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. | MEDICAL EMERGENCIES IN SPACE Tamarack R. Czarnik, MD Resident, Aerospace Medicine – Wright State University OVERVIEW Mechanical failures in spaceflight are so routine as to be considered unavoidable; whether you hear about it or not, nearly every spaceflight will have failures of one or more components. Usually these failures are not critical, and can be fixed in-flight without disrupting mission objectives. Occasionally, several failures occurring simultaneously will threaten to abort the mission (as on STS-93, with two engine computer crashes, loss of hydrogen fuel and low orbit), or one mission-critical or sensitive component will fail, cutting short the flight (as on Challenger’s O-ring or Apollo 13’s #2 oxygen tank). So it is with the human body in spaceflight; while minor ‘failures’ (e.g. skin infections, respiratory symptoms, etc) are commonplace, they can usually be easily treated in-flight with minimal mission disruption. But infrequently, several ‘minor’ problems will combine to complicate a mission, or one major exposure or illness in-flight will abort or shorten the flight. This paper will first examine the incidence of and accommodations to ‘minor’ medical breakdowns in-flight, then briefly describe the mission-threatening occurrences thus far. ‘MINOR’ AILMENTS SPACE MOTION SICKNESS By far the most common of ailments on entering space is Space Motion Sickness, or SMS. As discussed in a previous paper (‘Countermeasures to Long-Duration Spaceflight’, Part One), this poorly-understood syndrome of sweating, dizziness, nausea and vomiting affects 2/3rds to 3/4s of all astronauts and can be disabling. EVAs (extra-vehicular activities, or ‘spacewalks’) are not scheduled for the first 3 days of a Shuttle mission for just this reason. But since astronaut doctor Bagian gave the first intramuscular injection of Phenergan in-flight for a severe and disabling case back in 1990 (1), there has been slowly growing acceptance of this well-tolerated (though invasive) treatment. HEADACHE AND BACK PAIN Second only to medications (like Phenergan) for SMS is consumption of analgesics, predominantly for headache and back pain. Headache in space seems to be a function of fluid accumulation in the head and sinuses; try standing on your head for a few hours and see what happens. While Mercury crews carried nothing for pain, Gemini missions carried Aspirin and injectable Demerol, and Apollo added Tylenol and Darvon. Back pain, on the other hand, seems to result from the body’s ‘antigravity’ (slow twitch) muscles having nothing better to do. Because there is no gravity to hold yourself erect against, astronaut’s naturally assume a curled, fetal position when relaxed. Since the back is designed with a lumbar curve to help counteract gravity, muscles in the lower back begin to ache. I have not yet found data to suggest wearing the Russian ‘Penguin suit’ (with strategically placed bungee-like resistive cords) lessens this syndrome. INFECTIONS Minor infections of the skin, eyes and respiratory tract were reported 13 times in Apollo (including stomatitis, pharyngitis, recurrent inguinal and axillary infections) (2), and 8 times in Skylab (3), despite carrying Tetracycline, Ampicillin and Neosporin antibiotics (4). Viral upper respiratory infections occurred 3 times on Apollo (not counting nasal stuffiness and rhinitis of undetermined origins), but a ‘cold’ in space isn’t just a nuisance; just ask Wally Schirra. Developing a cold on Apollo 7, it quickly spread to shipmates Donn Eisele and Walter Cunningham. But in microgravity, the nose won’t drain, so the sinuses become more packed and with fluid and uncomfortable, aggravating the natural headward movement of fluid and congestion. Sinus pressure and pain caused some strained relations with Mission Control, worsened by the astronauts’ decision not to wear helmets on re-entry ( to allow pressure on the ear drums to equalize as cabin pressure changed on descent). None of the three ever flew in space again. Skylab also had one occurent of a urinary tract infection in-flight (3), but nothing to compare with Fred Haise’s UTI on Apollo 13 (of which, more later). Why are infections common in spaceflight? Without gravity, particles larger than a micron in size (which normally settle to the floor) remain in the cabin atmosphere, irritating eyes and lungs. Some potentially harmful bacteria grow faster and yield higher numbers in spaceflight (5,6). Lymphocytes, a kind of white blood cell that fight infection, show decreased activation in space (7). Immunoglobulins (‘antibodies’) are decreased after long-duration spaceflight (8), and cell-mediated immunity appears to be decreased as well (9). Cosmonauts routinely take Lactobacillus (a normal and harmless intestinal