5 Incredible Hawaii Medical Stories
Medical Stories make for gripping television because of the inherent drama and mystery doctors grapple with daily. We love them because, ultimately, they are about us, our lives, our deaths and the intricate workings of our amazing human bodies. We asked some of Hawaii’s top doctors for their most amazing stories. We got stories that include surgery under hypnosis, a mysterious malady that only affects malihini surfers and a doctor who raised the alarm on a deadly dietary supplement.
Children, Heal Thyselves
A pediatric bone specialist pioneers a minimalist fix for broken wrists.
Dr. Byron Izuka.
Photo: Rae Huo
A radical shift in the way doctors treat severe wrist fractures in children began with a 9-year-old Hawaii girl who snapped her wrist when she fell from her mother’s high-heeled shoes. The standard treatment for such injuries has long been the same for children as it is for adults. Doctors straighten the bones, either manually or surgically.
The new approach can be summed up in two words: Do nothing. Or at least do nothing other than putting a cast on the child’s arm and allowing the bones to straighten themselves as they continue growing.
“It’s a concept that’s completely counter-intuitive, but when the process is done, you can’t even tell that the bones were broken in the first place,” says Dr. Byron Izuka, the pediatric orthopedic surgeon who pioneered the approach and won a prestigious medical award for his efforts.
When Izuka saw the 9-year-old girl in the emergency room of Kapiolani Medical Center, her hand hung alongside her arm. After giving her a powerful sedative, Izuka used his hands to try and manipulate her fractured bones back into place, as orthopedic surgeons are trained to do. But this break was especially bad. No matter how much he squeezed, pushed and kneaded, Izuka could not get the fractured pieces back in place. That meant he would have to take the girl into surgery.
The girl’s father, however, refused. As Izuka recalls: “This was one of those dads who had this unreasonable fear of anesthesia. He said, ‘If you put her to sleep in the operating room, she will never wake up. She will die there.’”
The father was adamant. “He told me he’d rather leave her arm like that than let her go into the O.R.,” Izuka says. “I thought he was nuts.”
Izuka could go no further without the father’s consent. So he made sure the girl’s hand was pointed in the right direction, put a cast on her arm and sent her home. Initially, the arm healed crookedly. But as Izuka followed the girl’s recovery, he witnessed the bones begin to correct themselves. After a year, the arm had completely straightened.
The knowledge that children’s broken bones can straighten as they grow isn’t new. It’s part of a phenomenon called bone remodeling. Izuka found a handful of case studies in which orthopedists had, when conventional measures failed, let bone remodeling do its wonderful work. In every instance, the children healed perfectly. But in none of the cases was bone remodeling the first line of treatment.
Izuka realized that turning to bone remodeling first could have significant benefits. It would mean less pain for the child, it would eliminate the risks of surgery and sedation entirely, and it would consume less of the medical staff’s time. It also would cost significantly less. “I started thinking, If what I’m doing isn’t better than what nature is doing, should I be doing it?” he says.
Izuka decided to continue treating children with wrist fractures the way he treated the girl.
“For the first five or six kids, I was walking on eggshells because I wasn’t sure if maybe the first girl wasn’t just a lucky case,” Izuka says. “Maybe some kids do straighten out and some don’t. But the first five all turned out fine.” As did the next five, and the five after that.
Between 2004 and 2009, Izuka treated 51 children between the ages of 3 and 10 this way. All of them healed perfectly. He published these results in The Journal of Bone and Joint Surgery and won an award from the Pediatric Orthopedic Society of North America for outstanding scientific achievement. Other orthopedic surgeons in Hawaii and across the Mainland have adopted the technique, and three major teaching hospitals now teach it to doctors in training.
Izuka still marvels at how this all came about. “If it wasn’t for that 9-year-old girl, and if that crazy dad didn’t refuse treatment,” he says, “I’d still be straightening these things out.”
A NEW BONY YOU: BONE REMODELING
Bone remodeling is the biological process in which the body replaces old bone with new bone. Two different types of cells do the work. Osteoclasts absorb old, mineralized bone. Osteoblasts lay down new bone. Bone remodeling revamps about 10 percent of an adult’s skeleton per year. In children it works much faster. In the first year of life, it’s responsible for replacing almost 100 percent of the skeleton.
A 9-year-old girl’s fractured wrist, front and side views.
The bones were left unstraightened when the cast was applied.
After 42 days, the bones have healed crookedly.
Two years after the injury, the bones have straightened themselves.
X-Rays: Courtesy Dr. Byron Izuka
The Transplant Surgeon Who Went Out On A Limb
Getting a dangerous supplement off store shelves took urgent action by the FDA, the CDC—and one local liver transplant surgeon.
Dr. Linda Wong.
