06x03 - Deadly Silence

[bunniefuu]

[heavy music]

[suspenseful music]

NARRATOR A family vacation turns

tragic when a beloved grandfather suddenly collapses.

Maybe he was feeling bad but didn't

want to tell anybody because he didn't

want to ruin their vacation.

NARRATOR And things get complicated when his family

objects to an autopsy.

Honestly, at this point, I don't know what to think.

I got the family not wanting an autopsy on one side.

But on the other hand, I've got years of experience

saying this isn't adding up.

NARRATOR And then a seemingly healthy woman

dies without warning.

[siren wailing]

It is truly a mystery that this

-year-old perfectly healthy woman

just drops dead for no reason.

NARRATOR Now it's up to Dr. G to put the pieces of a very

unusual puzzle together.

We got to dig a little deeper here.

What's going on?

[theme music]

NARRATOR Altered lives, baffling medical mysteries,

shocking revelations--

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

[soft music]

As chief medical examiner of the District Nine

morgue in Florida, Dr. Jan Garavaglia's hours

are anything but to .

DR. G It's a long holiday weekend,

and I was actually expecting the worst today.

But it's still to come, I think.

So only two today, but we're expecting

more the rest of the weekend.

NARRATOR One of the bodies in the morgue today

is a retired schoolteacher from Arizona named Philip Greene.

DR. G This is a -year-old man that's on vacation here.

He's visiting his daughter who lives here.

NARRATOR But little did Philip know

this trip would be his last.

[gentle music]

It's early afternoon on a Friday.

And Philip, along with his wife, Nora,

is enjoying the day with his daughter,

Mattie, and her two children.

DR. G They've been out doing a lot of errands, sightseeing.

They've supposedly been having a good time.

[suspenseful music]

NARRATOR But as they make their way

through a park in downtown Orlando,

Philip takes a bad step and falls to the curb.

WOMAN Oh my gosh.

NARRATOR Fortunately, the -year-old appears uninjured.

WOMAN Did you hurt your leg?

NARRATOR But right away, he does complain

of some abdominal pain.

So Mattie and Nora insist he go home and at least try

to get some rest.

DR. G He went home to his daughter's house,

didn't do much that evening.

NARRATOR But as the hours pass, Philip begins

to feel increasingly ill.

He didn't seem well.

He seemed sick.

He has abdominal pain.

NARRATOR Although Nora's concerned,

Philip insists it's just a stomach bug

and that all he needs is a good night's sleep.

But just as he's about to lie down,

the -year-old collapses to the floor unconscious.

WOMAN Oh my god.

WOMAN Phil?

They call .

[siren wailing]

PARAMEDIC Sir, can you hear me?

DR. G EMS immediately took him to the emergency room.

But they really couldn't revive him,

and they pronounced him dead.

[heavy music]

NARRATOR The next morning, Phil's body

arrives at the District Nine morgue.

Now it's up to Dr. G to find out exactly why he d*ed.

Except there's a problem.

DR. G The family clearly didn't want an autopsy.

They didn't fill an autopsy was necessary.

And they cite religious objection.

NARRATOR In fact, the Greenes are devout Jehovah Witnesses

and do not believe in autopsies.

And while there's no official church mandate

against the procedure, Nora simply wants

her husband to rest in peace.

[suspenseful music]

In an effort to honor her wishes,

Dr. G will now attempt to determine Phil's cause of death

without performing an autopsy.

Not everybody that comes through my morgue

has to be autopsied.

If you have a known medical history, if you die in a way
[ … ]

that we would suspect with that history,

we could sign that out, and it's not a problem.

We often do that for people who are visiting from out of town

with very serious medical problems.

NARRATOR With this in mind, Dr. G

begins a careful review of Phil's medical records

and right away finds something that could explain his death.

He's had a heart att*ck about five years ago.

When you look at the EMS sheet, they

really suspected with his history

that it was the heart att*ck.

NARRATOR Each year in the US, an estimated

, heart att*ck survivors suffer a repeat episode.

And what Phil thought was just a stomach ache

may have very well been a symptom of another att*ck.

DR. G Abdominal pain can go along with a heart att*ck.

I have autopsied more than one person

who came in here with abdominal pain

and ended up having a heart att*ck.

NARRATOR Based on this history, it

appears she may very well be able to honor

the family's wishes and avoid a full autopsy.

And I thought, oh, good, I can sign this case out.

NARRATOR But just as she's about to close the book

on Philip Greene, a notation in the investigator's report

catches her attention.

