A New Resource for Evaluating Strangulation Injuries?

Prosecution of strangulation as a domestic violence assault challenges prosecutors. Half the time, strangulation survivors have no neck markings. In the remaining 1/2 of survivors, approximately 2/3rds of them have only minimal findings. This means that only about 1/3rd of survivors with neck markings have neck markings that can be photographed to show signs of the assault. Said another way, of all survivors of strangulation as a form of assault:

1. 50% have no findings
2. 35% have minimal findings that are so faint that they cannot be visualized in photos
3. 15% have significant findings that can be visible in photos taken of the neck

Now a new technique called alternative light source technology may be about to change all of that. See: www.baltimoresun.com/health/bs-md-als-dv-20100902,0,2655642.story

Excellent New Resource Collection on Strangulation

Today I got an email from the American College of Emergency Physicians (ACEP) Section on Forensic Medicine with this comment  and request: “We are encountering more violent strangulation victims in our DV population. I have been unsuccessful finding clinical guidelines for imaging/admit protocols for victims of significant strangulation as I try to objectify the approach to these vicitms for my ED partners”

This email prompts this post for two reasons:

• Do you have a protocol that you would be willing to share with other providers? If so, please email me at DrTSpeaks@gmail.com
• If you are in need of a good resource site for strangulation, please visit the Family Justice Center Resource Center by clicking here.

As always, comments and questions regarding this issue are most welcome.

Manual Strangulation As A Cause of Death

Approximately half of survivors of manual strangulation have neck findings to indicate that strangulation has taken place. Survivors differ from fatal strangulation victims in that the hyoid bone is often not fractured by the attack.

Not all victims of fatal strangulation have external neck findings but many do, especially on TV shows where forensic examiners play a key role.

To see an example of the neck markings in a fatal strangulation, click here. Note that the pathologist has the added benefit of “looking inside” of the injury markings.

Strangulation As A Youthful Activity

Alas, the “choking game” is back as an activity for 8th graders in Oregon. The “choking game” goes by several names including:

• Knock Out
• Space Monkey
• Flatlining
• The Fainting Game.

The object of the game is to achieve a “high” or euphoria from a brief period of hypoxia. The cost of these brief euphoric periods can be high. Strangulation, for whatever means, puts victims at risk for long-term disability as well as death. In 2008, the Centers for Disease Control and Prevention (CDC) reported that 82 deaths attributed to the “choking game” or other forms of strangulation activities occurring between the period of 1995 and 2007.

The CDC Morbidity and Mortality Weekly Report published in the February 24, 2010, issue of the Journal of the American Medical Association (JAMA) reports on the findings of an Oregon survey among public school 8th graders. The survey among other things was designed to assess awareness of the choking game among 8th graders as well as participation in the game.

The survey included 10,642 respondents. Of these, 73% answered the question addressing the choking game. Male and female respondents had similar responses:

• A little over a third of the respondents had heard of the “choking game”
• A little under a third of the respondents knew someone who had participated or helped someone participate in the “choking game”
• A little over 1 in 20 (5.7%) had participated in the
  “choking game”

This is the first large survey to address this issue. Previous mentions of the choking game in the medical literature came from anecdotal reports or were based on small surveys.

To learn more about the “choking game,” please visit these JAMA web pages:

• Unintentional Strangulation Deaths From the “Choking Game”
• “Choking Game” Awareness and Participation Among 8th Graders–Oregon, 2008

An Online Reference for Manual Strangulation in Domestic Violence

Chapter 16 on Strangulation in Intimate Partner Violence by Ellen Taliafero, Dean Hawley, George McClane, and Gael Strack in the Connie Mitchell, MD book, Intimate Partner Violence: A Health-Based Perspective, can now be accessed by clicking here. This is the first major, major textbook on a health-based perspective of Intimate Partner Violence. As noted in one of the editorial reviews of the book, “All in all, this is an excellent book, a major compilation and unique in its approach. It is highly recommended for anyone seeking to further the complex phenomena of intimate partner violence.”–PsycCRITIQUES”

Female homicidal strangulation in urban South Africa

Femicide (homicide of women) is a world wide problem as evidenced in an October 2008 article that can be accessed by clicking here.

The background piece of this article provides good information on strangulation as a homicidal or attempted homicidal act: “Strangulation is considered to be a form of mechanical asphyxia [17]. The mechanisms of death in strangulation include airway occlusion, resulting in hypoxia; occlusion of the neck vessels or compression of the carotid arteries, leading to cerebral ischemia; and carotid sinus reflex, leading to cardiac arrest [17]. The term strangulation is specifically used to indicate the external pressure applied to the neck either by means of a ligature or the hands [17]. Descriptions of homicide victimisation by strangulation are largely to be found within the legal and forensic medicine literature. …” Click here to read the complete article.

