00:00:03
[MUSIC PLAYING]
00:00:19
NARRATOR: A woman dies only days after undergoing
00:00:21
radical dental surgery.
00:00:23
So we've got a 42-year-old female today, who has recently
00:00:27
had her teeth pulled out.
00:00:30
NARRATOR: Was her death related to the surgery,
00:00:33
or could it have been the result of a tragic accident
00:00:35
caused by her own sister?
00:00:38
The sister was very upset.
00:00:40
She felt that she was under her care,
00:00:42
and she slipped away from her.
00:00:44
NARRATOR: And then when a depressed elderly woman
00:00:47
was found dead in her home, her family fears the worst.
00:00:51
When I talked to the family, they're
00:00:53
clearly quite worried that she might have committed suicide.
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When the family brings something like that up,
00:00:59
I have to worry about it.
00:01:07
NARRATOR: Altered lives, baffling medical mysteries,
00:01:10
shocking revelations--
00:01:12
these are the everyday cases of Dr. G, medical examiner.
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[ELECTRONIC MUSIC]
00:01:38
Hey, Sandi.
00:01:40
Sandi: Hey.
00:01:41
Their dog, it's like a little old lady dog.
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I hate to tell you that-- do you have to do
00:01:47
the tail on your dog like that?
00:01:49
That's like a little old lady dog.
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She is a little lady.
00:01:54
No, that's like for a little old lady.
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You're no little old lady.
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Does the dog's tail have to be like that?
00:02:00
Yes, she's a poodle.
00:02:02
(LAUGHING): Oh, god.
00:02:04
Sorry, but it is.
00:02:05
I didn't notice it.
00:02:06
You got it on this fancy pillow, and it's got
00:02:09
its little poo-foo--
00:02:10
That's not a fancy pillow.
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--tail.
00:02:12
That's just your regular, old, flat--
00:02:15
no, what's it called? - Paisley.
00:02:16
Sandi: Paisley.
00:02:17
All I can say is don't--
00:02:19
if you start acting like a little old lady,
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you'll become one.
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Sandi (LAUGHING): She's a poodle.
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NARRATOR: It's early morning at the district 9
00:02:28
morgue in Orlando, and Dr. G and her staff
00:02:30
are ready to begin the day's caseload.
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Today, their first autopsy will involve no old lady, but rather
00:02:39
a surprisingly young woman named Vivian Kaplin, who passed
00:02:43
away decades before her time.
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This case involves a woman that
00:02:47
dies somewhat unexpectedly.
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She has an interesting history, and I'm not quite sure how
00:02:52
this plays into what happened.
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[OMINOUS MUSIC]
00:03:05
NARRATOR: As a first step, Dr. G reads
00:03:07
through the investigator's report which details
00:03:10
the circumstances preceding the woman's death,
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and in this case, they're a bit unusual.
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So we have a 42-year-old female,
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who wasn't feeling very well yesterday, recently
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had her teeth pulled out.
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NARRATOR: According to the decedent's sister, several days
00:03:30
ago, Vivian Kaplin traveled five hours
00:03:33
by bus to an out-of-state clinic to have her teeth extracted.
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She's having a lot of problems with her teeth, a lot
00:03:40
of problems with her gums, and they say she
00:03:42
needs to have her teeth pulled.
00:03:45
NARRATOR: A few days later, Vivian
00:03:47
is released from the clinic.
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She makes the long trip back to her home in Florida
00:03:53
and is greeted at the bus terminal by her sister.
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Things seemed to have been going well.
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She came in last night.
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Things were fine.
00:04:02
Her sister was talking to her, and then about 6 o'clock
00:04:07
in the morning, she awakens her sister
00:04:09
and says that she feels like she's got a low blood sugar.
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Now she knows this because she's a diabetic.
00:04:17
She's had diabetes for about three years,
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and she's type 1 diabetic in that she needs insulin.
00:04:25
So her sister immediately responded to that
00:04:28
by getting her something to drink to raise her blood sugar,
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and then after that, she checked her blood sugar,
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and it was actually very high, not low at all.
00:04:40
NARRATOR: According to the blood meter,
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Vivian's glucose level registers 500 milligrams per deciliter,
00:04:46
more than five times what it should be.
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She immediately asks her sister Teresa
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to administer a dose of insulin in the hope
00:04:55
that it will bring her glucose levels back down,
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but that's when something goes terribly wrong.
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About an hour after the injection,
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Vivian loses consciousness and stops breathing.
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She is rushed to the hospital, but to Teresa's disbelief,
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Vivian doesn't survive the trip.
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They tried to revive her, but it's too late.
00:05:20
She's already pronounced by the time she gets to the hospital.
00:05:25
NARRATOR: For Vivian's sister, Teresa,
00:05:28
the sudden loss of her only sibling is devastating.
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The only thing more painful than her grief are her feelings
00:05:37
of guilt. Teresa is overwhelmed with the thought
00:05:42
that she might have caused Vivian's death by injecting
00:05:45
her with too much insulin.
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She was worried, because she's the one that gave her
00:05:50
the insulin injection, and then a couple hours later, she died.
00:05:54
So I think she's a little upset.
00:05:56
You know, maybe she did something wrong.
00:06:04
NARRATOR: If Teresa accidentally injected an overdose
00:06:07
of insulin, it would have caused Vivian's
00:06:10
glucose level to plummet--
00:06:12
a condition known as hypoglycemia, or insulin shock,
00:06:17
which can cause seizure, coma, and even death.
00:06:21
But on first blush, Dr. G thinks it's
00:06:24
unlikely that Teresa gave her sister
00:06:26
an incorrect dose of insulin.
00:06:29
You know, she was used to giving that insulin.
00:06:31
She knew about the insulin.
00:06:32
She'd done it before.
00:06:34
NARRATOR: She wonders instead if there might
00:06:36
be another explanation for Vivian's
00:06:38
unexpected death, one stemming from her recent dental surgery.
00:06:44
Well, I worry the teeth, in and of itself,
00:06:47
isn't too big a procedure being pulled,
00:06:52
but you've certainly have opened up your sockets.
