From Cryonics 2nd Quarter 1995

Elements of a Transport

by Tanya Jones

Elements of a Transport

People are usually surprised when I tell them that when handling the suspension of an Alcor patient, my biggest sense of accomplishment and relief usually occurs before the actual suspension procedures even begin. I've participated in about a dozen suspensions and almost that number of transports. With some suspensions, I've felt joy. With others, terror. But either way, from the moment I walk in the door with a patient, a huge weight begins to lift from my shoulders. While the job is far from over, the hard part is done.

Why is it that most of the major obstacles to a favorable cryonic suspension occur before the patient arrives at the Alcor facility? What makes transporting a "legally dead" person so complicated? Presenting and explaining the many aspects of a "successful" transport is difficult, but it's important that Alcor Suspension Members and potential Members understand the complexity involved, since each of you is in a position to dramatically improve your chances of a successful transport by taking some action now.

The major components of a cryonics patient transport are Infrastructure, Mobilization, Patient Acquisition, Stabilization, and Transport. Let's look at each of these separately.

Transport Summary and Timeline,
with Patient Temperature Correlation
by Ralph Whelan

The transport of a cryonic suspension patient can be broken down into five basic categories. Four of those categories are graphically displayed in the illustration at the top of this page, along with patient temperatures for a hypothetical transport beginning in New York and ending in Arizona. The fifth category, Infrastructure, is not depicted because it refers to transport readiness, rather than an aspect of the actual transport.

Mobilization

When Alcor is notified that a cryonic suspension is imminent, we immediately put our representatives in touch with the hospital personnel caring for the patient, while other Alcor personnel notify transport team members local to the patient, begin negotiations with local morticians, and begin air transport arrangements for team members and for the patient. In this example, the patient is distant from the Alcor facility, but is expected to live for several hours.

Patient Acquisition

About eight hours after Alcor's notification, and shortly after the arrival of the transport team, the patient is pronounced legally dead. The hospital allows the team to begin immediate surface cooling, so his temperature slowly begins to drop. Meanwhile, various legal requirements for his release are being fulfilled by Alcor personnel and a local mortician. Twenty minutes pass before the hospital is prepared to release the patient.

Stabilization

Once in Alcor's care, the patient receives medications that will prevent clotting, reduce metabolic demand, protect his cells and prepare them for the low temperatures ahead. The team relocates to a local mortuary, where a field Operating Theatre is already assembled. A "femoral cutdown" is performed and the patient's blood is replaced with an organ preservation solution, while his core temperature is quickly reduced to near (but above) freezing.

Transport

The patient is packed in ice in a specially designed transport container and taken to a local airport; the airport personnel are expecting him. He is placed on the very next available flight, though most of the transport team must take a later flight. Waiting in Phoenix are more Alcor personnel, who've negotiated with the local airline representatives for a prompt transfer to the waiting Alcor ambulance. The patient is driven to Alcor's main facility.

Infrastructure

A patient stabilization generally involves cooling the patient in a portable ice bath, administering medications to protect cellular integrity, replacing the patient's blood with an organ preservation solution, and preparing the patient for shipment to Alcor. For local emergency response, Alcor has an ambulance. This ambulance is well equipped to allow a transport team to carry out each of these steps internally, but naturally ambulance travel is usually limited to the Phoenix area. (Air travel is much faster for distant regions.) With several days' notice of a member's decline, however, the ambulance has traveled to northern and southern California, and may be used in other nearby states.

Remote emergency response (where "remote" means beyond ambulance range) requires Alcor's remote stabilization kit. This kit consists of eight sturdy boxes which accompany transport team members on a commercial airline. Together, these boxes replicate the capability of the ambulance in a relatively compact, if less convenient, package. Because shipment of the remote kit could cause serious delays in the patient's stabilization if pronouncement is unexpected, some local groups of Alcor members have been issued smaller versions of this kit. These kits generally contain medications and a portable ice bath. Some also contain a mechanical cardiopulmonary support device and oxygen. With this equipment and the cooperation of a local mortician or funeral director and/or trained local Alcor volunteers, a patient may be stabilized for shipment to Alcor.

