July 2001

NASA/TM—2001–210198

Considerations for Medical 

Transport From the Space Station via 

an Assured Crew Return Vehicle (ACRV)

Philip Stepaniak, M.D.

Lyndon B. Johnson Space Center

Glenn C. Hamilton, M.D.

Denis Stizza, M.D.

Richard Garrision, M.D.

David Gerstner, EMT-P

Wright State University

Department of Emergency Medicine

Kettering, Ohio

 
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July 2001

NASA/TM—2001–210198

Considerations for Medical 

Transport From the Space Station via 

an Assured Crew Return Vehicle (ACRV)

Philip Stepaniak, M.D.

Lyndon B. Johnson Space Center

Glenn C. Hamilton, M.D.

Denis Stizza, M.D.

Richard Garrision, M.D.

David Gerstner, EMT-P

Wright State University

Department of Emergency Medicine

Kettering, Ohio

National Aeronautics and

Space Administration

Lyndon B. Johnson Space Center

Houston, Texas 77058
Foreword

This document was initially completed and formally presented to the Medical Operations Branch at the Johnson 

Space Center in December 1989. During the time this document was originally compiled, Philip Stepaniak, M.D., 

was working as a senior resident in Emergency Medicine at Wright State University under the supervision of Glenn 

C. Hamilton, M.D. Dr. Stepaniak currently works for NASA in the Medical Sciences Division. 

Although in planning for many years, the International Space Station with its continuous human presence has only 

become a reality this year. This historic event has renewed interest in medical contingencies associated with 

spaceflight. The following document has existed within and been used by the Medical Operations Branch since 

1989, and it has recently been cited in internal documents relating to medical contingency planning and to the 

medical capabilities of the X-38. Renewed interest in low-Earth orbit medical operations and the potential for 

extended-duration missions on the horizon has led to it being formally submitted to the NASA Scientific and 

Technical Information Center for general access.

Available from:

NASA Center for AeroSpace Information National Technical Information Service

7121 Standard Drive 5285 Port Royal Road

Hanover, MD 21076-1320 Springfield, VA 22161

301-621-0390 703-605-6000

This report is also available in electronic form at http://techreports.larc.nasa.gov/cgi-bin/NTRS
Contents

Page

iii

Introduction................................................................................................................................ 1

Listing of Considerations Under Each Major Heading....................................... 2

Background................................................................................................................................. 4

Safety .............................................................................................................................................. 5

Assured Crew Return Vehicle Design........................................................................... 7

Equipment.................................................................................................................................... 10

Indications for Medical Transport................................................................................. 14

Transport Protocols................................................................................................................ 21

Transport Complications..................................................................................................... 25

Search and Rescue................................................................................................................... 27

Medical Transport Team..................................................................................................... 32

Other Considerations............................................................................................................. 34

Summary Consideration ...................................................................................................... 36
iv

Acronyms

ACRV assured crew return vehicle

BP blood pressure

CERV crew emergency return vehicle

CPR cardiopulmonary resuscitation

CVA cerebrovascular accident

DCS decompression sickness

ECG electrocardiograph

EMT emergency medical technician

ETT endotracheal tube

EVA extravehicular activity

GEU genitourinary

HEENT head, eyes, ears, nose, and throat

HMF health maintenance facility

IV intravenous

PASG pneumatic antishock garment

PEEP positive-end expiratory pressure

psi pounds per square inch

SAR search and rescue

SCRAM shuttle crew return alternative module
1

Introduction

On August 25, 1987, representatives of the Department of Emergency Medicine at the Good Samaritan 

Hospital and Health Center, Dayton, Ohio, outlined their “Considerations for Medical Rescue from Space Station” to 

a consulting group on the space station crew emergency return vehicle (CERV) and on medical transport. This group 

was assembled by representatives of NASA at the Johnson Space Center, Houston, Texas. It was chaired by Joe 

Boyce, M.D., CERV Medical Study Manager at that time for the Medical Operations Branch.

Because of continued interest expressed in this outline by the committee and the CERV Medical Study 

Manager, a grant proposal was submitted to NASA on January 28, 1988, under the auspices of the Good Samaritan 

Hospital and Health Center. The proposal requested support to develop the outline into a discussion paper. The 

paper promised to develop a list of medically important considerations that may influence decisions when designing 

an assured crew return vehicle (ACRV) and its protocols for operation in medical transport. It was understood that 

these considerations would not be all-inclusive but would, rather, delineate areas for future discussion and research.

The grant was approved to run for 1 year beginning September 1, 1988. Because of delays related to the 

primary investigator’s sabbatical, a 3-month extension—until December 1, 1989—was granted by the Space and Life 

Sciences Procurement Branch in September 1989.
2

Listing of Considerations Under Each Major Heading

1. Background

2. Safety

a. A discussion of the cost-to-benefit ratio of the ACRV specific to medical transport is necessary.

b. Listing and discussing safety issues for an ill or injured crewmember(s) and the accompanying crew is 

necessary.

c. Safety and medical integrity of the patient during transport must be considered.

3. Assured Crew Return Vehicle Design

a. Primary reasons for selecting an ACRV design, discussed in the context of medical transport.

b. Secondary reasons for selecting an ACRV design, discussed in the context of medical transport.

4. Equipment

a. Function and placement of all physiologic life support equipment in the ACRV should be determined. 

Capacity of selected equipment to function in microgravity and a +G environment requires assessment.

b. Equipment for transporting the patient to the ACRV and securing his/her position in the ACRV should 

be detailed, including demands on payload capability, ACRV maneuverability, and the position and 

role of other crewmembers.

5. Indications for Medical Transport

a. Decision to transport ill or injured crewmembers includes training of on-site persons who are making 

the decisions, the resuscitation capability of the health maintenance facility (HMF), the deconditioned 

status of the patient, the ACRV reentry profile, the severity and natural course of the illness or injury, 

and the availability of the shuttle for transport. At this time, only limited human experience with 

prolonged spaceflight can be used for reference in this work.

b. The value placed on a crewmember’s life or limb is an emotional and a complex point of discussion. 

Before removing an injured or ill crewmember, the inherent risks and benefits to the patient, crew, and 

the mission itself must be addressed.

c. Various disease possibilities and their evolution in a space station setting require discussion. The major 

potential disease categories are listed.

6. Transport Protocols

a. Coordination between station and ground rescue forces is necessary to seek the optimal window of 

opportunity for reentry in light of the availability of rescue forces with respect to the space station’s 

position. (See search and rescue (SAR).)

b. Preflight patient care protocols need to be developed, including general systems checks and items for 

specific disease entities.

c. In-flight patient care protocols are necessary. If possible, most resuscitation and stabilization will be 

performed in the HMF as part of the preflight protocol.

d. Loading/unloading protocols need to be developed.

7. Transport Complications

a. Possibility of crew-related complications during transport must be anticipated.

b. Possibility of ACRV-related transport complications must be considered.

8. Search and Rescue

a. Time-axis intervention relationship of transport and recovery must be anticipated.

b. Range of potential landing sites must be selected. Optional medical response must be identified within 

the confines of these sites.
3

c. SAR forces specific to the ACRV must be developed. They should not require significant retraining.

9. Medical Transport Team

a. Qualifications of medical personnel on board the space transport vehicle should be established.

b. Qualifications of Earth-based medical transport crew should be established.

10. Other Considerations

a. Replacement of an ACRV on the station.

b. Several medical issues require review and clarity, including health insurance, medical/legal issues, and 

the need for extended care.

c. Although many issues that involve decisions for medical transport, the means of transport, and the 

physiologic response and outcome of various diseases to reentry and recovery are unknown, they are 

as critical as supporting those issues that involve the engineering and mechanical aspects of the space 

station and the ACRV.
4

Background

In the development of a permanently crewed space station, the importance of medical care has been 

continually reaffirmed. The HMF is an integral component of the station. It has diagnostic, therapeutic, monitoring, 

and information management capability. It is designed to allow supportive care for:

1. Most non-life-threatening (Class I) illnesses; e.g., headache, lacerations.

2. Most moderate to severe, possibly life-threatening (Class II) illnesses; e.g., appendicitis, kidney stones.

3. Severe, incapacitating, life-threatening (Class III) illnesses; e.g., major trauma, toxic exposure.

Since the HMF is not anticipated to have a general surgical capability, and since the variety of significant 

hazards increases with prolonged stays in space, the need for emergency escape and recovery methods has been 

seriously studied. A number of reports within NASA and from consulting committees have supported the 

development of a CERV—a unit more recently known as an ACRV.

Medical risk assessments have determined that accurate prediction of the incidence of crewmember 

illness/injury on the space station is impossible. Epidemiologic data is of little use because of inaccuracies in 

extrapolation. A best estimate of a significant illness/injury rate is 1:3 per work-year, with 1% of these predicted 

to need an ACRV. For an eight-person crew, this means that one ACRV will be used every 4 to 12 years.

The ACRV has been seen as a multipurpose unit since its inception. As such, it would serve at least three 

basic objectives as:

1. A crew return if the space shuttle is unavailable.

2. An escape vehicle from a major time-critical space station emergency.

3. A full or partial crew return vehicle for a medical emergency.

The focus of this paper is the third objective for the ACRV. Although the frequency and severity of illness 

and injury in American space crews has been relatively low, it is understood that longer periods in space increase the 

risk of serious problems. This is corroborated by the Soviet space station experience of the mid-1980’s in which at 

least three cosmonauts returned under relatively “urgent” conditions for medical reasons. (Serious trauma had not 

played a major role in their illnesses.)

The space shuttle may be used as part of the recovery force for space station evacuation since it has 

numerous advantages for transporting a crewmember who requires medical attention. But, an unscheduled rescue 

attempt by the shuttle would cost approximately $200M and, depending on weather conditions and the status of the 

fleet, could require as many as 15 to 45 days to effect. This may be an unacceptably long delay for a critically ill 

crewmember or if immediate evacuation of the station is necessary. Finally, the shuttle requires highly trained 

onboard personnel to operate it safely. We therefore believe it is necessary to consider alternative means to 

using the shuttle to return space station personnel safely and quickly to Earth.

While they were designing a study for NASA on the cardiopulmonary effects of +Gx reentry profiles in a 

hemorrhagic shock model, physicians from the Department of Emergency Medicine at the Good Samaritan Hospital 

and Health Center in Dayton, Ohio, became interested in the issues and decisions involving the ACRV as a medical 

transport unit. Their initial work, which focused on when the ACRV might be used and on injured patient tolerances 

for reentry +Gx profiles, expanded into a list of considerations important to the timely and safe transportation and 

recovery of one or more crewmembers from the space station to Earth.

This paper, which has received NASA’s support, is an expanded discussion of these considerations from a 

medical perspective. It is not meant to be all-inclusive. Instead it represents the most important elements of planning 

for the effective return and recovery of an ill or injured space station crewmember.
5

Safety

Safety, an inherent goal of any medical rescue in a hazardous environment, is not only the moral 

responsibility of the operational planning process; it is an economic motivator. All decisions regarding safety require 

the inclusion of cost/benefit factors. This is more important when the terms “economic” and “cost” are defined in the 

broadest possible terms to include not only money, loss of work, and death but public image, morale, and political 

impact. The station ACRV will operate in an environment filled with significant risk. Safety can be best defined 

and implemented by maintaining an economic incentive to keep costs down.

CONSIDERATION 1: The cost-to-benefit ratio of the ACRV specific to medical transport must be 

discussed.

Facts/Comments

The importance of medical transport as an ACRV objective has steadily gained support within NASA. It 

now has a level of importance similar to crew return if the space shuttle is unavailable, or to providing escape from 

a major time-critical space station emergency. Because of the importance of medical transport, the following points 

are best discussed in a document specific to the issue of safety.

1. Cost

a. Actual cost in terms of money, time, and resources of ACRV construction, launch, assembly, 

maintenance, and replacement (if used). Cost will be calculated after the ACRV basic configuration 

has been decided.

b. Moral/psychological expense on personnel of not having a medical contingency transport system.

c. Media expense of having/not having a medical contingency transport system before, during, and after 

such a system is actually required.

d. Political expense, in regard to present and future funding, for having/not having a medical contingency 

transport system before, during, and after such a system is actually required.

e. Real potential cost of loss of life or limb should illness or injuries occur in space with or without a 

medical transport system available.

2. Benefit

a. Cost savings of constructing, maintaining, and replacing an ACRV with different configurations. The 

unit must have reasonably flexible capabilities that match the projected needs of medical transport, but 

it is not meant to be all things for all possibilities.

b. Cost savings of using existing engineering technology, materials, and equipment in the design 

and instrumentation of the ACRV. For example: Can standard resuscitation equipment be reasonably 

modified to serve the needs of an ACRV?

c. Moral, morale, media, and political benefits of subscribing to the safety-oriented image that has always 

been part of planning at NASA.

d. Real benefit of saving life and limb with an ACRV.

e. Scientific benefit from translating real experience back to the laboratory.

