X-Message-Number: 2867
Date: 09 Jul 94 03:02:55 EDT
From: Mike Darwin <>
Subject: CRYONICS Case Report (1/3)
BPI Tech Brief #9
The following is case history of an ACS patient cryopreserved
by Biopreservation. In accordance with the patient's wishes his
name has been disclosed in this report. Wherever XXXX, XXXX
appears it means that an individual did not wish (or we were
unable to reach or otherwise get authorization to disclose)
his/her name and we are respecting that individual's
wishes and/or erring on the side of caution.
A number of caveats about this report need to be made at the
start:
1) Graphic data is usually critical to understanding what went
on and it cannot easily be presented here -- in the case of
this author it cannot be presented at all. Individuals who wish
a copy of this report with the graphic data (charts, diagrams,
etc.) may obtain one by contacting either BioPreservation or ACS.
The report in its rough form (i.e., without photographs) will be
furnished at the cost of duplication and handling (probably
around $25.00). Copies of the finished report will be available
through both ACS and BPI at a lower cost (larger press run, less
administrative time) although when this final version will be
ready it is not now possible to say.
2) This report will be presented in two parts: an initial almost
exclusively descritive part, and a second and much shorter part
which will contain some conclusions, discussion, and suggestions
as to how this case might have been optimized and how future
cases might be better handled as a result of what was learned
here. Thus, I have deliberately avoided (wherever possible)
drawing conclusions or making comments in the first part.
Readers may find this frustrating but I believe it is important,
in an area as speculative as cryonics, to try and carefully
delinerate between simple observations and conclusion, opinion,
and speculation.
3) This is technical case report. No translation or brief
summary for the casual reader is provided. It will be tough
sledding for anyone who does not have either a lot of patience
and a couple of good reference books and/or a medical
background. I do not apologize for this, merely caution the
reader. I believe there is a need for reports such as this
because they lay down, with some precision, what is being done
and what results. I hope to routinely (in the future) begin
correlating the gross and laboratory results observed in human
patients with histological and ultrastructural results. To this
end BPI has spent considerable time and money acquiring
clinical biopsy equipment which allows for tissue sampling with
minimum invasiveness.
4) An added frustration in viewing this report will
probably be the hashing-up and/or omission of symbols such degree,
micron, and so on. There may also be the loss of regularity in
some of the tabular data. I regret that I do not have either
the time, or in some cases the expertise, to go into the text and
correct or otherwise replace characters which will be deleted by
conversion to ASCII. I ask the reader to bear with me and/or to
request a paper copy.
---Mike Darwin
Cryopreservation Case Report:
Jerome Butler White
American Cryonics Society ID #: ACS 9577
Patient Name: Jerome B. White
Date of Birth: 10-31-1938
Social Security #: 525-88-9577
Cryopreservation Date: 02-05-1994
Transport Staff :
Michael G. Darwin, C.T.T., C.R.T., Team Leader, Surgeon
Naomi Reynolds, C.T.T., Transport Technician (Medications)
Shawn Shermer, B.S., C.T.T., Perfusionist
Jim Yount, C.T.T., Transport Technician (Thumper, Logistic
Support)
XXXXX, XXXXX, C.T.T. (Scribe)
Cheryl Heisler, Videographer
Cryoprotective Perfusion Staff:
XXXXX, XXXXXX, Ph.D., Surgeon
Faye Smith, R.N., Scrub Nurse
Michael G. Darwin, C.T.T, C.R.T., Team Leader
Naomi Reynolds, C.T.T., Scribe
Shawn Shermer, B.S., C.T.T., Perfusionist
Sandra Russell, B.S., Assistant Perfusionist, Laboratory
Analysis, CPA Ramp Technician
Paul Wakfer, B.Sc., CPA Ramp Technician, Logistic Support
Jim Yount, C.T.T., Videographer/Photographer
Allen Lopp, B.S., Logistic Support
Michael Fletcher, R.T, Equipment Technician, Logistic Support
Mark Connaughton, B.S.M.E., -79 C Cool-Down Technician
Candy Wood, Circulator
Larry Wood, M.S., Logistic Support
Biographical Background and Social History
Mr. White became involved in cryonics shortly after the
publication of Robert Ettinger's book The Prospect of
Immortality in 1964. He was one of the founders of the American
Cryonics Society (ACS) (then the Bay Area Cryonics Society) in
1968. From 1968 through 1982, and from 1990 through 1992, he
served as an Officer, Governor and committee member for ACS.
Mr. White was the second President of ACS serving from 1971
through 1982. Mr. White was also a frequent spokesman for ACS,
and for the promotion of cryonics, appearing on radio and
television shows and speaking to schools, educational and civic
groups. Mr. White was also a one of the founders of Trans Time,
Inc., a commercial cryonics services organization.