00:06:57
And you're more apt to get an infection.
00:07:00
Well, what would that matter?
00:07:01
Normally, we could, you know, fight that off,
00:07:04
and we wouldn't have any problem.
00:07:05
Well, that's bad for people with diabetes,
00:07:11
because they don't have as good a defense
00:07:15
against getting an infection.
00:07:18
NARRATOR: Dr. G's concern--
00:07:20
perhaps Vivian developed an infection
00:07:21
[DRILLING]
00:07:22
from the dental work, which simply overwhelmed
00:07:25
her impaired immune system.
00:07:27
So that could be a major problem,
00:07:29
and that could be something I have to worry about.
00:07:33
NARRATOR: Was Vivian's death the result of a tragic accident
00:07:36
or from complications of illness and disease?
00:07:40
There's only one way for Dr. G to find out.
00:07:50
[ELECTRONIC MUSIC]
00:08:01
Sandi: I got everything on there.
00:08:03
All right, I'll be there in a second.
00:08:05
Oh, not just the IDs.
00:08:07
OK, which are the ones?
00:08:09
Dr. Hanson likes the blues, so what
00:08:11
is the consensus so far here?
00:08:13
Do you like the blues?
00:08:14
Sandi: Yes.
00:08:15
So you'll keep wearing the blues.
00:08:17
So these are for people like Dr. Hanson and I. Unfortunately,
00:08:20
she, I think, likes these.
00:08:21
So let me try these.
00:08:24
I think when those things get wet, you get a little--
00:08:26
The blues get, yeah, real slippery.
00:08:29
What?
00:08:31
The only problem is they are a little bit hard to get
00:08:33
on with the other glove.
00:08:38
DR. G (VOICEOVER): When I first see her,
00:08:40
I'm actually kind of taken back, because she looks much older
00:08:44
than her stated age of 42.
00:08:46
And when I do an exam, I'm usually quite generous
00:08:50
and always state that they look their stated age of 40
00:08:54
if you even maybe don't too good.
00:08:57
But, you know, with her, I really
00:08:59
had to say she didn't look her stated age of 42.
00:09:02
She looked older partly maybe because she
00:09:05
didn't have any teeth.
00:09:08
She was thin.
00:09:09
She didn't look like she had taken
00:09:11
very good care of herself.
00:09:12
She had wrinkles.
00:09:13
She was thin.
00:09:14
She had no teeth.
00:09:16
She just looked old.
00:09:18
NARRATOR: Dr. G inspects the body
00:09:20
carefully, looking for any unusual marks or trauma.
00:09:24
No bruises.
00:09:25
I don't see the injection site.
00:09:26
She does have some mild pitting edema, a little bit of edema
00:09:29
to her lower extremities.
00:09:33
NARRATOR: Then she turns to examine Vivian's mouth,
00:09:36
the site of her recent surgery and where Dr. G suspects
00:09:40
she might find a clue to her death.
00:09:44
Well, I'm looking-- you know, one of the things I want
00:09:46
to concentrate on is her mouth.
00:09:48
She just had all her teeth pulled.
00:09:50
And when I look in, sure enough, she
00:09:52
just had all her teeth pulled.
00:09:53
She had all those extraction pits,
00:09:56
and they were starting to heal.
00:09:57
But, you know, it looked painful to me, and it looked,
00:10:01
you know, inflamed a little bit.
00:10:08
NARRATOR: But Dr. G finds no obvious signs of infection,
00:10:12
such as pus or ulcerations.
00:10:14
Externally, at least, a deadly infection
00:10:17
now seems less likely.
00:10:19
For Vivian's sister, this kind of news could be devastating.
00:10:24
If Vivian didn't die from an infection,
00:10:27
perhaps something did, in fact, go wrong with the insulin
00:10:30
injection.
00:10:31
The sister was very upset.
00:10:33
And I think she felt that she was under her care,
00:10:36
and she slipped away from her.
00:10:42
[MUSIC PLAYING]
00:10:58
NARRATOR: Dr. G opens the body of 42-year-old Vivian
00:11:01
Kaplin with a Y-incision.
00:11:05
DR. G: Did anybody see that video
00:11:07
of the mistreatment of the cows before they were killed?
00:11:11
I couldn't.
00:11:12
I glimpsed it, and I couldn't look.
00:11:15
I had to turn away.
00:11:16
I turned the channel.
00:11:20
NARRATOR: Once the body is open, Dr. G's first priority is
00:11:24
to draw samples for toxicology.
00:11:27
Urine and eye fluid are collected,
00:11:29
which will give an indication of Vivian's glucose level
00:11:32
at the time of her death, and whether or not her sister
00:11:36
administered too much insulin.
00:11:38
I need to know what her glucose was.
00:11:40
I need to know if she was dehydrated.
00:11:43
I need to put all these things together still.
00:11:46
And so the toxicology and the chemistries on her eye fluid
00:11:49
are all going to play a major role.
00:11:51
I hope to have me put this all together.
00:11:55
NARRATOR: Then Dr. G prepares to draw blood from Vivian's heart.
00:12:00
If she developed a fatal infection
00:12:02
as a result of the dental surgery,
00:12:04
bacteria will surely be present in the samples.
00:12:08
It's very important that I get blood
00:12:10
right away for blood culture to see if there
00:12:13
is any bacteria growing.
00:12:15
I very gently open up the heart sac,
00:12:20
I go for the major blood vessels to try to remove some blood
00:12:26
and then put it in a blood culture tube,
00:12:28
to send to the lab, to see if it grows any bacteria.
00:12:31
I'm very careful.
00:12:32
I try to do this very sterilely.
00:12:35
A lot of people think that post mortem blood culture, because
00:12:38
of the bacteria kind of getting out of your gut,
00:12:40
going into your body, aren't worth anything.
00:12:44
But occasionally if you get the person fresh enough,
00:12:47
and you use good technique, you can
00:12:49
get either a single organism, meaning the one growing
00:12:52
in their blood, or you can get a negative meaning
00:12:56
nothing was there--
00:12:57
a non-contaminated specimen, which is helpful,
00:13:00
indicating they didn't have an overwhelming sepsis.