A Good Manual Strangulation Resource for Expert Witnesses

Women who are survivors of domestic violence physical assaults often report that they were “choked” during one of those assaults. More often than not, the attack leaves no physical signs of neck trauma. In fact, pathologists and criminal investigators have known for some time that manual strangulation can take the life of a victim without leaving a clue as to the cause of death.

As it turns out, the secret killing of victims by strangulation has quite a history as evidenced in the book, The Ancient Art of Strangulation. This startling book explores the history of strangulation as a form of bloodless killing in the land of ancient India. It also traces how elements of this ancient art form have been adopted by both military special operations and the martial arts.

The good news is that the information in this book can be life saving. As the back cover states, “The information in this book is shocking and is sure to be controversial. But it is hisotrically significant and it could save your neck…”

Note that a disclaimer comes with the book: For academic study only. To learn more about the book, please click here.

Breaking Free of A Chokehold During A Domestic Violence Attack

By

Ellen Taliaferro, MD, FACEP

We now know that manual strangulation as a form of domestic violence assault is not an uncommon form of physical assault.

How can victims be safe then this happens to them? Help comes from the Expert Village website video on how to escape a Sleeper Hold & Strangulation  using Fung Fu,

Click here to see this video now.

Focus on Manual Strangulation

by

Ellen Taliaferro, MD, FACEP

Prior to ten years ago, few health care and legal professionals had little awareness of the presence and seriousness of strangulation as a form of domestic violence assault. Indeed, the first hint that manual strangulation injuries might be more common than realized appeared in the medical literature in 1985.

In 2001, a landmark series of six articles addressing strangulation as a form of domestic violence assault appeared in the October issue of the Journal of Emergency Medicine. Since then, much has happened as more and more legal and health professionals have been trained in how to recognize and document strangulation assault and in how to care for victims of strangulation.

We now know:

• Manual strangulation accounts for 97% of all domestic violence strangulation attacks
• Of women who present to a busy emergency department for treatment of a domestic violence physical assault, 23% of them have been strangled
• 50% of women who are examined within a few hours of being strangled have no signs of strangulation injury
• Strangulation assault is a life-threatening event that takes a major toll on the lives of many of the survivors of the attack
• Women who have been strangled within the past 24 hours should be admitted or observed in the hospital

To learn more about this issue, please click here to see the issue of the Health After Trauma eZine dedicated to the single issue of manual strangulation as a form of domestic violence assault.

Improving Your Response to Intimate Partner Violence with 10 Action Steps

by
Ellen Taliaferro, MD
Zita Surprenant, MD, MPH

Intimate Partner Violence (IPV), the psychological, emotional, and physical abuse of your patients by a current or previous intimate partner affects close to four million women a year. A little over a third of these women report violent victimization. Like many other medical conditions, IPV often escalates in frequency and severity the longer it persists. For approximately 1,000 women each year the violence becomes fatal.

Few of us in healthcare are comfortable dealing with IPV. Couple this with the fact that many physicians feel that their patients do not have family violence issues and you end up with a devastating problem that goes unrecognized, unaddressed, and untreated.

The truth remains that IPV presents a major challenge to physicians in every practice setting and specialty, and the after effects of violence and abuse cast a long shadow on the patient’s current and future health.

Early recognition of IPV and an appropriate response to IPV goes a long way to getting patients the help they need to be safe and escape ongoing injuries and illness. In addition, a valuable added benefit occurs when the psychological and physical trauma of the abuse is addressed, laying the groundwork for the patient’s improved health and well being.

IPV problems can appear at any moment in any practice setting. In light of this fact, physicians and healthcare providers can improve patient care of IPV victims by implementing 10 Action Steps in their clinical settings.

Section One of our new book, Respond to Intimate Partner Violence—10 Action Steps You Can Take to Help Your Patients and Your Practice, provides guidance for the recognition and detection of IPV in the practice setting. Section Two stresses appropriate response to the identification of IPV by putting into place 10 action steps.

Action Step No. 1:  Respond Effectively to Patients Who Disclose Violent Relationships

When a patient tells you that IPV complicates her life, you have a unique opportunity to help her improve her health and well-being. Support her in making changes by validating the difficulties and challenges she is experiencing, as well as her need to make changes.

By validating victims and survivors of IPV, you give your patients a tonic more powerful than any prescribed drug. Validation occurs through therapeutic messages, listening, and providing supporting materials.

Some therapeutic messages that you tell the patient bear repeating several times during your time with the patient. Chief among these:

•    “You do not deserve to be hurt, no matter what.”
•    “You are not alone; help is available.”

Listening non-judgmentally is a therapeutic message in itself. Once you have validated your patient, you have her trust and can move to the next step in her care.

