PERSPECTIVE ON THE FIRES : ‘Doctor, Do You Believe in God?’ : A smile, a touch, acknowledgment of the ‘unknowable’: These bring about physical and emotional recovery.

The fires ravaging Southern California have emotionally traumatized thousands. Most will recover completely. Some will not.

Four men who also sustained major burns last week were L.A. city firefighters: Jan Bernard, Russ Nakamura, Gary Carpenter and Cleveland Tipton. They are at the Sherman Oaks Burn Center; Jan and Russ remain in critical condition, Cleveland and Gary are listed as “serious.” My responsibility as trauma psychiatrist is to ensure that they and their families come through this without lasting psychological damage. While because of patient-doctor privacy I cannot discuss their personal predicaments, I can describe how we on the burn team guide the recovery of these men and others.

Abrupt loss of control over an important part of life is at the heart of all trauma. A major burn is trauma in the extreme. First, there is shock and disbelief, then intense thirst as body fluids move to the burn site, then profound malaise as toxic breakdown products enter the bloodstream. The nervous system keeps replaying the trauma. Helpless, confined to bed, dependent on others, the patient feels and reacts like a child. Meanwhile, organ systems are stressed. The immune system may falter; kidneys, lungs, or heart may fail. As days and weeks pass with painful dressing changes, recurring infections and physically and emotionally depleting surgical procedures, there is the ever-present danger of loss of the will to live.

The stress response makes no sharp distinction between physical and emotional stress. Persons who have lost homes, possessions, pets or simply the illusion that they control their fate will respond to their suffering much as Jan, Russ, Gary and Cleveland do.

Decisive mental events happen within people when they are struck down by something life-threatening. It is when important, perhaps universal, truths come into focus. Here are some of them:

* Hands control objects; faces control people. He’s a 20-year-old roofer. Half of his face has keloids from tar burns. After three years, reconstructive work continues. “The first time I felt like a person again,” he says, “is when I smiled at a girl and she smiled back.”

* No matter how psychologically regressed a person may become in the face of catastrophe, there is one adult marker that is routinely preserved: the conjugal bond. A young man from a large, close-knit family was married three weeks before his accident to a woman he had known for less than a month. Whom did he call out for in his delirium? Only his wife.

* Trauma patients often feel they are in the presence of God. She’s a 17-year-old who lost her face and hands in a car fire. Two years later, the day after her 12th reconstructive surgery, she looks up at me: “Doctor, do you believe in God?” I answer: “For as long as I can remember, I have stood in awe of the unknowable.” She smiles. “So you’re saying ‘yes.’ ” And she drops off to sleep.

* If you have a problem, think it through; if you have a trauma, talk it out. The wounded animal that distances itself from the group, the rogue elephant, the lone wolf, lives a minimal life. A 16-year-old tough kid from the ghetto groans: “Leave me alone. I don’t need you or anyone else. I don’t want to talk about it. I don’t want to relive it. I just want to get back on my feet and get out of here.” As I leave the room, I notice that he is crying. It’s a start.

* Trauma should have a beginning, a middle and an end. The wife of a dying but still conscious patient asks that I be with them during their final visit. He knows he will be dead in a matter of hours. She places her left hand on his brow; her right hand clenches mine. With my free hand I touch his charred ankle, closing the circuit. Her voice is strong: “Dear, I’m saying goodby now. I’m all right. I’ll take good care of the baby. Good night, darling.” No one cries. No one turns away. All is well.

There will be other catastrophes. Other firefighters will burn. There will be divorces, bereavement, assaults. Trauma is never far away and there is no sure protection. It is well to know that there are rules governing recovery. You never know when life may depend on playing by those rules. That’s what Jan, Russ, Gary and Cleveland are doing.