From: hkhenson@cup.portal.com
Subject: Cryonic suspenson of an AIDS patient
Note: non-commercial reproduction.
Archive-Number: 4818
Organization: UCLA, Computer Science Department
Date: Tue,  7 Apr 92 01:14:29 PDT

I posted an account of another suspension to sci.med.general a few
months ago.  It kicked off several hundred kilobytes of interesting
discussion.  Sci.med.aids seemed more appropriate for this one.
If there is interest, I can post some general information on cryonics, 
its rational and technology. K. Henson  (hkhenson@cup.portal.com) 

NEUROSUSPENSION OF PATIENT A-1260

by H. Keith Henson and Mike Darwin
 
Transport Team:

Hugh Hixon, Transport Team Leader, Surgical assistant
Mike Darwin, Oversight, Consultant, Femoral Cutdown
Arel Lucas, Airway Management, Temperature Probe Placement
Tanya Jones, Medications, Scribe
Max More, Scribe, Airway Relief
Paul Wakfer, Logistics Support, Airway Relief, MALSS Monitoring
Carlos Mondragon, Film and Video Recording
Leonard Zubkoff, HLR Operator, Oxygen Supplies Management
Keith Henson, Carpenter Assistant, O.R. Nurse, MALSS Monitoring

Suspension phase:

Hugh Hixon, Surgical Assistant, Blood Gases, Housekeeping
Mike Darwin, Oversight, Bur Hole, Cephalic Isolation, Housekeeping
Ralph Whalen, Perfusionist
Mike Perry, Cryoprotectant Ramp Technician
Tanya Jones, Scribe, Sample Taking
Arel Lucas, Logistics Support, Housekeeping
Keith Henson, CPA Concentration Determinations, Housekeeping
Paul Wakfer, OR Circulator
Carlos Mondragon, Records, Transportation
Leonard Zubkoff, OR assistant, Cooldown Preparations
Mark Connaughton, pH and Blood Gas Calibration

    The responsibility of suspending members can be overwhelming at 
times.  After all, if medical personnel err and kill someone, they have 
cost that patient the remaining years of his or her life, at most a few 
decades, more commonly a few years.  If *we* fail, we could be costing 
one of our patients (who are often our friends) a chance at near 
immortality.  Worse yet, if we don't do it, (given the current state of 
cryonics) they will have no chance at all.  Thus, cryonics is a stressful 
occupation (or whatever you think it should be called) and much of this 
article will be illustrating this point.  The oversights are reported for 
the usual reason, so we can learn and do better next time. 

    A few weeks ago, patient A-1260 was one of that growing number of 
people well acquainted with cryonics, but not signed up.  He had been to 
a number of Alcor functions over the years and was friends with several 
key Alcor members.  Because of his desire to remain anonymous, he will be 
known as "Nick" in this article. 

    Nick had been diagnosed with HIV from the time tests became available 
in 1987.  As is common with HIV infection he remained symptom free and 
clinically well for a number of years following diagnosis of his HIV- 
positive status.  However, as is almost inevitable with this disease his 
T-cell count began to decline and he began treatment with zidovudine 
(AZT) and other chemotherapeutic agents to slow the progression of the 
disease, and ward off opportunistic infections. 

    Like many patients on AZT, he stayed relatively free of symptoms 
until the last five months of his illness.  At that point he began 
developing multiple problems starting with a cytomegalovirus (CMV) 
infection of his gallbladder which was treated by surgical removal and 
medication with the antiviral drug ganciclovir.  And again, as is typical 
of patients on AZT, he responded poorly to treatment.  This infection was 
followed by another, this time cryptosporidium.  (It now appears that 
patients on AZT do not live appreciably longer than those not taking the 
drug.  However, they have a course which is characterized by more "well" 
time followed by a rapid decline, with the opportunistic infections which 
cause death being unresponsive to treatment.  The reason for this 
difference is not yet understood.) 

    While the decision to join Alcor came late as a result of the usual 
mix of denial and funding problems (insurance is not available to 
HIV-positive people), once he and his lover "Jim" decided to make 
suspension arrangements, the sign-up process was completed in about two 
weeks. 

