Fluid Shifts Training Strategy Team (TST) Joyce Schultz Crew Training Coordinator, Inc

Agenda Introduction Experiment Description Experiment/Increment Points of Contact Planned On-Orbit Activities Fluid Shifts Hardware Fluid Shifts Training Sessions Experiment Start and Concerns Experiment Risks Training Milestone Schedule Backup Charts 2

Experiment Description 3 Experiment Title: Fluid Shifts Before, During and After Prolonged Space Flight and Their Association with Intracranial Pressure and Visual Impairment Op Nom: Fluid Shifts Principal Investigators: Michael Stenger, PhD, JSC; Scott Dulchavsky, MD, PhD, Henry Ford Health System Alan Hargens, PhD, University of California, San Diego Co-Investigators (all at JSC): Richard Danielson, PhD Douglas Ebert, PhD Stuart M. C. Lee, MS Brandon Macias, PhD David Martin, MS Steven Platts, PhD Robert J. Ploutz-Snyder, PhD Scott Smith, PhD

Experiment Description conc. 4 Description: The purpose is to systematically determine the impact of the fluid distribution in microgravity on a comprehensive set of structural and functional measures including, but not limited to, those related to intracranial pressure, vision, morphology of the eye and its associated parts and the vascular systems of the head and neck. The study will characterize the changes in fluid distribution including intra/extracellular and intra/extravascular fluid shifts. The study will examine the relationship between the type and magnitude of the fluid shift with any effects on eye morphology and vision disturbances, intraocular pressure (IOP), and measures of intracranial pressure. The study seeks to determine whether the magnitude of fluid shifts during space flight, as well as the above effects of those shifts can be predicted based upon crewmember baseline data and responses to acute head-down tilt tests performed before launch. The study will evaluate the effect of lower body negative pressure (LBNP) on the above parameters.

Experiment/Increment Points of Contact Kristen Kinder – Experiment Systems Manager Erik Hougland – Flight Project Manager, Instructor Jennifer Wilson – Experiment Support Scientist (ESS), Instructor Michelle Lawless – Experiment Support Scientist (ESS), Instructor Justine Wiles – Hardware Engineer (Ultrasound 2), Instructor Joyce Schultz –Training Coordinator Robert Strahan -- Procedures 5

Planned On-orbit Activities For 1-yr mission, three in-flight sessions will be scheduled across the increment: FD45, FD150, and R-45 days. Note: For 6-month missions, two in-flight sessions will be scheduled at: FD45 and R-45 days. Each FD session involves 4 days of testing: Day 1-- dilution measures, Day 2 -- baseline imagining measures, and Days imaging measures with Chibis. Day 1 -- dilution measures: ingest tracers [deuterium oxide (D 2 O) and sodium bromide (NaBr)]. Perform blood, urine, and saliva collections before and after ingestion. Sample galley water. Stow samples in MELFI 6

Planned On-orbit Activities Day 2 – baseline imaging measures: Cerebral and Cochlear Fluid Pressure (CCFP), Optical Coherence Tomography (OCT), Distortion Product Otoacoustic Emission (DPOAE), Intraocular Pressure (IOP), Blood Pressure (BP), and ultrasound scanning of multiple physiological sites. Days 3 – 4 – imaging measures with Chibis. All needed hardware will be moved to the Russian segment and set up along with the Chibis the day before data collection begins. Data collection will be split over 2 days due to Chibis wear limits. Imaging measures will be repeated while the crewmember is wearing Chibis. A Russian crewmember will be required to act as a dedicated medical monitor via the Russian GAMMA monitoring system during Chibis exposure. All non-Russian hardware will be moved back to the USOS following completion of these activities. 7

Fluid Shifts Hardware 8 Existing Hardware  NASA HRP Ultrasound  NASA Med Ops Optical Coherence Tomography (OCT) hardware  NASA Med Ops Tonometer  NASA PCs (med ops and HRP)  ESA Holter Blood Pressure Device (hereafter referred to as CDL HLTA)  RSA Chibis and GAMMA Medical Monitoring System New Hardware  Cerebral Cochlear Fluid Pressure Analyzer (CCFP): headset with strap and integrated earpiece plus attached cable to analyzer box, detachable at box.  Manometer: hand-held meter with built-in display and 5 buttons (size and shape of a fancy TV remote control with display screen). Connect to mouth via tube and syringe.  Distortion Product Otoacoustic Emission (DPOAE) measurement device: hand-held meter with built-in display and keyboard (size and shape of a fancy TV remote control with display screen). Connects to ear.

