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Beyond the Guidelines: Ignoring Non-Fatal Strangulation by Canada’s Frontline - Episode 3
35 Plays20 days ago
Content warning: This episode discusses intimate partner violence and non-fatal strangulation.
Non-fatal strangulation is common in intimate partner violence—and one of the most dangerous, misunderstood, and minimized forms of assault in Canada. Survivors often present with no visible injuries, yet face serious and sometimes delayed risks, including vascular injury, traumatic brain injury, and stroke.
In this episode of Beyond the Rape Kit: Canada’s Forensic Frontline, Forensic Nurse Practitioner Hannah Varto sits down with Dr. Michael Ellis, a neurologist specializing in cerebrovascular injury and traumatic brain injury in the context of IPV. Together, they go beyond guidelines to examine what actually happens in emergency departments, clinics, and courts—and why systems continue to miss the warning signs.
Through a real-world patient journey, Dr. Ellis breaks down the clinical realities of non-fatal strangulation: subtle symptoms, assessment challenges, missed diagnoses, and the devastating consequences when injuries are dismissed. The conversation explores red flags clinicians must not ignore, imaging and treatment decisions, long-term neurological outcomes, and how inadequate documentation undermines justice in court.
A must-listen for clinicians, forensic professionals, advocates, legal practitioners, and anyone committed to survivor safety and accountability.
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Transcript
Introduction to Forensic Nursing in Canada
00:00:06
Speaker
This is not just another medical podcast or a true crime series. This is the voice of forensic nursing in Canada. This is Beyond the Rape Canada's Forensic Frontline.
Focus on Non-Fatal Strangulation in IPV
00:00:22
Speaker
We're the Canadian Forensic Nurses Association, and we're pulling back the curtain on what really happens when trauma meets healthcare, when survivors seek justice, and when nurses stand the front lines of both.
00:00:36
Speaker
Follow us on Spotify, Facebook, LinkedIn, and Blue check us out on the Canadian Forensic Nurses Association website.
00:00:51
Speaker
Today we're shining a light where it's often dimmed. The conversation deserves clarity, compassion, and clinical precision without losing the human stakes. Today we're having a conversation that cuts past vague talk and into practice, outcomes, and systems.
Medical Seriousness and Under-Recognition
00:01:06
Speaker
Today we're talking about non-fatal strangulation in intimate partner violence. It is common, medically serious, and frequently minimized in healthcare, care police investigations, and courts.
00:01:18
Speaker
Survivors usually have no visible injuries, but the medical risks can still be high. I've seen clinicians, systems, and courts that are not treating non-fatal strangulation as a medical emergency or a lethality indicator.
Conversation with Dr. Michael Ellis on Strangulation
00:01:31
Speaker
So today I'm sitting down with neurosurgeon and medical director of Pan Am Concussion Program, Dr. Michael Ellis. He has a history of specializing in cerebrovascular injuries and traumatic brain injuries and has spent some time looking at this in the context of intimate partner violence.
00:01:47
Speaker
Today we're going to talk about the clinical realities and why guidelines are just not landing in our emergency departments or clinics. Mike's going to take us through the clinical assessment challenges, some treatment options, and the long-term outcomes of non-fatal
Case Study: Sarah's Experience
00:02:00
Speaker
strangulation.
00:02:00
Speaker
So today I welcome you to be Beyond the Rape Kit. We call our series today Beyond the Guidelines, Ignoring Non-Fatal Strangulation by Canada's Frontline. Dr. Ellis, welcome.
00:02:12
Speaker
Thank you for having me So let's start the conversation. I'm going to take you through a patient journey and I'm going to change names and some of the specific dates for confidentiality. But this is really typical of some of the patients that I've seen and worked with. So I've got Sarah. She's a 37 year old woman. She goes into the emergency department late one night. She's holding her wrist and she says to the triage nurse, my husband pushed me and I fell down and I think my wrist is broken.
00:02:37
Speaker
She's speaking clearly. no major signs of any airway obstruction or anything. And the triage nurse notes no bruises, no swelling, no obvious marks. Her vital signs are generally stable. The ER physician finally sees her and the yeah ER physician says, what happened, Sarah? And she says, oh, my husband pushed me and I fell and I landed on my wrist. No other questions are asked. She has an X-ray of her wrist and it's not broken. It's probably just sprained. and she's sent to the forensic nurse examiner.
