Management of body packers

Body packer

Body packer

2 out of 5 stars

Assessment of the management outcomes of body packers. Alfa-Wali M et al. ANZ J Surg 2015 Jul 14 [Epub ahead of print]


This article from Hillingdon Hospital in London — located a mere 4 miles from Heathrow airport — was intended to evaluate the facility’s existing protocol for managing body packers.

Although some details of their protocol are not justified or even well-described, in general they align with the trend towards conservative treatment of asymptomatic patients, with observation bowel cleansing agents — they used Picolax (sodium picosulfate with magnesium citrate) or Klean-Prep (polyethylene glycol.) Surgery was reserved for patients showing signs of toxicity from cocaine or heroin, or gastrointestinal obstruction, but not done just because ingested packets had not passed within a pre-specified time period.

The study retrospectively reviewed charts of 120 patients referred to the hospital between 2000 and 2013. One patient had a myocardial infarction and one had a cardiac arrest, but there were no deaths. Aside from this, the data from these patients is so sparse and poorly presented that it is difficult to glean much useful information from the paper.

The authors conclude that:

Conservative treatment is safe and effective for body packers.

This is most likely true, given the caveat that it applies to asymptomatic body packers only, and that “conservative treatment” specifically means not performing surgery routinely but only as indicated by clinical signs and symptoms. Unfortunately, as with much of the literature on this topic, it is far from proven by the evidence.

Periodically, Hillingdon Hospital publishes a review of its experience with body packers. For example, this paper reviewed patients seen between 2000 and 2005. Thus it seems that there are a number of patients being reported multiple times in the literature by this group. I have not previously found these reports coherent or convincing, and this paper is no exception.

Related posts:

Best paper yet on screening suspected body packers

Conservative treatment of asymptomatic body packers?

Body packers: can CT determine the number of drug packets?

MRI for body packers?

Low-dose abdominal CT is superior to plain film for imaging suspected body packers

Cannabis body packers

Treatment protocol for symptomatic body packers (mules)

Cocaine mules: what to do with body packers


Tox Tunes #100: Rehab (Amy Winehouse)

TPR started the series “”Tox Tunes” on January 3, 2010 with Keith Richards’ cover of Reverend Gary Davis classic “Cocaine Blues.” Our stated goal was to highlight selections “culled from the long tradition of popular songs about drugs, toxins, and poisoning.”

Amy Winehouse’s “Rehab” — sometimes called the most ironic song in history — is our one-hundredth selection. Of course, Winehouse died of alcohol intoxication in July 2011; the coroner’s report listed her blood alcohol level as 416 mg/dL.

As a look back, we will post a list of — and links to — our first 100 “Tox Tunes.”

Make the Diagnosis, Sherlock!

holmes2-150x150A 24-year-old man is brought to the emergency room with altered mental status. He was found wearing only his undershorts and shouting “I am God!” A friend reports that 3 hours before presentation the patient had been seen smoking marijuana. Can you make the diagnosis?

This case is part of the New England Journal of Medicine‘s “Interactive Medical Case” series. It is not behind the Journal‘s firewall and costs nothing to play. Subscribers can earn CME or MOC credit. To work through the case, click here.

Google Glass in toxicology: there may be less here than meets the eye(glasses)

Google Glass

Google Glass

3 out of 5 stars

The Feasibility and Acceptability of Google Glass for Teletoxicology Consults. Chai PR et al. J Med Toxicol 2015 Aug 6 {Epub ahead of print]


This paper takes up a fascinating subject — it has already received a fair amount of attention in the media — but I think there is somewhat less here than meets the eye.

Google Glass is an optical head-mounted device (OHMD) that looks like a a pair of eyeglasses with an extra do-dad placed in front of one lens. This structure contains a camera and a display. The Glass is connected to the internet through a wi-fi network. In addition, the Glass can function as a hands-free cell phone through its Bluetooth connection.

The research question here, somewhat vaguely stated, asks whether it is feasible to use Google Glass to facilitate toxicology consults. By “feasibility,” the authors seem to be asking merely whether the Glass can establish a reliable network connection and transmit adequate pictures. (Because Google Glass  is worn like a pair of eyeglasses, the visuals it captures should represent exactly what the wearer is looking at.)

The study was done at the Division of Toxicology at University of Massachusetts in Worchester, using the HIPAA-compliant Pristine Eyesight operating system:

When running the Eyesight software, Glass wirelessly streams live, first-person video feeds to a remove viewer. In addition, the remote viewer is able to communicate with the Glass wearer through either the computer microphone or HiPAA-compliant text messages.The Glass wearer is also able to take static snapshots that are transmitted to the remote viewer.

Residents rotating through the toxicology service wore GG during selected consultations, with the images transmitted to a supervising fellow or resident.

