05x06 - Cruel Intentions

[bunniefuu]

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NARRATOR A three-year-old toddler

was found dead in his bed.

It's just tragic.

Life-- you're just beginning.

NARRATOR Now, it's up to Dr. G to find out exactly what

cut this child's life so short.

This is important.

This is why I do my cases.

This is why I went into forensics.

NARRATOR And then a young man collapses

in front of his grandparents.

They had to call .

Paramedics arrive.

He's already lost his blood pressure and pulse,

and he d*ed.

NARRATOR Could this -year-old sudden death

become one of Dr. G's most surprising autopsies yet?

Oh, gosh.

You don't always know what that autopsy is going to show,

and that's what makes this job so exciting.

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NARRATOR Altered lives, baffling medical mysteries,

shocking revelations--

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

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JAN GARAVAGLIA Well, I think we have our cause of death.

Anyway, so not a bad day today--

just tragedy.

NARRATOR Dealing with death every day

can take a heavy emotional toll.

Oh, always a good time in the morgue.

NARRATOR But over the years, Dr. Jan Garavaglia--

chief medical examiner for the district

morgue in Orlando, Florida--

has learned to distance herself from the tragedy she sees.

First of all, it makes you realize how precious life is.

The people that will be autopsied tomorrow--

most of them are not thinking they're

going to be autopsied tomorrow.

They're kissing their kids and their loved ones,

and doing all sorts of things out there.

It might be one of us, so you might as well enjoy the day

and appreciate what you have.

NARRATOR But as a mother of two, Dr. G

understands that few losses are more heart wrenching

than the death of a child.

JAN GARAVAGLIA It's just tragic.

Life-- you're just beginning.

Yeah, it's a beautiful child-- absolutely

nothing wrong with her.

We're not geared to see our children die.

They're geared to see us die.

[inaudible frantic chatter]

NARRATOR It's AM on a cold, November

morning when Jack Garrity--

a resident of a low-income Orlando housing complex--

wakes up to the sound of frantic pounding at his door.

WOMAN Help, please help me.

NARRATOR He opens it to find his neighbor, Ruby Walsh,

holding her youngest son, -year-old Robbie.

And he's not breathing.

They immediately call .

But sadly, it's too late.

He's clearly already dead.

NARRATOR Robbie is pronounced dead at the scene, still

in his mother's arms.

Unfortunately, today, we've got a three-year-old

child to autopsy.

We don't really know what's been going on.

When I first get this case, all I have

is what my investigative sheet says.

NARRATOR According to his mother,

Robbie was a vivacious child who loved animals

but whose prominent birthmark made him shy around strangers.

She also reveals that her son experienced

one strange symptom in the days leading up to his death.

The mother said that a couple days ago

that he'd been complaining of some abdominal pain.

NARRATOR Ruby gives her son acetaminophen to ease the pain,

and it appears to do the trick.

JAN GARAVAGLIA The next day, he seemed to be in good spirits.

And according to her, he seemed fine.

NARRATOR But later that evening, when Max Walsh--

Robbie's stepfather-- checks in on the sleeping child,

he sees that Robbie has vomited.

Still, the toddler doesn't seem to be in any distress.

He was on a bunk bed, and the stepfather found

some vomit still on his sheets.

NARRATOR But when Robbie's mother goes to wake him

the next morning, she finds the toddler

lying face down on his bunk bed, unresponsive and cold

to the touch.

And when she turns him over, she discovers more vomit.

It's then that she gathers her son in her arms

and rushes to the neighbor's house for help.

The mother-- she doesn't give us any history of any trauma.

She doesn't give us any history of really anything,

except this kind of vague stomach pain

a couple days prior to death.
[ … ]

This is a relatively poor family.

Maybe he didn't have good health care

and something medically is going wrong.

So it's looking like maybe natural disease,

but we certainly always have to keep our eyes open.

NARRATOR Dr. G knows that Robbie's death could have also

been the result of an accident that his mom simply

wasn't aware of.

