13 Years in the ER: From Chaos to Bearing Witness: A Farewell in Two Acts. Act II

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~ Act II ~ 

A Letter to the Father Who Returned 

Dear Father,


You came back to the ER yesterday. Alone.

Your eyes searched for the place where your children had been, as though the walls might still hold their shadows. You wandered, lost, and when the tears came, they came quietly at first; grief without sound, until they could no longer be contained.

I stood there, silent, because what can you say in the face of such loss?

Your grief took me back to 2019, when another father arrived; with his five children, also victims of phosphine poisoning. They had come to Karachi from Quetta on a short vacation, staying in a modest guesthouse. No one knew that a cheap fumigant, silently seeping through the rooms, had already marked them.

They were Dead On Arrival (DOA in our lingo). Five small bodies laid side by side, from the youngest, a baby, to the oldest, a teenager. I remember the starched white sheets, how they barely moved as we covered those bodies. I remember drawing the curtain across the resuscitation bay: not for them, but for us. My nurses, my doctors, and I: we couldn’t keep looking at those shrouded bodies while managing other patients. The ER doesn’t stop. The doors don’t close. So, we did what we had to do: we pushed forward without processing any of it.

Yesterday, when I saw you, it was as if nothing had changed.

The Weight of Bearing Witness

I’ve asked myself, why me? I was the receiving physician then, and I was the receiving physician now. Perhaps it really is ‘bearing witness,’ as described in the literature of narrative medicine. To bear witness is to stand in the presence of suffering: not to fix it, because some things cannot be fixed, but to hold space for it.

It’s a heavy burden.

When your family arrived yesterday, we were already at capacity. There were two critically ill children in the ER, one of them on a ventilator, and no ICU beds available to move them to. Then came your children: more small bodies fighting for breath; and my team had to find a way to care for them, too.

The ER doesn’t shut its doors. My team: Drs. Ghani, Farhan, and Liza, RN Imran, Coordinator Tariq, and many others - they gave everything they had. But we are human too, and the cost of standing at this intersection between life and death is immense.


The Emotional Cost of the ER

In emergency medicine, we call this moral injury. It’s what happens when you do everything you can, and it still isn’t enough.

Yesterday’s chaos; the sick children, the lack of ICU beds, your presence in the aftermath...will stay with us. There’s no time to pause or grieve. There are no debriefing sessions, no counselors. We just keep moving because the ER demands it.

But ignoring it doesn’t mean it disappears. Over time, the weight of witnessing these tragedies leads to fractures:

  • We become numb.
  • We blame others: systems, governments, parents, sometimes even ourselves.
  • We become jerks at home with our spouses and kids, because we are unable to process our PTSD.
  • Or we stop feeling at all, because it seems like the only way to survive.

These are the negative coping mechanisms we lean on when we have no other tools.

But I’ve also learned that there are better ways to carry the weight:

  • Writing it down: Reflective writing, like this letter, helps process and honor what we’ve witnessed.
  • Talking to someone: A colleague, a counselor, or a friend who understands or simply listens.
  • Taking a breath: Exercise, meditation - anything that creates a moment of stillness.
  • Holding onto purpose: Remembering why we do this work keeps us from falling apart.

We cannot erase these memories, but we can choose how we carry them.


Phosphine: A Preventable Tragedy

Phosphine is a silent killer: odorless, invisible, and unforgiving.

It seeps into homes where children should be safe, and it takes without warning.

This isn’t your fault.

Families like yours don’t know the risks, because no one tells them. Regulations against phosphine exist, but they remain largely unenforced. Awareness is absent where it matters most. Prevention remains a promise left unfulfilled.

We know what needs to happen:

  • Regulation of toxic fumigants.
  • Community awareness campaigns to educate families about the dangers.
  • Accountability to ensure these tragedies don’t repeat. 

None of this is under your control. But inside the ER, we carry the weight of its absence.


The ER Cannot Be an Island

In moments like yesterday, the cracks in the system are impossible to ignore. I left messages, voice notes with department leadership, the pediatric ICU attending, and hospital leadership. I spoke to the transferring doctor, but by then, your family had already left for our ER. There was little reassurance.

The ER cannot function as an island. It is not a dumping ground for crises the system cannot manage. When we say there are no ICU beds, that judgment must be trusted. When we say the ER is full, it’s not because we want to say no - it’s because we can’t say yes.

Communication must be seamless. Without connection, the fractures widen, and families like yours fall through the cracks.


My Last Shift 

Yesterday and today were my last two shifts after 13 years in the ER.

I’m leaving, but I know I will carry these memories forever: the family from Quetta, the white sheets, the curtain I pulled closed, and the tears you shed yesterday.

I am writing this letter because these moments must mean something.

Your children deserved better.

That family in 2019 deserved better.

And we, as doctors, nurses, and humans, deserve better systems - systems that prevent tragedies before they happen.

I hope someone listens. I hope someone acts. Not just for your children, but for the next family that walks through these doors.

Until then, we will bear witness. We will hold space. And we will carry these memories, quietly and deeply, as we always have.

Sincerely,

Asad Mian, MD, PhD

Professor of Emergency Medicine
Clinical Process Innovation Consultant

Dedicated to Team ED, AKUH-K; Co-piloted with ChatGPT4o; First draft Dec 2024. Part I link here.  

from Narrative Medicine


Reference: https://tribune.com.pk/story/2518867/echoes-of-tragedy-the-recurring-trauma-of-the-er

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