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  Apollo 15: Mission Control and Irwin's heart issues (Page 2)

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Author Topic:   Apollo 15: Mission Control and Irwin's heart issues
Blackarrow
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posted 02-18-2014 08:26 PM     Click Here to See the Profile for Blackarrow     Edit/Delete Message   Reply w/Quote
Eddie, apologies for the delayed response, but to wrap this up (?) I can't answer technical medical questions, other than by quoting from the available NASA literature.
quote:
Originally posted by moorouge:
Who were the flight surgeons on Apollo 15? Wouldn't it have been their call rather than Berry's?
To the best of my knowledge, Dr. Charles Berry was NASA's Chief Medical Officer at the time of Apollo 15. I assume there were several other doctors in his team in Mission Control, but it was Berry who told Kraft, Kranz and the other senior personnel about Irwin's heart problems. They were not going to ignore NASA's senior doctor's concerns.
quote:
Wasn't it correct that post flight examinations revealed that Irwin was suffering from hypokalemia?
What happened after splashdown is neither here nor there: the important point is the nature of the discussion triggered by Berry's concerns while Apollo 15 was in lunar orbit. There is no record of that discussion and therefore no record of precisely why a decision was clearly taken not to inform Scott. The only clues are to be found in the brief accounts (very similar) in the books by Kraft and Kranz.

The point I have been making, and stand by, is that the level of concern attributed to Berry should certainly have resulted in the issue being referred to the mission commander. The only logical reasons why Scott was not informed would have been (1) a general discussion in Mission Control resulted in Berry conceding that there really wasn't a problem at all; or (2) the "top brass" of NASA feared that if Scott was informed, he might "do a Wally" and make his own onboard decisions (like Schirra on Apollo 7) about how best to protect the health of one of his crewmembers.

If the written accounts of Kraft and Kranz are correct, theory (1) seems unlikely. That leaves us with theory (2): NASA officials could not predict how Scott would respond, and that meant a risk to the forthcoming EVA to retrieve the SIM bay film cassettes.

This issue was discussed with Dave Scott in the Apollo 15 Flight Journal. He believes he would have allowed the EVA to proceed, but only after a detailed discussion with Houston, and with Irwin sitting quietly in a couch while Scott himself assisted Worden. But of course we will never know for sure how events would have unfolded because the one undisputed fact is that Houston did not tell Scott.

moorouge
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posted 02-21-2014 03:29 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Geoffrey, I'm not disputing your right to express the opinion that Scott should have been told if it was deemed necessary to do so. However, I am questioning whether this was in fact the case.

The Flight Directors for '15' were Gerald Griffin (Shift 1), Milton Windler (Shift 2) and Glynn Lunney/Gene Kranz (Shift 3). The only comment I can find about medical problems on '15' by others than Kranz are by Griffin after the first EVA on the Moon. This was that Scott's use of oxygen was higher than expected. From this rather flimsy evidence I would suggest that despite Berry''s comment, the general opinion amongst the other Flight Directors was that Irwin was doing fine and his irregular heart beat was not a concern. This being the case, I suggest that the question of whether Scott should be informed did not arise.

I'd still like to find some input from the Flight Surgeons for the mission. The only name I've been able to find was William Hawkins who was FS for Apollo 13. Was he involved with '15'? If so, what was his opinion?

Perhaps others can have better luck researching these queries than I've had.

On edit - Glynn Lunney makes no mention of an issue with Irwin in his lengthy interview for NASA Oral History, nor can I find any mention of this by Milton Windler.

Blackarrow
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posted 02-23-2014 03:14 PM     Click Here to See the Profile for Blackarrow     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by moorouge:
Geoffrey, I'm not disputing your right to express the opinion that Scott should have been told if it was deemed necessary to do so. However, I am questioning whether this was in fact the case.
Eddie, you make it sound like you support the right of anyone, however deluded, to express any opinion, however outlandish.

In this case, I must again refer to Chris Kraft's direct quotation from Dr. Charles Berry, commenting on Jim Irwin's EKG: "It's serious. If he were on Earth I'd have him in ICU being treated for a heart attack."

Berry was the chief flight surgeon. What the other doctors thought is somewhat academic, but I note that you aren't in a position to quote any contradictory medical opinions from Berry's team.

Since Berry's comment was the medical position as relayed to the senior personnel charged with controlling the mission, I am happy to leave it to anyone still following this rather repetitive debate to answer the simple question: If you were the commander of the mission, would you expect to be told about your crewmember's aberrant EKG readings and the concerns expressed by NASA's senior medical officer?

And on that note I rest my case.

Robert Pearlman
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posted 02-23-2014 03:48 PM     Click Here to See the Profile for Robert Pearlman   Click Here to Email Robert Pearlman     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by Blackarrow:
"It's serious. If he were on Earth I'd have him in ICU being treated for a heart attack."
If the sole source for this quote is Kraft's "Flight," then I would suggest that it is open to question. Kraft himself reportedly stated that he wrote the book based on his memory, and that it may not necessarily always reflect how the events played out. Can you remember the exact words you said to someone — or someone said to you — 30 years ago?

But let's say we accept everything Kraft wrote as gospel. Then what does he write immediately following that quote?

"What do we do?" I [Kraft] asked.

"Find out how he's feeling." Berry sent the query through the capcom and Irwin was honest. He was tired and felt a strange heart sensation. He was 240,000 miles and a high-g reentry from the nearest hospital. My own heart skipped a beat.

"The truth," he said, "he's already in an ICU. He's getting one hundred percent oxygen, he's being continuously monitored, and best of all, he's in zero g. Whatever strain his heart is under, well, we can't do better than zero g."

We stood at Berry's console and watched the EKG trace. Within minutes, it went back to normal. It stayed there all the way home, but no flight surgeon took his eyes off that trace for more than a moment...

As you, yourself, have pointed out in this thread, Kraft's account of Irwin's heart being continuously monitored all the way home is incorrect, so the passage is already subject to critique.

But if the gist of what Kraft writes is true than there was absolutely no need to inform Scott, as Scott was not in a better position than the flight surgeons to make a medical judgement.

Could they have told Scott? Sure, but to suggest (with hindsight) that they should have contradicts what Kraft wrote. And if you're going to doing that, then you can't pin your argument on Kraft's own writing.

schnappsicle
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posted 02-24-2014 05:00 AM     Click Here to See the Profile for schnappsicle   Click Here to Email schnappsicle     Edit/Delete Message   Reply w/Quote
I don't know about anyone else, but I'm not the least bit surprised the crew wasn't informed of Irwin's condition following lunar liftoff.

I would hope that Berry, being a doctor, would have known exactly what was going on with the crew, including Irwin. I don't know for sure, but I'd be willing to bet that if Berry had any reservations about Irwin's ability to carry out his part of the transearth EVA, it would not have taken place.

