# RMP-RESP-001 Shortness of breath: oxygen set-up support, oxygen saturation, relay # Version 0.2 (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: '0.2' status: draft conceptual: true not_for_clinical_use: true max_autonomy: 2 missions: - leo - commercial - moon - mars updated: '2026-10-21' review: state: reviewed-ai-assisted requested: '2026-10-21' reviewed: '2026-10-21' human_clinician_review: false text: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 6 review, 26 required corrections and 17 optional suggestions); all required corrections, and the low-risk suggestions, are applied in this version (see Corrections). No named human clinician has reviewed it. Not for clinical use. fixed_rules: flight_surgeon_is_medical_authority: true cmo_acts_under_delegated_care: true human_starts_and_restarts_robot: true robot_never_diagnoses: true no_drug_or_fluid_advice_by_robot: true safe_state_on_fault_or_no_response: true lost_link_pause_then_cmo_decides: true robot_lockouts: diagnosis: true drug_or_fluid_advice: true starting_stopping_or_adjusting_oxygen_or_any_medicine: true self_start_or_self_restart: true changing_own_protocol_thresholds_or_limits: true handing_over_a_mismatched_item_as_verified: true id: RMP-RESP-001 slug: rmp-resp-001 title: 'Shortness of breath: oxygen set-up support, oxygen saturation, relay' category: resp tier: 1 rung_note: >- 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. result_language: use: - logged, not interpreted - sent to flight surgeon - EMERGENCY FETCH – NOT VERIFIED (CMO command) - saturation as displayed - as stated by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - oxygen not needed - saturation fine - target met - verified - asthma - pneumonia - blood clot - safe - mild - minor - reading is reassuring - oxygen level is good - collapsed lung - probe error scope: summary: >- 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: >- 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. covers: - Shortness of breath, air hunger, or a low saturation reading, in flight - Support while the CMO runs the onboard oxygen checklist - Hand-off to RMP-CARD-001 if the crewmember becomes unresponsive or is not breathing normally - >- Routing to the cabin protocols (RMP-ENV-001, RMP-ENV-002, RMP-ENV-003, RMP-ENV-004) when a cabin alarm is active locked_out: - Diagnosis or naming a cause - Any medicine, fluid or oxygen advice; starting, stopping or adjusting oxygen - Touching the crewmember - >- Handing over any medicine outside RMP-PHARM-001, or after a MISMATCH or CANNOT VERIFY (the item stays quarantined; only the CMO can ask for it, through the RMP-PHARM-001 logged two-step override) - Opening the oxygen kit, placing a mask, or touching the regulator - Saying saturation is normal or that oxygen is not needed 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 roles: medical_authority: Flight surgeon (ground). Holds medical authority for every run. onboard_lead: >- Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link. others: - 'Second trained CMO: receives every alert and takes over if the CMO is the patient' - 'Vehicle commander: leads any cabin emergency procedure' - 'Other crew: help as the CMO or commander directs' robot_may: - Send an URGENT alert at once - Bring the sealed oxygen kit (closed) and pulse oximeter on command - Hold the oximeter display where the CMO can read it - Record readings and word-for-word answers on a clock-time timeline - Stream video when the link allows - Reconcile the kit afterwards through RMP-PHARM-001 as an inventory record only robot_may_not: - Start, stop or adjust oxygen - Interpret a saturation or name a cause - Place a mask or probe, or touch the crewmember - Start without a human command commercial: >- On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) preconditions: - id: PRE-1 text: >- A crewmember or the CMO started the protocol by command after shortness of breath was reported or a low reading was shown. check: human_start == true refs: - V2 10174 - id: PRE-2 text: Robot self-test passed; kit stowage locations known. refs: - V2 10161 - V2 7059 - id: PRE-3 text: Robot and supplies restrained when not moving. refs: - V2 7046 - id: PRE-4 text: Link status known. The crew never wait for the robot before acting. check: link_state in [live, delayed, down] consent: standard: Emergency care; recording by the CMO's agreement when the crewmember cannot speak. emergency: 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. inputs: - id: IN-1 name: Shortness of breath as stated by the crewmember or a witness source: Voice required: true if_missing: Log "no response"; keep the URGENT alert. - id: IN-2 name: Saturation and heart rate as displayed on the pulse oximeter (the CMO places the probe) source: Pulse oximeter required: false if_missing: >- After failed readings (L4), log "saturation not obtained" (never a reassuring value, never "probe error"); this is an URGENT