Ep 10: What If I Get Sick?

How can we prepare for medical emergencies in a space settlement? What equipment should we bring? What kinds of doctors? When resources are limited, who do we decide to treat first?

Physician Ken Iserson talks about the lessons we can learn from remote and disaster medicine here on Earth. Philosopher Keith Abney highlights the ethical challenges of practicing medicine in a resource-limited environment like space. And physician Jim Duff discusses some things to keep in mind when selecting a medical team for a wilderness expedition.

The transcript for this episode is below.

Imagine this: Today started off like any other day in the space settlement where you live. You’re working in the community health clinic, sorting supplies. But around lunchtime, you hear a muffled explosion from the far end of the habitat. A call comes out over the radio: There’s been an accident at the power plant. The habitat isn’t damaged, but dozens of people are injured. As the patients come pouring into the clinic, you realize that you don’t have enough first aid supplies on hand to treat them all. And the last time anyone saw the community’s only doctor, she was heading for the power planet to check in with a former patient. No one’s heard from her since. What do you do?

Welcome to Making New Worlds, a podcast about the ethical issues involved with settling space. I’m Erika Nesvold. Let’s talk about what happens when there’s a medical emergency in a space settlement. Specifically, what if there aren’t enough resources to treat everyone who’s sick or injured? Maybe there’s a disease outbreak, but not enough antibiotics to go around. Maybe it’s a flu epidemic, and you don’t have enough ventilators to keep the most severe cases alive. Maybe there’s been a large accident, with a lot of injured patients, but you don’t have enough medical providers to treat everyone quickly enough to save them all. How do we decide who gets treated immediately, and who has to wait? How do we choose who gets the life-saving treatment, and who doesn’t?

This is a problem that medical providers often have to face on Earth, and the method they’ve developed to address it is called triage.

Ken Iserson: “Triage is, essentially, sorting.”

This is Dr. Ken Iserson, Professor Emeritus of Emergency Medicine at the University of Arizona in Tucson. He’s a physician and an expert in disaster international medicine who’s worked clinically or taught on every continent, including Antarctica. He gave me some background on triage.

Ken Iserson: “And it comes from the French word trier, which means to sort agricultural products. But in reality, now, it’s strictly a medical term. And when we have limited resources, and that can be time– it’s always time– but then also personnel, equipment, we have to decide which patients get treated first and which will have to wait. That can be a really tough decision. It usually takes the most experienced health care providers, and sometimes a lot of fortitude, to do triage. Especially in really– in situations of big crunch. You know, there’s a lot of patients and very few resources, you have to decide who’s going to get treated and who’s not. And sometimes that means people are going to die.”

These sorts of decisions about who lives and who dies can go beyond medical treatment. There’s a class of scenarios in ethics known as the lifeboat problem: Imagine you’re on a lifeboat that can only hold fifty people. But there are one hundred people in the water who will die if you don’t let them on board. What do you do?

I talked with ethicist Keith Abney about how we might encounter the lifeboat problem in space. Keith is a philosopher at Cal Poly and also a senior fellow at the Ethics in Emerging Sciences Group. They study issues in the newest sciences and technologies that have ethical and policy components.

Keith Abney: “Suppose we have a limited amount of oxygen and not enough to keep everyone alive until things get fixed. So, who are we gonna kill? And if we don’t kill anyone, then everyone dies. So how would we make that decision? This is something that would happen not only, potentially, in a spacecraft on the way to Mars, but let’s be clear, you’re going to be living under domes or in other kinds of limited facilities once you get there, or on the Moon, or, well, anywhere else in space. And it’s not only about oxygen. Suppose we have something that has to be immediately fixed, a solar panel, shielding for— against radiation, and there’s a solar storm. Who draws the short straw to go out and fix it and, quite possibly, die of radiation poisoning?”

For now, let’s just focus on questions of medical treatment. How do you decide who gets treated first, or who gets to use the limited amount of medicine you have with you? It turns out there are a lot of different methods for making these decisions. Here’s Dr. Ken Iserson again.

Ken Iserson: “Who do we decide on? There’s a number of ways you can do it, but one of the keys– and certainly in space that would be– one of the keys is they would have to decide how they were going to do this in advance. It’s not, “Let’s make a decision and set up a plan when something happens.” This has to be well planned out, certainly in a space mission. And usually in other long-term missions that have medical components, especially in resource-poor areas or after disasters.”

Keith Abney gave me some examples of a few different approaches for triage.

