04x07 - Twist of Fate

[bunniefuu]

[ominous music playing]

NARRATOR A minor car accident lands a healthy woman

in the hospital, but the medical team

is stunned when the seemingly routine fender

bender suddenly turns fatal.

She appears to be doing better.

And then, all of a, sudden she's codes, and she dies.

NARRATOR And only Dr. G can unlock the mystery

behind her bizarre death.

This is a case that needed an autopsy.

NARRATOR Then, when an elderly man

dies during a battery of tests, everything points

to a heart att*ck.

But what seems like a cut-and-dry case

turns out to be a complete enigma.

JAN GARAVAGLIA I don't know what to put

on the death certificate.

I would like to know what's going on.

[music playing]

NARRATOR Altered lives, baffling medical mysteries,

shocking revelations--

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

[music playing]

It's AM in Orlando, Florida.

At the district morgue downtown,

the staff prepares for the day's cases.

One of them is a badly decomposing body whose autopsy

later this afternoon will be observed

by a group of prosecutors from the state attorney's office.

Ashley Shaughnessy, a recent graduate

of the University of Central Florida,

and newly hired morgue tech, is unsure about

whether the body should be left in the body bag or not.

I, personally, would do him outside of the bag

on the table.

He's going to be too messy.

He's not far gone enough, where he's nice and petrified

on the inside.

Yeah, I would.

ASHLEY SHAUGNESSY It's a fun environment.

The people are great.

There's so much you can learn here.

Dr. G and all the doctors possess

such a wealth of knowledge that I wish I

knew everything that they knew.

How are you today, Ashley?

Good, how are you?

Good.

It's like, I thought I was upstairs, and I had

to run down and [inaudible].

Oh, you thought you were working upstairs today?

Yeah, good thing I had scrubs in my car.

Do you have shoes besides your high heels?

Yeah.

Oh, good.

NARRATOR Once the station is prepped,

Ashley will assist chief medical examiner

Dr. Jan Garavaglia with the first case on the docket--

the death of a -year-old woman named Anna Lopez.

She passed away yesterday, several days

after a minor car accident.

The unexpected death has confounded

Anna's doctors and her family, and both

are now desperate for answers.

If you want to grab me a female for me and an internal.

When I'm first reading the case, my investigator

states that the family really wants an autopsy.

And although I don't do autopsies by request,

this is a case that needed an autopsy.

[music playing]

NARRATOR According to the investigator's report,

-year-old Anna Lopez--

a retired saleswoman-- was driving to her home

in Kissimmee, Florida, when suddenly she's

overcome with sh**ting pains.

She said, I got a pain in my neck

that kind of went into the head, and pain in my chest,

and in my back.

It appeared to radiate down her back.

She said, and it was severe and intense.

And then, she started losing her vision.

And the next thing she knows--

[tires squealing]

--the police are there, and she's been in an accident.

RALPH LEONARD She was semi-conscious.

And she's saying, do I look all right?

And I just said, yes, ma'am, you're fine.

She really wasn't overly coherent of what was going on,

and we waited for medical to arrive.

And once medical arrived, they transported her.

NARRATOR Mrs. Lopez is hospitalized for four days,

and doctors run a battery of tests,

including a detailed CAT scan of her head and abdomen, x-rays,

and blood work.

They think maybe she's got a heart att*ck,

or maybe she's had some minor fainting event

and then had some major trauma.

NARRATOR But tests are inconclusive.

Doctors can find no explanation for her sudden loss

of consciousness, or her episode of intense pain.
[ … ]

They really can't figure out what's wrong.

She appears to be doing better.

And then, all of a sudden, she's codes, and she dies.

[music playing]

And her family's bewildered.

Why did she die?

The doctors are bewildered.

Why did she die?

Did she die from trauma that was missed?

Did she die from natural disease that was missed?

So of course, the family wants an autopsy, and so do I.

Her history is not--

she looks like she's in great shape, besides this.

Not really much going on.

She had some breast implants.

So yeah, it'll be interesting to see if they missed trauma.

Did they miss natural disease?

What really is going to be going on with her?

