Thank you, Shannon. So good to have you here and appreciate your services. So welcome, everybody. I want to just say thank you for attending today's webinar, Quiet Suffering, Recognizing the Impact of Strangulation Across the Lifespan in Tribal and Native Communities. This webinar is being brought to you by the International Association of Forensic Nurses through the National Tribal Clearinghouse on Sexual Assault, and we're so grateful to have you all here today. I think my remote is moving a little slow, so I apologize. I just want to start out by letting you all know that this webinar is possible due to funding through the Office on Violence Against Women, and that the opinions, findings, conclusions, and recommendations expressed in today's webinar do not necessarily reflect the views of the U.S. Department of Justice. Today's presenters have no relevant financial relationships with ineligible companies to disclose. If you all have any multiple people watching the webinar with you, please send a list of attendees that have not formally registered to the webinar to Kari Knadel. I will drop the email for Kari in the chat. The email is Kari, K-E-R-I, Knadel, K-N-A-D-L-E, at ForensicNurses.org. The reason that we're asking you to do this is because in order for everyone to be able to actually get your CE, your Certificate of Completion, we need to have everyone's email that is actually viewing the webinar. If that is your situation, you have multiple people, please send an email to Kari Knadel with the name and email address of the individual that's watching with you. Please note that today's webinar does provide nursing CEs. After this webinar is ended, within a couple of days, probably sometime next week, you will get a webinar, sorry, you will get an email that will come from the National Tribal Clearinghouse for Sexual Assault Learning Center, and it's going to let you know that if you have an existing account already within the Learning Center that you need to log in, and there's going to be an evaluation assigned to you that you will be able to complete. If you don't currently have an actual account, you're going to have one created for you. So your email will actually say that you had an account created for you, and it's going to request that you log in and that you change your password and complete your profile. Once you do that, you will have assigned to you the actual evaluation for today's webinar. So as long as you're here, as long as you are here the entire time and we have the information for your actual email to send through your account, you will be able to access the evaluation to complete, and then once you complete it, you will get your certificate through the Learning Center. If you have any questions or you have any issues about that, you can also reach out to Kari Knadel at the email that I dropped into the chat. For those of you that have previously attended an IAFN webinar, you do understand that this particular process is different than what we have done in the past. So again, don't hesitate to reach out if you have any questions. The last thing I'm going to say for this slide is just what we have to say because of AMCC that the International Association of Forensic Nurses is the accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center Center's Commission on Accreditation. This webinar is being recorded and it will be archived in the Learning Center. Once the webinar is actually recorded and archived, an email will go out to all that have been registered to let you know that it's available to you in the Learning Center to access. With that, I will turn it over to Chenille so that she can introduce herself as one of our presenters today. Thank you, Angelita. My name is Chenille Vandenberg and I'm a forensic nursing specialist here at the International Association of Forensic Nurses. Sorry, I was just making sure I didn't miss any other questions in the chat about registration and evaluation. My name is Angelita Oluwu. I am one of the forensic nursing directors with the International Association of Forensic Nurses, and I'm going to be your second presenter today. We'll start out by acknowledging the people on who's and said, and I was just telling Chenille before we started that my mouth is completely not working. So I'm not sure how this webinar is going to go, but hopefully it'll go smooth for you. But it's a little bit of a struggle for some reason. I'll start this all over again. We want to gratefully acknowledge the people on whose ancestral homelands we gather, as well as the diverse and vibrant Native communities and people who make their homes here today. Thank you. I wanted to just take a few minutes to just talk about the National Tribal Clearinghouse Sexual Assault Project. I'm sure that many of you have been here before with us through our Indigenous Sexual Assault and Abuse Clearinghouse, or ISAC, project. If you have been to our website lately, you will notice that we put on a notice that we're in the process of transitioning to the National Tribal Clearinghouse on Sexual Assault. This is an exciting time for us. These changes are occurring as we grow our partnership with the Minnesota Indian Women's Sexual Assault Coalition, or MUSAC. Both organizations are really excited and proud to be able to deliver the new clearinghouse to you all. This clearinghouse will provide access to culturally relevant training, technical assistance, educational resources, and is designed specifically for those that are addressing sexual assault in tribal communities. Again, this is a super exciting time for all of us at both organizations. We really do hope that you guys find the same excitement that we do as we move forward in this transition. Here are today's learning outcomes. At the conclusion of this webinar, we hope that you all walk away with an increased knowledge of measures for screening, assessment, and responding to individuals across the lifespan that present to medical facilities. We want to make sure that you all have a better understanding of a new resource that has been updated and we released the strangulation toolkit as a resource for providing care to this patient population. I do want to throw a trigger warning out there. There are some actual photos of injuries that have been identified during a medical forensic exam of real patients that have actually experienced traumatic events. We just want everyone to be aware of them so that as we go through this, if you feel like you do not want to see those images, we will put another trigger warning up ahead before we actually go into those images. The goal is for everyone to take care of themselves. If at that time you need to walk away, feel free, but we just want to make sure that everyone understands that they're there. With that, we'll get started. Thank you. We're here today to talk about the impact of strangulation and why it's particularly important to discuss. It's not just about knowing what has happened to the patient or the survivor, but what does happen or can happen during strangulation. Health practitioners are optimally positioned to identify those subtle signs and symptoms of strangulation, as well as help individuals understand some of the delayed health consequences and potential future fatality that's associated with strangulation. We also are uniquely situated to help as well connect them with the appropriate resources that they might not otherwise seek out or be aware of. And in doing so, we want to reduce the risk of morbidity and mortality. In other words, healthcare providers can give voice to victims when they may not be able to speak about the occurrence literally and figuratively. Sorry. It's okay. I think it's important to at least start out with the definition. And although it seems pretty simple, strangulation is known as strangulation, especially if you are from the healthcare field, but it isn't necessarily always that simple for the lay person or even for patients themselves or survivors of strangulation themselves. Oftentimes, when individuals are explaining to us what happened to them, they use the term choking, that they were choked or they're choking, which actually is not the same thing as strangulation. So we thought we should at least start out with making sure that we all walk away on the same page of what exactly strangulation means. Strangulation is the obstruction of blood vessels and or airflow in the neck by external pressure, resulting in an inadequate amount of oxygen throughout the body, while choking is actually the obstruction of the airway due to a foreign object, and they're not the same thing. There are three types of strangulation. Hanging strangulation specifically is when something is around the neck and it's tightened and there's the gravitational pull of the body. So oftentimes we'll see where