Background:
In the following decades, human space exploration is about to extend beyond Low Earth Orbit, giving birth to a rising need to deal with medical emergencies locally while in space, and to provide ever-advancing surgical care. The permanently crewed International Space Station marks the first stage of continuous human presence in space, but the future will bring even greater demands related to the medical aspects of long-term missions. This is even more important when considering a human expedition to a near-Earth asteroid, maintaining continuous human presence on a lunar base or deep space habitat, or even witnessing the first human mission to Mars and its satellites. All of these are situations in which the crew will have no possibility of immediate evacuation to receive specialized assistance and healthcare. Thus, maintaining the health of astronauts over such a long period of time will require crew autonomy and telemedicine, including telesurgery if the need arises. Looking to our own planet, the conditions are similar in isolated and extreme terrestrial environments, where restrictions in transportation can affect healthcare provision and where direct external aid is not possible even in the face of the most demanding challenges. Antarctic bases with overwintering crews are such an example, since their inhabitants are completely cut off from the rest of the world for nine months. The conditions are comparable to those encountered by astronauts, such as confinement, circadian desynchronization, limitations in Internet bandwidth and other forms of telecommunication, and various psycho-socio factors that influence quality of medical care for both patient and the physician.

Purpose:
To better understand, explore and exploit the potential of telemedicine and telesurgery under the auspices of the Space Surgery Institute (SSI). The goal is to implement telesurgery in various medical emergency simulations in isolated environments and space analogues, to develop procedures, identify novel needs and challenges, including optimization and improvements of protocols.

Methodology:
The initital pre-pilot “Mars-to-Mars” telesurgery study was conducted in early January 2014, led by Principal Investigator Dr Susan Jewell.  ESA sponsored Concordia Station atop Dome Circe in the heart of the Antarctic continent, run jointly by France (IPEV) and Italy (ENEA-PNRA) is considered a space analog where the European Space Agency (ESA) conducts space physiology research. For the purpose of testing and improving telesurgery potential, a simulation was conducted by the medical teams located at the Concordia Station and the Mars Desert Research Station (MDRS) with the MarsCrew134 Analog Astronaut team in Utah, USA.

The hypothetical scenario envisaged two future manned bases on Mars, situated far from each other, which communicate for mutual medical care assistance .The crew medical officer from one station was injured and hemodynamically unstable, thus the crew members consulted the medics from their counterpart station for guidance. MarsCrew134 collaborated with Crew DC10 at Concordia to treat the “patient”, a simulation mannequin, based on instructions received from Concordia team together with pre-prepared emergency algorithms.

Results:
The outcome of this initial telesurgery simulation between analogs was productive. The hypothetical patient was stabilized, the wounds treated, and the surgeons and anesthesiologists obtained critical experience from participating in the simulation, such as, intra-crew incompatibility due to language or other differences or interpersonal problems. leadership roles assigned based on skill sets and knowledge, repetition of training and simulations is necessary to prevent degradation of knowledge. Additionally,a propose for an annual telementoring training and simulation at Concordia for the incoming doctors at the beginning of the season and as part of the “telesurgery evaluation” experiment during the nine months expedition is currently under discussion.

Many similarities in the need for telesurgery provision between human space missions and isolated populations on Earth were identified and this publication aspires to demonstrate them. We intend to share our preliminary deductions and present the new needs recognized, such as more accurate medical treatment algorithms and how to achieve more stable communications. The insights gained will lead to future improvements and gave valuable experience to the Concordia crew, who may face similar emergency situations in real life.

Telesurgery will be of increasing importance in the space sector in following years which can be applied for crisis management on Earth. With this paper we propose ideas for the refinement of telesurgery procedures and highlight the importance of initiating telementoring and telesurgery training for isolated crews in Antarctica and beyond. Future simulations will include incorporating higher fidelity environments, increased complexity of tasks and skills acquisitions, integration of more demanding emergency scenarios, implementing communication time-delay and raising standards of Internet communication between isolated crews and their team members assisting in the crisis intervention. We envision the pioneering research will have many terrestrial spin-off benefits which can offer medical relieve in remote populations and effectively improve the quality of lives and raise healthcare standards for millions of inhabitants on Earth,