04x05 - Deadly Journeys

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[music playing]

NARRATOR A young woman is stricken with a sudden illness

while on vacation in Orlando.

JAN GARAVAGLIA Her chest hurt.

She's actually coughing up some blood.

NARRATOR Within only hours, she dies in the hospital.

JAN GARAVAGLIA She codes.

And they don't have a cause of death.

NARRATOR But her k*ller shocks even Dr. G.

It is just something I probably will

never see in the morgue again.

NARRATOR And then a hitchhiker turns up

dead in a deserted parking lot.

And the only witness to her death could be the m*rder*r.

Whenever I have a woman who is dead in the presence

of a stranger, you know, I'm a little worried.

I don't know whether they need to arrest this guy or not.

The sooner we figure out what happened to her,

the sooner the police can work on apprehending somebody.

NARRATOR Altered lives, baffling medical mysteries,

shocking revelations.

These are the everyday cases of Dr. G, medical examiner.

Orlando, Florida, is a popular vacation

destination for millions of Americans

and many visitors from overseas.

Unfortunately, not all of the trips to the Sunshine State

end happily.

Each year in Orlando and Osceola counties

alone, approximately foreign tourists

die unexpectedly during their visit

and will require an autopsy to determine the cause

and manner of their death.

The final destination for these individuals

is the District morgue in downtown Orlando,

the Office of chief medical examiner Dr. Jan Garavaglia.

Today, her first case is the death of a -year-old woman

named Maribel Simon, who had just

arrived in Orlando from abroad when she d*ed unexpectedly.

She's from Antigua.

And she gets here and she's going to go out for breakfast

with her family this morning.

But she starts getting really out

of breath, sweating heavily, chest pain,

and she's coughing up blood.

NARRATOR According to the investigator's report,

a seemingly healthy Maribel Simon arrived in the US

to visit her family in Orlando just two days ago.

But shortly after her arrival, Maribel

begins feeling extremely sick.

Alarmed, her family rushes her to the ER, where doctors fear

she may be suffering from a pulmonary embolism,

a potentially fatal blood clot in the lungs' pulmonary artery.

They immediately take Maribel in for emergency diagnostic tests.

Unfortunately, she doesn't even make it to the exam room.

JAN GARAVAGLIA They were taking her in

to do the test for a VQ scan.

And that's one of the tests where they check to see

if she has pulmonary emboli.

And as they were taking her into that test,

they actually were taking off her oxygen mask,

and that's when she coded and d*ed.

NARRATOR Maribel's death has left her family wheeling

with anguish and disbelief over the sudden loss

of their loved one who was so far

away from home when she d*ed.

JAN GARAVAGLIA That's scary.

Because all of a sudden, you know,

their loved one, once they die, will be taken away from them.

And they don't know where they're going.

They don't know what these people are like.

NARRATOR Hoping to find answers,

Dr. G reviews the timeline and circumstances

of the young woman's death.

She finds the onset of symptoms--

chest pain, coughing up blood, and difficulty

breathing-- consistent with a pulmonary embolism,

making it a strong suspect in the case.

Moreover, as Dr. G reads through the case file,

she discovers that Maribel also had

a key risk factor for developing a pulmonary embolism--

a protracted -hour airline flight

the day before her death.

Some studies have linked air travel

lasting over eight to hours to an increased

risk of developing a pulmonary embolism.

People who are immobile and aren't walking around,

they're not contracting their muscles,

can develop thrombi in their vessels,

the deep vessels of the leg, and they go into the thigh.

And these can break off then once to start getting mobile.

And they can break off and then go to the lung.

And that's high on our list.

So we'll have to see.

I mean, her symptoms are good for a pulmonary embolism.

So I think, you know, maybe there's a good chance

that's what it is.

NARRATOR Dr. G has not yet received

Maribel's medical records.

But she has been in touch with Maribel's physician, who

is stunned by her sudden death.
[ … ]

He reports that Maribel was a relatively healthy woman,

a non-smoker and non drinker.

But he also discloses to Dr. G that, over the past few months,

Maribel had begun to take prescription steroids to treat

lupus, a disease of the immune system,

which she had been diagnosed with several years ago.

lupus is one of the classic autoimmune diseases.

