As I enter the paediatric emergency room, the lifeless bodies of children — from three months to fifteen years old — lay still. It was a horrific scene that will never leave my mind. Nor will their tragic story of five siblings dying one by one in the same ward.

This grim scene is not out of a film, but has actually happened in ERs of many hospitals quite a few times in the last few years, when children from the same family were brought complaining of respiratory issues, were put on ventilators one after the other, and they didn’t survive.

The most recent incident occurred in Karachi on December 13, where a family suffered extreme consequences after getting their home fumigated. If something as ordinary as that can kill people, it makes us think on how it happened and what can be done to prevent them.

“I was in the paediatric ER when the family was brought in,” recounts Dr Asad Mian, a former paediatric ER doctor at the Aga Khan University Hospital. “The eldest child was stable, but in just a few minutes, his condition also started deteriorating. The way the children responded and reacted showed clear effects of some toxic chemical in their systems, which started affecting their respiratory and cardiac functions.”

It was Dr Mian’s last day at the job. The Drug Regulatory Authority Pakistan is supposed to regulate toxic chemicals, yet the incident left many questions to be answered by fumigation companies and by families who had their homes fumigated, as to what protocols were to be followed and what were actually followed. Such incidents also leave an impact on the paramedic staff who deal with them.

“This moment took me back to 2019 when a father had arrived at the hospital with his five children, who were all victims of the same deadly poison,” he recalled. “This family from Quetta had been staying in a modest guesthouse as they were on a short vacation in Karachi. None of them had the slightest clue that the fumigant used to treat the rooms was seeping silently, marking them for death. The children were already gone when they arrived at the ER, five small bodies lay side by side, from the youngest, a baby, to the oldest, a teenager.”

“We covered their still forms with starched white sheets and drew the curtains not for them but for us,” Dr Mian shared. “We couldn’t bear to look at them while managing other patients. The doors never close in an ER, and the work never stops, but such incidents leave too much to take back home.”

What is phosphine?

Phosphine is a combination of phosphorus and hydrogen (PH3) that is frequently used as a fumigant for insect control in storage facilities and agriculture. Because of its fatal side effects and the health problems it causes when exposed, phosphorus, a highly poisonous and combustible gas, has made headlines all over the world. In many countries, its usage is strictly restricted or prohibited, but in Pakistan, its widespread availability and lax enforcement of the law have made it a double-edged sword.

The poisonous effects of phosphorus can appear quickly after exposure, and it is a quiet killer. Only at specific amounts can the colourless gas be detected because of its odor, which is sometimes compared to a rotting smell. It interferes with respiration, which leads to oxidative stress and, in extreme situations, organ failure.

Chronic respiratory problems, diminished lung function, and long-lasting neurological impairments can result from prolonged exposure, which is frequently caused by repeated fumigation procedures without proper safety precautions. One of the main causes of pesticide poisoning is ingesting phosphine-releasing pills, which are often sold as aluminum phosphide. Phosphine gas is rapidly released in the stomach after ingestion, which, if left untreated, can cause multiple organ failure and death.

Many nations have taken steps to outlaw or strictly control the use of phosphine because of the serious health dangers it poses. But despite international discouragement, phosphine is still freely accessible in Pakistan, frequently in the form of aluminum phosphide pills. These are frequently employed in agricultural settings to fight pests and fumigate grains that have been stored.

There are numerous gaps in Pakistan's hazardous chemical regulations. Although authorisation is required for the selling of dangerous chemicals, phosphine is marketed over the counter with inadequate oversight due to a lack of enforcement and monitoring. Farmers and fumigators frequently don't know enough about the risks posed by phosphine and the safety measures that are required.

Regulations on phosphine

The DRAP Act of 2012 is in charge of regulating therapeutic chemicals, such as medications and specific chemicals. The Department of Plant Protection (DPP) and the Ministry of National Food Security & Research are normally in charge of regulating pesticides and fumigants like phosphine, whereas DRAP is in charge of regulating medications and therapeutic goods. Regulations about the use, distribution, and safety of agricultural chemicals, including phosphine, must be implemented and enforced by these organisations.

Ensuring that phosphine is handled and applied by licensed specialists exclusively and that phosphine-containing goods are registered and authorised for use, the regulatory authority should also take legal action against people or organisations that break laws governing the use of phosphine.

