So good afternoon, almost done, my gosh, it's been a long weekend. So my name is Rhea Temmerman, I am a member of the ANA's Professional Development Committee. And before we begin our session, I have a few reminders. So make sure you download the app, and you need that app to submit your CE credits. So from the sessions page, you will need to click the evaluation icon at the bottom of the screen, fill out and submit for each individual session. You have until Monday, September 9th, noon Pacific time to submit all of your sessions, and then after that, the CE credits are no longer available. You can submit questions through the app in the questions icon, and I'm going to be monitoring them throughout the session. And also, you can come up to the mics at the end of the session and ask your questions. Lastly, mark your calendars. So we're looking for speakers for 2025 Annual Congress in Nashville, Tennessee. We are opening those abstracts August 14th, so make sure you get those in. So if you have more questions about that, you could actually come up to me and ask me questions about the submission process, or also visit the website at ANA.com. So now it is my pleasure to introduce our speaker for today, Catherine Walker. Ms. Walker is a CRNA and founder of the company Revitalist, as well as a psychiatric nurse practitioner, which is pretty cool. So please join me in welcoming Mrs. Walker as she presents, Entering the World of Psychedelics as an Anesthesia Professional. Hello, everyone. So I'm Catherine Walker. I go by Katie. And I'm kind of a loaded professional, per se. A little bit about me. I do work in the ketamine space, been working in the ketamine space for about seven years. And then I've been in the psychedelic space for about three years. So I've been traveling to Jamaica, British Virgin Islands and such. So it's going to be an interesting discussion, because what I'm going to talk about today is much bigger than me, and it's much bigger than each of you. This could change our entire profession. And I need really you all to kind of listen to this, because we should be leading this. And no one else has our skill set. But when I go to psychedelic conferences, there may be a couple of CRNAs there. There may be a psychiatric nurse practitioner there. But I have to keep explaining to people, like, I'm not a CNA. I'm not a nursing assistant. There's plenty of nursing assistants in the psychedelic space. And that doesn't need to happen, right? We don't need nursing assistants that are actually leading retreats with veterans that have complex PTSD. We need to have our skill set there. So what I'm going to talk about today kind of gives you the overall summary of what psychedelics are to a point. I could talk literally probably about six months about this, because I'm so passionate about it. But I want to make it to where it's very open for you all to ask questions, because this is very, very new. These substances are going to be the most scientifically unbiased substances that we've ever seen. And we have the mindset to where we don't only understand the research, but we can take the research. We can transition that research. We can apply ethical considerations. We can apply our empathy and our compassion, and we can actually help to address the whole mental health crisis, the whole addiction crisis, the whole pain crisis. So that's my summary before we start talking. But at any time, if you guys want to come up, ask a question, please do, because this is very, very new. So conflict of interest. So the American Association of Nurse Anesthesiology is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. So in order for you to obtain contact hours, you must attend or complete at least 85% of the session to receive the educational credits. And here are all of my following relevant relationships with financial interest to disclose. So I am the CEO of Revitalist Lifestyle and Wellness. I am a shareholder in Revitalist Lifestyle and Wellness. I'm also a shareholder and operator in Wake Network. I'm an author of a book called Inflamed Theory. And I've just recently created a proprietary scale called the Federal Unit Scale. And I will be discussing off-label use during this presentation. So outcomes to identify psychedelic medications with noted dates of legal approval from both federal and state requirements. Understand the pharmacologic nature of psychedelic medications and the applications for mental health, pain syndromes, and neurologic disorders. Then understand general concepts for working in the outpatient community and the general needs as a practitioner to meet state and federal guidelines. So here are some. I don't think I've included all of them because there's a lot. Here's some of your psychedelic medications. So we have psilocybin, also called magic mushrooms, ayahuasca, MDMA, which is also ecstasy, LSD, 5-MeO-DMT, ibogaine, mescaline, bufo, cannabis, hoppe, peyote, ketamine. And below you can see each of these substances. They're just now slowly starting to get a lot of this data that shows, is it serotonergic? Is it your endocannabinoids? Is it dopamine? Is it glutamate? Is it mix? Right? They're just now starting to get to these things. Psilocybin is, my specialty is ketamine psilocybin. I've seen some of the other guys, but I don't know too much about them. But psilocybin specifically has over 600 compounds in it. The FDA wants one. And one of our partners at Johns Hopkins, when they're trying to break down psilocybin, some of those strains start dying literally within seconds. So it's really brand new to the FDA, it's brand new to the DEA, it's brand new as practitioners. This is all new, all new. There needs to be leaders, again, in this space, and I truly believe CRNAs can do it. So pharmacology, this here, you can read this slide, hopefully we can have access to these slides as well. The pharmacology that I put here, and this is really, really, really interesting, is they're starting to show dopamine does not travel alone, serotonin does not travel alone, glutamate does not travel alone, or epinephrine does not travel alone. These guys travel in pairs, or maybe more than two at a time. So when you get on serotonergic medication, it may also change your dopamine levels, and vice versa, right? So they're seeing here, like the first one I mentioned is, glutaminergic projections in the midbrain play a major role in regulating the activity of the mesostriatal dopamine neurons. Direct pathways from the prefrontal cortex to the midbrain have an excitatory influence and enhance the dopamine release, whereas indirect pathways involving your gavinergic interneurons have the opposite effect. So what we're also seeing by looking at this is when they tell you, or when you hear that you have a chemical imbalance, there's now theories starting to come out that are showing chemical imbalances may not be the first thing to actually cause mental health issues. They may be more of a structural thing later down the road. And this is when I get excited, because this is where anesthesia brains start coming into mental health. And these three little guys here, your default mode network, your salience network, and your central executive network, make