00:03:06
Speaker
So when the forensic nurse sees her, it's been about six hours in the emergency department, And further and specific questioning by the nurse examiner finds that Sarah was strangled during this incident.
Systemic Failures in Healthcare
00:03:17
Speaker
And she says, quote, he put his hands around my neck. I couldn't breathe and I thought I was going to die.
00:03:23
Speaker
So the forensic nurse requests a reassessment by the emergency physician and the ER physician reluctantly agrees. And five minutes later, Sarah's back to the forensic nurse and the medical chart reads no visible injury, patient stable. And then she's discharged with reassurance.
00:03:39
Speaker
Two days later, Sarah comes back to the emergency department. This time she's got a pounding headache. She's dizzy. She's got blurred vision. She has a CT angiogram and it shows carotid artery injury.
00:03:50
Speaker
And we know now she's at risk for stroke. Then things progress finally. And in court, defense argues, if it was really that serious, wouldn't there be bruises? And i think we know the reality that non-fatal strangulation in intimate partner violence is common. Invisible injuries are common, delayed complications can happen, and it's in a system that often minimizes the dangers because things don't leave a mark. So today, Mike, we're going beyond the guidelines and we're asking why aren't physicians taking strangulation seriously?
00:04:20
Speaker
And I can expand that beyond my physician colleagues to why aren't clinicians or emergency departments taking this seriously?
Need for Education and Guidelines
00:04:26
Speaker
What are the long-term outcomes that these survivors are facing and why are our courts struggling to recognize the research, the evidence, the medical truths that that the evidence isn't just say skin deep.
00:04:38
Speaker
So thanks so much for the for the case. um I think like i can I can see this happening probably quite commonly in emergency departments, urgent care centers across Canada. um And I'm not an emergency physician by background. Most of the patients who I saw that were exposed to intimate intimate partner violence were patients who who were referred to me by a forensic nursing program. So I had the benefit of having a much more comprehensive sort of assessment. um But yes, you can see how this kind of happens. So, um and I wouldn't say that I'm in any way an expert in non-fatal strangulation. um I've been seeing patients who have been exposed intimate intimate partner violence and intimate partner violence related head trauma for about five years. And I would say that the vast majority of what I have learned has come from both my patients and the forensic nursing community. So when I began seeing these patients, I probably had an under appreciation for the how important these injuries were, how under recognized they were, and then maybe some of the the short and and long term medical consequences. um
00:05:44
Speaker
I have been fortunate enough to have been connected to some of the you know resources and and guidelines that have been carried out either by or published by the International Association of Forensic Nurses. And then there's a couple other strangulation guidelines that are available. from other sources. But this case kind of illustrates just how serious strangulation injuries or non-fatal strangulation injuries can be and what some of those consequences can be. And I think um I can't make a comment about, you know, in in general, why frontline service providers don't appreciate this. But I think it has a lot to do with education because I know when I started seeing these patients as a medical student, I can't recall one you know one lecture on non-fatal strangulation. As a neurosurgeon, I can't recall seeing a patient who had experienced these types of injuries. Obviously, we can kind of...
00:06:38
Speaker
you know um appreciate in our mind what type of injuries can occur in the context of blunt trauma to the neck and what those spectrum of injuries are. But unless you have you know access to specific training and guidelines and some clinical experience, you you probably don't appreciate how serious these injuries can be.
00:06:58
Speaker
I think the thing that that is the one of the lessons that I've learned the most about caring for patients who have experienced intimate partner violence, head and neck trauma is that we do we do indeed see patients who have significant injuries such as vascular injuries. in those that don't have any clear external signs of trauma. So just because there's not TKI or bruising or hand prints or you know significant findings, that doesn't mean that somebody can't have sustained injuries like this patient that you discussed can have.
00:07:32
Speaker
Is there any sort of specific symptoms that maybe we could point to for clinicians to be like, if they have this, this, and this, maybe we need to suspect something more serious?
