RMP-MSK-003 Musculoskeletal ultrasound assist with a crew-held probe (diagnostic only)

1 · Identity and scope

When the flight surgeon or CMO wants an ultrasound of a joint, muscle or tendon (for example after a shoulder, knee or ankle injury), the robot 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, and labels and stores each clip with the body site and view the CMO names and the clock time. The CMO holds the probe and the crew hold the limb steady. Every image is "non-diagnostic, for human review".

Why this protocol was chosen. On ISS Expedition 9, non-physician crewmembers guided from the ground completed a shoulder ultrasound examination of diagnostic quality in about 15 minutes (Fincke 2005), building on remote-guided abdominal ultrasound on the ISS (Sargsyan 2005). NASA's in-flight medical conditions evidence report describes the ADUM (Advanced Diagnostic Ultrasound in Microgravity) project, which guides "minimally trained crewmembers" by remote guidance and just-in-time instruction. Here ultrasound is diagnostic only: it never delays splinting (RMP-MSK-002), trauma care (RMP-MSK-001) or the call to the flight surgeon, and an onboard CMO is not an experienced operator, so images are for remote expert review only and never rule a fracture or tear out. Which sites and views are scanned is set by the onboard checklist or the ground expert (design judgment).

Autonomy: Max rung 2 for supervised fetching of the ultrasound kit, holding the display and reference card, and labelling and relaying clips, as in RMP-GI-001. The CMO holds the probe and the crew hold the limb: "Contact with the crewmember: not allowed".

Related: RMP-MSK-002 · RMP-MSK-001 · RMP-MSK-004 · RMP-GI-001 · RMP-INF-002 · RMP-PHARM-001

2 · Roles

Medical authority

Flight surgeon (ground). Holds medical authority for every run.

Onboard lead

Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link.

Others

• 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

Commercial flights

On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) [14]

3 · Preconditions and consent

• PRE-1 The CMO or the flight surgeon asked for a musculoskeletal ultrasound by command.human_start == trueV2 10174
• PRE-2 Robot self-test passed; kit stowage locations known.V2 10161V2 7059
• PRE-3 Robot and supplies restrained when not moving.V2 7046
• PRE-4 Link status known. The crew never wait for the robot before acting.link_state in [live, delayed, down]

Consent

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 consent

If the crewmember cannot agree, the scan waits; care under RMP-MSK-001 or RMP-MSK-002 goes on.

Withdrawal

The crewmember can stop the scan, images or video at any time; the record stands.

4 · Required sensor inputs

5–6 · Steps and decision points

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

1. S1RobotRung 2

   Send a "musculoskeletal ultrasound requested" notice to the flight surgeon and the CMO (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 <set by validation> seconds is repeated and sent to the next named crewmember.

   Done when: Notice acknowledged, or escalated.

   V2 10174V1 6003V1 3006

2. S2RobotRung 2

   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".

   Done when: Kit within reach after a matched ID and seal, or quarantined, or emergency fetch logged.

   Limit: <set by validation>

   V2 7046V2 7059

   D1DecisionRobot decides

   Which kit fetch was it, and what did the checked kit fetch show?

   • EMERGENCY FETCH (an URGENT red flag had fired, or a crewmember or the CMO stated an emergency) → Hand-over already done as an emergency fetch, logged as an override; reconciled afterwards (not a check before use).
   • KIT ID AND SEAL MATCH → Hand the kit over closed; log "KIT ID AND SEAL MATCH. Not a check of the contents." and the clock time.
   • MISMATCH, seal not intact or CANNOT VERIFY → 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.No hand-over
3. S3Crew

   The CMO examines the limb first, including feeling, colour and warmth below the injury; the crew hold the limb steady in the position the CMO chooses, and splinting under RMP-MSK-002 is never delayed for the scan.

   Done when: Human-led care; robot logs what is stated.

   V1 3004V2 7046

4. S4RobotRung 2

   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.

   Done when: Display and card in view; relay running or clips stored.

   Limit: <set by validation>

   V2 7045

5. S5Crew

   The CMO holds the probe and scans the sites and views 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.

   Done when: Scan done, stopped, or not possible.