    It is worth pointing out that while Nick and Jim had long considered 
making suspension arrangements it was their perception that it was not 
possible to do so given Nick's terminal status and his uninsurability.  
Due in large measure to the intervention and encouragement of Alcor 
member Steve Harris this misunderstanding was cleared up and financing 
was put in place with a mixture of some up-front cash and a second 
mortgage on their home.  While Alcor does not encourage this kind of 
last-minute preparation for cryonic suspension, it is very important to 
point out that flexible financial arrangements ARE available, and that 
Alcor will work with any reasonable person to facilitate their cryonic 
suspension.  This case also points out how the thoughtful intervention of 
a friend can make the difference between someone's getting suspended and 
not getting suspended.  This is not an easy subject to broach with 
someone you care about who is dying, and Steve is to be commended for his 
courage and his decency in undertaking to do this. 

    One of us (Mike Darwin) has had extensive experience both in-hospital 
and in cryonics-related situations in caring for terminally ill patients.  
Pain and discomfort are the handmaidens of death, and at best dying is 
not a pleasant business.  However, even Mike was unprepared for the 
degree of misery Nick was in.  Nick suffered from pancreatitis (perhaps 
as a result of his treatment with the new anti-retroviral drug 
didanosine, and perhaps as a result of CMV infection of his pancreas) 
which caused him severe abdominal pain, unrelenting (day and night) 
hiccuping, and near-constant nausea and vomiting.  In addition, he had 
frequent diarrhea as a result of cryptosporidium infection.  
(Cryptosporidium is an organism that normally infects sheep and 
occasionally infects humans, causing a one-time illness similar to a case 
of the "touristas" from which the patient recovers uneventfully.  It 
causes severe diarrhea in immunocompromised humans, and there is 
currently no effective treatment.  Experimental treatment with the newly 
available antibiotic azithromycin which had been anecdotally reported to  
be effective against cryptosporidium failed to control Nick's infection.)  
Any one of these would have been a nightmare; together, the infections 
had him in intense misery. 

    The constant nausea and vomiting had prevented Nick from eating or 
drinking for several months and his food and fluid requirements were 
being met by intravenous feedings with total parenteral nutrition (TPN).  
Nick had been on every anti-nausea medication available in the US, 
including Marinol, the FDA-approved version of marijuana.  Unfortunately, 
Marinol is not nearly as effective at suppressing nausea as its natural 
counterpart pot.  It was a source of some frustration that due to the US 
drug laws Jim was unable to secure any marijuana in an attempt to relieve 
Nick's nausea.  Mike has known several patients suffering intractable 
nausea secondary to cancer chemotherapy (including a lady in her late 
60s!) who found that the only thing that relieved their nausea was pot.  
The misery that Nick suffered as a result of this law is unconscionable.  
Since both Jim and Nick are libertarians the irony of this situation was 
not lost on them even in the midst of their suffering.  Compounding this 
stupidity is the recent ruling by the FDA that no further applications 
for releases will be accepted for the legal medical use of marijuana.  
Due to drug enforcement efforts marijuana has become difficult and costly 
to obtain--unlike cocaine, a far more dangerous drug, which continues to 
decline in cost. 

    Nick's suspension arrangements were completed by April 14th, so the 
next day Hugh Hixon and Keith Henson went to Nick and Jim's home in the 
Los Angeles area to set up to do the initial stages of the suspension at 
their home.  Hugh had already scouted out the situation, which was about 
as poorly set up for a MALSS-supported stabilization as could be 
imagined.  Nick's bedroom was up a staircase with three turns in it, and 
the twists and turns at the entrance of the house made it impossible to 
get the MALSS (Mobile Advanced Life Support System) cart inside.  The 
only feasible location to set up was a garage located about 60 feet from 
the front door up a steep street.  Considering that it took us over two 
minutes to move the last patient about six feet, there was concern over 
the ischemic time such a move would cause if he were pronounced in his 
bed. 

