NASA/TP–2006–213731 

The International Space Station 

Ultrasound Imaging Capability Overview 

for Prospective Users 

Ashot E. Sargsyan, M.D. 

Douglas R. Hamilton, M.D. 

Shannon L. Melton 

Jeffrey Young 

Wyle Laboratories, Life Sciences Group 

NASA Johnson Space Center, Houston, Texas 

December 2006 
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NASA/TP–2006–213731 

The International Space Station 

Ultrasound Imaging Capability Overview 

for Prospective Users 

Ashot E. Sargsyan, M.D. 

Douglas R. Hamilton, M.D. 

Shannon L. Melton 

Jeffrey Young 

Wyle Laboratories, Life Sciences Group 

NASA Johnson Space Center, Houston, Texas 

December 2006
Acknowledgments 

This publication draws together the knowledge in the area of ultrasound imaging on the 

International Space Station (ISS) accumulated in the initial several years of its piloted operation. 

Our respect and appreciation also goes to the teams that designed, created, and deployed the ISS 

Human Research Facility (HRF) Ultrasound System. The authors also recognize with gratitude 

the work of those who carried out ultrasound imaging experiments in the pre-ISS space programs; their unique experience will always retain its great value for the space biomedical 

science and clinical space medicine. 

We acknowledge with gratitude the support of our original efforts by the NASA Lyndon B. 

Johnson Space Center (JSC) Space Medicine Division and the NASA Medical Operations 

and Flight Surgeons, Wyle Laboratories Life Sciences Group, the ISS Program Office, JSC 

Bioastronautics/HRF, and the National Space Biomedical Research Institute. Special thanks 

to Drs. J. Jones and J. M. Duncan, D. Martin, and K. Garcia (NASA JSC Cardiovascular Laboratory), Drs. S. Dulchavsky and team at Henry Ford Hospital System Department of Surgery 

(Detroit, Mich.), Dr. A. Kirkpatrick (University of Calgary, Canada), ISS crew members S. 

Helms, P. Whitson, K. Bowersox, D. Pettit, M. Foale, A. Kaleri, M. Fincke, G. Padalka, L. Chiao, 

S. Sharipov, J. Philips, S. Krikalev, W. McArthur, and V. Tokarev, astronauts M. Barratt, E. Baker, L. 

Clark, R. Curbeam, M. Gernhardt, T. Marshburn, G. Reisman, D. Thomas, and D. Williams, and 

all other contributors who could not be listed in this limited space. 

Today’s robust imaging capability aboard the ISS and the knowledge it generates attest to 

the talent and expertise of these individuals and to their unending dedication to human space 

exploration and utilization. 

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://ston.jsc.nasa.gov/collections/TRS/ 
iii

Contents 

Acknowledgments ......................................................................................................................... ii

Contents ........................................................................................................................................iii

Figures........................................................................................................................................... vi

Tables ............................................................................................................................................ vi

Acronyms..................................................................................................................................... vii

Executive Summary...................................................................................................................... 1

1. Introduction............................................................................................................................ 2

2. Objectives ............................................................................................................................... 4

3. Assumptions and Conditions for Operational (non-research) Imaging ........................... 5

4. Fundamental Principles ........................................................................................................ 5

4.1. Balanced Expertise and Knowledge Distribution............................................................... 5 

4.2. Experimental Nature and Limited Evidence (applicable in clinical (non-research) use)...... 6 

4.3. Shared Resources............................................................................................................. 7 

4.4. Common Reference.......................................................................................................... 7 

4.5. Identification of Responsibility......................................................................................... 8 

4.6. Clinical and Operational Subordination (applicable in clinical (non-research) use)............. 8 

5. The International Space Station Ultrasound System ......................................................... 8

5.1. In-flight Hardware Resources........................................................................................... 8 

5.2. Communication Assets................................................................................................... 10 

5.2.1. Commanding............................................................................................................. 10 

5.2.2. Data management, uplink/downlink ......................................................................... 10 

5.3. Ground Infrastructure, Locations, Positions, and Assets .................................................. 10 

6. Essential Ground Personnel................................................................................................ 12

6.1. Crew Surgeon (if imaging is for medical purposes)......................................................... 12 

6.1.1. Suggested tasks during contingency ultrasound operations ..................................... 12 

6.1.2. Recommended relevant training ............................................................................... 13 

6.1.3. Recommended relevant experience ......................................................................... 13 

6.1.4. Relevant information resources ................................................................................ 13 

6.2. Biomedical Flight Controller (if imaging is for medical purposes)................................... 13 

6.2.1. Tasks during contingency ultrasound operations...................................................... 13 

6.2.2. Reecommended relevant training ............................................................................. 14 

6.2.3. Recommended relevant experience .......................................................................... 14 

6.2.4. Recommended information resources....................................................................... 14 

6.3. Remote Guidance Expert (if imaging is for medical purposes)......................................... 14 

6.3.1. Tasks during clinical ultrasound operations ............................................................. 14 
iv

6.3.2. Recommended relevant training ............................................................................... 14 

6.3.3. Recommended relevant experience .......................................................................... 15 

6.3.4. Relevant information resources available to the remote guidance expert ................ 15 

6.4. Remote Guidance Expert: Research Protocol .................................................................. 15 

6.4.1. Tasks during research ultrasound operations............................................................ 15 

6.4.2. Recommended relevant training ............................................................................... 15 

6.4.3. Recommended relevant experience .......................................................................... 15 

6.4.4. Relevant information resources ................................................................................ 16 

6.5. Imaging Physician or Investigator................................................................................... 16 

6.5.1. Tasks during ultrasound operations .......................................................................... 16 

6.5.2. Recommended relevant training ............................................................................... 16 

6.5.3. Recommended relevant experience .......................................................................... 16 

6.5.4. Relevant information resources ................................................................................ 16 

6.6. Telescience Center Operations Personnel........................................................................ 16 

6.6.1. Tasks during contingency ultrasound operations...................................................... 16 

6.6.2. Recommended relevant training ............................................................................... 17 

6.6.3. Recommended relevant experience .......................................................................... 17 

6.6.4. Relevant information resources ................................................................................ 17 

6.7. Human Research Facility Systems Engineer ................................................................... 17 

6.7.1. Tasks during ultrasound operations .......................................................................... 17 

6.7.2. Recommended relevant training ............................................................................... 17 

6.7.3. Recommended relevant experience for this position................................................ 17 

6.7.4. Relevant information resources available to this position ........................................ 17 

6.8. Human Research Facility Hardware/Experiment Science Support ................................... 17 

6.8.1. Human Research Facility personnel tasks during contingency 

 ultrasound operations................................................................................................ 17 

6.9. Telescience Center Data Systems Group......................................................................... 18 

7. Crew Knowledge, Skill Sets, and Training........................................................................ 18

8. Ultrasound Applications Available for Ordering ............................................................. 19

9. Hardware Configurations................................................................................................... 21

9.1. Human Research Facility Ultrasound Configuration........................................................ 21 

9.2. Ultrasound Probes.......................................................................................................... 21 

9.2.1. C5-2 curved array probe ........................................................................................... 22 

9.2.2. L 12-5 (38mm) linear array probe ............................................................................ 22 

9.2.3. P4-2 phased-array probe ........................................................................................... 22 

10. On-orbit Human Factors................................................................................................. 23

10.1. Subject Examination by Operator vs. Subject Self-examination....................................... 23 

10.2. Patient and Operator Positioning and Restraints.............................................................. 23 

10.3. Placement and Use of Reference Materials...................................................................... 24 

11. Supporting Evidence and Summary of Events ............................................................. 24

12. Expected Forward Work................................................................................................. 24
v

13. Appendices........................................................................................................................ 25

13.1. Appendix 1: Recommended Ultrasound Applications..................................................... 25 

I. Head, Neck, and Face .....................................................................................................................26

II. Heart...............................................................................................................................................27 

III. Thorax...........................................................................................................................................27 

IV. Abdomen and Retroperitoneum.....................................................................................................28 

V. Gynecology And Pelvis...................................................................................................................30 

Table VI. Extremities And Peripheral Vasculature.............................................................................30

VII. Any Location (Extracavitary) and Miscellaneous........................................................................31 

13.2. Appendix 2: Examples of Conditions with Sonographic Signs and Symptoms................. 32 

13.3. Appendix 3: Remote Guidance Experts with Experience of Remotely Guided Ultrasound 

on ISS..................................................................................................................................... 36 

13.4. Appendix 4: ISS Ultrasound Reference Image (aka “Cue Card”)..................................... 37 

13.5. Appendix 5: Target Image Reference Card (Samples)..................................................... 38 

13.6. Appendix 6: Sample Communication Timeline............................................................... 39 

13.7. Appendix 7: ISS Ultrasound Activities Through Expedition 11....................................... 39 

13.8. Appendix 8: Associated Documentation ......................................................................... 42 

13.9. Appendix 9: Selected Relevant Publications.................................................................... 43 

Journal Articles By Authors................................................................................................................43 

Other Publications By Authors ...........................................................................................................51 

Other Relevant Publications ...............................................................................................................53
vi

Figures 

1 Astronaut Peggy A. Whitson, Expedition 5 NASA ISS science officer, 

participates in a test to validate the use of the HRF ultrasound for potential 

medical contingencies............................................................................................. 3 

2 Above: Expedition Commander Michael Foale (ISS Increment 8) during 

his scanning practice session in the Payload Development Laboratory at JSC. 

Below: Dr. A. Sargsyan (Wyle Laboratories demonstrates the scanning 

technique to the Expedition 12 crew (W. McArthur, V. Tokarev)......................... 18 

3 Hardware configuration for ultrasound operations................................................. 19 

Tables 

1 In-flight Hardware, Accessories, Supplies, and Other Material Assets 

Necessary to Conduct Ultrasound Imaging ............................................................ 9 

2 Ground Infrastructure, Hardware, Accessories, Supplies, and Other 

Material Assets Needed for ISS Ultrasound ........................................................... 11 

3 Components of Training for a Potential Operator in Remotely Guided 

Ultrasound Imaging ................................................................................................ 18 

4 HDI-5000 Probe Applications by Anatomical Regions.......................................... 22 
vii

Acronyms 

ADUM Advanced Diagnostic Ultrasound in Microgravity 

ATL Advanced Technology Laboratories 

ATU audio terminal unit 

BMFC biomedical flight controller 

CAPCOM capsule communicator 

CEVIS cycle ergometer with vibration isolation system 

CHeCS Crew Health Care System 

CMO crew medical officer 

CMRS Crew Medical Restraint System 

DCN Document Change Notice 

DICOM digital imaging and communications in medicine 

DMCF definitive medical care facility 

DVD digital video disk 

DVIS Digital Voice Intercommunication Systems 

ECG electrocardiogram 

ESS experiment support scientist 

ETT endotracheal tube 

FAST focused assessment with sonography for trauma 

FCOH Flight Controller’s Operations Handbook 

FS flight surgeon 

FSD flat screen display 

FTP file transfer protocol 

GC ground control 

HMS Health Maintenance System 

HRF Human Research Facility 

IMG Integrated Medical Group 

IMS Integrated Medical System 

ISS International Space Station 

JSC Johnson Space Center 

MCC Mission Control Center 

MCC-H Mission Control Center-Houston 

MMOP Multilateral Medical Operations Panel 

MOD Mission Operations Directorate 
viii

MORD Medical Operations Requirement Document 

MPSR Multipurpose Support Room 

MSFC Marshall Space Flight Center 

MSL Medical Simulation Laboratory 

NRT non real time 

OCA orbiter communication adapter 

OPE on-board proficiency enhancement 

PDL Payload Development Laboratory 

PHHU portable, hand-held ultrasound 

PID pelvic inflammatory disease 

POH Payload Operations Handbook 

RDCS Registered Diagnostic Cardiovascular Sonographer 

RDMS Registered Diagnostic Medical Sonographer 

RVT Registered Vascular Technologist 

S/G space-to-ground 

SODF Station (Systems) Operations Data File 

SOL space-occupying lesion 

SSPCM solid-state power control module 

TSC Telescience Support Center 

US ultrasound 

UTMB University of Texas Medical Branch 

VOX voice activation mode 

VPPI visceral-parietal pleural interface 
1 

Executive Summary 

Prior success of ultrasonic imaging in space flight and promising research opportunities 

motivated the inclusion of an ultrasound system in the Human Research Facility (HRF) aboard 

the International Space Station (ISS). Since its delivery by the STS-102 space shuttle mission 

and subsequent activation by the ISS Expedition 2 crew in June 2001, 101 hours of successful 

imaging operations have been logged (17.5 hours for ISS medical operations experiments and 

83.5 hours for research by non-NASA investigators as of September 2006). Multipurpose ultrasound devices of this model (Advanced Technology Laboratories/Phillips HDI-5000, Bothell, 

Wash.) are used worldwide for both clinical and research purposes. The HRF Ultrasound System 

represents a significant advance in space-based medical imaging, surpassing any previously flown 

ultrasound system in image quality, versatility, and data handling. 

Ultrasound imaging events require extensive planning and coordination, as well as real-time 

support. The ISS ultrasound system is activated, configured, and operated through a coordinated 

effort by multiple Mission Control Center console positions and the ISS crew, using validated 

procedures and various resources and assets. 

Space Medicine and the HRF conducted a successful demonstration of the ISS ultrasound 

imaging capability in September 2002 during ISS Expedition 5. This event was initiated by 

Space Medicine to validate the configuration for real-time data transmission and the concept and 

tools for real-time remote guidance for complex imaging tasks for medical (operational) purposes. 

Using a restricted video downlink and two-way private audio, an ultrasound expert on the ground 

verbally guided the crew member through a series of sample imaging protocols with multiple 

thoracic (heart and lungs), abdominal, and other anatomical sites. This session established a 

foundation for subsequent development and validation of an effective scheme for ultrasound 

imaging aboard the ISS using crew members without professional medical experience. 

NASA and all ISS Partners, through the ISS Multilateral Medical Operations Panel, have 

recognized the HRF Ultrasound System as a clinical diagnostic resource to augment the ISS 

Integrated Medical System in case of a medical contingency. Recognition of the system’s operational potential is based on terrestrial evidence and experiments conducted by NASA and 

other investigators before and during the ISS Program in conditions of ground laboratories, parabolic flight, and space flight. As in mainstream terrestrial medicine, objective imaging data can 

optimize illness/injury management and outcome and minimize mission impact (e.g., avoiding 

unnecessary medical evacuation). Consequently, the ISS Program adopted a requirement that 

ultrasound imaging capability be available for medical contingencies aboard ISS. Internal 

NASA documents have been created to define the use of the HRF Ultrasound for augmentation of the ISS medical care capability. 

This publication seeks to review existing knowledge and define the principles and solutions 

for the use of ultrasound imaging on the ISS for either research or medical purposes. 
2 

1. Introduction 

The feasibility of ultrasonic imaging in human space flight has been demonstrated on NASA 

and Russian spacecraft. Several ultrasound systems have been successfully operated by both 

physician and non-physician astronauts and cosmonauts in pre-International Space Station (ISS) 

space flights, yielding valuable scientific information. A multipurpose ultrasound system was 

adapted for space and installed aboard ISS to continue human research in microgravity environments at a new level of sophistication and fidelity. Alone or in combination with other components of the Human Research Facility (HRF), the system provides a research capability never 

before available in space. 

The system is equipped with hardware components, transducers, and software to generate 

high-definition images in all conventional modes used for cardiac, vascular, general/abdominal, 

thoracic, musculoskeletal, and other ultrasound applications. Specifically, the system can operate 

in B, M, Color Doppler, Power Angiography, Flow Propagation, Pulsed Spectral Doppler, and Continuous Wave Doppler modes and their combinations. The system may be upgraded to add Tissue 

Doppler mode to the above list. Thus, the HRF Ultrasound System allows the realization of the 

great scientific potential of ultrasound imaging in conditions of space flight, acquiring morphological/morphometric as well as physiological/functional information from virtually every 

area or organ system of the human body. 

Ultrasound has never been used in space for the purpose of medical risk mitigation; its use 

has been limited to feasibility demonstrations or research. However, the potential of the HRF 

Ultrasound as a diagnostic tool for space medicine activities has been recognized. The ISS Integrated Medical System (IMS) was originally designed for use in concert with a vehicle that has 

capabilities to evacuate an ill or injured crew member to a definitive medical care facility (DMCF) 

on Earth. Since plans for such a vehicle were discontinued, a mismatch had existed between the 

on-board medical capabilities and the mission profile. This has driven the medical concept of 

operations to recognize and treat as many medical conditions as possible while on orbit, with 

return to a DMCF delayed or avoided. Therefore, enhancement of on-orbit diagnostic and 

treatment capability is highly desirable. The IMS includes NASA (Crew Health Care System (CHeCS)) and Roskosmos medical equipment. In addition, Medical Operations can 

claim any other ISS asset that is deemed necessary to manage a medical contingency. 

The HRF Ultrasound System is an example of such assets.

In the ISS setting, with no other imaging methods available, the full diagnostic potential of 

ultrasound could be exploited to assist in managing a medical event on orbit. However, it is 

not practical to train crew members and maintain their proficiency for performing ultrasound 

imaging independently.1 Therefore, the authors consider real-time guidance by an expert from 

the Mission Control Center (MCC) as the primary means for a minimally trained crew member 

to capture clinically useful images. The essential data acquisition expertise resides on the ground 

and is provided to the operator during the examination as needed. Preliminary assessment and 

interpretation of data can be performed in real time. Detailed data analysis and generation of an 

imaging report for clinical purposes (or data analysis for research purposes) are performed 

 

1

In the U.S. and Canada, certified sonographers are specialized in sub-disciplines such as abdominal, cardiac or vascular 

ultrasound. Generally, two-year full-time education and a year of experience (or completion of an ultrasound school) are 

prerequisites for a registry examination. To maintain the credential, Continuous Education credits must be regularly demonstrated 

(www.ardms.org). In the Russian Federation, most of Europe, and Japan, ultrasound imaging is performed by physicians. 
3 

through post-examination review of the video and still images, either by a physician properly 

credentialed and licensed for the given type of the clinical study or by the investigator(s). The 

paradigm of remote guidance, though unconventional for mainstream imaging services, is also 

applicable to certain terrestrial settings where remote provision of imaging expertise may 

translate into improved outcomes and cost savings. 