It should be an interesting case.

[music playing]

NARRATOR As a first step, Dr. G inspects the body.

And right away, she's taken aback by its condition.

You know, when I do the initial external exam,

I'm really kind of amazed how good she looks.

Her hair still looks really nice.

She's obviously been able to fix her hair in the hospital.

And her hair is dyed--

really pretty color.

She's got breast implants.

She's shapely.

She doesn't look years old, and she

doesn't look like she just spent four days in a hospital.

Do you want me to help you here in a second?

I like to try and struggle for a little bit first.

I'm going to help you.

Come on.

[laughs]

NARRATOR Dr. G carefully inspects

Mrs. Lopez's head, looking for any injuries

sustained in the crash.

I'm thinking, maybe they missed some trauma?

Maybe they missed some fracture or bleed somewhere

that they didn't pick up on.

NARRATOR She finds nothing externally,

but cannot rule out a traumatic brain injury,

or even the possibility of natural disease--

such as a stroke--

until the internal exam.

Looking next to the extremities, Dr. G

does find evidence of minor bruising

from the accident on Mrs. Lopez's arms and knees.

And then, she notices something that might not be so minor--

a bruise in the middle of Mrs. Lopez's chest.

Here, she has a little contusion--

a little ecchymosis-- bleeding under the skin of her chest.

NARRATOR The bruise may be simply a result

of resuscitation efforts in the hospital,

but it might also mean that Mrs. Lopez sustained internal chest

trauma in the accident.

The question now is, did the doctors miss something?

JAN GARAVAGLIA Is there hemorrhage in the muscle?

Is there anything broken under that that wasn't

picked up on chest X-ray?

I really need to investigate that

a little further when I make the incision and do the autopsy.

[ominous music playing]

She can start.

Can Arden start taking the wraps off of your lady?

Yes, right here?

[music playing]

NARRATOR Dr. G is ready to open the body of -year-old Anna

Lopez, who d*ed mysteriously in the hospital, several days

after a minor car accident.

Her family members, stunned by her sudden death,

are now anxiously awaiting word on the autopsy.

JAN GARAVAGLIA She was, to their eyes, completely healthy.

So they want an answer.

[music playing]

NARRATOR Dr. G begins the internal exam with the head.

Knowing that Mrs. Lopez lost consciousness just prior

to the accident, she wants to make sure

that she didn't have a stroke or suffer any traumatic brain

injury in the collision.

Well, you know, I am curious in this case,

because something is happening to her

that caused her to become unconscious

before the accident.

So we clearly have some natural disease.

So in what role do we have?

Now, you can have natural disease and faint,

and still have major trauma and die from the car accident.

That's clearly an accidental death.

Or you can have natural disease causing you to pass out, wreck

your car, and have very little trauma from that,

and then die from the natural disease--

just having a heart att*ck in the car,

and then dying from that.

So the question is, what role does the accident play?

What role does the natural disease

play, or do they both play?
[ … ]

So I reflect the scalp, and I'm looking for bruises

on the inside of the scalp.

I don't see any.

The calvarium looks good.

And I take the calvarium off, remove the brain,

and her brain looks good, too.

NARRATOR Until she begins to dissect the organ--

then she discovers that Mrs. Lopez suffered a stroke, one

known as a lacunar infarction.

Lacunar infarctions are tiny strokes,

less than millimeters in diameter,

which occur in the small vessels deep in the brain.

After the stroke, the body reabsorbs the clot,

leaving a small hole--

or lacune-- in the brain.

These holes can be benign, but may

also lead to major neurological problems, such as paralysis.

Basically that lacunar infarct is

a small area of brain, deep in the brain, that's dead--

that's got a little hole in it.

I, personally, don't want little holes in my brain.

NARRATOR The stroke might explain Anna's loss

of consciousness in her car.

Dr. G examines the infarct more closely

to determine its severity.

[music playing]

JAN GARAVAGLIA It looks acute.

It looks like it's probably several days old,

but it's only two millimeters in size.

That's very small.

