Ameer Farooq 00:00
This week on Cold Steel…
Mark Campbell 00:02
We wouldn’t think in America of letting anybody but a Board-Certified general surgeon take out an appendix. But that wasn’t the way it was in the 1950s. And it’s not the way it is, in these remote places in Canada. And and I think that our standards should be just really looked at what do we really need someone to be skilled in to be able to do that job?
Chad Ball 00:33
Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.
Ameer Farooq 01:14
Dr. Mark Campbell is a practicing general surgeon in Texas, and a retired NASA flight surgeon. He has been researching space medicine for over two decades. In this episode, we talked to him about prophylactic surgery for astronauts, what it would take to develop remote surgical space capacity, and telementored ultrasound. Dr. Campbell, thank you so much for joining us on the podcast. We wanted to start out by asking you what drove you into getting into space medicine.
Mark Campbell 01:40
It is kind of I think, an interesting story. I was, you know, brought up like a lot of kids with the, with the American space program. And I was 14 when the Apollo 11 landed and was very interested and in space. But really didn’t think that there was any realistic way that I could be involved as an as an adult. And so I, you know, my interest turned to medicine, and I became a general surgeon. And then in about 1987, I went to a meeting. And the speaker was Norman Thagard, who was an indie astronaut. And he gave a talk on space medicine. And I didn’t know there was even such a thing as space medicine. I was very ignorant about about space medicine, space physiology, but I got very excited about that. And he encouraged me to become involved in space medicine. And so, you know, that’s when I joined the Aerospace Medical Association space medicine branch, and, you know, started reading the literature, and just getting, you know, smart on space medicine. And then and I really started thinking a lot about, you know, how would you do surgery in space? You know, every time I did anything, I really kind of put the application of how would I do this, you know, in space. So I just started thinking about it a whole lot. And I came up with some ideas on some projects and, and to me the big issues were bleeding in space, and how to restrain the patient and the surgeon and the instruments. And so I presented my ideas to Roger Billica, who at the time was the director of the health maintenance facility project for Space Station Freedom. And so he was a very good mentor to me and allowed me to do start doing some projects. And I had really no funding for these projects. So I kind of had to give it my own time and my own money. But I went forward with it. And we did some, initially some small animal studies, and then some larger animal studies and parabolic flight, and really looking at those questions, you know, bleeding in space and how to restrain, how to restrain everybody for surgical procedure. And then also, you know, some of the things that we got into like laparoscopy and thoracoscopy, and things like that. And so I did a lot of this consultant parabolic research, and because I had I’d gone to Russia for about three weeks in 1990. And I’d taken Russian in college. So I did have some some Russian abilities. And in 1994, when we signed the US-Russian space cooperative pact, then all of a sudden, you know, NASA needed anybody who knew anything about Russia. Or or the Russian language, and there just weren’t many people out there. So I found kind of find that niche for myself. And with Roger’s help, I was able to become a get into flight operations, become a NASA flight surgeon, and was deployed to Russia. And the first time I was deployed to Russia, in fact, the very first day, it was to be sort of the backup flight surgeon to Norm Thagard, who was the person who gave the talk in 1987. So in 1994, I went over to Star City and supported his launch, and, and got to meet him again for the first time since 1987. That kind of came around full swing. So that’s kind of how I got involved. It’s kind of a weird thing.
Chad Ball 05:47
Well, that’s so interesting. You know, I’ve had the pleasure of parabolic flight with you, and, of course, our partner, Andy Kirkpatrick. And you go, we’ll go way back, you know, I was curious, for our listeners, you could describe what that experience was like in zero gravity in any other planes, you know, really that that you’ve been in or that we continue to use and, and just to give us a sense give the collective a sense of how that feels, and how you set up for it and what your thoughts are?
