I've known Eric since around 1985 or so when he came to work at Data I/O. Our friendship has ebbed and flowed over the years, but he's always been special to me.
I have a little anecdote to share that probably only I remember now, but it has always made me laugh and shows what an unusual thinker he was.
When he was first working at Microsoft around 1991 or 92, he was talking to a manager who had a problem. There was a program written in assembler language, about 50k in size or so. The program had a problem that needed to be fixed. The author no longer worked at Microsoft. The manager had repeatedly assigned various programmers the task of fixing it, and they'd all given up after days of effort.
The trouble was the author had used the macro language that came with the assembler to invent his own quirky, weird, undocumented and thoroughly impenetrable language. None of the programmers could figure it out. He was lamenting that he'd have to assign a programmer to recreating it from scratch, which would take months and cost a lot of money.
Eric says "I can fix it".
In 2 hours, he had it all fixed and checked back into the system.
The manager, astonished, asked: "how did you figure out the author's language?"
Eric: "I didn't. I disassembled the binaries using Walter's disassembler [a disassembler turns binary code back into source assembler code]. The problem was then obvious, I fixed it and checked the new source code back in!"
Eric then laughed uproariously, and so did I. Nobody but Eric would have thought of that shortcut to solve the problem. If he couldn't break through the wall, he'd go over it, under it, or around it. He was always like that.
Another example of how Eric was not constrained by conventional thinking. While at Microsoft in the 90's, he'd occasionally interview job candidates. He'd hand them his phone, and ask them "if it was your job to make a better phone, what would you do?"
The bulk would answer "Um, better sound quality? Maybe an address book?"
Eric just couldn't believe those responses. (Remember, this was in the 90's when a phone was just a phone.) He was always boiling over with ideas.
If only a phone could be invented that had sound quality as good as we had in the 90s. I can barely understand people anymore. I'm not losing my hearing in my old age. (much) In person is fine. Other recordings are fine. Even video conferences are fine. But phone calls sound unaccountably terrible.
It has been starkly noticeable since my company has moved from doing phone-in conference calls to using Teams just how compressed normal phone line conversations are. Combined with a couple of our members having piss poor mobile coverage where they were (but much faster internet) our meetings became a lot higher quality.
On the phone-line side I wonder if that is a degradation due to digital switchovers & compression, a lack of allocated resources, or just pure rose tinted glasses.
I probably make calls with apps more than POTS calls these days. The sample rate and codec on a typical social app is noticably better than POTS calls.
POTS is not POTS any more. Anything other than possible last mile is now digital, with lowest possible if not lower bitrate and old codecs. And that extends to mobile.
It really should be AMR-WB or even AMR-WB+ by now, and EVS if you are on VoLTE.
EVS are very good at 16-32Kbps bitrate, possibly better than even Opus. But generally speaking Social Apps uses higher bitrate you get better quality. Although latency tends to suffer a bit.
The highest bitrate EVS codecs finally get there I think. Though you'll need sufficient signal strength and networks which support them at both ends of the call.
At least in Germany, since we got VoIP the voice quality is absolutely crystal-clear if all devices on the line are digital. It will still sound muffled if you connect e.g. an analog phone to your VoIP router, but a DECT phone over VoIP will sound so bright and clear that it's almost frightening.
My idea at the time was to add a morse code key (a rocker switch, one side was dit the other dah) so you could send messages privately while in a meeting.
Another idea is to make a walkie-talkie mode, where you could communicate with nearby cell phones without needing a cell tower.
Not sure about the US, but Canada had such a mixed cellular & push-to-talk network in the 90s called MIKE, and it was quite popular in some industries (e.g. trades). I don’t think it was actually a walk-in-talkie, but the user experience was identical.
Exactly. Those phones were very popular on construction job sites. Have a buddy who used to sell them. He talked me into getting one that supported J2ME. It really wasn’t much, but, in 2002/3, was the aha moment that showed where programmable phones would go.
> My idea at the time was to add a morse code key (a rocker switch, one side was dit the other dah) so you could send messages privately while in a meeting.
When the very first phones had physical buttons, less sophisticated UIs and T9 text entry, I remember being able to send an SMS from my phone without ever taking it out of my pocket. All from muscle memory.
half as wide. cinematic 2.3 aspect ratio, maybe more.
less snark comment (but also true), just jaw dropping that these pocket PC's do so much. on the down sides, I think the main think that floors me, just stabs me in the heart, is that they are still almost totally trash at communicating with those around us. Google dropped Project Eddystone, that sucked; totally straightforward sensible way to broadcast a url to the world about you. Apple has their file sharing AirDrop, which Google continues to make floundering attempts at (Beam, then Fast Share/Nearby Share), & never via any open protocols or specs. amazing personal communicators... totally reliant on completely centralized infrastructure. The couple Bridgify/Open Garden alternatives, it all seems too stack specific & lacking the layering of protocols & extensibility that allows communication tech to grow over time, become of enduring value.
I forget what it is but someone was telling me the Bump competitor in Japan is still used, that you still have a physical little ritual with your devices that causes them to exchange contact info. That kind of real.world connectivity seems like it ought be just the start, for how tech can augment the real world, versus us needing to start & navigate the digital to connect. We're doing little favors, entrenching connectivity so reservedly in the digital all space.
Japan the land of paper business cards.. and the lovegetty! Does anybody remember the poken which you could carry on your keyring. Touch two together and there was a kind of lovering glow, to exchange contact info. Insert the usb side into laptop to download the contact information. It almost hit critical mass in Japan. Poken parties in Tokyo were fun. Such a pre-covid alt reality...
We got free Poken at a conference. I was a bit of a snob for a day or so, & didn't really know or trust the controlling entity, but I decided to try it. It was really fun! Easy to use.
I think Bump happened a year or two latter, which was also fun. But it felt far more intermediated, like it was pulling down much more data. Looking at who in the area also bumped at just that instant to triangulate who to put in contact with each other.
I remember back in the 90's wear(able)-comp(uting) world, PANs were going to be a thing. Personal Area Networks. Your skin itself would be a low-baud rate modem, so you could shake hands & transmit your contact information. Definitely pre-covid. ;)
I really think Project Eddystone has many of the answers for how we ought to make ourselves visible to the world. It was mainly focused on commercialized entities, and people are scared of the internet, but I think there's still great potential. Alternatively, it seems weird that NFC, which is much more tightly coupled, 1:1, "safe", is so under-utilized. I'm not sure if there are good open standards for data-exchange over it. Meanwhile proprietary AirDrop and FastShare/Nearby Sharing are some of the few, tightly controlled offerings for offering files. All these manners of tech needs some champions to drive good protocols, enable more interesting futures. Sorry, I think I'm repeating myself again. Thanks for the fun comments dcsan.
I don't know many people who care about the hardware except for the camera. How is it? Can it compete with the current phones from Apple and Google? Does it do all the standard things like include filters, portrait mode, night mode, etc...? Can I search for "dog" and get all my dog photos or search for a city and get all the photos taken there?
And how's the app store? When some random game goes viral and I want to play with my friends, am I going to be able to? Are the apps vetted for security and safety?
Does it integrate with my car? One of the primary uses of my phone is for navigation. Being able to plug it into my car and say "navigate to 123 main street" as I drive is pretty key.
Is their store only online? If they don't have their own retailers can I at least see them at a carrier store or BestBuy? Will Verizon activate the phone on their network? A decade ago they wouldn't approve the Nexus 7 tablet, so this is something I think about.
> I don't know many people who care about the hardware except for the camera.
These phones are not for many people.
> How is it?
In development. The pinephone can take still shots. The Librem 5’s camera isn’t functional yet AFAIK.
> Can it compete with the current phones from Apple and Google?
No. It’s not playing the same game. I would pay money not to have one of those.
> Does it do all the standard things like include filters, portrait mode, night mode, etc...?
AFAIK, no.
> Can I search for "dog" and get all my dog photos or search for a city and get all the photos taken there?
I don’t know of any apps for them that do that at the moment.
> And how's the app store? When some random game goes viral and I want to play with my friends, am I going to be able to?
Probably not. It probably has about 6 orders of magnitude fewer users, and 5–6 orders fewer devs. You can virtualize Android, but I wouldn’t be surprised if it was a much worse experience than Proton on desktop (it doesn’t have Valve behind it. Anti-cheat might get you banned).
> Are the apps vetted for security and safety?
Yes, in some repos. Most of the distros will let you use Debian’s, which IIUC have had z-e-r-o zero malware (not counting systemd ;)) in their decades-long history.
> Does it integrate with my car? One of the primary uses of my phone is for navigation. Being able to plug it into my car and say "navigate to 123 main street" as I drive is pretty key.
