The First Cryonics Case in Toronto, Canada: By Ben Best
Several years ago the cryonics kit that had been used in a Canadian case found its way to my apartment -- including a Brunswick heart-lung machine (thumper) and a chest of medications. In December of 2001 I also inherited a plastic bath gurney. No one other than me seemed to have room to store these things. At the time the gurney was being moved-in I decided it would be good to rent an oxygen tank, go through the supplies and have a cryonics local response training. I knew that there would be a cryonics case in the Toronto area eventually -- perhaps even me or one of the 5-10 signed-up cryonicists in the area.
(For background on cryonics emergency response protocol, see Emergency Preparedness for a Local Cryonics Group.) Veteran cryonicist Keith Henson had recently moved to Toronto -- seeking refuge from California Scientologists with whom he had been fighting in the courts. They had him charged with the "hate crime" of persecuting a "religious minority". He was able to show our local cryonics group how to use our Brunswick thumper. We had discussions about other meds and equipment we might need and how we might respond to a cryonics case in Toronto.
While going through all of this preparation I was increasingly dreading how a cryonics case could impinge upon my work and my studies and how poorly I would actually be able to handle it. I did not know if the equipment would be adequate, my training would be adequate or if I could (or would want to) devote adequate time at an inconvenient time.
In the Fall of 2002 I received an e-mail from Cryonics Institute President Robert Ettinger to the effect that a woman in Toronto was dying of ovarian cancer and that her son -- a dentist not living in Canada -- was making arrangements for her cryopreservation with the Cryonics Institute (CI). The funding was not yet in place and a fully cooperating funeral director had not been located. There were concerns about long delays with shipping paperwork, from a medical examiner or getting her across the Canadian/US border. There had never been a cryonics case in Ontario before. If there were long delays and the patient was held at water-ice temperature there could be considerable tissue degradation. We would either have to move her to Michigan to deanimate or perfuse her with glycerol cryoprotectant in Toronto. If we perfused her in Toronto we could cool her to dry ice temperature and the delays would not be so damaging. But the Toronto funeral director in CI's network did not want to perfuse, so I was asked to try to find a more cooperative mortician.
I made a list of funeral directors in Toronto, giving priority to those near the apartment of the patient and which seemed to be small, privately-owned & secular. I located a funeral director who was very close to the patient's apartment who seemed downright enthusiastic about taking the case. But I then learned from Bob Ettinger that their Toronto funeral director had agreed to perfuse if he received training and equipment from CI's Michigan mortician, Jim Walsh.
The funding was in place so I phoned the patient. I was concerned that cryonics was her son's idea and that she might not be personally interested. She answered the phone and quickly proved herself to be a sharp-witted elderly woman of few, but pointed, words. When I asked her about her feelings concerning cryonics she briskly replied with words to the effect: "You idiot, I'm dying! Of course I want to be cryopreserved!" When I tried to tell her the benefits of moving to Michigan to get a better preservation she was flatly opposed, saying "I am comfortable here". She abruptly ended the conversation. To others she might have seemed rude & abrupt, but I was frankly charmed by her terse, no-nonsense attitude.
I phoned her physician and was impressed & relieved by how accepting he was of the fact that his patient wanted to be cryopreserved. He acknowledged that since the patient was terminal that a nurse would be authorized to declare death and that we could begin our procedures immediately rather than have to wait for a medical certificate signed by a physician. (He later provided a written document certifying this.)
I made arrangements for Keith Henson, Christine Gaspar and me to visit with our prospective cryonics patient in her apartment on a Friday evening. She was an accomplished woman -- having practiced a profession for over 30 years -- so I will call her Ms. Professional (she was a widow). Ms. Professional was in her 70s, completely bedridden and looked to weigh not much over a hundred pounds. She was continuously connected to a subcutaneous line of morphine. She was being looked after by hospice care women who were not professional nurses -- although she was visited by doctors & nurses several times per week. Most especially she was taken care-of by a warmhearted neighbor woman whom I will call Neighbor and by her daughter, who I will call Daughter.
Both Daughter and Neighbor are Jehovah's Witnesses. Daughter regarded cryonics as Evil and a fraud, but she was in no position to oppose her mother's wishes -- although her hostility to us was sometimes evident. Neighbor loved Ms. Professional and was devoted to respecting her friend, looking after her comfort and assisting in fulfilling her wishes -- including cryonics. Neighbor sat with Keith, Christine and me around the bed of Ms. Professional -- but Daughter was not there at the time. Daughter wanted nothing to do with cryonics and preferred to avoid being around at the last moments of her mother's life for that reason.
