LAS VEGAS (AP) - The sound of the fist shattering his nose echoed in Dr. David Golan's head.
"I'm going to kill you," the patient shouted.
Reeling from punches and choking on his own blood, Golan, an emergency room physician, struggled to regain his vision as he wrestled with the man he had been trying to help at University Medical Center.
A 6-foot, 180-pound fitness enthusiast, Golan managed to get his patient in a headlock while another doctor rushed to help.
With help from security, they tackled the man to the bloody floor and a nurse injected him with a sedative.
"We appear to be waiting until someone is killed before we take the right security steps in emergency rooms," said Golan, who needed plastic surgery for his injuries.
Caregivers like Golan say violence in emergency rooms is a concern, considering the number of patients who are intoxicated, on drugs or have a history of mental disorders.
Nevada legislators recognized the issue in 2003 and made it a felony to commit a battery or assault on a health care provider.
A recent survey of emergency room physicians in Michigan found nearly 75 percent had been subject to verbal threats in the past year; 28 percent were victims of physical assaults; 11 percent were confronted outside the emergency department; and 3.5 percent said they had been stalked.
"Though this study dealt only with Michigan, we believe we're talking about a nationwide problem," said Dr. Todd Taylor, a spokesman for the American College of Emergency Physicians.
Similar statistics about southern Nevada aren't kept, aren't released, or are incomplete.
However, Dr. Dale Carrison, director of the emergency department at UMC and chairman of the state Homeland Security Commission, said hostile behavior toward doctors and nurses happens in every hospital emergency room in the Las Vegas area.
Some health care workers wonder if unarmed guards, cameras and a locked door to the inner workings of emergency departments provide enough protection.
Although emergency personnel receive psychological training to defuse situations, they say more liberal use of physical restraints on psychiatric patients, coupled with metal detectors to screen out weapons, might be necessary.
"I got thrown up against the wall in the UMC emergency room by somebody who I'm sure was on drugs," said 72-year-old Arlene Gilbert, who retired last week after 50 years as a registered nurse. "It's very, very scary. Something more has to be done about that sort of thing."
Dr. Gary Joseph Goldberg, associate medical director at the Sunrise Hospital and Medical Center emergency room, takes pride in being able to calm confrontational people. Still, he worries about abuse toward health care workers now that his hospital has joined UMC as a trauma center.
He said use of metal detectors to screen out weapons "should be explored."
At other major trauma centers across the country, trauma center personnel have become innocent victims of mental patients or drug-or gang-related vendettas.
No one knows that better than Golan. Before his arrival in Las Vegas in 1994, three of his colleagues in the University of Southern California emergency room were shot by a deranged patient. Two can no longer practice medicine.
"I was very lucky," Golan said. "I got caught up in a conversation or I would have been there, too. They put in metal detectors after my friends got shot."