2024 APEX Award winning article

An astronaut steps onto the rust-red surface of Mars, above her the expanse of the galaxy, bright against the darkness of space. Her teammates are setting up basecamp—after a seven-month journey they intend to stay for at least the next year. She wants to help, but her right upper quadrant pain from the past two days is worsening, and she knows she’s been running a low-grade fever. Suddenly, the pain intensifies, and she clutches her abdomen. Her teammates rush over and bring her back onboard their ship. An emergency-physician astronaut rapidly uses a hand-held ultrasound (US) machine to diagnose her with acute cholecystitis. Earth is seven months away, but the physician has trained for this. She takes the astronaut to the medical bay, and with the assistance of her teammates, runs labs, starts intravenous fluids and medications, and prepares to place an US-guided drain.

The Future of Space Medicine

Dr. Lehnhardt

Aviation medicine—the predecessor of today’s space medicine—has been around since the early 1900s, when aviation first took flight. Only a few decades later, President John F. Kennedy launched the nation’s space dreams. Though the technological difficulties seemed insurmountable to some, by 1969, the United States had achieved that dream of going to the Moon and returning safely to Earth. By 1998, the first element of the International Space Station was launched, and today, space tourism is a commercial enterprise, academic and commercial endeavors are eyeing low Earth orbit, and a return to the Moon and voyaging beyond to Mars are the next steps in space travel.

But how does the human body cope with the extreme environments of space? Our understanding of the effects of space on human anatomy and physiology is ever-expanding, and space medicine has grown to fill that niche. As Kris Lehnhardt, MD, the element scientist for exploration medical capability at the NASA Johnson Space Center and an emergency physician at Baylor College of Medicine, both in Houston, notes, “Some physiologic changes that occur in space are good—for example, less muscle mass in the legs is helpful in zero-gravity. The problems often occur when you return home—or to any celestial body. If you haven’t used effective countermeasures to maintain your body in an Earth-like state, the stresses of gravity become problematic. One of our jobs is to figure out what those changes are, especially in the long term when you’re thinking about three-year missions to Mars, and to come up with appropriate countermeasures.”

Dr. Aintlabian

While the National Aeronautics and Space Administration (NASA) has long provided cutting-edge research and medical advancements in space, the field is now expanding into the commercial sector and the need for more expertise is high. New space-medicine fellowship programs are coming to fruition to meet these demands of the space industry, with emergency medicine (EM), a pioneer and trailblazer among medical specialties, playing a role. In 2022, both the University of California Los Angeles (UCLA) and the University of Texas Health Science Center at Houston (UTHealth Houston) inaugurated their space medicine fellowship programs with Haig Aintablian, MD and Nicolas Heft, MD, respectively, as their fellows. Both are EM physicians.

Other aerospace medicine programs, such as the residency through the University of Texas Medical Branch, focus on public health and preventive medicine and are certified through the American Board of Preventive Medicine. These new programs at UCLA and UTHealth Houston distinguish themselves by concentrating on acute medicine rather than preventive medicine. As Dr. Heft puts it, “One day in the near future, we will need physicians who are trained and equipped to provide acute care on missions that take you beyond the immediate reach of Earth. From low Earth orbit, it only takes several hours to return to Earth and receive top-tier medical assistance, but what about from the Moon? From Mars? Or even further?”

Dr. Heft

Although physicians will always be needed for ground support, EM physicians are particularly well prepared for this evolution into a mission-integrated role. “We’re the Swiss army knife of specialties,” Dr. Aintablian notes. “If you’re a great terrestrial doctor, you’d likely make a great space doctor. We have 80–85 percent of the skills already. The space medicine fellowship focuses on closing those knowledge gaps: how to perform regional blocks, advanced dental procedures and extractions, US-guided nephrostomy and cholecystostomy tube placements, appendectomies, and long-term management of medical problems and psychiatric illnesses.” This last skill, they all agree, is likely the most important of all. On a months- or years-long journey with no escape and no quick way back to Earth, psychological stress builds up. Professional therapy and medication management en route can be both preventative and therapeutic. As such, in addition to rotations with surgery, orthopedics, ophthalmology, dentistry, and anesthesia, the space fellowships include psychiatry components. All this while maintaining EM clinical competency and learning the key tenets of aerospace medicine and biomedical engineering.

“The engineering aspect to our training teaches us how to integrate medicine into the design of the spacecraft, from spacesuits to medical devices,” Dr. Aintablian explains. “Given the mass and physical space restrictions, we need to learn how to make things smaller, lighter, and smarter, and we need to learn how to communicate and interface with our engineers in that regard.” A space physician, then, must be trained in the foundations of engineering design but must also improvise with limited resources. Perhaps this is why EM physicians can be such a natural fit for the role—we are an inventive field that thrives in critical thinking and innovation.

The crew of NASA’s Artemis II mission (left to right): NASA astronauts Christina Hammock Koch, Reid Wiseman (seated), Victor Glover, and Canadian Space Agency astronaut Jeremy Hansen. (Click to enlarge.)

Although both new space-medicine fellowship programs are currently for EM-trained physicians only, all three space physicians are hopeful that this will change. “EM doctors are certainly not the only ones who should be training to fill this gap,” Dr. Heft states. “We are currently diving into this field of providing acute care in space, but we are only one component of the cadre of doctors that will be needed to make humans a multi-planetary species. It’s a team effort and doesn’t belong to just one medical specialty. Of course, the ultimate priority is the safety of the crew and the combination of both preventative and acute care to ensure their safe return.” Their views on diversity extend to space travel as well, and they embrace the expansion of space travel to non-NASA astronauts as a natural next step in the development and evolution of space flight. As Dr. Aintablian puts it, “If space isn’t accessible to everyone, even to people with chronic medical problems, then it’s really not as exciting.”

Job opportunities for well-trained space-medicine doctors continue to grow, from NASA to the private space industry. The applications of their innovations, however, are not just limited to space. The technologies from space adapt to extreme environments or resource-limited settings on Earth. As Dr. Lehnhardt explains, “Some of our biggest obstacles in space include communication delays, limited diagnostic capability, and resource efficiency. We are at the forefront of developing new technologies for these austere settings.” One example Dr. Lehnhardt gives is a current NASA project to create intravenous fluids from potable water. This strategy avoids wasting expired intravenous fluids in space; on Earth the process could see use in disaster zones or remote rural hospitals.

Space medicine may not really be the final frontier—after all, we are always learning to push the boundaries of medicine and human capability—but it does provide a whole new field of study, a subspecialty whose intricacies and innovations will have ramifications on Earth as well as among the stars.

“We’re at an inflection point in space medicine with our needs and demands changing,” Dr. Lehnhardt muses. “The next 10 to 20 years will see a rapid growth in space travel, which makes this an exciting time to be in space medicine.”

Dr. Sophia Gorgens

Dr. Görgens is part of the Zucker Emergency Medicine Residency at North Shore University Hospital and Long Island Jewish Medical Center. Her work has been  published in the Journal of the American Medical Association and Annals of Emergency Medicine, and she is the newest guest resident editor for the AMA Journal of Ethics.

NASA’s international astronaut corps awaits the announcement of the four crewmembers of the Artemis II crew that will travel around the Moon during a Monday, April 3, 2023, crew announcement news conference at Ellington Field near NASA’s Johnson Space Center. (Click to enlarge.)