NASA and all ISS Partners through the Multilateral Medical Operations Panel (MMOP) 

have officially recognized the HRF Ultrasound imaging system as a strategic clinical diagnostic 

resource to augment the IMS in case of medical contingency.2

 This recognition is substantiated by 

terrestrial evidence, parabolic flight and space flight experiments, ISS-based demonstrations, and 

more recent end-to-end validations conducted by NASA. As a result, ultrasound imaging is officially 

included in the ISS medical requirements. This publication could contribute to the implementation 

of the above requirement, as it includes a comprehensive operational concept with implementation solutions for ultrasound imaging aboard ISS for medical or science purposes. 

The HRF Ultrasound was successfully activated aboard the ISS on June 12, 2001. NASA Space 

Medicine conducted an end-to-end demonstration of the entire ISS Ultrasound System during 

Expedition 5 (Sept. 13, 2002), and validated the principle and the basic techniques of remotely 

guided ultrasound imaging for crew medical support. For the first time, real-time video from the 

 

2

This consensus determination of the ISS MMOP was made on March 13, 2001. 

Figure 1. Astronaut Peggy A. Whitson, Expedition 5 NASA ISS science officer, participates in a test to validate the use of the HRF 

Ultrasound System for potential medical contingencies. 
4 

ultrasound system was routed to the MCC. Using a video downlink and a two-way private spaceto-ground (S/G) audio, an ultrasound expert on the ground remotely guided the crew member 

through multiple scanning sequences (figure 1). As a result of this activity, a set of formal space 

and ground operational procedures was created and validated. NASA Medical Operations, jointly 

with HRF, conducted subsequent on-orbit ultrasound activities during ISS Expeditions 6 and 7 to 

validate space echocardiography protocols, demonstrate stress echocardiography on orbit, and 

conduct focused image quality assessments. 

An external investigator’s operationally oriented experiment, “Advanced Diagnostic Ultrasound 

in Microgravity (ADUM),” was performed during ISS Expeditions 8, 9, 10, and 11 to thoroughly 

examine and upgrade the ISS imaging utility (Principal Investigator - Dr. Scott A. Dulchavsky). The 

ADUM experiment identified possible improvements to the methodology of real-time remote guidance, explored the capabilities and limitations of the system for a number of new applications, 

and substantially enhanced the training component. These and other activities are listed in 

Appendix 7 of this document. 

The goal of this publication is to define the principles and current solutions for the use of 

remotely guided ultrasound imaging on ISS for research or medical purposes.

2. Objectives 

The primary objectives of this publication are to define 

• Principles of ultrasound imaging on ISS with real-time remote guidance, with an emphasis 

on imaging support in the management of complex scientific tasks or contingency medical 

situations. 

• Composition and configuration of the ISS Ultrasound System, including 

 HRF Ultrasound and associated on-board and ground-based elements. 

 Hardware configuration, accessories, supplies, and other material assets necessary to 

conduct ultrasound imaging on ISS. 

 Communication assets necessary to conduct ultrasound imaging aboard ISS. 

 Ground infrastructure necessary to conduct ultrasound imaging aboard ISS. 

• Essential ground support personnel. 

• Training, knowledge, and skill sets of each ground support position/personnel necessary to 

conduct ultrasound imaging on ISS. 

• Crew knowledge, skill sets, and associated training needed for ultrasound imaging on ISS. 

• Feasible ultrasound applications available to the user (an investigator or a flight surgeon) 

categorized into the following three groups: 

 Complete (Standard) Exams (noninvasive, generally considered available), 

 Focused and Limited Studies (noninvasive, generally considered available), and 

 Image-Guided Manipulations (invasive, require consultants and special consideration due 

to the possibly higher risk of discomfort, failure, or iatrogenic complications). 

• Feasible on-board techniques and configurations for ultrasound data acquisition. 

• Pertinent documentation relevant to ultrasound imaging on ISS. 

• Supporting evidence, such as a summary of ISS ultrasound imaging events to date and a list 

of available sources of information (HRF, Medical Operations, and research community). 

• A list of relevant publications. 
5 

3. Assumptions and Conditions for Operational (non-research) 

Imaging 

As part of the HRF, the ISS Ultrasound System is flown on ISS for research purposes. The 

science/payload community therefore drives HRF configuration, support, and availability. HRF 

resources are allotted for scheduled payload activities, and HRF support is provided per schedule 

or via the increment-specific call tree for unscheduled events. 

An assumption is made that the in-flight caregiver (crew medical officer (CMO) or a designee 

if the CMO is the ill/injured party) is not a physician or other health professional, and does not 

possess current clinical expertise or ultrasound imaging skills and knowledge beyond those 

retained from the standard training (including ultrasound familiarization and CMO training). 

ISS Medical Operations would use the system for clinical purposes if the following conditions 

were met: 

1. The crew surgeon determines that an ultrasound imaging examination is clinically indicated 

and requests specific ultrasound applications to be performed. 

2. ISS Medical Operations is granted preferential access to the necessary space and ground 

resources, including the HRF Ultrasound System and the U.S. Orbital Segment communication assets. This assumption is supported by the existing ISS documentation. 

3. HRF and other essential support personnel are available at their console positions to 

initiate and maintain HRF rack commanding and to support HRF Ultrasound operation, data 

processing, and transfer. A contact list is maintained through specific agreements between 

Medical Operations and HRF. 

4. An ultrasound expert is available to obtain the imaging data by providing, in close coordination with the crew surgeon, real-time remote guidance of the crew member operator, using 

restricted/private communications to support a live video downlink and two-way S/G audio. 

4. Fundamental Principles 

The fundamental principles of ultrasound imaging aboard ISS are listed and explained in the 

following paragraphs. 

4.1. Balanced Expertise and Knowledge Distribution 

A robust set of skills and knowledge is essential for ultrasound imaging. In the case of the ISS 

Ultrasound System, the necessary information and expertise are distributed among ground- and 

space-based sources. Elements of this expertise are claimed/transferred as needed to perform a 

clinically indicated imaging procedure. 

Astronauts with diverse backgrounds are not expected to possess skills for specialized medical 

or science activities such as ultrasound imaging. Proficiency in this highly complex and operatordependent task cannot be attained without thorough formal training and hands-on experience, 
6 

neither of which is feasible or practical in case of on-orbit personnel. Limited knowledge and skills 

acquired for prior or current science activities cannot be fully retained throughout the time interval between training and actual on-orbit demand. Consequently, acceptable efficiency and 

quality of the given imaging application on orbit can be achieved only through optimized 

distribution of necessary expertise among space and ground personnel. 

The limited preflight training provides crew members with substantial hardware familiarity and 

general knowledge of principles, positioning, restraints, safety, and microgravity human factors. 

Crew members should also undergo a remotely guided practice session in the high-fidelity simulator (Payload Development Laboratory (PDL) to experience a full range of activities associated 

with the imaging procedures, to develop realistic expectations, and to minimize anxiety for 

future ISS ultrasound activities. All remaining knowledge (i.e., most of the general imaging 

procedure and the entire base of specific application protocols) “remains” on the ground 

and is provided by the guiding expert(s) as needed through 

(a) limited pre-session instruction uplinks. 

(b) referring to specific on-board information resources in real time. 

(c) real-time voice instructions. 

A significant amount of pertinent information (also considered part of “distributed expertise”) 

resides in the ISS Medical Checklist and the Station (Systems) Operations Data File (SODF). Also, 

HRF has a multimedia ultrasound training program called “On-Orbit Proficiency Enhancer” on 

board as a just-in-time training and refresher tool. This program was developed as experimentunique software and manifested on ISS by the operationally oriented research experiment ADUM. 

If needed, a user can request use of this tool in the planning phase of the ISS Ultrasound System 

activation. Such a decision would be made on a case-by-case basis. Other ground-based reference 

and instructional materials are available for selective uplink at the discretion of imaging experts, 

investigators, consultants, and the crew surgeon. Careful selection and timing of these information deliveries creates an essential intermediate link between the preflight training, equipment 

operating procedures and on-board documentation, and remote guidance during actual 

imaging procedures. 

4.2. Experimental Nature and Limited Evidence (applicable in clinical 

(non-research) use) 

Controlled trials have not been conducted to determine the accuracy of diagnostic ultrasound 

in special operational settings such as ISS; therefore ultrasound imaging aboard station must 

be considered experimental in nature, notwithstanding prior successes in demonstrations and research. Specific applications in microgravity for any clinical purposes may be supported by evidence that is purely anecdotal, partial, or indirect, or by expert opinion derived from terrestrial 

experience, microgravity simulations, or on-orbit experiments and demonstrations. No pathological conditions and only limited physiological alterations have been documented by ultrasound 

during space flight. Microgravity-induced physiological circumstances and the potential alterations of pathological processes may not be known or applicable in a given case. In addition, 

evidence may be lacking or limited regarding accuracy of a given imaging application in a given 

case and setting. Some imaging applications suggested in this publication are not routinely practiced even in terrestrial medicine due to above-average complexity, lack of evidence, or the 
7 

existence of effective alternatives. Furthermore, time constraints and limitations of remotely 

guided imaging may also affect the quality and completeness of data. For these reasons, Integrated Medical Group (IMG) physicians are expected to consider ISS contingency ultrasound 

reports in conjunction with information on any preexisting microgravity evidence, actual data 

quality and completeness, specificity of findings, and estimated probability of false results. 

4.3. Shared Resources 

• The HRF Ultrasound is flown aboard ISS for research purposes, and its configuration, 

support and availability are driven by the NASA/ISS payload community. HRF and other 

non-Medical Operations resources are allotted for specific scheduled payload activities and 

do not provide for support 24 hours a day/7 days a week. However, if the decision is made to 

activate the ISS Ultrasound System, essential resources are invoked to configure and operate 

the system as an enhancement to the ISS IMS. According to existing agreements, Medical 

Operations assumes all components of the system, including the HRF Ultrasound, to be 

intact and functional by default unless informed of any failure or outage. 

• The Crew Medical Restraint System (CMRS) is approved to be deployed at LAB1D2 

(temporary deployment) to support the ISS Ultrasound System. Investigators must request 

and receive approval for use of this asset in advance. 

• The Telescience Support Center (TSC) in the MCC is the nominal facility for the science 

experiment teams conducting real-time remotely guided ultrasound. This facility will also 

be used by the HRF support team to carry out rack commanding/monitoring operations for 

any scientific or clinical purpose, and will coordinate all ultrasound data products obtained 

during the ultrasound activity. The TSC will also function as the backup location for realtime clinical ultrasound downlink, should the Biomedical Multipurpose Support Room 

(Biomed MPSR) be unavailable. 

• Preflight training can also be a shared resource. Training sessions may be abridged (or 

waived in rare cases) for crew members having operated the HRF Ultrasound in previous 

flight(s) or having been trained to a comparable degree for another previous or current ISS 

experiment. Preflight training involving HRF Ultrasound will be coordinated with HRF to 

optimize crew time and other resource use through sharing (or mutually crediting) training 

and practice sessions. Appropriate modifications to enable mutual crediting should be 

attempted for each Expedition crew. 

4.4. Common Reference 

The imaging expert on the ground and the ultrasound operator aboard ISS use common sources 

of reference, terminology, and understanding of the principles of remote guidance. 

• ISS astronauts and imaging experts on the ground use identical remote guidance 

reference cards (also known as “ultrasound cue cards”) to identify anatomical reference 

points, ultrasound keyboard controls, and probe manipulation techniques. 

• In addition to the cue cards, ISS astronauts and the imaging experts on the ground may 

also use target image reference cards. These image sets are specific for the particular imaging 

protocol (application), and are provided before the imaging procedure to enhance efficiency 

of the session. 
8 

• Medical, anatomical, or medical-technological terms in English, Latin, Russian, or other 

languages are replaced by lay terminology whenever possible, or explained with utmost 

clarity. Medical or medical imaging jargon, acronyms, or concepts that may be unfamiliar 

to the on-board operator should not be used. 

4.5. Identification of Responsibility 

The ISS operator and the subject (or patient in a medical scenario) receive explicit disclosure 

of the goals and objectives of the ultrasound imaging procedure, its limitations, and the roles and 

responsibilities of ISS and ground personnel. Specifically, the ISS crew must clearly understand 

that the responsibility for quality and completeness of the imaging results rests with the ground 

personnel, not with the ISS operator. Disclosures must also be made to the crew regarding the identity of the guiding expert(s) and other personnel to have access to the real-time audio and video as 

well as to the recorded data. For a scheduled science experiment, this is accomplished through the 

preflight informed consent briefing. In acute medical scenarios, verbal communications with the 

crew surgeon are used to ensure compliance with current policies and legal requirements on 

the one hand, and full consent and understanding by the crew on the other. 

4.6. Clinical and Operational Subordination (applicable in clinical (nonresearch) use) 

Ultrasound experts, radiologists, and other imaging-related personnel, whether in-house or 

external, are operationally subordinated to the ISS crew surgeon (or IMG surgeon on console 

at the MCC). 

Ultrasound imaging studies are ordered by the ISS crew surgeon or an ISS IMG surgeon on 

console (if the crew surgeon is unavailable) when clinically indicated. The surgeon orders the 

study, defines its scope, poses specific questions, requests necessary resources from the flight 

control team, establishes priority and preferred timing of the imaging session relative to other 

medical activities and decisions, and receives preliminary and final imaging reports. 

5. The International Space Station Ultrasound System 

From the user’s perspective, the ISS Ultrasound System is comprised of space (in-flight) and 

ground hardware, software, and communication links. The core component of the system is the 

HRF Ultrasound. It is activated to perform a scheduled research activity (or, upon request of the 

crew surgeon, a diagnostic study on an ill or injured ISS crew member). The ISS Ultrasound 

System involves the shared space and ground elements listed below. 

5.1. In-flight Hardware Resources 

The HRF rack houses the ISS Ultrasound System and, as of September 2006, resides at location ISS Laboratory 1S2 (LAB1S2). It may be necessary to move the rack to accommodate new 

hardware and new internal ISS configurations as ISS construction continues. HRF will inform all 

recognized users of such moves so that appropriate procedures and documentation can be updated. 

Table 1 lists items specific to HRF Ultrasound, as well as the necessary general flight hardware. 
9 

Table 1: In-flight Hardware, Accessories, Supplies, and Other Material Assets 

Necessary to Conduct Ultrasound Imaging 

Element Redundancy Essential? Responsible Org(s) Function/Notes 

HRF Rack N Y MSFC; JSC 

HRF 

Location: ISS Lab1S2 

Houses the HRF Ultrasound, provides all interfaces. 

HRF Ultrasound N Y HRF Includes main unit (rack-mounted) and stowable components such 

as keyboard, monitor, cables, and bracket assemblies. 

HRF Workstation Y Varies HRF Not essential for real-time video downlink. Used for image file 

transfer in DICOM digital format from HRF Ultrasound after 

examination. HRF laptop is first choice for this function as it 

requires less crew time to configure. The workstation would only 

be required if more hard drive space is needed for images captured 

during the session. Due to HRF rack power constraints,3

 it is not 

recommended that the ultrasound and workstation run at the same. 

The decision to use the workstation in lieu of the laptop is made 

by HRF. 

HRF Laptop Y Varies HRF Not essential for real-time data collection. This is the primary 

computer for image file transfer from the HRF Ultrasound System 

to the ground after examination. The HRF workstation can replace 

the HRF laptop. 

CMRS N Varies Medical 

Operations 

Essential or highly desirable in most applications; also required by 

ISS medical checklist for contingency ultrasound imaging. The 

area in front of the HRF rack must be cleared for CMRS 

deployment (LAB1D2). 

Remote 

Guidance 

Ref. Card 

(Cue Card) 

Y Y Medical 

Operations/

HRF 

Hard copy of the cue card is stowed with other detachable 

components of the ultrasound system. Hardcopy is included in the 

medical checklist, electronic copy is available in the 

SODF/medical checklist. 

Voice 

Activation 

Mode 

(VOX) 

Audio 

Terminal 

Unit (ATU) 

Y Y Station 

support 

equipment 

Voice-activated headset for audio communication with ground 

expert. Replaces the push-to-talk audio system, allowing the 

operator to use both hands for the imaging procedure including 

probe manipulation, keyboard operations, gel application, and 

stabilization. VOX/ATU must be on a speaker to allow both the 

operator and the subject (or the patient) to hear commands from 

ground experts. 

PD100 

(camcorder) 

Y N ISS To capture cabin scene. The data are downlinked in non real time 

(NRT) to support data analysis. 

Electronic 

Camera 

Electronic 

Still Camera 

Y N ISS To capture cabin scene. The data are downlinked NRT to support 

data analysis. 

ECG 

Electrodes 

Y Varies Medical 

Operations 

For cardiac applications. Scientist users may require ECG for 

other research protocols to meet data collection objectives. 

Ultrasound 

Contact Gel 

N Y HRF and 

Medical 

Operations 

A TBD minimum amount is maintained on board for contingency 

support. Each experiment should develop and coordinate projections. Material safety data sheets and other details are available 

from HRF. 

 

3

The HRF rack was designed with multiple solid-state power control modules (SSPCMs), to accommodate 

powering all equipment. One SSPCM has failed and is not currently scheduled to be replaced; therefore, additional 

power constraints apply. 
10

5.2. Communication Assets 

5.2.1. Commanding 

• S-band: to command rack configuration and deconfiguration. 

• S-band: to send commands to initiate downlink of full-resolution digital images after 

examination (still and cine-loop). 

5.2.2. Data management, uplink/downlink 

• Ku-band 

1. Restricted4 real-time video, 15–30 frames per second (fps) of ultrasound video for 

real-time session management and remote guidance, routed to the Biomed MPSR 

(Medical Operations). 

2. Data collection: digital files of images captured in the ultrasound system are downlinked 

to HRF and then made available to the user (investigator(s) or Medical Operations at the 

Biomed MPSR) on removable media or via secure electronic transfer. Data are compliant 

with the DICOM [digital imaging and communications in medicine] standard and require 

a DICOM reader for viewing. 

