The protocol in this case was established previously by Suspended Animation in collaboration with the American Cryonics Society (ACS, of which the patient was a member) and the Cryonics Institute (CI, which received the patient for long-term cryopreservation).
The purpose of the protocol is to minimize cellular and structural brain damage, after legal death is pronounced, in anticipation of subsequent cryopreservation. To this end immediately after pronouncement the patient is cooled with ice in a Portable Ice Bath (PIB) to reduce metabolic demand. Cardiopulmonary support (CPS) is administered mechanically, with the triple objective of ventilating the lungs with oxygen, transporting oxygen and medications via the blood to the brain by chest compressions which act upon the heart, and cooling the core of the patient by circulating blood that is chilled near the skin by external contact with ice. Medications are administered to reduce the risk of blood coagulation and mitigate ischemic injury. (Since the medications list is considered proprietary information by Critical Care Research, it is omitted from the public version of this report.)
In the second stage of the protocol the patientís blood is washed out with a solution of glycerol which acts as a cryoprotectant, replacing water in the cells to mitigate the risk of subsequent freezing damage. The glycerol is introduced in escalating concentrations ranging from 5% (initial) to 70% (final). The cryoprotectant is augmented with constituents that are believed to provide metabolic support. After the terminal concentration has been reached, the perfusion circuit is closed until the chilled perfusate has reduced the patient's core temperature below 10 degrees Celsius (ideally, the terminal temperature should be 5 degrees). The patient is shipped in dry ice to CI for additional cooling and cryopreservation in liquid nitrogen. (As of January, 2005, SA has been forced to reassess this protocol in response to regulations limiting the quantity of dry ice allowed during air shipment. See section 9a, below.)
Pertinent data are collected throughout all procedures to assist personnel in monitoring the condition of the patient. Subsequently these data may help to evaluate performance, especially in comparison with other cases, and may facilitate future resuscitation.
Standby/transport personnel and their roles in the case of patient 2004-1 were† as follows:
Primary treatment decisions, intubation, cardiopulmonary support, surgery.
Interaction with family members and medical staff, logistics, scribe work.
Administration of meds, cryoprotectant management.
ATP operation, preparation of patient for shipment.
Surgery and associated tasks during cryoprotective perfusion.
Digital photographs and digital video of surgery and perfusion.
All team members in this list were fulltime employees of Suspended Animation with the exception of those marked with an asterisk, who functioned as independent contractors.
The history in this section is derived from handwritten and typed notes in the patient's record at Suspended Animation.
Patient 2004-1 joined ACS in 1990 and executed documents affirming his desire to be cryopreserved after legal death.
In 1999 the patient was diagnosed with bronchoalveolar carcinoma and underwent a right upper lobe resection. After this the patient had multiple scans and tests which showed no signs of recurrence; however an elevated Carcinoembryonic Antigen was documented since 2001. Late 2003 scans showed that cancer had recurred in the lung. The patient received radiation treatment, and one entry in the record indicates that his whole lung was removed, although this is not supported by any other information.
In 2003 Suspended Animation (SA) entered into an agreement with ACS to provide procedures including standby, stabilization, cryoprotectant perfusion and shipment to CI in Michigan. During the radiation treatment the patientís representatives made frequent contact with ACS and SA, although no standby was initiated. On August 25, 2004 SA was informed that cancer had returned to the patient's healthy lung and had metastasized to other parts of the body. On October 4, 2004 his physician estimated his life expectancy to be no more than 3 months. The patient had lost approximately 20 lbs and was observed to be getting weaker. It was agreed that if the patient had to move to the hospital the physician would ensure he would be maintained on life support until SA's standby team arrived. The family was informed about standby procedures and agreed to allow the team prompt access to the patient after pronouncement of legal death.
During the interim period the patient received chemotherapy. He went to the hospital emergency room when he complained of difficulty breathing, and was admitted for observation, but no bacterial or viral infection was found. On October 15, 2004 SA received extensive updates on the patientís condition, and determined that the patient might be in denial about his prognosis, causing him to refuse hospice services.
