RMP-ENT-001 Nosebleed: supplies, containment, pressure timing and video, relay to the flight surgeon (the crewmember or CMO applies pressure; the robot never touches the face)

1 · Identity and scope

When a crewmember has a nosebleed, the robot tells the flight surgeon and CMO, brings the nosebleed supplies (gauze, wipes, sealed waste bags, gloves and eye protection for helpers), times the pressure the crewmember or CMO is applying, asks short red-flag questions, records what is reported and entered, and collects only sealed waste. Bleeding that does not stop in the time the clinical lead sets, heavy bleeding, faintness or a nosebleed after a head injury is URGENT. Packing, medicines and any procedure are done by the CMO under the flight surgeon.

Why this protocol was chosen. NASA records list 6 nosebleeds among US astronauts through 2006 (space adaptation), and 2 on the ISS through Expedition 40; RMP-ENT-004 routes nosebleeds here. The US clinical practice guideline asks clinicians to identify patients who need prompt management, to treat active bleeding with firm sustained compression to the lower third of the nose for 5 minutes or longer, and to record factors that increase bleeding, such as anticoagulant or antiplatelet medicines. In weightlessness blood does not drip away: a surgical review notes that it tends to stay at the wound as a dome, while arterial bleeding can form a stream of droplets (surgical review; applied to nosebleeds by extrapolation), so containment and eye protection for helpers matter.

Autonomy: Max rung raised from 1 to 2 for supervised fetching and timing, as in batch 1.

Related: RMP-ENT-004 · RMP-ENT-003 · RMP-EVA-001 · RMP-NEURO-001 · RMP-NEURO-004 · RMP-GI-002 · RMP-PHARM-001 · RMP-PHARM-003 · RMP-INF-002

2 · Roles

Medical authority

Flight surgeon (ground). Holds medical authority for every run.

Onboard lead

Crew medical officer (CMO), acting under delegated care; uses the pre-approved onboard checklist when there is no link.

Others

• Crewmember with the nosebleed: applies pressure if able, and can stop the robot at any time
• Second trained CMO: receives alerts if the CMO is the patient
• Any helper: wears eye protection near floating droplets

Commercial flights

On commercial flights, 'flight surgeon' and 'CMO' mean the operator's designated medical authority and trained onboard responder. If no trained responder is aboard, this protocol is not used. (NASA-STD-3001 requires two CMOs per vehicle for NASA programs [V1 3006]; FAA rules set no medical standards for spaceflight participants.) [11]

3 · Preconditions and consent

• PRE-1 A crewmember started the protocol by command. Pressure on the nose is started by the crewmember or CMO at once; nothing waits for the robot.human_start == trueV2 10174
• PRE-2 The crewmember is awake and answering. If not, URGENT alert and a crewmember checks in person (X7).crew_responsive == true
• PRE-3 Robot self-test passed; nosebleed and containment supplies stocked.V2 10161
• PRE-4 Helpers near the bleeding wear eye protection; containment wipes are in place for floating droplets.V2 9053
• PRE-5 Robot and supplies restrained when not moving.V2 7046
• PRE-6 Link status and current delay known.link_state in [live, delayed, down]

Consent

The crewmember agrees to questions, timing and recording by voice; photos need agreement. Any question can be declined; an explicit "no" is logged as declined for that question only.

Emergency consent

If the crewmember cannot answer, the robot sends an URGENT alert and a crewmember checks in person (X7).

Withdrawal

The crewmember can stop at any time; an alert already sent is not withdrawn.

4 · Required sensor inputs

5–6 · Steps and decision points

Each step names who acts. Decision points sit after the step they follow and say who decides: Robot Crew Ground. Any stop rule in section 7 can interrupt any step.

1. S1RobotRung 2

   On a crewmember's command, open the log and send a "nosebleed" note to the flight surgeon and the CMO; it becomes an URGENT alert on any red flag. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within <set by validation> seconds is repeated and sent to the next named crewmember.

   Done when: Note or alert acknowledged, or escalated.

   V2 10174V1 6003V1 3006

2. S2RobotRung 2

   Bring gauze, wipes, sealed waste bags, gloves and eye protection for helpers from the medical kit, and restrain them within reach. This is an emergency fetch on a human command (CMO or crewmember): 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 or crewmember 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".

   Done when: Supplies restrained within reach; override logged.

   Limit: <set by validation>

   V2 7046V2 9053

3. S3RobotRung 2

   Ask the red-flag questions by voice and log answers word for word. D1 is checked after every answer.

   Done when: Answers logged, or "no response" logged.

