0:00 - 2:30 - Introduction
2:30 - 8:00 - Dr. Jones's Background and Path to CRPS Awareness
8:00 - 14:00 - Building Trust with Patients in Pain Management
14:00 - 21:00 - Effective Communication and Tailored Treatment Approaches
21:00 - 27:00 - Approach to Diagnosing and Treating CRPS
27:00 - 35:00 - Role of Ketamine Therapy in Treating Pain and Mental Health
35:00 - 42:00 - Research, Education, and Advancements in Ketamine Therapy
42:00 - 48:00 - Holistic and Personalized Pain Management
48:00 - 53:17 - Closing Reflections and Dr. Jones’s Mission
Would you mind sharing with us how you came to know of CRPS and what caused you to want to learn more about it and to treat it? Certainly I grew up in a very underserved rural part of Louisiana. Most of my background was education and agriculture. I actually did animal science pre vet in college, seriously considering doing large animal medicineand had a change of gears midway or toward the end of college and decided to go to medical school. And so I did research in both areas. I shadowed both types of physicians. And once I made the decision, I was fully committed in that direction. However, that initial direction was to do rural family medicine.
Because I was from a rural area and I was thinking about rural veterinary medicine. So I said, well, I may as well do rural family medicine. And midway through med school, I did an anesthesia rotation considering if I was going to be in a very rural area, and perhaps the only doctor for miles around, I needed to be capable to handle whatever came through the door.
So I did an anesthesiology rotation and found that I was very well suited for that environment to get people to relax very quickly, to establish some rapport, to help patients calm down, but also think very quickly on my feet and have good hands for procedures. Thank you very much. So I had another mid med, I had a mid med school crisis and switched to anesthesiology, but my exposure to CRPS Which is a pain related diagnosis, which maybe is part of the path that ultimately led me to anesthesiology Actually, I call it my first lesson in medical school And so I was flying from Louisiana to California to start medical school at Stanford And there was a young lady on the plane sitting beside me, and a small conversation started.
She learned I was going into medical school, and she's like, Cool, have you heard of RSD, or the new name is CRPS? I have. And I said, No, ma'am, I don't, but I'm all ears. And so I got my first lesson from medical school from a patient on the way to medical school who had CRPS. And she asked me to do my best to try to find some additional treatments and cures, and that was over 20 years ago, so that was my first exposure to CRPS.
I had dealt with pain treatment in animals before people's pets, dogs and cats, but mostly in horses mostly rodeo horses or racehorses or pleasure trail horses. Wow, that's a very neat story to learn from a patient on the way to medical school. I like that a lot. It seems sometimes our patients helping patients at times is the best for the least of the tips and the tricks.
Absolutely. I remember having a professor who I was picking her brain on clinical research, and she said she spun her and didn't make much progress for many years until she was at a community gathering. In Oakland, California, and she was explaining the research that she wanted to present for this community, and it's the low lady in the front row stood up and said, you know what your problem is, baby, you come in here and telling us what we need instead of asking us what we need.
That has also stuck with me to try to. Meet patients where they are and see what their needs are, and then take the scientific and evidence based knowledge that we have to try to apply it to that request. That's, I think, difficult at times because when patients have tried so many things, whether they're open to trying something new or willing to take a risk or just try something different is difficult at times.
Or just being willing to trust a physician. So if you're met with that, what do you, how do you handle that? I try to establish some rapport, so find some commonality that we can discuss. But the bottom line is just figure, as part of that process, figuring out where that patient is physically, mentally.
Emotionally life, family job, and from there see what they're open to and let them guide that path. From the clinical standpoint some of it comes down to, is it a focal area where one particular nerve is involved, which gives me some tools that can actually focus on one nerve, or is it something more total body?
Where we need to look at something more of a systemic treatment. Some of those things we discuss a lot of the challenges is perhaps for lack of a better explanation, undoing previous experiences. If a patient comes in with something new, and I'm luckily lucky enough to be the first position they speak to, then it's an open book.
But I've had several patients who have told me that, Oh, I've tried that before and it didn't work. And, sometimes the response is that you have to get down to really, determine whether or not it truly did not work, or if it was not done in the correct way, or if it just wasn't the right modality for that particular patient.
One example that comes to mind is I had a, I was working at one of our facilities covering the anesthesia services, and one of the ladies who worked in that facility, beyond healthy, looked like she went to the gym regularly, was walking around with crutches. And I just met her so I wasn't going to probe too much, but after a month of her being on crutches, I asked her how things were going and she mentioned an injury weeks.