SA personnel visited the patientís home to understand the layout of the house before the patient returned from the hospital. On October 18, although there were no specific medical indicators of an immediate crisis, SA personnel debated when they should preposition some standby equipment in the home.
On October 19 team members went to the patientís home to deliver a subset of SA's medications (heparin, streptokinase, and propofol), with a finger pulse oximeter. A short version of human cryopreservation protocol titled ďInstructions for Postmortem Care of Human Cryopreservation PatientsĒ was faxed to the patientís hospice, including a request that if legal death occurred in the absence of SA personnel, hospice nurses should administer Heparin, Streptokinase, and Propofol; perform cardiopulmonary support; and surround the patientís head and neck with ice.
During the next two days the desirability of a DNR order was discussed by the patient and his family, while SA made it clear that this was not not required but could be helpful under some circumstances. The choice was up to the family and the doctor.
Except for a note regarding another brief discussion about DNR with the patientís daughter, who was one of the two appointed health-care representatives, there are no written updates after October 21, 2004. On October 22, in a telephone conversation between SA's general manager and procedure manager, plans were made to preposition the PIB and mechanical cardiopulmonary support equipment on October 25. Unfortunately on October 23 the patient experienced sudden respiratory arrest. This event was unexpected since the patient had been alert, oriented, and talking to his nurses just one hour earlier.
On October 23, 2004, around 10:25 the Team Leader received an emergency call from the hospice nurse at the house, warning that the patient might not survive. (All times in this report are expressed in 24-hour format. For a complete timeline see the Appendix.) Three other team members were contacted, two of whom did not answer their phones right away but called back within less than ten minutes. Two team members were dispatched to SA's office to stow necessary equipment in the Transport Vehicle and load the Air Transportable Perfusion kit (ATP), cryoprotectant, scrubs, and styrofoam insulation into a pickup truck.
After the Transport Vehicle was ready the Medications Officer drove it to the patientís home while the Perfusion Technician and the Staff Photographer drove the pickup truck to SA's cooperating mortuary.
The Team Leader drove his own vehicle to the patient's home, where he found that nurses had placed small bags of ice around the patient's head and neck, and over the groin, while maintaining manual CPR in accordance with instructions given to them previously. In addition all three medications which had been left at the home had been administered by nursing staff after the time of legal death.
The Team Leader attempted to intubate the patient, which proved difficult, perhaps because of stiffness caused by ice or by onset of rigor. After hanging the patientís head over the side of the bed the Team Leader completed intubation successfully with a 7.5 endotracheal tube. Subsequently the Team Leader estimated that he spent a total of 10 minutes on intubation.
The General Manager arrived via personal vehicle.
An inflatable rectal plug and temperature probe were inserted without any problems. No soiling occurred through release of the rectal sphincter. A nasopharyngeal temperature probe was placed and taped in place and gave an initial reading of 31 degrees, indicating an error which remains unexplained. Subsequent data loss prevents us from knowing whether the temperature reading was in Fahrenheit or Celsius degrees, but the number would seem to be incorrect in either case.
Meanwhile the Medications Officer was driving the Transport Vehicle to the patientís home but was delayed by bad weather which exacerbated his difficulty steering the vehicle. After approximately 40 minutes the Transport Vehicle arrived and the PIB, ice chests, and other equipment were brought into the house.
An aluminum-framed backboard was taken out of the PIB and placed on the patientís bed. After rolling him onto it† and strapping him into position, two members of the team lifted the board with the patient into the PIB. With the help of the nurses the contents of two containers of ice (approximately 100 lbs) were distributed over and around the patient and SA's specially modified Michigan Instruments "Thumper" was locked into place on the side rails of the PIB and positioned over the patient's sternum. Powered by two 20-cubic-foot oxygen cylinders, the Thumper commenced Active Compression-Decompression (AC-DC) cardiopulmonary support.
At 12:50 the patient was transferred to the Transport Vehicle in the PIB. In the Transport Vehicle the oxygen supply for the Thumper was changed from the small portable cylinders to a single 250-cubic-foot cylinder while the Medications Officer administered all remaining meds and started a drip to administer THAM. Two gallons of water were added to the PIB.
