Clinical and Forensic Aspects of Strangulation Injury Presenting to the ER

so um welcome everybody to the UBC Department of Emergency medicine provincial Grand rounds for September um and uh thank you very much all for coming a special thank you to um uh Tracy Pickett who has agreed to be our first uh speaker of the Academic Year um Tracy has a long history in emergency medicine and has recently done some pretty amazing things that are unique and she's going to talk to us about uh forensic aspects and clinical aspects of strangling which is an interesting topic so Tracy trained at in the UBC program uh was on staff at St Paul's for a long time is working mostly at vgh now clinically but she has letters behind her name that nobody else has so she did a master's in Australia in forensic medicine and she has her Fellowship in emergency medicine in Canada she also is the only Canadian see if I get this right who has a fellowship in forensic uh clinical forensic medicine clinical forensic medicine from australasia so um pretty amazing as she sort of goes out she's the medical director of the sexual assault service and so she has these special expertise and we said well what what stuff do we need to know about this and um and Tracy has a special interest in the clinical and forensic aspects of strangulation injury and so that's what we're going to hear from her so we're so we're so excited she was recently promoted to a clinical Professor level and so congratulations on that too Tracy thanks you can take over well thank you very much so thank you everybody and thank you Jen for having rounds beforehand so there were actually people here I was and uh it's really great that there's uh some emerge people here but also thank you to I think I see a few Pathologists Eric and I think now it's there um I also invited Crown to this and uh Crown Council just because um I think one of our really important roles in medicine is to be an educator and that's part of what I want to do is educate hopefully you guys but also the other sort of Greater other people who need to know about this as well so um strangulation injury why did I pick this well I have some personal experience with it not that I strangled my kids but certainly having deal had to deal with patients in the emergency department but I also kind of recognize that it's not something that we really recognize very well or that we do a very good job of in emergency medicine so what we're going to talk about uh just some you know my objectives here is why strangulation a bit about terminology I thought I'd throw in some stuff about Canadian law just forensic medicine means the interface of medicine and the law and uh clinical forensic medicine is like forensic pathology but it's on people who aren't dead yet or people who are going to become dead so it's that that intersection of medicine law and so um we're going to talk about strangulation a little bit and Canadian law and recognition of strangulation injury just because again it's something I don't think that we necessarily do very well and then a proposed triangulation investigation pathway because again sometimes I think people may recognize that there's something going on but don't really know what to do about it and uh some references and resources and fire questions that mean you can stick your hand up anytime um hopefully everybody in the other places can hear and uh and we'll kind of get rolling here so why strangulation you know it's it's kind of a weird topic just sort of putting it out there how many people sitting in this room have seen a strangulation victim that they know about okay all right let me let me take a different tack on this how many people in the room or in the other rooms have seen somebody in the emergency department and have asked and the patient's asked for the morning after pill really come on you know most of most of you I would have thought okay how many people of those those ones that you where you you've asked you know the patient comes in for the morning after pill you've said was this because of sexual assault good one two I'll have to say that as an emergency doc that was never really on my radar when I sort of was doing just emergency medicine you know birth control pill here you go see you later sort of thing now I work for the sexual assault Service as well um social cell service I'll just kind of give you a little bit of background we see about 350 patients a year through vgh um who are sexual assaults um we know the numbers are probably a lot higher and uh and and I really thought in understanding that you know sometimes when people come in for a birth control pill they're actually they're the victim of the sexual assault so now as an emerge doc when somebody comes in and says can I have the morning after pill I say can you tell me a little bit about this or do you want to tell me a little bit about what might have happened here and I'm finding out you know what you ask the question you find out the answer well strangulation is the same thing okay so you know there's a lot of people who kind of come in well horse well you know oh I've got a sore throat you know and don't people don't ask the question why do you have that sore throat why are you having difficulty swallowing and uh now that I'm doing sexual assault I actually ask people the same thing have you been strangled well guess what more than 30 of my people that I see through sexual assault service have been strangled when I start asking the question outside of the sexual assault service and in the emerge why is your throat sore or why do you have that Mark on your neck guess what they're strangled too so I think if we don't do we don't necessarily do the the justice of asking people questions so why do we want to know about strangulation why is it important well you know it can kill people and other things but this is why okay and that's these victims of a prior attempt of strangulation so somebody's have survived this regulation are seven times more likely to become a victim of a homicide all right um and you sort of think well what is my role in the emergency department it's really easy to say oh you know what you're breathing and stuff is fine you can go but we actually have some duty to care for these people even if it's just letting them know that they can come back to the emergency department so some Canadian headlines I just these are just random cases that I kind of have remembered or picked up in the in fairly recent past Alberta healthcare's