Body Packing with Cocaine: A Simulation Exercise

Pedagogically sound simulation-based medical education (SBME) produces effective learning [1]. We present a simulation scenario for “body packing”, which is the concealment of an illicit drug in packets (usually condoms) inside the body by swallowing or recto-vaginal insertion, usually for transportation across borders. This scenario will train Emergency Medicine residents to suspect body packing under appropriate circumstances, and to treat the potential alimentary pathologies and drug toxicities which body packing with cocaine can cause. Categories: Emergency Medicine, Medical Education, Medical Simulation


Introduction
Also known as "muling", body packing involves filling a body cavity with wrapped packets of an illegal drug. It is sometimes confused with "body stuffing", an evasive tactic by a person carrying generally small amounts of illicit drugs, should they feel they are about to be apprehended by police. In contrast, body packing is typically suspected at international airports, where security personnel or drug dogs are trained to find contraband. Drug packets concealed in a body cavity can leak or burst, causing a massive overdose, usually of cocaine and heroin. The packets themselves can also cause bowel or esophageal obstruction, perforation, and peritonitis. The leakage of packets containing cocaine is a medical emergency and an indication for prompt surgical removal.
For medical learners in smaller residential and urban areas, where international traffic is limited or absent, the diagnosis of body packing may be challenging. For example, trainees at Memorial University of Newfoundland (MUN) located in St. John's Newfoundland (population 208,372 as of 2013) serve a relatively small population, in which the drug trade has recently taken hold where there was once mostly petty crime. It has been projected that recent offshore gas discovery and attendant international travel may bring more cases of body packing to this province's emergency departments.
We describe a simulation exercise designed to teach trainees at MUN an approach to cocaine toxicity in the setting of body packing.

Technical Report
This simulation session uses the Gaumard Noelle S575 human patient simulator, programmed to produce a cocaine intoxication. If requested by the learner, a plain abdominal x-ray image shows packets of drug within the bowel of a patient who is in handcuffs. Two confederates are employed as prison personnel. The detailed stepwise scenario is written and given to technical staff, who then programs the computer to control the simulation.

Case
The learning objectives for this simulation scenario are: 1. ABCs of resuscitation and forming an initial impression, 2. Recognition of the sympathomimetic toxidrome, 3. Recognition and treatment of cocaine toxicity while prioritizing its three most lethal complications: hyperthermia, hypertensive emergency, and cardiac arrhythmias, 4. Recognition of body packing.
In this simulation, the learners are informed that a young male, in this case, a Gaumard Noelle S575 human patient simulator, is brought in handcuffs to a tertiary care emergency room (ER), accompanied by two prison personnel. Trained Standardized Patients (SPs) act as the two prison personnel, who are present throughout the scenario to answer any questions (if relevant) but who are instructed not to provide any voluntary information. The learners are informed that the immigration authorities apprehended him from his Columbian flight when it landed unexpectedly in St. John's. They suspected drug trafficking because he paid cash for his one-way ticket, was wearing sunglasses at night, and seemed nervous. The patient is alert and well at the airport. His nose is running. Table 1 describes the simulation algorithm used in progressively deteriorating the patient (Gaumard Noelle S575 human patient simulator) by the educator using the computer.

Scenario
You are an emergency room physician at a tertiary care center and have just begun your shift. A 26-year-old patient who is accompanied by law enforcement, is your first patient. On return from Columbia he was arrested at the airport on drug related charges. He is currently being triaged.
Begin Scenario -Learner enters the patient's room

Debriefing
Debriefing has been described as a critical component of the simulation exercise [2]. Initially, students are encouraged to discuss their feelings about the case. To encourage candor, we allow a maximum of one teacher per learner. We use the advocacy-inquiry technique [3], which allows us to frame the trainee's thought processes non-judgmentally, and to neutrally suggest other approaches which might be more fruitful.

Post-scenario didactics
A brief didactic session, which addresses the learning objectives, is held after the debrief. This allows consolidation of the knowledge acquired during the simulation and closes any knowledge gaps.

