21 July 2015
Diagnosing aortic dissection
Clinicians at University Hospitals
Bristol have worked collaboratively to develop a program to educate
medics across the South West on aortic dissection, after previous
missed diagnoses at the Trust.
In 2013, emergency department consultant Emma Redfern attended
the inquest of a UH Bristol patient who had been misdiagnosed and
treated for gastro-oesophageal reflux. In fact, the patient had
suffered an aortic dissection and sadly passed away 24 hours after
discharge from the Bristol Royal Infirmary.
As part of a serious incident panel review, Emma and Alan Bryan,
consultant cardiac surgeon, looked into missed cases of aortic
dissection at the Trust to develop an education program to ensure
the same thing didn't happen again. Their program has been
delivered to consultants across the Trust and junior doctors at UH
Bristol. This has educated a broad spectrum of staff across adult
services on the diagnosis and symptoms of patients presenting with
aortic dissection, with plans to roll out more training across the
South West region.
Aortic dissection occurs when a tear in the inner wall of the
aorta causes blood to flow between the layers of the wall of the
aorta, forcing the layers apart. Emma says: "Symptoms are very
varied and present in many ways, including episodes of intense pain
in the chest and back. Patients most likely affected are males and
females in their 40s or older.
"It is essential aortic dissection is picked up early. Diagnosed
patients are operated on immediately by our cardiac surgery team.
Early diagnosis will increase the success rate and we therefore
encourage anyone experiencing unusual symptoms of sudden intense
pain in the chest or back to go to their local emergency department
to be checked."
Clinical examinations, bloods and X rays are not enough to
diagnose aortic dissection and to do so a CT scan must be carried
out. With support from the radiology department, the number of CT
scans being carried out has increased considerably to prevent
another case being missed.
Emma said: "Since our investigations we have realised the need
to test for the condition through CT scanning. In 2009, prior to
the review, we carried out fewer than 20 CT scans over the year to
test for aortic dissection and other conditions. However, last year
we carried out more than 180 CT scans.
Graham Papworth was diagnosed and treated for aortic dissection
in April 2014. He underwent life-saving surgery hours after he was
assessed in the Emergency Department at the BRI. Since making a
full recovery, Graham has given his time to share his experience
with a speaker slot at the University of the West of England
Patient Safety conference in September 2014 with Professor Jonathan
Benger, and is currently involved in a medical research funding bid
with the BRI and UWE.
Graham said "Thanks to the quick, accurate diagnosis I'm still
alive today and have retained all of my limbs, organs and bodily
functions. I firmly believe this is due to the great team at the
BRI. The team operated on me within hours of my arrival at A&E
and three days later I found myself in intensive care, followed by
a visit to the high dependency unit and ward 52. Throughout this
journey I was looked after by fantastic, caring teams and also had
brilliant support from my wife, children, family and friends."
Graham's wife Helen said that she was incredibly impressed by
Graham's quick diagnosis and the speed with which he was prepared
for surgery. She said "The staff in A&E picked up on the
possibility of aortic dissection very quickly. As soon as this had
been confirmed by the CT scan, preparations for surgery began
immediately. The staff were wonderful - both in the way that
they looked after Graham and in the time that they took to explain
the frightening diagnosis to me. He was in surgery within
hours of the diagnosis and was operated on by Mr Bryan and his
wonderful team. Graham then spent almost 5 weeks in hospital
and received exemplary care from everybody involved. I also
felt cared for, staff always had time for me and my many questions
- and tears. I am in no doubt at all that without this awareness
campaign, the speed of diagnosis and the incredible cardiac team I
would have lost my husband and our two young children would have
lost their dad. 'Thank you' doesn't even come close to expressing
how grateful I am".
Emma said: "As a department, we have learned the condition is
more common than we had thought. Before our training, I would have
expected to have seen no more than one case a year. We are now
picking up, on average, a case every six to eight weeks.
"The Trust has learned that this catastrophic condition can
sometimes present in young patients who can look well between
episodes of pain. While the diagnosis remains challenging, our
doctors and nurses are far more aware of aortic dissection.
"Aortic dissection remains a difficult condition to spot, but
following the missed diagnosis in 2013 we have created an excellent
programme that is helping us move in the right direction."
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