NARRATOR Dr. G's conclusion--

a stroke of this small magnitude could not have

caused any of Anna's symptoms.

JAN GARAVAGLIA I don't see anything that would cause

her to pass out necessarily, or explain

her severe onset of pain.

NARRATOR But while the stroke might not

explain Anna Lopez's death, it does disclose

something about her life.

She wasn't as healthy as her family thought.

JAN GARAVAGLIA Lacunar infarcts are associated

with high blood pressure.

So although it's probably not her symptomatology,

it does tell me that she's probably

got longstanding high blood pressure.

NARRATOR High blood pressure is a devastating and little

understood illness, which-- left untreated--

can lead to a myriad of critical health problems.

There are so many ways that it can affect you,

and it's usually through your vasculature.

Whether it's your vasculature in your brain, in your heart,

it affects your whole body.

And you feel great--

often until you're dead.

[music playing]

NARRATOR Could Anna's high blood pressure

be a clue to her sudden death?

And if so, could it be in some way related

to the strange chest trauma discovered

during the external exam?

[music playing]

Dr. G opens the body with a Y incision.

The Y incision is the standard incision in forensic science

to gain access to internal organs,

but it's not the only way to open a body.

Sometimes, when autopsying women who

have had breast augmentation, Dr. G uses

what is known as a U incision.

In a U incision, the scalpel is drawn from the collarbone,

down, under the breast, and back up again.

Occasionally, we'll do a U incision

and just go underneath the breast implants

and flip it up that way.

It really depends on the size of the implants for me

which way I'll do it.

But I didn't do a U incision on hers, because hers

weren't massive implants.

I thought I could easily still do the Y incision

and keep the implants in place.

So I do the Y incision, and I remove

the skin from the muscle, particularly on the chest.

I'm looking for hemorrhage.

I'm looking for hemorrhage in the muscle,

particularly under that pink area

that I saw kind of near the sternum,

and there's nothing there.

I don't see me hemorrhage that would suggest trauma.

I don't see any rib fractures.

So my initial Y incision doesn't really tell me much.

My next step then is to go into the chest.

NARRATOR While Dr. G didn't find any trauma in the ribs

or tissue overlying the chest, she

can't rule it out completely until she examines

the chest organs themselves.

JAN GARAVAGLIA I use my loppers and go up the anterior ribs.

Now, the chest plate has tissue that connects

to the pericardial sac.

And they have some arteries and veins coming down,

so I have to cut that off from the inside of the sternum.

And I remove that, slowly.
[ … ]

And then, that gives me the view of the lungs

and the pericardial sac.

Well, lo and behold, there's a lot of hemorrhage

that has gotten in that tissue.

I see blood in the left pleural cavity.

A little blood in there.

And I see blood--

a lot of blood--

extending down the aorta.

So the question is, where is this blood coming from?

What is the cause of this blood?

[ominous music playing]

[water rushing]

NARRATOR Dr. G has just discovered copious amounts

of blood in -year-old Anna Lopez's left chest

cavity and pericardial sac.

JAN GARAVAGLIA This is clotted blood around the heart,

and there is a lot of it.

So the question is, what is going on?

NARRATOR The blood could be from trauma sustained

in the car accident, even though it

appeared the bruise on her chest was only superficial.

But it might also be the result of a massive heart att*ck,

especially given Mrs. Lopez's age and history

of high blood pressure.

Sometimes, a stressful event raises your blood pressure

and can put you at risk for making your heart work harder

and end up getting a heart att*ck.

NARRATOR Did Anna Lopez die from chest trauma

or a catastrophic heart att*ck?

Ashley suctions the blood from around the heart

so that Dr. G can have a clearer look at the muscle.

JAN GARAVAGLIA I have to remove all that blood.

And then, I look at the heart muscle

itself, because if it's from a heart att*ck,

there's got to be necrosis of muscle and a hole in the heart

where the heart muscle weakens.

And then, it finally tears, and the blood rushes out.

So as I'm looking at that heart muscle in situ--

in her chest--

I see normal-looking heart muscle.

The heart muscle looks good.

NARRATOR But if Mrs. Lopez's heart

is normal, where is the blood coming from?

