Imagine a woman who's coming in seeking help saying like, I know I'm made a mistake. I'm on drugs and I'm pregnant, but I need to come off this. And most places will send these patients out once they're medically stable to a detox facility. Because she was 32 weeks pregnant and far enough along that like something can go wrong. They were like, "Okay, we're just going to keep her here and we're going to do this here." So all the nurses, no one on my unit had ever done this. And I was like, "Well, I'll volunteer as tribute." It just felt so inhumane. Just the the please, the cries for help. And I know that that's part of it. I know that there's like a mental coming off of drugs, but like literally just watching them say there's nothing we can do for you. And like I mean, I was in tears because I just felt like if this was a woman in labor behaving in that manner, we would have been in epidural. you would have been doing the things like that is we consider that level of pain like torturous. Yes. But not with a detox. Is it just because we don't have a protocol for it or is it just or is it all the stigma or both? I think it's both cuz a lot of people were like, "Well, she made these choices. She has to stick through it and she has to go through this." And I'm like, "Okay, but that's the problem. She starts down this path and when it gets to be overwhelming and too much, then she leaves because her care is not being managed properly. And then when she leaves, she uses and then she's like, "Crap, I'm pregnant. I can't keep doing this." And then she comes back in and she's begging, pleading for help. And it's just this vicious. And I know she's not the only one. And when I asked what the protocol was, they said it's to send them to a facility. And I was like, "Huh, what about pregnant people?" And they were like, "Well, psychiatry manages this." So, of course, it's Sunday and they didn't really want to come. I wrote multiple messages to the psychiatrist saying, "I this woman is in distress. I need help at bedside." And they were like, "This is just part of it." And I was like, "No, this is not part of it. This can't be part of it." So, I actually made some phone calls. I know some people in the rehab circles and they were like, "Yeah, it used to be back in the day you would just go to like mental institution. and they would lock you in a room and just let you kick and scream until it was all out of your body. Now the government kind of gets you rehooked on either Suboxin or methadone and then you're just kind of a controlled high. But the reality is there are legalized drugs like cratom and all these things that you can get. Um they don't have as good of a high but they're synthetic forms of these other drugs but the detox is way worse. Yes. I mean, she had been on fentanyl, street fentanyl. So, that's cut with lots of things during the whole pregnancy. But it just made me realize um when I teach my students in OB, we talk about drug use. And I'm like, listen, do not ever shame a mom who comes in smoking cigarettes because chances are she used that to get off meth or fentanyl or something else. And I will take a cigarette baby over a meth baby any day. the way we bring them in, the way we receive them, the facial expressions you make when they talk about either their sexual habits because we're identifying risk or, you know, their drug use is going to decide if they're going to continue to open up to you, which segus into what we're going to talk about.

Hi, I'm Sarah [music] Leavant and I'm so glad you're here. Here at Bundleberg, we believe that your life has the [music] potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability [music] to add value to every person and patient you touch. We want [music] to inspire you with the resources, education, and stories to support you to live your absolute [music] best life, both in and outside of work. But don't expect perfection over here. We're just here to have some conversations about anything birth, work, [music] and life. trying to add some happy to your hour as we all grow together. Bye nurses for nurses. This is happy hour with Bundleber Nurses. Well, welcome to the pod. Yeah, I have been waiting for this conversation for months now. I have to tell you the story of how I I quote unquote stumbled across Morgan. Um Morgan came to move and was a part of our culture court. And so the night before registration, we had a very special, intimate, beautiful dinner. Our culture corps and which is our volunteer nurses to sort of help us support with the culture we were trying to create at Move. We had multiple trainings with these volunteer participant nurses and then also our A team staff, which is what we call like the the like paid staff people that were there for move. And so we had this dinner and Morgan was uh I was going to say strategically placed but like the universe knew strategically placed directly in front of me. And I you know I'd been on calls with culture corps for what did we have like six trainings and so we all like got to know each other to a certain extent where there was like enough comfort there. But I had no idea. And so I have to tell you that prior to move, me and my mom went to go get our nails done and my mom who was head of culture corps had pulled all the culture core applications and had them printed at the nail salon and was going through and she was like, "Do you know about Morgan and her work?" And I was like, "I mean, which one?" Cuz there were three Morgans on culture. I know there were several. [laughter] And I was like, I mean, what do you mean? and she she started talking about your work which all of you are going to get to learn about today and I'm going to get to learn about today because I've held off on lots of this conversation for the pod for you. So this is some of the first time that I'm hearing some of this although we've had multiple conversations and I haven't really been able to help myself. So she started reading your application to me. There was no one else in the salon. Um and I hope so. I know. And I was like, "Oh, yeah. I do remember her, but I had not made the connection between which face it was from the application." And your background is very impressive and very unique in nursing. So, you're going to get to tell us about that. But I was like, "Oo, I can't wait to talk with her." And then, of course, you were you were placed right in front of me at Culture Core dinner. And I don't remember like it it happened so quickly. We sit down at this beautiful fancy meal and then you said to me, um, you use the word near fatal strangulation. She uses this and starts talking about the data on near fatal strangulation. I like had a moment, Morgan. Like I I remember I know I could see it on your face and I was so worried. I was like, "Oh, I just broke Sarah and I scared everyone around me." No, it's so so good. We need to be talking about this. But I I remember looking at you and being like, I mean, I know conceptually what those words mean, but like I don't actually know what you're talking about in nursing. Like, I literally know nothing. What do you mean? And then we got talking about your research. And then the rest of the night, I just was like, I need more. I need more. Tell me everything. And you know, of course, like we only got so far. And so I'm so excited to have this like very intentional conver conversation about your can I say your specialty? I'll let you introduce like your background to it in a second. Sure. Um but you know and and before we get going on this episode and the episodes to follow because I will give you a heads up. This is definitely not a one