Sure Scott was the commander, but I don't believe he had a medical degree. Why would he choose not to do the EVA if he's not an expert on Irwin's condition? It would have taken him years to learn everything necessary in order to make an informed decision. It seems to me that Scott's only choice in that matter would be to defer to the doctors on the ground (Berry and his staff).

The one thing NASA was good at was speeding up the training process by breaking up the tasks. If everyone had to learn everything required to be an astronaut, we'd still be waiting for Shepard to make the first flight. The tasks were broken up for a reason. Everyone had to rely on everyone else, including the doctors, in order for the missions to run as smoothly and efficiently as they did.

The crew is informed of things on a need to know basis. Obviously, the Flight Directors felt that the crew did not need to know about Irwin's condition because they couldn't have done anything about it anyway. Besides, why worry them needlessly?

If they were informed, they would have had more things to think about than getting home. In other words, they might have been so eager to get Jim back that they would have forgotten to do something on their checklist, or they would have done the task wrong. In that case, we'd be having a totally different discussion right now.

Blackarrow
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posted 02-24-2014 06:57 PM     Click Here to See the Profile for Blackarrow     Edit/Delete Message   Reply w/Quote
I disagree with the last 2 posts, so I am reluctantly re-opening my case.

Robert, Chris Kraft's Dr Berry quote is very specific, and it is broadly corroborated by Gene Kranz's account. As I posted on 9th February at 08.59pm, it's a matter for you whether you choose to believe Kraft's account. I agree that his subsequent reference to continuous monitoring of Jim Irwin's EKG is incorrect. So, incidentally, is the suggestion that Irwin was quickly asked, via Capcom, how he was feeling. That didn't happen: the first contact with the crew (very obliquely) on the issue of health was Deke Slayton's unexplained suggestion, 54 minutes after the bigeminy incident, that Irwin and Scott should take Seconal tablets. [On edit: does a sound recording exist of the discussions at Mission Control during those 54 minutes leading up to Deke's call to the crew? That would make interesting listening...]

I'm tempted to suggest that Kraft's two incorrect observations represent what he thought in retrospect ought to have been the consequences of Berry's revelation.

The "It's serious...." quote by Kraft is just too significant to have been made up or exaggerated. Kranz's account is consistent with Kraft's on that point at least. And the medical record does confirm that Irwin suffered bigeminy at that time.

I really think if anyone wants to challenge the essential truth of Kraft's Berry quote, the only person who can help would be Berry himself. Can he be contacted?

Robert again: I'm seriously puzzled that you would conclude from this debate that there was "absolutely no need to inform Scott, as Scott was not in a better position than the flight surgeons to make a medical judgment." You completely miss the point: the mission commander makes command decisions, but can only do so if he has all relevant information at his finger-tips. Had he been told, he could (and he has confirmed that he would) have debated the issue with Houston and if the doctors had satisfied him that there was no problem, then the mission would presumably have continued without many, or any, changes to the flight plan. Except that they probably WOULD have insisted on continuous monitoring of Irwin, something they couldn't do without telling Scott the background.

Schnappsicle: you suggest that the crew is told things on a "need to know basis." Absolutely. But that ought to include concerns about a crewmember's health, particularly when a forthcoming event in the flight plan (i.e. the deep-space EVA) calls for physical activity and concentration on that crew-member's part. It is NOT a matter for the doctors to make decisions on behalf of the mission commander, without giving him the necessary information.

You suggest that if Berry had had any reservations about Irwin's ability to carry out his part of the EVA, it would not have taken place. Two points: Berry was on Earth and had no personal experience of spaceflight. He could advise and warn, but was not best placed to make operational decisions. Second: one of the key individuals in Mission Control at that time was Deke Slayton, who had bitter personal experience of what happens to an astronaut when doctors raise health issues (and in his case the heart irregularities were considerably less significant). I can't help wondering if Deke was thinking: "Here we go again!"

As Kraft points out on p.163 of his book: "Slayton was the victim of overly fretful doctors and a NASA heirarchy that turned timid when it should have been bold."

Except that on Apollo 15, the decision to carry on being bold ought to have been a decision in which the crew, or at least the commander, had informed input.

Finally, if anyone doubts my conclusion that Scott should have been told, I call as my key witnesses the two people whose views should be respected without argument:

DAVE SCOTT: "Had we been informed of Jim's situation the Flight Director and I would have discussed the options in detail and would have jointly made a decision, the ultimate responsibility for which would have been mine as field commander." ('Footprints in the Dust' page 264).

AL WORDEN: "Still, the ground should have told Dave. As commander he needed all available information about his crew. By the time we got to sleep I'd been awake for more than 21 hours and my crewmates for 23. If we had known of Jim's serious condition we would have stopped much earlier. Instead, we slogged on for three and a half hours after Deke's call [the Seconal suggestion] before we finally finished our day." ['Falling to Earth' page 206].

They were actually there.

Robert Pearlman
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posted 02-24-2014 07:26 PM     Click Here to See the Profile for Robert Pearlman   Click Here to Email Robert Pearlman     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by Blackarrow:
The "It's serious...." quote by Kraft is just too significant to have been made up or exaggerated.
I don't understand the logic of selectively trusting someone's memory when there are demonstrable errors in the account as a whole. But that aside...
quote:
...the only person who can help would be Berry himself. Can he be contacted?
I agree, and yes, I am reaching out to someone who knows him (or at least knows how to reach him).

On edit: I will add though, that I think the fact that Scott wasn't told speaks more to the truth of the situation than anyone's recollection of the events 30 to 40+ years later. At the time of the mission, those with direct knowledge of the situation didn't feel it necessary to tell Scott and nothing in the historical record suggests that their decision was made without basis.

moorouge
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posted 02-25-2014 02:11 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Geoffrey - got my 'devil's advocate' hat on again.

What evidence is there that Slayton's suggestion that the crew take sleeping tablets were related to Irwin's heart irregularity and not simply to ensure the crew had sufficient sleep before facing critical tasks the next day? Isn't it the case that the crew were over-tied?

Seemingly lost in all this are two minor points that may, or may not, have a bearing. Scott had displayed a minor heart irregularity and was reported by Gerry Griffin at a press conference that his oxygen use was over expectations; Irwin had no water on the first EVA and was thus dehydrated, this being a well known cause of a heart irregularity. One has to give some weight that Irwin said he felt fine, was displaying no other symptoms of a heart attack and that his heart beat was regular for the remainder of the flight.

On edit - did Irwin have a heart attack? As a lawyer, Geoffrey, I'm sure you'll appreciate the Scottish trial verdict of 'not proven'.

An afterthought - if there was a genuine, real concern about Irwin's condition by Berry why wasn't it recommended that he take aspirin - a recognised initial treatment to thin the blood? The only aspirin use on '15' was by Scott to relieve a shoulder strain.

