Yellow Failure
Doctor/Coroner Story
Sid knew about this from his residency training. A senior resident had presented a case.
“A 23-year-old woman was dropped off at the ER at 2AM by her friends because she was ‘acting funny’.”
Case presentations have a format. The first line has to include the age, sex and chief complaint.
That was a real introduction to medicine, the ‘chief complaint’.
Why is the patient here? They have a complaint.
Think about that before you make your next doctor appointment. What is your chief complaint?
Sid found the complaint driven nature of medicine archaic. Why can’t they come see him to try to be healthy? It all goes back to the old days when people only went to doctors because they thought they were dying. And they probably were.
What is their chief complaint? In other words, where does it hurt the most?
Chief is important too. For they may have many.
Sid’s job, as physician, was to discern their chief one. And be alert for the ones that could kill them.
This was a struggle for him. Sometimes it’s not what they tell you. Sometimes they hide their chief complaint.
Sid came to learn this was normal. Nobody wants to fess up.
The 23-year-old woman’s ensuing hours of acute yellow failure taught him a lot about the mechanisms and numbers associated with liver failure and death.
We always think of heart attacks. Indeed, your heart stops, you die. And then there’s brain death. Heart still beating but the organ inside our skull isn’t functioning.
If the liver dies, we die too. The liver does a lot for us. It’s our recycling plant, our metabolism factory. It builds proteins for blood clotting, tissue repair. It keeps us alive. We really don’t appreciate our livers. We should.
For Sid, the fact that friends dropped her off and she would be dead in less than a day was the real story he heard. Though the numbers, the treatments, the physiology were of interest, and he remembered them.
Medical training is about remembering. Sid just wished he could remember names.
In medical terms, her “chief complaint” was not hers, but framed by those that dropped her off. The young woman that died in less than 24 hours of acute yellow failure never spoke a word. She never complained. We just tried to save her silent life. Sid pondered that too, for a long time. Maybe still.
Sid’s subsequent training showed him just how resilient the liver can be to insults, both chronic and acute.
Heck, even surgical. That would be iatrogenic.
Isn’t that a nice word?
It means caused by us physicians, or maybe, the medical industrial complex. The medical system can cause disease, injury. And that would be not accidental, not natural, not suicidal, but iatrogenic. Iatrogenic is not a box Coroner Sid could check on the death certificate for Manner of Death, though at times he thought it should be.
Back to the liver. We cannot survive without it.
Sid had spent hours pulling back on retractors on a medical school rotation to keep a 30-year-old Native American woman’s belly open so the chief resident surgeons could spend 8 hours cutting out three quarters of her liver invaded by cancer. The last quarter would recover and do the job of what they had resected.
Sid learned of the forgiveness of this wonderful organ.
There were the yellow, jaundiced drunks who perked up after a couple days and went back to the streets.
Sid had also seen a severely injured liver kill a young child quickly.
The viral diseases of hepatitis added more. Back when he was in training there was Hepatitis A (from fecal contamination, “food service workers must wash…”). And Hepatitis B. It was a viral infection transmitted by blood or body fluids. All medical professionals got tested and then immunized. Sid had learned of the third virus, labeled then “non-A and non-B”. That was an attempt to emphasize our medical ignorance, which Sid appreciated. It has now come to be called Hepatitis C, since we can now identify this virus. It still kills.
When the liver fails, one of its main functions can show up in our skin. If our livers don’t metabolize bile, a byproduct of cholesterol and fat metabolism, we become yellow. This is jaundice. But the yellow takes some time. Experience teaches you the timing. Medical training gives you the time to observe.
When we call it acute yellow failure, we are talking about folks who turn yellow and die. Some don’t even get the chance to turn yellow.
The case presentation progressed. The dropped off young woman’s liver dramatically failed; from the moment she was first pierced for blood tests to her death. The numbers we measure quickly are those of the enzymes, proteins in liver cells that can leak into the blood stream. As the liver cells explode from injury, they leak more. These climbed over the hours on an accelerating curve. The young lady’s numbers were over 100 times what was considered normal.
About two hours before her death the treating residents got back the labs that showed she had three viruses attacking her liver, two probably from IV drug use, and the worst, just from bad hygiene. And she died.
There are so many ways to die. She dramatically died from acute yellow failure. And she didn’t even have time to turn yellow after her friends had dropped her off. She would have had to live longer. Timing is learned with observation and experience.
The Madonna held her child at her breast and the simpering young father was on the examination table facing Sid. He knew them well.
Sid had delivered the babe.
The young man had been about. And here he was.
“What can I do for you?”
The young man looked down and to the left, not answering. Madonna barked. “Tell him.”
“Uh, well, I might have taken some pills.”
Sid took over to the Madonna. The loser was not a good resource.
“What pills?” Sid asked. The Madonna kept her gaze on the father.
The young man shrugged and looked down again.
Sid waited until he was afraid the young woman would bark again. So, he barked. “What pills did you take?” Maybe barking works with this guy.
He did the weaseling shoulder wiggle and looked at his wife. She was glaring at him. “I took some Tylenol. I wanted to kill myself.”
Sid’s family doctor mind clicked to the acetaminophen (Tylenol) toxicity nomogram, and this drove his questions.
Tylenol is available over the counter in the United States. Some companies make a lot of money. But when it is ingested above the recommended level, it is very toxic to the liver.
When?
Friday night.
This was Monday.
Sid now knew the nomogram for treatment was out the window.
How many? The dose is the question.
I don’t know, all of them.
Is that like ten pills, twenty pills, thirty pills?
