This past weekend, Innerbloom Ketamine Therapy (IKT) celebrated its one-year anniversary! As I reflect, I am astounded at how much my career has evolved over the past ten years. For instance, I remember the intense pressure of being a trauma surgeon, being on call, waiting to be summoned into the operating room at any moment, during consecutive 24-hour shifts. I recall the stress of running into the emergency department, knowing that any delay might mean a patient could die from hemorrhage caused by a traumatic injury (i.e. gunshot or stab wound). Now, at IKT, I maintain regular business hours four days a week, bring my golden retriever to work with me, and spend time learning techniques for stress-reducing practices, such as meditation and mindfulness to share with my patients.
While I have a much healthier relationship with my work now, I am extremely thankful that I started my career in surgery. From all the specialty options available to us in medical school, I chose surgery specifically because of its difficulty and my fascination the skillful art.
Today I will share some well-known, but powerful lessons from my days in the operating room. After treating hundreds of patients at Innerbloom Ketamine Therapy, I will also discuss how these lessons apply to anyone considering or undergoing ketamine therapy or ketamine assisted psychotherapy (KAP).
Prior to starting any operation, I mentally rehearse my surgical steps which includes a plan A, B, and C if things go awry. Even through I’ve already spent years studying and practicing as a surgeon, it is imperative to not only prepare each time, but to plan for anomalies, complications, and surprises. Because it is essential to remain calm, these plans help me anticipate issues and corrective actions before they happen. Plans may fall apart or change, but planning is key. The same principles apply to helping someone in their mental health healing journey.
Whether you are considering ketamine therapy or are scheduling your first appointment, I always emphasize the importance of preparation and planning. Understand that it’s best for many to work with a professional like a licensed therapist. With objective guidance, patients are able to truly learn about their unique lives and overcome challenges. Working with a team of medical providers also helps patients set realistic intentions and treatment goals.
Setting intentions and formulating a plan significantly increases the likelihood of a successful and durable healing experience. I always encourage my patients to do their homework and to talk with loved ones or their healthcare team before considering ketamine therapy. Since it is normal for many to have exaggerated expectations and some anxiety before treatment, take time to prepare and understand the process beforehand. This research will help you to consider potential obstacles, opportunities, and alternatives.
Good help is invaluable in the operating room. As a surgeon in the OR, I was surrounded by an anesthesiologist, surgical technicians, and nurses to ensure a smooth and successful operation. Outside the OR, I had the help of other doctors, nurses, administrators, and ancillary staff. For each patient, we must all join together as a cohesive unit, not unlike an orchestra of musicians led by a maestro. And while we all know that teams are only as strong as their weakest link, one overlooked point is that good teams must be free from distractions and detractors. Similarly, it is important to build a mental health team that you trust. Patients who surround themselves with trusted friends, family, and other licensed professionals have better outcomes. Most teams include the patient, trained professionals such as therapists and coaches, and a good social support system. If there are people in your orbit who are negative, or likely to distract (or sabotage) your healing, isolate yourself from their influence. Now is the time to lean on people who you love, trust, and who truly want you to become the happiest and best version of yourself.
When the difference between life and death (or permanent disability) is a matter of seconds, surgeons must be decisive. Once the decision is made, everyone in the OR must proceed forward and commit to whatever lies ahead, both good and bad. As a surgeon, there have been many instances where I had to make split-second decisions in the operating room.
One such memorable moment was during a surgery on patient who suffered a cardiac injury along with other injuries from multiple gunshot wounds to the abdomen and chest. Normally, the heart is encased in a membranous sac called the pericardium. If bleeding occurs from an injury to the heart, pressure may build between the heart and pericardium and prevent it from beating, resulting in inevitable death. This is called a cardiac tamponade. As I was operating in the abdomen to repair a bowel injury, unexpectedly, the patient’s blood pressure precipitously dropped, and the anesthesiologist looked to me for guidance to explain why our patient was very suddenly dying. Without hesitation, I assessed the situation, made an incision in the chest only to be confronted with a tense pericardium filled with blood and a non-beating heart. I made another incision to the pericardium sac to release the pressure, and a gush of blood shot across the room. The patient’s heart began to beat again and I quickly repaired a laceration to the heart with a suture. My decisive action taken in that critical moment ultimately saved the patient's life, reaffirming the importance of quick thinking and decisive leadership in the operating room.
While indecision generally is not as consequential outside the operating room, some patients question whether ketamine therapy is right for them at some point. It is normal to have doubt and ask yourself, “Will I respond to ketamine treatment?” or, “Will the benefits outweigh any potential side effects?” The reality is that healing will take work, patience, and trust. It won’t necessarily be easy and not everyone will respond the same way. My advice is to learn, gather information, talk to friends, family, and other licensed medical professionals, then make a decision that is right for you.
I remind patients that sometimes you don’t always feel better right away. This is part of the process and can take time. Ketamine is unlike traditional medicine where the effects are felt immediately then dissipate. The positive effects of ketamine are felt after continued therapy and subsequent infusions, hence the standard protocol series of six infusions. Once you start treatment, it is important to continue with the full series to increase the likelihood of positive outcomes. The benefits of ketamine may be subtle at first, but as momentum builds and the medicine compounds upon itself, the results become obvious.
During my surgical residency, one of my favorite attending physicians, Dr. Symmonds, would often tell us, “Make a lot of small mistakes now and you’re certain for a big problem later.” In other words, there is no room for cutting corners in surgery.
