X-Message-Number: 697
From: Henson/Darwin
Subject: Neurosuspension of Patient A-1260 (Part 2 of 3)

    Early on the morning of the 16th a call came in to Alcor from Jim and 
the RN attending Nick.  They reported that Nick's condition was very 
grave and that death seemed imminent.  A decision was made to involve 
Mike.  Mike was put in touch with Jim and the attending RN.  At that time 
Nick was unconscious and in deep shock with a blood pressure of 40/0, a 
respiratory rate of 3-4 a minute, and pupils which were only sluggishly 
responsive to light.  Since the suspension team could not be on location 
for a few hours and additional preparation to the MALSS cart and 
ambulance were needed, Mike asked the attending nurse if he could pour 
what prescribed IV fluids they had available into Nick to reverse his 
shock and give Alcor more time to set up.  Without this timely 
intervention, it is almost certain that Nick would have suffered hours of 
ischemia before an Alcor team could arrive.  As we know from previous 
unlucky patients, this would have resulted in a very poor quality 

    Since it was by no means certain that Nick would respond to fluid 
resuscitation, it was decided that Mike should come into the lab, and 
assist finishing up preparing the MALSS and setting up the operating room 
as quickly as possible.  Mike and Hugh worked throughout the night to get 
this done.  At about 8:00 a.m. a call came through that after he had 
stabilized, Nick was again deteriorating and that the transport team 
should come at once.  By this time the equipment and team were almost 
ready to depart, although several critical items were still not in place.  
They were delayed approximately another 45 minutes to an hour before they 
could depart. 

    On hearing the news, Arel, Leonard Zubkoff, and Keith flew into the 
Los Angeles area.  The available staff members drove the ambulance with 
MALSS cart over to Jim and Nick's home, and Max More was recruited from 
his university job for the standby.  By 11 a.m. on Tuesday we were on 
site and ready to go. However, nearly 2 liters of IV fluids had reversed 
Nick's shock and yanked him a good ways back from death's door.  He even 
got out of bed for short times that day.  It seemed we were in for an 
indeterminate wait, but after the scare, nobody was about to complain.  
Keith used a little of the time to check the calculations Max and Tanya 
had worked out on the transport medications against a medication spread 
sheet he had created the week before, and all were right on. 

    The team used the time to check over readiness, make final 
preparations, and to upgrade our safety precautions to reduce the risk of 
transmitting Nick's HIV and/or associated infections to the Alcor team 
that would be caring for him. 

    Mike sent out for puncture-resistant nitrile rubber gloves and 
fluid-barrier Tyvek jumpsuits with integral shoe covers.  These were 
added to surgical masks, full plastic face shields, and conventional 
latex surgical gloves which we normally use for suspensions.  (The 
nitrile rubber gloves were discovered to work well as "liners" under 
convention surgical or exam gloves which could be discarded as they got 
dirty).  Much credit goes to Paul Wakfer who took the initiative to run 
down these items at the last minute.  Paul also took the Cryovita van 
(backup for the ambulance) out and located a replacement tire for a blown 

    Nearly at the last minute, Keith suggested adding pool chlorine to 
the MALSS ice bath to reduce the infectivity of the ice water which is 
pumped over the patient.  The ice water, contaminated with body fluids, 
invariably splashes on anyone standing close to the cart.  Paul went out 
and found some at about 8:00 p.m. the night before the suspension began. 

    If these precautions seem excessive, let us assure you they are not-- 
especially three months later when you are getting your HIV status 
checked!  Those on the team with medical backgrounds are comfortable 
working with AIDS patients giving day-to-day care without gloves or masks 
except when handling body fluids (when gloves are required).  However, a 
MALSS- supported transport is *not* your normal day-to-day situation.  We 
are performing invasive procedures under field conditions using sharp 
instruments and in the presence of many gallons of splashing contaminated 
fluids.  We are also working with volunteers, and few of them have 
extensive medical training.  A high level of precautions is in order to 
safely conduct these suspensions.  Incidentally, we used the new sample 
collection method inspired by the last suspension when a team member got 
stuck.  This greatly reduced the number of contaminated sharps to which 
team members were exposed. 

    An added precaution we took was the prophylactic administration of 
AZT to the entire suspension team during the period of potential 
exposure.  While chronic administration of AZT to health care workers at 
risk for exposure to HIV is not warranted because of the nasty side 
effects of long-term use, it is acceptable to use it for an acute 
situation where risk of exposure may be high.  AZT is used as a 
prophylaxis against HIV for health care workers with known exposure.  It 
is even more effective if the drug is already present when the exposure 
occurs.  Fortunately, our precautions were effective and we were lucky.  
We had no incidents of exposure and there was no need for anyone to 
continue the AZT prophylaxis for the recommended 30 days following a 
needle stick or conjunctival (eye) exposure.  (Whew.) 

