Damage Limitation

The medics are going to need everyone's fullest support in the weeks to come.

Posted Mar 25, 2020

I’ve never shared this before.

My father was in the Fleet Air Arm in World War II: an onboard engineer for carrier-based fighter-bombers. I’ll never forget the time when, one night on holiday, he explained the concept of damage limitation to me. If it helps to set the scene, imagine that famous bit from Jaws. It's the emotional core of the movie. The part when the shark-hunting trio have been drunkenly joking around sharing scars, and Robert Shaw (he will stand in for my father) explains to a suddenly sober Richard Dreyfus (that’s me in this scenario) what it’s like to bob about in the water waiting to be eaten by sharks.

My father wasn’t on the Indianapolis—he was on other American ships. But he got sunk by Japanese torpedoes, in much the same way as the Indianapolis was. My father didn’t look a lot like Robert Shaw (and I don’t look like Richard Dreyfus either) but the sobering effect of suddenly being faced with a depth of reality you previously hadn’t appreciated, is much the same as what he told me back in the day.

I’m sharing this—well, what I am about to share—because there is a lot of tough talk at the moment about "only old people" dying of COVID-19, or only people with underlying conditions (“It’s a kindness really and think, please think of the economy"). Some people are thrilled at their toughness, and I don't have much to say to those people. At best, I think they are delusional. At worst, well, I'd rather not say. But there are other people who I would like to say something to.

Some of this tough talk is coming from friends of mine, people I love and respect. Some of them are doctors who spend time in hospitals—and they spend much more time than we civilians do around death and dying. They think, with some justification, that people in the general public go around in a sentimental fog about the reality of death much of the time, and that lots of things bring about death—cars, or airplanes, or flu—and we don’t go into a frenzy about those things. Some of this tough talk is coming from businessmen who also think that they have a handle on life’s realities. A handle that civilians lack.

They have a point. But there is something that, for all these doctors', and business peoples’ experience, there is a thing they haven’t had to do yet and all their experience so far has not—in many ways cannot have prepared them for. And it exerts a toll.

I know this myself because, towards the end of his life, vascular dementia started eating away my father’s frontal lobes—those bits of the brain that keep other, darker parts deep and buried. Alcohol has similar effects on the inhibition centers of the brain, hence that friend we all know who can’t be allowed to touch a drop, because that darker side comes out. Anyway, my father started reliving some of his wartime experiences through his nightmares towards the end of his life. He would wake up thinking he was living through, once again, what he told me about all those years before. He started reliving the experience of damage limitation—as the Navy used the term.

What is damage limitation? When a large ship gets holed by a torpedo it starts to take on water. If you don’t act fast, then the entire ship will go down, taking all hands with it. Even if you do act fast—it still might. What this means is that you have to seal off the bulkheads in those areas that are taking on water. And what that means is that you have to shut and lock a bulkhead door while men on the other side of it are screaming in terror, knowing that they are about to drown. And you take those screams with you to your dying day. Your comrades. Your buddies. They might have pulled you out of a burning plane the previous week, and now? You aren’t just listening to them die, you are causing it—by your action, or by your inaction. Oh, all for very good reasons. If you don’t do it, then the ship might go down. That won’t help the nightmares. Trust me on this.

Some of our medics, in the front line against COVID-19, are about to go through this psychological torture. They are about to decide that some people, that they could have saved, have to die, because the resources simply are not there to save everyone. They have a limited number of ventilators—and they will have to look at someone and say, silently, "Sorry, you don't get to live." They are going to have to watch (and listen) to people drowning—literally, because that is how SARS takes you. Some of them will be comrades too—like I said, the medics are on the front line.

These aren’t rational decisions about quality of life, or the stark facing of daily death that doctors and nurses go through, that most of the rest of us are in a fog about. This is damage limitation and, like I said, it exerts a toll. No amount of clever philosophizing about means justifying ends is going to help with the emotional impact of this. I’ve read the accounts of what the doctors in China or Italy have been going through. They sound just like my father did. It doesn’t matter how tough you are—medics don’t sign up to do damage limitation. We don't prepare medics (or soldiers for that matter) for the results of moral injuries.

Our medics need our fullest support as they face this. During, of course, but also after. And, please, less of the tough talk, eh? It isn’t going to age well.

Best of luck everyone.

References

For more on how moral injuries--where a person feels compelled to act against their moral code with resultant PTSD see Ying, Y., Kong, F., Zhu, B., Ji, Y., Lou, Z., & Ruan, L. (2020). Mental health status among family members of health care workers in Ningbo, China during the Coronavirus Disease 2019 (COVID-19) outbreak: a Cross-sectional Study. medRxiv. and Ying, Y., Kong, F., Zhu, B., Ji, Y., Lou, Z., & Ruan, L. (2020). Mental health status among family members of health care workers in Ningbo, China during the Coronavirus Disease 2019 (COVID-19) outbreak: a Cross-sectional Study. medRxiv. Available (online first) at https://www.sciencedirect.com/science/article/pii/S0889159120303482 and https://www.bmj.com/content/368/bmj.m1211