RMP-RESP-001 Shortness of breath: oxygen set-up support, oxygen saturation, relay

1 · Identity and scope

When a crewmember reports shortness of breath, or a pulse oximeter shows a low oxygen saturation (the share of the blood's haemoglobin carrying oxygen), the robot sends an URGENT alert at once, brings the sealed oxygen kit (closed) and a pulse oximeter on command, holds the display, records saturation, heart rate, breathing rate and symptom answers word for word, and streams video when the link allows. The CMO and flight surgeon decide whether to give oxygen and how much. The robot never opens the oxygen kit, sets a flow or names a cause.

Why this protocol was chosen. Shortness of breath can be the first sign of a cabin problem (smoke, ammonia, loss of pressure, high carbon dioxide), an allergic reaction, choking, a heart problem, a lung problem or a clot in a vein. NASA's in-flight medical conditions evidence report lists smoke inhalation and choking events in flight. On Earth, the British Thoracic Society (BTS) emergency oxygen guideline gives target saturation ranges for the clinicians who prescribe oxygen (94-98% for most acutely ill adults); these are context, not robot thresholds. The shared value SPO2_ALERT_PCT only raises an alert; it never gates a crew action (the crew act without waiting for a reading), and the clinical lead sets it per mission with the flight surgeon, because the cabin atmosphere can differ by mission. Pulse oximeters have limits the robot never hides: they can overestimate saturation (overestimation has been reported in people with dark skin; NICE NG253 context), a reading that cannot be obtained may mean poor circulation, and in carbon monoxide (CO) poisoning, for example after smoke, the oximeter reads falsely high (Hampson 1998). So the robot never calls a reading reassuring. Oxygen and fire: oxygen in use raises the fire risk. NASA-STD-3001 Volume 2 limits cabin oxygen partly because more oxygen lowers the ignition and flammability threshold (rationale to V2 6002 and V2 6003); so while oxygen is in use the robot keeps a set distance from the oxygen outlet, and "oxygen in use" goes to the commander and into RMP-ENV-001 (design judgment). Sudden breathlessness with one-sided chest pain, and breathlessness with new limb or neck swelling or pain or with coughing blood, are escalated as design judgment (Earth context: BTS pleural disease guideline 2023, PubMed record only; spaceflight context: a clot in the jugular vein of the neck was found in a crewmember on the space station, Marshall-Goebel 2019). The robot never names a cause. Open question for review: the value of SPO2_ALERT_PCT for each mission, and whether the onboard checklist starts oxygen before a saturation reading when a cabin alarm is sounding.

Autonomy: Max rung raised from 1 to 2 for supervised fetching of the closed oxygen kit and pulse oximeter, holding a display and video. The robot never starts, stops or adjusts oxygen: oxygen is a medicine, decided by the CMO and flight surgeon.

Related: RMP-RESP-002 · RMP-RESP-003 · RMP-CARD-001 · RMP-CARD-002 · RMP-CARD-003 · RMP-ENV-001 · RMP-ENV-002 · RMP-ENV-003 · RMP-ENV-004 · RMP-EVA-001 · RMP-INF-001 · RMP-MSK-001 · 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.) [17]

3 · Preconditions and consent

• PRE-1 A crewmember or the CMO started the protocol by command after shortness of breath was reported or a low reading was shown.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

Emergency care; recording by the CMO's agreement when the crewmember cannot speak.

Emergency consent

If the crewmember cannot agree, the robot proceeds on the CMO's or commander's command.

Withdrawal

The crewmember or CMO can stop video; the alert and record stand.

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 or the CMO's word, send an URGENT "shortness of breath" alert to the flight surgeon and the CMO at once. 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: Alert acknowledged, or escalated.

   V2 10174V1 6003V1 3006

2. S2RobotRung 2

   On the CMO's command, bring the sealed oxygen kit (closed) and the pulse oximeter to the CMO and restrain them within reach. 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". The robot never opens the oxygen kit.