Mark Campbell 06:16
Well, and I did about four years, 50 parabolic missions, but the the main thing is, it is a very artificial environment, you just have this, maybe 30-second window of weightlessness followed then by a 2g pullout. And so you have to realize that, you know, you do have some limitations. And then, if you’re using a a artificial model, like a mannequin, then there’s there’s another artificial variable added to that as well. I think that using a real animal model makes a huge difference. Just about everything that we predicted, that would happen in weightlessness when we got up there, it didn’t happen the way we thought it would. And if first, our first reaction was that we set the experiment up wrong, we weren’t able to show what we wanted to show. So it was our fault, the way we accept the experiment was flawed. But then with a little more knowledge and experience, we realize that, that our hypothesis of how things work in weightlessness was absolutely wrong. And we could never have found that out without using an animal model. So I think that was very important to use an animal bottle, you have to really tightly script everything for parabolic flight, and say, and this parabola, we’re going to do such and such, and during the 2g pull out, we’re going to reconfigure and then we’re going to demonstrate, you know, another, another aspect, and then we’re going to reconfigure, and you had to have it very tightly scripted and very well practiced in your mind, what you’re going to do. Because when you get up in parabolic flight, things happen very fast. And the more prepared you are, the more likely you’ll have success with your project. And we had some very successful projects that we really, really prepared. We did ground simulations and and and we did a lot of just script writing to prepare for those parabolic flights I think that’s what made it successful. You know, we we thought that bleeding would be a problem in weightlessness. And it wasn’t because of you that surface tension forces, which we had no idea how predominant they would be, are really very predominant and keep you from having a problem with fluids. And then we thought restraint would be very, very difficult. And we had a lot of really elaborate ways to restrain ourselves and the, and the animal and all of our instruments. We found that is really a lot more simple, especially if we planned for it and had a method as a lot more simple than we thought it would be. And then lap laparoscopy, we thought we would not have very good visualization when we did laparoscopy. And it turns out that we had very good visualization but for reasons we couldn’t have predicted and that is that, that the mesentery pulls all the bowel out of the pelvis and allows you to be able to visualize things. We also found that fluid in the chest acts completely different than then we would have expected. It doesn’t lay her out at all and it kind of sticks to every surface that it can and so it doesn’t localize it just kind of becomes very diffuse. And so all these things were kind of unpredicted and we had to learn them by going into parabolic flight.
Ameer Farooq 09:56
Dr. Campbell, listening to you talk about this, it’s clear that none of the things that you like lay person or anybody, any average surgeon, thinking about doing surgery in space would have ever really predicted. How can you walk us through how that sort of the concept of doing surgery in space has developed over time, and where we sort of sit in terms of being able to do surgery in space now, given all the work that you have, have done on this, and then maybe touch a bit about where you think surgery in space is going in the future?
Mark Campbell 10:36
Yeah, well, I would, I would put it let’s talk about the different environments a little bit. Now the International Space Station has a you know, like a 24-hour time to definitive medical care back on Earth. And so all the medical care system is really oriented towards stabilization and transport as it should be. So there’s very little surgical capability among the crew medical officers or even the equipment. Now the two criticisms I have about the International Space Station medical system is one they’d have no provision for putting in a chest tube. And, and I really think that that’s something that that can be easily trained and easily provided for, from an equipment standpoint, and it would be life saving, if you ever needed it. And then the other thing is, there’s no organized way to perform even a simple surgical procedure, like a laceration closure. All the surgical instruments are individually wrapped. And so you don’t have a surgical kit, or a method to take all those surgical instruments, even a simple way and restrain them so that they’re organized and can remain sterile and can remain not restrained but accessible, and it’d be real simple to have just a minor surgical kit, that and we did this in parabolic flight quite a bit that you can just take out and has Velcro on the back and you can stick it to a wall and it keeps your instruments organized and sterile. And it really makes the minor surgical procedure like say laceration closure, a lot, lot more simple. And so I think that was one thing that they should have had on the International Space Station. And I never could get them to accept it. I think it’d be very interesting if we go back to a moon landing. Because the, you know, we have about 200 pounds of medical equipment on the International Space Station, we even have an ultrasound. But when we go to landing on the moon, our medical equipment is going to be very, very, very small. I think we’d be lucky if we get if we get 20 pounds of medical equipment. And so when you’re on the moon, you’re obviously in a much more remote place than the International Space Station. And your time back to definitive medical care on the earth is going to be quite long, probably three or four days. So I think we’re kind of gonna, by necessity, box ourselves into a corner, when we go to a moon