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Space Medicine
1
Operational Space Medicine
Douglas Hamilton, M.D, Ph.D
Wyle Laboratories NASA Johnson Space Center
Houston, TX, USA
Star Trek TV Series. Photo Paramount Pictures
Kluwer Academic Publishers • Copyright © 2003 • All rights reserved
Fundamentals of Space Medicine — Chapter 7
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Space Medicine
2Key Concepts
• Space medicine: What is it?
• What are the health hazards of spaceflight. Comparison with analog environments
• Medical selection of astronauts and prevention of health hazards
• In-flight countermeasures
• Treatment of medical events in space. The onsite medical facility. Emergency and rescue
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Space Medicine
3Space Medicine
• What it is– It involves proactive and reactive care of humans to
optimize physical, physiological, and mental well-being, within the unique constraints of an extreme environment
• What it isn’t
– Space Medicine is different from Space Physiology
– Many aspects of adaptation to weightlessness are peculiarities, not necessarily pathology
– Even if not pathological, changes may alter the way a disease presents or may increase risks for a given medical problem
Photo NASA
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Space Medicine
4Space Medicine
“Your neuro-vestibular, cardio-vascular, and musculo-skeletal systems can’t support you anymore.”
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Space Medicine
5Operational Space Medicine
• Selection and Prevention are the primary means of maintaining crew health and performance
• Countermeasures are used when Selection and Prevention are unable to mitigate the deleterious effects of spaceflight
• Treatment is used when Selection, Prevention, and Countermeasures are unable to prevent or mitigate illness or injury
• Rehabilitation: return to flight status
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Space Medicine
6History of Space Medicine
Photos NASA
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Space Medicine
7Astronaut Selection
• Medical history
• Examination
– Physical exam
– Cardio-pulmonary
– Ear-Nose-Throat
– Ophtalmological
– Dental
– Neurological
– Psychiatric
– Radiographic
– Laboratory
• Others
– U.S.:
• Drug screen, microbiological, pregnancy, STD
– Russia:
• Decompression and hypoxia
• Centrifuge for +Gz and +Gx resistance
• Rotating chair
• Tilt table studies
• LBNP
• Heat stress
• Parabolic flight
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Space Medicine
8Astronaut Training
Jet training
Emergency egress training
Medical training
Water training
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Space Medicine
9Risk Assessment
• Most tests have a poor ability for detecting the presence of disease in very healthy individuals
• There are almost no tests which are designed to select-out the occurrence of pathology (illness) over the next three years. This is a problem for selecting a crew for a Mars Mission
• All risks cannot be predicted
Movie: 09_AlienSong
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Space Medicine
10Common Medical Events
• Space Motion Sickness: count on 50-70%
• Foreign bodies in the eye: particles do not “settle out”
• Decompression-related disorders: especially with active EVA schedule
• Toxic inhalation: e.g. from chemicals/reagents involved in investigations, pyrolysis products from fire, propellants
• Kidney stones: risk due to mobilization of calcium from skeleton, and possibly other factors
• Radiation: identified as the major career-limiting exposure for astronauts
Photo NASA
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Space Medicine
11Less Likely Medical Events
• Cardiovascular events: rigorous screening process during astronaut selection, flight certification
• Major fractures: largely, forces which lead to such events terrestrially, such as vehicle accidents and falls, not present
• Infectious disease: after a certain disease free “incubation period” no new pathogens introduced into a small group (however, there are also immune system changes with unclear effects on overall risk)
Note: all the above represents a large portion of events prompting visits to medical care facilities on Earth
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Space Medicine
12Source of Ionizing Radiation in Space
