Surgical Capabilities

  • Mark R. CampbellEmail author
  • Roger D. Billica


Although no surgical procedures have ever been performed on humans during space flight, the risk of a problem arising that requires surgical intervention is nonetheless real. Until the advent of long duration missions in the US Skylab program and the Russian Salyut and Mir programs, the probability of an inflight problem arising that would require a surgical solution was small; thus clinical experience and expertise in performing surgery on humans in microgravity remained quite limited. The lack of on-site surgical expertise was keenly felt when Russian space program officials were faced with the possible medical evacuation of a Salyut 7 cosmonaut who was experiencing abdominal pain thought to be due to appendicitis. Although that episode turned out to have been caused by probable ureterolithiasis rather than appendicitis—the cosmonaut recovered and did not require an early return to Earth—this experience nonetheless underscored a pressing need in space flight.


Surgical care in space Space surgery Trauma care in space flight Animal surgery in simulated microgravity Surgical procedures in microgravity Microgravity and surgery International Space Station surgical capability 


  1. 1.
    Wilken DD. Significant medical experiences aboard Polaris submarines: a review of 360 patrols during the period 1963–1967. US Naval Submarine Medical Center Report 560, Groton, CT: 1969.Google Scholar
  2. 2.
    Tansey WA, Wilson JM, Schaefer KE. Analysis of health data from 10 years of Polaris submarine patrols. Undersea Biomed Res. 1979;(6. Suppl):S217–46.Google Scholar
  3. 3.
    Campbell MR. Future surgical care in space. Surg Serv Manage. 1997;3:13.Google Scholar
  4. 4.
    Campbell MR. Surgical care in space. Tex Med. 1998;94:69–74.PubMedGoogle Scholar
  5. 5.
    Campbell MR. Surgical care in space. Aviat Space Environ Med. 1999;70:181–4.PubMedGoogle Scholar
  6. 6.
    McGinnis P, Harris B. The re-emergence of space medicine as a distinct discipline. Aviat.Google Scholar
  7. 7.
    Ad Hoc Committee of Members of the Space Medicine Association and the Society of NASA Flight Surgeons. Human health and performance for long-duration spaceflight. Aviat Space Environ Med. 2008;79:629–37.Google Scholar
  8. 8.
    Davis JR. Medical issues for a mission to mars. Aviat Space Environ Med. 1999;70:162–8.PubMedGoogle Scholar
  9. 9.
    Otto C, Comtois J, Sargsyan A, Dulchavsky A, Rubinfeld I, Dulchavsky S. The Martian chronicles: remotely guided diagnosis and treatment in the arctic circle. Surg Endosc. 2010;24(9):2170–7.PubMedGoogle Scholar
  10. 10.
    Musgrave S. Surgical aspects of space flight. Surg Annu. 1976;8:1–23.PubMedGoogle Scholar
  11. 11.
    Barratt MR. Medical support for the international space station. Aviat Space Environ Med. 1998;70:155–61.Google Scholar
  12. 12.
    Campbell MR, Billica RD, Johnston SL 3rd, et al. Performance of advanced trauma life support procedures in microgravity. Aviat Space Environ Med. 2002;73:907–12.PubMedGoogle Scholar
  13. 13.
    Boyce J. Medical care and transport in space flight. Probl Crit Care. 1990;4:534–55.Google Scholar
  14. 14.
    Billica RD, Doarn CR. A health maintenance facility for space station freedom. Cutis. 1991;48:315–8.PubMedGoogle Scholar
  15. 15.
    Houtchens B. Medical care systems for long duration space missions. Clin Chem. 1992;39:13–21.Google Scholar
  16. 16.
    Houtchens B. System for the management of trauma and emergency surgery in space: Final report. NASA Johnson Space Center. NASA Grant NASW-3744. Houston, TX, 1983.Google Scholar
  17. 17.
    McCuaig K, Houtchens B. Management of trauma and emergency surgery in space. J Trauma. 1992;33:610–25.PubMedGoogle Scholar
  18. 18.
    Rice BH. Conservative nonsurgical management of appendicitis. U.S. Naval Submarine Medical Center Report 444. Groton, CT: 1969.Google Scholar
  19. 19.