episode. This is at least a twopart, maybe a threepart because we're going to get into all the things. And I think um you know, I can just see that like I already have so many questions. But I do want to just give a note that if you are if there are little ears nearby that like this is probably not one to have on speaker and to just be mindful of how you feel through this. Um the topics that we're going to be talking about could potentially be triggering. they could be hard to hear. And so I I'm asking everyone to just and kind of giving you that heads up and noting in your own body that if you're feeling like I can't like ah I'm I'm getting disregulated that you would just pause and come back. We will always be here. And if you feel like you can never come back, then that's okay as well. Um, and I also think that if you are in this work, I'm going to strongly encourage you to come back because I think the epiphany that I've had is like, whoa, gap, holy moly. And it's need we we've got to start talking about this given the stats. So, that's my that's my intro to you, but please jump in and tell us who you are. And I know by the way you have heard her voice before because she was on the opener episode of this season with our move recap. Um but tell us who you are and then the work that you've been doing and sort of like this passion that you have been pouring yourself into. Someone once told me that once you've lived in the darkness, you can recognize darkness in someone else. And that's why I want to bring a little bit of light to those with a little bit of darkness. And as every labor nurse has always, we've been there. We've [clears throat] been there at some of the darkest times with families, right? Because not everybody's birth story is the most magical thing, but there's a whole another layer to this. So, um, when I came into nursing, I knew, um, I started as a doula. Um, so I wanted to go and become a nurse. I wanted to go into that next layer. and I went into labor and delivery nursing. And then um I quickly realized that the parents that were not going to take home a bundle of joy were the parents I felt like I was best serving. So I did a lot of extra education on dealing with fetal loss. So that was kind of my my segue to then get into sexual assault nursing. So that term is soon going to be put to bed and we're going to start see and and I'll talk more about that and why and we're trying to just say forensic nursing. Okay. Because I do so much more than sexual assault. Yes. Um so you know no longer wanting to put ourselves in this box of this is the only thing that I do. Um but that's where I started was uh sexual assault nursing. Um, so I do I'm an adult sane. Um, so I do ages 13 and up. Um, or about a tanner stage three and up. So that still includes our adolescence. Okay. So even though I don't do pediatric work, I still like in my heart and especially on labor and delivery when these 13-year-olds come in to deliver, that's a baby having a baby, you know. Um and then from there I started doing my PhD and my PhD is examining nursing self-efficacy and performing near fatal strangulation exams on patients that come into the ER OED or L & D triage. um those are our gateways to the hospital and when we start getting into the research um you'll see why um because pregnant women are in a particularly higher vulnerability space. So I just did this 20our training with Diana Fagno. She's one of the godmothers of forensic nursing. Um she was there at really that inception, writes a lot of the textbooks, is in on the research. You know, one of the things she talks about is the responsibility of the nurse. And the responsibility of the nurse is starting the nursing process, right? Like we start the process, we identify that there's a problem. And it's okay if it's not your specialty. We all have our specialty, right? Like it's okay that we bring someone to take a patient to ICU and then we take the L & D nurse up there to monitor the baby, right? We all have our wheelhouse. But when you start looking at the data, the signs and symptoms in pregnant women are worse when it comes to strangulation and the damage that it causes. And I was like, "Oh, it makes so much sense." Because the physiology behind pregnancy, the hypercoagility, I was like, "Oh, [clears throat] mind blown." There's studies that show they have statistically more hospital visits, more provider visits, they have more problems, which means we have more handson opportunities to save them. and we're missing it. How did you go from we'll call it sexual assault nursing to near fatal strangulation like as a as a specialty? Honestly, when women, men, anyone would come in for a sexual assault, but um women report more frequently than men because of just societal pressures and things. But um so please know when I talk mostly about women um I'm focusing more on pregnant women and the demographic that our nurses here deal with. But by no means am I discrediting what happens to men. Um they when women would come in and they were talking um sexual encounters and the the things that were going on, it was not just a rape, it was a rape and violence. And violence often includes restraint. And this a lot of times the restraint would include um what we call near fatal strangulation. So um hands or objects or arms placed uh against the throat that would occlude the airway or blood flow. Um and that is significant. And then once you start seeing this pattern over and over, some research came out. A lot of this ties back to pornography and the increases in all of these things. Um, and then once we started seeing more and more women with the same injuries, the same problems, the same complaints, I just dove right into the research. And I have some really powerful women around me in my um center that I work at. And it's just when you put these hive minds together and you start absorbing and talking and then it grows. Mhm. And so we want to keep this growing and we want to keep disseminating awareness about this. Mhm. Can you also just for context because it's been helpful for me to understand what are the different ways that you work in I'm going to say OB. Can I say that like so just also so that we know contextually when you say the clinic you know clinic you said or the center um that like what that means and then also um you're a smarty pants and [laughter] aren't you also teaching? So I am teaching. Okay. So, uh, I work full-time as a nursing professor cuz my um my my passion with L & D and all the things like that that if we're going to change maternal mortality rates, if we were going to truly affect change in our world, it's going to start with our students. I'm going to send new nurses out into the working force with evidence-based practice, a lot of bundle birth and things like that because if we're going to make a change, then we got to we have to have a a new caliber of nurse coming out into the workforce. Yeah. So, I do that and then I also work in labor and delivery. We have an obstetric uh emergency room there. So, I'll lovingly call that the OEED or OBED. And then I also work as a sexual assault nurse or a forensic nurse uh with Live Safe Resources, which is right here in Marietta, Georgia. So, we're right outside of Atlanta, the capital here. And so if I refer to the center or anything like that, I'm usually referring to my sexual assault job. And then if I'm working uh if I say the hospital or something like that or OED, it's I'm doing my labor and delivery. But I encounter both types of patients in both of these hospital settings. And for the first time ever, as a teacher, I encountered a patient from the center