- It is well recognized that RV is a healthcare issue.
- This chapter provides the historical perspective of Forensic Nursing and its role in changing the healthcare response to RV over the last five decades. These roles navigate the complexities associated with intersections between the health care and justice systems while attending to the assessment and treatment of trauma, and/or death of victims and perpetrators of violence, criminal activity and traumatic accidents.
- The role development of the Forensic Nurse Examiners highlights how a change in healthcare response to the individual who has been subjected to sexual violence, has led to changed responses in RV including child maltreatment, elder maltreatment, intimate partner violence, interpersonal violence, human trafficking, care of perpetrators of violence and trauma.
- The future shows promise for even more changes in the healthcare response to RV with increased emphasis on the value of forensic nursing science and forensic science in educating on best practices for the forensic patient populations they care for daily.
Relationship violence is any form of physical, emotional, spiritual and financial abuse, negative social control or coercion that is suffered by anyone that has a bond or relationship with the offender. In the literature, we find words such as intimate partner violence (IPV), neglect, dating violence, family violence, battery, child neglect, child abuse, bullying, seniors or elder abuse, male violence, stalking, cyberbullying, strangulation, technology-facilitated coercive control, honour killing, female genital mutilation gang violence and workplace violence. In couples, violence can be perpetrated by women and men in opposite-sex relationships (Carney et al., 2007), within same-sex relationships (Rollè et al., 2018) and in relationships where the victim is LGBTQ2SIA+ (lesbian, gay, bisexual, transgender, queer, Two-Spirit, intersex and asexual plus (The Scottish Trans Alliance, 2010; Rollè et al., 2018). Relationship violence is a result of multiple impacts such as taken for granted inequalities, policies and practices that accept sexism, racism, ageism, xenophobia and homophobia. It can span the entire age spectrum. It may start in-utero and end with death. This chapter discusses the role of the Forensic Nurse Examiner in RV.
What is Forensic Nursing?
In Canada, Forensic Nursing (FN) is an area of nursing that the majority of health care providers and the general public are not familiar with. The provision of health care to those who have undergone violence and trauma as well as being victims of crimes with legal implications has not been at the forefront of nursing as we know it in Canada. Ironically, the first aspects of Forensic Nursing started in Canada in 1975 when Dr. John Butt, a forensic pathologist in Calgary, Alberta hired registered nurses to work as death investigators in the Medical Examiner’s Office (American Nurses Association and International Association of Forensic Nurses [ANA & IAFN]; Pakosh, 2016). Dr. Butt concluded in a five-year study that “the registered nurse provided the qualities and professionalism essential to a scientific, social and cultural investigation of death” (Pakosh 2016, p. 528).
So, what exactly is Forensic Nursing? There are many definitions that have evolved since the 1990’s when the area of nursing expanded into mainstream nursing. In 1991, Virginia Lynch, a forensic nursing pioneer, stated forensic nursing is
[…]the application of the forensic aspects of healthcare that are combined with the bio/psycho/social/spiritual education of the registered nurse in the scientific investigation and the treatment of trauma, and/or death of victims and perpetrators of violence, criminal activity and traumatic accidents. The forensic nurse provides direct services to individual clients, consultation services to nursing, medical and law-related agencies, as well as providing expert court testimony in areas dealing with questioned death investigation processes, adequacy of services, delivery and specialized diagnosis of specific conditions related to nursing (Lynch 1991).
The International Association of Forensic Nurses (IAFN), formed in 1992, currently uses the following definition of Forensic Nursing: “the practice of nursing globally when health and legal systems intersect” (IAFN, 2009)
Similarly, the definition accepted by the Canadian Forensic Nurses Association (CFNA) refers to,
[…] the application of the forensic aspects of health care combined with the biopsychosocial education of the registered nurse in the scientific investigation and treatment of trauma, and or death of victims and perpetrators of violence, criminal activity, and traumatic accidents within the clinical or community institution (CFNA, 2020).
How Forensic Nursing Changed Canadian Healthcare
Forensic Nursing has changed how healthcare responds to specific patient populations, particularly in the settings relating to relationship violence, child maltreatment, elder care, intentional and unintentional trauma investigation, death investigation, corrections and, of course, public health settings. Forensic nursing, using forensic nursing science, forensic science, and overlaying justice systems has added a long-overlooked dimension to health care. Patients/clients not only deserve the best healthcare response to their individual circumstances but also the best forensic nursing care available to them. The Justice System depends on healthcare providers to contribute their healthcare expertise to the case at hand, whether it is within the criminal or civil systems. Often, this expertise left gaps that forensic nursing is filling and will continue to fill over the next decades. The goal is to provide the patient/client with the best outcomes possible for each individual.
