I turned to Lorraine. “I know he’s calm right now, but given everything that’s occurred,” I said, recalling Mr. Williams’s behavior during suturing, “I think it’s safer to do restraints until he’s medicated. That will give us time to see that he’s really psychiatrically stable and not a danger to himself or staff.” I glanced over into Mr. Williams’s room; he was still agitated but compliant. I saw that Mr. Carey was just being wheeled back to the room next to his.

Mr. Carey was a frequent flyer at the ER, someone who was once known to drive himself there weekly. When he arrived, he’d saunter through the waiting room and then stroll up to triage. The moment he thought he was within view, his pain would mysteriously intensify, to the point where he’d be doubled over, instantly unable to walk. He would begin shaking violently and scream in pain. Patients with gunshot wounds or kidney stones and women in labor didn’t even scream like that—they were the howls of someone who was insisting on full submission to his demands. Predictably, he would begin acting out convulsions, pausing only to explain that his symptoms had been evaluated for over a year with exhaustive tests, including labs, CTs, MRIs, ultrasounds, urine tests, endoscopies, and colonoscopies, that had all, sadly—audible sniff—yielded only normal results. He would then go on to explain that, thankfully, his incapacitating pain was singularly responsive to a couple of rounds of intravenous Dilaudid.

I made sure to stand in the hallway as he rolled by, so that he could see me. He knew that I was one of the physicians who would not give him narcotic medication, so it was likely he would walk out at any minute. I had seen him do it before.

“Lorraine, maybe we can just do restraints on his feet,” I said, referring again to Mr. Williams. “Or perhaps feet and one arm so that he can still eat and use the urinal. Whatever you think. Just let me know.”

“Okay, Doc.”

I wrapped my arms tighter around myself, shivering in my fleece, trying to keep the dry, chill air of the department at bay. Mr. Carey was on my left, Mr. Williams on my right. To my left, a medically well man with no diagnoses in his medical record except for nonspecific abdominal pain and mild reflux. His room was a theater of unparalleled noise. To my right, a psychotic man in mental distress. Nurses Lorraine and Bill were both with a calm Mr. Williams to administer medications and place restraints. I saw Lorraine speaking to him, presumably explaining what was about to happen. He slowly extended his left leg for her to affix it to the stretcher. Then the right leg he granted to Bill, who tied it to the bed. Next, he extended his left arm so it could be secured. Lorraine placed a urinal within reach on his right side. Mr. Williams kept his arm perfectly still as Bill started an IV to administer the sedative Ativan and draw blood. Lorraine removed two pills from a cup and raised them to Mr. Williams’s mouth. Mr. Williams lifted his chin and parted his lips to receive the meds.

I stood outside Mr. Carey’s door. “Mr. Carey, abdominal pain again?”

He shrieked something with a discernible “yes” in the middle.

“Well, in that case we’ll do the same workup,” I responded, before returning to my desk.

“Wait, Doc! I’ll need pain medicine first, before I can let you do anything!”

“Sure. I think it’s safest to give you a really strong antacid medication for your gastric reflux. That should help your pain while we get your blood work and X-ray completed.”

“No, I don’t want that! I need pain medicine. I won’t do anything without pain medicine!” he screamed, and then resumed his kicking and flailing.

I turned away from him. “You certainly have the right to refuse evaluation and any offered treatment. If you don’t want those things, you will need to leave.”

He continued to thrash about on the stretcher. “I am not leaving!” he shrieked. “I am not doing any useless tests, and I am not leaving!”

As I made my way back to my desk, I called out to the clerk, “Please call the hospital police to help Mr. Carey out of the department.”

Lorraine called out, “Dr. Harper. Psychiatry.”

I picked up the call and introduced myself.

“I’m one of the moonlighters, Ken. What’s up?”

“Well, we have a murder case.” I updated him about Mr. Williams and the detectives waiting for his psychiatric evaluation.

“I’ll come right down. This is a little complicated legally. Let me see the patient, then make a couple of phone calls. I’ll get back to you.” Ken was always very formal in his presentation. He wore white standard-fit cotton button-down shirts and plain dress shoes, and his language always matched his attire. He was also quite thorough and, despite his mechanical tone, clearly cared about doing right by his patients.

As Mr. Carey’s yelling intensified with the arrival of the VA police, I felt my father’s letter burning a hole in my bag—both, I knew, were best ignored so I could wrap up my work and be ready for the psychiatric input on Mr. Williams when Ken called back.

Lorraine again called out to me. “Doc, I’m sending a call in to you. It’s Psych again.”

“I saw Mr. Williams,” Ken said. “I agree with you. He’s psychotic and needs psychiatric inpatient stabilization. He can be hospitalized in a mental institution and be under arrest. It happens all the time. Unfortunately, it would be against hospital policy here to admit a person under arrest,” he said, sighing heavily. “So, I’ll have to write up my assessment, and then he’ll be released to the police. He’ll have to get his care through the prison system. It’s also true that psychiatric care in the prison system is inferior. It’s a shame, but it’s out of our control. We’ll keep him here until the police have their warrant. I spoke to the police already. Everyone’s on the same page.”

“Yeah, it’s a shame the way our systems fail patients.”

“It’s all we can do.”

“Thank you, Ken.”

I checked the clock: fifteen minutes until the day doc was to arrive. I looked back toward Room 17 to see Mr. Williams lying still on the stretcher, his eyelids soft. His hand had been sewn, his clothing changed to psychiatric scrubs, his shoes replaced by hospital socks, his agitation soothed by Ativan and Geodon. Now he could finally rest.

The VA police I’d called for a belligerent Mr. Carey were still with him. Negotiations had resulted in the police putting on their gloves and surrounding his stretcher. Apparently, Mr. Carey was still refusing to get up and walk back to the car he had used to drive himself here. Nursing slid open the glass doors of his room as the police wheeled Mr. Carey’s bed out the back entrance of the ER.

The clerk looked at the video feed of the scene outside and dissolved into laughter. “Wow, Mr. Carey just got up and gave the police the finger, and now he’s walking away. What an ass!” he chuckled. “You know, he’s walking just fine. Guess his pain got better!”

I packed up my things, wondering how Mr. Williams’s story would be told days later in the news, weeks later in court. Would the prosecutor conjure a story of a savage, cold-blooded killer? The “If it bleeds, it leads” mentality gives a distorted sense of reality. Mr. Williams was no more ferocious than the kids who pretend to look tough on Instagram, or the commercial artist from the burbs who raps about the hard life in the hood that he never had. But this sensationalism sells images that, while disconnected from the truth, can have very real consequences.