**2.3 Space Station medical operations**

Since the space station Mir recently re-entered the earth's atmosphere
after a long period of human habitation, the International Space Station
(ISS) is the only manned orbiting vehicle with the capability of
prolonged human habitation.

There are several unique problems associated with the complexity and
size and planning involved in the ISS. Because the space station is
truly a melding of international concerns and capabilities, there has
been proactive planning with the international partners early in the
planning for ISS. Multilateral medical operations groups were formed to
find common ground in potentially troubling medical and cultural issues.
They have determined what the joint medical requirements are for ISS,
and its medical capability. Common medical standards for crew selection
and certification, common environmental parameters to follow, and
toxicological considerations are some of the issues being covered. There
also was a plan to implement common guidelines and support across
international lines and between control centers. The Intentional
Partners (IPs) consist of the Russian Space Agency, the Canadian Space
Agency, the European Space Agency, the National Space Development Agency
of Japan, and the Italian Space Agency.

The approximate build time of the ISS was estimated to be five years
prior to the Columbia accident in 2003. Plans for completion will
probably depend on the timeline of the availability of the Shuttle in
the years following this accident.

Recent studies have estimated that the incidence of a significant
medical event for a three person ISS crew (standard crew at this time)
at one event per 5 ½ years, and the incidence of an incapacitating event
once every 33 years. For the full complement of seven crewmembers, the
incidence of a significant medical event was once every 2 ½ years and
the incidence of an incapacitating medical event to be once every 14
years. These estimates were extrapolated from data from the Russian
space station, the NASA Longitudinal Study of Astronaut Health, and
analogous population such as Antarctica and submarine crews.

The ISS medical support structure maintains overall responsibility for
all aspects of crew health and safety, including medical certification
and medical training, response to medical events, environmental
monitoring, and inflight medical countermeasures. This medical support
is expected to evolve over the years and as circumstances dictate. The
crew medical experience is not considered to be limited to the flight
itself, but also for all mission phases including preflight, inflight
and postflight. For physical training this would include preflight
exercise assessment and prescribed preflight exercise. Inflight physical
exams and monitoring also occur, as well as in-flight countermeasures
including exercise. The postflight medical exams and postflight
rehabilitation are used to measure and to restore physician health to
the preflight baseline.

For ISS, the crews are subject to a comprehensive launch minus 45 day
complete physical exam, audiogram, ophthalmological assessment, dental
exam, neurocognitive assessment, psychological assessment, nutritional
status assessment, clinical lab assessment, microbiological assessment,
musculoskeletal assessment, cardiovascular assessment, cardiopulmonary
assessment and pulmonary function tests. These are repeated I various
stages postflight to study the physiological return to earth's gravity
and to ensure that the crew returns to its preflight status

In-flight there are periodic health status evaluations performed by the
CMOs every 30 days, with cardiopulmonary assessment, and urinalysis.
There is also a 30 day fitness test scheduled very 30 days that occurs
in between the periodic health evaluations. There are 1 ½ hours of
exercise baseline daily for each crewmember.

The medical care that is being developed is similar and based on the
medical care provided for the Space Shuttle. There is an expanded
medical kit with more consumables and equipment that will be augmented
as the space and volume allow it.

Crew medical training is constrained by the time and travel necessary to
launch crew to ISS that has required international training in at least
two languages, Russian and English. One role to the medical monitoring
is to assess crew training timeline and the crew to help avoid launching
an exhausted tired crew. Medical training is similar to the training for
Shuttle flights, including training to use diagnostic and therapeutic
hardware, conduct medical assessments and physiological monitoring, and
perform environmental monitoring and microgravity countermeasure
measurements. The medical equipment available on the ISS is
international in origin, and each IP has to develop crew training and
the ground support necessary to for each of these medical systems. This
all has to fit within the overall training program. As in the Shuttle,
basic medical training is available for all crewmembers, and more
advanced paramedic type training for the two designated CMOs for each
ISS crew increment. One or two crew will be trained in the environmental
control and life support specialists to perform environmental monitoring
activities. As in the Shuttle training, these crewmembers will typically
be trained by mission assigned flight surgeons and biomedical engineers
from that also support the mission from the flight control stations.