landing. A lot less capability and a lot more risk, because our time back to earth will be longer. So I think I think it’ll be very interesting. Our risk will definitely be higher there. When you talk about going to Mars, and we’ve been talking about this for 30 years. You know, like about every five years, we have some someone comes up with some sort of conference about surgical care on a long duration mission. And, and I go to every single one of these, I’ve been to about six or seven of them now. And everybody who is in attendance always feels like, well, this is just a really new thing. No one’s ever talked about this before. But we do it about every five years. But we always talk about the same issues. But the knowledge base and the dialogue and the conversation is much more sophisticated every time we meet. And I think that one thing that becomes clear to me is that we don’t need something real sophisticated and elaborate, like robotic surgery, or even laparoscopic surgery on a long duration mission such as a Mars mission. What we need though, is to have somebody who is surgically capable, to be able to perform a variety of fairly simple surgical procedures. I think the paradigm to me is the general practitioner of the 1950s because that general practitioner had very minimal surgical training. But he was able to do appendectomies, they did hernia repairs, they took out gall bladders, they did all kinds of stuff. And that’s kind of what I think the crew medical officer on a Mars mission will need to be. Needs to be a general practitioner, with some surgical training to perform some fairly simple minor procedures. And I think a big part of that, a big part of that medical care system is going to be percutaneous veins, drainage, stenting, things like that. And so I think also ultrasound directed percutaneous procedures are going to be a real big part of that. But I don’t think you need a lot of sophisticated laboratory equipment. I think you need a knife, a hemostats, some scissors, some suture. I think he could do everything with a fairly minimal set of equipment. I think it’s also 3D printing is very exciting, that you can just actually print your surgical instruments as you need them. Although people get excited about 3D printing, I like to point out to them, the 3D printing now is still very low resolution. And so you get very crude, imprecise instruments that are that are not, I would not consider them a good enough quality to perform surgery with. They’re more like the plastic suture removal sets that you get up on the floor that they that they buy from the lowest bidder, you know, you can barely take out a suture with them. They’re so crude. And it’s kind of that kind of quality. But I think it’s obvious that the quality is going to get better over the next few years. We’ll get higher resolution instruments out of 3D printing, and they’ll be they’ll have material that’s much more hard instead of soft like they have now. So I think it’ll get better. I think it’ll be a big adjunct.
Ameer Farooq 17:04
There’s just degrees of remoteness when we’re thinking about concepts like space. But But I think that this applies even down on Earth as well, too. And so I’m curious how it one how you envision the operating room to look in space? Or if you do envision a scenario like that? And then the second part of that is, I’m curious how about what you think we could do to apply that type of thinking in remote locations in on earth?
Mark Campbell 17:40
Well, you know, we, we’ve looked at remote medical care on Earth as an analog to a long duration spaceflight, and the two things we were been most interested in is the Antarctic experience, and the US Navy submarine experience. You wonder when the US Navy submarine, those boomers go up underneath the Arctic ice, and that’s where they set up, you know, in case they’re needed. And they are three weeks away from definitive medical care, it takes them three weeks to get out of that ice pack and, and get to a position where a helicopter could do a medical evacuation. So they’re fairly remote. And they take care of a lot of things with just a independent duty corpsman. They’ve been treating appendicitis, nonoperatively for a long time. And we wrote our article back in I think it was 2004 about the nonoperative treatment for appendicitis. It was really a new idea. No one had really talked about that before. But the US Navy had been doing it since World War Two. Since that time, you know, the nonoperative treatment appendicitis, tons have been written about it. And nobody’s gotten real involved within the last five years. And so we have a lot more experience with it. But it definitely is, is, especially if you think about being on a space mission. If someone develops appendicitis, we’re going to diagnose it very, very early. It won’t be somebody it’s been sitting out there for several days, you know, like we often see on Earth. We’ll diagnose it very early, we’ll have fairly early intervention as far as you know, IV antibiotics and our success rate should be very high should be 95%, something like that. I still think we need to have a surgical capability to do an appendectomy, just simply because we need the surgical capability to do a lot of things, not just appendicitis actually has a fairly low incidence in the astronaut population. But we need that be able to do a whole lot of other things. And I think if you can just take someone and give them six months of very focused surgical training, I think that they can do everything that that we need to be that needs to be done from a surgical standpoint, on a long duration mission. We looked at Antarctica to and they have a lot of success with you know, dealing with appendicitis nonoperatively. And, and so I think those things serve as analogues for long duration space mission, and they’ve given us a lot more confidence in what we will actually see. And, and how we can take care of it. I think it makes us feel like that we can take care of things a lot easier than we think.