That was not healing and physical therapy wasn't working and she was resigning that she might be on crutches the rest of her life and she was in her 20s. And after visiting with her for about 5 minutes, I realized that she was having a neuropathy that was hyper, meet all the criteria for CRPS, but very similar treatment profile for a particular nerve in her leg.
And I insurance was a challenge for her. And so I talked to her about peripheral nerve stimulator and she said I can't do that. And I said, okay do you have a tens unit? And she said, yes, they've been having me put it on this muscle the whole time. I was like it shouldn't be over the muscle, it should be over the nerve.
And I showed her exact, I drew a line, I showed her exactly where to put it. Replace the tens unit to stimulate that nerve and two weeks later, she had no more crutches and went back to the gym. So it was a pretty amazing story and so she could have very easily told me I'm not going to try a tens unit because.
I've tried it before, which was true, but just a slight movement, literally about three inches of where she applied. It made all the difference. But I in that scenario, it wasn't a patient per se, but it was someone that I didn't just walk up to the very first day and say, let me tell you what to do.
And I had to establish some rapport and get to know her. And that's what is the trust factor. Thank you for sharing that. I really like that example, a lot of building that trust and that relationship and offering suggestions and not. Demands so much and I like that a lot of seeing what they're open to what they've tried and I think that it's very important that you brought up undoing what could have been done not correctly the first time.
And I think that as I've talked to more people, I've learned certain methods that certain treatments are done, and I. I can't help but think in my head how many people are walking around thinking, say, a nerve block doesn't work for them because it just wasn't put in the right spot or ketamine, it just wasn't the right dose or the right time frame, and it's hard to know that certain options have been closed to people in their minds because it wasn't Delivered to them correctly.
So I really like that. You brought that up and that you try to work past that and work with people and help them work through that. Yes, ma'am. The the other side of that same coin is. setting realistic and honest expectations. If I'm visiting with a patient, I will tell them there's a high likelihood or moderate likelihood that this may or may not work.
If it does work, then this is what you would expect. If I'm going to consider it not a successful therapy, then this is what you should expect. And if we get that point, then next steps would look like this or that. And so they go home having some idea of a larger plan rather than let me poke you right here and tell me if it worked or not.
Early on in my career, I can sometimes be a little long winded. Why use three words when 30 will suffice? But in me trying to be short winded with some patients and not disrespect their time by running over, I found that I needed that extra detail for some patients because for example, one patient came back to visit.
And they said, Oh, that shot didn't work. And this, by me telling them that they had probably two things going on, I had to ask them, okay tell me where the pain is at this point. And they, they said, in an area that we did not address. I said what about the area we did address? Oh, that pain's gone.
I was like great. We have, addressed one part of it. Now, let's move on to the next. And so it just takes a little bit of extra communication, effective communication, closed loop communication, and meeting people where they are. Walking around with a normal aptitude to speak English in the United States takes twelve to fifteen hundred English words Spanish is about the same, French is a little more but to be able to walk around as a physician and speak to other physicians in medical language, it takes five thousand words, but that doesn't mean we need to use all five thousand with our patients.
And in fact, sometimes I have to figure out what level of communication and understanding they have, and then start there, and then we can pick up on that point. And I, like that you make sure that they have that big picture, all the details, so we know what, we're doing, why we're doing, what to expect, what we can do next, and that part right there is really important, because I feel a lot of times, we get to the point of not having hope when we, try and try different things.
We might not fully understand what they're supposed to do. We just want some relief. So having that and having the hope that there's something else we can try if this doesn't take this time. And I was curious if we could talk about the different types of treatments that you would do and how you would evaluate what each client would need.
I'll true to what we just discussed, I'll start on the big picture and then drill down more specifically. But first I encounter CRPS from several different avenues. One is receiving them for the first time when things are very early on, which is an honor and a privilege to be able to be in that position.
Sometimes they've had things happen from various different people over the course of some extended period of time. And then there takes a little bit more trust building, because it's not just me that they have to trust, they have to trust the system and American medicine, period. But the other exposure I get on some occasion is expert witness review work for, pain procedures and seeing patients that have CRPS.
And I see the long term frustrations come out in a very different way. Oftentimes, One of the most common reasons for suits is that a patient feels abandoned. And so a lot of times I'll look at the chart and say, Oh, they didn't try this or didn't try that. Or I wonder how that could mean.
I wish I would have been a fly on the wall to see how the communication went with this because it's unfortunate that it has gotten to this point. So that's certainly very motivating to spend that extra time talking to patients and make sure that they feel heard, but also make sure that I feel understood by the patient.
And so drilling down a little bit. Oftentimes, I will approach patients that come in with pain that's neuropathic, meaning nerve related in nature, often radiating, which we call radicular. Then I'll start with an open mind with that and not jump down to CRPS. pathway because CRPS has a certain specific set of diagnostic criteria, but it's a continuum to some degree with other types of neuropathic pain and the treatments for all of them are quite similar.