Autoimmune is basically, your body starts forming antibodies

against your own body.

NARRATOR Maribel's lupus was apparently mild and managed

effectively with medication.

JAN GARAVAGLIA I talked to the doctor specifically,

her rheumatologist.

And she said her lupus seemed mild.

And we have to admit, I mean, lupus

is something relatively uncommon we would see down here.

NARRATOR Nevertheless, for Dr. G, the disclosure is vital.

While lupus is rarely fatal, the dr*gs used to treat the disease

have significant and deadly risks, such as stomach ulcers

and gastrointestinal bleeding.

Perhaps Maribel's symptoms were not

from a pulmonary embolism after all,

but fatal internal bleeding from steroids.

You know, it states that she's coughing up blood.

There's blood in the mouth when she gets to the emergency room.

Occasionally, we see people who can't tell where

that blood is coming from.

And they're actually getting it from their GI tract.

So we'll have to see.

What else did they say?

NARRATOR A pulmonary embolism, internal bleeding, steroids.

In this case, it will take a full autopsy

to know for sure what cut Maribel

Simon's life short, beginning with the external examination.

Dr. G examines Maribel's body.

She notes right away that her lupus does seem mild,

as the doctor indicated.

JAN GARAVAGLIA I don't see any of the classic, you know,

findings of lupus.

I don't see any-- you know, the discoid rash,

the malar rash on the face.

NARRATOR Approximately % to % of all patients

with lupus develop a malar, or a butterfly rash across the face.

Oral ulcers are also a common complication of lupus.

But Dr. G finds no sign of them either.

What she does discover, however, is that Maribel's lower

extremities are swollen with edema, or fluid, which

can indicate a blood clot in the legs, the prelude

to a pulmonary embolism.

JAN GARAVAGLIA We will often measure

the circumference of the leg.

And classically, what we would see

is, one leg maybe a little more edematous than the other,

because you tend to have it in maybe one than the other.

When I do the external on her, we do see swelling.

It's bilateral.

So maybe she does, maybe she doesn't.

NARRATOR Is the swelling a harbinger?

Did Maribel Simon die from a pulmonary embolism?

The answer might lie in Dr. G's next stop,

Maribel's heart and lungs.

That's what she was complaining of-- shortness

of breath and chest pain.

NARRATOR Dr. G and her staff are

ready to begin the internal examination

of -year-old Maribel Simon, who d*ed

while on vacation in Orlando.

JAN GARAVAGLIA She came to visit family.

She was going to hang out with some of her family members.

They were going to have fun down here.

And she certainly didn't expect to die that morning.

NARRATOR Dr. G opens Maribel's body with a Y incision.

Her first step is to examine the organs

in situ, or in their natural position within the body.

While it is suspected that Maribel d*ed

from a pulmonary embolism, there is still a possibility

that she succumbed to gastrointestinal bleeding

from therapeutic steroid use.

Dr. G methodically searches for any signs

of internal hemorrhage.

JAN GARAVAGLIA Her GI track I look at.

And her stomach's very dilated.

But that's from the resuscitation.

It's mostly air.

But I really don't see anything like an ulcer

or anything along that line.

NARRATOR Dr. G finds nothing suspicious in the abdomen.

At this point, she does not believe that Maribel d*ed

from gastrointestinal bleeding.

Next, she needs to examine the respiratory organs.

One of the things I'm going to look at very, you know,

closely is going to be her heart and lungs.

Because that's what she was complaining of-- shortness

of breath and chest pain.

So is it the heart?

Is it the lung?

I'm not sure?

NARRATOR Dr. G opens the chest cavity

and gets her first look at the lungs.

What she sees takes her aback.
[ … ]

Maribel's lungs are very diseased.

What I see is some dilated large vessels and

some little bit of hemorrhage.

NARRATOR The delicate pulmonary tissue is ravaged.

But why?

JAN GARAVAGLIA It's unclear what I'm seeing in the lung.

The lungs don't look completely normal.

But they don't look infectious either.

