Doctors At War: The Psychological Cost

Mark de Rond’s book Doctors at War (Cornell Univ. Press, 2017) is one the most painful books you’ll ever read. De Rond, a organizational ethnographer at Cambridge University, was embedded in a field hospital in Afghanistan, where a team of medical personnel from the U.K. and U.S. waited to operate on wounded flown in by helicopter-- allied soldiers, captured enemies, and injured civilians alike. Like Conrad’s Heart of Darkness, the horror is not so much in the gruesome physical scenes (although that is part of it), but more in the psychological costs of trying to do something about it. It is about feeling your failure in a terrible situation beyond your control; and how the things that members of the group do to cope with their feelings circle back to make things worse.

Each kind of patient delivered to this desolate outpost by a clattering helicopter creates its own kind of strains.

Wounded warriors: This is largely a war of home-made bombs on the insurgent side-- improvised explosive devices hidden under rubble at the side of the road or anywhere an allied patrol might go. This means wounds are often horrible, not bullets penetrating the body but limbs torn off, extensive burns, all kinds of fragments. Surgeons have to extract, patch, amputate and sew back up. It is not the kind of scene that one reads about from battlefield hospitals in the U.S. Civil War or the Napoleonic wars, where in the absence of sedatives there were anguished sounds of screaming, and doctors had to decide which ones to triage. Now the wounded are brought in already sedated by battlefield medics. And triage is not really necessary, this being a counter-insurgency war-- low-intensity if endless-- the doctors are not overwhelmed by numbers but instead have a steady drip of casualties to be patched up and flown out to medical facilities far from the war zone.

No, the strain is in the minds and emotions of the doctors, nurses, and auxiliary personnel as the same kinds of cases repeat themselves, day after day, with their endless variations.

A surgeon “had been operating for forty-one consecutive days, the last seven of which he said had consisted mostly of chucking dead or dying limbs into bins. Homemade explosives left few options other than lopping off the dying bits and dropping them in one of several buttercup-yellow buckets destined for the incinerator.” [p.31]

“I wandered into a waft of freshly burned bacon, its source soon obvious: two badly burned Afghans occupied opposite tables, attended to by emergency staff. The first registered at 53% burns, the second at 48%, both readings the result of a standard calculation using the ‘rule of nine’: divide the body into multiples of 9, with the head, chest and abdomen accounting for 9% each if completely burned, the back and buttocks for 18%, 9% for each arm and 18% for each leg, 9% for the front, 9% for the back. Anything over 35% isn’t considered survivable in Afghanistan... so such patients are given palliative care from the word go. The first of the two died within the hour. The second would follow soon after but insisted on seeing an interpreter.... ‘He wants you to take him and his friend back to the valley where the helicopter found them.’ ‘His friend’s dead.’ ‘Yes he says he knows. He wants you to organize a car to take them both back.’ ‘Right. So where does he think we’re going to get a taxi from?’ ... ‘Tell ‘em we will see what we can do.’... The Afghan slowly moved his blackened hand over his left upper chest and looked grateful.” [117]

“A US marine had called earlier to report the discovery of two partial legs belonging to Billy, one of the troops in his charge, and would it be all right if he dropped them off at the hospital? He and his troops had been told that if limbs could be reattached within six hours of an explosion, they’d have a chance of surviving. The legs had been cold too long, Smitty told him, and were probably too badly damaged to be reattached in any event, but the marine was not to be dissuaded and made his appearance soon after.

‘I gather you’ve got something for me?’ Smitty said.

‘Billy’s legs,’ he said and handed Smitty a floppy carton box that once upon a time held US army rations.

‘You be sure to fix him up, won’t you?’

‘Leave it with us.’

‘Billy’s a quarterback, you know, when we get time to play. Has one hell of an arm.’

‘His arm’s fine.’

‘You look after him now.’

“As soon as the marine took off, Smitty got hold of Ginger, a scrub nurse on his first-ever tour.

‘What’s this?’

‘Legs. Used to belong to the guy in theater three.’

‘Well what the fuck am I supposed to do with them?’

‘Walk them over to the incinerator, that’s what.’

‘...’

‘Sure whoever gave you this is gone?’” [52-3]

Captive enemies: Doctors operate under the rules of war, which stipulate that wounded enemies are entitled to medical treatment. At the forward hospital, surgeons do their best, although they know-- and openly say to each other-- that when they are fixed up and released into custody of Afghan troops, they will probably be killed.