Simply having equipment available is not enough to carry out a transport, nor is it enough to ensure that a patient will receive a good stabilization or transport. There are many things that people may do to prepare for their eventual suspension.

First and foremost, of course, a person must be a member, i.e. sign up. Generally, a cryonics organization will not suspend an individual who has not chosen to be frozen. Legal documents establish this intent, and some states have laws which require that a person's wishes for the disposition of their human remains must be followed as long as they don't impose a financial hardship on the family. A signed Cryonic Suspension Agreement and Authorization for Anatomical Donation will go a long way toward demonstrating the desire to be frozen. For those who haven't decided which organization to sign up with, but who know that they do wish to be frozen, the Declaration of Intent to be Cryonically Suspended is a form which establishes intent without obligating the individual to a specific organization, and without empowering or obligating a suspension organization to freeze him/her. (These forms are available from Alcor upon request.)

Another legal document which is useful to a cryonic suspension patient is the Durable Power of Attorney for Health Care. With this form, an individual chooses a medical surrogate (an agent to make medical decisions when the individual is unable to communicate his intentions) and states the degree of medical intervention in an emergency. For example, I have no desire to be connected to life support equipment if there is no hope of my waking from a coma with my identity intact, and this is specifically detailed in my DPAHC.

A transport may be impeded by relatives of the patient, especially if they haven't been informed of the patient's desire to be suspended before Alcor's services are required. In one of Alcor's cases, the patient's relatives had only heard cryonics mentioned by the patient once, and that had been years before he became ill. They had no idea that any paperwork had been signed and were initially defensive and unhappy. For this patient, things ultimately worked out well, because he came from an understanding and supportive family. The desire for confidentiality will always be respected by Alcor; however, a person who informs his family of his cryonics arrangements before decisions must be made during a crisis will probably receive a stabilization superior to one who does not. Family members will often be the ones to call Alcor when a member becomes ill, and having their cooperation is crucial. We are always willing to have discussions with family, medical staff, and morticians in advance of a suspension.

Having some familiarity with Alcor's cryonic suspension protocol will also help an individual explain cryonics to others. Alcor's introductory handbook, Cryonics: Reaching For Tomorrow, and Cryonics magazine carry information about Alcor's procedures, in the form of suspension or research reports and explanatory articles. Detailed information is available to those who attend Alcor's transport certification course. (To date, Alcor has offered this course at no charge.) During this week-long course and subsequent refresher weekends, Alcor members are introduced to the specific cryonic suspension protocol, to the equipment used during a transport, and to the multitude of technical and medical references used to formulate the procedures. They are shown how every hand can be of assistance during a transport. Many go home and share this information with other Alcor members, their family, and friends, thus expanding the resources upon which Alcor may call during an emergency.

Knowing about the protocol is great, but there's much more than that to optimizing your own chances for a favorable transport. Each Alcor member should consider preparing a list and map of local suppliers for transport supplies and consumables and sending copies of these to Alcor. As an example, oxygen cylinders may not be transported on commercial airlines, and oxygen is needed both to power the mechanical cardiopulmonary support (CPS) device and to oxygenate the patient during stabilization. Alcor's central remote kit carries an air compressor (which has never been tested in a field situation) as an alternative for the CPS device and a bagging device which will respirate the patient with room air as an alternative to pure oxygen. However, these alternatives are less effective and more labor intensive and will only be used in cases where compressed oxygen is unavailable. Ice (hundreds of pounds) must be available 24-hours a day. Generally, local grocery markets carry ice in this quantity and increasing numbers are perpetually open as well. Having a central list with this and similar information will aid the transport team in their attempt to do the best that they can for you.