there's like a noose tied and someone knocks the chair or knocks the table from beneath them, and then their body pressure pulls them down. That would be considered a hanging. Ligature is when there is actual material that's been around the neck that is somehow tightened. So whether it is that there is a piece of jewelry there, or a lot of times we'll see a shirt or a jacket where it's twisted and the person may be picked up or something like that, that would, the tightening of the actual material around the neck would be considered the ligature, which would be causing that type of strangulation. And then the third is the manual. When body parts are used, most often people think about the hands, but it could also be the arm. It could be something being pressed against the neck to have that external pressure pulled or external pressure placed on the neck. So we do have multiple poll questions in this webinar today. So here's going to be the first one. Shannon, if you don't mind launching the poll for us. Do you currently have a coordinated community response in place for reported or suspected strangulation within your community? We'll give a few seconds for everyone to chime in. So, for the most part, it looks like the answer is yes, there's some people that saying no about 38% of people say no and then there's a handful of you that are not completely sure, which is totally fine. Okay, and so we're going to launch the next poll question. For those of you that answer yes, is the medical examination a part of the coordinated response that is currently available in your community? I'm sorry, I'm not saying it if you can you launch the next poll question. We are launched with some responses. Oh, I don't see it on my side. So now if you see it, do you want to report out? Yeah, absolutely. It looks like we have the majority are saying yes, that there is a medical examination that's part of it with a 4% that's unsure. I'm sorry, 4% that's a no. And then 15% that's unsure, which is actually really encouraging. That is I agree. I see it now. Perfect. That is helpful to know. That's good. And so it's important to be aware that strangulation can be present in a variety of situations, whether it's intimate partner violence, but also child abuse and sexual assault as well. And one of the reasons that strangulation can be found in a variety of situations where interpersonal violence is present is because strangulation during an act of violence actually sends a message that the abuser literally holds the power of the abuser in their hands. And one of the reasons that strangulation can be found in a variety of situations where interpersonal violence is present is because strangulation during an act of violence actually sends a message that the abuser literally holds the power to take life at any moment with little effort in a short period of time. It impacts a wide range of age group, genders, identities, impacting children, adolescents, adults, and elders as well. So it's important to understand how it impacts and affects survivors of strangulation across the lifespan. That's what we're going to talk about today as well. We'll talk a little bit about some of the statistics, which are very eye-opening, in my opinion. I apologize, a little bit of technical difficulties. But statistics show that about one in five women have reported experiencing severe physical violence in general from an intimate partner in their life. Statistics show that about one in five women have reported experiencing severe physical violence in general from an intimate partner in their lifetime, and one in seven men. About one in five women and one in 12 men have experienced contact, have experienced sexual violence by an intimate partner. And then 10% of women and 2% of men report having been stalked by an intimate partner. Additionally, intimate partner violence in the elderly is also very significant, and studies have shown that victims age 61 and older are much more likely to experience abuse from an adult family member or current intimate partner. This impacts a person who's experiencing strangulation and intimate partner violence, the ability to leave to seek help. And of that statistic, many of these people in the elderly population are also more likely to have a disability, which also creates extra barriers and impacts their ability to receive help and assistance in this situation. Of that number, it's important to consider the impact of strangulation as well on different communities. And the Center for Disease Control and Prevention, the CDC study has shown that almost 10% of homicides that are related to IPV or intimate partner violence in American Indian and Alaska Native females has occurred as a result of strangulation or suffocation, specifically. Before we launch the next poll, I just want to add a comment about the strangulation and IPV within the elderly population. We're going to talk about screening a little bit more later, but I just think it's really important for us to keep in mind that there is a generational difference and the level of comfort of actually sharing things that are happening. And I think especially in the elderly population, we have to ask the question because sometimes they actually do want to talk about what they have experienced, but they're waiting for someone to actually ask them. I think it's really important for us to acknowledge the fact that is a population that often is not even asked. We usually just go about the care and focus on so many other things that we don't take the time to ask them what they're experiencing at home, what their relationships are like. I think that's important to keep in mind. So if we can launch the next poll question. This question is asking you how often are you receiving reports of strangulation within your community? The options that we have here are daily, weekly, monthly, occasionally, or you're unsure. And again, unsure is totally fair and appropriate answer. Great. So we will wrap it up here. So it looks like there are about 5% that are getting reports in daily, about 27% that are getting them weekly and monthly, 19% that's an occasional or infrequent response, and then there's about 22% of you that are unsure of what it looks like in your community. And what percentage of the reports that you are receiving are receiving medical forensic exams as a result of the disclosure? I do appreciate that we are not seeing anyone answer no. So that's good. We have a very small amount of folks that are saying 1-25%. Even smaller amounts are just saying 25-50%. 50-75% is where we have a lot of 11%, so not a whole bunch. But the bulk of you all are saying 75% to 100%, which is good. And then we have a lot of people that are still unsure, which is still, again, fair. Thank you for sharing that information. And so when we're looking at the response and how to understand some of the barriers that occur or why we may not be seeing disclosure or why people might not come forward and discuss readily what's happening, we have to understand the silence that surrounds that. Silence is a trauma response that must be recognized and understood by providers. This is because American Indian women, as well as others, voices have been silenced over hundreds of years through colonial power imbalances, and that through the generational trauma, they might feel that it's not safe to speak out about the violence that they experience. And that's really where we as providers can come in to provide that safety. And we'll talk a little bit more about that. So understanding some of the barriers are important when we provide care. So we're not just responding, but we're being proactive. So some of the barriers that may occur could be mistrust in the systems in general. Stigma. There's often a stigma that surrounds intimate partner violence, interpersonal violence, which may make a person not likely to disclose, but also they might feel their own sense of shame. And individual readiness. Only that particular person who's experienced the violence is aware of if it's a safe time to disclose, if they are in a situation where they're prepared to address what has happened, but also access to care. We can't just take for granted that everyone has the same ability to access care as others, especially when we're talking across the lifespan. Children might not be able to have access if they don't have a caregiver that's able to or willing or ready to get that help. And we talked about elderly individuals as well who might still be dependent on either the perpetrator or their own limitations as far as transportation and resources. And then lastly, the knowledge of the severity of strangulation. Not always is it readily available. The education might not be there for a person to understand the potential impact, the physical, emotional effects that