Photo: Rae Huo
By the end of last summer, Dr. Linda Wong knew something was terribly wrong after seeing four cases of acute liver failure in as many months. That was more suddenly crashing livers than Wong, the head of Hawaii’s only liver transplant program, would ordinarily expect to see in a year.
These weren’t, however, ordinary cases. The patients weren’t chronic alcoholics, they hadn’t overdosed on Tylenol, they didn’t have hepatitis B or C or any of the other illnesses associated with the life-threatening shutdown of the liver. Most of them were young, and they were either bodybuilders or people trying to lose weight.
The only thing Wong found that they all had in common was the use of a certain dietary supplement advertised as both a muscle builder and fat burner: OxyElite Pro.
On the night of Sept. 3, 2013, Wong saw a fifth patient, a young bodybuilder who had been rushed to Honolulu by air ambulance from the Big Island, his skin as yellow as a highlighter pen. When asked if he took supplements, he said he used just one, OxyElite Pro. The man was so sick, Wong expected he would soon die without a liver transplant.
“I thought, this is crazy,” she recalls. “I can’t watch people die like this.”
That night she phoned her hospital’s chief and told him the public needed to be warned about OxyElite Pro. The chief listened with interest, but cautioned her about jumping to conclusions. He suggested she write a scientific paper. Wong worried that in the time it would take to get a paper published, the human toll would soar. She decided that if the hospital wouldn’t sound the alarm, she would have to do it on her own. She told the chief she wanted to go to the newspaper. She would speak only for herself, a concerned surgeon, and she wouldn’t drag the institution into it. If OxyElite Pro’s manufacturer wanted to sue somebody, she would take the hit.
“The chief was skeptical,” Wong says. “But he didn’t say no. I took that as a green light.”
On Sept. 5, the story appeared in the the Honolulu Star-Advertiser, buried on page B5 of the business section. It was followed by neither feedback nor fallout. No reporters called for more information. No hints of pending lawsuits came her way. “I don’t think anybody read it except business people, and they probably aren’t the ones who take these supplements,” she says.
Wong had stuck her neck out, sounded the alarm, and nobody seemed to notice.
It wasn’t until Sept. 9 that Wong figured out her next move. By then she had seen seven liver patients who had taken OxyElite Pro. Two needed liver transplants or they would die. One was too sick for a liver transplant, and she did die.
It took an offhand comment from a Medicaid billing clerk to point Wong in the right direction. The clerk phoned to inquire about the sudden surge in requests for liver transplant evaluations. Wong explained, and the clerk asked, Does the Health Department know about this?
Calling the state Department of Health had not occurred to Wong, or to any of the colleagues with whom she had conferred. “When you think of the Department of Health, you think about infectious things, you think about mumps, measles, some kind of exposure,” Wong says.
But Wong’s phone call to the Health Department made all the difference. The state epidemiologist, Sarah Park, quickly launched an investigation, which soon included medical detectives from the U.S. Food and Drug Administration and the national Centers for Disease Control and Prevention. On Oct. 8, with 24 cases of liver failure in Hawaii now linked to OxyElite Pro, the Health Department asked local retailers to remove the product from their shelves. On Nov. 10, the Texas company that makes OxyElite Pro, USPlabs, issued a voluntary recall, under the threat of legal action by the FDA.
By then both local and national media were all over the OxyElite story. Two class-action lawsuits have since been filed against USPlabs, and a call for regulatory reform of the supplement industry has been issued.
Altogether, the CDC has identified 97 people in 16 states who suffered liver damage linked to OxyElite Pro, including the woman who died. Undoubtedly, this human toll would have been higher had it not been for one concerned liver transplant surgeon in Hawaii who knew she had to act.
Dangerous dietary supplements: They’re still out there
A recent article in The New England Journal of Medicine, which praises Dr. Linda Wong as “an astute liver-transplant surgeon in Honolulu,” lambastes the FDA for its delayed response in removing OxyElite Pro from store shelves and calls for sweeping reforms in how the agency monitors the safety of dietary supplements.
“This dietary supplement was recalled, but nothing has been done to prevent another supplement from causing organ failure or death,” writes Pieter Cohen, an assistant professor of medicine at Havard Medical School. “Nor have any changes been made to improve the FDA’s ability to detect dangerous supplements.”
Cohen proposes the creation of a database to document the ingredients, and other information, of every supplement sold in the U.S. He also recommends the formation of a multidisciplinary response team, which would be alerted immediately when consumers or physicians report problems with supplements.
A Mysterious Malady Afflicts Malihini Surfers
How a local doc identified a rare syndrome that can paralyze surfers on their first time out.
Dr. James Pearce.
