Ketamine instead of 5150?

I frequently see patients who are depressed and suicidal. It's tough for our patients and I wonder what can be done for them.

My typical plan of action is to medically screen these patients, including: history, physical exam, labs, urine toxicology screen, and call for a psychiatry consult, if available.

Usually, these patients wait for a long time to be transferred to a psychiatric medical center where they can be evaluated by a psychiatrist.

Now, studies have shown that giving a low-dose ketamine (0.5mg/kg) intravenous push can rapidly alleviate these symptoms. 

http://www.ncbi.nlm.nih.gov/m/pubmed/23982301/

http://mobile.nytimes.com/2014/12/10/business/special-k-a-hallucinogen-raises-hopes-and-concerns-as-a-treatment-for-depression.html?referrer=&_r=0

Would it be more beneficial for some patients to be treated with ketamine in the ED with outpatient psychiatry followup? 

This would enhance medical care in several ways:

1. No waiting in ED for psych bed

2. Rapid alleviation of depression symptoms

3. Return to home sooner for patients

The next step is to do randomized controlled studies in ED patients who present with suicidal ideation and see if they benefit from a dose of ketamine.

Starting to Get it Right

“The moment that you feel that, just possibly, you’re walking down the street naked, exposing too much of your heart and your mind and what exists on the inside, showing too much of yourself. That’s the moment you may be starting to get it right.”
- Neil Gaiman
“Neil Gaiman Addresses the University of the Arts Class of 2012” by The University of the Arts (Phl) on Vimeo.  http://vimeo.com/42372767

3 Reasons To Change Medical School to 3 Years

1.  The majority of learning happens in the first 3 years.  The fourth year of medical school is devoted for electives and interview season.  Once interview season is completed, there's plenty of downtime. Accordingly, the fourth year should be eliminated completely.  Or it can be offered as an option for those who don't know what specialty they have decided upon.  Students don't need to be in school for interviews and could spend extra time recuperating for internship or working part-time to pay off loans.

2. There is a shortage of doctors.  We can increase the number of graduating MDs each year and accordingly address the MD shortage that affects our society.  "The Association of American Medical Colleges predicts bigger shortages in all types of physicians: 63,000 by 2015 and 130,600 by 2025."  This means more doctors to help meet the needs of underserved areas, entering primary care, and more MDs doing research.

3. Doctors already have too much debt.  In 2012, the average graduating MD starts out with $170,000 of student loans.  If medical school were reduced by one year, it could reduce educational debt by up to $50K.  Additionally, there is the opportunity cost to consider of this extra year.

So how can we make it three years?  All schools should offer the option of an accelerated curriculum for interested students.  Medical students will be graded upon clinical competency and test scores. If they are incompetent or failing, then they simply don't graduate.

Day-In, Day-out Practice of Medicine

It’s the humdrum, day-in, day-out, everyday work that is the real satisfaction of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life.  I have never had a money practice; it would be impossible for me.   But the actual calling on people, at all times and under all conditions, the coming of grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me.  – William Carlos Williams

How to Quit Your Job Professionally

1. Use simple, direct language

2. Realize this is not an exit interview.

3. Never burn a bridge.

4. Ask for a written letter of reference and commitment to give you a verbal referral on request.

5. Offer to submit, just for documentation purposes, a letter of resignation.

6. Never except a counter-offer

p.s. Have another job or business already lined up before quitting

Reference:
Harpers Rule's: A Recruiters Guide to Finding a Dream Job and the Right Relationship, by Danny Cahill

Brain Training to Be More Positive

1. Write down 3 things you are grateful for each day for 21 days

2. Journal about one positive experience that happened in 24 hour period

3.  Exercise

4.  Meditate - Free yourself from our cultural ADHD

5.  Perform random acts of kindness

The Happy Secret To Better Work, By Shawn Anchor

Residency Should Be Limited to 40 hours Per Week

Residency should be set to a maximum of 40 hours per week.  The idea that a person can be productive, efficient, and offer their "best" selves for 80-100 hours per week is false.  By allowing a normal schedule for doctors in training, this will allow for balance in their lives and ultimately better care for patients. 

Residents will be happier and nicer to patients. The majority of residents who are apathetic, short with staff and patients, and visibly burnt out are in specialities where they work more hours per week.  One of the greatest gifts an MD can give to patients is truly listening and understanding their patients.  When you've only slept for 3 hours last night, this is impossible. 

"But we did it, so you have to do it too." I understand that before residency work hours were set to 80 per week, prior MDs' routinely worked 100-120 hours.  But times have changed.  We are busier than they were 20-30 years ago.  Before they probably got more sleep and had less patients in the hospital.  The number of patients seen in ED and hospitals has increased each year.  More hospitals are shutting down and the hospitals that are open continue to see more patients. 

"We won't get enough training."  During residency, I noted there was a lot of downtime and a lot of "non-clinical" activity.  For example, waiting for attendings in clinic to present, hunting down an old CT report that was done at an outside hospital, or faxing paperwork.  Residents spend time doing miscellaneous activities, not relevant to their clinical skills. Residency should be like an espresso of information. The rest should be delegated or deleted.

Less depression, anxiety, and alcohol/drug abuse.  Every year, 300-400 doctors commit suicide. That's almost an entire medical school.  I believe that one of the contributors to this is being overworked and burnout.  Since residency and medical school sets the foundation for our clinical careers, we need to get the right habits from the start. 

Doctors are human and need balance.  The way we treat and respect our residents will be the way they treat and respect their patients.  And sooner or later, we will all be patients.