January 20, 2025 • 40 mins
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.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
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, lindauniversity, oh, yeah, yeah, I
would.
Um, I considered you one of myprofessors because I, you were
(00:21):
always in my, in my airpods or Iguess that was pre-AirPods but
whether I was in the car or onthe phone, just always listening
to MRAP you, rob Borman, scottWangard, joe Lex, greg.
Speaker 2 (00:34):
Henry.
Speaker 1 (00:35):
Yeah, yeah.
What were you there?
I was there from 2008 to 2011.
Speaker 2 (00:46):
Right, yeah there then still is yeah, lance brown
is, was there.
Speaker 1 (00:52):
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 therankings.
So, yeah, lance brown, and Ithink emily rose yeah, she went,
she did her pdm fellowship atloma, linda, and then went to
usc.
Speaker 2 (01:11):
Yeah, yeah, she did residency at usc, peds
fellowship at loma, linda, backto usc as faculty yeah and then
I think, she was on mrap a fewtimes too.
Yeah, she's been on mrap a lotwe've used her over the years
and board of you and all thatstuff.
Emily is just like the mostwonderful person.
Speaker 1 (01:30):
Yeah, yeah, very cool .
And then we, you and I,actually met, we at La Quinta,
at a Cal ASAP conference.
Speaker 2 (01:38):
Really, when was that Way back in the?
I think it was a long time.
Speaker 1 (01:40):
It must have been a long time.
I think it was like 2008.
Yeah, I think it was 2008 or2009.
Anyways, I'll send you apicture that we took.
Oh, that's good.
You were talking about what wasit called Like the lap band?
I think that was the talk aboutlap band and how to deal with
the complications associatedwith that?
I don't know it doesn't seemfamiliar.
Speaker 2 (02:02):
Usually I do cardiology shit.
Speaker 1 (02:04):
Yeah, but anyways, thanks for all of your work.
I'm so happy to be able toconnect with you and I'm looking
forward to it.
Speaker 2 (02:10):
Thanks for doing this .
Yeah, I'm just doing a.
I started a new podcast becausethere's all these controversial
topics and stuff that peopleget 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 orit's ketamine, whether it's sort
of um jfk, whatever, the fuckit is.
Speaker 1 (02:31):
So we just rfk yeah, rfk.
Speaker 2 (02:33):
Thank you, um.
So we decided to do a newpodcast and we've only done two
of them so far and they'rereally popular, people really
like them.
So I wanted to talk aboutketamine.
So I just interviewed a PhD inNorth Carolina about my
experience and how she selectspatients.
But then I think your spin willbe maybe we can focus a little
(02:57):
bit on what you're doing as anER doc and then how to get into
it, if that's what people wantto do and you know just sort of
talk about the business aspectsof it and the training aspects
of it.
I was saying to her I've givenketamine a thousand times but I
don't know how to do a ketamineclinic for depression, PTSD.
I don't know what the fuck I'mdoing.
I mean, I lower the dose.
Okay, that's not very helpful.
So that's what I want to talkabout.
Speaker 1 (03:19):
Yeah, it's a little different.
So I mean for me and mybackground.
So I did residency finished,worked at, you know, the
community hospitals andassistant professor, I was an
associate medical director and Ihad to make a decision of
whether to start up Academy andClinic in Palm Springs or be the
(03:39):
medical director of an ERdirector of an ER and I was like
, okay, which?
Which way do I choose?
You know, do I follow my heartor 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 havingtaken this opportunity.
So I took the leap.
I opened up the clinic in 2018.
(04:06):
I was actually, I'm the first ERdoctor to have ever opened up a
ketamine clinic in California.
And this is like back in thedays 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 otherEM folks hey, sam, how do I open
up a ketamine clinic?
So I helped up, you know,several colleagues and then
(04:27):
eventually I started a onlinecourse which is like synchronous
and asynchronous training, andso far we've helped 16, 17
clinics open up nationwide.
And then we started the podcastrecently, which is one of the
reasons why I wanted to reachout to you, because when I heard
you on Rob's stimulus podcast,like you mentioned ketamine I'm
(04:49):
like what Mel ketamine?
I was like I got to get him onour podcast.
Speaker 2 (04:57):
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'redoing the thing, you're nights,
weekends.
Why ketamine?
What happened?
Uh, tell us that story.
How did you start getting intoketamine as a non-er doc?
You know, as er docs, we use itall the time.
Speaker 1 (05:17):
But yeah, so loma linda was one of the first
institutions where they wereusing ketamine for procedural
sedation.
They published like thelandmark article in 1990.
Steve Green Steve Green,analyst of emergency medicine
Like yes, it can not only beused in the operating room but
we can use it in the EDs.
(05:38):
So in my residency I was usingketamine all the time for
patients and procedural sedationnot only peds but for adults.
And then I came across a reallyfascinating article where they
were using ketamine for suicidalideation and I was like we got
all these patients who are on 72hour holds and we're kind of
just babysitting them until theyget transferred to a psych
(05:59):
facility.
So I started doing a deep diveinto the research of like hey,
what is this drug that we'reusing all the time for sedation
and how can it be used for mooddisorders?
And because I was familiar withit, I'm like, you know, I think
I'm gonna open this clinic up.
And I had initially, kind of inthe brainstorming phase, worked
(06:22):
with another ER doctor and ananesthesiologist and we were,
you know, the three of us werelike hey, let's start this up
and we're gonna open up in lomalinda and and it just kind of
fell apart.
I mean it wasn't not the rightpartners for the business, so
kind of put it on the backburner and then went back to it
with my wife, who is she's anophthalmologist and she's like,
hey, sam, like let this, I canhelp you, and at least as far as
(06:45):
like administrative, creativedirector, marketing, and so we
open it up.
But I would say you know,there's that saying, I think
Steve Jobs and his commencementspeech at Stanford.
He's like you can't really tellhow the path is going until you
look back, until you see itretrospectively.
So I look back on my life and Iwas giving ketamine to animals
(07:08):
back when I was in college.
We were doing variousprocedures and then emergency
medicine we're super familiarwith ketamine and then the
residency where I did mytraining just use ketamine all
the time.
And you know I've always beenkind of an entrepreneurial guy
as well.
I have an MBA.
So I was like you know what Iwant to do something where I can
really leverage my businessskills and it just kind of
(07:32):
coalesced into this ketamineclinic.
It's a reset ketamine and now,like, looking back, I'm like
this is what I was meant to bedoing, like I love my job, like
I literally it's one of the mostgratifying things I've ever
done, especially seeing patientswho have tried SSRIs, they've
tried ECT, they've tried TMS,they've tried you know all sorts
(07:53):
of stuff, and to be able tooffer them relief.
It's so gratifying, literallyit's.
It's just, it's nourishing,it's spiritually nourishing,
whereas in the ER it's a littlebit different.
Speaker 2 (08:11):
I mean, it's not as spiritually nourishing as you
and I both know.
So tell me that first clinicwho were you looking after?
What type of patients Did youhave?
A narrow focus, broad focus?
And then, how did you get theword out?
Like I have this clinic on thecorner, because it feels to me
(08:32):
like I only discovered ketaminewhen I was failing SSRIs and I'd
heard a little bit about it.
But it seems that now thatwithin a very short period of
time the neuropsychologicaleffects, neuroplasticity effects
, the antidepressant, PTSDeffects of ketamine sort of have
exploded, Now everybody knowsabout it.
So how many?
Speaker 1 (08:50):
years ago was that clinic and how did you first get
your first patients?
Yeah, so we first opened in2018 and it was very slow.
The first three months, I think, I did four treatments, the
entire like month and typicallythe standard treatment is six
sessions over a period ofroughly two to three weeks, as
far as the research goes, but itwas very slow.
Um, literally like googlesearch engine optimization.
(09:11):
Um, people were just looking.
They were looking for it forthemselves.
I even I thought I was going toget a ton of patients, so I
sent out letters to all thelocal psychologists and
psychiatrists and internists.
Ob-genyns didn't get any leadsor referrals because it was too
controversial.
This is seven years ago nowvery controversial.
(09:32):
So it was very slow, whichmeant I worked part-time in the
ER and I did part-time ketamineclinic and then, over time, just
word of mouth, people knewabout it I started getting more
referrals and it just grew andgrew and grew and then finally,
in December 2020, and that waswe had our daughter in 2020.
So it was just a goodtransition point where I worked
(09:56):
in the clinic or, excuse me, inthe ER for about a decade and I
was like you know what?
I think it's ready, for youknow it's time for a change,
especially with COVID and all ofthe stuff that was going on
with the pandemic, like I justneeded to transition out.
Speaker 2 (10:10):
Wow.
So what were your initialpatients and maybe you can
summarize the literature?
Speaker 1 (10:18):
The early, the first patients that I saw they were
mainly treatment resistantdepression patients that I saw.
They were mainly treatmentresistant depression and that's
where there's the most robustdata.
Um, and even now there's likenew england journal of medicine,
there was a recent publicationlooking at ketamine iv versus
ect, electroconvulsive therapy,and what they found in the study
(10:39):
that was published, I believe,october 2024, 2023, and they
found that it was just asefficacious as ECT and maybe
even more effective.
So initially we treatedtreatment resistant depression,
ptsd, anxiety, ocd so mooddisorders and then we also got
(10:59):
into the pain syndromes, sospecifically like fibromyalgia.
We also got into the painsyndromes.
So specifically likefibromyalgia, complex regional
pain syndrome, also known asreflex sympathetic dystrophy,
trigeminal neuralgia, so nerveor neuropathic related pain
conditions.
Speaker 2 (11:15):
So that study you're talking about is ketamine versus
ECT for non-psychotic treatmentresistant major depression New
England Journal, which was inMay 24th 2023, and found it to
be non-inferior and we'll gointo this article in more detail
later, but I just wanted totimestamp that.
So you're using ketamine forpretty traditional therapies, so
(11:36):
can you tell me what does itlook like when I go to your
ketamine clinic?
I want to sort of compare andcontrast, maybe with my
experience.
So what I did is I was failingSSRIs.
I went to my primary care doc.
There's a much longer storythere.
I was suicidal, it was fuckinghorrible.
And I went to this group atUCLA and I basically said look,
(11:58):
we have a private clinic and apublic clinic.
I decided to go to the privateclinic and they basically take
you to the nice little room inan office.
There's a doc there, there's atherapist there, you do therapy,
we did I am ketamine six timesover six weeks.
So how does it look if I go seeSam?
