# RMP-ENT-001 Nosebleed: supplies, containment, pressure timing and video, relay to the flight surgeon (the crewmember or CMO applies pressure; the robot never touches the face) # Version 0.4 (Draft). CONCEPTUAL. NOT FOR CLINICAL USE. # Space Medicine Foundation robot-readable protocol library. Format: https://spacemedicinefoundation.org/robotic-medicine/protocols/schema/ # Every threshold marked must be set by the named owner (see the schema) before any use. schema_version: '0.3' version: '0.4' status: draft conceptual: true not_for_clinical_use: true max_autonomy: 2 missions: - leo - commercial - moon - mars updated: '2026-10-21' review: state: reviewed-ai-assisted requested: '2026-10-20' reviewed: '2026-10-20' human_clinician_review: false text: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 20, 2026 (batch 3 review, 54 corrections); all corrections are applied in this version. No named human clinician has reviewed it. fixed_rules: flight_surgeon_is_medical_authority: true cmo_acts_under_delegated_care: true human_starts_and_restarts_robot: true robot_never_diagnoses: true no_drug_or_fluid_advice_by_robot: true safe_state_on_fault_or_no_response: true lost_link_pause_then_cmo_decides: true robot_lockouts: diagnosis: true drug_or_fluid_advice: true starting_stopping_or_adjusting_oxygen_or_any_medicine: true self_start_or_self_restart: true changing_own_protocol_thresholds_or_limits: true handing_over_a_mismatched_item_as_verified: true id: RMP-ENT-001 slug: rmp-ent-001 title: >- Nosebleed: supplies, containment, pressure timing and video, relay to the flight surgeon (the crewmember or CMO applies pressure; the robot never touches the face) category: ent tier: 2 rung_note: Max rung raised from 1 to 2 for supervised fetching and timing, as in batch 1. result_language: use: - logged, not interpreted - sent to flight surgeon - time as measured - as reported by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - stopped for good - minor - nothing to worry about - safe - mild scope: summary: >- When a crewmember has a nosebleed, the robot tells the flight surgeon and CMO, brings the nosebleed supplies (gauze, wipes, sealed waste bags, gloves and eye protection for helpers), times the pressure the crewmember or CMO is applying, asks short red-flag questions, records what is reported and entered, and collects only sealed waste. Bleeding that does not stop in the time the clinical lead sets, heavy bleeding, faintness or a nosebleed after a head injury is URGENT. Packing, medicines and any procedure are done by the CMO under the flight surgeon. why: >- NASA records list 6 nosebleeds among US astronauts through 2006 (space adaptation), and 2 on the ISS through Expedition 40; RMP-ENT-004 routes nosebleeds here. The US clinical practice guideline asks clinicians to identify patients who need prompt management, to treat active bleeding with firm sustained compression to the lower third of the nose for 5 minutes or longer, and to record factors that increase bleeding, such as anticoagulant or antiplatelet medicines. In weightlessness blood does not drip away: a surgical review notes that it tends to stay at the wound as a dome, while arterial bleeding can form a stream of droplets (surgical review; applied to nosebleeds by extrapolation), so containment and eye protection for helpers matter. covers: - Bleeding from the nose in a crewmember who is awake and answering, in flight or after landing - Prompt-only check-ins for the period the flight surgeon sets locked_out: - Touching the face, applying pressure or a clip, or inserting anything into the nose - Packing, cautery, or choosing or advising any spray, medicine or position - Saying the bleeding has stopped for good or is minor - Handling open waste or soiled gauze (sealed bags only) - Holding an open bag near the crewmember's face related: - RMP-ENT-004 - RMP-ENT-003 - RMP-EVA-001 - RMP-NEURO-001 - RMP-NEURO-004 - RMP-GI-002 - RMP-PHARM-001 - RMP-PHARM-003 - RMP-INF-002 roles: medical_authority: Flight surgeon (ground). Holds medical authority for every run. onboard_lead: >- Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link. others: - 'Crewmember with the nosebleed: applies pressure if able, and can stop the robot at any time' - 'Second trained CMO: receives alerts if the CMO is the patient' - 'Any helper: wears eye protection near floating droplets' robot_may: - Send the note or alert to the CMO and flight surgeon - Bring gauze, wipes, sealed waste bags, gloves and eye protection, and restrain them within reach - Time the pressure aloud from when the crewmember or CMO says it started - Ask the red-flag questions and log answers word for word - Show the dose log and record of bleeding risks to