up something called the triple network. So what a lot of your scientists are doing now, they're not looking at chemical imbalances. They're looking at, what does your brain do with the data that comes in? So if I'm sitting here, right, you've got my brain, CRNA, PMH and P. I've got a military personnel to my right, and I've got a therapist to my left. You tell the same statement to each of us, we're each going to interpret it differently. And the reason being is because of our environments that we've grown up in, the environments we've been trained in, all these different pieces. So what they're doing now is that we're trying to see, how do we auto-regulate when data comes in? What does our brain do with it? How does it hear it? Because we're seeing that the brain is not eccentric, right? It's not eclectic. It's not constantly changing. The brain duplicates what it knows. So when data comes in, it will duplicate the same process. And unless we can understand why it's doing that, we can't get to the root cause of it. And that's why ketamine and psychedelics are so amazing. It's allowing us to slow the brain down enough to where we can see kind of more of a categorical aspect to where we can get actually to the root cause of what's happening in the brain. So these three guys, you should read about them. Default mode network. To put it basic, your default mode network is your baseline pattern. That's your default mode network. Salience network. When data comes in, what does your brain do with it? Does it hyper-inflate the response, or does it hypo-inflate the response? Or does it just have a nil effect, where it has no response at all? That's your salience network. It's kind of your aggregator when data comes in. Central executive network. CRNAs mostly have a very good central executive network, meaning that we're task-oriented, and we can push everything to the side, and we can execute as we need to. But when you notice if your central executive network gets off track, that's when at nighttime, when you can't get things off your brain, you can't turn your brain off, that's more your central executive network. It functions, it lets you do all of your tasks in the daytime, but at nighttime, if you don't have a good balance there, that's when you kind of notice that little guy's out of whack. So this here, default mode network, I put these pictures up here. I put a little bit of context here, because I want you to kind of see, because it can be very complex. Again, fascinating if you start reading about it. But you can see, the default mode network, it's throughout different parts of your brain. And that's what we're seeing with the triple network. All these different areas are communicating to each other all at the same time. No one's siloed. They're all synergistic in their patterns. So your default mode network, I like to talk a lot about with it. I was the big guy who came out first. He came out first before really the salience network and the central executive network. Your default mode network has a lot to do with people who have addictions. And when I talk about addictions, I'm not talking about just drugs, I'm talking about sex, shopping, anything, exercise, working too much. But what they see with people with an addictive mindset is, with a healthy default mode network, a positive action is supposed to create a positive reward. A negative action creates a negative reward. I don't know if you guys have ever been around somebody who says, yeah, I go to the gym and I just start crying. I don't even know why I'm crying. I'm just crying while I'm at the gym. So they're trying to do something positive, but they're having a negative outcome. And that usually shows that their default mode network's off. So people with addiction, when you talk to them, I tell them, you know, it's kind of like the cycle. It's a cycle of psychological abuse. So they know, right, they don't want to use, they don't. But their brain has gone off track to where it doesn't have a positive equals a positive or a negative equals a negative, it will have a negative equals a positive. So you're addict, even though they don't want to use meth or whatever, they may go use meth, they get a positive placebo effect per se, right, from that. And then they have shame that comes afterwards. So they're in this constant cycle of psychological abuse, and they don't know how to stop it. And psychedelics, a lot of times, will actually just reset that. So it's actually kind of amazing. I had this one lady who despised me because I was smiling at her when she told me she stopped smoking. And, you know, she gave it and she said, hey, I stopped smoking. I was like, that's amazing. And she's like, no, it's not amazing. I was like, no, I mean, it is. I was like, you were a two pack a day smoker for 40 years and you stopped smoking. She said, yeah, because every time I go to smoke, I throw up. And I was so happy about it, you know, but she was like seven days, like in this conversation. And I was like, you know, how long has it been since you smoked? Seven days. I was like, oh, you got your nicotine patch on, right? She's like, no. I was like, you do feel bad. But she made it clear, right? She gave to me only for depression. But yeah, it's fascinating, fascinating. So it default mode psychedelics, default mode network, it disconnects the emotional want that that brain has for that substance. And again, you know, I pre-warn people sometimes now. Sometimes I don't. But, you know, they it's interesting. I've seen it with meth. I've seen it. You know, you get people sometimes will come in, they're like, yeah, I mean, like, you know, I'll hit meth like, I don't know, once a year, like, all right, and they come back and they're like angry. What are you angry about? I went to use the other day and I couldn't and I threw up and I'm like, oh, I thought you told me you didn't use it more. You don't now, do you? So default mode network, amazing. Salience network. This is one that I really, really like now is a salience network. Your salience network is why when you walk somewhere and you don't feel right, your subconscious, your baseline consciousness is picked up on something that makes you feel like there's a threat. Right? And when I say threat, a threat is not like the way we may interpret a threat. A threat, more so to the brain, is when we are in a period of vulnerability. Any time we get in a vulnerable situation, our brain picks up on that as a threat. And that's when our sympathetic nervous system is really ready to go. So your salience network will pick up on stuff like that. And military guys, I can see some of you guys out there. The salience network is a really, really big one for you all, because you're trained in an environment that's very, very structured, and it's at any time ready to create control in a chaotic environment. Us as civilians, when you get out of the military, we're like, well, this is great. You all should be great now. You're going back to the civilian world. You don't have this whole military thing. Your brain doesn't understand that just happened. Right? Your brain is trained this way. Your brain duplicates what it knows. It's just like muscle memory. And when you