From Cryonics, August 1987
THE JOURNEY BEGINS: ALCOR MEMBER ENTERS BIOSTASIS
by Mike Darwin
[See also an extensive and previously unpublished technical report on this case (53 pages 1.4 MB PDF)]
Every once in awhile the phone rings at ALCOR and the tone of the voice on the other end tells you something's wrong right away -- before the words can even reach you. Early in March I picked up the phone and knew I was taking just such a call. It was voice I hadn't heard in a long while and one I knew I couldn't expect to hear unless something was wrong.
Something Is Wrong
Something was wrong. The caller had a dear friend who had recently been diagnosed with AIDS. The situation was a complex one. The young man who was the focus of her concern was a hemophiliac with a 2-year history of AIDS Related Complex (ARC) who had recently gone on to develop full-blown AIDS and whose medical problems were very serious. The caller was a long time ALCOR Supporting Member and someone who was intimately familiar with cryonics and ALCOR from both the technological and the human dimensions. She realized that the odds weren't good in this case, and she wanted to talk to someone about whether she should even raise the issue. The people involved already knew about cryonics, but finances were likely to be a struggle (who has $35,000 or $100,000 lying around in cash?). Life insurance was out of the question as the young man was already clearly terminal. She also wanted to sound us out on the issue of infectious disease. The young man in question not only had AIDS, but hepatitis B in a particularly virulent and deadly form (probable delta particle co- infection) as well as one or two opportunistic infections of less concern. Would ALCOR even take such a case? Should she raise the issue of cryonics at all and perhaps jeopardize two close friendships?
A Difficult Situation
Offering advice in such situations is a hellish job. All I could do was to tell her to gently raise the issue with her friend in a nonthreatening way and react as is appropriate -- dropping the issue if the reception was anything less than enthusiastic. I also gave the usual cautions and "discouragements." Finances, the burdens and distractions of illness, and most of all, an unwillingness to squarely confront the real probabilities, would most likely combine to rule suspension out. She should be prepared for the worst and not press the issue.
A few weeks later I was sitting in the reception area of the ALCOR facility talking with the young man, who had only been a name and another of the many sad stories I've come to expect to hear when answering the phone at ALCOR. He did not wish to be identified publicly, so I'll give him the pseudonym here of "Carl Harper." Carl had no interest in exposing his family to the media limelight -- and his father and mother, who accompanied him on his first visit to ALCOR, shared his sentiments.
My first impression of Carl was that he would not be needing our services very soon -- and I told him so. Despite the gravity of his medical problems, he was alert and appeared in reasonably sound shape -- a far cry from the wasted, birdlike skeletons I've so often seen AIDS patients reduced to in the final weeks of their illness. I was prepared for a very unrealistic appraisal of his situation by Carl -- along with a lot of the usual false hope for an immediate cure. I got nothing of the kind. That was the first thing that really impressed me about Carl Harper -- his unflinching sense of realism and his total commitment to getting things arranged so that cryonics would be there for him when he needed it.
A Realistic Evaluation
That isn't to say that Carl had given up, or was morose about his prospects. Far from it. He said he intended to hang on for as long as possible, but that he realized the odds weren't very good and that the particulars of his condition were an added complication. Namely, the hepatitis B was rapidly destroying his liver, and had so reduced his liver function already that he could not tolerate any of the available HIV antiviral agents such as AZT or Ribavirin. An additional infection with mycoplasm avians (a cousin to tuberculosis) was destroying his bone marrow and further damaging his liver. He was on medication for these things and he was hopeful, but, given his limited reserve, he felt it wasn't prudent to count on too much time.
I have seen many people come face to face with the fact that they are dying. I have only seen one or two that even came close to handing it as intelligently and rationally as Carl Harper did. He said he had been thinking about cryonics since he was diagnosed with ARC two years before, but had not brought the issue up with his folks, largely because he didn't think they or he would be able to bear the financial burden.