   V1 3004

6. S6RobotRung 2

   Label and store each clip with the site, side and view 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.

   Done when: Clips labelled; gaps logged as "image not obtained".

   V1 7001

   D2DecisionRobot decides

   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?

   • Yes → 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 <set by validation> seconds is repeated and sent to the next named crewmember.
   • No → Continue.
   D3DecisionRobot decides

   Did the crewmember answer the last question?

   • Yes → Continue.
   • Declined explicitly (the crewmember says no to a question) → Log "declined" for that question only; the alert already sent stands.
   • No response, or the answer does not make sense → 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.
7. S7Crew

   After the scan, the crew clean the probe and any shared surface under RMP-INF-002; a probe on intact skin is noncritical equipment, and a probe cover never allows a lower level of cleaning. 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.

   Done when: Cleaning recorded as stated under RMP-INF-002.

   V2 7046

8. S8RobotRung 2

   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.

   Done when: Robot at rest in the module until a human releases it; alert acknowledged or escalated.

   V2 10173V1 3006

9. S9Ground

   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, activity limits, repeat scans and any evacuation [V1 3007].

   Done when: Decision logged.

   V1 3007

   D4DecisionGround decides

   What is the plan (care, activity limits, repeat scan, evacuation)?

   • Link live → Flight surgeon decides; robot logs.
   • Link down or delay too long → The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact.
10. S10RobotRung 2

    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.

    Done when: RMP-PHARM-001 run logged with its result, or none ordered.

    V2 7059

    D5DecisionRobot decides

    What did RMP-PHARM-001 show for the ordered item?

    • MATCH TO ORDER → 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.
    • MISMATCH or CANNOT VERIFY on any field, or a failed scan or recipient check → 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.No hand-over
11. S11RobotRung 2

    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.

    Done when: Reconciliation recorded; kit shown as opened – not restocked until resealed.

    V2 7059

12. S12RobotRung 2

    Send the flight surgeon one package: stated answers, pain scores, labelled clips, times and decisions; images go only to the people the flight surgeon names.

    Done when: Package delivered or queued.

    V1 6003V1 7001V1 7003

7 · Stop and escalate rules, red flags

Red flags

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

8 · Safety limits

9 · Logs and audit

• LOG-1 Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second.V2 10163V2 10164
• LOG-2 Mode changes and safety-limit events are announced to the operator as they happen and logged.V2 10162V2 10172
• LOG-3 Records are stored and sent as private medical data, encrypted, with access limited to the medical team.V1 6003V1 7003
• LOG-4 Results are kept in a permanent, retrievable format so the flight surgeon can see trends.V1 7001
• LOG-5 Stated answers, pain scores, each clip with its site, side, view, label and time, relay start and stop, and decisions.
• LOG-6 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.V2 10163
• LOG-7 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".V2 7059
• LOG-8 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.V2 7059
• LOG-9 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.V2 7059

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [9] and Volume 2 Revision F [10]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted injuries 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.
2. Training model. CMO scans a limb phantom with the robot holding the display and relaying to a ground expert. Pass: Every clip labelled; no robot wording about image content.
3. Parabolic or station demonstration. Display hold and relay in weightlessness on a phantom. Pass: Display distance limit held.
4. Flight use under flight surgeon supervision. First use in drills and scheduled scans. Pass: No safety events.

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

12 · Human sign-off

Before any use

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

Each run

Started by the CMO or the flight surgeon. The CMO holds the probe; a human reviews every image.

Restart after a stop

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

None of these sign-offs has happened. This is a Draft v0.2.

13 · Change control for learning

• Every change gets a new version number and a written reason; earlier versions are kept.
• Any change to steps, thresholds, limits or software that touches the patient repeats validation from the simulation stage before use.
• Software and learned-skill updates follow a pre-agreed change plan (what may change, how it is tested, how to roll back), modeled on the FDA predetermined change control plan approach.
• If a new version misbehaves, the robot rolls back to the last validated version and the event is reviewed by the flight surgeon and safety board.
• The robot never changes its own protocol, thresholds or limits.

Change-plan model: FDA guidance [13].

