Cynthia Blackjack was likely already too sick to receive treatment when she appeared at the Carmacks health centre the day before her death, an expert testified Wednesday.

Robert Saunders reviewed the coroner’s report following Blackjack’s death in 2013 and provided his medical opinion to jury members and counsel on Wednesday afternoon.

Saunders is an expert in emergency medicine and the medical causes of death. He testified alongside Matthew Orde, the supervisor of Blackjack’s postmortem examination report.

Blackjack’s cause of death was ruled as multi-organ failure triggered by hyper acute liver failure.

Saunders and Orde testified liver failure was likely caused by acetaminophen poisoning. Acetaminophen is more commonly known by its trademark name, Tylenol.

They noted, however, they cannot say with certainty that Tylenol poisoning was the cause of death. This is because it’s impossible to detect how much of the drug Blackjack took that week.

While the cause of death could have been another toxic substance, acetaminophen was the only one present in her system, the inquest heard.

On Nov. 6, 2013, Blackjack visited the health centre complaining of stomach pain, and was instructed to see a doctor in Whitehorse.

Matt Lewis, the nurse who treated her, was not aware that she had taken any Tylenol recently, though he testified on Monday he most likely asked her. Lewis noted her condition was seemingly stable when she left on Nov. 6.

Blackjack returned to the centre the morning of Nov. 7, severely ill, and was medevaced to Whitehorse. She suffered cardiac arrest aboard the flight and was pronounced dead shortly after landing.

Lewis told the inquest Monday he was extremely surprised to see how seriously Blackjack had declined when she returned to the health centre on Nov. 7.

Saunders called Blackjack’s rapid decline “very rare, 10 in a million.”

He said that more than 50 per cent of acute liver failure cases are caused by acetaminophen.

Saunders described Blackjack’s case as “almost hyper, hyper acute” due to the speed of her decline from relative stability on Nov. 6 to her death on Nov. 7.

“She had a level of liver death I’ve never seen,” Saunders said.

He suggested Blackjack may have been vulnerable to liver damage from acetaminophen due to her alcohol usage.

“She would have been a candidate for somebody who could have taken even a therapeutic dose and have such a result,” he said.

Alcohol depletes enzymes in the liver. When acetaminophen is metabolized in the liver, a small amount of it is turned into a toxic component.

If you’re lacking the enzyme required to fight the toxicity, you could suffer liver damage.

Most acetaminophen poisoning cases, however, are not found in patients who mix alcohol and Tylenol.

Saunders said Tylenol-triggered liver failure is more commonly seen in patients who take large amounts of the drug with the intent of harming themselves.

The innocuous symptoms of acetaminophen poisoning, paired with the rarity of Blackjack’s case, would have made it very difficult to accurately diagnose her, Saunders testified.

He suggested it wasn’t unreasonable for Lewis to tentatively diagnose her with gastritis.

“There are no specific signs at this point (on Nov. 6) of acetaminophen toxicity,” he said.

“Although the symptoms she had are compatible with that, the symptoms she had were compatible with many, many, many other things.”

Acetylcysteine is the antidote used to treat acetaminophen overdose.

Lawyers representing the Little Salmon-Carmacks First Nation pressed Saunders on whether the antidote should have been administered Nov. 6 in Carmacks.

Saunders said the antidote must be administered in the first 24 hours of overdose, a short window in which there are frequently no symptoms.

Saunders suggested she was already in the second phase of liver failure on Nov. 6, and beyond the help of the antidote.

He said the only way to save her life would have been through a liver transplant. Even in a larger centre, receiving a same-day liver transplant would not be possible.

Lucille Stuart, the doctor visiting Carmacks on the day of Blackjack’s death, testified Tuesday. She said she has never seen a case like Blackjack’s.

Generally, if a patient has taken a heavy dose of Tylenol, she said, they will make that known to nurses upon arriving for care.

“Statistically, in my 30 years’ experience as a doctor, the commonest case of severe abdominal pain in someone using Motrin, Tylenol and alcohol is gastritis –– which is stomach bleeding –– it’s not acute liver failure,” Stuart said.

“That’s a very unusual condition, and I really would not fault anyone for not thinking of it.”

Blackjack was instructed to find her own ride to Whitehorse on Nov. 6 because Carmacks only has one ambulance.

Stuart said the issue of transportation to care is a long-standing problem in the communities.

She described a patient who recently hitchhiked in -20 C weather to receive cancer treatment in Whitehorse.

“Everyone has the same problem in getting to Whitehorse,” she said. “It is a huge problem in the territory and I would like to see a solution to that.”

Thursday is the last day of testimony. Sheila Thompson appeared on behalf of the Health and Social Services' Community Nursing department. The planned reappearance of Vanessa Charlie and Zachary Cochrane from Carmacks was cancelled.

Peter Chisholm, a territorial court judge, is presiding over the proceeding at the Kwanlin Dün Cultural Centre.

It’s designed to determine the facts behind a death but not assign responsibility to any person nor agency.

The inquest is taking place after several years of court proceedings that originated with the Yukon Coroner’s Office’s initial refusal to hold an inquest, which Blackjack’s family and the First Nation had fought for.