workers strangulation scene describes the 2011. that was somebody who um went did a home visit like his own mental health uh worker and got strangled these are all deaths by the way Angela Wilson's killing sharks Clearwater BC two years ago what's the overcome resistance charge okay strangulation of Kathy Reed after drug binge was not a quick painless death so that's a quote from um the prosecution crossbow attack victims died of Bolt Arrow injuries and strangulation that was just two weeks ago so these are the ones that we know about these are the ones that make the headlines but there's an awful lot more of this happening that we're we're not aware of so why is it important from an ER perspective um non-fatal strangulation is reported in 10 of abused women and 43 percent of domestic violence-related homicides almost all women whose experienced violence have sought help from at least one resource that also means emerge right we see these people all the time and we don't necessarily recognize it women who've been sexually assaulted by an intimate partner are less likely to seek medical care we know that too um there was a subset of people who come into the sexual assault service um where they are repeatedly assaulted by the same person um and in fact the majority of our cases through the sexual assault service it's an intimate partner sort of um relationship and I can talk a little bit more about sexual assault and stuff um afterwards um extra General injuries so injuries outside of the genitals including strangulation are somewhere between 2 and 10 times more common than genital injury and sexual assault and uh it depends on Whose papers you read so most strangulation cases produce minor or no visible neck injuries now this comes I've got all my references listed at the end so you guys if you're interested in this I can give them to you but what it means is that more than 50 percent of people don't have any visible findings whatsoever with a strangulation injury and 35 percent of people um have visible injuries only 15 of these and this is off of the case series with 300 patients only 15 percent actually have injuries that are worth even photographing so you just you know that you don't always see it so there's often some sequility of that and we're going to go into that a little bit but documentable symptoms okay difficulty swallowing or a bit of hoarseness it's a gendered crime uh again I recognize that what we're seeing is kind of a skewed population with sexual assault service but of this series which is actually one of the biggest series um case series looking at survives regulations 300 patients 299 of them were um victims were women so um most people don't strangle somebody to kill them they do it to show that it's a power thing and that they can kill and they can kill this person at any time and uh there's lots of sequelae again we sometimes you know get any inkling of that with emerge because you know the people come in with PTSD or repeat visits or substance abuse or other sort of things and there's been some legal discordance it's only really sort of being I will say addressed I won't say being rectified now is is being rectified in the States but in Canada it's not illegal to strangle somebody which I find really interesting so we're going to talk about that a little bit more in a minute are you kind of with me on that any questions about sort of why it's important I'm not I don't want to say we're all doing a bad job but I think I think we can improve what we're doing so why does language matter well it's because patients will tell you things and we will interpret things differently than what the patient is necessarily telling us because we have a medical background and it happens all the time you know you get asked by a lawyer or somebody else to describe the injuries to the hip well to us the hip means the actual hip joint not the whole hip region so um so some pretty important definitions and so when you're searching and stuff too um the the definitions become important so what's suffocation pillow to the face something obstructing the airway at the mouth nose okay choking is when people always say he choked me or I got choked okay choking is when you gag on a hamburger right like it's something in your upper Airway um that impedes ventilation it can also be a gag or something stuffed in your mouth right so strangulation is the big one that we're sort of I'm trying to focus on but is this fixia the closure of the blood vessels and the and or the error passages of the neck as a result of an external compression and there's lots of terminology that even goes with that okay so that we talk about ligatures like ropes and cords and stuff talk about manual with hands um it can be hands or it can also be like an arm bar okay or a choke hold and in fact I I'm not advocating that maybe you guys do this but one of the things that I do it this is kind of a weird sort of thing I carry around my head and when I have to talk to cramp I have the head and we have to talk to court I talk to head but what it means is that you can actually hand this over to somebody and they can show you what happened so you know an arm bar like this is going to produce different injuries more than this or then this okay so it's a sort of a you should see me trying to get this across the border this in fact actually I had more trouble getting my shampoo across the border than I did with a head which says some little thing about border security but anyways um so so different forms of strangulation are are different um have different mechanisms hanging is a constriction band Titan BY gravitational weight do you have to be standing to be hung hanged I should say no right you can actually hang yourself down I'm taking weight and paying yourself off of beds and things and traumatic yeah so somebody's sitting on the chest or on the body um what was the uh the chap in the state so you know the police officers were sitting on them and the comment was I can't breathe I can't breathe yeah that's right so those those are all sort of forms of um different ways of impeding Airways okay segue into Canadian criminal code so in Canada you can't be strangled for you can't be strangled you can't be charged for strangling somebody you can be charged with assault or aggravated salt or salt contently harm sexual assault attempted murder or this generic sort of overcoming resistance so we'll talk a little bit more about overcoming resistance but choking so this is a quote from um