A 12-volt submersible pump, normally used to recirculate the water, was not used because the battery to power it had been taken by another team member to the mortuary to power another submersible pump which would be used for cooling the PIB's Extra-Corporeal Membrane Oxygenator (ECMO).
After two brief attempts to start the vehicle, the Team Leader drove it away followed by the General Manager and the Medications Officer who traveled together in a separate vehicle. During the drive the patient remained unattended in the rear of the Transport Vehicle.
Upon arrival at the mortuary at 14:05 the Thumper had consumed its remaining oxygen but the Team Leader recalls that he substituted a 20-cubic-foot cylinder within two minutes or less.
Inspection suggested that the Thumper had not moved significantly from its location on the patientís sternum, judged from the rings on his chest created by the suction cup mounted on the shaft of the Thumper.
While the Team Leader, the General Manager, and the Medications Officer went to the patient's home, the Perfusion Technician drove to the mortuary, picking up 10 bags of ice from a local gas station along the way. The Perfusion Technician had slight difficulty finding the mortuary because of confusion between a federal highway and state highway on the map provided.
At the mortuary the Perfusion Technician placed the cases containing cryoprotectant in a walk-in freezer. He then took about 45 minutes to set up the ATP and prime the circuit, after a brief delay because the tubes were tangled. Once the ATP was running the Perfusion Technician cut pieces of styrofoam insulation foam to fit a Ziegler box until the patient arrived at the mortuary.
The PIB containing the patient was unloaded and moved to the prep room. The patient remained in the PIB while the surgeon raised and clamped the femoral artery and femoral vein, assisted by the Assistant Surgeon. The cannula in the femoral artery was inserted up to the aortic arch. The cannular in the distal femoral vein was inserted up to the confluence of superior and inferior vena cava. These surgical procedures took approximately twenty-five minutes, while the Medications Officer and the Perfusion Technician prepared the perfusate.
Cryoprotective perfusion commenced at 15:05 using a slow initial flow rate to check for any leaks. At this point the previously placed temperature probe gave a reading of 30 degrees on the logger, but personnel remain convinced that all readings from the logger were unreliable. For further information see Section 9 below.
Oxygen was not supplied to the ECMO because (according to
recollections of the Perfusion Technician) the available supply was exhausted.
In the ATP circuit a probe measured perfusate temperature in a branch off the tubing near the point where the circuit was attached to the arterial cannula. The temperature from this probe persisted in the range of 11 to 15 degrees Celsius. Perfusion was introduced in sequential premixed concentrations of 5%, 10%, 20%, 40%, and 70% glycerol, using 10 liters of each, except for the final concentration, of which 20 liters were administered. The ATP remained in open-circuit mode throughout the procedure, with the intention of passing each volume of† perfusate once through the patient and out to the dump.
Initially there was a problem obtaining any flow from the venous return. Even with an arterial pressure of 60 to 80 mm of mercury the venous return remained empty. At the same time, some swelling of the upper torso became evident. The Team Leader decided to utilize the mortuaryís water-driven suction pump which he attached to the venous cannula. This established good flow through the patient. The suction was used at its lowest setting to avoid collapsing the tubing or the patient's vasculature.
During the 2.0 hours required to perfuse the patient one team member and the Photographer went out to get 180 pounds of dry ice from a convenience store a block from the mortuary.
After the highest concentration of glycerol was exhausted, wounds were closed and the patient was moved to a Ziegler box in which some dry ice had been placed at the bottom. More dry ice was placed around the patient until all the space was filled. Observers estimated that approximately 120 lbs of dry ice were used. The Ziegler box was closed and a single layer of half-inch styrofoam insulation was taped around all six sides of the box, which was placed on a standard mortuary shipping tray with cardboard cover.
A mortuary assistant made arrangements for the patient to be transported on a non-stop flight from Fort Lauderdale International Airport to Detroit at 09:30 the next day.
