Scenario: Mars Medical Emergency

        The view from Mission Control in Houston was grim. On the television screen, one of the astronauts – by bad luck, the team physician – lay badly injured and unconscious on a worktable. The crew commander, still dazed from the accident, sat back in a chair, in a corner of the screen. The other astronauts worked through emergency medical checklists in a frantic attempt to diagnose and treat the trauma that was killing their crewmate.
        And worst of all, all of the specialists and all of the knowledge in Mission Control were helpless to intervene directly. The medical emergency was on Mars, so the round trip signal time meant that what Earth was seeing had already occurred many minutes earlier. Any advice radioed to the people at the scene of the crisis would probably not arrive until after the right – or wrong – decisions had already been made.
        "Here's what we're going to do," proclaimed the Flight Director to his control room team. "Follow the checklists and anticipate where they will be by the time our words reach them. Predict the options that will face them, advise them of what we see as the best course. Specify steps to back out of any wrong paths they may have blundered into.
        "Each of you has a special team," he continued. "Let's get to work." The flight Director thought about proclaiming that failure was not an option, but didn't want to distract them.
*****
        This is not an imaginary scene; the events actually occurred, but it was only a drill. As part of a spaceflight medical emergency simulation staged at a medical conference late in 1997, I had organized the activity to exercise the participants' medical knowledge and also to drive home some specific lessons about emergency medicine in 'extreme environments.'
        The conference, entitled 'Pushing the Envelope II: Medicine on Mars,' had been sponsored by the Center for Aerospace Medicine and Physiology at the University of Texas Medical Branch in Galveston, Texas. The program chairman, Dr. Patricia Santy, was an international expert on spaceflight psychology and on astronaut selection.
        The medical exercise itself was hosted by the Burke Baker Planetarium at Houston's Museum of Natural Sciences, in their 'Challenger Center,' where grade school students go through mock space missions. Some students sit in the 'Mission Control' room, with real consoles, minicams and data screens. Others work in the 'space base' room upstairs, with research equipment, a mock space suit and other gear appropriate to space explorers. Television cameras link the two rooms together.
       For this more advanced exercise, each participant had a packet of information on 'Ares Base,' with references, charts and background data. The information described the Martian environment, the base hardware, the crewmembers' medical histories and other key data that would be needed to make the right decisions to save their lives.
        Page 1 contained the 'Handover Briefing.' It told how this was the crew's 146th day on Mars. They had spent 310 days on the way out from Earth, then had relieved the previous crew who had set up the base. These astronauts were not scheduled to leave Mars for another 18 months.        "It is now 20:00 GMT on Earth," the briefing stated. "This is 6:30 AM on Mars, sunrise at Ares Base, where the season is early autumn.
        "A major medical emergency has arisen at the base. Your mission is to provide proper guidance to the astronauts in the preparation, diagnosis and treatment of the injured crewmembers, without endangering the other crewmembers."
        "Several – perhaps all – lives depend on proper insight and action. The future of Earth's first foothold on Mars depends on your team's actions in the next several hours," the briefing chart concluded.
        The success of the exercise depended on making the participants believe it was real enough to engage them intellectually and emotionally. As with so many space-related activities in recent history, nobody had ever done this before and the odds of success were impossible to predict.

*****
        For this exercise, the one major new twist was the time delay. The implementation was low-tech and labor intensive. Four VCRs were running simultaneously. Two recorded the video and audio inputs from the two rooms, while two others played tapes made only minutes before. Every four minutes, all four VCRs were rewound and the tapes swapped in a carefully orchestrated pattern.
        The result was an eight-minute round-trip signal lag, with a 'loss of signal' of 20-30 seconds every four minutes (we just explained that away as a relay satellite glitch). The technique worked because of a tireless and very attentive technician who was in charge of juggling the four tapes.
        On Earth, the controllers saw a video that had originated on Mars four minutes earlier. On Mars, the ersatz-astronauts watched a view and heard verbal advice that Earth had transmitted four minutes earlier. Direct conversations were impossible.
        Even with this implementation, the delay was unrealistically short. Actual Earth-Mars signal transmission round trip times run from ten minutes or so all the way to almost fifty minutes. But this was the first time to our knowledge that any time-critical Mars crew simulation had implemented ANY sort of voice delay.
        The participants had never encountered such a time lag before, except perhaps in 'phone mail tag.' Its effect on the exercise was profound and at first, seemed to promise disaster.
