When it doesn’t help to check the label

I get paged in the middle of the night for all manner of reasons.

My “favorite” page story was from my last job.  I got a call at around 3 in the morning from a woman who, casual as could be, told me she’d forgotten to mention some bit of varia from her son’s medical history at his well check the day before, so she thought she’d call to tell us.  That it was 3 AM, that the bit of information was wholly innocuous, and that I was not the person who had seen her son for that visit were considerations that apparently did not preclude a phone call.

I croaked something along the lines of “thanks for letting us know” and went back to bed.

Taking calls in the dead of night is, as you might imagine, one of the aspects of my job I enjoy least.  That said, my practice considers it important to handle all patient care ourselves, so we haven’t farmed out our overnight call to a triage service.  As unpleasant as interrupted sleep may be, it’s a price I’m willing to pay to know my patients are getting advice I can stand by.

A lot of calls could have easily waited until morning, and in those cases I can direct the parents to call when the office re-opens and have them schedule an appointment.  Some calls require medical management then and there, sometimes as much as my directing them to the emergency department and then contacting the ED to discuss the plan of care.  And some calls require more brainpower than you might think.

This all sprung to mind this weekend as I was driving along listening to “This American Life.”  They devoted an entire show to an issue they covered in partnership with ProPublica — how easy it is to kill yourself by accident with Tylenol.  (It is also easy to kill yourself on purpose, but that’s the case with all manner of medications, both prescription and non-.)  It is, it turns out, distressingly easy.

Of particular interest to me was the bit about labeling for Children’s or Infant’s Tylenol.  The label as it currently reads is responsible for a significant number of calls that I get in the middle of the night.  Why?  Because the dosing instructions for children under 2 read “Ask your doctor” (or something similar).

Now, my own practice actually has dosing instructions for all children on our website.  But sometimes parents don’t know that, or lack the English skills to properly parse the chart.  So often enough I get woken up because, per the package instructions, I am being asked to dose Tylenol.

These are not uncomplicated calls.  I have to get the kid’s weight, which often parents don’t know and has to be determined with the ol’  “hold the kid and step on the scale, now step on the scale without the kid and subtract” method, then convert it into kilograms and then multiply by 15 (acetaminophen is dosed 15 mg per kg per dose), then figure out how what fraction of 160 mg per teaspoon they should administer.  And nothing brings out my smoldering OCD quite like making sure I’ve gotten the dosing right.  I tend to triple check it.

Why?  Because Tylenol can melt your liver.

It used to be even more complicated.  As the ProPublica article describes in great detail, there used to be a much more concentrated dose for Infant’s Tylenol than Children’s, available in drops with 80 mg per 0.8 mL.  (Children’s Tylenol is 160 mg for 5 mL.)  I would have the parents check the box until they could find the active ingredient list and then verify the concentration of what they were giving.  This may seem like a simple process, but 2 AM with a sick kid is not the ideal time for parents to be learning how to interpret a medication label.

As a result of several totally needless, preventable deaths due to confusion about the two concentrations, the more concentrated dosage form is no longer available.  While it’s obviously much easier to get 0.4 mL into an infant than 1.25 mL, this is a change for the better.  But you know what would really help?

Having dosing instructions on the damn box!  Lots of people don’t have ready access to medical advice at 1 AM (a separate issue unto itself), and will simply guess.  The FDA’s reasoning for not having the instructions available is… strained:

As McNeil saw it, the problem had always been the label and its lack of instructions for children under 2. The FDA’s rationale was that parents with children that young should speak to a doctor in case the symptoms indicated a more serious condition.

Then why have it available without a prescription at all?  Making it available without guidelines for use seems the very worst possible scenario.

The other bee that got buzzing in my bonnet after hearing the “TAL” episode regards multi-symptom products, such as Nyquil or Tylenol Cold and Flu.  I hate them.  Not only are people who take them often getting medications for symptoms they may not have, but they may not realize which medications they’re even taking.

It may seem intuitive to avoid combining Tylenol Cold with regular Tylenol, but what about Nyquil?  Or Theraflu?  How many people read the labels to check active ingredients to make sure they’re not doubling up on a surprisingly dangerous medication?

As I review this post before publishing, it strikes me that it’s more a public service announcement than particularly insightful commentary.  But with cold and flu season approaching, perhaps I can be forgiven for taking the opportunity to remind people to be careful.  Taken in appropriate doses, Tylenol (acetaminophen) is a pretty safe medication.  But the FDA has made it very difficult for parents to know what an appropriate dose is for vulnerable patients, so even seemingly benign medications are more potentially dangerous than they need to be.  And even for medications that are appropriately labeled, please make sure to read the active ingredient list to make sure you’re not accidentally ingesting too much of a potentially fatal compound.