RMP-RESP-002 Choking or blocked airway: bring kit, steady the scene; airway care by crew

1 · Identity and scope

When a crewmember is choking or has a blocked airway, the robot sends an URGENT alert at once, brings the airway / emergency kit on command, clears space, records the clock times of back blows, abdominal thrusts and any transition to CPR as the CMO states them, and streams video when the link allows. The crew assess severity and give all airway care under the onboard checklist and Resuscitation Council UK adult choking algorithm as Earth context. The robot never strikes the back, thrusts the abdomen, sweeps the mouth or starts oxygen.

Why this protocol was chosen. NASA records list 3 choking or obstructed-airway events among US astronauts through 2006 (in-flight medical conditions evidence report). On Earth, the Resuscitation Council UK adult choking algorithm splits mild obstruction (effective cough: encourage cough) from severe obstruction (ineffective cough: 5 back blows then 5 abdominal thrusts if conscious; CPR if unconscious). A loose crown or tooth fragment can be inhaled (see RMP-ENT-002). A helper that alerts, fetches the sealed kit and keeps the scene clear lets the CMO act at once. Design judgment: Earth abdominal thrusts assume a stable torso. In weightlessness the onboard checklist should name a restrained method (for example a foot restraint or bracing against structure), or chest thrusts if the checklist prefers them; no public spaceflight choking algorithm was found. The robot does not choose or teach the method.

Autonomy: Max rung raised from 1 to 2 for supervised fetching and scene support. The robot never performs back blows, abdominal thrusts, finger sweeps or any airway procedure.

Related: RMP-CARD-001 · RMP-RESP-001 · RMP-RESP-003 · RMP-ENT-002 · RMP-PHARM-001 · RMP-NEURO-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: helps or takes over if the CMO is the patient
• Other crew: help restrain the patient as the CMO 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.) [14]

3 · Preconditions and consent

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

Consent

Emergency care; recording by the CMO's agreement when the patient cannot speak.

Emergency consent

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

Withdrawal

The CMO can stop video; 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

   On a crewmember's or the CMO's word, send an URGENT "choking / blocked airway" alert to the flight surgeon and the CMO at once. 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, bring the sealed airway or emergency kit to the CMO at once and restrain it within reach. This is an emergency fetch on a human command (CMO): no barcode check runs before hand-over and nothing waits for one. The robot reads the kit's own label and seal status only if that adds no delay, says "EMERGENCY FETCH – NOT VERIFIED (CMO command)", and "seal not intact" if so, and hands the kit over anyway. The fetch is logged as an override: time, who asked, the reason as stated, kit ID and seal status. It never says "verified".

   Done when: Kit within reach, or skipped; override logged.

   Limit: <set by validation>

   V2 7046

3. S3Crew

   The CMO assesses severity and treats under the onboard checklist, which names a restrained thrust method for weightlessness (design judgment). Checklist context for the CMO only (Earth RCUK adult choking algorithm): encourage cough if effective; back blows and abdominal thrusts if conscious with ineffective cough; CPR if unconscious. The robot never demonstrates, counts or coaches blows or thrusts, and stays clear.

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

   V1 3004

   D1DecisionCrew decides

   Has the crewmember become unresponsive?

   • Yes → Start RMP-CARD-001 at once; this protocol's record continues as context.
   • No → Continue airway care under the checklist.
4. S4RobotRung 2

   Clear loose items, hold clear of the CMO, stream video when the link allows unless the CMO stops it, and log each stated manoeuvre on a clock-time timeline.

   Done when: Space clear; times logged.

   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 CMO answer when asked for a stated time?

   • 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.
5. S5RobotRung 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

6. S6Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) decides ongoing airway care, imaging, and any evacuation [V1 3007].

   Done when: Decision logged.

   V1 3007

   D4DecisionGround decides

   What is the plan (airway care, observation, 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.
7. S7RobotRung 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

8. S8RobotRung 2

   Send the flight surgeon one package: alert times, stated manoeuvres, video pointer 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 Alert time, each stated manoeuvre time, video start/stop, kit reconciliation.
• 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 [9] and Volume 2 Revision F [10]. 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 mild and severe choking, unresponsive transition to CARD-001, missing kit, CMO as patient, lost link. Pass: Zero patient contact; every emergency fetch logged as an override; transition to CARD-001 works.
2. Training model. CMO drills with the robot fetching the airway kit. Pass: Kit within <set by validation> seconds; CMO never obstructed.
3. Parabolic or station demonstration. Kit fetch and restraint 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. Alerts go to the CMO and flight surgeon at once; the crew give airway care.

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 [13].

Loss of signal and Mars delay

Live link

Low Earth orbit: the flight surgeon receives the alert and video when the link allows.

