Table of Contents and Disclaimer

STANDBY:

END-STAGE CARE OF THE HUMAN CRYOPRESERVATION PATIENT

by Michael G. Darwin
Copyright 1994 by Michael G. Darwin. All rights reserved.

Chapter 1: Standby and Transport



Definitions

The purpose of human cryopreservation is to arrest metabolism (both anabolic and catabolic) in a legally dead patient in such a way that it may be possible for metabolism to resume when medical technology has advanced beyond the capabilities available at the time of death.

Generally speaking, injury is the main factor which will reduce the chances for future resumption of metabolism. There are three potential sources of injury to a patient who has chosen cryopreservation: 1. Injury from the disease process. 2. Ischemic injury (damage to cells caused by lack of blood flow) during the antemortem period of shock and the post-mortem (post cardiac arrest) period of complete ischemia (loss of all circulation of the blood). 3. Injury caused during the cryopreservation process: surgery, introduction of cryoprotectant(s), and cooling and freezing the patient.

The third type of injury is beyond the scope of this book. We will focus, here, on all the ways in which the first two types of injury may be minimized. We can attain this objective only if we are able to prepare and intervene before cardiac arrest and the pronouncement of legal death. This intervention is through procedures generally referred to as "standby and transport."

"Standby" means dispatching personnel and equipment to the patient's bedside, to provide information and expertise about pre-mortem management of the patient and to prepare for transport. "Transport" means stabilizing and controlling the patient's condition, beginning at the time of legal death and terminating at the start of cryoprotective perfusion. The word "transport" is used because it is almost always necessary to move the patient from the place where legal death has been pronounced to an operating room maintained by the cryopreservation organization, where cryoprotective perfusion will take place.

Local and Remote Standby

In the narrowest sense, standby does not begin until personnel are deployed on-site to care for the patient. However, elements of antemortem care such as counseling the patient and family, beginning a program of premedication, and carrying out site assessment and planning for standby will be considered a part of standby operations here. A local standby is one in which legal death is going to be pronounced in a location that is within easy reach by ground transportation from the operating room maintained by the cryopreservation organization. If the organization owns an ambulance or similar special-purpose vehicle, most of the necessary supplies and equipment required to facilitate transport should be present and already organized in the vehicle so that they can be quickly moved to the patient's bedside. If the cryopreservation organization does not own an ambulance, supplies will need to be organized into a kit which can be transported to the patient's location by other means. It should be noted that reliance on commercial providers of patient transport such as mortuaries, removal services, and ambulance companies is problematic and presents many possible legal and logistic pitfalls.

A Remote Standby occurs where the patient is far enough from the cryopreservation facility for air transportation to be the preferred means of access. In this situation, the cryopreservation organization will dispatch its personnel, usually by common carrier, together with most of the equipment and supplies required to perform initial cardiopulmonary support, extracorporeal support, total body washout (i.e., blood washout with a tissue preservative solution), and refrigerated transport of the patient (again usually by common carrier) back to the operating room for cryoprotective perfusion. For a remote transport to be performed successfully there must be meticulous preparation and attention to detail. The Remote Standby Kit (RSK) must be carefully stocked and organized to anticipate a wide range of contingencies.

Whether a standby is local or remote, if a patient is going to receive stabilization at home and/or with the assistance of a mortuary, it is almost essential that the Transport Technician should visit the patient's home, meet mortuary staff in person, and inspect their facilities in advance. If the home has a garage, it may be usable as a field operating room to allow extracorporeal support and blood washout immediately after legal death. The home must also be evaluated to insure that the Portable Ice Bath (PIB) or Mobile Advance Life Support System (MALSS) can be moved in and out in a fully loaded condition, using available personnel.

Mortuary facilities must be similarly evaluated to insure that the Preparation Room (embalming room) has adequate space, lighting, and electrical outlets to allow for both Thumper and extracorporeal support. Mortuary personnel must be instructed to remove ambulance cot(s) or gurneys from transport vehicles to make room for the PIB, if this is going to be used. Mortuary personnel must also be carefully briefed on the equipment that will be used and on the need to keep personnel and oxygen beside the patient during the journey to the mortuary from the home, hospital or nursing home.

Just as important as what is in the RSK is what is not. It is both illegal and impractical to ship oxygen by common carrier. Thus, it will be critical to insure that an adequate amount of oxygen is available on-site. This is discussed in considerable detail later. Similarly, it is impractical to transport ice. This key material will also have to be acquired locally. Mortuary, medical (nurse and physician), and other personnel will need to be obtained locally, and transportation for both equipment and transport personnel will need to be arranged. The transport team must be ready and willing to explain the principles of human cryopreservation, and must have a clear plan of action which spells out the roles and duties of everyone involved. They must also have documents (cryopreservation paperwork) proving that they have necessary legal authority to act. A hold-harmless or other release of liability may also be needed to reassure local medical personnel and others who are reluctant to get involved in a procedure that seems unfamiliar and potentially threatening.

With the advent of home-hospice care, legal death of patients at home is becoming increasingly common. In situations where adequate notice of impending legal death exists, it will be of great importance to determine the best location for legal death to occur. The following chapters will explore all of these topics in more detail.


Go to Chapter 2: Perspectives on Death and Dying Today
or Table of Contents