Author: Paul Zilberman MD
I was born in 1960.
As a child I was thrilled to witness the first man in space, as per stories, in those years a direct TV transmission was still a dream. And even if it had been possible, I was one year of age, so…
But later on, I was able to see the launch of the Apollo missions and the common US-Soviet programs Soyuz- Apollo.
As many other terrestrials I was thrilled to watch, both from distance and close up, those “white pencils” with the painting of “The United States of America” climbing faster and faster, leaving behind a huge ball of fire… Then the first carrying rocket segment detaching and falling back to Earth…
I was amazed seeing how only after a short time those “people out there” were floating and smiling, waving their hands and telling us everything is ok.
I was reading about the many experiments that were carried out during the flights, I was even able to look now and then at the flight path, little understanding what were the sinusoidal lines appearing on the huge Command Center screen, where so many people were sitting in front of the computers with the microphones and earpieces connected. I didn’t understand then, exactly, why so many people were dealing with so few in space.
Well, time went on, Skylab appeared, then the ISS, the shuttles…wow…all in a lifetime.
As time went on and understanding grew, on top of my medical school and, later on, anaesthesia residency, other questions arose: how do the astronauts eat, drink, wash, use the toilets? And many other daily mundane things we take for granted down here.
Modern medicine is all about numbers. Not in the dry sense of how many patients we see or haw many beds a hospital has; that’s the headache of the medical administrators. In my education “numbers” are pressures, concentrations, volumes etc.
One question I was asking myself for a long time was how the astronauts breathe in those confined spaces for such long periods of time. After all you have several people in a closed artificial environment. Exactly like in the submarines, but with a critical difference. A submarine can produce its needed oxygen by water hydrolysis; and usually there’s plenty of it in the oceans. In case of problems a submarine can surface, problem solved.
Not so in space. And here come into play those numbers: how much oxygen an astronaut needs, how many astronauts are in that space, how much CO2 is produced, how it is removed, and how is oxygen produced when, think of it, you don’t have it around the spaceship or station. Metabolic issues are studied to the tiniest detail, and experience is gathered with every new mission. In many fields.
I would like to bring here only one aspect: the removal of CO2. This text is not intended to explain in detail all the process, but just to make the reader raise a brow and say “I never thought of that”! And open his appetite to search for more.
The CO2 we produce is related to many physiological factors. Once exhaled it needs to be taken away from our faces, otherwise we inhale it back, a process known in anaesthesiology (and not only) as “rebreathing”. Think of this specific issue in space where there is no wind to wash away the CO2 from your face. Well, another problem, the need for cabin fans to circulate the air.
The removal of CO2 and the whole chemical reactions used in order to clean the closed environment of this gas while retaining the oxygen is energy dependent and follows several chemical steps. The whole process is known as “The Sabatier reaction”, from the name of one of the two French chemists that discovered it in 1897, Paul Sabatier and Jean-Baptiste Sendersen.
The moment I got closer to one other way of CO2 removal in space was when I read, post factum, of the almost tragedy of Apollo-13. A faulty contact in the transport module produced an explosion. The astronauts were forced to move quickly to the lunar module but…the CO2 absorbent filters there were not enough to remove enough CO2 in order to keep them alive till return to Earth. Well, you are invited to read the whole story.
But on this occasion, I learned about the LiOH based CO2 filters. The chemical reaction is the same as for any -OH based CO2 absorbent used in the anaesthesia machines only that, at least as a theoretical chemical calculation, their absorbent capacity on a CO2 volume/unit of absorbent mass can go up to five times more than what is commonly used in operating rooms (ORs).
The contribution of a special technology that preserves the spatial configuration of the absorbent helps to prevent a mechanical process called “channeling” that further reduces the lifetime of the other absorbents. Recently, with the Li prices going up, most probably due to its use in electric car batteries, the LiOH absorbent became financially non-competitive. However, the technology of maintaining that spatial configuration was kept. It is used today in the production of the same CO2 absorbents but with CaOH as the active substance. The absorbent is manufactured as cartridges, each type fitting a special anaesthesia machine. It may seem like a drawback, but if we consider the longer lifetime, the almost non-existent dust producing issue, the ease of replacing them, by the end of the day it may be a step forward in making our existing ORs more efficient in all respects.
All that is happening in the space confined “piece of Earth out there” is in fact human activity and use of resources to the maximum. In anaesthesiology we call it “closed circuit”.
The same way we use our experience on Earth to preserve life in space, we can do the reverse, help preserve, or at least improve life here based on the experience gathered from the space missions.
It all depends on us.