NARRATOR A pulmonary embolism may explain part of the damage

to the lung tissue.

But as Dr. G searches for a clot,

she comes to a shocking realization.

I open the pulmonary artery and I don't

see any pulmonary embolism.

It's not a pulmonary embolism that k*lled her.

NARRATOR The seemingly straightforward case

of Maribel Simon has suddenly become a conundrum.

And when she examines Maribel's heart,

the death investigation becomes even more mysterious.

JAN GARAVAGLIA Something else is odd,

in that her right side of her heart

is very thickened and somewhat dilated.

So she's got right ventricular hypertrophy.

That's odd.

NARRATOR Right ventricular hypertrophy

is a heart condition in which the right side of the heart

is abnormally large and dilated.

Certain lung diseases can cause right ventricular hypertrophy,

such as chronic obstructive pulmonary disease

and emphysema.

But according to Maribel's physician,

she did not have any of these lung disorders,

which leaves Dr. G perplexed.

JAN GARAVAGLIA Something's going on in her lungs.

And I'm not quite sure.

I can't tell what it is until I look under the microscope.

So I take a lot of samples, biopsies of that lung,

to see what's going on.

NARRATOR As Dr. G finishes examining Maribel's

internal organs and collecting tissue samples,

findings continue to baffle.

Some organs, such as Maribel's brain and pancreas,

appear normal.

I certainly don't see meningitis.

I don't see a stroke.

I don't see bleed.

NARRATOR Others, such as her spleen

and kidneys in particular-- are quite diseased.

JAN GARAVAGLIA I look at her kidneys.

They were very scarred.

And so I need to look at those under the microscope too.

NARRATOR At the end of the autopsy,

Dr. G is left with many findings, but few explanations.

Well, the end of the autopsy externally and internally,

and reviewing her medical history with her doctor,

it's unclear why she d*ed.

I'm going to have to pend it until I look

at the microscope at her tissues to be able to figure

out what's going on.

NARRATOR In this case, microscopic examination

of tissue samples may be key.

But the slides will take several days to prepare.

And when they do finally arrive, Dr. G is in for a shock.

It is just something I probably will

never see in the morgue again.

NARRATOR Several days after the autopsy of -year-old Maribel

Simon, arrangements for the transport of her body

to her family in the Caribbean are finalized,

and it is released from the morgue.

JAN GARAVAGLIA Most people who die

here who are foreign nationals do not want to be buried here.

They want to go back to where they came from.

Their loved ones want to take them

back to their home country.

NARRATOR Later that day, Dr. G receives

the slide she has been waiting for,

the samples of Maribel's damaged internal organs.

I think the microscopic examination is

going to be key in this case.

NARRATOR First, Dr. G examines the lung tissue

samples under the microscope.

And what she sees astonishes her.

There's something in her vessels there.

NARRATOR Maribel's lung tissue is hemorrhaged.

In addition, the blood vessels in her lungs

are inflamed and narrowed, a condition known as vasculitis.

So when I look in the microscope,

I look, and I do see signs that she

has vasculitis, inflammation of the vessels,

narrowing of the vessels.

NARRATOR It is an indication of a very rare lung disorder

called pulmonary hypertension, a condition in which

narrowed pulmonary blood vessels lead to dangerous increased

blood pressure in the lungs.

This, over time, can severely damage the heart.

The pressures are too great for the blood to get

through those little narrowing.

And so the more peripheral, the bigger vessels dilate, and then

the heart has to start pumping harder,

and that's why that thickens.
[ … ]

So the reason her heart was thick

is because the vessels in her lung

were narrowed, associated with pulmonary hypertension.

NARRATOR But when Dr. G examines additional slides,

she discovers that Maribel's lungs aren't the only organs

damaged by vasculitis.

JAN GARAVAGLIA She has it in her kidneys.

She has it in her spleen.

When I looked through my microscope, it all made sense.

All the pieces fit together-- her shortness of breath,

her coughing up blood.

All of those things made sense.

She's dying from the pulmonary complications of lupus.

NARRATOR Maribel's lupus wasn't mild, as her doctor described.

In her case, it was fatal.

