Hearing blood flow in right ear

BECAUSE I love my wife and daughter, and because I want them to believe I am a good man, I have never talked to them about my year as a grunt with the 25th Infantry in Vietnam. I cannot tell my thirteen-year-old that once, drunk on Ba Muoi Ba beer, I took a girl her age into a thatched-roof hooch in Tay Ninh City and did her on a bamboo mat. I cannot tell my wife, who paints watercolors of songbirds, that on a search-and-destroy mission I emptied my M-60 machine gun into two beautiful white egrets that were wading in the muddy water of a paddy. I cannot tell them how I sang “Happy Trails” as I shoved two wounded Viet Cong out the door of a medevac chopper hovering twenty feet above the tarmac of a battalion aid station. I cannot tell them how I lay in a ditch and used my M-60 to gun down a skinny, black-haired farmer I thought was a VC, nearly blowing his head off. I cannot tell them how I completed the decapitation with a machete, and then stuck his head on a pole on top of a mountain called Nui Ba Den. All these things fester in me like the tiny fragment of shrapnel embedded in my skull, haunt me like the corpse of the slim dark man I killed. I cannot talk about these things that I wish I could forget but know that I never will.

TWENTY years have passed since the summer of 1968, when I flew home from the war and my “freedom bird” landed in the night at Travis Air Force Base, near San Francisco. I knew that in the city, soldiers in uniform were taunted in the streets by flower children. So I slipped quietly into a rest-room and changed from my dress khakis into jeans and a flannel shirt. Nobody was there to say “Welcome home, soldier.” It was as if I were an exile in my own country. I felt deceived and confused, and most of all angry, but I wasn’t sure at whom to direct my anger or where to go or what to do, so I held everything inside and went about forming a life day by day.

After I was discharged from the Army, I went home to Chicago and hung around there for a couple of years, haunted by memories and nameless faces. Devoid of hope or expectations, smoking dope and dreaming dreams of torment, I drifted from one meaningless endeavor to the next. I studied drawing at the art academy, cut grass with the grounds crew at Soldier Field, parked cars at The Four Seasons. Nothing seemed to matter; nothing changed what I was. I was still fire and smoke, a loaded gun, a dead survivor, a little girl on a bamboo mat, a headless corpse. I was still in the killing zone.

Gradually I grew weary of my hollowness, ran out of pity for my own self-pity. I wanted to take my life and shake it by the hair. I decided to use the GI Bill and give college a try.

I enrolled at the University of Wisconsin at Madison, the headquarters of the Weathermen and the SDS. I lived in a rundown rooming house on Mifflen Street, among all the long-haired war protesters and scruffy peaceniks. During the day I went to classes and worked as an orderly at a Catholic hospital, but at night, after work, I went back to my room to study alone. Through the window of my room I could see mobs of students marching through the streets, chanting “Ho, Ho, Ho Chi Minh” and “Bring home the war.” What did they know about war? I watched them, and I wanted to kick their hippie asses.

It was in caring for the patients at the hospital that I seemed to find what I had been searching for. While bathing or feeding a patient I felt simply good. It was better than my best trips with Mary Jane. I decided to apply to medical school, and I was accepted.

One night when I was a senior med student, a couple of radical war protesters blew up the Army Mathematics Research Center on campus. The explosion shook my bed in the hospital call room like the rocket that blasted me out of sleep the night of the Tet Offensive. I have never been a brave man, and I lay there in the dark with my heart pounding, thinking I was back in Firebase Zulu the night we were overrun. A nurse called me to the emergency room to help resuscitate a theoretical physicist who had been pulled from under the rubble. His chest was crushed and both his lungs were collapsed. He didn’t need resuscitation. He needed a body bag. The war I was trying to escape had followed me home. Now I practice plastic surgery in Lake Forest, a North Shore Chicago suburb of stone walls, German cars, and private clubs. On my arm is a scar from the laser surgery that removed a tattoo I woke up with one morning in a Bangkok whorehouse. The tattoo was a cartoon in blue and red ink of a baby in diapers, wearing an Army helmet and a parachute with the inscription “Airborne.” I feel that I am two people at once, two people fighting within myself. One is a family man and a physician who lives a comfortable external life. The other is a war criminal with an atrophied soul. Nothing I do can revive it.