red flag (the CMO checks the crewmember now). - id: IN-3 name: Breathing rate, counted by the CMO source: CMO required: false if_missing: Log "not stated". - id: IN-4 name: Cabin alarms the CMO or commander states are active (smoke, ammonia, pressure, carbon dioxide) source: CMO / commander required: true if_missing: Log "not stated"; do not assume none. - id: IN-5 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 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 seconds is repeated and sent to the next named crewmember. success: Alert acknowledged, or escalated. refs: - V2 10174 - V1 6003 - V1 3006 - id: S2 actor: robot rung: 2 action: >- On the CMO's command, 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. success: Kit and oximeter within reach, or skipped; override logged. limit: refs: - V2 7046 - id: S3 actor: crew action: >- 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. success: Human-led care; robot logs what is stated. refs: - V1 3004 - id: S4 actor: robot rung: 2 action: >- 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. success: Readings logged with times. refs: - V1 3003 - V1 6003 - id: S5 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: S6 actor: ground action: >- 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]. success: Decision logged. refs: - V1 3007 - id: S7 actor: robot rung: 2 action: >- Only after the CMO or flight surgeon has placed an order, run RMP-PHARM-001 for the ordered item (fetch, barcode match to every order field, recipient check). This protocol adds nothing to that check, never suggests an order, and never hands anything over outside RMP-PHARM-001. success: RMP-PHARM-001 run logged with its result, or none ordered. refs: - V2 7059 - id: S8 actor: robot rung: 2 action: >- When the CMO says the event is over, run RMP-PHARM-001 reconciliation on each kit fetched: record the items the CMO or crew state were used, the remaining contents against the kit list, seal status and expiry, labelled "inventory reconciliation after emergency use – not a check before use". Flag the override to the flight surgeon and the pharmacy lead, and show each kit as "opened – not restocked" until a human restocks and reseals it. success: Reconciliation recorded; kit shown as opened – not restocked until resealed. refs: - V2 7059 - id: S9 actor: robot rung: 2 action: >- Send the flight surgeon one package: alert times, readings, stated answers, oxygen decisions as stated, video pointer. success: Package delivered or queued. refs: - V1 6003 - V1 7001 - V1 7003 decisions: - id: D1 after: S3 decided_by: crew question: Has the crewmember become unresponsive or stopped breathing normally? branches: - if: 'Yes' then: Start RMP-CARD-001 at once; this record continues as context. - if: 'No' then: Continue. - id: D2 after: S4 decided_by: robot question: >- Checked after every answer and at any point in the run (even mid-question or mid-step): does any answer, reading or observation meet a red flag? branches: - if: 'Yes' then: >- Stop the current question or step at once and apply the action listed for each matching red flag (URGENT alert, flag, or stop), with the answer or reading itself, never a cause. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within seconds is repeated and sent to the next named crewmember. - if: 'No' then: Continue. - id: D3 after: S4 decided_by: robot question: Did the crewmember or CMO answer when asked? branches: - if: 'Yes' then: Continue. - if: Declined explicitly (the crewmember says no to a question) then: Log "declined" for that question only; the alert already sent stands. - if: No response, or the answer does not make sense then: >- URGENT: log "no response" (never "declined"); the CMO, or the second trained CMO if the CMO is the patient, checks the crewmember in person at once. - id: D4 after: S6 decided_by: ground question: What is the plan (oxygen, monitoring, evacuation)? branches: - if: Link live then: Flight surgeon decides; robot logs. - if: Link down or delay too long then: >- The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact. - id: D5 after: S7 decided_by: robot question: What did RMP-PHARM-001 show for the ordered item? branches: - if: MATCH TO ORDER then: >- RMP-PHARM-001 completes its own recipient check and hand-over; this protocol only logs "MATCH TO ORDER. Not a dose, interaction or allergy review." and the clock time. - if: MISMATCH or CANNOT VERIFY on any field, or a failed scan or recipient check then: >- MISMATCH or CANNOT VERIFY shown with the fields named. No hand-over under this protocol: the item stays sealed in the NOT VERIFIED bag in quarantine (the RMP-PHARM-001 default), and the robot never hands it over unprompted or to anyone but the CMO. The robot does not offer or suggest an override. Only if the CMO explicitly makes the two-step override request inside RMP-PHARM-001 can the item go to the CMO, logged there as an override with the reason