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How's Your Frequent Flyer Program?

     "Frequent flyer" is one of those phrases that seems to be used in EMS across the country. Acquired from the airline industry, the term is used to describe individuals who use our services most frequently and often far more disproportionately than others. The most famous flyer in the county where I work and live holds a record for being admitted to and discharged from five different hospitals within a single 24-hour period! Even when I was working as a part-time medic, I picked this guy up three times in one shift.

Is It Abuse, Misuse or Neither?
     When discussing frequent flyers, providers often raise the concept of "abusing the system." I agree there are some who clearly abuse our services; however, I believe that a number of folks we have labeled as abusers would be more accurately identified as misusers.

     EMS was founded on the principle of providing emergency care to the sick and injured. While we often focus our interests and energies on the emergency side of the equation, our customers-aka our patients-focus more on the services side. Given this mind-set, it's easy to see why providers get frustrated when the EMS system doesn't work the way they envision it, i.e., responding to emergency calls that meet their standards rather than responding to less glamorous calls, like people who've fallen and need help getting up.

     The fact remains that people will use our services to meet their healthcare needs. This is especially true of the poor, the habitually impaired and those struggling with behavioral issues. Whatever is out of control in someone's life, whether their heart is beating too fast or they can't seem to catch their breath, we are there to get a handle on things-to solve our patients' problems. Getting the chronically depressed patient into the pipeline so a mental health professional can intervene is just as important as treating the patient with crushing chest pain. But again, it's not as glamorous. Those types of biases create nothing more than scenarios where some patients receive better care than others, and that is unacceptable.

Math Will Prevail
     No matter how many times you pick up patients who exhibit drug-seeking behavior, or those who really just want to go to the hospital for "three hots and a cot" (some warm food and a place to sleep), at some point in time, they will have a real problem. Unfortunately, frequent flyers can easily lull a provider into a false sense of security: "It's just the same old routine."

     My recommendation is to always work up frequent flyers as though they are telling the truth. Assess and evaluate them exactly the way you would work up a patient with a similar complaint. At some point, your history and diagnostics may take you down another path, and if you determine that this is just another round of Scam the Medic 101, then you can make alternative decisions about patient disposition, whether it's a ride to detox or enlisting the help of social or pastoral services.

     Never forget, while your system's most frequent flyer may have been scamming you 99 days in a row, at some point, math will prevail, and the patient will actually have what he says he is having. If that happens to be the day you decide to blow him off, things probably won't work out well for anybody. At that point, you will come to realize that complacency can be deadly to the patient, your agency and your career.

The Ultimate Financial Risk
     Every now and then a legal case pops up that should serve as a wake-up call to our profession. The late Jim Page wrote about two paramedics who showed up at a scene to find one of their frequent flyers in the company of a number of bystanders. Apparently, Anthony had been drinking a lot and had fallen down, again. In this case, the medics never even got out of the rig. Multiple witnesses watched as one of the medics rolled down the window and yelled, "You are drunk again, Anthony. Go home and sleep it off." But that wasn't quite enough. The medic finished his little diatribe with, "You are nothing but a dirty old puke."

     As the story unfolded, the next morning, Anthony was dead from a subdural bleed. One of the bystanders who had witnessed the event knew Anthony's son and told him what had happened. Anthony's son got a lawyer, and, as Jim Page so eloquently put it, "They learned that a 'dirty old puke' was worth close to a million dollars and the jobs of two paramedics."

     The saddest part of this tale is, all that had to happen for this tragedy to be avoided was for two paramedics to simply do their jobs. They didn't have to perform any daredevil, lifesaving rescue or whip out some razzle-dazzle advanced life support procedure. They just had to open the door to their rig, get their lazy butts out and do what they were paid to do-provide emergency care for the sick and injured.

Conclusion
     For agencies that continue to allow their providers to treat some patients well, then turn around and treat other patients poorly, or not at all, I'd recommend having their administrators take a math course dealing with permutations and probability. They will then be able to predict with some certainty when they will reap what they have sowed. At that moment, I suspect they will realize that their frequent flyer program has failed miserably.

     Until next month...

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.

Mike Smith is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.

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