04x06 - Deadly Doses

[bunniefuu]

[somber music]

NARRATOR A devoted sister dies young after suffering

bizarre symptoms.

She developed severe itching.

NARRATOR And Doctor G's odds of solving the case

prove astronomically slim.

It's probably one in a million.

NARRATOR Then a mother's death shatters her family.

I miss everything about her.

NARRATOR But in autopsy, Dr. G uncovers answers her family

may not want to hear.

She's got some chronic pain.

And she also has depression.

I have to worry whether it's a su1c1de.

NARRATOR Altered lives, baffling medical mysteries,

shocking revelations.

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

You want to pick the pillow you're going to bring?

My older son Alex is going to college.

That's OK?

All right.

Did you see the dorm rooms when you were there?

Yeah.

Do they have more closet space or drawer space?

What else?

I think the hardest is when Eric and I are together,

my younger son, and we're going to sit around and miss Alex.

It's going to be touch.

All right, say bye to your sugar gliders.

Alex has had these since second grade.

ALEX Since seventh grade.

JAN GARAVAGLIA He's given me nothing but happiness.

He's a great kid.

Thank you.

(SOBBING) I'm going to miss you.

You too.

I think [inaudible].

All right.

Now I gotta go somewhere where I never cry.

So in this case, we have a -year-old black female

that's kind of an interesting story on how she got to us.

NARRATOR According to the investigator's report,

it all began the previous morning

in the home of Leah Conrad.

Leah lived with her younger brother Shane.

Saving every penny from her job at a local toy store,

she was putting him through night school.

Typically, Leah's at work by the time Shane gets up.

But on this morning, he's surprised to find her

on the couch.

Leah?

NARRATOR She's barely awake and incoherent.

JAN GARAVAGLIA She's getting slurred speech.

Her lips kind of turned blue.

The brother even thought maybe she was

having some seizure activity.

Huh?

NARRATOR Then Shane notices an empty box

and a half-empty bottle of over-the-counter dr*gs.

JAN GARAVAGLIA He gets her into the car.

They beeline it to the emergency room.

[tires screeching]

But by the time they arrive, Leah

seems to be doing a lot better.

She was walking, talking.

Normal level of consciousness.

NARRATOR She tells the ER doctors

she woke up that morning feeling flushed,

nauseous, and itchy all over.

Figuring it was an allergic reaction,

she took some diphenhydramine, an

over-the-counter antihistamine.

But the itch persisted, so she took more and more.

You know that old adage.

If one doesn't do it, let's try more.

Well, that's not good with medicine.

NARRATOR Concerned and a bit puzzled,

the ER doctors insist on running a few tests.

No, they obviously took her seriously

with the diphenhydramine.

You never know exactly how much she took.

They're kind of working her up on,

maybe it's an overdose, trying to figure

out what's wrong with her.

NARRATOR As they wait in the ER for the results,

Leah appears to be rapidly improving.

She looked like she was doing great.

NARRATOR Until suddenly, she falls unconscious.

The next thing they know, she starts to seize.

She goes into cardiac arrest.

Can I get some help here please?

NARRATOR The ER staff scrambles to revive her.

I need a defrib!

NARRATOR But tragically, they can't.

JAN GARAVAGLIA And she dies.

And they have no clue what's wrong with her.

NARRATOR Leah's brother can't believe she's gone.

And he desperately needs someone to explain what

happened to his big sister.

That someone is Dr. G. But like the hospital staff,
[ … ]

she faces a perplexing set of circumstances.

There's a lot of considerations in this case.

Certainly, the one thing I'm worried about

is, could she have d*ed from the diphenhydramine overdose?

NARRATOR In addition to its antihistamine properties,

diphenhydramine is a strong sedative that can cause

drowsiness even in small doses.

With the large amount Leah said she took,

the drug could have depressed her vital functions

to a dangerous level, low enough to stop her breathing.

Just a frank overdose where you actually cause

respiratory depression and die.

So we'll have to see how that plays a role in her death.

NARRATOR But then Dr. G finds something even more disturbing

and Leah's medical history.

Oh, boy.

She had systemic lupus erythematosus,

commonly known as lupus.

Systemic lupus is one of the autoimmune diseases.

That means basically your body is making

antibodies against yourself.

So somehow, your body almost-- just as

if you were going to react to a foreign substance in your body,

your body starts reacting to your own body.

