By Elia Petzierides
When 74 year old Connie Petzierides was sent home from hospital with the diagnosis of musculoskeletal pain no one expected her to collapse and die at home several hours later. So why did a seemingly well woman who had just spent the night being observed in hospital suddenly and unexpectedly die and what lessons can be learnt to prevent similar deaths?
First up, some important disclosures:
- This case occurred in the same state the author is employed in.
- The author is the nephew of Connie Petzierides.
It is important to note that neither of these relationships were utilised to obtain any information for this article. All information about this case has been sourced from publicly available information on the Victorian Coroners Court website. Every attempt has been made to ensure this article meets our usual high standards of fairness and accuracy.
What Happened?
Minutes after midnight on 26 April 2010, Mrs Petzierides was woken by a sudden and severe ten-out-of-ten left sided back pain which radiated up to both sides of her jaw. The pain was accompanied by nausea and sweating. An ambulance was called at 15 minutes past midnight which travelled lights and sirens and arrived seven minutes later. The paramedics’ initial impression was ischaemic chest pain (insufficient blood flow to the heart muscle) but they also suspected a possible dissecting thoracic aneurysm.
An aneurysm is a bulging or ballooning of an artery caused by a weakness in the inner most layer of the artery wall. If you’ve ever over inflated a bicycle tyre you may have noticed a bulging in the tyre wall. A thoracic aneurysm is one that occurs in the body’s largest artery, which is located in the chest, known as the aorta. A thoracic dissection occurs when the blood in the aneurysm tears or separates (dissects) through and along the inner and middle layers of the artery wall creating a blood-filled channel. The possibility of blood then breaking through the outer layer of the artery wall with (almost always) fatal consequences makes dissecting aneurysms a time critical emergency. Due to the potential for bleeding, any medications that may impair the blood’s ability to clot are contraindicated. Aspirin is one such medication and although it was indicated for Mrs Petzierides’ other suspected problem (ischaemic chest pain) it was withheld by the paramedics for fear of the possibility of a dissecting thoracic aneurysm.
The paramedics commenced treating Mrs Petzierides with oxygen therapy, inserted an intravenous (IV) catheter into one of her veins and requested a Mobile Intensive Care Ambulance (MICA) to attend. The MICA paramedics arrived at thirty minutes past midnight and received a verbal handover before taking over care for Mrs Petzierides. Their initial and final assessments were ‘acute coronary syndrome NSTEMI’ which is a type of ischaemic chest pain. Their management included increments of IV Morphine which reduced Mrs Petzierides’ pain down to a two-out-of-ten on arrival at the emergency department. Following further assessment and questioning regarding the possibility of a dissecting aortic aneurysm they administered Aspirin being of the belief that this was not the cause of Mrs Petzierides’ pain.
At 1:04am Mrs Petzierides arrived in the emergency department and was assessed by the triage nurse as needing to be seen by a doctor within ten minutes. One hour and forty-six minutes later Mrs Petzierides was seen by an emergency medicine registrar doctor with ten weeks’ experience. The doctor listed the following possible diagnoses: myocardial infarction, unstable angina, pneumothorax or musculoskeletal pain before ordering blood tests and a chest xray. According to the doctor, the tests ruled out the possibility of myocardial infarction, unstable angina and pneumothorax. Regular nursing observations were performed until 7:30am when Mrs Petzierides was discharged home with the diagnosis of musculoskeletal pain having had all other possibilities excluded.
At forty-five minutes past midday Mrs Petzierides was found by her family to be unconscious in her bathroom. An ambulance was called and arrived within six minutes. Cardiopulmonary resuscitation was commenced by paramedics. Despite some initial response to resuscitation efforts, a little over one hour after paramedics arrived and seven hours after being discharged from hospital, resuscitation was ceased and Mrs Petzierides was pronounced deceased.
What went wrong?
The autopsy revealed extensive loss of blood into the chest cavity secondary to dissection of the aorta in the chest. There were two distinct tears in the aorta which the forensic pathologist postulated that Mrs Petzierides may have experienced pain from one of the tears before her first call to 000 and the second tear before collapsing and dying at home approximately twelve hours later. The forensic pathologist concluded Mrs Petzierides cause of death was haemothorax (blood in her chest cavity) secondary to dissecting thoracic aneurysm.
An independent medical expert (the same one enlisted in our previous article Constellation) was consulted to review the care afforded to Mrs Petzierides. The first issue identified by the independent medical expert was the communication of information from AV paramedics to the emergency department. The first paramedics to attend to Mrs Petzierides suspected a dissecting thoracic aneurysm and were likely to have handed this over to the MICA paramedics who transported Mrs Petzierides to the Emergency Department. The clinical judgement of the first paramedics was commended however their clinical notes were not supplied to the hospital. This is in keeping with current AV practice whereby the first attending paramedics do not print out or transmit a copy of the clinical notes for the emergency department rendering this information “lost” to hospital clinicians. The independent medical expert stated that the first paramedics attended closest to the onset of pain and were best placed to obtain an accurate description of this pain along with an appreciation of just how unwell Mrs Petzierides was. Had this been shared with hospital staff it is possible this may have triggered consideration of or increased clinical suspicion for the diagnosis of aortic dissection.