3. Cabin view video downlink post session. 

4. Cabin view still image downlink post session. 

5. Pre-session file uplink through the orbiter communication adapter (OCA). 

6. Target image cards or other relevant illustrations, text instructions, and safety precautions 

can be provided for uplink through the HRF experiment support team (research). 

• S-band 

1. Private real-time two-way audio for real-time session management and remote guidance, 

routed to Biomed MPSR (Medical Operations). 

2. Target image cards or other relevant illustrations, text instructions, and safety precautions 

can be provided for uplink through the HRF experiment support team (research). 

• Ground recording 

1. Real-time video downlink from the HRF rack/ultrasound system with the realtime private audio track is recorded in digital format, and made available to the user on 

removable media (digital video disk (DVD) by default). 

2. Cabin view video downlink is recorded in digital format, and made available to the user 

on removable media (DVD by default). 

5.3. Ground Infrastructure, Locations, Positions, and Assets 

Table 2 contains a consolidated list of the ground assets necessary to conduct a remotely guided 

ultrasound imaging session on ISS. The one-way video feed and the two-way private audio loop 

are also included in the table. 

 

4

Access to real-time video is restricted as the information contained therein is always private/confidential, as well as 

proprietary (research). 
11

Table 2: Ground Infrastructure, Hardware, Accessories, Supplies, and 

Other Material Assets Needed for ISS Ultrasound 

Element Redundant? Essential? Responsible 

Org. 

Function/Notes 

Restricted 

video feed 

Y Y GC Restricted video to TSC or Biomed MPSR. 

There is only one restricted video feed to 

the above locations; however, additional 

video such as cabin video could be downlinked simultaneously. Two video feeds 

would require using half the maximum 

frame rate available. 

Private S/G 

audio loops 

Y Y Houston TV Private S/G configured on TSC or Medical 

Operations consoles. 

Video 

and Audio 

Recording 

Capabilities 

Y Y TSC or 

Biomedical 

Flight 

Controller 

(BMFC)/ 

Mission 

Operations 

Directorate 

(MOD) 

Video and audio can be recorded by the 

end-user in the Biomed MPSR, or by JSC 

Imagery Services. 

Note: JSC Imagery Services does not 

support 24/7 operations; it is nominally 

staffed on weekdays, first shift only. Special request is made for an off-nominal 

situation. 

Video 

Monitor 

Y Y TSC or BMFC Flat screen, low-glare, high-fidelity 

monitor for video; required to view 

ultrasound video. 

Digital Voice 

Intercommunication Systems (DVIS) 

Station 

Y Y TSC or BMFC At least one (in addition to crew surgeon 

and BMFC stations) DVIS station is 

needed to conduct clinical ultrasound. 

Ultrasound 

Reference 

Image5

Y Y TSC or BMFC There are multiple copies of the ultrasound 

reference images, a hard copy in the Ultrasound Console Handbook, and an electronic copy in onboard documentation. 

DVIS 

Headsets 

Y Y TSC or BMFC Additional DVIS headsets for personnel 

supporting ultrasound operations such as 

the remote guidance expert. 

Timer N N TSC or BMFC A timer helps the remote guidance expert 

in time management during scanning. 

DICOM 

viewer 

Software 

Y Y Remote 

Guidance 

Expert 

DICOM viewing software is needed to 

view the captured images downlinked from 

the HRF Ultrasound. 

 

5

The Ultrasound Reference Image is similar to a cue card with an anatomical reference chart, a color-coded HRF 

Ultrasound keyboard image, and a probe manipulation illustration 
12

6. Essential Ground Personnel 

A broad, closely coordinated involvement of multiple control positions and personnel at the 

Johnson Space Center (JSC) and Marshall Space Flight Center (MSFC) is necessary for the 

proper configuration and use of the system. Depending upon circumstances and availability, a 

control position may be supported by one or more individuals (personnel). HRF personnel listed 

in this section, including specific HRF console positions, are considered essential ground personnel. 

For performing clinical ultrasound imaging on ISS, the crew surgeon, BMFC, and remote guidance 

expert are considered essential Medical Operations ground personnel. For a research activity 

with real-time guidance, a remote guidance expert is considered essential. Main positions, roles 

and responsibilities, relevant training and experience, and respective information resources 

for the above individuals are listed in this section. 

Other personnel, such as the flight director, capsule communicator (CAPCOM), telescience 

operations personnel, or ground control (GC) are not specific for ultrasound operations, but are 

required to allot crew time, communicate procedures to the crew, and configure ground resources. 

These positions do not require specific knowledge or training for their roles related to clinical 

ultrasound imaging operations, and can be briefed as necessary by the user’s personnel. 

6.1. Crew Surgeon (if imaging is for medical purposes) 

6.1.1. Suggested tasks during contingency ultrasound operations 

• Identifies indications for an imaging study as part of clinical evaluation. 

• Obtains permission to invoke resources necessary to activate the Ultrasound System. 

• Orders imaging study(-ies), generally per the List of Applications (Appendix 1); this initiates 

activation of the ISS Ultrasound System. 

• Establishes priority and preferred timing of the imaging session relative to other medical 

activities and decisions. 

• Communicates with the remote guidance expert(s) to 

 share expectations from the imaging study and the current differential diagnosis. 

 develop a diagnostic support plan and prioritize clinical questions. 

 optimize the imaging sequence and maximize the effectiveness of the study. 

 provide history and other relevant information. 

 confirm the selection of probes for deployment. 

 confirm constraining and safety requirements. 

• Communicates with the subject of the ordered imaging study. 

• Communicates with the ultrasound operator on board to provide the purpose, goals, and 

significance of the study, patient and operator restraints, “GO” to power up the Ultrasound 

System, selection of probes, and directions to any notes/instructions/illustrations sent 

electronically. 

• Receives preliminary information during the study and modifies the scope of the study. 

• Receives the final imaging report. 

• Makes decisions regarding follow-up studies as clinically indicated, and communicates 

decisions to flight director, BMFC, HRF, remote guidance expert, and imaging physician. 
13

6.1.2. Recommended relevant training 

• ISS Contingency Ultrasound Class 

• Principles of Remote Guidance Class 

6.1.3. Recommended relevant experience 

• No specific imaging data acquisition or interpretation experience required. 

6.1.4. Relevant information resources 

• The current version of this publication complete with all appendices. 

• HRF ultrasound activation/deactivation procedures. 

• ISS medical checklist. 

• HRF Ultrasound Activation and Use for Medical Contingencies (a section in the Flight 

Controller’s Operations Handbook – an internal NASA document). 

• Patient medical documentation and relevant preflight imaging data if available. 

6.2. Biomedical Flight Controller (if imaging is for medical purposes6) 

Two ISS BMFCs are required for effective activation and support of the ISS Ultrasound Imaging 

System. 

6.2.1. Tasks during contingency ultrasound operations 

• Receives order for an imaging study from crew surgeon. 

• Calls TSC operations to request contingency (clinical) ultrasound imaging support. 

• Communicates with other console positions to coordinate timing and support of the 

ultrasound study (Operations Plan, GC, Communication and Tracking Officer). 

• Provides procedures for hardware configuration to flight director. 

• Confirms all space and ground components of the ISS Ultrasound System with the 

remote guidance expert, including reference tools, headsets, accessories, and hardware 

modes/settings. 

• Communicates with the flight director and HRF systems regarding rack commanding. 

• Coordinates private voice with Houston voice and video with GC. 

• Confirms display of restricted video at the Biomed MPSR and private audio loop(s), 

readiness of data recording capability. 

• Reports “All ready for remote guidance” to the crew surgeon, once all steps in the respective 

Flight Controller’s Operations Handbook (FCOH) procedure are completed. 

• Provides communication availability/outage information to the flight surgeon and remote 

guidance expert during the imaging session. 

• Monitors data acquisition process (number of still images or cine loops captured), and 

coordinates post-study data downlink with HRF systems. 

• Supports data storage, duplication, review, and archival as appropriate. 

 

6

Some of these functions, which are essential for imaging for research purposes, can be accomplished by an 

appropriately trained HRF personnel, if available 
14

6.2.2. Reecommended relevant training 

• ISS Contingency Ultrasound Class 

• BMFC or CHeCS console certification 

• Principles of Remote Guidance Class 

6.2.3. Recommended relevant experience 

• No specific imaging data acquisition or interpretation experience required. 

6.2.4. Recommended information resources 

• HRF Ultrasound Activation and Use for Medical Contingencies (a section in the FCOH – an 

internal NASA document) 

• ISS Operations Audio and Video Configurations (a section in the FCOH – an internal NASA 

document) 

• ISS Medical Checklist (an on-board information resource available in both English and 

Russian, in paper and electronic formats) 

• Medical Operations Console Handbook (an internal NASA document) 

6.3. Remote Guidance Expert (if imaging is for medical purposes7) 

6.3.1. Tasks during clinical ultrasound operations 

• Receives directions regarding the clinical aspects of ISS contingency ultrasound imaging 

from flight surgeon. 

• Receives directions regarding the engineering, technical, and logistical aspects of ISS 

contingency ultrasound imaging from the BMFC. 

• Conducts remotely guided ultrasound examination per the crew surgeon’s order, scope, 

differential diagnosis, prioritized clinical questions, and other information received from the 

crew surgeon. 

• Provides preliminary information on the quality, completeness, and overall success of the 

study in terms of meeting its objectives, and answers specific questions during the course of 

the remotely guided study to the crew surgeon. 

• Receives crew surgeon and imaging physician input to modify the course and/or scope of the 

study, based on the preliminary information. 

• Suggests preliminary interpretation to the flight surgeon, pending data review by the 

imaging physician. In some circumstances, the flight surgeon may also be qualified to serve 

as the imaging physician. 

6.3.2. Recommended relevant training 

• ISS Flight Surgeon Contingency Ultrasound Class 

• Principles of Remote Guidance Class 

 

7

Some of these functions, which are essential for imaging for research purposes, can be accomplished by an 

appropriately trained HRF personnel, if available 
15

6.3.3. Recommended relevant experience 

• Fully self-sufficient hands-on experience of ultrasound imaging in a respective 

area (currently classified as echocardiography, vascular technology, general/abdominal, 

musculoskeletal). 

• Familiarity with the ISS ultrasound hardware or its commercial precursor (HDI-5000, 

Advanced Technology Laboratories (ATL)/Phillips). 

• Remote guidance practice with the use of the ultrasound reference image in a simulated 

environment with a time delay and inexperienced operator.. 

6.3.4. Relevant information resources available to the remote guidance expert 

• The current revision of this document complete with all appendices. 

• Ultrasound reference image. 

• Access to relevant patient history information as determined by crew surgeon. 

• Access to relevant preflight imaging information. 

6.4. Remote Guidance Expert: Research Protocol 

6.4.1. Tasks during research ultrasound operations 

• Receives directions regarding the scientific goals to address with ultrasound imaging from 

the Principal Investigator. 

• Receives directions regarding the engineering, technical, and logistical aspects of ISS 

ultrasound imaging from HRF personnel. 

• Conducts remotely guided ultrasound examination per the Principal Investigators’ science 

proposal, scope, and prioritized scientific objectives. 

• Provides preliminary information on the quality, completeness, and overall success of the 

study in terms of meeting its objectives. 

• Receives investigator input to modify the course and/or scope of the study, based on the 

preliminary information. 

6.4.2. Recommended relevant training 

• Principles of Remote Guidance Class 

6.4.3. Recommended relevant experience 

• Fully self-sufficient hands-on experience of ultrasound imaging in a respective 

area (currently classified as echocardiography, vascular technology, general/abdominal, 

musculoskeletal). 

• Familiarity with ISS ultrasound hardware or its commercial precursor (HDI-5000, 

ATL/Phillips). 

• Remote guidance practice with the use of ultrasound reference image in a simulated 

environment with a time delay and inexperienced operator.8

 

8

The currently available facilities to support this requirement are the PDL at JSC and the Medical Simulation 

Laboratory (MSL) at Wyle Laboratories, Life Sciences Group. 
16

6.4.4. Relevant information resources 

• The current version of this document complete with all appendices. 

• Ultrasound reference images. 

• Access to relevant history of the subject as determined by crew surgeon. 

• Access to relevant preflight imaging information as determined by crew surgeon. 

6.5. Imaging Physician or Investigator9

6.5.1. Tasks during ultrasound operations 

• Provides input to flight surgeon and remote guidance expert to modify course and/or scope of 

the study, based on the preliminary and real-time information. 

• Interprets the imaging results and generates the final imaging report. 

• Provides recommendations regarding further follow-up. 

6.5.2. Recommended relevant training 

• Board-Certified Physician (U.S.) qualified and possessing required credentials to interpret 

ultrasound imaging data. Generally, a radiologist with regular involvement in ultrasound 

imaging. 

• ISS Flight Surgeon Contingency Ultrasound Class. 

• Principles of Remote Guidance Class. 

6.5.3. Recommended relevant experience 

• Familiarity with remote guidance methodology, capabilities, and limitations. 

• Basic familiarity with microgravity/space physiology. 

6.5.4. Relevant information resources 

• The current version of this document complete with all appendices. 

• Access to relevant patient/subject history information as determined by crew surgeon. 

• Access to relevant preflight imaging information as determined by crew surgeon. 

6.6. Telescience Center Operations Personnel 

6.6.1. Tasks during contingency ultrasound operations 

• TSC operations console positions support payload and TSC operations. 

• For a medically indicated examination, TSC operations are contacted by the BMFC to initiate 

HRF support for contingency ultrasound operations. 

• TSC operations contact HRF systems, operations, and hardware personnel and request that 

they report to the TSC. 

 

9

Note: This may be the same person as the remote guidance expert. 
17

6.6.2. Recommended relevant training 

• HRF Contingency Ultrasound Class: TBD class conducted by HRF training personnel. 

6.6.3. Recommended relevant experience 

• Certification as a TSC operations console operator. 

6.6.4. Relevant information resources 

• HRF Ultrasound Activation and Use for Medical Contingencies (a section in FCOH – an 

internal NASA document). 

• Payload Operations Handbook (POH): (an internal NASA document). 

6.7. Human Research Facility Systems Engineer 

6.7.1. Tasks during ultrasound operations 

• Commands configuration of HRF rack. 

• Monitors health and status of HRF rack and equipment (ultrasound, laptop, rack). 

• Coordinates downlink of all images captured from ultrasound. 

• Commands HRF rack shutdown at completion of ultrasound session. 

• Coordinates all above activities through the BMFC (medical) or HRF (science). 

• Informs MSFC of rack activity. 

6.7.2. Recommended relevant training 

• HRF Contingency Ultrasound Class 

6.7.3. Recommended relevant experience for this position 

• Certification as a payload support engineer. 

6.7.4. Relevant information resources available to this position 

• HRF Ultrasound Activation and Use for Medical Contingencies (a section in an internal 

NASA document) 

• POH (an internal NASA document) 

• Current version of this publication 

6.8. Human Research Facility Hardware/Experiment Science Support 

6.8.1. Human Research Facility personnel tasks during contingency ultrasound 

operations 

• If necessary, the ultrasound hardware engineer will be called to the Biomed MPSR during 

contingency ultrasound operations to monitor hardware and troubleshoot any anomalies. 

• If necessary, the ultrasound experiment support scientist (ESS) will be called to the TSC 

during contingency operations. The ultrasound ESS is the most familiar with all operations 

associated with ultrasound procedures and is the point of contact between HRF and Medical 

Operations regarding ultrasound procedures. 
18

6.9. Telescience Center Data Systems Group 

The TSC Data Systems Group is responsible for processing the data that come down from the 

ultrasound equipment through payload commanding. The Data Systems Group provides the data 

on removable media to TSC operations to deliver to the BMFC or the Principal Investigator. Personnel assigned to the Data Systems Group should be at their consoles in the TSC when the data 

are downlinked and should be prepared to process the data immediately following receipt. The 

processing time will depend upon the amount of data downlinked. 

7. Crew Knowledge, Skill Sets, and Training 

The use of remote guidance protocols eliminates the need for the crew to acquire and retain 

knowledge of specific imaging applications, target views and images, or scanning sequences and 

protocols. However, the crew must be familiarized with certain aspects identified in table 3, which 

was composed for purposes of preparedness for a potential contingency (medical) imaging session. 

The same basic knowledge and experience would allow conducting an out-of-schedule research 

activity. However, preflight training needs for scheduled research activities may be considered 

experiment-specific, hence may substantially differ from the training approach taken for the 

operational activity (figure 2). 

Table 3. Components of Training for a 

Potential Operator in Remotely Guided 

Ultrasound Imaging 

No Component Org. Time 

1 HRF rack operations, HRF 

Ultrasound hardware and its 

components, configuration, and 

operation (Standard HRF rack and 

ultrasound training conducted in 

Payload training flow) 

HRF 

120 

min 

2 The components, setup, and 

activation sequence of the ISS 

Ultrasound System 

Med 

Ops 

3 Physical principles of ultrasound 

imaging and its clinical utility 

Med 

Ops 

4 General imaging procedure 

including the use of gel, probe 

manipulation, microgravity factors, 

positioning and restraints, other 

relevant human factors 

Med 

Ops 

5 The principles of remote guidance, 

including associated items, activities, and procedures such as the 

use of VOX communication system 

Med 

Ops 

30 

min 

6 Practice as a remotely guided 

ultrasound operator (laboratory 

setting, human subject) 

Med 

Ops 30 

min 

Figure 2. Above: Expedition Commander Michael Foale (ISS 

Increment 8) during his scanning practice session in the Payload 

Development Laboratory at JSC. Below: Dr. A. Sargsyan (Wyle 

Laboratories) is conducting a demonstration of the scanning 

technique for the Expedition 12 crew (W. McArthur, V. Tokarev). 
19

As shown in table 3, specific training components for contingency ultrasound can be limited 

to one hour per crew member. This suggested ultrasound training requirement was satisfied for 

Expeditions 8 through 11 (and back-up crews), through the ADUM experiment training (figure 

3). No ultrasound training is currently included in the CMO curriculum. 

