liveSAFE Resources
Christine Foote-Lucero, MSN, RN, CEN, SANE-A, SANE-P
Forensic Program Manager
University of Colorado Hospital
Karen Marcus, RN, BS, SANE-A
Forensic Nurse
Forensic Health Services
Palomar Health
Sarah Marin, FNP-C, MSN, SANE-A, SANE-P
Forensic Nurse Practitioner
SART/Child Abuse
Forensic Nurses of SoCal, Inc.
Keri Sandy, RN, SANE-A
Forensic RN
Palomar Health Forensic Services
Angelia Trujillo, DNP, MS, RN, WHNP-BC, DF-AFN
Associate Professor of Nursing
University of Alaska Anchorage
FOREWORD
As a forensic nurse with more than 17 years of experience working with victims of violence across the lifespan, I am pleased to have been given the opportunity to write the foreword to Domestic Violence and Nonfatal Strangulation Assessment for Health Care Providers and First Responders, part of the Forensic Learning Series. I have had the opportunity to work with the editors and many of the contributors to this text over the years, and I consider them colleagues and mentors working to improve the response to victims of violence.
The Manual Nonfatal Strangulation Assessment was published January 2017 as a part of STM Learning’s Forensic Learning Series because the editors realized the need for training related to nonfatal strangulation assessment and care. Now, 3 years later, the editors and contributors to this text have updated the training manual for nonfatal strangulation to encompass domestic violence, male victim strangulation, and cases among the young and the old. There are a wide range of specialties that need a working knowledge of domestic violence and strangulation, including, but not limited to, nursing, medicine, emergency medical services, law enforcement, and legal system agencies. This text is designed to serve as:
—A companion resource to the other titles in the Forensic Learning Series
—An educational resource for forensic nurses seeking to prepare for specialty certification
—A valuable resource for the generalist
—An adjunct resource for nonmedical team disciplines
—An interdisciplinary text recognizing the common knowledge and unique skills of the multidisciplinary team
The editors and contributors bring decades of combined experience to the issue of strangulation assault, its impact on the human body, and the emotional impact to the victim whether they are male or female, young or old. The text relies on the use of standardized language, case studies, and case photographs to support the learning needs of health care providers responding to victims of domestic violence and strangulation. Unique case histories represent the myriad types of violence that impact men and women across the lifespan and the role that strangulation plays in the power and control sought by perpetrators of interpersonal violence. Chapters provide anatomic resources and activities for learning, and they demonstrate best practices for evidence collection, injury care, treatment, and follow-up examination options to serve victims of violence from the initial first responder to physicians/providers, hospitalists, and forensic examiners.
Recognition of strangulation injury and its sequelae has come a long way from a few short years ago when strangulation was considered “just choking,” to today, when nonfatal manual strangulation is now recognized as a felony and life-threatening crime. These changes were due much in part to the work of the editors and contributors herein. It is my expectation that this book will provide an effective educational and reference tool for health professionals caring for victims of strangulation.
Angelia Trujillo, DNP, MS, RN, WHNP-BC, DF-AFN
Associate Professor of Nursing
University of Alaska Anchorage
FOREWORD
“Tell me and I forget, teach me and I may remember, involve me and I learn.”
— Benjamin Franklin
It took the murders of 2 San Diego teenagers in 1995 to understand the seriousness and lethality of nonfatal strangulation. Before Casondra Steward and Tamara Smith were killed by their ex-partners, they were “choked.” Both of them called the police for help, but neither case was prosecuted because of a lack of sufficient evidence to prove an assault had occurred. As former prosecutors, we should have known more and done more. Back then, we called them “choking” cases, and most choking cases were handled as misdemeanors or simply not prosecuted at all. It was the rare case where strangulation was charged and prosecuted as a felony. We were trained to look for external signs of injury, and many prosecutors believed you needed a cooperative victim to prove a choking case, including testifying about her injuries. But choking victims often said they were fine and rarely requested paramedics or sought medical attention. They often would not remember the details of the assault. This seemed like it made the case even weaker. The usually said they were “fine” or “okay,” and it caused us to think they were fine too. But we were wrong.
The deaths of Casondra and Tamara triggered profound changes in San Diego. After their deaths, we needed answers. The San Diego City Attorney’s Office immediately launched one of the first and largest studies of nonfatal strangulation cases by conducting a careful analysis of 300 cases submitted for prosecution by the San Diego Police Department. The results of that study proved that most victims of strangulation did not present with visible injuries; however, there were subtle, identifiable signs and symptoms that could be documented by well-trained professionals. With the support of adequate laws, protocols, and leadership, the cases could be handled much more effectively.
Today, it is understood unequivocally that strangulation is one of the most lethal forms of domestic violence. Victims may have no visible injuries, but because of underlying brain damage or other internal injuries caused by the lack of oxygen during the strangulation assault, they may sustain serious internal injuries. They may die days or weeks after the attack because of a stroke, suffer a traumatic brain injury, or experience other long-term physical and mental health consequences. Nonfatal strangulation and suffocation assaults are also more prevalent than we realized years ago, with prevalence rates between 68% to 80% for high-risk domestic violence victims.
When a victim is strangled, she is at the edge of a homicide. Strangulation is one of the most accurate predictors for the subsequent homicide of victims of domestic violence. One study showed that the odds of becoming an attempted homicide victim increased by about seven fold for women who had been strangled by their partner. Women who are strangled multiple times are at even higher risk.
Strangulation has also been linked to officer-involved critical incidents, officers killed in the line of duty in intentional homicides, and mass murders. The research clearly shows the need for all professionals to improve their screening and documentation of strangulation cases. When working with a strangled victim, advocates, detectives, nurses, and prosecutors must all make good use of risk assessment tools, encourage medical treatment, create personalized safety plans, and offer long-term follow-up. Today, we know far more about strangulation than we knew in 1995.
It is now our responsibility to do something about it. We cannot continue to hear the words “He choked me,” and treat this assault like we would a slap or a punch. The difference