Strangulation: What We have Learned: Part 1 Part 1

Strangulation: What
We have Learned:
Part 1
Jacquelyn Campbell, RN, PhD, FAAN,
Ruth Downing, MSN, RN, CNP, SANESANE-A,
Gael B. Strack, JD
October 2009
1
Overview
Part 1 – Oct 9, 2009, 10:40 to 12:00
Assessing Risk – Jacquelyn Campbell
Anatomy, Signs & Symptoms – Ruth Downing
Laws, Defenses and Protocols – Gael Strack
Q & A - All
Part 2 – Oct 10, 2009, 9:50 to 11:10
Forensic Documentation – Ruth Downing
Prosecution & Resources – Gael Strack
Next Steps – Jacquelyn Campbell
Q & A - All
Feb 2009
2
“Choking” – An
Important Risk Factor for
Intimate Partner
Femicide
Jacquelyn C. Campbell, PhD, RN, FAAN
Anna D. Wolf Chair & Professor
Johns Hopkins University School of Nursing
3
Development of the Danger
Assessment
1982-85 first versions – based on first
1982homicide study (Campbell ’81) –
developed with women in support group
in shelter in Detroit, MI
Beginning research in shelter samples –
validating items & wording – also talking
with women
Elizabeth Stuart – MSN student – thesis –
added “choking” item
4
Danger Assessment Tool
www.dangerassessment.org
Strangulation is a red flag…
When battered women were asked what
made them believe they were in danger or
not -- the majority of women perceiving a
great amount of danger in both a shelter
& a hospital study mentioned “choking”
as a tactic used against them that made
them believe their partner might kill them.
Powerful stories of the fear – often panic,
of these episodes
Stuart & Campbell, 1989
6
Devastating to a victim
Overwhelming feeling of helpless and
vulnerability
Haunting experience
Realize you barely survived
But evil everever-threatening and ever present
Frightening to know that someone who
loves you is willing to kill you
Constant feeling of terror, danger and
doom
7
Chicago Women’s Health Study
Carolyn Rebecca Block
Past Violence 85%
Use of Weapon or Attempted strangulation
Leaving 45%
Associated with increase in frequency over
the prior 12 months
24.6% of 57 adult women killed by male IP
’95
’95--96 killed by strangulation
Of 494 women from Chicago hospitals and
clinics for any reason - IPV in past year,
47.3% at least one choking 57.6% “ever”
8
Intimate Partner Femicide Study
(Campbell et al AJPH ’03)
Attempted (43% of ) or actual femicide – 45%
of victims (or proxy) reported “choking” –
attempted strangulation (vs. 10% of other
abused women N= 427)
Strangulation analysis
6.70 AOR (95% confidence interval [CI] 3.91–
3.91–11.49)
of becoming an attempted homicide
7.48 AOR (95% [CI] 4.53–
4.53–12.35) of becoming an
actual homicide
•Glass, N., Laughon, K., Campbell, JC, Block, C. R., Hanson, G., Sharps, P. W.,
Taliaferro, E. (2008). Non-fatal strangulation is an important risk factor for
homicide of women. J of Emer Med 35, 329-335.
9
Intimate Partner Femicide Study
(Glass, Laughon, Campbell et al ‘08)
Attempted strangulation experience –
significantly more common for AfricanAfricanAmerican (40% vs. 17% for white & 22%
for Latina women) – abused, killed & not
But prior “choking” less a risk factor for
homicide & attempted for African
American women (AOR = 4.65; 3.72) than
white (AOR = 13.72; 14.22) & especially
Latina women (AOR = 21.16; 16.30)
10
Choking as a Risk Factor for
Femicide
Have to ask in language she can respond
to
Part of LAP – www.mnadv.org
11
Any Symptoms of PTSD?
Smith, Mills, & Talliaferro
Stress related disorders?
Psychological disorders?
Anxiety? Depression?
Substance abuse?
Suicidal ideation?
Sleeping disorders? Nightmares?
