RMP-ENT-004 Head and nasal congestion, sore throat: symptom log with red-flag escalation (no drug advice)

1 · Identity and scope

For a crewmember with a stuffy or runny nose, facial or head fullness, sinus pressure, ear fullness or a sore throat, the robot runs short check-ins (red-flag questions first), logs the answers, fetches tissues and hygiene supplies on request, bags used tissues, and sends a summary to the flight surgeon. Red-flag answers, such as swelling around the eye, a vision change, a severe headache, fever, trouble breathing, or sudden hearing loss or spinning vertigo after an EVA or pressure change, go to the CMO and flight surgeon at once; each red flag has its own listed action. It gives no drug advice; decongestants and other medicines are human decisions.

Why this protocol was chosen. In weightlessness, body fluid shifts toward the head, causing nasal and facial congestion in the first days of flight. NASA says it usually eases within hours to days, but calls it the leading cause of prolonged medication use in flight, and US astronaut records list 389 nasal congestion events. On the station, upper respiratory symptoms were the second most reported event among the immune-related problems studied. Most cases are minor, so the value is in catching the rare complication early: NICE's sinusitis guideline lists eye-socket and brain complications, and severe systemic infection, as reasons to refer to hospital, and its sore-throat guideline lists severe throat complications such as an abscess.

Priority: Moved up from Tier 3: nasal congestion is the most often recorded condition in the NASA HRP Table 2 counts (389 events; Shuttle, Mir and ISS through 2006), 1.93 events per person-year on the ISS, and the leading cause of prolonged medication use in flight; the rare complications need early escalation.

Related: RMP-ENT-001 · RMP-ENT-003 · RMP-RESP-003 · RMP-INF-001 · RMP-EYE-003 · RMP-ENV-004

2 · 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 symptoms: answers check-ins and can stop at any time
• Flight surgeon: reviews the log and decides any treatment

Commercial flights

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.) [14]

3 · Preconditions and consent

• PRE-1 A crewmember (the one with symptoms, or the CMO) started the log by command.human_start == trueV2 10174
• PRE-2 The crewmember is awake, answering and breathing comfortably. Trouble breathing, or swelling of the face, lips or tongue, goes to the CMO at once (RMP-RESP-003).crew_responsive == true and breathing_ok == true
• PRE-3 Robot self-test passed.V2 10161
• PRE-4 Link status and current delay known.

Consent

The crewmember agrees by voice; any question can be skipped, and declining is logged, not questioned.

Emergency consent

Not applicable; the robot does not continue without the crewmember's answers.

Withdrawal

The crewmember can stop at any time.

4 · Required sensor inputs

5–6 · Steps and decision points

Each step names who acts. Decision points sit after the step they follow and say who decides: Robot Crew Ground. Any stop rule in section 7 can interrupt any step.

1. S1RobotRung 2

   On a crewmember's command, open the log, tell the CMO, and send a "congestion log started" note to the flight surgeon (queued if the link is down).

   Done when: CMO acknowledges; note delivered or queued.

   V2 10174V1 6003

2. S2RobotRung 2

   Ask the red-flag questions first and log the answers word for word.

   Done when: Each red-flag question answered or marked for the CMO.

   D1DecisionRobot decides

   Is any red-flag answer "yes", or not answered?

   • Yes → Apply the action listed for each matching red flag (URGENT alert, stop, or private flag) now, with the answer itself. The robot does not say what it means.
   • Not answered → Ask the CMO to ask in person; never treated as "no".
   • All "no" → Continue to S3.
3. S3RobotRung 2

   Ask the symptom questions (each rated 0-10, one side or both, pressure changes) and log the answers.

   Done when: Answers logged.

4. S4RobotRung 2

   On request, bring tissues, wipes and a waste bag (no medicines) and restrain them within reach.

   Done when: Supplies within reach.

   V2 7046

5. S5RobotRung 2

   Bag used tissues and wipes per the biohazard procedure, so they do not float free.