The idea of cryonics was not new to either Carl or his family. Carl's father had attended an ALCOR meeting about four years before and was already reasonably familiar with the idea and the logistics, and of course the close friend who had placed the call had often discussed cryonics in the past with both Carl and his father as she was actively involved herself.
Finances were discussed and the issue of neurosuspension was brought up. Carl's reaction was level and rational. It was the only option he would consider. Cost was not the only factor in making the decision. A commonsense evaluation of what was important was foremost in his mind, and as I have often seen before, his sense of his self as his "body" as opposed to his "mind" had been greatly eroded by his disease. As he said to me shortly before leaving that Sunday, "This disease has pretty well destroyed my body, all I have left is my mind. That's the important thing. Everything else can replaced on the other end. And besides," he added with a half smile, "they can fix the hemophilia from scratch next time so it doesn't screw up my life again."
"Going For It"
I was quite surprised that when Carl and his parents walked out the door a decision had been made to "go for it" as Carl put it. What followed was an extraordinary unfolding of events, the kind of thing that movies are made about.
Right from the start, Carl made cryonics his top priority. He told me he wanted me to meet with his physician as soon as possible and that if she was not cooperative he would immediately switch to a physician who was. This was an incredibly gutsy thing to say -- and to mean -- because Carl's relationship with his doctor was excellent, and he had been treated at the same hospital since he was child and knew the staff fairly well (with hemophilia, hospitalizations are common).
As it turned out, Carl's physician was cooperative. She had many questions and she wasn't about to be "railroaded" into anything. I met with her about a month after my first meeting with Carl -- shortly after his paperwork had been completed and his suspension arrangements approved.
"Lillian Salter," M.D. was not what I expected. She was black, very businesslike, and possessed of a mind like a steel trap. She had plenty of brass-tacks questions to ask, and she was very concerned about her patient's well-being. She made it quite clear from the start that she was not about to "pronounce" (certify legal death) Carl in a home setting. She felt he should receive care in an in-hospital setting right up until the last, and once she became convinced we were no scam, she worked tirelessly to secure the hospital cooperation to make that scenario a reality. I think what motivated her most to do this was her personal relationship with Carl and her observation that "since Carl made these cryonics arrangements he has done a complete about-face. He is more optimistic, more involved in his care and nowhere near as depressed and hopeless as he was before becoming involved in this . . . ." The improvements in Carl's outlook and manner were strong motivating factors in her working to accommodate his wishes for suspension.
Our meeting, which lasted nearly an hour, ended with both of us expressing the opinion that Carl had quite a ways to go yet before he would need the arrangements.
The Hospital Cooperates
Over the next few weeks an agreement was worked out with the hospital and a pleasant, almost unbelievable coincidence was discovered. A physician who is an ALCOR Suspension Member, is on the ALCOR Suspension Team, and who is closely involved with ALCOR research, was also on staff at the same hospital! Dr. "Greg Smith" worked evenings in the hospital's emergency room to supplement his meager income as a researcher at a local University. This fact was uncovered quite by chance as I talked with him one evening about my negotiations with Carl's physician and how to solve a particularly knotty problem that had come up. The problem was that given the current staffing situation, the hospital could not guarantee that there would be anyone to promptly sign a death certificate on Carl -- there might be a delay up to an hour for a physician to come up from the emergency room. "What!" he exploded. "I'm on staff at that hospital and know half the ER and on-call docs there."
Dr. Smith's Solution
Dr. Smith had an elegant and very effective solution to the problem. Privately and quietly circulate the information that there would be a $1,000 bonus for prompt pronouncement of the patient and help with intubation, which would decay to nothing at the 15 minute post-arrest mark. Thus, any hungry ER physician could earn himself a quick $1,000 just by showing up and doing 5 minutes' work -- work he was basically being paid to do anyway. This plan was put in motion.
