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The National Aeronautics and Space Administration (NASA) has been challenged to develop capabilities designed to meet the unique challenges required to explore the solar system and is working toward a goal of landing humans on near-Earth asteroids, the Moon, and eventually Mars. 1 The current plan for NASA is to support the extension of the International Space Station (ISS) through 2020. The ISS will serve as a platform for space life sciences research as well as preparation for future exploration class missions by further increasing our understanding of space physiology. 2,3 The primary objectives in sending humans back to the lunar surface or to Mars are to explore, perform research, and gain knowledge. The safeguarding of human health and performance, using appropriate medical care, is essential to meet these mission objectives. History has shown that during the exploration of frontiers on Earth, human physiologic maladaptation, illness, and injury have accounted for more failures of expeditions than any single technical or environmental factor. 4 Carrying out this bold vision creates many new challenges, including a level of medical autonomy unprecedented for human spaceflight. Because a prompt evacuation back to Earth is not feasible in exploration missions, the capability of delivering medical care on site will be the key to success. 5 However, it will be impossible to provide medical care for all imaginable problems. The crew will, therefore, need improvisational skills and acceptance of a certain amount of risk. This paper focuses on the medical and communication challenges of exploration type missions and explicates the value of combined emergency medicine (EM) and wilderness medicine (WM) training for astronaut physicians. Communication Challenges and Self-Sufficiency The time to reach definitive medical care from the ISS may be as brief as 24 hours, but from a lunar base, it would be at best several days. Assuming there are no major developments in propulsion technology, even a Mars "fly-by" with direct return to Earth may represent a 9-month round trip. The entire trip may last as long as 1000 days. Radio communication will require up to 20

ObjectiveTo describe our experience performing ED procedural sedation in a country where emergency medicine (EM) is a relatively new specialty.MethodsThis is a prospective observational study of adult patients undergoing procedural sedation by emergency physicians (EPs) or EM residents in eight hospitals in the Netherlands. Data were collected on a standardised form, including patient characteristics, sedative and analgesic used, procedural success, adverse events (classified according to World SIVA) and rescue interventions.Results1711 adult cases were included from 2006 to 2013. Propofol, midazolam and esketamine (S+ enantiomer of ketamine) were the most used sedatives (63%, 29% and 8%). We had adverse event data on all patients. The overall adverse event rate was 11%, mostly hypoxia or apnoea. There was no difference in adverse event rate between EPs and EM residents. However, there was a significantly higher success rate of the procedure when EPs did the procedural sedation (92% vs 84%). No moderate (unplanned hospital admission or escalation of care) or sentinel SIVA outcomes occurred (pulmonary aspiration syndrome, death or permanent neurological deficit).ConclusionAdverse events during procedural sedation occurred in 11% of patients. There were no moderate or sentinel outcomes. All events could be managed by the sedating physician. In a country where EM is a relatively new specialty, procedural sedation appears to be safe when performed by EPs or trained EM residents and has comparable adverse event rates to international studies.

Implementing procedural sedation and analgesia in the emergency department is still is a challenge on an international scale. Here, we describe the Dutch setting of emergency medicine and explain the strategies that were successful for the implementation of safe and effective procedural sedation and analgesia by emergency physicians. We describe strategies on how to bridge the gap of knowledge and skills and how to deal with a resistance to change.

Newly trained Dutch emergency physicians can perform procedural sedation with propofol safely and effectively. Increased age and high Ramsay scores were the only risk factors for sedation events. All events were minor and responded to simple interventions.