# RMP-MSK-003 Musculoskeletal ultrasound assist with a crew-held probe (diagnostic only) # 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 9 review: 16 required corrections, R1 to R17 with R10 dropped, of which R17 applies to RMP-PHARM-002; 20 optional suggestions); all required corrections that apply to this protocol 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-MSK-003 slug: rmp-msk-003 title: Musculoskeletal ultrasound assist with a crew-held probe (diagnostic only) category: msk tier: 2 rung_note: >- Max rung 2 for supervised fetching of the ultrasound kit, holding the display and reference card, and labelling and relaying clips, as in RMP-GI-001. The CMO holds the probe and the crew hold the limb: "Contact with the crewmember: not allowed". result_language: use: - non-diagnostic - images acquired, for human review - image not obtained - sent to flight surgeon - pain score as stated - as stated by the crewmember never: - normal - no problem found - all clear - negative - any diagnosis or cause - looks fine - nothing seen - verified - no abnormality - clear - fracture - no fracture - broken - not broken - tear - torn - no tear - intact - sprain - just a strain - safe - mild - minor - dislocated - dislocation - effusion - fluid - good images - adequate scope: summary: >- When the flight surgeon or CMO wants an ultrasound of a joint, muscle or tendon (for example after a shoulder, knee or ankle injury), the robot brings the ultrasound kit by a checked kit fetch, holds the display and the probe reference card where the CMO can see them, relays live images and voice to the ground imaging expert when the link allows, and labels and stores each clip with the body site and view the CMO names and the clock time. The CMO holds the probe and the crew hold the limb steady. Every image is "non-diagnostic, for human review". why: >- On ISS Expedition 9, non-physician crewmembers guided from the ground completed a shoulder ultrasound examination of diagnostic quality in about 15 minutes (Fincke 2005), building on remote-guided abdominal ultrasound on the ISS (Sargsyan 2005). NASA's in-flight medical conditions evidence report describes the ADUM (Advanced Diagnostic Ultrasound in Microgravity) project, which guides "minimally trained crewmembers" by remote guidance and just-in-time instruction. Here ultrasound is diagnostic only: it never delays splinting (RMP-MSK-002), trauma care (RMP-MSK-001) or the call to the flight surgeon, and an onboard CMO is not an experienced operator, so images are for remote expert review only and never rule a fracture or tear out. Which sites and views are scanned is set by the onboard checklist or the ground expert (design judgment). covers: - >- Joint, muscle and tendon ultrasound with a crew-held probe, in flight or on a planetary surface, with ground remote guidance or store-and-forward - 'Suspected fracture or sprain: RMP-MSK-002; major trauma: RMP-MSK-001; back or neck pain: RMP-MSK-004' - Probe cleaning under RMP-INF-002 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) - Holding, moving or pressing the probe, or touching or holding the limb - Reading or measuring an image, or saying what an image shows or does not show - Splinting, moving or straightening a limb - Clearing a crewmember for exercise or duty - >- Scanning over an open wound or broken skin, unless the flight surgeon directs it with a sterile cover related: - RMP-MSK-002 - RMP-MSK-001 - RMP-MSK-004 - RMP-GI-001 - RMP-INF-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' robot_may: - Bring the ultrasound kit by a checked kit fetch (or an emergency fetch) - Hold the display and the probe reference card where the CMO can see them - Relay live images and voice to the ground imaging expert when the link allows - Label and store each clip with the site and view the CMO names and the clock time - Log stated answers word for word robot_may_not: - Hold, move or press the probe, or touch the crewmember - Read, measure or describe an image - Say what is wrong, or that nothing is wrong - Suggest a medicine - 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: The CMO or the flight surgeon asked for a musculoskeletal ultrasound by command. 