Author: Rohan Krishnan
Undergraduate, Bachelor of Science - Statistics & Healthcare Management | The Wharton School, University of Pennsylvania
In 1955, Walt Disney’s “Mars and Beyond” pondered human survival in extraterrestrial environments. The narrator envisions the colonisation of Mars as a feasible reality: a future where cities are encased in pressurised domes on the Red Planet to combat overpopulation and the depletion of natural resources on Earth.
Today, NASA’s Artemis Mission plans to return astronauts to the moon by 2025, this time with an eye toward lunar colonization and human exploration of Mars. The boundaries that once constrained human space exploration are shattering, as technological advancements and ambitious government space programs bring plans for travel to Mars closer to reality. Beyond government space agencies, private companies like Blue Origin and SpaceX are innovating to create faster, more efficient aircraft and bring space travel to the masses through commercial flights. As astronauts inch toward deep space missions, understanding the general health risks of long-distance space travel, as well as the varied conditions between environments, is crucial.
Missions to the International Space Station (ISS) and in low Earth orbit (LEO) have uncovered a variety of consequences for astronaut health, including bone loss, muscle atrophy, and a weakened immune system, amongst others. Radiation, microgravity, the distance from Earth, isolation, and the hostile environment inside spacecraft are the root causes behind the health issues that astronauts experience in space. Space exploration is vital for advancing life on Earth. Future missions across our solar system can help us understand the effects of microgravity and radiation on biological systems, locate valuable natural resources, and even combat overpopulation by exploring space colonisation. Given this need, ensuring the health of humans in space is the bedrock for further discovery.
In this blog, I will describe the significant health challenges associated with with spending time in LEO and on long-distance spaceflight to the Moon and Mars. I have narrowed the focus to the following branches of medicine, to outline and contrast the particular health issues between LEO and long-distance spaceflight: cardiology, ophthalmology, and neurology. Many of the health concerns associated with time spent in LEO persist during long-distance space travel, but there are also challenges specific to the Moon and Mars stemming from their unique environmental characteristics, such as the presence of regolith and varying radiation levels. Understanding these general and environment-specific health concerns will inform planning as we venture deeper into space.
The vast majority of human spaceflight has occurred within low Earth orbit (LEO), with the notable exception of the Apollo program’s lunar missions. All manned space stations, including the ISS, are in LEO. As a result, for more than two decades, countless experiments have been conducted on the ISS to understand how astronauts’ health is impacted in LEO.
Researchers studying the health of astronauts aboard the ISS have uncovered that long-term travel in LEO has notable effects on astronauts’ cardiovascular health. According to Dr. Thais Russomano, a leading expert on space medicine, the absence of Earth’s gravitational force in space causes bodily fluids and blood to shift from the legs and lower abdomen toward the upper torso and head. This phenomenon - referred to as ‘puffy-face and bird-legs syndrome’ - causes swelling in the face and head while reducing astronauts’ circulating blood volume and heart size. As less blood is pumped by the heart in microgravity, astronauts endure muscle loss in the heart, placing them at risk for cardiovascular deconditioning and cardiac myocyte atrophy.
Radiation is another significant concern impacting astronauts’ cardiovascular health. Aboard the ISS, radiation from galactic cosmic rays, solar cosmic rays, and particles from the Van Allen radiation belts are of primary concern. Astronauts are exposed to roughly 40-times more millisieverts of radiation compared to people on Earth. Exposure to space radiation over long-term missions increases astronauts’ risk for cancer and cardiovascular diseases, although effective shielding and radiation shelters aboard spacecraft have helped mitigate those risks.
Cardiovascular issues resulting from microgravity and radiation exposure over long periods aboard the ISS can follow astronauts well after returning to Earth. Some studies have determined that astronauts’ arterial blood pressure decreased throughout space missions due to the loss in circulating blood volume, although there could be many causes behind this change. Similarly, the reduction in circulating blood volume can cause orthostatic intolerance - the inability to stand due to lightheadedness or fainting - once astronauts return to Earth. Although radiation exposure and microgravity cause cardiovascular problems in space, studies on astronaut mortality have concluded that astronauts are at a lower risk of death from cardiovascular diseases relative to the general population on Earth.
The effects of bodily fluid shifting in microgravity extend beyond ‘puffy-face and bird-legs syndrome’, with consequences for the eyes. Following a six-month mission to the ISS in 2005, astronaut John Phillips’s perfect vision was found to have deteriorated due to spaceflight-associated neuro-ocular syndrome (SANS). SANS is formerly known as visual impairment and intracranial pressure (VIIP) syndrome, although the name was updated to reflect the uncertainty over whether increased intracranial pressure is the sole cause of the condition. One explanation is that SANS is caused by cerebrospinal fluid shifting toward the head, increasing intracranial pressure, particularly at eye level. The pressure causes the back of the eye to flatten, resulting in a hyperopic shift and blurred vision.
