RMP-SKIN-004 Rash and skin irritation photo log: symptom questions first, then standard consented photos for the flight surgeon (the CMO examines)

1 · Identity and scope

When a crewmember has a rash or skin irritation, on the crewmember's or the CMO's command, the robot first asks symptom questions on screen and raises an URGENT alert for any red flag. Then, with consent before the camera moves, it takes standard photos of the area the CMO sets, as in RMP-SKIN-003: an establishing view with a margin of surrounding skin, a close-up with a scale, and the same close-up without it. If the CMO does a glass test (pressing a clear glass on the rash), the robot records what the CMO states. Photos are labelled, stored in the medical record and sent to the flight surgeon, who judges every finding.

Why this protocol was chosen. Skin rashes were the most reported clinical event in long-duration ISS crew among the categories studied (Crucian 2016). A non-blanching rash, or one that spreads quickly, can be meningococcal disease and needs emergency care; it can be harder to see on brown, black or tanned skin and can change from blanching to non-blanching, so the CMO checks the whole body and the robot only records what the CMO states (NICE NG240). A painful spreading rash with blisters and sores of the eyes, mouth or genitals, usually in the first week of a new medicine, can be a severe drug reaction (DermNet 2016), so it is URGENT. Breathing trouble or swelling of the lips, tongue or throat is treated as a severe allergic reaction (Resuscitation Council UK). The photo rules follow RMP-SKIN-003 (IMI 2019); the robot's role is design judgment.

Autonomy: Max rung 2 for asking symptom questions on screen, moving the camera to the standard view the CMO sets at the set distance and without contact, and labelling, storing and sending photos, as in RMP-SKIN-003. The robot never judges a rash.

Related: RMP-SKIN-003 · RMP-SKIN-001 · RMP-RESP-003 · RMP-INF-001 · RMP-EVA-001 · RMP-ENV-005 · 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.) [14]

3 · Preconditions and consent

• PRE-1 The crewmember or the CMO started the protocol by command for a rash or skin irritation.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 the photos before the camera moves; photos frame only the area the CMO set, with a margin of surrounding skin. For the genital, breast or buttock area, the robot camera is used only if the crewmember chooses it; otherwise the CMO takes the photos with a handheld camera and adds them to the log. Photos go only to the CMO, the flight surgeon and people the flight surgeon names.

Emergency consent

If the crewmember cannot agree, no photo is taken; any red flag raises an URGENT alert.

Withdrawal

The crewmember can stop a photo or the whole log at any time; withdrawal stops future photos, and the flight surgeon decides on photos already taken.

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

   Tell the CMO and the flight surgeon that a rash photo log has started (URGENT if any red flag is stated). Before any photo, show the symptom prompt on screen (breathing trouble or swelling of the lips, tongue or throat is asked first) and log answers word for word. 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: Notice acknowledged; answers logged, or "no response".

   V1 3004V1 3006

   D1DecisionRobot decides

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

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

   Did the crewmember answer the symptom prompt, or say they want to skip it?

   • 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.
2. S2Crew

   The CMO examines the skin under the onboard checklist line "check all over the body and the conjunctivae (the inside of the eyelids); a rash may be difficult to see on brown, black or tanned skin", sets the standard view and the area to frame (with a margin of surrounding skin) and places the scale the flight surgeon chose. If the CMO does a glass test, the CMO states the result. For the genital, breast or buttock area, the robot camera is used only if the crewmember chooses it; otherwise the CMO takes the photos with a handheld camera and adds them to the log.

   Done when: View and area set; findings stated.

   V1 3004

3. S3RobotRung 2

   Record the CMO's findings and any glass test result word for word, marked "as stated by the CMO"; the robot never judges whether a rash fades. A fading glass test result never ends an alert and is never logged as reassuring.

   Done when: Findings logged.

   V1 7001

   D3DecisionRobot decides

   Before the camera moves: did the crewmember agree to this session's photos (each view is named on screen before it is taken)?

   • Yes → Continue to S4; the crewmember can say stop before or during any view.
   • No, or no answer → The camera does not move and no photo is taken; log "photo not taken – no consent" and tell the CMO.
4. S4RobotRung 2

   Only after the crewmember agrees (D3), move the camera to the standard view the CMO set (about 90 degrees, the same distance, light and plain background each time), no closer than the set camera distance, and take the standard set: an establishing view with a margin of surrounding skin (the area the CMO set), a close-up with the scale, and the same close-up without the scale. Label each with the area, view, date and clock time, and mark it "for human review". A photo with anything outside the area the CMO set in frame is held unsent and flagged to the flight surgeon, who decides whether to keep it.

   Done when: Photos taken and labelled, or "photo not obtained".

   Limit: <set by validation>

   V1 7001

5. S5RobotRung 2

   On request, show earlier photos of the same area side by side for the CMO; the robot never says what has changed.

   Done when: Photos shown on request.

   V1 7001

6. S6Crew

   The crew clean the camera, the scale and any shared surface under RMP-INF-002.

   Done when: Cleaning recorded as stated.

   V2 7046

7. S7RobotRung 2

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

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

   V2 10173V1 3006

8. S8Ground

   The flight surgeon (or the CMO under the onboard checklist when there is no link) reviews the answers and photos and decides on care, follow-up photos and any medicine through RMP-PHARM-001.

   Done when: Decision logged.

   V1 3004

   D4DecisionGround decides

   What is the plan (care, follow-up photos, any medicine)?

