"Attention all personnel, we are activating mass casualty incident protocols."
The PA system of the accident and emergency department of Southern Queen's Hospital made an announcement that had become all too familiar to the staff. Soon, the senior physician in the department gathered all the staff together at the nurse station.
"Everyone! There is a mass casualty incident at Haucon City University. We are expecting at least 30 casualties. The exact cause is unclear at the moment, but we do know it is a respiratory problem, with at least 20 casualties in respiratory arrest."
The blare of sirens from ambulances racing towards Southern Queen's Hospital filled the southern part of Haucon Island. When they arrived at the hospital's A&E department, a small army of paramedics pushed gurneys through the entrance into the empty department.
When Camila saw ambulances filling the ambulance bay outside the hospital, she quickened her pace. When she finally reached the entrance of the hospital, a security guard stopped her.
"Ma'am, we are currently having a mass casualty incident. You'll have to go somewhere else for— Stop! You can't just go inside right now!"
Camila ignored him and ran right into the A&E department. When she walked past a doctor who was walking away from the A&E department, she tapped him on the shoulder.
"It's carbon monoxide, by the way. Tell everyone else that."
"Wait, who are you?! How do you know it's carbon monoxide?! Wait!"
Before the doctor could even finish responding, she was already walking away to a different part of the hospital.
Camila walked into a conference room and took a seat. She winced as she held her head briefly. A man in a white coat at the end of the table stood up and began talking.
"As you are all keenly aware, hospitals all across Haucon Island are experiencing a mysterious surge in all sorts of deadly conditions. We voiced our concerns alongside other hospitals to the Department of Health. However, it appears they have yet to take our concerns seriously no matter how many times we attempt to communicate. As the chief executive of Southern Queen's Hospital, I am deciding to take matters into our own hands. I have invited the School of Biomedical Science and School of Public Health to investigate the source of these outbreaks. Please, Professor Abetz, Professor Wong."
Professor Abetz, sitting right next to the chief executive, stood up and cleared his throat.
"Good morning, everyone. I am the director of the School of Public Health. My colleagues have already begun researching the epidemiology of the current medical crisis. We have observed a two-fold increase in hospitalisations compared to the previous month…"
Camila covered her mouth as she let out a quiet yawn while listening to the director's speech. She muttered to herself.
"This is so boring. When are they going to get to the point?"
A second professor stood up and continued talking after Professor Abetz finished, while Camila was lying on the table, her hand on her forehead, wincing occasionally.
"I would like the School of Biomedical Science to establish a field team to cooperate with our epidemiologists in investigating the situation on the ground. I have an outstanding toxicologist and researcher in mind for this team. Associate Professor Fletcher, please."
Camila jumped at the sound of her name being mentioned, and she quickly fixed her disheveled hair and stood up, speaking with occasionally pauses.
"Ah, yes… I'll make this quick. I already have a doctoral student who will be working with me in the field, but as I've already said… through email, I'd like some personnel from the hospital as well to assist with the clinical side of things. The attrition rate has been… quite high this month thanks to the extreme workload… recently, right? Hopefully, you found some staff who quit medicine to change their line of work briefly and help us out."
The chief executive nodded, and soon, there was a knock on the door before it opened. The chief executive looked towards the two men who had just walked in.
"Dr. Noah Raymond from emergency medicine and APN Ronnie Lawrence from critical care. They were going to quit in a few days, but I made a deal with them to switch them over to your research team instead."
The doctor, Noah, looked at Camila and pointed at her with widened eyes before exclaiming.
"Wait, you're the lady who just barged in and diagnosed the patients with carbon monoxide poisoning! How did you do that?!"
Professor Wong from the School of Biomedical Science looked towards Camila with a raised brow, and Camila let out a small nervous chuckle.
"Well… I may or may not have been near the conference room when I was getting ready to leave the university to get here. And I may or may not have gone inside to take a look when the incident happened. Ugh......…. There… there were a bunch of unlabelled canisters of compressed gas stored in some small room connected to the conference room. Judging from the fact that the gas was completely colourless and… odourless and the fact that it was making me kinda nauseous and dizzy and not outright dead, I assumed it was carbon monoxide."
Both Noah and the nurse, Ronnie, had their eyes widen as they heard what Camila said. Both Noah and Ronnie urgently said to her.
"You were one of the victims?! Stop standing here and get treated!"
"No wonder you were looking a little off. You really should go to the A&E."
"B-but, I've still got to- I'll be fine if I get a bit more fresh air!"
Professor Wong looked at Camila and waved her off.
"Don't be stubborn and get treated you idiot. Don't do dangerous things like that again. You are already making me regret nominating you, Camila."
"Do we have any oxygen masks available?"
Noah inquired as he and Ronnie brought Camila to the A&E department. The nurse whom Noah asked looked at him in surprise.