(I made no attempt to argue with Daughter in any way, but I find it unfortunate when religious people assume that cryonicists are The Evil Enemy. Many of the very most active people in the Cryonics Institute are of strong Christian or Jewish belief and feel that cryonics is an advanced medical procedure which is not in conflict with religion. It is unfortunate that many people regard Cryonics or Heart Transplantation as "playing God" because medical science cannot advance in such atmosphere. Neighbor was the Soul of Goodness, helpful in every way and extremely friendly to each of us on the cryonics team. She truly exemplified "God is Love".)
I briefly again tried to explain how much better it would be if Ms. Professional could move to Michigan, but she quickly dismissed the idea. Keith made a remark about how when she is reanimated that her toothless mouth could be filled with diamond teeth, but she seemed uninterested. She did, however, warm easily to Christine, who is not only a cryonicist, but an emergency care nurse. Christine has a wonderful bedside manner, showing interest not only in the cryonics procedures, but in comfort & well-being. Christine suggested Gravol suppositories since Ms. Professional was even vomiting her Gravol. Christine review other medications and gave advice. In the end, our patient said, "I'm counting on you, Christine."
Ms. Professional's prospects certainly didn't look good. She was drinking no more than a cup of water per day, a half-cup of beer, occasionally sucking on a popsicle and getting a spoonful of creamed cereal. This had been going on for ten days and she was vomiting much of it. I did not think that she could live more than a week under these conditions. I was on pins & needles for the entire week following this Friday. I slept with my pager by my ear and encouraged Neighbor and the hospice people not to hesitate to page me at any hour of night or day. Every time my pager went-off my heart stopped. I informed my employer that I might be leaving on short notice at any time -- I could be at the apartment in half-an-hour.
The next day (Saturday) with the assistance of Toronto life-extensionists Gary Tripp and Brent Erskine I was able to rent a truck and move all our equipment into the apartment of Ms. Professional. We also bought two ice-chests. Both Gary & Brent are enthusiastic and intend to sign-up for cryonics.
On Sunday I was unable to talk to Neighbor about the current status because she had inadvertently turned-off her cell phone. I was sick with worry so I phoned Ms. Professional directly and asked her how she was doing. She simply said, "I'm dying" and hung-up. Later I learned that she had a difficult night because she had taken my call as a sign that she was close to death. I felt terrible and this increased my nervousness about making ANY contact with her -- making me more of a "lurker". Although Ms. Professional sincerely wanted be cryonically preserved, she associated it with death. She never really saw me in a positive light and I ended-up feeling that she perceived me as a vulture circling in the air -- anxious to feed on the carrion.
The cryonics kit I inherited included most of the medications for suggested use to prevent ischemic damage, edema, etc., as described on my website: Emergency Preparedness for a Local Cryonics Group
But when I told Robert Ettinger about my plans, he expressed skepticism -- CI normally uses no meds other than heparin. Robert consulted with CI's cryobiologist Dr. Yuri Pichugin who disagreed with my assertion that ischemic damage is potentially far more damaging than any damage incurred in cryopreservation. Yuri said that the most harmful factor is ice crystallization and that if Nanotechnology can fix freezing damage it should be able to fix ischemic damage. Robert Ettinger agreed, saying that cryothermic damage is much more important than warm ischemic damage in almost all circumstances.
I had no choice but to comply. Robert also had legal concerns. I don't think that Vitamin-E emulsion or mannitol would be a legal problem if heparin is not, but I probably would have given curare to prevent shivering (lower metabolism). In retrospect I realize that this had the possibility of being contentious insofar as the curare would be lethal when given to a living person and has the potential of raising suspicion of being given pre-mortem to hasten death. Also, if I had tried to give a cocktail of medications rather than just heparin this would have raised the anxiety of the physician, nurse and other health professionals who may have ended-up not even giving heparin. So it was probably for the best.
As things stood I was worried enough that a nurse would be on duty when the patient deanimated and that we would be able to get a declaration, get heparin injected & do a rapid cooldown. It would have been good to get Ms. Professional to take some pre-treatment with Vitamin E and aspirin, but she was having enough problem ingesting anything (and aspirin could have been especially irritating). I took the day off work on Monday to attend the training session given by CI's Michigan Funeral Director Jim Walsh to the Toronto Funeral Director's staff. I felt that I could only sacrifice this and one other vacation day (the day of deanimation). David, a cryonics friend from New York, joined me.
The Toronto Funeral Director had a staff of four, all of whom appeared to be in their 20s. There were two women, whom I will call Sweet & Sour on the basis of their apparent temperament. And one of the two men was the cheeriest looking embalmer you could expect to meet -- whom I will call Cheerful.