He never was quite right that evening.

He has confusion and then mental status changes

where he's totally out of it.

So it could be something just in his brain.

[philip groans]

NARRATOR According to his wife, Philip's

abdominal pain and confusion began

immediately after his fall.

DR. G That makes me worry.

Maybe he has some type of blow to the abdomen

that's causing problems.

[tense music]

NARRATOR Now with multiple suspects at hand,

Dr. G is facing a tough dilemma.

DR. G Honestly, at this point, I don't know what to think.

I got the family not wanting an autopsy on one side.

I've got a history of heart disease.

I got the hospital saying it's probably a heart att*ck.

But on the other hand, I've got years of experience

saying this isn't adding up.

The more I read, at least I want to look at him

and see what's going on.

[ominous music]

He looks good. BRIAN MACHULSKI Yeah.

He really looks good.

DR. G (VOICEOVER) For years old, he looks great.

He looks younger than the stated age of , which is a wish

of mine when I get to be .

[suspenseful music]

NARRATOR Dr. G begins the external exam, searching

for signs of head trauma.

But she doesn't see any overt cuts or palpable bumps that

would suggest a serious injury.

All righty.

Doesn't look so bad.

NARRATOR Next, she moves on to Phil's body.

DR. G (VOICEOVER) And I notice that he does have some trauma.

He's got a big bruise on his arm,

little scrape on his elbow, and a bruise

and a scrape on his knee.

NARRATOR But Dr. G quickly determines

that the wounds are superficial and not in any way

life-threatening.

DR. G (VOICEOVER) I mean, if he looks completely normal,

there's nothing that looks odd, you know,

I'll think about signing him out.

NARRATOR But as Dr. G and her assistant, Brian Machulski,

remove what's left of Philip's clothing,

she gets her first good look at his lower abdomen.

And right away, she's convinced that she won't be able to sign

this case out after all.

I take his clothes off, his boxer shorts.

And I'm not so sure the hospital noticed this.

This is no plain heart att*ck.

[ominous music]

[soft music]

NARRATOR Dr. G has just made a shocking discovery

in the external exam of Philip Greene,

a -year-old retired schoolteacher

who d*ed unexpectedly while visiting his family in Florida.

For religious reasons, his wife, Nora,

is hoping to avoid an autopsy.

And Dr. G has been doing her utmost to honor that request.

DR. G (VOICEOVER) We really tried

to work with people who have true religious objections

to an autopsy.

I have to have really good reasons

to put the family through that.

NARRATOR But this latest finding may throw

the entire plan into question.

Oh, gosh.

OK.

DR. G (VOICEOVER) He's got a huge inguinal hernia.

[heavy music]
[ … ]

NARRATOR An inguinal hernia occurs when a part of the bowel

protrudes through a weak point in the lower abdominal wall.

Usually, it's absolutely a benign.

I mean, it's usually not a problem.

NARRATOR But in Phil's case, Dr. G

can see that the skin surrounding

Phil's groin and lower abdomen has become discolored.

DR. G It's red on the left side,

and there's redness on his abdomen

coming up from his scrotal sac.

I mean, something's going on here.

[tense music]

NARRATOR At this point, only one thing is clear.

Dr. G must proceed with the full autopsy.

I do not feel comfortable signing

this case out, not at all.

So I have to talk to the family.

And so I call them up, and we talk about it.

NORA Yes, this is Nora.

DR. G We talk about the pros and cons of never knowing

why their loved one d*ed.

We talk about the problems with things

that you can find out for other family members,

you know, inherited things.

So we just talk about the whole gamut of the information

you can get from an autopsy.

And don't they really want to know why he d*ed?

She's said that Dad passed away--

NARRATOR It's not an easy call for either Mattie or Nora

to make.

But ultimately, they decide to put their trust in Dr. G.

They fully understood and actually

wanted the autopsy by the time I got done talking to 'em.

DR. G So we've got him ready to go.

If I can get the answer to the head

and it's a clear-cut answer, I may not have

to do the rest of the autopsy.

[tense music]

So I start at the head.

You ready? BRIAN MACHULSKI Yep.

DR. G (VOICEOVER) I'm going to be looking

for trauma from when he fell.

I'm going to be looking for natural disease,

a stroke or maybe a bleed inside of his brain.

NARRATOR First, she cuts the scalp from ear to ear,

then peels back the skin.

And there, she makes an unexpected discovery.

Lo and behold, he does have a bruise

to the back of his scalp.