So I look at it from that standpoint so that I make sure I'm not putting blinders on too early in the process to make sure we're hopefully Evaluating thoroughly before we were focusing on anything. Our pain clinic, which there's several of us that work together collectively, but our pain clinic will often see the patients.
The first line of therapy is physical therapy. And then whatever it takes to get them through physical therapy, which honestly is very similar to what I do in the perioperative setting when we're doing a total knee replacement or a total hip replacement, we want to get them through that process, let them know what to expect and then get them the physical therapy and do whatever it takes for them to engage in physical therapy, whether that be an air block or, just setting expectations, et cetera, because if you send a person to physical therapy and they're not, okay.
Mentally and physically ready for it, then it's has a less of a likelihood for success. So a lot of it is preparation and education. We can also do topical creams or lidocaine patches. There's, depending on the location, if it's a limited area, then there are certain blocks that can block primary nerves or the sympathetic nervous system to see if there's a response for that.
There are peripheral nerve stimulators that we place. One of which is a treatment peripheral nerve stimulator, but it actually is for a limited time period. So instead of implanting something and implanting a battery that's there potentially indefinitely the first line that I like to go to if it's a peripheral nerve that's the issue of peripheral nerve distribution is to place and nerve stimulator wire that's about the size of a hair, but the battery just sticks on a sticky pad on the, on your leg or on your arm.
And it stays in for eight weeks and 80 percent of patients that are well selected will respond very nicely to that. And then when we take the wire out, there are more devices that they have to go home with or live with. And about 80 percent of patients continue to have benefit from that. So that's a good modality to consider for certain situations.
If there's a broader distribution of pain, then cryoneurolysis or freezing peripheral nerves is another technique that I'll do. And we've talked about earlier in our conversations we talked about an ounce of prevention. The best way to treat CRPS is to not ever get it. We just don't always, we just don't always have a crystal ball.
But for high risk patients and for a lot of the patients that I see coming in or planning to come in for surgery, I'll get referrals to actually freeze the nerves going to the knee before the knee replacement ever occurs. Thanks. To minimize the risk of things happening. It's certainly a very broad and diverse option.
We'll ultimately also consider if need be central nerve stimulators or spinal cord stimulators or dorsal ganglion stimulators to help with certain situations as well. One of the things that is not, certainly not unique to our practice, but we have the oldest ketamine effusion clinic in the greater Houston area.
And we treat two large patients with that. Those with mental health diagnoses such as depression, particularly depression that has been resistant to other treatments including medications and electroconvulsive therapies and respond to ketamine infusions as can post traumatic stress disorder or PTSD chronic anxiety, and many other things in that category.
Neuropathic chronic pain with ketamine infusions as well, particularly if it involves multiple parts of the body or has similarly been resistant to more conservative therapies and physical therapy. So that would include CRPS, but it also includes other types of chronic radicular or neuropathic pains.
It's interesting that ketamine treats both of those because But those larger categories, because when I approach a patient, I'm approaching them from those two categories whether it's just before surgery, you're going to have a person who either is in pain or is expecting pain very soon, and you're going to have a person who's very anxious or nervous.
I also approach the CRPS patients or chronic pain patients in that same category. Okay, let's try to figure out physiologically what's going on and what's causing the pain, but also how are you doing up here? How are you handling it? How can we help you handle it better? Whether that's therapy sessions or ketamine infusion sessions or some combination of that, or is this maybe just me sitting and having a heart to heart with them? Ketamine does help to repair some of the neural pathways, whether it be for chronic pain or connecting the logical and the emotional centers of the brain to help there be better connectivity there.
But if I were if you've never I'm from rural Louisiana, so if you've never run a chainsaw or driven a tractor, I can't give you the keys and say go after it without teaching you. And so just because we help a patient to have better connectivity there, then they also need to be able to know how to have and use tools to address that.
So with better connectivity, you can realize that either myself or sending to a therapist or psychiatrist can teach you distracting maneuvers. Or teach you things that cause less stress in your, teach you ways to address things that are causing less stress in your life in a more proactive manner.
And ultimately that helps break that cycle between pain and depression, or at least improve. And I feel lawyers are constantly going through that cycle of grief, right? We're constantly mourning ourselves, but every time we lose an ability, now we have to start over, because now we're going to mourn that.
And I think it's been, for me, it's hard to get a handle on it and then something else. is taken. So then I have to start over and you never know when a CRPS patient walks in your door, what stage are they at or what stage are they at today? And being able to address both of those at the same time is, really huge.