According to a report from the British Journal of Anaesthesia, a questionnaire of 300 astronauts found that 28% of short-duration mission astronauts and 60% of long-duration mission astronauts experienced degradation of visual acuity. A study of seven long-duration mission ISS astronauts and nine short-duration mission space shuttle astronauts found that the long-duration astronauts had significantly greater post-flight flattening when compared with the short-duration astronauts. Given the increased severity of SANS on long-duration missions, understanding causes and possible treatments are vital for exploration in and beyond LEO.
Microgravity has notable effects on the nervous system, particularly due to the redistribution of bodily fluids in space. Neuroimaging scans show that astronauts’ brains have increased ventricular volumes following long-distance spaceflight. As fluids shift toward the upper torso and head during long-term exposure to microgravity, the volume of cerebrospinal fluid collected in the brain’s ventricles increases, resulting in ventricular expansion. Ventricular expansion could be a possible cause of SANS and may be linked to premature ageing of the brain. One study found that astronauts who spent 12 months in space displayed larger changes in ventricular volume than astronauts who spent 6 months in space, suggesting important implications for long-duration space missions.
The microgravity-induced fluid shift is also associated with alterations to white matter in astronauts’ brains. A study from the journal Science Advances reports that cosmonauts displayed increased white matter in the cerebellum following long-duration spaceflight, with white matter volume returning to roughly pre-flight levels seven months after spaceflight. The cerebellum handles fine motor control, postural balance, and oculomotor control, and white matter changes associated with spaceflight may offer evidence for motor system neuroplasticity. Various studies are employing different techniques to evaluate white matter changes due to spaceflight, which could affect other neurological functions including visual and sensory processing.
The health issues associated with LEO are also relevant for long-distance space travel. However, there are also environment-specific challenges unique to the Moon and Mars - such as high levels of space radiation and varying magnitudes of microgravity - that will be of primary concern to astronauts. Various studies simulate deep space environments to predict the effects of long-distance spaceflight on human health, informing mitigation strategies to keep astronauts safe.
In deep space, the microgravity environment induces similar cardiovascular effects to what astronauts experience in LEO. Blood and bodily fluids shift toward the upper torso and head resulting in ‘puffy-face and bird-legs syndrome’, while the decreased cardiac workload can lead to cardiovascular deconditioning. However, relative to the gravitational force in LEO of approximately 0.95g, the Moon’s gravitational force is 0.16g while Mars’ gravitational force is 0.36g. It is unclear whether varied microgravity conditions will produce additional cardiovascular effects beyond those studied in LEO, however, fluid shifts and cardiovascular deconditioning remain significant concerns.
Radiation-induced cardiovascular disease is another major challenge with traveling to the Moon and Mars. Compared to missions in LEO, the space radiation environment beyond LEO exposes astronauts to higher dose rates of HZE particles, the high-energy heavy ions of galactic cosmic rays. HZE particles are highly penetrating and can cause secondary radiation when interacting with shielding in spacecraft or spacesuits. According to the journal Frontiers in Cardiovascular Medicine, high doses of HZE particles over long-term deep space missions can lead to myocardial remodelling and fibrosis, potentially resulting in heart failure. While current shielding technology may protect astronauts in LEO, the power of HZE radiation makes more advanced shielding essential to protect astronauts in deep space.
Considering the microgravity-induced fluid shifts that astronauts experience in deep space, SANS remains a primary concern for missions to the Moon and Mars. SANS is typically studied on long-duration missions, although astronauts have reported blurred vision after only two weeks aboard the ISS. A mission to Mars would take up to 20 months and would require astronauts to encounter multiple gravity fields. The long duration and complex gravity shifts associated with deep space missions could cause more challenging SANS-related ocular issues compared to those faced by astronauts in LEO. The concerns surrounding radiation beyond LEO extend to ocular health. Galactic cosmic radiation has been linked to the development of phosphenes and cataracts, while studies show that repetitive spaceflights and high-radiation-dose exposure increase the prevalence of both conditions among astronauts. Considering the high volume of HZE radiation that deep space astronauts will be exposed to, the development of phosphenes and cataracts is of major concern for their ocular health.
