RMP-NEURO-007 Headache log: private log, red-flag escalation and routes (carbon dioxide, after a spacewalk or pressure change, head injury, vision change, dehydration); never says what caused it

1 · Identity and scope

When a crewmember reports a headache, or the flight surgeon or CMO asks for a headache log, the robot keeps a private log: red-flag questions first; onset, severity (0-10 as the crewmember states), location, character, what makes it better or worse, other symptoms, recent carbon dioxide (CO2) readings if available, recent spacewalk or pressure change, fluids, sleep and medicines as reported; shows the crewmember their own log as a clock-time timeline; and sends summaries to the flight surgeon. Red flags escalate at once to the CMO and flight surgeon, with routes to high CO2 (RMP-ENV-004), after a spacewalk or pressure change (RMP-EVA-001), head injury (RMP-NEURO-001), vision change (RMP-EYE-002 / RMP-EYE-003), dehydration (RMP-RENAL-004) and NICE headache red flags (RMP-NEURO-002 when stroke signs are present). The robot never says what caused the headache.

Why this protocol was chosen. Headache is one of the most common in-flight complaints. NASA records list 233 headache (space adaptation), 49 late and 20 CO2-induced events among US astronauts through 2006, and 33 headache events on the ISS through Expedition 40 (NASA in-flight medical conditions evidence report). Vein 2009, as cited in the NASA SANS report, found 12 of 17 astronauts (71%) had at least one headache in space, most moderate to severe and often not linked with motion sickness. On the station, the odds of reporting a headache doubled per 1 mmHg rise in CO2 (Law 2014), but headaches also have other causes, so the robot never attributes a headache to CO2, space, sleep or spaceflight-associated neuro-ocular syndrome (SANS). The SANS report notes that crewmembers have not reported the classic raised-pressure headache pattern; headache with a vision change, double vision, brief vision greying (transient visual obscurations) or a pulsing sound in the ears is escalated as design judgment (confirmed in the batch 5 review as the batch 4 recommended escalation for classic raised-pressure associates; flight surgeon sign-off still required). NICE CG150 lists sudden severe headache, headache with fever, new neurological deficit and reduced alertness among features that need further investigation. An exact private log with red-flag routes lets the flight surgeon see trends for CO2 and SANS without the robot naming a cause. Open question for review: whether headache with brief vision greying or a pulsing ear sound should be URGENT rather than a Flag, and whether a new Amsler-type distortion with headache should go straight to RMP-EYE-002.

Autonomy: Tier 2 as in the library contents. A private logging aid with red-flag escalation. Max autonomy 2 for check-ins and optional supply fetch after a human order; the robot never diagnoses or attributes a cause.

Related: RMP-ENV-004 · RMP-EVA-001 · RMP-NEURO-001 · RMP-NEURO-002 · RMP-NEURO-004 · RMP-NEURO-006 · RMP-EYE-002 · RMP-EYE-003 · RMP-RENAL-004 · RMP-INF-001 · RMP-BEH-002 · RMP-ENT-004 · RMP-MSK-004 · 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

• Crewmember with the headache: answers check-ins privately and can stop or pause them at any time
• Second trained CMO: receives alerts if the CMO is the patient

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.) [16]

3 · Preconditions and consent

• PRE-1 A crewmember (the one with the headache, or the CMO at the flight surgeon's request) started the log by command, and the crewmember agreed.human_start == trueV2 10174
• PRE-2 The crewmember is awake and answering. If not, stop and alert at once (X7).crew_responsive == true
• PRE-3 Check-ins are private; on the crewmember's own screen or by voice in a place they choose.V1 3004
• PRE-4 Robot self-test passed; any cabin CO2 access is read only.V2 10161
• PRE-5 Link status and current delay known.link_state in [live, delayed, down]

Consent

The crewmember agrees to the headache log and to who sees it (the CMO and the flight surgeon only). Any question can be declined; an explicit "no" is logged as declined for that question only.

Emergency consent

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 the log at any time; an alert already sent is not withdrawn.

4 · Required sensor inputs

5–6 · Steps and decision points

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

1. S1RobotRung 2

   On a crewmember's command, open the private headache log and send a "headache log started" note to the flight surgeon (queued if the link is down). The CMO is told only if the crewmember agrees or a red flag fires.

