Principles of Clinical Medicine for Space Flight

Principles of Clinical Medicine for Space Flight

Michael R. Barratt, MD, MSAstronaut and Physician, NASA Johnson Space Center,Houston, TX, USA

Sam L. Pool, MDChief, Medical Sciences Division, NASA JohnsonSpace Center (retired), Houston, TX, USA

Editors

ISBN: 978-0-387-98842-9 e-ISBN: 978-0-387-68164-1DOI: 10.1007/978-0-387-68164-1

Library of Congress Control Number: 2007939575

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Michael R. Barratt, MD, MSAstronaut and PhysicianNASA Johnson Space CenterHouston, TXUSA

Sam L. Pool, MDChief, Medical Sciences DivisionNASA Johnson Space Center (retired)Houston, TXUSA

Dr. Patricia Hilliard Robertson (Photo courtesy of NASA)

To our cherished friend and colleague Patricia Hilliard Robertson—pilot and flight instructor, physician and flight surgeon, adventurer and astronaut. She is greatly missed by the aerospace community and all who knew her.

viivii

Foreword

The space environment does strange things, both to the workings of the human body and to the behavior of ordinary medical equipment. Space medicine describes the “normal person in an abnormal environment” and is an outgrowth of aviation medicine.

Aviation medicine didn’t exist when my father was born in 1884. By the time he served in the Army during World War I, it did, but its medical standards were still under con-struction. The Air Service Medical Manual issued by the War Department in 1918 discussed the public’s impression that the medical examination of an aviator was “a form of refined torture.” One story was that of the needle test. This mythical examination supposedly involved placing a needle between the candidate’s forefinger and thumb, blindfolding him, then shooting off a pistol behind his ear. The examiner would then note whether, owing to a supposed lack of nerve, the applicant had pushed the needle through his finger. The test sounded plausible then.

Aviation medicine as a specialty grew quickly during World War II and the onset of the jet age in the 1950s. However, when the space age dawned suddenly with Sputnik in 1957, medicine was not ready. The pages of the Jour-nal of Aviation Medicine for the years 1959 through 1961 were filled with forecasts of the effects of “zero G” on the human body—most of them dire. For example, doubt was expressed whether the gastrointestinal system would func-tion when weightless; nourishment, it was reasoned, might have to be given intravenously. The altitude and solitude, it was opined, would cause “break off phenomenon,” a sort of psychosis of loneliness. My favorite of these predictions was that space travelers weren’t going to be able to urinate. This was “proven” in an experiment wherein a rookie medical technician was strapped into the back seat of a jet fighter-trainer, helmeted, masked, and instrumented, flown to 35,000 ft, then pulled up into a zero-G parabola. At the peak of the maneuver, the pilot cried “Go!” and the poor fellow couldn’t do it. Catheters were solemnly recommended for astronauts.

It sure was fun knowing so little about the physiology of weightlessness. Skylab was a prototype space station in which three crews spent 1, 2, and 3 months learning how to home-stead in space and to care for ourselves up there. A demand that a physician be on each crew was rejected, but a small medical kit was in place, and two members of each crew—most of whom were test pilots—were trained to sew up cuts, extract teeth, and examine and report on their fellow crew-men. Fortunately, the practice was slow; we never had a serious medical problem to treat.

The U.S. Space Shuttle program, and later the joint NASA–Mir and International Space Station programs, have given the physician-authors of this book experience with hundreds of person-trips into space. The dreaded space motion sickness has been conquered, end-of-mission problems with vertigo and fluid loss have been brought under control, and confidence in human capabilities has been engendered. But true long-duration weightlessness is still a frontier. A Mars mission is still a substantial challenge.

Another critical perspective on space medicine is the recognition of its inherently interdisciplinary nature. Weight-less humanity exists only in a special world, a “space craft” crafted by engineers, a closed-loop system with a man-made atmosphere and its own rules of up and down. This pulls doc-tors into the world of engineers and vice versa. We must help each other solve problems that arise not only from weightless-ness but also from where we are and what we’re in—a vessel where, to get to Mars, we will have to recycle the very air we breathe and the water we consume. Engineering equipment—medical and otherwise—is a challenge when everything floats and nothing settles.

The details are all in this book. The nature of interplanetary space, its effect on our bodies (and minds), the treatments and countermeasures we currently prescribe, and the mysteries that remain, are graphically described and illustrated. If you are a researcher needing a fact or reference, an engineer who wants to know how your design affects its users, or a curious student drawn to medicine or biology but also to the adventure

of space flight—fill your mind here, and let your imagination carry you to Mars.

Exploration of the heavens still has a value independent of the commercial and military arguments we use in its defense. The hunger to know and to see is one of our defining

characteristics as human beings. The future does not exist. We get to help write its story.

