A Day in an Iraqi Psychiatrist Life (part 2)

Yesterday was the last day of my break from work. I went to bed soon after the electric power was lost. That was at 12:45 midnight. It was hot. I woke up first at 6:00 am. I take a look at the clock. I felt how much my throat was dry. I tried to swallow but there was no saliva. I searched for the water bottle. It was hot water but it helped a lot. I decided that I sleep a little. I woke up at 6:45 am. I have some headache. Some neck pain too. Oooh I said to my self and walked drowsily to the refrigerator were I found a cold bottle of water. I felt better. Washing my face, taking on my clothes, putting the flash ram, a pencil, and money in my pocket I’m now in the street feeling that the sun’s light is so intense, so I contracted the muscles around my eyes. I took my first bus at 7:00 am trying to relax my forehead muscles which are already frowned, a thing that will cause me tension headache in an hour or two.
At 7:15am I bought a weekly magazine and took the second bus. At first it was so fast. The streets were not that crowded. I enjoyed reading about the history of Baghdad in the magazine. We reached that area. The road was blocked. Cars were stick one to another. We entered that irreversible crowd. Our driver tried to go back but he could not because of the cars behind us. We stayed that way for some minutes. Then cars started going back on the other part of the road. Our driver told us that there is no way he can made it to the place we were going to and that he will go back. I asked the driver whether I could walk for some distance and find another bus. He showed me the way. I went and it was so easy to find another bus, but it took me so long to reach another blocked road. But this time all the people left the bus silently and the driver started looking at me and told me: “this is it brother, it is blocked since one month!” I asked him how to reach my place of work; he took a pause and then told me to ask those men standing near that bus. I went to that bus, I asked them, they proposed that I take a bus that goes away from my working place then find a bus that goes to my working place. It was the only way. I made it. I took a bus, then a jeep. A jeep made in the 1930s or 1940s, with one sitting next to the driver, 8 in the back, and 2 or 3 stand on the back door. You know what? I was among those who stand on the back door.
So it took me 5 buses (4 buses and one jeep) to reach my job at 10:10am. I walked fast to my room to wash my face again. I took my white coat and went to where the committee must be now. It is Tuesday, and the forensic psychiatric committee is held to see the new cases and review the old cases. I was supposed to be there at 8:30, or at least 9:00 to see the new cases and write my notes before the committee is held at 10:00am. Anyway, nobody asked why I was late. They started there interviews. I listened and asked few questions. One of the new cases was a case of substance use disorder. He said he want Parkizol (=artane= trihexiphenidil). He repeated that. Then he started crying. The senior told him that it is ok. But he wanted it at the moment. Then all of a sudden he pulled a razor and put it in his mouth. He said: I will swallow it if you don’t bring me Parkizol NOW!!!!
We were all silent; only one senior was dealing with him. The police tried to help but all they did is just to make him more agitated. The senior asked them to be silent. They could not. The senior asked them to go. They did. The senior talked a little with the man who started crying profoundly. The senior asked one of the police men to come in, then the senior asked the man to give the razor out of his mouth to the police man. The man obeyed him. It was a lisson for me how to deal with theatrical patients and how to stay calm.
After that the senior next to me (there were 5 seniors today in the committee) asked me: Sami, what is the difference between school phobia, and truancy from school. It was an easy question. That senior loves me and loves to see whether I know things or not. He loves to ask easy important questions. I answered him. He said: Sami, you are good. At that moment I thought that my senior is just trying to raise my moral. To make me feel more confident. Especially after what that man with his razor did. My senior may had felt that I was tense. But why school phobia came into his mind? Well we can say that I’m a student in a school, and I may have some phobia especially after seeing such a man with multiple scars of self mutilation who threatened to suicide. Was that senior telling me that it is better to have a “school phobia”, like in my case, than to have “truancy from school”, like in that man with substance abuse disorder case? You may see those last lines silly but that was running in my mind when I was walking back to my room at 12:30 pm after the committee finished its work
I took my lunch at my work and it was: rice, a wing of chicken, yoghurt, and a half of an onion. At 1:30 pm I took the first bus back to my home. I reached my home at 3 pm exactly after another 3 buses that run so fast cause the streets were open this time. I took a bath. Oooh dear, I told my self, how beautiful life is! I put my head on the pillow for some minutes. Then took a thesis entitled “prevalence of depression in the physically disabled patients”. I thought about my coming thesis which will be entitled “prevalence of depression in psoriasis patients”, and wondered of the methodology I may use. It took me for about 30 minutes examining the tools of the methodology of the thesis in my hands. It uses the general health questionnaire-30 (GHQ-30), then used the ICD-10 structured interview on the positive cases of GHQ-30, then finally used the Beck Depression Inventory 13 to assess the severity. I wondered if that was necessary.
At about 5:00 pm, I took Michel Foucault book “history of madness” and started reading about the ship of fools. And I wondered wether the ship of fool is still existing in Baghdad symbolically.
At 5:30 pm water came back to my home. I started washing my clothes and dishes.
At 6:30 pm I took one of the psychopharmacology books to see whether there are long term side effects to the tricyclic antidepressants like a patient had asked me today. I told him that there is no need to worry but told him that I will look for the rare ones for him. I can remember I have read someday somewhere that there are reported cases of tardive dyskinesia due to long term treatment with tricyclic antidepressants. But I failed to find this note again today. I will look for it again before midnight in Companion to psychiatric studies because I think it was there were I read that thing. It must be that I read it somewhere but I want to make sure about it. After midnight I will go to the my sleep land to find some dreams waiting for me.

