{
  "$schema": "https://spacemedicinefoundation.org/robotic-medicine/protocols/schema/protocol.schema.json",
  "schema_version": "0.3",
  "version": "0.5",
  "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 2 review, 51 corrections), all applied in v0.2. Version 0.3 is an editorial update from the batch 3 review (item 44) that does not change the reviewed clinical meaning. 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-004",
  "slug": "rmp-ent-004",
  "title": "Head and nasal congestion, sore throat: symptom log with red-flag escalation (no drug advice)",
  "category": "ent",
  "tier": 2,
  "tier_note": "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.",
  "result_language": {
    "use": [
      "logged, not interpreted",
      "sent to flight surgeon"
    ],
    "never": [
      "normal",
      "no problem found",
      "all clear",
      "negative",
      "any diagnosis or cause",
      "just congestion",
      "sinusitis",
      "infection",
      "allergy",
      "safe"
    ]
  },
  "scope": {
    "summary": "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": "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.",
    "covers": [
      "Stuffy or runny nose, facial or head fullness, sinus pressure, ear fullness, sneezing or sore throat, in a crewmember who is awake and answering",
      "Repeat check-ins until the crewmember and flight surgeon close the log"
    ],
    "locked_out": [
      "Any drug advice, including decongestants, nasal sprays, allergy medicines and antibiotics",
      "Saying it is \"just\" congestion, an infection, an allergy or sinusitis",
      "Looking into the nose, ears or throat, or touching the face (otoscope support is RMP-ENT-003)",
      "Nosebleed care (RMP-ENT-001); the robot only brings supplies if asked",
      "Allergic reactions with trouble breathing or swelling of the face, lips or tongue (RMP-RESP-003)",
      "Treating ear or sinus problems after a pressure change (RMP-ENT-003; the flight surgeon decides). The robot only asks and escalates them (RF8)."
    ],
    "related": [
      "RMP-ENT-001",
      "RMP-ENT-003",
      "RMP-RESP-003",
      "RMP-INF-001",
      "RMP-EYE-003",
      "RMP-ENV-004"
    ]
  },
  "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"
    ],
    "robot_may": [
      "Ask the red-flag questions first, then the symptom questions",
      "Log answers and send them to the flight surgeon",
      "Fetch tissues, wipes and a waste bag the crewmember asks for (no medicines)",
      "Bag used tissues and wipes per the biohazard procedure",
      "Include the cabin CO2 reading in the flight surgeon's summary, for context only; the robot does not relate it to symptoms"
    ],
    "robot_may_not": [
      "Give drug advice or fetch any medicine without a human order through RMP-PHARM-001",
      "Name a cause",
      "Touch the face or look into the nose, ears or throat",
      "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 (the one with symptoms, or the CMO) started the log by command.",
      "check": "human_start == true",
      "refs": [
        "V2 10174"
      ]
    },
    {
      "id": "PRE-2",
      "text": "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).",
      "check": "crew_responsive == true and breathing_ok == true"
    },
    {
      "id": "PRE-3",
      "text": "Robot self-test passed.",
      "refs": [
        "V2 10161"
      ]
    },
    {
      "id": "PRE-4",
      "text": "Link status and current delay known."
    }
  ],
  "consent": {
    "standard": "The crewmember agrees by voice; any question can be skipped, and declining is logged, not questioned.",
    "emergency": "Not applicable; the robot does not continue without the crewmember's answers.",
    "withdrawal": "The crewmember can stop at any time."
  },
  "inputs": [
    {
      "id": "IN-1",
      "name": "Red-flag answers: swelling or redness around an eye, double vision or a vision change; severe headache, swelling over the forehead or a stiff neck; new weakness, numbness or confusion; fever; feeling very unwell; trouble breathing or swallowing, severe one-sided throat pain, trouble opening the mouth, drooling or a muffled voice; sudden hearing loss, spinning vertigo, ringing in the ear, or severe ear or sinus pain after an EVA or a cabin or suit pressure change; a nosebleed now, or one that would not stop",
      "source": "Crewmember, by voice",
      "required": true,
      "if_missing": "Ask the CMO to ask in person; never treated as \"no\"."
    },
    {
      "id": "IN-2",
      "name": "Symptoms: blocked or runny nose, facial fullness, sinus pressure, ear fullness, sore throat, sneezing (each rated 0-10)",
      "source": "Crewmember, by voice",
      "required": true,
      "if_missing": "Log \"not answered\"."
    },
    {
      "id": "IN-3",
      "name": "One side or both sides",
      "source": "Crewmember",
      "required": true,
      "if_missing": "Log \"not answered\"."