Chad Ball 20:43
You know Dr. Campbell, you mentioned your journal American College of Surgeons paper from 2004. And that’s a on our must read list for all the all the interns and junior residents that come into the program here. It’s, it’s a, it’s a superb, and really out of the box reviews, I encourage all of our listeners to check that out. I just want to swing back to the training a little bit. And I you know, although there’s not many countries in the world, that that still do this Canada is one of them at least some of our provinces, Alberta, British Columbia and Quebec, in particular, have programs that take quite remote general practitioners in a real rural setting, and are able to train them for 6 to 12 months for some of these basic surgical interventions, including percutaneous drainage, including remote telemetered ultrasound like you and Scott Dulchavsky and others that have proven so effective. And you know, whether they end up in places, not even Whitehorse, but much more remote to that, and they provide really impressive levels of care with quite often significant autonomy. And, you know, whenever I see that, and one of us folks come through, I always do think that probably a year, right, I mean, it’s probably the model for the longer duration spaceflight, whether that’s, you know, to the moon, or maybe even Mars one day for sure.
Mark Campbell 22:05
Right, I’d certainly don’t think you need a Board Certified surgeon, or even someone who’s been through a surgical residency, to be your crew medical officer. You need someone who is can take care of a lot of different medical situations. And, and I really think that Canada, it would be a great analog for deep space missions, because it’s that kind of physician that we need. Someone who can, you know, monitor, you know, psychiatric well being, be able to take care of medical situations to make medical diagnoses. And then if there if you need to do something real simple surgically, like drain an abscess, or even take out on the appendix, you don’t have to have a lot of surgical training, or surgical skills to be able to do that. We think we do nowadays, because we’re just used to, we wouldn’t think in America of letting anybody but a Board Certified general surgeon take out an appendix. But that wasn’t the way it was in the 1950s. And it’s not the way it is, in these remote places in Canada. And and I think that our standards should be just really looked at what do we really need someone to be skilled in to be able to do that job?
Chad Ball 23:30
No, for sure. I completely agree with you. You know, the another interesting topic is the concept of risk mitigation. You know, when we’re surgical rescue plays into that, and where palliation plays into that as well. It’s always a bit of a sensitive topic. But, you know, from an outsider’s observation, NASA and the Canadian Space Agency and other other groups have have been a bit of a pendulum back and forth, depending on the particular mission and goals for sure. Probably appropriately. So. No, I think back to the crew return vehicle or crew rescue vehicle, the CRV, that, that NASA shelved, in addition to some other other things. How does that conversation usually happen with regard to, you know, again, mitigation of risk versus therapy versus palliation?
Mark Campbell 24:16
Well, for one thing, I think that for any, every mission is different. And you need to know what capabilities you need to have. For each mission. It has to do with mission duration, and also time to definitive medical care back to Earth. And also has to do with what is your level of crew medical officer training? I mean, for the International Space Station, they get something like 40 hours of training, it’s not very much at all. And also what kind of equipment do you have? And so you shouldn’t expect someone to do to be able to treat a surgical disease if they don’t have the training or the equipment. I’ve always said also, you shouldn’t put equipment up there if the crew medical officer isn’t trained to use it, because then that puts him in a in a awful spot. So beforehand, you know, if you take, let’s say, a, a lunar landing mission, I think you have to draw up and, and have a dialogue about what are your capabilities? What can you do? And what can you not do? And that way, when that, when that happens, you can, you can say, you know, we don’t have the capability to do this. We don’t have the equipment, we don’t have the crew medical officer training, it’s just not something we’re capable of. And so we’re not going to attempt to do it. You know, we’ll mitigate it as best we can. But we’re not going to be able to take care of it. And to make sure that that you have a capabilities and a no-capabilities list that there’s been well thought out for each mission for each situation.
Chad Ball 26:00
Yeah, no, that’s very well said.
Mark Campbell 26:04
Back going way back, you know, to the old days, when I first started consulting for Space Station Freedom, one of the things that that they had on their capability list for Space Station Freedom. Now you had to realize Freedom was going to be up there with no ability to return somebody on a medical evacuation for 45 days. So they had a 45 day definitive medical care time. There was no shuttle no sure crew return vehicle. You were just stuck on the on the space station for 45 days without a shuttle. And so they had a lot of capabilities. And one of the capabilities they had was if someone developed a a head injury, of being able to drill a burr hole and trying to subdural hematoma. And I thought that was ludicrous. And and it was the first thing I threw out. I say, here, you get rid of the drill for the burr, you know, we’re not going to drill a burr hole on the Space Station Freedom and, and they had all sorts of things like that, that that with a little bit of a thought it was pretty easy to change that capability, thd capability list.
