A Country Doctor Reads: March 9, 2019

Ketamine, first synthesized in 1962, is in the news this week both for its antidepressant and its analgesic effects, again demonstrating the blurry line between Pain and Suffering.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.


“Moreover, based on the available preliminary evidence, the magnitude of the antidepressant effects of ketamine appears to be more than double that of conventional antidepressants.[10]On the basis of these findings, a 2017 review described ketamine as the single most important advance in the treatment of depression in over 50 years.”


FDA Approves Ketamine Nasal Spray for Depression

The U.S. Food and Drug Administration today approved Spravato (esketamine) nasal spray, in conjunction with an oral antidepressant, for the treatment of depression in adults who have tried other antidepressant medicines but have not benefited from them (treatment-resistant depression). Because of the risk of serious adverse outcomes resulting from sedation and dissociation caused by Spravato administration, and the potential for abuse and misuse of the drug, it is only available through a restricted distribution system, under a Risk Evaluation and Mitigation Strategy (REMS).

Ketamine Reduces Opioid Need in Severely Injured Patients – Pain Medicine News

San Diego—The first randomized, double-blind, placebo-controlled trial of ketamine in patients with rib fractures has shown that low-dose ketamine infusions are a safe adjunct in the setting of treatment of acute traumatic pain

Weight Loss Cures Diabetes. Is Anybody Surprised? – The Lancet Diabetes & Endocrinology

I keep writing about my small victories in sometimes motivating overweight Type 2 Diabetics to give up particularly processed carbohydrates and thereby reversing and curing diabetes.

But if you read the manual, it is actually a flex fuel body. It isn’t metabolizing carbs properly, but it can still run on fat and protein, and believe it or not, we now know that diets that are low in carbs and higher in protein and at least what we call good fats, are good for weight loss, diabetes control, lipid lowering and heart risk reduction.


I tell my diabetic patients that I agree with the notion that a balanced diet is generally best, but that their diet so far has probably been unbalanced enough to stress their carbohydrate burning system. It is as if they have already had their lifetime supply of carbohydrates and they now need to correct that imbalance.

Now The Lancet is saying he same thing…

The DiRECT programme sustained emissions at 24 months for more than a third of people with type 2 diabetes. Sustained remission was linked to the extent of sustained weight loss.


It’s Not Burnout, It’s Moral Injury

All medical bloggers write about BURNOUT and I am no exception:

The Root Cause of Physician Burnout: Neither Professionals nor Skilled Workers

The Counterintuitive Concept of Burnout Skills

Here’s a video I saw via a Canadian Rural Medicine Listserv, renaming “Burnout” as “Moral Injury” and calling it “Victim Shaming


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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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