strangulation can have on a person. And that impacts their ability to know whether or not this is actually serious enough to seek care. There's also, we talked about as a barrier, there's an issue with historical mistrust, and that could be something that's immediate or longer term. There might be someone that's had an experience shortly prior to the incident that made them distrustful of seeking care. They might have experienced a scenario where there was a lack of culturally informed care that made a person feel less comfortable in a scenario, and they will take that experience moving forward. They might be feeling invalidated, whether it's within the healthcare setting or in their community or within their own immediate support system. And they might feel dismissed as well. So whether that's an immediate history or maybe something that was experienced within the generation and it was passed down to them is something to consider and how we approach care. There's also a stigma, we've mentioned that a little bit, which is just in general associated with experiencing interpersonal violence. Many people who've experienced interpersonal violence tend to blame themselves or think about things that they may have done to cause this. And so by admitting that something happened to them, it's admitting as some sort of failure or sense of culpability and there's shame. Sometimes if strangulation occurred during an act of violence where the person who experienced the violence may have been using alcohol or some other substance, again, they might take on blame to themselves as though they were doing something that would cause that violence to happen to them. So again, that overall sense of shame and that shame creates an environment where a person is less likely to discuss what happened to them. There also may be concerns around the lack of privacy. Again, if you have a person who is in a smaller community, especially a close-knit tribal community, they might not want a feeling of everyone being involved in their personal, what they see as a personal scenario. There also may have been previous visits to a medical facility. If your provider is the same person that cared for your children, might be the same person who you have to go to and discuss what happened to you. That might not be something that you're ready to address. And that might be a sense of an invasion of privacy. Also, there might be personal relationships with those who are involved with staffing the medical facility or in the community as well. Maybe it's someone that is a family member or someone that you already know or have close familial ties with. Again, there's a sense of privacy that may be violated if we're not considering how we're approaching this. And there also might be concerns about being seen from others in the community getting help for this. Again, there's a sense of when one has privacy, they have dignity. And so an invasion of privacy or a feeling that your privacy has been exposed also threatens to impact your dignity and your sense of self-worth. And this feeling and barriers that could lead to lack of disclosing or seeking help for strangulation makes strangulation, nonfatal strangulation, especially insidious. It's a type of harm that often goes undetected without appropriate screening measures, without appropriate disclosure. And it's something that can cause serious physical, emotional, and cognitive consequences. However, this may not be a one-time occurrence. Strangulation may be used repeatedly over time as a mechanism of part of that coercive control that is seen so often in interpersonal violence. And so we're going to talk a little bit about the physicality and what occurs- Before we transition into the anatomy of the neck, I'm just going to take a few minutes and answer a question that came up in the Q&A for us. So the question is, for medical forensic exams of strangulation victims, does IFN have any resources on how to pay for the exam costs incurred by the sexual assault nurse examiner agency or program? The reality is, it's just other types of medical forensic exams. How it's paid for looks really different. In the majority of communities, there is no source of payment for IPV exams, for strangulation exam, but there are a few states that are working on it, like on a state level, that actually will cover. And when I say a few, there's literally only two to three states that I know of that are currently doing that. So for the most part, there is no dedicated source of payment for it. So if you have nurses that are responding, or clinicians that are responding specifically only for strangulation, and they're collecting evidence or they're doing the documentation, that may be something that you end up having to work out payment of with the insurance company and how what your particular hospital facility would want to- how they want to go about doing it. Someone put in the chat. The answer to that is there is no specific resource that we have right now, but I would say that if you have a SART, especially a state-level SART team, to continue to have these conversations and work with whoever currently pays for your sexual assault exams, whoever the funding source is for your sexual assault exams, to see if you can move the needle around getting payment for these exams as well. Utah, someone also mentioned, also pays as well. Those are two of the states. I think there's one more state. So we're going to spend a little bit of time talking about the anatomy of the neck. Now my remote is moving slowly now. So we'll start out with the most important structures. We're not going to talk about all the structures of the neck. We're really just going to focus on the ones that are, the majority of the time, most affected during strangulation. So the jugular veins, here the jugular veins are represented with the blue lines on this picture. So it's transporting deoxygen blood away from the head into the body. The carotid arteries are represented with red. Those are supplying blood through the neck to the neck and the brain. And then of course the trachea, which is the 20 rings of cartilage and some connective tissue that allows air to actually pass through the airways into the actual lungs. So one thing that we really need to make sure that we have a good understanding is around level of consciousness. One of the things that we do when we're assessing patients that have experienced strangulation is ask them about their level of consciousness. And that is because it's one of the key things that helps us to know how severe the strangulation actually is, because it doesn't take a lot for a person to actually lose consciousness when they have been strangled. So it's all going to be dependent on the pressure and how the pressure is actually applied, and then how much pressure is actually done. So if the pressure is immediately released, if a person loses consciousness during strangulation, they're going to regain consciousness within 10 seconds. I don't know how many of you have been to presentations where they have talked about strangulation, but it literally happens within seconds and the person will be completely out cold. And as soon as you, as soon as the pressure is released, they will wake right back up and be a little bit dazed, but they just go right back to normal for the most part. But if that pressure is maintained and they continue to be unconscious for an extended period of time, what will happen is that they're not getting any blood or any oxygenation to their brain, and so brain death will occur, and that can happen as quickly as four to five minutes. So I say quickly as four to five minutes, because in the time of the actual event happening, that's actually not a lot of time, that's really fast. But for the actual person that is experiencing strangulation, that feels like a really long time. When you're doing assessments and getting information from the patient, they'll let you know, they won't really remember how long it was, and they'll let you know that it feels like it was forever, which sometimes as the nurse makes it feel like, well, it had to be a long time, but it really doesn't have to be a long time. It just feels that way when you can't breathe, when you feel like death is impeding you. So when we're thinking about the causes of death in terms of strangulation, these are the things that we think about. So we talked about the carotid and we talked about the jugular. So if we have obstruction to the carotids and the jugulars, then that means there is no oxygenated blood going into the brain or coming out of the brain. And if we have obstruction of the trachea, that means no air is being moved into the lungs. This is going to cause a cardiac arrhythmia because the heart isn't going to be getting any new oxygen either, right? So if you add all of these