CORRESPONDENCE

sociated with a mild hearing loss. The patient was placed on an antih i s t a m i n e - d e c o n g e s t a n t and his s y m p t o m s resolved c o m p l e t e l y in three days. It was thought that this injury was caused by barotrauma resulting from the sudden impact of the air bag with the external ear concha. Virtually no reports of air bag injuries have yet been found in the medical literature, and we believe that such injuries will likely increase as the use of air bags becomes more widespread. The possibility of these injuries occurring should be made known to the physicians who are called on to see them.

Bernard Beckerman, MD, FACEP Scott Elberger, MD, FACEP Emergency Department Winthrop-University Hospital Mineola, New York

The Chest Pain Policy To the Editor: Having received ACEP's "Clinical Policy for Management of Adult Patients Presenting With the Chief Complaint of Chest Pain, With No History of Trauma," I am writing to urge that ACEP and its membership use the resources at their command to reverse the trend toward the development of such documents. The availability of such guidelines will lead to a primary redefinition of medical negligence, and a failure to follow them will become res ipsa loquitur evidence of malpractice. Current definitions of negligence require that there be a breach in the applicable standard of care that is causally related to damages. Clinical guidelines with "rules" are clearly different from the current use of a variety of textbooks and expert testimony to establish standards of care and causation in professional liability lawsuits. With the availability of such guidelines, plaintiff's attorneys will undoubtedly be able to convince juries that l) a failure to follow practice guidelines and 2) the demonstration of damages justify a presumption of negligence without the need to demonstrate that one caused the other. 196/832

How can the friendliest of expert witnesses argue with ACEP on what "should have been done"? We have been given this burden by ACEP even though their own document indicates that "the literature provided little evidence to support specific clinical actions" (p 14): An extensive review of the literature resulted in little evidence supporting the importance of specific historical, physical, and laboratory findings in establishing a diagnosis for the patient with chest pain. In the absence of such scientific evidence, ACEP largely relied on material found in textbooks and review articles as the basis for developing the Chest Pain Policy. As such, the Chest Pain Policy is a consensus document. (p 5) The only people who are helped by the illusion that these simplistic checklists have now established a new standard of care are our good friends the federal regulators, thirdparty payors, and the plaintiff's bar. I recognize that the government, and not physicians, is driving the dev e l o p m e n t of " c l i n i c a l l y relevant practice guidelines." There may not be much we can do to stop them, but I would like to see us try. ACEP argues that "if we don't do it others will do it for us." I fear that that argument (coupled with the seduction of funds from the newly created and heavily funded Agency for Health Care Policy and Research) may lead us to shoot ourselves in the collective foot more q u i c k l y and more readily than necessary. While I recognize that we may ultimately fail to modify these trends, I am dismayed that we seem to be embracing this turn of events when we should be working to limit our damages. The contention that we are best served by guidelines developed by our peers is open to question as well. We are often harder on ourselves than others might be. Personal observation suggests that our admission criteria are often more conservative than those of our consultants. When is the last time a patient's private physician or cardiology consultant Annals of Emergency Medicine

urged you to admit a patient with chest pain whom you wanted to send home? I urge ACEP and its membership to maximize their efforts to limit this trend rather than continue to contribute to the robotic control and definition of our medical practice.

Kenneth Frumkin, PhD, MD, FACEP Las Vegas, Nevada 1. American College of Emergency Physicians: Clinical Policy for Management of Adult Patients Presenting With a Chief Complaint of Chest Pain, With No History of Trauma. Dallas, ACE]?, 1990.

In Reply: As former chairman of the Professional Liability Committee and series editor for foresight, as well as an emergency physician/attorney interested in risk management, I was forwarded the letter from Dr Frumkin. The concern about the creation of ares ipsa loquitur evidence of malpractice is based on a misunderstanding. Res ipsa loquitur has a very narrow application in medical malpractice cases. Res ipsa loquitur is only available in cases of negligence that are either clearly understood by the layperson or cases that involve evidence established by a medical expert witness that an event could only occur as a result of negligence. This does not apply to the potential use of the chest pain policy. Dr Frumkin is concerned that the use of "rules" in the policy creates legal causation whereas the current use of textbooks, journals, and medical expert testimony does not do that sort of thing. The new policy does not create a new legal causation link and does not make the case for a plantiff any easier than before. If anything, the policy applies to standards of care, not causation. Dr Frumkin says that the policy will make it easier for plantiffs' attorneys to "convince juries that a failure to follow practice guidelines and the demonstration of damages justifies a presumption of negligence . . . . " The elements required for proving a medical malpractice case are the same and do not change because of the chest pain policy. A close reading of the policy shows that the standards committee clearly reinforced the im20:7 July 1991