05x07 - Fearing the Worst

[bunniefuu]

[music playing]

NARRATOR A woman dies only days after undergoing

radical dental surgery.

So we've got a -year-old female today, who has recently

had her teeth pulled out.

NARRATOR Was her death related to the surgery,

or could it have been the result of a tragic accident

caused by her own sister?

The sister was very upset.

She felt that she was under her care,

and she slipped away from her.

NARRATOR And then when a depressed elderly woman

was found dead in her home, her family fears the worst.

When I talked to the family, they're

clearly quite worried that she might have committed su1c1de.

When the family brings something like that up,

I have to worry about it.

NARRATOR Altered lives, baffling medical mysteries,

shocking revelations--

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

[electronic music]

Hey, Sandi.

Sandi Hey.

Their dog, it's like a little old lady dog.

I hate to tell you that-- do you have to do

the tail on your dog like that?

That's like a little old lady dog.

She is a little lady.

No, that's like for a little old lady.

You're no little old lady.

Does the dog's tail have to be like that?

Yes, she's a poodle.

(LAUGHING) Oh, god.

Sorry, but it is.

I didn't notice it.

You got it on this fancy pillow, and it's got

its little poo-foo--

That's not a fancy pillow.

--tail.

That's just your regular, old, flat--

no, what's it called? - Paisley.

Sandi Paisley.

All I can say is don't--

if you start acting like a little old lady,

you'll become one.

Sandi (LAUGHING) She's a poodle.

NARRATOR It's early morning at the district

morgue in Orlando, and Dr. G and her staff

are ready to begin the day's caseload.

Today, their first autopsy will involve no old lady, but rather

a surprisingly young woman named Vivian Kaplin, who passed

away decades before her time.

This case involves a woman that

dies somewhat unexpectedly.

She has an interesting history, and I'm not quite sure how

this plays into what happened.

[ominous music]

NARRATOR As a first step, Dr. G reads

through the investigator's report which details

the circumstances preceding the woman's death,

and in this case, they're a bit unusual.

So we have a -year-old female,

who wasn't feeling very well yesterday, recently

had her teeth pulled out.

NARRATOR According to the decedent's sister, several days

ago, Vivian Kaplin traveled five hours

by bus to an out-of-state clinic to have her teeth extracted.

She's having a lot of problems with her teeth, a lot

of problems with her gums, and they say she

needs to have her teeth pulled.

NARRATOR A few days later, Vivian

is released from the clinic.

She makes the long trip back to her home in Florida

and is greeted at the bus terminal by her sister.

Things seemed to have been going well.

She came in last night.

Things were fine.

Her sister was talking to her, and then about o'clock

in the morning, she awakens her sister

and says that she feels like she's got a low blood sugar.

Now she knows this because she's a diabetic.

She's had diabetes for about three years,

and she's type diabetic in that she needs insulin.

So her sister immediately responded to that

by getting her something to drink to raise her blood sugar,

and then after that, she checked her blood sugar,

and it was actually very high, not low at all.

NARRATOR According to the blood meter,

Vivian's glucose level registers milligrams per deciliter,

more than five times what it should be.

She immediately asks her sister Teresa

to administer a dose of insulin in the hope

that it will bring her glucose levels back down,

but that's when something goes terribly wrong.

About an hour after the injection,

Vivian loses consciousness and stops breathing.

She is rushed to the hospital, but to Teresa's disbelief,

Vivian doesn't survive the trip.

They tried to revive her, but it's too late.

She's already pronounced by the time she gets to the hospital.
[ … ]

NARRATOR For Vivian's sister, Teresa,

the sudden loss of her only sibling is devastating.

The only thing more painful than her grief are her feelings

of guilt. Teresa is overwhelmed with the thought

that she might have caused Vivian's death by injecting

her with too much insulin.

She was worried, because she's the one that gave her

the insulin injection, and then a couple hours later, she d*ed.

So I think she's a little upset.

You know, maybe she did something wrong.

NARRATOR If Teresa accidentally injected an overdose

of insulin, it would have caused Vivian's

glucose level to plummet--

a condition known as hypoglycemia, or insulin shock,

which can cause seizure, coma, and even death.

But on first blush, Dr. G thinks it's

unlikely that Teresa gave her sister

an incorrect dose of insulin.

