Frequent fliers

If you come into hospital it’s probably because you are ill, are in pain, or at least someone thinks you are ill and has arranged for you to be admitted. There is a subclass of patients that are not ill, at least not like the other people in the bay, that frequently come in to hospital and are known by us as frequent fliers (with a roll of the eyes, muttering fuck sake fuck sake).

General surgery in Bighospital have a number of them, they tend to go through a period of intense activity with a year or two of very frequent admissions and either they get bored of us and start having different symptoms necessitating admission somewhere else or they get better and stop coming in to hospital. Most of the time they are down in Urology with loin pain or getting CT’s of their head with imagined arm weakness and headaches.

Let’s take the example of Mrs Rotten Teeth, she appears every month with a story of small bowel obstruction, she has a personality disorder and a stoma and I imagine has a fairly miserable life. She is usually dirty and unkempt and has poor hygiene. She has never had a small bowel obstruction, her stoma works instantly on arrival in the hospital and she does not vomit. She usually stays 2 days, gets fed and washed and then sent away again.

Then there is Mr Stoma Sex, he wants a stoma, desperately and has tried to get all of us at one point or another to give him one for no real reason whatsoever. He turns up at all new consultants clinics claiming anal pain, rectal spasms, bleeding etc, hoping someone will give him a stoma. Bighospital legend has it that he wants to have sex facing his partner and believes a stoma would facilitate this, which seems faintly hard to believe to me and somewhat homophobic, but that is the legend.

There are plenty of seemingly normal people who have this sort of behaviour; there are the young women with right iliac fossa pain, they come in and out during periods of acute stress in their life with textbook symptoms of appendicitis but none of the signs. Some of my colleagues take their appendixes out so we don’t have to see them again, which is somewhat unethical.

It may be hard to believe that some people actively seek hospital admission for attention but I am afraid that they do. Münchausen syndrome is the real name of this chronic and debilitating condition. It is commonest in women aged 20 to 40, especially those with some sort of healthcare background and in unmarried, socially isolated males aged 30 to 50. In my experience these people start off being genuinely ill in some way and get stuck in their illness behaviours.

Many people with mental illness turn up as well of course, I see lots of women with eating disorders who claw stool out of their rectums and want “cleared out” for imagined constipation. Also there are the self harmers, usually young women who stick knives or needles into their abdomens, rectums and vaginas.

The set up of an acute surgical receiving ward is so woefully inadequate to even attempt to deal with these people. We lack the time, the resources, the skills and we also don’t care enough (consultant on call is on a 1 in 8 and the chances of them belonging to you more than once a year are slim). Similarly, general practice has changed so much over the past 10 years that out of hours care is provided by locum GP’s who don’t know the patient and are admitting these people willy nilly, as they have to believe them. I saw three frequent fliers in my last week on call, they are all quite nice, they aren’t much bother and they go home within 72 hours but what a waste of resources, of their own time and cost to the economy and society.

The saddest thing about frequent fliers is that nobody ever phones or comes to visit them, which suggests it’s not just us who find them annoying. These are challenging patients who do not get what they need from us or from general practice. I don’t have the skills or the time to gently explore if just maybe they are fabricating this for attention, what I need is a liaison duty psychiatrist to come and see them and that is for some reason totally impossible in Bighospital.

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