Missed Aortic Dissection in a Florida Emergency Room: When a Misread Chest Pain Becomes Malpractice

Modern emergency medicine can accomplish remarkable things in the span of a single shift — restarting a stopped heart, dissolving a dangerous clot, and moving a critically ill patient from triage to the operating room in under an hour. That said, every one of those interventions depends on the first step being right, which is an accurate diagnosis of what is actually causing the patient's symptoms.

Few conditions test that first step like acute aortic dissection, a tear in the inner layer of the aorta that allows blood to force its way between the layers of the vessel wall. It frequently arrives in the emergency department disguised as something far more common — a heart attack, a pulmonary embolism, a kidney stone, a pulled muscle, acid reflux, or even anxiety.

If you or a loved one went to a Miami-area emergency room with chest or back pain, were sent home or treated for the wrong condition, and later learned that an aortic dissection was the true cause, we understand how devastating that discovery can be. We know that for many families the correct diagnosis arrived too late, during emergency surgery or after a loss of life, and that the questions about what happened in that ER do not go away.

This guide explains how aortic dissection is recognized, what imaging the standard of care generally expects, and how Florida's pre-suit process under Chapter 766 and the limitations period in § 95.11 shape a potential claim. It is part of our broader coverage of failure-to-diagnose malpractice in Miami, where we examine the emergency misses that most often lead to preventable harm.

Aortic dissection is relatively uncommon compared with the many other causes of chest pain an emergency physician sees every day. Keep in mind, however, that rarity does not lower the stakes, particularly when the tear involves the ascending aorta closest to the heart.

Older studies that are still widely cited in emergency medicine teaching describe the early mortality of untreated ascending-aorta dissection as climbing by roughly 1% to 2% per hour in the first day or two. The precise figures vary by study and era, but the lesson clinicians draw from them is consistent — in a dissection, hours matter.

Physicians generally classify dissections using the Stanford system, which divides them into two categories:

• Stanford Type A. This type involves the ascending aorta, regardless of where the tear began. It is typically treated as a surgical emergency because it can rupture into the sac around the heart, cut off blood flow to the coronary arteries, or cause severe leakage of the aortic valve.
• Stanford Type B. This type involves the aorta beyond the ascending portion, usually downstream of the left subclavian artery. Many type B dissections are managed initially with strict blood pressure and heart-rate control, while complicated cases may require thoracic endovascular aortic repair (TEVAR) or open surgery.

Both types can cut off blood supply to the brain, spinal cord, kidneys, intestines, or legs as the false channel of blood expands. As a result, a missed dissection can lead to stroke, paralysis, kidney failure, bowel injury, limb loss, or death — injuries that often extend far beyond the original tear.

Research drawn from large databases such as the International Registry of Acute Aortic Dissection (IRAD) has shown that real-world presentations are often less textbook than clinicians expect. Some of the reasons a dissection is overlooked in the emergency department include but are not limited to:

• Anchoring on a heart attack. Chest pain paired with an abnormal ECG or an elevated troponin can push a team quickly toward acute coronary syndrome. A dissection that extends into a coronary artery — most often the right coronary artery — can even produce an ECG pattern that looks like a classic heart attack.
• Pain that migrates or fades. The pain may move from the chest to the back or abdomen, or it may ease after the patient arrives. A patient who looks and feels better can be mistakenly reassured and discharged.
• Atypical presentations. Some patients present with fainting, stroke-like symptoms, sudden leg weakness, abdominal pain, or pain they do not describe as severe. Older adults and patients with diabetes may report vaguer symptoms that are easier to attribute to something else.
• Over-reliance on a normal chest X-ray. A widened mediastinum on a chest X-ray is a helpful clue when it appears. However, a normal chest X-ray does not rule out an aortic dissection.
• Crowded departments and premature closure. Busy shifts, handoffs between providers, and pressure to move patients through the department can cut the diagnostic process short. Premature closure — settling on a diagnosis before the dangerous alternatives have been excluded — is a well-recognized source of diagnostic error.

All of these pitfalls are well documented in emergency medicine literature and training. This is why a potential malpractice case focuses on a narrower question — whether a reasonably careful emergency physician, facing the same patient and the same information, would have considered dissection and ordered the test that would have found it.

Florida defines the prevailing professional standard of care in § 766.102(1), Florida Statutes, as the level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. In an emergency room case, that generally means comparing what happened to what a reasonably prudent emergency physician would have done with the same symptoms, the same history, and the same resources.

The 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, published jointly by the American College of Cardiology and the American Heart Association, is a common reference point for these comparisons. Clinical guidelines are not law, and a departure from a guideline does not automatically equal negligence — but experts on both sides frequently use them to frame what careful practice looks like.