YankeeClipper
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posted 02-25-2014 08:03 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
Here's an interesting commentary from the Archives of Internal Medicine Arch Intern Med January 1, 1972, Vol 129, No. 1:
Anti-arrhythmic aboard

Procainamide hydrochloride capsules will be in the astronauts' medical accessory kit for the first time when Apollo XVI heads for the moon in March...

An anti-arrhythmia agent is being added because of experiences during the Apollo XV moon flight last summer, when a few premature ventricular contractions were registered by Col James B. Irwin, and a few auricular contractions by Col David R. Scott. Monitors on Col Irwin also registered what was interpreted to be brief nodal bigeminy.

Dr. Berry emphasizes that, although these premature contractions were occasionally noted in Cols Scott and Irwin during preparations for the July-August 1971 mission, so far none have been seen in the Apollo XVI crewmen.

The only other cardiac rhythm abnormality recorded during a United States space mission was during the Mercury orbital mission of Col. John H. Glenn, Jr., ten years ago.

Training for the forthcoming Apollo XVI mission includes instruction about the nature of premature contractions and how to use the procainamide hydrochloride capsules with medical advice.

Wise medical advice cautions a good physician to certainly take close note of diagnostic sensor signals but to always observe the patient first and foremost. For example, a disconnected ECG lead may suggest a patient has flat-lined and is apulsatile and asystolic when they are actually very much alive and talking.

moorouge
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posted 02-25-2014 09:55 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Both '16' and '17' had four additional tablets in their medical kits that the previous Apollo flights did not.

There were 80 tablets of pronestryl, a drug used to surpress abnormal electrical heart impulses and to allow the heart to return to normal beating. This was to be used with medical advice and only in severe situations.

There were 12 tablets of lidocaine. This was usually used as a painkiller, though in exceptional circumstances could be used to control an abnormal heart rhythm.

There were 12 tablets of atropine which was used to correct/control gastric problems.

Finally, there were 6 tablets of demerol, another pain killer. It was this drug that was thought to be involved with the death of Michael Jackson.

sev8n
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posted 02-25-2014 12:52 PM     Click Here to See the Profile for sev8n     Edit/Delete Message   Reply w/Quote
Since it would be impossible(?) to administer/ingest these tablets during an EVA I assume they were to be taken before suiting up to prevent a speculative problem rather than to address the problem after the onset of symptoms?

YankeeClipper
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posted 02-25-2014 03:53 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
Procainamide (Pronestryl) is a class Ia anti-arrhythmic sodium channel blocker whose indications include premature ventricular contractions (PVCs) and ventricular tachycardia (VT).

Lidocaine was an important class Ib anti-arrhythmic indicated for the treatment of ventricular arrhythmias, particularly those associated with acute myocardial infarction e.g. ventricular fibrillation (VF) and ventricular tachycardia (VT).

Atropine is a non-selective muscarinic acetylcholinergic antagonist which enhances cardiac conduction and was indicated for severe bradycardia.

Meperidine (Pethidine/Demerol) is a synthetic opioid analgesic indicated for acute pain.

PVCs can be induced by dehydration, intense physical exertion, electrolyte imbalance, a cigarette and cup of coffee, or they may occur spontaneously during normal activity. Premature ventricular beats may also occur after suffering a heart attack or having compromised overall heart function, which occurs in the setting of heart failure. Premature beats in these settings need to be evaluated carefully because they can signal a person at high risk for experiencing sudden cardiac death. Echocardiogram, cardiac catheterization, and electrophysiology studies are all potentially helpful to further delineate a person's risk for sudden death in the presence of frequent premature beats.

So basically the ECG signals on Apollo XV could have been simply due to the stresses of EVA, or a possible sign of something more ominous. Any flight surgeon would be legitimately concerned. A possible reason not to alert the crew may have been the desire not to further exacerbate the cardiac arrhythmia by inducing the extra stress of anxiety. A mission commander needs to be privy, however, to anything that adversely impacts on the health of his crew. It's a tough judgement call with merits for both arguments. The ancient medical wisdom of wait and see seems to have prevailed - ultimately, had Irwin suffered a serious cardiac event there was very little useful intervention possible aboard an Apollo CM.

It is clear, though, from the additional pharmacological agents being added to the medical kit, that NASA felt they needed to beef up their arsenal to cope with any eventuality. With the extended nature of the J missions and increased workload, this measure may have been simply precautionary and prophylactic or based on a genuine expectation of an adverse event during EVA. The cumulative experiences of Gemini IX and Apollo XV likely had raised sufficient red flags and provided the main impetus for the extra drugs.

moorouge
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posted 02-26-2014 02:59 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Which is what has been said, though not using such posh words.

However, whilst bowing to Yankee Clipper's superior knowledge, I would dispute his description of lidocaine. All the websites I consulted before posting my list of the extra drugs carried after the '15' flight say that lidocaine is primarily used as a painkiller. Only on specific occasions when deemed necessary by a doctor might it be used to control an abnormal heart rhythm.

Might I add one other point to the general discussion on whether Irwin actually had a heart attack. Today, and this is from bitter experience, the only way it can be determined without question that a patient has suffered a heart attack is by a blood test to see if a specific enzyme is present. This is released by the damaged muscles in the heart during the attack.

One has to assume that this test was not available 40 years ago. Nevertheless, the tests done on Irwin post flight did not come to the conclusion that his heart irregularity was caused by an attack but were the result of other difficulties encountered on the mission.

YankeeClipper
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posted 02-26-2014 07:06 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
Yes, that's correct early 21st Century gold-standard cardiac care involves diagnostic biomarker tests such as coronary arterial calcium scoring to predict a myocardial infarction (MI), and measurement of serum levels of cardiac enzymes e.g. creatine kinase (CK) and its myocardial MB isoenzyme to confirm a MI.

Cardiac troponin (cTn) testing is also an essential component of the diagnostic workup and management of acute coronary syndromes (ACS). Assays for cTn, namely cardiac troponin I (cTnI) and cardiac troponin T (cTnT), are the preferred diagnostic tests for ACS, in particular non–ST-segment–elevation myocardial infarction, because of the tissue-specific expression of cTnI and cTnT in the myocardium. The results of cTn testing often guide the decision for coronary intervention.

CK testing would have been state-of-the-art in the late 1960s. CK-MB testing emerged in the mid-1970s, and cTn testing emerged in the early-1990s. Source

Following onset of symptoms of myocardial infarction CK and CK–MB increase in serum within 3 to 6 hours; the peak levels occur between 16 and 30 hours. Significantly, CK–MB disappears from the serum at a more rapid rate than CK. For example, CK–MB returns to normal by 24 to 36 hours, whereas the elevated CK levels may be detected for up to 60 hours. This "window" dictates that CK and CK–MB must be determined as soon as possible after the onset of symptoms, and repeated several times in the first 48 hours. Source

In the absence of serum enzyme levels and any further abnormal ECG, and in the presence of an asymptomatic patient, then unless a flight surgeon wanted Irwin to undergo post-flight coronary angiography, it would be very difficult in 1971 to say definitively if any truly adverse cardiac event had occurred or not. During a mission and in the absence of any hard diagnostic data, all a flight surgeon could do remotely would be to adopt a concerned cautious approach and monitor his patient.

