Mapping Current Medical Systems to the IMPACT Medical Database Environment
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Shane Schwartz↗
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Stability Analysis of ISS Medications
It is known that medications degrade over time, and that extreme storage conditions will hasten their degradation. The temperature and humidity conditions of the ISS have been shown to be within the ideal ranges for medication storage, but the effects of other environmental factors, like elevated exposure to radiation, have not yet been evaluated. Current operational procedures ensure that ISS medications are re-stocked before expiration, but this may not be possible on long duration exploration missions. For this reason, medications that have experienced long duration storage on the ISS were returned to JSC for analysis to determine any unusual effects of aging in the low- Earth orbit environment. METHODS Medications were obtained by the JSC Pharmacy from commercial distributors and were re-packaged by JSC pharmacists to conserve up mass and volume. All medication doses were part of the ISS crew medical kit and were transported to the International Space Station (ISS) via NASA's Shuttle Transportation System (Space Shuttle). After 568 days of storage, the medications were removed from the supply chain and returned to Earth on a Dragon (SpaceX) capsule. Upon return to Earth, medications were transferred to temperature and humidity controlled environmental chambers until analysis. Nine medications were chosen on the basis of their availability for study. The medications included several of the most heavily used by US crewmembers: 2 sleep aids, 2 antihistamines/decongestants, 3 pain relievers, an antidiarrheal and an alertness medication. Each medication was available at a single time point; analysis of the same medication at multiple time points was not possible. Because the samples examined in this study were obtained opportunistically from medical supplies, there were no control samples available (i.e. samples aged for a similar period of time on the ground); a significant limitation of this study. Medications were analyzed using the HPLC/MS methods described in the United States Pharmacopeia (USP) to measure the amount of intact active ingredient, identify degradation products and measure their amounts. Some analyses were conducted by an independent analytical laboratory, but certain (Schedule) medications could not be shipped to their facility and were analyzed at JSC. RESULTS Nine medications were analyzed with respect to active pharmaceutical ingredient (API) and degradant amounts. Results were compared to the USP requirements for API and degradants/impurities content for every FDA-approved medication. One medication met USP requirements at 5 months after its expiration date. Four of the nine (44% of those tested) medications tested met USP requirements up to 8 months post-expiration. Another 3 medications (33% of those tested) met USP guidelines 2-3 months before expiration. One medication, a compound classed by the FDA as a dietary supplement and sometimes used as a sleep aid, failed to meet USP requirements at 11 months post-expiration. CONCLUSION Analysis of each medication at a single time point provides limited information on the stability of a medication stored in particular conditions; it is not possible to predict how long a medication may be safe and effective from these data. Notwithstanding, five of the nine medications tested (56%) met USP requirements for API and degradants/impurities at least 5 months past expiration dates. The single compound that failed to meet USP requirements is not regulated as strictly as prescription medications are during manufacture; it is unknown if this medication would have met the requirements prior to flight. Notably, it was the furthest beyond its expiration date. Only more comprehensive analysis of flight-aged samples compared to appropriate ground controls will permit determination of spaceflight effects on medication stability.
Wotring, V. E.↗
ISS Technology Demonstrations for Future Spaceflight Medical Systems
Throughout the history of human spaceflight, crewmembers have experienced various in-flight medical conditions including illness and injury. Planned missions to the Moon and Mars will require capabilities to maintain the health of future space travelers. Mass, power, and volume available in the vehicles and habitats for these missions will be severely constrained; resupply of resources will be limited or non-existent, as will opportunities for evacuation to Earth. Furthermore, ground-based support will be hampered by communication latencies and blackouts. These vehicle and mission constraints will necessitate a medical system that has been efficiently planned, providing on-board procedural guidance in addition to a variety of medical devices and consumable resources. Medical capabilities required for the diagnosis and treatment of potential medical conditions during future spaceflight missions may include real-time health monitoring, medical imaging, and biomarker analyses ( e.g., blood or urine). Terrestrial medicine shares these needs, thus many of these medical capabilities could likely be satisfied by Commercial-Off-The-Shelf (COTS) devices and methodologies; however, in some cases the unique space environment and increased mission duration will drive the need to modify technologies and the way care is provided. NASA’s Human Research Program (HRP) Exploration Medical Capability (ExMC) Element and Mars Campaign Office’s Exploration Medical Integrated Product Team (XMIPT) are working together to decrease medical risk during exploration missions. Flight-tested medical diagnostic and treatment technologies are necessary to effectively manage medical conditions relevant to exploration missions while meeting vehicle constraints, integrating with medical decision-support tools, and enabling increasingly Earth-independent operations. Several projects have leveraged the ISS as a testbed for exploration, including 1) i n- situ blood analysis, 2) medical inventory, 3) intravenous fluid generation, and 4) autonomous medical procedure guidance. Management of several in-flight medical conditions, such as bacterial and viral infections and acute radiation syndrome, is dramatically improved with ability to assess blood cell populations, electrolytes, and metabolites. I n December 2020 and January 2021 ExMC performed an ISS technology demonstration (Tech Demo) of the HemoCue® WBC DIFF analyzer (HemoCue, Brea, CA), a COTS device that was modified to enable functionality in a spaceflight environment. This Tech Demo marked the first time that hematology measurements were successfully performed real-time in microgravity. Also modified and demonstrated was the reusable Handheld Electrolytes and Lab Technology for Humans (rHEALTH) ONE analyzer (rHEALTH, Bedford, MA), which uses flow cytometry and sheath-based hydrodynamic focusing methodologies. The rHEALTH ONE ISS Tech Demo in May 2022 demonstrated test results obtained in-flight matched those on the ground. NASA currently relies on crew self-reporting to manage and maintain medical inventory on ISS.The ability to maintain an accurate inventory becomes more critical during long duration missions since the crew will need to be increasingly autonomous in finding and utilizing medical items, including those scenarios when alternative treatments need to be considered due to limited or no resupply. HRP’s Medical Consumables Tracking (MCT) project was developed by ZIN Technologies, Inc. (Cleveland, OH), and demonstrated real-time tracking of medical supplies aboard the ISS between December 2016 and July 2018. The MCT system design utilized Radio Frequency Identification Device (RFID) technology to perform automated inventory and was installed in the Crew Health Care System (CHeCS) Resupply Stowage Rack (RSR). The challenge of limited shelf life, exacerbated