NARRATOR The illness can affect almost any organ at any time.

Each lupus patient has their own flavor of disease.

patients with lupus have different disease

manifestations.

NARRATOR Many symptoms are benign

and occur during active periods known as flare-ups.

It is a common unknown entity of that disease that you have

flare-ups and then kind of remissions

and then flare-ups again.

Sometimes, people flare up during the normal course

of their menstrual cycle, just with the hormonal fluctuation.

NARRATOR But patients can also develop

serious complications, like hypertension and heart disease.

Certainly, there is a myriad of things

that you can die from with lupus.

NARRATOR Dr. G also notes that, between the occasional visits

to her specialist, Leah was taking prescription

dr*gs for her lupus.

Ironically, that treatment may have posed

another thr*at to her life.

And she's, lo and behold, on some very potent medicine.

That can have some side effects.

NARRATOR In particular, one of her dr*gs

prednisone, an immunosuppressant,

has been known to cause stomach ulcers.

An undiagnosed ulcer may have eroded

the lining in her stomach, erupting in

a fatal gastrointestinal bleed.

That's a possibility, something

maybe they didn't recognize right

away in the emergency room.

It's something I certainly want to look for.

NARRATOR But Dr. G doesn't know how

any of these possible causes of death

could fit with Leah's bizarre set of symptoms.

It seems pretty sketchy.

We've got the overdose.

We've got the drug she's on.

NARRATOR And then there's the itching.

You always worry when you have this really

weird symptomatology that maybe you're

not going to get an answer.

All right, let's see.

All right.

NARRATOR The first task at hand is for Dr. G

to see how severe Leah's lupus was.

She begins by checking for the most classic visible signs.

The butterfly rash and the malar rash right on the cheeks.

We look for a kind of a discoid rash, patches of red

with a scaly kind of surface on it.

NARRATOR But surprisingly, Leah has

none of these skin conditions.

She actually looked pretty good, except for, you know,

the resuscitation.

NARRATOR Dr. G then looks closer,

searching through other external marks of lupus--

swollen joints, ulcers in the nose and mouth, even hair loss.

She finds none.

She has a nice, thick head of hair.

NARRATOR The negative findings suggest

Leah's lupus was very mild, or at least

under complete control.

I don't even have any indication she has lupus,

except for the fact we have it in our history,

and it appears she's on meds that are consistent with lupus.

With modern medicine, most people

live for a very long time with lupus.

Maybe her lupus has nothing to do with her death.

NARRATOR But if complications from lupus

didn't k*ll this -year-old woman in the prime of her life,

what did?

I have to chart, you know.

Yeah, go ahead.

But after you do that, I'll do the ribs.

OK.

NARRATOR In the final stroke of the Y incision,
[ … ]

Dr. G cuts into Leah Conrad's abdomen

on a hunt for her cause of death.

One possibility is that Leah's lupus medication

caused severe ulcers, k*lling her

with a gastrointestinal bleed.

If so, the GI tract would be filled with hemorrhage.

Carefully, she reflects the skin and subcutaneous fat.

And with one look, it's clear.

Leah had no fatal blood loss whatsoever.

So I'm pretty much ruling out a gastrointestinal hemorrhage.

NARRATOR No signs of lupus and no signs the medication

for it caused her demise.

Dr. G must now consider the other drug

in Leah's history, the diphenhydramine she

took to ease her itchy skin.

It might be an overdose.

[inaudible] first.

NARRATOR With the help of her morgue technician,

Dr. G removes Leah's major organs

and isolates the stomach.

Because I wonder, you know, maybe she's

got a lot of pills in the stomach

and it's going to be a slam dunk.

NARRATOR But when she cuts open the organ, all she finds

is the natural lining of mucus.

Nothing really to write home about.

NARRATOR Unfortunately, whatever

Leah ingested before her death has already been absorbed.

And Dr. G will only be able to find out exactly how

much different diphenhydramine was in her system

through toxicology tests.

For now, it's time to shift gears.

JAN GARAVAGLIA OK, let's see.

If you have-- you know, I'm going

to take a lot of tissue, Arden.

NARRATOR Perhaps a natural disease could explain Leah's

symptoms, if not her death.

But with every organ she examines,

Leah appears as healthy internally

as she did externally.

JAN GARAVAGLIA All the organs look pretty good.

Her liver doesn't show signs of liver failure.