Accidents-- they're still the most common cause

for kids of this age group.

Certainly motor vehicle-- number one.

Drownings-- things like that.

NARRATOR But there is still another sad and sinister

possibility.

Unfortunately, in that age group,

we still see inflicted injuries.

We still see abuse, and that's always got to be in our mind.

NARRATOR Dr. G's investigators are her eyes and ears

on the scene, and they play a crucial role in helping

to identify signs of abuse.

JAN GARAVAGLIA When they looked at him,

they felt that he looked well cared for.

He did have some vomitus on his face,

but they didn't see any evidence of abuse or trauma.

And they felt there it was probably

an apparent, natural disease.

NARRATOR And at this point, natural disease

is high on Dr. G's list.

I don't like that vomiting, not feeling well a couple days.

But that's why we're doing the autopsy.

We'll see what it is.

Cute, cute kid though.

Yeah, he has soft hair.

Yeah, soft hair and long eyelashes.

Initially when you see him, he's a cute kid.

Your heart goes out to him.

Your heart goes out to the family.

Beautiful little baby.

NARRATOR But Dr. G knows that in order to do her job

she must leave her emotions at the door.

You want to give me the tape measure?

I sure will.

I have to be cool and collected

when I do these cases--

..

--because child cases are some of the hardest cases we have.

Pretty, dark brown eyes.

Two lowers-- acute.

Externally, he looks pretty good.

He's got four uppers.

Eyes OK.

NARRATOR But Robbie has one distinctive feature

that makes him stand out.

He's got a big birthmark on his face.

It kind of goes across the lateral, or side, part

of his eye and onto his cheek.

NARRATOR A birthmark is a discoloration of the skin that

is either present at birth or appears

a short time after delivery.

% to % of babies have some type of birthmark.

Some are permanent, while others fade with time.

Pigmented birthmarks, such as the one Robbie has,

are caused by an abnormal development of pigment cells.

And everything else looks good, except he

does have fixed lividity.

NARRATOR Lividity-- or livor mortis--

is a natural process that occurs after death.

It is characterized by a purplish-red discoloration

of the skin.

Once the body dies, gravity causes blood to settle.

Initially, the pattern of lividity

can be shifted if the position of the body is changed.

Yeah, put him back.

I can't get him that way.

NARRATOR But to hours after death, the blood

begins to clot, and the lividity becomes fixed, or permanent.

The fact that Robbie has fixed lividity

can mean only one thing.

He's clearly been on that bed face

down the way he was found for several hours.

We have a-- what happened to all our others?

- Do you want the other one? - It doesn't matter.

OK.

It doesn't matter, doesn't matter, doesn't matter.

All righty.

NARRATOR At first, the external exam reveals

nothing out of the ordinary.

OK, he looks perfectly normal.

NARRATOR But then, Dr. G takes a closer look at Robbie's torso

and gets her first surprise.

Belly's a little distended.

What was interesting on his belly

is that there's a little bruise there.

Look at that.

Just above the level of the belly button,

and a little to the right.

Faint.

Maybe-- It doesn't look too bad.

NARRATOR Dr. G can tell from its purplish-blue color

that this is a fresh bruise.
[ … ]

It probably is nothing, but it could be something.

NARRATOR But she's curious as to why

neither Robbie's mother, nor his stepfather,

mentioned any recent trauma.

There's always a possibility of some accidental injury

that they don't know about, or some unfortunate inflicted

injury.

I don't know what it is, but I will keep my guard up.

NARRATOR Taking no chances, Dr. G makes a meticulous record

of the bruise.

I photograph it.

I make sure there's a ruler, and documented it, and move on.

And hopefully, it doesn't mean anything.

Oh, I'm just going to try something.

NARRATOR But the surprises in this case are far from over.

Oh, sh**t.

Because you never know what the autopsy is going to show,

particularly with children.

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-centimeter scar.

Did you need the block?

Um, yeah, let's see how the block does.

