Frequent Flyers. We all know the feeling.
ER: "Dr Happy. We have Mr. Disheveled Drinker here."
ME: "Yeah. I know him. I just admitted him last week. I'll be down shortly."
The frequent flyer. Every field has them.
Every one of them. They are the users of the system. They are part of the 5% who consume 50% of the costs.
Lets dissect the Frequent flyer. In the spirit of Mulletsgalore.com (one of the funniest, classic web sites I have ever found. Go to "classifications"). It has adult themes on occasion so enter with care.
My Frequent Flyers.
PAIN
1) The Migraine: 15 Head CT's in the last year. Nothing works except Demerol. 99% females.
2) The Back Pain: 10 MRI's in the last year. Nothing works except morphine. 99% males.
3) Abdominal Pain: 99% females. 20 CT scans a year. Always normal. Nothing helps. Even morphine.
4) Chest Pain: Highly anxious females or antisocial males with known CAD. They consume uncountable CT Angiograms and heart Caths and stress tests.
5) The prisoner with pain. It always gets worse on the day of discharge.
6) The Drug seeker. It may be any of the above or a physiologically unexplainable pain complex
7) Sickle Cell patients wearing Bling Bling. They are always on massive doses of chronic narcotics and come in frequently with crises. And know exactly what works. I have to believe them.
8) The Car Accident 2 years ago with chronic unexplained pain ever since, and a lawsuit pending. I have my doubts.
Common denominator. Medicaid or Disability insurance. And they frequently use the ER as their PCP. Become aggressive and disruptive when presented with no as a response.
MENTAL ILLNESS
Add mental illness to any infra tentorial illness and you just quadrupled the yearly costs of evaluation and management.
1) The schizophrenic smoker. In their 40's. Four pack per day smoker. They all smoke. Group home. Will never quit. Has never taken a fresh breath of air. Comes in monthly with COPD exacerbation.
2) The suicidal who never quit finishes it on purpose. It is a perpetual cry for help. Some of the hardest patients to manage.
3) The depressed patient with chronic pain. It's ten times worse than chronic pain. It's always female.
4) The hypochondriac. Nothing is ever wrong. Until it is. Miss it and you get sued.
5) Personality disorders. Borderline (OH MERCY!), Dependent, Narcissistic, Antisocial, The first two for females, the last two for males. Just play the game and life is good.
Used to bother me. Not anymore.
DRUG ABUSE
1) The nice alcoholic. End stage liver disease. Varices. Frequent GI bleeds. Anemia, Thrombocytopenia. Horrible disease process that will never stop until death. Everyone feels sorry for them. Affects men and women equally, higher proportion of Native Americans.
2) The mean alcoholic. All of the above, but makes everyone's life miserable.
3) IV Drug abusers. Skin poppers, cellulitis, endocarditis.
4) Prescription abusers. When your HR is 60 and your blood pressure is 100/70, I don't believe you have 10/10 pain.
Unless they are on disability, they never have insurance and can never afford rehab. The cycle never ends until death. The hospital always eats this by charging me $3000 for an ER visit.
SOCIAL
1) The homeless. All you can do is tune them up and get them on their way. It's tough to do but a hospital isn't a hotel. They are usually hungry, and may just be looking for a meal.
2) The abused. I know there are lots out there that we miss the chance to intervene.
3) Noncompliance. They don't know they are non compliant. They can't afford the meds. They get confused with their meds. Total lack of understanding regarding their disease states. Too busy. Don't care. The CHF who uses salt, because he has "a right" to use salt.
NURSING HOME
Usually 85-95 years old. The top admitting presentation is confusion and shortness of breath. Universally, these folks have urosepsis with or with out pneumonia. Add heart failure to their diagnosis of old stroke, wheel chair bound, ischemic cardiomyopathy with an EF of 25%. Invariably, the families never seem to quite understand just how sick granny is. The full codes never get reversed and have families with unmanaged expectations. The consume hours of my time with circular logic and Google doctornomics and accusations of me playing God. The DNR's have families that get it. I love DNR families.
DIALYSIS PATIENTS
The infections
The blood pressure problems
The clotted fistulas
The infections
The blood pressure problems
LOW FUNCTIONING
There are the mentally retarded (are we still calling it this?) from birth or due to birth injury. There are the extremely low functioning fully developed folks. ( the 3rd grade drop outs). The long term drunks. The drug abusers who fried their brains. The "they just don't get it crowd". You can usually tell when it's genetic and when it isn't. They always smell like smoke and have "summer teeth" (some 'er there, and some aren't)
SINGLE ORGAN END STAGE DISEASE
1) End stage Emphysema from smoking
2) End stage Heart Failure from smoking
3) End stage liver disease from drinking
A pattern per say?