bacteria) supplements to offset the observed shift to (potentially harmful) Enterobacteria and Clostridia. There is even evidence that some antibiotics work less well in microgravity, presumable because of gravity-sensitive mechanisms of action (10). ‘RASHES’ Skin infections usually require a break in the skin to set in, and these too are frequent in space. Since humans cannot live in zero pressure, spacesuits are ‘inflated’ in space, like balloons. This makes joints hard to move, especially the fingers (which are moved most frequently), and working in space gloves can rub fingers raw and cause subungual hematomas (blood under the fingernails). These contributed to two skin infections on Skylab and five subungual hematomas on Apollo; no comprehensive data are yet available for the ongoing Shuttle program. Astronauts frequently wear biosensors, giving us data on their condition. But skin irritation from these biosensors is common, being reported 11 times during the Apollo program (2). As Apollo also had no toilet facilities, astronauts got excoriations from constantly wearing urine collection devices. SERIOUS AILMENTS As noted in ‘Adaptations to Long-Duration Spaceflight’, many ominous predictions of the consequences of spaceflight have been proposed. Increased urinary calcium, decreased urinary pH, decreased urine volume and decreased urinary citrate, which all occur in spaceflight (11), increase the risk of kidney stones. Bones thinned from long months in microgravity are expected to be more susceptible to fracture, either during the mission or on return to Earth. Orthostatic intolerance and loss of aerobic capacity could inhibit astronauts’ ability to quickly escape from an emergency landing (12). However, as also noted in ‘Adaptations’, many of the earlier fears did not pan out. Astronauts did not choke on their own saliva, the lungs did not fill with fluid, and hallucinations have not been a problem. So how real are these concerns? With literally dozens of cosmonauts having spent more than 6 months continuously in space, and 4 (Polyakov, Avdeyev, Manarov and V. Titov) for longer than 12 months, what serious medical ailments have been noted in spaceflight? CARDIAC DYSRHYTHMIAS Numerous irregularities of heart rhythm have been noted, both in the American and Soviet/Russian space programs. During Skylab, one crewmember had a 5-beat run of ventricular tachycardia (a rhythm that can progress easily into ventricular fibrillation and death) during a lower-body negative pressure protocol, while another had episodes of "wandering supraventricular pacemaker" (13). During reentry, one Shuttle crewmember showed up to 16 PVCs per minute, and another had sustained ventricular bigeminy during EVA (all rhythms which can lead to death). One Soviet cosmonaut had to be returned to Earth prematurely for abnormal heart rhythms; Alexander Laveikin, having spent 6 months on Mir with Yuri Romanenko (who went on to spend 430 consecutive days on Mir), had to cut short his mission and return due to dysrhythmias (14) (although there is also a suggestion that interpersonal issues played a role – see under "Psychological Problems). Finally, Vasily Tsibliyev was bumped from an ‘internal EVA’ in 1997 due to developing an arrhythmia (15). It is not known if spaceflight (or any of its attendant circumstances) is inherently arrhythmogenic, but incidence of arrhythmia has been elevated over preflight incidences. DECOMPRESSION Because humans cannot long survive at low pressures, spacesuits, shuttles and stations must be pressurized. On several occasions, a breach of pressurization has endangered astronauts’ lives. Vladimir Lyakhov & Aleksandr Aleksandrov, aboard Soyuz T-9 in 1983, prepared to evacuate after hearing a loud crack; investigation revealed a 3.8 mm impact crater on a window. They escaped decompression that time, but others were not so lucky. On STS-37, the palm restraint in one of the astronaut’s gloves came loose and migrated until it punched a hole in the pressure bladder between his thumb and forefinger. The astronaut bled out into space, but the skin of the astronaut’s hand partially sealed the opening. His coagulating blood sealed the opening enough that the bar was retained inside the hole. (16) On 25 June 97 resupply ship Progress struck the Mir space station, causing a 20-30 centimeter hole in the Spektr module and decompressing the station rapidly enough to make Michael Foale’s ears pop. During a subsequent IVA (‘internal’ EVA), Pavel Vinogradov’s left glove leaks, leaving him with 15 minutes air; it takes more than half this time to repressurize the node to safety. On Soyuz 11’s return from Salyut-1 in 1971, a pressure equalization valve was jerked loose at the jettison of the Soyuz Orbital Module, depressurizing the cabin. Viktor Patsayev tried