While there was no mention of aortic dissection in the doctor’s clinical notes, in his statement to the Coroner he deemed Mrs Petzierides was at low risk for aortic dissection based on history, clinical examination and investigation results. The independent medical expert deemed this to be flawed on three fronts. Namely these were the reliance on the absence of (one) mediastinal or heart cavity widening on xray, (two) the absence of low or high blood pressure – all of these were deemed to be insufficiently sensitive markers. The third flaw was the doctor’s statement that Mrs Petzierides’ pain was originally mild in the emergency department which discounts the initial sudden and severe onset, the analgesia (or pain relief) Mrs Petzierides was administered prior to arriving at the emergency department and the fact that aortic dissections can go through stages of pain settling then returning when the dissection extends.
The independent medical expert further explained that the doctor’s conclusion that Mrs Petzierides was deemed to be at low risk for aortic aneurysm was based on an incomplete examination, incorrect information and flawed reasoning. This flawed reasoning stemmed from insufficient knowledge regarding the limitations of criteria relied upon to rule out aortic aneurysm.
Mrs Petzierides’ clinical management while in the emergency department was directed by a ‘chest pain’ clinical pathway. The independent medical expert described the pathway as directly aiming to rule out ischaemic chest pain without prompting reassessment or consideration of other causes throughout or at the end of the guideline.
Aortic aneurysm was described by the independent medical expert as a relatively rare disease with correct diagnosis being made in only 15-45% of cases on initial presentation with a delay in diagnosis of greater than twenty-four hours occurring in 39% of cases. The absence of a reliable tool for identifying patients with aortic aneurysm increases the degree of difficulty in correctly diagnosing the disease. However, the independent medical expert asserted that based on the literature, a sudden onset of severe chest or back pain (as opposed to the slower onset of pain associated with myocardial infarction) is the main presenting symptom of aortic dissection which once elicited can greatly assist with correct diagnosis.
With regard to the doctor’s clinical management the independent medical expert confirmed this was acceptable for a doctor of his training and experience in the setting of Mrs Petzierides presentation which was not entirely typical.
The independent medical expert concluded that if the diagnosis of aortic dissection had been considered in hospital with appropriate investigation and treatment implemented, considering surgical survival rates range from 75-90%, Mrs Petzierides may have survived. However, even if Mrs Petzierides were in hospital at the time of the rupture of her undiagnosed aortic dissection it is possible that she would not have survived.
Will it happen again?
Given the preventable circumstances of Mrs Petzierides’ death and the Coroner’s own experience with the frequency of aortic dissection as a cause of death, the Coroner requested the Coroners Prevention Unit to investigate previous deaths from aortic dissection to identify (among other things) factors that may lead to improved patient outcomes. This information was compiled in a report and, along with the independent medical expert’s report, was shared with numerous emergency physicians. The Coroner later convened a round table discussion with these emergency physicians. The results of the above, along with the findings in Mrs Petzierides Inquest, assisted the Coroner in making the following three recommendations:
1. That the Australasian College of Emergency Medicine considers encouraging its members to consider the diagnosis of aortic aneurysm and in particular revisiting the possibility of aortic aneurysm at the conclusion of ‘chest pain’ clinical pathways as well as requesting review by a senior doctor. The Australasian College of Emergency Medicine’s response and implementation can be seen here.
2. That the Minister for Health consider funding research aimed at developing an assessment tool to assist with identifying patients with chest pain who are suspected of having an aortic aneurysm. The response from the Department of Health cited the rarity of aortic dissection and diversity of presenting symptoms as the two reasons an assessment tool may take “many years to develop”. Several alternatives to the assessment tool were listed and can be viewed here.
3. That Ambulance Victoria attempt to provide receiving hospitals with a copy of all clinical notes, including those of the first paramedics to attend to a patient, to provide hospital staff with a complete clinical picture. Ambulance Victoria’s response listed a new verbal handover format known as “IMIST_AMBO” as a solution in lieu of providing a copy of all clinical notes.
It was the wish of Mrs Petzierides’ family to have her death investigated with a view to preventing further deaths from aortic aneurysm. It is clear that the Coroner, with the assistance of the Coroners Prevention Unit and numerous medical experts, has thoroughly investigated the preventable death of Mrs Petzierides. The likelehood of reoccurrence now rests upon the adequacy of the responses to the Coroner’s recommendations.
The author Elia Petzierides is the nephew of Connie Petzierides.
The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.
Neither of these relationships were utilised to obtain any information for this article. All information was sourced from publicly available information on the Victorian Coroners Court website. Every attempt has been made to ensure this article meets our usual high standards of fairness and accuracy.
Any views expressed on this site are the views of the author and not the view of any organization or profession that the author is affiliated with.
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Interesting article as always.
Differential diagnosis should not be something that one cosiders simply with seniority; at least from a prehospital perspective, the abscence of hard signs fosters a reliance on simple objective assessment tools used from an early ‘age’ in prehospital care.
However the implementation of handover tools can be confounded when triage processes are geared towards data collection and don’t align themselves with those tools. Similarly, handover tools are only as good as the compliance of end users. Time is increasingly a barrier to sound handover at all levels of patient disposition, so much that I have seen little use of the IMIST AMBO in day to day paramedic practice. End users just don’t have time.
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Firstly, Elia I am very sorry to hear of the preventable loss of your Aunty. I can only hope that as a result of her passing that the circuimstances around her death can be avoided in the future. I am curious to know why a CT was never ordered for Connie as a Thoracic CT should have confirmed the dissecting aorta.
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Thanks Emma. I think a CT was never ordered because an aneurysm was not suspected. Aortic aneurysm was not listed as a differential diagnosis by the treating doctor.
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