“Teinte” Dave Thomas says to a nurse, and she hands him a small gleaming inkwell. Drawing the blue-tipped stick from it, he dots blue along the nose and mouth, diagramming the future “Cupid’s bow.” With small calipers, he measures the philtrum on the right, then computes where the left side of the nose and mouth should be, and discusses with Dean how best to assemble it. Taking a needle, he burrows under the skin, injecting norepinephrine-laced lidocaine all around the areas where he’ll be working. Then he puts on a headlamp attached to a wide black band around his forehead, at the front of which a small halogen lightbulb sits above his line of sight. An electrical cord running down his back connects the lamp to a battery pack worn on a white belt at his waist. He tilts the lamp’s mirrorlike dish to the correct angle. Then he calls for a scalpel.
Holding the blade steady, as if it were a single-haired paintbrush, he traces his blue diagram with movements fine, light, and feathery. In fact, he doesn’t seem to be making contact with the skin at all, and for a moment I wonder if perhaps he is just rehearsing his first incision. A thin line of blood wells behind his strokes, the blue ink turns to red as if by magic. With a tweezers, he lifts a flap of skin and cuts its edges loose with small gnawings of the scalpel. My eyes zoom in on the open flesh shining in the light, as I watch Dave begin to cut free one side of the nose, which is fused to the cheek. His wrists arch and pivot. His long fingers pick up an instrument, bend at several joints, assume acute angles as they work inside the mouth. At times they flex and pose like a praying mantis. He removes a large bolus of extra flesh from under the nose. Peering into the mouth, I can see where the pink, soft, emery-boardlike skin stops and the white, glossy lining of the nose begins. As he cuts, blood wells and he pinches the spot with tweezers, and Dean zaps the tweezers with a cautery gun which carries the current down to the flesh. A spark sizzles at the spot, then turns it black. Dave carves free the fused part of the nose so that he can pull it back where it belongs, more than an inch away. A red crescent appears, then a deeper red canyon. With a tweezer, he stretches the nose, now freed from the bone, to where it should be. “Going to be tight,” he says, more as a sigh than a statement. The chart says this is Rigoberto, a four-month-old boy from Santa Barbara. I remember seeing him with his father in the clinic. A Peace Corps worker, a twenty-seven-year-old woman from Michigan who found them in the mountains, told them of Luis Bueso’s program, and accompanied them on their bus journey. The trip had cost his father six lempiras, a full day’s wages.
Seeing blood and gore, in the absence of brutality, is not upsetting, but beautiful, fascinating, inspiring. It is when malice accompanies it that blood quickly becomes unbearable. I cannot glimpse a slasher movie without turning my head away in horror and disgust; but to watch an operation is to be enthralled by the red-and-white estuaries of the human body, and the finesse of surgeons who sail into them. There is no vicarious bridge, no sense that this could be me on the table as, hypnotic and beautiful, the body reveals its colors and textures. True, at first, there is a mild shock at seeing someone’s insides exposed to the light. But that is swiftly followed by a jolt of privilege, as you peer into the many levels of what is usually a closed crypt. The body is just a collection of hide, flesh, and fluid. But when you consider that from it come all-weather thinkers like Montaigne or artists like La Tour, that on a pedestal of flesh sits a mind, discomfort evaporates. Instead, you find yourself thinking: how amazing that mere matter should lead to this. How amazing that a dialect of fluid and bone can produce acts of mercy, heroism, and love.