Over the following 2 months I would talk to Carl frequently. He would call me with questions or concerns or just to chat, and I would call him to see how he was doing. He also had established a friendship with another ALCOR member, Arthur McCombs. Carl and Arthur had a number of interests in common -- including a love of heavy metal rock music. For Carl it was more than just an interest. He had spent his entire life performing music and at the time he became ill with AIDS he was bass guitarist in a heavy metal rock band. He had a couple of "minor" hospitalizations, but basically seemed to be doing pretty well. I called to talk with him on Friday evening, June 5th and his mother told me had gone to bed early. I asked her how he was doing, got a favorable report and said I'd give him a call on Monday, as I had a day hike up Mt. San Gorgonio scheduled for Saturday and dinner plans for Sunday. I checked on our other high risk members and called Jerry Leaf, our Suspension Team leader, to let him know he could relax a little for the weekend as everyone was doing well.
The Crisis Begins
The next day, after descending about 11,000 feet from the summit of San Gorgonio my pager went off. Carl's father had called to report that he had just been hospitalized with a high fever. This was not unusual and he said he would keep us posted. I told Hugh Hixon, who was manning the office, to call Jerry and let him know, and I proceeded to go out to dinner with some backpacking friends to relax after the day's climb. I never finished dinner. My beeper sounded an hour or so later. Carl was unconscious and in septic shock, and Jerry Leaf was nowhere to be found. He had left a message that he had gone to Mexico and would call in later to give us a phone number where he could be reached.
The next 24 hours were sheer hell. Despite every effort to do so, Jerry could not be reached and no call was forthcoming. What we had no way of knowing was that Jerry's brief trip to Mexico had turned into a nightmare with his wife becoming seriously ill, no hotel rooms available (the Baja 1000 was in progress), and the wrong key in the lock box at the condo they had rented for the day!
I deployed a team at the hospital with the ALCOR ambulance to stand by and get Carl on the HLR and then notified our physician of the situation. To complete the nightmare, Dr. Salter, Carl's regular physician, was away for the weekend and most of the following week at the International AIDS Conference in Washington D.C. She could not be reached at the conference and no one at the hospital knew what to do. The physician who was covering for Dr. Salter and who had been briefed on the cryonics aspect of Carl's care was also off this weekend. The on-call physician had never heard of any of this before.
A Race Against Time
This is where Dr. Smith stepped in and saved the day. He took over Carl's management from the on-call physician and arranged for his transfer to the ICU. This was no mean feat as it was miserably understaffed -- only one nurse for the whole ICU. The hospital nursing office asked if ALCOR could provide some skilled help (no, we're NOT kidding) since they were impossibly short staffed. Dr. Smith stood by until Carl's mother (who is a nurse) could reach the unit to assist with his care, and until Scott Greene, who is a 3rd year nursing student, could be put on the scene. Over the next 24 hours Scott, Arthur McCombs, and Mike Darwin would take turns providing basic nursing care for Carl, supplementing the meager ICU staff!
Dr. Smith started a dopamine drip, got Carl properly hydrated, and pulled him out of septic shock. Now it was a waiting game -- it was apparent that Carl would get better transport if Jerry Leaf was available to operate the Mobile Advanced Life Support System (MALSS) cart. No one else was sufficiently trained yet (a situation which has since been remedied) to set up and use the cart. Meanwhile at the hospital, Suspension Team members Scott Greene (who also is a certified EMT and ambulance driver) and Arthur McCombs were standing by. Carl's situation seemed stable and everyone relaxed. It seemed very likely he would make it through the night.
Jerry Leaf Returns
At around 9:30 PM Sunday evening, Jerry Leaf called in after a grueling trip back from Baja, Mexico. He was immediately apprised of the situation and came straight to the lab. The MALSS cart was loaded onto a van and Jerry and Hugh Hixon left for the hospital. Shortly after their departure a call came in from Scott Greene. The patient had been given 2 mg of Dilaudid for pain and was in profound shock. I asked Scott if he felt he and Arthur would be able to handle the transport. The answer was a calm "Yes." Co-operation from the hospital was excellent and they were offering every kind of support they could to see that things went smoothly.
