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Principles of Clinical Medicine for Space Flight

Principles of Clinical Medicine for Space Flight

Michael R. Barratt, MD, MS


Astronaut and Physician, NASA Johnson Space Center,
Houston, TX, USA

Sam L. Pool, MD
Chief, Medical Sciences Division, NASA Johnson
Space Center (retired), Houston, TX, USA

Editors
Michael R. Barratt, MD, MS Sam L. Pool, MD
Astronaut and Physician Chief, Medical Sciences Division
NASA Johnson Space Center NASA Johnson Space Center (retired)
Houston, TX Houston, TX
USA USA

ISBN: 978-0-387-98842-9 e-ISBN: 978-0-387-68164-1


DOI: 10.1007/978-0-387-68164-1

Library of Congress Control Number: 2007939575

2008 Springer Science+Business Media, LLC


All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business
Media, LLC, 233 Spring Street, New York, NY-10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection
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Dr. Patricia Hilliard Robertson (Photo courtesy of NASA)
To our cherished friend and colleague Patricia Hilliard Robertsonpilot and flight instructor, physician and flight surgeon,
adventurer and astronaut. She is greatly missed by the aerospace community and all who knew her.
Foreword

The space environment does strange things, both to the workings It sure was fun knowing so little about the physiology of
of the human body and to the behavior of ordinary medical weightlessness. Skylab was a prototype space station in which
equipment. Space medicine describes the normal person in three crews spent 1, 2, and 3 months learning how to home-
an abnormal environment and is an outgrowth of aviation stead in space and to care for ourselves up there. A demand
medicine. that a physician be on each crew was rejected, but a small
Aviation medicine didnt exist when my father was born medical kit was in place, and two members of each crew
in 1884. By the time he served in the Army during World most of whom were test pilotswere trained to sew up cuts,
War I, it did, but its medical standards were still under con- extract teeth, and examine and report on their fellow crew-
struction. The Air Service Medical Manual issued by the War men. Fortunately, the practice was slow; we never had a serious
Department in 1918 discussed the publics impression that medical problem to treat.
the medical examination of an aviator was a form of refined The U.S. Space Shuttle program, and later the joint NASA
torture. One story was that of the needle test. This mythical Mir and International Space Station programs, have given the
examination supposedly involved placing a needle between physician-authors of this book experience with hundreds of
the candidates forefinger and thumb, blindfolding him, then person-trips into space. The dreaded space motion sickness
shooting off a pistol behind his ear. The examiner would then has been conquered, end-of-mission problems with vertigo
note whether, owing to a supposed lack of nerve, the applicant and fluid loss have been brought under control, and confidence
had pushed the needle through his finger. The test sounded in human capabilities has been engendered. But true long-
plausible then. duration weightlessness is still a frontier. A Mars mission is
Aviation medicine as a specialty grew quickly during still a substantial challenge.
World War II and the onset of the jet age in the 1950s. Another critical perspective on space medicine is the
However, when the space age dawned suddenly with Sputnik recognition of its inherently interdisciplinary nature. Weight-
in 1957, medicine was not ready. The pages of the Jour- less humanity exists only in a special world, a space craft
nal of Aviation Medicine for the years 1959 through 1961 crafted by engineers, a closed-loop system with a man-made
were filled with forecasts of the effects of zero G on the atmosphere and its own rules of up and down. This pulls doc-
human bodymost of them dire. For example, doubt was tors into the world of engineers and vice versa. We must help
expressed whether the gastrointestinal system would func- each other solve problems that arise not only from weightless-
tion when weightless; nourishment, it was reasoned, might ness but also from where we are and what were ina vessel
have to be given intravenously. The altitude and solitude, it where, to get to Mars, we will have to recycle the very air we
was opined, would cause break off phenomenon, a sort of breathe and the water we consume. Engineering equipment
psychosis of loneliness. My favorite of these predictions was medical and otherwiseis a challenge when everything floats
that space travelers werent going to be able to urinate. This and nothing settles.
was proven in an experiment wherein a rookie medical The details are all in this book. The nature of interplanetary
technician was strapped into the back seat of a jet fighter- space, its effect on our bodies (and minds), the treatments and
trainer, helmeted, masked, and instrumented, flown to countermeasures we currently prescribe, and the mysteries
35,000 ft, then pulled up into a zero-G parabola. At the peak that remain, are graphically described and illustrated. If you
of the maneuver, the pilot cried Go! and the poor fellow are a researcher needing a fact or reference, an engineer who
couldnt do it. Catheters were solemnly recommended for wants to know how your design affects its users, or a curious
astronauts. student drawn to medicine or biology but also to the adventure

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of space flightfill your mind here, and let your imagination characteristics as human beings. The future does not exist. We
carry you to Mars. get to help write its story.
Exploration of the heavens still has a value independent
of the commercial and military arguments we use in its Joseph P. Kerwin, MD
defense. The hunger to know and to see is one of our defining Houston, Texas
Preface

There is no land uninhabitable, nor sea innavigable.


Robert Thorne, 1527

In 1768, Captain James Cook was preparing his vessel, the missions. Along with these standards, a more complete under-
Whitby collier Endeavour, and her crew for an extended sea standing of how the space environment affects the human body
voyage. At that time, mortality rates of 50% or more were is required. The application of standard medical practice in this
not uncommon for trade voyages. Scurvy, resulting from lack unique and challenging context defines space medicine as a
of dietary ascorbic acid (vitamin C), was the great enemy. distinct discipline. In 1968, after the first few years of human
Cook developed and, with the help of ships surgeon William space flight, Dr. Douglas Busby wrote Space Clinical Medicine,
Munkhouse, administered to his crew a preventive regimen a well-referenced and highly prospective and insightful work.
that included required consumption of antiscorbuticsfood Since that time, a tremendous amount of information has
supplements consisting of such items as onions, sauerkraut, accrued regarding the physiologic effects of weightlessness
fruit, and occasionally native grasses found on islands en as well as medical and environmental events occurring dur-
route. Not a single life was lost from scurvy. Subsequent voy- ing flight that influence crew health. In many ways, this text
ages by Cook and countless others were spared from the curse is a successor to Dr. Busbys fine work. Principles of Clini-
of scurvy, and many lives were thus saved. A new expectation cal Medicine for Space Flight was written by practitioners of
arose: that crews could safely remain at sea for the prolonged space medicine for practitioners of space medicine and for oth-
periods required to make their voyages. ers who may benefit from this knowledge in their own unique
We now stand near where Cook stood more than 200 years circumstances. Neither an overall basic medical text nor a
ago. Many bold steps have been taken into space over the comprehensive review of space physiology, this book focuses
past four decades, and we now contemplate still more ambi- on aspects of medicine that arise uniquely and are dealt with
tious missions of exploration and science. The mortality and uniquely in human space flight, and how the effects of space
morbidity rates associated with these preliminary efforts have flightwhether adverse or simply anomalousare addressed
been relatively low, though certainly not negligible. In tak- to provide the best care for space crewmembers.
ing these early steps, we have gained invaluable knowledge Principles of Clinical Medicine for Space Flight draws
of how humans live in the space environment, particularly heavily on the experience of the U.S. Skylab and Space
with regard to weightlessness. Key adverse influences and Shuttle programs as well as the Russian experience with long-
effects have been identified, including radiation exposure and duration missions aboard the Salyut and Mir space stations
acquired dose, bone and muscle atrophy, and cardiovascular and, most recently, from our joint work on the first several
deconditioning. Thus far these effects have been tolerable missions aboard the International Space Station (ISS). Con-
during the course of low-Earth orbit and preliminary lunar tributors have a rich and practical experience base of direct
explorations. However, future missions will involve greater space mission support and human life sciences research, and
distances and times and will demand that these effects be this is reflected in the detailed information presented. Read-
countered and other capabilities provided to sustain the human ers will find background information on the relevant physi-
presence and to support optimal work. Our current charge is cal forces and mechanical aspects of spaceflight necessary for
to expand human exploration while maintaining the safety and complete understanding of the environment and its influence
health of the exploring crewmembers. on the human space traveler. This is followed by a comprehen-
As Endeavours surgeon Munkhouse did, we too have a sive review of the human response to every aspect of space-
standard of medical care and safety that must be taken to sea flight, the most likely medical problems encountered, their
with us. To the extent possible and practical, current standards diagnosis, management, and prevention. Special emphasis
of medicine are expected to accompany space crews on their is given to those areas most limiting to long duration flights,

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x Preface

such as radiation, bone and muscle loss, cardiovascular and The size and scope of this book attests to the technical
neurovestibular deconditioning, nutrition and metabolism, support and logistical efforts that were required to bring it into
and psychological reactions. Flight crew medical selection being. Our thanks go to technical editors Sharon Hecht and
and retention standards are addressed, with discussion on Luanne Jorevich and graphics wizards Sid Jones and Terry
rationale and application. In addition, cutting-edge technical Johnson, who went extra miles during extra hours translating
issues particularly associated with provision of medical care space medical jargon into plain English and clear figures; to
in space are discussed, including selection and use of medi- space life sciences librarians Janine Bolton and Kim So for
cal systems, telemedicine, medical imaging, surgical care, and helping us to mine the worlds literature on space medicine;
medical transport. When warranted, reasonable speculations and to Brooke Heathman and Ellen Prejean, who helped orga-
are offered regarding principles of medical support and practice nize and mold the chapters into a coherent work. Special thanks
for future exploration missions involving a return to the Moon go to Chris Wogan, world expert on space life sciences techni-
and interplanetary flight. cal literature, for bringing her talents to bear on this project,
There is an expanding niche of medical practitioners who and to Merry Post and her exemplary skill and patience for
may utilize this book as a standard of care for supporting human guiding the transformation of our knowledge base into a user-
space missions. This cadre is international, both civil and mil- friendly text.
itary, and is now extending into the commercial sector. This Of course our deepest gratitude goes to our families, and
knowledge base should also greatly benefit the many groups especially to our spouses Michelle Barratt and Jane Pool, who
and academic institutions involved in space life sciences or have weathered our fascinations and obsession with space
other environmental human research. Those participating in flight these many long years; we can never adequately repay
aerospace program and mission support and planning which you for your dedication and support.
involves or overlaps with medical decision making should Finally, to all of the worlds space travelers of all flags
also find useful information in this book. In addition, those and professions who have undergone examination, monitoring,
involved with similar responsibilities of medical support in and sampling for medical certification and science for over
environments which are analogous to spaceflight, including four decades, we offer heartfelt thanks. A rising space-faring
submarine and surface ships, polar research stations, and other civilization owes you a debt of gratitude for your patience,
extreme or remote settings may benefit from our findings, as endurance, and your great contribution to human space
we have often benefited from such venues and exchange of flight.
experience. Finally, for the medically curious, we offer a com-
Michael R. Barratt, MD, MS
prehensive reference on one of the very latest medical special-
Sam L. Pool, MD
ties; none is more fascinating.
Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Part 1. Unique Attributes of Space Medicine

Chapter 1 Physical and Bioenvironmental Aspects of Human Space Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3


Michael R. Barratt
Chapter 2 Human Response to Space Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Ellen S. Baker, Michael R. Barratt, and Mary L. Wear
Chapter 3 Medical Evaluations and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Gary Gray and Smith L. Johnston
Chapter 4 Spaceflight Medical Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Terrance A. Taddeo and Cheryl W. Armstrong
Chapter 5 Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Thomas H. Marshburn
Chapter 6 Surgical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Mark R. Campbell and Roger D. Billica
Chapter 7 Medical Evacuation and Vehicles for Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Smith L. Johnston, Brian A. Arenare, and Kieran T. Smart
Chapter 8 Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Scott C. Simmons, Douglas R. Hamilton, and P. Vernon McDonald
Chapter 9 Medical Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Ashot E. Sargsyan
Part 2. Spaceflight Clinical Medicine

Chapter 10 Space and Entry Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211


Hernando J. Ortega Jr. and Deborah L. Harm
Chapter 11 Decompression-Related Disorders: Decompression Sickness,
Arterial Gas Embolism, and Ebullism Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
William T. Norfleet

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Chapter 12 Decompression-Related Disorders: Pressurization Systems,


Barotrauma, and Altitude Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Jonathan B. Clark
Chapter 13 Renal and Genitourinary Concerns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Jeffrey A. Jones, Robert A. Pietrzyk, and Peggy A. Whitson
Chapter 14 Musculoskeletal Response to Space Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Linda C. Shackelford
Chapter 15 Immunologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Clarence F. Sams and Duane L. Pierson
Chapter 16 Cardiovascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Douglas R. Hamilton
Chapter 17 Neurologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Jonathan B. Clark and Kira Bacal
Chapter 18 Gynecologic and Reproductive Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Richard T. Jennings and Ellen S. Baker
Chapter 19 Behavioral Health and Performance Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
Christopher F. Flynn
Chapter 20 Fatigue, Sleep, and Chronotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Lakshmi Putcha and Thomas H. Marshburn
Chapter 21 Health Effects of Atmospheric Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
John T. James
Chapter 22 Hypoxia, Hypercarbia, and Atmospheric Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Kira Bacal, George Beck, and Michael R. Barratt
Chapter 23 Radiation Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Jeffrey A. Jones and Fathi Karouia
Chapter 24 Acoustics Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Jonathan B. Clark and Christopher S. Allen
Chapter 25 Ophthalmologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
F. Keith Manuel and Thomas H. Mader
Chapter 26 Dental Concerns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Michael H. Hodapp
Chapter 27 Spaceflight Metabolism and Nutritional Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Scott M. Smith and Helen W. Lane
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Contributors

Christopher S. Allen, MS, BS Christopher F. Flynn, MD


Lead, Johnson Space Center Acoustics Office, Clinical Associate Professor, Menninger Department of
ISS Acoustics Sub System Manager, NASA Johnson Psychiatry and Behavioral Sciences, Baylor College of
Space Center, Houston, TX, USA Medicine, Houston, TX, USA

Brian A. Arenare, MD, MPH, MBA Gary W. Gray, MD, PhD


Director, Cardiopulmonary Lab, Kelsey-Seybold Clinic, Senior Consultant Flight Surgeon, Canadian Space Agency,
NASA Johnson Space Center, Houston, TX, USA Toronto, Ontario, Canada

Cheryl W. Armstrong, BS Douglas R. Hamilton, MD, PhD, MSc, E Eng, PE,


Biomedical Engineer, Wyle Laboratories, Houston, TX, USA P Eng, FRCPC, ABIM
Flight Surgeon, Electrical Engineer, Wyle Laboratories,
Kira Bacal, MD, PhD, MPH, FACEP Houston, TX, USA
Research and Developmental Branch Director, Mauri Ora
Associates, Auckland, New Zealand Deborah L. Harm, PhD
Senior Scientist, Human Adaptation and Countermeasures
Ellen S. Baker, MD, MPH Division, Neurosciences Laboratory, NASA Johnson Space
Astronaut, NASA Johnson Space Center, Houston, TX, USA Center, Houston, TX, USA

Michael R. Barratt, MD, MS Michael H. Hodapp, DDS


Astronaut and Physician, NASA Johnson Space Center, University of Texas Dental Branch, Houston, TX, USA
Houston, TX, USA
John T. James, PhD
George Beck, BA, RRT, FAARC Chief Toxicologist, NASA Johnson Space Center, Houston,
Director, Engineering and Research, Impact Instrumentation, TX, USA
Inc., West Caldwell, NJ, USA
Richard T. Jennings, MD, MS
Roger D. Billica, MD, FAAFP Associate Professor, Preventive Medicine and Community
President, Tri-Life Health, Center for Integrative Medicine, Health, University of Texas Medical Branch, Galveston,
Fort Collins, CO, USA TX, USA

Mark R. Campbell, BS, MD Smith L. Johnston, MD, MS


General Surgeon, Paris Regional Medical Center, Paris, Medical Officer, Flight Surgeon, University of Texas
TX, USA Medical Branch, Preventive, Occupational, and Environmental
Medicine, NASA Johnson Space Center, Houston, TX, USA
Jonathan B. Clark, MD, MPH
Space Medicine Liaison, Baylor College of Medicine, Jeffrey A. Jones, MD, MS, FACS, FACPM
National Space Biomedical Research Institute, Houston, Exploration Medical Operations Lead Flight Surgeon, NASA
TX, USA Johnson Space Center, Houston, TX, USA

xiii
xiv Contributors

Fathi Karouia, MS, ASD, MSS Sam Lee Pool, MD


Research Associate, Department of Biology and Chief, Medical Sciences Division, NASA Johnson
Biochemistry, University of Houston, Houston, TX, USA Space Center (retired), Houston, TX, USA

Joseph P. Kerwin, BA, MD Lakshmi Putcha, PhD, FCP


Captain, Medical Corps, United States Navy (retired), Chief Pharmacologist, NASA Johnson Space Center,
Houston, TX, USA Houston, TX, USA

Helen W. Lane, PhD, RD Clarence F. Sams, PhD


NASA Chief Nutritionist, NASA Johnson Space Center, Medical Project Scientist, International Space Station,
Houston, TX, USA SK/Human Adaptation and Countermeasure Division, NASA
Johnson Space Center, Houston, TX, USA
Thomas H. Mader, MD
Alaska Native Medical Center, Department of Ashot E. Sargsyan, MD
Ophthalmology, Anchorage, AK, USA Scientist, Wyle Laboratories Life Sciences Group, Houston,
TX, USA
F. Keith Manuel, OD
Former Sr. Vision Consultant, Flight Medicine, Linda C. Shackelford, MD
NASA Johnson Space Center, Houston, TX, USA Manager, Bone and Muscle Lab, NASA Johnson Space
Center, Houston, TX, USA
Thomas H. Marshburn, MD, MS
Astronaut, NASA Johnson Space Center, Houston, TX, USA Scott C. Simmons, MS
Assistant Director, The Telemedicine Center, Brody School
P. Vernon McDonald, PhD of Medicine, East Carolina University, Greenville, NC, USA
Director, Commercial Human Space Flight,
Wyle Laboratories, Houston, TX, USA Kieran T. Smart, MBChB, MSc, MPH, MRCGP
Flight Surgeon, Wyle Laboratories, Houston, TX, USA
William T. Norfleet, MD
Assistant Professor, Department of Anesthesiology, Yale Scott A. Smith, PhD
University School of Medicine, New Haven, CT, USA Manager for Nutritional Biochemistry, NASA Johnson Space
Center, Houston, TX, USA
Hernando J. Ortega, MD, MPH
Colonel, Chief Flight Surgeon, United States Air Force, San Terrance A. Taddeo, MD, MS
Antonio, TX, USA Medical Officer, Deputy Manager of Medical Operations,
NASA Johnson Space Center, Houston, TX, USA
Duane L. Pierson, PhD
Senior Microbiologist, NASA Space Life Sciences Mary L. Wear, PhD
Directorate, Houston, TX, USA Health Care Services Manager, NASA Johnson Space
Center, Houston, TX, USA
Robert Pietrzyk, MS
Project Scientist, Human Adaptation and Countermeasures Peggy A. Whitson, PhD
Division, Wyle Laboratories Life Sciences Group, Houston, Astronaut and Research Scientist, NASA Johnson Space
TX, USA Center, Houston, TX, USA
Part 1
Unique Attributes of Space Medicine
1
Physical and Bioenvironmental
Aspects of Human Space Flight
Michael R. Barratt

Life on Earth has developed and flourished under a wide range current efforts in space exploration, the field of space medicine
of diverse circumstances. These include familiar conditions is emerging as a distinct discipline.
at Earths surface and in upper layers of the seas, as well as Aviation medicine, diving medicine, and space medi-
the more exotic subterranean and deep ocean aphotic zones, cine all involve pressure excursions, operational changes in
where oxidative and anaerobic life processes can flourish at body attitude and position, controlled breathing sources, and
extreme limits of temperature, pressure, and exposure to what critical dependence on supportive mechanisms and protec-
are classically considered toxic substances. A static gravita- tive equipment. Many of the basic problems of space medi-
tional field of 9.81 m/s2 and a protective and physiologically cinehypoxia, dysbarism, thermal support, moderate levels
supportive atmospheric gas layer comprise the major factors of acceleration, response to unusual altitudeshad been stud-
that have profoundly influenced Earth as a place of human ied over the course of decades of aviation and high-altitude
life. We are designed to function optimally in this environ- balloon flight and were fairly well understood before the first
mentand within a fairly narrow envelope at that. Without human space flight ever took place. A basic working knowl-
protective methods and devices, human beings are effectively edge of aviation medicine and physiology remains required of
confined to a vertical gradient beginning at the surface of the the space medicine specialist. A review of these basics or of
sea to perhaps 5,000 m in altitude, the rough practical limit atmospheric science is beyond the scope of this chapter; the
of human adaptation for prolonged acclimation. Simply put, interested reader is referred to the sources in the Suggested
human performance and survivability seem optimized to near Readings section at the end of this chapter.
sea level. This book focuses on the unique medical circumstances and
Nevertheless, humans have now ventured to more than 10 km clinical problems associated with excursions outside of Earths
beneath the surface of the ocean, into near-Earth space, and to atmosphere. These circumstances include a wide range of accel-
the surface of the Moon. Advances in technology and politi- eration forces, adaptive processes and problems associated with
cal organizations have enabled large-scale cooperative projects weightlessness and partial gravity fields, radiation, excursions
that have led to the expectation that humans will travel and live to other planetary bodies, and biotechnical problems associated
well beyond our narrow envelope. We have adapted to a larger with life support systems in enclosed environments. This chap-
environment and expanded our original sphere of existence. ter provides an overview of the basic physics of space flight and
This expansion is a dynamic process that by all indications will physical conditions faced by human space travelers that influ-
continue and probably accelerate as more nations obtain the ence their physiologic responses and adaptation.
technology and industrial wherewithal to join this effort. As
humans continue to explore and survive in environments that
are beyond standard physiologic limits, an understanding of
human reactions to these new environments and development
General Physics of Human Space Flight
of protective systems and processes becomes more critical.
Over the past century, such disciplines as aviation medicine and
Leaving Earth
diving medicine have arisen and matured, playing key roles in A singular definition of space is elusive and somewhat arbi-
expanding human performance and endurance in new environ- trary in terms of a specific border and limit relative to the
ments. These disciplines have successfully fostered the neces- surface of Earth; the definition varies with the particular
sary interfaces between physical systems required to support parameter being assessed. For example, the pressure limit for
the human aviator or diver and the knowledge of physiology maintaining body fluids in a liquid state (the physiologic limit)
and practice of medicine. To this same end, keeping pace with occurs at a specific altitude (about 19 km), whereas the limit

3
4 M.R. Barratt

at which forces between aircraft or spacecraft surfaces and In the process of launching to a sustainable orbit, a lofting
the atmosphere support effective aerodynamic control (the force must be applied that exceeds the gravitational force on
physical limit) is quite different (about 80 km). The common the mass to be delivered. In the history of space flight thus
factor for most biophysical parameters in defining a limit is far, this force has been provided by chemical rockets, which
a threshold degree of removal from nominal atmospheric gas typically combine a fuel and oxidizer at high temperatures and
composition and pressure, and for mechanical parameters a pressures to create a reactive force through rapid combustion.
threshold reduction in density leading to, for instance, absence The hazardous aspects of these systems, with highly explosive
of aerodynamic lift and drag. mixtures flowing through conduits at extremes of material
Fifty years ago Hubertus Strughold, in a classic and insight- and hardware performance limits, are obvious. Engine perfor-
ful treatise on the interface between Earth and space [1], mance is described in terms of two basic parametersthrust
described three major atmospheric functions that serve as and specific impulse [2]. Thrust (F), is the amount of force
base points for understanding these limits: (1) the function of applied to a rocket based on expulsion of exhaust gases. In
supplying breathing air and climate; (2) the function of sup- simplified form:
plying a filter against cosmic factors (e.g., ionizing radiation,
ultraviolet light, meteoroids); and (3) the function of supply- & e
F = mV (1.1)
ing mechanical support to the craft. Each of these functions
.
can be further stratified into specific limits and borders. Table 1.1 where F = force in Newtons (in N or m/kg/s2), m = mass flow
lists several of these limits and physiologic milestones as one rate of propellant (in kg/s), and Ve is exit velocity of the propel-
ascends vertically through the atmosphere. For astronauts fly- lant (in m/s). Thrust increases with the product of combustion
ing to low Earth orbit (LEO), all of these limits and zones are chamber temperature and the ratio of combustion-chamber
traversed in a relatively short time, on the order of several min- pressure to nozzle-exit pressure. Thrust is usually expressed
utes. The flight crew is of course enclosed in a highly protec- in Newtons (N) or pounds (lbs). The five large kerosene and
tive and controlled environment; however, knowledge of these liquid oxygen F1 first-stage engines of the Apollo Saturn V
limits remains important with regard to mishaps that might vehicle each supplied 6.7 million N (1.5 million lbs) of thrust.
occur at any altitude during ascent or descent, and knowledge Each of the three Space Shuttle main engines, fueled by liq-
of these limits also defines the capabilities of protective and uid hydrogen and liquid oxygen, generates 1.67 million N
emergency systems. (375,000 lbs) of thrust at sea level.

Table 1.1. Physical and physiological milestones during the transition from the earth surface to space.
Altitude Event or Limit
1,5252,440 m (5,000 Cabin pressure of commercial air carriers; PAO2 = 8169 mmHg
8,000 ft)
3,048 m (10,000 ft) U.S. Air Force requires that pilots breathe supplemental oxygen. PAO2 = 60 mmHg if breathing ambient air.
4,570 m (15,000 ft) Approximate upper limit of human acclimation; PAO2 = 45 mmHg breathing ambient air. Supplemental oxygen is required if
not in pressurized cabin.
10,400 m (34,000 ft) Practical limit for breathing 100% O2 in an unpressurized cabin. Above this altitude, positive pressure breathing is required
to maintain normoxia. Ambient pressure = 187 mmHg; PAO2 on 100% O2 = 100 mmHg.
15,240 m (50,000 ft) Respiratory exchange limit; ambient pressure = 87 mmHg, equivalent to sum total of alveolar water vapor tension (47 mmHg)
and CO2 tension (40 mmHg). No respiratory exchange is possible. Pressure suit or pressurized cabin is required.
16 km (10 mi) Practical limit of atmospheric weather processes and phenomena at equator (the altitude is lower near the poles).
19,200 m (63,000 ft) Armstrongs line; Ambient pressure = 47 mmHg, equivalent to tension of water vapor at body temperature.
Above this altitude, body fluids vaporize.
2530 km (15.518.6 mi) Practical limit of ram pressurized cabin; above this altitude, fully enclosed pressurized cabins are required.
40 km (24.9 mi) Atmosphere ceases to protect objects from high-energy radiation particles.
45 km (28 mi) Little protective ozone.
80 km (50 mi) Van Karman Line; threshold of effectiveness of aerodynamic surfaces. Astronaut wings awarded.
100 km (62 mi) Minimal atmospheric light scattering, blackness of space
120 km (75 mi) The so-called atmospheric entry interface for returning spacecraft; initial onset of perceptible acceleration forces, control
surface resistance. Dysacoustic zone; insufficient atmospheric density to facilitate the effective transmission of sound.
140 km (87 mi) Meteor safe zone limit; insufficient atmospheric density to effectively stop entry of micrometeorites.
150 km (96 mi) Aerothermodynamic border; minimal aerodynamic resistance or structural heating.
200 km (124 mi) Essentially no aerodynamic support; sustainable orbital altitude.
700 km (440 mi) Border of atmosphere; collisions between atmospheric gas molecules become undetectable. Particle density gradually
diminishes over thousands of km to free space density of 110 per cc, mostly atomic hydrogen.

Note: PAO2 = alveolar oxygen tension


1. Physical and Bioenvironmental Aspects of Human Space Flight 5

Specific impulse (Isp), the other parameter of engine perfor- For initial launch to orbit, the velocity component of Earths
mance, is the ratio of the thrust F to the weight flow rate of rotation can provide a significant boost in v. Such a boost is
propellant: best afforded by launching directly into the rotational velocity
vector, or straight eastward (Figure 1.1). Practically, launch
&
I sp = F / mg (1.2) from the equator eastward would provide an additional 1,600
kilometers per hour (1,000 mph) in free v, or nearly 6%
Substituting for F in (1.1) above,
of final v required to achieve LEO, which would translate
I sp = Ve / g (1.3) into enhanced system performance and increased payload.
Thus launching from higher latitude sites, or for any given site
.
where Isp = specific impulse (in seconds), F = thrust in N, m launching to azimuth angles higher than the latitude, trans-
= propellant mass flow rate (in kg/s), Ve is the exit velocity of lates into degraded performance and diminished payload-to-
the propellant (in m/s), and g = gravitational acceleration at orbit capability. To date, all crewed launches have involved
Earths surface, 9.81 m/s2. Isp is thus a measure of the exhaust eastward or posigrade launches. The U.S. Space Shuttle,
velocity. Isp is proportional to the square root of combustion- launching from the Kennedy Space Center at about 28 degrees
chamber temperature divided by the average molecular north latitude, attains its maximum performance by launching
weight of combustion products and provides a measure of the directly eastward over the Atlantic Ocean. In doing so, the
energy content and thrust conversion efficiency of the pro- shuttle attains an orbit of 28 degrees of inclination, defined
pellant. Using a propellant with low molecular mass such as as the angle between Earths equatorial plane and the plane
hydrogen or increasing the temperature of the propellant will of the spacecrafts orbit (Figure 1.2). For a given launch site,
serve to increase Isp. Isp can also be defined as the time (in launching straight eastward attains an orbital inclination equal
seconds) required to burn one kg of propellant in an engine to the launch sites latitude. A vehicle can launch to a higher
producing one N of force. As a point of reference, the Space inclination while losing some of Earths rotational velocity
Shuttle main engines are among the most efficient chemical advantage. To date, Space Shuttle missions have ranged from
rockets yet developed, with a vacuum-rated Isp of 452.5 s. minimum inclinations of 28.35 degrees to a maximum of 62
The shuttles solid rocket boosters have a vacuum-rated Isp degrees, the latter extreme during STS-36, a Department of
of 267.3 s [3]. Defense Space Shuttle mission.
Limitations of engine performance are the most important The inclination of the desired orbit cannot be lower than the
factor currently influencing space exploration. These limita- launch site latitude without a significant performance penalty;
tions affect the amount of payload that can be delivered to in such a case, the ground site never rotates through the orbital
orbit and the payload mass and velocity that can be directed to plane, and no practical launch windows exist. Posigrade
a distant site out of LEO. For a given spacecraft, the ultimate
measure of overall performance is its capability to provide the
change in velocity, or v, required for a certain orbital maneu-
ver. This includes launch to orbit, in which the required v
is the difference between the velocity component of Earths
rotation in the desired orbital plane and the final orbital veloc-
ity. It also includes losses from drag and gravity while travers-
ing the atmosphere en route to orbit, as well as subsequent
changes in orbital altitude and plane and potentially escaping
from Earth orbit. For launching to orbit, provision of suffi-
cient v for a given payload depends greatly on the engine
efficiency and the amount of propellant. To gain an apprecia-
tion of the relationship between payload, spacecraft structure,
and propellant, it is instructive to examine the mass fractions
of a standard Earth-to-orbit spacecraft. Typical values for pro-
pellant, structural, and payload mass fractions are 0.85, 0.14,
and 0.01, respectively [4]. The Saturn V Apollo Lunar vehicle
had a total launch weight of 2,621,000 kg. Of this, 129,250 kg
(4.9%) was delivered to LEO, but only 45,350 kg or about
1.7% was accelerated to escape velocity away from Earth
toward the Moon [5]. After the lunar mission was completed,
including crew descent to the surface and subsequent shedding
of the lunar module, the final reentry weight of the command
module carrying the crew was only about 5,670 kgroughly Figure 1.1. Velocity assist from Earths rotation for eastward
0.2% of the original launch weight. (posigrade) launch
6 M.R. Barratt

Figure 1.3. The J2000 Inertial Reference Frame. With Earth at the
center (geocentric), the Z axis points through the rotational North Pole,
the X axis lies in the plane of the equator and points toward the vernal
equinox (first point of Ares) for the year 2000, and the Y axis passes
Figure 1.2. Orbital inclination, the angle between the orbital plane through the equatorial plane to complete a right-handed coordinate
and earths equatorial plane. For any launch site, the minimum system. The inclination of a spacecrafts orbit is the angle between the
achievable inclination is equal to the launch sites latitude. Higher orbital plane of the spacecraft and the earths equatorial plane
inclination orbits are mechanically achievable but obtain less advan-
tage from Earths rotation
needed to describe orbital motion; as such, an inertial coor-
dinate system has been adopted that characterizes the basic
launches from NASAs Kennedy Space Center site in Florida elements of an objects orbit. This system is based on a geo-
are constrained to orbital inclinations 28 degrees and above, centric model, which places the gravitational center of Earth
whereas launches from the Russian launch site in Baikonur, at the origin of a three-axis system (Figure 1.3). The plane
Kazakhstan are restricted to inclinations at or above the site of Earths equator contains two perpendicular axes, X and Y.
latitude of about 46 degrees. Geopolitical constraints prohibit The Z-axis extends through the axis of rotation, and X points
straight-east launches from Baikonur (to avoid dropping spent toward a fixed position in space, the vernal equinox or first
stages on Chinese territory), further limiting the effective incli- point of Ares defined for the year 2000. The Y-axis completes
nation. A practical implication of this fact is that target orbits a right-handed coordinate system. This so-called J2000 refer-
for large-scale projects involving multiple launch facilities are ence system recently replaced the M50 coordinates, for which
limited by the facility located at the highest latitude. For this X was defined as the vernal equinox for the year 1950.
reason, the orbital inclination of 51.6 degrees for the Interna- The most efficient insertion into a desired orbit comes about
tional Space Station (ISS) is defined by the Russian launch, by lofting from the launch site, which is fixed relative to the
range, and tracking capabilities and must be accommodated ground, directly into the desired orbit. Missions involving ren-
by the lower-latitude U.S. and European Space Agency sites dezvous and docking with another orbiting spacecraft require
(located in Khorou, French Guyana at 6 degrees latitude). The synchrony between launch time and the target objects motion.
most flexible launch site in terms of access to the widest range This requirement gives rise to launch windows, spans of time
of orbital inclinations would be located near the Equator; also, during which the launch site rotates through the target orbital
for a given orbital altitude, higher inclination orbits, although plane. Thus the time of the launch depends on the latitude and
deriving minimal launch benefits from Earth rotation, cover longitude of the launch site and the desired orbital plane and
more of Earths surface in their ground track, a situation that inclination. Launch opportunities may exist for both ascend-
influences Earth observation and access to ground communi- ing (northbound) and descending (southbound) legs of the
cation facilities. orbit. Higher inclination orbits imply steeper intersect angles
The desired orbit to which a spacecraft is lofted is said to between the launch site velocity vector from Earth rotation
be fixed in inertial space rather than relative to the ground, and launch azimuth as well as shorter launch windows. For a
although the central point of reference is the center of the Earth. Space Shuttle launching straight out from the Kennedy Space
In other words, the motion of the orbiting spacecraft becomes Center at a latitude of 28 degrees with no rendezvous require-
indifferent to the ground surface features rotating beneath it. ments, a launch window is not constrained by orbital mechan-
A reference system independent of Earth-surface features is ics and may last several hours. By contrast, launching from
1. Physical and Bioenvironmental Aspects of Human Space Flight 7

that site to a high-inclination rendezvous orbit, such as to the Even at these altitudes, over a period of months atmo-
51.6-degree ISS, the launch window, given the current perfor- spheric drag is sufficient to cause eventual orbital decay. Solar
mance limitations, effectively becomes 510 min long. Little magnetic activity also is dynamic along short-term spikes and
margin exists for steering sideways to intercept an orbital in long-term cycles, and it may increase to cause effective
plane if the optimal launch time is missed. Adverse weather thermal expansion of the atmosphere and increase its result-
conditions or hardware anomalies during the period immedi- ing drag influence on an orbiting spacecraft. A large orbiting
ately before launch that require assessment and timely action platform thus requires periodic reboosting to remain in orbit.
by the ground team thus can have a more profound effect on As an example, in its final configuration, the Russian space
the success of launches that attempt to reach higher inclina- station Mir, with a mass of about 90 metric tons and a large
tion rendezvous targets. cross-sectional area, required several hundred kg of propellant
Other launch-window determinants include constraints of per year to perform altitude reboosts. A typical reboost might
lighting from the angle of the Sun, the flight path over ground loft the station from the lower levels of the operating envelope
sites during critical activities, the planetary geometry for trans- (350 km) to the maximum levels (440 km) limited by the per-
planetary flights, and crew factors such as time spent in the formance of docking vehicles. Decreasing the cross-sectional
launch position in full launch suit and rescue gear and crew area of the craft relative to the velocity vector, which can be
duty day. For flights that do not involve rendezvous, lighting done by feathering solar arrays or changing the structures
and crew physical and duty limits become the primary factors attitude, serves to decease drag and maintain orbital altitude
determining the duration of the launch window. for longer periods.
For a given orbit, the launch window changes from day The orbital shape of an object gravitationally held by Earth
to day as Earth rotates eastward independent of the inertial is typically elliptical, with two major landmarks: the perigee,
orbital plane. The node of an orbit, the point where it crosses the point along the elliptical path closest to Earths center, and
the equator, can be seen to track westward for a given clock the apogee, the corresponding point farthest from the cen-
time relative to the day before. This phenomenon, known ter. The complete characteristics of a spacecrafts orbit can
as nodal regression, is due primarily to the oblate nature of be defined by six primary factors, or orbital elements. Also
Earth induced by the equatorial bulge. On successive days, the known as the classic Keplerian elements, these elements are
launch site rotates through the orbital plane earlier than on the based on a three-axis reference system using Earths center as
previous day. For a planned launch from Kennedy Space Cen- an inertial origin point.
ter to the 51.6-degree ISS orbit, for example, missing a launch Figure 1.4 describes the basic elements of a body in orbit.
opportunity because of weather or mechanical factors results The Z-axis is the earths axis of rotation and goes through
in the next days opportunity being approximately 20 min ear- the north (+Z) and south poles. The X and Y-axes are in the
lier than on the planned day. This time accumulates over a equatorial plane, with +X pointing to the vernal equinox and
delay of several days, and thus such a delay may require shift- +Y offset 90 degrees in a right-handed system. The following
ing the crews sleep period if the crew is adapted to a certain elements are required to completely describe an orbit for a
operational time schedule. two-body system [6]:
a: semi-major axis: describes the size of the ellipse (Figure 1.4A)
Earth Orbit
e: eccentricity: describes the shape of the ellipse (Figure 1.4A)
In attaining orbit, the influence of aerodynamics on a space-
i: inclination: the angle between the angular momentum vector
craft and its crew becomes negligible and the influence of
and the unit vector in the Z-direction. (Figure 1.4B)
the basic laws of Newtonian mechanics increases. Weight-
lessness (or free fall) is sustained when the inward force of W : right ascension of the ascending node: angle from the
gravity is exactly counterbalanced by the outward centrifugal vernal equinox to the ascending node. The ascending node
force of the spacecraft, with sufficient velocity forward to is the point where the satellite passes through the equatorial
result in a flight path tangential to the surface of Earth. For a plane moving south to north. Right ascension is measured as a
circular orbit, the flight path becomes a constant altitude; for right-handed rotation about the pole, Z. (Figure 1.4B)
an elliptical orbit, the altitude will vary depending on rela-
w : argument of perigee: the angle from the ascending node to
tive position on the orbital track. To be sustainable, the alti-
the eccentricity vector measured in the direction of the space-
tude must be sufficient to escape drag-inducing atmospheric
crafts motion. The eccentricity vector points from the center
interaction, and forward (tangential) velocity must be high
of the earth to perigee with a magnitude equal to the eccentric-
enough to keep the spacecraft falling around Earth rather
ity of the orbit. (Figure 1.4B)
than to Earth; this is the state of free fall, which is perceived
as weightlessness. The standard orbital velocity in LEO is n : true anomaly: the angle from the eccentricity vector to the
8 km/s (5 mi/s). A typical Space Shuttle mission is flown at satellite position vector, measured in the direction of satellite
an altitude of 320 km (200 mi) with a forward velocity of motion. This is a time component; alternatively, time since
28,160 km/h (17,500 mph). perigee passage could be used.
8 M.R. Barratt

Figure 1.5. Ground track of a spacecraft in low Earth orbit, in this case
the International Space Station with an orbital inclination of 51.6

22.5-degree westward precession of the ground track for each


90-min orbit can be seen as Earth continues to rotate eastward
independent of the inertial orbital plane.
Spacecraft can be placed into a wide variety of orbits,
including those involving retrograde launches (opposite the
direction of Earth rotation) and geostationary positions, which
maintain a constant position relative to a fixed ground point.
However, the human presence introduces limitations that are
Figure 1.4. A and B. The six primary elements describing a
based on environmental hazards. For human space flight, LEO
spacecraft orbit. These are known as the classic Keplerian elements
is for practical purposes bounded at the lower altitude by the
and define the size, shape, and orientation of the orbit, as well as the
position of the spacecraft on the orbit physical constraint of atmospheric interaction and at the upper
altitude by the physiologic constraint of increasing radiation
exposure from the geomagnetically held Van Allen radiation
The precise orbit of a spacecraft may not be fully described belts. These constraints result in the standard LEO work enve-
with these classical elements because of various perturbation lope for long-duration flight being between 200 km (124 mi),
forces such as third-body effects (e.g. lunar gravitational influ- below which atmospheric drag would cause rapid decay of the
ence), solar radiation, atmospheric drag, and the influence of spacecraft orbit, and approximately 500 km (312 mi), where
a nonspherical Earth. Although the effects of these perturba- depending on orbital inclination the daily radiation dose might
tion factors are smaller than those of the basic elements for a exceed 5 104 sieverts (Sv) (50 millirem [mrem]). The rela-
spacecraft in LEP, the perturbation factors must nevertheless tionship of orbital characteristics and radiation exposure is
be accounted for in mission operations. Detailed descriptions described further in Chap. 23.
of the classical elements and other factors is beyond the scope
of this text; however, a basic understanding of these factors is
Orbital Debris
useful for the space medicine specialists situational under-
standing of crewed space flight. Early seafarers had to contend with uncharted reefs and occa-
After launch and ascent, which typically lasts 79 min, a sional floating debris; space vehicles in LEO are faced with
crewed spacecraft such as the Soyuz or Space Shuttle quickly an analogous collision potential. Operations in Earth orbit can
crosses the atmosphere and realm of aerodynamics into LEO. bring spacecraft near other similarly held objects, primarily
The path of a spacecraft over the ground (its ground track) can originating from artificial sources. Given the standard orbital
be envisioned by flattening out Earths spherical shape, thus velocities of such objects and assuming unlimited radical orbital
producing the familiar sine-wave track over the Mercator pro- paths, the collision velocities can be formidable, with an aver-
jection maps used in mission control centers (Figure 1.5). The age relative velocity between two objects of 10 kilometers per
1. Physical and Bioenvironmental Aspects of Human Space Flight 9

second (kps); with this relative velocity, a 100-gram fragment to inflict substantial damage on spacecraft but are essentially
possesses kinetic energy equivalent to 1 kg of TNT [7]. invisible and therefore unavoidable. Risk parameters for colli-
Most of the material in LEO is artificial, consisting of active sion of orbital debris with crewed platforms and EVA systems
spacecraft, spent and inactive satellites, booster components, are discussed further in Chap. 12, which deals specifically with
and fragmentation products resulting from pyrotechnic sepa- the issue of decompression of habitable cabin atmospheres.
ration devices. More than 95% of tracked objects are consid- International efforts are currently being made to minimize the
ered unusable debris. The more heavily used orbits tend to be further generation of orbital debris by limiting the use of fran-
the most cluttered with debris. In contrast, the flux of natural gible bolts and actively deorbiting spent stages.
material, consisting mostly of fragmentation and disintegra-
tion products of comets and asteroids, is much lower than
that of artificial material. Natural material flux is primarily
Beyond Earth Orbit
confined to particles smaller than 1 mm with velocity on the Pulling away from Earth requires an escape velocity that
order of 16 kps. Such particles continually rain down on Earth depends on the radius of the orbit, according to the equation
and rarely slow enough to become trapped in LEO. Approxi-
mately 40 million kg of such matter is thought to reach Earths Vesc = 2 / r (1.4)
surface annually, with the peak in the size distribution at about
200 m in diameter. This mass amount is thought to be com- where Vesc is escape velocity (in km/s), is Earths gravita-
parable over very long time scales to the contribution from tional constant (equal to Earths mass multiplied by G, the
bodies of much larger size (in the 1-cm to 10-km range) [8]. universal gravitational constant, or 398,600.5 km3/s2), and
Orbiting objects are tracked by the U.S. Space Surveillance r is the distance from Earths center (the radius of the orbit).
Network; objects larger than 10 cm (4 in.) can be detected and The farther the distance from Earths center, the smaller the
tracked with Earth-bound radar. Currently about 8,000 such V required. At the surface of Earth, where the distance from
objects are being actively tracked [9]. Figure 1.6 depicts the Earths center to the equator is 6,378 km, a theoretical V of
rise over time in the number of tracked objects in LEO, where 11.2 km/s is needed to escape gravitational pull; an additional
most spacecraft operate, showing a nearly linear and parallel V would be needed to make up for atmospheric losses. For
relationship with the history of spaceflight activities. These example, from the typical LEO altitude of the ISS (386 km
tracking data occasionally allow avoidance maneuvers to be with an orbital radius of 6,764 km), the escape velocity is
made when imminent collisions or proximity are calculated, 10.8 km/s; for a spacecraft already established in this orbit
as has been done for the Space Shuttle, Mir, and ISS. However, with a velocity of about 7.8 km/s, only a small additional V
most of the material, in terms of both number and total mass, is required.
consists of small objects below the size threshold for track- For travel beyond near-Earth space, the factor of great-
ing by radar. Shielding can be reasonably afforded against est influence becomes sheer distance and its effect on travel
hypervelocity collision forces with objects up to 1 cm in size; time and subsequent radiation exposure. Near-Earth destina-
shielding for larger objects becomes unduly heavy and car- tions outside of LEO such as the Moon and Lagrangian points
ries substantial costs in terms of performance and structure. (points of Earth-Sun or Earth-Moon gravitational equilibrium)
As such, the greatest danger for large crewed space platforms can be reached relatively easily with currently available chem-
stems from objects 110 cm in size, which are large enough ical rockets, although the payload mass that can be delivered
to these sites remains limited. However, with conventional
chemical rocket technology, travel beyond near-Earth space
becomes much more daunting. Most Mars flight scenarios
have involved mission durations on the order of 450 to more
than 1,000 days [1012] and mission profiles at the extremes
of chemical rocket capabilities. These missions might also
involve some gravitational assist maneuver such as a plan-
etary (Venus or Earth) flyby. The bulk of the total mission
time could be taken up by interplanetary transit in weightless
conditions.
Aside from the limitations on the vehicles involved, such
mission scenarios also are well outside the current experi-
ence with human space flight. The longest space flight to
date was the laudable 438-day mission of the Russian phy-
sician-cosmonaut Dr. Valery Polyakov aboard Mir between
January 1994 and March 1995. Although this mission was
Figure 1.6. Population over time of orbital debris larger than 10 cm highly successful, the longer limit of flight duration must be
in low Earth orbit, as cataloged by the Space Surveillance Network extended significantly to entertain thoughts of very long mis-
10 M.R. Barratt

sions using current propulsive technology. Provision of some can be met, experienced long-duration space crewmembers
degree of artificial gravity en route, although fraught with with known in-flight and postflight performance can be sent,
medical, performance, and engineering challenges, may miti- and reasonable microgravity countermeasures can be used.
gate the adverse effects of prolonged exposure to microgravity Provision of artificial gravity may prove to be an effective
(described later in this chapter under Microgravity and Partial countermeasure if prolonged exposures to weightlessness are
Gravity). However, to consider distances to Mars and other inevitable. However, providing a constant rotational artificial-
more distant potential targets of crewed missions such as the gravity field confers substantial mechanical and engineering
larger asteroids, the development of advanced propulsion and problems in addition to human tolerance challenges. From a
power systems must be a high priority to enable human explo- life sciences standpoint, the most efficacious solution to ensure
ration of the solar system in earnest. Scenarios involving the mission success is to keep transit times short. Critical space
exposure of humans for many months to interplanetary transit, medical research objectives would thus focus on optimizing
with its harsh radiation environments, should be avoided by human performance within a familiar time envelope and on
applying technology to travel faster. Although the desirabil- developing true clinical autonomy during space flight.
ity of faster interplanetary transit times may seem obvious, Many new propulsion technologies are currently being
specific operational factors may be identified that bolster this examined to use propellants much more efficiently and reduce
requirement. Prominent among these factors is the absolute transit times to destinations such as Mars. Figure 1.7 compares
radiation dose to which a human can be exposed and still meet the relative performance characteristics of several propulsion
the annual and career limits of radiation exposure. Mainte- concepts. Although expounding on the details of propulsion
nance of bone and muscle mass and cardiovascular condi- is beyond the scope of this text, it is readily evident that con-
tioning in microgravity also becomes critically dependent on ventional chemical rocket technology is at the low end of the
the use of countermeasures, and to date no countermeasure scale with regard to enabling crewed solar system explora-
regimen has proven completely effective. Unlike crewmem- tion. Technical comparisons of new propulsion technologies
bers who return to Earth after a long-duration mission, crew- are factored into exploration mission planning [2,13]. Some of
members landing on the surface of Mars, with its gravitational these advanced technologies, such as nuclear thermal rocket
field of 0.38 G (where G is a multiple or fraction of g = unit engines, are relatively mature and offer performance well
gravity on Earth, or 9.8 m/s2), will be alone in managing their beyond that of chemical systems, although crews will need
postflight medical treatment and rehabilitation program, with to be shielded from artificial ionizing radiation. Other tech-
only remote guidance from ground specialists and onboard nologies, such as magnetoplasmadynamic engines, are more
medical references to augment their preflight medical train- exotic and require much forward work but offer tremendous
ing. The author and others, in observing several crewmembers
freshly returned from long-duration flight, have noted a con-
siderable degree of individual variability in postflight condi-
tion and performance despite similarities in flight experience
and use of countermeasures. It would be highly advisable that
those crewmembers embarking on inaugural remote explora-
tion missions with planned surface excursions have previous
experience with long-duration space flight and well docu-
mented postflight performance and readaptation to a gravity
field. The psychological tolerance and mission performance
of such crewmembers should also be known. A problem
becomes immediately apparent in making previous long-dura-
tion flight a requirement. Such experience on a LEO station,
for instance, coupled with 14- to 36-month interplanetary
transit times would probably result in radiation exposure that
exceeds established career radiation limits.
With a few notable exceptions, standard LEO duty tours
onboard the Mir and ISS have been on the order of 120180
days; this constitutes a reasonable period for performing effec-
tive work without incurring unacceptable cumulative radiation
exposure and bone mineral loss. Perhaps the only reason to
perform longer missions would be to expand the long-dura-
tion flight envelope for characterization of human response Figure 1.7. Relative performance of various propulsion concepts.
and development of more effective countermeasures. A clear Although chemical rockets have served well for near-Earth space
near-term goal, then, is to provide transit times well within exploration, exploration class missions must utilize advanced
this experience base. This would ensure that radiation limits technologies to become practical
1. Physical and Bioenvironmental Aspects of Human Space Flight 11

advantages in planetary transit scenarios. Given that Mars is at To venture confidently and frequently beyond near-Earth
an extreme limit of chemical rocket technology for round-trip space, high-yield and reliable power systems are required to
flights, it is logical to use a new technology on an evolutionary ensure autonomy and mission success and to enhance crew
step toward these advanced propulsion concepts, then apply safety and comfort. A transplanetary craft carrying four to
and enhance the same technology to go further and to increase six crewmembers might be expected to require 2060 kW for
the feasibility and practicality of maintaining a presence on systems operations, and the same would be true for a mod-
the surface of Mars. est surface habitat. These power requirements must be met
One such concept, the variable specific-impulse magneto- over periods of at least several months and must be absolutely
plasma rocket (VASIMR), consists of a plasma engine that assured. As such, a forward step beyond solar and fuel cells is
can be throttled. The relative balance of thrust F and spe- necessary. Submarines provide a historical analog: the transi-
cific impulse Isp is varied under constant power, enabling tion from fossil-fuel burning engines to nuclear-powered steam
the optimal use of propellant. Greater F is used for orbital turbines has afforded electrical power generally in excess of
boost and deceleration phases, whereas lower F and higher standard propulsion requirements. Power for life support
Isp are used for efficient transplanetary flight [14]. Plans for system functions, desalinization of seawater and processing
Mars missions involve multiple launches for vehicle assem- it into potable and hygienic water, electrolytic production of
bly and unmanned cargo missions, with transit times shorter breathing oxygen from seawater, and various other support
than those that can be achieved with chemical rockets. One systems has become relatively abundant.
representative piloted scenario uses a 12-MW nuclear-electric For space flight, access to abundant power with sufficient
VASIMR rocket to deliver a payload mass of 61 metric tons margins is critical for crew safety as well as for mission suc-
to Mars [15]. The cryogenic hydrogen propellant can also cess. Nuclear fission reactorsif they can be safely launched
be positioned around the crew cabin, providing an optimal and managedoffer an attractive and currently available
barrier against high-energy galactic cosmic rays. Along with option for generating electrical power for long-duration space
enabling the near-term exploration of Mars, this basic technol- flights. This approach would change the current situation
ogy could represent an evolutionary step over a greater time of resource and power limitation to one of resource limita-
scale, most likely on the order of several decades. Incorpora- tion only; resources could then be better managed, such as
tion of advanced power systems, such as nuclear fusion, as by advanced but power-intensive regenerative life support
they become available will afford a further drastic improve- systems. Using nuclear reactors as a power source for an
ment in performance. With 10100 gigawatts available, for advanced propulsion system might afford this electrical power
example, accelerations involving potentially protective frac- as a by-product and drastically increase the margin for mis-
tions of linear unit-gravity, on the order of 0.30.5 G, become sion success and safety. Obviously, many safety and engineer-
available. Such technology could fully open up the solar sys- ing issues are associated with nuclear systems; aside from the
tem to human exploration and exploitation. potential problems of further exposing the crews to ionizing
A similar need for advanced technologies exists for onboard radiation, such systems may require large radiators to dissipate
power generation. Systems such as environmental control and heat, which would be vulnerable to debris and micrometeor-
life support, avionics, communication, and laboratory and oid impact while the craft is in LEO. However, with no other
investigational facilities require electrical power in abundance. equivalent available power source in the immediate future,
Solar energy is readily available in LEO, and solar arrays have barring a breakthrough in fusion technology, the safe and
proven effective in supplying satellites and crewed stations. careful use of nuclear reactors for spaceflight propulsion and
At assembly-complete, the solar arrays of the ISS will sup- planetary surface use should be vigorously explored. Whether
ply the 75 kW needed for systems and laboratory operations. any sustainable crewed exploration beyond near-Earth space
However, these arrays typically provide little reserve power in can be undertaken without nuclear power is doubtful.
standard operations and, because of their large surface area,
are vulnerable to damage by orbital debris. Venturing further
outward in the solar system also means that diminished solar Acceleration Forces
energy flux will be available to generate power. Fuel cells,
Acceleration Basics
such as those used on the Space Shuttle, function well for
short-duration missions and provide the added by-product of With the advent of powered vehicles, notably aircraft and space-
potable and hygiene-grade water after reacting liquid hydro- craft, the possibility first arose for prolonged human exposures
gen and oxygen. Power requirements on the Space Shuttle to significant sustained acceleration forces. As stated earlier,
average 14 kW, and thus water is in fact produced in surplus, ascending the gravity ladder to leave Earth implies a climb to
necessitating periodic overboard dumps. However, coupled above the atmosphere and a v of 8 kps to attain a sustainable
with the relatively short operational life of fuel cells, a typical LEO. The time during which the spacecraft must accelerate to
Space Shuttle mission involves the consumption of 1,590 kg this new velocity determines the forces acting on the human
(3,500 lbs) of cryogenically stored hydrogen and oxygen to occupant. In theory, this acceleration could be slow enough to
generate the onboard electrical power needed. produce minimal effects; in practice, however, the time span is
12 M.R. Barratt

bounded by vehicle performancea slow ascent to final veloc- the pilot of a high-performance aircraft is seated upright,
ity and sustainable orbit involves more time fighting against which is necessary for optimal control in a dominantly hori-
gravity and hence greater propellant consumption, whereas an zontal reference plane. However, during tight turns, that posi-
overly rapid ascent incurs greater aerodynamic and structural tion subjects the pilot to G loads in the most physiologically
loads. The acceleration of ascent is not linear, but rather shows vulnerable axis (head to foot or +Gz). The major determinant
peaks and troughs based on engine staging and structural lim- and limiting factor of performance under sustained +Gz accel-
its. At the end of a mission, after a deorbit engine burn, the eration is the cardiovascular system; the hydrostatic pressure
spacecraft must reenter the atmosphere and slow to its origi- acting on the vertical blood column between the heart and
nal velocity in a reciprocal negative acceleration (deceleration) brain in particular renders cerebral perfusion vulnerable. In
profile, with aerodynamic drag as the prevailing force. Return- the early days of human space flight, control during ascent
ing from the Moon, the Apollo capsules carried more velocity and descent was highly automated; the human inputs that
than a spacecraft returning from LEO and thus were subject to were required were largely independent of the familiar hori-
even higher acceleration loads for entry. zontal vision reference required and maintained by the aviator.
Earth launch and landing loads will probably be the great- Thus for the first 20 years of space flight, the space flyer did
est acceleration forces experienced by human beings as more not require upright orientation, thus avoiding this physiologi-
remote exploration missions are considered, and these forces cally vulnerable position and allowing positions with the most
have shown to be tolerable. In any case, physiologically sig- favorable orientation to the G vector, +Gx (chest to back), to
nificant acceleration loads are a fundamental consequence of be assumed for launch and landing. Moreover, as spacecraft
transition between gravity fields of planetary bodies. Exten- have become less of a crewed ballistic missile and more of
sive reviews of acceleration forces and their effects on the the multiperson, payload-carrying, and cross-range-capable
human are available in the aviation medical literature; this spaceships of today, launch and landing loads have eased.
section focuses instead on the genesis of acceleration forces The basic types of acceleration are linear, radial, angular,
in the spaceflight environment and highlights the differences and Coriolis, all of which can occur alone or in combination,
between aviation and space crewmembers. and each of which contributes a vector component to a resultant
A review of Sir Isaac Newtons three basic laws of motion sum. Accelerations are characterized by the vector direction
is both useful and relevant in clarifying acceleration: (axis), rate of onset, magnitude, and duration of application to
the human occupant. The accelerations described also involve
1 A body at rest (in motion) will remain at rest (in motion)
reactive forces (linear and torque) determined by the mass of the
unless acted upon by an outside force.
object. From the three basic laws of motion, it is understood that
2 F = ma, where F = force in Newtons (kg/m/s2), m = mass in
mass provides inertial resistance to acceleration. These inertial
kg, and a = acceleration in m/s2.
forces, resulting from changes in linear and angular velocity,
3 For every action, there is an equal and opposite reaction.
are what actually lead to the physiologic effects. In addition to
The constant acceleration caused by Earths gravity at sea level considering the basic accelerations encountered in space flight,
is taken as 9.81 m/s2, and is denoted as g. Using this value one must also consider the forces resulting from those accelera-
as a reference, the notation G is used to denote fractions or tions; Coriolis accelerations in particular will be considered in a
multiples of g; G is thus a dimensionless quantity. The unit subsequent discussion of artificial rotational gravity.
G is not to be confused with G, the universal gravitational Linear acceleration. For linear acceleration, the direction
constant, as discussed later. of movement is constant, and only the velocity changes. The
equation for linear acceleration is:
Acceleration Forces in Space Flight a = v/t (1.5)
In many aerospace operations, components of basic accelera- where a = acceleration (expressed in m/s2), v = change in
tions can be mixed. However, the loads typically involved in velocity (in m/s), and t = time (in s). The resultant force on a
spacecraft launch and entry involve linear acceleration, with human undergoing linear acceleration, which acts opposite the
the spacecraft maintaining a more or less constant relation to perceived acceleration, is described by Newtons second law:
the acceleration vector. This situation allows crewmembers
F = ma (1.6)
and payloads to be placed in optimal positions relative to the
acceleration vector so as to best withstand those forces. An where F is the force acting on a body (in N [m/kg/s 2]),
exception is the U.S. Space Shuttle, which effectively becomes m = the mass of an object (in kg), and a = acceleration (in m/s2).
an airplane with standard upright seating as it reenters Earths The gravitational force that holds us to Earths surface implies
atmosphere during landing. a reactive force based on our mass and a linear acceleration
For any activity involving sustained acceleration loads, the of 9.81 m/s2, denoted as g or 1 G. Significant, sustained lin-
orientation of the human crewmember to the vector of G load- ear accelerations involving multiple Gs are a phenomenon
ing, along with the absolute G load incurred, can profoundly of spacecraft, associated thus far with launch and landing
influence crew activity and performance. In terms of aviation, activities. (For a hypothetical spacecraft capable of prolonged
1. Physical and Bioenvironmental Aspects of Human Space Flight 13

acceleration at 9.8 m/s2, the force acting downward on the In all piloted launch vehicles leaving Earth, crewmembers
body would be perceived as natural unit gravity.) are positioned such that the major G loads incurred by the
The well-known effects of multiple-G forces on the human body during ascent are taken along the body +Gx axis. Repre-
body depend greatly on orientation, and thus require a coordi- sentative G profiles of various piloted launch vehicles during
nate system to depict direction. The accepted body coordinate nominal ascent are shown in Figure 1.8; Figure 1.9 shows entry
system, along with resulting inertial forces and circumstances G loads for the same vehicles. The vector sum of the resultant
of these linear acceleration components in space flight, is loads on the human occupant depends on seat positioning and
shown in Table 1.2. orientation with respect to the vehicle and acceleration vector.

Table 1.2. Standard three-axis coordinate system describing linear accelerations and resulting inertial forces
on the human body for space flight.
Primary Spaceflight Circumstances
Axis/Direction Acceleration Resultant Inertial Force (Most involve mixed acceleration vector components)
+Gz Headward Head to Foot Space Shuttle entry (1.2 G sustained)
Shuttle landing turn (1.21.98 G)
Apollo Lunar Ascent Module
Gz Footward Foot to Head
+Gx Forward Chest to Back Launch (38 G all vehicles)
Entry (1.2 G recumbent in Shuttle to 8 G in Mercury-
type capsules)
Launch abort scenarios (1720 G)
Aerocapture maneuvers (future transplanetary flight)
Parachute opening (Apollo, Soyuz, etc.)
Landing impact (transient, 420 G)
Gx Backward Back to Chest Shuttle runway deceleration from brakes, drogue chute
+Gy To Right Right to Left Impact (land or water) on capsule from horizontal
velocity component (wind)
Gy To Left Left to Right Same
Note: Spacecraft orbital maneuvering can be applied to all axes, typically involving very low G forces.

