Strategies for Dealing with Nuisance Calls/Frequent Fliers

[WuLabsWuTecH]

This is definitely above my pay grade, but we were doing a thought experiment the other day. Details of the story have been changed, but the general feel has not.

A patient of ours is a known frequent flier. This person calls about 3-4 times per month. Now I know that doesn't seem like a lot at all, and it really isn't until you take into consideration the following facts:
- The person lives 12-15 minutes from station.
- The nearest hospital from him is 20 minutes away from the station. He used to request either the one that was 35 minutes away or 45 minutes away (more on that below)
- This is a small, rural department that covers 200 square miles
- Though we're getting better at it, there are still lots of times where we only have one EMS vehicle in service, and when we have 2, sometimes we have one ALS and one BLS
- The person's chief complaint to 911 is always either chest pain, difficulty breathing, or syncopal episode--regardless of what his actual complaint is which always necessitates an ALS response.
- There are days he calls in the morning, gets discharged, and calls again later that night.

None of our brass really have a good way to deal with this issue. The gentleman is always perfectly fine when we arrive, but he always insists on going to the hospital. His complaints are sometimes outright ridiculous (Him:I'm unconscious. EMT: Right now?! Him: Yes! Right now!). The man is of normal intelligence and worked as an orderly in a hospital until he went on disability so it's not like there's a lack of medical knowledge going on or MRDD.

So the main problem is that because of this person calling for non-emergency situations, our medic goes out of service for 1.5-2 hours at a time which, at best, leaves us down a unit, and at worst, leaves us with only a BLS unit or no unit at all with Mutual Aid being 25 minutes from their station to the center of our town.

The best solution the brass has come up with right now is to send law enforcement ahead of us, and to always transport him to the nearest ER (he used to request to go to one further). He will be afforded a choice of ER like all of our other patients should he present a doctor's note stating a medical necessity for him to be transported to another ER. Obviously this doesn't solve much except prevent a confrontation and save us 20 or 30 minutes of time we're out of service. Overall though, it's becoming a problem. For example, a couple of nights ago, I had to respond as a single unit first responder to a possible stroke. Since we were having a lot of issues getting mutual aid out, we were halfway to ordering a chopper before a mutual aid department was able to send me a driver.

Tossing ideas around the firehouse, here are the ideas we came up with, and reasons as to why they won't work:

1.) Send BLS - liability issue if it turns out to be a real ALS call
2.) Send volunteers who respond from home - once again, liability issue if it turns out to be a real emergency and even for $40, I would bet that most people won't take the run if they hear the address as he is known to be a rude person.
3.) Paramedic Initiated Refusal - tossed in there as a joke, no one in our area has this and the liability would also be huge

I'm wondering if anyone else out there has protocols to deal with this sort of situation. I'm guessing that most departments just "suck it up" and deal with being down a truck for a couple of hours, but I'd be interested to hear any ideas that are floating out there!

 

[Kevinf]

Sounds like you are going to have to set up a meeting with your local government officials and law enforcement about creating penalties and policy for abuse of 911.

 

[triemal04]

Look into state and local law. If there is something along the lines of "911 abuse" or however it may be termed, see if he is in violation. If he is, run with it.

Get your medical director and chief involved. His records for as far back as this has been a problem need to be pulled and evaluated; this includes the records from each hospital he has been taken to. (this is where getting the medical director involved will help) If it is clear that he is calling for innapropriate reasons the medical director may be more willing to sign off on refusing to take him unless he has clear complications, or to assess him, leave and wait for a volunteer crew to show up.

This will also include meeting with the POS and making it clear what is going to happen, what the consequences will be, and why it's happening. Really, being a smaller department (an town I'd guess) will be beneficial here.

Above all, document document DOCUMENT. You need a clear paper trail that shows how this is detrimental, how it is an abuse of the system, and how the "complaints" of the patient are not real.

 

[planetmike]

I’m guessing you don’t bill patients for transports.

 

[Tigger]

We go out and work with the patients and figure out why they need the system so much. Most of our medics have now completed a community paramedic education program so we are able to better work with home health/hospice and whatnot to make sure people are properly cared for at home. Individuals without an actual medical need that continually call 911 are referred to law enforcement.

 

[DrankTheKoolaid]

Had the same in another county I worked in. You can go 2 routes at the same time to curb the behavior. Start logging all calls complaint to dispatch vs actual complaint. Have your upper management perform a usage study on the patient over the last year. Present it 1. to law enforcement for 911 abuse and 2. to medicare/medical or whatever insurance they have. It worked amazingly well in our patient as they went to jail on 911 abuse and medicare/Medical stepped in and said if it continues they will lose all medical benefits from the state

 

[NomadicMedic]

We had a frequent flyer that called a couple of times a day. Eventually we got the police involved and the calls stopped...

