By Dave Jamieson
Sunday, November 29, 2009
Eight miles north of the U.S. Capitol, in Silver Spring, there is an office trailer on a tow lot where the telephone rings throughout the day. As one would expect, a lot of the calls come from stranded drivers who need a tow or a jump-start. But these days, most of the calls tend to come from debt collectors -- both human and automated -- searching doggedly for Ken Farnsworth, a chronically ill hospital regular known to first responders and nurses across the Washington area. A decade in and out of emergency rooms has turned Farnsworth into a wanted man.
Seated in an office chair one summer afternoon, Farnsworth stares at the receiver as the line lights up during a string of calls. "That phone never stops ringing," he says, shaking his head as the call goes to voice mail.
Farnsworth is a short and squat 59-year-old who walks like a man in search of a cane. His paunch hangs over his belt, and his eyes blink slowly behind horn-rimmed bifocals. He could easily be mistaken for a retired firefighter, thanks to the clothing he wears daily -- a matching Washington, D.C., fire department hat and T-shirt, in honor of the men and women who have treated his array of health problems over the years. Farnsworth has no home of his own, so the office trailer is one of a few places where he's been known to crash now and again, with the owner's permission. He lives out of two duffel bags that are stuffed with a few pairs of clothes, some toiletries, and his most recent medical bills and conditions' diagnoses.
The medical claims are too much for Farnsworth to keep up with. They arrive by the bundle every week. The bills come from just about every hospital in the Washington area, as well as from the collection agencies that handle overdue accounts for those hospitals. Farnsworth even has a tab with the D.C. government, which is trying to recoup money he owes it for the countless ambulance rides he has taken.
"I guess I wore out my welcome a long time ago," he says, managing a laugh.
He opens most of the letters and tries to sort through his debts, but the numbers have become too abstract -- "unfathomable" is how he puts it. He piles the bills into neat stacks until they become too unwieldy, then he stuffs them into grocery bags.
Eventually, when he starts to face reality, he throws the overflowing bags into the trash.
The first time paramedic Dave Cole picked up Farnsworth was on Thanksgiving Day in 1997. Cole was one year into the job in Washington, working a 12-hour holiday shift, when a call came over the radio for a man choking on a street corner near downtown. He and his partner raced to the scene.
"And there's old Kenny," Cole remembers. "He said he was eating some turkey and choked on a bone." Farnsworth showed the telltale signs of a blocked passageway -- he was grabbing at his throat and gasping for air -- so Cole put him on oxygen, loaded him into the back of the ambulance and headed to the nearest emergency room. "We went in and saw the hospital staff," Cole says, "and I could see it right on their faces." They had just released Farnsworth a few hours earlier, they said. They didn't think there was anything wrong with him. The medic felt duped. So began a long and complicated relationship between Cole and Farnsworth.
Farnsworth quickly carved out a reputation as an emergency room regular. Among even the city's most habitual 911 callers, he was virtually peerless. It wasn't out of the ordinary for a Washington ambulance driver to shuttle Farnsworth more than once on the same shift.
His transports were for conditions including choking, high blood pressure, trouble breathing and internal pains. Over the years, he has suffered from convulsive seizures; a deviated septum; pancreatitis; gastritis; two perforated ulcers; a hernia; lymphedema, which causes swelling in his legs; acid reflux disease; and irritable bowel syndrome. His problems have run literally from his head, where he once suffered a skull fracture, to his feet, which are two different sizes, thanks to some bone removal after a break in his left foot.
Early on, Cole realized his most regular passenger was taking 15 different pills -- some of them duplicates -- probably because he had seen 15 different doctors in the previous weeks. Together, they worked on weeding out the superfluous medicine. "I was impressed with his knowledge of pharmacology," Cole says. "He knew the meds and their side effects. He's had so much done to him over the years. He would ask me about different medical tests, and they were all tied to his personal medical crises."
As Farnsworth puts it, "I've had my little pre-med classes in this life."
