# RMP-CARD-003 Abnormal heart rhythm on monitoring: record, alert crew and ground # 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-CARD-003 slug: rmp-card-003 title: 'Abnormal heart rhythm on monitoring: record, alert crew and ground' category: cardio tier: 1 rung_note: >- Max rung raised from 1 to 2 for supervised recording, fetching the closed defibrillator and video. The robot never reads a rhythm, never says what it is, and never fires a defibrillator; the crew place every electrode. result_language: use: - logged, not interpreted - sent to flight surgeon - monitor alarm as displayed - EMERGENCY FETCH – NOT VERIFIED (CMO command) - as stated by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - benign - artefact - normal rhythm - atrial fibrillation - ventricular tachycardia - heart block - verified - safe - mild - minor - sinus rhythm - no arrhythmia - heart is fine - just palpitations - reading is reassuring scope: summary: >- When a heart monitor alarms or shows a rhythm the CMO calls abnormal, or a crewmember reports palpitations, the robot sends an alert to the flight surgeon and the CMO at once (URGENT with any red flag), records the rhythm strip and vital signs as displayed, asks structured symptom questions and logs the answers word for word, brings the closed defibrillator and the ECG kit on command, and sends everything to the flight surgeon. It names the alarm the device shows, never a rhythm. It hands off to RMP-CARD-001 if the crewmember becomes unresponsive. why: >- NASA's in-flight medical conditions evidence report states: "Both benign and more serious cardiac dysrhythmias (supraventricular and ventricular tachycardia) have been reported during previous Mir, Skylab, and Apollo missions; one case of dysrhythmia required that crewmembers be brought back to Earth." In active astronauts, atrial fibrillation (AF) is about as common as in the general population (about 5%) but at a younger age; in 13 astronauts, the left upper heart chamber (left atrium) grew transiently after 6 months in space, and none developed AF (Khine 2018). On Earth, the American Heart Association (AHA) 2025 adult advanced life support guideline covers peri-arrest rhythm problems such as atrial fibrillation or flutter with a rapid heart rate, the 2018 ACC/AHA/HRS bradycardia guideline asks clinicians to link symptoms to the recorded rhythm, and the 2023 AF guideline (American College of Cardiology, AHA, American College of Clinical Pharmacy and Heart Rhythm Society; PubMed record only) is for the clinicians who read the strips. A clean, time-stamped strip with stated symptoms is what the flight surgeon needs. Alarm levels match RMP-CARD-002 and RMP-INF-001: every monitor rhythm alarm is URGENT, unless the flight surgeon's logged order sets a reviewed recurring alarm for a named crewmember as a Flag; blood pressure and heart rate use the same clinical-lead values as RMP-CARD-002. 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. Open question for review: who on board reviews strips when the link is down (as in RMP-CARD-002, an onboard ECG reviewer named before flight). covers: - >- A heart monitor alarm or rhythm the CMO calls abnormal, during scheduled monitoring, exercise or care - Palpitations, fainting or near-fainting reported by a crewmember - Hand-off to RMP-CARD-001 (unresponsive) and RMP-CARD-002 (chest pain) 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) - Reading, naming or ranking any rhythm - Placing electrodes - Charging or firing the defibrillator, or opening it - Saying an alarm is artefact or harmless - Choosing or adjusting any device setting related: - RMP-CARD-001 - RMP-CARD-002 - RMP-CARD-004 - RMP-RESP-001 - RMP-SKIN-002 - 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' - >- Onboard ECG reviewer: the CMO, or a reader the flight surgeon names before flight, reviews every strip when the link is down or delayed robot_may: - Alert the flight surgeon and CMO at once - Record the strip and vital signs as displayed, with clock times - Ask structured symptom questions and log answers word for word - Bring the closed defibrillator and ECG kit on command - Show the electrode placement diagram - Send everything to the flight surgeon robot_may_not: - Interpret, name or rank a rhythm - Touch the chest or place electrodes - Open, charge or fire the defibrillator - Change any device setting - 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 a monitor alarm, an abnormal-looking rhythm or palpitations. 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: Monitor alarm text as displayed source: Heart monitor required: false if_missing: Log "no alarm text". - id: IN-2 name: Rhythm strip and heart rate as recorded (12-lead ECG if the CMO places it) source: Heart monitor / ECG required: true if_missing: >- Prompt the CMO to re-seat electrodes. After attempts, log "strip not obtained" and keep the alert. Never hold up the call. - id: IN-3 name: Blood pressure and saturation as displayed source: Monitor required: false if_missing: Log "not obtained". - id: IN-4 name: 'Symptoms as stated: palpitations, light-headedness, fainting, chest pain, breathlessness' source: Crewmember required: true if_missing: Log "no response"; URGENT. - id: IN-5 name: Link status and delay source: Communications system required: true if_missing: Treat as link down; the onboard ECG reviewer reviews. steps: - id: S1 actor: robot rung: 2 action: >- On a crewmember's or the CMO's word, send a "heart rhythm alarm" alert with the alarm text as displayed to the flight surgeon and the CMO at once (URGENT for any monitor rhythm alarm or any stated red flag; a Flag only where the flight surgeon's logged order says so). 