Previous studies have sought to evaluate the effects of space radiation on the human brain by delivering radiation doses to rodents over a few minutes. However, on missions to the Moon and Mars, powerful radiation will be gradually delivered to astronauts for the duration of the trip, ranging from weeks to years. A 2019 study from the journal eNeuro aims to more accurately simulate long-duration exposure by delivering low-level neutron radiation to mice for six months and evaluating the neurological implications. The study finds that exposure to cosmic rays impairs the brain function of the mice, affecting learning, memory, and mood. Lab tests reveal that following the neutron radiation, neurons are less responsive in the hippocampus - an area critical for the formation of memories and spatial navigation - and the medial prefrontal cortex - an area responsible for accessing preexisting memories, decision-making, and processing social information. Follow-up evaluations of the irradiated mice determine that neural circuitry damage may last for up to one year.
Some researchers dispute the study’s approach, claiming that neutron radiation used in the experiment is not a viable surrogate for the galactic cosmic radiation that astronauts would encounter during deep space missions. Still, the eNeuro study offers a novel analogue to the gradual doses of powerful space radiation that astronauts would face on missions to the Moon and Mars, further emphasising the importance of effective shielding from cosmic rays. Researchers are also studying how microglia - the immune cells of the central nervous system - can be manipulated to prevent the development of cognitive deficits due to galactic cosmic ray exposure, a promising step toward protecting astronauts on deep space missions.
Motivated government leaders and entrepreneurs alike have expressed their commitment to bringing the human race beyond low Earth orbit. As breakthroughs in deep space research and aerospace technology bring this goal closer to realisation, concomitant advancements in space medicine must be made to safeguard astronauts’ health as they travel to and thrive in extraterrestrial environments. Before we can walk on Mars, our first step must be understanding and mitigating the health challenges that await us deeper into the final frontier.
Author: The InnovaSpace Team
Space Without Borders!
InnovaSpace CEO Thais Russomano recently contributed an article to the magazine - Asian Hospital & Healthcare Management - examining the challenges humankind faces if we are to spend more time in space. It gives a good overview of the topic without being too technical and is open access, so we thought you might like to take a look!
The article features on pages 6-9 of the magazine and you can download the magazine free by following this LINK
Author: Hamzah Rahman
Year 3 student - Guy's, King's and St Thomas' School of Medicine & Space Enthusiast!
The General Practitioner (GP) medical professional has undoubtedly played a major role in providing a plethora of care packages and programmes for individuals seeking to travel; from immunisations and vaccinations to advice and even guidance for mothers in the late gestational stage. The advent of jet flight allowed the masses to venture to destinations that only aristocracy could once afford, which in turn generated a greater need for primary healthcare management. The GP is therefore the point of access to these healthcare packages and consequently plays a pivotal role in enabling tourists to travel safely. This responsibility is deeply intertwined with the historic increase in accessibility to affordable flight.
The first British commercial jetliner was the de Havilland Comet in 1949. This aircraft enabled more people to travel further, as well as reducing the price of tickets substantially. The GP during this age would have played an important role in ensuring that passengers were fit to fly, by managing their pre-flight healthcare requirements.
The Boeing 707 soon joined the aviation world in 1957 and dramatically changed the way we travelled; it opened flight corridors that were once untenable, and consequently, accessed a greater consumer market - the working classes. In 1969, Boeing unveiled the revolutionary 747, coined the “Jumbo Jet” due to its sheer size, which resulted in greater passenger capacity and far more affordable tickets.
With such quantum leaps forward in jet aviation, by the mid-70s the British GP was providing care and advice to thousands of travellers from all walks of life, different backgrounds and with all manner of pre-existing health conditions. The workload of the GP thus became much more diverse and they gained great responsibility in permitting the public to exercise their freedom to travel safely.
Just as jet flight was once an exclusive mode of transport for those from higher socio-economic backgrounds, spaceflight has now emerged onto the world market with exclusive and expensive tickets to fly. Undoubtedly, spaceflight will become more affordable in the coming years and decades, and as such will inevitably require a more established initial healthcare access point for travellers- a service that GPs could provide. As space tourism flights become more accessible through lower prices and increased provision, the remit of travel healthcare provided by general practice could evolve in the near future to encompass spaceflight health clearance.
Cardiopulmonary resuscitation (CPR) is a well-established part of basic life support (BLS), having saved countless lives since its first development in the 1960s. External chest compressions (ECCs), which form the main part of BLS, must be carried out until Advanced Life Support can begin. It is essential that ECCs are performed to the correct depth and frequency to guarantee effectiveness. The absence of gravity during spaceflight means that performing ECCs is more challenging.