A Suspension Gets Underway
At 3:30 AM, shortly before Jerry and Hugh arrived with the MALSS, Carl went into cardiac arrest and was pronounced legally dead by an ER physician who was anxiously standing by waiting to earn his $1,000. Carl was promptly intubated and manual and then mechanical CPR was begun. Arthur and Scott promptly transported the patient from the hospital and as they arrived at the ALCOR ambulance, ALCOR Treasurer Carlos Mondragon walked up and assisted them in lifting the gurney with Carl, the HLR, and the ice packs into the ambulance. No sooner was the gurney in the ambulance than Jerry and Hugh arrived.
Carl was quickly packed in ice from head to toe and transported to the ALCOR facility in Riverside. When the ambulance rolled in from L.A. about 45 minutes later, Carl was receiving the last of his transport medications and was already down to 28°C. Shortly after his arrival at the ALCOR facility it was noted that Carl had developed significant pulmonary edema, and his endotracheal tube required intermittent suctioning of blood-tinged secretions. It was at this point that a significant hazard associated with the Brunswick HLR units was experienced. Blood-containing secretions can back up into the respirator hose and be aerosolized and powerfully sprayed out by the blow-off valve at the end of the ventilator hose. When personnel lean over to disconnect the respirator hose to suction the patient, they can be sprayed directly in the face or eyes with blood contaminated (and presumably HIV positive) lung secretions! It is highly recommended that masks, face shields, and cover gowns be used during transport as well as in the operating room.
Scott Greene and Mike Darwin with "Carl" in the ambulance at the Alcor facility.
The MALSS Gets A Workout
After 5 hours of HLR support, a femoral cutdown was carried out and Carl was coupled to the MALSS unit. His core temperature was rapidly decreased to 12°C using the heat exchanger in the Sci-Med oxygenator. It was noted that the blood which backed up into the arterial cannula during HLR support was bright red, and the venous blood in the venous cannula was dark blue -- the HLR was doing its job. Carl was supported on the MALSS using a blood pump and membrane oxygenator for a little under 2 hours. After dropping his temperature to 12°C he was massively hemodiluted using base perfusate (not containing any cryoprotective agent) to a hematocrit of about 4% and his temperature was further reduced to 4.9°C. Perfusion was stopped due to massive pulmonary edema (and the fact that Carl's core temperature was safely low enough and he had been flushed free of blood). Carl was then transferred to the operating table in the facility Operating Room (OR) and completely repacked in ice.
Carl is placed on bypass: Suspension Team Leader Jerry Leaf adds volume to the circuit while Scott Greene disconnects the heart-lung resuscitator.
The femoral heart-lung bypass circuit in operation on the MALSS.
The Suspension Team Assembles
By the time MALSS support had been discontinued personnel were starting to pour in from all over. Brenda Combest arrived to coordinate meals and keep food supplied -- a job she handled with her usual aplomb. Fred Chamberlain flew in from Lake Tahoe to carry out note-taking and debriefing of the transport staff, and photographer Luigi Warren arrived to document the suspension with snapshots. Scott Greene changed roles and scrubbed in with Jerry as first assistant surgeon and Thomas Donaldson arrived on the scene to act as a backup support person. Carlos Mondragon, running on Coca Cola and adrenalin, changed into scrubs and acted as circulator.
Thomas Donaldson aids in mixing perfusate.
After positioning Carl on the table, the first thing that was done was to make a burr hole in the top of the skull and expose a small area of the cerebral cortex. This allowed us to evaluate the degree of blood washout during MALSS support/total body washout, and of course to subsequently monitor cryoprotective perfusion. Despite 5 hours of HLR support and 2 hours of MALSS support there was no sign of cerebral edema when the dura mater, the tough membrane covering the brain, was opened. The brain surface was a pristine, pearly white and free from blood-filled vessels. Blood washout was very good.
The burr hole in the skull, made to observe the state of perfusion to the brain.
Carl was then prepared for connection to the heart-lung machine and a median sternotomy was performed (the chest was opened and tubes were placed in the aorta and the right heart so heart-lung machine assisted circulation of cryoprotective agents could begin). At 3:40 PM cryoprotective perfusion (CPP) was begun.
