X-Message-Number: 2931
Date: 22 Jul 94 17:45:07 EDT
From: Mike Darwin <>
Subject: SCI.CRYONICS Standby Book
BPI TECH BRIEF #10
STANDBY: END-STAGE CARE OF THE HUMAN CRYOPRESERVATION
PATIENT by Michael G. Darwin
Copyright 1994 by Michael G. Darwin. All rights reserved.
This book is intended as an educational tool primarly for
those involved in the delivery of end-stage care to patients
who have chosen to be cryopreserved. It may also serve as a
resource to some patients, their family, and friends. I have
written it in anticipation that materials, both written and
video, specifically geared towards patient, family and
member education on these subjects will flow out of it.
Selected chapters are being presented here for criticism and
comment. Typographical or grammatical critiques should be
submitted in writing on hard-copy to the following address:
BioPreservation
10743 Civic Center Drive
Rancho Cucamonga, CA 91730
Preface
A Rudder to Guide Us
"From far, from eve and morning
And yon twelve-winded sky,
The stuff of life to knit me
Blew hither: here am I
Now--for a breath I tarry
Nor yet disperse apart--
Take my hand quick and tell me,
What have you in your heart.
Speak now, and I will answer;
How shall I help you, say;
Ere to the wind's twelve quarters
I take my endless way. "
--A. E. Houseman
The unprecedented progress in medical technology has saved
many lives that might otherwise have been lost; but it has
also imposed on us decisions which never existed before.
Fifty years ago, if a man had a heart attack, he was placed
in a quiet room and given morphine while his doctor waited
to see if he would recover or die. Today, there is a wide
range of treatment options, involving a high degree of
complexity. Is it an inferior wall infarct? Is the left
anterior descending coronary artery diseased? How much heart
tissue has been injured, where is the blockage, when did it
first occur? Failure to answer these new questions quickly
and accurately can cost a physician a large financial
judgment. More significantly, it can cost the patient his or
her life. We must pay a price, in anguish as well as well as
money, if we fail to live up to our new responsibilities as
medical decision-makers.
Cryonics, which is based on the seemingly simple concept
that a patient who is considered beyond help today may be
treatable using the medicine of tomorrow, now creates still
more choices. The rationale for cryonics has been discussed
in great detail elsewhere (1,2,3). Our objective here is to
look not at the case for and against human cryopreservation,
but at the consequences which medical personnel must deal
with when a patient chooses to be cryopreserved.
Currently, physicians are not accustomed to concerning
themselves with the state of a patient's brain after legal
death has been pronounced. If they are unable to maintain or
restore function using today's techniques, they have no
further interest in the case--just as a doctor fifty years
ago would not have been interested in knowing if it was the
circumflex artery that was occluded in a patient who had
suffered a heart attack. Doctors naturally restrict
themselves to the current state of their art. Those of us
who have accepted the logic of cryopreservation do not have
that luxury. We believe that the pattern of atoms in a human
brain determines whether that brain is potentially
functional tomorrow, even though it may not be functional
today. Since orthodox physicians are unlikely to share our
perspective, it's up to us to make the crucial decisions
that may determine whether that pattern of atoms is
preserved, and whether cryopreservation turns out to be a
success or a failure.
Our decisions begin before a patient dies. In fact, it is
our duty to treat a patient in such a way that he or she has
a "good death." That may sound like something of an
oxymoron, but I assure you, it is not. It is, in fact, the
primary concern of this book. To a patient who has no
interest in cryonics, the "mode of dying" is of little
importance. Death may be faced with courage or valor. The
patient may be meticulously prepared or hysterically
disorganized. It makes little difference in the long term,
since the final outcome is always the same.
Interestingly, there was a time in Western history when
people were much more concerned about how to die "properly."
Their anxiety was based in religious belief: they wanted to
die in a state that would be conducive to salvation and
everlasting life. Thus, Jeremy Taylor's *Rules and Exercises
of Holy Dying*, published in 1651, suggested that to die in
a state of grace and peace would provide greater hope of
resurrection in a land beyond. Today, the patient who
wishes to be optimally cryopreserved has a similar need,
though it is conceived through science rather than religion.
The success of a cryopreservation will depend on many
factors: finances, biology, medicine, psychology, and even
sociology.
This is a difficult sea of choices. Like the mariners of the
past who sailed uncharted waters, we lack precise
instructions to tell us which course to take; yet we still
need some sort of guide. So, like those explorers, we must
proceed with a compendium of hearsay and snatches of facts
and descriptions of the seas and coasts we may encounter,
usually told to us by other travelers who have been only
part of the way to our destination. Such gatherings of
information were called "rudders" during the great age of
maritime exploration, and while they were often imprecise,
they could still make a difference between a journey
successfully concluded and one that ended in oblivion. My
abilities are limited. I cannot take you on the journey into
tomorrow that you decide to make each day when you awake and
go on living, and I cannot take you to the end of your life
and through your death. The most I can do is offer a rudder
to guide us: general pieces of wisdom, cautions about rocks
and reefs to avoid, and advice on how to weather certain
types of storms. I have watched and listened to many
different dying people. I have held the hands of those who
were happy that they would meet their loved ones in the
kingdom of God, and I have cradled in my arms those who
looked into my face with hope that they would meet their
loved ones through my skills and the untested procedures of
human cryopreservation.
I would not pretend that my experiences have taught me even
a fraction of what there is to know. But I have learned
where a few of the rocks are and how to get through the fog
in the night without slipping beneath the waves. In this
book, I will attempt to share that information--within the
confines of my own prejudices and blindnesses. I share it
knowing that it is far from complete, and some of it may
even be incorrect. I share it also in the hope that others
will correct it and add to it, so that gradually, these
waters may become safer for all of us to travel.
------------------------------------------------------------
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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.
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