   Done when: Waste stowed.

6. S6RobotRung 2

   Send a summary to the flight surgeon (ratings over time, red-flag answers, medicines logged by humans, and the cabin CO2 reading for context only, not related to symptoms), or queue it.

   Done when: Delivered or queued.

   V1 6003V1 7001V1 7003

   D2DecisionGround decides

   What is the plan?

   • Link live → Flight surgeon decides; robot logs.
   • Link down or delay too long → The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact.
7. S7Crew

   The CMO assesses in person when asked or on any red flag; any medicine is ordered by a human and fetched through RMP-PHARM-001.

   Done when: CMO decision logged.

8. S8Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides any treatment and the check-in schedule; the robot logs them.

   Done when: Decision logged.

9. S9RobotRung 2

   Offer a check-in every <set by flight surgeon> hours, red-flag questions first every time, until the crewmember and flight surgeon close the log. 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.

   Done when: Each prompt accepted, postponed or answered; log closed by a human.

   V2 10174

   D3DecisionRobot decides

   Are symptoms on one side only, lasting beyond the time the flight surgeon set, or worse after first getting better?

   • Yes → Flag to the flight surgeon and CMO.
   • No → Continue the schedule.

7 · Stop and escalate rules, red flags

Red flags

The robot reports the sign or value only, never what it means. Numeric thresholds are placeholders for the clinical lead.

8 · Safety limits

9 · Logs and audit

• LOG-1 Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second.V2 10163V2 10164
• LOG-2 Mode changes and safety-limit events are announced to the operator as they happen and logged.V2 10162V2 10172
• LOG-3 Records are stored and sent as private medical data, encrypted, with access limited to the medical team.V1 6003V1 7003
• LOG-4 Results are kept in a permanent, retrievable format so the flight surgeon can see trends.V1 7001

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [10] and Volume 2 Revision F [11]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted check-ins with every red-flag answer and unanswered questions, at station, Moon and Mars delays. Pass: Every red flag alerts; zero advice or cause statements.
2. Earth analog. Analog crews (for example head-down bed rest, which also shifts fluid to the head) using daily check-ins. Pass: Data completeness at or above <set by validation>; crew acceptance at or above <set by validation>.
3. Flight use under flight surgeon supervision. Logging aid alongside private medical conferences. Pass: No safety events; the flight surgeon finds the log useful.

No stage has been run. Pass and fail criteria must be fixed in advance by the clinical lead and safety board.

12 · Human sign-off

Before any use

• Clinical lead for the specialty (sets every clinical threshold marked <set by clinical lead>)
• Flight surgeon, as medical authority
• Robotics and medical-device safety board
• Program approval for the mission

Each run

Started by a crewmember. The flight surgeon reviews the log at private medical conferences; red flags go to the CMO and flight surgeon at once.

Restart after a stop

Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself.

None of these sign-offs has happened. This is a Draft v0.5.

13 · Change control for learning

• 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.

Change-plan model: FDA guidance [13].

Loss of signal and Mars delay

Live link

Low Earth orbit: red flags reach the flight surgeon within minutes; routine logs are reviewed at the private medical conference.

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 running check-ins and logging offline.
• Red flags go to the CMO at once; the CMO decides under the pre-approved onboard checklist.
• Everything is sent as one package at the next contact.

Mars-class delay

• Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks.
• Red flags and the check-in schedule are set before flight; the CMO acts on them.