gianeshi's lawyer um the choking is not an offense in and of itself in of in and of itself is choking to commit another offense so that's actually what it is defined as in the criminal code Plus in order to have the charge actually stick the victim must have resisted so what that means is with is that there's a higher burden of proof If you're trying to prove that somebody was strangled so so the idea is this is the actual wording I'm not going to go through it but it's with the intent to enable or assist himself or another person to commit an offense so just to try and strangle somebody to make them unconscious is not actually prosecutable under this strangulation law um which is kind of problematic you know if you think about it because strangulation kills people and it's one of those ways that you can kill somebody without leaving a mark um 38 States actually I think it's up to 42 now but have passed regulation laws uh I think that's up from 22 about two years ago so there's a big Motion in the states to get this under the the laws uh the lesson this was really looked at in Canada was in 2006. uh I think that there's going to be a little bit more um more impetus to actually look at this uh recently now especially in light of gianeshi um this was a quite an interesting thing of 89 cases involving choking or strangulation between 1990 and 2006 so that's just in itself a comment of 16 years like not quite 90 cases not very many cases get to court for strangulation 39 offenders were charged so that means only half of those people were charged um but only 14 resulted in convictions so it's a really hard charge to prove and it's interesting because if you go back to the to the law the law actually was never intended for domestic violence or sexual assault or anything else it actually goes back to the the garretting uh wars in the late or the early 1800s in Britain it's actually the law as it's written in Canada is basically a paraphrase of the um of the law as it was written in 1874 and the garretting charges was um what would happen was it or the guarding riots in Britain were happening was that people were going and basically putting a small ligature around somebody's neck incapacitating them and robbing them and that uh was a a big thing in the early 1800s and so in 1874 the UK brought out this law and it hasn't actually changed since that so what I find kind of interesting is I will buy dinner for anybody who can tell me what um uh rule 245 is of the criminal code what the offense is for 245 or 247 I'll buy two dinners say so so so this one is kind of stuck off in the middle of nowhere nowhere so uh charge 245 is actually poisoning uh so it could so so overcoming resistance and strangulation comes after poisoning but it comes before booby traps so if you set a trap for somebody that's offense 247. so in all my spare time I sit there I'd sit down and I read the criminal code um so so what it means is it's not super high on the priority so strangulation signs and symptoms I'm not going to go through this a lot because you guys actually know this um whether or not you recognize it or recognize it in the context of somebody who may not be telling you a full story um is maybe another another issue one of the things I do want to um point out and mention is that straight we don't have a lot of information about strangulation there's not a lot of studies looking at strangulation there are some studies looking at hangings and and those that that's probably our best estimate for hanging for um what actually the physiology of what happens with a with a strangulation um injury and a lot of the information that comes on hangings is actually from Annie savageo who was the chief medical examiner in Alberta I don't think she's still there um but basically what she did was she looked at videotaped hangings basically snuff films uh people had either made that were suicides or um autoerotic sort of things and what she did was she classified these and basically what she found was that you know people would hang so these all had a suspension except for one so 14 of them um and looked at these and saw if there was any sort of physiological things that she could pick up basically people lose Consciousness between 10 and 18 seconds they do decor corticate and then decerebrate's sort of posturing somehow have a seizure and then there's some last agonal sort of rest somewhere between two and four minutes depending on on um you know what the the victim or patient was you know how long it took so but it very consistent 10 seconds you lose Consciousness so what we've done is we've tried to kind of translate that to what do we see clinically with people and the point I want to make is that sometimes people will come in and say I can't tell you what happened I don't know and if you think about it if it only takes 10 seconds to lose Consciousness then that person's not going to necessarily know what's happened right um not only that that whole losing Consciousness sort of thing it impairs your memory you can't lay down memory in a normal way if you're unconscious right so so the neurological things it's not that the person's not trying to tell you a story they may not know okay and then if you throw drugs or alcohol other things on top of it it's it becomes a bit of a quagmire so a lot of the symptoms that people complain about are a bit soft right um again I can print this out for anybody if you wanted it's actually not a bad summary it's it's a it's a little bit dumbed down it's it's primarily actually for EMS and for police providers just so that they can recognize some of the things um you know some of the bigger things chest pain redness scratch marks you know scratch marks take a nap and this isn't you know and and the defense will always say oh well you know but my client was injured and she she was you know she attacked him well it's actually somebody's trying to flaw away what is on the map okay so these are often self inflicted sort of linear um sort of scratch marks that you'll see I would hope that if you if you saw any of these sort of signs that you would at least you know pay attention to that um because you're never going to see them all together like this okay here's uh somebody with a mark on their neck okay now it's not a great picture because it only has I only have one view of it but you can see that there's something that looks to be at least partially circumferential on this view it was actually circumferential this was a hanging okay um and it was