X-Message-Number: 602
From: Keith Henson
Subject: Transport of Patient A-1312 (Part 2)

[ Part 2 of 2 - KQB ]

The Transport of Patient A-1312
by H. Keith Henson

In addition to the transport team, we had several helpers available to 
move Dennis from the bed to the PIB.  Dennis was a large guy (215 lb.), 
and while he was wasted in the upper body, he was *really* edematous in 
the legs, with a massive abdomen from his cancer-invaded liver.  Moving a 
person of that size can be nearly impossible.  We did it by the sheet- 
pickup method, and lots of helpers; I seem to remember 4 on each side.  
(A week later, at a memorial at our patient's house an old friend of mine 
repeated the aphorism that a friend is someone you call to help you move, 
and that a *real* friend is someone you call to help move a body.  We had 
lots of real friends that day.)  Moves of this type need to be carefully 
planned out in advance, and everyone told exactly how it is going to be 
done.  In this case, he went out over the end of his bed, and back over 
the end of the Pizer tank.  I removed the IV pole from the MALSS so it 
would not be in the way, and stuck it back on when they had him placed.   
The HLR was on Dennis in about 2.2 min from the time he was pronounced. 

Afterwards Leonard recommended that we measure our patients and adjust 
the HLR base to fit.  We had significant problems with the HLR plunger 
moving out of position during use--partly because the massive liver and 
ascites made the chest slope toward the neck.  As a result, the plunger 
walked upwards and twisted sideways, requiring frequent readjustment. 

In a matter of seconds, ice and water were dumped into the portable ice 
bath on top of the MALSS cart; within 2.5 minutes of his being pronounced 
the HLR was started.  The transport medicines were administrated through 
an indwelling Quinton catheter which had been left in place for us.  
Shortly after we started the HLR, the hose blew off the plunger.  I put a 
cable tie on it after Leonard stuck the hose back on.  Arel had trouble 
keeping the airway open, but she learned that when she could hear a death 
rattle the end-tidal CO2 monitor showed good oxygenation, and the only 
way she could keep the airway open was by hyperextending the neck.  This 
had to be done regularly to avoid poor ventilation.  After a couple of 
these adjustments, a lap pad was rolled up and placed under the patient's 
neck as a bolster.  To augment Arel's suggestion that a bolster should be 
included with the ice bath, Tanya made a better suggestion of an 
adjustable strap on the PIB to correctly hyperextend the neck for better 

It took a lot of strength from Joe or Leonard to keep the mask sealed to 
the patient's face because of facial wasting (which was also the case 
with Arlene Fried, whom we stabilized two years ago--taping the mask on 
didn't work because Arel had failed to put the tape all the way around 
the head, and because the water soaked it off, but an elastic or Velcro 
strap such as that used earlier on the patient's oxygen mask might have 
helped).  We should have intubated him, but what we did worked OK, and 
Mike, the only person who could have done it was otherwise fully 
occupied.  (We discovered during the glycerol perfusion the next day that 
the patient's head had been bruised, probably by being pressed against 
ice in the bottom of the bath because of the pressure needed to seal the 
About an hour into the stabilization the first cylinder ran out of 
oxygen.  There was a quick change of cylinders, and everyone vowed next 
time to put a regulator on the second cylinder *before* the first one 
runs out. 

While Leonard, Joe, and Arel were busy at the head end, Naomi was 
injecting the transport meds.  It was not until after the suspension that 
Naomi realized that she had forgotten to continue to add medications 
after the initial boluses and continuous infusions were set up.  During 
this Mike and I were doing a cutdown. (Tanya was taking notes, and Carlos 
was video taping.)  Dennis was very edematous, and his vessels were deep, 
over an inch.  We used up every gauze sponge we had in the kit and the 
ambulance trying to keep the operating field dry, and had use for the 
suction when we had a bleed.  The night before one of the nurses and Mike 
had spent a lot of time trying to find a pulse from these vessels, and 
had failed.  We tried on the side which had been used for chemotherapy 
infusions, and gave up. (In retrospect, we almost certainly did not go 
deep enough).  We cut into the other side, and eventually located a 
vessel with a clot in it, but no artery.  After enlarging the incision 
both directions, and cutting down to muscle in some spots, we finally 
found the femoral vein.  Cutting through tissue that edematous was a real 

