The patient was drunk, naked and covered in blood when he burst out of his emergency room cubicle around 2 a.m., brandishing scissors. He lunged at two nurses and began chasing them.
It took two police officers and three zaps from a Taser to subdue him.
Rattled by this attempted stabbing in 2009 and other attacks at Ventura County Medical Center, emergency room nurse Lorraine Sandoval began keeping count of every time a colleague was assaulted or threatened by patients. On average, she found, it was once or twice a day.
"We should not have to wait until a nurse, doctor or EMT or patient is seriously injured or killed before something is done," Sandoval recalled telling her bosses, who later installed an armed officer in the emergency room.
Although nearly invisible to the public except in extreme cases, violence against nurses and other hospital caregivers is commonplace in California and around the nation, according to surveys, state records and interviews with hospital employees and industry experts.
Some workers, especially in emergency rooms, say they experience some level of assault -- biting, hitting, kicking and chasing -- so often they consider it an unavoidable part of the job. Most attacks don't result in serious injury, but hundreds have resulted in workers' compensation claims in California alone in recent years, according to a Times review.
Nearly 40% of employees in California emergency rooms said they had been assaulted on the job in the previous year, according to a survey by UC San Francisco and other researchers in 2007. More than one in 10 emergency room nurses surveyed in 2010 said they had been attacked in the previous week, according to the Emergency Nurses Assn., which represents 40,000 emergency room nurses nationally.
Many industry experts and hospital staffers say they believe violence by patients and visitors is rising but can't say for sure because it hasn't been rigorously tracked over time. The issue has recently gained attention, however, as hospital employee unions, including the California Nurses Assn., have begun pushing for broader protections and more reporting by hospitals.
The violence flares most often in emergency rooms and psychiatric wards, say staffers, researchers and security officials. In emergency rooms, waiting times have grown as increasing numbers of unemployed and uninsured patients seek basic care they can't afford to pay for in doctors' offices.
"We have a lot of men who have lost their jobs, lost their homes, 50-year-old men who have worked their whole lives," said Colleen Sichley, a 17-year nurse at Antelope Valley Hospital in Lancaster and a union representative. "They're angry. Just between the cursing and the bad language, and the physical stuff, and it's anybody" who can lash out, she said.
Staffers are obligated by law to evaluate anyone who goes for treatment, said Michael B. Jackson, an emergency room nurse at UC San Diego Medical Center. He said that whether they be gang members, drug users, psychotic patients or just "people that get frustrated with wait times," they might act out.
Acutely ill mental patients are landing in general hospitals because many lack consistent outpatient care that might keep them from deteriorating.
Hospitals sometimes blame employees for mishandling violence rather than reporting and investigating it, said Kathleen McPhaul, an assistant professor at the University of Maryland School of Nursing who has written about hospital violence and believes it is rising. "Even if the staff did something wrong," she said, "the employer needs to take responsibility and get to the bottom of it and train the staff."
Jan Emerson-Shea, vice president for external affairs for the California Hospital Assn., said that hospitals "generally are very safe places," and that most have specific protocols to follow if trouble arises.
Every so often, a high-profile tragedy prompts hospitals to rethink their security plans. In 1993, a mentally disturbed gunman opened fire in the emergency room at Los Angeles County-USC Medical Center, wounding three doctors. Since then, County-USC and other major urban hospitals have installed metal detectors and posted armed police officers in emergency rooms.
But smaller hospitals have not always gone to the same lengths. Even facilities with armed guards don't tend to station them in private treatment areas. Assaults can be difficult to predict, and guards sometimes arrive too late.
Jackson, a former Marine, said some people give an indication that they may turn violent, such as pacing, yelling or making threats; "other times it just happens."
Jackson said he was checking in a patient once who said he was "frustrated with the system." Suddenly, the patient said, " 'Let me show you how serious I am' and then he pulled out a knife and started waving it around.... It was just me and a couple of secretaries standing behind me, and I started wrestling with this guy. I grabbed the arm that had the knife and it fell on the ground."
Nurse DeAnne Dansby said a patient tackled and tried to rape her in February 2010 in the emergency room at Mercy General Hospital in Sacramento. The patient, identified by paramedics as homeless, had been taken to the hospital earlier that morning with hypothermia, she said. As he warmed up, he became agitated. Dansby stepped in to prevent him from harming a student nurse, and the man went at her and she fell so hard to the floor that her head "ricocheted," she said.
"By the time they could get to me, this guy already had my scrub pants down almost to my knees," she said. "It took 13 people to get this idiot off of me."
Weeks after the attack, Dansby said, she was diagnosed with displaced herniated discs and severed nerves.
She lost the use of her left arm and can no longer move her neck enough to "look up at the sky," she said.