    Glover SD, Taylor EW. Surgical problems presenting at sea during 100 British Polaris submarine patrols. J R Nav Med Serv. 1981;67:65–9.PubMedGoogle Scholar
  20. 20.
    Lugg DJ. Antarctic epidemiology: a survey of ANARE stations 1947–1972. In: Polar human biology. Chicago: Year Book Medical Publishers; 1974. p. 93–105.Google Scholar
  21. 21.
    Campbell MR, Johnston SL, Marshburn T, Kane J, Lugg D. Nonoperative treatment of suspected appendicitis in remote medical care environments: implications for future spaceflight medical care. J Am Coll Surg. 2004;198:822–30.PubMedGoogle Scholar
  22. 22.
    Ball CG, Kirkpatrick AW, Williams DR, Jones JA, Polk JD, Vanderploeg JM, Talamini MA, Campbell MR, Broderick TJ. Prophylactic surgery prior to extended-duration space flight: is the benefit worth the risk? Can J Surg. 2012;55(2):125–31.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Satava RM. Surgery in space. Phase I: basic surgical principles in a simulated space environment. Surgery. 1988;103:633–7.PubMedGoogle Scholar
  24. 24.
    Stazhadze LL, Goncharov IB, Neumyzakin IP, et al. Anesthesia, surgical aid and resuscitation in manned space missions. Acta Astronaut. 1981;8:1109.PubMedGoogle Scholar
  25. 25.
    Yaroshenko GL, Terentiev VG, Mokrov MN. Characteristics of surgical intervention in conditions of weightlessness. Voenn Med Zh. 1967;10:69–70.Google Scholar
  26. 26.
    Campbell MR, Billica RD, Johnston SL. Animal surgery in microgravity. Aviat Space Environ Med. 1993;64:58–62.PubMedGoogle Scholar
  27. 27.
    Campbell MR, Billica RD, Johnston SL. Surgical bleeding in microgravity. Surg Gynecol Obstet. 1993;177:121–5.PubMedGoogle Scholar
  28. 28.
    McCuaig K. Aseptic technique in microgravity. Surg Gynecol Obstet. 1992;175:466–76.PubMedGoogle Scholar
  29. 29.
    McCuaig K. Surgical problems in space: an overview. J Clin Pharmacol. 1994;34:513–7.PubMedGoogle Scholar
  30. 30.
    Pinsolle V, Martin D, de Coninck L, Techoueyres P, Vaida P. Microsurgery in microgravity is possible. Microsurgery. 2005;25:152–4.PubMedGoogle Scholar
  31. 31.
    Kirkpatrick AW, Doarn CR, Campbell MR, Barnes SL, Broderick TJ. Manual suturing quality at acceleration levels equivalent to spaceflight and a lunar base. Aviat Space Environ Med. 2008;79:1065–6.PubMedGoogle Scholar
  32. 32.
    Broderick TJ, Privitera MB, Parazynski SE, Cuttino M. Simulated hand-assisted laparoscopic surgery (HALS) in microgravity. J Laparoendosc Adv Surg Tech A. 2005;15:145–8.PubMedGoogle Scholar
  33. 33.
    Rafiq A, Broderick TJ, Williams DR, Doarn CR, Jones JA, Merrell RC. Assessment of simulated surgical skills in parabolic flight. Aviat Space Environ Med. 2005;76:385–91.PubMedGoogle Scholar
  34. 34.
    Speich JE, Cagle YD, Rafiq A, Merrell RC, Doarn CR, Broderick TJ. Evaluation of surgical skills in microgravity using force sensing. Med Eng Phys. 2005;27(8):687–93.PubMedGoogle Scholar
  35. 35.
    Panait L, Merrell RC, Rafiq A, Dudrick SJ, Broderick TJ. Virtual reality laparoscopic skill assessment in microgravity. J Surg Res. 2006;136(2):198–203.PubMedGoogle Scholar
  36. 36.
    Rafiq A, Hummel R, Lavrentyev V, Derry W, Williams D, Merrell RC. Microgravity effects on fine motor skills: tying surgical knots during parabolic flight. Aviat Space Environ Med. 2006 Aug;77(8):852–6.PubMedGoogle Scholar
  37. 37.