Once we exposed the vessels, Mike had to tie off a number of small 
branches to get down to the femoral artery.  After tying off the distal 
ends, ligating the vessels and putting a small clamp on the proximal end, 
Mike clipped partway into the vessels (one at a time) with scissors.  He 
cut the vein first, and then the artery.  The cannulas went in with each 
of us holding one side of the vein or artery.  I managed to screw up and 
backed out the arterial cannula in error. 

Cannulas need to be *securely* tied down, because having one come out is 
very, very hard on the patient.  (I.e., in about a minute all their blood 
is gone.)   Operating an ECMO circuit is tricky; for one thing, you have 
to be sure to get all the bubbles out of the circuit where the tubing 
splices into the cannulas.  This is done by filling the end of the tubes 
and the cannulas from a syringe filled with saline.  When we finally did 
get things hooked up, it was a relief to see that the arterial blood, and 
even the venous blood was well oxygenated.  Hats off to the head-end 

The nurse who pronounced stayed and helped as scrub nurse.  It is 
impossible to say enough good things about her.  She was a welcome and 
valuable asset to Mike.  (I was green as grass as a surgical assistant).  

When we got the ECMO circuit hooked up, the patient's temperature was 
still rather high.  He went on bypass after an hour and 45 minutes with 
an arterial temperature of 23.2 deg. C.  (Far too much time to do a 
cutdown, but about the same as Arlene because of the time it took to 
transport her to a mortuary for the cutdown and washout.)  Arlene's 
smaller mass had cooled much further in that time.  Bypass greatly 
increased the cooling rate, though we could have used a larger heat 
During the surgery I noticed a few problems with the squid (ice water 
circulator).  Dennis, being such a large guy, took up the entire tank 
from side to side.  This caused the water to pile up on the head end, and 
not flow fast enough to the foot end where the pump intake was located, 
so the pump tended to suck air while the head end of the tank flooded.  
Two lengths of 2-inch plastic pipe about 4.5 foot long placed in the 
bottom of the tank would help get the water back to the foot of the tank 
and the pump. 

The heat sink for the blood heat exchanger is water in the Pizer tank.  
This works, but you need to watch and be sure there is plenty of ice 
where the water is flowing.  A lot of ice was melted between the intake 
and outlets.  I suspect that the heat transfer water was not as cold as 
it could have been, i.e., it was above 0 degrees C part of the time. 

Another improvement for getting heat out of the patient would be to put a 
grid of small pipes in the bottom of the PIB, and draw or release water 
through them.  This would prevent blocking the heat flow out of the 
patient's back by pressure on the bottom of the tank.  Large people just 
cool slowly from the surface.  By the time we had completed the cutdown 
on Arlene Fried she was at the washout temperature.  It took about the 
same time to get Dennis hooked up, but it took considerable additional 
time recirculating blood to get him down to washout temperature.  It just 
takes longer for a person with three times Arlene's weight. 

When the patient was cooled to about 12 degrees, Mike started dumping 
treated Viaspan into the bag reservoir on the MALSS cart, and opened the 
venous return line to begin the Viaspan flush.  He had hooked up an 
additional large-bore dump, but the special Viaspan spike broke off in 
the first bag.  We jury-rigged an IV spike replacement (which leaked some 
Viaspan on the floor) and used a small-gauge port as well.  The Viaspan 
flow rate was very slow, and Mike had to keep turning the pump on and 
off.  At one point he got distracted, and air was sucked into the system, 
but fortunately none got into the patient.  A cross-connect line at the 
patient end would have been a blessing to get the bubbles back in the 
reservoir.  In spite of all our troubles, which included blowing the 
tubing off the oxygenator and putting more Viaspan on the plastic sheet, 
we got all but one or two of the Viaspan bags into the patient.  Mike 
saved these for buffer for the trip to Riverside.   