CONSIDERATION 2: Listing and discussing safety issues for the ill or injured crewmember and 

accompanying crew is necessary.

Facts/Comments

The patient is not expected to administer self-care. During transport, because of relatively short transit times 

and gravity forces anticipated to exceed 3 Gx, the patient’s fellow crewmembers will have little or no opportunity to 

deliver care. The patient must therefore be secured and protected prior to placement in the ACRV. Once in the 

ACRV, the following elements must be considered:
6

a. Movement – Protection in all directions is necessary. The transport device (i.e., stretcher) from the 

HMF to the ACRV will optimally become an integral and secure part of ACRV transport. Appropriate 

padding and straps for securing the patient and for splinting injured extremities, including the spine, are 

necessary.

b. Pressure/Temperature Extremes – The patient’s thermoregulatory and cardiopulmonary capacity is 

likely to be compromised. Since it is unlikely he/she can be placed in an environmentally controlled 

suit or a “mini-capsule,” the ACRV should serve as an environmentally controlled space.

c. Noise – Standard precautions for noise reduction and protection during reentry are to be incorporated 

into the ACRV design.

d. Inhalation of Toxic Fumes – Precautions for maintaining clean air standards are part of the ACRV. 

These include the situation in which a patient may have materials remaining on his/her skin or in the 

body that may be toxic to other crewmembers.

e. Radiation – Protection from exposure to external radiation is part of the ACRV safety requirements. 

Handling of radiation exposure inside space station would be managed by a protocol in the HMF prior 

to ACRV transport. Ingestion or inhalation of radioactive material would not preclude ACRV transport.

CONSIDERATION 3: The patient’s safety and medical integrity must be considered during 

transport.

Facts/Comments

A patient’s medical stability is maintained, as much as possible, prior to ACRV transport. Minimally, 

equipment, protocols, and training must operate at advanced life support levels. Essentially all or most of this work 

must be done pre-transport—either in the HMF or immediately prior to departure in the ACRV.

Physiologic requirements for patient stabilization include:

a. A patent and protected airway.

b. Adequate oxygenation and ventilation.

c. Intravascular access.

d. Volume resuscitation.

e. Effective oxygen-carrying capacity; i.e. adequately functioning levels of hemoglobin or oxygencarrying substitute.

f. Spinal and extremity immobilization.

g. Cardiac homeostasis, including dysrhythmia prevention and adequate cardiac output.

h. Pain relief as needed. Sedation, secondarily, may also be needed.

i. Medications (primarily standard resuscitative medications) as needed.

j. An awareness of physical/psychological comfort and relief to be given to the degree available.

Basic physiologic parameter monitoring needs to be available to assess the effectiveness of resuscitative efforts and 

the evolution of the illness/injury over time. Parameters include:

a. Blood pressure.

b. Heart rate and rhythm.

c. Respiratory rate.

d. Oxygen saturation of blood by oximetry.

e. Level of consciousness.

Summary

By translating safety into an economic factor, cost-to-benefit considerations can be discussed in a realistic 

manner. The concept of “cost” must be broadly defined. Specific safety issues must be included in the design and 

equipage of the ACRV. Early inclusion of these medical concerns will not preclude ACRV use for other objectives.
7

Assured Crew Return Vehicle Design

Various vehicles are candidates for the ACRV mission(1). Among these is the Langley lifting body, a 

winged vehicle that can fly reentries with low-gravity loads. The loads for the Langley vehicle would be only 1 to 

2 G’s. It could also return crewmembers to a more specific range of landing sites. The disadvantage to the Langley 

vehicle is its added cost and complexity compared to that of a capsule designed for water landings. And, a winged 

vehicle such as the Langley vehicle may be considered more sophisticated than necessary to satisfy the medical 

transport objective.

An Apollo-derived configuration could provide a return to Earth with moderate gravity loads due to the lift 

generated by the aerodynamic design. The vehicle would have loads of 2.5 to 3.5 G’s. The capsule would descend by 

parachute to a water landing. Advantages to its use are that the design is similar to the generic concepts of the Apollo 

spacecraft, it is well understood, and it is less expensive than the winged vehicle. Disadvantages to its use include an 

operational pressure of 5 psi (compared with 14.7 psi for the space station), a complex interface with the station, 

and the time delay potential of a water recovery.

The ballistic capsule design (reference configuration), which is shaped like the earlier Discover Program 

vehicles, would cost least to develop. It has an extensive database from uncrewed flight experience and would have 

limited controls matching its flying characteristics. Problems with its design include acceleration loads of up to 7 to 8 

G’s during reentry and the fact that a vehicle of its planned size has not flown yet.

Although a fourth configuration, the shuttle crew return alternative module (SCRAM), is also being 

investigated, it is not considered viable for medical transport because of its reentry profile, limited capabilities, and 

high potential for extended crew rescue waiting time.

CONSIDERATION 4: The primary reasons for selecting an ACRV design should be discussed in the 

context of medical transport.

Facts/Comments

The design goal of the ACRV is to provide a transport and life support vehicle for a single mission event. 

Optimally, little or no new or inventive technology will be required. The challenge is to maintain balance between an 

effective crew return capability and the lowest practical life cycle cost(2).

In designing a vehicle for medical transport from the space station, various factors must be considered to 

ensure the overall safety of the injured/ill crewmember and of transport personnel. Primary considerations include 

the crewmember’s tolerance to reentry, rotation, and impact forces(3).

Design and G-forces (reentry, rotational, and impact)

Human resistance to acceleration forces depends on a number of physical, environmental, and physiologic 

factors. Significant physical factors include magnitude, duration, and direction of the force; position of the body and 

extremities in relation to the force; and whether that force is applied in a “plateau” or a “peak” mode. Environmental 

factors include the use of protective systems and body restraints and environmental conditions—e.g., temperature, 

pressure. Individual human tolerance, one of the most important factors, varies with the health, age, training, and 

individual motivation. An ill or injured patient is likely to be less tolerant of these forces. The physiologic tolerance 

of acceleration in humans is determined by (1) interference with normal hemodynamic relationships, (2) mechanical 

impedance of respiration, and (3) displacement and deformation of internal organs.

Studies have shown that the +Gx direction (chest to back) is the optimal axis for acceleration tolerance 

of humans in spacecraft since it results in less severe hemodynamic changes. Chest pain, visual disorders, petechial 

hemorrhage, and dyspnea are the usual limiting factors in voluntary +Gx exposure up to 10 G’s.

Previous experience with medical transport has shown certain illnesses are worsened by acceleration in 

any axis. These illnesses involve high patient risk during transport regardless of the vehicle, including the use of C-9 

medical aircraft and helicopters.

Some patients suffering illnesses such as acute psychotic reactions, kidney stones, and some burns could be 

transported with reentry forces of up to 8 to 11 Gx without incurring excessive danger. However, the majority of ill 

patients cannot tolerate high 8 to 11 +Gx axis load levels without worsening due to hemoglobin saturation decreases; 

detrimental gravity-induced fluid shifts; mechanical distortion during high gravity; and gravity-force effects on their 

cardiovascular and other body systems. Indeed, a number of critical medical/surgical illnesses could worsen to an 
8

unacceptable degree. The patient’s tolerance would be affected significantly by the degree of pre-transport 

resuscitation available.

Data on hemorrhagic shock and Gx acceleration supplied by Wright State University and Armstrong 

Aerospace Medial Research Laboratory, combined with knowledge of acceleration effects on normal subjects, may 

assist in predicting a variety of traumatic and cardiovascular disorders suitable for transport on an ACRV depending 

on reentry profiles. Medical research on the effects of varying gravity-load profiles on ill or injured crewmembers 

should continue to determine the safe range of reentry profiles in the context of potential illnesses, pre- and postresuscitation.

Spin stabilization, while helpful in guidance and control, may harm crewmembers in an ACRV. While spin 

rates of less than 5 to 8 RPM may be well tolerated in any axis by a healthy person, greater rates may lead to nausea, 

vomiting, and disorientation in an unhealthy person, depending on axis of rotation. X-axis roll is generally not as 

well-defined as Z- and Y-axis roll. Though healthy trained subjects may tolerate high RPM in the Z axis (ice skaters 

revolve up to 400 times/minute) and Y-axis pitch rotation about specific points may be tolerated up to 150 RPM 

without permanent harm, the mixed vector X-axis roll tolerance of capsule spin stabilization will be markedly lower.

Deconditioned station crewmembers will be especially susceptible to rotational effects because of several 

factors, including lack of similar vestibular cues during spaceflight and relative volume depletion. Ill crewmembers 

would almost always be unable to tolerate spin stabilization of more than 5 to 10 RPM.

Human tolerance to impact acceleration is fairly high for extremely brief periods of time (more than 0.2 

second). Primate model studies demonstrate an unrestrained lethal threshold of 20 Gx that increases to more than 60 

Gx when a primate is restrained properly. Human studies show that up to 50 +Gx may be tolerable for extremely 

brief periods (0.2 second) with optimal seat and restraint configuration. Persons who are ill or injured may need 

additional protection from impact acceleration. One method for protecting an injured or ill crewmember might 

be an impact-attenuating seat that’s been designed for transport.

Cabin Space/Entry Configurations

Other primary considerations in developing a medical transport vehicle include the availability of cabin 

space and the positioning of access doors for crewmember ingress/egress. The amount of care a crewmember will 

require during transport will determine the number of support personnel required to render that care and the amount 

of equipment needed. Patients who continuously use a ventilator and a monitoring system will require more space. 

Proper ingress/egress of that crewmember in making the transition from microgravity to a 1-G environment will 

determine the positioning, width, weight, and height of the access door. Also, the proper handling and familiarity 

with the access doors in both the microgravity and the 1-G environment will prevent damage and expedite loading 

and unloading protocols.

Payload Placement Effects

Another primary concern is the effect of placing and orienting a crewmember, combined with additional 

equipment, on the center of gravity of the vehicle. Consideration should be given to the importance of loading and 

unloading with the proper distribution of weight as well as to the effect on the safe operations of the vehicle during 

reentry, landing, and recovery.

CONSIDERATION 5: Secondary reasons for selecting an ACRV design should be discussed in the 

context of medical transport.

Facts/Comments

Secondary considerations in designing an ACRV to be used for medical transport include climate control, 

pressurization, oxygen supply, electrical supply, communications capability and rescue/escape appliances, ease of 

maintenance during infrequent use, ease of use when needed, and separation and guidance systems.

Climate control or the ability to heat or cool the cabin may require various degrees of sophistication. 

Consideration must be given to making the ill/injured crewmember comfortable for possible prolonged loiter times in 

space or for prolonged recovery times after reentry.

ACRV pressurization may the single most important consideration in making a decision to transport an 

injured/ill crewmember. The maximum altitude at which crewmembers can fly without supplementary oxygen is 

10,000 feet. An injured crewmember may need supplementary oxygen at a much lower altitude, however, and may 
9

be suffering from cardiopulmonary insufficiency, hypovolemia, etc., any of which can be adversely affected by a 

decrease in atmospheric pressure. The lower pressures found in the Apollo and ballistic vehicle designs would be 

inadequate for transporting an ill crewmember. A “flight suit,” 14.7-psi environment during loiter, reentry, landing, 

and recovery would provide the most adequate and optimum medical care. Pressure suits may be impossible to 

wear because of an intravenous (IV) line, a splint or spinal immobilization device, or an endotracheal tube (ETT).

An adequate oxygen supply, one provided by liquid oxygen or by an onboard oxygen-generating system, 

will be needed for the respiratory equipment. A problem to consider should a ventilator be required is excess oxygen 

buildup in a small cabin space. Buildup from expired 100% oxygen must be prevented to decrease the risk of fire. 

The design vehicle will need an electrical harness to allow access to outlets for monitors and respiratory and suction 

equipment. If electrical power is lost when the vehicle is shut down, batteries of sufficient capacity will be required. 

Also, electrical equipment carried in the vehicle must not generate electrical magnetic interference because it may 

interfere with the operation of essential navigation equipment.

A sophisticated communications capability is a necessity to efficiently transfer an ill crewmember. Radio 

voice communication to recovery forces after the ACRV separates from the station would improve rescue capability 

with minimal delays, maximum safety, and the reassurance of the ACRV crew.

Any vehicle expected to land in water during SAR will need to carry sufficient lifesaving equipment 

for everyone on board. If minimum equipment is carried, survival will depend on rapidly locating and retrieving 

crewmembers.

Because of an estimated usage frequency of once every 4 to 12 years, maintenance and ease of use when 

needed are important topics. The latter is pertinent in medical transport since the time may be short and more than 

one crewmember may be ill or injured. This situation is also closely tied to the need for both automatic and manual 

separation and guidance systems. The desire to crew the station as completely as possible when ACRV is necessary, 

and the possibility of multiple crew problems, make automatic separation and guidance important.