At last, nearly two hours later, Dave begins stitching, piercing the skin with a curved needle and pulling the catgut slowly through. Then he loops the suture around a clamp, grabs the other end of the suture, and slides the loop down the clamp, making quick, intricate knots between the instruments and his fingers. The motion is like a spider arranging its web. He draws the threads taut, and a nurse snips them. Then he pushes the needle through for another stitch. In the background, Linda Ronstadt croons a bluesy “What’ll I do, when you are far away, and I’m so blue … what’ll I do?” When she finishes, silence falls like a cleaver. Then, a few moments later, Patsy Cline begins swoonfully singing “I’m crazy …”
Meanwhile, on another table across the room, Isabel lies showered in light. Luis Bueso and Dave Fogarty face each other across her mouth, which they have opened up like an unfolded origami crane. Their glances meet at the crossroads of her skewed lips. A nurse seated low at the head of the table waits for their requests, her gloved hands folded. There is a certain kitchen intimacy to the group—two people sitting on worn stools at a table under a central light, with others standing close by and leaning forward; everyone’s attention is focused on the same spot. A painter, a Dutch master, would make much of this scene—the luster of concentration in the eyes of the surgeons, the overhead lamp rinsing the child’s face with white and casting the doctors in stark shadows. Light cascades over the hills, planes, and valleys of their faces, over Dave Fogarty’s prominent brows and Luis’s large glasses. Together they break open the mansion of her flesh, and roam through it with their hands. All their knowledge, training, and history run like voltage down their arms. To have hands as steady and probing as theirs is to touch life where it lives, in the cell, blood, and bone, in the pastures of yellow fat that bloom like wildflowers above the soft tissues. Their mouths are masked, and what they say is of no consequence, but their hands speak a silent, fluent Esperanto. Exchanging instruments, touching one another and the child, their hands are relentlessly eloquent, lyrical, and profound as they converse in an argot of tendon and nerve. Hours later, after orating inside the girl’s body, their hands will at last have argued persuasively with her flesh; and when they leave they will stitch up the entrance with a small trail of stars.
Back at table one, a little girl lies swaddled in sheets. The child looks so peaceful, she might be sleeping normally and dreaming. But I know that isn’t possible. Anesthesiologists prefer to give children drugs that will render their brains electrically silent. The brain’s metabolism, its requirement for oxygen for nutrition, then drops to a very low level. This is protective in various situations, but especially when a doctor is operating in a way that could interrupt the brain’s blood supply—on a blood vessel that supplies part of the brain, for example, or during a face or heart operation. Indeed, any time there’s a risk to the brain, it’s often desirable to have an anesthetic that will silence the brain. As a result, the children don’t dream during the operations, and they remember nothing afterward; their brains are idling. But the children don’t look dead. Their skin glows with a soft candle-wax sheen, and they seem suspended in time and space, like small hibernating astronauts.
Ruth pauses a moment, lifts a triangle of skin with a pair of tweezers, arranges and rearranges it, trying out various syllogisms. Her face seems to be saying: If I move this around, and that above, and this under, and that through, then those pieces of skin will fall there. Hours pass, but eventually the small face follows her logic into a more orderly mouth and nose. She pushes the cleft together to make a whole. All the pieces now fit like a machine-tooled jigsaw puzzle. Ruth rolls her cramped shoulders and straightens her back a moment, then leans forward again and continues stitching.
All the surgeons are raunchy and funny in the operating room, which sometimes sounds like an episode of M*A*S*H. Although some American surgeons prefer a quiet operating room, most don’t. Flirtatious, joking, and crude banter happen there so often that it makes one wonder if there isn’t a deep psychological need at work. Surgeons perform an act of controlled violence—unmalicious violence, therapeutic violence, ritualized violence—but violence just the same. We have evolved with certain instinctive responses to horror. And it is horror to cut open the protective armor of someone’s body, and expose the thick porridges inside. Although we don’t like to think of ourselves in that way, we are a heap of bright fluids in a sac; and we’re taught never to break the sac open, because
life can pour away so easily. Surgeons seem to defuse the horror in various ways—by blanking out any personal details about the patient, by draping the patient’s body so that it’s unrecognizably human, by allowing their hands to perform acts profound, solemn, and holy while their minds retreat into the opposite realm of the coarse, the casual, and the profane. “Is this a little girl or a little boy?” I sometimes ask Dave Thomas, and he always says, “I don’t know.” Only minutes before, he was looking at the patient’s chart, which includes personal details and a photograph, as well as evaluations made during clinic. How could he “forget” only minutes later if it’s a girl or a boy?
“When you’re operating, are you aware of the patient as a person?” I ask Dean Sorensen, while he’s stitching a cleft palate back together. He looks up at me, above the magnifying part of the loops. For a moment, his blue eyes fix me solidly. “If I did that I’d be petrified.”