For legal reasons, in most states no transport can be performed without a local funeral director or mortician's involvement. We expect this to change as cryonics continues to become more commonplace. Adding the names, addresses, and phone numbers of local funeral homes and mortuaries can save a lot of time during an emergency. Contacting some in advance is even better. Morticians are generally quite interested in cryonics and sympathetic to an individual's desire to be cryonically suspended instead of buried or cremated. Morticians are usually needed to secure the release of a patient from a hospital; they have space, equipment, and supplies which can be useful — especially in an emergency; they are frequently willing to assist with femoral surgery or perfusion and are experienced in carrying them out quickly; and they have a comprehensive knowledge of the legal and practical requirements for transporting a patient across state lines and are frequently willing to prepare the paperwork.

A member who chooses to assist Alcor in negotiating a contract with a local mortician has many things to discuss, and should have some familiarity with Alcor's protocol. (However, if a member simply finds a cooperating funeral director, Alcor personnel are available to conduct the contract negotiation.)

Mortuary contracts should at least address the 24-hour availability of an individual who is capable of signing for the release of a patient from the hospital. Some morticians have had sufficient personnel available to stand by with the transport team members to enable the fastest possible release of the patient from the hospital. If a mortuary transport vehicle is to be used to take the patient to the funeral home and the patient will be in the portable ice bath, the mortician will generally have to remove his gurney from the back of his vehicle before taking it to the hospital, so that the patient may be loaded.

Alcor will usually supply the personnel needed to stabilize the patient for transport, and in these cases, will need the uninterrupted use of a "prep" room table for at least two hours. If suction is available, it might be useful during the washout procedure.

Because of the volume of equipment needed during a stabilization, storage space is also required for the duration of the standby. If the equipment is placed in a prep room that will not be needed by the mortician during the time frame of the standby and transport, it may be possible to string the perfusion circuit in advance of pronouncement (and save up to thirty minutes later).

In cases where insufficient trained personnel or equipment are available, morticians have been used to perform femoral surgery, and their embalming pumps have been used (only when those pumps have variable pressures which may be set to meet our needs). The conservative approach to cryonics requires that the conditions of a hospital operating room be duplicated throughout a stabilization. As a result, any mortuary equipment which is used must be thoroughly cleaned and rinsed with sterile water (and sterilized, whenever possible) before being used on a patient.

It's important to note that, while morticians and their equipment are sometimes relied on heavily in an emergency, members can usually avoid the risks inherent in this option by (when feasible) keeping Alcor well-informed of all serious surgeries and life-threatening conditions. Note as well that, while mortuary contracts have been negotiated at the last minute, they have occasionally turned out to be with unprincipled persons who charge Alcor unreasonable amounts because of a misconception that cryonics is a profit-making venture. Emergency contracting should be avoided whenever possible.

When an emergency response begins, a transport team must have access to everything listed above (and more). Having things done in advance means that the team members may concentrate on other, equally critical aspects of preparedness.

Mobilization

Transport team members are deployed by Alcor Headquarters upon notification of an Alcor member's distress. There are three basic categories of emergency mobilization and each is dependent upon the condition of the patient when Alcor is called: the patient has a known terminal illness and will suffer a predictable course of deterioration; the patient has been admitted to the hospital after the sudden onset of illness or accident and is unlikely to survive for more than 12-24 hours; and the patient has died suddenly and is at risk of autopsy.

Advance Notice of Death

With advance notice, a remote standby may be deployed. In a standby, a transport team is deployed before the member has been pronounced legally dead. Advance deployment generally means that the team can prepare for the impending transport, take the time to negotiate service contracts, facilitate a smooth and speedy release of the patient, and procure all of the necessary equipment and personnel before the patient is pronounced. This significantly improves the chances of a smooth stabilization. Standby contracts are optional but highly recommended.

A transport team may be comprised of one or more Alcor staff members, one or more experienced transport team members flown in from around the country, and one or more local volunteers. These team members will invariably interact with members of the conventional medical community. Every interaction between that physician, hospital administrators, charge nurses, or hospice nurses and Alcor personnel will affect how well the patient is treated prior to and immediately following the pronouncement of legal death.

