It was July of my third year of residency, and we got a patient from the emergency room who came up in four-point restraints.

This was a man who had lived on the streets and had a known history of schizophrenia.

EMS brought him in because he was acting erratically.

In the ED they noticed that one of his legs was massive, hot to the touch.

They tried to scan the leg to see if he had a DVD or cellulitis,

but he screamed at anyone who came near him and physically threatened staff.

I woke up with nightmares about this patient for weeks. The first time I undid his restraints,

he lunged at me, and the next day he eloped three times.

Psychiatry guided his antipsychotic management but it was days before he was

calm enough for us to complete imaging. So we treated him empirically with both

blood-thinners and antibiotics until we could get more diagnostic certainty, and eventually Doppler showed a clot.

When I think back to this case, I feel shame and guilt and a profound sense of inadequacy. I was trying to be a good doctor, trying to lead my team

empathically and model compassionate care, but when I had to jump out of his way to avoid

being hit, I ordered Halderl and restraints.

The only part of this case that feels redeeming came months later,

when I was walking home from an overnight shift

and saw him sitting on the stoop to my apartment building.

He was back on the streets, but he was free, and his legs were back to normal.

In our last episode, we talked about an ethical framework, meant to help you weigh the pros and cons of treating

over objection.

But theory can be hard to put into practice.

Today we're going to talk about the on-the-ground experience of caring for these patients,

...