and the mismatched fields, and flagged to the flight surgeon. handoff: none stop_rules: - id: X1 trigger: The patient (or the crewmember being examined) says stop, or withdraws consent action: >- Robot stops all motion at once, backs away to its rest position and tells the CMO. Recording stops unless the patient agrees to keep it running. level: stop refs: - V2 10165 - id: X2 trigger: Any crewmember presses stop or takes over control action: Protective stop; robot holds its stopped position; only a human may restart it. level: safe-state refs: - V2 10165 - V2 10168 - V2 10174 - id: X3 trigger: Robot fault, sensor fault, or a force, speed or reach limit is reached action: Protective stop and hand control to the CMO; log the fault. level: safe-state refs: - V2 10172 - V2 10168 - id: X4 trigger: CMO is asked to take over and does not respond (for example, the CMO is the patient) action: Robot stays stopped; the next named crewmember is called. level: safe-state refs: - V2 10173 - V2 7045 - id: X5 trigger: Loss of link, or delay longer than the limit for live guidance action: >- Robot pauses its own movement in its stopped position and tells the CMO and the commander. This pauses robot movement only: crew bleeding control, CPR, defibrillation, oxygen, masks and the commander's vehicle procedure continue under the onboard checklist and never wait for the link or the robot. The CMO decides whether the robot continues 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 - id: X9 trigger: The CMO needs the robot's space action: Robot moves to its rest position at once and holds; it does not leave the module on its own. level: safe-state refs: - V2 10172 - id: X10 trigger: A smoke, fire, ammonia or pressure alarm becomes active action: >- Robot announces the alarm as displayed, says "oxygen in use" to the commander if oxygen is in use, keeps the URGENT alert and record, and follows the matching cabin protocol (RMP-ENV-001, RMP-ENV-002, RMP-ENV-003 or RMP-ENV-004) under the commander. level: urgent refs: - V2 6025 red_flags: - id: RF1 sign: Unresponsive, or not breathing normally threshold: any action: URGENT alert; start RMP-CARD-001 now source: aha2025bls - id: RF2 sign: Displayed saturation below the shared alert value threshold: below percent (shared parameter SPO2_ALERT_PCT) action: >- URGENT alert; the CMO decides on oxygen; the crew act without waiting for a reading; the robot keeps recording source: btso2 - id: RF3 sign: Chest pain or pressure with breathlessness (design judgment) threshold: any action: URGENT alert; see RMP-CARD-002 - id: RF4 sign: Swelling of lips, tongue or throat, or widespread hives, with breathlessness threshold: any action: URGENT alert; see RMP-RESP-003 source: rcuk - id: RF5 sign: Choking, ineffective cough or suspected inhaled object threshold: any action: URGENT alert; see RMP-RESP-002 source: rcukchoke - id: RF6 sign: Breathlessness, chest pain or cough after an EVA or a cabin pressure change threshold: any action: URGENT alert; see RMP-EVA-001 and RMP-ENV-003 source: tb037 - id: RF7 sign: >- Smoke, fire, ammonia smell, a cabin toxic alarm, or a high carbon dioxide alarm or reading as displayed threshold: any action: URGENT alert; see RMP-ENV-001, RMP-ENV-002 or RMP-ENV-004 source: atsdrnh3 - id: RF8 sign: Confusion or drowsiness (design judgment) threshold: any action: URGENT alert; a crewmember checks in person - id: RF9 sign: Fever with new breathlessness (design judgment) threshold: any action: Flag to the flight surgeon; see RMP-INF-001 - id: RF10 sign: >- The oximeter cannot get a reading after the validated attempts (L4), and "saturation not obtained" is logged threshold: any action: >- URGENT alert; the CMO checks the crewmember now (possible poor circulation); the robot never says "probe error" and never treats a missing reading as reassuring source: ng253 - id: RF11 sign: Sudden breathlessness with chest pain on one side (design judgment) threshold: any action: >- URGENT alert; see RMP-MSK-001 after an injury or RMP-EVA-001 after an EVA or pressure change; the robot never names a cause source: bts2023pleural - id: RF12 sign: >- Breathlessness with new swelling or pain in a limb or the neck, or coughing up blood, as stated (design judgment) threshold: any action: URGENT alert; the CMO assesses; the flight surgeon decides; the robot never names a cause source: marshallgoebel2019 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: Oxygen control by the robot value: not allowed enforced: No regulator or flow task is loaded; the kit stays closed in the robot's grip - id: L3 name: Robot speed near the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 - id: L4 name: Failed oximeter readings before "saturation not obtained" value: enforced: Software - id: L5 name: Robot distance from the oxygen outlet and mask while oxygen is in use value: enforced: >- Distance sensing; the robot holds its position beyond this distance