Action Step No. 2:  Respond to Your Patient’s Safety Needs

Start by determining how safe your patient is right now. There are numerous safety assessment tools you can us. One simple one is the Physical Abuse Ranking score. Ask about these ten things:

1.    Throwing things, punching the wall
2.    Pushing, shoving, grabbing, throwing things at the victim
3.    Slapping with an open hand
4.    Kicking, biting
5.    Hitting with closed fists
6.    Attempted strangulation
7.    Beating up (pinned to wall/floor, repeated kicks, punches)
8.    Threatening with a weapon
9.    Assault with a weapon

If your patient’s abuse-related incident ranked higher than five on this scale, your patient can be in extreme danger. However, even if the abuse ranks low on this scale, your patient may still be in danger. Any patient who feels in danger should be considered to be in danger.

Safety planning for your patient should be tailor made to conform to her needs. For instance, she may elect to stay in her relationship with her batterer because she feels that is safer than leaving at this time. Regardless of whether or not your patient elects to leave or stay with her batterer, she must not leave your clinical setting without a plan in place.

Action Step No. 3:  Manage Your Patient’s Referral Needs

Services available to help patients differ in each community. However, a fast call to the National domestic violence hotline, 1-800-799-SAFE, provides you with local resources that your patient can access. Be sure to identify yourself as a provider at the very beginning of the call.

Most patients dealing with the presence of intimate partner violence in their lives don’t need to be admitted to the hospital. If your patient has medical or mental health needs that require admission, and her perpetrator remains free or poses a threat to your patient, consider admitting her as a Jane or John Doe patient. Note that HIPAA provides that patients can request not to be listed in the healthcare facility directory.

Action Step No. 4:  Document Your Findings

Good documentation builds a bridge of communication among healthcare providers attending the patient and also assists when community advocacy and legal referrals are indicated. When taking care of victims of IPV, the three main modes of documentation consist of:

•    Charting
•    Body maps
•    Photo documentation

Action Step No 5:  Meet Your State and Local IPV Reporting Requirements

Mandatory injury reporting requirements vary considerably from state to state. To provide effective IPV intervention, you need to understand your state and local reporting laws, procedures, and the methods of enforcement, whether the issue is IPV, child abuse, elder abuse, abuse of someone with a disability, or assault involving weapons.

Specific information about state reporting laws can be found at the http://www.endabuse.org/ website.

Action Step No. 6:  Respond to Your Patient’s Stage of Change

Change is not easy. Leaving an abuser or staying in a relationship with new family dynamics often represents a major life change. You can best help your patient to bring about necessary changes in her life by understanding that change occurs in stages and that relapse is a normal part of the change process.

Action Step No. 7:  Address IPV in Special Populations

There can be additional barriers, special needs, and safety issues when working with IPV victims across age groups, gender, sexual orientation, and different cultures. You can best help individual patients in each of these groups by understanding the special needs each group has. For instance, a male victim of IPV struggles with issues separate from a teenage girl being abused by her partner or an elderly widow who remarries and then finds herself a victim of abuse.

Action Step No. 8:  Address Special Clinical Situations Involving IPV

In addition to separate populations, special clinical situations arise when treating IPV patients. For instance, the IPV victim and her perpetrator may both be your patient. Or your patient may be suicidal. Another special situation arises when her abusive partner manually strangled your patient during an assault.

Action Step No. 9:  Develop a System for Addressing IPV in Your Practice Setting

You need a team approach to lay the groundwork for effective IPV intervention in your practice setting. Two critical ingredients set the stage for success:

• Provide training for your staff to understand IPV and to respond to it.
• Designate a practice setting “IPV Champion” who becomes your local expert on policies, procedures, and local resource coordination.

Action Step No. 10:  Respond to Abusers

Although your first concern must be the safety of the IPV victim, who is not safe until the abuse and battering stops, you must also care about your patient’s abuser. Caring about IPV abusers can be a means of ending the abuse and ensuring the victim’s safety. Remember, even when victims leave their abusers and are safe, there is a high probability that their untreated abuser will victimize a new partner.

You can learn more about identifying IPV in your practice and preparing your practice setting for effective intervention in the book, Respond to Intimate Partner Violence—10 Action Steps You Can Take to Help Your Patients and Your Practice. The accompanying CD-ROM in the book contains resources such as medical record forms, patient handouts, and even a staff-training guide. The book can be ordered from the Virtual Lecture Hall of Medical Directions, Inc. by visiting their website or through Amazon.com. Online training with CME credits featuring the information in the book can also be found at http://www.vlh.com/.

Physicians and healthcare providers have a unique opportunity to identify and intervene with IPV in their practice settings. Doing so can save lives, promote their patients’ health, and enhance their patients’ well being. Los Angeles physician Bruce B. Ettinger sums this up quite well, “Set up a response system if one does not already exist, and take the risk and ask questions. The reward will equal anything you have ever done in medicine. You will save a life.”

Author’s note: You have permission to copy this article for distribution for web and print publications as long as you do not change content or remove hyperlinks in your online distribution. Notification of your use of the article is appreciated. For questions or to arrange for one of the  authors to speak at your event, please contact DrT at: DrTspeaks@gmail.com.