Even as a surgeon I have a split personality. I sculpt women’s bodies with breast augmentations, tummy tucks, face-lifts, and liposuction. I like the money, but I’m bored with these patients and their vanity, their urgent need for surgical enhancement. I am also a reconstructive plastic surgeon who loves Z-plastying a scar from a dog bite on a little girl’s cheek or skin grafting a burn on the neck of a small boy who fell against a space heater. I love reconstructing a lobster-claw deformity of the hand so that a child can hold a spoon and fork. I’m no Albert Schweitzer, but every summer I spend a couple of weeks in Haiti or Kenya or Guatemala with Operation Smile, repairing cleft palates and lips. Removing the bandages and seeing the results of my skill sends a chill up my neck, makes me feel like something of a decent man, a healer.

Today, in late September, I am sitting in a window seat in a Thai Airways jet on its way from Bangkok to Ho Chi Minh City. I am headed to the Khanh Hoa Hospital, in Nha Trang, for two weeks of my own little Operation Smile, repairing the cleft palates and lips of children on whose land I once wreaked havoc, whose parents and grandparents I murdered and whom, somewhere deep inside me, I still hold in contempt.

I stare out the airplane window at tufts of white clouds that look like bursts of artillery flak, and I break into a sweat, remembering the descent of the airliner that flew me, a machine gunner, an Airborne Ranger, an eighteen-year-old pissed-off, pot-smoking warrior, cannon fodder, to Vietnam. The pilot lurched into a steep, spiraling dive to minimize the plane’s exposure time to ground fire. I pitched forward in my seat, the belt cutting into my belly, my heart pounding. Until that moment I had felt immortal, but then fear came to me in an image of my own death by a bullet to the brain, and I realized how little I mattered, how quickly and simply and anonymously the end could come. I believed that I would never return home to my room with the old oak dresser and corner desk that my mother dusted and polished with lemon oil. Tears filled my eyes.

With the plane in a long, gentle glide, I gaze out the window and search for remnants of the war. I see a green patchwork of paddies and fields of grass, dirt roads whose iron-red dust choked me, whose mud caked my jungle boots. A sampan floats down a river. Smoke curls lazily from a thatched-roof shack. An ox pulls a cart. The land seems asleep, and the war only a dream. I drop back in the seat and close my eyes. Stirring in my chest is the feeling that a dangerous demon is setting itself free inside me.

I spend the night in Saigon at the Bong Song Hotel, a mildewing walk-up not far from the Museum of American War Crimes. The toilet doesn’t flush. The ceiling fan croaks so loudly that I turn it off. Oily tropical heat drenches the room, and I can hear rats skittering across the floor. I feel as I once did trying to grab a little shut-eye before going out on ambush patrol. I can’t sleep. My mind is filled with the image of myself dragging the lifeless body of a kid named Dugan by the ankles through mud.

In the orange light of dawn I board an old minivan that will take me north to the hospital in Nha Trang. The tottering vehicle weaves through streets teeming with bicycles, three-wheeled cyclos, motorbikes, an occasional car. People gawk at me as if I were a zoo animal of a breed they have never seen before. The driver is Tran, a spindly man with wispy Ho Chi Minh chin whiskers. He has been assigned to be my guide and interpreter, but he is really the People’s Committee watchdog. When I was here before, I would have called him a gook or a slope, a dink motherfucker, and those are the words that come to me now when I look at Tran. I picture his head on a pole.

We cross the Saigon River on Highway One, Vietnam’s aorta, the artery connecting Hanoi with Saigon. The French called Highway One ” la rue sans joie. ” We called it “the street to sorrow.” During the war I often traveled this road in convoys of tanks and half-tracks whose treads pulverized the pavement. I was always high on Buddha grass. Armed to the teeth. Frightened and mean. I was so young. I didn’t know what I was doing here. A few miles out of Saigon, Tran slows and points to a vast empty plain overgrown with olive-drab grass and scrub brush.