NARRATOR Dr. G now wonders if this might

indicate fatal head trauma.

DR. G Although they didn't think he hit his head.

You know, sometimes you can't tell.

Things happen so fast.

[saw whirring]

NARRATOR Doctor G's morgue technician, Brian Machulski,

cuts through the skull or calvarium

so she can access the brain itself.

[suspenseful music]

OK.

Let's see what we got here.

DR. G (VOICEOVER) And as soon as I open up that calvarium,

I peek in, and there's no blood.

Nothing.

He could have gotten that bruise on the curb,

but it didn't cause any internal brain trauma.

And when I cut the brain, there's no evidence of stroke

and no evidence of bleeding.

[suspenseful music]

NARRATOR No closer to solving the case,

Dr. G is now left with no choice.

We've got to finish the autopsy now.

I sure hope it doesn't end up to be a heart att*ck.

[tense music]

I start the Y incision, of course, on the chest.

They did say he'd hit his side.

And so I'm looking for rib fractures,

punctured lungs, anything along that line.

NARRATOR But her scalpel cuts into Philip's abdomen--

Oh, boy.

NARRATOR --an awful stench takes Dr. G by surprise.

It does smell bad.

DR. G (VOICEOVER) Something terrible has happened.

He's got bowel contents which have spilled

into his abdominal cavity.

There's clearly something wrong.

DR. G Look at that.

NARRATOR Right away, she can see that the bowel contents,

loaded with bacteria, have caused an infection

in the abdominal cavity, creating

pools of pus, inflammation, and dying fatty tissue.

It's a mess in here.

I don't know if his hernia is the cause of it yet.

But I suspect it is.

NARRATOR It's possible that Phil developed what's called

a strangulated inguinal hernia.

This occurs when the bowel protrudes into the scrotal sac

and becomes twisted or swollen.

DR. G The bile gets trapped into the scrotum sac,

and its blood supply gets cut off.
[ … ]

NARRATOR Starved of oxygen-rich blood, the bowel wall

begins to weaken and die, allowing

the bacteria to leak out.

And then that gets into your bloodstream

and you can die of sepsis.

OK.

NARRATOR But the only way to know for sure if Phil

suffered from this type of hernia

is to dissect his scrotal sac.

And while it doesn't take long to confirm Dr. G's suspicion--

There it is.

NARRATOR --there's an unexpected twist.

The hernia itself, though clearly present,

does not appear to have been fatal.

The bowel wall itself looks great.

There's no perforation.

It's not dilated.

There's no obstruction.

It looks good all the way around.

Nothing to do with that hernia.

[suspenseful music]

NARRATOR But if Phil's hernia didn't

cause the massive outflow of his bowel contents, what did?

The reason for it was not in that scrotal sac.

I have to look elsewhere in the bowel.

NARRATOR This means searching through pus, spillage, and more

than feet of bowels.

Oh, wow, that's nasty.

DR. G (VOICEOVER) You know, it's one thing

to deal with a decomposed body.

This is a whole different kind of smell

when you have bowel contents that have

gone into the abdominal cavity.

It's a nasty appearance, and it's a nasty smell.

This is going to be kind of a tedious, messy dissection.

[ominous music]

NARRATOR Dr. G surveys the jumble of internal organs

and spilled bowl contents in Philip

Greene's abdominal cavity.

A mess.

NARRATOR But there's a step she must

take before she can pinpoint the source of the leak.

It was such a mess in there that I

really wanted to do the chest first, give me some more room.

Go ahead.

NARRATOR With Brian's help, she cracks open the ribs

and removes the heart and lungs.

Given Phil's history of heart disease,

her next step is to weigh the heart and dissect it.

[suspenseful music]

Immediately, she can see the telltale mark

left by the first heart att*ck he suffered five years ago.

DR. G (VOICEOVER) From the nice, beefy, red heart muscle,

it's replaced by kind of white scar tissue.

So it clearly looks like a scar.

And when I look at his heart, he does

have coronary artery disease.

Hmm.

DR. G (VOICEOVER) But all his heart disease

looks very stable.

Nothing new, nothing acute, nothing

that's just happened to him, nothing that

would have k*lled him.

Even though he'd had a history of heart disease,

even though the ER said he had a heart att*ck,

it didn't really sound like a heart att*ck to me.

I'm glad it just didn't turn out to be a heart att*ck.

NARRATOR It's a huge relief knowing her initial instinct

was correct.