Summary

From a medical contingency perspective, the ideal ACRV design is a winged vehicle such as the Langley 

lifting body vehicle. This vehicle has the lowest entry gravity profile, and it can land at preselected runway sites that 

are presumably close to definitive medical care facilities. Unfortunately, it is also the most expensive option.

The least desirable vehicle for a medical contingency would be a minimally controlled ballistic-type 

vehicle. In its present design, this vehicle has many potentially medically hazardous design characteristics. Among 

these are poor spin stabilization, high entry gravity profile, insufficient life support for loiter, and inadequate 

clothing/protective gear. A ballistic-type vehicle is thus considered unacceptable for medical transport.

The Apollo-derived design, while not ideal, can supply some capabilities for ACRV use. The vehicle, 

with its 3- to 4-G entry profile, would be acceptable for many but not all medical contingencies. Its size should 

accommodate at least six persons, and it can be a compromise choice to serve as a medical rescue vehicle.

The environmental control and life support systems should be a “flight suit,” 14.7-psi atmosphere. Further 

requirements for injured/ill crewmembers should also be available; i.e. oxygen, medical equipment, survival gear.

Overall, the proposed ACRV should not expose healthy or injured crewmembers to more than a moderate 

level of risk. The ACRV should be capable of accommodating more than one injured or ill crewmember. And, the 

ACRV will need to provide stowage space for specific medical equipment and supplies.

References

(1)Covault C. NASA to Seek Design Concepts for Station Crew Escape Vehicle. Aviat. Week and Space Tech. Aug. 

17, 1987:30.

(2) Assured Crew Return Capability (ACRC). Phase A report. NASA/JSC ACRV Office 1A13. Houston, Texas: 

1988.

(3) Parker JF, West VR, eds. Bioastronautics Data Book. Washington, DC: National Aeronautics and Space 

Administration, 1973.
10

Equipment

A variety of equipment will be transported with the patient in the ACRV. A redundant module with 

several capabilities, or a module that has been assembled piecemeal to match the medical requirements of the patient, 

may be secured there. In either case, an underlying objective is to identify existing systems and to modify them rather 

than to design completely new equipment.

CONSIDERATION 6: The function and placement of all physiologic life-support equipment in the 

ACRV should be determined. The capacity of selected equipment to function 

in a microgravity and +G-environment will require assessment.

Facts/Comments

All physiologic life-support equipment must be selected to meet appropriate specifications of size, 

weight, battery life, power availability, tolerance of microgravity and high-gravity environments, and levels of 

electromagnetic interference. Equipment should be portable to provide, at the point of injury or illness, the capability 

for use throughout the station to the HMF or ACRV. Some portable items of duplicate equipment from the HMF 

might be carried to the ACRV. The ACRV may contain some dedicated equipment, either portable or installed.

Airway Protection/Supplemental Oxygen

Airway adjuncts, if needed, most likely will be placed while the patient is in the HMF. In some 

circumstances—when immediate patient transport is required, a damaged station with an unusable HMF must be 

evacuated, or an unforeseen airway obstruction or respiratory arrest occurs during in-space loiter or prior to rescue 

and post-splashdown—supplemental airway devices could be needed on board the ACRV. In this case, standard 

ETTs placed by laryngoscopy are preferred. Depending on the medical attendant’s training and experience, a 

blindly placed airway device such as a tracheal lumen airway might also be considered. It will be necessary 

to establish methods and secure materials to prevent airway movement during reentry.

Supplemental oxygen is an essential component of emergency patient care. As well as satisfying the 

oxygen requirements of uninjured crewmembers, equipment must be available to supplement the inspired oxygen 

concentrations of injured personnel to achieve elevated blood oxygen concentrations. If an ETT is unnecessary or 

cannot be placed, a tightly fitting aviation-style mask could be used instead. This would reduce the potential fire 

risks associated with oxygen leaks from nasal prongs or standard medical oxygen masks. Leakage is not likely to 

occur when the patient is endotracheally intubated. The presence of aviator-style face masks for all crew positions 

would allow supplemental oxygenation to treat smoke or toxic fume inhalation and would also increase survivability 

during a purge of the ACRV’s atmosphere following an evacuation that is associated with a toxic leak or fire.

Liquid oxygen must be transformed from its stored state to a room temperature gas. An onboard oxygen 

generator could be used to concentrate excess atmospheric oxygen and to store the excess oxygen in the supply tank. 

Administration device selection also depends upon vehicle pressurization, since standard medical administration 

equipment such as nasal cannula or non-rebreather masks are inadequate for low-pressure atmospheres.

Ventilatory Support

Either an oxygen- or electrically powered portable ventilator must be available for intubated patients, 

regardless of their respiratory status. The ventilator must be adjustable to provide for both normal ventilation and 

hyperventilation. A capability to provide positive-end expiratory pressure (PEEP) would benefit many diseases. It is 

unlikely a ventilation device that is manually operated by an attending crewmember would be sustainable throughout 

the recovery process.

Aspirator (Suction Equipment)

A suction device with appropriate catheters for removing the fluids that could obstruct respiration should 

be available within the ACRV. In a winged ACRV, this equipment could be used at any point in flight. But, even 

in other ACRV configurations, suction following station separation but prior to atmospheric reentry or subsequent 

to splashdown could be lifesaving. Suction devices for a nasogastric tube and urinary catheter should be available 

to provide intermittent and continuous suction, as required.
11

Monitoring Equipment

In addition to interventions, continuous monitoring of patient status is critical. The following equipment is 

important to perform this function:

1. Electrocardiograph (ECG) Monitor/Defibrillator – Provides support, at a minimum, by a three-lead 

ECG monitor with a defibrillator and a synchronized cardioversion. Through-the-paddle monitoring 

may also be advantageous in rare circumstances. An adhesive pad defibrillation system could provide the 

capacity for remotely ordered defibrillation or cardioversion when ground medical personnel are aware of 

significant dysrhythmias transmitted by telemetry. It would also be useful to minimize electrical arcing in a 

potentially oxygen-rich environment. If the device has a transcutaneous (external) pacing capability, pacing 

could be achieved through adhesive pads. An auto-defibrillation capability option may also be useful.

2. Blood Pressure (BP) and Pulse Monitor – Provides continuous evaluation of BP and pulse rate for the 

severely or critically ill patient, either by an in-flight attendant or via telemetry with ground crews.

3. Pulse Oximetry – Continuously estimates oxygenation throughout recovery.

4. Urinary Catheter with Temperature Sensor – Indirectly monitors systemic perfusion by kidney function and 

core temperature.

5. Computer Integration/Database – Maintains or transmits data for real-time intervention and post-recovery 

review.

Cardiovascular Support

A portable cardiopulmonary bypass or ventricular assist device could maintain perfusion in flight.

Drug Infusion Devices

In addition to the standard IV catheters, tubing, and bags that will provide various solutions and drip rates, a 

flow pump is needed to maintain and regulate the infusion. Gravity flow is not feasible in orbit or during reentry, nor 

may it be possible after landing or prior to rescue owing to uncertainty as to crew orientation in a floating vehicle. IV 

tubing that will be used with an IV pump should not include the usual “drip chamber” since air might enter the tubing 

and cause liquid separation.

If the ACRV design selected is a low-gravity, winged vehicle, no additional infusion equipment should be 

required because in-flight administration by a medical attendant would be possible. In a high-gravity, ballistic-style 

or Apollo-derived vehicle, no care during reentry could be initiated by an attendant; even continuation of care 

generally would be impossible. Depending on space and weight limitations, it might be possible to design and 

incorporate equipment that would permit ground-controlled administration of medications and fluids through 

established IV lines.

Medications

The list of medications carried will be determined largely by vehicle selection. This, in turn, will influence 

space and weight limitations and the crew’s ability to administer drugs during flight and immediately post-flight.

IV fluids must be carried since they can be initiated preflight. Fluid selection can be limited to Dextrose 5% 

in water to maintain a medication line, and to a pH-balanced isotonic crystalloid solution for volume repletion. As 

the development of synthetic oxygen-carrying blood substitutes progresses, it might also be considered. All fluids 

must be carried in sufficient quantity to allow for significant loiter and recovery times.

If administration is possible, the following medications would be useful:

Epinephrine HC1, 1:1,000 Morphine Sulphate

Epinephrine HC1, 1:10,000 Furosemide

Aminophylline Mannitol

Atropine Sulfate Haloperidol

Lidocaine HC1 Dexamethasone
12

Bretylium Diazepam

Dopamine HC1 Phenobarbitol

Naloxone HC1 Pancuronium

Meperidine HC1 Sodium Succinylcholine

The dose, function, and complications of each medication would be available to the administering crewmember 

using a method similar to that employed on the space shuttle medical system.

Immobilization Equipment

Spinal and extremity immobilizers will be required equipment in the HMF and might also be housed on the 

ACRV. Wooden or fiberglass spine boards, long in use, will need to be padded carefully before a patient is subjected 

to high-gravity forces. A vacuum-splint-style spinal immobilization device, available in the pre-hospital-care market, 

may offer better protection than standard spine boards because the device’s ability to mold to any configuration. 

Questions about the advantages of soft padding versus the risk of vertebral movement will have to be investigated 

regardless of the device selected. Similarly, vacuum splints may be preferred for extremities that do not require 

traction. Board or wire ladder splints and conforming splints such as the SAM splint are also versatile options. 

Traction splints must be chosen in view of space limitations in both the HMF and the ACRV. For this reason, 

the Sager traction splint has been found useful for helicopter aeromedical transport.

Pneumatic antishock garments (PASGs) should be available, although they most likely will be stored in 

the HMF rather than in the ACRV. A PASG, in addition to providing immobilization for fractures of the pelvis or 

lower extremities, may provide a hemostatic effect for intra-abdominal, retroperitoneal, or extremity bleeds. It also 

will temporarily elevate BPs in hypotensive patients. A ground-controlled pump to inflate the PASG during reentry 

would be useful. Vacuum splints and the PASG are potentially significant hazards because they rely on gas pressure 

to achieve their effect, and gas pressure is subject to considerable changes that depend on outside pressure. So, either 

a stable cabin pressure of 14.7 psi would need to be guaranteed or a device inflated with a substance less vulnerable 

to changes in outside pressure would be needed.

Miscellaneous Equipment

A Heimlich valve is carried to use with chest tubes. This valve is more practical for transporting patients 

with severe chest injuries than for trying to maintain a water seal.

Summary

Two equipment considerations are: (1) the type of equipment selected and (2) its configuration within both 

the HMF and the ACRV. The influence of equipment on ACRV payloads and on the ACRV’s “flying” ability is also 

important. Included in these considerations is the need for a highly flexible and functional transport litter—a device 

that will be completely designed rather than modified from the relatively limited pre-hospital-care choices.

CONSIDERATION 7: Equipment for transporting a patient to the ACRV and securing the patient’s 

position in the ACRV should be detailed, including demands on payload 

capability, ACRV maneuverability, and the position and role of other 

crewmembers.

Facts/Comments

While it is possible that no medical equipment will be needed for certain ACRV uses, in a medical transport 

module portable equipment may significantly impact the overall performance capability of the ACRV. A number of 

factors are important when selecting medical equipment.

Weight/Volume

The weight and placement of an ill/injured crewmember in a recovery system together with additional 

equipment may affect the maneuverability and operation of a spacecraft. The weight of all possible equipment and 

the maximum number of transport personnel may place an upper limit on certain payloads. The size and shape of 

equipment, how the equipment fits together, and equipment accessibility are also factors that might affect overall 
13

performance. Optimally, commercial components may be rearranged into lightweight modules with several 

functions.

Seats/Restraints

Crew seat, restraint, and harness design should provide minimal risk of injury to healthy or uninjured 

crewmembers. Special equipment, such as a seat with litter capability and impact attenuation, is important to protect 

an injured crew. The ability to position the patient in positions other than and inclusive of the standard position for 

reentry is necessary. Optimal transport positions for different illnesses or injury may vary.

For example, if an Apollo-derived design is used for medical transport, the best location for an ill or 

injured crewmember would be in the middle of the bottom row of seats situated on a removable upper middle seat. 

The attendant would ride next to the patient with required therapeutic and monitoring equipment on the other seat. 

When necessary, other crewmembers could ride on the upper row. This would separate the other crewmembers from 

distractions related to the ill/injured crewmember. The ill/injured crewmember’s seat should be separated from the 

other crew seats so that procedures could be performed without affecting the crew or the ACRV systems. Another 

possibility is designing two other seats, possibly on the bottom row, that will have basic immobilization capability. 

Each seat may be served by an individual set of equipment or from a central unit. This second option must be 

considered as a possibility should multiple crew injuries occur.