Forensic Nursing History in Canada
In order to understand Forensic Nursing’s impact on the healthcare systems in changing the response to relationship violence and other areas of violence and trauma in Canada, one has to look briefly at the history of this area as it has evolved since 1975. It was a slow start until the early 1990’s as most of the progress was based in the United States of America (USA) in the area of sexual violence. In Canada, a few nurses worked as death investigators, a large number of nurses worked in Corrections like prisons or specialized forensic psychiatric units and emergency department physicians and nurses managed acute episodes of relationship violence (IPV, child maltreatment, elder maltreatment), as well as intentional and unintentional trauma. Forensic and legal components to care for the individual were not considered the purview of the health system and only medical/nursing care was the priority.
In 1992, in two different Canadian locations, the long-standing issue of care of the adolescent/adult patient who presented with a post-sexual event to acute care became a target for change. In Winnipeg, Manitoba and Surrey, British Columbia, two pilot projects were championed by a Nurse Educator, Sheila Early (Surrey) and Beth Ariss, an Emergency Nurse (Winnipeg). The funding for the Surrey pilot was obtained by Sandi Schenstead, Nurse Manager of the Emergency Department (ED) at Surrey Memorial Hospital. The impetus was to change the current care of these individuals within the context of the ED. For decades, these patients were routinely subjected to delays and limited interventions of care for a variety of reasons:
- Triaged as non-urgent (often because there were no immediate physical injuries)
- Provision of care was by a physician and physicians were not always available 24/7 in EDs
- Nurses provided nursing care only and could not collect samples
- Law enforcement interviews with patients prior to bringing the patient for medical care
- Transportation was not always available for the patient
- Education was limited in medical and nursing curricula regarding sexual assault in general and forensic components to care in particular
The two pilot projects were formed to develop a new caregiver role for nursing. Sexual Assault Nurse Examiners (SANE) were registered nurses who were specifically educated to care for the medical, legal and forensic aspects for individuals presenting the post-sexual event. These nurses underwent an extensive education and practicum program in order to qualify for this new role in Canadian nursing. The role was based on existing programs in the USA, which had sprung up in Minneapolis, Minnesota, Amarillo, Texas and Memphis, Tennessee, in the mid-1980s to 1990s. The two pioneer programs commenced in late 1993 and early 1994. They were the forerunners for approximately 60+ established programs that exist in eight of the ten Canadian provinces today. Ontario, New Brunswick and Nova Scotia have established Provincial Nurse Examiner networks with Ontario’s 36 Centres spanning the province. To read more about the Ontario Network of Sexual Assault & Domestic Violence Treatment Centres, click here.
Understanding Forensic Nursing and its Impact on Relationship Violence (and other forms of violence and trauma)
In chapter 16 of the ‘The Lawyer’s Guide to the Forensic Sciences” (Pakosh, 2016), Early states that “the forensic nurse (FN) must be prepared to handle a variety of situations and patients, as the expertise of the FN may be helpful in the investigation of a range of offences including sexual abuse, intimate partner violence and human trafficking” (p. 530). The role of the FN in acute care expanded gradually with the advent of the SANE within EDs. Slowly, the realization came about that the specialized skills possessed by these nurses could be useful in many other areas within the ED. Obviously, any form of RV including intimate partner violence, child maltreatment, elder maltreatment, intentional and unintentional incidents of violence and trauma were among the “forensic patient population” (Henderson et al., 2012) that could benefit from the FN’s skills. Unfortunately, the FNs mandate initially only included competent adolescents/adults who presented post a stated non-consensual sexual event. So the RV/IPV/DV patient was not offered the services of the FN unless there was a sexual event as well. Gradually, the examination and documentation skills of the FN were recognized as useful in RV cases. Changes in other areas of RV have progressed over the last two decades. The table below shows what the care for victims of violence was before the mid-1990s and is currently.