She has the gamut of what you can have with pulmonary lupus,

lupus in her lungs.

And that's why she d*ed.

She couldn't breathe.

NARRATOR Lupus is a complex and little

understood autoimmune disease that

can cause the immune system to att*ck virtually

any organ in the body.

ELLEN GINZLER Lupus is a disease that primarily affects

women of childbearing age.

We believe that lupus develops because of abnormalities

of the immune system.

JAN GARAVAGLIA Basically, your body

is starting to see certain cells of your body as foreign.

And then you get a whole myriad of problems.

NARRATOR In Maribel's case, the disease

att*cked the blood vessels in her lungs

and other internal organs, leading to rare but deadly lung

complications.

JAN GARAVAGLIA You know, it's rare to die acutely from lupus.

But if you do get the pulmonary hemorrhage and some

of her manifestations, it is known you

can die rather quickly from it.

It is just something I probably will never see in the morgue

again.

NARRATOR The findings are shocking.

But Dr. G Finally knows what caused Maribel's

sudden and unusual death--

pulmonary complications from lupus.

She records her conclusions in the case file

and describes the events that led

to this young woman's rare death caused by a usually

manageable disease.

Several years earlier, -year-old Maribel Simon

is diagnosed with the autoimmune disease lupus.

Her symptoms-- skin rashes and joint discomfort--

seem to be mild and are managed effectively

with a prescription steroid.

JAN GARAVAGLIA She was on appropriate treatment.

And she wasn't having any symptomatology that

would suggest otherwise that she had

to have even more treatment, even more immunosuppressive.

NARRATOR But Maribel's mild external symptoms

are just the tip of an extremely dangerous iceberg.

As Dr. G discovered at autopsy, Maribel's lupus

caused widespread vasculitis, narrowed

and inflamed blood vessels in her kidneys, spleen, and lungs.

The symptoms that she had probably

developed very gradually.

And probably, she did not realize how seriously

involved her lupus was.

NARRATOR Over time, the narrowed blood vessels

in her lungs result in pulmonary hypertension,

or high blood pressure in the lungs,

which, in turn, leads to damage to the right side of her heart.

It was kind of below the radar.

Her disease in her lungs was kind of below the radar

until it just kind of went over the edge.

NARRATOR For Maribel, that critical point

occurs on the first day of her vacation in Orlando.

That morning, as her strained heart pumps blood

into her lungs, the lung tissue begins to hemorrhage,

and the blood seeps into the air passages of the lungs.

Why, all of a sudden, they get the hemorrhage into the lung

is really unknown.

But clearly, she wouldn't have these changes

if not for her lupus.

NARRATOR As her lungs hemorrhage,

Maribel becomes short of breath.

She then begins to cough up the blood

collecting in her airways.

At the hospital, doctors recognize that the right side

of her heart is enlarged.

But they misdiagnosed the cause.

They could see she had right ventricular

hypertrophy on the EKG.

They just didn't know the cause.

They thought maybe you had to do with her thrombi in her lungs.

NARRATOR But on the way to test for a potential

pulmonary embolism, Maribel's heart suddenly gives out

and she dies.

JAN GARAVAGLIA She basically can't oxygenate.

She can't breathe.

And she never recovers.

NARRATOR When they receive the explanation of her death,
[ … ]

Maribel's family is bewildered, but grateful that the autopsy

yielded answers.

Dr. G, too, is relieved to know that her conclusions

provided a measure of help.

You know, the beauty of being in the morgue

is, it's really interesting when we have,

you know, some of these interesting diseases

come through, and you can use some

of the skills you learned as a pathologist to diagnose things.

NARRATOR Death from lupus is extremely rare

and a surprise for any pathologist.

But the possibility of foul play is something Dr.

G faces everyday in the morgue.

And this is the question she must grapple with in her very

next case, the death of a -year-old woman

who was hitchhiking.

JAN GARAVAGLIA There's a lot of possibilities.

And I am afraid that foul play is right up there.

NARRATOR Dr. G opens the next file on her docket.

It is the death of a -year-old woman named Carla Brooke.

She was last seen alive yesterday afternoon,

hitchhiking.