the CMO as information (no advice) - >- Reconcile the medical kit afterwards through RMP-PHARM-001 as an inventory record (not a check before use) - Take photos or video only with agreement - Collect only sealed bags of used gauze and wipes robot_may_not: - Touch the face or nose - Apply pressure, a clip, packing or any medicine - Advise any spray, medicine or position - Suggest stopping, holding or reversing any medicine - Say that vomited blood is swallowed from the nose - Say the bleeding is minor or has stopped for good - Handle open waste - Start without a human command commercial: >- On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) preconditions: - id: PRE-1 text: >- A crewmember started the protocol by command. Pressure on the nose is started by the crewmember or CMO at once; nothing waits for the robot. check: human_start == true refs: - V2 10174 - id: PRE-2 text: The crewmember is awake and answering. If not, URGENT alert and a crewmember checks in person (X7). check: crew_responsive == true - id: PRE-3 text: Robot self-test passed; nosebleed and containment supplies stocked. refs: - V2 10161 - id: PRE-4 text: Helpers near the bleeding wear eye protection; containment wipes are in place for floating droplets. refs: - V2 9053 - id: PRE-5 text: Robot and supplies restrained when not moving. refs: - V2 7046 - id: PRE-6 text: Link status and current delay known. check: link_state in [live, delayed, down] consent: standard: >- The crewmember agrees to questions, timing and recording by voice; photos need agreement. Any question can be declined; an explicit "no" is logged as declined for that question only. emergency: >- If the crewmember cannot answer, the robot sends an URGENT alert and a crewmember checks in person (X7). withdrawal: The crewmember can stop at any time; an alert already sent is not withdrawn. inputs: - id: IN-1 name: >- Red-flag questions: heavy bleeding, blood running down the throat or vomited, dizziness or faintness, a recent blow to the head or face, clear fluid from the nose, a pressure change or EVA in the last hours source: Crewmember, by voice required: true if_missing: Log "no response"; URGENT; the CMO checks in person. Never logged as declined. - id: IN-2 name: Time pressure started, as stated by the crewmember or CMO source: Stated by crew; robot timer required: true if_missing: Ask the CMO; the timer starts when the robot is told. - id: IN-3 name: Number of nosebleeds in the past days, and which side source: Crewmember, by voice, and earlier logs required: false if_missing: Log "not known". - id: IN-4 name: >- Anticoagulant, antiplatelet or aspirin use, and any bleeding or clotting disorder, in the record or as the crewmember or CMO states, including any medicine taken in the last day (for example before an EVA), with the time of the last dose (shown to the CMO; the robot does not advise) source: Medical record and dose log (RMP-PHARM-003); crewmember or CMO, by voice required: false if_missing: Note "record not available"; ask the crewmember; a missing answer is never treated as "none". - id: IN-5 name: Heart rate and blood pressure measured by the CMO (recorded, not interpreted) source: Entered by the CMO required: false if_missing: Log "not measured". A missing value is never treated as reassuring. - id: IN-6 name: Link status and delay source: Communications system required: true if_missing: Treat as link down. steps: - id: S1 actor: robot rung: 2 action: >- On a crewmember's command, open the log and send a "nosebleed" note to the flight surgeon and the CMO; it becomes an URGENT alert on any red flag. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within seconds is repeated and sent to the next named crewmember. success: Note or alert acknowledged, or escalated. refs: - V2 10174 - V1 6003 - V1 3006 - id: S2 actor: robot rung: 2 action: >- Bring gauze, wipes, sealed waste bags, gloves and eye protection for helpers from the medical kit, and restrain them within reach. This is an emergency fetch on a human command (CMO or crewmember): no barcode check runs before hand-over and nothing waits for one. The robot reads the kit's own label and seal status only if that adds no delay, says "EMERGENCY FETCH – NOT VERIFIED (CMO or crewmember command)", and "seal not intact" if so, and hands the kit over anyway. The fetch is logged as an override: time, who asked, the reason as stated, kit ID and seal status. It never says "verified". success: Supplies restrained within reach; override logged. limit: refs: - V2 7046 - V2 9053 - id: S3 actor: robot rung: 2 action: Ask the red-flag questions by voice and log answers word for word. D1 is checked after every answer. success: Answers logged, or "no response" logged. - id: S4 actor: crew action: >- The crewmember or CMO applies firm pressure as the onboard checklist describes, and the CMO decides any further care (packing, medicines) with the flight surgeon. success: Pressure started by humans. refs: - V1 3004 - id: S5 actor: robot rung: 2 action: >- Announce the elapsed pressure time aloud from the start time the crew give; at the set time ( minutes (shared parameter NOSEBLEED_PRESSURE_MINUTES, the same value in RMP-ENT-001 RF1 and RMP-ENT-004 RF7)), ask whether the bleeding has stopped and log the answer. The robot never decides when to stop, and only the crew or CMO end the pressure. success: Time and answer logged. - id: S6 actor: robot rung: 2 action: >- Take only sealed bags of used gauze and wipes, label and stow them, and clean its surfaces (RMP-INF-002). It never holds an open bag near the crewmember's face. success: Sealed waste stowed; cleaning logged. refs: - V2 7102 - id: S7 actor: robot rung: 2 action: >- After any URGENT alert: After an URGENT alert the robot does not leave on its own: it stays at its rest position in the module, with its screen and voice link available, until a human has taken over or tells it to go. It never follows, blocks or touches anyone. It keeps time-stamping what humans say they did, and repeats the alert if it is not acknowledged. success: Robot at rest in the module until a human releases it; alert acknowledged or escalated. refs: - V2 10173 - V1 3006 - id: S8 actor: ground action: >- The flight surgeon (or the CMO under the onboard checklist when there is no link) decides further care, medicines, follow-up and any evacuation [V1 3007]. The robot logs the decisions. success: Decision logged. refs: - V1 3007 - id: S9 actor: robot rung: 2 action: >- Offer a check-in every hours for days (the period the flight surgeon sets). At each scheduled time the robot prompts the crewmember on their own screen; it approaches only when the crewmember (or the CMO) accepts, and a prompt never starts the robot. Bleeding that starts again is logged and goes to D1. success: Each prompt accepted, postponed or answered; log closed by a human. refs: - V2 10174 - id: S10 actor: robot rung: 2 action: >- Send the flight surgeon one package: times, answers, CMO entries, bleeding risks shown, alerts and decisions. When the CMO says the event is over, run RMP-PHARM-001 reconciliation on each kit fetched: record the items the CMO or crew state were used, the remaining contents against the kit list, seal status and expiry, labelled "inventory reconciliation after emergency use – not a check before use". Flag the override to the flight surgeon and the pharmacy lead, and show each kit as "opened – not restocked" until a human restocks and reseals it. success: Package delivered or queued; kit reconciled or shown as opened – not restocked. refs: - V1 6003 - V1 7001 - V1 7003 - V2 7059 decisions: - id: D1 after: S3 decided_by: robot question: >- Checked after every answer and at any point in the run (even mid-question or mid-step): does any answer, reading or observation meet a red flag? branches: - if: 'Yes' then: >- Stop the current question or step at once and apply the action listed for each matching red flag (URGENT alert, flag, or stop), with the answer or reading itself, never a cause. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within seconds is repeated and sent to the next named crewmember. - if: 'No' then: Continue. - id: D2 after: S3 decided_by: robot question: Did the crewmember answer the question? branches: - if: 'Yes' then: Continue. - if: Declined explicitly (the crewmember says no to a question) then: Log "declined" for that question only; the alert already sent stands. - if: No response, or the answer does not make sense then: >- URGENT: log "no response" (never "declined"); the CMO, or the second trained CMO if the CMO is the patient, checks the crewmember in person at once. - id: D3 after: S5 decided_by: robot question: At the set time, does the crewmember or CMO say the bleeding has stopped? branches: - if: 'Yes' then: Log it; continue to S6. - if: 'No' then: URGENT alert (RF1); the CMO decides further care. - if: No response then: 'URGENT: log "no response"; a crewmember checks in person.' - id: D4 after: S8 decided_by: ground question: What is the plan? branches: - if: Link live then: Flight surgeon decides; robot logs. - if: Link down or delay too long then: >- The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact. stop_rules: - id: X1 trigger: The patient (or the crewmember being examined) says stop, or withdraws consent action: >- Robot stops all motion at once, backs away to its rest position and tells the CMO. Recording stops unless the patient agrees to keep