Hong Kong Journal of Emergency Medicine

Management of body packers in the emergency department

GCK Wong

, KK Lai

, CH Chung

Body packing of illicit drugs is one of the means of drug trafficking. Asymptomatic suspects may be brought in by law-enforcement officers for body search of possible drug packing inside the body. Symptomatic body packers may present with gastrointestinal obstruction or toxicity of the leaking drugs inside the packets. Management strategies are largely determined by the modes of presentation. Asymptomatic persons must be persuaded with every effort for consent to the body cavity search as well as treatment for the safe passage of any packed drugs to avoid possible complications and medico-legal sequelae. Abdominal X-rays and computed tomography can be helpful in confirming the presence of drug packets and in identifying possible packet leakage. Gastrointestinal decontamination, whole bowel irrigation, use of specific antidote as well as operative intervention may be indicated. Emergency physicians must be conversant with the medical and legal aspects of the management of these body packers. (Hong Kong j.emerg.med. 2005;12:112-118)

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Keywords: Amphetamine, body packers, cocaine, foreign bodies, heroin

Introduction The problem of drug abuse is increasing in Hong Kong in recent years.1 Body packers smuggle illicit drugs by concealing the drugs in their gastrointestinal tract. 2 They are sometimes referred to as "swallowers",

Correspondence to: Wong Chi Keung, Gordon, MBBS(HK), FHKAM(Emergency Medicine),

"internal carriers", "couriers" or "mules".3 They may present to healthcare providers because of druginduced toxic effects, intestinal obstruction, or request by law-enforcement officers for medical confirmation of suspected body-packing. Emergency physicians are often the first encounter of these presentations. Hence it may be desirable to have relevant knowledge of the medical and legal aspects in the management of these clinical scenarios.

MSc(Health & Hospital Management)

North District Hospital, Accident & Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong Email: [email protected] Lai King Kwong,

FRCSEd, FHKAM(Community Medicine), FHKAM

(Emergency Medicine)

Chung Chin Hung, FRCS(Glasg), FRCSEd, FHKAM(Emergency Medicine)

Demographics of body packing Body packers can cross different demographic groups. Men, women and even pregnant ladies have been

Wong et al./Body packers

reported to be involved.3 A 12-year-old child with 84 packets of heroin has recently been reported in the USA. 4 Professional body packers usually swallow the packets of drugs,3 although insertion of packets into the rectum 5-8 and vagina 6,9 have also been reported. Constipating agents are sometimes used to delay the gastrointestinal transit time to as long as two to three weeks. 10-12 After successful trafficking, body packers may resort to use laxatives to promote the passage of the packets distally for retrieval. Heroin and cocaine are the usual drugs carried by body packers, but amphetamines, 13 3,4-methylenedioxymethamphetamine (ecstasy)5,9 and marijuana14 are sometimes discovered. Each packet may contain 3 to 15 grams of the drug.2 The drug is densely packed into a balloon, finger of latex gloves or in a condom. In recent years, there has been a significant change in the methods of packaging and professional drug smugglers may now use multilayered, tubular latex wrapping with a smooth tight tie at each end. 10 The number of packets concealed may vary from a few to more than 200. 3 Hence, each packet of heroin, cocaine or amphetamine contains a potentially lifethreatening dose of the drug.

Legal perspectives The mode of presentations of these body packers may determine the clinical management. For asymptomatic patients brought in by law-enforcement officials, emergency physicians may be requested to confirm the presence of drug packets inside the body. However, in the Dangerous Drugs Ordinance, there are areas of controversies and ambiguities that may necessitate further clarification and interpretation. The Hong Kong Law, Chapter 134, Dangerous Drugs Ordinance, Section 52 stipulates as that15: "(1A) For the purposes of enabling a person to be searched under subsection (1)(f )(i), a police officer of or above the rank of inspector or a member of the Customs and Excise Service of or above the rank of inspector may request a registered medical practitioner or nurse registered or enrolled or deemed to be registered or enrolled under the Nurses Registration Ordinance (Cap164), to examine the