My Most Far Memories

Tri ru rum….ti ti rum…..am walking away….from the troubles in my life…am walking away…to find a better day….am walking away….

What a great song…..I think I will have some type of addiction on it. I’ve already had withdrawal symptoms from it. I came craving for it. And it seems that I need a more dose of it today.

The most far memory I have is that we were in a car. Me, my father, and my mother. My sister was not born yet. I must be below 4 years old. Cause when I was 4 years and a half my sister was born. Is it possible to remember that far? Anyway. I remember I was in the backseat. Fairouz was singing “A hadeer il bousta” in the car’s radio. We were near Baghdad international gallery between Al Hartheya and Al Mansour. In a corner there was a restaurant called EL NASAEM. In its garden there were colored circles of lights. Red, yellow, blue, green, and white. I liked them a lot. Now every now and then when I hear that song of Fairouz I remember those lights. My mother was young and energetic. My father was teaching at secondary school but at the same time he was studying art at evening. I asked them why we did not go to that restaurant. I cannot remember what they answered.
I cannot remember something else till am 5 years old. Me, my mother, and my aunt went to Jordan to unknown cause to me. We went to Al Aqaba beach. I knew Zina, a girl of my age. Her mother became my mother’s friend. They were alone. We became neighbors at hotel. I remember my mom said something about me loving Zina. I was so bothered and annoyed by that and told her that I only like her. The little Sami said something like: “Zina is just a friend…..A FRIEND….I do not plan to marry her mama”.
I remember, and am sure of that, I loved her mother. I was so embarrassed when they put me on the table and tell me to stand up there so that we took a picture. They surrounded me. My mother, Zina’s mother, and my aunt were standing around the table while am standing above the table. I refused to stand there. I object, but they did not listen. The little Sami said to himself: “they treat me as a child. Why they put me to stand above the table. Why don’t they stand above the table like me. Why they surround me like idiots. Even Zina’s mother is smiling. Am I short to be put on the table? Do they think they are more mature than me?”
I was so embarrassed that I still remember that till now. When they did not listen to my objections I became quite and looked at the camera with a faked facial expression.
I remember one day, before leaving Al Aqaba, my mother asked me to bring back the white radio with that red line in the middle of it from Zina’s mother. I went to their room. Their door was opened. I froze. Zina’s mother was sitting, with her back on the door, while the radio was behind her. I froze again. I cannot remember what she was wearing but I always ask my self this question: “for the God’s sake, what she was wearing?”. A question that is abnormally recurrent. I think her dress affected my little heart. I froze again and again like a statue. Till she, without turning her head, said: “sami, why you stop like that? Come here”.
I went inside her room. My memory tells me that something like this dialogue runs between us:
- Sami, I wanna ask you
- ……
- Sami, you will tell me the truth.
-……
- Do you love me?
- I came to take the radio.
- I know, but tell me, do you love me?
- My mother wants her radio.

I cannot remember what happened later. I swear I cannot remember.

Free Associtaion (part 23)

Terri rum tirum....tum tirum....terri rum rum...tum tirum...am walking away...from the troubles in my life.....am walking away...to find a better day....