Like following a trail of blood at a crime scene,

Dr. G traces the path through the chest cavity.

And deep inside, she finally discovers the source

of the massive hemorrhage.

I see that there's something abnormal in the aorta.

NARRATOR The aorta is the largest

blood vessel in the human body.

JAN GARAVAGLIA Aorta should look kind of yellow and kind

of firm--

pliable, but firm.

And what I see is a lot of blood around it.

I don't even see the aorta tissue.

NARRATOR This could mean only one thing--

Mrs. Lopez's aorta must have a hole in it somewhere.

JAN GARAVAGLIA I want to see where the tear is

and what that tear looks like.

So the next thing I do is I remove the heart and the aorta

together.

And then, I start dissecting out the aorta.

I'll go ahead and open the aorta all the way up

and around the arch, which is almost

the size of a good sized hose.

And that's where I see the tear.

NARRATOR The tear on Mrs. Lopez's aorta

is four centimeters in length.

It is located on the ascending part

of the aorta, less than two inches

from the heart's aortic valve.

This is, without question, the smoking g*n and the cause

of Mrs. Lopez's sudden death.

She d*ed from a dissected aortic aneurysm.

[music playing]

[heart b*ating]

It's not survivable.

It's not compatible with life.

NARRATOR The critical question now is, what caused it?

Aortic dissections that occur in the chest cavity--

also called thoracic aneurysms--

k*ll approximately , people annually in the US.

They are typically caused by one of two factors--

disease or trauma.

[music playing]

Dr. G finishes up the autopsy.

Then, she must consider the evidence

in the case, both forensic findings and facts

from the investigator's report, to render a decision as

to what triggered Mrs. Lopez's fatal dissected

aortic aneurysm--

the force of the car crash, or natural disease?

JAN GARAVAGLIA Well, you have to look at the whole picture.

First of all, the aneurysm appears

to have started in the ascending portion of the aorta.

It's not in the area where we see the traumatic tears.

NARRATOR Second is the timeline.

Mrs. Lopez's symptoms began prior to the accident,

not after.
[ … ]

What's more, Dr. G found no significant trauma

to the body, which would be expected if the dissection

occurred during the collision.

JAN GARAVAGLIA I don't see any trauma.

Should did not look like she'd been

beaten up by the car accident.

[music playing]

NARRATOR But most important is Mrs. Lopez's history

of untreated high blood pressure,

which is a known risk factor for dissected aortic aneurysms.

Her conclusion-- Mrs. Lopez's aortic tear

and dissection was caused by natural disease,

a direct result of her high blood pressure.

JAN GARAVAGLIA That's terrible.

That is the one thing you can do that's easy to extend

your life, and that is--

no your blood pressure, and get it treated if it's high.

NARRATOR Dr. G can now record her findings

in the report of an autopsy and explain

the two remaining questions.

How did Anna survive for four days with a torn aorta,

and why was her condition not diagnosed in the hospital?

[ominous music playing]

-year-old Anna Lopez is a healthy and active woman.

But she also suffers from high blood pressure

and does not seek treatment for the disease.

She thinks her blood pressure is not affecting her.

It is.

NARRATOR Over the years, her untreated

condition damages blood vessels in her brain and in the aorta.

But as she's driving home that fateful day,

she's unaware of the deadly ravages

unfolding inside her body.

JAN GARAVAGLIA I think she's driving down the street,

and she's in her usual state of good health,

and she's feeling good.

She's got her nails painted.

And then, all of a sudden, her degenerating aorta

starts to tear open.

And then, blood starts going into the wall of the hose

and starts tearing it, and that's her severe pain.

And the next thing she knows, she faints.

[music playing]

NARRATOR In the hospital, the small initial tear

in Mrs. Lopez's aorta briefly stabilizes.

And despite a battery of tests, doctors

cannot find anything wrong.

What I suspect--

why they couldn't find it on all of their scans--

is that she's got a very small tear,

and it's being held in place by the aorta.

Then, as she's getting better and her blood pressure

is getting higher again, it tears the rest of it and blows

open, into the pericardial sac.