• Solar energetic particles emitted from the sun during solar flares
• Particles trapped by the Earth’s magnetic field in the Van Allen belts,
• Galactic cosmic radiation which crosses the galaxy
Each of these sources consists of all the types of space radiation, but at different energies and in different relative proportions
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Space Medicine
13Acute Radiation Syndrome
Dose (Sv) Probable Medical Effects0.1-0.5 No effects except minor blood changes0.1-1 5-10% subjects experience nausea or vomiting, fatigue for 1-2 days, slight
reduction in white blood cells1-2 25-50% nausea/vomiting, with some other symptoms, 50%
reduction in white blood cells2-3.5 75-100% nausea/vomiting, fever, with anorexia, diarrhea, minor
bleeding, 75% reduction in all blood elements. 5-50% subjects will die3.5-5.5 100% nausea/vomiting, fever, bleeding diarrhea, emaciation. Death of 50-
90% in 6 weeks. Survivors require 6 months convalescence5.5-7.5 100% nausea/vomiting in 4 hours. 80-100% die7.5-10 Severe nausea/vomiting for 3 days. Death within 2.5 weeks10-20 Nausea/vomiting within 1 hour. 100% die within less than 2
weeks45 Incapacitation within hours. 100% die within 1 week
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Space Medicine
14Radiation Exposure
• Exposure Limits for Ionizing RadiationBFO Eye Skin
30 Days 0.25 1 1.5 Annual 0.5 2 3 Career 1-4* 4 6
*The career dose-equivalent (in Sievert, Sv) is based upon a maximum 3% lifetime risk of cancer mortality. BFO: blood-forming organs
• Measured Radiation Dose during Spaceflight
Mission Absorbed Dose(mGy) Dose Equivalent (Sv)Space Shuttle 2-4 0.005 Sv(7-day mission orbiting Earth at <450 km)
Space Shuttle 5.2 0.05 Sv(8-day mission orbiting Earth at >450 km)
Apollo-14 11.4 0.03 Sv(9-day mission to the Moon)
Skylab-4 77.4 0.178 Sv(84-day mission orbiting Earth at 430 km, 28.5 deg inclination)
Mir 146 0.584 Sv(1-year mission orbiting Earth at 400 km, 51.5 deg inclination)
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Space Medicine
15Radiation Shielding
Time Event06:21 Optical flare observed13:00 30-day limit exceeded for skin and optical lens14:00 30-day limit exceeded for BFO; annual limit
exceeded for lens15:00 Annual limit exceeded for skin16:00 Annual exceeded for BFO; Career exceeded for lens17:00 Career limit exceeded for skin
• Effects of a Solar Flare Event with 2 g/cm2 shielding (Aug’72)
Shield Thickness BFO Skin Lens0.2 (g/cm2) 6.0 3.0 1.91.0 (g/cm2) 6.3 3.5 2.45.0 (g/cm2) 8.9 8.0 6.5
• Time to reach 30-day limit (hours)
Photo NASA
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Space Medicine
16Rules in Space Medicine
• “Common things occur commonly”
• Mission-specific operational hazards: e.g., harmful environment, toxic substances, etc.
• Injury / illness is occurring in a body which is adapting to microgravity
• Manpower is in short supply
• In-flight, the crew is on its own with limited support from Earth
Photo CNES
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Space Medicine
17Medical Hardware Selection
• Weight/volume: as small and compact as possible
• Simple and intuitive to use; training will be limited
• Power/data needs: add immensely to complexity; non-powered if possible
• Long shelf-life, "bullet proof” technology desired
• Supports identified standards of care; must meets clinical management analysis, e.g. provides useful information
• Modular, easy to replace and upgrade components
• Think 0-G or partial G as needed
Photo NASA
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Space Medicine
18ISS Crew Health Care System (CHeCS)
• Health Maintenance System
– Body Restraint System
– Cardiac defibrillator
– Advanced Life Support Pack
– Human Research Facility
• Gas Analyzer System
• Heart and vascular ultrasound
• Abdominal ultrasound, deep organ
• Gynecological ultrasound
• Muscle and tendon ultrasound
• Transcranial ultrasound
• Environmental Health System
• Countermeasures System
– Treadmill
– Cycle ergometer
– Resistive exercise
First ultrasound examination (lungs) performed on board
the ISS. Documents NASA
Movie: 18_lungs
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Space Medicine
19Examples of Flight Medical Hardware
• Cardiac Defibrillator / Monitor
– Early electrical defibrillation correlates best with survival in event of cardiac arrest (many roads to ventricular fibrillation)