Figure 3. Hardware configuration for ultrasound operations. Note: Operator is restrained in a position that ensures 

easy access to both the patient (right) and the keyboard (left) while viewing the flat screen (FS). 

Each crew receives hardware training on rack operations and ultrasound hardware configuration by HRF personnel, per the principle of shared resources (table 3, row 1). No knowledge 

retention practice or performance testing is provided presently or anticipated in the near future. 

8. Ultrasound Applications Available for Ordering 

Medical literature published by authors and other researchers, results of NASA developments 

and experiments, and expert consultations have been used in identifying and prioritizing medical 
20

conditions where ultrasound data are expected to substantially influence patient management on 

orbit. Implementation of operational ultrasound imaging for these medical conditions, in addition 

to the general microgravity imaging procedures, also requires application-specific protocols and 

techniques. Development of these protocols for the International Space Station (ISS) began in 

1999, and generally has followed a four-phased approach. It is not always necessary or practical to conduct Phases II and III, and assumptions may be made to transition directly from 

Phase I to Phase IV. The four phases are as follows: 

I. Identification of a proven terrestrial technique/application used on humans, or 

recognition of a potential technique 

II. Validation of technique/application on a model in one g (human or animal) 

III. Validation of technique/application on a model in a simulated microgravity 

environment (human or animal) 

IV. Operational implementation of technique for use on humans in microgravity (ISS) 

Such structured development and validation focuses on procedure, remote guidance techniques and terminology, scanning protocols, data consistency, and identification of microgravityinduced factors. The latter includes changes in normal anatomy and physiology, such as the redistribution of liquid, gas, and tissue, changes in blood flow and vascular patterns, and ergonomic 

challenges such as mutual positioning or operator fatigue. Multiple specific questions are answered 

partially or entirely with each ultrasound imaging session on the ground, in simulated microgravity, and on orbit. The imaging sessions conducted to date have resulted in a library of 

microgravity-adapted procedural components, focused scanning protocols and sequences, 

and “plug-in” modules to complement the standard techniques for ultrasound imaging. 

Feasible ultrasound applications categorized as Complete (Standard), Focused and Limited, 

and Image-Guided Manipulations are listed in Appendix 1. The first two groups of noninvasive 

imaging applications are available to surgeons on console for ordering. 

Applications classified as “Image-guided manipulations” are invasive procedures that have 

never been attempted in humans by remote guidance or in microgravity conditions. The limited 

experience acquired on animal models suggests the general feasibility of image-guided needle (i.e., 

instrument) introduction on ISS, but with an undefined risk of failure and/or iatrogenic complications. The probability of failure or complications would certainly depend on the particular 

application and circumstances surrounding the clinical case. Should such an interventional procedure be suggested for an ISS crew member, a clinically active interventional radiologist or 

another specialist with appropriate expertise would be required. The risk vs. benefit considerations must include a thorough ultrasound survey of the area, the efficacy of remote interaction 

with the CMO, and time and communications factors (including availability of simultaneous 

cabin view camera video). 
21

9. Hardware Configurations 

9.1. Human Research Facility Ultrasound Configuration 

The HRF Ultrasound System is an HDI-5000 (ATL/Philips, Bothell, Wash.) system that has 

been repackaged and modified to meet the power, cooling, and fire suppression requirements 

for a closed microgravity environment. This is a multipurpose ultrasound imaging system that is 

widely used for terrestrial clinical care and medical research. The on-board system is equipped 

with the three most broadly used probes, which are considered essential to cover a majority of 

foreseeable imaging applications in adults, including all applications listed in Appendix 1. Each 

probe features a set of advantages and limitations. None of the available probes individually 

covers the entire range of space medicine applications. 

The HDI-5000 configuration for a given space medicine application includes 

• Unstowing and connecting the ultrasound monitor and keyboard (MGUEHRFADUMR001 – 

cabling diagram used for ADUM experiment). 

• Unstowing the HRF personal computer laptop and activating image collection software 

to allow collected images to be downlinked following the scan (unstowing typically not 

required because the HRF laptop is nominally deployed). 

• Unstowing and connecting one or more probe(s). 

• Unstowing and connecting the ECG cable, if needed. 

• Locating the CMRS near the HRF rack and ultrasound, if needed. 

• Selecting a pre-connected probe for initialization. 

• Selecting a factory-programmed or custom “tissue preset” from the “transducer” menu of the 

system. 

• Initiating a new patient data record on the system hard drive by entering an alphanumeric 

patient ID in the “patient data” menu of the system. 

• Making further adjustments of system parameters as required to acquire the necessary 

scan(s), typically under real-time guidance by expert. 

• Providing support equipment (cue card, VOX, cameras, wipes for probes, electronically 

uplinked messages/reference cards specific for upcoming scan.) 

9.2. Ultrasound Probes 

The probes listed in table 4 are considered essential for meeting most foreseeable imaging needs. 

Other probes, currently unavailable aboard ISS, could be advantageous in specific situations and 

would provide desirable redundancy; however, financial and up-mass considerations have 

prevented their deployment on ISS at this time. 
22

Table 4. HDI-5000 Probe Applications by Anatomical Regions 

No. Design. Type Application Backup 

1 C5-2 Curved Array (convex) Abdominal / pelvic (primary) 

Vascular – deep vessels (alternative) 

Cardiac – limited (alternative) 

P4-2 

2 L12-5 Linear Array Superficial organs and tissues (primary) 

Musculoskeletal (primary) 

Chest wall/pneumothorax (primary) 

Peripheral vascular (primary) 

Ophthalmic (primary) 

Dental/facial (primary) 

C5-2 (limited) 

3 P4-2 Phased Array 

(electronic sector) 

Cardiac (primary) 

Abdominal/pelvic (alternative) 

C5-2 (limited) 

9.2.1. C5-2 curved array probe10 

This broadband curved array probe is the primary choice for all abdominal or pelvic sonography 

applications. The probe acquires fan-shaped images at depths up to 22 cm through a relatively large 

window. If this probe is unavailable, the P4-2 phased array probe is selected as a lower-resolution 

alternative acceptable for most respective applications. In certain situations, the P4-2 may be 

chosen as the primary probe; these include unsatisfactory imaging conditions when deeper 

penetration and (or) a very small imaging aperture are desired. 

9.2.2. L 12-5 (38mm) linear array probe 

The L12-5 linear array probe resolves superficial tissue with clarity, provides high tissue 

contrast, and spatial resolution. This high-frequency broadband probe acquires rectangularshaped images to a maximum depth of 7 cm. 

This is the only probe that is capable of resolving very superficial anatomical structures. 

Organs and issues subject to scanning with this probe include superficial soft tissues, eyes, 

thyroid gland, salivary glands, breast, and male gonads. This probe is also used for the detection 

or exclusion of pneumothorax by visualizing the chest-to-lung interface. L12-5 provides fine detail of muscles, fascia, tendons, ligaments and joints, as well as superficially positioned bones. 

For example, such use may be indicated if a muscle tear, a tendon rupture, or a rib fracture is 

suspected. 

9.2.3. P4-2 phased-array probe 

This phased-array probe has a very small footprint (face), hence its primary role is cardiac 

imaging. Through a narrow aperture (window) between ribs, it allows acquiring sector-shaped 

images with a field of view up to 22 cm in depth. This probe is also a backup, lower-resolution 

alternative for C5-2 for most abdominal and pelvic applications. However, it may be used as a 

primary probe for abdominal imaging in a large subject, or under imaging conditions where 

deeper penetration and small aperture are necessary. 

 

10Technical information, such as specifications of this and other HRF hardware, is available from the personnel 

supporting the ISS HRF facility. 
23

10. On-orbit Human Factors 

10.1. Subject Examination by Operator vs. Subject Self-examination 

In case of serious illness or injury, a patient is assumed incapacitated and unable to assist the 

operator (caregiver). Patient examination by operator is therefore considered the primary mode 

of contingency ultrasound. In this mode, the patient is restrained by the CMRS in the majority of 

applications. A dedicated operator is necessary if the patient (or research subject) is required to 

be restrained on the CMRS. 

Self-examination is a possible alternative only in a limited set of applications. It also limits 

examination to certain areas of the body and to a limited set of body positions. However, if 

mission circumstances render involvement of the second crew member unsafe or impossible, 

self-examination may be the only choice. Decisions in such circumstances would be made on a 

case-by-case basis. 

10.2. Patient and Operator Positioning and Restraints 

Positioning of both the patient and the operator is an important determinant of the quality of 

an imaging study. The restraining techniques are coordinated with the investigators or the flight 

surgeon. Nominally, the CMRS is installed in position LAB1D5/D6. An appropriate combination 

of straps provided with the CMRS is used to restrain the patient and, potentially, the operator. The 

choice of straps depends on the anatomical area of probe application, as well as other medical 

monitoring and treatment considerations. Both shoulder straps and the belt strap are used by 

default. The longitudinal (midline) strap is not applied as it interferes with probe application 

in most cases. 

Stability of the probe position, controlled pressure, and steady, purposeful movement of the 

probe are also important factors for image quality and success of remote guidance. A successful 

study (examination) can be initiated and maintained throughout the session only with the convenient, stable position of the operator. Foot restraints, CMRS CMO straps, and the space under the 

CMRS are nominally used to restrain the operator and free both hands for probe and keyboard 

manipulation. 

The flat screen display (FSD) must be viewed at an angle close to 90 degrees. The ultrasound 

keyboard must be within easy reach of the operator’s hand. Reaching the keyboard must not 

interrupt the imaging process, or result in a change in probe position or pressure on the probe. 

If the subject is capable, (s)he can assist the operator with keyboard strokes/manipulations, 

thus allowing the operator to concentrate on image acquisition during the scan. VOX should be 

on speaker to allow both crew members access to audio. In a number of applications, the imaging 

expert must communicate directly with the patient (e.g., giving commands such as “hold your 

breath,” “bear down,” etc.). 

Default positions of the crew members, ultrasound peripherals, and accessory items are shown in 

figure 3. 
24

10.3. Placement and Use of Reference Materials 

The Ultrasound Reference Image (Appendix 4) can be seen as an essential component of 

the ISS Ultrasound Imaging System. It should be attached to the frame of the HRF FSD. The 

application-specific reference images (Appendix 5), if provided by the Investigator or Remote 

Guidance Expert, are also positioned within the field of view of the operator. Hard copies of the 

“Cue Card” are located in the HRF rack (with the probes) and in the medical checklist (an onboard information resource available in both English and Russian, in paper and electronic 

formats). In addition, there is an electronic copy in the ISS manual procedures viewer. 

11. Supporting Evidence and Summary of Events 

As explained in section 4, imaging applications in a medical contingency may not be 

fully supported by knowledge and formal evidence, or may differ in their nature and from that 

commonly expected for mainstream terrestrial imaging procedures. Therefore, in each case and 

as possible, the imaging report must be supplemented with additional information regarding 

existing relevant knowledge and precedents as of the time of the examination. 

As of September 2006, multiple evaluations of remotely guided ultrasound imaging applications have been conducted on orbit (Expeditions 5, 6, 7, 8, 9, 10, and 11) by JSC Space Medicine 

Division and/or the HRF/ADUM experiment. Highlights of these events are provided in Appendix 7, 

which will be updated in future versions of this publication. ADUM session events and 

accomplishments will be described upon completion of the experiment report. 

12. Expected Forward Work 

• Efforts will be made to update the online version of this publication as relevant changes or 

new developments occur. 

• Training and familiarization mechanisms will be developed for transferring applicable 

knowledge and expertise from the JSC Space Medicine Division and Wyle Laboratories 

personnel to the potential users as such demands arise and circumstances permit. 

• Additional board-certified radiologists with enhanced ultrasound experience will be sought to 

act as ultrasound consultants in case of a medical contingency aboard ISS. 

• ADUM experiment results (including the ADUM final report) are expected to be completed, 

and recommendations contained in the ADUM final report will be considered for use to upgrade 

this text, to plan further studies, or for other relevant purposes. 

• Microgravity imaging/remote guidance techniques should be developed or refined for 

ultrasound applications that are currently deemed feasible but have not been demonstrated by 

Space Medicine or ADUM experiment. 

• Evidence should continue to be collected for conditions under which ultrasound may be 

applicable. 

• Documentation related to contingency ultrasound imaging must be kept in continued 

compliance with the HRF procedures. 
25

13. Appendices 

13.1. Appendix 1: Recommended Ultrasound Applications 

The majority of the following applications have been tested or demonstrated in the context of 

remote guidance and/or microgravity. Some applications are included that have not been tested 

but are considered feasible due to their similarity with other tested applications. 

Note: Image-guided manipulations are interventional (minimally invasive) therapeutic and/or 

diagnostic procedures in which ultrasound plays an accessory/supporting role. The risk of failure 

or iatrogenic complications of these procedures under remote guidance has not been evaluated. 

Also see text in section 8. 
I. HEAD, NECK, AND FACE 11

Application Title Type Notes/Scope

Ophthalmic Sonography Complete (Standard) B-mode sonography of the globe and orbital structures. Axial 

distance measurements (similar to A-mode) of the globe/ media are possible (correction factors may be necessary). 

Salivary Gland Sonography Complete Complete (Standard) Diagnostic or as enhancement to thyroid sonography. Thyroid Sonography Complete Complete (Standard) Standard clinical or research protocols. Carotid Duplex Sonography Complete Complete (Standard) Standard or specialized protocols with Doppler measurements of 

flow velocities in CCA, ICA, ECA, and VA. 

Paranasal Sinus Sonography Focused and Limited 

Studies 

If clinically indicated to confirm suspected maxillary or frontal sinusitis. Accuracy in microgravity is not established. 

Dental/Oral Sonography Focused and Limited 

Studies 

Extraoral approach only, if clinically indicated to confirm suspected periapical abscess. 

Salivary Gland Sonography Focused and Limited 

Studies 

Involves comparative imaging of contralateral gland and the thyroid. 

Ophthalmic Sonography – Limited Focused and Limited 

Studies 

Unilateral or F/U study (clinical); precise distance measurements (such as A-P diameter or retinal thickness) may require adjustment coefficients etc.). 

Ophthalmic Sonography – PLR Focused and Limited 

Studies 

Pupillary light reflex. 

Jugular Vein Sonography Specific Focused and Limited 

Studies 

Scope must be specified and protocols validated in ground tests. 

Image-Guided Vascular Access (Internal Jugular Vein) 

Image-Guided Manipulations 

See section 8. 

Ultrasound pupillometry Focused and Limited Experimental technique with visualization of the iris and 

recording of diameter and temporal parameters with high temporal and spatial resolution. 

11 Y: The application was successfully performed in full with remote guidance; D: the application was performed with remote guidance 

sufficient to demonstrate feasibility; A: the application was performed on animal model (s); NA: not applicable; N: the application has given setting. 

26 
II. HEART

Application Title Type Notes/Scope Echocardiography, Complete Complete (Standard) 

Studies 

Pericardial space, valves, chambers/walls, wall motion, color and spectral Doppler in standard locations, standard cardiac calcs). Thoracic windows may change in microgravity. Preflight baseline (supine and supine head-down tilt) is recommended to assess degree of difficulty of future in-flight tests. 

Stress-Echocardiography, Complete Complete (Standard) 

Studies 

Concurrent CEVIS use is required. Possible in the current (LAB module) location of the HRF rack. 

Echocardiography, Pericardial Space Focused and Limited 

Studies 

 

Echocardiography, Valve(s) Focused and Limited 

Studies 

 

Echocardiography, Chamber/Wall Focused and Limited 

Studies 

 

Echocardiography, Wall Motion Focused and Limited 

Studies 

 

Echocardiography, Limited Focused and Limited 

Studies 

Full-up or limited study (medical) or specific research protocol. 

Pericardiocentesis, by Ultrasonic Guidance 

Image-Guided Manipulations 

See section 8. 

III. THORAXBreast Sonography Complete Bilateral Complete (Standard) 

Studies 

Standard “terrestrial” protocol(s) 

Pleural Space Sonography Complete Bilateral 

Complete (Standard) Studies 

Bilateral, rule out or describe pleural effusion, hemo-, pneumothorax. 

Shoulder Sonography Complete Bilateral Complete (Standard) 

Studies 

Rotator cuff, joint, adjacent soft tissues. 

Sonography for Pleural Effusion Focused and Limited 

Studies 

 

Diaphragm Sonography Focused and Limited 

Studies 

 

27 
Sonography for Trauma / Subcutaneous 

Emphysema 

Focused and Limited Studies 

Scope must be specified. 

Pleural Space Sonography Ltd Focused and Limited 

Studies 

Involves multiple thoracic locations (primary diagnostic purpose) or a limited set of locations (follow-up). 

Thoracentesis, by Ultrasonic Guidance Image-Guided 

Manipulations 

See section 8. 

Thoracostomy (Chest Tube Placement) by Ultrasound Guidance 

Image-Guided Manipulations 

See section 8. 

Image-Guided Vascular Access Image-Guided 

Manipulations 

Subclavian vein. See section 8. 

Other Image-Guided 

Manipulations 

See under “Any Location.” 

IV. ABDOMEN AND RETROPERITONEUMApplication Title Type Notes/Scope Abdominal Sonography Complete Complete (Standard) Complete survey incl. liver, biliary system, pancreas, spleen, 

kidneys, AA, IVC, peritoneal space. 

Renal Sonography Complete Complete (Standard) Includes limited Doppler evaluation, urinary bladder, “ureteral 

jets.” 

Renal Arterial Duplex Sonography Complete 

Complete (Standard) Standard “terrestrial” protocol includes visualization plus 

Doppler spectra from AA and three locations or RA bilaterally. 

Adrenal Gland Sonography Complete (Standard) Bilateral. Abdominal Aorta Duplex Sonography Complete 

Complete (Standard) 

Scrotal Sonography Complete Complete (Standard) Standard terrestrial protocol, including color Doppler imaging. Prostate Sonographic Survey Complete (Standard) Trans-vesical (abdominal) approach. Requires a full bladder. Prostate and Urethra Sonography HighResolution Complete (Standard) External (perineal approach). Hepatic Sonography Focused and Limited Scope must be specified. Hepatic Sonography with Vascular Evaluation 

Focused and Limited Portal vein sonography for medical purposes (visualization, color 

Doppler, spectral Doppler). Research protocols must be validated in remote guidance setting in controlled laboratory conditions. 