You know, she was used to giving that insulin.

She knew about the insulin.

She'd done it before.

NARRATOR She wonders instead if there might

be another explanation for Vivian's

unexpected death, one stemming from her recent dental surgery.

Well, I worry the teeth, in and of itself,

isn't too big a procedure being pulled,

but you've certainly have opened up your sockets.

And you're more apt to get an infection.

Well, what would that matter?

Normally, we could, you know, fight that off,

and we wouldn't have any problem.

Well, that's bad for people with diabetes,

because they don't have as good a defense

against getting an infection.

NARRATOR Dr. G's concern--

perhaps Vivian developed an infection

[drilling]

from the dental work, which simply overwhelmed

her impaired immune system.

So that could be a major problem,

and that could be something I have to worry about.

NARRATOR Was Vivian's death the result of a tragic accident

or from complications of illness and disease?

There's only one way for Dr. G to find out.

[electronic music]

Sandi I got everything on there.

All right, I'll be there in a second.

Oh, not just the IDs.

OK, which are the ones?

Dr. Hanson likes the blues, so what

is the consensus so far here?

Do you like the blues?

Sandi Yes.

So you'll keep wearing the blues.

So these are for people like Dr. Hanson and I. Unfortunately,

she, I think, likes these.

So let me try these.

I think when those things get wet, you get a little--

The blues get, yeah, real slippery.

What?

The only problem is they are a little bit hard to get

on with the other glove.

DR. G (VOICEOVER) When I first see her,

I'm actually kind of taken back, because she looks much older

than her stated age of .

And when I do an exam, I'm usually quite generous

and always state that they look their stated age of

if you even maybe don't too good.

But, you know, with her, I really

had to say she didn't look her stated age of .

She looked older partly maybe because she

didn't have any teeth.

She was thin.

She didn't look like she had taken

very good care of herself.

She had wrinkles.

She was thin.

She had no teeth.

She just looked old.

NARRATOR Dr. G inspects the body

carefully, looking for any unusual marks or trauma.

No bruises.

I don't see the injection site.

She does have some mild pitting edema, a little bit of edema

to her lower extremities.

NARRATOR Then she turns to examine Vivian's mouth,

the site of her recent surgery and where Dr. G suspects

she might find a clue to her death.

Well, I'm looking-- you know, one of the things I want

to concentrate on is her mouth.

She just had all her teeth pulled.

And when I look in, sure enough, she

just had all her teeth pulled.

She had all those extraction pits,

and they were starting to heal.

But, you know, it looked painful to me, and it looked,

you know, inflamed a little bit.

NARRATOR But Dr. G finds no obvious signs of infection,

such as pus or ulcerations.

Externally, at least, a deadly infection
[ … ]

now seems less likely.

For Vivian's sister, this kind of news could be devastating.

If Vivian didn't die from an infection,

perhaps something did, in fact, go wrong with the insulin

injection.

The sister was very upset.

And I think she felt that she was under her care,

and she slipped away from her.

[music playing]

NARRATOR Dr. G opens the body of -year-old Vivian

Kaplin with a Y-incision.

DR. G Did anybody see that video

of the mistreatment of the cows before they were k*lled?

I couldn't.

I glimpsed it, and I couldn't look.

I had to turn away.

I turned the channel.

NARRATOR Once the body is open, Dr. G's first priority is

to draw samples for toxicology.

Urine and eye fluid are collected,

which will give an indication of Vivian's glucose level

at the time of her death, and whether or not her sister

administered too much insulin.

I need to know what her glucose was.

I need to know if she was dehydrated.

I need to put all these things together still.

And so the toxicology and the chemistries on her eye fluid

are all going to play a major role.

I hope to have me put this all together.

NARRATOR Then Dr. G prepares to draw blood from Vivian's heart.

If she developed a fatal infection

as a result of the dental surgery,

bacteria will surely be present in the samples.

It's very important that I get blood

right away for blood culture to see if there

is any bacteria growing.

I very gently open up the heart sac,

I go for the major blood vessels to try to remove some blood

and then put it in a blood culture tube,

to send to the lab, to see if it grows any bacteria.

I'm very careful.

I try to do this very sterilely.