Photo: Rae Huo
The patient was a 19-year-old Australian man, a rugby player in excellent shape, vacationing in Waikīkī with his family. He paid for a surfing lesson, practiced popping up to his feet as the board lay on the beach, then paddled out with an instructor to catch some waves, like countless tourists before him. While lying on the board, he felt pain in his lower back, but he stayed in the water until the lesson was over.
After returning to shore, his legs became alarmingly numb. By the time he got to Straub Clinic & Hospital, he couldn’t move his legs at all—he was paralyzed from the waist down.
The man had not suffered an obvious injury or big wipeout. He had paddled out in good health, and paddled back in to become paraplegic.
This apparent medical mystery was no mystery at all to the neurologist at Straub who treated the man. Dr. James Pearce had seen several similar cases since the early 1990s, so many, in fact, he succeeded in identifying the cause as a previously unrecognized medical condition, which he named surfer’s myelopathy.
Those who suffer from it are inevitably first-time surfers—and usually tourists. “Their stories are always exactly the same,” Pearce says. “It’s their first surfing lesson, they paddle out in the water, they experience back pain, they come back to the beach and there’s some component of numbness.”
That numbness can range from mild tingling in the legs to all loss of feeling and movement. In some cases, it resolves itself. In others, it’s permanent. As with other spinal- cord injuries, there is no cure.
Pearce believes surfer’s myelopathy is caused by repeated hyperextension of the back. For a small number of people predisposed to the condition, this puts a kink in an artery, blocking blood flow to the spine and causing a spinal stroke. But it would take an autopsy to confirm this, Pearce says, and since nobody dies from surfer’s myelopathy, the exact mechanism behind it remains a mystery.
“It doesn’t happen to established surfers,” he says. “It’s always people taking their first surf lesson.”
Surfer’s myelopathy is extremely rare. Only about 50 cases have been documented worldwide, and most of them have happened in Hawaii. Oddly, only two involved local residents learning to surf. This is another mystery: Why are tourists most affected?
Pearce has a theory: Novice local surfers follow the cues of experienced surfers, who sit on their boards while waiting for waves, relieving pressure on the lower back. Visitors taking surf lessons at Waikīkī Beach typically remain in a prone position, putting more pressure on the lower back. Why it happens so much in Hawaii is no mystery at all. “There’s no place on the face of God’s Earth that has more surfing lessons than Waikiki” Pearce says. “That’s the only reason I recognized it.”
As for the young Australian, he remained paralyzed for his first two days in the hospital, but eventually, he fully recovered. “He was a lucky one,” Pearce says.
Generally, the surfer’s myelopathy patients with the best outcomes are the ones who get out of the water as soon as they start to feel back pain. If they arrive at the hospital paralyzed, they usually remain paralyzed. Pearce’s advice for surfing newbies? “If you go out for your first surfing lesson and develop back pain, don’t stay out in the water,” he says. “Get back to the beach.”
A Severe Asthmatic Regains Her Breath, And Life
Relief comes with the help of a bold new therapy and a doctor willing to try it.
Patient Jennifer Purcell and Dr. Warren Tamamoto.
Photo: Rae Huo
Jennifer Purcell hated being a sickly grandmother. She hated being in such poor health that she couldn’t take her three young grandsons on outings to the park, the movies or Chuck E. Cheese’s. But her asthma had gotten so out of control in the last decade that doing the simplest things could set off an attack.
She couldn’t even shower anymore without wearing her ventilator, because water vapor would send her into convulsive fits of coughing and wheezing.
It got so bad she would barely leave the house, unless it was for a trip to the emergency room, where she had become a regular. Sometimes even the E.R. docs couldn’t get her tortured lungs under control, and she ended up staying in the hospital, once for three weeks.
The multiple and powerful medications Purcell was on were no match for her twitchy, inflamed airways. Her prognosis was as grim as her daily life had become.
“I felt imprisoned, lonely and frustrated, always gasping for air,” she says.
Desperate for improvement, she ended up doing something that doctors universally abhor: While watching TV she discovered a brand-new therapy that looked like it was made for her.
It’s called bronchial thermoplasty, and it is the first non-drug treatment the Food and Drug Administration has approved for severe asthmatics. Using the heated tip of a catheter, it works by gently burning away a thin layer of smooth muscle lining the bronchial tubes, reducing their ability to constrict during an asthma attack.
At Purcell’s next appointment with her pulmonologist, Dr. Warren Tamamoto, she asked about the treatment. “Right away, he had that look—Oh no, another patient watching those medical TV shows,” she recalls. “He made it very clear that he’s not one to jump on the bandwagon of every new procedure.”
Tamamoto, who is chief of pulmonology at Kaiser Permanente Moanalua Medical Center, knew all about bronchial thermoplasty, including the uncertainty over its long-term safety and effectiveness. “It’s new and very different,” he says.
Before introducing it into his practice, he wanted more evidence that it didn’t produce scarring or some other harm that would only show up years after treatment, leaving patients in worse shape than they started.