get out, it's not like you can just be like, oh, yeah, cool. I'm out. I'm done. Your brain's still trained that way, so you have to learn how to transition. And unfortunately, a lot of times, we think we know what we need to focus on in order to transition, and that's not what we need to focus on. And again, that's why ketamine and psychedelics come into play, because it allows us to focus on what's true to our core, not what we consciously think we should focus on. So when I say true to your core, I tell people, right, there's like six things. First three things that are very, very important to each of us, love, safety, trust, and that's how do you receive those three things. It's also how do you show those three things. The other three things are ethics, virtues, and values. So it's not my ethics on you. It's not your ethics that you think they might be, right? It's truly like what is your core, not what your family's telling you and not what your environment's telling you, not what your work life's telling you. What are your core ethics? What are your core virtues? What are your core values? And if you get those six things in alignment, you'll start seeing your salience network auto-regulating because it's not off track anymore and it's actually starting to feel like it's synergizing, you know, kind of in that medial path. So kind of a long-ended story, but you should read about salience networks. There's a lot of neuroscience chapters about salience networks. So basically the definition here, right, just looking at it from a very scientific standpoint is, you know, it's a collection of brain regions working in concert to evaluate the importance of internal or external stimuli and to assist in the coordination of the brain's responses to those stimuli. And then, here we go. Here's your triple network. So it's showing you, you can see the default mode, your central executive network, and then your salience network. And those three little guys like to communicate with each other pretty often. And you'll also see central executive network, it's also called the lateral frontal parietal network, most active during cognitive tasks, and it's implicated in cognitive functioning, including attention and working memory. Another thing to keep in mind with this, you get to the point where you can't turn your brain off, you can't drop a thought. You tell your significant other or your family, just drop it, and they don't. It's not a conscious decision to drop it sometimes. They've actually proven that's a weakness in the salience network. The brain starts losing a lot of its categorical power, per se, and it can't categorize thoughts and it can't drop them. It literally gets stuck. So that's another piece, right? Ketamine psychedelics help with that, too. So this here, mental health, pain syndromes, neurodegenerative conditions, and all these little guys listed below. This is just the tip of the iceberg. So they're proving that mental health, pain syndromes, neurodegenerative conditions are all directly correlated. I don't have on here listed, but I should, TBIs, your traumatic brain injuries, your CTEs, your chronic traumatic encephalopathies, with a lot of your repetitive concussions and such, they're actually all having changes, mostly positive, to psychedelics. What they're seeing in this space is they're seeing that when this data comes in, right? If your brain's not effectively interpreting the data, it can actually lead to where mental health actually turns into pain. Pain actually turns into mental health. I don't know how many of you guys looked at a lot of the studies with your lower back pains that started in 1990 with all the back surgeries that we like to do. Statistics are actually worse now since we started doing lower back surgeries than they were before we started doing them in 1990. And what they're seeing now, what they're trying to rule out, is all the lower back pain, cervical pain, is it actually anatomical pain? Or is it where we hold our stress? And when we hold our stress in these regions, does the brain actually start misinterpreting the data and it sends out pain signals? And that's what they're starting to try to look at to see if they can make a difference there. So with ketamine specifically, depression is the number one thing that it's looking at. Depression, treatment-resistant depression, which doesn't have a true definition, but treatment-resistant. Technically, most people look at it as you failed two medications or more. Anxiety is one that they're looking at. Some people use ketamine with that. LSD is actually probably going to be the first psychedelic that gets approved to treat anxiety. Believe it or not. I don't know how many people have done LSD in their lifetime, but it's interesting to see that that drug may treat anxiety. PTSD, ketamine, beautiful. Beautiful with PTSD. Suicidality, ketamine is beautiful with suicidality. OCD is hard. Ketamine does well with OCD, but it will do it for longer. Longer infusions actually respond better with OCD. OCD, not only is it mental with OCD, but it's also a physical grounding, so you're having to break both of those. Insomnia, most psychedelics help with insomnia. Yes, complex regional pain syndrome, type 1, type 2. Something else is called central sensitization. A lot of those places, I think most of you all understand. Do all of you know about CRPS? Yeah? Okay. So with the CRPS, right, basically what's happening with it is the body is having a physical reaction to threat. Touch it, it will hurt worse. The brain resets all of those. And what it does is it actually works on central sensitization. It decreases a lot of those different aspects to where you can actually get down to where your actual target for pain is. And that's when blocks work, right? So we can actually find the true target. Neuropathic syndromes, Parkinson's disease, Alzheimer's, ALS, Parkinson's and Alzheimer's, dementia, they do well. They do really well with ketamine. I've not been around any other substances except ketamine with them. But with Parkinson's and with Alzheimer's and dementia, the issue is they're so rigid when they feel better, they think you've healed them. And six months goes by, they don't come back because you healed them, right? And then they come back and they're like, nothing happened. I'm the same person that I was. And they don't understand, like, this is something that, you know, needs to be more maintenance over time because you don't have any healing for it yet. ALS, there's a lot of really cool studies out for ALS right now. And there's a lot of weirdness with ALS going on right now, too. So ketamine is in a, we're working with a stage two trial with ALS. And they're showing that it's not curing it, but it's actually slowing down the progression of it tremendously. So they're working on those different pieces. So that's a little bit more about me. I took a chance, right, and did a pretty big initiative with trying to start ketamine through a CRNA-led initiative. And with those pieces, I've learned a lot, right? And unfortunately, in a nursing school and anesthesia school, all the accounting, marketing, auditing, insurance, billing, classes that we get to take, I must have