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Principles for Termination of Medical Care in Austere Analog Environments for Development of Spaceflight Protocols

INTRODUCTION: When compared to operations in low earth orbit, exploration class missions will have substantially limited resources and ground medical support while the risk of a significant medical event is projected to be higher. Termination of care (TOC) may need to be considered in certain instances. We aim to utilize data from earth-based analogs to identify common principles that can help develop future guidelines to this complex medical and ethical challenge. METHODS: A comprehensive literature review was conducted in medline, nasa.gov, Defense Technical Information Center(DTIC) and google scholar. Key search terms including “withdrawal of care, termination of care, termination of CPR, military medicine, wilderness medicine, futility, potentially inappropriate” and others were used to identify analog studies of relevance. These were qualitatively evaluated for recurring principles or themes that were reviewed and structured. RESULTS: Mission planning termination of care principles: definitions of clear medical goals, separate protocols for each relevant condition, protocols developed using best available evidence, crew involvement in development, protocols rehearsal pre-launch, and inclusion of palliative capabilities. In-mission termination of care principles: 1. Crew Medical Officer directed stabilization of the patient; 2. Consultation with mission control with standardized information exchange; 3. Multidisciplinary medical and ethical conference among the mission directors, flight surgeons and relevant specialist experts; 4. Multidisciplinary risk review examining both medical and mission risks for relevant options; 5. Provision of a transparent explanation of the process and decision to crew; 6. Allowing crew feedback and inquiry to review board; 7. Support of the crew in the enacted decision. DISCUSSION: By utilizing the best available evidence in conjunction with expert opinion we have identified common principles from earth-based analogs that could be used to help design future TOC protocols.

Samuel Stephenson↗
NASA NTRS1987

Tutorial and hands-on demonstration of a fluent interpreter for CARE 3

This document updates one originally written as part of a workshop on the CARE 3 capability held at NASA Langley Research Center on February 22 to 24, 1984. Subsequent to the workshop, CARE 3 and its interface program were enhanced and extensive changes to the original document became necessary. This document, like its predecessor, is designed to illustrate the user interface capability and the salient CARE 3 features by describing various examples of reliability models and their solutions through the use of CARE 3.

Martensen, Anna L.↗
NASA NTRS1988

CARE 3 User's Workshop

A user's workshop for CARE 3, a reliability assessment tool designed and developed especially for the evaluation of high reliability fault tolerant digital systems, was held at NASA Langley Research Center on October 6 to 7, 1987. The main purpose of the workshop was to assess the evolutionary status of CARE 3. The activities of the workshop are documented and papers are included by user's of CARE 3 and NASA. Features and limitations of CARE 3 and comparisons to other tools are presented. The conclusions to a workshop questionaire are also discussed.

Source record↗
NASA NTRS1991

The Canadian experience: Using telemedicine for the support of medical care at remote sites

While the majority of Canadians live in a narrow strip about 200 miles wide just north of the 45th parallel, a significant proportion of the population lives in non-urban, remote and sometimes isolated areas. Given this widely dispersed population, the provision of health services has always been a challenge. A list of non-urban health needs include the following: consulting services; clinical laboratory resources; investigative techniques (e.g., EEG, radiology, ultrasound, nuclear medicine); continuing education for physicians, nurses and other health professionals; teaching and training programs for administrative and support staff (dietary, housekeeping, maintenance); community health education and improved general education for health workers and families. For nearly three decades physicians and other health care professionals in the United States and Canada have been exploring the application of telecommunications to health care in rural and remote areas. The terms telemedicine and telehealth are used interchangeably to describe this activity. The prefix 'tele' refers to distance and now includes all types of communication over distance that support health care and health educational programs. Actually, telemedicine is as old as the telephone, which is still the most widely used communications technology in health care.

House, Maxwell↗
NASA NTRS2003

Evaluation of Critical Care Monitor Technology During the US Navy Strong Angel Exercise

The NASA critical path road map identifies "trauma and acute medical problems" as a clinical capability risk category (http://criticalDath.isc.nasa.gov). Specific risks include major trauma, organ laceration or contusion, hemoperitoneum, pulmonary failure, pneumo- and hemothorax, burn, open bone fracture, blunt head trauma, and penetrating injury. Mitigation of these risks includes the capability for critical care monitoring. Currently, the International Space Station (ISS) Crew Health Care System (CHeCS) does not provide such a capability. The Clinical Space Medicine Strategic Planning Forum (4/8/97), sponsored by NASA Medical Operations, identified the development of trauma care capabilities as one of the top priorities for space medicine. The Clinical Care Capability Development Project (CCCDP) subsequently undertook the task to address this need.