Chad Ball 27:16
It’s such an important point, right? And it’s something that we forget sometimes, you know, down on Earth, it’s sort of like opening the chest in the emergency department, maybe as an emerge Doc, you you kind of have one or two moves. And after that, what do you do? And so, yeah, there’s a hole in the head. And then what do you do? It’s still an issue. I was wondering if you could talk to us a little bit about some of the remote telementoring that you’ve been involved with, and of course, our partner here, Andy Kirkpatrick as a Canadian lead and then Scott Dulchavsky as well. It’s, it’s remarkable, how transferable that skill, and that that that communication can be from, you know, untrained person to untrained person, and really what they can get done.
Mark Campbell 27:59
I think I think the biggest thing that we do not know about, that we don’t have experience at is doing remote telementoring. And I think we need to try to get more experience of that. And I think that’s a very low budget thing that can be done. And I wish that people would get more interested in it. You know, you put somebody doesn’t have to be 100 miles away, he could be in the next room, as long as your communication back and forth, is as if you were on a long duration mission. In other words, you have a time delay of, let’s say, five minutes, or even 10 minutes or, or, or a fairly significant time delay, and you try to talk somebody through someone who does have some very minimal but basic surgical skills, but is not a surgeon. And you’d have someone who is a surgeon, try to talk them through something like say, an appendectomy, or drain an abscess, or just some simple surgical problem, but with that time delay, and with someone who really, truly has very minimal training, and I think we need to get a lot more experience of that. And, and I think it has real world application, just as you say, in remote places in Canada, to do some surgical telementoring in in remote places in Canada. And course that has even more application with the with a future long duration spaceflight. But it seems to me like that would be a fairly easy exercise to do to get experience at because I think there’s a lot of things we don’t know about how you do that. I think that’s a skill set that we really haven’t developed yet. And we’re probably have a lot of ignorance in is how you telementor somebody remotely, even without a time delay. You know, how do you how do you talk to things? How do you talk to them? How they talk to you? You know, do you have a stop point where you kind of try to reorganize things? So I think there’s a lot to be learned there that that to me, I see that then a lot of research needs to be done in the next 5 or 10 years that will that will really open up that whole world.
Chad Ball 28:24
Yeah, I mean, certainly again, we’re biased up here, but Andy’s really tried to push the envelope and done some really neat things in the past five years or so. To be honest, the the place that I’ve seen sort of remote mentoring or telementoring in the world in terms of, you know, visiting and being doing professors, and then and sort of experiences like that has been Australia. There’s same thing their northern regions are, are incredibly supported by big cities, such as Brisbane and Sydney. I mean, they have cameras and trauma bay’s, they have ultrasounds and they don’t obviously have to deal with the, the long time delays that that you guys do, but what they can get done again, and the quality of care and the quality of teaching and the effectiveness at the other end is remarkable. Yeah, for sure. My sense is that it’s coming. It’s coming slowly. I mean, one of the interesting anecdotes, at least in Canada is Andy ran it, and then I ran it. And we handed it off to one of our partners, Paul Macbeth, when he came and joined us as a trauma surgeon here in Calgary, and it was the national ultrasound. You know, extended fast and beyond course, basically the American college course. And the demand for that course has almost gone to zero now, because ultrasound training is so ingrained in so many different types of residences. So I’m hopeful that what you’re describing will happen and that interest will continue to, to increase. I I’m just curious, as a penultimate question, how does all of this work in this this deep thinking about surgery and surgical care of maybe more broadly, in such remote environments? How does it inform your your daily practice and the way you think with your patients and, or does it at all?