Do I have different options?
Do I have different routes?
Do I have different schedules?
(12:20):
What is sort of the bestschedule?
Do you change it depending onthe patient?
Speaker 1 (12:24):
Yeah, thank you for that.
So I think of ketamine therapyat our clinic in four phases.
The first one is preparation,the second phase is intentions,
the third phase is experienceand the fourth phase is
integration.
So by preparation, specificallyone week before their first
(12:45):
ketamine session, we give them abunch of exercises to do and I
understand they're in achallenging place, they may not
be able to do, you know,journaling or exercise or
getting adequate sleep, but asbest as possible, kind of
preparing the mind.
The next phase is theintentions.
So this makes our clinic alittle bit different.
Where I have the patient I saywhat do you want?
(13:06):
What's your definition ofsuccess?
What's your goal for ketaminetherapy?
And that's what the patientfocuses on during the experience
.
So, for example, someone'sintention can be letting go,
forgiveness, love, loving myself, healing my inner child.
You know, and everyone hastheir own intention and we do a
little bit of coaching todecipher exactly what that
(13:28):
intention is.
Next is the experience.
So the patient comes in.
We do it very safely, like,almost like procedural sedation,
icu level of monitoring whereI'm looking at their O2 sats,
I'm looking at their cardiacrhythm, blood pressure, q10
minutes, respiratory rate, andso it's continuous vital sign
monitoring.
(13:49):
We have oxygen available and weadd in kind of a holistic
approach, because we are inCalifornia, we're in Palm
Springs, so we got the woo-woofactor, some really calming
music, including beta waves,binaural beats.
We do offer aromatherapylavender, sage, orange, whatever
(14:09):
it is because the sense ofsmell is really a powerful sense
that we want to take advantageof and leverage.
And then so they'll have theexperience which, as you know
and I'm really curious to hearabout your personal experience
you know, I call thesenon-ordinary states of
consciousness, nosc, where theymay have memories or emotions.
(14:31):
You know, like I've hadpatients cry like literally we
give them eye shades and somepatients, like, each time this
eye shade is just like drenchedin tears that have been held for
10, 20, 30 years.
And then they'll have theexperience 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 raftingclass five rapids, you're not
(14:54):
going to control that river, soyou just kind of go with the
flow, witnessing, breathing,surrendering, allowing, once the
experience is done, which isroughly a 40 minute infusion.
So it's a little bit differentbecause when I use it in the ER
it's, you know, rapid, you knowfairly rapid push one to two
megs IB over one to two minutes,whereas with the ketamine
clinic it's 0.5 milligrams perkilograms infused slowly over 40
(15:21):
minutes and with each sessionwe will gently titrate that dose
up, so it might be 0.75 thenext time, or 0.9 mg per kg, the
next time 1.1 mg, you know, andeveryone has a different
tolerance and threshold.
And, yeah, the infusion will becompleted.
I give them 10, 20 minutes torecover and then I'll have a
(15:43):
debriefing session post infusionand so kind of like talking
about what their experience waslike.
And I'm not a psychotherapist,so we're not doing psychotherapy
, but I am curious to learn andto help them process their
experience and create a meaningfrom it within with an action
post infusion, something thatcan they can actually do how do
(16:04):
you?
Speaker 2 (16:05):
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 differentways.
Do you do it iv every time?
Why did you?
Speaker 1 (16:17):
choose that I do, it be 99.9% of the time.
So the beautiful thing about IVis it's 100% bioavailable.
So if I put in 45 milligrams,like I know, 45 milligrams is
going in the other routes ofadministration.
I am, for example, um it's andsome studies are showing this
(16:38):
that it can be, you know, quiteeffective.
But the bioavailability islower depending upon the
patient's.
You know body mass, if theyhave more adipose tissue or
muscle, or you know it could bevariable absorption and then the
other routes of administrationalso lower bioavailability.
So like sublingual it's, youknow, 20, 30% bioavailable, but
like sublingual it's, you know,20 30 bioavailable.
(16:59):
But I would say the mostimportant thing about the iv for
me at our clinic is I can stopit at any time.
Right, so it's a slow infusionif the patient is having
something come up an adversereaction, a panic attack,
anxiety, severe hypertension,because I've seen that like I
can stop the infusion, whereaswith the other routes I am in
particular like once it's in,can't get it out.
(17:20):
So uh, the yeah, it's a hundredpercent bio, bioavailable, we
can stop at any time and I havethe advantage of having an IV
now.
So if they need a little bit ofmidazolam if they need a little
bit of on dance a drawn if theyneed you know other.
You know some Toradol forheadaches like I, have access
(17:41):
that I could treat.
If they need some bloodpressure medicine, maybe some
labetalol like I, have a ton ofoptions available with the IV.
And I guess you know, if youlook at the research and the
science, like 95% of theresearch is doing it
intravenously.
Speaker 2 (17:56):
So what does that clinic physically look like?
Again, again, my experience wasin a nice couch with a comfy
blanket and some beautiful music, but very non-medical.
Felt very much like I was insomebody's lounge room and I was
chill.
Um, what you're describingsounds a little bit more like
it's in an office, a clinic oran ear.
(18:19):
How does it look and how do youget rid of the noises and the
crap that we do in the ear?
Speaker 1 (18:26):
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 andthe setting.
So anyone in the psychedelicspace may be familiar with this.
Set refers to mindset of theperson receiving the ketamine
and then the setting, theenvironment.
So we pay really consciousattention to this.
(18:46):
So specifically when the personis coming in, like you know
it's, it is kind of a clinicalsetting.
So I'm blending in likeallopathic, traditional vital
sign monitoring mix per gigs.
We make it really safe.
We have o2 tank available, youknow, on the emergent aed, like
anything like we're.
We're like really honed down onthat.
But then we add in kind of likea eastern approach, a holistic
(19:10):
approach, where we're doing theintention setting, the rituals,
the music, the eye shades, thearomatherapy, the debriefing,
setting the lights in adifferent temperature and tone.
So all of these little factorsto make it less clinical.
Now what's interesting is Ihave given ketamine IV in the ED
(19:30):
for someone with suicidalideation.
This was before I opened theclinic and I was like doing a
deep dive into the data.
I was like, huh, hey, chargenurse, do you mind if I use room
nine to give a ketamineinfusion?
And so we administered it tothis patient.
She didn't quite meet thecriteria for 5150, but I
realized that the set andsetting of an ER, especially a
(19:53):
chaotic ER with a lot of otherstuff 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'svery relaxing.
We take our time with patients.
It's not like a bunch ofpatients, you know, hey, there's
a patient in room three.
They're screaming and yelling.
It's like, no, everything iscalm and mellow.
Because I know that's going toimpact the patient's experience.
Speaker 2 (20:16):
Right, yeah, in the ERs we'll often see people have
a bad trip in quotation marksand in large part that's because
the ER is the worst place to dosomething like this, because it
is chaotic and it's loud andthere's noises and you can't
control the setting and whenthey wake up they might see
somebody vomiting or dying.
So that's probably why we see alot more of these emergence
(20:39):
reactions than in the clinicliterature.
So where are your clinics?
Are you sort of in the mall, orwhere do you physically put
them?
I mean, I know that there'sreally high winds in ones that
are basically in Malibu in$10,000 a night hotels.
How does yours look?
Speaker 1 (21:01):
hotels.
Uh what, how does yours look?
So ours is.
Well, the first one I had was avery small location, about 700
square feet, so super tiny, anda really quiet place in Palm
Springs, about five minutes awayfrom the airport.
Um, the one I have now, becausewe did grow in transition out
of that clinic, the one we havenow, it's actually in a medical
office building with probably 10to 20, maybe 30 other
physicians and clinics and, um,our space, the one we lease,
(21:25):
it's, you know, kind ofseparated so they'll come into
the medical looking environmentof the building, but then once
they come in it's like acompletely different vibe.
We have, you know, the wholegreen wall and the lightings and
comfortable couches.
So it's, it um's a medicallyprofessional looking place.
And what I love about our placeis right next to it is an
(21:46):
emergency department, so therecan be emergencies that occur
and if anything does occur like,all right, three minute drive,
the ambulance two minutes it'sliterally a block away.
Speaker 2 (21:55):
Yeah, the beautiful thing about ketamine is it is
such a safe drug, but, as weknow, no drug is completely safe
.
So I love this mixed model thatyou talk about.
So now you're gone from doingyour own clinics to training
people to go and make their ownclinics.
So here's Mel Herbert.
(22:17):
I'm very comfortable withgiving ketamine from the medical
point of view.
I don't know how to set up aclinic.
I don't know how to do thefinancing, I don't understand
the laws and I'm not apsychologist.
So how do you take me from MelHerbert, who knows how to give
ketamine, to relocate yourshoulder to Mel Herbert that
could actually successfully runa clinic?
Speaker 1 (22:37):
So for me anyone who's an emergency physician we
wear many hats and we have theskillset, I believe, to create a
business.
The biggest challenge, as youand I both know, mel, is that ER
docs we're not, and doctors ingeneral we're not taught the
(22:58):
business side, whether in medschool or residency.
Like we're taught the clinicalside but no one teaches us, hey,
how do I get an authorizationfor X, y, z, or how do I bill
properly, how do I order gauzeor syringes?
So the course that we have,it's ketaminestartupcom, it's a
12 week course and it'sessentially the roadmap or
(23:18):
blueprint for an emergencyphysician who is interested.
And we just walk you through,like, hey, don't reinvent the
wheel, man, like we already didit.
I already made all the mistakes.
Let me just share with you whatI've learned and yeah, I would
say that because, again, of themany hats that we wear as
emergency physicians, likecreating a clinic, it's totally
(23:39):
within your wheelhouse and it'ssomething that you can do and
there's nuances, right.
And so how do, how do I learnanything?
Well, I just learned fromsomeone who's done it before and
that's the skillset.
It's like, yeah, let me justtransfer everything I know, put
it from my brain and transfer itto your brain with repetition
and practice brain and transferit to your brain with repetition
(24:04):
and practice.
Speaker 2 (24:04):
How much does it cost , like what's the financial
outlay to do a sort of a smallto moderately?
Speaker 1 (24:07):
sized clinic?
Good question.
I think it depends on location.
So if someone's going to openup one in New York City,
manhattan, right, that's goingto be a very different cost
versus, hey, if you're going toopen one up in Nebraska, for
example, right, so there's thecost of living in space
malpractice insurance.
