If you’re fascinated by the idea of humans traveling through space and curious about how that all works, you’ve come to the right place.

“Houston We Have a Podcast” is the official podcast of the NASA Johnson Space Center from Houston, Texas, home for NASA’s astronauts and Mission Control Center. Listen to the brightest minds of America’s space agency – astronauts, engineers, scientists and program leaders – discuss exciting topics in engineering, science and technology, sharing their personal stories and expertise on every aspect of human spaceflight. Learn more about how the work being done will help send humans forward to the Moon and on to Mars in the Artemis program.

On Episode 125 Nancy Fleming and Kris Lehnhardt describe the challenges of providing the necessary medical capabilities to astronauts traveling deeper into space. This is part three of a six part series on NASA’s Human Research Program. This episode was recorded on December 11th, 2019.

Transcript

Pat Ryan (Host): Houston, we have a podcast. Welcome to the official podcast of the NASA Johnson Space Center, Episode 125, “Deep Space Healthcare.” I’m Pat Ryan. On this podcast, we talk with scientists, engineers, astronauts, and other folks about their part in America’s Space Exploration Program, and today, that includes doctors. Because this is the next part in our series about how NASA is preparing to safely send human beings on future missions to space, from missions to the International Space Station, to the Moon, and eventually to Mars. NASA’s Human Research Program is working to learn how the human body is affected by being in the spaceflight environment, so we can figure out how to keep the bad things from happening and be prepared to fight back against those effects if and when they do happen. The HRP has divided that work up into five elements, and we’re learning about them in our current series of podcasts that started with Episode 123, “Humans in Space.” Today, we focus on developing the plans to take care of those future astronauts. As HRP says on its own website, “Identifying and testing next-generation medical care and crew health maintenance technologies.” We have two guests. Nancy Fleming is Element Manager for Exploration Medical Capability, which you’ll hear us refer to as ExMC. She began her career at NASA as an avionics and systems instructor for International Space Station and space shuttle astronauts, and for flight control team members, and she’s worked in program management, and in mission operations. And Dr. Kris Lehnhardt is the ExMC Element Scientist. Lehnhardt is board certified in emergency medicine in the United States and Canada. You’ll find out why. He also works in clinical shifts in the emergency department at Houston’s Ben Taub Hospital. That’s a top trauma center in our city. He has appointments as a senior faculty with the Baylor College of Medicine in the Center for Space Medicine, and in their Department of Emergency Medicine. So, here’s part three of six on NASA’s Human Research Program, Exploration Medical Capability. Here we go.

[ Music ]

Host: If you ask any astronaut, or engineer, or scientist, or flight controller around NASA, they will all agree that spaceflight is hard. And you add humans to the mix, and it makes it even harder. For example, we put any numbers of robots on Mars. They’ve got scientific instruments, and cameras, transmitting devices, so we here on Earth can see what they’re doing. But so far, zero people. When you add people to the equation, it becomes very much more complicated, because protecting people from the environment outside the protection of Earth’s atmosphere is really hard. It’s much harder than fortifying robots for work in outer space. Well, NASA has been working on this human problem since the very beginning of human spaceflight. The Human Research Program coordinates a wide range of studies, and experiments, and projects. They group it into five elements, including one called Exploration Medical Capability. And if you’ve been listening to the podcast, you’re hearing about all of the others in great detail, too. But for today, Nancy Fleming, the element manager for Exploration Medical Capability — I’ll start by asking you, so that we’re properly focused here. What is the work of your element, ExMC?

Nancy Fleming: Thanks. I’m happy to be here, and happy to tell you about the work of ExMC. I’m here with our element scientist, Dr. Kris Lehnhardt, and the work of our element — we work hand-in-hand together to solve the problems associated with long-duration spaceflight to Mars, and how we will address if an astronaut gets injured or sick during that time frame, and the best way to address that.

Host: What is an element manager at this element do?

Nancy Fleming:As an element manager– I’m part of the leadership team. I work in concert with Dr. Lehnhardt, and together, we set the technical direction of the work of the element. And as a manager, I manage the resources. I make sure that we get the people that we need to do the work, the scientists, the engineers, the physicians, the clinicians in order to accomplish that work. I manage the budgets. We do a lot of communication together. We, together, steer the ship of the work, and ensure that the taxpayers are getting the best bang for their buck.

Host: What was your career that led you to this? Because I think you’ve been at NASA for some time in other kinds of jobs, right?

Nancy Fleming: I have. My career to NASA is kind of circuitous. It’s not kind of circuitous. It’s really circuitous, and when I was young, my dad was an electronics technician. And I had this propensity for solving problems, and he recognized that in me. And when I was in sixth grade — so I think that’s — you’re about 12 in sixth grade. My dad sat me down one afternoon, because I was kind of a curious kid, too, and he taught me what hexadecimal was.

Host: Why were you being punished? [laughter]

Nancy Fleming: I thought — I found it absolutely fascinating.

Host: Really? OK.

Nancy Fleming: What I was excited about was, I had no idea that math and numbers could be manipulated in a creative way that could then be used to solve complex problems. And thus, started my curiosity down that path, and wanting to learn more about math. And I think when I was about 14, I decided I wanted to be a mathematician when I grew up.

Host: Oh, nice.