00:07:44
Speaker
i I don't know if
Challenges in Diagnosis and Guidelines
00:07:45
Speaker
I'm qualified to kind of make that comment. Like I've looked a little bit about about the guidelines for kind of clinical management and non fatal strangulation. A lot of those guidelines seem to be based upon case reports, case illustrations, case series and different studies. So I think that there needs to be a lot more research about what are the red flags or the clinical indicators that are most likely indicative of somebody that's that has sustained injuries that that show up on on imaging and which of those patients and the things that we kind of obviously are worried about are soft tissue injuries, injuries to the respiratory tract or you know the esophagus. And again, you know vascular injuries, either carotid, vertebral artery dissections. And I and I
00:08:30
Speaker
And I definitely saw some patients who had a history of of non-fatal strangulation and and had these types of injuries, whether or not it was manual strangulation or ligature. But I'm not sure if there's, I mean, I think it it really requires bringing together a lot of experts and there's different groups that have done this to try to educate the medical providers and frontline service providers about what are the red flags? When should you really consider this?
00:08:58
Speaker
I'm not sure if it's feasible in an emergency department setting to refer every patient for CT angiography or MRI angiography when they've had a history of strangulation. I'm not sure if it's feasible to you know refer all patients for that imaging, even in the setting of a historic type of of injury you know that was months ago or years ago. But I do think that there's more of a need to kind of bring together even in Canada because i don't I'm not aware of any national guidelines that are particularly applied applied in Canada.
00:09:28
Speaker
But you know there's been other countries that have done this and perhaps there's an opportunity in Canada to bring together a national group of experts, including forensic nurses and emergency department
Absence of National Guidelines in Canada
00:09:38
Speaker
physicians.
00:09:39
Speaker
to discuss their experience with this these type of injuries and come up with some, you know even if they are just expert opinion, kind of classified guidelines, some sort of guidance that emergency departments can and physicians can follow, but also that forensic nurses may be able to educate their emergency department colleagues to say, you know we had this patient, you know they do have these different types of red flags. um There are some guidelines that suggest consideration of of diagnostic imaging, such as angiography. What do you think about this? At least as a discussion point for providers.
00:10:19
Speaker
I wonder a lot when I think about perhaps missing some of the the physical injuries, specifically like the carotid dissections, and we know that that's a potential risk for stroke.
00:10:30
Speaker
I have a friend who's a neurologist in a stroke clinic and had not even thought about strangulation until I talked about it with him. um And I just wonder sometimes if we're missing those, say, young younger women having you know strokes when we shouldn't expect it, for example, and we're not tying it back to strangulation. Do you see that in your practice?
Strangulation and Brain Injuries
00:10:54
Speaker
I don't have like a general um like stroke practice. I think that'd be a question for you know the stroke neurologist. Obviously they would have their own algorithms to follow in terms of investigating people who who had stroke you know had had had been diagnosed with strokes or had ah imaging evidence of stroke.
00:11:11
Speaker
um but yeah no i think that it's it's quite possible i i don't know to what extent neurologists would um you know in a review of systems in a patient with you know stroke of unknown ideology would would ask about a history of strangulation um we know that strangulation is you know common among abusive or non-fail standard strangulation is common among abusive relationships We know that it's a common mechanism that is experienced by those who have or exposed to IPV related head and neck trauma.
00:11:42
Speaker
Like I said, before I started seeing these patients, I had ah i was very underqualified and undereducated when it came to you know just the extent to which non-fatal strangulation occurs.
00:11:55
Speaker
and And what are the questions I should be asking? And then who should I be kind of worried about? So I think there's always a need for for more discussion and education across, you know, different medical disciplines.
00:12:06
Speaker
Who are you most worried about? In my practice, you know, i'm actually I actually don't know if I would say I'm pretty lucky. i would say that among the patients that I often saw who presented to the emergency department setting and were seen by the forensic nursing programs, um a lot of those who had experienced non fatal strangulation actually ended up undergoing CT angiography. And as a physician who's managing those patients, let's say, after that initial assessment and long term, there is some benefit in knowing that there was no significant vascular injury at the time of that, you know, event, because it helps put into perspective some of the persistent symptoms that patients have.
