Space Medicine

CHAPTER 25

SPACE MEDICINE

George A Martin, M.D.

INTRODUCTION

For over thirty-five years the National Aeronautics and Space Administration (NASA), has carefully managed our initial sojourn into the "Final Frontier". This arduous and precarious trek has presented mankind with its most formidable, and hostile scientific challenge. In return, we have all benefited immensely from all of the new information, the many discoveries and technological achievements, and the incalculable value of the vast number of applications garnered from these efforts.

Thus far, through this the initial stage of space exploration, man has adapted remarkably well to microgravity and the many other challenges encountered in the extraterrestrial environment. This early stage of manned space operations has necessarily consisted of relatively brief encounters by small numbers of the most healthy subjects. They have been enclosed in small crafts, for relatively short periods of time, performing exhaustively rehearsed finite tasks. These strict operational parameters have intentionally decreased the probability of inflight medical contingencies.

Yet NASA has from the beginning understood the importance of health and medical issues, and how they impact upon the mission. Accordingly, exhaustive amounts of time, resources, and research have been expended towards understanding, preventing, and combating the medical sequelae of spaceflight.

The realm of Space Medicine has evolved significantly since the early days of manned spaceflight when its sole purpose was that of protecting man in his initial exposures to space. Through extensive basic and applied research activities, clinical studies, and inflight investigations, NASA is attempting to predict, prevent, and if necessary, provide treatment regimens for the potential operational health hazards. Considerable emphasis is also placed upon health maintenance of crew members, and to the development of countermeasures to prevent crew deconditioning, illness, and injury. The Life Sciences Division of NASA has evolved into a multi-disciplinary program which utilizes resources and researchers from all fifty states, and from around the world.

HISTORY OF SPACE MEDICINE

Thus far, space medicine has been defined and associated almost exclusively as a branch of aerospace medicine. This is only natural because the beginnings of space medicine were tied closely to aerospace medicine and its' practitioners. After World War II and the development of the V-2 rocket, aerospace medicine specialists began seriously considering the possible problems associated with spaceflight.

In 1948, Colonel Harry Armstrong of the Air Force School of Aviation Medicine, organized a meeting to discuss the "Aeromedical Problems of Space Travel".(70) Then in 1949, a Department of Space Medicine was created at the School of Aviation Medicine at Randolph AFB. Dr. Hubertus Strughold was selected as the director of the new department.(19) Dr. Strughold had come to the U.S. after World War II. He had taught in a number of universities in Germany, and was a colleague of Dr. Wernher Von Braun. Dr. Strughold is credited with predicting many of the medical problems to be encountered in microgravity, and he has received international recognition as the "Father" of space medicine.(28)

By 1950, the U.S. had already launched a few primates into space on board V-2 rockets. None of the first primate space travelers survived these tests, due to operational failures including the parachutes. However, these launches provided useful information regarding the hazards of spaceflight and served to increase interest in the scientific community in the possibilities of manned spaceflight.(5)

In the same year a number of aerospace medicine physicians petitioned the Aeromedical Association to form a Space Medicine Branch in order to exchange information and discuss research topics. In 1951 the petition was granted and the Space Medicine Branch came into being.(46)

Many projects related to space medicine were begun in the early 1950s by the Air Force and Navy Schools of Aviation Medicine, including studies related to life support, acceleration and deceleration tolerances, and reaction to confinement. The majority of these researchers were flight surgeons who had been trained in aviation medicine programs. The military programs as well as their civilian counterparts at Harvard, Johns Hopkins and Ohio State University, changed their curriculums and names to reflect the new orientation to "Aerospace" Medicine.

By 1958, Sputnik had orbited and the space race between the U.S.S.R. and the U.S. had begun. The National Research Council Committee on Bioastronautics had identified a number of potential medical hazards associated with "weightlessness" and spaceflight. The thirty projected medical problems included anorexia, nausea, inability to swallow food, disorientation, weight loss and hallucinations. Many of these problems have been actually encountered, while others were disproved.

Later in 1958, a working group was formed to study human factors and nonmilitary biomedical requirements for spaceflight, as well as other biological factors that should be part of a national space program.(32) Shortly after its creation in 1958, NASA selected a number of Air Force Flight Surgeons to help participate in the selection and medical testing of the first astronauts.(5)

The newly formed NASA at first had three flight surgeons assigned to its Space Task Group. Dr. Stan White and Dr. Bill Douglas both of the Air Force, and Dr. Charles Berry a civilian (former Air Force). These three were the first NASA flight surgeons and they served as the original seven astronauts' physicians.(27) They were joined in 1960, by a total of 28 other aeromedical physicians who were selected as medical monitors for the Mercury Project.