    That day, with Jim's assistance, Hugh and Keith cleaned out the 
garage, moved in a number of oxygen bottles, built a plastic enclosure 
large enough to hold the MALSS cart by stapling plastic sheeting to the 
ceiling beams, and installed 2000 watts of lighting.  While it was kind 
of rough and ready, the nurse who pronounced Nick when the time came 
commented that he had certainly seen worse used for operating rooms in 
Vietnam.  Keith and Hugh also restocked the cart and ambulance, refilled 
the cart oxygen cylinders, and ran through as much of the process as they 
could manage. 

    While the patient's name will not be given here, his name and the 
fact that he had made suspension arrangements circulated among his 
friends, and word of this reached Mike Darwin.  Mike (who knew Nick 
personally) offered his services, and, though the team thought they could 
manage without him, the offer was gladly accepted.  Mike came in and 
found a number of oversights and deficiencies and he worked most of the 
afternoon and evening of March 15th with Hugh Hixon to remedy these 
shortcomings.  One of the most glaring was Keith's failure to clean out 
(or even remember) the vacuum system on the MALSS cart from the last 
suspension.  One of the side effects of doing things while 20 hours short 
of sleep.  Well, that one goes on a checklist. 

    Earlier in the day (on the 15th) Mike had participated in a call from 
Steve Harris and conference with the Alcor Staff regarding Nick's medical 
situation and prognosis.  Nick had decided to end his misery by 
dehydration, and had stopped all food and fluids (with the exception of a 
morphine infusion) the previous Thursday (March 12th).  Both Steve and 
Mike expressed concern over this since with Nick's large fluid losses as 
a result of his diarrhea he was liable to dehydrate very quickly.  Both 
Steve and Mike expressed surprise that Nick was even still alive.  The 
Alcor staff related that they had been told by Nick's treating physician 
that death from dehydration would take a week to ten days.  
Unfortunately, this physician was probably not charting fluid intakes and 
outputs and was thus speaking in general rather than specific terms. 

    (Since Nick was still alert enough on Sunday to sit up and hold a 
conversation, knowing that dehydration cases typically last a week or 
sometimes more, and not being aware of the conversation between Steve and 
Mike, Keith went back to San Jose.  He was home for less than 24 hours 
when the call came through that Nick was near death, having dehydrated 
much faster than expected.  Keith now has a rather different view of 
dehydration times when a patient has large fluid losses from diarrhea or 
other causes.  In spite of the cost involved, he has become a champion of 
being on site and ready based on the *shortest* estimate.) 

    Early on the morning of the 16th a call came in to Alcor from Jim and 
the RN attending Nick.  They reported that Nick's condition was very 
grave and that death seemed imminent.  A decision was made to involve 
Mike.  Mike was put in touch with Jim and the attending RN.  At that time 
Nick was unconscious and in deep shock with a blood pressure of 40/0, a 
respiratory rate of 3-4 a minute, and pupils which were only sluggishly 
responsive to light.  Since the suspension team could not be on location 
for a few hours and additional preparation to the MALSS cart and 
ambulance were needed, Mike asked the attending nurse if he could pour 
what prescribed IV fluids they had available into Nick to reverse his 
shock and give Alcor more time to set up.  Without this timely 
intervention, it is almost certain that Nick would have suffered hours of 
ischemia before an Alcor team could arrive.  As we know from previous 
unlucky patients, this would have resulted in a very poor quality 
suspension. 

    Since it was by no means certain that Nick would respond to fluid 
resuscitation, it was decided that Mike should come into the lab, and 
assist finishing up preparing the MALSS and setting up the operating room 
as quickly as possible.  Mike and Hugh worked throughout the night to get 
this done.  At about 8:00 a.m. a call came through that after he had 
stabilized, Nick was again deteriorating and that the transport team 
should come at once.  By this time the equipment and team were almost 
ready to depart, although several critical items were still not in place.  
They were delayed approximately another 45 minutes to an hour before they 
could depart. 

