Dear Dr. Kirkpatrick,

              We are writing to you on behalf of 26-year-old Moke S. Kahalehoe, who was injured in November 2005 while serving in the United States Marine Corps. As a direct result of his injury, he developed Reflex Sympathetic Dystrophy. We appreciate you taking the time to evaluate Moke for the Ketamine Coma Study performed in Monterrey, Mexico.

              On November 26, 2005 while training aboard Marine Corps Recruit Depot, Parris Island, South Carolina, Moke was injured during a combat related martial arts training exercise that resulted in a fractured tibia and fibula, a broken ankle, and deltoid ligament strain. He was seen at the clinic on base, and evaluated by a U.S. Navy physician who made the decision to immobilize Moke’s left leg by the use of a Cam walker. He was non-weight bearing at this point, and ambulating with crutches. He was seen by a Podiatrist three days later. The Podiatrist then tried to cast Moke’s leg, however was unsuccessful in his attempts due to the fact that his foot was so severely swollen and painful to any touch. The podiatrist then placed him in a Bulky Jones cast.

              After three months of immobilization, the podiatrist re-evaluated Moke and felt he needed aggressive physical therapy to help regain Moke’s range of motion again. During the first physical therapy visit, the therapist noticed the discoloration, swelling, sweating, and severe pain to touch, and recommended he be evaluated by Pain Management for possible diagnosis of Reflex Sympathetic Dystrophy. He was sent off base to Beaufort Naval Hospital for evaluation by an Orthopedist who diagnosed him with RSD, and referred him to pain management at a civilian hospital.

              Moke was seen by pain management under the care of Dr. Karen Ellers who confirmed the diagnosis and began a series of Sympathetic Nerve Blocks to his spine. At the next evaluation, she asked how long his relief lasted, which was a total of 2-3 hours. (Moke was currently taking Neurontin, Elavil, and Vicodin) After unsuccessful attempts with the nerve blocks, Dr. Karen Ellers recommended the implantation of a trial Spinal Cord Neurostimulator. Moke’s insurance through the military would not authorize this procedure unless he was further evaluated. He was sent to Portsmouth Naval Hospital where he was seen by a neurologist, and once again diagnosed with Reflex Sympathetic Dystrophy. (This is now March 2006)

             After the evaluation, Moke was referred to another pain management specialist at Hilton Head Hospital, Dr. David Brosman, who also confirmed the diagnosis. He continued the series of sympathetic nerve blocks to Moke’s spine. After several attempts he went ahead and scheduled the implantation of the trial stimulator in May 2006. The stimulator provided about 15% relief, and therefore was not implanted at Moke’s request. Dr. Brosman then continued the sympathetic nerve blocks until Moke’s discharge from the Marines in August 2006.

              From August 2006 to December 2006 Moke was released from the Marine’s with no military insurance, and told to file a claim with the Veterans Affairs. He was sent home with a prescription for Neurontin and Vicodin. His disability rating of 40% was finally determined on December 29th, 2006. He was still ambulating only with the use of crutches.

              In the beginning of February, Moke finally received his primary care physician at Tripler Army Hospital Veteran Affairs in Honolulu, Hawaii. He was prescribed Neurontin, Elavil, Vicodin, and Citalopram. He was referred to pain management, but had to wait until an appointment date was mailed to him. Unfortunately, a few days later Moke had a fall and fractured his left tibia. He was seen at the ER at the VA hospital and placed in a Cam Walker again. They wanted to perform surgery on his ankle, by placing two screws in it; however the surgery was not performed at our request. (At this time, there were not any specialists who were treating the RSD, and we did not feel it safe to have surgery performed until receiving authorization from a specialist.)

             The podiatrist felt it was essential at this point to go ahead with de-sensitization therapy, but Moke could barely last two minutes because the pain was excruciating. We had to provide him with a bed cradle, due to the fact that the sheet touching his skin caused excruciating pain. The podiatrist also placed Moke in a foot brace, which he was unable to tolerate to help get his foot positioned back to 90 degrees. He was being treated for pain with a Morphine PCA. After his first PT session, Moke went into a full blown flare up, and was given several injections of Valium, and put on a Dilaudid PCA.

             The next morning he was found unresponsive, was intubated and sent to ICU. He had aspirated during the night and had developed full-blown ARDS (acute respiratory distress syndrome) with underlying pneumonia and was given a 40% chance to live. He also suffered a stroke and anoxic brain injury as well. He also developed three pressure ulcers on his left foot. He remained in a coma for 3 weeks, was trached and had a PEGG tube. 

             After waking from his coma, Moke was transferred to a Brain Injury Rehab hospital for a week, to fine tune all of his motor and cognitive skills. After being released from Bryn Mawr, Moke spent two days home and was re-admitted into the hospital for cellulitis and MRSA in his wound. During this time Moke also noticed that he was experiencing pain in his left shoulder, and his range of motion became more limited with each passing day. After 12 days, no relief, or diagnosis, Moke was sent home by his attending physician who said Moke was “confusing pain for discomfort.”

              It was then we decided to take Moke to Hahnemann University Hospital to see Dr. Schwartzman. Moke was seen by his Chief Resident, who helped get Moke get scheduled with Dr. Schwartzman for less than four weeks. He said that Moke’s RSD had spread up his entire left side. Two weeks later, Moke woke up with extreme pain while breathing and we took him to Hahnemann ER once again, and this time he was admitted. Dr. Schwartzman saw Moke and immediately began the 5-day lidocaine infusion, followed by the 5-day Ketamine Infusion. He also had foot surgery performed on his wound, and was fitted with a Wound V.A.C.

           He now receives Ketamine boosters through Dr. Schwartzman’s office; however his next one is not until November. The Ketamine does provided some relief during the two day infusion, however the pain does come back to its original state. Moke is now on a list to travel to Germany for the Ketamine Coma Study, and was given a tentative date of November 2007. Moke’s RSD has affected his entire body, except for his thighs and hands.

           Once a member of the marching band, Moke was also a semi-pro bowler who bowled in regional bowling tournaments, and who had a steady average in the upper 220’s. He used to bowl anywhere between 20-30 games during the day, then bowl in leagues almost every night. He was also an operations/general manager of LA Fitness, and would workout every morning before starting his work.

             He then joined the U.S. Marines, where he would have to endure strenuous physical obstacles, and would run a 22 minute three mile daily. Now our Marine is wheelchair-bound, fighting to hang on in hopes to receive any relief in the fight for this rare disorder. His RSD not only causes severe pain at this point, but has affected his breathing, his stomach, bladder, and digestive tract. We feel we have exhausted all forms of treatment at this point, and our hope is that Moke will be an eligible candidate for the Ketamine Coma Study, and he will be able to regain his quality of life again. Thank you for taking the time to evaluate Moke, and we look forward to meeting with you.

Sincerely,

Carol Lubinski

Amanda Santacroce

Levittown, Pennsylvania USA

July 20, 2007