A lot of people think that post mortem blood culture, because

of the bacteria kind of getting out of your gut,

going into your body, aren't worth anything.

But occasionally if you get the person fresh enough,

and you use good technique, you can

get either a single organism, meaning the one growing

in their blood, or you can get a negative meaning

nothing was there--

a non-contaminated specimen, which is helpful,

indicating they didn't have an overwhelming sepsis.

NARRATOR However, no sooner does Dr. G begin drawing blood

samples from the heart than she makes

an unexpected finding, one that may change the course

of the entire autopsy.

Oh, brother.

She's got adhesions.

NARRATOR In other words, there's scar tissue connecting

Vivian's heart and the pericardial sac,

the protective sheath surrounding the organ.

Pericardial sac was unusual in that there were

fibrous adhesions between the lining of the sac

and the top of her heart, and those are, like, little scar

tissues between the two.

That was important, because that indicates that she had

a pericarditis, or an inflammation of that heart

sac, which is interesting because that's

a common manifestation of Lupus.

NARRATOR Lupus is a chronic inflammatory disease

that causes the body to att*ck its own tissues.

This, in turn, can trigger serious and sometimes

life-threatening complications.

Lupus has tremendous amount of manifestations.

It can k*ll you many different ways.

It could be the heart.

It could be the lungs.

It could be the brain.

It could be the kidneys.

All of those things can be affected by Lupus.

[ominous music]

NARRATOR Up to this point, Dr. G

has had no indication besides this finding

that Vivian was ever diagnosed with Lupus.

But could it be the ultimate cause of her death?

DR. G (VOICEOVER) Now I'm really

interested in that heart, because believe it or not,

one of the most common ways that Lupus can k*ll you acutely,

particularly if you've had it for a long time,

is by a heart att*ck, because it accelerates atherosclerosis,

or the plaque in the coronary arteries.

And even women, who are relatively

young like this woman, could have a severe atherosclerosis

and have a heart att*ck.

[music playing]

NARRATOR Dr. G's next step is to examine

the heart more closely.

DR. G (VOICEOVER) Her heart was a normal-to-small size.

And I look at the coronary arteries,

which atherosclerosis can be accelerated
[ … ]

in both Lupus and diabetes.

NARRATOR But she finds no obvious damage to Vivian's

heart from either disease.

Her coronary arteries were completely normal.

Her heart muscle was a little soft,

and I'm not sure what that indicated.

It may be an infection, or it may be a myocarditis.

People with Lupus tend to have inflammation of the heart

tissue, but the heart doesn't appear

to be why she d*ed, unless I find something microscopically.

NARRATOR Next Dr. G turns to examine

Vivian's abdominal organs, looking for any signs

of disease or infection there.

But once again, she comes up empty handed.

DR. G (VOICEOVER) Well, internally,

I don't see much going on.

She's got some kidney changes.

She's got a fatty liver.

DR. G But overall, nothing too bad-- certainly nothing that I

can see acutely k*lled her.

So I don't really see a cause of her death.

I mean, I was hoping that it would be more clear cut,

but I do know there are many things, that could have caused

her death, that I may not see.

The infection, I need to look under the microscope.

The myocarditis associated with Lupus,

I need to look under the microscope.

I need to check her levels of glucose in her eye fluid.

So many things are still possible that I still

need to do the investigation, and I

haven't done the head yet.

[music playing]

[saw grinding]

NARRATOR Dr. G's morgue assistant, Sandi Ludwig,

opens Vivian Kaplin's skull.

DR. G (VOICEOVER) You know, there's

still possibilities that we could have had

the Lupus effect on the brain.

And we've certainly have had people come through here

with Lupus with bleeds in their brain, and that's why they die.

She could even have an infection.

DR. G So I think that would be what I'd be most worried about.

[ominous music]

DR. G (VOICEOVER) And I take the calvarium off.

Her brain's a little bit edematous,

a little bit swollen.

I cut the brain, and what I find is she

does have a bleed in her brain.

[ominous music]

DR. G (VOICEOVER) But it's not the kind of hemorrhage

that would k*ll you.

It's just a small, little hemorrhage

maybe millimeters by millimeters

in the white matter.

It's certainly an acute event.

But how does this cause her death?

I'm not convinced it did, and I need to know how

these pieces all fit together.