The likelihood of a dangerous cardiac event occurring during a space mission is remote, however, the possibility does exist. Nowadays, the selection process for space missions considers individuals at ages and with health standards that would have prohibited their selection in the past. With increased age, less stringent health requirements, longer duration missions and increased physical labour, due to a rise in orbital extravehicular activity, the risk of an acute life-threatening condition occurring in space has become of greater concern. The advent of space tourism may even enhance this possibility, with its popularity set to rise over the coming years as private companies test their new technology.
Therefore, space scientists and physicians will have a greater responsibility to ensure space travellers, whether professional astronauts or space tourists, are adequately trained and familiarised with extraterrestrial BLS and CPR methods. Recently, work has been undertaken to develop methods of basic and advanced life support in microgravity and hypogravity, and several CPR techniques have been developed and tested. This blog presents one of these, the Evetts-Russomano MicroG CPR Method.
Evetts-Russomano MicroG CPR Method
In the Evetts-Russomano (ER) method, the rescuer can respond immediately, as it requires no additional CPR equipment/medication or the use of a restraint system. To assume the position, the rescuer places their left leg over the right shoulder of the patient and their right leg around the patient’s torso, allowing their ankles to be crossed approximately in the centre of the patient’s back; this is to provide stability and a solid platform against which to deliver force, without the patient being pushed away. From this position, chest compressions can be performed while still retaining easy access to perform ventilation. When adopting the ER CPR method, the rescuer must be situated in a manner that also allows sufficient space on the patient’s chest for the correct positioning of their hands to deliver the chest compressions.
Extraterrestrial CPR simulation
The main difference between extraterrestrial and terrestrial CPR is the strength of the gravitational field. In microgravity, patient and rescuer are both essentially weightless. When thinking about the technique of terrestrial CPR, with the rescuer accelerating their chest and upper body to generate a force to compress the patient’s chest, it is obvious that this cannot work in microgravity without significant aids. To this end, the ER CPR method has been developed using a ground-based microG simulation, during parabolic flights, and subsequently tested under-water!
Ground-based MicroG Simulation (land) = Space Researcher Lucas Rehnberg, MD (MicroG Center PUCRS, Brazil)
Parabolic Flight MicroG Simulation (air)= Researchers = Thais Russomano, Simon Evetts, Lisa Evetts & João Castro (ESA 29th Parabolic Flight Campaign, Bordeaux, France)
Underwater MicroG Simulation (water) = Sea King Dive Center, Chengdu, China - Instructor Gang Wei;
Chinese Space First Responder & Space Researcher/Instructor Chris Yuan
A project of InnovaSpace, PECA and Guangxi Diving Paradise Club, China
Free Resource: Extraterrestrial CPR and Its Applications in Terrestrial Medicine
Authors: Thais Russomano, Lucas Rehnberg
In book: Resuscitation Aspects, Ed: Theodoros Aslanidis
Publisher: IntechOpen 2017
See Download Link at https://www.innovaspace.org/chapters.html
Luis E. Luque Álvarez, M.Mus.Ed.
Violin Teacher, Kittenberger Kálmán Primary & Arts School, Nagymaros, Hungary. Member of ELGRA
Across centuries playing and listening to music has been an important human psycho-physiological communication path with or without lyrics. It is clear that in space sciences music has intervened in the life of most scientists as a motivational and alternative health resource. Pythagoras of Samos studied the physiological effect of certain scales and melodies on the human body, he believed each different modal scale would induce a different mood state to the listener or player. Several astronomers like the Galilei family, and William and Caroline Herschel, among others, were strongly connected to music, indeed they were exceptional musicians themselves.
And it was during the Apollo 9 mission when Rusty Schweickart carried a Sony Tape recorder, strictly for the purpose of providing a musical environment for the astronauts. Since then, astronauts have often highlighted the importance of music for their mission performance and have taken their music with them, indeed a tradition of wake-up calls from Mission Control has long been established to begin the astronauts’ days. These anecdotes indicate how strong is the importance of music, at least psychologically, perhaps physiologically too, for astronauts under the stress and pressures caused by the confinement of a spaceflight mission.
Music for Space Project
As a music student in 2016 I became curious about the idea of experimenting with the effect of listening to and playing music in space. At that time, I didn’t find much scientific literature about the effects of music in microgravity, hypogravity or hypergravity. Music has been highlighted only as a leisure practice and for psychological support, though I believe it provides much more than that. In 2018, I was lucky enough to have the support of the ESA Education Office, DLR, European Astronaut Centre and the European Low Gravity Research Association, teaming up with some French and Hungarian students to perform a first experiment using personalized music intervention as a psycho-physiological countermeasure under exposure to hypergravity in a Short Arm Human Centrifuge. During the ESA Spin Your Thesis Human Edition programme, our student team, along with two others (SpinKings and Spin Doctors), were able to perform some very interesting research in different space physiology fields. Our research involved 10 male participants, divided equally into two groups of 5, and spinning them in the centrifuge at 1Gz and 1.5Gz of hypergravity, with one group listening to a different style of music per spinning protocol, while the other group were spun without music. We recorded many different variables, including sociocultural background, psychological mood states, muscle tone, and galvanic skin response, among others.
