photo courtesy of NASA
The View from Space
Two astronauts provide an inside look into the rewards and challenges of space research. By Leslie Mertz
W
ant the real scoop on doing research in space? Ask someone who’s been there. Two astronauts—Joe Kerwin, M.D., who was on the first manned mission to the U.S. Skylab space station, and Jerry Linenger, M.D., Ph.D., who spent nearly five months on the USSR’s space station Mir—recently spent time with IEEE Pulse to provide a unique and candid look at space-based biomedical research over the years, and they shared their perspectives on why such research is vital to future manned missions as well as improved health on Earth.
Digital Object Identifier 10.1109/MPUL.2014.2321213 Date of publication: 14 July 2014
24 ieee pulse ▼ july/august 2014
Joe Kerwin, Skylab Science Pilot, 1973 A year after U.S. President John F. Kennedy announced his intent in 1961 to land a man on the moon, Joe Kerwin earned his wings as a Navy pilot after already having earned his M.D. degree in 1957. Then, in 1965, he joined NASA as a scientist– astronaut and was swept up in the race to the moon. One of his many contributions was his role as commander of the Apollo Block II test command service module, a land-based simulation of a spacecraft in flight. The module was basically a vacuum chamber on a rotating platform that was bathed in the light of ultrabright lamps to replicate the brutal heat of the sun. As commander of the module, Kerwin was sealed inside with two other astronauts (Vance Brand and Joe Engle) as part of a test to help clear the way for Apollo 7. The module test was a
2154-2287/14©2014IEEE
They had to do that in a hurry, and they were success, and shortly afterward, Apollo 7 carried very successful. Of course, the data we were lookthe first U.S. astronauts into space orbit. Apollo 7 “It’s a fantastic feeling ing at from those flights were pretty basic stuff. For was a stepping-stone to Apollo 11, which set the to be able to do flips instance, “His heart rate is increasing, he must be first human on the moon in 1969. and 200 somersaults pretty excited.” (Laughs.) But nonetheless, it was Kerwin’s most publicized achievement, howin a row, but you medical telemetry, and it was the first step forward ever, came in 1973 as science pilot for the misdo pay a price, and in building an intensive care unit (in hospitals here sion to board the United States’ first space station, part of that price is on Earth). It was great to be in at the beginning Skylab, which had been launched just a few days of that. earlier (Figure 1). Kerwin, spacecraft commander muscle atrophy and IEEE Pulse: How much human moniCharles Conrad, Jr., and pilot Paul J. Weitz spent bone loss.” toring was done before Skylab? almost a month on Skylab and safely returned to Kerwin: There just wasn’t enough weight Earth on 22 June. It was on Skylab that Kerwin allowance or room to carry experimental equipment, and there had a chance to participate in biomedical experimentation. wasn’t enough time to train the crew. In addition, the crew IEEE Pulse: Drawing on your background as both an wasn’t too enthusiastic about having their bodies monitored durastronaut and a medical doctor, (see “Law in Space”), how ing the flight. As a result, much of the data came from exams has our understanding changed with regard to the effects that the doctors did on the crews before and after the flights. For of space travel on humans? all of the real questions about the physiology of weightlessness, Kerwin: At the beginning, going into space with human we had to wait until we had a space station. beings was something totally new. There was a great deal of specIEEE Pulse: How did Skylab change things? ulation about the consequences of weightlessness on the human Kerwin: Skylab was a very big, voluminous spacecraft with body, including medical journal articles that forecasted all sorts of lots of weight, lots of room, an excellent suite of experiments, dreadful things happening, so the challenge was great (Figure 2). but still not much in terms of telemetry. On the other hand, we Once the space program began with Mercury, Gemini, and didn’t really need it because we could take the data in flight, then Apollo, we had some problems to overcome. One was that store it, and bring it home with us. nobody knew how to telemeter medical data, so NASA engineers IEEE Pulse: What were some of the biomedical data and contractors had to work out how to put the electrodes on a you collected on board Skylab? human being to measure pulse, heart rate, respiration, and elecKerwin: We had vector cardiography, which was a 12-lead trocardiogram, and then get that data conditioned in the right electrocardiogram—no big deal, but it had good electrodes and voltage so that it could be added to the communications data— allowed a good collection of data. We also performed sleep the downlink—coming down to Earth from the spacecraft.
Law in Space When explorers lead the way, can the lawyers be far behind? The question of how to practice medicine in space is as old, if not older, then man’s exploration itself. The International Space Station (ISS) is a permanent residence for multiple nationalities. Although those who are selected as astronauts and cosmonauts are generally in peak physical condition, accidents will happen, and there will be unexpected medical events. In fact, these have already occurred. Apollo 13 almost had a catastrophic ending; not only as a result of the equipment disaster, but also as a result of one of the crew members developing sepsis toward the end of the flight. Dental emergencies have also arisen. In fact, Dr. Joe Kerwin performed an early documented medical intervention in space when he performed a full dental evaluation on his crewmember, Commander Pete Conrad, in Skylab in 1973 (see Figure 2). The prevention of medical illness in space has occupied the thought of all the international space agencies. In fact, there has been reasoned debate about the advisability of performing prophylactic surgery to remove unnecessary organs that might provide complications in deep space travel far from home. The argument here is that with minimally invasive surgery ubiquitous, prophylactic surgery under controlled conditions is substantially less risky than the situation where diseases would have to be managed far from Earth’s orbit. But there is no surgery without risk, and what if a complication ensues when the surgery was medically unnecessary?
