X-Message-Number: 33373
From: 
Date: Mon, 28 Feb 2011 01:51:43 EST
Subject: Melody Maxim's Distorted Reality 8

I think it likely that the above quote will  stun both Boon and Melody. I 
am long past that point. If you are an Alcor  patient receiving 

extracorporeal support you have (based on this woman's past  performance) a ~ 1 
in 5 

chance of being perfused with massive amounts of air at  some point during your
care (either in the field or in the facility). This does  not include 

microbubble embolization, which happens during every case, and which  they 
neither 
check for, nor apparently are sensitive to as a problem   
Not stated in the quote above, or the case summary  it came from, was that 
this patient was massively edematous and was  unrecognizable at the end of 
CPA perfusion (described by one person present as  looking like the Michelin 
tire man).  
Paradoxically, some of Alcor's in-field coordinators are far better  at CPB 
than are Alcor central staff. They are much more afraid and concerned  
about their limitations, and thus more cautious and vigilant.   
Having said that, none of these people have ever pumped a survival  case on 
either an animal or a human, and the enormous mass of acquired knowledge  
and experience which both of you (Melody and Boon) have, is completely 
absent.  Both of you are aware of basic things such as the effect of tubing 
diameter on  flow and pressure. You know the safe levels required for the 

reservoir you use  and you are intimately aware of your response time versus 
flow 
and reservoir  volume. I could easily write a textbook about all the things 
you know, and know  viscerally, leaving aside things like pharmacology, 
acid-base balance, and basic  physiology all which act to make you safe and 
competent perfusionists.  
I am writing this  to give you a perspective that this will not be the case 
with SA, Alcor, or  other cryonics organization perfusionists who will 
operate the ATP in the field.  No matter how thoroughly these sincere people 

master didactic training, they  will not have any real clinical experience, and
will not have the instincts and  embedded hand knowledge that even a 
marginally competent perfusionist will have.  This reality trumps all other 

considerations in circuit design. These people  will necessarily be like a 
person 
who has been taught the basics of operating an  automobile on a closed 
course. They can drive it forward and avoid hitting the  walls at low speeds. 

However, they have no crash avoidance skills, will freeze  up at intersections,
will often reach for and activate the wrong control, have  no instinctive 
feel for the vehicle or its control console, and will be unable  to backup, 
let alone parallel park. No one with even vestiges of sanity would  put such 
a person into a high performance racecar and turn them loose in a  NASCAR 
race, let alone Indycar racing!  
The obvious solution to this would be to  hire a professional perfusionist. 
This is simply not economically possible nor  is it really practical given 
the low volume of cases (less than 20 a year) even  at Alcor, or even in 
cryonics worldwide (less than 40 a year). And remember, of  these cases, many 
will not be perfusable due to delay, autopsy, sudden death,  financial 
constraints, or geographical remoteness.  
The next best thing is to train  appropriately skilled and motivated people 
in an animal research environment  where they can pump survival animals 
(typically dogs) and gain the enormous  array of both intellectual and manual 
skills required to be a safe, competent,  and flexible perfusionist. Alas, 
this kind of training stopped some years ago  and has been repeatedly rejected 
as an option for SA personnel. Only such  extensive in-house training on 
relevant models will do the job. This is not  going to happen. Please 
integrate this fact into your thinking.   
Hardshell vs. Bags  
First, a caveat: I may be seen as biased  since the current Alcor ATP was 
reconfigured by me prior to its clinical  implementation. The basic platform 
was designed by Alcor and I want to make  clear that most of the credit for 
this system, including the critical idea of  modularizing it in a Pelican 
case, is the work of Steve van Sickle and Hugh  Hixon at Alcor.  
Given logistic  constraints, and lack of training of personnel, 

recirculating in-field CPB will  be a relatively rare thing and, frankly, 
something I 
would rather not see done  solely due to skills issues. A patient who has 
been safely washed out and cooled  is vastly better off than a patient who has 
been embolized with macro air in an  attempt to cool a few more degrees or 
provide metabolic support in ultraprofound  hypothermia.  
To this end, I  configured the system to have almost no potential for 

administering macro air.  This was done by drawing from a collapsible perfusate
reservoir (Alcors' idea)  and using a collapsible venous reservoir which was 
to be kept largely purged of  air. Since the ATP cannot be moved there is 
always a sharp time constraint on  how long a patient can be maintained on 
CPB. This is so for at least the  following reasons:  
1) Most cryopatients have major  compromise to systemic capillary 

integrity. In particular, most patients will  have experienced massive pulmonary
edema and alveolar flooding. Many patients  will have active GI bleeds due to 
erosion of the gastric mucosa by hydrochloric  acid during agonal 

hypoperfusion (shock). Gastric blood flow is negligible in  many patients during
the 
last few hours of agonal hypotension. The effect of  this is that perfusate 
rapidly leaves the extracorporeal circuit either as  pulmonary transudate or 
via hemorrhage of compromised gastric mucosa. Even if  gastro-protection has 
been undertaken prior to cardiac arrest, there is usually  massive pulmonary 
transudation of perfusate, including the colloid. You will see  this in the 
intubated patient as a steady flow of blood-tinged perfusate  existing the 
ET tube at a rate of up to 20 ml/min. This will limit the time on  the pump 
unless a reserve of 10 to 20 liters of perfusate has been provided to  make 
up for this loss. Contemporary cryonics personnel are oblivious to this as  a 
problem and assume that, the patient is bleeding internally. If a reserve 
of  perfusate is on hand and MAP is kept to ~35 mm Hg it is possible to 

perfuse such  patients continuously for over 12 hours (Ive done it). It is also
physiologically desirable given the limitations of the current perfusate  
(MHP-2).  


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