    },
    {
      "id": "IN-4",
      "name": "Any recent cabin or suit pressure change or EVA",
      "source": "Crewmember or mission log",
      "required": true,
      "if_missing": "Ask the CMO."
    },
    {
      "id": "IN-5",
      "name": "Cabin CO2 (vehicle data, for the flight surgeon)",
      "source": "Vehicle sensors",
      "required": false,
      "if_missing": "Note \"no CO2 data\"."
    },
    {
      "id": "IN-6",
      "name": "Medicines given, as logged by humans (shown to the CMO and flight surgeon; the robot does not advise)",
      "source": "Medical record or dose log",
      "required": false,
      "if_missing": "Note \"no dose log available\"."
    },
    {
      "id": "IN-7",
      "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, tell the CMO, and send a \"congestion log started\" note to the flight surgeon (queued if the link is down).",
      "success": "CMO acknowledges; note delivered or queued.",
      "refs": [
        "V2 10174",
        "V1 6003"
      ]
    },
    {
      "id": "S2",
      "actor": "robot",
      "rung": 2,
      "action": "Ask the red-flag questions first and log the answers word for word.",
      "success": "Each red-flag question answered or marked for the CMO."
    },
    {
      "id": "S3",
      "actor": "robot",
      "rung": 2,
      "action": "Ask the symptom questions (each rated 0-10, one side or both, pressure changes) and log the answers.",
      "success": "Answers logged."
    },
    {
      "id": "S4",
      "actor": "robot",
      "rung": 2,
      "action": "On request, bring tissues, wipes and a waste bag (no medicines) and restrain them within reach.",
      "success": "Supplies within reach.",
      "refs": [
        "V2 7046"
      ]
    },
    {
      "id": "S5",
      "actor": "robot",
      "rung": 2,
      "action": "Bag used tissues and wipes per the biohazard procedure, so they do not float free.",
      "success": "Waste stowed."
    },
    {
      "id": "S6",
      "actor": "robot",
      "rung": 2,
      "action": "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.",
      "success": "Delivered or queued.",
      "refs": [
        "V1 6003",
        "V1 7001",
        "V1 7003"
      ]
    },
    {
      "id": "S7",
      "actor": "crew",
      "action": "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.",
      "success": "CMO decision logged."
    },
    {
      "id": "S8",
      "actor": "ground",
      "action": "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.",
      "success": "Decision logged."
    },
    {
      "id": "S9",
      "actor": "robot",
      "rung": 2,
      "action": "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.",
      "success": "Each prompt accepted, postponed or answered; log closed by a human.",
      "refs": [
        "V2 10174"
      ]
    }
  ],
  "decisions": [
    {
      "id": "D1",
      "after": "S2",
      "decided_by": "robot",
      "question": "Is any red-flag answer \"yes\", or not answered?",
      "branches": [
        {
          "if": "Yes",
          "then": "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."
        },
        {
          "if": "Not answered",
          "then": "Ask the CMO to ask in person; never treated as \"no\"."
        },
        {
          "if": "All \"no\"",
          "then": "Continue to S3."
        }
      ]
    },
    {
      "id": "D2",
      "after": "S6",
      "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."
        }
      ]
    },
    {
      "id": "D3",
      "after": "S9",
      "decided_by": "robot",
      "question": "Are symptoms on one side only, lasting beyond the time the flight surgeon set, or worse after first getting better?",
      "branches": [
        {
          "if": "Yes",
          "then": "Flag to the flight surgeon and CMO."
        },
        {
          "if": "No",
          "then": "Continue the schedule."
