Hey Ian --- thanks for the post. For Emergency Physicians, administering ketamine for multiple indications is a core skill - and considered a standard of care in many circumstances -- from low-dose analgesia to high-dose PSA/RSI/DSI and agitation contol.. I'm not familiar with ED docs not being "allowed" to use ketamine. The tricky part about using ketamine for suicidality / depression is not that it is unsafe or ineffective -- it's the problem with what happens next. Multiple SMALL studies (bear in mind the evidence is still considered wanting for lack of big studies) have shown ketamine to be safe and effective for suicidality when used IV or IN. However, the effect wanes over the course of several days and investigators are actively looking at repeated doses and other longer-acting analogues. So while we use ketamine quite freely on a daily basis in the ED, we do not give it for suicidality (yet) as our psychiatry colleagues are not (yet) on board with its use -- and they are the ones managing the patients on an ongoing basis.

Thank you for bringing this up, Ian. I think the most important issue here is that the College of Physicians of B.C. (CPSBC) have, in essence, decreed that only anesthesiologists can safely administer ketamine. This should concern all emergency physicians regardless of their feelings about the use of ketamine in mood disorders. The CPSBC is either unaware of or ignoring the fact that airway management and procedural sedation are core competencies for emergency physicians and that many of us have far more experience in using ketamine than most anesthesiologists. Even though the standards proposed by the CPSBC pertain to use of ketamine in clinics outside of the hospital setting, we should, as a profession, be very concerned about the fact that the CPSBC is so out of touch with our core competencies, training and skill sets. I would encourage members of the BC Emergency Medicine Network to review the CPSBC Non-Hospital Medical and Surgical Facilities Accreditation Program (NHMSFAP) Committee proposed standards for the "Parenteral Use of Ketamine For the Treatment of Mood Disorders" available through the College website. There is a link to a survey to express your views or, alternatively, you could write the College. But the deadline is February 17th, so please act soon. To be be clear: regardless of how you feel about ketamine in the treatment of mood disorders and despite the fact that few of us would ever be administering ketamine for that purpose, it is very important that we stand up for our specialty and educate the CPSBC about our scope of practice, core competencies and skill sets.

The issue of whether to use ketamine in a psychiatric patient I will leave to younger minds, but the underlying angst I get with this discussion is the long history of anesthesiology being the biggest impediment to providing good ER care. Having been in practice for over 35 years I am from the era where we used to intubate patient with Demerol and Valium, because the anesthesiologists wouldn't allow us to use succ. I have lived through the battles to get succinylcholine, midazolam, rocuronium, fentalyl, ketamine and most recently etomidate for use in emergency departments - all because the anesthesiologists were the only one capable of using such drugs. Maybe it is finally time for the ER docs to sit down with the Provincial Section of anesthesiologists and ask them to practice their jobs and we can practice ours?