The authors state:

During our study period, we attempted 19 consults through Glass. We were able to successfully complete 18 consults. In one case, we were unable to establish a wireless connection to the hospital network with Glass, and aborted the video consult.

However, in the very next paragraph, they write:

In 89% of cases, consults through Glass were considered successful by the supervisory consultant (N=16).

I am not quite sure why 2 cases were “successfully complete[d]” but then not considered ultimately successful.

In addition, the authors claim that: “Supervisory consultants reported that the virtual exam through Glass changed management of the patient in 56% (N=10) of cases.” Examples given of “changed management” included ICU admission, transfer to a hyperbaric chamber for treatment of carbon monoxide poisoning, and hospital admission for acetaminophen ingestion. It seems to me that these changes were the result of the consult itself  — not necessarily the Glass — and very well might have occurred even without the technological enhancement. If the Glass itself actually resulted in a change in management, it not clear from the paper.

This is clearly a topic that will be the subject of further investigation. My hunch is that these head-mounted devices may prove useful in international medicine and tele-consults in really remove locations, but not in an urban setting with comprehensive toxicology resources.

The following video gives an introduction to Google Glass Explorers’ Edition. Early this year, Google announced that it was stopping production of the prototype but still remained committed to the platform:

Ten cases of suspected palytoxin poisoning

Zoanthid colony

Zoanthid colony

3.5 out of 5 stars

Suspected Palytoxin Inhalation Exposures Associated with Zoanthid Corals in Aquarium Shops and Homes — Alaska, 2012-2014. Hamade AK et al. MMWR 2015 Aug 14;64:852855.

Full Text

Palytoxin is a huge molecule that jams sodium channels in the open position, impairing the ability of excitable cells to maintain normal electrical gradient across the cell membrane. In addition, the open channels provide a pathway for calcium to enter cells, resulting in release of catecholamines and ultimately cell death. Because of this effect, palytoxin is a potent vasoconstrictor.

Although most likely produced by smaller dinoflagellates, palytoxin is often found in zoanid coral (colonial anemone), a species often found in home aquariums. This coral can be difficult to remove, and when cut, scraped, or doused with hot water toxic aerosols can result.

This report describes the investigation by the Alaska Section of Epidemiology into at least 10 cases of palytoxin poisoning over a 2 year period. The index case, a middle-aged man, presented to the emergency department complaining of a “bitter metallic taste,” fever, weakness, headache, cough, as well as arthralgias and myalgias. Approximately 7-8 hours before presentation, live zoanthid coral was placed in his home aquarium. On presentation, he was tachycardic (135/min,) tachypnic, and febrile (103oF.) Two other persons who lived with the index case presented with milder symptoms.

The authors point out that there is no specific antidote. Manifestations of toxicity resolved in thiese patients with observation and supportive care.

[Photograph of zoanthid colony from MMWR]

Related posts:

Palytoxin: deadlier than fugu?

Palytoxin: just when you thought it was safe to go back to the aquarium . . .

Candiru: a catfish that’s small, eel-like, and penetrates the urethra

3.5 out of 5 stars

Candiru — A Little Fish With Bad Habits: Need Travel Health Professionals Worry? A Review. Bauer IL J Travel Med 2013 Mar-Apr;20:119-124.


Don’t know how I missed this paper when it was published 2 years ago. The author searched medical literature to answer the pressing question: Is there really a catfish native to the Amazon River that can swim up — and become embedded in — a man’s urethra?

TPR has posted on this subject before. The candiru (Vandellia cirrhosa) — a tiny eel-like catfish — is a blood-sucking parasite that preys on larger fish, following the stream of water and urea that flows from victim’s gill slits until it enters the gill opening and embeds itself by means of sharp spines.

The legend, going back centuries, is that if a person urinates in the Amazon, the fish can mistakenly follow the similar stream and actually swim into the urethral opening, where it becomes nearly impossible to remove because of its backward-pointing spines. Rumored treatments have included high-dose vitamin C and amputation. (Some claim that the things necessary for surviving a candiru attack is “a machete and a strong will to live.”)

As the author points out, there have been no confirmed cases reported in the scientific literature. The best documented case occurred in 1997, when urologist Dr. Anoar Samad claimed to have removed a candiru from a patient’s urea by means of cystoscopy. Supporting evidence includes a photograph of the dead fish and a purported recording of the procedure:

There have been questions raised about the authenticity of this case, based on inconsistencies in the history, physical evidence, and procedure note.

The author of this paper considers the candiru from the perspective of travel medicine: do clinicians have to warn their patients traveling to the Amazon about the fish, and advise them to wear a tight bathing suit and not pee in the river. She concludes that if piscine urethral attacks do in fact occur, they must be so rare as to be practically insignificant, and that “there appears to be no need for considering the candiru in health advice for travelers to the Amazon.”

That’s a relief.

Related post:

Just when you thought it was safe to go back to the Amazon . . .