Figure 1.9. Representative acceleration profiles and resultant G loads


on occupants of the Gemini, Apollo, and Space Shuttle (Space Trans-
portation System) spacecraft during atmospheric reentry. Gemini
Figure 1.8. Representative acceleration profiles and resultant G and Apollo crew capsules allowed most of the load to be taken in
loading for launch of the Gemini, Apollo, and Space Shuttle (Space the crewmembers +Gx axis. Space Shuttle crewmembers land in an
Transportation System) spacecraft. Most of the loading is received upright, seated position, exposing deconditioned crewmembers to
along the crewmembers +Gx axis much smaller loads but in the +Gz axis for much longer periods
14 M.R. Barratt

Such positioning is also related to vehicle structure, center of acting on the body in the opposite direction of angular accel-
gravity, and flight characteristics. eration (outward), the centrifugal force:
Crewmembers returning from a U.S. Space Shuttle mission
Fc = mv2/r (1.8)
assume an upright position, the position of greatest vulnera-
bility in the transition from being adapted to weightlessness to where Fc = centrifugal force (in N), v = velocity about the
being relatively deconditioned aviators. Crewmembers main- circular course, m = the mass of an object in kg, and r = radius
tain a standard aircraft seating arrangement during landing, of the circle. From the standpoint of human exposures, sig-
with the entry vector in the +Gz orientation for vehicle and nificant, multiple-G radial accelerations are experienced in
occupants. Shuttle landing forces are fairly gentle and grad- human-rated centrifuges, in which a rigid moment arm holds
ual, with a constant acceleration of about 1.2 G over 17 min a crew fixed to the center of rotation, and high-performance
during actual atmospheric entry, culminating in a turn to final aircraft, in which engine thrust applied in a constant direc-
approach resulting in a maximum of 2.0 +Gz, with 1.41.5 tion and aerodynamic lift forces circularize the path. Loads of
+Gz being typical. 112 G can be incurred by piloted aircraft, with the centrifugal
Mishaps during ascent and entry can lead to much higher force applied to the pilot in the +Gz body orientation caus-
loads, primarily in the +Gx axis. Escape tower systems, such ing the well-known adverse effects on the hydrostatic blood
as those currently used for the Russian Soyuz booster and column. For a spacecraft that is free of the atmosphere, such
those formerly used for the U.S. Apollo and Mercury space- radial motion and forces are fairly untenable because of the
craft, are designed to remove the crewmember from the launch huge expense in propellant necessary to apply thrust to sup-
pad or from an early launch explosion as rapidly as possible. port constant directional change. The one caveat, however, is
This design incurs very high (1020 G) acceleration loads in the Space Shuttle, which effectively becomes an aircraft upon
the +Gx orientation. This system has been used operationally landing. A turn around an imaginary heading alignment circle
on one occasiona fire on the launch pad during the Soyuz aligns the Shuttle for final approach to land, incurring a force
T10A launch. During that event, the escape rockets pulled the of between 1.0 and 1.8 sustained +Gz on its upright-seated
capsule containing cosmonauts V. Titov and G. Strekalov up occupants. Although this force is small compared with that
and away from the fire, briefly subjecting them to about on occupants of high-performance aircraft, the cardiovascular
17 +Gx while a safe altitude was attained for parachute deploy deconditioning and relative plasma-volume depletion charac-
followed by a soft landing about 4 km away from the launch teristic of returning space flyers renders them physiologically
pad [16,17]. Launch abort scenarios are also possible, such as equivalent to terrestrial pilots experiencing several Gs.
that experienced by cosmonauts V. Lazarev and O. Makarov The major implications of radial acceleration for human
in the Soyuz 18A flight bound for the Salyut 4 orbital station. space flight relate to the provision of artificial gravity, as dis-
Failure of third-stage separation on ascent subjected the crew- cussed in the next section.
members to a high-load suborbital flight lasting approximately Angular acceleration. Angular acceleration involves
21 min before the chute deployed and the craft landed. Maxi- change in rotation rate about an axis passing through the body,
mal forces were said to be 2021 +Gx. Although some minor as might be incurred in a rotating chair or rolling an aircraft.
injuries were sustained during the hillside landing, no persis- Angular motion may be expressed in degrees of rotation, revo-
tent effects from the high G loads sustained were reporteda lutions, or radians, where one radian is one revolution (360
remarkable testament to G-load tolerance in this axis [18,19]. degrees) divided by 2, or about 57.3 degrees. Angular veloc-
In both of these extreme cases, crewmembers were not ity and acceleration are given by:
already deconditioned from weightlessness. A more rapid bal-
w = (21)/t or d/dt (1.9)
listic entry after a LEO mission might result from an overly
long deorbit burn time, with higher transient G loads than
a = (w2w1)/t or dw/dt (1.10)
normal. Loads such as these typically would not be as high
as those in a launch abort scenario, but because they would where = angular velocity (in radians/s), = angular motion,
be applied to deconditioned individuals, they may have more = angular acceleration (in radians/s2), and t = time (in s). In
significant physiologic effects. general, angular acceleration is caused by torque, caused by a
Radial acceleration. Radial acceleration involves a force applied at a specific distance (the moment arm) from the
change in direction without a change in speed. In particular, center of rotation:
for an object traveling in a circular course, radial acceleration
M = Ja (1.11)
describes the inward or centripetal acceleration towards the
center of the circle: where M = torque applied to a rotating body (in N-m), J = rota-
2 tional inertia (in kg-m2/radian, where the radius of the rotation
a = v /r (1.7)
is expressed in meters), and = the angular acceleration (in
where a = radial acceleration (in m/s2), v = velocity about the radians/s2).
circular course, and r = radius of the circle. The force that In space flight, angular accelerations can be incurred by
produces the radial acceleration is balanced by a pseudoforce human occupants of a spacecraft undergoing orbital maneuvers
1. Physical and Bioenvironmental Aspects of Human Space Flight 15

or ballistic reentry vehicles undergoing spin stabilization (e.g., flight assignment, such as from an ISS or Mir station tour, do so
the early space capsules). These maneuvers involve some off- in a recumbent seat on the Shuttle middeck that positions them
set from the spin axis, so that components of both radial and on their backs with their feet forward to meet the +Gz limit
angular acceleration are involved (although the angular accel- noted above. (Such crewmembers are not involved in piloting
erations involved would be fairly small). Mishaps can provide the Space Shuttle during entry and landing.)
large and adverse components of angular accelerations; one
such event occurred on Gemini VIII as a result of a rotational
thruster that was stuck in the on position. In addition, crew- Landing Loads
members can themselves induce angular accelerations, both Landing loads associated with impact refer primarily to tran-
inside and outside the spacecraft, to levels that can produce sient acceleration events that last 500 ms or less. Before the
motion sickness in the first few days of flight. Unlike linear advent of the Space Shuttle, which lands on a runway like a
and radial accelerations, where the resultant forces mechani- conventional aircraft, U.S. spacecraft used parachutes to slow
cally affect organs and blood columns, the angular motion themselves as they passed through the atmosphere and landed
itself is provocative to the neurovestibular system at thresh- in water. Landing loads were somewhat variable, depending
olds greatly below those for mechanical organ effects. Angu- in part on wind and waves, which might induce horizontal and
lar accelerations exert these influences through their effects angular components to the impact forces. A typical Apollo
on the graviceptors and the visual system, both components capsule landing with an initial vertical velocity of 9 m/s (30 ft/s)
of body motion perception and control (discussed further in during the final parachute descent in 5-knot (2.6 m/s) winds
Chap. 17). might experience a sharp 17-G spike, peaking in the first few
ms, in the vehicles +Gx axis. Such spikes were also incurred
Acceleration Forces and Spaceflight in the body +Gx axis and were found to be tolerable by crew-
Deconditioning members returning from Apollo lunar and Skylab missions.
(The water impact was then followed by the real possibility of
The human response to sustained acceleration in the +Gx ori- seasickness.) Soviet and Russian spacecraft have used land-
entation has been known for several decades. However, these based landing systems that involve a combination of para-
responses have been characterized and documented primar- chutes, braking rockets, and form-fitting seat liners in couches
ily in healthy subjects in centrifuges and thus apply to nor- with independent compression struts. A typical Soyuz landing
mally conditioned individuals during launch. The hypokinetic profile induces a +Gx impact load on the crewmember of a
states of bed rest [20,21] and actual space flight [22] and its 400-ms square-wave pulse at about 4 G in the vehicles verti-
attendant physiologic deconditioning are known to adversely cal axis, with the possibility of an added horizontal component
influence the response to sustained accelerations. In terms of from wind velocity. Should the soft-landing engines fail, the
spacecraft operations, concerns focus on the pilots ability parachute-and-compression-strut combination affords a +Gx
to make manual inputs to spacecraft control during the entry transient spike of more than 20, which has been experienced
phase as well as the crews ability to perform physical tasks on two occasions without undue injuries. These impact profiles
immediately after landing, when the G load incurred in the have shown to be well within the tolerance of crewmembers
vulnerable Gz axis is fully dictated by the bodys postural returning from long-duration missions, provided that the seats
positioning. As such, more conservative limits are needed for and equipment are secured. During the landing of Apollo 12,
space flight than those in the aviation environment. The cur- a camera broke loose from its mounting and struck the pilot in
rent NASA limit for sustained linear acceleration in the +Gz the head, inflicting a minor laceration [23].
axis during landing after prolonged space flight is 0.5. This
limit would also apply to other linear acceleration loads that
may be encountered, including engine burns and aerobraking Microgravity and Partial Gravity
after transplanetary flight.
Microgravity
The Space Shuttle returns from space unpowered and human-
piloted, placing unique performance demands on the decondi- Probably the most pervasive physical factor associated with
tioned flight crew. Protective measures such as fluid loading, orbital operations, and certainly the one most associated with
anti-G garments, active cooling, and anti-G straining maneu- human space flight, is the absence of perceptible gravity, also
vers are used if needed (described further in Chap. 16). These known as weightlessness. Gravitational force is described by
measures have been relatively effective for Space Shuttle flights Newtons Law of Universal Gravitation:
lasting up to 18 days. However, missions that last 30 days or
F = GM1m2/r2 (1.12)
more (considered long-duration flights in the current system,
based on best available information and risk thresholds) engen- where F is the magnitude of force, G is the universal gravi-
der other considerations with regard to crew duty rotations and tational constant common to all bodies and planetary sur-
the need for mission-specific hardware. For example, crew- faces, M1 and m2 are the two masses being described, and
members returning on the Space Shuttle from a long-duration r is the effective radius between gravitational centers. For
16 M.R. Barratt

LEO operations, M1 is Earth and m2 represents the orbiting and mass handling such that end-to-end tasks are timelined
spacecraft. The term zero G is often used when referring to with reasonable accuracy as compared with their in-flight exe-
LEO, although from a physical standpoint this is somewhat cution. However, rapid limb movements are limited by hydro-
of a misnomer; as the above equation shows, the gravitational static drag in neutral buoyancy, which increases in proportion
force is nowhere near zero. With an equatorial Earth radius of to the square of velocity [24]. In addition, effects such as sinus
6,378 km (3,963 mi), a spacecraft orbiting over the equator at a pooling persist, a reminder that gravity is still at work on the
typical altitude of 370 km (230 mi) still experiences a relative body, and thus hanging upside down for prolonged periods
force of gravity of (6,378)2/(6,748)2, or about 90% of what in a water-immersed suit is uncomfortable.
would be felt at the surface. The practical influence of gravity The human response to microgravity is described in more
on an object persists until the object is removed from a domi- detail in Chap. 2. Among the more quickly perceived aspects
nant mass to such a distance that the force is negligible, or are the novel (e.g., flying from one place to another) and the
until forces of gravity and inertia are in balance and the object annoying (e.g., constantly losing items that float away upon
attains a state of free-fall. This is the dominant condition for being laid aside). Along with human factors and ergonomics
orbiting spacecraft. This weightless state affects all aspects of issues, microgravitys influences on some of the more funda-
physical activities, from liquid fuel transfer to any of a number mental physical forcesincluding buoyancy, sedimentation,
of standard processes relying on air-fluid separation (buoy- hydrostatic pressure, and convectionare relevant to life and
ancy), such as delivering intravenous infusions free of bubbles medical sciences and are noted below.
and handling body fluids and liquid laboratory reagents. The Buoyancy, the separation of substances, especially liquids
presence of any remaining or unbalanced gravitational force and gases, by gravity owing to differences in their densities,
will influence mechanical and fluid systems. For most scien- is absent in weightlessness, leading to a more homogeneous
tific and investigational purposes, microgravity is determined mixing of fluids and gases than on Earth. The implications of
as 106 G. However, below a certain arbitrary threshold, which loss of buoyancy range from difficulty in handling fluids to
probably resides near a few hundredths of a G (where fluid loss of standard air-fluid levels in diagnostic imagery. As an
shifts and body pressure on surfaces would be imperceptible), example, one cannot expect to see the familiar gastric bubble
the space flyer for all practical purposes resides in a weight- on chest or abdominal radiography.
less state. Sedimentation, the downward force, or physical separa-
Although humans thrive in a 1-G environment and may tion of liquids and solutes caused by the linear acceleration of
be said to physiologically maintain a 1-G set point, this ter- gravity, is typically opposed by buoyancy and frictional forces
restrial set point itself actually implies a dynamic condition. and is described by the expression:
Humans possess adaptive mechanisms to account for changes
Fs = mg Fb Ff (1.13)
in body orientation with respect to the standard G vector. For
example, lying down (i.e., shifting position from standing to where Fs is the sedimentation force, m is the mass of a sol-
recumbent) changes the effective G load on the hydrostatic ute, g is the linear acceleration of gravity, Fb is the buoyancy
blood column between the heart and brain from one or unit force, and Ff is the frictional force. Sedimentation is also
gravity to near zero. From the standpoint of cardiovascular absent in weightlessness, with the corresponding implications
(as well as musculoskeletal) regulation, the weightless state again including homogeneous mixing, this time between liq-
induces a much more constant loading condition that closely uids and solutes or suspended particles. For example, a urine
resembles the recumbent state. Entering weightlessness thus sample centrifuged for microscopic analysis must be spun and
does not imply entering a completely foreign physiologic con- read before the physical separation induced by the centrifugal
dition, and of course space flyers can endure very long periods force is undone by the lack of gravitational force. Also, con-
in weightlessness. taminants are not easily separated and must be filtered rather
Human response to microgravity can be adequately studied than eluted away from a supernatant unless centrifugally sepa-
only in space. Parabolic flight provides brief periods of free- rated. On a more macroscopic level, atmospheric particles do
fall, on the order of 2025 s, and has become a useful tool not settle out from spacecraft cabin air and as such may be
for evaluating hardware and human factors and for studying inspired or inadvertently ingested by crewmembers.
physical processes that react quickly to the absence of grav- Hydrostatic pressure is the force F of a liquid caused by its
ity. However, these brief periods of zero G alternate with weight standing above a certain surface area A, expressed by:
periods of increased G load as the aircraft pulls out of its
Ph = F/A (1.14)
powered dives. The resultant oscillating G field, between zero
and 1.8 G, does not invite the same possibilities for human and Ph is linearly proportional to g. The total pressure act-
adaptation and is provocative to the neurovestibular system ing on a fluid column consists of hydrostatic plus atmospheric
in a manner different from prolonged weightlessness (see pressure. In weightlessness, hydrostatic pressure is reduced to
Chap. 10). Water immersion provides a suitable analog for atmospheric pressure and any other induced forces, such as
some task-evaluation and training activities, notably EVA centrifugal or pump forces. The physiologic implications are
practice. Neutral buoyancy affords simulation of body motion that no changes in pressure in the hydrostatic blood column
1. Physical and Bioenvironmental Aspects of Human Space Flight 17

accompany changes in position, and blood pressure above the of cardiovascular regulatory mechanisms, endocrine changes
heart is dominated more by intrinsic cardiovascular dynamics associated with volume changes, and neurovestibular distur-
such as pumping forces and vascular constriction and dilation. bances. It should not come as a particular surprise that humans
This pressure can be added back in weightlessness by using function as well as has been observed in weightlessness. How-
centrifugal forces. ever, an awareness of the above forces and how they influence
Convection is the dynamic movement of fluids and gases human physiology is necessary for filling in the substantial
that facilitates heat transfer and affects mixing as well. Con- gaps remaining in our understanding of zero G physiology.
vection can be based on density variations and thus be driven A basic understanding of this physiology enables a practical
by buoyancy, or it can result from forced or induced flow. approach to various medical problems involving fluid han-
Standard terrestrial buoyancy-driven convection is the force dling, heat transfer, gaseous dispersion, and biomechanics.
that facilitates candle burning, involving movement of oxygen
to replenish the oxygen that is locally consumed and circula-
tion of volatilized fuel and combustion products. Without con- Fractional G
vection, a flame in weightlessness will consume the oxygen in
Partial gravitational fields, that is, fractional relative to Earth-
close proximity and if forced airflow from an outside source
normal, must be thought of on a graded scale with several prac-
or the means to propagate along a fuel source to an oxygen-
tical threshold values. From the human standpoint, threshold
ated area is not provided, the flame will extinguish itself. In
of detection stands at the far end, where in a spacecraft the
microgravity, forced convection is important to make up for
crewmember will notice objects (including himself) resting
the absence of buoyancy-driven convection for such processes
on a surface oriented opposite to the acceleration vector. This
as dispersion of metabolically produced CO2 and body cool-
probably occurs with a few hundredths of G. Other potentially
ing. The basic equation for convective heat transfer is:
relevant thresholds include effective air-fluid separation, a
C = hc(t1 t2) (1.15) force sufficient to support an active gait, and passive loads
sufficient to influence bone and muscle mass.
where C is the rate of heat transfer (typically watts/m2 of sur-
Sustained partial G is of interest for the human space flyer
face area), t1 and t2 are the temperatures of the body and fluid
in two main areas: planetary surfaces and provision of artifi-
medium, and hc is the convection coefficient, which includes
cial G as a countermeasure to the deleterious effects of pro-
consideration of fluid movement.
longed exposure to weightlessness. Planetary surface forces
Other forces and processes are not altered in weightless-
most relevant to us currently are lunar (1/6 G) and Mars grav-
ness. Heat transfer may still occur via conduction, radiation,
ity (about 1/3 G), and possibly smaller fields such as may be
and evaporation, and gases and liquids may still be mixed by
encountered during short-term flights to asteroids (or other
diffusion. Terrestrially, diffusion exerts a lesser influence on
planetary satellites). People have worked successfully on the
mixing and particulate dispersion than buoyancy, convection
lunar surface despite the changes noted in biomechanics and
and sedimentation, but this is one of the more prominent mix-
energetics [25], although none have stayed long enough to
ing forces in zero G. In a pressurized LEO module lacking
effect detectable changes in physiologic parameters, particu-
any artificial physical agitation, diffusion alone will drive the
larly bone and muscle mass losses. Given the demonstrated
dispersion of an atmospheric contaminant from a point source
feasibility of lunar surface exploration, Mars should not be
throughout the remainder of the volume. This process is slow
problematic for exploration efforts from the practical human
enough relative to physiologic CO2 production that local areas
standpoint; the major issue is that it will most likely follow
of increased concentration will build around a crewmember,
prolonged exposure to weightlessness. This implies neuroves-
who may then manifest signs of CO2 toxicity in an unventi-
tibular deconditioning, orthostatic intolerance, and bone and
lated module. Similarly, for a crewmember breathing supple-
muscle atrophy commensurate with the amount of time spent
mental oxygen in the same circumstance, the oxygen-enriched
in microgravity during the voyage.
exhalation may produce a local flammability risk. Induced air
Provision of artificial G as a countermeasure to deleteri-
movement is a fundamental requirement for human occupants
ous effects of weightlessness has been considered for many
of a weightless habitat.
decades. Shipov has written an excellent review of these
The human body is a highly active and dynamic machine,
considerations [26]. Artificial G may be afforded by rotat-
endowed with countless processes to facilitate mixing and
ing a spacecraft or a structure, which may be contained within a
transport. Circulation of blood and other fluids, active trans-
non-rotating spacecraft, to provide continuous centrifugal
port and diffusion across membranes, nerve conduction, and
force. This could be employed for a stable platform, such as
chemotactic mechanisms are basically left to function intact in
an orbiting station, or an interplanetary spacecraft. Expressed
weightlessness. It is mainly on the macro level that weightless-
in terms of angular velocity , the pseudoforce known as
ness exerts its primary effects. These effects, such as unload-
centrifugal force conveniently describes rotational artificial
ing of the hydrostatic blood column, thoracic fluid shifts, and
G and is expressed by:
unloading of otoconia and other gravitational sensors, give
rise to corresponding secondary effects such as desensitization Fc = mw2r (1.16)
18 M.R. Barratt

It is apparent that altering the rotational velocity and radius rotation rates will allow tolerance of these sustained rates [33]
components influence two extreme ends of a practicality up to 10 rpm [34]. With stepwise increases in rotational forces,
continuum. At the structural end, very large formations and it may be possible for crewmembers to adapt to rates whereby
masses well beyond anything built in space thus far would be structures a few tens of meters in diameter could provide use-
required to maintain a relatively low rotational rate while pro- ful and protective levels of G. For example, a structure with a
viding Earth-equivalent artificial G. For example, a structure 10-m (33-ft) rotational radius at 10 rpm would provide 1.1 G at
with a rotation radius of 900 m with an angular velocity of the rim; a 15-m (49-ft) radius at 7 rpm would provide 0.82 G.
one revolution per minute (about 0.1 rad/s) would be required Aside from potentially inducing cross-coupling effects and
to provide Earth-normal gravity [27]. Various approaches have neurovestibular dysfunction, a rotating structure implies a
been elaborated, from very large structures to distinct capsules gravity gradient extending from the rotational hub to the rim.
joined by a tether and spinning about a central axis. Problems The perception of this gradient would be most pronounced
include limitations in structural mass, tether performance with shorter radii, of which a human subjects height is a sig-
and reliability, abort capabilities for interplanetary spacecraft nificant fraction. Considering a rotating crew module with
because of a limited number of spin/de-spin cycles, mishaps a diameter of 7.2 m (23 ft) and a rotational radius of 3.6 m
that might require EVA repair, and interference with astro- (11.8 ft), a 1.8-m (71-inch) crewmember would assume half of
nomical observations. It is much more feasible to increase this height when standing. The force at the head will be half of
rotational velocity for short-radius structures to obtain a the force at the level of the feet, introducing a gradient of 50%
desired force. However, this is bounded by the biomechanical over the crewmembers standing height. This gradient induces
end associated with human tolerance of rotation. significant motor control and mass handling challenges as
A significant implication of rotation to a human occupant the crewmember bends and transitions between standing and
is unwanted Coriolis acceleration effects, induced with linear seated or horizontal postures. A rotational radius longer than
motion in a rotating reference frame. Coriolis acceleration Ac 12.2 m (40 ft) would be required to produce gravity gradients
and force Fc can be expressed by: below a recommended 15% for a rotating spacecraft or centri-
fuge [35]. In addition, an overall additive velocity effect serves
Ac = 2(v ) (1.17)
to increase weight while ambulating in the direction of rota-
tion and to decrease weight in the opposite direction. These
Fc = 2m(v ) (1.18)
anomalies, along with mass handling and motor control chal-
where v is the linear velocity of a moving object in m/s, is lenges, suggest that comprehensive adaptation to such rates
the angular velocity of a rotating system in rad/s, and m is the may be difficult. However ground studies have suggested that
mass of an object in kg. Coriolis forces will affect the motion humans can gradually adapt to these higher rotational rates
of any object or occupant, complicating motion sensation, with regard to head and arm control along with tolerance of
motor control, and mass handling. cross-coupling effects [36].
Humans are equipped with sensitive multiaxial accelera- An alternative to sustained rotation of a habitation module
tion sensors in the form of semicircular canals and otoliths, is provision of short periods of artificial G more intense than
designed to work optimally to sense motions and changes in one G. Various schemes involving human-rated centrifuges,
body orientation in a static 1-G background field. In a rotating some human-powered to couple cardiovascular countermea-
structure, head movement will change the orientation of these sures with this loading, have been proposed [3739]. Com-
sensors to the direction of rotation and induce an unwanted binations of time and multiples of G could be determined to
transient input suggesting whole body rotation. These are lead to a gravitational acquired dose curve [40] specifically
so-called cross-coupled responses to angular motions in two oriented toward maintenance of bone and muscle mass.
planes. Cross-coupled Coriolis responses are known to be The most elegant solution for interplanetary flight, most
annoying and potentially provocative to humans. Effects and likely relegated to the far future, is provision of a linear G
symptoms are greatest when moving in a plane perpendicular field in some significant fraction of Earth gravity. This implies
to the axis of rotation, and include neurovestibular instability, constant linear acceleration, which might be provided by a
vertigo, nausea, emesis, and disorientation. highly advanced propulsion system. Such advanced systems
Preliminary U.S [2830]. and Russian [31,32] studies in the would be needed to reach and practically sustain operations
early 1960s with human subjects have proven the capacity for on desirable targets of interest beyond Mars, such as asteroids.
sustained tolerance to angular acceleration in rotating rooms, Linear G would enable a constant vertical reference with pas-
but this tolerance was limited by neurovestibular disturbances sive exposure to the acceleration load, broken only at some
and motion disorders at rotation rates well below what might midcourse point when the ships engine is powered down to
be required to produce a significant fractional G level (when turn and begin the deceleration burn. Ironically, the ensuing
the pervasive Earth G component was subtracted). It was gen- sudden exposure to microgravity might imply a mid-mission
erally thought that rotational rates must be limited to 45 rpm risk of space motion sickness, albeit a transient one. Assum-
to avoid incapacitating vestibular and motor effects. Subse- ing that large stationary platforms may someday be built at
quently, it was demonstrated that gradually increasing the departure and destination points that can be spun and are large
1. Physical and Bioenvironmental Aspects of Human Space Flight 19

enough to avoid undesirable Coriolis effects, a propulsion were bolstered by further balloon experiments to 15,000 m in
concept affording linear G offers the best solution for long 1925, and prompted R.A. Millikan to term this background
transit times. flux cosmic radiation.
For rotational and linear G, it must be determined what The term radiation can be broadly defined as the emission
fraction of unit gravity would be required to maintain bone and propagation of waves transmitting energy through space or
and muscle. One G may be considered the gold standard, but a medium and includes electromagnetic energy (X rays, gamma
a lesser fraction is more in keeping with attainable structures, rays, visible light, radio waves, etc.) as well as charged par-
future propulsion, and energy cost. During in-flight artificial ticles (protons, electrons, alpha particles, etc.) and uncharged
gravity studies with centrifuged rats, Yuganov et al. observed particles (neutrons). Radioactivity refers to a certain type of
a threshold level of 0.15 G for bioelectric activity, which radiation emitted by a specific substance, typically from decay
steadily increased in parallel with transverse G forces up to of unstable nuclei. These particles and waves carry a wide
a level of 0.28 G. Between 0.28 and 0.31 G, the bioelectric spectrum of energies and may interact with a medium they
activity was equivalent to what was seen in ground controls, traverse. If this interaction involves collisions with atoms or
and no further increase was seen up to 0.7 G [41]. In an inves- molecules such that imparted energy expels electrons and cre-
tigation to determine the minimum fractional G load that ates new charged ion species, it is termed ionizing radiation.
would sustain bone in hindlimb-suspended rats, Schultheis Radiation may induce damage directly, as by a high-energy
and colleagues determined that 0.25 G may be equivalent to particle imparting energy to a cellular molecule, or indirectly,
0.75 G in preserving bone formation [42]. From the standpoint by inducing the formation of secondary ion species through
of human factors, studies in parabolic flight of progressive G collision events. These secondary particles may then go on to
levels have demonstrated that for walking, mass handling, and interact with biological material. High-energy electrons tra-
mechanical tasks such as bolt tightening, very little gain is versing a dense medium, such as metal structures, may interact
seen beyond 0.2 G [43]. Although much research remains to with the material, and, in the process of slowing and imparting
be done, provision of a constant force of perhaps 0.3 G may their kinetic energy to the material they induce the formation of
enable fairly normal biomechanical activity, and in combina- X rays. This phenomenon is termed bremsstrahlung (German for
tion with modest physical countermeasures augmented with braking radiation) and has obvious implications for shield-
heavy resistive exercise, may well maintain bone and muscle ing considerations. Non-ionizing radiation, such as from ultra-
mass at near Earth-normal levels. It is hoped that this critical violet light and radiofrequency energy, may also cause tissue
focus of investigation will be addressed with the laboratory damage from burns and local heating effects.
facilities on board the ISS. Throughout the early experiments mentioned above,
adverse health effects from radiation were observed, includ-
ing local effects such as eye irritation, skin burns, and dermal
Radiation Sources necrosis. Over time, more sinister effects such as blood and
lymphoid malignancies and solid tumors were noted. Many of
For what has been found to be such a pervasive entity in these effects were directly related to the overzealous use of X
the universe and among the more important factors limiting rays, in both diagnostic and therapeutic applications. Despite
human exploration beyond Earth, radioactivity was discov- the significant energies involved, human senses cannot detect,
ered relatively recently. In 1895, Konrad Wilhelm Roentgen and thus cannot avoid, radioactivity and most forms of elec-
discovered that invisible, penetrating rays (x rays) could be tromagnetic radiation. Rather, the damaging secondary effects
produced by electrically exciting a low-pressure gas. Radio- consisting of physical, chemical, and biological changes are
activity was discovered and first described a year later in what are eventually perceived. As such, dose-response rela-
1896 by Antoine-Henry Becquerel while he was experiment- tionships were slow to be identified, especially with regard
ing with uranium salts. Becquerel observed that these salts to malignancies arising after a prolonged latency period. The
could blacken a photographic plate in the absence of light, establishment of the International Council for Radiological
and he later determined that this was caused by the emission Protection, along with international acceptance of common
of energetic particles from the element uranium. Over the monitoring units in 1928, led to a more systematic under-
ensuing years, many other emitting substances were identi- standing of this relationship and the means for monitoring and
fied and their radioactivity characterized. As sensitive detec- mitigating radiation-induced health problems [45].
tors were developed, a background flux of radioactivity was We have learned that space is a radiation environment, or
noted to persist in the absence of known emitters. Some of more properly that Earth, thanks to its protective atmosphere
this radioactivity was eventually attributed to naturally occur- and magnetic field, is a radiation haven, a shelter from the
ring substances in the ground. However, balloon experiments effects of products of the most fundamental processes in the
conducted between 1911 and 1913 by V.F. Hess in which universe. These processes include the formation, life, and
these detectors were flown to altitudes of 9,000 m showed a death of stars, solar system accretion, and stellar and plan-
tenfold increase in this background flux over surface values, etary magnetism. Radiation exposures for humans in space
suggesting an extraterrestrial source [44]. These observations flight stem from three main natural sources: galactic cosmic
20 M.R. Barratt

rays, solar particles and electromagnetic radiation, and geo- [46], causing them to lose significant energy and some to be
magnetically bound charged particles. In addition, secondary deflected away. This modulation varies with the biphasic
particles (e.g. neutrons) are known to be produced from the 22-year solar cycle so that at solar maximum, the GCR bath-
interaction of primary particles with spacecraft structures. ing Earth is about half of the flux at solar minimum [48].
Future artificial sources (power sources, detonation of nuclear Particles with energies exceeding 10 GeV are minimally sus-
weapons) may also be considered. The character of radiation ceptible to the influence of the solar wind and magnetic fields
sources, their biological effects, and risk mitigation strategies and continue unimpeded.
are discussed in detail in Chap. 23. The present discussion
will be limited to the physical distribution of the major ion-
Solar Radiation and Solar Cosmic Particles
izing radiation sources pertaining to human space flight.
The Sun, with a radius of 6.95 105 km, is a generator of mas-
sive energies. Fueled by the fusion of H into He and heavier
Galactic Cosmic Radiation nuclei at its core, the Sun radiates energy at a rate of 3.86 1026
A background flux of high-energy-particle radiation is present W, virtually all in the visible light spectrum. Along with elec-
in interstellar space. This galactic cosmic radiation, or GCR, tromagnetic radiation, which among other things affords our
most likely originates in supernova explosions, in which mas- planet light and warmth, a continual emission of electrically
sive quantities of nuclei from hydrogen (H) and helium (He) neutral plasma known as the solar wind streams outward. Free
and a smaller proportion of heavier nuclei are ejected in the electrons are electrically balanced primarily by protons, as
stellar debris. Kinetic energy is imparted in the initial explo- well as alpha particles and some heavier ionic species, mov-
sion, and these charged particles may be further accelerated ing in magnetic field lines that spiral outward because of the
by interstellar magnetic fields to near light speed (3 108 m/s). Suns rotation. These particles carry the Suns magnetic field
Although supernova explosions are point events, the distribu- into the solar system and are thus distributed in an anisotropic
tion of GCR seems to be isotropic because of galactic mag- fashion. Irregularities in the solar corona alter plasma velocity
netic field lines that prevent travel along straight paths. It is and density. The velocity of these particles as measured near
estimated that supernovae can maintain the observed flux of Earth ranges 300700 km/s, with particle densities of 120/
GCR if such explosions occur, on average, every 50 years in cm3 [49]. Solar wind particles are of low energy, typically
our galaxy [46]. about 1,000 eV (1 keV).
GCR consists primarily of protons or H nuclei (about 90%), In contrast to the relatively gentle flux of the solar wind are
and alpha particles or He nuclei (about 9%), with the remain- solar cosmic rays (SCR), particles similar to those of the solar
ing species being heavier elements in ionized states. Com- wind but of much higher energy. These stem from solar flares,
pared with terrestrial radiation sources, which might generate which are associated with large magnetic disturbances on the
detectable counts of many millions of particles per cm2 per surface, and carry energies typically in the MeV range and
second, the flux from GCR is relatively low, at a few spe- possibly up to 20 GeV. These flares also radiate in the electro-
cies per cm2 per second. However, GCR species contain mas- magnetic spectrum, with such radiation ranging from gamma
sively higher amounts of energy. These energies are typically rays and X rays through ultraviolet and long-wavelength
denoted in electron volts, or eV, which is a convenient unit of radio waves. Along with electromagnetic emission and accel-
measure for particle physics. One eV is defined as the energy erating atomic particles, solar flares induce a blast wave that
gained by an electron accelerating between two plates, 1 m propagates through the solar wind at 1,500 km/s. The relative
apart, with a potential difference of 1.0 volts; one eV = 1.6021 energy distribution is such that about half is invested in the
1019 joules (J). Whereas radium may emit energies on the electromagnetic emission, half in the blast wave, and only
order of several mega eV (MeV, where mega = 106), GCR about 1% in the actual SCR. Most of the particles detected
particles must often be measured in the giga eV range (GeV, near Earth are protons, and a smaller fraction consists of He
where giga = 109). The most abundant GCR species are pro- nuclei. A large electron flux is stemmed by loss of energy in
tons with energy of about 2 GeV, and the remainder consists exciting radiofrequency bursts in the corona, the Suns outer
of an exponentially diminishing flux of progressively higher atmosphere.
energy species, up to 1011 GeV (1020 eV). To put this energy SCR particles at the high end of the energy range reach
into perspective, a single cosmic ray particle at the very high Earth vicinity 2030 min after the first optical evidence of
end of the energy spectrum, with 1.5 1020 eV, carries 25 the flare can be seen, with periods of maximal SCR flux last-
joules, sufficient to raise 1 kg a height of 2.5 m on Earth [47]. ing a few hours. Clouds of lower energy particles and solar
GCR is effectively attenuated by Earths atmosphere, which wind disturbance reach Earth in 624 h. A diminishing flux
has a thickness equivalent of 1,000 grams/cm2, and by pow- of high-energy particles followed by lower-energy particles
erful geomagnetic fields to a relatively low flux at the sur- can be detectable for several days after a large flare. The vast
face. Local solar system effects also modulate GCR. The majority of SCR particles is effectively stopped by the geo-
solar wind and interplanetary magnetic field lines distort the magnetic field and poses little threat to crewmembers in LEO
paths of charged GCR particles with energies less than 1 GeV in typical orbital inclinations. The main hazard with regard
1. Physical and Bioenvironmental Aspects of Human Space Flight 21

to human space flight arises for activities outside of the geo- Van Allen to study GCR flux above Earths atmosphere.
magnetosphere, such as interplanetary transit, occupation of Unexpectedly, this and subsequent Explorer and Pioneer
a Lagrangian point station, or lunar surface activities, where space probes led to the discovery that the external field lines
radiation flux could increase by a thousand-fold to a million- are heavily populated with highly energetic charged particles.
fold. A minimally shielded crewmember, such as one engag- Two main belts of intense trapped radiation, with fluxes many
ing in EVA operations, could receive a lethal dose of ionizing orders of magnitude over that of the background GCR, were
radiation in a few hours during a major solar flare. identified [51]. These now bear the name of their discoverer,
Solar flares correlate with the 22-year biphasic solar cycle, the Van Allen belts. The Van Allen belts are arranged as two
the most frequent and intense being at or near the solar maxi- concentric doughnuts centered on the geomagnetic equator
mum. The resulting periods of increasing probability of solar (Figure 1.10). Two distinct concentration bands with a defini-
flare occurrence can drive some operational considerations for tive gap between them have been mapped, although this gap is
long-term human space flight activities. However, although a not totally devoid of particles. The inner belt begins at roughly
buildup may be detected early enough to warn a crew to take 1,000 km in altitude and extends to 5,000 km; the outer belt
shelter in a radiation-hardened structure, buildups cannot be extends from about 15,000 km to 25,000 km at the equator.
reliably forecasted. As for solar wind emissions, SCR emis- The charged species populating the Van Allen belts are
sions are anisotropically projected into the solar system, in essentially captured particles from the solar wind and solar
part because of the regionality of their sources on the solar cosmic rays. Inner belt protons most likely originate from
surface. Most flares producing high-energy particles seem to interaction of GCR with atmospheric species, inducing the
originate in the Suns western hemisphere [44]; this coupled formation of short-lived neutrons. Some of these neutrons
with the Suns rotational rate of 25 days at the equator (slower decay into protons and electrons, which are then bound by the
at higher latitudes) means that not all flares are visible from geomagnetic field. Eventually, they are removed by interac-
Earth. For a spacecraft not in Earths vicinity, e.g., one en route tion with atmospheric molecules; the relative rates of removal
to Mars, a major flare detected on Earth may not be problem- and replenishment drive the concentrations observed. Outer
atic for or even detected by the spacecraft; however the oppo- belt particles originate from interaction of the solar wind with
site is also true. Transplanetary spacecraft should be equipped the magnetosphere, in which a small fraction of these parti-
with the means to detect sentinel electromagnetic and particle cles leak into the field lines rather than being deflected away.
emissions preceding high particle flux and guide appropriate The outer belt is more susceptible to the dynamic effects of
crew responses. Strategically placed solar-orbiting spacecraft the solar wind and SCR and so may vary considerably in
with electromagnetic and particle detection capability could
also relay such information to spacecraft and Earth, analogous
to ocean weather buoys.

Geomagnetically Bound Radiation


Magnetism and Earths magnetic field have been known and
exploited for centuries by ocean navigators. More recent is
the appreciation that Earth is endowed with a dipolar mag-
netic field, with field lines emerging at the North magnetic
pole and re-entering at the South magnetic pole. This dipolar
magnetic axis is offset by some 12 degrees from the rotational
axis. Most of the geomagnetic field originates from Earths
center, where conducting liquid iron of the outer core flows
around the solid iron inner core, with the motion probably
driven by convection resulting from heat flow from the core to
cooler outer layers. Movement of the conducting fluid around
the inner cores preexisting magnetic field, most likely a rem-
nant of core formation, induces an electric current, which in
turn induces a secondary magnetic field much stronger than
the original [50]. This is known as the geomagnetic dynamo
model. Although much remains to be learned about the intrin-
sic properties of the geomagnetic field, the first landmark Figure 1.10. The Van Allen radiation belts, showing relative distribu-
scientific discovery of the space age involved extraterrestrial tion and shape of the inner and outer bands of geomagnetically bound
implications of these field lines. charged particles. Darker shaded areas denote regions of greater par-
In 1958, the first successful U.S. satellite, Explorer 1, lofted ticle density. The orbital track of a typical crewed spacecraft in low
a Geiger counter in an experiment devised by James Alfred Earth orbit is seen to be well below the inner belt
22 M.R. Barratt

concentration. All bound particles travel along geomagnetic considerations for humans will likely be restricted to the moon
field lines, spiraling around these lines and bouncing back and Mars. Table 1.3 [46,53] shows comparisons of physical
and forth between northern and southern mirror points with attributes of Earth, the Moon, and Mars.
a period of 0.13 s. Lunar exploration efforts, although brief, were highly suc-
Inner belt particles typically carry high energies, with cessful, implying that more extensive and long-term efforts
protons of 50 MeV and electrons of 30 MeV. The flux may could be undertaken. However, particular medical consider-
be as large as 2 105 per cm2 per second, higher than the ations are associated with surface activities, some of which
GCR flux by a factor of 104. These energies and quantities were suggested during our brief time on the moon. Two of the
would constitute a grave radiation hazard to the occupants major factors underlying these considerations, partial gravity
of spacecraft and their systems if sufficient time were spent and surface dust, are discussed in the following sections. Radi-
in zones of high concentration. Most human platforms in ation sources have been noted in a previous section, and Chap.
LEO, such as the ISS at about 375 km altitude, operate well 23 will cover aspects of surface dosimetry and shielding.
below the floor of the inner belt. However, the borders are
not sharply defined, and a measurable increase in flux is Partial Gravity
observed with increasing altitude. In addition, an offset of
the geomagnetic and rotational axes causes a defect in the Even a fraction of Earth gravity offers a tremendous conve-
basic shape of the inner belt in which it dips down to a lower nience to human occupants. Locomotion in a familiar vertical
altitude. This defect, known as the South Atlantic anomaly reference frame is possible, and it is easier to adapt terrestrial
(SAA), consists of a region in which the radiation flux at a tools and processes to this environment. Fluids and gases can
relatively low altitude is equivalent to that at a much higher separate, and items remain where they are placed. Some of
altitude. The shape and boundaries of the SAA change with the fundamental physiologic problems associated with pro-
altitude. A spacecraft at 225 km altitude will experience a longed weightlessness, such as bone demineralization and
100-fold increase in radiation flux while passing through the muscle atrophy, may be mitigated to some extent by even a
SAA, whereas a 1,000-fold increase would be experienced partial gravitational field. Along with fractional Earth grav-
at 440 km altitude [52]. The greatest fraction of the radiation ity, the activities inherent in exploration and exploitation of
dose delivered to LEO crewmembers results from orbital resources will likely favorably augment this force with regard
crossings of the SAA. to bone and muscle loading. Such activities will include use
Although containing large quantities of charged particles, of heavy EVA suits, carrying heavy loads, and operating tools
the geomagnetic field serves the vital role of shielding Earth for construction and excavation. In addition, although partial
from the brunt of the solar wind and SCR as well as from gravity fields should not be considered benign environments,
lower energy GCR. The shielding afforded depends on posi- physical countermeasures are simplified by the existence of a
tion relative to the dipole; with the shape of the magnetic gravitational vertical and the ease of increasing resistive force
fields shown in Figure 1.10, higher-inclination orbits become loads. However, the presence of partial gravity also restores,
progressively less protected from GCR and SCR. A polar to some extent, a potential for injury that is largely absent in
orbiting spacecraft is exposed to radiation flux similar to that microgravity.
in free space.

TABLE 1.3. Selected physical attributes of Earth, Earths Moon, and


Planetary Surface Factors Mars.
Earth Moon Mars
By far the greatest portion of human spaceflight activity has Solar distance, semi-major 149.6 149.6 228
occurred in the weightlessness of LEO, with a small fraction axis (106 km)
of time spent on the lunar surface during the U.S. Apollo mis- Radius, equatorial (km) 6,378 1,738 3,394
sions. However, activities such as these are a much-anticipated Surface gravity (relative to 1.0 0.16 0.39
Earth-normal)
aspect of future endeavors, without which we are limited to
Escape velocity (km/s) 11.18 2.38 5.03
microgravity investigations and Earth-observation studies. On Atmospheric pressure, 760 mmHg Essentially 0 4.8 mmHg
planetary surfaces, we trade such problems as weightlessness, surface global
attitude control, and orbital thermal cycling for a stable base mean
to support more familiar locomotion, allow construction, and Atmospheric composition, N2 78%; CO2 95.3%;
major constituents O2 21% N2 2.7%
provide raw materials for use. Inherent in this situation is a
Rotational period (sidereala) 23.93 h 27.3 days 24.62 h
greater degree of isolation, both from the standpoint of dis- Rotational period (solar) 24.00 h 29.53 days 24.65 days
tance from Earth and the additional gravity ladder that must Sidereala period (days) 365.26 686.98
be climbed to leave the new surface. Because of the extreme
Source: Data from Lodders [53] and Zeilik [46].
distances and inhospitable radiation environments associ- a
The term sidereal refers to time relative to the stars; solar is referenced to
ated with the moons of the giant planets, near-term surface Earths Sun.
1. Physical and Bioenvironmental Aspects of Human Space Flight 23

Terrestrially, most major trauma is associated with forces in liftoffa great quantity of dust floated free in the cabin. This
events such as motor vehicle accidents and falls. Surface vehi- dust made breathing without the helmet difficult, and enough
cles were used on the Moon and will certainly be required for particles were present in the cabin atmosphere to affect our
further lunar and Mars exploration. Falls were not uncommon vision [57]. These effects seem to have been acute albeit mild
during the lunar EVAs, although those falls were not associ- reactions to airborne dust particles deposited in and cleared
ated with injuries [54]. Traversing more challenging terrain from the upper airways.
might easily lead to more serious falls, augmented by unfa- No lasting respiratory effects were seen in returning Apollo
miliar body mechanics. Carrying loads and obtaining samples crewmembers. However, the question arises regarding the pro-
may induce muscle strain injuries, as occurred during the core pensity of lunar dust to cause chronic pulmonary diseases after
drilling operation on one lunar mission [23]. Construction prolonged exposures, similar to terrestrial occupational lung
activities could also lead to penetrating trauma whereby an diseases. Pneumoconiosisinterstitial lung disease caused
EVA suit environment is compromised and injury is sustained. by dust exposure and the lungs subsequent reaction to the
These are the primary factors that drive a medical capabil- dustis caused by exposures to silica, coal dust, and asbestos
ity involving the means to manage orthopedic and penetrating (fibrous silicate) dusts. Classic silicosis results from moder-
trauma, as well as decompression disorders, beyond what is ate exposures to silica dust (SiO2) over many years, involv-
required for LEO. ing deposition of small particles into the alveoli and uptake
by alveolar macrophages. Subsequent activation of alveolar
macrophages causes them to release oxidants, cytokines, and
Surface Dust other mediators that injure surrounding tissue and stimulate
The surfaces of the Moon and Mars are largely covered with fibrosis. Typically, deposition occurs with particles in inspired
loose, unconsolidated rock material known as regolith. (This air of 5 m or smaller in size, with 1-m particles having the
term may also be applied to terrestrial surface rock and soils, best chance of deposition [58]; particles larger than 10 m in
although the extraterrestrial implication is more common.) diameter are effectively filtered by the upper and lower air-
Lunar regolith is fairly well known from first-hand observa- ways. Deposition may be enhanced for particles with electro-
tions and sample analysis; it consists primarily of fragments static charges [59].
less than 1 cm in size produced by shattering of material from Several factors make pneumoconiosis from lunar dust
meteorite impacts. Local lunar regolith formation begins with unlikely. Silicate minerals, consisting of repeating crystal-
a nearby large impact that deposits large boulders and coarse line structures of nonfibrous SiO4, are abundant and con-
material excavated from bedrock. Over geologic time, smaller tribute 90% of the volume of most lunar rocks. By contrast,
impacts erode and fragment the coarse material, forming a silica minerals, associated with terrestrial silicosis and char-
fine component, and given enough time, the original coarse acterized by the repeating formula SiO2, are fairly rare on
material disappears. Regolith can be 45 m thick in the lunar the Moon [60]. In addition, the particles in the bulk of natu-
mare and as much as 1015 m thick in the lunar highlands. In rally occurring lunar dust are large enough to preclude their
a mature regolith, the subcentimeter component is called lunar deposition in air exchange structures. More than 80% (by
soil. The average grain size of analyzed soils is between 60 weight) of dust grains from most Apollo samples are larger
and 80 m [55]. than 20 m, and most of the smaller particles are still larger
During the Apollo missions, lunar dust established itself than 10 m [55]. Certainly in the near future, exposures for
early as a nuisance because of its physical properties and the periods associated with terrestrial pneumoconioses are
associated difficulties in its control and cleanup. With the lack not anticipated.
of an atmosphere and in low-gravity conditions, lunar dust is The main health hazard associated with lunar dust will be
easily dislodged from the surface by walking, by operating probably be interference with environmental and life sup-
machinery, or by engine plumes. Lunar dust has a very low port systems and pressure seals as well as a greater chance
electrical conductivity and is prone to building up an elec- of foreign bodies in the eye because of reduced gravity and
trostatic charge, with subsequent electrostatic deposition on possibly local skin irritation from direct contact with this
surfaces. It is hard, abrasive, and easily embedded in loose- abrasive material. However, bearing in mind that terres-
weave fabrics. trial occupational lung diseases were largely unanticipated,
Although largely chemically inert, lunar dust did evoke simple pulmonary monitoring for long-term lunar or Mars
symptoms of respiratory irritation in some crewmembers. Dust inhabitants may be prudent. Periodic pulmonary spirometry
was introduced into the cabin atmosphere after ingress from and chest x ray or an equivalent imaging modality could
a surface EVA, adhering to the suits and equipment. Scientist be performed on site. In any case, means of dust control to
pilot Harrison Schmidt noted breathing irritation associated minimize levels in the habitable atmosphere will be neces-
with dust upon returning to the Lunar Module cabin after the sary both for crew health and mitigating adverse affects on
first EVA [56]. Some crewmembers used expectorants to facil- sensitive systems.
itate clearance of the particles from the upper airways. Alan Unlike the lunar regolith, which is formed by repeated
Bean, during the Apollo 12 mission, observed that after lunar impacts, Martian regolith is produced by physical weathering
24 M.R. Barratt

and chemical activity [61]. Mars surface dust, although only 5. Enzell LN. NASA Historical Data Book, Volumes II and III.
studied remotely, should be somewhat easier to control than Washington, DC: Scientific and Technical Information Division,
lunar dust, given the presence of a low pressure atmosphere National Aeronautics and Space Administration; 1988.
and a somewhat greater gravitational field. A particular haz- 6. Boden DG. Introduction to astrodynamics. In: Larson WJ, Wertz
JR (eds.), Space Mission Analysis and Design. 2nd edn. El
ard condition on Mars is the known ability of dust particles to
Segundo, CA: Microcosm, Inc. and Kluwer Academic Publish-
become windborne. Wind speeds are seasonal, being lowest
ers; 1992; 129156.
during the Martian summer, at 27 m/s, and highest in autumn 7. McKnight DS. Orbital debrisa man-made hazard. In: Larson
and winter, at 510 m/s. Despite the rarefied atmosphere, suf- WJ, Wertz JR (eds.), Space Mission Analysis and Design. 2nd
ficient dynamic pressure periodically builds to cause large and edn. El Segundo, CA: Microcosm, Inc. and Kluwer Academic
even global dust storms. During such storms, winds speeds Publishers; 1992.
can increase to 30 m/s. Such a dust storm could potentially 8. Love SG, Brownlee DE. A direct measurement of the terrestrial
halt surface activity for a period of several weeks to months mass accretion rate of cosmic dust. Science 1993; 262:550
and threaten sensitive systems. However, the observation that 553.
the solar-powered Viking Landers were able to function on the 9. Spencer DB. Orbital debris and space operations. Aerospace
surface for several years during the late 1970s suggests this America February 1997; 3842.
10. Single-Stage Mars Mission. Proceedings of the NASA/USRA
problem will not be insurmountable.
Advanced Design Program 7th Summer Conference; Univer-
sity of Minnesota; 1993:219226. N9329742.
11. Davis JR. Medical issues for a mission to Mars. Texas Med 1998;
Conclusions 94:4755.
12. Balance JD, Dabbs JR, Dudley HJ, et al. Scientific Experiments
This chapter was intended as an overview of the basic body for a Manned Mars Mission. Huntsville, AL: George C. Mar-
of information required of the space medicine practitioner shall Space Flight Center; March 1971. NASA TM X-2127.
to understand the adaptive and operational environment of 13. Rauwolf G, Pelaccio D, Patel S, et al. Mission Performance of
space flyers. An understanding of the physiologic and medi- Emerging In-Space Propulsion Concepts for 1-Year Crewed
cal implications of this environment enables the practitioner Mars Missions. Proceedings of the 37th Joint Conference of the
to provide optimal medical support. This information should American Institute of Aeronautics and Astronauatics/American
Society of Mechanical Engineers/Society of Automotive Engi-
provide a foundation for discussions of physiologic and psy-
neers/American Society of Electrical Engineers on Propulsion;
chological processes associated with space flight and allow
July 811, 2001; Salt Lake City, Utah.
the response to medical events to be placed in proper con- 14. Chang Diaz FR, Squire JP, Ilin AV, et al. The Development of the
text. Understanding this context also prepares the spaceflight VASIMR Engine. Presented at the International Conference on
surgeon to serve as a consultant in space program organiza- Electromagnetics in Advanced Applications; September 1317,
tions, where human needs must fit into mission parameters 1999; Torino, Italy.
and priorities. 15. Chang Diaz FR. The VASIMR engine: Concept development,
recent accomplishments, and future plans. Fusion Science and
Technology 2003; 43:39.
Acknowledgments The author thanks Drs. Kevin Ford, Stan- 16. Clark P. The Soviet Manned Space Programme. New York, NY:
ley Love, and Wendell Mendell for their thoughtful reviews Orion; 1988.
17. Newkirk D. Almanac of Soviet Manned Space Flight. Houston,
and constructive comments while this chapter was being
TX: Gulf Publishing Company; 1990:249251.
written.
18. Newkirk D. Almanac of Soviet Manned Space Flight. Houston,
TX: Gulf Publishing Company; 1990:136137.
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26 M.R. Barratt

Suggested Readings Rainford DJ, Gradwell DP (eds.), Aviation Medicine. 4th edn.
London, UK: Hodder Arnold; 2006.
DeHart RL, Davis JR (eds.), Fundamentals of Aerospace Medicine. Zenz C, Dickerson OB, and Horvath EP (eds.), Occupational
3rd edn. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. Medicine. 3rd edn. St. Louis, MO: Mosby-Year Book; 1994.
2
Human Response to Space Flight
Ellen S. Baker, Michael R. Barratt, and Mary L. Wear

Over the past 45 years of piloted space flight, we have gained Medical and physiological data were collected from the
the knowledge, and indeed built the expectation, that humans beginning of human space flight, consisting primarily of pre-
can adapt to this environment and endure long and productive flight and postflight studies and passive inflight biomedical
periods in space, up to and exceeding 1 year. Although the monitoring oriented toward high-level crew safety and veri-
dominant condition associated with space flight that affects fication that subsequent programmatic steps could be taken.
human physiology is weightlessness, other factors and phases Those steps included fundamental enabling technologies and
of flight can influence the health and performance of crewmem- practices such as extravehicular activity (EVA), piloted ren-
bers as well. Many of these factors have adverse consequences dezvous and docking, and deployment of equipment. Early
and require operational considerations, countermeasures, and results along with crewmember reports and experience helped
protection. As such, an understanding of these factors and their to quickly orient medical investigation and the provision
influences is necessary for optimizing human performance. of inflight medical care. As human space flight grew more
This chapter presents a comprehensive framework for routine, some missions specifically included assessments of
understanding the experience and clinico-physiological physiological responses and the gathering of medical data,
response of human beings to space flight. This is purposely particularly with regard to systems most overtly affected.
not an exhaustive physiology review, but rather an overview Scores of biomedical experiments have now been conducted
of consistent and predictable changes that are clinically rele- during space flight, and a small number of missions dedicated
vant. These changes include outward symptoms and effects on to life sciences issues have provided considerable detail about
health and performance as well as laboratory values and test some physiological systems.
results deemed important for understanding the clinical norms Although much has been learned about how humans
associated with space flight. Further physiological details respond to this new environment, that humans could tolerate
are included in the subsequent system-oriented chapters; or even survive space flight was hardly a foregone conclu-
interested readers are also referred to the more detailed work sion in the early days. The acceleration forces associated with
in the Handbook of Physiology [1] and the recent text Space launch into orbit and reentry into Earths atmosphere, as well
Physiology by Buckey [2]. as prolonged exposure to weightlessness, were seen by some
By way of introduction, this chapter offers a brief history of to preclude human existence, let alone performance of useful
human space flight to provide a context for the current state of work. The sentiments of the time preceding the first human
knowledge of space medicine. launches were nicely summarized by Charles Berry:
People who were concerned with the future of man in space quickly
became aligned with one of two points of view. On the one side, there
Historical Aspects of Space Medicine were the more cautious and conservative members of the medical
and scientific community who genuinely believed man could never
Many questions were raised in the early 1960s as the United survive the rigors of the experience proposed for him. The spirit in
States and Soviet Union were contemplating the first human the other camp ranged from sanguine to certain. Some physicians,
particularly those with experience in aeronautical systems, were op-
flights. However, based on the existing knowledge of aviation
timistic. It became the task of the medical team to work toward
and environmental medicine as well as educated speculation bringing these divergent views toward a safe middle ground where
at the time, the risk was considered acceptable to proceed with unfounded fears did not impede the forward progress of the space
the first few flights, and confidence was bolstered by the early program, and unbounded optimism did not cause us to proceed at a
experience demonstrating that humans could tolerate space pace that might compromise the health or safety of the individuals
flight reasonably well. who ventured into space. [3]

27
28 E.S. Baker et al.