by the lack of resupply opportunities, affects a plethora of medical system components including consumables, pharmaceuticals, and intravenous (IV) fluid. In 2010, ExMC funded ZIN Technologies, Inc. (Cleveland, OH), to develop the Intravenous Fluid Generation (IVGEN) system. IV fluids were successfully generated with IVGEN using the potable water supply on ISS during ISS Expedition 23. The XMIPT is in the process of developing a miniaturized version of the original IVGEN hardware for a future Tech Demo aboard the ISS. Current ISS medical operations rely heavily on preflight training and real-time remote guidance, both of which become impractical or impossible for exploration missions. The primary goal of the Autonomous Medical Officer Support (AMOS) Software Tech Demos on ISS was to confirm telemedical proof-of-concept for autonomous medical imaging in an operational setting. This novel software tool shifts emphasis from preflight training and real-time remote guidance to in-flight just-in-time instruction, a new and necessary paradigm for crew medical autonomy. AMOS introduces a novel, streamlined skill management concept for exploration missions featuring comprehensive training and guidance modules for ultrasound examinations using the ISS Ultrasound 2 (a modified GE Vivid-q™; General Electric HealthCare, Chicago, IL). With no prior crew training or remote guidance, two Tech Demos on the ISS (April 2020 and June 2022) resulted in high quality, clinically useful image sets. We will provide a review of historical, current, and planned medical devices and technologies considered for inclusion within future spaceflight medical systems and summarize hardware development activities and medical device tech demos conducted on the ISS.
Astronaut health and performance↗
Organization, Management and Function of International Space Station (ISS) Multilateral Medical Operations
Long duration crews have inhabited the ISS since November of 2000. The favorable medical outcomes of its missions can be largely attributed to sustained collective efforts of all ISS Partners medical organizations. In-flight medical monitoring and support, although crucial, is just a component of the ISS system of Joint Medical Operations. The goal of this work is to review the principles, design, and function of the multilateral medical support of the ISS Program. The governing documents, which describe the relationships among all ISS partner medical organizations, were evaluated, followed by analysis of the roles, responsibilities, and decision-making processes of the ISS medical boards, panels, and working groups. The degree of integration of the medical support system was evaluated by reviewing the multiple levels of the status reviews and mission assurance activities carried out throughout the last six years. The Integrated Medical Group, consisting of physicians and other essential personnel in the mission control centers represents the front-line medical support of the ISS. Data from their day-to-day activities are presented weekly at the Space Medicine Operations Team (SMOT), where known or potential concerns are addressed by an international group of physicians. A broader status review is conducted monthly to project the state of crew health and medical support for the following month, and to determine measures to return to nominal state. Finally, a comprehensive readiness review is conducted during preparations for each ISS mission. The Multilateral Medical Policy Board (MMPB) issues medical policy decisions and oversees all health and medical matters. The Multilateral Space Medicine Board (MSMB) certifies crewmembers and visitors for training and space flight to the Station, and physicians to practice space medicine for the ISS. The Multilateral Medical Operations Panel (MMOP) develops medical requirements, defines and supervises implementation of operational countermeasures, environmental monitoring, medical care, and emergency medical services. MMOP assures the medical readiness of the Station for each subsequent mission or critical event. All boards and panels have functioned effectively and without interruptions even in various challenging circumstances. Based on the experience of the authors, consensus has prevailed as the primary nature of decisions made by all ISS medical groups, at all levels. The six first years of piloted operation have demonstrated the ability of the ISS medical authority groups and the medical infrastructure to implement medical policies and requirements, effectively interface with non-medical groups, and maintain the health and productivity of the crew in an integrated, multilaterally coordinated fashion. The medical support system appears to be mature and ready for further expansion of all Partners roles, and for the anticipated increase in the size of ISS crews.
Duncan, James M.↗
The Near Earth Asteroid Medical Conditions List
Purpose: The Exploration Medical Capability (ExMC) element is one of six elements within NASA s Human Research Program (HRP) and is responsible for addressing the risk of "the inability to adequately recognize or treat an ill or injured crewmember" for exploration-class missions. The Near Earth Asteroid (NEA) Medical Conditions List, constructed by ExMC, is the first step in addressing the above-mentioned risk for the 13-month long NEA mission. The NEA mission is being designed by NASA's Human Space Flight Architecture Team (HAT). The purpose of the conditions list is to serve as an evidence-based foundation for determining which medical conditions could affect a crewmember during the NEA mission, which of those conditions would be of concern and require treatment, and for which conditions a gap in knowledge or technology development exists. This information is used to focus research efforts and technology development to ensure that the appropriate medical capabilities are available for exploration-class missions. Scope and Approach: The NEA Medical Conditions List is part of a broader Space Medicine Exploration Medical Conditions List (SMEMCL), which incorporates various exploration-class design reference missions (DRMs). The conditions list contains 85 medical conditions which could occur during space flight and which are derived from several sources: Long-Term Surveillance of Astronaut Health (LSAH) in-flight occurrence data, The Space Shuttle (STS) Medical Checklist, The International Space Station (ISS) Medical Checklist, and subject matter expert opinion. Each medical condition listed has been assigned a clinical priority and a clinical priority rationale based on incidence, consequence, and mitigation capability. Implementation: The conditions list is a "living document" and as such, new conditions can be added to the list, and the priority of conditions on the list can be adjusted as the DRM changes, and as screening, diagnosis, or treatment capabilities change. The NEA medical conditions list was used recently as the basis for identifying gaps in in-flight medical evaluation (screening) capabilities. Learning Objectives: The audience will become familiar with the approach taken by NASA's Exploration Medical Capability element in addressing the risk of inability to recognize and treat medical conditions in the setting of a Near Earth Asteroid mission. Which one of the following statements is incorrect? a) The Near Earth Asteroid (NEA) medical conditions list includes 85 medical conditions which could occur during space flight. b) Each condition on the NEA medical conditions list has been assigned a clinical priority and a clinical priority rationale. c) The NEA medical conditions list targets a mission to Mars. d) The NEA medical conditions list should be viewed as a "living document" where new conditions can be added and clinical priorities adjusted to address changes in the design reference mission or medical capabilities. The incorrect answer is c). The NEA medical conditions list targets a mission to a Near Earth Asteroid.