Discussion
Drug muling was first described in Canada in 1973 [4], when a single condom filled with hashish caused a small bowel obstruction and was uneventfully removed.
Body packing with sympathomimetic illicit drugs is globally increasing in frequency [5], partly due to increased airport security post-September 11th [6], but it remains an uncommon problem in many small centres. Failure to recognize the presence of body packing can lead to potentially fatal medical errors. For example, the patient in our scenario was taken to jail from the airport when it may have been more appropriate to bring him to the ER.
Several kinds of drugs can be carried in the alimentary tract or vagina, including cocaine, heroin, ecstasy, and cannabis products. Typically, only one kind of drug is transported at a time. The amount of drug carried is variable; 50-200 packets, each containing up to 10 gm of a drug, has been described. A single ruptured packet may cause death as more than 10 times the lethal dose of cocaine may be released [7]. Drug packets, once primitively constructed, are now precisely crafted with well-compacted contraband covered in latex and sometimes wax. They are uniform in appearance and occasionally wrapped in foil to alter their radiographic appearance [8]. Body packers usually know exactly how many packets they are carrying, but may deny carrying any. Luggage contents may include large numbers of condoms, latex fingers and gloves, petroleum jelly, coconut oil for swallowing packets, toilet paper, room deodorants, and coal packets, as well as medicines to control abdominal cramping and diarrhea. If body packers elude arrest, laxatives are taken to encourage packet expulsion; if they come to the hospital and remain asymptomatic, packets are counted when expelled, then given to police. Two consecutive normal stools indicate that the drug has passed [7].
Body packing with cocaine can be lethal. The condoms, balloons, or cellophane enclosing the drug can leak or rupture, causing a potentially fatal overdose. The packets themselves can cause a bowel obstruction, perforation, and/or peritonitis. Esophageal rupture can occur. As one leaking packet of drug can release a fatal amount of cocaine, it is important for emergency medicine trainees to recognize the sympathomimetic toxidrome, the other toxicities caused by cocaine, and the presence of body packing, which implies that many more packets of drug are concealed inside the body where they can leak and worsen the toxicity. In a stable patient, any free drug will be absorbed somewhat by oral charcoal, while the packets are expelled over time with whole bowel irrigation. Should symptoms and signs of cocaine toxicity develop, surgery must be consulted while resuscitation is underway for packet removal via laparotomy. Laparoscopic removal risks tearing the condoms. Conservative management is usually successful when the packets are not leaking [9][10].
This simulation scenario uses a computerized human mannequin to teach emergency medicine trainees an approach to the sympathetic toxidrome, cocaine toxicity, and body packing. It also uses a "fiction within a fiction": two real abdominal x-ray images are superimposed to create a third entity which helps tell the story. Because of the reports of controversy about the ethical difference between improving an image, and frankly altering it [11], we have decided to acknowledge this fact and admit to the factitious nature of the image while discussing our contract with the learner. In order to avoid disclosing details prematurely, the images themselves are not shown until later in the simulation. The x-ray depicting shackles and handcuffs in an otherwise unremarkable film came from an actual patient from a local jail. Usually shackles and cuffs are not imaged because the patient raises their hands above their head; on this occasion, an error in our xray department led to the inclusion of the hardware. We felt that such a striking and unusual image could form the basis for our body packing scenario. Since we rarely see body packing, and have no actual images of it from our own population, we acquired the x-ray showing packets within the bowel online and superimposed the two. The resulting image showing shackles and handcuffs as well as packets in the bowel, may be "larger than life", but it serves to illustrate the diagnosis in our setting, where body packing is rare now, but potentially will become more frequent.
As mentioned earlier, the learning objectives for this simulation scenario were: 1. ABCs of resuscitation and forming an initial impression, 2. Recognition of the sympathomimetic toxidrome, 3. Recognition and treatment of cocaine toxicity while priorizing its three most lethal complications: hyperthermia, hypertensive emergency, and cardiac arrythmias, 4. Recognition of body packing.
These objectives were developed because cocaine toxicity produces a multi-system assault. Hyperthermia must be promptly and aggressively managed with cooling techniques and benzodiazepines in order to reduce mortality. It is associated with rhabdomyolysis, hyperkalemia (which may worsen cardiac arrhythmias), renal failure, and myocardial ischemia (Figure 4). Hypertensive emergencies associated with cocaine overdose are treated with benzodiazepines and phentolamine (a pure alpha-blocker), and high-dose nitroglycerine or nitroprusside. Beta-blockade will worsen the situation. Cardiac arrhythmias seen are most commonly sinus tachycardia, but excess adrenalization may produce atrial fibrillation (AF) or supraventricular tachycardia (SVT). Wide-complex ventricular tachycardia may happen in association with fast sodium channel blockade ( Figure 5) and is treated with sodium bicarbonate. It may be preceded by the RSR' pattern in AVR, as in other sodium channel blockers overdoses, such as tricyclic antidepressants. Lidocaine and other 1A anti-arrhythmics must be avoided because they block sodium channels. The presence of body packing raises the possibility of worsening toxicity as well as mechanical bowel obstruction, perforation, and peritonitis.

FIGURE 4: Diffuse ischemic change
Commonly seen with chest pain in cocaine intoxication [12] FIGURE 5: RSR' pattern and wide QRS typical of sodium channel blockade.
Seen in cocaine and other toxicities like tricyclic anti-depressants [13].
Patients with cocaine toxicity often present with toxic delirium, in which it is important to consider other causes, such as infection, Wernieke's encephalopathy, or trauma. It is prudent to order blood cultures, if indicated, and administer thiamine and dextrose at the outset.

Conclusions
Simulation is a valuable tool for teaching emergency medicine trainees the effects of cocaine toxicity in the context of body packing. Simulation includes a fictional contract in which teachers and learners acknowledge that the case in question is not real, but agree to suspend their disbelief and proceed as though it is. We describe a simulation exercise in which the transposition of two real x-ray images produces a third image, which helps tell the story.

Additional Information Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.