“This Long Binh,” he says.

“Stop,” I say.

He pulls off the road and parks by a pile of rusty wire and scrap metal. I climb out of the van and stand, looking at acres of elephant grass blasted by the tropical sun. I think of Long Binh when it was an enormous military base, a sandbag city of tents, barbed wire, and bunkers. We called it LBJ, for “Long Binh Jail.” It was where I spent my first night “in country,” sweat-soaked on a sagging cot, listening to the distant chunk of artillery, fear clawing at my chest. Now all I see is emptiness. Nothing to verify my past, nothing to commune with. How hot it is. How quiet.

Since Nam, I have spent a lot of nights with bottles of wine, reading the poetry of war — Homer and Kipling, Sandburg and Komunyakaa. Through the haze of my thoughts, words by Sandburg are moving. The words are about grass and war and soldiers in Austerlitz and Gettysburg and Waterloo, but they are about this place, too. Shove them under and let me work — I am the grass; I cover all. I gaze out at Long Binh’s grass. It ripples in hot wind like folds of silk.

I climb back into the van, and we jostle on through paddies and rubber plantations, green groves of bamboo and banana trees. I have the strange feeling that my life has shrunk, that just around the bend an ambush will be waiting. I lean forward in my seat and ask Tran if he remembers Long Binh when the American soldiers were here.

“Vietnam believe it better not to remind of the past.” He speaks looking straight ahead through aviator sunglasses. “We live in present with eye on future.” The words sound rote, as if he is quoting from a propaganda paper. “Vietnam want to be thought of as country, not war, not just problem in other country’s past.”

On a berm old women in conical hats spread rice and palm fronds to dry in the sun. Charcoal fumes waft from cooking fires. White-shirted children with red kerchiefs tied around their necks march to school. Two men, brown and bent like cashew nuts, face each other over a big teak log and pull a crosscut saw back and forth slowly, rhythmically. For a brief moment the smell of gunpowder comes back to me, and I see little Asian men running headlong through tall grass, firing weapons and screaming. I see GIs running through smoke with green canvas stretchers.

THE arrangements for my mission in the coastal city of Nha Trang were made through Dr. Lieh Viet Dinh, the director of Khanh Hoa Hospital. The morning after my arrival, Dinh sends word to my hotel that he wants to meet me for a welcoming meal at a restaurant on the South China Sea. I have been told that Dinh was once in the North Vietnamese army and now is a high official in the province’s Communist Party. What does he want? For me to say I’m sorry?

I hire a cyclo driver to pedal me to the restaurant. Mopeds with their exhaust tinting the air blue and bicycles piled high with cordwood tangle the streets. The Sunday-afternoon sun is so bright it hurts my eyes. But there is a cool ocean breeze and the scent of bougainvillaea in the air. Under flame trees with brilliant-orange blossoms barbers trim hair and clean wax from ears. Street vendors hawk flowers and loaves of French bread. Everywhere I look, I see Vietnamese getting on with their lives. I marvel at their serenity. They are no different from the people that I was taught to distrust, that I once machine-gunned. This street is no different from streets that I once helped to fill with rubble and bodies. A man on a Honda raises his index finger and calls, “Hey, Joe. U.S. number one.” But I look away from him.

The restaurant is a rickety tile-roofed pagoda perched on stilts over a beach of sand the color of crème brûlée. Below, in a natural aquarium, sand sharks and tropical fish dart among the rocks. In the distance a soft vapor hangs over mountain islands in the bay. The restaurant is empty except for a gnarly little man sitting alone at a table with the sun splashing off turquoise water behind him. He is a militant figure with penetrating black eyes and hollow, acne-scarred cheeks that give him a look of toughness, a look that says, You could never defeat me no matter how many bombs you dropped. I know he is Dinh. The contempt that boiled inside me during the war bubbles up. I can feel it in my chest.