Barr, Yael R.↗
Are Medications Involved in Vision and Intracrancial Pressure Changes Seen in Spaceflight?
The Food and Drug Association Adverse Event Reports (FDA AER) from 2009-2011 were used to create a database from millions of known and suspected medication-related adverse events among the general public. Vision changes, sometimes associated with intracranial pressure changes (VIIP), have been noted in some long duration crewmembers. Changes in vision and blood pressure (which can subsequently affect intracranial pressure) are fairly common side effects of medications. The purpose of this study was to explore the possibility of medication involvement in crew VIIP symptoms. Reports of suspected medication-related adverse events may be filed with the Food and Drug Administration (FDA) by medical professionals or consumers. Quarterly compilations of these reports are available for public download. Adverse Event Reporting System (AERS) reports from 1/1/2009- 6/30/2012 were downloaded and compiled into a searchable database for this study. Reports involving individuals under the age of 18 and older than 65 were excluded from this analysis. Case reports involving chronic diseases such as cancer, diabetes, multiple sclerosis and other serious conditions were also excluded. A scan of the medical literature for medication-related VIIP-like adverse events was used to create a list of suspect medications. These medications, as well as certain medications used frequently by ISS crew, were used to query the database. Queries for use of suspected medications were run, and the nature of the symptoms reported in those cases were tabulated. Symptoms searched in the FDA AERS were chosen to include the typical symptoms noted in crewmembers with VIIP. Vision symptoms searched were: visual acuity reduced, visual impairment, and vitreous floaters. Pressure changes included: abnormal sensation in eye, intracranial pressure increased, intraocular pressure increased, optic neuritis, optic neuropathy, and papilloedema. Limited demographic information is included with the FDA AERS; relevant data were also sorted by age and sex from each report. RESULTS Steroid-containing oral contraceptives had the highest number of reports associated with vision (n=166) and pressure symptoms (n=54). Corticosteroid-containing medications were also high; prednisone, for example, had 137 reports of vision issues and 79 of pressure issues. Pain relievers were also a medication class with vision and pressure-related adverse events reported. Common over-the-counter medications such as acetaminophen, aspirin and ibuprofen each had multiple reports for both vision and pressure symptoms. Antimicrobial medications ciprofloxacin and diflucan were also associated with a number of vision and pressure-related AERS. Unexpectedly, pseudoephedrine and promethazine were mentioned in fewer than 20 reports each over the 3.5 years of data examined. The FDA AERS represents a wealth of data, but there are several limitations to its use. The data are entered by the public or medical professionals, but are not checked for accuracy or completeness and may even be entered multiple times. The causal relationship between a particular adverse event and a particular medication is not tested. The cases represent a broad spectrum of demographics, occupations, and health histories, and thus do not model the astronaut population well. There is no information on the frequency of use of a medication for comparison purposes; it is not possible to assign a rate for any particular adverse event. Nonetheless, there are compelling trends. Use of corticosteroid-containing medications, pain relievers (even over-the-counter), and oral contraceptives were associated with higher numbers of vision- or intracranial pressure-related adverse events. In general, there were more vision problems than pressure problems reported. Certain medications that were once suspected of playing a role in the crew VIIP syndrome, namely pseudoephedrine and promethazine, were found to have extremely low numbers of VIIP-like AERS in the FDA data. However, crew use of corticosteroid-containing medications and pain relievers may warrant additional investigation
Faust, K. M.↗
Quantifying Medical Risk on a Long Duration Lunar Mission: A Demonstration of NASA’s IMPACT Tradespace Analysis Tool
Background NASA’s human exploration spaceflight missions to the Moon and Mars present unprecedented challenges for in-mission medical care. The distance from Earth will mean increased mission durations, communication delays, limited to no resupply opportunities, and constraints on the medical evacuation of astronauts. Mass, volume, power, and data will be limited while higher demands will be placed on the crew to manage medical care. NASA’s Moon to Mars exploration strategy lays out increasingly complex Artemis missions both in terms of duration and operations. In these more challenging deep space missions, it is important to quantitatively estimate the human medical risk to inform a traditional heuristic approach to medical risk. Prior tools have been developed for missions in low Earth orbit, but a new tool is required to plan for future exploration missions. Methods IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a risk assessment tool developed by NASA to advance exploration mission medical system design by quantitatively estimating mission medical risk. IMPACT v1.0 includes a novel evidence library baselined to exploration environments; an expanded list of 119 medical conditions; the addition of medical resources; and the ability for rapid and iterative analysis. Medical system risk estimates include loss of crew life, consideration of the need for return to definitive care (medical evacuation), and an estimate of crew time affected due to medical conditions. A notional long duration lunar orbit and lunar surface design reference mission (DRM) was chosen with a 4-astronaut crew to represent a sustained exploration Artemis mission. Results/Discussion Overall, IMPACT successfully quantified medical risk and derived an optimized medical system to support crew on a long duration lunar mission. In this DRM, the calculated loss of crew life from a medical event was 0.008 events per mission, risk of potential need for evacuation was 0.30 events per mission, and cumulative crew time affected by medical conditions was 103 days. The medical conditions that most contributed to overall medical risk were decompression sickness, trauma conditions, and respiratory failure. The conditions that had the largest effects on crew performance included musculoskeletal injuries and lunar dust exposure. The IMPACT-generated medical system included resources that target the most common and highest risk conditions. This systematic analysis demonstrates the value of the IMPACT tool in medical system design for human exploration spaceflight missions.
