Hospitals can be scary places for patients, but for doctors, nurses and others who work there they can be downright dangerous. "Every emotion is expressed in the emergency room every day," says Thomas Arnold, a professor of medicine and acting chairman of the Emergency Medicine Department at Louisiana State University's Health Sciences Center. Care rarely comes fast enough for visitors, Arnold explains. "Sometimes they object violently when other, more urgent patients are treated before their relatives. Then, too, people sometimes turn on doctors when, unfortunately, we must inform them their relative has died."

Consider what happened to Paul Matera, emergency-room physician at Providence Hospital in Washington. "It was about 2 a.m.," Matera recalls. "I was working on a trauma patient with numerous, serious chest and abdomen stab wounds. He was 19 or 20 years old, and very large, weighing about 250 pounds. I had been talking to him, telling him what I was doing while trying to stabilize him and keep him alive. Suddenly he sat up and spun me around. He hit me in the back of the neck with his fist, rupturing a number of discs."

Despite the pain, Matera continued to treat his patient. Subsequently, he has had three surgeries to repair the damage to his back, the latest performed this summer finally easing the persistent pain. Two years ago, the American Medical Association awarded him its rare Medal of Valor for "courage under extraordinary circumstances in nonwartime situations."

Matera's story and similar tales are being repeated these days partly as a result of Sept. 11: Hospital administrators and health-care officials are examining whether medical facilities are equipped to cope with the consequences of terrorist acts. In the process, they have found that many lack the ability to protect their workers even in normal times -- much less in moments of chaos.

"Despite the increase in concerns about bioterrorist threats, respondents cited patient violence as the No. 1 threat to emergency-department personnel," reports a survey that asked emergency-room managers and other representatives from 50 hospitals about worker safety. The finding coincides with larger studies by the 154,229-member American Nurses Association (ANA). In its national, online survey of 4,826 nurses conducted in November, less than 20 percent said they felt safe in their "current working environment." Seventeen percent reported being assaulted physically in the last year, and more than half were threatened or abused verbally.

"More assaults occur in the health-care and social-services industries than in any other," states the largely ignored, voluntary Guidelines for Preventing Workplace Violence for Health Care Workers prepared by the Occupational Safety and Health Administration. The document points out that the incidence of violence is increasing, noting that between 1980 and 1990, 106 occupational violence-related deaths occurred among health-care workers including physicians, pharmacists, nurses and nurse's aides.

"The nursing staff at a psychiatric hospital sustained 16 assaults per 100 employees per year," according to the report. "This rate compares with 8.3 injuries of all types per 100 full-time workers in all industries and 14.2 per 100 full-time workers in the construction industry."

Officials of the ANA and the American College of Emergency Room Physicians, among others, say that about 80 percent of cursing, pushing, slapping, punching and throwing events go unreported. Some of the victims keep quiet because they consider such behavior normal job hazards. Others contend hospitals and hospital-management groups ignore their complaints and at times retaliate by firing them or transferring them to less desirable jobs.

Still, the Bureau of Labor Statistics has begun to recognize the dimensions of the problem, disclosing that in 1999 health-care providers were the victims in 43 percent of all nonfatal workplace assaults in the United States. The rate of assaults on health workers was five times the rate for employees in all other industries. Half the incidents involved hitting, kicking and beating. Nursing aides, orderlies and attendants were the victims in 61 percent of the attacks. Registered nurses were assaulted 13 percent of the time and licensed practical nurses 10 percent. Technicians, guards and police were targets also, but less often.

Compounding the problem is the fact that "incidents of hospital violence are reported in local media as isolated events," says Victoria Carroll, a teacher of medical-surgical nursing at Northern Colorado University School of Nursing who has studied hospital violence for a decade. "They're not usually reported nationally, and they're not seen as symptoms of what is a widespread, ongoing situation." When pressed for examples, she -- and others -- refer to a cluster of famous and dramatic cases that occurred in the 1990s:

* At Alta View Hospital in Sandy, Utah, Richard Worthington, 42, shot a nurse in the back, killing her. Then he took seven other staff members hostage for 18 hours. He claimed to want to kill the obstetrician who performed a tubal ligation on his wife, but he failed to locate the doctor.

* At the Los Angeles County-USC Medical Center, Damascio Ybarra Torres shot three emergency-room doctors and took two women hostage to get back at doctors whom, he said, treated him "like an animal."

* At Valley Lutheran Hospital in Mesa, Ariz., Jean Dooley, who was recovering from a hysterectomy, became upset, pulled a gun and shot a nurse and an ambulance attendant, wounding both.

It is common knowledge that unruly alcoholics, drug addicts, psychotics and hoodlums frequently are brought to hospital emergency rooms, and many -- one study says 25 percent -- are armed with guns, knives, blackjacks and other weapons. "The police and sheriff departments drop off at the emergency room prisoners they don't want to deal with," says Jeanne McGrayne, a former emergency-room nurse turned consultant who is working with VHA, a network of 2,200 community-owned health-care organizations and physicians based in Irving, Texas. "Often family members who are tired of dealing with Uncle John, who is drunk and violent at home, call for him to be committed. The rescue squad comes and takes him to the ER. There doctors have to examine him and see if he is a danger to himself or others so they can determine whether to commit him. Meanwhile, six or seven hours go by, and he's causing problems while the ER staff is trying to deal with really sick patients."

All concerned know the prescription for dealing with hospital violence: Hospitals have been advised to hire more nurses, beef up the security staff, install metal detectors, control entrances and exits to limit access, keep patients and relatives informed about what's happening and remove from waiting areas all lamps, ashtrays and anything else that can be thrown or used as a weapon.

Yet hospitals frequently do not have the resources to implement the needed security measures. "These days, hospital emergency departments are used as primary care units," Arnold says. "They're the family doctor. They're flooded with people who come in with colds and so forth. This taxes the system and stretches resources that otherwise might be available."

AUGUST GRIBBIN WRITES FOR Insight's SISTER DAILY, THE WASHINGTON TIMES.

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