The climate is changing. In the past, when transport team members discussed cryonics with conventional medical personnel they were often met with hostility and fear. Today, I can't remember when I last encountered this attitude during an emergency. This doesn't mean that there is uniform acceptance of cryonics in the medical community, but there certainly is more curiosity than ever before. An interested physician or nurse can do a lot to see that the patient is given a head start toward a good stabilization. (But this is a hospital — the shifts change every eight hours or so, and the cryonics arrangements must be discussed anew with each staff member.)

What would we ask for? We'd like access to the patient. (After all, it's something we ought to know if the rosy-cheeked patient who laughed heartily with you that morning is lethargic and pale by evening.) We'd like to wait nearby. Is the floor lounge comfortable? The transport protocol demands that cooling begin immediately after pronouncement. Ideally, we should have our equipment in place at the moment of pronouncement, and that can only be accomplished if it is stored nearby. How about the next room or the storage room down the hall?

Cryonic suspension procedures may only be implemented after legal death has been pronounced. Because of the known dangers of ischemia, we'd like to have a physician available at all times to pronounce. If we have to wait, may we pack the patient's head in ice? Can the hospital provide the ice? Many patients will receive intravenous (IV) therapy during their hospitalization. If any IV lines are in place, leaving them in means that once the patient is released, Alcor personnel can begin injecting cell-stabilizing medications immediately without placing a new line. (This also applies to airways.) Will they leave all lines secure? And if there are no IV lines, may one be placed before pronouncement? Lastly, we'd like to begin our transport procedures immediately after pronouncement, as we are running for the door.

Most doctors encountering a transport team have called in the hospital administrators when faced with these questions. The transport team leader will present cryonics to an administrator (and sometimes, to an accompanying attorney) who is primarily concerned about hospital liability. A Hold-Harmless Agreement may be offered to the hospital which states that Alcor will not hold the hospital responsible for any charges or damages arising from a civil lawsuit over the cryonic suspension of the patient.

Alcor literature and other cryonics information is carried with the remote kit, and may be handed out freely to doctors and administrators. Transport team members have occasionally found themselves performing impromptu talks when many hospital workers express an interest in Alcor. Taking the time to inform these individuals about cryonics and the unusual way they can help their patient is rarely a waste of time, and it can be quite invigorating to present a neat idea to a receptive group of people.

Some terminal patients are discharged from the hospital and placed into home hospice care. Home care is generally limited to patients with a terminal illness who wish to die at home. Performing a transport from an Alcor member's home can be challenging.

All of the above considerations apply in these cases as well. The question of prompt pronouncement becomes more critical, as in some states hospice nurses may pronounce legal death. In others, the patient's physician must pronounce. Whoever declares legal death, the patient's physician must sign the death certificate. Without a signed death certificate, no patient may be transported anywhere. (Certified copies are obtained later.)

Emergency Notification

In cases where little advance notice is available, there will be little time to negotiate contracts or cooperation. The quality of these transports is often determined by the caliber of people the team encounters, and the speed with which the team members and equipment arrive. Depending on how long it takes to obtain custody of the patient, the stabilization protocol may be modified.

If there is significant delay before the team can begin, oxygen may not be used at all. Reintroducing oxygen to a physiology which has used all of its oxygen supplies and is consuming alternative forms of energy causes additional damage. Some of this "reperfusion injury" may be avoided if the patient is not oxygenated during stabilization. This is generally only for patients who have experienced more than an hour without heartbeat or breathing before stabilization procedures are started.

If the delays are extreme (several hours), it may not be possible to replace the patient's blood with an organ preservation solution before shipment. Decisions of this nature are made by the transport team leader in consultation with Alcor Headquarters.

Sudden Death

Sudden deaths are rare, but they do occur. When they do, members of the transport team often will interface with a coroner or medical examiner, and the patient risks autopsy. Currently, five states (New York, California, Rhode Island, New Jersey, and Ohio) allow an individual to state his objection to being autopsied by signing a Religious Objection to Autopsy, and there is no requirement to state the specific objection. Maryland also has a weaker, but still useful, version of these statutes.