Transport Litter

When a crewmember is seriously ill or injured and the decision is made to transfer him/her from the 

HMF to the ACRV, a transport litter or patient restraint system is vital. To prevent inconvenience, discomfort, and 

possible injury caused by being transferred from one supporting structure to another, the transport litter should offer 

a minimal burden to the patient and transport personnel. It should be easily maneuverable between the space station 

airlocks and the entrance to the ACRV. The ACRV access door should accommodate the restraint system in a worstcase patient posture and orientation without significantly hindering patient loading or unloading. Rapid entry and 

egress must be possible in both microgravity and 1-G environments.

Ideally, the litter used in the HMF could be removed from a supporting structure and used for transport 

to, in, and from the ACRV. This litter should include a spinal immobilization device. Or, be a “patient pod” could be 

inserted and removed from the ACRV as a single structure. Also, to allow for rapid removal of a severely injured/ill 

patient from the confines of an ACRV vehicle, the patient pod could contain patient monitoring and care equipment 

that could be operated telemetrically. If flotation devices are incorporated in the pod, survivability would be 

enhanced—even in the event of ejection prior to ocean rescue by helicopter rescue forces.

Crew clothing will largely depend upon vehicle configuration and the selected environment. It is unlikely 

that a pressurized space suit would be appropriate for the patient.
14

Indications for Medical Transport

Indications for medical transport should be based on defined capabilities as well as on the HMF and 

crew, reentry forces involved with the ACRV, physiologic tolerance of these forces on individuals with different 

illnesses and injuries, and influence of time and treatment methods on specific diseases.

CONSIDERATION 8: The decision to transport ill/injured crewmembers includes the training of 

on-site personnel who are making the decisions, resuscitation capability of the 

HMF, deconditioned status of the patient, ACRV reentry profile, severity and 

natural course of the illness or injury, and availability of the shuttle. Only 

limited human experience with prolonged spaceflight can be used as a 

reference in this work.

Facts/Comments

The HMF is planned to care for Class I (mild) and Class II (moderate) illnesses, and to temporarily 

stabilize some class III (severe) illnesses prior to removal(1). It will have adequate diagnostic and therapeutic 

materials to diagnose and care for common injuries. Crewmembers will be removed from the HMF by ACRV or 

space shuttle.

The station should have a designated medical officer. Depending on the medical officer’s level of training, 

he/she will have enough experience and training to diagnose and treat most illnesses and injuries and to know when 

HMF capabilities are exceeded or when a crewmember must be transported from the station. Inadequately qualified 

medical officers, by providing inadequate care, could allow Class I and II illnesses to progress to Class III status.

Prolonged microgravity exposure will profoundly affect the disease state acutely after injury or illness, 

during a return flight, and following exposure to Earth’s environment. The impact of cardiac and musculoskeletal 

deconditioning together with neurovestibular changes will impact the patient’s condition both en route and during 

recovery. This would limit the ability of an accompanying crewmember to function usefully. Several sources have 

documented how these conditions could cause the crew to experience orthostatic hypotension, an inability to move 

unassisted, and possibly disabling neurovestibular symptoms(2).

The ACRV will have adequate space and facilities to provide patient care during and after reentry. 

The gravity profiles and recovery mode will play heavily in the decision to transport a patient. The ACRV’s gravity 

profile must not prove detrimental to a patient’s or rescuer’s functioning. Vehicle recovery must be rapid (> 1 hour) 

and the vehicle must be able to maintain life support and power systems while waiting for recovery. The shuttle, 

which would be assumed to be readily available for use, could be reserved for patients who require transport in 

a sophisticated, relatively low-gravity vehicle.

Summary

Crewmember removal must be planned with the patient in a protected environment that will cause no 

further harm during removal. Although this situation is unlikely, the ACRV is best used in medical conditions that 

are minimally or not at all affected by this transport-and-recovery profile. The ACRV is also used when there is no 

time to wait for shuttle deployment and the patient can only survival if rapidly removed. If possible, the space shuttle 

is used when more equipment and more cautious transport is needed in a stable or a complex patient. This is because 

it affords a choice of landing areas and the possibility of other crew to help care for a patient, and its use does not 

require removing crewmembers other than the patient from the station.

CONSIDERATION 9: The value placed on a person’s life or limb is emotional and complex. Before a 

patient is removed from the station, it is necessary to address the inherent risk 

and benefits to that patient, the crew, and the mission itself.

Facts/Comments

The cost of a space station runs into billions of dollars. But, the cost of a person’s life has an incalculable as 

well as an emotional value. The cost of rescue by the space shuttle is estimated at $200M (in 1989 dollars). The cost 

of ACRV deployment has yet to be determined, but it will not be inexpensive.
15

The government and the public value safety and the availability of medical care. To them, a crewmember’s 

life is not expendable. However, in terms of the mission, a crewmember’s life may not equal the risk of jeopardizing 

the crew’s and station’s viability by attempting a rescue. Or, simply put, the results may not be worth the risk.

Loss of an injured or ill crewmember will lessen effectiveness. The impact of illness or on-orbit death will 

affect the crew psychologically. Crewmembers are at risk during return and may be lost if recovery is prolonged or 

the vehicle cannot be located. Some transports may be so precipitous it will be difficult to assess benefits until long 

after the event. Many situations cannot be planned for, and the benefit of transport must be weighed at that time.

Summary

The space station must have a viable plan for patient evacuation—a plan that limits the loss of crew 

effectiveness and minimizes danger to patient and crew. All alternatives should be explored before a crewmember 

is allowed to die in flight. Simple or easily manageable illnesses should not be transported if supportive care can be 

safely provided on board the station without disrupting the mission or the crew’s psychological fitness. Each case 

will need to be studied to the extent allowed by time and personnel.

CONSIDERATION 10: A number of disease possibilities and their evolution in a space station setting 

require discussion. The major potential disease categories are listed.

Facts/Comments

The spectrum of potential neurologic problems includes cerebrovascular accident (CVA), head injury, and 

spinal trauma (neck injury). These conditions require thorough diagnosis and meticulous care.

Subarachnoid hemorrhage comprises 8% of CVAs. Its peak incidence occurs between 35 and 65 years—

the age range of most station crewmembers. Subarachnoid hemorrhage is anticipated to be the most common cause 

of CVA on the space station. Its presence is hard to detect on routine medical examination, and the HMF capability 

does not add to the diagnosis. It is likely that, depending on the medical officer’s skills, lumbar puncture will be 

part of the diagnostic testing. If the patient survives initial bleeding, treatment involves supportive care and 

elective surgery. A subarachnoid hemorrhage is at risk for rebleeding after 1 to 6 weeks.

Head injuries are common. A head injury occurs worldwide every 15 seconds, with one death occurring 

every 12 minutes. Indeed, head injury comprises 25% of all deaths due to trauma(3). Evaluation of head trauma is 

specific and repeated at regular intervals. The HMF will not allow for CT scanning capability. The availability of 

plain radiographs and other simple diagnostic techniques within the HMF is of limited usefulness.

Spinal trauma with cord injury occurs commonly, both alone and associated with other injuries. The rate of 

spinal cord injury in the United States is 50 in 1,000,000, and the diagnosis often can be made on examination. Most 

unstable spine injuries, with or without cord injury, may be diagnosed by plain radiography.

Rapid, definitive care in any of these traumas is the only way to save a crewmember’s life. The decision 

to transport will have to be made rapidly and accurately; for this, the ACRV is likely to be used. During transport, 

restraint and immobilization systems will have an important role to play. The capability for prolonged respiratory 

paralysis and barbiturate coma, along with other advanced medical therapies, may be necessary.

A severe head injury or spontaneous cerebral hemorrhage may progress rapidly to the point that care on 

the station may not be feasible and a return to Earth may be the only chance to save a crewmember’s life. However, 

return to a 1-G environment and the accompanying transient increase in gravity can deleteriously affect a patient’s 

cerebral tissue through fluid shifts and hypotension. Unstable spinal column injuries may impinge on the cord if 

immobilization does not overcome gravity forces. There is also a loss of tone in the muscles of the spine that on 

Earth help to splint these injuries by protective spasm.

Care on board the space station may not only be adequate in subacute situations but may actually be 

beneficial. The microgravity environment may allow temporary support for patients because of the ease of transfer 

and immobilization. Long-term care may be undertaken if the patient has sustained a head injury without focality. 

Though the evolution of cerebral edema in the microgravity environment is unknown, emergent transport is unlikely 

to make a difference in this case. The timing of intervention in subarachnoid hemorrhage may allow for less urgent 

transport after the initial event. And, although microgravity may slow healing of bony spine injuries, its effects on 

the edema of the spinal cord are unknown. Clearly, research in some of these areas is necessary to make educated 

decisions about the care of these injuries.
16

The type of neurologic problem and the rapidity of evolution and severity of signs and symptoms will 

dictate transport. Some conditions will be fatal within a short time. The patient with a probable intracranial injury or 

hemorrhage with rapidly evolving signs is a candidate for transport via ACRV. Spinal injuries and those intracranial 

processes that are stable after acute insult should be supported and transported via shuttle. A smooth transition to the 

most complete care will reduce the risk of additional injury in a possibly salvageable patient.

Head, Eyes, Ears, Nose, and Throat (HEENT)

The spectrum of illnesses and injury to a crewmember’s HEENT is large. Some illnesses and injuries will 

require expert care to save a vital sensory function.

Facts/Comments

Most eye injuries are minor and can be treated with simple procedures and medications. However, this does 

not include penetrating injuries, lens injuries, or acute retinal detachments. Ear injuries can be treated conservatively 

and rarely require immediate care. Nose and mouth injuries can profusely hemorrhage, although it is hoped that most 

of these could be managed with local pressure and the equipment provided. Nevertheless, the station should have a 

complete diagnostic and therapeutic complement of instruments and medications to deal with most HEENT 

conditions.

The treatment of ophthalmologic and otologic conditions should not change in microgravity. An 

exception to this is that conditions presenting neurovestibular symptoms may worsen in microgravity. The rate of 

aqueous/vitreous fluid loss may increase as a result of decreased or increased gravity forces and decreased cabin 

atmospheric pressures.

Summary

Rapid deployment of the ACRV will probably not occur for any HEENT injury or illness that does not 

endanger eyesight or hearing. By contrast, with an illness or injury for which there is only temporizing treatment—

e.g., intraocular hemorrhage—rapid transport by ACRV may be indicated.

Chest

Chest traumas account for 25% of all trauma injuries in the United States. A chest injury is a likely 

contingency for the crew of the space station.

Facts/Comments

Roughly 85% of chest injuries can be handled nonsurgically. Definitive care usually consists of tube 

thoracostomy and drainage of air or fluid. The remainder of chest injuries may entail surgery that may or may not be 

within the scope of the HMF. Respiratory support can be provided along with other procedures.

The HMF should be able to supply chest radiographs, oxygen, a ventilator, and the surgical capability 

to handle the majority of chest injuries. Some disorders that are sensitive to atmospheric pressure changes—e.g., 

pneumothorax—would be treated prior to transport. Other cases that could not be treated in the HMF would be 

rapidly reviewed for the best course of action. If the patient can be stabilized, most cases requiring surgical 

support may be transported to Earth by ACRV or shuttle.

Summary

The HMF and the medical officer should be able to provide all lifesaving techniques in chest trauma 

including thoracotomy. The latter is necessary in pericardial tamponade following a penetrating injury to the chest. 

In an emergency, timely cardiac or respiratory repair—including selective aortic cross clamping—may be lifesaving. 

Definitive care will require rapid transport.

Abdominal Trauma

Penetrating or blunt abdominal injury is common in trauma. Rapid diagnosis and treatment are paramount 

in patients suffering from abdominal trauma.
17

Facts/Comments

A traumatic abdominal injury can involve many organs—hollow, solid, and vascular—as well as the bony 

pelvis. The injury itself may be self-limiting, involving only hemorrhage in a closed space; e.g., splenic hematoma. 

But, the patient can bleed into the peritoneal cavity and rapidly exsanguinate. The rupture of a hollow viscous is a 

significant problem that requires early definitive care. While deciding on the need for surgical intervention is key to 

successfully evaluating abdominal trauma, this is a difficult decision to make even in a 1-G environment. Beyond 

physical findings, peritoneal lavage is probably the main diagnostic procedure that would be performed in the HMF 

to diagnose abdominal injury; its modality is about 92% sensitive. Lavage can be supported by simple laboratory 

tests and observations. Patient care would be predicated on the need for rapid surgery. Many of these cases are 

obvious because of associated symptoms or the hypotension or decompensation of a previously stable patient. 

Transport by ACRV depends on the additional constraints of access to definitive care after recovery.

