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.

Living like a resident...Financially

Living like a resident means working 80 hours per week, snagging free food, and driving an old beater car.

When doctors graduate and become attending level status, we want to spend our hard-earned money.  For the most of us, this is a big mistake.  Why?

First, we have an ocean of student loans to pay off.

Second, we have little to no savings during our time as students and residents.

Third, we will get used to a "rich" lifestyle and may get stuck on the never-ending treadmill of having more.

So, what's the solution?  Continue to live like a resident until you have all loans payed off, maxed out on your savings, have a 6 month emergency cash reserve, and work as much as you can healthily handle.

This is SPARTA!

"Medicine keeps getting harder. And fewer and fewer folks are doing it. America has no idea that the weight of it all is falling on the shoulders of the emergency physicians and hospitalists who lurk inside the trauma rooms and inpatient floors, the fast tracks and ICUs of their community and university hospitals. The pasty-pale, coffee-sucking, junk-food-eating Spartans of health care who will bear the full assault of health care reform when there aren't enough primary care doctors to manage an AARP convention, much less all of America."

Edwin Leap, Emergency Medicine News, January 2013

6 Tips to Get Inspired for Burnt Out MDs

So, how can you get inspired if you're burnt and crispy?

1. Change your job. Go academic if you're a community doc or vice versa.  Work locums tenens in Australia or New Zealand.

2. Take some time off to recharge. Relax in your favorite country. Maybe someplace where you're currency will stretch much further.

3. Add to your expertise. EMS, U/S, Critical care, or whatever niche you choose

4. Be the change at work.  Try to associate with positive people and avoid negative people.

5. Remember your purpose in being a doctor.  Dig out the files and re-read your medical school application essay, residency program essay, and even college essay.

6. Consider a life coach. Three MD life coaches to check out are: Dr. Heather Fork, Dr. Philippa Kennealy, and Dr. Michelle Mudge-Riley.

5 Stages of Physician Burnout

I was reading Dr. Graham Walker's article, Operation Burnout. It made me ponder, why do nearly 70% of emergency physicians feel burnt out?  Even more concerning, ER docs also have the highest burnout rate of ALL specialties.

Burnout is contagious. It's like MRSA and should be called a "staff infection" because it has a tendency to spread.

Ruptured MRSA abscess (via Wikimedia)

Haven't you noticed that when negative people are around you, it has a tendency to bring your energy down as well?

Jerry Edelwich, author of Burnout, writes that there are 5 stages of burnout:

1. Enthusiasm - When you first start the new position, you are super excited and everything is fresh.

2. Stagnation - Things become routine and everything becomes boring.

3. Frustration - By now, the new car smell has worn off and you see the imperfections. The frustration builds at work.

4. Apathy - It feels like you have no power to change anything, and you decide to go with the flow. The longer you stay in this stage, the harder it is to get out.

5. Inspiration - If you're able to get out of apathy, then you realize you can change or change your environment.

Have the courage to be happy and inspired.

20 Sacred Rules for Success

1. Ask
2. Ask again
3. Ask again
4. Ask again
5. Ask again
6. Ask again
7. Ask again
8. Ask again
9. Ask again
10. Ask again
11. Ask again
12. Ask again
13. Ask again
14. Ask again
15. Ask again
16. Ask again
17. Ask again
18. Ask again
19. Ask again
20. Ask again

10 Tips For Med Students Going Into EM

1.  Join AAEM, EMRA, and ACEP. Free or very inexpensive for medical students.

2.  Go to the annual meetings. AAEM is this Feb, 2013 and in Las Vegas. ACEP is this Oct. 2013 and in Seattle. Attend the medical student components of both conferences.

3.  Get honors in your emergency medicine clerkship.

4.  If you are committed to one program, do an away rotation there.

5.  Check out www.freeemergencytalks.net and listen to these 3 lectures to start:

http://freeemergencytalks.net/2012/10/joe-lex-an-old-fogey-speaks-45-years-on-the-front-lines/

http://freeemergencytalks.net/2010/03/amal-mattu-finding-your-niche-in-em/

http://freeemergencytalks.net/2010/04/peter-rosen-beginnings-of-emergency-medicine/

6.  Go to ACEP's leadership & advocacy conference in May 2013. http://www.acep.org/LACHome.aspx?MeetingId=LAC

7.  Score well on Step 1.

8.  Get a strong letter of reference from at least one emergency physician.

9.  Identify a niche in EM (Ultrasound, EMS, Pediatrics, Hyperbaric, EKGs, Social Media)

10. Seek balance in career, life, health, family, and fun.

What tips do you have?

If I could live my life again...

If I could live again my life,
In the next – I’ll try,
- to make more mistakes,
I won’t try to be so perfect,
I’ll be more relaxed,
I’ll be more full – than I am now,
In fact, I’ll take fewer things seriously,
I’ll be less hygienic,
I’ll take more risks,
I’ll take more trips,
I’ll watch more sunsets,
I’ll climb more mountains,
I’ll swim more rivers,
I’ll go to more places – I’ve never been,
I’ll eat more ice creams and less lima beans,
I’ll have more real problems – and less imaginary ones,
I was one of those people who live
prudent and prolific lives -
each minute of his life,
Of course that I had moments of joy – but,
if I could go back I’ll try to have only good moments,

If you don’t know – that’s what life is made of,
Don’t lose the now!