NARRATOR As she nears the end of three-year-old Robbie

Walsh's external exam, Dr. G is still

unable to draw any conclusions about the strange contusion--

or bruise-- on the toddler's abdomen.

JAN GARAVAGLIA I'm a little worried.

I don't know if it's an innocent bruise of play,

or if it's a deadly bruise of abuse.

NARRATOR To find out, she must look inside Robbie's body.

What looks normal on the outside

may be anything but normal on the inside.

NARRATOR Dr. G has one important tool that will help

her detect possible abuse--

the X-ray machine.

One of the signs of abuse is they get broken bones.

And so we do full-body X-rays looking at the head, the neck,

but particularly look at the long bones.

And we look for evidence of acute fractures

that have just happened.

And we look for evidence of old fractures,

because that can give us a history.

NARRATOR She pours over Robbie's X-rays,

looking for any signs of trauma.

And we don't see any fractures,

and that's a good thing.

NARRATOR But this doesn't mean that Dr. G can cross

abuse off her list of suspects.

You still have to autopsy this child,

because he can have a lot of soft tissue injuries,

he could have head injuries, with no fractures.

NARRATOR First, Dr. G focuses her attention

on the one part of Robbie's body most likely

to show signs of abuse--

his head.

Children-- oftentimes, they'll be flung, or hit.

And they'll get head trauma--

closed head injuries, sometimes with a skull fracture,

sometimes not.

NARRATOR Could Robbie have d*ed from a severe head trauma

after being att*cked by his mother,

Ruby, or his stepfather, Max?

I'm hoping it's not that, but it's

certainly in my differential.

NARRATOR The cranial exam will also help rule

out another possible suspect.

The other thing we have to worry about with children

are meningitis.

NARRATOR Meningitis is an infection

of the meninges, the membranes that protect

the brain and spinal cord.

And it can be fatal, especially in young children.

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Dr. G begins by cutting a slit across the top of Robbie's

head, freeing the scalp.

And we reflect the scalp, looking

for any kind of contusion, or bruising,

on the inside of the scalp.

And with this cute little boy, we don't see anything.

NARRATOR Next, morgue technician

Sandy Ludwig uses an oscillating saw

to cut through the skull cap.

All righty.

And I pull that off, and we don't

see any evidence of blood, or trauma to the brain,

or even evidence of meningitis.

Two of the big things we'll see with kids of this age

have already been dispelled by the autopsy.

He's fine.

NARRATOR This case is becoming more puzzling by the moment.

But Robbie's family background does give Dr. G another lead.

This is a poor family.

I'm not so sure how much medical attention he'd gotten.

Sometimes, we'll pick up congenital heart

abnormalities that were not picked up at birth.

Sometimes, we'll pick up lung infections that maybe

the family didn't pick up on.

So we're just going to see what we find.

OK, let me open this.

You can get your tox, and I'll go--
[ … ]

WOMAN All righty.

There should be some adhesions in this little guy's belly.

Let's see, do I have a-- WOMAN Here it is.

Oh.

NARRATOR Dr. G performs a Y incision

and opens up the abdominal cavity.

And that's where I see my first clue of what's going on.

Oh, sh**t.

NARRATOR In fact, what Dr. G finds inside Robbie's abdomen

is nothing short of shocking.

Oh, my god, look at that.

I find cc's of blood in his belly.

Wow, lots of blood.

NARRATOR For a child of Robbie's age,

cc's is a significant amount of blood.

This is about % to % of the total amount

of blood in his body.

It's making the autopsy rather difficult.

NARRATOR And if that weren't enough,

Dr. G soon spots another serious problem.

Oh, my god, all of--

Things are not looking good.

I see changes in the abdomen that suggest a peritonitis--

or inflammation-- of the lining of the abdominal cavity.

Something's happened to his abdomen.

NARRATOR Suddenly, a suspicious picture is beginning to emerge.

Somebody knows what happened to this child.

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NARRATOR Dr. G ladles out the blood

found inside three-year-old Robbie's abdominal cavity--

There you go.