   Done when: Note delivered or queued.

   V2 10174V1 6003

2. S2RobotRung 2

   Run a private check-in by voice or on screen: red-flag questions first, then onset, severity as stated, location, character, other symptoms, recent CO2/EVA/injury/fluids/sleep/medicines as reported. Log answers word for word. D1 is checked after every answer.

   Done when: Answers logged, or "no response" logged.

   V1 3004

   D1DecisionRobot 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.
   D2DecisionRobot decides

   Did the crewmember answer the check-in?

   • 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.
3. S3RobotRung 2

   If available, add the recent cabin CO2 reading (read only) to the log labelled "as recorded by the cabin system". The robot never says the headache is from CO2.

   Done when: Reading added, or "not available" logged.

   V2 6004

4. S4RobotRung 2

   Show the crewmember their own log as a clock-time timeline, with no cause, colour or words about whether it is serious. Medicines are shown only as entries on a clock-time timeline (what the CMO or crewmember states was taken, and when). No running counter or elapsed time per dose, and no tone, colour or spoken cue tied to a dose interval.

   Done when: Timeline shown; the crewmember can add notes.

5. S5Crew

   The CMO sees the crewmember when asked or on any red flag. Any medicine or other plan is ordered or decided by the CMO or flight surgeon.

   Done when: CMO entries logged.

   V1 3004

6. S6RobotRung 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.

   V2 7059

   D3DecisionRobot 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
7. S7RobotRung 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

8. S8RobotRung 2

   Every <set by flight surgeon> hours, or before each private medical conference, send the flight surgeon a summary: headache timeline, severity as stated, other symptoms, CO2 readings as recorded, EVA or pressure-change notes, medicines as logged, RMP-PHARM-001 results and alerts.

   Done when: Summary delivered or queued.

   V1 6003V1 7001V1 7003

9. S9Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides any medicine, work limits, further protocol (ENV-004, EVA-001, EYE-002, RENAL-004, NEURO-001, NEURO-002) or evacuation. The robot logs the decisions.

   Done when: Decision logged.

   V1 3004

   D4DecisionGround decides

   What is the plan (medicine, work limits, further protocol, 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

    Offer a private check-in every <set by flight surgeon> 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.

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

    V2 10174

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 Each check-in time, answer, severity as stated, CO2 reading as recorded, medicine entry and alert. No running counter of doses.
• 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-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

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [11] and Volume 2 Revision F [12]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted check-ins covering every red flag, no response, a CO2 caution without attribution, a post-EVA headache, a CMO who is the patient, an RMP-PHARM-001 MISMATCH, and lost link. Pass: Every red flag acts as listed; zero cause statements; zero "just a headache"; zero hand-overs after a MISMATCH.
2. Earth analog. Isolation analog volunteers logging headaches with the robot (no illness needed). Pass: Data completeness at or above <set by validation>; volunteers rate the check-ins as private.
3. Flight use under flight surgeon supervision. First use alongside the usual medical conferences. Pass: No safety events; the flight surgeon finds the log useful.

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

12 · Human sign-off

Before any use

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

Each run

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

Restart after a stop

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

None of these sign-offs has happened. This is a Draft v0.4.

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 [15].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon sees summaries at the private medical conference and can be alerted at any time.

Loss of signal

• Only the robot pauses; crew care never waits for the link or the robot.
• The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps running private check-ins and logging offline.
• 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 log, alerts and decisions.

Mars-class 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.

[14]