I was one of those who never goes anywhere
without a thermometer,
without a hot-water bottle,
and without an umbrella and without a parachute,

If I could live again – I will travel light,
If I could live again – I’ll try to work bare feet
at the beginning of spring till the end of autumn,
I’ll ride more carts,
I’ll watch more sunrises and play with more children,
If I have the life to live – but now I am 85,
- and I know that I am dying …

Attributed to Jorge Luis Borges

http://oceanflynn.wordpress.com/2007/06/13/if-i-could-live-again-my-life/

Phraseology for Crucial Communications

It's nice to have a few scripts and templates when talking with others.   Here are a few useful phrases for you to use:

“May I Speak Freely?”

“My purpose in talking with you is …” (a mutual goal)

“When you … I feel . . . ” (action you are giving feedback on – something they can change)

“I imagine that …” (positive intent/benefit of the doubt)

“And because we both want …” (common goal)

“I need …” (specific alternative behavior requested)

Most importantly, affirm him or her as a person

~Dr. Jay Kaplan's Lecture at ACEP Scientific Assembly, Boston 2009.

Take Action

I came across this parable, while reading, "Action! Nothing Happens Until Something Moves," by Robert Ringer.

Every morning in Africa, a gazelle wakes up.  It knows that it must run faster than the fastest lion or it will be killed.

Every morning in Africa, a lion wakes up.  It knows that it must run faster than the slowest gazelle or it will starve.

It doesn't matter whether you're a lion or a gazelle; when the sun comes up, you'd better start running.




"Whatever you can do, or dream you can, begin it. Boldness has genius, power and magic in it." ~Goethe 

Non-Medical Advice for Young Emergency Physicians

I was browsing through AAEM's Commonsense Journal (Sept/Oct 2012 Issue PDF) last week and came across a brilliant article by Dr. Andy Walker.  He is a mentor for young EM physicians and offers these points of advice:

Live beneath your means.  Save 15-20% of income if you are employed. Save 25-30% if you are an independent contractor.  Stay out of debt and pay off debt as quickly as possible. EPs should have at least 6 months of income saved, as ER jobs are inherently unstable.  Money may not buy happiness, but it does buy freedom - and freedom is pretty damn good.  Save your money.

Rent, don't own. There will be surprises and you will be in a stronger position if you can pick up and leave.  Especially, rent for the first year.

Insure wisely.  You absolutely need disability insurance, as you are far more likely to become disabled than to die early. Get "own occupation" disability insurance.  If you do get life insurance, get term insurance.  

Be a faithful and disciplined investor.  Start investing early and time will be on your side. Diversify widely. Educate yourself.  He recommends books by John Bogle, the founder of Vanguard. 

Participate in organized medicine. The biggest enemy of physicians is their own sense of hopelessness. But a difficult fight is not an impossible fight. Join your state medical society. Join AAEM today. 

I'd also like to add a couple of things:

Be happy now. You have arrived.  Stop getting trapped in thinking, "I'll be happier, once I get the BMW, house, etc."

Seek balance. Residency can be extreme and now is the time to focus on your health, family, friends, fun, leisure.

Be Yourself

"Be Yourself," is something frequently said and heard. But to be yourself, you have to know who you are. Take time to reflect on your life and how you came to be where you are right now.

What are your values? What do you want people to say at your funeral? What makes you different?

Emergency Haikus

What's causing the pain?
Myocardial infarct.
Transfer to cath lab.

Trouble with sleeping?
Worries and anxiety.
ER is open.

Can't move your right side?
And your speech doesn't make sense?
Head CT and then....

The spider bit you
Redness, swelling, and fever.
Here's doxcycline.

Vaginal bleeding.
What is causing this problem?
Not your period.

Dr. Raul Ruiz for Congress in 2012

During the CAL/ACEP Scientific Assembly in La Quinta, CA in 2009, Margaret Salmon MD, MPH (a close friend and co-intern) told me, "Sam, you have to meet my friend from Harvard."  This was my first meeting with Raul Ruiz and would not be the last. 

Sometimes, life surprises you with these incidental meetings that seeds the beginnings of life long friendships.  Raul's story is awe-inspiring.  He comes from a family of immigrant farm workers from the Coachella Valley desert.  To get into college, he went to his neighbors' doors and made a promise, "Help me pay for college.  I promise to come back here and make a difference."

Not only did he make it to college, but he went to Harvard and graduated with three degrees (MD, MPH, MPP).  Afterwards, he went on to complete an emergency medicine residency and an international medicine fellowship.

Now, he is a community ER doctor back in the Coachella Valley desert and Associate Dean at the University of Riverside School of Medicine.  He made a promise many years ago and kept it.

When Raul told me he was running for Congress, it just made sense to me.  He is the kind of leader that I want to see helping create laws and addressing disparities.  Raul is an emergency doctor who has the back ground in public health and public policy tools to make a positive impact.

Would you like to see someone who understands medicine, policy, and public health to help create legislation?

Do you want to have someone in Congress who keeps his promises?

Please make a donation to Dr. Raul Ruiz.  Even $5 makes a difference in this grassroots campaign. Here's the link: www.drraulruiz.com 

Raul Ruiz, MD, MPH, MPP