in my classroom. Um, she came up to me after class and she said, "It's so good to see you again." And I just kind of looked at her and I paused and I could just see her eyes start to melt a little bit, that like glossy emotional look. And then she goes, "You don't recognize me, do you?" And then it clicked. It like because the part of me that does the sexual assault nursing, the part of me that lives in that hospital space, I can put her away, you know? I can have to separate. So, she was not out. She was not on my shoulder. She was not protecting me in that moment. And when I and I just I I was like, "Oh my gosh, how are you?" And she's like, "One and this is recent, like really recent, like within the last month." And she's like, "One day at a time." And she's like, "And um she's like, "I'm doing something with my life." And she's [snorts] clearly in nursing school. And I [clears throat] and when I say she's at the beginning, she's at the beginning. And I was like, this is so amazing. And so I, you know, I realized then and there I was like, I've never seen one like out in the wild like this. [laughter] Like I was not prepared. This is the part that like we've had this part of the conversation, but I think it's necessary because I when I you first used the word strangulation, I was like, I mean, are we talking real strangul like word like strangle like the word? Yes. Um, and so I literally I think I said to you like that's a thing. Yes. So that's a thing, Morgan. It's a thing. So let's actually let's have a quick little vocabulary lesson. Tony. Okay. So remember choking is on the inside like you choke on like a grate, right? Like when kids put like a little hot dog in their mouth or something. But we will often in conversation or our patients will use the word choke. Okay. Strangulation is external. Okay. Um we say near fatal because you didn't die from it, right? But any compression on the external part of the neck that includes blood flow or you know uh air flow um this is very very dangerous and you don't need a lot of pressure on the neck. So you remember you've got your jugular veins and you've got your corateed arteries. Your jugular veins become accluded at about 4.4 pounds of pressure. Okay. The arteries in the neck, it takes about 11 pounds. Now, a strong male handshake is like 80 to 100 pounds of pressure. Um, to do like a soda can is like 20 pounds of pressure. Okay. So, PSI. Yes. So um I I mentioned that because I want to give you some reference, right? So we're not talking about so PSI is how we measure these things. So pounds per square inch, right? It does not take much to olude these vessels. Now you also have some deeper vessels. Those are the vertebral arteries. That takes about 66 pounds of pressure. That's a lot of pressure. So if you get all the way to those and those are the arteries that are really close to the vertebrae, okay? Not the ones that are floating out here in the neck like the corateed and the jugular. So but it doesn't handshake is 80. So 80 to 100. Yes, ma'am. So that's as much as a strong handshake. A strong man. Yeah. Like a good firm like welcoming handshake. Yeah. Um, and I just for anyone that does deal with, you know, pediatrics or whatnot, we do not know the numbers for children, okay? We don't know the pounds of pressure for children. That is just not something that's been tested or that we have accurate data on. So, these numbers only apply to adults. Okay. So, this is happening. Yes. How much? A lot. Um so to back up a little bit when I mentioned um so we saw during COVID um that the rates of pornography consumption went up and there's a lot of really cool research that's come out talking about and when we see it in pornography they don't call it strangulation that's choking okay so the rough play the air play all of these things um and it became very mainstream very common and we see a lot of our young people playing with it. So this became, you know, it we see it in pop culture, we see it in music, we see it in different places, we've seen it even in movies, right? So the quote unquote rough sex. So it's been like sexified. Yes, it is. It's sexy. It's risque. Um, you know, choke collars and that SNM type world. And I'm please know I'm not begrudging anyone their lifestyle, okay? But it it just became more mainstream. Um but the problem is not everyone is educating themselves on the appropriate ways to to have these lifestyles. And then when you find out how easy it is to damage these vessels and the ramifications, if damage does happen, um you cannot consent to something that can kill you. That is not an option. Like we don't we don't look at it this way. Um, and there's a big push for near fatal strangulation and IPV to start being investigated like homicide because we know now that when it comes to strangulation, um, the strangulation institute has wonderful data on this that they are finding that there are suicides that are really homicides and it's Yes. And especially when it especially when it comes to our pregnant and recently postpartum women, we are in that that they are in that highest demographic. If a woman has experienced intimate partner violence that included a near fatal strangulation, that woman is 700% more likely to experience homicide by that same partner. 700. Yes. Yes. And if she's pregnant, um, we know that they are going to have more visits to either your L &D triage, the office, they are going to come in more. They're going to seek more help. And these are more opportunities for us to be connecting, doing our IPV screenings, and asking these questions because these are the women we're, you know, hoping to save. I want that 700% to be a 0%. Yeah. Yeah. Well, and we know that domestic violence increases in pregnancy. Like pregnancy is a risk factor for DB. So it is. Um. O. Okay. But okay. So I remember I I was like so this is happening like I just I feel like I asked you that like so many times. Yes. You told me how many times a week do you see someone in your center for near fatal strangulation? es and flows. We I I hate to say this, we have busy busy seasons. Um but I would say between myself and the other nurses, there's probably like at least three to five women coming in on a regular just just for like strangulation screenings. And then if you add in the sexual assault screenings that include a stringulation assessment and we have weeks where there could be 10 or more and then you'll have weeks where maybe no one comes in. But I mean this is often this is in one center in Georgia that people are actually coming in for that to me. He told [clears throat] me that at at at move and I was like and we have other nurses. Um so because I have a primary job, there are other nurses that do these specific exams as well. And I love the women at my center. They are so good about sharing education and talking with each other. And the other thing is like when we have to go to court, one of the nurses I work with, Jenna, she shared she was like, "Girls, this is exciting because of the forensic interview and because of this and that, like we got him, you know, and she was talking about other things that went wrong, but because of the work that she did and because of the forensic interview and the evidence and the things like that was one of the things that would help convict this person." Wow. And it's so so important what we do. This is and sometimes it can make or break a case and you know to see all these women in our little group me and we're cheering for Jenna and we were so excited. I know. Yeah. Okay. So then you add a legal component. So then you would be considered an expert witness or a witness