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Microsurgeon races the clock - and wins


Kyle D. Bickel, dedicated triathlete, had just logged his training laps in the Downtown Athletic Club's swimming pool Monday when at his locker, he noticed his pager had been activated.

Within minutes, Dr. Bickel, reconstructive surgeon at Johns Hopkins Hospital, was racing 10 blocks toward the ultimate challenge of his medical career: Aaron Thompson, 7.

Aaron was in critical condition in the Hopkins emergency room, flown there by state police helicopter after his left arm was severed in an Eastern Shore motorbike accident. The child's left forearm lay in a case of ice.

While driving to the hospital, Dr. Bickel fought a quickening pulse and attempted to focus on what he and other surgeons say was the first arm reattachment in Hopkins' 106-year history.

When he arrived at Hopkins, the surgeon learned a quick-thinking passer-by had saved the child's life by stopping the bleeding and preserved the severed limb for medics. The next move was Dr. Bickel's.

After 10 grueling hours in the operating room -- most spent peering through a vertical microscope to tend to his delicate work -- Dr. Bickel had woven back together Aaron's elbow joint, ** an artery and two veins , three major nerves, muscles and skin to offer the boy a distant hope of one day using his arm again.

"I'm still high," Dr. Bickel, 34, said yesterday, talking publicly for the first time about the procedure that began Monday and crept into Tuesday.

"Reattaching Aaron's arm is the most gratifying thing I've done in my life. To see his pink fingers where blood flows again, the love for a child on his parents' faces -- that's why I became a doctor."

He also credited other surgeons on the team who assisted him -- Dr. Robert Carpenter, Dr. James Namnoum and Dr. Joseph Disa.

Dr. Paul Manson, chief of plastic surgery at Hopkins, yesterday called Dr. Bickel "excellent, a top-notch surgeon. He can operate on me any time."

Dr. Manson, a Hopkins surgeon since 1976, said, "I am not aware of any arm replantations done at Hopkins until this week."

Dr. Ronald A. Malt performed the first successful arm reattachment in 1962 at Boston's Massachusetts General Hospital, according to the Journal of the American Medical Association. A year later, the 14-year-old former patient shook hands with a friend and reported his limb sensitive to touch and temperature changes.

Aaron was listed in fair condition yesterday, said Dr. Bickel, who is assistant professor of hand surgery, microsurgery and reconstructive plastic surgery at Hopkins. The child's parents, Patrick and Pamela Thompson, have been at their son's side since the accident and could not be reached for comment.

"Aaron is stoic about his experience and scared, understandably," Dr. Bickel said. "He can't understand that when I press his fingertips, checking blood flow, why he doesn't feel anything."

Aaron should go home in about a week, the doctor said, but additional surgery and long hours of physical therapy are in his future.

"I'm cautiously optimistic about how the replantation will eventually work out," Dr. Bickel said. "The end result will be one of useful, but limited, function, including movement and touch."

Full restoration of the arm's function is improbable, he also said, although youth is on Aaron's side.

At 6:30 p.m. Monday, Aaron arrived on the hospital's seventh floor and was rolled into an operating room, where Dr. Bickel waited with his surgical team. "He was awake and alert, and he was scared."

While Aaron was anesthetized, his surgeon pondered the myriad medical steps he had to take.

His primary consideration was to re-establish blood flow to the severed limb.

"It was a race against the clock," the surgeon said. "Generally, we had four to six hours after the accident to get blood back to the lower arm before cell death would occur."

Working through a freestanding microscope that resembles a submarine periscope, Dr. Bickel attached a surgical tube from the clamped severed artery in the upper arm to the lower arm. Blood flow was established at 9:30 p.m., he said, and "gave us time to spare." Dr. Bickel also performed a vein graft from the child's leg to replace a shattered piece of vessel in the lower arm.

Another delicate part of the procedure was repairing the three major nerves of the arm. The median, ulnar and radial nerves serve separate territories in the limb but all must function in harmony for movements in the arm, hand and fingers.

They were rejoined after several hours' work. "Things were pink there, they were working," he said.

Later, two bones -- the humerus and ulna -- were reconnected with a series of metal rods and wires. Muscles were reattached to muscles and a skin graft was performed to replace some of the dead tissue.

Sometime after 4 o'clock Tuesday morning, the finishing touches of a cast were placed on Aaron, and Dr. Bickel posed for an operating room photograph taken by a colleague. Dr. Bickel had been on his feet 10 hours, and hadn't eaten for more than 20 hours.

He was exhausted, elated.

A Hopkins surgeon for a year, Dr. Bickel said he replaced "hundreds of severed fingers, hands and toes" while a fellow at the Raymond M. Curtis Hand Center at Baltimore's Union Memorial Hospital and at the Davies Medical Center in San Francisco.

He credited his athletic training for being able to withstand the physical demands of such an operation as Aaron's. If his medical duties permit, his weekly training schedule includes 100 to 200 miles a week of cycling, 20 miles of running and five miles of swimming.

"The stamina I have developed makes me a better surgeon," he said. "It keeps my human scales in better balance."

He also believes his first two years at the University of California at Berkeley when he majored in art considerably advanced his surgical career.

"There I fine-tuned precision, visualization and better developed hand-eye tactile skills that I apply to my work today," Dr. Bickel said.

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