Portal System Duplex Sonography Focused and Limited Includes PV, SMV, IMV, SV, with Doppler flow demonstrations 

and measurements per specific protocols. 

Gallbladder Sonography Focused and Limited Includes biliary system (intrahepatic and extrahepatic ducts). 

28 
Application Title Type Notes/Scope 

Pancreas Sonography Focused and Limited Spleen Sonography Focused and Limited Renal Sonography Specific Focused and Limited For example, Unilateral, F/U. Urinary Tract Obstruction – Sonography Localization 

Focused and Limited Identification of level and nature of obstruction; includes 

bilateral Doppler study of ureteral orifices. 

FAST Examination Focused and Limited Includes peritoneal, pericardial potential spaces. FAST Examination Expanded Focused and Limited Includes peritoneal, pericardial and both thoracic potential 

spaces. 

Peritoneal Space Focused and Limited Specify purpose, e.g. suspected effusion or F/U to FAST exam. Appendicitis (appendix) Sonography Focused and Limited 

Studies 

RLQ sonography with graded compression. 

GI Tract Sonography Focused and Limited Evaluates peristalsis, small bowel diameter, estimates content in 

terms of liquid / gas (fluid sequestration). Specific scope can be set for specific suspected conditions, levels of obstruction, and other clinical questions. Peristalsis can be described and monitored. 

Other Abdominal Vascular Duplex Sonography 

Focused and Limited Scope must be specified. Research protocols must be prevalidated in controlled laboratory conditions. 

Urinary bladder Sonography – Female Focused and Limited Bladder volume, presence of debris or clots, urethral angle, other 

signs per the specified scope. 

Urinary Bladder Sonography – Male Focused and Limited Bladder volume, presence of debris or clots, other signs per the 

specified scope. 

Abdominal Sonography, Limited Focused and Limited F/U, or limited study – scope must be specified. Laparocentesis, by Ultrasonic Guidance Image-Guided 

Manipulations 

See section 8. 

Image-Guided Aspiration, Drainage, Injection, or Infusion – Intraabdominal 

Image-Guided Manipulations 

See section 8. 

Other Image-Guided 

Manipulations 

See under “Any Location.” 

29 
V. GYNECOLOGY AND PELVIS

Application Title Code Notes/Scope

Per

w/ 

gu

Female Pelvic Sonography, Complete Complete (Standard) External (abdominal approach). Requires full bladder. 

Includes evaluation of the uterus, adnexae, and potential abdominal/pelvic space per the standard “terrestrial” protocol. No endocavity probe is available. 

Female Pelvic Sonography, Limited/Specific 

Focused and Limited For example, known or suspected uterine /pelvic mass, PID, 

F/U study (abdominal approach). No endocavity probe is available.

Female Pelvic Sonography, Endometrial Evaluation 

Focused and Limited Scope must be specified. 

Other Female Pelvic Sonography Focused and Limited Scope must be specified. Image-Guided Manipulations Image-Guided 

Manipulations 

NA 

TABLE VI. EXTREMITIES AND PERIPHERAL VASCULATUREArterial Duplex Sonography, Upper Extremity, Complete 

Complete (Standard) Specify side or bilateral. 

Venous Duplex Sonography, Upper Extremity, Complete 

Complete (Standard) Specify side or bilateral. Standard “terrestrial” protocol with 

compression. 

Arterial Duplex Sonography, Lower Extremity, Complete 

Complete (Standard) Specify side or bilateral. 

Venous Duplex Sonography, Lower Extremity, Complete 

Complete (Standard) Specify side or bilateral. Standard “terrestrial” protocol with 

compression. 

Musculoskeletal Sonography Complete (Standard) See under “Any Location.” Arterial Duplex Sonography, Lower Extremity, Limited 

Focused and Limited Specify side or Bilateral. Scope must be specified. Research 

protocols must be validated in remote guidance setting in controlled laboratory conditions. 

Venous Duplex Sonography, Lower Extremity, Limited 

Focused and Limited Specify side or Bilateral. Research protocols must be 

validated in remote guidance setting in controlled laboratory conditions. 

Musculoskeletal Sonography Focused and Limited See under “Any Location.” Research protocols must be 

validated in remote guidance setting in controlled laboratory conditions. 

Other Image-Guided 

Manipulations 

See under “Any Location.” 

30 
VII. ANY LOCATION (EXTRACAVITARY) AND MISCELLANEOUS

Application Title Type Notes/ScopeSoft Tissue Trauma Sonography Focused and Limited Specify. Soft Tissue Mass Sonography Focused and Limited Specify. Soft Tissue Infection Sonography Focused and Limited Specify. Foreign Body Localization Sonography Focused and Limited Specify. Sonography for Bone Trauma / Fracture Focused and Limited Specify . Sonography for Bone Fracture F/U Focused and Limited Specify. Articular Sonography Focused and Limited Specify. Other Musculoskeletal Sonography Focused and Limited Tendon, ligament, bursa – specify. Regional Lymph Node Sonography Focused and Limited Specify . Other Focused or Limited Soft Tissue Sonography 

Focused and Limited Specify. 

Image-Guided Fluid Aspiration –Diagnostic 

Image-Guided Manipulations12

Specify. See section 8. 

Image-Guided Fluid Aspiration –Therapeutic 

Image-Guided Manipulations 

Specify. See section 8. 

Image-guided Injection/Infusion Image-Guided 

Manipulations 

Specify. See section 8. 

Image-Guided Conductive Anesthesia – Peripheral nerves 

Image-Guided Manipulations 

Specify. See section 8. 

Foreign Body Localization – Needle, Soft Tissue 

Image-Guided Manipulations 

Specify. See section 8. 

Peripheral Vascular Access by Sonography Guidance 

Image-Guided Manipulations 

Specify. See section 8. 

Other Image-Guided Manipulation Image-Guided 

Manipulations 

Specify. See section 8. 

Y: The application was successfully performed in full with remote guidance; D: the application was performed with remote guidance p

sufficient to demonstrate feasibility; A: the application was performed on animal model (s); NA: not applicable; N: the application has given setting. 

12 Note: The feasibility of image-guided manipulations under remote guidance has been demonstrated on animal models in an animal la

parabolic flight. Some clinical circumstances potentially requiring these invasive procedures are addressed in our publications (Append

manipulations are not validated for ISS and are not included in the ISS Medical Checklist. 

31 
32 

13.2. Appendix 2: Examples of Conditions with Sonographic Signs and 

Symptoms 

No. Condition Examples Possible Sonographic Signs/Findings Terrestrial Use 

Alternate 

Diagnostic 

Modalities 

 Head, Neck, Face 

1 Retinal Detachment Typical pattern of retinal separation of various 

degree and topography. 

Common in 

specialized centers 

Slit Lamp 

2 Retro-vitreal and Intravitreal hemorrhage Typical patterns of irregularly altered 

echogenicity. 

Common in 

specialized centers 

Slit Lamp 

3 Lens Displacement 

(subluxation or dislocation) 

Failure to visualize lens in normal position; 

demonstration of the lens in abnormal position or 

location. 

Common in 

specialized centers 

Slit Lamp, MRI 

4 Other Trauma (anterior 

segment) 

Demonstration of hyphema, iris distortion, and 

other trauma anatomy. 

Common in 

specialized centers 

Slit Lamp 

5 Sialoadenitis Hypoechoic gland, enlarged and tender, rounded, 

possibly dilated ductal system, typical color 

Doppler signs. 

Uncommon Contrast 

Sialography, CT 

6 Thyroiditis Relatively hypoechoic gland, possible 

enlargement (compare to the baseline or adjacent 

structures - salivary glands and neck muscles), 

irregular texture; possibly altered color Doppler 

pattern. 

Common Laboratory tests 

7 Periapical Abscess Translabial/ transbuccal demonstration of a 

hypoechoic periapical focus. 

Uncommon X-ray, X-Ray 

tomography, CT, 

Panorex 

 Heart and Thorax 

8 Pericardial Effusion Demonstration of fluid separation of 

pericardium. 

Common Gated CT 

9 Pneumothorax Absent sliding of the lung, mirror-image artifact, 

absent “comet tails.” In severely symptomatic 

cases, expect same over entire hemithorax, 

displacement of the mediastinal structures. 

Uncommon, but 

increasingly 

recognized 

CXR, CT 

10 Pleural Effusion and 

Hemothorax 

Demonstration of fluid separation between 

parietal and visceral pleura. Expect wide area of 

distribution in zero g. Requires follow-up if 

negative. 

Common CXR, CT 

 Abdomen/Retroperitoneum 

11 Acute Appendicitis Thickened walls of appendix; noncompressibility, increased diameter, increased 

flow; if complicated - free fluid; localized fluid/ 

infiltrate, changes in peristalsis. Demonstration 

of normal appendix allows ruling out appendicitis in most cases. Failure to identify appendix 

does not rule out appendicitis. 

Common and 

increasing 

Non-Contrast CT, 

Contrast CT, MRI 

12 Acute Diverticulitis Nonspecific findings of focal bowel wall thickening and changes in surrounding fat/tissues; 

possible identification of the diverticulum, 

abscess formation, or associated fistula 

Known but 

uncommon 

Fluoroscopy, CT, 

Laparoscopy 
33 

No. Condition Examples Possible Sonographic Signs/Findings Terrestrial Use 

Alternate 

Diagnostic 

Modalities 

13 Blunt Abdominal Trauma Common (FAST) 

(includes internal bleeding) 

Free fluid at the site of injury; free fluid 

elsewhere in contiguous peritoneum; organ 

hematoma; capsular disruption; changes in 

peristalsis. 

Uncommon 

(comprehensive) 

CT, Laparoscopy 

14 Retroperitoneal Hematoma Detection of hematoma; possible abdominal 

fluid and/or signs of ileus. 

Uncommon, 

secondary 

CT, MRI 

15 Inflammatory Bowel Disease Thickened / infiltrated wall of terminal ileum. Uncommon CT, Small Bowel 

Series, 

Laparoscopy 

16 Hollow viscus perforation 

(peptic ulcer, trauma) 

Pneumoperitoneum; changes in peristalsis, free 

fluid. 

Known but 

uncommon 

CT, Laparoscopy 

17 Liver enlargement/Diffuse 

Process (e.g., toxic) 

Changes in shape, lower margin position and 

shape, dimensions, relative echogenicity, echotexture. 

Common Laboratory data, 

CT, Radionuclide 

(HIDA) Scan 

18 Liver or Splenic Hematoma Focal irregularity; Doppler signs of a spaceoccupying lesion (SOL).); subcapsular 

hematomas (typical pattern). 

Common CT 

19 Hepatic Abscess Demonstration of a gradually forming focal 

irregularity which assumes a round shape; 

Doppler signs of SOL. 

Common CT 

20 Biliary Hypertension due to 

Obstruction 

Dilation of intrahepatic bile ducts and 

extrahepatic ducts proximal to the cause; 

possible dilation of the gallbladder; possible 

dilatation of the pancreatic duct. 

Common CT, ECPG, 

Endoscopic 

Ultrasound 

21 Abnormal content of the 

Gallbladder – Sludge, Blood 

Clots, Calculi, Pneumobilia 

Demonstration of irregular echogenicity of 

gallbladder content; stones readily visualized; 

data will differ from terrestrial. 

Common CT, HIDA Scan, 

Endoscopic 

Ultrasound 

22 Acute Cholecystitis 

(calculous or acalculous) 

Thickened/infiltrated walls; possible peritoneal 

reaction; possible wall irregularity. 

Common CT, HIDA Scan 

23 Splenic Enlargement Changes in shape, relative position, size, relative 

echogenicity. 

Common CT 

24 Splenic Infarct Wedge-shaped zone of irregularity/low 

echogenicity. 

Common Contrast CT, 

Angiography 

25 Acute Pancreatitis; 

Pancreatic Hematoma 

Enlargement, low echogenicity; possible 

irregularity; possible dilation of the duct; 

possible free fluid and renal changes in severe 

cases. 

Common CT 

 Genitourinary/pelvic 

26 Renal Calcifications/Calculi Demonstration of calcifications and/or stones; 

typical pattern of obstruction if impacted. 

Common IVP, CT 

27 Ureteral Obstruction/Renal 

Colic (stone, blood clot in 

trauma, urinary reflux) 

Demonstration of renal pelvic distention/ureteral 

dilation proximal to the stone; renal 

enlargement; possible identification of the cause. 

Common IVP, CT 

28 Acute Pyelonephritis and 

Renal Abscess 

Renal enlargement, shape, low relative 

echogenicity, possible focal lesions/irregularity, 

possible signs of obstruction; demonstration of 

abscess (focal lesion of varying echogenicity, 

irregular contour of the kidney). 

Common Contrast CT, Renal 

Angiography, 

Scintigraphy 
34 

No. Condition Examples Possible Sonographic Signs/Findings Terrestrial Use 

Alternate 

Diagnostic 

Modalities 

29 Renal Trauma Zones of irregularity with associated perirenal 

changes; usually diagnostic in clinical context; 

Power/Color Doppler essential to evaluate 

damage and stage/classify. 

Common Contrast CT, Renal 

Angiography, 

Scintigraphy 

30 Acute Diffuse Pathology, 

Renal Enlargement (e.g., 

toxic exposure, ATN) 

Renal enlargement, shape, high relative 

echogenicity, medullo-cortical contrast, change 

in renal vascular resistivity (pulsed Doppler). 

Common Laboratory Data, 

CT, Scintigraphy 

31 Renal Vein Thrombosis Changes in size, echogenicity, shape, arterial 

flow pattern (pulsed Doppler); actual thrombus 

may be visualized; a complicated and timeconsuming procedure. 

Common Contrast CT, Renal 

Scintigraphy, 

Angiography 

32 Normal Pregnancy (early); 

Incomplete Abortion Or 

Blighted Ovum 

Demonstration of gestational sac, thickened and 

echogenic endometrium; typical patterns of 

complications. 

Common Laboratory data, 

Endocavity US 

33 Ectopic Gestation Adnexal mass, free pelvic fluid, thickened 

endometrium; possible demonstration of fetus 

with or without the heartbeat. 

Common Endocavity US; 

CT 

34 Pelvic Inflammatory Disease 

(PID) 

A variety of sonographic patterns; requires 

extensive guidance; ectopic gestation must be 

ruled out. 

Common HCG, CT 

35 Bladder Calculi or Blood 

Clots 

Demonstration of a calculus or displaceable 

irregularly echogenic structure in the bladder 

lumen; different in zero g vs. one g. 

Common Cystoscopy 

36 Bladder Infection Demonstration of turbulent urine in the bladder; 

thickening of bladder walls; color Doppler 

interrogation causes “stirring” of turbulence; 

different in zero g vs. one g. 

Common Lab 

37 Urinary Retention Distended bladder, possibly vesico-ureteral 

reflux with ureteral and renal distention. 

Common CT 

38 Acute Prostatitis/Relapse and 

Prostatic Abscess 

Enlarged prostate, irregularity of texture, contour 

irregularity, possible focal changes, low echogenicity; “chronic” background changes, e.g., 

calcifications. 

Common Endocavity (rectal) 

US 

39 Testicular torsion Critical information from color Doppler; 

Changes in echo-texture and asymmetry in 

echogenicity. 

Common Clinical 

Impression 

 Superficial 

40 Superficial Infections 

(cellulitis, lymphadenitis, 

cutaneous abscess, 

necrotizing cellulitis) 

Respective patterns, typical. Common Optical Images of 

Skin; Clinical 

Impression 

 Extremities and Peripheral Vasculature 

Lack of vein compressibility, visualization of 

thrombus, absent or abnormal flow. 

41 Deep Venous Thrombosis 

(lower extremities) 

May be time consuming. Technique may differ 

in zero g vs. one g. 

Common Contrast 

Venography, MRI, 

scintigraphy 
35 

No. Condition Examples Possible Sonographic Signs/Findings Terrestrial Use 

Alternate 

Diagnostic 

Modalities 

42 Superficial Venous 

Thrombosis (post-injection, 

post-catheter) 

Lack of compressibility, visualization of 

thrombus, absent or abnormal flow. 

Common Optical Images of 

Skin; Clinical 

Impression 

43 Venous Gas Embolism 

(Decompression) 

Demonstration of VGE in B-mode and power 

Doppler; pulsed Doppler may be used as well 

(duplex or color-duplex mode) 

Uncommon Pulsed Doppler 

Characteristic disruption of cortical bone 

reflection. 

44 Superficial bone fractures 

(rib, mandible, zygomaticomaxillary complex, skull) Distortion of the bone contour; soft tissue 

reaction/edema/hematoma. 

Common in 

Specialized 

Centers 

Radiography 

45 Long-Bone Fractures Similar to other fractures; additional techniques 

(e.g., axial rotation) may enhance study. 

Common in 

Specialized 

Centers 

Radiography 

46 Muscle Tears/Hematoma Hypoechoic zone, irregularity, local 

enlargement, displacement of adjacent structures. 

Common in 

Specialized 

Centers 

MRI 

47 Tendon Rupture Disruption of the normal pattern, asymmetry, 

hypoechoic zone; may demonstrate contracted 

muscle. 

Common in 

Specialized 

Centers 

MRI 
36 

13.3. Appendix 3: Remote Guidance Experts with Experience of Remotely 

Guided Ultrasound on ISS 

As of the time of this publication, remotely guided ultrasound aboard the ISS has been supported 

by the following individuals, who have significantly overlapping expertise in the area. 

Dr. Ashot Sargsyan, Space Medicine, Advanced Projects, Wyle Laboratories 

• Doctor of Medicine (Internal Medicine and Radiology) with emphasis on ultrasound imaging 

(not certified by boards in the U.S.) 

