Types of Patients VIII: Frequent Flyers

Pardon the rather long absence. Sometimes I have things to share and the time to share them, sometimes not.

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Every emergency room has it's FFs (frequent flyers). FFs are individuals who utilize emergency room services over and over again, often for the same complaint, and often for complaints that are dubious at best. FFs become familiar with the ER staff as well as to the ER staff, and their complaints are often well-known and predictable.

Some FFs have psychological problems. Bipolar and Borderline personality disorders are common, as well as various forms of psychosis and schizophrenia. Sadly, some FFs have Munchausen Syndrome, a psychotic disorder in which an individual fakes illness or injury, or intentionally injures him/herself, in order to garnish sympathy and be cared for by others.

Sadder still, some FFs have Munchausen Syndrome By Proxy. These are individuals who encourage their child (usually) or other vulnerable relatives to fake illness or injury, or may intentionally injury these people for the same reasons as above.

Some FFs are drug seekers. (See, Types of Patients III)

FFs are usually on some form of public assistance (e.g., Medicaid) but this is not a hard and fast rule. It is amazing, however, how much paying for one's own care directly or indirectly through insurance tends to discourage frequent flying.

Some FFs, however, have real complaints. Migraine headache sufferers, patients with epilepsy, and patients with chronic diseases that are prone to exacerbation (e.g., emphysema, congestive heart failure, etc.) might classify as FFs. Many of these patients actually require emergency care, and yet, it is sometimes hard to feel good about the sort of "buff and polish" we are often required to apply time after time.

FFs also present the ER staff with a potentially serious dilemma: you've seen the patient what seems like at least a million times, and they always come in with the same complaint, and their complaint today is no different...what do you do?

I would like to say that what you do is the sort of comprehensive physical assessment and medical history as well as examination of the chief complaint like you were seeing this person for the very first time. I'd like to say that these patients' complaints are always taken at face value. I'd like to say that the ER staff takes no shortcuts when it comes to FFs.

There are so many things I'd like to say, if only they were all entirely true.

FF status invites shortcuts. It invites seeing the same thing time and time again simply because nothing new is looked for, and consequently, treating FFs in the same way they have always been treated.

Worse yet, FF status discourages the willing suspension of disbelief. If something novel should come up in the cursory exam and assessment, it is all too easy to ignore it. This is potentially dangerous for the FF and a tremendous liability for the ER staff. Unusual symptoms are unexamined; potentially dangerous problems are ignored because they are not found.

There is no easy answer to these problems other than vigilance. The onus of this solution, however, is almost completely placed on the ER staff's shoulders.

Some of us bear the weight better than others.