# RMP-GI-001 Abdominal pain: abdominal ultrasound assist with a crew-held probe (diagnostic only) # 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: '2026-10-21' reviewed: '2026-10-21' human_clinician_review: false text: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 7 review, 14 required corrections and 17 optional suggestions); all required corrections are applied in this version (see Corrections). No named human clinician has reviewed it. Not for clinical use. 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-GI-001 slug: rmp-gi-001 title: 'Abdominal pain: abdominal ultrasound assist with a crew-held probe (diagnostic only)' category: gi tier: 1 rung_note: >- Max rung 2 for supervised fetching of the ultrasound kit, holding the display and reference card, and labelling and relaying images. The CMO holds the probe: every protocol from batch 3 on keeps "Contact with the crewmember: not allowed", so the robot-held probe of RMP-RENAL-001 (the Part 1 research example) is not reused here. result_language: use: - non-diagnostic - images acquired, for human review - image not obtained - sent to flight surgeon - pain score as stated - as stated by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - appendicitis - no appendicitis - free fluid - no free fluid - gallstones - no stone - obstruction - looks fine - nothing seen - verified - safe - mild - minor scope: summary: >- When a crewmember has abdominal (belly) pain, the robot alerts the flight surgeon at once, brings the ultrasound kit by a checked kit fetch, holds the display and the probe reference card where the CMO can see them, relays live images and voice to the ground imaging expert when the link allows (remote guidance), labels and stores each clip with the scan window the CMO names and the clock time, and logs the crewmember's stated answers word for word. The CMO holds the probe. Every image is "non-diagnostic, for human review": the robot never reads an image, never says what it shows, and never says nothing is wrong. why: >- Abdominal pain has many causes, and some need surgery, which may not be possible far from Earth. The ISS carries an ultrasound system: in 2005 a crewmember with minimal sonography training, guided from Mission Control with a 2-second delay and identical reference cards, completed a four-window abdominal FAST examination (focused assessment with sonography for trauma) in about 5.5 minutes (Sargsyan 2005). NASA's in-flight medical conditions evidence report describes the ADUM (Advanced Diagnostic Ultrasound in Microgravity) project, which "uses remote guidance, telemedical interfaces, and just-in-time instruction techniques to guide minimally trained crewmembers". On Earth, the WSES (World Society of Emergency Surgery) Jerusalem guidelines recommend combining clinical findings with ultrasound for suspected appendicitis, and WSES Recommendation 1.10 recommends point-of-care ultrasound (POCUS) as the most appropriate first-line imaging tool if imaging is indicated; Statement 1.11 adds "if performed by an experienced operator". An onboard CMO is not an experienced operator, so images are for remote expert review only and never rule anything out. Here ultrasound is diagnostic only, and it never delays the CMO's examination, the call to the flight surgeon, or emergency care. Open question for review: which scan windows the onboard checklist lists (for example the right lower and right upper quadrants, the four FAST windows, kidneys and bladder), and whether a ground-steered robot-held probe should ever replace the crew-held probe. covers: - New abdominal pain, in flight or on a planetary surface - Crew-held ultrasound with ground remote guidance, or store-and-forward when the link is down - >- Routing to RMP-RENAL-001 (flank pain), RMP-GI-002 (vomiting or diarrhea), RMP-GI-003 (constipation and bloating), RMP-RENAL-002 (cannot pass urine), RMP-MSK-001 (injury) and RMP-CARD-002 (chest pain) - >- After the scan, the probe and any shared surface are cleaned under RMP-INF-002 (a probe on intact skin is noncritical equipment, CDC 3.c; probe covers do not allow a lower category of disinfection, CDC 10.b). A probe that touched broken skin is semicritical equipment: the crew tag it "not for use" under RMP-INF-002 until it has had high-level disinfection (CDC 3.b) locked_out: - Diagnosis or naming a cause - Any medicine, fluid or oxygen advice; starting, stopping or adjusting oxygen - Touching the crewmember - >- Handing over any medicine outside RMP-PHARM-001, or after a MISMATCH or CANNOT VERIFY (the item stays quarantined; only the CMO can ask for it, through the RMP-PHARM-001 logged two-step override) - Holding, moving or pressing the probe, or touching the abdomen - Reading or measuring an image, or saying what an image shows or does not show - Saying the pain is not serious - Food or fluid advice - >- Scanning over an open wound or broken skin, unless the flight surgeon directs it with a sterile cover related: - RMP-RENAL-001 - RMP-RENAL-002 - RMP-RENAL-004 - RMP-GI-002 - RMP-GI-003 - RMP-INF-001 - RMP-MSK-001 - RMP-CARD-002 - RMP-EGR-001 - RMP-PREV-003 - RMP-PHARM-001 - 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: - 'Second trained CMO: receives every alert and takes over if the CMO is the patient' - 'Vehicle commander: leads any cabin emergency procedure' - 'Other crew: help as the CMO or commander directs' robot_may: - Alert the flight surgeon at once - Bring the ultrasound kit by a checked kit fetch - Hold the display and the probe reference card where the CMO can see them - Relay live images and voice to the ground imaging expert when the link allows - Label and store each clip with the window the CMO names and the clock time - Log stated answers word for word robot_may_not: - Hold, move or press the probe, or touch the crewmember - Read, measure or describe an image - Say what is wrong, or that nothing is wrong - Suggest food, fluid or medicine - 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 or the CMO started the protocol by command after abdominal pain was reported. check: human_start == true refs: - V2 10174 - id: PRE-2 text: Robot self-test passed; kit stowage locations known. refs: - V2 10161 - V2 7059 - id: PRE-3 text: Robot and supplies restrained when not moving. refs: - V2 7046 - id: PRE-4 text: Link status known. The crew never wait for the robot before acting. check: link_state in [live, delayed, down] consent: standard: >- The crewmember agrees to the scan, images and video; the CMO confirms. Images go only to the flight surgeon and the ground imaging expert the flight surgeon names. emergency: If the crewmember cannot agree, the robot proceeds on the CMO's command; the scan never delays care. withdrawal: The crewmember can stop the scan, images or video at any time; the alert and the record stand. inputs: - id: IN-1 name: Where the pain is, when it started and what it is like, as stated by the crewmember source: Voice required: true if_missing: Log "no response"; URGENT. - id: IN-2 name: Pain score 0-10 as stated source: Crewmember required: false if_missing: Log "not stated". - id: IN-3 name: Vomiting, bowel movements, passing urine, fever and appetite, as stated source: Crewmember required: false if_missing: Log "not stated"; never fill a blank. - id: IN-4 name: Vital signs as displayed or stated by the CMO source: CMO / monitor required: false if_missing: Log "not stated". - id: IN-5 name: Ultrasound clips, each with the window the CMO names source: Ultrasound unit required: false if_missing: Log "image not obtained" (never a reassuring value) and continue. - id: IN-6 name: Link status and delay source: Communications system required: true if_missing: Treat as link down; store and forward. steps: - id: S1 actor: robot rung: 2 action: >- Send an "abdominal pain" alert to the flight surgeon and the CMO at once (URGENT if a red flag is already stated). 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: Alert acknowledged, or escalated. refs: - V2 10174 - V1 6003 - V1 3006 - id: S2 actor: robot rung: 2 action: >- On the CMO's command, run a checked kit fetch of the ultrasound medical kit (unit, sealed gel and probe-cover pack): check the kit ID and seal before hand-over, and quarantine a kit whose ID or seal does not match (no hand-over; the CMO is told). Any medicine goes only through RMP-PHARM-001. If an URGENT red flag has fired or a human states an emergency, bring it instead as an emergency fetch: This is an emergency fetch on a human command (CMO): 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 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: Kit within reach after a matched ID and seal, or quarantined, or emergency fetch logged. limit: refs: - V2 7046 - V2 7059 - id: S3 actor: crew action: >- The CMO examines the abdomen and asks the onboard checklist questions; the crewmember and the CMO are restrained for scanning. success: Human-led care; robot logs what is stated. refs: - V1 3004 - V2 7046 - id: S4 actor: robot rung: 2 action: >- Hold the ultrasound display and the probe reference card where the CMO can see them, no closer than the set display distance, and relay live images and voice to the ground imaging expert when the link allows. When the link is down, show the onboard scan checklist and store the clips for forwarding. success: Display and card in view; relay running or clips stored. limit: refs: - V2 7045 - id: S5 actor: crew action: >- The CMO holds the probe and scans the windows that the onboard checklist or the ground expert names; the crewmember can stop at any time. The probe and gel are never