But she still doesn't know what caused the infection

in Phil's abdomen.

[suspenseful music]

I've got to deal with this bowel.

Let's see what's going on here.

DR. G (VOICEOVER) So you just--

you start at the beginning.

You start, you know, where the esophagus

goes into the stomach.

NARRATOR Then she follows the small intestine,

noting how it's abnormally expanded or dilated.

DR. G (VOICEOVER) It's got liquid and air in it.

That's a clear sign that he's got some type of obstruction.

NARRATOR Inch by inch, she works her way along his bowel.

Until finally, she hits pay dirt.

Well, look at that.

DR. G (VOICEOVER) I've got a -inch defect in the bowel.

It's open.

See that?

That hole?

DR. G (VOICEOVER) And the bowel contents are going

into the abdominal cavity.

That's not good.

Uh-uh-uh.

What caused that hole?

Well, one thing I'm worried about

is cancer may be eroding through.

But when I open it up, there's like necrosis or dead tissue

around the hole, but nothing that looks cancerous.

It truly was completely normal bowel except for the hole.

[suspenseful music]
[ … ]

So my assistant and I were kind of taking this bowel

out a little bit of time.

NARRATOR And then in a collection of pus,

she comes across something strange,

something surprisingly solid.

I'm like, what is this hard thing?

What is this hard thing loose in his belly?

NARRATOR Dr. G then grabs hold of the object

and pulls it out of the abdominal cavity.

DR. G (VOICEOVER) It was this round, hard stone.

[tense music]

NARRATOR The exact same size as the defect in the bowel.

DR. G (VOICEOVER) It took a second,

and then I realized this little stone-looking thing

is ultimately what k*lled him.

NARRATOR Now with the last piece of the puzzle literally

in her hand, Dr. G can finally replay

the bizarre chain of events that led

to Philip's unexpected death.

[heavy music]

[gentle music]

It's a gorgeous afternoon in Orlando.

And Philip Greene is enjoying his long-awaited family

vacation.

[child giggles]

Or at least he's trying to.

DR. G He's got this scrotal hernia

that nobody knows he had.

It must have been uncomfortable, but ultimately

didn't have anything to do with his cause of death.

NARRATOR But something else did--

a stone-like object in his intestines

called an enterolith.

DR. G An enterolith is like a rock that forms

inside your small intestine.

NARRATOR They may develop for a number of reasons,

ranging from a natural buildup of minerals in the body

to problems with the digestive system itself.

DR. G They're kind of like gall stones,

with concretions that form in layers, kind of like a pearl,

I guess, inside of an oyster.

Believe it or not, the most common reason for these things

are in the Middle East.

It's people who eat persimmons.

The undigested persimmon has this vegetable material

that kind of sticks together, coagulates, and kind

of forms this hard stone.

Any veterinarian you talk to knows

all about enteroliths because it's

a huge problem with horses.

If they eat enough alfalfa, the pH of alfalfa

is such that it kind of causes these stones

to form inside their bowel and they end up obstructing.

NARRATOR But in humans, they're extremely uncommon.

And most enteroliths are very small.

So Dr. G is surprised to find that Phil's

is nearly an inch wide.

They're not usually get that big,

and they just pass through your entire bowel

without any problem.

NARRATOR And Dr. G now believes it's

been forming inside his bowel for quite some time.

DR. G This man's enterolith took a while to develop--

days, weeks, maybe even months.

NARRATOR She suspects that the earliest symptom

was just a little constipation.

First, his problem was the obstruction.

Nothing was getting through.

NARRATOR But as the enterolith grows larger, a more

dangerous problem develops.

DR. G That enterolith is pressing on the inside wall

of the small intestine, kind of working

its way through that wall.

NARRATOR Gradually, it wears away the thin lining of tissue.

This was a time b*mb waiting to happen.

[tense music]

NARRATOR At this point, however, Phil most likely

could have defused the b*mb.

DR. G He could have had that bowel

obstruction easily corrected.

NARRATOR But Phil doesn't seek medical help.

DR. G Maybe he was starting to have these abdominal complaints

and really didn't want to tell anybody because he didn't

want to ruin their vacation.

NARRATOR And now on this beautiful day,

a minor misstep sends the enterolith

on a fatal trajectory.

DR. G When he falls and there's increased pressure,

it kind of pops it out through that weakened tissue.

And then clearly once that happened,

the bowel contents leaked out.

As that bowel contents leaks into his belly,

the bacteria start to multiply.

