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Note: there may be some small differences between this text and the text that appears in our actual newsletter, because of edits that were subsequently made. The text is substantially the same. If in doubt, please refer to the hardcopy version of CryoCare Report as the definitive one.
James Gallagher of Sunset Beach, California is CryoCare's first patient to enter cryopreservation. Despite a few procedural complications, Mr. Gallagher received excellent care, including the fastest cooling rate that has ever been achieved in a documented cryonics case. For technical details, see Mike Darwin's account.
A self-described Air Force brat, Jim served an enlistment of three years in the US Army and got out in 1962, before he could be sent to Viet Nam. He moved to Central America where he spent four-and-a-half years in Nicaragua working for IBM. He went from there to the Bahamas, where he established the data-processing department for Family Guardian Insurance Company in Nassau. Finally he returned to California, "to go to UCI and learn what I missed in my thirteen years outside the cauldron of the [computer] industry."
Along the way he had separated from his wife, who moved with his son back to Nicaragua and subsequently to Spain. He remarried, establishing a new bond that was to last for almost a decade, and he started his own consultancy company, James Gallagher and Associates, which developed small- business products such as an easy-to-learn data entry system. He was still working on programming projects up to the last three weeks before his cryopreservation, despite extreme discomfort caused by the cancer that had spread to many areas of his body.
Jim was a libertarian; he felt that the concept of government was inherently flawed. As he put it: "Since there will always be people that cheat, steal, pillage, maim and murder, we are told, society requires institutions that cheat, steal, pillage, maim and murder to protect us from those people."
He wrote an "immodest proposal" suggesting an answer to the problem: a private, walled community where every member would sign a covenant--a pledge to refrain from using or threatening force against any other member. Since acts of theft or violence would violate the covenant, they could be dealt with as civil contract violations which would be subject to arbitration. In this way, the usual conception of crime would disappear.
The vision may seem attractive to those of us who feel unhappy or out of place in a world where freedoms are limited and coercion exists in so many forms. Of course, Jim's life in the twentieth century ended before he ever had a chance to see his ideas become a reality; but we can hope that through cryonics, he may yet have the opportunity to live in a world of new possibilities and opportunities that we cannot even imagine today.
CryoCare will hold its first public meeting on
April 28th in New York City.
The size of the room that we rent will
depend on the number of people who plan to attend, so if you
expect to be there please let us know as soon as possible.
Contact our secretary:
Ben Best
Box 788 Station "A"
Toronto, Ontario M5W 1G3
CANADA
(Remember that postage to
Canada is more than postage within the United States.)
Alternatively you can call Ben at (416) 534-0967 (home) or
(416) 862-3193 (work), or email him at
.
The meeting will enable our members to meet us and discuss issues relevant to CryoCare's future. In addition, we'll be holding an election for a position on our board of directors.
CryoCare's directors are divided into two classes that have differing responsibilities. Member Directors are concerned with everyday running of the organization; Patient Directors possess additional authority regarding patients in cryopreservation. Currently there are three directors, one of them a Member Director, the other two being Patient Directors. All three were appointed when CryoCare was established. Our bylaws allow CryoCare to increase its number of directors from three to a maximum of nine, but at this point we have no plans to do so.
Each class of directors will be elected on alternating years. This year, we will be electing a Member Director. If you're a member of CryoCare and have been affiliated with us or with any other cryonics organization for a total of at least two years, you are eligible to vote for Member Directors and can cast your ballot in person or by mail. (We'll be sending a separate, detailed explanation of our voting system to everyone later this year.)
CryoCare members may also put their names forward as candidates for the Board of Directors. If you wish to do so, please send us a single page describing yourself and your platform before March 15th, so that we have time to duplicate it and mail it to our entire membership. Candidates must sign our Personal Disclosure Document and should be familiar with our bylaws, which are freely available to any CryoCare member from our secretary, Ben Best.
Since the directors and officers of CryoCare are scattered across America and Canada, they often communicate by email. It's not mandatory for candidates for the Board of Directors to have Internet access, but it's a definite advantage.
Once again, if you plan to come to our first public meeting, please let us know. And if you need advice on finding accommodation in the New York area, contact Charles Platt at 212 929 3983 (email ).
The 1995 conference sponsored by the American Academy of Anti-Aging Medicine was held in Las Vegas from December 9th through 11th, attracting about 1,200 people. There were more than fifty exhibitors. CryoCare sponsored a room where Carol La Valley presented a good assortment of food and literature, Ben Best was available to answer questions, and Paul Wakfer brought picture-posters and a video tape to promote CryoSpan.
About eighty percent of conference attendees were physicians. Saul Kent is hoping to take a more active role organizing the 1996 conference and believes it should be possible to double or triple the size of the event by attracting a wider range of people.
Thanks to Carol, Ben, and Paul for representing CryoCare and CryoSpan. Information for this report was provided by Ben Best.
Health and Longevity Seminar
The Optimal Health and Longevity Seminar was held in West Palm Beach, Florida, from January 13th through 15th. This event was run by the libertarian organization Terra Libra with backing from the Life Extension Foundation (LEF) and was scheduled to coincide with the beginning of the FDA trial against LEF. Happily, the FDA suddenly chose to drop its case against LEF and the trial was canceled.
Unfortunately, the conference was poorly promoted. Only fifty people turned up to hear presentations by well-known speakers such as Durk Pearson and Sandy Shaw, Dr. Ward Dean, Dr. Larry Dodge, and Doug Casey. As a result, Terra Libra lost a substantial sum promoting the seminar.
CryoCare's secretary, Ben Best, attended and distributed some of our literature. He also provided the information in this report.
World Science Fiction Convention
CryoCare will be participating at the World Science Fiction Convention in Anaheim, California from August 29th through September 2nd 1996. We are hoping to organize a cryonics panel, and we'll have a table in the dealers' room where we will be giving out literature. We also expect to host a room party.
If you're interested in attending the convention, write for details to L.A.con III, P.O. Box 8442, Van Nuys, CA 91409.
Training Course
BioPreservation will be offering a training course for anyone who wants to learn the basics of cryonics standby and transport techniques. The course will be held in the greater Los Angeles area during the last week of August, immediately before the World Science Fiction Convention. For details, call Mike Darwin at (909) 987 3883.
Mike Darwin has suggested a possible slogan or motto for us: "When they give up, we begin." He writes: "It's intended to accompany a photo of MDs and RNs standing around a hospital bed dazed and helpless, with a teary-eyed daughter holding Dad's lifeless hand. All the technology and instrumentation scattered about the room is impotent. The take-home message: When today's medicine gives up, CryoCare begins its efforts to save the patient's life."
If you have any feelings about this catchphrase, positive or negative, let us know. Also tell us if you think you have a better idea.
CryoCare currently has 79 members, plus one member in cryopreservation.
There are several hundred people who have expressed a strong interest in signing up but are now procrastinating. This is a familiar problem in cryonics, and we want to deal with it more actively. The only way this can be done is by calling people and talking to them: discussing cryonics, answering questions, and encouraging the person to make a decision--either pro or con. (We never pressure anyone into joining CryoCare; for legal and ethical reasons, the decision to join a cryonics organization must always be made freely, calmly, and rationally.)
We need extra help making phone calls. If you have some knowledge of cryonics, a reasonably good telephone manner, and some patience and determination, we are willing to give you additional guidance in the finer points of talking to people who are hesitating to sign up. The work is done entirely by phone, so you can do it from your own home. We will pay your expenses plus a substantial completion fee for each person who becomes a CryoCare member as a result of your efforts.
Interested? Contact Charles Platt at (212) 929 3983 (email ).
Timothy Leary, the one-time prophet of LSD, makes no secret of the fact that he is a CryoCare member. He has also been very frank in recent media appearances where he revealed he has prostate cancer and is planning to end his own life, even though he is still mentally and physically active.
We hope it's obvious to everyone that Mr. Leary's decision in favor of suicide has been made without any encouragement or endorsement from us. In fact, we have argued strenuously against it. Suicide cases are customarily autopsied, which usually means dissection of the brain and a long delay before cryoprotective perfusion can begin. As a result, chances of future revival become extremely remote.
This is a complicated case which raises some difficult issues. We will have much more to say about it as events unfold during the remainder of this year.
There's been some debate on CryoNet about the most secure way to record and preserve text, pictures, and other data. Mike Darwin reminded everyone that the subject has already been thoroughly researched, in particular by Hugh Hixon of Alcor. For those who aren't online or missed the CryoNet debate, here are some highlights:
Microfilm is an excellent way to preserve documents, since it is known to be stable for at least 150 years even at temperatures around 50 degrees Fahrenheit, so long as relative humidity remains constant.
Color photographs can be separated into three primary colors and stored on monochrome archival film that should last as long as microfilm.
When videotape is cooled to liquid nitrogen temperatures it is indefinitely stable. Color transparencies (slides) are also indefinitely stable at these temperatures.
The standard neuropreservation container for CryoCare patients has room for thousands of pages of microfilm, hundreds of 35mm color slides (unmounted), and five CDs.
1995 was a banner year for CryoCare. Most significantly, in December CryoCare became responsible for the care of its first patient, James Gallagher (details elsewhere in this issue). We designed our organization to offer the best long- term care in cryonics, and that design will now be put to the test. We have graduated from being a mere startup membership/promotional organization to one that has solemn long-term responsibilities.
Last year brought its share of problems as well, not the least of which was the loss of Brenda Peters, our founding President, signup administrator, and sales representative. We are still feeling this loss, especially in the sales area. Outreach (as measured by filled information requests) is going well, but we have been less effective at "closing" sales. This is an area that will require work in 1996.
On the brighter side, 1995 was a much better year for CryoCare finances. We trimmed some of our expenses and were helped by a regular monthly contribution from Saul Kent and Bill Faloon of the Life Extension Foundation. We also enjoyed generous financial support from CryoCare members Herman A. Earl, Billy Seidel, Bob Krueger, and several others on a confidential basis. You know who you are. Thank you all very much!