"Oh, Dr Raymond! I thought you left. Well, we do actually have a couple of oxygen masks available after… most of the respiratory arrest casualties expired and some of the patients were transferred to Nethersole Hospital for HBOT."
Ronnie brought Camila to one of the open beds while Noah put a non-rebreather oxygen mask on her face. A pulse CO-oximeter was brought to Camila, and Ronnie read the reading.
"Twenty-one percent COHb, that's a toxic dose. You really should have prioritised your own health over that meeting, Professor Fletcher."
"Call… me Camila. We're a… team now."
Camila struggled to talk through the oxygen mask, her voice muffled by the mask. Noah sighed and he put a finger over his lips.
"Stop trying to talk and focus on breathing. I can't believe our team leader already got poisoned before we even properly met each other."
Camila reached out with her hand and said.
"Bag…"
Ronnie grabbed her bag and handed it over to her. She took out her laptop and opened up a spreadsheet.
"You guys, we have a job to do. Start collecting data on all the patients, alive or deceased… I can't do science without some data. Go."
Noah and Ronnie looked at each other in the eye, then Ronnie began walking away.
"I'll go take the histories of all the conscious victims, Noah, you stay here and take care of Camila, okay?"
After several hours of Ronnie taking patient histories and Noah assisting treatment in the overwhelmed accident and emergency department, a girl ran through the front door and rushed inside Camila's cubicle.
"Camila! Camila! Are you okay? Oh god, what happened to you?"
Camila, now with her oxygen mask off, gave the girl a wave before responding.
"Just a little carbon monoxide, that's all. Don't worry too much about me, Juliet. In fact, I'm getting ready to move on to the next part of the investigation."
Noah and Ronnie returned to Camila after they heard the two women chatting. Ronnie gave Camila a thumbs up as the four walked out of the cubicle.
"I got the data that you requested. All the lab results, physical exam findings, and patient histories should have been sent already. By the way, who is the lady over here?"
"That's Juliet," Camila responded. "She'll be the fourth member of our team, a doctoral student in microbiology. Anything of an infectious origin will be her forte."
Camila stopped right next to the department's nurse station and turned around before continuing.
"Alright, now that the whole team is here. Please present everything we've found out so far. Noah, you go first."
"Thanks to Camila, we have determined carbon monoxide as the cause of the incident. Pulse CO-oximetry confirmed carbon monoxide poisoning in all the victims. However, there is something unusual. As an emergency medicine physician, I've dealt with my fair share of carbon monoxide poisoning cases, but this incident in particular was unusually deadly. I don't think carbon monoxide was the only cause."
Ronnie stepped forward and continued after Noah finished.
"I agree with Noah. The carboxyhemoglobin levels in the majority of the victims were far too low to cause this level of severity. So far, I have counted 28 patients with respiratory arrest and 22 deaths in this hospital alone, not counting any who have been transferred to Nethersole Hospital. The majority of patients had COHb levels hovering around the mid-thirties. The severity of the carbon monoxide poisoning does not correlate well with the extremely high fatality rate of this incident.
After Ronnie's report, Juliet finally gave her information as well.
"Before coming here I talked to Professor Wong, and we have gotten permission from the police to take a look at the conference room where the poisoning happened. With the forensic pathologists who would normally be in charge of this being the main victims of the incident, the job has fallen onto our hospital's investigative task force to examine the scene."
Camila clapped her hands together and began walking towards the exit, the other three following close behind.
"Well let's get to it. I've already prepared some sampling equipment at the university sitting in one of the labs a few days ago, we should be able to get at least some clues from the scene itself. Juliet and I will go investigate the crime scene, Noah and Ronnie, expand your search outside of this A&E department to the ICU and Nethersole hospital, get as much information as you can from the patients, and try to diagnose the condition. Find any commonalities you can between the patients, no matter how small."
The team split up and Camila and Juliet travelled to Haucon City University aboard the metro. After they made a quick detour to one of the laboratories to gather personal protective equipment and equipment, they arrived outside the conference room where the incident happened. Surrounding the entrance were groups of police officers and investigators, when Camila approached the door, one of the officers stopped her.
"This room is currently under investigation, you cannot enter right now until the investigation is over."
Camila grabbed her staff card and presented it to the officer.
"Dr. Camila Fletcher, and this girl is coming with me. We're here to assist in investigations in place of the forensic pathology service. We have already gotten approval to enter, please let us through."
One of the other officers approached them, he put his hands in his pockets while walking at an extremely slow pace, he snickered before he spoke.
"Let them in. The fire department has already made sure the carbon monoxide within the room is at a safe level and the canisters containing the gases have already been removed. I doubt you'll be able to help much considering we already have epidemiologists sent from the university on the case, but you're welcome to try I suppose."
The officer in front of the entrance opened the door, revealing a large room swarmed with investigators. Camila and Juliet stepped inside, Camila's eyes scanned the room, her eyes falling on the table in the centre of the room. She stopped one of the investigators with a question.