00:12:48
Speaker
And definitely, we know that patients who have experienced non-fatal strangulation can experience, you know, difficulty with swallowing difficulty with like hoarseness and can experience a lot of features of whiplash injuries, such as soft tissue you know think injuries and things like that. So it's for me, it was always helpful to be able to have that imaging result just to know whether or not this, what were we and dealing with this or not. And then in some cases, you know we may not have had a vascular injury,
00:13:17
Speaker
but there was soft tissue swelling or there was, let's say, swelling of lymph nodes and and hemorrhagic lymph nodes. And so it always was helpful for us to be able to kind of educate patients on why they may feel certain, you know, like, you know, I can feel this in my neck. You know, what is this? And and and and stuff like that. I know in the emergency department, because you have access to kind of urgent blood work and imaging, it's a lot easier to get these types of tests done in an emergency department setting. Whereas in an outpatient clinic like mine, you know, who that doesn't have access to a laboratory doesn't have onsite imaging.
00:13:48
Speaker
You know, we're we're sending a, you know, a wreck down for blood work and then we're waiting for that to come back and then we're putting in a rack as an outpatient. and and And, you know, this can take a lot of time and and isn't a very efficient way of delivering this. So whenever I had patients who I was concerned about and we really needed urgent imaging, oftentimes I would send a letter to my emergency department colleagues sort of outline what happened in this patient. What was I concerned about? And would you you know consider seeing this patient for an emergency department reassessment and consideration of CT angiography? And a lot of my colleagues were were willing to expedite those tests and collaborate. so I think that's ah a way of kind of looking at it.
00:14:28
Speaker
you know can you can you you know if you If you know each other can you and you have shared some expertise, can you do that? And so maybe that's an opportunity for forensic nurses to do some education around this among emergency department physicians and then build a little bit of a collaborative or collaborative relationship where, listen, if we do see these patients and this wasn't disclosed on your initial interview, but we do a more comprehensive assessment and we're worried,
00:14:52
Speaker
Would you consider seeing this patient again to consider some imaging that that may be indicated? i think that's something that probably would help a lot of these patients.
00:15:03
Speaker
So you talked a little bit about being able to have the opportunity to follow up with these patients maybe after the acute episode when we have a bit more information.
00:15:14
Speaker
um I suspect you also see people who've been hit in the head and may have concussive or mild traumatic brain injury from impact head injuries, not just the anoxic or hypoxic injuries from strangulation. Are you seeing any differences in the outcomes between those two patient populations when you're working with them? Like, do they present slightly differently? Do they tend to have more of one symptom than the other, for example?
00:15:39
Speaker
it's It's probably hard to say in my, in my experience, a majority of the patients that that I would see with IPV related head or neck injuries were coming from an emergency department setting and in a community based forensic nursing program.
00:15:54
Speaker
I would say that a significant proportion of the patients that we were seeing had multiple mechanisms ah of injury where they were experiencing head trauma and a non-fatal strangulation type
Access to Physiotherapy for IPV Injuries
00:16:05
Speaker
injury. there were definitely some that had experienced isolated, you know, non-fatal strangulation or isolated head trauma. So it was a combination. And I think when we look at patients who have either concussions or even whiplash, soft tissue, cervical spine injuries, we know that there's quite an overlap between some of those symptoms where patients can have headaches and vision changes and
00:16:29
Speaker
and dizziness and a lot of different symptoms that can have both of both a concussive and cervicogenic component. The big thing that was that was frustrating for me when we were caring for patients exposed to IPV related neck trauma was that a significant proportion of them did not have private you know insurance coverage or a means of being able to access physiotherapy. So I i think there was a lot of times where they the patients did have a whiplash type mechanism as a result of either non-fatal strangulation or head trauma, and they would have been able to benefit from you know um some visits with the physiotherapist to do you know manual treatment, different multimodal treatments and and exercises and things like that. So it was difficult to see a lot of those patients knowing that they would benefit from physiotherapy. they just didn't have the means or opportunity to access those services?
00:17:20
Speaker
Always coming back to access to services and the inequities that I think we see a lot, especially in interpersonal violence cases and that it's not the same as, say, a sports injury or a car accident or a workplace injury where sometimes insurance or people have the means and the capabilities to undergo the treatment protocols. Which then brings me to how do you adapt your treatment protocols then if they can't access physiotherapy or they can't access the typical supportive services?
00:17:55
Speaker
How are you adapting your protocols for these patients? It's a good question. I think that um I think there's a lot of work that needs to go into. and And again, this is interdisciplinary, but trying to decide what type of interdisciplinary individuals and professionals make up that core IPV, you know, acute assessment team, per se.