Member contributions (especially regular contributions) are vital to CryoCare. Remember, more than half your dues go to maintain emergency services. We depend heavily on donations to pay for promotional literature, conference attendance, Internet presence, and other activities designed to help us grow. In priniciple, there is no limit to the magnitude and diversity of growth-related projects that CryoCare could engage in. In practice, available resources always limit what we can do. If you would like to see more comprehensive, illustrated literature, glossy color pamphlets, professional conference displays, and full-force attendance at the 1996 meeting of the Anti-Aging Assocation of America, then please consider becoming a regular financial supporter of CryoCare. Alternatively, consider making a directed donation to any of these specific projects. Call Brian Wowk at (204) 254 6192.
In closing, I would also like to thank those people whose dedicated work keeps CryoCare going on a daily basis. These include CryoCare Vice President Charles Platt, Treasurer Kevin Brown, Vice President Billy Seidel, Secretary Ben Best, and our Member Services Administrator, Carol La Valley. CryoCare also frequently benefits from the business advice of Independent Patient Care Foundation (IPCF) Directors Courtney Smith and Bob Krueger. Thanks also to Erico Narita, who now designs CryoCare Report and our other literature.
I also thank our contract service providers, without whom CryoCare would not exist. These include Mike Darwin, Steve Harris, Sandra Russell, Carlotta Pengelley, and other staff at BioPreservation; Paul Wakfer and Mark Connaughton of CryoSpan; and Bob Ettinger at the Cryonics Institute.
--Brian Wowk, President
The cryopreservation of CryoCare's first human patient featured many positive "firsts," some of which pushed the envelope of cryonics technology, particularly in minimizing ischemic injury. This kind of progress doesn't happen without a lot of background work. Here's a brief overview of the many advances that have occurred during the past few months.
Data collection is one of the most frustrating and time- consuming aspects of research. At 21st Century Medicine, when we study brain resuscitation after periods of cardiac arrest at normal body temperature (37.5 degrees Celsius), we have to acquire a wide range of parameters as rapidly as possible: temperatures measured internally and externally, physiological pressures, blood flow rates, blood gases, blood pH, and so on. In the past we have relied on Joan O'Farrel, our primary scribe, the most incredible notetaker and documenter we've ever seen anywhere. (In the past, Joan supervised the clinical trials for Prozac and Xanax, two of the most prescribed drugs in the United States). Even with Joan, however, we've sometimes needed as many as three additional people recording data simultaneously.
This situation is untenable. Recording data requires smart, competent people; you can't just sit someone down any say, "Here, write down these numbers." And, let's face it, no matter how fast the pen, there is no substitute for continuous digital data acquisition. Moreover, when you see graphed/plotted data appear in realtime right before your eyes, trends become evident during an experiment.
Some months ago 21st and BPI began the daunting task of tooling for automated on-line data acquisition and graphing, with the additional capability of controlling the processes being monitored. Automated control isn't vital in most of the work we are doing with brain resuscitation or deep hypothermic perfusion, but it is very important for cryopreservation experiments and human cryopreservation clinical operations.
So, for the past few months we have been teaching our dedicated Pentium PC (1 gigabyte hard drive, 16 megs of RAM) to take notes. We are using a very sophisticated data acquisition and control program which has been modified in- house to meet our needs. Temperature, pressure, flow, and gases are now automatically monitored. EKG is, we hope, just around the corner. We have plans to incorporate cryoprotective agent (CPA) concentration monitoring soon, as well as control of CPA, flow, pressure, temperature and pH.
Within the next 12 to 18 months, we hope to develop a laptop version of this system for use during remote standby. This is especially desirable because it will free personnel who are urgently needed to care for the patient. Also, in circumstances where personnel are not available for data acquisition, we'll be able to log data that would otherwise be lost.
21st and BPI have jointly installed a darkroom and X-ray processor. It is now possible to shoot X-ray film for lung water evaluations and a host of other procedures and have results in about 3 minutes. The darkroom will also be used to print our electron micrograph negatives, greatly reducing the $2.00 per print charge that we currently pay.
We are now looking for a 5" x 7" enlarger for a reasonable price. Any help on this would be greatly appreciated.
The ability to make chest X-rays has become especially important because in selected patients, BPI is now adopting a policy of closed-chest perfusion in which the perfusate is administered via groin cannulae previously inserted in the field.
A major barrier to this in the past has been massive edema (swelling) of the lungs, even in patients given the best transport previously available. Recent advances by BPI and 21st have reduced or eliminated the problem of lung edema in cryopreservation patients who have been appropriately premedicated and rapidly stabilized (even with 2 hours of CPR), but we still need to verify that lung swelling is not occurring inside the patient's chest where it could interfere with return of venous blood from the tissues to the right heart where it is diverted to the perfusion circuit.
For many years we have used fluoroscopy (X-ray pictures displayed continuously on a cathode-ray tube) but this is not sufficient to determine if pulmonary edema is occurring. Chest X-ray films, which are inexpensive and easy to shoot, plus careful monitoring of central venous pressure, will allow us to safely perfuse "good" patients without opening the chest. This will dramatically cut cold ischemic time, since as soon as we roll in the door we can hook the patient up to the previously-placed groin cannulae. Also, closed- chest perfusion reduces costs, the skill of surgical personnel required, and the risk to personnel of sticks from instruments and consequent infection with blood-borne illnesses.
Currently BPI is anticipating performing a standby, transport, and cryoprotective perfusion on a patient with chronic active hepatitis C virus (HCV). Unlike hepatitis B (HBV), there is no vaccine for HCV available yet. The effects of HCV are much like those of HBV even though the two viruses are phylogenetically very distant from each other. The virus that causes HCV was only recently identified and is related to the same virus that causes yellow fever. Much like HBV, HCV carries a risk of acute mortality between 1% and 5%. However, unlike HBV, HCV leaves about half of its victims chronically infected. These chronic carriers can pass the illness to others, and in many of them--perhaps fifty percent--the disease slowly destroys the liver. It may also causes liver cancer in as many as ten percent of thhis group.
HCV is why Larry Hagman and Mickey Mantle needed liver transplants. Alcohol abuse was only a contributing factor.
Unlike AIDS, HCV is highly infectious. A single droplet of blood or contaminated body fluid or perfusate in the eye, in a cut, or inhaled into the lungs has considerable potential to cause infection. There is no treatment for the infection if it occurs; just supportive care.
Clearly this is a major risk for BPI personnel, and we are taking it seriously. BPI has acquired biosafety level 4 suits for handling patients with highly infectious diseases. We are also undertaking special training for staff using the most skilled people in the field. Puncture-resistant gloves and avoidance of opening the chest in this patient (if at all possible) will also be employed. The expense of this equipment has been considerable; we have spent nearly $2000 per suit.
A major cryopreservation upgrade at BPI is the ability to carry out subzero perfusion of human patients. Our ongoing research into cryoprotection has emphasized the serious problems caused by glycerol toxicity. As a result, we plan to move away from glycerol hopefully over the next 12 months and will use, instead, a mixture of other cryoprotective agents. These agents are potentially even more toxic than glycerol if temperatures are not tightly controlled. Therefore, engineering is underway to allow the drugs to be introduced starting just above 0 degrees Celsius and terminating below - 20 degrees.
This approach will not be used for patients who have experienced uncontrolled cardiac arrests, where there is too much warm and cold ischemic injury. However, even for ischemically injured patients where we will continue to use glycerol containing perfusate, we anticipate terminating perfusion at -3 to -6 degrees Celsius depending on the terminal concentration of glycerol. In these cases the limiting factor is the viscosity of glycerol at low temperatures and thus our ability to perfuse it in the subzero range.
BPI has had three terminal clients in the greater Los Angeles area during the last 6 months. In order to deal with this caseload we have created a home visit kit and associated paperwork. Joan O'Farrel, Sandra Russell, and Carlotta Pengelley deserve most of the credit here as they were instrumental in organizing the kit. It includes basic equipment for blood drawing, physical examination (including infared tympanic temperature monitor), collection of blood for antioxidant and blood lactate determination (requiring immediate centrifugation and dry ice preservation), and appropriate paperwork. The kit is designed to be used in conjunction with home visits not just from our nursing staff but from our medical staff as well. Steve Harris, M.D. has been fantastic at making house calls and spending large blocks of time in careful assessment of terminally ill BPI patients. Dr. Harris has not merely confined his efforts to assessing the patient's time-course to legal death for cryonics, but works actively with the patient's primary care physician and specialists. In two recent cases he was material in palliating severe bone pain (using radiotherapy), and in one case he discovered an unsuspected lemon sized brain tumor.
Home visits are vitally important. They help us to achieve a good rapport with the patient, the patient's family, and medical/hospice staff. They also provide the patient with a second opinion--which so far has resulted in improved quality and length of life in all cases (Steve is a damned good clinician). These visits also allow us to collect baseline data and data on the effects of premedication for cryopreservation.
The home kit contains helpful extras such as "pill planners" which aid patients in compliance not only with cryo-related premedication, but also in taking medications prescribed by their primary care docs for pain or treatment of their illness(es). Lastly, the kit helps us to evaluate the patient for the presence of infectious disease which could pose a risk to staff. In the patient mentioned above who is infected with hepatitis C, no one was aware of the condition--including the primary-care physician--until we diagnosed it. Thus, we may have prevented others from becoming ill, and may even have saved some lives (which is always nice, especially if they are your own).
BPI is now routinely doing infectious disease screening on all patients and will monitor the status of intercurrent wound or other bacterial infections for the presence of multiantibiotic resistant microorganisms. This kind of screening is expensive, but we believe it will pay off in improved patient care and in improved safety for staff.
Both 21st and BPI have been busy exapanding our basic research capability. Carlotta Pengelley, a highly qualified nurse, has joined our team, along with Joan O'Farrel. 21st has also hired Shaikh Jahangir, CLAT, ALAAC, a full-time Laboratory Animal Care Technician. Shaikh was previously chief animal care technician at Baxter's animal research facility in Orange County and we were lucky to lure him away.
We have established a working relationship with a fine cardio-thoracic surgical researcher with a wide range of clinical and laboratory experience. This relationship should greatly expand the scope and volume of 21st's contract work, offering the prospect not only of a significant increase in revenue but also contact with leading-edge device and drug developers and the researchers associated with them. We have found this kind of contact extremely valuable in the past.