it running. level: stop refs: - V2 10165 - id: X2 trigger: Any crewmember presses stop or takes over control action: Protective stop; robot holds its stopped position; only a human may restart it. level: safe-state refs: - V2 10165 - V2 10168 - V2 10174 - id: X3 trigger: Robot fault, sensor fault, or a force, speed or reach limit is reached action: Protective stop and hand control to the CMO; log the fault. level: safe-state refs: - V2 10172 - V2 10168 - id: X4 trigger: CMO is asked to take over and does not respond (for example, the CMO is the patient) action: Robot stays stopped; the next named crewmember is called. level: safe-state refs: - V2 10173 - V2 7045 - id: X5 trigger: Loss of link, or delay longer than the limit for live guidance action: >- Only the robot pauses; crew care never waits for the link or the robot. Robot pauses any movement in its stopped position and tells the CMO. The CMO decides whether to continue offline under the pre-approved onboard checklist; the robot resumes only on the CMO's confirmation. Everything is logged and sent to the flight surgeon at the next contact. level: pause refs: - V2 10172 - V2 10173 - id: X6 trigger: An URGENT alert is not acknowledged within the set time action: >- Robot repeats the alert and sends it to the next named crewmember (the second trained CMO first if the CMO is the patient), and keeps repeating at the set interval. It stays where it is: it does not leave on its own. level: urgent refs: - V1 3006 - V2 10173 - id: X7 trigger: The crewmember stops responding, or seems confused or drowsy, at any point action: >- URGENT alert at once, even mid-question or mid-step; the robot stops its current task, stays at its rest position and does not continue the run; a crewmember checks in person. level: urgent - id: X8 trigger: A crewmember asks the robot what is wrong, or for medicine, fluid or treatment advice action: >- Robot declines, says it cannot assess or advise, and routes the question to the CMO or flight surgeon. level: stop red_flags: - id: RF1 sign: Bleeding that does not stop with firm pressure threshold: >- still bleeding after minutes (shared parameter NOSEBLEED_PRESSURE_MINUTES, the same value in RMP-ENT-001 RF1 and RMP-ENT-004 RF7) of pressure (for context, the guideline advises firm sustained compression to the lower third of the nose for 5 minutes or longer) action: URGENT alert to the CMO and flight surgeon source: tunkel - id: RF2 sign: Heavy bleeding, blood running down the throat, or vomiting blood threshold: any action: >- URGENT alert; see RMP-GI-002 RF1. The robot never says vomited blood is swallowed from the nose. (Source: Tunkel KAS 1, prompt management; the specific criteria were not verified.) source: tunkel - id: RF3 sign: >- Dizziness, faintness, pale or clammy skin, or a CMO-entered heart rate or blood pressure beyond the alert level threshold: any; beyond action: URGENT alert; the CMO checks in person - id: RF4 sign: A nosebleed after a blow to the head or face, or clear fluid from the nose threshold: any action: URGENT alert; see RMP-NEURO-001 source: ng232 - id: RF5 sign: >- A nosebleed with severe sinus or ear pain, sudden hearing loss, spinning vertigo or ringing, after an EVA or a cabin or suit pressure change (matches RMP-ENT-004 RF8) threshold: any action: URGENT alert; see RMP-ENT-004 and RMP-ENT-003, and RMP-EVA-001 if within its look-back window source: v1 - id: RF6 sign: >- Anticoagulant or antiplatelet medicine (including aspirin, unlike RMP-NEURO-001 RF9), or a bleeding disorder, in the record or as stated threshold: any action: >- Flag to the CMO and flight surgeon, shown at once as information. The robot never suggests stopping, holding or reversing any medicine. source: tunkel - id: RF7 sign: Nosebleeds that keep coming back, or keep coming from one side threshold: more than in days action: Flag to the flight surgeon source: tunkel - id: RF8 sign: >- New bruising, bleeding gums or blood in urine (aims to catch a bleeding disorder, in line with Tunkel KAS 5; partial support only) threshold: any action: Flag to the flight surgeon and CMO safety_limits: - id: L1 name: Contact with the crewmember value: not allowed enforced: Keep-out zone in the robot controller refs: - V2 10172 - id: L2 name: Handling open waste or soiled gauze value: not allowed enforced: Robot grasps only sealed bags (seal check before grasp) - id: L3 name: Robot speed near the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 - id: L4 name: Closest approach to the crewmember's face value: enforced: Distance sensing; the robot stays outside it logs: - id: LOG-1 text: Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second. refs: - V2 10163 - V2 10164 - id: LOG-2 text: Mode