-Forensic nurses can play a crucial role in preventing domestic violence, but does Clark County have enough of them?

And what about the state?

That's this week on Nevada Week.

♪♪ -Support for Nevada Week is provided by Senator William H. Hernstadt.

-Welcome to Nevada Week.

I'm Amber Renee Dixon.

October is Domestic Violence Awareness Month, and already the Las Vegas Metropolitan Police Department is reporting more domestic violence homicides this year than in all of 2024.

Research shows strangulation is one of the strongest predictors of deadly domestic violence, which is why putting offenders behind bars can ultimately save lives.

But prosecutors rely on forensic nurses to help do that, and the recent death of a local forensic nurse is highlighting the need for more of them.

Here to explain are Elizabeth Abdur-Raheem, Executive Director of the Nevada Coalition to End Domestic and Sexual Violence; Rachelle Ekroos, Forensic Nurse Practitioner and Executive Director of Nevada HealthRight; Sarah Overly, Chief Deputy District Attorney in Clark County; and Liz Ortenburger, CEO of SafeNest.

Thank you all for joining us.

Let's first clear the air.

The nurse that I mentioned, who passed away in April, was Jeri Dermanelian, known as Nurse Jeri.

And for years she was referred to as the only forensic nurse in Clark County.

Rachell, what do you want to say about that?

(Rachell Ekroos) Well, I think you have to look at who's making the statements and in what context those statements are being made, if it's in reference to a UMC program or UMC contract versus what's available in the southern part of the state.

There have been-- There's been a forensic nursing team in place, providing additional services since 2017 to hundreds and hundreds of patients across the valley.

-Okay.

To the credit of this nurse, she was taking the bulk of these exams in Clark County.

But this does beg the question, how did this come to be that that was accepted, that she was the only forensic nurse in Clark County?

The district attorney's office has said that on the record.

Liz, you have said that as well.

What led you to believe that?

(Liz Ortenburger) Well, when we were working with survivors, both in sexual assault and domestic violence, there was only one place to take survivors that we were ever prescribed, and that was UMC.

And as a result, Nurse Jeri was the only nurse that was there providing those exams.

And we worked with UMC to talk about the bottleneck; and so in 2024, we had advocates in the emergency room at UMC, where Nurse Jeri worked 24 hours a day, seven days a week for that entire year.

And that is all we saw was Nurse Jeri doing those exams.

So that is how we came by that information.

Of course, we work closely with the DA's office and were under the same impression.

-Do you want to add to that, Sarah?

(Sarah Overly) Yes, that's correct.

As the team Chief of our Domestic Violence unit, I exclusively worked with Jeri Dermanelian.

She was our SANE exam nurse as well as our forensic strangulation examination nurse, and we utilized her for all of our cases.

-Elizabeth?

(Elizabeth Abdur-Raheem) I just say that like when there is a main resource that people are aware of, that becomes the resource that people use as their go-to resource.

So as another resource opens in 2017, But this is the one we've been using for years and decades.

It becomes really difficult, in the heat of a moment, right, for an officer to say, Oh, wait, I think a new clinic opened.

That's not what they're going to do.

They're going to go to the tried and true, the space they know.

And so getting known and getting advocates and officers and all of that information out is a really long process.

And that UMC system was known by the law enforcement system, by the advocacy system, and so it became the go-to system.

-I would like to correct one thing.

So we've been testifying this whole time, too.

So I think it also depends on which team at the DA's office we're referring to.

So we've been testifying since 2017 in domestic-- not domestic, sorry, in sexual assault cases and child sexual abuse cases.

-Which a forensic nurse can do sexual assault exams as well as the nonfatal strangulation exams.

We did ask the Las Vegas Metropolitan Police Department to be a part of this panel.

They declined.

But wouldn't that be the typical scenario in which a victim survivor would be recommended to go to UMC?

How does that typically work?

-When we're talking specifically about nonfatal strangulation, understand that that was not an exam that was covered by the state and reimbursement from the state or from any of the medical jurisdictions until 2023 when that legislation was passed.