Robotic intervention short-circuits the issue of adequacy of astronaut training. But it brings with it even more complications, some of them with legal implications. The international treaty governing the ISS is clear that each country’s module is operated under its own laws. In the United States, for example, the ISS has been designated a National Laboratory since the enactment of the 2005 NASA Authorization Act. This may affect how liability clams may be reviewed because physicians licensed to practice in any state can practice in a federal health care facility. It is therefore possible that as states increase their legal oversight of professional licensure with the use of telemedicine, those laws could affect the ability of a physician to practice robotic surgery on a patient on the ISS. But what of commercial space flight, and how about medical complications that may ensue in the practice of robotic surgery? Informed consent may not be enough. These are among the fascinating legal questions that arise as humans escape many of the confines of Earth, many of which we have yet to explore. Arthur Dula is a space lawyer, a patent attorney, the literary executor for major science fiction author Robert A. Heinlein, and chair and founder of the private spaceflight company Excalibur Almaz. Sheryl Tatar Dacso is a partner with the firm Seyfarth Shaw, LLP, and certified by the Board of Legal Specialization in Health Law.
july/august 2014 ▼ ieee pulse 25
FIGURE 1 In orbit aboard Skylab in 1973, science pilot Joe Kerwin, M.D., blows water through a straw in zero gravity and creates perfectly spherical droplets. Kerwin not only was part of the initial manned crew to Skylab, the first U.S. space station, but he was also involved in the station’s design and development. (Photo courtesy of NASA.)
electroencephalography, which showed that we slept about an hour less than on Earth but had all four phases (Figure 3); we collected blood once a week for postflight determinations of hormone levels, especially stress-related ones, and red-cell mass; and I tested out “doctor’s office” equipment, including blood counts and differentials. We also measured muscle strength and endurance (arms and legs) pre- and postflight. For exerciseresponse data, we had a bicycle ergometer and a spirometer to measure inspired and expired gas volumes, but the real development here was an in-flight mass spectrometer to take the gas from the spirometer and measure very accurately the oxygen, nitrogen, and carbon dioxide concentrations. That allowed us to develop metabolic rate as a function of time and workload to compare in-flight data to baseline. This was very important, because guys were coming back from space flight weak, having
(a)
FIGURE 2 With great speculation about the effects of zero gravity on the human body, much of the early experiments conducted in orbit involved careful monitoring of the astronaut’s health. Here, in-orbit weightlessness allows Kerwin (left) a rather unique vantage point while performing an oral physical examination of Skylab 2 Commander Charles Conrad, Jr. A piece of paper floats away at right, but Conrad stays in place with a restraining strap attached to his left thigh. (Photo by Skylab 2 pilot Paul J. Weitz and used courtesy of NASA.)
lost a pint or two of blood and 6–8 lb of weight, with most of it in the lower extremities. Then, we had an experiment that sounds pretty harmless: mineral balance. What it was, however, was a complete intake and output quantitative measurement experiment never before done outside of a hospital ward. The purpose was to collect information to figure out why astronauts were losing muscle and bone mass while they were in space. For this experiment, we were required to characterize everything that we ate; mass measure everything that was in the package but didn’t get eaten or drunk; collect our urine for 24 hours and then take a carefully shaken-up sample and freeze it, and bring the samples back at the end of the flight; and for feces, freeze-dry it and bring it all back. Using these
(b)
FIGURE 3 (a) Strapped into the sleep restraint aboard Skylab, Kerwin wears an instrumented cap for a sleep monitoring experiment. The experiment monitors electrical activity in the brain (electroencephalography) to evaluate the quantity and quality of sleep during prolonged space flight. (b) When Linenger went to orbit aboard Mir more than two decades later, he also donned an instrumented cap to monitor brain activity. In a ddition, both men slept with sensors attached to their eyelids to record rapid eye movements, another measurement of sleep quality. (Photos courtesy of NASA.) 26 ieee pulse ▼ july/august 2014
nutritional parameters, they could then tell if the loss in muscle and bone mass was related to a drop in calcium or protein. The mineral-balance experiment was actually a son of a gun to design. It was extremely frustrating for the contractors to come up with a system that permitted a high degree of accuracy but was still operable by the crew in less than two or three hours a day, but they ended up doing a good job of biomedical engineering to pull that off. IEEE Pulse: What challenges were involved in that? Kerwin: For one thing, they had to come up with the weightless equivalent of bathroom scales that could measure small masses, such as the unused food, as well as large masses. This was done by Dr. Bill Thornton, a very creative engineer who was also a flight surgeon and eventually became an astronaut. What he did was design a device with a strip of stainless steel that was firmly attached to a base and free at the other end. If you FIGURE 4 Nearly 50 years after NASA originally selected Kerwin flipped the free end, the steel strip would vibrate. The frequency to become a scientist–astronaut, he maintains his enthusiasm of that vibration was dependent on the mass at the tip of that about the importance of benefits of space exploration and strip of steel: the heavier the weight, the slower the frequency. experimentation. (Photo courtesy of NASA.) That was pretty cool. IEEE Pulse: Were there any surprises that came out of some really large forces—and they do minimize bone loss, it’s the experiments? still a concern, especially as we go from six-months’ duration Kerwin: We were surprised by the human vestibular experiin space to experimentally a year. (A one-year mission on the ment, which measured your motion-sickness threshold and how International Space Station is planned for 2015.) that changed in weightlessness. The attempt was to measure your IEEE Pulse: When did biomedical e xperimentation begin threshold without actually crossing it and barfing. So imagine yourexpanding beyond human health in weightlessness? self sitting in your chair and having it rotate at about 10 r/min, and, Kerwin: It started coming in during the space shuttle era, at the same time, to the beat of a metronome, you have to move before we built the International Space Station (ISS). In the late your head forward and up, to the right and up, back and up, left and 1980s or early 1990s, NASA had been flying the shuttle for a up, and keep on doing that until you have done 150 head moveweek to ten days but saw that they could go to 16, possibly even ments or until you get sick. We tried that out preflight once and 21 days, without making any major changes to went to the researcher in Pensacola and objected systems. That opened up possibilities of not only strenuously. He told us we