    On hearing the news, Arel, Leonard Zubkoff, and Keith flew into the 
Los Angeles area.  The available staff members drove the ambulance with 
MALSS cart over to Jim and Nick's home, and Max More was recruited from 
his university job for the standby.  By 11 a.m. on Tuesday we were on 
site and ready to go. However, nearly 2 liters of IV fluids had reversed 
Nick's shock and yanked him a good ways back from death's door.  He even 
got out of bed for short times that day.  It seemed we were in for an 
indeterminate wait, but after the scare, nobody was about to complain.  
Keith used a little of the time to check the calculations Max and Tanya 
had worked out on the transport medications against a medication spread 
sheet he had created the week before, and all were right on. 

    The team used the time to check over readiness, make final 
preparations, and to upgrade our safety precautions to reduce the risk of 
transmitting Nick's HIV and/or associated infections to the Alcor team 
that would be caring for him. 

    Mike sent out for puncture-resistant nitrile rubber gloves and 
fluid-barrier Tyvek jumpsuits with integral shoe covers.  These were 
added to surgical masks, full plastic face shields, and conventional 
latex surgical gloves which we normally use for suspensions.  (The 
nitrile rubber gloves were discovered to work well as "liners" under 
convention surgical or exam gloves which could be discarded as they got 
dirty).  Much credit goes to Paul Wakfer who took the initiative to run 
down these items at the last minute.  Paul also took the Cryovita van 
(backup for the ambulance) out and located a replacement tire for a blown 
spare. 

    Nearly at the last minute, Keith suggested adding pool chlorine to 
the MALSS ice bath to reduce the infectivity of the ice water which is 
pumped over the patient.  The ice water, contaminated with body fluids, 
invariably splashes on anyone standing close to the cart.  Paul went out 
and found some at about 8:00 p.m. the night before the suspension began. 

    If these precautions seem excessive, let us assure you they are not-- 
especially three months later when you are getting your HIV status 
checked!  Those on the team with medical backgrounds are comfortable 
working with AIDS patients giving day-to-day care without gloves or masks 
except when handling body fluids (when gloves are required).  However, a 
MALSS- supported transport is *not* your normal day-to-day situation.  We 
are performing invasive procedures under field conditions using sharp 
instruments and in the presence of many gallons of splashing contaminated 
fluids.  We are also working with volunteers, and few of them have 
extensive medical training.  A high level of precautions is in order to 
safely conduct these suspensions.  Incidentally, we used the new sample 
collection method inspired by the last suspension when a team member got 
stuck.  This greatly reduced the number of contaminated sharps to which 
team members were exposed. 

    An added precaution we took was the prophylactic administration of 
AZT to the entire suspension team during the period of potential 
exposure.  While chronic administration of AZT to health care workers at 
risk for exposure to HIV is not warranted because of the nasty side 
effects of long-term use, it is acceptable to use it for an acute 
situation where risk of exposure may be high.  AZT is used as a 
prophylaxis against HIV for health care workers with known exposure.  It 
is even more effective if the drug is already present when the exposure 
occurs.  Fortunately, our precautions were effective and we were lucky.  
We had no incidents of exposure and there was no need for anyone to 
continue the AZT prophylaxis for the recommended 30 days following a 
needle stick or conjunctival (eye) exposure.  (Whew.) 

    By Tuesday evening it seemed unlikely that Nick was going to be in 
dire straits for the next 12 hours or so.  We were very short of bed 
space, so half the crew went back to Riverside that night, and the rest 
of us found places to spend the night.  NOTE to standby people: consider 
adding an air mattress to your overnight kit! 
 
    Early the next morning we reassembled to move Nick to a downstairs 
bedroom which could be accessed by a gurney, but that was called off 
because he was in too much discomfort to be moved.  Nick continued a slow 
decline in vital signs all day Wednesday, and by that evening it seemed 
likely that he would not make it through the night.  All of us tried to 
get a little sleep that evening, but not many were successful at it.  
About midnight Jim and the nurse on duty decided Nick (who was again in 
deep shock and completely unresponsive) had under an hour to go, and (to 
minimize ischemic time) we were called in to move him near the MALSS 
cart. 

