Yvonne Hawkins's day began in morning quiet, bathing a woman in a big steel tub.

Then came chaos. The man down the hall started carrying on. He wanted Hawkins, not some other nursing aide he didn't recognize, to wheel him to dialysis. Then another man escaped in pajamas, setting off alarms. It was her job to chase him down.

Before she could, the woman in the tub, who had Alzheimer's disease, began to scream, insisting that there was no water. She slipped and slid and struggled to stand. Hawkins tried to steady her. "Before I knew it she fell on me, and I hit the floor, and she fell on top of me on the floor," remembered Hawkins, who works at Ravenwood Nursing and Rehabilitation Center in Baltimore, a corporate-owned facility with 300 beds.

She saved the woman from injury. It was Hawkins's shoulder that absorbed the impact. Her ligaments tore, her muscles bruised. She was away from work for two weeks, but had to return, in pain. There was no one else to support her four children and grandchild.

The second injury came six months later. Another Alzheimer's resident started for the smoking room, diaper off, legs streaked with urine. When Hawkins tried to coax him back, the man pulled on her still sore shoulder. He then stood back, and with great force--and some precision--kicked her in the stomach.

Hawkins, 34, works in private industry's third most hazardous job. A nursing aide's risk of serious injury is higher than that of a coal miner or steel mill worker, according to the Labor Department. The most common cause of on-the-job injury is overexertion: lifting immobile or disabled patients without proper assistance, leading to back problems and other ailments. About 50,000 nursing aides report injuries of this type each year. Assaults by patients are another major risk. Of all serious workplace assaults in private industry during 1997, the most recent year for which statistics are available, nursing aides suffered 27 percent of the attacks, compared with 7 percent for security guards.

Nursing aides work in neglected corners of the country's occupational health system, protected by few regulations or inspection regimes and rarely organized in unions. Most federal workplace safety laws were created to protect factory and construction workers in the industrial era. But for nursing aides, job risks don't stem from the dangers of machinery or faulty procedures on a supervised factory floor. Instead, they involve spontaneous encounters with confused or disabled patients in isolated, understaffed and undersupervised facilities. Since 1973, while injury and illness rates in construction jobs have fallen by 52 percent under pressure from workplace safety regulators, health care workers' injury rates have doubled.

The Occupational Safety and Health Administration is attempting to develop new rules to help protect nursing aides from injuries incurred while lifting and turning patients. But OSHA's proposals face resistance from Congress and the nursing home industry, and they are entangled in a larger controversy over how to control the emerging boom in workplace injuries caused by repetitive lifting and other straining motions.

Oversight problems are compounded by the marginal economic status of nursing aides and their high turnover rate on the job. The country's more than 1.3 million nursing aides constitute a white-shoe ghetto of women and blacks, many of them immigrants. According to the Labor Department, 34 percent of nursing aides are black, as opposed to 12 percent of the population. Nursing aides' average hourly wages are $6.94. Given such low pay and the demeaning and sometimes dangerous work involved, it is hardly surprising that every year, 93 percent of those who enter the profession leave it.

Labor union activists argue that the biggest, preventable cause of on-the-job injuries incurred by nursing aides is chronic understaffing in the nursing home industry. Hawkins, for example, is responsible for the care of 15 seriously ill residents. Nursing home reform advocates say the federal government should mandate staffing ratios, allocating no more than five residents per nursing aide. So far, 18 states have adopted staffing ratios; others are considering them.

Nursing home owners, while generally opposing ratios, say that changes in Medicaid and Medicare policies could help ease the burden on aides. They specifically want Medicaid to earmark more money for nursing aide care. But as the federal health care system seeks to contain spiraling medical costs, cutbacks in Medicare and Medicaid reimbursement policies continue to crimp support for relatively unskilled jobs such as nursing aides.

All this leaves aides caught, each day they go to work, between the risk of injury and the need to deliver personal, dedicated care to patients who are often helpless and needy. Nursing homes can be difficult, even shocking places to work. Some patients lose control of their physical functions. Others can become irrational, lashing out at those around them without even being aware of their actions. Yet at the same time, many patients are fully aware and in control, struggling to hold on to dignity and morale, in need of care that is careful, gentle, respectful.