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: >- The crewmember agrees to the scan, images and video; the CMO confirms. Images go only to the flight surgeon and the ground imaging expert the flight surgeon names. emergency: If the crewmember cannot agree, the scan waits; care under RMP-MSK-001 or RMP-MSK-002 goes on. withdrawal: The crewmember can stop the scan, images or video at any time; the record stands. inputs: - id: IN-1 name: The body site, side and views to scan, as the CMO or ground expert names them source: CMO / ground imaging expert required: true if_missing: The robot shows the onboard scan checklist; the CMO decides. - id: IN-2 name: How the injury happened, where it hurts and a pain score 0-10, as stated source: Crewmember required: false if_missing: Log "no response"; D3 applies. - id: IN-3 name: Ultrasound clips, each with the site and view the CMO names source: Ultrasound unit required: false if_missing: Log "image not obtained" (never a reassuring value) and continue. - id: IN-4 name: Link status and delay source: Communications system required: true if_missing: Treat as link down; store and forward. steps: - id: S1 actor: robot rung: 2 action: >- Send a "musculoskeletal ultrasound requested" notice to the flight surgeon and the CMO (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 seconds is repeated and sent to the next named crewmember. success: Notice acknowledged, or escalated. refs: - V2 10174 - V1 6003 - V1 3006 - id: S2 actor: robot rung: 2 action: >- On the CMO's command, run a checked kit fetch of the ultrasound medical kit (unit, sealed gel and probe-cover pack): 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". success: Kit within reach after a matched ID and seal, or quarantined, or emergency fetch logged. limit: refs: - V2 7046 - V2 7059 - id: S3 actor: crew action: >- The CMO examines the limb first, including feeling, colour and warmth below the injury; the crew hold the limb steady in the position the CMO chooses, and splinting under RMP-MSK-002 is never delayed for the scan. success: Human-led care; robot logs what is stated. refs: - V1 3004 - V2 7046 - id: S4 actor: robot rung: 2 action: >- Hold the ultrasound display and the probe reference card where the CMO can see them, no closer than the set display distance, and relay live images and voice to the ground imaging expert when the link allows. When the link is down, show the onboard scan checklist and store the clips for forwarding. success: Display and card in view; relay running or clips stored. limit: refs: - V2 7045 - id: S5 actor: crew action: >- The CMO holds the probe and scans the sites and views that the onboard checklist or the ground expert names; the crewmember can stop at any time. The probe and gel are never placed on an open wound or broken skin unless the flight surgeon directs it with a sterile cover. success: Scan done, stopped, or not possible. refs: - V1 3004 - id: S6 actor: robot rung: 2 action: >- Label and store each clip with the site, side and view the CMO names and the clock time, mark every clip "non-diagnostic, for human review", and log stated answers and pain scores word for word. A device image-quality prompt is passed on to the CMO as displayed; the robot never judges an image. success: Clips labelled; gaps logged as "image not obtained". refs: - V1 7001 - id: S7 actor: crew action: >- After the scan, the crew clean the probe and any shared surface under RMP-INF-002; a probe on intact skin is noncritical equipment, and a probe cover never allows a lower level of cleaning. A probe that touched broken skin is semicritical equipment: the crew tag it "not for use" under RMP-INF-002 until it has had high-level disinfection. success: Cleaning recorded as stated under RMP-INF-002. refs: - V2 7046 - id: S8 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: S9 actor: ground action: >- The flight surgeon with the ground imaging expert (or the CMO under the onboard checklist when there is no link) reviews the images and decides on care, activity limits, repeat scans and any evacuation [V1 3007]. success: Decision logged. refs: - V1 3007 - id: S10 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: S11 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; kit shown as opened – not restocked until resealed. refs: - V2 7059 - id: S12 actor: robot rung: 2 action: >- Send the flight surgeon one package: stated answers, pain scores, labelled clips, times and decisions; images go only to the people the flight surgeon names. success: Package delivered or queued. refs: - V1 6003 - V1 7001 - V1 7003 decisions: - id: D1 after: S2 decided_by: robot question: Which kit fetch was it, and what did the checked kit fetch show? branches: - if: EMERGENCY FETCH (an URGENT red flag had fired, or a crewmember or the CMO stated an emergency) then: >- Hand-over already done as an emergency fetch, logged as an override; reconciled afterwards (not a check before use). - if: KIT ID AND SEAL MATCH then: >- Hand the kit over closed; log "KIT ID AND SEAL MATCH. Not a check of the contents." and the clock time. - if: MISMATCH, seal not intact or CANNOT VERIFY then: >- Shown with the reason. No hand-over under this protocol: the kit stays sealed 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 kit go to the CMO, logged there as an override with the reason, and flagged to the flight surgeon. If the need becomes an