English 2010

The Frequent Flyer

Erving Pena Mary-Jayne Davis English 2010

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Erving Pena English 2010 Mary-Jayne Davis February 13, 2014 The Frequent Flyer The Emergency system in the United States is set up to be used for what its name implies, Emergencies. Cities around the country have countless of EMS (Emergency Medical Service) personal responding to 911 calls, ranging from the most ominous, to the absolute benign. As an EMS worker myself, I have seen my share of calls. Responding to the aid of others usually involves individuals interacting for the first time, with one or some placing their faith in the abilities of the crew that is there to assist them. However, any EMS worker can tell you that there are those that are well known users of the EMS system in any given area. People that use the emergency system continuously are referred to as Frequent flyers. These are individuals, or even a multiple of individuals that use the EMS system constantly, and often do so with no real emergency need. 911 calls are placed for the sniffles, to merely wanting a place to sleep over night. A myriad of solutions have been proposed to remedy the problem to no avail. The question is; who are these individuals that abuse the EMS system and why is it a concern? EMS abuse and those that cause it are not a new issue or one that is unknown. Magazines like JEMS and Fire Engineering continue to publish articles with regard to the subject. Even EMS, Fire and Police shows such as Trauma, Chicago Fire, and Third Watch, have episodes where the main characters deal with such individuals. Facebook is littered with EMS

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and Fire groups that post cartoons or Memes about these situations. A lot of the time, crews
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respond to frequent flyers so often that they can even remember their names and birthdays from memory. I know a few people in my designated area well enough, that I even know the medications they take. Even those in the hospital environment look for humor when dealing with the issue, but its no laughing matter. Jennifer Thomas, has been working as Advance EMT for four years in Salt Lake City says, Some of the people we go on make me feel like I am on the show Reno 911, but then I have to remember, this is the real deal, and that when Im helping them, someone with a serious emergency is not getting helped.(Thomas.) The Callers A frequent flyer is more than an individual that abuses the 911 system. A frequent flyer is someone that is continually transported to and Emergency room. These chronic EMS users cover the spectrum of people. From my experience in EMS, those that call 911 for repeated nonemergencies encompasses every age. However, because of the large number of Senior Citizen

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housing where I work, I get to go on a higher number of geriatrics. Some of them are sweet as pie, inviting us in with the upmost hospitality, and others not so sweet. It really depends on the area demographics. According to a Billittier, et al. study done in 1996; For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were < 40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was < $100. More than 85% of the patients whose ambulance transports were deemed medically unnecessary were unemployed; and nearly 85% reported a net annual income of < $20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance. (Billittier, et al.)

This study highlights how there is a relation to those who abuse the system and their economic and age demographics. This coincided with what I have experienced in the field. A great example of this is a call, my partner, and I had outside Salt Lake Regional Hospital. The call came out as a dislocated shoulder. Upon arrival the individual was walking around, on the corner

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across the street from the hospital. The patient refused to be walked or wheel chaired across the street to the hospital. He stated that he didnt care how much the ambulance ride cost because he was on Medicaid. He was transported from across the street in the ambulance. Some Frequent Flyers arent even calling 911 themselves. Homeless that become intoxicated and pass out within sight of the general public get constantly called on. Since their drinking habit does not change, they continue their pattern of intoxication followed by someone calling 911, which in turn results in another trip to the hospital. Sometimes, the individuals still have the arm bands from the hospital they were released from not too long before the call, and some even still have the EKG stickers on them. A New Mexico study found that repeated ambulance use by patients (Five or more transports during the two-year study period) was most often associated with alcohol related disorders, seizures and respiratory illnesses. In fact, although this
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group of patients accounted for only 4.3% of all patients, it accounted for 28.4% of all transports. (Bledsoe) Many times, because an individual is so intoxicated or has previous violent history, Detox (a building designated for housing individuals that need to sober up), ran by the Volunteers of America, refuse to take them. Then they become a medical emergency and are taken to local hospitals where they take up beds in the Emergency Rooms so that they may

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sober up. When it comes to the issue of seizers, and respiratory illnesses; as it applies to my district with the homeless shelter, many individuals are unable or neglect to continue their treatment with prescribed medication. There is a Frequent Flyer that knows when she is going to have a seizure (an aura), but because she is not taking her prescribed medication coupled with the severity of her seizures, she is continuously transported. Sentiments from this in EMS vary from the sympathetic to those who see Frequent Flyers with less sympathetic eyes. Fred Mertes has been an Advance EMT for a little over two years and is not shy about saying what he feels. I feel that they are using valuable resources. They are wasting everyones time involved. (Mertes) The Money The cost accumulated by an emergency can be pretty high. With the ambulance bill, then the hospital bill, many people with insurance try to avoid such a financial burden at all cost. The thought of having a $500 dollar bill added to anyones expenses is enough to raise some blood pressures. However, there have been times that we respond to frequent flyers, and we can see a stack of our companys ambulance bill on a table or counter top. Yet the debt incurred is not enough to deter Frequent Flyers from calling to be transported. A solution proposed by Salt Lake City, is to try to offer non-critical homeless patients transportation to the 4th Street clinic. The 4th street clinic is a free clinic that provides services to the homeless population. Many times, the individuals refuse.