The Red Flags Clinicians Are Taught To Weigh

Emergency physicians are trained to weigh a cluster of history, pain, and physical exam findings rather than any single symptom. Red flags that should raise suspicion for aortic dissection include:

• High-risk conditions. Marfan syndrome and other connective tissue disorders, a family history of aortic disease, known aortic valve disease including a bicuspid aortic valve, a known thoracic aortic aneurysm, or prior aortic surgery or catheter procedures.
• High-risk pain features. Chest, back, or abdominal pain that is abrupt in onset, severe in intensity, or described as ripping or tearing. Patients frequently describe it as the worst pain of their life.
• High-risk exam findings. A pulse deficit, a significant difference in blood pressure between the two arms, a focal neurologic deficit occurring alongside pain, a new murmur of aortic regurgitation, or low blood pressure and shock.

Additionally, longstanding or uncontrolled hypertension, cocaine or other stimulant use, and pregnancy are recognized risk factors that a careful history should capture. These are exactly the kinds of details that a rushed triage note can leave out.

The three categories above form the basis of the Aortic Dissection Detection Risk Score (ADD-RS), a bedside tool that assigns one point for each category present. Some research, including the ADvISED study, has examined combining a low ADD-RS with a negative D-dimer blood test to help identify patients who are unlikely to have a dissection — how that pathway applies to a particular patient is a question for a qualified emergency medicine expert.

The Imaging That Confirms Or Excludes Dissection

When suspicion is meaningful, the next step is definitive imaging of the aorta. The main options include:

• CT angiography (CTA) of the chest. Contrast-enhanced CT of the chest — often extended through the abdomen and pelvis — is fast, widely available in Miami-area emergency departments, and the test most commonly used to confirm or exclude dissection. A non-contrast CT, or a scan protocoled for another purpose, may not evaluate the aorta adequately.
• Transesophageal echocardiography (TEE). This ultrasound is performed through the esophagus and is especially useful for unstable patients who cannot safely travel to the CT scanner. It is frequently performed at the bedside or in the operating room.
• Point-of-care or transthoracic ultrasound. A bedside ultrasound can reveal a dilated aortic root, fluid around the heart, or a visible flap inside the aorta. That said, a normal bedside ultrasound does not exclude a dissection.
• MRI or MR angiography. Magnetic resonance imaging is highly accurate but slower to obtain. It is generally more practical for stable patients or follow-up than for the initial emergency workup.

Once a dissection is confirmed, the standard of care generally calls for rapid blood pressure and heart-rate control and immediate involvement of cardiothoracic or vascular surgery. If the hospital cannot perform aortic surgery, timely transfer to a facility that can becomes part of the expected care.

Sequencing matters as well. When a dissection is mistaken for a heart attack, a patient may receive blood thinners, antiplatelet drugs, or clot-dissolving medication — treatments that can worsen bleeding and complicate emergency surgery.

Our overview of medication dosing errors discusses how drug-related harm is analyzed in Florida claims. In a dissection case, the question is often whether the medication should have been given at all before the aorta was evaluated.

Not every missed or delayed diagnosis is malpractice, and we will tell you plainly if a case does not meet that threshold. A viable Florida claim generally requires proof of four elements:

• Duty. A provider-patient relationship existed, which in an emergency department is typically established once the patient is evaluated. Hospitals may also owe duties through their nursing staff, radiology coverage, and transfer policies.
• Breach. The provider departed from the prevailing professional standard of care. Examples include failing to consider dissection despite documented red flags or failing to order appropriate imaging.
• Causation. The breach more likely than not caused harm, meaning an earlier diagnosis would probably have changed the outcome. This is often proven through timelines built from triage times, vital signs, and imaging timestamps.
• Damages. The patient or family suffered measurable losses. These can include additional surgery, stroke, paralysis, medical expenses, lost income, pain and suffering, or a loss of life.

Causation is frequently the most contested element in dissection cases. Defense experts may argue that the tear developed after discharge or that the outcome would have been the same regardless of timing, which is why the records of symptoms, vital signs, and timestamps become so important.

Common fact patterns our attorneys review include:

• Discharge with a musculoskeletal or digestive diagnosis. A patient with sudden, severe chest or back pain is sent home with muscle relaxants, pain medication, or antacids. No imaging of the aorta was performed despite red flags in the chart.
• A heart-attack pathway that is never reconsidered. A patient is treated for acute coronary syndrome, and findings such as unequal arm pressures or a new murmur are not revisited when the workup does not fit. The dissection is found only when the patient deteriorates.
• Imaging that is misread or not communicated. A CT shows findings suggestive of dissection that are missed, not called to the ordering physician, or not acted upon. We discuss this pattern in our guide to unreported radiology findings.
• Delayed transfer. The diagnosis is made, but transfer to a center capable of aortic surgery is delayed without a sound clinical reason. Every hour of that delay may be relevant to causation.

Families who have been through a similar chest-pain miss may also find our guide to a missed heart attack in the ER useful, because the two conditions are frequently mistaken for each other. The same diagnostic-momentum problem appears in other emergency misses, including delayed recognition of cauda equina syndrome.

A Special Florida Rule For Emergency Care

Be aware that Florida law may apply a heightened standard to some emergency-department claims. Under § 768.13(2)(b), Florida Statutes, certain emergency care provided in a hospital in response to an emergency medical condition is subject to a reckless-disregard standard rather than ordinary negligence.