There are some cases where an autopsy is required by law, and the religious objection form will not prevent the dissection. The Centers for Disease Control (headquartered in Atlanta, Georgia) have the authority to require an autopsy for all patients dying from specific contagious illnesses. This has never happened to a cryonic suspension patient (to the best of my knowledge) and if it ever does, the patient will probably be fortunate if any portion of their brain is suspended. Local coroners have also been known to conduct independent investigations into disease. In one Florida county, the coroner stated his intention to autopsy every person dying of AIDS in his county. (He later softened his position on this somewhat, after local Alcor members met with him to discuss the matter.)

Autopsies may sometimes be unavoidable, but there are things which may be done to minimize the damage to the patient. Transport team members should try to have the scope of an autopsy limited to the minimum dissection necessary to determine the cause of death. The pathologist may be able to avoid damaging the brain and still fulfill the requirements of the investigation. An attempt should be made to have the autopsy performed right away. If the patient dies late in the afternoon, and no autopsies are scheduled until the next morning, the transport team leader may offer to compensate the county for any overtime involved, if the autopsy is performed immediately. If there will be a delay, the patient should be kept in a morgue cooler at temperatures above 0°C to prevent the tissues from freezing. Patients who are autopsied almost never receive a washout or cryoprotective perfusion.

Once the autopsy is complete, the transport team leader must verify that all of the organs are intact or have been placed with the patient. Then, the patient is shipped to Alcor.

Patient Acquisition

The legal status of cryonics is somewhat ambiguous. Because our patients have been declared legally dead, the custody of their human remains may be transferred to Alcor via the Uniform Anatomical Gift Act; but little legislation exists in this country which deals specifically with cryonics (see The Legal Status of Cryonics by Steve Bridge, Cryonics, 1st Qtr, 1995).

Personnel in the field will work with Alcor Headquarters to secure the release of the patient. Alcor will deliver copies of the patient's paperwork to the hospital and mortuary, as the situation merits. These legal documents consist of the Cryonic Suspension Agreement, the Authorization for Anatomical Donation, the Consent for Cryonic Suspension, and powers of attorney for health care or Relative's Affidavits.

The staff at Alcor Headquarters is available to provide documentation of the patient's intent, to discuss cryonics procedures with hospital personnel (over the phone), and to provide general support for the team members in the field. Copies of relevant court decisions are available, if the circumstances merit a firmer approach during negotiations. Additional letters have been generated for hospital administrators who are unfamiliar with cryonics, and these letters are sent from Alcor Headquarters after they've been modified for the situation. They may also be sent out in advance of a patient's admission to the hospital.

In some suspensions, little documentation has been needed except for the patient's legal paperwork. If a physician and hospital choose to cooperate with Alcor personnel, they may improve the patient's chances for a quality transport.

A physician has the opportunity to prescribe medications for a patient while legally alive, and there are a few which have been shown to improve later cryoprotective perfusion if administered before pronouncement. Some of them are also in Alcor's stabilization protocol. If these items will not interfere or react with the medications currently being taken, a physician might prescribe vitamins C and E, selenium, magnesium, and beta carotene. These are powerful anti-oxidants which help to reduce the damage caused by inadequate tissue oxygenation. Dilantin is also recommended as a calcium channel blocker. Cimetadine hydrochloride (Tagamet) will reduce the accumulation of stomach acid. Many patients have experienced gastric bleeding during stabilization, and have lost large volumes of fluid through holes in the stomach lining. This damage may be mitigated by the administration of Tagamet within the hours before pronouncement. Prior to pronouncement, these medications may be administered only by conventional medical personnel acting under a physician's orders. Premedicating a patient requires a cooperating physician and a patient willing to request the assistance, and generally, is one of the last topics broached by transport team members when discussing the prompt release of the patient.

Once the patient is released to Alcor personnel after pronouncement, the stabilization may begin.

Stabilization

At the earliest possible moment after pronouncement, transport team members will initiate the stabilization protocol. First, the patient is transferred to the portable ice bath and surrounded on all sides with crushed or cubed ice. Some water may be added to the bath if the team has access to a circulating pump and tubing. This device is called a "squid" and makes it possible to cool the patient using circulating ice-water, which cools much faster than simply surrounding the patient in ice.