This how Craig David starts. Am hearing it now. It was sent to me by a friend who has just reached the USA from Iraq. And the lyrics goes well with his situation. He suffered alot. He is a genius doctor. Hope he will find his better day there. Since I recieved this song and am hearing it repeated for hours till now. It took me away. How music can affect us so deeply? I think it was AL KINDIE who used music to treat patients before centuries here in Baghdad. I use music to treat my own crisis. I use it as type of crisis intervention. Does this mean that am in crisis now? No, am just in stress. In tension. I took a break from my work. A long one. And am already missing my job. Working seems to let me forget my problems. Is it right to forget our problems? Well...I don't know...Someone has just knocked my door. He is the same guy of yesterday. I never saw him. He says that he gave my father some money and he wants them back. My father don't remember this. Neighbors told me that this man made some problems before. Am affraid of him. As if all my problems were not enough to make this guy comes and disturbs me.After hearing this song many times it seems that I don't know what to do. Ok...I will go to one of my neighbours and pay this guy a visit. I wanna talk frankly to him. Ok let us do it....take care...

Fish’s psychopathology new edition

Fish’s psychopathology is our best text of descriptive psychopathology we use in Iraq. I have published a summary of the book in my blog before about 6 months. The previous edition of the book was published in the 80s. The new edition was published in 2007. It had many differences from the old one. Here are some of the main differences I found in the chapter of DISORDERS OF PERCEPTION. If somebody find it interesting just tell me so that I may continue searching for the differences between the 2 editions.

I will now enumerate the differences:

1st in the change of intensity of sensation we can find more examples: anxiety and depressive disorders, migraine, hangover from alcohol, and LSD ingestion lead to increase in intensity, while attention deficit disorder and depressive disorders may lead to a decrease).

2nd a change in the perception of the special form can occur in schizophrenia.

3rd there are three types of illusions: completion illusion, affect illusion, and pariedolia.

4th 3rd person and running commentary hallucinations have been described in mania (not only in schizophrenia).

5th there is a difference between Gedenkenlautwerden and echo de la pensee. In the old edition there is no difference between these two terms.

6th a newly mentioned phenomenon called PEDRE PIO PHENOMENON which entitled a pleasant olfactory hallucination.

7th mention of a new classification of tactile hallucination into 3 types: superficial, kinestethic, and visceral.

8th organic hallucinations part in newly written with the omission of hallucinatory syndrome of Schroder.

And 9th a new section on Body Image Distortions is added.

I didn’t go into the details of the differences so that if you interested you can go and see it by yourself. But I will be glad to answer any question you like to ask about the differences.

A day in an Iraqi psychiatrist life (part one)

It was in 2006 when I was working in Baghdad general hospital as a resident doctor in psychiatry in the psychiatry ward. Patients were very few in number. Cause Baghdad was not a safe place to live in. People were leaving it. It was late in afternoon when that lady came into our ward accompanied by her sister. Both were frightened. The lady’s eyes were widely opened while she was walking aggitated searching for someone to speak to. Her facial expression was that of a weeping woman, yet no tears seem to come from her eyes. It seemed that tears refuse to come. When she saw me she just started breathing deeply and making sounds of crying with no tears and her sister started talking telling me that her sister didn’t sleep for the past three days. I looked at the lady’s eyes. They were tired. Surrounded by black/bluish/reddish halos. Her sister added that the lady is from Dyala, and that she came to Baghdad with her 3 sons before 3 days to live with her sister cause Dyala is no more safe to live in. I told them that if they agree we can sit and talk. The sister looked at the lady and told her that she want to go home to be next to her family and the lady’s 3 sons. The lady turned to me and asked me with her widely opened eyes if I can admit her to the ward. She added that she doesn’t want her sons to see her in this unstable state anymore. In less than a second, without thinking, I agreed that the lady was in need of an admission. It seemed that that didn’t need thinking. It needed emotions. It needed empathy. I show them their room. And left them for few minutes. The sister came out and asked me to take care of her sister. She told me: she is your sister doctor, take care of her, she had suffered a lot. I answered: off course she is my sister, no need to worry about her, just keep in touch with her by phone ok?
The sister answered: sure doctor, I left her my mobile phone so that she can contact us. Then added: do you need my husband mobile phone number so that you call him if something happen?
I said: no, she got your number, that is enough.
She thanked me and went. I approached the room where the lady was. She was sitting there so frightened. I greeted her with a smile and told her that she needs to calm her self and control her breathing. “you don’t need to be frightened here, you are in the hospital”. I asked her if she had eaten her lunch. She said she did. I told her that I will interview her in 30 minutes.
After 30 minutes I went to interview her in her room. She was still shivering. I asked her about the problem. she started to talk fast & aggitated about what happened in the area she lives in. She wittenessed many violent acts. She was talking while she was having shorness of breath. I let her talk. I still remember what she told me. I even developed some posttraumatic stress symptoms when I heard her story. Actualy stories. But what I want to say here is that when she ended talking and she was shivering so severely I asked her:
- You seem so affraid now.
- .....
- you are in the hospital now, here with us, does that make you feel more secure?