Finally, we will be undertaking major construction to modify our operating room to comply with ALAAC and USDA standards. We will be adding a uniquely designed stockroom, cabinet banks, and an animal preoperative preparation area which will also serve as a staging and prep area for human cryopreservation patients before they are brought into the operating room.
All in all, a lot of progress in three months. And we haven't even mentioned the research which has continued during the same period.
BPI has also acquired a rather exotic and long-desired piece of equipment for human patients: a stereotactic assembly. This is a device which, while being quite unaesthetic (some would say disturbing in appearance) rigidly holds a human head in a framework allowing neurosurgical operations with a precision of 0.5 mm.
The device consists of a halo-like circular frame with "head-pins" that screw into the bone to attach the head solidly to the frame. The halo can then be repositioned along any axis in fine, vernier-controlled increments.
There are also many accessories such as compound arc blocks which allow for very precise and steady placement of tools, probes, or imaging equipment.
One reason BPI has wanted this equipment is that making a cranial perforation to assess the brain during perfusion of a cryonics patient is difficult if the patient's head is not immobilized. If the patient is not in rigor mortis (and most of ours are not), two people are required to hold the patient's head while the perforation is carried out. Insulated gloves are required, warming of the patient is a risk, the it simply isn't possible for human hands to hold the patient's head sufficiently rigidly.
The Codman Stereotactic Assembly eliminates this problem completely. By immobilizing the patient's head it allows the surgeon to obtain good visualization of the anatomy and be very deliberate in placement of burr holes. The device also elevates the head from the table surface, providing room for a wrap-around cooling assembly that reduces or eliminates the need for messy ice bags, which always carry the risk of breaching the sterile field.
Most importantly, though, the stereotactic assembly enables totally stable fiberoptic imaging of any area of the cortex which becomes accessible through the burr holes as the brain shrinks slightly during perfusion. As we noted in a previous article, BPI has excellent laproscopic instrumentation. The CPA makes the tissue translucent, so that by adjusting the point of focus, it is possible to see several millimeters into the surface of the cerebral cortex. The level of resolution we can achieve is about that of 4-8 red blod cells (20 to 40 microns). Thus it is possible to see agglutinated cells tumbling through very small arterioles and venules.
The catch is that you must be able to hold the imaging probes almost totally motionless. This is almost impossible by hand. We have achieved some spectactular occasional images, but they have not been consistently available. With the Codman stereotactic assembly, we can mount our fiberoptics scopes in special holders and position them motionlessly, allowing us for the first time to achieve systematic evaluation of the brain surface.
On December 12th, 1995 James Gallagher, a 55-year-old software developer from Sunset Beach, California, became CryoCare's first member to enter cryopreservation. He also became the first patient ever to benefit from new technologies developed to reduce three forms of injury:
The following is not quite a full technical report, but neither is it simply a lay-level of summary of key events without reference to the technical details and the impact those details had upon this patient's care and potentially, future patents' care. It is the aim of this report to include enough quantitative detail that direct comparisons can be drawn with previous cases. It can be argued that this is just *one* patient, that solid inferences or statistical significance cannot be established with n=1. Generally, this would be true. However, this patient's course is being compared with many other animals and humans subjected to similar protocols.
Using relevant animal models over the last three years, BioPreservation, Inc. (BPI), the transport and perfusion/cool-down service provider for this patient, in conjunction with 21st Century Medicine (21st) has been evaluating aspects of the protocol used on this patient. Further, BPI and several of BPI's core technical staff have had extensive experience applying pre-mortem medication, transport, and cryoprotective perfusion protocols with patients from other cryonics organizations in the past, and also have access to relevant case data from other cryonics patients whose illness, agonal course, and time to post- arrest intervention are directly comparable with this patient's.
At a minimum, we believe that the close correlation of this patient's response to that observed in the canine experiments using the same protocol, and especially when contrasted with results achieved in comparable human cryopreservation patients treated with previously used protocols (including a patient treated by BPI; ACS Patient #9577), is significant. Of particular importance is this patient's core temperature cooling data, since cooling is constrained by physical laws which are well understood, and where the predictability and simplicity of the system used to carry out cooling allows for little variation from case to case (where patient mass, body fat content and distribution, and surface area, are comparable, of course).
The significance of other measured parameters in this case, such as tissue-specific enzyme release (markers of ischemic injury for specific organs and for the patient as a whole) and metabolic parameters, is presently more open to debate. However, even here we believe that the results achieved with this patient are so different from that observed in patients with comparable diagnoses and agonal courses (and in such close agreement with animal data) that careful consideration should be given to the results.
The patient first contacted CryoCare (CC) on 15 July, 1995 to inquire about cryopreservation services. He was familiar with cryonics due to prior association with a contract worker whom he employed in the early 1980's who was heavily involved in cryonics. He had also read cryonics organizations' literature and met with various cryonics organization members and personnel (where cryonics was a topic of discussion) again since the early 1980s. The patient had been in-touch with several cryonics organizations before contacting CC, after being informed he was terminally ill.
Formal communication with CC administration began by e- mail on 17 July and Mike Darwin, President of BPI was brought in for a cryonics consult with the patient on 20 July.
At that time the patient informed BPI that he had been recently diagnosed with terminal cancer and was interested in putting cryopreservation arrangements in place. BPI questioned the patient extensively about his medical history and treatment and discovered the following relevant information:
At this time Mike Darwin refused to accept the patient as a BPI client until a definitive diagnosis of terminal illness was established. The patient was told that some moderately to highly treatable cancers such as non-Hodgkin's lymphoma may appear indistinguishable on CT from other, untreatable cancers. It was also noted that on the initial radiology report (which was read to Darwin) that the radiologist reading the CT remarked on what he felt might be a mass in the posterior part of the descending colon, but was unable to tell with certainty due to the presence of feces in the bowel. The radiologist listed primary adenocarcinoma of the colon (the most common type of bowel cancer) as the number one possibility to rule out.
Since the patient did not have health insurance, a variety of options was discussed to determine the nature and the treatability of the apparent malignant disease. The patient was referred to BPI's medical consultant Steven B. Harris, M.D. and the number of options was rapidly pared down. If it *was* primary renal carcinoma, the only way to definitively establish that would be to obtain a sample of the tumor using CT-guided needle biopsy or to do an "open biopsy" or lapropscopic biopsy wherein surgery is performed to open or access a body cavity with a trocar and fiberoptic scope, to inspect and directly obtain a sample of the questionable tissue.
Due to the statistically comparatively low likelihood of primary renal carcinoma in a 55 year-old man (versus the likelihood of primary adenocarcinoma of the bowel), the remarks of the radiologist about the possible presence of a bowel mass on the CT scan, and the absence of health insurance, it was decided that the most cost-effective and medically most conservative way to proceed would be to have the patient undergo fiberoptic colonoscopy (direct visualization with a flexible fiberoptic viewing device) of the colon and look to see if there was any tumor present. (Common things are common; metaphorically the CT was the equivalent of loud hoof beats in the distance, and when one hears hoof beats in the Western United States one generally thinks of horses, not zebras. In this case horses = primary adenocarcinoma of the bowel).
A few days later the colonoscopy was performed and our suspicions were confirmed; there was a large mass nearly obstructing the descending colon which appeared on visual inspection to be a malignancy.
Dr. Harris and Mike Darwin both advised the patient that bowel obstruction by the rapidly growing tumor was imminent and that he should consider a palliative colostomy. The patient was resistant to doing this for several reasons. First, he had considerable confidence that enemas with urea, and his alternative cancer treatment regime would at least shrink the tumor (he was receiving considerable encouragement from his alternative care provider in this regard), so that surgery could be avoided. Secondly, the anticipated cost of a colostomy and associated care would jeopardize the funding the patient had set aside from his savings for cryopreservation.
This created a new and difficult ethical problem for both BPI and CC. Clearly CC needed to maintain its funding minimums at a level sufficient to provide reasonable safety margins for continued cryogenic care of the patient. And, clearly, BPI is not in the charity business and has staff to pay and marginal costs to address. On the other hand, it is hardly tenable to confront a patient with the choice between foregoing cryopreservation or facing a gruesome and agonizing death from an obstructed bowel (months earlier than would be the case if colostomy or colectomy were performed)
Since this patient was low on funds already (nearly $50,000 of savings having been spent on piecemeal alternative "medical" care) he had already agreed to the use of new procedures and to the biopsying of his brain in exchange for reducing the basic cost of BPI's procedures. Confronted with this new situation, BPI reduced its charge to below the break-even level and the patient volunteered to cooperate with what then constituted extraordinary antemortem monitoring.
This was the first time BPI, CC, or, to our knowledge, any cryonics organization has been faced with a situation where a patient (and his cryonics organizations) was confronted with a choice between reasonable standard of care (avoiding a serious, life shortening, and definitely quality- of-life reducing complication of the illness), and being cryopreserved. This was deeply disturbing for all involved, and merits intense discussion in the immediate future, not just by CC and BPI, but by the cryonics community as a whole. While it is inappropriate to belabor this point here, this case points up that increasingly cryonics organizations will be dealing with both members and non-members who have no health insurance (not even HMO coverage), no access to government healthcare such Medicaid, Medicare or VA care, and/or who have limited access to health care with HMO, PSO, PPO or other care which forces them to make major quality of life or length of life decisions based on use of their non- healthcare allocated funds such as savings, property equity, and even accumulated cash value or resale value of life insurance policies--including those specifically earmarked for cryonics.
Further, in some cases the state, acting through the courts, may appropriate these assets at the request of guardians or relatives. The issues raised by the inevitability of a massive restructuring of health care cost and availability in the United States which is occurring now, should be considered now. This case should serve as a sentinel in this respect.
A few days after his colonoscopy, the patient began to experience symptoms of bowel obstruction (increased anorexia, nausea, shot-gun pellet stool, vomiting and abdominal distention), and so a double-barreled colostomy was performed on 29 July. This procedure was uneventful and the patient returned home where he was cared for by his sister, his brother-in-law and his nephew. The patient continued with his alternative medicine regime, although, due to increasing nausea, he abandoned use of the cesium chloride.