It is what makes it possible for Ruth Carr, before an operation on a man who has been burned on almost every part of the front of his body except the penis, to say: “He must have been wearing his flameproof jockstrap that day.” It’s what prompts Luis Bueso, during an operation on a well-built teenage girl, to say: “A good pair of tits have more pulling power than an oxcart.” It is what allows David Fogarty, while he tries to thread a suture needle, whose eye he misses, to say with a smirk to a male Honduran doctor: “If that hole were surrounded by hair, I wouldn’t have missed.” The banter is the anesthetic for the surgeon.
As the morning gives way to the afternoon and early evening, Spanish, French, Portuguese, and English mix in the operating rooms, where a procession of children arrives from their villages, appear suddenly on the tables, have their faces and lives rearranged while they are unconscious, and disappear into the recovery room and then into the pediatrics ward. Not only the children dwell in this shudder out of time. All of us are temporarily yanked out of the normal course of our lives. There is a war-zone feel to the day. In their normal practices, cosmetic surgeons can afford to do subtle, elective surgeries, touch-ups, and all the niceties. Interplast teams burst into a town like a squad of commandos, to operate on gross deformities. Teams are thrown together in emotionally charged circumstances, and, as a result, people often form intense friendships and interdependencies. Then the red alert of the trip ends suddenly, like a small death, and, returning home, team members often sink into parabolas of depression.
“It’s strange not knowing the before and after,” Dave Thomas says, as he operates on a boy with one upper arm that is so constricted it looks like an animal someone has twisted out of balloons. Opening the constriction, he does a “Z-plasty,” a favorite type of operation for lengthening, in which two pennants of skin are cut loose and rotated from the horizontal to the vertical plane. Lifting up a sail-shaped wedge of upper-arm skin, he folds it in one direction, then takes a second flap and folds it in the opposite direction. A small geyser of blood hits his smock and mask. “Bleeder,” he says matter-of-factly. He clamps it, cauterizes it, and goes on to put in two stitches, which he draws together to make a harlequin pattern of the skin. A Z becomes an N. “Suddenly these children appear with their predicamerits,” he continues. “Then they vanish. You only see them at that one moment in time. In that moment, you may be changing the whole course of their lives. But you never see them again. The good part is that plastic surgery is unique in that, with many surgeries—a hernia, for example—you can’t see the result right away. But I can see right away what I’ve done to reconstruct an arm or, especially, a face.”
By midweek, there are signs of our presence on all the children: colored deputy sheriff badges, colored barettes and earrings, toy trucks and tops and puzzles, new dresses and T-shirts. In the children’s ward, rows of full beds and cribs line the room. There is a sweet, mousey smell of pus, urine, and illness. On one wall, a framed, yellowing picture of a Gerber baby’s smiling and perfect face is the center of a large, open, dewy red rose. A hand-drawn rabbit with a merry smile and long lashes watches from the wall, near Raggedy Ann and Andy clothes hooks. Although the hospital is old and worn, it is very clean, and it is staffed by a caravan of devoted nurses. They get paid little—indeed, sometimes don’t get paid for weeks—yet they keep coming to work. In the same blue dress she wore to the clinic, Isabel’s mother feeds her daughter with an eyedropper. Shaped normally now, her mouth wears a design of fine stitches. Cardboard splints on her arms will keep her from pestering the stitches until they dissolve. Whenever possible, the doctors use dissolvable stitches because they can’t rely on the compliance of the patients, who might not have enough money to make a return trip. Mother bundles Isabel up in her arms, hugs her close. Smiling, relieved, she says good-bye and thanks everyone, emotionally, then turns around and thanks them all over again. The moment she leaves the room, nurses clean the crib and change its linens. Soon another young mother arrives with her baby, which is installed in the crib. Below the girl’s frizzy, golden topknot of hair, an unsightly cyst bulges; tomorrow, the doctors will remove it.