The HMF should be able to support the early treatment and diagnosis of abdominal trauma—excluding CT 

scanning—and volume repletion with crystalloid and available blood products. Nasogastric and bladder drainage 

will also be available. PASG’s will be available for circulatory support and splinting. Although the HMF will not 

support laparotomy, this procedure may be available in extreme circumstances. The ACRV should be capable of 

providing continuing care and life support systems. Surgical care is assumed to be available within 2 to 4 hours after 

leaving the space station via an ACRV. Care of a patient who is rapidly exsanguinating may be impossible in the 

HMF, although the use of surgical facilities in the HMF may be the only alternative to saving the patient’s life. The 

subacute abdomen remains a problem that may be either handled on the station or through being transported to Earth 

in a timely and controlled manner via an ACRV or a shuttle. The question of transport will be determined following 

the crew medical officer’s assessment of patient condition and prognosis. Consultation should also be available from 

ground-based resources. Diagnosing a need for surgical exploration in abdominal trauma is a difficult process. Errors 

in timing and judgment will occur. The availability of surgical suites and extensive medical resources has contributed 

greatly to the care of a patient with abdominal trauma. Care of these injuries in space and timing safe transport back 

to Earth will be some of the more difficult situations for the crew medical officer.

Genitourinary (GU) Trauma

An injury to the GU system is usually not immediately life threatening, but it may impair immediate and 

future urinary and sexual function. Therefore, a GU injury best lends itself to timely transport for definitive care.

Facts/Comments

Most injuries to the GU system either obstruct urine flow or disrupt urogenital tissue. External injuries 

can be repaired, with function restored or stabilized, and bladder drainage can be obtained. More significant internal 

injuries can be life-threatening either from retroperitoneal hemorrhage or infection.

The HMF should have the equipment needed to allow repair of simple external injuries. It should also 

have the means to stint the urethra and to provide suprapubic bladder drainage. The crew medical officer should be 

qualified in diagnosing and providing primary treatment of GU injuries. The station facility should be equipped with 

catheters, etc., of appropriate sizes and types. Since microgravity may cause an inability to drain a patient’s bladder, 

there may be a need for a negative pressure device to provide drainage. Most GU system injuries—unless associated 

with rapid exsanguination from direct, blunt, or penetrating trauma to the kidney itself—can be transported under 

more controlled conditions that will require little in-flight support and will permit loiter for some time before 

definitive care is administered. The ACRV would be ideal for these situations.

Musculoskeletal Trauma

An injury to any element of the musculoskeletal system can be, at worst, a limb- or life-threatening event. 

Healing patterns are well known in the 1-G environment. Repair of musculoskeletal injuries in a microgravity 

environment, by contrast, are not at all well understood and may not be trivial, even in the simplest injury.

Facts/Comments

The return of function to a fractured bone relies on the orderly deposition of bone and remodeling of 

that bone(2). Long-term exposure to reduced gravitational forces causes loss of bone density due to reabsorption and 

calcium excretion. These two processes may directly conflict with one another and may not allow normal bone 
18

healing. Loss of muscle mass in the microgravity environment may affect the repair and recovery of function in 

musculoskeletal injuries of the patient’s extremities, spine, and pelvis(2).

The effect of microgravity on fracture healing is unknown. A fracture in microgravity that would be 

inconsequential on Earth may result in a significant nonunion if the patient is allowed to stay in microgravity.

Injuries to tendons, vascular elements, nerves, open fractures, and intra-articular lacerations require 

prompt surgical treatment. While the HMF may offer basic surgical support, microsurgery and rehabilitation of 

injuries along with complex orthopedic procedures are unlikely to be available. The problem with open fractures 

occurring in microgravity is that the patient may experience an altered immunologic response with loss of T-cell 

function. This may potentially adversely affect the immunologic system and its ability to prevent tissue and bone 

infection both in flight and post ACRV/shuttle recovery.

The HMF will have facilities that permit the initial stabilization and treatment of orthopedic and other 

musculoskeletal injuries. Use of the ACRV or shuttle should allow traction and stabilization to be maintained during 

transport.

In most instances, complex musculoskeletal injures should be transported to Earth in a timely manner. 

Amputations or major vascular injuries may be the only indication for emergency transport. The ACRV may serve 

well in either scenario. Open fractures and more complex injuries should first be stabilized and initially cared for in 

the HMF. The facility should be able to provide adequate surgical and orthopedic support. The crew medical officer 

should be trained in such care and should have adequate access to expert consultation on the ground. Research into 

bone repairs in the microgravity environment is necessary.

Infectious Disease

The space station will not be a sterile environment. It will be colonized with microbial life that will, in 

certain cases, have pathogenic capabilities. Rotating crewmembers may spread infections to other crewmembers. 

Epidemics may occur within the station itself. The possibility of secondary infection in response to an initially trivial 

injury is also a concern. Food poisoning might occur. These problems may or may not require transport, but they 

would definitely affect crew efficiency.

Facts/Comments

The scope of infectious disease and its complications and sequelae are tremendous. Little data exists on the 

presentations and treatments of infectious diseases in microgravity. Generally, since crews on long-term missions are 

quarantined to prevent community-acquired infections, there have been few incidents of serious infectious disease. 

Skylab research shows there is some alteration of white blood cell function that primarily affects T-cell function(2). 

This decrease in T-cell responsiveness has also been shown to persist for a varying time on return to Earth. The 

implications are not yet completely, but clearly microgravity alters the human immune system. Methods of treating 

infectious disease on the station should be a minor problem, but the spectra of serious life-threatening or contagious, 

disabling disease could have devastating effects. It may be impossible to care for rapidly spreading diseases such as 

severe gastrointestinal symptoms and still adequately maintain the station. Large numbers of patients or recurrent 

cases may overwhelm HMF supplies. The possibility of a new or an altered microorganism, which may pose a 

threat to the general population on Earth, is another consideration in returning a crewmember to Earth.

The HMF should be supplied with a wide array of antibiotics as well as with the means to culture and 

identify organisms. There should be a way to isolate contagious crewmembers and to provide adequate supportive 

care. The HMF should therefore be supplied to care for a full complement of crewmembers, any or all of whom may 

be infected. Protocols should be established to prepare for wide disease spread and its possible effect on the integrity 

and mission of the station. At the earliest sign of spreading infection, infected crewmembers should be returned to 

Earth, decontamination should be instituted, and, possibly, the station should be re-crewed to save the mission. 

Transport of a septic or seriously locally infected patient should be expedited. The use of the ACRV should 

be predicated on patient stability.

Cardiopulmonary Conditions

The danger of cardiovascular and respiratory illness or injury is real. The possibility of hypoxia, toxic 

inhalation, decompression sickness (DCS), and even cardiac arrest also exists. There are standard approaches that 

can be used to treat these injuries. Their eventual course and subsequent care should be anticipated.
19

Facts/Comments

The space station can be equipped to provide advanced cardiac life support and prolonged ventilatory care. 

A stabilized patient could be maintained on board until orderly transport is arranged.

DCS, known to occur after extravehicular activities (EVAs)(2), can be effectively treated with hyperbaric 

oxygen therapy. Since EVAs are anticipated to be commonly performed from the space station, DCS will be a risk, 

but DCS rarely advances to a life-threatening entity.

The potential for exposure to toxic fluids and gases is significant. The shuttle has been exposed to at least 

10 such substances, and it is unlikely that the station will experience fewer. Some of these substances are ammonia, 

freon, hydrazine, nitrogen, hydrogen, and nitrogen tetroxide. Most inhalation injuries will require supplemental 

oxygen and supportive care. More severe inhalation injuries will require ventilatory and cardiovascular support.

HMF facilities could handle an uncomplicated myocardial infarction. The need for and use of thrombolytic 

therapy in this setting must be considered.

The HMF should also be able to provide prolonged ventilatory and circulatory support along with 

monitoring capability for patients, and the crew medical officer should be sufficiently skilled to care for them. The 

space station should have a two-place recompression chamber to enable DCS to be rapidly and correctly treated.

Summary

Microgravity may adversely affect the cardiovascular system and further complicate cardiorespiratory 

disease(2). The effect of gravity on reentry may adversely affect outcome as well. The care of patients suffering from 

problems with the cardiovascular system should center on stabilization and timely transport. The transport should be 

timed maximally to help the patient, and to maintain crew and mission integrity. Research is needed into the response 

of compromised cardiovascular and pulmonary function when exposed to high-gravity reentry profiles.

Physiological Readaptation to 1-G

The human body, after its return from microgravity, must readapt to Earth gravity. This process 

occurs in every person to some extent, even after only a few days in space. There are three basic physiological 

considerations: (1) orthostatic intolerance due to cardiovascular and fluid/electrolyte changes, (2) neurovestibular 

changes, and (3) musculoskeletal changes. Each has been documented in returning crewmembers. Any one or all 

three could severely limit performance after reentry. Many crewmembers are sufficiently readapted to be able to 

walk satisfactorily after 10 to 20 minutes. Others have great difficulty even after 10 to 20 minutes and will require 

several hours to get back their “Earth legs”. Several shuttle crewmembers have experienced serious neurovestibular 

symptoms that have totally incapacitated them for up to 1 hour or more post landing. There is also evidence that 

decrements in mass perception and discrimination may occur immediately post landing. The U.S. space program 

has had limited experience with long-term missions; but, after Skylab (the longest flight of which lasted 84 days), 

crewmembers were relatively incapacitated for as many as a few days after landing.

Readaptation is a great concern for an ACRV scenario. Even in the best of situations, where the entire 

crew is deemed “healthy,” there is considerable evidence that suggests the readaptational process will severely limit 

a crewmember’s ability to perform the complicated physical actions that might be necessary to effect a rescue. An ill 

or injured crewmember might not be able to make physical efforts on his/her own behalf, and the physiologic 

responses may not be the same.

It is important to consider the Russian experience. After a record-setting 237 days in orbit, the Salyut 

crew was unable to lift their arms to unbuckle their lap belts and had to be physically carried from their spacecraft. 

Significantly more research is needed into the physiologic response of the deconditioned individual to pathologic 

processes. As an example of the limited database for this information, the most recent available paper on 

deconditioned tolerance to Gx acceleration was written in 1965(4).

References

(1) Kimzey S.L. Hematology and Immunology Studies. In: Biomedical results from Skylab. Washington, DC: NASA, 

1977:248-282.

(2) Nicogossian A.E. Biomedical Challenges of Spaceflight. In: DeHart R.L., ed. Fundamentals of Aerospace 

Medicine. Philadelphia: Lea and Febiger, 1985:839-861.
20

(3)Johnson R.L., et al. Lower Body Negative Pressure: Third Manned Skylab Mission. In: Johnston R.S., ed. 

Biomedical Results from Skylab. Washington, DC: NASA, 1977:284-312.

(4)Miller P.B., Leverett S.D., Tolerance to transverse +Gx and headward +Gx acceleration after prolonged bed rest.

Aerosp. Med 36:13-15, 1965.
21

Transport Protocols

Should a medical emergency occur that is severe enough that the HMF cannot provide adequate care to an 

ill/injured crewmember, a decision must be made on the feasibility and advisability of returning that crewmember to 

Earth. Physical examination results, pertinent laboratory and radiological findings, and related information would be 

transmitted to JSC; and the transport/no-transport decision would be made after consulting with the crew, the flight 

medical officer, other Medical Operations personnel, and, possibly, outside consulting teams. This group will also 

need to coordinate with space operations and rescue team efforts, and to assess risks associated with various loiter 

times, splashdown or landing sites, and other flight-associated hazards versus the time required to obtain definitive 

care for a patient.

CONSIDERATION 11: Coordination with station and ground rescue forces is needed to seek the 

optimal window of opportunity for reentry. This must take into account the 

availability of rescue forces with respect to the station’s position. (See Search 

and Rescue.)

Facts/Comments

The time-axis is influenced by many factors, including patient condition, potential for intervention in 

the HMF, weather at recovery sites, loiter time, potential station movement, positioning of selected recovery forces, 

and medical capabilities of recovery forces.

CONSIDERATION 12: Preflight patient care protocols need to be developed, including general 

systems checks and items for specific disease entities.

Facts/Comments

Some injuries are non-survivable regardless of where they occur, and other injuries will not tolerate 

the stresses of reentry from Earth orbit. Preflight patient care delivered in the HMF will significantly enhance 

survivability during reentry and recovery. The general areas, for which function checklists need to be developed, 

include:

1. ACRV Systems – Environmental

• Temperature, pressure, oxygen

• Power

• Communications

2. Medical Life Support Equipment

• Airway and respiratory support

• Fluid-replacement delivery system

• Monitoring

• Medications

• Splinting, immobilization, and patient restraint

Patients must be appropriately restrained to prevent them from sustaining further injury from their own 

movements within a seat or stretcher and against the forces involved with reentry, landing, and recovery.

A patient with an altered level of consciousness or an underlying disease process that could adversely affect 

consciousness, airway patency, or respiratory capacity should have a protective airway inserted prior to placement in 

the ACRV. Optimally, an ETT should be used and a nasogastric tube should be placed afterward. Both tubes need to 

be secured to prevent movement. If ETT placement is not feasible, a surgical cricothyrotomy or a tracheal lumen 

airway is also an option. An IV line (peripheral or central) is placed to provide access for medication delivery or 

volume resuscitation.
22

Sedation must be considered not only to manage pain but to prevent patient movement that could dislodge 

airway or splinting devices, or aggravate patient injury. Sedation may necessitate intubating a patient who would not 

otherwise require it so that he/she can be placed on a ventilator to guard against the onset of respiratory depression in 

flight. Circumstances must be considered and detailed that would warrant administering a paralyzing neuromuscular 

blocking agent such as pancuronium or succiny1choline.