OK, well, we have a -year-old woman here.

And this should be interesting.

Because it's kind of odd circumstances.

NARRATOR According to the investigators report,

Carla was in Auburndale, a city on the outskirts of Orlando,

when she hitched a ride in the late afternoon.

JAN GARAVAGLIA She gets a ride from a stranger, which you

like to do when you hitchhike.

Things were going OK, but he takes her

to an abandoned parking lot.

NARRATOR At PM, paramedics receive a

dispatch to the secluded lot.

There, on the ground, next to a van,

they find Carla unconscious and unresponsive.

The van's owner identifies himself as Jack Brady.

He tells paramedics he only just met Carla an hour ago.

She was perfectly fine when he picked her up.

NARRATOR But a few minutes after she gets in his car,

they pull off the road into a secluded parking lot.

He claims that nothing really happened.

They just had a drink from the back of the van.

NARRATOR But then, according to Brady, Carla begins to shiver.

It's chilly out here.

NARRATOR And suddenly, to his horror,

she vomits and collapses.

He calls the ambulance right away.

And we know she's still alive somewhat.

Because they had a pulse and blood pressure.

NARRATOR The paramedics immediately

head for the hospital.

But while en route, Carla goes into cardiac arrest.

They try to keep resuscitating her.

NARRATOR Unfortunately, their efforts are in vain.

JAN GARAVAGLIA She's pretty much dead by the time

they get there.

NARRATOR When medical investigators finally

track down Carla's estranged family,

they are shocked to hear of her sudden death.

According to them, Carla was always energetic

and enjoyed good health.

But she also had a rebellious nature.

Sadly, she had left home more than eight years earlier,

sharing little about her life on the road.

But they suspect it wasn't easy.

Now, we contacted her family, and they

say she does have a possible promiscuous career

and that she may do dr*gs.

NARRATOR Now, given this background information,

police must consider the worst case scenario.

Could Carla have been the victim of a homicide?

Number one, as usual, I'm always worried about foul play.

I have to be suspicious of everyone.

You know, let's call it what it is.

She's probably a prost*tute hitchhiking a ride

with somebody, and they stop at a deserted parking

lot for, quote, a drink.

You know, bad things can happen.

I mean, I don't know if we can buy this guy's story or not.

NARRATOR Dr. G also wonders if the alleged

drink could have included something

more than just alcohol.

Maybe they were doing dr*gs.

Maybe it's a drug overdose.

NARRATOR Stimulants such as cocaine and methamphetamine

can trigger high blood pressure, irregular

heartbeats, and sudden death.

JAN GARAVAGLIA They could be doing

coke in the back of that van and she d*ed from an overdose.

You know, that could give the shaking

and the vomiting at the end.

I don't know.

NARRATOR Perhaps Brady had only called

to throw off suspicion.

She's not breathing.

What should I do?

NARRATOR It's also possible that his claims are true,

and Carla's fate involved no foul play at all.

Maybe it's a natural disease.
[ … ]

I'm not really sure.

NARRATOR But as far as Carla's family knows,

she had a clean medical history.

The family doesn't think that there's anything wrong with her

that they know of.

NARRATOR And the symptoms Brady describes are too

vague to pinpoint an illness.

Vomiting internally, I mean, that could just

be just nonspecific anything.

Was it a seizure?

Was it chills?

Was there pain?

I don't know.

NARRATOR With no eyewitnesses, it's now up to Dr. G

to unravel the truth, holding Brady's story up

against the forensic evidence.

Do we take what he says at face value?

Of course not.

That's why we do the autopsy.

The sooner we figure out what happened to her,

the sooner the police can work on apprehending

somebody, if need be.

NARRATOR Dr. G begins the external exam, searching

for signs of a fatal att*ck.

So now we're going to look and make

sure that nothing happened to her,

that he could have done something to her.

But we'll also be looking for definitely natural disease.

NARRATOR But as with many decedents,

Carla's body initially reveals less about her death

and more about how she lived.

Probably looks a little older than her stated age of .

Kind of looks like a hard life.

NARRATOR She gets another glimpse of that hard life

on Carla's arms.