placed on an open wound or broken skin unless the flight surgeon directs it with a sterile cover. success: Scan done, stopped, or not possible. refs: - V1 3004 - id: S6 actor: robot rung: 2 action: >- Label and store each clip with the window the CMO names and the clock time, mark every clip "non-diagnostic, for human review", and log stated answers and pain scores word for word. A device image-quality prompt is passed on to the CMO as displayed; the robot never judges an image. success: Clips labelled; gaps logged as "image not obtained". refs: - V1 7001 - 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 with the ground imaging expert (or the CMO under the onboard checklist when there is no link) reviews the images and decides on care, repeat scans and any evacuation [V1 3007]; evacuation preparation follows RMP-EGR-001. success: Decision logged. refs: - V1 3007 - id: S9 actor: robot rung: 2 action: >- Only after the CMO or flight surgeon has placed an order, run RMP-PHARM-001 for the ordered item (fetch, barcode match to every order field, recipient check). This protocol adds nothing to that check, never suggests an order, and never hands anything over outside RMP-PHARM-001. success: RMP-PHARM-001 run logged with its result, or none ordered. refs: - V2 7059 - id: S10 actor: robot rung: 2 action: >- 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: Reconciliation recorded; kit shown as opened – not restocked until resealed. refs: - V2 7059 - id: S11 actor: robot rung: 2 action: >- Send the flight surgeon one package: stated answers, pain scores, vital signs as stated, labelled clips, times and decisions; images go only to the people the flight surgeon names. success: Package delivered or queued. refs: - V1 6003 - V1 7001 - V1 7003 decisions: - id: D1 after: S2 decided_by: robot question: Which kit fetch was it, and what did the checked kit fetch show? branches: - if: EMERGENCY FETCH (an URGENT red flag had fired, or a crewmember or the CMO stated an emergency) then: >- Hand-over already done as an emergency fetch, logged as an override; reconciled afterwards (not a check before use). - if: KIT ID AND SEAL MATCH then: >- Hand the kit over closed; log "KIT ID AND SEAL MATCH. Not a check of the contents." and the clock time. - if: MISMATCH, seal not intact or CANNOT VERIFY then: >- Shown with the reason. No hand-over under this protocol: the kit stays sealed in quarantine (the RMP-PHARM-001 default), and the robot never hands it over unprompted or to anyone but the CMO. The robot does not offer or suggest an override. Only if the CMO explicitly makes the two-step override request inside RMP-PHARM-001 can the kit go to the CMO, logged there as an override with the reason, and flagged to the flight surgeon. If the need becomes an emergency, a crewmember or the CMO states it and the emergency fetch applies. handoff: none - id: D2 after: S6 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: D3 after: S6 decided_by: robot question: Did the crewmember answer the last 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: D4 after: S8 decided_by: ground question: What is the plan (care, repeat scan, evacuation)? 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: D5 after: S9 decided_by: robot question: What did RMP-PHARM-001 show for the ordered item? branches: - if: MATCH TO ORDER then: >- RMP-PHARM-001 completes its own recipient check and hand-over; this protocol only logs "MATCH TO ORDER. Not a dose, interaction or allergy review." and the clock time. - if: MISMATCH or CANNOT VERIFY on any field, or a failed scan or recipient check then: >- MISMATCH or CANNOT VERIFY shown with the fields named. No hand-over under this protocol: the item stays sealed in the NOT VERIFIED bag in quarantine (the RMP-PHARM-001 default), and the robot never hands it over unprompted or to anyone but the CMO. The robot does not offer or suggest an override. Only if the CMO explicitly makes the two-step override request inside RMP-PHARM-001 can the item go to the CMO, logged there as an override with the reason and the mismatched fields, and flagged to the flight surgeon. handoff: none 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: it holds a position clear of hatch routes and the crew, and tells the CMO. Crew care never waits for the link or the robot. The CMO decides whether the robot continues offline under the pre-approved onboard checklist; it resumes only on the CMO's confirmation. 