00:13:06
NARRATOR: However, no sooner does Dr. G begin drawing blood
00:13:09
samples from the heart than she makes
00:13:11
an unexpected finding, one that may change the course
00:13:15
of the entire autopsy.
00:13:17
Oh, brother.
00:13:18
She's got adhesions.
00:13:21
NARRATOR: In other words, there's scar tissue connecting
00:13:23
Vivian's heart and the pericardial sac,
00:13:26
the protective sheath surrounding the organ.
00:13:29
Pericardial sac was unusual in that there were
00:13:32
fibrous adhesions between the lining of the sac
00:13:35
and the top of her heart, and those are, like, little scar
00:13:38
tissues between the two.
00:13:41
That was important, because that indicates that she had
00:13:45
a pericarditis, or an inflammation of that heart
00:13:48
sac, which is interesting because that's
00:13:51
a common manifestation of Lupus.
00:13:56
NARRATOR: Lupus is a chronic inflammatory disease
00:13:58
that causes the body to attack its own tissues.
00:14:02
This, in turn, can trigger serious and sometimes
00:14:05
life-threatening complications.
00:14:07
Lupus has tremendous amount of manifestations.
00:14:10
It can kill you many different ways.
00:14:12
It could be the heart.
00:14:13
It could be the lungs.
00:14:14
It could be the brain.
00:14:15
It could be the kidneys.
00:14:16
All of those things can be affected by Lupus.
00:14:18
[OMINOUS MUSIC]
00:14:28
NARRATOR: Up to this point, Dr. G
00:14:30
has had no indication besides this finding
00:14:33
that Vivian was ever diagnosed with Lupus.
00:14:37
But could it be the ultimate cause of her death?
00:14:41
DR. G (VOICEOVER): Now I'm really
00:14:42
interested in that heart, because believe it or not,
00:14:45
one of the most common ways that Lupus can kill you acutely,
00:14:49
particularly if you've had it for a long time,
00:14:52
is by a heart attack, because it accelerates atherosclerosis,
00:14:56
or the plaque in the coronary arteries.
00:14:58
And even women, who are relatively
00:15:01
young like this woman, could have a severe atherosclerosis
00:15:05
and have a heart attack.
00:15:07
[MUSIC PLAYING]
00:15:09
NARRATOR: Dr. G's next step is to examine
00:15:12
the heart more closely.
00:15:14
DR. G (VOICEOVER): Her heart was a normal-to-small size.
00:15:18
And I look at the coronary arteries,
00:15:20
which atherosclerosis can be accelerated
00:15:23
in both Lupus and diabetes.
00:15:27
NARRATOR: But she finds no obvious damage to Vivian's
00:15:30
heart from either disease.
00:15:32
Her coronary arteries were completely normal.
00:15:34
Her heart muscle was a little soft,
00:15:37
and I'm not sure what that indicated.
00:15:40
It may be an infection, or it may be a myocarditis.
00:15:45
People with Lupus tend to have inflammation of the heart
00:15:48
tissue, but the heart doesn't appear
00:15:51
to be why she died, unless I find something microscopically.
00:15:57
NARRATOR: Next Dr. G turns to examine
00:15:59
Vivian's abdominal organs, looking for any signs
00:16:03
of disease or infection there.
00:16:07
But once again, she comes up empty handed.
00:16:11
DR. G (VOICEOVER): Well, internally,
00:16:12
I don't see much going on.
00:16:14
She's got some kidney changes.
00:16:17
She's got a fatty liver.
00:16:19
DR. G: But overall, nothing too bad-- certainly nothing that I
00:16:22
can see acutely killed her.
00:16:25
So I don't really see a cause of her death.
00:16:29
I mean, I was hoping that it would be more clear cut,
00:16:32
but I do know there are many things, that could have caused
00:16:37
her death, that I may not see.
00:16:38
The infection, I need to look under the microscope.
00:16:41
The myocarditis associated with Lupus,
00:16:43
I need to look under the microscope.
00:16:45
I need to check her levels of glucose in her eye fluid.
00:16:49
So many things are still possible that I still
00:16:53
need to do the investigation, and I
00:16:56
haven't done the head yet.
00:16:57
[MUSIC PLAYING]
00:17:00
[SAW GRINDING]
00:17:02
NARRATOR: Dr. G's morgue assistant, Sandi Ludwig,
00:17:05
opens Vivian Kaplin's skull.
00:17:07
DR. G (VOICEOVER): You know, there's
00:17:08
still possibilities that we could have had
00:17:11
the Lupus effect on the brain.
00:17:14
And we've certainly have had people come through here
00:17:17
with Lupus with bleeds in their brain, and that's why they die.
00:17:21
She could even have an infection.
00:17:23
DR. G: So I think that would be what I'd be most worried about.
00:17:26
[OMINOUS MUSIC]
00:17:29
DR. G (VOICEOVER): And I take the calvarium off.
00:17:33
Her brain's a little bit edematous,
00:17:35
a little bit swollen.
00:17:37
I cut the brain, and what I find is she
00:17:40
does have a bleed in her brain.
00:17:42
[OMINOUS MUSIC]
00:17:46
DR. G (VOICEOVER): But it's not the kind of hemorrhage
00:17:48
that would kill you.
00:17:49
It's just a small, little hemorrhage
00:17:52
maybe 8 millimeters by 3 millimeters
00:17:54
in the white matter.
00:17:57
It's certainly an acute event.
00:18:00
But how does this cause her death?
00:18:03
I'm not convinced it did, and I need to know how
00:18:07
these pieces all fit together.
00:18:09
DR. G: And I can't put it all together yet.
00:18:10
It's not making sense.
00:18:13
[MUSIC PLAYING]
00:18:27
[CART ROLLS]
00:18:30
NARRATOR: The autopsy of 42-year-old Vivian Kaplin
00:18:33
is over, but Dr. G still has no answers.
