X-Message-Number: 33370 From: Date: Mon, 28 Feb 2011 01:28:13 EST Subject: Melody Maxim's Distorted Reality 5 Content-Language: en Melody Maxim writes: Mike Darwin: "Your remarks about unreliable and malfunctioning in-house fabricated circuits certainly don't apply to my experience of nearly 25 years. I have never had a circuit fail - never. I have had an oxygenator fail, but that is really the only mechanical failure I've ever had on CPB. One qualification is that the Sarns venous reservoir bags did not have a rigid, internal fenestrated intake line. This meant that under high flow conditions the bottom of the bag around the orifice feeding the pump would sometimes collapse and cut off flow. This problem was remedied by switching to the Gish/Terumo bags." One of the key figures in the perfusion group SA is said to be working with is a prominent figure in the perfusion community. He's the co-author of a book that can be found in the lab coat pockets of a large percentage of clinical perfusionists, and is required reading material for many perfusion students. At the risk of being rude, I doubt his perfusionists need Mike's advice, regarding which reservoir bags to use. I believe Mike's persistence in naming as many specific perfusion devices he can, and remarking on things like "internal fenestrated intake lines" to be a major distraction from the REAL issues the amateurs working in cryonics, or the people reading this forum, need to be concerned with, (like the basics of maintaining proper perfusion pressures and preventing air embolization). Given that SA starts with a known volume of solution, it should be easy to determine, (even during a case), if the flow rate is approximately accurate. For the washout procedure, would it really matter if the flow were actually 3.2LPM, when the flow meter was reading 2.9LPM? For as long as you have good patient pressures and no air is getting pumped to the patient, the proper answer to that question would be a definitive, "No."" Mike Darwin: These remarks are not so much rude as ignorant. I'm glad SA has such a fine perfusionist. But, no matter how good this man is, he will almost certainly not have expertise unique to and essential to proper extracorporeal management of cryopatients. How could he? No patient presenting for clinical CPB even approximates the average cryopatient presenting for TBW and/or asanguineous ECMO. Even within perfusion there are areas of specialization that require additional knowledge and training: extended ECMO, emergency fem-fem CPB, neonatal and pediatric CPB, and normothermic CPB, to name a few. What is so extraordinary about the idea that cryonics should be the same? As just one small example, Ms Maxim had no idea how or why conventional CPB flow meters worked, or that they would not work in cryonics. That comparatively trivial lack of knowledge resulted in the following (quoting Ms. Maxim): When the flow transducer would not work with CI's solutions, I attempted to persuade Ben to allow me to find another way to measure the flow. There are other ways, and I felt the safety of the centrifugal pump, (it makes it virtually impossible to pump air to the patient), far out-weighed the inconvenience of finding an alternative for measuring flow. I did not try very hard to convince Ben, because I sensed he was uncomfortable with the pump, and I felt certain there was no way for me to make him comfortable with it, in the three short days I would be there. He seemed quite happy with the occlusive (roller) pump I had helped him acquire, so I volunteered to purchase the centrifugal pump back from CI. I told Ben I wanted to do some experiments with the pump, and I did, but the main reason I wanted to buy the pump back from CI was that I did not want them to be out $1,800 for a pump they purchased on my advice, but would not be using. I even paid for them to ship it to me. To summarize, the costs of this lack of existing knowledge were at least as follows: 1) Time and effort lost acquiring a pump that was not useable. 2) Any time and effort lost trying out others methods of determining flow that have already been explored and found unworkable. 3) Money expended needlessly on the system and on shipping it to and fro. 4) Loss of credibility that results when others learn that these problems had already been extensively explored in cryonics and that that information was readily available, some of it on the Internet. 5) Knowledge of new, scientific/industrial ultrasonic flow meters that may well work for cryonics applications (but which have not yet been tested). Melody Maxim writes: Mike Darwin: "One last point I'd like to make is that it is important to consider the context of the times. SA has, by any standards in cryonics, vast amounts of capital and human resources. Most of the history of cryonics has been one of negligible capitalization and in most of the world this is still the case. The SCPC system is lovely, but the question is, is it affordable for most cryonics operations not heavily financially subsidized?" Now, THAT'S a damn good question. However, it's long been my opinion that, if we are able to improve the quality of patient care in cryonics, the science will gain a wider acceptance, and more money will come in. (Sort of an "If you build it, they will come," kind of thing.) SA has the funding to provide quality equipment and qualified personnel to operate it. Would Mike have them remain in the dark ages and rely on self-taught amateurs with makeshift equipment, just in case the funds dry up? I think I have a better suggestion: SA could save hundreds of thousands of dollars each year, by cutting their staff to two full-time people managing a well-manned, well-maintained standby team of professionals. The professionals would determine what equipment will be used, and if anything needed to be built, it could be contracted out to reputable engineers who would deliver the projects within a specified time- and price- range. The professionals would be able to write their own case reports, so SA wouldn't have to pay a science fiction writer to make them look like fools." Mike Darwin: I'm in agreement with most of these sentiments, but not the idea that if you build it they will come in the sense that cryonics will instantly or even soon be transformed into a medical-professional undertaking. Here's the irony: Ms Maxim and many others took cryonics seriously enough to get involved because it APPEARED that biomedically sound perfusion technology was actually being used by some extant cryonics organizations. That that appearance was even possible was almost solely a result of a time in cryonics when such sound, medically-based perfusion practices were in fact being used. When Jerry Leaf and I were no longer present the patina of biomedical credibility was sustained, but NOT the reality. That reality, when it existed, used both professional medical personnel and in-house trained personnel. These people were trained to do perfusion procedures of sharply limited complexity to very high standards with safety as the core goal. No, they could not pump a clinical CPB case, just as a paramedic cannot manage a patient in septic shock in the ICU. However a paramedic CAN successfully manage a patient in septic shock long enough to get him to the hospital ED. Paramedics are not made in a weekend and neither were the (very few) in-field CPB techs we trained. In fact, NONE OF THEM WERE EVER USED; either Jerry or I did or supervised every TBW done during our tenure at either Alcor or BPI. The primary (and successful) use of the in-house perfusionists we trained was to mind the pump during dog research. This was a demanding and essential job which we could not afford to pay professional perfusionist to do on a long term basis. In a broader sense it IS true that if you build it they will come.' That sense is that IF you have a medically sound practice of cryonics which is rational and evidence based, then a few medical professionals will be attracted to cryonics and will not run away in disgust at what they find. A few of these people will stick around and get involved. Cryonics was lucky that two such people stayed around and worked to improve things DESPITE the horrible state it was in. The Chamberlains, Art Quaife, Jerry Leaf, myself and others are examples of this at different times in different places and in different ways. Melody Maxim writes: Mike Darwin: However, no amount of technology will protect you from incompetence and lack of skill. I couldnt have said it better, myself!" Mike Darwin: This has been my point since at least 1978. Even very crude equipment can be using with surprising safety and effectiveness if you have competent and experienced personnel. Ive seen CPB done safely in the Third World using procedures and equipment that would shock any Western perfusionist including using the same circuit for 3 different patients (all with the same blood type and cross-match compatibility) with no safety equipment and nothing to monitor CPB but a manometer, an oximeter and pH meter (no blood gas equipment!). Content-Type: text/html; charset="UTF-8" [ AUTOMATICALLY SKIPPING HTML ENCODING! ] Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=33370