Thread by @davehartin

Just read the whole Reg 28 report.

I don't think we need to labour the point but EM experts need to be providing commentary on EM matters for HM Coroner, not tertiary "specialists' who haven't set foot in an ED in decades...

Anyway - a thread on this... @ThinkAorta #AD #EMLife

https://twitter.com/OneLongPlait/status/1393967879368884227

My heart goes out to this person's family. His death was tragic but not definitely preventable. He is young and does not fit the "usual" age group for AD. He should not have been sent to a UTC with chest pain - our UTC colleagues would not see this presentation...

Time & again in EM I teach colleagues in training that you should not diagnose "costochondritis" / anxiety related CP etc in an ED - it's a made up diagnosis when you DON'T KNOW. That's why it's in tiny font on the final slide - put that on a chart and it's meeting w/out coffee

So when a GP who shouldn't have been seeing this patient at all makes a diagnosis in an Emergency Medicine patient they shouldn't be making, this is a governance issue with a streaming process, not just individual errors...

Stating that this parson's death most likely would have been avoided is stretching evidence to its limit especially saying that bilateral BPs and a CT scan would have prevented it. An Icelandic registry showed of those who made it to hospital alive, nearly half were dead at 30d

Oh and sensitivity of CT scan for #AD has been quoted as low as 83% BTW - not the panacea for diagnosis I'd suggest... but it's the best we have...

BPs and CTs do not stop people dying from #AD - prompt access to cardiothoracic surgeons and their skills does that.

Local experience suggests that even when the diagnosis is made, the CTh surgeon insists on reviewing the scans themselves before accepting transfer of a patient

...from a DGH ED to a tertiary CTh centre. There are delays in sending scans due to internet bandwidth issues. There are delays in accessing the surgeon themselves. There are delays due to lack of ambulance resource once a transfer is needed. Delay, delay, delay...

It appears that the CTh specialist has inadvertently misled the coroner due to their lack of experience in EM. There is no classic presentation of #AD - pain varies in site, intensity and may be absent. Pulse deficit is missing in 1/3 of aortic dissections...

If we're to base an imaging strategy to spot aortic dissection on bilateral blood pressure measurements, we will lose. It's not good enough. This is not how Emergency Physicians function.

We do need better risk assessment tools but unfortunately for the coroner I have bad news

Researchers are looking for tools to help EM clinicians clinically diagnose #AD reliably, but they don't exist.
Gestalt (clinical acumen + gut feeling) is what we have to work with in the main because we can't - and shouldn't - scan everyone. HT @TheSGEM thesgem.com/2018/04/sgem21…

I've reviewed evidence, attended conferences and looked at all sorts of tests and strategies to diagnose #AD but the truth as @davidcarr333 says is that "The Aorta Will F*** You Up" - patients & their doctors emergencymedicinecases.com/aortic-dissect…
emergencymedicinecases.com/ddimer-aortic-…
HT @EMCases @First10EM

What we need is money.

Money to spend on more research to derive the tools and tests to accurately diagnose #AD at the bedside - they don't exist yet.

Money to spend on CT scan access because diagnostic imaging are still reluctant to scan as many aortas as we would like...

Money for better internet for image transfer.

Money for better transport infrastructure.

And yes money for awareness and education.

But the Reg 28 is not the sole responsibility of @RCollEM.

Far from it.

It's a system problem that needs system solutions...

...and that starts at medical schools, university and clinical researchers, the NHS itself and the government.

More and more patients through the door, lots with chest pain, few with aortic dissection.

We need help spotting the needle in a very big and expanding haystack.

END