Frequent Flyers in the ED

RNin92 · Mar 8, 2004

What would you (collectively) think of the following person presenting in your ER with c/o migraine:
States hx/dx of migraine.
C/O severe HA, nausea, light/noise sensitivity.
States allergy to Toradol and Ultram.
States is unable to take other NSAIDS d/t hx of adverse reaction.
States unable to take Imitrex, Maxalt or Zomig d/t hx of adverse reaction
Is on large scheduled doses of a sustained release opiod, valium, a SSRI and a tricyclic.
Sits quietly in a corner of the waiting room with eyes closed sipping coffee.

I would think this person has a h/a and is seeking help.

I would also say that this person needs a pain managemnt referral if not already done...there are many treatments out there and different things work for different people.

I would also say that if I saw this person several times a week over the course of many months/years...I would question whether we have helped them or not...which do they have now? Migraine or Narcotic Rebound h/a?

Did they f/u or are we the clinic?

It is not as simple as how they present in triage.

teeituptom, BSN, RN · Mar 9, 2004

I would say just one thing

OK

kids · Mar 9, 2004

What would you (collectively) think of the following person presenting in your ER with c/o migraine:
States hx/dx of migraine.
C/O severe HA, nausea, light/noise sensitivity.
States allergy to Toradol and Ultram.
States is unable to take other NSAIDS d/t hx of adverse reaction.
States unable to take Imitrex, Maxalt or Zomig d/t hx of adverse reaction
Is on large scheduled doses of a sustained release opiod, valium, a SSRI and a tricyclic.
Sits quietly in a corner of the waiting room with eyes closed sipping coffee.

Whenever there is a discussion of frequent fliers in the ED there are comments regarding migraine fakers. Inevitably nurses with migraine will post about the poor treatment they receive when they resort to going to the ED. It frustrates me that some will then reply that they would not have treated the poster (with migraine) in such a way yet sometimes these same people have posted the kind of personal sentiments that create situations where people with legitimate migraine get treated like crud. I am not referring specifically to this thread but rather in general to threads of its type.

I am the patient asked about above.

I recently spent 7 hours in the ER with a migraine.

This was not a high traffic inner city ER, it is not a regional trauma center and there were points in time where I was the alone in the waiting room or there were empty beds in the ER. My "care" alternated between being ignored or reminded that "they" don't give narcotics for migraine (gee, that's good to know since I have narcotics on board and they aren't helping). I have no doubts my treatment was a reflection of preconceived notions. I really am allergic to Toradol and Ultram, both cause hives. I have a history of wheezing with ASA and GI bleeding with NSAIDS. Imitrex triggers arrhythmia, Maxalt and Zomig symptoms of serratonin syndrome. I get about 3-4 migraines a year and about half the time I am able to knock it down to a tolerable level with caffeine and Benadryl. Because of the infrequency of the migraines and side effects of the meds I am not on any preventives. I have been followed by the same neuro for 18 years, usually I can go to his office for treatment but this one happened on a Sunday.

When it got to be 8 am my husband was able to call the neurologist's office and tell them what was going on. I finally got the IV Benadryl and Phenenergan I had been begging for. Then I had to wait on discharge for a visit from the drug abuse counselor and referral to a pain mgmt clinic. It was just loverly considering I am a patient at the hospitals own pain mgmt clinic and with the exception of hormones am on no meds other than ones prescribed by the pain mgmt program. Yes, the ER had the info, my chart is flagged that I am a pain clinic patient with a contract and I had given them my clinic ID card.

BTW, yet more anecdotal examples of nonpharmocological self care for migraine: if coffee is tearing my stomach up to much I drink Coke or Pepsi on ice, the cold & cola help the nausea, the caffeine the head ache. If the nausea is really bad I eat plain Lays potato chips by pressing them 1 at a time against the roof of my mouth and sucking all of the salt out before swallowing. I also have a couple of CDs that I find very relaxing and play them with headphones to help tune out a noisy environment.