YankeeClipper
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posted 02-26-2014 03:47 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
From Circulation 1963 28 p486-491:
The Antiarrhythmic Properties of Lidocaine and Procaine Amide

The operative management of patients with congenital or acquired heart disease is often complicated by the occurrence of ventricular arrhythmias. Bigeminal rhythm or premature ventricular contractions are frequently noted with the induction of anesthesia, with tracheal intubation, during dissection and manipulation of the heart and great vessels, and with nasotracheal aspiration in the postoperative period. Their initial occurrence is most often related to a temporary period of hypoxia...

Lidocaine and procainamide are structurally similar and both have local anaesthetic and anti-arrhythmic properties. Lidocaine was very popular in the 1960s as an anti-arrhythmic agent but mainly via the intravenous (IV) or intramuscular (IM) routes. Oral (PO) administration would have been sub-optimal, but even when administered orally 30% of lidocaine is systemically available and depending on the dose may have offered some benefit.

From the American Journal of Cardiology Am J Cardiol Vol. 20, Issue 4, October 1967, Pages 475–483:

Intensive coronary care:
Arrhythmias after acute myocardial infarction
Patrick Mounsey, M.D.

Cardiac arrhythmias after acute cardiac infarction were previously thought to be rare, this opinion having been based on clinical observation and routine electrocardiography. Recently, continuous electrocardiographic monitoring has shown that transient arrhythmias after cardiac infarction are relatively common. Indeed, if simple extrasystoles are included, they probably occur in over 80 per cent of patients, while more serious arrhythmias are seen in roughly 60 per cent. The arrhythmias develop during the first 10 days after acute cardiac infarction ; many are asymptomatic, short-lived and terminate spontaneously without specific antiarrhythmic treatment. Others, however, are potentially serious and call for highly specialized forms of treatment, including the use of antiarrhythmic drugs, electrical pacing for complete heart block and resuscitation of cardiac arrest. It is essential in planning an acute coronary care unit to provide continuous electrocardiographic monitoring during the first two to three days and for as long as arrhythmias continue, which may be up to a week or 10 days in certain cases. Only thus can arrhythmias be rapidly recognized and immediate appropriate treatment given where required...

The essential features of arrhythmias after acute cardiac infarction are their transience and rapidly changing nature.

Berry was certainly justified in his concerns. It is uncertain whether the arrhythmias observed were premonitory and a portent of future cardiac events in Irwin's life. They could have been reflective of undiagnosed cardiovascular disease or the result of a myocardial insult inflicted during the EVA and which either led to or exacerbated later cardiac arrests. The benefits of an oxygen enriched and low-g environment may well have masked a myocardial injury that would have been more obvious and detectable on Earth.

moorouge
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posted 02-27-2014 01:26 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
This is quite interesting but beside the point. The debate between myself (for one) and Blackarrow (Geoffrey) is not so much whether Irwin had a heart attack but whether the irregular heart beats noticed on ECG traces were of sufficient concern to Flight Surgeons/Flight Directors to warrant Scott being told.

All there is to go on is a comment made by Berry as recorded sometime after the event. Geoffrey maintains that this is proof that Scott should have been told. Others, myself included, maintain that since Scott wasn't informed, there wasn't the concern on the ground to make this necessary.

I hope that this is a fair summary of what has gone before. So, can we get back to it.

YankeeClipper
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posted 02-27-2014 08:51 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by moorouge:
This is quite interesting but beside the point...
Really?

Before anyone can properly assess the decision to inform Scott or not, it's important to understand what constituted state-of-the-art cardiac care in 1971 - this would have been the benchmark against which a flight surgeon's decisions would be judged by himself and his peers. This is then tempered by the practical reality of the highly unique patient environment in the field. Compromise decisions inevitably are the result.

Berry was faced with a very difficult decision - having to weigh institutional (NASA) and national (US) program pressures against limited but potentially life-threatening clinical signs. Very often in medicine it is only with time that a pattern of signs and symptoms emerges to confirm a suspicion or diagnosis. Berry needed to make a decision in real-time fast.

What data did Berry have to work with? In Irwin's case it was the history of a well conditioned, physically fit, routinely examined 41-year old white male with a highly stressful occupation. Stress is a known pre-disposing risk factor for cardiovascular disease. Berry had noticed PVC waves in training. Now his patient was dehydrated after a period of intense physical exertion and throwing off PVC and nodal bigeminal (NSR-PVC-NSR-PVC) waves with declared symptoms of fatigue and an unusual heart sensation. Berry had no serum biomarkers to work with. The patient's environment was oxygen enriched and low-g. What should/could he have done?

What he was remotely seeing could easily have been attributed to intense exertion or it could have been the result of a myocardial insult/infarction. 50-50 either way - no way to tell for sure so far away. Was it potentially serious? Absolutely, a worrying ECG trace, no question about it.

The correct decision was to monitor closely over the next 48-72 hours, without unnecessarily alarming the patient and adding unhelpful anxiety into the mix. The patient's ECG reverted to normal and the patient became asymptomatic. I'm speculating but if Irwin had displayed more episodes of cardiac arrhythmia, Berry would most likely have intervened, red-flagged the issue to Scott and insisted on complete rest for Irwin. In the end, the call was made to wait-and-see which paid off in the short-term. Ultimately, we know the subsequent patient history and outcome. What happened on the EVA may or may not have been the genesis of later events, but it was not positive for Irwin's health and was likely the first clear flag of underlying trouble in the future.

YankeeClipper
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posted 02-27-2014 09:06 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
In Circulation 1998; 97: 119-120,
William J. Rowe, MD, Former Assistant Clinical Professor of Medicine,
Medical College of Ohio at Toledo, wrote about The Apollo 15 Space Syndrome. The full text can be read here.

In Spaceflight, Vol. 47, March 2005, p. 113., William J. Rowe, MD wrote:

Cardiovascular problem on Moon almost fatal

On the Moon, Irwin's heart rate rose to a dangerous level of 167 per minute after just two hours on the lunar surface [1] and he lost consciousness as a result of a brief heart rhythm disturbance, while transferring gear from the lunar to the command module [2].

References

1. Apollo 15 mission report, NASA Manned Spacecraft Center, Houston, Texas, 1971 10-1-15 NASAmsc.05161.

2. R.S. Johnson, L.F. Dietlein and C.A. Berry (eds) Biomedical Results of Apollo, Washington DC. NASA 1975: 227-264, 573-579, 581-591, NASA SP-368.

