His feet. That's the reason I saw him. They were impressive enough; smelly, swollen, red, pitted, and scaly. Pieces of dirty sock were imbedded in the skin, and cheesy material oozed from between the toes. They stuck out from beneath the sheets and hung over the edge of the stretcher like beacons. They reminded me of pictures of dead people I'd seen in news magazines, but these feet were moving. The toes circumscribed slow arcs back and forth, in time with his groans.

I looked at the ED triage sheet. His vital signs were normal. The chief complaint was listed simply as "bad feet". Understatement is often the rule in the medical record. Actually these were "incredibly, stupendously bad feet".

Naturally, the first impulse was to examine them. As I introduced myself and bent to look closer, he yelled at me, "Don't touch them feet!" In all honesty, without gloves, I had no intention of touching them. "They hurt bad," he said.

Once you got beyond his feet, he was impressive anyway; older, but impossible to say how old, and encrusted with grime. He had on more clothes than I would wear in a week. He had the pungent odors of wood smoke, sweat, and tobacco about him; not really that unpleasant. His hair was gray, long, and greasy, and he had an unkempt beard. He was big, with lots of muscle, only a little of which had gone to fat.

When I asked him why he came to the emergency department, he said, "I didn't. They brought me".

"Who brought you?" I asked. The room was empty of other people.

"My brother and sister," he grunted.

"Where are they?" I asked.

"Don't know. I wanna go home," he said.

"I think there's an infection in your feet. I don't see how you can get around at home," I explained.

"I can," he said simply.

"Well, let me finish examining you". The rest of the exam was unremarkable except there was no way to feel pulses in those blazing feet.

I tried to talk with him a bit more about his feet but he had nothing to add. He just kept saying he wanted to go home. I was sure he was retarded or demented.

As I left the room the nurse pulled me aside. "His family just dropped him off. I know him. He's something of a local character. He lives out in the woods and keeps to himself, a hermit. Kids sometimes give him a hard time but he gets along OK".

"I think we should admit him for a few days for IV antibiotics," I whispered. "I know he doesn't want to come in but I don't think he's competent".

After I received the lab results, I went back to see him. "I really think you should come into the hospital for a few days".

"No, gotta go home," he said.

"But your feet". I started.

"No! I gotta go home!" he yelled. "Give me some medicine".

He started to get up off the stretcher. "Wait a minute. Let me call your family," I pleaded. That seemed to calm him.

I called the number listed for next-of-kin on the front of the chart. There was no answer.

"I can't get your brother. Is there another number I can call?" I asked.

"No".

"When will he be back?"

"Don't know".

We called hourly for another four hours to no avail. He remained quiet, resting calmly in the bed.

I went back again. "I think you need to come into the hospital. There's no way you can go home like this".

As I started to explain my plans he got out of bed and, grimacing, said, "I'm going home".

"You can't," I implored. "Call Security!" I yelled to the nurse.

Before he had hobbled to the exit he had been tackled by four security guards, slammed onto a stretcher, and placed in full leather restraints. He was now screaming and thrashing. Bystanders were staring, shocked at the sudden, alien disturbance.

I sheepishly thanked the guards, wrote an order for some haloperidol, and called the admitting office.

After a tumultuous hour during which he screamed and I avoided his room, he was moved to an inpatient bed and things quieted down. I busied myself with patients for the rest of my shift. As I drove home later, though, I felt uneasy about the whole episode. I tried to convince myself that I'd done the right thing. Sleep was fitful that night.

I came in early the next day to see how he was doing. When I went to his room, I found him, his feet still poking out the end of the bedclothes, soundly asleep, snoring loudly, probably from the sedatives. He looked peaceful so I didn't awaken him. His feet even looked better. I felt uplifted because it appeared I had done the right thing after all.

A week later I was talking with a colleague when he asked, "Remember the guy with the feet?"

"Sure, how could I forget? Did you get him? How's he doing?"

"He died," he said matter-of-factly.

I felt dizzy and a swelling sensation rose in my chest. "What happened?"

"The next day he got out of his restraints, fell out of bed, and broke his femur. Then before the orthopedics guys could get OR time, he got acutely short of breath. He developed ARDS. We thought a fat embolism might have killed him. Tough case".

My ears were ringing. I excused myself and went to my office.

While I sat there a friend walked by and did a double take. "You look terrible. What's the matter?"

I related the whole story. "I killed him".

"What do you mean you killed him? He had a fat embolus. You just tried to help the guy. You didn't do anything wrong".

"But I did do something terribly wrong. I killed him. All because of his feet".

"What else could you have done?"

"I could have listened to him. I could have sent him home".