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Investigation Report, NSS Atlas #88817
[This is a write-up of IC events that occured on round #88817, NSS Atlas, Goon1 RP.
I just thought it would be nice to write an account of a round which I found particularly engaging so people can hear about the stories that our wonderful RP server is capable of creating smile   I guess this is also a request for a map update (namely the addition of a Restricted Medicines Locker to Atlas), I think it would be a great example of events that are acted out in-game and created by players having a lasting influence on the map that surrounds them]

DOCUMENT #192356
SHIFT #88817

DOCUMENT DESCRIPTION: Conclusions of investigation into death of Captain Catherina


A critically ill crew member onboard NSS Atlas succumbed to their injuries whilst undergoing surgery in the Medbay onboard. Whilst they were successfully cloned and fully reinstated in their assignment, as a death in medical care had occurred, a full investigation was launched and led by myself. The investigation finds that the lack of a reserve of Atropine in NSS Atlas' Medbay storage signficantly reduces the chance of survival for patients undergoing acute cardiac failure onboard, as well as a number of other operational & organisational issues which contributed to the death of a patient who was directly in the care of the medical team.


On shift #88817, Captain Willy Catherina died on the operating table in the surgery theatre aboard NSS Manta, for which I was supervising the crew. Whilst Captain Catherina did make a full recovery and returned to their post after a successful cloning procedure, a death in the care of the medical team had still occurred, thus I was obliged to open a full internal investigation into the circumstances that caused this to happen. In the course of the investigation I took the testimonies of 2 other crew members, and a 3rd crew member provided a voluntary testimony as well, which I allowed:
Dr Raphael Zahel, Medical Doctor
Dr Benny A Martinez, Director of Medicine NSS Manta
Dr Adrian Hoover, Roboticist (voluntary testimony)

From these testimonies, I constructed the following timeline of events:

Captain Willy Catherina (the patient) is believed to have ingested a beverage which contained an inhumane concentration of alcohol. He was rushed to the Medbay where he was immediately taken under the care of Dr Zahel & Director Martinez. The medical team diagnosed the patient with a deceased liver, cardiac distress, burns, "an ungodly load" of Ethanol presence, asyphyxiation & toxin poisoning. The patient was then administered 30u Charcoal (a.k.a. anti-toxin) & 15u Epinepherine (a common cardiac stimulant), which are the trivial treatments for toxin poisoning & cardiac distress respectively. In response to the deceased liver, an order was given to print a cyberliver for an immediate transplant. Surgery was immediately undertaken but could not start as the surgery theatre lacked any surgical scissors. After scissors were printed using a fabricator, the liver transplant was successful but then the patient immediately entered acute cardiac arrest. Dr Zahel applied a defibrilator once to the patient, which failed to revive them, and the death was announced immediately in hopes that the body would remain fresh enough for a DNA scan and cloning procedure to take place. The patient was then successfully scanned and cloned and returned to their assignment immediately.

Dr Zahel & Director Martinez agreed that the lack of availability of scissors with which to conduct the liver transplant did not significantly contribute to the death of the patient, as the eventual cause of death was the cardiac distress and resulting arrest. Director Martinez explained in his testimony that had Atropine, a more extreme cardiac stimulant which is under Restricted Use in Nanotrasen vessels, been available, the patient would have had a significantly higher chance of survival, and the need for a clutch DNA scan and use of expensive biomatter reserves for cloning would have been avoided. As such, the investigation finds that the lack of Atropine stores aboard NSS Atlas was the most critical shortcoming of the medical treatment provided. Furthermore, a general lack of organisation and forward thinking by the Medbay staff is noted by the investigation. Routine inspections of the emergency surgery theatre would have discovered the lack of surgical scissors, and more proactivity by the ship's Genetecists in acquiring DNA scans of all crew members would have meant that the medical team would have had more time to defibrilate the patient in hopes of reviving them, avoiding the expensive cloning process altogether. The Roboticist Dr Hoover also testified to a lack of organisation in the department, explaining that he had no idea the emergency surgery was taking place or indeed that a cyberliver had been requisitioned from his Department, and he only found out because of hearing commotion through the walls. As Head of Personnel aboard NSS Atlas I have already acted upon these organisational shortcomings and have adapted my routine inspection checklists to include these elements so that such an event may not happen again in the future. In my opinion, it now lies on Nanotrasen Regional Command to equip our medical team with the necessary medicines to treat crew members. As someone involved with the logistics of things coming on and off ship, I appreciate the difficulties with restricted medical shipments, however I believe a restricted medicine storage which will be rarely used and hence require little in terms of upkeep as Atlas is such a small vessel, will be of great benefit to the medical teamand hence the ability for Atlas to efficiently carry out its mission objectives for a long time to come.

I hope that my superior authorities who examine this log, including the Regional Director and Inspector who were both present for my verbal report of the investigation conclusions to the Captain and entire medical team, agree with the findings provided and that they will act upon this investigation. I have included a scan of my original notes of the testimonies as an attachment for reference

Ms Erin Leach
Head of Personnel, NSS Atlas

ATTACHMENT DESCRIPTION: Paper scan of testimony notes

Medical Death Investigation
Interview with Dr Raphael Zahel who gave treatment to patient:
Zahel took over from MD. Captain presented with deceased liver, cardiac distress, an "ungodly load" of Ethanol, and burns. In response, 30u of charcoal and 15u of Epinepherine were administered, and a cyberliver was requested for printing.
The OR was missing scissors. New scissors were printed, patient's liver was removed and cyberliver installed. Dr Zahel does not believe the delay of acquiring surgical scissors was a significant contributing factor. Patient then presented with massive deoxygenation, toxin damage. Patient was defibrilated once and then was deemed dead. Cloning was then initiated.

Addendum: Oxygen and toxin damage presented from patient's arrival.
Raphael Zahel
Testimony of Director Martinez: Director Martinez printed the cyberliver. He agrees with Doctor Zahel's assessment that the lack of available surgical scissors contributed significantly to the patient's death. Director Martinez believes that if Atropine had been available, the chance of survival would have been higher. He also said that the patient was only defibrilated once so that they could be brought to the DNA scanner as quickly as possible. If the patient had already been DNA scanned, they could have worked longer on the original body.

~Benny A Martinez
Testimony of Doctor Hoover, witness: Dr Hoover says that Dr Zahel looked "seriously frustrated" over his efforts to save the patient.Doctor Hoover testifies that the cyberliver was never installed, and the patient entered cardiac arrest *during* the surgery. Dr Hoover, as a Roboticist, also says that he was never informed of what was happening, and only noticed because of the commotion.

What an awesome write-up of a fun round! I definitely want to see more of these on the forum, and would love it if Atlas could be updated to reflect the lessons learned.

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