At this point BPI became disengaged from close involvement with the case over issues related to funding details. This was an issue between the patient and CC, and until the patient became a fully signed-up CC cryopreservation member, it was inappropriate for BPI to be as closely involved.
As financial negotiations proceeded favorably, BPI again became involved and made a home visit on 15 October with medical advisor Dr. Harris and BPI staff members Carlotta Pengelley, LVN, Joan O'Farrell, Sandra Russell, and Mike Darwin also present. The purpose of this visit was to evaluate the home for logistics of access (it was a second- story apartment with outside stair-access only) and equipment set-up, meet the family and prepare them for the reality of transport, assure the patient's medical and pain control needs were being met, encourage the patient to enroll in home hospice, and to carefully medically examine the patient in order to determine "staging" or likely time-course to legal death for cryonics reasons.
Dr. Harris examined the patient thoroughly during this visit and baseline blood chemistries were drawn, including samples collected, spun-down and frozen to dry ice temperature on-site for subsequent baseline antioxidant and lactate levels (the former to be done by Pantox Labs of San Diego, CA) as well as for a routine chemistry panel an a screening for infectious diseases.
During this visit Dr. Harris noted that the patient had right leg weakness (barely noticeable) a right visual field cut (right homonymous hemianopia), nausea and anorexia (lack of appetite) and that he weighed 73.1 kg down from a previous healthy weight of 86-88 kg. Careful history taking also disclosed recent (2 weeks duration) inability to read, which the patient attributed to lack of ability to concentrate, and urinary incontinence. The patient was noted to have cancer wasting syndrome and complained of severe back pain of eight months duration. Further, Dr. Harris felt it very likely the now nearly immobilizing back pain (the patient was constrained to lie face down on a specially modified cot most of the time) was due to involvement of the sacrum with metastatic disease.
Dr. Harris' presumptive diagnoses at the conclusion of the home visit were probable large metastases (4-6 cm) of the primary colon cancer to the left occipital lobe of the brain which was likely responsible for the right-sided visual field cut, weakness, and incontinence. Probable metastatic involvement of the sacrum was assumed, with resulting uncontrolled bone pain. Further presumptive diagnoses were tumor necrosis factor (TNF) and related cytokine cancer wasting syndrome, and poor nutritional status (calorie count estimated at 1500 kcal/day or less). The family was urged to take the patient to an imaging center and have an MRI or CT of the head done to rule out malignant involvement of the brain (the patient's family was informed of the high probability of the metastasis, but the patient at this time was not).
A CT scan with and without contrast was performed on 17 October and a 6cm mass was indeed found in the left occipital lobe of the brain. Dr. Harris, in conjunction with the patient's newly acquired primary care physician persuaded the patient that it was imperative that he undergo palliative radiotherapy to his head and to his sacrum (lower back). The patient was resistant to undergoing this treatment because of his disdain for "radiation treatment of cancer" and because of his concerns about possible damage to his brain from the radiation which might compromise his chances for good cryopreservation.
Dr. Harris was instrumental in convincing the patient to get palliative radiation treatment. He explained that failure to do so would result in hemiplegia (paralysis on one side) possible loss of speech, complete incontinence of bladder and stool, and likely death from elevated intracranial pressure which might very likely expose his higher brain to extended periods of periods of minimal or absent blood flow (ischemia) for hours prior to cardio- respiratory arrest and pronouncement of legal death. The consequences of unchecked growth of an aggressive malignant tumor in the brain, versus the by comparison trivial effect of palliative radiotherapy (increased sleepiness and fatigue, hair loss and modest compromise of short-term memory) were emphasized.
(In cases of metastatic brain disease the entire brain is usually radiated both to hold down the costs associated with shielding and selective irradiation of the tumor, and, more importantly, to "head off" the proliferation of other metastases; where you see one seed sprouting there are likely other to be others germinating. Whole brain irradiation decreases the likelihood of secondary tumors developing in a patient who is terminal with aggressive malignant disease).
The patient had previously been scheduled to have a chronic intrathecal line placed into his lumbar spine for delivery of chronic intrathecal morphine by pump for chronic pain control, and on 16 October, this was done. Within 48 hours, however, the patient was unable to walk, and was admitted to the hospital. There, neurological exam showed profound bilateral leg weakness and normal spinal fluid. X- rays also showed a metastatic lytic lesion to the right sacrum, with possible nerve compression to the right leg. The neurologist examining the patient for the first time thought that the new weakness was due to cauda-equina compression syndrome from tumor; and rejected the idea, put forth by Dr. Harris, that the very rapid onset of weakness coupled with the relationship to the intrathecal line placement, made that procedure suspect. Dr. Harris, however, was able to convince the patient's primary physician of this possibility, and the intrathecal morphine was discontinued. Within a day the patient recovered use of his legs, but a definitive diagnosis of the problem was never made. He continued for the rest of his course, however, on morphine delivered via peripheral line.
During hospitalization for the leg problem, the patient was seen by a radiotherapist, and radiotreatment to his brain and sacrum was initiated. In particular, he underwent 10 fractionated doses of palliative radiotherapy to his head, with 4,000 rads (cGy) to the whole brain and a 10,000 rad boost to the tumor.
The patient was also enrolled in a good Home Hospice program which did much to help the family by providing basic care advice and improved pain management.
Financial negotiations between the patient, the patient's representative family member and CC continued (with some last-minute input from BPI) and the patient became a fully funded CC cryopreservation member on 7 November, 1995.
On 5 November the patient spoke with Dr. Harris by phone and reported himself as being very depressed and wishing to withdraw from the program of anti-TNF and immune stimulating drugs the patient had been started on after the withdrawal of the alternative medicine practitioner. Dr. Harris noted that the patient sounded sort of breath (dyspneic) on the phone and asked the patient if he was, which the patient denied.
That evening the patient was transported to the emergency department (ED) of a nearby hospital acutely short of breath and panicky with air hunger. The paramedics who carried out the transport noted that the patient had diminished breath sounds on the right side nearly to the base of the right lung, and began oxygen at 2 liters per minute (LPM) during transport. When the patient was examined in the ED the ED physician said he could find no diminished breath sounds, stopped the oxygen, waited "a few minutes," noted the patient's oxygen saturation by pulse oximetry was 96%, and told him to go home. At that point Dr. Harris spoke with the ED physician and requested that arterial blood gases be drawn and a chest X-ray be taken. This was a medically sound request for several reasons: first, it would help establish the basis of the patient's shortness of breath and determine if palliative oxygen therapy should be considered to reduce or eliminate "air hunger." Or, failing relief of air hunger with oxygen supplementation, increase the degree of sedation to make the patient more comfortable. Second, from a cryonics standpoint it was important to know if the patient was experiencing a complication or exacerbation of the primary disease (such as pneumonia; a big risk here since the brain tumor required immunosuppressively high doses of dexamethasone to control intracranial pressure) which would justify deployment of the standby team.
The ED physician politely but firmly brushed off Dr. Harris' request (even though the patient was willing to pay for the requested tests in cash) and sent the patient home. During the trip home the patient again became acutely dyspneic and spent the night miserable and panicky with air hunger.
The next morning the patient's HMO waiting period was up (he had HMO coverage available regardless of pre-existing illness, but only after a waiting period) and the patient was again transported by ambulance, this time to the office of the internist employed by the HMO. The physician lifted the blanket, looked at the patient, informed the patient that "pneumonia was the cancer patient's friend," further informed the patient that he had end-stage cancer, and sent the patient home, *again without oxygen*. At this point Dr. Harris intervened and arranged for palliative oxygen therapy in conjunction with the patient's private physician.
The following weeks saw an up and down course for the patient. The radiotherapy restored his vision and ability to work initially, and he experienced much less bone pain. (Prior to this time the patient had worked as a consulting programmer on a part-time basis as his illness had permitted.) However, he continued to lose weight and eventually began to experience intermittent but progressive dyspnea, constant nausea with occasional vomiting, and exogenous depression associated with clearly deteriorating quality of life. Finally, he became unable to work once again. The patient was now receiving more or less continuous IV morphine administered peripherally through a strap-on battery-operated pump.
The day after Thanksgiving, 24 November, a second home visit by BPI staff (without Dr. Harris) was carried out for the purpose of collecting baseline cerebral functioning monitoring (CFM) data and evaluating the patient's condition first hand. The patient was noted to appear slightly more wasted, to be largely oxygen dependent, but to have well managed pain and to be ambulatory for hygiene, and limited socialization. Baseline EKG and CFM data were collected and the patient's feelings and thoughts about cryopreservation, and his informed consent were videotaped.
An unfortunate and unexpected sequelae to this visit was that one of the BPI team members was infected with influenza A and unaware of it at the time of the visit. Within 48 hours of the visit the patient was febrile (39 degrees C), severely dyspneic, and suffering profound malaise and myalgia. The patient called BPI to report he was ill and the hospice nurse was called in to evaluate breath sounds and consult with BPI's medical advisor (Harris). The hospice nurse reported no change in breath sounds, no cough and no evidence of pneumonia, but rather a febrile illness with myalgia consistent with the flu.
It was explained to the patient that he probably had early influenza (onset of symptoms was that AM) and that this could probably be treated with combination anti viral drugs and an antibiotic to protect against secondary infection. Alternatively, the patient was told he could elect to refuse treatment which would carry with it the likelihood of death from pneumonia or some other inter-current infection. These choices were reviewed with the patient because of the patient's prior, repeatedly stated desire to refuse further life-extending care, including refusal to see a pulmonologist and oncologist to evaluate the cause of the dyspnea and perhaps treat it, if it was secondary to tumor-related compression of a large bronchus. (Such treatment can be simply carried out with additional localized radiotherapy, or even laser ablation of tumor growing into a bronchus.)
The patient decided to accept treatment for the influenza infection and was started on p.o. (oral) ribavirin 400 mg q. 8 hours, and 100 mg b.i.d. rimantidine, an antiviral specific for influenza A. Antibiotic prophylaxis for secondary infection was instituted with doxycycline 100 mg b.i.d.
There was prompt improvement in symptoms and signs of the illness with the patient becoming afebrile in less than 24 hours from the start of treatment with antivirals and antibiotic.