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body cavities of that person. (added 40 of 1982 s. 3)", and "(1C) A medical practitioner or nurse carrying out an examination of a person at the request, under subsection (1A), of a police officer or member of the Customs and Excise Service who appears to be lawfully engaged in the performance of his duty shall not be bound to inquire whether or not the police officer or member is acting lawfully or within the scope of his duty. (Added 40 of 1982 s. 3)" Nonetheless, the fact that this statutory power is only granted to those officers ranked inspectors or above may not be familiar to all law-enforcing frontline staff, not to mention the emergency physicians of the medical profession. So to speak, emergency physicians, while being asked to perform these examinations, may not be legally empowered to do so, if the requesting officer is below the rank of an inspector. Therefore, the emergency physicians involved can and should ask f o r t h e p r o d u c t i o n o f t h e w a r r a n t c a rd f o r identification, unless it is reasonably obvious from the uniform of the officer launching the request. It may be even better if the officer's identities, e.g. name and rank, as well as his/her request for search can be recorded in the examination record. Having said that, the doctors are not required to ascertain whether the officer's suspicion of body packing in the suspect has any legitimate basis, so long as it appears to them that the officer is performing his duty. Moreover, the Hong Kong Law, Chapter 134, Dangerous Drugs Ordinance, Section 52, further stipulates that15: "(1B) A medical practitioner or nurse requested to examine the body cavities of a person under subsection (lA) may search the rectum, vagina, ears and any other body cavity of that person. (Added 40 of 1982 s. 3)" "(9) (a) (i) An examination of the body cavities of a person under this section shall, unless that person otherwise consents, be carried out by a medical practitioner or nurse of the same sex as that person. (ii) Where a female has consented, under sub-paragraph (i), to an examination

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of her body cavities by a medical practitioner or nurse of the opposite sex, such examination shall be in the presence of another female. (b) Subject to paragraph (a), no female shall be searched under this section except by a female. (c) No person shall be searched under this section in a public place if he objects to being so searched. (Replaced 40 of 1982 s. 3)" Emergency physicians should first explain to the suspect the potential life-threatening risk of the dangerous drugs packed inside the body. They should tr y to persuade the suspect to consent to the examination and/or treatment methods to facilitate safe passage of the drugs outside the body. If consent is obtained, the safest management option as agreed by the suspect should be the strategy of choice. However, if the suspect refuses the search, the doctors may be placed in the dilemma of whether they should proceed against the will of the suspect. In this regard, Section 52(9) does not actually authorise the doctors to perform examination of body cavities on a suspect without his/her consent. The doctors requested by the officer are not under a statutory duty to perform the examination of body cavities on the suspect although they may choose to comply with the request. Moreover, non-compliance with the officer's request is not an offence; and there is no positive statement in the Ordinance to enable the police to arrest or lay a charge against the non-compliant doctor. Moreover, Article 14 in the Hong Kong Law, Chapter 383, Bill of Rights Ordinance, Section 8, Part II stipulates that16:"No one shall be subjected to arbitrary or unlawful inter ference with his privacy, family, home or correspondence, nor to unlawful attacks on his honour and reputation" "Everyone has the right to the protection of the law against such interference or attacks". Hence in the absence of a clear statutory basis, it may be true that performing an examination of the body cavities without the suspect's consent is in breach of the Bill of Rights and therefore is unlawful.

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Although X-ray examinations and other instruments e.g. proctoscope can be very useful in detecting or locating possible dangerous drugs stored inside the suspect's body during the initial evaluation, these adjuncts require reasonable cooperation of the suspect. If, for any reasons, intentionally or unintentionally, the suspect moves or even struggles during the examination process, the findings may be obscured and may not be accurate enough to add any diagnostic value. Moreover, these relatively invasive procedures may inadvertently cause bodily harm and injury to the suspect and lead to unnecessar y medico-legal consequences. Hence, it is prudent to perform these roentgenographic and instrumental procedures only if the suspect, in addition to consenting to the bodily examination, fully understands the nature of the procedures to be undertaken.

Initial approach A detailed history, if possible, should be tale-telling to uncover the secret of body packing. An honest historian may be able to tell the number of packets inside the body and the nature of the drugs packed. Many a time, however, the patient may not be cooperative enough to lead a simple case. Skin hydration, vital signs, neurological status, pupil size, bowel motion and urinary retention are important clues in toxicological examination. If the packets have not leaked, ruptured nor caused any obstruction, the examination findings would be unremarkable, apart from the anxiety-related sympathetic surge. Abdominal distension and palpable packets may be noted in the abdomen. Drug packets or the threads leading from the packets may be found on rectal or vaginal examination. Nonetheless, if there is the slightest leakage of any one of the packets, the different toxidromes pertinent to the specific drugs may throw some light to the emergency resuscitation. Heroin overdosed patient may manifest in coma, miosis and respiratory depression or apnoea. Cocaine and amphetamine overdosed patient can present with pupil dilatation, diaphoresis, tachycardia, hypertension, seizure and coma.