Let me see if we can figure out what's going on.

NARRATOR --and makes a startling discovery.

He's got a lot of adhesions.

He has gotten such a blow to the abdomen

that he's bruised the entire abdominal wall.

NARRATOR And it doesn't take much to draw a line

from this internal damage to the bruise

found during the external exam.

Basically, this blow went straight through him.

NARRATOR The question is, was this an accident or abuse?

Really screwed up his omentum bowel.

What's really worrisome is that he's got a big bruise, even

on his omentum.

NARRATOR The omentum is the protective layer

of fatty tissue that hangs down in front of the bowels.

JAN GARAVAGLIA Ah, what else we got going on here?

NARRATOR And the more Dr. G looks,

the more damage she sees.

And he's got tears in the mesentery.

Oh, my god, no.

The mesentery is a connective tissue

that holds the bowels in place.

They kind of anchor the bowels to the back

of your abdominal cavity.

NARRATOR But its most important function is

to supply blood to the bowels.

Robbie's torn mesentery explains why

such a large amount of blood was found in his abdomen.

And it also spells disaster for the bowels.

What's happened is, where those tears are,

the bowels are starting to die because it's

not getting the blood it needs.

NARRATOR Starved of blood, the bowels

begin to break down, with disastrous consequences.

The bowels are full of bacteria,

and those bacteria leech out.

They leach out into the bloodstream.

They leach out in your abdominal cavity,

and you get this overwhelming infection.

I need the bowel.

Just save it for me, and I'll look at it.

There you go.

NARRATOR At this point, one thing is crystal clear.

The cascade of events was ultimately

caused by blunt trauma to the abdomen--

a death sentence in a child as young as Robbie.

This is his cause of death, and there is no question.

He's dying from this injury.

Tragic, tragic.

Could it have been caused by a fall?

It would have been caused by a fall

that you would have noticed.

This is not a subtle injury.

This is an inflicted injury.

Somebody knows what happened to this child.

This is a homicide until proven otherwise.

The first thing you do is you contact the police and say,

this is a homicide.

This is important.

This is why I do my cases.

Listen why I went into forensics.

This is a case of a little, innocent kid that

comes in as probably a natural.

And this turns out to be a kid that's beaten.

NARRATOR Armed with Dr. G's findings,

the police open a full-scale investigation.

And what they found was really quite interesting.

NARRATOR According to neighbors, Max Walsh--

who had married Ruby five months earlier--
[ … ]

has a history of v*olence.

And, of course, it was he who went in to check on Robbie

on that fateful night.

Investigators confront Robbie's mother, Ruby Walsh,

with Dr. G's findings and their growing suspicions

about her new husband.

Under pressure, the distraught mother eventually breaks down.

Through a veil of tears, Ruby begins to paint

a disturbing family portrait.

What they found is that this was

a child that had been chronically abused,

picked on by his stepfather.

And what was really sad is that the stepfather didn't

really pick on the other kids.

But he kind of picked on this little kid,

because he didn't like that birthmark,

and he was a little darker pigment

than the rest of the kids.

And what's really deplorable is that mother let that go on,

too.

NARRATOR Max Walsh is quickly emerging as the prime suspect

in the death of his stepson.

And when the police pull him in for questioning,

Max even confesses to what he calls "innocent teasing

of the toddler."

He admitted that he would often flick his birthmark.

He even admits to choking him, and holding him,

and tried to say that the kid liked it.

NARRATOR But when it comes to the night in question,

Max flatly denies intentionally harming Robbie.

The stepfather says, well, yeah, I might have accidentally

hit him on the railing.

NARRATOR Max claims that he may have bumped Robbie

against the ladder of his bunk bed

when he tried to put the toddler back to sleep.

But to Dr. G, the evidence proves otherwise.

JAN GARAVAGLIA This is no accident.

He has been picking on this child for a long time,

and he gave that child a big blow to the belly.

Whether he slammed him on the top of that ladder,

or whether he slammed him with his fist, I don't know.

