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Addressing patients by their first names
to that of tricyclic antidepressant overdose in that the patient received fluid resuscitation, NaHCO 3, phenytoin, and dopamine. The clinical picture of significantly decreased contractility which contributed to the persistent hypotension in the presence of more than adequate central venous pressure is also seen in tricyclic antidepressant overdose. In patients presenting with a similar clinical picture, the administration of increased doses of naloxone above that currently recommended may be helpful in treatment, particularly if the ingested agent is unknown, to allow clinicians to distinguish between tricyclic antidepressant overdose and pentazocine, propoxyphene, or other severe narcotic overdose prior to return of toxicologic studies.
We heartily support Dr Forbes's conclusion that emergency physicians not only consider pentazocine and propoxyphene in the differential diagnosis of coma of undetermined etiology, but also that they consider treatment with high-dose naloxone while awaiting the results of toxicologic analysis. As we mentioned in our case report, high-dose naloxone may not only benefit narcotic, pentazocine and propoxyphene overdoses, but may also partially reverse the coma and respiratory depression of diazepam, alcohol, barbiturates, and nitrous oxide.3-s We furthermore concur that a controlled study of highdose naloxone is a very important area for research by the fields of emergency medicine and prehospital care.
Dennis B Forbes, MD Emergency Medical Services Medical College of Virginia Hospitals Richmond 1. Goldfrank L: Propoxyphene overdose. Topics in Emergency Medicine 1979;1:51-55. 2. Sullivan JB, Rumack B, Peterson R: Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine 1979;1: 65-71.
Stephen M Stahl, MD, PhD Assistant Director VA-Stanford Mental Health Clinical Research Center Assistant Professor of Psychiatry and Behavioral Sciences
To the Editor: Dr Forbes cogently emphasizes the importance of the differential diagnosis of drug overdosage. His comments appropriately warn us not to be fooled by a clinical presentation which appears to resemble "another tricyclic overdose "1 when, in fact, the case may be a pentazocine or propoxyphene ~. overdose. Failing to consider these latter possibilities may lead to increased morbidity and mortality, because the treating physician may fail to treat with naloxone at all or, more likely, may fail to treat with naloxone at the appropriately high doses (ie, up to 10 to 50 ampules of 0.4 mg each). 3
Irwin S Kasser, MD Department of Medicine Sequoia Hospital Redwood City, California 1. Sullivan JB, Rumack B, Peterson R: Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine 1979;1: 65-71. 2. Goldfrank L: Propoxyphene overdosage. Topics in Emergency Medicine 1979;1:51-55. 3. Sawynok J, Pinsky C, LaBella FS: Minireview on the specificity of naloxone as an opiate antagonist. Life Science 1979;25: 1621-1632. 4. Bell EF: The use of naloxone in the treatment of diazepam poisoning. J Pecliatr 1975;87:803-804. 5. Berkowitz BA, Finck AD, Ngai SH: Nitrous oxide analgesia: Reversal by naloxone and development of tolerance. J Pharmacol Exp Ther 1977;203:539-547.