   D1DecisionRobot decides

   Checked after every answer and at any point in the run (even mid-question or mid-step): does any answer, reading or observation meet a red flag?

   • Yes → Stop the current question or step at once and apply the action listed for each matching red flag (URGENT alert, flag, or stop), with the answer or reading itself, never a cause. Every URGENT alert goes to the CMO and the flight surgeon at the same time (queued for the flight surgeon if the link is down). If the CMO is the patient, is busy treating, or does not answer, the alert goes to the second trained CMO, or the crewmember named before flight [V1 3006]. An URGENT alert that is not acknowledged within <set by validation> seconds is repeated and sent to the next named crewmember.
   • No → Continue.
   D2DecisionRobot decides

   Did the crewmember answer the question?

   • Yes → Continue.
   • Declined explicitly (the crewmember says no to a question) → Log "declined" for that question only; the alert already sent stands.
   • No response, or the answer does not make sense → URGENT: log "no response" (never "declined"); the CMO, or the second trained CMO if the CMO is the patient, checks the crewmember in person at once.
4. S4Crew

   The crewmember or CMO applies firm pressure as the onboard checklist describes, and the CMO decides any further care (packing, medicines) with the flight surgeon.

   Done when: Pressure started by humans.

   V1 3004

5. S5RobotRung 2

   Announce the elapsed pressure time aloud from the start time the crew give; at the set time (<set by clinical lead> minutes (shared parameter NOSEBLEED_PRESSURE_MINUTES, the same value in RMP-ENT-001 RF1 and RMP-ENT-004 RF7)), ask whether the bleeding has stopped and log the answer. The robot never decides when to stop, and only the crew or CMO end the pressure.

   Done when: Time and answer logged.

   D3DecisionRobot decides

   At the set time, does the crewmember or CMO say the bleeding has stopped?

   • Yes → Log it; continue to S6.
   • No → URGENT alert (RF1); the CMO decides further care.
   • No response → URGENT: log "no response"; a crewmember checks in person.
6. S6RobotRung 2

   Take only sealed bags of used gauze and wipes, label and stow them, and clean its surfaces (RMP-INF-002). It never holds an open bag near the crewmember's face.

   Done when: Sealed waste stowed; cleaning logged.

   V2 7102

7. S7RobotRung 2

   After any URGENT alert: After an URGENT alert the robot does not leave on its own: it stays at its rest position in the module, with its screen and voice link available, until a human has taken over or tells it to go. It never follows, blocks or touches anyone. It keeps time-stamping what humans say they did, and repeats the alert if it is not acknowledged.

   Done when: Robot at rest in the module until a human releases it; alert acknowledged or escalated.

   V2 10173V1 3006

8. S8Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides further care, medicines, follow-up and any evacuation [V1 3007]. The robot logs the decisions.

   Done when: Decision logged.

   V1 3007

   D4DecisionGround decides

   What is the plan?

   • Link live → Flight surgeon decides; robot logs.
   • Link down or delay too long → The CMO decides under the pre-approved onboard checklist; the flight surgeon reviews the log at the next contact.
9. S9RobotRung 2

   Offer a check-in every <set by flight surgeon> hours for <set by flight surgeon> days (the period the flight surgeon sets). At each scheduled time the robot prompts the crewmember on their own screen; it approaches only when the crewmember (or the CMO) accepts, and a prompt never starts the robot. Bleeding that starts again is logged and goes to D1.

   Done when: Each prompt accepted, postponed or answered; log closed by a human.

   V2 10174

10. S10RobotRung 2

    Send the flight surgeon one package: times, answers, CMO entries, bleeding risks shown, alerts and decisions. When the CMO says the event is over, run RMP-PHARM-001 reconciliation on each kit fetched: record the items the CMO or crew state were used, the remaining contents against the kit list, seal status and expiry, labelled "inventory reconciliation after emergency use – not a check before use". Flag the override to the flight surgeon and the pharmacy lead, and show each kit as "opened – not restocked" until a human restocks and reseals it.

    Done when: Package delivered or queued; kit reconciled or shown as opened – not restocked.

    V1 6003V1 7001V1 7003V2 7059

7 · Stop and escalate rules, red flags

Red flags

The robot reports the sign or value only, never what it means. Numeric thresholds are placeholders for the clinical lead.

