The Final Frontier for Emergency Medicine: An Inside Look at UCLA’s Space Medicine Fellowship Program

Sriram Venkatesan, FAWM
Vice Chair, EMRA Prehospital and Disaster Medicine Committee
Sri Ramachandra Medical College & Research Institute
University of Colorado-Denver

Kyle Essex, NRP, FP-C, CCP-C, C-NPT
Asst. Vice Chair, EMRA Prehospital and Disaster Medicine Committee
Burrell College of Osteopathic Medicine

In 1961, Dr. James Mills Jr. launched the first emergency medicine practice in Alexandria, Va.

That same year, the former Soviet Union successfully sent a human into space. In 1969, Neil Armstrong became the first man to set foot on the moon. Just one year later, Dr. Bruce Janiak became the first emergency medicine resident. With such similar time progression, it was only a matter of time before these paths intersected on the space-time continuum.

Fast-forward to the present: It now appears that space has met its physician, and the physician has met his program. The physician is Dr. Haig Aintablian, and the program is UCLA’s Space Medicine Fellowship.

Space: The Final Frontier. These are the voyages of the UCLA Space Medicine Fellowship. It's a 2-year mission — to explore strange new wounds, seek out new life, and discover new med calculations. To boldly go where no physician has gone before.

Dr. Haig Aintablian

During this time, Dr. Aintablian — inaugural fellow at UCLA’s (and the nation’s) newest Space Medicine Fellowship program — will trade his leatherman raptors for surgical scalpels and astronautics books, adding scope and skill that span multiple professions from surgery to engineering. He will endure a training program designed to produce physicians who will not only sit in mission control on the ground, but also in spacecrafts on missions.

EMRA’s Prehospital and Disaster Medicine (PH&DM) Committee spoke with Dr. Aintablian about this fellowship opportunity, offered exclusively to emergency medicine residency-trained physicians. He gave us an eagle’s eye view of his training experience so far, future direction for the field, and opportunities for medical students and residents who are interested in getting involved.

EMRA PH&DM Committee: How would you define “space medicine” for those not familiar with the term (i.e., emergency medicine residents and medical students)?
Dr. Aintablian: Space medicine is essentially the combination of skills and traits that would be needed in a physician to be able to treat someone in space — not just on the ground, like in mission control, but also to treat them as a member of the crew. So this includes understanding all of the terrestrial pathologies, but on top of that, understanding all of the pathologies that could develop in microgravity or zero gravity.

EMRA PH&DM: What was your path to space medicine? What inspired you to pursue this field?
Dr. Aintablian: I have always been fascinated with space since I was a little kid. My dad and I would look through a telescope and try to find distant stars and planets. I got more involved in the world of space medicine when I was doing my master’s degree in molecular genetics and biochemistry, where part of what I was looking at was structural changes in our DNA that could happen in microgravity and what structural limitations these could have. During medical school, I ended up doing an away rotation with NASA during my fourth year, which really piqued my interest. Later on in residency, when an opportunity came up for us to build this space medicine fellowship with the private space industry, I jumped on it.

EMRA PH&DM: What is your day-to-day or week-to-week life like as a space medicine fellow?
Dr. Aintablian: I have a baseline level of shifts that I do each month in the ED, as an attending. This is a requirement of the fellowship for us to be able to keep our clinical skills sharp, as being a good terrestrial doc, in our minds, is the best way to be a good space doc. On top of these shifts, I have a robust engineering curriculum that I work on asynchronously to better understand the fundamental principles of aerospace engineering and bioastronautics — things like aircraft mechanics up to biological exposures to ionizing radiation. It’s truly fascinating stuff. And then, I have clinical rotations, where I learn additional clinical and procedural skill sets, like percutaneous procedures, appendectomy, cholecystectomy, and even dental procedures. The goal of these is not to become an expert (as we all know how many years it takes to gain expertise in a field through our residency training), but to have a sort of competency in case specific scenarios were to arise in space. In addition to all this, my favorite part is just how heavily involved I get to be with the private space industry, doing specific projects that will help humanity reach places like the moon and Mars. I can’t discuss specifics, but I will say that it’s pretty awesome. In addition to this, we have an austere medical rotation, Mars analogs we get to practice in, and a few other gems. Overall, it's a pretty busy fellowship with so much crammed into 2 years, but I wouldn’t want it any other way.