things into one picture, this is going to cause immediate death. And so when strangulation, when there is a death that occurs related to strangulation, it usually is actually happening during the actual event. There are instances where people will die post-strangulation, but it's usually related to something that is a, there's my mouth not working, Chanel, what's the word I'm looking for? It's like a post-consequence of the actual strangulation itself. So just keep that in mind because everything works together, right? So in order for our brain to actually make our heart pump, our brain needs to get oxygen and it needs to have oxygenated blood. If the heart isn't pumping, we're not getting that. In order for the, in order for, to get that, the actual lungs have to be receiving. So if the trachea is actually closed off, that's not happening either. So all of those things work together. Yeah. It looks like there's a bit of a freeze. So again, basically just reiterating that they all affect each other. And I'm not sure if you guys can hear Angelita. OK, so I'm back. Can you guys hear me now? I was totally booted out altogether. Today is not a good technical day for me. I was sharing that with Shannon. She was saying it hasn't been a good technical week for her. So sorry, and we appreciate your patience. But with that being said, I also feel like there is a possibility that my remote that was not moving on my end has switched ahead multiple slides. So I just want to make sure, Chanel, that you haven't covered any content before I go back. No, we're back on the pediatric. We did not discuss the ages, the pediatrics and the elderly. OK, did you cover this one? No. OK, so thank you. So I just covered what happens that can actually cause death. But I also mentioned that it's about where you're applying the pressure as well. And this slide, in particular, kind of gives us a better overview about how we see injury within the actual patients that we see once there's been strangulation. So about 50% of patients will have visible injuries. So that means that there's about 50% of patients that won't have an injury that we can see with our eyes. And it's really important for us to keep that in mind, because many patients that will come to us, if they haven't actually shared their experience, we may not innately actually know that something has happened to them. And if they aren't seeing an injury themselves, even if sometimes they feel a little off, they still may not actually mention it. So again, screening is really important. The severity of injuries and the complications from strangulation are come about by several different variables. The exact anatomic location of the applied force is one thing. So where exactly is that pressure being applied? So in that last slide, we talked a lot about exactly that. So if we have an obstruction to the jugular by itself, that's problematic, right? Vice versa to the carotid. Or if there's actually no air movement, that actually could be a problem too. And then also, sometimes it's about how much pressure is applied and what that patient is feeling at that time, because some of the things that can also occur are like vomiting, that the patient can actually be vomiting at the same time, which could also cause some injuries that they're not going to see with their own eyes, but can potentially cause pneumonia. The quantity of applied pressure, the duration of pressure, and then the surface area of the applied pressure. When we look at the few slides, we're going to talk about pediatric considerations. The size of a child's neck looks really different than the size of an adult neck. And the size of an adult hand against the neck of a smaller person or a child may also affect how much surface area is actually being covered, which in turn may also affect where the location of the pressure is actually occurring. So this is really important to think about, because they all play a part in what we're actually going to see on the patient in terms of injury or not see for face value when we're assessing these patients. So I brought up pediatric considerations, and I talked about the fact that their anatomy is already innately smaller than the anatomy of an adult. So you have to keep that in mind, because they're going to be at greater risk. And I think it's really important to understand that we definitely have to screen pediatric patients, because they are experiencing strangulation, and we don't often take time to actually ask them about it. And if you ask them about it, they have no problem telling you about what happened to them and what it was like for them. And of course, that's going to put them at a greater risk for life-threatening injuries just based on the fact that their anatomy is smaller, is closer together. If the size of the person that is actually provoking the violence on them, most likely, it's going to be larger than theirs. Even if it's an older child, most of the time, they're still larger than the actual child that's being abused. So that's really important. The lack of ossification of the laryngeal cartilage and the hyphoid bone is also important to understand. So that just means that their bones are not completely hardened. They're softer. So it's going to obstruct a little bit faster than it would for an adult. The other population that we have to keep in mind would be the elder adult population. So I already mentioned in the previous slide about ensuring that we're screening them appropriately. But we also have to think about their anatomy structure as well. Their throat structures can have increased complications as well. So they may already have issues with swallowing and swallowing as it is. But when you throw in strangulation to that, it can make it potentially worse for them. It could also potentially cause them to have a higher risk of swelling than another person or a healthier person will have. Their throat may be longer and more dilated than the average younger person. A narrow entrance into the lower throat or the esophagus. Their muscle tissues, their muscles actually shrink. So atrophy actually occurs with their muscle. And then with some patients or a lot of elderly patients, they also have stiffening of the tissues. And so particularly, this could become a problem in the larynx in terms of what their response may be. And then overall, there can also be an increased time for them in their regular swallowing. So we have to keep that in mind when we're thinking about post-strangulation complications. What does this look like for this patient moving forward? Or even if the patient comes to you and that is really their only complaint is that they're having issues swallowing, that would be one that you may want to ask more questions around, especially if you do have a concern or they have previously shared that they have experienced IPV in their relationship. Chanel, is there anything that you wanted to add to any of those? I forgot to ask while I was there. No. OK. Sorry, I was going to say there was a question in the chat about the citation for the 50% of victims that have visible injury. And that's something we can provide at a later time. And the end of the PowerPoint also has references that we used to create this as well. So we can just make sure that we also add as a handout the PDF of slides as well. That's not a problem. Were there any other questions before I moved on? Because I haven't been looking at the chat. No, I think you covered them so far. While we are stopped, there's one question in the Q&A. So I'm just going to go ahead and look at that. Does IFN lobby for this throughout the different states? I don't know who is posting that question. I'm wondering when you say by lobbying, are you referring to we do advocacy days through the IFN? Is this something that we are talking amongst our lobbyists? Is that what you are asking? Or are you asking, are we advocating for states to pay for strangulation exams in general? And if you can either throw it in the chat or throw it in the anonymous, throw it into the Q&A, that would be helpful. In the meantime, I'll go back to the next slide here. So I think we've pretty much established the fact that strangulation is dangerous. And it is potentially a fatal event. I think it's really important for us to understand, as Chanel pointed out earlier, people don't always realize that they are actually in danger. That they are actually being harmed by strangulation to the extent of how much problems not having oxygen within your body can cause. And what can actually happen if it's not restored. So that just brings us to the point of how important it is for a person that experiences strangulation to actually have a medical evaluation. So we do understand that oftentimes the disclosure of strangulation comes up way outside of a medical context. It