>> So now we'll
get to Dr. Dervay.
Dr. Joe Dervay has been a flight
surgeon at NASA for the past 20
years and currently serves
as the lead of the medical
operations group.
He graduated from Cornell
University and Syracuse Upstate
Medical University.
Entering the US Navy and
completing training as a naval
flight surgeon, he served aboard
their aircraft carrier
USS John F. Kennedy.
That one's been decommissioned, right?
>> Dr. Joe Dervay: Yes indeed.
>> Dr. Dervay has completed
residences in emergency medicine
and aerospace medicine,
fellowship training in space
medicine, research and clinical
work undersea medicine, received
a master's in public health and
a masters of medical science
with a focus on nitrogen
bubble nucleation.
Prior to JSC included working
three years at NASA headquarters
and since being at JSC beginning
with STS-77 he has served as
crew or deputy crew surgeon
for numerous shuttle and ISS
missions.
He serves as co-chair of the
multi-medical operations panel
MMOP and is chair of the
MMOP EVA working group.
Dr. Dervay holds the rank of
captain in the US Navy with over
30 years of active duty and
reserve service with numerous
Navy and Marine Corps
units worldwide.
Thank you for your service.
>> Dr. Joe Dervay: Thank you.
>> And so we now introduce Dr. Dervay.
>> Dr. Joe Dervay:
Thank you [applause].
Well good afternoon and Janice
I'd like to thank you and your
team for the invite to come
here and speak to this group.
We're going to have a little fun
this afternoon and I also want
to welcome the clerks that are
in town for the month that are
going to be working with
us primarily in the medical
operations arena.
So today we're going to have a
chance to talk with you a little
bit about spaceflight
medical operations.
Some of you in this room are
experts in given areas and I'm
just going to kind of give you
the broad-brush perspective from
the flight surgeon's vantage
point to give you a sense of how
we deal with our crewmembers
pre-flight, during flight, and
post-flight.
And Dr. Blake Chamberlain, one
of my flights surgeon colleagues
is in the audience so Blake
please pipe in if there's
anything else you want to
add to the conversation.
So for those folks that are
visiting from out of town what's
the first word said from
the surface of the moon for all
you Jeopardy folks out there?
[ Inaudible Comment ]
Houston exactly, Houston
tranquility base,
the eagle has landed.
So we're very proud of our space
city here and hopefully during
your time here you'll have an
opportunity to see Houston and
Kemah and our entire area.
The space center is grand place
obviously, our big Apollo rocket
is now covered down here in the
corner, but hopefully you'll
have an opportunity to see a
variety of things, I know Aliska
[assumed spelling] is going to
have some great tours, as well
as some of the academics that
are going to take place for you
here.
If you brought your own car be
careful going down route 146
Officer Starsky
with the radar gun has
caught some of our clerks in the
past, so be a little careful as
you go zipping by
this area here.
So some of the objectives is
to give you a perspective and a
scope of the NASA medical
operations, highlight some of
the unique medical,
physiological and behavioral
aspects of spaceflight that we
deal with, and review some of
the challenges for remote care.
Our primary responsibility is
to ensure the health, safety and
well-being of the astronaut core
during all phases of the flight.
So it's a very broad
responsibility and we'll tease
some of those areas out.
Our docs come from a variety of
backgrounds, we have about 20
physicians or so, almost
everybody is clinically trained,
as well as aerospace trained.
We have a number of folks that
come from the military as well
and so for many of us our
medical care began -- our
learning of how to take care
of folks in high-performance
operations.
And the as mentioned earlier,
I spent two and a half years on
the John F. Kennedy
and we had a -- it's a
city unto itself 5,000 sailors
and Marines on board.
We had about 85 aircraft and it
was a very impressive operation.
Obviously, we've retired the
shuttle, how many folks have
been to a shuttle launch?
So it really is
sad to see it go.
Obviously, a beautiful vehicle
and so for those that have been
done there I think you'll attest
to the fact that every launch
was unique, the acoustics, the
lighting parameters were all
different and it still amazes
me to think that you can take
something that's 18 stories and
by the time it's clearing the
launch pad it's going over a
hundred miles an hour, so it's
very impressive.
Some of the physiological
issues, you've had some experts
already come and chat with you,
but I'm giving you a look how we
break down a couple of our
key physiological areas.
One of them is our space
motion sickness, cardiovascular
neurovestibular, musculoskeletal
and behavioral psychosocial and
we'll kind of talk through a
few of these different ones.
So there are some differences
when we take a pretty normal
human being and put them up
in an environment of space.
As I'm standing here right now
there's obviously blood going
down to my legs, there's various
muscles and also the vessels are
pushing the blood more cephalad.
As soon as you hit the space
arena what happens, you get that
cephalad fluid shift.
And we're also seeing changes
with all these different
components here, many of which
you'll have some specific
lectures on and I know you've
received some bone lectures
already.
So as I mentioned, the fluid
in space comes up cephalad, the
receptors your aortic receptors,
your carotid receptors sense
that extra fluid load and
what typically happens?
You want to unload
some of that fluid.
So the astronauts actually the
first few days they diurese,
they urinate a lot more
the first few days.
And there's overall about a 12
to 15% redistribution, we lose
some plasma volume, there's a
decrease in red cell mass as we
try to adjust for
that relative anemia.
So when you see the crewmembers'
faces initially they're rounder,
more cherubic type looking and
they also will maybe have more
of a nasal congestion type of
sound that will abate over a
period of time.
So that cardiovascular
rebalancing which the body is
brilliant at doing is an
issue for us when we bring our
crewmembers home.
So we have to adjust various
issues when they're coming back,
we use various fluid treatment
protocols, things like we call
astro raid or various salt
tablets and water solutions the
period of time before they come
home to try to rebuild up that
12 to 15% plasma volume.
On orbit exercise has been very
beneficial to our cardiovascular
system.
We've also looked at
various medications.
We had a study in midodrine
for example, which is used for
autonomic dysfunction
for folks on the ground.
That study went for a little
while and terminated because of
some issues regarding things
in the literature with a QT
duration.
But medications may have some
role as well down the road.
From a neurosensory perspective
it's pretty amazing to think
what happens.
The computer in the brain is
getting all these different
inputs because you think about
how long does it take to get
into space from the pad, anybody
know, about how many minutes?
About eight and a half minutes.
So eight and a half minutes
you're on orbit and particularly
taken for example the shuttle,
eight and a half minutes they're
getting out of their seats
pretty promptly, they're often
getting their cameras out to
take various pictures of the
external tank, setting up
laptops, getting out of their
gear and it can often be
a very provocative time.
So all those different inputs
the window's over here you see
the sun coming in at a different
angle, the earth's down there,
your crewmember might be upside
down and you're trying to get
your bearings and the computer
in your brain is getting all
these various inputs, as well as
your elbows in your joints the
proprioceptive aspects.
I know where my body knows where
my elbow is right now, but all
of a sudden in that environment
everything is very different.
So we have this sensory
overload that causes some of our
crewmembers to get ill.
It affects about 70%
of our crewmembers.
Interestingly though in the
Gemini, Apollo or Mercury,
Gemini and Apollo program very
few astronauts got sick at all.
Why is that, well they were in
essence strapped in their seat?
The Mercury and Gemini
crewmembers were in essence in
their seats they never got out
for the most part unless they
were going an EVA
through the Gemini hatch.
And so the body was able to
adapt to those inputs versus
what we experience
in the shuttle.
So about 70% of our
crewmembers get ill.
The range of symptoms could be
anything from just a little bit
of stomach awareness to frank
vomiting that is there's really
no projem they don't really
feel nauseous all of a sudden
boom they're setting up a
laptop and they get ill.
So that's why sometimes you'll
see the photographs of the folks
with a little vomit bag sticking
in their pocket because we
encourage them to be very
cautious with their head
movements, keeping their head on
a stick, trying to keep the 1G
orientation.
For example, in the shuttle when
they were going up the ladder
not to go diving down to the mid
deck from the upper deck, but
use the ladder as they
normally would until they could
equilibrate.
We also use various medications.
For example, meclizine
oral meclizine, Phenergan
intramuscular to help with
these various symptoms.
A few of the astronauts actually
have a voracious appetite, so
while some of their crewmembers
are getting ill and not feeling
too well a few of them are very
hungry when they get up there.
How does that translate, well
when they pick their menu items
out if you know you're someone
who feels pretty good the first
day and you watch your friend
pick their menu you might go,
you know, you really might want
to go with the shrimp cocktail
the first day or so because I'm
going to end up
eating it for you.
So some value there.
So the neurosensory responses
that eventually equilibrates and
the crewmembers will say once
they break through that wall
those first couple of days
everything is fine and so,
therefore, the sense of up and
down is really what you choose
to define it. We have all this workspace now.
The lighting is still set up
to be on top and some of the
footholds here they give you --
still have that
sense of up and down.
But the crewmembers once they
equilibrate they do
very, very well.
Musculoskeletal system, I'll
just cover this lightly, I think
Dr. Sibonga was here recently
and gave you
some perspective on it.
But the bone and muscles are
constantly remodeling due to
physical loads and so we're
tracking this, we're learning a
tremendous amount from
our colleagues
in the bone community.
And looking at how the different
spongy bone and compact bone how
they react with the balance
between the osteoclast and
osteoblasts are and this all
dovetails into
what we do for exercise.
Exercise is a key component of
our ability to maintain muscular
strength and as well
as our bony health.
A couple shots here of Jerry
Linenger back on the Mir space
station with the Russians on a
treadmill and Bob Curbeam here
is in the shuttle mid deck with
an ergometer,
a little cycler ergometer.