EMRA PH&DM: You’re involved in a newly launched fellowship, which means that everything — the curriculum and connections, for example — had to be developed from scratch. Describe your experience.
Dr. Aintablian: My experience has been fantastic. I think we’ve hit the ground running with this fellowship. It took us about a year-and-a-half to develop the curriculum, to build all the connections to make this happen. Since then, it has been going extremely well. The quality of the fellowship is top notch. It’s a very busy fellowship. It’s almost as busy as residency, if not equally busy. And honestly, every minute is filled with something that’s very intellectually stimulating. And we’re doing things with some of the best experts in these fields.

EMRA PH&DM: What makes this field unique in your mind, and what qualities do you think are necessary to be successful as a space medicine specialist?
Dr. Aintablian: I think the main thing that makes this field unique is that we’re training a physician to essentially also be part of a crew. That’s a pretty cool thing. It's almost like doing a hyperbarics fellowship but also training on what it takes to be a diver. You’re learning and understanding not just physiology in the field (space), but also how to be a Swiss army knife, of sorts, in case you go up to “the field.” It’s multidisciplinary. It’s way more than just medicine. It’s way more than just emergency medicine. It’s surgery, it’s ophthalmology. It’s dentistry, engineering, psychiatry, physics — there’s just a whole host of things that build the field.

What we’ve discovered is that having an EM background is ideal because it gives you most of the skills needed to treat most pathologies. But there are certain things we’re not trained in during an EM residency. Like what if an appendicitis or cholecystitis were to pop up in space? What would you do if antibiotics didn’t work and you’re 3 months into your 6-month journey to Mars? During the fellowship, we’re trained to do surgical procedures like appendectomies, cholecystectomies, nephrostomy tube placements, all the way down to dental procedures and US-guided minimally invasive procedures. We’re also getting trained to do fundoscopic exams at a higher level, using ultrasound more than just to diagnose emergency conditions, but also to understand physiological parameters to get the minutiae for research purposes, understanding radiation dosages and physics forces, etc. It’s a baseline skill set of being an EM doc, but on top of that, tossing in a bunch of additional skills to make you as much of a versatile Swiss army knife as possible — you know, the ones that are fatter with more and more tools!

EMRA PH&DM: Tell us more about the curriculum outside of clinical work. Where else do you get to train? Is there a standard set of skills that you’re required to know by the end?
Dr. Aintablian: Our curriculum can be found on the UCLA EM website. We’ve got a bunch of engineering courses that we take with the UCLA School of Engineering, as well as a customized curriculum developed with Caltech JPL. We do a few away rotations with the private space industries and national space agencies. We do clinical shifts in the ED every month to keep up with our clinical skills. And then we have additional exposure to certain specialties (similar to clinical rotations) including ultrasound, ophthalmology, dentistry, toxicology, general surgery, interventional radiology, orthopedic surgery, sports medicine, hyperbarics, and psychiatry. The curriculum is designed to help us get as wide a skill set as possible. And the engineering courses are designed to help us learn how to communicate effectively with engineers, as well as to be engineering-minded whenever we’re helping design medical systems for the moon, Mars, and other future missions.

EMRA PH&DM: How challenging is it for physicians to adapt this engineering mindset that’s needed to thrive in space medicine?
Dr. Aintablian: It’s definitely not easy because we don’t get much engineering training; the only real overlap with engineers is the physics that we take. And we take a life sciences version of the physics course. It has been very interesting for me; it has been an intellectual challenge. I hadn’t previously been exposed to, or read, most of this stuff. But it’s really interesting stuff. It’s also more than just becoming proficient in basic engineering — it’s being able to speak with engineers in their language, to understand what they’re looking at when they’re looking at a medical system, and understanding their specific limitations on what can or can’t be done.

