PATIENT INFORMATION FOR
KETAMINE STUDY
PRINCIPAL INVESTIGATOR:
Fernando Cantu MD is the Principal Investigator for the Ketamine Coma Study in Mexico. His study has been approved by his Institutional Review Board (IRB):
San José Hospital
Technological of Monterrey
School of Medicine
Monterrey, México
Email: fercan7@yahoo.com
The Ketamine Coma Study is supervised by Dr. Cantu who makes the final determination if a patient qualifies for the study.
THIS RESEARCH STUDY HAS NOT BEEN APPROVED BY THE INSTITUTIONAL REVIEW BOARD AT THE UNIVERSITY OF SOUTH FLORIDA. NEITHER DR. KIRKPATRICK NOR THE UNIVERSITY OF SOUTH FLORIDA ARE PARTICIPATING IN OR CONTROLLING THE MEXICO RESEARCH.
The information below is for patients of Dr. Kirkpatrick that might be part of Dr. Cantu's research studies. The doctors and researchers at San José Technological Hospital of Monterrey, School of Medicine, study illnesses and other health problems. They try to find the best ways to resolve these health problems. In order to do this, they need help from referring doctors of patients who agree to be part of the research study.
Dr. Kirkpatrick might suggest Dr. Cantu's research as an option for certain patients with RSD / CRPS. Dr. Kirkpatrick will attempt to assist Dr. Cantu with the following arrangements:
APPOINTMENTS:
Clinic appointments are scheduled at: 813 974-4115
If you are here just for an evaluation as a new patient = 0ne day
If the evaluation suggests that you are a candidate for the ketamine study = Two days in Tampa
Day 1 = Tuesday ~ New patient evaluation
Day 2 = Wednesday ~ Interview about the study and baseline measurements for study. This evaluation will be recorded on video. (No charge for day 2)
The following video will give you an idea of what to expect on Day 2:
Kaci Corrigan Family- Video
http://www.rsdfoundation.org/en/Kaci_Corrigan.html
Bring your medical records to the evaluation on Tuesday.
HOW LONG WILL YOU WILL NEED TO BE IN FLORIDA?
1. THE INITIAL EVALUATION ON TUESDAY TAKES 1-2 HOURS.
2. THE RESEARCH EVALUATION ON WEDNESDAY TAKES 1-3 HOURS WITH A VIDEO RECORDING. THE RESEARCH CONSENT FORM AND PROTOCOL THAT WILL BE DISCUSSED ON DAY 2. HERE IS A LINK TO THE ENGLISH VERSION OF THE CONSENT FORM FOR THE KETAMINE STUDY:
http://www.rsdfoundation.org/en/Cantu_MD_Consent.htm
3. ON THURSDAY YOU NEED TO BE EVALUATED BY OUR PSYCHOLOGIST (DR. RICHARD HOFFMAN) FOR 2-3 HOURS TO DETERMINE YOUR BASELINE MENTAL FUNCTION BEFORE THE RESEARCH STUDY. YOU NEED TO SCHEDULE AN APPOINTMENT WITH DR, HOFFMAN FOR THURSDAY – PHONE; 813 977-2924
THERE IS NO CHARGE FOR THESE RESEARCH EVALUATIONS ON WEDNESDAY AND THURSDAY.
REQUIRED LABORATORY TESTS IN USA
Typical labs completed in the USA prior to the study include:
Beta HcG
CBC
Chem 7
Thyroid Panel
Urinalysis
Chest X-ray
Venous doppler of the legs to rule out deep vein thrombosis
TRAVEL PREPARATION
Typical items to acquire in the USA prior to the study include:
Glycopyrolate (Robinol™) in 20 vials (0.2 mg/vial) for IV injection
Sedative for travel by air (e.g., Xanax, Ativan, etc)
Contact Information while in Mexico for all people traveling with patients needs to be provided to Dr. Fenrnando Cantu and Dr. Anthony Kirkpatrick
Physician's Letters for Airport Security and Ketamine Booster Infusions: See below for typical letters:
Draft Airport Security Letter
April 1, 2007
U.S. Department of State
Subject: Request for Emergency Passports
TO WHOM IT MAY CONCERN
Dr. Shannon Stocker MD is my patient with open ulcers on her arms due to her advanced complex regional pain syndrome (RSD / CRPS)
Ulcers due to RSD were reported by Dr. Robert Schwartzman more than 15 years ago:
Webster G, Schwartzman R, et. al. Reflex sympathetic dystrophy: Occurrence of inflammatory skin lesions in patients with Stage I and II disease. Arch Dermat 1991 127: 1541-44.