44 h actually spent in the capsule [4]. By comparison, the first


space flights were lasted several minutes to h. Life support
and medical monitoring systems, scientific observations, and
escape systems applicable to human space flight were fielded
and verified during these balloon flights, and psychological
and performance observations were made as well. The decade
of the 1960s, the briskly paced formative years of human space
flight, was begun with this information plus a fundamental
understanding of human tolerance to acceleration forces from
high-performance jet and rocket powered aircraft programs.
Most of the more overt and clinically relevant physiologi-
cal changes associated with space flight were identified early.
At the conclusion of the Gemini program in 1966, more than
2,000 man-hours had been accrued by U.S. flight crews, and
space flight was recognized to be associated with diminished
red cell mass, body calcium loss, diminished postflight exer-
FIGURE 2.1. Summary of human spaceflight experience as of Decem- cise capacity, and postflight orthostatic intolerance. By the
ber 2005, tabulated as person-flight experiences of orbital launches and conclusion of the Apollo program, many of the basic obser-
depicting the relative flight durations. Suborbital flight experiences are vations had been made that remain at the core of the human
not included. The time category of 120 days includes independent response to weightlessness (Table 2.1). Similar observations
spacecraft and short-duration stays on orbiting stations; subsequent and conclusions were made in the Russian program. Given the
categories involve long-term residence on orbiting stations effects of these findings on human performance, the goal of
both programs became to further characterize these findings
and to determine the mechanistic details underlying them, with
We now have decades of accumulated information and flight the aim of developing protective countermeasures that would
experience from which to plan follow-on spaceflight activi- allow safe extension of human missions in space. To this end,
ties. Figure 2.1 depicts the integrated experience of the Rus- more directed flight programs were developed involving well-
sian, U.S., and Chinese spaceflight activity to date, showing equipped orbital laboratories and long-duration stays.
the relative distribution of person-flight experiences over the The first U.S. long-duration experience was the three Skylab
duration of flights. However, some of the sentiments echoed missions, flown in 1973 and 1974, each of which were crewed
above still ring true as we contemplate taking steps beyond by three men; these missions lasted approximately 28, 59, and
Earth orbit and subjecting crewmembers to additional 84 days. The Skylab flights were dedicated to the systematic
challenges to health and performance, such as the increased investigation of the physiological effects of space flight as well
remoteness and duration of missions, environmental exposures as the conduct of astronomical, geological, and other experi-
such as radiation and planetary surface dust, and the physical ments and evaluation of equipment. Dietary issues, including
demands associated with lunar and Mars surface activities. In long-term food storage and provision of palatable foods, phys-
this regard, the role of the flight surgeon and medical support ical countermeasures including aerobic and resistive exercise,
team remains much as it did in the formative years. and methods of medical and hygienic support were all tested

A Brief Chronology of Space Flight


TABLE 2.1. Summary of significant biomedical observations in the
The pioneering human steps into space, beginning with Apollo program [5].
Yuri Gagarins flight on April 12, 1961, were preceded by Observation
directed ground experimentation with humans and animals. Vestibular disturbances
This information was augmented with knowledge of human Flight diet adequate; food consumption suboptimal
performance in other environments analogous in their isola- Postflight dehydration and weight loss
tion, crew composition, level of medical screening, and physical Decreased postflight orthostatic tolerance
demands, such as polar stations, submarines, and surface Reduced postflight exercise tolerance
Cardiac arrhythmiasa
ships. With regard to actual flight, the first terrestrial spacefar- Decreased red cell mass and plasma volume
ers in both the U.S. and Russian programs were animals. The Negative inflight balance of nitrogen, calcium, other electrolytes
Air Force Man-High and Navy Strato-Lab projects and Increased inflight adrenal hormone secretion
other balloon studies gave an understanding of and experience No inflight diuresisb
with sealed cabin atmospheres in a near-spaceflight environ- a
Sustained bigeminy during lunar orbit and surface EVA during Apollo 15
ment. The 1957 flight of Major David Simons, attaining an mission.
altitude of 31,100 m (102,000 ft) lasted more than 32 h, with b
An expected consequence of the thoracic fluid shift.
2. Human Response to Space Flight 29

and refined during this program. The biomedical findings of Preflight and Launch Factors
these missions still stand as relevant contributions to space
medicine; among the more significant outcomes were the Space crews launching to Earth orbit, either for a short-term
development of procedures for efficiently operating a crewed mission or a long-duration stay aboard a station, have typi-
space laboratory and the practical experience of long-duration cally been in training for a few to several years. The demands
flight. The Russian experience with the early Salyut stations of this preflight training are rigorous, and usually training
was similar to that of Skylab. By the mid 1970s, both nations requirements intensify in the few weeks to months preced-
had concluded that humans could live and work effectively ing launch. Health monitoring and physical countermeasures
in weightlessness for periods up to 3 months and that noth- are in place to ensure crew health, but accelerated training
ing precluded longer missions if sufficient countermeasures requirements, travel, and sleep shifting to the inflight schedule
were available [6,7]. Further Russian space activities involved may lead to crew fatigue in the final days before launch. The
a succession of orbital stations and longer duration missions; pressure to succeed, along with impending separation from
after a lag of several years, the United States began flying the family and other social factors, can induce additional levels
Space Shuttle. of stress. It is important to take these factors into account in
The U.S. Space Shuttle science program has made great strides developing prelaunch plans and schedules. Strict adherence
in working out details of human life sciences of short-duration to schedule limitations, methodical and effective circadian
space flight (i.e., up to 17 days). The ability to fly sophisticated entrainment when sleep shifting is required, and limiting crew
laboratory facilities with interchangeable payloads and support- contact with unscreened visitors to curtail transmission of
ing sampling and analysis equipment, abundant power, additional infectious disease are all part of the flight surgeons purview.
crew members (including trained scientists), and high-band- Since the beginning of human space flight and for the
width satellite communication have all been enabling aspects of foreseeable future, entry into space has involved a relatively
this program. Along with human life sciences, the Space Shuttle short chemical rocket ride into low Earth orbit, either as a final
program has benefited Earth observations, astronomy, materi- destination or as a transitional phase for leaving Earth vicinity.
als and physical sciences, and fundamental biology. One of the A typical transatmospheric flight for the Space Shuttle or
more tangible benefits has been expansion of the basic medical Soyuz lasts slightly more than 8 min, representing a best-fit
and clinical knowledge base owing to the large volume of human balance between ballistic factors and limitations of hardware
flight experiences supported by this program. This knowledge and crewmuch faster, and the greater acceleration loads
base has guided the development of successful medical opera- would exceed tolerance levels for crew and hardware; much
tional support to ensure that crew health and performance levels slower, and the vehicle stack would spend too much time in
are sufficient to execute mission tasks. the atmosphere, incurring excessive frictional heating and
By the early 1980s, the Russian flight experiences had requiring excessive propellant. Launch and landing are under-
exceeded 6 months in duration, and the era of nearly continu- standably the most critical phases of space flight with regard
ous Russian presence in long-duration flight had begun. The to vehicle performance and crew safety, and history certainly
Salyut series of space stations was succeeded by the vener- bears this out with the losses of the U.S. Space Shuttles Challenger
able Mir station, which saw nearly continual crewed service and Columbia and the loss of the Russian Soyuz 1 and Soyuz
from 1986 through 2000. Mir hosted scores of crewmembers T11 crews. As such, large portions of program infrastructure
in long-duration flights in addition to taxi and resupply flights and crew training are dedicated to the launch and landing
by the Soyuz and Shuttle. Russian specialists learned how to phases of space missions.
maintain long-duration flyers for routine missions of 6 months Without exception, crew positioning aboard spacecraft has
and longer, also building a systematic operational support pro- been oriented such that the major acceleration loads associated
gram emphasizing both physical and psychological counter- with flight to Earth orbit are incurred in the most favorable
measures. In addition, the Mir station provided a venue for the physiologic axis for sustained acceleration, that is, in the +Gx
United States to return to extended flight operations after a (chest to back) direction. After donning pressure suits, crews
20-year gap since the Skylab program. Seven U.S. crewmem- are seated and launch restraints are applied, usually between
bers flew long-duration missions on Mir in combination with 1.5 and 2.5 h before launch, with crewmembers positioned in
short-term Space Shuttle logistics flights. a semi-recumbent, legs-elevated position. Launch loads in the
The International Space Station (ISS) has seen continual Shuttle and Soyuz programs are variable and typically peak at
occupancy since 2000 and remains in assembly when this about 3 G for the Shuttle and 3.7 for the Soyuz (see Chap. 1).
chapter was written. The ISS will accommodate science and Vibrational forces also accompany launch into orbit and, in
technology development related to space flight and terrestrial combination with launch forces, may make throwing switches,
applications. Mature and validated countermeasures to adverse reading displays, accessing checklists, and other activities
effects of weightlessness and other practical products will be requiring arm and head movements difficult. Background
produced to contribute to further exploration efforts. Among noise can also interfere with voice communications. These
the anticipated products will be an enhanced knowledge of factors are accounted for in the design of hardware, displays,
practicing medicine in space with a greater evidence base. communication systems, and crew restraints, and such activities
30 E.S. Baker et al.

are routinely performed by flight crew members during ascent. The immediate effects of weightlessness on the human are
Flight crewmembers are constantly monitoring launch parameters not known. Relative to normal ambulatory conditions on the
and vehicle performance, ready to execute abort procedures ground, launch into space involves positional challenges,
and possibly assume full manual control if needed. acceleration forces, thermal loads, and psychological stress,
Ascent engines cut off abruptly, and the vehicle and crew which all occur over an interval preceding the first exposure
must transition quickly to the orbital flight phase. This phase to weightlessness. If the means were available to transition
involves crew duties such as monitoring guidance and flight immediately and cleanly from a normally active 1-G posture
parameters, additional engine burns to adjust and finalize into sustained weightlessness, certain physiologic details of
the orbit, loading new software into onboard computers, and early adaptation could be seen that are otherwise masked in
securing engines and other systems associated with ascent. the composite of forces and activities.
During this time, crewmembers may egress from restraints, Adaptation to weightlessness occurs at different rates in
doff launch suits, and begin stowing items no longer needed different systems. Multiple organ systems and tissue types
and deploying items needed during the orbital phase. The may react and adjust to weightlessness at different rates, pri-
immediate post-ascent phase is fairly demanding in terms marily based on the rapidity of response to loading in 1 G.
of crew activity, particularly as they are also adjusting to the Secondary effects such as reduction in blood cell mass lag
acute effects of weightlessness. behind primary effects such as reductions in plasma volume.
Processes requiring hormonal responses (e.g., certain fluid
regulation pathways) or cell turnover (e.g., skin desquama-
Weightlessness tion) will reflect their own timelines in their manifestations.
Longer-term processes are thought to include neuromotor
Weightlessness is often misrepresented as a physiologically adaptation, which depends in part on experience, as well as
challenging condition but is more accurately described as behavioral factors and exercise performance as the crew-
an absence of the accustomed physiological challenges with member settles into a balance of mission activities, nutrition,
respect to the gravity vector, to which the body is typically physical countermeasures, and sleep schedule. Crewmem-
subjected daily in 1 G (one multiple of g, 9.8 m/s2, the gravi- bers by and large are functional immediately upon arrival
tational load at the Earths surface). For normally active into weightlessness, but several stages of adaptation occur
humans, steady state in 1 G is not steady at all with respect over periods of days to weeks as their physiological sys-
to forces, but instead involves the dynamic and frequent reori- tems adapt to weightlessness, individually and in combina-
entation of organ systems to the gravity vector during lying, tion with other systems. For the sake of convenience, this
sitting, standing, and other activities. Many of these systems, process can be considered in terms of specific systems or
including the cardiovascular, pulmonary, neurovestibular, and performance parameters, but from the standpoint of overall
musculoskeletal systems, show specific or particular sensitivity to health and performance it represents a continuum. For some
force loading; their structure, function, and regulation are all systems, such as fluid regulation, an endpoint in adaptation
shaped by this gravitational dynamism. Stated simply, space can be identified; for others, such as loss of bone density in
flight freezes the natural outside physical forces acting on the skeletal system, the endpoint is not known.
the body in a state of neutrality as compared with standard Readaptation follows adaptation. Human space flight nec-
postural and loading changes. Any tissue, receptor, or organ essarily includes two phases of physiological responsethat
system that depends on or is susceptible to hydrostatic of inflight adaptation, in particular to weightlessness, and
pressure gradients and loading will demonstrate alterations of postflight readaptation after return to Earth. Both of these
function and possibly morphology in weightlessness. phases follow predictable time curves with distinct starting
A few of the assumptions and conditions that bound our points, and both influence human performance and clinical
understanding of microgravity physiology and human space findings. This process applies both globally (overall health
flight are worth highlighting and noted below. and functionality) and on a systems level. Because certain
The absolute effects of weightlessness on the human are inflight changes can only be assessed before and after flight,
not known. What has been learned about human beings in consideration must be given as to how these results could be
space has accumulated in the context of operational mis- influenced by the multisystem readaptation process at the time
sions. We have not studied the absolute effects of weight- of assessment. Some flight activities will include intermediate
lessness so much as the combined effects of weightlessness adaptation phases, as crewmembers are exposed to fractional
with a multitude of other factors, such as physical activ- gravity fields of the moon or Mars, again followed by weight-
ity associated with mission operations, deliberate exercise lessness and ultimately Earth return.
countermeasures, psychological factors, environmental Standard investigative and diagnostic methods are often not
parameters, medical investigations, medical treatments and possible. Because of limitations in launch mass and volume,
countermeasures, and other factors associated with space power, sampling and sample storage, interference with other
flight. It is doubtful that we will ever have true microgravity activities, and the difficulties associated with fluid handling
human control subjects. and other laboratory techniques in microgravity, inflight data
2. Human Response to Space Flight 31

may not be collected with the same level of control and scientific responses, each of which has multiple effects, are the thoracic
rigor as is possible during ground investigations. Investigators fluid shift resulting from loss of hydrostatic gradients and
and support technicians are replaced by multipurpose crew- neurovestibular disturbances, particularly in the form of space
members, who serve as subjects and operators in addition to motion sickness. Because these responses are immediate and
performing their other flight-related duties. Life scientists significant, they are described here separately from the
often must settle for less than optimal means of deriving system-oriented discussions that follow.
physiological and medical information during flight or simply
settle for observations made after flight. Fluid Shift
The sample size remains small. As of the end of 2005, 971
Upon reaching weightlessness, a thoracic body fluid shift
human flight experiences (defined as reaching a sustainable
beyond that induced by the launch position occurs in earnest,
orbit) have taken place with 435 separate individuals. Spe-
and it is this fluid shift that underlies many of the immedi-
cific medical parameters have been measured in standardized
ate effects of weightlessness. A sensation of fullness in the
fashions on only fractions of this group, and variability, both
head is commonly reported, with onset in a few minutes to
between and within individuals, remains a strong factor.
a few hours of becoming weightless, occasionally accompa-
Adaptation involves plasticity. Sustained weightlessness
nied by nasal congestion. Some crewmembers equate this to
provides a state in which the neutralization of forces influ-
the feeling of hanging upside down on Earth. Within minutes,
encing physiological processes can be observed. Changes in
objective facial edema and erythema may become apparent.
heart mass, baroreceptor sensitivity, and pulmonary ventila-
The volume of the lower extremities begins to diminish, and
tion-perfusion distribution have been noted that suggest a
the superficial vascular system of the upper body is seen to
greater degree of plasticity in mature organ systems than was
engorge. Subjectively, crewmembers may complain of dis-
previously thought.
comfort associated with feelings of facial fullness, especially
Overall, the human response to weightlessness involves
behind the eyes and in the maxillary and frontal sinus areas.
adaptation without functional impairment, largely preserving
The unpleasant sensation typically lasts from a few hours to
human work capacity as required by the new environment. As
a few days, and it usually resolves to a tolerable level as new
noted throughout this book, the basic direction of adaptation
set points for fluid regulation are established. Interestingly,
seems less like optimizing to weightlessness and more like
Skylab crews reported relief from these symptoms with cycle
shedding physiological capabilities and functional control that
exercise, presumably related to return of blood to the lower
help in the 1-G world but are no longer needed in space. Most
extremities [8]. Fluid shifting contributes to many of the
of the impairment associated with space flight occurs when
findings noted later in this chapter regarding anthropometric
the body must transition back to a steady-state gravitational
changes and fluid regulation.
field. The exceptions to this are transient and occur in the
period immediately after launch.
Space Motion Sickness
From entry into microgravity until 34 days into flight, approx-
Short-Term Responses imately two thirds of Space Shuttle crewmembers experience
Given the requirement for rocket ascent into Earth orbit, it some degree of space motion sickness [9]. Space motion
is understandable that the transition from normal terrestrial sickness among U.S. astronauts was first described during
activity to weightlessness can be difficult. Crewmembers don Apollo 9. The incidence was estimated to be 35% during the
protective pressure suits several hours before launch, which Apollo program and 60% during the Skylab program. Reports
are uncomfortable and may involve a degree of heat stress. from the Russian program indicate an incidence of 4050%
Ingress to the tight quarters of the Space Shuttle or Soyuz is among Salyut-6 and Soyuz crewmembers [10]. The syndrome
followed by secure restraint into a launch and entry seat in a varies in symptoms and intensity and includes increased sen-
supine position with the waist and knees flexed. Inevitably, sitivity to motion, headache, diminished appetite, stomach
some of the fluid shifting from the lower extremities to the awareness, nausea, and vomiting. Onset of motion sickness
central circulation begins in the vehicle before launch while has occurred as early as 15 min and as late as 3 days after
the crewmembers are seated in the required recumbent posi- reaching orbit. Symptoms generally last 23 days, but may
tion. After ascent, the transition to weightlessness is abrupt as persist for up to 710 days in a small number of people. In the
the engines switch off, and this transition is subjectively mag- U.S. program, the treatment of choice has been prometha-
nified by the greater-than-normal forces experienced during zine, given by intramuscular injection. Promethazine has been
the preceding several minutes. Crewmembers experience sub- effective in more than 90% of cases; it is normally adminis-
jective feelings of floating out of the launch seat, being held tered late in the first day before sleep, and reported side effects
in place only by restraint straps. Whatever objects had been have been few [11]. In particular, sedation is rarely reported as
resting unrestrained on the spacecraft floor now float free. a side effect in space relative to ground use.
Some of the more prominent physiological effects of microgravity Increased motor activity and head movements worsen the
appear almost immediately. The two dominant short-term illusions and symptoms of motion sickness, whereas diminished
32 E.S. Baker et al.

activity reduces the symptoms. Crewmembers are educated common, although considerable variability has been noted. In
before flight and also discover for themselves that slower describing a series of flight experiences on the Salyut 6 station
movements are less provocative. Consciously maintaining a lasting between 96 and 185 days, Kozerenko et al. reported
sense of a vertical in the environment also seems to be losses up to 5.4 kg and, less often, gains in body mass, with a
protective for many crewmembers during the early hours of maximum gain of 4.7 kg [15]. Smith and colleagues reported
flight. Purposely restraining the feet and bending down a mean body weight loss of 5% for 11 astronauts aboard the
to retrieve an object rather than flipping upside down with ISS for 128- to 195-day missions [16]. Although inflight find-
the newfound freedom of movement, for example, is a wise ings reflect individual variability and are subject to sporadic
choice early on. From a mission management perspective, measurements, most of the mass loss seems to occur within
EVA sorties are not scheduled within the first 72 h of launch the first 48 weeks of flight, followed by a slower decline or
to accommodate neurovestibular adaptation and to allow any plateau for the duration of the mission.
symptoms of space motion sickness to clear. Limb volume, as determined by standardized circumference
measurements, provides another more easily obtainable mea-
sure of tissue mass, reflecting body fluid shifting and muscu-
Anthropometric Changes lar growth or atrophy. Typically calf circumference decreases
rapidly within the first 48 h of flight in association with acute
The basic structure of the human body is a result of long-term
thoracic fluid shifting, which is not necessarily coupled to
terrestrial development. However, certain aspects of body
body mass loss. Buckey et al. reported a mean leg volume loss
size and shape are more dynamic and may be influenced by
of 748 ml after Space Shuttle flights of up to 14 days [12]. In
force loading. Although variability exists between individuals,
longer flights, this acute drop is followed by a more gradual
predictable trends are seen that influence the fit of highly
decline associated with muscular atrophy, typically reaching a
customized garments and spacesuits as well as physical crew
plateau depending on response to countermeasures and other
interfaces with the spacecraft such as work station restraint
individual factors. Measurements from two cosmonauts fly-
systems, medical and sleep station restraints, and landing vehicle
ing a year-long mission on the Mir station showed that calf
couches. Internal motion and redistribution of organs may
circumference declined steadily to about 20% below preflight
result secondarily from postural and musculoskeletal changes
baseline, whereas arm and forearm circumference remained
or independently from effects of fluid shifting and floating, all
essentially unchanged [17]. Figure 2.2 shows calculated left
of which can influence findings on physical examination and
upper and lower limb volume loss for three Skylab crewmembers
medical imagery. Both internal and external findings may be
during that 84-day flight.
influenced by the more long-term changes in physical activity,
Changes in thoracic and abdominal anthropometry reflect
metabolism, and energetics associated with space flight. An
axial unloading and perhaps represent the greatest threat to
understanding of these processes and findings is important to
fitting highly customized garments and restraints. Observed
space medicine practitioners and hardware designers alike.
increases in seated height in weightlessness presumably result
Body weight is a fundamental clinical measure reflect-
from expansion of the unloaded intervertebral disks and loss
ing immediate fluid balance and, on a more long-term scale,
of the thoracolumbar curvature [18]. Most of the increase
metabolism. Generally some degree of weight loss has been
occurs during the first 2 weeks and then stabilizes at approxi-
noted after both short- and long-duration flights. Buckey et al
mately 3% above the preflight baseline [19]. A corresponding
reported an average loss of 1.1 kg in 14 subjects immediately
decrease in abdom inal girth is seen as the abdominal viscera
after 10- to 14-day Space Shuttle flights [12]. Measurements
float in a rostral direction and are pushed in by unopposed
obtained before and after flight can be compared but are sub-
abdominal muscle tone, with a lesser decrease in chest girth.
ject to changes and fluid shifts during landing, and of course
Figure 2.3 shows trunk measurements for two Skylab crewmem-
cannot guide inflight activity such as nutritional support and
bers during the 84-day flight.
performance of countermeasures. The ability to assess body
mass during flight was recognized early as a health monitor- +0.3
ing requirement by the Russian and U.S. programs. Body
Volume change, liters

0
mass has for years been determined in weightlessness by
-0.3
means of fixing the body to a linear spring-tension system and
inducing oscillating motion. Knowing the mechanical char- -0.6

acteristics and in particular the spring-constant of the system -0.9


allows body mass to be assessed by the timing of the oscilla- -1.2
Arm
tion cycle. Currently on the ISS, body mass is measured every -1.5
Leg
2 weeks during long-duration missions. 0 4 8 31 37 57 59 82 0 2 4 6 8 10
Launch Landing
Losses in body mass of 45% are typical in long-duration
Mission Day
flights and most likely result from negative dietary and energy
balances [13,14] (see Chap. 27). A decline of a few kilograms FIGURE 2.2. Changes in left limb volume for three crewmembers on
below preflight baseline at the end of a 6-month mission is the Skylab 4 mission. Combined/redrawn from [18]
2. Human Response to Space Flight 33

+6 Postural changes also follow predictable trends and are


+4 relevant to the design of inflight crew systems. The neutral
+2 body posture assumed in weightlessness (Figure 2.4) typically
Change, cm

0 includes flexion of the musculature proximal to the limbs


-2 and thoracolumbar straightening with retention of the cervi-
-4 Height Circumferences cal curvature, resulting in neck flexion. This position should
Chest (insp)
-6 Chest (exp) be accommodated by crew restraints at work and sleep sta-
-8 Waist
tions; any other shape forces the body out of this position.
-10 Crewmembers testing a conventional medical restraint system
0 10 20 30 40 50 60 70 80 R+10 +17 during the STS-40 Space Shuttle mission noted significant
Mission Day
discomfort with being restrained in an Earth-normal recum-
bent position [20].
FIGURE 2.3. Changes in trunk measurements for two Skylab crewmem-
bers during the 84-day flight. Combined/redrawn from [18]
Physical Examination Findings
Physical examination is a time-honored means of obtaining vital
information without the use of invasive techniques, electrical
recording, or imaging. As is true on Earth, physical examina-

FIGURE 2.4. The neutral body posture assumed in weightlessness. Segment angles shown are means; values in parentheses are standard
deviations. Data were developed in Skylab studies and based on measurements from three subjects [19]
34 E.S. Baker et al.

tion has a crucial role in space flight for making initial diagnoses time but not returning to baseline. Rostral relocation of liver
and for monitoring health trends. Considered in light of medi- and spleen by palpation [21].
cal history, findings from physical examination can hasten the Musculoskeletal: All subjects assumed the neutral body
diagnosis and treatment of an ill or injured crewmember and posture. Noticeably diminished size and thinning of large
help to direct the use of other available investigative studies, muscle groups of lower extremities [21].
which must be used strategically because of resource limita- Neurological: Brisker tendon reflexes noted in five of seven
tions. Most of the basic techniques and instruments used in subjects [21].
terrestrial physical examination and diagnosis have been The following sections address more specifically the known
used during space flight. However, the known multisystemic clinical changes in specific physiological systems associated
physiological adaptation to weightlessness suggests that nor- with weightlessness.
mal physical findings achieve new baselines, which must be
considered for monitoring health and for interpreting new-onset
possibly abnormal findings.
Cardiovascular System and Volume Regulation
Harris et al. developed a systematic method for performing The cardiovascular system, which can be simplistically des-
physical examinations in weightlessness [21]. The techniques cribed as a closed hydraulic circuit oriented along the bodys
involved were verified during ground and parabolic flight ses- longitudinal axis with a more or less centrally located pump,
sions and then performed on seven subjects during the course is one of the systems most influenced by hydrostatic gradi-
of an 8-day Space Shuttle flight by a physician astronaut. ents. In an effort to maintain end perfusion of body tissues
Subjects underwent preflight and postflight examination and and support oxidative metabolism in highly variable demand
served as their own controls. Findings from longer flights are states, a complex system of interrelated subsystems and
expected to reflect findings that may not have been captured responses (neural, renal, endocrine) serves to compensate for
by this investigation; however, the results of Harris study dynamic changes in these hydrostatic forces as the body reori-
constitute the most complete systematic collection of space ents itself relative to the gravity vector and responds to other
normal physical findings obtained by inflight physicians thus physiologic perturbations. Volume-sensitive stretch recep-
far. Major findings are presented below in the order of their tors (baroreceptors) reside in the aorta and carotids in large
performance during a standard physical examination, with numbers and normally help to mediate the rapid response to
corroboration and supplementation from other sources as gravitational stresses to central circulation. Increasing pres-
available. Genitourinary and rectal systems were not examined. sure induces the firing of afferent nerves from baroreceptors
Eyes: Mild conjunctival erythema noted in some crewmem- to stimulate a centrally integrated and parasympathetically
bers, otherwise no changes. Normal funduscopic exam with mediated vasodilatation and reduction in cardiac output in
no papilledema [21]. Increases in intraocular pressure of 92% an effort to maintain normal arterial pressure. Conversely,
during the first 16 min and then by 2025% after 44 min of a reduction in sensed pressure by the baroreceptors stimu-
flight [22], suggesting a trend towards normal over time. lates a centrally mediated sympathetic response, driving the
Ears: No significant changes from preflight assessment opposite effect to maintain pressure during acute reductions.
[21]. This baroreceptor reflex preserves pressure during postural
Nose: Generally showed increased erythema and edema of changes, particularly in moving from recumbent to seated to
nasal mucosa [21]. standing positions [24].
Throat: Slight hyperemia of mucosal membranes [21]. In weightless environments, many of the non-gravitation-
Neck: Jugular venous distension extending along entire ally oriented factors that could influence demand and hence
length of neck [18,21]. Increase in jugular vein cross section cardiac output (e.g., exercise, cold stress, volume loss, hypoxia)
via sonography [23]. remain unchanged. However the hydrostatic gradients vanish,
Skin: Acutely edematous and hyperemic on face and upper along with them the periodic stimulus for maintaining cardiac
body; prominent eyelid edema. Some subjects showed hyper- output under various orientations to gravitational loading.
emia and injection of conjunctivae and mucosal membranes Venous pressure, normally under a significant gravitational
[21]. Loss of calluses on feet and normal weight-bearing skin influence, essentially equalizes throughout the body and
surfaces are noted after weeks in long-duration flight. directly reflects right atrial pressure. The changes of the car-
Chest: Barrel appearance resulting from standard anthro- diovascular and fluid regulatory system largely reflect the
pometric changes [18,21]. Elevation of the diaphragm by one removal of these hydrostatic gradients and, to a lesser extent,
to two intercostal spaces, with corresponding decrease in basal the hypokinesia relative to terrestrial activity.
lung sounds in some crewmembers. Investigations of cardiovascular variables during space flight
Heart: No discernible difference in intensity or rhythm. has been driven largely by the early recognition of postflight
Substernal displacement of point of maximal impulse in four orthostatic intolerance and attempts to elucidate how adapta-
of seven subjects, not palpable in three [21]. tion leads to this maladaptive condition on return to Earth.
Abdomen: Flattened abdominal contour [18,21]. Dimin- Some of the major findings associated with the cardiovascular
ished bowel sounds in five of seven subjects, increasing over system in weightlessness observed during carefully controlled
2. Human Response to Space Flight 35

studies are summarized in Table 2.2. Unless otherwise noted, Cardiovascular changes such as increased cardiac output due
these findings are based on inflight measurements; the to increased cardiac filling and stroke volume begin very early
exceptions are for those variables less influenced by the immediate during flight, accompanying the immediate central fluid shift.
reverse fluid shifts and other dynamic effects of landing, such The observed maintenance of mean arterial pressure implies
as cardiac mass and red blood cell (erythrocyte) mass. The a corresponding decrease of peripheral vascular resistance.
major time division is artificial and tied to vehicle experience. Space Unlike that in the terrestrial supine position, central venous
shuttle flights have included sophisticated science payloads pressure does not increase in response to this shift in weight-
and allowed high-fidelity results, but of course are time-lim- lessness [26]. This may relate to the increased thoracic diam-
ited (up to 17 days in duration). Longer-duration flights from eter consistent with the anthropometry changes noted above.
space station programs are better platforms for characterizing Parabolic flight studies have corroborated the thoracic shape
the long-term human response and changes over time. Gener- change [39] as well as the concomitant decrease of central
ally speaking, the cardiovascular system undergoes predict- venous pressure immediately upon entering weightlessness
able changes but adapts well to prolonged weightlessness, [40]. A lower thoracic pressure may result in lower central
with a few significant findings. venous pressure and increased cardiac output, but would also

TABLE 2.2. Major cardiovascular findings associated with weightlessness.


Variable Short-term response (Max 17-day flight) Long-term response
Heart rate Slightly decreased in comparative 24-h ambulatory studies, Unchanged c/w preflight, measured FW 8, 16, and
n = 12 [25]. No change early in flight c/w preflight seated 24, n = 4 [29]; unchanged at 1,3, and 5 months,
(n = 3 [26]; n = 4 [27]) or minimally decreased c/w supine n = 6 [23]; 1012 bpm n = 2, and to
(n = 6 [28]) moderate bradycardia n = 1, measured
periodically during 8-month flight [30]
Heart rate variability Decreased in comparative 24-h ambulatory studies, n = 12 [25]
Systolic blood pressure Unchanged, comparative 24 h ambulatory studies, n = 12 [25] Unchanged while awake, slightly during sleep c/w
preflight, measured FW 8, 16, and 24, n = 4 [29];
unchanged at 1, 3, and 5 months, n = 6 [23]
Diastolic blood pressure Decreased in comparative 24-h ambulatory studies, n = 12 [25]; slightly c/w preflight, measured FW 8, 16, and
c/w preflight supine, n = 6 [28] 24, n = 4 [29]; unchanged at 1, 3, and 5 months,
n = 6 [23]
Mean arterial pressure Unchanged c/w preflight seated, FD1 and FD 7/8, n = 4 [27]; Unchanged at 1, 3, and 5 months, n = 6 [23]
c/w preflight supine, n = 6 [28]
Central venous pressure 8.42.5 cm H2O c/w seated preflight, FD1, n = 3 [26]
Unchanged to slightly decreased c/w with preflight supine, n
= 1 [31]
Systemic vascular resistance No change early in flight c/w preflight seated, n = 3 [26];
24% FD1 and 14% FD8, n = 4 [27]
Plasma volume 17% in first 24 h, then stabilizing at 1015% by FD 5, 8.4%, n = 3, R + 0 of 28-day flight; 13.1%,
n = 6 [32] n = 3, R + 0 of 59-day flight; 15.9%, n = 3,
R + 0 of 84-day flight [33]
Red blood cell mass 10% within 1 week, n = 6 [34] 11.1%, n = 9, R + 0 of 28-, 59-, and 84-day flights
[33]
Echocardiographic findings
Left ventricular end diastolic volume 4.604.97 cm c/w preflight supine, n = 3 [26] 824% at 1, 3, and 5 months, n = 6 [23]
Left ventricular End systolic volume No change, n = 3 [26] up to 19% n = 2, and up to 20% n = 1, measured
periodically during 8-month flight [30]
Stroke volume 46% c/w preflight standing, n = 4 [35]; 5677 ml, 1016% at 1, 3, and 5 months, n = 6 [23];
n = 3 [26]; 55% c/w preflight standing, 9% c/w supine, 1215%, n = 2, and up to 20% n = 1, measured
n = 6 [28]; 40% early in flight (n = 2), followed by return periodically during 8-month flight [30]
to preflight values [36]
Left ventricular mass 12% c/w preflight, n = 4 postflight measurement after 10-day
flight [37]
8% c/w preflight, n = 3, postflight measurement after 84-day
flight [38]
Cardiac output c/w prelaunch supine, FD1, n = 3 [26] 17%20% at 1, 3, and 5 months, n = 6 [23]
c/w prelaunch seated, 29% FD1 and 22% FD 7/8, n = 4 [27];
26% c/w preflight standing, unchanged c/w supine, n = 6
[28]; 18% c/w preflight standing, n = 4 [35]

Abbreviations: FD, flight day; FW, flight week; , increase; , decrease; n, subject number; c/w, compared with.
a
Measured as part of a study of the effect of thigh cuffs on cardiovascular dynamics in space flight. Cuffs were worn 10 h each day, but measurements were
taken before the cuffs were put on.
36 E.S. Baker et al.

be expected to increase lung volumes. As described in the stroke volume, suggesting that the inflight status reflects
next section on pulmonary findings, the opposite is seen. This primarily the relative fluid deficit with normal [49] or even
seeming paradox remains to be definitively resolved, and is exaggerated sympathetic response to orthostatic stress [50].
discussed in detail in Chap. 16 and by Buckey [41]. No evidence exists to suggest that the cardiovascular
Plasma volume loss also begins early, with a predominant changes associated with normal adaptation to weightlessness
mechanism being extravasation from the vascular space to the are clinically threatening or functionally limiting of inflight
intracellular space, apparently because of increased capillary mission requirements. Particular attention has been paid to
permeability [32]. A resulting increase in hematocrit is seen the incidence of arrhythmias arising from space flight such as
along with other factors leading to inhibition of erythropoietin those involving ventricular bigeminy and profound bradycar-
[34]. Over the course of several days, stabilization of plasma dia during an Apollo mission [51], paroxysmal supraventricu-
volume is accompanied by a reduction in red blood cell mass lar tachycardia arising during and persisting after EVA [52,53],
to an appropriate space flight set point, with normalization and a run of ventricular tachycardia caught incidentally during
of hematocrit [34]. The decrease in erythrocyte mass seems a 24-h Holter study [54]. However, other stressors that may lead
to involve a process of selective hemolytic removal of the to arrhythmias are also present during space flight, including
youngest erythrocytes (neocytolysis), facilitating more rapid high physical workload, fatigue, psychological stress, hydra-
adaptation to the microgravity circulatory state [42]. This tional challenges, and electrolyte changes. Attempts are made
state represents a basic euvolemic set point for weightless- during astronaut selection to screen out those with underlying
ness (1015% reduction in plasma volume, 10% reduction in coronary artery disease, but the relatively high prevalence of
erythrocyte mass). this condition and the difficulties involved in screening it out
Diuresis is not observed to accompany the fluid shifting and with 100% accuracy cannot totally preclude the possibility
resetting to lower plasma volume in the first days of flight, in of someone with coronary artery disease flying in space. In
part because of decreased fluid intake related to reduced thirst a few astronauts, clinical manifestations of coronary artery
and space motion sickness and possibly due to intracellular disease appeared within 2 years after space flight, and the
fluid shifts. Further changes over time include a decrease in arrhythmias noted may have reflected the presence of under-
cardiac chamber dimensions to reflect the new volume status. lying disease. Closer systematic investigation into incidents
New homeostatic conditions for central circulation seem to of inflight arrhythmias has revealed no increase in incidence
most closely mimic those associated with the terrestrial seated during Shuttle flights, either during normal activities [25] or
posture [26,43]. Eventual decreases in resting cardiac output, during EVA [55].
left ventricular mass, and chamber volumes are seen, stabiliz- Acceleration and vibrational forces, along with the factors
ing to reflect the new balance between physical activity, diet, noted above, are also known to induce cardiac arrhythmias.
and fluid volume status. Cardiopulmonary performance Cardiac monitoring during the more dynamic phases of flight
is discussed in a separate section below, but in general left was instituted beginning with the first space flights; crew-
ventricular contractile function is maintained as normal as members wore electrocardiographic monitors during launch
assessed by echocardiography after 3-month [38] to 8-month and landing in the first three major U.S. programs, and they
periods of weightlessness [30]. continue to do so in the Russian program. In parallel with
Given that the baroreceptors, which normally help to medi- space program experience, aviation medical studies involv-
ate the rapid response to gravitational stresses to central circu- ing hundreds of subjects have demonstrated that a wide vari-
lation, are relatively unchallenged in zero G, downregulation ety of arrhythmic conditions normally accompany exposure
of this function would be expected. Although the aortic and to acceleration that are not associated with impairment and
cardiopulmonary baroreceptors are difficult to test directly, do not reflect underlying abnormalities [56]. Those studies
the carotid baroreceptors may be selectively and temporarily involved healthy, non-deconditioned subjects exposed to +Gz
deformed with a form-fitting pressure cuff. Under those con- accelerations up to 9 G. A follow-on study showed no differ-
ditions, the normal heart-rate and blood-pressure responses ence between men and women [57]. These findings, coupled
to carotid baroreflex activity are seen to be diminished both with observations during the early space program of a lack of
during [44] and after short-duration Shuttle flights [45,46]. negative clinical events correlated with these findings, led to
Changes in these responses to Valsalva maneuvers and respi- the abandonment of cardiovascular monitoring during launch
ratory frequency R-R interval spectral power further suggest and landing phases early in the Space Shuttle program. Heart
decreases in parasympathetic control of blood pressure and rate and rhythm are still monitored during EVA, where the
baroreflex gain during both short-duration [46,47] and long- physiological margins are lower and the workload is particu-
duration (9-month) flights [48]. Sympathetic neural control larly high, as well as during inflight activities that may involve
seems to be maintained, as ascertained by inflight responses more specific risk of arrhythmogenic responses (e.g., LBNP
to lower-body negative pressure (LBNP), which mimics the and maximal exercise testing). In such cases, real-time man-
lower-extremity volume redistribution of assuming an upright agement decisions can be made based on the cardiac findings,
posture on the ground. Increases in heart rate, blood pressure, such as calling for rest in the EVA cycle or terminating the
and peripheral vascular resistance accompanied decreases in LBNP session.
2. Human Response to Space Flight 37

Respiratory System exist to maintain sufficient pulmonary gas exchange dur-


ing transient high-G exposures and sustained moderate-G
As is true of the cardiovascular system, the respiratory system exposures in rotating rooms. The known changes of thoracic
is affected during the process of adaptation but is not function- shape and upward movement of abdominal viscera seen in
ally impaired during flight, and no reports have been made of weightlessness represent the opposite of this condition, and
difficulty in breathing or other primary respiratory complaints. they also influence chest wall mechanics. During a short-dura-
However, the respiratory system is an open-loop system and tion Shuttle flight as well as a long-duration flight on Mir, the
unique in its potential for interaction with the environment, abdominal contribution to tidal volume was shown to increase
particularly in a sealed cabin with an artificial atmosphere void significantly [59].
of the most prominent natural forces that normally remove A small number of Space Shuttle missions dedicated to life
particulates and heavy aerosols. Secondary effects, reactive sciences investigations have produced precise measurements
symptoms to dust and contaminant exposure, may overlap with of pulmonary indices from crewmembers on these short-dura-
other expected effects of adaptation. Distinguishing between tion flights. These measurements are summarized in Table
headward fluid shifting and atmospheric nuisance dust causing 2.3. Changes reflect the early process of adaptation, as forces
the often-reported nasal stuffiness can be difficult, and head- of fluid regulation, cardiovascular dynamics, abdominal and
aches early in the mission caused by a contaminant such as chest shape change, and perfusion distribution strike a new
CO2 can be confused with space motion sickness. balance. Performance of standard crew duties and exercise are
The risk of aspirating foreign particles in the weightless not impaired. Neither oxygen uptake nor CO2 output change
environment is higher than that on Earth, and mild cough reactions in microgravity [60]. The ventilatory response to hypoxia is
from such events are not uncommon. The risk is further attenuated in microgravity, persisting during a 16-day mission
elevated with activities that could cause inadvertent release of among five subjects and resolving quickly after return; how-
particulates, such as large-scale stowage transfer operations ever, ventilatory response to hypercapnia was unchanged from
involving movement of fabric bags, and when minute venti- preflight values [61].
lation is high, such as during exercise. Efforts are made to Decreases in tidal volume, with partially compensating
decrease the particulate levels during construction, outfitting, increases in respiratory frequency, have been observed; this is
and ground processing of modules and payloads by carefully
selecting materials and foods and by using standardized
processes for handling fluids and particulates. Forced air circula-
TABLE 2.3. Pulmonary changes associated with space flight.
tion and use of high-efficiency particulate-absorbing filters on
Variable Short-term response (Max 17-day flight)
ISS actively reduce the atmospheric particulate burden there.
High-risk activities such as cleanup of spills and transfer of Respiratory 9% c/w preflight standing, n = 8, 2 Shuttle flights of
some materials prompt crewmembers to don protective masks. frequency 9 & 14 days [60]
Tidal volume 15% c/w preflight standing, n = 8, 2 Shuttle flights
Aerosols may be released from leaking fluid lines, as occurred of 9 & 14 days [60]
when ethylene glycol coolant leaked onboard the Mir station, Vital capacity 5% after 24 h c/w preflight standing, then resolve to
and particulates and contaminant gases can be released from normal by 72 h, n = 7, during 9 day flight [62]
pyrolysis events such as those that occurred on the Shuttle Forced vital capacity 35% on FD2 c/w preflight standing, then resolved
(STS-40) and the Mir station (further discussed in Chap. 21). to normal by FD4, slightly by FD9, n = 4 [63]
The lungs themselves, easily deformable and well known Peak expiratory flow 12.5% c/w preflight standing on FD2, 11.6% on
to be sensitive to gravitational loads, are expected to undergo rate FD4, and 5.0% on FD5, returned to norm by FD9,
n = 4 [63].
changes in weightlessness. Gravitational and other accelera-
Functional residual 15% c/w preflight standing but higher than preflight
tion forces are particularly influential in a system whose func- capacity supine, n = 7 [62].
tion depends on regional interaction between substances of slightly early inflight c/w preflight, n = 2, resolved
vastly different densities, namely gas-filled lung tissue and to normal later inflight, n = 4 [36]
blood. The upright posture involves a gradient in which apical Residual volume about18% c/w preflight standing, n = 4 [62]
regions are less well perfused than basal regions, contribut- Alveolar ventilation Unchanged, n = 8, 2 Shuttle flights of 9 & 14 days
[60]
ing to alveolar dead space and creating a regional mismatch Tissue volume About 24 h, n = 2 no change; At FD9 & 10, n = 4, a
between ventilation and perfusion. The supine posture reduces 25% decrease c/w preflight controls (p < 0.001).
this mismatch, limiting the vertical gradient to the antero- (Concomitant reduction in stroke volume, to the
posterior dimension of the lung. In a high +Gz environment, extent that it was no longer significantly different
overall compliance of the respiratory system (lungs and chest) from preflight control.)
Pulmonary diffusing DLco and the membrane component (Dm) both
decreases. The diaphragm is displaced downward (caudally), capacity (DLco) increase 28% c/w preflight standing after 24 h,
resulting in an increase in functional residual capacity and unchanged over 9 days, n = 4; DLco increased 13%
tidal volume; reflex increases in abdominal wall tension and about 24 h into flight, n = 2, maintained at 13%
abdominal pressure prevent full diaphragmatic movement FD9/10, n = 4 (different method)
and reduce vital capacity [58]. However, functional reserves Abbreviations: FD, flight day; c/w, compared with.
38 E.S. Baker et al.

fully compensated by an observed decrease in physiological Bone


and alveolar dead space, attributed to more uniform distribu-
Bone integrity and calcium homeostasis are issues of concern
tion of pulmonary perfusion in the weightless environment
for long-duration space flight. Conditions of immobilization
such that alveolar ventilation remains normal [60]. Decreases
such as spinal cord injury [67,68] or deliberate bed rest [69,70]
in residual volume relative to preflight standing and supine
are well known to be accompanied by loss of bone mineral
values presumably reflect the diminished regional apico-basal
density (BMD). Measurable decreases in BMD have been
gradients seen on the ground [62]. Vital capacity [62] and
reported in professional scuba divers, presumably caused by
forced vital capacity [63] each undergo slight decreases within
the decreased loading associated with water immersion [71].
24 h of arriving in weightlessness, both resolving to normal
Loss of mineral from weight-bearing bones has been well
within 34 days. This early decrease in vital capacity has been
documented since the first long-duration space flights [72],
suggested to reflect the initial increase in intrathoracic blood
in combination with loss of bone density, loss of body cal-
volume, resolving as plasma volume decreases over the same
cium and phosphate, and decreases in calcium absorption. The
time course [34,64]. Despite early concerns that pulmonary
development of advanced assessment techniques and assays
edema would result from thoracic fluid shifts, diffusing capac-
for metabolic markers over the past two decades has enabled a
ity has been seen to increase during flight [35,36], presumably
better understanding of the process, although the mechanistic
because of more uniform capillary filling and the subsequent
details have yet to be fully identified.
increase in effective surface area supporting diffusion [35].
Bone mineral is lost preferentially from the weight-bear-
Although investigations indicate that the gravitationally sensi-
ing bones, including the lower extremities, lower pelvis, and
tive apico-basal gradients are largely absent in microgravity,
lumbar spine, during space flight. Loss in BMD at the rates
cardiogenic oscillations in expired oxygen and CO2 persist
incurred by space flight or bed rest typically requires several
[60,65], suggesting some nongravitational regional inhomo-
weeks to detect via imaging studies. For Skylab crewmembers,
geneity in ventilation perfusion. This topic is further discussed
photon absorptiometry did not detect bone loss in the calca-
in an excellent review by Prisk [64].
neus in the crew on the 28-day flight, but showed a 7% loss
Little information is available on pulmonary variables
for those on the 59-day flight and an 11.2% loss for those on
during long-duration missions, although many of the acute
the 84-day flight [69], with no losses seen in the distal radius
changes in volumes seem to resolve early in the course of short-
or ulna. Crewmembers on the Mir station flying multimonth
duration flights, and observations during exercise and EVA
missions lost BMD at an average monthly rate of 0.3% from
over the course of several months indicate no perceived limi-
the total skeleton, with 97% of that loss coming from the pel-
tation to pulmonary performance. During a 6-month mission,
vis and legs as assessed by magnetic resonance imaging and
vital capacity and expiratory reserve volume, measured in two
dual X-ray absorptiometry [73]. LeBlanc and colleagues used
subjects, was seen to reflect preflight supine values on FDs 9
dual X-ray absorptiometry to define the rate and distribution
and 175 [66]. On the day after return to Earth, vital capacity
of bone loss from long-duration missions in 18 cosmonauts
had decreased by 30%, presumably because of decreases in
(Table 2.4) [74]. In another study of 14 ISS crewmembers,
expiratory reserve volume and inspiratory capacity attributed
BMD was shown to be lost at a rate of 0.9% per month at the
to weakening of respiratory muscles. Future activities on the
spine, 1.41.5% per month at the hip, and 0.4% per month
ISS should help to further characterize the effects of long-
at the calcaneus [75]. Loss in BMD in these regions in ISS
duration space flight, if any, on pulmonary function.
crewmembers (Figure 2.5) identifies these areas as targets for
countermeasures [76].
Musculoskeletal System Calcium loss from the skeletal system, which also serves as
the bodys storage pool of this mineral, begins early in flight.
The musculoskeletal system provides the framework and
During comprehensive metabolic monitoring studies on Skylab,
means of motion, locomotion, and force exertion for the
human body. Muscle and bone are vital tissues that continually
respond structurally and functionally to loads, increasing TABLE 2.4. Changes in bone mineral density after 414.4 months of
space flight [74].
in mass and strength in response to sustained exposures to
increasing loads and decreasing with diminishing loads. As Percent change Standard
Anatomical site No. of subjects per month deviation
such, the musculoskeletal system is directly shaped by the
Spine 18 1.06* 0.63
outside loads against which it must react and oppose. The
Neck 18 1.15* 0.84
skeletal system provides rigid attachment points for the skeletal Trochanter 18 1.56* 0.99
muscle that moves the body and also applies direct loads Total 17 0.35* 0.25
to the bone at these points, further influencing bone struc- Pelvis 17 1.35* 0.54
ture. Working in concert, the muscles supplying the power Arm 17 0.04 0.88
Leg 16 0.34* 0.33
and the bones supplying the framework and system of levers
for force exertion, these two systems cannot, in practice, be *
p < 0.01.
considered separately. Source: From A LeBlanc et al. [74]. Used with permission.
2. Human Response to Space Flight 39

physical countermeasures may have a protective role against


loss of BMD; such countermeasures are evolving, and it is
hoped that new devices providing the means for heavy resistive
exercise, soon to be available on ISS, will help to further mitigate
bone loss. One such device, the advanced resistive exercise
device, can provide axial loading of up to several hundred
pounds for exercises such as squats and dead lifts.

Muscle
Skeletal muscle atrophy and loss of strength are long-known
consequences of space flight. Like bone, skeletal muscle is
also dynamic and depends on relative balances of demand
FIGURE 2.5. Mean percent change ( standard error) from preflight based on loading forces and metabolic factors regulating
values in bone mineral density of 15 U.S. crewmembers after return synthesis and breakdown. Changes in muscle manifest more
from ISS Expeditions 112 [76] quickly than changes in bone, because bone involves more
long-term deposition of mineral salts. Practically, this pro-
cess is influenced by nutrition, exercise countermeasures, and
crewmembers exhibited negative calcium balance, with individual genetic disposition. Muscle atrophy is associated
increased urinary and fecal calcium excretion and decreased with negative nitrogen balance, which was observed as early
intestinal absorption of calcium [72]. Reduced intestinal as the Apollo program and more thoroughly characterized in
absorption and increased urinary excretion were confirmed on the Skylab program. Significant losses of urinary nitrogen and
a subsequent long-duration mission [77]. Another biochemical phosphorus were documented during these flights and asso-
marker of skeletal turnover and breakdown, urinary hydroxy- ciated with observed reduction in muscle tissue [72]. Losses
proline, was noted to be elevated in Skylab crewmembers were accentuated during the first week, most likely correlating
[72], and more recently other markers of resorption, such as with the relative anorexia accompanying the first several days
n-telopeptide and deoxypyrodinoline, have been consistently of the flight. In postflight evaluations, corresponding losses of
elevated during flight [7880]. Markers of bone formation strength relative to preflight measurements, particularly in the
such as bone-specific alkaline phosphatase and osteocalcin lower extremities, were seen, with strength loss in extensors
have been either decreased [79] or unchanged [80] as a result reaching nearly 20% and that in flexors ranging from 10% to
of weightlessness. Increased resorption and diminished intes- 17% after the first two crewed Skylab missions [85]. After
tinal absorption of calcium seem to have central roles in the the first Skylab mission, in which physical countermea-
loss of BMD caused by space flight. Parathyroid hormone sures consisted only of bicycle ergometry, additional exercise
levels have been reported to be increased during [79] and capability was added to the next two missions; this additional
immediately after long-duration flight [81], unchanged dur- capability consisted of mild resistive exercise and a slippery
ing short-duration flights [82] and after long-duration flights surface to serve as a surrogate treadmill to allow running and
[80], and increased during short-duration flight [83]. Levels of jumping under loads. Additional food was also supplied with
active vitamin D (1,25-dihdroxycholecalciferol) were reduced the intent of increasing food intake. Muscle loss was much
during flight and unchanged immediately after landing from diminished compared with the loss experienced during the
long-duration missions [80] and were found to increase during first mission, but still persisted [85].
shorter flights [82]. The lack of ultraviolet light in the spacecraft Although coupled with comprehensive nutritional and met-
environment probably contributes to the reported reductions abolic studies, the Skylab data on muscle loss were influenced by
in vitamin D stores (25-hydroxycholecalciferol) after space the small sample size (only nine crewmembers total) and sub-
flight [80,84], and vitamin D supplements are given during stantial variations in nutritional states and availability of exer-
flights aboard the ISS to ensure adequate levels of this factor. cise countermeasures among the missions. Subsequent flight
Loss of BMD seems to continue unabated in weightless- experiments on the Space Shuttle and with Russian station
ness and presumably would eventually lead to clinically rel- crews have extended the Skylab findings and allowed better
evant losses of BMD and increases in risk of fractures. Bone characterization of the effects of weightlessness on skeletal
loss also carries an inherent risk of nephrolithiasis because muscle, as noted briefly below.
of hypercalciuria, which begins upon first arrival to weight- A basic understanding of skeletal muscle structure is helpful
lessness (discussed further below). Structurally, decreases for interpreting space flight findings of muscle morphology.
in BMD do not seem to breach the clinical threshold even in Demands on skeletal muscle with regard to power and endur-
standard long-duration missions; no increase in the incidence ance vary with required function and hence distribution
of fractures attributable to bone loss has been seen during the throughout the body. As such, differences in morphology and
postflight period, at least with current flight durations. Inflight supportive metabolism exist that serve to optimize functionality
40 E.S. Baker et al.

in these different roles. Broadly peaking, skeletal muscle can 5.5% to 15.4% for knee extensor, 5.614.1% for knee flexor,
be distinguished by fiber type, driven by these structural and and 8.815.9% for plantar flexor [87]. Postflight biopsies of
functional differences. The diameter, velocity of contraction, vastus lateralis muscle after 5-day and 11-day Shuttle flights
and ability to utilize different metabolic fuels are basic deter- in eight astronauts showed 68% fewer type I fibers than pre-
minants of fiber type. Individual skeletal muscles consist of a flight measurements. After the 5-day flight, cross-sectional
combination of the three basic muscle fiber types, with their areas were diminished by 11% for type I fibers and by 24%
proportions depending on the action of that muscle as well as for type II fibers. The number of capillaries per fiber was
genetic influences. diminished by 24%, although the ratio of capillaries to over-
Type I fibers, slow-twitch fibers with slow contraction veloci- all muscle cross-sectional area remained constant. Metabolic
ties, primarily utilize oxidative metabolism as an energy source changes in energy substrate utilization also differed among
and are resistant to fatigue. Type I fibers are relatively small in fiber types; myofibrillar adenosine triphosphate activity was
diameter, contain large amounts of myoglobin to enable oxy- increased after flight in type II but not type I fibers [88]. Long-
gen utilization and delivery, and are rich in capillaries and duration flights, in which the steady-state effects of physical
mitochondria. These types of fibers are distributed in greater countermeasures are more influential, show similar volume
proportions in postural muscles, such as the lower extremities losses, suggesting a plateau effect. Cosmonauts have shown
(soleus), back, and neck, which are nearly constantly active in loss of posterior calf volumes of 620% after 6-month flights
maintaining posture in 1 G. Type II fibers are fast-twitch fibers on the Mir station [89].
with high contraction velocities and are further divided into IIa Very little has been published regarding losses in upper
and IIb types. Type IIa fibers utilize oxidative and glycolytic extremity strength and mass since the early Skylab flights,
metabolic energy sources, and so they also contain myoglobin when deliberate countermeasures targeting the arms were
and are relatively rich in capillaries and mitochondria. Type not available or in development. The second and third Sky-
IIa fibers are moderately resistant to fatigue and are recruited lab crews, which made use of a dedicated resistive exercise
for exertions requiring a high force output for a short amount device, demonstrated negligible losses in strength except for
of time. Type IIb fibers are relatively large in diameter and arm extensors in the third crew, mostly accounted for by a
utilize primarily anaerobic energy sources such as glycogen single individual [85]. Since that time, more definitive coun-
and creatine phosphate; they contain low levels of myoglobin termeasures preserving upper extremity muscle groups have
and relatively few capillaries and mitochondria. Type IIb fibers been available during long-duration missions.
support high-power, short-duration exertions, such as lifting, Investigations of strength loss subsequent to the Skylab era
sprinting and jumping, and they fatigue rapidly. Type IIb fibers have helped to further characterize skeletal muscle behavior
are distributed in greater proportions in the arms and shoulders in space flight. Strength data from 17 individuals after Shuttle
as well as the gastrocnemius. flights of up to 16 days are shown in Table 2.5, classified by
Measurement of muscle volume and cross-sectional area concentric (muscle shortening against a load) and eccentric
by imaging provides an objective means of assessing skeletal (muscle lengthening against a load) test contractions [90].
muscle changes associated with space flight. These changes Again, more strength was lost in the lower extremities and
can be augmented by strength and power assessments, along postural muscles than in the upper extremities. Lambertz et
with the occasional histologic studies requiring muscle biopsy, al. found that after flights lasting 90180 days, 14 individu-
to fully assess the effects of weightlessness on skeletal muscle. als showed a mean 17% decrease in isometric plantar flexor
As expected, the postural muscles tend to be most affected in torque during maximal voluntary contraction [91]. Postflight
their relatively unloaded state in weightlessness. Calf muscle assessments of quadriceps and hamstring for 12 individuals
loss after the initial fluid-shifting response to weightlessness after 4- to 6-month flights on the ISS are shown in Figure 2.6
contributes to the bird legs appearance of crewmembers [76]. Maximal power of the lower limb, as assessed by force
during space flight. Less expected was the rapidity with which platform measurements and by short, intense bouts of cycling,
these changes manifest themselves in weightlessness. has been shown to decrease by 54% after 21 days of flight [92]
Volumes of postural muscles in four individuals after and by 50% after 169- to 180-day flights [93]. Some have pro-
an 8-day Shuttle flight, as assessed by magnetic resonance posed that a new steady state is established after roughly 110
imaging at 24 h after landing, showed the following changes: days in microgravity, and further losses in peak limb muscle
posterior calf (soleus-gastrocnemius), 6.3%; anterior calf, torque would not be expected after this time [94].
3.9%; hamstrings, 8.3%; quadriceps, 6.0%; and intrinsic In spite of the losses in muscle strength and mass due to
back 10.3% [86]. Similar muscle group assessments in four atrophy, contraction velocity has consistently been elevated
individuals after a 17-day flight revealed a muscle volume after both short-duration [95] and long-duration flights
decreases of 310% in all muscles measured [73]. In another [91,96]. This phenomenon partially compensates for the
study involving magnetic resonance imaging, three astronauts mass loss to preserve muscle power. In a thoughtful review
flying 9-, 15-, or 16-day flights had volumes of knee exten- of muscle behavior in space flight, Fitts and colleagues noted
sor, knee flexor, and plantar flexor muscles assessed before that although loading is the guiding determinant of muscle
and after flight. All showed volume reductions, ranging from size, the major mechanism for muscle protein loss and atro-
2. Human Response to Space Flight 41

TABLE 2.5. Mean percent changes (landing day vs preflight) in skel- in-depth investigation on Skylab into human performance in
etal muscle strength in 17 crewmembers after Space Shuttle missions anticipation of longer-duration missions.
up to 16 days. The constellation of factors associated with adaptation to
Test mode weightlessness includes several that might be expected to
Muscle group Concentric Eccentric decrease performance, such as blood volume loss, hypokinesia
Back 23 (4)* 14 (4)* with resultant skeletal muscle loss, and nutritional deficits.
Abdomen 10 (2)* 8 (2)* Assessment and eventual optimization of human physical
Quadriceps 12 (3)* 7 (3) performance with regard to these and other medical variables
Hamstrings 6 (3) 1 (0) broadly has a twofold aim: supporting the successful completion
Tibialis anterior 8 (4) 1 (2)
Gastrocnemius/Soleus 1 (3) 2 (4)
of mission objectives and ensuring crew health during and
Deltoids 1 (5) 2 (2) after the mission. The chief physical challenges associated
Pectorals/Latissimus 0 (5) 6 (2)* with space flight are associated with EVAs, entry, and land-
Biceps 6 (6) 1 (2) ing. Physical assessments and countermeasures are oriented
Triceps 0 (2) 8 (6) in part toward these activities. A performance decrement may
*
p < 0.05. be tolerable if the required functionality is maintained with an
Source: From Greenisen et al. [90]. adequate margin and sufficient capability returns after flight
to support long-term crew health.
Results from cardiovascular evaluations of exercise capac-
ity reflect in part the method of assessment and whether that
method accounts for the peculiarities and artifacts of weight-
lessness to make comparison with preflight findings meaning-
ful. Cycle ergometry is relatively transparent to the effects of
weightlessness, and metabolic rates associated with a given
level of cycle exercise are unchanged from preflight levels [8].
The same may not be true in assessments of activities that nor-
mally require postural muscles for stability, such as upright
locomotion and resistance-force assessments simulating
weight lifting. Both inflight findings and ground predictions
would seem to indicate a decrease in mechanical efficiency
associated with treadmill exercise in weightlessness [98].
Therefore assessments of cardiovascular fitness are typically
made by using graded cycle ergometry. Variables measured in
FIGURE 2.6. Mean percent change ( standard error) from preflight these assessments typically
. include heart rate and blood pres-
values in isokinetic strength of quadriceps (knee extension) and sure. Oxygen uptake [VO2] is a valuable integrated variable
hamstring (knee flexion) for 15 crewmembers after return from ISS measured to assess exercise capacity, which reflects global
Expeditions 112 [76] cardiovascular function. Oxygen uptake has been calculated
from heart rate and blood pressure and from preflight data,
phy seems to be a decline in synthesis without an increase or it can be measured directly by analyzing metabolic gases,
in muscle breakdown [94]. This observation underscores the typically as part of a research protocol.
importance of adequate nutritional support to augment physi- Echocardiographic findings during inflight exercise have
cal countermeasures during space flight. also contributed to our understanding of inflight cardiovascu-
lar fitness. Safety concerns preclude testing to maximum levels
during flight, although crewmembers are not prohibited from
Inflight Physical Performance exercising to max levels during personal exercise sessions. All
After reviewing the reactions of the body systems that con- assessments are monitored by inflight and ground personnel.
tribute most directly to human physical performance, it seems Skylab crewmembers did not show appreciable inflight
appropriate to consider this aspect of crew capability during decrements in mechanical efficiency during cycle ergometry,
the inflight period as well. Apollo medical testing showed a and in fact six of the
. nine crewmembers demonstrated a slight
significant postflight decrease in oxygen uptake for a given increase. Inflight VO2 decreased slightly in six crewmembers
exercise load, with heart rate significantly elevated for a given for a given. workload (determined as 75% of preflight
level of oxygen consumption on return day as compared with maximum VO . 2), and
. heart rate generally increased slightly
preflight values [97]. Of all 27 of the Apollo crewmembers, 20 for a givenVO2 [8].VO2 measured for four individuals during
showed significant decreases in exercise tolerance on return a 17-day Shuttle flight exercising at a workload correspond-
day, which largely resolved within 2436 h [8]. These find- ing to 85% of maximal capacity progressively decreased to
ings, along with other early observations, prompted further a value of 11.3% on flight day 13 [99]. The change in estimated
42 E.S. Baker et al.
.
VO2 for 15 ISS crewmembers during long-duration flight is upper extremity strength during flight. An increase in car-
depicted in Figure 2.7 [76]. diac output in response to exercise primarily results from
Physician-cosmonaut Atkov and colleagues assessed echo- an increase in heart rate rather than a change in stroke vol-
cardiographic variables during cycle exercise of two crewmem- ume, and in general cardiac output for a given workload
bers during an 8-month space flight. Resting left-ventricular does not attain the same level as before flight. Reduced
end-diastolic volume and stroke volume were lower during blood volume rather than cardiac impairment seems to
flight than before, and resting heart rate was 1012 beats be the dominant effect influencing altered cardiovascular
per minute faster, maintaining cardiac output at essentially dynamics, and these effects are expected to be accentuated
unchanged levels. Measurements during exercise at 175 watts upon Earth return and upon transition from relative to abso-
revealed decreases in stroke volume of 30% and 25% for the lute hypovolemia.
two crewmembers, with respective increases in heart rate of
16% and 11%, compared with preflight. An increase in car-
diac output from exercise was 1315% lower than preflight Neurological Findings
values at the same level of exercise, and was attributed to On Earth the visual, vestibular, and somatosensory systems
changes in heart rate only. Myocardial contractility was not use gravity as a reference for orientation. In the absence of
compromised, suggesting that diminished circulating blood gravity, new strategies for positional sensing are used, most
volume was primarily responsible for the decreases in stroke likely involving a reweighting of visual, otolith, and per-
volume and left-ventricular end-diastolic volume [30]. These haps tactile and somatic signals [101]. Several sensorimo-
results have been corroborated by other long-duration flight tor changes have been demonstrated during flight, including
studies aboard the Mir station [100] and aboard short-duration slowed pointing responses [102], degraded manual tracking
flights. Shykoff et al. noted a noted a lesser increase in cardiac performance [103], attenuation of postural responses [104],
output and a smaller stroke volume for a given workload in six and occasional illusory motion of the self and visual sur-
crewmembers during two Shuttle flights [28]. round [105]. Like the cardiovascular and respiratory systems,
EVAs primarily require upper body strength, which is gen- the neurological system undergoes changes that by and large
erally preserved in weightlessness. However, preflight training are not associated with impairment. Unlike changes in other
during water immersion to simulate neutral buoyancy, while systems, neurological changes are less likely to be manifested
crewmembers are not deconditioned and are exercising normally, in standard observations, and clinical neurological tests are not
is highly demanding. Upper extremity soreness and fatigue after available aboard the ISS. Sophisticated, directed investigative
EVA training as well as actual EVA is common. Because upper methods would be required to detect and quantify changes in
body performance is crucial to the success of EVAs, physical neurological functioning during flight. The exception is space
countermeasures to maintain arm and shoulder strength in a high motion sickness, which does breach the clinical horizon and
state of fitness, along with the means to monitor the effectiveness most likely results largely from this process of adaptation and
of countermeasures, are prudent during long-duration flight. reorientation. Other than that, clinically relevant, functional
In summary, crewmembers can maintain slightly dimin- consequences of changes in neurological system functions are
ished but nevertheless high levels of aerobic capacity and not problematic during flight. The major manifestations are in
the form of reentry and postlanding phenomena. Chapter 17
discusses neurological findings in detail.
The typical spacecraft environment is not particularly chal-
lenging with regard to body motion control. Spacecraft are rel-
atively confined, and the stowage and placement systems rely
on an artificially defined vertical. Crewmembers occasionally
report transient disorientation, especially when moving to
different modules, but in general these perceptions diminish
with time and do not affect operations. Turning ones attention
to outside the spacecraft or station, as is needed for robotic
operations, docking, and rendezvous activities, changes the
sense of orientation and may induce greater motion control
challenges. In these activities, operative cues rely largely on
camera views and interpretation of numerical data to deter-
mine the positions of objects being manipulated in space.
These views may be supplemented with dynamic virtual
views, constructed in real time with positional data inputs and
FIGURE 2.7. Mean percent change (. standard error) from preflight displayed to the crewmember. Such inputs augment whatever
values in estimated oxygen uptake [ VO2] index for 15 crewmembers direct visual cues may be used, which are sensitive to lighting
after return from ISS Expeditions 112 [76] and orientation.
2. Human Response to Space Flight 43

Adaptation mechanisms seem to serve flight crews well the renin/angiotensin/aldosterone axis as fluid volume is
during normal flight activities. Crewmembers have been reduced to a lower level.
able to perform complex tasks requiring fine motor control Although volume does contract fairly rapidly upon enter-
routinely during space flight, indicating adequate integrated ing weightlessness, other findings are somewhat paradoxical
functioning of the neurovestibular and somatosensory sys- when compared with a classical Gauer-Henry response. The
tems. Aside from the external operations noted above, typi- absence of diuresis and decreases in fluid intake were noted
cal on-board tasks include operation and sometimes intricate during the Apollo [5] and Skylab [111] programs. However,
repair of equipment, animal dissection, wiring and soldering, it has taken more complicated payloads supporting sophis-
among others. ticated inflight investigations to further elucidate the events
Beyond sensorimotor implications, the role of the neuro- associated with fluid regulation. The well-documented find-
logical system in cardiovascular control and blood pressure ings of thoracic fluid shift, cardiac chamber expansion, and
regulation is probably the next most important consideration. rapid volume contraction within the first 24 h of space flight
Inflight investigations have shown exaggerated catecholamine occur against a backdrop of apparently decreased intratho-
responses to physical stress challenges such as exercise [106] racic pressure, decreased urine output, and decreased oral
and LBNP [50], indicating maintenance of the sympathoadre- fluid intake, as noted in the discussion on cardiovascular
nal system. Vagal activity seems to be attenuated, as indicated response, and has been described in both the US and Russian
by diminished vagal baroreflex gain in inflight measurements programs [15].
of response to the Valsalva maneuver [48,107] and diminished Arguably the most thorough inflight investigation to date
heart rate variability [48]. on fluid regulation during short-duration flight has been the
Spacelab Life Sciences (SLS)-1 and SLS-2 flight experiments
described by Leach and colleagues [112]. To summarize, the
Renal and Endocrine Systems lack of diuresis and low fluid intake were confirmed, with no
Renal function and hormonal regulation of body systems in change in serum osmolality. The glomerular filtration rate
response to physical challenges are complex and interactive, was seen to increase early and remain elevated for at least a
highly sensitive to outside influences, and often require spe- week. Creatinine clearance was slightly decreased on flight
cialized and rigorously controlled investigative techniques to day 1 (FD1) but normalized by FD2 and remained normal-
isolate a relevant finding from other influences. In addition, ized thereafter. Volume contraction was most marked within
conditions associated with space flight other than weightless- the first 48 h and was characterized by a decrease in extra-
ness can influence endocrine function, including physical and cellular fluid, increase in intracellular fluid, and total body
psychological stress, confinement, heat stress, and dietary water remained unchanged. ADH levels increased by a fac-
changes. As such, much of the knowledge of endocrine sys- tor of four on FD1, returning to preflight levels by FD2. This
tem behavior in space flight is incomplete, and reported find- elevation in ADH may seem paradoxical in lieu of decreased
ings are at times contradictory and inconclusive. Findings that thirst; however, ADH has been seen to increase in response
seem to be consistent across studies or those particularly rel- to physical stress [113] and in response to motion sickness
evant to understanding the clinical picture will be discussed provoked via the Coriolis effect [114]. Plasma renin activity
here. Much of what is known relates to the role of the renal and aldosterone levels decreased significantly by FD1, then
and endocrine systems in the adaptation of fluid and plasma gradually increased toward normal levels. Atrial natriuretic
volume regulation to weightlessness. Beyond the general peptide, which normally increases in response to the disten-
observations seen in the acute stages of adaptation, most of tion of atrial stretch receptors in volume overload, tended to
these changes are clinically transparent but are described decrease during the course of the flights.
briefly here to be understood as possible new clinical norms. The SLS-1 and SLS-2 investigations confirmed that vol-
Many of the predicted findings with regard to renal and ume contraction does occur but that it is not primarily brought
endocrine control of fluid regulation in weightlessness have about by water or sodium diuresis. Interestingly, infusion of
not been realized. Decades ago, Gauer and Henry elucidated saline during space flight was associated with a significantly
mechanisms whereby different process leading to an increase attenuated volume and sodium excretory response compared
in intrathoracic volume would be sensed as an overall volume with preflight values when the subjects were supine; plasma
overload and elicit diuresis of water and salt, mediated in norepinephrine and renin levels approximated preflight
part by volume sensitive stretch receptors [108]. Indeed, seated levels, whereas aldosterone levels were between pre-
water immersion, used as an analog for weightlessness, has flight supine and seated levels [115]. These findings led Ger-
long been known to cause a brisk water diuresis resulting zer [116], Norsk [115], and others [117] to posit a previously
from central fluid shift [109,110]. It was anticipated that unrecognized large body capacity for extravascular storage
neutralization of hydrostatic forces in weightlessness would of sodium, uncoupled from normally understood water bal-
have effects similar to those of immersion, with subsequent ance mechanisms. Further details on this and other investiga-
cardiac distension, baroreceptor stimulation, and decreases tions into fluid regulation in weightlessness are provided in
in antidiuretic hormone (ADH) levels and in the activity of Chap. 27.
44 E.S. Baker et al.