emergency, a crewmember or the CMO states it and the emergency fetch applies. handoff: none - id: D2 after: S6 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: S6 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: S9 decided_by: ground question: What is the plan (care, activity limits, repeat scan, 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: S10 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: >- Only the robot pauses: before it holds, it moves to a position clear of a hatch route or a crewmember's route (it never pauses in one), and tells the CMO. This pauses robot movement only: crew splinting, holding the limb and all crew care 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; it resumes only on the CMO's confirmation. 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 crew need the robot's space action: >- Robot moves clear at once without contact and holds; it never pauses in a hatch route; it does not leave the module on its own. level: safe-state refs: - V2 10172 - id: X10 trigger: The crewmember says the probe makes the pain worse, or asks to stop the scan action: >- Robot stops relaying scan prompts and keeps the record; the CMO decides whether to continue. Pain getting worse is a red flag. level: stop red_flags: - id: RF1 sign: >- A limb that is numb, tingling, pale, blue or cold below the injury, as stated by the crewmember or the CMO threshold: any action: URGENT alert; see RMP-MSK-002 source: ng39 - id: RF2 sign: >- A visible deformity, a wound over the injury, or unable to bear weight or use the limb, as stated (design judgment; bone fragility after flight: OCHMO-MTB-013) threshold: any action: >- URGENT alert; see RMP-MSK-002 and RMP-MSK-001. A wound over the injury is treated as a possible open fracture: the RMP-MSK-002 open-fracture checklist applies (the RMP-SKIN-001 irrigation steps are not used unless the flight surgeon directs, NICE NG37 1.1.8), and no scan is done over the wound source: mtb013 - id: RF3 sign: Pain that is severe or getting worse, or swelling that is getting worse, as stated (design judgment) threshold: any action: URGENT alert; the CMO examines at once and the flight surgeon decides - id: RF4 sign: New back or neck pain, or numbness or weakness in the arms or legs, as stated threshold: any action: URGENT alert; the crewmember stays still; see RMP-MSK-004 source: johnston - id: RF5 sign: Injury from a high-energy impact, or more than one injury threshold: any action: URGENT alert; start RMP-MSK-001 source: ng39 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: Probe holding or movement by the robot value: not allowed enforced: No probe task is loaded; the robot holds only the display and reference card - id: L3 name: Robot speed near the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 - id: L4 name: Display distance from the crewmember value: enforced: Hard limit in the controller refs: - V2 10172 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: >- Stated answers, pain scores, each clip with its site, side, view, label and time, relay start and stop, 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 - id: LOG-9 text: >- Each checked kit fetch: time, who asked, kit ID, seal status and result (KIT ID AND SEAL MATCH, MISMATCH, seal not intact or CANNOT VERIFY), and any quarantine. refs: - V2 7059 requirements: - id: V1 3004 use: In-mission care includes imaging; the CMO scans and a human reviews every image. - 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 injuries with and without red flags, kit seal mismatch, image not obtained, CMO as patient, lost link. pass: Zero contact; no image described; red flags raised at once. - stage: training model what: CMO scans a limb phantom with the robot holding the display and relaying to a ground expert. pass: Every clip labelled; no robot wording about image content. - stage: parabolic or station demonstration what: Display hold and relay in weightlessness on a phantom. pass: Display distance limit held. - stage: flight use under flight surgeon supervision what: First use in drills and scheduled scans. 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 the CMO or the flight surgeon. The CMO holds the probe; a human reviews every image. 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 ground imaging expert can guide the CMO in real time when the link allows.' loss_of_signal: - >- Only the robot pauses non-essential motion, at a position clear of hatch routes and crew routes, and tells the CMO; it resumes offline only on the CMO's confirmation. - >- Crew splinting, holding the limb and all crew care continue under the onboard checklist and never wait for the link or the robot. - The CMO scans under the onboard checklist and the clips are stored for forwarding. mars_delay: - >- Mars: live remote guidance is not possible; the CMO uses the onboard scan checklist and the flight surgeon reviews the stored clips when they arrive. sources: - key: fincke2005 text: >- Fincke EM, Padalka G, Lee D, et al. Evaluation of shoulder integrity in space: first report of musculoskeletal US on the International Space Station. Radiology. 