[tense music]

NARRATOR But the final blow comes when the bacteria

infiltrates his bloodstream.

DR. G Your body starts reacting to the bacteria.

Your vessels start to kind of lose their integrity

and kind of get dilated.

Your heart starts b*ating faster.
[ … ]

And eventually, you can't maintain your blood pressure.

You go into shock, and you can't provide blood

and oxygen to your vital organs, including

your heart and your brain.

Dad?

[phil groans]

NARRATOR By the time the -year-old

collapses on the floor--

I think he's had an att*ck.

He's fallen.

NARRATOR --it's simply too late to save him.

[siren wailing]

[soft music]

With the full report now complete,

Dr. G once again reaches out to Phil's wife and daughter.

DR. G (VOICEOVER) I think the family was shocked.

It's such an odd thing.

Like, didn't he have complaints?

I know something is going on with him prior to him falling.

And they're like, no, he's really private.

He's really stoic.

I mean, this is the definition of stoic.

NARRATOR But while both Nora and Mattie wished

Phil had shared his discomfort with them,

they ultimately find solace in knowing

the autopsy wasn't in vain.

DR. G (VOICEOVER) They were actually very

thankful that I did an autopsy.

They were thankful to really know why he d*ed.

Oftentimes, people are so afraid to do

an autopsy on their loved one.

But there are, you know, many things

you can find out that might help you

come to grips with the death.

[tense music]

NARRATOR Dr. G is the first to admit

that the majority of autopsies she

performs on older patients like Philip are relatively routine.

But when a seemingly healthy young woman dies suddenly,

it will take all of her skill and experience

to track down a hidden k*ller.

DR. G (VOICEOVER) I love cases that I really don't know

what it's going to be going in.

She's healthy, active -year-old woman.

This death could be just about anything.

[heavy music]

[light music]

Well, it's a rare treat for me to get out of work.

And today, we're in Charleston, South Carolina,

and it is beautiful here.

We've been invited to come up to this company, Berchtold,

to look at their surgical lights.

We've been told that these lights

are very energy efficient.

MAN Good morning.

Good morning.

DR. G (VOICEOVER) It's important for me

because, you know, good lighting really makes

or breaks an autopsy room.

So it doesn't limit the vertical range of the lights.

DR. G (VOICEOVER) I'm looking for lighting

from my new green morgue.

These lights look good.

But there's really only one way to find out for sure.

Nice to meet you.

Would you?

[light upbeat music]

When's the last time you've been to the dentist?

Oh, no.

[laughter]

I'm teasing.

I get to hold the heart.

Yeah, you get to hold the heart.

But look how nice--

it does have--

WOMAN Ooh.

[laughter]

DR. G I don't usually put 'em back, but we'll put that back.

[laughter]

NARRATOR Outfitting the new morgue properly

is a top priority for the entire District Nine team.

[soft music]

But back in Florida, bodies are waiting.

And one particularly troubling case has

gotten the attention of Dr. G.

[dramatic music]

[gentle guitar music]

It's a busy Saturday morning, and -year-old Judith Kerckner

is at her flower shop meeting with two new clients,

a bride-to-be and her mother, about arrangements

for an upcoming wedding.

But just a few minutes into the consultation,

Judith is suddenly overcome by some unusual and frightening

symptoms.

She, all of a sudden, started getting short of breath

and having difficulty breathing.

And she just collapsed right in front of 'em.

[dramatic music] WOMAN My god.

WOMAN Are you OK?

NARRATOR One of the clients immediately calls .
[ … ]

Emergency crew got there.

WOMAN She just collapsed.

PARAMEDIC Let's get her on the stretcher.

DR. G They tried to resuscitate her en route to the hospital.

[tense music]

[siren wailing]

But she didn't make it.

[somber music]

NARRATOR When Judith's only sister,

Christine, gets the news, she's overwhelmed with grief.

DR. G As you can imagine, her sister was floored.

I mean, she's at work, and she starts getting short of breath

and dies.

[suspenseful music]

NARRATOR And as Dr. G reads through the investigator's

report, she, too, is bewildered by Judith's death.

It is truly a mystery that this

-year-old perfectly healthy woman

just drops dead for no reason.

NARRATOR But the abrupt nature of the death itself

might provide a critical clue.

I suspect something sudden in her brain,

something sudden in her lungs like a clot,

or something sudden in her heart.

NARRATOR Still, all theories aside, Dr. G

knows that the truth behind Judith's untimely death

may not come so easily.