The ISS Medical Checklist is a bilingual manual containing English and
Russian on facing pages. Dual language English-Russian language training
materials are being developed to aid crew training. Although other
languages are represented on ISS, English remains the predominant
language, and most of the medical equipment will be US or Russian in
origin. Although the training outline includes approximately 74 hours
specifically for the CMOs, additional medical training for the entire
ISS crew there are another 15 hours of generalized space medicine
training. A unique feature of training for the ISS CMO crewmembers is
scheduled on-orbit medical refresher training done via computer.

There is a Health Stabilization Program similar to the NASA Space
Shuttle program used to protect ISS crews and helps to prevent exposures
to infectious disease prior to flight.

The medical equipment for the ISS includes subsystems of health
maintenance, environmental health system, and the countermeasures health
system. The medical kit includes the Ambulatory Medical Pack (AMP), the
Advanced Life Support Pack (ALSP), the Crew Contamination Protection Kit
(CCPK), a defibrillator, the Respiratory Support Pack (RSP), the Crew
Medical Restraint System (CMRS), and the Medical Checklist. The Medical
Equipment Computer (MEC) downlinks data from the medical equipment that
is capable of doing so and contains physiological monitoring software,
an electronic medical record, and medical reference software, and is the
platform for the computer-based medical training.

Surgery in microgravity is not yet a practical endeavor for the ISS
because of medical equipment weight and space limitations, as well as
being a huge training issue for the CMOs. Surgery in zero gravity
although it has been studied extensively on the KC --135 in several test
articles to test zero gravity techniques and equipment. Most of the
tests have involved utilizing a clear box to contain and cover the
surgical field, and a suction device to keep airflow coming across the
surgical field to keep it clear of blood and bodily fluids. Foot
restraints are used to restrain the patient and the CMO and the patient.

All radiation exposure from space results in increased risk, and
generally the higher the exposure, the higher the risk. Radiation
exposure for the crew is generally based on orbital inclination and
altitude, and solar activity. Radiation exposure will also vary to some
degree by location within the ISS and the attitude of the station.
Radiation health concerns for the ISS crew is a particular concern
because of the inclination of the ISS is 51 degrees. This places the ISS
outside some of the protection of some of the Van Allen belts especially
during solar shock waves or solar particle events that might otherwise
contract the protection available from the Van Allen belts.

Radiation exposure includes exposure to galactic cosmic rays (GCR),
geomagnetically trapped radiation, and solar particle events and solar
wind. The geomagnetic-trapped particles are lower energy protons and
electrons. The South Atlantic Anomaly is an area of particular concern,
and EVAs are specifically planned to decrease the time in the anomaly.

The accumulated dose of each astronaut is monitored for each crewmember
via a personal dosimeter worn continuously and analyzed postflight. Also
the ISS inside crew volume is monitored with Radiation Area Monitors,
which are returned on the cycle coinciding with crew cycle. Real time
data from tissue equivalent proportional counters inside the station and
Charged Particle Directional Detectors inside and outside the vehicle
and serve to monitor GCR and trapped radiation. These data are
downlinked to Mission Control and are used to monitor the radiation
environment. Solar telescope and satellites in geostationary orbits
monitor the occasional solar events that can lead to significant
radiation exposure from the solar particle events.

Emergency shelter considerations in the event of solar radiation event
including isolation in a more shielded part of the station. Emergency
and urgent medical evacuation considerations are depended somewhat on
the availability of the Space Shuttle, but also there is an attached
Soyuz capsule that serves as a emergency return vehicle as well as a
safe haven in the case of a sudden station depressurization, or a toxic
chemical exposure or event. The Soyuz also serves as well as an
emergency de-orbit capability in the case of a medical emergency or a
toxicological event

There is also a body bag available in the unlikely event of a sudden
crew fatality.