The rather frantic pace of space related activities during the late 1950s, and early 1960s left very little time for strict adherence to standard scientific methods of research and data acquisition. Instead the development of operational space medicine was based on lessons learned from occupational and aviation medicine experience. Insight into the physiologic and medical problems of spaceflight as well as issues of life support, crew safety, and crew health, were necessarily generated more from mission results than from bench research conducted in ground-based laboratories.

In preparation for the Mercury flights these early space medicine practitioners developed the core of knowledge, methods, procedures, and biomedical equipment which would define this early period of the specialty. Their early efforts were directed at primarily preventive measures, but they established the core of procedures and programs which still stand today as the foundations for the "practice" of space medicine.

The early concerns related to space medicine where primarily of an operational nature. Table 25-1 presents a summary of many of the early operational concerns which formed the nucleus of early space medicine efforts. Foremost among these problems was establishing the medical selection criteria for astronauts. These medical criteria were particularly critical as astronauts would be primary datapoints to establish human responses during spaceflight. In the end, most of the criteria was taken directly from those used in military aviation.

The greatest problems were in the design of fail-safe life support and monitoring systems. Engineers, biomedical scientists, and physicians were required to provide a reliable system which would afford protection from the environmental extremes of space, insure proper atmospheric content and pressure, include the provision of food and water, and monitor and remove all potential metabolic or toxicologic by-products. All of these systems also had to conform to the severe size, weight, and power constraints inherent in the launch vehicle.

Much like the U.S. manned spaceflight program itself, advances in our space medicine knowledge and practice have gone through an incremental progression, which proceeds from lessons learned in successive launches. Although there are relatively vast numbers of laboratory and microgravity simulations analogues in use today throughout the world, and researchers from nearly all medical specialties are participating in space medicine studies, much of the procedures and protocols in use in the operational setting are still garnered from inflight experiences.

Ironically, despite all of the medical advances, technological equipment, space medicine diversification and specialization, practitioners in this specialty are still mainly concerned with the operational concerns first elucidated by the early aerospace medicine flight surgeons.

Table 25-1. Space Medicine Operational Concerns

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1. Selection and retention of the astronaut:

a. Establishing the medical standards for the selection and retention of astronauts.

2. Support to the astronaut:

a. Identifying and studying the physiological stresses of spaceflight through ground-based and in-flight experiments.

b. Developing a biomedical knowledge and database capable of predicting and appraising man's ability to function in space during progressively longer duration missions.

c. Providing medical supervision, biomedical indoctrination, and familiarization to the astronaut training programs.

d. Implementing medical protocols for support of launch, landing, rescue, and contingency operations of manned space missions.

e. Providing for any necessary pre, post, and inflight medical care for crew members.

f. Evaluating the medical results of human space missions.

3. Life support systems of the spacecraft:

a. Providing reliable biomedical inputs for the design of the spacecraft and all life support systems.

b. Developing means for protection of the terrestrial environment from back contamination of extraterrestrial origin.

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Space Medicine in the U.S. Manned Space Program

NASA, and the entire United States Manned Spaceflight Program have gone through gradual stages of development. Each successive manned program extended the previous experiences by investigating new parameters and testing required procedures. There were short-duration flights before longer ones, single person crews before multiple crew members, and various other instances of incremental application of experience and knowledge previously gained.

The formal approval of Project Mercury by NASA was on October 7, 1958, with its' mission "to send a man into orbit, investigate his capabilities and reactions in space, and return him safely to Earth...".(32) NASA accomplished this goal with great success. It took less than three years for the U.S. to launch its' first astronaut into space. Project Mercury did indeed prove the ability of humans to survive in space for at least short durations. The program lasted from May, 1961 to May, 1963, and consisted of two suborbital flights, followed by four orbital missions. The last mission lasted thirty-four hours and accomplished twenty-two Earth orbits.

The six Mercury astronauts had returned intact and in satisfactory condition. NASA had provided the astronauts with an environment in which they could survive and perform effectively, and then had recovered them safely. These early flights were just as valuable for dispelling many of the projected medical concerns as they were for verifying a few of the others. Weight loss caused primarily from dehydration did occur. On the final mission, orthostatic intolerance, dizziness as well as hemoconcentration were documented.

Encouraged by the successes of Project Mercury, the acknowledged goal set forth by President John F. Kennedy in 1961 was to land a human being on the Moon before the decade was over. NASA, driven by the rush to put a human being on the Moon, began Project Gemini with increased objectives and capability.