Johannesen, John↗
NASA NTRS2007

Pharmaceutical Care and the Role of a Pharmacist in Space Medicine

Space medicine is primarily preventative medicine Outcomes of space medicine pharmaceutical care are: a) Elimination or reduction of a patient's symptomatology; b) Arresting or slowing of long term effects from microgravity; and c) Preventing long term effects or symptomatology as a result of microgravity. Space medicine pharmaceutical care is about both the patient and the mission. Pharmaceutical care in the area of space medicine is evolving. A pharmacist serves a critical role in this care. Commercial space travel will require pharmacist involvement.

Bayuse, Tina↗
NASA NTRS2010

The History of the Animal Care Program at NASA Johnson Space Center

This slide presentation reviews the work of the Animal Care Program (ACP). Animals have been used early in space exploration to ascertain if it were possible to launch a manned spacecraft. The program is currently involved in many studies that assist in enhancing the scientific knowledge of the effect of space travel. The responsibilities of the ACP are: (1) Organize and supervise animal care operations & activities (research, testing & demonstration). (2) Maintain full accreditation by the International Association for the Assessment and Accreditation of Laboratory Animal Care (AAALAC) (3) Ensure protocol compliance with IACUC recommendations (4) Training astronauts for in-flight animal experiments (5) Maintain accurate & timely records for all animal research testing approved by JSC IACUC (6) Organize IACUC meetings and assist IACUC members (7) Coordinate IACUC review of the Institutional Program for Humane Care and Use of Animals (every 6 mos)

Khan-Mayberry, Noreen↗
NASA NTRS2011

Potential Effects of Health Care Policy Decisions on Physician Availability

Many regions in America are experiencing downward trends in the number of practicing physicians and the number of available physician hours, resulting in a worrisome decrease in the availability of health care services. Recent changes in American health care legislation may induce a rapid change in the demand for health care services, which in turn will result in a new supply-demand equilibrium . In this paper we develop a system dynamics model linking physician availability to health care demand and profitability. We use this model to explore scenarios based on different initial conditions and describe possible outcomes for a range of different policy decisions.

Garcia, Christopher↗
NASA NTRS2011

Astronaut Medical Selection and Flight Medicine Care During the Shuttle ERA 1981 to 2011

The NASA Shuttle Program began with congressional budget approval in January 5, 1972 and the launch of STS-1 on April 12, 1981 and recently concluded with the landing of STS-135 on July 21, 2011. The evolution of the medical standards and care of the Shuttle Era Astronauts began in 1959 with the first Astronaut selection. The first set of NASA minimal medical standards were documented in 1977 and based on Air Force, Navy, Department of Defense, and the Federal Aviation Administration standards. Many milestones were achieved over the 30 years from 1977 to 2007 and the subsequent 13 Astronaut selections and 4 major expert panel reviews performed by the NASA Flight Medicine Clinic, Aerospace Medicine Board, and Medical Policy Board. These milestones of aerospace medicine standards, evaluations, and clinical care encompassed the disciplines of preventive, occupational, and primary care medicine and will be presented. The screening and retention standards, testing, and specialist evaluations evolved through periodic expert reviews, evidence based medicine, and Astronaut medical care experience. The last decade of the Shuttle Program saw the development of the International Space Station (ISS) with further Space medicine collaboration and knowledge gained from our International Partners (IP) from Russia, Canada, Japan, and the European Space Agencies. The Shuttle Program contribution to the development and implementation of NASA and IP standards and waiver guide documents, longitudinal data collection, and occupational surveillance models will be presented along with lessons learned and recommendations for future vehicles and missions.