DR. G And I can't put it all together yet.

It's not making sense.

[music playing]

[cart rolls]

NARRATOR The autopsy of -year-old Vivian Kaplin

is over, but Dr. G still has no answers.

DR. G (VOICEOVER) I have some interesting history.

I have a few subtle findings.

DR. G I have the small bleed in the brain

that probably didn't k*ll her.

It's certainly not big enough to k*ll her, but how does

that play a role?

OK.

DR. G (VOICEOVER) It really doesn't

[running water]

make much sense to me, so I need to put this all together.

NARRATOR Dr. G has no choice at this stage but to append

the case until microscopic slides and toxicology

results are completed.

For Vivian's sister, still worried

that she may have been at fault, the wait will be agonizing.

DR. G (VOICEOVER) Well, this one, I told her sister,

I'm not sure. [spraying water]

Either there's no clear-cut evidence of why she d*ed,

and she's just going to have to give me time

to put this together.

I think I'm on the verge here of putting it together,

but I need a few more pieces to the puzzle.

NARRATOR And after several long days,

these final pieces begin to trickle in.

[ominous music]

First, microscopic slides confirm the effects of Lupus

in several internal organs, including

Vivian's brain and heart.

Her kidneys were also damaged by type diabetes.

Still, there is no sign of infection in any of her organs

or blood, but then Dr. G reads through the toxicology results.

DR. G (VOICEOVER) That actually gave

me a huge piece of the puzzle.

And that was she was in diabetic ketoacidosis.

[ominous music]

NARRATOR The results are certain.
[ … ]

Vivian Kaplin d*ed due to a life-threatening diabetic

complication known as ketoacidosis.

[instrumental music]

Insulin is the hormone, that is made by the pancreas, that

takes your blood sugar, your glucose,

and brings it into your cells, so your body

can use that for energy.

What happens is, without the insulin,

the glucose levels just keep getting

higher and higher in the blood, but your cells are starving.

Your cells don't have any energy.

So what happens is your body is going

to have to start breaking down other components,

like protein and fat, to get energy.

And the byproduct of breaking down that fat and protein

are fatty acids and eventually this production of acetone,

which is a very acidic substance, which, if it gets

high enough, can start denaturing

proteins-- causing body functions not

to work correctly.

And you can go into a coma and die, and this is why she d*ed.

NARRATOR And yet this finding defies logic.

DR. G (VOICEOVER) Something is causing this blood

sugar to go out of whack.

But why?

You know, she supposedly takes insulin just an hour

or two before this happens.

It really doesn't make much sense to me.

[instrumental music]

NARRATOR Now all Dr. G can do is

take a step back, revisiting the finding she's gathered to date."], index ,…}

DR. G (VOICEOVER) When I worry about diabetic ketoacidosis,

I also then have to think about what triggered

the diabetic ketoacidosis.

NARRATOR And it isn't long before she hits on a seemingly

inconsequential clue, one that not only explains Vivian's

sudden decline but can finally put

to rest the question of her sister's role

in this tragic chain of events.

In the midst of a Florida heat wave,

-year-old Vivian Kaplin travels out of state to undergo

radical dental surgery.

But Vivian is a type diabetic, so she

must take daily insulin injections to keep her blood

glucose levels in check.

According to her sister, Vivian carried her insulin kit

in her bag on the trip.

[drilling]

DR. G (VOICEOVER) She does well with her extractions,

getting all her teeth pulled in about five days.

She takes the trip back.

She's not having any problem.

When she gets home, she goes to bed.

But lo and behold, early that next morning

though, she wakes up.

She's not feeling well.

She thinks her blood sugar is low.

NARRATOR But Vivian is wrong.

She isn't feeling well, because as Dr. G discovered in autopsy,

she just suffered a minor stroke triggered by her Lupus.

One of the most common reasons for somebody

to go into diabetic ketoacidosis would

be major stressful events to your body,

like maybe a stroke, a heart att*ck--

all of those things are known to precipitate going

into diabetic ketoacidosis.

[ominous music]

NARRATOR In this case, the stress of the minor stroke

may have been the cause of a sudden and catastrophic spike

in Vivian's glucose level, but Vivian misinterprets

her symptoms as low blood sugar and drinks a fruit juice, which

only adds insult to injury, further

elevating her blood sugar.