“By the time I returned to the hospital the next morning, late and weary for lack of sleep, the early morning casualties had already been dispatched to the ward or the morgue, the youngest of the still warm only ten. Matching sets of double and triple amputees underlined the war’s agonizing ambiguities: which is the crueler, to prop up Afghans with quick fixes and the sort of sophisticated analgesics not available locally for the handful of hours they’d spend in Bastion, or let them cash in on their convictions pronto and meet their Maker? Ingenuity, after all, can render death quick nowadays and pretty much pain-free. All had been Afghans this morning, peeled off the desert floor by a helicopter crew after 106 pounds of AGM-114 air-to-surface missile did precisely what it said on the tin. The absurdity of the situation was plain for all to see: one budget is used to save those a different budget tried to kill only moments ago.” [11]

De Rond accompanies the transfer of three Afghan army casualties to their own hospital:

“ ‘This guy is high on opium,’ my escort said, having wrestled back one of our oxygen canisters [from a driver]. ‘These things fetch a fair bit of money on the black market, so we want to hang onto them if at all possible.’ He crouched down next to the most serious of the three casualties. The man had already been relieved of his 60% oxygen supply and now was cut loose from his morphine drip and antibiotics...

‘And the first thing these drivers do is look into the bags to see what drugs we’ve sent along. Anything morphine goes directly to the driver and never even gets to the patient. And so we leave them here to a slow and painful death. This guy here will die of pneumonia.’ ” Doctors argue about what they should do. “ ‘If you keep him here and treat him, he’ll ultimately die. If you take him to Kandahar, he will die too, but a little more quickly.’ ” [101]

Injured civilians: The situation with patching up civilians was much the same, with some additional twists.

0400, four a.m. “Two local women had arrived with bullet holes in their legs. Someone who identified himself as a brother stood idly by, insisting, as they did too, that they should be treated by a female attendant. Weegee, the attending emergency department coordinator, ignored the request, saying they have no such luxury in Afghan hospitals so why give them that option here?

“After a quiet day, at around 1900, nine casualties arrived within thirty minutes of each other, including five girls with gunshot wounds: two to the chest, the rest through the arms, legs, and belly. The girls had long eyelashes and olive complexions, their hands covered with henna tattoos. There wasn’t a tear in sight. The emergency and surgical teams were brilliant to watch. When the proverbial shit hit the fan, they salvaged what war destroyed, giddy for being productive. The curse in Bastion was never that of too much work but rather the insufficiency of it. Once the casualties had received emergency treatment and the surgeons had repaired for near beers in the Doctors’ Room, it turned out the girls might have been shot by our own helicopters in error. Their thirty-millimeter cannon rounds were designed to fragment upon impact such that anyone within ten meters of an exploding round risked serious injury, and tonight’s GSW’s looked far more like fragments, the docs said, than the usual bullets.” [125-6]

Friendly fire and collateral damage, as the jargon goes, are endemic in a counter-insurgency war where the guerrillas hide in the civilian population. The civilians in the middle get treated if allied medivacs bring them in. But there are no hospitals to release them to, and back in their villages, care is poor and many will probably not survive. But release them we must.

Sometimes the borderline between civilians and enemies disappears, green-on-blue attacks where Taliban sympathizers among Afghan army troops turn their weapons on American soldiers-- or perhaps suddenly snap under their own pressure, as indeed some American troops have done.

De Rond observed doctors talking about such incidents with the medical staff.

One doctor “told of a British nurse who had arrived in the hospital with severe burns. She had befriended a young boy, plying him with candies, until one day he threw a plastic bucket at her, dousing her in petrol and setting her alight. The Taliban, he said, are not shy about using children to advance their interests, whether by forcing them to walk donkeys heavy with explosives toward the infidel or by leaving injured kids by the roadside as bait to attract a medivac helicopter.” [52]

This, at any rate, is the conversational culture of the forward hospital. It does not stop them from treating everyone who comes in, to a high medical standard, in the brief time they are there. And this adds to the incongruities that make up the psychological dissonance of the place.

Isolation, boredom and surreal disconnect

In traditional wars, on the whole, the psychological pressure on doctors in battlefield hospitals was severe but not so complex. Of the three kinds of patients treated-- allied soldiers, enemy captives, injured civilians-- such doctors mainly dealt with the first. If they treated wounded enemies, they at any rate were not handed over to others who were going to kill them. In traditional battles with high casualties in a short period of time, the problem for doctors was being overwhelmed, and having to pick out those most likely to survive. This was not a problem in the Afghanistan field hospital, where there were plenty of medical staff to handle the daily influx of casualties. Their problem was that they practiced good medicine, then felt much of it went to waste. And unlike traditional battles, they didn’t even have the consolation of winning a battle or the war.

