Dirty White Coat
Mel Herbert, MD, and the creators of EM:RAP, UCMAX, CorePendium, and the collaborators on "The Pitt" and many of the most influential medical education series present a new free podcast: “Dirty White Coat.” Join us twice a month as we dive into all things medicine—from AI to venture capital, long COVID to ketamine, RFK Jr. to Ozempic, and so much more. Created by doctors for clinicians of all levels and anyone interested in medicine, this show delivers expert insights, engaging discussions, and the humor we all desperately need more of!
Dirty White Coat
ER Doctor Transitions to Ketamine Therapy: Founding a Clinic and Transforming Mental Health
Mel Interviews Sam Ko for an enlightening episode where we explore the extraordinary journey of an ER doctor who switched gears from the chaotic world of emergency medicine to the innovative realm of ketamine therapy. Gain insights into how medical podcasts influenced his path, ultimately leading to the first ER doctor-led ketamine clinic in California. This episode promises a deep dive into the transformative impact of ketamine clinics, the challenges of leaving traditional ER careers, and the successful expansion across the nation through online education.
Our guest shares the meticulous approach taken in his clinic, which blends medical precision with holistic elements for an optimal therapeutic experience. Hear about the importance of setting intentions, the safety measures during administration, and the unique process of integrating music and aromatherapy. We discuss the nuances of different ketamine administration routes, with a special focus on the benefits of intravenous therapy, offering listeners a comprehensive understanding of this emerging treatment and its emotional breakthroughs.
Venturing beyond ketamine, we tackle broader topics such as the necessity of personal experience in psychedelic therapy and the historical and legal landscapes that shape it. Delve into the psychological underpinnings that draw some to high-adrenaline careers like emergency medicine, with reflections on how childhood trauma might influence such career paths. This episode is packed with compelling narratives and expert knowledge, offering a fresh perspective on the evolving world of mental health treatment.
um yeah, so I've been following your work for a long time, though I'm sorry that must. You might need a cat scan yeah, so back in the days when I was in residency, uh, loma, linda university, oh, yeah, yeah, I would. Um, I considered you one of my professors because I, you were always in my, in my airpods or I guess that was pre-AirPods but whether I was in the car or on the phone, just always listening to MRAP you, rob Borman, scott Wangard, joe Lex, greg.
Speaker 2:Henry.
Speaker 1:Yeah, yeah. What were you there? I was there from 2008 to 2011.
Speaker 2:Right, yeah there then still is yeah, lance brown is, was there.
Speaker 1:I think he was the chair of the pede side and now he's like vice chair he's. He's moved on, moved up in the rankings. So, yeah, lance brown, and I think emily rose yeah, she went, she did her pdm fellowship at loma, linda, and then went to usc.
Speaker 2:Yeah, yeah, she did residency at usc, peds fellowship at loma, linda, back to usc as faculty yeah and then I think, she was on mrap a few times too. Yeah, she's been on mrap a lot we've used her over the years and board of you and all that stuff. Emily is just like the most wonderful person.
Speaker 1:Yeah, yeah, very cool. And then we, you and I, actually met, we at La Quinta, at a Cal ASAP conference.
Speaker 2:Really, when was that Way back in the? I think it was a long time.
Speaker 1:It must have been a long time. I think it was like 2008. Yeah, I think it was 2008 or 2009. Anyways, I'll send you a picture that we took. Oh, that's good. You were talking about what was it called Like the lap band? I think that was the talk about lap band and how to deal with the complications associated with that? I don't know it doesn't seem familiar.
Speaker 2:Usually I do cardiology shit.
Speaker 1:Yeah, but anyways, thanks for all of your work. I'm so happy to be able to connect with you and I'm looking forward to it.
Speaker 2:Thanks for doing this. Yeah, I'm just doing a. I started a new podcast because there's all these controversial topics and stuff that people get pissed. When we talk about them on MRAP, they're like we don't want to talk about that soft shit. Talk about them on mrap, they're like we don't want to talk about that soft shit. So, whether it's politics or it's ketamine, whether it's sort of um jfk, whatever, the fuck it is.
Speaker 1:So we just rfk yeah, rfk.
Speaker 2:Thank you, um. So we decided to do a new podcast and we've only done two of them so far and they're really popular, people really like them. So I wanted to talk about ketamine. So I just interviewed a PhD in North Carolina about my experience and how she selects patients. But then I think your spin will be maybe we can focus a little bit on what you're doing as an ER doc and then how to get into it, if that's what people want to do and you know just sort of talk about the business aspects of it and the training aspects of it. I was saying to her I've given ketamine a thousand times but I don't know how to do a ketamine clinic for depression, PTSD. I don't know what the fuck I'm doing. I mean, I lower the dose. Okay, that's not very helpful. So that's what I want to talk about.
Speaker 1:Yeah, it's a little different. So I mean for me and my background. So I did residency finished, worked at, you know, the community hospitals and assistant professor, I was an associate medical director and I had to make a decision of whether to start up Academy and Clinic in Palm Springs or be the medical director of an ER director of an ER and I was like, okay, which? Which way do I choose? You know, do I follow my heart or do I go this down this traditional path that had been, you know, laid out? And I took a leap. Man, I just said you know what, if I'm 80 years old, I'm going to take a. I'm going to regret not having taken this opportunity. So I took the leap. I opened up the clinic in 2018.
