The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who’d watched him hobble down the building’s stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

“Of course, if things get worse before the week’s up,” I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, “come back here right away.”

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man’s face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. “Just admit him,” she whispered. “It’ll cost more, but it’s the only way you’ll be sure he’s getting the right care.”