But for all Farnsworth learned as a patient, preventive care was never his thing. As someone who was often homeless, he came to rely upon the emergency room for all his health problems, whether or not they were life-threatening. When something seemed wrong, he demanded service. "Most of my problems happen on a short-term basis," he explains. "What's wrong is wrong then. If I have to wait three days to see a doctor, it won't do me any good."
It didn't matter that ER workers would let him sit for hours in triage or kick him out when he became unruly and cursed in frustration. He simply went to another hospital. And if none of the hospitals in Washington met his standards, he would ride the Metro to Northern Virginia and dial 911. He viewed emergency care as a basic right, and he sought it whenever a problem arose, regardless of how his previous trip went. After so many visits, Farnsworth thought he was unfairly labeled as "very low priority" throughout the metro area. His attitude toward hospitals became a combative one: "I have to fight to get medical care."
With each additional ambulance ride, his legend grew. After a while, it seemed as if every firefighter and medic in the city had a Farnsworth yarn to tell at the bar. For instance, there was the time he leaped clear out of the back of an ambulance as it rolled through Northeast Washington, sirens blaring. The medics had told him he was being taken to Washington Adventist Hospital. Farnsworth thought he hadn't been treated well at Washington Adventist in the past. He swung open the back door, dropped to the street and hopped a bus to another hospital, both parties happy to be rid of the other.
Then there was the time he called 911 for medical help -- when he was already at the hospital. A couple of D.C. medics had picked him up for high blood pressure and run him to Howard University, where they encountered a long wait in the emergency room. While the medics were inside filling out their report, Farnsworth wandered outside and dialed 911 from a pay phone across the street. The city has no right to refuse service to a citizen, regardless of a situation's absurdity, so a separate ambulance had to pick up Farnsworth at Howard. The new crew hauled him to Providence Hospital.
The firefighters probably wouldn't have believed it, but Farnsworth says he never relished the idea of taking them away from their dinner. "I don't mean to wear out anybody," he says. "Many times I've felt like a burden. You can't help but feel like one."
In a city that fields a million emergency calls each year, Farnsworth dialed so frequently that some Washington dispatchers seemed to recognize him by his voice alone. In honor of his chronic gastrointestinal problems, he was often called "the Burpin' Man." Farnsworth noticed that a call from the Burpin' Man could spice up a dispatcher's wearisome shift. As he struggled to describe his ailment of the day through a volley of burps and excuse me's, he would sometimes hear the dispatcher say, "It's the Burpin' Man!"
But out on the street, the medics called him by another handle: "the Choker." The name was a nod to Farnsworth's greatest affliction. He was constantly choking. He didn't understand what caused it, but at some point nearly every day he started to feel as if his throat were closing in on itself. His panic would accelerate the process, and by the time the medics arrived, he'd be clutching at his throat and speaking in hoarse whispers and grunts. His treatment often amounted to an X-ray or two and a gastrointestinal cocktail, a mixture of antacid and anesthetic, which he growled for in the ERs.
Many paramedics thought the problem was self-inflicted; others thought it was a fiction. How could a man choke every day of his life and never manage to die? "They realized he was bouncing from hospital to hospital," Cole says. "It's probably easy to just stick him in the waiting room or kick him out. ... But I started to think this guy really might have a problem."
In fire departments and emergency rooms around the country, patients such as Farnsworth are known as "frequent fliers" -- people of modest means and poor health who go in and out of emergency rooms day after day, their fundamental health issues rarely resolved, at a tremendous and ever-growing cost to hospitals, municipalities and taxpayers. Though Farnsworth presents an extreme example, the burden of dealing with inveterate patients like him has been straining hospitals in all cities for years now. In a town with as much poverty and homelessness as Washington, frequent fliers are like barbershops -- every neighborhood's got one, and if you walk past it enough, you'll eventually forget it's there.