The patient arrived in Detroit at 12:30. After approximately a 1.5 hour turnover time and a 45 minutes drive the patient was delivered to CI at around 15:00. Inspection at the facility suggested that the internal temperature of the box had not increased during transport, since substantial amounts of dry ice remained.
Information in this section was supplied by CI personnel.
Because the patient arrived in a solid state, CI was not able to place any internal thermocouples in his neck or head. A thermocouple was placed at the back of his head and another thermocouple was placed on his forehead to monitor the temperature during cooldown. The patient was placed in a sleeping bag for more protection and covered with dry ice for two-and-a-half more days so that he spent a total of three days cooling to dry ice temperature.
After reaching dry ice temperature the patient was moved into CIís liquid nitrogen cool down unit for six days. When this process was complete he was put into an aluminum pod before being transferred to a cryostat for long term storage.
The patient's health history (stretching back over more than a year) had been compiled by at least three people, none of whom was solely responsible for maintaining the notes. Many entries provided incomplete information, without adhering to a consistent format. In the future SA will use a system whereby one person has ultimate responsibility for maintaining patient notes consistently.
The pulse oximeter which had been placed previously in the patient's home was used once by a nurse but failed to function afterward. When the oximeter was recovered, its batteries had been discharged. Since the batteries were purchased recently beforehand, this anomaly remains unexplained.
The Medications Officer complained of difficulty driving the Transport Vehicle from SA's offices to the patient's home. The vehicle had been serviced recently but the Medications Officer had trouble controlling the steering. SA subsequently has asked three other personnel to test-drive the vehicle. They agree that its performance is adequate for its age and they are confident about driving it in future cases. At the same time, SA does plan to acquire a newer vehicle within the next year. This will be a van which will be converted for transport work.
When the patient was ready to be moved to the mortuary, the Transport Vehicle did not start at the first turn of the key. Subsequently the vehicle has been checked and no fault can be found to explain this. The vehicle's two batteries appear to have been installed relatively recently. The vehicle has been started periodically since that time, and no problem has been found.
A submersible pump was not utilized to circulate icewater during initial cooling in the PIB because the only available battery was taken to the funeral home by the Perfusion Technician. Although the shaking of the Transport Vehicle circulated water around the patient in the PIB to some extent, the issue of active water circulation over the patient will be fully addressed, commencing with an experiment to verify that it provides a significant advantage compared with application of copious amounts of loose ice. (The patient was still covered in ice when he reached the mortuary.) In the meantime SA has designed and constructed a new icewater recirculation system using a submersible sump pump that runs for up to 3 hours on included batteries and can also be supported by an external DC power supply. Perforated tubes that disseminate water across the patient have been redesigned with an additional loop directing water to the forehead and scalp of the patient. Use of these icewater-cooling enhancements will depend on the outcome of the experiment to compare the efficacy of icewater and static ice, mentioned above.
The drive from the patientís home to the mortuary took more than an hour. Since a typical patient derives diminishing benefits from a Thumper over time, and ischemic injury becomes more likely, a shorter transport to the mortuary would have been desirable. Shorter transport is also preferable because it reduces the risk of technical, logistical, and other problems, including mechanical failure and exhaustion of oxygen supply.
Three SA personnel had attempted to find a cooperative mortuary closer to the patient's location during the two weeks prior to the patient's unexpected legal death. A mortuary in this area also would have enabled air shipment from a closer airport. Although experience suggests that mortuaries have been very willing to rent out their prep rooms for human cryopreservation work, Suspended Animation was unable to find a cooperative mortuary in the vicinity of the patient's residence.
The unwillingness of local mortuaries to allow procedures in their prep rooms remains unexplained at this time. Several funeral directors were obviously familiar with news stories mentioning cryonics, including baseball player Ted Williams, who died in a Florida hospital. One funeral director cited liability concerns if† standby team members should contract a blood-borne or infectious disease while using his prep room. We may speculate that funeral directors generally have been influenced by negative or sensationalized news reports about cryonics during the past two years.
During the drive from the patientís home to the mortuary no one was in the back with the patient. SA has established that a team member will accompany the patient in all future cases.