DR. G (VOICEOVER) Lo and behold,

when she tests her blood sugar after that, it's really high,

like over .

Then at that point, she knew she needed to get some insulin.

NARRATOR The insulin injection should

help to normalize Vivian's glucose level, but it doesn't.

While it's possible that her sister administered

an incorrect dosage, Dr. G believes there

may be another explanation.

DR. G (VOICEOVER) The insulin that they

gave her was the same insulin she had taken on that ride up

to Georgia to get her teeth pulled,

and it wasn't refrigerated.

NARRATOR Dr. G now wonders if the insulin, which could have

saved Vivian's life, might have been rendered less effective,

given its exposure to excessive heat.

DR. G (VOICEOVER) Insulin, if it's exposed to heat,

it will lose its effectiveness.

Now I would have loved to have tested that,

but it's very difficult to test for that kind of insulin

in her body after death.

So at this point it's only a theory,

but I think it's an appropriate theory.

So we have everything going on here.

We have a stroke that's probably precipitating her blood sugar

to go up, but then we have the insulin, which probably isn't

very effective because she had it exposed
[ … ]

to some high temperatures.

NARRATOR Because her body can no longer utilize glucose

for fuel, it begins to break down

fat and protein for energy.

DR. G (VOICEOVER) That causes her blood

to get very acidic, which then spirals into her going

into diabetic ketoacidosis.

Her sister comes back in to check on her

and realizes she has passed out.

She calls .

They try to revive her, but it's too late.

Her body had already shut down.

She wasn't breathing.

She's got edema in her brain, so there is nothing

they could do to save her.

Hi, there.

She is right here.

You're welcome.

NARRATOR With the puzzle of Vivian's sudden death solved,

Dr. G calls Vivian sister to explain her findings

and to reassure her that she was not at fault.

DR. G (VOICEOVER) The sister did the best she could.

DR. G She feels bad about that insulin,

but nobody thought about that until after the fact.

And hindsight is always /.

OK, but just so you know, you know, how this all plays out,

it's kind of complicated.

OK, just so you know we're on the same page.

OK.

OK.

Bye, bye.

She fully understands the complexity of the case.

Only because of your ability to communicate, doctor.

We're so proud.

My chest swells.

DR. G Oh, you get out.

[music playing]

DR. G (VOICEOVER) You know, I take away that sometimes

just unfortunate things happen.

We can try our best to stay as healthy as we can,

but nobody knows what causes Lupus.

Nobody really knows what triggers type diabetes.

Then it just shows how, for those of us who don't have

these devastating diseases, we should

be thankful for our health.

And those that do, they need to work

as hard as they can to stay as healthy as they can,

because they can.

[ominous music]

NARRATOR Dr. G knows that most people do what they can to try

to avoid a premature death.

[music playing]

But in our next case, it seems that death may be exactly

what the decedent wanted.

DR. G (VOICEOVER) You know, I feel bad for the family,

because maybe they could have prevented this.

Maybe they should have been more attuned to what

she was going through.

[ominous music]

[instrumental music]

STAFF Oh, he's the owner.

He's the owner?

NARRATOR Chief investigator Steve Hanson

is responsible for leading the death investigations

at the district morgue.

Today, however, he's checking on a new purchase

he made, for Dr. G and her staff,

to possibly replace towels in the morgue with sea sponges.

Everybody that I talked to seems to think they're

a good idea.

How expensive?

STEVE HANSON Well, they're supposed

to last like a long, long time.

I didn't say how long they were going to last.

I said how expensive.

I think we bought six of them for $.

NARRATOR But a decision on sponges versus towels

will have to wait.

Dr. G's priority at the moment is her next case,

the unexplained death of a -year-old woman

named Rose Paxton.

[ominous music]

DR. G OK.

NARRATOR Reading through the investigator's report,

Dr. G learned that Rose was a retired Orlando

teacher, who'd recently been struggling with depression.

DR. G (VOICEOVER) She had lost her husband about

a year and a half earlier.

She was really grieving over that,

but she seemed to go on beyond grieving.

Her family was very worried about her.

NARRATOR Concerned, her son Jason and his family

traveled to Orlando to visit her.