So this is a relatively short period of time on nonfatal strangulations that we're talking about and talking about that being a covered item.

And so, yes, that's generally how it works.

A survivor needs medical attention for abuse that they received related to strangulation or sexual assault, and they are taken to UMC, or were.

It's different now.

They're taken to the closest hospital to where the incident occurred, and then I believe Nurse Ekroos is contacted and then moves forward with making sure those exams happen.

-I want to follow up on that.

But real quick, 2023, what was happening prior?

Who was paying for those exams?

-From the Safenest lens, when we would take survivors to UMC or survivors would report back to us that they went to UMC, they would be told a price tag of what that exam would cost.

In fact, we have billing documentation of clients being charged $6,000-plus for strangulation exams that were happening at UMC.

So that was what prompted us to start to move forward in that 2023 legislative session to get these exams covered the same way that a SANE exam is covered so survivors could get the help and support they needed.

Often misunderstood in domestic violence, women who are at and below the poverty level are five times more likely to be victims of abuse.

So these are not folks that have ready access to the $1,500-plus they were being quoted for treatment.

-And Elizabeth, that's kind of a rarity in terms of the entire United States of how many states do pay for these exams.

-So at that time in 2023, we had four other states that had pay for the strangulation exams.

Now we have a few others that have picked it up, but it hasn't been a groundswell across the country, so it is one of the rare and wonderful places that we are ahead of the curve.

-Okay.

Rachell, you have been practicing alongside Nurse Jeri when she was alive, but now you are the new Nurse Jeri with Nevada HealthRight.

Is there any danger in there only being one entity handling all the cases for one county?

-So first of all, I would like to clarify.

I'm not the new Nurse Jeri.

I've been doing this for over 25 years, so I've been doing this for a very long time in many different states.

And one of the challenges with the legislation, even the 2023 legislation, actually, it was intended to open up access points, and it actually created more barriers because the language wasn't informed by those of us who could actually provide the services.

And it created a barrier for payment because reimbursement was to hospitals only, which was forcing survivors to go to hospitals and not have any other choice.

But unfortunately, hospitals didn't provide those services.

They, even UMC, contracted with Rose Heart, which was Nurse Jeri's program.

So there's been challenges in legislation across that.

And as far as having one agency, if any health system called me today and said, We want to start a program, Dr.

Thimsen at UNLV and I would be, How can we support you?

One of the positive outcomes of the recent legislation is that the forensic nurses across the state have come together to form an alliance so that we are providing this expertise so that we can prevent future, or hopefully prevent future, legislation that creates barriers.

-But prior to 2023, victim survivors had to pay for this exam on their own, so that is a positive.

-It is-- I'm sorry.

-Slight correction.

So what that legislation in 2023 did is it used the mechanism of the county billing the state, which caused a problem on tribal lands.

Tribal Lands can't bill through a county, so they had no mechanism to get to that money.

And then the state was frustrated because the $2 million we had set aside for those exams was not accessed, because the counties didn't really have a mechanism to bill the state.

Fast forward to 2025 when the next set of legislation came up, when we were able to say, Okay, let's adjust this and have direct billing to the state.

Perfect or imperfect, everything is designed to open up those access points so that there is more than one nurse in a county of 2.4 million people doing exams.

-Okay.

We're going to talk about the bill that addresses that Senate Bill 87, but I want to bring you back in the conversation, Sarah.

Will you tell me the significance of a forensic nurse in what you do when you are trying to prosecute someone for nonfatal strangulation.

And what is the penalty for that?

-So the penalty for a battery domestic violence strangulation in Nevada is a Category C felony.

It carries a one- to five-year sentence.

But it is nonprobationable, so it definitely carries more of a punishment than a typical Category C felony, because a judge does not have discretion to grant probation if they are convicted of that charge, so they would have to go to prison.

And so the strangulation exams are, I would say, critical for us for a variety of reasons, but the first of which is that, you know, oftentimes in domestic violence situations, we're dealing with sometimes situations between two parties and no additional witnesses.

So if we're going to prove something up beyond a reasonable doubt, we need to establish it with a variety of evidence.

