# RMP-MSK-004 Back pain in flight: symptom tracking with red-flag escalation (no drug, position or exercise advice) # Version 0.4 (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: '0.4' 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: '2026-10-20' reviewed: '2026-10-20' human_clinician_review: false text: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 20, 2026 (batch 2 review, 51 corrections); all corrections are applied in this version. No named human clinician has reviewed it. 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-004 slug: rmp-msk-004 title: >- Back pain in flight: symptom tracking with red-flag escalation (no drug, position or exercise advice) category: msk tier: 2 result_language: use: - logged, not interpreted - sent to flight surgeon - 'red-flag answer: URGENT' never: - normal - no problem found - all clear - negative - any diagnosis or cause - just space back pain - not serious - no nerve problem - safe scope: summary: >- When a crewmember reports back or neck pain in flight, the robot runs structured check-ins: red-flag questions first (bladder, saddle-area feeling, bowel, both legs, arms and hands with neck pain, sudden tearing pain, fever, injury), then pain rating, where it is, where it spreads and what changes it. It logs the answers word for word and sends them to the flight surgeon; any red-flag answer goes to the CMO and flight surgeon at once. It can show a care plan a human has already entered, word for word, but gives no drug, position or exercise advice and never touches the back. why: >- In a NASA records review, 52% of astronauts (382 of 728) had space adaptation back pain, mostly mild (86%), usually in the first days of flight; it is thought to come from the spine straightening and lengthening without gravity. Because it is so common, the rare serious causes can be missed. Disc herniation was 4.3 times more common in US astronauts than in matched controls, relatively more often in the neck, with evidence that the risk is increased immediately after flight (the study looked at diagnoses after flight, not during it). On Earth, suspected cauda equina syndrome (pressure on the nerve roots at the base of the spine) needs emergency assessment, and no single symptom rules it in or out. Neck disc problems can press on the spinal cord, and sudden tearing back pain can be an aortic emergency, so both are asked about too. Asking the same red-flag questions every time makes a missed warning sign less likely. covers: - Back or neck pain that starts in flight, in a crewmember who is awake and answering - Repeat check-ins until the flight surgeon closes the log locked_out: - Naming the cause, or saying it is "just" space adaptation back pain - Any drug advice, including pain relief - >- Suggesting positions, stretches, exercise or exercise-device changes (the CMO and flight surgeon decide; the robot only shows a plan a human has already entered) - Touching, massaging or pressing on the back - Testing strength, reflexes or feeling (the CMO does any examination) - Back pain after a fall, impact or crush (RMP-MSK-001 or RMP-MSK-002) - Back pain after landing (the flight surgeon and recovery team; see RMP-EGR-003) related: - RMP-MSK-001 - RMP-MSK-002 - RMP-RENAL-001 - RMP-RENAL-002 - RMP-INF-001 - RMP-CARD-002 - RMP-EGR-003 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 pain: answers check-ins, can skip any question and can stop at any time' - 'Flight surgeon: reviews the log and sets the care plan' robot_may: - Ask the red-flag questions first, then the pain questions, by voice or touch screen - Log answers word for word and send them to the flight surgeon - Alert the CMO and flight surgeon at once on a red-flag answer - Show, on request, the care plan the CMO or flight surgeon has entered, word for word - Remind the crewmember when a check-in is due robot_may_not: - Diagnose, or say the pain is not serious - Give drug, position, stretching or exercise advice - Touch the crewmember - Show any plan that a human has not entered and signed - 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 (the one with pain, or the CMO) started the log by command. check: human_start == true refs: - V2 10174 - id: PRE-2 text: >- The crewmember is awake and answering; no fall, impact or crush injury (if there was, use RMP-MSK-001 or RMP-MSK-002). check: crew_responsive == true and injury == false - id: PRE-3 text: Robot self-test passed. refs: - V2 10161 - id: PRE-4 text: Link status and current delay known. consent: standard: >- The crewmember agrees by voice or touch; any question can be skipped. Questions about bladder, bowel and