At about 6am one ordinary morning, nurses in Tuen Mun Hospital's accident and emergency department quickly noticed the danger signals when a disturbed-looking middle-aged man turned up complaining he had had a sleepless night. He spoke quickly and nervously. The electronic medical record system showed he had a history of mental illness. The nurses put him in a waiting room and called a security guard to stand by. The man was asked to wait for a doctor; instead, he went berserk within a few minutes. He jumped up from the chair and yelled at the workers in the department. He kicked a trolley into a corner and threw the blood pressure monitor it was carrying on the floor. He heaved a chair at the ceiling and produced a thunderous din. With the department reduced to chaos, patients were evacuated to other areas. 'We called the only police officer on duty at the hospital for help,' a nurse, who wanted to be identified only as Chan, said. 'I and my colleagues tried to protect ourselves by stretching a bed sheet in front of us as a shield. Then more police officers arrived to put the patient under control ... I was scared but I kept telling myself to stay calm. It was not the first time such a thing happened here and certainly will not be the last.' According to the Hospital Authority, accident and emergency departments, medical departments and psychiatric wards are the top three black spots for workplace violence in public hospitals. Health workers have come to expect violence, physical and verbal, from patients or their relatives. Authority figures show 2,704 hospital staff were attacked in the workplace from 2005 to last year, resulting in such injuries as bruises, abrasions, sprains, strains and bites. In 2007, a serious case took place at Castle Peak Hospital, Tuen Mun, where a health care assistant was attacked by a mentally ill patient with a pen and suffered severe impairment of the sight in one eye. In a separate incident, a consultant doctor at the hospital suffered head and shoulder injuries when a mentally ill patient attacked him with a piece of stone. Dr Elvis Mak Ying-leung, head of a workplace violence task force at Tuen Mun Hospital and a doctor in its accident and emergency department, said he encountered a patient who broke the sprinklers in his department, causing serious flooding. Some patients became angry when doctors refused unreasonable requests for sick leave. 'In one case, a pregnant nurse here was choked by a patient,' he said. Since it was formed in 2005, the task force has organised training for staff on handling violence in the workplace, including 'break-away' skills to escape the grip of attackers. According to Damian O'Shea, the Hospital Authority's senior manager of staff well-being, many attackers are patients frustrated by long waiting times or mentally ill patients at psychiatric hospitals. Patients sometimes have to wait for several hours for a consultation at accident and emergency departments if their condition is classified as non-urgent. Most victims of workplace violence at public hospitals are the nurses and support staff who have first contact with patients. Some attackers are alcoholic or have a history of drug use. Apart from physical violence, workers are also exposed to verbal abuse and intimidation. There were 860 cases of verbal abuse from 2005 to last year. Since 2005, 31 people have been convicted under the Hospital Authority's bylaws for verbally abusing or intimidating health workers. The authority launched a reporting system for verbal abuse in 2005, after realising it was a common source of stress for frontline staff. Those convicted of verbal abuse and annoying behaviour can be fined between HK$500 and HK$1,000. Some hospital workers have needed psychological counselling after working under constant stress caused by such abuse. Under the Hospital Authority's bylaws, any person who uses 'any language likely to cause offence or annoyance to any person, or behaves in an indecent or disorderly manner' may be fined up to HK$1,000 on first conviction. The maximum penalty for a second conviction is a HK$2,000 fine and one year's imprisonment. The first person convicted under the bylaws was the wife of a Wong Tai Sin Hospital patient. The woman had caused a nuisance at an infirmary ward for two years, the authority's manager for occupational safety and health, Julie Ma Yuen-ting, said. The woman consistently scolded nurses and support staff in the wards with 'very abusive' language. 'On one occasion, she took out a used sanitary napkin from the toilet and waved that in front of other patients, most of whom were terminally ill elderly people. Her act scared everyone there. At least three times a week, the ward staff had to call security guards and police for help.' Ma said staff in the ward were so disturbed that some eventually quit and others needed psychological counselling. Dr Chung Kin-lai, service director for quality and risk management of the New Territories West group of hospitals, said the authority now required department heads and supervisors to go to the site to support staff after cases of violence. Chung, who worked at Tuen Mun Hospital's accident and emergency department and is now chief executive of Castle Peak Hospital, said clear protocols existed to help staff deal with violence. 'Some staff have taken verbal abuse from patients as part of their jobs, but that is not the right attitude,' Chung said. 'We encourage them to report. Staff are asked to call for assistance from security guards immediately if the patients speak foul language or get very aggressive.' The authority's safety manual for staff reminds workers in accident and emergency departments to be careful handling patients under the influence of alcohol or other drugs. Sharp objects should be kept away from such patients in clinical areas. Dr Ho Pak-leung, president of the Public Doctors' Association, believes more should be done to manage patients' expectations, a key point in improving doctor-patient relations. Patients waiting for consultations in accident and emergency departments or outpatient clinics, for example, should be told how long they have to wait, he said. Patients were frustrated by long waits and uncertainty in consultation arrangements. 'Public accident and emergency departments now use notice boards to tell patients about waiting times, but such information is not available in outpatient clinics,' Ho said. To promote harmony in hospitals, the authority will show newly produced videos in high-risk clinical areas. The videos relate five different stories on how to improve relations between staff and patients. The vice-chairman of the Patients' Alliance, Cheung Tak-hai, who acted in the videos, said patients should be made aware of the stress on workers and limits of service. 'Patients usually don't know that doctors have to treat patients in the wards and outpatient clinics on the same day,' he said. 'Sometimes doctors are late for outpatient consultations because they have to handle some emergency matters in the wards; they don't even have time for lunch. But patients do not know this and get very angry with doctors after waiting for three or four hours. There should be more communication.'