DR. G (VOICEOVER) They came to spend some time with her,

to try to get her out of the house

and just see what was going on.

Things seemed fine.

She, you know, did seem depressed,

but she went out with them and had been having fun, at least

going to the attractions with them.
[ … ]

NARRATOR But by the time the family

returns home later that evening, Rose is feeling very fatigued

and decides to turn in early.

She stays in her room the rest of the night.

[music playing]

[birds chirping]

DR. G (VOICEOVER) The next morning, her grandson

came in to wake her up for breakfast,

and she was found unresponsive.

Then he immediately went and got his dad, and she was dead.

They called , but there was nothing they could do.

And they pronounce her in the home.

NARRATOR For Rose's family, the unexpected loss is devastating."], index ,…}

Well, at this point, the family just has a hard time

accepting that she d*ed.

They were very surprised-- very unexpected for that family.

To them, she was a picture of health.

She'd just gone to the doctor about a month

or so prior to her death, and according to the son,

he had given her a clean bill of health.

And so they're very worried about her depression

and that maybe she committed su1c1de.

[ominous music]

NARRATOR Rose's family is particularly concerned

that she may have overdosed on one

of the many over-the-counter medications in the house.

Elderly people do have a higher su1c1de rate

than the general population.

You know, if you take all the elderly people over to ,

it's about, you know, between and per , population,

while the general population is close to

per , population.

So they have an increased rate of su1c1de.

DR. G (VOICEOVER) When the family brings something

like that up, that's usually a red flag for me,

because they'll usually underplay that.

And the fact that they brought it up to me,

and that they were worried about it, I have to worry about it.

[music playing]

DR. G (VOICEOVER) Well, I had to agree with the family.

She looked pretty good.

She looked like she was sleeping,

and she looked like she taking care of herself.

I see no trauma on her.

I see no swelling in her legs.

I see someone that looks like they just went to sleep.

I mean, some people will come through my morgue,

and you'd think, well, they're all dead.

They can't look that good.

But some people look sick, and some people look pretty good.

She looked pretty good.

NARRATOR Dr. G notices that Rose still

wears her wedding ring even though her husband

d*ed more than a year ago.

DR. G (VOICEOVER) She's still cares

very much for her husband.

I see that in most widows that they're still

wearing their wedding band.

Let's see her mouth.

NARRATOR As a first step, Dr. G inspects

the inside of Rose's mouth.

Some dr*gs can leave traces on the surface of the tongue.

Sometimes you take a lot of pills,

they'll leave some discoloration.

And I looked even for seizure activity-- bite marks

to the cheeks or the tongue.

I don't see really much of anything except someone who

looks pretty good for her age, and whose of normal weight,

and no evidence of trauma or natural disease externally.

So we really have a clean slate.

But, you know, keep in mind, you never

know what you're going to find.

[music playing]

NARRATOR Dr. G prepares to open the body

of -year-old Rose Paxton.

Her family fears she was driven to commit su1c1de

over the recent death of her husband,

and now it's up to Dr. G to find out.

You ready?

In this case, I do my Y-incision,

you know, always hoping that I can

tell right away why somebody d*ed,

and I don't see much of anything.

[electrical equipment]

DR. G (VOICEOVER) Once I see the general look of what

the chest and abdominal cavity look like,

I will remove blood for my toxicology.

I'm worried about that this is su1c1de

and a possible overdose.

[music playing]

NARRATOR Next Dr. G begins removing each

of Rose's internal organs for closer inspection,

starting with the heart.

If an overdose didn't k*ll her, there's

a good chance her heart did.

DR. G (VOICEOVER) Now this is where I think the money is.

You know, somebody d*ed suddenly and unexpectedly--

years old.

Oh, I'm going to find heart disease.

DR. G (VOICEOVER) I take out her heart.
[ … ]

Her heart is of normal size.

It's not enlarged.

I do a very careful dissection of her coronary arteries.

There was no narrowing to those coronary arteries.

DR. G (VOICEOVER) The heart muscle, to me, looked fine.

The heart valves looked fine.

You can die suddenly and unexpectedly

with a narrowed aortic valve.

We see that sometimes.

Let's see what's going on here.

Anything interesting around here?

I look at the other organs.

I look at her lungs.

There is no evidence of disease to her lungs.

