Patient Care

Commercial Spaceflight Challenges for Emergency Medical Response

Issue 12 and Volume 41.

Deep in the California desert at 9:19 a.m. on Oct. 31, 2014, Virgin Galactic’s WhiteKnightTwo took off from Mojave Air and Space Port, carrying SpaceShipTwo under its wing. SpaceShipTwo carried two pilots, and was operating under an experimental permit from the Federal Aviation Administration (FAA) Office of Commercial Space Exploration (AST). Just after 10 a.m., SpaceShipTwo dropped from WhiteKnightTwo and ignited the hybrid rocket designed to carry it to suborbital space. Thirteen seconds later, at approximately 50,000 feet, ground controllers lost contact with SpaceShipTwo.

Observers on the ground said that SpaceShipTwo “broke apart and started coming down in pieces over the desert.”1 One pilot died and the other pilot suffered serious injuries, but was able to escape the craft and parachute to the desert floor.

The first emergency medical responder arrived at the crash site at 10:52 a.m., nearly an hour after the vehicle broke up.2 Despite being on standby, non-standard communications delayed his departure. The Mercy Air medical transport helicopter arrived at 11:16 a.m., and didn’t transport the surviving pilot until 11:23 a.m. The pilot arrived at definitive medical care at 11:53 a.m., an hour and 46 minutes after the accident.

This event was the first major in-flight failure of the burgeoning commercial human spaceflight industry, and it provided significant lessons learned for emergency medical response. The National Transportation Safety Board (NTSB) was charged with determining the causes of the accident.

After several months of investigations and hearings, the NTSB issued an abstract of its report on July 28, 2015. In their recommendations to the Commercial Spaceflight Federation (the private spaceflight industry trade association), the NTSB advised that commercial operators should “work with local emergency response partners to revise emergency response procedures and planning …” To facilitate this cooperation, local emergency responders need to understand the unique challenges of commercial human spaceflight.2

Commercial Spaceflight Challenges for Emergency Medical Response
Photo courtesy Blue Origin

Commercial Spaceflight

For decades, human spaceflight has been the exclusive domain of governments with private industry playing a supporting role. Today, a handful of pioneering companies have taken the lead in a quest to provide transportation for not only government astronauts, but to other commercial entities and space tourists.

Despite decades of experience launching humans into space, however, spaceflight isn’t yet routine. Along with these exciting new opportunities comes a level of risk unprecedented since early aviation. Increasing commercial launch frequency could mean more events that require emergency medical response and intervention.

Creating an appropriate medical response plan for a commercial human spaceflight endeavor requires a working knowledge of different types of vehicles and flight profiles. Spaceflights can be classified into three categories: high-altitude and suborbital flights (which last for minutes to hours); short-duration orbital flights (which last for days to weeks); and long-duration orbital flights (which last for months to years).

High-Altitude & Suborbital

High-altitude flights planned by World View Enterprises will involve a large helium-filled balloon carrying a pressurized gondola supporting two crewmembers and six passengers. The balloon will take off vertically and ascend for two hours to an altitude of over 100,000 feet where the gondola will separate from the balloon and glide to a landing site using a specially designed parachute. The entire flight experience will last five to six hours. The distance between launch site and landing site can be as much as 300 miles, depending on the high-altitude winds.3

Virgin Galactic is planning to fly six commercial passengers on a reusable suborbital vehicle SpaceShipTwo with two crewmembers. SpaceShipTwo is carried to its launch altitude of approximately 45,000 feet by the carrier aircraft WhiteKnightTwo. It’s then air-launched and fires its rocket motor, executing a turn for a steep climb that lasts about 70 seconds, carrying the vehicle to a maximum altitude of approximately 360,000 feet. SpaceShipTwo follows a typical ballistic arc and offers several minutes of microgravity before deploying its feathered wing configuration for re-entry. After approximately 70 seconds into its descent into the atmosphere, the wings return to standard configuration and SpaceShipTwo glides to a horizontal landing at its launch base.4

Blue Origin, a company founded by founder Jeff Bezos, is developing the New Shepard, a reusable vertical takeoff and landing vehicle comprised of a pressurized capsule with room for six passengers and a booster. The capsule and booster launch vertically, accelerating for approximately two and a half minutes before the engine cuts off and the capsule separates from the booster. The capsule climbs over 328,000 feet and offers several minutes in microgravity before landing using retro- rockets and parachutes to decelerate.5