Table 11.1 Changes in Healthcare Response to Relationship Violence: Forensic Nursing acting as a Change Agent (1992-present) Adapted from Early (April 17, 2015). Forensic Nursing: Game Changer in Healthcare (presentation). American Association of Legal Nurse Consultants National Conference. Indianapolis, Indiana.
|Historically||Evolved to the Present|
|Medical and nursing education curricula did not include in-depth knowledge on the care for patients who presented post-sexual violence, domestic violence, child abuse, elder abuse (RV).||Violence across lifespan education is available at post-secondary educational facilities. British Columbia Institute of Technology (BCIT) offers a Graduate Certificate in Forensic Health Sciences and undergraduate courses are available in other educational institutions in Canada.|
|Patients presenting post a non-consensual sexual event waited in acute care settings for varying lengths of time, often hours. They were cared for by professionals who had little or no experience in assessment of sexual violence, recognition of significant injuries, forensic sample collections or documentation of findings.||Specialized healthcare response teams in centers respond within 0 -60 minutes to provide best practice medical and forensic care based on the individual’s needs. Sexual Assault Nurse Examiner/ Forensic Nurse Examiners Programs are present in 8/10 provinces in Canada and approximately 800 programs in the USA by 2016 (Office for Victims of Crime [OVC], n.d.). Community agencies collaborate with acute care programs to provide resources before, during and after medical interventions to provide additional services to survivors who have a variety of needs beyond acute interventions. The Victoria Sexual Assault Center in Victoria, B.C. is the only community-based examination center in Canada opening in 2016 with FN’s on call to the site.Avalon Sexual Assault Centre in Halifax, N.S. began operational control as Canada’s only community-based service employing FNs to work in partnership with three local hospitals EDs providing direct patient care. A previous SANE pilot project had failed even though it had run from 1997 to 2000.|
|IPV/DV/RV patients presenting to an ED for care were often not recognized as having intentional injuries vs. non-intentional injuries. The patient’s history did not always fit with the physical findings in many cases. Patients were treated for physical findings with minimal documentation. Many were seen in EDs frequently for ‘accidental injuries”.||Specialized screening tools for IPV/DV/RV identification are available to identify high-risk patients. Many such tools are utilized in EDs across Canada. At one point universal screening of all patients presenting to EDs took place. As education increased on the identification of RV patients, the tools have been in less use.
Healthcare costs of IPV/DV have been identified in numerous studies as documented in chapter 5 increasing the desire to identify and treat the causes of RV on a public health level.
See NEVR’s mission.
|Child maltreatment/abuse often undetected and treated as unintentional injuries as an awareness of the differences between intentional and unintentional injuries was not always included in educational curricula. The availability of social workers in the ED was limited to larger centers and follow up not always available.||Along with mandatory reporting of child maltreatment/abuse (see Chapter 9 for pertinent legislation) came more education on intentional injuries and social workers became part of the ED team. Community follow up was linked to acute care visits. Specialized child abuse teams both acute and non-acute developed. FNs were educated in pediatric acute sexual abuse care and added this mandate to the existing Adolescent/Adult teams in many provinces in the mid-2000s. Post-secondary pediatric sexual abuse education became available for both medical and nursing professionals online at BCIT (2013).|
|In care deaths (acute and non-acute) were not always preserved intact as HCP (healthcare professional) awareness of legal implications was lacking. Deaths such as suicide/homicide/foul play may have been attributed to natural causes.
Medical Examiners were required to have a medical background; however, Coroners were not always required to have medical knowledge. In rural areas, Coroners might be non-professionals for example.
|Death scenes are preserved intact by HCP who are educated in the importance of not altering a scene until legally allowed to do so.
In provinces with Coroner’s system, RNs now bring nursing science expertise to the Coroner role. For several years, the Chief Coroner of Saskatchewan was a Registered Psychiatric Nurse. In Ontario’s Office of the Chief Coroner, a Nurse Practitioner (NP), a former forensic nurse examiner serves as Provincial Nurse Manager, Chair of the Domestic Violence Death Review Committee and has R.N.s as Coroner investigators.
