Not Allowed to Lose
Parallels Between ER Doctors and Police
In the middle of the night, when someone in a mental health crisis is brought to my ER by police, I know what’s coming.
The patient has threatened suicide. I assess them and determine they’re at risk to themselves. By law and by conscience, I cannot let them leave. When I tell them they’re being admitted involuntarily under a mental health hold, they often lash out verbally and physically, sometimes violently. I try to talk them down. I fail. Then I restrain them, first physically, then chemically. I document everything.
I do not have the option to fail. I am not allowed to let them go. If I do, and they die, I could face a lawsuit, a medical board investigation, or worse. My actions are dissected with the full benefit of hindsight by people who were never in the room.1
This is what it means to be a first responder. And in many ways, my role as an emergency physician mirrors that of the police officers who bring these patients to me in the first place.
First Responders in the Crosshairs
Both ER doctors and police officers are first responders. We are summoned in moments of chaos, such as drug overdoses, violent assaults, and psychotic breaks. We make high-stakes decisions in real time, often with incomplete information and little margin for error. And both of us are increasingly finding ourselves judged harshly after the fact, not only in courts of law, but in the more unforgiving court of public opinion.
When a police officer uses force to restrain someone, they are often accused of brutality. When I sedate an agitated psychiatric patient to prevent them from harming themselves, I can be accused of the same. And yet we are both legally and ethically obligated to act.2
Emergency physicians often enter the field driven by a commitment to science and altruism, not a desire for confrontation. Unlike law enforcement officers, we are not trained or equipped for combat; we don’t carry weapons or wear protective gear. Yet, the reality of emergency medicine frequently places us in situations where we must assert control over uncooperative or violent individuals. This role is at odds with the typical physician’s disposition, which leans towards empathy and collaboration. The necessity to enforce compliance, sometimes through physical or chemical restraints, is a stark deviation from our professional expectations and personal inclinations.
Compounding this challenge is the fact that many patients arrive at the ER already agitated, having been brought in against their will by police or under false pretenses by concerned family members. These confrontations often intensify the patient’s distress, making meaningful de-escalation nearly impossible. As physicians, we are thrust into the aftermath of these encounters, tasked with managing the heightened emotions and potential aggression that result.
Just as a police officer is not allowed to let a suspect flee, I am not allowed to let a suicidal, homicidal, or psychotic patient leave the ER. If they walk out and hurt themselves or others, I may be held liable under EMTALA, state law, or civil malpractice claims.3
The Mental Health Crisis No One Talks About
There is a nationwide mental health crisis, and emergency departments are at its breaking point.4 On any given day, a significant portion of ER beds are occupied by psychiatric patients, many of whom are held involuntarily.5
The legal framework varies by state, but in my state of Ohio, for instance, I can place a patient under an involuntary psychiatric hold, known as a “pink slip,” if they are deemed a danger to themselves or others.6 Importantly, the decision to detain the patient is not always mine to make; law enforcement officers in Ohio also have the authority to initiate a pink slip, and often do so before the patient ever arrives in the emergency department. Once that decision is made, the patient becomes, for all intents and purposes, a detainee. But instead of law enforcement tools, I am given Haldol, Ativan, and hospital security staff with minimal training in crisis response.
The public does not understand this process. And when patients resist, when they scream or fight, cell phones come out. If that video makes it online, I cannot tell my side of the story, not because I don’t want to, but because I’m bound by HIPAA.7 The patient can say whatever they want. I cannot respond. In some ways, a doctor’s hands are tied even tighter than a police officer’s.
Vilification Without Defense
In the wake of the Black Lives Matter movement, society turned a critical lens on policing. Some of that scrutiny was warranted; America’s law enforcement history is stained with abuse of power, from stop-and-frisk to Rodney King to George Floyd. But there is a growing risk that emergency physicians will be next.
We are increasingly portrayed as cold, racist, or uncaring in online narratives, especially when we deal with Black or marginalized patients in distress. The history is not on our side. The Tuskegee syphilis study, the exploitation of Henrietta Lacks, the writings of Margaret Sanger and the legacy of eugenics all cast a long shadow over American medicine.8
I understand the suspicion. But I also fear that if we cannot speak up in our own defense, and if the public continues to conflate necessary intervention with cruelty, we will drive good people out of this profession. Already, burnout rates among emergency physicians are among the highest in medicine.9 Add fear of viral retribution to that list, and it’s no wonder so many are walking away.
The Force We’re Forced to Use
No doctor wants to restrain a patient. But we are forced into a corner, just like police. The patient escalates, and we must escalate too; we aren’t permitted to lose.
This is the uncomfortable truth of emergency medicine. It’s not clean or polite or easily understood. It happens at 2 a.m., behind closed doors, in the real world of trauma and mental illness. Just like our counterparts in law enforcement, we achieve what we can under impossible conditions. Very often, we do so without thanks, without understanding, and without the benefit of public trust.
Pary R, Lippmann S. When Suicidality Is Suspected. South Med J. 2025;118(4):242–245. doi:10.14423/SMJ.0000000000001810
Bernstein CA, D’Onofrio G, Mamtani M, et al. Ethical and legal aspects of emergency psychiatry: balancing patient autonomy and public safety. Psychiatr Clin North Am. 2022;45(1):1–14. doi:10.1016/j.psc.2021.10.001
Pary et al 2025. (See reference 1)
National Institute of Mental Health. Mental Illness. Updated 2023. Accessed May 1, 2025. https://www.nimh.nih.gov/health/statistics/mental-illness
Nicks BA, Manthey DM. The Impact of Psychiatric Patient Boarding in Emergency Departments. Emerg Med Int. 2012;2012:360308. doi:10.1155/2012/360308.
Ohio Department of Mental Health and Addiction Services. Involuntary Psychiatric Commitment: A Guide for Emergency Room Physicians. Accessed May 1, 2025. https://mha.ohio.gov/
45 CFR §164.502 - Uses and disclosures of protected health information. Code of Federal Regulations. Accessed May 1, 2025. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.502
Reverby SM. Examining Tuskegee: The Infamous Syphilis Study and Its Legacy. University of North Carolina Press; 2009.
Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Anchor Books; 2006.
Birth Control or Race Control? Sanger and the Negro Project. Life Issues Institute Newsletter. 2001;28(Fall). https://www.supremecourt.gov/opinions/URLs_Cited/OT2018/18-483/18-483-1.pdf. Accessed June 30, 2025.
Lin M, Battaglioli N, Melamed M, Mott SE, Chung AS, Robinson DW. High Prevalence of Burnout Among US Emergency Medicine Residents: Results From the 2017 National Emergency Medicine Wellness Survey. Ann Emerg Med. 2019;74(5):682-690. doi:10.1016/j.annemergmed.2019.01.037.