As a an emergency room doctor married to a psychiatrist, I have had the opportunity to see how varied the landscape of western medicine is. Each specialty has its own vocabulary, assumptions, and metaphors. Working in the emergency room, one of my main sources of enjoyment is the fact that I have access to so many specialists. Being able to pick up a phone and call someone who has devoted their career to the deep understanding of a complex system is like wandering a buffet of intellect. My experience is that the best way to make a thoughtful treatment plan is to talk to several specialists and focus on their points of agreement. These intersections among differing perspectives, to me, offer the best glimpse of truth.
Intersection One
Several years ago in the emergency room, I was taking care of a patient that we had seen many times for opioid use disorder and frequent overdoses. The patient suffered heavily from their addiction to narcotics and I, and most of my partners, had placed them on a ventilator multiple times for overdoses. This same patient also suffered from severe asthma and on the day that I was seeing them, they were suffering both from a significant overdose and an asthma exacerbation. When the decision was made to put them on a ventilator, we chose ketamine as a sedative because it also has beneficial properties for asthma. The patient was admitted to the ICU and we moved on to other patients in the department. Several weeks later, I again saw the patient, but they were clean, articulate, sober and in the ER for reasons unrelated to substance abuse. When I asked them about their last hospital stay, they told me "When I woke up in the ICU, I just didn't want to go back to using."
As far as evidence based medicine goes, this counts as an anecdote, not as meaningful evidence of anything in particular. But, I had been reading about ketamine as a treatment for depression and it really stimulated my curiosity. Had the use of ketamine potentiated a significant change in this patients' mental health? This prompted a lot of discussion between my wife and I. She, as an integrative psychiatrist, is passionate about moving away from our current paradigm of lifelong medications for symptom management and ketamine was becoming more widely discussed in psychiatry as a potentially useful therapy. I was very familiar with ketamine as a medicine in the ER and it is one we use frequently because of how safe it is. It is our sedative of choice for children who require otherwise painful procedures because it is unlikely to have concerning side effects.
This overlap between psychiatry and emergency medicine was thought provoking. Within my specialty we had a deep knowledge of how to use ketamine safely with over 30 years of research and experience using it in high doses as a sedative. In psychiatry, research was showing that ketamine at lower doses could work well as a powerful and fast acting treatment for depression, but psychiatrists had little familiarity with using the drug. Researching it together was a rare opportunity for my wife and I to collaborate on a project besides dinner and housecleaning. The outgrowth of this research is our protocol of ketamine assisted psychotherapy (KAP) combined with nature connection for the treatment of depression, anxiety, trauma, and assistance with life transitions that we use at Asheville Integrative Psychiatry. The addition of nature connection therapy was based on her prior experiences with prescribing nature and working outdoors with clients and our shared belief in the ability of nature to nourish each individual's inner healer.
Intersection Two
A second area of overlap between psychiatry and emergency medicine is in the concept of trauma. This commonality was not obvious to me when I first started hearing the word "trauma" used in mental health. Initially, it seemed very different from the life and limb scenarios that we see in the ER. But, if we consider trauma to be an event which necessitates regrowth, then physical and psychological trauma begin to seem very similar. In the ER, it is rare that we are truly repairing or undoing trauma; we are just trying to create the conditions that potentiate functional regrowth. With the use of psychedelic assisted psychotherapy and nature connection therapy, our goal is not to remove or excise trauma but to create the conditions that allow regrowth from the injury.
My wife, Dr Tiffany Sauls, is currently the principal investigator for the MAPS expanded access program using MDMA assisted therapy for treatment of PTSD and I am a site physician for the same. Even with our different backgrounds and perspectives, it is clear to us both that people can learn to activate their inner healer in a way that allows them to move forward from the life-interrupting insult of a severe traumatic experience. It will be a pleasure to be able offer this therapy when it becomes available in the near future.
As with so many things, it is our differences that provide the most fruitful grounds for learning. There was a point where I could not have imagined an intersection between psychiatry and emergency medicine, but as time progresses I see that, ultimately, the most powerful approach to healing is the one that best creates the conditions needed for our inner healer to flourish and to do what it is most capable of. Like so many other areas in life, the more we can bring our different experiences to bear on the same problems, the more likely we are to find meaningful solutions.
Josh Short MD
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