On a freezing day last month, a 52-year-old homeless man suffering from mental illness lay unable to walk and covered in his own urine under a bridge at Sixth and Vine streets just west of downtown Reno.

As with many people with a severe mental illness, the man did not want to go to the hospital. When REMSA paramedics arrived, he refused to let them take his vitals and said he didn't want to go to the hospital. So after about 15 minutes of trying, the paramedics left him under the bridge.

But the Northern Nevada HOPES community case manager, Lisa Lee, who found him under the bridge and called REMSA that day refused to leave. She gently persuaded him that he needed medical care, found a wheelchair for him, wrangled some volunteers and a van from HOPES and got him to the community clinic.

That's when she found out just how severely the frostbite had eaten away his feet.

"He had allowed his frostbite to get to the point where his feet literally almost came off in our clinic," Lee told Nevada lawmakers at a budget hearing Friday.

Ghastly photos of the man's feet provided to lawmakers showed misshapen black lumps barely attached by exposed tendons to ankles thick with pus and rotting skin. Once at the hospital, the man's feet were amputated and he was treated for sepsis. He is now in a rehabilitation hospital learning how to walk again.

Lee had prevailed in saving his life and getting him the services he needed.

"Our caseworker told him, 'Your story doesn't end here under this bridge,'" said Sharon Chamberlain, chief executive officer of HOPES, a nonprofit community health center that last year opened a new facility west of downtown.

Lee shared the story to illustrate the extreme challenges faced by social workers, police and health care providers treating Reno's homeless and mentally ill as the Legislature considers Gov. Brian Sandoval's proposed cuts to some state-provided mental health services.

But the incident also prompted Chamberlain to consider filing a complaint against REMSA. She opted instead to hold a meeting with RESMA, Reno police, Reno Mayor Hillary Schieve and county officials to discuss the problem.

"The frustration that I experience is that we have this happening in our community and that it goes unnoticed and untalked about," Chamberlain said. "We are not a Third World country. We are Reno. This happened a few blocks from my house.

"I really just wanted to get everybody in a room and just explore what happened. Everyone came around the table and we had a great conversation."

J.W. Hodge, REMSA's director of public affairs, said the paramedics' hands were tied when they encountered the man. If a patient refuses care, they can't compel the person to go to the hospital.

"We left him with his caseworker," Hodge said. "Every situation is different, but our crews do what is legally appropriate and also what is appropriate for the patient. We do our best to say, 'You really need care.'"

In Nevada, paramedics aren't allowed to initiate what's called a "legal 2000," which is a petition to have a person involuntarily committed to receive physical and mental health care. Police officers, psychiatrists and registered nurses can submit such a petition for a 72-hour hold.

In this case, it doesn't appear Reno police officers were called. Lee just went to work persuading the man to accept care.

"We all understand the need to provide additional education across all agencies," Chamberlain said of the meeting she had Friday morning. "In addition, we got some insight about how to follow up in the moment if something isn't transpiring the way we feel it should."

But Chamberlain said the incident also illustrates the need for more community case managers. Currently, Washoe County has three case managers who work with Reno police and other officials on mobile outreach efforts.

"It is a remarkable program," Chamberlain said. "They go out and find some of our most vulnerable people in the community and assist them in getting housing."

So far the case managers have succeeded in getting 53 people into housing, Chamberlain said.

"Police do law enforcement and they are stretched thin," Chamberlain said. "REMSA does transport and they are stretched thin. The case manager creates a relationship and builds trust and helps get them off the street. It's something our community needs to focus on."

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