Although not hit by a falling apple, Newton-style, it was a question about gravity that eventually drew her to the space medicine program at the National Aeronautics and Space Administration’s (NASA) Johnson Space Center in Houston, Texas.

“I had always been interested in the space program, interested in astronomy and was a space hound, so to speak. When I was in college I participated in a summer program that NASA sponsored that introduced life sciences majors to the research that NASA does,” says Kira Bacal, M.D., Ph.D., M.P.H.

“I spent the summer at Kennedy Space Center in Florida and was just fascinated by a lot of the questions that were asked. As I learned that, generally speaking, the human body works pretty much the same in space as it does on earth, I thought, ‘Why on earth should that be?’” No pun intended, she says.

“When you think about how we as a species have developed and evolved, the one constant in our environment is gravity. There are people who live in all sorts of climates, all sorts of terrains and have all kinds of diets. But when you drop an apple anywhere, it falls at the same speed. I wondered why it should be when you take gravity away, we still continue to function.”

This was one of the “neat” questions she found irresistible — questions that put her on a career path that would intersect with the final frontier.

Although now a Robert Wood Johnson Foundation Health Policy Fellow, Bacal has spent most this century as a physician scientist guiding the development of medical systems for NASA’s space vehicles and the International Space Station (ISS). Bacal has a Ph.D. in molecular physiology and biophysics and medical specialties in emergency medicine and aerospace medicine.

During her Thursday, Aug. 11, lecture, “Building a Better Sickbay for Dr. McCoy: Medical System Design at NASA,” Bacal will discuss how, as chief clinical consultant and clinical lead for Wyle Laboratories and Life Sciences, she helped direct the redesign of the ISS medical system. While at Johnson Space Center, she was extensively involved in improving the medical systems on orbit and designing new systems for use on exploration class space missions. Bacal says her talk will present a “microcosm” of the kind of design thinking that could go into the development of all types of medical systems.

Medical system design involves taking the research and resources available to you and combining them in such a way as to give patients the best possible care in the most efficient possible system, given that there will always be constraints — whether these are money, time or the number of trained personnel, she says. 

“Our first thought was that if there were a very serious medical problem aboard the ISS, we’d leave it and come home. We’d all leave the station in an evacuation vehicle and return to earth to a definitive medical care facility — a level one trauma center in America. But then the vehicle that was to accomplish this was canceled,” Bacal says.

When evacuation vehicle was scrapped the ISS medical system needed to be capable of providing more extensive on-orbit care.

With the change of functionality, Bacal says, “I had the opportunity to work on building a brand new kind of medical system for the space station.”

Conceptual thinking, resource organization and management and technology were key considerations in redesigning the high-tech medical project.

“How do you work with the software engineers to get the decision support or medical records that are needed? How do you work with the engineers to make sure that the devices and equipment will work properly in space? How do you work with the crew trainers and educators to come up with just the right curriculum that’s needed?

“How much are you willing to pay for a certain level of medical care capability? Did we want to accept a higher level of risk for the crew? And based on those decisions, were you willing to risk someone’s life or limb? Or did we really need to come up with an alternative vehicle?

“It’s always a balance among the costs,” Bacal says, “whether those costs are financial, human or time.” You have to ask how will your decisions affect the level of risk involved, she says.

Other factors impacted the planning and outcomes for the ISS, such as the grounding of the shuttle fleet after the Columbia accident. With the fleet grounded, there were very limited deliveries of renewed supplies or additional items to the ISS. Then the ISS crew was cut from three to two persons. That would mean it would much more difficult to care for a seriously injured or ill person.

The problem of providing a lot of emergency care onboard, she says, is that in very few cases do patients receive the care and just get up and walk away. Usually they are initially resuscitated but then they would go — in a hospital setting — from the emergency room to intensive care.

“What a lot of people assume is that when you’re that remote and help is very, very far away, you either have to be very self sufficient and highly trained or that you have to accept a high level of risk.

“Right now what we’re actually trying to do is split that difference through more efficient and effective uses of training and devices and technology, which will allow us to minimize the upfront training time and limit the amount of risk.”

How intubations would be performed on the ISS is an example of rethinking “efficiency and effectiveness” in a medical system.

“The technique that puts a breathing tube in place is technically difficult and has to be practiced consistently to be done right time after time,” she says. “It’s typically done by nurse anesthetists and anesthesiologists. We used a new technology device to simplify the intubation process. This device gets the same outcomes as traditional methods would.

“It was not an outrageously expensive device, didn’t have a power supply, wouldn’t interfere with the avionics and didn’t outgas anything toxic. It was made of materials that already had been flown into space. It required less training time as well.

“Once we made that change, we asked why were we positioning the patient in a very traditional, terrestrial-type way in which you stand at the head and look down the body? We didn’t have to do that. Paramedics who used this device down here didn’t have to put themselves in this position, so why were we? That led to studies during freefall to help further test and tweak our techniques in a microgravity environment.

“The reason, for example, that we don’t try to build a ‘tricorder’ is because whether you’re talking about a drug or device, you really need to try it out on a large number of people to be sure that you trust it.

“If I had a tricorder and scanned you with it, and it told me that you had high cholesterol, you’d want to know I was sure of its accuracy. Has it been right on the last 50 patients? In outer space we have a very, very small population that tends to be unusually healthy. What we’re more likely to see from my tricorder device are false positives.”

The best way to ensure reliability — the fewest false positives and negatives — she said, is to try it out on large numbers of people and compare the results to a “gold standard” and make sure it agrees with that standard most, if not all, of the time.

“Only then will you start to have faith in it as an effective diagnostic or therapeutic tool. If we invented something for use only in the astronaut corps, I think, frankly, it would take me, as a physician, a really long time to trust it,” Bacal says.  

“You want to be able to say, ‘We tried this on 2 million men and 2 million women, and boy, this really works!’ Then you only have to worry if the device will work properly in outer space. For instance, will the device still work if it’s floating? You don’t want to worry that it’s not working because of whom you are using it on.”

Bacal’s lecture will take place at noon in Irvine Hall 194.