You can clearly see she didn't smoke.

I look at her liver.

I look at her spleen and her kidneys,

and I don't really find much of anything,

in her chest and abdomen, that would have caused her death.

Internally, everything looks great.

NARRATOR Next Dr. G turns to inspect

the contents of Rose's stomach.

DR. G (VOICEOVER) The stomach contents is of importance

to me, because I want to see-- sometimes we'll

have residual pills, or material that they've ingested,

where the levels will go up.

Like, part of it will be digested to the point where it

will k*ll her, and there'll still be some of those pills

left in the stomach.

DR. G Oh, brother.

That's not very good.

There's really nothing here.

Everything looks good.

In this case, she really didn't

have much in her stomach.

A little autolysis-- you know, the mucosa,

or the lining of the stomach, was starting to break down.

Very common finding at autopsy--

but not much stomach contents.

Just a little bit of liquid in the stomach.

I certainly don't see any food.

I don't see any pill fragments.

It is consistent with her dying during her sleep in bed,

you know, sometime after she'd eaten,

because her food is clearly digested out of her stomach.

So at this point, I carefully looked at her heart.

I carefully looked at her stomach contents.

I don't really find any disease anywhere.

So far, her family's looking correct.

She seems the picture of health.

[music playing]

You know, at this point, I don't have a cause of death.

And it would be nice to just end this, and not keep looking,

and find something in her brain.

Certainly, an inner cerebral hemorrhage

or an embolic stroke, I think everybody would feel

happy with that just knowing their mom

didn't commit su1c1de, and that it was sudden and painless.

So I'm hoping along that line.

[saw running]

NARRATOR Morgue technician, Tom Hemphill,

uses the oscillating saw to open Rose's skull.

I'm going to use this.

And then I need the--

DR. G (VOICEOVER) I open her calvarium.

I'm OK.

I'm OK.

DR. G (VOICEOVER) Nothing looks abnormal on the surface.

I slice the brain very carefully,

and I do find a lacunar infarct.

NARRATOR A lacunar infarct is a small stroke, typically

less than . centimeters, which occurs in the deeper

parts of the brain.

DR. G (VOICEOVER) It's basically a tiny little stroke.

It looked like it was in the process of healing.

It still had some swelling around it.

I'm not really sure what that lacunar infarct

is telling me at this point.

They're sometimes considered associated with high blood

pressure, diabetes, but we don't tend to see

those as a cause of death.

Well, we finished the autopsy.

I thought she surely would have had a heart disease,

but her heart looked pretty good.

So it's tox and microbes.

We don't have a cause of death, and I am-- unfortunately,

I have to call the family and tell them we're going to have

to wait for the toxicology.

And, you know, I feel bad for the family,

because not finding a cause of death at autopsy,

not finding natural disease, makes them more anxious

that maybe it was su1c1de.

Maybe they could have prevented this.

Maybe they should have been more attuned to what

she was going through.

We'll see.

[ominous music]

NARRATOR At the Wuesthoff lab in Melbourne, Florida,

technicians have just completed a blood

sample and body fluid analysis on -year-old Rose Paxton.
[ … ]

The results are delivered directly to Dr. G.

DR. G (VOICEOVER) Well, I think the toxicology

will be very interesting.

Basically, we're looking at all those dr*gs

that she could possibly have taken to k*ll her.

[electronic music]

We've tested thousands of dr*gs, and when we test.

We certainly look at the illicit dr*gs,

but we also screen that blood in a way that

checks for just thousands of different types

of dr*gs that aren't illicit.

And it was completely negative.

NARRATOR It's official Rose Paxton did not commit su1c1de.

The news will undoubtedly bring welcome relief

to Rose's family, but for Dr. G, the results

only bring a deepening sense of frustration.

DR. G (VOICEOVER) What's really going to be bad,

and it happens in a small percentage of cases,

we never find out why she d*ed.

And I'm hoping it's not that.

NARRATOR But at this point, all Dr. G has left to examine

are microscopic slides of Rose's internal organs.

DR. G I get really surprised at microscopic examinations.

Because if it looks normal to my eye,

it usually is normal under the microscope.

So I didn't have high hopes for the microscopic examination.

Certainly, the liver looked normal.

I look at her kidneys.