And sometimes witness-- While witness testimony alone, it can be enough; oftentimes, juries expect more and want more, understandably so.

So what forensic examinations do is they really bridge the gap between, you know, kind of the silent or kind of invisible lethality of these, these offenses of strangulation and the actual offense and shows that there can be internal signs, external signs.

Oftentimes, people associate with strangulation and expectation that there's going to be these excessive signs on your neck or in your eyes, with petechiae, and a variety of different things.

And that's not always the case.

In fact, most of the times it's not the case.

And forensic examinations are critical for us because they reveal that those can not exist but that a strangulation still occurred and that there can be internal signs or a variety of other risk factors associated with what happened to a victim.

So they provide corroborating evidence for us.

They not only provide, you know, medical necessities for the victim, but it really allows us to establish that burden of proof.

-What do you think is most misunderstood about strangulation, Elizabeth?

-I think what's most misunderstood is that it is a broader set of activities than somebody putting their hands around your throat, right?

Like, it is whenever we're stopping the airflow, right?

And so people can be strangled like the medical definition of "strangled" and have no idea that it happened.

This is similar to traumatic brain injury, and both of these things have the same problems in that victims aren't recognizing this as something that happened to them.

And it can have huge health concerns down the way.

Also, many of those things will look like trauma.

So when we're having things interacting with our brain, it can really look like trauma.

And it can be very difficult for a victim, an advocate, someone who's not a medical professional, to figure out what's going on.

But so often victims are like, No, I feel fine.

Let's move on.

-How would a victim not know that they had been strangled?

-Because if somebody puts pressure, right, and cuts off the airflow, you know that that happened.

There was a moment in which it was hard for you to breathe, but you were also panicked, right?

There were so many things going on that may make you feel like you had a hard time breathing, that you're not going back to, like, That actually was a medical thing that happened to me that is going to cause long-term damage.

-And Liz, what are the statistics to back how significant strangulation is in relation to domestic violence?

-So we know when a survivor is strangled once, her likelihood of being murdered is 750% higher than someone who is also being abused but not being strangled as part of that domestic violence portfolio.

That's once.

Most survivors, to Elizabeth's point, do not call 911 until they have been strangled five times.

And not only that, there's also a frightening correlation with cop killers.

So most, almost all cop killers have domestic violence within their portfolio.

80% of those have a known strangulation.

And then mass shooters.

And so not only is it for that family that is suffering in the abusive situation, it is our police and it is our community at large that is in abhorrent danger when we are not properly prosecuting these cases.

-Speaking of prosecuting these cases, Sarah, how many cases remain from Nurse Jeri that she did the exam and now cannot testify?

-Right.

I think we were able to account for roughly around 80, maybe closer to 100 now at this point, for outstanding cases that are still in our system that have not reached conclusion with either a conviction or a resolution.

So those are cases that are active that, you know, if proceeding to trial, we would not have Nurse Jeri there to be able to testify to her findings.

So that's a lot of cases when you think about it.

-What do you do?

-So in cases like that is where Dr.

Ekroos really becomes a critical part of our management, because, ultimately, what we're able to do is we're able to take another expert in that field, and Dr.

Ekroos is clearly one of them, and they can independently review Jeri's findings.

So they can look at her strangulation examination, her SANE examination, her photos, her findings.

They can look at all of that and draw their own independent conclusion.

Based off that independent conclusion, they can then testify to that.

We often do it with coroners in a variety of homicide cases, but now we're able to do that in one of our cases.

We had it with a case last year for Dr.

Ekroos alone.

I believe it was Perkins v. State, where they allowed Dr.

Ekroos to testify to a prior finding for a SANE examination for an examination for a nurse that was not present.

She wasn't available for trial, so Dr.

Ekroos could come in, draw her own independent findings, and testify.

So what it really allows for is those cases to have just as much weight for us to be able to proceed forward with prosecution and get the resolution that we're looking for.

-And when we say "SANE," that stands for sexual assault nurse exam.

Rachell, you now have this caseload.

What is your workload like?