2005;234(2):319-322. url: https://doi.org/10.1148/radiol.2342041680 doi: 10.1148/radiol.2342041680 pmid: '15533948' supports: >- Abstract: on ISS Expedition 9, non-physician crewmembers, remotely guided from the ground, completed a musculoskeletal (shoulder) ultrasound examination of diagnostic quality in about 15 minutes. Abstract read Oct 21, 2026. - key: sargsyan2005 text: >- Sargsyan AE, Hamilton DR, Jones JA, et al. FAST at MACH 20: clinical ultrasound aboard the International Space Station. J Trauma. 2005;58(1):35-39. url: https://doi.org/10.1097/01.ta.0000145083.47032.78 doi: 10.1097/01.ta.0000145083.47032.78 pmid: '15674147' supports: >- An ISS crewmember with minimal sonography training was remotely guided from Mission Control through a FAST (focused assessment with sonography for trauma) examination of four abdominal windows in about 5.5 minutes, with a 2-second delay, private two-way audio and video downlink, and identical reference cards for crew and ground expert. Abstract read. - 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: >- NASA in-flight medical conditions evidence report: the ADUM (Advanced Diagnostic Ultrasound in Microgravity) project "uses remote guidance, telemedical interfaces, and just-in-time instruction techniques to guide minimally trained crewmembers in acquisition of adequate imaging". - key: mtb013 text: NASA OCHMO. Bone Loss. Medical Technical Brief OCHMO-MTB-013 Rev D (2026). url: https://www.nasa.gov/wp-content/uploads/2026/02/ochmo-mtb-013-bone-loss.pdf supports: >- Bones during and after spaceflight may not be as strong as before the mission, and "fracture may occur for activities otherwise unlikely to induce fracture prior to space missions". Saved copy read Oct 21, 2026. - key: ng37 text: >- National Institute for Health and Care Excellence. Fractures (complex): assessment and management. NICE guideline NG37 (2016, last updated 2022). url: https://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. - key: ng39 text: >- National Institute for Health and Care Excellence. Major trauma: assessment and initial management. NICE guideline NG39 (2016). url: https://www.nice.org.uk/guidance/ng39/chapter/Recommendations supports: >- Injury pathway (NICE major trauma guideline); signs of poor circulation or deformity go to RMP-MSK-002 and RMP-MSK-001. - key: johnston text: >- Johnston SL, Campbell MR, Scheuring R, Feiveson AH. Risk of herniated nucleus pulposus among U.S. astronauts. Aviat Space Environ Med. 2010;81(6):566-574. url: https://doi.org/10.3357/asem.2427.2010 doi: 10.3357/asem.2427.2010 pmid: '20540448' supports: >- In-flight back pain is presumably due to elongation of the spine; disc herniation was 4.3 times more common in US astronauts (321) than matched controls (983), relatively more often in the neck, with evidence that the risk is increased immediately after spaceflight. - key: cdcdis text: >- U.S. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities (2008): summary of recommendations. url: https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html supports: >- 3.b: at least high-level disinfection for semicritical equipment that touches mucous membranes or non-intact skin; 3.c: low-level disinfection for noncritical equipment that touches intact skin; 10.b: probe covers do not allow a lower category of disinfection. Read live (WebFetch, Oct 21, 2026; 3.b as quoted in RMP-INF-002). - 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 3004 (in-mission imaging), V1 3006, V1 3007, V1 6003, V1 7001, V1 7003. - 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 9 review) items: - >- Probe on broken skin: the probe and gel are never placed on an open wound or broken skin unless the flight surgeon directs it with a sterile cover; a probe that touched broken skin is semicritical and tagged "not for use" under RMP-INF-002 until it has had high-level disinfection (CDC 3.b) (R4). - >- Never-words added: "dislocated", "dislocation", "effusion", "fluid", "good images", "adequate" (S7, Q2). - >- RF2: a wound over the injury is treated as a possible open fracture; the RMP-MSK-002 open-fracture checklist applies (no RMP-SKIN-001 irrigation unless the flight surgeon directs, NICE NG37 1.1.8) and no scan is done over the wound (R5). - >- RF2 is now labelled design judgment, with OCHMO-MTB-013 cited only for bone fragility after flight (R6). - >- Batch 9 protocols now record the review as AI-assisted (Medical Research Assistant, Oct 21, 2026); no named human clinician.