Frequent Flyer

Some patients are known as frequent fliers to the emergency department. The ones I've seen come in regularly for drug-related problems: alcohol intoxication, alcohol withdrawal, cocaine, amphetamines, opiate withdrawal. As an idealistic medical student, I try my best to persuade them to change their habits knowing it takes more than a scolding. We send them out, and they come back, pretty much the same.

When I was on my ICU rotation, I took care of a patient who stroked from cocaine hypertension. Looking at her past ED records and discharge summaries, I gathered that she had been to the emergency department a dozen times, admitted several times, and each episode was due to cocaine. All the discharge summaries emphasized the substance-use counseling given and the importance of quitting. Yet she kept on coming back, until her latest admission for a severe hemorrhagic brain bleed landed her in the ICU. She had several kids, all under 10. None of us thought she was likely to recover, but because of her family, we pushed on.

This is frustrating. What can we do to prevent frequent fliers from coming back to the emergency department? Although some patients have exacerbations of asthma or congestive heart failure, most of the frequent fliers I've seen have been due to drugs and alcohol. The nonchalance they have scares me, and the power of addiction they face controls them. One of these days, they won't be lucky enough to leave the emergency department to get another drink or high. So each time I see someone like this, no matter how futile the situation, I do my best to get him to change.