During the closing days of November the patient experienced the typical interleaving of relatively "good" days with progressively worse and more frequent "bad " days. The patient's p.o. medications at this time were:
aspirin 1.25 grain, p.o., daily co-enzyme Q10, 100 mg p.o. t.i.d. dexamethasone, 4 mg t.i.d. doxycycline, 100 mg, b.i.d. d-alpha tocopherol, 1,000 I.U., t.i.d. ascorbic acid, 1 g t.i.d. phenytoin (Parke Davis), 300 mg q.d. morphine sulfate by IV pump p.r.n. for pain. 50 mg thalidomide, p.o. before retiring 10 mg melatonin, p.o. before retiring
At the beginning of December the patient became increasingly oxygen dependent and began experiencing a return of visual disturbances which were prodromal to his prior homonymous hemianopia. He also experienced a return of urinary incontinence. The patient expressed justifiable concern that the original brain metastases, or another, was again beginning to cause problems, or that structures adjacent to the tumor were experiencing the un-typical delayed death as a result of the high dose radiation to which they were exposed.
Further, the nausea which had been present since shortly after the illness was diagnosed was now more or less constant with occasional vomiting. Attempts at pharmacologic control of the nausea using hydroxyzine, chlorpromazine, compazine, ginger, and tetrahydrocannabinol (THC) were unsuccessful.
During the first days of December the patient repeatedly contacted BPI and expressed a desire to withdraw from palliative oxygen and to abruptly stop steroids and "get it over with." He explained that his quality of life was no longer acceptable, and that he wished to take action to end his life in a legal manner before the quality deteriorated further, and especially before he became unable to exercise choice in the matter.
Unfortunately, while the patient had responded well to prompt anti-viral therapy for influenza, two of the team members were ill with the flu and with the non-bacterial bronchitis which accompanied it. Complicating matters further was the illness (again with the flu) of one of the team members' two small children. The patient was told that while we would respond if he was set upon immediate implementation of this course of action, optimum response would best be had by delaying a week or so longer in order to give team members time to recover and to permit final set-up of equipment in the home and last minute preparations to be made.
When staff were largely recovered, a window of time was agreed for discontinuation of life support. The patient's private primary care physician (not involved with BPI) was closely involved in this decision, and advised BPI that he felt withdrawal of oxygen would result in rapid decompensation and cardiovascular collapse. He said he felt the patient was making an informed and "rational" choice (i.e., he saw no indication of compromising psychiatric illness, organic brain disorder, or undue influence). The physician commented that he was comfortable with the patient's decision since the patient had repeatedly told him he would have withdrawn from life support far earlier had it not been for his cryopreservation arrangements. The physician expressed a willingness to be present when the patient discontinued life support and to pronounce legal death. Further, the physician ordered that a Hickman catheter be implanted in the patient to facilitate administration of pain medication (his peripheral veins were "exhausted" from repeated sticks and catheter placement). BPI requested that the catheter be a large-bore Hickman to facilitate rapid, low resistance of transport medications, and the physician agreed to this request.
During the weekend of 9-10 December the patient's home was fully prepared for standby and transport. The Mobile Advanced Life Support System (MALSS) was set up in the living room and the extracorporeal circuit strung. An operating room light was put in place, back tables were set up and instrument trays and ancillary supplies were laid out and readied. Specialized monitoring equipment for blood pressure, cerebral function, pulse oximetry, and acute lab collection (blood gases) was also put in place. The CDI point-of-care in-line blood gas system was also set up next the MALSS and the monitoring cells cut into the arterial and venous lines of the extracorporeal circuit to allow for continuous acquisition of blood gas data during initial bypass-assisted cooling, and during blood washout and replacement with 21CMBP-002 flush-store solution.
The patient's physician was then consulted about the possibility of administering pre-cryopreservation medications to reduce the insult from the agonal hypoperfusion/hypoxia and post-pronouncement ischemia which would necessarily occur prior to mechanical restoration of circulation and breathing during transport by BPI. The physician reviewed the medications suggested and agreed to prescribe all those available in the U.S. and Mexico. The patient had made arrangements through an AIDS buyers' club to obtain other medications which he believed would be efficacious in helping to ameliorate ischemic injury. These were largely drugs which 21st Century Medicine animal research had shown to be cerebro-protective if given before the ischemic insult. The following schedule of pre-cryopreservation medication was begun by the patient on 10 December, 1995:
Medications for 10 December:
aspirin, 1.25 grain, p.o., daily ascorbic acid, 1 g t.i.d. N-t-butyl-a-phenylnitrone, 500 mg, p.o. with evening meal sodium selenite, 1000 mcg selenium p.o. co-enzyme Q10, 100 mg p.o. t.i.d. dexamethasone, 4 mg p.o. t.i.d. doxycycline, 100 mg p.o. d-alpha tocopherol, 1,000 IU, t.i.d. phenytoin (Parke Davis), 100 mg, t.i.d. morphine sulfate by IV pump p.r.n. for pain. 50 mg thalidomide, p.o. before retiring 10 mg melatonin, p.o. before retiring
Medications for 11 December:
aspirin, 1.25 grain, p.o., daily ascorbic acid, 1 g t.i.d. piracetam 800 mg p.o. at 10:00 N-t-butyl-a-phenylnitrone, 1g mg, p.o. with evening meal sodium selenite, 1000 mcg selenium p.o. co-enzyme Q10, 100 mg p.o. t.i.d. dexamethasone, 4 mg t.i.d. doxycycline, 100 mg, t.i.d. d-alpha tocopherol, 1,000 IU , t.i.d. phenytoin (Parke Davis), 100 mg, t.i.d. morphine sulfate by IV pump p.r.n. for pain. 50 mg thalidomide, p.o. before retiring 10 mg melatonin, p.o. before retiring
Patient agreed to take no solid food after 11 December at 2400 since it was his decision to withdraw life support the following afternoon.
Medications for 12 December:
aspirin, 1.25 grain, p.o., daily ascorbic acid, 1 g t.i.d. N-t-butyl-a-phenylnitrone, 1 g, p.o. with evening meal sodium selenite, 1000 mcg p.o. co-enzyme Q10, 100 mg p.o. t.i.d. dexamethasone, 4 mg t.i.d. doxycycline, 100 mg , t.i.d. d-alpha tocopherol, 1,000 IU , t.i.d. phenytoin (Parke Davis), 100 mg, at 100 and 1600 morphine sulfate by IV pump p.r.n. for pain. misoprostol, 100 micrograms at 1600 melatonin, 50 mg, p.o. at 1900 prilosec, 20 mg, p.o. at 1900 800 mg ibuprofen at 1900 phenytoin, 500 mg, p.o. at 1900 Maalox, 60 cc p.o. immediately before discontinuing oxygen.
The patient obtained on his own, and self-administered without assistance at about 2100 through his implanted Hickman catheter, 250 cc of Dextran 40 in normal saline (Baxter, Irvine, CA) containing 1 mg of Nimodipine (A.G. Bayer, Germany), 40,000 IU of sodium heparin and 5 grams of a proprietary agent developed by 21st Century Medicine.
This latter agent will be hereinafter referred to as 21CM-006; it was developed to protect against ischemic injury, up-regulate the efficacy of anaerobic metabolism, and ameliorate V/Q mismatch (where blood flows through unventilated area of lung and thus does not get oxygenated) and prevent loss off normal vasomotion (where blood delivered to the tissues is not distributed to the capillaries properly resulting in "shunting" and failure of delivery of oxygen and nutrients to the tissues in shock) concurrent with discontinuing high flow oxygen support (8-10 LPM by mask with reservoir bag: FIO2 was ca. 80-90%).
A final conversation was had with the patient at about 1900 at which time he was repeatedly advised that he could change his mind without any problem to BPI and that he should feel no pressure to pursue this course of action. His response was: "You don't understand. This is easy. The hard thing would be taking one more day of life like this." The patient appeared in good spirits and laughed and joked with family and team members. He explained that he had accepted he was either to die or recover from cryopreservation, and that either way he was fully prepared and psychologically ready. He had played a card game with family and friends that afternoon, and explained that while he was a little apprehensive, he intended to take some alprazolam (Xanax) and get ready for the journey ahead.
Several BPI team members spoke with the patient privately and said their good-byes.
At the request of the patient and his family (for reasons of intimacy; saying farewells etc., and basic privacy) the entire BPI team withdrew to the BPI transport vehicle parked outside the patient's apartment. The patient's attending and primary care physician remained with the patient and the patient's family to supervise withdrawal of life support, assure adequate palliation of air hunger and discomfort, and promptly pronounce legal death. BPI personnel were to be summoned immediately after pronouncement by cell phone (four BPI personnel had cell phones!).
At approximately 22:50, the patient discontinued oxygen. He had taken approximately 3 mg of alprazolam about an hour before discontinuing oxygen, and he had access to self- administered morphine (pump limited boluses) to ease air hunger.
It was reported that the patient rapidly lost consciousness on withdrawal of oxygen and experienced cardiopulmonary arrest at 2311 on 12 December, 1995.
Intubation was accomplished at 23:13 by Dr. Harris, and "Active Compression-Decompression-High-Impulse CPR" (ACDC- HICPR), using a custom built Michigan Instruments "Thumper" mechanical chest compressor, was initiated at 23:14. A standard Ambu ACDC silastic suction cup was used on the Thumper to achieve the ACDC component of the ACDC-HICPR. Placement of a tympanic temperature probe was achieved concurrent with intubation (during securing of the endotracheal tube). The initial tympanic temperature reading was 36.8 degrees C.
Tympanic (eardrum) temperatures were used in this patient because it is well established that tympanic temperature reflects true brain temperature since the blood supply for the eardrum and midrain and cerebral cortex are the same. Typmanic temperature is thus a much more reliable measure of the temperature of the iorgan we are *most* interested in preserving (the brain) than are esophageal or rectal temperatures. Further, work with dogs at 21st has established a far closer correlation between tympanic temperature and actual measured brain temperature (via invasive probes) than esophageal or rectal temperatures
Family and friends had begun icing the patient at the time of pronouncement (legs, abdomen and lower thorax; leaving the head unencumbered so that airway management could be instituted before icing) and the head, thorax and axilla were iced concurrent with the start of cardiopulmonary support.