while the CMO says oxygen is in use 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: >- Alert time, each displayed saturation and heart rate, breathing rate, active cabin alarms, oxygen decisions as stated, video start/stop. - id: LOG-6 text: >- Each URGENT alert, who received it, the time it was acknowledged (or the escalation to the next named crewmember), and the time a human released the robot. refs: - V2 10163 - id: LOG-7 text: >- Each emergency fetch as an override (time, who asked, reason as stated, kit ID, seal status) and the later inventory reconciliation, labelled "not a check before use". refs: - V2 7059 - id: LOG-8 text: >- Each RMP-PHARM-001 run started from this protocol: order ID, result (MATCH TO ORDER, MISMATCH or CANNOT VERIFY with the fields), quarantine, and any CMO override logged by RMP-PHARM-001 (reason and mismatched fields), at clock time. No running counter of doses. refs: - V2 7059 requirements: - id: V1 3003 use: Monitor physiological well-being in flight, including oxygen saturation. - id: V1 3004 use: >- In-mission care includes vital signs; administering and managing medications, including oxygen, 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 3007 use: Medical evacuation when needed; the flight surgeon decides. - id: V1 6003 use: Logs and alerts sent to the ground are private medical communications. - id: V1 7001 use: Records kept so the flight surgeon can see trends. - id: V1 7003 use: Secure handling of medical records. - id: V2 6025 use: >- Contamination monitoring and alerting: a cabin toxic alarm routes the crew to the matching cabin protocol. - id: V2 7045 use: Usable by non-physician crew, including when the CMO is the patient. - id: V2 7046 use: Patient, caregiver and supplies restrained. - id: V2 7059 use: >- Kit inventory and seal status are tracked; after an emergency fetch the robot reconciles the kit through RMP-PHARM-001 as an inventory record (never a check before use) and shows it as "opened – not restocked" until resealed. - id: V2 10161 use: Robot shows its status and health. - id: V2 10162 use: Mode changes are announced to the operator. - id: V2 10163 use: Robot records and shares its data. - id: V2 10164 use: Shows whether the human or the robot is expected to act. - id: V2 10165 use: Human can override and shut down the robot. - id: V2 10168 use: Human can take over. - id: V2 10172 use: Protective stop when a limit is exceeded. - id: V2 10173 use: Robot stays stopped if no one takes over. - id: V2 10174 use: Only a human starts or restarts the robot. validation: - stage: simulation what: >- Scripted 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. - stage: training model what: CMO drills with the robot fetching the closed oxygen kit. pass: Kit within seconds; kit stays closed. - stage: parabolic or station demonstration what: Kit fetch and display hold in weightlessness without a patient. pass: Kit closed and restrained. - stage: flight use under flight surgeon supervision what: First use in drills. pass: No safety events. signoff: protocol: - Clinical lead for the specialty (sets every clinical threshold marked ) - Flight surgeon, as medical authority - Robotics and medical-device safety board - Program approval for the mission restart_after_stop: >- Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself. each_run: >- Started by a crewmember or the CMO. Alerts go to the CMO and flight surgeon at once; the CMO decides on oxygen. 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 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_delay: - Breathing support cannot wait for the ground; the onboard checklist and two trained CMOs lead. sources: - key: btso2 text: >- British Thoracic Society. Guideline for oxygen use in healthcare and emergency settings (emergency oxygen guideline page). Fetched Oct 21, 2026. url: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/emergency-oxygen/ 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. - key: ermed text: >- NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to Medical Conditions that occur in Flight, as well as Private Medical Conditions, in Exploration Missions (In-Flight Medical Conditions). url: https://humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf supports: >- Smoke inhalation and choking or obstructed airway are listed among in-flight medical events; breathlessness can be the first complaint. - key: aha2025bls text: >- 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. url: https://doi.org/10.1161/CIR.0000000000001369 doi: 10.1161/CIR.0000000000001369 pmid: '41122888' supports: Hand-off to cardiac arrest support when the crewmember is unresponsive or not breathing normally. - key: rcuk text: >- 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). url: >- https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf 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. - key: rcukchoke text: Resuscitation