Code Blue on Orbit: Treating Cardiac Arrest on the ISS

As a result of the Columbia tragedy on February 1,2003, the International Space Station (ISS) crew size has been temporarily reduced from three to two. This change forces adaptations in many operational procedures used by the crew, including medical protocols which were designed for scenarios involving one casualty and two caregivers. The Office of Space Medicine directed that the procedure for the resuscitation of a crewmember in cardiac arrest be rewritten for use by a single care provider. Methods: Adaptation of this procedure made use of current American Heart Association Advanced Cardiac Life Support (ACLS) procedures and reflects necessary compromises between the realities of the operational environment and prompt provision of medical care. Results: Numerous changes were incorporated due to the diminution in available personnel, including substitution of endotracheal rather than intravenous delivery of drugs, more rapid defibrillation, addition of a precordial thump, removal of transcutaneous pacing, streamlining of procedural steps, and clarification of termination criteria. Discussion: The on-orbit care available to the ISS crewmembers is constrained by numerous factors, including crew medical training, minimal medical assets, limited air/ground communication , and a single caregiver for the foreseeable future. All of these combine to make a successful resuscitation unlikely, however, this procedure must ultimately deal with not only the patient's welfare, but also that of the caregiver, the mission, and the program

Creating a Scenario Suitable for Multiple Caregivers

The HPS can be utilized for the training of a wide variety of caregivers, ranging from physicians to laypeople. Methods: A single scenario was developed and adapted for a number of clinical scenarios and operational environments, ranging from in-flight to the immediate postflight timeline. In this way, different caregivers, from astronauts to search and rescue forces to specialty-boarded physicians, could make use of a single clinical situation. Five crew medical officer analogs and sixty anesthesia residents, serving as flight surgeon analogs, and, were briefed on space medicine and physiology, then were exposed to the scenario and asked to manage the patient as if they were part of the in-flight or recovery team. Results: Basic themes, such as crisis resource management, were standard across the student audiences. Discussion: A single clinical script can easily be adapted for multiple uses

Communicating Medical Needs to Non-Medical Managers

Differences in communication styles and languages between groups often lead to miscommunication, confusion, and/or frustration. Engineers, computer specialists, clinicians, and managers often utilize the English language in very different ways, with different groups using the same words to represent different concepts ("complaint" is a typical example). In addition, medical issues are often perceived as "off-nominal" and not "primary mission tasks" by managers, which can cause them to assign lower priorities to medical training time and resources. Knowledge bases differ due to variations in training and skill sets, and the goals (both immediate and long-term) of the communicators may also vary, with managers being primarily concerned with overall mission objectives, while clinicians focus on individual or group health issues. Furthermore, true communication is only possible when clinicians possess a deep understanding of mission requirements as well as the ability to communicate medical requirements on a priority basis using risk assessment, added value, and cost benefit analysis. These understandable differences may contribute to difficulties in expressing concerns and ideas in an efficient manner, particularly in projects, such as the space program or many military operations, where these varied groups must collaborate, and where the final decisions must be made by fully informed mission commanders. Methods: Three scenario-based approaches were developed utilizing decision trees and problem based learning, to help define and integrate these concepts. Results: Use of these techniques by NASA and military personnel will be presented. Discussion: To enhance communication, particularly of medical needs, one must identify the concerns and motivating factors for the other groups; for example, members of management may focus on financial concerns, a desire for risk mitigation, public perceptions, mission objectives, etc. Training clinicians to frame issues in these terms may lead to better understanding of the medical concerns by other groups

Medical Scenarios Relevant to Spaceflight

The Medical Operational Support Team (MOST) was tasked by the JSC Space Medicine and Life Sciences Directorate (SLSD) to incorporate medical simulation into 1) medical training for astronaut-crew medical officers (CMO) and medical flight control teams and 2) evaluations of procedures and resources required for medical care aboard the International Space Station (ISS). Development of evidence-based medical scenarios that mimic the physiology observed during spaceflight will be needed for the MOST to complete these two tasks. The MOST used a human patient simulator, the ISS-like resources in the Medical Simulation Laboratory (MSL), and evidence from space operations, military operations and medical literature to develop space relevant medical scenarios. These scenarios include conditions concerning airway management, Advanced Cardiac Life Support (ACLS) and mitigating anaphylactic symptoms. The MOST has used these space relevant medical scenarios to develop a preliminary space medical training regimen for NASA flight surgeons, Biomedical Flight Controllers (Biomedical Engineers; BME) and CMO-analogs. This regimen is conducted by the MOST in the MSL. The MOST has the capability to develop evidence-based space-relevant medical scenarios that can help SLSD I) demonstrate the proficiency of medical flight control teams to mitigate space-relevant medical events and 2) validate nextgeneration medical equipment and procedures for space medicine applications