Jim Walsh was delayed an hour at the Canadian border by authorities concerned about the perfusate. But he finally arrived with the perfusate, plus a perfusion machine, a shipping box and a Michigan Instruments heart-lung machine ("thumper"). He gave a demonstration of the assembly and operation of the thumper -- and explained the perfusion device and the perfusate, describing the ways in which the process differed from their usual morticians' procedures. He said how much he wished that all corpses could be infused with heparin immediately because clotting normally creates so many problems during embalming -- and the others concurred. He answered technical and procedural questions and attempted to ensure that all concerned were clear on what is required.
After the training session David drove me to pick up another oxygen bottle which we delivered to the patient's apartment along with the MI thumper. Christine had told us that there are usually (but not always) predictable signs of impending death in cases such as this -- not so sudden as with a heart attack. Christine later decided that every effort should be made to get future patients into a hospital to benefit from monitoring equipment.
I was wanting us (our local cryonics team) to have a presence in the apartment both for early warning and to improve our familiarization with the situation and of the hospice people with us.
I requested that Sophie be the first cryonics person to spend time doing standby in the apartment. Sophie is quite genial & soft-spoken so I thought she would be a gentle introduction for our team. Sophie spent Wednesday and Thursday evening in the apartment. Ms. Professional treated Sophie as if she were the chief caregiver. Sophie's presence evidently raised the consciousness of the hospice people that they really did not know what they were supposed to do in a cryonics case. This evidently upset Ms. Professional who passed the word to her son, who then began contacting CI and the funeral director to make sure everyone knew what should be done. One good thing that came out of this was that I had a very supportive phone call from the head of the hospice group. She said that if Ms. Professional wanted cryonics, their people would do whatever was required.
Neighbor also expressed concern to Sophie that the Heart-Lung machine might actually cause Ms. Professional to regain consciousness after declaration of death. Christine had told me that this was unlikely since our patient would probably go into an irreversible coma some time before deanimation. Our heart-lung machine does not deliver more than a third of normal circulation, but I did become concerned. The cryonics organization Alcor was originally giving barbiturate not only to reduce brain metabolism but to preclude this kind of disaster. Currently they use propofol for the same purpose -- which does not have the stigma of being a narcotic.
I arranged for Brent Erskine to spend the day Thursday, Gary Tripp to spend the day Friday and myself to spend the day Saturday in the apartment. I eventually wanted 24-hour coverage, but the hospice people were concerned about having a man in the apartment overnight with female staff. Frankly, there did not seem a great advantage in having one of our cryonics people on hand when they would be helpless to do anything without a nurse to declare death. It would probably take us less time to get there in an emergency than to get a nurse with authority to declare.
On Thursday Neighbor informed me that the patient had taken a turn for the worse with severe vomiting and incoherence -- and was close to death. I was urged to implore the son to get 24-hour nursing care for her mother -- both for her well-being and to have the authority to declare. I could reach the son by e-mail, but he was impossible to contact by phone -- I always got an answering machine and only once did he return a call. Only I seemed to have his e-mail address. (He was not on good terms with his sister, Daughter).
Sophie was still of the opinion that Ms. Professional could last weeks. Friday I spoke with the physician who seemed to think that nausea & vomiting were the the most immediate problems. He was putting the patient on a continuous subcutaneous infusion of anti-emetic. Under these conditions she might even begin to eat & drink again and perhaps live for weeks. After having spent a week in a high-strung condition began to think that the situation was far less urgent and impending.
The funeral people had been on alert all week. I appraised of them what the physician had said. The funeral director had been concerned about loading-up on dry ice only to see it evaporate. I also e-mailed Ms. Professional's son saying that 24-hour nursing care appeared to be premature if it was not an expense that he could easily bear -- knowing that it was always possible that the patient could die at any time.
I was certainly not wanting to rush the death of the patient, but I was becoming concerned about the availability of our cryonics volunteers as well as concerned about the patience of the funeral people and how they would feel about accepting a future cryonics case. Sophie told me that she had other things to attend to and could not do standby again for more than a week. My own nerves were becoming blunted. Gary, by contrast, had made arrangements to take the following week off work so he could spend time in the apartment. I feared this might be a waste if our patient lived 2 or 3 weeks and Gary would be back at work when deanimation occurred.
(At least twice Alcor has done a standby lasting about three weeks and finally removed the exhausted teams -- only to have the patient deanimate within a couple of days.)