        }
      ]
    }
  ],
  "stop_rules": [
    {
      "id": "X1",
      "trigger": "The patient (or the crewmember being examined) says stop, or withdraws consent",
      "action": "The robot stops the check-in at once and moves away; declining is logged, not questioned.",
      "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. On loss of link the robot pauses any movement and tells the CMO. On the CMO's confirmation it continues check-ins and logging offline; everything is queued and sent to the flight surgeon at the next contact.",
      "level": "pause",
      "refs": [
        "V2 10172",
        "V2 10173"
      ]
    },
    {
      "id": "X6",
      "trigger": "Trouble breathing or swallowing, noisy breathing, or swelling of the face, lips or tongue",
      "action": "Robot stops the check-in and calls the CMO at once; switch to RMP-RESP-003.",
      "level": "urgent"
    },
    {
      "id": "X7",
      "trigger": "The crewmember asks the robot for medicine advice",
      "action": "Robot declines and routes the question to the CMO or flight surgeon.",
      "level": "stop"
    }
  ],
  "red_flags": [
    {
      "id": "RF1",
      "sign": "Swelling or redness around the eye, a bulging eye, double vision, or newly reduced vision",
      "threshold": "any",
      "action": "URGENT alert to the CMO and flight surgeon. A vision change also goes with the next SANS images (RMP-EYE-003).",
      "source": "ng79"
    },
    {
      "id": "RF2",
      "sign": "Swelling over the forehead, severe headache at the front of the head, stiff neck, or new weakness, numbness, confusion or speech change",
      "threshold": "any",
      "action": "URGENT alert",
      "source": "ng79"
    },
    {
      "id": "RF3",
      "sign": "Sudden-onset severe headache, or reduced alertness",
      "threshold": "any",
      "action": "URGENT alert; never attributed to congestion or CO2",
      "source": "nice150"
    },
    {
      "id": "RF4",
      "sign": "Fever",
      "threshold": "<set by clinical lead> °C or higher",
      "action": "URGENT alert; see RMP-INF-001",
      "source": "ng253"
    },
    {
      "id": "RF5",
      "sign": "Feeling very unwell",
      "threshold": "any",
      "action": "URGENT alert",
      "source": "ng253"
    },
    {
      "id": "RF6",
      "sign": "Trouble breathing or swallowing, noisy breathing, or swelling of the face, lips or tongue; or severe one-sided throat pain, trouble opening the mouth, drooling, or a muffled voice",
      "threshold": "any",
      "action": "URGENT: CMO at once; RMP-RESP-003 for breathing or swelling",
      "source": "ng84"
    },
    {
      "id": "RF7",
      "sign": "Nosebleed",
      "threshold": "now, or one that would not stop; URGENT if it does not stop with pressure after <set by clinical lead> minutes (shared parameter NOSEBLEED_PRESSURE_MINUTES, the same value in RMP-ENT-001 RF1 and RMP-ENT-004 RF7)",
      "action": "CMO checks in person (RMP-ENT-001; the robot only brings supplies if asked); URGENT alert if it does not stop with pressure within the set time",
      "source": "tunkel"
    },
    {
      "id": "RF8",
      "sign": "Sudden hearing loss, spinning vertigo, ringing in the ear, or severe ear or sinus pain after an EVA or a cabin or suit pressure change",
      "threshold": "any",
      "action": "URGENT alert; the flight surgeon and CMO consider pressure-related illness (RMP-ENT-003)",
      "source": "ermed"
    },
    {
      "id": "RF9",
      "sign": "Ear pain or fullness without those features",
      "threshold": "any",
      "action": "Flag to the flight surgeon; RMP-ENT-003"
    },
    {
      "id": "RF10",
      "sign": "Symptoms on one side only, lasting, or worse after first getting better",
      "threshold": "beyond <set by flight surgeon> days",
      "action": "Flag to the flight surgeon",
      "source": "ng79"
    }
  ],
  "safety_limits": [
    {
      "id": "L1",
      "name": "Contact with the face",
      "value": "not allowed",
      "enforced": "Keep-out zone in the robot controller",
      "refs": [
        "V2 10172"
      ]
    },
    {
      "id": "L2",
      "name": "Robot speed near the crewmember",
      "value": "<set by validation>",
      "enforced": "Hard limit",
      "refs": [
        "V2 10172"
      ]
    },
    {
      "id": "L3",
      "name": "Check-in length",
      "value": "<set by validation>",
      "enforced": "Timer"
    }
  ],
  "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"
      ]
    }
  ],
  "requirements": [
    {
      "id": "V1 3003",
      "use": "Capability to monitor physiological well-being in flight."
    },
    {
      "id": "V1 3004",
      "use": "In-mission care includes personal protective equipment (biohazard containment) and the capability to diagnose and treat pressure-related illness or injury (item o; a human task, escalated by RF8); administering and managing medications is a human capability."
    },
    {
      "id": "V1 3006",
      "use": "Two crew medical officers per vehicle for NASA programs (see the commercial-flight note)."
    },
    {
      "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 6004",
      "use": "Cabin CO2 limit (1-hour average no more than 3 mmHg); the reading is included in the flight surgeon's summary for context only, not used to explain symptoms."
    },
    {
      "id": "V2 7045",
      "use": "Usable by non-physician crew, including when the CMO is the patient."
    },
    {
      "id": "V2 7046",
      "use": "Supplies restrained within reach."
    },
    {
      "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 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."
    },
    {
      "stage": "Earth analog",
      "what": "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>."