Johnston, S.↗
NASA NTRS2019

Development of a Point of Care Technology for Military Medical Applications in Austere Environments

NASA, Lawrence Livermore National Laboratory (LLNL) and the Department of Defense (DoD) share a common interest in compact medical diagnostic technologies—also known as “point of care testing” (POCT) technologies. For NASA, the need is to take care of astronauts on deep space missions. For LLNL, the focus is on technologies needed to support homeland security applications. For DoD, the need is to support warfighters in military theaters of operation, especially for prolonged field care and en route care. A recently patented technology, “Portable Medical Diagnosis Instrument” (U.S. Patent 9824870), co-invented by NASA and LLNL, is being developed further in a partnership between NASA, LLNL and Travis Air Force Base, with a focus on military applications. This instrument, the NASA-LLNL Medical Tricorder, can be used for a wide range of clinical samples including breath, saliva and blood. One component of the Tricorder is the NASA E-Nose, a carbon nanotube-based chemical sensor, integrated into a hand-held smart phone, that can detect and measure “breath biomarkers” in the gas phase of exhaled breath. The response of the NASA E-Nose is rapid, which makes it possible to detect various gas-phase substances in real time. The NASA E-Nose, with modification, can also be used for breath condensate analysis. Another component of the Tricorder is a miniaturized microfluidic analyzer, under development by LLNL, that does not require any pumps. The microfluidic analyzer can detect and measure biomarkers in liquid samples, such as blood, saliva and breath condensate. This microfluidic system requires small quantities of liquid sample and can perform analysis very rapidly (seconds to minutes), which makes it possible to detect relevant biomarkers in near real time in the field. The Clinical Investigation Facility (CIF) at Travis Air Force Base is currently conducting research with the goal to develop improved field-able technologies and procedures for the emergency response to life threatening injuries soldiers may receive in theater. This work includes experimental large animal systems and comprehensive collection of clinical specimens and physiological data. NASA and LLNL are partnering with Travis to test and further develop the Tricorder technology for high priority military applications, initially focused on lung injury models and traumatic brain injury.

Loftus, David J.↗
NASA NTRS2019

Communication Bandwidth Considerations for Exploration Medical Care During Space Missions

Destinations beyond low Earth orbit, especially Mars, have several important constraints, including limited resupply, limited to no possibility of medical evacuation, and delayed communication with ground support teams. Therefore, medical care is driven towards greater autonomy and necessitates a medical system that supports this paradigm, including the potential for high medical data transfer rates in order to share medical information and coordinate care with the ground in an intermittent fashion as communication allows. The medical data transfer needs for a Martian exploration mission were estimated by defining two medical scenarios that would require high data rate communications between the spacecraft and Earth. One medical scenario involves a case of hydronephrosis (outflow obstruction of the kidney) that evolves into pyelonephritis (kidney infection), then urosepsis (systemic infection originating from the kidney), due to obstruction by a kidney stone. A second medical scenario involved the death of a crewmember’s child back on Earth that requires behavioral health care. For each of these scenarios, a data communications timeline was created following the medical care described by the scenario. From these timelines, total medical data transfers and burst transmission rates were estimated. Total data transferred from the vehicle-to-ground were estimated to be 94 gigabytes (GB) and 835 GB for the hydronephrosis and behavioral health scenarios, respectively. Data burst rates were estimated to be 7.7 megabytes per second (MB/s) and 15 MB/s for the hydronephrosis and behavioral health scenarios, respectively. Even though any crewed Mars mission should be capable of functioning autonomously, as long as the possibility of communication between Earth and Mars exists, Earth-based subject matter experts will be relied upon to augment mission medical capability. Therefore, setting an upper boundary limit for medical communication rates can help factor medical system needs into total vehicle communication requirements.

Krihak, Michael↗
NASA NTRS1997

Health Care Robotics: A Progress Report

This paper describes the approach followed in the design of a service robot for health care applications. Under the auspices of the NASA Technology Transfer program, a partnership was established between JPL and RWI, a manufacturer of mobile robots, to design and evaluate a mobile robot for health care assistance to the elderly and the handicapped. The main emphasis of the first phase of the project is on the development on a multi-modal operator interface and its evaluation by health care professionals and users. This paper describes the architecture of the system, the evaluation method used, and some preliminary results of the user evaluation.

handicapped mobile robots↗
NASA NTRS1971

Reliability estimation procedures and CARE: The Computer-Aided Reliability Estimation Program

