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J U N E 2 0 0 0
URING my first week I don't have any more conversations with Dinh, but I see him every morning when he comes in his white lab coat to the surgery suite to watch me operate. At the door he slips off his sandals and pads barefoot into the room, where he stands at the head of the table, his black eyes peering at the children whose lips are like hook-ripped fish mouths. He rarely speaks, and when he does, it is usually to address the Vietnamese doctors and nurses in a tone that suggests sarcasm.
It is impossible to know what his silence toward me means, but I become immersed in my work, and I don't worry about him. Once the operation starts, my concentration is complete, my only concern the child's face, framed in blue towels and bathed in bright light. I have always been gifted at drawing and carving, and with a scalpel in my hand I feel like an artist, forming something beautiful out of chaos. I love mapping out flaps of skin around a child's mouth and then rotating them over the cleft to create a nice Cupid's bow of lip with a clean vermilion border. My sutures are like the brushstrokes of a portrait. Dinh must envy the collaboration of my brain and fingers.
Between cases I rest in the doctors' lounge at a wooden table. I drink a pot of pale-tan tea, eat litchi fruit, and look out into the hospital courtyard that serves as the waiting room. I often see Dinh with his hands hidden in the pockets of his lab coat, squatting in the dust, talking with the parents of the cleft-lipped children who are undergoing surgery. His face, glistening under the hot sun, looks as if it has been oiled. His chronic scowl has become a comforting smile. T the end of my first week I call my wife and daughter to tell them that all is going well. When I report that I have repaired eighteen cleft lips without a complication, my wife seems proud of me. I am getting to like the nurses and doctors in the operating room. My feelings of guilt and ambivalence are being replaced by a sense of good will and atonement, as if Vietnam and I were two bad people who had unexpectedly done something nice for each other. But on Sunday, Dinh sends word for me to meet him in his "cabinet," as he calls his private office. I worry that I have done something wrong.
The room is the size of an armoire and sparsely furnished. A single bookcase contains the medical texts of the hospital's meager library. On the wall is a little green lizard and a yellowed photograph of Ho Chi Minh. From a cassette player on a homemade wooden table comes the music of a symphony orchestra playing Vivaldi's The Four Seasons. The hospital sewer system is backed up, and the air smells brackish. My stomach churns. I sit in a straight-backed chair across a metal desk from Dinh. My office in Lake Forest, with its Oriental carpet and polished cherry furniture, seems infinitely far away.
"Vivaldi," I say to break the silence.
Dinh looks up from a journal article in which he is underlining with a wooden pencil. His face, shadowed by years of hardship, is expressionless. He wears a white shirt and a clip-on red rayon tie. He has a small Band-Aid on his chin where, I assume, he nicked himself shaving. I imagine him handling a razor, buttoning a shirt, tying a tie or shoestrings. Without a thumb's ability to pinch and oppose, even simple tasks must be difficult for him.
"Do you enjoy Vivaldi?" he asks.
"The Four Seasons is one of my favorites. When did you develop a taste for Western music?"
"When I was in medical school in Hanoi, French doctors play music in surgery room. Music only good thing about Frenchmen. Music good healing medicine. I play music to calm my patients."
He clicks off the tape and hands me the article he has been reading. It is a reprint from a French journal of hand surgery. I leaf through its pages, scanning illustrations that depict an operation in which a toe is transferred to the hand to replace a missing thumb.
"Can you make thumb?" Dinh asks.
I sit for a moment, remembering my last toe transplant, performed a couple of years ago. It was on a young farm boy who had lost his thumb in a corn picker.
"Yes," I say. "I've done this operation. Not often, but I've done it."
"I want you do this to me," Dinh says.
"Here? Now? You want me to make you a thumb?"
"Yes. I want you make me new thumb."
It is as if, fighting a losing battle, I suddenly see the enemy waving a white flag. For a moment I look at his narrow, bony hands with the red ridges of scar tissue where thumbs once protruded.
"It's a very hard operation," I say. "Quite delicate. A microvascular procedure. Even under perfect conditions it often doesn't work."
"I watch you operate." Dinh lowers his eyes and his voice. "You very careful surgeon. I know you can do."
"Let me see your hand."
He extends his right hand toward me. I rise and move around the desk. I take his hand in mine and turn it slowly, studying skin tone and temperature. His radial pulse bounds against my fingers. His nail beds are pink with good capillary circulation. The skin of the palm is creased and thickly callused.
"Thumb reconstruction must be carefully planned," I say. "You don't just jump into it. There are several techniques to consider."