And you answered my question because I was going to ask if you were treating someone for CRPS pain, if it would help. The depression, anxiety and PTSD, because a lot of people that have this have all of those. So it's very important to, like you said, as well, teach them how to have that new mindset view or relationship with pain after hitting that soft reset.
And yes, ma'am. Yes, treating the whole individual because this is definitely a whole body and mind diagnosis. Yeah, probably in spirit as well, right? Yeah. Mind, body and spirit, yeah. I was, I just actually came from taking care of some patients very recently, earlier today. And I noticed that if it was a new patient and I sat down and said, how are you doing, they looked at me and I had to really explain that.
I really wanted to know how they were doing. Whereas the patient that I've seen me several times. I sit down and say, how are you doing? We'll go right into telling me exactly how they're doing which is great. So that's 1 of my kind of tests for that trust factor that we talked about earlier.
Yes, and I have noticed as well to the difference between Patients is the difference between a newly diagnosed and somebody that's had this for a very long time. The level of hope is very different. And even the difference between men and women is substantially different as well of how men grieve themselves and how women do.
And I think for men, it seems to be a little bit harder. And I think that's because they're there to be the protector. And they feel that's been taken from them and I can't imagine what that would feel like because I don't have anything to associate that to so for women to understand that concept I think is a little bit more difficult, but it's just really individualized of each person of what their makeup is what their history is and what they're doing to handle it.
And making sure that they're equipped on all aspects of that, and I, and that's comforting to know that you do that. Absolutely. And the other factors that come into it is gender, certainly a very large part of it. Culturally, some people are more conditioned to accept and speak of pain or challenges, and others are taught to hold it in, which can, both of those can be very challenging as well as the type of personality type the typical type A personality wants control.
And if anything hinders that control there's a war on their hands so I'm sure a lot of your warriors out there are trying to balance that combination, which is challenging. Yes, it seems a lot of people that I've met with this illness though. They're fighters. They want to fight for something better.
They don't give up. So they're definitely strong. We're all very strong to carry it in general, just because it's out there when it comes to the level of pain. I, didn't understand really until it had jumped to my foot because I had it in my hand for years and didn't know. And the pain there is so different than the pain when it went to my foot.
And it's difficult, I think, to constantly have to remind people, but. It's they're not going to register something that's not supposed to cause pain is painful and having anybody that understands that or having a physician look at you and say, no, this is real, what you're experiencing is real. And I think that alone is the start to that relationship that you build with your patients.
Absolutely. Yeah. We can, mentally try to identify, but until you have some life experiences, it's much harder you have to have a very vivid imagination such as anxiety and panic it's not something that had been a big issue for me, but I remember, after taking one of our big physician examinations I started going through my answers and everything.
And I actually had chest pain and I was like, Oh, okay. So this is real. I feel it, man. I can identify with my patients in the future. So I was curious to see, I read on your website about how you are involved in ongoing research and education and also teaching other colleagues. your techniques and facilitating learning opportunities, advancing the field of ketamine therapy.
And I was just wondering if you could maybe elaborate a little bit on that for us. Sure. So two things that I like to think about is the big picture making sure we're not going down a rabbit hole, but then as you look at the big picture, you've got to turn the page and go from one chapter to the next.
So as you go to those chapters, make sure you actually. Read the footnotes and read each word on the page, as opposed to just looking at the title of the chapter and moving on, because that's where those slight nuances on where to put the stimulator make a huge difference. And for our group of anesthesiologists, we're fairly spread out across multiple sites across town, and so each year I'll have a conference where we all get together and we'll Discuss lessons learned.
We'll discuss our newer techniques that we use for ultrasound guided procedures and nerve blocks, et cetera. We have found that for example, lower doses of some of the local anesthetics. Allow us to get these and walking but not affect the pain that we're helping or not affect our pain treatment.
So that's important at some of our Organizations our societies anesthesia societies. I'll also teach some of the cryo ablation techniques not sponsored by the Companies or anything like that just on my own because I feel like it's important with the ketamine You can have anybody walk in and put an IV in a person to do a ketamine infusion, but I would say as much as half of the outcome has to do with that first 10 or 15 minutes of sitting down, talking, listening, and setting expectations.
And so that interaction, is key, just like the interaction before a patient going to sleep before surgery can either make them wake up more relaxed or more anxious before they even realize that they're waking up. And I've had some very good stories with patients first waking up when I have them pick out their favorite dream or vacation spot before they go off to sleep.
The other things are trying to drill down with ketamine and use less of a shotgun approach as far as the diagnosis. So what diagnoses are actually responding? Which ones are not? What's the appropriate dose? What's the minimal dose that you can get away with and still have good effects? So those, studies are all ongoing.