The lack of temperature data for this case is regrettable. A probe was placed and the logging device was started, but its readings appeared to be erroneous and unreliable. The device was switched off and then on again at one point, and a member of the nursing staff dropped it into the PIB. In the future Suspended Animation will provide two logging devices for redundancy and has taken additional precautions to protect them from abuse, by enclosing them in protective cases.
Another factor negating data acquisition was that the Perfusion Technician at the mortuary could not determine how to reset the temperature logging interval on the DuaLogR which had been supplied. A new, simplified instruction card has been created and is now enclosed with every logger.
A relatively recent decision to purchase voice data recorders (which automatically time-stamp the audio stream) was validated, since this case yielded an exceptionally clear and detailed timeline of major events. Suspended Animation has now acquired additional voice recorders to maximize the probability of a recorder being available among team members as early as possible after legal death. Each recorder is augmented with a tie-clip microphone for hands-free voice-actuated audio note-taking. Subsequently the digital audio is uploaded into a desktop computer, and the audio can be transcribed as plaintext with the aid of a stop/start foot pedal that plugs into the USB port and controls transcription software.
The automated time stamp which each recorder includes at the beginning of each audio segment is obviously not useful unless the recorders are synchronized beforehand. This has not been an item in the standard procedure and was not done in this case, but will be included as a task in SA's transport manual.
Medications were pushed unusually quickly. The patient already had an IV in place.
Surgery was rapid compared with most human cryopreservation cases involving femoral cutdown. This case benefited from having not one but two experienced laboratory surgeons.
We have acquired additional oxygen, to be carried in our transport vehicle at all times, to avoid any repeat of the situation that occurred in this case where oxygen was exhausted by the time the patient was ready for washout.
While the application of negative pressure to the venous return in this case compensated for failure to position the venous reservoir as low as is customary, we would prefer to avoid avoid this kind of improvisation. SA has received extensive advice from a professional perfusionist with 15 years of experience, and is implementing a plan to apply precisely measured negative pressure via a centrifugal pump using a disposable pump head that is widely used in bypass work on human patients. In addition SA has completed design and prototyping of a new ATP mounting board that positions the venous reservoir as low as possible and anchors the tubing layout so that its orientation will not deviate from one case to the next.
A terminal perfusate temperature of 11 degrees Celsius was 6 degrees higher than the optimum target of 5 degrees. Subsequent discussions have suggested two possible contributing factors: The temperature sensor was not placed in the active stream of perfusate, and the diffuser which returns icewater to the cooling reservoir may have been allowed to sink to the bottom of the reservoir. Mathew Sullivan of Alcor has suggested that retaining the diffuser at the top is important, so that returning water runs through intervening ice before it is pumped back to the heat exchanger.
In this case, as in all human cryopreservation cases reported to date, no tissue sampling or other technique was used to verify the penetration of glycerol into cells.
The purpose of this broader historical and organizational context is to enable the case data to be interpreted more meaningfully.
a) Change of Management at Suspended Animation
Premortem contact between Suspended Animation and this patient began more than a year before legal death occurred. During this substantial period of time Suspended Animation went through a major reorganization as the CEO left the company and the CFO gave notice that he intended to quit. Meanwhile four new people joined the company (two fulltime employees, one halftime employee, and one consultant on a halftime basis). Only two former fulltime employees continued at the company after the management transition which occurred during August, 2004.
The incoming personnel could have benefited if they had received a more formal briefing on the history of the patient from the outgoing management. Unfortunately research commitments and reorganization of the company took precedence, but in any case the patient's history had included at least two "false alarms" which tended to erode a sense of urgency even among the people who were fully informed.
This is a familiar pattern in human cryopreservation cases where a patient suffers slowly declining health punctuated with minor crises over a period of months or even years. One lesson to be learned from this is that successful human cryopreservation can require a very long attention span. Another lesson is that although accidental death or sudden cardiac arrest are often perceived as the worst scenarios for good cryopreservation, a very slow decline may create its own problems for the standby team, since team members must turn to other priorities during the long waiting period.