8 · Safety limits

9 · Logs and audit

• LOG-1 Every input, robot action, decision (with who made it) and hand-off, time-stamped to the second.V2 10163V2 10164
• LOG-2 Mode changes and safety-limit events are announced to the operator as they happen and logged.V2 10162V2 10172
• LOG-3 Records are stored and sent as private medical data, encrypted, with access limited to the medical team.V1 6003V1 7003
• LOG-4 Results are kept in a permanent, retrievable format so the flight surgeon can see trends.V1 7001
• LOG-5 Pressure start and stop times as stated, answers, CMO entries and each sealed waste bag stowed.
• LOG-6 Each URGENT alert, who received it, the time it was acknowledged (or the escalation to the next named crewmember), and the time a human released the robot.V2 10163
• LOG-7 Each emergency fetch as an override (time, who asked, reason as stated, kit ID, seal status) and the later inventory reconciliation, labelled "not a check before use".V2 7059

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [7] and Volume 2 Revision F [8]. NASA-STD-3001 binds NASA programs; it is not a regulation for commercial flights. Its robot rules are general automation requirements, not medical-device rules.

11 · Validation

1. Simulation. Scripted nosebleeds with every red flag, bleeding that does not stop, no response, a CMO who is the patient, and lost link. Pass: Every red flag acts as listed; zero face contact; zero spray, medicine or position advice; unacknowledged alerts escalate.
2. Training model. CMO training on a bleeding-nose task trainer with the robot fetching supplies and timing. Pass: Supplies delivered within <set by validation> seconds; timing accurate.
3. Parabolic or station demonstration. Fetching supplies and collecting sealed bags in weightlessness, with simulated droplets and no patient. Pass: Zero escapes of test fluid; sealed waste only.
4. Flight use under flight surgeon supervision. First use as a fetching and timing aid. Pass: No safety events; the record is complete.

No stage has been run. Pass and fail criteria must be fixed in advance by the clinical lead and safety board.

12 · Human sign-off

Before any use

• Clinical lead for the specialty (sets every clinical threshold marked <set by clinical lead>)
• Flight surgeon, as medical authority
• Robotics and medical-device safety board
• Program approval for the mission

Each run

Started by a crewmember. The flight surgeon receives every nosebleed note; red flags go to the CMO and flight surgeon at once; the CMO does any procedure.

Restart after a stop

Human only. After any emergency or protective stop, a crewmember must restart the robot; the robot never restarts itself.

None of these sign-offs has happened. This is a Draft v0.4.

13 · Change control for learning

• Every change gets a new version number and a written reason; earlier versions are kept.
• Any change to steps, thresholds, limits or software that touches the patient repeats validation from the simulation stage before use.
• Software and learned-skill updates follow a pre-agreed change plan (what may change, how it is tested, how to roll back), modeled on the FDA predetermined change control plan approach.
• If a new version misbehaves, the robot rolls back to the last validated version and the event is reviewed by the flight surgeon and safety board.
• The robot never changes its own protocol, thresholds or limits.

Change-plan model: FDA guidance [10].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon receives the note at once and can join by voice and video.

Loss of signal

• Only the robot pauses; crew care never waits for the link or the robot.
• The robot pauses any movement and tells the CMO; on the CMO's confirmation it keeps timing and logging offline.
• Alerts go to the CMO (or the second trained CMO); the CMO decides under the pre-approved onboard checklist.
• At the next contact the robot sends one package: times, answers, entries and alerts.

Mars-class delay

• Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks; the pressure time and alert levels are set before flight and the CMO acts on them.

[9]