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 ECG medical kit and the defibrillator (closed; the robot never opens, charges or fires it) to the crewmember 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". success: Kit and defibrillator within reach, or skipped; override logged. limit: refs: - V2 7046 - id: S3 actor: robot rung: 2 action: >- Show the electrode placement diagram and lead-contact indicators; record the strip, heart rate, blood pressure and saturation as displayed, each with its clock time. success: Strip and readings recorded, or "strip not obtained" logged. refs: - V1 3004 - id: S4 actor: robot rung: 2 action: Ask the structured symptom questions and log the answers word for word. success: Answers logged. refs: - V1 3003 - 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: robot rung: 2 action: >- Send the strip, readings and answers to the flight surgeon; when the link is down or delayed, send them to the onboard ECG reviewer at once (sending to the ground does not count as review). success: Strip with the flight surgeon or the onboard reviewer. refs: - V1 6003 - V1 7001 - id: S7 actor: ground action: >- The flight surgeon (or the onboard ECG reviewer and CMO under the onboard checklist) decides on monitoring, any treatment and any evacuation [V1 3007]; the robot repeats recordings only on that schedule. success: Decision logged. refs: - V1 3007 - id: S8 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: S9 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; kits shown as opened – not restocked until resealed. refs: - V2 7059 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; the defibrillator is already at the scene, closed, for the crew. - 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 answer the last question? 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: S7 decided_by: ground question: What is the plan (monitoring, treatment, 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: S8 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 CPR, defibrillation, oxygen 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 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: Fainting or near-fainting threshold: any action: URGENT alert source: kusumoto2018 - id: RF3 sign: Chest pain or pressure (design judgment; same route as RMP-CARD-002) threshold: any action: URGENT alert; see RMP-CARD-002 - id: RF4 sign: Breathlessness, or displayed saturation below the shared alert value threshold: any; saturation below percent (shared parameter SPO2_ALERT_PCT) action: URGENT alert; see RMP-RESP-001; the crew act without waiting for a reading source: btso2 - id: RF5 sign: Confusion, drowsiness or new weakness (design judgment) threshold: any action: URGENT alert; a crewmember checks in person - id: RF6 sign: Any monitor rhythm alarm (design judgment; the same level as RMP-CARD-002 RF7 and RMP-INF-001 RF13) threshold: any action: >- URGENT alert; the robot names the alarm, never a rhythm. Only the flight surgeon, by a logged order, may set a reviewed recurring alarm for a named crewmember as a Flag - id: RF7 sign: Palpitations with no other symptom, as stated (design judgment) threshold: any action: Flag to the flight surgeon; the robot keeps recording on the flight surgeon's schedule - id: RF8 sign: Displayed systolic blood pressure low or high (design judgment; same values as RMP-CARD-002 RF1) threshold: below or above mmHg action: URGENT alert to the CMO and the flight surgeon - id: RF9 sign: Displayed heart rate low or high (design judgment; same values as RMP-CARD-002 RF2) threshold: below or above beats per minute action: URGENT alert - id: RF10 sign: Sweating, or pale or clammy skin, as stated (design judgment) threshold: any action: URGENT alert; a crewmember checks in person - id: RF11 sign: >- The oximeter cannot get a reading after the validated attempts (L5), 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 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: Defibrillator use by the robot value: not allowed enforced: Robot cannot open, charge or fire it; carry task only - id: L3 name: Robot speed near the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 - id: L4 name: Electrode re-seat prompts before "strip not obtained" value: enforced: Software - id: L5 name: Failed oximeter readings before "saturation not obtained" value: enforced: Software 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, alarm text as displayed, strips and readings with clock times, symptom