could be that a person is explaining what happened to them to law enforcement. It could be a person sharing with someone in victim services what has happened to them. Or it could be specifically within interactions with advocacy. We really do hope that everyone comes together at some point and has a good understanding of how dangerous strangulation is and how much healthcare should be a part of that response. Or at least getting the initiation of a medical exam whenever someone has disclosed or there's concern that there is a potential for strangulation across all populations, across the lifespan. Because we know that we can see things acutely. So right then, right when it's happening. But we also just heard that we don't always see it with our own eyes what's happening. And sometimes things don't happen right away. Sometimes it takes a couple of days. So swelling may not innately happen right away or it may not be as bad enough for you to see it externally. The survivor may actually feel it within them. They may feel like something is off or they may feel like their throat feels raspy or something like that. But it may not feel like it's swollen to them. Besides that, we also understand how trauma works, right? So there's a lot of other things happening in our brains that we may not necessarily even feel what's happening in some of the spaces. So it's over time that some of that continues to worsen and that worsening can happen pretty fast. So we just wanna make sure that as soon as possible that they are actually assessed. But on the flip side of it, it can also be the things happen days out or weeks out, right? There are residual signs and symptoms that could potentially happen. And there's also studies that even show that strangulation can also cause an anoxic brain injury. So an anoxic brain injury is when the brain is, it's a traumatic brain injury that is caused when the brain has not received enough blood for extended period of time. And those are the kind of things that we wanna make sure that the patients are aware of, that they're assessed for and that they're following up on appropriately to try and prevent long-term complications associated with the strangulation. Especially if it's a ongoing thing that's happening to them repeatedly. This particular webinar is not about traumatic brain injury but we see a lot of injuries and ongoing long-term issues when people are having repeated traumatic brain injuries. So think about the fact that every single time a person is strangled, they're having all these things happen to them. And strangulation is one of those things that's used for control and it's often used for control often, especially if it works or seems to work for the person who does it right away. So again, advocating for some kind of medical evaluation. So a comprehensive strangulation evaluation should include obtaining a history from the patient. It should include a complete physical head-to-toe exam, a focused strangulation assessment. It should include photo documentation if photography is being offered and the patient agrees to it. It should include a complete documentation of everything that is done within the exam. It should include evidence collection if it's within the timeframe and if the patient is agreed upon it. And of course it should include education of the patient, right? And sometimes of the patient's family or people that they're gonna be going home with. So knowing exactly when and how to implement this type of exam will depend on a variety of topics and circumstances that we discussed, such as how a person discloses and when. The way that a person tells you or talks about what happened and how it happened can really impact their willingness to participate in care and treatment. Did they come on their own? Was it voluntary? Also, who's with them and what are their resources after the fact? Again, Angelita had discussed a variety of ways. Sometimes that a person will talk about what happened and to whom, whether it's law enforcement, whether it's a victim service provider, those all will come into play as far as how the patient discloses. And based on that, we can identify what intervention should be utilized as well as who to involve as part of that response. So sometimes the disclosure may be a direct self-disclosure where the patient comes in and right away says that they have been strangled or they blacked out or something like that. And then that strangulation is the primary complaint. And the patient or the caregiver who brought the patient in will specifically seek treatment for that complaint, strangulation. That isn't necessarily typical or often, but it does happen. Similarly, more often than not, it will be an indirect self-disclosure. Maybe it's something that either they were seeking medical care for a different primary complaint or they were brought in for some other reason. And then during the medical assessment and care or screening, it was revealed that the patient experienced strangulation and that there is concern. Depending on how, well, I would say regardless of how that disclosure happens, providers still must be prepared to provide an adequate screening. And that isn't just a generalized violence screening. It should be specific to the act of strangulation. All patients being seen for interpersonal violence or being even considered or suspected of experiencing interpersonal violence should be screened. And that screening should be done in private. And I know that seems pretty obvious, but you also must consider what you as a provider or what a provider might consider private still may not be private enough for a patient. So questions shouldn't be asked in an open area where they can be overheard by maybe people in the waiting room. Also, it shouldn't occur with a person present that isn't the patient. Because again, we don't know what context that person is bringing them in. They might appear supportive or there might not be an opportunity to fully disclose what happened to that person. And then lastly, we have to be sure that screening is done in a patient-centered trauma-informed manner. The last thing a provider wants to do is further traumatize a patient by asking things in a way that seems judgmental or impersonal or in a way that might prevent or discourage inadvertently a patient from discussing the full information that we as providers will need to provide that care. And then last but not least, the screening should also have built in questions and considerations for individuals who might need extra adaptability, things like that in order to either ask the right questions or provide ways for the patient to answer appropriately and adequately. And considerations should be made for individuals with disabilities. Are there questions that are written in a variety of different languages? Are they, is there an interpreter present who is not only asking the questions in a different language, but in a way that's going to appropriately, in a way that's set up so that a patient could feel comfortable enough and really understand what is being asked. And then also consider the patient comfort level with provider, especially if you're dealing with maybe a pediatrics or elder population, perhaps a child needs to have special adaptations in place to make them comfortable with the person who is asking these screening questions. And then after the screening is done, it is also important to consider a medical forensic history. The history is a bit more comprehensive and it guides the clinical decision-making for the next phases, which are the assessment, treatment and diagnosis of the patient. It should also include a disclosure of other types of violence. The questions will be asked in a way that then will capture other potential acts of violence and also the symptoms that occurred during the strangulation, immediately after the strangulation ended, and also what's happening at the time. It's important to include questions about what happened or what symptoms were experienced prior to coming to seek treatment because certain symptoms may have subsided by the time that the patient gets there. Because we know oftentimes disclosure doesn't happen immediately after the event. And again, as Angelita had mentioned, but it is important to know all the symptoms that have occurred. And also consider children or maybe people with cognitive barriers that they've experienced differences in their ability to describe the events as well. That's a consideration as well. The physical assessment, as I said earlier, it should be a full head to toe assessment and needs to be a thorough assessment. So a cranial nerve assessment should be done on these patients to make sure there's no neurological deficits. The head and scalp should be very much looked at. So if the person has a lot of hair on their