-So it's been a little challenging due to some system challenges from the state and the county that, as we're implementing SB 87 and making those transitions, we have had-- We've always had a wait list of forensic nurses wanting to, or people wanting to enter forensic nursing that we could only hire based on the number of patients we had to serve.

And so now we're actually at a point where we can start hiring and training those nurses.

And so there's been a lot of transitions in the courts.

We had to take a step back while we were waiting on the funding to get determined and focus on our cases and our patients.

-When you say "waiting list," are you talking about your own waiting list for your own organization?

-For nurses, people who are interested.

-You weren't going to hire until you had enough of a caseload?

-Right, because we have, because you need-- Your nurses have to have the ability to do the exams; otherwise, they lose their expertise, their proficiency, and all of that.

-Okay.

So they have to be active.

Are there enough forensic nurses in Clark County?

Elizabeth, what were you going to say, first?

-I was going to say the experience that Rachell is having is the same experience that we see across the state.

In many other parts of the state, forensic exams are done in what's called a CAC, a child advocacy center, whether it's for adults or children.

And as we speak to the people managing those centers, they say there are a lot of nurses who want to do this.

Our hiring process can be a little tricky, can be this and that.

But there are the nurses who are interested.

It's getting them into the practice with enough space so they can mentor so then they can be at a space where they can do it independently, because that's what we have to get, is to the point where they can do it independently.

But the experience is not that there aren't enough nurses or that nurses aren't interested enough in this specialty, but getting the system set up so that we can have five and six nurses on a team is really what we need to work on.

-And so that was the intent of SB 87 this past session was to remove one particular barrier.

This bill passed with nobody voting against it in either the House or the Senate.

The governor signed it.

The Clark County District Attorney supported it.

Elizabeth, your organization did as well.

What does SB 87 do?

-So it really, and I want to be clear, it didn't remove a nurse; it removes, it removed the county as the biller.

So it allowed nurses to go directly to the state to bill for the services that they were providing, right?

And the thought process behind that was, Fantastic.

If people can actually bill directly, we've removed a barrier, then we will have more nurses participating and practicing in this.

And so it went live July 1.

We are here in October.

It's, you know, there will be time, hopefully, that more nurses will come to the table.

I think what has been interesting in Clark County is how the county is then now going to probably have to step in as the state exhausts its resources, because the number of exams being done, by our metric, is much higher than the number of exams that were being done when we had a sole provider.

-As a result of this legislation?

-So I don't think there's more assault happening.

I think that the legislation opened up the ability for people to get exams more easily, so that access to that exam has created more people being willing to get an exam.

-Part of the reason you brought this legislation was because of what your advocates were seeing in the UMC emergency room.

This was all during 2024.

What did they see?

-Yes.

For 2024, we had advocates in UMC's emergency room where Nurse Jeri was practicing for 24 hours a day, seven days a week.

So we kept our own statistical data.

We were seeing survivors that were being turned away, we were seeing survivors that were waiting six- to eight-plus hours for exams, and we were seeing survivors that were not even given the opportunity to talk to an advocate.

So we put our legislative strength behind changing that dynamic.

-Okay.

And Rachell, I mentioned the vast support for this bill, but what are your issues with it?

-It's not as much issues with the intent of the bill as it is on how we came together as a state.

And there's a difference between local system issues or organizational issues versus what affects the entire state.

And we know in forensic nursing and in healthcare, in general, you don't go to state and do state legislation to address local issues or system, specific system issues.

You need to do that first.

And so now we do have a bill, as Liz mentioned, that any nurse can now bill.

But any nurse may not be qualified, and that's going to be where our challenges are, because now we've opened up this mechanism without having like a state coordinator for forensic nursing that is a specialist in this area.

-You want to respond to that?

I mean-- -I think everybody wants perfect legislation on Day 1.

We started working on this as soon as the state removed the covenant that a domestic violence agency couldn't also work inside sexual assault.

That was in 2021.

We have rapidly pushed through, in two legislative cycles, things that have dramatically changed access for survivors.