*****
        On Mars, a small emergency had quickly become a crisis.
        Two of the astronauts had been in a rover, an open jeep-like wheeled vehicle, which they had taken to a remote campsite about 24 miles west of the lander vehicle. It was a routine operation and had been done a dozen times before. They were to stay there several days, using an inflatable tent-like shelter for overnighting.
        But shortly before arriving at the site, late in the afternoon, they had been called back. Earth had sent out a warning of a solar flare, with a dangerous radiation surge due at Mars the following morning, sometime between 8 and 10 AM. The main camp had adequate shielding, but the remote campsite did not.
        The two astronauts on the rover had been the mission commander (CDR) and the physician (MD). They immediately turned around and began an emergency night drive home. They were following a marked trail and had lights, but about ten miles from home the rover somehow missed a turn and rolled over in a ravine. CDR was thrown clear, but MD was pinned underneath.
        The main camp soon learned of the crash when a radio relay satellite passed within range. The expedition's other rover was dispatched with two more astronauts. The remaining two men at the base prepared to receive the injured crewmates. Although the rescuers plan at first was to right the other rover and tow it back, when they arrived they found it was too badly damaged.
        The CDR's helmet faceplate had been cracked and its ultraviolet shield had broken off; there were other major dents in the helmet. Her forehead was bruised and bleeding and she acted disoriented. She reported by radio that she remembered vomiting twice. Her chest was in severe pain and ribs may have been broken.
        MD was in worse shape. Trapped under the vehicle, he had evidently experienced serious chest trauma. Furthermore, the legs of his spacesuit had been severely lacerated, tearing off insulation and opening several small leaks. In a moment of clarity, CDR had been able to reach him and lash tape around the legs, while hooking up a buddy air link to keep his suit torso adequately pressurized. But both his legs had been exposed to low pressure and temperature for several hours, even though some warm air seeped past the thigh cuffs and into the lower leg area.
        The MD, still unconscious, was wrapped in an inflatable 'rescue bag' and placed on the rear of the rover. The dazed CDR was seated in the left front seat. One of the rescue astronauts (the flight engineer, or FE) drove, but there was no room for the other (the mission biochemist, or BIO).
        Since it was only ten miles and there was still plenty of time, BIO elected to walk home. In the script, she was the second woman on the six-person crew. In the past, the reference documents stated, astronauts had been able to walk at about 2 to 3 mph for several hours in the 40% Earth-normal gravity. The return trip began at 5 AM local. The rover, with both injured astronauts, was expected to get back to base shortly after sunrise.
*****
        In the real world, in the Houston of today, running the Mars base cast of actor-astronauts was a task for a professional emergency physician, who had the script and the 'cheat sheet' of what was really wrong. He stood outside the camera range in the 'Mars Base' room, while the actor-astronauts went through their performances.
        The script we had prepared consisted of numbered 'Events' keyed to clock time or to specific responses from Earth. There were verbal communications to be performed by the 'astronauts,' expected questions and responses from Earth, and descriptions of the actual situation compared to how it looked.
        For example, the first item dealt with the CDR's slipping into and out of consciousness. Was this the result of the head trauma or merely fatigue?
        Script: "It is fatigue – head wounds are superficial. If MCC looks at medical logs, they will discover that CDR's had some trouble sleeping lately, especially on away team. Somebody should be reviewing medical records and notice CDR's recent history of inadequate sleep."
        Each of the 'astronauts' was just another conference attendee, selected by random drawing the day before. They also had been given scripts to study, to understand the situation they would pretend to be in, and the hints and clues they would send to Earth.
        "That 30-second gap every four minutes was critical," the Mars base director told me later. "It gave me time to run down what was supposed to be said in the next four minutes and to plan ad hoc responses to verbal and faxed advice coming up from Earth."
        It also helped that we had fudged the 'random drawing' and had inserted a specially-prepared doctor as the mission commander. She had helped develop the actual script and knew how to act out some very special situations once the simulation was well under way. But at first, all she had to do was act dazed and complain loudly that when she had arrived at the base and had taken off her helmet, sand from her spacesuit had gotten in her eyes.
        It was up to Mission Control to figure out what she really meant by that, and what – if anything – they had to do about it.
        Their task, as spelled out in the briefing chart, was fourfold.
1.Prepare to advise re treatment of MD upon arrival.
2.Prepare to assist with assessment of CDR injuries.