I’m confused why it needs to integrate with you car to give directions. Do you mean connect with Bluetooth to use your speakers?
> Is their store only online?
Yep.
> If they don't have their own retailers can I at least see them at a carrier store or BestBuy?
Nope.
> Will Verizon activate the phone on their network? A decade ago they wouldn't approve the Nexus 7 tablet, so this is something I think about.
Nope, not as far as my crystal ball can see. The pine wiki says you can activate a SIM on a burner phone and swap it into the pinephone, and Verizon shouldn’t care.
It’s not necessarily irrelevant (depending on the role). After interviewing a lot of people, I’ve found you can ask a handful of questions and get a pretty good sense for their work style (outside of technical knowledge).
That can be helpful in hiring.
If you’re looking to hire someone for a technical role on some big hairy project that might not work or seems crazy, it’s helpful to select for people who won’t say “this idea is dumb”.
That's a very good question though. It allows assesing how other people approach problem solving, how they think and how they communicate. A question like this will often tell you more about a candidate than seeing them invert a binary tree.
I disagree. You're asking the candidate to guess what kind of answer you're looking for.
Possible answers, all valid, all tell you absolutely nothing
* I'd change nothing, it works "AS A PHONE' just fine. There are better things to to work on
* I'd attach it to the side of a rocket so you could use it as a handle. I'd much rather ride a rocket than use the phone
* I'd double the speakers and mic and offset them at 45 degrees so two people could hug cheeks while talking to the same person
* I'd give it a display, add a computer, and have it pocket size and it would annoy you all day long with notifications and distract you from getting anything done. People would stop using it as a phone and mostly only write text messages to each other which would be way less efficient than voice. Oh wait, you said "improve". Yea, ok, bad suggestion
You don't understand. When you get a question like this as an interviewee, they want to see how you arrive at your answer regardless of what the answer is. The answer by itself is less important than what made you pick it in the first place.
For example, possible takeaways from your answers:
* Lacks critical thinking, takes things for granted, doesn't show initiative or not comfortable with it.
* Elevated smartassness, possibly as a defense mechanism or due to inability to read between the lines. Maybe just nervous at the moment.
* Better. At least this solves some specific problem based on one's personal experience. It's possible to discuss that and see what else surfaces.
* Also good. Miraculous even if you'd managed to produce all that in the early 90s. Again, this also opens things up for further discussion.
The fact that you think "leave it alone" is an example of lacking critical thinking skills shows just how subjective this is.
On the assumption that not many people being interviewed by Microsoft in the 90s had an iPhone style plan or a desire to revolutionize cell phones, "leave it alone" is the most realistic, objectively useful answer a candidate might give. Sure, it demonstrates zero creativity, but it's totally unfair to say that person lacks critical thinking skills as their answer is the most rational.
To pass that question, you need to know the interviewer is looking for creativity and be able to make something up on the spot. That's obvious to many of us, but depending on the role I wouldn't fault someone for not being in tune to that question or ready for it.
> That's obvious to many of us, but depending on the role I wouldn't fault someone for not being in tune to that question or ready for it.
The job interview gets debated endlessly, week after week, on HN. There isn't one interview method or question that numerous people would consider unfair, irrelevant, broken, etc.
Eric was interviewing people for very high paying jobs. A decision has to be made about the candidate based on something. A person who wants such a job should go in eager and ready to convince the employer that they're a great fit for the job, and do what it takes.
And yeah, Eric's question was pretty obvious. It's open ended, and you can interpret it as you like, which is part of the point. But being a smartass and/or complaining about the question isn't likely to leave a favorable impression. A "faster horse" answer isn't likely to, either.
That's not the point. The point is the judgement of the answers to "how do you improve the phone" are totally subjective. Maybe as the interviewee I guess you want some crazy answer like "well we could built it into your car" but what you really wanted was proof that I wouldn't waste time on this but instead focus on getting stuff done.
As an aside, IMO smartphones are not an improvement on phones. They are an improvement on PDAs. As phones they've utterly failed. People called each other (as in use a phone) way more before smartphones. So smartphones are not better "phones". They're worse phones and better something else.
I was at Microsoft around the time of Eric’s departure (I left a few months before him).
Ironically, the two men arguably most responsible for the success of the Xbox were strongly opposed to the entire “Manhattan” project at the time.
Eric was instrumental in the DirectX runtime design that Microsoft ended up porting to the original Xbox hardware with shared high level components.
The other guy was Dave Cutler, who led the NT and hypervisor groups at the time. Xbox v1 borrowed heavily from Dave’s work on modular, stable-userspace NT. 360 was basically running a full-fledged NT iirc. Dave, like Eric, hated the Xbox project early on.
In today’s terms, it would be like Facebook deciding to make a search engine or mobile OS, so their reactions were hardly surprising. Word was that even BillG was hesitant, but Ballmer really wanted more product lines.
"Manhattan" project was the code name for the original XBox.
At the time Japan dominated video consoles with the last western attempt being the disaster which was the 3DO. Thus Microsoft was going "nuke the japanese industry" and gain a foothold.
For further irony the Xbox was in effect was a spiritual successor to Sega's Dreamcast. That Microsoft went with such a distasteful name despite partnering with Sega highlights their cultural issues. Issues which have continued to prevent Xbox from building relationships with Japanese studios.
"Manhattan" was about DirectX, not the XBox. (That's why DirectX had the weird weird radioactive logos, even before the XBox was an idea.)
It wasn't about consoles but gaming in general. Programming Games for DOS required a lot of assembly knowledge (at least, if you wanted something fluid) and deviation from industry norms only increased development cost (thinking things like High res support necessitating VESA code, to say nothing of sound support in DOS.)
Devs hated dealing with all this extra work, extra compatibility, extra libraries (old gamers may recall MILES or DMX setup screens in some titles.) The libraries for Windows 3.1 were... not at all up to the task.
Thus, DirectX was created. Not so much to create a console competitor, as to show PCs as superior to consoles overall.
Which, when one thinks about it, may explain why Eric/etc were not big fans of the XBox; in some ways it conceded defeat on a level.
No it was not a coincidence as testified by Eric in his interview with the University of Washington business school.
He actually comes across a mix of interesting and unpleasant in this interview. It takes me back to the nineties when he and St. John were routinely pissing off people including myself.
According to Eric when he told me about this, it was HIS idea to name it that. When he said this, it made sense because it followed his sense of humor (this was literally in September he told me this story).
That's beautiful. Thanks for sharing. It reminds of a similar experience I had.
A few years back one of the systems I ended up inheriting stopped working on January 1st. As most people, I had taken the day off, but my manager called me to fix the issue in prod.
After much researching, I found out the assembly causing the issue. Similarly, the original dev had left and the source code was lost. So I used ildasm and found out the year was hardcoded. I patched the binary and went home.
When debugging a web app, you can debug the code (and add print statements / breakpoints). Or look at the HTTP queries its making in the inspector. Or debug the server - look at what queries its receiving and returning. Or experiment with different values in the database.
Last year I was trying to track down a memory leak in some wasm code. The tooling for that sort of thing in wasm was/is quite primitive, so I did some work to compile the module natively then ran valgrind on the resulting executable. That didn't work - the C code executed differently from the wasm and didn't exhibit the bug! So I added print statements randomly through the program and ran it both natively and through wasm, then diffed the text output to track down when the execution traces diverged. (It wasn't a compiler bug, fwiw.)
I wanted more information about the memory leak. So I wrapped all the malloc/free calls with a replacement that stored all outstanding allocations in a list, with the stack trace when malloc was called. When the leak happened, I could ask for the stack trace of all outstanding allocated objects[1]. That was fast and effective, and I added a memory leak check in my CI.
At one of my first programming jobs we were using visual source safe (oh god, kill it with fire). I ended up losing some changes I'd made in a ~3000 line java class that we'd already deployed to production. I didn't want to do my work over again (or admit the mistake to my boss!). So I ran a decompiler against the class file we deployed to production - but it was huge and unreadable. To find the changes I'd made I took the current version of the java file, then compiled it and decompiled it again. So then I had two ugly files - but I could diff them, and that highlighted immediately the dozen or so changes I'd made. Then I just manually rewrote each change back into the original source file. Importantly, I had complete confidence that I didn't miss any of my changes.
Diffing log output is a great technique for tracking down weird, hard to repro bugs I find - log out as much as you can in a normal session and then in a buggy session, and diff the two, just as you describe.
Have also used this technique to compare build logs when you have a version of a project which will compile and one which doesn’t (eg when trying to integrate a second project into an existing one, or battling CI issues), useful if you aren’t an expert in that particular tool chain especially.
Personally I use VS Code’s diff these days, since they added support for word wrap recently, it’s the easiest to read.