Mark Campbell 32:31
I think it affects it in, in how I pass on information to other team members. I think a lot of times, when you are discussing medical issues, surgical issues, especially trauma care, whether the team members, you assume that they know, A, B and C, and you find out very quickly that, that they may not know that, that you may have to, to dial back and become even more basic. You have to be very careful about assuming what somebody is knowledge base is, or what their skill set is. And so you kind of have to be able to figure that out as you go along. And, and be able to communicate effectively, to make sure that that you know what their knowledge base is, you know, what their skill set is. And everybody tries to do the best job they can. And, and a lot of times they tried to do things that they’re not really capable of, or maybe don’t have a skill set for, but they don’t want to speak up and tell you that. And so you kind of have to very judiciously monitor them and, and make sure that they’re not getting out of their league. I think about that a lot when I think about trying to do telementoring on a remote distance. You know, you can’t assume that you can’t give them capabilities that they may not have, you kind of have to figure out what their capabilities are and, and, and factor that into the situation.
Ameer Farooq 34:13
Dr. Campbell for any residents or trainees who were interested in getting involved in space medicine or space surgery, what would you recommend in terms of getting involved?
Mark Campbell 34:25
Right well that yeah, that that was the same thing as when I first got involved with this. Because if you have to get involved with the professional medical organization, which is the Aerospace Medical Association, and the Space Medicine Association. And you have to start trying to develop relationships with people who are in the field and, and and try to connect with them as best you can. Of course so what you do that most of the time is by going through the annual meetings, and you just need to just become familiar with the literature. There’s, there’s a set of literature out there for space medicine and set literature for surgical care in space and just become familiar with, with all of those that literature and what the issues are and what issues have been solved and what issues are, are remaining. And that’s number one. Now, you have to realize that the research opportunities are very thin, there’s not much money for research. And it’s going to be probably less as time goes on, especially with the US debt being so high after the Coronavirus of that. And so I think that the federal budget is going to be very, very skimpy. And I think research money is going to be very, very minimal. So there’s not a lot of opportunity. And you just kind of have to be as knowledgeable as you can, and and then try to seek opportunity, wherever it is.
Ameer Farooq 36:16
It’s hard to see anything without the word COVID in it getting a lot of play in the next little while.
Mark Campbell 36:24
Well, we just added 6 trillion to the debt. I don’t think they’re going to be springing a lot of money for space exploration or space medicine.
Ameer Farooq 36:33
Yeah. I also want while we have you, I wanted to ask about your work on prophylactic surgery for astronauts. Where it is, where do the space agencies really stand in terms of prophylactic surgeries for astronauts said going on extended duration missions?
Mark Campbell 36:53
Well, you know, I think it’s something that everybody likes to talk about and discuss about, and we, we’ve been discussing it for 20 or 30 years. My own feeling is you take a specific surgical disease, let’s say appendicitis. The incidence of that disease is actually going to be fairly low. And so by doing a prophylactic procedure, you’ve eliminated the possibility of having that disease. But it’s such low incidence, you really haven’t, haven’t changed things very much. And, and I still think that, that you ought to try to be capable, surgically capable of taking care of as many things as you possibly can. Not just one thing, but just a lot of things in general. So you take appendicitis, and if you do an appendectomy prophylactically, you’ve eliminated that risk. But the incidence is very, very low. So you really haven’t changed things very much. And you still have to have a surgical capability to take care of a whole bunch of things in general. So it really hasn’t changed your medical system either. So I’m not really been I’ve never been in favor of prophylactic procedures. I just don’t think they’re going to really change what your medical care system needs to be.
Chad Ball 38:19
Mark, the last question that we want to ask you, and again, I’ll preface it with thank you so much for your time, we know how busy you are. And the Canadian audience in particular was really excited to hear from you. My question is, you know, you’ve been at this game for a very long period of time, and you’ve seen administrations come and go in particular in the NASA world. I’m curious what your overall view of the culture of NASA as a government run agency sits in terms of what seems from the outside to be a bit of a freight train with Space One and SpaceX and all the sort of private slash, you know, commercial entities that that are moving along. Where do you see all that settling out with the roles of each side? And where’s it going?
Mark Campbell 39:09
Well, it’s definitely the Wild West. And a lot of the companies and entities that are around now probably won’t be around 10 years from now. So if it is very chaotic and confusing. NASA itself tends to like to do things in house, and they like to hold their cards close to their chest. And so I think it’s important that if anybody is really seriously wanting to do something in space medicine, they need to get inside they need to try to become a part of the part of that NASA space medicine culture. And I don’t know exactly what that means and if they need to find a way to get involved in research if NASA funded or get involved in medical operations at NASA. But that they need to get a need to become a part of a NASA culture to be able to get any benefit out of it.
Ameer Farooq 40:27
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