The full commentary can be read here.

Significant tachycardia, and exertional syncope with cardiac arrhythmia would definitely have worried any NASA flight surgeon.

Michael Davis
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posted 02-28-2014 09:06 AM     Click Here to See the Profile for Michael Davis   Click Here to Email Michael Davis     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by YankeeClipper:
(Irwin) lost consciousness as a result of a brief heart rhythm disturbance, while transferring gear from the lunar to the command module

Jim Irwin did not lose consciousness at anytime during the Apollo 15 mission. The "Biomedical Results of Apollo" publication was cited for that by Dr. Rowe. Take a look for yourself and see if you can find that reported. Also ask yourself if you have ever seen that event stated in any other official document, autobiography, or history of the mission. Irwin did say that he felt 'lightheaded."

As for the "elephant standing on my chest" quote from "To Rule the Night", well, it was a 6g reentry from a lunar mission. That sensation would appear to be the norm, and not a symptom of angina. Also note that Irwin does not mention losing consciousness during the flight in his own autobiography.

This publication linked was a letter to the editor and not a peer reviewed scholarly article. Dr. Rowe's work on the subject seems to be an odd assortment of random facts pulled together to form a "syndrome." I don't find painful and swollen fingers to be a troubling sign of cardiac problems. I find it to be expected after some 19 hours of difficult work while wearing stiff Apollo-era EVA gloves.

We seem to be headed toward conspiracy theory land. Personally I place Chris Kraft's quotes on the subject into the questionable bin as well. I get suspicious when I see direct quotes being employed from a conversation what took place some 30 years in the past. That is especially true when there is no other source to confirm the date or context of that conversation.

YankeeClipper
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posted 02-28-2014 03:11 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by Michael Davis:
Jim Irwin did not lose consciousness at anytime during the Apollo 15 mission.
In Section VII Chapter 2 [587-588] of SP-368 Biomedical Results of Apollo, Charles A. Berry, M.D wrote:
Apollo 15 will remain an anomaly in the Apollo Program. Preflight and inflight activities went well. The lunar surface operations were characterized by heavy work schedules and some sleep difficulties. The crewmen worked to a point of near exhaustion on some occasions, and the Commander pulled a shoulder muscle while operating the lunar surface drill. The pain from the muscle injury interfered with his sleep on the lunar surface and during the return flight to Earth, and persisted for several weeks. At the conclusion of Apollo 15's lunar surface activities, a very tired crew departed the moon to rendezvous with the Command Module.

The schedule of the labors after the link-up was also heavy, and the Command Module Pilot had to rely on his already fatigued companions to transfer equipment from the Lunar Module to the Command Module, a task he himself had been slated to perform. Once transfer operations were complete, difficulty was experienced in sealing the hatch between the two vehicles. This problem necessitated two additional lunar orbits and additional labors before the tunnel connecting the vehicles was successfully sealed and the LM could be jettisoned.

After Lunar Module jettison, the crew was engaged in a space suit integrity check when a bigeminal rhythm appeared on the console monitoring Astronaut Irwin's electrocardiogram. Paper copies of the trace were called for to establish that the irregularity was not artifactual. The bigeminal arrhythmia lasted for 10 to 20 beats, and was followed by a series of premature ventricular and atrial beats, interspersed with normal ones. One other crewman had exhibited some arrhythmias, but they were far less serious than those with which Astronaut Irwin was afflicted. The crew had transmitted no messages indicating a problem. In fact, Astronaut Irwin reported later that he had experienced a feeling of a brief loss of contact as though he had momentarily gone to sleep. In retrospect, this episode could have been a momentary loss of consciousness at the precise time the arrhythmia was noted. After the arrhythmias were noted, continuous electrocardiographic recordings were obtained for all three crewmen while they slept.

It took the Apollo 15 crew three to four weeks after the flight to return to preflight normal levels of exercise and cardiovascular orthostatic tolerance. This was the longest recovery period seen in our space program and was uncomfortably reminiscent of the findings of the eighteen-day Soviet Soyuz 9 mission. This Soviet mission had been marked by a prolonged recovery wherein cardiovascular, vestibular, and musculoskeletal difficulties were experienced by the crewmen. While it would have been, ideally, preferable to shield the two astronauts from public attention, it [588] was judged in the best interest of the space program to provide information about their conditions.

There is a reasonable basis for suspecting that the Apollo 15 crew was launched with a potassium deficit. They had engaged in very rigorous training for lunar surface tasks prior to this space mission in intense summer heat. The crew drank considerable amounts of an electrolyte solution during this training, which tended to leach potassium from the system. These factors, coupled with inflight diets that were not particularly high in potassium, are believed to have contributed to negative potassium balances.

Apollo 16 and 17 crewmen were free of any cardiac difficulties during their missions. This may have been in part due to the institution of a program involving dietary potassium supplements and revised work/rest schedules to preclude a negative potassium balance. Such a negative balance can contribute to cardiac irritability and can predispose to arrhythmias. The crews of both missions were also free of any clinical illness during flight. Again, the meticulously conducted Flight Crew Health Stabilization Program seemed to be effective. All crewmen took sleeping medications to ensure sufficient rest to complete busy lunar surface schedules. Both the Apollo 16 and 17 missions were unqualified successes from an operational and a medical standpoint.

In Section VII Chapter 1 [575] of SP-368 Biomedical Results of Apollo, Lawrence F. Dietlein, M.D. wrote:
One of the Apollo 15 crewmen experienced a single run of bigeminal cardiac rhythm (22 coupled beats) as he lay in his couch observing Lunar Module tunnel leak rates. This was the fir-t significant arrhythmia observed during any American space flight. Another Apollo 15 crewman exhibited a few supraventricular premature contractions resulting in coupled beats but not a sustained bigeminal rhythm. It was at first conjectured that a dietary deficiency of potassium might have been a contributory factor. Subsequent careful analysis of the dietary intake and mission simulation studies with potassium restriction failed to substantiate this hypothesis. The etiology remains obscure. Fatigue following strenuous lunar surface activity most certainly was a factor. Other contributory factors are speculative and are likely to remain so. It should be noted that the crewman with the sustained bigeminal episode subsequently sustained a myocardial infarction in April 1973, some 21 months after his flight of July 1971. Thus, coronary atherosclerosis was very likely a factor in this case.
As regards Dr. Rowe's hypothesis, his background entitles him to hold his opinion, which I posted to add a further medical viewpoint to the discussion. His views were published in the peer-reviewed Circulation and open to his peers to agree/disagree with him.