You know, you had sudden infant death syndrome.

I have sudden middle-aged woman death syndrome

because their cause of death are a lot more subtle

and take a lot more work for some reason.

[tense music]

NARRATOR But it's this very challenge that motivates

Dr. G to find the answer.

DR. G (VOICEOVER) I love cases that

are mysterious, that I really don't know

what it's going to be going in.

[suspenseful music]

DR. G Let's see.

Quite attractive.

DR. G (VOICEOVER) When I first look at her,

I notice something I hardly ever see in my morgue--

a dress.

I don't get too many people who die in a dress.

Do you want me to go ahead and undress her?

Yeah.

Yeah, go ahead and undress her.

DR. G (VOICEOVER) Most of my clientele

are hospital gowns or pajamas.

So right off the bat, I thought this is going to be unusual.

NARRATOR Next, Dr. G turns her attention

to Judith's arms and legs.

Oh, look at this.

When I get to her leg, she's got pitting edema,

fairly marked pitting edema.

NARRATOR Pitting edema is a common form

of swelling in the extremities.

The pitting refers to the telltale indentations

that briefly remain on the skin when pressure is applied.

If you press on it, it puts a little pit.

NARRATOR It may mean nothing.

But it can be an indication of some serious

underlying medical problems.

Well, there's many things that can cause that.

One of the things we look for-- may be kidney

failure, maybe heart failure.

I mean, she's kind of young for both of those things.

NARRATOR Dr. G records the observation on the body sheet,

then turns to examine Judith's head.

And as she palpates her scalp, she

discovers another abnormality.

Oh, her head's not good.

I feel a small contusion in her scalp.

NARRATOR There is a bruise on the back of Judith's skull.

The injury most likely occurred when Judith collapsed at work.

[tense music]

But now Dr. G must contend with another disturbing possibility.

What if the blow to her head is unrelated to her fall

in the flower shop?

Nobody really knows what she was

doing the previous hours.

Maybe the day before, the night before,

she had slipped and fallen.

[suspenseful music]

I mean, what's going on?

I don't know.

I'm not going to know until I do the autopsy.

[heavy music]

[suspenseful music]

NARRATOR Doctor G's morgue technician, Tom Hemphill,

prepares the body of -year-old Judith Kerckner for autopsy.

The florist d*ed suddenly the previous morning

while working with clients in her flower shop.

She just got up.

She was complaining of shortness of breath,

and then she collapsed.

We don't really have a lot to go on.

DR. G (VOICEOVER) And I'm hoping the autopsy

is going to give me the answer.

[tense music]
[ … ]

Just something to hold her head a little bit.

I got it.

NARRATOR But before opening her body,

Dr. G wants to further investigate

the bruise found on Judith's head during the external exam.

Did she slip and fall earlier in the day or the night before?

Got it?

DR. G (VOICEOVER) A delayed head

injury, that's not unheard of in a -year-old woman.

NARRATOR But the possibility of trauma isn't her only worry.

DR. G (VOICEOVER) In this case, I'll

also be looking for bleeding inside the brain

maybe from hypertensive disease or maybe

even a ruptured aneurysm.

So there are things in the brain that

could k*ll you quite suddenly.

[ominous music]

[suspenseful music]

NARRATOR Using her scalpel, Dr. G

cuts an incision across the back of Judith's head

and reflects the scalp to examine the tissue.

And what she sees immediately deepens

her concerns about trauma.

DR. G (VOICEOVER) I do see the scalp contusion,

the bruising of the scalp.

NARRATOR But did the bruise cause her death?

To find out, Tom opens Judith's skull or calvarium

with an oscillating saw.

[saw whirring]

Dr. G then pries of the skullcap for a closer look

at the surface of the brain.

All righty.

There's no significant edema.

There's no bleed in the subarachnoid space.

NARRATOR Next, she dissects the brain,

searching for any abnormalities or injuries.

DR. G (VOICEOVER) There's no bleed,

tumor, or other abnormalities inside the tissue of the brain.

The contusion on her head was clearly from when she stood up

with her shortness of breath and then

she had her sudden collapse onto the floor.

NARRATOR But the lack of findings

starts to raise her concerns that Judith's

death might go unsolved.

DR. G (VOICEOVER) I'm not going to like

this case if, once I'm done with the autopsy, it's negative.

[heavy music]

OK.

NARRATOR Dr. G opens the torso with a standard Y incision.

[suspenseful music]

Peeling back the skin, she gets her first look

at the abdominal organs.