One thing that is not very well borne out is, what's a good timeframe. Ketamine is not an infusion where we can, or a drug where we can give you one dose and expect a person never to need to come back. But we want to get that as infrequently as possible. So what is that correct treatment dose to determine whether or not this patient is truly getting benefits?
So those are some of the things we're looking at to try to get a better feel. And each diagnosis seems to Carry something different. For pain now, you heard me stress that we treat chronic neuropathic pain Certainly nerve pain is the pain that responds better than other types of things. So we really focus on that We felt like the benefit of trying to treat other pains with this was not appropriate as we get more and more information and data with the anxiety depression diagnosis, then it seems that the dosage amount and the treatment frequency is slightly different as well.
Teasing those two things apart, and then when you have, as you mentioned, a patient has both some anxiety, depression, and pain, and they may actually be interrelated. One is causing the other, or vice versa, then trying to figure out the correct dosing timing to get that done appropriately, especially since there are other factors, In the background insurance companies do not currently acknowledge ketamine as a therapy for these.
And so insurance companies do not cover ketamine for this purpose. And so we want to be as respectful of people's time and money as we can. And the more data that we do get out there and get published, then it would, it's going to hopefully push the bar more towards having insurance companies ultimately have to acknowledge that.
There's also legislation that was passed. that will take effect in 2025 called the No Pain Act. And so the No Pain Act dictates, at least for Medicare patients, that if there's any FDA approved, non opioid modality, that Medicare has to cover that that, that idea, or that device. So I'm not we'll still have to see if they actually honor the ketamine for that, but certainly many of the other things that we have not been able to do, such as some of these stimulators, et cetera for patients because insurance did not approval.
We have one more feather and I kept to push against that for FDA approved items. So that's a bigger viewpoint and drilling down a little bit. And to some of the questions and movement forward and trying to figure out what combination of things and what frequency and dose interval makes the most sense for patients, knowing also that there are many more drugs in the pipeline now that can also be additional non opioid adjuncts.
So the point is not to find 100 things and give every patient 100 different things. Combo the, challenge is to know that there are a hundred things out there, listen to the patient, and see where they are, and figure out the combination that may work best for that particular patient. And I have patients come to the ketamine clinic, and as we talk, they may decide that they would also need or would prefer to have a peripheral nerve stimulator, or the cryoneuralysis to the nerves, or stellate, anglion block, or lumbar sympathetic block which are those specific things Blocks are ones that block the sympathetic nervous system, try to help upper extremity or lower extremity CRPS.
Still a ganglion block has also been shown to also help with PTSD. So that could be a 2 for 1 special for a person whose pain is turned into more kind of an anxiety, traumatic experience. I have a question with the. I always say it wrong cryo freezing. Yes. Sorry. The fancy word is cryo neuro license, but hey, I'm hearing you and you said freezing of some nerves.
I was curious if that how that would work with the patient that has that hypersensitivity to cold. One of the contraindications, I'll just start there, with cryoneurolysis is patients who do have a true cold related diagnosis. There are various blood disorders that when a patient gets cold, their blood may red blood cells may burst or may super thick blood or etcetera.
So certainly we don't want to subject those patients to it. Those patients that I would consider nerve block or the typical radio frequency ablation. We actually burn the nerve as opposed to freezing. But yes one of the nuances where we talk about the being up front with the patient to determine likelihood of benefit expectations and next steps is how hypersensitive they are and whether or not I think the cryoneuralysis is the correct therapy versus topical versus the stimulator.
So if I have a patient who is on the hyper hypersensitive side but doesn't have CRPS diagnosis, then most of them do very well with the cryoneuralysis. If I have a patient that truly is you can barely touch them, they're at the point where they're closed, they can't stand touching their clothes, then if the affected nerve is closed, Is in a distribution where I can catch it above the super sensitive area.
So let's say, for example, it's you mentioned your hand. I can catch a particular higher up in the arm or somewhere that I may choose to do that. But if based on the location of the body of where that nerve is. I'm going to be addressed, if it's in the area that's super sensitive, then I'm going to probably not go there first for risk of being slapped by the patient or something.
Just a reaction. We don't mean to do it. Exactly. When they say does it hurt, I say it won't hurt me a bit unless you slap me. But in those scenarios where I am concerned about that's when I started thinking more tens unit to catch the nerve up higher. or peripheral nerve stimulator, or trying to get things under better control with other modalities, whether it be medication, or sympathetic block, or physical, of course physical therapy is always in the background, so I haven't mentioned it in a bit here, but that's always in the background.