As I ended my last word, a loud explusion burst just next to the hospital, all the windows and doors made echos, and then, nearby bullet firing aggressive sounds started entering our frightened ears....
We both stood up and run to the corridor. She sat on the floor with her downcasting gaze and terrible shortness of breath. I felt speechless. I told my self that she is safe in the corridor more than in her rrom which contain many windows. I was so speechless. I took a deep breath.

My Father's Paintings

After I published that post entitled "wadi3 il safi" my father send me these new paintings he made lately.

Sumerian Friendship

As a child at primary school I was amazed by those simple, easy going, spontaneous, highly energized students in my class who were all relatives. There were about 8 of them. We were about 40 students in my class. Those 8 relatives, 4 male and 4 female, were the poorest ones. It was evident for me from their bags, and clothes. They were so happy. Maybe the happiest among us. It was clear for me that other students avoided them. Every two of us shared one desk. I was sitting with my friend A on the first desk near the blackboard. Behind us sat three sisters on the same desk. Those three were part of that avoided group. I still remember one of them who was playing with me a game. She used to knock on my back when the lesson started. When I turn around at her she was always just smiling. I liked her. All those avoided relatives were poor, I guest at that time. That was evident from their clothes and bags. They have more dark skin than most of us. My friend told me not to play with them. I asked him why. He said they are people living near the small river (a small canal of water came from the main river Tigris), and their job is to serve other rich people by caring for their animals. He said to me something like: they live with animals, don’t play with them. As a child in my first year I followed cautiously my friend’s advice. He used to give me video tape of Bruce Lee, and some rare cartoons. And I never knew from where he brought them. I think it is because of those video tapes he used to give me I was looking at this guy as someone with greater knowledge than me. He was also the one who taught me the slang names of the genitalia in Iraqi language, and that was much appreciated by me at that time. So I followed his advice. But deep inside my heart I loved them. I was more eager to be close to them. But at the time I tried to make that into action it was clear for them that they were avoided, so they closed the door, not so tied, against my approaches. The three sisters behind me all avoided me. I was just a kid. I didn’t have the capability to open those doors again.

During my teenage years I started having ambivalent feeling to those who lives on earth, as I like today to call them. Those who can walk bare foot. Those who can know what the whether will be the coming day just by looking to the sky. Those who know the stars and their places and names. Those who know about trees, insects, animals, & agriculture in their special way. They learn by observing nature. The got a heritage from ancient times of their special knowledge. You can rarely find a book talking about their knowledge, cause unfortunately most of them don’t have time to learn read or write.

I remember that elderly male cleaner in the that hospital in which I was working in 2003. he was so proud of his self. Actually he was arrogant. He got a policy that says: I know my job, I don’t want anybody to talk to me! I asked about his family, and his background. They told me that they are very poor, living in houses made of mud on the city borders, and that his family take care of animals of the rich people. He used to sit in my room, on my chair. He was old. I was so young. When I enter my room in the ward, found him sitting on my chair, behind my table, I usually get confused what to do. I greet him then act as if there is something to do around the room. Either looking into the plants, counting the files, act as if reading from a paper, or at least looking through the window. That malingering is just to give him time to leave my chair and table. My room door was always open and I never thought of locking it. But his behavior was really making me tense a little.
The war of 2003 started. Nobody was forced to come to work. Most of workers went to their homes and never came back till the war ended. Me and three other doctors volunteered to work. I was working every night from 10 pm till 8 am. That arrogant worker was coming almost daily to his work. He sometimes sleep in the hospital. I was spending the nights in the ward and the nearby emergency room for pediatrics. Sometimes he spend the night with me. He never talked to me.

One night I was exhausted. I was supposed to do an exchange blood transfusion to 2 babies having jaundice. In the operation you got to take 20 ml of blood from the baby, through it in a waste bag, then take 20 ml of fresh blood from the blood pint and inject it in the baby. And you repeat that for about 25 times. I called a colleague so that he works in the emergency unit while I do the exchange. There was no nurse to help. I asked one of the babies relatives to help me and he did well. It took us about 1 and a half hour and it was ok. The second’s family members were so emotional. They could no offer help I thought. No one to help, I decided to do it alone (my first dangerous mistake). I started. Took 20 ml of blood from the baby and injected it into the waste blood bag. I forgot to give him the 20 ml fresh blood. I took another 20 ml of blood from the baby and through it in the waste bag again. Do that for another 3 times. In total I took 100 ml of blood from the baby and through it away. Then. Oops. My God. The baby was ok but I was about to die from fear and shame. I started sweating. Little shivering. I hold the syringe and started taking fresh blood and injecting it into the baby slowly. I monitored his vital signs. It was ok. I gave him the 100 ml of blood. Then called that arrogant cleaner and asked him to call the doctor working in the emergency room. He did. I told the colleague doctor about what I did. To my surprise, that colleague became so angry at me and shouted at me something then pushed me toward the door and told me to go to sleep.