So currently our crewmembers
exercise on orbit about two
hours a day, it might seem like
a lot of time to you, but for
them it's something they look
forward to, they're doing a
balance of aerobic exercise,
resistive exercise, and some of
them are in better shape than
when they left because their
schedule is often very, very
busy before they left so for
them to have a chance to focus.
And they're often coming back
and we're almost able to retire
the risk of some of these bone
losses because we're really
seeing some excellent muscular
strength when they come back.
Dr. Shannon Lucid here she is on
the Mir and you'll notice she's
on the treadmill, so
particularly for our new folks
coming in you'll notice that
she has a harness on because
obviously due to simple physics
equal and opposite reactions as
soon as you hit that treadmill
she's going the other direction.
But the Mir was pretty it's
like being in the back of your
garage, there was stuff
everywhere and our inventory
systems now are much more
designed to help keep a cleaner
environment and make sure
we know where things are.
But she's working out and
having a good old time.
And now on the ISS with the
treadmill Dr. Thirsk, a Canadian
physician and you'll see
him there with his bungies.
Now Deitra I think you said that
it should work on the next slide
if I double-click it.
>> Just double click.
>> Okay, let's see how we get.
We have a little video clip just
of him running on that, which
you may have seen with the
exercise class, I'm not sure why
this is not taking
on the wav file.
And you get a little bit of a
feel for the advanced resistive
exercise device, you
got a sense that.
So this device again, if you
want to take a quick peek at
this see if we can
get that going.
The exercise device the
engineering behind it allows us
to get loads up to 600 pounds.
Now think about that for a
moment, the device doesn't weigh
anything in space it has inertia
of course, but the engineering
is such that we're able to get
up to 600 pounds for some of the
squats, other work
that's necessary.
So there we go.
I might have you just do the
other one and we'll go backwards
for a second after
this one is done.
But you can see that the motion
of it this gentleman is working
-- one of our Russian colleagues
is working pretty hard here.
But notice there has to be a
system here vibration isolation
system because you cannot impart
the loads into the vehicle for a
couple reasons.
You guys and ladies have been to
the gym you see people throwing
weights down and just
all that movement.
So we don't want to impart the
loads
to a couple of different areas.
One of them is where the modules
come together at the joints and
secondarily and probably most
important is
to the big solar arrays.
You don't want to get those
solar arrays wafting in the
breeze from all these energies
that are imparted there.
So we're were seeing some great
work with this gentleman and
love the results.
If we can go back to the
treadmill for just one second,
two slides back.
And here is the astronaut Ron
Garan, you got it up I think it
just needs to, there we go.
You'll see him running and the
crewmembers will often watch a
movie, listen to some music.
How long does it take to go
around the earth once,
anybody know?
Ninety minutes, so you can
basically -- we've had multiple
folks in essence that was their
goal to run around the world.
We've also had folks that
have -- Captain Sonny Williams
actually did the Boston
Marathon, while some of her
friends were on the ground
running the marathon she was on
orbit performing that.
But the bungees themselves and
the harnesses they impact some
abrasions and some other issues
-- thank you, I think we're in good shape.
So we often have to deal
with some of those issues.
So let's just talk about the
behavioral psychosocial, this is
a big arena for us.
The two limiting factors in
many respects to go to Mars for
example are radiation and
behavioral psychosocial.
You know, how do you pick six of
your best colleagues to spend a
couple years with you, how do
you pick those people,
how do we do that?
There's so many factors involved
with the personalities and habits.
And as we're doing an
international space station with
16 countries we've learned
a tremendous amount.
Some cultures, some people when
they get very mad
they get very quiet.
There's other people that get
very demonstrative when they're
upset about little things.
And so the personalities are
very important
for us to learn about.
We have NOLS National Outdoor
Leadership School where some of
our crewmembers will go and some of our physicians
Dr. Chamberlain and I have both
gotten to do that with
some of our flight directors.
We actually go out in the field
either on it could be a kayaking
expedition or some kind of trek
and the crew is put in various
scenarios where they have to
learn how to work together, they
learn a lot about their
strengths and weaknesses and
various leadership styles that
they have very, very helpful.
And as well as issues not
here with our family contact.
The crewmembers now have
what they call an IP internet
protocol phone where they have
the opportunity to call their
family up and talk
to their families.
We also have private family
conferences once a week where
they can actually have a video
linkup so
they are able to see their families.
So those elements are all very
important as we try to maximize
their health and performance.
Anybody know who
this gentleman is?
This is a shot from I believe
around 1994 of the Mir Space
Station that's Dr. Polyakov,
he spent 438 days in space.
Now think about that.
We're going to close the doors,
we're going to get you a little
bathroom, a little galley, some
exercise equipment, some good
science, but you're going to
stay here for 438 days,
it's a long time.
We have about four folks that
have had over a year-long space
expeditions and obviously we're
very proud of Captain Scott
Kelly going up here launching
very recently, so his year his
clock is starting to
wind down backgrounds.
But I've met this gentleman,
a very interesting fellow.
When you first met him you kind
of were looking for that deer in
the headlights look, I mean
that's a long time, but he's
very engaging and wonderful.
But it is a long time and we're
going to obviously have to have
a lot more experience in
this arena, as well as some
ground-based studies to help us
really understand some of the
cycles of behavioral aspects
before we send folks far away.
Another shot of Dr. Lucid here
she's got a big smile on her
face, she's doing some
hydroponics activity.
Growing some wheat, at least
I hope it's wheat on space
station, but these activities
are very, very good
and very helpful.
Fresh fruit is another one when
the little delivery truck came
up or a visiting vehicle came
up with some fresh carrots and
grapes big smiles on our folks.
So these things they may
seem small, but they're very
important to the behavioral
support of our crewmembers.
Some different medical events
that we've had in the program as
I had mentioned earlier with
Mercury and Gemini where we
didn't have any space motion
sickness, we really didn't get
anything until really around
Apollo 8 when the crewmembers
started to move within the
confines of the capsule.
We had some space motion
sickness during EVA Apollo 9, as
you recall just went around the
earth it was to test the lunar
lander in earth orbit.
And we had a delay in one of
the EVAs
because of some motion sickness.
DCS stands for decompression
sickness and for those of you --
any divers here you
understand what the bends are.
We never really had
decompression sickness during an
EVA that's been reported,
but Mike Collins in his books
reported some knee pain that
existed when the capsule went
from 14 pounds per square inch
to 5 pounds per square inch 100%
percent oxygen, he had some knee
discomfort that arose and that
may have been attributed to
some kind of DCS for that knee.
Urinary tract infection during
Apollo 13, you're all very
familiar with the Apollo
13 movie and how cold that
environment got as they had to
power things down and a urinary
tract infection existed
for the crewmembers.
There was some cardiac
dysrhythmias that took place on
the lunar surface that were
noted during one of the
crewmembers.
The fidelity and the ability
for us to look and evaluate
cardiovascular issues with our
aeromedical boards is at a much
higher capability now, so we
spent a lot of time really
looking at our crewmembers
-- for all the international
crewmembers in that capacity.
And then the Apollo test project
as you recall when the Americans
and Russians shook hands and the
two vehicles docked in orbit and
when the Apollo capsule came
back there was a little bit of a
leak through one of the vents of
nitrogen tetroxide and it caused
some chemical pneumonitis and
the crewmembers ended up just
spending a couple of days in
the hospital in Hawaii as they
recovered and did quite well.
So these things
have all happened.
And in the Russian program
issues that helped that result
-- not resulting in mission
termination or early return, but
as we looked at a couple of
these different areas these
arose before our space
station was built.
So what are the two worst
things you can think about in a
confined closed environment,
fire and decompression of the
vehicle and those
happened in various ways.
Some small fires with some
oxygen generating candles.
For example, on the Mir we had
a decompression when a visiting
vehicle came up and impacted
it and caused some the
pressurization.
Kidney stones, we believe the
Russians had one that they were
able to treat on orbit without
having to return the crew member
with various medications
and hydration.
And there was a psychological
stress reaction that took place
that may be related to
carbon dioxide buildup or the
crewmembers not
getting along well.
A lot of this information we
never even were able to get from
the Russians for years until we
started to work with them much
more closely and had good
working relationships with them.
So obviously the hazards of
spaceflight includes some of the
issues we've already covered
in terms of the physiological
aspects, but just radiation,
debris and various other aspects
and we're going to touch on
a few of these in terms of
circadian and
decompression sickness.
From the radiation perspective
our workers are considered --
our astronauts are
considered radiation workers.
And the principle is the ALARA
principal as low as reasonably
achievable and so we try to
prevent the radiation dose for
their lifetime experience to
result in greater than 3% risk
of developing cancer.
So obviously, we have solar
particle events, cosmic galactic
radiation coming in and once
we leave the Van Allen belts
because currently we're within
that and our astronauts get a
slightly higher
dose of radiation.
But it's when we start going
into deep space that that's
going to be a big deal.
So how do you develop the
vehicle to protect them, I mean
you can't fly led vehicles
that weighs a lot.
Do you use water as an
insulator, water is known to be
insulated for some radiation.
We do we have a shield around
the vehicle of a certain
thickness of water.
What about some pharmaceuticals,
what medications can we fly on
board that are going to help
the DNA repair medications?
What about ladies of
childbearing age, should we be
going and harvesting some of
their eggs so if they eventually
finish their spaceflight and
they said it's time for me to be
a mom or to be a mom again,
approaching
all those different issues.
