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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".

aortic dissection

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."