Nancy Fleming: And as life takes different routes, it did for me, but eventually, I got back to college, and I became a mathematician. And that gave me — what was exciting about that is, again, solving problems in a creative way, and using a variety of techniques — mathematical techniques, and things that you don’t really normally think of, because they’re happening behind the scenes in machines. And that gave me a step — a foot in the door to be introduced to the work that NASA is doing. So, I moved to Clear Lake, and as you know, Johnson Space Center is in Clear Lake, in Houston, Texas. And I had a professor who was solving problems here for NASA, and he said, “Hey, do you want to solve some problems with me?” I said, “Absolutely. Let me go do that.” And while I did that, I met folks at NASA, and then I was hired in. And my first job here at NASA, 20 years ago, was training the first International Space Station crews.

Host: Nice.

Nancy Fleming: So, the very first crews for the ISS — I trained them on the computer systems, and the environmental control and life support systems, and the communication systems.

Host: Nice.

Nancy Fleming: 20 years later, I am now a manager that works with an amazing team of very talented and gifted scientists, physicians, engineers that are working to solve problems in creative ways.

Host: I remember doing an interview with Bill Shepherd, who was the Expedition One Commander, who was fascinated by the fact that, unlike other spaceships or ships that he’d been on before, the International Space Station all was on computers. He was — told me, “There isn’t a light switch to turn things on and off. It’s all on the computers.” And you —

Nancy Fleming: I trained him on those computers.

Host: — were teaching on the computers.

Nancy Fleming: Absolutely.

Host: Nice.

Nancy Fleming: We — I spent a lot of quality time with Shep.

Host: Kris Lehnhardt, what does an element scientist do for ExMC?

Kris Lehnhardt: The job of the element scientist is, as Nancy said, to be part of a team, a leadership team that — I try to describe to people — we’re sort of the conductors of the orchestra, if you will. So, if the orchestra are all of our clinicians, and physicians, and scientists, and engineers who are helping to design medical systems to go to Mars, we provide them with guidance and direction for what they’re going to do. And a lot of our work — a lot of my work is focused on really trying to dig deep into the problem of providing medical care for space exploration and developing concepts or solutions for that problem. And then our team goes off and actually develops and builds those solutions.

Host: As Nancy mentioned, you’re a doctor, but give me the thumbnail of your background.

Kris Lehnhardt: So, mine is equally circuitous to Nancy’s.

Host: You guys that competitive, that you’re arguing about [laughter] who took the longest route to get here?

Nancy Fleming: We are not competitive. You will find that we are very much a team. We are very much a — and we have other people that are part of our team as well, our leadership team.

Host: You’re — go ahead, Kris.

Kris Lehnhardt: So, if my accent hasn’t given me away yet, I’m originally from Canada, and I grew up as a space nerd. But I also had an intense love of biology. It was in high school that someone encouraged me to think about going into medicine, and I saw that there were astronauts who had been physicians previously. And in fact, there was a Canadian astronaut who was an emergency physician.

Host: Dave Williams.

Kris Lehnhardt: Dave Williams, exactly right. And so, I said, “Well, maybe I’ll go be an emergency physician, and then I can be involved in space.” And so, that was my initial path, and what I learned as I was doing that was that there was this entire field in medicine called aerospace medicine that I knew nothing about. But what it was, essentially, was the study of medicine in extreme environments, and there’s no more extreme environment than space. But there’s a lot to learn from all these other environments, as well. So, I studied about wilderness medicine, and diving medicine, and flight medicine, and space medicine, and all of that was focused on how do you provide medical care to people in these terribly difficult places where they don’t have any of the stuff that they would otherwise want to have with them? And that path is what brought me to NASA.

Host: You went to some of those extreme environments on your own, didn’t you?

Kris Lehnhardt: I do enjoy taking some smart risks, if you will. So, I learned to fly planes. I’m a reservist in the military in Canada, in the Royal Canadian Air Force, as a medical specialist, and I learned to be a scuba diver as well. And so, what I realized as I was training and learning about how to provide medical care in these environments is that I had to actually understand the environments. And these environments, like spaceflight, are what we refer to as operational environments. And so, if you don’t understand the challenges of being in those places, it’s very hard to think about the problems of providing care in those. As a doctor, most doctors think about hospitals, and large teams of people, and lots of equipment.

Host: Right.

Kris Lehnhardt: And these environments preclude all of that.

Host: There’s something you said there a moment ago that struck me. You’re talking about how to provide care to people who are in these environments, but not necessarily because that environment impacted them, but it sounds like because they’re in a hard place for you, the physician, to get to.

Kris Lehnhardt: Yes, to both. The environment itself, frankly, is trying to kill you, so that is part of the problem. Another part of the problem is that even the healthiest and most fit people in these extreme environments — we’re all still human, and the human system inevitably breaks down. Like your car, various components break down over time. So, treating the human system in that environment is challenging, but changing the mindset of the physician or the clinician who’s providing care to people in these environments is essential as well. Because if they are reliant upon their equipment, and their facilities, and their ability to consult with other people, once you take all of that away, can they still do their job?

Host: What can they do? In getting ready to talk with you today, what seemed to filter out to me, as I was thinking about it, was that what you’re trying to develop now for future spaceflight is the hospital, or the clinic, or the sick bay capability for taking care of crews on future missions who are farther away, much farther away even than they are on the International Space Station right now. Is that a good analogy, or a valid one?

