No: it’s a word we’re all familiar with and have heard from an early age. “No, you can’t have another popsicle.” “No, you can’t go over to your friend’s house.” “No, you can’t have your own island in the Caribbean.” At a young age the word seems like more of an inconvenience but as we grow older, and hopefully wiser, we realize that the word no is sometimes just the easy answer when those in the position to make decisions don’t want to be bothered or, even worse, don’t want to educate themselves on a given topic. Take the various regulatory organizations you may interact with for example. In a previous life I was responsible for the regulatory compliance of a smaller aviation operation. Due to our overall compact size and organizational structure we prided ourselves on our ability to perform a lot of specialized work at a moment’s notice, a feat that generally seems to become a bit more complicated proportional to the number of lines on a company’s organizational chart. The specialized nature of our work led to a lot of aggressive negotiations with the various alphabet soup regulatory organizations simply for the reason that what we were trying to do did not fit the standard mold of what aviation companies were supposed to do. In the world of public use aircraft there are little restrictions regarding operations that you can and cannot perform however when you’re trying to fit those same specialized operations into the restrictions placed on a commercial operator your inspectors’ faces start to cringe and you hear the word no a lot. After a while the word no seems more like a comma than an actual word.
While on some occasions the word no precipitated a lot of creative thinking regarding how we could perform the operations we needed to within the confines of imposed regulatory restrictions. More often than not it became an educational session for all involved parties to develop a mutually agreeable solution. A major portion in these educational sessions, if you will, is to have the right parties at the table. By that I mean people that are willing to educate themselves on all aspects of an issue, hear opinions that differ from their own and base a decision on information presented rather than personally held beliefs alone.
Segue the above story into the EMS and transport medicine industry, specifically when it comes to the use and administration of Ketamine. First appearing in the 1960’s, Ketamine was a popular anesthetic due to the dissociative state that it left patients in. To quote a friend and former co-worker, “…it separates the brain from the pain.” Combine the induced dissociative state with the sedative, amnesic and analgesic effects, how could you go wrong? Unfortunately, it was seemingly these hallucinogenic effects that ultimately led to Ketamine’s fall from favor. It wasn’t until the 1990’s that Ketamine re-emerged from the ashes with renewed interest in the potential uses for the medication. Nearly thirty years following the re-emergence of this medication, and countless studies, medical directors, and even facilities as a whole, still remain hesitant in its utilization. As such the easy answer is, once again, no. One must ask themselves why the hesitation. Was a doctor, now turned medical director, once witness to a bad emergence reaction so now the blanket answer is no? Is it a general lack of understanding regarding the mechanism of actions at the various dosing regiments so, once again, the answer is no? Is it a general disregard for the medication because of the most dangerous words in any profession: “we’ve always done it this way”? Whatever the reason, services that do not currently have Ketamine approved in their protocols owe it to their patients to discuss its addition with their medical directors. Sit down and have a discussion with them regarding potentially updating your protocols. Don’t just go in and ask for a change simply because “everyone else is using it” though. Present legitimate medical evidence and rationale regarding your position. Would your medical director be amicable to its use on a trial basis? Crawl, walk, run.
I’m fortunate to work for a service where our protocols are very liberal and allow a practitioner quite a bit of leeway in how they treat their patients and while I don’t utilize Ketamine on an overly frequent basis, the times I have I’m very glad I had it at my disposal. I work with quite a number of individuals that still get that terrified look when you even think the k-word. In talking about it after the fact it is usually because they had a bad experience once and are now hesitant in its use thereafter. After a chat and a bit of education, most of my coworkers that were once hesitant in the use of Ketamine are utilizing it on a more regular basis themselves. Full disclosure here, I used to get that same fear and look when I first had Ketamine at my disposal too. It wasn’t until I took that fear and used it to educate myself on the medication, and even started to utilize it myself, that I gained a comfort level with it.
While Ketamine is not the proverbial magic bullet, it is a valuable tool to have in the toolbox and one that, properly utilized, its advantages far outweigh its disadvantages. Presenting an accurate and rational argument substantiating a request for a new medication or procedure, not necessarily just Ketamine, you may just be able to turn a “no” into a “maybe” or even a “yes”.