Preliminary results have shown there is a clear tendency in the effect of music to decrease the tension, anxiety levels compared with the control group without music, and there was a certain stabilisation of stress muscles, which previous centrifuge studies have shown to be affected in a different way. Currently, the data is being re-analysed with the cooperation of scientists at ESA aiming to publish the complete data results. Since the Spin Your Thesis Human Edition campaign, the audio device with stereo signal installed specifically for the music experiment still remains attached to the short arm human centrifuge, where nowadays ESA astronauts and study participants can enjoy their favourite music playlist on the centrifuge.
This experiment was the initial phase of the Music For Space project, which aims to continue the research with music as a psycho-physiological countermeasure to improve astronaut’s health with alternative medicine methods and perhaps one day for Earth citizens as well.
We have in music history thousands of music styles, genres, instrumentations, and performance versions. To determine their specific benefits or disadvantages, we would need to perform more terrestrial tests, such as using a human centrifuge, parabolic flights, and analog simulations. In addition to music listening, I aim to measure in space how the playing of musical instruments could support brain, muscles, and bone health. Further studies could lead us to obtain enough data to approach an adequate and systematic music therapy method for spaceflight crews.
I encourage all students and young researchers from fields that seem to be far from space sciences to feel curious, to pursue your dreams and to try the student experiments offered by the ESA Education Office. These are an unforgettable life experience and a wonderful opportunity for students to contribute to space-related research.
Author: Nina Louise Purvis
Medical student, Queen Mary University of London; Postgraduate Researcher, King’s College London
Earlier this year, it was reported that an astronaut in space had developed a potentially life-threatening blood clot in the neck. This was successfully treated with medication by doctors on Earth, avoiding surgery. But given that space agencies and private spaceflight companies have committed to landing humans on Mars in the coming decades, we may not be so lucky next time.
Surgical emergencies are in fact one of the main challenges when it comes to human space travel. But over the last few years, space medicine researchers have come up with a number of ideas that could help, from surgical robots to 3D printers.
Mars is a whopping 54.6 million kilometres (33.9 million miles) away from Earth, when closest. In comparison, the International Space Agency (ISS) orbits just 400 kilometres above Earth. For surgical emergencies on the ISS, the procedure is to stabilise the patient and transport them back to Earth, aided by telecommunication in real time. This won’t work on Mars missions, where evacuation would take months or years, and there may be a latency in communications of over twenty minutes.
As well as distance, the extreme environment faced during transit to and on Mars includes microgravity, high radiation levels and an enclosed pressurised cabin or suit. This is tough on astronauts’ bodies and takes time getting used to.
We already know that space travel changes astronauts’ cells, blood pressure regulation and heart performance. It also affects the body’s fluid distribution and weakens its bones and muscles. Space travellers may also more easily develop infections. So in terms of fitness for surgery, an injured or unwell astronaut will be already at a physiological disadvantage.
But how likely is it that an astronaut will actually need surgery? For a crew of seven people, researchers estimate that there will be an average of one surgical emergency every 2.4 years during a Mars mission. The main causes include injury, appendicitis, gallbladder inflammation or cancer. Astronauts are screened extensively when they are selected, but surgical emergencies can occur in healthy people and may be exacerbated in the extreme environment of space.
Surgery in microgravity is possible and has already been been carried out, albeit not on humans yet. For example, astronauts have managed to repair rat tails and perform laparoscopy – a minimally invasive surgical procedure used to examine and repair the organs inside the abdomen – on animals, while in microgravity.
These surgeries have led to new innovations and improvements such as magnetising surgical tools so they stick to the table, and restraining the “surgeonaut” too.
One problem was that, during open surgery, the intestines would float around, obscuring view of the surgical field. To deal with this, space travellers should opt for minimally invasive surgical techniques, such as keyhole surgery, ideally occurring within patients’ internal cavities through small incisions using a camera and instruments.
A laparoscopy was recently carried out on fake abdomens during a parabolic “zero gravity” flight, with surgeons successfully stemming traumatic bleeding. But they warned that it would be psychologically hard to carry out such a procedure on a crew mate.