Nancy Fleming: The sick bay is a great analogy. As you know if you’re a Star Trek fan, there’s a sick bay in Star Trek, and as you also know if you’re a space fan at all, you know that spacecraft are incredibly small. And so, the problem to solve about creating a sick bay for a spacecraft is just how do you get all the things that you need in that to be small and efficient, and we are working towards that.

Host: Yeah, you don’t have — you don’t have a warehouse.

Nancy Fleming: We don’t have a warehouse, no, and things need to be integrated, and they need to be multi-functional — that they have the ability to be used for the highest probability of illness or injury that we’re anticipating.

Host: And I wanted to — to touch on this later, but I think what we’re — we want to realize — and I learned this only just recently — is that as you’re trying to put this all together, you don’t have unlimited resources. And you can’t supply everything that might possibly be needed, because that spaceship is small, and there’s no room for it.

Nancy Fleming: That is very correct.

Host: And the fact is, in the cases of going to the Moon, or going to Mars, they’re going so far away that you can’t even send it to them.

Nancy Fleming: That is true. You can’t send things, and you can’t — you have no resupply, which is sending supplies up. And you can’t send things back for analysis, or care.

Host: At least not in a timely fashion.

Nancy Fleming: Right, not in a timely fashion. So, the way that we work for — with the ISS right now, and even for the Moon, because they are so much closer to the Earth than heading to Mars and Mars is, we have those luxuries of return and supply, and constant communication. And as you get further from the Earth, when you’re headed out towards Mars, you lose those luxuries.

Host: As you’re working with some of those concepts in mind, you’re also working with the other people in the Human Research Program who are working on other focused areas. Give me a sense of how your element works in coordination with the others to tackle this whole big problem of taking care of human bodies outside this safety umbrella.

Kris Lehnhardt: We have to work really closely with the other elements of the Human Research Program, because as you just said, our resources that we’re going to have for these missions are extremely limited. And what we’re going to have to do is, we’re going to have to make tough decisions about what we can actually take with us. And so, as a result, if we each — if each group does their own individual research, and comes up with their own solution, but we don’t look at how that — all those different solutions combine together into an integrated system, then we’re going to end up with a bunch of disparate stuff. And the ultimate goal of the Human Research Program is to help NASA to provide a crew that is both physically and mentally fit to accomplish the mission. And the way that we do that is by developing a crew health and performance system for Mars that integrates all of the work of HRP, to make sure that we can keep them safe and healthy while we do the mission.

Host: It has struck me in talking and hearing you — some of your colleagues talk, too, that overall, HRP is looking at finding ways to keep people well and safe in this environment, and your element is looking at how to take care of them when they get sick or injured anyway.

Nancy Fleming: That is true. We always like to tell folks, “We’re the tail end of the dog.” We’d like — prevention is the best cure, but we’re also realists. And we know that people aren’t healthy 100 percent of the time, regardless of how well you take care of yourself. Even here on Earth, you may be the epitome of taking care of yourself in all of the right ways, but eventually, your body is a machine, and it’s going to break down at some point. And we know that that will be the case in space, and so, we must plan for those contingencies.

Host: Let me get you to help educate us a bit about space medicine, or — and taking care of people in space. I have heard — and in the past year, while we’ve been hearing about anniversaries of Apollo missions, there have been references to things that are even older than that. And back in — before Mercury flew, it’s like doctors were concerned that if they sent people to space, they weren’t going to even be able to swallow, because of — because of the lack of gravity or such. Give me a sense of how space medicine has evolved from those days, through Mercury up to where we are right now, and the ways that we are now able to care for people that we send to space.

Kris Lehnhardt: The space medicine, in the beginning, as you described, was really about how does the human body even work in space? And if it does work in space, can we try and anticipate what types of events are going to occur, and then treat them? And so, from the beginning of space medicine, that’s what people have been studying. When we started out with Mercury, they had a very small kit of stuff that they took with them. In fact, I think it fit in a pouch, or a pocket on their leg, and it was like the kind of thing you would take if you were going hiking for a day. And it was really about managing immediate problems, and taking these very healthy people, and giving them some very simple solutions for if they had any ailments that would impact the mission.

Host: And on a very short mission. They weren’t expected to be gone for very long.

Kris Lehnhardt: Yes, absolutely. The short mission duration for all of Mercury, Gemini, and Apollo meant that the medical kit was relatively small and didn’t have a lot of capability. As we evolved from there to the space shuttle, and then to the ISS, we started developing more robust capabilities for taking care of people. So, for example, on ISS, right now, there’s an ultrasound machine that allows us to diagnose medical problems in spaceflight. That ultrasound machine in the future — our vision of medical care when we go to Mars, and the transition from current-day ISS operations to the future, is this integrated system, where we have all of these amazing capabilities — laboratory analysis for blood and urine, imaging analysis for ultrasound, all of the medications we’re going to need, all of the equipment we’re going to need. We’re going to have that all as an integrated system, and we’re going to try and move past the days of the medical kit, the kind of thing that you take when you go hiking, or you go on a camping trip, to something that’s going to be taking care of people for years at a time.