Missions to Mars↗
Quantifying Medical Risk on a Long Duration Lunar Mission: A Demonstration of NASA’s IMPACT Tradespace Analysis Tool
Background NASA’s human exploration spaceflight missions to the Moon and Mars present unprecedented challenges for in-mission medical care. The distance from Earth will mean increased mission durations, communication delays, limited to no resupply opportunities, and constraints on the medical evacuation of astronauts. Mass, volume, power, and data will be limited while higher demands will be placed on the crew to manage medical care. NASA’s Moon to Mars exploration strategy lays out increasingly complex Artemis missions both in terms of duration and operations. In these more challenging deep space missions, it is important to quantitatively estimate the human medical risk to inform a traditional heuristic approach to medical risk. Prior tools have been developed for missions in low Earth orbit, but a new tool is required to plan for future exploration missions. Methods IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a risk assessment tool developed by NASA to advance exploration mission medical system design by quantitatively estimating mission medical risk. IMPACT v1.0 includes a novel evidence library baselined to exploration environments; an expanded list of 119 medical conditions; the addition of medical resources; and the ability for rapid and iterative analysis. Medical system risk estimates include loss of crew life, consideration of the need for return to definitive care (medical evacuation), and an estimate of crew time affected due to medical conditions. A notional long duration lunar orbit and lunar surface design reference mission (DRM) was chosen with a 4-astronaut crew to represent a sustained exploration Artemis mission. Results/Discussion Overall, IMPACT successfully quantified medical risk and derived an optimized medical system to support crew on a long duration lunar mission. In this DRM, the calculated loss of crew life from a medical event was 0.008 events per mission, risk of potential need for evacuation was 0.30 events per mission, and cumulative crew time affected by medical conditions was 103 days. The medical conditions that most contributed to overall medical risk were decompression sickness, trauma conditions, and respiratory failure. The conditions that had the largest effects on crew performance included musculoskeletal injuries and lunar dust exposure. The IMPACT-generated medical system included resources that target the most common and highest risk conditions. This systematic analysis demonstrates the value of the IMPACT tool in medical system design for human exploration spaceflight missions.
Missions to Mars↗
Configuration and Projected Capabilities of the Common Habitat Medical Care Facility
The Common Habitat is a large, long-duration habitat being explored as part of a conceptual study (not an active NASA program) that uses an SLS core stage Liquid Oxygen (LOX) tank as its primary structure. It is intended for use on the Moon as part of a permanently occupied outpost, on Mars as part of an outpost that will be occupied for hundreds of days at a time, and in deep space as part of the Deep Space Exploration Vehicle where it will support crewed missions up to 1200 days in duration. A study of internal orientation and crew size resulted in a Common Habitat configuration sized for a crew of eight with a three-deck horizontal orientation. Additional work outside the scope of this paper is developing a vertical translation system, a crew mobility aids system based on wearable gecko-derived grippers, and a crew seating/restraint system. These systems are all assumed for use in conjunction with the Medical Care Facility, which is needed to maintain crew well-being during these missions, where distance from Earth precludes the possibility of evacuation to Earth. This paper describes recent improvements in the Common Habitat Medical Care Facility and associated benefits for crew survivability in long duration missions beyond Earth orbit. These improvements were made with the assistance of a NASA Pathways intern whose experience includes a tour of duty in Afghanistan as an Army combat medic with the 691st GHOST-T, attached to the 1st and 7th US Special Forces Groups as part of Operation Freedom’s Sentinel, where he helped provide far-forward surgical capabilities in austere combat environments. The initial baseline Medical Care Facility was developed working in conjunction with University of Houston Space Architecture graduate students. The facility was placed on the upper deck of the Common Habitat in a location that provided privacy, operational volume, and was close to the vertical translation pathway. The notional outfitting repurposed component CAD models from unrelated studies and notionally indicated a level of care roughly equivalent to that aboard the International Space Station. The CAD modeling provided notional stowage volumes, a deployable surface, some fixed equipment, an ultrasound, and a potentially reconfigurable treatment table. While this facility is clearly a competent arrangement, it was desired to leverage available expertise and upgrade the station given the vast distances from Earth to be experienced by the Common Habitat. Key driving requirements applied to the upgrade included to provide NASA’s Medical Level of Care V, offer enhanced telemedicine capabilities, provide patient physical accommodation, provide caregiver access to the patient from all sides, include sliding pocket doors for access to hygiene and to the Vertical Translation System, and to add any additional capability possible for the best achievable medical care. The first step in the facility upgrade was to quantify the current medical inventory on the International Space Station and ensure that sufficient stowage volume was present for this purpose. To that end, the ISS medical kits were reviewed, and eight full size mid deck lockers were placed in the facility. A number of additional devices were also added, based on the co-author’s combat medic experience. Also, two fixed shelves and one horizontal work surface were added to the Medical Care Facility, with the shelves providing storage space for the additional devices and the work surface providing a location for the caregiver to work or stage equipment. Four display monitors were added to the wall above the horizontal work surface, supporting data display, telemedicine, conferencing, or other needs. The existing treatment table was replaced with a mobile surgical stretcher-chair. Two additional doors were added to the Medical Care Facility. One leads directly to the hygiene compartment, allowing it to support medical operations in addition to providing galley/wardroom support. The other door leads directly into the Vertical Translation System. The wall adjacent to the subsystems bay was moved, adding additional volume to the Medical Care Facility. This improved caregiver access to the patient and allowed for a larger number of caregivers to be present. It also provided options for relocation of support equipment relative to the patient as needed. In the upgraded Medical Care Facility, the Surgical Stretcher-Chair and the Vertical Translation System can work together to provide incapacitated crew member transport from a site of injury on any deck of the Common Habitat to the Medical Care Facility. It can also support patient treatment in a variety of positions including a variety of sitting postures and a supine posture at a variety of pitch angles. The facility can also support caregiver office work for review of examination results, private consultation, inventory and maintenance, and a variety of other purposes. A forward activity will be to conduct evaluations of the Medical Care Facility with different medical scenarios. Additionally, ambient and task lighting selections remain as forward work. The eight middeck lockers can be augmented to use as portable equipment carts, similar to a manner in which maintenance facility stowage was used as portable carts during the NASA Desert Research and Technology Studies in the Constellation Program. Trash accommodation will also need forward work to assess, including provision for wet trash, dry trash, and biological waste. It will be important to assess a redesign of the surgical stretcher-chair. The commercial version used in the upgrade can only enable vertical translation in the seated configuration, requiring the patient to bend both hips and knees. A possible redesign of the chair will allow for vertical translation without requiring any bending at the hip or knees. Also, the commercial version is wheeled, making it mobile in gravity but unanchored in microgravity. Work will be needed to adapt the chair for gravity-independent performance. The hygiene compartment can be redesigned to serve both as a medical scrub facility and for galley hand washing. Pending sufficient volume, it may also be possible to place sanitation equipment in this location to clean medical tools. Finally, most space architectures have never allowed for more than one incapacitated crew member, but several scenarios could potentially injure two or more crew in the same incident. This facility could be assessed to determine its present ability to address two or more injured crew in parallel and determine the potential upper limit for number of treatable crew in a multi-crew injury scenario, or to treat polytrauma of a single patient.