Blackarrow
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posted 02-28-2014 03:32 PM     Click Here to See the Profile for Blackarrow     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by Michael Davis:
Personally I place Chris Kraft's quotes on the subject into the questionable bin as well. I get suspicious when I see direct quotes being employed from a conversation what took place some 30 years in the past. That is especially true when there is no other source to confirm the date or context of that conversation.
You seem to have overlooked Gene Kranz's very similar account on p.363 of "Failure is Not an Option." I grant you he doesn't repeat Kraft's Berry quote, but he wasn't privy to the conversation between Berry and Kraft. However, Kranz DOES confirm both the date and the context of the conversation.

moorouge
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posted 02-28-2014 04:22 PM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
I notice the word could in the passage highlighted by Yankee Clipper in his extract of the Berry report. The use of this word only indicates that Berry has an opinion that it was a possibility, not that it was the actual explanation.

Michael Davis
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posted 02-28-2014 04:39 PM     Click Here to See the Profile for Michael Davis   Click Here to Email Michael Davis     Edit/Delete Message   Reply w/Quote
Gene Kranz's account in “Failure in Not an Option” certainly does not support the extreme Charles Berry accredited statement of "I would have him in an ICU" as made by Chris Kraft in 2001. He does say that Bob Gilruth, Charles Berry, and Chris Kraft had a discussion in front of him about James Irwin's irregular heart rhythms.

Kranz also noted frustration that as a flight director, he was not informed sooner. Please note that once he was fully informed, he did not make the call to inform the crew. He likely considered the situation to be under control and saw the next steps as suggested by the flight surgeons to be appropriate. He certainly did not see the need to pull the flight crew into the discussion or he would have done so.

In terms of dates and context: if Dr. Berry's statement was made to Kraft five years after the mission over a few Scotches while discussing the "good old Apollo days" they bear little weight. If they were made in Mission Control as the situation was unfolding that would be a different matter. Kranz's account and subsequent actions do not support the extreme level of concern as stated in the latter version. There is also no other independent account that I have seen to support Kraft’s stated level of concern, much less one from Charles Berry or other flight surgeons

YankeeClipper
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posted 02-28-2014 07:59 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
In Section VII Chapter 2 [587-588] of SP-368 Biomedical Results of Apollo, Charles A. Berry, M.D wrote:
One other crewman had exhibited some arrhythmias, but they were far less serious than those with which Astronaut Irwin was afflicted.
It would seem that Berry is implying here that Irwin's cardiac arrhythmias were serious.

YankeeClipper
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posted 02-28-2014 10:08 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
In Section II Chapter 1 [71-73] of SP-368 Biomedical Results of Apollo W. Royce Hawkins, M.D. and John F. Zieglschmid, M.D. wrote:
Shortly after docking with the Command Module at 178 hours ground elapsed time (GET), the Lunar Module Pilot experienced five ventricular prematurities in a 30-second period. Approximately one hour later at 179:07 GET, while the crewmen were observing the Lunar Module tunnel leak rate in their couches, the Lunar Module Pilot suddenly converted from normal sinus rhythm to a nodal bigeminal rhythm. During the 14 seconds in which the abnormal rhythm persisted, a total of eleven coupled beats were observed. The Lunar Module Pilot s heart rate preceding and during the arrhythmia was approximately 95 beats per minute. One and one-half minutes prior to onset of the bigeminal rhythm, his heart rate had peaked at 120 beats per minute for a 20-second period. Following this bigeminal episode, the Lunar Module Pilot experienced approximately ten additional premature atrial contractions during the time he was monitored over the next 60 hours of the mission. The last atrial prematurity in the Lunar Module Pilot was observed at 240:24 hours GET. The Lunar Module Pilot's premature ventricular contractions, however, persisted at the previously cited rate of one to two per hour.
Any NASA flight surgeon seeing tachycardia followed within minutes by nodal bigeminy would have been alarmed. With no direct access to the patient, no serum biomarkers, and no knowledge in real-time of what was coming next, a physician would have cause to worry.

Incidentally, in addition to the Pronestyl, Lidocaine, and Atropine carried in the Command Module Medical Kit on Apollos 16-17, the Lunar Module Medical Kit also carried Pronestyl, Injectable Lidocaine and Injectable Atropine all for cardiac arrhythmia. This information is detailed in Section II Chapter 1 [63-65] Tables 12-14.

moorouge
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posted 03-01-2014 02:40 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Might I suggest that what was written AFTER the event, however learned and possibly correct, is totally irrelevant. What is (was) important is what was said and observed at the time.

Scott himself went to great lengths to emphasise that what was said, how it was said and the context in which it was said was just as important as the data being shown on the monitors in Mission Control. He said that those directly involved with the flight had spent many months working together, not just to refine the detail of the flight but also to develop a bond whereby the seriousness of any problems that might not be immediately obvious could be quickly recognised and acted upon.

With this in mind, I would suggest that the irregularity on an ECG trace shown by both Scott and Irwin and taking into account the circumstances surrounding those traces together with the voice exchanges between the astronauts and the ground, there was little concern in Mission Control that would warrant a direct intervention on medical grounds AT THE TIME.

Further, was there another logical explanation to account for the ECG traces displayed by two healthy crew other than a heart attack? Yes there was. Exertion, stress and in Irwin's case severe dehydration.

YankeeClipper
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posted 03-01-2014 09:50 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
It is true that accounts of the medical events on Apollo 15 written several years later have benefitted from the additional insight provided by time and have been somewhat influenced by Irwin's subsequent series of MIs.

I too have tried to emphasize what a flight surgeon would have experienced in real-time during the live mission. No other astronaut had presented such an ECG trace as Irwin's. There was no possibility of clinically examining the patient, running a diagnostic blood work-up, administering anti-arrhythmia drugs, performing effective CPR if required or any serious cardiac intervention. In real-time in those minutes, there was no way of knowing whether the patient had had an MI, was about to arrest, or would simply revert to normal sinus rhythm. No way of knowing if the oxygen-enriched low-g environment was masking the true nature of the cardiac event. If I was a flight surgeon seeing that trace, my heart would be throwing a few PVC waves of its own.

To suggest there was little concern in Mission Control suggests complacency. The truth was there was very little anyone could do for Jim Irwin where he was. He was already in an oxygen-enriched low-g environment. Alarming the patient and crew wasn't going to help. All Mission Control could do was hold its breath, monitor very closely and hopefully ride out the ECG storm. Any further ominous signs, however, and Mission Control would have had no choice but to inform the crew. It was a judgement call that paid off - one of many difficult, carefully risk-weighed decisions made in the face of uncertainty during Project Apollo.

Blackarrow
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posted 03-01-2014 01:36 PM     Click Here to See the Profile for Blackarrow     Edit/Delete Message   Reply w/Quote
I have read Yankee Clipper's contributions with interest, but I must take issue with some of his concluding comments.
quote:
Originally posted by YankeeClipper:
...there was very little anyone could do for Jim Irwin where he was.
Mission Control could have ordered continuous wearing of his biosensors. As we have seen in my earlier post [9th Feb at 09.39pm] there were several significant gaps in the monitoring of Irwin, and without giving Scott a reason, Mission Control could do nothing about that. On at least one occasion, Scott overrode Mission Control's rather vague attempt to keep Irwin on the sensors. Had Scott been told, he presumably would have insisted on continuous monitoring.