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Radiological investigation is useful in the initial evaluation of suspected body packers. In the emergency department, plain abdominal X-ray may be able to reveal multiple radio-dense foreign bodies suggesting the presence of underlying body packing. There may be oval soft tissue shadows surrounded by a gas halo (Figures 1 & 2).17 Sometimes, the tiny amount of air trapped in the knot of the condom may present as a rosette-like pattern.8,18 If there is air trapped between the layers of latex, the "double-condom" sign may be evident.10,18,19 Abdominal radiographs, however, are not of value for detecting cellophane-wrapped packets.20 Plain abdominal X-ray has a sensitivity of 74% 10 to 100%. 21 False-positive findings may be the result of copious stool, especially if the patient has taken some constipating agents deliberately to delay the bowel transit time. Large bladder stones 22 and intraabdominal calcifications23 have also been incriminated as causing false-positive radiological findings. On the other hand, false-negative studies can be due to inexperience or poor quality films. It is alarming to note that as many as 135 packets had been passed in a patient on whom the initial screening abdominal radiograph was reported as negative. 10 Contrastenhanced X-rays can better identify the packets as filling defects from the background of the contrast medium. The false-positive and false-negative rates had been reported to be 4%. 11 The widespread use of abdominal ultrasonography in the emergency department may be attractive in the evaluation of body packing. Two small studies have reported high correlation between sonographic and plain radiography findings. 18 However, there are not enough data to support or refute the use of this fast and safe tool in the evaluation of body packers. Computed tomography (CT) is less readily available in the emergency department setting. Contrastenhanced CT can pick up the packets as radio-opaque foreign bodies surrounded by a rim of gas. In one study, CT Hounsfield units were used to differentiate between the different contents of the packets, with cocaine having a Hounsfield unit of -219 and heroin -520.3

Figure 1. Tubular soft tissue packets surrounded by a rim of gas halo.

Figure 2. Multiple small drug packets inside a larger pack with gas-halos.

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Management of asymptomatic body packers Asymptomatic patients usually present to the emergency department because of custodial request for medical examination and confirmation of body packing. However, there has not been a unified systematic approach to the initial management of asymptomatic body packers. Medical observation to await spontaneous passage, use of cathartics, activated charcoal, whole bowel irrigation, immediate surgical decontamination, fibreoptic upper and lower endoscopic removal have all been suggested. It is likely that the longer the packets remain inside the gastrointestinal tract, the higher the risk of leakage.2 Therefore, earlier recommendations advocated immediate surgical removal of the drug-filled packets for all asymptomatic patients. 24 Subsequent reports suggested the use of cathartics and laxatives to speed up the transit time. Bisacodyl (Dulcolax) suppositories can be used to facilitate rectal passage of the drug packets. There have been studies warning against the use of oil-based cathartics.10 Mineral oil in paraffin will dissolve latex, decrease the strength and flexibility within 15 minutes and increase the risk of rupture of the latex packing.25,26 No attempt should be made to remove the packets rectally because of the risk of iatrogenic rupture. 26 Whole bowel irrigation with a polyethylene glycol-electrolyte lavage solution can flush down the drug packets towards the anal opening to effect safe and gentle evacuation.27 During the procedure, the lavage solution is administered at the rate of two liters per hour until the effluent is clear and no drug-filled packets are detectable in a follow-up contrast study. Activated charcoal may reduce the absorbed dose of the free leaking cocaine or heroin inside the body. However, the lethality of just one ruptured packet of cocaine renders the therapeutic potential of activated charcoal relatively useless, and the efficacy of the antidote naloxone limits the clinical roles of activated charcoal in those scenarios with leaking heroin packets. Although earlier studies reported successful endoscopic removal of packets from the stomach, 28 the risk of rupture during the procedure and the small load of the drug accessible to endoscopic removal outweigh

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the meager benefit so obtained. While some may advocate endoscopic removal in operating room or intensive care settings, this potentially dangerous practice is not recommended.26 Patients who are managed conservatively should be observed in a hospital setting until all packets are evacuated. Packet count can be used to indicate successful evacuation; however, this method may not be reliable for those uncooperative historians who may refuse to disclose the exact number of packets packed inside the body. Alternatively, the passage of two26 or three3 packet-free stools after continuous whole bowel irrigation for 12 hours plus a negative abdominal radiography may be used as a guide to suggest complete clearance. Nonetheless, the slim yet genuine chance of delayed rupture of any residual packets has been reported29 and cannot be overemphasised.