EMRA PH&DM: How important is fellowship training to the field of space medicine? Is it possible to be a space medicine physician without the additional training?
Dr. Aintablian: Potentially it’s possible. But going through the fellowship pathway is a good way to really build that skill set under a controlled environment — especially with what we’re trying to do, with the additional surgical training or dental and other subspecialty training, as well as all the specific engineering courses we take. You never know if you can get that sort of training outside of a fellowship. I can’t imagine, for example, emergency physicians asking to scrub into the OR for these types of things when they’re attendings. Or for an ER doc to start taking graduate-level engineering courses at Caltech. It’s possible, but it wouldn't be easy. With regards to space-related physiology, it’s possible to read and gain expertise with the knowledge base that’s available, but it would be difficult to practice it in real life without formal training. That being said, I’ve had many mentors in the space industry who are self-taught physicians, and they are some of the legends who built the structure of this field. I think, though, as we are formalizing this training pathway, fellowship training is going to become a more desirable and necessary attribute.

EMRA PH&DM: As a space medicine physician-in-training working in all these different clinical subspecialities, how have folks in these areas viewed you? Have you received any pushback for specialty encroachment?
Dr. Aintablian: That’s a good question. Surprisingly, there hasn’t been as much territorialism as you’d expect, perhaps because we’ve built this fellowship with the understanding that we’re not going to be specialists in any of these fields. And this isn’t stuff we're going to practice terrestrially. I’m not going to go to the ER and start pulling teeth, or, you know, start doing appendectomies. This is more like, if we were to send one doctor up to space, who would we send? And what skill sets would be needed? When we built this fellowship, we made it clear: When we spoke to the surgeons, we conveyed that we’re not trying to be surgeons, but just want to be familiar enough with the anatomy of a procedure to be able to do this, if we had to, ideally under the guidance of a surgeon in mission control. Our goal is to be a Swiss army knife, not to have the biggest set of scissors or the biggest knife or the sharpest whatever tool, but to have every tool in some capacity, and the ability to do everything the best we can with the resources available. We’ve been really surprised with just how many departments and specialists reached out willing to help in whatever way they can, which was so awesome to see. There’s a saying that it takes a village to make a doctor. That saying can absolutely be applied to the type of training needed here — it takes a village to train a space medicine physician.

EMRA PH&DM: Given current and future EM workforce concerns, what are the job prospects for a space medicine-trained EM physician? Where do you see yourself in the next 5-10 years?
Dr. Aintablian: I’m always going to work in the ER one way or another when I’m not involved with space medicine full time. As space becomes more and more available, we are going to be sending a lot of people up. The trajectory is that it’s booming, and we’re at the point now where we’re at the bottom of that curve, and we’re just about to see that steep rise in space tourism and expedition missions. So I think the market is going to be fantastic for space medicine. And, in the coming years, we’re going to need many more space medicine-trained physicians for these crewed space expeditions.

EMRA PH&DM: In a basic exam, we often take gravity for granted in positioning for heart/lung sounds (understanding where fluid accumulates) and testing reflexes. I would imagine even EKGs look quite different with reduced stresses and lack of gravity. How differently is medicine practiced?
Dr. Aintablian: Yeah, totally! So I think EKG is not as big a deal. But with regards to drawing medications up from a vial or how to perform CPR in space when you’re both floating around … There are all these things that need to be dealt with in the space environment. And these are all things that are being addressed for long-duration spaceflight. Then you have structural changes of the heart or eye changes that happen in microgravity. There are lots of changes that we don’t have a lot of information about just yet. So it’s a whole host of factors to consider, and we’re going to have to be very well-versed in all of these space medicine issues to have successful long-duration space missions.

EMRA PH&DM: What’s your advice for EM residents and medical students who are interested in the field and would like to learn/explore more? Does your program offer or plan to offer electives or rotations for prospective residents?
Dr. Aintablian: I think the biggest piece of advice is to be a good EM physician first. Learn your clinical skills really well because they’re going to pay dividends later, even possibly in space. If you’re actually interested in doing space medicine, and you know you’re pretty committed to this, feel free to reach out. Email us, follow us on Twitter, follow me on IG. I definitely foresee rotation opportunities in the future. Right now, we’re just focused on making this fellowship as great as it can be. But yeah, learn to be as good a clinician as you can be, and don’t be scared to reach out if you’ve got any questions.

The UCLA Space Medicine Program is an EM-based fellowship designed to develop the next generation of flight surgeons who will advance the understanding of human physiology in space and directly support the medical endeavors of human space travel and planetary expeditions. Learn more about the program here. Email spacemed@mednet.ucla.edu if you have any questions. Follow @UclaSpaceMed on Twitter and @Haig.MD on Instagram!

The interview with Dr. Aintablian was edited for length and clarity.