Another observation in the SLS studies was the inference of Inflight data from long-duration flights are fewer. Skylab
decreases in sweating and insensible fluid losses [112]. These studies of urinary hormone levels showed increases in aldoste-
variables were noted to be decreased in Skylab crewmembers rone, cortisol, and total 17-ketosteroids, whereas epinephrine,
by 11% relative to preflight values, and the decreases were norepinephrine, and ADH levels tended to be lower during
attributed to the buildup of a sweat film during exercise owing flight than before. Plasma cortisol levels were also elevated,
to the absence of gravity and convective forces, exerting a sup- though not always significantly [111]. The 438-day flight of
pressive effect on further sweat production [118]. These find- physician-cosmonaut Polyakov revealed that plasma renin
ings, along with the observation of increased core temperature activity, ADH, and aldosterone were maintained within normal
for comparable levels of exercise and decreased sweating 5 clinical limits, but atrial natriuretic peptide levels remained
days after return from long-duration space flight relative to lower during flight than before [129]. Both epinephrine and
preflight values [119] suggests that multiple mechanisms may norepinephrine were significantly increased at 5 and 9 months
affect thermoregulation during flight. but within normal limits in the early and late mission stages.
Several factors associated with space flight interact to Adrenocorticotropic hormone and cortisol did not show con-
increase the risk of nephrolithiasis. Mobilization of calcium sistent changes [129].
and phosphate from bone begins rapidly in weightlessness. A few other hormonal responses to space flight have been
Analyses of urine samples collected before and after Space noted. Parathyroid hormone, which is relevant to calcium
Shuttle flights show significant increases in the relative super- homeostasis and bone metabolism, is discussed in the preced-
saturation of the stone-forming salts calcium oxalate, calcium ing section on the musculoskeletal system. Insulin resistance
phosphate (brushite), and uric acid as well as low urine volume, is known to develop in individuals in sedentary conditions,
low pH, and hypocitraturia [120]. Studies on long-duration and this has been observed in space flight [130,131]. Con-
flights involving inflight urine collection demonstrate similar sidering space flight to be a physiological stress, Strollo and
findings of hypercalciuria and increases in urinary concentra- colleagues studied four individuals, expecting a decrease in
tions of stone-forming salts [121]. The relative hypovolemia testicular androgens mediated through the pituitary gonado-
associated with Earth return makes this a particularly vulner- tropin luteinizing hormone. Salivary, urinary, and plasma
able period [122]. One probable event of inflight nephrolithia- testosterone were found to be diminished during flight, along
sis occurred in the Salyut program [123], and several events with a decrease in sex drive as assessed by questionnaire.
have been seen clinically in the immediate postflight period However, luteinizing hormone levels were found to be para-
after short-duration flights. This topic is discussed in detail doxically increased [132]. The causes remain to be elucidated,
in Chap. 13. although salivary testosterone levels were noted to recover by
Stein and colleagues conducted studies of inflight return day one.
urinary hormone levels associated with the SLS-1 and SLS-
2 missions [124]. Norepinephrine levels were decreased
Gastrointestinal System
but epinephrine levels were maintained at normal levels
throughout the flights. Further analysis of the catecholamine That gravity has a role in digestion is evident to anyone who
findings revealed a sex difference in norepinephrine, with has tried to eat while recumbent; there is a definite assist in
three female crewmembers showing essentially no change assuming the upright position for swallowing and esophageal
and four male crewmembers showing significant decreases transit. Although the gastrointestinal (GI) tract follows a cir-
[125]. Levels of free 3,5,3-triiodothyronine, prostaglandin cuitous and convoluted route, the general gradient is favored
E2, and its metabolite prostaglandin EM were decreased by the upright posture. Arun has speculated that a loss of
during flight relative to preflight levels, which could be polarity of propulsion of digested material occurs in micro-
related to muscle atrophy. Cortisol levels were significantly gravity as the bowel floats but that this effect is partially
increased on FD1 only but tended to be higher than preflight compensated by movement that is driven by diaphragmatic
values throughout the flights. In other studies, cortisol levels excursions [133]. Bowel activity seems to be diminished
have been shown to remain unchanged [126] or to increase, during the first hours to days of flight, as assessed by electro-
possibly related to stress [127]. gastrography [134] and by recording of bowel sounds [135].
Concern has been expressed over suppression of thyroid This reduction in bowel activity seems to be related to space
function during flight from exposure to pharmacologic doses motion sickness, and by and large it clears after a few days.
of iodine, used on the Space Shuttle to disinfect potable A study of GI function involving a lactulose-hydrogen breath
water. McMonigal et al. documented a transient increase of test showed a trend toward increased transit time, but these
thyroid-stimulating hormone in postflight laboratory studies findings, from only two individuals, were considered incon-
of Shuttle crewmembers suggestive of thyroid suppression, clusive [136]. Russian studies have documented hyperacidity
which resolved after installation of equipment that removes during long-duration flights that seems to arise after about 3
iodine before drinking the water [128]. No increase has been months in flight [137]. This observation, along with evidence
detected in the incidence of clinical thyroid disease associated of slight hepatic and pancreatic enlargement on sonography
with this iodine exposure. (apparently due to edema), slowed gastric emptying and
2. Human Response to Space Flight 45

gastrointestinal motility, and mild pancreatic insufficiency are urinary albumin excretion is reduced in long-duration flight
considered to reflect digestive tract adaptation to long-dura- compared with preflight values [140].
tion flight [131].
Nevertheless, digestion does not seem to be clinically
problematic in weightlessness. Crew reports of esophageal Entry and Landing
reflux, abdominal distension, or other GI complaints do not
seem to be more common in space than on Earth, with the The cadence of entry and landing day varies considerably with
possible exception of constipation. The weight loss typically the type of flight. Free-flying spacecraft such as the Apollo
seen associated with long-duration space flight can be primar- capsules and Shuttle simply reconfigure controlling software
ily accounted for by decreased energy intake. Further study is and systems and land. The Soyuz, and at times the Shuttle,
warranted, however, to better define the effects of weightless- may be returning after separation from an orbital station such
ness on GI function with regard to nutritional utilization and as Mir or the ISS. If a mission involves crew rotations on an
the bioavailability of pharmacologic agents. orbiting station, that implies a handover between the departing
crew and the oncoming crew, which typically takes place over
several time- and labor-intensive days. Crew rotations aboard
Inflight Clinical Laboratory Findings the Space Shuttle may also involve cargo transfer, EVAs, and
Laboratory studies have been an important part of preflight robotics activities during this period. Activity density dur-
and postflight medical evaluations since the first space flights. ing such docked operations is high, and often crewmembers
Postflight findings, however, are almost certainly influ- depart with some degree of fatigue. The Shuttle usually loiters
enced by the multisystemic readaptation process associated on orbit for a day or two after separation, whereas the Soyuz
with return to gravity and thereby reflect a combination of lands within a few hours after separating from the station. In
weightlessness and 1-G effects. Blood and urine samples are anticipation of descent, crewmembers don the same pressure
occasionally collected during short flights for investigational suits as are used for launch for protection in case of loss of
purposes; typically samples are stored frozen or otherwise pre- pressure.
served to allow postflight analysis in definitive ground-based The return from low Earth orbit is fairly brief. After a low-
laboratories. During long-duration flight, limited inflight thrust braking burn that serves to lower the orbit to a point
analytical capability is available to support two main clinical sufficient for atmospheric drag to further decelerate the space-
functionsassessment of selected blood values that are either craft, less than 1 h remains until landing. As is the case for
relevant to periodic health assessments or used for diagnosis launch to orbit, the crew must pass again through the velocity
and monitoring of a clinical problem. The results may also be barrier that sustains their orbit, decelerating from 7.8 km/s to
used investigationally, but their primary worth is in determin- 0 relative to the Earth surface. Acceleration loads are again
ing clinical normative values for space flight and detecting present, but for landing the prime source of these loads is the
potential health anomalies that may require remediation or braking effect of the atmosphere rather than engine power,
further research. with the direction of the loading dependent on vehicle and
The Russian medical support program has used an onboard crew orientation to the entry velocity vector. In both launch
analyzer to periodically measure enzymes in blood samples and landing, physical loads beyond the orbital or terrestrial
during long-duration flight. Preflight baseline values are norms separate crewmembers from either endpoint. The now-
obtained for each variable to be measured inflight. In an deconditioned crewmembers do not transition cleanly back
assessment of 17 Mir station crewmembers, increases were to 1 G but rather pass through a hyperloaded state, inducing
seen in fasting levels of glutamic-oxaloacetic transaminase, greater physiologic stress and influencing the clinical profile
glutamate pyruvic transaminase, total amylase activity, glu- and readaptation process. It is during entry that the effects of
cose, and total cholesterol; decreases were noted in creatinine gravity and the implications of the relative deconditioning are
kinase activity, hemoglobin, high-density lipoprotein, choles- first felt.
terol, and the ratio of high-density to low-density lipoprotein. As is true for launch, landing is a dynamic and dangerous
Despite these apparent changes, values remained within normal phase of flight, with critical control inputs and event moni-
clinical limits [138]. The US space program has made use toring required of crew and ground personnel. Moreover, for
of a smaller clinical analyzer to assess primarily electrolyte crews returning after a long-duration flight, formal high-fidel-
values during periodic health evaluations aboard long-dura- ity training may have taken place more than 6 months earlier.
tion missions on the ISS [139]. The findings are inconclusive For Soyuz crews, inflight refresher training is provided before
as yet, but suggest that most values remain within clinically landing with laptop-based simulator programs and proce-
normal ranges. Periodic inflight urinalysis is performed with dural reviews. Shuttle flight crewmembers with piloting and
chemical reagent sticks. Results are generally remarkable monitoring duties are constrained to short duration flights.
only for specific gravity tending to be high (between 1.025 Crew duties during entry and landing vary, but as a minimum,
and 1.030), reflecting a state of reduced hydration. No pro- required flight crew monitor engine operation during the deor-
teinuria has been seen, consistent with the observation that bit burn and the postburn maneuvering, guidance and navi-
46 E.S. Baker et al.

gation, and vital spacecraft systems, being ready to assume supports the efficacy of recumbent seating in returning from
manual control if needed to respond to contingencies. This weightlessness.
monitoring requires vigilance and fairly intense concentration, Although the numbers are small, observations suggest that
as well as close communication with the ground and among female crewmembers returning on the Soyuz are physiologi-
other crewmembers. Control inputs and instrument scans may cally stressed to a greater extent than their male counterparts
require occasional head movements, which may be both pro- if the anti-G garment is not worn; use of the garment abolishes
vocative and adaptive with regard to motion sickness. the sex difference [143].
As noted in Chap. 1, each vehicle has a characteristic entry Neurovestibular disturbances are also expected to begin with
G-profile to which the crew is subject. The Space Shuttle is the onset of entry loads, as the otoconia again assume weight
unique in that crewmembers are seated in the upright position, and the ability to signal independent of head movement, as
thereby incurring body +Gz loads during entry and landing. visual cues transition from a three-dimensional reference
Crews returning from long-duration missions (for this purpose frame to an inherent vertical, and as proprioceptors and other
arbitrarily defined as 30 days) are situated in a recumbent seat positional sensors detect direct and indirect effects of body
system on the middeck to circumvent these loads, and thus weight and movement. Unlike monitoring for cardiac activity,
take the prolonged 1.2 G primarily in the body +Gx direction. direct monitoring of vestibular function is complicated and
The Soyuz places all crewmembers in the recumbent posi- thus is not performed during landing. Subjective reports have
tion, as did the US space capsules. In either type of spacecraft, been given of vestibular disturbances provoked by head move-
measures are taken to protect crewmembers from the effects ments out of the velocity vector. Cosmonauts report sensations
of cardiovascular adaptation, which begins to transition from of positional illusions and mild vertigo during entry, which are
a state of relative to absolute hypovolemia at the first onset more frequent with longer exposures to weightlessness [141].
of G loads. Crewmembers begin a program of oral fluid and Crewmembers are taught to minimize provocative head move-
salt loading before the deorbit burn to increase their vascular ments and, as is true for the aviation environment, to believe
volume, and they don anti-orthostatic garments beneath their their instruments. The Shuttle becomes a highly complex
launch and entry suits. The Shuttle suit accommodates a pneu- aircraft at the end of a mission, and it is precisely guided to
matic anti-G garment with pressure bladders controlled by the a manual landing by the flight crew after flights of up to 17
crewmembers, along with active liquid cooling. Soyuz suits days. Neurovestibular disturbances that may be occurring dur-
use gas cooling and accommodate a highly customized elastic ing entry seem to be largely compensated by training, task
garment, primarily for postlanding anti-G protection. focus, and flight instruments, although continued analysis and
Cardiovascular reactions are among the first to manifest dur- vigilance in this area is warranted.
ing entry and landing. An increase in heart rate is a sensitive Spacecraft landings are highly planned and rehearsed
indicator of orthostatic stress and is expected during landing. operations, with recovery personnel standing by to assist crew-
Crewmembers returning on Soyuz undergo active monitor- members and help ensure the safety of the vehicle. However,
ing by electrocardiography, sensed cardiac contractions, and spacecraft can and have landed off target. In addition, emer-
respiratory rate. In a comparative study of 16 crewmembers gency deorbit, either from a suddenly uninhabitable station
returning on Soyuz after short (821 days, 4 subjects) or long (e.g., fire, loss of pressure) or from a major systems problem
(186380 days, 12 subjects) Mir station flights, Kotovskaia with the primary spacecraft, could cause a landing at an
and colleagues noted more pronounced sinus tachycardia and unplanned time. These possible scenarios compel the crew to
a greater frequency of arrhythmias, neurovestibular effects, maintain some degree of self-sufficiency and possibly require
labored breathing, speech difficulties, and petechial hema- higher levels of performance in the postlanding period.
tomas in the back in the long-duration crew as compared
with the short-duration crew during entry monitoring [141].
Arrhythmias consisted primarily of isolated monomorphic Postlanding Period
extrasystoles for the short-duration crews, joined by polymor-
phic and occasional grouped extrasystoles for long-duration At the words contact during landing in the Soyuz, or wheel-
crews. However, no changes in consciousness and no visual stop during Shuttle landing, the dynamic phase of space
disorders were noted, supporting the protective effect of crew flight is over and much of the psychological stress associated
orientation and anti-G countermeasures. In an investigation with space flight is relieved. Crew duties in the immediate
comparing three individuals returning in a recumbent posi- postlanding period involve powering off unneeded equip-
tion from a 4-month flight on the Mir station with a larger ment and ensuring safe configurations of engines and cool-
pool of upright Shuttle flight crewmembers returning from ing systems that may be hazardous to recovery personnel. For
short-duration missions, heart rate was seen to be 25 beats nominal landings, none of these duties require that the crew
per minutes lower in the recumbent crewmembers than their stand or manipulate heavy loads before vehicle egress; for both
seated counterparts on prior missions. This difference was Soyuz and Shuttle, crewmembers are typically aided by recov-
abolished upon standing, during which heart rate increased in ery and medical specialists within several minutes. Returning
both groups to the same extent [142]. This observation again long-duration flyers describe a profound sense of heaviness
2. Human Response to Space Flight 47

in the minutes after landing, especially noted with the first limb Investigationally, cardiovascular functionality in the post-
movements made while unfastening the restraints. In spite of flight period is often equated with stand test results; how-
active cooling systems, heat stress is common for landing ever, the results require some interpretation. These tests were
crews because of the pressure suit and vehicle heating during designed largely to delineate mechanisms of physiological
entry and on the ground after landing. Passive readaptation to response rather than to assess functionality, and they typically
normal gravity is occurring during this time. proceed to near-syncope or voluntary cessation by subjects due
Many of the processes involved in adaptation to weight- to symptoms. Orthostatic intolerance as determined by stand
lessness now proceed in reverse during Earth readaptation. testing correlates with, but is not equivalent to, postflight func-
Returning to gravity and its resulting hydrostatic gradients tionality. In the hundreds of short-duration flight experiences
and the reintroduction to the upright posture demand a return to date, postflight syncope is rare. Remaining motionless in the
to the 1-G volume status and reawakening of regulatory cir- upright position does not allow movement of the lower extrem-
cuits. Those systems most sensitive to loading forces, such ities or cycling of the venous valves to aid in augmenting the
as cardiovascular and volume control, muscle, and bone, both preload. Highly fit normovolemic individuals occasionally
declare themselves during adaptation to weightlessness and fail this test before flight, and some crewmembers have been
are particularly affected during readaptation. As expected, the upright and ambulating for 1 or 2 h after short-duration Shut-
effects of this readaptation on performance are pronounced, tle flight before performing and failing to finish a stand test.
because the functional capacity-to-demand ratio, which was Buckey et al. have noted that reported failure rates during
more positive on entering weightlessness, is now decidedly investigational stand testing vary from 10% to as much as 64%
negative upon returning to gravity. In addition, a neuroves- depending on the working definition of orthostatic intolerance
tibular system accustomed to weightlessness must now inter- and methodologic variables such as tilt angle and duration of
pret gravitational cues and guide purposeful body and eye upright posture [12]. Thus, stand testing should be viewed as
movements in Earths constant gravity. Although readaptation an objective and clinically useful tool to delineate mechanisms
begins immediately, systems return to preflight functional lev- of orthostatic intolerance and guide the development of coun-
els at different rates. termeasures, but it should not be used as a singular clinical
The dominant clinical entities associated with immedi- assessment to determine postflight functionality.
ate return from space flight are orthostatic intolerance and Stand testing does allow controlled and detailed compari-
neurovestibular impairment. They can occur individually or sons of physiological characteristics between those who finish
in combination, and entry adaptation syndrome may lead to and those who do not. Given the hypovolemic state common
emesis, which can further degrade volume status. These enti- to all returning crewmembers, those who are able to com-
ties, which most affect human performance in the immedi- plete a stand test are distinguished from those who are not by
ate postlanding period, are discussed in greater detail below. relatively greater peripheral vascular resistance [12,146]. Pre-
Further information on areas most affected can be found in vious findings suggest impairment of the baroreflex response
systems-oriented chapters (cardiovascular, neurological, and associated with space flight [45,46], possibly most prominent
musculoskeletal) elsewhere in this book. in those crewmembers who cannot finish the test. Release of
norepinephrine has been shown to be lower in those who do
not finish relative to those who do [146]. More recent stud-
Orthostatic Intolerance
ies show that most of the baroreflex response to orthostatic
Functionally, orthostatic intolerance can be defined as an stress remains functional following space flight [12,146,147].
inability to maintain adequate central perfusion when assum- The observation that sympathetic tone was maintained in six
ing an upright posture in the performance of required nominal individuals who completed a stand test after a 16-day Shuttle
or reasonable-risk contingency activities. Cardiovascular and flight [148] and that norepinephrine release induced by tyra-
blood volume status associated with adaptation to weightless- mine was not impaired after flight [146] suggests that the
ness produces, upon landing, a state of acute hypovolemia and efferent limb of the baroreflex remains intact and that those
absolute anemia, which combine with decreases in barorecep- who can finish the stand test are in part distinguished by their
tor sensitivity, cardiac mass, and lower-extremity muscle mass sympathetic response. Noting an increase in ADH and epi-
to diminish venous valvular function and render crewmembers nephrine in non-finishers, Meck and colleagues suggested
more vulnerable to orthostatic intolerance. Consistent cardio- that the afferent limb of the baroreflex also remains intact,
vascular findings in the postflight period include decreased pointing toward an impairment in central integration of this
stroke volume and increased heart rate for crewmembers after reflex resulting from space flight [146]. Although the exact
both long-duration [38] and short-duration missions [12,144]. mechanism limiting the vasoconstrictive response remains
Convertino [145] and others have identified orthostatic intol- to be delineated, reduced blood volume and impaired ability
erance as the most significant operational cardiovascular risk to vasoconstrict appear to be the dominant factors associated
associated with space flight and have appropriately made with post-flight orthostatoic intolerance. Sex differences have
orthostatic intolerance a major focus of study, both to deter- also been observed during stand testing, with men faring bet-
mine its causation and to develop countermeasures for it. ter than women in completing stand test protocols [149].
48 E.S. Baker et al.

Further investigations may better delineate the mechanisms Only limited studies were performed in the last few crews
that maintain blood pressure after flight. However, crewmem- returning from the moon, but mild postural instability was
bers freshly returned from weightlessness are above all treated noted for subjects standing with eyes closed for 3 days after
as clinically hypovolemic. Crewmembers are typically thirsty landing, suggesting a shift toward reliance on visual cues for
in the few hours after landing, and vigorous oral volume reple- orientation and a lessening of vestibular and proprioceptive
tion is provided. Urine and sodium output are decreased on control [154].
landing day, and a three-fold increase in ADH has been mea- The Skylab flight experience involved both longer flight
sured [112]. Maintaining cooling to prevent undue peripheral durations and a significant increase in habitable volume, which
vascular dilatation is crucial. Use of a liquid-cooling garment allowed unhindered adaptation to weightlessness. During
during entry and landing has been associated with signifi- return, as was true for the Apollo crews, Skylab crewmembers
cantly lower heart rates upon standing after Shuttle flights, had the added motion challenge of a sea landing followed by
independent of use of the anti-G suit [150]. Doffing the entry a helicopter transfer onto a recovery ship. Postflight changes
suit as early as possible after landing is recommended to avoid in locomotion and other purposeful movements were noted
further heat stress. Long-duration crewmembers are main- in all returning crewmembers. Investigators noted that all
tained in the recumbent position and are brought upright only crewmembers were able to walk immediately after exiting the
as needed and tolerated for the first few hours. Showers, one spacecraft, albeit with a wide-stance shuffling gait and bent-
of the first desires of returning crewmembers, are kept warm forward posture now very familiar to space crew recovery per-
but not hot to avoid undue vasodilation. sonnel. The crewmembers themselves reported that walking
Recovery of function is rapid after short-duration flights, required conscious effort and that cornering was difficult and
with improvements in heart rate responses observable over accompanied by the tendency to lean to the outside. Improve-
several hours. After the crew is recovered from the Shuttle ment was rapid, and few noticeable signs of ataxia or postural
and changes into normal clothing, short-duration crewmem- instability were noted by the second return day. Objective test-
bers often perform a walk-around to inspect the vehicle ing showed degradation in postural stability while standing
within the first 90 min or so of landing. The vast majority are upright and motionless, particularly with eyes closed, high-
able to do this without difficulty. lighting the increased reliance on visual cues. Vertigo induced
As plasma volume is replenished, the hematologic deficit is by rapid head movement was also reported by all crewmem-
manifested by decreases in hematocrit and hemoglobin con- bers; this improved gradually and completely resolved within
centration. This drop induces erythropoietin release, which has 34 days after landing, except for one crewmember on the
been seen to increase the day after return for crewmembers 84-day flight, who had persistent sensations of vertigo for up
returning after both short-duration [34] and long-duration to 11 days after return [155].
missions [151], which in turn stimulates erythropoiesis and In addition to the formal investigations the mechanisms
gradual complete replenishment of erythrocyte mass back of neurological adaptation accommodated by the U.S. Space
to preflight baseline. Reticulocyte counts are low on landing Shuttle, this program has also allowed a relatively high vol-
day and begin to increase within a few days to a week [33]. ume of flight experiences, which has bolstered understanding
Replenishment is complete by about 3 months after return, and of the degree of impairment after exposure to weightlessness.
some recovery may actually start during flight, after the first During the postflight walk-around noted above, flight sur-
12 months in weightlessness [152]. After the 84-day Skylab geons can readily observe rapid improvements in locomotion
flight, observed decreases in left ventricular end-diastolic vol- and posture control over the course of this 20- to 30-min activ-
ume had completely recovered by 30 days after return [38]. ity. Cornering and gait in particular improve to the extent that
Regulation of body fluid compartments after short-duration many returning crewmembers show minimal outward differ-
flight returns to normal within a week [112]. After a 430-day ences in normal ambulation within a few hours of landing.
flight, the hormonal response to controlled LBNP stress had Flight surgeons conduct formal debriefings with members
returned to normal by 3 months [153]. of Space Shuttle crews in addition to postlanding medical
examinations. Both are considered clinical tools to assess
function and landing experience rather than investigative
Neurovestibular Symptoms
activities. Debriefs and medical examinations are performed
Essentially no significant subjective neurovestibular symp- within a few hours of landing and again 3 days later, and both
toms were noted during or after Mercury and Gemini flights, include queries about the presence of certain symptoms dur-
presumably because of the tight volume constraints of the ing the postflight period. They do not capture the duration of
spacecraft, which limited adaptation to weightlessness, symptoms, nor are they tied to formal testing; as such, both
and objective postflight findings were minimal [154]. The are prone to subjectivity and the potential for reporting bias.
larger volume of the Apollo spacecraft, allowing freedom of However, debrief comments capture a broad spectrum of infor-
movement and full adaptation to weightlessness, is thought to mation and help to guide postflight activities. Bacal and col-
underlie the greater incidence of space motion sickness and leagues retrospectively examined medical debrief comments
more pronounced postflight symptoms seen in this program. from Space Shuttle missions over a period of 18 years with
2. Human Response to Space Flight 49

regard to neurovestibular symptoms. The number of responses diate prelaunch level may not be reflective of the usual long
to specific questions varied from 128 to 389. Symptoms were term level. The time required to return to a normative curve
classified as absent, mild, moderate, or severe, with the classi- of bone density is known to exceed the time of exposure to
fication generated by both the reporting crewmember and the weightlessness by a factor of 2 or 3, and complete recovery
recording flight surgeon. Three symptoms were noted in more may require between 1 and 3 years [159,160].
than half the respondentsclumsiness in movements (69%), Functional fitness assessments consisting of a variety of
difficulty walking a straight line (66%), and persistent sensa- strength and endurance activities are done with U.S. crew-
tion aftereffects (60%). Most of these symptoms were noted as members after long-duration missions to provide an over-
mild. Some degree of walking or standing vertigo was noted all gauge of functional ability. Selected results are shown
in about 30% of respondents, with the great majority again in Figure 2.8. These assessments are not conducted before
being in the mild category. Although not formally queried, flight day five to avoid overexertion injuries in the immedi-
the period of resolution for most of these symptoms was 1 ate postflight period, but they should still reflect end-of-mis-
day (the first return day), although minimal sensations may sion musculoskeletal capability. Some decrements remain at
persist for a week. The incidence of postflight nausea (15%) 5days after return, but substantial functional ability remains
and emesis (8%) of any degree is considerably lower than its and the variables measured typically return to or exceed pre-
counterpart syndrome after launch [156]. In such cases, read- flight baseline levels within 30 days of landing. Further data
aptation sickness occasionally persists for a few days but typi- from ISS crewmembers will help to better characterize the
cally resolves within 24 h. readaptation process to guide postlanding activity require-
Postural assessments of 23 individuals after short-duration ments and rehabilitation efforts and in anticipation of plan-
Space Shuttle flights revealed instability and confirmed an etary exploration after prolonged transit in weightlessness.
increased reliance on visual and somatosensory cues for main-
taining orientation, which resolved in 48 days after landing Clinical Laboratory Values
[157]. Another investigation showed significant decreases in
head rotation velocity on landing day as compared to before An integral part of ascertaining the effects of space flight on
flight after short-duration flights [158]. crew health has been clinical laboratory monitoring, and a broad
Crewmembers on flights lasting 6 months or more show program was initiated at the outset of the Space Shuttle pro-
similar symptoms that essentially require more time to gram. Results are used by space medical personnel to identify
resolve. Two cosmonauts returning from a 1-year mission on health impacts and guide further examination of individuals as
Mir were noted to have hypogravitational ataxia for more needed, in addition to determining health effects on the overall
than 2 weeks, along with anomalies in control of voluntary flying population. Results from this program have helped in
movements and gaze fixation [17]. Crewmembers flying stan- establishing the clinical norms associated with short-duration
dard 4- to 6-month tours on Mir or the ISS are usually able to flight. In examining preflight and postflight operational data
for Shuttle flyers, Barratt and colleagues looked at differences
ambulate unassisted on the day of or after landing, but they
between lab values taken 3 days before launch and those taken
typically require deliberate concentration to do so and are
appropriately conservative, avoiding sharp corners and abrupt
stops and starts.

Other Postflight Findings


The timeline for complete recovery of all affected systems
after exposure to weightlessness has not been well charac-
terized. For crews on short-duration missions, this is largely
because the crewmembers can perform most of their required
duties without undue limitations and along a known trend of
improvement after landing. Fluid volume, bone, and muscle
are replenished and regulatory mechanisms are restored, and
these systems are not directly monitored in the postflight
period. Gradual return to accustomed preflight activities is
done largely at the discretion of the crewmembers themselves,
with participation of the medical team and further assessments
only as clinically indicated after the 3-day postflight assess- FIGURE 2.8. Selected functional fitness variables for ISS crewmem-
ment. For long-duration flyers, a more rigorous and regulated bers after space flights lasting 130197 days. Data are shown as
program of rehabilitation incorporates assessments of muscle means standard error for 15 subjects. *Mean preflight value, num-
strength and bone density. Muscle strength returns within ber of repetitions; **Mean preflight value, force in pounds for a single
several weeks, although due to intensive training the imme- maximum exertion
50 E.S. Baker et al.

within a couple of hours after landing [161]. Operational data were all within normal limits. The very small, albeit statisti-
collected over 50 sequential Shuttle missions were analyzed, cally significant, changes do not seem to be physiologically
with consideration limited to first-time flyers to avoid any or clinically significant, and none of the averaged values fall
reflight bias. Selected results are shown in Table 2.6, which outside of established clinical norms.
emphasizes those modules that manifest significant changes.
Globally, these values reflect physiological reaction to Postflight Clinical Disposition
microgravity, a mild physiological stress reaction to entry and
The responses to weightlessness and landing involve multi-
landing, and relative hypovolemia in the immediate postflight
systemic physiologic changes and an acknowledged degree of
period. They were obtained during a period of transition in
impairment in comparison with preflight functionality. How-
fluid regulation and volume status, and as such they do not
ever any such impairments are typically mild and recover rap-
indicate frank pathology. Preflight and landing-day variables
idly. On landing day after short-duration (up to 17-day) Space
Shuttle flights, crewmembers are examined by flight sur-
geons, participate in limited debrief and investigational activi-
TABLE 2.6. Landing day vs preflight differences in blood chemistry,
ties, and then almost without exception are discharged into the
hematology, and endocrine variables in Space Shuttle crewmembers.
care of their families. A medical team is available continually
Mean
for consultation and further clinical care as needed. Physical
N difference SD p value
and laboratory examinations are repeated 3 days after landing,
Biochemistry module
after which crewmembers return to their normal activities and
Glucose (mg/dl) 93 8.65 18.77 0.0001
Uric acid (mg/dl) 89 0.91 0.86 0.0001
duty, including driving, light exercise, and flight in high-per-
Creatinine (mg/dl) 93 0.03 0.15 0.0434 formance aircraft, at their own discretion.
Alkaline phosphatase (U/L) 89 1.48 6.87 0.0448 After long-duration flights, dispositioning varies accord-
Lactate dehydrogenase(U/L) 89 7.19 21.44 0.0021 ing to program. After initial medical assessments on land-
Amylase (U/L) 89 8.93 17.68 0.0001 ing day, crewmembers are usually kept in special facilities
Sodium (mmol/L) 93 0.85 2.69 0.003
Potassium (mmol/L) 93 0.27 0.44 0.0001 for observation and assistance. In the United States, crew-
Phosphate (mg/dl) 89 0.43 0.76 0.0001 members are transported home from the landing site on
Magnesium (mg/dl) 89 0.15 0.18 0.0001 the day after landing, and if they show no evidence of
Carbon dioxide (mmol/L) 88 1.26 3.44 0.0009 complications such as debilitating orthostatic intolerance
Cholesterol (mg/dl) 88 5.64 20.33 0.0109
or neurovestibular impairment, they are typically released
Triglycerides (mg/dl) 89 9.79 30.67 0.0034
High-density lipoprotein (mg/dl) 84 6.86 8.78 0.0001 to their families on that day. For Soyuz landings, crew-
Very low-density lipoprotein 84 1.88 6.55 0.0101 members are transported from the landing site in Kazakh-
(mg/dl) stan back to the Gagarin Cosmonaut Training Center near
Apolipoprotein A1 (mg/dl) 62 16.27 25.25 0.0001 Moscow and live in a rehabilitation facility for as long
Hematology module
as needed. In both the US and Russian programs, a pro-
Red blood cells (1,000/mm3) 89 0.08 0.32 0.0166
Reticulocytes (%) 80 0.16 0.38 0.0003 tracted period of physical rehabilitation begins after return
Hematocrit (%) 89 0.27 3.16 0.4155a and forms the core of all postflight activities. The three
Hemoglobin (g/dl) 89 0.6 0.84 0.0001 main elements of rehabilitation in the immediate postflight
Mean corpuscular volume (FL) 89 1.04 3.23 0.003 period are rest, passive exposure to normal gravity loads,
Mean corpuscular hemoglobin (pg) 89 0.69 1.6 0.0001
and return to familiar surroundings. Activities and load-
Mean corpuscular hemoglobin 89 0.93 2.03 0.0001
concentration (g/dl) ing challenges are presented slowly and progressively as
Platelets (1,000/mm3) 88 14.52 37.8 0.0005 tolerated. A multidisciplinary team consisting of medi-
White blood cells (1,000/mm3) 89 1.31 1.66 0.0001 cal, physical training, psychological, and other specialists
Neutrophils (%) 89 17.81 11 0.0001 guide the process of full readaptation to gravity and nor-
Lymphocytes (%) 89 16.23 9.08 0.0001
Monocytes (%) 90 0.46 3.3 0.193a
mal life. Families are educated as to the expected effects of
Eosinophils (%) 88 1.41 2.22 0.0001 space flight and the progress of rehabilitation, and medical
Basophils (%) 87 0.07 0.33 0.573a personnel are continually available for response to clinical
Band cells (%) 87 0.38 1.44 0.0161 events. Typically crewmembers are cleared for return to
Endocrinology module normal activities and duties by 30 days after return from
Triiodothyronine (ng/dl) 78 17.2 28 0.0001
Thyroxine uptake (binding ratio) 61 0.03 0.1 0.004
long-duration flight.
Thyroxine (g/dl) 78 0.45 0.8 0.0001
Angiotensin (ng/ml/h) 76 3.07 5 0.0001
Cortisol (g/dl) 78 3.19 7.8 0.0005 Lunar Surface
Abbreviation: SD, standard deviation.
Preflight samples were taken under fasting conditions. p values are from To date, human experience operating in the fractional gravity
paired t tests, of another surface remains limited to the six Apollo missions
a
not significant but included for context. to the moon. In all, 29 astronauts flew in the Apollo program,
2. Human Response to Space Flight 51

with 12 landing to spend a total of 4 man-weeks on the lunar the spacecraft close to the lunar surface and effect landings,
surface. This experience allowed comparison of conditions of changing the coordinates of flight to accommodate terrain
otherwise similar vehicles and flight profiles in attempts to characteristics as needed [3]. There were no reports of vestibu-
isolate effects attributable to the stay in the one-sixth G lunar lar illusions or disorientation during any of the dynamic lunar
gravity. Cardiovascular deconditioning and reduced exer- flight phases. Surface activities proceeded as crewmembers
cise capacity were known from earlier flight programs and naturally adopted new, energy-efficient loping gaits more
neurovestibular disorders from the Apollo flights preceding suitable to the reduced gravity. Severe constraints on time and
the first moon landing. Thus, concern was high about these spacecraft volume precluded any standard investigations of
and other lesser known effects that might influence landing vestibular function during the Apollo lunar flights, although
and surface performance. EVA experience and knowledge of limited assessment of postural stability and purposeful move-
crew performance in the EVA environment was still in a very ment by video imagery could be done as crewmembers dis-
early phase. However, with the first surface mission of Apollo covered and tried new methods of locomotion. No incidents
11, much of the concern in these areas was alleviated. of vestibular illusions or disorientation were reported during
surface activities among the 12 moon-walkers. Lunar gravity
seems to be an adequate stimulus for otolith organs to define a
Cardiovascular Issues gravitational vertical and guide posture control [154].
After launch, the Apollo crews typically spent 34 days in
weightlessness during a period of Earth orbit, translunar
Other Aspects of Lunar Gravity
coasting, and lunar orbit before landing on the lunar surface.
Descent in the lunar excursion module took place with the Apollo surface activities were associated with clinical effects
crewmembers in a vertical standing position involving +Gz that probably resulted less from direct effects of reduced
acceleration forces, during which the commander integrated gravity and more from the increase in workload and physical
information from flight instruments and outside visual cues exertion. Thermal stress, overuse injuries, and fatigue were
while making piloting control inputs. Launching from the seen in many of the missions during exploration activities that
lunar surface in the modules ascent stage after a period of included equipment moving, sample collection, and surface
one-sixth G exposure involved a transient phase of nearly drilling [51]. Indirect effects of reduced gravity, such as dust
1+Gz. There were no crew reports of lightheadedness or irritation because of lesser settling as compared with Earth,
visual disorders to suggest symptoms of orthostatic intoler- were noted. Thus the clinical response to fractional gravity
ance during these phases. Postflight response to cardiovascu- may be viewed in terms of the activities required, rather like a
lar challenges were expected to be different for moonwalkers construction workplace.
than for other Apollo flyers who remained weightless, includ- Although Apollo crewmembers did not spend enough
ing orthostatic response to LBNP. However, no difference was time on the lunar surface to show cumulative musculoskel-
found in resting and stressed heart rate between these two etal changes, muscle and bone loss can be expected given
groups [162]. Interestingly, the cardiothoracic ratio, a radio- sufficient time there. Adaptation must be viewed differently
graphic index reflective of the heart size and position, was from adaptation to the weightless environment, in which the
significantly decreased in those who remained weightless but vast majority of crew time is spent operating normally in
was preserved in the moon-walking group [162]. Whether this an unloaded state. Lunar crews will be expected to under-
was related to actual work effects on the heart, anthropomet- take heavy exertions and load manipulations during surface
ric changes influencing the heart shadow, or other influences activities, donning heavy suits and life support systems while
remains unknown and a subject for further investigation. manipulating lunar material and equipment. The optimal bal-
A crewmember on the Apollo 15 mission did manifest a ance among effects of lunar gravity, surface EVAs, and delib-
period of bigeminal rhythm during surface activities, correlated erate countermeasures during long-duration stays remains to
with symptoms of extreme fatigue. A self-induced period of be delineated.
rest was taken before continuing with activities. This experi-
ence prompted the inclusion of anti-arrhythmic medications on
subsequent flights; potassium supplements were also included Conclusions
to address the possibility that hypokalemia may have been
involved. The affected crewmember was later found to have had The past four decades have amply demonstrated that humans
undetected coronary disease at the time of the flight and experi- can tolerate space flight well for long periods in orbiting
enced a myocardial infarct 18 months after the mission [51]. spacecraft. Historically, the direct causes of mortality have
been accidents occurring during dynamic phases of flight.
The vast majority of flight time has been spent in Earth orbit,
Neurovestibular Issues but both in orbit and on the lunar surface, humans have dem-
After the weightless period of translunar coast and lunar onstrated the ability to maintain adequate health and to work
orbit, pilots of the lunar excursion modules were able to fly productively.
52 E.S. Baker et al.

The dominant condition associated with Earth orbit affect- engineering and medical details are worked out in these envi-
ing human physiology and health is weightlessness, which ronments to characterize human response and to further opti-
induces predictable changes in crewmembers during adapta- mize human health and performance. The few explorers of the
tion. Acutely, these changes can induce adverse symptoms beginning stages are then joined by larger numbers to increase
such as space motion sickness from neurovestibular adap- activity and productivity in these new environments.
tation and facial congestion associated with a rostral fluid Human space flight is no exception. The transition in space
shift. Typically these symptoms do not limit crew activity and from the few to the many is well underway. Currently we oper-
resolve within a few days. Significant but clinically asymp- ate in a middle phase of this process, where the risk of adverse
tomatic early changes include regulation to a lower plasma events associated with weightlessness is considered accept-
volume with a concomitant decrease in red blood cell mass, able yet the maladaptive responses to weightlessness cannot
changes in cardiac and respiratory dynamics, and changes in be ignored. From a safety standpoint, current knowledge does
anthropometry. Food intake is volitionally reduced and weight not restrict us from continuing missions in weightlessness up
loss is common. Changes in skeletal muscle morphology are to a year. However, investigating and documenting details of
seen, and mass and strength in postural regions are reduced weightless physiology will inevitably reduce the overall risk
after several days. Aerobic fitness is reduced but does not of human occupancy. This effort will guide the development
limit inflight performance. Although bone demineralization of effective strategies to mitigate health hazards and provide
begins almost immediately upon gravitational unloading, it is a more scholarly basis on which to practice modern medicine
not detected following short-duration flights. Over periods of in this environment.
weeks to months, loss of postural bone mass accumulates to
detectable thresholds, prompting the need for physical coun-
termeasures to apply loads to these selected areas.
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3
Medical Evaluations and Standards
Gary Gray and Smith L. Johnston

Rationale outcomes in different countries and agencies based on differ-


ences in the distribution of disease and risk factors.
Candidates for space flight are medically screened to ensure
the success of each mission by providing healthy crews who Health Maintenance After Selection
are able to perform operational objectives. Screening is
carried out according to a framework of medical standards Medical screening after crew selection is based on the prin-
based on operational requirements. Consistent applica- ciples of preventive medicine. The objectives are to main-
tion of medical standards helps to establish an informa- tain health, detect disease early, and ensure medical fitness
tion database against which the assumptions underlying for ongoing training and operations. Screening programs are
the standards can be objectively reviewed. These standards designed in the interests of the individual (to maintain health)
are revised over time as additional findings are collected. and of the mission (to detect any medical problems that could
The ultimate goal is to produce rational, evidence-based, affect the mission). Hickman points out that in aerospace
refined standards that reflect the operational requirements medicine one generally encounters three types of individu-
and the medical risks involved in space flight. By doing so, als: (1) those with overt disease; (2) those with documented
potentially larger subsets of the population that are today asymptomatic disease; and (3) those who have no symptoms
excluded from space flight may be able to participate in but have abnormal test results [1].
future space exploration. The first type is the one most often encountered in clinical
medicinethe patient with an overt disease. The latter two
cases are more common to aerospace medicine.
Objectives For the second case, the patient with documented but
asymptomatic disease, aerospace medical flight disposition
is based on both the natural history of the disorder and the
Selecting Healthy Candidates
pathophysiologic effects of that disorder in the often ill-
Well-considered standards are expected to ensure selection of defined or poorly understood space environment. The rela-
spaceflight candidates who are healthy and likely to remain so tively small number of spaceflight crewmembers means that
throughout their careers, and who will meet defined medical it may take decades to derive sufficient epidemiologic data
requirements of their mission or missions. Medical testing is for evidence-based decisions. Aeromedical decisions made in
geared to three objectives: to identify those individuals with the context of the space environment often rely on analogue
overt symptomatic disease, to identify asymptomatic disease data derived from military aviator populations. This gener-
in individuals with no apparent manifestations, and to identify ally results in conservative decisions about flight disposition
individuals with a high probability of developing a flight-lim- for asymptomatic disease.
iting disorder during their careers. In meeting this third objec- The third case, a patient with no symptoms but abnormal
tive defining and applying standards becomes most difficult. test results, often requires further investigations. The prob-
Estimating the probability of future disease is generally based ability of finding an abnormal test result during screening is
on risk factors (typically related to biochemical, genetic, directly proportional to the number of tests performed. This
or lifestyle factors) that apply to entire populations, but for Type I, or alpha, error is seen when the null hypothesis is
which extrapolation from population data to individual risk is true and n independent statistical tests are performed. The
imprecise. The lack of precision in applying population data probability that at least one test will appear to be statistically
on disease probability to individuals may lead to different significant (p 0.05) is [1.0(0.95)n]. If 10 tests are per-

59
60 G. Gray and S.L. Johnston

formed, there is a [1.0(0.95)10] = 0.40 probability of a Type Establishing Normative Data


I error. If 20 tests are performed, there is a [1.0(0.95)20] =
0.65 probability of a false-positive test result. Further, the A less obvious but important reason to define medical stan-
spaceflight crew population represents a highly select group dards is the need for data to be obtained and pooled accord-
with a generally low prevalence of disease. Hence, apply- ing to standards that have been consistently applied with a
ing clinical tests that have sensitivity and specificity char- standardized, systematic approach. NASAs Life Sciences
acteristics typical for a clinical environment will result in effort has recognized the importance of this aspect of medical
frequent false-positive findings. In other words, the positive screening since the initial astronaut screening for Project Mer-
predictive value of a screening test decreases with decreas- cury in 1959, when medical screening data at the Lovelace
ing prevalence of disease. Therefore we must understand the Foundation were recorded on IBM color-coded punch cards
operating characteristics of medical screening procedures in [2]. This concept evolved into a standardized battery of medi-
the spaceflight crew population and the potential for false- cal tests to be performed on all Shuttle missions (the so-called
positive findings. baseline data collection), the goal of which was to establish
an epidemiologic normative medical database in the space
environment.
Operational Considerations This process, now known as medical assessment testing,
An important goal for medical selection and subsequent continues in the International Space Station (ISS) era. Medical
medical evaluations is to certify that the crew is healthy. assessment testing is a vital aspect of medical screening that
Conditions with the potential to compromise flight safety, helps to address the quintessential occupational medicine
such as a seizure disorder, are disqualifying. The disposition questionnamely, does an abnormal finding in an individual
of other medical conditions is based on a risk-assessment, reflect an abnormal (pathologic) individual response or a nor-
evidence-based model. NASAs selection and retention mal physiologic response to an abnormal environment? Medi-
standards should be related to bona fide mission require- cal assessment testing, by developing longitudinal normative
ments. For example, visual standards should be based on data, plays an important part in providing data to address
actual vision requirements for operational tasks (e.g., fly- this question in the environment of space. By establishing
ing, performing extravehicular activities, controlling remote new population norms, medical assessment testing provides
manipulators, or escaping in a contingency situation). Such important space medicine information for current and future
data can be acquired from simulator environments or from spaceflight crews and, eventually, space travelers. (Collating
actual operational settings. In many cases, however, stan- medical assessment test data has demonstrated, for example,
dards are based on best estimates of operational require- that the microgravity environment is conducive to renal stone
ments as made by physicians on space medicine boards. formation; medical screening procedures have been modi-
Every effort should be made in drafting and reviewing stan- fied accordingly to identify crewmembers who are at risk of
dards to objectively relate those standards to actual opera- forming stones during flight.)
tional requirements. In some respects, medical assessment testing seems to over-
For spaceflight crewmembers, standards for selection and lap with Life Sciences experimentation. However, medical
periodic evaluation reflect the operational role of the indi- assessment testing provides a longitudinal view of health that
vidual crewmember. In Space Shuttle operations, standards facilitates the definition of abnormality and new population
for pilot astronauts differ from those of mission specialists norms in spaceflight crews. Medical assessment testing does
for mission-specific variables such as visual acuity. In the not seek to study basic physiologic mechanisms in the space
past, less-restrictive standards have been defined for crew- environment (Life Sciences) but rather to clarify the definition
members designated as payload specialists (i.e., non-career of normal vs. abnormal responses in the environment (Opera-
crewmembers who manage a specific Shuttle payload rather tional Space Medicine) for the greater good.
than Shuttle systems).
Medical standards must further reflect the incremental
risk associated with extended, long-duration, and, ulti- Select-In Versus Select-Out Concepts
mately, exploration-class missions. The statistical risk of in Medical Screening
a medical event occurring increases with mission duration;
this increase in risk must be reflected in medical standards Selection and retention standards are generally directed
and screening procedures. For example, experiencing an toward identifying and excluding persons who do not meet
episode of renal colic would disqualify a trained mission defined standards (e.g., those for vision or hearing). A greater
specialist for extended or long-duration missions but per- challenge is the ability to identify those physical and psycho-
haps not for short-duration Shuttle missions, since preflight logical attributes that might be considered advantageous in the
sonographic screening can rule out significant retained space environment. These concepts have been applied in the
calculi and the probability of developing a calculus during area of psychological assessment to identify individuals who
a brief Shuttle mission is very low. have the right stuff, i.e., those who are not only technically
3. Medical Evaluations and Standards 61

competent but who can sustain the rigors of long-term space New Mexico; an evaluation to assess responses to environ-
flight while maintaining their equanimity, demonstrating mental stressors such as acceleration and hypoxia at Wright-
leadership when required, and remaining team players [3]. Patterson Air Force Base in Dayton, Ohio; and psychological
Select-in concepts can also be applied to physical attributes. and psychiatric evaluations. The importance of maintaining
Since its inception, the Russian selection system has included a database of such information was recognized and imple-
functional loading tests such as those that assess tolerance mented from the outset.
of hypoxia in an altitude chamber, tolerance of acceleration The medical screening battery for the initial Mercury astro-
and high-g forces in the human centrifuge, and performance nauts took 1 week to complete. Of the 100 military test pilots
under conditions of high thermal loading and sleep depriva- who were initially screened, 31 very outstanding men were
tion. The results of these tests are included in the overall medi- selected to proceed in the program and to undergo the medi-
cal selection process for cosmonauts but are rarely used to cal screening detailed in Table 3.1. (Findings from these 31
exclude candidates. candidates are shown in Table 3.2.) Of the final 7 astronauts
Although medical standards are generally based on the selected from that group of 31, 1 had visual acuity of less than
select-out principle, this is likely to change in the future 20/25, 5 had hearing loss of more than 15 dB, 1 had a vocal
as tests are developed with high individual specificity. For cord tumor (removed), and 1 had an abnormal lumbosacral
example, the multinational Human Genome Project currently spine. In the absence of defined standards, the 7 Mercury
under way will, within the next decade, facilitate identifica- astronauts were chosen by a panel of both technical and medi-
tion of individuals with disease-causing genes (select-out). cal representatives.
However, it may also allow us to identify individuals with In 1977, using medical standards from the U.S. Air Force,
a genetic makeup that is resistant to the health problems of the U.S. Navy, the U.S. Department of Defense, and the
expeditionary space missions, including radiation damage and Federal Aviation Authority, NASA developed specific astro-
bone mineral loss. naut medical standards that were incorporated into a work-
ing set of medical evaluation requirements. These standards
continue to evolve; they were revised in 1991 to include the
Evolution of Medical Standards potential effects of space station missions and the long-dura-
tion nature of such missions. The ISS Multilateral Medical
Early in the human spaceflight program, selection standards Operations Panel, which includes all ISS partners, adopted
for astronauts and cosmonauts were not defined. Because the a further revision of these standards as the basis for ISS
risks of the space environment were largely unknown, the medical standards.
approach to medical screening in both the U.S. and the Rus- Although the ultimate goal is to define common stan-
sian programs was, by necessity, conservative and involved dards for all crewmembers who are involved in ISS opera-
essentially testing everything that was possible to test. The first tions, the process is challenging because of cultural, ethnic,
Mercury astronauts were medically selected in four phases and philosophical differences in the approach to medical
[2]: an initial records review; an extremely thorough medical screening among the countries and agencies that are partici-
evaluation held at the Lovelace Foundation in Albuquerque, pating in the ISS. Examples of such nuances in the Russian

Table 3.1. Medical screening tests conducted with mercury astronaut candidates at the Lovelace foundation.
Test type Details
Detailed history, including Attitude of family members to hazardous flying
Aviation history
Physical examination Proctosigmoidoscopy
Ophthalmology, including dark adaptation studies, retinal photography
Otolaryngology, including calorimetric stimulation tests
Audiometry, including voice discrimination
Cardiology, including ECG, vectorcardiography, ballistocardography, tilt table testing and a special screen
for ASD and PFO based on measurement of arterial O2 saturation during Valsalva maneuvers
Neurology, including nerve conduction studies, EMG, EEG
Radiography Chest x ray (PA and lateral views), inspiration and expiration, cardiac fluoroscopy, barium enema,
lumbosacral spine, teeth, sinuses
Laboratory analyses Hematology, fasting blood sugar, cholesterol, blood group and type, serology, electrolytes, urea clearance,
catecholamines, protein-bound iodine, protein electrophoresis, blood volume, carbon monoxide, total body water
(tritiated water), liver function tests, urinalysis, 24-h urine ketogenic steroids and ketosteroids, throat cultures,
stool examination and culture, total sperm counts, total body radiation count and body potassium, pulmonary
function testing, maximum O2 uptake, body density
Abbreviations: ECG, electrocardiography; ASD, atrial septal defect; EEG, electroencephalography; EMG, electromyography; PA, posteroanterior; PFO, patent
foramen ovale.
62 G. Gray and S.L. Johnston

Table 3.2. Summary of clinical findings in the initial 31 mercury Medical requirements are subject to a regular review pro-
astronaut candidates. cess during which the standards are revised on the basis of
Physical system Finding factors such as new epidemiologic data derived from analysis
Eyes Visual acuity <20/25 5 of current standards procedures, normative population data
Convergence weakness 2 derived from medical assessment testing, information derived
Exophoria 2 from risk assessment of space flight, changes in operational
Borderline night vision 2 requirements for a particular mission, and changes in medical
Ears, nose, and throat Sinusitis and sinus cyst 7
Hearing loss >15 dB 19
support facilities available to crews during space flight. The
Allergic rhinitis 6 development of new medical technologies may also result in
Chronic pharyngitis 1 revisions to medical standards; for example, successful radio-
Cervical adenitis 1 frequency ablation of a Wolff-Parkinson-White bypass tract
Deviated septum with obstruction 8 allows medical qualification of candidates who would have
Hyperactive caloric response 1
Small Eustachian tube openings 2
been disqualified in the past.
Vocal cord tumor 1
Beta hemolytic strep carrier 3
Cardiovascular Hypertensive vascular disease 1
Vasomotor instability on tilt table 2 Medical Procedures for Selection
Increased carotid sinus sensitivity 1 and Periodic Evaluation
Gastrointestinal Retrocecal appendix 1
Inverted cecum 1
Dilated external inguinal rings 3 The following sections outline the procedures for selection
Diverticulosis 2 and annual evaluation of ISS crews.
Fissure and pruritus ani 1
Hemorrhoids 5
Abnormal stool examination 2 Outcomes of Medical Selection
Genitourinary Abnormal urethral meatus 2
Varicocele 2 It is interesting to compare the first Mercury screening, in
Orchitis (inactive) 3 which seven astronauts were selected, with the results of the
Testicular atrophy 2
process carried out at the Canadian Space Agency in 1992 to
Prostatitis 1
Glycosuria 1 select four astronaut finalists from an application pool of more
Orthopedic Abnormal dorsal spine 3 than 5,000 men and women [4]. After initial aptitude/qualifi-
Abnormal lumbosacral spine 5 cation screening by rsum review, 337 candidates underwent
Tight hamstrings 1 medical screening in three phases. NASA medical standards
Osteochondrosis dessicans 1
for mission specialists were used. Phase 1 screening involved
Neurological Borderline EEG 1
Dermatological Acne 1 the use of a detailed medical questionnaire. Of the 337 appli-
Epidermophytosis 1 cants given the questionnaire, 145 (43%) were disqualified
Seborrhea 2 (Table 3.5). Additional screening carried out on this group led
Abbreviation: EEG, electroencephalography. to 51 candidates undergoing Phase 2 screening, which involved
a baseline medical examination carried out by a flight surgeon
at a Canadian military base. Of the 51 candidates who under-
and U.S. cardiovascular standards are shown in Tables 3.3 and went Phase 2 medical examination, 10 (20%) were screened
3.4. The outcome of addressing these differences has been to out. The final phase, Phase 3, of selection involved 1 week of
define a set of evolving standards that reflects the need to meet psychiatric, and medical screening carried out at a hospital on
mission objectives while providing flexibility for individual an outpatient basis. Of the 20 finalists who underwent Phase
agencies to use equivalent methods for testing and to conduct 3 medical screening, which included all aspects of the NASA
additional screening depending on ethnic and cultural differ- mission specialist screening battery, 4 (20%) were medically
ences in disease prevalence. For example, upper gastrointesti- disqualified.
nal endoscopy is included in medical screening in Russia and The results of this screening are similar to the Mercury
Japan, where the incidence of gastric erosions and ulcers (in astronaut screening as well as the much larger NASA astro-
Russia) and gastric cancer (in Japan) is significantly higher naut selections in the decades that followed (Table 3.6) [5].
than in the United States. Such variances in test methods and Of 826 applicants to the NASA astronaut program, selected
agency-specific requirements for testing that go beyond those for interview, and medically screened from 1977 through
defined in the basic medical requirements document are mani- 1991 using NASA standards, 190 (23%) were disqualified for
fested in a matrix document that is reviewed and agreed upon medical reasons, the most common being inadequate vision
by all involved agencies. These equivalence matrices, specific (78, or 9.4%). The most common medical causes for rejec-
to each agency, revolve around a core of common medical tion of NASA astronaut candidates in recent years are listed
standards that apply to all spaceflight crews. in Table 3.7.
3. Medical Evaluations and Standards 63

Table 3.3. Cardiovascular system disqualification standards for U.S. astronauts and Russian cosmonauts.
United States Russia
1. Clinically significant hypertrophy/dilation Organic diseases of the cardiac muscle
2. Ejection fraction <50% Intracardiac hemodynamic disturbances
3. Elevated blood pressure (140/90) Hypertonic diseaseall stages and forms
4. Recurrent symptomatic orthostatic hypotension Low tolerance of changes in body position
5. Case-by-case history of pericarditis Pericarditis
6. Case-by-case history of myocarditis Myocarditis
7. Case-by-case history of endocarditis Not specified
8. Clinical evidence of coronary artery disease, with myocardial infarction Atherosclerosis, all cardiovascular system disease, cardiac rhythm
and angina pectoris disturbances all forms of cardiac failure
9. History or findings of major congenital abnormalities of the Not specified
heart or vessels
History of atrial or ventricular septal defects or patent ductus,
successfully repaired after 1 year, case-by-case
10. Persistent tachycardia with supine resting pulse rate >100 beats per All cardiovascular diseases with cardiac rhythm disturbances
minute
Clinical evidence of cardiac arrhythmia or conduction defect on resting
electrocardiography or Holter monitor abnormalities
11. Failure to meet NASA exercise stress test loads (maximum exercise, Decreased tolerance of physical loads
ergometer, heat load, LBNP, and orthostatic/antiorthostatic stress tests)
12. Peripheral vascular disease Diseases of the peripheral vessels obliterating endarteritis
13. Cardiac tumors of any type Malignant tumors
Cardiac tumors, unless benign and successfully resected without residual Benign tumors causing functional disruption of organs
cardiac disease after 6 months are reviewed on a case-by-case basis Numerous, benign, small-neoplasms (histologically confirmed lipomatosis)
that do not disturb organ function, impede movement, or interfere with
wearing special equipment are acceptable.
Single benign tumors must be surgically removed with re-examination
14. All valvular disorders of the heart, including mitral valve prolapse Organic disease of the cardiac valvular systemprolapsed mitral
or tricuspid valves with pronounced regurgitation
15. History of recurrent thrombophlebitis or thrombophlebitis with Disease of and consequences of trauma to peripheral vessels
persistent thrombus, evidence of circulatory obstruction, or deep
venous incompetence
16. Varicose veins if more than mild in degree, or if associated with edema, Disease of and consequences of trauma to peripheral vessels
skin ulceration, or scars from previous ulceration

Abbreviation: LBNP, lower body negative pressure.