changes and safety-limit events are announced to the operator as they happen and logged. refs: - V2 10162 - V2 10172 - id: LOG-3 text: >- Records are stored and sent as private medical data, encrypted, with access limited to the medical team. refs: - V1 6003 - V1 7003 - id: LOG-4 text: Results are kept in a permanent, retrievable format so the flight surgeon can see trends. refs: - V1 7001 - id: LOG-5 text: Pressure start and stop times as stated, answers, CMO entries and each sealed waste bag stowed. - id: LOG-6 text: >- Each URGENT alert, who received it, the time it was acknowledged (or the escalation to the next named crewmember), and the time a human released the robot. refs: - V2 10163 - id: LOG-7 text: >- Each emergency fetch as an override (time, who asked, reason as stated, kit ID, seal status) and the later inventory reconciliation, labelled "not a check before use". refs: - V2 7059 requirements: - id: V1 3004 use: >- In-mission care includes medical kits and biohazard containment (b), recording the history and exam (d, e) and vital signs (h), and the capability to diagnose and treat pressure-related illness (dysbarism, o) for RF5; procedures and medicines are human capabilities. - id: V1 3006 use: >- Two trained CMOs per vehicle for NASA programs; the second trained CMO receives alerts when the CMO is the patient (see the commercial-flight note). - id: V1 3007 use: Medical evacuation when bleeding is beyond onboard capability; the flight surgeon decides. - id: V1 6003 use: Logs and alerts sent to the ground are private medical communications. - id: V1 7001 use: Records kept so the flight surgeon can see trends. - id: V1 7003 use: Secure handling of medical records. - id: V2 7045 use: Usable by non-physician crew, including when the CMO is the patient. - id: V2 7046 use: Patient, caregiver and supplies restrained. - id: V2 7059 use: >- Kit inventory and seal status are tracked; after an emergency fetch the robot reconciles the kit through RMP-PHARM-001 as an inventory record (never a check before use) and shows it as "opened – not restocked" until resealed. - id: V2 7102 use: Waste is contained; the robot handles sealed bags only. - id: V2 9053 use: Protective equipment for helpers (eye protection, gloves) is provided; the robot fetches it. - id: V2 10161 use: Robot shows its status and health. - id: V2 10162 use: Mode changes are announced to the operator. - id: V2 10163 use: Robot records and shares its data. - id: V2 10164 use: Shows whether the human or the robot is expected to act. - id: V2 10165 use: Human can override and shut down the robot. - id: V2 10168 use: Human can take over. - id: V2 10172 use: Protective stop when a limit is exceeded. - id: V2 10173 use: Robot stays stopped if no one takes over. - id: V2 10174 use: Only a human starts or restarts the robot. validation: - stage: simulation what: >- Scripted nosebleeds with every red flag, bleeding that does not stop, no response, a CMO who is the patient, and lost link. pass: >- Every red flag acts as listed; zero face contact; zero spray, medicine or position advice; unacknowledged alerts escalate. - stage: training model what: CMO training on a bleeding-nose task trainer with the robot fetching supplies and timing. pass: Supplies delivered within seconds; timing accurate. - stage: parabolic or station demonstration what: >- Fetching supplies and collecting sealed bags in weightlessness, with simulated droplets and no patient. pass: Zero escapes of test fluid; sealed waste only. - stage: flight use under flight surgeon supervision what: First use as a fetching and timing aid. pass: No safety events; the record is complete. signoff: protocol: - Clinical lead for the specialty (sets every clinical threshold marked ) - Flight surgeon, as medical authority - Robotics and medical-device safety board - Program approval for the mission restart_after_stop: >- Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself. each_run: >- Started by a crewmember. The flight surgeon receives every nosebleed note; red flags go to the CMO and flight surgeon at once; the CMO does any procedure. change_control: - Every change gets a new version number and a written reason; earlier versions are kept. - >- Any change to steps, thresholds, limits or software that touches the patient repeats validation from the simulation stage before use. - >- Software and learned-skill updates follow a pre-agreed change plan (what may change, how it is tested, how to roll back), modeled on the FDA predetermined change control plan approach. - >- If a new version misbehaves, the robot rolls back to the last validated version and the event is reviewed by the flight surgeon and safety board. - The robot never changes