For one female intensive care nurse, it's the spitting.
For another, who also works in intensive care, it's a sudden kick, delivered as she gets close to a patient's bedside.
For a male nurse who works in the emergency department at a large local hospital, it could be almost anything, any bodily fluid or physical object a patient can hurl in his direction.
Most people think of nurses in a healing context, but patients often target them for abuse. In 2014, three out of four nurses said they had experienced physical or verbal abuse, with three in 10 reporting physical assaults, according to a study in the Journal of Emergency Nursing. The study blamed overcrowding in emergency departments, long waits for care, and patients under the influence of drugs and alcohol for what it called "the epidemic of violence in health care."
More than 30 states have toughened penalties for assaulting a nurse, according to the Emergency Nurses Association. Last year, Georgia Gov. Nathan Deal signed a bill that raises the punishment for aggravated assault or aggravated battery against medical or EMS personnel to five to 20 years in prison.
In recent interviews at a local hospital, four nurses talked about what they encounter regularly from patients and patients' families. They all asked their names and hospital not be used.
"People get punched, kicked, tables are thrown," said the male nurse, who has worked in the emergency department for six years. "Someone who is acutely psychotic or under the influence of drugs, they just don't know what they are doing. I've seen people kick whatever is in front of them, grab anything they can and throw it. They will pick up the vital sign machines, there's spitting, biting."
"I've been scratched by an 80-something lady," said one of the ICU nurses, a 12-year-veteran.
"I have been hit with a walker," said one veteran nurse who now is an administrator but who worked for a while in a rehabilitation facility. "The patient didn't want to get up. Really, it was just because they were hurting, they were tired of doing rehab."
"I got head-butted," one of the ICU nurses with 10 years' experience said. A stroke patient had been confused all night, she said, but now seemed to be fine. "I was getting ready to leave and handing off to another nurse and he was singing, entertaining himself. I think we were bending over, trying to straighten him up — I woke up with ammonia salts under my nose."
Because nurses spend a lot more time with patients than doctors do, they are much more likely to be targeted for abuse. They also are the ones who may be enforcing limits on what a patient can do or eat or drink.
"You're limiting the things they can have because the doctor won't allow it, or they are having a procedure that doesn't allow it," one of the ICU nurses said. "Maybe they are on bed rest and they want to go outside to smoke or something. It happens so quick — they go from being themselves and then they are tired and scared, and they find out they have a health issue and now we're limiting things. It's all too much at one time."
Another major problem is mental illness, the nurses agreed.
"Some of the most combative people you will find will be someone who has dementia, and they hurt," the veteran nurse manager said. "They are more likely going to try to hit out at you."
"At times you feel like you have worked at a psychiatric facility rather than in an ICU," one of the ICU nurses said. Emergency rooms or intensive care units often become dumping grounds for the mentally ill until a bed can be found for them in a behavioral health facility. Those mentally disturbed people may take time away from other patients.
"I didn't realize how big an issue mental health is until I worked at a hospital," the male ER nurse agreed.
The 2014 study recommended hospitals put more emphasis on identifying patients who are potentially violent and working to de-escalate the situation before an assault occurs.
The Emergency Nurses Association has developed an online course aimed at teaching nurses, managers and other emergency room staff how to recognize when violence is likely to occur, to develop appropriate responses to defuse the situation, and to find organizationwide solutions rather than leaving nurses to deal with the problem on their own.
Local hospitals now train nurses in "crisis prevention intervention" and nurses warn each other from shift to shift when they need to be wary.
Among the advice? Never have anything dangling from your neck — a stethoscope, for example, or a name tag. If you have long hair, pull it back in a bun. Never go into the room alone, particularly if you need to turn the patient.
"You know where your distance needs to be," said one of the ICU nurses. "You are not going to engage with them and make the patient more upset. If it gets to the point where a nurse doesn't feel safe, security is here." Particularly violent patients can also be physically restrained or sedated.
If a patient strikes a nurse or other hospital staffer they could press criminal charges, but that almost never happens unless the staffer is seriously injured, the local nurses all agreed. "They [patients] often don't understand what they are doing, they are under the influence of who knows what," the emergency room nurse said.
None of the nurses said the physical or verbal abuse has led them to consider quitting nursing.
"My mom was a nurse years and years ago, and she got kicked across a room," said one of the ICU nurses. "I feel like it has always been an issue."
Sometimes nurses will ask doctors to make it clear to patients that abuse won't be tolerated.
"They listen when it comes from the doctor," the other ICU nurse said.
But that doesn't always work.
"As an administrator, I have been spit on because I am wearing a white coat and I come in a room," the veteran nurse said. "The patient is being mad and sees a white coat and thinks I am the doctor who has come in and they are telling me to get out and spitting before I even get to say anything."
Patients often apologize later. "They will say 'My family told me I was acting out but I don't remember the details,'" one of the ICU nurses remembered.
"As a society we think of quick results, but to get well takes time," she said. "We want the test done now, we want the doctor here now, we want the test results now. But it takes time to get better when you are sick. That's usually what people are upset about."