After 30 years in practice, I am rarely spooked by a patient in the emergency department. But, a recent visit in a large urban emergency department unnerved me.

As soon as the double glass ambulance doors swung open, everyone in the ED knew that an irate, out-of-control patient had arrived. 

A large, solid man who was strapped to a gurney was escorted in by paramedics and police officers. He may have just gone through a bad breakup or he may have recently lost someone dear to him, but something had clearly happened to upset him. It is also very likely that he had some form of mental illness. Whatever the reason, he was extremely angry and suicidal, which is an incredibly dangerous mix.

He had told a family member that he wanted to die and planned to have the police complete the job. The plan was to bring a baseball bat to a public place and cause a confrontation. The family member called police to warn them and at about that same time, dispatch received a report of an extremely irate individual who was threatening people at a nearby store.

Police and other emergency responders learn early that there is often a thin line between suicidal and homicidal. When a large, angry man with a professed dislike for police officers follows through with a plan to force them to kill him in a public place, everyone nearby is in danger.

A very young appearing officer was the first to respond to the scene. There he encountered a man who was terrorizing customers and who deliberately threatened the officer in a manner that could reasonably be expected to be met with deadly force. Incredibly, the police were able to get the man under control without causing injury to him or anybody around them. 

When I saw our patient, he was handcuffed, spitting and screaming: “Just let them kill me,” and “Let me out of these handcuffs right now.” In truth, his language was far more colorful.

Even more alarming than the words was the way he looked. He had a piercing and intense stare and every muscle in his body was straining in an attempt to complete his mission. There was foam about his mouth. In a very real sense, he was out of his mind. I had the impression that he didn’t care whether he killed himself or the nearest person to him. As it was clear I was the person making the decisions in the room, and I was the closest to him, I was confident he wanted to kill me.

We medicated him by injecting a strong sedative through his jeans and eventually his anger defused into drowsiness.

After the immediate problem was more settled, I went to find the two officers who had brought him in. The young officer who was first on scene had that big-eyed look that you often see when people have had a very narrow escape. His pupils were dilated and he seemed a little jittery and distracted, like he had about a month’s supply of adrenaline in his system. An older officer, who was a sergeant, was standing close by, clearly offering support to his less-experienced colleague.

I thanked them for their capable and professional work, for bringing in a very dangerous man without hurting him or allowing him to hurt anybody else. When you consider what it must have been like to wrestle a suicidal individual into handcuffs knowing that if he was able to reach your sidearm, he could just as easily kill you as himself, you can understand the risk these men were taking. 

There is a certain commonality between the police and emergency medical providers in that we both spend a lot of time dealing with societal problems that most people, thankfully, don’t have much contact with on a day-to-day basis. Driving past a homeless person asking for money on the street is very different than working with them one on one.

In the emergency department, we routinely see police officers dealing with the mentally ill or people who are in crisis for one reason or another with real compassion.

Often, they take a dangerous, violent person into custody with the least amount of force possible even though they might be safer if they used more violent means.

Those kinds of incidents, the ones that end peacefully, don’t make it into the paper but they need to be documented just the same.

They need to be documented not just because the public needs to understand how often police officers put themselves in harm’s way to help the vulnerable (even when the vulnerable are dangerous), but also because our society is doing a terrible job of caring for the mentally ill.

Many of our homeless emergency patients would have in previous times been cared for in a state-owned mental institution, where they would have received therapy as well as three meals a day and a roof over their head.

When we deinstitutionalized the mentally ill, in theory we offered them a less restricted lifestyle with access to the same resources in the community that they previously had in institutions.

The problem is that there were not enough resources in communities to provide anything like adequate care. One result is people with serious mental illness become homeless, use drugs or alcohol to manage their suffering and commit crimes to feed their addictions. Sadly, many feel hopeless and believe suicide is the only way out.

It is a problem that is handled by our emergency departments, our police officers and our emergency medical responders every day and it is a national tragedy.

All too often a mentally ill person has to demonstrate the intention of hurting themselves or someone else before our mental health system can find room for them in a treatment facility, and even then it can be days or weeks before they receive appropriate care.

That system creates crisis almost by design and it puts our police, our jails and our emergency providers in a terrible position. More importantly, it tolerates extremely inhumane conditions for one of society’s most vulnerable groups.

Mark Fourre, MD, is an emergency physician and Chief Medical Officer of LincolnHealth. He also serves on their Board of Trustees. Prior to joining Lincoln- Health, Dr. Fourre was an attending faculty physician at Maine Medical Center where he developed the Emergency Medicine Residency Program and served as Residency Director.