Simultaneous with the start of external cooling, a Darwin rectal thermocouple probe was placed in the descending leg of the double barreled colostomy and the 60 cc balloon inflated to anchor it in place. A Darwin colonic lavage tube with a 60 cc silastic balloon and fenestrated tip was also inserted in the stoma of the ascending end of the colostomy, and the balloon on the lavage tube was also inflated to anchor it into the ascending colon.
Immediately thereafter a stab wound was made (using sterile technique) through the medial aspect of the right external oblique muscle 3 cm to the right of the navel, at the level of the iliac crest. The stab wound was rapidly extended in depth by blunt dissection with Metzenbaum scissors (Mets) until the peritoneum was reached, and a 1 cm incision was made in the peritoneum with Mets and a Darwin peritoneal lavage tube was inserted and its 60 cc silastic balloon rapidly inflated to seal and anchor it in place.
Once all lavage tubes were in place the patient's ascending, transverse colon, and terminal ileum were irrigated with 2 liters of iced Normosol-R, pH 7.4, and the peritoneal cavity was irrigated with 4 more liters of this solution (Abbott Pharmaceuticals, Chicago, IL). Reservoirs connected to the colonic and peritoneal lavage tubes were placed on the floor and the lavage fluid was allowed to drain into the respective bags by gravity.
The first pulse oximetry and end-tidal CO2 readings were obtained at 23:16 and were 95% and 5% respectively. Wave form acquisition on the pulse oximeter was excellent and the pulse rate of 80 per minute correlated exactly with the action of the Thumper. At 23:19 the patient's tympanic and descending colon temperatures had declined to 29.8 degrees C. By 23:20 the descending colon temperature had rebounded to 34 degrees C. At 23:21 the peritoneum was lavaged with 2 additional liters of iced Normosol. At 23:22 the tympanic temperature was 28.7 degrees C and the descending colon temperature was 28.6 degrees C. Oxygen saturation at that time was 93%, and End tidal CO2 (EtCO2) was 4%.
Administration of Transport Medications began at 23:12 and was as follows:
Epinephrine 12.6 mg, 23:12, IV push (given to support blood pressure during CPR).
The drug 21CM-005 3.15 g, IV push, 23:16, (This drug is a proprietary compound given to inhibit lactic acidosis and increase the efficacy of anaerobic metabolism). 3.15 g of 21CM-005 contains approximately 40 mEq of potassium, an amount sufficient to preclude restoration of spontaneous cardiac activity.
Soporate (21CM-004) 6.30 g IV push, 23:12 (Soporate is a proprietary compound given to inhibit excito-toxicity in a class of brain receptors found to be critical in mediating cerebral re-perfusion injury in dogs following 12+ minutes of global cerebral ischemia using a cardiac arrest model. The drug also acts as a general anesthetic preventing patient's from regaining consciousness during cardiopulmonary support.)
21CM-005 6.30 g IV push, 23:12 (see above for explanation of the pharmacology of this agent).
Oxynil (21CM-003) 630 mg IV push, 23:13 (Oxynil is a proprietary agent which has been shown to ameliorate brain ischemia in dogs by its free radical trapping ability. It is useful primarily as an adjunct and potentiator of other antioxidant medications).
21CM-002 100 ml; 50 ml IV push, 50 ml over ca. 10 minutes. Push dose given at 23:15, infusion completed at 23:28. (21CM-002 is a cremophor emulsion (micellized) mixture of two proprietary antioxidants which rapidly cross the blood brain barrier. One of these antioxidants crosses mitochondrial membranes rapidly and prevents failure of high energy metabolism in neuron and glial cells following re- perfusion after global ischemic injury in dogs of 12+ minutes duration).
Deferoxamine 2g was added to the mannitol infusion (126 g mannitol as 20% solution in water). Mannitol infusion was begun at 23:32 and concluded at 23:40.
Exiquell (21CM-005) 315 mg IV push. (Exiquell is a proprietary agent used to inhibit the quaint-quisqualate receptor system which is a significant source of excito- toxicity following global cerebral ischemia in the dog.)
THAM (tromethamine) 15.75 g in 250 cc (50 cc IV push), with the balance by IV infusion, 23:18 Mannitol (see Deferoxamine above). Pavulon (pancuronium bromide) 2 mg, 23:16, to inhibit shivering and prevent return of spontaneous respiration. Methylprednisolone 1 g IV infusion over a minimum of 5 minutes, begun 23:16, ended, 23:20. Cipro IV (ciprofloxacin; antibiotic causing no cold agglutination) 400 mg IV infusion given slowly between 23:16 and 23:30. Dextran 40 (Gentran) in 10% saline, 500 cc. Administration of all transport medications to this patient was completed at 23:40.
The first blood sample for gases, chemistries and electrolytes could not be collected until after the conclusion of medication administration. A central venous sample was collected via the patient's Hickman line at 23:50 on 13 December and yielded the following results:
Tympanic Temperature: 25.7 degrees C, Descending Colon Temperature 19.0 degrees C
| MEASUREMENT | RESULTS | NORMAL RANGES |
| pH | 7.34 | 7.35 (mean) |
| pCO2 | 52.4 mmHg | 45-55 |
| pO2 | 37.0 mmHg | 40-50 |
| O2 Sat | 89% | 70-75 |
| BUN | 15.0 mg/dl | 7-25 |
| Creatinine | 1.1 mg/dl | 0.7-1.4 |
| Sodium | 120 mEq/l | 135-146 |
| Potassium | 5.5 mEq/l | 3.5-5.3 |
| Chloride | 82 mEq/l | 95-108 |
| Magnesium | 1.7 mEq/l | 1.2-2.0 |
| Calcium | 7.2 mg/dl | 8.5-10.3 |
| Phosphorus | 7.8 mg/dl | 2.4-4.5 |
| Protein, Total | 5.8 g/dl | 6.0-8.5 |
| Glucose | 251 mg/dl | 70-125 |
| Bilirubin,Total | 0.8 mg/dl | 0.0-1.3 |
| Alk Phosphatase | 76 U/L | 20-125 |
| LDH, Total | 227 U/L | 0-250 |
| GGT | 58 U/L | 0-65 |
| AST | 101 U/L | 0-42 |
| ALT | 69 U/L | 0-48 |
| Uric Acid | 0.5 mg/dl | 4.0-8.5 |
| Iron, Total | 138 mcg/dl | 25-170 |
| Iron Binding Capacity | 748 mcg/dl | 200-450 |
| % Saturation | 18 | 12-57 |
| HCT | 26% | 41-50 |
The next central venous blood sample collected during CPR at 0020 on 13 December, yielded the following results:
Tympanic Temperature: 23.0 degrees C, Descending Colon Temperature13.8 degrees C
| MEASUREMENT | RESULTS | NORMAL RANGES |
| pH | 7.115 | 7.35 (mean) |
| pCO2 | 27.8 mmHg | 45-55 |
| pO2 | 35.1 mmHg | 40-50 |
| O2 Sat | 88% | 70-75 |
| BUN | 17.0 mg/dl | 7-25 |
| Creatinine | 1.1 mg/dl | 0.7-1.4 |
| Sodium | 132 mEq/l | 135-146 |
| Potassium | 4.3 mEq/l | 3.5-5.3 |
| Chloride | 91 mEq/l | 95-108 |
| Magnesium | 1.8 mEq/l | 1.2-2.0 |
| Calcium | 7.8 mg/dl | 8.5-10.3 |
| Phosphorus | 9.9 mg/dl | 2.4-4.5 |
| Protein, Total | 3.4 g/dl | 6.0-8.5 |
| Glucose | 300 mg/dl | 70-125 |
| Bilirubin, Total | 1.1 mg/dl | 0.0-1.3 |
| Alkaline Phosphatase | 92 U/L | 20-125 |
| LDH, Total | 376U/L | 0-250 |
| GGT | 69 U/L | 0-65 |
| AST | 182 U/L | 0-42 |
| ALT | 126 U/L | 0-48 |
| Uric Acid | 0.5 mg/dl | 4.0-8.5 |
| Iron, Total | 177 mcg/dl | 25-170 |
| Iron Binding Capacity | 779 mcg/dl | 200-450 |
| % Saturation | 18 | 12-57 |
| HCT | 26 | 41-50 |
At 0050 another central venous sample was collected from the Hickman catheter and revealed the following results:
Tympanic Temperature: 21. degrees C, Descending Colon Temperature 9.9 degrees C
| MEASUREMENT | RESULTS | NORMAL RANGES |
| pH | 7.087 | 7.35 (mean) |
| pCO2 | 25.2 mmHg | 45-55 |
| pO2 | 39.2 mmHg | 40-50 |
| O2 Sat | 91% | 70-75 |
| BUN | 17.0 mg/dl | 7-25 |
| Creatinine | 1.0 mg/dl | 0.7-1.4 |
| Sodium | 134 mEq/l | 135-146 |
| Potassium | 4.9 mEq/l | 3.5-5.3 |
| Chloride | 91 mEq/l | 95-108 |
| Magnesium | 1.9 mEq/l | 1.2-2.0 |
| Calcium | 7.9 mg/dl | 8.5-10.3 |
| Phosphorus | 10.6 mg/dl | 2.4-4.5 |
| Protein, Total | 3.5 g/dl | 6.0-8.5 |
| Glucose | 308 mg/dl | 70-125 |
| Bilirubin, Total | 1.1 mg/dl | 0.0-1.3 |
| Alkaline Phosphatase | 91 U/L | 20-125 |
| LDH, Total | 366 U/L | 0-250 |
| GGT | 69 U/L | 0-65 |
| AST | 204 U/L | 0-42 |
| ALT | 140 U/L | 0-48 |
| Uric Acid | 0.5 mg/dl | 4.0-8.5 |
| Iron, Total | 179 mcg/dl | 25-170 |
| Iron Binding Capacity | 778 mcg/dl | 200-450 |
| % Saturation | 23 | 12-57 |
| HCT | 26 | 41-50 |
The final central venous sample taken during CPR was at 01:20 on 13 December and yielded the following results:
Tympanic Temperature: 19.3. C, Descending Colon Temperature 7.5 degrees C
| MEASUREMENT | RESULTS | NORMAL RANGES |
| pH | 7.047 | 7.35 (mean) |
| pCO2 | 23.7 mmHg | 45-55 |
| pO2 | 110.4mmHg | 40-50 |
| O2 Sat | 98.1% | 70-75 |
| BUN | 17.0 mg/dl | 7-25 |
| Creatinine | 1.0 mg/dl | 0.7-1.4 |
| Sodium | 133 mEq/l | 135-146 |
| Potassium | 5.7mEq/l | 3.5-5.3 |
| Chloride | 92 mEq/l | 95-108 |
| Magnesium | 1.9 mEq/l | 1.2-2.0 |
| Calcium | 7.9 mg/dl | 8.5-10.3 |
| Phosphorus | 11.3 mg/dl | 2.4-4.5 |
| Protein, Total | 3.5 g/dl | 6.0-8.5 |
| Glucose | 364 mg/dl | 70-125 |
| Bilirubin, Total | 1.2 mg/dl | 0.0-1.3 |
| Alkaline Phosphatase | 92 U/L | 20-125 |
| LDH, Total | 380 U/L | 0-250 |
| GGT | 69 U/L | 0-65 |
| AST | 214 U/L | 0-42 |
| ALT | 148 U/L | 0-48 |
| Uric Acid | 0.5 mg/dl | 4.0-8.5 |
| Iron, Total | 178 mcg/dl | 25-170 |
| Iron Binding Capacity | 777 mcg/dl | 200-450 |
| % Saturation | 23 | 12-57 |
| HCT | 22 | 41-50 |
From the laboratory and temperature data above, several important conclusions can be drawn, particularly when taken in the context of the protocol used in this case, in comparison with results obtained in two previous cases which compare with this one closely (Alcor patient A-1260, and ACS patient 9577).
