Tylenol “likely” caused Cynthia Blackjack’s liver to fail, according to a doctor, but it was too late to save her life when she first arrived at the health centre in Carmacks.
It was too late to give her an antidote that would have reversed the effect of the drug on Nov. 6, 2013, the day before she died, when she complained of stomach pain, says Dr. Robert Saunders in a report prepared for the inquest into her death, as her liver was already shutting down then.
It was too late to get her to the hospital in Whitehorse then, too. She required a liver transplant, he says, surgery that takes advance planning to pull off.
“The intricacies and complexities involved in preparation for a liver transplant usually means that it takes weeks or months, at a minimum, before the procedure can be done,” he says.
“I see no conceivable way this would have been possible in Cynthia Blackjack’s case.”
It’s impossible to know how much Tylenol Blackjack took leading up to her death on Nov. 7, Saunders says, but, coupled with alcohol, it might have been enough to kill her.
“With the rapid deterioration she experienced I believe that whatever agent she was exposed to, it happened within a relatively short time (in terms of days) before she died,” he says.
The original coroner’s report in 2014 says Blackjack succumbed to multiple organ failure while on route to Whitehorse via medavac on Nov. 7, 2013.
Evidence that’s part of the inquest zeros in on potential reasons why her liver began to fail.
“I’ve never seen such a deterioration, certainly in a chemical sense,” said Saunders, who’s been a practicing doctor for 44 years, told the inquest on Jan. 29.
“I’ve seen this a couple of times over the years in people who have taken Tylenol to commit suicide or harm themselves and then feel bad and have to go to the hospital two or three days latter, and that’s too late to do anything about it, if they’ve taken enough,” he said, adding that there may be no symptoms within the first 24 hours.
“You might have some malaise, you might have some vomiting, and this is the period of time when it’s amenable to treatment.”
An antidote capable of reversing the effects of acetaminophen (the pain-killing component in Tylenol) should be given within the 24 hours, according to Saunders’ report.
Saunders said that acute liver failure as a result of Tylenol is “quite rare.”
Blackjack was tentatively diagnosed with alcohol-induced gastritis the day before she died.
Saunders said such a determination was appropriate, adding that subsequent treatment was reasonable, including the decision to not call on an ambulance to transport her to the Whitehorse hospital.
Matt Lewis, a nurse, tended to Blackjack that day. He testified that he advised Blackjack to go to the hospital in Whitehorse in order to see a doctor or to come back to the health centre if she couldn’t find a ride herself. She didn’t, he said, adding that she didn’t require an ambulance that day.
Lewis said, “At that time, I was not thinking of acetaminophen levels, to be honest.”
According to a postmortem examination by pathologist Matthew Orde, who was also called on to be an expert witness, Blackjack had traces of Tylenol in her system when she died.
When her liver started to fail, it caused collateral damage to neighbouring organs like the kidneys and lungs, he says, noting that this is common in cases where there’s hyper acute liver failure.
But Tylenol dosage doesn’t seem to matter.
Blackjack had a history of heavy drinking. There was evidence of her doing so for upwards of 10 days straight before she died (she was sober when she went to the health centre). Alcohol, Saunders said, can strip away cleaning agents in the liver, which can make acetaminophen more dangerous, regardless of how much was taken — even regular doses can impact the organ.
“To use acetaminophen, even at the recommended dose of four grams a day — if you’re an alcoholic and drinking to the extent that Ms. Blackjack did, it certainly increases the risk of hepatic (liver) damage,” Saunders said.
Last week, Blackjack’s cousin, Dacia Tulk, said she gave her roughly six Tylenol and two Gravol. She said she did this because Blackjack worried no one would help her at the health centre.
Tylenol 3s, which is what Blackjack ostensibly took, have very low doses of acetaminophen per tablet, said Dr. Lucille Stuart, who testified this week.
“It should really not cause liver failure,” she said. “It’s impossible to say whether Tylenol did or did not contribute because we don’t have any accurate, objective information about her actual Tylenol consumption.”
According to Saunders’ report, acute liver failure is rare, with a roughly 60 per cent mortality rate.
“(There’s) an annual incidence of less than 10 cases per million population and in North America almost half of the cases are attributable to acetaminophen overdose …” he says, going onto say that 50 per cent of these are intentionally ingested, whereas the remainder aren’t.
Her dental health might have compounded the problem.
According to Orde’s report, Blackjack’s teeth were reduced to “blackened stumps.” This might have led her to take Tylenol. And, coupled with alcohol use, her liver was particularly susceptible to damage.
The final witness testified on Jan. 30. The inquest returns on Jan. 31, with presiding coroner Peter Chisholm charging the jury with the facts of the case. The jury is to come up with a verdict, which is expected sometime in the afternoon.
Contact Julien Gignac at julien.gignac@yukon-news.com