Common Habitat↗
Configuration and Projected Capabilities of the Common Habitat Medical Care Facility
The Common Habitat is a large, long-duration habitat being explored as part of a conceptual study (not an active NASA program) that uses an SLS core stage Liquid Oxygen (LOX) tank as its primary structure. It is intended for use on the Moon as part of a permanently occupied outpost, on Mars as part of an outpost that will be occupied for hundreds of days at a time, and in deep space as part of the Deep Space Exploration Vehicle where it will support crewed missions up to 1200 days in duration. A study of internal orientation and crew size resulted in a Common Habitat configuration sized for a crew of eight with a three-deck horizontal orientation. Additional work outside the scope of this paper is developing a vertical translation system, a crew mobility aids system based on wearable gecko-derived grippers, and a crew seating/restraint system. These systems are all assumed for use in conjunction with the Medical Care Facility, which is needed to maintain crew well-being during these missions, where distance from Earth precludes the possibility of evacuation to Earth. This paper describes recent improvements in the Common Habitat Medical Care Facility and associated benefits for crew survivability in long duration missions beyond Earth orbit. These improvements were made with the assistance of a NASA Pathways intern whose experience includes a tour of duty in Afghanistan as an Army combat medic with the 691st GHOST-T, attached to the 1st and 7th US Special Forces Groups as part of Operation Freedom’s Sentinel, where he helped provide far-forward surgical capabilities in austere combat environments. The initial baseline Medical Care Facility was developed working in conjunction with University of Houston Space Architecture graduate students. The facility was placed on the upper deck of the Common Habitat in a location that provided privacy, operational volume, and was close to the vertical translation pathway. The notional outfitting repurposed component CAD models from unrelated studies and notionally indicated a level of care roughly equivalent to that aboard the International Space Station. The CAD modeling provided notional stowage volumes, a deployable surface, some fixed equipment, an ultrasound, and a potentially reconfigurable treatment table. While this facility is clearly a competent arrangement, it was desired to leverage available expertise and upgrade the station given the vast distances from Earth to be experienced by the Common Habitat. Key driving requirements applied to the upgrade included to provide Medical Level of Care V, offer enhanced telemedicine capabilities, provide patient physical accommodation, provide caregiver access to the patient from all sides, include sliding pocket doors for access to hygiene and to the Vertical Translation System, and to add any additional capability possible for the best achievable medical care. The first step in the facility upgrade was to quantify the current medical inventory on the International Space Station and ensure that sufficient stowage volume was present for this purpose. To that end, the ISS medical kits were reviewed, and eight full size mid deck lockers were placed in the facility. A number of additional devices were also added, based on the intern’s combat medic experience. Also, two fixed shelves and one horizontal work surface were added to the Medical Care Facility, with the shelves providing storage space for the additional devices and the work surface providing a location for the caregiver to work or stage equipment. Four display monitors were added to the wall above the horizontal work surface, supporting data display, telemedicine, conferencing, or other needs. The existing treatment table was replaced with a mobile surgical stretcher-chair. Two additional doors were added to the Medical Care Facility. One leads directly to the hygiene compartment, allowing it to support medical operations in addition to providing galley/wardroom support. The other door leads directly into the Vertical Translation System. The wall adjacent to the subsystems bay was moved, adding additional volume to the Medical Care Facility. This improved caregiver access to the patient and allowed for a larger number of caregivers to be present. It also provided options for relocation of support equipment relative to the patient as needed. In the upgraded Medical Care Facility, the Surgical Stretcher-Chair and the Vertical Translation System can work together to provide incapacitated crew member transport from a site of injury on any deck of the Common Habitat to the Medical Care Facility. It can also support patient treatment in a variety of positions including a variety of sitting postures and a supine posture at a variety of pitch angles. The facility can also support caregiver office work for review of examination results, private consultation, inventory and maintenance, and a variety of other purposes. A forward activity will be to conduct evaluations of the Medical Care Facility with different medical scenarios. Additionally, ambient and task lighting selections remain as forward work. The eight mid deck lockers can be augmented to use as portable equipment carts, similar to a manner in which maintenance facility stowage was used as portable carts during the NASA Desert Research and Technology Studies in the Constellation Program. Trash accommodation will also need forward work to assess, including provision for wet trash, dry trash, and biological waste. It will be important to assess a redesign of the surgical stretcher-chair. The commercial version used in the upgrade can only enable vertical translation in the seated configuration, requiring the patient to bend both hips and knees. A possible redesign of the chair will allow for vertical translation without requiring any bending at the hip or knees. Also, the commercial version is wheeled, making it mobile in gravity but unanchored in microgravity. Work will be needed to adapt the chair for gravity-independent performance. The hygiene compartment can be redesigned for dual-use medical scrub and galley handwash facility. Pending sufficient volume, it may also be possible to place sanitation equipment in this location to clean medical tools. Finally, most space architectures have never allowed for more than one incapacitated crew member, but several scenarios could potentially injure two or more crew in the same incident. This facility could be assessed to determine its present ability to address two or more injured crew in parallel and determine the potential upper limit for number of treatable crew in a multi-crew injury scenario, or to treat polytrauma of a single patient.