could back off once we looking at human biomedical problems but also got to malaise 2A, which was a certain set of symp“Skylab was a very examining other organic and inorganic systoms that you got before you actually got sick. big, voluminous tems. At about that time, the European Space The surprise came when we did the experispacecraft with lots of Agency developed and delivered to NASA what ment on the space station. We discovered, to weight, lots of room, they called the Space Lab, which was a module my absolute amazement, that we couldn’t get an excellent suite of that went into the cargo bay of the shuttle and motion sickness to that degree in weightlessness, provided a large increase in volume and also in even after doing the full 150 head movements. experiments, but still electrical power and computer resources for perAnd after we were in space for five days, we had not much in terms forming other experiments. This was the begincompletely acclimatized to the environment. So of telemetry.” ning of real opportunities. overall, that experiment was a very nifty job of IEEE Pulse: Even after a nearly 50-year biomedical engineering with an important negcareer, first with NASA and later with ative result. NASA contractors, you continue to be passionate about IEEE Pulse: Were most of the experiments done on space (Figure 4). What is it about space that has kept you Skylab health related? involved? Kerwin: The principal goals of Skylab were to determine Kerwin: I read science fiction as a kid, and I thought space how long people can live and function in weightlessness, was a fascinating concept—the idea that you might be able to go whether they can do science while they’re up there, and what off the Earth and into space. That I was actually able to do that accommodations are necessary to keep the astronauts healthy. In as a young adult was mind-blowing. How lucky I was to be alive that third category, we found that although we returned to Earth when I was! So it’s a combination of that and the feeling that this healthy, we had, in fact, lost a lot of strength in our arms and was not only a great adventure for an individual but also that this legs, and the bicycle ergometer was not enough. We needed more is something of national importance, that working out the space and different kinds of exercise in space. That’s still true today. problems, and getting better at it, and making it routine are good Although astronauts now have much better resistive exercise things to do. We still don’t have all the answers, but we do our devices—a zero-gravity equivalent of weightlifting that delivers july/august 2014 ▼ ieee pulse 27
It has limits. Other physiological changes happen, too, but the body adapts and things level out. Bone loss, however, is a straight Jerry Linenger, upward line: you just keep losU.S. Astronaut/ ing bone the whole time you’re Mir Cosmonaut, 1997 up there. Your body basically In 1997, astronaut Jerry looks at your bone like an overLinenger spent 132 consecbuilt I-beam and starts remodelutive days orbiting approxiing it, getting rid of excess load, mately 240 mi above the Earth and dumping the calcium from aboard the Russian space the bone into the blood. Actustation Mir (Figure 5). Durally, a couple of Russian cosmoing that time, he and the two nauts have passed renal stones cosmonauts that made up because they’re hypercalcemic. the crew survived a number IEEE Pulse: One of your of very close calls, including objectives on Mir was to repeated system failures, comfind ways to reduce the plete electrical power outages amount of bone loss. What that not only enveloped the did you do? crew in total darkness but Linenger: The way that we also left them tumbling out of tried to counter that was with control through space at some exercise that put stress on the 17,800 mi/h, and a raging bones. I did two one-hour perifire that spewed blinding and ods of exercise a day. I mainly choking smoke and threatened used a treadmill (Figure 6). the station itself. I used a 70-kg plate and a windAlthough he finally surfer harness, and that would returned safely to Earth, yank me down so it felt as if I Linenger was left with yet FIGURE 5 Linenger floats in Mir’s Priroda module. He and his had a person on my shoulders, another challenge: to recover two cosmonaut crewmates mainly conducted remote-sensing experiments in this module. In all, Mir spent 15 years in orbit and then I’d run at different physically from space travel. (1986–2001) and served as the laboratory for some 23,000 scienspeeds. Toward the end of my This battle, which would con- tific and medical experiments. (Photo courtesy of NASA.) time in space, I added bungee tinue for many months—much cords (to the treadmill apparalonger than his five-month Mir tus), and I would also do squats and whatever else I could think voyage—was perhaps the most difficult hurdle, and one that of to concentrate on the weight-bearing areas of the hip, lower could waylay future long-term space travel. He spoke with IEEE spine, and the head of the femur. Pulse about this obstacle and the additional everyday challenges IEEE Pulse: How well did that work? he encountered while conducting scientific experiments, scramLinenger: Before I went to space, I tried to be in as good bling to preserve their miniature ecosystem, and trying to maina shape as I could be so that I could use that as a baseline to tain his own physical condition aboard a cramped, cluttered, and see what the differential was between preflight and postflight relentlessly demanding space station. and also what recovery time I needed to get back to 100%. IEEE Pulse: What was the greatest physical challenge As it turned out, my bone loss from preflight to postflight of the weightlessness of space? was 13%. I was very disappointed and almost shocked when Linenger: One of the things I could never convey enough— I found out I had that much bone loss, because I worked to and you just have to be there to understand it—is that it is effortprevent it. less in space. If I wanted to go from here to the end of the room, IEEE Pulse: Is this amount of bone loss typical? it literally takes this. (Linenger points to the opposite side of the Linenger: It’s hard to say. There’s a lot of individual variaroom about 30 ft away, touches a finger to the wall next to him, tion—one astronaut had just 6%, for instance—and there are not and barely pushes off.) It’s a fantastic feeling to be able to do flips that many people who go to space, so there’s really not enough and 200 somersaults in a row, but you do pay a price, and part of of a sample number to make statistically significant conclusions. that price is muscle atrophy and bone loss. That’s one of the reasons astronauts are asked to volunteer for That bone loss is something that’s still a possible showstopper every medical study they can. when you’re thinking about long missions in space. Most physiOne year after my return, I had cut the bone loss down to ological measures dampen out over time, but not bone loss. When about 7% in the hips and lower spine, and, at the two-year you go up into space, for instance, you grow a little bit as your interpoint, the bone loss was about 2%. Of course, it’s hard to tell vertebral spaces and discs fill. You get about an inch taller on the what my bone would have lost from normal aging, so I think first day, and, by the second, you’re two inches taller, but that’s all. best. And that’s worth spending your career on.