Management of symptomatic body packers The unlucky body packers may present with symptoms of overdose toxicity. The effective and safe antidote naloxone can usually be used to antagonise the toxic effects of heroin, but very high bolus doses and infusion may be required. Sometimes, the heroin packages may be as large as 5 x 2.5 cm.26 The larger drug packet may cause obstruction, initially at the pylorus or later at the ileocaecal valve. Surgery is indicated if there are repeated bouts of heroin toxicity, radiographic evidence of packet retention in stomach, intestinal obstruction or perforation.3 Cocaine packet may contain 3-7 g of cocaine but as little as 1.2 g can already be fatal for a 70-kg man.30 There is no effective antidote against the lethality of cocaine, although temporising measures with drugs to antagonise the sympathomimetic effects may be considered. Hence, immediate surgical gut decontamination is emergently indicated if there is any sign of packet leakage with cocaine toxicity. 3,26 Prompt surgical management is indicated for complications of bowel obstruction. Residual retained packets after surgical decontamination has been reported.2 Confirmation of complete bowel evacuation may therefore be necessary after operative intervention.2,3

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Conclusion Body packers are not common encounters in the emergency department. However, these uncommon clinical situations may present medical and legal challenges

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to novice and sometimes experienced emergency physicians. Development of algorithm strategies (Figure 3) and thorough understanding of the medico-legal limitations may help alleviate the misunderstanding and aid appropriate decisive management.

A=airway, B=breathing, C=circulation, GI=gastrointestinal Figure 3. Suggested algorithm for the management of body-packers.

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legislation.gov.hk/eng/home.htm. 16. Laws of Hong Kong, Chapter 383, Hong Kong Bill of Rights Ordinance, Section 8: Hong Kong Bill of Rights, Part II. [cited 2004 Dec 5]. Available from: http://www. legislation.gov.hk/eng/home.htm. 17. McMullen MJ. Cocaine, amphetamines and other sympathomimetics. In: Rosen P, Barkin RM, editors. Emergency Medicine - concept and clinical practice. 4th ed. St Louis: Mosby Year Book; 1998:1428-42. 18. Hierholzer J, Cordes M, Tantow H, Keske U, Maurer J, Felix R. Drug smuggling by ingested cocaine-filled packages: conventional x-ray and ultrasound. Abdom Imaging 1995;20(4):333-8. 19. Pinsky MF, Ducas J, Ruggere MD. Narcotic smuggling: the double condom sign. J Can Assoc Radiol 1978;29 (2):79-81. 20. June R, Aks SE, Keys N, Wahl M. Medical outcome of cocaine bodystuffers. J Emerg Med 2000;18(2): 221-4. 21. Bogusz MJ, Althoff H, Erkens M, Maier RD, Hofmann R. Internally concealed cocaine: analytical and diagnostic aspects. J Forensic Sci 1995;40(5):811-5. 22. Wilgoren J. Misdiagnosis led to man's handcuffing, suit claims. New York Times 1998 Dec 6;62. 23. Traub SJ, Hoffman RS, Nelson LS. False-positive abdominal radiography in a body packer resulting from intraabdominal calcifications. Am J Emerg Med 2003; 21(7):607-8. 24. Suarez CA, Arango A, Lester JL 3rd. Cocaine-condom ingestion. Surgical treatment. JAMA 1977;238(13): 1391-2. 25. Visser L, Stricker B, Hoogendoorn M, Vinks A. Do not give paraffin to packers. Lancet 1998;352(9137):1352. 26. Ellenhorn MJ. Medical toxicology - diagnosis and treatment of human poisoning. 2nd ed. Baltimore: Williams & Wilkins; 1997. 27. Hoffman RS, Smilkstein MJ, Goldfrank LR. Whole bowel irrigation and the cocaine body-packer: a new approach to a common problem. Am J Emerg Med 1990;8(6):523-7. 28. Robinson T, Birrer R, Mandava N, Pizzi WF. Body smuggling of illicit drugs: two cases requiring surgical intervention. Surgery 1993;113(6):709-11. 29. Deitel M, Syed AK. Intestinal obstruction by an unusual foreign body. CMAJ 1973;109(3):211-2. 30. Miller JS, Hendren SK, Liscum KR. Giant gastric ulcer in a body packer. J Trauma 1998;45(3):617-9.