AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2009, Volume 11, Number 10: 799-803.

Medical Narratives

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Sami, the Methanol Guy

A look through the eyes of an emergency room physician in Baghdad at a 5-year-old boy who died for his grandfather’s religious beliefs.

Nabil Al-Khalisi, MD

Health is a multistep process that starts with community awareness and ends with patient care. When the community education level is nonexistent, there is little a physician can do to help patients, no matter how skilled he or she is. The following is a story of an after-midnight shift in an Iraqi ER—one where I had a problem that was more cultural than clinical, and one I could not face on my own. I was traumatized, threatened, had flashbacks and deep moral conflicts; I ran away.

Learning Objective Look through the eyes of an emergency room physician in Baghdad at a 5-year-old boy who died for his grandfather’s religious beliefs.

It was midnight; the weather, cold and foggy. I sat before the glass door of the pediatrics emergency department main entrance. I was tired and headachy, having spent the day working with a senior colleague. We both worked quickly, discharging as many stable patients as possible. My senior colleague left me alone to face the after-midnight shift so that he could get some rest.

I looked through the glass door, hoping that no one would come. After 16 hours of labor I was ready for a break. Knowing there were 8 hours more made me feel sick, but I tried to be optimistic and take things easy.

A loaded after-midnight shift can bring up to 20 patients; I was hoping for a max of four or five. The good news is only one patient came asking for help that night. The bad news is that after I finished my duty I wished I had had 30 patients screaming and shouting instead of this one.

Sami had brown hair, shiny blue eyes, and a small mouth wide open. He was about 5 years old. He was so drowsy that he was unable to walk for any distance without a stumble. He arched his back a little bit, hanging over his grandfather’s big hand. They were both walking in a slow stride that made me follow their every move as they advanced toward the main entrance. Sami looked curious about what was really going on; he had not been into a hospital before I guessed.

As they opened the door I could not face Sami without a smile on my face. His charm threw a spell on me from the very first glance. He was an adorable little fellow who made me feel that every little effort and every drop of sweat for the sake of every child was worth it. I forgot about my headache and started talking to Sami right away. His grandfather appeared worried and anxious and he kept interrupting my conversation with Sami. It was as if he really knew that we were all running out of time. Sami’s hands were cold and he was clearly unbalanced; he smelled like alcohol and his clothes were covered in vomit. I asked him what was wrong, but he replied with a faint smile, saying, “Nothing, I feel sleepy; where is mom?” Just then I turned to the grandfather who was shaking and stuttering. He said, “Doctor, he almost drunk the whole bottle, all of it, thinner, we were painting, the whole bottle!” I suddenly realized that I was dealing with a time bomb here. A “thinner” means methanol; in Iraq it is used to dilute paints.

I fetched my stethoscope and listened to the child’s chest, which was mostly clear with a few scattered wheezes. I ordered Ipecac solution and IV fluids right away and tried to talk with Sami to assess his level of consciousness; he seemed to be oriented but a bit sleepy. Telling Sami that everything would be ok was a joke but I had no other choice. I had to lie; at least it would alleviate his fears.

Treating methanol poisoning is quiet simple. You bring some friendly ethanol molecules that shift hostile methanol molecules away from liver cells and we are all happy and safe—no retinal damage; no liver failure; no nothing. The problem was that the list of 20 generic, commonly used drugs carried by our pharmacy—the pediatric emergency department pharmacy at the medical city complex that is the best health institution in Iraq—did not contain ethanol. My mind raced with thoughts of how I could get some ethanol in Baghdad at midnight. No stores were open; no pharmacies. I remained silent for a while thinking deeply, trying to solve a problem that was 10 times more logistical than medical. I had never run into such a problem during my entire 12-month career. I bent down and looked directly into Sami’s eyes. I touched his cheek and told myself, “this kid must make it.” I was bothered by Sami’s strong aromatic smell with every breath, as if he were an alcoholic. Just then I had an idea—let’s drink some Arak (a traditional colorless Iraqi spirit that contains up to 80 percent ethanol—affordable and at hand. My initial plan was to make the grandfather get a bottle or two of Arak from a nearby shop, as alcohol stores tend to stay open later than pharmacies.

I turned to the grandfather, took him away from Sami, and tried to be assertive and informative at the same time. “Sir, Sami is dying. We have got only one shot. He has methanol poisoning, it is very serious, and we need to act fast. Methanol has only one antidote which is ethanol, and unfortunately we do not have medical ethanol here; do not feel panic please; we can make it. Arak contains ethanol as its main component, and we can use it to cure Sami. Bring me a bottle of Arak and I promise to do my best but please hurry up.”

After this short speech things changed dramatically; the grandfather’s face turned from pale yellow to red; he became obviously angry and aggressive. He attacked me with both his hands, trying to smother me. He was taller and heavier than me so within seconds he grasped my neck. He started shouting “You bastard; you have no mercy; you want me to bribe you? Are you trying to blackmail me? Are you bargaining Sami’s life for alcohol? If he dies, you die too, understand?”