Her gallbladder looks fine.

I don't see anything that'll give me a hint so far.

Yeah, that's it.

NARRATOR In the meantime, Leah's brother

is waiting for answers as to how his seemingly

healthy -year-old sister could die so suddenly.

But Dr. G is no closer to identifying her cause of death.

She now has only one internal organ

left to dissect, the heart.

And it doesn't look promising.

She's never complained of heart disease.

She doesn't drink.

She doesn't smoke.

She leads a clean, healthy life.

So I'm not thinking that it's probably her heart.

NARRATOR First, she examines its exterior.

I look at the epicardial surface,

the surface of the heart.

That looks normal.

NARRATOR Yet there's something slightly odd.

It's somewhat rounded and dilated.

NARRATOR She cuts in for a better look.

I start with the left main coronary artery and just

dissect it out every few millimeters

and do a cross-section of that coronary artery.

NARRATOR And there, in these cross-sections,

Dr. G discovers that Leah's heart is riddled with disease.

She has % narrowing of her left main coronary artery.

She has % narrowing of her left anterior descending

coronary artery, the coronary artery that supplies

the front of the heart.

NARRATOR In fact, her vessels have been completely overrun

by arteries atherosclerotic plaque, layers of cholesterol,

and other waxy materials that obscure blood flow

and often trigger a heart att*ck.

[ambulence siren]

The condition afflicts more than .

million Americans every year and kills one patient every hour.

Most are older than .

But Dr. G believes there's a good reason

why Leah had such severe atherosclerosis

at almost half that age.

People with lupus have an earlier onset

of corneal artery disease.

So it looks like maybe she's got just

a run of the mill heart att*ck.

NARRATOR At last, it seems Dr. G has

found Leah's cause of death.

But then she detects something very strange.

Oh, boy.

NARRATOR Something else that could have k*lled Leah.

This is separate from the atherosclerosis.

NARRATOR It's on the lining of the arch

of the aorta, where the body's biggest blood vessels diverge.

She's got a thrombus attached to the aorta,

tightly attached to the wall, / of an inch in length

and about a half an inch in width.

It comes out maybe about a fourth of an inch.
[ … ]

NARRATOR Thrombi, or blood clots,

most often form in the body's smaller blood vessels

for reasons ranging from trauma to genetics.

But Leah's thrombus grew in her aorta, a large central vessel.

This is highly unusual.

And it could have been deadly if pieces of it

traveled to her brain and cut off the flow of blood.

She's had two episodes where people

say she had some mental status changes and maybe seizing.

MAN Can I get some help here?

I mean, it is a possibility she's

throwing these little clots that break off and go to the brain.

NARRATOR A minute ago, Dr. G had no possible cause of death.

Now, she has one too many.

It is always worrisome when I do an autopsy

and I don't find anything.

It's also worrisome that I'm not putting

it together when I have several things that could k*ll her.

Sometimes, actually, I wish I could save something

I found on one person and, you know, give it to somebody

that I can't figure out.

Because you know, if somebody already

has three reasons to die, they don't really need all three.

This guy needs one.

But unfortunately, I can't do this.

And I have to kind of figure out what really went on.

NARRATOR Unfortunately, none of the theories

would explain Leah's strangest symptom.

We've got her pure pruritis or diffused itching.

NARRATOR Still, Dr. G must explore every option.

Determined to unlock this mystery,

she extracts Leah's brain for inspection.

The search will be difficult.

The problem is, it's going to be a needle in a haystack

for me to find one of those little thrombi that

flicked off.

NARRATOR Ultimately, Dr. G finishes the internal exam

with a wealth of evidence and nothing that ties it together.

I don't have the smoking g*n yet that tells me why she d*ed.

NARRATOR To untangle this perplexing death,

Dr. G must now rely on the two forensic tools

left in her arsenal--

toxicology and the microscope.

JAN GARAVAGLIA I'm still worried

about the diphenhydramine overdose.

So I'll be interested to see what her level is.

NARRATOR Somewhere in Leah's blood and tissue

is the key to closure for her grieving

brother, if Dr. G can find it.

And I was going to say--

I was going to say-- you remember that--

There's no peanuts!

No!

My lunch staple!

All right, I'm going to run across the street.

Yeah.

NARRATOR A quick bite and it's time

to buckle down with Leah's tissue

slides and toxicology report.