Looking at the genetics are
certain crewmembers predisposed
because of their genetic makeup
that may have more implication
due to the radiation
they may be exposed to.
So some wonderful topics
for us to dive into.
Anybody remember
what this is here?
>> The vomit comet
The KC-135, an aircraft that we
used to have we fly a DC-9, but
it flies over the Gulf of Mexico
about 26,000 feet in parabolic
flight and you get about two
second or I'm sorry about 20, 30
seconds of microgravity and then
downhill you're kind of slammed
down into the cabin
under a 2G load.
But this is the vomit comet,
weightless wonder and you can
see some shots here of some
procedures
that we have to do.
For example, here is something
with some blood draw and IV.
This guy's not having a
good day here obviously.
And there's some airway
work being done here.
So a lot of this is to test how
do you do these procedures and
also to develop checklists.
Everything has to have a
checklist and a procedure
because for those of you that
have drawn just a simple thing
-- have drawn blood, have done
some suturing, every time you
touch something basically put it
down, but now you got to imagine
this floating environment where
the alcohol pad you let it go
it's going to corkscrew that
little edge of the alcohol pad
could easily hit you in the eye
and cause a corneal abrasion.
The end of your suture
is going to wrap up.
All those things have to
be taken into account.
So a lot of work is done to
develop the procedures that the
crewmembers will utilize.
ACLS procedures
had to be utilized.
How do you do CPR?
We talked earlier about running
on the treadmill as soon as you
hit you're going the
opposite direction.
Well, the same thing when you're
in this aircraft and you do a
compression for your CPR on
the mannequin, which way do you
think you're going,
the other way exactly.
So we looked at various devices
that you can put compressors on,
various belts that you
can be close in proximity.
One of the best ways was
actually this piston method
where you actually had your feet
up on top and you were able to
get that that vertical push and
kind of regulate how much force
you put on.
So very interesting trying to
find the simple solutions to
problems.
We've also flown -- this is some
shots where we've actually flown
this is a pig that we flew and
we were doing various procedures
here on if we can do a
diagnostic peritoneal lavage,
which really isn't done so much
now because
we have ultrasound capability.
But it was to look for blood
in the abdominal cavity.
Putting in chest tubes.
We actually also fed the cameras
through the urethra and up into
the ureters to see if we can
go in and kind of snag a kidney
stone if it existed here.
So there's some great work that
that was done
over a period of time.
Very challenging because you got
to imagine you're doing these
parabolas and you're only
getting about 30 seconds and
then you're pushed down and then
you're also trying to keep all
the anesthesia and everything
else going with
the pigs up there.
And then once in a while you
have a little bit of fun and you
get to spin around here.
You can't do this your first
few parabolas because if you do
you're going to be pretty
worthless, but I wish everybody
would have a chance to
experience it, it is an E ticket
amusement park fun no doubt.
This is to remind me about the
settling of dust and foreign
body and injuries to the eyes.
This is Steve Smith, one of our
astronauts, who's showing how he
had to get something
out of the eye.
The Russian colleagues would
squeeze some water and you kind
of float in, put his eye in
there and kind of blink up and
then take a towel
and then dab it out.
And that was how they got
something out because as we're
sitting and standing here dust,
debris, anything falls to the
ground.
But obviously when you're
floating all those little
particulate matters which we
hope gets pulled out through our
filtration system still exists.
And we've had occasion where
folks have opened a panel behind
a -- near a locker and had a
small little piece of metal that
was there that got shaken during
the launch that corkscrewed out
and get in somebody's eye.
We've had foreign bodies
that we've had to remove.
Now that could have a big impact
if it happens a day or so before
your spacewalk, of course.
So those ocular issues
are important for us.
We have a device and this is one
of our colleagues here, Chuck
Lloyd, who's in the KC flight
with flying basically a little
simple set of Speedo goggles.
We're trying to figure out how
do you go about if you get a
toxicological element in your
eye, how do you rinse your eye
out?
Do you just keep squirting
the water with a towel?
And so a few folks came up with
a rather elegant way to do this
and basically it was a $6.96
set of goggles with some water
hooked up which on the shuttle
for example was from the galley
and the waste collection system
would be through the waste
management system.
And so basically it was a very
elegant way to bring water in as
opposed to goggles keeping the
water out we do the opposite.
We put the goggles on, run
the water through and that way
you're able to go
ahead and utilize it.
And we've used it in space,
we've used it at least on a
couple of occasions.
I could think of two spacewalks
where the visor on the inside of
the visor you put a thin layer
of the anti-fog, it's almost
like dishwasher detergent
to keep it from fogging up.
And some it's a drink bag -- the
water from the drink bag leak
got in there and it caused these
things to run off and it got in
the crewmember's eyes.
So when you're in a spacesuit
you can't rub your eyes sand so
it was very uncomfortable
toward the end of their EVAs.
And they came into the shuttle
and put these goggles on and
were able to
irrigate their eyes.
So 650 or whatever it is for
the goggles probably cost us a
hundred grand just to do the
paperwork and the certification.
But it is nice to see that
sometimes there's an elegant
solution to a problem that
could be right in front you when
you're sitting there watching
your kiddies in the pool.
So anybody know who this and
where this shot was taken?
This is a shot from Skylab and
this is Dr. Joe Kerwin, Navy
captain doc, first US physician
in space and he's taking care of
Pete Conrad.
And this is how he had his
office set up, pretty ingenious
way for him to go ahead
and do some medical care.
So this leads him to a little
bit -- some specifics about the
support of our medical cadre.
And we have what we call private
medical conferences that take
place with our crewmembers
in essence, once a week.
For the shuttle, for the short
duration missions we used to do
it every day.
And everything that's said on
the loop, the communication loop
is on open air to ground
for open consumption.
Medical stuff is private, so we
have a private conference where
we have an opportunity to
discuss with the crewmember how
they're doing, a whole variety
of aspects on their sleep,
their physical condition.
Remember they're exercising, but
there's no showers on ISS,
so you got to imagine that.
Six months or a year without a
shower, so they're using various
sponge baths, baby wipes,
etcetera so we're monitoring
their skin condition.
We're talking to them about
their sleep, their rest, any
other physical problems that
they're having, the medications
that we have up there for
them for a variety of reasons.
So we work very closely with our
crewmembers and make sure that
we try to maximize their health
in every way that we can.
We have various kits, I'm
highlighting this because I just
like the way it's -- this is
from the shuttle orbital kit and
it's just going to give
you the same perspective.
We have medical kits for the
international space station, but
you can see things are broken
out by various subsystems.
We've got a trauma sub pack,
ear, nose and throat, an IV
administration sub
pack, drug sub pack.
How much it cost to send
1 pound of gear uphill?
If I was going to take 1 pound
of something and send it uphill,
it costs about $10,000 or more.
So think about that, so you're
in charge of designing a medical
kid.
How are you going to do that?
Well you start looking at
Antarctica, you start looking at
the submarine community, prior
space experience, aircraft
carriers and you try to find
out what do you really need.
Plus we have a pretty good sense
of the hundred or so different
medical conditions that we've
identified that really think
could have an impact for us.
Try to maximize what
stuff we bring on orbit.
So everything is laid out in
kind of a kit formation and in
this case the packs we don't
have a lot of room so everything
has to be carefully packed.
We have -- everything is also
labeled so when we open that
procedure book that we talked
about before everything has a
procedure, we tell a crewmember
to go and get some dexamethasone
in slot number 28 and everything
is queued up so that they can go
through and rather efficiently
take care of the medical work
that they have to.
We also have a medical checklist
up there, so if you name the
system whether it's foreign body
in the eye, if it's diarrhea,
whatever it is we also have all
those medical procedures listed
out as well for them.
We also support with -- we used
to fly a defibrillator, we had a
defibrillator for some of the
space shuttle missions where we
did some science and that's now
moved over to an AED and we also
have a respiratory support pack
that we utilize should there be
any issues with maintaining an
airway either through various
serious problem with a
decompression hit, a type 2
neurological hit or some
toxicological exposure.
CMRS, crew medical restraint
system, we have to have a device
that we can actually put a
crewmember on, strap them on and
take care of them, and it also
has to be electrically
isolated so if we're delivering
some type of a shock we don't
want that delivered
to the entire vehicle.
So this is designed and we run
various simulations and on orbit
training with the crewmembers
utilizing some of the emergency
procedures.
What happens when you get things
in your eye, some
foreign bodies in your eye?
We have the emergency eye wash
that we talked about, we also
have a contamination cleanup
kit because there's been various
leaks that sometimes you'll be
working on replacing a battery
for the spacesuit, the EMU
battery and there's compounds
that come out and crewmembers
go what is this white material.
And so we have a hazmat database
we can figure out what that is
and do they need to put goggles
or gloves on, what's the best
manner for them to
protect themselves.
So the international space
station, how long has this been
up on orbit, anybody
have an idea?
This is a shot from 1998,
November 1998 when the FTB, the
Russian FTB functional cargo
block and the node 1 unity were
put together for the first time.
And subsequently, the space
station was put together over
time until we get
to where we are now.
So just to think this is pretty
amazing to think that we've had
permanent human presence,
continuous presence I should say
since November of 2000.
Think about that for a second.
I think most of the public
doesn't realize that it's been
that long.
Who's in space right now, well
you know Captain Kelly is in
space, but a lot of
people don't know.
Sometimes that's good that means
we are up there, we are doing
the work, we are
doing the science.
And the flipside of it is
sometimes we're not lighting the
fire for some of our young
people to really pay attention
to some of the unique things
that are going on and look at
some of the great work
that's being done.