• > 14 years of medical practice, all including hands-on ultrasound imaging 

• > 50 hours of remote guidance practice in Payload Data Laboratory 

• > 20 hours of remotely guided ultrasound with ISS 

• Expertise in abdominal, pelvic, thoracic, superficial, ophthalmic, and musculoskeletal 

ultrasound 

David Martin, Cardiovascular Laboratory, Wyle Laboratories 

• Registered Diagnostic Medical Sonographer (RDMS), Registered Diagnostic Cardiovascular 

Sonographer (RDCS), and Registered Vascular Technologist (RVT) 

• 24 years of hands-on scanning 

• > 30 hours of remote guidance ultrasound practice in Payload Data Laboratory 

• > 20 hours of remote guidance ultrasound practice in Cardiovascular Laboratory 

• > 10 hours of remotely guided ultrasound with ISS 

• Expertise in echocardiography, abdominal, superficial, musculoskeletal, and vascular 

ultrasound 

Kathleen Garcia, Cardiovascular Laboratory, Wyle Laboratories 

• RDCS and RVT 

• 16 years of hands-on scanning 

• > 6 hours of remote guidance ultrasound practice in Payload Data Laboratory 

• > 1 hour of remotely guided ultrasound with ISS 

• Expertise in echocardiography and vascular ultrasound 
37 

13.4. Appendix 4: ISS Ultrasound Reference Image (aka “Cue Card”) 
38 

13.5. Appendix 5: Target Image Reference Card (Samples) 

ADUM ABDOMINAL REFERENCE IMAGES 

 R1- Liver (Ref Card A1) R2 -Kidney (Ref Card A3-4) 

R3 - Urinary Bladder (Ref Card A9) 

 R4 - Gall Bladder (Ref Card A2-3) R5 - Pancreas (Ref Card A1-2) 

 R6 - Common Bile Duct (Verbal) R7 - Spleen (Ref Card A6L)
39 

13.6. Appendix 6: Sample Communication Timeline 

13.7. Appendix 7: ISS Ultrasound Activities Through Expedition 11 

September 14, 2002: Medical Operations: 

Activation and Check out of the HRF Ultrasound for Medical Contingencies – (ISS-5) 

Purpose: Validate procedures, protocols, and hardware operations should ultrasound be needed 

for a medical contingency. 

Summary: The HRF rack containing the Ultrasound System was configured through ground 

commands by HRF personnel on console in the TSC. The crew member unstowed and connected the keyboard, the monitor, and three probes (designated L12-5, C5-2, and P4-2), and executed 

the ultrasound power-up sequence per procedures developed specifically for medical operations 

jointly with HRF. Real-time video from the ultrasound was transmitted to the ground for the first 

time, and was watched on a monitor at the Biomedical MPSR in the Mission Control CenterHouston (MCC-H). Using the video downlink and two-way private space-to-ground audio, an 

ultrasound expert on the ground remotely guided the crew member through multiple clinical 

scanning protocols adapted for the zero-g environment and the specific setting of a remotely 

guided self-examination. During this session, all clinical ultrasound imaging modes were used 

and all three available probes were tested. A secondary activity was also performed to identify 

human factors relevant to conducting a two-person ultrasound exam using the CMRS. 

Main Results: 

• Demonstrated microgravity ultrasound imaging (microgravity sonography) for the first time 

aboard ISS by a minimally trained, remotely guided astronaut. 

• Used near-real-time medical video downlink with full-duplex space-to-ground voice. 

• Supported remote feedback and guidance system by minimal training and shared reference 

tools (“cue card”). 

• Validated sonographic protocols adapted for zero g and the specific application of remote 

guidance. 
40 

March 2003: Medical Operations: 

Microgravity Echocardiography Validation – (ISS-6) 

Purpose: Validate all procedures necessary to perform a clinical diagnostic echocardiography 

exam in microgravity for potential medical contingencies. 

Summary: The HRF rack containing the Ultrasound System was configured through 

ground commands by HRF personnel on console in the TSC. One crew member unstowed 

and connected the keyboard, the monitor, and the P4-2 probe, and executed the ultrasound 

power-up sequence. Real-time video from the ultrasound was transmitted to the MCC-H. Using 

the “privatized” video downlink and two-way private space-to-ground audio, an RDCS (Medical 

Operations) guided one crew member through real-time cardiac scanning on a second crew member. Time was allowed for the crew members to exchange positions, therefore two echocardiography 

sessions were completed instead of one. Scanning protocols were based on the American Society 

of Echocardiography standards. Leading clinicians from Baylor College of Medicine with expertise in cardiology and echocardiography (A. Raizner, M. Quinones) were present to view 

the data in real time, and to evaluate the data post examination to find them clinically adequate 

for the majority of acute cardiac conditions possible on ISS. 

Main Results: 

• Captured clinically valid and interpretable data with a minimally trained and a non-trained 

user. 

• Primarily through analysis of the above data, validated echocardiography procedures 

modified for zero g, on two subjects, including 

o Hardware and communications procedures. 

o Scanning (data acquisition) protocol. 

o Remote guidance techniques and terminology. 

• Identified external clinical experts to review data for clinical validity; provided these external consultants with an opportunity for exposure to operational space-to-ground activity, 

and assured their willingness to assist NASA Space Medicine in case of relevant medical 

contingency. 

June 2003, HRF: 

Clinical Image Quality Validation – (ISS-7) 

Purpose: Compare quality of real-time video from ultrasound with digital images downlinked 

after the event. 

Summary: The HRF rack containing the Ultrasound System was configured through 

ground commands by HRF personnel on console at the TSC in the MCC-H. One crew member 

unstowed and connected the keyboard, the monitor, and the C5-2 and L12-5 probes, and executed the ultrasound power-up sequence. For the first time, real-time video from the ultrasound 

was transmitted to the TSC. The experience of the two previous events was directly used to 

facilitate this milestone capability. A series of known test patterns was transmitted from the 

ultrasound system to the ground and recorded for comparison. In addition, using the “privatized” 

video downlink and two-way private space-to-ground audio, an ultrasound expert guided the 
41 

crew member through a self exam involving the capture of specific clinical images with anatomical details. Digital images were stored on the ultrasound and real-time video was recorded 

on the ground. The digital images were downlinked following the activity for comparison with 

the video. The initial image comparison showed very minimal differences between the digital 

images and images captured from the real-time video. Further analysis is being done. 

Main Results: 

• Conducted real-time ultrasound operations with ISS from the TSC for the first time, with 

private video and audio. 

• Validated the capability of HRF ultrasound use in this mode for science. 

• Tested and validated ground procedures for this purpose. 

• Created a backup capability for medical operations. 

• Captured data to measure image quality and to estimate data loss through the ISS video 

system and communication pathways. 

September 2003, HRF: 

Feasibility of Exercise Echocardiography in Microgravity –- (ISS-7) 

Purpose: Demonstrate the feasibility of performing a stress echocardiography exam on ISS for 

both medical and research applications. 
42 

Summary: The HRF rack containing the Ultrasound System was configured through ground 

commands by HRF personnel on console at the TSC in the MCC-H. One crew member unstowed 

and connected the keyboard, the monitor, and the P4-2 probe, and executed the ultrasound power-up 

sequence. A second crew member configured the cycle ergometer with vibration isolation system 

(CEVIS) for nominal operations. Both HRF and medical operations personnel were involved and 

on console at the TSC. Real-time video from the ultrasound was transmitted to the TSC. Using 

the “privatized” video downlink and two-way private space-to-ground audio, an RDCS) with 

remote guidance experience (medical operations) guided one crew member through real-time 

cardiac scanning on a second crew member while resting on the CEVIS, then while pedaling 

at slow, medium, and fast rates. Scanning protocols were based on the American Society of 

Echocardiography standards. 

Main Results: 

• Captured clinically valid and interpretable stress (exercise) echocardiography data with a 

minimally trained and an untrained operator using remote real-time guidance. 

• Identified constraints and limitations of the procedures, hardware configurations, and human 

factors associated with stress (exercise) echocardiography on ISS. 

• Determined that it would be feasible to conduct stress (exercise) echocardiography on ISS 

should it be indicated or necessary for research purposes, and modifications were identified 

for the procedures employed during the activity. 

March 2004 – March 2005, HRF: 

Advanced Diagnostic Ultrasound in Microgravity – (ISS-8, 9, 10) 

Official information on the ADUM experiment is available on the following NASA Web site: 

http://hrf.jsc.nasa.gov/science/default.asp?e_id=4. Additional information may be requested from 

the ADUM experiment Principal Investigator Scott A. Dulchavsky, MD, PhD, at: 

sdulcha1@hfhs.org. 

The information for this section was prepared by Space Medicine Operational Ultrasound Team. 

• Shannon Melton, SMelton@wylehou.com, (281) 212-1435 

• Ashot Sargsyan, ASargsyan@wylehou.com, (281) 212-1388 

• Douglas Hamilton, DHamilton@wylehou.com, (281) 212-1391 

Additional information about the above listed and other activities from the HRF perspective, as 

well as details of HRF-related information, can be requested from 

• Ms. Cynthia Haven, HRF Project Manager, cynthia.p.haven@nasa.gov, 281-483-6045. 

• Ms. Jacqui van Twest, HRF, jacqui.vantwest@lmco.com, 281-218-3072. 

13.8. Appendix 8: Associated Documentation 

References to the internal NASA and International Space Station Program documentation are 

withheld in this section as they are not available from normal bibliographic sources. Revisions 

to these documents are made on a regular basis. Users of ISS Ultrasound that are “internal” to 
43 

NASA and the ISS Partnership have access to the documentation, and will obtain necessary 

information through the HRF points-of-contact. Potential “external” users will be provided 

necessary information by HRF in early phases of the consideration of the given research 

program. 

13.9. Appendix 9: Selected Relevant Publications 

JOURNAL ARTICLES BY AUTHORS

1. Sargsyan AE, Hamilton DR, Jones JA, Melton S, Whitson PA, Kirkpatrick AW, Martin D, 

Dulchavsky SA FAST at MACH 20: clinical ultrasound aboard the International Space 

Station. J Trauma. 2005 Jan;58(1):35-9. 

BACKGROUND: Focused assessment with sonography for trauma (FAST) 

examination has been proved accurate for diagnosing trauma when performed by 

nonradiologist physicians. Recent reports have suggested that nonphysicians also may 

be able to perform the FAST examination reliably. A multipurpose ultrasound system is 

installed on ISS as a component of the HRF. Nonphysician crew members aboard ISS 

receive modest training in hardware operation, sonographic techniques, and remotely 

guided scanning. This report documents the first FAST examination conducted in 

space, as part of the sustained effort to maintain the highest possible level of available 

medical care during long-duration space flight. METHODS: An ISS crew member 

with minimal sonography training was remotely guided through a FAST examination 

by an ultrasound imaging expert from the MCC using private real-time two-way audio 

and a private space-to-ground video downlink (7.5 frames/se). There was a 2-second 

satellite delay for both video and audio. To facilitate the real-time telemedical 

ultrasound examination, identical reference cards showing topologic reference points 

and hardware controls were available to both the crew member and the ground-based 

expert. RESULTS: A FAST examination, including four standard abdominal windows, 

was completed in approximately 5.5 minutes. Following commands from the MCC-based 

expert, the crew member acquired all target images without difficulty. The anatomic 

content and fidelity of the ultrasound video were excellent and would allow clinical 

decision making. CONCLUSIONS: It is possible to conduct a remotely guided FAST 

examination with excellent clinical results and speed, even with a significantly reduced 

video frame rate and a 2-second communication latency. A wider application of trauma 

ultrasound applications for remote medicine on Earth appears to be possible and 

warranted. 

2. Chiao L, Sharipov S, Sargsyan A, Melton S, Hamilton D, McFarlin K, Dulchavsky S, Ocular 

Examination for Trauma; Clinical Ultrasound Aboard the International Space Station. J 

Trauma. 2005 May;58(5):885-9. (Featured article). 

BACKGROUND: Ultrasound imaging is a successful modality in a broad variety of 

diagnostic applications including trauma. Ultrasound has been shown to be accurate 

when performed by non-radiologist physicians; recent reports have suggested that 

nonphysicians can perform limited ultrasound examinations. A multipurpose ultrasound 

system is installed on ISS as a component of the HRF. This report documents the first 
44 

ocular ultrasound examination conducted in space, which demonstrated the capability 

to assess physiologic alterations or pathology including trauma during long-duration 

space flight. METHODS: An ISS crew member with minimal sonography training was 

remotely guided by an imaging expert from the MCC through a comprehensive 

ultrasound examination of the eye. A multipurpose ultrasound imager was used in 

conjunction with a space-to-ground video downlink and two-way audio. Reference 

cards with topological reference points, hardware controls, and target images were used 

to facilitate the examination. Multiple views of the eye structures were obtained 

through a closed eyelid. Pupillary response to light was demonstrated by modifying the 

light exposure of the contralateral eye. RESULTS: A 

crew member on ISS was able to complete a 

comprehensive ocular examination using B- and Mmode ultrasonography with remote guidance from an 

expert in the MCC. Multiple anteroposterior, oblique, 

and coronal views of the eye clearly demonstrated the 

anatomic structures of both segments of the globe. The 

iris and pupil were readily visualized with probe 

manipulation. Pupillary diameter was assessed in real 

time in B- and M-mode displays. The anatomic detail 

and fidelity of ultrasound video were excellent and 

could be used to answer a variety of clinical and space 

physiologic questions. CONCLUSIONS: A 

comprehensive, high-quality ultrasound examination 

of the eye was performed with a multipurpose imager 

aboard ISS by a nonexpert operator using remote guidance. Ocular ultrasound images 

were of diagnostic quality despite the 2-second communication latency and the 

unconventional setting of a weightless spacecraft environment. The remote guidance 

techniques developed to facilitate this successful NASA research experiment will 

support wider applications of ultrasound for remote medicine on Earth, including the 

assessment of pupillary reactions in patients with severe craniofacial trauma and 

swelling. 

3. Foale CM, Kaleri AY, Sargsyan AE, Hamilton DR, Melton S, Martin D, Dulchavsky SA. 

Diagnostic Instrumentation Aboard ISS: Just-In-Time Training for Non-Physician 

Crewmembers. Aviat Space Environ Med. 2005 Jun;76(6):594-8. 

INTRODUCTION: The performance of complex tasks on ISS requires significant 

preflight crew training commitments and frequent skill and knowledge refreshment. 

This report documents a recently developed “just-in-time” training methodology, which 

integrates preflight hardware familiarization and procedure training with an on-orbit 

CD-ROM-based skill enhancement. This “just-in-time” concept was used to support 

real-time remote expert guidance to complete ultrasound examinations using the ISS 

HRF. METHODS: An American and a Russian ISS crew member received 2 hours of 

hands-on ultrasound training 8 months prior to the on-orbit ultrasound exam. A CDROM-based on-board proficiency enhancement (OPE) interactive multimedia program, 

consisting of memory enhancing tutorials and skill testing exercises, was completed by 
45 

the crew member 6 days prior to the on-orbit ultrasound exam. The crew member was 

then remotely guided through a thoracic, vascular, and echocardiographic examination 

by ultrasound imaging experts. RESULTS: Results of the CD-ROM-based OPE 

session were used to modify the instructions during a complete 35-minute real-time 

thoracic, cardiac, and carotid/jugular ultrasound study. Following commands from the 

ground-based expert, the crewmember acquired all target views and images without 

difficulty. The anatomical content and fidelity of ultrasound video were adequate for 

clinical decision making. CONCLUSIONS: Complex ultrasound experiments with 

expert guidance were performed with high accuracy following limited preflight training 

and multimedia based in-flight review, despite a 2-second communication latency. Inflight application of multimedia proficiency enhancement software, coupled with realtime remote expert guidance, facilitates the successful performance of ultrasound 

examinations on orbit and may have additional terrestrial and space applications. 

4. Hamilton DR, Sargsyan AE, Kirkpatrick AW, Nicolaou S, Campbell MR, Dawson D, Melton 

S, Beck G, Guess T, Rasbury J, Dulchavsky SA. Sonographic detection of pneumothorax and 

hemothorax in microgravity. Aviat. Space. Environ. Med. 75; 272-277, 2004. 

INTRODUCTION: An intrathoracic injury may be disastrous to a crew member 

aboard ISS if the diagnosis is missed or delayed. Symptomatic or clinically suspicious 

thoracic trauma is treated as a surgical emergency on Earth, usually with immediate 

stabilization and rapid transport to a facility that is able to deliver the appropriate 

medical care. A similar approach is planned for ISS; however, an unnecessary 

evacuation would cause a significant mission impact and an exorbitant expense. 

HYPOTHESIS: The use of ultrasound imaging for the detection of pneumothorax and 

hemothorax in microgravity is both possible and practical. METHODS: Sonography 

was performed on anesthetized pigs in a ground-based laboratory (n = 4) and 

microgravity conditions (zero g) during parabolic flight (n = 4). Aliquots of air (50–500 

ml) or saline (10–200 ml) were introduced into the pleural space to simulate 

pneumothorax and hemothorax, respectively. RESULTS: The presence of “lung 

sliding” excluded pneumothorax. In microgravity, a loss of “lung sliding” was noted 

simultaneously in the anterior and posterior sonographic windows after 100 ml of air 

was introduced into the chest, indicating pneumothorax. The presence of the fluid layer 

in simulated hemothorax was noted in the anterior and posterior sonographic windows 

after 50 ml of fluid were injected into the pleural space. During the microgravity phase, 

the intrapleural fluid rapidly redistributed so that it could be detected using either 

anterior or posterior sonographic windows. CONCLUSION: Modest to severe 

pneumothorax and hemothorax can be diagnosed using ultrasound in microgravity. 