Mr. White had a varied professional and educational
background. He received his B.A. in philosophy from the
University of New Mexico in 1966 and continued his education at
the University of California at Berkeley where he studied
Computer Science and education with special emphasis on the
psychology of learning, programmed learning, and computer aided
learning.
From 1983 to 1992 Mr. White was lead designer for software
for Sterling Federal Systems, Inc. a contractor to NASA Ames.
While at Sterling Mr. White worked on a variety of NASA projects
including participating in the development of software to
analyze the Martian atmosphere. He also participated in design
work on a variety of programs to develop tilt-wing aircraft.
Mr. White was also responsible for the first paper
describing a detailed and scientifically plausible approach to
the repair of cryopreservation-induced damage: "Virus-induced
repair of damaged neurons with preservation of long-term
information content" which was presented at the First Annual
Cryonics Conference in Ann Arbor Michigan in 1969.
Over the course of his nearly three decades of active
involvement with cryonics Mr. White repeatedly updated and re-
executed legal and financial paperwork to provide for his
cryopreservation, including a Consent for Cryonic Suspension
(cryopreservation) executed on 27 August, 1985 and Durable
Powers of Attorney for both finances an healthcare executed in
August of 1993.
Mr. White's academic background, his long years of active
involvement in cryonics, and his first-hand participation in
every aspect of a number of human cryopreservations establishes
his informed consent.
Medical History
The patient is a 55-year-old Caucasian male homosexual who
was diagnosed with HIV (Human Immunodeficiency Virus Type I)
disease in 1989. The first CD4 cell count noted in the
patient's medical record was 465 per cmm on 01-24-1992. The
patient experienced an atypical precipitous decline in CD4 count
from 386 per cmm on 01-31-1992 to 114 per cmm on 04-29-1992. A
formal diagnosis of AIDS (Acquired Immune Deficiency Syndrome)
Related Condition (ARC) was made on 08-10-1989. Prior to that
time the patient had enjoyed good health with a medical history
remarkable only for long-standing seasonal allergic rhinitis and
hepatitis B, the latter of which ran its course without
complications in 1977. At the time of his diagnosis with ARC
the patient was begun on Nizoril for onychomyocosis. On 08-28-
1989 the patient was started on an antiretroviral treatment
consisting of 100 mg Zidovudine q. 4 hours. On 06-11-1991 the
patient was begun on 300 mg Nebupent (aerosolized pentamadine
for pneumocystis carinii prophylaxis) q.d. and the
antiretroviral ddC (2',3'-dideoxycytidine) was added to his
regimen at a dose of 500 mg t.i.d.
As of 03-31-1992 the patient was described as doing well
and all organ systems were negative for pathology with the
exception of the skin which presented a rash thought to be due
to ddC (ddC was discontinued for this reason on 02-28-92).
Record of an office visit to his primary care physician
Dennis McShane, M.D. on 05-28-1992 notes the following: ddC
restarted on 05-14-1992 without complications, the development
of simple bronchitis on 04-29-1992, complaint of depression on
04-29-1992, and the presence of hairy leukoplakia on 05-08-1989.
The patient's Karnofsky score at the time of the 05-28-1993
visit was 80%.
During an office visit on 07-02-1992 the patient noted the
beginning of intermittent diarrhea, some decrease in energy
level, and slight numbness in the feet. By 09-10-1992 the
patient was experiencing chronic watery diarrhea on a daily
basis and his Karnofsky score had declined to 70%. Medications
were transiently discontinued to evaluate for their possible
effect on diarrhea. By 10-15-1992 the patient had experienced
considerable weight loss as a result of chronic diarrhea (down
to 65 kg from a normal baseline of 75 kg), consistent daily
fatigue, and his CD4 count had declined to 45 per cmm. At that
time, 1 tbs. of Metamucil b.i.d. and 400 mg Trental t.i.d. (the
latter as an inhibitor of tumor necrosis factor/treatment for
AIDS wasting syndrome) were added to his daily medications.
On 10-29-1992 the patient's condition was noted to be
continuing to deteriorate with a further decline in his CD4
count as well continued deterioration in the patient's
subjective condition. At that time 200 mg of ddI (2',3-
dideoxyinosine) b.i.d. and 250 mg Azithromycin q.d. (for
mycoplasm avians intracellularae (MAI) prophylaxis) were added
to the patient's regimen with concurrent discontinuation of the
zidovudine and ddC. The ddI resulted in exacerbation of the
diarrhea and was discontinued with a return the zidovudine/ddC
protocol resulting in lessening of the diarrhea. On 11-11-1992
a flexible sigmoidoscopy was performed in an attempt to
determine the cause of the diarrhea. The results of
sigmoidoscopy were unremarkable.