He calls to me to join him. I settle into a wooden chair across from him and extend my hand for him to shake, but he ignores it and offers a stiff little bow of his head. Nervousness dries up the saliva in my mouth. A waitress in a blue ao dai brings us bottles of Ba Muoi Ba beer. With her lustrous black hair and slim, silk-sheathed figure, she is beautiful and exotic like a tropical bird. The shy young girl with a dimple in her cheek that I took on the bamboo mat in Tay Ninh would be about her age now. I wonder what became of her.

In English that I have to listen to closely to understand, Dinh talks for a while about the Khanh Hoa Hospital, the only hospital for the one million people of his province. He tells me that my visit has been advertised on television, and that thirty children with cleft lips to be repaired will be there. His jaw tight, his voice intimidating, he tells me that the hospital has trouble getting medicine and equipment because of the American embargo. I pick up my bottle of beer and press it to my lips and tilt it. The liquid is warm, with the slight formaldehyde taste that I remember from the war. I look at Dinh’s slanty black eyes and stained teeth, thinking how easy it would be to kill him. I’ve been taught to do it with a gun or a knife or my hands. It would come back to me quickly, like sitting down at a piano and playing a song that you mastered a long time ago but haven’t played in years. Suddenly the thought of operating on little children in all this heat and dirt, with archaic equipment, jolts me back into the present. I ask him who will give the anesthesia.

“My doctors,” he says. “Vietnamese doctors as good as any in the world.”

The waitress brings a plate of lightly fried rice paper, bowls of rice and noodles, and a platter of sea bass smothered in peppers, onions, and peanuts. She gives me chopsticks and Dinh a metal spoon. When we begin to eat, I see Dinh’s hands for the first time. I am startled. Now I know why he didn’t shake with me. His thumbs are missing. I watch him spoon rice onto his plate, clutching the utensil in his thumbless hand. He has learned a pinch grip between his second and third digits, like children I have operated on who were born with floating thumbs or congenital absence of the first metacarpal bone. Using his fingers as if they were tongs, he wraps some fish in a sheet of the rice paper and dips it in nuoc cham sauce. The sauce smells rancid, and a sourness rises up my esophagus.

“I hear you in Vietnam during war,” Dinh says between bites of fish and rice.

“Yes,” I say. I can’t take my eyes off his hands.

“Where?” he asks.

“South of here, along the Cambodian border near Tay Ninh.”

“You see Nui Ba Den,” he says. “How you call it? The black virgin mountain. This fish good. Dip your fish in nuoc cham.”

I picture that black-haired man’s head skewered on a bamboo pole.

“Yeah, I’ve seen Nui Ba Den,” I say, feeling as if he must somehow know what I did on top of the mountain.

“Were you Army surgeon?”

“No. That was before I went to medical school. I was with the infantry.” I take a gulp of beer. “That was a long time ago.”

“Not so long ago,” Dinh says. His lips curl into a smile that is filled with crooked yellow teeth. “Americans always think time longer than it is. Americans very impatient. Vietnamese very patient. We believe life is circle. Everything comes and goes. Why grasp and cling? Always things will come around again if you give them time. Patience is why we win victory.”

In the filthy little village across the bay I can see tin-roofed shacks, teeming streets, the haze of smoke from cooking fires — the thick stew of peasant life.

“How about you?” I ask. “Were you a doctor during the war?”

He wipes his mouth with his shirt-sleeve and says, “In war against French colonialists, I was Vietminh infantry man. Fifteen years old.”

He raises a maimed hand and, with a wave motion to demonstrate high altitude, tells how he twice climbed the mountains of Laos and Cambodia on the Ho Chi Minh Trail — once to fight the French and once to fight the Americans and their Vietnamese puppets. He was wounded at Dien Bien Phu. I wonder if that was when he lost his thumbs. I’m fascinated by his thumblessness. The ability to oppose a thumb and a finger is what sets us apart from lemurs and baboons.