forgotten. So learning all this business stuff, it's really, really eye-opening. You're pretty humble, because you eat a lot of crow. But we treat, you know, a whole bunch of different people. And the reason that we treat a whole bunch of different people is because what I've learned in the outpatient world, if we don't treat them, they're not going to get treatment. Because a lot of times, there's the providers in the outpatient world, they are so risk-averse, they would prefer for that person to die than to try. And that is what I know CRNAs don't do, that we know if there is data out there that actually supports the things that we're doing, we will try. And it's really, really, really sad to see a lot of this. I mean, the youngest kid we've treated is 12. The oldest person we've treated is 92. The 12-year-old had coexisting suicidality, homicidality. She was kicked out of school. Nobody would touch her, because she's 12. And I don't know if you guys keep up with suicide statistics like I do. The second leading cause of death right now for kids aged between 10 and 14 is suicide. You've got 8-year-olds that are trying to hang themselves. So, again, why CRNAs should be out in this world actually helping with this is because we can make a difference. And ketamine, as we know, is safe across a lifespan. So it's something that we all should be considering. The reason I bring that up is because one of my suppliers for medical products found out that I was treating more than just treatment-resistant depression. And literally in the same day, they cut me off and told me I couldn't have ketamine that day, because I was treating other conditions besides treatment-resistant depression. And that didn't go over well. I didn't win the argument, though. I tried. I didn't win. So I say that because this is a case report that we did. And this case report is on a child. I think he was 29 years old. And he had bipolar, autism, homicidality, suicidality. And the reason he came to us is because his parents were his complete caregivers, and they just couldn't control him. He's a big guy. They couldn't control him anymore. And what we do, we have therapists that are actually involved with ketamine. And that's a whole other lecture, working with therapists. Amazing. Completely different styles of training. Completely different communication styles. It's a completely different world. But when you find a really, really good therapist you can work with on your team, night and day different. So I had a therapist sit with this kid. During his session. And the biggest thing, he was talking about, because a lot of kids with autism, they hear emotions, but they don't really feel them. So she was actually able to get him to imitate what it felt like to feel love, to smell the flowers, and what feeling does that give you when you smell flowers, and things like that. So he went from bipolar, autism, suicide, homicidality, after this, he went and got his first job, he had his first girlfriend, and he started driving a car. You know, and it is, ketamine's like that. It's night and day different. So, you know, unfortunately, it says it in here. There's scant evidence of any of this. So this right now is a wide open field. And again, when I go to psychedelic conferences, there was a psychedelic conference in Colorado last year. 17,000 people were there. Huge conference. There's another one. Psychedelic science is what it's called, in 2025. There's another one, yeah. So you all, I mean, hopefully you all will look and try to come to that. Because again, we're so special because we have both sets of skills that other people don't have. And if we don't step in to try to help lead this to a point, they're going to not include us. So you've got psychiatrists that are trying to lead this. I got chewed out by a very well respected psychiatrist because he told me I was just being egocentric by saying that IV worked better than IM with ketamine. He said, it's just because you're an anesthesia provider. You just want to show people you can start IVs. I'm like, all right, whatever, dude. But, you know, it's nuts. So you've got psychiatrists, right, that are doing that. You've got anesthesiologists that are doing it. A lot of times they'll have like 10 people going at the same time in the OR and PACU, kind of at your base. So, you know, it's, I don't know. They don't have the nursing touch. Some do, actually, but not traditionally. So this is a big piece, and I love this. This is what I talk to people about a lot. And this is for not only ketamine psychedelics, but this is for all of our own mental health and wellness. Recall and awareness. In our anesthesia mind, very, very different than conscious versus subconscious. Some people say non-conscious. I don't say that just because I feel like somebody's probably sleeping if they're non-conscious. But conscious versus subconscious. So this here statement, and I saw it for a long time. I just never was able to kind of put it together. So they stated, given that much more brain activity occurs unconsciously than consciously, approximately on the order of 20 to 1, it is doubtful even at a surface level that there is no rational aspect to unconsciousness. So really it's kind of like, what does any of that mean? What that basically means is that 5% of our brain, our analytical brain, our conscious thoughts, are making the decision. 95% is your subconscious. So right now, you all are hearing me speak. I'm talking. But the other 95% of our body is listening, taking in light, taking in sound, looking. It's serving the entire environment right now. And if all these lights went off right now and something terrible happened, we would go, our subconscious would come out. Right? We would go to our baseline S and S. And we would be more in a reactive environment. So your subconscious is more of your reactions. Your consciousness is more of your actions. So consciously, I want to go shopping. Consciously, I'm going to make a grocery list. Consciously, I'm going to plan my vacation. That's your consciousness. It's 5%. Subconscious is, why did I yell at my kid? Why did I get nervous? Why was I so short-tempered? Why do I feel anxious right now? That's your subconscious. And that's what we don't look at at all, ever. And I actually went and spoke at the Mental Health Association. You got all these people, right? I did a lot of the Medicare laws for behavioral health. And I was there. And the first thing I said was, hey guys, I really want to talk about everyone's emotional intelligence today. What's yours? Nobody knows. What's your emotional intelligence? We may know our IQ, but what's our EQ? Nobody's focusing on that. And that's what ketamine and psychedelics are allowing us to do, is to build our EQ because we're able to identify our EQ. And one thing that I've actually, again with veterans, we have a contract with the VA. So the VA actually covers ketamine 100% for vets that apply or that they follow their protocols. And I will say this, so the VA's protocols, they take veterans as their own historian. They're not going to make you send in records. You can tell them what you want to tell them. They're going to believe you. But in the protocols for the