Medic946RN · Mar 9, 2004

My dad was one of the toughest guys I have ever known. I think maybe he missed 5 days of work in his entire life for illness. If he injured himself while working, he'd wrap the injury with his hankerchief and keep going until the job was done. I saw my dad cry twice. Once when my grandfather died and once when he had a migraine. I know how awful these things are. If you present to me with migraine sx and a list of allergies, I take them at face value, and treat you as I would anyother pt. who needed my assistance.

But......when I see you every Friday or Saturday with a rotating list of complaints. Migraine, back pain, abd pain and your list of "allergic" meds grows by whatever we gave you last time for your pain.

Pt:"Oh that Bextra you gave me last time made me break out in hives and I couldn't breathe.

Me: That was aserious reaction, why didn't you come back to the ED so we could treat that for you?

Pt: I couldn't find anyone to take me to the hospital.

Me: For a reaction that serious you should have called 911.

Pt: I didn't want to bother those guys.

Then you are seeking a legal weekend high and nothing more.

RNin92 · Mar 10, 2004

Whenever there is a discussion of frequent fliers in the ED there are comments regarding migraine fakers. Inevitably nurses with migraine will post about the poor treatment they receive when they resort to going to the ED. It frustrates me that some will then reply that they would not have treated the poster (with migraine) in such a way yet sometimes these same people have posted the kind of personal sentiments that create situations where people with legitimate migraine get treated like crud. I am not referring specifically to this thread but rather in general to threads of its type.
I am the patient asked about above.
I recently spent 7 hours in the ER with a migraine.
This was not a high traffic inner city ER, it is not a regional trauma center and there were points in time where I was the alone in the waiting room or there were empty beds in the ER. My “care” alternated between being ignored or reminded that “they” don’t give narcotics for migraine (gee, that’s good to know since I have narcotics on board and they aren’t helping). I have no doubts my treatment was a reflection of preconceived notions. I really am allergic to Toradol and Ultram, both cause hives. I have a history of wheezing with ASA and GI bleeding with NSAIDS. Imitrex triggers arrhythmia, Maxalt and Zomig symptoms of serratonin syndrome. I get about 3-4 migraines a year and about half the time I am able to knock it down to a tolerable level with caffeine and Benadryl. Because of the infrequency of the migraines and side effects of the meds I am not on any preventives. I have been followed by the same neuro for 18 years, usually I can go to his office for treatment but this one happened on a Sunday.
When it got to be 8 am my husband was able to call the neurologist’s office and tell them what was going on. I finally got the IV Benadryl and Phenenergan I had been begging for. Then I had to wait on discharge for a visit from the drug abuse counselor and referral to a pain mgmt clinic. It was just loverly considering I am a patient at the hospitals own pain mgmt clinic and with the exception of hormones am on no meds other than ones prescribed by the pain mgmt program. Yes, the ER had the info, my chart is flagged that I am a pain clinic patient with a contract and I had given them my clinic ID card.
BTW, yet more anecdotal examples of nonpharmocological self care for migraine: if coffee is tearing my stomach up to much I drink Coke or Pepsi on ice, the cold & cola help the nausea, the caffeine the head ache. If the nausea is really bad I eat plain Lays potato chips by pressing them 1 at a time against the roof of my mouth and sucking all of the salt out before swallowing. I also have a couple of CDs that I find very relaxing and play them with headphones to help tune out a noisy environment.

The picture you paint of your symptoms is not, by any means what I think of by the FF I first referred to.

It was completely ignorant of the ED staff wherever you were to treat you as they did. As another poster stated...it's the people who are in many times a week over the course of months and years that this thread refers to.

And...even my FF do not get left sitting in the ED for hours with empty beds available...I prefer to "treat 'em and street 'em".

