The Deadly Delivery
Want to know what risky behavior often targets pregnant women and children? What massive overdose requires surgical intervention? What exactly is a drug loo and where can you find one?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is called the Deadly Delivery. Want to know what risky behavior often targets pregnant women and children? What massive overdose requires surgical intervention? What exactly is a drug loo and where can you find one? Then stay tuned.
A 34-year-old woman is brought to the emergency department by EMS. They picked her up at a bus stop after a bystander called 911 reporting she was unresponsive. When the medics arrived, the patient was awake but lethargic. She protested, saying she didn’t want to be treated. The medics felt she was too lethargic to refuse, so they transported her.
Via the Spanish-speaking nurse, the patient denies complaints, and says she needs to leave. She’s on a tight schedule and her friends are awaiting her arrival at their apartment. She doesn’t want medical care and says she’s merely sleepy after a long flight. That said, she doesn’t refuse or attempt to get up off the stretcher as the nurse hooks her up to the monitor. She’s having trouble keeping her eyes open.
Her temperature is 98.5F, heart rate 90 beats per minute, respiratory rate is 10 and oxygen saturation 97%. Vital signs are unremarkable. The nurse reads the bag tag on the patient’s suitcase as she pushes it out of the way.
“BOG,” she says. “Bogota. I was just there a few months ago for vacation. Loved Columbia.”
The patient smiles weakly as the nurse chats with her in an effort to figure out what’s going on. The patient says she’s visiting college friends and mumbles something about the Statue of Liberty. The nurse talks her into some lab work and an IV.
You can’t put your finger on it, but something seems off. Watchful waiting is the best option at the moment. Either she’s going to wake up, be fine, and leave or she’ll get worse and develop more symptoms. Thirty minutes later, on your way to another patient’s room, you notice the woman bent over, clutching her stomach. She pops a pill from her purse. She tries to hide the bottle, but you see the label. You don’t need to know Spanish to translate the word “antidiarreico.” An antidiarrheal.
Question #1 This is an antidiarrhea medicine overdose.
A. True
B. False
Answer: A. True. Full disclosure, though, this is a trick question. Back to that in a minute. You may have taken anti-diarrheal medicines, likely without any problems. Loperamide, brand name Imodium, is available over the counter in the US and many other countries.
You can overdose on loperamide and it can be abused. Why? It’s an opioid. In 2019, the FDA changed the over-the-counter preparations to a max of 48mg per box and each dose now has to be packaged individually – like in blister packs. This was in an effort to reduce loperamide abuse. It’s very interesting in overdose, and worth it’s own podcast episode. It can cause sedation and in contrast to most opioids, causes a prolonged QTc. If you’ve listened to other episodes, you know that puts patients at risk for lethal arrythmias.
You ask the nurse to check an EKG and ask the patient to see the box of medicine. She reluctantly hands it over. She’s only taken half the box and her EKG is normal. Loperamide can cause sedation, so it might be the cause of her sleepiness. This is a side effect even in therapeutic doses. She might be taking too much, but it’s doubtful this is a serious overdose.
The real issue here, and the reason question #1 is a trick question, is why is this woman taking too much loperamide. Did she develop a bad case of diarrhea before she left Columbia?
Maybe. Probably not. The clerk announces a call overhead. You pick up the phone. A man says he’s your patient’s husband, he’s in the waiting room, and wants to know when she’s going to be released.
Uh oh. The woman didn’t mention a husband. You say, “Sorry can’t help you” and hang up. This is a real code brown. Figurately, at the moment. If your suspicion is correct, it’s about to become a literal code brown as well.
There are several red flags raising my concern something much more serious is happening. Question #2. What are they?
A. Her mental status at the bus stop
B. Loperamide
C. Her suitcase
D. The phone call from the “husband”
Answer: B and D. I’m concerned about why she’s taking this loperamide. And side note, she hasn’t had a bowel movement in the ER yet, so how bad is this diarrhea? And the suspicious phone call.
You sit down at your computer and pull up the order screen. Deciding what to order, your mouse hovers over abdominal Xray and abdominal CT. The nurse looks up from her computer and says the patient’s bloodwork is normal, except her pregnancy test. It’s positive.
You move the mouse away from the x-ray and CT options since they are relatively contraindicated in pregnant patients. I say relatively because whatever is best for the mother is always best for the baby. But obviously we try to avoid radiation in pregnant patients.