Loss of signal

• The robot pauses non-essential motion and tells the CMO; recording continues offline on confirmation.
• Crew back blows, thrusts, CPR and oxygen continue under the onboard checklist and never wait for the link or the robot.
• The CMO treats under the onboard checklist; nothing waits for the link.

Mars-class delay

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

[12]

Sources

1. Resuscitation Council UK. Adult choking algorithm (2021). PDF fetched Oct 21, 2026. www.resus.org.uk/sites/default/files/2021-04/Adult%20Choking… Supports: Assess severity. Mild obstruction (effective cough): encourage cough. Severe obstruction (ineffective cough): if conscious, 5 back blows then 5 abdominal thrusts, continuing to check for deterioration; if unconscious, start CPR.
2. Resuscitation Council UK. Guidance: Choking (additional guidance page). Fetched Oct 21, 2026. www.resus.org.uk/library/additional-guidance/guidance-chokin… Supports: Additional RCUK choking guidance page (public). Cross-check for the adult choking algorithm.
3. 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: Table 2 (US astronauts, Shuttle, Mir and ISS through Expedition 13 / 2006): headache (space adaptation) 233, headache (late) 49, headache (CO2 induced) 20; choking/obstructed airway 3; smoke inhalation 3. Table 1 (ISS through Expedition 40): headache 33.
4. Menon A. Review of Spaceflight Dental Emergencies. NASA/TM-2012-217368 (NASA Johnson Space Center, September 2012). ntrs.nasa.gov/api/citations/20120002807/downloads/2012000280… Supports: No written record of an in-flight dental emergency in US astronauts, but a NASA dentist described an in-flight crown displacement temporarily repaired by the crewmember with onboard supplies; cosmonauts reported lost fillings and crowns in flight, thought to be dislodged by launch vibration, and incapacitating dental pain on a 96-day flight; repair must weigh the risk of aspiration (inhaling) of a loose crown; Integrated Medical Model estimates (events per person-year) include dental abscess 0.0230, exposed pulp 0.0201, crown replacement 0.00518 and filling replacement 0.00511, and a dental abscess was the condition most likely to end in evacuation from the ISS in that model; fillings can be linked with tooth pain on pressure change (barodontalgia).
5. Scottish Dental Clinical Effectiveness Programme (SDCEP). Management of Acute Dental Problems, 2nd edition (2026): Cracked, fractured, loose or displaced tooth fragments and restorations (guidance website, read Oct 20, 2026). www.acutedentalproblems.sdcep.org.uk/guidance/management-of-… Supports: An inhaled or swallowed tooth fragment or restoration needs immediate emergency care (SDCEP restorations page).
6. Resuscitation Council UK. Emergency treatment of anaphylaxis: guidelines for healthcare providers (May 2021; printed review date May 2026, which has passed. The RCUK guideline page, as fetched on Oct 20, 2026, still lists May 2021 as the most recent version; a newer version was not found). www.resus.org.uk/sites/default/files/2021-05/Emergency%20Tre… Supports: Anaphylaxis is characterised by sudden onset and rapid progression of symptoms, Airway and/or Breathing and/or Circulation problems, and usually skin or mucosal changes; airway problems include throat or tongue swelling, hoarse voice and stridor; breathing problems include wheeze, persistent cough, increased work of breathing, tiredness and hypoxaemia (SpO2 below 94%); circulation problems include pale clammy skin, fast heart rate, low blood pressure, dizziness, decreased conscious level and collapse; skin or mucosal changes alone are not a sign of anaphylaxis and may be absent in up to 20% of reactions; in up to 30% of cases there may be no obvious trigger; gastrointestinal symptoms without airway, breathing or circulation problems do not usually indicate anaphylaxis; call for help early; biphasic reactions occur in around 5% of patients, also after milder reactions, with a median time of around 12 hours, and observation for 6-12 hours may miss over half of them; adrenaline is the first-line treatment, given intramuscularly, and is repeated after 5 minutes if airway, breathing or circulation problems persist; medication accounts for 39% of anaphylaxis-related deaths (Table 1), and allergens given by a parenteral route (for example an IV drug or intramuscular injection) cause a more rapid onset; patients must not walk or stand during acute reactions.
7. 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).
8. Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult Basic Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16_suppl_2):S448-S478. PMID 41122888. doi:10.1161/CIR.0000000000001369 Supports: Adult basic life support: initial recognition of cardiac arrest, activation of the emergency response, high-quality CPR and use of an automated external defibrillator; also respiratory arrest and foreign-body airway obstruction. Earth guidance; the onboard checklist leads. Abstract read via PubMed Oct 21, 2026; full text not read.
9. 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.
10. 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.
11. 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.
12. 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.
13. 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.
14. 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.