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In Utah, Per the Utah Department of Health, the base rate for a ride on my ambulance, which is and Intermediate Ground Ambulance, is $813.00 per transport. This does not include the Standard Mileage Rate $31.65 that is added per mile. For a Paramedic Ground Ambulance the Base Cost of transport is $1189.00 per transport. (State of Utah) Those of us that work in
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EMS make an attempt to advise the patient on what their options are and what we consider the most appropriate given the situation. Still, the blatant disregard for financial responsibility is prevalent amongst Frequent Flyers. With the cost of health care increasing the expenses get bigger and bigger. $4.4 billion were spent annually in 2010 for the use of the ER for routine, non-urgent care. (Falkenberg) This huge expense has left States trying to find solutions to the abuse of Medicaid. An example is Washington States attempt to crack down on frequent flyers, by limiting the amount of times per year the

recipients can be seen, down to 3. Although this move by Washington State was later blocked by a judge, it only goes to show, that continuing to allow the frivolous miss use of Medicaid and the EMS system is enough to get states to try to do something about it. A large number that is not taken into consideration are the number of patients treated on scene. I cannot count how many heroin overdoses I have responded to where the person is for sure dead. We bring equipment on scene like we are going to work a full cardiac arrest. We get

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things ready like setting up an IV and have the Bag Valve Mask set to go. The Paramedic will administer a dosage of Narcan, and within a few minutes, the patient is back from their unconscious state. The patients usually refuse transport to a hospital and are turned over to the Police Officers. The equipment that was use has to be discarded, and since the patient was not transported, they are not billed. This also becomes a loss. Emergency Room. As described in the Billitier et al. study, the majority of non-emergency transports to an Emergency Room via ambulance, 82% were because the patient did not have an alternate mode of transportation. (Billitier et al.). I can say that this is by no means the only reason why individuals end up in the emergency room. Every call is different and thus the reason why someone is transported is different as well. Some of the reasons not mentioned that a frequent flyer would be transported for, are the following: 1. They have a consistent legitimate problem that is not improving. 2. Not having a primary care physician. 3. They avoid going through the 911 system and contact the Ambulance company directly. 4. People that believe they are sick (hypochondriacs) 5. EMS personnel fearing legal consequences for denying transport 6. Getting out of being arrested. 7. Reoccurring suicidal ideations 8. Cold Weather (winter). 9. Dehydration (summer).

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Those are all examples of reasons that have not been previously stated. Some of them are used continuously by individuals. It is not always the frequent flyer trying to get something. I have had my share of calls were we transport a drunk because Salt Lake City Police Department did not want to deal to with the individual. In a blog dedicated to highlighting the dangers police officers might be putting EMS personnel in, the phrase You can either go with them to the hospital or go with me to Jail, (DT4EMS) serves as the title and the subject of the blog. It is a real look at how EMS is utilized by Law Enforcement as an out, for the person in question. The is especially true if the person being arrested is covered in fecal matter or has really bad hygiene. Frequent Flyers will continue to be a problem. Every community with is faced with the challenge of dealing with this issue. Yet it is not a simple one to solve. There are many factors that come into play. EMS is still a fairly new service. It is constantly changing and developing. So will the way it deals with Frequent Flyers. For now, they will continue to be part of the cliental EMS workers serve. I for one knew what I was getting into when I took on this job. Others, however, would be happier if change came sooner, rather than later.

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PHOTO INDEX Figure 1: PaulCombs. Artstudioseven.com/page-fire-ems-prints.htm Figure 2: Erving Pena personal pictures. GoldCross Ambulance Unit 586 Figure 3: Google Search. Difference Between Ambulance and Taxi. Tweeter: @quietlyEvolving WORK CITED Billittier, A.J., Moscati, R., Janicke, D., Lerner, E.B., Seymour, J., & Olsson, D. A multisite survey of factors contributing to medically unnecessary ambulance transports. Academic Emergency Medicine. 3(11), 1046-50. Nov 1996 Bledsoe, Bryan. EMS System Abuse. The mystery of the frequent flyer. Admin & Leadership. JEMS Emergency Medical Services, 26 Jan. 2014. Web. 26 Jan. 2011 DT4EMS, You can either go with them to the hospital or go with me to Jail. DT4EMS.com. 25 May, 2013. Web. 31 Jan, 2014 Falkenberg, Kai. One Great Idea for Reducing Health Care Costs: Keep Non-Emergencies Out of the ER. Forbes Magazine. 31 Jan, 2014. Web. 18 Nov, 2011. Mertes, Fred. Personal interview. 25, Jan. 2014 Thomas, Jennifer. Personal interview. 23, Jan. 2014 State of Utah. Utah Department of Health, Bureau of Emergency Medical Services. Ambulance Rates, effective Oct 21, 2013. Utah Code Annotated 26-8a-403 Admin Rule R426-8-2