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.
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