Agraphia Medical Tragicomedy

7Jan/1410

Righteous outrage

I came across this blog post recently by a retired surgical chair who is pretty upset with a court case about an emergency physician.

Here's the short and outraged version: a man is found during a routine traffic stop to have marijuana in the car. He's taken to jail, doesn't comply with the officer's questions, then barricades himself in the interview room. They proceed to violate all of his 4th amendment rights by strip searching him, but don't find anything. Then they cart him off to the Emergency Department for a forcible cavity search. They have an ER doctor who has done a few rectal exams for them before, so he decides to aid the police, and follows their orders. He's unsuccessful, so he sedates the guy against his will, intubates, and puts him on the ventilator all for a rectal exam ... then the doc pulls a 5.7 gram rock of crack cocaine out of his rectum, and turns it over as evidence.

People are demonizing the physician for forcing this poor man to undergo a "warrantless search" and being a "tool of law enforcement." What I find so frustrating is how quickly people decry the actions of this emergency doc - and assume that law enforcement was just out to make an unconstitutional bust. In my mind, this is a medical case, not a legal one.

Why? Because here's how I can retell the story. Bear with me for just a moment, and assume that the doctor and the police are good people trying to do the right thing. Also, read the actual court case.

A man is pulled over with expired tags. He consents to a search of his car, but his passenger, Felix Booker, is really bugging out and making the officer nervous. The officer actually recognizes Booker; he's taken drug-deal quantities of marijuana from him before. The officer finds marijuana and a "powdery substance" in the car and brings Booker in. At this point, this guy really starts losing it. He barricades himself in the interview room - not a normal thing to do - and starts acting crazier and crazier. There are several physical altercations with police. He keeps clenching his buttocks and trying to use his hands to stuff something further up his rectum. What he's doing is so obvious that the officers actually re-cuff him with his hands in front so he can't reach in back. They strip search him and see a string hanging out. In conjunction with the white powder in the car, they figure this might be a medical emergency.

So, imagine you're Dr. LaPaglia. Police bring you a guy that is acting so crazy he's naked and strapped to a chair, and the officers tell you they brought him in on a drug bust with $1,700 in cash in his pocket. They found a white powder in the car, and now he keeps trying to reach around to shove something further up his rectum. Remember - it is not normal for someone to be so agitated that you have to strap them down. Most normal people calmly and politely ask you to take the restraints off and apologize for all the confusion.

Booker is acting crazy enough you suspect it's either cocaine or PCP in his rectum. Who knows, maybe he's been dipping wet or doing bath salts. The concern is, if he's a known drug dealer, has a bunch of cocaine stuffed in his rectum and he's already this agitated, his baggie may have ripped and now is leaking high-grade cocaine directly into his GI tract. Just like a lot of Emergency Medicine, you cannot know what it is until you take it out; it's Schrödinger's baggie. Then the cops tell you there is a string hanging from his rectum. It's pretty clear you need to get it out.

Your patient actually agrees to let you do a rectal exam, but even after giving him 10mcg of Versed you can't retrieve the baggie - which you now know is there because you can feel it - and the only real way to get it past his anal sphincter is to paralyze him. Is this a medical emergency? Absolutely. If it leaks and he dies, it is your fault. This is a classic toxicology scenario, and that baggie might be a ticking time bomb. So, you sedate and paralyze him, pull the baggie out and... sure enough, you pull out a 5.7 gram rock of crack cocaine. Congratulations, you're a hero! You just saved this man's life. Then you get hit with a lawsuit.

Now, I don't know which version of the story is correct. I'm sure there is truth to both. From what I can tell, the court ruling is still in appeals. I don't have the benefit of seeing the medical record. That said, I have been in situations similar to this more times than I can count. People do drugs, and some people do so many drugs that we need to intubate them for the staff's safety and for their own. We don't like to do it, but I have seen people tear through bed restraints, spit HIV+ and HepC+ bloody saliva at nurses and police, and bash their heads against the wall until they bleed. I've been kicked and punched. We routinely find knives and guns in our metal detectors. If you don't think it's scary to deal with someone who is high on cocaine/PCP/wet/bath salts in the ED, you have never been in the situation. It is one of the few things that still makes me nervous.

It is really easy to armchair quarterback this story and to get all upset about how this man's rights were violated. A lot of the court brief centers around Booker's "consent" to the rectal exam but not to the intubation. This is a very difficult, murky area, especially in the heat of the moment. To the best of my knowledge, if the patient is altered, they no longer are capable of refusing consent. You as their physician must act in their best interest. It seems to me that there was no other way of getting the cocaine out of this guy, and that the doctor had enough reasonable suspicion that it was medically indicated.

Not having been there in the moment, I really can't say. On the flip side, if that cocaine was left in Booker and Dr. LaPaglia refused to do the rectal exam - and Booker died in police custody from a cocaine overdose - well, then there would be an entirely different court case.

And there would be a whole lot of fingers pointing at Dr. LaPaglia then.

Comments (10) Trackbacks (0)
  1. Go to see you are back! I think, either way emergency doctor was just doing his best to help the patient/suspect, why is being put the circus of justice system? It doesn’t make sense.

  2. I have a hard time sympathizing with the EP on this one…yeesh. RSI for a DRE of a suspected drug mule is ridiculous, and if anything more charges need to be brought against the police and the physician (and hospital, and any actor who was complicit in these actions). I put these actions on par with rape.

    If they’re competent to refuse care, they are able to refuse care. Even if the EP thinks the care is medically necessary.