its own protocol, thresholds or limits. comms: live: 'Low Earth orbit: the flight surgeon receives the note at once and can join by voice and video.' loss_of_signal: - Only the robot pauses; crew care never waits for the link or the robot. - >- The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps timing and logging offline. - >- Alerts go to the CMO (or the second trained CMO); the CMO decides under the pre-approved onboard checklist. - 'At the next contact the robot sends one package: times, answers, entries and alerts.' mars_delay: - >- Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks; the pressure time and alert levels are set before flight and the CMO acts on them. sources: - key: tunkel text: >- Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1 Suppl):S1-S38. url: https://doi.org/10.1177/0194599819890327 doi: 10.1177/0194599819890327 pmid: '31910111' supports: >- At first contact, distinguish the patient with a nosebleed who needs prompt management; treat active bleeding with firm sustained compression to the lower third of the nose for 5 minutes or longer; use nasal packing when bleeding continues despite compression (resorbable packing with a suspected bleeding disorder or anticoagulant or antiplatelet medicines); document factors that increase bleeding, including bleeding disorders, anticoagulant or antiplatelet medicines and intranasal drug use; nasal endoscopy for recurrent bleeding despite treatment, or recurrent one-sided bleeding; educate patients about signs that warrant prompt reassessment. - key: ermed text: >- NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to In-Flight Medical Conditions (2017). url: https://humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf supports: >- Table 2: 6 nosebleeds (space adaptation) among US astronauts (Shuttle, Mir and ISS through 2006); Table 1: 2 nosebleeds on the ISS through Expedition 40. - key: khanna text: >- Khanna R, Li Y, Cook M, et al. Surgery for interplanetary space missions. Br J Surg. 2026;113(3):znag005. url: https://doi.org/10.1093/bjs/znag005 doi: 10.1093/bjs/znag005 pmid: '41823369' supports: >- In weightlessness blood tends to stay at the wound (surface tension makes it dome), though arterial bleeding can form a stream of droplets, so fluid containment must be planned for. - key: ng232 text: >- National Institute for Health and Care Excellence. Head injury: assessment and early management. NICE guideline NG232 (May 18, 2023). url: https://www.nice.org.uk/guidance/ng232/chapter/Recommendations supports: >- Recommendation 1.2.4: community services should refer to an emergency department anyone with a head injury and any of: a Glasgow Coma Scale score below 15 on initial assessment; any loss of consciousness; any focal neurological deficit; suspected complex skull fracture or penetrating head injury; amnesia for events before or after the injury; persistent headache; any vomiting since the injury; any seizure; previous brain surgery; a high-energy head injury; a bleeding or clotting disorder; current anticoagulant or antiplatelet treatment (except aspirin alone); intoxication; or continuing concern about the diagnosis. Signs of basal skull fracture include blood behind the eardrum, "panda" eyes, cerebrospinal fluid leaking from the ear or nose and Battle's sign (1.5.8). With a suspected neck injury, paraesthesia in the arms or legs or a focal peripheral deficit is a high-risk factor (1.6.2). CT is the primary investigation, and people who need CT where none is available are transferred (1.5.1, 1.5.5). CT within 1 hour for a GCS score of 12 or less on initial assessment, below 15 at 2 hours after the injury, a suspected open or depressed skull fracture, any sign of basal skull fracture, a post-traumatic seizure, a focal neurological deficit, or more than 1 episode of vomiting (1.5.8); CT within 8 hours after loss of consciousness or amnesia with a bleeding or clotting disorder or a dangerous mechanism (1.5.9); consider CT for anticoagulant or antiplatelet treatment other than aspirin alone (1.5.13). Only assume a depressed conscious level is due to intoxication after an important brain injury has been excluded (1.4.2). Consider referral for irritability or altered behaviour (1.2.5). Signs of deterioration include agitation or abnormal behaviour, a drop in GCS, severe or increasing headache, persistent vomiting, and new neurological signs (1.9.13); a second competent person confirms deterioration if possible, otherwise the supervising doctor is contacted without waiting (1.9.14). With a suspected neck injury, an axial load to the head is a high-risk factor (1.6.2). - key: ismpadc text: >- Institute for Safe Medication Practices. Guidelines for the safe use of