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 - id: X9 trigger: The crew need the robot's space action: Robot moves to its rest position at once and holds; it does not leave the module on its own. level: safe-state refs: - V2 10172 - id: X10 trigger: The crewmember says the probe makes the pain worse, or asks to stop the scan action: >- Robot stops relaying scan prompts and keeps the record; the CMO decides whether to continue. Pain getting worse is a red flag. level: stop red_flags: - id: RF1 sign: >- Pain that is severe or getting worse, or a very tender or rigid belly, as stated by the crewmember or the CMO (design judgment) threshold: any action: URGENT alert; the CMO examines at once and the flight surgeon decides - id: RF2 sign: Vomiting blood or material like coffee grounds, or black or bloody stools, as stated threshold: any action: URGENT alert; see RMP-GI-002 source: cg141 - id: RF3 sign: Upper abdominal pain with chest pain or pressure, shortness of breath or sweating threshold: any action: URGENT alert; see RMP-CARD-002 source: gulati - id: RF4 sign: Abdominal pain with shaking chills or new confusion, as stated threshold: any action: URGENT alert; see RMP-INF-001 source: ng253 - id: RF5 sign: Abdominal pain after an injury or impact threshold: any action: URGENT alert; see RMP-MSK-001 source: ng39 - id: RF6 sign: Flank pain with fever or chills, or not passing urine, as stated threshold: any action: URGENT alert; see RMP-RENAL-001 and RMP-RENAL-002 source: eau - id: RF7 sign: Vomiting with a swollen belly and no bowel movement or gas, as stated (design judgment) threshold: any action: URGENT alert; see RMP-GI-003 - id: RF8 sign: Fainting, or the crewmember looks pale and sweaty, as stated by the CMO (design judgment) threshold: any action: URGENT alert; a crewmember stays with the crewmember 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: Probe holding or movement by the robot value: not allowed enforced: No probe task is loaded; the robot holds only the display and reference card - id: L3 name: Robot speed near the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 - id: L4 name: Display distance from the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 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: >- Stated answers, pain scores, vital signs as stated, each clip with its window, label and time, relay start and stop, and decisions. - 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 - id: LOG-8 text: >- Each RMP-PHARM-001 run started from this protocol: order ID, result (MATCH TO ORDER, MISMATCH or CANNOT VERIFY with the fields), quarantine, and any CMO override logged by RMP-PHARM-001 (reason and mismatched fields), at clock time. No running counter of doses. refs: - V2 7059 - id: LOG-9 text: >- Each checked kit fetch: time, who asked, kit ID, seal status and result (KIT ID AND SEAL MATCH, MISMATCH, seal not intact or CANNOT VERIFY), and any quarantine. refs: - V2 7059 requirements: - id: V1 3004 use: In-mission care includes imaging; the CMO scans and a human reviews every image. - 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 needed; 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 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 pain cases with and without red flags, kit seal mismatch, image not obtained, CMO as patient, lost link. pass: Zero contact; no image described; red flags raised at once. - stage: training model what: CMO scans a phantom with the robot holding the display and relaying to a ground expert. pass: Every clip labelled; no robot wording about image content. - stage: parabolic or station demonstration what: Display hold and relay in weightlessness on a phantom. pass: Display distance limit held. - stage: flight use under flight surgeon supervision what: First use in drills and scheduled scans. pass: No safety events. 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 or the CMO. The CMO holds the probe; a human reviews every image. 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 ground imaging expert can guide the CMO in real time when the link allows (about a 2-second delay in the 2005 ISS example). loss_of_signal: - >- Only the robot pauses non-essential motion and tells the CMO; it resumes offline only on the CMO's confirmation. Crew care never waits for the link or the robot. - The CMO scans under the onboard checklist and the clips are stored for forwarding. mars_delay: - >- Live remote guidance is not possible; the CMO uses the onboard scan checklist and the flight surgeon reviews the stored clips when they arrive. sources: - key: wses2020 text: >- Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27. url: https://doi.org/10.1186/s13017-020-00306-3 doi: 10.1186/s13017-020-00306-3 pmid: '32295644' supports: >- World Society of Emergency Surgery (WSES). Recommendation 1.7: combine clinical parameters with ultrasound (US) to improve diagnostic sensitivity and specificity and reduce the need for CT; Recommendation 1.10: point-of-care ultrasound (POCUS) as the most appropriate first-line imaging tool in adults and children when imaging is indicated after clinical assessment. Earth context for the flight surgeon; the robot never reads an image. Full text read (Europe PMC PMC7386163). - key: sargsyan2005 text: >- Sargsyan AE, Hamilton DR, Jones JA, et al. FAST at MACH 20: clinical ultrasound aboard the International Space Station. J Trauma. 