answers, reviewer and decisions. - 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 heart rate and rhythm. - id: V1 3004 use: In-mission care includes vital signs, electrocardiography and defibrillation by the crew. - 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 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 alarms on a rhythm simulator, palpitations only, fainting, unresponsive transition to CARD-001, failed strip, lost link with onboard reviewer. pass: No rhythm ever named; every strip reaches a reviewer. - stage: training model what: CMO drills with the robot recording strips on a manikin. pass: Strip recorded within seconds of electrode placement. - stage: parabolic or station demonstration what: Defibrillator and kit fetch in weightlessness without a patient. pass: Defibrillator 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. Strips are reviewed by the flight surgeon or the onboard ECG reviewer. 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 CPR, defibrillation and oxygen continue under the onboard checklist and never wait for the link or the robot. mars_delay: - Rhythm review cannot wait for the ground; the onboard checklist and two trained CMOs lead. sources: - 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: >- Serious abnormal heart rhythms (supraventricular and ventricular tachycardia) have occurred in flight; one case of an abnormal rhythm required that crewmembers be brought back. - key: aha2025als text: >- Wigginton JG, Agarwal S, Bartos JA, et al. Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16_suppl_2):S538-S577. url: https://doi.org/10.1161/CIR.0000000000001376 doi: 10.1161/CIR.0000000000001376 pmid: '41122884' supports: >- AHA 2025 adult advanced life support covers peri-arrest conditions such as atrial fibrillation or flutter with a rapid ventricular rate, and the importance of identifying causative versus secondary arrhythmias. Context for the clinicians; the robot never interprets a rhythm. - 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: kusumoto2018 text: >- Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. Circulation. 2019;140(8):e382-e482. url: https://doi.org/10.1161/CIR.0000000000000628 doi: 10.1161/CIR.0000000000000628 pmid: '30586772' supports: >- Earth guidance on evaluating and managing slow heart rhythms and conduction delay, including correlation of symptoms with recorded rhythm. Context for the flight surgeon reading the strips; the robot never interprets rate or rhythm. PubMed record verified Oct 21, 2026 (publisher page blocks automated fetch). - 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: joglar2024 text: >- Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193. PMID 38033089. PubMed record only (full text not read). url: https://pubmed.ncbi.nlm.nih.gov/38033089/ supports: >- Earth guideline on atrial fibrillation for the clinicians who read the strips; cited as context only (PubMed record). - key: khine2018 text: >- Khine HW, Steding-Ehrenborg K, Hastings JL, et al. Effects of prolonged spaceflight on atrial size, atrial electrophysiology, and risk of atrial fibrillation. Circ Arrhythm Electrophysiol. 2018;11(5):e005959. doi:10.1161/CIRCEP.117.005959. PMID 29752376. url: https://pubmed.ncbi.nlm.nih.gov/29752376/ supports: >- Abstract: atrial fibrillation (AF) prevalence in active astronauts is about 5%, similar to the general population but at a younger age; in 13 astronauts, left atrial volume rose transiently after 6 months in space, and none developed AF. Context only. - 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: 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 (vital signs, ECG, defibrillation by crew), 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: Requirement IDs beginning V2. - 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: - >- RF6: any monitor rhythm alarm is URGENT; the robot names the alarm, never a rhythm; only the flight surgeon, by a logged order, may set a reviewed recurring alarm for a named crewmember as a Flag; S1 matches. Same level as RMP-CARD-002 RF7 and RMP-INF-001 RF13 (item 21; design judgment). - >- New URGENT RF8 (displayed systolic blood pressure below or above mmHg), RF9 (heart rate below or above beats per minute) and RF10 (sweating, pale or clammy, as stated), design judgment, the same values as RMP-CARD-002 (item 22). - >- The "why" quotes the evidence report exactly and adds Khine 2018 (PMID 29752376) as AF context; the 2023 AF guideline (Joglar, PMID 38033089, PubMed record only) added as context; RF3, RF5, RF6 and RF7 labelled design judgment, with their stretched sources removed (item 23, suggestion 39). - >- X5 and the comms loss-of-signal branch: only the robot pauses; crew CPR, defibrillation and oxygen never wait for the link or the robot (item 24). - >- RF4 says the crew act without waiting for a reading; new URGENT RF11 and limit L5 for "saturation not obtained" (item 25). - >- Never-words "sinus rhythm", "no arrhythmia", "heart is fine" and "just palpitations" (suggestion 38). - >- 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.