Direct comparisons of many of the parameters in these two cases is not possible owning to absence of data in the previous cases. For instance, in patient A-1260 no temperature data was acquired until 32 minutes after cardiac arrest. Thus, a direct comparison between cooling rates during (say) the critical first 10 minutes post arrest is not possible here. However, comparisons can still be made where data does exist at corresponding intervals.
These three patients are of particular interest to compare because they match each other closely in sex, weight, fat distribution, and body surface areas, and they are of reasonably close ages. All patients were cooled at a minimum using a portable ice bath and ice-water circulating pump/distribution assembly (two with identical equipment). All patients had cooling and CPR begun within 2-4 minutes of cardiopulmonary arrest, and all were promptly medicated using the specified protocol. It is also important to note that all patients died of illnesses, two of AIDS and one of disseminated cancer, which left them cachectic and which involved compromise to multiple organ systems. One notable difference was the prolonged agonal course of ACS-9577 compared to the other two patients, and the poor response to cardiopulmonary support this patient exhibited, probably as a result of the antemortem ischemic injury and pulmonary compromise.
Data from one other patient, A-1049, a 32.8 kg severely wasted patient who arrested from dehydration secondary to end-stage adenocarcinoma of the lung, is also relevant. This patient is included since her mass and fat content/distribution and response to cardiopulmonary support were the most favorable of any patient cryopreserved by comparable methods available to this author. This patient thus serves as "best-case" for the efficacy of previously used methods of cooling, medication and CPR.
The number of asterisks after the case number indicates the overall score, from zero to ****, for response to cardiopulmonary support as evaluated by EtCO2, skin-color, femoral pulse, and other parameters when available.
A critical determining factor in how well a patient will cool during transport in addition to surface area, mass and fat quantity and distribution (fat is a good insulator) is the adequacy of blood circulation. Warm blood being delivered to the surface of the body and to structures with good surface to volume ratios that facilitate good exchange (such as fingers, toes, arms, and legs) will clearly be superior in patients with good cardiac output. The patient's antemortem condition will be a major factor in determining how well s/he will respond to CPR. However, also of great importance is the use of highly efficient means of CPR and the use of drugs which prevent shunting of blood away from tissues that need it, and which prevent shunting of blood through parts of the lung which are fluid filled or not able to exchabfe oxygen. No doubt part, but by no means all of the superior cooling results observed in this patient were as a result of better perfusion during CPR.
As can be seen from the table above, patient C-2150, the subject of this report, cooled at a rate of approximately 1 degree C/min during the first ten minutes post arrest, and at a rate of 0.56 degrees C/min for the entire 30 minute period after arrest. This is a rate twice that of a patient with roughly half his mass and with far less subcutaneous fat during the first 10 minutes post arrest, and twice that at 30 minutes post arrest. It is also interesting to note that the 30-minute post arrest cooling rates of all three other patients are well below 0.5 degrees C/min., and are in close agreement (0.24 and 0.21) for the two patients whose mass, fat distribution and surface area most closely approximate those of this patient.
We believe that this patient experienced such superior rates of cooling--indeed, rates achieveable in a patient of his surface area only with extracorporeal (blood/body core) cooling--because of the following factors:
Superior perfusion due (blood circulation) during CPR as a result of:
Superior cooling due to the use of colonic and peritoneal lavage with ice cold solution in addition to external cooling using the portable ice bath (PIB) and a circulating water system to pump ice cold water over the patient's body.
The use of these modalaties and the cooling rates achievable with them was established in dog lab. Further, other cooling approaches such as the use of ice-slush lavages in stomach, inaddition to the colon and peritoneum, and the addition of liquid ventilation (using perfluburon chilled to 0-2 degrees C) or subzero jet gas ventilation, are currently under investigation (and patent) and may provide for cooling rates approach 1.5 to 2.0 degrees C per minute if added to the modalities used in this patient.
Administration of all transport medications to this patient was completed at 2340.
Surgery to raise the right femoral artery and vein was begun at 23:30 following standard prep of the right groin with Betadine scrub/solution, and creation of a sterile field with sterile muslin towels and disposable drapes. Two femoral arteries of 3-5 mm in diameter were rapidly located and a pressure line was placed in one at 23:55 (initial pressure measured was MAP 47 mmHg).
However, despite extensive further dissection of the right groin no femoral vein could be located. Dissection along the tissue plane of the femoral arteries failed to reveal the femoral vein (although the sciatic nerve was identified) and the femoral arteries appeared to bifurcate within the abdomen. (Subsequent autopsy disclosed that the patient had no femoral vein and a right iliac artery that bifurcated into two femoral vessels at the terminus of the abdominal aorta). Several small veins (3-5 mm in diameter) were located and one of these opened to determine feasibility of cannula placement for venous return. While this was deemed not possible, it was noted that the venous blood was free-flowing and arterial red in color, indicating adequate oxygen delivery to the patient (the patient's tympanic temperature at that time was approximately 23 degrees C, colonic temperature 14.5 degrees C).
By 00:15 a decision had been made to abandon the right groin wound and proceed with surgery to raise the left femoral artery and vein. Prep of the left groin was made at 00:21 and the femoral artery and femoral artery and vein were rapidly identified. The femoral vein was cannulated with a Biomedicus Carmeda-coated, 21 Fr. x 50 cm venous cannula (#34284).
However, a further complication occurred in that the femoral artery was invaded with malignancy; apparently between the tunica media vasorum and the intima of the vessel. The vessel also was moderately atherosclerotic (soft yellow atheroma). This complicated arterial cannulation and required extensive further dissection of the groin to avoid a dissecting aneurysm of the entire arterial tree secondary to cannula placement.
Thumper support was discontinued at 01:07 at a tympanic temperature of 20.2 degrees C and a colonic temperature of 8.4 degrees C. MAP had dropped to 35 mmHg at this time, and it was felt that further Thumper support was not productive.
Both cannulae were in place by 01:18 and closed circuit femoral-femoral bypass was begun at about 01:18, using a prime consisting of 750 cc Dextran 50 in Normal saline, 1500 cc of Normosol-R pH 7.4, 500 cc 20% mannitol in water, and 50 cc (1 mEq/cc) of sodium bicarbonate solution. At 01:21 a "popping sound" was heard, and the polycarbonate housing of the Sarns 9444 Turbo oxygenator was noted to have developed a leak at the joint between the two halves of the housing. This occurred at a pressure of 260 mmHg, well below the 760 mmHg pressure this unit is rated for.
The problem (popping sound) was noted at exactly 01:20 and the pump was shut down and lines were clamped at 01:21. The circuit was carefully inspected for air from the oxygenator through the filter and up to the patient, and none was noted. The oxygenator was changed out of the circuit and replaced with a fresh one and the bypass line was used to prime the new oxygenator and debubble the circuit. Bypass was resumed uneventfully at 01:33, 12 minutes later. Closed circuit bypass was continued at a MAP of 45 mmHg and flow rate of 2-3 liters per minute (LPM).
When the patient's tympanic temperature reached approximately 16 degrees C (colonic , 6.2 degrees C) the patient was progressively hemodiluted with 10 liters of Viaspan using 2 liters of open circuit flush at a MAP of 45- 50 mmHg. At the conclusion of the Viaspan flushes, the patient was flushed with 10 liters of 5% (v/v) glycerol in 21CM-BPI-002 base perfusate. Glycerol-containing flush was introduced slowly in two liter aliquots. Flushing with 5% glycerol began at 01:42 and was followed by flushing with 10 liters of 10% w/v glycerol perfused in the same fashion. Flushing with 2 liter aliquots of 10% w/v glycerol was completed at 02:35. Flushing proceeded more slowly than normal due to partial cold and chemical-induced rupture of both plastic bags containing the flush solution, with leakage which required a great deal of effort to contain.
At 02:02 the tympanic probe was replaced with a frontal sinus probe to facilitate movement of the patient at the conclusion of bypass. It is interesting to note that frontal sinus and tympanic temperatures agreed to within 0.2 degrees C. Frontal sinus temperature at the conclusion of flushing/glycerolization was 5.5 degrees C, colonic, 1.6 degrees C.
Following the conclusion of total body washout and phase I glycerolization, the patient was disconnected from the extracorporeal circuit with care taken to avoid introduction of air into either the arterial or venous cannula (the cannulae were cross-connected with a short length of 3/8" x 3/32" bypass tubing which was filled with perfusate and carefully purged of air before the occluding clamps on the cannulae were removed).