Host: The Swiss Army knife of medical care?

Kris Lehnhardt: That’d be a nice — it’d be nice to have one of those. I’m sure that we would find some uses for that, but it would be very important for us to know how that piece of equipment worked with all of the other equipment as well.

Host: As we said, in early days of human spaceflight, people were not gone for very long, and they weren’t leaving their spacecraft. And the — I think that, realistically, the chances that they become injured were probably pretty small, but doctors were concerned that they didn’t know how the people were going to be able to even function in that environment, right?

Nancy Fleming: That’s what 50 years have brought to us. The human body is — in space has been studied over that time, and we’ve learned a lot. In fact, over just the last 20 years, with continuous presence in the ISS, you’ve had people in space for 20 years, and we’ve been collecting data on those bodies for 20 years. And we are using that data in ways to inform how we design the next system.

Host: You doctors, and engineers love you data, I know [laughter]. So, you’ve —

Nancy Fleming: Scientists, too. [Laughter]

Host: — been — you’ve been — but you’ve been keeping track of all 200 and — I think it’s 39 right now — different human beings who have been onboard the International Space Station in 19-plus years. I take it that’s been useful? [Laughter]

Kris Lehnhardt: We are putting that data to very good use. That information is going to help us to try and predict the kind of medical events that are going to occur on the way to Mars, and it’s through that prediction — we do a risk analysis, and we essentially come up with lists of conditions, and the most likely conditions. And that helps us to scope a medical system. We would love to take a hospital emergency room on the way to Mars, but that is simply not feasible. And so, what we have to do is, we have to use the data to help us to make evidence-based decisions for what we are going to take to go to Mars. Because the worst-case scenario is that you take stuff that you don’t end up using, because that means that that stuff took up space that could’ve been used for something else.

Host: Else that was needed.

Kris Lehnhardt: Exactly. And so, the — at the end of the day, this is actually a — believe it or not, this is an economics problem, which is called the backpack problem.

Host: OK.

Kris Lehnhardt: And it’s based all upon maximizing benefit and minimizing risk, or cost. And so —

Host: Which sounds thoroughly reasonable, yeah.

Kris Lehnhardt: — right. How can we get the best stuff that takes up the least amount of space, that gives you the most bang for your buck.

Host: On the — studying the astronauts on the space station, you’re familiar with the data, and I’m not. Can you give me some sense of things that you’ve learned after 19-plus years of people in space? What do we know now that we didn’t know then?

Nancy Fleming: Well, something that we know now, but we kind of knew before then, was the human body is really just a bag of water with some bones in it. [laughter] And that becomes more apparent when you’re in space. [laughter]

Host: Yeah. In — whoops — in the — in what sense?

Nancy Fleming: And what that means is, is in space — while on the ground, everything your body — how your body works is used to the gravity pulling it down towards your feet, and so all of your fluid functions get pulled towards your feet. And your body knows how to counteract that with gravity. When you’re in a zero-gravity environment, it all equalizes out, no different than when you’re diving. You know how you equalize, or you get into a neutral position? That’s what happens to your body in space. It becomes a sack of water, and all of those fluids just float. They don’t — they aren’t pulled anywhere, and so, your systems have to work differently to push and pull them. You get more fluid in your head, and you’re not used to that fluid in your head on the ground, because it all goes towards your feet. And so, that fluid in your head can have different effects on your vision, or depending on how that is, it could have an effect on the way that you’re thinking about problem-solving.

Host: It effects your thought processes, too? Is that what you’re saying?

Kris Lehnhardt: So, the spaceflight environment — the lack of gravity, the radiation associated with it, the isolation and confinement on the space station — all of that affects the performance of the people onboard and has the ability to affect their thinking as well. And so, when we talk about health, we often talk about medicine, but in this case, the health and performance of the crew is as equally — is equally important.

Host: You take what you’ve learned from this data, studying these astronauts over this time — have you had an opportunity — or, not you personally, but NASA had the opportunity, then, to try to use these astronauts on the space station as — to test out ways to counteract those things?

Kris Lehnhardt: The space station is the perfect environment that we have — the best available environment that we have right now to study how humans are going to explore the rest of space.

Host: And I make — I’m going to stop you there, but first, how do we compare the microgravity environment on the space station to the environment that crews on the way to Mars would experience? Are they very comparable, or very different from one another?

Kris Lehnhardt: They are more similar than they are different.

Host: OK.

Kris Lehnhardt: And so, the spaceflight environment —

Host: On the station — even better for studying.

Kris Lehnhardt: — on the station is a great analogue for studying what we need to learn to go to Mars, absolutely right. So, the microgravity that you experience on the space station is essentially identical to the micro-gravity that you’re going to experience on the way to Mars. The — we have no way of simulating that for an extended period of time on the ground. So, we need the space station in order to study microgravity deep space has a different radiation environment than the space station does.

Host: OK.

Kris Lehnhardt: So, there are some elements of deep space on the way to Mars where the radiation is going to be substantially different, but the ISS is still exposed to that same space radiation, just in different ways, and is still a better place to study that than we can do on the ground. We have the ability to create or mimic space radiation on the ground, but nothing beats the real thing.