By 02-25-1993 the patient's weight had declined to 59 kg
and his Karnofsky score to 60%. Stavudine (2'3'-
didehydrodideoxythymidine) (d4T), 4 ea., b.i.d. was begun 02-05-
1993.
On 05-05-1993 the patient's weight had declined to 57.7 kg
with diarrhea, cachexia and marked temporalis muscle wasting
noted. On 02-06-1993 a peripherally inserted central venous
catheter (PICC line) was placed and the patient was started on
total parenteral nutrition (TPN) at 2000 cc per day with 10%
lipids at a rate of 167 cc/hr over 12 hours.
Due to persistent abdominal pain a CT of the abdomen was
performed on 05-14-1993 which disclosed fatty infiltration of
the liver, mild to moderate splenomegaly, and a 2 cm non-
contrast filling mass just below the cecum. Cefelexin was added
to the patient's antibiotic regimen to cover for the possibility
that the abdominal mass was an abcess. On 05-20-1993, 50 mg
pyridoxine q.d. and 50 mg thiamine q.d. were added to his
treatment program. The patient's weight was stable at 57.7 kg
and his Karnofsky score was 80% at that time.
On 06-18-1993 the patient was noted to have markedly
increased pain secondary to ddC neuropathy with unexplained
reluctance to take analagesics in the prescribed way (possibly
indicative of early neurological deficit secondary to his
illness). Medications added on 06-03-1993 were as follows: 25
mg Elavil, h.s., Vicodin, 1 q. 4 hrs., 100 mg Diflucan
(fluconazole) q.d. Elavil was increased to 50 mg h.s. on 06-18-
1993.
The patient continued to do fairly well with some weight
gain on TPN (62 kg) until 08-11-1993 at which time the patient
was seen with complaints of falling due to lack of balance.
Neuro exam disclosed intact cranial nerves, PERRLA, ability to
rise from seated position without assistance, oriented x 3 (but
with verbal responses slightly slowed), negative Romberg,
unsteady gait without ataxia, and inability to stand on tiptoe
or hop on each foot.
A CT scan of the head was performed 08-12-1993 at Standford
Medical Center which revealed a mass in the right thalamus with
surrounding edema which involved the thalamus, right internal
capsule, posterior limb and globus pallidus. Post contrast scan
disclosed a mass approximately 12 mm in diameter.
Following the CT scan the patient was admitted to Sequoia
Hospital in Redwood City, California for stereotactic biopsy to
discover the etiology of the thalamic mass and begin
appropriate medical treatment of the lesion. At the time of
this admission, in addition to the acute thalamic mass, the
patient was noted to be suffering from AIDS wasting syndrome,
oral thrush, AIDS and/or antiretroviral peripheral neuropathy,
myopathy due to AIDS and zidovudine, and depression due to his
underlying poor condition. At the time of his admission the
patient's mentation was noted to be intact, but with some
slowness and thickening of speech. Thalamic lesion biopsy
results reported on 08-13-1993 disclosed the presence of
toxoplasmosis gondii, and initial treatment consisting of
pyremethamine and sulfadiazine was commenced. On 08-24-1993 the
patient developed an erythamatous mobiliform rash which was
believed due to sulfonamide sensitivity. Sulfonamide was
discontinued and the patient was begun on I.V. clindamycin. He
slowly improved and was discharged on 08-12-1993 on maintenance
doses of 75 mg pyrimethamine, 600 mg clindamycin q. 6 hrs, and
10 mg leucovorin b.i.d. all administered p.o. for treatment of
the toxoplasmosis.
The patient was readmitted to Sequoia Hospital on 08-16-
1993 following an episode of prolonged confusion, possible
(unwitnessed) seizure, fever (39.3 C) and rapidly progressive
debilitation. A CT scan revealed an increase in the size of the
right thalamic lesion with involvement of the head of the right
caudate nucleus. The patient was begun on broad spectrum
antibiotics (ceftazidine and vancomycin) for the possibility of
sepsis. Because of the presumed progression of his CNS
toxoplasmosis he was begun on high dose pyrimethamine in
addition to clindamycin and atovaquone.
On 10-16-1993 the patient was again admitted to Sequoia
Hospital with recurrent seizures. At that time it was
determined that the patient had become noncompliant in taking
his medications (discontinued taking his medications 2-3 weeks
prior to this admission) due to depression and deteriorating
mental state. The patient was started on Dilantin (phenytonin) which was
subsequently discontinued due to skin rash and substituted with
Phenobarbital (120 mg at bedtime, 60 mg in the a.m., both given
p.o.). During this admission the patient also developed Staph
cellulitis at the site of his PICC line with culture of the
catheter tip revealing coagulase negative Staphylococcus. The
patient was treated with vancomycin and the catheter was
removed. A new PICC line was placed prior to discharge. The
patient was discharged on 11-04-1993.