After the last operation of the day, the team gathers in the break room to change back into street clothes and try to find places to rest on the benches and school desk-chairs. Some sit on a table, or lean against a wall. We have finished earlier than expected—it is only 6:30. Lightning flashes from the black batteries of the sky, and the rain falls thick as rubber. The rain is so dense we joke about needing a machete instead of an umbrella, and no one wants to run through the down pour to the parking lot to see if the driver is waiting with the blue van. Grabbing our rucksacks and satchels filled with scrub clothes, medicine, and personal items, we finally sprint to the van and arrive drenched, laughing. All fourteen of us pile on board. After dinner at a restaurant downtown, we head for a glitter-ball-hung discotheque full of colored lights, loud music, local beer, and never-ending songs. Today there were twelve hours of operations, and we are shot through with every caliber of exhaustion. Tomorrow there will be twelve hours more. Strobes splatter the dancers with light, cutting them into fast, dizzying snapshots. Overwrought from the day, and filled with too many warring emotions to name, people dance out their pent-up furies. Midnight arrives like an express train, and we leave. Tomorrow there will be another sea of faces to heal; over a hundred will be operated on by the week’s end. Swamped by fatigue, we pile into the van. If possible, the starless night has grown even hotter. The rain has stopped, but lights continue to sizzle overhead. As part of a fiesta to celebrate a local political candidate, fireworks fill the sky like small perfect cauteries.
FOR THE LOVE OF STRANGERS: LIFE AND DEATH IN THE SOUTH SEAS
In the South Seas, the morning sun scalds the water, the air feels close and damp, and a single hot breath pours around the islands. One could die in the suffocating stammer of the winds that blow for days on end without ever cooling or refreshing. One could live in the relentless searchlight of the sun that will find you wherever you hide and hold you in its glare, the sun that also sneaks like a bright rodent into the smallest and grimmest holes, and at some point fills every shadowy corner with a moment of illumination. The sun that brands one’s retinas with yellow sparks, and hurls comets of blinding glitter onto the waves. Beneath such a sun one lives in the penitentiary of one’s own body. Beneath such a sun one wears an ocean of sweat wherever one wanders. But, at twilight, the heat lathers out of the sky behind a heap of red plumes, the moon rises with its seas stark and clear, and night lays a cold compress on the brow of the Pacific.
It was April, and we had set sail from Tahiti, once an almost mythic place, now tawdry and cheap in the way that tourist lay-bys come to be. We arrived at Makatéa Island, in the Tuamoto Archipelago, and dropped anchor near the port of Temao, where the rusty derricks of an abandoned phosphate mine stood offshore like a species of giant seabird. For sixty years, the thriving mine filled the pockets and bellies of the 1,200 islanders, and then at last the phosphate ran out, and the locals fled to Tahiti and other spots. What is
it about such ports of call that people always find irresistible? You would think that degradation had its own small magnetisms of decay, a force strong enough to draw decent and simple people over ornery seas and impassable lands to become part of a neon swill. Anyone who has watched the carcass of an animal for any length of time, seen the insect armies arrive and begin boiling in the flesh, knows that it is the habit of the fly to leave the sound parts of an animal and rush to the festering wounds. I do not know why. When the phosphate ran out, the people of Makatéa fled to Tahiti, and took jobs in its factories, hotels, restaurants, and sin parlors. They left behind a small green gazebo of an island.
The loading platform collapsed long ago, ravaged by the salty talons of tropic storms, and undone by time, that great mindless rearranger of places and people. Occasionally, the local authorities tried to blow up the rusting structures for fear someone might get injured on them, but such efforts always failed, leaving the jagged cranes shuffled around a little, but still above water. One could see where the main conveyor belt had been, and the loading chutes, in the tangle of metal now green with algae and pitted by salt. Beyond the shore, a thick expanse of vine-clad trees led up a winding hill, where fairy terns fluttered like small, white, perfect angels; hibiscus and chenille plants spilled their intense red; and a small village lay nestled with cast-off machinery among the dense undergrowth. All this was visible in the distance, through binoculars, and the passengers clustered at the cruise ship’s rails for their first glimpse of an island remote in time, distance, and culture.