Loss of signal and Mars delay

Live link

Low Earth orbit: the ground imaging expert can guide the CMO in real time when the link allows.

Loss of signal

• Only the robot pauses non-essential motion, at a position clear of hatch routes and crew routes, and tells the CMO; it resumes offline only on the CMO's confirmation.
• Crew splinting, holding the limb and all crew care continue under the onboard checklist and never wait for the link or the robot.
• The CMO scans under the onboard checklist and the clips are stored for forwarding.

Mars-class delay

• Mars: live remote guidance is not possible; the CMO uses the onboard scan checklist and the flight surgeon reviews the stored clips when they arrive.

[12]

Sources

1. Fincke EM, Padalka G, Lee D, et al. Evaluation of shoulder integrity in space: first report of musculoskeletal US on the International Space Station. Radiology. 2005;234(2):319-322. PMID 15533948. doi:10.1148/radiol.2342041680 Supports: Abstract: on ISS Expedition 9, non-physician crewmembers, remotely guided from the ground, completed a musculoskeletal (shoulder) ultrasound examination of diagnostic quality in about 15 minutes. Abstract read Oct 21, 2026.
2. 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. PMID 15674147. doi:10.1097/01.ta.0000145083.47032.78 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.
3. 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). humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf Supports: NASA in-flight medical conditions evidence report: the ADUM (Advanced Diagnostic Ultrasound in Microgravity) project "uses remote guidance, telemedical interfaces, and just-in-time instruction techniques to guide minimally trained crewmembers in acquisition of adequate imaging".
4. NASA OCHMO. Bone Loss. Medical Technical Brief OCHMO-MTB-013 Rev D (2026). www.nasa.gov/wp-content/uploads/2026/02/ochmo-mtb-013-bone-l… Supports: Bones during and after spaceflight may not be as strong as before the mission, and "fracture may occur for activities otherwise unlikely to induce fracture prior to space missions". Saved copy read Oct 21, 2026.
5. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37 (2016, last updated 2022). www.nice.org.uk/guidance/ng37/chapter/Recommendations Supports: 1.1.8 Do not irrigate open fractures of the long bones, hindfoot or midfoot in pre-hospital settings; 1.1.9 consider a saline-soaked dressing covered with an occlusive layer; 1.1.10 consider prophylactic intravenous antibiotics as soon as possible (Earth pre-hospital context; any antibiotic is a flight-surgeon order). 1.1.11 Consider pre-hospital splinting of suspected long-bone fractures of the leg. 1.2.7 In tibial fractures, maintain awareness of compartment syndrome for 48 hours after injury. 1.3.7 When assessing neurovascular status in a limb injury, document for both limbs which nerves and functions were tested and the findings. The robot never says fracture or sprain and never splints.
6. National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline NG39 (2016). www.nice.org.uk/guidance/ng39/chapter/Recommendations Supports: Injury pathway (NICE major trauma guideline); signs of poor circulation or deformity go to RMP-MSK-002 and RMP-MSK-001.
7. Johnston SL, Campbell MR, Scheuring R, Feiveson AH. Risk of herniated nucleus pulposus among U.S. astronauts. Aviat Space Environ Med. 2010;81(6):566-574. PMID 20540448. doi:10.3357/asem.2427.2010 Supports: In-flight back pain is presumably due to elongation of the spine; disc herniation was 4.3 times more common in US astronauts (321) than matched controls (983), relatively more often in the neck, with evidence that the risk is increased immediately after spaceflight.
8. U.S. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008): summary of recommendations. www.cdc.gov/infection-control/hcp/disinfection-sterilization… 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).
9. NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023). www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-… Supports: NASA-STD-3001 Vol 1 Rev C: V1 3004 (in-mission imaging), V1 3006, V1 3007, V1 6003, V1 7001, V1 7003.
10. NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 Supports: Requirement IDs beginning V2.
11. NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical… Supports: The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist.
12. NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). www.nasa.gov/wp-content/uploads/2024/01/mars-communications-… Supports: One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction.
13. U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). www.fda.gov/regulatory-information/search-fda-guidance-docum… Supports: A model for planning, validating and rolling back software updates.
14. U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements. www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-… Supports: Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants.

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