# RMP-GI-002 Vomiting or diarrhea: intake and output log, sealed containment and clean-up supplies, relay to the flight surgeon (no drug or fluid advice) # 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-GI-002 slug: rmp-gi-002 title: >- Vomiting or diarrhea: intake and output log, sealed containment and clean-up supplies, relay to the flight surgeon (no drug or fluid advice) category: gi tier: 2 result_language: use: - logged, not interpreted - sent to flight surgeon - count as reported by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - just a stomach bug - food poisoning - not infectious - dehydrated - not dehydrated - safe - mild - minor scope: summary: >- When a crewmember reports diarrhea at any time, vomiting that is not space motion sickness in the first flight days (RMP-NEURO-004 covers that), or vomiting together with diarrhea at any time, the robot tells the flight surgeon, brings containment, hygiene and protective supplies, hands over fresh bags and collects only sealed waste, runs short voice check-ins (red flags first; episodes, fluids taken and urine passed, as reported), and sends summaries. Red flags go to the CMO and flight surgeon at once. Space motion sickness in the first flight days stays with RMP-NEURO-004; if unsure, the CMO chooses, and the robot never decides which applies. Vomiting after a blow to the head goes to RMP-NEURO-001, and gastrointestinal symptoms with allergy signs to RMP-RESP-003, as URGENT. why: >- NASA records list 33 episodes of diarrhea and 4 of gastroenteritis among US astronauts through 2006, and diarrhea is recorded on the ISS. In a closed cabin, body waste must be contained so that feces or vomitus do not escape into the habitable volume [V2 7102], and an infection can spread to the rest of the crew. Acute diarrhea is often defined as 3 or more loose stools above baseline in 24 hours; fever, bloody stools and abdominal pain can come with it (ACG 2016). A helper that keeps supplies coming, collects sealed waste and keeps an exact log lets the sick crewmember rest and limits contact with others. covers: - >- Diarrhea at any time, vomiting that is not first-days space motion sickness, or vomiting with diarrhea, in a crewmember who is awake and answering (the CMO chooses between this and RMP-NEURO-004 if unsure) - Repeat check-ins until the crewmember and flight surgeon close the log locked_out: - Suggesting, choosing, fetching or dosing any medicine (a human order and RMP-PHARM-001 are needed) - Advising how much to drink, or judging whether someone is dehydrated - Saying what the cause is, or that it is or is not infectious - Handling an open sample, open waste or soiled items with bare manipulators (sealed bags only) - Touching, holding or restraining the crewmember - Holding an open bag near the crewmember's face related: - RMP-NEURO-004 - RMP-NEURO-001 - RMP-RESP-003 - RMP-INF-001 - RMP-INF-002 - RMP-INF-003 - RMP-GI-001 - RMP-RENAL-004 - RMP-PREV-004 - RMP-PHARM-001 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 or pause them at any time' - 'Second trained CMO: receives alerts if the CMO is the patient' - 'Other crew: told by the CMO which hygiene measures to follow' robot_may: - >- Fetch emesis bags, wipes, a clean-up kit, gloves, masks and eye protection, and any drink pouch the crewmember asks for (unless a human has logged "nothing by mouth"; then it routes the request to the CMO), and restrain them within reach - >- Hand over a fresh bag on request; take only bags the crewmember has closed, then label and stow them as biohazard waste - Log episodes, fluids taken and urine passed as reported - Send summaries to the flight surgeon; alert the CMO and flight surgeon on a red flag - Clean its own surfaces after each visit (RMP-INF-002) robot_may_not: - Suggest, fetch or dose any medicine without a human order - Advise on fluids or say whether someone is dehydrated - Say what the cause is - Touch the crewmember, open waste or soiled items - Hold an open bag near the crewmember's face - 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 and answering. If not, stop and alert at once (X7). check: crew_responsive == true - id: PRE-3 text: >- Robot self-test passed; containment, hygiene and protective supplies stocked; the robot's cleaning supplies are available. refs: - V2 10161 - id: PRE-4 text: Robot and supplies restrained when not moving. refs: - V2 7046 - id: PRE-5 text: Link status and current delay known. check: link_state in [live, delayed, down] consent: standard: >- The crewmember agrees to check-ins by voice. Bowel questions are asked privately, and the crewmember chooses who is present. Any question can be declined; an explicit "no" is logged as declined for that