Specific physiologic parameters to be met before transport should also be considered. Specific focus should 

be placed on protocols by disease category, including those discussed below.

Head and Neck Injury

Intubation and hyperventilation must be initiated rapidly in case of significant head injury. When 

an expanding intracranial lesion or other indication for rapid neurosurgery beyond the capacity of the HMF 

occurs, treatment is urgent. This situation may justify risks that would not otherwise be considered involving 

ACRV transport. Prior to transport, IV access is established and fluid is infused at the slowest possible rate unless 

hypotension or hypovolemia is also present. Diuretics, corticosteroids, barbiturate coma, and anticonvulsants should 

be considered.

Unstable spinal injury—with or without neurologic deficit—requires preflight immobilization that, 

if possible, should be applied at the scene of occurrence. Microgravity conditions may ease application of spinal 

immobilization devices, but reentry from orbit and splashdown with its potentially high gravity loadings, particularly 

in a wingless ACRV, will require extensive protection against vertebrae movement. A vacuum-splint-style spinal 

immobilization device may offer better protection than standard spine boards will. A major challenge is developing 

techniques and devices, which provide on-site immobilization without risking cord disruption, and adequate impact 

attenuation while restricting spinal motion under high- and microgravity conditions.

Head, Eyes, Ears, Nose, and Throat

Assuming that impending loss of vision is the most likely reason for returning to Earth, little specific 

preflight or in-flight care is needed. Supine positioning is generally recommended for transporting these patients, but 

there is no information concerning the potential effects of high- or microgravity conditions on ocular injuries. Low 

atmospheric cabin pressures may also increase the risk of ocular fluid loss. Preflight therapy aimed at reducing 

intraocular pressures may prove beneficial in some cases.

Chest Trauma

The patient should have IV access with an appropriate resuscitation fluid started, and, in most cases, a 

chest tube with a Heimlich valve placed. If the airway is at risk or if the airway may lose its protection or patency, an 

ETT is placed as part of the preflight protocol. Pericardiocentesis by catheter or window techniques, or thoracotomy 

with or without aortic cross-clamping may be performed in the HMF. If performed, the patient will require 

appropriate support during ACRV transport. Sedation or analgesia/anesthesia will typically be required.

Abdominal Trauma

In addition to IV placement, sedation, and possible intubation, a PASG should be placed on the patient. 

Preflight inflation of the PASG will depend on the patient’s condition and whether the garment can be inflated during 

flight. The likelihood of spinal cord and renal infarction before rescue will most likely obviate the use of aortic 

cross-clamping.

Genitourinary Trauma

Analgesia will be needed prior to transport. If possible, urine should be adequately drained. If the bladder 

must be continuously emptied, a suction pump should be used.

Musculoskeletal Trauma

Depending on the nature of the injury, transport may have a high or low degree of urgency. Optimal 

timing will need to be discussed with medical personnel on Earth. Affected limbs must be adequately splinted prior 

to placing a patient in the ACRV. IV analgesia will be essential as high gravity conditions with a fracture are likely 

to cause severe pain. PASGs or air splints may be used for hemostasis and splinting, even in extremity amputations, 
23

and are less likely to cause significant tissue damage than narrow tourniquets. This depends on the pounds per square 

inch (psi) of surrounding atmosphere, or the ability to maintain constant pressure within the splint or PASG. Traction 

will be needed for some injuries. Amputated parts will need to be packaged to keep them dry and chilled, without 

freezing.

Burns

Many burns will be cared for in the HMF without necessitating an early return to Earth. Burn patients who 

need to be evacuated from the station will require initiation of analgesia and IVs for fluid replacement preflight.

Cardiovascular/Respiratory Emergencies

Any patient returned to Earth as a result of a cardiovascular/respiratory emergency will require an IV 

infusion and, probably, analgesia. Intubation and ventilation may be required in cases of heart failure, shock, and 

severe DCS. Monitoring apparatus must be applied prior to flight. A 12-lead diagnostic ECG should be performed 

in the HMF, and any thrombolytic therapy being considered should probably be completed before departure. Postthrombolytic exsanguination due to high-gravity reentry injury may be a risk. The risk of anticoagulation will also 

need to be considered.

In cases of DCS and air embolism, repressurization should be initiated immediately on the station. Oxygen 

therapy should also be initiated, and the usual IVs, monitors, and analgesia should be instituted before placing the 

patient in the ACRV. A similar sequence is necessary for toxic inhalations.

Psychiatric Emergencies

In a psychiatric emergency, physical or pharmacological restraints should be applied, as required, to prevent 

any possibility of the patient interfering with controls on board the ACRV.

CONSIDERATION 13: In-flight patient care protocols are necessary. If possible, most resuscitation 

and stabilization will be performed in the HMF as a preflight protocol.

Facts/Comments

General Support Measures

Airway and ventilation must be maintained at all times if a patient is to survive. An onboard or a portable

ventilator will likely be used, regardless of the vehicle. Suction may be important to preserve the patient’s airway, 

but the use of suction in flight is probably not feasible in a ballistic or an Apollo-derived ACRV.

An IV infusion should be maintained throughout flight. A pumping administration device is needed to 

control fluid flow rates, maintain flow during varying gravity conditions, and prevent air entry into the tubing that 

could result in liquid separation and air embolism. A quantity of fluid adequate for flight duration, including loiter 

and recovery times, must be available to the patient before departing the station.

Installing a device that can instill a variety of selected drugs and fluids into the IV line would permit the 

flight medical officer in the ACRV to administer emergency medications during reentry and post-splashdown in 

vehicles with gravity characteristics that preclude active medical attention and intervention by crewmembers. The 

same device could be used in cases of abnormal orientation after splashdown, or when recovery is prolonged but 

other crewmembers are too weak or unable to deliver patient care.

Specific Problems

1. Head and Neck Injury – Any significantly head-injured patient must be hyperventilated during flight. 

Infusions of diuretics and/or corticosteroids can be continued. Anticonvulsants may also be needed. If a 

telemetrically operated drug selection device is unavailable and flight conditions prevent crew intervention, 

prophylactic anticonvulsant therapy should be strongly considered. If possible, the patient’s head should be 

positioned above the cardiac level. The vacuum-splint style spinal immobilization device (currently available 

in the pre-hospital-care market) may offer better protection than standard spine boards.

2. Chest Trauma – In flight, the medical attendant or a physician on Earth should be prepared to adjust IV 

flow rates as necessary to manage hypotension. The patient most likely will be intubated and on a ventilator. 
24

Although the possibility of a patient developing tension pneumothorax exists even after a chest tube has been 

placed, it is a rare event. In any case, needle thoracentesis in flight will be impossible unless a winged ACRV or 

the shuttle is used for transport.

3. Abdominal Trauma – The capacity to adjust IV flow to maintain blood pressure should be available. Ideally, 

either a crew attendant or a ground-based medical officer should be able to inflate the PASG if the patient’s 

condition dictates its use.

4. Musculoskeletal Trauma – Replenishment of IV analgesia may be required, depending on loiter time.

5. Burns – Fluid replacement and analgesia must be maintained during flight.

6. Cardiovascular/Respiratory Emergencies

• Continuous ECG monitoring is essential. If possible, the capacity to provide defibrillation, synchronized 

cardioversion, or transcutaneous pacing through adhesive pads during flight would significantly enhance 

patient safety.

• Although thrombolysis following infarction will most likely be completed prior to departure, it may 

be necessary to continue therapy to prevent reocclusion, and preparations should be made to deal with 

reperfusion dysrhythmias.

• The effect of anticoagulation and its risks during transport and recovery must also be considered. In the 

event of cardiogenic shock, a portable cardiopulmonary bypass or a left ventricular assist device might 

preserve myocardial and cerebral perfusion during transport.

• The station would be used to provide therapy for cases of DCS or air embolism. Whether this capability 

would be feasible or necessary in the ACRV needs to be discussed. Providing continuous therapy while en 

route to Earth may be impossible or impractical.

7. Infectious Diseases – Continuing antibiotic therapy and hydration should present no difficulty during flight.

Optimally, the crew or ground-based medical officer should be prepared to administer epinephrine in the event 

of an anaphylactic reaction.

CONSIDERATION 14: Loading/unloading protocols need to be developed.

Facts/Comments

Ideally, any device hooked to the patient by wire or tubing will be permanently mounted to the litter or 

patient pod to reduce the chances for entanglement while moving the patient into or out of the ACRV.

IV patency and ETT position should be reassessed each time the patient is moved into or out of the ACRV. 

Adequate personnel should be available to assist with patient unloading, which can probably best be achieved after 

bringing the ACRV aboard ship rather than attempting it in the water. Standard quarantine will be adequate in most 

circumstances but may require modification if an unidentified infectious disease led to the need for transport.

Summary

Preflight and in-flight protocols will establish the parameters to monitor in a variety of potentially 

transportable disorders. Although preflight work will produce the majority of stabilization, in-flight interventions 

will maintain the patient’s condition and allow landing and recovery in the best possible condition.
25

Transport Complications

CONSIDERATION 15: Crew-related complications during transport must be anticipated.

Once it has been determined that a medical transport from the station will take place, crewmembers must be 

prepared for in-flight transport emergencies. These emergencies present danger to the ill/injured crewmember and to 

anyone else on board the space station. These emergencies can be unexpected and can occur relatively sudden. By 

considering the various types of emergencies preflight, the onset of emergency becomes less unexpected and there 

is a contingency plan in place to handle the problem. Consideration of contingencies can indicate what equipment 

may be needed and what direct behavior and actions might prevent the contingencies from occurring. Transport 

complications considered are those related to the injured/ill crewmember and to the vehicle(1,2).

Facts/Comments

Crewmember Transport Complications

Possible transport complications include hypoxia and gas expansion in flight. Additional attention must be 

given to the deterioration of the patient, the risk of further injury, and, ultimately, death.

The atmosphere selected for an ACRV must offer a compromise between the engineering and medical 

physiological needs of crewmembers. Decreased cabin pressure will necessitate supplementary oxygen to prevent 

hypoxia and may exacerbate pressure-responsive disorders (e.g., pneumothorax) and interventions (e.g., PASG). 

When preparing to transport a patient in the ACRV and if a lower-pressurized cabin is used, it is important to 

determine the patient’s altitude equivalent with respect to oxygen status. A fully pressurized spacecraft could 

eliminate many of the physiologic effects of altitude secondary to hypoxia and would contribute to crew comfort.

The physiologic effects of decreased atmospheric pressure can also contribute to the gas expansion that 

can affect the closed and semi-closed cavities of the body, as well as gases within medical equipment. Preventing this 

effect is another advantage of a 14.7-psi environment.

Preventing deterioration of a crewmember’s condition will depend on adequate preflight assessment 

and ongoing observation during flight. Medication and equipment can be chosen that might be needed should 

deterioration occur. Some major emergencies to be considered are hemorrhage, sudden cardiac dysfunction, and 

pneumothorax and pulmonary embolus. Patient history and other information gathered during preflight evaluation 

should indicate whether any danger of these conditions exists. Attention should be paid to avoiding prolonged 

pressure in the legs and venous stasis during long SAR attempts.

Although the patient may sustain additional injuries from acceleration, rotational, and impact forces, 

these forces should not cause injury if sensible precautions are taken. The security of the patient restraint at its 

attachment to the cabin floor and the method by which a crewmember is secured to the restraint are obvious parts 

to be considered. Danger is also likely to come from flying objects in the cabin, a result of insecure attachments of 

things such as fire extinguishers and IV fluid bottles. A repeated inspection of the cabin for loose and potentially 

detachable items is recommended.

CONSIDERATION 16: The possibility of ACRV-related transport complications must be considered.

Facts/Comments

Transport complications related to the ACRV include vibration and noise, fire, fumes, and depressurization.

Vibration sources include rocket engines and air turbulence. Most of these would be transmitted directly 

to the body of the ACRV and its contents. Properly designed crew seats and restraints should dampen some of the 

vibrations. And, although vibrations as such are not usually harmful to a patient or an attending flight crewmember, 

they can interfere with performing certain procedures. They can also add artifacts to monitoring equipment. Some 

vibrations can cause sufficient stress to hinder performance.

For the most part, noise sources are the same as vibration sources. The noise associated with vibration 

frequencies above 10 Hz is detrimental to crewmember care because of the physiological effects of those vibrations. 