Addressing Patients by Their First Names To the Editor: In recent years the subject of how to address patients has been raised in the literature. ~-4 In addition, it is a subject of frequent discussion in the community. The issue has particular relevance to the emergency department, where the staff members generally greet and treat patients they have not previously met. Natkins, in an engaging piece entitled "Hi, Lucille, This Is Dr. Gold, 'q suggests that calling patients by their first names serves no other "purpose than to underscore my lack of dignity and helplessness . . . , " and argues for the use of the last name in addressing patients, or at least reciprocity ("... it goes 'Hi, Lucille, this is Jim' or 'Hi, Mrs Natkins, this is Dr Gold'"). Cunningham 2 agrees. She points out that "... those in the medical field who call patients (mostly women) by their first names are subtly relegating them to an inferior level." She suggests that "... if a survey were done, most people 13:1 January 1984
would share the sentiments that Mrs Natkins expressed so eloquently." Conant3 makes a "... plea to the medical c o m m u n i t y . . . to call patients by their full names until you can ascertain their preference...," and points out that the use of the first name may disempower the patient and thereby impede the patient's progress. Heller4 studied this question in an OB-GYN practice. One hundred forty-five patients [69% of the total seen during that time period)were asked, among other questions, the following: "How would you like to be called by people who work in the Clinic?" Of the respondents, 78% preferred to be addressed by their first names, 20% had no preference, and 2% wished to be called by their last names. Heller noted: "I do not think that these results justify addressing all patients by their first names . . . On the other hand, expectations in this matter seem to v a r y . . . . "
Annals of Emergency Medlclne
66/117
CORRESPONDENCE
A study was undertaken to determine the preferences of a patient population presenting to the emergency department of a community teaching hospital. During the initial intake procedures, the clerk asked patients two questions: i) Would you rather be addressed by your first name or last name by the nurses caring for you? 2) Would you rather be addressed by your first name or last name by the physicians caring for you? Two hundred fifty patients answered these questions during an eight-day period. These 250 patients comprised 24.4% of all patients seen during that time period. Inclusion or lack of inclusion in the study was more or less random, being decided primarily by which intake processor happened to care for a given patient. Of the 250 patients, 200 (80%) preferred to be called by their first names, 46 I18.4%) had no preference, and 4 patients (1.6%1 preferred to be called by their last names. Of the 250 patients, all but one had the same preference regarding nurses and physicians. These data did not vary with age. Looking at patients aged 50 years or older, the respective numbers were 44 (81.5%), 9 (16.7%), and 1 (1.8%). This study seems to reinforce Heller's conclusions, and
the data are remarkably similar to those he collected. Expectations in this matter certainly do vary considerably. We were struck by the frequency with which patients volunteered comments such as "I like the intimacy of being called by my first name," or "[being called by my] last name is cold," although one patient echoed Natkins's sentiments, asking "Can we call doctors by their first names?" It appears that, at least in this population, most patients prefer to be addressed by their first names by the physicians and nurses caring for them.
Robert A Rosen, MD Berkshire Medical Center Pittsfield, Massachusetts 1. Natkins L: "Hi, Lucille, this is Dr Gold!" lAMA 1982;247: 2415. 2. Cunningham J: Use of first names. JAMA 1982;248:1708. 3. Conant E: Addressing patients by their first names. N Engi J Med 1983;308:226. 4. Heller M: Addressing patients by their first names. N Engl J Med 1983;308:1107.
Blue Jean Hands Syndrome To the Editor: A recent case of interest that baffled our emergency department staff for more than an hour before diagnosis was that of a 22-year-old woman who was previously healthy and who presented with a chief complaint of "blue hands." This was noted four hours prior to her visit. The patient had been sitting in a language classroom all day and denied immersing her hands in dyes or paint. She was a nonsmoker and denied taking any drugs. Examination revealed an anxious woman with a light bluish hue to the dorsum of both hands. The hands were warm to touch and nontender, with normal capillary refill. The remainder of the examination was within normal limits. During the course of her evaluation the patient was noted to be sitting on her hands. She was wearing blue jeans. On closer examination, and with the use of an alcohol pad, it was determined that the patient's blue hands were the result of sitting on her hands while wearing recently put-
chased blue jeans. We propose that this previously unreported condition which may present to an emergency department be coined "Blue Jean Hands Syndrome." [The contents of this letter are the opinions and assertions of the authors, and are not to be construed as official or as reflecting the views of the Department of the A r m y or the Department of Defense.]
Carson R Harris, CPT, M C Associate Director. Emergency Medicine Service Daniel Evans, PAS Cornelio Mariano, MC Silas B Hays A r m y C o m m u n i t y Hospital Fort Ord, California
[Editor's note: Another point to be considered is not sitting on your hands.]