Speaker 1:I was actually, I'm the first ER doctor to have ever opened up a ketamine clinic in California. And this is like back in the days when it was, you know, even more controversial and yeah, there's just been I was doing part-time ketamine clinic, part-time ER, and then later I started getting all these other EM folks hey, sam, how do I open up a ketamine clinic? So I helped up, you know, several colleagues and then eventually I started a online course which is like synchronous and asynchronous training, and so far we've helped 16, 17 clinics open up nationwide. And then we started the podcast recently, which is one of the reasons why I wanted to reach out to you, because when I heard you on Rob's stimulus podcast, like you mentioned ketamine I'm like what Mel ketamine? I was like I got to get him on our podcast.
Speaker 2:Go back then. I'm interviewing you right now. We're recording this. How did you get into ketamine? So so you're an er doc, you're doing the thing, you're nights, weekends. Why ketamine? What happened? Uh, tell us that story. How did you start getting into ketamine as a non-er doc? You know, as er docs, we use it all the time.
Speaker 1:But yeah, so loma linda was one of the first institutions where they were using ketamine for procedural sedation. They published like the landmark article in 1990. Steve Green Steve Green, analyst of emergency medicine Like yes, it can not only be used in the operating room but we can use it in the EDs. So in my residency I was using ketamine all the time for patients and procedural sedation not only peds but for adults. And then I came across a really fascinating article where they were using ketamine for suicidal ideation and I was like we got all these patients who are on 72 hour holds and we're kind of just babysitting them until they get transferred to a psych facility.
Speaker 1:So I started doing a deep dive into the research of like hey, what is this drug that we're using all the time for sedation and how can it be used for mood disorders? And because I was familiar with it, I'm like, you know, I think I'm gonna open this clinic up. And I had initially, kind of in the brainstorming phase, worked with another ER doctor and an anesthesiologist and we were, you know, the three of us were like hey, let's start this up and we're gonna open up in loma linda and and it just kind of fell apart. I mean it wasn't not the right partners for the business, so kind of put it on the back burner and then went back to it with my wife, who is she's an ophthalmologist and she's like, hey, sam, like let this, I can help you, and at least as far as like administrative, creative director, marketing, and so we open it up.
Speaker 1:But I would say you know, there's that saying, I think Steve Jobs and his commencement speech at Stanford. He's like you can't really tell how the path is going until you look back, until you see it retrospectively. So I look back on my life and I was giving ketamine to animals back when I was in college. We were doing various procedures and then emergency medicine we're super familiar with ketamine and then the residency where I did my training just use ketamine all the time. And you know I've always been kind of an entrepreneurial guy as well. I have an MBA.
Speaker 1:So I was like you know what I want to do something where I can really leverage my business skills and it just kind of coalesced into this ketamine clinic. It's a reset ketamine and now, like, looking back, I'm like this is what I was meant to be doing, like I love my job, like I literally it's one of the most gratifying things I've ever done, especially seeing patients who have tried SSRIs, they've tried ECT, they've tried TMS, they've tried you know all sorts of stuff, and to be able to offer them relief. It's so gratifying, literally it's. It's just, it's nourishing, it's spiritually nourishing, whereas in the ER it's a little bit different.
Speaker 2:I mean, it's not as spiritually nourishing as you and I both know. So tell me that first clinic who were you looking after? What type of patients Did you have? A narrow focus, broad focus? And then, how did you get the word out? Like I have this clinic on the corner, because it feels to me like I only discovered ketamine when I was failing SSRIs and I'd heard a little bit about it. But it seems that now that within a very short period of time the neuropsychological effects, neuroplasticity effects, the antidepressant, PTSD effects of ketamine sort of have exploded, Now everybody knows about it. So how many?
Speaker 1:years ago was that clinic and how did you first get your first patients? Yeah, so we first opened in 2018 and it was very slow. The first three months, I think, I did four treatments, the entire like month and typically the standard treatment is six sessions over a period of roughly two to three weeks, as far as the research goes, but it was very slow. Um, literally like google search engine optimization. Um, people were just looking. They were looking for it for themselves. I even I thought I was going to get a ton of patients, so I sent out letters to all the local psychologists and psychiatrists and internists.
Speaker 1:Ob-genyns didn't get any leads or referrals because it was too controversial. This is seven years ago now very controversial. So it was very slow, which meant I worked part-time in the ER and I did part-time ketamine clinic and then, over time, just word of mouth, people knew about it I started getting more referrals and it just grew and grew and grew and then finally, in December 2020, and that was we had our daughter in 2020. So it was just a good transition point where I worked in the clinic or, excuse me, in the ER for about a decade and I was like you know what? I think it's ready, for you know it's time for a change, especially with COVID and all of the stuff that was going on with the pandemic, like I just needed to transition out.
Speaker 2:Wow. So what were your initial patients and maybe you can summarize the literature?