Sources

1. Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1 Suppl):S1-S38. PMID 31910111. doi:10.1177/0194599819890327 Supports: At first contact, distinguish the patient with a nosebleed who needs prompt management; treat active bleeding with firm sustained compression to the lower third of the nose for 5 minutes or longer; use nasal packing when bleeding continues despite compression (resorbable packing with a suspected bleeding disorder or anticoagulant or antiplatelet medicines); document factors that increase bleeding, including bleeding disorders, anticoagulant or antiplatelet medicines and intranasal drug use; nasal endoscopy for recurrent bleeding despite treatment, or recurrent one-sided bleeding; educate patients about signs that warrant prompt reassessment.
2. NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to In-Flight Medical Conditions (2017). humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf Supports: Table 2: 6 nosebleeds (space adaptation) among US astronauts (Shuttle, Mir and ISS through 2006); Table 1: 2 nosebleeds on the ISS through Expedition 40.
3. Khanna R, Li Y, Cook M, et al. Surgery for interplanetary space missions. Br J Surg. 2026;113(3):znag005. PMID 41823369. doi:10.1093/bjs/znag005 Supports: In weightlessness blood tends to stay at the wound (surface tension makes it dome), though arterial bleeding can form a stream of droplets, so fluid containment must be planned for.
4. National Institute for Health and Care Excellence. Head injury: assessment and early management. NICE guideline NG232 (May 18, 2023). www.nice.org.uk/guidance/ng232/chapter/Recommendations Supports: Recommendation 1.2.4: community services should refer to an emergency department anyone with a head injury and any of: a Glasgow Coma Scale score below 15 on initial assessment; any loss of consciousness; any focal neurological deficit; suspected complex skull fracture or penetrating head injury; amnesia for events before or after the injury; persistent headache; any vomiting since the injury; any seizure; previous brain surgery; a high-energy head injury; a bleeding or clotting disorder; current anticoagulant or antiplatelet treatment (except aspirin alone); intoxication; or continuing concern about the diagnosis. Signs of basal skull fracture include blood behind the eardrum, "panda" eyes, cerebrospinal fluid leaking from the ear or nose and Battle's sign (1.5.8). With a suspected neck injury, paraesthesia in the arms or legs or a focal peripheral deficit is a high-risk factor (1.6.2). CT is the primary investigation, and people who need CT where none is available are transferred (1.5.1, 1.5.5). CT within 1 hour for a GCS score of 12 or less on initial assessment, below 15 at 2 hours after the injury, a suspected open or depressed skull fracture, any sign of basal skull fracture, a post-traumatic seizure, a focal neurological deficit, or more than 1 episode of vomiting (1.5.8); CT within 8 hours after loss of consciousness or amnesia with a bleeding or clotting disorder or a dangerous mechanism (1.5.9); consider CT for anticoagulant or antiplatelet treatment other than aspirin alone (1.5.13). Only assume a depressed conscious level is due to intoxication after an important brain injury has been excluded (1.4.2). Consider referral for irritability or altered behaviour (1.2.5). Signs of deterioration include agitation or abnormal behaviour, a drop in GCS, severe or increasing headache, persistent vomiting, and new neurological signs (1.9.13); a second competent person confirms deterioration if possible, otherwise the supervising doctor is contacted without waiting (1.9.14). With a suspected neck injury, an axial load to the head is a high-risk factor (1.6.2).
5. Institute for Safe Medication Practices. Guidelines for the safe use of automated dispensing cabinets (2019). www.ismp.org/system/files/resources/2019-11/ISMP170-ADC%20Gu… Supports: Override is limited to medicines needed in emergent circumstances where waiting could harm the patient (3.3b); limit what is available on override (3.4b); require documentation of the override rationale (3.4d); routinely analyze override reports (3.6). Used for the emergency-fetch pattern by analogy (a robot fetching a sealed kit is not a dispensing cabinet).
6. NASA OCHMO. Medical Operations. Technical Brief OCHMO-TB-044 (2025). www.nasa.gov/wp-content/uploads/2025/08/ochmo-tb-044-medical… Supports: The crew surgeon keeps medical authority when care is delegated; crew medical officers train on the JSC 48522 medical checklist.
7. NASA. NASA-STD-3001, Space Flight Human-System Standard, Volume 1: Crew Health, Revision C (2023). www.nasa.gov/wp-content/uploads/2023/11/nasa-std-3001-vol-1-… Supports: NASA-STD-3001 Vol 1 Rev C: V1 3004 item o requires the capability to diagnose and treat pressure-related illness or injury (dysbarism); cited for the pressure-change red flag (RF5).
8. NASA. NASA-STD-3001, Volume 2: Human Factors, Habitability, and Environmental Health (Rev F, 2026), including Section 10.6 Automated and Robotic Systems. standards.nasa.gov/standard/NASA/NASA-STD-3001_VOL_2 Supports: Requirement IDs beginning V2.
9. NASA. Mars communications disruption and delay (fact sheet, 2023 Moon to Mars Architecture Concept Review). www.nasa.gov/wp-content/uploads/2024/01/mars-communications-… Supports: One-way Earth-Mars delay up to about 21-23 minutes, plus blackouts of about 2-3 weeks near solar conjunction.
10. U.S. Food and Drug Administration. Marketing submission recommendations for a predetermined change control plan for artificial intelligence-enabled device software functions (guidance). www.fda.gov/regulatory-information/search-fda-guidance-docum… Supports: A model for planning, validating and rolling back software updates.
11. U.S. Code of Federal Regulations, Title 14, Part 460: Human space flight requirements. www.ecfr.gov/current/title-14/chapter-III/subchapter-C/part-… Supports: Federal rules for crew and spaceflight participants on licensed commercial flights; they set no medical standards for spaceflight participants.

Checked on 2026-10-20: links opened (HTTP 200 or publisher redirect), DOIs and PubMed IDs matched, NASA documents read in full text. The framework comes from Part 1.