I'm sure it is difficult for you when you go in for your migraines...but at most EDs we are talking about the people who are there more that we are.

teeituptom, BSN, RN · Mar 10, 2004

Treat em street em

one shot and OTD

keep it simple

FutureNrse · Feb 27, 2005

I try not to bunch migraine sufferers all in one group. IMHO there are those who present c/o a migraine headache, drinking mountain dew, eating potato chips and laughing with their friends... and then there are those who present obviously in pain, vomiting, and even to an untrained eye, experiencing a headache. The latter group of individuals are the ones I get back to see a doc right away, I make sure they have a room with a door, I darken the room and put the chart up ahead of the routine stuff because I feel they do need rapid treatment.
The first group of "migraine" sufferers will wait, sometimes a long time. They are not high priority, as long as they are eating drinking, using their cell phone and laughing it up.
we have some docs who use Toradol, but not enough. Most everyone will get a demerol injection (sometimes morphine) and then get discharged. I am trying to convince our docs to get PO Toradol put in our pyxis so that they can address pain without giving narcs to everyone.

Has anyone else noticed the connection between Mountain Dew and alleged drug seekers? :chuckle

FutureNrse · Feb 27, 2005

I've been called a FF and a drug seeker because I have chronic pain issues. I feel so bad for the people who's posts I just read for having to put up with what I came to think of as normal. It's humiliating to be treated that way in the ER, and to try to make them understand that your PCP just doesn't give a damn. If you tell them that you called your PCP several times and they just didn't get back to you, then they assume that the PCP thinks you're a seeker too. They don't understand that it's the same PCP who didn't bother to call you back when your daughter had an earache, or when your son developed a rash after eating berries. The doc just doesn't care. Maybe he has too many patients, or maybe he's just a butthead. I just know that there are times when the ER is the only choice I have. I don't want to hear "We don't give narcotics" before I've even finished explaining what's wrong. I don't want to read that people who can't take NSAIDS are seekers, especially when the few that I can take don't do a thing for me anyhow. Narcotics are available because sometimes an aspirin just isn't enough, it is that simple. Narcotics wouldn't be used for medical purposes if they weren't necessary.

I think the only way to handle this whole issue is by starting at square one. First, every ER needs someone in charge of this problem, let's call this job the narc police. Then, all pain patients need to be told to follow up with their PCP in X amount of time. If they don't have one, the narc police helps them find one, if they don't have insurance, the narc police knows about every cheap or free clinic in the area. If the pain patient wants the right to use the ER again, they will follow up with a PCP and have a form completed by the PCP that is sent to the ER. The form should state the diagnosis, current meds, and what the ER should do for the patient, if anything, should they need to return. Make the patient do a little leg work. The narc police can verify that the patient did the follow, verify that the form is valid, and make a note in the patients chart clearing them for ER treatment, and stating if the PCP approved use of narcotics or not.

it's a win win situation. The patient gets a PCP, and has the ER to fall back on if necessary. The ER loses the FF's who don't cooperate and they feel better about giving narcotics if they know they aren't just being a glorified dealer. The hospital saves enough money that they can afford to have a member of the narc police on every shift.

Now, tell me that isn't a good plan.

teeituptom, BSN, RN · Feb 28, 2005

Narc police thats cute

FutureNrse · Mar 1, 2005

Narc police thats cute

Well, I was trying to add some levity, but for the most part I was serious. There are no easy answers or quick fixes for the issue of FF's and drug seekers. My way, or some version of it, is going to cost more in the beginning, but eventually it will save money. It will also help put an end to FF's, or at least make a dent in the number of them, which is priceless.

boztc · Aug 20, 2007

Just because they are drunk, it doesn't mean they are not sick. If they have an AMS, cut their clothes off to check for Trauma, intubate for respiratory compromise, insert a Foley and IV. Get some bloodwork. Provide (nasty) food and fluids when appropriate. Don't give cab vouchers.

Also, for suspected drug-seekers, keep a private record of frequent visitors, refuse discharge until they can provide someone to take them home (to protect them from injury as a result of the clouded sensorium that may accompany the administration of narcotics).

You can also get your buddies at the local PD to check for wants and warrants before you cut them loose.

They may not ALL stop coming, but a few of them will look for an ER that is more convienient.

teeituptom, BSN, RN · Aug 21, 2007

I love cutting clothes off, very large bore IVs for safety, foleys.