3.Remain alert to impending solar proton arrival impacts on crewmembers in various locations and states.
4.Provide strategic guidance to the crew health maintenance and functioning of Ares Base both in the immediate future and related to all long-term requirements including Earth return.        But exactly HOW they would accomplish these goals – that was up to them to figure out, with guidance from the Flight Director. We'd soon see if our checklists and our cleverly planted clues led the team in the direction we had intended.
*****
        Mission Control watched the two injured crewmembers and their rescuer enter the main base – or rather, watched a view of them having come into the shelter four minutes earlier. The unconscious doctor was carried awkwardly, even in the lower gravity.
        The two astronauts who had remained at the base were the mission pilot (PLT) and the geologist (GEO). They had prepared the emergency medical kit and cleared a worktable for MD, their unconscious crewmate. GEO was the designated backup EMT, or 'Emergency Medical Technician,' and he simulated a standard procedure of cutting MD's spacesuit off and examining the wounds.
        Back on 'Earth,' the group of doctors in Mission Control were organized into several specialized teams. There was the standard 'Flight Surgeon' team, responsible for normal crew health issues. Also, a 'Science' team monitored the research work. Especially with a solar flare approaching, there are some equipment set-up activities that need to be scheduled. A 'Life Support' group monitored status of the crew's air and other consumables, while the 'Space Radiation' team concentrated on issues associated with the solar flares effect on crew health. Lastly, a special 'Tiger Team' for emergency medical care watched the progress of the medical treatment.

        We also designated a 'CAPCOM,' the traditional sole contact point for voice transmissions. Actually, we had two, one for organizing and sending the verbal (or fax) messages from Earth to Mars (the 'UP-CAPCOM') and a second to monitor and log all voice calls from Mars to Earth (the 'DOWN-CAPCOM'). Because of the time lag, these two communications channels operated independently and often simultaneously, requiring a split into two parts.
        Everyone in the room had an intellectual understanding of the task, but getting synchronized with requisite rhythms was a daunting psychological challenge. As I moved from group to group, defining what they had to do and when they had to complete it, the metaphor of 'pushing string' kept popping into my mind.
        Then, when it seemed we'd never even get the ducks in a row for the basic scenario, another scripted element kicked in.        A radio message came in from BIO, the walking-home astronaut. "Houston, I think I've got a problem in my suit's right knee hinge."
*****
        In the real world, we never selected an actual person to play 'BIO,' because she never appeared in person. One of the conference organizers recorded the voice messages we scripted to be played at appropriate intervals.
        The answer that we planned to reach was that somebody did have to go pick up BIO in the remaining rover. But that decision wouldn't be made until the solar flare was imminent.
        Either of two men could go. The FE had made the earlier trip and knew the road best, but the PLT was also qualified. What the control team had to decide was which one could go with minimal risk to themselves and minimal impact on the on-going medical care of the other two injured astronauts.
        Their medical records for cumulative exposure provided the key, if and when the doctors checked – as they should have. PLT had a far lower cumulative dosage from earlier exposures and he was the obvious medical choice. But there would soon be mitigating circumstances.
*****
        Providing emergency medical care for space travelers has long been the subject of the cold-blooded calculus of 'value added' computations. On voyages to low Earth orbit, or even the Moon, most conceivable medical crises either are tolerable for the duration of the mission, or are so serious they are untreatable. In some situations – and this has happened a few times on Russian space station flights – the crew has to return to Earth early, prior to the planned end of their missions.
        Debate still rages about the value of having an emergency medical specialist on a crew and about how much diagnostic and treatment equipment should be sent along. All such gear replaces scientific research equipment, or redundant life support equipment and supplies.
        Today's conventional wisdom is that for years-long voyages to Mars, a full-time doctor (who carries out other functions most of the time) is desirable, not least for the emotional reassurance his presence gives the other crewmembers.
        So it was easy enough, for this simulation, to make things interesting by making the doctor himself the patient. And since this had occasionally really happened on Earth (two incidents at the South Pole come to mind), it wasn’t even far-fetched.

*****
        Twenty minutes into the exercise, GEO is well along in his examination of the unconscious MD. With moderate acting skill, he reads from the script as if he is actually observing medical parameters.        "Blood pressure is 130/88, pulse is 80," he reports to Houston. "Respiration seems normal, rate is 14. Pupils are equal and react to light."