And they were isolated and bored. Their base was a fort in a hot desert, dangerous to go outside the perimeter, and nowhere to go if they did go out. They were stuck with the same people, who worked, slept, ate together, and tried to amuse themselves in the down times between the hours when the emergency alarms sounded and the helicopters unloaded. It was a total institution, in the sociological sense of the term, but not one in the Goffmanian sense of a hierarchy where a staff guarded a lower class of inmates. The wounded were in a sense like inmates, except that they were so badly incapacitated that they remained passive-- at least de Rond never noted any acts of defiance. And the medical staff were idealists and committed professionals; they didn’t pull rank on each other, and their culture was one of “we’re all in this thing together”, a common task and a common malaise. They all had the same problem and they couldn’t get away from each other.

“Boredom hung in the air like a peasouper that wouldn’t lift except for the briefest of periods. In principle, this should have been good news-- after all, no one was getting hurt-- except that it left the docs with nothing meaningful to do. There was the occasional bit of exercise in a muggy gym to provide a temporary lift, or reading or daytime television, but little to take pride in, to feel productive about. And so they found themselves pining for work to come in, even if this invariably came at the expense of someone else getting hurt.

“But boredom extracts its pound of flesh in other ways, too. Left with little or nothing to do, [the doctors] have begun to criticize each other’s handling of patients and discharge decisions... Left to their own devices these docs became broody and aware of the relative futility of some of what they do here, particularly when it comes to providing emergency treatment for Afghans whose chances of recovery were badly compromised as soon as they were transferred to local hospitals, or so they think.... Periods of great intensity followed periods of boredom in which it was nevertheless impossible to relax.” [70-72]

They tried to keep up a semblance of normal life. They celebrated the holidays as best the could. A Christmas party wearing Hawaiian shorts, tee-shirts and Santa Claus hats, although no one felt very jovial.

“ ‘Sometimes I try telling my family some of these things, but they don’t understand,’ Smitty said... He went on to tell me about a double amputee who had come in over Easter weekend. One of his legs had been attached by only a skin flap and came off during the usual logroll. The attending nurse, who’d been left standing with a leg in her arms, asked one of Smitty’s team to please take it away for disposal. As the lad made his way to the morgue, crossing the ambulance bay en route, he was met by Solesky and a nurse walking the other way, sporting bunny ears and carrying Easter eggs.” [85]

The early morning helicopter patrol brought in an American, but the tourniquets had come off as he was carried to the helicopter under fire, and he had already bled to death: “A glum band of brothers, the docs trundled back to their lair to feast on Apocalypse Now. A famous scene shows a swarm of American helicopters advancing like locusts on a Vietnamese settlement to the tones of Wagner’s ‘Ride of the Valkyries.’ It didn’t seem to strike any of those glued to the telly as ironic that less than klick away their own Apaches were taking off on similar missions... It would quite literally have taken no more than stepping outside the Doctors’ Room and onto the wooden patio to fast-forward to a similar scene. Alas, the patio door was closed shut, and the telly on, and they around it in a half circle, ‘near beer’ and homemade cookies and ginger cake and chocolate to hand.

“ ‘My favorite line’s coming up,’ Southwark said excitedly. ‘Wait for it...ah, “I love the smell of napalm in the morning.” Absolutely first class that is.’ ” [64-5]

Obviously they appreciate the irony of it all, but they have gone beyond that. Gallows humour, but nobody was laughing, not even sardonically. The doctors wallowed in escapist Hollywood war films. M*A*S*H was another favorite, about a similar forward hospital in the Korean War, supplied by helicopters with wounded soldiers. Except this, like all war films, did not show the medical gore these doctors faced everyday. Their lives were not censored for the screen and there was no rollicking good fun, even when they had time away. Why didn’t they escape to something else, films that had nothing to do with war? They were obsessed, perhaps with distancing themselves from their lives by viewing the Hollywood version. But it didn’t help, only cycled through the day.

“At the onset of sunset, just as Sloppy Joe called for volunteers to help him lug around the weekly pile of pizzas... [the beeping of pagers carried by the on-duty medicals] heralded the arrival of a Cat A [severely wounded]. The whiteboard listed it as a US marine who’d been hit by a rocket-propelled grenade... We made our way from reception into the black hot night to where the light pollution was, signposting the makeshift square with its crude KFC-Pizza Hut combo and games room. A short queue had already formed at the shipping container’s window. The scent they gave off was unmistakable, evoking a lazy day topped off with fast food and soda and feet-up television. Stacked up on one of the two ovens were twenty-one pizzas, hot to the touch, though there’s always a risk they’ll be stone cold by the time the casualty is dispatched with. To my surprise, this happened more quickly than I expected.