Table 3.5. Reasons for medical disqualification among 337


candidates for Canadian astronaut selection.
Table 3.4. Cardiovascular system screening procedures for U.S. No. (% of subgroup)
astronauts and Russian cosmonauts. Reason for disqualification disqualified
Times performed in each Phase 1. Medical Questionnaire (n = 337)
countrys program Vision 105 (31)
Procedures United States Russia Migraine history 12 (3.6)
Thyroid disorders 5 (1.5)
Chest x ray S S, A Ears/Hearing 4 (1.2)
Electrocardiography S, A S, A, MS Lungs/asthma 3 (0.8)
Echocardiography S S, A, MS Misc. (1 each); including Hodgkins disease, multiple 16 (4.7)
24-h Holter monitoring S S, A, MS sclerosis, Crohns, epilepsy, obesity, vertigo, others
Treadmill test S, A S, A, MS Totals 145 (43)
Orthostatic and MS S, A, MS Phase 2. Initial Medical Assessment (n = 51)
antiorthostatic tests Uncorrected visual acuity of <20/100 3 (5.8)
Lower-body negative pressure tests MS S, A, MS Cardiac 3 (5.8)
Cycle ergometry S, A, MS Asthma 2 (3.9)
stress test Neurologic 1 (1.9)
Heat load stress test S, A, MS Obesity 1 (1.9)
Neuroendocrine/dynamic S, A, MS Totals 10 (20)
electrocardiography Phase 3. Hospital-based Assessment (n = 20)
Capillaroscopy S, A, MS Chronic sinusitis (evident on computed tomography) 2 (10)
Phono/mechanocardiography S, A, MS Ophthalmologic (retinal disease) 1 (5)
Abnormal electroencephalogram 1 (5)
Abbreviation: S, selection examination; A, annual examinations; MS, mis-
Totals 4 (20)
sion-specific examinations.
64 G. Gray and S.L. Johnston

Table 3.6. Requirements for astronaut selection and annual requalification examinations.
Procedure Selection Annual
Medical history Yes Yes
Physical examination Full Full
Otolaryngology
Specialist examination Yes If indicated
Audiogram Yes Yes
Tympanogram If indicated
Sinus imaging If indicated
Ophthalmology Full examination, including: Full examination, including:
Visual acuity Visual acuity
Color vision Color vision
Depth perception Depth perception
Phorias Phorias
Tonometry Tonometry
Perimetry Perimetry
Fundoscopy Fundoscopy
Retinal photos
Corneal topography
Dental examination Clinical examination and imaging, to include Clinical examination with bite-wing
panorex and complete periapical dental x rays within x rays when clinically indicated
the previous 2 years
Cardiopulmonary
Exercise stress test Yes Periodica
Pulmonary function tests Yes Yes
Resting ECG Yes Yes
24-h ECG monitor Yes
Echocardiogram Yes
Imaging
Chest x ray Yes If indicated
Mammogram Women Women over 40: every 2 years until
age 50 then yearly
Bone densitometry No First annual and every 3 years
Abdominal sonography Yes
Panorex Within the previous 2 years If clinically indicated
Pelvic sonography Women
Gastrointestinal
Proctosigmoidoscopy Yes Periodicb
Stool
Culture Yes If indicated
Occult blood Yes Yes
Ova and parasites If indicated If indicated
Laboratory
Blood work, including hematology, Yes Yes
clinical biochemistry,
immunology, endocrinology
Urinalysis Yes Yes
Tuberculin test (PPD) Yes Yes
Screening for sexually Yes Yes
transmitted diseases
Musculoskeletal
Aggregate joint movement Yes
Anthropometry Yes
Muscle mass Yes
Selected strength measurements Yes
Radiation exposure evaluation Yes Annual
a
At ages 30, 35, and 40, then biannually to age 50, then annually, or as otherwise indicated.
b
Beginning at age 40, every 5 years to age 50, then every 3 years.

Military pilot screening also yields similar results, with through 1 year of flight training, during which time 7.4% were
a 21% rejection rate of finalist candidates in the Israeli Air rejected for medical reasons that were not discovered during
Force [6] and a 1418% rejection rate (general and academy selection. Of these, 17% resulted from nondisclosure during
candidates) among Royal Australian Air Force applicants [7]. the initial selection process. Many aspects of medical screen-
Interestingly, the Israeli study followed selected candidates ing continue to rely on accurate historical information that is
3. Medical Evaluations and Standards 65

Table 3.7. Most frequent causes for disqualification in U.S. astro- experience become significant factors in determining medical
naut selection. suitability for continuing crew duties. Although standards
Physical system Findings based on factors that might affect mission and flight safety
Ophthalmologic Distant visual acuity, depth perception, color vision, are the same for selection and retention, standards that reflect
esotropia, refractive error, astigmatism, corneal mission objectives or personal crew health may differ for
distortion retention. This difference reflects both the expenditure of
Cardiovascular Dysrhythmias (supraventricular or ventricular training resources as well as the operational mission expe-
tachycardias), hypertension, left bundle-branch
block, pulmonary stenosis
rience of the crewmember. For example, hearing standards
Otolaryngologic Sinusitis, allergic rhinitis, hearing loss for selection are stricter than those for retention; this differ-
Genitourinary Kidney stones, renal anomalies ence acknowledges the degradation in hearing thresholds that
Endocrine Abnormal thyroid takes place with age and noise exposure and recognizes that
Psychological Personality disorder, drug abuse, physical abuse these thresholds, while still within acceptable limits for mis-
Other Positive tuberculin test, chronic liver enzyme
abnormalities, chronic headaches, irritable bowel
sion requirements, are likely to be lower in older, experienced
syndrome, carbohydrate intolerance crewmembers.
Trained crewmembers who fail to meet retention medi-
cal standards may still be considered for continuing duties
through a waiver process, during which the crewmembers
not always entirely reliable, since candidates may be reluctant medical condition is reviewed. Considerations include the
to divulge information that they perceive may be disqualify- crewmembers ability to carry out training requirements,
ing. The Israelis found that a way to improve this accuracy any potential risk to mission safety, possible risk to mission
was to concurrently obtain a history of the applicant from the objectives, and risk to the individual from further deteriora-
applicants parents [6]. tion of the condition with continued duties. A panel of flight
surgeons develops and periodically assesses a risk-assess-
ment model based on known variables related to the crew-
Mission-Specific Medical Screening members medical condition and operational experience as
well as mission objectives. If the risk assessment is favor-
In addition to the selection and annual health screening aspects able, a waiver of a particular standard may be recommended
of astronaut medical evaluations, which are similar to evalua- to allow the crewmember to continue with limited or full
tions in aviation medicine, space medicine has the significant duties, with monitoring and follow-up of the medical con-
additional requirement for further screening leading up to and dition. Astronauts have been granted waivers for continuing
during missions of short duration (days), extended duration duties for hearing loss that falls below standard, for certain
(weeks), and long duration (months to years). Long-duration cardiac arrhythmias (such as self-limited supraventricular
missions (those lasting more than 30 days) include medical tachycardia), and for nonmetastatic testicular cancer that has
assessments at 180 days before launch (L 180), L 30 or been removed with no sequelae. The waiver process has been
L 45, L 7 or L 10, L 2, landing (or return) day (R + 0), carefully and successfully applied throughout the U.S. space
R + 2, R + 3, R + 5-7, R + 10, R + 15, R + 20, and R + 30. Medical program. Military and civilian aviation regulatory authorities
screening is also planned during long-duration missions every use similar procedures.
30 days as well as before and after extravehicular activities and
before landing. The rationale for these assessments is twofold:
first to confirm a crewmembers medical fitness to carry out Population Bias in Astronaut
the mission, and second to gather normative medical data with Medical Screening
which to compare apparent excursions from the norm. Indi-
vidual preflight data and population normative data are used to One outcome of the intensive medical screening and ongoing
guide postflight rehabilitation activities and to evaluate return periodic health assessments that are in use for astronauts is the
to preflight health and fitness to return to duty. generation of a population base that differs greatly from the
general population in terms of disease prevalence. Population
studies in analogous population cohorts, such as airline pilots
Selection vs. Retention Standards: [8,9] and U.S. Air Force pilots [10], have identified a much
The Waiver Process lower incidence of cardiovascular and respiratory diseases,
but a small excess risk of cancer (colon and brain cancer,
The goal of medical selection standards is to identify can- malignant melanoma, and Hodgkins disease in commercial
didates with the requisite physical and mental attributes to pilots and testicular and urinary bladder cancer in Air Force
accomplish mission objectives and to identify candidates pilots) when compared to the general age, sex-matched, U.S.
who have no apparent evidence of potential career-limiting population. The prevalence of death from all accidental causes
medical problems. For trained crews, training and mission is higher in fliers, but the excess in cancer mortality is of
66 G. Gray and S.L. Johnston

concern. Airline pilots, like astronauts, are exposed to greater


amounts of cosmic radiation and electromagnetic forces than Medical Standards for Future
are Earth-bound individuals, and the potential link between Space Exploration
such exposure and long-term astronaut health continues to be
a focus of study. A return to Earth from low Earth orbit because of a medi-
Because of the difference between the highly select popula- cal event or an emergency is an expensive proposition that
tion resulting from astronaut medical selection and the general would seriously affect mission objectives. Nevertheless,
population, extrapolation of disease incidence and prevalence such a return is possible and, in fact, has been done on
from other large studies are not likely to be valid. In the Fram- at least three occasions from Russian space stations. One
ingham Study, a prospective, longitudinal population study of these returns to Earth involved chronic prostatitis and
of the residents of Framingham, Massachusetts, investigators sepsis; another involved a potentially serious cardiac dys-
defined the risk of a cardiovascular event on the basis of clas- rhythmia that had not been noted before flight [13]. The
sic risk factors, including age, total and high-density lipopro- most likely scenarios prompting medical return, would
tein cholesterol, blood pressure, and covariables (smoking, involve subacute or escalating processes that allow some
diabetes, and left ventricular hypertrophy) in the population time for planning. However, if the need for return is urgent,
[11]. Since the distribution and prevalence of standard risk Shuttle contingency plans allow an emergency landing to
factors in the astronaut population are often different from be made within several hours. Contingency plans for the
those in the Framingham population [12], extrapolation of the ISS include the possibility of emergency evacuation and
Framingham predictive equations to the astronaut population return to Earth within 24 h using a Soyuz or crew return
may not be valid. vehicle (see Chap. 7). The choice of medical support pro-
A further complication in terms of standard medical screen- vided on orbit is also based on the premise of a potential
ing procedures is that the low prevalence of disease, such as emergency return to Earth.
cardiovascular disease in the highly select astronaut popula- In the realm of expeditionary missions to Mars, return-
tion, makes the predictive value of screening tests, such as ing to Earth for a medical emergency will not be possible.
exercise stress testing, extremely low (Bayes theorem). This Communication from an expeditionary spacecraft will be
low disease prevalence makes the probability of false-posi- increasingly delayed the further the craft is from Earth; for
tive findings more likely than true-positive findings for many example, a maximum round-trip communication delay of
standard clinical testssuch as exercise stress testingthat 44 min can be expected between Mars and Earth. Even a Mars
have specificity in the 7080% range. The implications of this fly-past with direct return to Earth may represent a 9-month
are that in both initial and periodic screening, standard testing round-trip, and most Mars mission scenarios involve mission
must be applied with a careful understanding of the probable durations of 1836 months. Analysis of spaceflight data sug-
meaning of positive (abnormal) findings, and tests with the gests that the risk of a serious medical eventwhich in near-
highest possible specificity are preferable. Earth orbit would affect the mission by possibly requiring a
These and other concerns about astronaut health are cur- medical evacuation to Earthis approximately 0.06 per per-
rently being addressed in an important initiative, the NASA son-year of flight. This translates to 1 event per 2.8 years of
Longitudinal Study of Astronaut Health. This long-term spaceflight operations for a crew of six (see Chap. 7).
study, begun in 1994, is designed to follow current and for- Medical selection and provision of medical services for
mer astronauts; its goals are to examine the incidence of acute space expeditions thus takes on a new dimension. Onboard
and chronic morbidity and mortality of this group and to com- medical facilities for early expeditionary missions are likely
pare the risks of morbidity and mortality associated with the to be more comprehensive than they are for Shuttle missions,
astronauts occupational exposures to the corresponding risks for example, weight and space constraints will impose sig-
for a control population of civil service employees at Johnson nificant limits on the ability to provide medical care. Priority
Space Center in Houston. This prospective, longitudinal epi- must be given to providing for contingency situations such as
demiologic study will provide much-needed data on the health trauma or fire, and more emphasis should be placed on provid-
implications of occupational exposure in the environment of ing primary prevention of medical diseases through stringent
space, from short-duration flights through extended and long- preflight screening and treatment.
term, low Earth orbit missions and, ultimately, expedition- The first crew to depart for Mars is likely to be the most
ary space exposures. The study will also provide ongoing intensely medically studied crew in the history of space
prevalence data from which predictive equations for disease flight. Medical technology has advanced at a pace exceed-
probability can be derived that are relevant to the astronaut ing even that of space technology in the past several decades.
population. A somewhat reassuring negative finding is that to Medical technology will allow us to identify not only indi-
date, no statistical difference in the incidence of cancer has viduals with disease potential (screen-out procedures) but
been found between the control and astronaut populations, also individuals with characteristics that may make them
although an apparent trend toward a higher incidence in astro- resilient to the hazards of long-term space flight (screen-
nauts has been noted. in attributes). Within the next decade, the Human Genome
3. Medical Evaluations and Standards 67

Project is likely to have completed human genetic mapping, References


thereby providing tools with which to identify genetic
markers for a host of human diseases. Noninvasive medical [1]. Hickman JR. The clinical basis for aeromedical decision mak-
ing. AGARD Conference Proceedings 553, K112; 1994;
imaging will allow us to define organ structure, including
Neuilly-Sur-Seine, France.
vascular anatomy, and will facilitate our identification of [2]. Lovelace WR, Schwichtenberg AH, Luft UC, Secrest RR. Selection
individuals with lesions such as central arteriovenous mal- and maintenance program for astronauts for the National Aeronau-
formations. Developments in radiation biotechnology may tics and Space Administration. Aerospace Med 1962; 33:667684.
allow us to identify individuals whose cellular makeup is [3]. Santy PA, Jones DR. An overview of international issues in
more resistant to radiation damage. astronaut psychologic selection. Aviat Space Environ Med
This intensive medical evaluation, including genetic test- 1994; 65:900903.
ing, that will be incorporated into future medical standards [4]. Gray GW. Selection of astronauts/medical issues: The 1992 Cana-
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unidentified genetic marker of serious disease in a trained cal evaluations for astronaut selection and longitudinal studies. In:
Nicogossian AE, Huntoon CL, Pool SL (eds.), Space Physiology and
astronaut undergoing screening for an exploration mission
Medicine. 3rd edn. Philadelphia, PA: Lea & Febiger; 1993:375393.
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also affect other life issues such as insurability. Before such A prospective study. Aviat Space Environ Med 1988; 59:165167.
testing is introduced, the issues associated with it must be [7]. DeHart RL, Stephenson EE, Kramer EF. Aircrew medical stan-
scrutinized by medical ethicists as well as by flight surgeons dards and their application in the Royal Australian Air Force.
who are involved in developing medical standards for flight. Aviat Space Environ Med 1976; 47:7076.
Ethical considerations should include the greater good of [8]. Band PR, Spinelli JJ, Ng VTY, Moody J, Gallagher RP. Mor-
the mission, as well as the relative risks and benefits to the tality and cancer incidence in a cohort of commercial airline
individual. pilots. Aviat Space Environ Med 1990; 61:299302.
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ron Med 1992; 63:276279.
bers with desirable psychological attributes to minimize the
[10]. Grayson JK, Lyons TJ. Cancer incidence in the United States
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might jeopardize mission safety or effectiveness. Although 67:101104.
we have learned a great deal from human behavior in ana- [11]. Anderson KM, Wilson PWF, Odell PM, Kannel WB. An
logue environments (e.g., polar expeditions and nuclear sub- updated coronary risk profile. Circulation 1991; 83:356362.
marines) as well as from isolation experiments, there clearly [12]. Berry MA, Squires WG, Jackson AS. Fitness variables and the
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The psychological aspects of space flight are discussed [13]. Newkirk D. Almanac of Soviet Manned Space Flight. Houston,
further in Chap. 19. TX: Gulf Publishing Company; 1990.
4
Spaceflight Medical Systems
Terrance A. Taddeo and Cheryl W. Armstrong

Providing adequate medical care for spaceflight crews requires communications resources may enable a ground-based flight
that appropriate diagnostic tools and treatment modalities be surgeon to guide a CMO through a technical procedure, the
available to them throughout their mission. The challenge extent of the CMOs training will correlate strongly with
for mission planners is deciding what medical capability to medical success. The CMOs skill level must therefore be
provide and then packaging it in a way that meets the many taken into account in the selection of medical hardware.
unique constraints of space flight. Crews also must receive Medical hardware flown should be appropriate to the skill
adequate training that will help them to make correct diag- level and training of the crew. There is no sense in selecting
noses and administer the appropriate level of care to an ill or medical hardware that a CMO has not been trained to use.
injured crewmember. Although including a physician in every spaceflight crew
As discussed in Chap. 7, identification of appropriate levels would greatly enhance mission safety [1], there are too few
of medical care is driven by the risks that have been iden- NASA astronaut-physicians for this to be possible. Flight
tified in space flight. One practical way of identifying such rules now designate that each Space Shuttle crew of five to
risks is by studying risks among analogous populations, such seven individuals must include two CMOs who, whether
as military pilots, submarine crews, and Antarctic winter-over they are physicians or not, must complete a training sylla-
research teams. From these groups, which undergo medical bus designed to provide them with the basic knowledge and
screening processes similar to those of spaceflight crews, the skills necessary to provide first-line care on orbit. Similarly,
probabilities and risks of illness occurring during a mission two CMOs are designated from the crew complement of three
can be estimated. Review of reported illnesses in U.S. and Rus- to six long-duration crewmembers on the International Space
sian spaceflight crews also can be useful, although such data Station (ISS). These individuals are trained by flight surgeons
were not available to medical mission planners in the earliest and other operational personnel.
days of space flight. The duration of a space mission and the The medical kits provided on various spacecraft (including
number of high-risk activities associated with it (e.g., extrave- the ISS, the Space Shuttle, and the Russian space station Mir)
hicular activities) will also influence decisions concerning the were and are designed to meet identified mission-specific
content of onboard medical systems. Mission planners must risks and to account for any limitations in the medical back-
also consider environmental factors that are unique to the ground of the crew. CMOs are trained to a basic degree of
space environmentfactors that include microgravity, radia- competence through a series of structured classes and field
tion, toxicology, microbiology, and purity of reclaimed water. exercises. Onboard refresher training for medical emergency
Finally, the unique physiological responses to space flight procedures is included for long duration flights.
must also be examinedspace adaptation syndrome, cardio-
vascular deconditioning, and bone demineralization, among
others. Only by accounting for all of these factors can the best Medical Hardware Considerations
possible care and facilities be provided to spaceflight crews.
The desired medical capability must be weighed against the
limited resources available on board a spacecraft. Electrical
Space Medical Practitioners power, potable water, and other consumables are valuable and
limited commodities and are not always available for routine
Two groups are charged with providing real-time care medical purposes. The most expensive and scarce commod-
for spaceflight crews: the onboard crew medical officers ity is crew time. Vehicle operations and maintenance tasks,
(CMOs) and the ground medical support personnel. Although payload operations, and other important activities compete

69
70 T.A. Taddeo and C.W. Armstrong

with medical requirements for time in the crew schedule. To systems have been tested during parabolic flight [2] and space
ensure that medical tasks are completed, the procedures must flight [3]. The ideal medical restraint would accommodate
be simple and intuitive and must involve a minimal number the neutral body posture assumed in microgravity (by both
of personnel. A medical evaluation procedure that is either patient and CMO) and would support basic procedures, such
awkward to perform or requires an inordinate amount of time as simple wound repair, as well as more complex operations.
to complete may not be completed. Also, an injured or ill This restraint also would incorporate interfaces for medical
crewmember will reduce the workforce for onboard activity equipment and medical waste management, such as body-
significantly. fluid-saturated pads and discarded sterile packaging.
Providing terrestrial standards of care to space crews requires For the near future, dedicated constantly deployed medical
careful planning and forethought. Mass, volume and power restraints are unlikely to be included in spacecraft because of
are extremely valuable on a spacecraft, and the medical sys- volume constraints. Other available surfaces have been and
tems flown must minimize their consumption of these assets. will be used, however, such as cabin walls and galley tables.
Priority must also be given to items with a long shelf life, However, a smaller hybrid system consisting of a rapidly
stability at ambient temperature and humidity, and minimal deployable surface attached to dedicated structural mounts
maintenance requirements. Simple and intuitive designs for offers a viable alternative. In an acute, life-threatening situation,
equipment will aid in its effective use, particularly by the non- the time to deploy a restraint is a critical factor that could well
medical user who may handle the items very infrequently. affect patient survival. These considerations contributed to the
This is especially important for resuscitation hardware. development of the current ISS crew medical restraint sys-
Microgravity itself presents many design challenges. For tem. That system consists of a rapidly deployable rigid plat-
example, any process that includes gas-fluid separation will form that quickly restrains both patient and operator in close
require centrifugal force or gas-fluid filter systems to act proximity to the onboard medical system. This restraint sys-
in place of gravity. Procedures that generate particulate or tem also affords electrical isolation from the station systems
fluid contamination of the spacecraft, such as dental drilling, and rescuers should defibrillation be required.
specimen handling, or surgical procedures, must be performed
in specialized enclosures. Finally, restraint of operator, sub-
ject, and support items is a fundamental requirement in
Automated Ventilation
microgravity. Advanced airway handling methods have been developed for
In microgravity, most examination techniques are use in the weightless environment and have been taught to
unchanged, and most of the standard diagnostic and therapeu- CMOs. Equipment for endotracheal intubation has been on
tic instruments need not be modified. Stethoscopes, otoscopes, hand on Skylab, Space Shuttle, Mir space station, and ISS
venipuncture kits, and many other familiar items have been missions. Some type of manual respirator has always been
used successfully for years in space flight, once crews have available during these programs, and a small automated
become accustomed to moving and managing these items in ventilator also is now part of the ISS medical inventory.
weightlessness and adjusting for other factors such as high Because of electrical power constraints in spacecraft, the
ambient noise and low light levels. best option for automated ventilation is a compact pressure-
The following subsections provide a discussion of selected driven ventilator that uses the storage pressure of respirable
medical equipment and capabilities and some of these unique gas. On Earth, such ventilators are typically used for short-term
considerations. Astronauts with spaceflight experience must acute care. For a patient who is incapable of adequate spon-
be included in the design of new medical systems, as they taneous respiration, the compact pressure-driven ventilator is
have insight not available to ground engineers. Each new a potentially lifesaving device that replaces a crewmember
generation of hardware must reflect the hard won lessons of who would otherwise be required to give manual respirations
space medical operations. with a bag device. As noted above, ample assistance may
not be available should a medical crisis occur in flight. In
the ground-based transport and acute roles, pressure-driven
Medical Restraint Systems ventilators are generally powered by 100% oxygen. This
Experience has shown that medical examinations, intrave- immediately creates a problem in the enclosed environment
nous (IV) techniques, and other procedures can be accom- of a spacecraft in that the patient-ventilator exhaust is nearly
plished in the microgravity environment without specialized 90% oxygen, with the remaining 10% being expired CO2 and
restraint systems. However, more complicated medical proce- water vapor. In an enclosed cabin, ambient concentrations of
dures cannot be performed without the use of proper restraint oxygen can rise quickly and exceed flammability limits.
systems to bring CMO, patient, and medical support items A short-term option in such a contingency would be to add a
into close proximity. To support contingency events in which diluent gas such as nitrogen to the cabin atmosphere to main-
acute care would be required, the best solution is a dedicated tain safe concentrations. However, this option comes at a cost
medical restraint table that either can be deployed quickly in consumables as overall atmospheric pressure bleeds off to
or is always deployed and at the ready. Prototypes of such maintain cabin pressure limits.
4. Spaceflight Medical Systems 71

Two potential solutions exist that could lessen that cost in Cardiac Defibrillation
consumables. The first would be to provide an overboard dump
in which only the expired ventilator gas is vented overboard Contemporary advanced life support methods require the
into space or into some vessel from which the gas may be capability for cardiac monitoring and defibrillation. A monitor/
reclaimed later. The second solution is to provide a dual-gas defibrillator may consist of an off-the-shelf item that has
system (oxygen/nitrogen) and a gas blender that would allow been modified for space flight, with capabilities for monitor-
the CMO to use only the oxygen concentration required to ing, defibrillation over a range of selected energy levels, and
address a clinical need. This solution also would mitigate the external cardiac pacing. Some unique considerations arise in
potential problems of pulmonary oxygen toxicity, usually microgravity. A notable example is the application of charged
seen after 18 or more hours of breathing 100% oxygen, should paddles to a patients chest, an act that normally requires a
ventilation be required for that length of time. However, since force of 11 kg (25 lbs) to ensure adequate electrical contact.
high concentrations of oxygen may still be needed to meet Since the rescuer has no weight in microgravity, self-adhesive
medical requirements, some combination of these 2 solutions defibrillator pads (which are becoming more common in
may be optimal. ground use) must be used. Insulation and electromagnetic
Any future contingency respiratory capability should use a interference shielding must also be considered to protect those
closed system that will minimize loss of consumables. Also, delivering care from inadvertent electrical shock as well as
the use of an advanced technology such as molecular sieve beds to protect sensitive avionics from damaging electromagnetic
would enable a gas delivery system to obtain and concentrate interference pulses.
oxygen from the ambient cabin atmosphere before venting the As an acute response item, the monitor/defibrillator must
exhaust directly back into the cabin, with a minimal effect on be maintained in a state of readiness. Batteries must be
atmospheric composition. charged to energize the capacitor, which delivers the direct
current counter-shock, and the unit must be rapidly and
easily accessible. Since much of the patient positioning and
Intravenous Fluid Therapy insulating requirements will be met by a medical restraint
Administration of small doses of IV medications is not system, restraint deployment may be a rate-limiting step in
problematic in weightlessness. However, large volumes of flu- delivering lifesaving defibrillation. The CMO must be well
ids for hydration cannot be administered in the same manner trained in the safe and effective use of the defibrillator, since
as on Earth, by using gravity-driven free-flow devices or situations requiring cardiac defibrillation, although rare, will
pumps that automatically separate air and fluid. The simplest very likely arise and require treatment well before ground
means of providing IV fluids in weightlessness combines a consultation can be obtained.
soft fluid packaging with a surrounding pneumatic pressure
device, such as a blood pressure cuff. Regulating the pressure
Cardiopulmonary Resuscitation
and the size of the flow orifice provides a rough means of
controlling the rate of fluid administration. Injection fluids Common methods of closed-chest cardiac massage depend on
must be specially packaged with a minimum amount of air, the weight of the rescuers upper torso to drive the force of
and care must be taken while preparing the infusion system to compression; however, this weight, and hence this force, are
avoid introducing further air into the line. Additional air-fluid absent in microgravity. A restrained rescuers muscular power
separation may be facilitated with an in-line filter system, or alone may provide adequate compressive force for a short time.
a bubble trap. More precisely regulated infusion rates, such Such methods have been tested during parabolic flight [7] and
as those required to administer continuous or controlled-dose during space flight [8]. However, delivering compressions of
medications, will require an automated pump. Prototypes of adequate force can quickly become exhausting, particularly
powered infusion pumps have been tested during space flight for crewmembers who have experienced musculoskeletal
[1,4], and a small commercially available device has been deconditioning during space flight. Effective compressions
adapted and included in the ISS inventory. can be delivered more easily by the rescuer if he or she is
Although prudence dictates maintaining at least a small reacting against an opposite surface with the feet rather than
stock of prepackaged IV fluids, storing large quantities of by being restrained in a more terrestrial-standard position at
IV fluids would represent a significant overhead in launch the patients side. This position requires no dedicated rescuer
mass and stowage. Moreover, most IV fluids have 1-year restraint, it uses combinations of extensor muscles throughout
shelf lives. A more efficient use of resources would be to the body, and it keeps the area near the patients chest and
produce sterile injection-grade fluid as needed during flight head clear for airway and IV procedures.
from potable water. Exploration-class missions should have Alternatively, mechanical devices may be used, such as
this capability. Technology to produce sterile injection- pneumatically powered thumpers, or simpler lever devices,
grade fluid for space flight using ion exchange columns such as those tested during the STS-40 (June 5 to June 14,
and premeasured electrolyte and drug aliquots has been 1991) Space Shuttle mission [8]. Such devices would be best
extensively examined [5,6]. integrated into an advanced medical restraint system.
72 T.A. Taddeo and C.W. Armstrong

The On-Site Medical Checklist The number of medications flown increased slightly dur-
ing the 10 crewed Project Gemini space flights (March 23,
Like the medical support hardware, written medical procedures 1965 to November 15, 1966). The contents of the Gemini VII
carried on board spacecraft for the use of crewmembers must be (December 4 to December 18, 1965) medical kit reflect this
as user-friendly and as intuitive as possible. Preflight training change (see Table 4.1 and Figure 4.3). In addition to the medi-
with the hardware must use the same procedures as those to cal kit, medications were also carried in a separate survival
be used in space flight. Moreover, since training sessions with package. The contents of the Gemini VI-A (December 15 to
the hardware may have taken place months or even a year December 16, 1965) survival package medical kit included a
before use, documentation of the supporting procedures must stimulant, motion sickness medication (oral and injectable),
be clearly and concisely written. Diagrams, photos, simple cue pain medication (oral and injectable), an antibiotic, and aspi-
cards, logical grouping of items, and effective labeling can rin [11].
increase crew efficiency and effectiveness. These design prin-
ciples are even more important as multinational crews, whose The Apollo Program
members are reading and writing in nonnative languages,
work together on the ISS. Notably, the ISS Medical Checklist During the crewed Apollo Program flights (October 11, 1968
is a bilingual guide that is printed on facing pages in the two to December 19, 1972, consisting of two Earth orbit flights,
main operative languages of the ISSEnglish and Russian. two lunar orbit flights, one lunar swingby flight [Apollo 13,
April 11 to April 17, 1970], and six lunar landing flights),
separate medical kits were required for the command mod-
Medical Systems of Spacecraft ule and the lunar module (see Figures 4.44.6). These kits
included primarily medications and bandage items. An aux-
and Space Stations iliary kit was added to the command module kits for Apollo
16 (April 16 to April 27, 1972) and Apollo 17 (December 7 to
Projects Mercury and Gemini December 19, 1972). The contents of the Apollo command-
Spaceflight medical systems have evolved from a few medi- module medical kit are listed in Table 4.2, and the contents
cations and monitoring devices to advanced life support of the lunar-module medical kit are listed in Table 4.3.
hardware. The medical kit (see Figures 4.1 and 4.2) for the
six piloted Project Mercury flights (May 5, 1961 to May 15,
The Skylab Missions
1963) included an anti-motion-sickness drug, a stimulant,
and a vasoconstrictor to treat shock. The astronauts electro- The 3 crewed Skylab missions lasted 28 days (May 25 to June
cardiograph, blood pressure, respiratory rate, galvanic skin 22, 1973), 59 days (July 28 to September 25, 1973), and 84
resistance, and rectal temperature were monitored by physi- days (November 16, 1973 to February 8, 1974) and provided
cians on the ground [9]. new challenges for medical support teams. Onboard medical

FIGURE 4.1. Mercury medical kits containing items such as antibiot- FIGURE 4.2. Mercury medical kit containing items such as saline
ics, decongestants, stimulants, electrode paste, and medications to solution, bandages, stimulants, and decongestants (Photo courtesy
treat nausea and diarrhea. (Photo courtesy of NASA) of NASA)
4. Spaceflight Medical Systems 73

TABLE 4.1. Contents of the Gemini VII medical kit [10].


Medication Indication Dose Amount
D-Amphetamine sulfate Stimulant 5-mg tablets 8
Aspirin-phenacetin- Pain Tablets 16
caffeine
Cyclizine HCl Motion sickness 50-mg tablets 8
Diphenoxylate HCl Diarrhea 2.5-mg tablets 16
Meperidine HCl Pain 100-mg tablets 4
Methyl cellulose solution Eye lubricant 15-ml bottle 1
Parenteral cyclizine Motion sickness 45 mg (0.9-ml 2
injector)
Parenteral meperidine HCl Pain 90 mg (0.9-ml 2
injector)
Pseudoephedrine HCl Decongestant 60-mg tablets 16
Tetracycline HCl Antibiotic 250-mg coated 16
tablets
Triprolidine HCl Decongestant 2.5-mg tablets 16

FIGURE 4.5. Apollo clinical physiological monitoring kit and emer-


gency medical kit (Photo courtesy of NASA)

FIGURE 4.3. Apollo medical kit containing items such as skin cream,
antibiotic ointment, nasal spray, band-aids, and stimulants (Photo
courtesy of NASA)

FIGURE 4.6. Apollo emergency medical kit (Photo courtesy of NASA)

The Space Shuttle


The Shuttle Orbiter medical system (SOMS) has flown on all
Space Shuttle flights and is designed to support a crew of five
FIGURE 4.4. Apollo Command Module medical kit (Photo courtesy to seven for up to 20 days. A process exists to make necessary
of NASA) changes and upgrades to the SOMS, and over the course of
more than 100 Space Shuttle flights, the SOMS has evolved to
meet mission needs and to keep up with advances in medical
systems were upgraded to provide an enhanced drug formulary therapy and pharmacology. This process of change and review
and capabilities including wound care, dental care, minor sur- also permits some degree of customization for each mission.
gery, urinary catheterization, and microbiology assessment. The current SOMS comprises several subpacks, namely the
Skylab astronauts received 80 h of paramedic-level training emergency medical kit (EMK), the medications and bandages
before launch. The contents of the Skylab medical kits are kit (MBK), the medical accessory kit (MAK), the airway
listed in Table 4.4. medical accessory kit (AMAK), the contaminant cleanup
74 T.A. Taddeo and C.W. Armstrong

TABLE 4.2. Contents of the Apollo Command-Module medical kit [12].


Items Indication Formulation Amounta
Actifed (triprolidine/pseudoephedrine) Decongestant Tablets 60
Afrin (oxymetazoline) Decongestant Nose drops 3
Ampicillin Antibiotic Tablets 60
Aspirin Analgesic Tablets 72
Atropineb Cardiac arrhythmias Injectable solution 12
Bacitracin Antibiotic Eye ointment 1
Benadryl (diphenhydramine)c Antihistamine Tablets 8
Darvon (propoxyphene) Analgesic Tablets 18
Demerol (meperidine)b Analgesic Injectable solution 6
Dexedrine (d-amphetamine) Stimulant Tablets 12
Lidocaineb Cardiac arrhythmias Injectable solution 12
Lomotil (diphenoxylate) Diarrhea Tablets 24
Marezine (cyclizine) Antihistamine Injectable solution 3
Marezine (cyclizine)d Antihistamine Tablets 24
Methylcellulose Laxative Capsules 2
Multivitamins Tablets 20
Mylanta (simethicone) Antiflatulent Tablets 40
Nasal emolient 1
Neosporin (polymixin B) Antibiotic Ointment 1 or 2
Ophthaine (proparacaine preparation) Topical anesthetic Eye drops 1
Pronestyl (procainamide)b Cardiac arrhythmias Tablets 80
Scopolamine-dexedrine Motion sickness Tablets 12
Seconal (secobarbital) Sleeping aid Tablets (100 mg) 21
Seconal (secobarbital)c Sleeping aid Tablets (50 mg) 12
Skin cream 1
Tetracycline Antibiotic Tablets Varied
Tetrahydrozoline HCle Eye drops 1
Tylenol (acetaminophen)c Analgesic Tablets 14
Band-aids 12
Compress bandages 2
a
Not all medications were carried in the amounts noted on all flights.
b
Carried on Apollo-16 and -17 only.
c
Carried on Apollo-8 only.
d
Carried on the first 4 missions only.
e
Carried on Apollo-17 only.

TABLE 4.3. Contents of the Apollo Lunar Module medical kit [12].
Items Indication Formulation Amounta
Actifed (triprolidine/pseudoephedrine) Decongestant Tablets 8
Afrin (oxymetazoline) Decongestant Nose drops 1
Aspirin Analgesic Tablets 12
Atropine Cardiac arrhythmias Injectable solution 4
Darvon (propoxyphene) Analgesic Tablets 4
Demerol (meperidine) Analgesic Injectable solution 2
Dexedrine (d-amphetamine) Stimulant Tablets 4
Lidocaine Cardiac arrhythmias Injectable solution 8
Lomotil (diphenoxylate) Diarrhea Tablets 12
Methylcellulose Eye drops 1
Neosporin (polymixin B) Antibiotic Ointment 1
Pronestyl (procainamide) Cardiac arrhythmias Tablets 12
Seconal (secobarbital) Sleeping aid Tablets 6
Band-aids 6
Compress bandages 2
Urine collection and transfer devices 6
a
Not all medications were carried in the amounts noted on all flights.
4. Spaceflight Medical Systems 75

TABLE 4.4. Contents of the Skylab In-Flight Medical Support System [13].
Equipment Kit Usage requirement
Accumulator assembly Microbiology No restriction
Adhesive tape, Dermicel Bandage No restriction
Adhesive tape, Micropore Bandage No restriction
Air sampler Bandage Not applicable
Airway, pharyngeal Therapeutic No restriction
Aneroid sphygmomanometer Diagnostic No restriction
Applicator, dental Bandage No restriction
Applicators, silver nitrate (12) Bandage No restriction
Antibiotic lubricant Catheterization No restriction
Band-Aids (100) Bandage No restriction
Barrier, sterile field (2) Minor Surgery Physician use/approval required
Batteries (8 AAA), (8 AA), (8 C) Diagnostic No restriction
Betadine squares (4) Minor Surgery No restriction
Bili-Labstix/Urobilistix Hematology/Urinalysis No restriction
Binocular loupe Diagnostic No restriction
Blood lancets (75) Hematology/Urinalysis No restriction
Calcium alginate balls (50) Hematology/Urinalysis No restriction
Can opener Not applicable Not applicable
Cannula Therapeutic Physician use/approval required
Capillary pipettes (50) Hematology/Urinalysis No restriction
Catheter, urinary Catheterization Physician use/approval required
Coagulase plasma Command Module Resupply No restriction
CO2 accumulator assembly Microbiology No restriction
CO2 generators (24) Microbiology No restriction
Collection bag (3) Catheterization No restriction
Container, injectables Therapeutic Physician use/approval required
Demerol injectors (5) Therapeutic No restriction
Dermicel surgical tape Hematology/Urinalysis No restriction
Digital hand counter Hematology/Urinalysis No restriction
Disinfectant pads (60) Not applicable No restriction
Disposable bags (20) Microbiology No restriction
Dressing boot (Unnas) Bandage No restriction
Dressing, abdominal (6) Bandage No restriction
Drug modules (2) Drug Supply Module Not applicable
Elastic wraps (3) Bandage No restriction
Elevator Dental No restriction
Endotracheal tube Therapeutic Physician use/approval required
Eye patch, cotton (8) Bandage No restriction
Eye patch, plastic (2) Bandage No restriction
File Dental No restriction
Filter strips (10) Microbiology No restriction
Fluorescein strips (12) Bandage No restriction
Forceps, 6-in (3) Microbiology No restriction
Forceps, mandibular anterior Dental No restriction
Forceps, mandibular posterior Dental No restriction
Forceps, maxillary anterior Dental No restriction
Forceps, maxillary posterior Dental No restriction
Forceps, mosquito Minor Surgery Physician use/approval required
Forceps, splinter Bandage No restriction
Forceps, tissue Minor Surgery Physician use/approval required
Gauze, dental Dental No restriction
Gauze, roller (6) Bandage No restriction
Gauze squares No restriction
4 in. 4 in. (24) Bandage
2 in. 2 in. (12) Bandage
2 in. 2 in. (20) Minor Surgery
Gauze squares, Betadine Bandage No restriction
Minor Surgery Physician use/approval required
Gauze, Vaseline (6) Bandage No restriction
Glass marking pencil (2) Microbiology No restriction
Gloves, examination (2 pair) Hematology/Urinalysis No restriction
Gloves, surgical (2 pair) Catheterization No restriction
(continued)
76 T.A. Taddeo and C.W. Armstrong

TABLE 4.4. (continued)


Equipment Kit Usage requirement
Glucose (2) Therapeutic Physician use/approval required
Heat sink Command Module Resupply No restriction
Hemacheck assembly Hematology/Urinalysis No restriction
Hemoglobin meter Hematology/Urinalysis No restriction
Hemolysis applicators (50) Hematology/Urinalysis No restriction
Hemostat Catheterization No restriction
Hemostat, Crile, curved Minor Surgery Physician use/approval required
Hemostat, Crile, straight Minor Surgery Physician use/approval required
Hemostat, Kocher Minor Surgery Physician use/approval required
Hemostat Therapeutic No restriction
Hydrogen peroxide Command Module Resupply No restriction
Immersion oil bottles (3) Microscope No restriction
Incubator Not applicable Not applicable
Injectables container Therapeutic No restriction
Lancets (75) Hematology/Urinalysis No restriction
Laryngoscope Therapeutic Physician use/approval required
Lens (100) Drug Supply Module No restriction
Lens tissue Microscope No restriction
Light bulbs (14) Diagnostic No restriction
Loop holders (2) Microbiology No restriction
Light source, head-mounted Diagnostic No restriction
Microscope Microscope No restriction
Microscope stage Drug Supply Module No restriction
Mirror/light Dental No restriction
Myringotomy knife Diagnostic Physician use/approval required
Nasogastric tube Catheterization No restriction
Needle holder Minor Surgery Physician use/approval required
Needles, hypodermic
16-Gauge (2) Therapeutic No restriction
18-Gauge (2) Therapeutic No restriction
20-Gauge, 4 in. (1) Command Module Medical Kit Physician use/approval required
20-Gauge (2) Therapeutic No restriction
25-Gauge (4) Therapeutic No restriction
27-Gauge, 13/16 (3) Dental No restriction
Neurologic exam instruments Diagnostic Physician use/approval required
Nozzle Catheterization Physician use/approval required
Ophthalmoscope Diagnostic No restriction
Otoscope Diagnostic No restriction
Otoscope specula (33) Diagnostic No restriction
Oxidase strips (25) Command Module Resupply No restriction
Petri dish, large (20) Command Module Resupply No restriction
Petri dish, small (20) Command Module Resupply No restriction
Pressure infusor assembly Not applicable Physician use/approval required
Probe Minor Surgery Physician use/approval required
Resupply container (2) Command Module Resupply No restriction
Retractors, skin/muscle (ALMS) Minor Surgery Physician use/approval required
Scalers, curette Dental No restriction
Scalpel, #10 (2) Minor Surgery Physician use/approval required
Scalpel, #11 (2) Minor Surgery Physician use/approval required
Scissors Bandage No restriction
Scissors, sharp/sharp Minor Surgery Physician use/approval required
Sedative restorative material (8) Dental No restriction
Sensitivity discs Command Module Resupply No restriction
Ampicillin (50)
Cephalothin (50)
Erythromycin (50)
Sulfasoxazole (Gantrisin) (50)
Penicillin G (50)
Tetracycline (50)
Sensitivity disc dispenser (3) Microbiology No restriction
Silver nitrate applicators (12) Bandage No restriction

(continued)
4. Spaceflight Medical Systems 77

TABLE 4.4. (continued)


Equipment Kit Usage requirement
Slide dispenser (75 slides) Microscope No restriction
Slide stainer Not applicable No restriction
Slide streaker (2) Drug Supply Module No restriction
Slide stainer expendables Not applicable No restriction
Specific gravity refractometer Hematology/Urinalysis No restriction
Specula, disposable Diagnostic No restriction
Sphygmomanometer Diagnostic No restriction
Splint assembly (4) Not applicable No restriction
Sterile water (2) Command Module Resupply No restriction
Steri-Strips (20) Bandage No restriction
Stethoscope Diagnostic No restriction
Stewarts transport media (58) Command Module Resupply No restriction
Streaking loops Microbiology No restriction
Suture material, chromic catgut; 000 with fingerstick Minor Surgery Physician use/approval required
(2 needle)
Suture material, dermal #5-0 with fingerstick (2 needle) Minor Surgery Physician use/approval required
Suture material, silk, 00 Minor Surgery Physician use/approval required
Swabs, cotton (24) Bandage No restriction
Swabs, dry (20) Therapeutic No restriction
Swabs, dry, crew nasal and throat samples (18) Microbiology No restriction
Swabs, dry, crew illness (12) Microbiology No restriction
Swabs, dry, cultural transport (48) Microbiology No restriction
Swabs, wet, antibiotic Sensitive (48) Microbiology No restriction
Swabs, wet, crew body sample (18) Microbiology No restriction
Swabs, wet, environ. surface sample (90) Microbiology No restriction
Syringe, dental Dental No restriction
Syringe, epinephrine Therapeutic No restriction
Syringe, plastic, 2.5-cc (2) Therapeutic No restriction
Syringe, plastic, 50-cc with needle (2) Therapeutic No restriction
Syringe, 1-cc tubex holder Therapeutic No restriction
Syringe, plastic with needle, 50-cc (3) Therapeutic Physician use/approval required
Syringe, 2-cc tubex holder Therapeutic No restriction
Syringe, 5-cc Therapeutic No restriction
Syringe, with needle, 1-cc (6) Microbiology No restriction
Syringe Catheterization No restriction
Taxos A discs (50) Command Module Resupply No restriction
Taxos P discs (50) Command Module Resupply No restriction
Thermometer, oral (2) Diagnostic No restriction
Three-way valve Command Module Medical Accessory Kit Physician use/approval required
Tissue forceps Minor Surgery Physician use/approval required
Tongue depressor Diagnostic No restriction
Tourniquet Hematology/Urinalysis No restriction
Towel Catheterization No restriction
Tracheostomy equipment Therapeutic No restriction
(Unnas) Boot dressing Bandage No restriction
Urinary catheter Catheterization Physician use/approval required
Urine sample bag (6) Microbiology No restriction
Valve, three-way Command Module Medical Accessory Kit Physician use/approval required
Vaseline gauze (6) Bandage No restriction
Velcro, sticky-back (6) Hematology/Urinalysis No restriction
Vials (58) Command Module Resupply No restriction
Water, sterile (2) Command Module Resupply No restriction
Work table Minor Surgery No restriction
Zephiran (benzalkonium chloride) wipes (81) Hematology/Urinalysis Catheterization No restriction

kit (CCK), the operational bioinstrumentation system, the dental items, IV fluid administration equipment, and other
electrode attachment kit, patient and rescuer restraints, and a diagnostic and therapeutic instruments. The MBK contains
resuscitator (see Figure 4.7). oral medications, topical medications, and bandages for
Only the EMK and the MBK flew on STS-1 (April 12 to treating most in-flight problems. Oral medications are
April 14, 1981). The EMK contains injectable medications, in shrink-wrapped plastic bottles with attached tops and
78 T.A. Taddeo and C.W. Armstrong

developed. The CCK redesign reduced the overall size of


the kit and added an eyewash capability to decontaminate
the eyes. This Shuttle emergency eyewash was designed to
interface with the Space Shuttle galley (as the water supply
source) and the waste collection system (for disposing of the
contaminated water). The Shuttle emergency eyewash design
includes a pair of swim goggles and tubing with special
interfaces for the galley and waste collection system. The
MEDOP was designed specifically for extended-duration
Orbiter missions (that is, for Space Shuttle missions last-
ing longer than 12 days). The MEDOP contains additional
supplies located in the EMK or MBK as well as a skin sta-
pler and a rapid test for oropharyngeal group A -hemolytic
streptococcal infection, among other unique items [15].
An IV accessory kit was developed in 1998. IV supplies are
kept in the IV accessory kit, which is similar to the AMAK,
for quick access. Although the IV accessory kit is not currently
FIGURE 4.7. Shuttle Orbiter Medical System. Following redesign in
part of the Space Shuttles standard medical complement, it
2000, components include Saline Supply Bag, EENT Subpack, IV
flew on four missions at crew surgeon request.
Administration Subpack, Trauma Subpack, Sharps Container, Drug
Subpack, and Airway Subpack (Photo courtesy of NASA) Because of hazards posed by particular payloads and medical
experiments, a defibrillator has been flown on two Space Shuttle
missions. This commercial-off-the-shelf device was modified
push-up dispensers for easy management in microgravity. to meet flight certification specifications. In addition to the defi-
Crewmembers record medication use in data logs stowed brillator, a cardiac drug kit and crew medical restraint system
in the MBK. At the recommendation of an experienced were developed. The cardiac drug kit contains primarily ACLS
Space Shuttle CMO, a space motion sickness kit was also cardiac medications to be used with the defibrillator. The crew
developed. This kit, which is stowed in the pocket of the medical restraint system attaches to the middeck lockers and
MBK, includes, in one convenient location, all of the items restrains a crewmember while rescuers provide that crewmem-
necessary for giving an intramuscular injection of prometha- ber with appropriate medical care. The crew medical restraint
zine, thus saving crew time early in the mission, when space system also ensures that the patient is electrically isolated, so
motion sickness is most prevalent. that the defibrillator can be used without risk of damage to
The operational bioinstrumentation system and the electrode Space Shuttle systems from extraneous electrical current.
attachment kit were added to the SOMS in 1982. These two The contents of the standard SOMS, excluding the MEDOP,
items can be used during a medical contingency to downlink are listed in Table 4.5. The SOMS package was redesigned
a crewmembers electrocardiogram waveform to the Mission after a review by a panel that included extramural experts
Control Center. in pharmacology and wilderness medicine. This redesign,
The SOMS was reevaluated in the wake of the STS-51-L finalized in 2000, improves the layout and user-friendliness
Challenger accident (January 28, 1986), and the MAK, the of the system and mirrors the structure of the ISS medical
CCK, patient and rescuer restraints, and a resuscitator were kits. A key element is the use of dedicated subpacks, with
added for the return-to-flight mission, STS-26 (September each subpack serving a specific function or classification of
29 to October 3, 1988). The MAK, which contains additional care. The subpacks include an airway subpack, an IV admin-
IV fluid and urinary catheterization supplies, is used to stow istration subpack, a saline supply bag, a trauma subpack, an
additional mission-specific medical items. The CCK pro- otolaryngologic (eye, ear, nose, and throat) subpack, and a
vides protective equipment, including gloves, goggles, masks, drug subpack. No changes were recommended for the CCK.
containment bags, and hazard identification labelsitems The MEDOP will continue to be manifested for missions
used to protect the crew in the event of a hazardous spill or lasting longer than 12 days. The new SOMS was first flown
another contamination event. The restraints and resuscita- on the STS-98 mission in early 2001.
tor enhance the crews ability to perform cardiopulmonary
resuscitation on board the Space Shuttle.
The Russian Space Station Mir
After a review of the system by emergency medicine consul-
tants in 1990, the AMAK was added. The AMAK allowed all The medical capability on the Mir space station (19862001)
of the airway management equipment to be located in a single was a product of many years experience in long-duration
place and added the capability for advanced airway procedures. space flight. Medical items carried on Mir were oriented
In 1992, the CCK was redesigned, and a supplemental toward supporting two or three crewmembers; these items
medical extended-duration Orbiter pack (MEDOP) was were replenished continuously to support the permanent
4. Spaceflight Medical Systems 79

TABLE 4.5. Contents of the Shuttle Orbiter Medical System.


Name Description Amounta
Absorbant wipes 72
Ace bandage 3 in. wide 2
Adaptic bandages 3 in. 3 in. 3
Afrin (nasal spray) 3-ml bottles 6
Air temperature monitors 90120 F 2
5888 F 2
Airway Oral 1
Alcaine (Proparacaine eye drops)b 15-ml bottle 1
Alcohol wipes 36
Ambien (zolpidem) 10 mg 75 tablets
Ambulatory leg bag 600-ml bag 1
Amikin (amikacin)b 250 mg/cc, 2-cc unit 1
Amoxil (amoxicillin)b 500 mg 24 capsules
Anusol-HC suppositories 6
Ascriptin (aspirin) 325-mg aspirin w/Maalox 25 tablets
Atropineb 1 mg/cc, 2-cc unit 2
Bactrim DS (trimethoprim/sulfamethoxasole)b 28 tablets
Bags
Chemical resistant 16 in. H 12 in. W 8
Double stick tape closure
Mess-up mitts 12 in. 11.5 in. 2
Tape closure
Red bio-wipe 12 in. 11.5 in. 2
Tape closure
Ziploc 12 in. 12 in. 9
Ziploc closure
Band-aids 1 in. 3 in. 15
Sheer spot 16
Benadryl (diphenhydramine)b, injectable 50 mg/cc, 1-cc unit 2
Benadryl (diphenhydramine), oral 25 mg 20 capsules
Biohazard identification labels 20
Blistex lip balm 1
Blood pressure cuff with aneroid sphyg 1
Butterfly infusion sets 2
Catheter, Foley 16 Fr, 30-cc balloon, silastic 2
Chemstrip 10 13
Ciloxan (ciprofloxacin) ophthalmic solutionb 0.3%, 2.5-ml bottle 3
Cipro (ciprofloxacin)b 500 mg 22 tablets
Claritin (loratadine) 10 mg 20 tablets
Cotton balls 10
Cotton swabs 6
Cough lozenges 5 mg dextromethorphan 15
Cyclogyl (cyclopentolate)b 1%, 15-ml bottle 1
Demerol (meperidine)b 50 mg/cc, 1-cc unit 4
Dental kit
Carver/file 1
Mirror 1
Needles Long: 27 G, 1.25 in. 6
Short: 27 G, 0.75 in. 6
Orangewood sticks 2
Syringe 1
Temporary filling 1
Toothache kit 1
Eugenol anesthetic drops
Tweezers
Cotton pellets
Marcaine (bupivacaine)b 0.5% w/epinephrine 1:200,000 6 dental carpules
Dexamethasoneb 10 mg/cc, 1-cc unit 2
Dexedrine (dextroamphetamine)b 5 mg 30 tablets
Diamox (acetazolamide)b 250 mg 30 capsules
Drape, sterile 1
(continued)
80 T.A. Taddeo and C.W. Armstrong

TABLE 4.5. (continued)


Name Description Amounta
Dulcolax (bisacodyl) 5 mg 30 tablets
Suppository, 10 mg 6
Duricef (cefadroxil)b 500 mg 20 capsules
Elastoplast tape 4 in. wide 1 roll
Electrode attachment kit 1
End-tidal CO2 detector 1
Entex LA (long-acting) (phenylpropanolamine/guaifenesin) 75 mg phenylpropanolamine hydrochloride, 400 mg 40 tablets
guaifenesin
Epinephrineb 1:1000, 1-cc unit 5
Eye pads 6
Finger splint 1
Flagyl (metronidazole)b 250 mg 28 tablets
Fluorescein strips 8
Forceps Blunt 1
Fox shield Metallic eye patch 1
Gauze pads 4 in. 4 in. 27
Genoptic (gentamicin) ophthalmic ointmentb 3.5-g tube 1
Gloves Chemical resistant 7 pair
Gloves Nonsterile, surgical 9 pair
Gloves Sterile, surgical 2 pair
Goggles Eye protection 7
Haldol (haloperidol)b 5 mg/cc, 1-cc unit 2
Hazard identification labels Decals (6 each level) 30
Hemostat Small 1
Curved 1
Imodium (loperamide HCl) 2 mg 32 capsules
Isoptin (verapamil)b 2.5 mg/cc, 2-cc unit 2
IV administration set 2
IV intracatheters 18 G 2
20 G 2
Kenalog (triamcinolone) cream 15-g tube 1
Kerlix dressing 4.5-in. wide 1 roll
Kling 3-in.-wide gauze dressing 5 rolls
Laryngoscope Handle with med blade 1
Lever lock cannula 2
Lidocaine/cardiac 20 mg/cc, 5-cc unit 2
Lidocaine/cardiac injector 2
Lotrimin (clotrimazole) cream 15-g tube 1
Lubricant (water-soluble) 3g 7
Magnifying glass 4 magnification 1
Masks, surgical 7
Medical data logs Crew size + generic variable
Merocel Pope (posterior nasal packing) 10 cm 3
Morphine sulfateb 10 mg/cc, 1-cc unit 3
Motrin (ibuprofen) 400 mg 30 tablets
Mycelex-7 (clotrimazole)b 100-mg suppositories 7
Mylanta Double Strength 24 tablets
Narcan (naloxone)b 0.4 mg/cc, 1-cc unit 2
Nasostat balloons 2
Needles 22 G, 1.5 in. 2
18 G, 1.5 in. 2
Neosporin Plus cream with lidocaine 0.5-oz tube, 40-mg lidocaine 1
Nitroglycerin patchb 15 mg 1
Nitrostat (nitroglycerin tablets)b 0.4 mg (1/150) 25
Op Site Transparent dressing 6
Operational Bioinstrumentation System Electrocardiograph monitor
Electrode attachment kit 1
Operational Bioinstrumentation System belt 1 each
w/signal conditioner 1
Sternal harness 2
Intravehicular activity cable 2
Biomed cable
Ophthalmoscope head 1
(continued)
4. Spaceflight Medical Systems 81

TABLE 4.5. (continued)


Name Description Amounta
Ophthalmoscope spare bulb 1
Otoscope 1
Otoscope spare bulb 1
Otoscope speculum 1
Ovral-21 (norgestrel/ethinyl estradiol)b 21 tablets
Patient/rescuer restraints 2 sets
Penrose tubing (tourniquet) 2
Pepto Bismol 24 tablets
PH strips 10 strips
Phazyme-125 (simethicone) 20 soft gel cap-
sules
Phenergan (promethazine) 50 mg/cc, 1-cc unit 11
Phenergan (promethazine) Oral, 25 mg 30 tablets
Suppository, 25 mg 14
Polysporin (polymyxin/bacitracin) 1-oz tube 1
Pope otowicks 6
Povidone-iodine swabs 20
Proventil (albuterol) inhalerb 17-g container 2
Pyridium (phenazopyridine) 200 mg 20 tablets
Radiation dosimeters
Refresh (artificial tears, eye drops) 0.3 cc 12
Restoril (temazepam) 15 mg 40 capsules
Resuscitator
Rimantadine 100 mg 42 tablets
Roller clamp irrigation assembly 1
Ruler, plastic measurement
Saline 100 ml 3
250 ml 1
500 ml 2
0.9% NaCl
Salt tablets 1 g NaCl 128 tablets
Scalpels No. 10 2
No. 11 1
Scissors, curved w/in surgical instrument assembly 1 pair
Shuttle emergency eyewash Irrigation goggles 1
Silvadene (silver sulfadiazine) cream 20-g tube 1
Silver nitrate sticks 5
Skin temperature monitors 84106F 15
Space Motion Sickness Kit 1
Alcohol wipes (10)
Band-aids (10)
Phenergan injectables (10)b
Tubex injector (1)
Splint Finger 1
Steri-Strip skin closures 3
Stethoscope 1
Suction device Toomey syringe 1
Sudafed (pseudoephedrine) 30 mg 100 tablets
Surgical Instrument Assembly 1 each
Forceps, small point
Needle holder
Hemostat, small
Tweezers, fine point
Scissors, curved
Suture 4-0 Dexon w/needle 1
5-0 Ethilon w/needle 1
4-0 Ethilon w/needle 2
3-0 Ethilon w/needle 2
2-0 Vicryl w/CT-1 needle 1
Syringes 10 cc 3
3 cc 6
Tape, Dermicel 1 in. wide 2 rolls
(continued)
82 T.A. Taddeo and C.W. Armstrong

TABLE 4.5. (continued)


Name Description Amounta
0.5 in. wide 2 rolls
Telfa pads 3 in. 4 in. nonstick bandages 5
Thermometers, disposable (Tempadot) 96104F 18
Tongue depressors 5
Tracheal tube with stylet 1
Tracheostomy Kit 1
Alcohol wipes
Dissecting scissors
Curved hemostats
Tracheal hook
Silk ties
Tracheostomy tube
Tracheostomy tube holder
Scalpel
Transparent dressing (Tegaderm) 5
Tubex injector 2
Tylenol (acetaminophen) 325 mg 60
Tylenol #3 (acetaminophen with Codeine)b 300 mg acetaminophen with 30 mg codeine 20 tablets
Urine Test Package 1
Chemstrip 10 13 strips
Color chart
Valium injectable (diazepam)b 5 mg/cc, 2-cc unit 2
Valium, oral (diazepam)b 5 mg 30 tablets
VIRA-A (vidarabine) ophthalmic ointmentb 3%, 3.5-g tube 1
VoSol HC otic solution 10-ml bottle 1
Xylocaine (lidocaine)b 2% w/epinephrine, 1:100,000, 2-cc unit 1
Xylocaine (lidocaine) Plainb 2% without epinephrine, 2-cc unit 1
Y-Type catheter extension 2
Zithromax (azithromycin)b 250 mg 18 tablets
a
Not all medications were carried in the amounts noted on all flights.
b
Indicates item to be used only after surgeon approval or as directed in medical checklist.

human presence on the station. Therapeutic items were distrib- which was derived from the SOMS, and the Mir medical
uted among several small, problem-oriented kits, an approach kits. Developed jointly by the U.S. and Russian medical
that provided convenient access for the crew and decreased communities, the MSMK was composed of reconfigured
the time required for resupply because the needed items were U.S. EMK, MBK, and MEDOP kits. Airway management
conveniently added to the next launch opportunity on either items were included in the MEDOP, and astronauts and
a Soyuz crew transport or a Progress freighter vehicle. Mir cosmonauts were trained accordingly in life support and
medical kits contained primarily medications, bandaging sup- airway handling.
plies, and splints (Table 4.6). After the NASA-1 (March 14 to July 7, 1995)/Mir-18
Other diagnostic and medical monitoring equipment that mission, the Mir resupply kit was added to the MSMK
were available on board the Mir included both a manual and system. The Mir resupply kit included a pulse oximeter, a
an automatic blood pressure monitor; a 12-lead electrocardio- portable clinical blood analyzer, and additional IV fluid. The
graph; a rheoencephalograph; and devices to measure labo- Mir defibrillator, the cardiac drug kit, and the crew medical
ratory analysis values in blood (Reflotron) and urine (Urilux restraint system were added for the NASA-5 (May 15 to Octo-
analyzer). ber 6, 1997), NASA-6 (September 25, 1997 to January 31,
Throughout the joint U.S.-Russian NASA-Mir Program 1998), and NASA-7 (January 22 to June 12, 1998) increments.
(March 14, 1995 to June 12, 1998), the Mir space station was Items found in the MSMK are listed in Table 4.7.
sequentially home to seven NASA astronauts and witnessed
nine visiting US Space Shuttle missions (June 27, 1995 to
The International Space Station
June 12, 1998). To augment the Russian on-orbit medical
capability and to add a small degree of advanced life sup- NASA and the Russian Aviation and Space Agency each pro-
port capabilities to the medical capabilities already extant on vide medical equipment for the ISS. The NASA-provided
Mir, the Mir supplemental medical kit (MSMK) was devel- medical equipment is the crew health care system (CHeCS).
oped. Minimal redundancy was present between the MSMK, As well as supplying traditional medical kits to the ISS,
4. Spaceflight Medical Systems 83

TABLE 4.6. Contents of the Mir medical kits. TABLE 4.6. (continued)
Onboard Medications/Supplies Sydnocarb
Adhesive bandages, bactericidal Tolfisopam (Grandaxin)
Ammonia spirit (inhalant) Valerian extract
Aspirin Vitamin/mineral preparation (Pantogem)
Atropine sulfate Aseptic Medicine Kit
Bandage Brilliant green tincture
Belalgin (Analgin [dipyrone], belladonna, ethyl aminobenzoate, Ethyl alcohol
sodium hydrocarbinate) Iodine tincture
Caffeine Medicine for Burns and Injuries
Chloramphenicol (Levomycetin) Brilliant green tincture
Clemastine (Tavegil) Flucinar ointment (corticosteroid)
Dressing pack Ethyl alcohol
Furosemide (Lasix) Iodine tincture
Metapyrin (Analgin [dipryone]) Lincomycin ointment
Menthyl valerate (Validol) Lorindin C ointment (flumethasone, iodochlorhydroxyquinolone)
Methyluracil ointment Olasol spray (chloramphenicol, boric acid, ethyl aminobenzoate,
Nitrazepam (Radedorm) sea buckthorn oil)
Nitroglycerin (Nitrostat) Ophthalmic spatula
Oleandomycin/tetracycline (Oletrin) Sulfacetamide solution (Sulamyd)
Ophthalmic spatula Dressing Kit
Papaverine (Papazol) Bandage, 5 cm 7 cm
Perphenazine (Aethaperazine) Bandage, adhesive
Phenibut (beta-phenyl-gamma-aminobutyric acid) Bandage, adhesive, bactericidal
Potassium/magnesium asparaginase (Panangin, Asparcam) Bandage, elastic
Promedol (trimeperidine) Dressing pack
Scissors Gauze, 14 cm 16 cm
Senadexin (Senokot, Senade) Gauze, 45 cm 29 cm
Sulfadimethoxine (Madribon) Scissors
Tetracycline ointment Tampons, cotton
Tusuprex (Libexin, prenoxdiazine hydrochloride) Waxed paper
Verapamil (Isoptin) Antiphlogystic Medicine Kit #1
Splint Kit Aspirin
Splints (12) Clemastine (Tavegil)
Bandage (4) Diclofenac (Voltaren)
Tourniquet Dipyrone (Analgin)
Cardiovascular Medicine Kit Erythromycin
Ammonia spirit (inhalant) Pyrabutol (phenylbutazone, amidopyrine, dimethylaminoantipyrine)
Atropine sulfate injection Sulfadimethoxine (Madribon)
Menthyl valerate (Validol) Tetracycline/oleandomycin (Oletetrin)
Moricizine HCl (Ethmozine) Tusuprex (Libexin, prenoxdiazine hydrochloride)
Nitroglycerin (Sustac Forte) Antiphlogystic Medicine Kit #2
Nitroglycerin (Trinitrolong) Ascorbic acid
Papaverine (Papazol) Camphomen aerosol
Potassium/magnesium asparaginase (Panangin) Capsicum plaster
Propranolol (Anaprilin) Cefecon suppositories (salicylamide, caffeine, amidopyrine, phenacetin)
Trimeperidine (Promedol) Ethyl alcohol
Gastrointestinal and Urologic Kit Nozzle
Atropine sulfate 1% injection Sulfacetamide solution (Sulamyd)
Baralgin (Analgin plus antispamodics) Xylometazoline (Xilomesolin)
Charcoal, activated (Carbolen) Antiphlogystic Medicine Kit #3
Nifuroxazide (Ercefuryl) Ascorbic acid
Nitroxoline Ampicillin/oxacillin (Ampiox)
Senadexin (Senokot, Senade) Bromehexine expectorant
Sodium carbonate Doxycycline (Vibramycin)
Triamterene (Triampur) Nystatin
Trimeperidine (Promedol) Rimantadine
Trimethoprim/sulfamethoxazole (Bactrim) Antiphlogystic Medicine Kit #4
Vitamin K (Vicasol) Ethyl alcohol
Psychotropic Medications Faringosept
Glutaminic acid Fluoroquinolone (Taravid)
Nitrazepam (Radedorm) Gauze pads
Phenibut (beta-phenyl-gamma-aminobutyric acid) Sofradex drops (Neomycin B, gramicidin, dexamethasone)
Phenazepam Syringes
Pyritinol (Encephabol) Syringe needles
(continued) (continued)
84 T.A. Taddeo and C.W. Armstrong

TABLE 4.6. (continued) TABLE 4.6. (continued)


Tampons, cotton Aural probe with thread
Prophylactic Medicine #1 Aural speculum, large
Potassium/magnesium asparaginase (Asparcam) Brilliant green tincture
Potassium orotate (Orotas) Catheter
Riboxine (Inosin-F) Camphomen aerosol
Prophylactic Medicine #2 Ethyl alcohol
Lactobacillus acidophilus/colibacillus (Bifidobacterium) Faringosept
Levamisole (Decaris) Forceps, bayonette
Prophylactic Medicine #3 Forceps, nasopharyngeal extraction
Piracetam (Nootropil) Forceps, ophthalmic
Ointment Kit Gauze pads
Bandage Gentamycin sulfate (Garamycin)
Clostridil peptidase/chloramphenicol (Iruxol) Illuminator/protective cover, spare bulb
Nonivamide/nicoboxil (Finalgon) Laryngeal mirror
Solcoseryl ointment Light guide, nasal
Spatula, plastic Lorindin C ointment (fulmethasone iodochlorhydroxyquinolone)
Troxevasin gel Metapyrin (Analgin)
Aspro Kit Ophthalmic extraction instrument
Aspirin Ophthalmic loop
Aspirin dissolvable tablets Ophthalmic spatula
Aspirin/caffeine (Aspro S Forte) Scissors, blunt
Scissors Slit lamp (nozzle)
Emergency Kit #1 Sulfacetamide solution (Sulamyd)
Atropine sulfate injection Sulfadimethoxine (Madribon)
Ethyl alcohol Tampons, cotton
Gauze pads Tetracycline ophthalmic ointment
Lincomycin ointment (Linocin) Turunda, anterior nasal tamponage
Scissors Turunda, posterior nasal tamponage
Trimeperidine HCl (Promedol) Turunda, ear
Emergency Kit #2 Vitamin K (Vicasol)
Adrenaline 0.1% (epinephrine) Xylometazoline (Xilomesolin)
Ampule saw Stomatologic (Dental) Kit
Atropine sulfate Aspirin
Baralgin (Analgin plus antispasmodics) Cement spatula
Bendazol HCl (Dibasol) Cutters
Caffeine Dental drill
Dexamethasone (Dexacon) Dentine paste
Diazepam 0.5% (Relanium, Valium) Drills, hand-operated
Drofaverine 2% (Nospa) Ethyl alcohol
Enclosure bag for manipulations Excavator, double-ended
Ethyl alcohol Extractor, type 33
Fentanyl 0.005% (Duragesic) Extractor, type 51A
Furosemide (Lasix) Flask, sterilized instruments
Gauze pads Forceps, curved dental
Lidocaine 2% (Xylocaine) Fuse
Lidocaine 10% (Xylocaine) Gauze pads
Metapyrin (Analgin) Indomethacin (Indocin)
Needles for injection Metapyrin (Analgin)
Nikethamide (Cordiamine) Nozzle, angled
Scissors Plugger
Sectioned pack Pulp extractors
Sulfocamphocaine (sulfocamphoric acid, procaine) Promecon (Emete-Con, benzquinamide)
Syringes Pyrcophen (dimethylaminoantipyrine, caffeine, analgin)
Syringes with needles Scraper, double-ended
Triplenamine (Suprastatin, chloropyramine) Smoother, double-ended
Vitamin K (Vicasol) Speculum, dental
Waste product pack Scalpel, dental
Otorhinologic and Ophthalmologic Kit Tampons, cotton
Adapter Tampons, small ball
Atropine sulfate Tooth probe, angled
Aural extraction instrument Triplenamine (Suprastatin, chloropyramine)
(continued) Source: Data courtesy of the Institute of Biomedical Problems, Moscow.
4. Spaceflight Medical Systems 85

TABLE 4.7. Contents of the Mir supplemental medical kits [15].