– It is no longer simple to apply force to defibrillator paddles; adhesive conductive pads are used
– Must provide insulation from delivered voltage and consider effects of electromagnetic interference (EMI) on sensitive avionics
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Space Medicine
20Examples of Flight Medical Hardware
• Advanced Life Support Pack
– Accessibility and use strongly influence success / survival
– Medical waste, e.g., sharp needles must be carefully disposed
– Medications must be tracked and discarded when shelf-life exceeded
– Absorption of oral medications may be sensitive to digestive function, which may be altered in space
– Alternate routes of administration may be better for some drugs (intramuscular, intravenous, nasal)
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Space Medicine
21Advanced Life Support Pack
Document NASA
Deployment and utilization of the Advanced Life Support Pack on board the ISS
Movie: 21_contingency
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Space Medicine
22Telemedicine
Care MedicalOfficer (CMO)
Onboard MedicalCare Facility
Injured or ill Crewmember
Telemedicine Link
Crew Surgeon
EngineeringSupport Consultants
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Space Medicine
23Telemedicine Pack
• Voice / video communications both ways (private medical conferences, diagnostic and procedural aid)
• Continuous physiological monitoring (eases requirements on crew; ground personnel can analyze trends)
• Video Imaging– Eye– Ear, nose, throat– Skin
• Biomedical Monitoring– ECG– SpO2
– Blood pressure– Heart rate
• Electronic Stethoscope– Heart, lung, and bowel sounds
Photo NASA
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Space Medicine
24Emergency and Rescue
• Response to an orbital medical event depends on 5 factors:
– Severity of illness / injury
– Capability of onboard medical system
– Ability of surgeon to assist during medical event
– Level of skill / training of onboard medical officer
– Ease / feasibility of medical evacuation to Earth
• Crew Medical Officer
– 3 -7 crewmembers on ISS
– Crew Medical Officer (CMO) on ISS is usually not a physician
– CMO receives 40-60 hours of medical training completed at least 3 months prior to flight
– Trained to recognize, treat, and stabilized acute injury
– Trained to prepare patient for transport
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Space Medicine
25Treatment
• Treatment structure highly desirable
• Requires means of transporting patient
• Necessary medical hardware in proximity
• Restraint function integrated with diagnostic and therapeutic systems
• Some new procedures need to be adapted for microgravity (e.g., CPR)
Documents NASA
Movie: 25_restraint
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Space Medicine
26Surgery in Space
• Operator and patient restraints
• Instrument deployment and fixation
• Sterile environment
– Increased population of antibiotic resistant bacteria
– Decreased immune function documented in space
• Lighting and exposure
• Control of atmosphere contamination (bleeding)
• Decreased proprioceptive (muscle and skin) sensation
• Time delay for telesurgery
Photo NASA
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Space Medicine
27Emergencies — Soyuz
Photos NASA
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Space Medicine
28Emergencies — Egress
Photos NASA
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Space Medicine
29Additional Reading
• Billica RD, Simmons SC, Mather KL, et al. (1996) Perception of the medical risk of spaceflight. Aviat Space Environ Med 67: 467-473
• Clément G (2003) Fundamentals of Space Medicine. Dordrecht: Kluwer Academic Publishers
• Lane HW, Schoeller D (eds) (1999) Nutrition in Spaceflight and Weightless Models. Boca Raton, FL: CRC Press
• Wilson WJ, Miller J, Konradi A, Cucinotta FA (eds) (1997) Shielding Strategies for Human Space Exploration. NASA CP-3360 Washington, DC: NASA
• Institute of Medicine (2001) Safe Passage: Astronaut Care for Exploration Missions. Ball HR, Evans CH, Ballard JR (eds) Washington, DC: National Academy Press
• International Workshop on Human Factors in Space. Aviat Space Environ Med 71, Number 9, Section II (Supplement) 2000
• National Research Council (1996) Radiation Hazards to Crews of Interplanetary Missions. Task Group on the Biological Effects of Space Radiation. Washington, DC: National Academy Press