By Aschwin de Wolf

The goal of standby-stabilization-transport is to preserve viability of the brain by contemporary medical criteria. In other words, our objective is to preserve the patient in a condition no worse than the patient was in at the time of legal pronouncement of death.

There are a variety of good reasons for this including, but not limited to:

1. We don’t yet have a detailed understanding how memory and identity are encoded in the brain and by minimizing injury to the brain we hope to minimize the risk of losing this information.
2. Even if patients with significant brain injury can be resuscitated to good health in the future, this may require additional advances and techniques that may turn out to be costly in some respects, despite the rapidly declining cost curve that has been predicted for nanotechnology. Minimizing injury to the brain may minimize the time that a patient needs to remain in cryostasis.
3. We don’t believe that allowing more brain injury constitutes proper medical care. Because we do not share the view of conventional medicine that our patients are dead in any scientifically rigorous meaning of the word, we attempt to provide a level of care and commitment at least equal to, or better than, the care the patient received before pronouncement of legal death.

A reason not always appreciated, but important enough to deserve independent treatment, is that minimizing ischemic injury and achieving optimal cryopreservation are not independent of one another. There is extensive evidence in cryonics that patients who have experienced a long period of circulatory arrest at room temperature are very hard to perfuse with a cryoprotectant agent as a result of a compromised circulatory system, swelling of the brain, and cellular injury. For this reason some of the worst cases in cryonics get a "straight freeze", meaning that they are cryopreserved without any form of cryoprotectant. Even when cryoprotection is possible, it’s not as comprehensive as it should be, and often cryoprotective perfusion needs to be stopped before reaching concentrations sufficient for acceptable cryoprotection (or vitrification).

One objection that has often been raised against standby-stabilization-transport is that the injury inflicted by cryopreservation is much more serious than the injury inflicted by ischemia. Not only does this perspective ignore the observations about the relationship between minimizing ischemia and the quality of cryopreservation, adding insult to injury (literally) is not compatible with human cryopreservation as a form of critical care medicine.

This argument is also becoming less persuasive because of recent breakthroughs in vitrification at cryobiology companies like 21^st Century Medicine. As technologies become available that offer minimal (or zero) ice formation and minimal cryoprotectant toxicity, the issue of maintaining cerebral viability by contemporary medical criteria will take center stage.

When Suspended Animation is notified that a client is in a terminal condition, we deploy a team of standby members to the bedside of the patient. This team will typically include personnel qualified in emergency medicine, a surgeon, a perfusionist, and individuals with extensive knowledge of cryonics. During the terminal phase of the patient we study the patient’s health records, current pathology, and monitor the patient’s condition as closely as we are permitted to. This helps us in determining how much time the patient has left. It also helps us in tailoring our stabilization protocol to the patient in consultation with our medical advisors.

After pronouncement of legal death, we immediately restore circulation, start ventilation, induce hypothermia, and administer a series of medications to inhibit the return of consciousness, support circulation, reverse and prevent blood clotting, and mitigate cerebral ischemia and reperfusion-injury. If the patient has been pronounced at a remote location from the Cryonics Institute, a transportable perfusion machine is used to wash out the patient’s blood and substitute an organ preservation solution to eliminate cold-induced clumping of red blood cells and maintain viability of the brain during transport of the patient to the Cryonics Institute. If the patient is pronounced legally dead close to the Cryonics Institute facility, this step is eliminated and our objective is to stabilize the patient and minimize the time between pronouncement of legal death and cryopreservation.

An important element of successful stabilization of a patient is a cooperative hospital or hospice staff. Diplomacy, professionalism, and the ability to communicate with medical staff at their own level, will certainly help, but we cannot guarantee anything. Ultimately the quality of human cryopreservation procedures is affected by the degree our procedures are recognized by the general public and medical professionals, in particular.

Another limitation is sudden death. Not only will sudden death generally result in autopsy of the patient, geographical factors may prevent us from reaching someone quickly. For this reason, we will not hesitate to ask for assistance from local funeral directors and volunteers. As much as we try to develop our capability mirroring the areas where our clients live, we will not hesitate to give the case "back" to the Cryonics Institute if we believe that our involvement will be of no, or limited, value to the patient. Also, if we cannot implement some or all of our procedures, our contract with CI specifies that we will refund an appropriate fraction of any prepaid fee to the patient’s account.

As a general rule, being a client of Suspended Animation shouldn’t relieve a Cryonics Institute member of his responsibility to improve the chance of an optimal cryopreservation by executing additional legal paperwork (Advance Directives, Last Will and Testament, Do Not Resuscitate Order, Religious Objection to Autopsy etc.) talking to relatives, friends and medical caregivers about his desire to be cryopreserved, and establishing local support groups.

One trade-off in cryonics that is often discussed is the problem of optimizing cryopreservation of both the brain and the body. In order to better preserve the brain, compromises may need to be made in the case of the body. A similar situation exists in stabilization. Immediate examples that come to mind are the prolonged use of vasoactive medications that limit blood flow to peripheral areas of the body, cold-induced vasoconstriction, and surgical procedures that limit perfusion to certain parts of the body. It needs to be pointed out, however, that such trade-offs are not an intrinsic part of the art of human cryopreservation, but are the result of having to perform our procedures in an emergency medicine context.

A topic that sometimes has been raised in cryonics is that cryonics with standby-stabilization-transport is not necessarily better than cryonics without. One can imagine a scenario where the "pre-mortem" condition of the patient doesn’t guide treatment; serious logistical and technical errors are made; medications that are contra-indicated are administered; substantial reperfusion injury occurs, major surgical difficulties are encountered; and the patient’s circulatory system is compromised in an attempt to substitute the blood with an organ preservation solution.

A scenario in which many of these issues combine to produce results that are inferior to no stabilization procedures at all may be quite rare, but it highlights the need for education, professionalism, quality assurance, and transparent case reporting. This is not only the responsibility of Suspended Animation; cryonics "consumers" in general should follow their own organizations with a critical eye. This is especially important in an environment lacking the profit motive to produce superior services, and the absence of organizations setting and enforcing standards for the industry.

One major limitation in stabilization is the relative ineffectiveness of external cooling. Suspended Animation is currently working on a method of internal cooling called liquid ventilation in which a chilled perfluorocarbon is pumped in and out of the lungs to induce cooling of the core of the body as rapidly as possible. We are also exploring an alternative method of doing mechanical cardiopulmonary support. To better evaluate patient care, and facilitate real time intervention, new modalities of data acquisition will be introduced such as bedside blood gas analysis.

Suspended Animation is also working on having its own vitrification capability in Boynton Beach, based on the cryobiology research at 21^st Century Medicine. Although the name of our company is ambitious, we hope that by developing and adopting technologies that will reduce, or delay, brain injury and eliminate ice formation, we will take important steps toward the goal of real suspended animation.