Outside it was an uneventful, warm Wednesday night. Down the street, at Camden Yards, the Marlins were beating the Orioles. Inside the hospital it was that notorious July 1^st when the combined experience of every intern could fit into the pocket of a rumpled white coat.

The evening truly began around 7:45 on Ward A, our locked acute psychiatric unit. A cursory glass at the video monitor revealed that one of our patients, a hulking 250-pound man, was standing on the wrong side of the ward doors. His repeated pounding against the steel security doors had destroyed the lock assembly. Technically speaking, the patient had eloped, though there was nothing clever or clandestine about his exit. What was shocking then and puzzles me now, is what he did after that: like a tired salesman at the front stoop, he waited politely, facing the door, to be allowed back in.

We moved quickly towards the doors, then escorted the patient back to his room. I believed that this was going to play out in a smooth and professional way. I sat down to talk. His menacing pacing made the room feel small. His breathing was irregular and his arms remained stiffly at his sides. His speech was pressured and chaotic. His eyes were wild and he was agitated. The nurses waited outside.

I will never know what, if anything, my words meant to my patient. I gleaned, through his jumbled utterances, that he felt he needed to leave the hospital to protect his little sister from his lascivious stepfather. He talked about the endorphins in his brain….just like eating chocolate….just like the pizza that a marine buddy in handcuffs had wanted. The associations flew, and we feared that a struggle was about to ensue. I assumed a fireside posture that I hoped might de-escalate the scene, by example, or something. His words became more threatening, and his urgency to leave increased.

I reminded him that he was in the hospital now, and could not leave. He talked of hand grenades and bayonets; he was fuming and I was stalling. All I could think to resort to were the standbys of a cartoon therapist: "How do you feel?" and "Why are you scared?"

In the meantime, consensus emerged in the hallway that the patient needed to be medicated and secluded. A nurse with a dixie cup and sedatives entered the room. The orbit of our patient's erratic trajectory moved closer to us, and she offered him the medication. His torso balked, but his feet planted. He reached for the cup, and at an arms-length distance, it was difficult for us to hide our visceral interest in his cooperation. He protested, yet he swallowed. The tide had turned and we guided him into the hallway, and then into the seclusion room. Like a punctuation mark, the door slammed emphatically behind him. We heaved a joint sigh of relief that The Commotion had ended.

Though really, it had not ended at all. In a frenzy, our patient disassembled the seclusion room doors, then awaited our response. Again, it was the same uncanny pattern of rage, submission, and ineffective doors. This time we approached him more directly with security guards and a loaded syringe. This 'take down' was not negotiated; it was smooth and professional, with one man per limb.