question only. emergency: >- If the crewmember cannot answer, the robot does not continue the log; it sends an URGENT alert and a crewmember checks in person (X7). withdrawal: The crewmember can stop or pause check-ins at any time. inputs: - id: IN-1 name: >- Red-flag questions: blood in vomit or stool, black stool, severe or one-place belly pain, fever or shaking chills, dizziness or fainting, confusion, a recent blow to the head, hives or swelling of the lips, tongue or throat, trouble breathing, a known allergen, and wearing a helmet, mask or suit 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: Vomiting and diarrhea episodes since the last check-in (number and time) source: Crewmember, by voice; count of sealed bags required: true if_missing: Log "no response" and apply D2. - id: IN-3 name: Fluids taken and urine passed since the last check-in, as reported source: Crewmember, by voice, or the waste-system log if available required: true if_missing: Log "no response" and apply D2. - id: IN-4 name: >- Heart rate, blood pressure and temperature, measured by the CMO when the CMO chooses (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-5 name: Other crewmembers with similar symptoms, as reported to the CMO source: CMO required: false if_missing: Log "not known". - id: IN-6 name: >- "Nothing by mouth" orders and medicines given, including any antibiotic course now or recently, as logged by humans source: Medical record or dose log (RMP-PHARM-003) required: false if_missing: Treat as no order; ask the CMO before bringing a drink pouch if unsure. - 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 "vomiting or diarrhea 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: >- Bring emesis and waste bags, wipes, a clean-up kit, gloves, masks and eye protection for helpers, and any drink pouch the crewmember asks for (unless "nothing by mouth" is logged; then route the request to the CMO). Restrain them within reach. success: Supplies restrained within reach. limit: refs: - V2 7046 - V2 9053 - id: S3 actor: robot rung: 2 action: >- Run a voice check-in: red-flag questions first, then episodes, fluids taken and urine passed. Log answers word for word. D1 is checked after every answer. success: Answers logged, or "no response" logged. - id: S4 actor: robot rung: 2 action: >- On request, hand over a fresh bag; the crewmember closes it; the robot takes only sealed bags, labels and stows them as biohazard waste, and cleans 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 - V2 10172 - id: S5 actor: crew action: >- The CMO sees the crewmember in person when asked or on any red flag, and decides hygiene measures for the crew (RMP-INF-003). Any medicine is ordered by the CMO or flight surgeon and fetched through RMP-PHARM-001. success: CMO decision logged. refs: - V1 3004 - id: S6 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: S7 actor: robot rung: 2 action: >- Every hours, or before each private medical conference, send the flight surgeon a summary: episodes over time, fluids and urine as reported, CMO entries, medicines logged by humans, other crew affected, and alerts. success: Summary delivered or queued. refs: - V1 6003 - V1 7001 - V1 7003 - id: S8 actor: ground action: >- The flight surgeon (or the CMO under the onboard checklist when there is no link) decides treatment, fluids, testing, hygiene measures and work limits. The robot logs the decisions. success: Decision logged. refs: - V1 3004 - id: S9 actor: robot rung: 2 action: >- Offer a check-in every hours 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. A routine check-in never wakes a sleeping crewmember unless the CMO or flight surgeon has set wake checks. success: Each prompt accepted, postponed or answered; log closed by a human. refs: - V2 10174 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 check-in? 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: S8 decided_by: ground question: What is the plan (treatment, fluids, testing, hygiene, work limits)? 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: it pauses any movement in its stopped position and tells the CMO. This pauses robot movement only: crew bleeding control and CPR continue under the onboard checklist and never wait for the link or the robot. 