Til we went back and coded her a year later. (Totally unrelated to the original calls, she choked on a huge wad of deli meat.)

 

[Carlos Danger]

Til we went back and coded her a year later. (Totally unrelated to the original calls, she choked on a huge wad of deli meat.)

What a way to go

 

[NomadicMedic]

What a way to go

It was at least a pound of sliced deli turkey. It just kept coming... We didn't need Magills, we needed serving tongs.

 

[medicdan]

I'd encourage you to take the medical perspective on this. It's not just a drain on your EMS system, but also the hospital EDs. Work with your service MD, the ED management, hospital management, social services, etc., to troubleshoot.

Sit down with the patient, figure out why he's calling, and if you can get him the services he needs another way. In my area, we've found several of these patients are lonely, or don't have support systems. Taking advantage of community mental health and elder support services has been very useful. If there's a medical reason, get the PCP involved.

 

[Chewy20]

You think that's bad, I took a lady 4 times on Wed. She was at the hospital a total of ten times that day. All taken by EMS...She calls 3-4 times a day on average. Not much the law can do about it in Texas. Someone in the system just needs to step up and put an end to it. It is ridiculous.

 

[MonkeyArrow]

The only thing I'm scared about is what about the one time when they legitimately are sick. We have a gentleman who frequents our ED (has been there over a 100 times this calendar year so far) mostly with BS complaints. Our ED medical director has stepped in and says to evaluate him out in triage and D/C him with a Rx but without giving him anything in hospital, so as to show him he won't get anything and stop coming. That hasn't worked. He's here practically every day, so obviously he just comes to visit with nothing medically wrong, but there has been times when he has come and been legitimately sick. What will happen that one time when he comes in with some seemingly BS complaint but actually is sick?

 

[Chewy20]

The only thing I'm scared about is what about the one time when they legitimately are sick. We have a gentleman who frequents our ED (has been there over a 100 times this calendar year so far) mostly with BS complaints. Our ED medical director has stepped in and says to evaluate him out in triage and D/C him with a Rx but without giving him anything in hospital, so as to show him he won't get anything and stop coming. That hasn't worked. He's here practically every day, so obviously he just comes to visit with nothing medically wrong, but there has been times when he has come and been legitimately sick. What will happen that one time when he comes in with some seemingly BS complaint but actually is sick?

This question always comes up. Maybe it is my syndical side kicking in, but you dug yourself into that hole by calling 911 EVERYDAY, and MULTIPLE times EVERYDAY with no real medical complaint. They are putting the surrounding population in danger by taking up what should be an available unit. Not to mention the countless bills they don't end up paying.

You need that much medical attention? They should be checked into a nursing home or psych facility. There is going to come a time that you are running a call on this "patient", when a critical call comes in. You could have been 2-5 minutes away, but since you are running on the person who you just did two hours ago, the next available unit is 10-15 minutes away. Big difference in EMS? Not usually, but big difference to the family of that patient, who needs you there and pay to have you there as quickly as possible.

At the very least, someone needs to step in and say "evaluate, and if everything you find is good then no transporting." Is there a risk? Sure, much rather take that risk than put the rest of the nearby population at risk.

But what do I know. I am a basic, not a medical director. So I will keep running the same person multiple times a day...best believe I will not pick up OT at that station though.

TJ's service is allowed to deny transport and give them taxi vouchers...just an FYI to the rest of the EMS world.

Also, yes most of the calls EMS run are BS for the most part. I am not saying to deny transport to al of these calls. Unless they BLATENTLY do not need an ambulance, like when their whole family with 4 cars is sitting in the living room. Or if they abuse the 911 system. It is dangerous and selfish IMO.

Pointless rant over.

 

[WuLabsWuTecH]

Hey guys, I was out of town on a well-deserved break, but thank you all for your replies!

I will try to address everything you guys brought up here:

Sounds like you are going to have to set up a meeting with your local government officials and law enforcement about creating penalties and policy for abuse of 911.

Look into state and local law. If there is something along the lines of "911 abuse" or however it may be termed, see if he is in violation. If he is, run with it.

I'm guessing this has been looking into, but, at least how I'm reading it, the "misuse" has to mean that the person is knowingly lying to us such that we provide services. There's no way that we can prove whether someone is really having chest pain or really having a terrible headache or if they are lying about it. And as we all probably know here, there are lots of benign causes of chest pain, headaches, etc that aren't emergencies but when some of the general public calls, they genuinely do not know it's most likely not life threatening.