Infection due to RSD-induced skin ulcers can lead to multiple extremity amputations as a result of life-threatening septicemia. So far, all patients have showed improvement in skin ulcers following the 5-day ketamine coma procedure.
Please grant an emergency US Passport in order for my patient to travel to Monterrey, Mexico for treatment. Failure to do so will increase the risk of amputation.
Please be advised that these ulcers are extremely painful and sensitive to light touch (allodynia). Also, the patient’s husband (Greg) will need to accompany the patient at all times to insure her safety. Therefore, Mr. Stocker will require an emergency passport as well.
Feel free to contact me at 813 974-2870 or 813 390-8690 if you require additional information.
Sincerely,
Anthony Kirkpatrick, MD, PhD
Director, Pain Management Service
USF Ambulatory Surgical Center
Draft Letter for Ketamine
Booster Infusions
Dear Dr. ______________:
Dr. __________ tells me that your pain group at the University of ____________ is interest cutting-edge developments in the field of pain medicine. Therefore, you might be interested in our ketamine coma trials in Germany and Mexico.
Would someone in your pain group be interested in collaborating with me in managing the care of one of my patients (Elena Cohen) when she returns to California from Monterrey, Mexico after completing the 5-day ketamine coma study?
Is someone in your pain group available to help this nice lady with 2-hour ketamine infusions at USC? These research subjects sometimes require about one ketamine “booster” per month for six months.
The ketamine infusion treatment protocol consists of conscious sedation with ketamine over a 2-hour period. Typically, pretreatment with 0.2 mg of glycopyrolate IV is the only other drug necessary.
Here is Ms. Cohen’s medical synopsis:
http://www.rsdfoundation.org/en/Elena_Cohen.htm
The billing codes and the “Ketamine Treatment Protocol” for the 2-hour ketamine infusions are at the following site:
http://www.rsdfoundation.org/en/Ketamine_Treatment.html
My cell # 813 390-8690.
Thanks
Anthony Kirkpatrick, MD, PhD
Director, Pain Management Service
USF Ambulatory Surgical Center
KETAMINE BOOSTERS :
Patients will require ketamine boosters approximately every two weeks for the first two months after the ketamine coma procedure. Then, there will a final booster at three months. Generally, ketamine boosters are not performed after three months. It is recommended that the boosters be performed locally near the patient's home.
OTHER ISSUES :
You will be sent a new patient information form to complete. Please find a copy of this form below to complete and bring with you to the evaluation.
To get a list hotels near the University, call Angela at 813 974-2870.
Patients 18 years and younger can stay with their family for free at the Ronald McDonald House.
For reservations, call Betsy Wilkinson at 813 254-2398, ext: 314
Address to USF Clinics:
University of South Florida Medical Clinics
12901 Bruce B. Downs Blvd., MDC 59Tampa, Florida 33612 USA
Anthony Kirkpatrick, MD, PhD
Related links:
Video: Physician becomes patient for ketamine coma study
Video: Preparation of patient for 5-day ketamine coma
Video: Low dose ketamine infusions
Video: 15-year old Kaci Corrigan
Physician becomes patient for the study
NEW PATIENT INFORMATION FORM:
UNIVERSITY OF SOUTH FLORIDA
PHYSICIANS GROUP
DEPARTMENT OF ANESTHESIOLOGY
PAIN MANAGEMENT OUTPATIENT CLINICS
PATIENT INFORMATION FORM
To better serve your care, please complete the following and bring this form with you to your first appointment. Important: It is strongly recommended that you provide the following documents at the time of your evaluation:
1.) Your doctors’ dictations for the last two years about your pain problem.
2.) A copy of reports for the tests listed under “K” in this questionnaire.
A. General Information:
Today’s Date_______________________
Name:_________________________________ S.S.#__________________
Age:__________ Sex: M F Date of Birth ______________
Address:________________________________
City: __________________
Home Phone:____________________________
Work Phone:_____________________________
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B. Referral Source:
Physician: ________________________________________
Attorney: _________________________________________
Insurance Carrier:___________________________________
Other: ____________________________________________
Name of Primary Care Physician:__________________________________________
Address of Referral Source:______________________________________________
C. Chief Complaint:
(1) What is your main problem?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
D. History of Present Pain:
(1) Location: Please describe exactly where your pain is located on your body.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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(2) How many months ago did your pain begin? ______________
(3) What event led to your present problem? (Please circle)
Cancer Disease Operation Injury Other _______________
(4) What was the date of your injury? ________________
(5) Do you have pain free intervals? Yes No
If so, how long do these intervals last? ______________________
(6) Short McGill Pain Questionnaire: Please check one box per file line that describes your pain in words and severity.