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: Blood or dark "coffee-ground" material in vomit threshold: any action: URGENT alert to the CMO and flight surgeon source: cg141 - id: RF2 sign: Blood in the stool, or black stool threshold: any action: URGENT alert source: acg - id: RF3 sign: Severe or constant belly pain, or pain in one place threshold: any (never waits for a time limit) action: URGENT alert; the flight surgeon may request RMP-GI-001 - id: RF4 sign: Unable to keep fluids down, or no urine passed threshold: for hours action: URGENT alert (logged separately from RF14, so the package shows which fired) source: ng253 - id: RF5 sign: Fever or shaking chills threshold: °C or higher, or any shaking chills action: URGENT alert; see RMP-INF-001 source: ng253 - id: RF6 sign: Dizziness, fainting, confusion, drowsiness or new change in behavior threshold: any action: URGENT alert; the CMO checks in person source: ng253 - id: RF7 sign: Many episodes threshold: >- more than in 24 hours (for context, acute diarrhea is often defined as 3 or more loose stools above baseline in 24 hours) action: Flag to the flight surgeon source: acg - id: RF8 sign: Symptoms lasting threshold: >- beyond days (for context, the guideline uses more than 7 days as one reason for stool testing) action: Flag to the flight surgeon source: acg - id: RF9 sign: Another crewmember with similar symptoms, as reported threshold: any action: Flag to the CMO and flight surgeon; see RMP-INF-003. The robot does not say why. - id: RF10 sign: Vomiting while wearing a helmet, mask or suit (airway risk in a closed helmet; design judgment) threshold: any action: >- URGENT alert and Stop: the vehicle or suit emergency procedure leads; the robot keeps clear and brings supplies only if asked - id: RF11 sign: Vomiting after a blow to the head threshold: any action: URGENT alert; see RMP-NEURO-001 source: ng232 - id: RF12 sign: >- Vomiting, belly cramps or diarrhea with hives, swelling of the lips, tongue or throat, or trouble breathing, or after a known allergen threshold: any action: URGENT alert; see RMP-RESP-003 source: wao - id: RF13 sign: Diarrhea during or after an antibiotic course (from the dose log) threshold: any action: Flag to the flight surgeon source: idsacdi - id: RF14 sign: A CMO-entered heart rate or blood pressure beyond the alert level threshold: beyond action: URGENT alert (logged separately from RF4) source: ng253 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 items 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: Check-in length value: enforced: Timer; then the check-in ends 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: >- Each check-in time, count, answer and alert, and each sealed waste bag stowed, so the flight surgeon can follow the trend. - 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 requirements: - id: V1 3003 use: Capability to monitor physiological well-being in flight. - id: V1 3004 use: >- In-mission care includes recording the history, personal protective equipment and biohazard containment (b), and privacy (c); administering medicines (m) is a human capability. - 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 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 7102 use: >- Body waste (including vomitus) is collected and contained so it does not escape into the cabin; the robot handles sealed bags only. - id: V2 9053 use: Protective equipment (gloves, masks, eye protection) is provided; the robot fetches it on request. - 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 covering every red flag, no response, a second sick crewmember, a CMO who is the patient, and lost link. pass: >- Every red flag acts as listed, including the routes to RMP-NEURO-001 and RMP-RESP-003; no response escalates; zero advice or cause statements; zero self-starts. - stage: Earth analog what: >- Bed-rest or isolation analog volunteers using voice check-ins and supply fetching (no illness needed). pass: Data completeness at or above ; volunteers rate the robot as not intrusive. - stage: parabolic or station demonstration what: >- Fresh-bag hand-over, sealed-bag collection and surface cleaning in weightlessness, without a patient. pass: Zero open-bag handling; zero escapes of test material. - stage: flight use under flight surgeon supervision what: First use as a logging aid alongside the usual 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 ) - 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; 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: the flight surgeon sees summaries at the private medical conference and can be alerted at any time. loss_of_signal: - >- The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps running check-ins and logging offline. - >- Crew bleeding control and CPR continue under the onboard checklist and never wait for the link or the robot. - >- Red flags go to the CMO (or the second trained CMO) at once; the CMO decides under the pre-approved onboard checklist. - 'At the next contact the robot sends one package: the trend, counts, alerts and decisions.' mars_delay: - >- Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks; red-flag thresholds and the check-in schedule are set before flight and the CMO acts on them. sources: - 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: 33 diarrhea and 4 gastroenteritis events among US astronauts (Shuttle, Mir and ISS through 2006); Table 1: diarrhea recorded on the ISS through Expedition 40. - key: acg text: >- Riddle MS, DuPont HL, Connor BA. ACG clinical guideline: diagnosis, treatment, and prevention of acute diarrheal infections in adults. Am J Gastroenterol. 