Host: Mm-hmm. And so, using the space station, as we were saying, is a way to test ideas, or theories about how we are going to take care of those future astronauts. And some of those things have worked out. Tell me about some of those — those ideas that have been tested.

Nancy Fleming: So, in Exploration Medical Capability, we do a lot of technology demonstrations on the space station. We do medical technology demonstrations. We want to try to find out if — how fluids work in space, if we can put an IV in in space. We need to find out if we can do — how we can analyze blood in space. We’ve done analysis on — we have done technology demonstrations on imaging, different type of imaging equipment, and if they can be extended to be used for more different types of things. Do you want to tell them about IVGEN?

Kris Lehnhardt: Sure. So, we, a number of years ago, developed a system that would be able to take the water on the space station and generate fluids that can be used intravenously, in case an astronaut were sick or injured.

Host: Is that what the IB-GEN you mentioned is?

Nancy Fleming: IV, yes.

Kris Lehnhardt: IV Generation.

Host: Generation. OK, go —

Nancy Fleming: Like you have an IV in a hospital.

Host: — yeah, got you. Go ahead, Kris. Continue.

Kris Lehnhardt: That type of system would allow future astronauts to develop and use IV fluid at the time that they need it. Right now, what we have to do is, we fly bags of IV fluid to the space station. Those bags all have expiry dates on them, so if we don’t use them, that was mass and volume that could’ve been used in some other, better way.

Host: Yeah, that trade-off you referred to a few minutes ago.

Kris Lehnhardt: Exactly. So, an integrated system in the future has an environmental control and life support system that’s already providing water to the astronauts to drink. We want to take that same water, transform it into IV fluids, and be able to use it in case someone gets sick or injured. That’s the kind of system integration and technology development that we hope to continue to do on the space station, to prepare for Mars.

Host: Not to go too far off, but how do you transfer — transform regular water into IV solutions? What do you — do you have something you have to add to it?

Kris Lehnhardt: You sterilize the water, and then you add certain solutes to that water to make it — essentially, you’re adding salt to the water, and the technology that is developed there is one that has applications for spaceflight, but also has applications on the ground.

Host: And I guess similar to the way they do it on the ground, except that they — as you can see, I’m pointing up to the station — they don’t have the benefit of gravity to help mix those components, right?

Kris Lehnhardt: Correct.

Host: The next step in testing — he thinks — is going to be when the Artemis program puts astronauts on the Moon, which is further away than the space station, but not nearly as far away as Mars is. Is that the next step in this process, that — Nancy’s shaking —

Nancy Fleming: Absolutely it is.

Host: — eyes all lit up. Yes, we want that.

Nancy Fleming: It is. You know, the purpose of Artemis is not just the boots on the Moon, but it’s also to have a Moon base, and explore more on that Moon — on the Moon and see what you can get — what the Moon can provide to us. If there is a Moon base, once that is there, that is — that will become the best analogue. It will supersede ISS as an analogue for Mars, and it is a stepping stone to Mars. And the reason for that is you will be there long — long duration, and as Kris mentioned earlier, the galactic cosmic radiation is more similar on the Moon to what you will experience going forward.

Host: On Mars, but not as similar to what they get on the space station.

Nancy Fleming: On ISS, because the ISS is still within the atmosphere, the protection.

Host: The Moon also has some gravity that the space station doesn’t have.

Nancy Fleming: Absolutely, and —

Host: And Mars has gravity, although they’re not the same as each other, right?

Nancy Fleming: — correct.

Kris Lehnhardt: So, we refer to that, in most cases, as partial gravity. And so, if Earth is one G, and the space station is zero G, then the Moon is about 1/6th G, and Mars is about 1/3rd. And so, the partial gravity environment of the Moon is something that is very important for us to become more familiar with, and to study in depth. We know that the human body changes significantly on the space station because of the lack of gravity. What we don’t know is whether or not — what amount of gravity the human body needs in order to function in a way that’s most similar to Earth, and it may be that the gravity on the Moon is actually sufficient for us to be able to function more like we do on the ground, on Earth, than we do on the space station. And so, being able to study people for long durations on the Moon is going to give us invaluable data.

Host: Longer than just the couple of days that they were there in the Apollo program.

Nancy Fleming: Sure, mm-hmm.

Host: What other things are you thinking that you can do at a — at a sustainable Moon base that you need to do for the — for future Mars missions?

Nancy Fleming: So, one of the key things that we’ve been studying is how medications change in space, in the zero-G environment, and in a radiation environment.

Host: You mean like become less potent over time, or —

Nancy Fleming: Yeah, maybe become less potent, and if they become toxic.

Host: — oh.

Nancy Fleming: Yeah, so we’re very concerned about that.

Host: Not good.

Nancy Fleming: [Laughter] Right. And so, we’re actually working with the [Food and Drug Administration] FDA on — to gather data associated with that, and then we fly medications to the space station, and bring them back, and studying them as well. We’d like to do that on the Moon because of the different environment, and because it is more analogous to heading to Mars for us, to find out which medications can be safe and effective for that longer-duration trip to Mars.

Host: I know that, because I did stories on it a long time ago — that on the space station, they were touting what was called a telemedicine capability, the ability with two-way video for doctors on the ground, for flight surgeons here in Houston to talk to and to see the astronauts on the station back and forth, and to diagnose them. And that sort of thing is even used on the planet, for people in remote locations, too. Is that not something that you could employ for crews going to Mars?