"It's not like lifting a box," said Olgarene Oliver, 64, who has worked as an aide for 25 years. "Residents are hard to work with. They resist. They're shaking and fighting. A lot of demented people . . . and on top of that they have anger in them. They attack, they fight. We cannot fight back, we have to give them proper care."

In the sliver of a row house where Phyllis Freeman lives in Baltimore, order rules. Plastic slipcovers protect her upholstery, and still more plastic keeps her broadloom carpet spanking clean. But at work, where she is the only nursing aide in an intensive care unit of nine incapacitated patients, anarchy waits.

Freeman doesn't even know the causes of her patients' symptoms at the Mariner Health of Overlea nursing home in Baltimore, a corporate chain-run facility with about 180 beds. All she knows is they are incontinent and immobile. They live in their beds, most on feeding tubes, most unable to speak or hear. Those who can express themselves shift between infantile pliancy and furious frustration.

"They go back to their childhoods. They're so sweet," Freeman said. "But the holidays, it's so stressful. Nobody's there for them. They'll cuss you out, they'll spit on you. You still have to love them and care for them."

Freeman, 56, has navigated this upside-down world for 15 years. She travels to work by bus (she cannot afford a car) and brings home $450 every two weeks in pay. With it, she supports herself and a 28-year-old son whose rare liver disease has left him diminutive and permanently disabled.

Freeman has been injured twice. Five years ago, she encountered a woman weighing more than 300 pounds who was slumped down in her bed, on a feeding tube. The woman had to stay at a 45 degree angle while she was fed so she would not choke on her food.

Freeman got another aide to help her. "We was pulling her up, and she accidentally let down on my arm. I felt a sharp pain in my thumb." After her supervisor sent her by bus to the hospital, Freeman had her hand, wrist and arm placed in splints. The pain lessened; like many aides, Freeman learned to live with it.

Then one day last October, she noticed a woman, also slumped down, also on a feeding tube. But this time, the patient's face was brick red, meaning she might be suffocating. "I didn't think I had time to go around to the nursing station and get someone," Freeman said.

Freeman heard her own hand snap as she pulled the woman upright. She took the same bus to the same hospital and went through another round of treatment for four months. But this time, it hasn't worked. Her doctor says she has tendinitis and arthritis in her wrist, fingers and arm. To keep working, she'll need regular cortisone injections, which she fears will damage her internal organs--a potential side-effect.

She has applied for a job at a retirement center with less onerous duties. But she fears it won't pay enough. As it is, she has been working double shifts--from 3 p.m. to 11 p.m., and then 11 p.m. to 7 a.m.--to bring home an extra $100 a week. "I done four back-to-back doubles this week," said Freeman. "It be hurting. It be hurting."

Marlene Russell calls herself a CNA, short for certified nursing assistant. President of her nursing home's union and a longtime coordinator of Pittsburgh's Labor Day parade, Russell has always been active on nursing home workplace issues. Now she is an issue herself.

Back in May 1998, "we were working short," she said. "Normally we have four CNAs. That day we had three, and I was just running. We were just virtually running from room to room, putting people to bed. At one point I was lifting a patient and I felt the back of my leg--the pain was incredible."

She worked three more weeks, she said, thinking the pain would stop, but her hobbling got worse. She finally went to a doctor, who told her she needed surgery--two discs in her spine had ruptured and were protruding through the vertebrae. Surgery was successful at first, but after she returned to work, the discs ruptured again.

"This injury has leveled me," Russell said. "I've been stripped of everything I've worked for. It goes beyond what people know on the surface."

How workplaces should try to prevent such injuries--and who should be held accountable for them--is at the center of a brewing national debate. Compared with job injuries where, say, a factory machine slices a worker's hand or a steel beam falls on a construction laborer's head, the causal connection between lifting and injury is more debatable.