or a what would you be in these trials? So we're just like the arresting officer, right? like if someone gets arrested and they bring the officer in like what happened, what did they say, what or the interviewing officer, things like that. Um, we will come in and keep in mind we're talking to a jury. So, this is people like everyone that's listening right now that might not know anything about what I do. So, we come in, we talk about what is a sexual assault kit, what is a strangulation exam, what is all of this, and we also talk about how emotional and how honestly traumatizing it is to we try so hard not to retraumatize our patients, but it's like, hey, we're about to talk about probably the worst day of your life, and I'm going to ask you to relive it again, second by second, and then I'm going to take evidence and swabs and pictures and photos, and it's it's very it's very intimate. It's very long. It's daunting. Um, and we share all of that with the jury. We explain some of the evidence. We explain it. Just depends on what they're trying to present. Um, you know, it doesn't take long. It takes about five to 10 seconds to render someone unconscious. Like the timeline is very short. And so when we go to trial, we will have the DA like will bring like handouts and things to try to help visualize this for the jury and to try to disseminate this and for people to understand like how serious it is. Because just like I'm explaining to you, they're going to get on there and be like, "What's near fatal strangulation? Like why do we care about this?" You know, like what's and like, "Oh no, you care." Yeah. Let me tell you why. And you didn't know you cared until this moment. Here's your moment. Yeah. Wow. Okay. So, near fatal strangulation is happening. More prevalent than we realize. This feels like almost niche and kind of like unknown. But how does this relate to morbidity mortality data? Okay. So, um, one in four women are going to experience intimate partner violence in their lifetime. Okay. Of those women at high risk, we'll say between 68 and 80%, they're going to experience a near fatal strangulation by their partner. Okay. Of the so of the the one in four, so keep in mind, one in four are going to experience Yeah. that intimate partner violence in their lifetime. And then those women about 60 to 80% of them are going to experience near fatal strangulation, right? I know that's a I know. Um so here's the thing. Um when you start breaking this down, women who've experienced like IPV, including strangulation, are estimated to have suffered like some type of traumatic brain injury. about 92% and up will end up with some type of traumatic brain injury because when we talk about um so axic brain injury, right? So we just talked about pounds of pressure, it doesn't take much and it doesn't take long for us to have injury in that area. Um about 58% are that are strangled along with sexual abuse and about 9% of those are also pregnant at the same time. So I mean that's you know 58% of those one in four are going to get sexually assaulted at the same time and of those about 9% are going to be pregnant when it happens. Like that's like so this is actually happening and like we've all been exposed to this without even knowing it. Yes. Um, so the strangulation institute has got great great data on this and infographics and I I'm definitely leaning on their research right now. So I love all of their stuff that they put out. And one of the things they talk about, you know, is about 38% of of these women are going to lose consciousness, you know, um 97% of them report that the strangulation is done with um hands. So, it's not always someone using something else. It's just, you know, them using their hands. But the biggest thing that hit home for me is 94% of the women that I talked to with this believed that they were going to die.

And when something so serious happens that you think you're going to die, that is a very significant moment in your life, right? Just just like we deal with labor and delivery, right? Like they're going to remember the birth of their child forever. This is a this is another milestone moment in someone's life that's going to stay there forever. Yeah. It's a big tea trauma. Yep. It is. Well, and then you that's the that's the psych psychological layer that you add on to this of you're not only dealing with the physiology that could be potentially fatal. And if it's not fatal today on the day of the incident, it may be fatal later, which I'll have you talk about, but also you add the psychological trauma and the needs of somebody when they've gone through a traumatic experience. And then you throw that they may they may potentially be going straight home to their abuser. And then you add the like pathophysiology of pregnancy. So now you're concerned about the triple hypercoagulable state is yes and what that means for potentially labor and birth which we don't even think about and we should be thinking about and knowing about but in theory like it's that becomes the risk factor for a complicated we say pregnancy labor birth postpartum yes and the the other thing with this is that there's a delayed fatality so this is something that we started talking about. And so death can occur days to weeks later after an attack where if there's what's called a corateed artery dissection or any type of pneumonia complication and this can result in a stroke which can happen because blood clots will travel from where that dissection is. Um and this can be small. It doesn't need to be something that we necessarily see on the outside and then it'll travel to the brain. So causing that eskeemic stroke. Um about 50% of near fatal strangulation cases are not going to have visible injuries on the outside which is why if someone is reporting this um we always say I don't have X-ray eyes and neither does a doctor. So at the moment the recommendation is a a CTA or CT andogram of the the head and neck to make sure that those vessels are okay. Um, there have been cases of women dying of stroke and nobody knew why. It was just always like, oh, a mystery. Why did this happen? Now we know why. Now we know why. Back in 2022, um Harvard um put out an article. It's often referred to in our circles as the THAN article. and they talk about the act the actual number one cause of maternal mortality is homicide. Um so when it comes to pregnancy related death so homicide and suicide like violent you know uh manners of death are actually higher than the ones that are happening in the hospital. So homicides with firearms is is the biggest one, but then homicide in general being so high, one of the number one predictors of that homicide for a woman is experiencing near fatal strangulation. I think this that part is what what got me because as I was prepping for move, I was we were we were talking about the patient experience, which by the way, you can take the class yourself. It's now live and online and anybody can go to it. Not that you need to because you were there but I'm saying to our audience and I as I was prepping for the like the patient experience piece I'm asking the question like what do patients want from their birth you know and my first response was actually like they don't want to die you know and that that is the reality of what patients are hearing and certain demographics are going to be more likely to die during childirth but I think us as labor and delivery nurses We think labor and birth death and rarely do we see that. And so if we pull it back a little bit beyond just the labor and birth experience to be honest like I've always heard that cardiac is number one killer. Yeah. And