NARRATOR Arterial blood pours into the pericardial sac

and quickly compresses the heart.

Each time it contracts, more blood is coming.

It can't fill up as much.

It contracts what it had in there,

and more blood is coming in, surrounding it.

And so it can't expand to push the blood out.

And finally, it just can't pump anymore,

because there's so much blood in the pericardial sac.

They find her unresponsive in bed.

They start immediately trying to resuscitate her.

But it's too late, and she's dead.

[ominous music playing]

We got a DC here for you.

You just need to sign there and print there.

Yeah.

Good, let's start bringing her out.

[music playing]

(SINGING) Step off the plane, and I can't

say that I feel any different.

And though I've missed you I always

knew that we'd end up here.

Oh, the day is going slow.

And though the sun is up, it feels like going down.

When I explained it to the family,

I think they just understood it as it was her time.

I don't think they were mad at the hospital.

I don't think they were mad at anybody.

It was just the unfortunate way things went.

[music playing]

(SINGING) Means so much to have you here by my side.

Don't pressure me.

I want to stay here with you.

NARRATOR Unexpected deaths are always tragic, even when

there's no one left to grieve.

Such is the case of Marco Dominguez,

who d*ed alone in the hospital during a routine battery

of tests.

He just seems like a nice guy.

I know that's hard to believe, but he seemed like a nice guy.

And I would like to know what's going on.

[ominous music playing]

NARRATOR It's mid-afternoon, and Dr. G

is finishing up the autopsy of a decomposed body.

The case is being observed by a group of prosecutors

from the state attorney's office who
[ … ]

are witnessing their first autopsy

as part of their training.

Lawyers come down and they're trying

to kind of learn some terminology

and understand what we do.

So that's one of the few people that we allow down here.

So this is the heart.

I've opened up the pericardial sac.

Look at that-- it's his air.

What am I doing?

I'm removing peripheral blood from him, and he's decomposing.

So the blood is lysing, and it's thick,

and it's difficult to get.

It was interesting, definitely.

The smell was the worst thing.

I think he was dead for a few days, so--

I don't smell him.

So I guess I am used to it.

[laughter]

Yes, this is was my first autopsy with Dr. G.

I worked here as a prosecutor in Orlando.

We came over here with five people, and three of them

were waiting up in the lobby because they

couldn't handle it, I guess.

But it was definitely informative.

I learned a lot.

Dr. G was very helpful in answering all of our questions.

It was a lot of fun.

That one took a lot longer than I wanted it to.

NARRATOR But Dr. G's day isn't over yet.

Morgue technician Tom Hempill is already preparing

for her third autopsy--

the death of an -year-old Kissimmee resident

named Marco Dominguez who checked into the hospital

yesterday but never checked out.

Well, this case-- you know, I don't usually like

to autopsy people in their s.

But this gentleman-- years old--

is presented to us through the emergency room,

and they weren't able to diagnose what he had.

[ominous music playing]

NARRATOR According to the investigator's report,

-year-old Marco Dominguez woke up yesterday feeling fine.

But shortly after breakfast, he begins

experiencing abdominal pain.

By PM, his symptoms have not improved.

So he drives himself to the local emergency room

to have it checked out.

JAN GARAVAGLIA He seems to be a very independent, very healthy,"], index ,…}

man.

But the pain seems to be getting worse.

So they admit him to the emergency room,

and they start the workup of what's wrong with him.

They take his history.

They just find out that he's in relatively good health.

He might have some heart problems--

been seen by a cardiologist.

He's got some coronary artery disease.

NARRATOR Given his medical history,

doctors suspect that Mr. Dominguez's his pain could

be due to a minor heart att*ck.

Heart att*cks can manifest their pain very different way.

Sometimes, it'll cause abdominal pain, sometimes back pain.

Sometimes, it'll manifest it just by being very tired.

His pain does not get any better,

and they decide to send him to the CAT scan.

But as soon as the CAT scan is complete, he codes.

NARRATOR Despite their best efforts,

the medical team is unable to revive Mr. Dominguez.

