The difficult patient

We had an interesting discussion today about difficult patients. I didn't offer my experiences, but as I sat back and thought about it - I've had very few "difficult" patients. The only patient that came to mind was an obese 64 year old African American diabetic who's already had bilateral below-the-knee amputations - one due to trauma, and the other as a complication of his vascular disease likely from long-standing diabetes. His blood glucose control was extremely poor, often in the 200mg/dL range, and required intensive insulin therapy. In the meantime, he continued to sneak in food against the recommended diet, and often refused blood draws, finger sticks, and was otherwise a rather uncooperative patient. During his protracted hospital stay, he had an episode of altered mental status, likely a transient ischemic attack (TIA), and aspirated on some food. He then developed aspiration pneumonia, spiked fevers but never had a positive blood culture. Meanwhile, the surgeons were debating who's going to get first crack: neurosurgery who wanted to perform an endarectomy since his carotids were both >90% occluded (no surprise he's had strokes in the past), or the cardiothoracic surgeons who wanted to perform coronary artery bypass grafting. The reality of the situation was that neither team really wanted to touch him at all given his high risk factors. To make the situation worse, he refused to cooperate when the surgery PAs came over to see him and evaluate him for surgery.

After nearly 1 month in the hospital, he was finally discharged home - without any surgeries because that's what he decided. Listening to my friends' tales of "difficult" patients, I'd say I had a relatively easy case.