No - we had a small team (5 people). We still managed to corrupt the sourcecode database every couple of weeks and needed to reinitialize the whole thing.
We did daily backups to a second machine keeping the last 3. When it corrupted itself we copied it all back. I liked sourcesafe. It was kind of cool the way it worked and integrated into all the MS tooling we used at that time. Plus it was decently cheap enough for a small inhouse group of devs to afford. Its semantics for usage were very straightforward and easy to learn. BUT it was a pain for how it would corrupt itself randomly. That 'one' bug is why no one dares use it today and hates the thing. To this day because of how easy it was to use I compare the UX of all other source controls to it.
Map the problem into other domains. In this case, he could work with the original (hard to understand) source code. Or he could use a tool that would translate it (or the binary) into a more sensible language.
In other tasks, consider different data structures or representations that fundamentally represent the same data, but in different ways that offer different guarantees. Representing a graph with a matrix may let you answer some questions very quickly, but it may make others harder to answer, for example.
Its an eastern mode if thinking. When faced by a problem, walk around the problem and examine all avenues of approach. Much like scaling a mountain. Seek the path of least resistance.
To often we simply reach for our trusty hammer, and it's not always an efficient or usable tool.
How is this an "eastern" mode of thinking. It's a pretty typical way we'd approach solving problems in physics anyway, and this was all in very western university here in the US.
It may be prevalent in niche industries. But it's largely not culturally apart of historically western culture. And would you apply that problem approach prior to becoming a physics expert, did they teach that in kindergarten?
Eg in school we learn as kids derivatives, rote routines to solve a type of problem, and we plug and chug, but we are not shown (necessarily) by govt education the underlying theories that may create a solution. This/my opinion is of course dependant on how expert an instructor is ...
Edit:
Also in the usa we're taught do your own homework for example. In asian cultures often students band together to succeed in classes (I work in higherEd and this is culturally visible in peers in classes). This is another example of this philosophy being different between cultures.
The quote you have included is based on Taoism. Is that common? I was under the impression that Confucianism has the more dominant influence on values and thought.
Anyways, at least that's one thing we can agree on - Taoism's philosophy encourages an open mind and awareness.
> In contrast to eastern education which tends to greatly focus on memorization through repetition..
Wouldn't quite say that is true. People use a variety of techniques to get scored higher and there's always a certain percentage who will use such rote learning techniques, be it eastern or western.
I think what what's missing in the discussion is the western focus on individualism as compared to east asian communitarianism. Both have their pros and cons and mutual dislikes.
There was a book by 2 high level western/eastern women managers in Hewlett Packard that highlights this dichotomy. It's a great read.
> individualism as compared to east asian communitarianism
Again, that's because of a deep rooting in Confucianism. Also, "Communitarianism" is a western (Christian) philosophy. It may have been borrowed from Confucianism? I'm not sure. A lot of religions and philosophies share these kinds of values, so it's not unique to just one region / culture, IMO.
Anyhow, neither is better or worse, and probably a balance between communitarianism and individualism is best. All cultures can learn from each other.
> Edit: Also in the usa we're taught do your own homework for example.
I went to a mix of 7 private and government schools between K through 12th grades in the US, and I don’t remember any of them not having group projects. Some, or most of the homework is individual, but there’s plenty of group work too.
He's referring to the phenomenon of certain groups of students cheating on homework and justifying it by claiming it's a cultural difference in approach to learning. It's not. It's outright splitting up work between peers, often with the use of illicit solutions manuals, for the purpose of gaming the grading system. It's especially beneficial in classes where the professor just writes exams from homework problems or problems very similar to them.
There isn't anything special or insightful, mystical or different or "eastern" about cooperative learning. I'm thoroughly "western" and had plenty of homework groups in both undergrad and grad school. Nor is there anything special about the cooperative cheating I described: "certain groups" applied to plenty of western peer groups I saw in undergrad especially, though they didn't claim what they were doing was some "cultural" thing, as they knew it was simply cheating.
Nope you're giving him too much credit. He meant projections as in to a different view on the problem. Not anything more well defined than that. Your manner of explaining it is much better.
Two classic examples (Cartesian vs polar coordinates, frequency vs time domain) are mentioned in other comments.
I would certainly add "looking at values vs looking at differences" and "looking at the generator vs looking at what's generated" (which the top level story is an example of).
It may take a little squinting, but we can see the common mathematical practice of reducing one problem to an example of another as an instance of this. There are also tweakier math examples where treating something as topology or something makes it easy to solve.
@Jtsummers puts it as “Map the problem into other domains”; another interpretation (or a variation on the same) is “look at it from a different angle” or “look at it in a different light”. Do both -- move around with your light source, shine a torch/flashlight at your problem, and different shapes will be “projected” onto the wall behind it. Kind of like, if you are familiar with Hofstadter's _Gödel, Escher, Bach_ -- remember that “G,E,B” cube pictured on the cover of many editions? A more or less abstract “thing” or idea can be “projected” into different practical views depending on perspective. In actual practical work talking about “projections” can of course feel a little highfalutin’; to me it's a bit like always talking about your RDBMS tables or views as “relations”.
But in a more philosophical sense it is of course perfectly valid. And AFAICS it's an age-old idea in Western philosophy; what I described above is essentially precisely what is known as _Plato's Cave_. (Which incidentally is why @tenken’s identifying it as “Eastern” feels quite peculiar to me.)
In the spirit of gentleness, at HN comments which don't add substance to the conversation are discouraged. So in this case it's not just word choice that people are reacting to.
Which is ironic given that a GPT generated article made it to the top recently IIRC.
I'm glad hn isn't like /r/programmerhumor (i.e. if I argue a point I don't want to explain what a pointer is) but the delusions of grandeur are in equal parts tragic and hilarious sometimes.
It's actually correct in english, especially in sporting contexts. Like this guy is a BEAST, or that guy is a machine, or that guy is a monster opponent. But that is very tone dependent, so if you say it in the wrong tone or someone interprets it differently then it can be taken badly.
Interesting! I wonder, back in those days, when your day to day job involves coding in Assembly, I guess reaching to a disassembler on a regular basis also should've been a norm, no?
Unintentionally, yes. One day I realized I just knew them. The code generator used to hardcode the opcodes, but I have since slowly migrated to use mnemonics, and the opcodes have faded somewhat in my mind.
Of course, I mean the 16 bit opcodes. The SIMD ones, no freakin' way!
It's like the Wizard of Oz. I know most of the dialog, though I never made any attempt to memorize it. A friend of mine knows all the dialog for all the Star Trek TOS episodes. He just realized one day he knew it.
I don't think Eric told me, and if he did, I forgot. In those days asm was often used for efficiency, as compilers weren't that good compared to hand-coded asm. He knew I'd purposely written the disassembler to produce MASM source code, and thought I'd enjoy hearing about the use he put it to (and I did!).
BTW, this anecdote is one of the reasons that I've strongly resisted adding macros to D.
I know. I did, too. But over time, I used the macros less and less. More than once I've used Eric's technique to figure out exactly wtf some wretched macro was actually doing.
I also purged my own C and C++ code of macro usage.
> He died at a hospital in Seattle. His wife, Cindy Engstrom, said he had injured one of his feet in October, accidentally took too much Tylenol for pain relief and suffered liver damage.
As sad as it is to lose a person at age 55, it's even harder to digest the tylenol induced liver failure part until you experience foot injury/pain. I spent last December in excruciating foot pain that came out of nowhere and the thought of wanting to guzzle down entire bottle of Advil/Tylenol touched my mind at least couple times.
Both of my parents are physicians, and both have worked in emergency rooms at some point in their careers. One thing they've taught me is to be cautious about taking too much Tylenol.
At the right dose, Tylenol may well be the safest pain medication we have, even compared to Advil, which can occasionally cause problems if taken regularly over a lifetime. However, the gap between a useful dose of Tylenol, and the amount of Tylenol which will kill you, is relatively small compared to similar medicines.
My parents say they've watched a lot of people die in the hospital from Tylenol overdoses. There is an antidote, but only if you get it in time.
Wow, we recently had a scare with our five year old passed out in her room with a bottle full of Tylenol strewn about. Getting an artery stick on a five year old is one of the most awful things I’ve had to endure, but I wasn’t going to trust a five year old on whether she had taken the pills or not. Turned out she hadn’t taken any! But it was super scary, Tylenol poisoning is no joke, and we have lock boxes for all our medications now.
Yes, exactly, the dangerous dose is not far past the safe dose.
One of the common causes is that many medicines contain Tylenol/acetaminophen, but don't have it in the name [1]. For example, DayQuil or Alka-Seltzer Plus Cold and Sinus.