So I'll preface my answer withsaying that there's a ton of
(24:29):
variability depending upongeographic location.
If I had to put a hard number onit, I would say anywhere from
75K to 150, 50 K initially forthe build out process and of
course, you want to have somemoney set aside to pay rent,
insurance, staff et cetera.
You know we call this therunway, just in case it is slow,
cause typically what I've seenwith our other students, like it
(24:51):
can be slow, especially ifyou're opening up a you know a
clinic.
It's like, yeah, people may notknow about you, it takes time
for Google SEO to pick up yourclinic's website and stuff.
So anticipate that and don'thave a huge overhead, but keep
things lean.
Maybe continue workingpart-time in the ER or doing
whatever you're doing clinically.
(25:12):
Have that financial stabilityas the clinic volume ramps up.
Speaker 2 (25:16):
And what do you think ?
The utility of hiring a trainedpsychologist versus just the
experience itself, maybe alittle bit of extra training
versus having somebody that doesthis for a living outside of
the ketamine?
Speaker 1 (25:29):
Yeah.
So we find that some clinicsare actually doing this where
some of our students they'relike one guy, he's an
anesthesiologist and hepartnered with the psychologist
and they co-created the clinictogether.
So that's also known asketamine assisted psychotherapy,
where they're getting theketamine and then they're
engaging actively in adiscussion with the psychologist
(25:52):
or therapist.
So that is one model of how todo it.
At our clinic we do it a littlebit differently where I'm doing
higher doses of ketamine.
So they're getting pretty notfully dissociated, but quite
dissociated, sub dissociated,where they're not really
engaging or talking like we wantto go deep, we want to hit the
NMD receptors hard when to getas maximal effect.
(26:14):
But what I do recommend and Icall it, refer to this as the
integration is like have anappointment with your therapist
or psychologist 24, 48, 72 hourspost infusion so that the
things that have come up duringthe experience can be processed
with, you know, the therapist.
So I think it can work bothways, where you actually have
(26:37):
someone in-house or where yououtsource it, maybe even hire
them as an independentcontractor.
But I don't think it has to bedone within that same time
period, and the reason being isneuroplasticity of ketamine.
It's not just during theinfusion, but it's 24, 48, 72
hours, and we're going to takeadvantage of that time period,
yeah, so you brought up a reallygood point hours, and we're
(26:59):
going to take advantage of thattime period.
Speaker 2 (27:00):
Yeah, so you brought up a really good point.
There's the effects of ketamine, which are neurochemical,
neuroplastic, separate from thetherapy.
I did ketamine-assistedpsychotherapy so I was with a
therapist before, during, afterand I found that very useful.
I don't know yet.
We're going to, in our nextinterview, be talking to a group
that does ketamine-assistedpsychotherapy.
About what's the literature?
How much of both do you need?
(27:21):
What do you do if it's mostlyPTSD or if it's depression or if
it's childhood trauma?
How do you define which way togo?
Do you have any opinion on that?
Do you like ketamine's going tohelp everybody?
Maybe some people needpsychotherapy.
Speaker 1 (27:36):
I don't know, I don't think it helps everyone.
The studies are showinganywhere from 60 to 80% benefits
and in particular with, likeyou know, measurement
instruments PHQ-9.
So, all right, here's the way Ilook at it.
The initial studies on ketaminewere done in the rodent model,
so rats and they have models ofdepression in the rodents and
(27:58):
one of them is called, like, theforced swim test, where if a
rat is not willing to swim aslong and they just put them in a
tub and they're like, well, howlong is this rodent going to
swim for?
And the longer that they'rewilling to swim is associated
with less depression, right, andif they give up swimming, then
that's like more depression.
So these rats were not gettingpsychotherapy, they were not
(28:20):
getting um counseling pre andpost.
So we know that even withoutthe therapeutic, without therapy
, like, it's still beneficialbecause it's creating changes in
the brain.
Now, adding, because we knowwe're not rodents for the human,
adding that psychotherapy canbe beneficial.
I don't think there's been anystudies comparing directly head
(28:42):
to head, but what I would say isthat ketamine, independently,
with or without psychotherapy,can be quite robust and
beneficial for the patients.
Speaker 2 (28:56):
Those rodent studies.
I find so funny that we'vedecided that the rat continuing
to swim must be because he's notas depressed.
I want to live.
It's an interesting model wherethe literature that I first
read about was basically givingsingle dose ketamine for another
procedure in somebody that alsohappened to be suffering from
depression, who then later cameout of that after having the
procedure done, going.
Oh my God, I've not felt thisgood in years.
(29:18):
And so there was clearly anindependent effect of the
ketamine itself.
Then it wore off, and that'swhen we realized, oh, one dose
isn't enough.
So tell us about your dosingschedule.
One dose, fine, for a few daysor a week, but where are we
right now with how many doses tohave a more prolonged effect?
Speaker 1 (29:35):
Good question.
So the initial studies were onedose and then they were like,
yeah, it's kind of wearing off.
So the standard it's sixsessions and there's two studies
.
One study did it three times aweek, so Monday, wednesday,
friday.
Monday, wednesday, friday, weektwo.
And then other studies areshowing twice a week for three
weeks and then even more recentdata is showing once a week for
(30:00):
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 boostersessions, maybe rough, every one
to three months depending onthe patient.
Some patients need it morefrequently, some patients need
it less frequently.
Speaker 2 (30:21):
Yeah, I did the once a week for six weeks and then, a
number of months later, did twomore sessions and I wasn't
aware of what the literature was.
I just went with my team andfor me that worked great.
Speaker 1 (30:39):
Yeah, so we're seeing some patients who just do the
initial six with completeremission, and then other
patients are getting, you know,monthly or every two months,
boosters for maintenance.
But I kind of think of ketaminein a way as a catalyst.
So doing the initial six andthen using that activation
(31:00):
energy, if you will, to make thechanges that one needs to make
or gain the insights or theideas, so I think that's really
important.
So it's a little bit differentin how I approach it.
It's not like, hey, everyoneneeds to do it and you need to
just need to do this for therest of your life.
It's like, well, maybe we needto, you know, engage in
psychotherapy If someone's likeyou know previously not doing it
(31:21):
and then don't get back into it.
Or maybe even using variousantidepressants Like I've had
patients where they're like,yeah, that didn't work for me,
that Prozac or Welbutrin, andthen after the ketamine therapy
they will restart one of theseother meds and it's like, yeah,
actually now it's working.
Speaker 2 (31:40):
Tell us about the legalities of ketamine.
Does it differ from state tostate?
Can anybody get it?
Do you have to have aphysician's license?
Speaker 1 (31:48):
How does that work?
Yeah, so ketamine is schedulethree per DEA regulations,
meaning it's a controlledsubstance.
So the DEA just for folkslistening, there's, you know,
dea schedule one, which is likeillegal and not allowed to use,
only under research settings,schedule two, which is like
hydromorphone fentanyl, and thenyou got schedule three, which
(32:11):
is lower risk, and then there'sschedule 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 DEAregulations that one needs to
abide by to act.
To actually order ketamine youneed to have a DEA license, so
that can be a nurse practitioner, a physician assistant, it can
be an MD, so someone with anactive DEA license that is
(32:32):
allowed to prescribe controlledsubstances.
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 andnot have an adequate record
keeping of that.
And then the other importantthing to consider is it's not
just the ketamine but it's aboutwho can own a medical clinic.
(32:55):
So, for example, in Californiawe have the corporate practice
of medicine laws, meaning thatif you're not a physician you
cannot open up a medical clinic,whereas in Florida state, for
example, like anyone can open upa medical clinic.
They don't have to be alicensed professional, so they
would have to consult with theirlawyer of like who can actually
open up a medical clinic in mystate.
Speaker 2 (33:18):
Have you had personal experience with ketamine?
Some clinicians we talk to saythat we think everybody who's
giving ketamine should have usedketamine and others like no.
I don't think that's true.
Not everybody that has needs todo that.
So where do you stand?
Speaker 1 (33:34):
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 toexperience it.
Well, does every doctor whogives IV Dilaudid need to
experience IV Dilaudid or VersedLike that's psychoactive, or
(33:55):
can they give it knowing that itcan help?
And then the other argument islike well, these people are
having the psychedelic,non-ordinary state of experience
, state of consciousness.
The provider should know how todo 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 someexperience with various other
(34:21):
substances that have been prettymind blowing.
And it's, it's transformational, really, and in the right set
and setting, with the rightintention, I think it can help a
lot of people yeah.
Speaker 2 (34:34):
So I come down on your side of the argument, in
fact, most people here.
I think that, um, it's helpfulbecause it is such a different
experience.
I mean I wish I had have hadketamine at the beginning of my
clinical career to explain topeople who are getting ketamine,
even in the here's, what thisis going to be like, and I
couldn't tell them because theywould just tell me afterwards
(34:55):
wow, I can't explain what justhappened, like I know it's such
a bizarre state.
Now, having done it, I could bemuch better physician to them.
So I think there's an argumentthere.
But I also agree you don't haveto have kids to know how to
look after kids, and you don'thave to get drunk to know how to
look after somebody who's drunk.
But I think it's probably avery powerful and useful thing
to do in the right setting.
(35:16):
And so maybe one of the last fewquestions is you talked about
different agents.
So we've got psilocybin, we'vegot LSD, we've got MMDAs, we've
got a litany of drugs.
What's the best one?
We're using ketamine, in mymind, because it's available,
and again I hear arguments onboth sides Well, it actually
might be one of the best, versusit's not really the best, but
(35:37):
it's available, so we use whatwe've got.
Where do you stand on thisargument?
Speaker 1 (35:42):
I've been thinking a lot about this question and for
me, I think about medicine and Ithink 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 andbank, or do I need to?
You know, consider, you know, adifferent, maybe it's, maybe I
(36:02):
need to do an antiviral, maybe Ineed to do an antifungal.
So I don't know if there's onebest right, like there's not one
best antibiotic for pneumonia.
It really depends on you knowwhat type of pneumonia I'm
treating, right.
So same thing with mentalhealth.
It really depends Ketamine maybe effective for that patient or
they may need anothermedication.
Maybe they do need MDMA orpsilocybin or 5-MeO-DMT or
(36:27):
ayahuasca or salvia divinorum ornit nitrous oxide or propofol
or the 10 to 20 othermedications that are in FDA.
So I don't think it's one, butrather it's one tool amongst
many tools, and let's figure outwhich one it is for that
patient.
Speaker 2 (36:45):
Many of the ones that you listed are not legal and
that's why they're not beingused.