Sources

1. 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: 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.
2. Law J, Van Baalen M, Foy M, et al. Relationship between carbon dioxide levels and reported headaches on the International Space Station. J Occup Environ Med. 2014;56(5):477-483. PMID 24806559. doi:10.1097/JOM.0000000000000158 Supports: For each 1 mmHg rise in CO2, the odds of a crewmember reporting a headache doubled; keeping headache risk below 1% would need a 7-day average below 2.5 mmHg (ISS range at the time 1-9 mmHg).
3. NASA OCHMO. Spaceflight Experience and Medical Care. Technical Brief OCHMO-TB-033 (2023). www.nasa.gov/wp-content/uploads/2023/12/ochmo-tb-033-spacefl… Supports: Headaches are more common in spaceflight, with elevated CO2, fluid shifts and pressure changes among contributing factors; pre-mission exams include ECG, eye exams and photo documentation of skin.
4. National Institute for Health and Care Excellence. Headaches in over 12s: diagnosis and management. Clinical guideline CG150. www.nice.org.uk/guidance/cg150/chapter/Recommendations Supports: Headache features that need further investigation or referral include worsening headache with fever, sudden-onset headache reaching maximum intensity within 5 minutes, new-onset neurological deficit, and impaired level of consciousness.
5. NASA Human Research Program. Evidence Report: Risk of Spaceflight Associated Neuro-ocular Syndrome (SANS) (2017). humanresearchroadmap.nasa.gov/evidence/reports/SANS.pdf Supports: With optic disc edema as the primary metric, the overall incidence is considered to be 16%, and 38% to 51% of long-duration crewmembers have developed one or more findings; no crewmembers have reported the type of headaches typically associated with raised intracranial pressure, and no preflight or in-flight invasive measures of intracranial pressure have been made.
6. Vein AA, Koppen H, Haan J, Terwindt GM, Ferrari MD. Space headache: a new secondary headache. Cephalalgia. 2009;29(6):683-686. PMID 19187344. doi:10.1111/j.1468-2982.2008.01775.x Supports: As cited in the NASA SANS evidence report: 12 of 17 astronauts (71%) had at least one headache in space; most episodes were moderate to severe and not associated with motion sickness. Primary paper not re-read this round; figures taken from the SANS report citation.
7. National Institute for Health and Care Excellence. Head injury: assessment and early management. NICE guideline NG232 (May 18, 2023). 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).
8. NASA OCHMO. Decompression Sickness (DCS) Risk Mitigation. Technical Brief OCHMO-TB-037 Rev D (Oct 5, 2026). www.nasa.gov/wp-content/uploads/2023/12/ochmo-tb-037-decompr… Supports: DCS is caused by inert gas bubbles forming during rapid reductions in ambient pressure, most significantly in the move from cabin pressure to EVA suit pressure; NASA classifies DCS as Type I (itching, musculoskeletal pain, mild rashes) and Type II (neurological symptoms, numbness, weakness, cognitive issues, inner ear problems, cardiopulmonary issues), and describes cutis marmorata (a mottled, patterned skin rash); arterial gas embolism can cause stroke-like neurological effects, loss of consciousness and seizures; U.S. Navy protocols are widely adopted on Earth; diagnosis is based on symptoms; the majority of cases present between 60 and 240 minutes and inflammatory responses can last more than 24 hours; no hyperbaric chamber is available in flight, and increasing suit and cabin pressure may be combined to treat symptoms, depending on the scenario; a break in prebreathe rapidly reintroduces nitrogen; NASA has never experienced a Type II event in spaceflight.
9. National Institute for Health and Care Excellence. Suspected sepsis in people aged 16 or over: recognition, assessment and early management. NICE guideline NG253 (2025, last updated Sept 23, 2026). www.nice.org.uk/guidance/ng253/chapter/Face-to-face-assessme… Supports: People with sepsis may feel very unwell and may not have a high temperature; do not rely on fever alone; a rise in temperature can be a physiological response; assess temperature, heart rate, breathing rate, blood pressure, level of consciousness and oxygen saturation; look for mottled or ashen skin, blue skin, lips or tongue, a non-blanching rash, and breaks in the skin; ask how often the person passed urine in the past 18 hours and about fever or shaking chills (rigors); pay attention to new changes in behavior and to concerns raised by others.
10. NASA OCHMO. Space Adaptation Sickness (SAS) and Space Readaptation Syndrome. Medical Technical Brief OCHMO-MTB-004 Rev A (Sept 25, 2025). www.nasa.gov/wp-content/uploads/2025/09/ochmo-mtb-004-space-… Supports: Space adaptation sickness and its parts (motion sickness, congestion, headache, back pain, urinary retention) in the first days of flight.
11. 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 3003 item a; V1 3004 items c, d, m and r.
12. 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: NASA-STD-3001 Vol 2 Rev F: V2 6004 (CO2); Section 10.6 automated and robotic systems.
13. 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.
14. 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.
15. 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.
16. 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.