What are these red flags pointing to and what are we looking for with abdominal imaging? Is there something we can do instead? Will our patient consent to the care she needs?
Aright. A lot of questions. First, I’m concerned this patient is a body packer, in lay terms, a drug mule. She’s from Columbia country a place we know drugs originate from. Second, the antidiarrheal. It works by slowing down your gastrointestinal tract. Body packers often take medicines to slow intestinal transit until they arrive at the delivery point. It doesn’t help to have a bowel movement and expel the drugs on the airplane. Lastly, this so-called husband. Someone is tracking her movements and waiting for the delivery of their drugs. And they are in your waiting room.
Let’s talk about the packets. They are typically an inch or two long. Initially wrappers were things like condoms or balloons, but these days the packets are typically well-prepared to prevent bursting. Composition varies, but it’s often several layers of latex encased in a wax coating. Packers can swallow 50 to 100 of these. One case reported five hundred packets in the GI tract. Can you even imagine?
Each package contains anywhere from 1/2g to 10 g of drug. Meaning one person can easily carry a kilo or a kilo and a half. Typically, the packets are swallowed, but they can be inserted in the rectum or vagina. Cocaine and heroin are the most common drugs transported. Anything could be inside, including cannabis, ecstasy, and meth.
Basically, the person swallows the drugs, takes the flight, and then excretes, yes poops out the drugs after they arrive at the delivery destination. Picture a very seedy airport hotel. They stay there until each and every packet is passed and accounted for. The man on the phone isn’t her husband, but someone tracking a kilo or two of drugs belonging to a cartel.
X-rays are useful screening tools to see if packets are present and CT is the best imaging study giving a lot of detail, including how many. Before we get into how to treat her, we have to discuss whether or not we can treat her. She’s agreed to labs and an IV, but she’s also said she doesn’t want medical treatment and I’m pretty sure, she doesn’t want us to discover her secret.
Everything about the treatment of body packers is fraught with ethical issues. We could have several podcasts with heated debates on both sides of these arguments. Let’s touch on what the issues are, then come back to our patient. In the US, patients who are awake, alert and oriented can make any medical decisions they like, including bad ones. They’re allowed to refuse care, refuse medicines, and refuse surgery, even if the outcome is certain death. As Americans we value our freedom and autonomy, and these laws protect those rights.
However, if the patient is confused and unable to understand the ramifications of their decisions, then they may not have the right to refuse treatment. An easy example is a drunk person in the ER. They aren’t allowed to leave until sober, even if we have to restrain or sedate them, because they are a danger to themselves and can’t understand the ramifications of refusing care.
The other category where patients don’t have the right to make decisions is in the case of suicidal or homicidal ideation. Suicidal patients are danger to themselves and lose the right to refuse at least basic psychiatric care. Similarly homicidal patients can’t be released to harm someone else.
Body packers have the same rights and can refuse care, even if they are under arrest. They can be kept in the hospital against their will, but not made to consent to any medical care.
Bottom line, if awake and alert, the patient makes the decisions. However, once they became altered, for any reason, we can and must, do what’s medically indicated. It sounds black and white, but the reality is often gray and very complicated. The best bet is to involve the hospital ethics committee to help navigate ethical and legal issues that unfailingly arise.
Speaking of legal issues, the second problem, and one far more hotly debated is whether to involve law enforcement. I feel very strongly, as do many, that our first duty is to the patient. We’ve sworn an oath to do no harm. And while it doesn’t strictly apply to legal issues, having the patient arrested will likely qualify as harm in their own opinion. I think of it like the 1980s when people were afraid to seek care for HIV and AIDS, concerned that they would lose their insurance, lose their job and become ostracized from their community.
Unfortunately, this issue is, once again, not that simple. There are dangerous people, as I noted, looking for the patient. In this case, he’s in our waiting room. We have to consider the patient’s safety as well as that of the other patients and the staff.
The nurse tells you the patient’s developed intractable vomiting. Nausea medicine is not helping. You go in the room to find out what is going on and to assess her mental status to determine if she’s able to make her own decisions.
She is currently awake and alert, the sedation from the loperamide seems to worn off, at least for now. You tell her she’s pregnant, expecting her to be surprised. She’s not, saying she’s about twelve weeks. She does consent to treatment because now she’s having excruciating abdominal pain in addition to the nonstop vomiting.