Name Description Amounta
Ace bandage 3 in. wide 2
Adaptic bandages 3-in. 3-in. nonadherent dressing 6
Afrin (nasal spray) 3-ml bottle 6
Air temperature monitors 3249C (90120F) 2
1331C (5888F) 2
Airway Oral 1
Alcohol wipes Ethyl alcohol 114
Alupent (metaproterenol)b 20 mg 30 tablets
Ambien (zolpidem tartrate) 10 mg 75 tablets
Ambu bag, O2 reservoir 1
Ambu mask 1
Ambu O2 tubing 1
Ambulatory leg bag 600-ml bag 1
Amikin (amikacin)b 250 mg/cc, 2-cc unit 2
Amoxil (amoxicillin)b 500 mg 24 capsules
60 tablets
Anusol-HC suppositories 6
Ascriptin (aspirin) 5 grain 50 tablets
Atropineb 1 mg/cc, 2-cc unit 3
AYR (saline nasal mist) 8-ml bottle 3
Bactrim DSb (trimethoprim/sulfamethoxazole) 56 tablets
Bactroban (mypirocin) ointment 2%, 30-g tube 1
Bags
Ziploc 12 in. 12 in. 2
Biohazard 6 in. 6 in. 10
Band-Aids 1 in. 3 in. 51
Bar-code index card 3
Batteries AA 2
Alkaline, 9 V 4
DC, 10 V (defibrillator) 3
Benadryl (diphenhydramine)b, injectable 50 mg/cc, 1-cc unit 5
Benadryl (diphenhydramine), oral 25 mg 50 capsules
Benzoin swabs 11
Blistex lip balm 1
Blood Analysis Items
Alcohol wipes Ethyl alcohol 20
Band-Aids 1 in. 3 in. 26
Battery Alkaline, 9 V 4
Biohazard bags 6 in. 6 in. 10
Capillary Tube Kit 1 kit
Capillary bulb 3
Capillary tube 26
Cartridges
EC6+ 27
EC8+ 9
Gauze pads 2 in. 2 in. 15
Gloves Nonsterile 10 pair
Lancet Finger 26
Portable clinical blood analyzer 1
Portable clinical blood analyzer control solutions
Level I Blue 3
Level II Red 3
Tubex injector 1 ml 2
Blood pressure cuff 1
Butterfly INT sets 19 G 2
21 G 4
Cardiac Drug Kit 1
Alcohol wipes Ethyl alcohol 4
Atropineb 1 mg/cc, 2-cc unit 1
Butterfly INT set 21 G 1
Dermicel tape 0.5 in. wide 1 roll
Epinephrineb 1:10,000, 10-cc unit 5
(continued)
86 T.A. Taddeo and C.W. Armstrong

TABLE 4.7. (continued)


Name Description Amounta
Heparinb 100 units/cc, 1-cc unit 1
Tubex injector 2 ml 1
Verapamil (Isoptin)b 2.5 mg/cc, 2-cc unit 1
with plunger 1
Xylocaine (lidocaine)b, cardiac 20 mg/cc, 5-cc unit 2
with plunger 1
Catheters
Intravenous intracatheters 14 G 2
18 G 5
20 G 8
Foley (bladder) 16 Fr, 5-ml balloon 2
Chemstrip 10-SG Urine test package 13 strips
Ciloxan (ciprofloxacin)b ophthalmic solution 0.3%, 2.5-ml bottle 3
0.3%, 5-ml bottle 1
Cipro (ciprofloxacin)b, oral 500 mg 48 tablets
Cotton balls 5 per pack 15
Cotton swabs 2 per pack 12
Cough lozenges 39 tablets
Cyclogyl (cyclopentolate)b 1%, 15-ml bottle 1
Dalmane (flurazepam) 15 mg 30 capsules
Debrox (urea hydrogen peroxide) 15-ml bottle 1
Defibrillator Resupply Kit
Batteries DC, 10 V 3
Electrocardiogram electrodes for electrocardiogram monitoring 4 sets
Multifunction electrodes 3 sets
Deltasone (prednisone)b 10 mg 100 tablets
Demerol (meperidine)b 50 mg/cc, 1-cc unit 5
Dental items
Carver file 1
Mirror 1
Needles Long, 27 G 6
Short, 27 G 6
Orangewood sticks 2
Syringe 1
Temporary filling 1
Toothache kit 1 kit
Eugenol anesthetic drops
Tweezers
Cotton pellets
Marcaine (bupivacaine)b 0.5% w/epinephrine 6 dental carpules
Dental floss Single-use packet 1
Dycal (base) 13-g tube 1
Dycal (catalyst) 11-g tube 1
Dermicel tape 1 in. wide 1 roll
0.5 in. wide 4 rolls
Dexedrine (dextroamphetamine)b 5 mg 30 tablets
Diamox (acetazolamide)b 500 mg 15 capsules
Dilantin (phenytoin sodium)b, injectable 50 mg/cc, 2-cc unit 10
Dilantin (phenytoin sodium)b, oral 100 mg 35 capsules
Drapes, sterile 40 cm 40 cm 2
Dulcolax (bisacodyl), oral 5 mg 30 tablets
Dulcolax (bisacodyl), suppository 10 mg 6
Duricef (cefadroxil)b 500 mg 20 capsules
Ear loop for earwax removal 1
Elastoplast tape 4 in. wide 1 roll
Entex LA (phenylpropanolamine/guafenesin) 75 mg of phenylpropanolamine hydrochloride, 400 mg of guafenesin 80 tablets
Epinephrineb 1:1000, 1-cc unit 8
1:10,000, 10-cc unit 5
Erythromycinb 250 mg 48 tablets
Eye pads 6
Flagyl (metronidazole)b 250 mg 28 tablets
Fluorescein strips 8

(continued)
4. Spaceflight Medical Systems 87

TABLE 4.7. (continued)


Name Description Amounta
Forceps
Small point Surgical Instrument Assembly 1
Blunt 2
Fox Shield Metallic eye patch 1
Gauze pads 4 in. 4 in. 27
2 in. 2 in. 15
Gloves Sterile, surgical 4 pair
Nonsterile 16 pair
Haldol (haloperidol)b 5 mg/cc, 1-cc unit 2
Hemostats
Small Surgical Instrument Assembly 1
Curved 1
Heparinb 100 units/cc, 1-cc unit 11
Hexadrol (dexamethasone)b 10 mg/cc, 1-cc unit 2
with plunger 2
Imodium (loperamide HCl) 2 mg 64 capsules
Injector (Tubex) 2 ml 4
1 ml 2
Irrigation assembly, roller clamp 1
Isoptin (verapamil)b with plunger 2.5 mg/cc, 2-cc unit 3
2
Intravenous administration set 3
Kenalog cream 15-g tube 2
Kling 3 in. wide 4 rolls
Laryngoscope Handle w/Miller blade 1
Lasix (furosemide)b 10 mg/cc, 2-cc unit 5
Lotrimin cream (clotrimazole) 15-g tube 2
Lubricant (water-soluble) 3g 9
Magill forceps 1
Magnifying glass Magnification 4 1
Medical data logs 6 expanded
Merocel Pope (posterior nasal packing) 10 cm 3
Milk of Magnesia 60 tablets
Morphine sulfateb 10 mg/cc, 1-cc unit 6
Motrin (ibuprofen) 400 mg 100 tablets
Mylanta Double Strength 24 tablets
Narcan (naloxone)b 0.4 mg/cc, 1-cc unit 2
Nasostats 2
Needles 22 G, 1.5 in. 4
18 G, 1.5 in. 4
16 G, 1.5 in. 2
Needle holder Surgical Instrument Assembly 1
Neosporin Plus cream with lidocaine 0.5-oz tube with 1
40 mg lidocaine
Nitroglycerin patchb 15 mg/24 h 1
Nitrostat, sublingualb (nitroglycerin) 0.4 mg (1/150) 25 tablets
One-way valve and connecting tube 1
Ophthalmoscope head 1
Otoscope 1
Otoscope speculum Disposable 10
Penrose tubing (tourniquet) 2
Pepto Bismol 48 tablets
Phazyme-125 (simethicone) 125 mg 20 capsules
Phenerganb, injectable (promethazine) 50 mg/cc, 1-cc unit 4
Phenergan, oral (promethazine) 25 mg 30 tablets
Phenergan, suppository (promethazine) 25 mg 14
Polysporin (polymyxin/bacitracin) 1-oz tube 2
Pope Otowicks 6
Povidone-iodine (Betadine) swabs 35
Pred Forte (prednisone acetate)b ophthalmic solution 1%, 5-ml bottle 2
Prilosec (omeprazole)b 20 mg 60 tablets
Proparacaine eye dropsb 5%, 15-ml bottle 1
Proventil (albuterol) inhaler 17-g container 1
(continued)
88 T.A. Taddeo and C.W. Armstrong

TABLE 4.7. (continued)


Name Description Amounta
Pulse Oximetry Kit 1 kit
Adhesive finger sensor 2
POx instruction card 1
POx data card 1
Reusable finger sensor 1
Pulse oximeter 1
Pyridium (phenazopyridine) 200 mg 35 tablets
Refresh (artificial tears, eye drops) 0.3 ml 20
Restoril (temazepam) 15 mg 40 capsules
Saline 100 ml 1
250 ml 2
500 ml 3
Salt tablets (NaCl) 1g 20 tablets
Scalpels #10 3
#11 2
Scissors (curved) Surgical Instrument Assembly 2 pair
1 pair
Seldane (terfenadine) 60 mg 56 tablets
Silvadene cream (silver sulfadiazine) 20-g tube 2
Silver nitrate sticks 5
Skin temperature monitors 2941C (84106F) 15
Soma (carisoprodol)b 350 mg 25 tablets
Steri-Strip skin closures 4
Stethoscope 1
Suction Items
Suction cartridge 1
Suction collection bag 7 in. 6 in. 2
70-cc syringe 1
Suction tip 2
Sudafed (pseudoephedrine) 30 mg 180 tablets
Surgical Instrument Assembly 1 kit
Forceps (small point)
Needle holder
Hemostat (small)
Tweezers (fine point)
Scissors (curved)
Suture 4-0 Dexon, with needle 1
5-0 Ethilon, with needle 1
4-0 Ethilon, with needle 2
3-0 Ethilon, with needle 2
2-0 Vicryl with CT-1 needle 1
Syringes 10 cc 3
3 cc 1
70 cc 1
Tears Naturale (eye drops) 30-ml dropper bottle 1
Tegaderm (transparent dressing) 10 cm 12 cm 5
6 cm 7 cm 5
Telfa pads 3 in. 4 in. 8
Thermometers, disposable, oral 35.540.4C (96104F) 18
Tobrex (tobramycin)b ophthalmic solution 0.3%, 5-ml bottle 1
Tongue depressors Sterile 10
Toradol (ketorolac tromethamine)b 30 mg/cc, 2-cc unit 2
Tracheal tube 7.5 mm with stylet 1
8.0 mm with stylet 1
Tracheostomy tube 5.5 mm cuffed 1
Tweezers (fine point) Surgical Instrument Assembly 1
Tylenol (acetaminophen) 325 mg 90 tablets
Tylenol #3 (acetaminophen with codeine)b 30 mg of codeine and 40 tablets
300 mg of acetaminophen
Urine Test Package 1 kit
Chemstrip 10-SG 13 strips
Color chart 1

(continued)
4. Spaceflight Medical Systems 89

TABLE 4.7. (continued)


Name Description Amounta
Valium (diazepam)b, injectable 5 mg/cc, 2-cc unit 2
Valium (diazepam)b, oral 5 mg 30 tablets
Vancocin (vancomycin)b 250 mg 28 capsules
VIRA-A (vidarabine ophthalmic ointment)b 3%, 3.5-g tube 1
Voltaren (diclofenac sodium) 50 mg 60 tablets
VoSol HC otic solution 10-ml bottle 1
Xylocaine (lidocaine)b with epinephrine 2% with epinephrine 1:100,000, 2-cc unit 2
Xylocaine (lidocaine)b 2%, 2-cc unit 2
Xylocaine (lidocaine)/cardiac with plungerb 20 mg/cc, 5-cc unit 6
Zithromax (azithromycin)b 250 mg 18 caplets
Zovirax (acyclovir)b ointment 15-g tube 1
a
Not all medications were carried in the amounts noted on all flights.
b
Indicates item to be used only after surgeon approval or as directed in checklist.

CHeCS incorporates exercise and monitoring equipment Toxicology hardware includes the formaldehyde moni-
and environmental monitoring hardware. CHeCS consists tor kit, grab sample containers, the solid sorbent air sampler,
of three subsystems: the countermeasures system (CMS), the carbon dioxide monitor kit, compound specific analyzer-
the environmental health system (EHS), and the health combustion products, and the volatile organic analyzer. In-
maintenance system (HMS). flight and archival sampling capabilities are also provided.
The CHeCS CMS consists of exercise hardware and Acoustic hardware includes an audio dosimeter, a sound
monitoring devices. Exercise hardware includes a treadmill, level meter, and an acoustics countermeasures kit. ISS
a resistive exercise device, and a cycle ergometer. A portable crewmembers are provided with custom-molded filtering and
computer, a heart rate monitor, and a blood pressure/electro- non-filtering ear plugs, as well as with noise-conditioning
cardiogram monitor make up the monitoring devices. In addi- headsets. Noise levels on the ISS are monitored as needed.
tion to daily exercise, crewmembers using the countermeasures The HMS is designed to support routine minor medical
system perform a fitness evaluation periodically to monitor needs, similar to ground first-aid, as well as basic and advanced
their fitness levels, determine what degree of deconditioning life support for a crew of three for up to 180 days. Six compo-
has occurred, and modify their daily exercise prescription as nents make up the HMS. The first component, the ambulatory
needed. medical pack, provides for daily needs and periodic health
The EHS provides hardware with which to monitor the examinations. The second component, the crew contamina-
water, surfaces, and atmosphere of the ISS, aspects of the tion protection kit, protects the crew in the event of a toxic
ISS environment that are essential to crew health. The EHS spill or contamination. The remaining four componentsthe
is subdivided into water quality, microbiology, radiation, toxi- advanced life support pack, the crew medical restraint system,
cology, and acoustic monitoring. a defibrillator, and the respiratory support pack (Figure 4.8)
The water quality hardware includes the total organic car- provide for advanced life support and transport. The contents
bon analyzer and the water sampler and archiver kit. These of the ambulatory medical pack and the advanced life support
items provide in-flight and archival analysis of ISS potable pack are listed in Table 4.8.
water. The Russian medical support system is provided by the
Microbiology hardware includes the water microbiology Russian Aviation and Space Agency. This assemblage is
kit, the surface sampler kit, and the microbial air sampler. very similar to the Mir medical system, and consists of mul-
The microbiology kits enable in-flight analysis of total colony tiple problem-oriented medical kits, medical monitoring
count in potable water as well as counting bacteria and fungi equipment, and countermeasures hardware. The overall system
on surfaces and in the atmosphere. can be divided into six major subsystems: first-aid equipment,
Radiation hardware includes the tissue equivalent propor- medical monitoring and observation hardware, microgravity
tional counter, the intravehicular-charged particle directional countermeasures equipment, an individual dosimetric moni-
spectrometer, the extravehicular-charged particle directional toring system, station cleaning and atmospheric monitoring
spectrometer, high rate dosimeters, radiation area monitors, equipment, and sanitary-hygiene support equipment.
and crew passive dosimeters. These devices provide the means The contents of the first-aid equipment subsystem are listed
for active and passive radiation monitoring. in Table 4.9.
90 T.A. Taddeo and C.W. Armstrong

Biomedical Crew Training


As a means of preparing for early crewed space flight, bio-
medical crew training was a product of military aviation
medicine, focused primarily on the physiological aspects of
high-speed and high-altitude flight. Flight training involved
exposing crewmembers to extreme conditions such as jungle
and desert environments (as part of survival training), centri-
fuges, altitude chambers, and a motion-based simulator [9].
As crew size, mission duration, and onboard medical capa-
bilities increased, biomedical training began to focus more on
medical treatment. For the three crewed Skylab missions, two
CMOs were assigned to each crew. The prime and backup
CMOs received 80 h of medical training at military and civil-
ian medical facilities. Training ranged from basic physical
examination and blood drawing techniques to supervised
FIGURE 4.8. ISS Health Maintenance System. Components include medical care in a local emergency department [17].
(from left) defibrillator, Advanced Life Support Pack, Respiratory All Space Shuttle crewmembers receive between 8 and
Support Pack, and Crew Medical Restraint System (Photo courtesy 11 h of medical instruction as part of mission-specific train-
of NASA). ing, including space physiology, CO2 exposure training,

TABLE 4.8. Contents of the Ambulatory Medical Pack and Advanced Life Support Pack [16].
Name Description Amounta
16-G catheter 16 g 1.25 in. 2
18-G catheter 18 g 1.25 in. 2
20-G catheter 20 g 1.25 in. 2
3-cc syringe with 22-g needle 2
10-cc syringe 1
20-cc syringe 1
Ace bandage 3 in. 2
Adaptic dressing 3 in. 3 in. 6
Adenocard (adenosine)b 2 ml @ 3 mg/ml 3
Afrin nasal spray 3-ml bottle 20
Air Temperature Monitors OMNI Air Temp Monitor
90120F 2
5888F 2
Alcohol pads 106
Ambien (zolpidem)b 10 mg 50 tablets
AMBU bag 1
Amikacinb 2 ml @ 250 mg/ml 4
Amoxil (amoxicillin)b 500 mg 84 tablets
Anusol HC (hydrocortisone) 25-mg suppositories 6
Articulating paper 1 pkg
Ascriptin (aspirin) 325 mg 150 tablets
Atropineb 2 ml @ 1 mg/ml 2
Automatic blood pressure cuff Lumiscope model #1085-M 1
Ayr Saline Mist 8-ml bottle 10
Bactrim DS (cotrimoxazole)b Double strength 56 tablets
Bactroban cream 30-g tube 1
Bandage scissors 2
Band-aids 3 in. 1 in. 100
Band-aids Sheer Spot 26
Benadryl (diphenhydramine) 25 mg 50 capsules
Benzoin swabs 20
(continued)
4. Spaceflight Medical Systems 91

TABLE 4.8. (continued)


Name Description Amounta
Blistex lip balm 0.14-oz tube 1
Blood pressure cuff Cuff w/aneroid sphygmomanometer 2
Bretyliumb 10 ml @ 50 mg/ml 2
Butterfly needles 21 g 2
23 g 2
Capillary bulbs 3
Capillary tubes with protective sheath 32
Carver/file 1
Catheters 14 G, 2 in. 2
Chemstrip 10 with specific gravity (SG) and color chart Dipstick 3 pkg
Chest drain valve Heimlich 1
Ciloxan ophthalmic solution (ciprofloxacin)b 0.3%, 2.5 ml 3
Cipro (ciprofloxacin)b 500 mg 48 tablets
Claritin (loratadine) 10 mg 28 tablets
Compazineb 25-mg suppositories 14
Cotton balls 40
Cotton swabs 13 packages
Cough lozenges (dextromethorphan) 0.5 mg 54
Cyclogyl (cyclopentolate)b ophthalmic solution 2%, 15-ml bottle 1
D5W solution dextrose solution, 500 ml 1
Debrox otic drops 15-ml bottle 1
Deltasone (prednisone)b 10 mg 100 tablets
Dental elevator size 301 1
size 34 1
Dental floss single-use package 1
Dental forceps size 17 1
size 151A 1
size 10S 1
Dental mirror 1
Dental syringe Technitouch syringe 1
Dexamethasoneb 1 ml @ 10 mg/ml 2
2 ml @ 0.4 mg/ml 2
Dexedrine (dextroamphetamine)b 5 mg 10 tablets
Diamox (acetazolamide)b 250 mg 50 tablets
Diazepamb 2 ml @ 5 mg/ml 3
Diflucan (flurazepam) 150 mg 3
Dilantin (phenytoin) 100 mg 35 tablets
Diphenhydramineb 1 ml @ 50 mg/ml 3
Dopamineb 400 mg/500 cc D5W 1
Dulcolax (bisacodyl) 10-mg suppositories 6
Dulcolax (bisacodyl) 5 mg 30 tablets
Duricef (cefadroxil)b 500 mg 40 capsules
Dycal Base 13 g 1
Dycal catalyst 11 g 1
Ear curettes 2
Elastoplast tape 2.5 yards 1
Electronic simulator for portable clinical blood analyzer 1
Entex LA (phenylpropanolamine/guafenesin) 400 mg 80 tablets
Epinephrineb 1 ml @ 1:1000 3
Epinephrine, cardiacb 10 ml @ 0.1 mg/ml 5
Endotreacheal tubes 7.0 mm with stylet 1
8.0 mm with stylet 1
Explorer/probe size 23/11 1
Eye pads 6
Eye shield Fox metallic shield 1
Fingersplint 1
Fingerstix single-use, sterile 30
Flagyl (metronidazole)b 250 mg 28 tablets
Fluorescein strips FUL-GLO Fluorescein sodium 8
Foley catheters 16 Fr, 30-ml balloon 2
Furosemideb 2 ml @ 10 mg/ml 10

(continued)
92 T.A. Taddeo and C.W. Armstrong

TABLE 4.8. (continued)


Name Description Amounta
Gauze pads 4 in. 4 in. 57
Haldol (haloperidol)b, injectable 2 ml @ 5 mg/ml 2
Haloperidolb, oral 5 mg 400 tablets
Hemostat size 5.5 in., curved, Kelly 1
Imodium (loperamide) 2 mg 64 capsules
Inderal (propanolol)b 20 mg 24 tablets
Intubation bulb esophageal detector device 1
Iodine pads 1% 10
Intravenous administration sets (powered) IMED 2
Intravenous administration sets (not powered) 2
Intravenous flowmeter 0250 ml/h 1
Intravenous infusion device 11,000 ml/h 1
Intravenous Kit 1 kit
Intravenous administration set (nonpowered)
Y-type catheter
Lever lock cannula
18 g catheter
Cue card
Intravenous pressure infusor 1L 1
Kenalog cream (triamcinolone) 0.1%, 15-g tube 2
Kenalog in Orabase 0.1%, 5-g tube 1
Kerlix dressing 4.5 in. 2
Kling dressing 3 in. 7
Laryngoscope blade Macintosh, Size 3 1
Laryngoscope handle Pediatric 1
Leg bag 600 ml 1
Lever lock cannulas Interlink 5
Lidocaineb 5 ml @ 20 mg/ml 3
Long needles 27 g, 1.25 in. 6
Lotrimin (clotrimazole) cream 15-g tube 2
Lubricant sterile, Surgi-Lube 4
Magill forceps Adult 1
Magnifying glass 5 magnification 1
Meperidineb 1 ml @ 50 mg/ml 6
2 ml @ 50 mg/ml 4
Milk of magnesia 80 tablets
Morphineb 1 ml @ 10 mg/ml 6
2 ml @ 10 mg/ml 3
Motrin (ibuprofen) 400 mg 70 tablets
Mouth/throat mirrors laryngeal mirror, size 3 2
Mylanta DS double-strength 100 tablets
Narcan (Naloxone)b 2 ml @ 0.4 mg/ml 2
Nasal airway 7 mm 1
Nasogastric tube 14 Fr 1
Needles 18 G, 1.5 in. 2
Neosporin Plus cream with lidocaine 1
0.5-oz tube
Nitroglycerin patchesb 15 mg/24 h (0.6 mg/h) 3
Nitrostat (nitroglycerin tablets)b 0.4 mg 25 tablets
Nonsterile gloves Latex, large 8 pair
Nortriptylineb 50 mg 400 capsules
Ophthalmoscope head 1
Ophthalmoscope spare bulb 1
Oral airway 90 mm 1
Otoscope 1
Otoscope spare bulb 1
Otoscope specula plastic 20
Ovral-21 (norgestrel/ethinyl estradiol) 42 tablets
Portable Clinical Blood Analyzer
Control ranges card 1
Control solution kit 1 kit
Control solutions
BK wipes

(continued)
4. Spaceflight Medical Systems 93

TABLE 4.8. (continued)


Name Description Amounta
Band-aids
Tubex injector
Gauze pads
Peak flow meter Spir-O-Flow pocket monitor 1
Penlight model #1000186 2
Pepto Bismol 48 tablets
Phazyme (simethicone) 125 mg 80 gel caps
Phenergan (promethazine)b 25 mg 30 tablets
1 ml @ 50 mg/ml 6
Phenytoinb 2 ml @ 50 mg/ml 10
Polysporin (polymyxin/bacitracin) ointment 1-oz tube 2
Polytrim ophthalmic solution 10-ml bottle 1
Pope otowicks 6
Pope posterior nasal packing 10 cm, Merocel 3
Portable clinical blood analyzer i-STAT 1
Povidone-iodine (Betadine) swabs single-use swabs 32
Pred Forte ophthalmic solution (prednisone acetate)b 1%, 1-ml bottle 1
Prilosec (omeprazole)b 20 mg 30 capsules
Proparacaine ophthalmic solutionb 0.5%, 15-ml bottle 1
Proventil inhalerb 17 g albuterol 2
Prozac (fluoxetine Hydrochloride)b 20 mg 400 capsules
Pulse oximeter transducers Oxisensor II, D-25 2
Pulse oximeter with finger sensor Nellcor 1
Pyridium (phenazopyridine) 200 mg 20 tablets
Reflex hammer 1
Refresh ophthalmic solution (artificial tears) single-use vials 20
Restoril (temazepam)b 15 mg 80 capsules
Resuscitation mask Respironics 1
Romazicon (flumazenil)b 2 ml @ 0.1 mg/ml 4
Saline solution 0.9% NaCl
100-ml bag 1
500-ml bag 2
1-L bag 3
SAM splint 36-in. 4.5-in. splint, instruction pamphlet 1
Scalpel #10 3
#11 2
Sharps container Lexan box 1
Short needles 27 g, 0.75 in. 6
Silvadene cream (silver sulfadiazine) 1%, 20-g tube 2
Silver nitrate sticks package of 5 2 pkg
Skin staple remover 6.0 in. 2.5 in. 1
Skin stapler Precise 15 shot 2
Skin temperature monitor crystalline temperature trend indicator 84106F 15
Sponges 5-in. 9-in. hermitage dressing 4
Sodium chloride 1g 128 tablets
Soma (carisoprodol)b 350 mg 25 tablets
Sterile drape 40 cm 40 cm 4
Sterile gloves size 8 5 pair
Steri-strips (skin closure) 0.25 in. 4 in. 6 pkg
0.5 in. 4 in. 2 pkg
Stethoscope 2
Stethoscope earpieces spare earpieces 2
Suction curette tip 1
Suction device 1
Suction device collection bags 2
Suction device ET catheter with Tygon tubing 1
Suction device syringe 70 cc 1
Sudafed (pseudoephedrine)b 30 mg 180 tablets
Surgical Instrument Assembly 1 kit
Forceps (2)
Hemostats (2)
Needle driver (1)

(continued)
94 T.A. Taddeo and C.W. Armstrong

TABLE 4.8. (continued)


Name Description Amounta
Iris scissors (1)
Surgical Instrument Assembly 1 kit
Forceps (2)
Hemostats (2)
Needle Driver (1)
Sutures w/needle
4-0 Dexon 1
5-0 Ethilon 1
4-0 Ethilon 4
3-0 Ethilon 2
2-0 Vicryl 1
Syringe 10 cc, with Luer lock 2
Tape 0.5-in. roll 1
1-in. roll 5
Tears Naturale 30-ml bottle 1
Tegaderm dressing occlusive dressing 16
Telfa pads 3 in. 4 in. 13
Tempadot disposable thermometers 35.540.4C, oral, disposable 36
Temporary filling (Cavit) tube 1
Tobrex ophthalmic solutionb 0.3%, 5-ml bottle 1
Tongue depressors wooden, sterile 20
Tonopen tip covers Latex 18
Tonopen tonometer model #23 1
Toothache Kit 1 kit
Eugenol
Cotton pellets
Tweezers
Toprol XL (metoprolol succinate)b 50 mg 20
Toradol (ketorolac tromethamine)b 2 ml @ 30 mg/ml 2
Tourniquet Penrose tubing 1
Tracheostomy tube cuffed, 5.5 mm 1
Tubex injector plastic 3
Tylenol (acetaminophen) 325 mg 300 tablets
Urinary straight catheters 16 Fr 2
Urine human chorionic gonadotropin detector 2
Urocit-K (potassium chloride)b 10 meq 45
Valium (diazepam)b, oral 5 mg 30 tablets
Vancocin (vancomycin)b 250 mg 28 tablets
Vaseline gauze 3 in. 18 in., sterile 2
Vasocidin ophthalmic ointmentb 3.5-g tube 1
Verapamilb 2 ml @ 2.5 mg/ml 3
Vicodin (hydrocodone)b 5 mg 36 tablets
VIRA-A (vidarabine)b ophthalmic ointment 3%, 3.5-g tube 1
Visual acuity card 1
Voltaren (diclophenac) 50 mg 60 tablets
VoSol HC otic solution 10-ml bottle 1
Xylocaine (lidocaine) jellyb 5 ml @ 20 mg/ml (2%) 1
Xylocaine with epinephrineb carpules, 2%, 1:100,000, 1.8 ml 10
Y-type catheters Interlink system Y-type catheter extension sets 2
Ziplock bags 8 in. 8 in. 7
12 in. 12 in. 8
Zithromax (azithromycin)b 250 mg 20 tablets
Zovirax ointment (acyclovir)b 5%, 15-g tube 1
a
Not all medications were carried in the amounts noted on all flights.
b
Indicates item to be used only after surgeon approval or as directed in medical checklist.
4. Spaceflight Medical Systems 95

TABLE 4.9. Medical support system first aid equipment.


Name Description Amount
Anti-Inflammatory Agents-1 Kit
Aspirin
Oletetrin [tetracycline/oleandomycin, Sigmamycin] 125,000 units 120 tablets
Analgin [dipyrone, Novaldin] 0.5 g 56 tablets
Artrotek 16
Tavegil [Suprastin, clemastine fumarate, chloropyramine] 30 tablets
Voltaren (diclofenac)/indomethacin/ortophen TBD
Erythromycin 0.1 g 68 tablets
Tusuprex [Oxeladin, Libexin, prenoxdiazine hydrochloride] 0.01 g 48 tablets
Sulfadimethoxine (Madribon) 0.5 g 56 tablets
Anti-Inflammatory Agents-2 Kit
Cametonum arosolum 1
Pepper plaster 3 packs
Cefeconum suppositories 15 units
Ethyl alcohol 6 test tubes
Sulfacetamide sodium solution [Albucid-natricum] 20% 2 squeezable droppers
Halazolin [Otrivin] 0.05% 2 units
Tsiprolet 80
Anti-Inflammatory Agents-3 Kit
Ampiox [ampicillin/oxacillin] 0.25 g 81 capsules
Doxycycline hydrochloride [Vibramycin] 0.05 g 18 capsules
Nystatin 500,000 units 36 tablets
Ascorbic acid 0.5 g ~48 tablets
Rimantadine 0.05 g 33 tablets
Bromhexine [Bisolvon] 0.008 g or 0.004 g 33 tablets
Anti-Inflammatory Agents-4 Kit
Falimint (5-nitro-2-propoxyacetanilide) 80 tablets
Sofradex (Neomycin B, gramicidin, dexamethasone) 2 bottles
Ethyl alcohol 2 test tubes
Disposable injection needles 2 units
Disposable injection syringes 2 units
Wipes 14 cm 16 cm 2 units
Cotton balls 3 packs
Tarivid [ofloxacin] 200 mg 27 tablets
Pharyngosept [ambazone] 0.1 g 63 tablets
Antiseptic Remedies Kit
Iodine solution 5%, 0.8 ml 14 test tubes
Viride nitens solution 1% 14 test tubes
Ethyl alcohol 28 test tubes
Aspro (Aspirin) Medical Kit
Aspirin (tablets) 45
Aspirin (water-soluble tablets) 24
Aspirin, Cardio 100 mg, 300 mg 90
Scissors 1 pair
Burns and Wounds Kit
Olasol (chloramphenicol, boric acid, ethyl aminobenzoate, sea buckthorn oil) 3 aerosols
Lorinden C ointment 15.0 g 1 tube
Methyluracil ointment 10% (10 g) 1 tube
Flutsinar ointment 0.025% (15 g) 1 tube
Viride nitens solution 1% 3 test tubes
Iodine solution 5% (0.8 ml) 14 test tubes
Ethyl alcohol 3 test tubes
Spatula for applying ointment to the eyes 1 unit
Lincomycin/erythromycin ointment 15 g 1 tube
Sulfacetamide sodium solution [Albucid-natricum] 20% 2 squeezable droppers
Gentamicin sulfate solution [Garamycin] 2
Cardiovascular Remedies Kit
Kardiket 20
Validol [menthyl valerate] 0.06 g 18 tablets
Sustac forte [Nitro-Mac retard] 6.4 mg 16 tablets
Aetmozinum 0.1 g 80 tablets
Papazol (papaverine) 34 tablets

(continued)
96 T.A. Taddeo and C.W. Armstrong

TABLE 4.9. (continued)


Name Description Amount
Anaprilin [inderal] Obsidan 0.04 g 48 tablets
Isoptin [verapamil, Finoptin] 40 mg 66 tablets
Athenolol 40
Trinitrolong [nitroglycerin] 0.0010.002 g 10 patches
Ammonium hydroxide [spirit of ammonia] 10% 3 test tubes
Aethacizinum 0.05 g 48 tablets
Atropine 0.1% (1.0 ml) 6 squeezable syringes
Enapren [enalapril] 0.01/0.02 (g) ~20
Dressing Pack
Bandages 5 in. 7 in. 2 units
Bandages 5 in. 5 in. 2 units
Adhesive plaster 1 unit
Wipes 14 in. 16 in. 6 units
Wipes 45 in. 29 in. 2 units
Pack of dressings 3 units
Bactericidal adhesive plaster 20 units
Ace bandage (#1 and #2) 3 units
Cotton balls 2 packs
Scissors 1 unit
Compress paper 1 sheet
Emergency First-Aid Medical Kit
Lidocaine 2% (2 ml) 5 ampoules
Adrenaline 0.1% (1 ml) 2 ampoules
Nospa [Drofaverine] 2% (2 ml) 6 ampoules
Relanium (diazepam) 0.5% (2 ml) 4 ampoules
Sulfocamphocainum (sulfocamphoric acid, procaine) 10% (2 ml) 2 ampoules
Cordiamine [nikethamide] 2 ml 2 ampoules
Lasix 6 ampoules
Lidocaine 10% (2 ml) 4 ampoules
Caffeine 2 ampoules
Baralgin 5 ml 6 ampoules
Dibazolum [bendazole hydrochloride] 1% (2 ml) 3 ampoules
Analgin [Novaldin] 50% (2 ml) 3 ampoules
Vicasol (vitamin K) 1% (1 ml) 4 ampoules
Platyphyllin [papaverin] 0.2% (1 ml) 3 ampoules
Suprastin [chloropyramine] 2% (1 ml) 3 ampoules
Dexamethasone/prednisolone [Dacortin] 5 ampoules
Ethyl alcohol 30 test tubes
Gauze pads x 30 units
Atropine 0.1% (1 ml) 8 squeezable syringes
Scissors 1 unit
Bag for handling 2 units
Syringes with needle 2 ml 42 units
Syringes with needle 5 ml 6 units
Needles 90 units
Waste packet 48 units
Appliance for opening ampoules (file) 48 units
Package with section dividers 15 units
Gastrointestinal And Urologic Remedies Kit
Soda 0.5 g 24 tablets
Senadexin (Senokot, Senade) 48 tablets
Carbolen [activated charcoal] 0.25 g 32 tablets
Biseptolum [Bactrim] 480 70 tablets
Ercefuril [Imodium, loperamide HCl) 27 capsules
Baralgin 56 tablets
Nitroxoline 0.05 g 48 tablets
Triampur (triamterene) 33 tablets
Vicasol (vitamin K) 0.015 g 16 tablets
Atropine 0.1% (1 ml) 6 squeezable syringes
Ointment Kit
Solcoseryl ointment 20 g 2 tubes
Troxerutin gel [Venoruton] 2% (40 g) 2 tubes
(continued)
4. Spaceflight Medical Systems 97

TABLE 4.9. (continued)


Name Description Amount
Finalgon ointment [nonivamide and butoxyethyl nicotinate] 15.0 g 2 tubes
Plastic plates 2 units
Bandages 2 units
Heparin ointment [Liquaemin] 1 tube
Zovirax (eye ointment) 1 tube
Zovirax cream 1 tube
Kelestoderm (cream/ointment) 1
Onboard Pharmacy Kit
Radedorm [nitrezepam] 0.01 g or 0.005 g 9 tablets
Tavegil [clemastine fumarate, Suprastin, chloropyramine] 9 tablets
Fenibut [beta-phenyl-gamma-aminobutyric acid] 0.25 g 16 tablets
Tusuprex [Oxeladin, Libexin, prenoxdiazine hydrochloride] 0.01 g 24 tablets
Panangin [Asparkam] [a preparation containing potassium and magnesium asparaginase] 16 tablets
Senadexin (Senokot, Senade) 24 tablets
Validol [menthyl valerate] 0.06 g 9 tablets
Analgin [Novaldin] 0.5 g 14 tablets
Aspirin 0.5 g 14 tablets
Madribon (sulfadimethoxine) 0.5 g 14 tablets
Levomycetin [chloramphenicol] 0.25 g 8 tablets
Oletetrin [Sigmamycin] 125,000 units 16 tablets
Caffeine 0.2 g 17 tablets
Isoptin [verapamil, Finoptin) 40 mg 16 tablets
Nitroglycerin [Anginine] 0.0005 g 25 tablets
Belalgin 16 tablets
Ammonium hydroxide [spirit of ammonia] 10% 1 test tube
Papazol 10 tablets
Tetracycline ointment 3g 1 tube
Methyluracil ointment 3g 1 tube
Bactericidal adhesive plaster 3.8 3.8 20 units
Bandages 1.5 6 5 units
Dressings 1 package
Scissors 1 pair
Spatulum for applying ointment to the eyes 1 unit
Atropine 0.1% (1 g) 4 squeezable syringes
Furosemide [Lasix] 6 tablets
Camphomen inhaler 1 unit
Preventive Remedies-1 Kit
Riboxine [Inosie F] 0.2 g 216 tablets
Panangin 112 tablets
Potassium orotate [Dioron] 0.5 g 112 tablets
Preventive Remedies-2 Kit
Vetoron TBD
Decaris [Ascaridil] 150 mg 24 tablets
Vitrum TBD
Essentiale TBD
Preventive Remedies-3 Kit
Nootropil (piracetam) 0.4 g 180 capsules
Preventive Remedies-4 Kit
Vitamins
Psychotropic Remedies Kit
Phenazepam 0.001 g 66 tablets
Fenibut [beta-phenyl-gamma-aminobutyric acid] 0.25 g 80 tablets
Persen 33
Radedorm [nitrazepam] 68 tablets
Pyritinol [Encephabol] 0.1 g 48 tablets
Rudotel (medazepam) 48
Glutamic acid 0.25 g 40 tablets
Grandaxin [tolfisopam] 50 mg 68 tablets
Pantogam [hopantenic acid] 0.25 g 16 tablets
Xanax [alprazolam] 40
Splint Kit
Splints 12 units

(continued)
98 T.A. Taddeo and C.W. Armstrong

TABLE 4.9. (continued)


Name Description Amount
Bandages 5 cm 10 cm 4 units
Tourniquet 1 unit
First Aid Kit [in the Portable Survival Kit]
Analgin (tablets) Item 1 10
Tetracycline (lozenges) Item 2 16
Sulfadimethoxine (tablets) Item 3 10
Sydnocarb (tablets) Item 4 55*
Phenazepam (tablets) Item 5 6
Diazoline (lozenges) Item 6 10
Pantocide (tablets) Item 7 40
Potassium permanganate (powder) Item 8 1 package
Promedol (syringe tubes) Item 9 6 units
Tetracycline ointment Item 10 1 package
Lip balm Item 11 1 package
Deet cream Item 12 3 packages
Gauze bandages Item 13.1 3 packages
Dressings Item 13.2 2 packages
Bactericidal adhesive plaster Item 13.3 3 packages
Razor blades 3 packages
Safety pins 3 units

decompression sickness evaluation and treatment, cardiopul- programs, two crewmembers are trained as CMOs. These
monary resuscitation, and first aid. Two CMOs are selected crewmembers receive training in the HMS and associated
from each crew by the mission commander. (As noted ear- medical procedures. Before HMS training, the CMOs are
lier in this chapter, these crewmembers typically do not have encouraged to participate in a field medical training course that
a medical background.) The CMOs receive an additional consists of 20 h of classroom instruction and 50 h of clinical
710 h of training in diagnostics and therapeutics. CMO training in an emergency room, in an operating room, on an
training is hands-on, using lifelike training mannequins to ambulance, and in an animal laboratory. As has been done in
practice procedures such as injections, airway management, the Space Shuttle training program, CMOs are also given the
and wound care. Additional IV proficiency training is also opportunity to train with the IV virtual-reality simulator and
offered, including training in a virtual-reality simulator and with human test subject volunteers.
with human test subject volunteers. The overall emphasis of In addition to preflight training, ISS crewmembers receive
preflight training is on procedures, how to use the medical refresher training on board the ISS. Computer-based training
checklist, and how to make cogent medical observations so as on all CHeCS hardware is provided. CMOs are allowed 1 h per
to make the best use of ground consultation. month for such training on the HMS; computer-based training
When the defibrillator was flown on the two Space Shuttle for the EHS and countermeasures system is made available
missions (STS-90 and STS-95), advanced cardiac life support to the crew for refresher training, although this is optional
refresher training was conducted for the CMOs. The CMOs and is not scheduled at a specific time. The multimedia com-
on both of these missions were physicians so the additional puter-based training sessions allow crewmembers to work
training requirements were minimal. at their own pace and review the items they feel are neces-
MSMK training was based on the Space Shuttle CMO sary. At least once per increment, an HMS contingency drill
training flow, with additions to include the pulse oximeter will take place. The drill is one of several emergency drills
and portable clinical blood analyzer. Training duration was in which the crew participates every other week. Other drills
increased from the standard Space Shuttle duration to accom- include those for response to fire/smoke, toxic spill, and rapid
modate the use of interpreters. All three Mir crewmembers decompression. Crewmembers will not know which type of
received 21 h of MSMK training. The training template drill is planned, only that a drill is scheduled. The specific
increased by 15 h when the Mir defibrillator and associated medical contingency scenario may change each time an
hardware were added, including training in advanced cardiac HMS drill is scheduled. Finally, the monthly performance of
life support protocols. medical evaluations by the CMO, involving simple physical
NASA provides crew training on all CHeCS equipment and examination and laboratory analysis, ensures that the CMO
associated in-flight activities for ISS crewmembers. Two or maintains some degree of proficiency in basic examination
all three crewmembers are trained in the use of the EHS and and specimen collection skills.
countermeasures system hardware and procedures, depending The Gagarin Cosmonaut Training Center in Star City,
on crew tasking. As was true in the Skylab and Space Shuttle Russia, provides crew training on all Russian medical support
4. Spaceflight Medical Systems 99

system equipment and associated in-flight activities. This References


includes training in medical response, countermeasures
performance and physical evaluation, and some environmen- 1. Polyakov VV. The physician-cosmonaut tasks in stabilizing the
crew members health and increasing an effectiveness of their
tal monitoring. Baseline data are collected before flight to
preparation for returning to Earth. Acta Astronautica 1991;
determine cosmonaut fitness for training and space flight and 23:149151.
to aid in achieving the required level of functional reserves 2. Houtchens BA. Minor Surgery and Anesthesia Capabili-
and psychological abilities corresponding to the tasks to be ties for Space Station Health Maintenance Facility (HMF).
performed during the spaceflight phase. Unpublished document prepared under NASA-JSC Contract
T-1419M; 1987.
3. Billica RD, Barratt MR. Inflight evaluation of apparatus and
Future Systems techniques for performance of medical and surgical procedures
in microgravity: STS-40/SLS-1, SMIDEX Medical Restraint
Next-generation CHeCS hardware is already in development. System. In: Spacelab Life Sciences-1 Final Report. Houston, TX:
It is sometimes difficult to use cutting-edge medical technolo- NASAJohnson Space Center; 1994: 5-675-82. JSC-26786.
4. Lloyd C, Creager GJ. SMIDEX IV pump experiment. In:
gies for spaceflight operations because of flight certification
Spacelab Life Sciences-1 Final Report, Vol. 1. Houston, TX:
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[18]. However, continual evaluation of mission needs and teral fluids for the Space Station Freedom Health Maintenance
performance of flown medical systems will ensure a process Facility. Paper presented at the 20th Intersociety Conference on
of steady upgrades and improvements. Environmental Systems; July 912, 1990; Williamsburg, VA.
The new CHeCS devices will expand onboard diagnos- SAE Technical Paper Series No. 901325.
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7. Barratt M, Billica R. Delivery of cardiopulmonary resuscitation
for human missions beyond low-Earth orbit. These missions in the microgravity environment. Presented at the 63rd Annual
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5
Acute Care
Thomas H. Marshburn

After more than 40 years of human spaceflight operations, the On-Orbit Medical Resources
U.S. and Russian spaceflight programs now have sufficient
experience to identify the most common medical problems that Ground-based flight surgeons provide each crewmember with
occur in space. This experience base allows the development of medical care training and equipment appropriate for the
means to diagnose and treat the medical problems anticipated to mission, within the constraints of available payload weight and
occur during flightthat is, to provide spaceflight crews with volume and crewmember training time. A medical kit, medical
acute care. Acute care, in this sense, refers to the treatment of the references, computer-based training, and consultation with
common minor medical problems that can occur during crewed members of the ground support team are all means by which
spaceflight missions. Acute care also refers to the assessment flight surgeons deliver medical experience and knowledge to
and stabilization of the more serious illnesses and injuries that each spaceflight crew.
can affect missions or cause significant crewmember morbidity. All crewmembers can access and use nonprescription phar-
The high cost of space travel demands maximum perfor- maceuticals in the medical kit without reporting to either
mance from each crewmember during a mission both to a CMO or the ground team, although they are requested to
maintain health and to accomplish mission objectives. Conse- record in a personal file the type, dose, and frequency of
quently, the common, relatively minor medical problems dis- medication used. Two members of each Space Shuttle crew
cussed in this chapter can significantly affect a mission. For are designated CMOs; CMOs are rarely physicians, but they
instance, an ankle injury sustained by a crewmember during a have enough autonomy and training to assess and treat minor
long-duration space flight can result in an inability to perform trauma and illnesses without calling the ground-based flight
the strenuous treadmill exercises that maintain muscle mass, surgeon for immediate consultation. CMOs who are not phy-
lower-extremity proprioception, and aerobic capacity. This sicians may use prescription medications only at the direction
would further lead to diminished performance upon return to of the flight surgeon or after satisfying the circumstances cited
gravity (e.g., upon arrival to Mars or rapid egress from the in the medical procedures manual. The controlled-substance
Space Shuttle after landing). Likewise, an extravehicular category and side effects of all medications supplied in the
activity (EVA) (i.e., a spacewalk) could be cancelled because medical kits are listed in the procedures manual.
of contact dermatitis or some minor hand injury that is not The CMO has access to 2 on-orbit medical resources
aggressively treated. the procedures manual and the private medical conference
Experience with human space flight has taught us that seri- (PMC). The procedures manual is written and updated by
ous illnesses can occur during missions. The crew medical ground-based flight surgeons. This manual has several unique
officer (CMO) who is assessing the seriously ill or injured characteristics. It contains a minimum of medical terminol-
crewmember faces several challenges. The CMO not only ogy, step-by-step procedures that reference only the limited
must correctly diagnose the problem so as to prevent either a hardware and pharmaceuticals available in the on-board medi-
premature end to the mission or an increase in crewmember cal kit, and a listing of possible side effects of the prescription
morbidity from delaying return, but also must work with lim- drugs in the kit. Since human performance decrements would
ited resources in an extreme environment, the effects of which be detrimental to a mission, adverse side effects from medica-
on humans are poorly understood. tions are of primary concern in the pharmaceutical treatment
This chapter summarizes the experience gained in diagnos- of crewmembers.
ing and treating acute medical problems in space and provides The on-orbit CMO also can confer with the ground-based
recommendations for treating expected problems in future flight surgeon through daily PMCs, which are considered an
space flights. integral part of Space Shuttle operations. During the PMC,

101
102 T.H. Marshburn

the Mission Control Center establishes a completely private a non-attributable database (in which incidents cannot be
link between the Space Shuttle crew and the flight surgeon. attributed to any identifiable individual) to better prepare for
PMCs are held to enhance the medical capability of the future medical contingencies.
crew and to allow the flight surgeon to communicate to the
ground team any need for mission or timeline changes that
have been driven by an onboard medical problem. PMCs Common Disorders Requiring
are scheduled and conducted daily during a Space Shuttle Care in Space
flight, eliminating the need for the crew to use open air-
to-ground communications to request a private conference Space Motion Sickness
with the flight surgeon, thereby helping to maintain medical
privacy as well as to facilitate proactive and anticipatory Space motion sickness (SMS) is very common among astro-
medical advice from the flight surgeon. PMCs typically last nauts and cosmonauts. Although it bears some resemblance
from 515 min. to the motion sickness that is experienced on Earth, SMS
A PMC is also held daily during the first few days of a long- is nonetheless part of a symptom complex that is unique to
duration mission to the International Space Station (ISS), dur- microgravitythat is, the space adaptation syndrome. The
ing the period of acute adaptation to the new environment. nausea and vomiting associated with SMS, one of the more
On a long-duration ISS mission (or any other long-duration deleterious symptoms of space adaptation syndrome, are very
mission), after the first few flight days, PMCs are held weekly common during the first few days of entering a microgravity
and at the request of the flight surgeon or the crew. environment. SMS has been estimated to affect 67% of crew-
The flight surgeon must provide to the ground control team members on their first space flight [1]. Investigations into the
a summary of the state of the health of the crew after each etiology, prevention, and recovery from space adaptation syn-
PMC. Although the flight surgeon and CMO make the medical drome are discussed more fully in Chap. 10. In this section,
diagnosis and treatment decisions for an affected crewmem- only the on-orbit treatment options available to crewmembers
ber, the mission commander is best able to assess the effect are discussed.
of the treatment plan on the mission as a whole. Before the Astronauts and cosmonauts experience SMS at different
conclusion of the PMC, the CMO, commander and the flight symptom intensities. Davis and colleagues used a symptom
surgeon agree on the content of the PMC report to the ground intensity score to evaluate symptoms experienced during
team. In cases in which a medical problem on orbit does not the first 24 Space Shuttle flights [1]. Of the astronauts who
result in timeline or mission changes, individual problems are experienced any symptoms, 47% had mild symptoms only,
not discussed or reported by the flight surgeon. In such cases, with no more than one episode of emesis and complete res-
the PMC report typically states no mission impact. Medi- olution in 3648 h; 35% experienced moderate symptoms,
cal privacy is paramount, both to maintain the trust between with waxing and waning malaise, fewer than three episodes
flight surgeon and each crewmember, which may take years to of emesis, and symptom resolution in 72 h; and 19% expe-
develop, and to prevent distraction from the mission by inor- rienced severe symptoms, consisting of persistent malaise,
dinate media attention. three or more episodes of vomiting, and symptom persis-
If the CMO and commander determine that the diagnosis tence beyond 72 h [1].
or treatment of a crewmembers medical problem will affect Slight differences can be expected between SMS symp-
the mission, which will necessarily involve the flight control toms and those of terrestrial motion sickness. For example,
team in some fashion, the flight surgeons report will con- crewmembers with SMS display less pallor and sweating,
tain only the information needed to implement changes to and more flushing and headache, than do people with ter-
the crew timeline and tasking or to modify plans for use of restrial motion sickness. Nausea, vomiting, and general mal-
consumables (e.g., O2). All attempts are made to preserve the aise are common to both syndromes. However, the vomiting
physician-patient relationship while also acting to best serve associated with SMS can be sudden, often without anteced-
the interests of the mission. In such cases, a public statement ent nausea, can occur sporadically (one episode of emesis
is made noting the diagnosis, prognosis, and likely effect on every few hours), and can be exacerbated by head move-
the mission. ments and olfactory stimuli (e.g., the smell emitted from the
This scheduled PMC is one of the most important components waste containment system) [2]. Unfortunately, no physical
of medical care in space flight. By facilitating communica- sign or motion analog, other than prior spaceflight experi-
tion between the crew and ground-based medical support, the ence, has yet been discovered that can be used to predict
CMOs greatly expand their resources in knowledge and the occurrence or severity of symptoms a particular crew-
expertise while being assured of complete privacy; the flight member will experience. In general, symptoms improve with
surgeon can work with the ground team under established rules subsequent flights.
of communication to support the medical treatment of an ill or Despite an incomplete understanding of the etiology of
injured crewmember (as necessary); and the Medical Opera- SMS, the use of promethazine for treatment has met with suc-
tions team at the NASAJohnson Space Center can develop cess in the U.S. space program. Physician-astronaut James
5. Acute Care 103