So if we can get things better for them and take them from a 10 out of 10 to an 8 or a 7 out of 10, and everybody's perception of pain is different, so again, seeing where the Is this tolerable for you? And it's do the allow you to do things you want to do if the answer is yes, then you know We'll hold the course, but if it's no I want I need more help Then sometimes those patients are under better control where it's inappropriate to consider doing some of the things that maybe we could not do a lot of that, tolerance for functionality comes with Seeing where the patient is if they're a person who just wants to be able to go to the mailbox and back and go to church on Sunday in the grocery store, then our bar is not quite as high for that.
75 year old grandma just wants to see her grandkids versus someone who still wants to go play golf or go fishing or go hiking or whatever. So that has consideration as well. That's awesome with everything is it's all personalized to the individual and what they're going through and what they.
Need and seek and what they've tried in their own makeup, instead of having that standard treatment or a person of the way this much. This is what you're going to get or is there your symptoms going to get. So I like that. That's very, nice to have that individualized plan for each person. See, we're almost down to time here for you.
1 thing I always like to ask is how you learned about the foundation and what made you decide you want it to be a resource.
I can't remember who on your staff emailed us, but someone emailed I called our clinic and when I was asked if I would mind. Being involved, the answer was emphatically, yes, it was just a question of when do we get together on a time? So I'm glad we were able to get together.
But anything that I can do to connect with other clinical colleagues that have a similar philosophy of establishing a good culture and relationship with patients to work towards a win scenario. Not necessarily a win loss scenario, or you're absolutely healed versus not life is a journey, and we all have our challenges, so we have to get through it together, and we're humans are meant to lean on each other none of us as, macho as we want to be, are going to make it through life on our own.
The challenges are the our mission in my opinion is to do as good as we can for other people to Get a lot of credits in the bank so that when you do need help, you know You can not feel too bad about swallowing your pride and leaning on others And not you know, and not feel like you're a bird And that's how I approach it I want the patients to be able to get to where they need to be And who they need to be for the rest of their family or friends and sometimes that's challenging.
Sometimes it changes and You mentioned having to grieve a loss or an activity I would challenge one of my patients, or as we were speaking, I would say, okay we have, life's a book of chapters, and some of us are warriors enough that we never want to close a chapter, and so the chapter sometimes has to be closed for us.
Now let's figure out what we're meant to do. And I've even sent patients to Take interest inventory examinations, for example. So it's just an online personality profile questionnaire that asks you a bunch of questions you answer from the heart And it takes your personality profile and compares it to other people who are doing worthwhile things careers or community service That are very happy doing those things with a similar personality and you know A lot of things on that list most likely people have heard of but there inevitably is one or two things on that They say you never heard of that when you look into it or Wow, I had and so I would highly recommend that for anybody when a chapter closes, particularly if it's a chapter they didn't necessarily were ready to have closed whether you're going from high school to college or college to workforce or workforce to retirement.
Or what have you I've had family members that made significant career changes just based on doing that questionnaire and following it up and doing some, research. So we're all here for a purpose. We're meant to do something. It's not always at the right time that we planned or the exact thing that we're planning, but if you keep positive and keep an open mind and.
And something always comes about just you started this nonprofit. I'm sure you wouldn't have started this nonprofit if you hadn't been faced with some challenges in your life as well. So I appreciate you setting up CRPR for us. Yes. Deb actually is the founder.
She set it up for it. And that, was really what it was, it was exactly that she she had been through so many experiences of doctors not knowing. And, Surgery is not going well that she just, she had to do something. She wanted to make an impact and spread the awareness because I, my personal opinion is this all starts with that lack of awareness and.
And really that's why I found her and I never left because it was the same feeling of just half having to try and do something or make an impact. And if you can help 1 person and make their day a little bit better than it was, that's good for me and trying to. Just get the word out a little bit more, and I have noticed over the past year, it seems more people are aware than they were of what of the diagnosis itself, not necessarily past that, but.
There's been a couple of times I've went and not had to fully explain it. It's progress, Right. Progress, not perfection. Getting, back to Ketamine. Ketamine also has been in the news media much more this year because of the death of a famous actor Matthew Perry. And so it's gotten a bit of a bad light, but so did propofol, which is one of the drugs that I use every day as well.
So it's frustrating from my standpoint to have people that should be my colleagues doing the exact opposite of what I would expect them to do. So that's frustrating. But. The very next day after that news first came out, we had 3 or 4 patients come to clinic and said, are y'all okay? I hope this doesn't affect you.
I'm being able to care for them because this is my life. 1 was a patient who has long COVID syndrome. And this is the only thing that has allowed her to spend some amount of quality time with her child, which is very important to her. So it's. It's important to us because it's important to patients and we'll continue to do the correct thing for our patients and if we can help shed some light on the appropriate ways to do it, to use the medication and that's another reason we do that.