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that 2% loss is acceptable after many of those experiments, five months in space. what other things should IEEE Pulse: Since bone the designers of such experloss was a major issue for you iments take into account? during your five months in Linenger: It’s a mentally space, how will that impact taxing thing to do experiments extended space travel, such that you know are valuable, as travel to Mars, where the and to do them for scientists astronauts will be exposed around the world who you to weightlessness for an know are waiting for those even longer time? results. It’s a lot on your shoulLinenger: Going to Mars ders when you’re up there by will include an approximately yourself with an experiment six-month transit to get there, that you trained on many a stay for about a year, and months earlier, and usually then another six months to get without any feedback about back. The vehicle itself will be FIGURE 6 As a consequence of prolonged space travel, astronauts whether you executed it corsmall, so there will be weight lose muscle and bone mass. This has led to the development rectly until you get back down of numerous countermeasures, including exercise equipconstraints, which means there ment designed for a microgravity environment. Taken before to Earth. So if I’m a designer won’t be room for large tread- astronaut Jerry Linenger went up to the Mir space station in of any of these experiments, I mills and bicycle ergometers. 1997, this photo shows Linenger trying out a treadmill during would work in as much redunThat does not look good as far an 11-day mission aboard the space shuttle Discovery in 1994. dancy as possible, harden it While on Mir, he spent two hours a day exercising. Despite the as bone loss goes during the work, he still returned to Earth with 13% bone loss. (Photo couragainst radiation if I can, and transit. The good news is that tesy of NASA.) add self-correcting mechanisms Mars is (about 39% of) Earth’s in case the software does get gravity, so the astronauts may polluted by radiation hits. not lose more once they’re there. IEEE Pulse: With all of the challenges, IEEE Pulse: Are there other concerns including some of them being near-fatal “The principal goals about travel to Mars? catastrophes, do you miss it? Would you go of Skylab were to Linenger: Radiation is a major problem back to space? determine how for the human being, with higher cancer risk Linenger: Obviously, there were close calls long people can as the main issue. Personally, my cumulative when we were up there: a fire, loss of power, live and function radiation level is beyond the lifetime accufailing life-support systems, a collision with an in weightlessness, mulation of a nuclear worker, so if my odds of unmanned cargo ship. And then there were just getting cancer were one in a million preflight, the normal things, like launch, landing, and the whether they can do they’re now, say, one in 10,000. And that dynamic processes where you’ve got to have science while they’re changes depending on your orbit. If you’re up data and input going in split seconds, and it’s up there, and what higher, say 340 mi doing a Hubble Space Telegot to be exactly right or you could be dead. accommodations are scope repair, you’re outside the Van Allen belt, You might call that harrowing, but to me, it’s a necessary to keep the so you have less radiation protection, espemiraculous thing, and such a privilege to be sitastronauts healthy.” cially from solar events that emit a lot more ting in a spacecraft that can do what it’s doing. radiation hits and heavy nuclei. The fact that human beings have figured out the The same is true for the electronics. Radiacorrect way to bring together the electronics, tion hits can cause computer bit flips (a 1 becoming a 0, or vice the computer systems, the feedback, the control surfaces, and versa), and you can get up to 30 a day just by increasing your everything else is just incredible. altitude and getting outside of the Van Allen belt. If that comAbout whether I’d go back, I’ve got four kids, but they’re getputer is getting bombarded, eventually you get a bit flip that is ting older, and one’s going off to college. So, yes, at some point, I significant. As a result, computers have to have self-correcting would still love to go. programs to be able to detect them and to be able to reboot. In IEEE Pulse: On a Mars mission? fact, there are typically five computers working aboard a space Linenger: When my family’s grown, I think I’d sign up for vehicle. If one goes out of whack, the other four eliminate it that one. It was fantastic going to space: a great experience that I and then (the ousted computer) tries to reboot and catch back have in my back pocket. up. And sometimes a radiation hit can actually take the comLeslie Mertz ([email protected]) is a freelance science, medical, and puter down. technical writer, author, and educator living in northern Michigan. IEEE Pulse: Radiation could also, then, be an issue for in-space experiments that have electronic components. From your perspective as an astronaut who has conducted july/august 2014 ▼ ieee pulse 29
The View from Space
Two astronauts provide an inside look into the rewards and challenges of space research. By Leslie Mertz
W
ant the real scoop on doing research in space? Ask someone who’s been there. Two astronauts—Joe Kerwin, M.D., who was on the first manned mission to the U.S. Skylab space station, and Jerry Linenger, M.D., Ph.D., who spent nearly five months on the USSR’s space station Mir—recently spent time with IEEE Pulse to provide a unique and candid look at space-based biomedical research over the years, and they shared their perspectives on why such research is vital to future manned missions as well as improved health on Earth.