    By Tuesday evening it seemed unlikely that Nick was going to be in 
dire straits for the next 12 hours or so.  We were very short of bed 
space, so half the crew went back to Riverside that night, and the rest 
of us found places to spend the night.  NOTE to standby people: consider 
adding an air mattress to your overnight kit! 
    Early the next morning we reassembled to move Nick to a downstairs 
bedroom which could be accessed by a gurney, but that was called off 
because he was in too much discomfort to be moved.  Nick continued a slow 
decline in vital signs all day Wednesday, and by that evening it seemed 
likely that he would not make it through the night.  All of us tried to 
get a little sleep that evening, but not many were successful at it.  
About midnight Jim and the nurse on duty decided Nick (who was again in 
deep shock and completely unresponsive) had under an hour to go, and (to 
minimize ischemic time) we were called in to move him near the MALSS 

    The logistics of moving our patient downstairs resulted in more 
discussion, arguments and testing than any other aspect of the whole 
transport.  (Mike missed this because he was in the garage priming the 
MALSS cart.)   Keith's suggesting of using a gurney was tried with an 
empty gurney, but the required 70-degree angle looked so scary that 
nobody was willing to be a test subject.  Hugh`s suggestion of a 
fireman's carry was ruled out because a slip on the carpeted stairs might 
seriously hurt both the patient and the carrier.  We finally tried and 
settled on Carlos's proposal, with Max on one arm, Paul on the other, 
Hugh taking Nick's feet under his arms, and Keith held his head.  We got 
him downstairs without any problems (good suggestion, Carlos), onto the 
gurney, and (in our white Alcor lab coats) wheeled him up the street into 
the garage.  Then we all got into face shields, double gloves, and the 
Tyvek "bunny suits."  Tyvek, incidentally, is the tough water-resistant 
material used for floppy disk sleeves and Federal Express envelopes. 

    The nurse, who was extremely supportive and competent, had called it 
close.  Nick (with Jim holding his hand to the end) quit breathing and 
experienced cardiac arrest about half an hour after we got him into the 
garage.  We used a standard hospital sheet carry, picking him up on the 
bottom bed-sheet and going in over the foot end of the MALSS cart.  HLR 
support was begun on him within less than 60 seconds.  Unfortunately, 
although circulation was promptly restored, Nick had vomited (without it 
being evident) a small amount of blood derived material looking much like 
coffee grounds.  This blocked Arel's attempt at placing the PTL airway (a 
device which had been purchased some time ago by Mike for evaluation, but 
which had never been used).  Seeing her difficulty, Mike cleared Nick's 
airway of vomitus, tried to position the PTL airway, failed, and then 
managed to get a backup Esophageal Obturator Airway (EOA) in place.  
Unfortunately we did not have an Esophageal Gastric Tube Airway (EGTA) in 
the emergency response kit.  (It seems that all of them had been 
distributed to the field kits.)  A disadvantage of the (older) EOA is 
that they have no passage way for a tube to neutralize stomach acid with 
Maalox or to place a temperature probe. 

    A disadvantage of both the EOA and the EGTA is that they both require 
a mask.  The relatively high airway pressures generated by the new high 
impulse HLRs makes holding the mask on (in a spray of ice cold water) a 
very painful task, mostly borne by Arel who was spelled by Max and Paul.  
Added practice with the PTL might help to solve this problem since it 
does not require a mask. 

    Arel suggested that next time we have a large bore suction line 
available to handle respiratory emergencies, and Mike adds that the bag- 
valve respirator should be set up with a conventional mask to facilitate 
prompt respiratory support in the event there is trouble placing an EGTA, 
ET-tube or PTL airway.  Early airway management has turned out to be a 
major problem in several cases.  Arel was sore for several days up to the 
shoulders from holding the mask on, but after the quickly solved initial 
problems, the patient was well oxygenated, with the end-tidal CO2 monitor 
showing a 3 to 5% reading on each breath: the best obtained so far.  Keep 
in mind that 5% CO2 is what is expired by a normally perfusing and 
respiring person! 

    Tanya administered the transport medications through a central venous 
catheter which had been left in place for this purpose.  After 
administrating the initial medications, Tanya went back to taking notes, 
with Mike dealing the IV drips.  Mike was having difficulty getting the 
dextran into the patient, and wanted to proceed with the femoral cutdown 
as soon as possible, so he asked Leonard if he would administer the 
remaining dextran.  Since Leonard had no experience with this, Mike 
quickly explained the procedure of first filling the syringe through a 
3-way valve, then turning the valve the opposite way and squeezing the 
plunger (more sore muscles) to force the dextran into the patient.  He 
also explained to watch carefully for air in the IV line, and even though 
Leonard thought he was pointing to the opposite (mannitol) bag from the 
correct one, and was watching the wrong bag.  Leonard completed the 
dextran, and shut off that line.  When Leonard reported that the dextran 
was complete, Mike asked him to start the other bag, which was apparently 
already hooked up.  Leonard checked and found that it was already 
started, and reported this to Mike, assuming that someone else had 
started it, and was responsible for watching it.  Because Leonard had not 
had training on this subject, (not to mention that he was busy watching 
and changing oxygen cylindars) he missed understanding that the 
responsibility for the medications was being handed off to him, and 
nobody noticed at first when a pneumatically compressed IV bag started to 
pump air into the patient.  Fortunately Tanya had removed most of the air 
from the bag prior to its being hung up, so at most a few cc of air got 
into the patient.  However, this experience reenforces the opinion that 
note taking is too complex to combine with any other task, and that IV 
medications MUST be monitored by a trained person until they are turned 
off.  We also somehow missed hanging an occluder clamp on the IV pole. 
Another item which is going on a checklist. 
[ End of Part 2 of 3 ]

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