   Done when: Kit and oximeter within reach, or skipped; override logged.

   Limit: <set by validation>

   V2 7046

3. S3Crew

   The CMO places the oximeter probe, counts the breathing rate, checks cabin alarms with the commander, and decides on oxygen under the onboard checklist or the flight surgeon's order.

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

   V1 3004

   D1DecisionCrew decides

   Has the crewmember become unresponsive or stopped breathing normally?

   • Yes → Start RMP-CARD-001 at once; this record continues as context.
   • No → Continue.
4. S4RobotRung 2

   Hold the oximeter display for the CMO, record each displayed saturation and heart rate with the clock time and the probe site and device as stated, log stated answers word for word, and stream video when the link allows unless the CMO stops it.

   Done when: Readings logged with times.

   V1 3003V1 6003

   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 or CMO answer when asked?

   • 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.
5. S5RobotRung 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

6. S6Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides on oxygen, further monitoring and any evacuation [V1 3007].

   Done when: Decision logged.

   V1 3007

   D4DecisionGround decides

   What is the plan (oxygen, monitoring, 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.
7. S7RobotRung 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
8. S8RobotRung 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

9. S9RobotRung 2

   Send the flight surgeon one package: alert times, readings, stated answers, oxygen decisions as stated, video pointer.

   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 Alert time, each displayed saturation and heart rate, breathing rate, active cabin alarms, oxygen decisions as stated, video start/stop.
• 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

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [12] and Volume 2 Revision F [13]. 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 breathlessness with and without low readings, failed oximeter, active cabin alarm, CMO as patient, lost link. Pass: Zero contact; oxygen never touched; failed reading never logged as a value.
2. Training model. CMO drills with the robot fetching the closed oxygen kit. Pass: Kit within <set by validation> seconds; kit stays closed.
3. Parabolic or station demonstration. Kit fetch and display hold in weightlessness without a patient. Pass: Kit closed and restrained.
4. Flight use under flight surgeon supervision. First use in drills. 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 a crewmember or the CMO. Alerts go to the CMO and flight surgeon at once; the CMO decides on oxygen.

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 [16].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon receives the alert, records and video when the link allows.

Loss of signal

• Only the robot pauses its own movement and tells the CMO and the commander; recording continues offline on confirmation.
• Crew oxygen, CPR, masks and the commander's vehicle procedure continue under the onboard checklist and never wait for the link or the robot.

Mars-class delay

• Breathing support cannot wait for the ground; the onboard checklist and two trained CMOs lead.

[15]

