The term “frequent flyer” is medical slang for somebody who regularly visits the hospital. For better or worse, frequent flyers are well known to physicians and other health care staff. These health care providers are tempted by assumption and sometimes perform a cursory assessment before doling out some stereotyped intervention.

There are several types of frequent flyers including young adults in the midst of sickle-cell emergency who are administered pain medications and fluids, people with bipolar disease who have a history of discontinuing their mood stabilizers and thus find themselves temporarily confined to the in-patient psych unit or homeless people with long histories of polysubstance abuse who are brought in by police after a most recent bender. This cautionary tale involves this last type of frequent flyer: A 39-year-old homeless man with polysubstance abuse and quadripelegia, who came into the emergency department with complaints of excruciating abdominal pain.

This man was well known to the staff at one particular Kentucky hospital. He had a reputation for being combative and noncompliant. When he first came into the emergency department, the emergency medicine physician ordered him an x-ray, which proved inconclusive, and then sent on his way. The next month, this same man showed up with a 4-day history of abdominal pain. The emergency medicine physician who served him made no diagnosis, and the hospital sent the man to a family member’s house by ambulance. The family member refused to accept the man, and he was sent back to the hospital. Social services then placed the man in a motel across the street where staff claimed he continued to scream in pain for another 5 hours. He was brought back to the emergency room covered in bloody vomit. At the hospital, two emergency physicians--including the one who had seen him hours earlier--ordered the man an enema and had him disimpacted. Afterwards, the man was sent back to another relative’s house. Of note, he claimed the hospital told him not to come back (a claim the hospital denies). Sadly, the man died 4 hours later from a ruptured duodenal ulcer.

In retrospect, here’s what should have probably happened, and why the hospital eventually had to pay out $1.4 million. When the man first came into the emergency department, he should have been diagnosed with peptic ulcer disease. Instead of performing a plain radiograph, the emergency physician should have performed a radiograph with contrast (barium) or even done a more-costly CT scan, which in this litigious age is oftentimes a “go-to” emergent diagnostic test. The next time this man showed up in the emergency department, it should have been apparent that he was suffering from a perforated ulcer. He should have received some form of diagnostic test, been stabilized and been entrusted in the care of a surgeon. Instead, he was disimpacted and received an enema.

By not stabilizing this patient before discharge, the hospital violated the federal Emergecy Medical Treatment and Labor Act (EMTALA); hence, the plaintiffs (probably the man’s family—which I find ironic because at least one family member refused to previously accept him upon his arrival by ambulance) received a $1.4 million settlement after a protracted legal process.

I learned about this case from an article in The Journal of Family Practice. (This journal--along with several others--“impact” our mailbox every month. In this publication, there’s a fascinating department titled “What’s the Verdict?” If for no other reason than to read this section, I highly suggest that anybody so inclined get their hands on this journal.) At the end of this little article, there’s a great comment that perfectly summarizes what can be learned from this case:

“Most of us [the audience of the publication--which I’m assuming is physicians and other health care providers] have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.”

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