So, um, that's for people whoare sort of the lay public
listening.
There's one reason that we'renot using a lot of these is
because they're not legal.
There's not necessarily logicbehind that, um, because, as we
know, we've talked about on thisprogram before, a lot of these
(37:06):
drugs were being used, um in the60s, 50s, and then there was
sort of this political thingslike we should get rid of all of
them.
That's bad, instead of studyingthem 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 outhow to use these drugs and now
we're only now coming back like,hang on a second, we should be
(37:26):
studying these.
So that's why I think ketamineis being used so much right now
is because it's legal and manyof these other very powerful
agents are not.
Speaker 1 (37:36):
A hundred percent and so you know for the listeners.
What happened was in the 1950sand 60s.
There was a ton of LSD researchhappening but then it got
leaked out into the public.
You may have heard of a Harvardeducated professor named
Timothy Learyary and he wantedeveryone on lsc.
You know he had the ones sayinglike tune in, drop in, drop out.
(37:56):
And that created this politicalbacklash where richard nixon
was like, hey, these people whoare doing lsc, like they don't
want to go to the vietnam war,like we need to quash this.
And so then the controlledanceAct came in 1970 and it shut
down everything.
It turned it into a scheduleone illegal drug.
But I will say the research waspaused for about 30 years and
(38:22):
then there are things changingand there's laws changing.
So, for example, in Colorado,psilocybin is legal.
In Oregon State believe it'slegal.
Um, people can.
It's not as accessible.
But in other countries brazil,costa rica, peru, colombia, etc.
Uh, australia or, excuse me, Idon't know about yeah, australia
just recently approved mdmatherapy.
(38:43):
Uh, south africa.
So in the united states what ismost easily readily available
and safe is ketamine right.
Speaker 2 (38:52):
yeah, australia is uh .
It's legal since july 2023 touse m?
Uh, mdma, um.
It's really interesting for mepersonally, because my mother
suffered from depression and inthe 60s, uh was getting lsd
therapy, um, and then she wasn'tallowed to do it anymore
because laws changed there aswell.
(39:14):
So it's fascinating that we'vecome around all this way.
It's taken us so long, but herewe are, back to understanding
that these are powerful drugs.
We need to study them and theyoffer an enormous amount of
relief to people in the rightcircumstances.
So do you have any finalthoughts for Sam?
Tell us your website again.
(39:34):
I need to say explicitly I'mnot in business with Sam, but
he's an ER doc, and so he'scertified ER doc in California.
That doesn't mean he's not apsychopath.
It just reduces his chance ofbeing one and me substantially.
So what's the name of your site?
Okay?
Speaker 1 (39:52):
So the name of the site for that.
So it's ketamine startup, k E TA M I N?
E startup S T A R T?
U, pcom, all one word.
I do want to mention one lastthing, and this is also
something right up emergencyphysicians alley, something
right up emergency physician'salley, and it's it's a, not a
psychoactive, it's called thestellate ganglion block SGB, and
(40:20):
you may or may not have heardof this, mel, but it's a really
bad-ass procedure.
It's so cool where we go in tothe neck using ultrasound
guidance C6, c4 level, find theexact target structure of where
we want to be, which is abovethe longest coli, next to the
carotid artery, next to theinternal jugular vein, use a
special echogenic needle, 25gauge, go in real-time
(40:44):
ultrasound, we numb up themiddle and superior cervical
chain which goes down into thestell cell ganglion and bottom
line is it resets thesympathetic nervous system and,
in particular, very effectivefor PTSD symptoms.
And that's something that I'vebeen incorporating in my private
(41:04):
practice clinic at ResetKetamine, where I'm just started
offering this very coolprocedure for patients and
getting amazing results.
They've done randomized placebocontrolled trials on this.
This is not some, you know,voodoo thing like scientific,
evidence-based medicine, but theSGB is a really cool procedure
that we can do to help patients.
Speaker 2 (41:26):
Yeah and I should say a plug for MRAP that July 2024,
jaylen Avila has a greatultrasound guide Stirlit
Ganglion Block video that youcan go check out, if this is not
something that you're doing.
I didn't realize.
I didn't know that this wasbeing used for PTSD.
So a lot of the symptoms ofPTSD are sympathetic nervous
system related and this is likeshutting that down for a moment
(41:48):
and resetting.
Is that the concept?
Speaker 1 (41:52):
Yeah, so normally how we use sgb is for patients with
complex regional pain syndrome,so autonomic mediated pain
conditions, so dysfunctionalsympathetics, as well as
intractable v-fib, v-tach.
That's where we'll use it inthe er icu setting and this
would be for a mood disorder.
So what it's doing is thinkabout it like um, between the
(42:15):
brainstem and running all theway down the spinal column is
your sympathetic chain, likejust literally like a train
track, and the most activeportion is kind of at the T1
level.
And by temporarily shuttingthat down using a local
anesthetic, specificallyrepivacaine, we shut down the
(42:35):
sympathetic nervous system onone side.
The other side's so active forabout four to six hours.
Turn it back on.
When it's turned back on, itresets it and it creates these
long-lasting effects ofdecreasing norepinephrine levels
in the brain, decreasingactivity to the amygdala, and
that's how we think it's workinglong-term wise, even though the
ropivacaine wears off in youknow, 46 hours.
Speaker 2 (43:01):
That is fascinating.
We're going to have to do awhole show on that, because I
don't know that literature atall.
So I've just known about it forVFib, VF and these people who
are in this cataclysm surge thatmaybe we can shut it down.
Speaker 1 (43:11):
Well, if you're up for it, you can always come down
to Palm Springs.
I'd be more than happy to haveyou do a little.
Speaking of personal experience.
Speaker 2 (43:21):
No, if I need it, I'll get you.
It's good, sam, this has beenawesome.
I hope we get to talk to youagain about this.
I think this offers anopportunity for a number of
things For us as patients.
As I've been saying on thisshow, I think every ER doc
suffers from PTSD.
I think it is the nature of ourwork that we all suffer from
PTSD, and here is anothertherapy that can help us.
(43:44):
It's also an opportunity foryou to have some non-ER work,
and your skills are reallyneeded here.
I mean, the best person I wantto give me my ketamine is an ER
doc.
Thank you very much.
Has all of the experience usingit clinically the airway skills
.
I really like this idea that wehave ER docs in these clinics.
It really makes me heartenedthat that can extend your career
(44:07):
.
Fewer shifts in the ER is nottoo bad for you as well.
A couple less night shiftsAwesome.
So, sam, thank you for whatyou're doing and hopefully we
get to talk to you again aboutthis stuff soon.
Speaker 1 (44:18):
All right, I love that.
Thank you so much, mel.
It's been an honor talking withyou and sharing the information
.
Thanks.
Speaker 2 (44:24):
All right, Sam.
So what I'm going to do isgoing to edit that up and I'm
going to publish it on our showsoonish.
If you want to use any of it,feel free.
Or if you want to do adifferent interview where you're
the interviewer, I'm happy tojump on with you at any time.
Speaker 1 (44:37):
Yeah, I would love to interview you for the Can I
Mean Startup podcast and I'velistened.
I've read your book, Ire-watched Ace of Vegas 2018,
listened to Rob's podcast, againwith you Ken's podcast, so I
have a ton of questions.
But if you're up for it, what Iwant to interview you is like,
(44:58):
what was your ketamine therapylike?
Where were you at beforeketamine therapy?
What it's been like postketamine?
And then we can talk about EMand we can talk about adverse
childhood experiences, ketamineand just kind of like just
sharing the information of, yeah, it's so important.
So, yeah, I would love to doanother interview specifically
for the podcast yeah, let's dothat.
Speaker 2 (45:20):
I'm happy to do that.
Speaker 1 (45:22):
Let's just work out of time and I'll go through the
whole thing and I had no idea wewere 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 differentuh devices.
Speaker 2 (45:40):
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 (45:53):
what is that?
Speaker 2 (45:54):
adobe's adobe has a really great tool for cleaning
up audio.
You got to be careful with itbecause you can overdo it and it
can be a little too compressed,but fucking hell, it just takes
normal zoom meetings and makethem sound really good okay,
awesome, awesome you soundreally great and once I put it
through this thing it'll be likeoh, he was in the studio.
Like no, he wasn't.
Speaker 1 (46:16):
Well, I really appreciate it, and I listened to
Dirty White Coat all theepisodes so far, so I'm excited
for you.
You'll be coming up soon.
Speaker 2 (46:23):
Yay.
Speaker 1 (46:24):
Awesome.
Speaker 2 (46:25):
Great, great to meet you.
Let's just do some emailingwork at a time and we'll flip
the roles.
Speaker 1 (46:30):
Yeah, actually I wanted to ask you how
comfortable do you feel?
With getting into yourexperience and specifically with
ketamine, and I mean you'vebeen very open and vulnerable.
Speaker 2 (46:40):
Yeah, I just want to say to everybody it's this is my
job.
I believe that I have to dothis because of my role is
pretty prominent and our fuckingspecialty is suffering so much.
This is my job, so I amcompletely open with it, More
than I'd like to be, but it's myjob.
So I will tell you everychildhood fucking trauma and
(47:03):
everything about it, because Ithink our specialty in
particular medicine in general,but I think emergency medicine
is suffering and my job is toreduce the suffering.
So I'm going to fucking talkabout it until people are sick
of it.
Speaker 1 (47:16):
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'tknow if there's data for this I
think people who have fucked upchildhoods are more likely to go
into EM because we get addictedto the adrenaline and we're
just, like I'm, used to thestate of hypervigilance as a
child growing up.
(47:36):
Well, what specialty has thatall the time?
And what I make up is if wewere to look at the adverse
childhood experiences and runthem through all the specialties
, I think EM, maybe, ICU,probably, where it's just
intense all the time we wouldhave.
You know, I think there's acorrelation or association there
.
Speaker 2 (47:55):
Yeah, my therapist and I talk about all that time.
It's like I got to run away for40 years through med school and
through doing ER, all of thosethoughts because of what ER?
And then you stop, you retire,and then it's like you're
supposed to have your shittogether, right?
No, the fucking house of cardsjust falls down.
It's like, yeah, I've beenrunning away from this shit for
(48:15):
40 years and EA was a great wayto run away.
It's absolutely true.
Awesome, Sam, Talk to you soon.
Speaker 1 (48:23):
Let's get this thing done.
I'm looking forward to it.
Mel, Take care, you know you'reabout some dates.