Digital Object Identifier 10.1109/MPUL.2014.2321213 Date of publication: 14 July 2014
24 ieee pulse ▼ july/august 2014
Joe Kerwin, Skylab Science Pilot, 1973 A year after U.S. President John F. Kennedy announced his intent in 1961 to land a man on the moon, Joe Kerwin earned his wings as a Navy pilot after already having earned his M.D. degree in 1957. Then, in 1965, he joined NASA as a scientist– astronaut and was swept up in the race to the moon. One of his many contributions was his role as commander of the Apollo Block II test command service module, a land-based simulation of a spacecraft in flight. The module was basically a vacuum chamber on a rotating platform that was bathed in the light of ultrabright lamps to replicate the brutal heat of the sun. As commander of the module, Kerwin was sealed inside with two other astronauts (Vance Brand and Joe Engle) as part of a test to help clear the way for Apollo 7. The module test was a
2154-2287/14©2014IEEE
They had to do that in a hurry, and they were success, and shortly afterward, Apollo 7 carried very successful. Of course, the data we were lookthe first U.S. astronauts into space orbit. Apollo 7 “It’s a fantastic feeling ing at from those flights were pretty basic stuff. For was a stepping-stone to Apollo 11, which set the to be able to do flips instance, “His heart rate is increasing, he must be first human on the moon in 1969. and 200 somersaults pretty excited.” (Laughs.) But nonetheless, it was Kerwin’s most publicized achievement, howin a row, but you medical telemetry, and it was the first step forward ever, came in 1973 as science pilot for the misdo pay a price, and in building an intensive care unit (in hospitals here sion to board the United States’ first space station, part of that price is on Earth). It was great to be in at the beginning Skylab, which had been launched just a few days of that. earlier (Figure 1). Kerwin, spacecraft commander muscle atrophy and IEEE Pulse: How much human moniCharles Conrad, Jr., and pilot Paul J. Weitz spent bone loss.” toring was done before Skylab? almost a month on Skylab and safely returned to Kerwin: There just wasn’t enough weight Earth on 22 June. It was on Skylab that Kerwin allowance or room to carry experimental equipment, and there had a chance to participate in biomedical experimentation. wasn’t enough time to train the crew. In addition, the crew IEEE Pulse: Drawing on your background as both an wasn’t too enthusiastic about having their bodies monitored durastronaut and a medical doctor, (see “Law in Space”), how ing the flight. As a result, much of the data came from exams has our understanding changed with regard to the effects that the doctors did on the crews before and after the flights. For of space travel on humans? all of the real questions about the physiology of weightlessness, Kerwin: At the beginning, going into space with human we had to wait until we had a space station. beings was something totally new. There was a great deal of specIEEE Pulse: How did Skylab change things? ulation about the consequences of weightlessness on the human Kerwin: Skylab was a very big, voluminous spacecraft with body, including medical journal articles that forecasted all sorts of lots of weight, lots of room, an excellent suite of experiments, dreadful things happening, so the challenge was great (Figure 2). but still not much in terms of telemetry. On the other hand, we Once the space program began with Mercury, Gemini, and didn’t really need it because we could take the data in flight, then Apollo, we had some problems to overcome. One was that store it, and bring it home with us. nobody knew how to telemeter medical data, so NASA engineers IEEE Pulse: What were some of the biomedical data and contractors had to work out how to put the electrodes on a you collected on board Skylab? human being to measure pulse, heart rate, respiration, and elecKerwin: We had vector cardiography, which was a 12-lead trocardiogram, and then get that data conditioned in the right electrocardiogram—no big deal, but it had good electrodes and voltage so that it could be added to the communications data— allowed a good collection of data. We also performed sleep the downlink—coming down to Earth from the spacecraft.
Law in Space When explorers lead the way, can the lawyers be far behind? The question of how to practice medicine in space is as old, if not older, then man’s exploration itself. The International Space Station (ISS) is a permanent residence for multiple nationalities. Although those who are selected as astronauts and cosmonauts are generally in peak physical condition, accidents will happen, and there will be unexpected medical events. In fact, these have already occurred. Apollo 13 almost had a catastrophic ending; not only as a result of the equipment disaster, but also as a result of one of the crew members developing sepsis toward the end of the flight. Dental emergencies have also arisen. In fact, Dr. Joe Kerwin performed an early documented medical intervention in space when he performed a full dental evaluation on his crewmember, Commander Pete Conrad, in Skylab in 1973 (see Figure 2). The prevention of medical illness in space has occupied the thought of all the international space agencies. In fact, there has been reasoned debate about the advisability of performing prophylactic surgery to remove unnecessary organs that might provide complications in deep space travel far from home. The argument here is that with minimally invasive surgery ubiquitous, prophylactic surgery under controlled conditions is substantially less risky than the situation where diseases would have to be managed far from Earth’s orbit. But there is no surgery without risk, and what if a complication ensues when the surgery was medically unnecessary?