There are two options for imaging, neither as good as CT, the gold standard. But both MRI and ultrasound can show the packets and both are safe in pregnancy. At your hospital, ultrasound is quicker, so you order that study. Her urine drug screen comes back negative. A relief, though it doesn’t change our suspicion. More on this in a minute.
Question number three what are the potential complications of body packing drugs?
A. Bowel obstruction
B. Packet rupture
C. Bowel perforation
D. Cardiac arrest
E. All of the above
Answer E, all of the above. While we’re waiting on the ultrasound let’s talk about what can go wrong. Really what can’t go wrong. There are two main categories. The first is mechanical problems caused directly by the packets. They can get stuck, causing a bowel obstruction and they can cause bowel perforations, leading to sepsis and death.
The second category is related to what’s inside the packets. As I mentioned each contains as much as 10g of pure, uncut drug. If a single packet ruptures, the patient is exposed to a lethal amount of an illicit drug.
Our patient returns from ultrasound and you pull up the images. You don’t need to be a radiologist to see a whole bunch of large foreign bodies.
With this confirmation, I’d do two things right off the bat. I’d tell the clerk to give her an alias, meaning changing her chart to a fake name so the people tracking her at least have a harder time. Second, I’d call the security and the hospital ethics committee for backup.
The ultrasound shows the packets, but doesn’t show if she has a bowel obstruction because it’s not a great test for this. Her symptoms, however, are definitely consistent so you call surgery. The surgeons complain you haven’t proven that there’s an obstruction and argue back and forth about more imaging, including the risks of Xray and CT versus the risk of waiting hours to get an MRI. Basically, stalling. No one wants to operate on a pregnant woman.
Let’s get back to the pregnancy. Why would she become a drug mule when pregnant? Why do it at all? Like last week’s episode the Mad Hatter, it’s a simple question to ask from here at my desk. In reality, the answers are complicated. Often its for the money or for the plane ticket. Packers can have a low socioeconomic status in places without many opportunities. A great movie showing the nuances of this issue is Maria Full of Grace. Packers can earn several thousand dollars for one plane ride. Often children and pregnant women are targeted. Why? Because they are less likely to be caught.
International airports like JFK, LAX and international hubs in Europe and Asia are prepared to deal with drug smugglers. What raises suspicion? Nervousness, sweating. Signs of drug intoxication, obviously. An interesting one is people who don’t eat, even on long international flights. They avoid food to avoid the urge to defecate.
Once suspicion is raised, these airports have x-ray machines to screen for packets. If present, the person might have to use a drug loo. This is toilet on a raised platform that monitors defecation and cleans the packets if excreted. If you needed another reason not to do this, defecating in front of the TSA is right up there at the top of my list.
Who wouldn’t get a screening x-ray? That’s right. A pregnant woman.
And what about her drug screen. Why was it negative and why was I relieved?
I’ve said it before, and I’ll say it again. The UDS is an almost completely useless test, a fact not understood by most people, including most physicians. Why? That’s another whole podcast. Let’s skip it and focus on what it means for our patient.
First, I’m sure you know opioids are part of the drug screen. The patient was taking loperamide, an opioid. We saw her do this. Why didn’t it show up? Because the urine drug screen only tests for naturally occurring opioids like morphine and codeine. Loperamide is synthetic and therefore doesn’t typically show up. If her drug screen is positive, it may, let me stress it may, give you information about what’s inside the packets. If her test lit up for opioids or cocaine, I’d be suspicious this was the drug she’s carrying. I’d also be scared a positive result meant a ruptured packet. Again, this isn’t definitive, it could simply indicate a contaminant on the outside of a package.
You’re still caring for her in the ER since the surgeons don’t want to admit her to the ICU until after she goes to the OR. The nurse calls you back to the bedside. The patient’s blood pressure is now 200/100, and her heart rate is 150 best per minute. She’s pale and sweaty. She grabs your hand and says, “Please doctor, don’t let me die.” The hair stands up on the back of your neck. You call surgery for an emergent intervention.
Question number 3. What toxidrome is this?
A. Opioid
B. Sympathomimetic
C. Anticholinergic
D. Sedative-hypnotic
Answer B. This is a sympathomimetic toxidrome. She’s hypertensive, tachycardic and sweating, or wet. Meaning this is probably cocaine and one of the packets has ruptured. The surgeon stop arguing with you and rush her to the OR.