He is pronounced dead at PM.

The doctors who treated the -year-old man

suspect he simply d*ed from a heart att*ck,

but they lack a solid diagnosis, so no one is willing to sign

the death certificate.

Now, the only hope for an answer lies in the hands of Dr. G.

JAN GARAVAGLIA This poor guy.

He dies alone in the emergency room,

obviously without people he knows around him.

They never diagnose him.

We don't bury him and say, oh, too bad.

The fact that our society cares enough to put resources

into the medical examiner's office to say,

you know what, sometimes is important to understand

why people die.

And although we couldn't do anything for him,

we cared enough to at least give him a diagnosis.

We'll just take a look.

And I think we'll just go ahead do the autopsy

and maybe just put to rest why he d*ed.

Because I hate to have--

the poor guy doesn't have a diagnosis.

I don't know what to put on the death certificate.

Nobody's willing to sign it, and I would

like to know what's going on.

[ominous music playing]

NARRATOR As she begins the external exam,

Dr. G can see right away that something is wrong with Mr.

Dominguez's body.

JAN GARAVAGLIA He's very thin.

He's a thin man--
[ … ]

a little bit of temporal muscle wasting,

a little bit of interosseous muscle wasting

between the bones of the hands.

You lose a lot of tissue there.

So he's thin.

Could I see his back real quick before you take that shirt off?

Let's see the back of his jeans.

NARRATOR His frail appearance suggests that Mr. Dominguez

is possibly quite ill.

Dr. G's first thought?

It looks as if he may have been suffering from cancer.

You know, he looks so thin, although they

said he was in good health.

And maybe he just exercised a lot and was very active.

But boy, I am worried that maybe it's some type of cancer.

NARRATOR A heart att*ck is still high on the list

of possible causes of death.

But given the appearance of the body

and Mr. Dominguez's bout of abdominal pain,

Dr. G must now consider cancer, as well.

JAN GARAVAGLIA A tumor is a possibility.

A cancer is certainly a possibility on him.

[music playing]

NARRATOR As Dr. G continues her examination of the body,

she discovers yet another unusual finding,

one not mentioned in his medical history--

a large surgical scar on his abdomen.

JAN GARAVAGLIA This abdominal surgery

was in the epigastric region, the upper part of the abdomen,

pretty much from the lower sternum

down and just around the umbilicus, or belly button.

NARRATOR The incision appears to be old and well healed,

but Dr. G has no information at all on the surgery.

Could it have been the result of an earlier bout with cancer?

And does it have anything to do with his recent abdominal pain?

JAN GARAVAGLIA I don't even know

what that previous abdominal surgery is for yet.

And I am still very worried about cancer.

[ominous music playing]

NARRATOR Dr. G and her assistant

are eager to begin the internal examination of Marco Dominguez.

What am I doing?

NARRATOR But before she can get started,

they're interrupted by one of her medical investigators.

Oh, he wants me to meet him?

CAROLE CROSBY Oh, I could--

I can come out.

All bloody, give him a hug.

I'll go give him a hug, yeah.

I got bloody, give him a hug. [laughs]

Tell him I'll be out in a second.

All right.

All right, let me go say hi to this guy.

Hey, where's my friend?

Hey, how's it going?

This is Steven, he's--

I'm your biggest fan.

No!

Yeah, seriously, I am.

- Oh, you're so sweet, Steven. - Nice to meet you.

I can't believe it.

Well, Steven, yeah, I heard I had a big fan out here.

I had to come out. - Oh, really?

JAN GARAVAGLIA Yeah, I actually work here.

[laughs]

Yeah, yeah, I thought it was just you a show.

I think he was a little surprised.

She's here?

I'm going, yeah, she's back here working.

And I'm like--

Let's get out of here.

Get out of here.

No, apparently, you're just from Hollywood

and you just work on Rodeo Drive.

Did you hear that guy yesterday?

He says, I think I know you from TV.

I go, you know, it could be.

And he goes, aren't you--

I guess I met you on Rodeo Drive.

I go, I don't think so, I spend my time in the morgue.