Performing the cannulations inside the chest to isolate the head prior to cryoprotective perfusion. Carlos Mondragon holds a reference anatomy text, while Scott greene assists Jerry Leaf in the cardiovascular surgery.
CPP proceeded smoothly with vascular resistance remaining fairly constant, and desirably low, over the entire course of the perfusion. Overall, Carl's perfusion went better than in any other patient we have had so far. A terminal concentration of glycerol (the compound we are currently using to minimize freezing injury) of 3.80 Molar (35%) was reached. This is a higher glycerol concentration than we have ever been able to reach in a human patient. For the first time we were able to achieve what we call "Smith's Criterion," of not turning more than 60% of the water in the patient's brain into ice. (Cryobiologist Audrey Smith was the first to show that golden hamsters could survive 60% of the water in their brains being converted into ice with no ill effects.) Given a 3.8 M concentration of glycerol we should have converted just 60% of the water in Carl's brain into ice -- right at the threshold suggested by Smith's work.
The operating room heart-lung machine, with its tubing pack installed and ready to go.
Fred Chamberlain takes notes, while Mike Darwin filters cryoprotectant into the gradient maker.
Cryoprotective perfusion lasted a little over 4 hours and was terminated at 8:43 PM. Surgical separation of the head was completed at 8:54 PM and Carl was submerged in a Silcool bath at -15°C at 9:04 PM on Monday evening. Over the next 18 hours he was slowly cooled to -79°C in the Silcool bath by the gradual addition of dry ice to the bath.
After cooling to dry ice temperature was complete, Carl was transferred to a standard aluminum neurocan, placed inside an MVE TA-60 cryogenic dewar and slowly cooled to -196°C by being lowered into a whole-body dewar over a 14-day period. At 9:10 PM on June 29, Carl was transferred from the TA-60 to long-term storage submerged in liquid nitrogen. For Carl the journey has begun. Subjectively, for him, it will be over within an instant, in the blink of an eye. If he is to reawaken at all he will do so without any awareness of the long years of struggle which will be required to deliver him to an era of technological ability equal to his needs.
The Journey Begins
I can see him as he was on that first visit to ALCOR as if it was yesterday: his trust and his confidence in us, the rational certainty that cryonics was the only option that made sense. If only more people had that kind of honesty and awareness, the task at hand would soon be realized.
As it is, the struggle which confronts us, to get Carl and ourselves to a point where death is not an ever-present shadow, will not be an easy one. Carl's calm certainty that cryonics was the right thing to do and that it could work for him will go a long way to sustain me on the long journey that lies ahead for both of us. May his courage and determination serve as an inspiration to us all.
A HOPEFUL MEMORIAL
On June 8, 1987, Alcor member "Carl Harper" deanimated and was placed in neurosuspension. Aged 29, he was a rock musician who, as a hemophiliac, had contracted AIDS through a transfusion some years before, and as a consequence fought a long and heroic battle against multiple and debilitating illnesses. His parents asked Mike Darwin to speak briefly at a memorial service held in a chapel at Forest Lawn on June 11; the following is a reconstruction of Mike's address:
"We're here today to talk about Carl Harper. I didn't know Carl well, but I did know him during a very difficult time in his life, namely, the last few months that he was alive, and, while I don't go back as far as many of you do with him, I think I got the feel of the man, and I got to know him in a way that perhaps none of you did.
"Carl was not in any way a conventional person. He was somebody who was independent, strong-willed, able to think for himself. His decisions were not always the easy ones or the conventional ones, and I think as all of you know who knew him, he had a very hard time in life. Physically, he had a lot of things going against him from the very start, and with my background, which is medicine, I've seen a lot of people take the kind of stresses he took and not handle it well, not manage to become full people, not manage to become complete human beings. It's very rough when you're in the hospital, in and out all the time -- a whole lifetime of that -- to form the normal kinds of relationships and develop the strengths and personality that are required to live in this world and live in it well. And, I'm here to say that my personal estimation is that Carl did that, and he did it against tremendous odds. He managed to be productive, he managed to do something that enriched the lives of other people, with his music, and that's a hard thing to do given the odds that were stacked against him.