"Have any of you collected a sample of the tea? The most likely route for a toxin or disease to simultaneously be transmitted to a room of 40 people would be the liquid that they are all drinking."
The girl who asked the question turned towards her and nodded before handing over a paper bag with a small plastic container inside filled with a light brown liquid.
"Yeah, here it is. You're a toxicologist right? Then I'll leave it to you to analyse it with your fancy equipment considering no one will be staffing the forensic pathology lab."
At the same time, Juliet collected a few of the papers on the table that were already photographed by the police and carefully placed them in a plastic bag with her gloved hands. Camila called out to Juliet across the table.
"Go send the two boys a text telling them to ask some questions about the tea that the patients drank. See if we can establish a correlation between the severity of their condition and their consumption of tea."
Juliet returned an enthusiastic nod and stepped outside to take out her phone. Meanwhile, Camila took a step back and took a good look at the whole room.
There was a long table in the centre with over thirty seats surrounding it. On the table in front of every seat were a stack of papers, some of them swept onto the floor, and a small paper cup with light brown milk tea. There were some light brown stains, and some very small dark red and black stains on the floor carpet. At the back of the room, there was a door right next to the large monitor displaying a presentation slide. Outside of a few stains of spilled tea, the carpet on the floor was in pristine condition.
Camila brought out a camera and took several photographs of the scene, before she walked towards the door. Juliet, who had just finished the call with the rest of the team nearly didn't notice Camila walking out and frantically caught up with her.
"Camila? That's all you needed to see? Are we seriously just going to leave after looking at the place for a few minutes with only two samples in hand?"
Camila nodded in response, taking large and steady steps while she walked out of the conference room after taking off the PPE and headed towards one of the university's chemistry labs.
"My specialty is in toxicology. Our purpose is to figure out any toxicological causes of these mysterious incidents. I don't see any other snacks, drinks, or personal care items that would have been shared by all the victims. The rest of what we need will be found on the patients themselves."
Juliet tilted her head with her gaze shifted towards the corner of her eye as they entered an elevator. Camila continued talking, filling in the silence of the elevator ride.
"Think about it like this. Clearly, it can't be a coincidence that around forty people simultaneously developed life-threatening illnesses at the same place at the same time. We haven't received any reports of similar incidents happening outside of the conference room, so the chance of an accident causing such an unusually well-contained incident is also low. This leaves…"
"An attack. A purposeful murder of the forensic pathologists is most likely, isn't it? It seems like whoever was behind this was probably also behind many of the other outbreaks, and they're trying to cut off our ability to stop them by taking out the forensic experts."
Juliet completed Camila's statement right as the elevator doors opened. The two entered a lab where they put on their lab coats. As Camila took out the sample of the tea and diluted it, she continued chatting with Juliet.
"Right. To be able to cause multiple people to go ill simultaneously, there are only two likely causes, infectious and toxicological. If a toxin was given in the room, then it was probably put inside their drinks. Otherwise, it may have happened at some group activity outside the conference group, in which case it will be up to Noah and Ronnie's history-taking skills to figure out what common thing the victims came into contact with."
Juliet nodded along slowly as she helped Camila filter the sample and set up the LC-MS machine. The sample was injected inside the machine, and it slowly began separating the liquid into all of its components and conducting analysis. When the results came back, Camila's eyes darkened.
The results turned back nothing. Absolutely nothing. Not even tiny traces of heavy metal or anything that could have hurt a fly, let alone killed anyone. Camila and Juliet's eyes hiding behind their safety goggles met, both of them hoping for answers from the other. Camila's phone suddenly rang and she took off her gloves and answered, the caller was Noah.
"Camila, the samples we sent to pathology on our side came back. LC-MS/MS confirmed extremely high levels of nicotine in at least three of the deceased patients. History taking hasn't been very successful, we were too focused on treating the carbon monoxide that we overlooked the nicotine overdose, so most are either dead or intubated in the ICU. We won't get many answers from them. Have you and Juliet found anything that would explain how the nicotine got in their system?"
Camila let out a sigh when she received the news, and Juliet slowly shook her head in defeat as Camila responded.
"Nothing on our side. We tried testing the milk tea that they were all drinking for contaminants, not a speck of nicotine. It could have been mixed in with the carbon monoxide in the air. Nicotine could have also been absorbed through dermal exposure, so we'll go analyse the documents we've collected to see if there are any traces of nicotine. Thanks, you two, I'll update you guys if we find something."
Camila and Juliet prepared the papers they had collected from the scene of the incident for analysis, the papers, which would have been distributed to everyone in the room, seemed like a possible vector for nicotine poisoning. Again, the results turned up nothing. Out of ideas, Camila and Juliet returned to Southern Queen's Hospital to meet up with Noah and Ronnie.