Commercial Spaceflight Challenges for Emergency Medical Response
Combined medical and engineering teams attend to the StratEx pilot in his space
suit who fell from almost 136,000 feet in altitude before landing
by parachute in the desert. Photo courtesy Erik Antonsen


The orbital launch system developed by Blue Origin will be comprised of a two-stage rocket and capsule that will carry astronauts and payloads to low-earth orbit (LEO) destinations.5 It’s designed to carry a maximum of seven passengers.6

The Crew Dragon capsule under development by SpaceX in collaboration with NASA’s Commercial Crew program could also be used for commercial passengers. The capsule is launched on the Falcon 9 rocket, carries up to seven passengers to LEO, and is designed to be fully autonomous.6,7

Sierra Nevada is developing the Dream Chaser Space System, a reusable lifting-body spacecraft capable of transporting up to seven passengers to LEO. The vehicle will be launched vertically on an Atlas V rocket and lands horizontally on commercial runways. The vehicle uses all nontoxic consumables.8

High-Altitude Physiology

The changes to the human body as a result of spaceflight are extensive—every system is affected in some manner. Having a general understanding of all the changes related to high-altitude flight and/or spaceflight can assist prehospital personnel in providing appropriate care to these individuals if needed.

Although the nature of these changes is dependent upon the type of flight, there are a few that are universal: excitement/anxiety, disorientation, and nausea/vomiting.9 For vehicles with rocket motors, acceleration forces (i.e., G-forces) can have a profound physiological impact depending upon their power and physical orientation relative to the participant; they can cause transient vision loss, acceleration-induced loss of consciousness, cardiac dysrhythmias and increased work of breathing.10

Commercial Spaceflight Challenges for Emergency Medical Response
Significant hazards throughout space flight required an
elevated EMS presence. Photo courtesy World View Enterprises

Rocket-powered vehicles also have significant noise and vibration associated with their function, potentially leading to headaches, neck and back pain, vertigo, hearing loss, and ear pain.11

Once exposed to a microgravity environment, there are several changes that begin to occur slowly over time: body fluid redistribution, sinus congestion, blood volume loss secondary to diuresis, neurovestibular changes (disorientation), orthostatic hypotension, anemia, bone loss and muscle atrophy.12 These effects will likely be insignificant for short suborbital fights but can be quite profound for longer orbital flights.

Other interesting but perhaps not clinically relevant physiological impacts of spaceflight may include circadian dysrhythmias (i.e., feeling of jet lag or disturbed sleep patterns), immunosuppression, anorexia, urinary retention and dermatitis.13,14

Medical Challenges

EMS providers need specialized education and training to respond to the unique threats to human health posed by high-altitude flight and spaceflight. Although high-altitude and suborbital flights are unlikely to result in impairment in nominal operations, the extreme flight environments encountered are associated with some unique medical risks.15–18

The risk of decompression illness increases around 18,000 feet as one ascend in the atmosphere.16 This is commonly called the “bends” and affects scuba divers as dissolved nitrogen bubbles in their system, and can develop within minutes causing anything from joint pain and paresthesias to outright paralysis. Untreated, it can even result in death.

As one climbs above 30,000 feet, the decreased oxygen pressure can cause incapacitating hypoxia within seconds, and can be lethal within minutes.18 Pressurized supplemental oxygen becomes necessary to maintain consciousness above 40,000 feet.

Above 63,000 feet, often referred to as “Armstrong’s line,” the ambient pressure drops below the vapor pressure of water at body temperature—47 mmHg. Body fluids start to vaporize, particularly in the lungs, causing significant respiratory injury that’s fatal within 1–2 minutes. Maintaining a pressurized environment by using a pressurized cabin and/or pressure suit is critical to prevent death. Any rapid depressurization can also cause significant barotrauma, which can range from sinus pain and ruptured tympanic membranes to pneumothorax, pneumomediastinum and arterial gas embolism (AGE).16,18

The thermal environment can also cause significant exposure injury, as the air temperature drops approximately 3.8 degrees F (2 degrees C) with every 1,000-foot gain in altitude to a minimum that can dip below
-80 degrees F (-60 degrees C).