A Multipurpose Resuscitation Catheter To the Editor: In the letter by Redmond describing a multipurpose resuscitation catheter (February 1983;12:123-124), Figure 1, which provides a schema of the apparatus, shows an inner "dilator." This appears to be a very important part of the device. Usually in such devices, after introducing an introducer and then a flexible guide wire and removing the intro118/67
ducer, the dilator is introduced over the guide wire in order to dilate the soft tissues and the opening into the vein. It is then that the catheter is introduced over the dilator and the dilator is withdrawn. In the description and directions for use, however, there is no mention of the inner dilator. There is mention under
Annals of Emergency Medicine
13:1 January 1984
We heartily support Dr Forbes's conclusion that emergency physicians not only consider pentazocine and propoxyphene in the differential diagnosis of coma of undetermined etiology, but also that they consider treatment with high-dose naloxone while awaiting the results of toxicologic analysis. As we mentioned in our case report, high-dose naloxone may not only benefit narcotic, pentazocine and propoxyphene overdoses, but may also partially reverse the coma and respiratory depression of diazepam, alcohol, barbiturates, and nitrous oxide.3-s We furthermore concur that a controlled study of highdose naloxone is a very important area for research by the fields of emergency medicine and prehospital care.
Dennis B Forbes, MD Emergency Medical Services Medical College of Virginia Hospitals Richmond 1. Goldfrank L: Propoxyphene overdose. Topics in Emergency Medicine 1979;1:51-55. 2. Sullivan JB, Rumack B, Peterson R: Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine 1979;1: 65-71.
Stephen M Stahl, MD, PhD Assistant Director VA-Stanford Mental Health Clinical Research Center Assistant Professor of Psychiatry and Behavioral Sciences
To the Editor: Dr Forbes cogently emphasizes the importance of the differential diagnosis of drug overdosage. His comments appropriately warn us not to be fooled by a clinical presentation which appears to resemble "another tricyclic overdose "1 when, in fact, the case may be a pentazocine or propoxyphene ~. overdose. Failing to consider these latter possibilities may lead to increased morbidity and mortality, because the treating physician may fail to treat with naloxone at all or, more likely, may fail to treat with naloxone at the appropriately high doses (ie, up to 10 to 50 ampules of 0.4 mg each). 3
Irwin S Kasser, MD Department of Medicine Sequoia Hospital Redwood City, California 1. Sullivan JB, Rumack B, Peterson R: Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine 1979;1: 65-71. 2. Goldfrank L: Propoxyphene overdosage. Topics in Emergency Medicine 1979;1:51-55. 3. Sawynok J, Pinsky C, LaBella FS: Minireview on the specificity of naloxone as an opiate antagonist. Life Science 1979;25: 1621-1632. 4. Bell EF: The use of naloxone in the treatment of diazepam poisoning. J Pecliatr 1975;87:803-804. 5. Berkowitz BA, Finck AD, Ngai SH: Nitrous oxide analgesia: Reversal by naloxone and development of tolerance. J Pharmacol Exp Ther 1977;203:539-547.
Addressing Patients by Their First Names To the Editor: In recent years the subject of how to address patients has been raised in the literature. ~-4 In addition, it is a subject of frequent discussion in the community. The issue has particular relevance to the emergency department, where the staff members generally greet and treat patients they have not previously met. Natkins, in an engaging piece entitled "Hi, Lucille, This Is Dr. Gold, 'q suggests that calling patients by their first names serves no other "purpose than to underscore my lack of dignity and helplessness . . . , " and argues for the use of the last name in addressing patients, or at least reciprocity ("... it goes 'Hi, Lucille, this is Jim' or 'Hi, Mrs Natkins, this is Dr Gold'"). Cunningham 2 agrees. She points out that "... those in the medical field who call patients (mostly women) by their first names are subtly relegating them to an inferior level." She suggests that "... if a survey were done, most people 13:1 January 1984
would share the sentiments that Mrs Natkins expressed so eloquently." Conant3 makes a "... plea to the medical c o m m u n i t y . . . to call patients by their full names until you can ascertain their preference...," and points out that the use of the first name may disempower the patient and thereby impede the patient's progress. Heller4 studied this question in an OB-GYN practice. One hundred forty-five patients [69% of the total seen during that time period)were asked, among other questions, the following: "How would you like to be called by people who work in the Clinic?" Of the respondents, 78% preferred to be addressed by their first names, 20% had no preference, and 2% wished to be called by their last names. Heller noted: "I do not think that these results justify addressing all patients by their first names . . . On the other hand, expectations in this matter seem to v a r y . . . . "