Joseph P. Kerwin, MDHouston, Texas

viii Foreword

ix

Preface

There is no land uninhabitable, nor sea innavigable.

—Robert Thorne, 1527

In 1768, Captain James Cook was preparing his vessel, the Whitby collier Endeavour, and her crew for an extended sea voyage. At that time, mortality rates of 50% or more were not uncommon for trade voyages. Scurvy, resulting from lack of dietary ascorbic acid (vitamin C), was the great enemy. Cook developed and, with the help of ship’s surgeon William Munkhouse, administered to his crew a preventive regimen that included required consumption of “antiscorbutics”—food supplements consisting of such items as onions, sauerkraut, fruit, and occasionally native grasses found on islands en route. Not a single life was lost from scurvy. Subsequent voy-ages by Cook and countless others were spared from the curse of scurvy, and many lives were thus saved. A new expectation arose: that crews could safely remain at sea for the prolonged periods required to make their voyages.

We now stand near where Cook stood more than 200 years ago. Many bold steps have been taken into space over the past four decades, and we now contemplate still more ambi-tious missions of exploration and science. The mortality and morbidity rates associated with these preliminary efforts have been relatively low, though certainly not negligible. In tak-ing these early steps, we have gained invaluable knowledge of how humans live in the space environment, particularly with regard to weightlessness. Key adverse influences and effects have been identified, including radiation exposure and acquired dose, bone and muscle atrophy, and cardiovascular deconditioning. Thus far these effects have been tolerable during the course of low-Earth orbit and preliminary lunar explorations. However, future missions will involve greater distances and times and will demand that these effects be countered and other capabilities provided to sustain the human presence and to support optimal work. Our current charge is to expand human exploration while maintaining the safety and health of the exploring crewmembers.

As Endeavour’s surgeon Munkhouse did, we too have a standard of medical care and safety that must be “taken to sea” with us. To the extent possible and practical, current standards of medicine are expected to accompany space crews on their

missions. Along with these standards, a more complete under-standing of how the space environment affects the human body is required. The application of standard medical practice in this unique and challenging context defines space medicine as a distinct discipline. In 1968, after the first few years of human space flight, Dr. Douglas Busby wrote Space Clinical Medicine, a well-referenced and highly prospective and insightful work. Since that time, a tremendous amount of information has accrued regarding the physiologic effects of weightlessness as well as medical and environmental events occurring dur-ing flight that influence crew health. In many ways, this text is a successor to Dr. Busby’s fine work. Principles of Clini-cal Medicine for Space Flight was written by practitioners of space medicine for practitioners of space medicine and for oth-ers who may benefit from this knowledge in their own unique circumstances. Neither an overall basic medical text nor a comprehensive review of space physiology, this book focuses on aspects of medicine that arise uniquely and are dealt with uniquely in human space flight, and how the effects of space flight—whether adverse or simply anomalous—are addressed to provide the best care for space crewmembers.

Principles of Clinical Medicine for Space Flight draws heavily on the experience of the U.S. Skylab and Space Shuttle programs as well as the Russian experience with long-duration missions aboard the Salyut and Mir space stations and, most recently, from our joint work on the first several missions aboard the International Space Station (ISS). Con-tributors have a rich and practical experience base of direct space mission support and human life sciences research, and this is reflected in the detailed information presented. Read-ers will find background information on the relevant physi-cal forces and mechanical aspects of spaceflight necessary for complete understanding of the environment and its influence on the human space traveler. This is followed by a comprehen-sive review of the human response to every aspect of space-flight, the most likely medical problems encountered, their diagnosis, management, and prevention. Special emphasis is given to those areas most limiting to long duration flights,

such as radiation, bone and muscle loss, cardiovascular and neurovestibular deconditioning, nutrition and metabolism, and psychological reactions. Flight crew medical selection and retention standards are addressed, with discussion on rationale and application. In addition, cutting-edge technical issues particularly associated with provision of medical care in space are discussed, including selection and use of medi-cal systems, telemedicine, medical imaging, surgical care, and medical transport. When warranted, reasonable speculations are offered regarding principles of medical support and practice for future exploration missions involving a return to the Moon and interplanetary flight.

There is an expanding niche of medical practitioners who may utilize this book as a standard of care for supporting human space missions. This cadre is international, both civil and mil-itary, and is now extending into the commercial sector. This knowledge base should also greatly benefit the many groups and academic institutions involved in space life sciences or other environmental human research. Those participating in aerospace program and mission support and planning which involves or overlaps with medical decision making should also find useful information in this book. In addition, those involved with similar responsibilities of medical support in environments which are analogous to spaceflight, including submarine and surface ships, polar research stations, and other extreme or remote settings may benefit from our findings, as we have often benefited from such venues and exchange of experience. Finally, for the medically curious, we offer a com-prehensive reference on one of the very latest medical special-ties; none is more fascinating.