actually a ligature Mark uh now I know that the people elsewhere can't see my pointer if I use the latest printer but you can see here there's actually a bit of a pattern abrasion and there's actually a level of abrasion here too so so the petiki that we're talking about this is also a hanging uh there are some a little bit of a maybe a bruise there and maybe a bruise or an abrasion there but these are those patikia that we're talking about um the TKA are caused in strangulation particular from little uh Earth's tiny capillaries and the the pathophysiology isn't a hundred percent certain but it's it's probably As Good As It Gets and it's uh comes from the chief medical examiner of New York state from about uh he died uh recently but uh from 1986 Charles Hirsch and he was talking about what is it what does this cause this is anoxic blood vessel damage or is there a mechanical issue what we think that this is caused by is that if you think you've got pressure on the neck what gets occluded first it's going to be your venous system right low pressure system and then um higher pressure system which is going to be the capillary or sorry the um arteries and then probably Airway last okay if you had to sort of quantify things from force and so petite are caused by the fact that you're compressing the veins but not necessarily the arteries so you've got back flow it's kind of like you know think about your garden hose right before we had water restrictions and you go and stand on the garden hose the first thing that happens is your your spray of water is kind of half as high because you're standing on holes but you know if you've got a hose like mine you stand on the hose and you spring a little leak you get a little proximal to where you're standing okay that's basically what's causing fatigue eye in this sort of case so that's the the pathophysiology for that and so what sort of characteristic with a hang or a strangulation is that they're above the site of obstruction okay and they can be fluorid like this or it can just be a few and it depends a little bit on lots of different features you know if there's other issues other you know tissue damage you may not see these or if the force is so strong that the arteries get occluded as well then you may not see it okay Deco bleeding is very close to the surface of the skin and this may resolve very quickly within 24 hours it can last for weeks okay up to two weeks bad things this is the stuff that you guys need to worry about okay I don't know about you but I kind of go in to see my patient and I sort of in my head I'm thinking what are the five things they're going to kill this person in the next whatever two hours and how am I going to sort that out and then the rest I don't really care about so these are the things that are going to kill this person um Airway stuff cardiovascular and neural um I'm just gonna I'm not gonna go through a lot of these okay because you guys know all this stuff I'm I'm I don't have to teach you this um vocal cord paralysis is one I never really appreciated um somebody grabs you around the neck so she can get like a neuropraxia of the recurrent laryngeal nerve what resin one of the residents here if you paralyzed uh vocal cord what position is it in when you're learning the scope open closed uh any of the attendings want to answer that if you have a paralyzed just one say one vocal cord a paralyzed vocal cord is closed okay so if you look down you should normally get your nice little triangle of your vocal cords like this a paralyzed vocal cord is like this okay it's like the Ringo spasm so this doesn't necessarily and what do you do when you're looking down and you see somebody with laryngoscope spasm that your sphincter tightens a little bit right and then what do you do yeah it sucks yeah exactly okay so so both chord paralysis is is a really big finding that we can get with this okay so that person that comes in a little bit hoarse you need to look at their Airway and make sure that those vocal cords are actually moving they close so will you paralyze someone for around the debation you the vocal cords are paralyzed but they're open but they're they're not they're not they're not movable right like they're not how do you say it there's that little tiny slip and that's all you're seeing and if you when the patient breathes if you're doing a laryngoscopy and you haven't given them socks the paralyzed vocal word is going to sit and the one that's not paralyzed moves right and so one from a vocal cord paralysis not going anywhere and it's basically there's even if you have both of them closed what do you see tiny little slit right not much so we'll go back to that carotid artery dissection vertebral Artery Dissection I know in my 20 years or so of doing emergency medicine I've picked up probably only three or four vertebral artery dissections one was from a woman who was having a chiropractic manipulation of her neck one was of a snowboarder who happened to be looking to the side and got struck and fell and one was with a strangulation injury so those are the ones I know about I've probably missed two or three dozen I don't know um arrhythmias I put that in with a question mark because we don't really know why people die with strangulation injury there's probably something to do with the Carotid body being compressed that's still a little bit controversial the last one I really want to sort of point out here is chronic traumatic encephalopathy so who gets that yeah that's like being punch drunk right like the so mm what do you call mixed martial arts guys boxers football players soccer players guess what domestic violence victims too so um that's sort of evolving literature and stuff that's sort of in the works right now okay so this I I put this in from the context of if you're a medical student or a resident you're working with your attending uh what do you you know what what do you do and how do you work this up and the thing is is that there's not a lot of great protocols and and you know every Department's a little bit different everybody does things differently it depends on your your relationship with with um Radiology but proper investigation is going to be some combination of of prop of Investigations can be x-rayed from Costco vascular studies depending on what's sort of available but it was a bit of a mishmash and it is a bit of a mishmash so what sort of came of this is that there have been sort of working groups looking at what should we be doing for strangulation