Fluid Shifts New Hardware Cerebral Cochlear Fluid Pressure Analyzer (CCFP) Distortion Product Otoacoustic Emission (DPOAE) 9 Manometer Probe attachment

Fluid Shifts Training  Session Title: Fluid Shifts Overview (subject class)  PLCR Title: P HRF Fluid Shifts Ov  Prerequisite: N/A  Crew Prerequisite: participation interest from subject  Session Duration: 15 minutes  Session Scheduling: between L-18 to L-12 months; schedule immediately before first Fluid Shifts class for subject [Imaging Measures #1 or #2 (Ultrasound Imaging)]  Location: J9 PDL.  Session Synopsis: Crewmember will be provided an overview of the experiment and its objectives. On-orbit sessions and their timing will be described along with all the hardware that will be used. The method and goals of the pre- and postflight BDC sessions will be discussed. The subject will gain complete understanding of expectations for data collection activities for the Fluid Shifts experiment. 10

Fluid Shifts Training Cont.  Session Title: Fluid Shifts Imaging Measures #1 (subject class)  PLCR Title: P HRF Fluid Shifts Imaging Measures  Prerequisite: Fluid Shifts Ov (can be scheduled in PDL prior to this class)  Crew Prerequisite: Signed consent for subject  Session Duration: 60 minutes  Session Scheduling: between L-18 to L-12 months  Location: J9 PDL  Session Synopsis: Crewmember will practice self data collection using the CCFP and DPOAE. Proper data saving to PC and set up of data downlink will be trained. Subject safety will be emphasized. Note: Med Ops currently trains the crewmember on the tonometer. If Med Ops should discontinue this training, then ISSMP may have to add it to payload training. 11

Fluid Shifts Training Cont.  Session Title: Fluid Shifts Imaging Measures #2 (ultrasound) (subject and operator class, can be scheduled separately)  PLCR Title: P HRF Fluid Shifts Ultrasound Imaging  Prerequisite: P HRF Ultrasound, ESA CDL HLTA, Fluid Shifts Ov (can be scheduled in PDL prior to this class as needed)  Crew Prerequisite: Signed consent for subject  Session Duration: 60 minutes  Session Scheduling: between L-18 to L-12 months  Location: J9 PDL  Note: Surrogate subjects provided  Clothing note: Crewmember subject should wear shorts. For ultrasound of the chest area, subjects will be provided a loose-fitting garment/cover-up to avoid getting gel on clothing. It is preferable for no brassiere to be worn to allow for easier data acquisition. If subject prefers to wear a brassiere or swimsuit top, it should not include an underwire or a stiff elastic band (such as in a sport bra) since those features can inhibit data acquisition. Session Synopsis: The subject will practice ultrasound data collection activities including some self-scanning and/or operator scanning of the different target areas via remote guidance. Subject training will also cover blood pressure data using the ESA CDL HLTA and manometer operations. Operator-only scanning will focus on ultrasound data collection and may require less time (TBD). 12

Fluid Shifts Training Cont.  Session Title: Fluid Shifts Dilution Measures (subject class)  PLCR Title: P HRF Fluid Shifts Dilution Measures  Prerequisite: Fluid Shifts Ov  Co-requisite: P HRF Phlebotomy Task  Crew Prerequisite: Signed consent for subject  Session Duration: 60 minutes  Session Scheduling: between L-12 to L-6 months  Location: J9 PDL  Session Synopsis: Crewmember will be provided summary overview of inflight session including hardware involved. Proper techniques for sample collection will be trained. Inflight, crewmember will ingest tracers and perform blood, urine, and salvia collections. Blood samples will be processed in the centrifuge. A sample of galley water will also be collected. All samples will be stowed in MELFI. The importance of sample collection timing will be emphasized. 13

Fluid Shifts Training Cont.  Session Title: Fluid Shifts Imaging Measures #3 (Russian Segment Ops ) (subject and operator class, can be scheduled separately)  PLCR Title: P HRF Fluid Shifts Russian Ops  Prerequisite: Med Ops Optical Coherence Tomography (OCT)  Crew Prerequisite: Signed consent for subject  Session Duration: 60 minutes  Session Scheduling: between L-12 to L-6 months  Location: J9 PDL, J9 Russian Segment Session Synopsis: The crewmember will transfer experiment hardware from USOS sections and configure the hardware in the Russian Segment (RS). Data collection using a variety of hardware (CCFP, DPOAE, OCT, tonometer, manometer) and data transfer/ downlink operations will be covered. The crewmember subject will gain an understanding of the operations needed to move hardware, set up, and operate in the RS. The crewmember operator will practice scanning activities while subject (or surrogate) is outfitted with RS operations hardware (Chibis simulator – no power). Note: Russian crewmembers will be trained on Chibis and GAMMA ops in Russia. NASA crewmember needs safety familiarization training from RSA. 14