Habitat↗
Preliminary Medical Risk Estimates and Clinical Capability Needs for Artemis IV
BACKGROUND Human exploration spaceflight missions to the Moon and Mars present unprecedented challenges for in- mission medical care. Compared with the ISS, the greater distance from Earth will mean increased mission durations, communication delays, limited to no resupply opportunities, and significant limitations on the evacuation of ill or injured crew. Spacecraft mass, volume, and power will be curtailed while higher demands will be placed on the crew’s knowledge, skills, and abilities. In this higher risk environment, it is important to: a) quantitatively estimate human system risk attributable to medical conditions, a process known as Probabilistic Risk Analysis, and b) use these estimates to inform medical system design. IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a PRA and medical trade space analysis tool developed by NASA to advance exploration mission medical system design. IMPACT v1.0 improves upon and will soon replace NASA’s existing tool, the Integrated Medical Model, with: a novel evidence base baselined to exploration environments; an expanded list of 119 medical conditions; a significant increase in the number of medical resources that can be utilized and in the flexibility of their use; and the modelling of time lost performing mission-specific tasks due to medical conditions. METHODOLOGY: This abstract will present IMPACT estimates of medical system risk and clinical capability needs for the Artemis IV mission. Artemis IV is currently scheduled for 2026 and will visit the Gateway space station in lunar orbit prior to the second lunar landing of the Artemis program. The baseline Artemis IV mission that was modeled was 28 days in duration with phases including Orion outbound, 4 days on the Gateway space station in lunar orbit, 2 crew on the surface of the Moon for approximately one week, an additional 5 days on Gateway, and then return to Earth. This baseline was compared to two alternative 34-day design reference missions (DRMs) that shifted the lunar sortie earlier or later in the mission profile. Assumptions included 2 female and 2 male crew and a notional medical system mass of 25 kg. Medical system risk estimates include loss of crew life (LOCL), consideration of medical evacuation (known as return to definitive care – RTDC), and an estimate of crew time lost due to medical conditions (Task Time Lost – TTL). The presentation will also describe the medical conditions that are the greatest drivers of risk as well as the clinical capabilities and resources that have the largest effect on risk. RESULTS: All three DRMs had very low probability of LOCL from medical conditions, primarily due to short duration. RTDC was also similar across the DRMs. In contrast, TTL was higher in the early lunar sortie DRM due to earlier occurrence of EVA-related medical conditions. Taken as a whole, there was no clinically significant difference in medical risk across the three missions. Results for clinical capabilities and an example medical equipment list will be discussed but were similar across DRMs.
D Hilmers↗
Preliminary Medical Risk Estimates and Clinical Capability Needs for Late Artemis Missions
BACKGROUND Human exploration spaceflight missions to the Moon and Mars present unprecedented challenges for in- mission medical care. Compared with the ISS, the greater distance from Earth will mean increased mission durations, communication delays, limited to no resupply opportunities, and significant limitations on the evacuation of ill or injured crew. Spacecraft mass, volume, and power will be curtailed while higher demands will be placed on the crew’s knowledge, skills, and abilities. In this higher risk environment, it is important to: a) quantitatively estimate human system risk attributable to medical conditions, a process known as Probabilistic Risk Analysis, and b) use these estimates to inform medical system design. IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a PRA and medical trade space analysis tool developed by NASA to advance exploration mission medical system design. IMPACT v1.0 improves upon and will soon replace NASA’s existing tool, the Integrated Medical Model, with: a novel evidence base baselined to exploration environments; an expanded list of 119 medical conditions; a significant increase in the number of medical resources that can be utilized and in the flexibility of their use; and the modelling of time lost performing mission-specific tasks due to medical conditions. METHODOLOGY: This abstract will present IMPACT estimates of medical system risk and clinical capability needs for the Artemis IV mission. Artemis IV is currently scheduled for 2026 and will visit the Gateway space station in lunar orbit prior to the second lunar landing of the Artemis program. The baseline Artemis IV mission that was modeled was 28 days in duration with phases including Orion outbound, 4 days on the Gateway space station in lunar orbit, 2 crew on the surface of the Moon for approximately one week, an additional 5 days on Gateway, and then return to Earth. This baseline was compared to two alternative 34-day design reference missions (DRMs) that shifted the lunar sortie earlier or later in the mission profile. Assumptions included 2 female and 2 male crew and a notional medical system mass of 25 kg. Medical system risk estimates include loss of crew life (LOCL), consideration of medical evacuation (known as return to definitive care – RTDC), and an estimate of crew time lost due to medical conditions (Task Time Lost – TTL). The presentation will also describe the medical conditions that are the greatest drivers of risk as well as the clinical capabilities and resources that have the largest effect on risk. RESULTS: All three DRMs had very low probability of LOCL from medical conditions, primarily due to short duration. RTDC was also similar across the DRMs. In contrast, TTL was higher in the early lunar sortie DRM due to earlier occurrence of EVA-related medical conditions. Taken as a whole, there was no clinically significant difference in medical risk across the three missions. Results for clinical capabilities and an example medical equipment list will be discussed but were similar across DRMs.