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, lindauniversity, oh, yeah, yeah, I
would.
Um, I considered you one of myprofessors because I, you were
(00:21):
always in my, in my airpods or Iguess that was pre-AirPods but
whether I was in the car or onthe phone, just always listening
to MRAP you, rob Borman, scottWangard, joe Lex, greg.
Speaker 2 (00:34):
Henry.
Speaker 1 (00:35):
Yeah, yeah.
What were you there?
I was there from 2008 to 2011.
Speaker 2 (00:46):
Right, yeah there then still is yeah, lance brown
is, was there.
Speaker 1 (00:52):
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 therankings.
So, yeah, lance brown, and Ithink emily rose yeah, she went,
she did her pdm fellowship atloma, linda, and then went to
usc.
Speaker 2 (01:11):
Yeah, yeah, she did residency at usc, peds
fellowship at loma, linda, backto usc as faculty yeah and then
I think, she was on mrap a fewtimes too.
Yeah, she's been on mrap a lotwe've used her over the years
and board of you and all thatstuff.
Emily is just like the mostwonderful person.
Speaker 1 (01:30):
Yeah, yeah, very cool .
And then we, you and I,actually met, we at La Quinta,
at a Cal ASAP conference.
Speaker 2 (01:38):
Really, when was that Way back in the?
I think it was a long time.
Speaker 1 (01:40):
It must have been a long time.
I think it was like 2008.
Yeah, I think it was 2008 or2009.
Anyways, I'll send you apicture that we took.
Oh, that's good.
You were talking about what wasit called Like the lap band?
I think that was the talk aboutlap band and how to deal with
the complications associatedwith that?
I don't know it doesn't seemfamiliar.
Speaker 2 (02:02):
Usually I do cardiology shit.
Speaker 1 (02:04):
Yeah, but anyways, thanks for all of your work.
I'm so happy to be able toconnect with you and I'm looking
forward to it.
Speaker 2 (02:10):
Thanks for doing this .
Yeah, I'm just doing a.
I started a new podcast becausethere's all these controversial
topics and stuff that peopleget 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 orit's ketamine, whether it's sort
of um jfk, whatever, the fuckit is.
Speaker 1 (02:31):
So we just rfk yeah, rfk.
Speaker 2 (02:33):
Thank you, um.
So we decided to do a newpodcast and we've only done two
of them so far and they'rereally popular, people really
like them.
So I wanted to talk aboutketamine.
So I just interviewed a PhD inNorth Carolina about my
experience and how she selectspatients.
But then I think your spin willbe maybe we can focus a little
(02:57):
bit on what you're doing as anER doc and then how to get into
it, if that's what people wantto do and you know just sort of
talk about the business aspectsof it and the training aspects
of it.
I was saying to her I've givenketamine a thousand times but I
don't know how to do a ketamineclinic for depression, PTSD.
I don't know what the fuck I'mdoing.
I mean, I lower the dose.
Okay, that's not very helpful.
So that's what I want to talkabout.
Speaker 1 (03:19):
Yeah, it's a little different.
So I mean for me and mybackground.
So I did residency finished,worked at, you know, the
community hospitals andassistant professor, I was an
associate medical director and Ihad to make a decision of
whether to start up Academy andClinic in Palm Springs or be the
(03:39):
medical director of an ERdirector of an ER and I was like
, okay, which?
Which way do I choose?
You know, do I follow my heartor 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 havingtaken this opportunity.
So I took the leap.
I opened up the clinic in 2018.
(04:06):
I was actually, I'm the first ERdoctor to have ever opened up a
ketamine clinic in California.
And this is like back in thedays 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 otherEM folks hey, sam, how do I open
up a ketamine clinic?
So I helped up, you know,several colleagues and then
(04:27):
eventually I started a onlinecourse which is like synchronous
and asynchronous training, andso far we've helped 16, 17
clinics open up nationwide.
And then we started the podcastrecently, which is one of the
reasons why I wanted to reachout to you, because when I heard
you on Rob's stimulus podcast,like you mentioned ketamine I'm
(04:49):
like what Mel ketamine?
I was like I got to get him onour podcast.
Speaker 2 (04:57):
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'redoing the thing, you're nights,
weekends.
Why ketamine?
What happened?
Uh, tell us that story.
How did you start getting intoketamine as a non-er doc?
You know, as er docs, we use itall the time.
Speaker 1 (05:17):
But yeah, so loma linda was one of the first
institutions where they wereusing ketamine for procedural
sedation.
They published like thelandmark article in 1990.
Steve Green Steve Green,analyst of emergency medicine
Like yes, it can not only beused in the operating room but
we can use it in the EDs.
(05:38):
So in my residency I was usingketamine all the time for
patients and procedural sedationnot only peds but for adults.
And then I came across a reallyfascinating article where they
were using ketamine for suicidalideation and I was like we got
all these patients who are on 72hour holds and we're kind of
just babysitting them until theyget transferred to a psych
(05:59):
facility.
So I started doing a deep diveinto the research of like hey,
what is this drug that we'reusing all the time for sedation
and how can it be used for mooddisorders?
And because I was familiar withit, I'm like, you know, I think
I'm gonna open this clinic up.
And I had initially, kind of inthe brainstorming phase, worked
(06:22):
with another ER doctor and ananesthesiologist and we were,
you know, the three of us werelike hey, let's start this up
and we're gonna open up in lomalinda and and it just kind of
fell apart.
I mean it wasn't not the rightpartners for the business, so
kind of put it on the backburner and then went back to it
with my wife, who is she's anophthalmologist and she's like,
hey, sam, like let this, I canhelp you, and at least as far as
(06:45):
like administrative, creativedirector, marketing, and so we
open it up.
But I would say you know,there's that saying, I think
Steve Jobs and his commencementspeech at Stanford.
He's like you can't really tellhow the path is going until you
look back, until you see itretrospectively.
So I look back on my life and Iwas giving ketamine to animals
(07:08):
back when I was in college.
We were doing variousprocedures and then emergency
medicine we're super familiarwith ketamine and then the
residency where I did mytraining just use ketamine all
the time.
And you know I've always beenkind of an entrepreneurial guy
as well.
I have an MBA.
So I was like you know what Iwant to do something where I can
really leverage my businessskills and it just kind of
(07:32):
coalesced into this ketamineclinic.
It's a reset ketamine and now,like, looking back, I'm like
this is what I was meant to bedoing, like I love my job, like
I literally it's one of the mostgratifying things I've ever
done, especially seeing patientswho have tried SSRIs, they've
tried ECT, they've tried TMS,they've tried you know all sorts
(07:53):
of stuff, and to be able tooffer them relief.
It's so gratifying, literallyit's.
It's just, it's nourishing,it's spiritually nourishing,
whereas in the ER it's a littlebit different.
Speaker 2 (08:11):
I mean, it's not as spiritually nourishing as you
and I both know.
So tell me that first clinicwho were you looking after?
What type of patients Did youhave?
A narrow focus, broad focus?
And then, how did you get theword out?
Like I have this clinic on thecorner, because it feels to me
(08:32):
like I only discovered ketaminewhen I was failing SSRIs and I'd
heard a little bit about it.
But it seems that now thatwithin a very short period of
time the neuropsychologicaleffects, neuroplasticity effects
, the antidepressant, PTSDeffects of ketamine sort of have
exploded, Now everybody knowsabout it.
So how many?
Speaker 1 (08:50):
years ago was that clinic and how did you first get
your first patients?
Yeah, so we first opened in2018 and it was very slow.
The first three months, I think, I did four treatments, the
entire like month and typicallythe standard treatment is six
sessions over a period ofroughly two to three weeks, as
far as the research goes, but itwas very slow.
Um, literally like googlesearch engine optimization.
(09:11):
Um, people were just looking.
They were looking for it forthemselves.
I even I thought I was going toget a ton of patients, so I
sent out letters to all thelocal psychologists and
psychiatrists and internists.
Ob-genyns didn't get any leadsor referrals because it was too
controversial.
This is seven years ago nowvery controversial.
(09:32):
So it was very slow, whichmeant I worked part-time in the
ER and I did part-time ketamineclinic and then, over time, just
word of mouth, people knewabout it I started getting more
referrals and it just grew andgrew and grew and then finally,
in December 2020, and that waswe had our daughter in 2020.
So it was just a goodtransition point where I worked
(09:56):
in the clinic or, excuse me, inthe ER for about a decade and I
was like you know what?
I think it's ready, for youknow it's time for a change,
especially with COVID and all ofthe stuff that was going on
with the pandemic, like I justneeded to transition out.
Speaker 2 (10:10):
Wow.
So what were your initialpatients and maybe you can
summarize the literature?
Speaker 1 (10:18):
The early, the first patients that I saw they were
mainly treatment resistantdepression patients that I saw.
They were mainly treatmentresistant depression and that's
where there's the most robustdata.
Um, and even now there's likenew england journal of medicine,
there was a recent publicationlooking at ketamine iv versus
ect, electroconvulsive therapy,and what they found in the study
(10:39):
that was published, I believe,october 2024, 2023, and they
found that it was just asefficacious as ECT and maybe
even more effective.
So initially we treatedtreatment resistant depression,
ptsd, anxiety, ocd so mooddisorders and then we also got
(10:59):
into the pain syndromes, sospecifically like fibromyalgia.
We also got into the painsyndromes.
So specifically likefibromyalgia, complex regional
pain syndrome, also known asreflex sympathetic dystrophy,
trigeminal neuralgia, so nerveor neuropathic related pain
conditions.
Speaker 2 (11:15):
So that study you're talking about is ketamine versus
ECT for non-psychotic treatmentresistant major depression New
England Journal, which was inMay 24th 2023, and found it to
be non-inferior and we'll gointo this article in more detail
later, but I just wanted totimestamp that.
So you're using ketamine forpretty traditional therapies, so
(11:36):
can you tell me what does itlook like when I go to your
ketamine clinic?
I want to sort of compare andcontrast, maybe with my
experience.
So what I did is I was failingSSRIs.
I went to my primary care doc.
There's a much longer storythere.
I was suicidal, it was fuckinghorrible.
And I went to this group atUCLA and I basically said look,
(11:58):
we have a private clinic and apublic clinic.
I decided to go to the privateclinic and they basically take
you to the nice little room inan office.
There's a doc there, there's atherapist there, you do therapy,
we did I am ketamine six timesover six weeks.
So how does it look if I go seeSam?
Do I have different options?