Just for some of your patients often. A question is what to expect. So ketamine is a drug that at higher doses causes general anesthesia. It's a drug that was developed in the 1960s. So anesthesiologists have used it for many years with a lot of experience in its use. If you've, a person who likes to watch Animal Planet or National Geographic and you see the veterinarians guarding wild animals and the animal has their eyes open and is breathing and is stable, but they're just not responding and most likely with ketamine.
So ketamine has a person kind of space out a little bit at the larger, at the higher doses, which is one of the few general anesthetics that we have that does not drop a person's blood pressure and make the person stop breathing right away. So we use it in high risk patients where that's a challenge either because the patient has a difficult airway for whatever reason.
Or we want to keep them as hemodynamically stable during the initial periods of going to sleep, choosing the emergency department to free fracture reductions and things like that as well. But over the course of those years, it was noted that. The patients that did get ketamine for whatever reason often had lower pain scores after surgery and needed less opioids after surgery.
So there started the early investigations on what's this medicine about? It's not an opioid. It does have some opioid receptor activity, but it's mostly receptor activity in other places as well. In addition to that, it was also found that Patients who got a new dose of ketamine around the time of surgery also had lower incidence of post operative depression or anxiety as well.
Again, that kind of started the initial looking to see what this was about. So all that being said, when a patient comes in for ketamine infusion therapy, then after we talk and set expectations, then. Once the infusion starts, common descriptor that we frequently get is that a patient feels floaty.
They'll feel floaty. The textbook medical definition or term is called dissociation or dissociative anesthesia, where you just you're disconnected. Some people will literally feel like they have they're, That are able to come outside their body and evaluate their body or their, life or what's going on.
Kind of like a, an adult would do to their child. The child's usually see the big picture, but they don't say, I'm telling you, you got to stop doing that at school or you need a study partner, et cetera. And during that infusion, some people may see some floats or or the side, one of the side effects of ketamine is it makes your eyes twitch a little bit.
So sometimes people will see the walls moving a little bit. So often times people just close their eyes and relax. If the patient has iris or nausea, they will get an anti nausea medicine as well. And the infusion lasts for usually between 40 and 60 minutes. During that time period, we closely monitor them to see if they were in the operating room, so they have blood pressure, heart rate, oxygen, apnea, and respiratory rate monitored throughout, and we watch them to make sure that they're safe and stable while they get the treatment effect.
The two examples I give a patient, particularly the first time, is During the infusion, you're often like an astronaut doing a space walk. So you're in space, you come outside the space shuttle, but you're not floating off to infinity. You are connected to the space shuttle. You're in your space suit, your space walk suit.
You have your communication, you have your oxygen and you're doing your job. And then once you finish your assessment or repair of your job, then you go back into the, body or the space of the space shuttle. And so that's often how the ke infusion may feel for some patients. The longer term effects that we're working towards is trying to increase the connectivity for anxiety depression between the logical part of the brain and the emotional part of the brain, or for chronic pain, we're trying to increase the connectivity and pathways for the nerves to actually function as they, should and have the pain nerves be less active and have the non painful generating nerves for light touch and et cetera respond as they're supposed to, which is not, should not be but from the emotional part Of the brain connectivity, I like to give an example of an adult, whether it's a mom, dad, uncle walking down the street with a toddler, let's just say a three year old, and they're holding the toddler's hand not too tight, not too loose, but just right, as they go down the street.
Imagine the toddler being the emotional part of the brain of just one, one large organism and the adult being the logical part of the brain. And so the toddler sees something across the street that's bright and shiny and the toddler, emotionally, just automatically wants to cross the street. And the adult will automatically grab a little bit tighter grip while they assess the situation.
And they'll look over and decide that it's not, wise to cross the street right now. And depending on the toddler the toddler may want a broke leg and kind of fall and have a tent for a tantrum. Particularly since they're a two or three year old or they may just say okay and walk on, but in the challenging situations where there's a temper tantrum, then that's where the logical part of the brain or the adult hopefully has enough tools to help get through that emotional kind of, I'll use the term breakdown, but help get through that period.
And they may or may not. There's a situation where you can imagine The adult just immediately chastising the child in a loud voice, and the child getting more, more upset, and the adult is not able to handle that situation. But with therapy reading, journaling, talking through things, visiting with other warriors, you, then you put more tools into your toolbox.
And so for, in this scenario, when the child gets triggered through their temper tantrum, the adult may look around and say, Hey, there's a playground over there. Let's go to the playground. Then the emotional part of the toddler tends to come calm down and read that letter. And if you can imagine being able to be more aware, it's Within ourselves on those connectivities and, realizing when things are causing stress before they cause you to have a panic attack and you have the tools to address that, and then that's what kind of allows you to do in conjunction with a multimodal approach, whether the other pain management modalities and or fair, right?
