One Drug Interaction

The unveiling of Drug Interactions from The Medical Letter® reminded me of the profound effects of a single drug interaction that occurred in the emergency room of New York Hospital in 1984.

Libby Zion was an 18-year-old college student who came to the hospital seeking treatment for a flu-like illness. She had been taking the MAO inhibitor phenelzine (Nardil) for depression. After an evaluation by two residents failed to establish a diagnosis, she was treated with meperidine (Demerol). The long hours the two residents had been working became the focus of what followed, but at that time hospital pharmacies did not have computerized drug interaction programs, and even the most rested emergency room physicians probably did not know that the combination of meperidine and an MAO inhibitor could cause serotonin syndrome. The next morning the patient’s temperature rose to 107°F, she had a cardiac arrest, and she died.

A grand jury convened by the Manhattan District Attorney considered indicting the doctors for murder, but decided instead to charge them with 38 counts of gross negligence. Eventually, however, the two residents were cleared of all charges by a state appeals court.

As a result of this case, the New York State Health Commissioner established a committee to consider recommendations for limiting the hours that a resident could work. In 1989, this group, known as the Bell Commission after its chairman, recommended that residents not be allowed to work more than 80 hours a week or more than 24 hours consecutively. In 2003, these and other new rules were extended to all accredited medical training institutions in the US.

All because of one drug interaction.

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  1. Thomas White says:

    How arrogant can you be! The law was created not because of “…one drug interaction…” but because of one senseless and needless death!!! This young woman was not just tissue for your residents to practice their mistakes on!! She was a young human being who should not have died this way. If we can’t do better than this we should be plumbers, not medical providers.

  2. Barry Gloger, MD says:

    Libby Zion was a drug addict who had been taking cocaine and Percocet, which she did not tell the ER doctors. It was probably the interaction between the MAO inhibiter and the cocaine/opioids that was causing the flu like symptoms that brought her to the ER in the first place. Her death had nothing to do with the training system (brutal as it was then) and the Bell commission was a fraud promulgated by a socialize medicine zealot.


    In terms of Thomas White’s comment: Human beings and human physiology are complicated, and physicians are human. The physician who has never made a mistake hasn’t ever practiced medicine.

    In terms of the Bell Commission: To the best of my knowledge, there is no convincing evidence that 80 (or more) hour weeks are required for resident’s to learn their professions. In the absence of such evidence, it is difficult to conclude that the reason for long hours is other than to reduce labor expenses. There are lots of studies that suggest that, for most occupations, productivity drops when one moves about 60 or so hours per week. While the evidence supporting the 80 hour week as a threshold for increasing medical error is (ahem) exceedingly weak, and the selection of that threshold for both implementation and later study seemingly arbitrary, this is NOT evidence that 80 hour weeks are good for either patients or for physicians.

  4. Victor G Ettinger. MD says:

    It is always sad when someone dies unnecessarily even a drug addict. The major problem was the very little known interaction between meperidine and MAOI’s which even then were rarely used. We did a survey at my hospital at the time and only a VERY small number of my colleagues were aware of the interaction. It is ironic that now after 30 plus years the time restrictions are being loosened because the data is unconvincing that it is beneficial for patients and may even be DETRIMENTAL because of the increased hand-offs required. There are no free lunches in Medicine and there are NO side-effect free processes as the brain dead Republicans in congress are discovering.

  5. Bill Siroty, MD says:

    I checked the PDR for interactions when this story broke and I couldn’t find any interactions between MAOI’s and meperidine. This story is about more than interns’ working conditions.

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