Immediately, she checks the report

to see if Leah had overdosed on the diphenhydramine

she took too ease her itch.

The numbers tell a disturbing tale.

Her diphenhydramine level was very high,

past even the level that we see where you would take it

for a hypnotic to go to sleep.

NARRATOR But surprisingly, the dosage

is still far from deadly.

You don't really start getting lethal

until you start seeing seven or eight milligrams per liter.

Hers was closer to maybe a one or two milligrams per liter.

She clearly doesn't have enough that would k*ll her.

NARRATOR But the high levels do explain the state

her brother found her in--

lethargic and slurring her speech.

And she really didn't have anything else

of significance in her blood.

So I think we've ruled out an overdose on this case.

NARRATOR This leaves her with one more sh*t at deciphering

Leah's sudden death.

I really, at this point, can't wait until I look

at this under the microscope.

What is going on with this woman that

would really explain and unify all of her symptoms

and my findings?

NARRATOR Dr. G slides the first tissue sample under the lens.

Now, the thing that I was most fascinated with

was, why is there a thrombus on her aorta?

And so that's where I'm going to.

NARRATOR At times magnification,

she can discern the cell structure of the vessel wall.

Slowly, she turns the dial.

And what comes into focus takes her completely aback.

She's got inflammation-- like white cells and breakdown

products of the white cells--

all through the aorta.

NARRATOR The invasion has visibly damaged

the vessel's delicate tissue.

And the body is reacting to that

and putting a clot over it.
[ … ]

NARRATOR This is a sign of vasculitis, a condition

in which white blood cells att*ck and inflame blood

vessels all over the body.

The affliction is a rare complication of lupus.

Externally, Dr. G had found no symptoms of lupus.

But clearly, Leah's immune system had gone haywire,

and her medication was not enough to stop it.

What's happened is, this immune complex--

the antigen and that antibody which have formed together--

go into the vessel wall.

And that causes your body to react to it

and causes the white cells to get there.

NARRATOR Dr. G realizes vasculitis perfectly

ties together Leah's symptoms.

In the small blood vessels of her skin,

the inflammation gave her a vicious itch.

And in the large vessels of her heart,

the condition actually led to her death.

Her coronary arteries, when you look at them,

are completely inflamed.

The blood wasn't getting through those vessels enough.

And she ultimately has a heart att*ck.

She already had severe atherosclerosis.

And this was just the coup de grace.

NARRATOR The extent to which vasculitis assaulted

Leah's body stuns Dr. G.

Now, it just so happens, in lupus,

it tends to occur in the smaller blood vessels.

You don't usually see it in the large blood vessels.

Coronary vasculitis in a lupus patient

would be extremely rare--

certainly less than % of patients,

and maybe even less than that.

NARRATOR And Leah's vasculitis is not

just in the coronary arteries.

It's in the aorta, the biggest blood vessel in her body.

In the annals of forensic pathology,

Dr. G has made an almost unheard of finding.

Very, very, very rare.

It is vanishingly rare.

There's really only just a handful of cases truly that

are reported that lupus affects your aorta that way.

NARRATOR But for her, it's more than

an incredibly rare discovery.

You know, and this is probably one in a million

for me to see in the morgue.

I'm probably never going to see that again.

But it's just really--

that's just a really cool part of the job,

is to put the pieces together and say, boy,

I can really explain what was going on with her.

NARRATOR It's AM on a Monday morning,

and Leah Conrad wakes up to a fierce, unfamiliar itch.

Believing it's an allergy, she tries to fight it

with diphenhydramine.

times more than what you should normally take.

NARRATOR The drug impairs her motor functions.

She got some lethargy, some slurred speech.

NARRATOR Fearing an overdose, her brother

rushes her to the hospital.

But unbeknownst to him, or the doctors, or even Leah herself,

the real thr*at to her life is neither

allergies nor antihistamines.

I think what happened is, about three to four days prior

to her hospitalization, she was starting to get a horrible

flare-up of her lupus, manifesting itself

in just diffused vasculitis.

NARRATOR In her skin, white blood cells

ravaged the vessel walls, causing an unbearable itch.

And then they make an extraordinary move

into Leah's aorta.

She was getting more and more inflammation of her aorta.

The intima, or the lining, got irritated.

The blood tries to repair that by forming a clot on it.

NARRATOR But the vasculitis also strikes

in her coronary arteries, which were already

narrowed by atherosclerosis.