Kris Lehnhardt: It is, but it’s going to look different.

Host: Is, but.

Kris Lehnhardt: But. [laughter] They — the communication challenges we’re going to have going to Mars are significant. So, because we are stuck with the speed of light as it is, we can’t get information back from Mars faster than ten minutes, which means that back-and-forth communications between here and Mars will take 20 minutes. And so, trying to have a conversation —

Host: Or more.

Kris Lehnhardt: — or more. Trying to have a conversation with somebody where you’re waiting 20 minutes for their response is a very boring conversation.

Host: And let’s be really blunt about this to everybody. The reason for that is because Mars is so far away.

Kris Lehnhardt: Absolutely. If you consider the ISS, and the Moon, and Mars, the Moon is about 1000 times further away from Earth than the ISS, and Mars is about 1000 times further away from the Moon. So, the distances are immense that these communications have to transit, and one of the challenges that we’re going to have, even beyond the delay in the communications for Mars, is that during a mission to Mars, there’s going to be a period of time where the sun is in between Mars and the Earth. And the sun is going to prevent all communications from going back and forth. So, there’s going to be a period of time where we are going to have people on the surface of Mars, probably about a week and a half to two weeks where we can’t see or talk to them at all.

Host: At all, wow.

Kris Lehnhardt: So, the ability to provide telemedicine or remote medicine support is something that is very useful but is limited by communications. So, one of our jobs at ExMC is to start trying to develop ways for our crews, our astronauts, to become more Earth-independent, so that they can do their job and take care of themselves if we can’t help them.

Host: Sounds like they’re going to have to do that for everything, not just their medical care. But yeah, how do you do that? Do you just — do you send crews who are made up entirely of doctors?

Kris Lehnhardt: As a doctor, that sounds fine to me.

Host: I know you’re in line. [laughter] I know you’re in line, but that — [laughter] I mean, do they have to be medical professionals, or is the training that they can get over the course of getting ready going to be sufficient to let engineers and scientists go, too?

Kris Lehnhardt: In order to accomplish the mission, we have to send more than doctors. That’s for certain. Right now, NASA intends to send a doctor on a mission to Mars, but there’s always a chance that that doctor is the one who becomes sick or injured. So, you have to have a more robust capability than that. So, what we need to do is, we need to find ways to not only train and prepare people on the ground to deal with medical emergencies and maintain health and performance. We need to give them all the tools that they need in-mission to try and help themselves. And so, that includes different things like procedure support. So, we are developing a module right now, software module that we’re going to fly to the space station in the spring, and what that module is going to do is, it’s going to guide astronauts to perform their own ultrasounds on each other without talking to the ground, and without medical training. So, we’re looking at trying to develop all of the tools they’re going to need to take care of themselves that will augment whatever their training and preparation was on the ground before they left.

Host: As you think about the fact that they’re going to be gone so far away, which also means they’re going to be gone for such a long period of time, and they’re going to have to learn how to be more self-sufficient, entirely-self-sufficient, because Houston — Earth can’t talk to them. That — you really have to have them fully prepared to — as if it were going to be a one-way trip. They’ve got to be able to take care of themselves.

Nancy Fleming: They have to be able to take care of themselves. Absolutely, they do. And so, again, one of our approaches is enabling them to take care of themselves with a training module, so that they can do refresher training, or just-in-time training. And software will lend itself very well to that, just like with our ultrasound technology that we’re developing for them right now. But we are. They will have to become self-sufficient. They’re going to become more like explorers that we think of from the past, like Shackleton, or those types of folks who really did go exploring and were in hostile environments. And they had to depend on themselves for their health, and maintenance, and survival, and we are expecting them to thrive, not just survive.

Host: Sure, sure. Now, we referenced this before, and I wanted to get back to it. You talk about the planning that you’re doing, and the trade-offs that you’re trying to work out about what things you — they — you can bring, you need to bring, are most important to bring, are vital, or just luxuries. What kind of variables do you guys have to weigh in this equation to figure out — to figure out what fits there? I mean, one thing, I realize, is the size of the spacecraft, and you’re not building the spacecraft. But they’re saying, “Here’s the size of the closet that you get to fill up.” What do you have to — give me a sense of the discussions that you all have, and the variables that you look at in trying to determine what goes and what can’t.

Kris Lehnhardt: You’re absolutely right that when most people talk about the constraints, we talk about the mass, and the volume, and the power that each individual device or piece of technology’s going to have. But the other things that are less talked about, but equally important — one is data. How are we going to manage the flow of all of this information back and forth? If it requires huge amounts of data to be transmitted to Earth, for people on the ground to interpret, and then send back to the astronauts what to do with that information, maybe that’s not the best solution. The other thing that we are also looking at are the — what are going to be the knowledge, skills, and abilities of the crew? If we send a piece of equipment that is designed to be used by a highly-experienced physician, and that person is the person who is sick or injured —

Host: And then not capable of doing it.

Kris Lehnhardt: — and not capable of doing it, how are the other crew members going to be able to use that equipment? And so, we don’t want to send something on a mission to Mars that people are not going to be able to use effectively, because that, again, is a wasted resource. So, we have to weigh the mass, power, and volume, which are the typical things we talk about on spacecraft, but the data, and the knowledge, and the training are equally important.