5. Dulchavsky, SA; Schwarz, KL; Kirkpatrick, AW; Billica, RD; Williams, DR; Diebel, LN; 

Campbell, MR; Sargsyan, AE; Hamilton, DR Prospective evaluation of thoracic ultrasound 

in the detection of pneumothorax Journal Of Trauma-Injury Infection and Critical Care, 

2001 Feb 50(2) 201–5. 

BACKGROUND: Thoracic ultrasound may rapidly diagnose pneumothorax when 

radiographs are unobtainable; the accuracy is not known. METHODS: We 
46 

prospectively evaluated thoracic ultrasound detection of pneumothorax in patients at 

high suspicion of pneumothorax. The presence of “lung sliding” or “comet tail” 

artifacts was determined in patients by ultrasound before radiologic verification of 

pneumothorax by residents instructed in thoracic ultrasound. Results were compared 

with standard radiography. RESULTS: There were 382 patients enrolled; the cause of 

injury was blunt (281 of 382), gunshot wound (22 of 382), stab wound (61 of 382), and 

spontaneous (18 of 382). Pneumothorax was demonstrated on chest radiograph in 39 

patients and confirmed by ultrasound in 37 of 39 patients (95% sensitivity); two 

pneumothoraces could not be diagnosed because of subcutaneous air; the true-negative 

rate was 100%. CONCLUSION: Thoracic ultrasound reliably diagnoses 

pneumothorax. Expansion of the FAST examination to include the thorax should be 

investigated for terrestrial and space medical applications. 

6. Fincke EM, Padalka G, Lee D, van Holsbeeck M, Sargsyan AE, Hamilton DR, Martin D, 

Melton SL, Dulchavsky SA. Evaluation of shoulder integrity in space: first report of 

musculoskeletal ultrasound on the International Space Station. Radiology. 2005 

Feb;234(2):319-22. Epub 2004 Nov 8. 

Investigative procedures were approved by Henry Ford Human Investigation 

Committee and NASA Johnson Space Center Committee for Protection of Human 

Subjects. Informed consent was obtained. Authors evaluated ability of the nonphysician 

crew member to obtain diagnostic-quality musculoskeletal ultrasonographic (US) data 

of the shoulder by following a just-in-time training algorithm and using real-time 

remote guidance aboard ISS. Expedition 9 crew members attended a 2.5-hour didactic 

and hands-on US training session 4 months before launch. Aboard ISS, they completed 

a 1-hour computer-based OPE program 7 days before examination. Crew members did 

not receive specific training in shoulder anatomy or shoulder US techniques. Evaluation 

of astronaut shoulder integrity was done by using an HRF US system. Crew used 

special positioning techniques for subject and operator to facilitate US in microgravity 

environment. Common anatomic reference points aided initial probe placement. Realtime US video of shoulder was transmitted to remote experienced sonologists in the 

TSC at JSC. Probe manipulation and equipment adjustments were guided with verbal 

commands from remote sonologists to astronaut operators to complete rotator cuff 

evaluation. Comprehensive US of crew member’s shoulder included transverse and 

longitudinal images of biceps and supraspinatus tendons and articular cartilage surface. 

Total examination time required to guide astronaut operator to acquire necessary 

images was approximately 15 minutes. Multiple arm and probe positions were used to 

acquire dynamic video images that were of excellent quality to allow evaluation of 

shoulder integrity. Post-session download and analysis of high-fidelity US images 

collected on board demonstrated additional anatomic detail that could be used to 

exclude subtle injury. Musculoskeletal US can be performed in space by minimally 

trained operators by using remote guidance. This technique can be used to evaluate 

shoulder integrity in symptomatic crew members after strenuous extravehicular 

activities or to monitor microgravity-associated changes in musculoskeletal anatomy. 

Just-in-time training, combined with remote experienced physician guidance, may 

provide a useful approach to complex medical tasks performed by nonexperienced 
47 

personnel in a variety of remote settings, including current and future space programs. 

(c) RSNA, 2004. 

7. Melton S, Beck G, Hamilton D, Chun R, Sargsyan A, Nicolaou S, Campbell MR, 

Dulchavsky S, Dawson D, Kirkpatrick AW. How to test a medical technology for space: 

trauma sonography in microgravity. Mil. Med 2003;168:312-313. 

8. Sargsyan AE., Hamilton DR, Nicolaou S, Kirkpatrick AW, Campbell MR, Billica RD, 

Dawson D, Williams DR, Melton SL, Beck G, Forkheim K, Dulchavsky SA Ultrasound 

evaluation of the magnitude of pneumothorax: a new concept, Am Surg 2001:67(3):232-5. 

Pneumothorax is commonly seen in trauma patients; the diagnosis is confirmed by 

radiography. The use of ultrasound where radiographic capabilities are absent is being 

investigated by NASA. We investigated the ability of ultrasound to assess the 

magnitude of pneumothorax in a porcine model. Sonography was performed on 

anesthetized pigs in both ground-based laboratory (n = 5) and microgravity conditions 

(zero g) aboard the KC-135 aircraft during parabolic flight (n = 4). Aliquots of air (50–

100 cm3

) were introduced into the chest to simulate pneumothorax. Results were 

videotaped and digitized for later interpretation. Several distinct sonographic patterns of 

partial lung sliding were noted including the combination of a sliding zone with a still 

zone and a “segmented” sliding zone. These “partial lung sliding” patterns exclude 

massive pneumothorax manifested by a complete separation of the lung from the 

parietal pleura. In zero g, the sonographic picture is more diverse; one g differences 

between posterior and anterior aspects are diminished. Modest pneumothorax can be 

inferred by the ultrasound sign of “partial lung sliding.” This finding, which increases 

the negative predictive value of thoracic ultrasound, may be attributed to intermittent 

pleural contact, small air spaces, or alterations in pleural lubricant. Further studies of 

these phenomena are warranted. 

9. Marshburn TH, Legome E, Sargsyan AE, Melton SM, Li J, Noble VA, Dulchavsky SA, Sims 

C, Robinson D. Goal directed ultrasound in the detection of long-bone fractures. J. Trauma 

57(2):329-332, 2004. 

BACKGROUND: New portable US systems are capable of detecting fractures in the 

remote setting. However, the accuracy of ultrasound by physicians with minimal 

ultrasound training is unknown. METHODS: After one hour of standardized training, 

physicians with minimal US experience clinically evaluated patients presenting with 

pain and trauma to the upper arm or leg. The investigators then performed a long-bone 

US evaluation, recording their impression of fracture presence or absence. Results of 

the examination were compared with routine plain or computer-aided radiography 

(CT). RESULTS: 58 patients were examined. The sensitivity and specificity of US were 

92.9% and 83.3%, and of the physical examination were 78.6% and 90.0%, respectively. 

US provided improved sensitivity with less specificity compared with physical 

examination in the detection of fractures in long bones. CONCLUSION: US scans by 

minimally trained clinicians may be used to rule out a long-bone fracture in patients 

with a medium to low probability of fracture. 
48 

10. Hamilton, D.W., Sargsyan, A. , Nicolaou, S., Dulchavsky, S., Dawson, D., Kirkpatrick, A., 

Campbell, M., McDonald, V., Beck, G., and Melton, S.L. Remote diagnosis and treatment of 

illness and injury using ultrasound on the International Space Station. Telemedicine Journal 

and e-Health, 2001 Summer 7(2):131. 

11. Melton, S.L., Hamilton, D., Martin, D., and Sargsyan, A. Remote ultrasound diagnosis for 

the International Space Station. Telemedicine Journal and e-Health 2001 Summer 7(2):132. 

12. Kirkpatrick AW, Nicolaou S, Sargsyan AE, Melton S, Beck G, Hamilton DR, Campbell MR, 

Dulchavsky SA, Feiveson A, Dawson DL. Focused assessment with sonography for trauma 

in weightlessness. J Am Coll Surg 2003;196:833-844. 

BACKGROUND: The FAST searches for fluid in gravitationally dependent regions. 

There is no prior experience with this technique in weightlessness, such as on ISS, 

where sonography is currently the only diagnostic imaging tool. STUDY DESIGN: A 

ground-based (one-g) porcine model for sonography was developed. We examined both 

the feasibility and the comparative performance of the FAST examination in parabolic 

flight. Sonographic detection and fluid behavior were evaluated in four animals during 

alternating weightlessness (zero g) and hypergravity (1.8g) periods. During flight, 

boluses of fluid were incrementally introduced into the peritoneal cavity. Standardized 

sonographic windows were recorded. Postflight, the video recordings were divided into 

169 20-second segments for subsequent interpretation by 12 blinded ultrasonography 

experts. Reviewers first decided whether a video segment was of sufficient diagnostic 

quality to analyze (determinate). Determinate segments were then analyzed as 

containing or not containing fluid. A probit regression model compared the probability 

of a positive fluid diagnosis to actual fluid levels (0–500 ml) under both zero-g and 

1.8g conditions. RESULTS: The in-flight sonographers found real-time scanning and 

interpretation technically similar to that of terrestrial conditions, as long as restraint was 

maintained. On blinded review, 80% of the recorded ultrasound segments were 

considered determinate. The best sensitivity for diagnosis in zero g was found to be 

from the subhepatic space, with probability of a positive fluid diagnosis ranging from 9% 

(no fluid) to 51% (500 ml fluid). CONCLUSIONS: The FAST examination is 

technically feasible in weightlessness, and merits operational consideration for clinical 

contingencies in space. 

13. Kirkpatrick AQ, Nicolaou S, Campbell MR, Sargsyan AE, Dulchavsky SA, Melton S, Beck 

G, Dawson DL, Billica RD, Johnston SL, Hamilton DR. Percutaneous aspiration of intraperitoneal fluid in weightlessness: a potential component of the management of peritonitis in 

space. Aviat Space Environ Med 2002;73:925-930. 

BACKGROUND: As a medical emergency that can affect even well-screened, healthy 

individuals, peritonitis developing during a long-duration space exploration mission 

may dictate deviation from traditional clinical practice due to the absence of otherwise 

indicated surgical capabilities. Medical management can treat many intra-abdominal 

processes, but treatment failures are inevitable. In these circumstances, percutaneous 
49 

aspiration under sonographic guidance could provide a “rescue” strategy. Hypothesis: 

Sonographically guided percutaneous aspiration of intra-peritoneal fluid can be 

performed in microgravity. METHODS: Investigations were conducted in the 

microgravity environment of NASA’s KC-135 research aircraft (zero g). The subjects 

were anesthetized female Yorkshire pigs weighing 50 kg. The procedures were 

rehearsed in a terrestrial animal lab (one g). Colored saline (500 ml) was introduced 

through an intra-peritoneal catheter during flight. A high-definition ultrasound system 

(HDI-5000, ATL, Bothell, Wash.) was used to guide a 16-gauge needle into the 

peritoneal cavity to aspirate fluid. RESULTS: Intra-peritoneal fluid collections were 

easily identified, distinct from surrounding viscera, and on occasion became more 

obvious during weightless conditions. Subjectively, with adequate restraint of the 

subject and operators, the procedure was no more demanding than during the one-g 

rehearsals. CONCLUSIONS: Sonographically guided percutaneous aspiration of intraperitoneal fluid collections is feasible in weightlessness. Treatment of intra-abdominal 

inflammatory conditions in space flight might rely on pharmacological options, backed 

by sonographically guided percutaneous aspiration for the “rescue” of treatment 

failures. While this risk mitigation strategy cannot guarantee success, it may be the 

most practical option given severe resource limitations. 

14. Chun R, Kirkpatrick AW, Sirois M, Sargsyan AE, Melton S, Peng; Hamilton DR, 

Dulchavsky SA. Where’s the Tube? Evaluation of Hand-held Ultrasound in Confirming 

Endotracheal Tube Placement. Prehopsital and Disaster Medicine, 2004; 19(4):366-369. 

INTRODUCTION: The diagnosis of endotracheal tube (ETT) mal-position may be 

delayed in extreme environments. Several methods are used to confirm proper ETT 

placement, but these methods can be unreliable or unavailable in certain settings. 

Thoracic sonography, previously used to detect pneumothoraces, has not been tested to 

assess ETT placement. HYPOTHESIS: Thoracic sonography could correlate with 

pulmonary ventilation and, thereby, help to confirm proper ETT placement. 

METHODS: Thirteen patients requiring elective intubation under general anesthesia 

and data from two trauma patients were evaluated. Using a portable, hand-held 

ultrasound (PHHU) machine, sonographic recordings of the chest wall visceral-parietal 

pleural interface (VPPI) were recorded bilaterally in each patient during all phases of 

airway management: (1) pre-oxygenation; (2) induction; (3) paralysis; (4) intubation; 

and (5) ventilation. RESULTS: The VPPI could be well-imaged for all of the patients. 

In the two trauma patients, right main stem intubations were noted in which specific 

pleural signals were not seen in the left chest wall VPPI after tube placement. These 

signs returned after correct repositioning of the ETT. In all of the elective surgery 

patients, signs correlating with bilateral ventilation in each patient were imaged and 

correlated with confirmation of ETT placement by anesthesiology. CONCLUSIONS:

This report raises the possibility that thoracic sonography may be another tool that 

could be used to confirm proper ETT placement. This technique may have merit in 

extreme environments, such as in remote, pre-hospital settings or during aerospace 

medical transports, in which auscultation is impossible due to noise, or capnography is 

not available, and, thus, requires further scientific evaluation. 
50 

15. McFarlin K, Sargsyan AE, Melton S, Hamilton DR, Dulchavsky SA. A surgeon's guide to 

the universe. Surgery. 2006 May;139(5):587-90. 

16. Kirkpatrick AW, Dulchavsky SA, Boulanger BR, Campbell MR, Hamilton DR, Dawson DL, 

Williams DR. Extraterrestrial resuscitation of hemorrhagic shock: fluids. J Trauma. 2001 

Jan;50(1):162-8. 

17. Kirkpatrick AW, Campbell MR, Jones JA, Broderick TJ, Ball CG, McBeth PB, McSwain 

NE, Hamilton DR, Holcomb JB. Extraterrestrial hemorrhage control: terrestrial 

developments in technique, technology, and philosophy with applicability to traumatic 

hemorrhage control in long-duration spaceflight. J Am Coll Surg. 2005 Jan;200(1):64-76. 

18. Sarkisian (Sargsyan) AE, Khondkarian RA, Amirbekian NM, Bagdasarian NB, Khojayan 

RL, Oganesian YT. Sonographic screening of mass casualties for abdominal and renal 

injuries following the 1988 Armenian earthquake. J Trauma. 1991 Feb;31(2):247-50. 

The value of sonography in acute trauma evaluation is generally underestimated, and 

the opinions are controversial. Sonography was performed as a primary screening 

procedure in 400 of 750 mass casualty patients with trauma admitted to a large hospital 

within the first 72 hours after the 1988 Armenian earthquake. Two real-time sector 

scanners were used in the reception area of the hospital, and the average time spent on 

one patient was 4 minutes. More than 130 follow-up sonographic examinations were 

required. Trauma-associated pathology of the abdomen and retroperitoneal space was 

detected in 12.8% of the patients, with 1% false negatives and no false positives. The 

authors believe that sonographic screening of mass casualties is a quick and effective 

means for detection of abdominal and retroperitoneal injuries. Sonography should be 

used for this purpose more routinely to gain experience and maintain preparedness of 

sonographers for screening of trauma cases in mass casualty situations. 

19. Houtchens BA, Clemmer TP, Holloway HC, Kiselev AA, Logan JS, Merrell RC, 

Nicogossian AE, Nikogossian HA, Rayman RB, Sarkisian (Sargsyan) AE, et al. 

Telemedicine and international disaster response. Medical consultation to Armenia and 

Russia via a Telemedicine Spacebridge. Prehospital Disaster Med. 1993 Jan-Mar;8(1):57-66. 

The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four 

U.S. and two Armenian and Russian medical centers, permitted remote U.S. consultants 

to assist Armenian and Russian physicians in the management of medical problems 

following the December 1988 earthquake in Armenia and the June 1989 gas explosion 

near Ufa. Methods: During 12 weeks of operations, 247 Armenian and Russian and 

175 U.S. medical professionals participated in 34 half-day clinical conferences. A total 

of 209 patients were discussed, requiring expertise in 20 specialty areas. Results:

Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies 

for 70, altered diagnostic processes for 47, and modified treatment plans for 47 of 185 

Armenian patients presented. Simultaneous participation of several U.S. medical 

centers was judged beneficial; quality of data transmission was judged excellent. 

Conclusion: These results suggest that interactive consultation by remote specialists 
51 

can provide valuable assistance to on-site physicians and favorably influence clinical 

decisions in the aftermath of major disasters. 

20. A. E. Sargsyan, C. R. Doarn, and S. C. Simmons. Internet and World Wide Web 

Technologies for Medical Data Management and Remote Access to Clinical Expertise. Aviat 

Space Environ Med. 1999 Feb;70(2):185-90. 

21. Aucar JA, Doarn CR, Sargsyan A, Samuelson DA, Odonnell MJ, DeBakey ME. Use of the 

Internet for long-term clinical follow-up. Telemed J. 1998 Winter;4(4):371-4. 

Use of the Internet for patient-specific consultation across international boundaries has 

been demonstrated. This report describes the efforts of Baylor College of Medicine and 

NASA to conduct a telemedicine consultation with Moscow, Russia. Consultation 

between Russian and U.S. physicians was performed over the Internet with a 

combination of real-time and store-and-forward techniques. The clinical focus involved 

a 65-year old Russian scientist who had undergone mitral valve replacement in the U.S. 

5 years earlier. Development of new activity related chest pain, dyspnea, and 

intermittent atrial fibrillation led to a consultation with his U.S. cardiologist and cardiac 

surgeon. Real-time video was supplemented with telephone voice communication to 

overcome bandwidth limitations. Prior to the video link, the patient’s recent history and 

clinical data were made available via the Internet using file transfer protocol (FTP). The 

patient’s medications, new electrocardiographic findings, and activity status were 

reviewed. Specific clinical recommendations were made as a result of this telemedicine 

consultation. This case illustrates the technical factors, clinical implications, and 

confidentiality issues related to using the Internet for telemedicine consultations and 

demonstrates that the Internet may provide an alternative means for long-term clinical 

follow-up of patients. 

22. Beck G, Melton S, Dulchavsky SA. Critical care medicine in space. Aviat Space Environ 

Med. 2005 Feb;76(2):163. 

