Alcor 1997 Stabilization and Transport Manual
Table of Contents
Cryonics is a science still in its infancy, and one with many available avenues for improvement both in theory and in practice. A typical cryonic suspension blends elements of diverse disciplines, including medicine, physics, molecular biology, materials science, cryobiology, and psychology into a new form of health-care. This manual presents the cryonic suspension procedures employed by the Alcor Life Extension Foundation and is designed solely for the use of Alcor personnel in educational or training endeavors. Procedures presented here are designed specifically for the stabilization and transportation of Alcor clients.
The ultimate (and still distant) goal of a cryonic suspension is the successful conclusion of “suspended animation”: a process in which a person travels through time unchanging, to awaken with personality and identity intact. Such recovery, after decades or centuries in storage, is science fiction today but is likely one day to be sober fact.
Current cryonic suspension procedures are performed upon those for whom contemporary medicine has already failed. These patients have exhausted the available medical resources and skills and have subsequently been pronounced LEGALLY DEAD. Some remedies for today’s medical inadequacies may require decades or centuries to perfect, but these patients are already “dead” and can wait no longer for new treatments.
Once a person’s body has stopped functioning on the levels necessary for life, deterioration begins at every level. For these people to reach the physicians of the future, a way must first be found to arrest the structural deterioration. At Alcor, this is accomplished by placing the patient into liquid nitrogen, where — at -196°C — virtually no metabolic activity occurs even over thousands of years [1, 24].
To optimize the chances of a healthy individual ultimately emerging from liquid nitrogen, each person must be placed into storage with as little structural injury as possible. Freezing human tissue to subzero temperatures presently causes damage irreparable by current technology. Additional damage is caused by the dying process and the application of cryonic suspension procedures (other than cooling). Minimizing this damage is the goal of Alcor’s transport and suspension procedures, and the damage notwithstanding, cryopreservation and low-temperature storage is the only known method for preserving living cells indefinitely [1, 8, 24].
Death, Dying, and Donations
Alcor is a non-profit, tax-exempt, research, and educational organization (IRS classification: 501(c)(3)) authorized to accept anatomical donations under the Uniform Anatomical Gift Act. Anatomical donation is the mechanism through which an individual may participate in Alcor’s research program for cryonic suspension.
Before an anatomical donation and cryonic suspension protocol may be executed, an individual must be pronounced “dead” according to cur-rent medical standards. Under most circumstances, this requires the person’s heartbeat and breathing to stop and a physician to sign the death certificate. (In rare situations, the attending physician may demand the cessation of brain waves, as verified through the use of an EEG monitor or the absence of cerebral blood flow for more than 24 hours, before legal death is pronounced.) The unavoidable requirement of pronouncement of legal death means that all cryonic suspension patients will experience varying degrees of damage during and immediately following the dying process.
Oxygen deprivation causes one of the most destructive forms of damage that a cryonic suspension patient will encounter: ischemia. Ischemia is a condition of inadequate or absent blood flow. Ischemic damage results from insufficient oxygen reaching an area of the body — due to mechanical obstruction or functional constriction of a blood vessel or other absence of circulation. When this condition persists, the tissue will begin to die. (Ischemia has many components, some of which will be introduced in later chapters.) On a localized scale, we all experience ischemia on a daily basis: an arm “falls asleep” after supporting our head in one position for too long; sitting in a chair for lengthy intervals leaves our backsides with ischemic damage. The difference to emphasize here is the degree of damage. Localized ischemic injury, resulting from simply resting too long in one position, is naturally reversed by our bodies. Unfortunately, ischemic damage resulting from the cessation of heartbeat and breathing has a global effect that is generally much more than our bodies can tolerate, or repair, without assistance.
Emergency Response System
Time is a significant factor in the injury that ischemia can cause. Alcor has expended considerable effort to develop, deploy, and maintain an emergency response system capable of recovering, stabilizing, and transporting suspension patients with minimal ischemic damage. Given reasonable notice, this system has the flexibility to respond to a client anywhere in the world.