Speaker 1:The early, the first patients that I saw they were mainly treatment resistant depression patients that I saw. They were mainly treatment resistant depression and that's where there's the most robust data.
Speaker 1:Um, and even now there's like new england journal of medicine, there was a recent publication looking at ketamine iv versus ect, electroconvulsive therapy, and what they found in the study that was published, I believe, october 2024, 2023, and they found that it was just as efficacious as ECT and maybe even more effective. So initially we treated treatment resistant depression, ptsd, anxiety, ocd so mood disorders and then we also got into the pain syndromes, so specifically like fibromyalgia. We also got into the pain syndromes. So specifically like fibromyalgia, complex regional pain syndrome, also known as reflex sympathetic dystrophy, trigeminal neuralgia, so nerve or neuropathic related pain conditions.
Speaker 2:So that study you're talking about is ketamine versus ECT for non-psychotic treatment resistant major depression New England Journal, which was in May 24th 2023, and found it to be non-inferior and we'll go into this article in more detail later, but I just wanted to timestamp that. So you're using ketamine for pretty traditional therapies, so can you tell me what does it look like when I go to your ketamine clinic? I want to sort of compare and contrast, maybe with my experience. So what I did is I was failing SSRIs. I went to my primary care doc. There's a much longer story there.
Speaker 2:I was suicidal, it was fucking horrible. And I went to this group at UCLA and I basically said look, we have a private clinic and a public clinic. I decided to go to the private clinic and they basically take you to the nice little room in an office. There's a doc there, there's a therapist there, you do therapy, we did I am ketamine six times over six weeks. So how does it look if I go see Sam? Do I have different options? Do I have different routes? Do I have different schedules? What is sort of the best schedule? Do you change it depending on the patient?
Speaker 1:Yeah, thank you for that. So I think of ketamine therapy at our clinic in four phases. The first one is preparation, the second phase is intentions, the third phase is experience and the fourth phase is integration. So by preparation, specifically one week before their first ketamine session, we give them a bunch of exercises to do and I understand they're in a challenging place, they may not be able to do, you know, journaling or exercise or getting adequate sleep, but as best as possible, kind of preparing the mind. The next phase is the intentions.
Speaker 1:So this makes our clinic a little bit different. Where I have the patient I say what do you want? What's your definition of success? What's your goal for ketamine therapy? And that's what the patient focuses on during the experience. So, for example, someone's intention can be letting go, forgiveness, love, loving myself, healing my inner child. You know, and everyone has their own intention and we do a little bit of coaching to decipher exactly what that intention is.
Speaker 1:Next is the experience. So the patient comes in. We do it very safely, like, almost like procedural sedation, icu level of monitoring where I'm looking at their O2 sats, I'm looking at their cardiac rhythm, blood pressure, q10 minutes, respiratory rate, and so it's continuous vital sign monitoring. We have oxygen available and we add in kind of a holistic approach, because we are in California, we're in Palm Springs, so we got the woo-woo factor, some really calming music, including beta waves, binaural beats. We do offer aromatherapy lavender, sage, orange, whatever it is because the sense of smell is really a powerful sense that we want to take advantage of and leverage.
Speaker 1:And then so they'll have the experience which, as you know and I'm really curious to hear about your personal experience you know, I call these non-ordinary states of consciousness, nosc, where they may have memories or emotions. You know, like I've had patients cry like literally we give them eye shades and some patients, like, each time this eye shade is just like drenched in tears that have been held for 10, 20, 30 years. And then they'll have the experience and we tell them to go with the experience. I use this metaphor it's like, hey, if you're doing a whitewater river raft or rafting class five rapids, you're not going to control that river, so you just kind of go with the flow, witnessing, breathing, surrendering, allowing, once the experience is done, which is roughly a 40 minute infusion.
Speaker 1:So it's a little bit different because when I use it in the ER it's, you know, rapid, you know fairly rapid push one to two megs IB over one to two minutes, whereas with the ketamine clinic it's 0.5 milligrams per kilograms infused slowly over 40 minutes and with each session we will gently titrate that dose up, so it might be 0.75 the next time, or 0.9 mg per kg, the next time 1.1 mg, you know, and everyone has a different tolerance and threshold. And, yeah, the infusion will be completed. I give them 10, 20 minutes to recover and then I'll have a debriefing session post infusion and so kind of like talking about what their experience was like. And I'm not a psychotherapist, so we're not doing psychotherapy, but I am curious to learn and to help them process their experience and create a meaning from it within with an action post infusion, something that can they can actually do how do you?
Speaker 2:why did you choose iv? It has been given. Uh, mine was im iv. I am sublingual, I mean orally. You can do it lots of different ways. Do you do it iv every time? Why did you?
Speaker 1:choose that I do, it be 99.9% of the time. So the beautiful thing about IV is it's 100% bioavailable. So if I put in 45 milligrams, like I know, 45 milligrams is going in the other routes of administration. I am, for example, um it's and some studies are showing this that it can be, you know, quite effective. But the bioavailability is lower depending upon the patient's. You know body mass, if they have more adipose tissue or muscle, or you know it could be variable absorption and then the other routes of administration also lower bioavailability. So like sublingual it's, you know, 20, 30% bioavailable, but like sublingual it's, you know, 20 30 bioavailable.
