Treatment protocol for symptomatic body packers (mules)

January 19, 2011, 11:10 pm

★★★☆☆

Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules). Mandava N et al. Emerg Med J 2011;28:98-101.

Abstract

A body packer or “mule” is an individual  who swallows packets filled with drugs (usually heroin or cocaine) in an attempt to smuggle them past customs. This retrospective review, from Mary Immaculate Hospital in Jamaica NY (now closed), looked at 56 patients referred from JFK airport over a 12 year period for symptoms deemed related to body packing. Symptoms prompting hospital referral included changes in mental status, abdominal pain or vomiting, and chest pain.  Plain abdominal films confirmed body packing in 49 patients; seven patients with negative plain films had packets seen on non-contrast CT. Twenty-five patients required surgical intervention for 3 indications: bowel obstruction (8 patients), packet rupture or toxicity (9), and failure to pass all packets after five days (8).

The authors note that counting expelled packets — based on the patients’ history — may be misleading, and that an objective clearance test should be done before discharge.  They recommend not clearing patients until they have two packet-free bowel movements and a normal plain abdominal film (or CT of the abdomen and pelvis if the original plain abdominal film was falsely negative).  As for surgical intervention, based on their experience they recommend manual expulsion of packets through the anus; for packets in the proximal small bowel their preferred procedure is expression of the packets into the stomach and then removal by gastrotomy.  They suggest avoiding distal enterotomies which carry an increased risk of infection.

The authors also provide their algorithm for managing body packers.  The title of the article is somewhat misleading. This was not a study gathering data to establish a treatment protocol.  It’s what’s called a “mikey likes it” type paper — they describe what they did and say it seemed to work.  However, there’s good information here and the article is worth reading.  As with a previous paper on this same topic, I find that some important details are missing.  What happened to the almost 1200 confirmed — and presumably asymptomatic — body packers in this time period who were not referred from JFK to the hospital.  The paper suggests that  they expelled all packets after a short course of whole bowel irrigation  (WBI). Was that done at the airport? What sort of imaging and treating facilities were available there? Were those patients cleared only after 2 normal bowel movements and a negative film? Since only 56 of 1200 body packers were referred to hospital, I think it’s somewhat misleading to look only at in-patient treatment without detailing the workings of the entire system, including the airport facility. Also, the authors state that 31 of their symtomatic patients did well with conservative management alone. However, it was not clear to me exactly what this conservative management consisted of: observation alone? WBI? activated charcoal? Inquiring minds want to know.

Related post:

Cocaine mules: what to do with body packers

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