Tylenol Overdoses

In the last week, we've had two terrible Tylenol overdoses. Neither was a clear-cut suicide attempt, though both were certainly suspicious for intentional overdoses. It seems to me that every year around the holidays, we have an uptick in suicide attempts; I'm not sure if it's true, but I certainly wouldn't be surprised if it were. It's a awfully sobering feeling, and I wish I understood suicide better at the individual patient level and at the societal level. It's heartbreaking to see and care for these patients.

Both patients overdosed on acetaminophen, presented to outside emergency departments, and were transferred to Stanford for possible liver transplant. Neither survived to get a liver, though both were actually offered an organ. Acetaminophen is a strange drug; the vast majority is processed by the liver to perfectly harmless byproducts. A minuscule amount is excreted directly in the urine. The rest, about 8%, undergoes metabolism to a dangerous byproduct. This byproduct immediately binds a neutralizing agent in the liver, but in the case of overdose, there is a buildup of this toxic byproduct and it causes severe hepatocyte damage. Patients develop fulminant hepatic failure; their liver cells die, they stop processing toxins and stop synthesizing necessary proteins. These patients develop bleeding, brain swelling, kidney injury, electrolyte imbalances, low blood pressure, seizures, and infections among other complications.

Both patients were young, and we were aggressive trying to save them. We placed breathing tubes, started continuous dialysis, supported blood pressure with vasopressors, prescribed antibiotics. In fulminant hepatic failure - acute life-threatening liver injury without pre-existing cirrhosis - patients get a special status on the organ transplant list. They are first in line, but even then, organs come too late. One patient developed refractory brain swelling and had a cardiac arrest. The second patient had raging pancreatitis which lead to intestinal injury. He actually made it to the operating room, and the donor organ was on its way, but when the surgeons looked in the belly, it was clear he would die regardless and futile to transplant the scarce organ. For both patients, this was a race against the clock, and despite what we could do, both died.

It's been an emotional week. These patients were previously healthy and functional members of society. Although the social milieu was complicated - especially if these were suicide attempts - I was tasked with medically trying to ward off the inevitable. And seeing the family at bedside in shock, witnessing the tragic end of life of these two patients, I struggled with the ups and downs of my job.

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