So the space station as you
know, it's about the size of a
football field and for our
clerks here if you haven't had a
chance to see this at night you
can go on wherever you live type
in international ISS sighting and usually just after sunset or
just before sunrise as the sun
angles hitting it
you'll see it coming across your area.
And it is pretty remarkable,
it says you'll see it for five
minutes and then it comes south
southwest and north northeast
and it tells you how many
degrees off the horizon and it's
pretty accurate.
So you go outside and you look
and it's the brightest object
moving it's hauling and
it really is remarkable.
And for us that work closely
with the crewmembers to realize
that there's human heartbeats
on board is pretty incredible.
In particular, if a spacewalk
is going on and then you scoot
outside and you look at that and
you think that these folks are
hanging off the side of this
vehicle it's really impressive.
So it's over 800,000 pounds of
pieces and equipment and gear
were hauled up there over the
construction phase,
that's pretty incredible.
This is to me is one of the most
angelic photos of the entire
space program, it's Captain
Bruce McCandless in the man
maneuvering unit.
I just think it's phenomenal,
which I want to lead into the
section about spacewalks.
So when we look at the spacesuit
in this case he's on the man
maneuvering unit we don't
utilize this anymore, we use it
during a shuttle for
a couple missions.
But our crewmembers now are all
tethered so they can't float
away from the space station
when they're doing their various
work.
But it really just makes me stop
to realize that this is a space
vehicle unto itself.
It's got cooling and heating,
it's got -- they wear a diaper
so there's some ability
to collect fluids.
We have a drink bag in there,
we have multiple layers of
protection from the environment,
from the hot, cold, and also
from the micrometeorite.
We have a communication system
in, we have cameras, lights, it
really is a remarkable --
CO2 scrubbing, things of that
nature, oxygen delivery.
This shot is from the Hubble,
so this is about 310 nautical
miles, you can definitely see a
little bit more
curvature of the earth.
So we call it spacewalking,
but really it's very upper body
intensive, very shoulder, arm
intensive and our crewmembers
unless you're on a planetary
surface is when you're walking
you can see the various
handholds here as the
crewmembers are going on and
also the various tethers so they
can't get out of
reach of the vehicle.
And the crewmembers also tell
you when they first open that
hatch it's pretty breathtaking.
They know they're not going to
fall, intellectually you know
you're not going to fall, but
when you open it up and you're
looking down 220 miles it's
quite energizing for them.
So during the mission control
aspect of it we are -- the
circuit control we're monitoring
various -- we're monitoring the
CO2, the 02, the
bio-environmental such as like
the metabolic rate.
We know when they're underwater
doing their training what their
normal metabolic load should
be to do a given task.
So we're monitoring this and
keeping in touch with the EVA
officer and the flight director
because if they're doing
something and you say man, their
metabolic rate doesn't look
right, why is that, are they
working too hard on a given
task, is this going to impact
their ability to continue to
work for a few more hours.
And so we carefully follow that
and in conjunction with any
medications that they may be on.
For example, say if someone
was on a decongestant or
pseudoephedrine for example, it
might impact their heart rate a
little bit.
So we know that so when we look
at their metabolic rate and
their heart rate we
balance all that out.
So we have a pretty good
understanding of the physiology.
Folks been out to the Sunny
Carter Training Facility?
Even for our folks that work
here sometimes we see JSC
colleagues that have never
had a chance to go out there.
Please go out and take a peek at
that, it's a tremendous national
asset and it's the
world's largest pool.
It's 100 feet by 200 feet by
40 feet, 6.2 million gallons.
So how much is 6.2 million
gallons, imagine going out to
you corner where you live and
taking the fire hydrant and
opening it up full-bore January
1st and letting it run 24 hours
a day, 31 days later
you can turn it off.
That's about how much water,
it's an incredible amount there.
And obviously, we have various
cranes that we can take pieces
in, we don't have the space
shuttle component in
like we used to.
But various aspects of the
international space station
where our crewmembers
can go and work.
Dr. Scott Parazynski you see him
getting ready to go, he's got
various tools set up on his
workstation there and he's going
to be lowered into
the water here.
You can see some weights
that are put here to make him
neutrally buoyant once he's in
the water and being lowered in.
These are all our control rooms,
we have some
medical monitors out there.
And we have one of our
physicians that works there is a
hyperbaric trained doc.
We have a hyperbaric chamber out
there should there be any issues
with the astronauts or
the folks that are diving.
Can't swim in the spacesuit so
these divers basically have to
move them from one workstation
to the next workstation.
There's also cameras down there
monitoring, filming,
so folks can see.
And the crewmembers when they're
underwater there is a certain
inertial drive, the water has
a certain resistance to it and
also when they're upside down
they still have that sense of
blood rushing to their head.
So we don't keep them upside
down for an
extended period of time.
But the crewmembers will tell
you it's the next best thing to
being in space and they operate
about 10 hours of training for
every one hour that they're
going to be doing a spacewalk.
Just take a little mental
snapshot of this picture and
this is on the edge of the
sill of the payload bay of the
shuttle and compare that to what
it looks like in space and
the blackness of space.
And the crewmembers will
say this is really excellent
fidelity training.
And here's another picture of a
crew member on the -- an arm, a
foot restraint being moved
underwater and then take a look
at this image in space.
So that the training, the
fidelity is
really quite wonderful.
The spacesuit beats
you up though.
You're in there and you're
kind of like the Michelin man,
Michelin lady in there the suit
is there to protect you, but you
got to work against the
resistance of it sometimes.
In of our crewmembers we have a
few injuries that come up from
time to time and for example,
in this one we have some issues
within the fingernails.
The nails get banged up and
there's some demyelination.
So the design of the
gloves are very important.
You think about when you put
your hand up what's the longest
finger, it's the middle finger.
But when you close your hand
ergonomically what's the longest
finger now, it's
your ring finger.
And so it's a little different
than just wearing a pair of
gloves that keep your hand warm
because you're having to do work
against the resistance.
So what we're learning is that
the design obviously is very important.
So some of our crewmembers
have these issues not everyone,
sometimes it may be due to the
moisture component, it could be
due to the fact that the length
of the fingers compared to the
depth of the webs.
So we try to manage this.
We looked at things like
phenols, Retin-A,
various creams.
We also for some crewmembers
we actually put bandages and
Dermabond on there to give them
a little protection and there's
other crewmembers that don't
have any issues at all.
But it's important because if
you've ever had a fingernail
start to come off it could
be a real painful thing.
And if you had a few more EVAs
to do that would not be a real
pleasant experience.
Here's a shot of the first
metacarpal getting banged up
over here, MCP joint getting
banged up because of the nature
of the glove and the
metal ring there.
Here we have somewhat of a
little bit of a suit pressure on
the shoulder, we've had some
shoulder injuries that take
place in the training facility.
So we're very careful
to monitor that.
But these things are all
important to highlight because
for those divers decompression
sickness can often result in a
joint pain or a discomfort
in a shoulder or a knee.
So we want our astronauts when
they're in the tank to really
understand what they're feeling
so if that happens on orbit they
go this is very similar to
what I feel in the pool or I'm
getting this kind of knee or
joint pain that I've never had
before and maybe a clue that
we're having
some decompression issues.
And you can see some folks
putting some moleskin on their
anterior shins for
some discomfort.
And here you see that the
bladder inside the suit was
causing some hot red spots and
we've had that happen on orbit
where a piece of the fold of
bladder felt like somebody said
like a knife was being driven
into the top of their foot.
And they're out there doing a
spacewalk and the suit was being
pressurized and they were
out there it was
very, very uncomfortable.
So we really try to work closely
with our suit folks to make sure
we get a good fit and look at
all these different aspects that
can impact them.
Anybody know where
this picture is from?
This is the shot from Russia,
this is the Russian hydro lab,
the equivalent of our neutral
buoyance lab and this is the
strela arm and you can see there
the crewmember is in an Orlan
spacesuit outfit.
This is a hydro lab and
it's round as opposed to our
rectangular one.
And here's an Air Force Colonel
Mike Fink ready to get into the
Orlan suit and you can see him
in this thermal garment and
there's various little plastic
tubes here which carry the heat
and cooling through a liquid
to maintain a comfortable
environment for him.
And this suit is basically
unlike our US suit which has a
lower torso harness, upper,
the gloves, the helmet.
This is sort of basically a
one-size fit all you kind of
slide in, grab a handle here
and close the door on it.
And basically you do have some
gloves that are more custom fit.
This is a good suit for big
bulkier tasks, our US suit is
much better for some of the fine
things that we've done like for
example with the Hubble
repair, things of that nature.
Our suit is 4.3 pounds per
square inch like being at 30,000
feet and the Russian suit is
5.8 pounds per square inch.
So it isn't as much
of a custom fit.
We've had some smaller
diminutive ladies in this suit
who actually have to pull their
arms up and almost kind of
scratch themselves a little bit
whereas you could never do that
in our suit because it's
a different type of fit.
And whereas we have the big
cranes that come in and pull our
equipment out of the bottom,
here's a picture of the hydro
lab the floor is like a sieve.
So the floor kind of comes up,
the water drains out, a guy
pulls up in his little golf cart
type of device
and pulls the equipment off and
changes it out.
So an elegant way to handle a
problem in a different manner.
At the neutral buoyancy lab
we also have a hyperbaric
capability there should we ever
have to
do any treatments in there.
We really don't use it for
research per se, but it is out
there to treat any of the divers
or crewmembers
that get injured or hurt.
We also have an altitude
chamber out there.