[laughter]

I'll get a picture for you [inaudible]..

OK.

Oh, man, I appreciate that, all right.

Steven, there you go, my good friend.

Yeah, thanks, I appreciate it.

I can't believe it--

Dr. G.

- [laughs] It's nice to-- - Thank you.

Oh, I don't want to touch you. I'm OK.

Oh, I'm used to it.

NARRATOR OK.

Bye bye, Steven, thank you.

STEVEN Thank you.

[music playing]

NARRATOR Back at the autopsy table,

Dr. G opens the body of -year-old Marco Dominguez.

JAN GARAVAGLIA I go ahead and do my Y incision.

My next step then is I need to take the chest cavity off.

I use my loppers and then cut right at the clavicular heads.
[ … ]

[chopping]

NARRATOR Once the chest cavity is open,

Dr. G removes the chest plate and draws toxicology samples.

But the blood is difficult to draw into the syringe.

Yeah, it doesn't look like it's going to be that great.

I do not think tox is a big problem with this man,

but I'll go ahead and remove my toxicology.

The blood's very clotted when I try

to take it out of the heart.

That often indicates that they're sick,

that they've got a bacteremia.

The blood isn't real fluid.

It's real clotty-- post-mortem.

It will clot postmortem.

So I have a difficult time getting

my blood from the heart.

Just getting the one peripheral.

And then I go ahead, I remove the heart, I remove the lungs.

NARRATOR She takes the heart to the dissecting table

and examines the organ closely.

What she sees is troubling.

JAN GARAVAGLIA He does have some

significant coronary arteries.

He's got at least an % narrowing

to his coronary arteries--

to least two of them-- and some thickening of the heart.

NARRATOR Heart disease is the leading k*ller

of the elderly in the US.

And sure enough, Mr. Dominguez's heart is very ill.

Several coronary arteries are clogged with atherosclerosis,

or plaque--

enough to have triggered a fatal heart att*ck.

The question is, is this what k*lled him?

Before she can prove this one way or the other,

Dr. G needs to make sure there is nothing else

amiss in Mr. Dominguez's body.

Given his frailty, and the discovery

of a large surgical scar on his abdomen,

Dr. G wonders if this -year-old could also have

been suffering from cancer.

So now, after I've gotten the heart--

the lungs-- done, I want to turn my attention to that belly.

NARRATOR Dr. G examines the abdominal organs

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

And right away, it's clear that Mr. Dominguez's his heart

isn't the only concern.

JAN GARAVAGLIA Oh, boy, right there

you see that he's got problems.

Most of his small intestine is maroon, and bloated,

and necrotic looking.

It is very unusual.

[ominous music playing]

Did you see that right here?

Goes across?

What is that?

NARRATOR Dr. G has just opened the abdomen

of -year-old Marco Dominguez and discovered

an astounding sight--

nearly eight feet of dead small intestine.

JAN GARAVAGLIA He's got necrotic,

maroon to black tissue.

It's necrotic small bowel.

NARRATOR Examining the dead bowel,

Dr. G knows that this is, without a doubt,

the cause of Mr Dominguez's abdominal pain.

And it's most likely what caused his death, as well.

Once it becomes necrotic--

where it just really is starting to die,

and you don't do anything with it--

it's % fatal.

NARRATOR But the discovery begs the question, why

is Mr. Dominguez's bowel dead?

Organs don't just die for no reason.

JAN GARAVAGLIA Once I see the necrotic bowel,

I just can't close up the body.

We don't have all the answers yet.

We have to figure out why he has necrotic bowel.

What is it that caused that?

[music playing]

NARRATOR Dr. G considers the possibilities.

Given Mr. Dominguez's medical history,

a likely culprit is atherosclerosis--

the narrowing of a blood vessel in the bowel due to plaque.

In his age, one of the most common reasons

for ischemic small bowel would be decrease of blood flow

to that bowel from atherosclerosis

where they just don't get enough blood going to that bowel.

NARRATOR Atherosclerosis is most commonly associated

with heart disease, but it can clog blood vessels

in other parts of the body as well, including the vessels

leading to the intestines.