then I started pushing into that and I I had it on the slide where I'm like number one is homicide suicide and but I remember coming across that and being like how did I miss that? What in the world? And then I I think isn't substance use disorder in there isn't there now? Yeah. Yeah. And and that has been a recent one for me because um and actually I was speaking at an A1 a state A1 and they had all the stuff on substance use and I was just like I mean great for them and then I was like wait a second where am I missing this? like and I and maybe it's just me that like somewhere in there like it's I've been lost in there. But let's be clear, the number one reason for mortality is homicide, suicide, substance use. Um and then you start to get into some of the other things. And so this directly links to all of us. We all talk about morbidity, mortality, let's prevent morbidity, mortality. And so when when we got going on this conversation, I just was like, "Wait, like we've we've we've like missed the thing." Like this wait, this is like an entire humongous potential gap for us. It is a potential gap. But here's the thing. It's really difficult to train nurses on, hey, you need to do this because we're going to prevent a homicide, right? Like that that sounds that sounds crazy. Yeah, [laughter] that's fair. But when you take a step back and you're like, "Okay, the the study that Harvard put out um talked about that the data they pulled was 2009 to 2019. 68% of pregnancy related homicides like you know involved firearms." So we're like, "Okay, sure. This is a gun problem." No, it's really not. It's way more than that, right? And it took from 2019 until honestly there's articles coming out this year that have really dove into this. Okay. And unfortunately because of the rates we have in the United States, we know that black women face like substantially higher risk for homicide and death and all the other things. But nobody has the answer right now to the homicide piece. But the answer is that we were trying to like okay if we can't fix that let's fix the cardiac piece let's fix the hemorrhaging piece like let's make and and we need to keep making good efforts in those arenas by no means do I think that the data and the things should stop in those arenas but we really need to get a handle on this other piece too and where we come in right is that if it's cons it's truly a health emergency for a pregnant woman to experience intimate partner violence. Okay? Because pregnancy related homicides are preventable. And that's what I want people to remember. Pregnancy related homicides are preventable. Um they have checkups, healthc care providers that they get to see. And we know on average they're going to come in more often, which are more opportunities for us to connect with them, to build relationships. And if they're not ready to leave, okay, we can't make them leave. That's not what we're here for. But what we can do is we help them get a safety plan in place. So when the moment does come, they know what to do and they're ready to go. So tell me where like what's in a safety plan. So there's a lot of things. It depends um on where your patient is in the process. Okay. If she's ready to go, then we start immediately establishing like, okay, do you have pets? Do you have kids? Where are you going to go? Can they get into your phone? Do they have keys to your house? And we start making plans. Now, let's say this woman is not ready to leave, right? She does have kids and they have school and this and that. We go, okay, is it when the person drinks or uses substances? Is that when the problems happen? Okay. Well, if he's drinking and using, can we go somewhere else for the night? Can we take the kids and go to grandma's house? Right? We make a plan. We're sitting there in a calm space, not judging her because she doesn't want to leave, right? That's not what we're there for. We're like, "Okay, let's make a plan." That way, when things start hitting the fan, she's not racking her brain going, "What am I going to do?" Yeah. We have a plan. We keep our keys by the door. We know where our purse is at all times because when we need to, these are the steps we're going to take when we need to leave. Whether it's forever, whether it's shortterm, whatever, that's our safety plan. What happens to the dog? What happens to the cat? Where did the kids go? Because you don't want to be thinking and panicking in the moment when you can't think clearly. You want to have a plan and you want your patient to feel good about their plan. And then when things start happening, they already know what to do. Yep. That's that's part of it. I think that's helpful for me to it's like there is an quote unquote intervention that can help that can help because I think about you know we'll talk we'll talk so everyone listening like I'm going to ask the question about your assessment. What would you see? What like what are the signs and all of that. So, we're getting there, but before we get there, I think for me to know that like it's not just rescuing them and saying you need to leave them. No. You know, and that's actually probably not helpful because it feels so overwhelming and and doesn't lead to actually any good outcome. And so, but this idea of a safety plan does feel tangible and does feel like okay. And me as a nurse, I'm like, okay, if I can initiate slash, and that's my question for you is like, I'm not doing the safety plan because I don't know what the heck I'm doing unless I'm trained in it. And so, what would be the call? And then we're going to backtrack to like assessment and all of that to get to a safety plan. How does that how does that work? And what's your suggestion there? So there are great forms and just standard things that you can follow and we can get on your unit. You know when it comes to safety planning if any patient not just strangulation not just if any patient opens up and there is any type of problem right an unsafe environment okay this is all very personalized to that patient. Yeah. So the first step is okay, can we get out of the dangerous situation wherever that may be? So sometimes it's getting them to a shelter having like and sometimes it's driving to a shelter. Sometimes it's knowing like hey when this happens when you're ready come to this shelter, come to this place and then we'll find help you find more temporary housing something like that. Um, but they also, like you said, when a person is experiencing intimate partner violence, a lot of or assault or rape or anything like that, all of their decision-m is taken away from them. All of their control is taken away from them. So, the main thing when it comes to safety planning is, you know, how do we let them make decisions about what's going to happen with their care, with their life, and support them in those decisions. So, little things to think about like, you know, taking the facial ID off of your phone because if your partner, you know, strangles you and you pass out, they can just hold the phone up to you and it reads your face and now your phone is open, right? So, having them do the numeric codes, you know, do does this person have access to your house? Do do we need to get new locks? Right? Do we need to change codes on things? Do they know where you work? You know, so it all depends on the the patient themselves. Um there are different just generic safety plan questions on different forms that are available free to hospitals and centers to use that provide some like basic like do you have a cat? Do you have a dog? Do you have kids? and like making sure that you cover those things. But the reality