Mission Control should have considered whether it was appropriate to require Irwin to struggle into his spacesuit and perform a stand-up EVA in support of Worden's retrieval of the SIM-bay films. (I would be interested in Yankee Clipper's specific comment on this, bearing in mind that there had been gaps in the monitoring of Irwin's heart and therefore no way of telling if Irwin had suffered any further heart irregularities during those "gaps".)

quote:
Alarming the patient and crew wasn't going to help.
I can understand this in principle. Is there really a need to inform a former shipyard worker that a chest CT scan has shown pleural plaques, causing no symptoms and merely indicating a future risk of mesothelioma, since there is nothing he can do about it, and telling him might cause him to spend the rest of his life consumed with worry?

But in the case of Jim Irwin, the only way to have guaranteed continuous monitoring would have been to tell Scott. I suppose Mission Control could have given Scott a simplified version ("a few heart irregularities, nothing to worry about, but keep him on the biosensors...") but even that solution would almost inevitably have raised concerns in Scott's mind (not to mention Irwin's and Worden's) about a possible impact on the deep-space EVA.

quote:
All Mission Control could do was hold it's breath and monitor closely...
I suggest that Yankee Clipper might accept on reflection that this was not quite the case.
quote:
Any further ominous signs, however, and Mission Control would have had no choice but to inform the crew. It was a judgement call that paid off...
Except that if those "further ominous signs" had occurred during the "biosensor gaps" Mission Control would not have known about them, and Scott and Worden had no special reason to be looking out for their companion. It was therefore a judgment call made without the best evidence which could have been available.

Furthermore (and I am happy to defer to Yankee Clipper's medical knowledge on this) can we be sure that it did pay off? That the additional exertions of the SEVA did not in any way contribute to the processes which culminated in Irwin's heart attack in 1973? And should Mission Control not have extended to Scott, as mission commander, the right to participate in the "judgment call" bearing in mind that it affected all three astronauts to a greater or lesser extent?

As a final observation, I suggest that the role of Deke Slayton should not be underestimated in this matter. I suspect all of us have sympathy for Deke in the matter of his grounding at the hands of doctors. This must surely have impacted on his thinking during Project Apollo, but might it have caused him to go too far in downplaying genuine medical concerns in the case of Jim Irwin's heart irregularities?

Why did Deke speak to the crew to suggest that Scott and Irwin take Seconal? Why not Capcom? Was this Deke's version of the classic medical advice: "Take a couple of aspirins and get a good night's sleep and you'll feel much better"?

And, with the example of medical concerns wrecking his astronaut career still in his mind, how concerned might he have been to prevent any interference with a crucial part of the Apollo 15 mission: the retrieval of the SIM-bay film cartridges?

moorouge
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posted 03-01-2014 02:37 PM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Geoffrey, I have sympathy with your arguments. However, they are based on the assumption that AT THE TIME those in Mission Control thought there was a life threatening situation developing with Irwin.

This, is it not, a false premise. You offer no evidence to justify a 'cause for concern' other than a statement made by Berry some time after the event. As I've tried to point out, there was a much more likely reason to explain the ECG traces and this was accepted. One cannot go back and say after the event that these assumptions were both wrong and ill-advised and should have resulted in a different course of action.

YankeeClipper
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posted 03-01-2014 03:19 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
Blackarrow certainly makes a number of very valid observations.

Deke Slayton's and Ken Mattingly's experiences may well have subtly influenced the collective decision making in this context. Physicians, within and outside aerospace medicine, try to adopt a conservative clinical approach to their patients. Judgements are made on the available evidence and, on occasion, restrictions are imposed which may later prove to be unfounded. Medicine is an art and a science - both are difficult to practise.

Under normal circumstances, truly conservative medical management of Jim Irwin would have dictated rest and performing a battery of tests as others and I have mentioned. It does seem somewhat strange that monitoring was not continuous - some of Dave Scott's dysrhythmia, for example, was detected while he slept. Also I would have had a concern that while oxygen and low-g may have aided recovery from their exertions, it may also have masked the true effect of what was very strenuous exertion.

Medicine is practised based on evidence. Absent any further serious dysrhythmia on Irwin's ECG, and I'm cognisant here of the caveat regarding intermittent monitoring, there just may not have been enough hard evidence to prohibit Irwin from the SEVA. Under any other circumstance, it may well have been considered risky to allow a patient perform further physical activity until all tests had proved negative.

But then Jim Irwin was not a patient in the conventional sense. The environment he was in was literally out of this world. He was a US Air Force officer and this was a mission of national and historical significance, of great scientific interest and geopolitical importance, as part of Project Apollo. It was a mission he was prepared to risk his life for. In the context of this cold war period and the spirit that engendered, it may have been that Berry's caution was overruled or set aside or negatively weighted.

Irwin's SEVA role may have been perceived to constitute a relatively lower risk compared with the demands on Worden, assuming no emergency occurred. Only those in Mission Control close to the decision on Irwin's SEVA truly know what calculus was involved in weighing all the risks.

In a much earlier post, I alluded to the fact that the decision paid off in the short-term. Long-term, the coronary arteriosclerosis that necessitated a by-pass years later probably had the most bearing on the MI in 1973.

moorouge
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posted 03-02-2014 07:42 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
Just a small point about the possible influence of Slayton mentioned by Yankee Clipper above.

It's worth remembering that medical opinion was greatly divided about Slayton's fitness to fly his scheduled Mercury flight. As with Irwin possibly?

Skylon
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posted 03-02-2014 08:23 AM     Click Here to See the Profile for Skylon     Edit/Delete Message   Reply w/Quote
The way Slayton's disqualification was handled was possibly one of the worst bunglings in NASA history and would never happen today. I think partially because of that, astronaut health privacy concerns have been respected far more. Slayton's case would never have played out publicly, today the way it did in 1962.

It was some years before we heard exactly why Gus Loria was disqualified from STS-113. Karen Nyberg's disqualification from STS-132 was something quite benign, but still kept under official wraps. We still don't know whatever happened to Neil Woodward, and why he never flew but for all we know it could be medical. Tim Kopra's injury prior to STS-133 was unusually public, but maybe it was due to it being so close to the launch.

Can any old-timers say if NASA disclosed why John Bull was disqualified from flight in the 1960's? Or Alan Shepard's exact circumstances?

Getting back to Irwin, if there were medical concerns, and he gained flight status, they would have been regarded as "private" and I suspect, based on his experience, Slayton would have raised holy damnation on someone who brought concerns about Jim Irwin's health to the public.