00:18:39
DR. G (VOICEOVER): I have some interesting history.
00:18:41
I have a few subtle findings.
00:18:43
DR. G: I have the small bleed in the brain
00:18:45
that probably didn't kill her.
00:18:48
It's certainly not big enough to kill her, but how does
00:18:50
that play a role?
00:18:51
OK.
00:18:52
DR. G (VOICEOVER): It really doesn't
00:18:53
[RUNNING WATER]
00:18:54
make much sense to me, so I need to put this all together.
00:18:58
NARRATOR: Dr. G has no choice at this stage but to append
00:19:01
the case until microscopic slides and toxicology
00:19:05
results are completed.
00:19:07
For Vivian's sister, still worried
00:19:09
that she may have been at fault, the wait will be agonizing.
00:19:14
DR. G (VOICEOVER): Well, this one, I told her sister,
00:19:16
I'm not sure. [SPRAYING WATER]
00:19:17
Either there's no clear-cut evidence of why she died,
00:19:19
and she's just going to have to give me time
00:19:21
to put this together.
00:19:24
I think I'm on the verge here of putting it together,
00:19:27
but I need a few more pieces to the puzzle.
00:19:32
NARRATOR: And after several long days,
00:19:34
these final pieces begin to trickle in.
00:19:37
[OMINOUS MUSIC]
00:19:40
First, microscopic slides confirm the effects of Lupus
00:19:44
in several internal organs, including
00:19:46
Vivian's brain and heart.
00:19:51
Her kidneys were also damaged by type 1 diabetes.
00:19:55
Still, there is no sign of infection in any of her organs
00:19:59
or blood, but then Dr. G reads through the toxicology results.
00:20:06
DR. G (VOICEOVER): That actually gave
00:20:07
me a huge piece of the puzzle.
00:20:09
And that was she was in diabetic ketoacidosis.
00:20:14
[OMINOUS MUSIC]
00:20:18
NARRATOR: The results are certain.
00:20:20
Vivian Kaplin died due to a life-threatening diabetic
00:20:24
complication known as ketoacidosis.
00:20:26
[INSTRUMENTAL MUSIC]
00:20:28
Insulin is the hormone, that is made by the pancreas, that
00:20:33
takes your blood sugar, your glucose,
00:20:35
and brings it into your cells, so your body
00:20:38
can use that for energy.
00:20:40
What happens is, without the insulin,
00:20:43
the glucose levels just keep getting
00:20:45
higher and higher in the blood, but your cells are starving.
00:20:50
Your cells don't have any energy.
00:20:51
So what happens is your body is going
00:20:54
to have to start breaking down other components,
00:20:57
like protein and fat, to get energy.
00:21:01
And the byproduct of breaking down that fat and protein
00:21:05
are fatty acids and eventually this production of acetone,
00:21:10
which is a very acidic substance, which, if it gets
00:21:13
high enough, can start denaturing
00:21:16
proteins-- causing body functions not
00:21:18
to work correctly.
00:21:19
And you can go into a coma and die, and this is why she died.
00:21:27
NARRATOR: And yet this finding defies logic.
00:21:30
DR. G (VOICEOVER): Something is causing this blood
00:21:32
sugar to go out of whack.
00:21:34
But why?
00:21:35
You know, she supposedly takes insulin just an hour
00:21:37
or two before this happens.
00:21:39
It really doesn't make much sense to me.
00:21:42
[INSTRUMENTAL MUSIC]
00:21:44
NARRATOR: Now all Dr. G can do is
00:21:46
take a step back, revisiting the finding she's gathered to date.
00:21:51
DR. G (VOICEOVER): When I worry about diabetic ketoacidosis,
00:21:53
I also then have to think about what triggered
00:21:58
the diabetic ketoacidosis.
00:22:01
NARRATOR: And it isn't long before she hits on a seemingly
00:22:04
inconsequential clue, one that not only explains Vivian's
00:22:08
sudden decline but can finally put
00:22:10
to rest the question of her sister's role
00:22:13
in this tragic chain of events.
00:22:27
In the midst of a Florida heat wave,
00:22:29
42-year-old Vivian Kaplin travels out of state to undergo
00:22:33
radical dental surgery.
00:22:36
But Vivian is a type 1 diabetic, so she
00:22:39
must take daily insulin injections to keep her blood
00:22:42
glucose levels in check.
00:22:44
According to her sister, Vivian carried her insulin kit
00:22:48
in her bag on the trip.
00:22:49
[DRILLING]
00:22:51
DR. G (VOICEOVER): She does well with her extractions,
00:22:53
getting all her teeth pulled in about five days.
00:22:56
She takes the trip back.
00:22:58
She's not having any problem.
00:23:00
When she gets home, she goes to bed.
00:23:03
But lo and behold, early that next morning
00:23:07
though, she wakes up.
00:23:08
She's not feeling well.
00:23:10
She thinks her blood sugar is low.
00:23:14
NARRATOR: But Vivian is wrong.
00:23:16
She isn't feeling well, because as Dr. G discovered in autopsy,
00:23:19
she just suffered a minor stroke triggered by her Lupus.
00:23:24
One of the most common reasons for somebody
00:23:27
to go into diabetic ketoacidosis would
00:23:29
be major stressful events to your body,
00:23:32
like maybe a stroke, a heart attack--
00:23:35
all of those things are known to precipitate going
00:23:39
into diabetic ketoacidosis.
00:23:41
[OMINOUS MUSIC]
00:23:43
NARRATOR: In this case, the stress of the minor stroke
00:23:46
may have been the cause of a sudden and catastrophic spike
00:23:49
in Vivian's glucose level, but Vivian misinterprets
00:23:53
her symptoms as low blood sugar and drinks a fruit juice, which
00:23:57
only adds insult to injury, further
00:24:01
elevating her blood sugar.
00:24:03
DR. G (VOICEOVER): Lo and behold,
00:24:04
when she tests her blood sugar after that, it's really high,
00:24:07
like over 500.
00:24:09
Then at that point, she knew she needed to get some insulin.