Now severely inflamed, the vessels can no longer

carry blood to the heart.

Even as the diphenhydramine wears off,

the damage reaches a catastrophic peak.

And finally, Leah suffers a heart att*ck.

MAN Can I get some help in here please?

Do it again.

Do it again.

Do it again.

NARRATOR No amount of medical intervention can save her.

Ultimately, you can boil this whole thing down

as complications of systemic lupus erythematosus.

Life is random.

Lupus is part genetic.

It's part environmental.

Nobody really knows what combination

of those environment and genetics

causes you to get lupus.

It's quite unlucky to to have to deal with a disease like that.

And then she has, you know, added unluckiness

of a rare complication from it.

NARRATOR Shane is relieved to finally have an answer.

But he's also overwhelmed by the truth behind his sister's
[ … ]

bizarre death.

He only wishes now that she had seen her doctor more often.

You know, a regular doctor might have picked up that this

was a flare-up of her Lupus.

Maybe this wouldn't have happened.

OK, that one's done.

NARRATOR Sadly, sometimes no amount of medical care

nor all the love in the world can save a person's life.

Such is the tragic case of Deborah Grunow a beloved mother

whose fight against chronic pain may

have driven her to her death.

She's been expressing that she'd

like to die for a long time.

I'm sure that's very difficult to live with.

It's been a long week since my son Alex left for college.

I told you today about Alex calling me last night, right?

WOMAN Yeah.

He is, like, so excited about school.

He's so excited about classes starting

and just, you know, having fun and doing

what he wants and, you know, the usual -year-old.

I miss him.

But you know, I can't complain.

Because in the morgue, I see plenty of people whose families

will miss them forever.

Tom, could you hand me a chart please, and an internal?

We have a -year-old white female

that was found unresponsive in a residence by her husband.

NARRATOR As she begins to read through the investigator's

report, Dr. G is immediately drawn

to a devastating automobile accident, one that

occurred years earlier and changed

Deborah Grunow's life forever.

She went off a cliff, and went into the windshield,

and hit the windshield with her head,

and caused the initial injury.

And then that just escalated over time

into degenerative disk disease.

NARRATOR Deborah was lucky to survive.

But her life would soon become consumed with a string

of surgeries and treatments all in a seemingly futile

attempt to ease her suffering.

But incredibly, in light of her constant battle with pain,

her sense of humor and free spirit

made Deborah the heart and soul of her close-knit family.

MARK GRUNOW Very enthusiastic about life.

She had a great sense of humor.

She was always cracking jokes.

And we always found something to laugh about.

In the name of love.

NARRATOR But no one could have imagined that yesterday

evening would be the last time anyone

heard Deborah's laugh again.

It all begins at around AM in the Grunow house.

Deborah is having difficulty sleeping

and decides to take a shower.

Her husband, briefly awakened by the noise,

drifts back to sleep in the bedroom down the hall.

And he hears the shower water go off.

That's the last he remembers.

NARRATOR A few hours later, he wakes up.

From outside the room, he hears a strange wheezing noise.

I just remember thinking that it was the dog snoring.

Then I got up and opened the door.

NARRATOR But it isn't the dog.

Honey?

She was on the floor there, just face down.

I lifted her head up to wake her up.

And I could tell by the look on her face

that it was-- it was big trouble.

NARRATOR His wife of almost years is barely breathing.

Frantic, Mark calls , then immediately begins performing

CPR until paramedics arrive.

They rush to the local hospital.

How long has she been like this, sir?

They try to resuscitate her for a good bit of time.

NARRATOR But Deborah remains unresponsive.

EMT I need you to step back.

We're going to have to shock her again.

They couldn't save her.

NARRATOR Her daughters don't even

get a chance to say goodbye.

When I got to the hospital, they took us into the room.

And they told us that she was gone.

They pulled the sheet down, and I looked at her

and pretty much just lost it then.

But--

[laughter]

MARK GRUNOW Ew.

- Don't spit. - No?

OK.

MEGAN GRUNOW I miss Everything about her--

the way she smelled, the way that she would

just make everything better.

DESIREE GRUNOW I talked to my mom everyday.

That's probably one of the hardest,

that I can't just pick up the phone and call.

[sniffs]

NARRATOR But the family's loss is

made even worse by the mysterious circumstances
[ … ]

surrounding Deborah's death.