The doctor’s trauma

The paediatric ER is where human fragility is laid bare. “I’ve seen children shattered in mind, body, or spirit by unspeakable abuse,” reminisces Dr Mian. “The stories of young lives forever altered linger long after the shift ends. There’s the father who doesn’t realise his baby, brought in cold and stiff, has likely been dead for hours. With each pill she swallowed, the teenager's cries for help—echoing from her latest return to the ER after another overdose—reverberate anew.

The role of emergency medicine isn’t just about treating patients; it’s about bearing witness to suffering. When tragedy strikes, there’s no fixing it as some things cannot be undone. “This is what we call moral injury, the emotional fallout of doing everything you can, only to find it’s not enough,” he laments. “There is no time to pause or process. No debriefing sessions, no counsellors. We keep moving because the ER demands it, but the trauma doesn’t disappear. Over time, it accumulates and fractures us.”

Just like Dr Mian, several doctors deal with life and death every day, and they also take that trauma home with them, where they also have a family to look after. “Our system doesn’t provide adequate support in such matters, and one has to deal with most of it individually,” shares clinical psychologist Syeda Masooma Zehra, adding that she took a six-month break from work when her mother passed away to get back to normal after such a big loss. She is aware that she could afford the luxury to do this and not all people can. “This is the basic protocol in trauma situations according to the American Medical Association,” she added.

What doctors and other paramedics face in their daily routine makes them thick-skinned, but some incidents or chains of events do leave a lasting impact, and Post-Traumatic Stress Disorder (PTSD) is real among paramedics as well, be it a doctor or a nurse who cleans up the bed after the death of a young one. “Someone shared their experience that nothing ever affected them until a body which was dismantled and was not in a proper shape. That triggered his PTSD because they also have children at home and they can understand what the family has gone through when such incidents happen,” says Zehra. She explained that a significant factor contributing to doctors' struggles with PTSD is the culture of silence that discourages them from discussing their trauma and expressing their true emotions.

With time, the idea has evolved, and now many organisations emphasise counselling and therapy for professionals who are more prone to having PTSD. “In recent times, we have been asked to conduct mental health and well-being sessions with hospital staff and firefighters, which is a good sign, but it’s a long road still,” the clinical psychologist shares.

She also said that most of the time, the patients do not realise that they are going through any trauma because, in normal routine, they laugh, enjoy, go back to work, and function normally, but with time, their body starts giving them signs such as physical ailments starts to appear which points towards stress or any trauma they have administered previously. “Disease, timeline, and recovery vary from person to person and case to case, but nowadays people are more open to accepting that they are suffering from a mental health issue while the older generation still does not accept it as a medical condition,” she laments.

Another problem that paramedics face is that they accept the culture of silence and do not speak about it, but slowly, it leads to their efficiency and performance getting impacted. “It can be fear of anything, maybe if they speak up about trauma they will be removed from their job or be replaced and then how will they manage a house and family, so there are many factors why doctors don’t speak up,” Zehra explains adding that in most cases doctors also do self-analysis. So if they feel there is some discomfort they take relaxants and think that their trauma will subside.

Counselling for the staff in hospitals is not mandatory, but some hospitals have taken initiatives where they encourage the staff if they are facing any trouble in regard to PTSD. A larger scale discussion is the need for a time when paramedic staff, after certain incidents, feel their efficiency to work in the wards and specific departments could get compromised. “Each big hospital has psychiatry wards and help, but it is not considered mandatory for doctors who go through such experiences in their routines,” says the Executive Director at the Jinnah Postgraduate Medical Center, Dr Shahid Rasool.

He also said that the hospital has its separate Department of Medicine and Clinical Toxicology, and they get such cases often where not just inhaling such toxic chemicals, but the majority are admitted because they had something toxic to drink. “Such incidents of toxicology occur, and they do leave an impact on the mental well-being of the hospital staff, but unfortunately, there is no system in place to make it mandatory for doctors or the staff to go through therapy, but if they feel that they need it, they are provided therapy.” Dr Rasool points out.

Cracks in the system

The December 13 incident also points out issues afflicting inter-hospital communication that can sometimes lead to catastrophic failure. “The ER cannot function well when ICU beds aren’t available,” explains Dr Mian. “The ER absorbs the overflow, stretching already scarce resources to their limits. Communication between departments and leadership must be seamless to prevent families from falling through the cracks. When the ER says it’s full, it’s not because we want to say no, it’s because we can’t say yes.”