        Both legs show signs of frostbite and Martian soil is imbedded in MD's right shin. There is no sign of bleeding and – to everyone's relief – no sign of gangrene. Both lower thighs are severely bruised from the pressure cuffs. GEO 'discovers' the right leg is broken and he splints it.

        So far, Earth has been only passive onlooker. Their advice has been merely to follow existing checklists and announce all developments as they occur. But then GEO asks for advice on treatment of the legs and on responses to MD's unconsciousness. Mission Control has to prepare a one-minute verbal synopsis to be read up to Mars.
        Meanwhile, the medical log shows that a month before, the MD had developed some allergies to Martian soil and was taking the non-sedating antihistamine Claritin. Earth will have to remind the GEO shortly to inject an additional dose. We plan to give the MCC team ten minutes to realize this on their own, before prompting them to check previous medical history.
        PLT, as the acting commander, now was faced with a dilemma. Who should he send – if anyone – on a rover to pick up the limping-home BIO? Will she make it back in time to avoid accumulating too much radiation? He asks Earth for advice.        "Hi, this is me again," came a radio voice from BIO. "The suit right knee has locked up and something is gouging into the side of my leg – my foot feels squishy, I'm probably bleeding. But I'm still moving."
        "Don't send anybody out, I'll be home soon," she advised, describing her passage of the most recent milepost. "I can still move okay, I fell down twice but got up with no problem."
        The voice paused, then resumed with a little less confidence. "But I'd like your advice on a puzzle. I'm looking at my suit gauges. My O2 consumption rate looks a little high."
*****
        In the real world of Mission Control in Houston, where I spent 22 years, there are certain principles of space operations that have been developed and honed to perfection. I knew I wasn't going to make REAL flight controllers out of these doctors, but I could give them some helpful checklists and principles.
        The first is to know when to leave well enough alone. "If it ain't broke, don't fix it," goes along with the saying that, "The better is the enemy of the good." That is, trying to improve something that already works well enough can do more harm than good. Or as NASA's first Flight Director, Chris Kraft, used to say, "When in doubt, do nothing."
        But when action was required, it was necessary to prioritize your problems. Don't keep a list by adding new problems at the bottom and solving the problems highest up, like seating customers at a restaurant. As each new problem comes in, its priority has to be assessed against all other problems.
        Further, any failures or anomalies in one system could ripple into others, so a profound systems engineering knowledge is required of good flight controllers. More seriously, failures in one system could create false indications of failures in others, so one had to know enough not to chase phantoms.
        But most insidiously, failures in one system could mask the appearance of indications of real failures in other systems, so under such conditions, evidence for those other possible problems had to be sought in unusual ways.
        None of these principles could really be learned in a three-hour drill, but their importance could be demonstrated. And at this stage of the simulation, we were about to do exactly that.
*****
        MCC was starting to get into the rhythm of 'talking to the future' on their voice calls to Mars. Once it was clear that GEO was following a standard checklist, the earthside advisors were able, based on their own real-world experience, to anticipate what he would be wondering about, or observing, several minutes later.
        As a result, they began offering options for treatment, or requests for observations, that would be annunciated over the Ares Base loudspeaker at about the time the Martian team was actually involved in exactly those issues.
        They had also figured out that important clues to current and future problems had been buried in the reference books. Each team assigned members to look over the packages again now that they knew the kinds of hints they might find there.
*****
        As the CDR is heard to mumble again about sand in her eyes, the 'Flight Surgeon' group on Earth suddenly recognized the hints. "She's got snow blindness!" one doctor exclaimed with the delighted smile of someone who's discovered a carefully hidden Easter Egg. "Don't lavage her eyes – don't treat her for foreign objects at all."
        In an animated discussion, the team saw all the clues fall into place. The CDR's UV faceplate had been dislodged in the crash. The rover had been driving east, right into the rising sun, for the last half-hour or so. The Martian environment involved unattentuated solar UV on the surface, as clearly specified in reference documents in their information packets.
        Telemedicine, the practice of medicine at a distance, had just broken the light barrier, made a successful diagnosis and become an interplanetary art.
*****
        The injured CDR had been left to doze on a chair, her simulated two broken ribs undiagnosed in the correct triage decision to concentrate on the MD. Her occasional mutterings were audible back on Earth and were noted in logs, but not responded to.
        Suddenly she leapt to her feet and in absolute lucidly proclaimed that the rover had to be sent back immediately for the walking astronaut. The FE was still suited from his first trip and she ordered him to depart immediately.