and hanging injuries to identify the life-threatening things this is where this comes from I know this is really busy we're going to go through parts of it so don't worry if you can't read at all so um I was very fortunate to recently go down to San Diego uh I was invited down to be part of this training institute of strangulation prevention which is sponsored by the U.S federal department of justice and it was looking at basically identifying and how to prosecute strangulation injury from um generally the U.S perspective and um it was quite an interesting experience uh this is what they um have come up with not they but this is sort of consensus from emerge docs that are doing clinical forensic medicine um and uh Pathologists on what we should be doing and also Radiologists to work up strangulation injury so uh the main thing here that we're doing is evaluating the Carotid of vertebral arteries um looking for bony cartilaginous issues and evaluate the brain for anoxic injury so how does that fit into what we do here okay okay I'm going to throw this picture up here this is one of those ones it's kind of bad things right you can see somebody want to take a stab at this just to just you know part of what we do in emerge is injury interpretation right so we want to try and strike describe that bruising to the neck so start yeah kind of wedge-shaped again I only have that one picture for swimming yeah I think there's I think there's probably a little bit of sweat too and in fact you actually can get some appreciation that there's maybe some areas where the bruising looks a little bit more intense there's sort of four sort of things there and then some more sort of diffuse falling over the larynx and stuff so I would if you guys saw that patience voice is normal what would you do like I know what I do I know what I do now and I know what I used to do I'd say you're having any trouble swallowing no okay see you later okay so this protocol was sort of brought up to try and address these things that we're missing and how to do it okay so we're going to focus on this history and our physical exam with any of the following okay and it gives nice little list of symptoms again I'm not going to go through all these because you guys know what a petite is you know you know when you see something that looks like a band around the neck you can probably make some sort of conclusion that might have been a ligature um incontinence okay bowel and bladder okay what happens when you get strangled and you lose Consciousness in that 10 to 18 seconds often people will defecate and wet themselves and they'll have no recall of why they did it that's because they're unconscious um dysphonia aphonia dyspnea Sub-Q emphysema those are the end of the big big ones okay what are you going to do depends on where you work a little bit so fortunately we've kind of gone through all this um with this uh protocol workup of this protocol now different things are going to be available to different people what I did was I I looked at this and I took it to the RADS at bgh and said what do you guys think of this they loved it they loved it they said bring it on put it as part of our our workup because that they said you know what it's not us has trouble knowing what to do he said but it's it's not it's not being identified so the first thing I would say that comes out of this is make friends with your radiology department this isn't what it was like 20 odd years ago where everything was a bun fight over now whether or not you could get a head CT scan okay these people if they've had a loss of consciousness or Amnesia you're probably going to be seating their head anyways right it doesn't take a lot to carry on and go down and it's I don't know it's been a while since I've worked at St Paul's but it's pretty easy to get a CT angio at least at vgh to look at vertebral arteries and things and um and it's just a matter of talking to Radiology okay if you can't do that at least at CT and I could contrast talk to them they want to do this stuff and they want to be like us they want to educate us right they love it um so the rats were pretty on board with this Emory of the neck uh MRI of the neck a lot more difficult to get in Canada it's something that's they're using a little bit more in the states ultrasound probably not something that's going to help you too much here especially me I'm terrible at ultrasound Trace yeah sorry um so these are recommended for which patients so these are for strangulation patients I would actually trans transfer that and actually say I would also do it for hanging patients and in fact recently I saw somebody who was a clothesline injury with an MVA um he actually had Atlanta occipital dissociation um and uh but you know these kind of vascular studies are important to anybody who's being kind of lifted right like because it's usually a traction injury that's just causing the dissection not always but so I would say that this is specifically for strangulation but I would actually take it for hangings and for clothesline signatures okay uh Eric first so so just to be clear so someone comes in they said they were strangled they have bruises or whatever they Mark but they feel okay they otherwise they I mean you're doing this for every patient who's I I actually am and you know what that's how I picked up the other one she came in two weeks after right with her vertebral Artery Dissection what was it no symptoms her symptoms was were headache and ongoing difficulty swallowing I'm not sure what the difficulty swallowing was yeah so so in fact because that's the question that comes up all the time how long do you have to do these studies for or what or what's your window six months they're saying here six months okay and uh and because it does put you at risk for these things do we treat vertebral artery dissections not really but we do put them on in again I want to be clear that the the recommendation anybody who SE or not you're you're recommending this or are you telling people if symptoms change or I I am when they come in whatever a week later four days later or two weeks later I'm I'm doing these and if they come in acutely if they come in acutely I'm doing it as well so and you know what I want to say that my false negative rate is really really high but how many patients or sorry my false like I'm not get I'm like I'm not getting positive studies in a lot of these okay um how many patients do you order uh a CTE chest on for a D-dimer of 618. well you know