It may not be immediately evident when someone was strangled so it’s vital for first responders, nurses and doctors to recognize the signs.

Firefighters, police officers and representatives from social services organizations heard that message from Lynne Berthiaume, a forensic nurse who is an expert on strangulation in domestic violence situations, during the South King County Regional domestic violence task force meeting May 16. The event was hosted by the Covington Domestic Violence Task Force at Covington City Hall.

“We know that domestic violence is extremely costly,” Berthiaume said. “As health care providers and mental health care providers it is important that we can quickly intervene.”

There are close to two million injuries and 1,300 deaths annually related to domestic violence as well as $4.1 billion in direct medical and mental health care costs, according to information provided by Berthiaume.

Visible indicators of strangulation don’t often appear within the first 24 hours after the act, Berthiaume said.

“It’s really important that we become knowledgeable in strangulation,” Berthiaume said. “It really takes putting on that hat and looking at these with a fine toothed comb and a strong eye and some skills that I’ll be able to provide for you and you’ll feel more well-versed in this matter.”

Berthiaume first became involved with assault victims while working at Tacoma General Hospital in the late 1990s.

“I went to an information session and was immediately drawn in,” Berthiaume said. “I knew that we needed to have a response that was more than just on-call, that it needed to be comprehensive … and that it needed to be more than sexual assault, it needed to include domestic violence.”

As a result, she completed her bachelor’s degree a master’s degree while working at Tacoma General. During that time, she became an expert on sexual assault and domestic violence, all while helping the unit at the hospital grow.

She now works in the emergency department at St. Joseph’s as a forensic nurse consultant.

Berthiaume explained the signs to watch for, the questions to ask and how to approach victims who may have been strangled.

She also talked about how victims she sees are mostly women because men often don’t report domestic violence to medical providers.

“You need to ask the question, has anybody been hurting you? You would be surprised at the things they will tell you,” Berthiaume said. “It’s astounding to hear the accounts when someone starts with ‘I fell.’”

Often patients won’t disclose the truth, in part or in full, the first time she asks.

If the evidence — marks on the front or back of the neck, black eyes, blood in the eyes, breathing difficulties or a raspy voice, as a few examples — don’t match the victim’s account, Berthiaume will say so.

If that doesn’t elicit a response, she tries another tactic, because it is important to treat victims as well as offer them help to get away from their abusers.

“I often say, and this is very strong, but it works, I say, ‘I know you don’t want to leave him but I have been doing this work for some time and I can tell you this won’t stop … there’s either two ways it will stop, you will either find a way to separate from the violence or he will stop it by killing you.’ I generally get a full disclosure or nearly a full disclosure when I say that.”

Then she leaves the patient alone to think about things then checks back in on them.

Berthiaume explained to the audience that domestic violence victims struggle to leave for a variety of reasons and a victim is at greatest risk when attempting to get away from the abuser.

Sometimes, Berthiaume said, doctors, nurses and others who provide treatment are afraid to ask the questions when they suspect domestic violence because they don’t know how to intervene.

That is why she speaks on the topic, specifically strangulation, because time is critical.

The effects of strangulation take time to develop and patients have been found dead up to 36 hours after being strangled.

Strangulation, Berthiaume said, is the most lethal and insidious form of domestic violence because symptoms and evidence often do not immediately present themselves unless someone is trained to look for them.

“On the first day strangulation occurs, unless it is extremely forceful, there are no external indications,” Berthiaume said. “It takes a lot of patience to work these cases.”

In fact, 62 percent of strangulation victims have no visible injuries on the first day, however 50 percent have changes in their voices, swallowing and breathing problems.

Berthiaume went through a series of photographs, describing the situations the victims were in, how they were strangled and other injuries suffered at the hands of abusers.

She explained what police and firefighter-EMTs can look for when responding to reports of domestic violence.

This knowledge could help save lives but Berthiaume said it’s not easy work to do.

Berthiaume said forensic nurses often burn out in two years or less.

“When you’re in the work and you’re seeing how important the work is and the impact it can have … you cannot drop that ball,” she said. “The work has been extremely challenging and extremely rewarding.”