Noise is also a stress-producing factor that can lead to decreased human performance and more rapid fatigue. It can 

interrupt communications not only within the cabin but in air-to-ground or air-to-air transmissions. Communications 

can be less accurate or misinterpreted. The interior of the ACRV cabin should be constructed with lining materials 
26

that absorb some of the external noise and dampen the internal noise level. The shape of the cabin is important 

since any flat areas are likely to resonate with some frequencies of noise and act as a sounding board.

Although fire is unlikely to break out during reentry or landing, precautions should be taken as though it 

will. All crewmembers should consider evacuating the spacecraft to a safe distance as soon as practical since fire is 

always accompanied by fumes and can quickly increase the toxicity within the confines of a cabin. Supplementary 

oxygen sources—preferably a well-fitting mask on hood—should always be available for use. Proper knowledge 

and use of fire extinguishers is essential.

Sudden cabin decompression is one of the more serious emergencies that could occur during transport. The 

physiologic effects on the crew of this will depend on the rapidity of decompression, a relationship determined by the 

volume of the cabin to the size of the cabin defect. Supplemental oxygen should be available for use immediately to 

prevent DCS and hypoxia. After decompression, the ill/injured crewmember will need to be assessed for vacuum 

effects in body cavities and for cardiovascular and respiratory stability.

The degree of danger after landing is related to the landing area, the structural design of the spacecraft, 

and the skill of the crewmembers who are initiating proper egress procedures. Actions within the cabin must follow 

all security arrangements for normal and emergency egress procedures. The crew should be trained in how to rapidly 

locate and open emergency exits. All preparations for a rapid exit should be made before the incident, including 

knowledge on how best to quickly release an injured crewmember from his/her securing devices. The proper 

use of emergency flotation devices should be considered if the landing takes place on water.

Summary

Once the decision is made to activate the ACRV for transport, a considerable amount of coordination 

is necessary to ensure a smooth transfer at each step. Each step of this transfer may meet complications that could 

prevent successful recovery. Contingency plans at each phase of the transport will need to be developed to meet the 

unexpected. Planning, training, and simulating emergencies can promote an attitude that can lessen the consequences 

of most of these emergencies.

References

(1)McNeil EL. Emergencies in the air. In Low M, ed. Airborne care of the ill and injured. lat ed. New York: 

Springer-Verlag, 1983:171-177.

(2) Air Ambulance Guidelines. US Department of Transportation and American Medical Association, 1981.
27

Search and Rescue

SAR is a complex system of operations that requires coordinated activity among multiple disciplines to 

render aid in a safe and timely manner to persons in distress. The essential components of SAR include organization, 

equipment, trained personnel, communications, and emergency care. Since the network of SAR systems will be used 

only in the event of an emergency, it must be able to become operational in a short time. Although the timely arrival 

of SAR forces increases the survivability of victims, a limit may exist beyond which the use of SAR resources 

cannot be justified. For example, prolonged SAR operations are unwarranted when the probability of finding 

survivors has been exhausted.

Should the space station need to be evacuated, the shuttle may be used—depending on its availability and 

the urgency of the need to evacuate. If either the shuttle or a winged/maneuverable ACRV is used, a predetermined 

landing site can be chosen. In this scenario, SAR is a contingency plan that operates only if the intended rescue 

vehicle fails. If the ACRV is a ballistic or an Apollo-derived vehicle design, the landing site cannot be precisely 

determined and a recovery zone must be designated. In that case, SAR becomes an integral component of space 

station evacuation. The more flexible the SAR system is and the more completely its variables are considered, 

the greater the chance for a successful recovery.

CONSIDERATION 17: The time-axis intervention relationship of transport and recovery must be 

anticipated.

Facts/Comments

Several aspects of time must be considered when evacuating the space station. These include, but are not 

limited to, recovery time on Earth, elapsed time since the injury or discovery of a critical illness, and the amount of 

time required to recover space station personnel.

To optimize the amount of daylight available to SAR forces, dawn is the ideal recovery time. This would be 

vital whether SAR is a contingency plan, as in the case when a shuttle or a highly maneuverable ACRV is used, but 

especially so when SAR is an integral component of the recovery, as in an Apollo- or a ballistic-type ACRV. The 

decision to land at dawn should be made after considering how urgently the station must be evacuated, the ability 

to loiter in space—either in the station or on board the ACRV—the urgency of need for medical attention, and 

weather conditions at the proposed landing site.

When a crewmember is disabled, time is a critical factor in delivering definitive medical care. There has 

been extensive research on the effect of time to medical care for the victim of major trauma. If care is not initiated 

within the first “golden hour” after trauma is sustained, the mortality rate increases dramatically.

Figure 1
28

Should a crewmember suffer a deteriorating illness, the effect of time to definitive medical care is less 

well-defined. Moreover, the deleterious effects of microgravity will complicate his/her condition further. In either 

a traumatic or medical emergency, the urgency for transport to an Earth-based medical facility would depend on the 

capability of station personnel to stabilize the disabled crewmember at the HMF prior to space station departure.

If the shuttle is used to evacuate a disabled crewmember, more extensive medical care can be rendered en 

route to the Earth-based facility than in the confines of an ACRV. This may decrease the time necessary for, and the 

extent of stabilization prior to transport. Either the shuttle or a highly maneuverable ACRV could bring an ill station 

crewmember to within proximity of an Earth-based treatment facility, eliminating search time and greatly reducing 

recovery time. If a ballistic or an Apollo-type ACRV is used, the crewmember must be stabilized at the HMF to 

optimize survivability despite the possibility of prolonged SAR time on Earth. This is due to the less precise 

landing zones and subsequently increased search times for these designs.

The current U.S. SAR system relies on early rescue and short-term loiter time for victims. Studies derived 

from military and civilian aircraft mishaps show that the first 12 to 24 hours after an incident are the most critical for 

the recovery of survivors. Injured survivors have a decreased life expectancy of up to 80% after the first 24 hours. 

Uninjured survivors also have a rapidly decreased life expectancy after 3 days. Review of the recovery time for 

607 survivors of aircraft accidents demonstrates the need to effect a rapid recovery.

Figure 2

Individual survival in the ACRV depends on climatic conditions and the endurance and psychological 

stability of survivors, the equipment available to them, and the extent of their injuries. All these factors will impact 

the time an individual will survive in the ACRV as well as the amount of time SAR has to complete its mission.

Disabled crewmembers will have sustained a significant injury or become critically ill prior to departing 

the station. And, only minimal medical care can be achieved within an ACRV. Our opinion, which is based on the 

survivability of a crewmember under these circumstances, is that SAR forces should be configured to allow no more 

than 90 minutes and, optimally, fewer than 60 minutes of loiter time prior to pick up survivors and resume medical 

care. Also, injured crewmembers should be at a definitive care facility within 120 minutes of landing. Nevertheless, 

the ACRV should be designed to ensure survivability for uninjured crewmembers for at least 12 hours and optimally 

24 hours.
29

CONSIDERATION 18: A range of potential landing sites must be selected. Optimal medical response 

must be identified within the confines of these sites.

Facts/Comments

To improve the chances of existing recovery forces performing a successful SAR mission, potential landing 

sites must be selected based on the terrain needed by the escape vehicle, the climatic effects on the human body, and 

the optimal time-axis intervention. The planned orbital ground track of the station is between 28.5 degrees North and 

28.5 degrees South of the Earth’s surface. Although it is possible to land anywhere within or near this large area, it is 

far likelier that, even if immediate evacuation of the station is necessary, any delay in the escape vehicle’s retrofire 

will more precisely select the landing site. The more accurately a landing site can be predetermined, the more 

effectively recovery forces can be assembled there. Both land and sea contingencies must be considered 

depending on shuttle availability and the ultimate ACRV design.

A land contingency is likelier if a shuttle rescue or a maneuverable ACRV design is employed. These would 

allow for precise designation of the landing site, thereby eliminating search time and greatly reducing recovery time 

compared to a ballistic or an Apollo-derived design. It is unlikely that either of these vehicles would permit a landbased recovery. The impact forces encountered, once these vehicles landed, would be better tolerated in the water. 

Also, water provides a greater degree of landing safety in a vehicle intended to operate without the assistance of a 

skilled pilot. Water is a difficult environment for humans to survive in. Although immediate egress from the ACRV 

by healthy crewmembers may be possible, it is unrealistic to expect significantly ill/injured crewmembers to assist 

in their own escape or for other crewmembers to be able to safely evacuate patients while on water.

If survivors of a station evacuation must egress from the ACRV prior to arrival of the SAR forces, the time 

for recovery will be significantly affected by climactic conditions. If the temperature of the water is lower than 34°C, 

the human body begins to cool. The rate of heat loss is inversely proportional to the temperature of the air and water; 

and water has a 25 times greater rate of heat exchange than air has at the same temperature. The life expectancy of 

uninjured survivors immersed in seawater at various temperatures is shown in Figure 3.

Figure 3

Hypothermia may also be accelerated by wind chill. The effect of wind velocity and air temperature is 

shown in Figure 4.
30

Figure 4

Because of these factors, occupants of an ACRV designed to land at sea would have a greater chance of 

survival if its occupants were kept within the ACRV. The ACRV should provide a suitable internal environment for 

its occupants while awaiting recovery.

Motion of an ACRV while on water awaiting arrival of SAR forces may hinder crewmembers in their 

attempts to provide medical assistance for the ill or injured. The experience of Skylab teaches us that at least half 

of the crew may develop motion sickness. Violent movement of the vehicle in water may make the performance of 

medical procedures—such as intubation or starting an IV line—impossible. It is expected that crewmembers will be 

able to provide minimal assistance during loiter time in the water.

Multiple potential sites should be chosen between 28.5 North and 28.5 South longitude. These should 

be sufficiently varied and geographically separated to encompass the Earth. This would provide for multiple reentry 

windows on a given day. Additionally, it would provide the opportunity to select the best time on Earth for landing 

(i.e., dawn) as well as optimal weather conditions. The closer together the sites are, the fewer the cross-range 

requirements and the smaller the area of coverage at each site.

If a water-based recovery is chosen, potential landing sites should be located in close proximity to 

onshore facilities. As well as allowing for the evacuation of a crewmember to a tertiary care facility, this choice 

would enable special personnel and equipment to move quickly into the recovery area. Ideally, the onshore facility 

would be able to provide a runway for fixed-wing aircraft, too.

CONSIDERATION 19: SAR forces specific for ACRV are to be developed. They should not require 

significant retraining.

Facts/Comments

The amount of equipment and number of personnel needed for a SAR operation depend on the size of the 

search area, the degree of illness or injury suffered by crewmembers, the type of terrain that crewmembers must be 

recovered from, and the survivability of uninjured crewmembers. The final size of the available SAR forces will 

depend on a cost/benefit analysis; however, some general comments on the composition of these forces should be 

considered. A SAR system should be capable of rapidly locating station crewmembers, administering emergency 

care, and extracting and transporting the crew to definitive medical care facilities. The assumption is that SAR 

forces will be rapidly successful and only short-term survival of fewer than 12 hours will be necessary.
31

If a ballistic or an Apollo-derived ACRV vehicle is used, a water-based recovery is likely. Although 

ground tracking forces will probably closely monitor the ACRV’s progress to touchdown, satellites should be used 

for high-altitude surveillance. Operational satellites are today used to monitor the low-power radio distress signal 

from emergency locator transmitters. These satellites can locate a source to within approximately 5 to 10 miles. 

Although the size of the recovery zone is expected not to exceed this distance, positioning recovery forces to 

within 10 miles of the actual landing site may be more difficult.

Fixed-wing aircraft (e.g., helicopters) should be considered for search operations because of their speed 

and long-range capabilities. In the event they are not immediately available, these aircraft could deploy a pararescue 

team. The first personnel on the scene would need self-contained breathing apparatus, and they would also need to 

ensure that no propellant (i.e., hydrazine) has leaked from the ACRV. A pararescue team could render lifesaving 

and life-sustaining services with a minimum of delay.

In a water-based rescue, helicopters are the most efficient means of rescuing and transporting ACRV 

personnel. Because of their ability to hover, helicopters provide the only means of evacuation from an ACRV by air. 

Vertical takeoff and landing aircraft currently under development may be considered in future. Landing zones for the 

ACRV will need to be within a 150-mile radius of the base station unless midair refueling of helicopters is planned 

for, or naval vessels are used to, bring the helicopters to within the 150-mile range. The use of helicopters to provide 

medical transport has been extensively evaluated in the military and civilian sectors. Noise, vibration, and turbulence 

in a helicopter provide a difficult environment in which to perform medical procedures and any needed monitoring. 