Speaker 1:But I would say the most important thing about the iv for me at our clinic is I can stop it at any time. Right, so it's a slow infusion if the patient is having something come up an adverse reaction, a panic attack, anxiety, severe hypertension, because I've seen that like I can stop the infusion, whereas with the other routes I am in particular like once it's in, can't get it out. So uh, the yeah, it's a hundred percent bio, bioavailable, we can stop at any time and I have the advantage of having an IV now. So if they need a little bit of midazolam if they need a little bit of on dance a drawn if they need you know other. You know some Toradol for headaches like I, have access that I could treat. If they need some blood pressure medicine, maybe some labetalol like I, have a ton of options available with the IV. And I guess you know, if you look at the research and the science, like 95% of the research is doing it intravenously.
Speaker 2:So what does that clinic physically look like? Again, again, my experience was in a nice couch with a comfy blanket and some beautiful music, but very non-medical. Felt very much like I was in somebody's lounge room and I was chill. Um, what you're describing sounds a little bit more like it's in an office, a clinic or an ear. How does it look and how do you get rid of the noises and the crap that we do in the ear?
Speaker 1:Yeah, it's a great question. So ketamine is unique in that, especially the way we're doing it. I refer to this as the set and the setting. So anyone in the psychedelic space may be familiar with this. Set refers to mindset of the person receiving the ketamine and then the setting, the environment. So we pay really conscious attention to this. So specifically when the person is coming in, like you know it's, it is kind of a clinical setting.
Speaker 1:So I'm blending in like allopathic, traditional vital sign monitoring mix per gigs. We make it really safe. We have o2 tank available, you know, on the emergent aed, like anything like we're. We're like really honed down on that. But then we add in kind of like a eastern approach, a holistic approach, where we're doing the intention setting, the rituals, the music, the eye shades, the aromatherapy, the debriefing, setting the lights in a different temperature and tone. So all of these little factors to make it less clinical. Now what's interesting is I have given ketamine IV in the ED for someone with suicidal ideation. This was before I opened the clinic and I was like doing a deep dive into the data.
Speaker 1:I was like, huh, hey, charge nurse, do you mind if I use room nine to give a ketamine infusion? And so we administered it to this patient. She didn't quite meet the criteria for 5150, but I realized that the set and setting of an ER, especially a chaotic ER with a lot of other stuff going on, is not the most optimal place. So, knowing that the clinic, it's kind of the opposite of that, it's very calming, it's very relaxing. We take our time with patients. It's not like a bunch of patients, you know, hey, there's a patient in room three. They're screaming and yelling. It's like, no, everything is calm and mellow. Because I know that's going to impact the patient's experience.
Speaker 2:Right, yeah, in the ERs we'll often see people have a bad trip in quotation marks and in large part that's because the ER is the worst place to do something like this, because it is chaotic and it's loud and there's noises and you can't control the setting and when they wake up they might see somebody vomiting or dying. So that's probably why we see a lot more of these emergence reactions than in the clinic literature. So where are your clinics? Are you sort of in the mall, or where do you physically put them? I mean, I know that there's really high winds in ones that are basically in Malibu in $10,000 a night hotels. How does yours look?
Speaker 1:hotels. Uh what, how does yours look? So ours is. Well, the first one I had was a very small location, about 700 square feet, so super tiny, and a really quiet place in Palm Springs, about five minutes away from the airport. Um, the one I have now, because we did grow in transition out of that clinic, the one we have now, it's actually in a medical office building with probably 10 to 20, maybe 30 other physicians and clinics and, um, our space, the one we lease, it's, you know, kind of separated so they'll come into the medical looking environment of the building, but then once they come in it's like a completely different vibe. We have, you know, the whole green wall and the lightings and comfortable couches. So it's, it um's a medically professional looking place. And what I love about our place is right next to it is an emergency department, so there can be emergencies that occur and if anything does occur like, all right, three minute drive, the ambulance two minutes it's literally a block away.
Speaker 2:Yeah, the beautiful thing about ketamine is it is such a safe drug, but, as we know, no drug is completely safe. So I love this mixed model that you talk about. So now you're gone from doing your own clinics to training people to go and make their own clinics. So here's Mel Herbert. I'm very comfortable with giving ketamine from the medical point of view. I don't know how to set up a clinic. I don't know how to do the financing, I don't understand the laws and I'm not a psychologist. So how do you take me from Mel Herbert, who knows how to give ketamine, to relocate your shoulder to Mel Herbert that could actually successfully run a clinic?
Speaker 1:So for me anyone who's an emergency physician we wear many hats and we have the skillset, I believe, to create a business. The biggest challenge, as you and I both know, mel, is that ER docs we're not, and doctors in general we're not taught the business side, whether in med school or residency. Like we're taught the clinical side but no one teaches us, hey, how do I get an authorization for X, y, z, or how do I bill properly, how do I order gauze or syringes? So the course that we have, it's ketaminestartupcom, it's a 12 week course and it's essentially the roadmap or blueprint for an emergency physician who is interested.
