Supporting GPs in assessment of non-fatal strangulation

Aotearoa has a high incidence of intimate partner violence (IPV), with the New Zealand Crime and Victims Survey showing that approximately 23 per cent of females and 10 per cent of males who have ever had a partner have experienced IPV in their lifetime.¹

Anyone may experience IPV, but the incidence of IPV is higher in some groups, including people aged 15 to 29, Māori, members of the rainbow community, and those with a disability. It’s important because IPV is a “driver” of ill health, resulting in both physical injuries and chronic stress-related conditions, all of which are commonly seen in primary care.

Applying pressure to the neck (strangulation), and airway obstruction by covering the nose and mouth with an object such as a pillow or hands (suffocation), have been recognised as common forms of intimidation used to exert power and control within IPV relationships.

Applying pressure around the neck is a high-risk activity, particularly in the context of anger or rage. When someone is strangled, it can take as little as 10 seconds for them to lose consciousness, 15 seconds to lose control of the bladder, and within two to three minutes of constant neck pressure, death may occur. In 2018, the New Zealand law was changed to reflect the increased risk of serious harm or death if strangulation or suffocation occur within a relationship.

Nationally, police respond to a family harm incident approximately every four minutes; however, only about 25 per cent of incidents are actually reported to police. If strangulation has occurred, referral by police for a non-acute specialist medical assessment in a Sexual Abuse Assessment and Treatment Service (SAATS) is increasingly available in urban centres. However, for patients in rural areas, or for the large majority who do not involve police, access to this service is currently unavailable (unlike sexual assault assessments, strangulation assessments are only funded if the referral is made by police).

These patients may present to any general practice requesting help, or may disclose experiencing strangulation or suffocation following a routine enquiry about IPV by a clinician. Patients may also be directed to see their own GP by police in areas where there is no provision for a SAATS assessment. These patients need a “well-informed” medical assessment and engagement with support services; however, few of us covered this topic in our training.

What is a well-informed assessment?

It is about knowing what information regarding the alleged event might be useful, what symptoms and signs might be expected, and ruling out other potential causes. The examiner needs understanding of head and neck anatomy, the ability to evaluate findings and to manage the consultation using a trauma-informed approach.

People may describe a significant event, possibly losing consciousness, yet there may be no subsequent visible findings

The neck is ideally suited to being compressed, with major vessels and the trachea situated superficially and anteriorly, resulting in symptoms relating to breathing and brain function when pressure is applied. Soft tissue injury to the delicate larynx, together with the supra and infra-hyoid muscles can result in symptoms relating to swallowing and talking.

Pressure can be applied to the neck in various ways, including using hands, an arm or a ligature. Different mechanisms may result in different symptoms and signs, depending on the amount of pressure, the exact location and the length of time that pressure is applied.

It is important to be aware that people may describe a significant event, possibly losing consciousness, yet there may be no subsequent visible findings.

It is Monday morning in a rural practice and the next patient comes in. Amy is a 24-year-old woman who says she was assaulted by her ex-partner yesterday, including a period when he “choked” her. She was advised by police to see her doctor to record her injuries.

You reflect on the variety of emotions Amy may be experiencing following this trauma, including uncertainty, anxiety, shame, fear, guilt and anger, among others. Empowering Amy by checking in with her about what she would like from the consultation is important. She asks for you to check her over, as requested by police.

Amy answers your questions (Panel 1), and you examine her (Panel 2). Amy does not have any concerning symptoms (Panel 3), has a safe place to stay and has good supports in place. You record your notes factually and objectively (Panel 4), being aware they may be used in a future court case.

It is useful to have a standard approach to describing injuries. For each injury, note the site, shape, size and characteristics (eg, colour, depth, edges and surroundings). Recording injuries accurately also enables future assessment of the likely injury mechanism by an expert, which may be of medicolegal significance, rather than impacting on immediate treatment.

Beware of using confusing terms (eg, contusion); instead, use simple terms – everyone knows what a bruise is, but there can be confusion about what a contusion is. If it is a bruise, call it bruise. If it’s swollen, describe it as a bruise with swelling (see Panel 4 for examples).

To record findings, consider using body diagrams (available on HealthPathways) and photographs (with patient consent), including a measurement scale close to the injury whenever possible.

The ACC descriptor and event code for non-fatal strangulation/suffocation is “Asphyxiation or Strangulation NOS SN47z”. Options for injury codes depend on the examination findings – for example, sprains of the neck or jaw, abrasions, contusions, or concussion if you are concerned about possible traumatic or hypoxic brain injury.

There are a variety of community agencies available to provide information and support for patients who have experienced IPV. Contact details for many of these are available through your local HealthPathways or the Family Services Directory (www.familyservices.govt.nz).

Back to the case study: some weeks later, police contact the medical centre asking for clinical notes. It is good practice to get the patient’s consent to do this – often easiest at the time of the original examination (see Panel 4). However, even with prior permission, informing the patient that police have subsequently requested the notes is important.

In a situation such as Amy’s, be aware that police can obtain clinical notes without consent of the patient if the notes relate to a family harm incident and charges are to be laid, by using a production order or a search warrant.²

The clinical notes may be useful in a subsequent court case. Police may ask the clinician to write a report, or they may create a report from the clinical notes and ask the clinician to sign it. Depending on the circumstances of the case and the quality of the notes, the clinician may or may not be asked to attend court (the better the quality of the notes, the less likely court attendance will be required). Sometimes, the clinical notes will be used by an expert clinician to write a report for the court.

HealthPathways has pages covering family violence, physical assault including strangulation, and report writing.

Medical Sexual Assault Clinicians Aotearoa (MEDSAC) has developed a free, interesting, interactive e-learning module on strangulation, which is especially relevant for those working in general practice and emergency or accident and medical settings. It is available through their website (medsac.org.nz), together with other useful resources for members (membership is free).

Shine (2shine.org.nz) and areyouok.org.nz have excellent information and resources for clinicians and patients.

This case study does not represent an identifiable person

Clare Healy is a specialist GP and forensic physician who examines and supports people who report being physically or sexually assaulted