[12]

Sources

1. NASA OCHMO. Space Adaptation Sickness (SAS) and Space Readaptation Syndrome. Medical Technical Brief OCHMO-MTB-004 Rev A (Sept 25, 2025). www.nasa.gov/wp-content/uploads/2025/09/ochmo-mtb-004-space-… Supports: The fluid shift toward the head in weightlessness causes nasal and facial congestion and facial fullness, most evident in the first 3 days; congestion lasts from a few hours to a few days and eases as fluid levels readjust; it is the leading cause of prolonged medication use in flight.
2. NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to In-Flight Medical Conditions (2017). humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf Supports: Table 2: 389 nasal congestion (space adaptation) events, 31 barotrauma (ear or sinus block), 6 sinusitis and 6 nosebleed events among US astronauts (Shuttle, Mir and ISS through 2006); Table 1: 1.93 nasal congestion events per person-year on the ISS (through Expedition 40). Used for RF8 together with [V1 3004] item o; no specific inner-ear pressure-illness guideline was verified for this draft.
3. Crucian B, Babiak-Vazquez A, Johnston S, et al. Incidence of clinical symptoms during long-duration orbital spaceflight. Int J Gen Med. 2016;9:383-391. PMID 27843335. doi:10.2147/IJGM.S114188 Supports: Among 46 long-duration ISS crewmembers, upper respiratory symptoms (0.97 per flight year) were the second most reported event after skin rashes, in the categories studied (infections, allergies, rashes and hypersensitivities).
4. National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing. NICE guideline NG79 (2017). www.nice.org.uk/guidance/ng79/chapter/Recommendations Supports: Refer to hospital if acute sinusitis comes with severe systemic infection; eye-socket complications (swelling or redness around the eye, a displaced eyeball, double vision, eye-movement problems, or newly reduced vision); or brain complications (swelling over the forehead, signs of meningitis, severe frontal headache, or focal neurological signs). People are advised to seek medical help if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell (the 3 weeks is not used as a threshold here).
5. National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescribing. NICE guideline NG84 (2018). www.nice.org.uk/guidance/ng84/chapter/Recommendations Supports: Recommendation 1.1.13: refer people to hospital if acute sore throat comes with a severe systemic infection or severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal or retropharyngeal abscess, or Lemierre syndrome). NICE names the complications only; the plain-language symptoms in this protocol are the reviewer's clinical wording.
6. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. www.nice.org.uk/guidance/cg150/chapter/Recommendations Supports: Headache features that need further investigation or referral include worsening headache with fever, sudden-onset headache reaching maximum intensity within 5 minutes, new-onset neurological deficit, and impaired level of consciousness.
7. National Institute for Health and Care Excellence. Suspected sepsis in people aged 16 or over: recognition, assessment and early management. NICE guideline NG253 (2025, last updated Sept 23, 2026). www.nice.org.uk/guidance/ng253/chapter/Face-to-face-assessme… Supports: People with sepsis may feel very unwell and may not have a high temperature; do not rely on fever alone; a rise in temperature can be a physiological response; assess temperature, heart rate, breathing rate, blood pressure, level of consciousness and oxygen saturation; look for mottled or ashen skin, blue skin, lips or tongue, a non-blanching rash, and breaks in the skin; ask how often the person passed urine in the past 18 hours and about fever or shaking chills (rigors); pay attention to new changes in behavior and to concerns raised by others.
8. Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1 Suppl):S1-S38. PMID 31910111. doi:10.1177/0194599819890327 Supports: Clinical practice guideline: treat active bleeding with firm sustained compression to the lower third of the nose for 5 minutes or longer (key action statement 2). Cited for RF7 (batch 3 review item 44); the time stays a placeholder.
9. NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical… Supports: The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist.
10. NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023). www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-… Supports: Requirement IDs beginning V1.
11. NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 Supports: Requirement IDs beginning V2.
12. NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). www.nasa.gov/wp-content/uploads/2024/01/mars-communications-… Supports: One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction.
13. U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). www.fda.gov/regulatory-information/search-fda-guidance-docum… Supports: A model for planning, validating and rolling back software updates.
14. U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements. www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-… Supports: Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants.

Checked on 2026-10-20: links opened (HTTP 200 or publisher redirect), DOIs and PubMed IDs matched, NASA documents read in full text. The framework comes from Part 1.