Human drug couriers, colloquially known as “drug mules,” are people who smuggle drugs across a national border by hiding the drugs in the lining of their luggage, in clothes, by strapping the goods onto their bodies, or even by using their bodies as containers. The latter category of drug mules have been the focus of much media attention, and have been the subjects of numerous movies and television shows.
Most of these couriers are men, although a significant portion are women, originating from South America, the Caribbean or Africa. The drugs, most commonly heroin or cocaine, are usually packed into condoms or similar bags that are either swallowed or stuffed into the courier’s anus or vagina. Hence terms “stuffers,” and “swallowers.” If swallowed, the drugs are later recovered from the feces with the aid of laxatives.
While it is believed that most couriers “stuff” or “swallow” willingly in exchange for money or other favors from the drug dealers, there have also been documented cases of extortion as well as threats to the courier or her family.
“Mules” risk imprisonment if caught, or even the death sentence. British grandmother  was sentenced to death by an Indonesian court on January 22nd, 2013 for smuggling $2.5 million’s worth of cocaine (3.8 kilograms) to Bali. Of course, the “stuffers and packers” also face a serious health risk if and when those pellets leak or burst before they emerge from the body.
At various border crossings, travelers who raise suspicions of being drug mules may be intercepted and investigated. A plain x-ray is the detection method of choice when packing in the gastrointestinal tract is suspected. Although x-rays are the least costly imaging technique, they may not be the most effective way to uncover a “swallower”. A different type of imaging technique is warranted especially when there is high health risk involved.
Initial Presentation
A twenty year-old Hispanic female with no known medical or surgical history was brought to Lincoln Medical and Mental Health Center’s Emergency Department after flagging down an EMS vehicle and complaining of not feeling well after using cocaine. She then suffered a seizure.
In the ED, although post-ictal, patient revealed that she had tried cocaine for the first time. Urine toxicology confirmed the presence of cocaine in her system. She remained tachycardic with a heart rate of 140 - 160 bpm with prolonged QT on EKG, despite being given 2 g IVPB of magnesium sulfate, 6 mg IVP, then again 12 mg IVP of adenosine, and 1 mg of lorazepam. Since the patient’s heart rate failed to respond significantly, she was given 10 mg IVP of diltiazem, after which heart rate dropped to 120 bpm. The patient was then sent for a brain CT scan, and again suffered a seizure while in the scanner. On re-evaluation, her oxygen saturation had dropped to the 80s% and then 70s%. She was bagged and intubated. After successful intubation, however, the patient’s condition deteriorated with her heart rate dropping to the 40s bpm. She then lost her pulse. CPR was started, and patient was repeatedly found to cycle between ventricular fibrillation (Vfib) and ventricular tachycardia (Vtach).
She received a total of 7 mg of epinephrine, 2 mg of bicarbonate, 1 mg of calcium carbonate, 1 push of amiodarone, 1 of atropine and was defibrillated seven times before spontaneous circulation returned after about 21 minutes. Hypothermia protocol was initiated on time and the patient was transferred to the Medical Intensive Care Unit for further care.
Patient completed hypothermia protocol for 24 hours and remained on the mechanical ventilator. Although awake and responsive, she repeatedly became tachycardic and tachypneic and exhibited decreased oxygen saturation level whenever sedation was held. Both dobutamine and norepinephrine drips were required to maintain adequate mean arterial pressure (MAP.)
The patient was finally identified when multiple family members showed up from her home country stating that she had gone missing for days. The mother raised concerns about her daughter’s expanded abdomen. A radiograph taken while the patient was still still on hypothermia protocol proved negative for foreign bodies.
On the fourth day of her MICU stay, the patient developed low grade fever and a chest X-ray revealed new left lower lobe opacity. She was started on intravenous cefepime. A therapeutic bronchoscopy was also performed to remove mucous plug. At the same time, the patient still required high dose norepinephrine to maintain a MAP of over 65 mmHg. Intravenous hydrocortisone was started.
Daily efforts were made to wean patient off the ventilator with CPAP trials. Vasopressors were removed by the seventh day but the patient remained drowsy, tachycardic and intermittently tachypneic when off sedation. She remained on a tapered dose of hydrocortisone. The antibiotic regimen was maintained for one week for empirical treatment of HCAP since patient was intermittently spiking low fevers, although atelectasis was believed to be more likely, especially when blood culture returned negative for bacterial growth. Repeated chest radiographs revealed increased bibasilar consolidations and small pleural effusions.