The size and scope of this book attests to the technical support and logistical efforts that were required to bring it into being. Our thanks go to technical editors Sharon Hecht and Luanne Jorevich and graphics wizards Sid Jones and Terry Johnson, who went extra miles during extra hours translating space medical jargon into plain English and clear figures; to space life sciences librarians Janine Bolton and Kim So for helping us to mine the world’s literature on space medicine; and to Brooke Heathman and Ellen Prejean, who helped orga-nize and mold the chapters into a coherent work. Special thanks go to Chris Wogan, world expert on space life sciences techni-cal literature, for bringing her talents to bear on this project, and to Merry Post and her exemplary skill and patience for guiding the transformation of our knowledge base into a user-friendly text.

Of course our deepest gratitude goes to our families, and especially to our spouses Michelle Barratt and Jane Pool, who have weathered our fascinations and obsession with space flight these many long years; we can never adequately repay you for your dedication and support.

Finally, to all of the world’s space travelers of all flags and professions who have undergone examination, monitoring, and sampling for medical certification and science for over four decades, we offer heartfelt thanks. A rising space-faring civilization owes you a debt of gratitude for your patience, endurance, and your great contribution to human space flight.

Michael R. Barratt, MD, MSSam L. Pool, MD

x Preface

xi

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Part 1. Unique Attributes of Space Medicine

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

Chapter 2 Human Response to Space Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Ellen S. Baker, Michael R. Barratt, and Mary L. Wear

Chapter 3 Medical Evaluations and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Gary Gray and Smith L. Johnston

Chapter 4 Spaceflight Medical Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Terrance A. Taddeo and Cheryl W. Armstrong

Chapter 5 Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Thomas H. Marshburn

Chapter 6 Surgical Capabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Mark R. Campbell and Roger D. Billica

Chapter 7 Medical Evacuation and Vehicles for Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Smith L. Johnston, Brian A. Arenare, and Kieran T. Smart

Chapter 8 Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Scott C. Simmons, Douglas R. Hamilton, and P. Vernon McDonald

Chapter 9 Medical Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Ashot E. Sargsyan

Part 2. Spaceflight Clinical Medicine

Chapter 10 Space and Entry Motion Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Hernando J. Ortega Jr. and Deborah L. Harm

Chapter 11 Decompression-Related Disorders: Decompression Sickness, Arterial Gas Embolism, and Ebullism Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223William T. Norfleet

Chapter 12 Decompression-Related Disorders: Pressurization Systems, Barotrauma, and Altitude Sickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247Jonathan B. Clark

Chapter 13 Renal and Genitourinary Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273Jeffrey A. Jones, Robert A. Pietrzyk, and Peggy A. Whitson

Chapter 14 Musculoskeletal Response to Space Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293Linda C. Shackelford

Chapter 15 Immunologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307Clarence F. Sams and Duane L. Pierson

Chapter 16 Cardiovascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317Douglas R. Hamilton

Chapter 17 Neurologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361Jonathan B. Clark and Kira Bacal

Chapter 18 Gynecologic and Reproductive Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381Richard T. Jennings and Ellen S. Baker

Chapter 19 Behavioral Health and Performance Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391Christopher F. Flynn

Chapter 20 Fatigue, Sleep, and Chronotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413Lakshmi Putcha and Thomas H. Marshburn

Chapter 21 Health Effects of Atmospheric Contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427John T. James

Chapter 22 Hypoxia, Hypercarbia, and Atmospheric Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Kira Bacal, George Beck, and Michael R. Barratt

Chapter 23 Radiation Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Jeffrey A. Jones and Fathi Karouia

Chapter 24 Acoustics Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521Jonathan B. Clark and Christopher S. Allen

Chapter 25 Ophthalmologic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535F. Keith Manuel and Thomas H. Mader

Chapter 26 Dental Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545Michael H. Hodapp

Chapter 27 Spaceflight Metabolism and Nutritional Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559Scott M. Smith and Helen W. Lane

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

xii Contents

xiii

Contributors

Christopher S. Allen, MS, BSLead, Johnson Space Center Acoustics Office, ISS Acoustics Sub System Manager, NASA Johnson Space Center, Houston, TX, USA

Brian A. Arenare, MD, MPH, MBADirector, Cardiopulmonary Lab, Kelsey-Seybold Clinic, NASA Johnson Space Center, Houston, TX, USA

Cheryl W. Armstrong, BSBiomedical Engineer, Wyle Laboratories, Houston, TX, USA

Kira Bacal, MD, PhD, MPH, FACEPResearch and Developmental Branch Director, Mauri Ora Associates, Auckland, New Zealand

