21 April 2000
Features - Habitat (None)
Paramedics in Space
by Peter Wainwright
by Michelle Mackay

The year is 2010 and you've just settled in for a long winter's vacation at the trendiest hot spot this side of the moon. It's a pricey break from your daily grind, but after seeing the Grand Tetons, visiting the seven wonders and riding the surf at various world resorts, the thrill of gravity based adventure has grown old quickly. Reaching into your suitcase, you pull out your camera and look around at the blackness punctuated by a few points of light. Feeling dizzy, you grab the safety bar located just below your viewing portal. You're nauseated and sweaty, not to mention stuffed up. But that's par for the course in Zero G. Shaking the feeling, you marvel at God's heavens, all the while rubbing distractedly at your chest. It was fine when you left earth, but now it feels as if your heart might climb out of your chest. Your skin is clammy and cold and a channel of perspiration is steadily streaming from your brow. You're having a heart attack. It's time to call the paramedics.

As early as 1975, NASA began toying with the idea as commercial space travel. Envisioning one scenario with a wheel shaped space station that housed 10,000 colonists, the dream is day by day inching closer to reality. The days of the physically fit astronaut specimen are waning;the era of the couch potato space traveller is about to begin. And just as with ordinary earth communities, a greater populace brings with it a broader spectrum of illness, both chronic and emergency. Heart attacks, strokes, decompression incidents and trauma are just some of the conditions which emergency medical practitioners will face in space. Whereas once evacuation, accomplished over a period of hours, may have been the preferred treatment modality for situations in space requiring immediate medical attention, the option is not feasible when larger populations are involved.

Today the United States space program's emergency response is framed largely around telemedicine. On earth the technology is beginning to catch on too. The United States Navy, for example, makes use of telemedicine by using experts at one location to screen patients on board ships at sea. The information is transmitted via satellite between the two locales. In space, while nearby colonies might benefit from such measures, distant exploration to planets in the outer galaxy or even someday in other galaxies could see this strategy become unworkable. By their very nature, medical emergencies are time dependent. Often mere seconds make a difference in patient survival. The precious minutes lost evaluating a condition via telemedicine could mean the patient's very life. Paramedics, therefore, skilled in rapid triage and treatment, are a necessary progression in the provision of emergency medical care.

How then would prehospital care work in space? To better understand the answer, one need only look to the earth model of tiered response. A popular concept embraced by many emergency medical providers, the theory is especially salient for rural outposts, where emergency calls can occur at great distances from appropriate treatment facilities. The paramedic, therefore, is the bridge between the initial trauma and more extensive care at the hands of medical specialists. The front line providers, the chain of survival begins with first responders (FRs) attending the scene, followed by a basic life support (BLS) crew and/or a paramedic team. While FRs initially assess and attempt to stabilize the patient through such procedures as Cardio Pulmonary Resuscitation (CPR) and semi automatic external defibrillation (SAED), BLS providers and paramedics complete more detailed assessments. For more serious conditions or injuries, the paramedic can provide front line cardiac drugs, manual defibrillation, intubation, and medicate for symptom relief. Scene down times are kept at a minimum and rapid transport is undertaken when emergency medical care can't be provided on scene.

Rapid response and treatment in space will remain elusive due to the environment the emergency takes place in. Zero gravity robs the individual of fluid movement. Cumbersome space suits complicate the problem of immediate medical care, particularly on planet surfaces or outside space stations, as any compromising of the suit's shell results in rapid decompression and death. Still the necessity for treating traumatic injuries or life threatening conditions in a fast and efficient manner remains.

Dr. Martin McNamara is both a former paramedic and a current emergency physician in Ontario, Canada. Not a space specialist, he has extensively studied emergency medical service delivery throughout Canada and the United States. Although cautious on the role paramedics would immediately play in the space environment, he said he believes colonization of space will, of necessity, have to include some provision for prehospital care.

"Due to the environment, most situations would have to be "load and go", McNamara said. "The only exceptions would be where this wouldn't be practical, as in when the patient was hours away from a care facility. In this case, paramedics would have to have small, portable, fully equipped shelters in which the patient could be disrobed and cared for.

"Cases involving infections, decompression etc, would also necessitate a broader scope of standing orders than are currently available. I liken this environment to that of the far north or of rural Australia. The rules are, by necessity, different. Air ambulance officers in northern Ontario in the 1980s often performed skills they were not mandated to do, only because it had to be done and no one else was semi qualified to do it. Paramedics, when it can be accomplished, could be taught to do surgical procedures like appendectomies, Incision and Drainage with distance instructions via telecommunications or audio visual prompts."