The question of how to handle frequent fliers speaks to health-care reform in a fundamental way. As members of Congress wrangle over whether the government should be in the business of underwriting health care for Americans, we should acknowledge that to a large degree we have already underwritten it, at least on the messiest and most wasteful level. Generally speaking, we don't let people die in the street because they lack money or insurance. Paramedics are required to scoop up repeat callers, and emergency room staffs have no right to refuse patients treatment. For many of the poor and underinsured who are chronically ill, the emergency room itself serves as their health-care system.
But providing basic health care in an emergency room makes no economic sense. According to the New England Healthcare Institute, a Cambridge, Mass.-based policy research organization, Americans' overdependence on the ER leads to tremendous waste. By treating chronic and nonurgent problems with emergency care rather than primary care, the group estimates that we fritter away as much as $32 billion nationally each year. The same treatment from a primary care doctor is usually two to five times more expensive through the emergency room. The main reason is that the staff in an ER is practicing defensive medicine: They're often trying to rule out what may be wrong with you, hence all the expensive blood tests and X-rays. ERs also have to be open at all hours and be staffed with high-priced specialists, unlike at primary care offices.
If emergency rooms don't help regulars manage their long-term health problems, it's because they're not designed to. According to Melissa McCar-thy, a professor in the Johns Hopkins Department of Emergency Medicine, when it comes to frequent fliers, "It's almost like we have no memory. Each time they come in, we greet them -- 'Hi, Mr. Smith' -- but we don't try to manage their care in a longitudinal fashion. We treat them episodically. But people shouldn't expect us to treat them any other way. It's an emergency room."
Some city hospitals have looked for ways to unclog their emergency rooms, but diverting patients to primary care physicians hasn't been easy. Since 2005, the University of Chicago Medical Center has been running a program now known as the Urban Health Initiative, which steers walk-in patients with non-urgent problems away from the medical center's emergency room and toward health clinics and primary care practices on the city's South Side. While some have lauded the program as a health-care model, others have denounced it as a profit-minded "patient dumping" scheme. As controversial as it has been, such an initiative at least tries to address what any paramedic or ER nurse already knows: For many patients, especially frequent fliers, receiving costly emergency care for chronic health problems does little good.
The high costs associated with frequent fliers have led city agencies in Washington and elsewhere to target them for treatment outside of the ambulance and emergency room. The idea was born in California's Bay Area five years ago, after a paramedic named Niels Tangherlini started applying social science theory to emergency care. Tangherlini had taken a break from the ambulance to get his master's in social work at the University of California, Berkeley. The repeat customers he had been handling on the job tended to suffer from alcoholism, drug problems or mental illness. After just a few years in the ambulance, he'd realized that being a paramedic was often closer to doing social work than emergency medicine.
"My vision was that six months out of [paramedic] school, I would be dangling beneath a helicopter in a life-and-death struggle," Tangherlini says laughing. "Instead, I was trying to coax a guy back into the ambulance who thought spiders were crawling all over him."
The program Tangherlini developed in 2004 sent a small team of paramedics, social workers and nurse practitioners out into San Francisco in search of frequent fliers. "A lot of the problems these folks suffer from are things that are not fixable with an ambulance or an emergency room," Tangherlini says. Soon his crew was probably putting more people into detox than any other organization in the city. After just a year and a half, statistics showed that the city's top 911 users had cut back their ambulance rides by as much as 80 percent. The San Francisco program was soon replicated in Memphis, San Diego and Washington.
When Washington's frequent flier program started in March 2008, the city had five patients who were being transported by the fire department every single day on average. "Whether it's a hangnail or a heart attack, they know the ambulance has to come if they call," says Mytonia Newman, director of the program, which is called Street Calls. But after the program had been running for a year, only one of those original callers was still at the top of the city's frequent flier list. Several of the city's most constant 911 callers haven't been transported at all since paramedics and social workers intervened to find them regular treatment, counseling or housing.
Weaning ER regulars off of emergency care can save cities a considerable amount of money. Frequent fliers soak up a disproportionate amount of a city's resources, through police, fire and mental health agencies, for starters. Taxpayers bear the costs whether through social services, through government-funded insurance programs such as Medicare and Medicaid, or through unpaid ER bills that are ultimately absorbed into rising health-care prices and insurance premiums.
