RMP-MSK-002 Suspected fracture or sprain: splint supplies, video; the crew hold the limb steady

1 · Identity and scope

After a limb injury, the robot alerts the flight surgeon at once, brings the splint and immobilisation supplies by a checked kit fetch (or an emergency fetch when an URGENT red flag has fired or a human states an emergency), shows the onboard splinting checklist and a both-limbs neurovascular record form, logs the CMO's stated checks word for word, takes photos on the CMO's request, and streams video when the link allows. It never says fracture or sprain, never touches the limb and never applies a splint.

Why this protocol was chosen. Bone loss in long-duration flight raises the question of fracture risk on exploration missions (NASA in-flight medical conditions evidence report, bone fracture section), and surface operations add falls. On Earth, NICE guideline NG37 asks clinicians to record nerve and circulation checks (neurovascular status) for both limbs, and to consider splinting a suspected long-bone fracture of the leg before hospital; open fractures and heavy bleeding go to the major-trauma guideline (NG39). A record of what the CMO checked and when helps the flight surgeon decide without the robot judging the injury. Open question for review: whether a robot limb hold under ground control (rung 1) should ever be allowed, given the no-contact rule.

Autonomy: Max rung raised from 1 to 2 for supervised fetching of splint supplies, holding a display and video. The library outline had the robot hold the limb steady; this draft keeps the no-contact rule, so the crew hold the limb. A robot limb hold stays a research item.

Related: RMP-MSK-001 · RMP-MSK-003 · RMP-MSK-004 · RMP-SKIN-001 · RMP-PHARM-001

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

• 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

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.) [10]

3 · Preconditions and consent

• PRE-1 A crewmember or the CMO started the protocol by command after a limb injury.human_start == trueV2 10174
• PRE-2 Robot self-test passed; kit stowage locations known.V2 10161V2 7059
• PRE-3 Robot and supplies restrained when not moving.V2 7046
• PRE-4 Link status known. The crew never wait for the robot before acting.link_state in [live, delayed, down]

Consent

The crewmember agrees to photos and recording; the CMO confirms.

Emergency consent

If the crewmember cannot agree, the robot proceeds on the CMO's command.

Withdrawal

The crewmember can stop photos or video at any time; the alert and record stand.

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

   Send a "limb injury" alert to the flight surgeon and the CMO at once (URGENT if a red flag is already stated). 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: Alert acknowledged, or escalated.

   V2 10174V1 6003V1 3006

2. S2RobotRung 2

   On the CMO's command, run a checked kit fetch of the splint and immobilisation medical kit: check the kit ID and seal before hand-over, and quarantine a kit whose ID or seal does not match (no hand-over; the CMO is told). Any medicine goes only through RMP-PHARM-001. If an URGENT red flag has fired or a human states an emergency, bring it instead as an emergency fetch: 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".

   Done when: Kit within reach after a matched ID and seal, or quarantined, or emergency fetch logged.

   Limit: <set by validation>

   V2 7046V2 7059

   D1DecisionRobot decides

   What did the checked kit fetch show for the kit ID and seal?

   • Kit ID and seal match → Hand the kit to the CMO; log the check.
   • MISMATCH of kit ID or seal, or cannot read → Quarantine the kit with no hand-over; tell the CMO; the CMO may command an emergency fetch of another kit.No hand-over
3. S3RobotRung 2

   Show the onboard splinting checklist and the both-limbs neurovascular form on the robot's screen, held clear of the crewmember.

   Done when: Checklist and form on screen.

   V2 7045

4. S4Crew

   A crewmember holds the limb steady; the CMO checks both limbs and splints under the onboard checklist (Earth context: NICE NG37).

   Done when: Human-led care; robot logs what is stated.

   V1 3004

5. S5RobotRung 2

   Log each stated check, pain score and time word for word; take photos only when the CMO asks; stream video when the link allows unless the crewmember stops it. After the splint is on, show an on-screen prompt the crew accept every <set by flight surgeon> hours for a <set by flight surgeon>-hour watch, to re-ask the RF3 and RF7 questions (Earth context: NICE NG37 1.2.7); the robot never loosens or adjusts anything.

   Done when: Record complete or gaps logged as "not stated".