Creating Simulated Microgravity Patient Models

The Medical Operational Support Team (MOST) has been tasked by the Space and Life Sciences Directorate (SLSD) at the NASA Johnson Space Center (JSC) to integrate medical simulation into 1) medical training for ground and flight crews and into 2) evaluations of medical procedures and equipment for the International Space Station (ISS). To do this, the MOST requires patient models that represent the physiological changes observed during spaceflight. Despite the presence of physiological data collected during spaceflight, there is no defined set of parameters that illustrate or mimic a 'space normal' patient. Methods: The MOST culled space-relevant medical literature and data from clinical studies performed in microgravity environments. The areas of focus for data collection were in the fields of cardiovascular, respiratory and renal physiology. Results: The MOST developed evidence-based patient models that mimic the physiology believed to be induced by human exposure to a microgravity environment. These models have been integrated into space-relevant scenarios using a human patient simulator and ISS medical resources. Discussion: Despite the lack of a set of physiological parameters representing 'space normal,' the MOST developed space-relevant patient models that mimic microgravity-induced changes in terrestrial physiology. These models are used in clinical scenarios that will medically train flight surgeons, biomedical flight controllers (biomedical engineers; BME) and, eventually, astronaut-crew medical officers (CMO)

An Ophthalmologic Summit for On-Orbit Care

Ophthalmologic issues are a source of concern for NASA flight surgeons, due to the remote nature of the space station as well as the microg ravity environment. Methods: A panel of external consultants was conv ened to evaluate the adequacy of the current in-flight medical system for the diagnosis and treatment of ophthalmologic issues. Participants were acknowledged experts in their field who also had experience in operational medicine. Results: Nine extramural experts provided assi stance, and six of them participated in a face to face meeting held a t NASA-Johnson Space Center. Changes were recommended for the space s tation pharmacopoeia, and diagnostic, therapeutic, and deorbit criteria protocols for a variety of ocular conditions were developed. Discus sion: The results of the panel provide an evidence based approach to the diagnosis and care of ophthalmologic conditions on the International Space Statio

Scripting Scenarios for the Human Patient Simulator

The Human Patient Simulator (HPS) is particularly useful in providing scenario-based learning which can be tailored to fit specific scenarios and which can be modified in realtime to enhance the teaching environment. Scripting these scenarios so as to maximize learning requires certain skills, in order to ensure that a change in student performance, understanding, critical thinking, and/or communication skills results. Methods: A "good" scenario can be defined in terms of applicability, learning opportunities, student interest, and clearly associated metrics. Obstacles to such a scenario include a lack of understanding of the applicable environment by the scenario author(s), a desire (common among novices) to cover too many topics, failure to define learning objectives, mutually exclusive or confusing learning objectives, unskilled instructors, poor preparation , disorganized approach, or an inappropriate teaching philosophy (such as "trial by fire" or education through humiliation). Results: Descriptions of several successful teaching programs, used in the military, civilian, and NASA medical environments , will be provided, along with sample scenarios. Discussion: Simulator-based lessons have proven to be a time- and cost-efficient manner by which to educate medical personnel. Particularly when training for medical care in austere environments (pre-hospital, aeromedical transport, International Space Station, military operations), the HPS can enhance the learning experience

Sex- and Age-Related Differences in Morbidity Rates of 2009 Pandemic Influenza A H1N1 Virus of Swine Origin in Japan

BACKGROUND: The objective of the present study was to determine whether the morbidity rates of the 2009 pandemic influenza A H1N1 virus (pdmH1N1) varied by age and/or sex. METHODS AND FINDINGS: Retrospective analysis of 2,024,367 cases of pdmH1N1 was performed using the national surveillance data from influenza sentinel points in Japan. The male-to-female morbidity ratios (M/F ratios) in nineteen age groups were estimated as the primary outcome. The M/F ratios for pdmH1N1 influenza were: >1 in age groups <20 years and ≥80 years (p<0.001); <1 in age groups 20-79 years (p<0.001). This data suggests that males <20 years of age may be more likely to suffer from pdmH1N1 influenza than females in the same age categories. When the infection pattern for pdmH1N1 was compared with that of seasonal influenza outbreaks between 2000 and 2008, the M/F ratio for pdmH1N1 influenza was higher in ages 3-29 years and lower in ages 40-79 years. Because the present study was based on the national surveillance, it was impossible to estimate the morbidity rate for the Japanese population. It is also likely that the data did not capture asymptomatic or mild infections. CONCLUSIONS: Although exposure to the pdmH1N1 virus is assumed to be similar in both boys and girls, M/F ratios were >1 in those younger than 20 years. The subsequent reversal of the M/F ratio in the adult generation could be due to several possibilities, including: greater immunity among adult males, more asymptomatic infections among males, less reporting of illness by males, or differences in exposure to the virus and probability of visiting a clinic. These results suggest that the infection and virulence patterns of pdmH1N1 are more complex than previously considered

Age- and Sex-Related Differences in Morbidities of Sexually Transmitted Diseases in Children

Sexually transmitted diseases (STDs) are causes of public health burden globally. The purpose of this study is to document age-specific and sex-related changes in the morbidity of four representative STDs in children. Japanese national surveillance data from 1999 to 2017 on morbidities of the following four STDs were analyzed by age and sex: Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), condylomata acuminate (CA), and genital herpes simplex virus (GHSV). The morbidities of males and females in each age group were compared through the male-to-female morbidity (MFM) ratios. The MFM ratios were not different from one in infants, less than one in children, and greater than one after puberty in all four STDs. The reversal of MFM ratio less than 1 to greater than 1 for NG infection was observed between 10&ndash;14 and 15&ndash;19 year of age, i.e., during the puberty, while that for GHSV infection was observed between 35&ndash;39 and 40&ndash;44 year of age, i.e., during adulthood. In conclusion, the morbidities of the four STDs were similar between the sexes in infants, and were higher in female children than in male children, while the morbidities in all four diseases were higher in men after puberty