By 11-08-1993 the patient's mental state had deteriorated
to the point that the reliability of self-care of his PICC, and
of his self-medication were questionable (the patient had
formerly been meticulous in his self-care). On a follow-up
visit by the home healthcare nurse on 11-11-1993 it was
determined that the patient had become incapable of further
medical self-care and at this point I.V. medication and TPN
treatments were administered by his Primary Caretaker and
medical and financial power of attorney, Margaret Bradshaw (a
close friend). At this time the patient's Karnofsky score was
50% with the patient requiring full-time assistance and
considerable medical care.
On 11-22-1993 the patient was seen in his primary care
physician's office emergently for acute pain and swelling of his
left arm apparently secondary to infection of his PICC line.
The PICC line was removed and the patient was continued on 1 g
vancomycin q. 12 hrs. At this time the patient was also started
on 2 mg dilaudid q. 4 hrs for pain.
Following the discontinuation of TPN the patient lost 5.45
kg and decided to restart TPN. A PICC line was again placed and
TPN was restarted on 12-15-1993. Medications at this time were
as follows:
Table I: Medications as of 12-15-1993
Drug Dose Frequency Start Date
Nebupent 300 mg q.d. 06-11-91
Trental 400 mg t.i.d. 10-15-92
Pyridoxine 50 mg q.d. 05-20-93
Thiamine 50 mg q.d. 05-20-93
Vicodin tablet q. 4hr, p.r.n. 06-03-93
Riopan 1-2 tab q.i.d. 07-12-93
Leucovorin 10 mg b.i.d. 08-15-93
Haldol 2 mg h.s., p.r.n. 08-31-93
Diflucan 50 mg q.d. 08-20-93
Azithromycin 250 mg q.d. 09-23-93
Zantac 150 mg b.i.d. 08-31-93
Pyramethamine 25 mg q.d. 11-11-93
Phenobarbital 120 mg h.s. 11-01-93
Clindamycin 600 mg q.i.d. 11-11-93
Dilaudid 4 mg q. 4hr 01-06-94 (+ 2 mg from11-22)
Testosterone 100 mg q.m.o., I.M. 12-23-93
By 01-20-1994 the patient was severely disabled with a
Karnofsky score of 30%. Ms. Bradshaw noted that the patient
was increasingly somnolent and bed-bound and there was
discussion of discontinuing life-supporting treatment in the
near future (i.e., TPN, antibiotics, etc.). Diagnoses at this
time were as follows:
Table II: Diagnoses as of 01-20-1994
Diagnosis Start Date
Hairy Leukoplakia 05-08-89
Depression 04-29-92
Diarrhea 07-02-92
Weight Loss 01-08-93
AIDS 02-16-93
AIDS Wasting Syndrome 05-05-93
Peripheral Neuropathy 05-20-93
Myopathy 07-29-93
CNS Toxoplasmosis 08-11-93
Impotence 10-07-93
Knowledge Deficit 11-11-93
On 01-28-1994 the patient experienced an acute febrile
episode (39.6 C) with pulmonary congestion (rhonchi present
bilaterally), labored respirations. Pulse oximetery was
instituted on the afternoon 01-28-1994 using Criticare Model 503
pulse oximeter. Oxygen saturation at that time was 85% and the
patient was obtunded with a Glasgow Coma score of 4. The
patient was started on 4LPM oxygen and given 1 g vancomycin
b.i.d. under advice from a consulting physician, Ronit Katz,
M.D. Due to the patient's poor quality of life and the
advanced stage of his disease (multisystem organ failure) it was
determined by Ms. Bradshaw (his medical power of attorney) in
accordance with the patient's previously expressed wishes
concerning what constituted an acceptable quality of life to
him, and in consultation with his primary care physician Dennis
McShane, M.D., that hospitalization was medically
inappropriate. It was the opinion of both of his physician and
his attending home healthcare R.N. that death was imminent.
Standby personnel from both Northern and Southern
California were deployed. Shortly after the arrival of Standby
personnel the patient's condition stabilized and improved
markedly. There was considerable improvement in breath sounds,
return of responsiveness, and decrease in fever to 38.0 C. By
01-13-1993 the patient was able to take fluid by mouth and was
able to be assisted to a chair for short periods of time. The
patient's mental state was one of confusion and apraxia/aphasia
although he did seem to recognize friends and caretakers, and
was able to respond to verbal commands/interrogation by nodding
his head appropriately. The Standby Team stood down at this
time.
Agonal Course
-- To Be Continued --
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