Speaker 1:And we just walk you through, like, hey, don't reinvent the wheel, man, like we already did it. I already made all the mistakes. Let me just share with you what I've learned and yeah, I would say that because, again, of the many hats that we wear as emergency physicians, like creating a clinic, it's totally within your wheelhouse and it's something that you can do and there's nuances, right. And so how do, how do I learn anything? Well, I just learned from someone who's done it before and that's the skillset. It's like, yeah, let me just transfer everything I know, put it from my brain and transfer it to your brain with repetition and practice brain and transfer it to your brain with repetition and practice.
Speaker 2:How much does it cost, like what's the financial outlay to do a sort of a small to moderately?
Speaker 1:sized clinic? Good question. I think it depends on location. So if someone's going to open up one in New York City, manhattan, right, that's going to be a very different cost versus, hey, if you're going to open one up in Nebraska, for example, right, so there's the cost of living in space malpractice insurance. So I'll preface my answer with saying that there's a ton of variability depending upon geographic location.
Speaker 1:If I had to put a hard number on it, I would say anywhere from 75K to 150, 50 K initially for the build out process and of course, you want to have some money set aside to pay rent, insurance, staff et cetera. You know we call this the runway, just in case it is slow, cause typically what I've seen with our other students, like it can be slow, especially if you're opening up a you know a clinic. It's like, yeah, people may not know about you, it takes time for Google SEO to pick up your clinic's website and stuff. So anticipate that and don't have a huge overhead, but keep things lean. Maybe continue working part-time in the ER or doing whatever you're doing clinically. Have that financial stability as the clinic volume ramps up.
Speaker 2:And what do you think? The utility of hiring a trained psychologist versus just the experience itself, maybe a little bit of extra training versus having somebody that does this for a living outside of the ketamine?
Speaker 1:Yeah. So we find that some clinics are actually doing this where some of our students they're like one guy, he's an anesthesiologist and he partnered with the psychologist and they co-created the clinic together. So that's also known as ketamine assisted psychotherapy, where they're getting the ketamine and then they're engaging actively in a discussion with the psychologist or therapist. So that is one model of how to do it. At our clinic we do it a little bit differently where I'm doing higher doses of ketamine. So they're getting pretty not fully dissociated, but quite dissociated, sub dissociated, where they're not really engaging or talking like we want to go deep, we want to hit the NMD receptors hard when to get as maximal effect.
Speaker 1:But what I do recommend and I call it, refer to this as the integration is like have an appointment with your therapist or psychologist 24, 48, 72 hours post infusion so that the things that have come up during the experience can be processed with, you know, the therapist. So I think it can work both ways, where you actually have someone in-house or where you outsource it, maybe even hire them as an independent contractor. But I don't think it has to be done within that same time period, and the reason being is neuroplasticity of ketamine. It's not just during the infusion, but it's 24, 48, 72 hours, and we're going to take advantage of that time period, yeah, so you brought up a really good point hours, and we're going to take advantage of that time period.
Speaker 2:Yeah, so you brought up a really good point. There's the effects of ketamine, which are neurochemical, neuroplastic, separate from the therapy. I did ketamine-assisted psychotherapy so I was with a therapist before, during, after and I found that very useful. I don't know yet. We're going to, in our next interview, be talking to a group that does ketamine-assisted psychotherapy. About what's the literature? How much of both do you need? What do you do if it's mostly PTSD or if it's depression or if it's childhood trauma? How do you define which way to go? Do you have any opinion on that? Do you like ketamine's going to help everybody? Maybe some people need psychotherapy.
Speaker 1:I don't know, I don't think it helps everyone. The studies are showing anywhere from 60 to 80% benefits and in particular with, like you know, measurement instruments PHQ-9. So, all right, here's the way I look at it. The initial studies on ketamine were done in the rodent model, so rats and they have models of depression in the rodents and one of them is called, like, the forced swim test, where if a rat is not willing to swim as long and they just put them in a tub and they're like, well, how long is this rodent going to swim for? And the longer that they're willing to swim is associated with less depression, right, and if they give up swimming, then that's like more depression.
Speaker 1:So these rats were not getting psychotherapy, they were not getting um counseling pre and post. So we know that even without the therapeutic, without therapy, like, it's still beneficial because it's creating changes in the brain. Now, adding, because we know we're not rodents for the human, adding that psychotherapy can be beneficial. I don't think there's been any studies comparing directly head to head, but what I would say is that ketamine, independently, with or without psychotherapy, can be quite robust and beneficial for the patients.
Speaker 2:Those rodent studies. I find so funny that we've decided that the rat continuing to swim must be because he's not as depressed. I want to live. It's an interesting model where the literature that I first read about was basically giving single dose ketamine for another procedure in somebody that also happened to be suffering from depression, who then later came out of that after having the procedure done, going. Oh my God, I've not felt this good in years. And so there was clearly an independent effect of the ketamine itself. Then it wore off, and that's when we realized, oh, one dose isn't enough. So tell us about your dosing schedule. One dose, fine, for a few days or a week, but where are we right now with how many doses to have a more prolonged effect?
