A recent study has uncovered alarming statistics regarding missed diagnoses of aortic dissection in Canadian emergency departments. Over a decade, 43 cases were documented where patients suffered from delayed or missed diagnoses, leading to medical-legal actions. Tragically, 36 of these individuals died, with 30 diagnosed only posthumously. Notably, 40% of these missed diagnoses occurred after patients were discharged from emergency care, a situation described by Calgary emergency doctors Eddy Lang and Niklas Bobrovitz as a significant concern for both patients and healthcare providers.

Aortic dissection is a serious vascular emergency characterized by a tear in the aorta, the body's main artery. Bobrovitz, an emergency medicine resident at the University of Calgary, explained that this condition can lead to rapid death if not diagnosed and treated promptly. "When blood gets diverted through that tear in the inner wall, and the inner wall separates from the outer wall, you can get decreased flow to your vital organs," he said. The consequences can be dire, especially if the tear is near the heart, potentially leading to a heart attack within minutes.

The study highlights the challenges in diagnosing aortic dissection, often referred to as the "great imitator" due to its symptoms mimicking other conditions. Not all patients present with classic symptoms such as severe chest pain. Bobrovitz noted that some may experience persistent discomfort similar to a kidney stone, making it difficult for emergency staff to identify the issue.

Chest pain is the most common complaint in emergency departments, complicating the diagnostic process. Bobrovitz pointed out that many diagnostic tests can return normal results even in cases of dissection. Risk factors for aortic dissection include untreated high blood pressure and certain connective tissue disorders.

The study analyzed 3,531 medico-legal cases involving emergency departments from January 2014 to December 2023, revealing that only 43 were related to aortic dissection. Despite its rarity, the mortality rate for untreated aortic dissection is alarmingly high, with nearly 50% of patients dying within 48 hours of symptom onset.

The research identified several recurring issues leading to missed diagnoses, including inadequate physical examinations, failure to conduct necessary tests, and misinterpretation of chest X-rays. Systemic issues such as overcrowded emergency rooms and lack of available radiologists also contributed to the problem. The study found that the dissection miss rate in Ontario is 12.5%, significantly higher than the acceptable threshold of less than 1% for most Canadian physicians.

Bobrovitz expressed concern over cases where patients presented with atypical symptoms. In one instance, a patient with shoulder pain was discharged after a normal examination, only to die the next day from an aortic rupture. Another case involved a patient who was sent home with a diagnosis of chest wall pain after presenting with sudden chest pain, later dying from aortic dissection.

The study concluded that atypical symptoms, such as younger age or transient pain, often mislead clinicians. In 21 cases, the outcomes were ruled against the physician. Notably, not all missed dissection cases are reported, as doctors seek support from the Canadian Medical Protective Association at their discretion.

To address these diagnostic challenges, a Canadian-developed tool called the RIPP Score has been introduced to assist emergency staff in evaluating suspected cases of aortic dissection. Bobrovitz emphasized its effectiveness, stating, "It’s the most sensitive tool out there, meaning it catches most cases of dissection. It can really help with patients where it’s not super obvious but you’re thinking about maybe dissection."