On Saturday I went to the apartment and Ms. Professional was quite lucid. When I asked her how she was doing she did not answer -- giving me the look of death. But when I asked her for her Social Insurance number she gave Neighbor detailed instructions on where to find it. When I told her that I wanted to test some of the cryonics equipment and that it might be noisy she encouraged me to do the testing.
I spent most of the day reading, but I also was able to assemble and test the Brunswick Heart-Lung machine and assemble & disassemble the Michigan Instruments thumper. I left the Brunswick assembled (connected to the oxygen tank). Gary joined me and was very helpful in wiring the Brunswick to the gurney. He also insisted on filling the ice chests with ice. A nurse installed the anti-emetic subcutaneous line. Not long thereafter Ms. Professional was wanting a drink of beer. Gary cautioned her against this because alcohol is dehydrating and the anti-emetic would probably require more time to take effect. Ms. Professional objected that she was beyond worrying about her health, but had second thoughts about her immediate well-being. She then requested that the beer be set aside for a while and that she be given water. I was as impressed by her rationality as I was by the good relationship that Gary had created with her.
Since the patient seemed to be in such good condition, none of our cryonics people stayed with her on Sunday. On Monday Gary phoned my workplace from the apartment to say that Ms. Professional seemed to be in good shape and that the ice in the ice chests had not melted. But late in the afternoon Gary phoned again to say that our patient was deteriorating and would probably not last more than 24-hours. A nurse was being called for overnight coverage who would arrive at 7pm and install a lock (venous port for injection of medications).
Gary wanted to spend the night, and wanted to go home to get some bedding, but did not want to leave the patient alone. I told Gary that I would come later in the evening -- and was making plans to take the following day off work. But at 7pm Gary phoned again saying that things had become very critical and that I should come immediately. I left for the apartment, but still had not grasped how critical the situation really was.
When I arrived at the apartment the patient was in the gurney and the Brunswick was running. The nurse had declared death and injected the heparin into the lock while Gary was operating the Ambu AC/DC cardiopump on her. Gary and the others had then placed the patient in the gurney. I was awe-stuck and impressed (and still am) at how efficiently Gary had carried-out this entire operation. He is a Cryonics Hero!
The gurney only had ice-cubes, so I added some water and more ice. I tried to keep the ice-water circulating by bailing water on the patient. I was struck by how "dead" she looked -- and it gave me a sense of hopelessness and futility. Perhaps her own feeling of defeat by death was part of what I saw in her face. Gary later told me that about half an hour before she deanimated she told Neighbor "I want to die". Later Christine arrived and she was soon tilting the patient's head back to improve ventilation -- something I had thought about earlier and had forgotten in the heat of the moment. I had also purchased rubber gloves, but we were not using them until Christine raised the issue. I also wish we had had a means of monitoring the patient's temperature as well as the temperature of the water.
Gary, Christine & I were soon all working together to keep Mrs. Professional cooling and well-ventilated. By now we were somewhat more relaxed and chatting good-naturedly. Gary was saying that I am the expert and I was talking about the difference between being an expert and being a hero. I was startled when Neighbor suddenly began to cry. I never asked for an explanation, but in my imagination something in her Jehovah's Witness soul was touched by the caring that cryonicists could express by their actions and the goodwill they could express to each other when working together.
The patient's head was resting on ice bags, but could not get full benefit of the moving ice-water. It would have been awkward to splash the head -- and difficult to do so without splashing Christine. At least the head was being cooled by cold blood pushed up by the thumper. A cryonics professional later told me that I should have stuck a thermometer in her nose and not turned her over to the funeral people until the temperature was just above freezing.
I was told that a physician was on the way to sign the death certificate so I phoned the funeral director. Soon thereafter Neighbor pointed-out that one side of the gurney was coming unfastened from the weight of the water, the ice, the patient and the equipment. Although Gary and I were able to secure it, I am certain that the gurney would not be suitable for a heavier patient. There was another problem when the oxygen tank ran out of gas, but we were able to get the other tank hooked-up in about a minute.
The funeral people arrived shortly before the physician -- it was Sweet & Sour -- but they waited until the physician had signed the death certificate. The physician insisted that he be given a nice table to sit at before he would sign anything. He really gave the nurse the Third Degree about her declaration of death and I was sorry to see her endure this treatment. But after extracting his pound of flesh the physician signed the certificate and gave it to Sweet.
Sour seemed resentful of my involvement, but relented when she was unable to properly assemble the Michigan Instruments thumper. I did some fumbling with the oxygen hookup for which she sharply criticized me, but she was very intelligent & competent and we made a good team.