More weaseling.
I don’t know. It was what was left in the bottle. Maybe thirty pills. Maybe forty. I chugged it with some vodka. He smirked.
Madonna nodded.
“Were they 325 mg or the extra strength 500 mg?”
Weasel was proud. “We get the strong stuff.”
Sid knew the math, the choices.
“I need you to go over to the hospital right now. They will take blood tests and you need to be in the hospital. I hope this turns out okay.”
Sid saw acute yellow failure coming. He would need to work to save this new young father. But he kind of knew, at this point, the cards had been dealt.
Saving lives can beg the question of just who should we save? And at what cost? But that’s for late night garage reflections. Sid just wanted to do his job right now. Sid had learned how fast the failing liver can kill you from that long ago case presentation.
The first test just showed the weasel’s liver cells were leaking ten times what they should and his Tylenol level wasn’t toxic now, but high. But the treatment graph no longer mattered. No treatment would be effective this late after ingestion. The damage had been done and the question was now just how much? Could his liver survive? Time was crucial. Sid now knew, we were just going to have to see the course.
Two hours later Weasel’s liver was leaking thirty times what it should. Four hours later they were a hundred-fold above normal. Time and pathology were meeting.
Sid called Seattle between afternoon patients. He got the gastroenterology chief resident. Sid knew this guy would know his shit, but he might be an asshole. Sid hoped not. He wasn’t.
Sid did the case presentation over the phone, saying the vital numbers and skipping the surplus. This guy might die, and Sid needed to cover the bases. “Can he be considered for a transplant?”
Sid heard the long pause, hinting the chief resident’s awareness of Sid’s small-town ignorance. But Sid knew the long lines, the waits, the futility. He just wanted this guy on the phone to know his desperation. A young man, a recent young father might die. And Sid is a small-town family doctor. Help me out big city doc with all the resources, he hoped into the phone silently. But Sid knew it was not going to fly.
The phone said, “Yeah, this doesn’t look good. But get another test at midnight and check his coags. Call me with those numbers.”
Sid finished his afternoon clinic. A couple colds, an old, demented lady, a worried student, an angry back pain guy who wanted narcotics. Sid couldn’t remember any names.
He crossed the street to the hospital.
Weasel wasn’t yellow. He acted like he didn’t understand why he had to be there.
“Do you still want to kill yourself?”
Sid thought this was a reasonable question to ask. The guy had no idea his liver might soon melt into mush, his blood might no longer clot, his ammonia would climb and poison him. His blood could become toxic, and he could die in the next few hours. Or not. Sid was in the balance. As was the Weasel and the Madonna and the babe.
So, Sid thought this was a reasonable question for the guy with his orange sherbet and the Madonna with babe by his bedside.
He looked blank. “Oh, that. Nah. I’m over that. Can I go home?”
Sid did his best to explain the situation. If Mr. Weasel’s Tylenol dose was enough to kill his liver, he would die in the next 48 hours. If not, he would survive. There was no treatment available at this point short of a liver transplant. And Sid told them he had started this discussion with Seattle.
Weasel dipped orange sherbet and Madonna looked out the dark window at the black. Night came earlier in the fall. She seemed to see something out there in the dark, but Sid had his focus.
Sid noticed the sleeping babe in her arms, quiet.
The blood tests in the next few hours would tell us the direction, the curve we were on.
“So, I gotta stay here tonight?”
Yup.
Sid ordered the midnight lab draws and went home to maybe have dinner with his family, his Madonna, and his babes. He knew he maybe be back here in the wee hours. He knew his sleep would be disturbed.
As he went out to the rusty Hilux in the doctor’s parking lot, he looked up at the dark sky, but he didn’t see anything. He just thought of the not yellow yet young father who said that suicide shit was past, behind him. Sid knew the numbers would come.
But he slept, nonetheless. That’s another thing you learn in medical training. Get what you need when you can.
Sid left in his order for the lab to call him with the midnight numbers. The phone on his side of the bed woke him. They recited the numbers, and he remembered them. Sid could not remember a patient’s name, but he could remember the three five-digit liver function numbers.
He called the chief resident in Seattle.
“Huh, that’s good, I think he might make it.” Sid heard.
“Should I check his coags again in the morning?”
“Yeah, that’s probably a good idea but this guy isn’t getting surgery soon, is he?”
“No. He wants to go home. Is that okay?”
“Yeah, his liver should recover back to normal in the coming week. You can keep checking if you want to. He may not even turn yellow. Tell him the usual, no alcohol, no drugs, no Tylenol.”
“Thanks.”
Sid checked on the groggy weasel early since he had a surgery at 7AM. He woke him up to tell him he would live. He rolled over and mumbled something.
Doctor story ends, coroner story begins.
Sid’s nurse interrupted a summer afternoon patient with “Paradise PD on line 3.” That was her code for a coroner call. Sid left the depressed young woman and listened to the dispatch lady.
“We need you to respond to 174 South Peach Street for a suicide.”
Sid did. It was a warm late spring day.
He greeted the detective on the street. “Guy shot himself up there.” He tipped his chin toward the second-floor apartment.
“You got a name?”
He flipped through his notepad and told Sid the weasel’s name.
There were 9mm casings on the steps. The guy had shot off a few rounds sitting there overlooking the parking area. Then he’d gone back onto the couch and put the gun under his chin. And fired.
Sometime later, as Sid was examining the beautiful babe at the six months well child check, the Madonna had said. “I never thought he would do anything like that to mess up his hair.”
Cause of Death: Gunshot wound to the head.
Manner of Death: Suicide