People take something like that, then they layer Tylenol on top of it thinking that is the first Tylenol they are taking, and it pushes them into the danger zone.
I always try to buy individual drugs for this reason. If I want DayQuil, I look at the ingredients on the box, and buy each of them individually. Then I only take the ones I need.
I wish they would ban the codeine boosted Tylenol for this reason. People will take more than prescribed at once because the codeine really knocks the edge off, but they forget about the overdose of Tylenol. If they need codeine, just prescribe that and let patients supplement with reasonable doses of NSAIDS.
Or, they'll take normal Tylenol alongside a number of other products that unbeknownst to them also contain Tylenol, like NyQuil, and overdose that way despite taking a normal dose of each medicine individually.
What should be banned IMO are products which combine acetaminophen/Tylenol with something else.
I don't think I believe that. Firstly, in order for that strategy to be effective, Tylenol's deadliness would have to be widely known, which I don't think it is. Secondly, the "punishment" is that you kill someone.
I agree it sounds strange to use Tylenol like that, but the part about adding something that causes fatal poisoning to spite people who might use it as a vice... that's what denatured alcohol is.
We'd rather make something poisonous than miss out on taxes
That's the strategy used by prohibition-era denatured alcohol manufacturers who spiked their product with methanol and other toxic additives. Instead of stopping people from using it as surrogate alcohol, it lead to dozens of deaths
As someone taking a lot of Tylenol after a car accident a week ago, thanks for the advice!
I'll switch to Ibuprofen now. They didn't give me any prescription meds because there were no broken bones, but my chest and left shoulder are in so much pain, specially when I wakeup. Airbags were deployed, and I went from 84 mph to zero when the crash happened (dashcam had the speed on it).
Just make sure you have food in your stomach when you take ibuprofen. I used to take 12 a day in high school to play (badly) at sports and it can do a number on your stomach lining. Iirc the mechanism that causes it to dull the pain also creates stomach acid.
When I was younger (and stupider) I was prescribed giant 800mg ibuprofen pills for an injury. I wasn't in the habit of eating with them, and ended up burning the end of my esophagus with stomach acid. I could only eat popsicles and slurpees for a couple weeks because it was too painful to swallow anything else.
> Iirc the mechanism that causes it to dull the pain also creates stomach acid.
Maybe it also increase stomach acid production, but my understanding is that the primary problem is that it thins the protective stomach lining.
Ibuprofen is a non-selective inhibitor of the COX enzymes. Inhibiting COX-2 reduces pain and inflammation. Inhibiting COX-1 inhibits stomach lining growth and the clotting process. Pharma has created selective COX-2 inhibitors, but some of those have run into their own problems (blood clots leading to myocardial infarctions in the case of Vioxx patients who weren't also on aspirin, IIRC... though, an increase in MIs would seem to be the natural and obvious side effect of intentionally reducing COX-1 inhibition. IIRC, the increase in MIs was in contrast to the traditional Ibuprofen treatment, not compared to an unmedicated baseline.)
I also took it daily and heavily in high school during basketball season for shin splints. Probably a couple of years of pulling that mess. I often think back now to how I had a complete system that timed for efficacy, taking a few 30 min before practice then more while suiting up, then even more if I could during and then after practice. I'd alter this timing on game days since practices were walk-thrus, etc.
In some ways it's a relief to hear from someone else with that experience (this was 20 years ago for me).
Large doses of vitamin C taken with aspirin or ibuprofen also seem to help with the stomach acid problem. Inspired by a paper on PubMed (so this isn't entirely anecdotal) I tried it and it works for me.
Food also helps but not 100%. IME it does not seem to "soak up" all of the excess acid. Vitamin C is also not 100% but IME more effective than food.
I'm not a frequent or high dose user of NSAIDs, I just seem to have an easily irritated stomach.
Talk to you doctor before trying this, but it is usually OK to take both acetaminophen (Tylenol) and ibuprofen (Advil) at the same time.
They work in different ways, so using them together can let you stay well away from a harmful dose of either and still get better pain relief that taking a maximum dose of just one.
I somehow injured my rotator cuff, an injury normally associated with athletes but that I somehow got while sleeping?! With my doctor's permission, I did 1000 mg of acetaminophen every 8 hours and 400 mg of ibuprofen every 4 hours. The later was originally going to be 800 mg every 8 hours, but I asked if I could do it 400 mg every 4.
You still have to be careful with NSAIDs. I have kidney failure but when being diagnosed they presumed it was likely due to NSAIDs but the real reason was finally autoimmune disease. I think they say long term use of NSAIDs is not good for kidneys. For me NSAIDs are entirely excluded. But my nephrologist say Tylenol is fine for long term if I stay within limits. Fortunately I've not had to use it often. And I don't take OTC medicines now without doctor review.
Since I'm on an anticoagulant, I can tell you that the deal with NSAIDs is bleeding: they have anti-platelet properties which can make you more susceptible to bleeding.
My second hand knowledge from a talk with a pharmacist: both paracetamol (tylenol) and ibuprofen are much more dangerous, than I previously believed.
Both have very tight margins between normal dose and overdose. If I remember correctly overdosing is 50% over the normal dose. So take couple more pills a day than it says on the label - and you can land in the hospital.
I was super glad for that info, because I treated instructions more as a suggestion. Now I am much more cautious. _Never_ go above what's instructed, use them as instructed (before/after a meal, etc.), do not mix drugs unless explicitly allowed by your doctor and for the love of god do not mix medicine and alcohol. It's too easy to overdose these common drugs.
The maximum safe dosage of Tylenol is 4000mg; an extra-strength pill is 500mg, and a normal dose is 2 pills, meaning the dose you'd have to take to push the danger zone is 400% over the normal dose.
But Tylenol’s label says a maximum of 4g per day or 8 extra strength tablets (500 mg each).
From what I’ve gathered, you can detect some liver damage as you get close to 10g per day, but we’re talking mildly elevated ALT/AST enzymes. But if you’re sick, or drink a lot or not eating, you could see serious toxicity at 200% of the maximum daily dose.
Yes, but Tylenol’s toxicity is due to glutathione depletion. Your body can handle the toxic metabolites with no issue, as long as there isn’t a lot of them.
Once you’ve depleted your liver’s glutathione stores (too much tylenol, too much alcohol, not enough food to replenish glutathione) then the Tylenol becomes very toxic to liver tissue.
Take both to help not overdo the dosing on either. While tylenol can be bad for the liver, like someone else said ibuprofen can wreak havok on your GI system. That's not all -- it can stain or injure your renal system if you overdose it. Tylenol overdoses, if caught in time, can be mitigated by acetylcysteine (as an antidote). I am unaware of any such equivalent for ibuprofen besides dialysis (usually if it gets concentrated enough to cross the blood-brain barrier).
That's crummy you didn't get at least a small rx for narcotics for the first few days - there is a time and place for them. Don't forget to make sure the chest pain is not preventing adequate respirations.
not a doctor, but careful with Ibuprofen also, it has its own risks. Paracetamol / Acetaminophen is one of the safest taken at the right levels. You can actually have both at the same time as well.
My cousin burned a hole in his stomach with Ibuprofen trying to quash some pain that turned out to be metastatic esophageal cancer. (Somehow, he's still alive.) Mind your NSAIDs!
what ever the medication you use, just read carefully the instructions, there's all the info in there that you need to safely use it. Paracetamol (Tylenol) is perfectly safe as long as you don't cross the recommended dosages.
If you might be taking Ibuprofen for a while, I encourage you to also look at its long-term-usage side-effects. Probably NBD, but worth keeping in the back of your mind.
It isn't NBD, ibuprofen will absolutely destroy your esophagus. The difference is that ibuprofen is safe once and will kill you over time, but Tylenol is safe over time and will kill you once.
There's a protocol where you switch between them which is okay, but you should get the good stuff if you need it.
You can also take NAC, which is what they give you for the antidote. As a bonus it's also effective against acne, addictive behavior, and stimulant tolerance.
This seems to be a country-specific lack of awareness. In the UK it's hard to buy large quantities of Acetaminophen/Paracetamol and pretty much everyone is aware that it's dangerous in quantity.
Interesting. When I was a kid, I enjoyed the taste of Tylenol a lot. One night, I elaborated a very bold plan to get the medicine and drink it without my parents seeing. Fortunately, I was caught. Your comment made me realize how lucky I was.
A lot of things such as OTC cough medicine and some opiods contain the active ingredient of Tylenol so that's a good use case for avoiding it. Ibuprofen has issues of its own, but IIRC it's typically safe to take 2-4x the recommend dose on the bottle, which could be pushing it if you did the same with Tylenol over an extended period (especially if you're a drinker). I've heard anecdotally that if Tylenol were invented today the FDA wouldn't approve it because it's relatively easy to OD.