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posted 03-02-2014 08:58 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by moorouge:
It's worth remembering that medical opinion was greatly divided about Slayton's fitness to fly his scheduled Mercury flight. As with Irwin possibly?
Yes, quite possibly in Irwin's case. Doctors, as we all know, do differ in their opinions hence the good advice to seek a second one.

Had a flight surgeon actually been in a position to witness Irwin during the arrhythmia perhaps that would have changed the decision calculus. At the time, with no knowledge of what would later transpire in Irwin's life, all Mission Control had was two brief anomalous ECG runs, one more serious than the other, which appeared to revert to more-or-less nominal with rest. Not much information to work with really.

In a sense, Project Apollo had experienced moments like this before e.g. the Apollo 11 powered descent 1202 program alarm, and Apollo 12 launch lightning-induced platform drop-out. Perhaps in the wake of these successfully overcome 'heart-stopping' overload scenarios, and with the successful failure of Apollo 13, there may have been a subconscious belief in Mission Control that they could overcome any difficulty? Psychologists would probably have something to say about the wisdom of that particular cognitive construct, but that's another topic for another time!

YankeeClipper
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posted 03-02-2014 09:32 AM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
My previous post was directed toward decisions made at the time of Irwin's Apollo 15 arrhythmia.

During my on-line travels, I came across an interesting medical opinion from CitabriaFlyer - an interventional cardiologist and an Air National Guard flight surgeon - posted on 03 March 2011 on the subject of Jim Irwin and CT scanning at NASASpaceflight.com forum where he wrote:

Today NASA uses CT scans to screen ASCANS for heart disease. CT scans are very useful in excluding heart disease for a number of years in younger patients with a low pretest probability of heart disease. CT scans are not, in my view, that great for higher risk groups or patients who have already been diagnosed with heart disease. Having said that I think it is very possible that Col. Irwin would have been found not qualified for duty when he joined the astronaut corps in 1966.

moorouge
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posted 03-04-2014 06:22 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
A lot has been made of the fact that Irwin was in the best place for a suspected heart attack, always assuming that that is what it actually was, i.e. oxygen environment and low gravity/weightlessness.

So a question. Am I wrong in thinking that low gravity/weightlessness would not affect blood pressure? Doesn't this depend on internal arterial/vein resistance rather than external factors?

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posted 03-11-2014 06:52 PM     Click Here to See the Profile for mjanovec   Click Here to Email mjanovec     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by moorouge:
So a question. Am I wrong in thinking that low gravity/weightlessness would not affect blood pressure? Doesn't this depend on internal arterial/vein resistance rather than external factors?

I would imagine that external factors can influence blood pressure too. As one sits or lies down in a gravity environmental, there is a compression of tissues (and blood vessels) in the area where weight is being supported. This compression could impact overall blood pressure readings.

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posted 03-27-2014 03:27 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
quote:
Originally posted by moorouge:
Am I wrong in thinking that low gravity/weightlessness would not affect blood pressure? Doesn't this depend on internal arterial/vein resistance rather than external factors?
Blood Pressure (BP) is influenced by internal/endogenous factors e.g. blood vessel diameter/condition/age, blood volume, hydration level, oxygenation, sodium/potassium levels, catecholamine hormone levels (epinephrine/norepinephrine - adrenaline/noradrenaline), disease, pain, emotional shock, stress etc.

Blood Pressure (BP) is also influenced by external/exogenous factors e.g. gravity, posture/orientation (see Orthostatic Hypotension), exercise level, talking/laughing, eating, catecholamine analogue levels (stimulant drugs), tight clothing, trauma/injury etc.

This list of factors is representative and not exhaustive.

In a normotensive euvolemic person (ie. normal BP, normal blood volume) the heart's systolic contraction (SBP) has to be of sufficent force to perfuse blood to peripheral tissues in the hands/feet and back to the heart against the force of gravity. Venous valves and tone help to achieve venous return. The act of simply lying down will reduce BP. If a person (especially the elderly or sick) stands too quickly after sitting, blood will pool in the lower extremities and not return to the heart and head fast enough to prevent the person feeling faint from cerebral hypoperfusion.

I took the opportunity at the weekend to ask NASA astronaut and surgeon Dr. Rhea Seddon about the effect of microgravity on the heart and BP, as she studied this aboard the Space Shuttle in her role as a Mission Specialist. She indicated that the BP drops in the microgravity environment of LEO. Quite simply the heart has less work to do. She said that after her third mission she experienced hypotension and pre-syncope during post-flight exercise tests.

There is an interesting 2012 article about this low BP effect here.

moorouge
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posted 04-10-2014 10:38 AM     Click Here to See the Profile for moorouge   Click Here to Email moorouge     Edit/Delete Message   Reply w/Quote
My apologies for re-opening this discussion, but I've had the opportunity of talking to my doctor about it at last.

They said that with no other symptoms and the patient not complaining of anything else, an irregularity on an ECG trace would not immediately lead them to think of a heart attack bearing in mind that the subject was under stress and possibly dehydrated.

Further, when told about Berry's comment, with due respect for Berry, they thought that in the circumstances he was over reacting especially without further evidence.

YankeeClipper
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posted 04-10-2014 01:16 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
Emergency medicine operates on a precautionary principle. When formulating a differential diagnosis (DDx) for a patient, a good physician will consider possible worst-case scenarios and then perform tests and diagnostic work-ups looking to systematically include/exclude possible causes.

In fairness to Berry, as I alluded in my post of 03-01-2014 09:50am, he was trying to care for his patient remotely, in a very unique incompletely understood environment, with 1971 medical knowledge and resources, in real-time during a live lunar mission. He couldn't examine his patient nor perform tests as he would like.

There is a huge world of difference between that scenario and a patient in a 21st Century hospital or MD/GP's room.

YankeeClipper
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posted 09-25-2014 05:14 PM     Click Here to See the Profile for YankeeClipper   Click Here to Email YankeeClipper     Edit/Delete Message   Reply w/Quote
During his Saturday lecture at last weekend's Autographica in Birmingham UK, Al Worden made an interesting observation regarding Dave Scott's and Jim Irwin's pre-flight training. Al indicated that due to the weight of their EVA suits and the high heat / humidity of Florida, Dave and Jim routinely drank very large quantities of Gatorade, which is potassium-enriched, in the period prior to Apollo 15.

This is not too surprising considering that Gatorade was first formulated by 4 doctors at the University of Florida in the summer of 1965 as a medical treatment for heat-induced dehydration.

After the lecture, Al indicated that Jim Irwin may have had a pre-disposition to high cholesterol formation, something which was noted years after the flight.

Al also said of his spacewalk to retrieve the Apollo 15 film cassettes:

That EVA was very important to NASA - they were willing to risk Jim's life for it.


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Ultimate Bulletin Board 5.47a





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