00:24:14
NARRATOR: The insulin injection should
00:24:16
help to normalize Vivian's glucose level, but it doesn't.
00:24:22
While it's possible that her sister administered
00:24:24
an incorrect dosage, Dr. G believes there
00:24:27
may be another explanation.
00:24:30
DR. G (VOICEOVER): The insulin that they
00:24:32
gave her was the same insulin she had taken on that ride up
00:24:38
to Georgia to get her teeth pulled,
00:24:41
and it wasn't refrigerated.
00:24:53
NARRATOR: Dr. G now wonders if the insulin, which could have
00:24:56
saved Vivian's life, might have been rendered less effective,
00:25:00
given its exposure to excessive heat.
00:25:03
DR. G (VOICEOVER): Insulin, if it's exposed to heat,
00:25:05
it will lose its effectiveness.
00:25:07
Now I would have loved to have tested that,
00:25:10
but it's very difficult to test for that kind of insulin
00:25:13
in her body after death.
00:25:16
So at this point it's only a theory,
00:25:18
but I think it's an appropriate theory.
00:25:22
So we have everything going on here.
00:25:24
We have a stroke that's probably precipitating her blood sugar
00:25:27
to go up, but then we have the insulin, which probably isn't
00:25:32
very effective because she had it exposed
00:25:35
to some high temperatures.
00:25:37
NARRATOR: Because her body can no longer utilize glucose
00:25:40
for fuel, it begins to break down
00:25:43
fat and protein for energy.
00:25:45
DR. G (VOICEOVER): That causes her blood
00:25:46
to get very acidic, which then spirals into her going
00:25:50
into diabetic ketoacidosis.
00:25:54
Her sister comes back in to check on her
00:25:56
and realizes she has passed out.
00:25:59
She calls 911.
00:26:01
They try to revive her, but it's too late.
00:26:04
Her body had already shut down.
00:26:05
She wasn't breathing.
00:26:06
She's got edema in her brain, so there is nothing
00:26:10
they could do to save her.
00:26:16
Hi, there.
00:26:17
She is right here.
00:26:19
You're welcome.
00:26:20
NARRATOR: With the puzzle of Vivian's sudden death solved,
00:26:23
Dr. G calls Vivian sister to explain her findings
00:26:27
and to reassure her that she was not at fault.
00:26:31
DR. G (VOICEOVER): The sister did the best she could.
00:26:33
DR. G: She feels bad about that insulin,
00:26:36
but nobody thought about that until after the fact.
00:26:39
And hindsight is always 20/20.
00:26:42
OK, but just so you know, you know, how this all plays out,
00:26:46
it's kind of complicated.
00:26:49
OK, just so you know we're on the same page.
00:26:53
OK.
00:26:54
OK.
00:26:55
Bye, bye.
00:26:57
She fully understands the complexity of the case.
00:27:01
Only because of your ability to communicate, doctor.
00:27:05
We're so proud.
00:27:07
My chest swells.
00:27:08
DR. G: Oh, you get out.
00:27:09
[MUSIC PLAYING]
00:27:24
DR. G (VOICEOVER): You know, I take away that sometimes
00:27:28
just unfortunate things happen.
00:27:30
We can try our best to stay as healthy as we can,
00:27:34
but nobody knows what causes Lupus.
00:27:37
Nobody really knows what triggers type 1 diabetes.
00:27:41
Then it just shows how, for those of us who don't have
00:27:46
these devastating diseases, we should
00:27:48
be thankful for our health.
00:27:50
And those that do, they need to work
00:27:54
as hard as they can to stay as healthy as they can,
00:27:56
because they can.
00:28:04
[OMINOUS MUSIC]
00:28:09
NARRATOR: Dr. G knows that most people do what they can to try
00:28:12
to avoid a premature death.
00:28:13
[MUSIC PLAYING]
00:28:14
But in our next case, it seems that death may be exactly
00:28:18
what the decedent wanted.
00:28:20
DR. G (VOICEOVER): You know, I feel bad for the family,
00:28:21
because maybe they could have prevented this.
00:28:24
Maybe they should have been more attuned to what
00:28:26
she was going through.
00:28:31
[OMINOUS MUSIC]
00:28:43
[INSTRUMENTAL MUSIC]
00:28:46
STAFF: Oh, he's the owner.
00:28:47
He's the owner?
00:28:48
NARRATOR: Chief investigator Steve Hanson
00:28:50
is responsible for leading the death investigations
00:28:53
at the district 9 morgue.
00:28:56
Today, however, he's checking on a new purchase
00:28:59
he made, for Dr. G and her staff,
00:29:01
to possibly replace towels in the morgue with sea sponges.
00:29:06
Everybody that I talked to seems to think they're
00:29:08
a good idea.
00:29:09
How expensive?
00:29:10
STEVE HANSON: Well, they're supposed
00:29:11
to last like a long, long time.
00:29:13
I didn't say how long they were going to last.
00:29:14
I said how expensive.
00:29:15
I think we bought six of them for $120.
00:29:19
NARRATOR: But a decision on sponges versus towels
00:29:21
will have to wait.
00:29:23
Dr. G's priority at the moment is her next case,
00:29:27
the unexplained death of a 69-year-old woman
00:29:31
named Rose Paxton.
00:29:32
[OMINOUS MUSIC]
00:29:43
DR. G: OK.
00:29:48
NARRATOR: Reading through the investigator's report,
00:29:50
Dr. G learned that Rose was a retired Orlando
00:29:53
teacher, who'd recently been struggling with depression.
00:29:57
DR. G (VOICEOVER): She had lost her husband about
00:29:58
a year and a half earlier.
00:30:00
She was really grieving over that,
00:30:02
but she seemed to go on beyond grieving.
00:30:05
Her family was very worried about her.
00:30:09
NARRATOR: Concerned, her son Jason and his family
00:30:12
traveled to Orlando to visit her.
00:30:16
DR. G (VOICEOVER): They came to spend some time with her,
00:30:20
to try to get her out of the house
00:30:22
and just see what was going on.