D. Hilmers↗
Medical Data Architecture (MDA) Project Status
The Medical Data Architecture (MDA) project supports the Exploration Medical Capability (ExMC) risk to minimize or reduce the risk of adverse health outcomes and decrements in performance due to in-flight medical capabilities on human exploration missions. To mitigate this risk, the ExMC MDA project addresses the technical limitations identified in ExMC Gap Med 07: We do not have the capability to comprehensively process medically-relevant information to support medical operations during exploration missions. This gap identifies that the current in-flight medical data management includes a combination of data collection and distribution methods that are minimally integrated with on-board medical devices and systems. Furthermore, there are a variety of data sources and methods of data collection. For an exploration mission, the seamless management of such data will enable a more medically autonomous crew than the current paradigm. The medical system requirements are being developed in parallel with the exploration mission architecture and vehicle design. ExMC has recognized that in order to make informed decisions about a medical data architecture framework, current methods for medical data management must not only be understood, but an architecture must also be identified that provides the crew with actionable insight to medical conditions. This medical data architecture will provide the necessary functionality to address the challenges of executing a self-contained medical system that approaches crew health care delivery without assistance from ground support. Hence, the products supported by current prototype development will directly inform exploration medical system requirements.In fiscal year 2018, the MDA project developed Test Bed 2, the second iteration in a series of prototypes with functionality focused on data security through role-based access control and encryption, integration with One Portal exercise software and ingestion of an ultrasound Digital Imaging and Communications in Medicine (DICOM) file and image display. Test Bed 2 advances the medical data system architecture framework by providing these functionalities in a scalable system that maintained a layered, modular design. The architecture framework uses a data services approach with role-based access to data in a customized medical record system suitable for space exploration. These functionalities were demonstrated as part of the Next Space Technologies for Exploration Partnerships (NextSTEP) ground test demonstrated at the NASA Johnson Space Center Integrated Power, Avionics and Software (iPAS) facility. Interfacing to a Core Flight Software (CFS) system, the MDA system, using Consultative Committee for Space Data Systems (CCSDS) protocol, transferred an exercise file from the simulated flight MDA system to a mirrored MDA system on the ground through the CFS system. The selection of data sources and demonstrations enabled the team to address stakeholder concerns throughout the development process. In the next iteration, the MDA team will work with stakeholders to identify additional relevant functionalities to further advance system data models, standards and principles that will inform the medical system requirements development.
medical data architecture↗
Medical Optimization Network for Space Telemedicine Resources
INTRODUCTION: Long-duration missions beyond low Earth orbit introduce new constraints to the space medical system such as the inability to evacuate to Earth, communication delays, and limitations in clinical skillsets. NASA recognizes the need to improve capabilities for autonomous care on such missions. As the medical system is developed, it is important to have an ability to evaluate the trade space of what resources will be most important. The Medical Optimization Network for Space Telemedicine Resources was developed for this reason, and is now a system to gauge the relative importance of medical resources in addressing medical conditions. METHODS: A list of medical conditions of potential concern for an exploration mission was referenced from the Integrated Medical Model, a probabilistic model designed to quantify in-flight medical risk. The diagnostic and treatment modalities required to address best and worst-case scenarios of each medical condition, at the terrestrial standard of care, were entered into a database. This list included tangible assets (e.g. medications) and intangible assets (e.g. clinical skills to perform a procedure). A team of physicians working within the Exploration Medical Capability Element of NASA's Human Research Program ranked each of the items listed according to its criticality. Data was then obtained from the IMM for the probability of occurrence of the medical conditions, including a breakdown of best case and worst case, during a Mars reference mission. The probability of occurrence information and criticality for each resource were taken into account during analytics performed using Tableau software. RESULTS: A database and weighting system to evaluate all the diagnostic and treatment modalities was created by combining the probability of condition occurrence data with the criticalities assigned by the physician team. DISCUSSION: Exploration Medical Capabilities research at NASA is focused on providing a medical system to support crew medical needs in the context of a Mars mission. MONSTR is a novel approach to performing a quantitative risk analysis that will assess the relative value of individual resources needed for the diagnosis and treatment of various medical conditions. It will provide the operational and research communities at NASA with information to support informed decisions regarding areas of research investment, future crew training, and medical supplies manifested as part of the exploration medical system.
Shah, R. V.↗
Quantifying Risk to Improve Medical System Design for Long Duration Artemis Missions: A Demonstration of NASA's IMPACT Tradespace Analysis Tool
BACKGROUND NASA’s human exploration spaceflight missions to the Moon and Mars present unprecedented challenges for in-mission medical care. A greater distance from Earth will mean increased mission durations, communication delays, limited to no resupply opportunities, and constraints on the evacuation of ill or injured crew. Mass, volume, and power will be limited while higher demands will be placed on the crews to manage medical events. NASA’s Moon to Mars exploration strategy outlines increasingly complex Artemis missions both in terms of duration and operations. In these more challenging deep space missions, it is important to quantitatively estimate the human system risk attributable to medical conditions and use these estimates to advance medical system design. METHODS IMPACT (Informing Mission Planning via Analysis of Complex Tradespaces) is a probabilistic risk assessment (PRA) and tradespace analysis tool developed by NASA to advance exploration mission medical system design. IMPACT v1.0 includes a novel evidence library baselined to exploration environments; an expanded list of 119 medical conditions; a large increase in the number of medical resources and the flexibility of their use; and the ability for rapid and iterative analysis. Medical system risk estimates include loss of crew life, consideration of the need for return to definitive care (medical evacuation), and an estimate of crew time affected due to medical conditions. A notional long duration lunar orbit and lunar surface design reference mission (DRM) was chosen with a 4-astronaut crew to mimic a foundational exploration Artemis mission. The DRM profile includes outbound transit on Orion, Gateway space station rendezvous in lunar orbit, 6 months on the Lunar surface with extravehicular activity (EVA), return rendezvous with Gateway, and transit back to Earth. RESULTS/DISCUSSION: Overall, IMPACT successfully quantified medical risk and derived an optimal medical system to support crew on a long duration lunar mission. In this DRM, the calculated loss of crew life from a medical event was 0.008 events per mission, risk of potential need for evacuation was 0.30 events per mission, and cumulative crew time affected by medical conditions was 103 days. The medical conditions that most contributed to medical risk were decompression sickness, trauma, and respiratory failure. The conditions that had the largest effects on crew performance included musculoskeletal injuries and lunar dust exposure. The IMPACT-generated medical system included resources that target the most common and highest risk conditions and performed as expected. This demonstrates the value of the IMPACT tool in medical system design for human exploration spaceflight missions.