Meanwhile, doctors I've been to offer out prescriptions for 800mg ibuprofen pretty freely and don't seem too worried about side effects (IMO it's easier to just take a bunch of the smaller ones instead of a single horsepill)
> I've heard anecdotally that if Tylenol were invented today the FDA wouldn't approve it because it's relatively easy to OD.
That seems a little suspect to me. It's a very useful medicine, and a better choice than Advil for some people. And it really is safe at the right dose.
The argument is that the delta between normal use and liver toxicity especially if one adds in a few drinks is pretty small. I have heard the same thing and it's probably not an unreasonable argument. (Or, if approved, it might be a prescription med.)
> Or, if approved, it might be a prescription med.
That seems much more likely—but, very few drugs are approved for OTC use out of the gate! They generally want OTC drugs to have been in use for a long time.
To be clear, the message (which I'm passing on second-hand, I'm not a doctor myself!) wasn't that you shouldn't take Tylenol, just that you need to be careful with the dosage. My father in particular thinks Tylenol is better than Advil if used regularly over decades (although he'd probably say it depends on other health conditions too; both are safe medicines overall.)
Neither Paracetamol (Tylenol) nor Ibuprofen (Advil) is side-effect free - and thus you should stick to prescribed amounts unless you've received medical advice.
Having said that, given I am not a doctor/clinician/pharmacologist/pharmacist, you can usually alternate them to take a higher dosage of pain relief.
"always" is too much of an absolute. It really depends on a variety of factors, not least if which are other medications you might be on and underlying conditions. For example, ibuprofen doesn't play nicely with prednisone. Or if you have any sort of existing liver problems then acetomenophen is really not a great idea.
If you have a regular doctor, it's probably a good idea to ask which of a few different options are safe for you for occasional use, and probably check in if you find yourself needing something for longer than a few days. (And if you don't have a regular doctor, find one... If you lack insurance, it's still probably worth the money to pay once a year for a physical, and also have a resource that knows your health history that you can consult with. For basic questions, like "does my medical history rule out acetomenophen", most doctor's offices will take a message for the doctor and then call you back with an answer)
No-one here can answer that because the only people qualified to do so (pharmacists, doctors, some nurses) also have a professional duty preventing them.
The answer is "it depends" on your history and any other meds you're taking and also your home situation.
If you're Asthmatic (it's generally not advised to take Aspirin or Ibuprofen as you could be allergic to it), if you have an ulcer, if you're on a blood thinner such as warfarin.
IIRC you can take them both on interleaved but overlapping schedules, for those times when the maximum frequency of advil isnt good enough. Check on that before doing it though.
I think this sort of issue is more common than non-medical people realize. It amazes me how often in movies and real life you see people wake up after a night of heavy drinking (sometimes still drunk) and take tylenol or other NSAIDs with liver/drinking warning labels. Or guzzling more NyQuil than they should (contains acetaminophen). The movie industry has cracked down on showing smoking, yet they still show people doing things that could cause liver damage in a unintuitive way.
Johnson & Johnson recalled every single bottle of Tylenol and re-designed the packaging. Actually worked out pretty well for the brand and they sold more after the murders than before.
> accidentally took too much Tylenol for pain relief and suffered liver damage
For non-USians, Tylenol is a brand of paracetamol. The recommended maximum daily dose for an adult is three to four grams. Paracetamol toxicity is the foremost cause of acute liver failure in the Western world.
I find it highly confusing how Americans seem to always reference branded medication. In the UK people generally take generic Ibuprofen (an NSAI) or Paracetamol at a standard does e.g. 500mg for paracetamol. Over time this seems way less confusing. There are quite a few branded versions but once you have an idea of the component parts it seems far less confusing to understand what you are taking.
The BNF provides some accessible guides to all pharmaceutical drugs:
I share this sentiment. Not knowing that "Tylenol" is Paracetamol I assumed it had to be some heavy, special, US-only painkiller, like those opioids which killed so many.
I have a box of this in my drawer - it's 20 pills totalling 10g - that's enough to damage a healthy liver if taken in the span of 24h.
I can't imagine the pain this man must have been going through to do this and mind you, I had kidney stones.
Some versions of Tylenol have codeine in them as well. I got some stronger ones (Tylenol 3) after oral surgery and I had a few pills left and when a few months later my back was acting up and I was eyeing those pills I immediately flushed them down the toilet because I don't want to get addicted to that shit.
Please don't flush drugs down the toilet! If they are on the flush list (https://www.fda.gov/drugs/disposal-unused-medicines-what-you...) that may be ok, but in general bring them to a drug take back site. (Of course, when you are really at risk of addiction, there might be no choice...)
They might, but I think this is particularly common in the US due to the mandated branded medication in many healthcare scenarios even for drugs with lapsed patents. I think most younger, educated people in the UK would refer to them by the generic names.
It seems awfully silly for a random internet stranger to diagnose your issue from "excruciating foot pain that came out of nowhere" but...
I had basically that off and on again for seven years before it was correctly diagnosed and treated. (As a healthy, active, relatively young person, gout wasn't suspected, but eventually an MRI gave a clue, and blood tests confirmed it.)
As someone in their mid-40s I can attest that random pains seemingly caused by nothing are part of the journey of life.
A few days ago I got out of bed and couldn't straighten my leg without insane knee pain. It lasted about a day and now it's absolutely fine. Yesterday I was vacuuming and my ankle just starts hurting like crazy. Fine in about 15 minutes. The other day I was bending over the sink washing dishes and my left shoulder blade gave me 7/10 pain. Seemed to be caused by an aggravated neck extensor but IDK.
Getting old sucks but I suppose it beats the alternative.
For me (also mid 40s) things got better after I diagnosed with Vitamin D3 deficiency - unrelated to the foot pain I had somewhat similar problems - vacuuming would blow my back out, game of tennis similar thing with shoulders. It got much better over the years and I like to think becoming D3 sufficient was part of it.
I had a year or two of chronic lower back pain and thought it was just the price of getting older (also mid 40s) and living a largely sedentary life. Then I started taking a Vitamin D supplement for a totally unrelated reason (mood, basically) and my back pain disappeared! I was extremely surprised (and happy!).
I got an X-Ray and it showed nothing. The doctor basically thought I was there to score narcotics but he wasn't going to get me any (I wasn't looking for them either but was told to eat Turmeric pills believe it or not - I did and don't have any way to know if it helped.)
Does gout come and go - I have not had trouble since then. If it returns I will be sure to do a blood test - and I really appreciate you asking. I am always for problem solving with or without strangers help :)
(I guess we're off topic now, but please please please don't do what I did and ignore it.)
Me, age 29, I've mentioned before that I'm a lifelong medium endurance cyclist (4-8hrs, 75-120miles): started to get foot pain. Went to the doc (Stanford Hospital GP), doc says you have gout, here's the pills you will take for the rest of your life. Me: nah, I'm healthy, I'll eat better. I was already eating better. Long story short, moved to a rural area, and had probably 30 attacks over 20 years, and none of the 5 (or was it 8?) docs diagnosed it correctly, or prescribed the pills, which are allopurinol. Take the pills. As you might imagine from my preferred exercise I have a very high tolerance for pain. Or did. I am not suicidal, but there have been several two week stretches where I became quite understanding about how people could be made suicidal from chronic pain.
Gout is not necessarily a virtue test. Take the pills. And you don't want advil/tylenol, you want indomethecin for the pain. For the last 5 years I take a half dose everyday and I've not had a single disabling attack, hallelujah. My joints still hate low pressure weather systems though.
In my case, the initial pain was relatively sudden, throbbing, enough to keep me awake at night. I also got an x-ray which doesn't tend to indicate gout, but did show some mobility issues (hallux limitus/rigidus) which were treated with increasingly expensive orthotic inserts.... and it went away after the initial issue for five years. Then it came back, new custom inserts (and some naproxen), went away for another twenty months. When it came back, it kind of stuck around, not the full on pain, but a dull aching that just wouldn't quit, thus the more thorough investigation.
In my case, I think the causes were a combination of gout triggers - not enough hydration, alcohol intake, high protein diets, etc.
I drink plenty of water - rarely drink alcohol but diet on the other hand may not have been all that good in the past although now I am on a lean one and move around a lot - I will definitely check for gout if it happens again. Thanks for bringing this up - it was bugging me on and off that I had something happen that I don't know the root cause for!
You might be interested in this NY Times article from last month. The comment thread also seems useful, with contributors talking about their own experiences. I was surprised to see fructose fingered as a chief suspect, mainly because of modern consumption of high-fructose corn syrup in many foods:
Fellow gout person here. I was finally prescribed allopurinol but I am not sure I want to take it long term due to the chance that it could cause liver and kidney damage but I need to do more research.