head, you actually want to be making sure that you have conversation about where they're feeling things, looking through their actual hair at their scalp to see if you're seeing things such as petechiae, if there's any other types of injuries, such as their head was hit up against something, or their hair was pulled, that there's nothing there injury-wise based on those things. Their face, you want to be looking at all components of their face, even the lower level of their jawline and under their neck. Again, is there petechiae? Is there any bruising that has occurred? You're looking at the mouth, having them open their mouth, looking at their tongue, looking at the roof of their mouth, looking in the back of their mouth. Do we note any petechiae there? Is there any injury of biting their tongue from the event? As I said, part of the assessment should be ensuring if the patient has vomited or not, looking at their eyes, having them look around and how is their, this is part of the cranial nerve assessment, but making sure their eye muscles are working appropriately, looking at the sclera of the white of the eyes to see if you're seeing any petechiae or actual burst vessels within there, looking inside of their ears, on the inside of the ears and the outside of the ears and behind the ears, making sure you, again, aren't seeing petechiae, you aren't seeing any dry blood, you aren't seeing any bruising noted from the event, looking at the actual nose and then within the nostrils for the same thing, and then looking really thoroughly at the neck, all around the neck. Does the neck look swollen? Does the patient feel like the neck looks swollen? Are you seeing any injuries? Are you seeing any patterned injury based on something that they had in the neck or patterns from the hands or the fingers or whatever is actually a part of the strangulation? We talked about those three different types of strangulation. Just getting a good assessment of that and documenting it appropriately. And again, if photography is available and the patient agrees, documenting both written and with images of what you're seeing. Making sure that it was a complete review of all symptoms because there's so many different things that are affected by strangulation. So just making sure that you are, during your neurological assessment, understanding the history that the patient came to you with, their own actual medical history, so you have a better understanding of if any of their medical history that they brought with them prior to the actual strangulation can also affect what you're seeing in front of you. Doing a psychological evaluation as well. Did they have any agitation since then? Do they have any altered mental status? We think a lot about that when it comes to traumatic brain injury, but the reality is when there is a decrease in oxygen to the brain, we can also see some of the same kind of neurological deficits that we see with traumatic brain injury, such as agitation, confusion, and altered mental status. How does the patient feel? Do they have a complaint, a headache? Do they have any changes in their vision? All of that is a part of what you wanna make sure you're thinking about. Looking really thoroughly at their skin and their mucosal surfaces. I know that I talked about looking at the head and the neck, but this goes across everything. When strangulation occurs, a lot of times the patient is being, trying to fight back. So you may see that they actually have pulled at their neck trying to actually pull off the, whatever is actually strangling them. So you may have injury to their neck that is based on that. Sometimes they're trying to fight back on the actual person. So they may actually have what we call defensive wounds on their hands and their arms as well. Vascular assessment is really important. So we're looking at, they're looking to see at their blood vessels. So we talked about petechiae, which rupture vessels. There's a lot of pressure and a lot of our vessels are macular. So there's a lot of things that can actually rupture it in there. We talked about looking in the eyes to see if there's any kind of hemorrhaging in the eyes and the nose, throat, all of those things are something we can see. The other thing we think about with the vascular system is the concern about dissection of the carotid. Again, it's not something that happens, but there can be a concern for that. It's not just about us looking at things. It's actually about getting the information, asking the questions, and really understanding what the patient is experiencing so that you, so that the clinician, whether it's a nurse, whether it's a nurse practitioner, physician assistant, has a better idea of what things they need to do to better assess to get a true diagnosis. The ears, eyes, nose, and throat, again, do we have any changes in their voice? Is the patient saying that they feel like their throat is swollen? Can you look at the patient and note swelling within their throat, whether in their throat themselves or in the neck? For those of you that are medical, do we have any subcutaneous emphysema that we're seeing? Do we have any subcutaneous, I can't even think, my brain is breaking down here. Go ahead, feel free. Thank you, Elizabeth. That's exactly what I was trying to get to. I appreciate that. What are we seeing in this patient? These are really important things to think about. Are we concerned about any kind of fractures? Again, we don't always see cartilage fractures, but there is a potential that it could happen within the airway. We do want to make sure that we are thinking about that. The other thing is when you're looking in the mouth and making sure that you don't see a frenula tear. A frenula is the actual piece of tissue that holds your tongue to the base of your mouth. Listening to lung sounds, it's the patient in respiratory distress. I talked about vomiting. Does the patient remember vomiting? Do they know vomiting on them? Sometimes if they pass out, they may not actually remember vomiting, but you will see that they have vomit on their clothes, or they'll tell you that they woke up with vomit on them. That is a concern for aspiration pneumonia. Do they have a cough? Have they been coughing up any blood? Do they have a complaint of shortness of breath? Making sure that we're thinking about their GI tract. Did they lose their bowels when they were strangled? Did they urinate on themselves? Again, this isn't something that typically people say to you. That is typically a question that you have to ask of them. Then looking at their skeletal system as well, are we concerned about any fractures, any bones being broken? We want to make sure that we have all of those assessed, all those things assessed appropriately so that the appropriate imaging can be done. Let's have a think about considerations with patient skin tones. You need to make sure that you have the appropriate lighting in whatever room you're going to be conducting the assessment in. If photos are being taken, hopefully they're being taken with a camera that works really well in the lighting that you have, and if for some reason you feel like you don't have that, I would just say just make sure that you do really good documentation in your written documentation about what you're seeing. Remember that the photographs are there to validate what you're seeing. If you feel like you can't get a good photograph, then at least make sure that you're describing it really well in your written documentation. Be mindful that injuries such as bruises may not necessarily be as easy to see based on the amount of pigmentation that a person has within their skin. One of the things that I always recommend is we have their measuring cards that we use to measure injuries, but there are some that have actually a color scale on there. If you could get one of those, if you have people in your community that have darker pigmentation, sometimes that's helpful to place up against where you're thinking you may see a bruise so that you can contrast the color and see if it looks different. Make sure that you are actually assessing techniques with all of your nursing skills when you're doing that, so it's not just about, do I see an injury? Just like we would assess injury anywhere else, is the patient feeling pain there? Is there swelling being noted? Is there tenderness to palpation? All of the things that you usually would do for injury assessment needs to be done and paid attention to when we're assessing patients with darker skin tone. Anything you want to add there? The next two slides will be slides where we actually cover injury that we identify on actual patients, so just as our little trigger warning. On the first slide here, we see that there is an image of an eye, and if you look down at the bottom of the eye, you'll