This system has twofold capability: sophisticated response is available on short notice in the area local to Alcor’s Scottsdale, Arizona headquarters, and to clients within the range of our ambulance if more notice (a minimum of 24 hours) is given; and an international network of specially trained technicians is available to provide transport services around the globe. Many of these technicians are also immediately available by pager. They are trained to apply the cell-stabilizing protocol described in this manual, and most have practical experience as well.
Clients are tied into the emergency response system by wearing stain-less steel medical identification tags (either necktags or bracelets) and by carrying wallet cards at all times. In a sudden, life-threatening emergency, the Alcor medical identification tags furnish a brief description of the emergency stabilization procedures for the patient and instructions to call the Alcor for further information. This number is manned 24 hours a day, every day of the year, and is connected to a paging system capable of summoning skilled personnel for remote telephone conferencing to provide additional information and instructions to medical personnel.
Alcor maintains a minimum of four emergency response technicians available by pager at all times. In the event of an emergency involving an Alcor suspension client, these personnel will be immediately contacted and connected with the emergency room physician treating the client. If the situation merits such a response, the Alcor technicians will deploy an emergency stabilization team to the client’s location to implement the cryonic suspension procedures after pronouncement of legal death.
Alcor also maintains a local transport system consisting of an ambulance containing a state-of-the-art, mobile rescue cart (MRC III). This system consists of a custom-engineered frame upon which is mounted: an ice bath; a heart-lung resuscitator capable of providing mechanical cardiopulmonary support; a complete heart-lung machine, including a blood pump, membrane oxygenator, and heat exchanger; and an independent power supply. The MRC III enables a transport team to re-initiate circulatory and respiratory function and to facilitate rapid cooling of the patient to a few degrees above the freezing point of water, both which reduce ischemic injury.
Since Alcor has a suspension clientele which is widely dispersed across the United States and in many foreign countries, a growing effort is underway to provide trained local personnel with the equipment and support necessary to respond of an emergency. In addition to local equipment, Alcor has a portable emergency stabilization kit for responding to remote situations. This kit is a compact version of the ambulance, and it contains all the equipment (lacking only the mobility) needed to implement the stabilization procedures packed in containers which may be shipped by commercial airlines.
In October, 1990, Alcor opened a cryoprotective perfusion and temporary storage facility in Eastbourne, England (south of London) to augment the existing primary (Scottsdale, Arizona) and secondary (near Miami, Florida) U.S. facilities. This auxiliary facility was made possible through the generosity and determination of Alcor member, Alan Sinclair, and it houses a complete capability for retrieval, cryoprotective perfusion, and patient cooling to dry ice temperatures. At this time, and for the foreseeable future, all Alcor clients perfused and cooled overseas will be transported to the United States for long-term cryogenic care.
As additional willing and competent individuals become part of a rapidly expanding, worldwide network of emergency coordinators, initial response times will decrease for all locations, and the range and sophistication of Alcor’s emergency response services will broaden.
There are three basic situations that transport team members will encounter. Each of these situations requires a specific transport protocol designed to optimize the primary transport objective: arresting metabolic deterioration for the patient, with as little structural damage as possible. This objective remains the same whether the damage results from the dying process, the application of the transport procedures, or any other circumstances.
Before any transport protocol may be implemented, it is necessary to first assess the condition of the patient, as this determines which transport protocol will be used. There are three basic alternatives: the patient has experienced legal death and is at risk of autopsy; the patient is either very nearly or already legally dead, but there is no risk of an autopsy being performed and little or no preparation time is available for planning the transport; or the patient is nearing pronouncement of legal death, and there is adequate notice to negotiate institutional cooperation and coordinate for prompt arrival of transport personnel and equipment.
Each of these situations will be discussed later, in conjunction with the recommended transport protocol for each. However, it is important to note that these are recommended transport protocols. Every cryonic suspension is different, and given the small number of patients from which these protocols have been derived, future suspensions should be expected to deviate from the patterns described here. We must expect to encounter new situations and improvise new approaches with each suspension patient, as our understanding of the dying process and the demands of cryonics widens. Transport team members must be flexible and innovative.
Patient Stabilization and Transport
Every effort must be made to prevent or minimize the effects of ischemia following pronouncement of legal death. If the patient is dying in a medical setting (hospital, nursing home, or hospice situation) where his condition is being monitored regularly, and given that standby arrangements have been made, a transport team will be dispatched to wait nearby. (This procedure is available to anyone, provided the appropriate arrangements have been made.)