Fortunately gout can be controlled fairly well with diet but in the midst of a flare up, it is excruciating.
It’s called Paracetamol in the UK. We can only buy small packs of it (16 tablets or so) to try and prevent things like this. It’s very very rare to see Paracetamol issues in the UK news.
Yes, that is one of the things I was amazed with when I moved from Australia to the USA. You can buy Acetaminophen over here in America in jumbo size 500 or even 1000 tablet containers over the counter - that's a lot of a pretty powerful drug.
Tylenol is deadly, the difference in the dosing between Children's Tylenol and Infants Tylenol has also unfortunately killed many babies - Acetaminophen is a very powerful drug. The FDA failed to fix it for more than 15 years during which many children died of Tylenol overdoses.
It’s bizarre that in the USA they didn’t label infant Tylenol dosage. It’s labelled in other countries. We used infant Tylenol whenever our baby had a fever or otherwise was fighting off a cold. The dose size for children’s Tylenol goes way up (5ml). You'd think something was up when the syringes they give you for the infant type are max 2 ml.
One of my classmates died of Tylenol overdose when I was younger, so this lesson was imparted upon me rather quickly. She wasn't that close to me personally, but still, its a lesson I won't forget.
In that case, she got into a car accident and started taking Tylenol for some chronic pain related to the accident. A few months later, she was dead.
I...was in a car accident last Tuesday and been taking Tylenol like crazy. They refused to give me any prescriptions because I didn't have broken bones, despite the impact going 84 mph to zero in subsecond.
Thank you!
Do you know what's a good alternative to Tylenol? My chest and shoulder are hurting like hell.
Ultimately, that's a "talk to a doctor" kind of question.
My understanding is that if you stay below the warning labels, Tylenol is safe. But if you need doses high enough that you start bumping up against the recommended dose, DEFINITELY talk to your doctor about long-term use and possible kidney / liver damage. They may know of a safer solution (possibly an opioid: which has risks of addiction but... its the doctor's job to weigh the risks / rewards and your various options. Figuring out the right medicine probably requires a decent interview with you).
Getting addicted to an opioid might be "lower overall risk" than dying to kidney failure. Its bad options all around, but that's why we have doctors to help navigate your options.
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Good luck. I've never experienced chronic pain myself. I just know that being in that state means that you're probably not thinking through all your options 100% (just focusing on the pain-relief side of things). Which is why its important to get consultation from a doctor.
I know the urgent care facility in my neighborhood does primary care. Search around for urgent care facilities, they accept walk-in appointments. Ideally, you'd talk to a primary-care physician who has your medical history... but not everyone stays up-to-date with their doctor. (I certainly don't, and instead rely upon the urgent care walk-in appointments)
No broken bones probably means strained tendons / muscles and a (badly) bruised chest. Both are known to hurt a lot and for days if not weeks. Pain is a good thing in that it reminds you to rest.
If the doc already declined stronger painkillers, it's probably not without reason. I dont get why you would suggest opioids being the less evil in this case. I once got 60 pills of codein for a torn off toe nail while visiting over in TX. Needed maybe 2 of them.
As other said, really talk to your doctor, not just as the generic advice but also because there are many other options that can replace/complete/work better than Tylenol.
For instance there are Codein (an opioid) laced versions that are more efficient at lower doses (with other obvious aspects to watch for), or better identifying the source of pain can help target it more precisely (e.g. direct application gels).
There can be other mon drug related actions that help, if your doctor doesn’t give a shit finding another one would be your safest option IMO.
Never take tylenol "like crazy", the max dose of acetominophen is 4000g per day, but better to stick to 3000 if taking for more than a few days.
In the UK you can get cocodamol (paracetamol and codeine) over the counter for lower dosages, but pretty sure that's prescription only in the US, and more likely to lead to dependence.
It depends on the root cause of the pain; for inflammation and swelling that result from soft tissue injuries, I prefer diclofenac, although you need to be careful not to take it with an empty stomach, or mix with ibuprofen.
I would say, though, that this is something to talk through with your GP or a pain relief specialist.
Was it just the ED that refused you? Would be wise to go speak with your primary care provider and get their input, if you don’t have one it’s time to get one (if nothing else having one physician who has a complete history on you is a huge benefit).
The cop gave me a ride to the ED/ER after the accident, and the dr literally said "your x-ray is fine, take Tylenol or Ibuprofen" and just opened the door and left! Didn't talk to him more than two minutes total before and after the x-ray. They charged me 1,008 USD for that! The X-Ray itself was a separate charge by Radia and was just twenty bucks!
The nurse said the pain should improve within a week, but its been so already and I am still in pain even when I breath or move my arm up.
I'll tough it up for another week before seeing a Dr. I can handle the pain (had double kidney stones, one in each kidney before).
Ah, also, FYI for folks in the US: Do not reject Personal Injury Protection. The insurance agent told me my primary insurance will cover me, but then the hospital and my lawyer said that's false and insurance companies reject to pay hospital bills for auto-accidents. Later, they said they'll try to get a formal denial from my auto-insurance first and then try and see if my primary insurance will pay for it.
ER docs have, I think, been trained or conditioned to resist giving pain meds to people. I broke my foot about 6 years ago - badly. Lisfranc fracture, which is most common in football players (and is a career ending injury typically). I went to the ER in blinding pain, quite nearly passed out from that pain in the waiting room. They gave me a morphine injection, which helped a great deal while they did X rays. The doctor (mis-)diagnosed me with a severe sprain and tried to send me home without meds. I asked for some, and was reluctantly given a prescription for Tylenol w/codeine. I've heard similar stories from other people.
As a contrast, any time I've had even the most simple dental or other procedure, the doctors give me a prescription for pain meds without me asking for them (and in many cases not really needing them). So this seems to be specific to ER docs. I suspect it's a reaction to having to deal with people who are drug-seeking, but I don't really know for sure.
When I had my double kidney stones I only took a single Hydromorphone pill, and it was useless anyway for the pain, and didn't get me high either. Only psychoactive effect it had on me, was making it impossible to enjoy music for the rest of the day. I know the pill caused it, because the same thing happened at another time.
Holy shit. That's insane. People don't realize how terrible it is to die from tylenol induced liver damage. That's often considered one of the worst ways to commit suicide. You're in an incredible amount of pain for a long time.
> That's often considered one of the worst ways to commit suicide.
I came close to seeing that first-hand some years ago: My (widowed) dad suffered a long, agonizing death from a form of leukemia. I was with him, at his house, for his final week, with a hospice nurse checking in periodically. He refused morphine and instead took a fair amount of acetaminophen; for calories, he drank a lot of beer and V-8 juice mixed together. I warned him about the danger of mixing alcohol and acetaminophen; he immediately perked up, thinking that would be a way for him to end things. He was disappointed when I explained that it wouldn't be a quick death: he'd just wreck his liver and be in even more agony. (He died a few hours later.)
This is scary to read, as I've been there. All my friends know not to give me Tylenol. I think on two occasions now I had slight pain and took maybe two or three extra strength Tylenol, and was found on the floor shivering, sweating, waiting for death. This wasn't even an OD, this was recommended dosage. I don't think I'll ever take Tylenol again, I'll deal with the pain. This felt like my kidneys were on fire and not so much liver, so what do I know.
Based on having that reaction, I wouldn't suggest you take Tylenol again.
For others, the recommended dose of extra strength Tylenol is two 500mg tablets; but if you only have a minor pain, you don't need to take two tablets, or you could take regular strength (325mg), again the recommendation is two tablets, but you can take less. More than 1g in one dose, or 3g over a day is extremely inadvisable. Acetaminophen (paracetamol) is toxic at a small multiple of the recommended dose; prescription strength acetominophen products add other active ingredients, they don't add more acetaminophen; as opposed to ibuprofen where prescription strength is just more ibuprofen. I'm not a doctor, this isn't medical advice, etc.
Why would some think excessive Tylenol would be preferable over narcotic pain meds
How much Tylenol would a person have to consume over a two month period to permanently damage their liver
This is bizarre.
Tylenol is surprisingly easy to overdose on and is well known to cause liver damage. This is especially true if you take extra strength tylenol. It is recommended to stay below 3,000 mg of tylenol within 24 hours, which is only 6 extra strength pills. If you take a bit extra and get over 4,000 mg per day for multiple days, you can get major issues. There just is not much margin for error with tylenol.
I think people often get confused because you can typically take a bunch of ibuprofen pills for pain and there are rarely serious side effects. But ibuprofen and tylenol are much different in this regard, despite the fact that both relieve pain and both can be easily bought in a drug store.
