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."
Carrison, who says guns have been found on some patients, isn't sure metal detectors would be helpful. He said someone who wants to get a gun past authorities generally can. And the cost of hiring people to man detectors could be problematic, said Carrison, a former FBI agent.
Brent Hall, a Clark County Fire Department emergency medical supervisor, said he and his staff are adept at defusing situations, but he has been bruised by violent patients or their friends.
"It's usually a loss of life that brings about this kind of change," he said of metal detectors. "It would be nice if we could learn from other people's situations instead of acting like it can't happen here."
Las Vegas police Lt. Craig Platt, who helps direct the area that includes UMC, said a combination of hospital security and police has been able to "de-escalate gang situations" that arise there.
The National Institute for Occupational Safety and Health reports that long waits at hospitals are a major factor in provoking hostile behavior among people who already are under stress.
The same study reported that stationary metal detectors supplemented by hand-held screening in a Detroit hospital found 33 handguns, 1,324 knives and 97 Mace-type sprays during a six-month period.
A 2002 study of violence in hospitals, though not focusing strictly on emergency rooms, reported 8.3 assaults per 10,000 workers compared with the rate of nonfatal assaults for all private-sector industries, which is 2 per 10,000 workers.
Las Vegas law enforcement authorities, who file reports by address, don't keep statistics on crimes in emergency rooms.
UMC was the only hospital to release such data, but UMC spokeswoman Cheryl Persinger said the documentation might be incomplete because people who go into health care "want to help people and probably tolerate more than they should."
"Our administration wants them to start reporting more of what happens," she said.
In 2004, there were eight disturbances at the adult emergency room and trauma unit involving altercations blamed on patients or visitors, Persinger said. UMC also took 13 "informational reports" at the two units in which something occurred that concerned an employee. Six trespassing cases were reported.
For-profit hospitals, which provide most health care services in the Las Vegas area, refuse to release statistics.
"We just want people to know that they have a safe place to come to," said Amy Stevens, who oversees marketing efforts at Sunrise, Southern Hills and MountainView hospitals.
Mike Tymczyn, public relations chief for Valley, Spring Valley, Desert Springs and Summerlin hospitals, said not discussing security concerns at Valley Health System hospitals will help "prevent acts of terror."
Golan said the beating he received at UMC the night of March 27, 2004, could have been prevented. He has since quit to take a similar position at St. Rose Dominican Hospitals.
Golan said the man who assaulted him told a nurse he was a schizophrenic and heard voices urging him to kill people.
"He was then taken back to a waiting area and left alone," Golan said. "Even though he appeared calm, action should have been taken right then. No one even checked him for weapons. We were just lucky he didn't have anything other than his fists."
In the past, he said security would be called when a person made threats. The person would be searched and restrained.
But the Joint Commission on Accreditation of Healthcare Organizations, which sets standards for medical institutions, decided in 2001 that restraints should seldom be used.
Dr. Mary Cesare-Murphy, executive director of behavioral health accreditation for the commission, said restraints aren't prohibited but should be used only as a last resort.
Golan said if leather restraints are used correctly and a sedative is administered, patients should not be harmed.
"What is happening in emergency rooms is just insane," he said. "We give people who say they're going to kill people a chance to do it."