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)
X
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
113
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
114
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.
Hong Kong j. emerg. med. „ Vol. 12(2) „ Apr 2005
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.
Wong et al./Body packers
115
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.
116
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
Hong Kong j. emerg. med. „ Vol. 12(2) „ Apr 2005
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
Wong et al./Body packers
Conclusion
Body packers are not common encounters in the
emergency department. However, these uncommon
clinical situations may present medical and legal challenges
117
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.
118
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