Robotic intervention short-circuits the issue of adequacy of astronaut training. But it brings with it even more complications, some of them with legal implications. The international treaty governing the ISS is clear that each country’s module is operated under its own laws. In the United States, for example, the ISS has been designated a National Laboratory since the enactment of the 2005 NASA Authorization Act. This may affect how liability clams may be reviewed because physicians licensed to practice in any state can practice in a federal health care facility. It is therefore possible that as states increase their legal oversight of professional licensure with the use of telemedicine, those laws could affect the ability of a physician to practice robotic surgery on a patient on the ISS. But what of commercial space flight, and how about medical complications that may ensue in the practice of robotic surgery? Informed consent may not be enough. These are among the fascinating legal questions that arise as humans escape many of the confines of Earth, many of which we have yet to explore. Arthur Dula is a space lawyer, a patent attorney, the literary executor for major science fiction author Robert A. Heinlein, and chair and founder of the private spaceflight company Excalibur Almaz. Sheryl Tatar Dacso is a partner with the firm Seyfarth Shaw, LLP, and certified by the Board of Legal Specialization in Health Law.
july/august 2014 ▼ ieee pulse 25
FIGURE 1 In orbit aboard Skylab in 1973, science pilot Joe Kerwin, M.D., blows water through a straw in zero gravity and creates perfectly spherical droplets. Kerwin not only was part of the initial manned crew to Skylab, the first U.S. space station, but he was also involved in the station’s design and development. (Photo courtesy of NASA.)
electroencephalography, which showed that we slept about an hour less than on Earth but had all four phases (Figure 3); we collected blood once a week for postflight determinations of hormone levels, especially stress-related ones, and red-cell mass; and I tested out “doctor’s office” equipment, including blood counts and differentials. We also measured muscle strength and endurance (arms and legs) pre- and postflight. For exerciseresponse data, we had a bicycle ergometer and a spirometer to measure inspired and expired gas volumes, but the real development here was an in-flight mass spectrometer to take the gas from the spirometer and measure very accurately the oxygen, nitrogen, and carbon dioxide concentrations. That allowed us to develop metabolic rate as a function of time and workload to compare in-flight data to baseline. This was very important, because guys were coming back from space flight weak, having
(a)
FIGURE 2 With great speculation about the effects of zero gravity on the human body, much of the early experiments conducted in orbit involved careful monitoring of the astronaut’s health. Here, in-orbit weightlessness allows Kerwin (left) a rather unique vantage point while performing an oral physical examination of Skylab 2 Commander Charles Conrad, Jr. A piece of paper floats away at right, but Conrad stays in place with a restraining strap attached to his left thigh. (Photo by Skylab 2 pilot Paul J. Weitz and used courtesy of NASA.)
lost a pint or two of blood and 6–8 lb of weight, with most of it in the lower extremities. Then, we had an experiment that sounds pretty harmless: mineral balance. What it was, however, was a complete intake and output quantitative measurement experiment never before done outside of a hospital ward. The purpose was to collect information to figure out why astronauts were losing muscle and bone mass while they were in space. For this experiment, we were required to characterize everything that we ate; mass measure everything that was in the package but didn’t get eaten or drunk; collect our urine for 24 hours and then take a carefully shaken-up sample and freeze it, and bring the samples back at the end of the flight; and for feces, freeze-dry it and bring it all back. Using these
(b)
FIGURE 3 (a) Strapped into the sleep restraint aboard Skylab, Kerwin wears an instrumented cap for a sleep monitoring experiment. The experiment monitors electrical activity in the brain (electroencephalography) to evaluate the quantity and quality of sleep during prolonged space flight. (b) When Linenger went to orbit aboard Mir more than two decades later, he also donned an instrumented cap to monitor brain activity. In a ddition, both men slept with sensors attached to their eyelids to record rapid eye movements, another measurement of sleep quality. (Photos courtesy of NASA.) 26 ieee pulse ▼ july/august 2014
nutritional parameters, they could then tell if the loss in muscle and bone mass was related to a drop in calcium or protein. The mineral-balance experiment was actually a son of a gun to design. It was extremely frustrating for the contractors to come up with a system that permitted a high degree of accuracy but was still operable by the crew in less than two or three hours a day, but they ended up doing a good job of biomedical engineering to pull that off. IEEE Pulse: What challenges were involved in that? Kerwin: For one thing, they had to come up with the weightless equivalent of bathroom scales that could measure small masses, such as the unused food, as well as large masses. This was done by Dr. Bill Thornton, a very creative engineer who was also a flight surgeon and eventually became an astronaut. What he did was design a device with a strip of stainless steel that was firmly attached to a base and free at the other end. If you FIGURE 4 Nearly 50 years after NASA originally selected Kerwin flipped the free end, the steel strip would vibrate. The frequency to become a scientist–astronaut, he maintains his enthusiasm of that vibration was dependent on the mass at the tip of that about the importance of benefits of space exploration and strip of steel: the heavier the weight, the slower the frequency. experimentation. (Photo courtesy of NASA.) That was pretty cool. IEEE Pulse: Were there any surprises that came out of some really large forces—and they do minimize bone loss, it’s the experiments? still a concern, especially as we go from six-months’ duration Kerwin: We were surprised by the human vestibular experiin space to experimentally a year. (A one-year mission on the ment, which measured your motion-sickness threshold and how International Space Station is planned for 2015.) that changed in weightlessness. The attempt was to measure your IEEE Pulse: When did biomedical e xperimentation begin threshold without actually crossing it and barfing. So imagine yourexpanding beyond human health in weightlessness? self sitting in your chair and having it rotate at about 10 r/min, and, Kerwin: It started coming in during the space shuttle era, at the same time, to the beat of a metronome, you have to move before we built the International Space Station (ISS). In the late your head forward and up, to the right and up, back and up, left and 1980s or early 1990s, NASA had been flying the shuttle for a up, and keep on doing that until you have done 150 head moveweek to ten days but saw that they could go to 16, possibly even ments or until you get sick. We tried that out preflight once and 21 days, without making any major changes to went to the researcher in Pensacola and objected systems. That opened up possibilities of not only strenuously. He told us we