She's certainly got needle puncture marks in her arms.

She's got vascular scars where she's

sh*t up, obviously, before, and a fresh needle puncture mark.

NARRATOR The scars confirm her illicit drug use.

She could have been sh**ting up dr*gs before she met him.

Or they could have done this together.

NARRATOR But whether or not narcotics played

a part in her death will have to wait

until the toxicology report.

For now, Dr. G must set aside this possibility

and return to her foremost concern.

Was this a homicide?

What were they doing in an abandoned parking lot?

Why did she want to stop there?

She's in this a promiscuous career.

You know, did he strangle her and k*ll her?

Did he-- you know, did he get mad at her for some reason?

Did he try to rob her?

Did he hit her over the head?

NARRATOR Now, Dr. G intensifies her search

for wounds on Carla's body.

I'm looking at any evidence of trauma to the hands,

like she'd maybe been fighting somebody off.

NARRATOR With no obvious ones in sight,

she methodically looks for subtle clues,

starting at the head.

She's got a nice full, thick head of hair.

So it's very difficult.

NARRATOR She palpates the skull for bumps, cuts,

underlying fractures, and finds no external indications

of trauma.

But it's far too early to rule it out.

We're going to have to wait until we open her up

to see if there's any internal trauma to her head.

NARRATOR As a next step, Dr. G turns to Carla's neck,

looking for any evidence of strangulation.

If I find a woman dead, and there's no evidence externally,

like a b*ating or a s*ab wound, we would

be worried about strangulation.

NARRATOR Dr. G carefully begins to inspect

the neck of -year-old Carla Brooke,

searching for any signs of strangulation.

JAN GARAVAGLIA Very congested neck.

There's a lot of possibilities.

And I am afraid that foul play is right up there.

And that certainly has to be ruled out.

NARRATOR And sure enough, as Dr. G examines Carla's neck,

she notices an abnormality.

I saw distended neck vasculature.

You can see the external jugulars

very prominently on her.

NARRATOR But the distended vessels are not a typical sign

of strangulation.

They're a symptom often associated with heart failure.

You know, a lot of times, you'll see distended neck

veins with heart failure.

Because your heart's not pumping.

The blood's returning.

And it kind of starts building up pressure,

because it's not all pumping out of that heart.

Most heart att*ck victims are years or older.

But a history of drug use can greatly alter this age.

Yeah, I've certainly had -year-olds--

particularly -year-olds that use cr*ck cocaine--

you can accelerate atherosclerosis
[ … ]

in even young women.

NARRATOR Atherosclerosis, or the hardening of arteries,

is an underlying factor in nearly /

of all heart-related deaths in the US,

k*lling more than , Americans each year.

Now, Dr. G wonders if Carla's long-term drug abuse might have

caused her to develop atherosclerosis,

which often paves the way for a deadly heart att*ck.

Her neck certainly looked like a typical heart att*ck.

NARRATOR A heart att*ck can also

trigger nausea and vomiting, which would

corroborate Brady's story.

But to completely rule out foul play or a lethal overdose,

she must find more hard evidence in the internal exam.

Once I start hitting bone or hit anything metal,

it ruins the scalpel, and I've got to get a new one.

NARRATOR Dr. G makes the standard Y incision.

While removing the skin and subcutaneous fat,

she keeps an eye out for any hint of v*olence.

I'm looking for hemorrhage underneath the skin,

subtle signs of pressure or trauma.

I don't see any.

NARRATOR Next, she turns to the internal organs,

looking for clues.

I don't see any trauma inside the chest

cavity or the abdominal cavity.

Everything looks fine.

OK, Arden, just get in--

NARRATOR With her technician's help,

she begins to remove the organs one

by one for closer inspection.

And almost immediately, she discovers

a striking abnormality in a pair of organs.

JAN GARAVAGLIA Black lung.

These are going to be heavy.

.

She has very heavy lungs-- very heavy, wet lungs.

NARRATOR Wet lungs or pulmonary edema

can have several different causes, including

prolonged resuscitation, a coma, and problems

with the nervous system and brain.