Keith Abney: “In medical ethics, there are considerable discussions about the best way to realize protocols for rationing. So one common approach is called, “QALY utilitarianism.” We’re going to do whatever— we’re going to give treatment out in such a way as to maximize the Quality-Adjusted Life Years of the patient. So if we only have enough resources for one cancer treatment, and there’s a twenty-year-old, and a eighty-year-old, then the twenty-year-old gets it. But by the same token, we might instead think about this in terms of traditional emergency triage, which is to divide patients into groups and using what’s called the “rule of rescue” as the primary principle, such that we prioritize treatment of those for whom treatment is a life-or-death issue. And only after we’ve treated all of those folks, do we treat people with non-terminal, non-lethal problems. Whether that’s a broken leg or a cold. And then last, and least, we treat those who we cannot save their lives, whose condition is terminal, and who really have only palliative care. If we decide to do things that way, that’s an entirely different approach, common in the military, but would cause very different decisions.”

I have some experience with this last kind of triage, myself. I’ve been an EMT at a volunteer fire station for the last fifteen years, and I’ve been trained in emergency triage and used it in the field. This is the kind of triage most often used in emergency rooms, and might be the kind you’re most familiar with. It doesn’t matter who you’re treating, just what’s wrong with them, and how urgent their condition is. It can be tough to make those decisions, but in some ways it’s the easiest method of triage: you don’t have to try to think about the comparative value of the lives of the people you’re treating.

But now imagine you’re in space, where the lives of certain people might matter more to the settlement than others. If those people die, then the whole settlement could die, because their expertise or training is lost. If you want to save the highest number of people in the long run, this could change the way you handle triage.

Keith Abney: “Another way we could think about things is in terms of social value, or mission value. So, if we have to decide between the pilot of the craft versus a passenger, maybe we better save the pilot, right? If we have to decide between the person who’s responsible for keeping the atmosphere breathable versus a passenger, well, maybe we better make sure the atmospheric engineer lives. This is the kind of thing we might consider as well. All of these might well have different decisions when there’s a limited amount of medical care available.”

Ken Iserson gave a similar example of this kind of triage, where it matters who the patient is, or more specifically, what their function is in the community.

Ken Iserson: “Another is basically, treat and return to service those people who are most valuable to the team. In military, that seems to be pretty obvious. And the Germans did this in World War II, is they took their front-line soldiers and they tried to patch them up before anybody else. In civilian disasters, it might be the firemen, it might be the physician and nurse, it might be the rescue person, you know, who goes into buildings. If they get hurt, try to patch them up so they can maximize the good.”

Triage isn’t just necessary in the fast-paced world of an emergency room or a battlefield. In places with more limited resources, like disaster zones or remote areas, triage can be a slower process, but these decisions still have to be made. Maybe you have a patient who is stable for now, but requires lifesaving care like surgery or chemotherapy in the next few months, or they’ll die. How much should the community contribute to helping this patient?

Ken Iserson: “One thing that we didn’t talk about yet is the cost/benefit ratio. And sometimes, certainly in civilian settings, cost really means cost. How much might it cost to, for example, evacuate a patient from the South Pole in the winter? Certainly in terms of risk to the pilots, but also in terms of just the dollars and cents that it takes. That’s exactly the same scenario that would come to play in trying to evacuate a patient from a space station, let’s say.”

Philosopher Keith Abney made a similar point about cost.

Keith Abney: “In general, triage is going to be a huge issue because resources are limited. They’re limited here on Earth. Medical rationing is, in fact, a fact… Just, on Earth, it’s usually rationed by ability to pay. And so, poor people don’t get as much as rich people. In space, it’s gonna have to be more radically rationed, and we’re going to need to decide on the basis on which it’s rationed. Certainly, NASA doesn’t ration healthcare based on ability to pay. At least, not for the foreseeable future. But you could easily imagine, if you’re going up with Mars One or Elon Musk’s SpaceX, that you might be able to pay just a little, and be told, “You’re going have only minimal medical care on your voyage.” Or you could pay for the elaborate version, the platinum edition. And get much better guaranteed health care. There are all kinds of possible solutions to this, but we’re going to have to think through what we believe to be ethical and what we should allow.”

No matter how you decide to fund your medical care, the amount of cargo you’ll be able to take on your initial founding of a space settlement will be limited. What do you bring with you to try to prepare for the largest range of possible emergencies? The question of what medical equipment and medication to bring is already being studied by groups like NASA, who have to think about this for the International Space Station. But what about the medical team? What kind of physician do you need to bring to space in the early days of your settlement?

I put this question to Dr. Jim Duff, a retired GP and an expert in wilderness medicine who’s worked as the doctor on a number of expeditions in the Himalayas.