DR. G (VOICEOVER) My initial examination

revealed relatively normal appearing abdominal cavity.

You want to get the tox?

So at this point, I go ahead and take my toxicology.

Because ultimately, tox may be the answer in this case.

After I take my toxicology, I open

up the rib cage in my usual style

and lift off that breastplate.

And I know something unusual--

Oh, look at that.

DR. G (VOICEOVER) --something I don't usually

see in the morgue--

an enlarged thymus.

NARRATOR The thymus is a small gland that rests

just under the breastbone.

It helps in the early development

of the body's immune system, changing in size

as a person grows older.

The thymus gland increases to its largest size of puberty,

and then it starts to decrease in size.

And by the time you're an adult, it's very, very small.

NARRATOR But in Judith's case, something is clearly wrong.

DR. G (VOICEOVER) Her thymus was very enlarged.

It was grams, way bigger than we normally see.

NARRATOR And this unexpected finding gives Dr. G

her first significant clue.

DR. G (VOICEOVER) The first thing

you think of when you think of an enlarged thymus,

for me, is myasthenia gravis.

NARRATOR Myasthenia gravis is a rare autoimmune disease

that severely weakens muscles throughout the body.

The disease can cause sudden death.

But typically, the person would experience symptoms for years.

DR. G (VOICEOVER) It'd be very rare, but it's a possibility.

TOM HEMPHILL OK.

OK.

NARRATOR Unfortunately, Dr. G cannot

diagnose myasthenia gravis until blood

tests return from the lab.

All right.

NARRATOR In the meantime, she turns her attention

to Judith's chest cavity.

Well, then I want to look at her lungs.

As you recall, the symptom was shortness of breath.

NARRATOR On first glance, they appear healthy.

But it isn't long before she finds cause for alarm.

DR. G (VOICEOVER) When I cut the lungs,

there's a lot of pulmonary edema or fluid buildup in the lungs.
[ … ]

NARRATOR This fluid buildup can often

indicate serious heart trouble.

So I really need to look at the heart.

NARRATOR Carefully, she cuts into the pericardial sac

that surrounds the heart and gets

her first glimpse at the organ.

It looks like the heart's enlarged.

That's not good.

DR. G (VOICEOVER) There are definitely some abnormalities.

[tense music]

NARRATOR To get a closer look, Dr. G removes the heart

and dissects it.

DR. G (VOICEOVER) When you cut the muscle,

the muscles appear somewhat soft,

and there's some pallor to it.

Hmm.

DR. G (VOICEOVER) The heart looks like it's

playing a role in this.

NARRATOR Judith's enlarged dilated heart, combined

with its pale appearance or pallor,

point Dr. G to one undeniable conclusion.

She's dying of some type of congestive heart failure.

NARRATOR Congestive heart failure

is a condition in which the heart becomes so weak it

can no longer pump effectively.

I know this is why she d*ed.

[soft music]

NARRATOR But this finding raises

more questions than answers.

How could a young woman who had no history of heart failure

suddenly die from the disease?

DR. G (VOICEOVER) It's not making sense to me how

a -year-old woman who's now dying

with congestive heart failure.

What is causing that heart to fail?

We got to dig a little deeper here.

What's going on?

[heavy music]

[soft music]

NARRATOR Dr. G has just discovered

that -year-old Judith Kerckner d*ed from heart failure.

DR. G (VOICEOVER) We know she's in congestive heart failure.

We know there's something wrong with her heart.

But inquiring minds want to know,

what is the reason for this?

OK, let's see.

NARRATOR One reason may be atherosclerosis, a buildup

of fatty plaque that can block arteries,

which, over time, can damage and weaken the heart muscle.

To investigate this possibility, Dr. G

carefully dissects the heart's slender vessels

and is surprised by what she sees.

DR. G (VOICEOVER) Her coronary arteries were actually clean.

She didn't have any atherosclerosis.

NARRATOR Furthermore, there's not a single sign

of abnormalities or defects that would have led

to congestive heart failure.

Right now, I'm not seeing much.

NARRATOR So far, the findings make no sense.

And Dr. G is quickly running out of options.

The only thing left is the neck.

I usually save that for last.

[suspenseful music]

NARRATOR And as Dr. G slices through the delicate neck

tissue, she encounters something completely unexpected.

She has a very enlarged thyroid gland.

A normal thyroid gland doesn't weigh that much.

Maybe grams, it weighs.

Hers weighed grams, really enlarged.