But given Carla's autopsy findings so far,

Dr. G suspects two other reasons.

Pulmonary edema can be a subtle sign of drug overdose.

We can see it also in congestive heart failure.

NARRATOR At this point, both are strong possibilities.

Since we have extra, here's how we'll do it.

Put some in there.

Fill that up.

And give me another one.

NARRATOR First, to test for an overdose,

she takes samples of Carla's blood

for a full toxicology screen.

She will get the results in a few weeks.

Certainly, one of the things I am going to be very interested

in is the stimulants-- the cocaine, methamphetamine,

things along that line.

Because those can k*ll you rather suddenly.

NARRATOR Next, she turns her attention to the heart.

If Carla had premature atherosclerosis that triggered

a heart att*ck, Dr. G should be able to find

the blocked arteries.

Right off the bat, she notes a slight abnormality in its size.

for the heart.

So it is a little bit large, as if she had high blood pressure.

NARRATOR But it does not appear enlarged enough

to have caused her death.

She proceeds with the full dissection,

slicing the heart to inspect the cross-section

of each main artery.

And before long, she finds her answer.

JAN GARAVAGLIA I don't see any natural disease

that certainly would k*ll her.

Her heart looked fine.

NARRATOR It's clear.

Carla did not die of heart disease.

Now, Dr. G wonders if narcotics could be behind her death

after all.

I'm thinking it's probably not foul play at this point.

I'm not seeing any trauma.

I see these heavy lung.

It's looking like maybe this is going to be a drug overdose.

NARRATOR But the autopsy is not over.

Before she can make the final call,

Dr. G must completely eliminate foul play

as the cause of death.

That means searching one last place for trauma--

inside Carla's head.

She's got a big head of hair.

So what we're going to do is, we do an incision from basically

the back of your ear to the back of your ear

and reflect off your scalp from your calvaria, your skull.

NARRATOR Dr. G reflects the scalp, looking for injuries

on the skin and bone beneath.

On the calvarium, the top of the skull,

I don't see any fractures.

We don't see any bruising on the inside

of the scalp, which is, you know, making

trauma a little less likely.

NARRATOR But then she digs deeper,
[ … ]

lifting off the calvarium to expose the brain.

And there, she makes a shocking discovery.

She's got blood.

NARRATOR Captured in the membrane around the organ

is a pool of excess blood.

And I see blood coming up at the base

of the brain up to the sides, along the sides of the brain.

So she's definitely bleeding inside her cranial cavity.

NARRATOR The question is, what is causing the bleeding?

She's got trauma to the head.

Where did this trauma come from?

NARRATOR Dr. G carefully removes Carla's brain

to find out what caused the heavy bleeding

inside the cranial cavity.

I'm a little worried that she might have some head

trauma, maybe a blow far down.

NARRATOR First, the collected blood is carefully washed away.

So I take very gently a stream of water

and try to take out all the loose blood.

Because I need to get down to where those vessels are.

Let's clear some of this blood off.

NARRATOR Slowly, the area clears up.

And there at last, Dr. G finds what caused the bleeding.

And it's not trauma.

Instead, on a vessel near the main circular artery

in the brainstem, she discovers an aneurysm,

or abnormal outpocketing.

JAN GARAVAGLIA It's like a little tiny berry

sitting atop the vessel.

They call them berry aneurysms because they

look like a little berry sitting there.

NARRATOR Berry aneurysms often occur

when high blood pressure pushes against a weak spot

in a blood vessel.

The force creates a kind of balloon,

ranging in size from a few millimeters

to over two centimeters in diameter.

Carla's is small, only about three millimeters wide.

It's probably a congenital weakness that, over time,

with the high blood pressure, causes

that little outpocketing.

NARRATOR This type of brain aneurysm

often stays dormant, growing throughout a person's lifetime,

but never bursting.

A lot of people have them and don't know it.

NARRATOR But it's clear to Dr. G that Carla's has ruptured.

It doesn't have a lid anymore.

You could see the top had blown off of it.

NARRATOR Unfortunately, aneurysms

typically rupture quickly, the warning signs coming too late.