   V1 6003

   D2DecisionRobot 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.
   D3DecisionRobot decides

   Did the crewmember answer the last 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.
6. S6RobotRung 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

7. S7Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides on imaging (crew-held ultrasound, see RMP-MSK-003), splint checks, activity limits and any evacuation [V1 3007].

   Done when: Decision logged.

   V1 3007

   D4DecisionGround decides

   What is the plan (imaging, splint checks, activity, evacuation)?

   • 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.
8. S8RobotRung 2

   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.

   Done when: RMP-PHARM-001 run logged with its result, or none ordered.

   V2 7059

   D5DecisionRobot decides

   What did RMP-PHARM-001 show for the ordered item?

   • MATCH TO ORDER → 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.
   • MISMATCH or CANNOT VERIFY on any field, or a failed scan or recipient check → 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.No hand-over
9. S9RobotRung 2

   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: Reconciliation recorded; kit shown as opened – not restocked until resealed.

   V2 7059

10. S10RobotRung 2

    Send the flight surgeon one package: stated checks for both limbs, pain scores, photos, times and decisions.

    Done when: Package delivered or queued.

    V1 6003V1 7001V1 7003

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 Stated both-limbs checks, pain scores, photos, splint time as stated, and decisions, with clock times.
• 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
• LOG-8 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.V2 7059

10 · Links to NASA-STD-3001

IDs as published in Volume 1 Revision C [5] and Volume 2 Revision F [6]. 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 sprain-like and deformity cases, numb limb, kit seal mismatch, CMO as patient, lost link. Pass: Zero contact; seal mismatch quarantined; no injury named.
2. Training model. CMO splint drills with the robot fetching supplies and recording. Pass: Both-limbs form complete or gaps marked.
3. Parabolic or station demonstration. Kit fetch and checklist display in weightlessness without a patient. Pass: Kit closed and restrained.
4. Flight use under flight surgeon supervision. First use in drills. Pass: No safety events.

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 or the CMO. The crew hold and splint the limb.

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 v0.3.

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 [9].

Loss of signal and Mars delay

Live link

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 holding and splinting the limb and bleeding control continue under the onboard checklist and never wait for the link or the robot.

Mars-class delay

• Splinting cannot wait for the ground; the onboard checklist and two trained CMOs lead.

[8]

Sources

1. National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37 (2016, last updated 2022). www.nice.org.uk/guidance/ng37/chapter/Recommendations Supports: 1.1.8 Do not irrigate open fractures of the long bones, hindfoot or midfoot in pre-hospital settings; 1.1.9 consider a saline-soaked dressing covered with an occlusive layer; 1.1.10 consider prophylactic intravenous antibiotics as soon as possible (Earth pre-hospital context; any antibiotic is a flight-surgeon order). 1.1.11 Consider pre-hospital splinting of suspected long-bone fractures of the leg. 1.2.7 In tibial fractures, maintain awareness of compartment syndrome for 48 hours after injury. 1.3.7 When assessing neurovascular status in a limb injury, document for both limbs which nerves and functions were tested and the findings. The robot never says fracture or sprain and never splints.
2. National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline NG39 (2016). www.nice.org.uk/guidance/ng39/chapter/Recommendations Supports: 1.8.1 Assess catastrophic haemorrhage, airway with in-line spinal immobilisation, breathing, circulation, disability (neurological), exposure and environment (<C>ABCDE); 1.8.2 record whether the patient is improving or deteriorating. 1.5.1 Use simple dressings with direct pressure to control external haemorrhage; tourniquets when direct pressure fails (1.5.2). 1.5.3 Pelvic binder if active bleeding from a pelvic fracture is suspected after blunt high-energy trauma. The robot never applies pressure, a tourniquet or a binder.
3. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management. NICE guideline NG41 (2016). www.nice.org.uk/guidance/ng41/chapter/Recommendations Supports: 1.1.1 On arrival, use a prioritising sequence to assess people with suspected trauma, for example <C>ABCDE, including airway with in-line spinal immobilisation; 1.1.2 protect the cervical spine with manual in-line spinal immobilisation. Earth context for the CMO's onboard spinal-precautions checklist; the robot never coaches neck or spine handling.
4. 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). humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf Supports: Bone fracture risk on exploration missions is assessed by model because observable fracture events in flight are rare; ultrasound has been proposed to help bone healing (research).
5. 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, V1 3006, V1 3007.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.