Frequent Flyers. We all know the feeling. Who are they?
ER: "Dr Happy. We have Mr. Disheveled Drinker here."Happy: "Yeah. I know him. I just admitted him last week. I'll be down shortly."
The frequent flier. 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 (Fliers).
1) The Migraine: Excessive CT radiation for 15 head CTs a year. Always a normal scan. 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 for a chronic ileus or a CT that is 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. Third party insurance such as Medicaid or disability insurance. And they frequently use the ER as their PCP. Become aggressive and disruptive when presented with no as a response.
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, dependent, narcissistic and 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.
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. You need a vein light device just to get IV access. 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.
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.
Usually 85-95 years old. The top admitting presentation is confusion and COPD dyspnea related 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 patient expectations. They consume hours of 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.
The blood pressure problems. Hypotension.
The clotted fistulas
The low blood pressure problems
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) due to poor personal hygiene out of choice or lack of resources.
SINGLE ORGAN END STAGE DISEASE
1) End stage emphysema from smoking forever.
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. These patients are internal medicine like patients. 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, including pharmacists, social workers, IT, subspecialists, primary care, home health, hospice, nursing care and 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. You need 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.
Track your changes.
This is when MORE=LESS
These are my frequent fliers. 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?