is you're you're having to specialize it to whomever you're talking to and their individual situations. I know one of the nurses I worked with um they had to find a place for a horse to go and it turns out there are like Yeah, there are centers that like shelters and things that will take animals and somehow they found a place that it was like a rescue barn and it took the source. Yeah. So, I mean, like there's resources out there that you don't even realize exists until you start digging and looking. And I would have never known [clears throat] that it existed until we had a patient come in who needed that type of care and that help. So, then I just download a form and walk them through it or first off, there's different like risk assessment type tools. So, the DA5, you do need to get certified to do a DA5 like appropriately, but you can look up the DA5, but there's great websites like um women'slaw.org has uh safety planning. There's one through um the hotline.org, which is the national domestic um violence hotline. And I love theirs because theirs is great. It's almost like the person can do it on their own and they don't have to feel like they have to talk to you about it. Um, and it will ask them questions and you can walk through it with them and it it's literally establishing all of those things. So, when you're talking to your patient and you're finding out like where they live, okay, is that a safe place? And you literally are just checking off um and I don't want to say checking off because that sounds like they're a box, right? The when it comes to planning safety, right? when we're trying to create these safety plans, we're trying to support this person and get them out of this space, right? So, sometimes these tools, these safety planning tools, they're there to remind you to ask about these things, right? Because at first when I started doing this, I didn't think to ask about facial recognition, you know? I didn't think about asking like, you know, oh, are you in school? Is this person in school with you? right? Like you know and it makes it reminds you to ask these things of your patient so that you can think about all these potential scenarios that they might need intervention, you know, asking about trusted people, family, do they have a code word, right? Like so code phrases. So if you know if you're my person Sarah and I call you and I'm like, "Hey, remember that book I lent you about Bluey? Um are you done reading it?" Yes. Super normal thing. and you'd be like, "Oh, okay." But you know, that's my code phrase. That means I need help. I need you to come over. I need whatever it means. You know, um, you know, do you have some somewhere to stay with? Like do you have somewhere you can go in public near you? Some like things like that. Like where are you going to go in case of like an actual emergency? Like what if they're following you home? Like you know, it just depends on the situation. So there's basics you know and then talking about school talking about children and then also we talk about emotional safety in this. Do they have a therapist? Do they have a counselor? Do they have access to this? So that is all part of this. So everything from their home, their technology, passwords on things, you know, children in the home, pets in the home, and all the things that like I'm never going to think about. And here's the other thing, too. when we're nurses and we're connecting with someone on that level, you know, and you're talking about these things, it's helpful for me to have those check boxes so I can remember, right? Okay. Did I ask her about all of these things because my personal life is so different from her life? I might not think to ask about a horse, you know? Yeah. [laughter] You know, maybe the maybe they'll have some kind of crazy fish tank or something that you've got to figure out a plan for now. Like, who knows? But we want to be able to ask those questions and we want to have some type of and so there's tons of resources for that. So they you do the safety plan and then and then what they're left with a piece of paper or they just they have a note in their phone or they have it in their head or you have it in their chart. It's so if we do one at the center sometimes we will I'll put a copy of it in like I'll take a photo of it and it goes into their electronic MAR with us. Um, and we they can have a paper copy. If we're worried about their partner seeing it, maybe a paper copy is dangerous. Again, every person's situation. That's why I really like um the one at the hotline.org because that one can be on their phone or in their email. Um, sometimes going through it and going, "Okay, like this is what I'm going to do when this happens and this is what I'm going to do when this happens." A lot of times these women will remember these things, but they can keep it in the notes in their phone, keep it in their email, and if they start to panic and they don't remember, they can easily pull pull it up. We also encourage like, you know, like Sarah, if you're my person, I'm going to send you my safety plan, you know, so that if I panic and I call you and I ask for that book about Bluey, you're going to be like, "Okay, what do you need?" And you can start helping me remember or work through whatever I'm dealing with. Sure. You know, if I ask for the Bluey book, you're like, "Okay, meet me at the Quick Trip. I'll be there." And or whatever gas station, whatever safe place is nearby, you know, and that's those are the specific things that you you do with a patient. So, they're not meant to be long drawn out documents. They're short, they're quick, and you know, if you got to get up and go, okay, what do you need? You need your purse and you need your keys. Where are Put them in the same place every time. Where are we going to keep them? have her tell you, "I'm gonna keep them by the door. I'm gonna keep them here." And you and you remind her, okay, when you get home, remember to do this because when you need that moment, you know where they're at. You have that moment of clarity. Go grab them, get what you need, and go. And we're here waiting for you. It feels so autonomous versus what I can imagine could happen when you're it comes from such a good place like you care and I'm like oh my gosh you you disclose something to me that makes me nervous about your safety or makes me nervous for your life and I want to help but like our instinct is well you got to run you got to leave. It's not that simple. One of the things I talked about at move slightly was just about being curious not judgmental and first thought second thought which you'll learn in the live colorfully class if you join us. And I think a lot of that and even just the like respectful care of like I respect that and when you're hearing something that is hard to hear and we want to save them. A lot of us have a little bit of savior complex in us as well of like that's why we got into this work that I think it's easy to be like well they just have to leave and why not and then we very quickly become judgmental about our patients and about their life circumstances. You know you told a story at the beginning of this about a patient that you had Yeah. with a with substance use disorder. And so, you know, it's like easily we we we think we know, but also all of us need to just slow our roll and realize we do not know what it's like to be in their shoes. Here's the thing. When if you're telling her what to do, telling her how to live her life, telling her all, she knows. She knows. She already knows. You're not telling her anything new. You're no different than the person that was abusing