|Health care professional’s awareness of laws governing their professions and practice has been evolving past 50 years.||Many laws and statutes must be adhered to by HCPs. Provincial laws have changed over the decades and now include, but are not limited to: Information and Privacy acts, Infants Act, Health Professions Act, Criminal Code of Canada, For a more detailed description of such laws see Chapter 4. For the FN, the Criminal Code of Canada is an integral part of their education.|
|Educational aspects of forensic nursing not included in basic, post-secondary nursing and continuing education after the emergence of the subspecialty in the 1990s.||Currently, several post-secondary educational institutions offer post-secondary education including certificates and degrees. Continuing education in forensic nursing and medicine and forensic science are also offered in a variety of formats in North America and globally. To access the list of offerings, click here.|
|Prior to 1994 in Canada, an RN testifying in the Criminal Justice Sexual Assault charge case was not recognized as an Expert witness. The RN provided fact testimony without the opinion testimony an Expert is able to provide.||Since 1994, the FN Examiners have been frequently deemed an Expert witness in many provinces in Canada “In Surrey, British Columbia. the forensic nurse examiner testifying as an expert in sexual violence routinely provides opinion evidence in criminal cases involving children, adolescents and adults” (Pakosh 2016). The move to forensic nurse-based care for sexual violence has been validated as a viable and important tool for Crown in the justice systems of Canada.|
|Documentation of findings in RV by HCPs caring for patients was not consistently complete, accurate and objective in medical/nursing charting and reports.||“Written documentation in the ED or acute care record also needs to be viewed as valuable evidence and must be free of bias and subjectivity” ( Constantino et al., 2013, p.320) With increased education on documentation which meets the needs for both healthcare and medico-legal documentation the care provided to the RV patient becomes a principle tool of that care. Defining medical terms consistently and using them correctly (for example difference between a cut and a laceration) and recording “all observations, interactions, and outcomes between the FN and the patient” (Pakosh 2016, p.541) has become best practice. Documentation may take many forms including the use of standardized forms, video, photography and body maps. A Canadian Forensic Nurse. Cathy Carter-Snell developed a documentation tool called “BALDSTEP” to aid documentation of bruises, abrasions, lacerations, deformities, swelling, tenderness, erythema, and patterned injury (Pakosh 2016).|
|Elder maltreatment/abuse in healthcare settings might not be recognized for similar reasons as RV in general. Lack of education, lack of knowledge on what constitutes maltreatment, even the definitions themselves were not clearly defined. Lynch stated in 2011 “elder maltreatment and neglect is dangerously underdiagnosed and underreported” (Lynch 2011 p. 355)||Lynch also stated that “it is the forensic nurse’s professional responsibility to identify and appropriately intervene in elder maltreatment cases” (Lynch 2011, p. 365). Consequently, ED and acute care units became more responsive to the elder patient presenting with overt and covert symptoms of neglect and/or abuse including sexual abuse. Awareness of the multiple forms of elder maltreatment in healthcare education and the general public has resulted in the identification and assessment of cases that previously may have been missed.|
The previous table highlights significant changes in how the healthcare response to RV and other forms of violence and trauma has changed over the last three decades. There are certainly more changes that have not been documented in this chapter as they relate to conceptual change other than RV. They include the premise that perpetrators of violence and/or crimes have the same healthcare and medico-legal rights as victims and require the same objectivity and neutrality in their care. The healthcare professional is not a determiner of guilt or innocence.
Healthcare Change for Victims of Sexual Assault
More importantly, how has the healthcare response changed the care of the individual who has been the victim of a non-consensual sexual event? (Sexual assault is a crime under the Criminal Code of Canada but not a medical diagnosis see chapter 9 for Sections of Criminal Code relating to sexual assault). Read about service providers and their roles in chapter 10 to see that there are community and healthcare based responses that did not exist in the historical past.
- Patients are provided with the information and resources to make informed decisions on what services and care are available to them (please note this is for competent adolescents and adults, competent being the keyword).
- The decision as to whether or not they report the incident to law enforcement is still currently only theirs to make. In the USA, there is mandatory reporting of sexual violence in California for example.
- Healthcare of the individual is not based on whether law enforcement is involved or not.
- Patients usually have the choice of having forensic samples collected and stored for varying periods of time. For example, in B.C. samples collected may be stored for up to one year by specialized forensic nursing units.
- The health and well being of the individual always comes as the first priority. For example, if collecting a forensic sample interferes with life-threatening procedures, that collection is deferred. However, documentation of all findings and observations continues to be valuable even when there is not a collection of forensic samples.