The patient was then removed from the PIB of the MALSS and placed in a more easily transportable PIB for transfer to the BPI/21CM facility for cryoprotective perfusion. Originally it had been planned that the patient would be moved with extracorporeal support on the MALSS continuing. However, the patient occupied a second story apartment with a stairway that became extremely slick and hazardous during what was the first (and unexpected) rain of the Los Angeles basin's winter season. For the safety of the patient and the personnel, a decision was made not to attempt to transport the 600 pound-plus MALSS, with the patient in it, down the stairs in heavy rain.
The patient was transported by BPI ambulance from Huntington Beach to Rancho Cucamonga, CA starting at approximately 0350. Driving conditions were very poor with heavy rain and an earlier than usual morning rush hour traffic beginning by the time the freeway was reached at 0400. The patient arrived at the facility at 0545 on 13 December.
(The second, concluding section of this report will appear in the next issue of this newsletter.)
Transport:
Michael G. Darwin, C.T.T., C.R.T., Team Leader, Surgeon
Steven B. Harris, M.D., C.T.T., Medical Advisior,
Surgeon, Airway Management
Carlotta Pengelley, L.V.N. Medications, Physiological
Monitoring
Sandra Russell, B.S., Surgical Assistant, Physiological
Monitoring, Perfusion Assistant
Michael Fletcher, C.R.T., Equipment Tech, Logistics
Support
Joan O'Farrell, Scribe, Logistics Support
Billy Seidel, Videographer
Mel Allen, Logistics Support
Edwin Shortess, Logistics Suppport
Cryoprotective Perfusion:
Michael G. Darwin, C.T.T., C.R.T., Team Leader, Perfusionist
Steven B. Harris, M.D., C.T.T., Medical Advisior,
Sample/Data Collection
Carlotta Pengelley, L.V.N. Sample/Data Collection
Sandra Russell, B.S., Perfusion Assistant, Data
Collection, Logistics Support
Mark Connaughton, Perfusate Preparation, Facility
Readiness, ABG & Electrolyte Analysis
Paul Wakfer, Cryoprotective Ramp Technician, Logistics
Support
http://www.cryocare.org/cryocare/
For those who have somehow managed to miss all the media coverage and techno-hysteria, the web is an Internet protocol that allows anyone to create illustrated pages that can be viewed by other people using computers and modems. Services such as Webcrawler (http://www.webcrawler.com/) provide a searchable database of web sites that can be located by keywords. Thus, if people want to learn about cryonics, they type the CRYONICS as a keyword and get a list of "hits," one of which will be our page.
CryoCare's site contains general information about cryonics, specific facts about CryoCare, pictures of our personnel, online editions of our literature, and back issues of CryoCare Report. Our bylaws and signup documents are also available. So far, we've received about 50 net visitors per week.
The site also contains an Events section maintained by CryoCare member Ken Wolfe. This lists all events (even T.V. shows) that are relevant to cryonics. If you know of something that should be included, email Ken Wolfe at .
Special thanks to CryoCare members Kevin Brown and Micheal O'Neal for creating and maintaining our web site.
You can find out more about our first patient, James Gallagher, by visiting a web site that has been established as a memorial to him by his family and friends. Point your browser to:
http://www.deltanet.com/users/jim/
CryoCare Forum is an Internet discussion group open to our members only. Recent topics have included methods of data archival and ethical and legal considerations in last-minute cryonics cases. Traffic averages between 10 and 20 messages a week, most of them high in content and low in noise. The group is not moderated, but there have been no flame wars and hardly any digressions into areas such as nanotechnology, uploading, the definition of identity, or the meaning of life--topics that may seem uncomfortably familiar to readers of the more widely distributed CryoNet news group.
CryoCare Forum allows directors and officers of CryoCare to discuss policy issues as they occur and receive instant feedback from our members. If you want to participate, send a message to Micheal O'Neal at asking to be added to the list, and include the ID number from your bracelet or necktag to confirm that you're a member of CryoCare.
The man on the phone was deeply distraught. "My wife always had an interest in cryonics," he said. "We talked about it. I know she wanted to do it. But we never imagined we'd need it so soon."
He had recently learned that his wife had between a week and a month to live. He was calling to ask if we could arrange for her cryopreservation; and it was my unfortunate task to explain why this might not be possible.
Signing up for cryonics requires calm thought, rational planning, and solid financial arrangements. The fact is, though, many people don't do it this way. They put it off because they don't have time, they don't want to think about their own mortality, and they're sure that nothing will happen to them for the next few years. When a sudden health crisis strikes, then we receive an emergency call.
Such calls force us to make some agonizing decisions. On paper it looks simple enough: we require that payment arrangements must be made in advance, and we insist that the person seeking cryopreservation must be mentally competent and must understand that cryonics is an untested, experimental procedure. We have to follow these rules because our first loyalty is to existing members who did have the foresight to make arrangements while they are still in good health. They--now depend on CryoCare, which means that we can't do anything that would jeopardize the organization's financial or legal security.
But it isn't always easy to say "no." Consider this hypothetical case: a man's 10-year-old daughter has died through medical malpractice. He says he wanted to arrange for cryopreservation, but everything happened so quickly, he didn't have time to locate a cryonics organization till after the little girl was legally dead. He's not wealthy, but he has savings. He's willing to spend all of them if there's a chance--any chance at all--of his daughter regaining her life one day.
This man is deeply distraught. Is he really capable of deciding rationally whether to spend more than $50,000 for a procedure that has only a tiny chance of success, bearing in mind that the patient has already been legally dead for several days? The father seems eager--desperate--to do this; but is he competent to understand the situation? How can we begin to explain ischemic damage when he's having trouble even remembering his own phone number, because he's so full of grief?
Under the circumstances it seems unethical to accept payment from such a client. This isn't the only consideration, though. Suppose we do take the case, the cryopreservation is carried out, and a few months pass. The father starts reading cryonics literature and begins to understand how important it is to preserve brain structure. He realizes that he may have wasted his money. Will he blame us for taking it? Will he remember that we tried to warn him of the risks, or will he have the incorrect impression that we induced him to pay us? If there's a close relative who dislikes the whole idea of cryonics, will (s)he accuse CryoCare of fraud? We should have no trouble defending ourselves against such a suit, yet the defense will cost money that we can't afford to spend. Wouldn't it be better to avoid this kind of risk by applying an absolutely inflexible rule against accepting last-minute cases where the applicant is highly emotional, has no previous knowledge of cryonics, and barely has enough money to cover the costs?
Personally I tend to hold this view. I believe that a cryonics organization should be almost as dull and conservative as an insurance company, trying to minimize risk for the sake of financial stability. Other people, however, disagree. They point out that our primary obligation is to offer people a chance at renewed life, no matter how small that chance may be. We are a small company, and small companies have to take risks in order to grow. If someone is desperate for our services, we should respect that person's feelings and not try to second-guess him for his own good. We should also be able to evaluate his personality to decide whether he is likely to regret his decision. And we should be capable of finding out whether there are relatives who may be hostile and potentially troublesome in future.
Easier said than done--especially since people who call us at the last minute can't be trusted to tell the whole truth. A person may be so desperate to have a loved one frozen, he'll claim to have more money than he really does, or he may conceal crucial facts about the patient's condition.
One factor that I find reassuring is that if CryoCare turns down a last-minute case, it's quite possible that another cryonics organization will take it. Thus, someone in need will not necessarily be denied help just because we say "no."
On the other hand, if this happens and the cases turn out well, we're in the position of giving away new clients to our competitors.
Clearly this is one of the most difficult topics for any cryonics organization. Moreover, as the concept of cryonics becomes more widespread (but not "real" enough to encourage people to sign up while they're healthy), we're likely to get an increasing number of people wanting to sign up (or wanting to cryopreserve a loved one) when the patient has already been diagnosed with a terminal illness and life insurance is unobtainable.
So far, we have only accepted one case on this basis: James Gallagher, our first member to undergo cryopreservation. Note that Mr. Gallagher already had extensive knowledge of cryonics, he was very level-headed about the risks involved, and his family were entirely supportive. In fact, they helped him to make the necessary arrangements. All of these factors made it easy for us to take this case--and make us very glad that we did.
One of the objectives of LES is to gather sufficient local support for the purchase and maintenance of cryonics stabilization equipment to serve cryonicists (of all cryonics organizations) in the mid-Atlantic states. CryoCare members in this region are already not far from the stabilization kit placed by BioPreservation in New York City last year. Still, a second kit on the East Coast could substantially improve local response capability. This will be especially true if the purchase of the kit is accompanied by training of LES personnel in cryonics stabilization procedures, which appears to be what LES has planned.
CryoCare welcomes greater local involvement in the procurement of cryonics equipment and know-how. We hope that the LES initiative, if successful, might form a model for other local groups to follow.
CryoCare Report is published four times a year by CryoCare foundation, a non-profit corporation whose main office is located at 10627 Youngworth Road, Culver City, California 90230.
| Effective 1996 the new address is: |
|---|
| CryoCare Foundation |
| Suite 3410 NorthEast Hercules Plaza |
| 1313 North Market Street |
| Wilmington, Delaware 19801-1151 |
President: Brian Wowk
Directors:
Brenda Peters, Brian Wowk, Peter Crowley.
Vice Presidents: Charles Platt, Billy Seidel.
Treasurer: Kevin Brown.
Secretary: Ben Best.
Members of CryoCare receive the newsletter at no charge.
If you are a non-member and wish to continue receiving CryoCare Report, write a check made payable to CryoCare Foundation for just $9. The next four issues will be sent to you via first class mail.
Provided your name and address are on the check, you don't need to enclose anything with it. Just write "Subscription" on the memo line of the check and send it to Kevin Brown, Ph.D., Treasurer of CryoCare, at 19-353 Dell Place, Stanhope, NJ 07874. We'll do the rest.
Overseas subscriptions: by air mail only, $15 per year. Payment must be made in US funds: cash, a check drawn on a US bank, or an International Money Order.
Back issues: $3 each ($4 overseas).