That makes complete sense. And that really does showcase to that mind body connection that we have that how much those two things can play off of each other. Like we said, you mentioned that the. They can be causing each other or increasing the dysfunction and. Seeing how that all works together, and that can correct that.
Absolutely, and it can correct more than 1 at the same time at the same time. Excuse me. Sure, so that's huge. Let's see here right about 5 o'clock. Is there anything else that you wanted to include that we haven't touched on so far?
The other thing that I'll just say is that one of my missions is to, on the anesthesia side, is to get to an opioid free or near opioid free total joint because of the risk of opioid addiction. On the backside of a patient's coming in for surgeries people have never had opioids as often as the first time they get exposed which really increases their risk of addiction.
If people do have a previous history, it's the one time where they get re exposed or their exposure increases which increases their risk of opioid use disorder. Exacerbation as well. So that translates into the world of chronic pain, and we really want to minimize and where appropriate eliminate opioid use.
So all these modalities, including ketamine or modalities that help us with that. So that's very important to us, especially in this time. And you talked about CRPS being more of a household word. Lately, certainly ketamine this year has been more of a household word, but also the opioid epidemic and wanting to minimize opioids has been a big.
Consideration for lots of people as well, or they'll either come in or ketamine with questions about that. I wanted to clarify that opioids do have withdrawal, they do cause constipation, other things. Ketamine is not an opioid and whereas we do monitor people for coming in to make sure that they're not just wanting to have the psychosocial effect just for the fun of it.
We don't see on a regular basis, any type of withdrawal, some of the patients do come in for a few infusions and then stop. That also in time is very important to us. The typical infusions for anxiety depression is often times patients will need to have about six infusions over about a six week period.
To come out of the valley and get back up on plateau that can be done twice a week over a 3 week period. It can be done once a week over a 6 week period. The ultimate end point is the same. So I generally counsel patients that if you're really having crisis in a bad place right now, then you may want to start twice a week initially, and then we'll start spacing it out because ultimately the goal is to, of course, space it out.
But patients often feel, let's just say they're feeling super bad, zero out of ten, and whatever you want to call it. Anxiety, depression, PTSD, CRPS, what have you. Then after the first infusion, they may feel less negative or less pain. But oftentimes it starts to fade after one, one to three days.
And so that's why those patients may want to choose to come in twice a week initially. And then with each infusion, that step period of effectiveness tends to get expanded further and further. So ultimately after six infusions. Our goal is to have a patient coming in maybe once a month or so for a period of time, making sure that they've got the tools that they need they've seen therapy, they have whatever it needs.
From the multimodal approach, and then ultimately we would love to get them to the point where they need to come once a quarter or maybe twice a year. For the pain patients, if they strictly pain with no anxiety, depression, and we may not start that aggressively up front, we may try to do once every two weeks or once a month with the infusion to try to get the pain under better control.
Which there's very few times where a patient will come in and, let's just say 8 out of 10 pain and not leave with 0 out of 10 pain. So that's not the question. The question is the length. Patients I don't want to say always because I don't want to be absolute, but patients often will leave feeling very good.
And then the question is, after the first infusion, do we get them to a week or two or, three weeks and then when did they come back? So it's more about the timing. And that's what we're spending a lot of energy on right now is trying be able to better tell patients ahead of time what we expect on the timing once they get to the initial, therapies.
I can imagine too, it might be a shell shock for them as it's not an increasing treatment, it's decreasing as we progress, right? Yes, yeah, true. That's, very true. Yes, ma'am. So that's a good thing. Yeah, that's a good thing. I like that. We like to work and we work with the Houston chapter of NAMI, which is National Association of Mental Illness.
We've gotten connected with you. I've also worked with event solutions, which is a veterans program that's nationwide. So we're also doing our best to find other avenues and resources for non profit. Collaboration grant funding, et cetera, so that we can cast this net wider. That's good to know.
I thank you so much for everything that you are doing and trying to get these leaps and strides going for patients and for caring and listening. I'm very grateful for you very much appreciated to know that there are physicians out there like you looking. And researching and trying to make changes in a better world for people that have these illnesses.
Thank you for sharing and thank you for spreading the word. It means a lot. It's very helpful for us because we often do get into that grind of helping one patient at a time, but stepping back out to visit with you, hopefully, in some way, shape, or form, will help allow us this podcast to help many patients at one moment, one time.
Thank you for taking the time out to sit with me and share everything. Yes, ma'am. Thank you.
