Agraphia Medical Tragicomedy

7Jan/14Off

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.