sexual function are asked privately, and the crewmember chooses who is present. emergency: >- Not applicable; the robot does not continue without the crewmember's answers. If the crewmember cannot answer, it calls the CMO. withdrawal: The crewmember can stop at any time; the robot logs where it stopped. inputs: - id: IN-1 name: >- Red-flag answers: trouble starting to pass urine or reduced feeling of urine flow; numbness between the legs (saddle area); loss of the feeling of needing to open the bowels, or loss of bowel control; weakness or numbness in both legs; pain down both legs; with neck pain, new weakness, numbness or tingling in an arm or hand, clumsy hands, or new trouble with balance or walking; new pain below the knee, or numbness or weakness, in one leg; sudden severe tearing or ripping back pain, or back pain with chest or belly pain, fainting or breathlessness; fever; any fall or impact source: Crewmember, by voice or touch screen required: true if_missing: Ask the CMO to ask in person; never treated as "no". - id: IN-2 name: New sexual dysfunction (asked privately; optional) source: Crewmember required: false if_missing: Log "skipped". - id: IN-3 name: Pain rating (0-10), where it is (back, neck, one side or flank) and where it spreads source: Crewmember required: true if_missing: Log "not answered". - id: IN-4 name: When it started, and what makes it better or worse (as reported) source: Crewmember required: true if_missing: Log "not answered". - id: IN-5 name: Care plan entered by the CMO or flight surgeon source: Medical record required: false if_missing: Show "No care plan entered; ask the CMO." - id: IN-6 name: >- Medicines given, as logged by humans (shown to the CMO and flight surgeon; the robot does not advise) source: Medical record or dose log required: false if_missing: Note "no dose log available". - id: IN-7 name: Time since launch source: Mission clock required: true if_missing: Ask the CMO. - id: IN-8 name: Link status and delay source: Communications system required: true if_missing: Treat as link down. steps: - id: S1 actor: robot rung: 2 action: >- On a crewmember's command, open the log, tell the CMO, and send a "back pain log started" note to the flight surgeon (queued if the link is down). success: CMO acknowledges; note delivered or queued. refs: - V2 10174 - V1 6003 - id: S2 actor: robot rung: 2 action: >- Ask the red-flag questions first (privately for bladder, bowel and sexual function), and log the answers word for word. success: Each red-flag question answered or marked for the CMO to ask. - id: S3 actor: robot rung: 2 action: >- Ask the pain questions: rating, place, spread, timing, and what makes it better or worse. Log answers word for word. success: Answers logged. - id: S4 actor: robot rung: 2 action: >- On request, show the care plan the CMO or flight surgeon has entered for this crewmember, word for word, with who entered it and when. If there is none, say "No care plan entered; ask the CMO." success: Plan shown, or "no plan" shown. - id: S5 actor: robot rung: 2 action: Send the answers to the flight surgeon, or queue them and show the CMO the onboard checklist page. success: Delivered or queued. refs: - V1 6003 - V1 7003 - id: S6 actor: crew action: >- The CMO assesses in person when asked or on any red flag. Any medicine is ordered by a human and fetched through RMP-PHARM-001. success: CMO decision logged. - id: S7 actor: ground action: >- The flight surgeon (or the CMO under the onboard checklist when there is no link) sets the care plan and the check-in schedule; the robot logs them. success: Plan logged. - id: S8 actor: robot rung: 2 action: >- Offer a check-in every hours, red-flag questions first every time, until the flight surgeon closes the log. 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. success: Each prompt accepted, postponed or answered; log closed by a human. refs: - V2 10174 decisions: - id: D1 after: S2 decided_by: robot question: Is any red-flag answer "yes", or not answered? branches: - if: 'Yes' then: >- Stop the routine questions. Apply the action listed for each matching red flag (URGENT alert, stop, or private flag) with the answer itself; on any URGENT flag the CMO assesses in person. A normal CMO examination does not cancel a "yes" answer; the flight surgeon decides. The robot does not say what it means. - if: Not answered then: Ask the CMO to ask in person before the pain questions; never treated as "no". - if: All "no" then: Continue to S3. - id: D2 after: S5 decided_by: ground question: What is the plan? 