Fluid Shifts Training Cont.  Session Title: Fluid Shifts Integrated (subject and operator class, schedule together, if possible)  PLCR Title: P HRF Fluid Shifts Integrated Ops  Prerequisite: all previous classes  Crew Prerequisite: Signed consent for subject  Session Duration: 120 minutes  Session Scheduling: between L-6 to L-3 months  Location: J9 PDL  Clothing Note: Crewmember subject should wear shorts. For ultrasound of the chest area, subjects will be provided a loose-fitting garment/cover-up to avoid getting gel on clothing. It is preferable for no brassiere to be worn to allow for easier data acquisition. If subject prefers to wear a brassiere or swimsuit top, it should not include an underwire or a stiff elastic band (such as in a sport bra) since those features can inhibit data acquisition.  Session Synopsis: Crewmembers will configure for on-orbit operations and complete all imaging measure collections using ultrasound with manometer and CDL HLTA, CCFP, DPOAE, OCT, and tonometer. Ultrasound scanning will be directed via remote guidance. Data will be transferred by crew for downlink. Session will be evaluated on crewmembers’ abilities to capture quality scientific data. 15

Summary of Fluid Shifts Training Class Suggested POIC Name Timeframe (months) HrsSubject/ Operator Location Fluid Shifts Overview P HRF Fluid Shifts Ov L-18 to SubjectJ9 PDL Fluid Shifts Imaging Measures #1 P HRF Fluid Shifts Imaging Measures L-18 to 121SubjectJ9 PDL Fluid Shifts Imaging Measures #2 (Usnd) P HRF Fluid Shifts Ultrasound Imaging L-18 to 121Subj, OprJ9 PDL Fluid Shifts Dilution Measures P HRF Fluid Shifts Dilution Measures L-12 to 61SubjectJ9 PDL Fluid Shifts Imaging Measures #3 (RS) P HRF Fluid Shifts Russian Ops L-12 to 61Subj, OprJ9 RS Fluid Shifts Integrated Imaging P HRF Fluid Shifts Integrated Ops L-6 to 32Subj & Opr Together J9 PDL Total time (pre-PTDR)6.25 hrs 16

Fluid Shifts Training conc.  Efficiencies: Several classes required to support Fluid Shifts already exist (USND 2, Phlebotomy, Med Ops OCT -- all generic). No new materials or resources required.  Current Experiment Letter requests CDL HLTA hardware training from ESA. This device is a relative simple blood pressure cuff. It is hoped that the Experiment Letter with ESA, will be changed to allow NASA to include CDL HLTA training in our experiment unique class.  Much of the material in the Fluid Shifts classes will be similar to other classes (scanning techniques; blood draws; urine, salvia, and gallery water sampling; RC setup; MELFI insertion). As such, these class materials will be easy for the team to compile. Crew will also be familiar with all but the experiment specific elements (new hardware, new ultrasound scanning sites) and setup and operations in the Russian Segment.  If crewmember is subject for another experiment involving ultrasound scanning; blood, urine, saliva, galley water sample collection; RC operations; and MELFI stowage, the generic skills training will not be repeated.  Reference material will be available on-orbit. 17

Experiment Start and Concerns 18  It is anticipated that this experiment will start with the 1-yr mission crewmembers. (Note: if Ks and Kor participate, no subjects will be requested from Inc. 44 or 46 crews.)  It was presented to Kelly during his August 2013 Informed Consent Briefing (ICB) and he indicated interest.  It will be presented to the Russian crewmember during a January 2014 ICB.  Signed consent forms are expected in March 2014 at earliest.  Russian crewmember will require translator for experiment training sessions.  Russian crewmember will need to train at NASA. Unclear whether current crew rotation template includes NASA payload training.  The Experiment Support Team is currently working all schedules to support readiness for Inc. 43.  New flight hardware has been ordered and is undergoing modifications for flight verification and certification.  Payload Training Dry Runs (PTDRs) for the first three or four sessions are planned for Jan  Due to anticipated 1-yr crewmember participation, operators from Increments 42, 44, and 46 will need to be trained.