VA, before you get ketamine, which is just nuts, it will say that you have to do ECT first before you get ketamine. And one trick that they don't tell veterans, but we tell veterans, is if you refuse to get ECT, you tell them I don't want it, they will actually list that in your record as a contraindication. So that's how you get past it, right? But unfortunately, there's a ton of veterans that have now had ECT that could have bypassed that and went to more of a lesser invasive procedure. So why should CRNAs lead this? And that's a loaded question. I'll tell you, when you go to these psychedelic conferences, I had no idea so many people in the community despise Western providers. They hate us. Hate. So when I go to psychedelic conferences, I just don't tell people what I am at all. I will not dress up. I mean, some of us told somebody earlier, like, there's a psychiatrist. I don't know if I'm right, but he's like a white Rastafarian psychiatrist, and he had on his tie-dye sweatshirt, you know, and a hoodie and his tie-dye sweatpants at the psychedelic conference. Amazing psychiatrist. But there's, when you go to these conferences, the people that are leading psychedelics right now, they're all your hippies. They're your hippies that know everything about every drug. And if I've, even though, you know, we've had, what, like 80 hours of pharmacology, even, they don't hear that, right? They're like, no, but have you done 5-MEO? Like, no. And they're like, well, you shouldn't be in the space. And I'm like, isn't that how drug dealing got started, you know, that you all just like start doing all the drugs on each other? And they're okay with that. Like, it's hilarious. You know, like, I got invited to a conference that I'm going to, and they're like, yeah, we want to do, like, a ketamine, like, meditation group. Can you bring ketamine here? I'm like, no, I'm telling you. They're like, oh, yeah, it's accepted. And I'm like, when's the last time you talked to the DEA? Because I do talk to them. But it's, yeah, it's, I'm like, guys, come on. You know, but it's interesting. But yeah, so I tried not to. I actually had a guy, it takes me back to another story. We were in Jamaica, and we do psilocybin retreats there. We go around the table, right? And it's, you all would be flabbergasted somewhat. There's amazing people in this space, and there's other people who are like, yeah, you probably shouldn't be here. But I had a guy, and he was a psilocybin 6 guy, amazing guy. And we're sitting around the table just talking about what we do, right? And I, again, try not to tell people what I do. So I'm sitting there, because I don't want to be, what is it? They tell me I'm too, I'm bringing too much power, too much force, too much, you know, I'm like, all right, fine. I'll just sit there and not talk. But I told him, I said, I'm a nurse, and I've got a background in psychiatry and anesthesia. And he, like, pulled me to the side afterward. And he was like, why did you say that? Like, because I want people to know they have trouble with, like, meds or their brain, that I'm here to help. He's like, no, you're trying to show power over other people. I was like, I don't think so. But, you know, it's just, it's really, really interesting, because you will see in this space that there's so much that we know that can lead to space that the other people, they don't know it, but they're very matter-of-factly coming in, right? I was told that I was too white to be in the psychedelic space by an indigenous person who told me that I demanded, she demanded my respect because it came from her land. And I was like, what? Like, but it's something to where, you know, when you guys get into this space, and hopefully you will eventually, you're going to hear a whole bunch of different things to where maybe we can start a support group, talk about it. But, yeah, so anyway, so with that, right, we understand the drugs. We understand if there's a bad reaction. We understand if there's a naked person in the pool thinking that God's coming when the sun comes down and she's got to fight all the demons, right? Because if they're not properly prepared, they can go into psychosis during some of these things. And the people that are leading the retreats, they have no idea what they're doing. I think there was a 22-year-old who just died, ayahuasca retreat in Florida at a church. He ended up getting it. He's hyponatremic, I believe. But he died a few years ago, and his family just won a pretty significant lawsuit. And I was scrolling on the website, and I'm like, well, I wonder who was there. And it was all shamans, right, which is great as long as, you know, you have some type of medical training to recognize when there's actually a medical emergency going on. So I've got the background with that. But the two big things here in this space, you'll hear psychedelics integration, and then you hear the term transition. Integration is when you're going through a session and your brain is showing you all this stuff, and it may not make sense to like kind of the way our brain works consciously through algorithms, but from a subconscious like brainstorm, per se, it eventually makes sense. So what you do, right, during these sessions is this stuff comes up, and I tell people, I'm like, when stuff comes up, good, bad, ugly, whatever, it's got substance to it. Just try to hold on to that stuff that has some type of substance, and then let's try to integrate it. So integration basically is where you, things come up, but you kind of have this third party view, and then you're able to identify it, and then you're able to recognize it, and then you're able to actually integrate it. And what they've shown when you're able to do that is a lot of the memories will eventually go into your long-term memory. So something with PTSD, I don't have this in here, but something with PTSD is a lot of times when we go through something heavy, it can be anything. It doesn't have to, you know, I get so many people who are like, well, I didn't serve in the military because I must not have PTSD. I'm like, I'm pretty sure we all have PTSD to a point with something. But what will happen a lot of times is you'll get a thought in your frontal lobe. In your frontal lobe is where memories and emotions are enmeshed. So if a memory comes up, it may trigger an emotion. If an emotion comes up, it may trigger a memory. And we can't differentiate it. They're like a bowl full of noodles. Ketamine and psychedelics disassociate that. You're sitting back in a third party. You have the memory, you have the emotion, and you can analyze those two things. And from your viewpoint at that time is when you say, huh, I could see exactly why I would feel that way during that time. So you're acknowledging the memory and you're acknowledging the emotion, but you're not in it to feel it. And that's what PTSD is, right? PTSD is when people get triggered and they feel that emotion. There's a lot of quantum physics, believe it or not, in psychedelics. Our brain doesn't understand time. If something could have happened 40 years ago and you're still having the same reaction today and you feel like a loser because that happened 40 years ago, why can't I