    The logistics of moving our patient downstairs resulted in more 
discussion, arguments and testing than any other aspect of the whole 
transport.  (Mike missed this because he was in the garage priming the 
MALSS cart.)   Keith's suggesting of using a gurney was tried with an 
empty gurney, but the required 70-degree angle looked so scary that 
nobody was willing to be a test subject.  Hugh`s suggestion of a 
fireman's carry was ruled out because a slip on the carpeted stairs might 
seriously hurt both the patient and the carrier.  We finally tried and 
settled on Carlos's proposal, with Max on one arm, Paul on the other, 
Hugh taking Nick's feet under his arms, and Keith held his head.  We got 
him downstairs without any problems (good suggestion, Carlos), onto the 
gurney, and (in our white Alcor lab coats) wheeled him up the street into 
the garage.  Then we all got into face shields, double gloves, and the 
Tyvek "bunny suits."  Tyvek, incidentally, is the tough water-resistant 
material used for floppy disk sleeves and Federal Express envelopes. 

    The nurse, who was extremely supportive and competent, had called it 
close.  Nick (with Jim holding his hand to the end) quit breathing and 
experienced cardiac arrest about half an hour after we got him into the 
garage.  We used a standard hospital sheet carry, picking him up on the 
bottom bed-sheet and going in over the foot end of the MALSS cart.  HLR 
support was begun on him within less than 60 seconds.  Unfortunately, 
although circulation was promptly restored, Nick had vomited (without it 
being evident) a small amount of blood derived material looking much like 
coffee grounds.  This blocked Arel's attempt at placing the PTL airway (a 
device which had been purchased some time ago by Mike for evaluation, but 
which had never been used).  Seeing her difficulty, Mike cleared Nick's 
airway of vomitus, tried to position the PTL airway, failed, and then 
managed to get a backup Esophageal Obturator Airway (EOA) in place.  
Unfortunately we did not have an Esophageal Gastric Tube Airway (EGTA) in 
the emergency response kit.  (It seems that all of them had been 
distributed to the field kits.)  A disadvantage of the (older) EOA is 
that they have no passage way for a tube to neutralize stomach acid with 
Maalox or to place a temperature probe. 

    A disadvantage of both the EOA and the EGTA is that they both require 
a mask.  The relatively high airway pressures generated by the new high 
impulse HLRs makes holding the mask on (in a spray of ice cold water) a 
very painful task, mostly borne by Arel who was spelled by Max and Paul.  
Added practice with the PTL might help to solve this problem since it 
does not require a mask. 

    Arel suggested that next time we have a large bore suction line 
available to handle respiratory emergencies, and Mike adds that the bag- 
valve respirator should be set up with a conventional mask to facilitate 
prompt respiratory support in the event there is trouble placing an EGTA, 
ET-tube or PTL airway.  Early airway management has turned out to be a 
major problem in several cases.  Arel was sore for several days up to the 
shoulders from holding the mask on, but after the quickly solved initial 
problems, the patient was well oxygenated, with the end-tidal CO2 monitor 
showing a 3 to 5% reading on each breath: the best obtained so far.  Keep 
in mind that 5% CO2 is what is expired by a normally perfusing and 
respiring person! 

    Tanya administered the transport medications through a central venous 
catheter which had been left in place for this purpose.  After 
administrating the initial medications, Tanya went back to taking notes, 
with Mike dealing the IV drips.  Mike was having difficulty getting the 
dextran into the patient, and wanted to proceed with the femoral cutdown 
as soon as possible, so he asked Leonard if he would administer the 
remaining dextran.  Since Leonard had no experience with this, Mike 
quickly explained the procedure of first filling the syringe through a 
3-way valve, then turning the valve the opposite way and squeezing the 
plunger (more sore muscles) to force the dextran into the patient.  He 
also explained to watch carefully for air in the IV line, and even though 
Leonard thought he was pointing to the opposite (mannitol) bag from the 
correct one, and was watching the wrong bag.  Leonard completed the 
dextran, and shut off that line.  When Leonard reported that the dextran 
was complete, Mike asked him to start the other bag, which was apparently 
already hooked up.  Leonard checked and found that it was already 
started, and reported this to Mike, assuming that someone else had 
started it, and was responsible for watching it.  Because Leonard had not 
had training on this subject, (not to mention that he was busy watching 
and changing oxygen cylindars) he missed understanding that the 
responsibility for the medications was being handed off to him, and 
nobody noticed at first when a pneumatically compressed IV bag started to 
pump air into the patient.  Fortunately Tanya had removed most of the air 
from the bag prior to its being hung up, so at most a few cc of air got 
into the patient.  However, this experience reenforces the opinion that 
note taking is too complex to combine with any other task, and that IV 
medications MUST be monitored by a trained person until they are turned 
off.  We also somehow missed hanging an occluder clamp on the IV pole. 
Another item which is going on a checklist. 
      