00:18:17
Speaker
And I definitely think that forensic nurses should be the leaders of that. They have the the best background in in terms of IPV and sexual assault. And I think that there's a lot that as a frontline service provider, they would be able to do those assessments and then collaborate with, let's say, like a social worker or a mental health professional or an emergency department or a physician as needed. But I do think that it's an under recognized. We certainly had patients who had you know features of vestibular disorders who we were fortunate enough to connect to a publicly funded vestibular physiotherapist as part of our trauma hospital.
Interdisciplinary Teams in IPV Care
00:18:51
Speaker
But we don't have the ability to connect patients to cervical spine physiotherapy.
00:18:57
Speaker
I do think that there's a huge need for being able to involve physiotherapists in in that you know treatment plan and in that interdisciplinary team, because I do think that there are different, there are definitely components of IPV related head trauma that they would be best suited to to manage.
00:19:18
Speaker
So when you're talking with survivors in these circumstances, what kind languaging you use that might be different, say, from someone with a sports or workplace head injury?
00:19:35
Speaker
i think a lot of these survivors risk repeated injuries or may not appreciate some of the risks to their neurological system or their ongoing cognition.
00:19:48
Speaker
Tell me about how you talk with patients. You know, a lot of kind of how I approach this topic has come from, you know, interactions with our forensic nurse, you know, colleagues here.
00:20:01
Speaker
When I began seeing patients five years ago, I probably had not really developed much of an approach to, you know, caring for patients who had experienced IPV related head trauma. Again, you know, we talk about things like trauma informed approaches and patient centered approaches, but um Again, we don't receive a lot of training, at least in the medical medical field about that. So I think what you're trying to do is is trying to collect information, obviously in a nonjudgmental objective way, but in a way that tries to limit the re-traumatization of of patients. So as a physician, you know oftentimes I'll have a lot of information before, so I don't necessarily take the patient through this entire story word for word. Sometimes you can ask patients to confirm some of the things that they've already reported to others while giving them the opportunity to to share other ah details.
00:20:51
Speaker
When I started seeing these patients, I was always worried that I would not be able to build a rapport with them or they wouldn't want to share details, but I've been surprised with how forthcoming a lot of my patients are with some of the details. I think in many cases for people that and individuals who've been experiencing long history of intimate partner violence. Sometimes this is the first time they've had the chance to sit down and talk to any about anybody about their experiences. Oftentimes they're isolated and nobody's ever asked, or you know maybe they went to a health center where they didn't feel comfortable disclosing that information. so
00:21:24
Speaker
It's been surprised. It used to be surprised when patients would kind of reveal a lot and more than I had kind of asked. But I think that just speaks to the fact that, you know, if patients do feel comfortable, oftentimes, like I said, they've never been able to kind of open up about this and disclose things.
00:21:41
Speaker
And, you know, it kind of so I've tried to tailor my approach in such a way that um that I'm trying to collect the bare minimum amount of information to be able to formulate a bit of an individually tailored you know management plan and also give them the opportunity, if I can, to connect with others that can deal with sort of that trauma based response and and impact of what's happened.
Programs for Concussion and Social Needs
00:22:05
Speaker
I think that if we were able to develop more interdisciplinary programs where we could address some of these concussion you know related and features and in clinical characteristics, while at the same time meeting their social and mental health needs, I think a lot of patients concussion symptoms per se would improve.
00:22:25
Speaker
And then we could you know you know make sure that they were connected to you know social workers and mental health professionals that could kind of carry them on through that longer term you know journey of healing. But i I definitely even even now, I probably don't feel completely comfortable taking care of this patient population, i oftentimes feel unqualified. and And again, I learn a lot from you know interacting with other people in the field like forensic nurses.
00:22:51
Speaker
You keep mentioning you feel unqualified, but Mike, I think you're probably more qualified than most of the clinicians I've come in contact with other than forensic nurses for that matter, because we are not learning about strangulation. We're barely learning about violence.
00:23:07
Speaker
in our courses. So I know in nursing school, granted that was many, many years ago, but in nurse practitioner school, we learned very little about interpersonal violence. And as a forensic nurse 20 years ago, we were not asking about head injuries. We were not asking about strangulation. It wasn't even on our radar. So it's really only been on the forensic nursing radar for maybe 10 years. And i think that the physicians are catching up. um Are you integrating this when you take on students or residents? And how are you making that change at at your level in your profession?