Even with all the cold Viaspan, the patient was still at a little higher 
temperature (4.1 deg C) than desirable for transport, but we had to go.  
Fortunately we still had plenty of people around, because we used them to 
move the MALSS cart down a step, and take much of the weight off the 
overloaded wheels as we moved it to the ambulance.  (The MALSS cart 
started life as a *gurney*.)  We bailed out the PIB, and removed much of 
the ice for the short move to the ambulance, still, the MALSS cart and 
Dennis weighed about 800 pounds. The lift gate on the ambulance worked 
great; whatever was paid for it, it was well worth it. 
During the transfer to the ambulance and for almost the entire drive to 
Riverside, Dennis was maintained on low-flow circulation.  The MALSS cart 
has two large deep-cycle batteries and a charger built in.  We kept the 
cart hooked up to AC power until we left the house.  That left enough 
power in the batteries to run the cart for many hours.  Dennis arrived 
with no rigor, an indication of adequate metabolic support all the way.  

We (Mike, Carlos, Tanya, Arel, Keith, and Naomi) managed to get on the 
road at 9:16 pm. I drove the ambulance from Dennis' house to Stockton.  
After getting out of the Bay Area we hit a solid wall of fog.  What with 
the lack of sleep, I was fading and felt my competence to drive fast into 
dense fog was lacking, so I swapped with Carlos and drove the van 
(following lights on the ambulance) for a while.  At a gas stop Arel took 
over driving, and she lost the ambulance in dense fog.  (The unholy rush 
down Interstate 5 was to get the patient to Alcor before the contract 
surgeon had to leave--although Arel didn't know this.)  We drove on a for 
a while then swapped again after picking up gas at Kettleman City.  The 
fog was so dense at Kettleman City that you could only see one of the gas 
stations at a time.  I made it almost to the Grapevine before deciding 
that going any further was going to result in a wrecked van.  We pulled 
off the road, called Alcor from a phone, and got a nap between 4 and 5 
am.  The cold woke us up and we reached Alcor close to 8 am, an hour and 
a half behind the ambulance, and just as Saul was rushing the contract 
surgeon to the airport.  He had only managed to get part of the perfusion 
"plumbing" in place, but Mike was able to take over and complete the job.  
I know we may have to make do with contract personnel, but I sure am not 
happy about it.  Arel had the shakes from lack of sleep and sheer terror, 
and since there were plenty of OR people available, she appropriated one 
of the beds in the crew room for the next three hours. 

Wasted as I was, I felt I could not go to sleep, so I scrubbed and dried 
the PIB on the MALSS cart, and got the cooling setup together and down to 
temperature.  Later I had to get into scrubs and help Mike, Hugh, and 
Arel with the cephalic isolation. 

During the operation Mike took over he had a serious problem with the 
aorta's tearing, but he was able to clamp off the tear.  How well our 
patient had been supported was apparent from the complete lack of brain 
swelling.  All three of the last well-supported patients have lost a 
profuse amount of fluid from the bur hole (used to see how the brain is 
perfusing.)  Almost the entire perfusion circuit withdrawal amount (which 
sets the rate at which cryoprotective glycerol is introduced) was going 
through the bur hole.  We almost certainly did not transect a blood 
vessel on the brain or in the dura.  It is possible that this behavior 
just may be normal for uninjured brains. 

Dennis perfused beautifully to a 4.5 molar glycerol concentration with no 
brain swelling; in fact, the bur hole and x-rays indicated a little  
shrinkage.  Such a good perfusion was the result of a number of factors; 
Cynthia's complete cooperation, Dennis' personal physician who wrote 
pre-mortem prescriptions to limit ischemia damage, an incredibly 
cooperative nurse, relatives who started out semi-hostile and became 
supporters, a number of friends, a team which could recover from glitches 
minor and major, and a large amount of luck. 

After a suspension I always take time to reflect on how things went, and 
how we might improve them.  This one, coming just before Mike Darwin's 
resignation became effective, has more the flavor of "can we ever do this 
well again"?  I think we can, but it is very clear to me that a lot of 
hard work (and money!) will be required to even partly replace the skills 
and leadership we have lost. 


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