Body packers, stuffers, and pushers may present to the emergency department (ED) for evaluation of symptoms or for medical clearance before prosecution. It is important for the ED physician to have a keen framework for diagnosing, evaluating, and treating these patients.

A 25-year-old woman with a past medical history of anxiety presents to the emergency department with right sided chest pain. She describes approximately two hours prior to arrival, she tripped in the bathroom while bathing her child, striking the right side of her chest on the tub. She denies head strike or loss of consciousness, shortness of breath or abdominal pain. She denies any other specific complaints. Her physical exam demonstrates unremarkable vital signs in a patient appearing stated age, without acute distress. Primary survey including airway, breathing, and circulation (ABCs) is unremarkable. Secondary survey is significant for mild tenderness to right lateral chest wall with ecchymosis in the same area. There is no crepitus. Additionally, the patient has a healing ecchymosis to the left thigh.  A chest x-ray was obtained which demonstrated an acute fracture of the right fourth rib without associated pneumothorax.

Monkeypox is a double-stranded DNA virus and a member of the poxviridae family. They infect a range of creatures including reptiles, birds, insects, and mammals. Interestingly the main reservoir is rodents, (specifically the African giant pouched rat and squirrels) but sporadic outbreaks occur in primates e.g. monkeys, who seem to have taken unfortunate credit and monopolised the name!  To date, there have been 11 poxvirus species that have been shown to cause human infections – the other well-known member of the family being Variola (smallpox). Smallpox led to over 300 million fatalities worldwide. The impact of which is a reminder to take these poxviruses seriously. International immunisation programmes against smallpox ended over 40 years ago. A significant proportion of the population does not have immunity against it and other orthopoxviruses. The worry is that with more infections and reduced immunity, a zoonotic virus, like monkeypox, might gain the ability to transmit more efficiently between humans and cause larger outbreaks.

A 38-year-old male with no history presents to the ED for dental bleeding. He was at the dentist earlier today for a simple tooth extraction but noticed that the bleeding has not stopped. He complains of only mild pain at the extraction site and has never had issues with bleeding before. Vital signs include T 37.1, HR 82, BP 130/82, RR 14, O2 99% on RA. On inspection of the bleeding site, it appears he had a right mandibular molar (Tooth #30) extracted with visible blood clots and active oozing. His airway is patent, breath sounds are normal, and the patient appears well-perfused.