Getting frequent fliers the help they need has another, less calculable effect -- it keeps the medics and ER staffers from burning out before their time. Emergency workers can't help but develop relationships with their regulars. Watching them gradually decline on the streets can take a considerable psychic toll. In the end, most cases resolve themselves in one of two ways: Either the frequent flier moves to another neighborhood and becomes someone else's problem, or whatever's ailing him finally kills him.
As he sifts through his most recent stack of bills one afternoon, Farnsworth offers an estimate on the total claims he owes: half a million dollars. Probably none of that money will ever be repaid. And what makes this figure so stunning is that Farnsworth is insured; the debt collectors are after him for his Medicare co-pays, which typically account for a small percentage of his health-care tabs. In reality, the price tag of his care in Washington area hospitals has almost surely run into the millions.
A quick, random sampling of his bills shows how that could happen. Consider a single visit he recently made to the emergency room for internal pains. According to his Medicare statement, his treatment from doctors during the admission cost $642. Throw in more than a dozen charges for an array of standard procedures -- an electrocardiogram, a chest X-ray, a blood test to check the health of his liver -- and suddenly Medicare is on the hook for more than $1,000, and Farnsworth for more than $150, before he's put back out on the street. The array of standard tests partly explains why treating a non-emergency health problem in the ER is so expensive. Furthermore, constant visits to the ER put a guy such as Farnsworth in contact with dozens of different doctors, few of whom, if any, are on the same page. "There are too many people involved," Farnsworth concedes. "They all have different ideas."
Every once in a while, a trip to the ER has led to a needed surgery, such as when he had his spleen removed after a fall several years ago. But for the most part, Farnsworth's visits have been routine. He has logged hundreds of them. (Because of privacy laws, medical personnel are reluctant to discuss particular patients.) He has undergone so many X-rays and CAT scans that Cole, the paramedic who is now a captain, eventually grew concerned with the amount of radiation he was subjected to, urging him to stay out of the ER. Farnsworth guesses he has been to the emergency room at George Washington University Hospital on 150 separate occasions. He approximates the same for Washington Hospital Center, not to mention trips to five or so other hospitals in the area. About half of these visits were by train or bus; the other half, by ambulance.
"I don't consider it a free ride," he says. "I don't do it on purpose. It's medical care. I didn't go drink a bottle of wine or do drugs. I've got serious medical problems. ... I don't get my jollies out of going to the hospital. I hate hospitals with a fervor."
In his earlier days, Farnsworth's medical needs were perfectly typical. He was born into a stable, middle-class family in Bethesda, and was the son of a bank manager and a homemaker. He dropped out of high school but picked up his GED before taking classes in emergency care in College Park. He thought he might spend his years in the back of an ambulance -- not as a patient, but as an ambulance assistant. It never panned out, and he wound up bouncing between unstable jobs at gas stations and tow companies, usually in the Washington area.
He volunteered at firehouses and earned a decent living as a tow-truck operator, but the health problems of the people in his life sent him toward financial ruin. He married and moved to Southern Virginia, but he says his wife developed liver complications and their life together unraveled. He says he moved back to Washington and cared for his ailing parents for several years. "I just ran out of money," he says.
His mother and father died in 1995 and 1996, respectively, leaving him without any family in the area. He filed for bankruptcy protection, and his own health problems soon began. After a series of bad falls starting in 2001, he became eligible for Social Security disability pay, which now comes to $769 a month and serves as his only income. Once he could no longer work, he wasn't able to afford his apartment in Maryland. He started bouncing from one cheap living arrangement to another, sometimes resorting to sleeping in city shelters or camping out in the woods near his childhood home.
By 2003, Farnsworth was calling 911 so often that many first responders believed he was gaming the system; by dropping certain trigger words to the dispatcher -- "chest pains," "trouble breathing," "choking" -- he would automatically vault to the front of the queue, per department protocol. He would also take a costlier ride in a more advanced ambulance.