Bodily fluids will also behave differently in space and on Mars. The blood in our veins may stick to instruments because of surface tension. Floating droplets may also form streams that could restrict the surgeon’s view, which is not ideal. The circulating air of an enclosed cabin may also be an infection risk. Surgical bubbles and blood-repelling surgical tools could be the solution.
Researchers have already developed and tested various surgical enclosures in microgravity environments. For example, NASA evaluated a closed system comprising a surgical clear plastic overhead canopy with arm ports, aiming to prevent contamination.
When orbiting or settled on Mars, however, we would ideally need a hypothetical “traumapod”, with radiation shielding, surgical robots, advanced life support and restraints. This would be a dedicated module with filtered air supply and a computer to aid in diagnosis and treatment.
Robots and 3D printing
The surgeries carried out in space so far have revealed that a large amount of support equipment is essential. This is a luxury the crew may not have on a virgin voyage to Mars. You cannot take much equipment on a rocket. It has therefore been suggested that a 3D printer could use materials from Mars itself to develop surgical tools.
Tools that have been 3D printed have been successfully tested by crew with no prior surgical experience, performing a task similar to surgery simply by cutting and suturing materials (rather than a body). There was no substantial difference in time to completion with 3D printed instruments such as towel clamps, scalpel handles and toothed forceps.
Robotic surgery is another option that has been used routinely on Earth, and tested for planetary excursions. During NEEMO 7, a series of missions in the underwater habitat Aquarius in Florida Keys by NASA, surgery by a robot controlled from another lab was successfully used to remove a fake gallbladder and kidney stone from a fake body. However, the lag in communications in space will make remote control a problem. Ideally, surgical robots would need to be autonomous.
There is a wealth of research and preparation for the possible event of a surgical emergency during a Mars mission, but there are many unknowns, especially when it comes to diagnostics and anaesthesia. Ultimately, prevention is better than surgery. So selecting healthy crew and developing the engineering solutions needed to protect them will be crucial.
Rosemary S. A. Shinkai, DDS, MSc, PhD
Professor of Dentistry, Pontifical Catholic University of Rio Grande do Sul, Brazil
We still do not know much about the changes in dental and orofacial structures, functions, and diseases beyond Earth. Early studies on aerospace dentistry published at the end of the 1960’s and 1970’s addressed some concerns about oral health in astronauts and challenges for dental treatment delivery in space. If astronauts are selected for being the most prepared and healthy humans to withstand the hard conditions in outer space, what about everyday regular people, the very young or old individuals? Or pregnant space voyagers? Microgravity and radiation in long-term spaceflights and a lifelong stay in space stations or settlements would require specific oral health care.
Teeth, gums, tongue, bones, and muscles are part of a complex system, which is highly innervated and irrigated by blood vessels to allow chewing, swallowing, speaking, and smiling. Saliva is produced by a number of large and small salivary glands to lubricate the mouth, form the food bolus, and counterbalance acids produced by mouth bacteria after meals. Recent studies have shown that the microgravity and spaceflight environment alters jaw bone physiology, dental development, saliva proteins, and salivary gland morphology in mice flown on a US shuttle and a Russian biosatellite. Another study revealed that adult rats submitted to gravity tests showed remodeling of craniomandibular bones. Simulated microgravity also modified gene expression and physiology of Streptoccocus mutans and Streptoccocus sanguinis, possibly altering the cariogenic potential of these bacteria. However, the specific effect of space radiation also needs to be investigated.
It still is unknown to what extent the same effect would occur in human astronauts. Besides the potential structural and physiological changes in the craniomandibular system, other behavioral factors and epigenetics are involved in space oral health. For example, dental caries result from a frequent exposure to acids produced by mouth bacteria after ingestion of sugar, mainly sticky or soft, paste-like foods. Thus, eating and cleaning habits modify the risk for dental caries. And the protective saliva flow and composition vary with water drinking, chewing stimulation, medication, and stress. All these factors may be altered in space life and would affect individual responses to not only dental caries risk, but also gum inflammation, orofacial pain, bone loss and repair. Understanding the underlying mechanisms to prevent oral health problems and have effective interventions seems to be appropriate for the planning of long-term space travel.
So, space dentistry may be an interesting job in the future!
Prof. K. Ganapathy
InnovaSpace Advisory Board member, Past President Telemedicine Society of India, Former Secretary/Past President Neurological Society of India & Indian Society for Stereotactic & Functional Neurosurgery, Emeritus Professor Tamilnadu Dr MGR Medical University, Former Adjunct Professor IIT Madras & Anna University Madras, Founder Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health.
