From Alcor News Number 11, March 23rd, 2003
Case Summary: Patient A-1234
by Charles Platt
At the end of February this year we initiated a brief standby for A-1234, an elderly woman in Southern California (whose signup documents requested confidentiality). Although she was suffering from severe circulatory problems and had been admitted to an ICU with pneumonia, she managed to recover, and we discontinued our standby. Subsequently she relocated in a nursing home in Hollywood.
On Saturday March 22nd at 8:02 AM Mountain Standard Time a staff member at the nursing home found that A-1234 had suffered cardiac arrest. Attempts to revive the patient were unsuccessful, and the nurse called Alcor's emergency number at approximately 8:15 AM. (All times in this report are in MST, which is one hour later than Pacific time during the winter months.)
Dr. Jerry Lemler contacted me at my home in northern Arizona around 8:20 AM and said he would coordinate activities in Scottsdale while I would organize the Southern California response. I telephoned one of our California coordinators, Bobby June, who was not entirely happy to be woken since he had been up partying for most of the night. Still, he tackled the task of finding a van that we could rent to transport the patient to Arizona. I was worried that renting the vehicle might be the most time-consuming task in the transport operation. This concern turned out to be correct.
I called our other Southern California coordinator, Todd Huffman, who had been planning to go snowboarding with a friend and had already started driving out of Los Angeles. He promptly changed his plans and returned home to grab a backup meds kit. Next I checked my map of Southern California volunteers and found that Peter Voss was located closest to the nursing home. Peter was awake and ready to respond. He left his house to retrieve our primary standby equipment from its storage location before continuing to the nursing home.
Alcor's paramedic Larry Johnson, in Phoenix, tried unsuccessfully to contact A-1234's son, an Alcor member possessing durable power of attorney for health care for the patient. Under California law the nursing home could refuse to release the patient without signed consent from the next of kin, and the son was the only person who could provide this. Since he was probably 60 miles away and is legally blind, I didn't know if it would be physically possible for him to reach the nursing home and sign a release within a short time. However, after I asked our California mortician Joe Klockgether to discuss this situation with staff at the nursing home, they agreed to waive the requirement for a signed release. Mr. Klockgether also had a copy of the death certificate which we had prepared in advance when we arranged the standby for the same patient at the end of February.
In the meantime the nurse who had discovered A-1234 had injected heparin, had administered chest compressions, and had placed ice around the patient. Peter Voss had collected our kit and was on his way, and Todd Huffman would soon be joining him.
The patient's son received our messages and called me, and I told him the news about his mother. He seemed calm but said that the death had come as a surprise, since his mother's health had been improving during the past couple of weeks.
By 10 AM our team members were at the nursing home and I asked Larry Johnson to give instructions via the phone to Todd Huffman regarding medications. (Larry had considered flying to Los Angeles himself, but clearly he would have been unable to get there in time.) Larry described to Todd the technique for putting the patient in the Trendeleburg position, which causes the external jugular veins to become distended. This enabled Todd to place an IV line. It was then relatively easy to push the various medications that we use to mitigate ischemic injury.
I checked back with Bobby June, who was having difficulty finding a truck that we could rent. Trucks often tend to be in short supply for last-minute rentals on a weekend, because this is when many people move personal possessions. Finally Bobby found a truck that was available reasonably close to the nursing home. Peter went to collect it while I conferred with our medical advisor, Dr. Steve Harris, regarding the option of doing a washout before the patient was moved to Arizona.
Intravenous cooling is many times faster than cooling by external application of ice or icewater, and for each 10- degree (Celsius) reduction of temperature, we halve the metabolic rate. If a patient's temperature is reduced from 35 (close to normal) to 5 (our terminal target value), theoretically we reduce the rate of ischemic injury by a factor of eight.
On the other hand, I realized that in order to perform the washout our transport team would have to leave the Interstate highway, find the lab where our surgical team consisting of Steve Harris, Sandra Russell, and Joan O'Farrell were located, wait for the procedure to be completed, and then drive back to the Interstate and continue to Arizona. Depending on how much difficulty our surgeons might have in obtaining vascular access, I estimated that the detour could cost us three hours. Since the patient's temperature was already down to 21 degrees (measured via a nasopharyngeal probe which had been placed by team members at the nursing home), we were already halfway from normal body temperature to the target terminal temperature. With concurrence from Steve Harris I decided that it would make better sense for the patient to go straight to Arizona, packed in ice, with occasional chest compressions along the way.
I called Alcor Central and told Jerry Lemler that the patient's probable arrival time would be between 6 PM and 7 PM. He suggested that I didn't need to come to the operating room myself, since he had assembled adequate staff for the procedure.
The patient entered the facility at 7:02 PM with a probe temperature of 4.1 degrees Celsius. When I called Alcor at 8:30 PM I was told that neuroseparation was complete and perfusion had begun. I was very relieved to learn that no one could find any evidence of blood clotting. Todd Huffman can take much of the credit for this by having managed to place the IV and administer heparin and streptokinase, in resonse to the valuable instructions from Larry Johnson. Another fortuitous factor is that the patient had been taking Coumadin, an anticoagulant medication, before she died.
No edema was visible, and despite a moderate flow rate, by 11:30 PM the patient exceeded the concentration of cryoprotectant necessary to vitrify. We can regard this as a successful case, especially since it occurred with no prior warning. Less than eleven hours elapsed from the moment when we received the emergency call to the time when the patient arrived at our facility. Our only concern is that the time of death remains unknown, since nursing homes typically do not monitor patients constantly. It is possible that A-1234 arrested several hours before she was found at 7:02 AM.
The question of whether to take time for washout and intravascular cooling of California patients during the transport phase remains unresolved. Clearly the procedure is necessary when a patient is located farther away and we want to achieve rapid initial cooling prior to a relatively lengthy transport. Washout is also advisable if the patient has a higher initial temperature, has been collected by a mortuary service, or is close to the location where the procedure can be done. But when our own team members have collected the patient without any paperwork problems and can reach Alcor from Los Angeles in less than seven hours, the simplicity of this option is attractive.
Once again we thank our Southern California team for performing outstandingly at short notice. We regret the loss of A-1234, a longtime Alcor member who would have been 83 next month and showed great courage and tenacity in dealing with her health problems. We're thankful that she opted for cryopreservation, and hope that her decision will be justly rewarded in a future world where death and aging are no longer regarded as inevitabilities.