Once the patient has been transferred to the portable ice bath, a mechanical CPS device (such as the Michigan Instruments Heart-Lung Resuscitator) is placed and started. This will restore circulation. An airway is placed to restore respiration, and IV medications are administered to combat the damage of oxygen deprivation and hypothermia. Ideally, all of this is done and documented in the transport notes before the patient leaves the hospital premises. As a minimum, the patient should be packed in ice and administered heparin (an anticoagulant), which should be circulated for 5-10 minutes using conventional manual cardiopulmonary resuscitation.

A local patient may be brought directly to the Alcor facility, with all of the stabilization procedures (except the washout) being performed in the ambulance. Whether the organ preservation solution will then be administered before cryoprotective perfusion begins depends upon the readiness of the perfusate. This perfusate takes many hours to prepare in sufficient quantity for a cryonic suspension (although we are working on shortening this procedure), and if mixing the perfusate is expected to take longer than the open-heart surgery, the washout may be performed while the perfusion preparations are completed.

Once released from the hospital, a remote patient will be transported to the cooperating funeral home. There, the blood replacement surgery will begin, and the patient's blood will be replaced with an organ preservation solution through the femoral artery and vein. During the blood replacement, a heat-exchanger will cool the fluids being introduced, and the patient's core temperature will drop to about 5°C.

After the washout is complete, the patient must be packed for shipment to Alcor. This usually involves Alcor's custom-engineered water-tight container. This is sent out as part of the central remote kit, and its arrival might delay the shipment of a patient to Alcor if there was little or no advance notice of the suspension. A conventional mortuary shipping container also maybe modified to hold the patient and ice. The patient should be placed inside a body bag and completely surrounded by sealed bags of ice. (Ziploc bags work well.) Containers carrying human remains must not leak, or they will be removed from the commercial carrier and quarantined until the coroner has an opportunity to inspect them.

Once the patient is packed for shipment, the necessary transit paperwork has been prepared, the operating theater has been cleaned, and the mortician paid, the patient may be taken to the airport for transport. A cooperative mortician will be able to recommend commercial carriers and will have a familiarity with the shipping requirements; he may even be willing to make all of the necessary arrangements and should also provide transportation for the patient to the airport. Alcor should be kept apprised of progress, since we have often been able to speed arrangements through the local airline offices.

Transport

Shipping a patient should be the easiest aspect of the operation, but there are still occasional snags. The patient should be placed onto a direct flight to Phoenix, if possible, and care should be taken when selecting an airline and flight path. Some airlines advertise their flights as direct, when in fact, the plane will make additional stops before it reaches its ultimate destination. Avoid these flights as long as there will be no significant delays in transport time.

Delays can be expected before the patient is loaded onto the aircraft. Most commercial airlines require that cargo be taken to the loading dock at least four hours before flight time. In the past, we have found a few airlines (like America West) to be especially cooperative, and they have waived this requirement for our suspension patient. Such cooperation has been unusual, though, and should not be expected or planned for during a transport.

At least one transport team member should be on the same flight as the patient and should have copies of all relevant transport permits and the death certificate. All of the transport equipment should also be shipped. Medication kits and other consumables are inventoried and replaced at Alcor Headquarters before the remote kits may be redeployed.

Conclusion

Of course, even after all of this has been accomplished, the actual suspension has still not begun. But it may be clearer to you now why my overwhelming emotion is relief when I finally arrive at the Alcor facility with each new patient. There are many, many variables affecting the quality of a stabilization and transport, several of which are completely out of the hands of Alcor personnel. Once those variables can no longer prevent a successful cryonic suspension, the patient's future is a little more secure.

Please remember that much of the groundwork for a successful transport can be done in advance by local cryonicists. Many of you live in areas which Alcor has not had the time or opportunity to include in its transport preparedness infrastructure. You can help us change this, and though it will certainly save Alcor personnel a major headache if you do, the primary beneficiary is you.

Anyone wishing to discuss local preparedness should contact me at Alcor for more information.

My thanks to Ralph Whelan for his invaluable assistance in the preparation of this article.