get over it? Your brain still has the same reaction in this time as it had in this time plane. So until you can disconnect the emotion from the memory and show the brain it can actually do that, it keeps coming up. It'll keep coming up forever. But once you can disconnect these two things, they go through your amygdala and then your amygdala takes it to your long-term memory. So your long-term memory, the emotion's not attached to the memory. So one example I give, I give really powerful examples because I want to get my point across. The one example I give is you got two people, they've each been raped. You got one person here who says, you know what, when I was raped, that was the worst time in my life. I don't know if I can handle it again. Thank God I'm done with that. That was a horrible experience. But I've been able to work on myself, I've been able to help others, you know. So you see that person, right, and that's called like post-traumatic growth, kind of. You hear that person talk about it versus the second person who got raped who says, I can't, I can't, I can't talk, too much, too much, too much, right? What do we do as people? That one's strong, that one's weak. No. The second one that can't talk about it is feeling the emotional turmoil as if the situation is happening in real time again because their brain's still seeing that as a threat. That's where ketamine and psychedelics come into play big time. It disconnects it and allows it to go into the long-term memory. So the person can then remember the story objectively first and then the subjectiveness comes behind it. So I will tell people, if you are leading with an emotion, you need to get help with your mental health because we should all be objective, not, you know, like antisocial, but we should be able to talk about a story, bring an emotion with it should we choose. If the emotion leads and then we have to talk about the story then our brain's kind of off track. So long-winded answer to that's kind of what integration is. A lot of things here in the mental health space, if you've all worked in it, it's highly non-functional, like placebo sometimes is actually higher than what we're doing in mental health right now. So considering in anesthesia, we have a pretty good track record. They need our skills in the mental health space because it's not theories. It's all neurologic patterns. And now we're starting to see there's neurologic patterns with the way that we hear things, the way that we do things. There's neurologic patterns with the inflammatory cascade. There's neurologic patterns with the cytokine storm. There's neurologic patterns to where, as CRNAs, we have, I won't say some of, I will say we have the best assessment skills there are. We're sitting there trying to figure out when a person's going to start breathing from the paralytics. We're predicting when they're going to breathe before they even breathe, right? Nobody else is doing that. They need our skills in this space. They don't need our egos. They'll tell you that. But they need our skills. So assessment is huge. Empathy. Huge with empathy. The thing about CRNAs, we don't diagnose. And I love that. Because you will see people will diagnose and they start treating the diagnosis. They stop looking at the person. We treat the symptoms that we're seeing at that time. And that's exactly what the brain needs. It needs more symptom treatment. And then leadership. These people, when they come in, they stop trusting themselves. You'll see. You can see it when they stop listening. Sometimes I'll talk for like 90 seconds. I'm like, did you hear anything I said? They'll go, nope. I'm like, all right, let's go. And then I try to just say, here are the risks. Just barely, right? Because you can see they are at the end of their rope. I've had guys come into the clinic. One guy lost his daughter at 21 years old. It's great for complex grief, too. Lost his daughter at 21 years old. And he told me, if you don't help me right now, I have a gun in my car. I'm going to go blow my brains out. Like, all right, let's go. So, you know, but it's that type of leadership, right? Because what would other people do sometimes? They would be like, I don't feel comfortable. I need to go to the ER. I'm like, does anybody know what we do with mental health in the ER? Like, we traumatize them more. You know, and I'm like, why do we keep sitting? You understand, we know nothing about mental health in the ER. And now they're trying to start doing ketamine, right, in the ER. I don't know how many of you all have been around ketamine in the ER, or just around ketamine in general. All their senses get heightened. The last thing you need is a fast ER doing ketamine infusion. But each their own. Transition. So you start treating these people, and you see them, right? You just see them start improving, and they look amazing. You've pulled them out of their hole of survival. They're back in the world. They're back in the game. But now they're like, what do I do? Like, literally, they lose their critical thinking skills because they've been in survival mode for so long. They're fight, flight, freeze. All three, right? That's just where they live. So with this transition, they need a care plan. They need to know how to start wiping their tail again. They need to know when to take a shower again. They're all striving for normal. And normal doesn't exist. And initially, when we used to do objective measurements of normal, and they said, I just want to feel more normal. We'd be like, okay, well, you were sleeping two hours. Now you're sleeping eight hours. You were just eating one meal a day. Now you're eating three meals a day. You've been in the gym like five days, but I don't feel normal. So your treatment was ineffective. So then you go back to measurable, right? Specific measurables with your care plan. Your ADLs, huge. They forget them. And then ethical support. I'm not sure how much you all know this. There's a lot of people that sleep with each other in the mental health space. Psychiatrists sleep with patients. Therapists sleep with patients. It's interesting. When I see this now, I mean, there's a couple of ER physicians who just lost their license in Virginia, I believe, for sleeping with clients. Psychiatrist, great psychiatrist in Australia slept with this client, had a relationship with her. She killed herself. And it's common. So having those nursing ethics, big deal in this space for sure. So, again, why should we be leading in this space? We have the assessment. We have the communication skills. We have empathy. And a huge thing is we have advocacy. So when somebody comes into the hospital, right, gunshot wound, what are we going to do? We're going to call in every specialist that we need to help this person. That does not exist in the outpatient space. It's more of a business in the outpatient space. They're very territorial, very territorial. So I had one guy come in. He had like 38 surgeries. He was on 17 medications, had nine specialists. I was like, well, your therapist talks to your psychiatrist, right? He's like, no, my psychiatrist doesn't believe in therapy. My therapist doesn't believe in medication. I'm like, okay. And I