What could have cut down their beloved mother and wife

so suddenly?

Now, Dr. G is the only one who can try to provide

some sense of closure.

But it won't be easy.

As she studies Deborah's medical history,

she does notice one clear red flag.

She has a history of high blood pressure.

She doesn't necessarily take her high blood pressure medicine.

So her blood pressure is not well controlled.

NARRATOR Deborah's hypertension,

or high blood pressure, had almost

k*lled her more than once.

Her blood pressure would be so high.

And there would be people in the waiting room.

And they would usher her right in, because it

was so dangerously high.

NARRATOR It is estimated that blood

pressure-related conditions, such as strokes and heart

att*cks, k*ll approximately , people each year

in the US.

Perhaps Deborah was one of them.

She may have had a stroke.

But high blood pressure is also a risk factor for developing

coronary artery disease.

NARRATOR But there's another red flag--

Deborah's history of degenerative disk disease.

This disease can develop after a severe accident,

resulting in damage to the disks of the neck and spine.

JAN GARAVAGLIA They can get a lot of pain in the neck.

Most people, it's mild to moderate.

And with some people, it can be quite severe.

NARRATOR This condition had plagued Deborah since her car

accident years ago.

DESIREE GRUNOW She tried massages.

She tried acupuncture, meditation, yoga.

NARRATOR But nothing seemed to work.

Eventually, Deborah turned to medication for relief.

But over many years, the dosage she required to feel normal

continued to increase.

Dr. G knows that any time a decedent

is on prescription painkillers, there is a possibility

of an accidental overdose.

But that's not the only scenario the pills present.

Chronic pain and depression can go hand-in-hand.

She just didn't want to hurt anymore,

and she didn't want to hurt us anymore.

For Dr. G and Deborah's family,

her depression presents another fatal scenario,

one that her family can't bear to face--

su1c1de.

She talked about taking her life,

because she just couldn't take the pain anymore.

NARRATOR Is it possible that this mother of two

took her own life, leaving her pain and her family behind?

The first thing Dr. G notices in the external exam

is three suspicious marks on Deborah's face.

A small abrasion on her chin and on her upper forehand

and one in her hairline.

NARRATOR This in and of itself doesn't raise alarm bells.

But soon, she begins to uncover dozens of small injuries

all over Deborah's body.

She's got a lot of multiple bruises

on her body of various ages.

NARRATOR The discovery raises an entirely new possibility.

Did Deborah simply die from some fatal injury?

I think it's just that left hand, isn't it?

NARRATOR Dr. G catalogs scrapes and contusions

as she continues the external exam on Deborah Grunow's body.

She certainly has a lot of bruises on her.

NARRATOR Deborah, a -year-old mother of two,

d*ed suddenly yesterday.

Based on her history of taking large doses of medication

for neck pain, Dr. G now speculates as to how she may

have gotten all those bruises.

Probably consistent with her falling,

as if she had been staggering for a while.

NARRATOR If the pain medication had begun to impair Deborah's

motor functions, she may have fallen and suffered

a fatal internal injury.

Maybe she fell and hit her head.

And then she gets a subdural, or she gets bleeding.

NARRATOR Every year, nearly million

Americans trip or fall in their homes and land in the ER.

Thousands die from their injury.

[ambulance siren]

I've had somebody fall where they get bleeding

into the lungs from a punctured lung or a torn vessel

from the fracture.

And we get some kind of delayed deaths from the fall.

NARRATOR Now, Dr. G turns to the most likely place

to find signs of trauma--

the head.

If she can prove Deborah d*ed from an injury and not su1c1de,

her findings could provide tremendous relief.

Keep your fingers crossed.

We've got the head.

NARRATOR First, Dr. G pulls back the scalp,

then carefully takes off the calvaria,
[ … ]

or the roof of the skull.

I'm looking for anything unusual in her brain.

NARRATOR So far, the organ looks normal.

Carefully, she extracts it for a closer look.

I slice it.

And I don't see any evidence of hemorrhage, any trauma.

NARRATOR She also checks for infarcts, or dead tissue, that

may indicate that Deborah's hypertension

had triggered a deadly stroke.

But she finds none.

There's nothing that would suggest that her brain

was the cause of her problems.

NARRATOR Deborah's brain may be clear of trauma and illness.

But in the fatal injury scenario,

several of the internal organs could still be likely suspects.

Dr. G makes her usual Y incision and reflects the skin.