    Panait L, Broderick T, Rafiq A, Speich J, Doarn CR, Merrell RC. Measurement of laparoscopic skills in microgravity anticipates the space surgeon. Am J Surg. 2004 Nov;188(5):549–52.PubMedGoogle Scholar
  38. 38.
    Campbell MR, Dawson DL, Melton S, et al. Surgical instrument restraint in weightlessness. Aviat Space Environ Med. 2001;72:871–6.PubMedGoogle Scholar
  39. 39.
    Campbell MR, Williams DR, Buckey JC, Kirkpatrick AW. Animal surgery. During spaceflight on the Neurolab shuttle mission. Aviat Space Environ Med. 2005;76:589–93.PubMedGoogle Scholar
  40. 40.
    McCuaig K, Lloyd C, Gosbee J, et al. Simulation of blood flow in microgravity. Am J Surg. 1992;164:114–23.Google Scholar
  41. 41.
    Mutke HG. Equipment for surgical interventions and childbirth in weightlessness. Acta Astronaut. 1981;8:399–403.PubMedGoogle Scholar
  42. 42.
    Campbell MR, Billica RD. A review of microgravity surgical investigations. Aviat Space Environ Med. 1992;62:524–8.Google Scholar
  43. 43.
    Markham SM, Rock JA. Microgravity testing of a surgical isolation containment system for space station use. Aviat Space Environ Med. 1991;62:691–3.PubMedGoogle Scholar
  44. 44.
    Markham S, Rock J. Deploying and testing an expandable surgical chamber in microgravity. Aviat Space Environ Med. 1989;60:76–9.PubMedGoogle Scholar
  45. 45.
    Rock J. An expandable surgical chamber for use in a weightless environment. Aviat Space Environ Med. 1984;55:403–4.PubMedGoogle Scholar
  46. 46.
    Rock JA, Fortney SM. Medical and surgical considerations for women in spaceflight. Obstet Gynecol Surv. 1984;39:525–35.PubMedGoogle Scholar
  47. 47.
    Hayden J, Pantalos G, Burgess J, Antaki J. Creating a hermetically sealed, fluid-filled surgical enclosure to perform procedures in reduced gravity. Aviat Space Environ Med. 2013;84:1298–303.PubMedGoogle Scholar
  48. 48.
    Colvard MD, Kuo P, Caleb R. Laser surgical procedures in the operational KC-135 aviation environment. Aviat Space Environ Med. 1992;63:619–23.PubMedGoogle Scholar
  49. 49.
    Johnston SL, Campbell MR, Billica RD, Gilmore S. Cardiopulmonary resuscitation in microgravity: efficacy in the pig in parabolic flight. Aviat Space Environ Med. 2004;75:546–50.PubMedGoogle Scholar
  50. 50.
    Schweitzer EJ, Hauer JM, Swan KG, et al. Use of the Heimlich valve in a compact autotransfusion device. J Trauma. 1987;27:537–42.PubMedGoogle Scholar
  51. 51.
    Mattox KL, Walker LE, Beall AC, et al. Blood availability for the trauma patient—autotransfusion. J Trauma. 1975;15:663–9.PubMedGoogle Scholar
  52. 52.
    Rumisek JD. Autotransfusion of shed blood: an untapped battlefield resource. Mil Med. 1982;147:193–6.PubMedGoogle Scholar
  53. 53.
    Campbell MR. Surgical care in space: a review. J Am Coll Surg. 2002;194:802–12.PubMedGoogle Scholar
  54. 54.
    Campbell MR, Kirkpatrick AW, Billica RD, et al. Endoscopic surgery in weightlessness: the investigation of basic principles for surgery in space. Surg Endosc. 2001;15:1413–8.PubMedGoogle Scholar
  55. 55.
    Campbell MR, Billica RD, Jennings R, et al. Laparoscopic surgery in weightlessness. Surg Endosc. 1996;10:111–7.PubMedGoogle Scholar
  56. 56.
    Kirkpatrick AW, Keaney M, Hemmelgarn B, Zhang J, Ball CG, Groleau M, Tyssen M, Keyte J, Campbell MR, Kmet L, McBeth P, Broderick TJ. Intra-abdominal pressure effects on porcine thoracic compliance in weightlessness: Implications for physiologic tolerance of laparoscopic surgery in space. Crit Care Med. 2009;37:591–7.PubMedGoogle Scholar
  57. 57.