Do I have different routes?
Do I have different schedules?
(12:20):
What is sort of the bestschedule?
Do you change it depending onthe patient?
Speaker 1 (12:24):
Yeah, thank you for that.
So I think of ketamine therapyat our clinic in four phases.
The first one is preparation,the second phase is intentions,
the third phase is experienceand the fourth phase is
integration.
So by preparation, specificallyone week before their first
(12:45):
ketamine session, we give them abunch of exercises to do and I
understand they're in achallenging place, they may not
be able to do, you know,journaling or exercise or
getting adequate sleep, but asbest as possible, kind of
preparing the mind.
The next phase is theintentions.
So this makes our clinic alittle bit different.
Where I have the patient I saywhat do you want?
(13:06):
What's your definition ofsuccess?
What's your goal for ketaminetherapy?
And that's what the patientfocuses on during the experience
.
So, for example, someone'sintention can be letting go,
forgiveness, love, loving myself, healing my inner child.
You know, and everyone hastheir own intention and we do a
little bit of coaching todecipher exactly what that
(13:28):
intention is.
Next is the experience.
So the patient comes in.
We do it very safely, like,almost like procedural sedation,
icu level of monitoring whereI'm looking at their O2 sats,
I'm looking at their cardiacrhythm, blood pressure, q10
minutes, respiratory rate, andso it's continuous vital sign
monitoring.
(13:49):
We have oxygen available and weadd in kind of a holistic
approach, because we are inCalifornia, we're in Palm
Springs, so we got the woo-woofactor, some really calming
music, including beta waves,binaural beats.
We do offer aromatherapylavender, sage, orange, whatever
(14:09):
it is because the sense ofsmell is really a powerful sense
that we want to take advantageof and leverage.
And then so they'll have theexperience which, as you know
and I'm really curious to hearabout your personal experience
you know, I call thesenon-ordinary states of
consciousness, nosc, where theymay have memories or emotions.
(14:31):
You know, like I've hadpatients cry like literally we
give them eye shades and somepatients, like, each time this
eye shade is just like drenchedin tears that have been held for
10, 20, 30 years.
And then they'll have theexperience 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 raftingclass five rapids, you're not
(14:54):
going to control that river, soyou just kind of go with the
flow, witnessing, breathing,surrendering, allowing, once the
experience is done, which isroughly a 40 minute infusion.
So it's a little bit differentbecause when I use it in the ER
it's, you know, rapid, you knowfairly rapid push one to two
megs IB over one to two minutes,whereas with the ketamine
clinic it's 0.5 milligrams perkilograms infused slowly over 40
(15:21):
minutes and with each sessionwe will gently titrate that dose
up, so it might be 0.75 thenext time, or 0.9 mg per kg, the
next time 1.1 mg, you know, andeveryone has a different
tolerance and threshold.
And, yeah, the infusion will becompleted.
I give them 10, 20 minutes torecover and then I'll have a
(15:43):
debriefing session post infusionand so kind of like talking
about what their experience waslike.
And I'm not a psychotherapist,so we're not doing psychotherapy
, but I am curious to learn andto help them process their
experience and create a meaningfrom it within with an action
post infusion, something thatcan they can actually do how do
(16:04):
you?
Speaker 2 (16:05):
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 differentways.
Do you do it iv every time?
Why did you?
Speaker 1 (16:17):
choose that I do, it be 99.9% of the time.
So the beautiful thing about IVis it's 100% bioavailable.
So if I put in 45 milligrams,like I know, 45 milligrams is
going in the other routes ofadministration.
I am, for example, um it's andsome studies are showing this
(16:38):
that it can be, you know, quiteeffective.
But the bioavailability islower depending upon the
patient's.
You know body mass, if theyhave more adipose tissue or
muscle, or you know it could bevariable absorption and then the
other routes of administrationalso lower bioavailability.
So like sublingual it's, youknow, 20, 30% bioavailable, but
like sublingual it's, you know,20 30 bioavailable.
(16:59):
But I would say the mostimportant thing about the iv for
me at our clinic is I can stopit at any time.
Right, so it's a slow infusionif the patient is having
something come up an adversereaction, a panic attack,
anxiety, severe hypertension,because I've seen that like I
can stop the infusion, whereaswith the other routes I am in
particular like once it's in,can't get it out.
(17:20):
So uh, the yeah, it's a hundredpercent bio, bioavailable, we
can stop at any time and I havethe advantage of having an IV
now.
So if they need a little bit ofmidazolam if they need a little
bit of on dance a drawn if theyneed you know other.
You know some Toradol forheadaches like I, have access
(17:41):
that I could treat.
If they need some bloodpressure medicine, maybe some
labetalol like I, have a ton ofoptions available with the IV.
And I guess you know, if youlook at the research and the
science, like 95% of theresearch is doing it
intravenously.
Speaker 2 (17:56):
So what does that clinic physically look like?
Again, again, my experience wasin a nice couch with a comfy
blanket and some beautiful music, but very non-medical.
Felt very much like I was insomebody's lounge room and I was
chill.
Um, what you're describingsounds a little bit more like
it's in an office, a clinic oran ear.
(18:19):
How does it look and how do youget rid of the noises and the
crap that we do in the ear?
Speaker 1 (18:26):
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 andthe setting.
So anyone in the psychedelicspace may be familiar with this.
Set refers to mindset of theperson receiving the ketamine
and then the setting, theenvironment.
So we pay really consciousattention to this.
(18:46):
So specifically when the personis coming in, like you know
it's, it is kind of a clinicalsetting.
So I'm blending in likeallopathic, traditional vital
sign monitoring mix per gigs.
We make it really safe.
We have o2 tank available, youknow, on the emergent aed, like
anything like we're.
We're like really honed down onthat.
But then we add in kind of likea eastern approach, a holistic
(19:10):
approach, where we're doing theintention setting, the rituals,
the music, the eye shades, thearomatherapy, the debriefing,
setting the lights in adifferent temperature and tone.
So all of these little factorsto make it less clinical.
Now what's interesting is Ihave given ketamine IV in the ED
(19:30):
for someone with suicidalideation.
This was before I opened theclinic and I was like doing a
deep dive into the data.
I was like, huh, hey, chargenurse, do you mind if I use room
nine to give a ketamineinfusion?
And so we administered it tothis patient.
She didn't quite meet thecriteria for 5150, but I
realized that the set andsetting of an ER, especially a
(19:53):
chaotic ER with a lot of otherstuff 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'svery relaxing.
We take our time with patients.
It's not like a bunch ofpatients, you know, hey, there's
a patient in room three.
They're screaming and yelling.
It's like, no, everything iscalm and mellow.
Because I know that's going toimpact the patient's experience.
Speaker 2 (20:16):
Right, yeah, in the ERs we'll often see people have
a bad trip in quotation marksand in large part that's because
the ER is the worst place to dosomething like this, because it
is chaotic and it's loud andthere's noises and you can't
control the setting and whenthey wake up they might see
somebody vomiting or dying.
So that's probably why we see alot more of these emergence
(20:39):
reactions than in the clinicliterature.
So where are your clinics?
Are you sort of in the mall, orwhere do you physically put
them?
I mean, I know that there'sreally high winds in ones that
are basically in Malibu in$10,000 a night hotels.
How does yours look?
Speaker 1 (21:01):
hotels.
Uh what, how does yours look?
So ours is.
Well, the first one I had was avery small location, about 700
square feet, so super tiny, anda really quiet place in Palm
Springs, about five minutes awayfrom the airport.
Um, the one I have now, becausewe did grow in transition out
of that clinic, the one we havenow, it's actually in a medical
office building with probably 10to 20, maybe 30 other
physicians and clinics and, um,our space, the one we lease,
(21:25):
it's, you know, kind ofseparated so they'll come into
the medical looking environmentof the building, but then once
they come in it's like acompletely different vibe.
We have, you know, the wholegreen wall and the lightings and
comfortable couches.
So it's, it um's a medicallyprofessional looking place.
And what I love about our placeis right next to it is an
(21:46):
emergency department, so therecan be emergencies that occur
and if anything does occur like,all right, three minute drive,
the ambulance two minutes it'sliterally a block away.
Speaker 2 (21:55):
Yeah, the beautiful thing about ketamine is it is
such a safe drug, but, as weknow, no drug is completely safe
.
So I love this mixed model thatyou talk about.
So now you're gone from doingyour own clinics to training
people to go and make their ownclinics.
So here's Mel Herbert.
(22:17):
I'm very comfortable withgiving ketamine from the medical
point of view.
I don't know how to set up aclinic.
I don't know how to do thefinancing, I don't understand
the laws and I'm not apsychologist.
So how do you take me from MelHerbert, who knows how to give
ketamine, to relocate yourshoulder to Mel Herbert that
could actually successfully runa clinic?
Speaker 1 (22:37):
So for me anyone who's an emergency physician we
wear many hats and we have theskillset, I believe, to create a
business.
The biggest challenge, as youand I both know, mel, is that ER
docs we're not, and doctors ingeneral we're not taught the
(22:58):
business side, whether in medschool or residency.
Like we're taught the clinicalside but no one teaches us, hey,
how do I get an authorizationfor X, y, z, or how do I bill
properly, how do I order gauzeor syringes?
So the course that we have,it's ketaminestartupcom, it's a
12 week course and it'sessentially the roadmap or
(23:18):
blueprint for an emergencyphysician who is interested.
And we just walk you through,like, hey, don't reinvent the
wheel, man, like we already didit.
I already made all the mistakes.
Let me just share with you whatI've learned and yeah, I would
say that because, again, of themany hats that we wear as
emergency physicians, likecreating a clinic, it's totally
(23:39):
within your wheelhouse and it'ssomething that you can do and
there's nuances, right.
And so how do, how do I learnanything?
Well, I just learned fromsomeone who's done it before and
that's the skillset.
It's like, yeah, let me justtransfer everything I know, put
it from my brain and transfer itto your brain with repetition
and practice brain and transferit to your brain with repetition
(24:04):
and practice.
Speaker 2 (24:04):
How much does it cost , like what's the financial
outlay to do a sort of a smallto moderately?
Speaker 1 (24:07):
sized clinic?
Good question.
I think it depends on location.
So if someone's going to openup one in New York City,
manhattan, right, that's goingto be a very different cost
versus, hey, if you're going toopen one up in Nebraska, for
example, right, so there's thecost of living in space
malpractice insurance.
So I'll preface my answer withsaying that there's a ton of
(24:29):
variability depending upongeographic location.
