By: Kate Masters
FREDERICK, MD – The call came on the afternoon of July 21, 2014 — a reported sexual assault in the area of East Patrick Street in Frederick. The victim’s voice was panicked over the phone, said Det. Doug Ames, an officer with the Frederick Police Department.
She told dispatchers that the man had choked her for so long that she lost consciousness — that it felt like her eyes were popping out of her skull. When Ames took her to Frederick Memorial Hospital for treatment, forensic nurse Pam Holtzinger noticed physical symptoms that weren’t typical for sexual assault cases.
The victim’s voice was raspy, and there were burst blood vessels in her eye — a symptom known as petechiae. Her underwear had been stained, but not with semen — a later analysis by the Maryland State Crime Lab showed that she lost control of her bladder during the attack.
“When I went to go see her, I started to realize immediately that she wasn’t just a sexual assault patient,” said Holtzinger, who has 30 years of experience as an emergency room nurse. “So I started to ask her questions and realized, in her history, she had been strangled during the event. But that wasn’t what was on her mind. Her complaint was that she thought she had been sexually assaulted. She said she was raped. So, she was concerned about other medical problems related to that.”
For Holtzinger, though, the most pressing medical concern wasn’t the attempted sexual assault — it was the strangulation event that nearly killed her patient. And as she worked to gather evidence for the case, she made a startling realization. Despite the prevalence of strangulation — a method of assault employed in roughly 23 percent of domestic violence and sexual assault cases — and the often serious complications that can develop after an attack, no one in the county, or even the state, was considering it as a high lethality indicator.
In other words, no one was looking at strangulation — often called “choking” by survivors — as an event that could place a patient at a higher risk for death.
“But when we started to look into this, and look at the statistics, we learned that if a woman is strangled even one time, her likelihood of dying as a victim of homicide related to domestic violence increases by 700 percent,” Holtzinger said. “So, it might be one small piece of assault overall, but it’s a very important piece because the lethality is so significant in these cases.”

Bringing police into the fold

Ames knew little about strangulation when he brought the victim to the hospital that Monday afternoon. A longtime police officer, he had handled plenty of domestic cases that involved a reported “choking” in his time with the Brunswick and Frederick police departments. But before the 2014 case, no one was teaching law enforcement in Frederick County to identify those events or refer the victims to treatment.