However, personnel trained to work in this environment can safely administer emergency medical care to injured 

crewmembers while en route to a more definitive care facility. All medical equipment on the helicopter should be 

compatible with, and complimentary to, that used on the ACRV. Low flight evacuation profiles from the rescue site 

are preferred to minimize the effect of the decrease in atmospheric pressure and the resultant decrease in oxygen 

tension associated with increased altitude. Moreover, the volume of space that a gas will occupy increases at higher 

altitudes. This increase would be deleterious to a patient with air in the cranium, a pneumothorax, an obstructed 

bowel, or pneumomediastinum. Another possibility would be to airlift the entire ACRV vehicle with the station 

crewmembers still on board it onto a naval vessel. This would allow for a more controlled environment during 

extrication. This step would depend on the proximity of a naval vessel to the landing site and the urgency for 

medical assistance.

U.S. Navy vessels may be required to medically stabilize ill/injured ACRV crewmembers pending 

evacuation to a tertiary care facility. If a particular medical condition is known to exist prior to departure from the 

station, the naval vessel may function as an assembly point for specialized personnel and equipment so that more 

definitive medical care may be rendered on board.
32

Medical Transport Team

Should a crewmember become ill or be injured while on station, medical assistance must be immediately 

available. The HMF would be able to provide for routine and minor medical care. But, the facility may only be able 

to offer supportive care for certain life-threatening illnesses because of limited equipment and the difficulty met in 

attempting to perform intricate medical procedures in microgravity. A physician crewmember assigned to the space 

station would be advantageous for the initial diagnosis and treatment of an ill/injured crewmember. If, however, a 

crewmember sustains a life-threatening injury or illness that is beyond the capability of the HMF and the station 

medical officer to address, emergency transport to an Earth-based definitive care facility may be necessary.

Transport of an ill/injured crewmember can be broken down into several phases, with a patient encountering 

different medical assistance with varying medical qualifications at each phase. The appropriate level of training for 

members of the medical transport team at each phase of the transport must be considered. The time the ill/injured 

crewmember will spend at each phase of the transport, available space and environmental conditions, and available 

equipment will impact the level of training necessary for medical attendants at each phase of transport.

CONSIDERATION 20: Qualifications of medical personnel on board the space transport vehicle 

should be established.

Facts/Comments

Once the decision is made to transport an ill/injured crewmember to an Earth-based treatment facility, the 

patient should be sufficiently stabilized to maximize the potential for survival despite a transport time of possibly 

several hours. If a shuttle or a winged/maneuverable ACRV is available, the transport time may be significantly 

reduced. Since the combination of a short flight time and being able to direct exactly where the landing site will 

occur decreases the time available to perform extensive medical management, it is unlikely that a physician’s skills 

would be used in flight. After the shuttle or maneuverable ACRV lands, the patient could be quickly extricated and 

transported to a definitive care facility by pre-positioned Earth-based medical transport crew. Because of this short 

time interval, only life-sustaining management will be performed on the ill/injured crewmember prior to extrication.

If a ballistic or an Apollo-derived vehicle is used with a water landing, the G profile during reentry would 

make most medical intervention impossible. Moreover, these vehicles would likely have very limited space available, 

thereby prohibiting movement during flight. It is unlikely that a physician’s skills would be used during flight. After 

a water landing, there may be as much as a 90-minute loiter time prior to extrication by SAR forces. Because of the 

limited space and the vehicle’s erratic movement in water, only life-sustaining management could be performed. 

These lifesaving maneuvers include, but are not limited to: airway management including endotracheal 

intubation, suction, IV medications and fluids, electrocardiogram interpretation, and defibrillation.

Paramedic training ensures that the person administering lifesaving procedures will master these skills as 

well as 15 training modules, including:

1. Emergency medical technician: 8. Soft tissue injuries

his/her role, responsibility, 9. Musculoskeletal

and training 10. Medical emergencies

2. Human systems and patient assessment 11. Obstetrics/gynecology

3. Shock and fluid therapy 12. Pediatric and neonatal

4. General pharmacology 13. Management of the 

5. Respiratory system emotionally disturbed

6. Cardiovascular systems 14. Extrication/rescue 

techniques

7. Central nervous system 15. Telemetry and communication

If a physician-crewmember is available on the station, his/her skills may be better used in remaining on station. 

Since some advanced skills may be necessary after the ACRV lands and while awaiting SAR forces, an ill/injured 

crewmember should be accompanied by an individual with at least EMT [emergency medical technician]/paramedic 

qualifications, or by someone who has received a modified version of standard paramedic training.
33

CONSIDERATION 21: Qualifications of Earth-based medical transport crew should be established.

Facts/Comments

For routine shuttle landings, NASA always has a physician standing by at the landing site. This policy 

becomes even more critical if an ill/injured crewmember is being returned from the station. Because of NASA’s 

ability to precisely determine a landing site, a physician who is familiar with space adaptation, emergency medicine, 

flight medicine, ACRV extrication techniques, and the ill/injured crewmember’s medical history could easily be at 

the landing site. If a ballistic or an Apollo-derived ACRV vehicle is used with a water landing, a physician with a 

similar background could be brought to the landing site by helicopter.

Data can be extrapolated from civilian helicopter emergency medical services. Numerous U.S. studies 

have demonstrated the benefits of physicians operating in the field. These have concluded that physicians are able 

to decrease the morbidity and mortality of some transported patients. In their comparison of Level I trauma patients

transported by flight nurse/paramedic teams versus flight nurse/physician teams, Baxt and Moody comment that the 

physician team experienced a significantly lower mortality rate than did the paramedic team(1). In an analysis of 395 

flights performed by Metro Life Flight in Cleveland, Ohio, it was shown that, for optimal patient care, a physician 

was necessary in 25% of flights and that, in 35% of the remaining flights, a physician might have been necessary(2). 

Also, the study found that there had been many flights in which unexpected complications such as loss of airway, 

hypotension, or cardiopulmonary resuscitation (CPR) were necessary. The study concluded that having a 

physician present on Metro Life Flight benefited patients.

By having a physician on board a transport helicopter, critical care could be brought to the patient rather 

than delaying treatment until the ill/injured patient is brought to the receiving hospital. This would be especially vital 

in the case of a water-based landing where a 30- to 60-minute transport time is highly likely.

Summary

Although a paramedic-crewmember can accompany an injured crewmember during emergency transport 

from the station, the patient should be met by a team or a physician skilled in both emergency and flight medicine. 

The physician (or team) would then act as the on-scene medical commander, directing the extrication, immediate 

treatment, and transport of the ill/injured crewmember.

References

(1)Baxt WG, Moody P, The Impact of a Physician as Part of the Aeromedical Prehospital Team in Patients with 

Blunt Trauma, JAMA 257(23): 3246-50, 1987.

(2) Samuel I, Emerman CL, Effson D, et al. Physician Presence in an Aeromedical Helicopter Emergency Service. 

Proceedings of the Aeromedical Evacuation Congress, 1985.
34

Other Considerations

Three unrelated considerations warrant discussion: (1) replacement of the ACRV, (2) medical issues, and 

(3) the ethics of illness, injury, or death in space.

CONSIDERATION 22: Replacing an ACRV on the space station.

Facts/Comments

An ACRV will most likely be needed when a number of crewmembers remain on the station. Since an 

ACRV is anticipated to be used only every 4 to 12 years, its return may not be a high priority. Nevertheless, for all 

the reasons that the ACRV should be in place on the station, it should be replaced as quickly as possible. This could 

be done with the shuttle or by a pilotless rocket. An important assumption is the existence of a second ACRV and the 

ability of the original ACRV to be reconditioned to serve as backup for the new ACRV. The apparent need for two 

ACRVs will be a major factor in estimating costs.

CONSIDERATION 23: A number of medical issues require review and clarity, including health 

insurance, medical/legal issues, and the need for extended care.

Facts/Comments

Healthcare financing and medical/legal issues have become fairly standardized over the years of crewed 

spaceflight. In light of the inherent risks associated with prolonged exposure to spaceflight, however, it would be 

useful to review short- and long-term healthcare financing packages for crewmembers. At the same time, an open 

stance should be taken toward the possibility of errors in judgment or technological failure during care in the HMF 

and throughout reentry and recovery. In the present legal and medical climate, it is necessary to consider the risks 

of medical legal claims and to anticipate their occurrences. Specific insurance policies, waivers, or medical legal 

opinions are best instituted before they are needed. The status of these discussions should be documented and 

shared with the crewmembers, their families, and the public via the media.

CONSIDERATION 24: The ethics of and decisions about critical illness/injury and death in space 

must be discussed.

Facts/Comments

Ethics and decisions surrounding critical illness/injury and death in space must be discussed well in advance 

of their occurrence. Deliberations should be shared in an appropriate manner with the crewmembers, their families, 

and the public through the media. With the growth of ethics as a medial specialty, the availability of competent 

individuals to appropriately analyze these complex issues has never been greater. Questions include:

1. What constitutes a critical, non-transportable disease?

2. What are the criteria for death in space?

3. Who pronounces death, and how is it recorded for medical/legal issues such as time and location?

4. How is the body stored? Is it returned to Earth? Is it “buried” in space? How does this differ if there is a 

possibly contagious disease?

5. What information is documented concerning the circumstances of death? Are blood tests or other pre-autopsy 

studies done? If so, which ones?

6. Is an autopsy necessary? If so, how is it arranged? What security measures are necessary?

7. How are these possibilities initially communicated from the space station, ACRV, or landing site to the Mission 

Control Center?

8. How is this information conveyed to a crewmember’s family and to the public via the media?

9. What plans are established to manage the burial of a crewmember?

10. What efforts will be made to support the physical and psychological wellbeing of the living, the families, 

crewmembers (some of whom may be on the station), and mission specialists?

11. How are “living wills” and similar requests to be handled?
35

12. Should the ACRV be used to transport the dead?

13. How are the skills of the dead replaced?

14. When is a space station mission stopped and the remaining crew brought back to Earth?

Each of these questions and the many more these questions will generate should be openly discussed and 

the conclusions publicized. Approaching this difficult task early in the development stages of the station and ACRV 

will allow appropriate time for analysis, and it will send a clear message of a fully planned mission to all involved.
36

Summary Consideration

CONSIDERATION 25: Many issues are unknown involving decisions for medical transport, the 

means of transport, and the physiologic response and outcome of various 

diseases to reentry and recovery. Nevertheless, they have the same importance 

and support as those involving the engineering and mechanical aspects of the 

space station and the ACRV.

Facts/Comments

The space station is, firstly, a human endeavor. The physiology and psychology of medical transport 

issues thus warrant considerable discussion and expert opinion. The combination of this input with the technical 

aspects of design and trajectories will optimize the potential for the successful use of an ACRV.

This last consideration is, in many ways, the most important consideration. If it is accepted, the 

previous 24 considerations and the many others that have not come to mind will fully contribute to a planned and 

defensible outcome.

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1. AGENCY USE ONLY (Leave Blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED

July 2001 NASA Technical Memorandum

4. TITLE AND SUBTITLE 5. FUNDING NUMBERS

Considerations for Medical Transport From the Space Station via an Assured Crew Return 

Vehicle (ACRV)

6. AUTHOR(S)

Glenn C. Hamilton, M.D.*; Philip Stepaniak, M.D.; Denis Stizza, M.D.*; Richard Garrision, 

M.D.*; and David Gerstner, EMT-P*

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION 

REPORT NUMBERS

Lyndon B. Johnson Space Center

Houston, Texas 77058

S-877

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING 

AGENCY REPORT NUMBER

National Aeronautics and Space Administration

Washington, DC 20546-0001

TM-2001-210198

11. SUPPLEMENTARY NOTES

* Wright State University, Department of Emergency Medicine

Kettering, Ohio

12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE

Available from NASA Center for Aerospace Information (CASI)

7121 Standard

Hanover, MD 21076-1320 Subject Code: 51

13. ABSTRACT (Maximum 200 words)

In developing a permanently crewed space station, the importance of medical care has been continually reaffirmed; and the health 

maintenance facility (HMF) is an integral component. It has diagnostic, therapeutic, monitoring, and information management 

capability. It is designed to allow supportive care for: (1) non-life-threatening illnesses; e.g., headache, lacerations; (2) moderate to 

severe, possibly life-threatening illnesses; e.g., appendicitis, kidney stones; and (3) severe, incapacitating, life-threatening illnesses; 

e.g., major trauma, toxic exposure. Since the HMF will not have a general surgical capability, the need for emergency escape and 

recovery methods has been studied.

Medical risk assessments have determined that it is impossible to accurately predict the incidence of crewmember illness/injury. A 

best estimate is 1:3 per work-year, with 1% of these needing an ACRV. For an eight-person crew, this means that one assured crew 

return vehicle (ACRV) will be used every 4 to 12 years. The ACRV would serve at least three basic objectives as: (1) a crew return if 

the space shuttle is unavailable; (2) an escape vehicle from a major time-critical space station emergency; and (3) a full or partial crew 

return vehicle for a medical emergency. The focus of this paper is the third objective for the ACRV.

14. SUBJECT TERMS 15. NUMBER OF 

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16. PRICE CODE

space station; health; spacecrews; rescue operations; medical equipment; medical 

sciences; medicine; medical personnel; medical services 42

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