Nancy Fleming: And the way that we’re doing that is, we’re building a tool, a model. As you know, a lot of science relies on models to calculate and predict, or capture trends and patterns, and weigh probabilities. And so, one of the key areas of focus that we are doing is building a model that can run all of these complex computations to make the trades even with inputs. So, we can give it a mass constraint, or a power constraint, or a volume constraint, or a data constraint, and we can have it run through a variety of algorithms. And it will help us define what our options are for an optimized medical system. So, we’re using math to do that.

Host: Yeah. It’s a good thing you have some mathematicians that are available. [laughter] But what are the — what are the variables that you’re considering, that you’re building into these algorithms? What are you trying to protect against, or ensure?

Kris Lehnhardt: That’s one of the hardest challenges that we have, is trying to predict what’s going to occur. And so, the best way that we do that is not only using previous spaceflight data — so the last 20 years of people on the ISS has given us lots of great information about what kinds of conditions may occur. But we’re also trying to use other information that we can get on the ground, from analogues, from similar situations. So, we look at how people provide medical care in remote locations like Antarctica, what happens on a submarine that can’t surface and is under the water for weeks at a time. How do they provide medical care? There are also analogue populations on the ground of people who are similar to astronauts, and we can study what happens to them over time and use that information to extrapolate what’s going to happen to our astronauts. So, we’re trying to take all of that data and incorporate it into our models and perform our risk analysis to come up with a list of the most likely conditions that are going to occur, and we use that list to help define what our medical system is going to be able to provide care for.

Host: I would assume that you’re trying to design a system that could provide whatever medical care they need.

Nancy Fleming: Absolutely. [laughter]

Host: We’re not drawing a line that says, “We’ll be able to take care of you up to this point, and if you get something worse, too bad.”

Kris Lehnhardt: One of the challenges that we have is that, at the end of the day, we are going to be constrained in what we can take, and we’re going to have to make some hard decisions. But we want our astronauts to be able to use parts of our system in flexible ways. We want them to improvise, and be prepared for the unexpected, because one of the things we have learned on the space station is that things occur that we were not predicting.

Host: Yeah.

Kris Lehnhardt: And the more time we have people spending in space, and the more people who go to space, the more data we get to tell us about that.

Host: Right.

Kris Lehnhardt: And a great example is a recent paper just came out that was published that talks about an astronaut who had a blood clot. No one was anticipating blood clots in astronauts. We did not have a capability to treat that problem within our models. So, the more time we spend in space, the more people we send to space, the better the data is that we can use to make our predictions going forward.

Host: I’m aware that Human Research Program is involved with running a lot of different analogues — not just natural analogues, like Antarctica, but ones that have been built here to try to gather some data. Have they been fruitful for you?

Kris Lehnhardt: Those analogues — one of the great things that we can study in those environments is how different people work together. And one of the things we know for an exploration crew, like the astronauts going to Mars, is that they are going to have to be a highly effective team. And if a medical emergency is going to occur, how are the people in that environment going to respond to that emergency? How are they going to know what to do, what procedures to follow, and how are they going to execute on that training that they’ve had to take care of their sick or injured crew member? Because those folks — they train for years together. They become like family to each other. So, if you could imagine what it’d be like, trying to provide medical care to someone in your family if they have a medical event, and you do it in a really difficult environment — we need to know how they’re going to respond. And so, using these analogues on the ground to study how people respond in these kinds of circumstances are going to help us to develop better procedures that the astronauts going to Mars can use.

Host: I think it’s important to point out, too, that NASA’s not doing all this work on its own. You guys are involved with a lot of people outside the gates here in trying to build this up. Tell me about that.

Nancy Fleming: Sure. We have agreements with other federal agencies. As I mentioned earlier, we’re working with federal drug administration to help us with our pharmaceutical studies. We have been — we’ve asked the Mayo Clinic for — we’re working with the Mayo Clinic to gather incidence rates for conditions. We also work with international partners. We have agreements with Canadian Space Agency, and HRP as a whole works with the European Space Agency. We were working with them on a technology demonstration coming up soon, in the next year, for a medical device as well. And so, as with anything, the more diverse minds and capabilities you bring to solve a problem, the greater outcome you get of that solution. And so, we have partnerships — in fact, our teams of scientists, and clinicians, and engineers are stationed all over the United States. We have virtual teams that are part of our element.

Host: They’re not all just working here in Houston.

Nancy Fleming: They’re not here. They’re not all here at Johnson Space Center. They’re at other space centers, and they’re at just remote locations.

Host: As you do this work, try to figure out what is needed, what sort of communications are you still having with the people who are building the spaceships, in order to make sure that plans that — you know, I have a genius plan, but it won’t work on this vehicle. I mean, you don’t want to get into that position. So how do you still work with the spaceship builders?