PTSD Alliance
www.PTSDAlliance.org
1-877
877--507
507--PTSD
12
Ask Victim To Log Symptoms
13
Strangulation & Sexual Assault
At least 50% of all DV cases include
sexual assault.
At least 25% of all DV cases include
strangulation.
At least 25% of all sexual assault cases
include strangulation.
It’s difficult for victims to talk about sexual
assault and it’s difficult for professionals to
ask.
Feb 2009
14
Strangulation:
Medical Perspectives
and Documentation
Ruth Downing MSN RN CNP
SANE--A
SANE
Forensic Healthcare
Consulting
Some material in this presentation used
with permission from Gael Strack JD, San
Diego City Attorney’s Office and Dr. George
McClane
Strangulation vs. Choking
Choking
Obstruction of the air passages due to a
foreign body such as a piece of food
Strangulation
A form of asphyxia characterized by closure of
the blood vessels and air passages of the
neck as a result of external pressure on the
neck
Although the victim reports “choking”, and
we use these words in their history, we use
“strangulation” in our documentation
Seconds to Unconsciousness,
Minutes to Death
“Choking,” more accurately defined as
strangulation, is a common mechanism of
injury in victims of IPV and is often under
assessed and underappreciated by health
care professionals.
Sheridan and Nash, 2007
3 Forms of Strangulation
Hanging
Suicide
Autoerotic--asphyxia
Autoerotic
Ligature
Manual
4 Important Structures
Vessels
Muscles
Bones
Cartilage
Vessels: arteries & veins
Gray, Henry. Anatomy of the Human Body. Philadelphia:
Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/. [September 26, 2009].
Gray, Henry. Anatomy of the Human Body. Philadelphia:
Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/. [September 26, 2009].
Gray, Henry. Anatomy of the Human Body. Philadelphia:
Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/. [September 26, 2009].
Gray, Henry. Anatomy of the Human Body. Philadelphia:
Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/. [September 26, 2009].
Hyoid bone fracture
Supports the tongue and floor of mouth
May close off airway in a matter of hours
If isolated fracture, as a rule, only in
strangulation
Gray, Henry. Anatomy of the Human Body. Philadelphia:
Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/. [September 26, 2009].
Vessel Occlusion
Carotid artery
occlusion
Anterior neck
11 pounds of
pressure for 10
seconds
Jugular vein
occlusion
Lateral neck
4.4 pounds of
pressure for 10
seconds
UNCONSCIOUSNESS
Evidence of unconsciousness
Loss of memory
Standing up one minute then waking up
on the floor
Bowel or bladder incontinence
Unexplained bump on head
Signs and Symptoms
Voice changes
50% of victims
Laryngeal nerve and/or larynx injury
Hoarseness (dysphonia)
Loss of voice (aphonia)
Signs and Symptoms
Swallowing changes
Due to larynx injury
Difficulty swallowing (dysphagia)
Painful swallowing (odynophagia)
Signs and Symptoms
Neck swelling
Venous engorgement
Soft tissue injury
Internal hemorrhage
Laryngeal fracture
subcutaneous emphysema
hemoptysis
Signs and Symptoms
Tongue swelling due to venous
engorgement
Petechiae – due to venous congestion
Subconjunctival hemorrhage
Signs and Symptoms
Breathing changes
Difficulty breathing (dyspnea) ?asthma
Inability to breathe (apnea)
Hyperventilation
Due to laryngeal microfractures or swelling
May appear mild; HOWEVER, soft tissue
swelling can cause airway obstruction and
death within 36 hours
Raspy breathing (stridor) may be prepre-mortal
Signs and Symptoms
Negative pleuritic pressures
Pulmonary edema
Aspiration pneumonitis
Pneumonia
Signs and Symptoms
Vomiting
When struggling to breathe, air is swallowed
and distends the stomach
Signs and Symptoms
Neuropsychiatric effects
Early: Restlessness, combativeness, panic
attack, flat affect, dizziness, headaches,
paralysis, tinnitus, sensory defects, loss of
consciousness,, INCONTINENCE
consciousness
Long term: psychosis, amnesia and
progressive dementia
Anoxic encephalopathy may lead to brain
death
Signs and Symptoms
Carotid dissections and occlusions may
occur later (TIAs and stroke)
Miscarriage – may occur later
Hyoid bone fracture
Supports the tongue and floor of mouth
May close off airway in a matter of hours
If isolated fracture, as a rule, only in
strangulation
Neck Injuries
Erythema
Bruises
Abrasions
Rope burns
Pressure erythema
Bruises Behind the Ear
Thumb--print bruise
Thumb
Red marks (erythema) - often 3.