Throbbing ? None ? Mild ? Moderate ? Severe
Shooting ? None ? Mild ? Moderate ? Severe
Stabbing ? None ? Mild ? Moderate ? Severe
Sharp ? None ? Mild ? Moderate ? Severe
Cramping ? None ? Mild ? Moderate ? Severe
Gnawing ? None ? Mild ? Moderate ? Severe
Hot-Burning ? None ? Mild ? Moderate ? Severe
Aching ? None ? Mild ? Moderate ? Severe
(Continued)
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Heavy ? None ? Mild ? Moderate ? Severe
Tender ? None ? Mild ? Moderate ? Severe
Splitting ? None ? Mild ? Moderate ? Severe
Tiring-Exhausting ? None ? Mild ? Moderate ? Severe
Sickening ? None ? Mild ? Moderate ? Severe
Fearful ? None ? Mild ? Moderate ? Severe
Punishing-Cruel ? None ? Mild ? Moderate ? Severe
(7) What factors aggravate your pain? (circle)
Massage Anxiety Lying down
Sitting Walking Coughing
Sex Running Cold
Heat Straining Standing
(8) What helps your pain?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(9) What is a comfortable position for you?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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(10) Please describe your activities before your pain problem started.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
E. Previous physicians. Please complete the following information regarding doctors who have evaluated your pain problem. Start with the first doctor who evaluated your pain.
Doctor #1
Doctors Name: _______________________________________________
Doctors Specialty: _____________________________________________
Year of Doctors Care: __________________________________________
Doctors Diagnosis: ____________________________________________
List Treatments Performed by Doctor______________________________
____________________________________________________________
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Doctor #2
Doctors Name: _______________________________________________
Doctors Specialty: _____________________________________________
Year of Doctors Care: __________________________________________
Doctors Diagnosis: ____________________________________________
List Treatments Performed by Doctor______________________________
____________________________________________________________
Doctor #3
Doctors Name: _______________________________________________
Doctors Specialty: _____________________________________________
Year of Doctors Care: __________________________________________
Doctors Diagnosis: ____________________________________________
List Treatments Performed by Doctor______________________________
____________________________________________________________
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Doctor #4
Doctors Name: _______________________________________________
Doctors Specialty: _____________________________________________
Year of Doctors Care: __________________________________________
Doctors Diagnosis: ____________________________________________
List Treatments Performed by Doctor______________________________
____________________________________________________________
* If evaluated by more than four doctors for the pain problem, list their names and same information on the back of this page.
F. Social History
(1) Marital Status: Single Divorced Widowed Married
(2) Highest Level of Education: _________________________
(3) Children: Yes No How Many? __________
Ages_________________
(4) Present source of financial support: (circle)
Personal earnings Workman’s Comp Spouses earnings
Disability payment Pension Insurance
None Other___________________
(5) Do you work? (circle) Full time Part time
(6) Do you smoke? Yes No Do you drink alcohol? Yes No
(7) Is there legal action pending? _____________________________
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G. Past medical history: (circle condition)
Asthma/breathing problems
Bleeding Problems
Diabetes
Liver Problems
Kidney problems
High Blood Pressure
Headaches
Other___________________
H. Previous Treatments for pain:
Modalities | Yes | No | Effectiveness |
Blocks |
|
|
|
TENS |
|
|
|
Physiotherapy |
|
|
|
Biofeedback |
|
| |
Counseling |
|
|
|
Pain Management |
|
|
|
Surgery |
|
|
|
Other |
|
|
|
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I. Surgical History
Surgeries performed on you and the dates that they were performed:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
J. Medications:
(1) Allergies: ___________________________________________
(2) Previous medication for pain:
Drug | Effectiveness | Side Effects |
(3) Current Medications:
Drugs | Dosage | Purpose | Effectiveness | Doctor |
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K. This portion of the questionnaire is extremely important. Please provide the dates and the results of the tests listed below. Also, provide a copy of these reports (not films) at the time of your evaluation.
Previous Studied Laboratory Tests Performed to Evaluate Pain:
1. X-rays
2. CAT scan
3. MRI
4. EMG
5. Nerve conduction studies
6. Myelogram
7. Thermogram
8. Bone scan
L. Physical Status:
Height _________
Weight _________
~ ~
~ ~
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