Accidents on ascent or an ejection from high altitude can result in significant traumatic injuries. Blunt force trauma and post-crash fires are common injury mechanisms in aviation accidents. In high-altitude falls, the human body has a propensity to enter a “flat spin” that forces blood at high pressure into the head and feet and can cause syncope, intracranial hemorrhage and cardiac contusions.15

In addition to the risks posed by high-altitude travel, there are also significant environmental and industrial hazards on the ground. Commercial spaceflight operations will require a ground crew and supporting equipment similar to an industrial site: toxic fuels, pyrotechnics, high-pressure gases, cryogenic liquids, heavy lifting equipment, moving aircraft (helicopters and fixed wing) and moving vehicles are almost always present.19–21

Further complicating the emergency medical response to commercial spaceflight incidents, paying participants are unlikely to have the uniformly high physical or medical standards that have historically been seen in astronauts. Limited testing has been done to understand the effects of suboptimal baseline health on the ability to tolerate accelerations expected in suborbital flight.22,23 However, it’s still unclear what, if any, real-time monitoring will be available for commercial spaceflight participants to understand the physiologic responses during a normal flight or to provide information to EMS crews in the event of a problem.24 Additionally, crews of these vehicles may be wearing spacesuits, which can impede access to the patient in emergency medical situations.25 As a result, emergency medical responders may see impacts of spaceflight that are outside the normal scope of what has been observed in their prior experience.

Response Planning

Planning begins with familiarity with the flight operations plan, the vehicle being flown and its flight profile, and potential chemical and energy hazards (including familiarity with safety data sheets, handling of pressurized gases, recognizing and treating exposures).26

In addition to unique medical challenges of this type of flight, the logistics of emergency response for spaceflight operations can be difficult. There are currently 11 spaceports located around the U.S., and many of them are in remote areas with significantly long transport times to definitive care. This dictates that a high level of capability should be deployed onsite to maximize survival.21 Because of the austere environment, emergency response plans need to be carefully crafted, coordinated with local authorities and response resources, and frequently reviewed and rehearsed.

Emergency medical response staffing and training plans should be carefully thought out. Staffing should include a medical director well-versed in the specific risks of the spaceflight operation. It should also include a core group of medical providers appropriate for the number of potential victims—not just the pilots and passengers, but ground support crew, observers and members of the press. Onsite and transport protocols should be developed collaboratively by all relevant stakeholders, including the onsite medical director, prehospital personnel (e.g., EMS medical director, operations manager, EMS providers) and medical personnel with operational aerospace medicine expertise and experience.19–21

Protocols already exist for patients who experience ebullism,16 flat spins, are unresponsive,15 or are hypotensive and unresponsive with high-altitude exposures.

Effective evacuation should also be considered, and evacuation modalities need to include alternates for weather risks that could impact helicopter or ship response, and operational issues such as ambulance delays caused by a single access road that gets jammed with observers. The medical transport plan shouldn’t just identify the nearest trauma facility, it should also include the nearest Level 1 trauma hospitals, hyperbaric chambers, burn centers, a redundant facility and other relevant specialized treatment sites. Communications with the possible treating facilities should be started well before operations begin to ensure they’re aware of the unique medical challenges of these patients. A site visit and direct personnel meeting is recommended to establish a relationship before the project gets underway.

During an early World View high-altitude balloon test flight called StratEx, the parachutist had difficulty controlling his parachute during descent. As a result, tracking him became impossible. Due to the danger of having him run out of air in flight, the assistance of a nearby helicopter was requested for tracking support, which successfully located him. This event led to the recognition that air-based assets for tracking plus the ability to immediately deploy high-capability
medical resources was critical to survival and transport in these types of flight activities.17–20

Finally, all providers should be well versed in proper communications protocols, both internally (e.g., the proper use of radios) and externally, in order to both protect patient confidentiality and control the flow of information to the public.21,26


New frontiers of private space tourism and transportation are opening. With these exciting changes come new risks and challenges.

Emergency medical responders for high-altitude flight and spaceflight need to be prepared for a broad range of potential medical problems, challenging logistical issues, and potentially severe environmental conditions. This requires a deep understanding of the risks associated with these types of flight experiences, the development and testing of comprehensive EMS protocols that are coordinated with local resources, and the execution of a complex logistical plan for treating and evacuating injured crew, passengers and spectators in an effective and efficient manner. Successfully accomplishing all of these tasks will ensure access to definitive medical care for patients in minutes rather than hours, enabling a future where many more people will be able to journey to the stars.


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