00:30:25
Things seemed fine.
00:30:28
She, you know, did seem depressed,
00:30:30
but she went out with them and had been having fun, at least
00:30:34
going to the attractions with them.
00:30:36
NARRATOR: But by the time the family
00:30:38
returns home later that evening, Rose is feeling very fatigued
00:30:42
and decides to turn in early.
00:30:45
She stays in her room the rest of the night.
00:30:48
[MUSIC PLAYING]
00:30:49
[BIRDS CHIRPING]
00:30:53
DR. G (VOICEOVER): The next morning, her grandson
00:30:55
came in to wake her up for breakfast,
00:30:56
and she was found unresponsive.
00:30:59
Then he immediately went and got his dad, and she was dead.
00:31:04
They called 911, but there was nothing they could do.
00:31:08
And they pronounce her in the home.
00:31:14
NARRATOR: For Rose's family, the unexpected loss is devastating.
00:31:19
Well, at this point, the family just has a hard time
00:31:22
accepting that she died.
00:31:24
They were very surprised-- very unexpected for that family.
00:31:28
To them, she was a picture of health.
00:31:31
She'd just gone to the doctor about a month
00:31:35
or so prior to her death, and according to the son,
00:31:39
he had given her a clean bill of health.
00:31:42
And so they're very worried about her depression
00:31:45
and that maybe she committed suicide.
00:31:47
[OMINOUS MUSIC]
00:31:51
NARRATOR: Rose's family is particularly concerned
00:31:53
that she may have overdosed on one
00:31:55
of the many over-the-counter medications in the house.
00:32:06
Elderly people do have a higher suicide rate
00:32:10
than the general population.
00:32:12
You know, if you take all the elderly people over 60 to 85,
00:32:15
it's about, you know, between 14 and 15 per 100,000 population,
00:32:20
while the general population is close to 11
00:32:23
per 100,000 population.
00:32:25
So they have an increased rate of suicide.
00:32:28
DR. G (VOICEOVER): When the family brings something
00:32:29
like that up, that's usually a red flag for me,
00:32:34
because they'll usually underplay that.
00:32:37
And the fact that they brought it up to me,
00:32:39
and that they were worried about it, I have to worry about it.
00:32:48
[MUSIC PLAYING]
00:32:51
DR. G (VOICEOVER): Well, I had to agree with the family.
00:32:54
She looked pretty good.
00:32:56
She looked like she was sleeping,
00:32:58
and she looked like she taking care of herself.
00:33:01
I see no trauma on her.
00:33:03
I see no swelling in her legs.
00:33:05
I see someone that looks like they just went to sleep.
00:33:10
I mean, some people will come through my morgue,
00:33:12
and you'd think, well, they're all dead.
00:33:13
They can't look that good.
00:33:14
But some people look sick, and some people look pretty good.
00:33:18
She looked pretty good.
00:33:20
NARRATOR: Dr. G notices that Rose still
00:33:23
wears her wedding ring even though her husband
00:33:25
died more than a year ago.
00:33:27
DR. G (VOICEOVER): She's still cares
00:33:29
very much for her husband.
00:33:31
I see that in most widows that they're still
00:33:33
wearing their wedding band.
00:33:36
Let's see her mouth.
00:33:39
NARRATOR: As a first step, Dr. G inspects
00:33:42
the inside of Rose's mouth.
00:33:44
Some drugs can leave traces on the surface of the tongue.
00:33:48
Sometimes you take a lot of pills,
00:33:50
they'll leave some discoloration.
00:33:52
And I looked even for seizure activity-- bite marks
00:33:55
to the cheeks or the tongue.
00:33:58
I don't see really much of anything except someone who
00:34:01
looks pretty good for her age, and whose of normal weight,
00:34:05
and no evidence of trauma or natural disease externally.
00:34:09
So we really have a clean slate.
00:34:11
But, you know, keep in mind, you never
00:34:13
know what you're going to find.
00:34:18
[MUSIC PLAYING]
00:34:38
NARRATOR: Dr. G prepares to open the body
00:34:40
of 69-year-old Rose Paxton.
00:34:43
Her family fears she was driven to commit suicide
00:34:46
over the recent death of her husband,
00:34:49
and now it's up to Dr. G to find out.
00:35:02
You ready?
00:35:05
In this case, I do my Y-incision,
00:35:08
you know, always hoping that I can
00:35:10
tell right away why somebody died,
00:35:12
and I don't see much of anything.
00:35:14
[ELECTRICAL EQUIPMENT]
00:35:15
DR. G (VOICEOVER): Once I see the general look of what
00:35:17
the chest and abdominal cavity look like,
00:35:19
I will remove blood for my toxicology.
00:35:22
I'm worried about that this is suicide
00:35:25
and a possible overdose.
00:35:28
[MUSIC PLAYING]
00:35:31
NARRATOR: Next Dr. G begins removing each
00:35:34
of Rose's internal organs for closer inspection,
00:35:37
starting with the heart.
00:35:41
If an overdose didn't kill her, there's
00:35:43
a good chance her heart did.
00:35:46
DR. G (VOICEOVER): Now this is where I think the money is.
00:35:48
You know, somebody died suddenly and unexpectedly--
00:35:50
69 years old.
00:35:51
Oh, I'm going to find heart disease.
00:35:54
DR. G (VOICEOVER): I take out her heart.
00:35:55
Her heart is of normal size.
00:35:58
It's not enlarged.
00:36:02
I do a very careful dissection of her coronary arteries.
00:36:10
There was no narrowing to those coronary arteries.
00:36:15
DR. G (VOICEOVER): The heart muscle, to me, looked fine.
00:36:17
The heart valves looked fine.
00:36:19
You can die suddenly and unexpectedly
00:36:21
with a narrowed aortic valve.
00:36:24
We see that sometimes.
00:36:25
Let's see what's going on here.
00:36:29
Anything interesting around here?
00:36:30
I look at the other organs.
00:36:32
I look at her lungs.
00:36:34
There is no evidence of disease to her lungs.