2016;111(5):602-622. url: https://doi.org/10.1038/ajg.2016.126 doi: 10.1038/ajg.2016.126 pmid: '27068718' supports: >- Acute diarrhea is often defined as an abrupt onset of 3 or more loose or liquid stools above baseline in 24 hours; infectious diarrhea often comes with nausea, vomiting, abdominal pain and cramps, bloating, fever, bloody stools, tenesmus and urgency; stool testing is used for dysentery, moderate-to-severe disease and symptoms lasting more than 7 days. - 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: 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. Cited only as context for vomiting blood as a red flag: it is a management guideline, not a symptom list. - 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: wao text: >- Cardona V, Ansotegui IJ, Ebisawa M, et al. World Allergy Organization anaphylaxis guidance 2020. World Allergy Organ J. 2020;13(10):100472. url: https://doi.org/10.1016/j.waojou.2020.100472 doi: 10.1016/j.waojou.2020.100472 pmid: '33204386' supports: >- Anaphylaxis is highly likely with acute skin or mucosal involvement plus respiratory or cardiovascular involvement, or severe gastrointestinal symptoms (severe crampy abdominal pain, repetitive vomiting), especially after exposure to non-food allergens; intramuscular epinephrine (adrenaline) continues to be the first-line treatment; remove exposure to the trigger if possible (for example, discontinue administration of drugs or therapeutic agents). - key: idsacdi text: >- McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-e48. url: https://doi.org/10.1093/cid/cix1085 doi: 10.1093/cid/cix1085 pmid: '29462280' supports: >- Guideline on C. difficile infection, which the ACG acute diarrhea guideline does not cover. Only the abstract was read; its testing criteria are not used here, and the flag on diarrhea during or after antibiotics is a referral to the flight surgeon only. - 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: >- NASA-STD-3001 Vol 2 Rev F: V2 7102 requires body waste, including vomitus, to be collected and contained; its rationale notes that vomiting may trigger bystander nausea and vomiting in adjacent crewmembers, so a cluster is not necessarily an infection. Section 10.6 covers automated and robotic systems. - 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: 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: - >- Scope: diarrhea at any time, vomiting that is not first-days motion sickness (RMP-NEURO-004), or both; the CMO chooses if unsure, never the robot (item 18). - 'New RF11: vomiting after a blow to the head is URGENT, see RMP-NEURO-001 (NG232) (item 19).' - >- New RF12: gastrointestinal symptoms with allergy signs or after a known allergen are URGENT, see RMP-RESP-003 (WAO 2020) (item 20). - >- New RF13: diarrhea during or after an antibiotic course is a Flag to the flight surgeon (IDSA/SHEA guideline, abstract only) (item 21). - >- RF3 (belly pain) stays URGENT with no waiting period and is shown as a general clinical red flag; no verified source was found (item 22). - >- RF9 no longer implies a cause ("possible spread" removed); bystander vomiting is noted from the V2 7102 rationale (item 23). - >- RF10: vomiting in a helmet, mask or suit is now URGENT as well as a Stop (airway risk; design judgment) (item 24). - >- RF4 split: fluids or urine stay RF4; CMO-entered heart rate or blood pressure is the new RF14, logged separately; no orthostatic trigger in weightlessness (item 25). - >- 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: '0.2' source: Batch 5 editorial (AI-assisted), Oct 21, 2026; batch 4 review item 49 items: - >- Inherited stop-rule and requirement wording: "holds a safe position" → "holds its stopped position"; "stays in its safe state" → "stays stopped"; "take over safely" → "take over"; "Robot stays safe if no one takes over" → "Robot stays stopped if no one takes over". Schema level name safe-state and never-word list entry "safe" unchanged. - 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 say only the robot pauses: crew bleeding control and CPR continue under the onboard checklist and never wait for the link or the robot (batch 7 review item 13). Editorial; robot behaviour unchanged.