Bagian performed the first intramuscular (IM) injection in must be weighed against the risk of emesis inside the space-
space, using promethazine to treat SMS [3]. Approximately suit. For this reason, EVAs cannot be scheduled earlier than
60% of astronauts receiving IM promethazine since that time 72 h after arrival on orbit in the Space Shuttle Program. The
have reported a significant improvement in SMS symptoms flight surgeon and the EVA crewmembers are also required to
in postflight debriefs [4]. Early in the Space Shuttle Program, conduct a PMC before EVAs to ascertain the extent of SMS
the crewmembers occasionally took scopolamine with dex- and its resolution and to address any other medical issues that
troamphetamine as prophylaxis for SMS [5]. This strategy may have arisen. The crewmembers sedative response to pro-
was largely unsuccessful in reducing the symptoms associ- methazine, established during preflight testing, is helpful in
ated with SMS and is no longer used. The antiemetic agent this determination.
granisetron has been investigated in a ground-based study for Antiemetics have been used before performing an EVA,
its efficacy in preventing motion sickness, but it was no more although rarely. The first use of an antiemetic agent before
effective than a placebo in that study [6]. EVA occurred during the Apollo Program [10]. In the Space
During preflight training, flight surgeons teach CMOs how Shuttle Program, persistent, mild residual SMS symptoms
to give a dorsogluteal IM injection (see the section on Proce- have similarly been treated by small doses of promethazine in
dures later in this chapter). Although the injection is gener- combination with oral dextroamphetamine before EVAs.
ally well tolerated in space flight, the occasional experience Severe or prolonged cases of SMS, although rare, can result
of local soreness at the injection site has led to attempts to in significant dehydration, so intravenous (IV) normal saline
use other routes of administration. The combination of opera- is available and can be administered on orbit. The techniques
tional demands in the intense workload of the first hours on of venous cannulation and IV hydration are discussed briefly
orbit and limited flight opportunities have prevented the con- in the section on Procedures later in this chapter.
duct of controlled trials to evaluate the efficacy of each route;
however, the following observations have been made.
Crewmembers have taken promethazine, 25 mg with 2.5 Trauma
5.0 mg of dextroamphetamine, orally while on the launch pad
Superficial Trauma
for SMS prophylaxis with variable success. (Commanders and
pilots are prohibited from this practice.) Oral consumption of Findings from the Longitudinal Study of Astronaut Health
the same dose during flight is not generally successful, per- being conducted at NASAJohnson Space Center indicate that
haps because of the reduced GI absorption associated with the superficial skin trauma is one of the most common reasons
ileus common upon introduction to microgravity [7]. Some for a Space Shuttle or Mir space station crewmember (during
crewmembers prefer the autonomy of self-administration that the joint U.S.Russian flights of the NASA-Mir Program)
the rectal route provides, and have therefore taken a 25-mg to access the resources of the medical kit once symptoms of
suppository as soon after arriving on orbit as the workload SMS have resolved. Superficial abrasions and minor cuts are
allows. In general, however, this route of administration is not inevitable on board a spacecraft, because construction, repair,
as effective as an IM injection. IM injection is the most com- and transfer operations as well as working with abrasive mate-
mon route of administration. Crewmembers have the option rials such as Velcro are a part of daily life during a mission.
of receiving IM injection of promethazine from their CMO Minor contusions and bruises are common as crewmembers
either as prophylaxis or after the onset of symptoms; about learn to propel and stabilize themselves in the novel micro-
30% of IM promethazine injections have been used immedi- gravity environment. The hands often sustain such minor inju-
ately before sleep [4]. ries, since astronauts or cosmonauts use them in space much
Because the sedative effects of promethazine might be more often for stability and propulsion than on the ground.
expected to cause performance decrements, flight surgeons Chafing from wearing the U.S. space suit (extravehicular
determine the level of sedation associated with prometha- mobility unit, EMU), particularly in areas subject to inter-
zine for each astronaut or cosmonaut in preflight tests of oral trigo and on the fingertips, is also common. Since the Apollo
preparations. No problems have been reported with in flight Program, spacewalking U.S. astronauts have often reported
somnolence to date, nor has any evidence appeared of per- blunt nail trauma from working in the EVA suit gloves.
formance decrements during the early in-flight period from Five of the 12 Moon-walking astronauts had at least one
promethazine use [8]. Davis and colleagues speculate that the subungual hemorrhage of the hands [10]. The manual dex-
-adrenergic effects of the excitement after arrival into the terity and tactile sensitivity required to perform EVA tasks
novel environment of orbital flight may largely override seda- demand that the fingertip be in close contact with the space
tive effects [9]. Objective in-flight measures of crewmember suit glove, especially during preflight training. The resultant
vigilance and performance are being developed to aid in titration pressure often leads to nail elevation, which, with sufficient
of antiemetic doses during critical phases of the mission. pressure and repeated trauma, can lead to damage to the nail
One such critical phase occurs during EVAs. During an matrix. This damage may be confused with onychomycosis,
EVA, the sedative effect of an antiemetic, considering the need which can also occur with prolonged activity in the moist
for optimal performance by spacewalkers during critical tasks, environment of the space suit glove. Placing water-resistant
104 T.H. Marshburn

tape over benzoin on the nails has been moderately success- some of the soreness in back and abdominal muscles. Since
ful in preventing this problem. avoidance of strain is more effective than treating a strain once
it has occurred, the flight surgeon needs to act as an advocate
Muscle Strain and Overuse Syndromes
for the crew by encouraging the inclusion of properly designed
Back pain is the most common muscular syndrome in space restraint devices in the launch manifest.
flight and is one of the most common physical complaints of Rarely, the back pain that occurs in space flight is associ-
spaceflight crewmembers. The pain seems to be caused by ated with lancinating pain or patchy paresthesias in the lower
elongation of the ligamentous components of the vertebral extremities. Mild distraction of sensory nerve roots may con-
spine, which is known to lengthen by 12% early in space tribute to these symptoms. Although the symptoms are usu-
flight because of unloading of the axial skeleton in micro- ally transitory, patchy anesthesia has persisted after space
gravity [11]. The pain is spasmodic, is located in the para- flight in some crewmembers. Postflight diagnostic imaging
lumbar musculature, and can be intense enough to prevent and neurologic investigations have not revealed the cause or
sleep. The pain usually subsides after the first several days any abnormalities after return. The CMOs clinical evaluation
on orbit. Crewmembers have found relief from discomfort is the only in-flight diagnostic modality available, and to date
in many cases by positional changes, such as drawing their symptomatic treatment with anti-inflammatory agents, benzo-
knees up to their chest. Restraint straps and the Soyuz reen- diazipines for direct muscle relaxation, and stretching tech-
try couch, which can be used to maintain a semifetal position niques have been sufficient to control symptoms.
during the sleep period, also may afford relief. Nonsteroidal
Lacerations
anti-inflammatory agents are often accessed from the medi-
cal kit for relief as well. Although no astronauts or cosmonauts have sustained lac-
Several muscular strain syndromes are common during mis- erations of sufficient depth to require surgical repair during
sion training and during flight. Shoulder rotator cuff, forearm a space flight, minor lacerations and contusions occur often,
lateral epicondylar, and lumbar strains are among the most and thus inclusion of repair hardware in an on-board medical
common of these syndromes. One of the first recorded cases kit is appropriate.
of in-flight shoulder strain in the U.S. space program was after For minor injuries, a variety of bandages are included; ban-
an Apollo EVA that involved drilling operations on the lunar dages are one of the most commonly accessed components
surface [10]. Given the compressed timelines during a space in the medical kit. Handling flight checklists and Velcro are
mission, crewmembers can be expected to sustain operations reported to be the most common sources of minor injuries.
at a task without relief for hours at a time. If the work requires Recently developed Space Shuttle and ISS medical kits (see
an unusual posture that demands limb positioning outside of Chap. 4) also include tissue adhesives. No difficulties have
the neutral position, muscle soreness and ligamentous strains been experienced to date using tissue adhesive terrestrial
can be expected. Such conditions most commonly occur applicators in the microgravity environment (personal com-
during an EVA, when abduction and anterior rotation of the munication, Richard Linnehan, 1998). Even though the liquid
shoulders is required to position the hands properly within adhesive does not tend to leave the operative field in micro-
the space suit gloves. Work with a glove box also requires gravity, crewmembers currently apply it in a glove box or
a similar position, and prolonged operations may result in a while using eye protection.
similar overuse syndrome. The flight surgeon can anticipate The medical kits flown on the Space Shuttle and the ISS
this problem before flight by closely monitoring the crew after contain synthetic absorbable and nonabsorbable suture mate-
sustained training sessions and by starting them on stretching rial with a small, sterile, minor surgery subpack for repair of
and strengthening regimens under the guidance of physical deeper lacerations. The CMO also has the option of using tis-
trainers, if necessary, to eliminate pain and reduce the risk of sue adhesives or small skin staples on orbit. Tissue adhesives
further injury on orbit. would be used for wounds less than 5 cm (2 in.) long in non-
Another common syndrome associated with sustained work mucosal facial lacerations and selected extremity and torso
at a laboratory bench or glove box in microgravity is lum- wounds [12]except for the those on the hands, feet, and
bar and anterior abdominal muscular strain. Such strain is par- joints, since most studies that compare tissue adhesives with
ticularly common when toe/foot loops are the only hardware suturing have excluded hand and foot lacerations and lacera-
available for self-restraint. Proper body stabilization in micro- tions that cross a joint [13]. Staples are also included in the
gravity requires three points of contact with a firm surface, medical kits to quickly close wounds in the scalp, trunk, and
which means that crewmembers can be expected to assume an extremitiesagain excluding the hands and feet. Contraindi-
uncomfortable posture for many hours at a time. To free the cations for use of staples on orbit are the same as those on the
hands for delicate tasks in the glove box, for example, crew- ground: wounds that are more than 12 h old, those that are
members may use toe loops and press their forehead against grossly contaminated, or those that have devitalized margins
the firm surface of the glove box. Use of T-shaped chairs or flaps. Because a crewmember could sustain a contaminated
also allows crewmembers to maintain a stable posture close wound in a spacecraft (as discussed later in this section), the
to the microgravity-neutral position, which helps to prevent primary advantage of staples is the speed of closure, which
5. Acute Care 105

may reduce the frequency of infectious complications. Use of temperature and humidity. Airborne bacterial concentrations
staples on Earth, when these indications are followed, does on the Mir were generally comparable to Space Shuttle lev-
not seem to increase the rate of cosmetic or infectious compli- els (120325 colony forming units (CFU)/m3) [24], bacterial
cations, although the staples are painful to remove and may be counts of up to 1,000 CFU/m3 have been noted during tem-
associated with inflammation [1416]. perature elevations [25] after failure of the cooling system.
The components of the surgery subpack in the Space Shuttle By comparison, a conventional operating room particle count
medical kit have been tested during parabolic flight [17,18]. is 133158 CFU/m3 [26]. The potential therefore exists for
To date, the greatest challenge of suturing in microgravity has greater risk of airborne contamination of wounds. The ISS
been restraining the hardware. Magnetic pads have been tested will likely experience similar temperature fluctuations, but
[18], but they have been replaced by simple sterile pouches high-efficiency particulate air filters that have been installed
that are smaller, lighter, and more adequately restrain suturing in the air revitalization system on the ISS may reduce the par-
tools. The elastic memory of suture helps it maintain a coil, ticle and microorganism burdens. HEPA filtering is planned
and thereby keeps the entire length within close proximity of for planetary exploration vehicles and habitats.
the surgical field. However, suture also floats above the surgi- Another potential source of infection is condensate, which
cal field, so contamination is still a possibility. Crewmembers can accumulate in space stations that rely on adequate, laminar
who have performed animal surgery in space simply cut the intramodular airflow and a functioning water recovery system
suture to use the shortest length needed (personal communi- to remove excess moisture from the atmosphere. Condensate
cation, Richard Linnehan, 1998). Use of staples for wound that is left to adhere to surfaces near waste collection systems
closure has also been investigated in parabolic flight; the only has shown a microorganismal population similar to that in
matter of concern was maintaining control of the loose staples found in pond water. Bacterial mats with amoeboid species,
after they are removed [17]. ciliated protozoa, and spirochetes have been recovered from
Much has also been learned about the feasibility of a collection of condensate. Lacerations sustained near waste
hemostasis in parabolic flight and in space flight with ani- management systems (which could occur during maintenance
mal models of surgery and surgical wound repair. Venous of those systems) or lacerations contaminated by condensate
and capillary bleeding is easier to control in microgravity left standing in a remote area of the spacecraft should thus be
than on the ground, since surface tension forces overcome considered dirty wounds.
inertial forces in the absence of a gravity field, and blood Adequate irrigation of lacerations is likely to be at least
tends to pool and form a dome around a wound. Arterial as important in preventing wound infection in space as it is
bleeding, however, has been more difficult to control in on Earth [27]. Currently, sterile solutions for irrigation are
microgravity. Control of irrigant solutions is somewhat very limited on board spacecraft. On-orbit instructions for
more difficult because low irrigation rates are necessary to irrigation specify that only sterile physiological saline be used,
prevent splashing. However, loose-weave absorbent gauze but potable water from the spacecraft galley can be used as
held next to the surgical field easily maintains adequate well. Ground-based studies have demonstrated that irriga-
control of irrigant splash [1821]. tion of wounds with tap water can result in the same, or
Prevention of wound infection may be a challenge in the lower, infection rates as irrigation with sterile solutions [28].
microgravity environment. Superficial laceration infection The highest microbial counts from the Space Shuttle galley
rates of 50% have subjectively been noted by U.S. astronauts to date are 1,600 CFU/100 ml (measured after flight), and
and flight surgeons [22]. Although minor infections are easily generally those counts are much lower. Microbial growth in
resolved with topical bactericidal ointments, their occurrence uniodinated or inadequately iodinated Space Shuttle water is
leads to the suspicion that infection rates in space may be almost universally caused by a single organism, Burkholdera
slightly higher than on the ground. Whether direct effects of cepacia, a pseudomonad that is nonpathogenic in individuals
microgravity on humoral immunity, on atmospheric charac- with normal immune function. No literature exists regard-
teristics, or both, contribute to an increased wound infection ing whether this microorganism has a role in wound con-
rate remains unknown. (The function of the immune system in tamination. Pasteurized Space Station water has shown very
space flight is addressed in Chap. 15.) For example, the Space low microbial growth rates as well, although gram-positive
Shuttle atmosphere in microgravity contains more free-float- species such as Staphylococcus aureus have been known
ing particulates than are found in one-g environments, where to survive the pasteurization process on the Mir [25]. The
heavier particulates settle to the ground. The Space Shuttle iodinated water available in the Space Shuttle contains 34
atmosphere can contain 11 times the airborne particle mass parts per million (ppm) of free iodine. This water typically
concentration (for particles larger than 100 m) than terrestrial carries less than 1 CFU/100 ml of microbial growth, and it
indoor controls [23]. Airborne microorganisms also are associated contains less than the 1% free iodine associated with tissue
with these heavier particles [20]. destruction [29].
Investigations during both Space Shuttle and Mir missions have Syringes and intracatheters are available in the medical kits
shown that the microbial content of spacecraft air increases for high-pressure irrigation of wounds. Blood products in an
with mission duration and also increases with elevations in irrigant splash are more of a housekeeping concern than a
106 T.H. Marshburn

biohazard, because crewmembers are well-screened for the space flight have shown increased inflammatory responses,
presence of human immunodeficiency virus and for hepatitis reduced angiogenesis, and abnormal arrangement of colla-
A, B, and C. A loose-weave absorbent gauze placed next to gen fibers, leading to decreased scar strength at the wound
the wound is therefore usually sufficient for catching splashing margins. These findings suggest an increased risk of wound
irrigant [19]. dehiscence [3335]. Gross observations, however, have not
Particulate matter could also pose a biohazard to space indicated any change in wound infection or dehiscence rates
crewmembers in terms of its possibly being retained in an during the 12 days after surgery (personal communication,
open wound. Although safety restrictions limit use of glass Linnehan, 1998). More research is needed in this area, since
or wood aboard spacecraft, sawing of coolant pipes and metal delays in wound healing will affect wound management
structural components, as was required on Mir [30], could principles such as time to suture or staple removal, which in
result in retained metallic foreign bodies if a crewmember turn will affect mission operations.
sustains a laceration. Particulates pose more of a risk of eye
irritation or corneal abrasion than wound irritation. Diagnostic Musculoskeletal Trauma
sonography will be available on the ISS (see Chap. 9); a 7.5-
The Lower Extremities
MHz probe can detect plastic and wooden foreign bodies with
9598% sensitivity and 8998% specificity [31]. Updates for More significant trauma is also possible during space flight.
tetanus prophylaxis are also given to crewmembers before The magnitude of forces involved in most terrestrial trauma
missions to cover them for the duration of the flight. events (falls, motor vehicle accidents) are largely absent
Lidocaine and bupavicaine solutions (with and without in microgravity. However, the massive objects handled by
epinephrine) are also available in the medical kits for local crewmembers during EVA or during Space Shuttle-to-ISS
anesthesia in wound repair; pending results from actual expe- transfer operations have sufficient momentum to cause
rience on orbit, the principles of local tissue anesthesia are injury, particularly in the larger spacecraft interior volumes
expected to be the same in space than on Earth. Lidocaine of ISS. Moreover, the elastic restraint straps that are used to
will be used for local anesthesia when return of normal sen- secure stowage items and stabilize crewmembers carry sig-
sation is desirable within a few hours. Bupivacaine is flown nificant kinetic energy when they fail. Snapping of an exer-
for situations in which longer periods of anesthesia (48 h) cise bungee cord or a treadmill harness can, and has, resulted
may be needed. in significant injury.
For wound repair outside the scope of the CMOs capa- Risk of injury also increases when the speed of crewmem-
bilities and outside the capability of the medical kit, wilder- ber translation between modules increases, which occurs in the
ness medical principles apply. Currently, neither the Space activity-intense phases of a flight such as during an in-flight
Shuttle nor the ISS provides the capability for repairing emergency response or a Space Shuttle-to-ISS transfer opera-
complex wounds such as hand tendon, eyelid, or lacrimal tion. In the U.S. space program, the Space Shuttles capacity
sac lacerations. The hardware is not available, and the to ferry a relatively large payload volume to the ISS demands
intense training schedule for Space Shuttle and ISS crew- rapid transfer of the constituents of that payload (supplies and
members does not allow time to train CMOs in procedures experimental hardware) in a short time, increasing the risk of
that are typically the purview of specialists in the terrestrial soft tissue injuries and fractures.
setting. Delayed primary care is therefore the only treat- In-flight ligamentous sprains have generally been mild
ment option currently in low Earth orbit (LEO), and that in the U.S. Space Shuttle Program to date, usually occur-
option may be appropriate for some kinds of injuries. Hart ring in the hands, the knees, and the ankles. Treatment has
and colleagues assert that care provided for flexor tendon required little more than symptomatic therapy with nonste-
injuries, for example, can be delayed as many as 10 days roidal analgesics. Although crewmembers in microgravity
after injury with little change in outcome as compared with are essentially non-weightbearing, they are at risk of more
immediate definitive care [32]. Irrigation, antibiotics (if severe ligamentous injuries. Astronauts and cosmonauts
indicated), skin closure, and splinting can all be performed exercise daily on a treadmill and other devices to minimize
on orbit. As the number of crewmembers on future missions the muscle atrophy and bone mineral density loss known to
increases, serious consideration will be given to including occur with exposure to microgravity.
a physician as a member of the crew. For maximal training benefits, crewmembers adjust the
Relatively little is known about wound-healing rates in treadmill harness tension to exert a load equal to 7080% of
space flight. Anecdotal evidence from flight surgeons, astro- the crewmembers body weight, distributed over the crew-
nauts, and cosmonauts indicates that superficial lacerations members hips and shoulders. These loads increase the risk
or phlebotomy wounds may take longer to heal in space of ankle injuries during treadmill exercise sessions. Also,
than on Earth. No photo documentation or other objective spacewalking astronauts or cosmonauts have commented that
measure of wound repair and healing has been conducted repeated entry into and exiting from the foot restraints can
to date, although such a project is currently under way. result in soreness in the ankle and knee ligamentous struc-
Repaired surgical wounds in animals after short-duration tures. The motion consists of foot internal and external rota-
5. Acute Care 107

tion with a compression or distraction force applied to the wrap, which has been shown to be beneficial for any grade of
ankle and knee joints. The problem may be exacerbated in ankle sprain [44].
the crewmember with preexisting knee injuries, which is the After a crewmember sustains an ankle sprain, expedient
most common orthopedic problem in the U.S. astronaut corps return to treadmill exercise is essential, because aggressive
[36]. Prior meniscal or anterior cruciate ligament injuries may return to function is shown to hasten recovery and reduce
remanifest during these operations. Conceivably, then, an functional limitations after an injury [43]. This could be
ankle sprain or a knee medial or lateral collateral ligament accomplished by a treadmill program using lower tensions on
sprain could occur or be exacerbated during flight. the harness and by an exercise program using the cycle ergom-
Preflight injuries may place an astronaut or cosmonaut at a eter, bungee cords, and (on the Space Shuttle) rudder pedals
higher risk of injury during a mission as well. A survey con- to strengthen the ankle everters and the muscles of plantar and
ducted as part of the JSC Longitudinal Study of Astronaut dorsiflexion. Crewmembers have found that they can simulate
Health showed that astronauts sustain nearly three times as ambulation in a spacecraft cabin by providing counterpressure
many musculoskeletal injuries during the period beginning with their hands on an opposite wall. In this way, they can
1 year before flight to 1 year after flight than at other times. control the pressure on the ankle.
Both ankle and knee injuries tend to occur in the period before Since estimates of healing time would be very important for
the mission, probably because of the high training intensity at future timeline planning, an accurate determination of degree of
that time. Therefore, weaknesses in knee and ankle ligamen- injury will be essential. Return to full function for ankle sprains,
tous complexes can be expected in flight for those astronauts for instance, depends on the grade of the sprain. For a grade 1
who are recovering from a previous injury. sprain, the expected full return to function is 7 days; that for
Inadvertent inversion of the foot with a sprain of the lateral a grade 2 or 3 sprain can take several weeks [44]. The type of
ligamentous complex is the most common ankle sprain ter- immobilizationsuch as a simple compressive dressing or splint
restrially [37]. The same injury occurring on orbit would for suspected syndesmotic injuries and fractures [45,46]and
most likely be less severe without the stronger inversion stress the duration of treatment also depend on an accurate diagno-
driven by the weight of a person in one-g. Presentation of an sis. After assurance that no fracture or third-degree sprain is
injured ankle will most likely differ in microgravity. Local present, aggressive rehabilitation can begin. With no roentgen-
edema from a ligamentous injury may be reduced in space ography capability on orbit to rule out fracture of an extremity,
flight, since diminished hydrostatic pressures in the lower CMOs and flight surgeons will need to use established decision
extremities would result from cephalad total body water redis- algorithms based on the findings from clinical and sonographic
tribution in microgravity. These shifts likely will achieve the examinations. In such cases, the Ottawa Ankle Rules can be
same effect that elevation of the injured extremity would on applied: crewmembers with ankle pain after trauma, with pain
Earth [38]. The examiner would then expect to see less swell- at further attempts at ambulation on the treadmill or on palpa-
ing than would occur in one-g and thus could underestimate tion of the lateral malleolus and medial malleolus, or indeed
the degree of ligamentous injury. Although a CMO would any crewmember over age 55 years, would be suspected of hav-
not be expected to perform an expert physical examination, ing sustained a fracture. However, in some studies [47,48], the
he or she could assess swelling and bruising and perform Ottawa Ankle Rules have proven only 9498.5% sensitive for
the squeeze test to rule out syndesmotic injury. Palpation detecting ankle fractures.
about the ankle joint will help determine which ligaments are Sonography, as noted above, is available on the ISS and is
affected. The anterior drawer and talar tilt tests are of limited currently the only imaging modality available in spacecraft.
diagnostic accuracy, even in the hands of an experienced spe- Fortunately, sonography has recently shown to be useful for
cialist [3941]. These studies suggest that gentle stress testing detecting occult ankle and foot fractures [49], and its sensitiv-
immediately after the injury can provide useful information, ity surpasses that of roentgenography for identifying the for-
in that laxity without pain is suggestive of a third-degree tear, mation of callous after injury [50].
and pain with minimal or no laxity is suggestive of a first- Splints (other than finger splints) are not available in the
or second-degree tear [42]. As is true in terrestrial medicine, Space Shuttle medical kit because of volume constraints,
the examiner should rule out a fifth metatarsal or fibular head although crewmembers have worn air stirrup ankle splints
fracture in the examination as well. during flight to stabilize preflight injuries. (An ankle splint
Not surprisingly, treatment options of an ankle sprain are must fit inside a boot that is worn during launch and entry, and
limited on orbit. Cryotherapy will usually not be available air bladders are opened inside of the boot to provide pressure
because of limited refrigerator/freezer storage volume. If relief in case of cabin depressurization.) Both the U.S. and
available, it should be applied early [43]. As noted above, the Russian ISS medical kits carry a variety of splints, and splints
classic terrestrial principle of elevating the affected extremity can also be constructed from available on-orbit materials.
to limit swelling is meaningless in microgravity. An injured Assessments of knee injuries would be similar to those on
crewmember should be able to continue most tasks and Earth, although the potential for a fracture would be unlikely
remain non-weightbearing. The available medical kits have without the added force applied by a one-g field. Several deci-
sufficient supplies to compress the ankle with tape or elastic sion algorithms similar to the Ottawa Ankle Rules have been
108 T.H. Marshburn

developed for knee injuries. A review of these algorithms indi- ics amikacin and imipenem are available on orbit, a complete
cates that the Pittsburgh Knee Rules allow sufficient specificity course of treatment will have to involve the use of oral antibi-
without sacrificing much more sensitivity than the Ottawa Knee otics because the parenteral agents are in limited supply.
Rules [51]. The Pittsburgh Knee Rules can be summarized
as follows: A fracture can be considered very unlikely in the
Burns
absence of blunt trauma in a person younger than 55 years if the
head of the fibula and patella are not tender; if the person can Eight instances of onboard combustion have been documented
flex the knee to 90 degrees, and if the person can bear weight to date, four on the U.S. Space Shuttle and four on the Russian
immediately or simulate ambulation for about four steps. The space stations Salyut and Mir [30,54]. Of particular note is the
Pittsburgh Knee Rules do not apply, however, if crewmembers fire that took place during the Shuttle-Mir increment NASA-4
have a history of surgery or prior fracture. in February 1997. Lithium-perchlorate canisters were used on
Elements of the crewmembers history and physical that board Mir to supplement the Russian space stations Elektron
will help the CMO determine whether an anterior cruciate oxygen-generation system. One of these canisters caught fire,
ligament injury has taken place are whether the crewmem- producing (by some accounts) a 1-m (3.28-ft)-long flame and
ber heard or felt a pop, whether swelling is present, and releasing enough smoke to obscure visibility within seconds.
whether any mobility is lost. Pain upon simulated ambulation A crewmember sustained second-degree burns of the forearm
indicates a meniscal tear. Once both the patient and the in association with this event.
CMO are sufficiently restrained, Lachmans maneuver or Clearly spaceflight medical kits must contain hardware
the anterior drawer test can be performed. Although a com- and medications to support the treatment of burns. The
pression dressing and knee immobilization can be achieved Space Shuttle and ISS medical kits contain silver sulfa-
on orbit, no hardware is currently available on the ISS or diazine, sterile gauze, parenteral opioid analgesics, and
Shuttle to support knee joint aspiration. crystalloid solutions. As is usual in space flight, weight
Microgravity is less stressful than one-g on the extremi- restrictions limit the ability to replace fluid volume in severe
ties and axial skeleton, and ligamentous injuries of the lower burns. The maximum quantity of crystalloid planned for
extremities can be worked around in the course of most ISSabout 12 Lwould support a 70-kg (154-lb) crew-
intravehicular tasks. Nevertheless, an injured crewmembers member who has sustained burns over 40% of his or her
ability to return to a gravity field remains a concern. The abil- body for 24 h (following the Parkland prescription of 4 ml
ity to perform safely at maximum capability upon arrival in a per kg per percentage of surface area burned), which is the
gravity field makes appropriate in-flight management of these minimum time needed to leave LEO, return to Earth, and
injuries a necessity. deliver the patient to a definitive medical care facility. Given
Perhaps most important, the flight surgeon should ensure the high concentration of particulates present in spacecraft
before launch that the assigned crewmembers are maintaining atmospheres, CMOs will have to pay special attention to
an adequate exercise training regimen that includes aerobic secondary infection of burn wounds. With this in mind,
and anaerobic exercises so that the risk of on-orbit injury is antiseptic cleaning, debridement, and topical antimicrobial
minimized. The flight surgeon should ensure that the in-flight application can be performed with the resources provided
exercise schedule is maintained and that other mission activi- in both the ISS and Space Shuttle medical kits.
ties do not interfere with maintaining that schedule. First-degree burns have occurred as a result of ultravio-
let (UV) light exposure through unfiltered spacecraft win-
dows. Sunlight that is not filtered by atmosphere or window
Hand Injuries
coatings carries high-intensity UV rays (180400 nm) that
Because the hands are used to provide stability and propulsion can cause dermal burns in seconds. The ISS windows con-
in microgravity, the chance of injuring them may be greater sist of three fused silica panes, with a scratch pane that can
in space flight than on the ground. Standard terrestrial splint- be removed for high-quality imaging. When this pane is
ing practices can easily be implemented on orbit; however, removed, the window admits a higher spectral range [55].
establishing the presence or absence of a fracture will be prob- Skin exposure to sunlight for less than a minute through
lematic. Sonography has shown some success in delineating windows without this added filter has resulted in first-degree
tendon injuries [52] but not in delineating scaphoid fractures burns. The principles of management for first-degree burns
[53]. The ability of sonography to detect phalangeal, metacarpal, are the same in space flight as on the ground, and adequate
or other carpal injuries is not known. oral analgesics and topical antimicrobials are accordingly
Infectious tenosynovitis will also be of concern during a flown in medical kits.
long-duration mission because of its profound operational
impact owing to its morbidity when treatment is delayed.
Staphylococcus aureus and Streptococcus pyogenes cause Headache
most hand-wound infections that are not caused by mamma- Headache relief is one of the most common reasons space-
lian bites. Although the broad-spectrum parenteral antibiot- flight crewmembers take oral analgesics during Space Shuttle
5. Acute Care 109

missions [4]. A review of 89 Space Shuttle flights involving not yet demonstrated the presence of high levels of these
508 crewmembers and 4,443 flight days by the JSC Longi- compounds.
tudinal Study of Astronaut Health revealed headache in 304 Despite the inability to clearly identify a specific environ-
(69%) of 439 men and 38 (55%) of 69 women. Headaches mental cause for headaches in space flight, exposure to freshly
can afflict crewmembers with SMS, and they seem to be scrubbed air results in symptom resolution in less than an hour
associated with the cephalad fluid shifts that occur soon after in most cases. Crewmembers with headaches that develop while
orbital insertion; however, headaches can also occur later they are working in space modules that have no active air revi-
during flight, even as late as several months into a mission talization systems describe relief of symptoms after retreating to
[56]. This section reviews the most commonly suspected a module with contaminant removal systems that contain both
causes of headache in the unique environment of space flight activated charcoal and lithium hydroxide. (These modules are
and the well-screened space crew population, and suggests capable of removing CO2 as well as most low molecular weight
treatment options that can be used by crewmembers, CMOs, volatile organic compounds.) Thus regardless of the cause of
and flight surgeons. the headache, symptoms usually resolve with improvement of
Headaches occurring during the first few days of space flight intramodular airflow, placement of portable fans by the work-
are most often associated with space adaptation syndrome, site, or exposure to freshly scrubbed air. The CMO and flight
with nausea as an accompanying symptom. The headache is surgeon can work with the ground control team to plan mission
self-limiting and usually resolves along with other symptoms objectives around areas of suspicious airflow and to avoid accu-
of space adaptation syndrome as the crewmember adapts to mulation of crewmembers in a single area.
microgravity, usually within 72 h. Carbon monoxide has been the known cause of headache in
Caffeine withdrawal, which can occur during any expedition one case after a microimpurities filter overheated (see Chap.
to a remote site, can occur early in a space flight. Although 21). The flight surgeon should presume that any crewmem-
caffeinated beverages are available to spaceflight crews, busy ber with a headache at the time of a smoke alarm warning,
work schedules often preclude their preparation. Taste prefer- with visual identification of smoke or fire, or with olfactory
ences also change on orbit, and crewmembers may choose not detection of smoke has been exposed to carbon monoxide.
to maintain their usual caffeine intake. Therefore, caffeine- ISS flight rules dictate that crewmembers in this scenario
containing oral medications should be provided for spaceflight should don oxygen masks and retreat to a module with uncon-
crewmembers who are known to be susceptible to caffeine taminated air. One hundred percent oxygen is available in the
withdrawal symptoms. These medications can provide a sub- Space Shuttle and the ISS for treatment of suspected carbon
stitute for colas or coffee, 8 oz (0.25 kg) of which contain monoxide poisoning, although means of determining carboxy-
approximately 35 mg and 85 mg of caffeine, respectively. hemoglobin levels in real time are not available.
Headaches that occur beyond the initial 72 h of microgravity Apart from headaches associated with the aforemen-
exposure should alert the flight surgeon and CMO to consider tioned causes, the flight surgeon and CMO must also con-
the possibility of atmospheric contaminants. CO2 contamina- sider endogenous causes of headache. During the medical
tion, for example, is a well-known cause of headache. A con- screening necessary to become an astronaut or a cosmonaut,
centration of CO2 of 2% or more in a cabin at sea level will applicants with a history of migraine or cluster headache or
produce headaches in humans [57] and is the suspected cause with cardiovascular disease are disqualified. Computerized
of some of the headaches that were experienced on board the tomography or magnetic resonance imaging of the central
Mir space station and the Space Shuttle. The average CO2 lev- neuroaxis of prospective candidates is not currently per-
els on the Space Shuttle are 0.26%. The onset of headaches in formed, and so subclinical central nervous system abnormali-
crews aboard Mir has led at least twice to the discovery that ties may pass undetected. However, this will be implemented
the CO2 removal system had failed [30]. soon for long duration crewmembers. Endogenous causes of
Headaches can occur while crewmembers are working headache that the CMO and flight surgeon must consider
in small, poorly ventilated volumes such as behind panels or include tension headaches, cluster headaches, trigeminal
among tightly packed payloads. In cases such as these, archi- neuralgia, and temporal arteritis. Tension headaches are the
val air samples have not yet revealed a causative contaminant, most common cause of headaches in general, producing 78%
perhaps because no sample has yet been collected at the spe- of headaches in terrestrial practice [58]. The high workload
cific location, and at the exact time, of symptom onset. Recent of crewmembers during a mission makes tension headache a
use of a portable CO2 sensor also has not demonstrated elevated likely diagnosis for in-flight headaches after the first days on
CO2 levels in these areas. Therefore, as a cause of headache, the orbit. The age at first onset of cluster headaches and trigemi-
accumulation of CO2 in pockets in modules that otherwise nal neuralgia can be 4050 years, a range only slightly older
display nominal CO2 readings has yet to be demonstrated. than that of the average U.S. astronaut. Similarly, temporal
A distinct odor may precede headache onset. Crewmem- arteritis can become evident for the first time in individuals
bers have identified glue or adhesive smells antecedent older than 50 years.
to their symptoms, suggesting that acetates or xylenes may be Examination of a crewmember with a persistent headache
causative agents. Again, however, archival air samples have that has no apparent cause should include documentation of
110 T.H. Marshburn

vital signs and a directed physical examination. Signs and nevertheless, the combination of sleep shifts, workload,
symptoms that should raise suspicion of serious intracranial and crew motivation for high work output can result in
abnormalities are headaches that increase in frequency and chronic sleep debt.
severity; headaches associated with mental status changes, Sleep medications are therefore among the most commonly
fever, or meningeal signs; focal neurological deficits; and used medications by spaceflight crews [4]. Non-benzodiazipine
headaches that occur in individuals over 55 years of age [59]. hypnotics that have a short onset of action and half-life, such
The physical examination should evaluate the affected as zolpidem, are being used with increasing frequency to
crewmember for otitis media and sinusitis (see the section on assist in ensuring the onset of sleep. Melatonin is preferred,
Upper Respiratory Disorders later in this chapter). Variable- either alone or with zolpidem, by some crewmembers. Benzo-
applanation tonometry is available on the ISS, and glaucoma diazipines such as temazepam are used less often. Guidelines
should also be considered, particularly in crewmembers with for use of these medications are determined before launch and
associated visual changes [59]. The fundoscopic examination are discussed more fully in Chap. 20.
should include a search for flame hemorrhages, papilloedema, Flight surgeons can also assist in preventing crewmember
and subhyaloid and retinal hemorrhages, which are diagnostic fatigue by limiting interruptions by ground control in the
of subarachnoid hemorrhage in the age group of spacefarers. crews before- and after-sleep periods. Flight surgeons also
A focal finding on an in-flight neurologic examination (see monitor and protect the crews exercise time, which is par-
Chap. 17) should heighten concern regarding significant intra- ticularly important during long-duration flights. In postflight
cranial abnormalities. debriefings, long-duration crewmembers have stated unani-
Although few diagnostic and treatment modalities are avail- mously that the daily exercise period is one of the most impor-
able on spacecraft, pain control with non-narcotic analgesics tant factors that promotes sleep onset and reduces the amount
such as acetaminophen, ibuprofen, and aspirin in addition to of time spent awake during the sleep period.
air purification and provision of 100% oxygen are available if
needed. The flight surgeon must work with other members of
the ground team in adjusting the mission timeline so that the
Skin Disorders
crewmembers can avoid areas in which air contamination or Skin disorders are another common problem during space
accumulation of metabolites may have occurred. The flight flight [4]. As discussed previously, the particulate components
surgeon should also remind crewmembers who are exhibiting of spacecraft air may increase the risk of superficial infections
symptoms that even if the symptoms resolve spontaneously, in crewmembers with breaks in the skin from superficial cuts
they should obtain an archival air sample from the area of the and abrasions. The relatively dry air on board Space Shuttles
spacecraft occupied by the crewmember when the headache typically results in only minor drying of the skin during brief
began. This practice may not aid in management of the medi- missions. More serious skin conditions such as folliculitis,
cal problem for that crew, but it may enable a problem with contact dermatitis, and fungal infections can occur during
contaminants to be identified and addressed for the benefit of longer-duration missions. Although the cause of these skin
future crews. conditions has yet to be determined, contributing factors may
include the higher humidity of space station atmospheres and
the exposure of the crews to relatively exotic compounds.
Sleep Disorders Space station maintenance operations demand close physi-
The risk of chronic fatigue in spaceflight crews is signifi- cal contact with substances such as ethylene glycol (which
cant. The crewmembers drive to complete multiple mission was used as a coolant on Mir), cadmium and nickel (con-
objectives and the need for spacecraft maintenance into the stituents of anticorrosives in coolant lines), and urea (located
period before sleep reduces the amount of sleep obtained near waste containment systems). Problems from contact with
during flight. Also, since orbital mechanics is the main these materials can be prevented by using chemical-resistant
driver of the crew mission schedule, crews must often sleep gloves and suits to protect the skin during contingency opera-
in shifts to accommodate launch, rendezvous, and landing tions and in-flight maintenance.
times. Crewmembers can begin to experience a sleep debt Treatment of skin disorders depends on avoiding the source
before launch. Trainers and crews typically train heavily in and treating with topical steroidal, antifungal, or antibacterial
the weeks before launch; and despite guidance given in the creams, alone or in combination. Since dermatologic problems
judicious use of bright lights, dark goggles, sedative-hyp- lend themselves to video downlink, the flight surgeon and
notics and melatonin to regulate sleep and rest cycles, sleep consultants can assist in the diagnosis. Cellulitis has occurred
debt can still accrue. Thus for ISS rendezvous missions, during space flight; treatment with oral antibiotics according
a launch slip of 24 h requires a 20-min phase advance in to standard terrestrial protocols has been successful on orbit.
the sleep schedule (i.e., the crew must go to sleep 20 min Aggressive treatment is necessary to minimize performance
earlier for each 24-h delay that occurs.) Schedulers of the degradation. EVA operations in particular cannot be effectively
on-orbit timeline abide by documented constraints to the conducted while the crewmember has a distracting derma-
amount of sleep shifting that can be imposed on a crew; tologic problem.
5. Acute Care 111

Eye Disorders seem to enhance healing rates and may increase the risk of
secondary infection [61]. Cycloplegics and topical ophthalmic
Ocular injuries, in addition to being common, are among the antibiotic preparations such as gentamicin, erythromycin, and
most serious of ambulatory care disorders confronted dur- ciprofloxacin are easily stowed in spacecraft medical kits and
ing space flight. The microgravity environment increases have been included in the Space Shuttle and ISS medical kits
the risk of eye injury and contamination from free-floating as well. Because the CMO can reexamine an eye injury often,
foreign bodies that would otherwise settle onto a surface in follow-up and early detection of complications or treatment
one-g. Failure of the elastic cords used to restrain hardware failures should not be a problem on spaceflight missions.
and tether crewmembers during exercise has resulted in both As the use of tissue adhesives increases in the microgravity
scleral and corneal injuries and abrasions. Crewmembers environment, misplaced adhesive into the eye is a potential
have sustained potentially vision-compromising eye injuries hazard. If a crewmembers eye is thus contaminated, the medi-
that have required topical antibiotic therapy, pain control, and cal kit contains sufficient ophthalmic ointment to apply to the
reevaluation over several days. affected eye. The eyelid should spontaneously open 14 days
The flight surgeon should be aware of the mission phases after treatment as the adhesive bond releases [62].
when foreign body injuries are most likely. Perhaps the most The ISS and Space Shuttle medical kits also contain oph-
hazardous time for this type of injury is during entry and thalmic antimicrobial preparations. The relatively high con-
transfer operations to a station and into a new module such centration of carbonaceous particles in spacecraft air, the
as a cargo vehicle. The act of opening and entering new mod- frequent and potentially prolonged use of contact lenses, and
ules does not seem to pose a hazard, but as transfer operations the increased risk of ocular foreign bodies all increase the
begin, metal shavings, loose debris, and dust can be released risk of bacterial keratitis and conjunctivitis. The dilation of
[56]. For this reason, crews are advised to wear protective conjunctival vessels associated with the cephalad fluid shifts
goggles during these operations. at microgravity onset should not be confused with conjunc-
A magnifying lens, proparacaine drops, an ophthalmoscope tivitis. A crewmembers eye must be carefully examined to
with a cobalt-blue light filter, cotton-tipped swabs, pH strips, rule out foreign body contamination for any case of unilateral
and fluorescein strips are available on orbit for diagnosis. red eye. Also, given the increasing use of soft contact lenses
Because no slit lamp is available, subtle injuries to the anterior among members of the U.S. Astronaut Corps, preflight train-
chamber are difficult to detect. However, CMOs are trained to ing includes the caution to remove lenses before sleep.
perform a complete primary ocular examination with lid ever- Ciprofloxacin ointment and drops are flown in the Space
sion and examination with an ophthalmoscope. Shuttle and ISS medical kits for treatment of contact lens-
If a foreign body is suspected of being present, an effective associated pseudomonas keratitis. In a contingency in
initial technique for removing it is to place a bolus of drinking which a portion of the station is rendered uninhabitable, as
water over the affected orbit. In microgravity, the fluid forms occurred after the collision between the Progress and the
a dome over the eye. This dome adheres via surface tension Mir in 1997, ISS crewmembers can be separated from their
and creates a bath in which the crewmember can blink, which lens cleaning and storage system. ISS crewmembers who
usually removes the foreign body. Water can then be absorbed wear lenses are now cautioned to carry back-up spectacles
and contained with a towel. Alternatively, a drink bag can be with them at all times.
used to direct a low-velocity stream of potable water onto the Although applying ophthalmic solutions poses little diffi-
eye, again using a towel for water containment. To prepare for culty in microgravity, a significant amount of solution is wasted
such eventualities, Space Shuttle and ISS crewmembers are with each application. Titration of a dose into single drops is
instructed to place a drinking bag of potable galley water in difficult because of the lack of gravity-induced separation of
modules where activities will be performed that present a high air and fluid in the bottle, which results in inconsistent doses
risk of exposure to ocular foreign bodies. of solution with each application. For this reason, ointments
Space Shuttle and ISS medical kits also contain an emer- are used for serious infections such as corneal ulcers, where
gency eyewash system for removing ocular foreign bodies prudent use of a limited supply of antibiotic is necessary to
and for treating ocular chemical exposure. The emergency ensure that a complete antibiotic course is available.
eyewash system consists of goggles into which galley drink- Judicious use of ocular antibiotics applies to the treat-
ing water can be infused, creating a turbulent flow over the ment of the red eye on orbit as well. Conjunctivitis, for
affected eye at a rate of 1 L/min [60]. CMOs for Shuttle and example, is generally self-limiting, showing cure or signifi-
ISS are also trained to remove foreign bodies from the eye cant improvement by 25 days in 64% of patients, but use
with a moistened cotton-tipped swab or a 20-gauge needle. of topical antibiotics is associated with an improved clinical
Eye burrs for removing more stubborn foreign bodies or rust remission rate [63].
rings are not available on the Space Shuttle or the ISS. Eye UV keratitis can and has also occurred on orbit [56]. Unfil-
patches, including a metallic eye shield, are available for use tered sunlight, as noted above, can cause ocular injury in sec-
as needed. However, CMOs are cautioned to limit the use of onds. Crews are instructed to wear UV protection at all times
patches as needed for comfort only, because patching does not when Earth-observing at any window that does not block UV
112 T.H. Marshburn

light, and the medical kit contains sufficient means to treat distinguish SMS from gastric disturbances of infectious
UV keratitis should it occur. Proparacaine is used to facilitate cause. Theoretically, preflight quarantine of spaceflight crews
the examination, and a short-acting cycloplegic and antibiotic reduces the incidence of viral gastroenteritis during flight, but
ointment or drops is then applied. Eye patches are available as breaches can conceivably occur. Peculiarities of the clinical
needed for comfort. Hydrocodone and acetaminophen in oral evaluation of hydration status and challenges to parenteral
preparations are also available for pain control. The pain and fluid administration in microgravity are discussed later in this
loss of visual acuity associated with UV keratitis is usually chapter in the section on Procedures.
resolved in 24 h. Evaluation of abdominal pain, particularly cases of right
lower quadrant abdominal pain, may prove to be one of the
most difficult diagnostic dilemmas on orbit. Abdominal pain,
Gastrointestinal Disorders
a diagnostic dilemma on Earth, may present in a substantially
Upper gastrointestinal problems have not significantly affected different way in microgravity. Movement of abdominal organs
spaceflight operations to date, but mild complaints suggestive in microgravity is not well described, so the positioning of the
of gastritis and esophageal reflux are commonly reported mesentery, the stomach, and the appendix is unknown. During
by space flyers. These symptoms are generally self-limited laparoscopy of an insufflated abdomen of a porcine sub-
and are usually relieved by the over-the-counter medications ject during parabolic flight, mesenteric retraction of viscera
(simethicone and antacids) flown in the medical kit. towards the diaphragm was noted at the onset of simulated
The source of these symptoms is unknown, as no attempts microgravity [67]. Russian sonographic investigations of the
have been made to document esophageal motility or changes human abdomen, conducted on a Mir flight, described eleva-
in lower esophageal sphincter tone during space flight. tion of the diaphragm and increases in hepatic, splenic, and
Water dispenser malfunctions in an early Apollo mission renal volumes that persisted 4 months into that long-duration
[10] and some Space Shuttle missions resulted in air being mission [68] and were thought to be due to normal anatomic
entrained into the water stream, which produced mild gastritis changes associated with the absence of gravity. These results
symptoms that were easily treated with simethicone. Gastro- raise the question of whether changes in the position of the
esophageal reflux symptoms have been reported after a large appendix and peritoneum in microgravity may affect the
meal or ingestion of a large bolus of fluid (which is required classic presentation of appendicitis.
before reentry to offset postflight orthostasis from intravas- Given the lack of onboard imaging modalities, information
cular depletion). obtained from the physical examination of a crewmember
Constipation, which can have a greater effect on operations, with abdominal pain will be of paramount importance to further
is also a common problem for crewmembers upon introduc- decision making. The differential diagnosis in the medically
tion to microgravity, most likely because of the large bowel screened population of astronauts and cosmonauts is less
ileus, as noted in physical examinations by astronaut physi- extensive than is seen in terrestrial medicine. Vascular abnor-
cians [64,65] and in experimental investigations of gastroin- malities and mesenteric ischemia are very unlikely causes of
testinal motility [66]. The decrease in bowel sounds noted on abdominal pain. Indeed, crewmembers undergo sonographic
physical examination, associated with increased transit time evaluation of the abdomen and pelvis as part of astronaut
of foodstuffs through the colon, is probably exacerbated by selection and again 30 days before a long-duration flight; thus
dehydration from SMS and homeostatic hormonal responses gross abnormalities would be detected before flight. Ure-
to fluid redistribution. Russian cosmonauts undergo bowel teral colic may be difficult to distinguish from appendicitis in
preparations before launch to reduce the need for bowel move- space; the crew and ground flight controllers of a Salyut mission
ments in the Soyuz spacecraft while in transit to Mir. Some were faced with this dilemma [56].
U.S. astronauts also follow this practice, whereas others use Even though pregnancy is contraindicated during exposure
a liquid diet for 23 days before launch. Bowel preparation is to space radiation, a urine pregnancy test is available in the
not a preflight requirement in the U.S. space program. ISS medical kit to rule out ectopic pregnancy. Any differences
Oral and rectal bowel stimulants and psyllium wafers are in the presentation of or risks associated with pelvic pain in
available on orbit for constipation. Crewmembers also need to microgravity vs. those on Earth are unknown at this time.
maintain hydration, and aggressive resolution of SMS symp- However, no abdominal symptoms or shoulder pain have been
toms is needed in the early in-flight period to allow oral rehy- described by female crewmembers to date that would suggest
dration. Sufficient hardware is available to perform enemas an increased risk of endometriosis caused by microgravity
as needed. Constipation usually resolves in the first few days enhancement of ectopic endometrial implantation [19].
on orbit, although crewmembers have gone as long as 1 week On the ISS, sonography will most likely be used to evaluate
upon arrival on orbit without defecation. a crewmember with abdominal pain. Sonography will be of
Gastroenteritis is a less likely condition, although a few particular use in distinguishing ureteral colic from appen-
crewmembers have experienced a combination of nausea, dicitis. Although technologic advances continue to improve
vomiting, and diarrhea in the first week of space flight. Diar- the accuracy of sonography in the evaluation of appendicitis,
rhea and fever are not components of SMS, and thus they the examination remains highly dependent on the skill of the
5. Acute Care 113

operator [69]. Because the onboard sonographer will probably blockage of the Orbiter cabin air-cleaner filter between the
have had limited experience, training, or skill maintenance, middeck and flight deck. Removal of the blockage results in
appropriate downlink of captured images may be necessary rapid relief of symptoms.
to consult with experts on the ground. However, the flight Sinusitis, although not a prominent disorder among space-
surgeon will need to compete with other consoles in the flight crews, can be promoted by cephalad fluid shifts and
Mission Control Center for the bandwidth required for real- the resultant engorgement of sinus mucosal vasculature. It is
time continuous downlink of images. Also, the ISS, in certain important to distinguish true bacterial sinusitis from uncom-
orientations, can shadow ground stations by antennae, trusses, plicated sinus congestion; even though evidence exists to sup-
modules, and solar arrays, thereby blocking communication port the use of antibiotics for bacterial sinusitis for 714 days
with the ground. Limitations on the availability of satellites [73], profligate use of antibiotics for presumed sinusitis will
or ground stations can lead to loss of communications for 50 strain on-orbit supplies as well as predispose a crewmember
70% of the time during ISS operations. For exploration-class to infection by resistant organisms. In one review, clinical
missions, the round-trip time of a communications signal findings of tenderness to palpation over the sinus areas, ele-
renders real-time consultations impractical. Therefore, maxi- vated body temperature, and purulent rhinorrhea were found
mizing the capabilities of the on-orbit CMOs is paramount, to be 58% sensitive and 88% specific in detecting sinusitis
and in-flight training and onboard mentoring programs for that is treatable with antibiotics [74] in comparison to the
this purpose are being developed by NASA and the international gold standard of antral aspiration [75]. Sonography, when
space medical community. available to the ISS CMO, may be useful as well. A review
No surgical capability exists on the Space Shuttle or the of five studies evaluating sonography for diagnosing maxil-
ISS, which makes parenteral antibiotics the only treatment lary sinusitis showed it to be 83% sensitive and 88% specific
option for abdominal abscesses before an ill crewmember can [74]. Although mucosal thickening is not easily visualized on
be returned to Earth from a space mission in LEO. Although sonography, a sinus that is partially or fully filled with secre-
the optimal antibiotic regimen for medically managing tions can transmit ultrasound waves. The effect of micrograv-
appendicitis in adults has yet to be established, in general the ity on the diagnostic accuracy of sonography is not known,
use of parenteral antibiotics that cover aerobic and anaerobic although the layering of secretions that forms a typical sign
organisms is relatively successful. Oral metronidazole has on x-ray evaluations would not be present in microgravity.
shown some efficacy in the medical management of appen- Other upper airway inflammatory processes that can occur
dicitis [70]. Imipenem and metronidazole are present in commonly on the ground can also occur in space flight; the
space medical kits and would be used to attempt stabiliza- preflight 7-day quarantine used by the U.S. and Russian
tion of the ill crewmember before return to Earth. Gastric programs was established to limit viral or bacterial infections
decompression, essential to reduce peristalsis, can also be in crewmembers. The flight surgeon and the CMO must still
accomplished on orbit [71]. consider upper airway inflammation in the differential diag-
Administration of morphine sulfate to a crewmember who nosis of pharyngitis, however. Since breaches in preflight
has acute nonbiliary abdominal pain will be considered, quarantine are possible, treatment of a crewmember with phar-
because such treatment can effectively relieve pain and may yngitis in the first days of a space flight is similar to that on
not affect the ability of CMOs to accurately evaluate the patient the ground. Carrier states are known to occur in the astronaut
[72]. Any analgesia would be administered in close consulta- or cosmonaut population, both in the quarantine period and
tion with the flight surgeon and other ground consultants. during flight; lateral transmission of Staphylococcus aureus
between crewmembers during missions has been documented
[76]. Changes in the crews immunity secondary to the stress
Upper Respiratory Disorders
of the high workload, sleep debt, or an as yet undetermined
Nasopharyngeal congestion is another common problem for effect of space flight may reactivate these pathogens, resulting
astronauts and cosmonauts in the early period of exposure to in clinical disease.
microgravity. Facial swelling from cephalad fluid shifts has Clinically based predictions of the presence of bacterial
been well-documented, and nasal congestion is a frequent pharyngitis are relatively poor. As noted above, headache
associated complaint. Although nasal congestion poses mini- and rhinorrhea in spacecraft have multiple causes and are not
mal risk to the crew, it can distract from mission tasks and necessarily suggestive of upper airway infection. Sore throat,
increase insensible fluid loss from mouth breathing. Intra- cervical lymphadenopathy, and fever are more suggestive of
nasal oxymetazolone is used most often for this condition, bacterial pharyngitis [77]. A rapid streptococcal immunoassay
followed by anti-allergenics and diphenyhydramine. It has is available in ISS medical kits that may assist in diagnosing
become increasingly apparent from crew comments and flight bacterial pharyngitis. Generally, treatment is recommended
surgeon observations that adequate filtering of the spacecraft when the clinical picture is clear, the symptoms noted above
air also lessens nasal congestion. Supporting this contention are present, and findings on a rapid strep test are positive;
is the fact that some Space Shuttle crewmembers have noted a however, in giving such treatment, the CMO accepts the
rapid onset of nasal congestion immediately after accidental possibility of unnecessary treatment of crewmembers who do
114 T.H. Marshburn

not have disease and that of unnecessarily depleting the on-orbit absence of pneumonia. Recent evaluations of the accuracy
supply of oral antibiotics [78]. An advantage in on-orbit medi- and interobserver reliability of auscultation in detecting pneu-
cal care is the opportunity for close, frequent reevaluations, so monia (with the chest x-ray used as the gold standard) show
crewmembers with negative findings on a rapid strep test or that auscultation alone has a sensitivity of less than 70% and a
an unclear clinical picture can be easily followed without the specificity less than 75% [81]. Thus a high degree of suspicion
need for overly aggressive early treatment [75]. will have to be maintained when a crewmember has a produc-
Several classes of oral antibiotics are available in Space tive cough and fever.
Shuttle and ISS medical kits, including penicillins, -lactamase Crewmembers are always at increased risk of inhaling for-
penicillins, macrolides, and cephalosporins. These antibiotics eign bodies during space flight, particularly during activities
can be used to reduce the incidence of suppurative complications that increase minute ventilation (e.g., exercise). Sudden onset
and perhaps shorten the duration of symptoms [77]. of cough accompanied by a local monotonic wheeze on aus-
Because the ambient spacecraft atmospheric pressure cultation would suggest foreign body aspiration. The CMO
changes regularly in the course of mission operations, otitis must assess all anatomic lung segments in the physical exami-
media suspected during space flight must be aggressively nation, since the classic gravity-dependent segments may not
treated with oral antibiotics and decongestants. Moreover, be at increased risk in microgravity. An affected crewmember
microgravity may change the physical presentation of otitis should be followed closely for atelectasis or pneumonia devel-
media with effusion, as exudate would not layer out behind opment in lung segments distal to the occlusion.
the tympanic membrane. Otherwise the principles of clinical Toxic contamination of the spacecraft atmosphere can also
diagnosis of otitis media and its treatment are no different in lead to significant pulmonary injury. Firsthand experience
space flight than in terrestrial practice. with this problem unfortunately occurred in July 1975 at the
The dry air present in the Space Shuttle atmosphere in end of the Apollo-Soyuz Test Project, when the three-member
combination with cephalad fluid shifts may predispose crew- Apollo crew was exposed to 250 ppm of nitrogen tetroxide, an
members to nosebleeds. The lack of gravity also prevents free oxidizer commonly used in spacecraft propulsion systems, for
blood from descending into the nasal alae early in the nose- 45 min during the atmospheric reentry of the Apollo com-
bleed, so more blood may be present in the nasopharynx at mand module. Initial symptoms were eye burning with tearing,
the time of presentation than in one-G. Shuttle and ISS medi- burning and itching of the skin, chest tightness with retroster-
cal kits are stocked with cotton pledgets, topical deconges- nal burning, and nonproductive cough upon deep inhalation.
tants and anesthetic, silver nitrate sticks, and nasal packing The crewmembers lungs were clear on initial examination
as needed to treat anterior epistaxis. Foley catheters can also after splashdown and recovery, but radiologic evidence of pul-
be used for posterior bleeds; in that technique, the catheter is monary edema was present a day later [82]. They recovered
inserted through the nasopharynx into the posterior pharynx fully, without sequelae.
and its balloon is inflated and then drawn back to tamponade Nitrogen tetroxide is a gas that decomposes into nitric acid
the posterior nasopharynx [79]. and other compounds on contact with the water in mucous
membranes. In sufficient amounts, it is highly irritating to
upper airway passages; less severe exposures may produce only
Pulmonary Disorders
cough and coryza. Indeed, this presentation is first in a typical
Pulmonary problems unique to space flight include exposure triphasic progression of injury manifestation after significant
to exotic atmospheric contaminants and inhalation of foreign pulmonary exposure to nitrogen tetroxide. Within 330 h, one
bodies. Hydrazine, ammonia, ethylene glycol fumes, and the can expect onset of pulmonary edema and adult respiratory
products of pyrolysis can produce disorders ranging from distress syndrome. Bronchiolitis obliterans can then affect 50%
minor irritation of the upper airway to disruption of pulmo- of survivors. Intubation and respiratory support with applica-
nary capillary/alveolar integrity with resultant adult respiratory tion of positive end-expiratory pressure (PEEP) is necessary for
distress syndrome. patients with hypoxemia. Treatment with steroids is controver-
Although pulmonary infections do not seem to occur at a sial; trials with human subjects have not shown steroids to be
higher rate in space flight than on Earth in a standard medi- effective after nitrogen tetroxide exposure [83].
cal practice [80], infections are a risk if breaches in infection Hydrazine gas, a propellant used in both the Space Shuttle
defense are present secondary to pulmonary injury. Inhalation and the ISS, is also extremely irritating to upper airway passages,
of toxic substances or aspiration of foreign bodies are two of skin, and eyes. Similar damage to the lower pulmonary tree
the most likely examples of such an injury. Since neither roent- can ensue with significant exposure [83].
genographic nor bronchoscopic imaging capability will exist Ammonia, which is used as a coolant on the Space Shut-
on board spacecraft in the near future, accurate assessment by tle and the ISS, presents another pulmonary hazard. Any
the CMO will be essential. The relatively noisy environment contamination of the spacecraft atmosphere by ammonia
of spacecraft will make auscultation, the traditional chest would require simultaneous breaches in several barriers
physical examination technique, difficult. Moreover, auscul- [84] or passage into the cabin via a contaminated space suit
tation is not sufficiently accurate to confirm the presence or exposed during EVA. Ammonia is very irritating to upper
5. Acute Care 115

airway passages, but crewmembers can adapt to exposures for carbon monoxide, hydrogen chloride, and hydrogen cya-
of limited severity. A few seconds of ammonia gas exposure nide is possible with portable chemical and infrared sensors
cause inflammation of the conjunctiva and pharynx, pharyn- available on both the Space Shuttle and the ISS.
geal and retrosternal pain with cough, and dyspnea, but no Crewmembers experiencing symptoms after exposure to
abnormalities on x-rays. Hypoxemia from chemical burns to combustion products must be monitored for 24 h for signs of
the tracheobronchial tree may be delayed by 12 days. The pulmonary edema and hypoxemia. This was done after the
presence of rales and wheezing can predict the onset of adult Mir space station fire in 1997, when the onboard CMO set up
respiratory distress syndrome and progression to worsening an airway station and continued reevaluation of his crewmates
hypoxemia that can take weeks or longer to resolve. However, over 24 h. This episode led to the design of new Space Shuttle
quick removal of the affected crewmember from the source medical kits that allow easier access to airway equipment with
can limit pulmonary injury, with symptomatic improvement better hardware restraint.
in a week and complete recovery in 12 months. Conversely, For spaceflight crews who will return to the Moon or go
some victims have developed moderate obstructive pulmo- on to explore Mars, exposure of spacecraft cabin interiors to
nary dysfunction presenting as reactive airway disease 26 native dust may cause cough and airway irritation to airway
months after exposure [84]. passages. One Moon-walking astronaut relayed after land-
The first steps in preventing injury are to protect the crew- ing that the lunar soil caused breathing problems, although
members and contain the contaminant. Crews can don oxygen no evidence of a medical problem was reported during flight
masks that cover the eyes and mucous membranes of the nose and postflight examinations were normal. Some Moon-walk-
and mouth. Skin protection should be maintained with use of ing astronauts reported that lunar dust caused nasopharyngeal
gloves and chemical-resistant suits. Any contaminated cloth- irritation as well [88].
ing should be disposed of in wet trash containment systems
that entrain air through filters and dump the air overboard.
EVA-related contamination can take place if a reaction control
Allergic Reactions
system jet leaks or fires inadvertently with impingement on A severe allergic reaction could be disastrous during a space
the space suit; the spacecraft atmosphere becomes contami- mission. All crewmembers are tested before a flight for their
nated when the crewmember returns to the spacecraft. The responses to common medications in the Space Shuttle and ISS
onset of irritation, cough, and coryza in other crewmembers medical kits to determine any unexpected allergic responses or
immediately after an EVA should raise suspicion of such con- adverse side effects. An allergic response to these medications
tamination. The source of the contamination can be removed is not disqualifying for space flight, but it allows appropri-
by the EVA crewmember returning to the airlock and expos- ate planning of the medical kit inventory. Other antigens that
ing the space suit to the sun, which bakes out or sublimates could initiate an anaphylactic response are tracers and mark-
the contaminant from the suit [85]. ers used in life sciences experiments, although these markers
Primary treatment and stabilization of crewmembers can be are evaluated carefully with the crewmembers before flight.
accomplished with the hardware provided on the Space Shut- The clinical manifestations of vasodilatation-induced hypo-
tle and the ISS. After the exposed crewmember is removed tension in microgravity are unknown, but presumably the
from the source of the offending contaminant and an initial presentation would be different without a gravity gradient to
assessment is performed, -adrenergic aerosols are available exacerbate orthostatic hypotension.
to treat reactive airway manifestations. Parabolic-flight stud- Items in the Space Shuttle and ISS medical kits for treating
ies showed that albuterol aerosol dispensers operate similarly allergic reactions include subcutaneous epinephrine, paren-
in simulated microgravity and on the ground, dispensing a teral and oral steroids, -agonist aerosols, and IV fluid supple-
90-g dose per activation as expected [86]. Repeat examina- mentation. The challenge for treatment on board spacecraft is
tions and pulse oximetry monitoring should be continued for the need for rapid response in microgravity. The medical kits
at least 24 h. Carbon monoxide diffusion capacity studies of therefore contain epinephrine autoinjectors, syringes filled
normal crewmembers during space flight have also indicated with 1:1,000 epinephrine and diphenhydramine, steroids, and
that thoracic fluid shifts do not produce subclinical pulmo- -aerosols packaged together in an easily accessible location
nary edema, so any hypoxemia could not be attributed to a and restrained on Nomex fabric pallets.
normal physiologic response to microgravity [87]. The onset
of hypoxemia mandates consideration of return to Earth (for
Dental Disorders
missions in LEO) and provision of 100% oxygen. Increasing
levels of ventilation support up to intubation and mechanical Dental problems are one of the most common reasons for
ventilation can be accomplished on the ISS. evacuation from submarines and surface ships [89]. Although
Similar principles apply to crewmembers who are exposed dental care is of paramount importance for crewmembers who
to toxic pyrolytic products after a spacecraft fire. Shuttle and are preparing for space flight, dental trauma or infections can
ISS flight rules mandate that crewmembers don oxygen masks and have occurred during missions. For example, in the Russian
when a fire is detected. Real-time monitoring of spacecraft air space program, the forces associated with the vibrations and
116 T.H. Marshburn