If I had to put a hard number onit, I would say anywhere from
75K to 150, 50 K initially forthe build out process and of
course, you want to have somemoney set aside to pay rent,
insurance, staff et cetera.
You know we call this therunway, just in case it is slow,
cause typically what I've seenwith our other students, like it
(24:51):
can be slow, especially ifyou're opening up a you know a
clinic.
It's like, yeah, people may notknow about you, it takes time
for Google SEO to pick up yourclinic's website and stuff.
So anticipate that and don'thave a huge overhead, but keep
things lean.
Maybe continue workingpart-time in the ER or doing
whatever you're doing clinically.
(25:12):
Have that financial stabilityas the clinic volume ramps up.
Speaker 2 (25:16):
And what do you think ?
The utility of hiring a trainedpsychologist versus just the
experience itself, maybe alittle bit of extra training
versus having somebody that doesthis for a living outside of
the ketamine?
Speaker 1 (25:29):
Yeah.
So we find that some clinicsare actually doing this where
some of our students they'relike one guy, he's an
anesthesiologist and hepartnered with the psychologist
and they co-created the clinictogether.
So that's also known asketamine assisted psychotherapy,
where they're getting theketamine and then they're
engaging actively in adiscussion with the psychologist
(25:52):
or therapist.
So that is one model of how todo it.
At our clinic we do it a littlebit differently where I'm doing
higher doses of ketamine.
So they're getting pretty notfully dissociated, but quite
dissociated, sub dissociated,where they're not really
engaging or talking like we wantto go deep, we want to hit the
NMD receptors hard when to getas maximal effect.
(26:14):
But what I do recommend and Icall it, refer to this as the
integration is like have anappointment with your therapist
or psychologist 24, 48, 72 hourspost infusion so that the
things that have come up duringthe experience can be processed
with, you know, the therapist.
So I think it can work bothways, where you actually have
(26:37):
someone in-house or where yououtsource it, maybe even hire
them as an independentcontractor.
But I don't think it has to bedone within that same time
period, and the reason being isneuroplasticity of ketamine.
It's not just during theinfusion, but it's 24, 48, 72
hours, and we're going to takeadvantage of that time period,
yeah, so you brought up a reallygood point hours, and we're
(26:59):
going to take advantage of thattime period.
Speaker 2 (27:00):
Yeah, so you brought up a really good point.
There's the effects of ketamine, which are neurochemical,
neuroplastic, separate from thetherapy.
I did ketamine-assistedpsychotherapy so I was with a
therapist before, during, afterand I found that very useful.
I don't know yet.
We're going to, in our nextinterview, be talking to a group
that does ketamine-assistedpsychotherapy.
About what's the literature?
How much of both do you need?
(27:21):
What do you do if it's mostlyPTSD or if it's depression or if
it's childhood trauma?
How do you define which way togo?
Do you have any opinion on that?
Do you like ketamine's going tohelp everybody?
Maybe some people needpsychotherapy.
Speaker 1 (27:36):
I don't know, I don't think it helps everyone.
The studies are showinganywhere from 60 to 80% benefits
and in particular with, likeyou know, measurement
instruments PHQ-9.
So, all right, here's the way Ilook at it.
The initial studies on ketaminewere done in the rodent model,
so rats and they have models ofdepression in the rodents and
(27:58):
one of them is called, like, theforced swim test, where if a
rat is not willing to swim aslong and they just put them in a
tub and they're like, well, howlong is this rodent going to
swim for?
And the longer that they'rewilling to swim is associated
with less depression, right, andif they give up swimming, then
that's like more depression.
So these rats were not gettingpsychotherapy, they were not
(28:20):
getting um counseling pre andpost.
So we know that even withoutthe therapeutic, without therapy
, like, it's still beneficialbecause it's creating changes in
the brain.
Now, adding, because we knowwe're not rodents for the human,
adding that psychotherapy canbe beneficial.
I don't think there's been anystudies comparing directly head
(28:42):
to head, but what I would say isthat ketamine, independently,
with or without psychotherapy,can be quite robust and
beneficial for the patients.
Speaker 2 (28:56):
Those rodent studies.
I find so funny that we'vedecided that the rat continuing
to swim must be because he's notas depressed.
I want to live.
It's an interesting model wherethe literature that I first
read about was basically givingsingle dose ketamine for another
procedure in somebody that alsohappened to be suffering from
depression, who then later cameout of that after having the
procedure done, going.
Oh my God, I've not felt thisgood in years.
(29:18):
And so there was clearly anindependent effect of the
ketamine itself.
Then it wore off, and that'swhen we realized, oh, one dose
isn't enough.
So tell us about your dosingschedule.
One dose, fine, for a few daysor a week, but where are we
right now with how many doses tohave a more prolonged effect?
Speaker 1 (29:35):
Good question.
So the initial studies were onedose and then they were like,
yeah, it's kind of wearing off.
So the standard it's sixsessions and there's two studies
.
One study did it three times aweek, so Monday, wednesday,
friday.
Monday, wednesday, friday, weektwo.
And then other studies areshowing twice a week for three
weeks and then even more recentdata is showing once a week for
(30:00):
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 boostersessions, maybe rough, every one
to three months depending onthe patient.
Some patients need it morefrequently, some patients need
it less frequently.
Speaker 2 (30:21):
Yeah, I did the once a week for six weeks and then, a
number of months later, did twomore sessions and I wasn't
aware of what the literature was.
I just went with my team andfor me that worked great.
Speaker 1 (30:39):
Yeah, so we're seeing some patients who just do the
initial six with completeremission, and then other
patients are getting, you know,monthly or every two months,
boosters for maintenance.
But I kind of think of ketaminein a way as a catalyst.
So doing the initial six andthen using that activation
(31:00):
energy, if you will, to make thechanges that one needs to make
or gain the insights or theideas, so I think that's really
important.
So it's a little bit differentin how I approach it.
It's not like, hey, everyoneneeds to do it and you need to
just need to do this for therest of your life.
It's like, well, maybe we needto, you know, engage in
psychotherapy If someone's likeyou know previously not doing it
(31:21):
and then don't get back into it.
Or maybe even using variousantidepressants Like I've had
patients where they're like,yeah, that didn't work for me,
that Prozac or Welbutrin, andthen after the ketamine therapy
they will restart one of theseother meds and it's like, yeah,
actually now it's working.
Speaker 2 (31:40):
Tell us about the legalities of ketamine.
Does it differ from state tostate?
Can anybody get it?
Do you have to have aphysician's license?
Speaker 1 (31:48):
How does that work?
Yeah, so ketamine is schedulethree per DEA regulations,
meaning it's a controlledsubstance.
So the DEA just for folkslistening, there's, you know,
dea schedule one, which is likeillegal and not allowed to use,
only under research settings,schedule two, which is like
hydromorphone fentanyl, and thenyou got schedule three, which
(32:11):
is lower risk, and then there'sschedule 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 DEAregulations that one needs to
abide by to act.
To actually order ketamine youneed to have a DEA license, so
that can be a nurse practitioner, a physician assistant, it can
be an MD, so someone with anactive DEA license that is
(32:32):
allowed to prescribe controlledsubstances.
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 andnot have an adequate record
keeping of that.
And then the other importantthing to consider is it's not
just the ketamine but it's aboutwho can own a medical clinic.
(32:55):
So, for example, in Californiawe have the corporate practice
of medicine laws, meaning thatif you're not a physician you
cannot open up a medical clinic,whereas in Florida state, for
example, like anyone can open upa medical clinic.
They don't have to be alicensed professional, so they
would have to consult with theirlawyer of like who can actually
open up a medical clinic in mystate.
Speaker 2 (33:18):
Have you had personal experience with ketamine?
Some clinicians we talk to saythat we think everybody who's
giving ketamine should have usedketamine and others like no.
I don't think that's true.
Not everybody that has needs todo that.
So where do you stand?
Speaker 1 (33:34):
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 toexperience it.
Well, does every doctor whogives IV Dilaudid need to
experience IV Dilaudid or VersedLike that's psychoactive, or
(33:55):
can they give it knowing that itcan help?
And then the other argument islike well, these people are
having the psychedelic,non-ordinary state of experience
, state of consciousness.
The provider should know how todo 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 someexperience with various other
(34:21):
substances that have been prettymind blowing.
And it's, it's transformational, really, and in the right set
and setting, with the rightintention, I think it can help a
lot of people yeah.
Speaker 2 (34:34):
So I come down on your side of the argument, in
fact, most people here.
I think that, um, it's helpfulbecause it is such a different
experience.
I mean I wish I had have hadketamine at the beginning of my
clinical career to explain topeople who are getting ketamine,
even in the here's, what thisis going to be like, and I
couldn't tell them because theywould just tell me afterwards
(34:55):
wow, I can't explain what justhappened, like I know it's such
a bizarre state.
Now, having done it, I could bemuch better physician to them.
So I think there's an argumentthere.
But I also agree you don't haveto have kids to know how to
look after kids, and you don'thave to get drunk to know how to
look after somebody who's drunk.
But I think it's probably avery powerful and useful thing
to do in the right setting.
(35:16):
And so maybe one of the last fewquestions is you talked about
different agents.
So we've got psilocybin, we'vegot LSD, we've got MMDAs, we've
got a litany of drugs.
What's the best one?
We're using ketamine, in mymind, because it's available,
and again I hear arguments onboth sides Well, it actually
might be one of the best, versusit's not really the best, but
(35:37):
it's available, so we use whatwe've got.
Where do you stand on thisargument?
Speaker 1 (35:42):
I've been thinking a lot about this question and for
me, I think about medicine and Ithink 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 andbank, or do I need to?
You know, consider, you know, adifferent, maybe it's, maybe I
(36:02):
need to do an antiviral, maybe Ineed to do an antifungal.
So I don't know if there's onebest right, like there's not one
best antibiotic for pneumonia.
It really depends on you knowwhat type of pneumonia I'm
treating, right.
So same thing with mentalhealth.
It really depends Ketamine maybe effective for that patient or
they may need anothermedication.
Maybe they do need MDMA orpsilocybin or 5-MeO-DMT or
(36:27):
ayahuasca or salvia divinorum ornit nitrous oxide or propofol
or the 10 to 20 othermedications that are in FDA.
So I don't think it's one, butrather it's one tool amongst
many tools, and let's figure outwhich one it is for that
patient.
Speaker 2 (36:45):
Many of the ones that you listed are not legal and
that's why they're not beingused.