Get your medical director and chief involved. His records for as far back as this has been a problem need to be pulled and evaluated; this includes the records from each hospital he has been taken to. (this is where getting the medical director involved will help) If it is clear that he is calling for innapropriate reasons the medical director may be more willing to sign off on refusing to take him unless he has clear complications, or to assess him, leave and wait for a volunteer crew to show up.

This will also include meeting with the POS and making it clear what is going to happen, what the consequences will be, and why it's happening. Really, being a smaller department (an town I'd guess) will be beneficial here.

Above all, document document DOCUMENT. You need a clear paper trail that shows how this is detrimental, how it is an abuse of the system, and how the "complaints" of the patient are not real.

The chief had a phone call with this individual and has told him about Law Enforcement going in ahead of us and that we're always going to the closest hospital.

I’m guessing you don’t bill patients for transports.

Yes we do--but we don't really care about the money--the issue is usage of resources. As to why medicaid/disability/insurance hasn't caught on, I have no idea.

We go out and work with the patients and figure out why they need the system so much. Most of our medics have now completed a community paramedic education program so we are able to better work with home health/hospice and whatnot to make sure people are properly cared for at home. Individuals without an actual medical need that continually call 911 are referred to law enforcement.

Ironically, a ruling was issued a couple of years back from the state department that oversees EMS specifically stating that EMS personnel were not to be providing medical advice/care/community education beyond what was required of us on runs. In a lot of small communities (like ours), the station is the only place for miles around with medically trained personnel and apparently a lot of other towns had their medics providing community education and outreach. Our department took the ruling as blood pressure checks are still ok, but no more answering questions on "should I take little Tommy to urgent care for this?" My other department didn't change any of our practices, but I'm guessing this one isn't going to fly at my department--though I think it is a very good idea and is a very good solution to our "thought experiment." (Keep in mind that none of us kicking this idea around actually have any power to do anything about it--it's just something we do in our downtime to exercise our problem solving skills)

We had a frequent flyer that called a couple of times a day. Eventually we got the police involved and the calls stopped...

Til we went back and coded her a year later. (Totally unrelated to the original calls, she choked on a huge wad of deli meat.)

I think this is the fear of everyone involved. I like the idea mentioned for an ALS crew to go evaluate him and then if there is no apparent life threat, leaving and waiting for a BLS crew to show up to transport as this would be a good middle ground between the two. Of course the logistical side would then be, what happens if we tone out 3 times for a transport crew and no one shows up to the station? Do we kick it to mutual aid which would then take them out of service? Do we then go back with our ALS crew who would then be going out of services again!

The only thing I'm scared about is what about the one time when they legitimately are sick. We have a gentleman who frequents our ED (has been there over a 100 times this calendar year so far) mostly with BS complaints. Our ED medical director has stepped in and says to evaluate him out in triage and D/C him with a Rx but without giving him anything in hospital, so as to show him he won't get anything and stop coming. That hasn't worked. He's here practically every day, so obviously he just comes to visit with nothing medically wrong, but there has been times when he has come and been legitimately sick. What will happen that one time when he comes in with some seemingly BS complaint but actually is sick?

This question always comes up. Maybe it is my syndical side kicking in, but you dug yourself into that hole by calling 911 EVERYDAY, and MULTIPLE times EVERYDAY with no real medical complaint. They are putting the surrounding population in danger by taking up what should be an available unit. Not to mention the countless bills they don't end up paying.

You need that much medical attention? They should be checked into a nursing home or psych facility. There is going to come a time that you are running a call on this "patient", when a critical call comes in. You could have been 2-5 minutes away, but since you are running on the person who you just did two hours ago, the next available unit is 10-15 minutes away. Big difference in EMS? Not usually, but big difference to the family of that patient, who needs you there and pay to have you there as quickly as possible.

At the very least, someone needs to step in and say "evaluate, and if everything you find is good then no transporting." Is there a risk? Sure, much rather take that risk than put the rest of the nearby population at risk.

But what do I know. I am a basic, not a medical director. So I will keep running the same person multiple times a day...best believe I will not pick up OT at that station though.

TJ's service is allowed to deny transport and give them taxi vouchers...just an FYI to the rest of the EMS world.

Also, yes most of the calls EMS run are BS for the most part. I am not saying to deny transport to al of these calls. Unless they BLATENTLY do not need an ambulance, like when their whole family with 4 cars is sitting in the living room. Or if they abuse the 911 system. It is dangerous and selfish IMO.

Pointless rant over.