Purcell’s timing was perfect. Not long after asking Tamamoto about bronchial thermoplasty, a study was published that followed patients for five years after treatment. It found the benefits of the procedure held up, with no unforeseen side effects. With the five-year data in hand and a qualified candidate eager for the therapy, Tamamoto began bronchial thermoplasty on Purcell in October. “She was the right patient at the right time, with all the indications that she might benefit,” he says.
The treatment is broken into three sessions separated by several weeks. One of its drawbacks is that a patient’s condition may initially worsen. This happened to Purcell, who came down with pneumonia after each of the first two sessions. A couple of weeks after the final session, though, something marvelous happened. “I woke up in the middle of the night, and I was lying there thinking something’s different,” she says. “I couldn’t put my finger on it. Then it hit me. I wasn’t wheezing. It was so quiet.”
Purcell’s quality of life has improved markedly. Although she is not cured, and she must still take medication, her asthma is back under control. She is able to do things she hasn’t done for years. And her grandsons now go on regular outings with their grandmother.
“I didn’t want my grandchildren to remember their grandma as the one who was always sick,” Purcell says. “It’s so heartwarming for me to know that when they see me now, they know we’re going to go out and do something. They know we’re going to have fun.”
By the numbers: Bronchial Thermoplasty
Year the FDA approved the use of bronchial thermoplasty for the treatment of severe asthma.
Year that Medicare and Medicaid agreed to cover the cost of the catheter used in the treatment.
Temperature the tip of the catheter is heated to, in Fahrenheit. Also, the approximate temperature of a cup of coffee.
Average decrease in severe asthma attacks in people who underwent the therapy, over five years.
Average decrease in emergency room visits, in the same time period.
Bronchial thermoplasty uses the heated tip of a catheter to destroy a thin layer of muscle lining the lung's airways.
Rendering: Courtesy Boston Scientific Corp.
The Hypnotist in the O.R.
A retried neurosurgeon describes his most interesting case ever.
Dr. Maxwell Urata.
Photo: Rae Huo
In his long career as a neurosurgeon at Kuakini Medical Center, Dr. Maxwell Urata saw plenty of amazing cases. But ask what his most amazing case was, and he immediately goes back to a surgery he performed in 1979. The patient was a chiropractor who had previously worked as a cop on the Mainland. Before giving up police work, he had been shot in the line of duty. He had two bullet fragments still embedded in his neck, and he wanted Urata, who is now retired, to remove them. The man did not, however, want anesthesia. Instead, he wanted a hypnotist.
Such a thing had not been done at Kuakini before, and it took the hospital’s administration six months to grant approval. In the meantime, the patient worked extensively with a psychologist who was trained in hypnosis.
On the day of the surgery, the hypnotist was at the patient’s side as he was administered a local anesthetic to block the pain where Urata would make the incision. The patient was fully alert and talkative throughout the procedure. Urata kept him in a seated position to help reduce bleeding. Urata also administered epinephrine, which constricts blood vessels, to reduce bleeding. Still, there was blood, and the hypnotist—to Urata’s chagrin— was quick to point this out.
“That was not particularly complimentary of me as a surgeon,” Urata says. “But it was an honest observation.”
Then, as Urata recollects, the hypnotist said to the patient: “OK, do you recall how we practiced reducing bleeding in the neck area? Now is the time to do that.”
Urata was dubious. Fat chance, he thought.
But remarkably, the bleeding suddenly stopped. The patient’s blood pressure remained normal, but the oozing from the wound simply ceased. “It was as if a faucet had been turned off,” Urata says.
Next Urata focused on locating the bullet fragments. He found the first one easily and removed it. The second one eluded him. The patient realized Urata couldn’t pin-point the fragment, and, as Urata recalls, he said: “Doc, put an instrument near where you think the bullet is.” Urata did. “Go five millimeters to the right.” Urata complied. “A little bit more.”
“When I spread the connective tissue the bullet came into view,” Urata recalls. “This in its own way was just as mystifying as the first event.”
The patient spent the night in the hospital (this was 1979) and went home the next day. Three days later, he got married and—“against medical advice,” Urata says—went on his honeymoon.
“This was my most interesting and fascinating case,” Urata says.
A Brief History: Hypnosis in Surgery
The first documented use of hypnotism in surgery dates to the 1830s, when a French surgeon performed a mastectomy using hypnosis as the only anesthetic. Twentieth-century physicians paid little attention to hypnosis until 1956, when the British Medical Association declared: “(T)here is a place for hypnotism in the production of anesthesia or analgesia for surgery and dental operations, and in suitable subjects it is an effective method of relieving pains in childbirth without altering normal course of labor.” Interest in hypnotism among surgeons has waxed and waned since then.