    Considering how poor the informed consent appears to be from the court records, I doubt the EP would have done a stellar job with an informed refusal of treatment…but whatever. He made his mind up about searching the man’s rectum prior to the police bringing him in.

    If the police would like to search your anus, they need a warrant plain and simple.

    • I agree with several of your points, Christopher, but the lynchpin here is the patient’s competence. If he was as wild as the police statements make him out to be, I don’t think you’d be able to argue that he was in his right mind – and thus, not able to make decisions for himself.

      If the doc refused to do the DRE on ethical grounds, and the patient later died in custody, I guarantee you that the prosecuting attorney would argue that Booker was not competent/capable of making decisions. How could he be? There were 5.7 grams of coke working through his system!

      “Informed consent” really only comes into play when the person is capable of making that decision themself. When you’re on a scene call and a patient has a GCS of 3, do you stop to consent them before you intubate? It’s the same general concept.

  3. I am the surgeon who wrote the post you refer to in your first paragraph.

    You are right that there are usually two sides to every story

    I admire your loyalty to your colleague, but I must call your attention to page 4 of the narrative of the court case. It says, “At 2:50 p.m., the cruiser arrived at the hospital. Although Booker denied having anything in his rectum, had no physical symptoms, and had normal vital signs, LaPaglia proceeded without waiting.”

    There was clearly time to obtain a warrant. Also, the presence of something in the rectum could have been determined with a plain x-ray of the pelvis.

    You probably aren’t going to like my post from yesterday either. It’s about some even more dubious searches in New Mexico and Texas. Here’s the link: http://www.physiciansweekly.com/searching-drugs-crossing-ethical-line/

    • I don’t dislike either of your posts, I’m simply trying to argue a point. That said, if I reviewed the medical records and felt that they supported my version, I would absolutely argue against you on the stand that there is “clearly time to obtain a warrant.” That process can take a very long time; time which this patient may not have had.

      I know that you have had your share of surgical emergencies throughout your career. I suspect some of those were exploratory laps for drug ingestions, either from packers or stuffers. I hope none of those patients died while you were waiting for a warrant before you got the ruptured packet/condom/baggie out.

      I should also mention; I’m aware that the court seems to have decided against Dr. LaPaglia in this particular brief. That’s a legal opinion though, not a medical one. Just remember, these are not medical personnel and may not understand the decisions we have to make.

  4. I want to preface by saying I’m an ER doctor in Canada where statutes/laws/etc. may be different but I certainly would hope doctors in the States would have the comparable idea of keeping the patient’s best interests in mind.

    I’ve seen hundreds of drugged out patients (some brought in by police, most not) and my impetus to act is clear – if they verbally tell me no to a test or procedure, I will back the fuck off until 1) a medical emergency requires me to act (usually they fall into a coma / become severely obtunded) or 2) a warrant requires me to act or 3) they are so agitated because of their psychosis/etc. that they can be treated under a mental health law (which allows doctors to ONLY give medications/restraints to calm the agitation – antipsychotics/sedatives/etc. or treat acute medical emergencies, until they are assessed by a psychiatrist).

    Furthermore, I will specifically NOT test for things that may incriminate my patients in the courts unless absolutely necessary – most certainly not even OFFER a rectal exam for a suspected packer (unless they specifically request it, not under duress of law). Are we working on the same planet? Do you work in some wonderland hospital where drug mules become future saints of society thanks to the kind ER doctor who forcibly removed what they themselves decided to insert 2 days earlier? Yes, there’s the (potentially fatal) risk of perforation, but that risk did NOT suddenly increase because they were brought in to the ER by police (as opposed to say, by EMS because they were complaining of acute chest pain).

    Of course this is different if someone wants it out (e.g. bowel obstruction because of the multiple packs) or it has perforated – a true medical emergency. I’ve only seen one true perforated pack in my time, barely touched my hands (enough for me to get the scoop from EMS) before being whisked off by surgery and ICU afterwards. This guy? He sounds like 90%+ of addicts brought in by police. And yes, some of those are packing. And no, I don’t give a shit without a warrant. Even if there is a string hanging out of his ass, if the addict doesn’t want it out, the police can get a warrant or fish it out themselves.

    So the idea that a guy is brought in by police and because of “suspicion of packing” that a doctor would forcibly subject a patient to those tests, in the LACK of an emergency situation, is certainly barbaric to me. And yes, I get it, it could turn into an emergency, it may have been an impending emergency, sure. Every time I send back home a failing-to-cope 80 year old with COPD and CHF I may be sending home an impending emergency. But to me it’s pretty clear – there was no ACUTE medical emergency; therefore regardless of consent there should have been ASSENT for any medical procedures (which there was not).

    The fact that this same doctor did the EXACT SAME THING a few years ago to a person with an ultimately NORMAL rectal exam makes me seriously doubt he had the patient’s (as opposed to the police’s) best interests in mind.

  5. I wonder if you also support the doctors in Mr Eckert case and Timothy Young case where NO DRUGS WERE FOUND and innocent people were subjected to anal searches, enemas and in Mr Eckert’s case – colonoscopy? How about “Jane Doe”‘s case where she was subjected to multiple searches, enemas, X-rays and a CT scan – again no drugs found? Is it OK according to you to subject people to degrading and potentially harmful procedures because it “might” be needed? What exactly was the benefit in any of these cases to justify emotional harm, potential risks and in Jane Doe’s case risks of cancer because of completely unnecessary CT scan?

    Oh, and in all of these cases the “patients” were billed for the ‘services’…

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