but but we because we've had to become a little bit you know we have to become cautious because we're missing things and I don't have a huge Baseline to know that because I'm not sure what my Baseline is of how many patients are coming in but I think that by not doing these and because that we are missing them because I've actually now seen a couple of these that were not part of SAS or anything else that and I'll show you a couple of pictures in a minute of of other patients coming in uh sorry Andy and then Todd had a question too yeah thanks Tracy I guess I'm wrestling with this one a little bit because if they really have um you know maybe they're brought in because the police brought them in because there was an assault or something and so they're not really they tell you they were strangled they're not having any symptoms maybe they didn't even lose Consciousness you don't see any external trauma okay in a lot of these women are young reproductive age you know so these are also the people we're trying to avoid CTS on so in that patient you would still feel that your um I'm gonna give you a charge sheet that we send people home with so that they know what to come back for okay what I'm what I want to do is try and put it on people's radar because there there's lots of places to stumble here uh if you know if police get called to a domestic violence or whatever you know the police missed the boat okay they may see that this person's got you know bleeding into the whites of their eyes and that she's hoarse and she's hysterical but it's like you know they they're not necessarily picking up on those signs because of that ambulance isn't necessarily getting called and the patient's not being asked to seek medical attention the patient comes to you they emerge and you know like we're like what the hell are you here for you know you seem fine right and and people kind of get blown off and you know what I admit that sitting in the waiting room for four hours you know waiting to get seen is kind of a way of observing them um but I think it's probably important to do these these studies um I've been a little bit surprised by the fact that that um I have picked up some of these it just kind of almost randomly and almost almost ones that I wouldn't necessarily have expected so I will go over the ones sorry Todd did you have a question too you're good okay we'll go over the ones you don't have to investigate uh this has got the colored Arrow sign anybody want to have a go at it anybody look at plain films anymore at least it's not the one that you have to put up somebody stick their hand up and tell me what this is what are those arrows pointing out continuous diaphragm sign okay you see the diaphragm all the way along here you don't usually see the diaphragm where the heart sits on top of it so the pneumo mediastinum okay see it on the lateral aspect too the CT showed air all around the arch of the aorta and around so I had a really interesting case here at St Paul's about three years ago with a guy who came in on I still remember this January 4th and on Christmas or New Year's Eve you've been having sex with his partner and had a strangulation episode she strangled him it was consensual and he came in whatever four days later and said every time I turn my head I get this weird popping sound and I don't get it and uh and he has subcutaneous emphysema that went from basically his clavicles all the way up into his occipit and uh he had a pneumonidastinum and uh it was really to me it was really interesting and it also sort of I you know I thought I should probably write this up from a point of view there's not a lot of you know there are lots of case reports about you know bilateral carotid artery dissections vertebral artery dissections it's not actually a lot about pneumo mediastinum with consensual consensual sex but okay so you see that pneumonidastinum you see that the bruising you get the investigations what do you do now okay now again this gets a little bit wishy-washy right it depends on what your resources are it depends on what the patient's resources are basically what they're saying from the case reports and what's happening in other places in the world any positive Radiology findings patient should be consulted and like consulted to a service and admit it and this is actually even happening in the States where people don't have health insurance negative Radiology findings observe and they're actually recommending up to 24 hours and then discharge okay I you know I I'm not wedded to that in an Ideal World maybe but okay so if you this is that same graph I'm going to put the graph back up again but you know if you've got some findings positive findings consult neurology neurosurge trauma whoever for admission um consider ENT somebody to actually look at the larynx all right sometimes easier than done okay it's said than done uh if they don't have any findings continue Hospital observation and again the recommendations have been up to 24 hours if you look at the ASAP guidelines on strangulation which are written by Bill Green who's one of the guys who did this protocol with Bill Smock um they'll say 24 hours but and then discharge home with detailed Institute instructions and I'll show you those in a sec okay so the who doesn't need investigation sure go for it we do we we do but we're sorry the question is um if if for example this happened at vgh and the patient say gets admitted to the trauma service does the sexual assault service or whatever round or or or um follow that patient and I would say we're primarily a Consulting service but yes I like we would do that that would be probably my patient um now I recognize that not everywhere has a sexual assault Service uh and also not everywhere has a trauma service so and this is where we get into that whole bun fight again about it's like the little subdurals right that you know end up getting it at St Paul's admitted to medicine but they don't really want them because they might decompensate I have things change things probably haven't changed right so anyways so that part's going to be a battle okay but if you can get these people admitted to somewhere and I would say actually trauma would probably be a perfect sort of place for them um that that would that would be ideal and yes we would follow that patient and just uh for the record if at St Paul's if people are admitted uh say to ICU following a sexual assault or whatever if they're an admitted patient or to Psycho whatever sexual assault