‘Casualty’s a hero,’ Joe said.

‘Right,’ I replied. ‘Gone to Camp Hero.’..

‘The guy is dead.’

“It was right about then and there that I became aware of a nauseating feeling ascending from my gut: a rotten-to-the-core sense of relief, less at a merciful end to years of pain and rehabilitation than at the prospect of hot pizza and companionship. The sense of shame I felt then I’ve not felt since. After all, what was a pizza compared to the life of a soldier? What the fuck was wrong with me?

“We sat down to watch Lock, Stock and Two Smoking Barrels.” [118-19]

The doctors were becoming querulous as their beepers sound, calling them to surgery, only to return abruptly to the TV room when they find the new arrival is dead. “They sunk back into the spots they had vacated only moments before, to resume their involuntary stupor, only to be told that a fresh hail of casualties was on the way: a gunshot wound to the neck, a gunshot wound to the thigh and yet another unlucky victor in the roadside bomb lottery.” The most experienced surgeon griped to no one in particular that today he is supposed to be in charge but the other doctors are going ahead of him. No one pays attention.

“Southwark and Fernsby, in the meantime, were taking bets (to be paid off in pizza purchases) on whether the incoming amputee would turn out to be a single or double, left or right leg. ‘A pepperoni on the left,’ Southwark said. ‘I’d say a double. If it is you’re buying Friday,’ Fernsby replied. [123]

This is beyond gallows humor, beyond cynicism. It is a way of passing the time, living in a surreal disconnect. They disconnect even from their cynicism. It is one more layer of psychological distress, piled up and revolved by the hour.

De Rond winds up: back in England, his battlefield tour over, he can’t get over the pain, and the guilt. The doctors he corresponded with say the same.

Meanwhile, back Home

A medical sociologist who reviewed de Rond’s book in an American journal was horrified. He denounced publication of the book, calling it a pornography of pain, voyeurism of medical horrors for its own sake. He saw the book as pointless, no hypotheses, no theory, no take-away. As a reader, I thought this the most unprofessional review that I can recall. No doubt the reviewer missed the standard academic formalities, reviews of the literature, and writing in bland abstractions. Perhaps de Rond writing about his own emotions in the field set off the reviewer into ranting about his own emotions as a reviewer.

Before concluding that this closes the circle of absurdities mingled with (academic and military-medical) realities, it is well to remind ourselves that de Rond’s ethnography is about surreal experiences, but the report is not surreal. It is tell-it-like-it-is, you-are-there participant observation, focusing in on micro-sociological moments in the verbatim conversations of daily life and their bodily context.

It is about the psychological costs of working in an endlessly prolonged artificial situation, without adequate social support. Does it say anything to us about doctors and medical personnel in the COVID-19 epidemic?

Obviously the kind of medical treatment is quite different-- traumatic injuries for quick surgery, vs. prolonged treatment of agonized patients gasping to breathe. One similarity, in hospitals where there are many severe virus cases, may be the stresses of social isolation. Medical personnel constantly masked and keeping physical distance from each other may experience more isolation stress than at the battlefield hospital, where medical teams are constantly hanging around together. Medicals repeatedly exposed to the virus, some of whom themselves become sick and die, are presumably isolated from their families and friends. Of course they can make contact by phone and on-line, but this was true in Afghanistan as well: the social isolation there was intensified by inability to explain to their families the emotions they were going through. In both cases, a kind of total institution may be created, cut off from the normal supports of social life. Witnessing the social isolation of the bereaved, who cannot be at bedside nor take part in funeral rituals, must create a bleak atmosphere somewhat resembling the battlefield hospital.

Such stresses build up over time. Most people can handle extreme situations for a short period of time; there is a rallying-around burst of solidarity at the outset of any public crisis. In the immediate aftermath of the 9/11/01 attacks,* this period of public solidarity lasted 3 months-- but that was a period where mass ceremonies honoring firefighters and police took place at every public gathering. In the absence of this kind of ritual support, the uplifting period of shared dedication may be shorter, under a regime of enforced social distancing. The field unit in Afghanistan had been operating for six years when de Rond studied it, and some surgeons had served ten or more tours of duty. If anything like this kind of endlessness comes out of the struggle with COVID-19, the experience of doctors at war may start to converge.

For a more formal social-science presentation of the battlefield hospital study, see:

Mark De Rond and Jaco Lok. 2016. “Some Things Can Never Be Unseen: The Role of Context in Psychological Injury at War.” Academy of Management Journal 59: 1965-1993.