To the Editor:
We read with interest the essay by Kuypers 1 recommending an additional training in wilderness medicine to train for medical challenges that are expected on space exploration missions. The author states the importance of environmental effects on human physiology and psychology and the need for the ability to learn novel techniques and solutions to problems not encountered in previous medical training. Next to wilderness medical professionals, emergency medical services (EMS) operating in remote and mountainous areas have to negotiate extremely adverse environmental, topographical, and logistical conditions, making clinical decisions without robust evidence-based data. 2 In special situations such as cave rescue, EMS are required to work like a team for an extremely long time, with limited medical resources and continuous stressful factors both for the victims and the rescuers. 3 The dark and alien underground environment of caves offers many analogies to space exploration missions, including isolation and limited resources. Thus, this environment provides a more accessible yet situation-specific training ground. The European Space Agency (ESA) established a course in 2011 for Cooperative Adventure for Valuing and Exercising human behavior and performance Skills (CAVES) in caves. 4 Astronauts who work on the International Space Station come from Russia, Europe, Japan, the United States, and Canada. Astronaut training is different among space agencies, and astronauts do not always have time to get to know each other and implement teamwork. Teamwork is a fundamental element not only in urgent settings and emergencies, but also for prevention issues. The 2-week course not only prepares astronauts to work safely and effectively in an environment where safety is critical but also trains them in teamwork. The procedure for moving along a cave wall resembles spacewalking, and cave explorers need to know that preventing illness or injuries is of paramount importance. As stated by the author, a fall on “Martian rocks” can lead to an emergency situation. 1 The recognition of the correct red flags is a pressing issue, eg, when “you also notice a leak in your suit,” hypoxia seems to be the most pressing issue and not “decompression illness.” Prolonged environmental exposure can also affect human health concerns during exploration missions, eg, the postural-loading demineralization related to microgravity 5 can lead more likely to a lower extremity fracture than to a wrist one.
Behavioral activities are woven into the course to foster effective communication, decision-making, problem-solving, leadership, and team dynamics, a lifesaving element when “communication with Earth is not possible from your position, and you expect the loss of communication will last the next 14 days.” 1 On the other side, caves offer a controlled environment for instructors to adapt a situation to keep astronauts under continuous tension. They can introduce problems that need to be solved, and the astronauts plan their activities, learn from their mistakes, and improve their interactions. 4
An important element of CAVES is the daily debriefing, a typical element of emergency medicine. The debriefing reflects on the successes and errors of the day, on similarities with spaceflight experiences, and on how to reapply successful strategies or improve by learning from mistakes. Finally, the learning is enhanced by the presence of experienced astronauts, who share their valuable flight experience with rookies, similar to the learning process between junior and senior medical consultants.
Science is also an important part of the CAVES course. 4 As on the International Space Station, the cave-training astronauts run experiments each day that have been designed by field scientists. The scientific tasks that the astronauts are asked to carry out during CAVES are numerous, but most importantly astronauts learn how to solve the problems in the collection of reliable data and samples in an austere environment. The same problem arises every time that scientific research is conducted in a prehospital environment, and in particular in wilderness and remote areas. The implementation of the quality of present and future data collection in space missions could provide better insight into various aspects during space exploration missions.
In agreement with Kuypers, we encourage the fostering of teamwork between fields of medicine and science when humans inevitably have to face an extreme environment. Space, wilderness, and emergency medicine, in fact, can learn a lot from each other in their fight between the need of evidence-based guidelines and the paucity of data in terms of population and different experiments.