The handbook governing prehospital care would, in effect, need to be rewritten. Necessary though the role of the paramedic is in space, the hurdles are daunting. Like an upside down world, few of the rules governing the profession on earth apply in the zero gravity environment. While experiments on the KC-135 parabolic flight plane have proven certain procedures, such as the insertion of endotracheal tubes (ETs) and mechanical ventilation, can be performed, others common skills done by paramedics are considerably more tricky. CPR, for example, would require both the paramedic and the patients to occupy restraints, possibly made of velcro, to ensure proper land marking on the chest. A device known as The Thumper could be strapped on to the chest for cardiac compressions. Controlling bleeding, which is accomplished in earth applications in part through elevation would not apply, since one can not elevate a bleed above the level of the heart in the zero g of space where there is no up or down.

In some cases, NASA and other cooperating research and development agencies have compensated for the difficult environment where gravity no longer rules. Intravenous lines are one example. Pressure pumps, which use a microgravity air trap to eliminate deadly air bubbles, are one example. The Baroneckcuff blood pressure (BP) monitor is another. In the latter, electronically controlled positive or negative pressure is applied to the carotid arteries on either side of the neck to affect heart rate, as well as blood pressure. The device can be used to determine blood pressure or to adjust it.

Still for all the recent developments, a very important aspect of the paramedic's job has yet to be effectively worked out for space. The administration of drugs, whether to assist in symptom relief or to attempt to convert a condition such as a heart arrhythmia, is an uncertain thing in zero G. While conditions like chest pain may prompt a paramedic to administer a thrombolytic or blood thinner like aspirin or a vasodilator like nitro, the treatment modality in space is far less clear. Other condition treatments are equally murky. It is questionable, for example, whether a Ventolin face mask, which dilates the bronchi, would perform properly. Without gravity, the liquid medication would not sit in the bottom of the nebulizer chamber.

"We're only now starting to sort out how microgravity effects pharmacokinetics or what the body does to a drug and pharmacodynamics or what the drug does to the body," Dr. Tom Czarnik said. "The short answer is nobody knows. But drugs given orally have much more unpredictable levels, and hence effects, than drugs given by intramuscular injection (IM)."

Czarnik is in his second residency in Aerospace Medicine at Wright State University. He is also the Chair of the Ohio Chapter of the Mars Society. A former Ohio paramedic of three years, he also functioned as an emergency medical technician (EMT) for four. The author of the paper, Medical Emergencies In Space, he has examined how the human body reacts to the space environment. In his paper, Physiological Changes in Space flight That May Affect Drug Action, Czarnik notes that the space environment changes the very process by which a drug is broken down by the body. Whether when it is dissolved in the stomach, emptied into the small intestine, moving through the bloodstream or binding to an adequate receptor site, the substance's normal process is altered by a lack of gravity.

Like a never ending maze, EMS in space is equally hampered by some of the apparently less bothersome maladies. Common annoyances such as the little understood space sickness and the nasal congestion associated with fluid accumulation in the head and sinuses can cloud accurate diagnoses with the tools currently available to earth practitioners. With infection fighting white blood cell lymphocytes less active in space and antibodies fewer in number during longer missions, it is not hard to see how grave illnesses can develop. Infections, which are mostly aerobic in nature on earth, will become largely anaerobic in zero atmosphere, all the more so if body parts are exposed. In addition, hypertension could become worse. Daunting, but not completely discouraging, some serious conditions could actually improve. Patients suffering from Class IV heart failure, for example, might greatly benefit from the lack of gravity in space. For damaged or dead heart pumps, the stressful process of pumping blood would become considerably alleviated in an atmosphere where gravity no longer rules. Wealthy clientele could, therefore, patronize space health resorts in the interest of easing a pained existence or prolonging one which might have halted considerably sooner on earth.

Hurdles though there may be, the field of paramedicine is uniquely suited to adapt itself to the future needs of space. The youngster among the allied health professions, EMS has progressed from being largely run by funeral services to a highly skilled discipline with ever increasing educational demands. This remarkable journey has, for the most part, taken place during a period of just over 25 years. By their very nature, paramedics must quickly assess new, and often rugged, environments and adjust accordingly. Change in the emergency medical field is constant. Unlike medical doctors, these jacks of all trades, are not hampered by being pigeon holed into one specialty and do not command the hefty fees of their physician counterparts. When all these factors are considered, it doubtful that a better plan for emergency medical service provision in space can be discerned. With commercialization and colonization, the paramedic may be a pioneer who boldly goes where no man has gone before when it comes to medical emergencies in space.
Source: Michelle Makay, Paramedic Network News

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Peter Wainwright 21 April 2000
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