"That guy could have killed me," said Dansby, who received workers' compensation payments -- uncontested by the hospital -- before going back to Georgia and finding a less strenuous job.
Under California regulations, among the strictest in the country, all significant injuries must be reported to the state and law enforcement. But the law does not spell out what "significant" means.
Dansby said her supervisor told her: "If you are going to work for this hospital, you are not going to press charges," so she did not.
Two months after she was assaulted but before the full extent of her injuries became clear, Dansby said, she was dismissed. Because she was a probationary employee, hospital officials did not need to cite a cause.
Later, she said, the nurses union representative accused her of exaggerating her injuries to avenge her firing.
Officials at Mercy hospital issued a statement saying that "the hospital's actions were in compliance with its policies and procedures, and with California law."
Bonnie Castillo, head of the California Nurses Assn., said hospital officials discourage nurses from reporting assaults because "it interferes with their image of being a safe haven."
A 2009 study published in the Annals of Epidemiology found that more than half of hospital workers in California and New Jersey had not told their supervisors after being assaulted, in part because "workers often accept these events as part of their job."
Nine assaults involving significant injury or death were reported to California's Department of Public Health from fiscal year 2007 to fiscal 2009, according to records released to The Times.
During the same period, 370 hospital workers filed compensation claims alleging that they were injured in assaults involving criminal acts, although the significance of those injuries was not clear.
Those workers' compensation numbers do not include many more people who were injured in assaults not deemed crimes, which could include attacks by someone with dementia or psychosis, said Susan Gard, head of policy for California's Division of Workers' Compensation.
The Times also reviewed crime reports taken by the Los Angeles Police Department at all hospitals in Los Angeles over a recent 10-month period, finding that not a single assault was reported at nearly a third of the 40 hospitals in the city. At California Hospital Medical Center in downtown Los Angeles, however, nine were reported, most of which clearly involved attacks on employees.
Katreena Salgado, the hospital's director of public affairs, said it's not because there's more violence at her hospital but because the administration takes the staff's safety seriously and encourages employees to report assaults by patients or visitors capable of understanding their actions.
Even low-level violence can bring great stress, staffers at many hospitals said.
Amelia Mendoza, 53, a nurse's assistant at Huntington Hospital in Pasadena for six years, was struck by a patient on her arm in April 2009, according to allegations by her family in a workers' compensation case. The assault was relatively minor, according to her family's lawyer, but her blood pressure shot up so high she required treatment.
A few days later, Mendoza was assaulted again by the same patient, her family alleged. After unsuccessfully seeking treatment at the hospital again for her blood pressure, she had a massive stroke and died last October.
This spring, a workers' compensation judge found that the death "arose out of and in the course of" her employment and that the attacks may have played a role.
In a written statement, Huntington officials said: "We strongly disagree with the decision and are proceeding with a formal appeal."
Some violence may be unavoidable, but staffers complain that they haven't been trained in the best way to contain it.
In 2008, a 338-pound patient was admitted for chest pain at a Kaiser Permanente hospital in Oakland and was observed by staffers to be angry and anxious, according to state documents. The next morning he got out of bed, took off his clothes and began punching his 68-year-old roommate in the face.
Hearing screams, a nurse ran to the room.
The patient then began chasing her. "I ran," the nurse later told state investigators. "I didn't know what to do.... No one knew what to do."
The patient cornered a group of nurses by the elevators and struck four staffers before picking up a fifth employee and "swinging" him around, according to the state's investigative report.
Even after security officers handcuffed the patient and placed him in a chair, he ran away again before being wrestled to the ground.
He experienced "some degree of head trauma," according to the state report, and died a week later "after another episode of increased agitation" that was not described.
Later, the California Department of Public Health found that the hospital had failed to provide proper supervision to an acutely ill mental patient.
Kaiser officials called the case "extremely unusual" and said they had since provided training to staffers and "strengthened the hospital's security plan."
Even though extreme violence is rare, many employees and union leaders say, it often occurs after a trail of unheeded warnings.
At Danbury Hospital in Connecticut, nurses had been lodging complaints for months about violence against staff members, including a nurse who was punched in the jaw, then fell and broke her hip in 2009, said Mary Consoli, a nurse and president of the local nurses union.
Their pleas were ignored, she said, until last spring, when an 85-year-old patient with dementia took a gun out of his pocket.
A nurse tried to intervene and was shot three times, sustaining long-term damage to his hand, according to Consoli.
Occupational safety investigators issued $6,000 in fines, noting a long list of previous fractures, bites and bruises to staffers.
"You don't want to be grateful for this shooting," Consoli said. "But if it wasn't for this shooting," she said, nothing would have been done.