00:36:36
You can clearly see she didn't smoke.
00:36:38
I look at her liver.
00:36:39
I look at her spleen and her kidneys,
00:36:42
and I don't really find much of anything,
00:36:46
in her chest and abdomen, that would have caused her death.
00:36:50
Internally, everything looks great.
00:36:54
NARRATOR: Next Dr. G turns to inspect
00:36:56
the contents of Rose's stomach.
00:36:59
DR. G (VOICEOVER): The stomach contents is of importance
00:37:01
to me, because I want to see-- sometimes we'll
00:37:03
have residual pills, or material that they've ingested,
00:37:07
where the levels will go up.
00:37:09
Like, part of it will be digested to the point where it
00:37:12
will kill her, and there'll still be some of those pills
00:37:15
left in the stomach.
00:37:16
DR. G: Oh, brother.
00:37:17
That's not very good.
00:37:26
There's really nothing here.
00:37:30
Everything looks good.
00:37:32
In this case, she really didn't
00:37:33
have much in her stomach.
00:37:35
A little autolysis-- you know, the mucosa,
00:37:37
or the lining of the stomach, was starting to break down.
00:37:40
Very common finding at autopsy--
00:37:42
but not much stomach contents.
00:37:45
Just a little bit of liquid in the stomach.
00:37:47
I certainly don't see any food.
00:37:49
I don't see any pill fragments.
00:37:51
It is consistent with her dying during her sleep in bed,
00:37:57
you know, sometime after she'd eaten,
00:37:58
because her food is clearly digested out of her stomach.
00:38:03
So at this point, I carefully looked at her heart.
00:38:06
I carefully looked at her stomach contents.
00:38:09
I don't really find any disease anywhere.
00:38:12
So far, her family's looking correct.
00:38:14
She seems the picture of health.
00:38:16
[MUSIC PLAYING]
00:38:20
You know, at this point, I don't have a cause of death.
00:38:23
And it would be nice to just end this, and not keep looking,
00:38:26
and find something in her brain.
00:38:29
Certainly, an inner cerebral hemorrhage
00:38:31
or an embolic stroke, I think everybody would feel
00:38:34
happy with that just knowing their mom
00:38:37
didn't commit suicide, and that it was sudden and painless.
00:38:42
So I'm hoping along that line.
00:38:47
[SAW RUNNING]
00:38:51
NARRATOR: Morgue technician, Tom Hemphill,
00:38:53
uses the oscillating saw to open Rose's skull.
00:39:01
I'm going to use this.
00:39:04
And then I need the--
00:39:05
DR. G (VOICEOVER): I open her calvarium.
00:39:10
I'm OK.
00:39:11
I'm OK.
00:39:12
DR. G (VOICEOVER): Nothing looks abnormal on the surface.
00:39:19
I slice the brain very carefully,
00:39:22
and I do find a lacunar infarct.
00:39:29
NARRATOR: A lacunar infarct is a small stroke, typically
00:39:33
less than 1.5 centimeters, which occurs in the deeper
00:39:37
parts of the brain.
00:39:39
DR. G (VOICEOVER): It's basically a tiny little stroke.
00:39:41
It looked like it was in the process of healing.
00:39:44
It still had some swelling around it.
00:39:47
I'm not really sure what that lacunar infarct
00:39:49
is telling me at this point.
00:39:52
They're sometimes considered associated with high blood
00:39:55
pressure, diabetes, but we don't tend to see
00:39:58
those as a cause of death.
00:40:08
Well, we finished the autopsy.
00:40:10
I thought she surely would have had a heart disease,
00:40:13
but her heart looked pretty good.
00:40:17
So it's tox and microbes.
00:40:19
We don't have a cause of death, and I am-- unfortunately,
00:40:23
I have to call the family and tell them we're going to have
00:40:25
to wait for the toxicology.
00:40:27
And, you know, I feel bad for the family,
00:40:30
because not finding a cause of death at autopsy,
00:40:33
not finding natural disease, makes them more anxious
00:40:37
that maybe it was suicide.
00:40:38
Maybe they could have prevented this.
00:40:40
Maybe they should have been more attuned to what
00:40:43
she was going through.
00:40:47
We'll see.
00:40:52
[OMINOUS MUSIC]
00:41:06
NARRATOR: At the Wuesthoff lab in Melbourne, Florida,
00:41:09
technicians have just completed a blood
00:41:11
sample and body fluid analysis on 69-year-old Rose Paxton.
00:41:18
The results are delivered directly to Dr. G.
00:41:22
DR. G (VOICEOVER): Well, I think the toxicology
00:41:24
will be very interesting.
00:41:26
Basically, we're looking at all those drugs
00:41:28
that she could possibly have taken to kill her.
00:41:32
[ELECTRONIC MUSIC]
00:41:34
We've tested thousands of drugs, and when we test.
00:41:37
We certainly look at the illicit drugs,
00:41:39
but we also screen that blood in a way that
00:41:44
checks for just thousands of different types
00:41:47
of drugs that aren't illicit.
00:41:50
And it was completely negative.
00:41:55
NARRATOR: It's official Rose Paxton did not commit suicide.
00:42:00
The news will undoubtedly bring welcome relief
00:42:02
to Rose's family, but for Dr. G, the results
00:42:07
only bring a deepening sense of frustration.
00:42:10
DR. G (VOICEOVER): What's really going to be bad,
00:42:12
and it happens in a small percentage of cases,
00:42:15
we never find out why she died.
00:42:18
And I'm hoping it's not that.
00:42:23
NARRATOR: But at this point, all Dr. G has left to examine
00:42:27
are microscopic slides of Rose's internal organs.
00:42:31
DR. G: I get really surprised at microscopic examinations.
00:42:35
Because if it looks normal to my eye,
00:42:38
it usually is normal under the microscope.
00:42:42
So I didn't have high hopes for the microscopic examination.
00:42:46
Certainly, the liver looked normal.
00:42:49
I look at her kidneys.
00:42:50
I'm looking for evidence of high blood
00:42:52
pressure, even long-term diabetes that wasn't diagnosed.