Poor thing.

NARRATOR Then she starts searching for injuries

and internal bleeding.

I'm looking underneath for hemorrhage.

I'm certainly looking at the ribs

to see if there are any rib fractures.

NARRATOR But she soon realizes it's a dead end.

She's got a few little things, but nothing

that should have k*lled her.

NARRATOR Deborah's bruises, likely caused

by repeated falls while under the influence

of her medication, were only superficial, not fatal.

But the medication may have had another possibly fatal effect--

an overdose.

It's a sad state of affairs.

She is constantly taking too much medication,

all because of chronic pain.

There would be times I would come home and find her curled

up in the fetal position on the floor,

just crying like a baby, just because of the pain.

NARRATOR Did Deborah drug herself to death in a su1c1de?

Dr. G begins her search for evidence.

Often an overdose, whether intentional or accidental,

leaves the decedent with very heavy, wet lungs.

Whatever the reason, the lungs often will fill up with fluid.

NARRATOR But Deborah's lungs are not congested.

You know, as soon as you just don't see those tremendously

heavy lungs, you kind of think, eh, maybe it isn't an overdose.

NARRATOR Still, there is one other organ

that could clearly point towards an overdose and to su1c1de--

the stomach and its contents.

The stomach, on a case like this, may be important.

Because a lot of the stuff in her stomach is pills.

That usually indicates it might be a su1c1de.

People who want to k*ll themselves

will take a lot of pills at once--

, pills at once.

And some of those may still be in the stomach.

NARRATOR To examine the contents, Dr. G

first ties off both ends of the organ

at the esophagus and the duodenum.

Then she cuts it open and empties it out

into a container.

I went up the gastric and scooped

out what was left there.

I took the duodenum, , what's in the duodenum scooped it out,

put that in there.

I can do it through a strainer.

I can sometimes just pour it over my gloved hands

and catch some of the solid pieces.

Or you can just swirl it around and look at it and smell it.

NARRATOR It's a moment in the autopsy

that puts aspiring medical examiners to the test.

This would keep a lot of people out of this profession.

So stomach contents is a source in the autopsy where

some people will walk away.

It can have some type of melodious odor.

But it is an important part of the autopsy.

So if you can't look at stomach contents,

don't go into forensics.

NARRATOR She painstakingly thumbs

through several indecipherable remnants of food

before finding her first clue.

I see two-- a fragment of maybe two pills.

NARRATOR Her finding confirms that Deborah

had ingested medication shortly before dying.

But it's not nearly enough to have k*lled her on its own.

If I'd have found , it would have been a smoking g*n.

But I'm finding fragments of two.

Eh, that'll help you get the tox.

NARRATOR Any evidence of an overdose

will need to come from a toxicology screening.

Dr. G has her assistant, Arden Monroe,

package fluid samples from Deborah's arteries,

bladder, and eye.

But test results won't be in for several weeks.

Until then, there's nothing more Dr.

G can do to determine whether Deborah d*ed from an overdose.

But she can look for evidence of the other suspected

culprit, high blood pressure.

She has been diagnosed with high blood pressure.

And she's not taking their high blood

pressure medication regularly.

NARRATOR Dr. G knows Deborah's hypertension
[ … ]

didn't k*ll her with a stroke.

But it's possible that it thickened her heart

and led to a fatal arrhythmia.

So it's Deborah's heart that she examines next.

OK, let's see.

NARRATOR Yet, after careful scrutiny,

Dr. G is surprised by the organ's condition.

I didn't see any evidence of heart disease.

She didn't have any evidence that it was failing.

Now I've pretty much ruled out that her heart

is a contributing factor.

It looked fine.

We've looked at the organs, the chest, the abdomen.

I don't see anything really wrong.

NARRATOR No trauma.

No signs of an overdose.

No indications that their high blood pressure

caused a stroke or heart att*ck.

After a full autopsy, Deborah Grunow's death has become

more of a mystery than ever.

At a laboratory in Melbourne, Florida,

the blood and urine of Deborah Grunow spins in a centrifuge.

It's the first of many steps in identifying

what substances were in her fluids when she d*ed.

For Dr. G, these toxicological tests

are the last hope of determining what k*lled

this -year-old mother of two.

I miss everything about my mom.

MARK GRUNOW It was sudden and unexpected.

And it was very painful.