Paramedics in the inner city started going out of their way to haul him to far-flung hospitals just to get him out of the neighborhood. Yet, he always managed to reappear, sometimes on the very same day. Cole had experiences where he ran Farnsworth in four consecutive shifts. Even when Cole was running other patients, he was never surprised to stumble upon Farnsworth lying beneath a blanket in one of the local hospitals.
Gradually, Farnsworth became everyone's problem, and no one's. By his own admission, he was hard to deal with. What he saw as a fall from respectable middle-class life filled him with anger. With his remarkable call volume, he inspired contempt in many fire department employees. His dealings with them often devolved into shouting matches. A firefighter handling him once lost his temper when another call came over the radio for a man with heart problems nearby. "We could be on that cardiac right now!" he screamed.
As it happens, Farnsworth's medical problems have led to a couple of brushes with the law. In 2005, he was charged with second-degree assault and disorderly conduct in Montgomery County after an argument with emergency responders. Court papers allege that Farnsworth dialed 911 from a Silver Spring pay phone and made threats to firefighters because they hadn't helped him the previous night. The cop on the scene called in a request for an ambulance. "When Farnsworth was told he was not going to be transported he became irate and had to be restrained by other fire personnel," the charging papers say. Farnsworth says he took a swing at a firefighter who had put a hand on him. Farnsworth spent a month in the county jail, where the medical staff came to know him well.
Then, last year, he was charged again with second-degree assault following an altercation with a Montgomery County paramedic who had taken him to the emergency room. "Farnsworth became agitated with Fire/Rescue and hospital personnel because he was asked to wait in triage," court papers say. "It should be noted that Farnsworth is well known to Fire/Rescue personnel. Farnsworth has a lengthy history of being treated and transported." He pleaded guilty to assault and served another month-long stint in lockup.
Farnsworth's imprisonment upset a handful of firefighters on the Washington side of the line, where he has garnered far more sympathy over the years. "He was labeled [a 911] abuser," says Harry Subacz, a recently retired D.C. fire captain, "but he's got legitimate problems."
Cole didn't view Farnsworth as a burden, either -- he saw a decent but troubled guy, with no home and no money, who had grown frustrated as he fended for care. Cole kept an ear out for Farnsworth calls over the fire department radio. When Farnsworth needed clothes, Cole managed to scrounge up a shirt or two. And when Farnsworth was short on cash, Cole might lend him a few bucks to get him through the end of the month.
Farnsworth has had checkups with a general practitioner from time to time, but it hasn't been enough to keep him out of the emergency room. Like other frequent fliers, he has trouble getting around and showing up for appointments on time, so perhaps a caseworker is in order, as well. And then there are those particular medical conditions -- high blood pressure, pain and swelling in his legs -- that are no doubt connected to the stress and discomfort of sleeping on a chair in a trailer or out in the woods rather than on a mattress each night. "I would like to lie down on a bed at night like a human being," Farnsworth says. "Take my shoes and socks off, maybe take a shower. That would be nice." He splurges a good portion of his disability check on pricey motel rooms early in the month, to get clean and sleep well. He once showered 11 times in two days during a motel stay just to take advantage of the personal bathroom.
Farnsworth's case bolsters the argument for the concept known as "housing first": the idea that if you put a homeless person in steady housing, then you can better address his health issues. But he has to want housing badly enough to not be picky. Farnsworth, for instance, refuses to live in a transitional group home or subsidized housing because he worries about cleanliness and theft, which is partly why the D.C. frequent flier program didn't get anywhere with him. What he wants is a clean place of his own, which isn't cheap or easy to find.
Instead of thinking only about the economic savings of eliminating frequent fliers, people need to think of the less tangible benefits, says Martha Burt, an expert at the Urban Institute who has studied poverty and homelessness. Even if the costs of detox, a case worker and transitional housing run high, the ER regular is no longer diverting ambulances from where they should be headed. "People think of not doing anything as free, and it's not," Burt says. "So what if you break even? It's better for the people of the community and it's better for the public systems because you don't have drunks lining the walls of the ER."