her. So instead of belittling her and pushing her down, let's build her up and give her the tools that she needs so that and my my hope deep down inside is when I give her when I empower her. I don't I don't want to give her when I empower her when I empower her with these tools that when the moment comes that she's going to feel that power inside of her and she's going to pick up that purse and keys and go. and that'll be the last time, you know, but all I can do is remind her that she is a strong woman or or man if I'm dealing with a man because we do deal with this with men. Um but, you know, um for, you know, we we want them to feel strong, you know, and feel like you do have a choice and you can do this and when you're ready, we will be here with open arms. Yeah. you know, well, and how much more empowering that actually is. You know, as stupid as this example is, this is a really dumb comparison, but I think for most of many of us can relate to this one more than we can, like near fatal strangulation, is um is when you're you're dating someone wrong or like you have a friend that's dating someone wrong. Like, I know that I'm like he's bad for me. I know that like I should break up with him. And you can tell me that till you're blue in the face. And like I don't care. I'm going to do what I'm going to do. And I have to get to a place that I'm ready and I feel settled about that decision to break up with them or whatever. And often times we want to control our environments. We want to control those around us because we're uncomfortable with what we're hearing and we we want good for other people. So it comes from a really beautiful place and it's not actually helpful. What's helpful is for my friends to support me and say, "I believe in you. You're strong and you're worth it." And you know, if you're not happy, then you need to you need to like think about that and consider what it what else your life could look like and how you know, whatever. Like anything, but just telling me what to do. And once again, it's like it's about putting control back in their hands. We talk about that for labor and birth, how important that is in preventing trauma in the process. And that's true for life as well. Yes. I would love for you to walk me through what a nurse would see in an instance of near fatal strangulation. So, someone presents to triage sometimes disclosing, but honestly, I've worked a lot of triage and I've literally never had anybody tell me anything about being strangled. Yes. So, what walk me through this? The best thing that I've ever seen that kind of gave me this comparison. Um, I was in some training recently with Diana Bagno and she it was a generic little video off YouTube and it was a dog that had done something bad and the owner was like, "Come here." And you see it kind of peer around the corner and like the the owner is making the dog come in the room and it had torn up something or but its head was down and like turning to the side and it was just so sad like it knew it was in trouble, right? And you know she paused and she's like look at this. This dog doesn't look beaten. There's no no signs or but its head was down. It was turning to the side. It was not making eye contact. It was scared. It was vulnerable. It knew it had messed up. it it it didn't know how to respond and it was timid, right? So, think about how many women have come in saying, um, I don't feel right or I'm not feeling my baby move or just all of these things, right? And we we push it off or they didn't eat, they dehydrated, this, that, the other, right? Um, or we put them on the monitor and they're like, "Oh, well, now the baby's moving because I'm here. They're moving now because she's safe." the, you know, the adrenaline's down, the, you know, the fight or flight is coming down because she's safe, you know. Um, so they're going to come in and you may not see injuries, you may not see anything, but most hospitals, I say most because I don't want to speak for all, do have some basic safety questions, right? And you as a nurse should not ask those with other people in the room. And if you're going to be doing those types of screenings, um, doing them correctly is so, so important. So, so important. If your patient jumps at being touched, can't tolerate being touched. If you're going to do an IV and you see a bruise and you're like, "Hey, how'd that happen? I don't know. I bumped into something." And then you see one on their leg or this or that. Um, doing that full head to toe on admission is so important because sometimes those signs are are under our clothes, right? It's not always on our face and our head. Um, once near fatal strangulation has gone long enough and there starts to be visible signs, they they had occlusion of blood flow or air flow for a while. And when I say a while, we're talking more than 10 seconds, okay? because that is I mean 10 seconds is a long time when you can't breathe. Yeah. Um but you know if they're arguing or fighting and keep in mind too as soon as something is around someone's neck they're going to stick their hands up and try to start relieving that pressure. So you know even if they're the argument the fight whatever is going on longer than that the consistent pressure might not be enough to give those signs and symptoms right away. Think about like when you hit yourself, how long it might take for a bruise to form. Sure. How quick is she coming into you? How quick, like, so we don't know. Um, so this is why you have those risk assessment questions, right? Um, but if someone were to mention that they had a fight, um, or they've been arguing or, you know, they give you some reason to think that you should do more questions, right? There's just something there. You can um, I mentioned the danger assessment or the DA5. Um it's a really good assessment to do and you know it has questions on it that allow you to assess um how high risk for homicide or severe injury that person is by their current or former intimate partner. Okay. So this tool is an amazing tool. Um [snorts] this um tool comes up a lot in our training. So it's a great piece. There are also strangulation questionnaires. So, um there's training, right, that goes with this. But as far as being, you know, labor and delivery or oed or wherever you work, if someone tells you that they have had some type of physical altercation with um their their partner, something as simple as, "Hey, did they put their hands or anything around your neck or over your nose and mouth?" Separate it into two questions. get one for the neck and then at any point was anything over your nose or mouth or did you feel like you couldn't breathe? If you get a yes to either of those, you need to get more information, right? Just like you would your nursing process, right? Oh, tell me more. Mhm. I'm so sorry this happened to you. Can we talk about it? And if they say not now, assess what's happening in the room. Y Okay. Can we can we get the person out of the room? Do we need to take a trip to go do a test that doesn't exist in the ultrasound room or something like that so that we can separate our patient without it being obvious, you know, whatever the case may be. And then um there are um strangulation questionnaires that you can go through. And then we have um some great there's some great great resources on you know testing cranial nerves. Um one of my favorite that someone shared with me is testing cranial nerves with a piece of gum. And I know right you can test all the cranial nerves with a piece of gum. Um I'll share that article with you to share with our nurses. I can't even take credit for it. It's a wonderful