Kris Lehnhardt: We have a team that works within our element that is focused on systems engineering, and what you’re describing is exactly that. What we are trying to do is develop the information that vehicle designers and mission planners are going to need early on in their plans, so they can incorporate a crew health and performance system into their spaceships, essentially. And so, the model you described earlier, where someone says, “Here’s the closet. You can fill the closet with whatever you want” — we are actually trying to change that paradigm to one where a crew health and performance system is integrated into the spacecraft, like every other system is. So, if the spacecraft provides oxygen to the crew members, which it hopefully does in order for them to live —

Host: It does. [laughter]

Kris Lehnhardt: — then —

Host: As I understand it —

Kris Lehnhardt: — why, as a — on the medical side, should I have to have separate oxygen for medical purposes? If the vehicle already does that, I need to leverage that capability from the vehicle. And all I need to do is provide an interface between the vehicle and the patient. So, the integration and the systems engineering functions that our group is doing is trying to influence these programs early on in their development, so that we can have those systems, that crew health and performance system, as part of the spacecraft.

Nancy Fleming: And one of the ways that we do that — our systems engineering team — is using model-based systems engineering. And in fact, our systems engineering team is working — is part of an agency initiative, headquarters initiative that is trying to infuse model-based systems engineering in all of the future programs. And so, we are working at the forefront of the agency towards that goal. Our team has created — has a model, and has created requirements, concepts of operations, functional decomposition of those requirements, so that when any — a program like Artemis comes online, that they have something to start from for the requirements to build their spacecraft.

Host: In general, if it can be said, when you think about crews on two-year-long, three-year-long missions, are you thinking that they are more likely to get a cold, or, you know, have an old back injury flare up, as opposed to break an arm or something? Is there a certain kind of thing that you’ve come to believe is more likely to happen?

Kris Lehnhardt: As I said before, the biggest challenge is probably trying to predict the unpredictable. But we also know, as I said before, that these are all normal people, and we try to send up as healthy of people as we can. But at the end of the day, they have a lot of the same problems that we have. They have backaches, and headaches, and rashes, and we have to be able to manage those kind of more minor problems to prevent them from becoming more serious problems. The other kinds of issues that they are — that they could have, that we people have on the ground, we try to prevent or screen out before we send them. So, we ideally don’t want to send someone to space that’s going to have a heart attack, or a stroke, but at the end of the day, because we can’t predict everything that’s going to occur, we need to have a list of capabilities that we can take with us, that are going to manage a wide variety of conditions. So, our goal, ultimately, is to develop that list of conditions and capabilities so we can design the system necessary to treat them. History has shown us that lots of different things can occur. Apollo 13 is a great example of someone who became sick and was completely unpredicted from happening.

Host: Right.

Kris Lehnhardt: And it turns out that, even when that person did become sick, we didn’t have the capability onboard to effectively treat them. So, it was a good thing they were already on their way home again. We don’t want that to happen on the way to Mars.

Host: Right, and — but it’s — you know, it certainly could, and you’re trying to come up with a way to — that those people can take care of themselves. Because once they take off for Mars, they can’t turn around and come back for years, literally years. In an earlier podcast segment, Jennifer Fogarty, your boss, talked about not only developing things that people will need, but also a decision support culture. And that strikes me as being really important. You’re sending some people out there on their own to take care of themselves, and this is a way that we can help them after they’re gone.

Nancy Fleming: That is true, and for ExMC, we have just started our decision support research. We want to ensure that the crews have the capability to be able to rely on the information from the ground, and the technologies that can help them decide between two illnesses or help them decide which pieces of equipment are the best things to use to solve this — to help with this illness, or this injury. And so, we have kicked off research to develop decision support. That is a key component to having crews being able to take care of themselves on their way to Mars.

Host: And it struck me, too, that it’s a way to give them some confidence that what they’re doing is the right thing to do —

Nancy Fleming: Yes.

Host: — as they take care of themselves. This is fascinating, and I wish you luck as you continue to do it. Nancy Fleming and Kris Lehnhardt, thank you very much.

Nancy Fleming: Thank you.

Kris Lehnhardt: Thank you.

[ Music ]

Host: If you’re like me, and you watch some science fiction movies and television, and you can come away thinking that most of the problems of human spaceflight are pretty easy to solve — once you get better shielding technology and artificial gravity locked in, and then I think we’ll find that a lot of the medical questions will pretty much solve themselves. But until then, hearing Nancy Fleming and Kris Lehnhardt talk about working through the real problems facing humans trying to live out from under the safety of our atmosphere is terrifically interesting. And please don’t forget that we have three more episodes coming up on the remaining elements of NASA’s Human Research Program. You can find out more about all the elements by going online to NASA.gov/hrp. I will also remind you that you can go online to keep up with all things NASA at NASA.gov, and you can follow us on Facebook, Twitter, and Instagram at all of the NASA JSC accounts. When you go to those places, use the hashtag #askNASA to submit a question, or suggest a topic for us. Please indicate that it’s for Houston, We Have A Podcast. You can find the full catalog of all of our episodes by going to NASA.gov/podcasts and scrolling through to our name. You can also find all of the other exciting NASA podcasts right there at the same spot where you can find us, NASA.gov/podcasts — very convenient. This episode was recorded on December 11th, 2019. Thanks to Alex Perryman, Beth Weissinger, Gary Jordan, Norah Moran, and Belinda Pulido for their help with the production, to Emmalee Mauldin, Brett Redden, and the HRP team, and to our guests, Nancy Fleming and Kris Lehnhardt, for a great conversation. We’ll be back next week.