Soon after that the Facility Protection Service (FPS) intervened. Suddenly I was surrounded by guards; they pulled the grandfather away and tried to calm him. On my hands and knees, I took a few deep breaths. Just then I saw noticed that Sami was looking at me strangely, like he was saying, “What is going on? Grandpa loved you a moment ago? What did you do to make him so angry?” In this moment I felt that time had stopped and it was just me and little Sami looking at each other. I realized that Sami’s life was on the line and I had to convince his grandfather that I was saying the truth or else.

In the other corner of the ER, Sami’s grandfather was forced to sit on the floor. FPS’s attempts at calming him were not successful and he continued shouting and threatening me. He felt so angry that both his hands were shaking—he was hysterical. Convincing such a man is almost impossible, but I had to try no matter what. I slowly advanced and stopped about 1 meter away from him while the guards were still holding him down to the floor. I asked him to listen carefully. He looked at me with disgust and told me that God would punish me for my horrible acts; no one could escape the rage of God. I talked as keenly as I could and tried to be convincing. “I am not asking for a bribe; this is my job and I am doing it in the best way that I can. Arak contains ethanol and we really need it. Bring it and you will see that I will not sip a drop of it. Trust me please; Sami’s life is on the line here.”

He replied in an indignant way, “Drinking alcohol is a sin; God told us that no benefit can be sought from alcohol; God knows what he is doing.” It became obvious that I had failed to convince him. I went to the lobby and called the chief resident immediately; fortunately he was awake and willing to come to the ER right away. Five minutes later the chief was examining Sami and soon after talked to the grandfather, telling him that every word I had said was right and that he should do as I say. At this very moment the grandfather became insane, calling me names and shouting very loudly, “Corruption, you both are corrupted physicians, you do not deserve to live, God help me, if anything happens to Sami I will kill you both, I will tell the minister of health.” The drowsy chief resident whispered a few words in my ears, telling me to discharge Sami. He said we had done all we could, and the grandfather would have to accept the consequences of his actions.

While the grandfather was crying for help and cursing me at the same time, I stood a few meters away, thinking of alternatives. I thought maybe I could go fetch the bottle, but realized that this was impossible because there were too many critically ill patients in the ER that could not be left alone. I thought about waking up an off-duty fellow colleague to do the job, but would the grandfather let us give alcohol to Sami? Why would anyone risk himself at this late time to help a guy who was refusing help in the first place? Feeling hopeless and incapacitated, I decided to wait and see whether Sami’s deterioration would push the grandfather and make him listen to me. This was my last option.

Time passed slowly. I watched Sami fading minute by minute without being able to do anything. First he started vomiting; then he became drowsier and drowsier; a few hours later he became completely unconscious. The grandfather never changed his mind; he continued to blame me for what was happening and promised revenge if Sami died. I felt sad watching a child’s life slipping away in vain. Despite Sami’s deteriorating condition, the grandfather decided to stand still, and he was intending to report what happened to the hospital officials the next day. I felt so tired and confused at that time and let my eyes close. Meanwhile, the grandfather tired of shouting and crying too; he became silent, letting out a brief cry every now and then. At 4 a.m. the three of us fell asleep.

Suddenly at 5:30 a.m. a scream broke the silence. The grandfather shouted, “Help me, he is not breathing, his hands are turning into blue, God please save him, he is still so young to die, oh God, help.” I rushed to Sami with my stethoscope and checked his vital signs; he was dead. I tried to resuscitate him but to no avail. A few minutes later when I lost hope that I could bring him back I looked into his face and said, “Forgive me dear Sami, I did my best, I hate this world for not giving you another chance, which you really deserve to have.” He was cold and pale; his face was still as charming as before but less expressive. I think that he did not even know what had happened to him. The grandfather collapsed soon after that. I spent the next 2 miserable hours remembering every little detail of what had happened. Five minutes before my shift ended the grandfather started weeping and then came straight toward my desk; he looked me into the eye and said “I will kill you, Sami must be revenged, you are corrupted, and I will never feel peace till you are dead.” I felt so sorry for everyone, including myself. I also felt scared that this distraught man might really try to kill me.

On my way home, I thought deeply about this event. I realized that medical training alone was not enough to cure people. It is not always about training and equipment; sometimes ignorance, illiteracy, and a chance are all that matter. Putting the pieces of this story together tells us one fact: healing people is a multistep process that starts with education and ends with treatment. I could not oppose societal values on my own. Being a doctor is a doubled-edge sword; you can help sick people more than you can imagine because you are in the middle, surrounded by sickness. On the other hand, providing health care alone is not enough. We should adopt a new way of thinking; humans are so precious, we should cherish our lives, and abandon our disagreements because they simply do not matter anymore.

After the incident, a dozen questions popped up into my exhausted mind; can I keep doing this in Iraq? Should I try harder or just give up? Whose fault is it? Am I doing the right thing? I got home, took off my shoes, and lay down in bed. I closed my eyes and ran away. I could face no more truth. I ran away, far away in my bed.



Nabil Al-Khalisi, MD, works at the Iraq Medical City in Baghdad, and is a Nongovernmental Organization (NGO) activist. Dr. Al-Khalisi frequently writes about his medical experiences. His work has been published in the British Medical Journal, among others. He recently represented Iraq in the Global Changemakers programme run by the British Council.

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