Sources

1. British Thoracic Society. Guideline for oxygen use in healthcare and emergency settings (emergency oxygen guideline page). Fetched Oct 21, 2026. www.brit-thoracic.org.uk/quality-improvement/guidelines/emer… Supports: Recommended target saturation range for acutely ill patients not at risk of hypercapnic respiratory failure is 94-98%; for known COPD or other risk factors for hypercapnic respiratory failure, 88-92% pending blood gas results. Context for the CMO and flight surgeon only; the robot never starts, stops or adjusts oxygen.
2. 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: Smoke inhalation and choking or obstructed airway are listed among in-flight medical events; breathlessness can be the first complaint.
3. Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult Basic Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16_suppl_2):S448-S478. PMID 41122888. doi:10.1161/CIR.0000000000001369 Supports: Hand-off to cardiac arrest support when the crewmember is unresponsive or not breathing normally.
4. Resuscitation Council UK. Emergency treatment of anaphylaxis: guidelines for healthcare providers (May 2021; printed review date May 2026, which has passed. The RCUK guideline page, as fetched on Oct 20, 2026, still lists May 2021 as the most recent version; a newer version was not found). www.resus.org.uk/sites/default/files/2021-05/Emergency%20Tre… Supports: Anaphylaxis is characterised by sudden onset and rapid progression of symptoms, Airway and/or Breathing and/or Circulation problems, and usually skin or mucosal changes; airway problems include throat or tongue swelling, hoarse voice and stridor; breathing problems include wheeze, persistent cough, increased work of breathing, tiredness and hypoxaemia (SpO2 below 94%); circulation problems include pale clammy skin, fast heart rate, low blood pressure, dizziness, decreased conscious level and collapse; skin or mucosal changes alone are not a sign of anaphylaxis and may be absent in up to 20% of reactions; in up to 30% of cases there may be no obvious trigger; gastrointestinal symptoms without airway, breathing or circulation problems do not usually indicate anaphylaxis; call for help early; biphasic reactions occur in around 5% of patients, also after milder reactions, with a median time of around 12 hours, and observation for 6-12 hours may miss over half of them; adrenaline is the first-line treatment, given intramuscularly, and is repeated after 5 minutes if airway, breathing or circulation problems persist; medication accounts for 39% of anaphylaxis-related deaths (Table 1), and allergens given by a parenteral route (for example an IV drug or intramuscular injection) cause a more rapid onset; patients must not walk or stand during acute reactions.
5. Resuscitation Council UK. Adult choking algorithm (2021). PDF fetched Oct 21, 2026. www.resus.org.uk/sites/default/files/2021-04/Adult%20Choking… Supports: Assess severity. Mild obstruction (effective cough): encourage cough. Severe obstruction (ineffective cough): if conscious, 5 back blows then 5 abdominal thrusts, continuing to check for deterioration; if unconscious, start CPR.
6. 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.
7. Agency for Toxic Substances and Disease Registry (CDC). Medical Management Guidelines for Ammonia (NH3). Fetched Oct 21, 2026. wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=7&toxid=2 Supports: NIOSH IDLH (immediately dangerous to life or health) 300 ppm. Ammonia is corrosive to eyes, skin and airways; upper airway swelling and pulmonary edema may lead to airway obstruction; after severe exposure, injury to the eyes, lungs and skin may continue to develop for 18 to 24 hours. Eye exposure: irrigate with plain water or saline for at least 15 minutes. Rescuers should be trained and appropriately attired before entering the contaminated (hot) zone. No antidote; treatment is supportive (humidified oxygen is given by clinicians).
8. Marshall-Goebel K, Laurie SS, Alferova IV, et al. Assessment of jugular venous blood flow stasis and thrombosis during spaceflight. JAMA Netw Open. 2019;2(11):e1915011. doi:10.1001/jamanetworkopen.2019.15011. PMID 31722025. pubmed.ncbi.nlm.nih.gov/31722025/ Supports: Abstract: stagnant or reverse flow in the internal jugular vein in 6 of 11 crewmembers on the space station, an occlusive thrombus in 1 and a possible partial thrombus in another. Spaceflight context for the new-swelling red flag (design judgment).
9. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax. 2023;78(11):1143-1156. doi:10.1136/thorax-2023-220304. PMID 37553157. PubMed record only (full text not read). pubmed.ncbi.nlm.nih.gov/37553157/ Supports: Earth context for the sudden one-sided chest pain red flag (design judgment); the robot never names a cause.
10. Hampson NB. Pulse oximetry in severe carbon monoxide poisoning. Chest. 1998;114(4):1036-41. doi:10.1378/chest.114.4.1036. PMID 9792574. pubmed.ncbi.nlm.nih.gov/9792574/ Supports: Abstract: pulse oximeters overestimate arterial oxygenation in severe carbon monoxide (CO) poisoning; an elevated carboxyhaemoglobin level falsely raises the pulse oximeter saturation. Why the robot never calls a reading reassuring during a smoke or fire event.
11. 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.
12. 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, V1 3004 (medications, including oxygen, are human-managed), V1 3006, V1 3007.
13. 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 6025 (contamination monitoring and alerting), V2 7046, V2 7059 and Section 10.6 automated and robotic systems.
14. 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.
15. 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.
16. 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.
17. 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.