Altitude chamber is utilized
for us to go ahead and do our
physiological testing.
So when folks are flying in the
T-38 or another aircraft we can
go up and take them up to 25,000
feet or so and get them off the
mat so that they understand what
the symptoms of hypoxia are and
that's very important.
To understand what it feels like
to be a little hypoxic and also
important we train them
separately on what their carbon
dioxide symptoms are.
And those are two different
things and why that's important
is if they're doing inside their
spacesuit and the sensor goes
out of the spacesuit and the
carbon dioxide is building up we
want them to know what
does it actually feel like.
And there are often different
type of physiological systems or
sensations.
Our prebreathe programs, I'm
just going to highlight this a
little bit to give you a sense.
When we put folks in those
spacesuits there is a risk of
decompression sickness.
Decompression sickness arises
because of nitrogen that's
mobilized that comes out in
solution and causes impacts
either in the capillaries, it
can put pressure on nerves, it
can get into your brain,
spinal cord,
and so we try to mitigate that.
Well one of the simplest ways to
do that is to breathe oxygen for
four hours before you
get in your spacesuit.
So now think about that we'll
put you an oxygen mask and
you're going to sit
here for four hours.
That's kind of you're using a
lot of resources and astronaut's
time is very valuable, the
team's time on the ground
as well.
So we look for variously
strategies to how we mobilize
that nitrogen and get it out
of your system
a little bit quicker.
Well, you can't take people
up into the vomit comet and do
those kind of research.
So we do various things in
chambers, hyperbaric chambers
and in order to do that we have
various ways that we try to use
some elegant solution, things
we've learned from the Air Force
and other researchers to try
to get this nitrogen mobilized.
So it's along the theory of that
if you go out and you run, you
do some exercise and then you go
right to the gym and you start
to lift some weights your
cardiovascular system cardiac
output I is still going,
you're still mobilizing blood.
And in our case we want to
mobilize that liter of nitrogen
or so to start getting
it out of your system.
So we come up with little
elegant ways
to simulate microgravity.
Well, in this particular case
we put people in chambers and we
used to have them do various
tasks like they would utilize
their EVA tools, but
they're walking around.
Well that's not really a good
representation because now
you're loading your
joints, your hips.
And so what we did is we came up
with this solution here, we put
people in the semi recumbent
position, we had various tasks
they had to do to simulate
things they would do in the
suit, we had bungee cords kind
of giving them a little sense a
resistance of the suit.
We had a no kidding bathroom
scale here, we knew exactly how
many found pounds of force it
as if you were locking your feet
into the foot restraint
before you were moved.
So we would put all this
together, we would choreograph
it, we had the astronauts get
in they go yeah, it's pretty
fidelity for
something like this.
And then we would put folks in
the altitude chamber after we
would utilize this to test
our various protocols.
And we also did a lot of
monitoring with the heart.
When you put somebody in the
chamber and you want to listen
if they're developing bubbles,
you listen to the right outflow
tract with a Doppler and you
hear this chirping sound
[making chirping sound].
And if you hear those little
bubble sounds that means you're
starting to generate
this nitrogen gas.
We want, of course, minimize
that and we also are trying to
make sure that we don't see
through any hole in the heart,
patent foramen ovale or any
other intrapulmonary shunts.
We don't want to see bubbles
going from the right side to the
left side of the heart.
So this is one of our techniques
as we study EVA bubbles.
I'm going to talk to you just
the sense -- I just to focus on
a couple key things to talk
to you about
our pre-breathe protocol.
So if you're watching NASA TV
and a spacewalk is ready to
begin and they say they're doing
their pre-breathe protocols.
So what does that actually mean,
what are they actually doing?
Well there's a program that we
don't utilize right now, but
this was the key program that
allowed us to help build the
space station initially and
it was the CEVIS, the cycle
exercise vibration
isolation system protocol.
So what does this actually mean?
Well, what would happen on the
day of EVA you would get up in
the morning, you and your
colleagues would dawn a mask and
you start breathing oxygen.
And where these little green
areas are we'd put you on a
cycle ergometer, an exercise
bike in the space station and
you'd start to pedal for about
10 minutes and you'd ramp up to
about 75% of your VO2 max.
The purpose of which was to
kind start of mobilizing that
nitrogen, get it moving, get
it going and this was all
predicated on a lot of things
that we had done
with the Air Force.
When that was done you stayed on
your mask and then we would take
the airlock where you were going
to put your equipment on, take
that to 10.2 pounds per square
inch, 10,000 feet and then you'd
put your spacesuit on.
And one of your colleagues would
help two of you
put your gear on.
Once you're all buttoned in we
take you back up to 14.7, we
open the hatch and the
crewmember who's not going on a
spacewalk that day will go back
into the cabin and then you'd
sit and you'd breathe oxygen for
another hour before
you'd go out the doors.
So instead of four hours
you're breathing an hour.
And this we utilized as 21 times
and this was really the crux of
how we initially
built space station
and it was very, very valuable.
So after a while we realized
that there were 21 single point
failures that can happen with
this and NASA always likes to
minimize things
that can go wrong.
So 21 point failures everything
from the way the ergometer
worked to the settings to the
shoes that you had to the mask,
all that stuff added up.
So we went to something a little
bit different and what we came
up with this is what we call --
we utilized that were campout.
Because what the campout
protocol was that eliminated
that bicycle and it basically,
this little yellow line here
represents eight hours and 40
minutes sleeping overnight in an
airlock with your EVA partner
at 10,000 feet
to off gas that nitrogen.
So imagine you finish up your
work day, you grab some urine
collection bags and some other
things, some food, some tools,
some last-minute study you go
and close the hatch, do a little
study, get your sleep.
And the next morning you get up
and we put you on a hose, you go
out and get some food, use the
lavatory, come back in, button
up on your suit
and then you have
a 50 minute final prebreathe.
So we used this 73 times and it
was beautiful because it really
was the crux of so many of our
spacewalks and we've never had a
reported decompression hit.
Now does that mean it didn't
happen, well by and large we try
to educate our astronauts that
if you've got a problem you need
to be pretty forthcoming
because nobody wants to be bad
protoplasm, nobody wants to say
well you know I think
I had some DCS.
But what's happening is your
setting yourself or your buddy
to have a problem down the road.
So we think we've been pretty
forthcoming, I think the
crewmembers have as well, I
don't think they've been hiding
a lot of things.
We know the suit beats you up
and there's certain aches and
pains you get from that, but we
really don't think we've had --
we think we've got some
real safe protocols.
The protocol we use now is
it stands for
in-suit light exercise.
What we were trying to do is our
holy grail was to get down to
like a 90 minute
in-suit pre-breathe.
And what we came up with is that
one where we don't have to do
the exercise on the bike and we
don't have to sleep for eight
hours and 40 minutes overnight.
So the in-suit light exercise
program basically utilizes the
simple principles of movement
and exercise and increased
cardiac output and getting
rid of those nitrogen bubbles.
So the protocol we use now we've
used it 16 times to date, the
crews love this.
Because basically they get up in
the morning, they prepare, they
have their breakfast, they get
on a mask for a while and then
we go down to 10.2, the airlock
is decompressed at 10,000 feet
and then they're
putting on their suits.
And after that's all done they
button back up, their colleague
gets out.
Now they're in their suit for
50 minutes and when they're in
there they're doing
this light exercise.
And this is things that we've
learned over the years, we put
all this together.
And the light exercise it's
basically a series of leg
movements that are pretty light,
we affectionately call it the
hokey pokey because the
crewmembers are kind of doing
this and we train them on the
ground to understand what that
metabolic rate is.
And for those that like
the numbers it's about 6.2
milligrams per
kilogram per minute.
That's like walking a mile in
70 minutes, that's not that
intense.
Four times around the track
in 70 minutes it's not a lot.
But it's an effective way to
get that nitrogen immobilized.
So the crewmembers are able
to go out the door, so it's a
shortened protocol where you use
less assets and it's been very
effective and easy for
the crew to perform.
Everything the crewmembers do
are often in these checklists.
Now we could have a bad day and
Dr. Chamberlain and I and others
we practice our simulations with
our biomedical engineers and the
whole control team during
some of our simulations.
So we have to ready for
that day when you can have a
decompression hit when
the crewmember says, I am
experiencing pain in my shoulder
and hip like I've never -- this
doesn't feel like the normal
suit rubbing up against me, this
is different, I can't grab my
tool anymore or I've got some
paralysis or weakness on one
side and it may be because of a
decompression sickness.
Like I said we've never had
that, but we got to be
ready for it.
So we have a series of
procedures which incorporate
various switch throws, change
outs for carbon dioxide
scrubbing, etcetera, as well as
other medical procedures as we
utilize -- basically we're
going to utilize the suit as a
treatment vessel.
We don't have a hyperbaric
chamber on ISS and some flight
directors will tell you can fly
the entire Brooks Air Force Base
chamber we don't want it if it's
going to hurt somebody and not
be utilized very well.
And so we look at is there any
portable chambers, things of
that nature and we haven't
really found anything that's
compelling to fly yet.
So we use the suit as
a treatment vessel.
So if you were in your spacesuit
and you had a decompression hit
we would bring you back into
the vehicle so you'd be at 14.7,
which is normal atmosphere
plus 4.3 in the spacesuit.
So you would stay in that for a
couple hours until
your symptoms abated.
So theoretically, for those that
died if you got hit we would
take you in a chamber like at a
local hospital down to 60 feet
of seawater and that's
the pressure load.
So, theoretically in our suit
we can get almost 112 feet, 113
feet of seawater by just
simple Boyle's law of physics.