OTHER PUBLICATIONS BY AUTHORS

BOOK CHAPTERS

1. Hamilton DR. Chapter: Cardiovascular disease. In: Principles of Clinical Medicine for Space 

Flight. Barratt MR , Pool SL (Eds.). Springer Verlag; in press (2006). 

2. Sargsyan AE. Chapter: Medical Imaging. In: Principles of Clinical Medicine for Space 

Flight. Barratt MR , Pool SL (Eds.). Springer Verlag; in press (2006). 

3. Simmoms SC, Hamilton DR, McDonald PV. Chapter: Telemedicine. In: Principles of 

Clinical Medicine for Space Flight. Barratt MR , Pool SL (Eds.). Springer Verlag; in press 

(2006). 

4. Billica, RD, Voronkov, YI, Sargsyan AE, and Voronin, LE. Medical Monitoring Before and 

After Flight. In: Space Biology and Medicine, A. Nicogossian et al. (Ed.),Vol. 4: Health, 

Performance and Safety of Space Crews. pp. 43-59. 
52 

NASA PUBLICATIONS

1. Sargsyan A, Melton S, Hurst V, Martin D. Evaluation of Human Factors, Interfaces, and 

Remote Guidance Techniques for Collection of Ultrasound Images in Microgravity, NASA 

CR 208932, KC-135 and Other Microgravity Simulations Summary Report, NASA Aug 

2002. 

2. Melton S, Sargsyan A, Martin D, Hamilton D, Moghaddam A. Measuring Fluid Shifts in the 

Vascular System with Ultrasound During Parabolic Flight. NASA CR 208936, KC-135 and 

Other Microgravity Simulations Summary Report, NASA, Aug 2003. 

3. Melton SL, Sargsyan AE: Evaluation of Human Research Facility Ultrasound with the ISS 

Video system. NASA Technical Publication 2003-212056. 

4. Dulchavsky S, Sargsyan A, Melton S, Hamilton D, Beck G. Minimally Invasive Diagnosis 

and Therapy of Microgravity Medical Contingencies. NASA CR 208940, KC-135 and Other 

Microgravity Simulations Summary Report, NASA, Aug 2004. 

SELECTED PRESENTATIONS

1. A.E. Sargsyan, S.A. Dulchavsky, J.A. Jones, D.R. Hamilton, S.K. Roden, S.L. Melton, D. 

Martin, K. Garcia, J.M. Duncan. Abdominal Imaging with Ultrasound on the International 

Space Station. AsMA 77th Annual Scientific Meeting, May 14-18, 2006, Orlando, Fla. In: 

AsMA 2006 Meeting Abstracts, Aviation, Space, and Environmental Medicine, 2006 March, 

77(3), p.277 

2. K. McFarlin, A.E. Sargsyan, S.L. Melton, D.R. Hamilton, S.A. Dulchavsky. Non-Physician 

Thoracic Ultrasound for Trauma. AsMA 77th Annual Scientific Meeting, May 14-18, 2006, 

Orlando, Fla. In: AsMA 2006 Meeting Abstracts, Aviation, Space, and Environmental 

Medicine, 2006 March, 77(3), p.230. 

3. A.E. Sargsyan, S.A. Dulchavsky, D.R. Hamilton, S.K. Roden, S.L. Melton, D. Martin, K. 

Garcia, J.M. Duncan. Mulculoskeletal Diagnostic Imaging with Ultrasound on the 

International Space Station. AsMA 77th Annual Scientific Meeting, May 14-18, 2006, 

Orlando, Fla. In: AsMA 2006 Meeting Abstracts, Aviation, Space, and Environmental 

Medicine, 2006 March, 77(3), p.334. 

4. D.R. Hamilton, J. Polk, C. Van Velson, B. Temple, M. Christensen, and H. Better. “Sim as 

you fly and fly as you sim” debrief of an ISS medical deorbit simulation. AsMA 77th Annual 

Scientific Meeting, May 14-18, 2006, Orlando, Fla. In: AsMA 2006 Meeting Abstracts, 

Aviation, Space, and Environmental Medicine, 2006 March, 77(3), p.276. 

5. J.A. Jones, D.R. Hamilton, and R.A. Scheuring. CEV/Lunar medical contingency 

management and medical care systems. AsMA 77th Annual Scientific Meeting, May 14-18, 

2006, Orlando, Fla. In: AsMA 2006 Meeting Abstracts, Aviation, Space, and Environmental 

Medicine, 2006 March, 77(3), p.284-5. 

6. Ashot Sargsyan, M.D., Wyle Life Sciences: Ultrasound Imaging Aboard the ISS: A Review 

of Experience to Date. In: UTMB/JSC Aerospace Medicine Residency Program Space 

Medicine Grand Rounds, Houston, Texas, July 26, 2005: 

http://www.dsls.usra.edu/archive_2005.html (Cat.A PRA CME lecture by University of 

Texas Medical Branch (UTMB)). 
53 

7. Ashot E. Sargsyan, M.D. and Douglas W. Hamilton, M.D., Ph.D. Wyle Laboratories Life 

Sciences Systems & Services: Diagnostic Ultrasound Imaging in Space. In: UTMB/JSC 

Aerospace Medicine Residency Program Space Medicine Grand Rounds, Houston, Texas, 

October 24, 2000, http://www.dsls.usra.edu/archive_2000.html (Cat A CME lecture by 

UTMB). 

8. Ashot E. Sargsyan Diagnostic Ultrasound Imaging on ISS: A Review of Today’s Capability. 

Aerospace Medicine Grand Rounds, Baylor College of Medicine, Houston, Texas, NASA 

Lyndon B. Johnson Space Center Aug 29, 2005 (Cat A CME lecture by the Baylor College 

of Medicine). 

9. Melton, S., Jones, J., Hamilton, D., Meir, J., Hurst, V., Sargsyan, A. Activation and checkout 

of the Human Research Facility (HRF) Ultrasound for Medical Contingencies on the 

International Space Station (ISS) Bulletin of Aerospace Medicine Association 74th Annual 

Scientific Meeting San Antonio, Texas, May 5, 2003. 

10. Sargsyan, A., Hamilton, D., Jones, J., Martin, D., Whitson, P., Melton, S. Clinical capability 

enhancement with diagnostic ultrasound imaging aboard the International Space Station 

(ISS) Bulletin of Aerospace Medicine Association 74th Annual Scientific Meeting San 

Antonio, Texas, May 7, 2003. 

11. Jones, J., Sargsyan, A., Whitson, P., Melton, S., Martin, D., Hamilton, D. Development of 

imaging protocols for in-flight screening of genitourinary diseases on the International Space 

Station (ISS) Bulletin of Aerospace Medicine Association 74th Annual Scientific Meeting 

San Antonio, Texas, May 7, 2003. 

12. Sargsyan, A., Jones, J., Hamilton, D., Martin, D., Whitson, P. Melton, S., Logan, J. 

“Development of Diagnostic Imaging Capability for the International Space Station (ISS) 

and Implications for Future Spaceflight” Bulletin of the 14th International Academy of 

Astronautics- Humans in Space Symposium: Living in Space: Scientific, Medical, and 

Cultural Implications Banff, Alberta, Canada, May 21, 2003. 

13. Sargsyan A.E., Dulchavsky S.A., Jones J.A., Hamilton D. R., Kirkpatrick A.W. Development 

of Imaging Algorithms on ISS for the Diagnosis of Surgical Conditions. Presented AsMA 

annual meeting 2004, Aviation, Space and Environmental Medicine, suppl. 75(4) section II, 

#251: B54 April 2004. 

14. Hamilton, D.W., Sargsyan, A. , Nicolaou, S., Dulchavsky, S., Dawson, D., Kirkpatrick, A., 

Campbell, M., McDonald, V., Beck, G., and Melton, S.L. Remote diagnosis and treatment of 

illness and injury using ultrasound on the International Space Station (Slide presentation): 

American Telemedicine Association Sixth Annual Meeting, June 3-6, 2001, Florida 

Convention Center, Fort Lauderdale, Fla. 

15. Melton, S.L., Hamilton, D., Martin, D., and Sargsyan, A. Remote ultrasound diagnosis for 

the International Space Station. (Slide presentation): American Telemedicine Association 

Sixth Annual Meeting, June 3-6, 2001, Florida Convention Center, Fort Lauderdale, Fla. 

OTHER RELEVANT PUBLICATIONS

1. Jones, J.A., Johnston, S., Campbell, M., Billica, R.: Endoscopic Surgery and Telemedicine In 

Microgravity, Developing Contingency Procedures for Exploratory Class Space Flight. 

Urology 53(5); 1999, pp. 892-897 
54 

2. Johnston, S., Jones, J.A., Campbell, M.: The use of parabolic flights to evaluate new 

microgravity techniques in advanced cardiac life support, endoscopic surgery, ventilation 

support, crew medical restraint, defibrillation, crew medical officer training and 

physiological monitoring. NASA/JSC document 28318- KC-135 and Other Microgravity 

Simulations Summary Report of the Space and Life Sciences Directorate, Medical Sciences 

Division. Aug 1, 1998. 

3. Summers RL, Martin DS, Meck JV, Coleman TG. Mechanism of spaceflight-induced 

changes in left ventricular mass. Am J Cardiol. 2005 May 1;95(9):1128-30. 

4. Arbeille P, Ruiz J, Ayoub J, Vieyres P, Porcher M, Boulay J, Moreau V, Poisson G. The 

robot and the satellite for tele-operating echographic examination in Earth isolated sites, or 

onboard ISS. 

J Gravit Physiol. 2004 Jul;11(2):P233-4. 

5. Hatfield TR, Klaus DM, Simske SJ. An ultrasonic methodology for muscle cross section 

measurement to support space flight. Microgravity Sci Technol. 2004;15(3):3-11. 

6. McCarthy ID. Fluid shifts due to microgravity and their effects on bone: a review of current 

knowledge. Ann Biomed Eng. 2005 Jan;33(1):95-103. Review. 

7. Lang T, LeBlanc A, Evans H, Lu Y, Genant H, Yu A. Cortical and trabecular bone mineral 

loss from the spine and hip in long-duration spaceflight. J Bone Miner Res. 2005 

Dec;20(12):2271-2; author reply 2273. 

8. Afonin BV, Noskov VB, Poliakov VV. The state of the digestive system organs during long 

space flight. Fiziol Cheloveka. 2003 Sep-Oct;29(5):53-7. (Russian) 

9. Vieyres P, Poisson G, Courreges F, Merigeaux O, Arbeille P. The TERESA project: from 

space research to ground tele-echography. Ind Rob. 2003;30(1):77-82. 

10. Arbeille P, Herault S, Roumy J, Porcher M, Besnard S, Vieyres P. 3D real-time echography 

and echography assisted by a robotic arm for investigating astronauts in the ISS from the 

ground. 

J Gravit Physiol. 2001 Jul;8(1):P143-4. 

11. Martin DS, South DA, Garcia KM, Arbeille P. Ultrasound in space. Ultrasound Med Biol. 

2003 Jan;29(1):1-12. Review. 

12. Arbeille P, Herault S, Roumy J, Porcher M, Besnard S, Vieyres P. 3D real-time echography 

and echography assisted by a robotic arm for investigating astronauts in the ISS from the 

ground. J Gravit Physiol. 2001 Jul;8(1):P143-4. 

13. Martin DS, South DA, Wood ML, Bungo MW, Meck JV. Comparison of echocardiographic 

changes after short- and long-duration spaceflight. Aviat Space Environ Med. 2002 

Jun;73(6):532-6. 

14. Mulvagh SL, Charles JB, Riddle JM, Rehbein TL, Bungo MW. Echocardiographic 

evaluation of the cardiovascular effects of short-duration spaceflight. J Clin Pharmacol. 1991 

Oct;31(10):1024-6. 

15. Nicogossian AE, Charles JB, Bungo MW, Leach-Huntoon CS Cardiovascular function in 

space flight. Acta Astronaut. 1991;24:323-8. 
55 

16. Hart R, Campbell MR. Digital radiography in space. Aviat Space Environ Med. 2002 

Jun;73(6):601-6. 

17. Afonin BV, Nichiporuk IA, Nesterov MA, Belousova IV. Ultrasonic research of abdominal 

organs in conditions of long-term antiorthostatic hypokinesia. J Gravit Physiol. 1998 

Jul;5(1):P121-2. 

18. Pourcelot L, Patat F, Defontaine M, Gregoire JM, Berson M. Microgravity.Ultrasound Med 

Biol. 2000 May;26 Suppl 1:S144-6. 

19. Herault S, Fomina G, Alferova I, Kotovskaya A, Poliakov V, Arbeille P. Cardiac, arterial 

and venous adaptation to weightlessness during 6-month MIR spaceflights with and without 

thigh cuffs (bracelets). Eur J Appl Physiol. 2000 Mar;81(5):384-90. 

20. Afonin BV, Nichiporuk IA, Nesterov MA, Pechenkina RA, Goncharova NP, Belousova IV. 

[Results of studies of carbohydrate metabolism and ultrasonography of the pancreas in man 

after continuous anti-orthostatic hypokinesia] Aviakosm Ekolog Med. 1999;33(4):23-8. 

Russian. 

21. Arbeille P, Fomina G, Sigaudo D, Alferova I, Porcher M, Boulay J, Gharib C. Monitoring of 

the cardiac and vascular response to LBNP during the 14 day spaceflight “Cassiopee.” J 

Gravit Physiol. 1997 Jul;4(2):P29-30. 

22. Arbeille P, Fomina G, Pottier J, Porcher M, Coulon J, Kotovskaya A, Poliakov V. Heart, 

and peripheral arteries and veins during the 14 month MIR space flight. J Gravit Physiol. 

1996 Sep;3(2):93-4. 

23. Videbaek R, Norsk P. Atrial distension in humans during weightlessness induced by 

parabolic flights. J Gravit Physiol. 1996 Sep;3(2):48-9. 

24. Arbeille P, Fomina G, Achaibou F, Pottier J, Kotovskaya A. Cardiac and vascular adaptation 

to 0g with and without thigh cuffs (Antares 14 and Altair 21 day Mir spaceflights). Acta 

Astronaut. 1995 Oct-Dec;36(8-12):753-62. 

25. Pasdeloup T, Mas M, Stevenin H. Remote assistance experiment during the manned space 

flight Altair. Acta Astronaut. 1995 Oct-Dec;36(8-12):625-8. 

26. Mulvagh SL, Charles JB, Riddle JM, Rehbein TL, Bungo MW. Echocardiographic 

evaluation of the cardiovascular effects of short-duration spaceflight. J Clin Pharmacol. 1991 

Oct;31(10):1024-6. 

27. Atkov OYu, Bednenko VS, Fomina GA. Ultrasound techniques in space medicine. Aviat 

Space Environ Med. 1987 Sep;58(9 Pt 2):A69-73. 

28. Bungo MW, Goldwater DJ, Popp RL, Sandler H. Echocardiographic evaluation of space 

shuttle crewmembers. J Appl Physiol. 1987 Jan;62(1):278-83. 

29. Bystrov VV, Zhernavkov AF, Savilov AA. [Human cardiac activity during the 1st hours and 

days of exposure to antiorthostatic hypokinesia (according to the results of 

echocardiography)] Kosm Biol Aviakosm Med. 1986 Mar-Apr;20(2):42-6. Russian. 

30. Pourcelot L, Pottier JM, Arbeille P, Patat F, Berson M, Roncin A, Le Toullec C, Guell A, 

Gharib C. [Cardiovascular function in astronauts (Mission STG 51 G--June 1985)] Bull Acad 

Natl Med. 1986 Mar;170(3-4):341-4. French. No abstract available. 
56 

31. Pottier JM, Patat F, Arbeille P, Pourcelot L, Massabuau P, Guell A, Gharib C. 

Cardiovascular system and microgravity simulation and inflight results. Acta Astronaut. 1986 

Jan;13(1):47-51. 

32. At'kov OIu. [Cardiovascular function of the cosmonauts on a long-term orbital flight] Biull 

Vsesoiuznogo Kardiol Nauchn Tsentra AMN SSSR. 1985;8(2):97-100. Russian. 

33. Bednenko VS, Kozlov AN. [Ultrasonic Doppler-cardiography as a method of study of 

cardiodynamics during flight based on patent and information analysis] Kosm Biol 

Aviakosm Med. 1983;17:4-8. Review. Russian. 

34. Charles JB, Bungo MW. Cardiovascular research in space: considerations for the design of 

the human research facility of the United States Space Station. Aviat Space Environ Med. 

1986 Oct;57(10 Pt 1):1000-5. 

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 December 2006 Technical Paper 

4. TITLE AND SUBTITLE 5. FUNDING NUMBERS

The International Space Station Ultrasound Imaging Capability Overview for Prospective 

Users 

 

6. AUTHOR(S) 

Ashot E. Sargsyan, Douglas R. Hamilton, Shannon L. Melton, Jeffrey Young 

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REPORT NUMBERS

Wyle Labs, Life Sciences Group, Lyndon B. Johnson Space Center 

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S-989 

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13. ABSTRACT (Maximum 200 words)

The feasibility of ultrasonic imaging in human space flight has been demonstrated on NASA and Russian spacecraft. Several 

ultrasound systems have been successfully operated by both physician and non-physician astronauts and cosmonauts in preInternational Space Station (ISS) space flights, yielding valuable scientific information. A multipurpose ultrasound system was

adapted for space and installed aboard ISS to continue human research in microgravity environments at a new level of sophistication 

and fidelity. Alone or in combination with other components of the Human Research Facility (HRF), this system provides a research 

capability never before available in space. The system can operate in B, M, Color Doppler, Power Angiography, Flow Propagation,

Pulsed Spectral Doppler, and Continuous Wave Doppler modes and their combinations. Thus, the HRF Ultrasound System allows the 

realization of the great scientific potential of ultrasound imaging in conditions of space flight, acquiring morphological/morphometric 

and physiological/functional information from virtually every area or organ system of the human body. This will now allow ultrasound 

to be used in space for medical risk mitigation and has driven the medical concept of operations to recognize and treat as many

medical conditions as possible while on orbit, delaying or avoiding return to a definitive medical care facility. 

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medical equipment; telemedicine; risk; clinical medicine, patients; microgravity 

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