Ellen S. Baker, MD, MPHAstronaut, NASA Johnson Space Center, Houston, TX, USA

Michael R. Barratt, MD, MSAstronaut and Physician, NASA Johnson Space Center, Houston, TX, USA

George Beck, BA, RRT, FAARCDirector, Engineering and Research, Impact Instrumentation, Inc., West Caldwell, NJ, USA

Roger D. Billica, MD, FAAFPPresident, Tri-Life Health, Center for Integrative Medicine, Fort Collins, CO, USA

Mark R. Campbell, BS, MDGeneral Surgeon, Paris Regional Medical Center, Paris, TX, USA

Jonathan B. Clark, MD, MPHSpace Medicine Liaison, Baylor College of Medicine, National Space Biomedical Research Institute, Houston, TX, USA

Christopher F. Flynn, MDClinical Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA

Gary W. Gray, MD, PhDSenior Consultant Flight Surgeon, Canadian Space Agency, Toronto, Ontario, Canada

Douglas R. Hamilton, MD, PhD, MSc, E Eng, PE, P Eng, FRCPC, ABIMFlight Surgeon, Electrical Engineer, Wyle Laboratories, Houston, TX, USA

Deborah L. Harm, PhDSenior Scientist, Human Adaptation and Countermeasures Division, Neurosciences Laboratory, NASA Johnson Space Center, Houston, TX, USA

Michael H. Hodapp, DDSUniversity of Texas Dental Branch, Houston, TX, USA

John T. James, PhDChief Toxicologist, NASA Johnson Space Center, Houston, TX, USA

Richard T. Jennings, MD, MSAssociate Professor, Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA

Smith L. Johnston, MD, MSMedical Officer, Flight Surgeon, University of Texas Medical Branch, Preventive, Occupational, and Environmental Medicine, NASA Johnson Space Center, Houston, TX, USA

Jeffrey A. Jones, MD, MS, FACS, FACPMExploration Medical Operations Lead Flight Surgeon, NASA Johnson Space Center, Houston, TX, USA

Fathi Karouia, MS, ASD, MSSResearch Associate, Department of Biology and Biochemistry, University of Houston, Houston, TX, USA

Joseph P. Kerwin, BA, MDCaptain, Medical Corps, United States Navy (retired), Houston, TX, USA

Helen W. Lane, PhD, RDNASA Chief Nutritionist, NASA Johnson Space Center, Houston, TX, USA

Thomas H. Mader, MDAlaska Native Medical Center, Department of Ophthalmology, Anchorage, AK, USA

F. Keith Manuel, ODFormer Sr. Vision Consultant, Flight Medicine, NASA Johnson Space Center, Houston, TX, USA

Thomas H. Marshburn, MD, MSAstronaut, NASA Johnson Space Center, Houston, TX, USA

P. Vernon McDonald, PhDDirector, Commercial Human Space Flight, Wyle Laboratories, Houston, TX, USA

William T. Norfleet, MDAssistant Professor, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA

Hernando J. Ortega, MD, MPHColonel, Chief Flight Surgeon, United States Air Force, San Antonio, TX, USA

Duane L. Pierson, PhDSenior Microbiologist, NASA Space Life Sciences Directorate, Houston, TX, USA

Robert Pietrzyk, MSProject Scientist, Human Adaptation and Countermeasures Division, Wyle Laboratories Life Sciences Group, Houston, TX, USA

Sam Lee Pool, MDChief, Medical Sciences Division, NASA Johnson Space Center (retired), Houston, TX, USA

Lakshmi Putcha, PhD, FCPChief Pharmacologist, NASA Johnson Space Center, Houston, TX, USA

Clarence F. Sams, PhDMedical Project Scientist, International Space Station, SK/Human Adaptation and Countermeasure Division, NASA Johnson Space Center, Houston, TX, USA

Ashot E. Sargsyan, MDScientist, Wyle Laboratories Life Sciences Group, Houston, TX, USA

Linda C. Shackelford, MDManager, Bone and Muscle Lab, NASA Johnson Space Center, Houston, TX, USA

Scott C. Simmons, MSAssistant Director, The Telemedicine Center, Brody School of Medicine, East Carolina University, Greenville, NC, USA

Kieran T. Smart, MBChB, MSc, MPH, MRCGPFlight Surgeon, Wyle Laboratories, Houston, TX, USA

Scott A. Smith, PhDManager for Nutritional Biochemistry, NASA Johnson Space Center, Houston, TX, USA

Terrance A. Taddeo, MD, MSMedical Officer, Deputy Manager of Medical Operations, NASA Johnson Space Center, Houston, TX, USA

Mary L. Wear, PhDHealth Care Services Manager, NASA Johnson Space Center, Houston, TX, USA

Peggy A. Whitson, PhDAstronaut and Research Scientist, NASA Johnson Space Center, Houston, TX, USA

xiv Contributors