Weaning trials continued to result in tachycardia with maximum heart rate in the 140s bpm, and tachypnea with maximum respiratory rate in the 40s bpm.
On the eighth day, the patient was extubated severe tachypnea with RR 50s bpm, breathing with stridor, and desaturating to 88%. Post-extubation ABG evidenced respiratory acidosis with increased pCO2.
That same evening, three suspicious foreign bodies – white substance in translucent wrappings - were found in the patient’s diaper. One packet appeared to be leaking. An abdominal and pelvic CT without contrast was immediately performed, revealing eight radiopaque foreign bodies in the stomach, three in the sigmoid colon, one of which appeared less dense than the others, raising suspicion of rupture, and one more in the rectum. In addition, small bowel intussusception was observed. The radiological findings were consistent with condom-packed drugs.
After a short debate amongst the surgical and gastroenterological services regarding the best approach, as well as with Poison Control’s input, the patient was taken to surgery for an emergent exploratory laparotomy.
She underwent gastrotomy, enterotomy, reduction of ileo-ileal intussusceptions, and removal of all foreign bodies. The packets were found to be strung together and were sent to pathology.
Her subsequent recovery in the Surgical Intensive Care Unit (SICU) was unremarkable and she was successfully extubated two days after surgery, then discharged a few days later.
Discussion
A “” has been granted as an investigative tool by the Supreme Court beginning in 1980. This means that if a person matches certain characteristics, the police may initiate action to detect the transport of illegal drugs. While there is no standardized profile, each state, city, or local police department may have its own criteria for a search. Some common criteria include a person who travels alone; someone who appears excessively anxious, especially with darting looks back-and-forth; a traveler who is dressed inappropriately for the weather, an individual with an odd bulky abdomen. Statistically, there are more male than female drug couriers. Whether to “profile” somebody based on their ethnicity or country of origin raises a range of ethical concerns.
In the case of our patient, suspicion probably should have been raised when she arrived without any clear identification. Furthermore, her family members showing up from a different country, claiming that she had gone missing, as well as her mother’s concern about patient’s enlarged abdomen, were all clues that patient might have been carrying drugs in her body. However, all doubts were thwarted by negative findings on plain abdominal radiograph, and the issue was never raised again as patient had normal bowel movements for one week. One caveat that should be mentioned is the fact that patient was wearing a hypothermia blanket in the x-ray, which could have somewhat obstructed the view.
A plain radiograph is more cost-and time-efficient than other imaging modalities to screen suspicious individuals, however, in a case of high suspicion, especially when there is imminent health danger, a CT might be warranted.
In  presented at the annual meeting of the Radiological Society of North America (RSNA) in 2010 by Patricia Flach, M.D. et al., (from the University Hospital of Nerne and Institute of Forensic Medicine of Nerne in Switzerland) CT was found to be 100 percent accurate in detecting cocaine containers in a drug mule’s body, compared to an 85 percent success rate with low-dose linear slit digital radiography (LSDR), and only 70 percent with digital x-ray. While not surprising, these findings, along with our case, should encourage more CT use when warranted.
In retrospect, patient’s persistent tachycardia, tachypnea and difficult weaning can conceivably all be explained by the constant level of cocaine in her body. Moreover, cocaine’s effect on the heart, by decreasing left ventricular function, is a possible explanation for the patient’s developing new pleural effusion.
There is a lack of definitive guidelines for action to be taken once a person is found to harbor illegal drugs in their body. Drug mules usually take laxatives to aid in expelling the goods upon meeting up with the drug lord, usually in a motel room. The same procedure could be initiated by police or health officials. However, hemodynamic instability is a clear unspoken contraindication to such approach. As in our patient, when the packets are suspected to have ruptured, extreme care must be taken to extract all foreign bodies as quickly and as delicately as possible, without causing further packet rupture. This could only be achieved by surgical intervention; scoping of any kind is likely to be catastrophic.
X-rays may not be enough to detect the presence of concealed drugs in the body due to “overlap of intestinal air, feces or other dense structures.” Moreover, visibility of the foreign bodies depends on the wrapping material, as “rubber condoms would appear hyperdense on CT, while plastic foil wrapping would be ."
Melody Ko is a Critical Care Physician and a McGill alumnus.