00:23:45
Speaker
Yeah. um I, you know, it is, it is funny, like for someone who's only been seeing these patients for about five years, how many times I've, the bar is pretty low in terms of experts, I think from a medical perspective. So it's, it's surprising how often I get asked to kind of give talks about this, you know, this topic and yes, when my mara residents come by, um you know, get on my soapbox about, you know, IPV and how under recognized and underfunded, you know, the resources are and things like that. But yeah, no, I think,
00:24:14
Speaker
um you know, I think we can all kind of benefit from that shared experience. Like it's always great to be able to get into these interdisciplinary meetings. I was in Toronto not long ago, speaking with, you know, forensic nurses in Ontario. And it's just great to hear other people's views about this, because I do agree with you. I think that there's undereducation across probably all frontline service providers. And obviously, if we're looking at sectors outside of health,
00:24:42
Speaker
where you're looking at shelter workers or police or victim services or, you know, um law enforcement or Crown attorneys. I think the thing that I've always learned about connecting with all these different multisectoral individuals is that everybody wants to learn more about it. And I think everybody's readily, you know,
00:25:00
Speaker
I'm very happy to disclose that they don't really understand this that well, that they weren't provided a lot of education on about this when they were in their training and they want to learn more. So, yeah, I think it's just ah an ongoing discussion and among you know different service providers and and.
00:25:20
Speaker
And again, sharing some of these, you know, clinical illustrations like you did today, I think is is helpful because sometimes it's hard to kind of understand what this looks like unless you can kind of share, you know, what this looks like in and in an individual patient.
Legal Implications of Medical Risks
00:25:34
Speaker
Let's go back to translating some of these medical risks and the medical concerns and guidelines and things that that we've mentioned today into a legal context. I don't know if you've had the opportunity, Mike, to talk with, say, Crown Counsel or defense attorneys or judges, juries, et cetera, about why strangulation is different. than other forms of violence, other other acts that we see, and why strangulation fits into maybe a different category. and And if you've not had the opportunity, how do we translate this medical risk and this medical seriousness into a legal understanding, like evidence that maybe survives scrutiny?
00:26:18
Speaker
Those are good questions. And again, I'm not sure if I'm the best person to kind of answer that. i've I've had the chance to do some education around um you know lawyers and and attorneys.
00:26:29
Speaker
um I think one of the things that is probably that I wouldn't have known kind of moving into this is just the association between non-fatal strangulation and the future risk of intimate partner homicide. I don't think people understand the extent to which you are at such a significantly higher rate of being you know murdered by your partner if you've experienced this. That's something that I did not know kind of walking into this.
00:26:53
Speaker
And you know I know that in certain, I'm not sure if it's in all jurisdictions in Canada, but in certain jurisdictions, I know that it's important to understand whether or not in the course of that non-fatal strangulation event, whether or not there was a loss of consciousness, whether or not there's a loss of bladder control, um because that can sometimes translate into more serious you know charges. So again, not an expert in the legal kind of application of this, but those are some of the relationships and discussions we've had with those in the justice system to try to be a bit better at at being able to to capture that information because it does it does make a difference in court.
00:27:34
Speaker
I think about the medical documentation and in the example I gave that the emergency physician wrote, no visible injury, patient stable, which doesn't really tell us a whole lot about what kind of assessment was done or what might have happened. And I know there's always a challenge in asking about loss of consciousness. You're asking someone to consciously recall something that was unconscious.
00:27:57
Speaker
How do you go about that? I mean, i it I agree. I appreciate what you're saying that to go back to your comment about the fact that like no visible injury, like there, there are medical diagnoses that are serious diagnoses where there isn't, you know, visible injury in a lot of cases, as we've said, concussions, one of them, whiplash injuries, one carotid dissection can be one, obviously.
Medical Documentation in Legal Contexts
00:28:19
Speaker
um I mean, and it is sometimes it's difficult. It's difficult for patients. Sometimes we know that. The biology of trauma can impact the way that people put together memories.