Three decades ago even contemplating the subject of the human brain in space would have been considered preposterous. Two decades hence and Extra Terrestrial Neurosciences could become a distinct sub-speciality. With periods of stay in the International Space Station steadily increasing, manned missions to the Moon being revived, and even humans going to Mars being seriously planned, it is imperative we know what happens structurally and functionally to various parts of the human brain when it is exposed to microgravity and cosmic radiation for prolonged periods. This is no longer a theoretical academic discussion. For decades we have relied on experimental simulation studies on the brains of rats exposed to microgravity and cosmic radiation. Mice exposed for six months to the radiation levels prevalent in interplanetary space exhibited serious memory and learning impairments, also becoming more anxious and fearful. Structural changes at a microscopic level, including changes in neurotransmitters were demonstrated.
It is only in the last decade that reliable, prospective clinical and sophisticated imaging studies have been carried out on astronaut brains before and after exposure to real world conditions. The human brain was primarily designed for standing in gravity on Earth with almost no exposure to radiation. When we leave the Earth’s gravitational pull all bodily fluids move upward. The first evidence for structural changes in the brain after long-term spaceflight includes narrowing of the central sulcus, a shrinking of the cerebrospinal fluid (CSF) spaces at the vertex, and an upward shift of the brain. MRI scans before spaceflight, shortly after and several months after return to Earth revealed a significant increase in size of the lateral and third ventricles immediately post-flight and a trend towards normalization at follow-up. There was an upward shift of the brain after all long-duration flights. Significant volumetric gray matter decreases, including large areas in the temporal and frontal poles and around the orbits have been documented. This effect was more noticeable in crewmembers with prolonged stay in the International Space Station. Bilateral focal gray matter increases within the medial primary somatosensory and motor cortex (cerebral areas representing lower limbs) were noted. Cortical reorganization in an astronaut’s brain after long-duration spaceflight has now been confirmed.
MRI documented structural changes raise the risk of possible impairment of behaviour, cognition and performance. This could compromise mission critical decisions. In 2017, a study revealed that long missions in space results in reduction of protective CSF surrounding brain volume at the top of astronauts’ brains. These changes underlie the astronauts’ performance on certain critical tasks, such as opening the space station’s hatch, climbing a ladder, exiting a vehicle or even walking along the surface of a planet. Follow up MRI scans have revealed that re-exposure to Earth’s gravity and lack of continuing exposure to unnatural radiation can generally reverse these space travel induced changes. Astronauts have to undergo extensive training before and during spaceflight to maintain muscle mass, and this can result in localised increased grey matter, particularly in the sensorimotor regions of the brain, representing the lower limbs. This is due to neuroplasticity or adaptation within the cerebrum and cerebellum.
The most notable findings in the MRI’s were a post-flight increase in the stimulation-specific connectivity of the right posterior supra marginal gyrus with the rest of the brain; a strengthening of connections between the left and right insulae, decreased connectivity of the vestibular nuclei, right inferior parietal cortex and cerebellum with areas associated with motor, visual, vestibular, and proprioception functions. Study of permanent visual acuity impairments associated with spaceflight have demonstrated structural changes in the CSF around the optic nerves and the globe of the eyes.
Domain expertise in Extra Terrestrial Neurosciences will eventually be a reality. While the number of subjects studied may at the best be a few hundreds, the lessons learnt could make us relook at the traditional neurosciences we have been believing in for the last two centuries.
Let us never forget that the future is always ahead of schedule !!
Nelson A. Campos Vinagre
Commercial pilot / Professor of Sports Science
Sporting activities for athletes with disability have existed for more than a 100 years. Relevant contributions to this area of knowledge occurred in the 18th and 19th centuries that demonstrated the importance of sports participation in the rehabilitation and re-education process of people with special needs. Cutting-edge research has targeted methods that can reduce the consequences of living with reduced mobility and, at the same time, provide new ideas and possibilities for engaging in sporting activities as a means of treatment and rehabilitation. This has led in recent decades to greater opportunities for people with disabilities to participate in sports, and the prospect of further moves for inclusion in the coming years should continue to help improve their quality of life.
The mobility provided by assistive technologies is known to contribute positively to the medical and psychological needs and treatment of casualties of armed conflict and has provided them with opportunities to overcome the life-changing injuries they have endured, both the physical and mental challenges. The Invictus Games, championed by Prince Harry, Duke of Sussex, which first took place in London UK in 2014, is an excellent example of how the power of sporting inclusion can inspire wounded and sick service personnel in their rehabilitation, providing an arena to not only motivate them in their personal journeys to recovery but also to generate a wider understanding and respect from the general public for those who serve their country.
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