was like, what about your, like, your rheumatologist, you know, talking to your neurologist? No. They all are actually arguing about the diagnoses that I have. Okay. So I told my husband at the time, I was like, I feel like I'm working in an outpatient ICU. And really that's kind of what it is. And the beautiful thing about CRNAs, again, which is kind of a gold thing for us, tell me how many people have worked with specialists in the ICUs where we worked before we went to anesthesia school with all those specialties, and now we're in the OR and we work with all these specialties. So we know how to kind of transition. Like my language will change if I'm speaking to a neurosurgeon versus if I'm speaking with a pediatrician versus if I'm speaking with an obstetrician. And that's, again, one of the strengths that we have is CRNAs. We can change our communication styles in order to be best communicative to our audience. And, again, that's something that is needed. There's nobody in the space, guys. Nobody. Another example I'll give is there's a lot of vets that like to go to Mexico to do psychedelics. And I was talking to this lady. Again, apparently I did have a Rasta party and a guy in Jamaica told me that his most exciting thing to watch during a ceremony one time was my facial expressions. So I've got to watch those. But I had this girl come up who leads one of the biggest military retreats. And she's well-spoken, right? And I was like, so what do you do? Oh, I work in human medicine. Like human, like I've never heard that term, right? And I was like, okay. What else do you do? Oh, I lead the retreats down in Mexico. I was like, okay. How did you get into human medicine? I used to be a vet tech. Okay. How did you get into human medicine? Well, I became a certified nursing assistant. I was like, what? Oh, okay, and you're the leader of these retreats? And I'm, you know, playing completely dumb. And she was like, uh-huh. Great. So as CRNAs, right, like we've been to school forever in the medical space. We've been trying to tell people we are good enough. I promise you we're good enough. I promise we can do it, right? We're begging for people in the traditional space to accept us as one of their own or better, right? And it's slowly getting there. We still have a heck of a climb to go. Nobody can compete with us in the psychedelic space. And this is going to be a multiple trillion dollar business. Period. MDMA? Ecstasy? Not sure how much you guys are keeping up with that. The FDA, I've heard, is supposed to come out with a decision on August the 9th, whether they're going to approve MDMA or not. I'm going to guess it's going to be a no, reason being they've been looking at MDMA since basically 1985. That was when an organization called MAPS was created. MAPS is a nonprofit. It became Lycos for profits so they can make money off MDMA. They didn't really think that the FDA didn't understand therapy when they were actually doing these trials. So MDMA, six-hour session, two therapists at the same time, and they went and presented it to the FDA. And where they messed up and where they probably should have looked at what Janssen did with Spravato, if you guys know Spravato, it's esketamine. Janssen got Spravato approved in like 2013. They did not use therapy at all. It's too much of a variable. The FDA doesn't understand how to put therapists in there yet. So when they, the FDA board advisory board met, I think it was in June, they ate them. Like it was, they said it was horrible. And it was a lot of people who hate the FDA. They say the FDA is basically crap and they're idiots and they don't know what they're talking about. They didn't say that after the FDA ate them. I'm pretty sure the FDA made a good point as to what they were looking at. So MDMA, who knows? But what I do know, there's already psychedelic codes that the AMA has approved. You've got CPT codes for psychedelics already. They went into effect January the 1st, 2024. And they had negotiated that they are going to pay, Medicare is going to pay for one MDMA session, which apparently is showing about 74% efficacy for about six months for PTSD after one session. So it's complete resolution for about six months. They're going to pay between $25,000 and $35,000 for one six-hour session. But they're going to pay enough to where they could actually hold a CRNA salary. But if we're not in it, they don't know about us. So that's something that I highly, highly encourage you all to look into. So here's your future of psychedelics. CRNA should be leading. Psychiatric nurse practitioners should be in there. Family nurse practitioners are actually pretty good in this space. And nurses, right? We should all be leading the psychedelic space. Psychiatrists, anesthesiologists, primary cares, all those guys, they should all be secondary tertiary to us. And that's it. Anybody have any questions on anything? »» Nancy from California. Thank you so much. Reimbursement. Do you think it will branch out other than just the VA at some point in time? »» I think so. So the VA pays about 300% more than what cash is charging right now. They're still saying it's investigational. But who's starting to pay for it is disability companies for pain. I do think it's going to get covered for pain first. And then it will be mental health. They're trying, but they just don't have the data. They need to have 100,000 cases apparently showing treatment with depression before they start covering it. There are three groups out there. One of them is called Taramind. It's actually led by a SEAL Team 6 guy, Marcus Capone. He's pretty big with pushing for psychedelics. There's Taramind, there's Enthea, and there's MECO. Those are all three insurance companies that are doing B2B. So they go to your employee. It's like Aflac. It's a supplementary plan. If they're starting there, then they're going to approve the cost analysis on that. And then hopefully insurance will accept it eventually. But trying. Great. Thank you. Thank you. Hi. So I found a very interesting topic. In terms of looking into going into this, what are looking online or companies to look at to learn more about it or get into psychedelics for providers? So that's a great question. And so with ketamine specifically, right? So ketamine is Schedule 3. All the other guys are Schedule 1. Ketamine specifically, right now, it's a lot of CRNAs that are just like, I want to open a clinic. You know? So we do have some CRNA support groups on social media that will help with stuff like that. There's something called the ASKP, American Society. It used to be Ketamine Physicians. Now it's like Ketamine Physicians, Providers, and Psychotherapists, I believe. They help with that. There is a CRNA named Jason DePrat. Jason helps with some things to help people to start their own. But right now, honestly, it's still very, very siloed from a standpoint to where there's not big companies looking in to doing it. There's a lot of people in the business space that will see us as opportunity. And that's happened to me more than once. They will come in, they think it's a great idea, and they will put money behind you until they don't. So you've got to be careful with that. And some of the CRNAs