00:28:29
Speaker
We know that people may lose consciousness or find that they passed out multiple times. We do know that sometimes these circumstances or events occur in the context of somebody that's consumed alcohol or drugs, and which can obviously lead to changes in in mental state or consciousness. So I do try to connect this or collect this information as I can.
00:28:49
Speaker
um Patients in in some cases will be very clear that, yes, I felt that I lost consciousness and there's a period of time I don't remember. There are patients for sure that that will recall being you know incontinent. There are patients that um that will that are that can graphically recount that they felt that they were going to be murdered by their partner at the time that this happened, or you know my ears were ringing, it felt like my head was gonna explode, those types of things. So I think, I mean, from the forensic nursing point of view i think
00:29:21
Speaker
a lot of forensic nurses would try to collect that information in the patient's own words if they can, because I think that that is helpful. But we also recognize that in the context of trauma, some of these stories can change you know depending on the time in which they're you know um they're collected.
00:29:38
Speaker
So from my from my standpoint, again, oftentimes I am seeing patients that i have the benefit of of of receiving a referral from a forensic nursing program that's done a much more comprehensive non-fatal strangulation assessment or a forensic assessment for IPV. So oftentimes I am collecting that information just as a has an idea of trying to identify the severity of the
Complexities in Symptom Attribution
00:30:03
Speaker
injuries that the patient has you know sustained and then how does that impact management including ordering a diagnostic imaging if that hasn't been done.
00:30:12
Speaker
I think sometimes it comes down to the documentation piece. And I will often think about medical documentation influencing how the the courts interpret the severity or the seriousness of the injury.
00:30:27
Speaker
you know, using the word concussion, for example, might indicate, oh, this was more serious because lay people think of concussions as maybe something more serious. I'm thinking then to clinical guidelines and checklists and things like that that I know a lot of clinicians like to use to be able to sort of quickly, let's do this assessment quickly without having to document a paragraph of the positive and negative signs and symptoms.
00:30:53
Speaker
um What have you found most challenging in working on some of these guidelines and checklists over time? I know you've helped to put out some with the International Association of Forensic Nurses. I know there's some Canadian stuff in the works right now. What's the most challenging putting this together? Like, why don't we have a nice, simple five-question checklist at this point?
00:31:15
Speaker
You know, I don't know, like I'm interested to hear like what those discussions are like. You know, I do know that there are some more standardized assessment tools that sort of ask people a small number of questions to try to ascertain whether or not somebody sustained a brain injury or not, or Did they develop a suspected injury or not? I think it has a lot to do with the training or expertise of the person who's asking those questions and how they're using that information. um you know when it When it comes to patients who have experienced IPV related head trauma, we need to understand that there's a lot of different factors that can cause different symptoms. And so oftentimes when I'm seeing patients and i try to teach this when I talk to other you know providers, we're not just looking at somebody who's it had an isolated head injury like a hockey player who's got hit into the boards and presents with these five symptoms. you know Oftentimes we're seeing somebody who may have a background of repetitive head trauma or previous nonfatal strangulation. We're seeing somebody who now has had an acute trauma.
00:32:16
Speaker
that can include head trauma, facial trauma, injuries to the neck, nonfatal strangulation, extracranial injuries. Oftentimes we're seeing somebody who's experiencing, like I said, the biological impacts of trauma itself and IPV. And then we oftentimes will see patients sometimes who have other medical conditions that are superimposed on that situation, such as mental health condition, sorry, mental health conditions or you know challenges around substance use. So sometimes you know looking at a specific symptom and saying, well, I think this is attributable to this specific mechanism of injury is not always easy. So oftentimes you're trying to collect a lot of this information because again, it's driving what
00:32:59
Speaker
what your management plan is going to kind of detail. Are you going order new imaging? Are you going to send this person to a different provider or or specialist? but it's difficult and you know i look at the validated symptom inventory inventories that we have for concussion. And they are not you know specific for IPV. Obviously, there's a lot of other features that I would and things that I would ask about that are outside of those for our patients. When we were seeing patients, we would ah have them you know fill out the Rivermede post concussion symptom questionnaire. But again, that's not specifically built for the IPV you know setting. And a lot of patients, to be honest, don't have, they just don't aren't able to complete those inventories at the time that you
Lack of Standardized Assessment Tools
00:33:41
Speaker
assess them. So you want to make sure you ask about different things, depending on the types of mechanisms of injuries that they've sustained the injuries that you suspect.
