The effects of delaying care are far worse than initiating treatment that may ultimately not be needed, in which case therapy can be stopped. Additional elimination techniques exist, including hemodialysis. Indications for hemodialysis include patients with exceedingly high acetaminophen levels (greater than 500 ug/mL) who are at high risk for hepatotoxicity despite NAC therapy as well as those with elevated lactic acid levels and metabolic acidosis. Hemodialysis also removes NAC, and subsequently, NAC infusion rates need to be doubled during dialysis.²

Patients can also present with chronic acetaminophen toxicity from repeated supratherapeutic doses. However, the incidence of serious acetaminophen toxicity is small following chronic ingestion and much more common in acute, massive dosing. Patients at greater risk for hepatotoxicity following repeated supratherapeutic ingestions have increased activity of CYP 2E1 leading to increased NAPQI formation or have decreased glutathione stores and turnover rate. In patients with suspected chronic ingestion with risk of hepatotoxicity, an acetaminophen level and liver function enzymes should be obtained. Patients with elevated liver enzymes and/or elevated acetaminophen level should be treated with NAC to prevent further liver damage.²

Discussion

The responsibility to provide the best care for patients is incumbent on emergency physicians, and they may have to overcome numerous barriers to fulfill that responsibility. Language barriers can have deleterious effects, and patients who face such barriers are less likely than others to have a usual source of medical care. In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum that states that the denial or delay of medical care because of language barriers constitutes discrimination. Ad hoc interpreters including family members, friends, and untrained members of the support staff are commonly used in clinical encounters. However, they are more likely to commit errors that may have adverse consequences. Ad hoc interpreters are unlikely to have had training in medical terminology and confidentiality. Their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, or mental illness, as illustrated in this case.³ Barriers such as these leave emergency physicians more vulnerable to medical error that could be harmful to their patients. For this reason, it is important to be knowledgeable about the potential pitfalls and to approach each patient with the same objectivity.

Dr. Peña is an emergency medicine resident at St. Joseph’s University Medical Center in Paterson, New Jersey.

Dr. Kashani is a medical toxicologist emergency medicine faculty at St. Joseph’s University Medical Center.

References

1. Algren DA. Review of N-acetylcysteine for the treatment of acetaminophen (paracetamol) toxicity in pediatrics. World Health Organization website. Accessed Feb. 10, 2018.
2. Hoffman RS, Howland MA, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill Education; 2014:447-458.
3. Flores G. Language barriers to health care in the United States. New Engl J Med. 2006;335(3):229-231.