Speaker 1:Good question. So the initial studies were one dose and then they were like, yeah, it's kind of wearing off. So the standard it's six sessions and there's two studies. One study did it three times a week, so Monday, wednesday, friday. Monday, wednesday, friday, week two. And then other studies are showing twice a week for three weeks and then even more recent data is showing once a week for six weeks. So there's kind of two phases. There's the initiation phase, which is the six sessions, and then, after the initiation phase, maintenance phase, which are kind of look like booster sessions, maybe rough, every one to three months depending on the patient. Some patients need it more frequently, some patients need it less frequently.
Speaker 2:Yeah, I did the once a week for six weeks and then, a number of months later, did two more sessions and I wasn't aware of what the literature was. I just went with my team and for me that worked great.
Speaker 1:Yeah, so we're seeing some patients who just do the initial six with complete remission, and then other patients are getting, you know, monthly or every two months, boosters for maintenance. But I kind of think of ketamine in a way as a catalyst. So doing the initial six and then using that activation energy, if you will, to make the changes that one needs to make or gain the insights or the ideas, so I think that's really important. So it's a little bit different in how I approach it. It's not like, hey, everyone needs to do it and you need to just need to do this for the rest of your life. It's like, well, maybe we need to, you know, engage in psychotherapy If someone's like you know previously not doing it and then don't get back into it. Or maybe even using various antidepressants Like I've had patients where they're like, yeah, that didn't work for me, that Prozac or Welbutrin, and then after the ketamine therapy they will restart one of these other meds and it's like, yeah, actually now it's working.
Speaker 2:Tell us about the legalities of ketamine. Does it differ from state to state? Can anybody get it? Do you have to have a physician's license?
Speaker 1:How does that work? Yeah, so ketamine is schedule three per DEA regulations, meaning it's a controlled substance. So the DEA just for folks listening, there's, you know, dea schedule one, which is like illegal and not allowed to use, only under research settings, schedule two, which is like hydromorphone fentanyl, and then you got schedule three, which is lower risk, and then there's schedule four, which is even lower risk, and schedule five. So it's kind of in the middle, meaning the legality. There's a bunch of DEA regulations that one needs to abide by to act.
Speaker 1:To actually order ketamine you need to have a DEA license, so that can be a nurse practitioner, a physician assistant, it can be an MD, so someone with an active DEA license that is allowed to prescribe controlled substances. And then just keeping it secure, because you don't want the DEA come into your clinic and like, hey, how many milligrams or how many vials do you have left and not have an adequate record keeping of that. And then the other important thing to consider is it's not just the ketamine but it's about who can own a medical clinic. So, for example, in California we have the corporate practice of medicine laws, meaning that if you're not a physician you cannot open up a medical clinic, whereas in Florida state, for example, like anyone can open up a medical clinic. They don't have to be a licensed professional, so they would have to consult with their lawyer of like who can actually open up a medical clinic in my state.
Speaker 2:Have you had personal experience with ketamine? Some clinicians we talk to say that we think everybody who's giving ketamine should have used ketamine and others like no. I don't think that's true. Not everybody that has needs to do that. So where do you stand?
Speaker 1:I think it's important. I see arguments for both sides. So the people who argue, hey, anyone who's administering this drugs that psychoactive needs to experience it. Well, does every doctor who gives IV Dilaudid need to experience IV Dilaudid or Versed Like that's psychoactive, or can they give it knowing that it can help? And then the other argument is like well, these people are having the psychedelic, non-ordinary state of experience, state of consciousness. The provider should know how to do it or know what the experience is like. So I can see arguments for both. But to answer your question, yes, I have, and not only ketamine, but I've had some experience with various other substances that have been pretty mind blowing. And it's, it's transformational, really, and in the right set and setting, with the right intention, I think it can help a lot of people yeah.
Speaker 2:So I come down on your side of the argument, in fact, most people here. I think that, um, it's helpful because it is such a different experience. I mean I wish I had have had ketamine at the beginning of my clinical career to explain to people who are getting ketamine, even in the here's, what this is going to be like, and I couldn't tell them because they would just tell me afterwards wow, I can't explain what just happened, like I know it's such a bizarre state. Now, having done it, I could be much better physician to them. So I think there's an argument there. But I also agree you don't have to have kids to know how to look after kids, and you don't have to get drunk to know how to look after somebody who's drunk. But I think it's probably a very powerful and useful thing to do in the right setting.
Speaker 2:And so maybe one of the last few questions is you talked about different agents. So we've got psilocybin, we've got LSD, we've got MMDAs, we've got a litany of drugs. What's the best one? We're using ketamine, in my mind, because it's available, and again I hear arguments on both sides Well, it actually might be one of the best, versus it's not really the best, but it's available, so we use what we've got. Where do you stand on this argument?
Speaker 1:I've been thinking a lot about this question and for me, I think about medicine and I think about pneumonia. So let me explain this to you. So, if someone has pneumonia, well, what antibiotic am I going to use? Does everyone get Zosyn and bank, or do I need to? You know, consider, you know, a different, maybe it's, maybe I need to do an antiviral, maybe I need to do an antifungal. So I don't know if there's one best right, like there's not one best antibiotic for pneumonia.