see that is subconjunctival hemorrhage. The second image is of the cheek, and you will see these little red dots. That is what we call petechiae, so this image is the petechiae of the cheek. On the image to my left, I am seeing a ligature mark with petechiae above it, so that is the image that looks like it has a line going across the neck, and if you look right above the line, you can see white little dots like pinpoint dots that almost look like freckles. That is petechiae noted above the point of pressure, so the actual item that was tied around this patient's neck caused pressure above it, so we usually see the petechiae above the line of pressure. And then on the last image, this is an image of multiple abrasions to the neck, lower jaw line of a patient. And so remember the nursing care or the medical care does not just end at the physical assessment. As you're completing that, you should also keep in mind that there should be a form of a lethality assessment, which is basically an assessment that evaluates the likelihood of more serious injuries or death following. It should identify risk factors that will occur after leaving, obstacles to provide, obstacles that might prevent a patient from seeking follow-up care or receiving follow-up care, and also just being aware of potential danger. And also the assessment should include the available resources as well as the likelihood of being able to access those resources for safety planning. And also consider patient education needs and not just telling a patient what the risks are and what the assessment looked for and found, but rather are there, is there a need to provide further information and education about the patient's current status, risks, and also resources that are available. And remember it should be not in the provider's language, but rather language that the patient can understand and take away. And whether that's considering their, not just their language that they're most comfortable in, but also in layman's terms. And then we do have some information, if you want a little bit more information about the lethality assessment, there is that link there that gives a little bit more, some examples on the type of assessments that one can use during a medical visit. And also part of this examination can include evidence collection if the patient chooses to do that. These types of evidence that can be collected, again, is based on the patient's medical history, the forensic history of the occurrence. And that would include neck swabs, fingernail debris. Again, consider what Angelita had said is oftentimes patients in defending themselves will use their fingernails on their own neck to try to get the patient's, the perpetrator's hands away, but also may pick up scrapings from the perpetrator. Buckle swabs, clothing, if applicable. Again, remember clothing is really good at retaining DNA evidence longer than the body might retain it, as well as any other particular areas that might be determined based on the patient's history. Consider, really pay attention to the answers to the questions in that medical forensic history to help guide you as far as what evidence is collected. Also consider the timing of when you're collecting that, as well as the availability and the patient's comfort level. And then once that's all complete, it is crucial to prepare some sort of safety plan prior to discharging the patient. And remember that safety planning has to be individualized to that patient. And we really want to emphasize patient sovereignty so that the patient is feeling their own agency, but also we're not offering protection. We're not creating a situation where that patient is dependent on one person to oversee, quote unquote, safety, but rather we're providing an atmosphere of safety so that the patient has a feeling of trust and support so that they can make their own decisions and determination based on their circumstances of what they need to feel safe. It's an ongoing collaborative process that extends beyond the walls of the facility that the patient has come to. Throughout the exam, it's not just a matter of giving a patient just a phone number or the name of a place, but rather identifying the type of care that they need, that they're looking for, and their ability to access those resources. It's about providing support. And we also want to make sure that accommodations are made for barriers that might exist to them seeking those resources and care, such as we talked about language barriers, but also community comfort levels with providers as well. And this is where advocacy is really helpful and essential for being part of that avenue for care as well, and that collaboration, because the success and safety happens not just with what happens inside that facility, but also outside. So again, involving advocacy wherever possible, and those interactions extend beyond the initial encounter and can help form that bridge to the community as well. And consideration must be made for community and societal pressures and concerns. Those might prevent a person from being able to access or feel comfortable enough to do those follow-up cares, and then seek out those services that might be helpful. Also, confidentiality, not just, again, the information that was shared in the facility, but what's going to be shared afterwards. Consider figuring out how you're going to communicate test results, follow-up care information. Sometimes places have apps or things like that. Think about who has access to that information. Also, how are follow-up appointments going to be made? So establish a way to communicate with the patient afterwards, if necessary, that's going to be safe for them to receive that information. Also, the patient has to trust that if you tell them that information will not be shared, that information won't be shared. You also have to consider mandatory reporting and things of that nature, and if that is a concern or if that is something that has to be taken into account, it's important to be honest and upfront with the patient, but expressed in a way that is not traumatic. Go ahead, Angelina. Can I just throw in, you mentioned mandatory reporting. I think it's really important to know your mandatory reporting laws, especially around injury and around strangulation within your community, because if you're specifically trying to address someone with strangulation and you live in a community where there's a required report based on this type of injury, you want to make sure that the patient understands that even before you get started with everything. So just keep in mind what your specific jurisdictional laws are around the violence that occurs in your community and how you have to report it, not just the mandatory reporting to CPS and APS for our adults, but really in terms of injury as well. And I did see, just jumping back just a bit, there was a question in the chat about the probative value of collecting DNA swabs, and I totally understand what you're saying. However, it's important to remember that as collectors of evidence, that's what we're doing. It's not for us to determine what would be probative or not. If it does, based on the medical forensic history, indicate that maybe there was contact. If that's something to collect, just consider collecting it because we won't necessarily know how prosecutors would use that or what kind of DNA or how that would be helpful to a case further on the line. So again, yeah, I think that's a great question, but that's not something necessarily that we need to answer as part of providing that care. I would say this to add to that. It's going to be the patient's choice. If the patient is telling you that they would like to have it done, I would go along with what they're telling you. But it's also a discussion that if you have a coordinated response team, which we haven't got to that slide yet, but if you have a coordinated response team specifically looking at strangulation and IPV, this will be a conversation to have and have your prosecutors at the table because you have a better idea of what that looks like, especially if you're in a community that doesn't have payment for evidence collection. And if you're in a community that may not necessarily be even testing strangulation kits, it's really important for you to really know as a responding to this what that looks like. I hope that helps. Yeah, I think that's a great question. And also as part of that, the safety planning, then we have the overall discharge planning, which also includes if there's a recommended time period for follow-up and if there's any other types of things that you would hope that the patient can consider. And again, this just reiterates the same things we were talking about for the safety planning. Establish a secure method for follow-up communication. It's very