00:33:49
Speaker
And then i think when you're asking about these symptoms, you need to have a clear plan about what you're going to do. So if you ask somebody about whether or not, you know, do you have double vision in the setting of somebody that has facial bruising or periorbital bruising.
00:34:02
Speaker
Do you have a way of being able to further investigate that? Do you can you connect that person to ophthalmology? Can you order imaging to rule out a potential orbital fracture? Can you you know assess for possible extraocular muscle entrapment? And do you have a plan for how you're going to deal with that? Do you have oral maxillofacial surgery, plastic surgery? So um Yeah, I think there's a lot of work to do, but I think it also has to do with you know what your context is, what your background is and and and why are you asking those questions and and how are you trying to guide the patient?
00:34:36
Speaker
This is complex. That's what I'm hearing. It's not as simple as a quick five-question checklist that can be used across clinicians or across different subspecialties or different types of providers.
00:34:50
Speaker
It's really dependent on the program and service and the background and training. And so this gives us a big... chunk of work to do, I think, especially when I think about early days of concussion and sports concussion, right? We, I think we're in the same similar place where we we're trying to figure out what's the the top five or 10 symptoms that really guide us into initial assessment and then take us from there into the more specialty care. So there's a lot of challenges coming up.
00:35:20
Speaker
As we sort of wrap up here, Mike, is there any final thoughts and things you would like to say to our audience? Thanks for having me on the show. Like I said, it's my second podcast. So it's a bit of an increase and build with some comfort for this. But, you know, I said this before, like I just i have an enormous amount of respect for forensic nurses, just their background and the wealth of of information and experience they have in these managing IPV patients and those exposed to you know sexual
Forensic Nurses as Leaders
00:35:52
Speaker
assault. I really think that there's
00:35:55
Speaker
a to kind of connect the rest of our medical field to forensic nurses to learn more about you know the patients that we're seeing i think that they need to be the leaders in this field and i think that moving forward as we try to improve ipv and and sexual assault services across canada the forensic nurses need to be the leaders in this and we need to find a way to be able to support them and provide them, you know, the, you know, the backup and the, and the specialization that they need. But no, I've been, I've been, like I said, I've been completely indebted to my forensic nursing colleagues. i would never have been able to start seeing these patients without having them on call to be able to call and say, what do I do but this patient said this, what am I supposed to say next kind of thing. So, but I do think that there's great opportunities for more interdisciplinary collaboration. And as you said, there's a lot of work to be done to further um understand IPV brain injury and nonfatal strangulation and develop ways that we can work together to provide more equitable and and comprehensive care.
00:36:56
Speaker
Thanks so much, Mike. I think I can echo our forensic nurses to say that it takes physician collaborators like yourself as well to make changes within the physician context because traditionally, nursing is not always seen as the leaders of complex topics or not invited to the tables. And so to have physician collaborators and supportives like yourself to assist us in bringing those colleagues on board, i think we start to move the molehills into mountains.
00:37:30
Speaker
So today we've gone beyond the guidelines and we've confronted some hidden dangers of non-fatal strangulation in intimate partner violence. And we've heard how invisible injuries can carry devastating neurological risks, that clinical protocols are challenging and often overlooked and complex. We've looked at how courts struggle to recognize the seriousness of these assaults sometimes when the evidence isn't skin deep.
00:37:52
Speaker
So a sincere thank you to our guest, neurosurgeon and medical director of Pan Am Concussion Program in Winnipeg, Dr. Michael Ellis, for sharing his expertise and insight. It's conversations like these that are collaborative and insightful that push Canada's forensic frontline forward.
00:38:09
Speaker
And thank you to our listeners for joining us today on Beyond the Rape Kit, Canada's forensic front line. If you're feeling impacted by today's discussion, please know you're not alone. Support is available and change is possible. Please reach out to your closest support services.
00:38:24
Speaker
Stay with us for future episodes as we continue to explore our intersections of health, legal, and systems and advocacy, and we shine a light on the stories that matter most. This is forensic nurse practitioner, Hannah Varto, and Beyond the Rape Kit, Canada's Forensic Frontline, podcast by the Canadian Forensic Nurses Association.
00:38:43
Speaker
Thank you for listening. Stay safe.