One memorable instance where an ignored ‘small’ problem led to a complication that ultimately required reoperation was during a routine colonic resection operation for colon cancer. As a lower-level surgical resident, I assisted while my senior chief resident proceeded with closure of the abdominal wall at the completion of the operation. During closure, the suture broke and he half-hazardously repaired the suture rather than replacing it with a new one. A few days later, during the recovery process, the patient coughed, the suture unraveled, and the abdominal contents, including the bowel, eviscerated from the open abdomen. This is called dehiscence. The patient was emergently returned to the OR for placement of the intestines back into the abdomen and repeat closure. As one could imagine, this was quite a horrific event to witness for both the patient and staff members. Unfortunately, the unaddressed ‘small problem’ led to an easily avoided ‘big complication’ had the issue been addressed early and properly.
This lesson was repeated to us students as a stark reminder of the importance of attentiveness and proactive monitoring during surgery since even seemingly minor issues can potentially escalate into life-threatening complications. It reinforced the importance of thoroughness, attention to detail, and adhering to protocols to ensure patient safety and well-being. I believe the same principle applies to mental health.
Ignoring warning signs, unhealthy thoughts and behaviors, even if they appear seemly benign or subtle, is only likely to lead to more problems down the road. Now is the time to focus on your healing and becoming mentally fit to prepare for life’s difficulties which lie ahead. It may seem easier to postpone your healing for a more convenient time. But if not now, then when? Don’t postpone your healing. Don’t postpone your happiness.
One of the defining characteristics of surgery is limited time. All else equal, the shorter the procedure the better the patient outcomes. This is because the patient’s body is vulnerable for less time and there is a smaller window for adverse responses and mistakes. While you do your best to prepare and plan the procedure, once it starts, surgeons must do the best they can with limited time. Striving for perfection or waiting for the perfect conditions is typically unattainable. Fortunately (or unfortunately, depending on your perspective), surgeons have many opportunities to practice.
During my surgical residency training, I removed more gallbladders than any other resident in my graduating class. Although slow at first, with time and practice I became more proficient. While this is a routine procedure, it is not without risks, especially the longer the procedure lasts. Therefore, it is imperative for surgeons to do their best work in the least time possible. While I worked slowly and steadily on those first few patients, once my job was done, I did not hesitate to consider whether my work was perfect. It was the best I could do in the time allowed. With more practice, I made incremental improvements to my planning and techniques. These incremental improvements built upon themselves like compounding interest. Today, I can safely remove a gallbladder in a fraction of the time with the same level of patient care.
Ideally it would be nice to have dramatic and immediate improvements after a single ketamine therapy session. However, just a single positive shift can have profound downstream effects. Your healing affects not only you, but also other people that are involved in your life. As you become healthy and happy, your goodwill spreads to your immediate circle, then exponentially multiplies to others.
It’s best to appreciate that healing yourself first can in turn help others live happier and healthier lives. Your happiness is contagious and will impact others. Wisdom will teach you to appreciate and be grateful for becoming a better person than you were yesterday.
Scars are physical reminder of our past mistakes. Hopefully, they teach us to avoid repeating unnecessarily risky and dangerous behaviors. Similarly, as we age and inevitably experience difficult things—ranging from uncomfortable to traumatic—unpleasant memories won’t be erased or forgotten. But past bad experiences and trauma do not have to define you.
It is also inevitable that surgeons will face complications and death. If I considered myself a failure or a poor surgeon following such an event, then what good would that have done for my next patient? If there are lessons to be learned, then reflect and make an effort to be better going forward. Dwelling in the past, which is something that can never be changed, cannot help. Appreciate that life is a struggle, healing is not always easy or a pleasure, and focus on making improvements, no matter how small, rather than ruminating in the unchangeable past.
My experience as a surgeon taught me invaluable lessons on how to best address our mental health crisis at a local level with IKT. In some ways, my role is the same: help people get better. In other ways, my role has changed. For example, I faced life and death emergencies almost daily in the hospital. Now, I have learned how ketamine therapy has saved some of my patients from destructive behaviors and even suicide. It has been immensely rewarding to witness our Innerbloomers start new careers, end toxic relationships, develop healthy life habits, and find new purpose in life.
It’s hard to believe that I saw my first patients at IKT nearly a year ago. And since I moved on from the hospital last fall, it has been immensely fulfilling to serve the community outside of the operating room. During this time of reflection, it has become clearer to me that my time as a trauma surgeon has helped prepare me for a career in mental health, pain relief, and ketamine therapy.
I continue to be impressed by the amazing people in our community who share a passion for healing. There are big plans in store to expand our healing repertoire, build a team of like-minded and talented individuals, and to make significant impact on our patients’ lives and the lives of their team: family, friends, and other medical professionals. My hope is that you can appreciate how our practice is striving to curate a special experience that fosters the potential for healing and growth.
About the Author
Dr. Ray Rivas, a former general and trauma surgeon with over a decade of experience utilizing ketamine, became a ketamine therapy specialist to treat mental health and pain after witnessing its profound impact on his hospital trauma patients and his own mental health. As the founder and medical director of Innerbloom Ketamine Therapy in San Luis Obispo, California, Dr. Rivas applies his extensive medical expertise to provide safe, evidence-based ketamine treatments for mood disorders, including depression, anxiety, PTSD, and chronic pain. His passion lies in helping patients find relief and rediscover hope through personalized, compassionate care.
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