    Although the intent was for Hugh and Keith to do the femoral cutdown, 
their inexperience with the prep and drape phase (inadequately practiced 
on pigs) slowed them down so much that they turned it over to Mike.  Mike 
went on to do the femoral cutdown with Hugh assisting and Keith handing 
off instruments.  (The first thing they ran into was a set of arterial 
branches gnarled like tree roots.)  Several sessions working with pigs 
made it possible for Keith to anticipate when instruments, suture or 
heparinized saline would be needed next, and had also sharpened up Hugh's 
surgical skills.  From arrest to going on bypass required 80 minutes, not 
as fast we'd like, but better than last time (105 minutes) and the record 
so far.  Oxygenation and perfusion during HLR support was excellent, and 
the patient had a strong femoral (groin) pulse which made it easier to do 
the cutdown.  The patient's temperature was 22.3 C at the time bypass on 
the MALSS was started.  This works out to a drop in temperature of 0.18 C 
per minute - excellent for HLR-supported surface cooling, though this is 
largely a function of patient mass/surface ratio. 

    Cooling to washout temperature went both smoothly and rapidly.  Mike 
had installed an extra heat exchanger in the bypass circuit (in addition 
to the one on the Bentley hollow fiber oxygenator) and switched to a 
higher output pump for delivering the ice water to the heat exchangers.  
This resulted in a cooling rate of 0.47 C/min.  When Nick's temperature 
reached 10 C, washout with Viaspan began.  This procedure took about 7 
minutes and (with large bore lines this time) went very smoothly.  Blood 
washout was deemed excellent in the field and confirmed upon arrival at 
the Alcor facility:  Nick's hematocrit was 1%, indicating that about 98% 
of his blood had been washed out. 

    At 5:01 a.m. we shut down the pump/oxygenator on the MALSS in order 
to safely load it and Nick into the ambulance.  At that time Nick's 
esophageal temperature was 3.5 C (he could have been kept off bypass 
safely for hours) and he had cooled approximately 34 C in 3 hours and 20 
minutes - a powerful testimony to the effectiveness of the portable ice 
bath and MALSS-supported cooling.  Within a few minutes after Nick was 
loaded in the ambulance, clean-up in the garage was completed, all the 
support gear was loaded into the Cryovita van and assorted personal 
vehicles, and transport to Riverside was begun.  The ambulance arrived at 
the lab about 7 a.m.  Keith and Arel (who had dropped off Max and picked 
up breakfast) made it by about 8 a.m. 

    Since there was at least a six-hour gap before the contract surgeon 
could get there, most of the team headed off to get some badly needed 
sleep.  Even though Keith had not slept at all the previous night, he did 
not feel like trying to sleep, so he remained awake to monitor and 
operate the MALSS.  By that time Nick was on intermittent (10 minutes on, 
20 minutes off) low-flow bypass to minimize the risk of cold-perfusion- 
associated-edema.  Intermittent circulation of the Viaspan has been found 
to be important to supply tissues with needed oxygen and glucose, remove 
wastes and control pH.  Initially Hugh was going to operate and monitor 
the MALSS cart, but he was in worse shape than Keith, so he headed for 
bed.  This was Hugh's first transport-team leadership, and he had gotten 
little sleep since days before it started from worrying about all the 
things were needed and which can go wrong. 

