The Cryonics Institute’s 106th Patient — Robert Ettinger
Connie's and my experience in getting ready for my father's suspension may provide useful information for lots of people facing the same issues. The key lessons are pretty simple; preparation, homework, and attention to detail. We also used multiple vehicles, hiring our own nursing care, using hospice, and coordinating with EMS. Two of the three proved critical. But we needed all three, since we didn't do know what would come through most quickly.
My father began to decline significantly about a month before he expired, for reasons that weren't clear to his doctor or to us. That decline became precipitous in the last week. We tried very hard to suggest measures to the Dr to try to turn things around. He did what we suggested, and they ultimately didn't work. But that didn't become crystal clear to me, at least, until the day my father died.
Nevertheless, we knew that death (or deanimation, but I prefer simple, colloquial English words, and we all know what is meant) was a strong possibility. So simultaneously with our work to try to get him better, we prepared for the need to suspend him. The key, of course, was to be ready to suspend him as soon as possible after legal death, to minimize any damage from warm ischemia (lack of oxygen to the brain).
First, we obtained 24 hour nursing care. This was critical to try to get him better (which involved, in part, active efforts to feed him every couple of hours), to keep him comfortable, and to have someone there who could start the plan in action at a moment's notice if he stopped breathing or if he began to exhibit the signs of impending death.
There are lots of nursing agencies out there, but we ended up relying on friends of friends (one of whom we found through Connie's Facebook posting), who turned out to be much more reliable than the random people we might have gotten. The three women we found (two certified nurse assistants, one of whom was just finishing up her RN training, and one home health worker with much experience with the elderly) did a great job. Connie spent time with the nurses, talking to them about cryonics, making sure they were comfortable with it, explaining the great importance of the timing, and making clear that they didn't have to do anything relating to cryonics, except (critically) identify the signs of impending death and make the key phone calls. She also prepared instruction sheets, posted on the refrigerator, reminding them EXACTLY what to do if my father stopped breathing, and (before that) if he showed signs of imminent death. We said who to call, and in what order, with phone numbers. We emphasized to call us immediately, day or night. We thought through what could happen, and tried to leave nothing to chance.
Second, we got my father into hospice care (after having to get his doctor to push the hospice people, who first said, absurdly, that he didn't qualify because his weight was too good). The hospice people helped in two important ways. They educated us as to the physical signs of impending death, which are imperfect but fairly well understood. This gave us some notice (by a couple hours) as to when things became urgent.
Hospice also provided a possible vehicle for quick pronouncement of death, necessary to proceed lawfully with the suspension process. The law on pronouncement varies from state to state, and in Michigan we discovered that it varies from county to county based on the discretion of the individual medical examiner. State law says that any Dr or RN can pronounce death, but the Macomb County Medical Examiner will only accept an RN through hospice. The Oakland County ME also requires police verification. This may be a legacy of Dr Kevorkian, who operated here.
So by establishing hospice, we had access to RN's who could pronounce death. The problem is that there are limited numbers of such nurses, and they are on call. We were concerned that a call in the middle of the night might not be responded to for an hour, and that the cooling process would be delayed by that long. I explored paying hospice to station an RN full time with my father, using other RN's not employed by hospice, or other combinations. None was feasible.
So we (Connie in particular) pursued a second angle: EMS. Connie talked at length with Clinton Township EMS officials. These officials, in Clinton Township at least, commonly pronounce death with the cooperation of hospital physicians (who are e-mailed EKGs and given reports from the scene). Typically, though, if they get a call indicating a death, that goes to the bottom of their list, because it is regarded as less urgent than emergencies with living people. Connie convinced them that we needed immediate attention, and they notified their people that a call about my father should receive an immediate response. They posted notices in their office to that effect. Connie helped the process along by pointing out that my father was both the founder of cryonics and a decorated World War II veteran.
This was encouraging, but also not perfect. First, we didn't know if the particular EMS clerk receiving a 911 call would have read or would follow the posting. Second, we understood that even after breathing ended, sometimes EKGs would contain effectively electronic noise, random tracings. We knew that some doctors would require a "flatline" before pronouncing death, and I discovered that there was support for this in the literature. I prepared an argument to make to a doctor who balked; my father was 92, under hospice care, had signed a do not resuscitate form under Michigan law (key to allow us to act), and the doctor was delaying our freezing, points I would raise as necessary.