So we hope that that would work
and that's what we simulate.
This shot is to remind me of
going around the earth in 90
minutes, 16 sunsets
and sunrises every day.
And so sleep is important and
your circadian rhythm is going
to change for a little bit.
You can see the crewmembers this
gentleman is floating in this
capacity, very relaxing to sleep
in that environment like that.
Here's some other shots of
folks sleeping in the shuttle.
We have individual
crew sleep stations.
Now even just look at some of
the interesting things, this
gentleman always liked to
have the sensation of his head
against the pillow, so he
would have his head like that.
We have this other gentleman
who liked the sensation of being
jammed under some covers, so you
can see him in kind of tighter.
Some folks wear
earplugs and ear marks.
So they really do sleep quite
well, they're slated for about
eight and a half hours sleep
on the space station, they
typically don't speak as much
maybe six and a half to seven.
But the environment is pretty
quiet and pretty comfortable and
so sleep is very,
very important.
This is just to show somehow we
utilize our circadian shift this
was during STS-108, but similar
principles when we go over to
Star City in Russia and
launch through there.
So in this particular case, you
see these lightbulbs to show
that we use some bright light
as we were shifting them.
We had conference rooms in the
crew quarters of up to 10,000
watts of light, light is a very
powerful stimulant to help make
some sleep adjustment.
So we would go ahead and
utilize various techniques.
So when you look at the
physiology of it obviously,
darkness is going to be working
to help stimulate melatonin for
sleep and light of
course, changes that.
And we're not going to go into
a lot of depth on this, but the
key thing I just want to show
you is that when you look for
peak melanopsin which helps
suppress melatonin, the peak is
about 480 nanometers of light.
But what does that mean and
initially some of us we were a
little uncertain of this.
Is this a little bit of voodoo
or does this actually work?
So the idea of the blue light
and I don't endorse Phillips
products just to let you know,
but this just to show, this is a
little device for example that
emanates light at about that
frequency.
And why we're utilizing items
like this is that in the middle
of the night in the mission
control center if you're the
person getting up at 2:30 in the
morning and you got to go work
some mission control shifts.
What happens at 4:35 in
the morning, you're in your
circadian you're feeling
like dog meat it is not good.
The first night usually you do
pretty good you got
it out of you, you
got a little coffee,
but the second and
third they're often the worst.
So we will often look at the
lighting in here and we actually
in some of our workstations have
those little lights that are
available.
And for those folks that travel
a lot go overseas, we will often
allow them to go ahead and
utilize that so when you get to
a different area and you get up
and you want to try to adjust
your biorhythms utilizing
some light is very effective.
And to the point where when you
look at the space station, I
mean there's various areas where
we have lights and a ton of
gear, but we're also looking
at the lighting in the space
station is going to be changed
and eventually it's going to be
changing in your home as well.
So when you get up in the
morning you're going to have a
higher frequency of that 480
nanometer type of light, it's
not going to really look blue
per se, but it'll be different.
And as your day goes by your
lighting scheme is going to be
more normal.
And then at home at night you
can set your lighting such that
you start to get a little bit
more of a reddish wavelength not
red like those that have ever
been on a ship and we try to
adjust your vision at night, but
just a higher percentage of that
light to help you kind
of download a little bit.
Because what's the worst
thing that happens, what does
everybody do with their
computer there or their little
Blackberry, they're all playing
on their phones and that's the
worst thing before
you go to bed.
You're sitting there looking
at this your phone and it's the
exact opposite of what
you should be doing.
So we're doing some neat things
on orbit eventually to change
the lighting.
I'm going to talk just a little
bit here to give you an idea of
one issue that's high on
our list and things that you
might've heard or read about is
some visual changes that we've
noticed for some of our
long-duration crewmembers.
And it is a change in their
vision oftentimes that's a
little bit of a hyper-shift,
it's hyperopic such that their
near vision, have little more
problem with their near vision.
But what really noticed we saw
some crewmembers coming home and
they weren't complaining
of any symptoms at all.
But when you examined the back
of the eye you started to see
some swelling back at the
optic disc and cup area.
And you look at that and you
go that's a little odd, are you
having any symptoms,
no I'm doing fine.
You know, they might be at that
given age where they're starting
to have some presbyopic changes
which take place with age normally.
But we started notice some
different things, anything from
some cotton wool spots to some
folds in the back of retina to
some flattening of the globe
here and it led us to start
looking at things.
What's going here, what is
physiologically happening.
We know we've got these fluid
shifts coming up is that
impacting it?
Are we changing the intracranial
pressure, is there something
going on within the brain spinal
cord system that dovetails into
the optic nerve,
is that an issue?
So we started to look at things
we were doing tonometery, eye
pressures, we started
doing ultrasound on orbit.
We now have a device called
OCT ocular coherence tomography
where we can actually measure
the thickness
of the retinal layer.
We're trying to get all this
data and put it together and
figure out what's going on.
We're seeing it in some crewmembers,
not all crewmembers.
We're seeing it sometimes in
just one eye not another eye.
Does this have something to do
with the salt load that you eat
in your diet?
Is it intracranial pressure?
It is something with the
resistive exercise and all that
-- what we generate
the forces there.
So this is one of our big
enigmas right now that we're
trying to continue to get data
at and maybe it'll help us with
some on earth issues as we try
to translate all the sciences we
learn to issues on the ground.
But this is a very, very
interesting phenomena that we're
trying to chip away
at and get smarter on.
And now our Russian colleagues
and our internationals are
working with us as well.
We have ultrasound, we do
ultrasound for various organ
systems and it's a
tremendous tool for us.
And here you see Don Pettit he's
doing some ocular ultrasound as
well for us, doing some of
our science and clinical work.
So coming home, as we're
wrapping up here today we
obviously don't fly the shuttle
home, but a nice shot from
Kennedy.
But we're going back now to some
of the physiological issues.
Remember we talked earlier we
said we lose about 12 to 15% of
our plasma volume, well when we
want to get some of that back
when the crewmembers come home.
So here is just a simple example
that right around landing for
the shuttle a few hours before
we started to do a fluid load.
As I mentioned, this kind of
salty solution kind of a chicken
consomme type of thing to
increase that salt load,
retain some fluid.
So of that 12% loss we've got
maybe -- we're back about 5% of
that loss, so that when we hit
the ground and we got out of the
vehicle we were able
to do better on that.
And so that was interesting
physiological work that we did.
Even after only 10 days of
spaceflight this is 10 days
before flight and this
is at return plus zero.
So if you're flying a vehicle
and you're tracking a moving
target you're just watching
something, your head, your eye
and the target.
Your eyes move in a certain
capacity here and you can see
the eye movements.
But look at this, look at this
just look at the variation this
is only after 10 days in
spaceflight
how the systems adapt.
So this could have been an issue
for us somebody's trying to land
the shuttle and as you know, the
shuttle is a glider you only got
once chance to do it so you want
to maintain that visual system.
So we actually used to
have a laptop on orbit where the
crewmembers would practice some
of their visual landings and try
to overcome some of these
pursuit tracking issues.
So some very
interesting physiology.
So when the crew landed, here's
a shot at Edwards Air Force Base
with the shuttle we had all
kinds of devices that come up to
safe the vehicle and make
sure it was in a good
safe capability.
We see a little vehicle over
here like you've seen at the
airport in Dulles for example,
the people mover and
this is where we had our entire
medical suite in there where we
have various little emergency
medicine suits, we had some
recliners, we kept it very cool.
We also were able to do some
various sciences here and we
used to make that right up to
the shuttle and we'd begin some
of our sciences pretty quickly.
So now you fast-forward here
to what we're doing, here we're
launching out of Baikonur in
Kazakhstan with a crew of three
and it still takes about eight
and a half minutes
to get in space.
It's based on the
simple physics there.
And where we are we're
dealing with areas in Russia.
So this is the longitude is
about 12 time zone differences
and you're basically almost
north of Kabul, Afghanistan if
you will and it's on the
other side of the earth.
And that's where we're coming in
and our vehicle was coming home
under the chute and just
before they land there's some
retro rockets that help slow it
and they use the term here the
steps of Kazakhstan.
And you know here's part of the
welcome wagon and here you see
the vehicle landing on its side
and the helicopters and this is
how we get there, Dr.
Chamberlain and I and others
that rotate over there.
This is how you get there
basically
through the Russian system.
And here you see the crewmembers
being extracted from the side
and we try to minimize their
movements because things can be
very provocative.
You've been in space for six
months and now you're trying to
do a lot of this and those head
movements can be
very, very provocative.
And here you see another way
if the capsule lands vertical,
there's a stanchion they put
in here you get your elementary
park amusement ride down here.
But this is the slide so the
crewmembers are extracted and we
try to keep their heads still
and then bring them
right down here.
And you can see they're a little
bit pale and they got that
pensive look like
don't move too quick.
And there is a range how folks
do, some folks have a lot of
difficulty and other
folks adjust pretty well.
And then they're hauled off in
some chairs as we bring them
over to some medical facilities
and it's a tent that's put up
and in there you can see the
snow in this particular case.
And in there we have some of
those cubicles that we can start
to desuit the crewmember, we
can start intravenous because
they're usually
down on some fluid.
We can start to consider giving
them fluids, we can start doing
some basic sciences there, and
we don't stay there very long.
We get back into these vehicles,
move the crewmembers over to the
helicopters and subsequently
load up on the helicopters and
then fly back a couple hours
to an airport for example in
Karaganda and at that airport
we'll have the
NASA 992 aircrafts.