Ultrareliable fault-tolerant onboard digital systems for spacecraft intended for long mission life exploration of the outer planets are under development. The design of systems involving self-repair and fault-tolerance leads to the companion problem of quantifying and evaluating the survival probability of the system for the mission under consideration and the constraints imposed upon the system. Methods have been developed to (1) model self-repair and fault-tolerant organizations; (2) compute survival probability, mean life, and many other reliability predictive functions with respect to various systems and mission parameters; (3) perform sensitivity analysis of the system with respect to mission parameters; and (4) quantitatively compare competitive fault-tolerant systems. Various measures of comparison are offered. To automate the procedures of reliability mathematical modeling and evaluation, the CARE (computer-aided reliability estimation) program was developed. CARE is an interactive program residing on the UNIVAC 1108 system, which makes the above calculations and facilitates report preparation by providing output in tabular form, graphical 2-dimensional plots, and 3-dimensional projections. The reliability estimation of fault-tolerant organization by means of the CARE program is described.

Mathur, F. P.↗
NASA NTRS1977

Space age health care delivery

Space age health care delivery is being delivered to both NASA astronauts and employees with primary emphasis on preventive medicine. The program relies heavily on comprehensive health physical exams, health education, screening programs and physical fitness programs. Medical data from the program is stored in a computer bank so epidemiological significance can be established and better procedures can be obtained. Besides health care delivery to the NASA population, NASA is working with HEW on a telemedicine project STARPAHC, applying space technology to provide health care delivery to remotely located populations.

Jones, W. L.↗
NASA NTRS1982

The CARE 3 Phase 3 Report: Test and Evaluation

CARE 3 (Computer-Aided Reliability Estimation, version three) is a computer program designed to help estimate the reliability of complex, redundant systems; although the program can model a wide variety of redundant structures, it was developed specifically for fault-tolerant avionics systems, systems distinguished by the need for extremely reliable performance since a system failure could well result in the loss of human life. CARE 3 further generalizes the class of system structures that can be modeled and greatly expands the coverage model to take into account such effects as intermittent and transient faults, latent faults, error propagation, etc. The initial test and evaluation of CARE 3 are reported.

Stiffler, J. J.↗
NASA NTRS1983

Review and verification of CARE 3 mathematical model and code

The CARE-III mathematical model and code verification performed by Boeing Computer Services were documented. The mathematical model was verified for permanent and intermittent faults. The transient fault model was not addressed. The code verification was performed on CARE-III, Version 3. A CARE III Version 4, which corrects deficiencies identified in Version 3, is being developed.

Rose, D. M.↗
NASA NTRS2001

Lactating Rats Retain Nursing Behavior and Maternal Care in Space

In 1997, suckling mammals were flown in space for the first time as part of the NIH.R3 experiment sponsored jointly by NIH (National Institutes of Health) and NASA. Six rat dams and litters (Rattus norvegicus) were launched on an eight-day Space Shuttle mission at each of three postnatal ages (P5, P8, and P15). Dams and litters (N = 10 pups/litter) were housed within modified Animal Enclosure Modules (AEMs). Comparisons were made to ground controls. Dams and litters were videotaped daily in flight. The P8 and P15 flight litters showed excellent survival (99%) and weight gain relative to AEM ground controls, whereas P5 litters showed reduced survival (0% and 60%, respectively) and weight gain (less than 40% AEM). To examine the possibility that failures of maternal care contributed to P5 results, we analyzed the dams' in-flight nursing, licking and retrieving from four video segments ranging from twelve to fifteen minutes in length with control data derived from multiple ground segments. Video analyses revealed clear evidence of maternal care in flight. For P5 dams, frequency and duration of nursing and licking bouts fell within or above one standard deviation of control values. Retrieving was noted in the P5 and P8 groups only. The observed results suggest that factors other than maternal care contributed to the low survival rates and body weight gains of the P5 flight offspring.

Daly, Megan E.↗
NASA NTRS2007

Integrated Crew Health Care System for Space Flight

Dr. Davis' presentation includes a brief overview of space flight and the lessons learned for health care in microgravity. He will describe the development of policy for health care for international crews. He will conclude his remarks with a discussion of an integrated health care system.

Davis, Jeffrey R.↗