Arian Anderson↗
Medical Optimization Network for Space Telemedicine Resources
INTRODUCTION: Long-duration missions beyond low Earth orbit introduce new constraints to the space medical system. Beyond the traditional limitations in mass, power, and volume, consideration must be given to other factors such as the inability to evacuate to Earth, communication delays, and limitations in clinical skillsets. As NASA develops the medical system for an exploration mission, it must have an ability to evaluate the trade space of what resources will be most important. The Medical Optimization Network for Space Telemedicine Resources (MONSTR) was developed over the past year for this reason, and is now a system for managing data pertaining to medical resources and their relative importance when addressing medical conditions. METHODS: The MONSTR web application with a Microsoft SQL database backend was developed and made accessible to Tableau v9.3 for analysis and visualization. The database was initially populated with a list of medical conditions of concern for an exploration mission taken from the Integrated Medical Model (IMM), a probabilistic model designed to quantify in-flight medical risk. A team of physicians working within the Exploration Medical Capability Element of NASA's Human Research Program compiled a list diagnostic and treatment medical resources required to address best- and worst-case scenarios of each medical condition using a terrestrial standard of care and entered this data into the system. This list included both tangible resources (e.g. medical equipment, medications) and intangible resources (e.g. clinical skills required to perform a procedure). The physician team then assigned criticality values to each instance of a resource, representing the importance of that resource to diagnosing or treating its associated condition(s). Medical condition probabilities of occurrence during a Mars mission were pulled from the IMM and imported into the MONSTR database for use within a resource criticality-weighting algorithm. DISCUSSION: The MONSTR tool is a novel approach to assess the relative value of individual resources needed for the diagnosis and treatment of medical conditions. Future work will add resources for prevention and long term care of these conditions. Once data collection is complete, MONSTR will provide the operational and research communities at NASA with information to support informed decisions regarding areas of research investment, future crew training, and medical supplies manifested as part of any exploration medical system.
Rubin, D.↗
Design of Autonomous Medical Response Agent (AMRA) Aggregate Information Dashboard (AID)
Future astronauts in deep space missions will rely on tools and technologies empowering them to self-diagnose and self-treat medical conditions. Given communications delays and limited bandwidth in future long-duration exploration missions (LDEMs), medical decision support technologies must empower the crew to manage routine medical activities, acute medical incidents, as well as emergency medical scenarios independently from ground support.The Autonomous Medical Response Agent (AMRA) is envisioned as a digital tool enabling crew to issue medical complaints and interact with a medical decision support algorithm which develops a differential diagnosis and recommends a treatment protocol for the condition. AMRA will draw from individual crew medical history in addition to crew symptoms to more efficiently identify high-risk medical conditions. A new symptom could be indicative of a chronic condition or a normal adaptation to long-duration spaceflight, but could just as easily be indicative of an adverse vehicle condition affecting the entire crew.While real-time communication with a flight surgeon may not possible, the crew will nonetheless require a means to communicate and document both routine and emergency medical incidents to ground support. Conversely, flight surgeons and medical specialists on the ground will need to understand information such as crew vitals or responses to medical check-ups and examinations within the larger context of crew schedule, mission activities, and vehicle performance. A user interface which establishes communication protocols between an individual crew member and AMRA, as well as ground support to the crew is a significant area of research demanding input and consideration.The design of AMRA AID is intended to: a) represent routine medical activities as well as new (unplanned) medical incidents within the larger context of crew schedule and mission activities, and b) increase confidence between ground support and crew members over the course of LDEMs. Maintaining situation awareness of unplanned medical incidents between ground and crew will be a critical element within LDEMs. Two medical incidents headache and difficulty breathing are being explored within a user interface prototype which captures communications protocols between crew members and mission control, human health monitoring, vehicle or environmental monitoring, as well as crew schedule and mission activities holistically.
Yashar, M.↗
Medical System Requirements Development for Lunar Operations
The major health hazards of spaceflight include higher levels of damaging radiation, altered gravity, extended periods of isolation and confinement, a closed and potentially hostile living environment, and the stress associated with being a long distance from Earth. As we increase the duration of lunar stays with foreseeable communication latencies and disruptions, there will be a progressive need for crew to maintain their own health and independently respond to critical medical events. The Exploration Medical Capability element of the NASA Human Research Program is developing a set of Medical System requirements for lunar transit and surface operations. These requirements specify the capabilities, processes and procedures of a habitat Medical System needed for a range of conditions known to occur during spaceflight. Requirement text is written so as not to constrain innovative design solutions necessary for a resilient system. The requirement set includes attributes and functions the Medical System imposes on eight additional habitat systems. A key property of the Medical System is the provision of medical knowledge that will be stored, updated, analyzed, and secured within a Habitat Data System. A Task Performance Support System will aid in medical data acquisition and interpretation, crew training, medical condition prevention, diagnosis and treatment, provide interactive procedures, and track medical inventory. A Wellness System will focus on the provision of countermeasures to prevent, mitigate or treat adverse physical and behavioral health effects while the Medical System recommends adjustments to these countermeasures to maintain crew health. An Environmental Monitoring System will share out-of-bounds readings of air and water quality, acoustics, and radiation exposure levels with the Medical System to help identify issues before they affect crew health and performance. A Communications System will provide secured and private consultations between crew and the ground medical team and their loved ones on Earth. The Medical System also imposes requirements on a Research & Testbed System, fostering advanced medical science such as human research. A Waste Management System provides biohazard waste containment and waste disposal options (recycle and reuse). An Extravehicular Activity System supports crew health during lunar surface activities. And finally, a Maintenance Support System ensures that medical equipment is performing as expected. These requirements are being specifically developed for lunar surface operations but could help to identify Medical System requirements for any space habitat (e.g., I-Hab, commercial endeavors, etc.).
technology↗