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: D3 after: S8 decided_by: robot question: >- Is the pain rating rising, or is pain lasting beyond the time the flight surgeon set, or new after the first flight days? branches: - if: 'Yes' then: 'Flag to the flight surgeon and CMO: not assumed to be space adaptation back pain.' - if: 'No' then: Continue the schedule. stop_rules: - id: X1 trigger: The patient (or the crewmember being examined) says stop, or withdraws consent action: The robot stops the check-in at once and moves away; declining is logged, not questioned. 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; crew care never waits for the link or the robot. On loss of link the robot pauses any movement and tells the CMO. On the CMO's confirmation it continues check-ins and logging offline; everything is queued and sent to the flight surgeon at the next contact. level: pause refs: - V2 10172 - V2 10173 - id: X6 trigger: A red-flag answer at any check-in action: >- Robot stops the routine questions and applies the action listed for that red flag (D1); URGENT flags go to the CMO and flight surgeon at once. level: urgent - id: X7 trigger: >- Sudden, severe, tearing or ripping back pain, or back pain with chest or belly pain, fainting or breathlessness action: >- Robot stops the check-in and calls the CMO at once; URGENT alert to the flight surgeon; switch to RMP-CARD-002. level: urgent - id: X8 trigger: The crewmember asks the robot for drug, position or exercise advice action: >- Robot declines, shows the human-entered plan if there is one, and routes the question to the CMO or flight surgeon. level: stop red_flags: - id: RF1 sign: >- Trouble starting to pass urine, reduced feeling of urine flow, or not knowing when the bladder is full threshold: any, new action: >- URGENT alert to the CMO and flight surgeon (possible cauda equina syndrome; the flight surgeon may also start RMP-RENAL-002). Early-flight urinary retention is common and can mask, or look like, nerve compression; the robot never downgrades this flag because of time since launch. source: girftces - id: RF2 sign: Numbness or changed feeling between the legs, around the anus or genitals (saddle area) threshold: any, new action: URGENT alert source: girftces - id: RF3 sign: Loss of the feeling of needing to open the bowels, or loss of bowel control threshold: any, new action: URGENT alert source: girftces - id: RF4 sign: Severe or worsening weakness or numbness in both legs threshold: any action: URGENT alert source: girftces - id: RF5 sign: New sexual dysfunction (asked privately) threshold: any, new action: URGENT alert source: girftces - id: RF6 sign: Pain down both legs, or one-leg pain that spreads to both threshold: any action: URGENT alert (a warning sign for cauda equina syndrome) source: girftces - id: RF7 sign: Fever, or feeling very unwell, with back pain threshold: any action: URGENT alert; see RMP-INF-001 source: ng59 - id: RF8 sign: Back pain after a fall, impact or crush threshold: any action: Stop; CMO trauma care (RMP-MSK-001 or RMP-MSK-002) source: ng59 - id: RF9 sign: Pain in one side or the flank, with or without blood in the urine, nausea or vomiting threshold: any action: >- URGENT alert; the flight surgeon considers the kidney stone pathway (RMP-RENAL-001; the risk of stones is raised in flight). The robot gives no fluid advice. source: renal - id: RF10 sign: Pain rating threshold: or higher on a 0-10 scale, or rising across check-ins action: CMO assesses in person source: kerstman - id: RF11 sign: Pain lasting, or starting late threshold: beyond days after launch, or new after the first flight days action: Flag to the flight surgeon source: ng59 - id: RF12 sign: >- With neck pain: new weakness, numbness or tingling in an arm or hand, clumsy hands, or new trouble with balance or walking threshold: any, new action: URGENT alert; the CMO assesses in person source: johnston - id: RF13 sign: >- Sudden, severe, tearing or ripping back pain, or back pain with chest or belly pain, fainting or breathlessness threshold: any action: 'URGENT: CMO at once (possible aortic emergency); RMP-CARD-002' source: gulati - id: RF14 sign: New pain spreading below the knee in one leg, or new numbness or weakness in one leg threshold: any, new action: CMO assesses in person; flag to the flight surgeon (URGENT if RF4 or RF6 also applies) source: ng59 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: Robot speed near the crewmember value: enforced: Hard limit refs: - V2 10172 - id: L3 name: Showing a plan not entered and signed by the CMO or flight surgeon value: not allowed enforced: Only signed plans in the medical record can be displayed - id: L4 name: Check-in