Whether that provision applies — and whether an exception applies, such as care provided after the patient was stabilized — depends on the specific facts. This is a threshold legal issue in many ER cases, so confirm with counsel how it may affect yours.

Florida does not allow a medical malpractice lawsuit to be filed immediately. Chapter 766 requires a structured pre-suit investigation first, and each step carries its own timing rules.

Here is how the process generally unfolds:

1. Obtain the complete medical records. This includes triage notes, vital-sign flowsheets, physician documentation, imaging orders and reports, and electronic audit trails that show who viewed what and when. Section 395.3025, Florida Statutes, generally governs patient access to hospital records.
2. Secure a corroborating expert opinion. Section 766.203 requires the claimant's reasonable investigation to be corroborated by a verified written medical expert opinion that reasonable grounds exist to support the claim. Under § 766.102, that expert generally must meet specialty-matching qualifications — often an emergency medicine physician for an ER claim.
3. Serve a notice of intent to initiate litigation. Section 766.106 requires written notice to each prospective defendant by certified mail, return receipt requested, before a lawsuit is filed. The notice triggers informal discovery, including the exchange of records and statements.
4. Complete the 90-day investigation period. After receiving notice, the prospective defendants have 90 days to investigate the claim. The statute of limitations is tolled while that period runs.
5. Respond to the outcome. At the end of the period, a prospective defendant may reject the claim, make a settlement offer, or offer to arbitrate damages. If the claim is rejected, the claimant generally has 60 days or the remainder of the limitations period, whichever is greater, to file suit.

Keep in mind that § 766.104 also allows an automatic 90-day extension of the limitations period by filing a petition with the clerk of court. This extension can provide additional time to complete a thorough pre-suit investigation, but it must be requested before the deadline passes.

The Florida Statute Of Limitations

The limitations period for medical malpractice appears in § 95.11(4), Florida Statutes. The provision has long been cited as § 95.11(4)(b), and 2023 amendments re-lettered some of the subsections of § 95.11(4), so confirm the current citation with counsel.

Under that provision, a claim generally must be commenced within two years from the time the incident occurred or within two years from the time the incident is discovered, or should have been discovered with the exercise of due diligence. It also contains a statute of repose, which generally bars claims filed more than four years after the incident, extended to seven years where fraud, concealment, or intentional misrepresentation prevented discovery.

In dissection cases, the date of discovery is not always the date of the ER visit. A family may not learn that an earlier visit missed the diagnosis until an autopsy, a surgeon's comment, or a later records review, and when the clock began running is a fact-specific question.

If a missed dissection led to a loss of life, the claim is typically brought by the personal representative of the estate under Florida's Wrongful Death Act, and it still passes through the Chapter 766 pre-suit requirements. Be aware that § 768.21(8) limits which survivors may recover certain damages in medical malpractice death cases, and that provision has been the subject of repeated legislative efforts — confirm its current status with counsel.

If you believe an aortic dissection was missed, a few practical steps can protect both your health and your potential claim. Here is a list of the steps you may want to consider:

• Follow your current treatment plan. Survivors of aortic dissection typically need long-term blood pressure control and scheduled aortic imaging. Your health comes first, and consistent follow-up care also documents the lasting impact of the injury.
• Write down the timeline. Note when symptoms started, what you told the triage nurse, what you were told at discharge, and when the diagnosis was finally made. Memories fade quickly, especially in the aftermath of a traumatic hospitalization.
• Keep discharge papers and bills. Discharge instructions often list the working diagnosis and the medications given. They are among the most useful early documents in any failure-to-diagnose review.
• Request records early. Hospital records, imaging files, and ambulance reports can take weeks to arrive. Starting early leaves more time for expert review within the pre-suit window.
• Be cautious with insurers and social media. Statements to adjusters or posts online can be taken out of context later. It is generally wise to speak with counsel before giving recorded statements.
• Speak with counsel before the clock runs short. Because the pre-suit investigation can take months, waiting until near the two-year mark can make it difficult to complete the required steps. An early review preserves your options.

Many patients survive an aortic dissection that is diagnosed and repaired in time. When it is missed, the consequences — emergency surgery under the worst conditions, stroke, paralysis, kidney failure, or the loss of a parent, spouse, or child — can change a family's life permanently.

We understand that nothing can undo what happened in that emergency room, and we also know that you may be entitled to compensation for medical expenses, lost income, and pain and suffering. Our team works with emergency medicine, cardiothoracic, and radiology experts to review what the records show — and what they leave out.

Do you think a Miami emergency room missed your or a loved one's aortic dissection? We welcome the opportunity to speak with you about your situation and help you determine the next steps, beginning with our failure-to-diagnose resources.

Free consultation. No fee unless we recover. Florida's two-year clock generally starts when the injury is discovered or should have been discovered — do not wait to find out where yours stands.

This article is for informational purposes and does not constitute legal or medical advice. Consult a qualified attorney licensed in Florida about your specific situation.