It took Carla Martin 20 days to die.

A security guard found the petite housekeeper on Sept. 3, unconscious and bleeding from the head in her apartment bedroom.

When police arrived, Tony Wilson told them that his wife hit her head two weeks ago, at work.

Doctors told investigators something different: She’d been struck twice by a blunt object.

Her medical team noticed something else, too.

Martin had brain trauma that suggested at some point, she’d been strangled, according to court documents.

The 54-year-old died Sept 23. Wilson has been charged with first-degree murder.

At a time when the Violence Policy Center ranks Oklahoma fourth in the nation in the rate of women killed by men, Martin’s death is a grim reminder that nonlethal strangulation makes homicide by an intimate partner seven times more likely, experts say.

“When the hands are around the neck, it’s a sign you have a killer on your hands,” said Gael Strack, the chief executive officer of the Training Institute of Strangulation Prevention. “There’s no going back. It’s only going to get worse from there.”

Missed signs

Victims don’t use the term “nonlethal strangulation.” They say they were choked, said Strack, whose California-based institute is a prominent voice concerning strangulation and its issues in the battle against domestic-violence.

Strack said few people — from victims to first responders — understand how serious being choked is.

In half of nonlethal strangulation cases, there are no outward signs that a person has been strangled, said Lauren Garder, shelter director for the YWCA Oklahoma City, the state’s largest provider of domestic violence shelter and prevention services.

Injuries are widely internal, Strack said. A choking victim might tell police or her doctor she is OK, but the reality is that it takes very little to cause severe injury, and the subtle signs are easy to miss.

“Strangulation is really scary, particularly, because it doesn’t leave markings or indications unless it’s very severe,” Garder said.

Rhonda McKinney is a sexual assault nurse examiner for the local YWCA whose patients have often experienced domestic violence, including strangulation.

“Once you’re strangled, no matter how severe it is, you’re at risk of dying from it for up to two weeks after your injury,” McKinney said. “You can be strangled, be discharged, and three or four days later die from delayed internal swelling and trauma to the structures in the neck.”

The YWCA dispatches forensic nurses like McKinney to administer sexual assault and domestic violence exams at health care centers throughout metropolitan area. Between July 2015 and June 2016, YWCA nurses recorded 88 instances of strangulation while helping patients who had been sexually assaulted or experienced other forms of domestic violence.

Those who have been strangled are also more likely to suffer stroke or progressive dementia at an early age, McKinney said. Even milder cases of strangulation can lead to depression, anxiety, amnesia and PTSD.

There is a growing body of evidence that links domestic violence, including strangulation, to traumatic brain injury, Strack said.

Making progress

Strack said Oklahoma communities are making progress when it comes to recognizing strangulation as a lethal marker and a serious health issue, but more could be done, and faster.

Family Justice Centers in Tulsa, Shawnee and Oklahoma City, she said, are a big step in the right direction. At Family Justice Centers, victims of domestic violence can access the myriad services under one roof. It’s common that domestic violence victims faced with the daunting task of navigating the services available to them will give up, Strack said. Oklahoma City’s Family Justice Center is slated to open in late fall in the former Northcare facility, 1140 N Hudson Ave.

Dispatchers, paramedics, police, nurses and doctors, attorneys, even the victims themselves, often do not understand how serious strangulation is, Strack said. That’s something she learned while reviewing hundreds of homicide cases of women in San Diego, Calif. as an assistant prosecutor in the mid 1990s. Strangulation proved to be a critical marker leading up to these deaths.

Multidisciplinary training can help bring awareness to the health dangers of nonlethal strangulation and its ties to homicide.

Strack and Casey Gwinn, the co-founder of the Training Institute, travel the country helping communities use existing tools to work smarter and develop more multidisciplinary teams to tackle the issue.

In states like Arizona, which has seen its domestic violence murders drop, it appears the efforts are paying off, Strack said.

The Maricopa County Attorney’s Office has started to work with a health care system in instituting the use of high-tech cameras that can show broken capillaries in the lips, on the neck and around the eye, all signs of strangulation. The otherwise hard-to-collect evidence has been used to prosecute perpetrators of domestic violence.

The Training Institute did a four-day training in Shawnee, but has not worked in any other Oklahoma communities, Strack said.

Violence continues

In the meantime, the violence against Oklahoma women continues.

The Oklahoma City Police Department received 35,603 domestic violence-related 911 calls in 2015, said Capt. Juan Balderrama, the department’s spokesman.

Eighty five percent of domestic violence victims are women, said Garder, the YWCA Oklahoma City shelter director.

As Carla Martin, the woman who died on Sept. 23, lie in a coma at OU Medical Center, Moore police were called to the home of Jillian Riddle, 31, on Sept. 19.

They found Riddle dead on the floor of the home she shared with her boyfriend, Bobby Lee Rogers. Police said she’d been strangled; the state medical examiner ruled she died of a broken neck and a laceration to her liver.

Rogers has been charged with first- degree murder in connection with her death.

“I think there’s always more we can do to help victims of domestic violence going through abusive situations,” Strack said.