These missions built upon the experience gained from Project Mercury and developed long duration, docking, control and extra-vehicular activity procedures. The ten two-man Gemini missions (Gemini-3 through Gemini-12), from March 1965 to November 1966, led to the medical conclusion that humans could survive, live, and work in space for at least fourteen days. This was as long as would be required for a lunar mission. Significant medical findings from the Gemini missions included loss of red cell mass (5-20% from baseline); continued universal post-flight orthostatic intolerance; loss of bone density in the os calcis (up to 7% from baseline); sustained loss of bone calcium and muscle nitrogen; and higher then expected metabolic rates and fatigue during spacewalks, or extravehicular activity (EVA).(46) Gemini answered some medical questions and left others unresolved.

Next came the eleven three-man Apollo missions (7-17), of the Apollo Lunar Landing Program that were launched between October 1968 and December 1972. They followed the singular goal of landing a human on the Moon and returning him safely to Earth. This was accomplished less than a year after the first manned flight test of the Apollo vehicle. Six of these missions put a total of twelve people on the Moon by 1972.

Neurovestibular disturbances and Space Motion Sickness were among the many medical observations from the Apollo Program. Other significant findings of Apollo included sub-clinical problems like arrhythmias and decreased nutritional balance, as well as clinically significant problems, such as URIs, rashes, dehydration, UTIs, and continued postflight orthostasis.(21)

The Skylab Project, which followed the Apollo program, was used to learn more about human responses to the space environment. Three Skylab missions were accomplished from 1973 to 1974, and the longest of these was for 84 days. They contributed a vast amount of information on human beings in space. The Skylab data sets were particularly useful in differentiating self-limiting physiological changes from those that continue throughout exposure to weightlessness. It was postulated at that time, that the cardiovascular, pulmonary, neurosensory, fluid and electrolyte, immune and hematological changes all stabilized at some point, where as the musculoskeletal changes exhibited progressive deterioration.(49)

Unfortunately, much of the space medicine data which we have today relies heavily on the Skylab information garnered back in 1975. Many of the same conditions in Apollo were confirmed from the Skylab series.

The Space Transportation System (STS), or Shuttle, is the next step in our space program. This system utilizes a reusable orbiter that lands on a runway rather than splashing down at sea.. It is a near-Earth investigational platform that can be utilized by many different organizations, civilian as well as military, for multiple purposes including the launching of satellites.

Also with the introduction of the STS program, separate crew positions and duties dictated the necessity for developing separate medical standards. These separate NASA positions were defined as Pilot/Astronaut (the pilot/commander crew member); Mission Specialist (a versatile crew member trained to manage the systems of the Shuttle and participate in all of the various payloads experiments and projects); and the Payload Specialist (a scientist temporarily assigned to handle a specific experimental payload on a single flight, not a career astronaut).(41)

Although mission specialists must adhere to most of the same medical standards as the pilot astronauts, the payload specialists are held to less rigorous standards. This enabled regular citizens to fly into space for the first time. It also serves to increase the possibility of a medical contingency occurring in space.

The USAF's involvement and commitment to the United States Spaceflight Program grew with the formation of the US Space Command in 1982. To support these military space programs, a second space Shuttle launch complex was built at Vandenberg AFB, California, for launching vehicles into polar orbits. To complement this, a new control facility, dedicated for DOD missions or for mixed payload missions with the presence of military members, was built at Colorado Springs, Colorado. The Air Force also created a position, the Mission Spaceflight Engineer, that was similar to a mission specialist but was to be utilized for management of dedicated Department of Defense (DOD) payloads.

The first launch was planned for 1985, but because of changes and delays and then the Challenger disaster, planning for STS launches from Vandenberg AFB has been put on indefinite hold and the facility at Vandenberg mothballed. Likewise, the USAF crew position of Mission Spaceflight Engineer has also been placed on indefinite hold.

The Shuttle era has revolutionized space exploration and utilization. There have been over 60 flights over the past 14 years. Hundreds of men and women have flown in space, performing all types of missions. Satellites have been released, repaired, and returned. There have been two missions dedicated solely to life sciences research, and nearly every mission contains life science experiments. Much new information has been accumulated and many new innovations have been utilized to help curb some of the medical maladies associated with spaceflight. Yet, many of the same biomedical problems which plagued the early programs remained unresolved today.

Space Medicine Today

Space medicine today is a very diverse field. There are many different schools of thought as to its' proper place in the medical world. It is complicated by the fact there are numerous researchers, scientists, and physicians from very different specialties who are doing space medicine related activities. To date, the vast majority of research in space medicine is concerned with the many physiologic changes which the human body experiences when exposed to microgravity. The clinical practice of space medicine has been comparatively limited, and with a few notable exceptions, has been the domain and practice of the aerospace medicine specialist. The primary operational focus still remains on prevention of medical problems, and insuring crew health and well being.