The patient was then rolled out of the room on the stretcher with the MI thumper in operation and me carrying the oxygen. But the set-up would not fit into the elevator and they had to remove the thumper. We rushed out of the elevator to the funeral van in front of the building and re-assembled the thumper on Ms. Professional. Sour then told me that I had to get out of the van because I was not licensed to ride in it. I did not like the idea of leaving the patient, but I had no choice.
I was uncertain whether we would even be allowed to watch the perfusion, but I wanted to rush to the funeral parlour anyway. I wanted to learn as much as I could from the experience. Back in Ms. Professional's apartment I dumped most of the ice & water out of the gurney into the sink until I felt the remainder was not enough to worry about. Then Christine, Gary and I rushed to Christine's car and she drove us to the funeral parlor. Christine saw no point in going-in, so she drove home.
In the funeral parlour Gary & I saw our patient in the first stages of perfusion. Sour was gone and Sweet was just leaving. The funeral director and Cheerful were doing the perfusion. The perfusion was a 2-stage process -- first an hour doing the head, then an hour doing the body. The head perfusate was pumped-in through the carotids and out the jugulars in 5 boluses: 5 liters each of washout, 10% & 20% glycerol and then 8 liters of 40% and 12 liters of 75%. (That is the protocol for a CI patient up to 200 pounds, but since Ms. Professional was small she used less than these volumes. The complete CI washout/perfusate formula is given on page 5 of the May-June 2002 issue of THE IMMORTALIST.)
The patient's head was resting on ice-bags, but otherwise there was no special attempt at cooling -- and the room was not particularly cool. But the perfusate was cool because it had been stored in the fridge. Cheerful and the funeral director said that the heparin had worked like a charm -- there were no clotting problems and the perfusate was flowing uniformly.
Realizing that there was still no dry ice I attempted to phone a dry-ice supplier who was reachable by pager. I thought that they would get us some dry ice if we told them it was an emergency and offered to pay extra. But the supplier said that no one in the city could provide dry ice at that time of night and that he could only deliver first thing in the morning. I ordered a hundred pounds for dry ice for morning delivery. The patient would be stored in water ice for 8 hours in the fridge along with the corpses that required 40ºF.
Gary had been wanting to use dry ice in the ice bath, thinking that it would lower water temperature more quickly than water ice. But this difficulty in obtaining dry ice in the evening (and presumably on weekends) increased our concern about dry ice for non-American groups -- which so often have shipping delays and require local perfusion. We were told that dry ice cannot even be stored in an ice-chest for more than 24 hours without complete evaporation. This means that a local group could only have secure dry ice availability by having a dewar for storage.
Cheerful told me that what they were doing -- dehydrating the patient -- violated all of the principles they were taught. He said deviation from standard practice was only justified because the patient was classified as an Anatomical Donation. She certainly did look dehydrated. Her head was very "bronze" looking. Andy Zawacki (CI facilities manager) later told me that their sheep-head experiments had taught them that the bronzing corresponds with good preservation in terms of reduced cracking and better electron micrographs.
Ms. Professional was shipped to the Cryonics Institute in dry ice the next day. The death certificate & transit permit had been obtained in short order and there was no undue delay at the border. At CI she was held at dry ice temperature for two days before spending a week in liquid nitrogen vapor to cool her to liquid nitrogen temperature for long-term storage.
Unfortunately I had not dumped enough of the water & ice from the gurney. Evidently the gurney began leaking (it had not leaked when we were using it -- the plug may have come loose) and awakened the neighbors below Ms. Professional's apartment when water came through their ceiling at 2am. I accepted accepting full financial responsibility for the costs -- but Gary offered to pay half. Fortunately another member of our Toronto local group paid the water-damage costs as his contribution to the case.
I certainly made a lot of mistakes, and the preservation left a lot to be desired, but I have kept reminding myself that without my efforts the situation would have been much worse. The majority of cryonics patients are not so lucky as to get rapid pronouncement, immediate heparin injection, heart-lung resusitation and cooldown shortly after deanimation. We were amateurish, but there are few professional in cryonics and one must start somewhere -- especially if far removed from a cryonics facility and when a long & unpredictable standby is required.
I don't feel terribly proud, but neither do I feel too ashamed. Ms. Professional had every opportunity to get more professional treatment by moving to Michigan to de-animate -- as I urged her to do. By remaining in Toronto she put herself at the mercy of amateur volunteers whose donated time, effort and ability were untested and unpredictable. So she must bear some responsibility if her preservation was not as good as it could have been.
I hope someday that Ms. Professional can be reanimated to a healthy and youthful condition. And I hope that I have the opportunity to experience her sharp intelligence under better circumstances.