important to ask if it's okay to leave a voice message or who has access to your phone. Sometimes patients prefer to call you. So those are things to just establish when you're doing that. And also ensure that the safety plan is agreed upon and shared if there's anybody else that they would like to be involved in that safety planning. Perhaps that's not information that they want to keep on their person, but rather maybe there's a trusted person that they want to involve in that care as well. And making sure that the appropriate connections and referrals are made. And that's again where Angelita was talking about that community response and collaboration so that there's some sort of idea within the community of the appropriate people to provide referrals to as well. And that could also include counseling and other related services. And I'd like to add, sorry, Chanel. I just want to add, I thought I should have said it when we were doing the safety planning slides, but it's appropriate here as well. If you feel like you've never done safety planning before or you don't really know what the process is, it's really important to make sure that you are aware of what you have access to. Do you have access to social work that could come in and work with you and the patient to actually make sure that you have that information in place prior to setting out your discharge, the discharge instructions, or just referring out? You want to make sure that you actually have a connection with someone if that is not your role and that you've actually documented that you're going to be who's doing what I wanted to get out. Yeah, I think that's great. And especially knowing that, and it seems like a no-brainer, but just make sure that the resources that you have on hand are current. Sometimes numbers change or contact information changes. So just make sure that's up to date before you pass it along to patients. We'll go through really quickly the IAFN Non-Fatal Strangulation Documentation Toolkit. This is a toolkit that has been around for a while, but within the last year, we actually did update to the toolkit and re-released it. Within this toolkit, it's really some information or some guidance on formal strangulation documentation and assessment and documentation of the assessment. The toolkit itself is totally free and downloadable, and you can access it at our main IAFN website, www.forensicnurses.org. And it's something that we suggest that people familiarize themselves with and share amongst others just so that it's helpful in getting the same kind of response across communities. So what the toolkit covers is making sure that there's clarity on assessment, what should be assessed, what documentation can look like, and if there's evidence collection, what that can look like. We have within the toolkit sample policies and procedures that you can download and that you can tweak to make your own. There's also sample documentation forms available. In addition to that, there is a sample clinical evaluation outline. So this comes from a particular program. Yours doesn't have to be set up like that at all, but the whole goal is to see what are they asking, what are they actually utilizing, and just to give you some ideas on how you can make something your own. And there's also a sample discharge instruction specific for strangulation. Within the toolkit, there is a hefty resources and references biography section for all of the healthcare people and people who love to find articles and research that is a very current and up-to-date list in there for you. This is just an image that gives some examples of what documents we have available in there. So there's an assessment toolkit that's multiple pages long. There are some body maps in there, and then there is sample history forms for both pediatric patients and adult and adolescent patients. Again, as we're talking about the collaborative piece and the community, it's important if you don't already have a multidisciplinary team or task force to consider enhancing one that you already have or develop one. Again, we know not everybody has the same resources, but sometimes it's not necessarily the amount of members that you have, but who's coming to the table and that there is a collaborative effort. And within that team, make sure you can develop a multidisciplinary non-fatal strangulation protocol. It's not necessarily something that should be blanketed over. There is enough consideration and concern to make a specific protocol just for that. And the team, as well as the protocol, should include responses from law enforcement, medical, prosecutors, advocacy, dispatch, shelter staff, social services, or again, whoever else may be appropriate within your community. Think about the resources that you have and how to amplify them. And then also consider anybody else that isn't necessarily listed, but that might interact with those who have been impacted by strangulation. And then another thing that's not on this slide, and it's not necessarily about a full community response, it's more about like an interdisciplinary response. If you are within a healthcare system or you are working with multiple healthcare organizations within a particular community, maybe you come together and it doesn't have to be every single person, but a few people who oftentimes see the bulk of patients that are disclosing or regularly being exposed to being seen by these individuals. So that could be social work, that could be your L&D folks, your OBGYN folks, it could be ED, it could be primary care. Have those people come together and talk about what is currently happening within this healthcare system, within these clinics, what are you seeing within the community, and how are you as a healthcare system actually responding to it and how can you do a better job or how can you work together to make sure that everyone, all staff within your organizations are actually getting the knowledge about IPV, getting the knowledge about strangulation, so that they know how to respond if they're not, if they come across it, just in general conversation with patients, because that happens all the time and they hear something that they don't want to, they don't know how to respond to, or they ask a question that they don't know how to respond to when they get a positive answer for it. So super important to think about that. Sorry, Chanel. Oh, no, I appreciate that. That's perfect. And we've also included a few IPV resources, just general hotlines, hotline information, as well as sites and things like that. Not just things that you can make available to patients, but for your own resources as well, like I said, just make sure that you're pre-screening and doing your own kind of research as well as to the resources that you're about to provide to a patient. Again, we had mentioned, don't just hand off something to a patient and say, good luck with that. Really become part of the process and that collaborative piece will definitely help. It doesn't look like we have any unanswered questions in the Q&A, and it doesn't look like we have any questions in the chat. We have about four minutes, so feel free to throw any questions in the chat if you have any additional questions, but otherwise, thank you for joining us today. Shaniel and I are both available. If you have any questions, you feel free to email us and let us know about any questions that you may have. And then through the National Tribal Serving House on Sexual Assault—oh, I think I did skip a slide—we do technical assistance, so you can definitely reach out for professional technical assistance or support within your communities. If you have any questions related to what we talked about today, if you have any questions related to community response, if you have any questions related to getting training in your communities, feel free to either reach out via email or reach out via the resource line. We would love to hear from you all. Shannon, thank you so much for being here today and helping us get through today. We always appreciate the services that you guys provide us. And just as a recap, you will get an email that will let you know to log into the National Tribal Clearinghouse Sexual Assault Learning Center to access your actual evaluation for today's webinar. And once you complete the evaluation, you will get a certificate for being here today for nurses, a certificate for your nursing credit for continuing education. Chanelle, you did an amazing job, and thank you as well. Thank you. Thank you, everybody, for taking your time out of the day to be here with us.

strangulation impact

tribal communities

native communities

healthcare providers

anatomical considerations

pediatric population

elderly population

screening importance

challenges in disclosure

medical exams

trauma-informed care