- Patients have supports available to them prior to accessing healthcare, during the process and after by any number of community agencies that have developed since the 1970s. It is not uncommon for patients to hug their FN caregiver at the end of an extensive medical-forensic examination.1
- If legal proceedings become part of the individual’s process, the FN is available to provide testimony as either a fact or expert witness as part of their ongoing role. With an extensive education in court and legal proceedings, the FN is well equipped to provide the court information to guide in the determination of a legal outcome.
- Holistic care is best practice for all victims and perpetrators of any form of RV. “Early screening, identification and treatment of intimate partner violence patients can help break often serious and deadly cycles of violence” (Lynch 2011, p. 370).
Studies and published articles over the last two decades validate that healthcare response to RV needed to change its response to the individual patient’s medical and forensic needs. Here are just a few pertinent studies:
Shared decision making – as a better approach to the care HCPs (Healthcare Professionals) provide to patients/clients. This refers to providing the individual with information and resources in order that they make the best-informed decision appropriate for that individual at that particular time. According to Mohammed & Montori (2015), this approach is not taught in medical schools. Studies do show patients want more information than HCPs may have provided in the past. Today, the internet seems to be the “second opinion” with sometimes drastic negative effects. So, the FN is in a position to provide a patient with appropriate information and resources and take the time to assist rather than direct a patient to their decision. The FN is dedicated to that particular patient so clinical time is not the drawback it is within a busy and sometimes overwhelming ED. To learn more, watch the video, click here (Mohammed & Montori, 2015).
Canadian Emergency Department Survey – published in 2008 by McClennan, Worster and McMillan, the survey wanted to determine how many Canadian EDs used universal screening tools and intervention policies and procedures over a 10 year period. The results were compared to a 1994 study to see if research and education regarding IPV were instrumental in integrating changes in the healthcare response to IPV. The survey concluded that “despite increased research into IPV issues, there was no significant change between 1994 and 2004 in the existence of IPV policies or universal screening in Canadian EDs” ( McClennan et al., 2008, p. 325).
Forensic Education in the ED – Henderson et al. (2012) studied ED physicians’ and nurses’ forensic knowledge, their practice experiences and their forensic learning needs. They compared the results finding no significant difference in education, knowledge and confidence in caring for the forensic patient between the two professions. However, only just over half of both physicians and nurses felt confident to care for and manage a forensic patient indicating forensic knowledge was not only needed in the EDs but desired. Further, the study reached conclusions including the recognition that “proficient, safe, quality care for the forensic patient must be operationalized in the ED setting” (Henderson et al., 2012, p. 176).
Canadian Client Satisfaction Survey – on Nurse-led SV/DV Services. Du Mont et al. (2014) surveyed 30 of the 35 SA/DV Centres in Ontario regarding client satisfaction. The large scale survey involved over 1000 participants with the following results: 98.6% stated they received the care they needed, 98.8% stated their overall care was excellent or good, and 95.4% stated the care was provided in a sensitive manner. The negative findings were long wait times, negative ED staff attitude, privacy and confidentiality issues and difficulty in accessing services. So, there is still improvement to be made in the healthcare response to RV.
Future Healthcare Response Changes
Historically, there have been significant positive and much-needed changes to how healthcare responds to RV and all forms of violence and trauma. Forensic healthcare is now entering areas that have been identified as health-related and could benefit from the specialized skills of the FN and others who have had specialized forensic nursing science, forensic science and forensic medicine education.
- Human trafficking is becoming part of the healthcare mandate for forensic nurses. B.C. led the way in producing an education module in 2015 for all healthcare providers in the identification of the human trafficked person. To read the module, please, click here (Fraser Health, 2018).
- Strangulation in RV has not been recognized as the life-threatening event it can be. Forensic Emergency Medicine has developed a protocol for the medical and forensic care of the patient who has or may have been strangled in any violent event. To learn more about strangulation, click here (Training Institute on Strangulation Prevention, n.d.).
- Forensic science and forensic nursing science research is conducting studies to determine the presence of bruising underneath the skin not visible to the naked eye. Anecdotally, an alternate light source seemed to indicate unseen bruising; however, research is being conducted to validate findings. Read the studies here (Scafide et al., 2020).
*Based on the personal experience of Sheila Early, a Forensic Nurse for 14 years.
American Nurses Association. (2009). Forensic nursing: Scope and standards of practice. Silver Spring.