Speaker 1:It really depends on you know what type of pneumonia I'm treating, right. So same thing with mental health. It really depends Ketamine may be effective for that patient or they may need another medication. Maybe they do need MDMA or psilocybin or 5-MeO-DMT or ayahuasca or salvia divinorum or nit nitrous oxide or propofol or the 10 to 20 other medications that are in FDA. So I don't think it's one, but rather it's one tool amongst many tools, and let's figure out which one it is for that patient.
Speaker 2:Many of the ones that you listed are not legal and that's why they're not being used. So, um, that's for people who are sort of the lay public listening. There's one reason that we're not using a lot of these is because they're not legal. There's not necessarily logic behind that, um, because, as we know, we've talked about on this program before, a lot of these drugs were being used, um in the 60s, 50s, and then there was sort of this political things like we should get rid of all of them. That's bad, instead of studying them and deciding, like you said, sam, who should we use it, in whom We've lost basically 30 to 40 years of time to work out how to use these drugs and now we're only now coming back like, hang on a second, we should be studying these. So that's why I think ketamine is being used so much right now is because it's legal and many of these other very powerful agents are not.
Speaker 1:A hundred percent and so you know for the listeners. What happened was in the 1950s and 60s. There was a ton of LSD research happening but then it got leaked out into the public. You may have heard of a Harvard educated professor named Timothy Learyary and he wanted everyone on lsc.
Speaker 1:You know he had the ones saying like tune in, drop in, drop out. And that created this political backlash where richard nixon was like, hey, these people who are doing lsc, like they don't want to go to the vietnam war, like we need to quash this. And so then the controlledance Act came in 1970 and it shut down everything. It turned it into a schedule one illegal drug. But I will say the research was paused for about 30 years and then there are things changing and there's laws changing. So, for example, in Colorado, psilocybin is legal. In Oregon State believe it's legal. Um, people can. It's not as accessible. But in other countries brazil, costa rica, peru, colombia, etc. Uh, australia or, excuse me, I don't know about yeah, australia just recently approved mdma therapy. Uh, south africa. So in the united states what is most easily readily available and safe is ketamine right.
Speaker 2:yeah, australia is uh. It's legal since july 2023 to use m? Uh, mdma, um. It's really interesting for me personally, because my mother suffered from depression and in the 60s, uh was getting lsd therapy, um, and then she wasn't allowed to do it anymore because laws changed there as well. So it's fascinating that we've come around all this way. It's taken us so long, but here we are, back to understanding that these are powerful drugs. We need to study them and they offer an enormous amount of relief to people in the right circumstances. So do you have any final thoughts for Sam? Tell us your website again. I need to say explicitly I'm not in business with Sam, but he's an ER doc, and so he's certified ER doc in California. That doesn't mean he's not a psychopath. It just reduces his chance of being one and me substantially. So what's the name of your site? Okay?
Speaker 1:So the name of the site for that. So it's ketamine startup, k E T A M I N? E startup S T A R T? U, pcom, all one word.
Speaker 1:I do want to mention one last thing, and this is also something right up emergency physicians alley, something right up emergency physician's alley, and it's it's a, not a psychoactive, it's called the stellate ganglion block SGB, and you may or may not have heard of this, mel, but it's a really bad-ass procedure.
Speaker 1:It's so cool where we go in to the neck using ultrasound guidance C6, c4 level, find the exact target structure of where we want to be, which is above the longest coli, next to the carotid artery, next to the internal jugular vein, use a special echogenic needle, 25 gauge, go in real-time ultrasound, we numb up the middle and superior cervical chain which goes down into the stell cell ganglion and bottom line is it resets the sympathetic nervous system and, in particular, very effective for PTSD symptoms. And that's something that I've been incorporating in my private practice clinic at Reset Ketamine, where I'm just started offering this very cool procedure for patients and getting amazing results. They've done randomized placebo controlled trials on this. This is not some, you know, voodoo thing like scientific, evidence-based medicine, but the SGB is a really cool procedure that we can do to help patients.
Speaker 2:Yeah and I should say a plug for MRAP that July 2024, jaylen Avila has a great ultrasound guide Stirlit Ganglion Block video that you can go check out, if this is not something that you're doing. I didn't realize. I didn't know that this was being used for PTSD. So a lot of the symptoms of PTSD are sympathetic nervous system related and this is like shutting that down for a moment and resetting. Is that the concept?
Speaker 1:Yeah, so normally how we use sgb is for patients with complex regional pain syndrome, so autonomic mediated pain conditions, so dysfunctional sympathetics, as well as intractable v-fib, v-tach. That's where we'll use it in the er icu setting and this would be for a mood disorder. So what it's doing is think about it like um, between the brainstem and running all the way down the spinal column is your sympathetic chain, like just literally like a train track, and the most active portion is kind of at the T1 level. And by temporarily shutting that down using a local anesthetic, specifically repivacaine, we shut down the sympathetic nervous system on one side. The other side's so active for about four to six hours. Turn it back on. When it's turned back on, it resets it and it creates these long-lasting effects of decreasing norepinephrine levels in the brain, decreasing activity to the amygdala, and that's how we think it's working long-term wise, even though the ropivacaine wears off in you know, 46 hours.