What’s the treatment for body packing? Let’s take a step back and discuss a few common scenarios. First, an asymptomatic patient. Perhaps brought in by law enforcement. The main treatment is watchful waiting, collecting the packets from the stool as they’re passed. The patients know exactly how many packets they’re transporting as they are responsible for delivering each and every last one. Most of the time the packets do pass uneventfully.
What about a laxative to speed up expulsion from the rectum? Sounds like a good idea, since getting them out means less chance of rupture. However, many laxatives are oil based and therefore a bad idea because they might dissolve the wax or latex wrappings.
There is one treatment we recommend, if the patient consents, though there isn’t much data to prove it works. Whole bowel irrigation, a method of gastrointestinal decontamination, consisting of drinking 1 to 2 liters of Golightly per hour. Think of it like an extra, extra strong colonoscopy prep.
A mechanical complication, bowel obstruction or perforation, is treated surgically to remove the packets. This is a tough job for the surgeons. They check every inch of the bowel to ensure all packets are removed. The human bowel is about 20 feet long!
What if a packet ruptures? It depends on what’s inside.
If it’s heroin, the patient will develop an opioid toxidrome, which I’m sure you remember from previous episodes is an altered mental status, depressed breathing and pinpoint pupils. Naloxone isn’t going to work here. Why not? because no matter how much you have, it can’t reverse the massively lethal amount of heroin the patient is exposed to. The treatment is a ventilator to breathe for them until the body metabolizes the drug and they wake up.
Massive cocaine toxicity is a bigger problem. As with naloxone, you can try an alpha blocker called phentolamine and sedatives like benzodiazepines, valium for example. Again, you won’t be able to give enough to counter the huge overdose. Cocaine packet rupture is also a surgical emergency, in a desperate attempt to remove the packet before the patient dies. While theoretically possible, the odds are not in favor of the patient.
What happened to our patient? The nurse calls upstairs to the OR for an update. You hold your breath, waiting to hear she died on the table. The nurse hangs up. To your surprise, the patient is still alive and the surgeons have stabilized her. How? She had a micro perforation, a leak, rather than a rupture. They removed 98 packets from inside her intestines. That’s the good news. The bad news, she’s likely having a miscarriage as she’s having heavy vaginal bleeding. Cocaine is associated with miscarriages, this early in the pregnancy, there’s nothing OB/GYN can do to stop or prevent it.
This returns us again to the issue of law enforcement. The surgeons now have several kilos of cocaine belonging to a cartel in the operating room. If law enforcement is involved, they will take the packets. If not, hospital security will dispose of the drugs a according to local protocols and record they did so, so there’s no question of theft by hospital staff.
This is a fictional case as are all our cases to protect the innocent however it is based on real cases that occur around the world. The first reported case of body packing was in 1973 in Canada. A 21-year-old-man had a bowel obstruction after swallowing a condom filled with hashish from Lebanon.
While we’re here, I’d be remiss if I didn’t mention another category of patients called body stuffers. Body packers swallow large amounts of well-packaged drugs to smuggle them. Body stuffers swallow drugs to hide them from the police. In contrast, the drugs are typically in smaller amounts, but are very poorly packaged in say, cling wrap or dime bags.
I always say if you need another reason not to do drugs, aside from the many obvious, remember the drugs might have been inside someone’s gastrointestinal tract and pooped out.
Sadly, many cases of body packing are discovered postmortem. Patients are afraid to come to the hospital, not allowed to come, or simply can’t arrive in time for treatment. I know there are crime writers listening so I’m going to touch briefly on some graphic details. If you’re listening with a child or have delicate sensibilities, you might want to skip ahead about 30 seconds.
The postmortem cases can be gruesome as patients are eviscerated to remove the drugs. Thankfully, the published cases I’ve seen were cut open after death, not before. The images of eviscerated bodies in hotel bathrooms are very graphic. I caution you about googling them because once seen, can’t be unseen.
One a much lighter topic and the last question in today’s podcast. Question #4. What food was mistaken for drug packets on CT scan?
A. Meatballs
B. Fufu (a starchy West African food)
C. Hotdogs
D. Empanadas
Post your answers on our Twitter and Instagram feeds both @pickpoison1. Follow and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.