NARRATOR But while the family is desperate to know what

happened, there's one answer they don't want to hear--

su1c1de.

I was very concerned that she may have taken her life.

I really was afraid of that.

NARRATOR Will the truth bring Deborah's loved

ones relief or more heartbreak?

Ultimately, I get the scientific facts.

Certainly, my call will give them either peace or sometimes

anguish.

It always is a tough time for the family, and I know that.

NARRATOR Dr. G Finally sits down with the report

from the toxicology lab.

And the extent of Deborah's medication regimen

soon becomes very clear.

JAN GARAVAGLIA She's on three anti-anxiety medications.

She's on a lot of antidepressive medications.

NARRATOR On top of that, she had

two potent painkillers in her system, one of which

is another sedative, methadone.

Her methadone level was very high.

And you put that with a combination of all

these medications levels.

It's clearly why she d*ed.

So we have a cause of death.

And that's mixed drug intoxication.

NARRATOR For the family, this could

be the answer they feared most.

Deborah might have k*lled herself.

But Dr. G must now weigh the evidence and make the call.

How am I going to determine whether it's

su1c1de versus accidental?

Which one is more compelling?

Which one is more compelling to me?

Well, one, you look at the history.

And we don't have any previous su1c1de attempts.

NARRATOR Dr. G also considers the hard numbers

in the tox report.

All of those medications were in the therapeutic range.

And her level is all just a little bit high.

And we do know that she's chronically

trying to treat her pain.

NARRATOR Taking into account all of this evidence,

Dr. G comes to her conclusion.

We know that she walks the line--

that razor line between what can k*ll her and what

puts her out of her misery.

This time, she just crossed the line a little too far.

And it really-- when you look at the combination of dr*gs

that she's on and the levels, it looks much more

like an accidental overdose.

And I think the preponderance of evidence in this case

is that it was accidental.

It's very difficult to really swing the other way

with su1c1de when we know she's taken

so many dr*gs for so long.

And it doesn't take much more to put her over.

NARRATOR After careful analysis,

Dr. G can now replay the final hours leading

up to Deborah's tragic death.

It's AM, and Deborah Grunow is too uncomfortable to sleep.

Her back and neck are aching again,

so bad she can barely stand it.

Hoping to get some relief, she takes several methadone pills.

But when that doesn't do the trick,

she opts for still more medication.

She probably pops a lot of dr*gs,

adding more central nervous system depressant.

NARRATOR By AM, she's likely

in a drug-induced stupor.
[ … ]

Then, at some point, she goes into the shower.

JAN GARAVAGLIA Maybe she had vomited on herself.

Maybe she's trying to wake up.

NARRATOR But inside Deborah's body,

the mixture of central nervous system depressants

is taking effect.

The dr*gs attached to receptors in Deborah's brain,

suppressing the signals that control her vital functions.

They affect sites in your brainstem

that control your restoration.

NARRATOR Her breathing and pulse start grinding to a halt,

and Deborah falls into a coma.

When we hear the snoring, usually, it indicates to us

that the person's in a coma.

NARRATOR By the time her husband finds her,

no amount of CPR, no amount of professional help

can bring her back to consciousness.

JAN GARAVAGLIA It's too late.

She eventually stops breathing and dies.

NARRATOR The cause of death is clearly

an overdose, but, according to Dr. G, not an intentional one.

On this night, she simply pushed the limits of

her many prescriptions too far.

I was very relieved to know that it wasn't a su1c1de.

And I felt very reassured after speaking with her.

DESIREE GRUNOW She really, truly cared.

And she took the time to dig and find out what happened.

NARRATOR But despite the reassuring finding,

Deborah's death continues to fill the family

with lingering grief.

MEGAN GRUNOW My mom's still gone, so I can't change that.

I have regrets that I just couldn't have been there

with her right at the last minute,

and just to tell her how much I loved her,

and how much I cared for, and how much she meant to me.

I learned a lot from him what it was like on his end,

living with that.

So you know, I believe that's a big part of forensic.

You learn a lot from the family.

But you also can give them a lot of comfort.

And I get comfort from my family.

I made the mistake.

I bought roasted peanuts instead of raw.

Here, guys. You want one?

You want a peanut?

Do you like the roasted?

Do you like it?

Oh, he took it.

The worst part of Alex missing is, Eric

and I have to clean that cage.

[tranquil music]

ANNOUNCER Atlas.