Council UK. Adult choking algorithm (2021). PDF fetched Oct 21, 2026. url: https://www.resus.org.uk/sites/default/files/2021-04/Adult%20Choking%20Algorithm%202021.pdf 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. - key: tb037 text: >- NASA OCHMO. Decompression Sickness (DCS) Risk Mitigation. Technical Brief OCHMO-TB-037 Rev D (Oct 5, 2026). url: https://www.nasa.gov/wp-content/uploads/2023/12/ochmo-tb-037-decompression-sickness.pdf 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. - key: atsdrnh3 text: >- Agency for Toxic Substances and Disease Registry (CDC). Medical Management Guidelines for Ammonia (NH3). Fetched Oct 21, 2026. url: https://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). - key: marshallgoebel2019 text: >- 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. url: https://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). - key: bts2023pleural text: >- 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). url: https://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. - key: hampson1998 text: >- Hampson NB. Pulse oximetry in severe carbon monoxide poisoning. Chest. 1998;114(4):1036-41. doi:10.1378/chest.114.4.1036. PMID 9792574. url: https://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. - 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: v1 text: 'NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023).' url: https://www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-rev-c-with-signature.pdf supports: >- NASA-STD-3001 Vol 1 Rev C: V1 3003, V1 3004 (medications, including oxygen, are human-managed), V1 3006, V1 3007. - 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 6025 (contamination monitoring and alerting), V2 7046, V2 7059 and Section 10.6 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: marsdelay text: >- NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). url: https://www.nasa.gov/wp-content/uploads/2024/01/mars-communications-disruption-and-delay.pdf supports: >- One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction. - key: pccp text: >- U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). url: >- https://www.fda.gov/regulatory-information/search-fda-guidance-documents/marketing-submission-recommendations-predetermined-change-control-plan-artificial-intelligence supports: A model for planning, validating and rolling back software updates. - key: faa460 text: 'U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements.' url: https://www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-460 supports: >- Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants. corrections: - date: '2026-10-21' version: '0.2' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 21, 2026 (batch 6 review) items: - >- Oxygen and fire: the "why" links oxygen in use to fire risk (NASA-STD-3001 Vol 2 rationale to V2 6002 and V2 6003); new limit L5 (robot distance from the oxygen outlet while oxygen is in use, set by validation); X10 says "oxygen in use" to the commander; RMP-ENV-001 gains an "oxygen in use" input (item 1; design judgment). - >- RF7 adds a high carbon dioxide alarm or reading and routes to RMP-ENV-004. New URGENT RF11 (sudden breathlessness with one-sided chest pain; routes to RMP-MSK-001 or RMP-EVA-001; the robot never says "collapsed lung") and RF12 (breathlessness with new limb or neck swelling or pain, or coughing blood), both design judgment with BTS pleural 2023 (PubMed record only) and Marshall-Goebel 2019 as context (item 2). - >- RF2 split: RF2 is now only a displayed saturation below SPO2_ALERT_PCT; new URGENT RF10 for no reading after the validated attempts (L4): the CMO checks now (possible poor circulation), never "probe error". S4 records the probe site and device (item 3). - >- The "why" says carbon monoxide makes the oximeter read falsely high (Hampson 1998, PMID 9792574) and that overestimation has been reported in people with dark skin (NG253 context); new never-words "reading is reassuring" and "oxygen level is good"; mirrored in RMP-ENV-001 (item 4). - RF3, RF8 and RF9 labelled design judgment; their stretched sources are removed (item 5). - >- SPO2_ALERT_PCT: the "why" says it only raises an alert, never gates a crew action, and is set per mission by the clinical lead with the flight surgeon; the older saturation placeholders in other protocols are left separate (SPO2 section, suggestion 41). - >- X5 and the comms loss-of-signal branch: only the robot pauses; crew bleeding control, CPR, defibrillation, oxygen, masks and the commander's vehicle procedure never wait for the link or the robot (item 24). - The "why" drops the 88-92% range, which was not needed for any robot step (suggestion 27). - >- Batch 6 protocols now record the review as AI-assisted (Medical Research Assistant, Oct 21, 2026); no named human clinician. - >- 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: v2). Editorial; no change to steps, thresholds or limits.