"And, even at what we will call the 'end' for the purposes of this service, he was not conventional either. Because Carl was never one to give up. He couldn't have been, given the history that he had, and the odds he had against him from the start. And that in fact is something that I met. When Carl found out that he was dying, he was not willing to accept that, and that's good, because that's my philosophy too. I think everything you see here around you is an attempt by people not to accept a very ugly, a very unthinkable thing: the loss of life. For some people there are religious comforts that are available, and I hope that they are able to provide a comfort people need to function, when they have no other alternative. But Carl didn't see it that way, and neither do I. What he chose instead was another option, the option of trying to fight, to continue -- to go on -- and that's where he's at right now. Because in my estimation, Carl Harper isn't gone. He's with us, meaning in our care at ALCOR, and he's going to stay there, and we're going to continue to fight for him, as long as it's necessary, until we win that battle. That battle is to return him to this life, to this world, alive and whole and healthy. That's what we're out to do, and believe me, if there is any way it is physically possible to do that, we're damn well going to do it. He counted on us for that, and the battle has not yet ended, it has merely begun.
"For most people, a memorial service, the death of a loved one, is a time to walk away, an ending. For us it is not. Indeed the responsibility is heavier now than it has ever been at any point in the past. The battle is really just beginning, and it's beginning not only for Carl but for the other people who are in our care right now. Ultimately it will be a battle for ourselves, when we enter a similar state. We call that state cryonic suspension. I don't know if it will work; I hope it will. I do know that, in lieu of any other alternative, any other possible belief in an afterlife, it's the only game in town, and we're going to continue to fight for that game, and to see to it that the odds, however great, are overcome.
"So I guess my only message to you, as you walk out of here, is: don't for a minute think that Carl Harper is gone. He's in the same state that anybody would be in, in an intensive care unit, in a hospital, in some uncertain circumstance, where you ask a doctor, 'Is he going to make it?' and the doctor says, 'I don't know. All we can do is do the best we can, and hope for the best.' That's the position we're in right now. We're just going to do the best we damn well can, and hope for the best. And I think it's going to work out okay. I think that biologically there's no question that everything that made Carl what he is, is still there. The real question is, can we ourselves work hard enough and long enough, to hold this world together that we're a part of, this civilization that we're a part of? Can we hold it together long enough to get him back, and to get ourselves back as well? I prefer to be an optimist rather than a pessimist, and that was Carl's position as well. As I'm sure he would say, "What the hell, there's nothing to lose, I might as well give it a go," and that's what we're doing.
"'Mary,' Carl's mother, made a remark to me, shortly after Carl 'deanimated,' as we call it. She said she wondered if there'd be rock music in the future, and whether Carl would be able to do okay there. And I think, Mary, he's going to do just fine, because we come into this world with nothing but a desire to live -- nothing. We're born with nothing, other than people around us who care, and who want to give us some of their life, and a strong desire to live, to get as much out of this life, to live as long and as well as we possibly can, and to give that to our children, and to the other people we love and care about. And I think Carl had that in spades. He loved life, and he was willing to take this gamble at tremendous odds, in order to go on with it. That's really all I can say about his chances for the future. His love of history, his concern about intellectual things in the last few years of his life, and most important, his passion for music -- I think those are values that are going to last however long people last. If there are people in this world a thousand years from now, or two thousand or ten thousand, those basic values of loving life, of music and art, of seeing the world in a way that helps you appreciate those basic values that are part of life, those values are going to be there, and I have no doubt in my mind at all that Carl is going to be able to handle those values, and find new ways to interpret them, just fine. He'll do just fine. So, I won't keep you here any longer. I'll just close by saying that the battle has just begun, and we're not giving up, and we at least are not walking away. Thank you.
[See also an extensive and previously unpublished technical report on this case (53 pages 1.4 MB PDF)]