The best argument for spending money on frequent fliers may come from David Rosenbaum. On Jan. 8, 2006, Rosenbaum, a 63-year-old retired political reporter for the New York Times, died at Howard University Hospital after being struck on the head during a mugging in Northwest Washington. The city's Inspector General's report on the incident brought to light a sequence of blunders made on the part of emergency workers, from the scene of the crime to the hospital emergency room. According to the report, the ambulance arrived late; Rosenbaum wasn't properly assessed on the scene; he wasn't taken to the closest hospital; and the nurse at Howard failed to properly diagnose and triage him.
Once the firefighters and medics smelled alcohol on Rosenbaum's breath, they stopped focusing on other possible explanations for his unconsciousness, according to the report. He was deemed low priority and "ETOH," which stands for ethanol, shorthand for being drunk. Once Rosenbaum was at Howard, the nurses did what they often have to do with presumed alcoholics -- they left him in the hallway for over an hour.
In other words, Rosenbaum was handled as a frequent flier. He died from head trauma, not alcohol. Many of Rosenbaum's handlers seemed to share one thing in common: dulled senses. Perhaps with fewer frequent fliers, emergency workers wouldn't be conditioned to make assumptions.
Last year, Farnsworth went under the knife at George Washington University Hospital. What had been bothering him for so many years was a damaged hyoid bone, the horseshoe-shaped bone above the Adam's apple. Cole and a few other paramedics encouraged him to undergo throat surgery. Specialists had had different opinions and recommendations over the years, but in the end, they reached a consensus. "The doctors knew what the problem was," Farnsworth says. "But there were risks with the surgery, and it was complicated. This was known for years. Too many people finally said it was operable."
The surgery was a success. Farnsworth almost never experiences the choking sensation anymore, and his 911 call volume has fallen dramatically. He still checks into the hospital every couple of weeks for health issues, usually swelling in his legs, but he almost never calls for an ambulance. To a small degree, he has also rehabilitated his image among some of the city's emergency workers. "He really changed after the operation," Cole says. "He became pleasant to be around."
Not long after the surgery, Farnsworth started dropping by the Tenleytown firehouse, where Cole works. Firehouses can be like neighborhood parlors; citizens are free to stop in and say hello. Farnsworth likes to come by when Cole is on duty. These days, Farnsworth is more of a guest than a patient. He is invited to dine with the firefighters and medics whenever the third platoon is working.
In return for the meals, Farnsworth tries to pitch in around the firehouse, cleaning up and doing small chores. Firefighters there and at other houses in Washington have been known to offer him a cot when he needs it, and one of Cole's co-workers has put in a favor to see if he can get him an apartment. The firefighters have even given him a new nickname: "the Fonz," a play on Farnsworth that he greatly prefers over "the Burpin' Man."
"Since I've been hanging around these firefighters," Farnsworth says, "I've learned how to care about other people. These guys have literally saved my life."
He and the city's first responders have reached something of a detente. Rather than calling 911, Farnsworth shows up at the firehouse when he's not feeling well and asks to have his vitals checked. On the now-rare occasion when he needs a hospital, they run him to the ER.
For all the goodwill, Farnsworth feels indebted to the department. And after all those ambulance rides, he doesn't like knowing he owes the city so much money. He recognizes that he's physically broken, but he says he would like to do something, anything, to mitigate the time and money devoted to him over the years. In light of his past experience as a dispatcher, Farnsworth says he would like to make the fire chief an offer.
"I would gladly be a dispatcher for D.C. Fire," Farnsworth says, admitting that it's a long a shot. "I would gladly work my bill off. I know it's extremely excessive ... [but] I was brought up to be a gentleman. All the anger, it came from the health problems. I used to be a hateful person, but I don't want to be that kind of person anymore. I want to go on living decently."
Dave Jamieson is a freelance writer in Washington. He can be reached at email@example.com.