To: CA/Donald K. Slayton From: CB/Joseph P. Kerwin Subject: Pulling Teeth

A one percent chance ofa serious dental problem on a 28-day mission is not sur­prising. That’s (28x 3 =) 84 man-days, which is onepercent of 8,400 man-days or 23 man-years. If we have 46 astronauts, one ofthem will need emergency den­tal care every six months — which matches Dr. Frome’s experience.

I have asked Dr. Frome to set up his proposed 1.5-day training program and run me through it as a guinea pig….

I believe that the right thing to do is to let them put the hardware on board, agree to train one of three crewmen (which cuts the risk but does not eliminate it) and reevaluate after the first mission.

“Management decided to go ahead and train two members of each crew, and we had a ball,” Kerwin said. “We traveled with Dr. Frome to San Anto­nio, to the U. S. Air Force Dental Clinic at Brooks afb. Bill and the den­tal staff had recruited a number of volunteers who needed to have a tooth extracted. (One of the first lessons was that you didn’t pull teeth, you extract­ed them.) So there we were, six of us, wielding syringes filled with xylocaine and wicked-looking dental forceps (and much more nervous than the patients were), getting those jaws numb and those molars out under the watchful eye of our dentist instructors.

“Paul Weitz drew a retired Air Force general. My patient’s molar broke in two during the procedure and had to come out in pieces. We were very glad when it was over. But I believe we could have done the deed in flight had we needed to. (We didn’t, and no dental emergencies arose during any mission.)

The dental kit became part of a medical kit for taking care of illness and injury aboard the Skylab space station. It was called the In-Flight Medical Support System. In retrospect, it looks like supplies for a pretty modest doc­tor’s office, but at the time it was quite a leap forward. It contained minor surgical instruments, a laryngoscope and tracheostomy kit, intravenous fluids, and lots of medications including injectables. Diagnostic equipment included equipment to make and examine blood smears and do cultures and antibiotic sensitivity tests on various body fluids. Kerwin, the doctor of the group who was quite familiar with the tools, was very much in favor of car­rying the equipment to Skylab. Some of the others, familiar with medical equipment primarily from being on the receiving end, were less so.

To: CA/Donald K. Slayton

From: CB/Joseph P. Kerwin

Subject: In-Flight Medical Support System (imss)

It’s clear from glancing through the list that this is mostly a doctor’s bag, not a first-aid kit. The document doesn’t say that, and it even proposes to train pilots to use all the equipment, which I find unrealistic. (Medschool was easy, but not that easy!) It’s also apparent that to justify the more elaborate equipment opera­tionally —from the standpoint of mission success— is darn near impossible. Major medical catastrophes just aren’t that much more likely to happen in eight weeks than they were in two. Minor illnesses are, but not heart attacks, etc… .

But that’s not the only point of view. Let me give, from my point of view, some reasons for carrying a doctor’s bag:

1. Up to now, the medical program has been unbalanced in the direction of pure research instead of treating illness and injury in space. This is a capa­bility we don’t need today, but we certainly will need it in space station times —for economic reasons at the least. It seems prudent to start using Skylab to develop equipment andprocedures to meet this need, just as we used Gemini to develop a rendezvous capability.

2. It’s true that a doctor isn’t mandatory on any Skylab flight. But if you do happen to have one along, you ought to allow him to do a little goodfor the program in his spare time by providing him with some of the tools of his trade. He could do an occasional physical exam on his buddies, and try out the simple laboratory tests on himself, by way of proving that they work. It would sure beat looking out the window.

In retrospect Kerwin found that last statement to be really dumb — noth­ing in Skylab beat looking out the window. But the In-Flight Medical Sup­port System was approved, and the same two crewmen who wielded the dental forceps were taught to use an otoscope and an ophthalmoscope, pal­pate and percuss, and report their findings to a doctor in Mission Control. “It was a wild experience for the pilots and a valuable refresher for me,” Ker­win said. “We were even taken to the trauma unit at Ben Taub Hospital in

Houston on a Friday night, where under the skilled tutelage of Dr. Pedro Rubio, the chief resident, we watched one of the best emergency medicine teams in America deal with life-threatening trauma and illness.”