This victim was strangled repeatedly with two hands.
Can you see the finger marks & bruising?
Impression
marks
Courtesy of San Diego District Attorney’s Office, DDA Dan Goldstein
Scratches
Scratches
Claw marks
Claw marks may be on suspect
May be difficult to identify primary
aggressor
Primal instinct is to defend oneself
From Polsky & Markowitz (2003)
The Color Atlas of Domestic Violence
Petechiae
Petechiae eyelid/inside the eye
If there is petechiae on the skin
surface, there is petechiae in
the brain
Dean Hawley MD
Forensic Pathologist
Indiana University
Subconjunctival Hemorrhage
Confluent capillary rupture in white
portion (sclera) of the eyes
Intermittent compression, release of
victim’s neck by assailant (peaks &
valleys)
Subconjunctival Hemorrhage
Massive tongue swelling
(edema)
ROPE BURNS
Hanging vs. Ligature
The Law, Defenses and
Protocols
Gael Strack
Feb 2009
65
Thank You
In memory of Casondra Stewart & Tamara
Smith
Feb 2009
66
What do you charge?
Misdemenor?
Misdemenor?
Felony Assault?
Attempted Homicide?
Feb 2009
67
What is a Severe, LifeLife-Threatening
Strangulation Case? (Plattner,
Plattner, 2005)
Class 1: Superficial skin lesions
Class 2: Signs of soft tissue injury or injury
to pharynx and larynx (bruising, swelling,
pain, hoarseness, sore throat, etc)
Class 3: Petechaie
Class 4: Signs of unconsciousness (anoxic
or hypoxic brain insult), urination and/or
defecation, headaches, sleeplessness, etc.
*Caution: lack of findings can be tricky;
could mean occulsion of arteries & veins
Feb 2009
68
Strangulation Demands a Felony
Arrest & Law Supports It.
Assault with force likely to produce
great bodily injury. (PC245)
People v. Covino (1980) 100 Cal.App.3d 600
(force of defendant’s assault by choking was
likely to produce a serious injury although victim
only had redness to neck and pain to throat).
Attempted spousal abuse (PC273.5)
does not require injury.
People v. Kinsey (1995) 40 Cal.App.4th 1621
Feb 2009
69
Missouri, Chapter 565, Offenses
Against the Person, Section 565.073
August 28, 2003
Domestic Assault, second degree
(1) Attempts to cause or knowingly causes
physical injury to such family or household
member by any means, including but not
limited to, by use of a deadly weapon or
dangerous instrument or by choking or
strangulation; or
Domestic Assault in the second degree is a
class C felony.
Feb 2009
70
The Impact of Minnesota’s Felony
Strangulation Law
By Heather Wolfgram, MSW, LGSW, Court
Monitoring Coordinator. Interviewees
believed the law:
Increased awareness of the potential
lethality of strangulation
Increased victim safety
Increased offender accountability
Should prevent homicides
Feb 2009
71
The Impact of Minnesota’s Felony
Strangulation Law
One judge said: “This law is doing what
we hoped it would do: it is drawing
attention to the potential lethality of this
crime. More resources are being devoted
to this type of case. We have also
increased the consequences and in some
ways educated the public on domestic
violence.” Hennipen Judge
Feb 2009
72
The Impact of Minnesota’s Felony
Strangulation Law
Shortcomings:
Inconsistencies in charging patterns
Lenient sentences
Failure to adequately address probation
violations
Need to increase probation supervision
Need for more training
Feb 2009
73
Identifying the Primary Aggressor
Identifying the Primary Aggressor
Feb 2009
74
Potential Defenses
Self--inflicted injuries
Self
Autoerotica
she is trying to set me up. Ask why?
