frivolous or nonmeritorious claims in the series. The article might give one the impression that 85% of the complaints or demands by patients or plaintiffs' attorneys are valid, when that is not the case. I think Dr Fastow's editorial com- ments (pages 737-738) were based somewhat on this mis- taken impression.

Overall, the article was enlightening and stimulating, and I hope it will result in a greater effort to reduce the inci- dence of malpractice events and help to reduce the number of successful malpractice claims.

John Dale Dunn, MD, JD, Director Hospital Services~Risk Management Coastal Emergency Services, Inc Durham, North Carolina

To the Editor: I have frequently been consulted by attorneys regarding

evaluation of possible "malpractice" and write from a sub- stantial experience base. Thus I found Trautlein's article to be of particular interest.

There are some differences in their analysis from my per- sonal experience:

1) Misdiagnosis was noted in 66% of their cases. Just mis- diagnosis, however, is not necessarily indicative of malprac- tice. Physicians are not expected to be 100% accurate all of the time.

2) While the charting might have been poor, it is pre- mature to conclude that "in 109 instances, grossly deficient examination was causally related to the misdiagnosis or mismanagement . . . . " The fact that an examination is not recorded is indeed a handicap, but on deposition or at trial frequently one can demonstrate a much fuller physical eval- uation than appears on the initial chart. Some doctors are poor at charting, but this omission is not malpractice.

3) The legal outcome of these cases is important for anal- ysis of "malpractice," not solely, but along with the medical analysis. How many came to trial, for example, or what was the settlement amount. The chart is only a fragment of the event.

George R Schwartz, MD Albuquerque, New Mexico

In Reply: Dr Dunn's point is well taken regarding the possibility for

misinterpretation of our data. It was stated explicitly, but

not vehemently, that these were cases brought to the atten- tion of the medical director at a major malpractice insur- ance carrier. The risk management team of the particular institution gives its field representatives considerable lati- tude of action, and only cases in which a professional judg- ment is needed or in which it is obvious that substantial harm took place are referred out of the great body of "PCEs" that are handled on a daily basis by field representatives. Cases also are referred, however, even when the medical is- sue is not tremendously in doubt, if there is a potential for substantial exposure or there is definite knowledge that there will be legal activity. The actual denomina tor is, frankly, unknowable.

Dr Dunn's summary is quite to the point. It is something of a paraphrase of Osler's old remark: "Listen to the patient, he is trying to tell you what is wrong with him."

In response to Dr Schwartz's letter, w e must point out that under "methods" part of our data base included hospi- tal records, depositions, interviews, legal allegations, and testimony where applicable. In each case, if anyone other than the defendant claimed that the data base by their di- rect testimony was more extensive than documented, that was accepted as fact. We certainly would not want to hold anyone to a standard of perfection in diagnosis, but the combination of a bad outcome in the setting of a duty to examine, a dereliction of that duty, real damages and poten- tial for direct causation certainly leaves the physician in a very vulnerable position. Regarding his third point, we did in our initial overview look at the outcome of the cases from a financial point of view. Actual numbers could be defined only in closed claims. At the time of the generation of this study many of the cases were still under litigation. Some have been settled out of court. The insurance com- pany's modus operandi is to try to reach an early judgment as to whether or not a case is defensible, make prompt and equitable settlement where appropriate and, in general, go to the mat on those cases that appear defensible after expert review. I am sure that Dr Schwartz would agree that the dollar outcomes in cases can be affected significantly by such diverse variables as the relative skills of the contesting lawyers and the emotional content of the alleged injury. We hope in some small way to modify behavior because it is proper to do so, not only because it is economically expedi- ent to do so.

Joseph J Trautlein, MD Associate Professor of Medicine The Pennsylvania State University College of Medicine Hershey, Pennsylvania

Blind Nasot rachea l In tubat ion

To the Editor: We recently had an opportunity at a local advanced trau-

ma life support course to simulate ventilation during the placement of a nasotracheal tube, but we were unable to locate the rubber female-female adaptor as described by Iser-

son ("Blind Nasotracheal Intubation: A Model for Instruc- tion," August 1984;13:601-602). Instead, the cuffed end of a 7.0-ram endotracheal tube was inserted into the manikin's left bronchus after the "lung" had been removed. After the

14:1 January 1985 Annals of Emergency Medicine 88/159

CORRESPONDENCE

cuff was inflated with 2 to 3 mm of air to obtain a good seal, the bag ventilator was connected and respirations were simulated. No problems were encountered, and we were pleased with this mechanism simulating respiration.

We would like to suggest that this method of using the endotracheal tube rather than the female-female adaptor may be preferable for several reasons. First, the endotracheal tube is readily available. Second, it is longer than the adapt- or described, which allows the bag ventilator to be held at a comfortable distance from the manikin.

For these reasons we would like to recommend the endo- tracheal tube as an alternative to the female-female adaptor in the teaching model.

Michael Murray, MD Jan Ahuja, MD, FACEP Emergency Department Ottawa Civic Hospital Ottawa, Ontario, Canada

Errata

In the article by McGill and Ruiz entitled "Central Venous pH as a Predictor of Arterial pH in Prolonged Cardiac Arrest" (September 1984 [Part 1];13:684-687), an editing error may have misled readers. Sixty-five patients who arrived in the ED in cardiac arrest were studied prospectively to determine whether central venous pH could be used as an accurate predictor of arterial pH in prolonged cardiac arrest. The correlation was excellent in the subgroup of 15 patients who had a pulse at some point during emergency department resuscitation. Because much of the resuscita- tion occurred in the prehospital phase, deletion of the words "emergency department" in this sentence was inaccurate, and may have led to incorrect assumptions in data interpretation.

In the collective review by Weinstein entitled "Recognition and Management of Poisoning with Beta-Adrenergic Blocking Agents" (December 1984;13:1123-1131), an error appeared in Table 1. Column 4 of that table should have been labeled "Lipid Soluble" rather than "Soluble."

160/89 Annals of Emergency Medicine 14:1 January 1985