    Kirkpatrick AW, Keaney M, Kmet L, Ball CG, Campbell MR, Kindratsky C, Groleau M, Tyssen M, Keyte J, Broderick TJ. Intraperitoneal gas insufflations will be required for laparoscopic visualization in space: a comparison of laparoscopic techniques in weightlessness. J Am Coll Surg. 2009;209:233–41.PubMedGoogle Scholar
  58. 58.
    Kirkpatrick AW, Campbell MR, Jones JA, Broderick TJ, Ball CG, McBeth PB, McSwain NE, Hamilton DR, Holcomb JB. Extraterrestrial hemorrhage control: terrestrial developments in technique, technology, and philosophy with applicability to traumatic hemorrhage control in long-duration spaceflight. J Am Coll Surg. 2005;200:64–76.PubMedGoogle Scholar
  59. 59.
    Satava RM. 3-D Vision technology applied to advanced minimally invasive surgery systems. Surg Endosc. 1993;7:429–31.PubMedGoogle Scholar
  60. 60.
    Green PS, Piantaniada TA, Hill JW, et al. Telepresence: dexterous procedures in a virtual operating field. Am Surg. 1991;57:192.Google Scholar
  61. 61.
    Satava RM, Green PS. The next generation: telepresence surgery—current status and implications for endoscopy. Gastrointest Endosc. 1992;38:277.Google Scholar
  62. 62.
    Bowersox JC, Cordts PR, LaPorta J. Use of an intuitive telemanipulator system for remote trauma surgery: an experimental study. J Am Coll Surg. 1998;186:615–21.PubMedGoogle Scholar
  63. 63.
    Bowersox JC. Telepresence surgery. Br J Surg. 1996;83:433–4.PubMedGoogle Scholar
  64. 64.
    Satava RM. Minimally invasive surgery and its role in space exploration. Surg Endosc. 2001;15:1530.PubMedGoogle Scholar
  65. 65.
    Jones J, Johnston S, Campbell M, et al. Endoscopic surgery and telemedicine in microgravity: developing contingency procedures for exploratory class space flight. Urology. 1999;53:892–7.PubMedGoogle Scholar
  66. 66.
    Wong JY, Pfahnl AC. 3D Printing of surgical instruments for long-duration space missions. ASEM. 2014;85:758–63.Google Scholar
  67. 67.
    Billica RD, Simmons SC, Mathes KL, et al. Perception of medical risk of spaceflight. Aviat Space Environ Med. 1996;67:467–73.PubMedGoogle Scholar
  68. 68.
    Kirkpatrick AW, Campbell MR, Novinkov OL, et al. Blunt trauma and operative care in microgravity: a review of microgravity physiology and surgical investigations with implications for critical care and operative treatment in space. J Am Coll Surg. 1997;184:441–53.PubMedGoogle Scholar
  69. 69.
    Wade C. Translational medicine: from ground-based studies of traumatic injuries to astronaut health and Earth benefits. Gravitational Space Biol. 2006;19(2):65–75.Google Scholar
  70. 70.
    Taylor G, Neale L, Dardano J. Immunological analysis of U.S. Space Shuttle crewmembers. Aviat Space Environ Med. 1986;57:213–7.PubMedGoogle Scholar
  71. 71.
    Taylor G, Janney R. In vivo testing confirms a blunting of the human cell-mediated immune mechanism during spaceflight. J Leukoc Biol. 1992;51:129–32.PubMedGoogle Scholar
  72. 72.
    Sears JK, Arzenyi ZE. Cutaneous wound healing in space. Cutis. 1991;48:307–8.PubMedGoogle Scholar
  73. 73.
    Davidson J, Aquino A, Woodward S, et al. Sustained microgravity reduces intrinsic wound healing and growth factor responses in the rat. FASEB J. 1999;13:325–9.PubMedGoogle Scholar
  74. 74.
    Kaplansky A, Durnova G, Burkovskaya T, et al. The effect of microgravity on bone fracture healing in rats flown on Cosmos 2044. Physiologist. 1991;34:S196–9.PubMedGoogle Scholar
  75. 75.