So we had two plans in place to obtain a quick pronouncement, neither perfect, but both likely to result in at least a pretty quick response if my father expired.
We also updated my father's legal documents before he declined precipitously. He had signed relevant forms in Arizona, and this did not work under Michigan law, which prescribes very precisely the forms needed. This is a very important lesson; you need to check what your state needs. One size does not fit all.
Finally, we arranged with CI to have lots of coolers filled with ice, a cooling box for the head and a full ice bath for the body, along with the iron heart to pump blood during the cooling process at my father's house, courtesy, of course, of Andy and Ben. We kept them away from the room in which my father was, because we didn't want to discourage him about his situation (knowing him, it wouldn't have mattered, but we didn't want to take a chance). But we had things close enough at hand so that we could begin to use them within seconds or minutes. (Everything involved but the iron heart can pretty easily be replicated at any location.)
As indicated above, our nurses were instructed about exactly what to do if my father stopped breathing, and a sheet laying that out, with phone numbers, the exact order of the calls to be made and scripts of what was to be said, was posted on the refrigerator. Connie went over all this with each nurse. They were also instructed to call us immediately, at any time of the day or night, if signs of impending death began to occur. (I called the night nurse once at 3 am, just to make sure she was awake and to emphasize that we meant any time.) As far as we were advised at that time, my father was a couple of weeks away from death, assuming we couldn't turn his condition around.
On Saturday, July 23, I talked to the nurses on duty in the morning, and then went over to see my father in the afternoon, arriving at 2 pm. The nurse on duty showed me that he had the first signs of more imminent death; his feet were blue and there was blue "mottling" on his legs. We immediately informed hospice. He then began rapid breathing, another sign. We also informed hospice (these are signs of demise within "hours or days" according to hospice). Hospice then dispatched an RN.
When the first signs appeared, I called Andy and Ben and told them that things could be happening sooner than we expected. I also called Connie to come over and to bring me additional clothes; I expected to stay through the weekend. But things happened much faster than that. When the additional signs began to appear, I told Andy to come over right away, and asked Connie to pick up additional ice.
The CNA on duty began to time my father's breathing, which was intermittently lapsing; that is a sign of very imminent death. I called the hospice nurse, who was on the way. She arrived just as my father ceased breathing. She consulted with the CNA, observed that my father was not breathing, and pronounced death. Within a minute, I packed his head in ice. We then pulled out the ice bath, began to fill it with ice, and transferred my father's body to the ice bath almost immediately thereafter, when Andy arrived. The cooling process proceeded immediately, and Andy's temperature gauge measured cooling to below room temperature (well below body temperature) within 10 or 15 minutes.
This became a near textbook suspension (if there were a textbook.) Of course, we benefited from the fact that my father's expiration proceeded in a manner that gave us some warning (though, as noted, it was unexpected when it did happen). But all the work and preparation were critical. The expense was relatively modest, a few thousand dollars for the 3 nurses.
Robert Ettinger's Perfusion by Andy Zawacki
Mr. Ettinger's perfusion went very well because of the standby provided by his family.
He wanted only his head to be perfused to give maximum protection to his brain and this is what was done. He was perfused through the aortic arch and all other arteries were clamped off so only his head and brain were being perfused.
There were no clots in the blood and no edema at all was observed in the head, eyes, face or neck. Considerable dehydration was observed in the eyes face, head and neck along with bronzing of the skin.
We used 5.5 liters of 10%, 4 liters of 30% and 32.5 liters of 70% solution.
When perfsuing with 10% a flow rate of 1.7 lpm was maintained while maintaining approximately 120mm pressure. When perfusing with 30% solution a flow rate of 1.27 lpm was maintained and a pressure of approximately 120mm was maintained. When perfusing with 70% solution a flow rate of 0.5 liters per minute was maintained and a pressure of approximately 120mm was maintained.
Canulas were placed in the jugular veins once perfusion with 70% solution was started. The final refractive index measurement from the right jugular was 1.4166. The final refractive index measurement from the left jugular vein was 1.4188. Higher refractive index measurements were observed from both the right and left jugular veins prior to the end of the perfusion.
A thermocouple was placed in his nose to reach the sinuses. The temperature reading when the perfusion was completed read 0c. As usual, the patient was transported to the CI facility while keeping his head covered in dry ice.