length value: enforced: Timer 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: >- Every red-flag answer, with the time it was asked and when the alert was acknowledged, so missed or late escalations can be audited. requirements: - id: V1 3003 use: Capability to monitor physiological well-being in flight. - id: V1 3004 use: >- In-mission care includes privacy considerations (private questions); administering and managing medications is a human capability. - id: V1 3006 use: Two crew medical officers per vehicle for NASA programs (see the commercial-flight note). - id: V1 3007 use: Evacuation for problems beyond onboard care; 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 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 check-ins with every red-flag answer, unanswered questions and rising pain, at station, Moon and Mars delays. pass: >- Every red-flag answer alerts within ; zero advice; zero plans shown that a human did not enter. - stage: Earth analog what: >- Analog crews (for example bed-rest or isolation studies) using the check-ins, reviewed by remote clinicians. pass: Clinicians judge the logs usable; crew rate the private questions acceptable. - stage: flight use under flight surgeon supervision what: Logging aid alongside private medical conferences in the first flight days. pass: No safety events; no red flag missed when compared with the conference notes. 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. The flight surgeon reviews the log at each private medical conference; red flags go to the CMO and flight surgeon at once. 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: red flags reach the flight surgeon within minutes; routine logs are reviewed at the private medical conference. 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 running check-ins and logging offline. - Red-flag answers go to the CMO at once; the CMO decides under the pre-approved onboard checklist. - 'At the next contact the robot sends one package: answers, alerts and decisions.' mars_delay: - >- Replies may take up to about 21-23 minutes each way, with blackouts of about 2-3 weeks, so the CMO acts on red flags onboard. - >- Red flags, the check-in schedule and the onboard plan for suspected nerve-root compression are set before flight. sources: - key: kerstman text: >- Kerstman EL, Scheuring RA, Barnes MG, DeKorse TB, Saile LG. Space adaptation back pain: a retrospective study. Aviat Space Environ Med. 2012;83(1):2-7. url: https://doi.org/10.3357/asem.2876.2012 doi: 10.3357/asem.2876.2012 pmid: '22272509' supports: >- Space adaptation back pain in 52% of astronauts (382/728); mild in 86%, moderate in 11%, severe in 3% of those affected; fetal positioning (91%) and analgesic medicines and exercise (85% each) were the most effective treatments; usually mild and self-limited, but moderate or severe pain that does not respond carries a risk of functional impairment and mission impact. - 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 (18 of 44 astronaut herniations, against 3 of 35 in controls), with evidence that the risk is increased immediately after spaceflight. Used here for the neck red flag; no guideline listing spinal-cord (myelopathy) red flags was verified for this draft, so that wording is a clinical judgment. - key: mtb004 text: >- NASA OCHMO. Space Adaptation Sickness (SAS) and Space Readaptation Syndrome. Medical Technical Brief OCHMO-MTB-004 Rev A (Sept 25, 2025). url: https://www.nasa.gov/wp-content/uploads/2025/09/ochmo-mtb-004-space-adaptation-sickness-sas.pdf supports: >- Space adaptation back pain occurs in 52% of space travelers in the first 2-5 days of flight; microgravity reduces the usual curve of the back, causing it to straighten. Urinary retention can occur in the first few days of flight. - key: girftces text: >- NHS England Getting It Right First Time (GIRFT). Spinal Surgery: National Suspected Cauda Equina Syndrome (CES) Pathway (February 2023). Also hosted by an NHS trust: https://www.gloshospitals.nhs.uk/media/documents/GIRFT_CES_Guidelines_2023_EJRRVj5.pdf (the copy that was read; the GIRFT-hosted copy could not be opened by automated retrieval). url: >- https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/02/National-Suspected-Cauda-Equina-Pathway-February-2023-FINAL-V1-1.pdf supports: >- Emergency referral for back or leg pain with recent onset of: difficulty starting to pass urine or impaired sensation of urine flow; altered perianal, perineal or genital (saddle) sensation; severe or progressive weakness of both legs; loss of the feeling of rectal fullness; or sexual dysfunction. Sudden pain down both legs, or