2005;58(1):35-39. url: https://doi.org/10.1097/01.ta.0000145083.47032.78 doi: 10.1097/01.ta.0000145083.47032.78 pmid: '15674147' supports: >- An ISS crewmember with minimal sonography training was remotely guided from Mission Control through a FAST (focused assessment with sonography for trauma) examination of four abdominal windows in about 5.5 minutes, with a 2-second delay, private two-way audio and video downlink, and identical reference cards for crew and ground expert. Abstract read. - key: ermed text: >- NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to Medical Conditions that occur in Flight, as well as Private Medical Conditions, in Exploration Missions (In-Flight Medical Conditions). url: https://humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf supports: >- Table 2 (US astronauts, Shuttle, Mir and ISS through Expedition 13 / 2006): headache (space adaptation) 233, headache (late) 49, headache (CO2 induced) 20; choking/obstructed airway 3; smoke inhalation 3. Table 1 (ISS through Expedition 40): headache 33. - key: cdcdis text: >- U.S. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008): summary of recommendations. url: https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html supports: >- 3.b: at least high-level disinfection for semicritical equipment that touches mucous membranes or non-intact skin; 3.c: low-level disinfection for noncritical equipment that touches intact skin; 10.b: probe covers do not allow a lower category of disinfection. Read live (WebFetch, Oct 21, 2026; 3.b as quoted in RMP-INF-002). - key: cg141 text: >- National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s: management. Clinical guideline CG141 (2012). url: https://www.nice.org.uk/guidance/cg141 supports: >- Management of acute upper gastrointestinal bleeding; context for vomiting blood or black stools as a red flag only. - key: gulati text: >- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22):e368-e454. url: https://doi.org/10.1161/CIR.0000000000001029 doi: 10.1161/CIR.0000000000001029 pmid: '34709879' supports: >- Chest pain includes pressure, tightness or discomfort in the chest, shoulders, arms, neck, back, upper abdomen or jaw; context for upper abdominal pain with chest symptoms. - 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: ng39 text: >- National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline NG39 (2016). url: https://www.nice.org.uk/guidance/ng39/chapter/Recommendations supports: Injury pathway (NICE major trauma guideline); abdominal pain after an injury goes to RMP-MSK-001. - key: eau text: European Association of Urology. EAU Guidelines on Urolithiasis. url: https://uroweb.org/guidelines/urolithiasis supports: An infected, obstructed kidney needs urgent drainage plus antibiotics. - 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 (in-mission imaging), V1 3006, V1 3007, V1 6003, V1 7001, V1 7003. - 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: 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: 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: '2026-10-21' version: '0.2' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 7 review) items: - >- Why: WSES Recommendation 1.10 (POCUS as first-line imaging if indicated) now carries Statement 1.11 ("if performed by an experienced operator"); an onboard CMO is not an experienced operator, so images are for remote expert review only and never rule anything out (item 1). - >- Batch 7 protocols now record the review as AI-assisted (Medical Research Assistant, Oct 21, 2026); no named human clinician. - date: '2026-10-21' version: '0.3' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 8 review), editorial items: - >- Why: adds NASA remote-guidance context (ADUM, from the in-flight medical conditions evidence report) (batch 7 suggestion 15). - >- Related and covers: probe cleaning under RMP-INF-002 (CDC 3.c and 10.b); no new step (batch 7 suggestion 16, cross-link part only). - >- "Cannot pass urine" now routes to RMP-RENAL-002 (trouble passing urine), not RMP-RENAL-004 (fluid intake and urine output log). - date: '2026-10-21' version: '0.4' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 9 review) items: - >- Probe on broken skin, mirrored from RMP-RESP-004 and RMP-MSK-003: the probe and gel are never placed on an open wound or broken skin unless the flight surgeon directs it with a sterile cover; a probe that touched broken skin is semicritical and tagged "not for use" under RMP-INF-002 until it has had high-level disinfection (CDC 3.b) (R4).