One of the paradigms I think we had going into this thought experiment was how to we ethically provide this patient with the care he needs. One medical ethics principle is justice--that everyone gets treated fairly and with as much equality as possible. That's why we have still been transporting him, and the only difference so far is that he doesn't get to choose which hospital he goes to which we justified saying that is we don't know what's wrong with him, then it could be a real emergency that the closest facility needs to evaluate.

But perhaps we can view this from the opposite perspective saying that by providing him with the same level of care any other patient would get, we are actually denying handfuls of other patients their fair share of the EMS system.

There's nothing that we can prove that this patient is faking the symptoms. For all we know, he has a rare condition that no one has been able to piece together and a year from now, the Mayo Clinic will publish a paper on him. Or more likely, if he is not making this up, he has a psychiatric disorder (conversion disorder, hypochondriasis, etc.) that's causing a somatization disorder to occur where he actually thinks he is experiencing these symptoms. Perhaps it's a personality disorder.

But I thank you all for your contributions. I'll kick these to they guys on Tuesday and see what we think would shake out in our situation.

The leading idea, without regard to feasibility, I think is getting some sort of social work out there to hook up the patient with a PCP to manage all of these issues and transportation to PCP. The treatment for hypochondriasis and a lot of the somatization disorders if frequent, scheduled visits with a physician so perhaps that's all we need.

I do think that eventually law enforcement is going to get tired of running on him and perhaps they, being closer with the DA, might have a better idea of how to persuade this guy from not calling anymore.

And it seems like we're just going to have to bite the bullet on the liability issue. Any workable solution to put us back in service is going to require someone taking on more liability. To that end, I like the idea of responding to give him an evaluation, and then, if nothing is wrong, either refusing to transport him, or transporting him when we have an extra unit available.

 

[sarweim]

We're a small agency, covering a village, and the surrounding town by the same name, and a bit further. We have a guy that calls nearly once a day. Sometimes more. Fell, can't get up is his usual one. Dropped his toolbox. The list goes on. And he's always fine. Gross, but fine. Today? Got stuck on his lawn mower. Yup, stuck on, as in, he couldn't get off his riding mower. How is that an ems call?! Always refuses to go to ED. He uses a life alert type system, so dispatch doesn't actually talk to him directly. I can't figure out how the Lifeline system lets him keep his dang pendant and system! Just not sure what we can do about him. It's definitely a drain on our resources. And our providers get beyond irritated. Any thoughts would be great. Upstate NY, if that helps at all.

 

[Chewy20]

We're a small agency, covering a village, and the surrounding town by the same name, and a bit further. We have a guy that calls nearly once a day. Sometimes more. Fell, can't get up is his usual one. Dropped his toolbox. The list goes on. And he's always fine. Gross, but fine. Today? Got stuck on his lawn mower. Yup, stuck on, as in, he couldn't get off his riding mower. How is that an ems call?! Always refuses to go to ED. He uses a life alert type system, so dispatch doesn't actually talk to him directly. I can't figure out how the Lifeline system lets him keep his dang pendant and system! Just not sure what we can do about him. It's definitely a drain on our resources. And our providers get beyond irritated. Any thoughts would be great. Upstate NY, if that helps at all.

You are honestly just gonna have to suck it up and be grateful it is usually just once a day with no transport. Lifeline nor your company will deny him because one day it will be a real call. Like others have said, we have multiple people who call 3-4 times a day easy and are transported. Welcome to EMS were 99% of the calls are not REAL EMS calls. Get used to it.

Best thing you can do is try to educate him and try to find out why he is really calling. Though, even if you do the calls will more than likely keep coming in. Think of it as an easy call with a weird story and move on.

 

[blindsideflank]

Mental health is obviously a factor here. Whether it's just loneliness/depression or an inability to understand and cope with life (TBI, low IQ etc.) try to remain compassionate for that reason.

That being said, our last issue was dealt with through the ED and his parents were contacted to discuss the issue (he was an adult). Every time he called 911 ems arrived and he would have to call his mom prior to transport. At first he quit calling, but then it picked up again (daily) and his family decided to take responsibility and moved him home.
Another one we had quit calling once homecare was set up to come by twice a day (mostly just to chat). That is still cheaper than an ambulance and ER stay.
We have some others that poloce are actively trying to deal with but no luck. All I can say is don't be the hero and try to end their habit, it's not worth your job.

 

[NYBLS]

Create a community paramedicine program.

 

[medicaltransient]

Paramedicine is a practice. Use the BS calls to practice your assessment and develop good habits. Sometimes I can be real irritating with a very elaborated and thorough history and exam but when it counts it becomes muscle memory.

 

[medicaltransient]

Treat it like a training exercise. Like a nr medical or trauma assessment.