service will actually come uh to St Paul's and follow those patients as well so okay okay who doesn't need investigations anybody who doesn't have a loss of consciousness doesn't have sort of visual changes no particular hemorrhages it's no evidence of any soft tissue injury to the neck remember 50 of patients don't have any soft tissue findings uh no dyspnea no neural symptoms like they didn't seize or anything and I love this reliable home monitoring okay that one's always a bit tough right like if partner beats a partner I you know I'm not sure about safety planning there but um that becomes part of your discharge planning okay discharge home with detailed instructions to return to the emergency department so there's the whole sort of framework again I just kind of broke it down so it was sort of a little bit uh sort of in sort of the workable sort of sides of things okay um have we instituted this at anywhere I've spoken to RADS I've spoken a little bit to the vgh people I I you know it's something I feel really passionate about um I do think that it's something that we can um we can improve on and uh part of it is just not knowing what to do so hey uh Eddie did anybody see the bog people when uh you guys know about the bog people these are uh people that were uh thrown into a bog in Denmark probably 2500 years ago and they were essentially perfectly preserved because of the tannins in the Bog and uh this is one of the bog people everybody's got around his neck it's got ligature around his neck and I remember seeing this about 20 years ago when I was in Ottawa for something and it was just kind of a anyways and uh at that point in time became quite interested in the fact that this guy had been preserved with his ligature around his neck done uh brief word about documentation uh your charts are really hopeless uh we write so little on them and what is usually written is pretty much illegible dictations are probably a little bit more useful um I personally am still trying to learn how to use the dictation system at St Paul's or apartment at vgh um but especially if there's pertinent negatives that are listed pictures it would be great to be able to take pictures of these people often I only get the context of the pictures if the police have been involved um and the police are pretty good they um generally try to take pictures in the emergency department and then they'll usually do another set of pictures about a week later uh just to show so the evolution of the injury and stuff and uh and when I get involved from uh going to court point of view it's usually on the basis of pictures because I haven't necessarily seen the patient and then the trauma Gram now again our trauma grams are not great and the ones that are on the trauma handouts aren't great but we actually have one for the sexual assault service which is a strangulation checklist and I'll show that to you if you guys are welcome to help out and use that if you think it's useful um remember to include the things that are important and make sure that when you discharge your patient that they know what to come back for okay any signs of a stroke for example or increasing difficulty with their breathing so here's our stress strangulation um checklist uh it's just helpful because it helps it reminds you to sort of try and ask about some of the symptoms that you may not have um specifically remembered you know was it bruising around the mouth uh or is there a laceration is that from maybe somebody putting something over the person's face as well or hand right um you know redness under the chin what's the first thing you do if somebody does this to you what's the first thing you do your best right can you do this so often people have sort of abrasions under the chin um so that's uh you know those are the little things to kind of look for you wouldn't necessarily think about that you might think oh she might maybe she lost Consciousness and fell and hit her chin okay that could be part of it too but you know somebody suddenly puts a hand over your your mouth you're getting a blunt force trauma to the to the nose and the lip and you know often a split laceration to the to the left those kind of things so um I'm not asking anybody to be an expert in injury interpretation but just think of things in the context of of what you're seeing or or maybe what you're hearing okay this is our strangulation form that we hand out to patients with sexual assault service and I love the bottom because it basically says if you get any of these symptoms go to merge and then the emerge stock I've had two experiences where the very shot kind of look at this is why are you here right so um we're we are asking people to come back and uh at least be evaluated um you know and I hope that all of those studies are negative but uh I don't think they will be once we start doing a little bit more of them so uh this is a slide that I put in for my sexual assault examiners who are nurses okay not all of our examiners are Physicians on sexual assault service um but it actually goes out to Residence and to the medical students as well you know like anything if you kind of go in and you're kind of like oh I'm not this isn't sitting well for me talk to your attending okay um educate yourself learn about these things how did I get into this I I I'll be within Spectrum it wasn't because you know I watched all these you know snuff films with Annie savage or that was not my thing you know I got interested in this because I had a patient who hanged himself in my psych unit here at St Paul's and uh resuscitated this guy and so um there was in my face and what I recognized was that there weren't a lot of people who knew very much about strangulation injury and when I went to court on that case there you know there was not a lot of people who knew a lot about strangulation injury so it pays to educate yourself and then when you educate yourself you get to educate other people so um if you see a strangulation case in your resident you're one of the attendees go back read about it ask somebody about it talk to me I like you know this is you need to educate yourself and also educate the police officers educate the nursing staff these are important things um I've got some resources at the end that I can pass on for people you know you've got 20 minutes one night when you're trying to set up your Netflix you can look at this stuff it's easy and it's fast and you'll get it um support your patient safety planning violence resources sorry