automated dispensing cabinets (2019). url: https://www.ismp.org/system/files/resources/2019-11/ISMP170-ADC%20Guideline-020719_final.pdf supports: >- Override is limited to medicines needed in emergent circumstances where waiting could harm the patient (3.3b); limit what is available on override (3.4b); require documentation of the override rationale (3.4d); routinely analyze override reports (3.6). Used for the emergency-fetch pattern by analogy (a robot fetching a sealed kit is not a dispensing cabinet). - key: tb044 text: NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). url: https://www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical-operations.pdf supports: >- The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist. - key: v1 text: 'NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023).' url: https://www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-rev-c-with-signature.pdf supports: >- NASA-STD-3001 Vol 1 Rev C: V1 3004 item o requires the capability to diagnose and treat pressure-related illness or injury (dysbarism); cited for the pressure-change red flag (RF5). - key: v2 text: >- NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. url: https://standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 supports: Requirement IDs beginning V2. - key: marsdelay text: >- NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). url: https://www.nasa.gov/wp-content/uploads/2024/01/mars-communications-disruption-and-delay.pdf supports: >- One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction. - key: pccp text: >- U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). url: >- https://www.fda.gov/regulatory-information/search-fda-guidance-documents/marketing-submission-recommendations-predetermined-change-control-plan-artificial-intelligence supports: A model for planning, validating and rolling back software updates. - key: faa460 text: 'U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements.' url: https://www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-460 supports: >- Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants. corrections: - date: '2026-10-20' version: '0.2' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 20, 2026 (batch 3 review) items: - >- RF5 now matches RMP-ENT-004 RF8 (sudden hearing loss, spinning vertigo, ringing, or severe ear or sinus pain after a pressure change), cites V1 3004 item o, and links RMP-ENT-003 and RMP-EVA-001 (item 43). - >- RF1 uses the shared parameter NOSEBLEED_PRESSURE_MINUTES, the same placeholder as RMP-ENT-004 RF7 (now v0.3, editorial only) (item 44). - >- RF3 stays URGENT and is shown as a general clinical red flag; Tunkel KAS 1 criteria were not verified (item 45). - >- RF6 counts aspirin (unlike NEURO-001) and is information only; the robot never suggests stopping, holding or reversing a medicine (items 46, 52). - >- RF8 kept as a Flag and labelled as aimed at a bleeding disorder, with partial support only from Tunkel KAS 5 (item 47). - >- RF2 links RMP-GI-002 RF1; the robot never says vomited blood is swallowed from the nose; the Tunkel tag says the specific criteria were not verified (item 48). - >- Scope "why" quotes Khanna precisely and labels it a surgical review applied by extrapolation (item 49). - >- Flight-surgeon windows and schedules that were prose only are now placeholder tokens the build can track, with context figures only where the review quoted a source (item 50). - >- One emergency-fetch pattern: kits are fetched on a human command with no barcode gate, logged as an override ("EMERGENCY FETCH – NOT VERIFIED"), never called verified, reconciled afterwards through RMP-PHARM-001 as an inventory record only (never a check before use), and shown as "opened – not restocked" until resealed (item 51; ISMP). - '"Mild" and "minor" are never-words in every batch 3 protocol (item 54).' - >- Cross-links added for the new routes; the build checks that each target exists in the library, and planned protocols link to their library entry (item 53). - date: '2026-10-21' version: '0.3' source: Batch 7 editorial (AI-assisted), Oct 21, 2026 items: - >- Citation labels changed to the site's year-only convention: "(approved for public release )" now reads "(YYYY)", and NASA-STD-3001 Volume 2 "Revision F (approved July 14, 2026)" now reads "(Rev F, 2026)" (sources: ermed, v2). Editorial; no change to steps, thresholds or limits. - date: '2026-10-21' version: '0.4' source: Batch 7 review and batch 8 editorial (AI-assisted), Oct 21, 2026 items: - >- X5 and the comms loss-of-signal branch now open with "Only the robot pauses; crew care never waits for the link or the robot." (batch 7 review suggestion 29). Editorial; robot behaviour unchanged.