October 7, 2024

The importance of providing trauma-informed care begins with YOU! Every patient encounter leaves an impact. The sooner you can build trust with a patient, better care can be provided and, ultimately, better outcomes. As one of the first points of access to medical care after sexual assault or domestic assault, your interactions with the patient can be the start of their healing process. 

You should assume that everyone experiences trauma and understand that the impact of trauma goes beyond patients. Trauma also affects families, staff, and even work colleagues. There are three possible reactions during acute trauma: Fight, Flight, or Freeze. During acute trauma, the instinctive brain overrides the logical brain and things tend to happen automatically without the ability to fully process what’s happening in the moment. This leads to various reactions and emotions that are different for everybody. As trauma-informed providers, we must maintain a non-judgmental approach and recognize that a survivor's trauma response is a normal natural reaction. We should do our best to be patient and compassionate and practice active listening. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of a trauma-informed approach involves the four R’s:

Realize the widespread impact of trauma and understand the potential paths for recovery 

Recognize the signs and symptoms of trauma in patients, families, staff, and others involved with the system, including colleagues 

Respond by fully integrating knowledge about trauma into policies, procedures, and practices; and 

Resist and actively avoid re-traumatization

One of the first steps we can take to start being trauma-informed is to rephrase the question “What’s wrong with you?” to “What’s happened to you?” Be mindful that the words we use can convey so much more meaning to our patients. Incorporate the following six guiding principles in your everyday practice to provide a trauma-informed approach: 

1. Safety: Provide a place where patients feel both physically and psychologically safe 

2. Trustworthiness & Transparency: Conduct decisions with transparency and build a relationship of trust with the patient 

3. Peer Support: Involve trauma survivors in utilizing their stories and life experiences to promote healing and recovery 

4. Collaboration & Mutuality: Recognize that everyone has a role to play in a trauma-informed approach 

5. Empowerment Voice & Choice: Allow shared decision-making with your patients, give them options and the power to make decisions for themselves 

6. Cultural, Historical, & Gender Issues: Move past cultural stereotypes and biases, leverage the healing value of traditional cultural connections as well

It is your initial interactions with patients during the acute phase of their trauma that are so crucial and can set the tone for how they will respond and eventually recover after sexual or domestic assault. Remember that every patient encounter leaves an impact and just one incident can be life-altering. However, by providing trauma-informed care, you can be the difference in patient outcomes. 

Thank you for providing wonderful care and for serving our most vulnerable patients,

Stephanie Gaines, MD

October 14, 2024

Strangulation is one of the most dangerous and lethal forms of interpersonal violence. Research shows that, for a victim who is strangled just once, they are 10 times more likely to die at the hands of their perpetrator. That’s why in April of 2023, the state of Ohio reclassified strangulation as a felony crime due to its severe implications and its strong correlation with future lethal domestic violence incidents.  

Strangulation is a form of asphyxia characterized by the closure of the blood vessels and/or airways by external pressure applied to the neck. It is a form of assault commonly used in intimate partner violence because it instills fear and control over the victim conveying the message, “I am so powerful that I can easily kill you by simply using the strength of my hands.” Despite being a common act, it, unfortunately, is often minimized and underreported due to the lack of visible injuries and even victims failing to realize the seriousness of the act. 

Patients don’t usually disclose being strangled but may report being “choked,” seeing stars, blacking out, or often stating they were scared they were going to die. While there are different ways for strangulation to occur, most often (83%) strangulation is done manually where the assailant uses their hands to squeeze the neck. It doesn't take much force on the neck to inflict serious injuries. Only about 4.5 lbs of pressure is needed to obstruct the jugular veins to cause cerebral hypoxia and render someone unconscious in just a few seconds. If strangulation persists, brain death can occur in about 4-5 minutes. 

Intimate partner violence is a prevalent public health problem, and we must maintain a high index of suspicion, especially in patients with less obvious complaints or if their injury pattern doesn’t fit the picture of their story. Remember that strangulation is a significant predictor of future lethal violence, and it is something we should screen for and view as a sentinel event. Ask respectful, but direct questions about patient safety. It may be an opportunity for intervention and to potentially save a life. 

Keep up the great work! 