article. Oh okay. So very simple. Um the Academy of Forensic Nurses has um a cranial nerve assessment where it has all the little the little tasks. They're quick because keep in mind we don't want to prolong these types of assessments any longer than they need to be, right? This is not what a labor and delivery nurse would be doing. a forensic um they could get they could do the cranial nerve test and do the strangulation questionnaires and things, but once they identify that like, okay, we have something more here, you know, depending on hospital protocol, we can get a a forensic nurse in there, we can get whatever in there, but while they're in your care, right, if you know that there's potential that something has happened to the vessels in their neck or something has happened that could cause problems later, Um, in my research, one of the questions that I ask is, have you ever cared for a patient that had ramifications of a neuro fatal strangulation after they were in your care? And everybody said, like, I don't want to say everybody because like, but almost everybody said no. And I desperately wish I could go back and start combing through all of their records, be like, "No, there was this one and this one and this one." But the point of the question was um knowing that so many nurses were just unaware of the things that you know had come through their oped or their ER or like the outcomes and that was a little sad for me to see that one but it was a necessary question. Sure. And it also brought awareness to me of like how many women came through because we we know we can see when there's uh bad vibes between partners and there's tension in the delivery room. You know, dad throws something or you know, mom can't answer a question, she has to look at him to answer the question or, you know, um how many of those did have bad outcomes and I just don't know about it. And I didn't I didn't say anything. I didn't ask in the moment. I didn't separate them. I didn't do more. Like I just kind of And this was before I knew. Before I knew better. Are there external signs that would be obvious? Yeah. Yeah. Now, now it now keep in mind like I said 50% of the time there are no external signs. Sure. Um, petiquei are one of the first things to show up and um, when petiki show up when you look at the timeline usually there's occlusion of those vessels for more than 10 seconds at that point. So, um, we look at these timelines to establish like what like what happened. Um, at 14 seconds that's when like an anoxic seizure can happen. So, all of this comes, by the way, from a study that was done in the 40s, but we could never do this this study again. Okay, this never never um I believe these men were in prison um and they wore a device and it compressed their neck and they timed all of these things and got all of this. This is just as bad as Tuskegee. Yeah. So we will never we will never be able to have this type of data again. But it literally puts what happens, you know, like when there's loss of bladder, when there's loss of bowel, it's a it's a great timeline. Uh we use it a lot when you have to testify. Um so when you hit about that 10se second mark and you know that they could lose consciousness, they could have all of these things go happen, right? Um, you can have petique eye on the scalp, on the soft palette, behind the ears, okay, around the eyes, especially in the eyes. Um, you know, you'll you'll want your patient to lift or lower their lids. Um, you can see congestion in the vessels or even blown vessels. Around the neck, there can be bruising, swollen tongue, swollen lips, scratches. if they use a ligature um which means um they didn't use their hands, they used like a cord or something like that, sometimes that will leave an indent. Um and the way that we look at that, right, is if someone were to try to harm themselves, the angle would go more up in the back versus a straight across the neck if it was done by someone else. Um, and these are, I guess, more obvious. Sometimes you'll see scratch marks at the neck. Um, because if something's around your neck and you can't breathe, you're going to start scratching and pulling at it, right? Fingernails and hands. If your patients have got severely broken nails, like, and I'm talking like, you know, not just some chipped palace, like if their hands are like like broken nails, blood around them, like take a look, right? How often do we inspect their hands? Hands and fingernails are so important. So important. Bruising. Um, another thing is paptosis or the droopy eye. But the the main things there, you know, dizziness, headache, horse voice, sore throat. So, you might not have any visible stuff out here, but I'll ask women, you know, this is my first time I'm seeing you. I'll have them look in the mirror. Does anything look swollen to you? Does this sound like your normal voice? and they'll tell you like, "No, my voice sounds different." Um, "No, this eye looks a little puffier than it normally does."

Um, with our pregnant women, if they came in and they're like, you know, um, and sometimes it is just they peed themselves, right? What was going on? Why'd you pee yourself? You know, oh, my water broke, maybe, but you peed yourself. Why'd you pee yourself? Sometimes it's just as simple as a baby kicking a bladder. Okay. Sure. So, of course, don't start assuming that anybody who came in that's not actually ruptured. Yeah. Yes. But if she's coming in and she's very emotional, she's disheveled, she's shaken, she tells you that she thinks her water broke, you know. Yep. Those listening, this is a lot to ingest. For me, especially now, I've known you for a few months and we've had multiple conversations, so I'm like not quite as shell shocked as I was that first conversation. And to be honest, like I thought about you the entire way through move and was like, I need to know more. I need to know more. So, if you are feeling like I did, we are coming back next week and we're going to continue this conversation. What I want to talk about is continuing to look at the nursing assessment of what we would see. So, these signs and then I want to know what your suggestion would be on what we do because I think you touched on it, but I have some more follow-up questions on that. I want to talk about some specific strategies on how to ask those questions or how to get people out of the room because that's super awkward for us. So, I want to talk about that and I want to talk about your research specific to this and nurse nurse is it nurse confidence self-efficacy with similar to efficacy. Yeah. Um, your confidence is your emotional part. Your self- advocacy is how well you think you do it. Ooh. Okay. So, we're going to come back for episode two and continue this conversation and then we're going to have another conversation specifically about sane nursing and that forensic arm and what we can do in that realm. So, like y'all, we are on a ride and thank you for being here. [laughter] Um, and we will be back next week with more from Morgan and this super important conversation for our practice. Thanks for spending your time with us during this episode of Happy Hour with Bundle Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirth nurses.com, subscribe to our newsletter, or follow us on Instagram. Now it's your turn to take what you learned today, apply it to your life, and just sit with the information, and think about what your next step is in learning more about this very pertinent and also very undertalked about topic. Check out the show notes down below for some resources if you are looking for more. And then we will see you next time.