In my mind I review them: using a skin flap and a bone graft from the pelvis; pollicization, in which the index finger is rotated to oppose the third finger; and my favorite technique, which uses a tube graft of abdominal skin -- but it has to be staged over several weeks.
"The new thumb must be free of pain," I say, carefully palpating the bones of his hand, searching for the missing thumb's metacarpal. I find it intact. "It has to have sensation so it can recognize objects. It has to be long enough to touch the tip of opposing digits. It must be flexible."
"You don't have to teach me," Dinh says gruffly. "I know about this. I read everything in literature. Toe transplant best for me."
"I'm not so sure about that."
"Toe transplant best."
"Maybe so, but you're the patient this time. I'm the doctor. Let me decide."
I bend over and lift his dusty foot into my lap. I slip off his tire-tread sandal. His foot is the size of my daughter's, the toenails poorly cared for. My fingers find strong dorsalis pedis and posterior tibial pulses at the ankle. I would prefer to transplant the second toe, but his is very small; I decide the big toe would make a better thumb.
"What you find?" he asks anxiously.
"You have good circulation and a metacarpal bone."
"So what you think? Toe transplant?"
I look up at Dinh's face. It is pale yellow, contrasting with the density of shadowed books and wall behind him. His haughty eyes have softened into a look of hope and longing.
"I agree," I say. "A toe transplant would be best for you."
"You must do it, then," he says.
"Maybe you could come to the States and have it done."
"I no rich American. No can get visa."
"There's a good chance the graft won't take. I don't have an operating microscope or some of the instruments I use."
He flexes and unflexes the four fingers on his right hand and smiles.
"Do it here tomorrow. I want to hold chopsticks again. I tired of eating like a Frenchman."
"Look," I say, "you don't realize how many things could go wrong."
"It work. I know it work."
I think how the fortunes of the Vietnamese always seem to be in the hands of others.
"Okay," I say. "I'll do it. A local anesthetic would be safest. Would that be all right?"
"Pain no matter. You do it."
"You're on. But don't be surprised if it doesn't work."
HAT night I lie awake under the mosquito net on my bed, reviewing the technique of toe transplantation, suturing in my mind tendons and tiny digital nerves, minute veins and arteries. Tropical heat drenches me. The bark of dogs comes in from the street. When I finally fall asleep, I dream again of the man whose head I severed and stuck on the end of a pole. We meet in the Cao Dia temple in Tay Ninh, a vast, gaudy cathedral with a vaulted ceiling, pillars wound with gilded dragons and pink serpents, and a giant eye over the altar. He stands naked in front of me, holding his head with its sheen of black hair in the crook of his elbow.
HE surgery suite is high-ceilinged, with dirty windows and yellow tile walls, like the restroom in an old train station. The air is drowsy with the odor of ether that leaks from U.S. Army surplus anesthesia machines. Outside the operating room I attach magnifying loupes to a pair of glasses. I focus the lenses on the lines of my fingertips and begin scrubbing my hands in cold water at an old porcelain sink. Through the door I see Dinh sedated and strapped to the operating table. Bathed in fierce white light, with his arms extended on boards at right angles to his body, he looks as if he has been crucified. I have sent an orderly to his office for his cassette player, and The Four Seasons plays softly at the head of the table.
For a moment I rinse my hands, designing in my mind skin incisions and tendon transfers. In the past, to decrease operating time and diminish my fatigue, I used a second surgical team to prepare the recipient site in the hand while I removed the donor tissue from the foot, but here I am alone.
With water dripping from my elbows, I step into the room. Suddenly I feel a surge of force, a sense of power that has been mine in no other place but surgery, except when my finger was on the trigger of an M-60.
The instruments I have brought with me lie on trays and tables. My weapons are tenotomy scissors and mosquito hemostats, atraumatic forceps and spring-loaded needle holders. A scrub technician, who worked as an interpreter MASH unit during the war, hands me a towel. Two masked nurses prep Dinh's foot and hand with a soap solution. The surgery team's spirits are high. Listening to them talk is like hearing finches chirp.
Gowned and gloved, I sit on a stool beside Dinh's right hand. I adjust the light and begin the numbing with an injection of Xylocaine. The prick of the needle rouses him from his narcotized slumber, and he groans.
"Everyone ready? Let's go. Knife."
The nurse pops the handle of the scalpel into my palm. A stillness settles over me and passes into my hand.