Evidence of a ligature mark or a hanging
Look for evidence at the scene
Consent – Applied or monitored by sexual
partner
she likes sex that way
Bondage
“choke holding” during anal intercourse
Feb 2009
75
AutoeroticAutoeroticAsphyxia
Kotzwarraism
Hypoxyphilia
Asphyxophilia
Sexual asphyxia
Sexual hanging
Eroticized sexual
hanging
Sexual bondage
suicide (L.A.)
Feb 2009
Courtesy of Dr.76Dean
Hawley
How do you know? Evidence
Brent Turvey says look:
The location -- ample privacy to live out his fantasy
The presence of sexually stimulating paraphernalia:
vibrators, dildos, and pornographic magazines;
The presence of bondage or complex ligature
arrangements: ropes, chains, blindfolds, and gags;
The use of mirrors or other reflective devices;
History. Repeated use of special fantasy items and
objects;
The use of feminine attire or crosscross-dressing.
Feb 2009
77
The Results After
Training
The beginning of a new era
Feb 2009
78
The Results from Detective
“She had small red spots on her forehead
and around her eyes that appeared to be
small broken capillaries. This has been
described to me in the past by Dr. George
McClane during training. The condition has
been described as petechiae spots and are
caused by tiny capillaries bursting from
pressure of a chokehold. She also
complained of a sore throat and a hoarse
voice. I encouraged her to seek medical
attention. This was the first time he
choked her”.
Feb 2009
79
Include Your Expertise in your
Reports - Tip from Ofc. Rivera
Based on my training and experience, I
know strangulation is serious and can
cause internal injuries.
I have received training in strangulation
I have responded to *** domestic
violence cases
Victim’s injuries and symptoms were
consistent with strangulation
Feb 2009
80
After two years….
Feb 2009
81
Tip from Detective Simon Ty
Feb 2009
Attach a copy of the
articles from the
Journal of Emergency
Medicine to your
report.
Routinely gets felony
prosecutions on his
strangulation cases.
Go TY!!
82
Good Things Have
Happened
Feb 2009
83
New Protocol
Feb 2009
84
POST - Incorporated strangulation
into all training programs
Feb 2009
Dispatcher’s training
First Responders
40
40--Hour Course
Telecourse Interviewing
witnesses
Interactive CD
Cal--Mosaic
Cal
85
San Diego Regional Academy
Added Two Hours of Strangulation
Training
Feb 2009
86
Det. Mike Agnew – Fresno PD
developed a brochure
Feb 2009
87
Kevin Dunn & Ken Edwards –
CT State’s Attorney Office
Feb 2009
Regional/Statewide
training
Officer’s card
New state form
New Law
88
Advocacy Protocol
Aftercare
Instructions
Educate victims
Encourage them to
log their symptoms
and seek medical
attention
Encourage
counseling
Feb 2009
Conduct Safety
Planning
Educate all the
players in civil,
criminal and
juvenile court
Long term
disability
89
Forensic Nurses
Feb 2009
90
Questions
Feb 2009
91
How to Reach us:
Jacquelyn C. Campbell, PhD, RN, FAAN
Ruth Downing,
www.rwjfnursefacultyscholars.org
410 955955-2778; jcampbel@son.jhmi.edu
Forensic Healthcare Consulting
www.ForensicHealthcare.com
ruth@ForensicHealthcare.com,, 740.815.8167
ruth@ForensicHealthcare.com
Gael Strack, JD, CEO & CoCo-Founder
www.familyjusticecenter.org
gael@nfjca.org or 760.445.3559
Feb 2009
92