Speaker 2:That is fascinating. We're going to have to do a whole show on that, because I don't know that literature at all. So I've just known about it for VFib, VF and these people who are in this cataclysm surge that maybe we can shut it down.
Speaker 1:Well, if you're up for it, you can always come down to Palm Springs. I'd be more than happy to have you do a little. Speaking of personal experience.
Speaker 2:No, if I need it, I'll get you. It's good, sam, this has been awesome. I hope we get to talk to you again about this. I think this offers an opportunity for a number of things For us as patients. As I've been saying on this show, I think every ER doc suffers from PTSD. I think it is the nature of our work that we all suffer from PTSD, and here is another therapy that can help us. It's also an opportunity for you to have some non-ER work, and your skills are really needed here. I mean, the best person I want to give me my ketamine is an ER doc. Thank you very much. Has all of the experience using it clinically the airway skills. I really like this idea that we have ER docs in these clinics. It really makes me heartened that that can extend your career. Fewer shifts in the ER is not too bad for you as well. A couple less night shifts Awesome. So, sam, thank you for what you're doing and hopefully we get to talk to you again about this stuff soon.
Speaker 1:All right, I love that. Thank you so much, mel. It's been an honor talking with you and sharing the information. Thanks.
Speaker 2:All right, Sam. So what I'm going to do is going to edit that up and I'm going to publish it on our show soonish. If you want to use any of it, feel free. Or if you want to do a different interview where you're the interviewer, I'm happy to jump on with you at any time.
Speaker 1:Yeah, I would love to interview you for the Can I Mean Startup podcast and I've listened. I've read your book, I re-watched Ace of Vegas 2018, listened to Rob's podcast, again with you Ken's podcast, so I have a ton of questions. But if you're up for it, what I want to interview you is like, what was your ketamine therapy like? Where were you at before ketamine therapy? What it's been like post ketamine? And then we can talk about EM and we can talk about adverse childhood experiences, ketamine and just kind of like just sharing the information of, yeah, it's so important. So, yeah, I would love to do another interview specifically for the podcast yeah, let's do that.
Speaker 2:I'm happy to do that.
Speaker 1:Let's just work out of time and I'll go through the whole thing and I had no idea we were recording, so I didn't even set up my good microphone. I was not planned, I not, uh, not in the right room, but if it doesn't. If it doesn't work out like, I'm happy to re-record with different content or different uh devices.
Speaker 2:No, it sounds good. You know one of the I used to. I spent 25 years, as you know, trying to fucking make audio sound good in these interviews, and ai now makes it so fucking easy are you using the um?
Speaker 1:what is that?
Speaker 2:adobe's adobe has a really great tool for cleaning up audio. You got to be careful with it because you can overdo it and it can be a little too compressed, but fucking hell, it just takes normal zoom meetings and make them sound really good okay, awesome, awesome you sound really great and once I put it through this thing it'll be like oh, he was in the studio. Like no, he wasn't.
Speaker 1:Well, I really appreciate it, and I listened to Dirty White Coat all the episodes so far, so I'm excited for you. You'll be coming up soon.
Speaker 2:Yay.
Speaker 1:Awesome.
Speaker 2:Great, great to meet you. Let's just do some emailing work at a time and we'll flip the roles.
Speaker 1:Yeah, actually I wanted to ask you how comfortable do you feel? With getting into your experience and specifically with ketamine, and I mean you've been very open and vulnerable.
Speaker 2:Yeah, I just want to say to everybody it's this is my job. I believe that I have to do this because of my role is pretty prominent and our fucking specialty is suffering so much. This is my job, so I am completely open with it, More than I'd like to be, but it's my job. So I will tell you every childhood fucking trauma and everything about it, because I think our specialty in particular medicine in general, but I think emergency medicine is suffering and my job is to reduce the suffering. So I'm going to fucking talk about it until people are sick of it.
Speaker 1:Thank you for doing that, and I was thinking about this why do people go into EM? And what I make up and I don't know if there's data for this I think people who have fucked up childhoods are more likely to go into EM because we get addicted to the adrenaline and we're just, like I'm, used to the state of hypervigilance as a child growing up. Well, what specialty has that all the time? And what I make up is if we were to look at the adverse childhood experiences and run them through all the specialties, I think EM, maybe, ICU, probably, where it's just intense all the time we would have. You know, I think there's a correlation or association there.
Speaker 2:Yeah, my therapist and I talk about all that time. It's like I got to run away for 40 years through med school and through doing ER, all of those thoughts because of what ER? And then you stop, you retire, and then it's like you're supposed to have your shit together, right? No, the fucking house of cards just falls down. It's like, yeah, I've been running away from this shit for 40 years and EA was a great way to run away. It's absolutely true. Awesome, Sam, Talk to you soon.
Speaker 1:Let's get this thing done. I'm looking forward to it. Mel, Take care, you know you're about some dates.