Annals of Emergency Medlclne
66/117
CORRESPONDENCE
A study was undertaken to determine the preferences of a patient population presenting to the emergency department of a community teaching hospital. During the initial intake procedures, the clerk asked patients two questions: i) Would you rather be addressed by your first name or last name by the nurses caring for you? 2) Would you rather be addressed by your first name or last name by the physicians caring for you? Two hundred fifty patients answered these questions during an eight-day period. These 250 patients comprised 24.4% of all patients seen during that time period. Inclusion or lack of inclusion in the study was more or less random, being decided primarily by which intake processor happened to care for a given patient. Of the 250 patients, 200 (80%) preferred to be called by their first names, 46 I18.4%) had no preference, and 4 patients (1.6%1 preferred to be called by their last names. Of the 250 patients, all but one had the same preference regarding nurses and physicians. These data did not vary with age. Looking at patients aged 50 years or older, the respective numbers were 44 (81.5%), 9 (16.7%), and 1 (1.8%). This study seems to reinforce Heller's conclusions, and
the data are remarkably similar to those he collected. Expectations in this matter certainly do vary considerably. We were struck by the frequency with which patients volunteered comments such as "I like the intimacy of being called by my first name," or "[being called by my] last name is cold," although one patient echoed Natkins's sentiments, asking "Can we call doctors by their first names?" It appears that, at least in this population, most patients prefer to be addressed by their first names by the physicians and nurses caring for them.
Robert A Rosen, MD Berkshire Medical Center Pittsfield, Massachusetts 1. Natkins L: "Hi, Lucille, this is Dr Gold!" lAMA 1982;247: 2415. 2. Cunningham J: Use of first names. JAMA 1982;248:1708. 3. Conant E: Addressing patients by their first names. N Engi J Med 1983;308:226. 4. Heller M: Addressing patients by their first names. N Engl J Med 1983;308:1107.
Blue Jean Hands Syndrome To the Editor: A recent case of interest that baffled our emergency department staff for more than an hour before diagnosis was that of a 22-year-old woman who was previously healthy and who presented with a chief complaint of "blue hands." This was noted four hours prior to her visit. The patient had been sitting in a language classroom all day and denied immersing her hands in dyes or paint. She was a nonsmoker and denied taking any drugs. Examination revealed an anxious woman with a light bluish hue to the dorsum of both hands. The hands were warm to touch and nontender, with normal capillary refill. The remainder of the examination was within normal limits. During the course of her evaluation the patient was noted to be sitting on her hands. She was wearing blue jeans. On closer examination, and with the use of an alcohol pad, it was determined that the patient's blue hands were the result of sitting on her hands while wearing recently put-
chased blue jeans. We propose that this previously unreported condition which may present to an emergency department be coined "Blue Jean Hands Syndrome." [The contents of this letter are the opinions and assertions of the authors, and are not to be construed as official or as reflecting the views of the Department of the A r m y or the Department of Defense.]
Carson R Harris, CPT, M C Associate Director. Emergency Medicine Service Daniel Evans, PAS Cornelio Mariano, MC Silas B Hays A r m y C o m m u n i t y Hospital Fort Ord, California
[Editor's note: Another point to be considered is not sitting on your hands.]
A Multipurpose Resuscitation Catheter To the Editor: In the letter by Redmond describing a multipurpose resuscitation catheter (February 1983;12:123-124), Figure 1, which provides a schema of the apparatus, shows an inner "dilator." This appears to be a very important part of the device. Usually in such devices, after introducing an introducer and then a flexible guide wire and removing the intro118/67
ducer, the dilator is introduced over the guide wire in order to dilate the soft tissues and the opening into the vein. It is then that the catheter is introduced over the dilator and the dilator is withdrawn. In the description and directions for use, however, there is no mention of the inner dilator. There is mention under
Annals of Emergency Medicine
13:1 January 1984