On the Saturday when the patient's death was pronounced, legal death had seemed very unlikely. The patient was oriented, alert, and conversational with attending nurses only an hour before respiratory arrest occurred. No hard data (such as blood pressure, temperature, oxygen saturation, or respiration rate) had been received by Suspended Animation personnel during the preceding week, but subjective assessments had been communicated verbally by an experienced nurse who knew the patient personally, and even if these assessments had been accompanied by numeric data, the data might not have provided any cause for concern. A general consensus was that the patient was expected to survive for two weeks or more.
Therefore it is understandable (although regrettable) that three Suspended Animation personnel felt sufficiently confident of the situation to leave Florida over the weekend during which legal death occurred. At least one of the people who was absent was unaware that other people also were absent. This underlines the need for a single individual to take responsibility for monitoring and coordinating a case, and if a change of management occurs, responsibility should be passed formally to a newly designated person. Also, SA has set up a wall chart which tracks all movements of personnel so that everyone will be properly informed about the future movements of team members.
The four Suspended Animation personnel who remained within reach of the patient were regarded as providing, between them, sufficient capability in case of emergency, and this assessment turned out to be correct, especially since they were augmented with two additional team members on a consulting basis.
Two of the full-time employees had joined SA recently and had not participated in previous cases. However they had received instruction about human cryopreservation and four sessions of specific formal training with practice of key procedures. This training and practice turned out to be valuable and effective, as the Perfusion Technician was able to set up and run the Air-Transportable Perfusion kit at the mortuary without errors or additional assistance. The importance of practice sessions for personnel who lack comparable experience is significant.
Prior to mid-October, 2004 the patient had been reluctant to see human cryopreservation personnel or allow equipment in his home. Thus SA was confronted with the all-too-familiar scenario of a patient who was deeply committed to the concept of human cryopreservation yet was stubbornly reluctant to admit his own mortality, even after all treatment options had been exhausted and the oncologist offered the grimmest possible prognosis. Since standby team members clearly cannot force a patient to accept their presence, the problem of denial among people who have expressed a sincere desire for cryopreservation remains intractable.
After the home visit on October 18th it was evident that family members did not share the patient's ambivalence and were receptive to human cryopreservation procedures. When SA's General Manager and Procedure Manager realized this, they had an opportunity to begin deploying standby equipment but chose to wait for an additional week, largely because the patient's condition seemed insufficiently serious.
Admittedly the PIB would have been of limited use without ice, but when team members received their emergency call at least one could have picked up ice while driving directly to the house. The Procedure Manager did suggest to the General Manager on October 22nd, 2004 (during a phone call from Arizona) that the PIB should be deployed, and the General Manager agreed to begin general deployment of standby equipment as of October 25th. Unfortunately the patient defied expectations and arrested on Saturday, October 23th. The lessons to be learned from this conjunction of events are as follows:
Equipment should always be deployed as early as possible, even if there is no apparent cause for alarm (assuming no other case is pending).
Any team member who travels directly to a patient's house in response to an emergency call should collect ice along the way, unless instructed otherwise. While ice cannot be applied optimally outside of the PIB, improvised steps can be taken, such as dumping the ice into several trash bags and placing them on the patient until the patient can be moved into the PIB.
Fortunately in this case the patient arrested during a nursing shift change, so that four nurses were present simultaneously. The Team Leader had taken precautions to insure that the refrigerator freezer at the house contained several pounds of cube ice, and he instructed the nurses (by phone) to place this ice, in gallon-sized plastic bags, around the head and neck, under the armpits, and in the groin area, while manual CPR continued. The Team Leader also had placed the three most essential meds in the house, and these were promptly administered by nursing staff. The combination of ice cooling in crucial areas, medications administered via IV, and vigorous manual CPR seems to have been effective. When the patient received washout at the mortuary, no evidence of clotting was reported.
c) Future Revisions in Protocol
The procedure of shipping in dry ice has been called into question since CI employees in Michigan have stated that recent airline regulations place a severe limit on the weight of dry ice allowed in any container accepted as air cargo on a scheduled passenger flight, and Hugh Hixon at Alcor has stated that airlines will regard dry ice in quantities exceeding 5 lbs as a "miscellaneous hazardous substance" after January 1st, 2005.