Dissecting out the filamentous vessels and nerves that once brought blood and sensation to Dinh's thumb is tedious and takes more than an hour. While I work, a nurse sits at Dinh's head, murmuring to him and wiping his forehead with a wet cloth. I wonder what Dinh is thinking. Is he remembering the men who cut off his thumbs? Is he dreaming of what he might do if he met them again? When all the digital nerves and vessels and tendons are isolated and tagged with black-silk sutures, I cover the hand with a sterile towel. Before I move to Dinh's foot to harvest his spare part, I step to the head of the table.
"It's going well," I say. "You all right?"
"Don't worry about Dinh," he replies. "Worry about operation."
I make a circular incision around the base of the phalanx, taking care to preserve skin in the web space so that the defect can be closed without a skin graft. When the toe is finally transected, with its trailing tentacles of tendons, nerves, and vessels, it looks like a baby squid. I wrap it in saline-soaked gauze and carry it to the hand. I'm tired and sweating. My back hurts. My eyes ache. I feel as if I were on a long forced march.
First I join the bones, using wires to fuse the toe's bone to the hand's metacarpal in a position of flexion and pronation, to provide Dinh with a good pinch. Next I unite the tendons with strong nylon sutures -- extensor hallucis longus to extensor pollicis longus, flexor hallucis longus to flexor pollicis longus.
Fighting off fatigue, I begin the most critical and tedious part of the procedure -- the anastomosis of filamentous nerves and vessels. It is like sewing strands of hair together. Under the magnification of the lenses the delicate instruments seem big and blunt; the slightest tremor of my fingers appears to be an awkward jerk. Blood oozes into the wound and obscures my vision. A few drops seem like a crimson flood.
"Suck. Will someone please suck."
I take a stitch in the digital artery, and Dinh's hand rises from the drapes. I push it down, pinning it to the table.
"Goddamn it," I say. "Hold still, Dinh."
"Dau," Dinh moans in pain. "Dau. Dau."
"He feel it," the nurse says.
"More Xylocaine," I say. His hand jerks again. "Hurry up, Goddamn it. Xylocaine."
After four hours Dinh has a new thumb, pinned in place by Kirschner wires through the bones and a neat ring of black-nylon skin sutures. Exhausted, I sit for a moment cradling his hand in mine and staring at my work. The graft is cool and cadaveric, as pale as plaster, but it twitches slightly with his pulse. I haven't prayed in years, and doubt that it does any good, but I silently ask the Lord to give the transplant life. The nurse hands me a sterile dressing, and I wrap Dinh's fingers in loose layers of fluffy gauze followed by a light cast of plaster of paris. I strip off my gloves and step to the head of the table. I look down at Dinh's face, resting my hand on his shoulder. His pitted cheeks puff with each breath, and his half-closed eyelids flutter.
"All done, Dinh," I say.
"How does it look?" he asks groggily.
"Like a thumb."
INH believes that our lives move in circles, repeating themselves endlessly like The Four Seasons, like the cycle of his country's rice crop. Planting. Weeding and waiting. Harvesting. Fallowness. Planting again. If things don't work out, so what? Another chance will come around, the way winter always gives in to spring. But I believe that my life is somehow outside these circles, that I am on a straight march toward something final, and on that journey to the end of existence, the journey itself is all there is. When I fail along the way, when something I need eludes me because of a mistake I have made, the mistake itself becomes a defeat, and I am left with only loss, with emptiness, uncertainty, and regret.
Because that is my nature, the fate of Dinh's transplanted toe takes on a monumental importance. I lie awake at night in unbearable heat, sweating and worrying about infection and thrombosis. Each morning, before I start my surgery schedule, I visit Dinh in his stark hospital room, with its metal cot and the clay pot that serves as a bedside commode. Peering up at me from his pillow through circular Uncle Ho wire-rims, he seems calm and confident, talking of all the things that will be easier for him to do with his new thumb -- holding a pen when he writes haiku, picking hibiscus blooms for his wife's table, playing his bamboo flute, and, of course, eating with chopsticks. He says he may even do a little minor surgery. The thought of him trying to operate makes me cringe.
One day I show him a few snapshots of my daughter. He leafs through the pictures and nods politely. Then he talks about all the children I operated on who can now smile and suck their bottles. The children, tender and pliant, are what is important, he tells me, not old people like him, who have become dry and rigid and whose lives are behind them.