“I just didn’t know how serious it was,” Ames said. “And we didn’t have any of those protocols in place to get them the help they needed.”
As Holtzinger continued her research on the case, she realized that was a problem. Since the mid-1990s, strangulation has been identified as one of the most lethal forms of domestic violence and one that carries significant risk for medical complications, according to the Training Institute on Strangulation Prevention in San Diego.
Beyond the trauma that often follows an assault, survivors can develop life-threatening complications days or even weeks after the event. Holtzinger has heard of patients who died from blood clots that formed after the trauma to their necks and later traveled to the brain. Strangulation patients are at higher risk of stroke or aneurysm, and can experience lasting neurological damage and respiratory conditions such as pneumonia or acute respiratory distress syndrome.
Even in the most severe cases, though, only 50 percent of victims exhibit visible injuries. Sometimes the signs are so subtle — a slight cough, a raspy voice or a few pinpoint red dots in the whites of the eye — that victims themselves downplay the experience.
Law enforcement officers, often the first to respond in cases of domestic assault, might not even realize a strangulation took place unless a patient explicitly tells them. And because so little is known about the long-term dangers of strangulation — and because it’s often just one part of a domestic or sexual assault — that’s not always a guarantee.
“A domestic violence victim might show up at Frederick Memorial with a raspy voice, and we would ask them, ‘Why is your voice so raspy?’” said Sgt. Andrew Alcorn, an assistant supervisor with the Frederick Police Department Criminal Investigations Division. “And they might say, ‘Oh, I have a cold,’ or ‘Well, I was yelling at my partner.’ And for a while, we might have just documented that and then moved on.”
Months after the 2014 assault, Holtzinger and Ames — along with a representative from the Heartly House, a domestic abuse treatment center in Frederick — flew to California for a weeklong session at the Training Institute on Strangulation Prevention. When they returned to the county, they began to implement some serious changes.
The most notable, Holtzinger said, was launching a still-ongoing effort to train every law enforcement officer in Frederick County on strangulation protocol. The group wanted to ensure that police not only felt confident in identifying strangulation victims, but understood the importance of encouraging hospital care and follow-up with the forensic nursing program.
Given the medical risks of strangulation, the importance of follow-up treatment is obvious. But forensic evaluations can also be crucial to collecting evidence and securing charges and convictions against perpetrators.
Until Holtzinger and Ames brought the training back to Frederick County, it was often difficult for prosecutors to seek first-degree assault charges in strangulation cases, said Lindy Angel, the chief of the child abuse, sex offense and domestic violence at the Frederick County State’s Attorney’s Office. Staff members there also had little understanding of the seriousness of strangulation, and there was often little to no evidence to prove a serious attack had occurred.
“For a first-degree assault, we need to show that the perpetrator intended to do serious injury,” Angel said. “Somebody who’s got their hands around somebody’s neck — that’s not enough. We need to have injuries that are consistent with intense strangulation.”
Holtzinger and rest of the forensic nursing team at Frederick Memorial are able provide that evidence, both in medical reports and as witnesses in court. They can attest to injuries that might not have been visible to police on the scene — petechiae on the palate of the mouth, for example, or bruising behind the ears. The hospital has special photography equipment that can show faint bruising or ligature marks under different light filters to make the injuries more obvious to jurors.
Nurses can also provide context for symptoms that can make survivors less credible to juries, Angel said. Patients often experience memory loss or confusion after strangulation events, which can lead to inaccurate or contradictory statements.
“We saw that with the victim in the 2014 assault case,” Angel continued. “She was very confused when she woke up, she wasn’t getting timelines right, and with this particular victim, there were some inconsistent statements that she made.”
After Ames and Holtzinger returned from their training in San Diego, they actually used their newfound expertise to organize and present evidence in that case. Both could attest that the victim urinated during the attack, a serious side effect that’s often missed by officers who don’t know to ask and victims who are too embarrassed to tell them.
“We learned that victims will urinate or defecate themselves, and they’re almost always ashamed to tell people that happened,” Ames said. “Those are two of the things we look for now, that we didn’t look at before, because they’re some of the biggest indicators of what they call near-fatal strangulation.”
Holtzinger was also able to explain the memory loss to jurors during the case, Angel added. It was one of the first times in the county that medical testimony was used as evidence for a strangulation event. The perpetrator was sentenced to 18 years in prison thanks largely to forensic testimony and the victim’s own subject description after the attack.
“This type of medical evidence has made a huge difference in our ability to get convictions for felony assault as opposed to a misdemeanor assault,” Angel said. “There’s much more success now. And I’d say it’s because we’re more aware, law enforcement is more aware, and we’re able to call in testimony that can satisfy that burden we have, which is that there was high-level violence and intent to do serious bodily harm.”
Just a few months after that conviction, Holtzinger and Ames celebrated an even bigger success. In May 2016, after Holtzinger petitioned for the bill in Annapolis, the Maryland Legislature passed a new law that required the state Police Training Commission to develop a lethality screening protocol and strangulation training program for law enforcement throughout the state.
That agencywide collaboration is crucial, Alcorn said, for successful convictions in strangulation cases.
“Let’s say we go out to a case and we write it up as a regular domestic,” he said. “Then, that victim goes to the hospital and the nurses identify it as a strangulation. Well, if that goes to court, the nurse will get up on the stand and say, ‘This was a strangulation,’ and the officer will say, ‘No, it wasn’t.’ Those conflicting reports could lead to an acquittal. But if we’re on the same page and attacking it as a team, then everyone knows what to look for. Everyone has the same goal — to get help for the victim and then go after the bad guy.”