    Kirchen ME, O’Connor KM, Gruber HE, et al. Effects of microgravity on bone healing in a rat fibular osteotomy model. Clin Orthop. 1995;318:231–42.Google Scholar
  76. 76.
    Johnson RL, Hoffler GW, Nicogossian AE, et al. Lower body negative pressure: third manned Skylab mission. In: Johnston RS, Dietlein LF, editors. Biomedical results from Skylab. Washington: US Government Printing Office; 1977. p. 284–312. NASA SP-377.Google Scholar
  77. 77.
    Stepaniak PC, Hamilton GC, Olson JE, Gilmore SM, Stizza DM, Beck B. Physiologic effects of simulated +Gx orbital reentry in primate models of hemorrhagic shock. Aviat Space Environ Med. 2007;78,. Suppl. 1:14–25.Google Scholar
  78. 78.
    Kirkpatrick AW, Dulchavsky SA, Boulanger BR, Campbell MR, Hamilton DR, Dawson DL, Williams DR. Extra-terrestrial resuscitation of hemorrhagic shock: fluids. J Trauma. 2001;50:162–8.PubMedGoogle Scholar
  79. 79.
    Hirschberg A, Mattox K. “Damage control” in trauma surgery. Br J Trauma. 1993;80:1501–2.Google Scholar
  80. 80.
    Kirkpatrick AW, Broderick T, Ball C, et al. Implications regarding the abdominal compartment syndrome in space. ANZ J Surg. 2005;75:A5–A60.Google Scholar
  81. 81.
    Kirkpatrick AW, Campbell MR, Brenneman FD, et al. Trauma laparotomy in space: a discussion of the potential indications, conduct of operation, and technical support for the treatment of abdominal trauma during long-duration space exploration. Presented at the 28th International Conference of Environmental Systems, Danvers, MA, 13–16 July 1998. SAE Technical Paper Series 981601.Google Scholar
  82. 82.
    Kirkpatrick AW, Ball CG, Campbell M, Williams DR, Parazynski SE, Mattox KL, Broderick TJ. Severe traumatic injury during long duration space flight: Light years beyond ATLS. J Trauma Manag Outcomes. 2009;3:1–11.Google Scholar
  83. 83.
    Dulchavsky SA, Henry SE, Moed BR, et al. Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination. J Trauma. 2002;53:28–32.PubMedGoogle Scholar
  84. 84.
    Kirkpatrick AW, Brown R, Diebel LN, et al. Rapid diagnosis of an ulnar fracture with portable hand-held ultrasound. Mil Med. 2003;168:312–3.PubMedGoogle Scholar
  85. 85.
    Noble VE, Legome E, Marshburn T. Long bone ultrasound: making the diagnosis in remote locations. J Trauma. 2003;54:800.PubMedGoogle Scholar
  86. 86.
    Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma. 2000;48:613–23.PubMedGoogle Scholar
  87. 87.
    Norfleet W. Anesthetic concerns of spaceflight. Anesthesiology. 2000;92:1219–22.PubMedGoogle Scholar
  88. 88.
    Agnew JW, Fibuch EE, Hubbard JD. Anesthesia during and after exposure to microgravity. Aviat Space Environ Med. 2004;75:571–80.PubMedGoogle Scholar
  89. 89.
    Datta R, Mohan CVR. Space and the anaesthesiologist. J Anaesth Clin Pharmacol. 2008;24:13–24.Google Scholar
  90. 90.
    Komorowski M, Watkins SD, Lebuffe G, Clark JB. Potential anesthesia protocols for space exploration missions. ASEM. 2013;84:226–33.Google Scholar
  91. 91.
    Silverman GL, McCartney CJ. Regional anesthesia for the management of limb injuries in space. Aviat Space Environ Med. 2008;79:620–5.PubMedGoogle Scholar
  92. 92.
    Keller C, Brimacombe J, Giampalmo M. Airway management during space flight. Anesthesiology. 2000;92:1237–41.PubMedGoogle Scholar
  93. 93.
    Beck G. Emergency airway management in orbit: an evidence-based review of possibilities. Respir Care Clin. 2004;10:401–21.Google Scholar
  94. 94.