one-leg pain that spreads to both, is a warning sign. No single symptom has good diagnostic accuracy, and negative physical tests do not rule out cauda equina syndrome if the symptoms are present; bladder scans should not be used in isolation or as a discriminator. - key: ng59 text: >- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59 (2016, last updated July 29, 2026). url: https://www.nice.org.uk/guidance/ng59/chapter/Recommendations supports: >- Think about alternative diagnoses, particularly with new or changed symptoms, and exclude specific causes of low back pain such as cancer, infection, trauma or inflammatory disease. - key: gulati text: >- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22):e368-e454. url: https://doi.org/10.1161/CIR.0000000000001029 doi: 10.1161/CIR.0000000000001029 pmid: '34709879' supports: >- Sudden onset of ripping chest pain (with radiation to the upper or lower back) is suspicious of an acute aortic syndrome. - key: renal text: 'NASA Human Research Program. Evidence Report: Risk of Renal Stone Formation (2024).' url: https://humanresearchroadmap.nasa.gov/evidence/other/2024%20Renal%20Evidence%20Report_Final.pdf supports: >- The increased risk of renal stone formation occurs rapidly during spaceflight and continues throughout the mission; stones can cause renal colic or severe flank pain, blood in the urine, infection or sepsis; there have been no symptomatic kidney stones in flight to date in US crewmembers on the ISS. - key: ermed text: >- NASA Human Research Program. Evidence Report: Risk of Adverse Health Outcomes and Decrements in Performance due to In-Flight Medical Conditions (2017). url: https://humanresearchroadmap.nasa.gov/evidence/reports/Medical.pdf supports: >- Table 2: 382 space adaptation back pain events among US astronauts (Shuttle, Mir and ISS through 2006); Table 1: 1.99 back pain events per person-year on the ISS. - 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: 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: Requirement IDs beginning V1. - 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: 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: '2026-10-20' version: '0.2' source: >- AI-assisted clinical and source review by the Medical Research Assistant, Oct 20, 2026 (batch 2 review) items: - >- Added RF12: with neck pain, new arm or hand weakness, numbness or tingling, clumsy hands, or new trouble with balance or walking (URGENT). Source: Johnston 2010 neck-disc data; no myelopathy guideline was verified (item 9). - >- Added RF13 and a stop rule: sudden severe tearing or ripping back pain, or back pain with chest or belly pain, fainting or breathlessness, as a possible aortic emergency (URGENT; RMP-CARD-002; Gulati 2021) (item 10). - >- D1: a normal CMO examination does not cancel a "yes" answer; added RF14 for new one-leg symptoms at "CMO assesses" level (item 11). - >- RF1: early-flight urinary retention can mask or look like nerve compression; never downgraded by time since launch (item 12). - >- RF9 now cites the NASA renal stone evidence report and says the risk of stones is raised in flight (not that stones are common) (item 13). - >- Johnston wording: risk increased immediately after flight; the study looked at diagnoses after flight (item 14). - >- The GIRFT cauda equina pathway is cited at its GIRFT address, with the NHS trust copy as a mirror (item 15). - >- Each red-flag decision now applies the action listed for each matching red flag (URGENT alert, stop, or private flag), not URGENT for everything (review item 47). - >- Repeat check-ins inside an open log are now on-screen prompts; the robot approaches only when the crewmember or CMO accepts, and a prompt never starts it (item 49, [V2 10174]). - >- Red flags that had no source now cite one where a source fits; the rest are shown as general clinical red flags with no source cited (item 50). - >- The "item that failed a check" lockout is kept and now notes that it applies when RMP-PHARM-001 is used (item 51). - NASA evidence reports are cited as "approved for public release" (item 48). - date: '2026-10-21' version: '0.3' source: Batch 7 editorial (AI-assisted), Oct 21, 2026 items: - >- 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: ermed, renal, v2). Editorial; no change to steps, thresholds or limits. - date: '2026-10-21' version: '0.4' source: Batch 7 review and batch 8 editorial (AI-assisted), Oct 21, 2026 items: - >- X5 and the comms loss-of-signal branch now open with "Only the robot pauses; crew care never waits for the link or the robot." (batch 7 review suggestion 29). Editorial; robot behaviour unchanged.