could back off once we looking at human biomedical problems but also got to malaise 2A, which was a certain set of symp“Skylab was a very examining other organic and inorganic systoms that you got before you actually got sick. big, voluminous tems. At about that time, the European Space The surprise came when we did the experispacecraft with lots of Agency developed and delivered to NASA what ment on the space station. We discovered, to weight, lots of room, they called the Space Lab, which was a module my absolute amazement, that we couldn’t get an excellent suite of that went into the cargo bay of the shuttle and motion sickness to that degree in weightlessness, provided a large increase in volume and also in even after doing the full 150 head movements. experiments, but still electrical power and computer resources for perAnd after we were in space for five days, we had not much in terms forming other experiments. This was the begincompletely acclimatized to the environment. So of telemetry.” ning of real opportunities. overall, that experiment was a very nifty job of IEEE Pulse: Even after a nearly 50-year biomedical engineering with an important negcareer, first with NASA and later with ative result. NASA contractors, you continue to be passionate about IEEE Pulse: Were most of the experiments done on space (Figure 4). What is it about space that has kept you Skylab health related? involved? Kerwin: The principal goals of Skylab were to determine Kerwin: I read science fiction as a kid, and I thought space how long people can live and function in weightlessness, was a fascinating concept—the idea that you might be able to go whether they can do science while they’re up there, and what off the Earth and into space. That I was actually able to do that accommodations are necessary to keep the astronauts healthy. In as a young adult was mind-blowing. How lucky I was to be alive that third category, we found that although we returned to Earth when I was! So it’s a combination of that and the feeling that this healthy, we had, in fact, lost a lot of strength in our arms and was not only a great adventure for an individual but also that this legs, and the bicycle ergometer was not enough. We needed more is something of national importance, that working out the space and different kinds of exercise in space. That’s still true today. problems, and getting better at it, and making it routine are good Although astronauts now have much better resistive exercise things to do. We still don’t have all the answers, but we do our devices—a zero-gravity equivalent of weightlifting that delivers july/august 2014 ▼ ieee pulse 27
It has limits. Other physiological changes happen, too, but the body adapts and things level out. Bone loss, however, is a straight Jerry Linenger, upward line: you just keep losU.S. Astronaut/ ing bone the whole time you’re Mir Cosmonaut, 1997 up there. Your body basically In 1997, astronaut Jerry looks at your bone like an overLinenger spent 132 consecbuilt I-beam and starts remodelutive days orbiting approxiing it, getting rid of excess load, mately 240 mi above the Earth and dumping the calcium from aboard the Russian space the bone into the blood. Actustation Mir (Figure 5). Durally, a couple of Russian cosmoing that time, he and the two nauts have passed renal stones cosmonauts that made up because they’re hypercalcemic. the crew survived a number IEEE Pulse: One of your of very close calls, including objectives on Mir was to repeated system failures, comfind ways to reduce the plete electrical power outages amount of bone loss. What that not only enveloped the did you do? crew in total darkness but Linenger: The way that we also left them tumbling out of tried to counter that was with control through space at some exercise that put stress on the 17,800 mi/h, and a raging bones. I did two one-hour perifire that spewed blinding and ods of exercise a day. I mainly choking smoke and threatened used a treadmill (Figure 6). the station itself. I used a 70-kg plate and a windAlthough he finally surfer harness, and that would returned safely to Earth, yank me down so it felt as if I Linenger was left with yet FIGURE 5 Linenger floats in Mir’s Priroda module. He and his had a person on my shoulders, another challenge: to recover two cosmonaut crewmates mainly conducted remote-sensing experiments in this module. In all, Mir spent 15 years in orbit and then I’d run at different physically from space travel. (1986–2001) and served as the laboratory for some 23,000 scienspeeds. Toward the end of my This battle, which would con- tific and medical experiments. (Photo courtesy of NASA.) time in space, I added bungee tinue for many months—much cords (to the treadmill apparalonger than his five-month Mir tus), and I would also do squats and whatever else I could think voyage—was perhaps the most difficult hurdle, and one that of to concentrate on the weight-bearing areas of the hip, lower could waylay future long-term space travel. He spoke with IEEE spine, and the head of the femur. Pulse about this obstacle and the additional everyday challenges IEEE Pulse: How well did that work? he encountered while conducting scientific experiments, scramLinenger: Before I went to space, I tried to be in as good bling to preserve their miniature ecosystem, and trying to maina shape as I could be so that I could use that as a baseline to tain his own physical condition aboard a cramped, cluttered, and see what the differential was between preflight and postflight relentlessly demanding space station. and also what recovery time I needed to get back to 100%. IEEE Pulse: What was the greatest physical challenge As it turned out, my bone loss from preflight to postflight of the weightlessness of space? was 13%. I was very disappointed and almost shocked when Linenger: One of the things I could never convey enough— I found out I had that much bone loss, because I worked to and you just have to be there to understand it—is that it is effortprevent it. less in space. If I wanted to go from here to the end of the room, IEEE Pulse: Is this amount of bone loss typical? it literally takes this. (Linenger points to the opposite side of the Linenger: It’s hard to say. There’s a lot of individual variaroom about 30 ft away, touches a finger to the wall next to him, tion—one astronaut had just 6%, for instance—and there are not and barely pushes off.) It’s a fantastic feeling to be able to do flips that many people who go to space, so there’s really not enough and 200 somersaults in a row, but you do pay a price, and part of of a sample number to make statistically significant conclusions. that price is muscle atrophy and bone loss. That’s one of the reasons astronauts are asked to volunteer for That bone loss is something that’s still a possible showstopper every medical study they can. when you’re thinking about long missions in space. Most physiOne year after my return, I had cut the bone loss down to ological measures dampen out over time, but not bone loss. When about 7% in the hips and lower spine, and, at the two-year you go up into space, for instance, you grow a little bit as your interpoint, the bone loss was about 2%. Of course, it’s hard to tell vertebral spaces and discs fill. You get about an inch taller on the what my bone would have lost from normal aging, so I think first day, and, by the second, you’re two inches taller, but that’s all. best. And that’s worth spending your career on.
