We often have the pleasure of working with colleagues from Police Scotland and Her Majesty's Prison when attending to patients in the Emergency Department. Those members of our society who are on their way towards, or are already enjoying, some form of incarceration are regular users of our service, and can test the most patient of us at times. They are, of course, prone to as many, and often more, illnesses as their free compatriots, and receive exactly the same consideration of their wellbeing as everyone else.
Occasionally we are involved in assessing patients who may have concealed substances in the heat of the moment of arrest. These are often hastily wrapped illegal or prescribed drugs that the patient does not want to have confiscated or found on their person, and they are usually swallowed or sometimes pushed up where the sun doesn't shine. These patients are termed "body stuffers", and often the packages re-emerge from said hiding places quite quickly, with or without the effects of the drug(s) as they leak out.
A few months ago, I was involved in the less frequent variant of this, the "body packer" or "mule". These desperate folk take the potentially fatal gamble of swallowing many small and carefully packaged bundles of drugs to cross boarders and customs. One evening last year, at around 7pm, I was asked to see a man who had been brought to the ED by HMRC staff from Edinburgh Airport, who they had been tracking and suspected of body packing.
He had been taken aside at the airport, read his rights and given an explanation of what was going to happen, and then had had a urine test that tested positive for cocaine. He had then had a CT scan organised that showed between 60 and 70 packages in his intestine. His CT pictures looked like he had a massive string of small fat sausages running round the inside of his belly. He was under arrest for alleged drug running, and had been brought to us to assist removal of these packages in as safe an environment as possible.
The slight hitch was that he was denying all knowledge of the packages, and was refusing to allow any form of examination or treatment. If the customs officers were correct in their assumptions, and if he did indeed have several hundred thousand pounds worth of cocaine in his intestine, then if even one of the packets ruptured, he would be unlikely to survive without immediate treatment.
One of my colleagues from our Toxicology service and I went in together to speak to this gentleman to try and talk him round. He retained his very forthright denial for many minutes, until we managed to convince him that it didn't matter one jot to us, but that we had to try and ensure his safety if nothing else. At this point, he at least admitted that he had the packages inside him, and that it was indeed a large shipment of cocaine. He was still, however, refusing any form of removal against his wishes, even with the risk of death looming large over him.
At this point, my colleague Michael and I had to try and make a judgment regarding his capacity to take this decision. We went back into speak to him together, and talked through what he understood to be the dangers to himself, the potential outcome, and his ability to retain all this information. He had probably thought through this exact scenario many times before agreeing to undertaking this transit, and it was clear to us that he had pristine mental capacity to be able to refuse all removal attempts.
We were obliged to let nature take its course, and so he was admitted to our toxicology unit under the vigilant eyes of the Customs officers, with careful monitoring of the toxic effects of cocaine, until every packet had been passed and accounted for. Who says medicine isn't glamorous?
Fortunately, this man survived this gamble on this occasion. Many do not.
We are sometimes completely surprised by body stuffers. Only a few days ago did a patient of ours who required emergency surgery for a bleeding vessel suddenly start passing packets of cocaine during his recovery from anaesthetic. He clearly didn't want to leave the house without them, and thought the safest thing to do would be to just swallow the lot.
One patient who was brought in by the police prior to going to the cells for the weekend was seen trying to conceal something in his trousers. After a few hours in the Emergency Department, he had passed several "Kinder Egg" containers with some drugs in them back through his undercarriage, which we thought would be the end of it, and he could return to Hotel St Leonard's. Imagine our surprise when he then passed not only his mobile phone, which he clearly couldn't do without whilst in custody, but also his phone charger. Sometimes you just have to admire the human spirit of endeavour and planning, even if it does bring tears to your eyes.