So, um, that's for people whoare sort of the lay public
listening.
There's one reason that we'renot using a lot of these is
because they're not legal.
There's not necessarily logicbehind that, um, because, as we
know, we've talked about on thisprogram before, a lot of these
(37:06):
drugs were being used, um in the60s, 50s, and then there was
sort of this political thingslike we should get rid of all of
them.
That's bad, instead of studyingthem 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 outhow to use these drugs and now
we're only now coming back like,hang on a second, we should be
(37:26):
studying these.
So that's why I think ketamineis being used so much right now
is because it's legal and manyof these other very powerful
agents are not.
Speaker 1 (37:36):
A hundred percent and so you know for the listeners.
What happened was in the 1950sand 60s.
There was a ton of LSD researchhappening but then it got
leaked out into the public.
You may have heard of a Harvardeducated professor named
Timothy Learyary and he wantedeveryone on lsc.
You know he had the ones sayinglike tune in, drop in, drop out.
(37:56):
And that created this politicalbacklash where richard nixon
was like, hey, these people whoare doing lsc, like they don't
want to go to the vietnam war,like we need to quash this.
And so then the controlledanceAct came in 1970 and it shut
down everything.
It turned it into a scheduleone illegal drug.
But I will say the research waspaused for about 30 years and
(38:22):
then there are things changingand there's laws changing.
So, for example, in Colorado,psilocybin is legal.
In Oregon State believe it'slegal.
Um, people can.
It's not as accessible.
But in other countries brazil,costa rica, peru, colombia, etc.
Uh, australia or, excuse me, Idon't know about yeah, australia
just recently approved mdmatherapy.
(38:43):
Uh, south africa.
So in the united states what ismost easily readily available
and safe is ketamine right.
Speaker 2 (38:52):
yeah, australia is uh .
It's legal since july 2023 touse m?
Uh, mdma, um.
It's really interesting for mepersonally, because my mother
suffered from depression and inthe 60s, uh was getting lsd
therapy, um, and then she wasn'tallowed to do it anymore
because laws changed there aswell.
(39:14):
So it's fascinating that we'vecome around all this way.
It's taken us so long, but herewe are, back to understanding
that these are powerful drugs.
We need to study them and theyoffer an enormous amount of
relief to people in the rightcircumstances.
So do you have any finalthoughts for Sam?
Tell us your website again.
(39:34):
I need to say explicitly I'mnot in business with Sam, but
he's an ER doc, and so he'scertified ER doc in California.
That doesn't mean he's not apsychopath.
It just reduces his chance ofbeing one and me substantially.
So what's the name of your site?
Okay?
Speaker 1 (39:52):
So the name of the site for that.
So it's ketamine startup, k E TA M I N?
E startup S T A R T?
U, pcom, all one word.
I do want to mention one lastthing, and this is also
something right up emergencyphysicians alley, something
right up emergency physician'salley, and it's it's a, not a
psychoactive, it's called thestellate ganglion block SGB, and
(40:20):
you may or may not have heardof this, mel, but it's a really
bad-ass procedure.
It's so cool where we go in tothe neck using ultrasound
guidance C6, c4 level, find theexact target structure of where
we want to be, which is abovethe longest coli, next to the
carotid artery, next to theinternal jugular vein, use a
special echogenic needle, 25gauge, go in real-time
(40:44):
ultrasound, we numb up themiddle and superior cervical
chain which goes down into thestell cell ganglion and bottom
line is it resets thesympathetic nervous system and,
in particular, very effectivefor PTSD symptoms.
And that's something that I'vebeen incorporating in my private
(41:04):
practice clinic at ResetKetamine, where I'm just started
offering this very coolprocedure for patients and
getting amazing results.
They've done randomized placebocontrolled trials on this.
This is not some, you know,voodoo thing like scientific,
evidence-based medicine, but theSGB is a really cool procedure
that we can do to help patients.
Speaker 2 (41:26):
Yeah and I should say a plug for MRAP that July 2024,
jaylen Avila has a greatultrasound guide Stirlit
Ganglion Block video that youcan go check out, if this is not
something that you're doing.
I didn't realize.
I didn't know that this wasbeing used for PTSD.
So a lot of the symptoms ofPTSD are sympathetic nervous
system related and this is likeshutting that down for a moment
(41:48):
and resetting.
Is that the concept?
Speaker 1 (41:52):
Yeah, so normally how we use sgb is for patients with
complex regional pain syndrome,so autonomic mediated pain
conditions, so dysfunctionalsympathetics, as well as
intractable v-fib, v-tach.
That's where we'll use it inthe er icu setting and this
would be for a mood disorder.
So what it's doing is thinkabout it like um, between the
(42:15):
brainstem and running all theway down the spinal column is
your sympathetic chain, likejust literally like a train
track, and the most activeportion is kind of at the T1
level.
And by temporarily shuttingthat down using a local
anesthetic, specificallyrepivacaine, we shut down the
(42:35):
sympathetic nervous system onone side.
The other side's so active forabout four to six hours.
Turn it back on.
When it's turned back on, itresets it and it creates these
long-lasting effects ofdecreasing norepinephrine levels
in the brain, decreasingactivity to the amygdala, and
that's how we think it's workinglong-term wise, even though the
ropivacaine wears off in youknow, 46 hours.
Speaker 2 (43:01):
That is fascinating.
We're going to have to do awhole show on that, because I
don't know that literature atall.
So I've just known about it forVFib, VF and these people who
are in this cataclysm surge thatmaybe we can shut it down.
Speaker 1 (43:11):
Well, if you're up for it, you can always come down
to Palm Springs.
I'd be more than happy to haveyou do a little.
Speaking of personal experience.
Speaker 2 (43:21):
No, if I need it, I'll get you.
It's good, sam, this has beenawesome.
I hope we get to talk to youagain about this.
I think this offers anopportunity for a number of
things For us as patients.
As I've been saying on thisshow, I think every ER doc
suffers from PTSD.
I think it is the nature of ourwork that we all suffer from
PTSD, and here is anothertherapy that can help us.
(43:44):
It's also an opportunity foryou to have some non-ER work,
and your skills are reallyneeded here.
I mean, the best person I wantto give me my ketamine is an ER
doc.
Thank you very much.
Has all of the experience usingit clinically the airway skills
.
I really like this idea that wehave ER docs in these clinics.
It really makes me heartenedthat that can extend your career
(44:07):
.
Fewer shifts in the ER is nottoo bad for you as well.
A couple less night shiftsAwesome.
So, sam, thank you for whatyou're doing and hopefully we
get to talk to you again aboutthis stuff soon.
Speaker 1 (44:18):
All right, I love that.
Thank you so much, mel.
It's been an honor talking withyou and sharing the information
.
Thanks.
Speaker 2 (44:24):
All right, Sam.
So what I'm going to do isgoing to edit that up and I'm
going to publish it on our showsoonish.
If you want to use any of it,feel free.
Or if you want to do adifferent interview where you're
the interviewer, I'm happy tojump on with you at any time.
Speaker 1 (44:37):
Yeah, I would love to interview you for the Can I
Mean Startup podcast and I'velistened.
I've read your book, Ire-watched Ace of Vegas 2018,
listened to Rob's podcast, againwith you Ken's podcast, so I
have a ton of questions.
But if you're up for it, what Iwant to interview you is like,
(44:58):
what was your ketamine therapylike?
Where were you at beforeketamine therapy?
What it's been like postketamine?
And then we can talk about EMand we can talk about adverse
childhood experiences, ketamineand just kind of like just
sharing the information of, yeah, it's so important.
So, yeah, I would love to doanother interview specifically
for the podcast yeah, let's dothat.
Speaker 2 (45:20):
I'm happy to do that.
Speaker 1 (45:22):
Let's just work out of time and I'll go through the
whole thing and I had no idea wewere 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 differentuh devices.
Speaker 2 (45:40):
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 (45:53):
what is that?
Speaker 2 (45:54):
adobe's adobe has a really great tool for cleaning
up audio.
You got to be careful with itbecause you can overdo it and it
can be a little too compressed,but fucking hell, it just takes
normal zoom meetings and makethem sound really good okay,
awesome, awesome you soundreally great and once I put it
through this thing it'll be likeoh, he was in the studio.
Like no, he wasn't.
Speaker 1 (46:16):
Well, I really appreciate it, and I listened to
Dirty White Coat all theepisodes so far, so I'm excited
for you.
You'll be coming up soon.
Speaker 2 (46:23):
Yay.
Speaker 1 (46:24):
Awesome.
Speaker 2 (46:25):
Great, great to meet you.
Let's just do some emailingwork at a time and we'll flip
the roles.
Speaker 1 (46:30):
Yeah, actually I wanted to ask you how
comfortable do you feel?
With getting into yourexperience and specifically with
ketamine, and I mean you'vebeen very open and vulnerable.
Speaker 2 (46:40):
Yeah, I just want to say to everybody it's this is my
job.
I believe that I have to dothis because of my role is
pretty prominent and our fuckingspecialty is suffering so much.
This is my job, so I amcompletely open with it, More
than I'd like to be, but it's myjob.
So I will tell you everychildhood fucking trauma and
(47:03):
everything about it, because Ithink our specialty in
particular medicine in general,but I think emergency medicine
is suffering and my job is toreduce the suffering.
So I'm going to fucking talkabout it until people are sick
of it.
Speaker 1 (47:16):
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'tknow if there's data for this I
think people who have fucked upchildhoods are more likely to go
into EM because we get addictedto the adrenaline and we're
just, like I'm, used to thestate of hypervigilance as a
child growing up.
(47:36):
Well, what specialty has thatall the time?
And what I make up is if wewere to look at the adverse
childhood experiences and runthem through all the specialties
, I think EM, maybe, ICU,probably, where it's just
intense all the time we wouldhave.
You know, I think there's acorrelation or association there
.
Speaker 2 (47:55):
Yeah, my therapist and I talk about all that time.
It's like I got to run away for40 years through med school and
through doing ER, all of thosethoughts because of what ER?
And then you stop, you retire,and then it's like you're
supposed to have your shittogether, right?
No, the fucking house of cardsjust falls down.
It's like, yeah, I've beenrunning away from this shit for
(48:15):
40 years and EA was a great wayto run away.
It's absolutely true.
Awesome, Sam, Talk to you soon.
Speaker 1 (48:23):
Let's get this thing done.
I'm looking forward to it.
Mel, Take care, you know you'reabout some dates.
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