    Mike left Keith with instructions to check pH once an hour and adjust 
with bicarbonate as required.  Keith decided to check glucose as well, 
located a test kit, found the level to be low, and (following the 
directions in the transport manual) adjusted it with glucose.  This was 
keeping Keith as busy as a one-armed paper hanger, so it was a great 
relief to him when Paul came back in to help after a quick trip home for 
a wake up shower.  About the time Paul came in, Keith stuck a clamp on 
the wrong line (no harm to the patient, thank goodness) opened a seam on 
the oxygenator, and sprayed a couple of hundred ccs of perfusate on the 
floor.  Arel later made a suggestion of taping the lines with stripes of 
narrow-gauge tape: red for arterial, blue for venous, and green for the 
bypass line.  It might not prevent all accidents, but it would sure help 
dead-tired people.  After cleaning up the mess, Paul and Keith checked 
each other when they changed the clamps. 

    Paul and Keith had problems with both measurements and keeping the 
ice water flow really at ice cold temperature.  Near the end of the MALSS 
support they moved the esophageal probe, and the reading dropped from 2.2 
to 1.5 degrees, more likely representing the patient's core temperature.  
The arterial probe must have been off by about 5 degrees, because the 
arterial temperature (after going through the heat exchanger) had to be 
lower than the patient's core temperature.  The readings were still very 
useful:  they could see small rises in arterial temperature and take 
steps to correct it.  The heat-exchanger water flow kept channeling 
between the pump and the return line, and required constant stirring and 
fiddling to keep the right level of water and enough ice in the cooler 
chest they were using.  They kept at it for about 6 hours, until the rest 
of the crew returned, both rested and fed, and the contract surgeon 
showed up. 

    Three problems should be mentioned.  First, the glucose test kit was 
missing the calibration strip for the meter, so the test strips had to be 
roughly read by hand.  Due to unfamiliarity with procedures, and a 
failure of communication (side effect of a lack of sleep) no analysis 
samples were taken during the long period of low flow.  Last, we run one 
oxygen cylinder out.  While it did not hurt the patient, it was not 
noticed for some tens of minutes.  Oxygen flow should be read with each 
temperature. 
   
    Nick was moved from the MALSS to the operating room table.  With Hugh 
assisting, surgery to access the heart was seemingly uneventful.  
Arterial and venous cannulas were placed, Mike did a bur hole using the 
DuPuy pneumatic bur-hole tool.  This time he did not open the dura.  
Brain swelling or shrinking was assessed by depressing the dura with a 
blunt instrument to "sound" the cortical surface, and observing the dura 
in the bur-hole for being flaccid or bulging.  It seems that the profuse 
leaking of perfusate observed in previous well-supported cases was due to 
cutting nearly invisible vessels in the dura, not (as Keith had 
speculated) from the brain surface itself.  This was the first time the 
DuPuy was used in a suspension and it worked very well, making a small 
hole in the skull in a fraction of the time it took to open a hole with a 
conventional hand drill.  Observations of intracranial pressure were 
consistent with low injury patients: low pressure and some shrinkage of 
the brain during perfusion. 

    While all this was going on, Arel made a food run.  Later she and 
Keith got busy cleaning out the MALSS cart.  They used a lot of Clorox, 
and this time the vacuum system got checked. 

    With surgery completed, Carlos took the surgeon back to the airport, 
and Ralph started on the perfusion ramp.  After a quick lesson Keith was 
put on measuring perfusate refractive index--which converts to a 
measurement of the level of cryoprotective agent going into and coming 
out of the patient.  From the start, the computer model and the measured 
results were not agreeing.  Dr. Perry was called over to see if anything 
odd was going on with his program, but it seemed to be OK--reality was 
out of adjustment.  Early measurements indicated that the glycerol 
concentration was not increasing as rapidly as predicted and that we 
might not reach target.  The reason for this was not apparent until the 
conclusion of perfusion, and after cephalic isolation.  At that time we 
discovered that the umbilical tape (heavy duty surgical ties) the 
contract surgeon had used to tie off the aorta (so that the body did not 
perfuse) had not completely closed off flow--with the result that the 
patient's body had partially perfused! This was a potentially very 
serious problem.  We now know better and in the future only metal 
(Satinsky) occlusion clamps specially designed for closing large vessels 
will be used for neurosuspension isolation. 