Reaching for difficult convictions

Since Holtzinger returned from San Diego in 2015, she’s pointed to various successes that have stemmed from the county’s increased focus on strangulation. Just a few months after she began in-service training at the Frederick County Sheriff’s Office, a deputy responded to a domestic case involving strangulation and convinced a reluctant victim to go to the hospital for treatment.
“He did a fantastic job of explaining to her how important it was, and she did agree to come in, even though she didn’t think she needed anything,” Holtzinger said. “She ended up being admitted for observation because of her injuries. So, it’s been very successful, in my opinion.”
With help from the Heartly House, she also reviewed more than 1,000 lethality assessments that were conducted in Frederick County before 2015. The assessments, part of a program first established at Johns Hopkins University in 2005, are conducted by law enforcement and hospital staff to assess a victim’s risk of being killed or seriously injured by an intimate partner, said Elise Wong, the lethality assessment program coordinator at the Heartly House.
In their review of the documents, Holtzinger and Heartly House staff found that strangulation was one of the most common experiences among patients who screened at high risk for lethal domestic violence.
“One of the biggest things that we have noted is that strangulation incidents become more intense over time and will happen more often,” Wong said. “So here at the Heartly House, we try to follow up with those survivors and ask them — have you received medical attention? Have you been to the hospital? Because we want to connect them with those services.”
Those kinds of accomplishments are worth celebrating, Angel said. But they don’t change the fact that domestic assaults and strangulation can still be very difficult to convict. Ames still remembers a strangulation case involving a Walkersville High School student who was pinned to the floor and strangled by her brother. The girl had one of the worst cases of petechiae he’d ever seen, with burst blood vessels from her neck all the way up her face.
“I locked him up at the scene, brought him back here, and he told me everything he did,” Ames said. “But somewhere in the court case, the defense managed to turn it around that the girl had lied to them somehow, that she had a phone she wasn’t supposed to have, and it just kind of — disappeared.”
Not every victim is protected, even if they do decide to press charges against the perpetrator. A strangulation survivor from Frederick County said that she was denied a permanent protective order against an abusive former partner after the judge ruled that she could not meet the “required burden of proof” and there was “no statutory basis for relief.”
The terms essentially mean that the court did not find sufficient evidence of an ongoing threat by the former partner.
The Frederick News-Post does not generally identify victims of domestic violence, but the woman’s story was corroborated through police reports and court documents. In September 2015, a sheriff’s deputy responded to an assault between the woman and her partner after she went to his house to pick up some of her belongings. The two argued, and the woman said that she took her partner’s cellphone and went into the other room.
Her partner charged after her, and the woman said she ran outside to try and escape in her car. Her partner reached the driver’s side door, wrapped his arm around her neck, and pulled her from the vehicle. She lost consciousness at some point and urinated as he was holding her by the neck.
“My feet actually left the ground, and I can remember feeling uncomfortable — uncomfortable breathing,” she said. “I remember feeling something warm on my leg in the air, and I think he must have thrown me.”
The report from law enforcement noted that there was grass and dirt on the back of her shirt, and that she told the responding deputy she had been “choked” by her partner.
The deputy did not note any visible physical injuries or report that he asked follow-up questions about the strangulation. But the woman later received a forensic exam from Holtzinger, who provided medical evidence when she petitioned for a protective order.
The woman said it was the first time her partner had become physically abusive. She also worried that she would be blamed for the assault because the two had argued and she took his phone.
It can be easy, she said, for a perpetrator to justify an attack.
“Sometimes I feel like victims aren’t allowed to be angry about anything,” she said. “We’re not supposed to show that we’re angry. Which is absurd.”
Angel has run into similar issues as a defense attorney, she said. Victim-blaming isn’t uncommon, especially in situations where the plaintiff initiated the fight.
“I just reviewed two new cases, and in both cases, the female victim was strangled, but they slapped the partner first,” she said. “And that’s a difficult situation. You can imagine how jurors are going to respond to that.”
In those cases, Angel said, it’s up to the attorney to remind juries that the partner becomes the aggressor by responding with greater force. A slap isn’t the equivalent of a punch to the face, she added. And strangulation, to those with experience, stands in a class all its own.
“I mean, it’s pretty obvious,” Alcorn said. “Strangulation can be fatal. And the difference between it being fatal and nonfatal is very minimal. You could take someone literally to the point of death and let go and they’d return to consciousness. But if you hung on for literally a second longer, they’d die.
“I think it’s absolutely, 100 percent physical,” he continued. “But I think it definitely turns to mental abuse capacity even if suspect doesn’t explicitly say so to their victim. That victim is always going to have in the back of their mind — that person attacked me to the point where I almost died. And that makes it one of the easiest forms of physical and mental control.”

Article Source: How Frederick County became a state leader in preventing nonfatal strangulation, one of the deadliest forms of domestic violence