Experiment Risks 19  Implementation negotiations with Russian counterparts have begun; however, no agreements have been signed.  Use of Russian Chibis and Gamma System is under discussion.  Operations in the Russian segment including moving and operating USOS hardware therein is under discussion.  Recent US government furlough has impacted schedules for Russian meeting at NASA with PI and NASA meeting in Russia. Schedule impacts are TBD.  ISS Program Office broad direction has been given to proceed with training through existing channels.  We are interpreting this direction as being able to schedule the Russian 1-yr crewmember for operator training through the normal POIC process without any further agreement.  Due to the risk of not getting a Russian operator (new territory), we would like to plan to train Inc. 42, 44, and 46 crewmembers as operators.

20 Training Milestone Schedule Targeting Expedition 43 (42S) crewmembers: ActivityStartComplete Institutional Review Board (IRB) approval 06/30/13 Op nom for experiment name 07/12/13 ICB held for NASA crewmember08/22/13 Training Strategy Team (TST) meeting10/24/1311/13/13 Lesson Plans (for six classes)10/04/13 12/xx/13 Courseware Development (first classes)10/20/1312/xx/13 Draft Crew Proceduresxx/xx/13xx/xx/14 Ops assessment with crew officeTBD Internal Training Dry Run (ITDR)11/xx/1312/xx/13 Payload Training Dry Run (PTDR) 01/06/14 (first four classes) Signed consent forms received 01/20/1403/xx/14 J9 Training Readiness Review packageTBD ICB for Russian crewmember01/xx/14 First crew training sessions targeted to be ready for March 2014 training rotation.

Backup Charts 21

Experiment Start: Increment 43 1-Yr Crewmembers (42S): Inc. 43–46  American- Scott Kelly (I45/46 CDR)  Russian- Mikhail Kornienko (Med Officer) Inc (41S) Crewmember (Possible Operator)  ESA – Samantha Cristoforetti Inc (43S) Crewmember (Possible Operator)  JAXA – Kimiya Yui or  NASA – Kjell Lindgren Inc (45S) Crewmember (Possible Operator)  ESA – Timothy Peake or  NASA – Tim Kopra 22 Scott Kelly Mikhail Kornienko  Key Launch Dates  42S launch: March 2015  41S return: May 2015  43S launch: May 2015  44S launch: Sept  42S return: Oct without Kelly and Kornienko  43S return: Nov  44S return: March 2016 with Kelly and Kornienko

Launch Sequence Ts 44S 40s 42s 41s 43s 44s 46s 45s 47s 46s 45s 42s 46s 46s – 42S Bkup 46s 41s 43s - Kononenko 43s- Lindgren Up 42s / down 44s - Kornienko Up 42s / down 44s – Scott Kelly 42s – G. Padalka 44s- Volkov 45s - Zaletin 45s - Peake 43s - Yui 47s 45s - Kopra47s 43s 23

ITIWG Crew Template for Exp SeptemberOctoberNovemberDecemberJanuary '14FebruaryMarchAprilMayJuneJulyAugust Shk (41S)RRRRRRRAAAARRRRRRVVVRRRRREAAARRRRRRRRR 39S VVRAAAR R/E RRRRR Ct (41S)VEERRAAAAAAHERRRVVHERRRRRJJAAAERRRRRRR 39S EVVAAAAARRRJJ Vr (41S)AAERRAAAAAAAVARRVVAAARRRRJJVAAAAERRRRR 39S VVAAAAAARRRJJ SeptemberOctoberNovemberDecemberJanuary '14FebruaryMarchAprilMayJuneJulyAugust Lon (42S)VVRRRRRRAAARRRRRRVVVRRRREEVVVAAARRVVERRRRJRAAARRRRRR Kor - 1 year (42S)VVVRRRRRAARRRRRRRVVVRRRRREVVVRAARRVVRRRRRJRAAARRRRRR Ks - 1 year (42S)AAAAAAAAARRRVAAAVVAARRRAAAAAAEAAVAAAARRRRAAAAAJJVAER Ov (42S BU)RRRRRRRRRRRRRRRRRVVRRRRRRRRRRRRRRRRRAAAARJRRRRRVVVVA  Ct trips to NASA: March 10 – 28, 2014, June 23 – July 25, 2014, Sept. 8 – Oct. 2, 2014  Ks trips to NASA: Dec. 2 – 20, 2013, Jan. 6 – 17, 2014, Feb. 10 – Mar. 21, 2014, Mar. 31 – May 16, 2014, June July 18, 2014, Oct. 6 – 31, 2014, Jan. 5 – Feb. 13, 2015