    Rabitsch W, Moser D, Inzunza MR, Niedermayr M, Köstler WJ, Staudinger T, Locker GJ, Schellongowski P, Wulkersdorfer B, Rich JM, Meyer B, Benumof JL, Frass M. Airway management with endotracheal tube versus Combitube® during parabolic flights. Anesthesiology. 2006;105:696–702.PubMedGoogle Scholar
  95. 95.
    Marescaux J, Leroy J, Rubino F, et al. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg. 2002;235:487–92.PubMedPubMedCentralGoogle Scholar
  96. 96.
    Haidegger T, Sandor BZ. Surgery in space: the future of robotic telesurgery. Surg Endosc. 2011;25(3):681–90.PubMedGoogle Scholar
  97. 97.
    Hart R, Campbell MR. Digital radiography in space. Aviat Space Environ Med. 2002;73:601–6.PubMedGoogle Scholar
  98. 98.
    Rozycki G, Ochsner M, Jaffin J, et al. Prospective evaluation of surgeon’s use of ultrasound in the evaluation of trauma patients. J Trauma. 1993;34:516–27.PubMedGoogle Scholar
  99. 99.
    Sargsyan AE, Hamilton D, Kirkpatrick AW, et al. Ultrasound evaluation of the magnitude of pneumothorax: a new concept. Am Surg. 2001;67:232–6.PubMedPubMedCentralGoogle Scholar
  100. 100.
    Dulchavsky S, Schwartz K, Hamilton D, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. 1999;47:970–1.PubMedPubMedCentralGoogle Scholar
  101. 101.
    Martin DS, South DA, Garcia KM, Arbeille P. Ultrasound in space. Ultrasound Med Biol. 2003;29:1–12.PubMedGoogle Scholar
  102. 102.
    McFarlin K, Sargsyan AE, Melton S, Hamilton DR, Dulchavsky SA. A surgeon’s guide to the universe. Surgery. 2006 May;139(5):587–90.PubMedGoogle Scholar
  103. 103.
    Kirkpatrick AW, Jones JA, Sargsyan A, Hamilton DR, Melton S, Beck G, Nicolaou S, Campbell M, Dulchavsky S. Trauma sonography for use in microgravity. Aviat Space Environ Med. 2007;78:A38–42.PubMedGoogle Scholar
  104. 104.
    Kirkpatrick A, Hamilton D, Nicolaou S, Sargsyan A, Campbell M, Fievson A, Dulchavsky S, Melton S, Beck G, Dawson D. Focused assessment with sonography for trauma in weightlessness: a feasibility study. JACS. 2003;196:833–44, 546–50.Google Scholar
  105. 105.
    Sargsyan AE, Hamilton DR, Jones JA, Melton S, Whitson PA, Kirkpatrick AW, Martin D, Dulchavsky SA. FAST at MACH 20: clinical ultrasound aboard the International Space Station. J Trauma. 2005;58:35–9.PubMedPubMedCentralGoogle Scholar
  106. 106.
    Kirkpatrick AW, Nicolaou S, Campbell MR, et al. Percutaneous aspiration of fluid for management of peritonitis in space. Aviat Space Environ Med. 2002;73:925–30.Google Scholar
  107. 107.
    Kirkpatrick AW, Nicolaou S, Rowan K, Liu D, Cunningham J, Sargsyan AE, et al. Thoracic sonography for pneumothorax: the clinical evaluation of an operational space medicine spin-off. Acta Astronaut. 2005;56:831–8.Google Scholar
  108. 108.
    Hamilton DR, Sargsyan AE, Kirkpatrick AW, Nicolaou S, Campbell M, Dawson D, Melton S, Beck G, Guess T, Rasbury J, Dulchavsky SA. Sonographic detection of pneumothorax and hemothorax in microgravity. Aviat Space Environ Med. 2004;75:272–7.PubMedGoogle Scholar
  109. 109.
    Jones JA, Kirkpatrick A, Hamilton DR, Sargsyan AE, Campbell M, Melton S, Barr YR, Dulchavsky SA. Percutaneous bladder catheterization in microgravity. Can J Urol. 2007;14:3424–9.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Paris Regional Medical CenterParisUSA
  2. 2.Trilife Health, PCFort CollinsUSA

Personalised recommendations