I'm looking for evidence of high blood

pressure, even long-term diabetes that wasn't diagnosed.

Her kidneys look good.

I look at all these organs, and they look good except for one.

And that was her heart muscle.

NARRATOR Staring at the slide, Dr. G

can now say exactly why Rose Paxton d*ed

even though it's a cause of death

she has never diagnosed before.

It's Saturday May , and Rose Paxton

is spending a busy day, with her son and grandchildren,

visiting the sites of Orlando.

Her family is worried that she's suffering from depression

due to the recent loss of her husband,

and they hope the activity will brighten her spirits.

But today, Rose faces a much more

dire problem, one that she and her family

are completely unaware of--

a heart ravaged by small vessel disease.

Her heart muscle looked really bad.

It was quite remarkable.

NARRATOR Under the microscope, Dr. G

discovers that the tiny blood vessels within her heart muscle

had become significantly narrowed.

DR. DARLENE GO The smaller materials become spastic.

These small spasms that basically choke the vessels

that give oxygen to the heart.

And while that happens, your heart

cannot function without oxygen.

NARRATOR The reduction in blood flow

causes muscle cells to die off one

by one, resulting in a buildup of dangerous scar tissue.

DR. G They're little, tiny, basically heart att*cks

just a few cells at a time.

And when you start having this increase in fibrous tissue

and this decrease in blood flow, you

are at risk for a sudden cardiac arrhythmia.

NARRATOR Small vessel disease typically

strikes postmenopausal women like Rose,

but it is very difficult to detect

with standard cardiac tests.

And doctors are still unsure of its cause.

DR. DARLENE GO The small vessels, you don't see.

Therefore, it's very difficult to diagnose that they are

dysfunctional until, down the road,

you do all the workup with persistent symptoms.

And most of the workup does not show anything.

There used to be a debate whether this small vessel

disease really was even a risk factor for sudden death

or bad outcomes.

It used to be thought, no.

In fact, there was a percentage of women that would be having

chest pain, that would go to a cardiologist,

would get a cardiac catheterization where

they put the dye through the coronary arteries.

They'd have completely normal coronaries.

And they'd send them on their way,

saying, well, it just must be anxiety--

you know, just in your head.

Then over the past few years, they're

starting to see, no, you don't have to worry about it.

It is associated with sudden death.

It is associated with heart disease.

[music playing]

NARRATOR However, in Rose's case

her symptoms were so vague, only mild fatigue,

that she didn't even realize anything was wrong.

Now this woman is interesting, because we

don't have any history of any kind of chest pain.

But we certainly have microscopic evidence

of the heart muscle dying off.

So when you put two and two together
[ … ]

with no other cause of death, negative toxicology,

it really points to this as her cause of death.

NARRATOR That night at home with her family,

Rose doesn't know it, but her heart is failing.

She feels tired and goes to bed early,

looking forward to another day with her family,

but she won't live to see morning.

Dr. G believes that, sometime during the night as Rose is

sleeping, her damaged heart suddenly falls

into a deadlier arrhythmia.

[heart pumping]

Instead of pumping, it quivers.

DR. G There is a tremendous amount of scar

tissue in that heart muscle.

The electrical system kind of goes out of whack.

The heart can't pump.

And the blood doesn't get to her brain, and she dies.

[ominous music]

NARRATOR Dr. G is certain that Rose's death

was a result of natural causes and not su1c1de.

Her last step is to call the family

and inform them of her findings.

DR. G (VOICEOVER) They were so thankful that they

didn't have to worry that she committed su1c1de--

that they should have picked up on things.

And they felt bad that she d*ed of that.

But, you know, when you don't have symptoms,

and you're not complaining, there was really nothing

they could have done for her.

[instrumental music]

DR. G (VOICEOVER) You know, when you see this--

and this is probably the first case

of small vessel disease, that was causing the death,

that I've autopsied.

There are so many ways your body can eventually cause you

to die, and there's so many ways your body

can eventually betray you.

But you have to remember so many of those ways

are still associated with us betraying our body

and what we do to our body.

[spraying water]

And, you know, it's kind of a give-and-take.

Your body will try to stay good to you

if you stay good to your body, but sometimes, no matter what

we do, bad things still happen.

Destroying all the evidence.

[music playing]