He lay on the stretcher, clasping and unclasping his hands, exclaiming “No!” and then slapping himself on the thighs and forehead. I reminded him not to do anything to hurt his already injured hand.

This was not going to be a quick treat-and-street. Sure, now that I’d stitched him up, I could have given him his papers and sent him on his way. This sort of thing happens all the time: We ignore the inconvenient problem because it doesn’t have a rapidly accessible answer. As a physician, I cannot fix intimate partner violence, homelessness, addiction, or their brethren in one ER encounter. I can help, but I can’t fix them, so it can feel easier to focus instead on what I can fix, the laceration I can suture shut. Asking the other questions opens a Pandora’s box. Heaven forbid a patient said, “Yes, my boyfriend stabbed me; and he hits me all the time.” Then I’d have to offer comforting words, followed by a call to social services—and we all know that social work involvement can prolong a patient’s ER visit by several hours. But what’s even worse is when I ask the question, and the patient declines assistance. Their doing so shouldn’t feel like a personal affront, but for an instant, it can. Of course, if a patient declines help, that has nothing to do with me personally. Clearly, I’ll go home to my life and not be beaten just the same. Perhaps what bothers me most is the raw realization that I care more deeply for the welfare of another human being than he cares for himself, and that that human being will leave my care to suffer more needless violence.

Even though I had no idea what had happened to Mr. Williams, I could see that this man was seriously ill. There was the problem of his injury, yes, but there was also a more penetrating problem of his psyche.

“Mr. Williams, you seem very upset, very anxious.”

“Yes, yes.”

“I think it could be a good idea for you to speak with the psychiatrist. He could help you feel less anxious. What do you think?”

“Yes, yes. He can help?”

“Absolutely. Would you also like some medicine to calm down?” He bobbed his head in compliance. “All right. Why don’t we have you change into a gown and we’ll check some labs just to make sure everything is okay.”

“Okay, Doctor.”

He was fragile but compliant. I walked over to Lorraine, relieved to be safely out of his room.

Lorraine looked up at me. “Good to go, Doc?”

I pulled my chair over to her and looked back to the room to make sure Mr. Williams was out of earshot. He was pacing again, resuming the argument with himself, one that, sadly, he appeared to be losing.

I leaned in close to Lorraine. “I cannot discharge this man. He is truly not stable. I don’t have much information on him, so I can’t know how close this psychosis is to his baseline. I’m very sorry, but I have to keep him on one-to-one observation because he certainly can’t leave unless Psychiatry clears him. We’ll need to get some labs for medical clearance, too. Let’s have him get changed, the way we do with all psychiatric patients. Amazingly, he has agreed to everything. He’s very redirectable and cooperative.”

As I passed the triage area on my way to the psychiatric department, the triage nurse, Steve, called out to me. “Dr. Harper, can you come here a minute?”

“Yup. Are there more people out there to be seen?”

“Not exactly,” he replied.

With coffee in hand, I leaned on the desk next to him, waiting for his update, but mostly I was stealing a lovely opportunity to quietly sip coffee in a department still filled with Sunday morning calm.

“There are some detectives out here waiting to talk with you.”

“City police? About what?”

“Something about a murder. Apparently, that last patient—”

“You mean the only patient in the department?”

“Yeah, the patient is a suspect in a murder that happened in Old City this morning.”

“Whhaaaat?!” I set my coffee down and took a seat next to Steve. “Okay, wait a second. What happened?”

“I don’t know all the details, but the cops were saying an old woman was stabbed in Old City outside her church and they got a tip that led them to Mr. Williams, so they followed him here.”

“How long have the cops been here?”

I looked out and saw three middle-aged men in suits sitting in a semicircle. One was leaning forward with a notepad in hand, joking with the other two, who were seated casually as if in reclining chairs.

“I dunno, maybe thirty minutes or so. But they’ve been on the case since the tip.”

I thought back to how I had been in the room with Mr. Williams alone. I recalled him mumbling to himself and staring at the sharp instruments as I repaired his hand. I remembered the exact moment my gut told me that he and I were both unsafe there, and then the moment my instinct told me I could and must deliver us from that danger quickly. At that same moment, unbeknownst to either of us, the police were just outside, waiting for us both.

“So, you mean we were all back there with this guy who had probably just murdered someone while the cops sat outside in the waiting room joking? I was actually in the room alone suturing him, and none of those cops thought it a good idea to alert the staff or maybe even come back to the department to make sure we were safe?”

Steve frowned. “Yeah, that’s a good point, Doc,” he said. “Guess not.”

I picked up my mug and headed toward the waiting room. As I approached the officers, all three stood up, each one of them at least six feet tall.

“Doc, you’re taking care of Mr. Paul Williams?” one of the detectives asked. I nodded. Apparently, as they explained, my patient had been witnessed attacking an elderly woman, and the police were in the process of obtaining a warrant for his arrest.

“Is he good for us to take to the station?”

“Well, he’s okay medically. I just had to stitch him up, and in that respect he’s fine. But he is banana nuts. I mean nuts and berries not okay.”

“Is that a medical term, Doc?” one of the white detectives asked, throwing his head back in laughter.

“Yes, it’s one of our new terms. But in all seriousness, I’ve just ordered him some medication to help calm him down. In my opinion, he is truly psychotic. I’m having the psychiatrist see him.”

“C’mon, Doc. Don’t you think he’s just faking? Pretty convenient to be mentally ill all of a sudden,” the black detective said with a smirk.

I smiled because I knew that the acute onset of an assortment of medical symptoms when a person is arrested or doesn’t want to report to work on a nice day are all epidemics that present to the ER. “Yeah, I have to tell you, I’ve seen a lot of people malingering or, as you say, faking. I’ve seen a lot of mentally ill people, too. Either he’s ill or he’s an Academy Award–winning actor, and an actor he is not. Sorry.”

The detectives shuffled around. They seemed disappointed. I told them that I was still waiting for lab results, and more critically, the psychiatrist would need to see the patient before any decision could be made.

“We think it’s best if some of our guys stay in the department,” one of the detectives said. “We spoke to the VA police, but they don’t have the staff to leave a couple of their guys here the whole time. Okay if we set up here for a while?”

“Of course. I think it’s safer, too. Right now he’s fine. He was redirectable all along and should be medicated now. He’s honestly more cooperative than many, perhaps even more than the majority, of the sane patients I’ve treated,” I said, smiling.

“Okay, Doc. We got you.” It was nice to hear. It was the type of collegial collaboration I was used to with the police in the ER back in my South Bronx days.

I turned to Steve and called through the triage window. “Please show the detectives back. They’re gonna hang out for a while. Introduce them. Make them comfortable,” I said.

The psychiatrist on call was not in the psychiatric ER but undoubtedly sleeping in the on-call room. I asked the psych nurse to page him to the main ER and then walked back to the department to update the staff.