When a physician pronounces legal death, the transport team takes over the care of the patient and begins cardiopulmonary support (CPS) to re-initiate circulation and tissue oxygenation. Often, circulation is restored within as little as 2-4 minutes of pronouncement. The patient is quickly coupled to a heart-lung resuscitator, a mechanical CPS device more effective at providing circulation than manual efforts. (You may have seen emergency medical personnel, like paramedics, use this device.)
Once circulation has been restored, team members administer medications designed to support the body’s metabolism as it attempts to ward off the effects of ischemia and the damage resulting from re-initiating circulation (called “reperfusion injury”).
Concurrent with the administration of CPS and medications, external cooling of the patient is begun. The patient is surrounded with ice and circulating water (which improves the rate of cooling for the patient). External cooling must be initiated immediately, because of the dramatic effect hypothermia has on reducing the metabolic demands of the body (more than a 50% reduction in energy consumption per 10°Celsius drop in temperature)[4, 21]. However, without additional protective measures, external cooling is insufficient to provide the level of structural protection we desire.
Providing more comprehensive support requires accessing the circulatory system directly to replace the patient’s blood with an organ preservation solution and is usually the next phase of a transport. The femoral vessels (on the inside front of the thigh) provide the access route; and a replacement solution, blood pump and membrane oxygenator provide the means.
Using machinery to support a patient’s circulation and respiration provides the additional benefit of improving cooling efficiency. Under optimum circumstances, a patient may be on blood pump support within as little as 45 minutes (60-90 minutes is typical) after declaration of legal death by a physician. (Faster and more efficient methods for obtaining circulatory access are currently being investigated.) With this level of support, the patient may be cooled to a core temperature of 5°C within 15 minutes.
Once the patient’s temperature is sufficiently lowered and the blood washout is complete, the patient is transported to an Alcor facility for cryoprotective perfusion. Cryoprotective perfusion is usually performed in Scottsdale at Alcor’s headquarters. Deep cooling (to liquid nitrogen temperature) and long-term storage will be performed only at Alcor’s headquarters.
If death occurs at a location not easily accessible to Alcor’s ambulance, local morticians are generally used to assist with transporting the patient from the hospital, nursing home, or hospice to a local mortuary or other suitable facility where the stabilization procedures may be performed.
Unfortunately, sudden death situations do happen (nine of Alcor’s twenty-nine patients have died unexpectedly). When Alcor is notified of a patient’s legal death only after pronouncement (no matter what the cause of death, whether it occurred while the patient was receiving medical care or it was the result of an accident, sudden stroke, or other unexpected cause), Alcor’s emergency response is compromised. Response capability is then dictated by the regulatory climate of the place of death. Most individuals who die under compromised conditions will be autopsied. Death under these (or similar) circumstances will result in the onset of prolonged ischemia with virtually no opportunity for intervention. Alcor’s emergency response personnel must then concentrate their efforts on negotiations with the local medical and legal authorities to restrict the scope of an autopsy, initiate preliminary external cooling with ice packs, and facilitate prompt release of the patient for transport to the appropriate Alcor facility.
Several states have legislation affording residents the right to refuse an autopsy when that refusal is based upon religious grounds. However, the nature of the “religious objection” need not be specified. A “Religious Objection to Autopsy” form will prevent most autopsies in five states: California, New York, New Jersey, Ohio, and Rhode Island. This objection will not prevent an autopsy if the patient died of a communicable disease of interest to the Communicable Disease Center.
Alcor will provide a “Religious Objection to Autopsy” form which has been tailored to the statutes of each state to all interested members. Many states are considering similar legislation, and this is something for which local transport team members should watch their local legislatures.
This introduction only hints at the range of information contained in the following chapters. More precise descriptions and instructions of the further aspects of a transport and suspension will be presented.
Do not be intimidated! Armed with a general understanding of the purpose of a cryonic suspension, even new team members should be able to understand ‘what comes next’ and may be able to offer invaluable assistance.
Anyone who has questions about any of the procedures and policies in this manual, should call the Suspension Services Manager at Alcor Headquarters.
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