"How many repetitions are too many? How heavy a lift is too heavy? How much lifting causes back pain? What are the possible effects of non-work factors such as poor physical fitness, a worker who smokes, a worker with diabetes, a worker with an unrelated injury or a worker who plays video games 20 hours a week?" asked Rep. Roy Blunt (R-Mo.) during an April House hearing on a bill he sponsored to stop OSHA from establishing new ergonomic rules.

Blunt believes the new standard should wait until a National Academy of Sciences study is completed at the end of next year. President Clinton has promised to veto Blunt's bill, which passed in the House this summer.

OSHA hopes to publish next month its proposal for a workplace standard for "ergonomics"--the science of matching a job's physical requirements to the physical capabilities of workers. OSHA hopes to begin public hearings in February. Labor unions have spurred on OSHA, arguing that the agency has been dragging its feet during many years of study and review.

Competing scientific studies about how workplace back injuries occur and what might be done about them are tossed like brickbats by competing sides in this debate. Researchers who have looked specifically at the hazards faced by nursing aides recommend lifting devices to help turn immobile patients. Such work can be especially difficult because an inert human body is bulky and uneven, difficult to manipulate safely while lifting. But mechanical lifts are expensive, and some aides resist using them--they, like some patients and nursing home owners, believe that mechanical lifts can help make life in a care facility that much more impersonal and depressing.

Betty White, 44, who has been injured several times during the last several years while working as an aide at Baltimore's Keswick Multicare Center, sprained her back in one incident when a mechanical lift collapsed and she broke a 150-pound patient's fall. Later, she aggravated her injury when a patient rolled out of bed and she tried to grab her, and again when a patient's legs gave out and she tried to scoop the patient up. "If I just let them get hurt, I wouldn't get hurt," White said. "But I don't have that in my heart."

For insurers dealing with nursing aide cases, "the leading source of loss is patient handling," said Albert Mangone, an analyst at Liberty Mutual Insurance Co. "When people use the parts of the body--like the back, wrists--and they get injured, the causes are multicausal and complex. You have a real challenge in prevention. The causes are sometimes within the person, sometimes environmental, sometimes combination."

Injuries from lifting can be confounding, but the risks nursing aides face from direct attacks by patients are unambiguous. In the rare cases in which aides are permanently disabled on the job, or even killed, it is usually due to violence suffered at the hands of a patient. "Patients hit, kick, spit, throw stuff. You have some patients like that," said Baltimore nursing aide Deborah Odom, 45.

Abuse of the elderly at the hands of aides captures much more public attention and scrutiny than the opposite kind of violence. Efforts to check the criminal backgrounds of aides--a valuable tool in preventing nursing home abuse--have received widespread support. But stopping patient attacks on aides would require improving the overall quality of care a nursing home resident receives, aides say--including increasing the number of staff--which would be more costly and complex.

The kick to the stomach that Yvonne Hawkins endured did not disable her. It knocked her to the floor. It brought her to tears. It made her vomit twice during her shift. But she managed to stay at work. And she has kept working.

Olgarene Oliver has seen only a few aides permanently disabled during her more than two decades on the job. In the most recent instance she witnessed, an irate resident slammed a nursing aide between a wall and a bathroom door. The aide's collarbone was broken and crushed, Oliver said, and she can work no more.

Oliver herself has worked in a back brace since 1977, when a shower chair broke, bringing patient and chair down on her pelvis. Her sacroiliac disc has never recovered. "You do what you have to do to survive," she said.

Dependent on her slender income, she is motivated to keep going in part by her own intimate, daily knowledge of the alternative. "I think I want to keep working, for fear I would not work and then get crippled," Oliver said. "Then I'd have to get someone to care for me."

NEXT: One nursing aide's bittersweet world of loss.

CAPTION: Olgarene Oliver, an aide for 25 years, must wear a back brace since a 1977 accident. "You do what you have to do to survive," she said.

CAPTION: "Residents are hard to work with," says Olgarene Oliver, a 64-year-old nursing aide from Mt. Vernon, N.Y. "They're shaking and fighting. . . . We cannot fight back, we have to give them proper care."

CAPTION: Phyllis Freeman, 56, who attends to nine intensive care patients in a Baltimore nursing home, has been injured twice.