<PRE> Message: #2931 - Standby Book Date: 22 Jul 94 17:45:07 EDT From: Mike Darwin <> Message-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. ------------------------------------------------------------ - 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. </PRE>