So this is pretty amazing to
think from the time they land we
can have them back at Ellington
Field typically in about 24
hours to see their family,
that's pretty impressive,
it really is.
And in there we have our crew
surgeon, as well as another
physician, so we
have it laid out.
We have a variety of medical
equipment and capabilities and
so we're able to put them down
and let them rest, give them the
appropriate medications as
we need to, additional fluids
either by mouth
or IV, and acclimate.
We have two stops on the way
home, one's in Prestwick,
Scotland and one's
typically in Bangor, Maine.
Crew health coming back,
rehabilitation is very, very
important and we have a 45 day
intensive program where the
astronauts are working almost
every day for a couple hours
with our trainers and it is
remarkable to see the changes
and how quickly
they're coming back.
All that work we're doing
for their aerobics and their
musculoskeletal work is paying
huge dividends because we're
seeing them come back.
We want to mitigate risk, we
don't want people getting hurt
because they're not in
good physiological status.
So they're coming back well.
And even every day almost
hour by hour you see their
neurovestibular
aspects come back.
Some of the crewmembers will
tell you that they do make a few
mistakes at home.
For example, if they have
something in their hand now
they're at home they got a
coffee cup and the phone rings
or something they just let go
of the coffee cup to go get the
phone well everything crashes
because they're used to just
letting things go for example.
The shower, they haven't had
a shower for a long time.
Some crewmembers will tell you
that it's the most heavenly
feeling on earth to
have that first shower.
Other folks will say the
percussion of the water pellets
on their back was a little
uncomfortable, it felt weird.
Sitting, so you've been sitting
here for a good hour you haven't
been sitting on your toochie in
space for six months even though
you get on an ergometer you're
more kind of standing on an
ergometer when you're pedaling.
So when we put them back here we
take them to the lab and we try
to test their VO2 max, sometimes
they peter out not because their
legs are tired it's because
the seat is really comfortable.
And we try to buy really nice
soft gel lined seats, but there
are certain things that
are very interesting.
On the exam besides the
neurological things that
Dr. Chamberlain and I deal with
is the skin for example, you
almost kind of molt
to some degree.
So right now if I was to go and
examine all of your elbows and
your feet and your heels ladies,
you know what I'm talking about
right whatever those special
emollients are for your feet.
Their feet come back they're
like little baby's feet because
after about a month or two they
almost kind of shed that
thick layer of skin.
So when you look at their elbows
they're little shiny,
pink, soft skin.
The same thing with their feet
they're just like these little
pristine little feet because
they haven't had that impact
forces, they're not wearing
those same shoes, they're not
scuffing up against them.
So there are some very
interesting physiological
differences that we see.
And I only have a few more
slides here as we close out.
I want to talk to you a little
bit about the personal aspect of
some of things we do.
I'm sharing this slide this
is STS-134, next to the last
shuttle mission.
And this was the crew they were
bringing up the alpha magnetic
spectrometers.
So for the science folks
out there alpha magnetic
spectrometer is really
to study dark matter.
And Professor Ting, Dr. Ting
a Nobel Prize winner was very
involved with the design and
implementation of this and this
crew brought it up.
And a great group, an Italian
astronaut, they have an Air
Force, a Navy guy and Captain
Mark Kelly and you probably know
who Captain Mark Kelly is.
Well Captain Kelly's wife was
Gabrielle Giffords and she's a
U.S. Congresswoman and January
8th, 2011 she was shot.
And I'm telling you this story
because part of what we do is
all this great science, but we
really have --
these people are our family.
And I was the crew surgeon for
this mission and the day this
happened was a Saturday and I
was -- I had done some coaching
some lacrosse and we were
watching game film at a pizza
place with our team and I see in
the corner of the place I see a
picture of Gabby Giffords on the
TV and what's she doing up there
and I look and then I see this
horrible banner
that she had been shot.
I picked up my cell and called
Mark I go Mark, where are you
and he goes I'm in my car.
I go do you know what just
happened, he goes yes I found
out I'm on the way
to the airport.
He had a friend who had a
private plane that was going to
take he and his
family out there.
And a few hours later I found
myself in Tucson Arizona and I
walked into the emergency
department almost in disbelief
that this just
actually happened.
As I'm walking in I asked Mike
who's running the trauma program
at Tucson, Arizona.
They go well it's Dr. Peter
Rhee, I go Peter Rhee I says is
he a Navy guy, Korean
background, former Navy guy,
retired and they
go yeah that's him.
Dr. Rhee and I were in
Afghanistan or in Iraq at the
same time in 2005 serving with
the Navy and the Marine Corps.
So my comfort level went from
0 to 99 in a heartbeat because
he'd been there, done
that, he'd seen it.
And the care that she got was
phenomenal and eventually we
were able to transport her
back to Houston, Texas
for her rehabilitation.
And she's a remarkable lady,
it's a remarkable family.
But there's a lot of tremendous
decisions that have to take
place on how do you fly a guy
like this he wanted to go back
and fly in April, the shooting
was in January and in April was
when the first
launch attempt was.
So how do you as an
organization, how do you come
together and say okay, can we
fly this individual while his
wife is still
going through this.
He's had a lot of training.
The folks that he's worked with
these guys really wanted him to
fly if they could.
He knew the mission well,
but what's going on.
So this was a very interesting
aspect for us to get our medical
team together, our behavioral
folks, our psychiatrists, our
representatives from the
astronaut corps and to figure
out how we make a determination
is he safe to fly.
He's flying a $3 billion
spacecraft with another couple
billion dollar alpha magnetic
spectrometer, you're paying for
it as taxpayers are we doing
the right thing putting him in.
And Mark is a remarkable guy and
we went through a very detailed
evolution where we had a plan,
we looked, we monitored him, we
put him back into some
simulations, into some flying
environments in a T-38 and other
things and he had all these
checks and balances to the point
where we got an opportunity to
say, you're good to go, you
can go fly this mission.
It very motivating for him, very
motivating for his wife
and for the crewmembers.
First launch attempt was in
April and that day the mission
was scrubbed as we were putting
the crewmembers in the vehicle
there was an auxiliary power
unit heater line sensor failure,
so the crew never even
got in the vehicle.
So we brought them
back to the quarantine facility.
And as we're bringing them back
in the quarantine facility the
phones are going off Air
Force One was landing.
Air Force One was landing
because the president and his
family were showing up, they had
never seen a shuttle flight and
they were going to
go see this flight.
And Gabby Giffords actually came
over there as well during part
of her rehab she got flown there
and so she was going to have a
chance to witness
her husband launch.
Very, very motivating
across the board.
But the President of the United
States wants to go
and see the crewmembers.
Well, if anybody works here they
know about something called HSP,
Health Stabilization Program.
It really doesn't matter who you
are you're not getting to see
the crew in quarantine until
there's a screening process
involved.
Now why is that, it's because
not only do we want to keep
these folks healthy before they
go uphill
think about who's on orbit.
There's six individuals on orbit
whose immunological system is
dialed down a little bit, we
know that immunological system
isn't as responsive
to various problems.
So we have this program we've
only had one mission in the
history of the space shuttle
delayed because of illness, it's
STS-136, the commander got ill.
A couple days later after an
upper respiratory infection we
were able to fly.
So we screen folks.
So if you were a trainer and you
were going to come in and give
the crew some last-minute
training at the Kennedy Space
Center you would go through a
series of evaluations the doc
would make sure you're
healthy, etcetera.
So now the president wants to
go meet with the crew and I'm
handed this baton and I go -- I
called the White House physician
and I said, you know with all
due respect it doesn't matter
who you are, we have to go
through a certain process.
If you can tell me that the
present is absolutely healthy,
he has had his flu shot, he is
non-communicable, afebrile, you
tell me he's good to go we will
clear it otherwise,
it's not going to happen.
So he says okay, I'll call
you back in 15 minutes.
He calls me back he goes okay, I
talked to the president we want
you to do his
physical, I go what.
Next thing I know I am brought
into this room after the Secret
Service does their handy-dandy
pat-down and everything and this
is a shot from the Kennedy Space
Center where the president, his
wife and his two daughters and
his mother-in-law are there and
I'm brought into this room and
the president comes up he goes
okay doc, what's the story?
And I go well sir, I'm thinking
the whole time I'm going why do
they want me to do this if
anybody else if the White House
physician says the president
is good to go he is good to go.
Then I said well maybe this is
plausible deniability because if
something goes wrong it's
the NASA guy's fault right.
So I am explaining to him now
that we have this -- just as I
shared with you, we have this
Health Stabilization Program and
we have certain wickets to check
and I explained this to him very carefully.
And then there this was this big
pregnant pause and I was kind of
unsure what he was going to say,
then he goes doc you do what you
need to do we don't want to be
the ones to get the
crewmembers sick.
Roger that sir,
thank you very much.
So we proceeded to do a -- make
sure that everything was in
place, did a limited physical
examination and eventually
cleared him and then had to
do the same with his wife.
So they were able to spend
some time with the crew.
So it was a very interesting
evolution
that you just never expect.
I mean I don't think later that
day when I called my kids up I
go you're not going to believe
this, you know, my whole mission
that day was to keep my crew
healthy and get them ready for
launch the last thing I
ever expect was to meet the
president, let alone examine
him, I mean it just doesn't
happen right because
that's the White House.
So anyway, you've got to be
ready and for the future docs of
the world here the other bottom
line is you've got do your
medical work with him like you
would do with every other single
patient, don't cut corners
because sometimes you can't be
intimidated by who somebody is
you've got to proceed and do
everything like you normally
would because if you don't do
that that's when you're going
to make an error, that's when
you're going to make a mistake.