Jim five minutes okay all right Your Role is an EP recognize that strangulation is probably or is it potentially life-threatening injury this is what I want you to take home okay investigate it as thoroughly as you can talk to the Radiology they are on board with this they want this okay they love being able to show us stuff and learn from them okay go and talk to them afterwards say what did that CTC show me that pneumo mediastinum show me the the section um CTA is probably going to be the easiest thing to get here uh prudent observation referral in an ideal world it would be great to be able to have that identify that strangulation injury in the context of interpersonal violence is a marker for a need for a really detailed risk assessment you know what you can't send this person back home to this sort of situation if they choose that that's what they want to do at least give them the resources so that they know you know you can start a little bit of a safety plan and all this we are really crappy at that okay that's what social work is for that's what your helpers are for okay um a few thanks to uh Bill Smock in Louisville Kentucky uh the U.S federal department of justice justice references if you get a chance try and go to strangulation training institute um I send a lot of the police and stuff there they've got some really quick sort of five minute videos got some pretty good references and stuff these were references that I used these are the references for how they got to that protocol for the Radiology stuff okay I know that one of you keeners is going to go research all of those okay but anyways it's all there and that's pretty much it questions I got like one minute questions got a few minutes that was really interesting Tracy can you sort of print a tangential question a little bit but can you you talk about um what is the the duty of the responsibility of the emergency position if you have some let's say it was a very violent crime even and you investigated and um and everything's okay they can be discharged home and they don't want to do anything about it they want to go right back into that domestic situation I mean do we have any obligation to do anything about it we just say adios you're on your own no we don't in Canada in in British Columbia and in Canada we don't have an obligation to report that um that's not the case in all of the states but um what I say to them is we are always here in the emergency department you can come back anytime maybe a bit of a wait but anyways and I I give them that opportunity I make sure that they're connected with social work and um and in fact we have some really subtle ways of being able to give people information there's like the little card they can put in their shoe actually with sexual assault service we have a little um it's a nail file like just that you would use like an emery board actually has the phone number for like weva on it so there are sort of ways to give people some information but basically try and Link them with social worker and that's going to be the best you can do it's a really kind of bad situation and the other thing I would say is don't interview this person with partner right there right so like that's a really important thing and it sounds a little bit of a no-brainer and so the way that I've gotten around this is you know what um I see you they're really sore throat and you know I'm a little bit concerned about this I need to do some investigations okay I know in fact I talked to them in the CT scanner and that's where I sometimes get a bit of the information okay so you sometimes have to be a little bit covert yeah Frank hey Tracy uh it's been a while since all of us have seen you I've known you for 10 years and uh you know it's uh it's all I know just I think most people know Tracy's used to work here and now works at vgh I've never seen you so confident and poised as this and it's obvious you're passionate about this and I think that translates to everybody in the room so congratulations on on really a great talk that we get no exposure to Mike my question is uh going to be has to do with um obviously you work at a center where you can get pretty much anything you want fairly quickly and uh you know what about the 95 or 98 hospitals in British Columbia which do not have a trauma service do not have any kind of radiology and you're going to get a patient coming in saying three days ago so and so did this had a couple drinks that might have lost Consciousness and it was my voice was hoarse for a day or two like what do you do in any other Hospital in British Columbia yeah yeah you know what the answer is David could comment on the two after Tracy you do the best you can um use your resources like there is that Eric what the hell is that called the 1-800 read call and emergedoc.com line like what is that there's that Ray CD so you know what so if somebody calls you can you know maybe arrange that some of these patients may need to be transferred okay and you know from it we're also looking at this also from a sexual assault perspective too and we do recognize that there are some patients that we need to transfer uh for sexual assault there are there's also in some cases maybe the ability to transfer the sexual assault service to the patient so you know there's there is some ideas of being able to transfer I don't you do the best you can most places I think in BC you can get a CT scan really like I think ish ish within six hours you know like yeah you know what you do the best you can you what you do you do what we've been doing for the last 30 years keep your fingers crossed as well right so somebody else but you were you referred to David essler yeah okay yeah anybody else on another note happy to see any patients from sexual assault surface you guys have questions about um patients who've been sexually assaulted just call the number there's a there's like a call switchboard and you will be able to talk to one of the special assault nurses or examiners and we'll be able to walk you through what needs to be done or how to transfer the patient so okay and just as I decide Tracy has also been Consulting with the Emergency Services advisory committee setting up the approach to sexual assault in all of the regions of British Columbia including smaller hospitals and so there's Regional protocols

Channel: EmergencyCareBC

Views: 1,492

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Id: mAzuDES9sTc

Length: 54min 15sec (3255 seconds)

Published: Wed Jul 05 2017