By failing to discuss strangulation, we are failing our patients

Six seconds is the amount of time it would have taken for him to render me unconscious.

Shortly thereafter, I might have lost my life.

One month before I finally found the strength to leave an abusive ex-partner, he rushed at me with unexpected force during an argument and wrapped his hands around my throat. I kicked desperately at his chest, terrified, heart racing, during what I believed might be my final moments.

My memory of that attack exists in brief flashes: first sitting on the bed, then suddenly finding myself helpless on my back, staring at the silver ceiling light swinging several feet above my face. Feeling his hands around my throat, praying that this would not be my end. I don’t want to die. I don’t want to stop breathing. When he let go, my feet in their little gray socks were still flailing in the air.

Later, I relayed the experience to a physician who specializes in trauma, who listened as I downplayed the assault, “It could have been worse, I didn’t lose airflow, he didn’t press down …” I recalled what my then-partner had said to me afterward: “I would never hurt you. I was only trying to scare you.” The physician shook her head ruefully.

“No, Chloe. You could have been unconscious within six seconds.”

It takes between 5 and 10 seconds to render a victim unconscious by strangulation. Death can occur within minutes.

No one unexpectedly goes for their partner’s throat with good intentions.

The Training Institute on Strangulation Prevention defines strangulation as “the obstruction of blood vessels and/or airflow in the neck resulting in asphyxia.” Importantly, it is caused by the external application of physical force vs. choking, an internal obstruction of the airway.

That definition remained an impersonal fact to me until I experienced it myself.

68 percent of a convenience sample of 62 women from a domestic violence advocacy program reported experiencing strangulation in a 2001 study. 93 percent of the time, the abuser resided with the victim. 78 percent of the time, the strangulation attempt occurred in the victim’s home. In the vast majority of cases, either a husband, boyfriend, or fiancé was cited as the abuser.

The adverse health outcomes for victims of non-fatal strangulation in the setting of intimate partner violence (IPV) cannot be overstated. Physical consequences include, but are not limited to: neurological symptoms, loss of consciousness, vision changes, difficulty speaking, trouble swallowing (dysphagia), and respiratory distress. Psychiatric outcomes include depression and PTSD.

A 2008 case-control study assessed non-fatal strangulation as a risk factor for homicide of women. Women who were the victims of attempted or completed homicide were found to be much more likely to have had a history of strangulation compared with matched controls who had experienced IPV at some point in their lives. Frighteningly, the study revealed that the odds for homicide increase by 750 percent for domestic abuse victims who have experienced strangulation compared to those who have not.

In other words, a woman whose partner puts their hands around her neck is at inordinately high risk of losing her life.

These data highlight a grim message: clinicians should absolutely ask about strangulation when screening for IPV, especially in the emergency department, if there is a remote question about a patient having experienced IPV. And for clinicians to consider asking about strangulation either in the high-acuity environment of the emergency department or in the calmer primary care setting, clinicians must first be educated on strangulation.

Medical education has made enormous strides in the last few decades. For our knowledge base, we have significantly more material to cover in 4 to 5 years of medical school in today’s day and age than previous generations of physicians. Certainly, some topics may inadvertently fall by the wayside.

I assert that we cannot afford to let medical education on IPV and strangulation fall by the wayside. Even a sentence or two about the risks of non-fatal strangulation would have been a starting point for me, as both a potential victim and a female student doctor. We owe it to ourselves and to our patients to be thoroughly informed on this subject.

We do not talk about this in medical school. We need to. It could quite literally be the difference between life and death for our patients.

A domestic violence counselor summarized my own experience with the bleak statement: “I call it ‘practice murder.’ He didn’t kill you at that moment. But he showed that he was willing to.”

Chloe N. L. Lee is a medical student.

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