Jim Duff: “First of all, I think the doctor has to be aware that he’s the Tail End Charlie in all this, because when he gets sick or ill, he– there’s no one, really, to back him up on the spot. I doubt there’ll be two doctors. There might be a paramedic or something like that. So I think the doctor has to be chosen very, very carefully. I think they’ve got to be psychologically fit, resilient and tough. And I think they’ve got to have, you know, it’s really– I see it as a– like, you’ve got to be a family physician with a very broad range of medical skills plus they have to have, you know, specialties like emergency medicine and a bit of surgery and so on. So they’ve got to have a really broad base of skills. And then, you know, a number of essential specialties.”

As time goes on, more people will arrive in your space settlement, and you’ll be able to diversify your medical team. Here’s Ken Iserson again.

Ken Iserson: “But after that, it will have to include the surgeon, and the obstetrician, and the anesthesiologist, as well as other people who can treat what will inevitably occur medically in those situations. You can’t send them back immediately, you’re going to have to have a robust enough team– medical team to treat what you know is going to happen.”

But initially, there’ll be a lot of pressure placed on the few doctors in the settlement. This can potentially be really dangerous if the person with the highest level of training is the one who needs medical care. There are a few examples of this happening in Antarctica when there was only one physician present at a base. One of the most well-known examples is about a doctor in Antarctica who removed his own appendix.

Ken Iserson: “It was actually a surgeon. It was decades ago. There’s a photo of him doing it. Or more than one photo of him doing it. It was a Russian. I’m sure he was paranoid. He didn’t want anybody else touching him, so he used a set of mirrors and he did an appendectomy on himself. I can’t think of anything worse [laughs] to do. Although, at one of our stations, a number of years ago, the physician actually came down with a large abscess in her mouth. She couldn’t drain it herself. So, using mirrors and instructions, she had the other, non-physician clinician drain it.”

One key component of space missions, and a very important part of future space settlements, is cross-training. If only one person knows how to work the life support system, and that person is killed, then everyone dies. So you want to cross-train your crew to make sure that you have redundancies built in.

Ken Iserson: “Well, we do cross-training. But you can’t cross-train someone to be a surgeon. You know, a general surgeon. We do dental work, including extractions and fillings and other things. And that’s cross-training, the physician generally does that. But you can’t– you just can’t train someone adequately to do general surgery. You know, in a week or whatever.”

Fortunately, on Earth, technology allows us to take advantage of experts on the other side of the planet, even if you’re stuck in a remote location with a patient in need of more care than you can give them.

Jim Duff: “Traditionally, you would go off into the Himalayas and you’d be away for, you know, a month, two months, three months. And you’d come out again. And if someone got sick, it was pretty much, you had to carry them out. Then helicopters came in. And then sat phones. So you could actually, you know, someone gets frostbitten on a Himalayan expedition these days, I mean, you just take some pictures and email them to the experts in the various countries you come from, and you get direct advice. And I can imagine that could be a quite– you know, with the– Once we get to the technological level where we have bases on Mars, that we’d probably put in a kind of surgical robot, and you could have telemedicine. Might be a bit of a delay, might be a slow process, but, you know, maybe you’re remote in terms of experts getting their hands on the– physically, on the patient, but there should be, one would assume, you know, a vast array of expertise available through telemedicine.”

That “bit of a delay” in communications could be significant, the farther we travel from Earth, but initially, we will at least be able to do some slow research for non-emergency situations. Ken Iserson stressed the importance of having remote consultants who understand your situation and limitations in space.

Ken Iserson: “You want to have the best possible consultants available for the clinicians who are onsite. And you want them to be as knowledgeable as possible about the situation at the South Pole or in space as possible because otherwise, they’ll be using a mindset from their civilian practices, which is totally inappropriate. And we saw that, certainly, in Antarctica.”

Dr. Jim Duff emphasized that when you’re picking your medical team, you need to consider the psychological toll that living in a harsh environment can have on a person. It’s vital for a space settlement to have experts who can care for their patients’ mental health.

Jim Duff: “You know, in selecting a doctor for such a remote trip, the psychological side would become even more important. They’d have to be really, really capable of bringing people– grounding them and getting them back into the, you know, into a positive mental state. And you know, that’s a real skill. And you might have a top neurosurgeon, or a top emergency room doctor, but they might be just hopeless in that area. So I would put that skill up front and as an essential.”