JAN GARAVAGLIA It's relatively common.

I see it as almost an acute cause of death, even coming

through here, where they don't go to the doctor

for that abdominal pain.

The bowel becomes necrotic and a lot of fluid

ends up going into that bowel.

They have electrolyte problems.

And of course, once the bowel wall no longer protects you

from the bacteria in that bowel, that bowel
[ … ]

can get into your bloodstream.

And you can end up being septic, or hypotensive--

your blood pressure go down--

and then you end up dying.

So when I initially see the necrotic small bowel,

my first thought is, oh, he's got

atherosclerosis in the vessels that supply the bowel.

So I start looking and looking around in that abdomen,

and I notice that something's not quite right.

NARRATOR Dr. G quickly realizes that Mr. Dominguez's

anatomy is not normal.

A portion of his small intestine and stomach are missing,

as well as part of the omentum, or apron--

a layer of fatty tissue that loosely covers the intestines.

To Dr. G, it looks like these were

removed in what was a routine ulcer surgery many years ago--

probably the source of the surgical scar

she found on the abdomen.

The problem is, it appears that the surgery has led

to a very unusual complication.

Scar tissue from the surgical incision

has developed in Mr. Dominguez's abdominal cavity,

causing what is left of the omentum

to stick to the back of the abdominal wall.

And there, the bowel has become trapped and twisted.

The bowel has wrapped itself through that adhesion

and turned until it strangled itself.

NARRATOR It is an extremely rare condition called valvulas,

or twisting of the bowel, which cuts off blood supply

to the organ and kills it.

Dr. G now knows for certain what k*lled

-year-old Marco Dominguez.

It wasn't his heart or atherosclerosis.

It was a stunning complication resulting

from routine abdominal surgery performed decades earlier.

Of all the things we had to guess why he d*ed,

the valvulas on an -year-old guy

would not be high on my list.

It's not that common in the United States for older people

to have this kind of valvulas.

NARRATOR The cause of Mr Dominguez's death

is extremely unusual but crystal clear.

And Dr. G can now record her surprising findings

in the report of autopsy.

[music playing]

It's AM, and -year-old Marco Dominguez is cleaning up

from breakfast when he begins to feel the worst stomach

ache of his life, only the pain is not coming from his stomach.

Inside his abdomen, his small intestine

has wrapped around scar tissue, which developed after an ulcer

surgery decades earlier.

[music playing]

Whatever happened with him, it was fairly acute.

Now, why did it happen today instead of or years ago?

I don't know, but we know that happened.

It's not uncommon for when these adhesions

do cause trouble that they can be years later.

NARRATOR As the intestine twists,

the arteries that nourish the organ are eventually cut off.

Strangled and starved of blood and oxygen,

the bowel begins to die.

By the time Mr. Dominguez arrives at the hospital later

in the afternoon, his condition is critical.

Eight feet of his bowel are dead.

Even so, doctors cannot diagnose what's wrong with him.

It is very difficult on an adult to diagnose valvulas.

You're not just going to necessarily

pick it up on an X-ray.

NARRATOR By the time he reaches the CAT scan,

bacteria from the dead bowel begin to flood his bloodstream.

His blood pressure drops catastrophically,

and Mr. Dominguez goes into cardiac arrest.

They try to resuscitate him, but it's too late.

His heart can't b*at anymore, and he dies.

[music playing]

(SINGING) I try and try, but I--

JAN GARAVAGLIA OK, I will be there in a minute.

Just hold on.

(SINGING) --just don't know what to do.

Hanging questions by a thread and I don't have the answers.

Ultimately, I think from this we learned that your past is

always part of you.

And no matter how much you want to run from it,

it ultimately still is part of you.

(SINGING) I don't want to leave you now.

I don't think that I know how.

Can't you take some time to ask me what I'm thinking?

Help me, I can't even--

[inaudible]

(SINGING) --help myself.

MAN [inaudible]

Have a nice night.

You, too.

Good night, Dr. Garavaglia.

Good night, Stu.

[music playing]

MAN Atlas.