    },
    {
      "stage": "flight use under flight surgeon supervision",
      "what": "Logging aid alongside private medical conferences.",
      "pass": "No safety events; the flight surgeon finds the log useful."
    }
  ],
  "signoff": {
    "protocol": [
      "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"
    ],
    "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 reviews the log at private medical conferences; red flags go to the CMO and flight surgeon at once."
  },
  "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: 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_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."
    ]
  },
  "sources": [
    {
      "key": "mtb004",
      "text": "NASA OCHMO. Space Adaptation Sickness (SAS) and Space Readaptation Syndrome. Medical Technical Brief OCHMO-MTB-004 Rev A (Sept 25, 2025).",
      "url": "https://www.nasa.gov/wp-content/uploads/2025/09/ochmo-mtb-004-space-adaptation-sickness-sas.pdf",
      "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."
    },
    {
      "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: 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."
    },
    {
      "key": "crucian",
      "text": "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.",
      "url": "https://doi.org/10.2147/IJGM.S114188",
      "doi": "10.2147/IJGM.S114188",
      "pmid": "27843335",
      "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)."
    },
    {
      "key": "ng79",
      "text": "National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing. NICE guideline NG79 (2017).",
      "url": "https://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)."
    },
    {
      "key": "ng84",
      "text": "National Institute for Health and Care Excellence. Sore throat (acute): antimicrobial prescribing. NICE guideline NG84 (2018).",
      "url": "https://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."
    },
    {
      "key": "nice150",
      "text": "National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Clinical guideline CG150.",
      "url": "https://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."
    },
    {
      "key": "ng253",
      "text": "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).",
      "url": "https://www.nice.org.uk/guidance/ng253/chapter/Face-to-face-assessment",
      "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."
    },
    {
      "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": "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."
    },
    {
      "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": "Requirement IDs beginning V1."
    },
    {
      "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 2 review)",
      "items": [
        "Split the ear flag: sudden hearing loss, spinning vertigo, ringing or severe ear or sinus pain after an EVA or pressure change is now URGENT (RF8); other ear pain or fullness stays a flag (RF9) (item 16).",
        "Fixed the nosebleed contradiction: a nosebleed now goes to the CMO in person, and is URGENT if it does not stop with pressure in the set time (item 17).",
        "RF6 adds severe one-sided throat pain, trouble opening the mouth, drooling or a muffled voice (NICE NG84 names the complications; the wording is clinical judgment) (item 18).",
        "Added sources for fever (NG253) and for one-sided or lasting symptoms (NG79; the 3 weeks is not used as a threshold) (item 19).",
        "Cabin CO2 is included for context only; the robot does not relate it to symptoms (item 20).",
        "NICE wording: \"reasons to refer to hospital\", not \"urgent\" (item 21).",
        "Tier note now gives the Table 2 time frame and the ISS per-person-year rate (item 22).",
        "Each red-flag decision now applies the action listed for each matching red flag (URGENT alert, stop, or private flag), not URGENT for everything (review item 47).",
        "Repeat check-ins inside an open log are now on-screen prompts; the robot approaches only when the crewmember or CMO accepts, and a prompt never starts it (item 49, [V2 10174]).",
        "Red flags that had no source now cite one where a source fits; the rest are shown as general clinical red flags with no source cited (item 50).",
        "The \"item that failed a check\" lockout is kept and now notes that it applies when RMP-PHARM-001 is used (item 51).",
        "NASA evidence reports are cited as \"approved for public release\" (item 48)."
      ]
    },
    {
      "date": "2026-10-20",
      "version": "0.3",
      "source": "AI-assisted batch 3 review by the Medical Research Assistant, Oct 20, 2026 (item 44); editorial only, the reviewed clinical meaning is unchanged",
      "items": [
        "RF7: the nosebleed pressure time is now the shared parameter NOSEBLEED_PRESSURE_MINUTES, used by RMP-ENT-001 RF1 too, so the two pages cannot diverge. It stays a placeholder set by the clinical lead; the action is unchanged.",
        "RF7 now cites the US nosebleed guideline (Tunkel 2020: firm sustained compression to the lower third of the nose for 5 minutes or longer), so it no longer shows as a general clinical red flag with no source."
      ]
    },
    {
      "date": "2026-10-21",
      "version": "0.4",
      "source": "Batch 7 editorial (AI-assisted), Oct 21, 2026",
      "items": [
        "Citation labels changed to the site's year-only convention: \"(approved for public release <date>)\" 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": "0.5",
      "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."
      ]
    }
  ]
}