American Nurses Association and the International Association of Forensic Nurses. (Ed.). (2017). Forensic Nursing Scope and Standards of Practice.
Canadian Forensic Nurses Association. (2020). Education. https://forensicnurse.ca/education/
Carney, M., Buttell, B., & Dutton, D. (2007). Women who perpetrate intimate partner violence: A review of the literature with recommendations for treatment. Aggression and Violent Behavior 12, 108 –115. https://www.researchgate.net/publication/222426549_Women_Who_Perpetrate_Intimate_Partner_Violence_A_Review_of_the_Literature_With_Recommendations_for_Treatment
Constantino, R. E., Crane, P. A., & Young, S. E. (2013). Forensic nursing evidence-based principles and practice. Davis Plus.
Du Mont, J., Macdonald, S., White, M., Turner, L., White, D., Kaplan, S., & Smith, T. (2014). Client satisfaction with nursing-led sexual assault and domestic violence services in Ontario. Journal of Forensic Nursing, 10(3), 122-134.
Early, S. (2015). Forensic nursing: game-changer in healthcare. Presentation at the American Association of Legal Nurse Consultants National Conference. Indianapolis, Indiana.
Enfermeiros Forenses. (2015, January 6). Forensic nursing documentary part I. [Video]. YouTube. https://www.youtube.com/watch?v=W2ayabr6RoI
Enfermeiros Forenses. (2015, January 6). Forensic nursing documentary part II. [Video]. YouTube. https://www.youtube.com/watch?v=tFmh3xpPr8o
Enfermeiros Forenses. (2015, January 6). Forensic nursing documentary part III. [Video]. YouTube. https://www.youtube.com/watch?v=ZOFeKHg4n_0
Fraser Health. (2018). Human trafficking. https://www.fraserhealth.ca/health-topics-a-to-z/sexual-assault-and-violence/forensic-nursing-service/human-trafficking#.Xs23R2hKiwU
Henderson, E., Nahoko, H., & Amar, A. (2012). Caring for the forensic population: Recognizing the educational needs of emergency department nurses and physicians. Journal of Forensic Nursing, 8, 170-177.
International Association of Forensic Nurses. (n.d.). What is Forensic nursing?. https://www.forensicnurses.org/page/WhatisFN
Lynch, V. (1991). Proposal for a new scientific discipline: Forensic nursing. In Presentation to the general section at the annual meeting of the American Academy of Forensic Sciences, Anaheim, CA. Feb (pp. 18-23).
Lynch, V. A. & Duval B. J. (2011). Forensic nursing science. Elsevier Mosby.
McClennan, S., Worster, A., & MacMillan, H. (2008). Caring for victims of intimate partner violence: A study of Canadian emergency departments. EM Advances Survey.
Mohammed, S. F., & Montori, V. (2015). Making decisions with, not for patients. https://www.medscape.com/viewarticle/844541
Mohammed, S. F., & Montori, V. (2015, May 27). Making decisions with, not for, patients. [Video]. Mayo Clinic. https://medprofvideos.mayoclinic.org/videos/making-decisions-with-not-for-patients
Office for Victims of Crime. (n.d.). History and development of SANE programs. https://www.ovcttac.gov/saneguide/introduction/history-and-development-of-sane-programs/
Ontario Network of Sexual Assault & Domestic Violence Treatment Centres. (2017). https://forensicnurse.ca/education/
Pakosh, C. (2016). The Lawyer’s Guide to the Forensic Science. Irwin Law.
Rollè, L., Giardina, G., Caldarera, A. M., Gerino, E., & Brustia, P. (2018). When intimate partner violence meets same-sex couples: A review of same-sex intimate partner violence. Frontiers in Psychology, 9, 1506. https://doi.org/10.3389/fpsyg.2018.01506
Scafide, K. N., Sheridan, D. J., Downing, N. R., & Hayat, M. J. (2020). Detection of inflicted bruises by alternate light: Results of a randomized controlled trial. Journal of Forensic Sciences.
The Scottish Trans Alliance. (2010). https://www.scottishtrans.org/
Training Institute on Strangulation Prevention. (n.d.). Recommendations: medical radiographic evaluation of acute adolescent, adult, non-fatal strangulation. http://www.ncdsv.org/TISP_Recommendations-Medical-Radiolographic-Eval-of-Acute-Adolescent-Adult-Non-Fatal-Strangulation_2-2016.pdf