ITIWG Crew Template for Exp SeptemberOctoberNovemberDecemberJanuary '14FebruaryMarchAprilMayJuneJulyAugust Lon (42S)VVRRRRRRAAARRRRRRVVVRRRREEVVVAAARRVVERRRRJRAAARRRRRR Kor - 1 year (42S)VVVRRRRRAARRRRRRRVVVRRRRREVVVRAARRVVRRRRRJRAAARRRRRR Ks - 1 year (42S)AAAAAAAAARRRVAAAVVAARRRAAAAAAEAAVAAAARRRRAAAAAJJVAER SeptemberOctoberNovemberDecemberJanuary '14FebruaryMarchAprilMayJuneJulyAugust Kko (43S)RRRRRRRRRRRRRRRRRVVRRRRRERRAAAAARRREERRRRJRAAARRRRRR Yui (43S)RRAAAAARRRRRHAAAVVARRRRRJJHVAAAAAAAEERRRVAAAAERRRRJ J/H Lg (43S)AAAAAAARRRRAVAAAVVAARRRRJAAVAAAAAAAEAARRVVAAAARRRRJJ/A  Ks trips to NASA: Dec. 2 – 20, 2013, Jan. 6 – 17, 2014, Feb. 10 – Mar. 21, 2014, Mar. 31 – May 16, 2014, June July 18, 2014, Oct. 6 – 31, 2014, Jan. 5 – Feb. 13, 2015  Yui/Lg trips to NASA: Dec. 2 – 20, 2013, Jan. 6 – 17, 2014, Mar. 17 – May 1, 2014, June 16 – July 14, 2014, Sept.1 – 26, 2014, Jan. 19 – Feb. 6, 2015 Mar 2 – Apr 2, 2015

Fluid Shifts: Russian Segment Connectivity Option: Live Cabin Video, no Remote Desktop from Ground OCT USND2 USOS Resource USOS I/F in RS DPOAE (Tonometer, Manometer – NC) Ground Resource CCFP RS I/F SSC (Existing in RS) Digitized Video To Ground (Cabin) T61P Video Adapter 28V HRF Common Power Cable Adapter Cable RS Inverter (future) VPC Existing Digital Video Decoder SSC (Existing in RS) Digitized Video To Ground (USND2) USOS Ethernet (Downlink) GFE GFCI Cable OCT’s ASC Laptop 28V Brick RBS-?? 28V RS Cabin Video for USND2 Remote Guidance, Tonometer & CCFP HRF Laptop Connected to HRF Laptop After test day, in USOS 28V Brick COTS Power Adapter (to 120V A/C) OCT Remote Guidance Using Screen Sharing PowerVideoDataLegend: GFE GFCI Cable Device I/F CCFP Analyzer USND2 Laptop (top) VPC (bottom) <--New Video Cable 26 USOS Ethernet (Downlink) PS-28 Outlet Strip RBS-?? 28V PCR 28V PCR 28V Firewire 400 & 800 Ethernet Existing Digital Video Decoder Battery-powered USOS or RS Camcorder 28V Inverter 28V Brick Adapter Cable

Acronyms and Abbreviations BPBlood pressure CCFPCerebral and cochlear fluid pressure CDL HLTAESA’s holter monitor CDRCommander Cont.Continued CtCristoforetti, Samantha D 2 ODeuterium oxide DPOAEDistortion product otoacoustic emission ECGElectrocardiogram ESAEuropean Space Agency ESSExperiment Support Scientist FDFlight day FEFlight Engineer Hrhour HRFHuman Research Facility HRPHuman Research Program ICBInformed Consent Briefing IOP Intraocular pressure IRBInstitutional Review Board ITDRInternal Training Dry Run KoKopra, Tim KorKornienko, Mikhail KsKelly, Scott LLaunch LBNPLower body negative pressure LgLindgren, Kjell MELFIMinus Eighty-Degree Laboratory Freezer for ISS NaBrSodium bromide OCT Optical coherence tomography Op NomOperations Nomenclature OvOverview PCPersonal computer PDLPayload Development Lab PePeake, Timothy P/LPayload PTDRPayload Training Dry Run RReturn RSRussian Segment RSARussian Space Agency RtnReturn SSoyuz TBDTo be determined TSTTraining Strategy Team USNDUltrasound USOSUS Operating Segment YrYear YuiYui, Kimiya 27