The mortician advisor for Suspended Animation cases has confirmed that new airline regulations will not allow sufficient dry ice for safe shipment of a cadaver. The mortician states that in cases where embalming is not allowed by the religion of the deceased person or the person's family, he has already started to use "gel packs" precooled in the mortuary freezer. While this may be satisfactory for noncryonics cases, it is clearly not acceptable for a patient who has been perfused with a high (potentially toxic) concentration of glycerol.
In the future, truck transport or chartered jets may be the only ways to use dry ice if field glycerolization continues as the preferred procedure for ACS patients. ACS has registered a strong preference for this.
SA appreciates the advantages of field glycerolization followed by cooling to dry-ice temperature but is concerned about road-transport logistics, especially to Michigan in winter weather. At this time SA would prefer to perform blood washout with an organ preservation solution (blood substitute) followed by air shipment in water ice, with no attempt at cryoprotection until the patient reaches a mortuary.
At the time of writing Suspended Animation is waiting for electron micrographs showing the condition of rabbit brains which have been kept for 24 hours, slightly above 0 degrees Celsius, after perfusion with various washout solutions at a laboratory in California. The micrographs may provide valuable data to assist in weighing the relative merits of field glycerolization followed by dry-ice transport, as opposed to field washout with organ preservation solution followed by water-ice transport. Until these data are available, the discussion of dry-ice vs. water-ice transport remains unresolved.
Although we have gone into extensive detail regarding problems that occurred during this case, it can be regarded as generally successful in that the patient received prompt attention immediately after pronouncement, the most important meds were pushed at that time, chest compressions were administered, and necessary team members were promptly available. They administered medications, provided mechanical cardiopulmonary support with oxygen via intubation, completed bypass surgery very rapidly, and provided cryoprotection within the limits of the open-circuit, stepped-concentration, glycerol-based system currently available. Although this case was complicated by the patient's unexpected and unpredictable legal death, the relative lack of experience of some personnel did not affect the outcome of this case adversely, and recent training and practice sessions were very valuable.
Future cases may benefit from earlier deployment of equipment, more comprehensive medical and transport data, and technical improvements in field perfusion capability if field perfusion with glycerol-based cryoprotectant continues as the protocol of choice for ACS patients.
This case report was drafted in December, 2004. Revisions were added in June, 2005, at which time the report was posted publicly. Since neither of the authors was present during the case, they obtained information from team members and voice recordings.
Team Leader contacted by private nurse: Patient is close to death
Team leader is contacted by hospice nurse
Nurses take turns doing CPR
Nurses administer Heparin, Streptokinase and Diprivan
Nurses put ice on the patientís head, neck, and groin
Team Leader arrives at patientís home
Perfusion technician arrives at SA and starts loading the transportable perfusion kit, insulation, and other items for the mortuary
General Manager contacts the funeral home and then calls a local supermarket for dry ice
General manager arrives at the patientís home
Perfusion technician reaches the mortuary and sets up equipment
Transport Vehicle arrives at the patientís home
Assistant Surgeon arrives at the mortuary
Mechanical CPS begins
Patient is loaded into Transport Vehicle
Medications Officer pushes the remaining meds
Transport Vehicle arrives at mortuary
Incision is made to expose femoral vein and artery
Photographer starts shooting video at the mortuary
Artery is raised and clamped
Artery is cannulated
Vein is raised and clamped
Vein is cannulated
Perfusion of the patient is initiated
Perfusion of the patient is completed
Wounds are closed
Patient is placed in Ziegler case
Cleanup of mortuary begins
Insulation is placed around Ziegler case
Ziegler case is ready for shipment
Patient leaves on a nonstop flight from Ft. Lauderdale to Detroit
Patient arrives at Detroit airport
Patient arrives at CI's cooperative mortuary