When I examine him, I am relieved to find that he is free of fever. His pain is minimal. The dressing smells clean, and a little blood stains the cast, which is a good sign. The graft has to be taking. I begin to look forward to removing the dressing and seeing a nice new pink thumb. It will be a kind of miracle. HE day before I am to leave Vietnam is the day of atonement, the time of truth, the moment to unwrap Dinh's hand and see if his thumb is viable. It is also the end of the rice harvest, and the farmers are burning off the fields to the west of the city. As I walk to the hospital, I can see a gray haze of smoke hanging over a horizon curtained with flames. It is a scorched-earth image, reminiscent of napalm and war.
In the surgery clinic I meet Dinh, sitting in a wheelchair with his bandaged hand in a sling and a confident smile on his face. Hoa, a petite nurse with a pretty smile and pearl earrings, places his hand on a white towel. A hush hangs over the room. My heart gallops. I cut the cast with heavy scissors and begin carefully unwinding the dressing. The gauze is stuck with dried blood, so I moisten it with saline and let it soak for a few minutes while I re-dress his foot. I am pleased to find the donor-site incision clean and healing well, but when I peel the last layer of gauze from his hand, I smell the faint odor of necrosis. Dinh's new thumb is the cold clay color of mildewed meat. I feel his eyes on me. I want to leave now, get on an airplane and fly home, let someone else amputate the dead thumb, let someone else clean up my mess. I glance up at his face. He is staring at the dead toe. God damn this dirty little Job of a country. Nothing turns out right here. I look out the window. The monsoon season is only a few days away, and already it is raining. Big drops kick up dust like rifle fire.
"It doesn't look good," I say. "Maybe I should re-dress it and give it a little more time."
"Gangrene," he says. "It dead. Take it off."
N the operating room everyone works in silence. On the table Dinh looks small and fragile, exhausted, as if he had just climbed one of those mountains on the Ho Chi Minh Trail. I pull the Kirschner wires from his hand with a hemostat and snip the nylon sutures. It is a bloodless operation. The necrotic transplant falls off onto blue drapes, stiff and cold, no longer a thumb or a toe. Looking at it, I can scarcely believe my childish hope that it would survive. I pick it up with sterile forceps and drop it into a stainless-steel pan. I think of Dinh's torturers in their purple berets chopping off his thumbs with a big knife. I see him drinking soup made with his own flesh and bone.
HE day of my departure Dinh sends a driver in an old Toyota to take me to the airport. I am disappointed that he isn't riding with me, but something tells me he will be waiting for me in the terminal. I want to apologize to him because the transplant didn't work, and then have him laugh and say no problem, that in his next life he will have thumbs.
I check my bags at the ticket counter and hurry to the lounge, hoping that Dinh will be waiting there in a rattan chair with his bandaged foot propped up while he drinks a cup of green tea. Over the door to the sunny room a sign announces, Nha Trang a good place for resort. With my heart hammering high in my chest, I step inside. No Dinh. The lounge is empty and silent except for the groan of a ceiling fan that churns warm, viscous air.
I move heavily between tables and out glass doors onto the tarmac. Silence surrounds me. The sun. The quiet blue sky. I stand for a while, gazing at tall brown grass and prickly pears that sprout through cracks in the airstrip. Concrete revetments built during the war to shelter American F-4 fighter jets from rocket attacks are empty and crumbling, like mausoleums of an earlier civilization. Beside the runway rests the rusty carcass of a US C141 Starlifter. I watch an old F-4, now a Vietnamese fighter jet with rocket launchers riveted to its wings, practice a touchdown. The plane bounces on the concrete, its tires screeching like the cry of some fierce predator. The gray gunship rises into sparkling blue sky. My eyes follow its flight until it disappears into the glare of the sun.
Soon an Air Vietnam passenger plane lands on the runway and taxies to the tarmac, where it shimmies to a stop. It is an old Russian turboprop with a dented skin and chipped blue-and-white paint. I have heard that Air Vietnam's planes are in poor repair because the airline has trouble getting parts, and that Japanese businessmen refuse to use it.
I mount the steps into the aircraft. Inside the fuselage, heat and the oily odor of fuel squeeze the breath out of me. Only two other travelers are on board, a mamasan in a conical hat and the baby she carries in a broad sling around her waist. She stands in the aisle, swaying back and forth to rock the infant. I choose a window seat with tattered upholstery. Soon the engines on the wings cough and sputter to life. I try to buckle my seat belt, but the clasp doesn't work. I shake my head and smile. In Vietnam danger has always been ubiquitous, life tenuous. For some reason I welcome the risky ride. It makes me feel a part of the land.
Copyright © 2000 by The Atlantic Monthly Company. All rights reserved.
Copyright © 2000 by The Atlantic Monthly Company. All rights reserved.