Chapman, Aschwin de Wolf.

Telepresent:
Brian Harris, Todd Huffman

  • Communication: Communication among team members was challenging at the onset of the case as multiple calls were being placed simultaneously. There was an idea put forth of using a conference call system to facilitate; possibly using Yammer or Alcor's conference call device in the conference room.
  • Booking airline: Aaron did not know that he had the authority to book a flight in anticipation of deployment without obtaining prior permission. It is better to book and secure a seat rather than run the risk of missing the next available flight. Jennifer has since told Aaron that he has this latitude to make a best judgment call.
  • Handoff of the Meds Kit: Excellent team work in getting the meds kit to the airport for Aaron to take on the flight, however the Mannitol medication, which was stored separately, was not included when the meds were gathered.
  • Pre-deployment of Meds Kit: The effectiveness of this action was evident by the thinness of the blood after 10 hours and 36 hours after clinical death. The home health care agency expressed their appreciation in having Regina sending them a current med kit to have in place for the patient.
  • Med Kit as airline carry on item: It would be beneficial to have a "script" issued by Steve Harris to allow us to take the meds kit on board rather than sending it as checked luggage. TSA has issues with sending this much liquid medication on board without a label or script associated. This could save as much as an hour if you do not have to wait for baggage.
  • Additional supplies in Med Kit: There needs to be IV supplies such as catheters, tubing, saline bags, saline lock with 3 way stopcock, syringe flushes etc. Some of these items are contained in the support kit but it did not come with the meds kit. Aaron was only able to start an IV since he brought a personal kit of supplies from home.
  • Research new TSA shipping regulations: Starting July 1, 2009, the TSA is establishing new requirements for shipping of human remains. We need to identify a method of how to quickly locate a funeral home that has gone through the process of becoming a certified shipper.
  • Article in funeral home industry magazine: To gain visibility in the funeral home industry, we should try to write an article about cryonics in an industry publication. Our expectations are not that every funeral home director will read it but that we will gain credibility by being able to refer to it.
  • Need staff training on Alcor's member database: Jennifer commented that few staff members have the knowledge of how to get into the membership database to identify if someone is a member or not. We could also consider using a licensed Google document database so we can access the information remotely.
  • When to perform a remote washout: Jennifer would like to have a document that identified what criteria to use when determining when to perform/not perform a washout in the field.
  • Remote temperature profile: It is very important to have the data from a DualLogR of the temperature readings of the patient while on scene and during transportation. This should be included in the expanded Med Kit container.
  • Difficulty in introducing the NG tube: This tube was homemade by Hugh and should really be used as an OG tube due to its size and thickness. The size was chosen because of the thickness of the Maalox.
  • Use of Personal Protective Equipment during moving of the patient: We did not really wear the appropriate PPE in the OR while moving the patient. We stayed fairly clean but this will probably not be the case as a matter of course. Typical OR protocols call for dual layer of protection from patient and provider when moving or handling.
  • Need to identify additional surgical personnel: We do not have as many people around Phoenix that have practical surgical experience that we can call on to participate on a case. We need to identify and/or cross train more people.
  • Use of a surgical knife over a scalpel when performing neuro separation: The scalpel blade came off during the procedure and left a very jagged appearance. A specific knife would eliminate both of these issues.
  • We need to investigate the cause of the shipping delay: In order to prevent this from happening again we need to identify the cause. We do not have the authority to obtain this information from the airlines. We will need to go through Steve Rude and National Shipping.
  • We need a list of time checkpoints to include, but not limited to: Call received; confirmation; launch determination; departure; on-scene arrival; begin meds administration; complete meds administration; complete legal paperwork; complete shipper; depart for airport; departure time; arrival at PHX; arrival at Alcor; time to first cut; time to begin perfusion; time to end perfusion; time to cool down start; time to end cool down; time to transfer, etc.

Graphs and Tables:

Manual Refractive Readings