        The PLT, assisting GEO in the medical treatment of the doctor, tried to push the CDR back into her seat. He had already been advised by the MCC that he was in temporary command during the CDR's medical incapacitance. But nobody had bothered to tell the CDR, who grew quite agitated.        "I thought she really had gone nuts," the ersatz-PLT told me later. "This wasn't in any script I had seen. I didn't know how to restrain her."
        CDR, our deliberate ringer on the cast of the Mars crew, was pulling out all the stops on the psych-crisis we had secretly scripted. It forced the Mars crew to ad lib in their roles, while the MCC watched in horror and wondered what had already happened while the TV signals were making their long transit.
        As 'Flight Director,' I demanded quick answers. "Do we order them to restrain her, or sedate her? What's the operational status of the command authority?"
        "And don't everybody get distracted," I added. "There's a solar flare coming and a crewmember caught out on the road. What do we need to do NOW?"
        With gratifying concentration, the teams dove into their special responsibilities.

        "Disregard the CDR's advice," the Flight Surgeon declared. "Sedate her and if necessary restrain her."
        "Get the FE out of the suit so he can relieve the PLT with medical work," the 'Tiger Team' advised. "The PLT's the one to drive out on the pickup since his cumulative career radiation exposure is much lower than FE's." They HAD found the 'Easter Egg' in the simulated medical records!
        The Science Team didn't want to be ignored either. "Don't forget to deploy and activate the dosimeters," they advised CAPCOM for about the fifth time. After being repeatedly dropped off the bottom of the priority problem list, they finally got their request relayed up to Mars.
        The CDR was still arguing loudly that she was declaring herself fit to resume command, when I got a note from the Flight Surgeon team. The treatment for her eye injuries was rest, which required they be blindfolded. She would be effectively blinded for hours or even longer.
        "She can't be in command," the grinning doctor told me triumphantly. "She can't argue with this mandatory treatment."
        I handed the note to the UP-CAPCOM for relay to Mars. No matter what hand the CDR thought she held, this card trumped it.
*****
        We had a number of further scripted malfunctions to throw at the team if things got boring, such as a 'delta-P alarm,' a pressure sensor detecting a slow air leak in the base. It would be caused by a strip of film caught in the large airlock and would be slow enough to be ignored for hours. It was designed to test the MCC's presence of mind to prioritize it properly.
        The MD also got his big acting chance when he went into convulsions as a lung collapsed. The two astronauts providing emergency medical care began a new checklist. The MCC team began feeding them future advice, planned to arrive several minutes in the future as they reached predictable stages in their checklist.
        Even when no decisions needed to be made, the MCC kept feeding reassuring descriptions of what the team on Mars SHOULD be seeing if all was going well with the diagnosis and the procedures.
        They had the medical problem absolutely nailed and as they 'talked to the future' on Mars I saw their eyes gleaming with triumphant confidence.
        We got one close-up of the MD's face, in recovery, as he blinked his eyes and muttered a semi-coherent question.
        And then we decided to call it a day, or as they say on Mars, a 'sol.' That's the sunrise-to-sunrise period that's 36 minutes longer than the sunrise-to-sunrise 'day' on Earth.
        We had only spent two hours on the exercise. During the slowness of the start, we almost could SEE the signals creeping from Earth to Mars and back. But we finished in a headlong rush and gained a new intuitive appreciation of communicating life-and-death knowledge to Mars and back.
*****
        Later, sitting in the planetarium cafeteria over coffee, we enjoyed the grins on the faces of the doctors. "This was the best medical conference simulation I've ever had," we heard several times.
        "Have you thought of adding – X?" we were repeatedly asked. We took good notes, since we hadn't thought of these variations. The most common comment was that next time it should be longer.
        The ersatz-CDR was still grinning uncontrollably from having successfully freaked out her fellow Mars 'astronauts' until Earth fired its 'silver bullet.' That was the proper 'snowblindness' diagnosis that required CDR to be blindfolded. She gleefully exchanged impressions with the now-fully-revived ersatz-MD. His view, from the horizontal, differed in many ways from hers and from ours in the control center.
        But one theme was common to all the perceptions. Medicine on Mars was a real requirement and it was going to be very, very different from on Earth. We had just barely scratched the surface with this exercise and had newer, bolder scripts to develop. And we still had a few decades to hone the skills to be needed for real.