So lock that in your mind.
So if you're taking care of --
at the military base if you're
taking care of a general or a
senator you've got to everything
the same on everybody because
otherwise
you can make those errors.
But anyway, it was a great honor
to meet them and they had some
quality time with
the crewmembers.
The last couple of slides,
anybody know
who these folks are?
This is the original seven, the
Mercury astronauts getting ready
for some of their
field training.
And this particular gentleman
over here is now in his 90s John
Glenn and he flew on the STS-95
and Senator Glenn he was like 77
years of age when he flew,
pretty remarkable
if you think about it.
And I think we learned some
things about the fact that if
you take care of yourself
physiologically you never know
what's going to happen to you,
what's going
to end up on your plate.
He was, of course, volunteering
himself to learn some things
about geriatrics and other
physiological aspects that might
be of value added.
But he went up and he did some
remarkable things up there for
us and it was a big motivator
I think for folks back at home
they're sitting on their couch
realizing if I take good care of
myself I might not fly in space,
but I can have some pretty good
years ahead of me.
So where are we going from here,
well a lot to be determined.
The space station is in essence
built, we're going to be doing a
lot more science here.
Hopefully, our commercial
programs will be able
to get us up there.
We've got the Orion program on
tap, we've got the space launch
system hopefully to get us into
deeper space opportunities.
How that's going to translate if
we're going to have a chance to
go back to the moon and here's a
shot of what was conceptualized
as the Altair lander and perhaps
some folks advocate going back
to the moon.
Whatever planetary body we go to
we have a lot of issues to deal
with in terms of whether it's
1/6 gravity, 1/3 gravity, what
about the various compounds and
how is the dust going
to be an issue.
And you're not going to be doing
an EVA once or twice, you may be
doing an EVA almost every
day or couple of days.
So there's a lot of interesting
medicine and physiology that
awaits us.
If we go to the moon how do you
use the lunar regal then, how do
you use this as a protective
environment from radiation?
We had an encounter between two
of the different landing on the
moon where the crew could have
been in grave danger for acute
radiation if they were on
the surface at that time.
So we've got to have warning
systems and we've got to be real
smart on how we protect
our crewmembers.
So some good work ahead of us.
And Deitra, I just wanted
to click this for a second.
This is a couple of short little
videos, but this came up from a
summit we had.
We brought back the Apollo
astronauts, particularly the
ones that landed on the moon.
And we were talking to them
about various things for
example, we were talking about
the design of a habitat, to live
on on a surface and about how to
make it quiet and [inaudible].
And one thing that they said
that was very interesting they
go don't make it too quiet.
And we go what do you mean
by that, there was something
innately comfortable about the
hum and the sounds of fans and
motors, it means the vehicle
is working in essence.
So it was an interesting little
tidbit yeah, make it quiet
but not too quiet.
We also talked to them about the
spacesuits as we're looking at
the next-generation spacesuits.
How do you design that?
When we see people fall on the
surface of the moon we're going
to look at that here, we were
asking what kind of loads, what
did that feel like when you fell
or you moved, how much torque on
the elbow, on the back because
we want to look where do we put
the center of gravity with
the PLSS we call it, the
life-support system.
And it was very interesting for
them and I just want to show you
a couple of these
if we they pop up.
As we're queueing this up, but
basically when you see them they
didn't actually walk
they kind of loped.
Remember that kangaroo walk
at 16 gravity they said that was
the most efficient manner for
them not a simple gait, but kind
of a loping gait and it was
physiologically good for them.
But when they fell we were
watching some of this and we go
oh my God, that's got to be
tough and they go it was like
falling on a bed of pillows
in essence, it wasn't a lot of
torque on our joints.
So I think we learned a lot from
those kind of discussions and
hopefully we'll utilize
that for future events.
I think we may just no joy okay.
And they were basically and
you could online and see them
they're about 20-second clips
and it just shows the crewmember
working on picking up some rocks
and he stumbles and falls and
the legs come flying out and
he hits the ground and when you
first see it you go whoa
that cannot be good.
But in essence it wasn't
that bad of a load.
We'll just press that's okay, oh
there it is, there it is,
hey we got it.
I don't know what you did but.
That's okay just queue me up and
we'll just proceed that's good.
And again, 2 30-second clips if
you ever want to have a chance
to look at it.
So in closing, you know,
December 17th, 1903, 66 years
later we're on the surface of
the moon, pretty incredible.
So what we're going to see
in the next few years given a
budgetary balance and giving us
some zest it'll be very, very
fascinating to see where we go.
This gentleman is obviously --
passed away the other year, but
Neil Armstrong and when you
think about -- when you're
thinking about 1492,
what do you know?
Columbus sailed the
ocean brew, the brew.
Thinking about beer here.
He sailed the ocean blue.
So the fact is that that's
what marked that epic of time.
And when you think about what's
going to happen here a thousand
years from now when people
look back at our epic they will
realize that this is the first
time humanity stepped off our
planet and went to do a
different celestial body.
So for those of us that are
in the arena of taking care of
these, you know, we look at it
as our mission statement of we
take care of the men and women
who go into space, willing to go
into space and do science and
work and explore on behalf of
all mankind.
So I think we all collectively
here that work here try to
support in whatever way we
can this this noble venture.
And with that I will close and
thank you for your attention,
hopefully we shared some good
insights on how we from the
medical operations side view
our role, some of the challenges
that we have, and we would be
more than happy
to take any questions.
[ Applause ]
Yes mam.
>> How do you account for eye changes on orbit?
You know, if they are experiencing any
change in vision.
Do you have spare, various contacts or glasses or somethign
like that on orbit, or has that not really been...
>> Good question.
So how do you handle,
the question is
how do you handle
any ocular changes that
we're having on orbit?
Well, obviously it's of concern
to us because it is a single
point failure, you only
got one set of eyes going.
We do have a couple things one
thing we have is we have some
glasses and crewmembers
sometimes will notice some
differences over time because
remember their focal distance is
typically within the
confines of a node.
Every once in a while they do go
look outside and have a chance
to change their focal distance.
But we do have some glasses that
we fly that are almost what we
call variable, there's an
opportunity with a little bar to
change the curvature of it.
This kind of had its origins
back on some of the things that
the Navy and the Army and others
overseas would do,
various parts.
I'll give you an example, some
of the healthcare that was done
in parts of Africa where these
folks never had access to
glasses and they had these
glasses you put on and you
inject silicone through a
stopcock and it
changed the curvature.
And all of a sudden somebody in
a fairly rural environment can
go oh my goodness, I
can see and I can focus.
And you close that off and
they had an immediate
pair of glasses.
So that principle of just
changing the curvature of the
lens is something that
transformed into a little bit
fancier version where
we can utilize that.
So we do fly some
different glasses up there.
We are now looking at the
challenge of what medications
can we fly that if these
symptoms get worse, we haven't
had any real problems, but what
happens if they get worse and
it's really noticeable.
Are there medicines for example,
for any of you that have gone to
high-altitude environments
Diamox, Acetazolamide we use
that for glaucoma
and eye pressures.
But does that have a role,
could that help us out.
So we're looking at a
variety of medicines.
But there is no magic -- one
magic cure I know, we got to
figure out why does this happen.
If any of you out there know
of a non-invasive intracranial
measurement we love that.
We're looking at the
technologies around
the globe on that.
How do we measure without having
to put a bolt through the skull,
how can we measure
that pressure?
Is it an intracranial pressure
issue or not, that's something
we really need to tease out.
Any the other questions?
Yes mam.
>> Has anyone received stitches
>> Has anyone received stitches?
We have had some injuries for
example, somebody may be moving
too quickly through a given
module and banged their head up
on a hatch.
We've had some injuries where
folks we actually use a compound
called Dermabond, it's like
a superglue that's safe for
biological tissues, so we've
actually closed those up.
And I think we have had a couple
of scenarios where we've had a
few stitches put in, in a minor
way
but not what we thought it would be.
A lot of ocular issues, we've
had foreign bodies in the eye
and procedurally that's one of
the things
we've had to deal with.
Yes mam.
>> What kind of protocols have you considered
if someone does end up with a flu or cold?
>> Protocols for the flu or cold, very similar to what you
do on the ground in terms of keeping somebody well hydrated
we have various decongestants, we fly medications like
Claritin non-sedating antihistamines,
pseudoephedrines, Afrin nasal spray.
We also have antibiotics that we
can use if we think it's turning
into a bacterial infection.
We also have some nasal inhalers
of people getting any bronchial
spasms that sometimes folks
will get a cold and they end up
having a little bit of a
residual cough or a little
bronchospasm, we have some
inhalers that
we can use for that.
>> Do you assume more than one person would have the problem
under those circumstances?
>> The question isn't how do we
assume more than one person
is how you get the virus
transmitted up there.
Obviously if they're up there
for a stable period of time
there should be no entrance
into any new virus.
So when our upcoming crews up,
we do spend time on the order of
three weeks or so in quarantine
or a couple of weeks in
quarantine with the crew in
Baikonur
and we monitor them very carefully.
We really limit who's coming
in, so we've been very blessed.
We have not had
any big problems.
We've had one or two issues in
the shuttle days where we think
that there was some late
transmission to the crewmember,
perhaps there's some trainers
or family, but we've been very
fortunate it hasn't impacted
us in any substantial way.
All right, well great thanks for
questions and thanks for your
attention.
[applause]
>> I just want to inform you of upcoming classes we have
coming up. On the 14th of april we have the human reseach
program overview with-