00:42:56
Her kidneys look good.
00:42:58
I look at all these organs, and they look good except for one.
00:43:02
And that was her heart muscle.
00:43:05
NARRATOR: Staring at the slide, Dr. G
00:43:07
can now say exactly why Rose Paxton died
00:43:11
even though it's a cause of death
00:43:13
she has never diagnosed before.
00:43:23
It's Saturday May 14, and Rose Paxton
00:43:26
is spending a busy day, with her son and grandchildren,
00:43:29
visiting the sites of Orlando.
00:43:32
Her family is worried that she's suffering from depression
00:43:35
due to the recent loss of her husband,
00:43:38
and they hope the activity will brighten her spirits.
00:43:42
But today, Rose faces a much more
00:43:44
dire problem, one that she and her family
00:43:47
are completely unaware of--
00:43:51
a heart ravaged by small vessel disease.
00:43:55
Her heart muscle looked really bad.
00:43:58
It was quite remarkable.
00:44:01
NARRATOR: Under the microscope, Dr. G
00:44:03
discovers that the tiny blood vessels within her heart muscle
00:44:07
had become significantly narrowed.
00:44:10
DR. DARLENE GO: The smaller materials become spastic.
00:44:12
These small spasms that basically choke the vessels
00:44:17
that give oxygen to the heart.
00:44:19
And while that happens, your heart
00:44:20
cannot function without oxygen.
00:44:23
NARRATOR: The reduction in blood flow
00:44:24
causes muscle cells to die off one
00:44:27
by one, resulting in a buildup of dangerous scar tissue.
00:44:32
DR. G: They're little, tiny, basically heart attacks
00:44:34
just a few cells at a time.
00:44:36
And when you start having this increase in fibrous tissue
00:44:42
and this decrease in blood flow, you
00:44:44
are at risk for a sudden cardiac arrhythmia.
00:44:48
NARRATOR: Small vessel disease typically
00:44:50
strikes postmenopausal women like Rose,
00:44:53
but it is very difficult to detect
00:44:55
with standard cardiac tests.
00:44:57
And doctors are still unsure of its cause.
00:45:01
DR. DARLENE GO: The small vessels, you don't see.
00:45:03
Therefore, it's very difficult to diagnose that they are
00:45:06
dysfunctional until, down the road,
00:45:08
you do all the workup with persistent symptoms.
00:45:11
And most of the workup does not show anything.
00:45:13
There used to be a debate whether this small vessel
00:45:17
disease really was even a risk factor for sudden death
00:45:21
or bad outcomes.
00:45:22
It used to be thought, no.
00:45:25
In fact, there was a percentage of women that would be having
00:45:28
chest pain, that would go to a cardiologist,
00:45:31
would get a cardiac catheterization where
00:45:33
they put the dye through the coronary arteries.
00:45:35
They'd have completely normal coronaries.
00:45:38
And they'd send them on their way,
00:45:40
saying, well, it just must be anxiety--
00:45:43
you know, just in your head.
00:45:45
Then over the past few years, they're
00:45:47
starting to see, no, you don't have to worry about it.
00:45:51
It is associated with sudden death.
00:45:54
It is associated with heart disease.
00:45:58
[MUSIC PLAYING]
00:46:01
NARRATOR: However, in Rose's case
00:46:03
her symptoms were so vague, only mild fatigue,
00:46:07
that she didn't even realize anything was wrong.
00:46:10
Now this woman is interesting, because we
00:46:12
don't have any history of any kind of chest pain.
00:46:15
But we certainly have microscopic evidence
00:46:18
of the heart muscle dying off.
00:46:20
So when you put two and two together
00:46:22
with no other cause of death, negative toxicology,
00:46:25
it really points to this as her cause of death.
00:46:30
NARRATOR: That night at home with her family,
00:46:32
Rose doesn't know it, but her heart is failing.
00:46:36
She feels tired and goes to bed early,
00:46:38
looking forward to another day with her family,
00:46:42
but she won't live to see morning.
00:46:45
Dr. G believes that, sometime during the night as Rose is
00:46:49
sleeping, her damaged heart suddenly falls
00:46:52
into a deadlier arrhythmia.
00:46:53
[HEART PUMPING]
00:46:54
Instead of pumping, it quivers.
00:46:57
DR. G: There is a tremendous amount of scar
00:46:59
tissue in that heart muscle.
00:47:01
The electrical system kind of goes out of whack.
00:47:04
The heart can't pump.
00:47:05
And the blood doesn't get to her brain, and she dies.
00:47:09
[OMINOUS MUSIC]
00:47:21
NARRATOR: Dr. G is certain that Rose's death
00:47:23
was a result of natural causes and not suicide.
00:47:29
Her last step is to call the family
00:47:31
and inform them of her findings.
00:47:34
DR. G (VOICEOVER): They were so thankful that they
00:47:35
didn't have to worry that she committed suicide--
00:47:38
that they should have picked up on things.
00:47:41
And they felt bad that she died of that.
00:47:43
But, you know, when you don't have symptoms,
00:47:45
and you're not complaining, there was really nothing
00:47:48
they could have done for her.
00:47:49
[INSTRUMENTAL MUSIC]
00:48:16
DR. G (VOICEOVER): You know, when you see this--
00:48:18
and this is probably the first case
00:48:20
of small vessel disease, that was causing the death,
00:48:23
that I've autopsied.
00:48:25
There are so many ways your body can eventually cause you
00:48:33
to die, and there's so many ways your body
00:48:35
can eventually betray you.
00:48:39
But you have to remember so many of those ways
00:48:43
are still associated with us betraying our body
00:48:45
and what we do to our body.
00:48:47
[SPRAYING WATER]
00:48:48
And, you know, it's kind of a give-and-take.
00:48:50
Your body will try to stay good to you
00:48:53
if you stay good to your body, but sometimes, no matter what
00:48:56
we do, bad things still happen.
00:49:02
Destroying all the evidence.
00:49:05
[MUSIC PLAYING]