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

   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
10. S10RobotRung 2

    Send the flight surgeon one package: answers, findings as stated, labelled photos, alerts and decisions. Photos are stored only in the crewmember's medical record, encrypted in storage and in transit as the program requires; access is limited to the CMO, the flight surgeon and people the flight surgeon names. They are never shown on a shared display and never used for robot or AI training, research or outreach without separate written consent.

    Done when: Package delivered or queued.

    V1 6003V1 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 Answers as stated with times; findings and glass test results as stated by the CMO; consent before each session; each photo with area, view, date and time; photos held unsent and the flight surgeon's decision; photos taken by the CMO with a handheld camera; who viewed the photos.
• 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-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 [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 logs with breathing trouble, a non-blanching rash stated by the CMO, mucosal sores, a missed consent, something outside the set area in frame, CMO as patient, lost link. Pass: Every red flag URGENT before any photo; zero photos without consent; zero contact.
2. Training model. Photo drill on skin models with rashes on different skin tones. Pass: Photos comparable (same view, light and scale); every photo labelled.
3. Parabolic or station demonstration. Camera positioning in weightlessness. Pass: Camera distance limit held.
4. Flight use under flight surgeon supervision. First use for a rash. Pass: No safety or privacy 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 the crewmember or the CMO. Symptom questions come first; the CMO examines and the flight surgeon judges every finding.

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 v0.2.

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 answers and photos 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 care already under way and all other care continue under the onboard checklist and never wait for the link or the robot.
• Photos are queued; any red flag goes to the CMO at once.

Mars-class delay

• Mars: photos arrive with delay; the CMO decides under the onboard checklist.

[12]

Sources

1. Crucian B, Babiak-Vazquez A, Johnston S, et al. Incidence of clinical symptoms during long-duration orbital spaceflight. Int J Gen Med. 2016;9:383-391. PMID 27843335. doi:10.2147/IJGM.S114188 Supports: Among 46 long-duration ISS crewmembers, skin rashes were the most reported clinical event in the categories studied (infections, allergies, rashes and hypersensitivities), at 1.12 per flight year. Wounds were not studied.
2. National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. NICE guideline NG240 (2024). www.nice.org.uk/guidance/ng240 Supports: Strongly suspect meningococcal disease with a haemorrhagic, non-blanching rash with lesions larger than 2 mm, or a rapidly progressive or spreading non-blanching rash; check the whole body, including the conjunctivae; a rash can be harder to see on brown, black or tanned skin and can change from blanching to non-blanching; transfer as an emergency. Read Oct 21, 2026 (saved copy in src/b11).
3. DermNet. Stevens-Johnson syndrome/toxic epidermal necrolysis (2016). dermnetnz.org/topics/stevens-johnson-syndrome-toxic-epiderma… Supports: Usually starts within the first week of a new antibiotic; a prodrome of fever above 39 °C, sore throat and sore red eyes; then an abrupt, tender or painful red rash spreading over hours to days, flaccid blisters, and sores of at least two mucosal surfaces (eyes, lips and mouth, genitals). Read Oct 21, 2026 (saved copy in src/b11).
4. 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.
5. National Institute for Health and Care Excellence. Suspected sepsis in people aged 16 or over: recognition, assessment and early management. NICE guideline NG253 (2025, last updated Sept 23, 2026). www.nice.org.uk/guidance/ng253/chapter/Face-to-face-assessme… Supports: People with sepsis may feel very unwell and may not have a high temperature; do not rely on fever alone; a rise in temperature can be a physiological response; assess temperature, heart rate, breathing rate, blood pressure, level of consciousness and oxygen saturation; look for mottled or ashen skin, blue skin, lips or tongue, a non-blanching rash, and breaks in the skin; ask how often the person passed urine in the past 18 hours and about fever or shaking chills (rigors); pay attention to new changes in behavior and to concerns raised by others.
6. NASA OCHMO. Decompression Sickness (DCS) Risk Mitigation. Technical Brief OCHMO-TB-037 Rev D (Oct 5, 2026). www.nasa.gov/wp-content/uploads/2023/12/ochmo-tb-037-decompr… Supports: DCS is caused by inert gas bubbles forming during rapid reductions in ambient pressure, most significantly in the move from cabin pressure to EVA suit pressure; NASA classifies DCS as Type I (itching, musculoskeletal pain, mild rashes) and Type II (neurological symptoms, numbness, weakness, cognitive issues, inner ear problems, cardiopulmonary issues), and describes cutis marmorata (a mottled, patterned skin rash); arterial gas embolism can cause stroke-like neurological effects, loss of consciousness and seizures; U.S. Navy protocols are widely adopted on Earth; diagnosis is based on symptoms; the majority of cases present between 60 and 240 minutes and inflammatory responses can last more than 24 hours; no hyperbaric chamber is available in flight, and increasing suit and cabin pressure may be combined to treat symptoms, depending on the scenario; a break in prebreathe rapidly reintroduces nitrogen; NASA has never experienced a Type II event in spaceflight.
7. Institute of Medical Illustrators. IMI National Guidelines: Wound Management Photography (2019). www.imi.org.uk/wp-content/uploads/2019/04/2019_Apr_IMINatGui… Supports: Standardise equipment, lighting, background, viewpoint and magnification so serial photographs can be compared; use the same light source each time where possible; hold a measurement scale on the same plane as the wound and photograph from 90 degrees; acute wounds are photographed at each dressing change, and any significant change is photographed; written guidance on consent for clinical photography. Earth hospital context. Saved copy read Oct 21, 2026 (a 2025 version 2.0 exists).
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 6003, V1 7001, V1 7003.
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.