> This is especially true if you take extra strength tylenol. It is recommended to stay below 3,000 mg of tylenol within 24 hours, which is only 6 extra strength pills. If you take a bit extra and get over 4,000 mg per day for multiple days, you can get major issues. There just is not much margin for error with tylenol.
Huh? To actually think that taking 6 extra strength pills in 24 hours isn't enough margin of error? I mean maybe if the person is completely clueless and doesn't read the medicine instructions.
Honestly, if you're in that much pain that you're gobbling up 6-8 extra strength pills per day, every day, you should be in the hospital with an IV hooked up, or addressing the chronic pain issue that's causing it. Or have the doc prescribe you something way stronger.
I don't know about other people, but for me paracetamol does very little, so if I had even moderate pain I could see why I would be tempted to take too much.
On the other hand, UK has OTC ibuprofen+codeine which can fix essentially anything.
OTC painkillers are usually not meant for moderate+ pain, at least the stuff available in USA.
They're meant for taking you from 3/10 to 1/10. I know most people don't think about it in-depth, but surely we can expect at least some basic logic from them?
Like don't swallow pill #6 if the first 5 extra strength pills did nothing.
-take 2 caplets every 6 hours while symptoms last.
-do not take more than 6 caplets in 24 hours, unless directed by a doctor.
It's not too crazy that someone in pain or feverish could think "maybe if I just take an extra pill or two I'll feel better and it will be totally safe..."
> How much Tylenol would a person have to consume over a two month period to permanently damage their liver
Liver damage can occur after a single incident. People have died from single time overdoses of paracetamol. There is a quick fix in an ER of giving NAC which can help eliminate most of the damage, but there is a small window(a day or two) where it is effective.
I have a load of NAC on hand. Would it be a good idea to take it whenever I take Tylenol? I can't imagine a pharma pathway that would result in it attenuating the painkiller effect. Just mop up the oxidative damage.
Not a doctor and I wouldn't listen to medical advice from HN, but you can find a lot on this:
>Therefore, it may be beneficial to administer APAP(Tylenol) in combination with NAC routinely to reduce rates of liver failure and death. Because NAC's main role is to reduce the accumulation of APAP's toxic metabolites, the concomitant administration of NAC should have no impact on the efficacy of APAP as an antipyretic and analgesic.
It's quite common. At least in Europe, available sizes of Paracetamol were severely limited not too long ago because it was the leading cause of overdose deaths.
Individual risk isn't exactly high, but OTC painkillers are ubiquitous.
Both accidents and suicide attempts are/were frequent. It's a rather terrible way to die, IIRC, with excruciating pain and entirely too much time to regret the decision/accident.
I know someone who ended up hospitalized from accidentally taking two over-the-counter meds that both contained Tylenol. It just doesn't take that much to cause damage.
In my case I went to the doctor only after trying to bear it for as long as I can - they did an x-ray and said there's nothing wrong with your foot and you'll just have to ride it for some days. Heck the doctor asked me to eat Turmeric pills - not even kidding. He made sure I wasn't getting a narcotic - and I wasn't looking for it because I am really afraid of side effects. (My wife is the same way - brave woman went without touching the narcotic meds after tooth removal.)
That pretty much leaves you with OTC pain meds - I know in these cases probably narcotics of the right kind in restricted doses sound much better but I am just truly afraid of side effects because of what we saw earlier in life.
Tylenol is over-the-counter, while you need a doctor to prescribe narcotics.
As such, Tylenol overdose is more common. The labels are very clear about how much to take, but when you're in chronic pain, you may not be thinking much about the warning stickers or labels.
Many stronger drugs have acetaminophen in them. I've tried oxycontin and had very little benefit. People should know for themselves what works for their pain but never underestimate the damage drugs can do, even if they're over the counter.
Honestly, this one does surprise me. American doctors give out opioids like nobody's business. They give you narcotic painkillers for post-tooth-extraction pain! That's ridiculous! The problem, I think, is that many people are foolish enough to "return their unused prescription". I never do that. I make sure to retain unused drugs to their true expiry.
It must have been really quite painful. Still, I'd strongly recommend keeping drugs of all manner handy if you've got good self-control around them. They have high utility.
Mine gave me high strength ibuprofen and percocet after wisdom tooth removal. I didn't take either because it didn't hurt, but they called me up after to make me take the ibuprofen - apparently the anti-inflammatory effect is needed for healing or something.
The DEA has cracked down tremendously on healthcare providers that over-prescribe opioids, though. Granted I'm sure there are many who still prescribe them like crazy, but it seems like active measures are being taken to curb it.
That's unfortunate. I've always wanted backup in case I really need it. Pity that we policy society by its least capable but I understand why it's necessary.
I've seen probably a dozen people in my high school class die from their narcotic pain meds originally prescribed to them. I only took a quarter of what was prescribed after surgery from shattering my leg, and yet weening off was worse than the pain from the injury.
I don't blame him for the choices he made, having been there.
Depends on what "die from their narcotic pain meds" means, and how big the high school class is, how long they've been out of school, and where their school is located.
So your class had a 1% death rate due to prescription opioids. Why do you suppose it was so far out of proportion to the general population? drugabuse.gov says prescription opioids accounted for around 15,000 deaths in 2017 [1], so 12 in a single high school graduating class is either a massive unexplained spike in the data, or something you made up.
I'm not who you're replying to, but don't you think that given we know pill mills exist, it's likely the data is actually highly location specific? I.E., a city with one is more likely to have lots of ODs compared to the national average? Have you taken a statistic course? At this point I'm not sure what you're objecting to anymore.
You're referencing media I don't know, I don't understand why you don't think the scope of the opioid crisis that has claimed thousands could involve the deaths of 12 people with 1 thing in common. Pill mill pharmacies are a thing, and some of those pharmacists have been charged with crimes.
Just consuming more than 4g on one day may be enough to start the liver failure, especially if using alcohol or other drugs.
Protip: have some N acetyl cysteine handy. It's freely available on amazon, and it protects your liver from acetaminophen abuse (and helps rebound faster the next day after a night of heavy drinking, but the FDA absolutely hates when people mention that :-)
EDIT: replying here as HN things I'm "posting too fast"
Whenever in doubt, by default, you take it due to its extremely good tolerance.
There are no bad side effects at usual doses, even after 50+ years on the market (well, at very large doses, vomiting, which I think is good in case of acetaminophen or alcohol poisoning)
Tylenol is really not to be abused. Much better to go heavy with Ibuprofen and remember the old-time drugs like aspirin as well as new ones like naproxen.
But really a doctor/nurse is critical if the pain is going on for more than a day or two.
And there was me thinking 'Tylenol' was ibuprofen.
I think it's so weird (different English speaking) countries having different names for drugs, you'd think it would be something worth standardising. Well, acetaminophen is the standard/medico name I believe (paracetamol to Britons), but why don't we just all use that? Weird.
While I'm at it, Advil = ibuprofen. The latter being both the common UK and 'standard' name I think.
It's branding, it's a marketing thing.. Which has been quiet effective seeing how many people say Advil and Tylenol on here.
Do other brands of 'Tylenol' and 'Advil' even exist inside the US? It amazes me because branded medicines are so much more expensive as well. Like 5 to 10 times more
Yeah, it's just weird. In the UK paracetamol isn't a brand name, it's the generic term for a commodity product, 'nobody' cares who's name is on their paracetamol, I usually buy it with groceries if I'm low, so it's whichever supermarket brand.
The only (non-supermarket/chemist) brands I could name even would be e.g. Lemsip, where the paracetamol isn't the main constituent (it's a lemon flavoured sore throat/cold soothing drink, if you don't have it there) but an additive in some SKUs (also caffeine).
So you can get generic brands of 'tylenol'? People just trust/think better of Tylenol?
Many medical professionals recommend against alternating, not because it is unsafe but because the mental overhead and differing schedules depending on dose can lead to mistakes and lead to accidental overdose if you aren’t paying attention or writing it down.
Also, make sure you are only taking one NSAID (acetylsalicylic acid/asprin, ibuprofen/Advil/Motrin, naproxen sodium/Aleve) if you are alternating painkillers - if you take excedrin/generic “migraine” formula you are already getting a dose of asprin and should not take anything else with it.
You should absolutely read the labels of your pain medications and know what's in them. If you aren't sure about interactions, Don't screw around. Just take one and follow the directions.
Be particularly aware of cold medicines as they very commonly like to do the mixing for you.
Yet many people take paracetamol without issue - you just need to read what the max dose you can take is (2x500g tables at least 4 hours apart and no more than 4 times per day) and not for more than a few days at a time.
The bigger danger is people mixing it with other cold and flu medication that ALSO contains paracetamol.