CHRONIC MULTIORGAN FAILURE
This is the Holy Grail of cost savings. It is Internal Medicine. It is what I trained for. To learn the ins and outs. It is what we need to grab by the horns to show any real long term cost savings. This takes massive coordination and time. Access to multiple disciplines.
Simultaneously.
Pharmacists
Social Workers.
IT
Specialists
Primary Care
Home Health
Nursing care.
Physical therapy
You need a centralized center of care for these folks. An absolute minimum of one hour of face to face contact with all the players. A coordinated care plan to prevent expensive hospitalization and progression of disease. Physicians need to DICTATE the care of our patients instead of being the transcribers. And it needs to be fully funded.
Data Analysis
Interpretation
Communication
Teaching
Appropriate intervention
Track your changes.
Excellent outcomes.
This is when MORE=LESS
These are my frequent flyers. They are by no means mutually exclusive of each other. In fact most fall into some or all of the categories. They are expensive to insurance. They make care unaffordable for everyone. They make my ER visit $3000.
What are your frequent flyers?
Thursday, December 13, 2007
Frequent Flyer Club
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11 Outbursts:
mulletsgalore is definitely one of the more amusing sites on the net. The repeat work ups on chest pain and abdominal pain are pretty much unavoidable.
Well, I think you just about got the list...There are the ambulatory demented(87 year old who SHOULD be in an assisted living, calls 911 when the toast is burning)but much rarer than the personality disorder group.
I tried as a family physician to understand each patients pathology and needs and balance them with mine. Some people need to be seen frequently( weekly, monthly) to keep them out of the ER...Others need carefull monitoring and a team approach....But, honestly, this sort of patient management is not taught in residency or Med school. Ed Walker, UWSM gives a great talk on "The Difficult Patient".
Part of the truth is that docs often don't Want to care for these folks...They are a pain in the XXX. So maintaining an indefinite"Not MY Patient" relationship serves the doc too, as it can the patient.
This speaks to an earlier post you gave about your statistics. Indeed, can you answer the question, "Who is responsible for the care of this patient?" If that cannot be answered, and it most times cannot, since we want market free choice, (ie doctor shopping) then how can we measure quality? How can we motivate change without responsibility?
The atopic dermatitis adult who chronically gets oral pred or intramuscular kenalog claiming that topicals don't work.
I realize, if that's as bad as it gets, I got it pretty good. No argument here.
Awesome. Will link.
We get our fair share of sickle cell patients who come in with constant 10/10 pain. The most recent admission was in a drug-induced stupor when I found them in the ER. I had a sternal rub to wake him up. He groggily opened his eyes, told me he was still having 10 out of 10 pain, and required more dilaudid in order to ease the excruciating full body pain he was experiencing. He then proceeded to hit on every female nurse who walked by his room.
You have summed up 95% of ER medicine in a nutshell. Every wonder how did we as a society get here?...
Great list. That about covers it. I would add:
Seizure. History of seizures. Forgets to take medicines to prevent them. Family or bystander always, and mostly unnecessarily, calls 911. Predominantly Mexican where I work.
Since when did it become part of a doctor's posture toward patients to be harsh and cruel? You start with an adversarial posture and appear to be proud of it.
Do you think these people deserve to be blamed and slapped around by the people they go to for help?
Where are your ethics?
You might develop into a compassionate person if you took your obligations seriously.
This kind of snide brutality has no role in medicine. It is a side effect of the role you play as a drug cop,something doctors have unconsciously allowed to pollute their attitudes toward patients.
I hope you wont simply dismiss what I have said, because I am telling you something you need to consider. I lived on the other side of your attitude and watched as it killed my husband.
You have no idea how many people you are killing by spreading this ugliness.
Siobhan Reynolds
Painreliefnetwork.org
siobhan, I understand your pain, but I think your anger is misdirected.
My list is just that. A list. It is a reality of what I as a doctor experience as the frequent flyers, the high consumers, of our medical resources.
It was not a judgement on anyone.
Simple a statement of fact.
Most of the behavior and utterances of patients that you describe would fit mentally retarded folk who truly need supervision by responsible adults.
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