to close the pressure equalization valve, but only got it half closed before he died. As the cosmonauts were not wearing pressure suits, Dobrovolskiy, Volkov, and Patsayev were found dead in their cabin (17). TOXIC EXPOSURE Following the 1997 fire aboard Mir, Jerry Linenger and 2 cosmonauts don gas masks to avoid smoke inhalation, benzene and carbon monoxide. Linenger prepares to intubate victims, but they emerge safely (18). Later, ethylene glycol (a frequent problem from 1995-97) leaking from the Kvant-1 coolant loop hits cosmonaut Tsibliyev head-on, causing eye irritation, lethargy and nausea (19). Carbon monoxide buildups cause Shannon Lucid to complain of difficulty thinking (20). But Mir is by no means the only spacecraft plagued by toxic exposures. In 1977, during reentry of the Apollo capsule from the Apollo-Soyuz Test Project, inadvertent firing of the reaction control system during descent exposed the 3 American astronauts to toxic gases (mostly nitrogen tetroxide). After a very hard landing, the crew was able to escape the gas by donning oxygen masks, but not before Vance Brand lost consciousness. All crewmembers developed a chemical pneumonitis, and all required intensive therapy and hospitalization (21). And as recently as 1999, astronauts aboard STS-96 to the nascent International Space Station complained of headaches, burning and itching eyes, flushed faces and nausea, suspected to be due to carbon dioxide buildup (22). INFECTIONS After Apollo 13’s oxygen tank exploded, the Command Module lost all power and the three astronauts had to use the attached Lunar Module as a lifeboat. In addition to enduring freezing temperatures and dehydration (water was rationed to six ounces per person per day), all three had to wear their condom-style urinary catheters constantly. Fred Haise became feverish and lethargic; medical examination after their successful recovery indicated a Pseudomonas aeruginosa urinary tract infection brought on by dehydration. Had their 87-hour ordeal gone on much longer, all three would likely have had the infection. (23) In September 1985, Vladimir Vasyutin rode a Soyuz-14 to Salyut-7 with fellow cosmonauts G Grechko and A Volkov for another record-breaking stay in space. In late October, however, Vasyutin had lost his appetite and was obviously sick, staying in bed all day. Mission Control told him to wait for his condition to change and continue working. But by November his condition had not improved, and on November 21 the crew returned to Earth. The Soviets released to the press that he had a fever of 104o F (40o C) and inflammation for three weeks; the press initially reported that he had appendicitis, then a prostate infection. (24) But there is some indication that Vasyutin’s problem may have been psychological, rather than inflammatory. The crew did not return immediately, unhurriedly mothballing the station. Vasyutin himself said he thought the problem was in his frame of mind, and his condition improved a bit when they were told to come home. On landing, Vasyutin rejected a stretcher; he was the first out of the capsule, and reported "I’m feeling all right, the way I should after a landing. I am very happy to see people. It has been just the three of us for so long, it is nice to see so many people." (25) PSYCHOLOGICAL PROBLEMS While NASA seems only now to be discovering psychological concerns in spaceflight, the Russians have been dealing with it for years. Nonetheless, numerous problems have arisen. Information is scant, as both NASA and the RSA are loathe to discuss them (both for patient confidentiality and for image control). John Blaha, aboard Mir for 4 months in 1996-7, began experiencing fits of anger, insomnia and withdrawal, exacerbated by an overdemanding workload. "He was hurting," Linenger recalls. "He was, in essence, depressed." (26) Blaha confirms the depression; with a reduced workload and improved support, he completes his mission. Salyut-5’s visit by the Soyuz-21 cosmonauts Volynov and Zholobov, slated to beat the 63-day record, was cut short after seven weeks, and no official reason was given. Based on medical records (released a year later) indicating a marked decline in the copilot’s health, Soviet news items on the problems of psychological isolation and sensory deprivation, and the statement of the crew’s general health as "satisfactory" rather than the far more usual "excellent", author James Oberg conjectures that psychological problems cut short the mission (though there is some suggestion that an "acrid odor" from the cabin air-regeneration system may have been the culprit). (27) Burrough, in Dragonfly, quotes ‘NASA sources who have spoken at length with Russian psychologists’ as stating Soyuz-21 (Volynov and Zholobov) as terminated early due to "interpersonal issues", Soyuz