Jim Duff: “The other thing is that, on expeditions that I’ve been on, it tends to be pretty boring. People get on with their jobs. And then there’s little niggles, you know, there might be a cut, or an abrasion, or, you know, I suppose they’re unlikely to get colds or flus, because they’re isolated. But they might get sore throats from dry atmospheres or skin problems or whatever. Simple stuff like that. And then, you know, the proverbial hits the fan. And in extreme mountaineering, that often results in someone being dead. And you can’t do much for them. And occasionally, you are, you know– you do have to deal with broken limbs or stuff like that, or major, you know, tough lacerations. And I suppose, you know, there’d be occasional abdominal problems, neurovascular problems that might occur over a period of years. So, you know, I think being able to have some skills to cope with those major things might appear to be very important, but actually, I would think that more of the basic skills and the psychological ones and the, just dealing with, you know, bits and pieces. And that brings it round to the doctor needs to be able to cope with stress, needs to be able to ground himself. You know, needs to be able to practice mindfulness and demonstrate it, you know. You’ve got to be actually there– He’s probably one of the most, maybe the leader as well, but the doctor has to personify those psychological strengths that you need on such a trip.”

Of course, it’s important to look out for the doctor’s mental health, too.

Jim Duff: “Most doctors deal with death and dying and seeing, you know, seeing their patients die. I mean, we’re all grounded in that. But in my opinion, it’s not very well dealt with in the West. Doctors accumulate huge amounts of stress, and unless they’re good at having a mentor or debriefing, they just accumulate huge amounts of stress. Doctor have got terrible statistics for suicide, and for, you know, drinking too much and things like that. And it’s sort of, like, not taking care of themselves. It’s not very well taught in universities or medical schools, at least it wasn’t when I was a junior doctor. And, you know, patients died and you just, sort of, “Mm, okay, next, please,” and move on from it. But obviously, when you go into a family doctor, as well, a family physician you call them in the States, they actually live with their mistakes. They, you know, they take a family and see them through various stages of life and then might end up, you know, palliating them in a terminal sense. So I would say it’s gonna be pretty intense in such a remote situation.”

So what can we do to minimize the pain and suffering of future space settlers when they encounter injury or illness? All three of my guests stressed the importance of planning ahead. Here’s philosopher Keith Abney again.

Keith Abney: “One way to think about philosophy is that we engage in thought experiments. But then, so does science. I mean, Carl Popper put it this way: “The advantage of science is that it allows our ideas to die in our stead.” [laughs] So, we don’t have to actually jump off a cliff, we can calculate the vector and the acceleration and we can realize that, no, that’s gonna be too much acceleration for our bodies to be able to take. No, that would be a bad idea. By this token, we can think about issues that are going to arise and reason fairly conclusively– although, let’s be clear, it’s hideously complex, ethics is hard. Policy is hard. But we can think through some of these issues and say, “No, for sure, these are going to be serious problems and you need to try to decide these beforehand, or else things will be disastrous.””

So what do you think? How should we triage patients in a space settlement with limited resources? If you were in charge of building a medical clinic in space, what would you be sure to bring? What kinds of providers would you staff your space hospital with?

Join the conversation on Facebook at facebook.com/makingnewworlds. Or hit us up on Twitter @makingnewworlds. You can also visit our website at makingnewworlds.com. Remember that Episode 12 will be our audience feedback episode, so please send in your written or audio commentary on any of the topics we’ve discussed so far if you’d like to be featured in the episode. Get your comments in by February 7th to be included.

If you’re interested in the ethics of emerging technologies, Keith Abney has a book that just came out called Robot Ethics 2.0: From Autonomous Cars to Artificial Intelligence. If you want to learn more about how healthcare workers adapt their care to resource-limited environments, Ken Iserson has a book called Improvised Medicine: Providing Care in Extreme Environments. He’s also written a couple of books for non-physicians that you might be interested in, including Death to Dust: What Happens to Dead Bodies and another called Demon Doctors: Physicians As Serial Killers. And Jim Duff has written a book called Pocket First Aid and Wilderness Medicine, now in its 12th edition. He also asked me to mention an organization he founded twenty years ago to support local porters in the Himalayas and around the world:

Jim Duff: “Over 40 years in the Himalayas, I realized that the porters– not the sherpas on the, carrying loads on the mountains, but the porters lower down, who were below base camps– were getting a bad deal. So I started the International Porter Protection Group, which you can– IPPG, you can Google that. And we advocate decent treatment, like decent gear, shelter, and medical care, for porters in any mountain area on the planet, not just the Himalayas. That’s been going, ah, twenty years this year, 1997. And we’ve got a couple of rescue posts in the Everest National Park, and we’ve built porter shelters in various mountain areas.”

If you’re interested in learning more about this group, you can find them online at ippg.net.

Next week, we’ll be talking about religion and culture. How will space settlers adapt their religious beliefs to their new environment? How can our cultural values and practices help us survive and thrive in space? Join us next week.

This has been Making New Worlds, a podcast by me, Erika Nesvold. Our intro and outtro music is by Herr Doktor.