that have ketamine clinics have seen that, too. So, yeah. So what I would recommend is reaching out to a CRNA that has a ketamine clinic and asking them, right? Like, hey, I want to get into this space. I'd be glad to help whoever, because I've made a lot of good decisions and a lot of bad ones. But I've learned from them, right? But, yeah, that's what I would say. And even if you wanted to start doing ketamine at your hospital or clinic or whatever else, I think the hospitals in the rural areas that have, like, open bays, right? That would be an amazing place to do it. And then, you know, talk to administration if they have open beds there to where you can partially rent that out and have people come in to help with that. It's amazing. It's one of those things you start going, and you're just like, I don't know if I can stop, because it's so, it's like 85% effective. Thank you. You're welcome. My name is Randy. I've been practicing for 44 years as a nurse anesthetist. And I have the privilege of living in Northern California, which probably north of the Mexican border is one of the largest drug-producing areas in the United States of various kinds. And we have a lot of opportunity to help people there, because their mental health services north of Sacramento are almost nonexistent. And so we have talked about, in the pain clinic I work in, we've talked about doing a sleep lab or, you know, a sleep treatment center for ketamine. And the question I have is, what is a blanket policy for a liability insurance is going to cost us to do this? You know, AANA is actually pretty good with that, right, with the insurance. Me personally, so I have three clinics, and I pay $5,000 a year for each clinic. And that's the umbrella, right? That's everybody. Yeah. So it's not. Now, the interesting thing, primary carers can't usually get insurance. They won't cover them. Malpractice will not get primary care physicians insurance. Yeah. So yeah, so that's not a bad cost. Your biggest cost, and this is where I messed up before. CRNAs are going to come in and say, give me a salary. Don't do it. Because, you know, there's a lot of people who say, hey, I'm going to do all this stuff. And you're like, okay, let's go. And not everybody likes to do 90-hour weeks. I don't get it, right, for this. So, you know, so if you get them to come in, you get them to make sure that they know they're going to take more than one person at a time, because you easily can do that. Right. And really do a cost analysis from that standpoint. But, no, it can be very lucrative. It really can. You just have to have people that are coming through the door. You can't have two patients a day. If you have 10 a day, you're good. Thank you. You're welcome. Hello. Hi. I practice all over the place. Many of my patients, I give them ketamine for pain control. However, I also like the little mood booster. Is there a minimum dose that we know of that does help mood, or is it more of a continual or an infusion situation for ketamine? That's a good question. You know, I mean, the baseline will say to run 40 minutes, right, that's your base. And that kind of starts your whole neuroplasticity and something called BDNF. They'll tell you the dose, right, is half a mg per kilo. That's your starting dose. People who are like 70. Now, people between 70s and 80s are amazing. My favorites between 70s and 80s and teenagers. Love them. They're just the coolest people to treat. But some people, if they come in and they're a little bit, you know, more immunosuppressed, 70 or older, I go down to 0.3 mg per kg. But really, and there's argument on this both ways, but this is my personal, I've been around maybe 15,000 people with ketamine. It's their level of disassociation. So when you have ketamine and you have psychedelics, you want them to be neutral, and you want them to kind of be in the present. And that's where, when they're in the present, they're not connected to other things. So my personal assessment questions that I ask them are three. I say, basically, it's about weight, about time and thought processes. So if you ask them, do you feel heavy right now? They'll say, yeah, my feet feel like concrete. Okay, do you feel light right now? And they're like, yeah, my hands feel like marshmallow. So they can feel both sides of weight. Time, I'll ask them, does time feel like it's sped up? And does it feel like it's slowed down? But you can't ask them both at the same time, because they literally, their brain is so focused over here, it has to be slow elsewhere. So I'll ask them, does it feel like, you know, you've been here forever? And they're like, yeah. I'm like, okay, does it feel like you just got here? And they're like, yeah. So they're right in the middle. And then I'll ask them thought processes. So do you feel foggy right now? Yes. Do you have a special sense of clarity right now? Yes. If they answer yes to those polarities of those three questions, they're beautiful. And that's what you want. So what you want to do with ketamine psychedelics, not from a scientific standpoint, but you want them to be in the center. And it's truly in a meditative mindset. That's all you're doing. You're stimulating the brain to put it in a meditative mindset to where it's truly sitting with itself in the present. When that happens, all these negative things that they're connected to, coping mechanism, anxiety, depression, OCD, trauma, all these things, they don't feel connected to them. So they're just at one with. So when you have patients who are like, oh, my gosh, it's peace. I feel peace. I feel calm. They're perfect. That's where you want them. If you have ketamine, and we'll talk about the negatives. If they feel like they're a bubble or a Lego or if they're floating in outer space, they feel like they're in hell, that's too much disassociation. And you can bring them right back down. But their brain will go from like 4D to 3D to 2D to 1D. And sometimes they'll be in the 1D space. It's too much ketamine. Slow it down. Some people think they need that much. They don't. They don't need that much. They need to be neutral. And if they can be neutral, they can start manipulating the brain. And manipulation is actually not always a negative thing. They can manipulate their own brain when they're in that neutral space. And these things come up, and they're like, oh, my gosh, why do I react like that? Oh, I can see now. Because I felt threatened. It's the same way that what my dad made me feel when I was seven. So they see these things, and then they can actually manipulate their thought processes and their actions more positively. And they can take that experience that they see and really feel truly immersed in, and they can duplicate it outside of ketamine. So, yeah, just get them to feel neutral. And then you're good. All right. And then let's see. Here's my references. And then, yeah, if you want to learn more, I'm online a lot. A lot of education out there. You can just type my name in. You're going to learn about ketamine psychedelics something. So I appreciate you all's time. Thank you.

psychedelics

mental health

CRNA

ketamine

pharmacology

default mode network

triple network theory

depression

PTSD

addiction