T-14 (Vasyutin) due to "mood and performance issues", and Soyuz TM-2 in 1987 (Laveikin) due to "interpersonal issues and cardiac irregularity". (28) Stress from the fire aboard Mir led Jerry Linenger himself to become more withdrawn and isolated; eventually he even refused to participate in voice communications. Burrough observes, "Linenger’s voice is high-pitched and shrill; he sounds as if he is on the verge of some kind of breakdown." (29) When psychological problems are discussed the "24-hour mutiny" aboard Skylab-4 is frequently brought up; for one 24-hour period, astronauts Carr, Gibson and Pogue ‘refused’ to do any work, choosing instead to relax, look out the window, and rest. This is given as evidence that long-duration spaceflight engenders conspiracy and revolt, and in fact, the rebellion against NASA Ground Control overtasking led to none of the crew ever flying again (30). An alternate explanation for the ‘sedition’ is that all Sundays were scheduled to be ‘down time’; the astronauts worked through most of their ‘vacation Sundays’ to keep up, but claimed one Sunday as their own for rest and relaxation. Be that as it may, it is unlikely to be a coincidence that none of the three ever flew again. Psychological Special Case – ‘The Call of the Abyss’ In the days of sailing ships, physically sound young men would occasionally throw themselves from the boat and drown, overcome by fascination with the sea. This "Call of the Waters", as it was named, may have a latter-day equivalent in spaceflight. Just as some are compelled to stand on the edge of precipices or stare off bridges into the void below, some astronauts are fascinated by the free-falling view of space afforded by spacewalking. Valeri Ryumin’s diary from his 1979 stay aboard Salyut-6 described his August 15 spacewalk: "You’re out of your mind, I was telling myself – hanging on to a ship in space, and to your life, and getting ready to admire a sunset." (31) In fact, right from the start some spacewalkers have been reluctant to return to the safety of the ship. America’s first spacewalker, Ed White, had to be ordered back into the capsule by Mission Control. When McDivitt had to tell him it was time to come back inside, White sighed, "It's the saddest moment of my life." (32) But this compulsion to stare into the void almost turned deadly for rookie cosmonaut Yuri Romanenko. During his 1977 stay on-board Salyut-6 with Georgi Grechko, a 20 December spacewalk was scheduled; Grechko would spacewalk, and Romanenko was to stay inside the airlock, monitoring medical readings. But Romanenko’s curiosity got the better of him; he stuck his head out of the hatch, then drifted further and further out. When he started thrashing wildly, Grechko realized his friend’s safety line wasn’t attached, and Romanenko was drifting off into space! By leaning over as Romanenko drifted by, Grechko was able to grab hold of the safety line and pull him back in. Had Romanenko been further out, he would have drifted off and eventually suffocated. (33) Future spacewalkers would do well to heed Nietzsche’s advice: "When you look long into an abyss, the abyss also looks into you." Space is a dangerous place to get sick (mentally or physically), and help is currently a long way off: evacuation time is estimated to be 24 hours from Low Earth Orbit (LEO), 3 days from the Moon, and as long as 2 years from a Mars colony. But what if definitive treatment could be provided on-site, whether it be in LEO, on the Moon, on Mars, or beyond? This possibility is the subject of the final ‘Aerospace Medicine 101’ paper, "Surgery in Space".
REFERENCES
13) Ibid, pg. 302. 14) Wade M. ‘Laveykin’ entry, Encyclopedia Astronautica CD-ROM, 1998. 15) Burrough B. Dragonfly, pg. 448. HarperCollins Publishers; New York, NY. 1998. 16) Landis, G. Personal communication, 1999. 17) Oberg J. Red Star in Orbit, pg. 104. Random House Inc.; New York, NY. 1981. 18) Burrough, pg. 135. 19) Ibid, pg. 355. 20) 1997 letter from NASA Inspector Roberta Gross to Representative F. James Sensenbrenner, Appendix C. 21) Nicogossian AE, Pool SL, Uri JJ. "Historical Perspectives’, pg. 12. In: Space Physiology and Medicine, 3rd ed. Edited by Nicogossian AE, CL Huntoon and SL Pool. Malvern, PA. Lea & Febiger. 1993. 22) Borenstein S. ‘NASA Has Health Problems’, published in Detroit Free Press, 24 July 99. 23) Berry, pp 94-5. 24) Newkirk D. Almanac of Soviet Manned Space Flight. Newly printed; ISBN 0872018482. Chapter 5 available on-line, currently at www.mcs.net/~rusaerog/aosmsf/ch5.html . 25) Burrough, pp 111-4. 26) Oberg, pp. 145-6. 27) Burrough, pg. 185. 28) Ibid, pg. 178. 29) Ibid, pp. 185-6. 30) Oberg, pg. 217. 31) Wade, ‘White’ entry, Encyclopedia Astronautica CD-ROM, 1998. 32) Oberg, pp. 165-6.
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