So from the lens in which SafeNest sits, which is, how do we do the best work we can possibly do for survivors, it's a success.

Things always need to be adjusted.

We have a legislative system that meets every other year.

It's highly, pretty much voluntarily.

They do phenomenal work in short periods of time.

And it's not a perfect system.

-And that's a fair point, the lens.

-One of-- So the role of the coalition is to make sure that statewide voices get to the table.

So when people in an agency are bringing forth a concern, that is such a valid concern.

And we want to hear it, and we want to work on it.

And our role is also, as we did in this legislation, to bring the people from the other parts of the state to the table so that we don't accidentally have unintended consequences, that there's no way Liz would have seen them, right?

And so we really, that's the role of the coalition.

And I think we tried very hard on this legislation, and I think we were primarily, you know, mostly successful on this legislation.

And as she says, like no legislation is perfect and we have to start somewhere and then we have to keep building.

So one of the big successes of this bill is that there were, especially in our frontier space, in 2023, the coalition testified that people could get forensic exams in only 6 of our 17 counties without leaving their county.

So that's a huge problem.

But it also means that victims are crossing county lines.

And then, typically, that billing would go back to the prosecution of the county in which the assault happened.

And what we were seeing was that those counties were saying, Well, this exam didn't happen in our county.

We don't want to pay for it.

The county where the exam did happen said, This isn't our prosecution.

We don't want to pay for it.

Through this bill, that is no longer an issue.

We have yet to see, those counties have been holding off because, as she said, it just started July 1, right?

And so they said, We know it's going to take the state a long time to figure out this system.

We're going to wait on billing.

They could afford to do that because, as Liz said, like they hadn't necessarily been charging the state anyway.

They'd been using other county funds.

So they're going to continue using those as the state system.

We had the problem with the state electronics, right-- -The cyber attack.

-The cyber attack.

Thank you.

And then we have, currently, they're changing their financial processes in that platform.

And so after that goes, I think we will see in those spaces if this billing process goes more smoothly, but it certainly has a huge potential to really help, especially in those cross-county cases.

We've also seen, primarily through the expansion of the mobile forensic exam unit, that now we're at a space where you can get an exam in your county in about 11 of our counties.

So we've made extreme progress there in the last two years, but also knowing that, especially in our frontier spaces, people are going to be crossing counties for medical care.

-Okay.

And then whoever is conducting those mobile exams will be billing the state versus multiple counties.

-They won't have to bill six different counties.

-Sarah, how many more forensic nurses do you think Clark County needs?

-As many as we can get, honestly.

The more, the better.

The more access that victims have, ultimately, victims don't necessarily want to go and get an exam the day of the incident for a variety of reasons: either they're traumatized, they have children, they have work, they don't want to deal with it right then and there, they're exhausted.

So they have up to, I believe, three days, five days to get an examination.

So the more access that they have, the more people that they can go to, the more opportunities that the, you know, they're given, the better our chances are at being able to proceed on these cases.

-And when you and I spoke off camera, you mentioned that forensic nurses sometimes are simply called in just to testify.

They don't have anything to do with the exam that was done.

Why would that be the case?

-So oftentimes people have, and understandably so, have a misunderstanding of what strangulation really is, whether that be how the mechanism is.

But oftentimes, what it looks like and what it doesn't look like.

And I would say in the majority of cases, you do not see external signs of strangulation.

So oftentimes a victim can come in, she can say that she was strangled to the point of, you know, passing out or urinating or something like that and have no external signs.

And to be able to bridge that gap and get a jury to understand that that is possible, it's possible to have suffered a horrible crime like that and to not reveal any external signs on your person.

It's critical to educate the jury on that, because even myself, before I started doing domestic violence, was not aware of those statistics.

I was not aware that that was ultimately the outcome in most strangulation cases.

So our experts are critical in terms of their medical expertise and how they can educate our juries.

-We have run out of time, but I appreciate all of your time.

Thank you for joining Nevada Week.

-Thank you.

-And for more information on any of the resources discussed in this show, go to vegaspbs.org, and I'll see you next week on Nevada Week.