The arrogant cleaner saw all that. I sat speechless in the nearby emergency room. There were maybe 2 patients receiving treatment. No patient came till my colleague finished the operation. The arrogant cleaner was passing every now and then next to me looking into my face. I did not give him eye contact as I remember. The colleague came back. Told me that everything is ok. He added that he was sorry for what he did and that he wanted me to go to sleep. I nodded my head and go walking slow to my nearby room. Next to the door of my room I saw that arrogant cleaner sitting on a chair, not mine. He stood up. I passed. Sat in my room. He sat on his place. I wondered why he stood up. Was that to show me respect? I asked my self. I stood up, drag my chair outside the room and put it next to him. and this dialogue run between us:
- How are things? (I said)
- Good.
- Do you have a cigarette?
- Um…ahh…a bad one.
- Bad?
- I mean a cheap one.
- Sumer? (Sumer is an Iraqi cigarette trade mark)
- Sumer Abu Il Chees (means those one that sold not in a packet but in a paper container).
- I like them give me one please.
- Here it is doctor.

He smiled wide. Gave me one. Took one for his self. With his lighter he approach me to lighten my cigarette. Then his. We took deep breaths. Outside were some sounds of explosions. And from that moment we became close friends.

Erbil

Akavo klah


One of the oldest cities in the world. It had been mentioned in Sumerian writings as Erbilium . Now it is the capital of the Iraqi Kurdistan.

I never visited Kurdistan before. Till this April when suddenly I got an unbelievable opportunity to visit it. I was so happy to see all these Kurdish people with their characteristic costumes, music and accent in speech. I even knew some Kurdish psychiatrist and one psychotherapist. Their names weren’t that easy for me to remember at the first time, but after few days I found it so easy and so beautiful. Their names got some musical tone that is really characteristic.
Erbil is called by Kurdish people as Hewler. Hewler means “the place of the sun” as I can remember somebody told me. When I knew its meaning I remembered that this city got a rich heritage full of civilizations and religions. Some old religions in the area worship the sun, or regard it as something holy. From those old believes, I think, came the name.

I went to the old castle. I took many photos. I was unlucky in that the most beautiful photos were damaged during transferring them from the camera to the computer. The rest are not my best shots but they were wonderful cause Hewler is wonderful. Hewler got many secrets and untold stories. It wasn’t enough for me to get close to it. I spent just 5 days there.
But am happy I visited a part of Kurdistan at last. Hope in the future I can visit more.

These are some photos. The music accompanying them is a traditional Kurdish music called “Akavo klah” played by the great Iraqi Auth (3ud) player Muneer Basheer.

Thank You Tracy

I still remember that day in Mosul. It was Saturday. I was usually on call every Thursday, Friday, and Saturday. While all my colleagues were in their wives’ arms, me, the single, work on the weekend. It is known to me that during weekends the mentally ill relapses. So I was really annoyed every weekend.
It was Saturday. I did not shave. Why should i? all my patient are neglected. My ward is neglected. It was weekend so I neglect myself. I went walking on that corridor. Dr. P was walking on the corridor on the opposite direction. I noticed before that he doesn’t like me. He never greeted me before. I never let myself hate someone. But this one with his long beard, was challenging my emotions. When we came to be near each other in the corridor he smiled to me. How strange. He even greeted me. I suddenly felt that I like that man. I greeted him and walked stunned. Dr. Y was in front of me suddenly. He also did not greeted me before. But today he nodded his head for me and greeted me. I smiled to him and greeted him and it was really strange how I found my self I like these 2 men.
The working day passed quickly. I went to the library to find a book. But the librarian said:
- Dr. P told you?
- What?
- So Dr. Y told you?
- Told me what?
- How did you know then?
He said that and gave me a big envelope from USA, it was heavy and it I read the name, it was Tracy. Wow. She sent me the books I need. I went happily to my room. Open it. And it was a magnificent 4 books. I felt so happy. I shaved my beard. And I start reading from this book then change to the other and I was really a happy. When I went to sleep that night I said to myself: “ohh! I knew why Dr.P and Dr.Y greeted me this morning!”