“We have little to fight with,” Dinh says. “After we shoot our guns, we pick up empty cartridges to use again. We eat nothing but tapioca roots and half a can of rice a day. For seven years I fight hungry.” I listen to him tell of his wars, and it takes me back to mine. Cold-sweat nights peering out of a muddy bunker through concertina wire at tracers and shadows. Waiting. Listening. Grim patrols through elephant grass and jungle greased with moonlight. I can hear screams, see faces of the dead. What is memory and what is a dream? When it comes to the war, nothing seems true. It seems impossible that something that tragic, that unspeakable, was once a part of my life. Suddenly I’m overwhelmed with emotion. I wonder if Dinh ever feels like crying. In the shallows below the restaurant a sea turtle snaps at silver fish trapped in a net.

“How about in the war against America?” I ask. “Were you a doctor then?”

“I was surgeon in the war against you and your South Vietnamese puppets.”

“Where did you serve?” I ask. “Were you in a hospital?”

“My hospital the forest. My operating table the soil of the jungle.” He holds up both hands and rotates them for me to see. “I have thumbs then. I clever surgeon. I operate on everything from head to toes.” He looks up at the ceiling as if an airplane were circling overhead. “Your B-fifty-twos drop big bombs. They make earth shake. They scare hell out of me.”

Dinh flashes a smile that makes me uncomfortable. He takes a drink of beer.

“Were you wounded?” I ask.

“You mean my hands?”

“Yeah. What happened?”

He rests them on the table, displaying them as he talks. He tells me that he was captured in the central highlands, not by Americans but by South Vietnamese Special Forces in their purple berets. When they learned he was a doctor, they chose him for torture. They tied him to a stake under merciless sun and every day pulled out one of his fingernails with a pair of pliers. At night they locked him up in a tiger cage. He speaks softly. On the eleventh day they cut off his thumbs. Then they cooked them in a soup and told him to drink it. He hadn’t eaten for two weeks, so he did.

“How did you survive?” I ask. “Why didn’t you go crazy?”

“I pretended to be somewhere else. Somewhere at a time after our victory. I always knew we would win.”

Dinh looks at my hands.

“You lucky,” he says. “You have thumbs to do surgery. I can’t even eat with chopsticks.” He raises his hands, flexing his fingers. He glares at me with eyes as hard and black as gun bores. “This should happen to no one.”

We finish our meal in silence. Under the afternoon sun the restaurant is stifling, and I feel queasy. I can get down only a little rice. But Dinh eats hungrily, shoveling in the food with his spoon as if to make up for all those years of rice and tapioca roots. When his plate is clean, he rinses his hands in a bowl of hot lime water with tea leaves floating on the surface.

He looks up at me and says, “To take the smell of fish from your skin.”

IN the morning I walk from my hotel through steamy air, on streets boiling with people, to the hospital. Around the entryway dozens of crippled peasants and ragged children with skin sores squat on the powdery earth. Everything is dusty. I understand why Vietnamese peasants call themselves “the dust of life.” A boy with weight-lifter arms calls to me in English from a bicycle that he pedals with his hands. He wants me to fix his paralyzed legs.

Khanh Hoa’s pale-yellow façade gives me an impression of cleanliness and light, but inside, the wards are dim and grungy, with no glass or screens in the windows to keep out flies and mosquitoes. Often two patients occupy a single narrow bed, with family members sleeping on the floor nearby to assist with the feeding and bathing, the emptying of bedpans. A tiny, toothless woman with skin like teakwood waves a bamboo fan over a wasted man on a mattress without sheets. She gazes at me with longing. Everywhere I go, someone with sorrowful eyes looks at me as if I were Jesus.

DURING 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. AT 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.”

THAT 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.

THE 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.”

DINH 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. THE 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.”

IN 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.

THE 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.

Daly Walker is a surgeon and a Vietnam veteran. He is completing a collection of short stories and is working on a novel.

Illustrations by Jeffrey Decoster.

The Atlantic Monthly ; June 2000; I Am the Grass – 00.06 (Part Two); Volume 285, No. 6; page 88-97.