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that 2% loss is acceptable after many of those experiments, five months in space. what other things should IEEE Pulse: Since bone the designers of such experloss was a major issue for you iments take into account? during your five months in Linenger: It’s a mentally space, how will that impact taxing thing to do experiments extended space travel, such that you know are valuable, as travel to Mars, where the and to do them for scientists astronauts will be exposed around the world who you to weightlessness for an know are waiting for those even longer time? results. It’s a lot on your shoulLinenger: Going to Mars ders when you’re up there by will include an approximately yourself with an experiment six-month transit to get there, that you trained on many a stay for about a year, and months earlier, and usually then another six months to get without any feedback about back. The vehicle itself will be FIGURE 6 As a consequence of prolonged space travel, astronauts whether you executed it corsmall, so there will be weight lose muscle and bone mass. This has led to the development rectly until you get back down of numerous countermeasures, including exercise equipconstraints, which means there ment designed for a microgravity environment. Taken before to Earth. So if I’m a designer won’t be room for large tread- astronaut Jerry Linenger went up to the Mir space station in of any of these experiments, I mills and bicycle ergometers. 1997, this photo shows Linenger trying out a treadmill during would work in as much redunThat does not look good as far an 11-day mission aboard the space shuttle Discovery in 1994. dancy as possible, harden it While on Mir, he spent two hours a day exercising. Despite the as bone loss goes during the work, he still returned to Earth with 13% bone loss. (Photo couragainst radiation if I can, and transit. The good news is that tesy of NASA.) add self-correcting mechanisms Mars is (about 39% of) Earth’s in case the software does get gravity, so the astronauts may polluted by radiation hits. not lose more once they’re there. IEEE Pulse: With all of the challenges, IEEE Pulse: Are there other concerns including some of them being near-fatal “The principal goals about travel to Mars? catastrophes, do you miss it? Would you go of Skylab were to Linenger: Radiation is a major problem back to space? determine how for the human being, with higher cancer risk Linenger: Obviously, there were close calls long people can as the main issue. Personally, my cumulative when we were up there: a fire, loss of power, live and function radiation level is beyond the lifetime accufailing life-support systems, a collision with an in weightlessness, mulation of a nuclear worker, so if my odds of unmanned cargo ship. And then there were just getting cancer were one in a million preflight, the normal things, like launch, landing, and the whether they can do they’re now, say, one in 10,000. And that dynamic processes where you’ve got to have science while they’re changes depending on your orbit. If you’re up data and input going in split seconds, and it’s up there, and what higher, say 340 mi doing a Hubble Space Telegot to be exactly right or you could be dead. accommodations are scope repair, you’re outside the Van Allen belt, You might call that harrowing, but to me, it’s a necessary to keep the so you have less radiation protection, espemiraculous thing, and such a privilege to be sitastronauts healthy.” cially from solar events that emit a lot more ting in a spacecraft that can do what it’s doing. radiation hits and heavy nuclei. The fact that human beings have figured out the The same is true for the electronics. Radiacorrect way to bring together the electronics, tion hits can cause computer bit flips (a 1 becoming a 0, or vice the computer systems, the feedback, the control surfaces, and versa), and you can get up to 30 a day just by increasing your everything else is just incredible. altitude and getting outside of the Van Allen belt. If that comAbout whether I’d go back, I’ve got four kids, but they’re getputer is getting bombarded, eventually you get a bit flip that is ting older, and one’s going off to college. So, yes, at some point, I significant. As a result, computers have to have self-correcting would still love to go. programs to be able to detect them and to be able to reboot. In IEEE Pulse: On a Mars mission? fact, there are typically five computers working aboard a space Linenger: When my family’s grown, I think I’d sign up for vehicle. If one goes out of whack, the other four eliminate it that one. It was fantastic going to space: a great experience that I and then (the ousted computer) tries to reboot and catch back have in my back pocket. up. And sometimes a radiation hit can actually take the comLeslie Mertz ([email protected]) is a freelance science, medical, and puter down. technical writer, author, and educator living in northern Michigan. IEEE Pulse: Radiation could also, then, be an issue for in-space experiments that have electronic components. From your perspective as an astronaut who has conducted july/august 2014 ▼ ieee pulse 29