Trauma training at Ben Taub Hospital proved a memorable experience for the astronauts. It was always scheduled on a Friday or Saturday evening when the probability of gunshot or knife wounds was apparently the high­est. Sure enough the crew saw their share but usually kept their distance from the emergency team engaged in what was a life-or-death procedure for some incoming patients. More relevant to their Skylab situation, they also had personal discussion and training with the experts in ear, nose, and throat; gastrointestinal tract; and eye and other specialties about how to handle in-flight emergencies. Even in these early days, they could expect to have experts in prompt voice contact and even with TV downlink to pro­vide images to the ground. So they ended up with reasonable confidence that most emergencies could be handled if they should arise.

The astronauts were also introduced to a fine team of consultants from the Houston medical community—specialists who would be on call dur­ing all the Skylab missions to advise the NASA flight surgeons should trou­ble arise in flight. Drs. Page Nelson, Hiram Warshaw, Everett Price, Kamal Sheena, and Jules Borger gave freely of their time and talent. Knowing they were there provided the crew with a feeling of security.

One of the best things to come out of the In-Flight Medical Support System, Kerwin said, was the checklist. Stimulated by the need to explain medical equipment and procedures to a bunch of pilots, the medical team linked up with the training team to produce a fine, very graphic, and explic­it manual showing with simple line drawings what everything looked like and what to do.

“We had one more treat in store,” Kerwin said. “Drunk with enthusiasm by the opportunity to experiment in space, the medical research team pushed for one final capability—to take and return blood samples. Not a big deal, you say; but it was, first because it had never been done before and second because it posed some hardware challenges in weightlessness.”

It was done. The crews agreed to give blood weekly; one member of each crew was trained to be the “vampire”; and an assortment of air-evacuat­ed tubes, a centrifuge to separate cells from plasma, and arrangements to freeze and return the samples were designed and flown. It all worked quite well. “I drew my own blood, not wanting to put Pete or Paul to the trouble of learning (and perhaps forgetting) how,” Kerwin said. “Pete hated being stuck and on the ground tended to become light-headed. But the blood couldn’t rush from your head in zero-G, so Pete was fine. He just looked away from the needle.”

The first crew, by benefit of being first and of having the physician of the group among its number, bore much of the hard work in planning for crew participation in the medical experiments (with a lot of help from Bill Thorn­ton, also a medical doctor and a Skylab guinea pig himself during simula­tions) . Therefore the training activity for the second and third crews fol­lowed much the same protocol as developed for the first flight team.

“Of course there were always some personal differences in practice,” Gar – riott said. “Whereas the first mission would have a doctor on board who knew the medical objectives and protocol in detail, as he had helped devise them, plus the fact that some of his other crewmembers were apparently not too enthusiastic about some of the procedures (e. g., blood draws), the sec­ond flight team all started substantially at the same level in terms of med­ical experience.”

Garriott described his crew with respect to the medical procedures as being all novices but with a keen interest in the protocol and personal results. No deference was provided to the scientist astronaut in this area, he said; everyone wanted to know about and participate in all that they could. They were all trained to draw blood and planned to do it in flight. They started with practice puncturing the skins of oranges or grapefruit with a hypoder­mic needle to simulate that of a human arm. Next came human volunteers, usually from life-science workers in the msc laboratories. As it turns out, there were more female than male volunteers (“Perhaps tougher constitu­tion, or more highly motivated?” Garriott remarked), and this often made the task more difficult—perhaps having less visible and accessible veins to attack. But all three of the crewmen successfully accomplished the blood draws a number of times, finally even drawing their fellow crewmen’s blood at least once. “It was good practice and we actually enjoyed the training,” Garriott said.

During flight all three crewmembers put their training into practice. Gar­riott routinely drew the blood of Bean and Lousma, while one or the oth­er would draw his blood on the desired schedule, every week or so. On one occasion in the middle of the crew’s two-month stay, the ground asked to have a video of the actual procedure. Lousma was scheduled to draw Gar – riott’s blood.

“We got all the cameras placed properly and the video recorder running for later dump to the ground,” Garriott said. “With all the paraphernalia in place, I bared my left arm, got the tourniquet tight, Jack made an excellent ‘stick,’ and the blood flowed freely just as desired. When finished, we with­drew the needle and blood promptly squirted all over the place! I had for­gotten to remove the tourniquet first and all the blood pressure trapped in the lower part of the arm took the path of least resistance into space. So we cleaned up the mess I had made, rewound the tape recorder and did it all over again using my right arm. The physicians on the ground seemed hap­py with the demonstration.”