accelerations during launch have dislodged crewmembers but this has yet to be verified because urine cultures have not
crowns. Dental trauma is also possible through the use of the been available in flight. Broad-spectrum coverage of Pseu-
mouth as a convenient means of holding tools such as flashlights domonas spp. is necessary as well, because this was the offend-
when working in enclosed areas. CMOs are trained to stabilize ing organism in a case of urosepsis in the Apollo Program [10].
fractured teeth and perform temporary crown replacement, and Urinalysis is available to assist in the diagnosis of urinary tract
the Space Shuttle medical kit contains sufficient supplies to infections, but measurement of blood leukocytes is not currently
perform these procedures. Russian and ISS medical kits also possible with the ISS or Space Shuttle medical kits.
contain tooth-extraction tools for dental trauma or for infection Urinary retention has occurred on a few occasions during
that has not responded to other means of treatment. Sufficient space flight. Urethral catheterization with leg bag drainage is
oral and parenteral antibiotics are also on board Russian and possible and has been performed in space flight. Simultane-
U.S. spacecraft to treat apical abscesses. Lower light levels, ously restraining hardware while maintaining sterility is the
limited dental training for CMOs, limited supplies, and the most significant difficulty in performing catheterization in
need to restrain tools remain the most significant challenges for microgravity. Wearing a leg bag in microgravity by itself does
assessing and treating dental problems on orbit (see Chap. 26). not affect intravehicular operations, although the increased
potential for urine reflux from the catheter into the bladder
may predispose crewmembers to urinary tract infection [17].
Urologic Disorders
Reasons for a possible increased rate of urinary hesitancy dur-
Urologic problems during space flight can involve ureteral ing space flight missions are discussed in Chap. 13. The flight
stones, urinary tract infections, urinary hesitancy, and urinary surgeon must be aware of the amount of promethazine used
retention. Prostate infections have occurred at least twice by crewmembers for treatment of SMS, as its anticholinergic
during space missions [10,30], and available documentation activity may add to any predisposition for urinary retention.
indicates that one case led to the return of the crew from LEO.
Urologic problems in space flight are addressed in detail in
Cardiac Problems
Chap. 13, and only general principles are described here.
Astronauts and cosmonauts are theoretically prone to ureteral As spaceflight missions increase in duration, complexity of
stone formation in the first hours of arrival on orbit and imme- payloads, and number of high-risk activities (e.g., EVAs), the
diately after return to Earth. Although no episodes of ureteral need for on-site cardiac life support capability has increased
colic have occurred during flight in the U.S. space program, it as well. The 1990s have seen acceptance of smaller, more
almost caused the deorbit of a Russian Salyut crew from LEO autonomous, and user-friendly defibrillator units outside of
[30]. The on-orbit challenge, in addition to pain management, traditional hospital and emergency medical service settings
will be diagnosis, since IV pyelography or other roentgeno- in terrestrial medical care. A defibrillator is now part of the
graphic evaluation will not be available. Clinical presenta- medical inventory on some Space Shuttle and all ISS flights.
tion of ureteral colic is not expected to differ substantially on Medical care in space flight is approaching the terrestrial
orbit from that on Earth. Standard terrestrial urine dipsticks ambulance-level medical care.
can be used to assist in the diagnosis, but urine hemoccult The first defibrillator flown in space (on the fifth NASA-
tests are only 67% accurate (for more than five red blood cells Mir mission of the joint U.S.Russian Phase I program, May
per high-power field) for making a definitive diagnosis [90]. 15October 6, 1997) was left on board the Mir space station.
Sonography, available on the ISS, may be used to visualize Since that time, Space Shuttle medical payload manifests have
significant hydroureter or hydronephrosis. included defibrillators and cardiac medications on specific
Parenteral nonsteroidal anti-inflammatory agents are car- missions, if required by the unique characteristics of that mis-
ried in the ISS medical kits, and both the Space Shuttle and sion and its payload activities.
the ISS medical kits contain parenteral opioid analgesics for Although the astronaut and cosmonaut populations are
pain management of ureteral colic. The only concern is the extensively screened for cardiovascular disease before flight,
limited supply of analgesics. Substantial parenteral analge- episodes of arrhythmia and symptoms suggestive of cardiac
sia cannot be maintained for much longer than 24 h using the ischemia have nevertheless occurred during flight. During
medical kits on either spacecraft. Medical management will the Apollo Program, a crewmember experienced a 14-s run
focus on maintaining adequate hydration and monitoring for of bigeminy during flight, concomitant with a feeling of
fever or sonographic evidence of hydronephrosis from com- extreme fatigue. That same crewmember experienced a myo-
plete ureteral obstruction. A stone visualized by sonography cardial infarction 2 years later, from which he recovered [10].
that is larger than 8 mm (0.3 in.) is not likely to pass and may The Russian medical community terminated one mission
require surgical removal [91]. early because of an episode of paroxysmal supraventricular
Oral and parenteral antibiotics that cover the common tachycardia [31]. In at least one other incidence, a cosmonaut
offending organisms are available in the Space Shuttle and was placed on cardiac medications for symptoms suggestive
the ISS medical kits. E. coli is thought to be the most common of ischemic heart disease (personal communication, V. Bogo-
cause of urinary tract infection in space flight (as it is on Earth), molov, 2002). Moreover, long-duration space flight may
5. Acute Care 117

predispose crewmembers to arrhythmias. Review of electro- cular saline as needed, and aspirin, sublingual nitroglycerin,
cardiographic tracings during EVA [92] and the results of in- morphine sulfate, and -blockers, all of which are available
flight Holter monitoring during Space Shuttle missions [93] to the crew as needed. ISS medical kits contain sufficient
do not show a predisposition to arrhythmias during short- epinephrine and lidocaine to provide two runs through the
duration space flight, but limited data suggest this may not ACLS pulseless ventricular tachycardiaventricular fibrilla-
be true for long-duration space flight [94]. Also, electrocu- tion algorithm [95,96]. Vasopressin and amiodarone are not
tion remains a potential cause of cardiac arrhythmia during a yet included in the ISS medical kits pending resolution of
mission. The electrical power systems (28 Vdc on the Space packaging and storage issues.
Shuttle and 120 Vdc on the ISS) represent a potential electri- Some aspects of ACLS, however, are unique to the space-
cal injury hazard. Finally, depressurization in preparation for flight environment. In the case of the full arrest, transfer of the
EVA exposes crewmembers to an increased risk of cardiopul- affected crewmember to the ACLS location, where space must
monary decompression sickness (DCS), which may require be dedicated for restraint hardware, access to 100% oxygen,
advanced cardiac life support (ACLS) capability as well. and ACLS medications will be necessary. Fortunately, transfer
The effects of microgravity on the symptoms and clinical of an unconscious crewmember is much easier in micrograv-
manifestations of ischemic heart disease are unknown. A ity than on Earth, so the time to cardioversion could be shorter
crewmember may be reluctant to assign early symptoms of than on Earth.
chest pain, diaphoresis, or dyspnea to cardiac causes because Multiple simulations during parabolic flight demonstrate that
of reliance on extensive medical screening performed before a CMO could easily perform rescue breathing while transporting
the mission and because of reluctance to cause unnecessary an unconscious patient [9799]. These simulations assessed the
mission impact. Because an astronauts or cosmonauts awake effectiveness of a variety of cardiac compression techniques.
pulse rate and diastolic blood pressure are nominally about In general, the rescuer could deliver adequate compressions, as
10% lower on orbit than on Earth [38], ischemic symptoms measured by mannequin compression recordings, either from
may not become apparent until the crewmember is partici- the patients side by using a waist restraint or by planting
pating in some vigorous activity that significantly increases his or her feet on a surface opposite the patient and placing his
myocardial demand (e.g., exercise on the treadmill or perfor- or her hands in the standard position. In the inverted position,
mance of an EVA). thrusts are delivered by knee and elbow extension. This method
Evaluation of a crewmember with ischemic heart disease has been simulated on orbit as well (Figure 5.1). Both of these
will probably rely heavily on the clinical impression of the options seem to be successful because they simultaneously
CMO and on consultation with the flight surgeon and ground allow adequate compressions and positional stability. Performing
specialists. Some degree of jugular venous distension is present cardiopulmonary resuscitation with one hand (while the other is
in all crewmembers in space flight because of the cephalad used to restrain the provider), with the provider either aside or
movement of intravascular volume. Signs and symptoms of straddling the patient, was too fatiguing and allowed too much
cardiac ischemiadiaphoresis, nausea, shortness of breath movement between provider and patient [17].
are expected to be similar in space and on Earth, but this is External mechanical and pneumatic compression devices
not certain. Auscultation will be difficult on orbit because have also been evaluated in Space Shuttle and parabolic
of high ambient noise levels, so subtle murmurs and per- flights. Given the required deployment time and lack of sig-
haps even rales will be difficult to detect. Dependent edema nificant improvement in compression efficacy, these devices
would probably not be a prominent feature in a crewmem- have not been considered for use in spacecraft [17].
ber with significant myocardial injury and subsequent decre- In general, restraining the provider and the patient is of
ment in ejection fraction, although edema would presumably paramount importance throughout resuscitation. Engineering
be present in a general distribution as well as in the face or constraints do not officially allow free-floating cardioversion
upper extremities. Although sonography will be available on at this time [17] to avoid unintentional grounding through
the ISS, the ability to determine wall motion abnormalities or wires or other floating hardware and exposing critical space-
valvular damage will depend on the severity of disease, the craft-control electronics to damaging electrical pulses. Defi-
skill of the CMO, and the bandwidth availability for real-time brillation units are tested to comply with electromagnetic
assessment of images with terrestrial consultants. field limits during charging, defibrillation, and pacing. A crew
In the U.S. space program, rhythms can be monitored medical restraint system flown on the ISS allows electrical
on orbit with a 5-lead electrocardiograph on the ISS and a isolation of the patient from the module. This restraint system
3-lead electrocardiograph on Space Shuttle flights. Rela- also serves as a stable platform on which the providers can
tive resting bradycardiac and decreased diastolic pressures restrain the patient, themselves, and their hardware. Consistent
are known to be associated with space flight, and further training of CMOs with choreographed resuscitation procedures
manifestations of ischemic disease on electrocardiography is one of the best safeguards against inadvertent grounding
in microgravity are unknown. through the providers.
Treatment in space would follow standard terrestrial regi- Hardware restraint is a significant challenge for perform-
mens: O2 via nasal cannula or non-rebreather mask, intravas- ing a resuscitation in microgravity. Hardware and instru-
118 T.H. Marshburn

face tension forces that cause secretions to adhere to oropha-


ryngeal surfaces. A manual suction device, developed to allow
one-handed operation, has been tested in parabolic flight and
is part of the current ISS medical airway kit [101].
Ensuring proper endotracheal tube placement in space flight
is expected to be the same as on the ground, with a couple of
notable exceptions. Low ambient light levels may make accu-
rate reading of colorimetric end-tidal CO2 difficult, and rela-
tively high ambient noise levels will limit auscultation. For
these reasons, an esophageal detector bulb is provided in the
ISS medical kit.
Drugs for ACLS will be given by means of an endotracheal
tube or by intravenous injection. Pulmonary function studies
in microgravity during the Apollo-Soyuz Test Project missions
[102] and those performed later by West and colleagues [87]
suggest that no significant barriers exist to using the endotra-
FIGURE 5.1. Astronaut Dan Bursch demonstrating posture and posi- cheal route for drug administration in microgravity. The lack
tioning for performing cardiopulmonary resuscitation chest compres-
of sedimentation of aerosolized droplets in microgravity can
sions using the crew medical restraint system in the U.S. Laboratory
result in decreased deposition of medication [103]. How this
Module of the ISS (Photo courtesy of NASA)
difference would affect medications delivered by the endotra-
cheal route is unknown.
ments are inevitably misplaced in the flurry of activity Guidelines from the American Heart Association suggest
surrounding a simulated-microgravity resuscitation. Blood that the recipients arms be elevated to facilitate the flow of
products, packaging, and used hardware that ordinarily fall intravenously injected medications through the venous sys-
to the floor in a terrestrial resuscitation will float in micro- tem to the central circulation. Obviously, this will not help
gravity. Thus CMOs are trained to be constantly aware of in microgravity, and IV medications will have to be chased
equipment placement, and straps, waste bags, and needle with saline boluses.
containers are incorporated in the design of the medical
kits, floor layout, and restraint system to restrain critical Procedures
hardware and waste.
Microgravity allows a wide variety of unique approaches Intramuscular Injection
to attaining a definitive airway in patients in respiratory
distress. Restraint of the patient is essential for adequate Promethazine is most commonly given in space flight by IM
direct laryngoscopy; that restraint is provided by the crew injection; IM injection is in fact the most commonly performed
medical restraint system. To perform direct laryngoscopy in-flight medical procedure in the U.S. Space Shuttle Program
in microgravity, the provider can use his or her knees to [4]. CMOs use syringes from the SOMS kit that are filled
grasp the head of the restraint system or even grasp the on the ground before flight to minimize the need to remove
head or shoulders of the patient so as to establish adequate bubbles from the solution. Although the injection itself differs
stability for excellent visualization. Microgravity also little from terrestrial IM injections, the CMO must ensure ade-
allows the CMO to float above the patient and to more quate restraint of both himself or herself and the patient. The
easily perform blind digital intubation. Investigators have most common technique for preventing inadvertent movement
evaluated intubation from the side of the patient for those is for patients to stabilize themselves in the corner of a cabin.
cases in which the patients head is close to a bulkhead IM injections are almost always delivered into the superior
or another structure. Although possible, this technique gluteal area to prevent subsequent limitation of motion of the
requires more time because of difficulties in restraining upper extremities from the muscle soreness that occasionally
the rescuer. However, the expected low success rate of results from the procedure.
intubation via direct laryngoscopy by minimally trained
personnel has led to use of the intubating laryngeal mask
airway as the primary method of attaining a definitive air-
Intravenous Catheterization
way during space flight [100]. A definitive airway should CMOs and mission specialists performing biomedical investi-
be secured before the affected crewmember is transported gations have inserted IV catheters on orbit in antecubital veins
to the ground, either by Space Shuttle, Soyuz, or a future with success rates similar to those in ground operations. The
dedicated return vehicle [17]. greatest challenges in accomplishing venous catheterization
Methods of saliva containment in simulated microgravity are in microgravity are again restraint of hardware and patient.
different from those in terrestrial practice because of the sur- A rapid and common means of restraint is to apply a strip of
5. Acute Care 119

duct tape, adhesive side facing out, near the workstation. IV procedures can be performed with some modifications. Other
tubing, saline locks, alcohol wipes, iodine swabs, and trash considerations for surgical care in the microgravity environ-
are stuck to the tape and easily kept in place and within reach. ment are addressed in Chap. 6.
Several kinds of sharps containers are available, including
foam blocks and metal containers with hinged lids; both have
been used successfully. Transport
Phlebotomy and catheterization are otherwise somewhat
easier in microgravity once the CMO and patient are well Specific techniques for transporting patients from a space-
restrained. No obvious differences have been observed in craft in LEO to a definitive care facility on the ground vary
flashback or fluid flow through IV tubing, and blood control depending on which rescue vehicle is used (i.e., Soyuz,
is rendered simpler by the predominance of surface tension Space Shuttle, a U.S. crew return vehicle) and the medical
in the absence of gravity. Air elimination filters that use a problem being experienced. The parabolic flight and Space
hygroscopic membrane were shown to perform adequately Shuttle investigations mentioned earlier in this chapter
in removing air bubbles in the continuous microgravity con- revealed a series of basic principles that can be applied in
ditions of the Spacelab Life Sciences-1 mission (STS-40). all emergency deorbit scenarios. Specifically, at least 24 h
The filters can dry out, however, and a continuous pressure from the moment of declaration for deorbit until delivery of
head is required to maintain filter filling. Such pressure can a patient to a definitive medical care facility on the ground
be provided by squeezing the IV bag or by placing the bag will be required to deorbit an injured or ill crewmember.
in a blood pressure cuff and inflating it to between 50 and Stabilizing the patient before transport is as important in
75 mmHg [104]. space flight as in terrestrial emergency service settings. IVs,
monitors, a ventilator, and an airway need to be secured in
preparation for return [17]. Monitors available to the CMO
Resconstitution of Medications during reentry will be limited; such monitors currently
Fluid reconstitution of drug powders offers some challenges consist of pulse oximetry and monitoring provided by the
in space flight. A bubble in a bag of normal saline or a vial, defibrillator. An automatic blood pressure monitor will be
for instance, does not float to the top. If the container is available as well. Injured or ill crewmembers will not be
agitated, froth forms, which makes accurate aspiration of a transported in their pressure suits, as patient access is too
desired volume difficult. Syringes cannot be thumped to limited. Returning an ill crewmember to the one-G environ-
send bubbles toward the needle hub. Therefore, at present all ment in a recumbent position is both desirable and possible
parenteral medications and saline bags are stored in a form in in the Space Shuttle. Also, an injured or ill crewmember
which bubbles are removed before flight. Parenteral medica- returning in the Space Shuttle does so in a supine position,
tions in powdered form are desirable because of their smaller with lower extremities flexed at the hip and knees, so that
storage volume and generally longer shelf life; thus an under- the lower legs can rest in a forward middeck locker [98].
standing of how these medications can be reconstituted in Return in a crew return vehicle or Soyuz offers other chal-
microgravity is necessary. Flight surgeons and space crews lenges; these issues are covered in Chap. 7.
have used several techniques to create a single airfluid level,
both in parabolic flight and on orbit. All of these techniques
involve spinning the IV bag or syringe to centripetally drive Conclusions
the fluid away from the center of spin and against the outlet
port (e.g., the needle). IV doses of medications mixed on orbit Further refinement of these and other spaceflight medical
are not as consistently titrated manually as on the ground. Sev- procedures, application of new technologies in the microgravity
eral mixing devices have been developed for use on orbit, but environment, and better understanding of human physiology
none has been so effective as to be worth its cost in terms of in space flight are all areas of ongoing investigation. Two other
weight and volume [105]. issues now being actively addressed are also critical to the suc-
cess of treating an acutely ill or injured spaceflight crew-
member: first, the optimal training schedule and environment
Other Procedures for CMOs and astronaut physicians, to ensure expertise
Cricothyrotomy, tonometry, thoracostomy, laparoscopy, diag- in medical procedures relevant to space flight; and second,
nostic peritoneal lavage, throacic, or abdominal sonography, development of means to transport a critically ill patient, with
and urethral catheterization have all been performed with a pharmacopoeia that is necessarily limited in volume and
animal models in parabolic flight. The general principles of scope, using predefined procedures that are specifically rel-
restraining hardware, patient, and operator apply for each evant to spaceflight operations. Resolution of these issues will
procedure. The investigators who performed these procedures enhance the medical capabilities of spaceflight crews in LEO
have established that once familiarity with self-stabilization and will be essential to medical operations during expeditionary
and locomotion in microgravity are attained, any of these spaceflight missions.
120 T.H. Marshburn

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6
Surgical Capabilities
Mark R. Campbell and Roger D. Billica

Although no surgical procedures have been performed on these studies have suggested that illnesses or injuries that will
humans during space flight, the risk of a problem arising that require major surgery will be rare.[1,2] However, as these
requires surgical intervention is nonetheless real. From a time- authors have noted, when such illnesses or injuries do occur,
weighted standpoint, until the advent of long-duration missions the effect could be disastrouspossibly leading to a mis-
in the U.S. Skylab program and the Russian Salyut and Mir sion abort or a partial crew return. At the very least, an event
programs, the probability of an in-flight problem arising that requiring that major surgery be performed on a crewmember
would require a surgical solution was small; thus clinical will greatly affect the overall mission and necessitate a large
experience and expertise in performing surgery on humans in amount of resources to be treated successfully. Although ill-
microgravity remained quite limited. The lack of on-site sur- nesses and injuries that require minor surgery will probably
gical expertise was keenly felt when Russian space program be more common, they will also pose challenges in the micro-
officials were faced with the possible medical evacuation gravity environment.
of a Salyut 7 cosmonaut who was experiencing abdominal
pain thought to be due to appendicitis. Although that episode
turned out to have been caused by probable ureterolithiasis The Challenges of Performing Surgery
rather than appendicitisthe cosmonaut recovered and did in Space Flight
not require an early return to Earththis experience nonethe-
less underscored a pressing need in space flight. Numerous challenges will arise in performing even minor
With further increases in crew size and mission duration surgical procedures in microgravity (Table 6.1). Some of the
projected in the near future for the International Space Sta- challenges that will need to be addressed include achieving
tion (ISS) and the exploration-class missions that will follow, adequate anesthesia, maintaining a sterile field and technique,
the likelihood of events occurring in space flight that will providing appropriate lighting and exposure, maintaining
require surgery will also increase. Moreover, the probability of hemostasis, deploying instruments, and restraining the opera-
trauma (including penetrating trauma, lacerations, crush injuries, tor and patient. The current weight and volume restrictions on
and thermal and electrical burns) occurring will increase as spacecraft severely limit the availability of surgical and anes-
astronauts and cosmonauts conduct ISS construction-related thetic equipment to cover all but the most likely situations.
extravehicular activities that involve manipulation of high- The surgical capability of any medical care system in space
mass hardware. A surgical need could also be precipitated flight also will be limited by the surgical capability and train-
by exercise countermeasures, which may lead to minor and ing of the crew medical officers (CMOs), those members of
major orthopedic injuries. Routine surgical diseases such the crew specially tasked with and trained for rendering medi-
as appendicitis and cholecystitis can occur indiscriminately cal aid to their crewmates.
at seemingly random times. The physiological changes and Current limits on crew size and capabilities make it impos-
deconditioning effects of prolonged weightlessness will influ- sible to provide CMOs with the intensive training needed to
ence surgical diseases and treatment in predictable as well as handle major surgical procedures. Even if a clinically com-
unknown ways. Finally, the possibility of previously unknown petent and experienced surgeon is a crewmember, it is highly
surgical problems in the unexplored long-duration microgravity doubtful that that individual would be able to perform suc-
environment must be considered. cessful major surgery with minimal staff support, minimal
Analog remote medical care systems (e.g., equipment, resources, and possibly months of surgical inactivity. The risk
instruments, and personnel) have been studied to ascertain that the surgeon-crewmember might actually be the patient
the incidence and risk of surgical events. The authors of must also be considered.

123
124 M.R. Campbell and R.D. Billica

TABLE 6.1. Issues to be considered for performing surgery in microgravity. the simulated microgravity produced during parabolic flight
Restraining patient, operator(s), and equipment (Table 6.2) has explored many of these issues. These stud-
Providing and maintaining sterile field ies have led to the conclusion that after the patient, operator,
Providing appropriate lighting and exposure instruments, and equipment have been properly restrained,
Managing wastes, including sharps disposal
Maintaining hemostasis
surgical procedures may be more difficult to perform than in
Preventing contamination of the closed-loop spacecraft environment 1 G, but are nonetheless feasible in microgravity.
Accounting for the lack of gravitational retraction during surgical procedures
Providing suction and drainage
Providing anesthesia and appropriate monitoring Challenges in Exploration-Class Missions
Managing fluid levels and blood replacement
Providing capabilities for imaging and surgical diagnosis In future exploration-class missions to the Moon or Mars, the
Accounting for changes in endoscopic techniques on-board medical care system must become more capable and
Accounting for changes in physiology
Accounting for changes in fluid dynamics that affect the behavior of
autonomous as the crew size expands and the time required
bleeding and drainage to return an ill or injured crewmember to Earth to reach definitive
Accounting for changes in physical landmarks (shifting of internal organs) medical care (defined as the quality of medical care that is
Providing appropriate support during recovery available only in a hospital setting) increases. The time to
reach definitive medical care from the ISS may be as brief as
24 h but from a lunar base would be at best several days and
TABLE 6.2. Surgical issues addressed in the NASA microgravity program. from a Mars expedition would be more than 9 months. This
Dental care and intervention issue is discussed further in Chap. 7.
Wound closure techniques Mortality and morbidity related to illness and injury have
Airway management and percutaneous tracheostomy
accounted for more failures and delays in terrestrial expedi-
Advanced life support, including cardiopulmonary resuscitation and
defibrillation tions and new exploration than have defective transportation
Chest tube placement and drainage systems. Historically, these failures and delays can be attrib-
Peritoneal lavage uted to the long separation of the terrestrial expeditions from
Hemostasis definitive medical care. This has not been the case for space
Prevention of cabin atmosphere contamination from bleeding and
travel thus far, but becomes a more serious consideration for
drainage fluids
Bandaging and splinting the exploration activities now planned.
Sterile technique and maintenance of sterile field The medical care system on a future Mars expedition,
Patient, operator, and equipment restraint for example, will need to be autonomous because of the
Surgical instrument organization, restraint and logistics extremely long separation from definitive medical care.
Trash management and handling of sharp disposal
Planning for exploration-class missions must include judi-
Bladder drainage with Foley catheterization
Percutaneous drainage procedures cious analysis of the limitations on mass, volume, power, and
Suction techniques and drainage behavior of fluids medical training and careful balancing of those limitations
Monitoring technology against the need for comprehensive medical and surgical
Sonographic imaging care capability, including the need for surgical interventions
Intravenous fluids and therapy
(see Table 6.3). A system that includes a CMO and greater
General anesthesia techniques
Endoscopy technique and technology, including laparoscopy, thorascopy, on-board surgical capability than past space missions will
and cystoscopy be necessary because of the increased risks inherent in an
Telemedicine direction of surgical procedures exploration-class mission and the need to reduce the effect
of such risks on the mission and on crew health. Such a capa-
bility may be provided through a combination of traditional
Concerns have also been raised regarding the unknown resources and newer innovative technologies now in devel-
effects of microgravity on surgical bleeding, the need to pre-
vent contamination of the spacecraft atmosphere, and the
need to protect the operative field from the relatively high TABLE 6.3. Mission-related factors affecting surgical care.
particulate content of the spacecraft atmosphere. Physicians Remoteness and correspondingly long periods to reach definitive medical care
who have experience in microgravity quickly raise a host of Communication delays
other issues related to surgical capabilities during space flight, Limited medical care resources (weight, power, volume, lighting)
including basic questions regarding diagnosis and imaging, Microgravity
Physiological changes of long-duration space flight
the positioning of tubes, techniques for suction and drainage, Limited crew training and experience
the management of waste, and many other concerns. Some of Radiation exposure
the simplest functions that we take for granted on Earthsuch Enclosed environment
as restraint and positioning of the patient and accessibility of Psychological stresses
instrumentscould be factors that limit the successful perfor- Possible delays in wound healing
Possible immunosuppression affecting healing and the incidence of disease
mance of surgery in space. Research involving animal surgery in
6. Surgical Capabilities 125

opment, such as smart medical systems, medical infor- as well as laceration closure techniques that do not require
matics, telemedicine, and telerobotics. substantial surgical skills (Steri-strips, Dermabond adhesive,
and staples). The hardware available on the Russian space
station Mir was similar to the Space Shuttle medical system
Surgical Care System Capabilities in its capabilities.

The capabilities of the CMO and the medical hardware available


Surgical Capability for the International
on board will determine the surgical capabilities of any future
spaceflight medical care system; however, the CMOs training Space Station
is the factor that will most limit capability [35]. Medical and An advanced life support pack is included on board the ISS
surgical hardware is subject to strict limits in terms of weight, [9] to allow advanced cardiac life support, including venti-
volume, and electrical power required. Moreover, all of the lation and defibrillation, and advanced trauma life support.
hardware must function accurately and reliably in the micro- The invasive portions of these procedures have been evalu-
gravity environment after extended storage time with minimal ated in parabolic flight using animal models to validate their
checkout and maintenance and without expert operators or feasibility [10].
repair technicians on site. Hardware will probably be available Because evacuating a seriously ill or injured crewmember
on future space flights to perform surgical procedures that will from the ISS to a definitive ground medical facility
be beyond the capability of the CMO, but the availability of would take 624 h depending on the evacuation spacecraft
such hardware will also allow flexibility in handling a variety available (currently a Russian Soyuz capsule), the surgi-
of surgical problems on board. cal capabilities of the ISS medical care system need not
Reviews of other remote medical care systems under- be extensive. Current ISS procedures do not require that
score not only the importance of emphasizing CMO training a physician be on board, and the CMO has only 80 h of
but also the need to consider the possibility of using medi- medical training; thus the ISS surgical hardware does not
cal treatment for diseases traditionally considered surgical, provide the capability for major surgical procedures such
such as appendicitis, during space flight. Assessments of as thoracotomy, exploratory laparotomy, vascular repair, or
space medicine requirements and training with regard to crew invasive orthopedic procedures. The emphasis instead is on
selection have emphasized the importance of surgical capabil- stabilization, medical transport, and initial advanced life
ity and have proposed 23 years surgical training for future support capability [11].
CMOs for long-duration exploration-class space flights such
as a Mars expedition [6]. Telemedical consultation, a recent
modality with which substantial clinical experience has yet Future Surgical Systems
to be accumulated, will be important to augment the clini- As exploration-class activities such as constructing a lunar base
cal experience necessary for spaceflight medicine. Although or an expedition to Mars become a reality, the time required
clinical experience with telemedicine is limited, telemedicine to reach definitive care will greatly increase, as will the need
has been shown to be valuable in remote-care environments. for surgical capabilities in the medical care facility. The medi-
Nevertheless, a Mars expedition will face the problem of sig- cal care facility for these programs may be similar in size and
nificant communication delays because of the long distances capability to the Health Maintenance Facility that was origi-
involved; two-way communication times will range from nally planned for Space Station Freedom [12,13]. That facility
about 856 min, depending on the orbital configuration of the weighed 5,291 kg (2,400 lb) and displaced 30.5 m3 (100 ft3) in
Earth and Mars, making telemedicine awkward and real-time volume. It consisted of a microgravity surgical workstation,
input impossible [7]. which was similar to an operating table and was designed to
restrain both the patient and the operator. It also was to have
Surgical Capabilities During Previous Missions had a digitized x-ray capability, a ventilator, a defibrillator,
monitors, an intravenous pump, a medical computer, stor-
Early space missions had only rudimentary medical kits on age for medical and surgical supplies, and a microgravity
board until the longer-duration Skylab missions [8] (see also suction unit. That suction unit used centrifugal force [13,14]
Chap. 4). A minor surgical kit that allowed laceration closure to separate air/fluid mixtures and allowed the measurement
was included for the first time on Skylab, as was expanded and containment of biological fluids (urine, blood, gastric
diagnostic and medical therapeutic hardware. The Space contents, and pleural fluid).
Shuttles medical system, which is used today, contains the The effects of new and evolving technologies on future
components of a minor surgical kit for laceration closure surgical care systems for exploration-class space flights are
using conventional suturing techniques, but the components difficult to predict. Many fascinating possibilities are being
are individually wrapped, making the logistics of actually considered, and new choices will certainly emerge. The major
performing a surgical procedure more difficult than if an effect that these technologies are expected to have on surgi-
integrated system were used. Local anesthetics are available cal care will be to reduce the impact of remoteness, short-
126 M.R. Campbell and R.D. Billica

ages of resources, and limited surgical skills. For example, riences. The incidence of appendicitis in these analog pop-
hemoglobin-based oxygen carriers, developed as a substitute ulations has been reported as 12 per 100,000 person-days,
for blood transfusions, would greatly affect a CMOs ability [1,2,1517] which would be equivalent to 12 cases every
to resuscitate a trauma patient during space flight. Develop- 45 years in a six-person space station.
ments in nanorobotics, smart medical systems, computer
medical informatics, noninvasive sensors and diagnostics, and
telemedicine all have the potential to increase the autonomy of Surgical Research in Simulated-Microgravity
the remote surgical team. It is hoped that the development and Environments
validation of these technologies will allow a paradigm shift in
the requirements for traditional surgical capabilities for space
flight and will also provide feasible solutions to reducing
Neutral Buoyancy
medical and surgical risks. Research has only recently begun into surgical techniques
to be used in microgravity. Although neutral buoyancy
(underwater) evaluations of surgical techniques have been
Experience from Analog Environments suggested [18], such evaluations are not as feasible or as
realistic as those conducted in a true microgravity envi-
The Russian experience in long-duration space flights has ronment, because surgical fluids interact with the water
been helpful in verifying that medical issues will affect the environment far differently than they do with an air envi-
mission in terms of lost crew work time, diminished crew per- ronment. The water environment negates the predominant
formance, and, in some instances, early crew return. Most of effects of surface tension forces on surgical fluids such as
the medical events that have taken place occurred 26 months blood. Moreover, the water interacts with the operator to
into the mission, well after the acute period of physiological create resistance and drag with any movements, and thus
and psychological adaptation. Although most medical care each individual piece of hardware and tissue component
issues have been minor, medical evacuations have been neces- must be made neutrally buoyant so that their behavior mim-
sary during Russian space flights. These evacuations resulted ics that in microgravity.
from specific medical events, but they were also enhanced by
the psychological stress of long-duration space flights.
Parabolic Flight Program
The experiences of non-spacefarers using various remote
medical care systems have also been helpful in predicting Parabolic flight (Figure 6.1) is the only method to investigate
the incidence of specific surgical diseases and the ability surgical techniques in near-weightlessness without actually
to medically treat some diseases that have classically been going into space. In the NASA Microgravity Program, the
considered surgical. Epidemiologic studies of analog popu- aircraft is typically flown in 40 parabolas for each mission,
lations, especially those on U.S. Navy submarine [1,2,15,16] with each parabola generating approximately 25 s of free fall
and Antarctic [17] expeditions, indicate that major surgical (weightlessness) followed by a 25-s 1.8-G pullout (Figure
events, although rare, are catastrophic to the mission, as they 6.2). The short duration of the microgravity window and its
often require medical evacuation. On the other hand, sus- alternation with hypergravity windows are obvious limitations
pected appendicitis (a so-called minor surgical disease) was, to applying parabolic flight experience to space flight; how-
in combination with psychiatric events, the most common ever, parabolic flight remains the best simulation of micro-
cause of medical evacuation from patrol submarines. The gravity available on Earth for this purpose.
incidence of minor surgical diseases in analog populations
seems to range between 1 per 8,000 to 1 per 13,000 person-
Findings from Parabolic Flight Studies
days [1,2]. This rate translates to a single event every 36
years for a six-person space station. Russian investigators performed limited surgical procedures
Analysis of other remote care medical systems reveals that (laparotomy and celiotomy) on locally anesthetized rabbits in
some surgical diseases can be treated medically in combination parabolic flight in 1967 [19,20]. A closed, transparent surgi-
with careful and continuous evaluation of the patient. The cal canopy and magnetic instrument holder were used. The
successful nonsurgical treatment of acute appendicitis in the reports, which were observational and brief, stated that no
crews of both British Royal Navy Polaris submarines and problems were encountered in controlling venous bleeding,
U.S. Navy submarines is well documented [1,2,15,16]. The as the blood typically pooled at the site of injury. Arterial
U.S. Navy protocol for treating suspected acute appendicitis bleeding, however, formed droplet streams that contaminated
consists of bowel rest, intravenous fluids, and antibiotics such the atmosphere and canopy wall. Also noted was that bowel
as cefoxitin and gentamycin. Patients are evacuated when evisceration during the laparotomy could affect visualization
possible, and evacuation is expeditious if improvement is not and could make abdominal wall closure difficult. Altered pro-
immediately evident, as was true for 5% of those cases in the prioception in the short-duration microgravity environment
British Royal Navy and 15% of those in the U.S. Navy expe- reportedly caused past pointing and overreaching. The overall
6. Surgical Capabilities 127

and restraining equipment, providing appropriate lighting


and exposure, and using conventional suturing techniques
have been evaluated and successfully performed in parabolic
flight [23,24]. However, these simulations have also shown
that certain basic procedures must be relearned. For instance,
glove packages must be restrained during gloving and gloves
must be removed with great care and minimal disturbance.
Because of their surface tension properties, conventional anti-
septics such as Betadine and Duraprep are easily adaptable for
use in microgravity. Finally, use of commercial sterile surgi-
cal drapes that have an adhesive surface that can be applied
directly to the surgical site greatly simplifies the otherwise
cumbersome procedure of draping in weightlessness.

Need for Restraint


FIGURE 6.1. The NASA KC-135 in parabolic flight. The aircraft is Restraining the patient, the operating personnel, and all surgical hard-
beginning another parabola that will produce about 25 s of weight- ware is a critical consideration in providing effective surgical
lessness. Usually 40 parabolas are flown on a typical mission (Photo care in microgravity. Clearly the patienteven if fully awake,
courtesy of NASA) conscious, and cooperativemust be rigidly restrained. The
operating personnel also must be securely restrained and yet
be able to move their arms and hands freely. Restraint has been
shown to enable the use of standard surgical techniques and
the maintenance of sterile fields. Several options have been
examined to facilitate instrument and supply restraint, such as
procedure-oriented kits, small surgical packs deployed on an
adjacent wall, magnetic surgical trays, and a sterile surgical
restraint scrub suit that allows supplies and instruments to be
restrained in the chest area [25].
Procedure-oriented kits offer an advantage over individually
packaged instruments because all of the supplies that are
necessary for the procedure are already available and organized
on a sterile field. The disadvantage is that the entire kit is con-
taminated if only one item is needed. Velcro, elastic cords, and
magnetic areas can be used to stabilize supplies. A plastic-lined
pocket, a guarded Styrofoam block (for sharp objects), and an
adhesive pad area (for suture ends) allow trash disposal.
FIGURE 6.2. Flight profile of the NASA KC-135. Each parabolic
Sterile instruments and supplies should be restrained in
maneuver gives 25 s of weightlessness followed by a 1.8 G pullout
such a way as to allow efficient, organized, and conventional
procedures and to maintain sterile technique in space flight.
conclusion was that surgery was possible in microgravity Conventional operating room concepts, such as a surgical tray
without major difficulties. for immediately needed sterile items and a surgical back table
U.S. parabolic flight research to examine surgical techniques for eventually needed sterile items, should be incorporated in
in weightlessness has also established several important the procedures. Trash items must be disposed of securely and
concepts. Surgical procedures in weightlessness can be per- safely without compromising sterile technique. Indeed, the
formed with no more difficulty than in the 1-G environment orderly disposal of discarded supplies is critical in the small
if the principle of restraining the patient, the operating per- volume of a spacecraft, particularly given the rigid constraints
sonnel, and the surgical hardware is adhered to [21]. Surgical on atmospheric contamination. The spacecraft atmosphere
bleeding and free blood may be adequately controlled by local must also be protected against the surgical debris generated,
methods such as the use of sponges and suction [22]. especially if bleeding occurs, irrigation is used, or pus and
The experience of medical personnel in simulations aboard other infectious fluids are encountered.
Skylab and Space Shuttle as well as in neutral buoyancy Restraining operating personnel has been simpler than
and parabolic flight indicates that many aspects of perform- anticipated. The initial concept of using waist belts and shoe
ing a surgical procedure are feasible in space flight. Simu- cleats that engage an omnigrid floor, as proposed for the Health
lations involving prepping and draping, gloving, deploying Maintenance Facility [13,14], has been discarded. Instead, a
128 M.R. Campbell and R.D. Billica

simple, low-placed horizontal bar, which allows the operators


feet to be placed underneath, has been found to provide secure
but flexible restraint.
Currently, a floor-level, easily stored crew medical restraint
system is present on the ISS; earlier versions of this device were
flown on Mir and Space Shuttle missions (Chap. 4). Although this
restraint system is designed for transporting a critically injured
crewmember, it also allows the patient, operating personnel,
and supplies to be restrained for minor surgical procedures.
Despite the usefulness of the crew medical restraint system,
a rigid, stable, waist-level table with multiple capabilities is
still considered a more optimal configuration for a procedure-
oriented restraint system. Such a system would need to be
compact, lightweight, and flexible enough to accommodate
crewmembers of different body sizes and positions, including
the microgravity neutral body position that is characterized by FIGURE 6.3. A prototype surgical canopy is tested with a mannequin arm
slight flexion of the knees, hips, shoulders, elbows, wrists, and during a zero gravity maneuver in parabolic flight. Human operators
cervical spine (see Chap. 2). are restrained at the feet and waist, with arms inserted into sterile
The need for more complex medical restraint systems will glove ports. A magnetic surgical instrument tray is in the foreground;
increase as the medical environment on board spacecraft becomes at the opposite end is an outlet for providing laminar airflow to carry
more independent. The first surgical simulations performed in away escaping fluids and surgical debris (Photo courtesy of NASA)
parabolic flight demonstrated that if operating personnel and
instruments were not restrained, even simple tasks such as drap- were found to form large fluid domes that adhered closely
ing a patient became extremely awkward. With restraint, the to the bleeding tissue because of the surface tension forces
parabolic flight environment was not found to be much different unopposed by gravity. Bleeding escaped local control methods
from the 1-G environment. Simulations of minor surgical proce- (e.g., suction and surgical sponges) only when an arterial
dures on the Spacelab Life Sciences-1 (STS-40) and the Neurolab droplet streams were allowed to form. This finding was con-
Space Shuttle (STS-90) missions and during parabolic flight also sistent with results of previous experiments in which citrated
confirm that surgery in weightlessness may be performed with bovine blood ejected from a syringe was used inside a glove-
little more difficulty than in the 1-G environment if the principle box during parabolic flight to simulate arterial and venous
of restraint is adhered to. bleeding (Figure 6.4) [26]. Those investigators concluded that
the surgical overhead canopy (Figure 6.5) would be useful if
Bleeding and Hemostasis uncontrolled arterial bleeding was present, if large amounts of
A major concern regarding surgical procedures in microgravity has surgical debris were generated, if large amounts of irrigation
been the behavior and control of arterial and venous bleed- fluid were used, or if pus was encountered.
ing. A related concern regards the potential for contamina- Other investigators have proposed the use of large, inflatable
tion of the fragile, closed-loop spacecraft atmosphere with environments that would surround the patient, operator, and
surgical debris and blood, and whether such contamination supplies during surgical procedures in microgravity. Although
could reasonably be prevented [26]. Mutke, in a 1978 study such an arrangement may seem impractical, the prototype
[27], conceptualized operating through an advanced inflat- hardware has surprisingly low weight and storage volume.
able, Lexan surgical bubble. Soviet investigators had actually Laser surgical techniques have also been suggested as a means
built several early versions of this concept and flown them of effecting bloodless surgical procedures in weightlessness
in parabolic flight simulations [19,28]. Markham and Rock, [33]. These techniques could be useful if the tools were min-
in the United States, also tested several prototypes simulating iaturized (handheld and battery-powered) and their safety
laceration closure on a mannequin in parabolic flight [2932]. validated. (Electrocautery devices generate too much radiofre-
Their prototype, which required inflation, was able to contain quency interference to be practical in a spacecraft, so their use
floating instruments and fluids ejected from a syringe. is not currently considered feasible.)
A NASA team evaluated a similar closed-system surgical Another approach to preventing atmosphere contamination
overhead canopy in parabolic flight (Figure 6.3) [28]. During was the concept of generating laminar airflow over the opera-
surgical procedures on anesthetized animals, this team exam- tive field to sweep up surgical debris and transport the debris
ined the behavior of arterial and venous bleeding and the ability to a collecting suction apparatus. NASA has evaluated a lami-
to control bleeding and prevent atmospheric contamination. nar airflow device in parabolic flight using mannequins and
Venous bleeding was subjectively increased over terrestrial surgery on animals. This device controlled the bleeding that
norms, possibly because of the lack of venous wall compression escaped local control methods and cleared the operative site of
in weightlessness. Also, both arterial and venous bleeding debris that would have otherwise impaired visibility. However,
6. Surgical Capabilities 129

first time in parabolic flight seemed to be unchanged from


such ventilation in the 1-G environment. Respiratory mechanics
and performance of artificial ventilation hardware were not
affected to a clinically significant degree. The adjunct pro-
cedures of intravenous infusion, laceration closure, and Foley
catheter drainage were also achieved without difficulty.
Although cardiopulmonary resuscitation is more difficult to
perform in weightlessness, it can be done effectively if both the
patient and the CMO are properly restrained. Although the basic
trauma support procedures of venous cutdown, cricothyroidot-
omy, peritoneal lavage, and chest tube insertion were found to
FIGURE 6.4. Blood pooling in weightlessness, which is characteristic be no more difficult to perform in microgravity than in the 1-G
of most bleeding whether the source is arterial or venous. Large fluid environment, restraint principles had to be observed, and manage-
domes are formed due to surface tension forces at the bleeding site, ment of fluid infusions and drainage required minor modifications
largely preventing dispersion into the enclosed cabin of hardware and techniques. These modifications include degas-
sing all infusion bags and lines, using pressure pumps instead
of gravity flow, keeping drainage tubes as short and as large in
diameter as possible to negate the effects of surface tension and
capillary action, and eliminating all possible communication to
the cabin atmosphere to prevent leakage. Percutaneous peritoneal
lavage, although it required less training to perform, was found
to be dangerous in weightlessness because of the additional pres-
sure of the bowel on the anterior abdominal wall, a direct effect
of the microgravity environment that created a high risk of bowel
perforation. Although an open peritoneal lavage technique was
shown to be feasible in microgravity, it required additional
training and experience. Also, the lack of 1-G capillary fluid pull
and the increased effects of fluid surface tension forces in weight-
lessness led to decreased drainage of peritoneal lavage fluid.
A Heimlich valve and a Sorenson drainage system were used
to provide chest tube drainage and fluid collection with minimal
equipment. This combination eliminated the risk of atmospheric
contamination and also provided the capability to use autotrans-
fusion to drain blood from a hemothorax (Figure 6.6). The use
FIGURE 6.5. An arterial droplet stream forming from an incision made
in the abdominal aorta of an animal model in microgravity as viewed
through an overhead surgical canopy. Operators have access to the
surgical site via arm portholes. This could easily be converted into
a non-dispersible fluid dome that remained adherent to the wound.
Some droplets have been stopped on the surface of the surgical canopy.
Instruments are well restrained on the surgical tray

that experience indicated that the use of standard surgical


techniques would be adequate to control most surgical bleeding
in weightlessness because of the formation of large, nondis-
persing fluid domes that adhere to the bleeding surface.

Advanced Cardiac and Trauma Life Support


In a series of dedicated parabolic flight experiments, NASA
space medicine experts evaluated the feasibility and practicality
of many standard techniques used for cardiac and trauma life FIGURE 6.6. Chest tube placement in an animal model demonstrating
support. Initial basic and advanced cardiac and trauma support the passive drainage of a simulated hemothorax. Fluid flows up
procedures could be performed in parabolic flight despite lim- without difficulty in weightlessness. This was performed using a
itations in having only minimal equipment available and using Heimlich valve and a Sorenson drainage system, which gives the
a nonphysician CMO. Artificial ventilation performed for the capability of immediate autotransfusion (Photo courtesy of NASA)
130 M.R. Campbell and R.D. Billica

of a percutaneous dilational technique for chest tube insertion procedure. Finally, such a system would provide for disposal
resulted in a procedure that required minimal CMO training and of dry trash, biological waste, and any instruments with sharp
minimal equipment, was technically easier to perform, and edges or points.
further decreased the risk of atmospheric contamination. Suturing
the wound tightly around the chest tube was found to be more
Atmospheric Contamination
important in microgravity than expected to control fluid leakage
and to prevent contamination. Performance of the procedure by Another theoretical concern associated with performing a
a nonsurgical physician required a minimal amount of train- surgical procedure during space flight (as compared with a
ing, on the order of 1 h of ground instruction. Telemedicine was standard operating room) is that of contamination of the
found not only to be feasible but also of clear benefit in this operative site by the relatively dirty spacecraft atmosphere,
project, because it facilitated the insertion of a chest tube under which could increase the incidence of wound infection. The
the direction of a remotely located general surgeon. amounts of particulates and colony-forming units in spacecraft
Chest tube drainage was still effective in weightlessness atmospheres are higher than in a conventional operating room
when passive drainage systems (without suction) were used atmosphere by a factor of 10 [21]. In microgravity, particles
because of inherent intrathoracic pressure. The Sorenson tend to be larger and are composed mostly of scurforganic
drainage system used for these experiments had previously particles from skin sloughing.
been proposed for the autotransfusion of chest tube contents Moreover, in light of preliminary evidence that the rela-
from a traumatic hemothorax. Immediate autotransfusion of tive numbers of pathogenic bacteria on skin and surfaces may
blood collected from a hemothorax without further processing increase during long-duration space flights and that in-flight
or anticoagulation has been shown to be safe and effective, medical facilities may be located near waste-management
especially in remote medical care situations [3436]. The facilities or kitchen or exercise areas on future spacecraft,
1-G disadvantage of using a short or a relatively anterior chest concerns have been expressed that the atmosphere may
tube, in which removal of thoracic fluid is limited because of contaminate wounds in microgravity. This concern may be
dependent pooling, should not be a factor in the micrograv- mitigated through the use of surgical overhead canopy and
ity environment. In microgravity, hemothorax fluid distributes laminar flow devices, which have been shown to lower these
itself uniformly as an adherent sheet along the chest wall, and counts logarithmically [22]. The rate at which clean wounds
neither the length of the chest tube nor its position in the chest become infected may also be higher in space than on the
cavity should influence the drainage flow rate. Some locula- ground because of possible immunosuppression and altered
tion of fluid also occurs in microgravity within the chest cav- cellular responses in healing of wounds and suppression of
ity because of surface tension forces. infections (Chap. 15) in addition to the high particulate counts
in the spacecraft atmosphere.
Patient Monitoring
Surgical Endoscopy
Although a standard medical monitoring system (including
electrocardiography and measures of blood pressure and The feasibility of performing a laparoscopy in microgravity
ventilatory parameters) functioned normally in parabolic has been questioned, with concerns focusing on the potential
flight, the hardware setup and the logistical management of for impaired visualization from the lack of bowel retraction in
the large number of tubes and wires would be problematic if the absence of gravity and from floating debris such as blood.
it were the responsibility of a single CMO. A more self- In response to these concerns, parabolic flight experiments
contained, centrally located, and easily deployable system were designed to investigate the feasibility of performing
would be better. Wires and tubing should be kept as short as laparoscopy and thorascopy on anesthetized animals in simu-
possible to prevent interference with other hardware floating lated microgravity [38]. These experiments showed that use of
in the microgravity environment. sophisticated endoscopic surgical tools is indeed feasible and
Another form of patient monitoring that has been consid- valuable in weightlessness but only when the CMO has the
ered is a trauma pod that could be rapidly deployed and ability, training, and experience to use them and when the nec-
transported and provide restraint for the operator and the essary supporting functions are in place. Cavitary endoscopy
patient [37]. Such a trauma pod could be used for advanced in microgravity also has the advantage of acting as a natural
cardiac and trauma life support operative procedures as well containment bubble that protects the operative site from the
as for more routine medical examinations. The pod would high-particulate spacecraft atmosphere and contains surgical
contain surgical hardware, instruments, and supplies for logis- debris and fluids.
tical efficiency and rapid deployment, and it would reduce the Laparoscopic surgery has been performed successfully in
intense labor required to perform a procedure in weightless- parabolic flight. Visualization was not impaired, apparently
ness. By providing routing interfaces, the trauma pod concept because of the elastic mesentery tethering the bowel and the
would also ease the difficulties caused by wires and medical surface tension forces present that cause any surgical debris
tubing in weightlessness that interfere with even a simple and blood to adhere to the abdominal wall [39]. In microgravity, the
6. Surgical Capabilities 131

bowel does not float within the abdomen or fall into the pelvis, 1-mm (0.04-in.) manipulation at the surgical site. Teleprescence
as it would in 1-G, because of this mesenteric influence, which surgery could also allow a surgical procedure to be performed
although minor in the presence of gravity, becomes predomi- at a remote location. Telerobotics can enhance both images
nant in microgravity. In 1-G, the abdominal cavity in a supine and dexterity in a surgical procedure, but telerobotics currently
individual forms a flattened oval because of the weight of that requires enormous hardware logistics and extensive training
persons anterior abdominal wall. The round shapes assumed even for the on-site personnel. These techniques also naturally
during microgravity increase the anterior-to-posterior diameter lend themselves to real-time telemedicine consultation and
and are better suited for laparoscopic visualization and manip- telementoring if no communication delays are present [45].
ulation because they increase the laparoscopic domain. Unfortunately, use of these techniques in space will be limited
Thorascopy, on the other hand, was found to be extremely by the long communication delays that make them impractical;
difficult in weightlessness because of the loss of the gravi- even the 2-s delay that occurs in low-Earth orbit (owing to
tational retraction of the mediastinum, which is critical to indirect satellite routing) is crippling to the performance of
visualization. More complicated techniques such as selective remote telerobotic surgery.
bronchial intubation and chest insufflation will probably Endoscopic urologic stenting to treat ureterolithiasis in
be required to make thorascopy a feasible procedure. The conjunction with telemedicine monitoring has been shown
technical difficulty of establishing a pneumoperitoneum to be feasible in parabolic flight [46]. On Earth laparoscopic
without the high risk of bowel perforation, the miniaturization surgery has rapidly evolved into a system that is technically
of laparoscopic support hardware, and the availability of easier, consistently more successful, and more broadly appli-
laparoscopically trained CMOs are other issues that prevent cable. In future long-duration space exploration missions, the
laparoscopy from being a practical component of any present presence of more surgically capable CMOs will allow lapa-
in-flight medical care system. roscopic procedures to be performed instead of open surgical
Also, because large amounts of support equipment and procedures.
specialized laparoscopic instruments are required to perform
even a simple laparoscopic procedure, such a capability would
be difficult to justify in a medical care system that has strict Experience with Surgical Procedures
weight and volume limitations. More important, laparos- in Space
copy requires considerable experience and proficiency and
is usually performed only by highly trained surgeons. This In April 1998, the crew of the Space Shuttle STS-90 Neurolab
requirement would severely limit CMO selection. The ability mission performed the first survivable surgical procedure
to treat surgical complications that might arise would likewise on animals in space. In this procedure, a leg wound was
be limited in a remote medical care system. On Earth, the created in adult rats to inject an isotope tracer in the rats
incidence of laparoscopic complications depends greatly on thigh muscle. The wound was then closed with Dermabond
the experience of the operator. adhesive. Other, more complicated surgical dissections
Nevertheless, future development of technologies could (i.e., craniectomy, C-section, laminectomy with spinal cord
well make laparoscopy in weightlessness more feasible. The removal) were also performed on adult rats that did not survive
most important of these developments would be miniaturiza- by experimental design.
tion of the large, bulky support equipment, such as the video The results of the Neurolab mission validated several
monitor, video camera, insufflator, and fiber-optic light source. concepts of surgery in space. First, the surgical procedures
Minimally invasive surgery can have the substantial potential within the scope of the Neurolab experiments were no more
advantage of requiring only local anesthesia. In the future, difficult to perform in microgravity than in 1-G. Second, the
these procedures may be performed with abdominal wall lift surgical procedures that were performed in space flight were
devices that would eliminate the need for CO2 insufflation. similar to those performed in parabolic flight, thus validating
The effect of such retracting lift devices is to pull the anterior the parabolic research model. Third, space flight was not asso-
abdominal wall anteriorly, thereby enlarging the volume of the ciated with any changes in surgical dexterity, proprioception,
intra-abdominal cavity while mesenteric attachments maintain or fine hand-muscle motor control. Fourth, good restraint of
the bowel in place. This approach would greatly simplify the the patient, operator, and all of the equipment was, as expected,
procedure and reduce the logistical support required. of utmost importance. Fifth, surgeons must anticipate logistics
Methods of controlling hemorrhage that are easier than and diligently restrain all equipment, supplies, instruments,
endoscopic suturing include the use of fibrin glue injectors, and discarded trash. For this reason, procedures will take
laser technology, and advanced stapling devices. Replacing longer to perform in microgravity than in 1-G. Sixth, in the
the video display with three-dimensional stereoscopic, virtual- absence of gravity, fluids coalesce and do not disperse because
reality headgear and with remote surgical telerobotics is also surface tension forces predominate; thus blood and other body
actively being investigated [4044]. Telerobotics and telepres- fluids were easy to control by using simple measures such as
ence will allow a logarithmic increase in surgical precision, sponging. Seventh, special care was needed in the use of sharp
because a 1-cm (0.4-in.) control input can be translated into a objects such as scalpels and needles; simple measures, such as
132 M.R. Campbell and R.D. Billica

calling out sharps on deck, increased the safety awareness Biological fluids in weightlessness must be evacuated,
of the surgical team. Finally, no subjective gross changes in separated from air suspensions (as airfluid levels do not exist
wound healing were noted; however, no objective measures of in microgravity), collected and contained, measured, and dis-
wound healing were used. As noted by Dr. David Williams of posed of. Active suction pumps that use rotational centrifugal
the Canadian Space Agency, who served as a crewmember on force to separate gas from liquid have been studied in para-
the Neurolab mission, if appropriate restraints are provided, bolic flight and were proposed for the Health Maintenance
surgical procedures are feasible if the individual operator has Facility of Space Station Freedom [13]. This concept may be
adequate 1-G surgical skills. revived and refined for future use on the ISS or other crewed
installations.

Limitations to Surgical Care in Space Resource Limitations and Trade-Offs


Successful surgical care on Earth depends on many factors, Medical and surgical hardware in space flight will always
including the diagnostic capability that is available, preop- be limited because of constraints on its volume, weight,
erative preparation, intraoperative logistical support, ability and electrical power; hence a long-duration space flight
to provide postoperative care, and the availability of specialty crew may encounter medical events that will overwhelm
consultations and safe medical evacuation to a center that the onboard medical care system. The NASA space medi-
can provide more definitive medical care as needed. The cine team has carefully analyzed what medical problems
presence of a surgeon who is well-trained, technically skill- are most likely to be encountered and will constitute the
ful, and proficient is also an important determinant. Surgical most serious danger to the crew and mission [47]. This
care in space will, by necessity, have limitations, including research will help in designing a medical care system that
the skill level of the surgical operator, the available medical will be able to handle those medical events that are most
hardware, the altered environment of microgravity, and the commonly encountered, have a substantial effect on crew-
state of the physiologically compromised patient. member health, or could affect the mission.
Regardless of the Earth-based surgical capabilities and Providing supplies and equipment for the most common
experience of an operator, that operators technical skills may and most serious medical events will enable treatment
well be limited by changes in proprioception, a lack of experience of other, less common or less serious medical events.
in operating in a microgravity environment, and the need to be Many rare but nonetheless serious surgical events will
restrained in microgravity. From the experience gained thus far not be provided for, and such events could overwhelm
from parabolic flight and space flight, the time required to the systems ability to respond adequately. Many vascu-
perform a given operation in low Earth orbit is estimated to lar injuries, for example, would be untreatable because
increase by a factor of 1.53 because of the need for restraint, of lack of operator expertise even though the equipment
meticulous control of bleeding, and careful specialized han- may be available. Logistics may prevent stocking the
dling of logistics and fluids. This situation may be worse on equipment to treat many orthopedic injuries, for which
exploration missions, where ground resources are even more operator expertise may not be as critical.
remote. On a Mars expedition, for example, the delay in com-
munications will limit the utility of consultation. Moreover, in
Effects of Physiological Adaptation
that setting, evacuation to a facility that could provide a higher
level of care or more definitive care will not be an option. The on Surgical Care
medical care system infrastructure will therefore obviously be The microgravity-adapted physiological state may well affect
limited in diagnostic and therapeutic options. the surgical patient in terms of preoperative preparation,
intraoperative response to surgical stress, and postoperative
recovery [48]. The process by which the body adapts to micro-
Need for Specialized Equipment gravity has been relatively well described, albeit incompletely
Medical and surgical hardware must be accurate, reliable (as investigated. (Specific descriptions and references are given
remote repair will be difficult), simple (as expert operators in Chap. 2.) The effects of such adaptation include cardiovas-
will be unavailable), and have very long lifetimes. Most hard- cular deconditioning (1020% loss of stroke volume), shifts
ware items will not be specifically developed for flight; rather, in fluid and electrolyte levels, muscular deconditioning, neu-
commercially available equipment will be only minimally rovestibular deconditioning, short-term gastrointestinal distur-
modified to withstand vibration and to function in micrograv- bances, changes in pharmacokinetics, sustained calcium loss,
ity. Hardware items also must be composed of nonflammable osteoporotic changes, protein catabolism, psychological stress
materials that are not subject to prolonged off-gassing, which (which has affected medical care in previous Russian flights),
would exclude many plastics. Given the complexities of the radiation exposure, changes in cellular immune function that
engineering and flight certification processes, the lead time affect the immune response and wound healing, blunting of the
from system design to flight is often 510 years. baroreceptor response to blood pressure changes, decreased
6. Surgical Capabilities 133

lung volumes, loss of red blood cell mass, and decreases of Chap. 16). The decreased ability of crewmembers to tolerate
about 15% in circulating blood volume. lower-body negative pressure, as shown by increasing tachy-
The physiology underlying wound healing in microgravity cardia and hypotension, after about 2 months on Skylab [55]
is unknown and requires further investigation. Cellular suggests a decrease in the ability to tolerate blood loss or
immune functions seem to be altered and suppressed in shock in space.
microgravity; consistent spaceflight findings have included A reduction in the ability to tolerate blood loss or shock
neutropenia; lymphocytopenia; reductions in the popula- during space flight may have other repercussions as well. For
tions, activity, and responses of T