NARRATOR The thyroid is a tiny butterfly-shaped gland

that sits just below the Adam's apple.

But despite its small size, the thyroid has a big job--

regulating the body's metabolism.

DR. G When I saw her thyroid gland, it gave me an idea.

NARRATOR Putting all the clues together,

Dr. G now suspects that the enlarged thyroid

may have played a critical role in Judith's heart failure.

DR. G But I'm not going to be sure

until I look under the microscope

and get some of my blood tests back.

NARRATOR She takes tissue samples of Judith's thyroid

and sends them to the lab for processing.

Now all she can do is wait.

[heavy music]

[soft music]

A week later, the microscopic slides finally come back.

And Dr. G anxiously puts the sample of Judith's

thyroid tissue under the lens.

So when I look at the thyroid under the microscope,

all of these kind of subtle, weird things

that I'm finding in autopsy are making sense.

But before I sign the death certificate,

I want it confirmed with the blood test.

[suspenseful music]

NARRATOR She quickly turns her attention to the tox report,

zeroing in on Judith's thyroid hormone levels.

DR. G (VOICEOVER) Once I get the results,

I see that her thyroid hormone was extremely high.

Hmm.

NARRATOR Based on these findings
[ … ]

and the enlarged thyroid she saw at autopsy

and under the microscope, Dr. G now

knows exactly how and why the -year-old d*ed so suddenly.

The mystery's solved.

[heavy music]

[soft music]

NARRATOR It's just before noon, and Judith

Kerckner is meeting with new clients

about an upcoming wedding.

--having a flower girl, flower boy?

NARRATOR But today, she isn't feeling quite herself.

DR. G She's probably starting to feel a little jittery.

She's probably sweating a little bit.

WOMAN We'll see how that works together.

NARRATOR And Dr. G finally knows why Judith feels so sick.

She's got Graves' disease.

NARRATOR Graves' is an autoimmune disease that

att*cks the thyroid gland and causes

it to produce excessive amounts of the thyroid hormone.

DR. G This thyroid hormone, it affects every cell in your body

on how it metabolizes energy.

And so with a very high thyroid hormone,

you're going to get a very high metabolic rate.

NARRATOR The disease also explains the enlarged thymus

gland found during autopsy.

DR. G (VOICEOVER) She has an enlarged thymus gland, which

is what we often see with autoimmune diseases,

particularly Graves' disease.

NARRATOR Autoimmune conditions like Graves'

can be difficult to decipher.

But there are certain risk factors for developing them.

DR. PENNY GLICKMAN Women have more risk, about eight

times as much risk as men do.

Also, there's a genetic predisposition

if someone in your family has an autoimmune disease,

and you may be more at risk for developing that as well.

[suspenseful music]

DR. G I'm sure she had symptoms days and probably

weeks prior to this crisis--

the jitteriness, the tremor, difficulty sleeping,

sweatiness, the loss of weight, the palpitations.

[tense music]

NARRATOR In the weeks leading up to Judith's death,

her body starts making antibodies that

stimulate her thyroid gland, causing

it to produce more hormone.

This chemical imbalance causes Judith's heart

to b*at harder and faster.

And on that fateful morning, the weakened organ begins to fail.

DR. G The grave problem with that elevated thyroid hormone

is that it causes your heart to b*at faster that it can't

even get all the blood out each time

because it's b*ating so fast.

Her heart cannot keep pace with that b*at anymore.

And it's starting to dilate because not

enough blood is getting pumped out with each pump.

[tense music]

She stands up.

She's trying to take her breath.

And she collapses.

[somber music]

Her heart goes into a terminal arrhythmia.

And they can't revive her.

Ultimately, she d*ed from congestive heart failure

brought on by Graves' disease.

It's just sad because she could have prevented her death if she

had taken some of these symptoms a little more

seriously and sought medical help.

[MUSIC - DAN MAY, "FATE SAID NEVERMIND"]

NARRATOR But before she can close the book on the case

of Judith Kerckner, Dr. G must share the news

with her sister, Christine.

When you tell their next of kin

that they had a chronic disease that they knew nothing about,

they're always floored.

DAN MAY (SINGING) Where is the candlelight?

DR. G (VOICEOVER) Her sister said, I didn't know there

was anything wrong with her.

Unfortunately, she didn't think there was

anything wrong with her either.

DAN MAY When is it healing time?

When does the peace of mind--

DR. G It doesn't bring them closure,

but it gives them a little bit of peace at least

knowing what happened.