    Fortunately we came very close to the minimum target glycerol 
concentration of 4.0 M (the final venous reading was 3.86 M or 27.84%).  
We just reached this concentration with the last drop of glycerol.  Hugh 
was running blood gases, and we were pleased to see that Nick was using 
oxygen (as determined by the arterial-to-venous oxygen differences) at 
levels comparable to those observed in our (viable!) canine 
total-body-washout animals cooled to similar temperatures. 

    About an hour before ending the cryoprotective ramp, a comment by 
Mike led to the realization that nobody had been assigned to get dry ice.  
The only source at that time in the night was two hours away, so Carlos 
took off to get some.  He made it back in time, but in the meantime Mike 
and Leonard had rigged a way to get cooling with the Silcool oil started 
using liquid nitrogen. 

    During our efforts to reach the target glycerol concentration another 
problem surfaced, one which really requires an immediate fix.  During 
early cryonic suspensions it was discovered that when glycerol 
concentrate is added to the recirculating system (the perfusate being 
pumped through the patient) it tends to stratify, i.e. it sinks to the 
bottom of the reservoir and ends up being pumped into the patient without 
first being safely diluted.  (Glycerol is the very best available 
cryoprotective, but very high glycerol concentrations are used to 
*dissolve* some tissues!)  This problem was solved by continuous mixing 
of the perfusate with a magnetic stirring bar.  Unfortunately, if the 
reservoir level drops too low, the stir bar creates a vortex--which sucks 
in air and fills the perfusate with micro-bubbles.  This happened during  
Nick's perfusion, though--fortunately--the in-line  arterial 
filter/bubble trap caught the air.  However, we cannot rely on this in 
the future and several (patentable?) suggestions have been put forth on 
how to eliminate this problem.  A decision has also been made to acquire 
(as soon as we can locate one) an air-bubble detector for use on the 
circuit.  Operating room perfusionists have had bubble detectors for so 
long that few of them would willingly do without one. 

    Cephalic isolation has been greatly improved due to the introduction 
of new tools by Keith and Mike.  (Details on the procedure are available 
to those who ask.)   We now have this procedure down to a fraction of 
Jerry Leaf`s best time.  After trying umbilical tape (which proceeded to 
untie itself), Mike found cable ties to be an efficient way to occlude 
(tie off) the esophagus and trachea.  This goes a long way to maintain a 
clean surgical field during cephalic isolation. 

    Cooling to -79 C was started at about 11 p.m.  After cooling was 
started, the grueling and seemingly endless process of cleaning up began.  
About this time Mark Connaughton came in and calibrated the blood-gas 
machine so we could try to make better sense out of pH data that did not 
agree between two machines.  Cleanup was fairly well completed by about 
2:30 a.m., though there was a lot of work left for the next few days, 
restocking, re-ordering, and cooldown. 

    The final result of this suspension was close to or perhaps the very 
best to date.  It is fairly clear that the most serious problem (nearly 
having the patient deanimate with us hours away) was the result of faulty 
pre-suspension medical evaluation and had nothing to do with the cryonic 
suspension aspects on which so much recent effort has been expended. 

    Organization and attention to detail need a lot more work, and we are 
really going to have to train some of the suspension team members (in 
addition to Mike) as backups to do the cardiac surgery.  Emotionally 
suspensions are about as rough on people as can be imagined, but there 
was great (and effective) effort by all concerned to be more supportive 
of each other.  Sadly, we have to expect to be doing more HIV cases (this 
was our third) as time goes on and Alcor grows.  Mike Darwin wishes to 
add his thanks to all involved for allowing his participation in the 
suspension, and his special thanks to Arel Lucas for her constant and 
invaluable support and to Paul and Maureen Genteman and Brenda Peters for 
their facilitation of his participation.  Keith adds that *he* is 
responsible for the harshest presentation of our problems in this 
article. 
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