They'll just leak a little bit and you'll get a really bad

headache, like the worst headache of your life,

or a headache like somebody just hit

you on the back of the head.

NARRATOR This headache is caused by the leaking blood,

which irritates the brain.

When the aneurysm ruptures, the blood

suddenly rushes out, putting pressure on the brainstem.

And the brainstem, of course, is

where the cardiac and respiratory functions are.

And you can cause that to stop.

And that's what caused her to die rather quickly.

The mortality rate's very high.

A good % to % don't even make it to the hospital.

NARRATOR But one question remains.

What, if anything, could have caused this often dormant

aneurysm to suddenly explode?

When the toxicology report comes back,

Dr. G notices something that could have contributed

to Carla's tragic death.

We found the byproduct of cocaine.

Probably, she used that cocaine within that day

or maybe the day before.

I mean, she's certainly got needle

puncture marks in her arms.

And so maybe she's sh**ting up cocaine.

NARRATOR The trace amounts prove Carla

did not die from an overdose.

Instead, Dr. G suspects that chronic cocaine use had given

Carla high blood pressure, as seen

in the condition of her heart.

And the resulting high blood pressure had put her at risk

for the aneurysm to burst.

Any kind of stress-- sometimes, people--

we see people die suddenly with berry aneurysms that are

in fights, because the stress of the fight causes

their blood pressure to go up.

NARRATOR In Carla's case, Dr. G believes that a natural defect

in the vessel combined with her hypertension

created the perfect setup.

Maybe part of that vessel that just form quite right.

And that's prone to the effects of your blood pressure on it

to cause it to eventually weaken.

NARRATOR Now, with all the pieces of the puzzle in place,

Dr. G can finally explain what happened to Carla Brooke

on the day of her untimely death.

Carla left home eight years ago.

According to her family, soon after,

she developed a drug habit and a promiscuous lifestyle.

Then, one day, she hitches a ride with a total stranger.
[ … ]

JAN GARAVAGLIA They go to an abandoned parking lot.

He offers her a drink from the back of the van.

Thank you, baby.

You're welcome.

NARRATOR But this stranger does not att*ck her.

Instead, another fatal blow is about to strike.

She had a little ticking time b*mb in the space of her brain

that she didn't know about, which

was a little outpocketing in the blood vessel

at the base of the brain that was stretching.

NARRATOR The wall of this aneurysm, or outpocketing,

has been expanding for months, perhaps even

years, made worse by her high blood pressure,

brought on by cocaine use.

A lot of times, when we see ruptured berry aneurysms,

they might be doing something to cause

their blood pressure go up.

And cocaine is certainly one that causes

your blood pressure go up.

NARRATOR Now, as Carla sips on a beer in an abandoned parking

lot, the wall of that vessel comes

closer and closer to giving way, until finally, it explodes.

JAN GARAVAGLIA It couldn't hold the blood in anymore.

It bleeds very fast.

NARRATOR Pressure quickly builds on her brainstem,

interrupting signals between the brain and vital organs.

As a result, her heart and lungs begin to fail.

JAN GARAVAGLIA She gets very sick.

She probably started seizing a little bit.

And then the terminal vomiting.

So it really does all fit to what he said.

NARRATOR Then suddenly, Carla collapses.

Uh, a friend of mine just collapsed.

We were just having some fun.

NARRATOR Shocked, the driver calls .

But it's too late.

By the time paramedics arrive, she's unconscious and soon goes

into cardiac arrest.

JAN GARAVAGLIA They try to resuscitate her, but she dies.

NARRATOR Despite the traces of cocaine in Carla's system,

Dr. G files the case as a natural death.

We're going to go ahead and call this a natural.

Because you don't need cocaine to get these.

You can-- anybody can have these, little outpocketings.

And they felt-- like, you know, the actual defect

is probably congenital.

She certainly didn't choose to die this way.

But unfortunately, it was very bad luck.

Well, I think that helps the family, that they don't--

they're not worried that something happened

to her, some foul play.

It was just an unfortunate incident.

Sometimes, you know, your number's up, your number's up.

And I-- there's--

I don't know what you can say about that.

ANNOUNCER Atlas.