Paracetamol/acetaminophen has an extremely small therapeutic range for an over-the-counter drug. Yes, if you follow the dosing instructions (and are aware of all sources of the drug you're taking and also aren't drinking alcohol or something simultaneously) you'll be fine, but if you discovered this drug today the odds that it would be approved for over-the-counter use are basically zero.
Reading this whole thread, it almost seems like an opioid or an opioid combined with naloxone (suboxone?) would be rather safer than tylenol/acetaminophen. At least with opioids, the risk of overdose is far more widely understood, and a remedy to overdoses (naloxone) exists, in case it happens. There is the downside of its addictiveness, but in particularly severe cases of patients suffering from really bad pain, it sounds like controlled, limited doses of opioid-based pain killers might be safer? I'm not a doctor, I'm just wondering.
Hmm, acetaminophen/paracetamol is listed here next to aspirin, ibuprofen and opioids are also listed there. I don't think it would not be approved at all, maybe not for over the counter sale. Here in Germany you get it only in pharmacies. No prescription is needed for buying up to 10g of active substance per visit.
I have gout and when it flares up it is the worst. I am in serious foot pain for anywhere from a week to a month or longer. Currently I'm dealing with a buildup of gouty tophi on my heel that has been there for a few years and finally surfacing and causing real issues. I thought it was just a callous from walking with flip flops for too long or something, but nope, just more gout coming around to ruin my days.
It is very depressing that, on top of the pain, I feel like I'm constantly making excuses why I can't do things with my family. Often times I will "power through it" and just make things worse.
Nowadays I am quick to get on my crutches and keep my foot elevated at any hint of a flare up.
I did not know of Eric but can certainly understand taking too much Tylenol for foot pain.
I'm not sure if it's true, but I recall reading that Tylenol is the most commonly overdosed and misused drug. Combined with alcohol it'll destroy your liver, even in low dosages.
I smashed my middle toe into a table while play-chasing my dog around the house. I was instantly in enormous pain, but able to hobble around.
Later that night, I was in so much pain that I literally could not walk at all. I was laughing and crying at the same time, it was ridiculous that I was in so much pain over a TOE. Not even the big toe at that. I had to crawl to the bathroom to pee. Luckily it just took another day and I could hobble on it again.
Ugh, it is shocking how many people don't seem to realize what acetaminophen does to the liver. I had buddies who used to pound tylenol after a long night of drinking to try to help a hangover in college. I'm actually kind of shocked this didn't happen to any of them.
PSA: don't drink and take tylenol, please. The warnings on the bottle aren't a joke.
As someone who takes paracetamol instead of NSAIDs (ibuprofen, aspirin) because of increased sensitivity, this scares me. I do have a hard cut-off of three 500mg tablets in 24 hours, and I never take more than 500mg in a 6 hour period.
I should ask my doctor for a non-NSAID alternative painkiller.
I heard somewhere that under 40 (or was it 45?), most people die of suicide or trauma. After that, people can die of pretty much anything. Just goes to show...
This is really sad but I can totally see how it happens. Check out this label for Amazon brand Acetamenophen. Under directions, the first line says "Take 2 caplets every 6 hours while symptoms last." If you only read that line you would take 8 caplets, or 4000 mg, per day. Unfortunately, the next line says "Do not exceed 6 caplets in 24 hours" making the max OTC dosage 3000 mg per day.
https://images-na.ssl-images-amazon.com/images/I/71bQIsLJPrL...
I read a lot of cool stuff about this guy in the book "Opening the Xbox" by Dean Takahashi[1] and on Alex St. John's blog (which is unfortunately offline now)
He sounded like every bit as great a programmer as John Carmack or any of the relatively famous linux maintainers
I had the privilege of working for Eric at one of his startups. He had an outsized personality. He was the most gregarious person I've known. He could be very intimidating until you got to know him. He was also positive and generous, and his enthusiasm was contagious. We will miss him.
Engstrom was happiest working in his lab. His death came from medical complications related to an accident in the lab, after he dropped a monitor on his foot.
His friend, St. John, managed to get permission to visit Engstrom and deliver some blood collection kit vials to him so he could extract his blood and DNA for cryogenic cold storage.
“We’re going to get a full genetic sequence of Eric’s DNA,” St. John said. “Eric’s going to live on forever.”
St. John played Viking music at the end of the service.
> riends said that Engstrom didn’t have any organization, process, or discipline as a manager. He would promise products and schedules, without checking with his team first. He would simply inspire them to hit the targets, and that was his view of leadership through the “haze of barely controlled chaos.” He didn’t write things down. He was not the most “warm and fuzzy guy unless you were truly in his circle.”
There was another blog with a detailed rundown on the politics behind the Fahrenheit drama but the site wend down 10 years ago and I can't remember what the link was.
I almost forgot about that whole mess. OpenGL was always a faster and better choice to run, but D3D and MS knew this and beat it out of PCs with the pure business force that made MS the company that it was.
Sad to hear. My first programming memories were getting the DirectDraw 2D Sprite demo running by copying C++ tutorial code from the documentation. I didn't understand Windows COM then and I still don't understand it today :P
We should all be so lucky to be remembered this way.
I didn't know the man, but very grateful for DirectX and all the amazing experiences it's allowed myself and others to have. For many of us, games are an escape from things that are not so pleasant. As a kid/young man, they definitely got me through some tough times.
I can still remember playing Pitfall on Windows 95 like it was yesterday, due to DirectX.
Thanks Mr. Engstrom, for being one of the crazy ones.
I recall (albeit vaguely) reading an interesting book "Renegades of the Empire: How Three Software Warriors Started a Revolution Behind the Walls of Fortress" by Michael Drummond.
My recollection of the genesis of DirectX was in fact a skunkworks project create their vision of the next generation web-browsing experience. I think it was demoed and they had begun touting to developers/publishers with work with, but was axed.
I think it had a 3D aspect to it -- perhaps all 3d, I can't recall. But my memory was that they needed a significant 3D library, and they didn't want to go down the OpenGL (I think it was fundamentally political and personality disagreements with themselves and the maintainer(s) of the OpenGL implementation within MS) They convinced their boss to acquire a company that had a 3d engine product and hacked together a more comprehensive library, that ultimately became DirectX.
"... His death came from medical complications related to an accident in the lab, after he dropped a monitor on his foot."
That's tragic, but come on... if you were in decent health a frigging monitor on your foot isn't going to kill you.
In my short 47 years I've known a professor of CS to die at 52 while running. I've known a computer friend to die at 32 from colon cancer. Steve Jobs at 52 from pancreatic cancer.
The computer world is not that big, so there should not be so many of these outcomes.
Programmers seriously need to focus a bit on health. I've been studying how not to die for the past year, since my own father allowed his prostate cancer to go from lamb to lion. Maybe I'll write an ebook & call it "how not to die".
Why not? It's the only moment in time when people are interested in the life achievement of a person. There will never be enough interest for a second discussion that balances his achievements with the negative consequences.
As a society, where else could you show that people shouldn't ignore negative consequences when they seek their success?
Compared to the life of a person, graphics standards seems like a trivial issue. It's like wanting to talk about how he didn't come to complete stop at stop signs while driving.
I'm curious to know how directx has been so bad for humanity.
For one I recommend you read John Carmack interviews from the time directx was being developed. Straight from the horse's mouth. I can assure you, things before directx were not pretty.
Since he contributed to XBox, and each game console since Atari days has used its own API, he couldn't have help to prevent something that never existed in first place.
And as everyone is saying, there are better things to remember and look on a person's life work that is sadly no longer among us.
I have a little anecdote to share that probably only I remember now, but it has always made me laugh and shows what an unusual thinker he was.
When he was first working at Microsoft around 1991 or 92, he was talking to a manager who had a problem. There was a program written in assembler language, about 50k in size or so. The program had a problem that needed to be fixed. The author no longer worked at Microsoft. The manager had repeatedly assigned various programmers the task of fixing it, and they'd all given up after days of effort.
The trouble was the author had used the macro language that came with the assembler to invent his own quirky, weird, undocumented and thoroughly impenetrable language. None of the programmers could figure it out. He was lamenting that he'd have to assign a programmer to recreating it from scratch, which would take months and cost a lot of money.
Eric says "I can fix it".
In 2 hours, he had it all fixed and checked back into the system.
The manager, astonished, asked: "how did you figure out the author's language?"
Eric: "I didn't. I disassembled the binaries using Walter's disassembler [a disassembler turns binary code back into source assembler code]. The problem was then obvious, I fixed it and checked the new source code back in!"
Eric then laughed uproariously, and so did I. Nobody but Eric would have thought of that shortcut to solve the problem. If he couldn't break through the wall, he'd go over it, under it, or around it. He was always like that.
I'll miss him a lot.