Stephanie Gaines, MD 

October 21, 2024

There are special considerations of pre-hospital care involved when caring for patients after sexual assault or intimate partner violence. In the state of Ohio, evidence may be collected within 96 hours after the time of sexual assault and submitted as part of the sexual assault forensic examination (SAFE) kit. Remember, the patient’s body is evidence. Be sure to wear gloves during patient interactions to avoid contamination. DNA analysis today is highly sensitive and can be analyzed and detected after they have been washed! The evidence found in DNA can be collected from patients even if they have showered after the assault. If the patient has changed clothes, package the clothes they were assaulted in, especially underwear, in a paper bag and transport the items with them to the hospital. Tell patients that the clothes they are wearing may be collected as evidence and offer a chance for them to grab spare clothes to have upon hospital discharge. Regardless of how heinous the assault was, seeing a SANE RN and undergoing a sexual assault forensic examination is always voluntary and up to the patient to complete. 

In cases of intimate partner violence (IPV), trust your instinct. You may be stepping into a very volatile environment. Always assess scene safety and determine the need for law enforcement accompaniment. Many cases may not be identified as domestic assault since victims often feel embarrassed, or that it is a private matter, so they won’t be forthcoming. The call may come over as something vague such as abdominal pain or headache or may be repeat 911 hang-ups. Document any injuries suspected to be a result of IPV regardless of whether the patient discloses or not. Describe what the scene looked like and any utterances from the patient or others by using quotes in your documentation. What you document may be the only paper trail that can be used one day as future evidence. If a patient declines hospital transport, but your suspicion for IPV is high, directly ask with a statement such as: “Because violence is so common I ask all my patients about it…” If you cannot convince the patient to be transported, be prepared to provide them with education regarding their injuries as well as discrete resources such as the National Domestic Violence Hotline (800-799-7233) or National Sexual Assault Hotline (800-656-4673). Caring for this vulnerable population is complex and challenging. It requires delicate skills and steadfast outreach. 

Thank you for providing that care,  

Stephanie Gaines, MD 

October 28, 2024

Access to forensic nursing services in your community is hospital dependent. For adult patients, hospitals with forensic nurse services include:  

• Akron General 

• Cleveland Clinic Main Campus 

• Fairview Hospital 

• Hillcrest Hospital 

• Metro Health 

• UH Portage 

• UH St. John’s Medical Center 

• UH CMC Main Campus 

Pediatric patients needing SANE RN services can receive forensic care at Akron Children’s Hospital or UH Rainbow Babies and Children's Hospital.

Over the last three years, University Hospitals has been diligently working to expand SANE RN coverage to make forensic nursing care available across the entire UH system. In 2021, the UH SANE program became an endowed program and is named to honor the legacy of Blair Dickey-White who was passionate about the well-being and healing journey of survivors. The UH Blair Dicky-White Sexual Assault Program is committed to ensuring the highest level of care for victim-survivors through comprehensive services, advocacy, and a focus on healing. The program has dedicated full-time SANE Lead RNs who cover and oversee the UH community hospitals.  

The Central Region is led by SANE Coordinator Denise Robinson and includes UHCMC and UH Ahuja. The SANE RN at UHCMC cross-covers cases at UH Ahuja. The Southeast Region is led by Jen Moreland and includes UH Portage, UH Geauga, and UH Conneaut. UH Geauga is currently undergoing SANE RN training, however, for patients presenting to UH Geauga during a time when a SANE RN is not available, the patient may be able to be transferred to UH Portage which provides 24/7 SANE coverage. Michelle Kendall is the SANE lead for the UH Western Region which includes UH St. John’s, UH Elyria, and UH Parma. St. John’s has 24/7 SANE capability, but for patients to UH Elyria or UH Parma, call the ED quarterback or charge nurse to determine SANE availability and options for care. Nia Long heads the UH Lake Region. In addition to a full-time SANE lead position, Lake currently has 2 PRN SANEs with plans to add additional positions and boost SANE training to expand coverage further. For patients presenting in the Lake Region, call the ED quarterback or Charge nurse to assess current SANE RN coverage. 

I have been honored to serve as the inaugural endowed director for the program and continue to push forward our mission which starts with education and increased awareness. Thank you for your continued pursuit of excellence in care and commitment to lifelong learning. 

Have an awesome week,

Stephanie Gaines, MD