Mcgill J Med. 2011 Jun; 13(2): 66.
I joined the Canadian Space Program in 2009. I am currently undergoing basic astronaut training leading, hopefully for a future mission aboard the International Space Station (ISS). My perspective is therefore that of a newcomer without spaceflight experience. I do, however, have some experience working as a family physician in northern Canada and, as my understanding of how medical care is provided on orbit grows, it has been interesting for me to see the parallels with my former practice.
The first thing that comes to mind when discussing medical care “up north” is that, compared to their colleagues working in large centers, northern first-line physicians are more on their own. The absence tradeof readily available consultants has a big impact on their practice; there is a strong incentive to strive for maximum autonomy and to stay current on as many topics as possible. Diagnostic tools and therapeutic pharmacopeia are also limited, and sometimes you just have to make do with what you have!
All of that is also true of the Crew Medical Officer (CMO) on a space mission. Readiness, inventiveness, outside-the-box thinking and a broad knowledge base are important to all physicians, but are particularly key to those working on their own in remote locations. Incidentally, there is not always a physician on-board the ISS; every crewmember receives basic emergency medical training, and the designated CMO receives more advanced training.
Of course, up north, one is not completely alone: help is always available in one form or another thanks to telehealth. For physicians working in northern communities, telehealth most often simply means a phone call to a specialist. Satellite internet now allows the transmission of clinical photographs and locally obtained x-rays. Where and when videoconferencing bandwidth permits, one can even perform ultrasound under the live guidance of a remote specialist. This has, for example, revolutionized pre-partum care for Inuit women, who don’t have to fly “south” just for a regular exam. Telehealth is also a great way for specialists to provide mentoring to remote personnel.
All these tools currently apply to on-orbit medical care. There is always a flight surgeon available for advice, and selected imagery can be downlinked to Earth. For example, commonly transferred images include cardiovascular ultrasound loops, fundoscopic images and dermatological photographs. X-Ray, MRI and CT are not available due to the prohibitive launch weight of the required equipment. Interestingly, telehealth is a good example of bidirectional technology transfer, where tools and protocols developed for terrestrial applications are used on-orbit, and viceversa.
However, as we contemplate deep-space missions back to the Moon, and on to Mars, the trade-off between support from Earth and medical autonomy becomes an issue. Basically, the further away, the more autonomy is required.
This is driven firstly by the increasing delay in communications. Since we can’t transmit radio signals faster than the speed of light, from Mars it could take up to 40 minutes to get an answer back, making consultations very cumbersome. Secondly, increasing distance makes an emergency medical evacuation less and less practical. Whereas evacuation from the lowearth orbit where ISS is located would be expensive but possible, an evacuation from Mars would probably not be an option.
Environmental and cultural issues
There are other obvious parallels between medical practice in northern Canada and on-orbit. One is the harsh and unforgiving nature of these beautiful environments; this modifies the frequency of various pathologies and drives the requirements for preparedness. For example, up north, the occurrence of exposure is relatively high, whereas on orbit decompression accidents are a threat – fortunately, this has not happened yet!
The other parallel one can draw is the crosscultural element. Physicians working in northern Canada serve an Inuit population with different lifestyles and different expectations towards healthcare compared to urban Canadians. The physician must adapt to these differences and avoid imposing his own perspective. The same is true on orbit, with crews generally of international composition.
Living in a remote area is a health risk in itself: for example, the chances of surviving a major head trauma are several orders of magnitude lower when the nearest neurosurgeon and ICU are several hours away by flight. Remoteness also drives the way we organize patient follow-up for more benign ailments: northern physicians tend to err on the conservative side, in general, to further minimize risks of complications.
The local population understands and accepts these risks; the challenge for northern health care providers, and the responsibility of the healthcare system, is to ensure these discrepancies are minimized, within reason. To quote an Inuit participant to the Romanow Commission: “I believe that the success of our Health Care System as a whole will be judged not by the quality or service available in the best urban facilities, but by the equality of service Canada can provide to its remote and northern communities.”
Similar concerns apply to on-orbit medical care. For example, in deciding the content of the onboard medical kit, one must decide what pathologies the crew could likely treat successfully. Deciding whether a particular illness or injury is survivable or not on-orbit is a matter of ongoing speculation and debate. This uncertainty is essentially what drives the requirement for crewmembers to undergo such stringent medical screening, in the hope of minimizing risk.
Again, as we envision deep-space missions wherein medical evacuation is not an option, the sobering consideration of what one should realistically prepare to treat only gets more relevant.
David Saint-Jacques (MD, PhD) is an astronaut candidate with the Canadian Space Agency. He and is currently in basic training at NASA’s Johnson Space Center in Houston, Texas. He was selected in 2009 while he was working as a family physician in the Inuit community of Puvirnituq, in Nunavik, Northern Quebec. He received a B.Eng in engineering physics from École Polytechnique in Montreal, and worked as a biomedical engineer in Paris, France. He subsequently obtained a PhD in astrophysics at Cambridge University, UK and worked as an astrophysicist in Tokyo, Hawaii and Montreal. He then returned to pursue an M.D. from Université Laval, and completed a residency in family medicine at McGill University.
*To whom correspondence should be addressed:
Dr. David Saint-Jacques