But it's not trivial.

That was an intended inflicted injury.

NARRATOR Despite Max's persistent denials,

authorities now feel they have enough forensic evidence

to bring charges against him.

Relying on Dr. G's findings, investigators can finally

reconstruct what they believe happened to little Robbi Walsh

on the last night of his short life.

The day Max Walsh married Ruby and moved in

with her three children, three-year-old Robbie's life

changed forever.

JAN GARAVAGLIA This is a kid that was singled out.

He was being picked on.

He was called names because his skin

was a little darker than the rest of the family.

It wasn't just physical abuse.

There is a lot of emotional abuse with this poor kid.

NARRATOR On the night of Robbie's death,

Max checks up on his stepson, asleep in his bunk bed.

That night, for whatever reason,

he was more angry with this child.

And this child suffers a severe blow

to the abdomen, whether it be with the ladder,

or with his fists.

NARRATOR This blow leaves a trail of devastation

in its wake, bruising Robbie's skin,

his entire abdominal wall, his omentum,

and then tearing his mesentary.

JAN GARAVAGLIA He is leaking out blood from those tears.

He vomits.

The stepfather then puts him in the bed.

He knows he vomited, and he just lets him lie there.

NARRATOR But it isn't long before the damage to Robbie's

organs begins to compromise the blood supply

to a section of his bowels.

The bowel is slowly losing its integrity

to hold back the bacteria.

The bacteria leak into his abdominal cavity and leak

into his bloodstream, eventually,

and he dies from this injury while he's

in bed with vomit on him.

As a mother, it's deplorable.

As a human being, it's deplorable.

This is an innocent kid that's being picked

on because of a birthmark?

NARRATOR Thanks to Dr. G's testimony at his trial,

Max Walsh was convicted of serious bodily injury

to a child and is currently serving a -year sentence.

Ruby Walsh was charged with failure to protect

the welfare of a child.

Her two remaining children were placed in foster care.

You would think that these would be emotionally hard

cases for me, but they're not.

Those are the kind of cases that we exist for, where it comes in"], index ,…}

as a natural, and we can speak for that little kid

and say, hell, no.

It's no natural.

Somebody did this to him.

There is no time for any kind of emotion
[ … ]

when you have a child abuse case to do.

NARRATOR Many of Dr. G's cases are heartbreaking,

but very few take her so completely by

surprise as her next autopsy.

I thought it was going to be a run-of-the-mill

drudgery type of case that I just have to get through.

But what's happening to this guy is actually very rare.

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NARRATOR As a medical examiner, Dr. G knows firsthand

the benefits of exercise.

That's why she's recently been trying

to amp up her own workout.

Go to the gym three times a week,

but you just kind of get in a rut.

The most important thing is you have to tell the person

what you're looking for, what you want to achieve.

pounds.

It's not really that hard.

It's not.

I can find you a simple routine.

You need a starting point.

I know, but you won't push me.

You're too nice a guy.

[laughs] See, Brian, it's not a good idea

for you to do this for me, because I'll

take my aggression out on you.

It'll be just bad.

NARRATOR But talk of working out and losing weight

must move quickly to the backburner

as a troubling new case arrives at the district morgue.

The previous afternoon, paramedics

responded to an emergency call from a couple

in their s living just outside Orlando.

But when they arrive, they find that the elderly couple

is fine.

It's their grandson, -year-old Stefano Medina, who is not.

He's slumped on the floor and has no pulse.

Leah Victor frantically explain that their grandson

hadn't been feeling well but insisted

on helping with the yard work.

Before long, he became too weak to continue,

and that's when the nightmare began.

He arrested in front of his grandparents, collapses.

They had to call .

Paramedics arrive.

He's already lost his blood pressure and pulse.

NARRATOR The paramedics work furiously to revive him,

and they succeed, to some degree.

They were able to get his blood pressure back

and his pulse rate back, but he still

doesn't have any mental status.

It looks like he's in a coma.

NARRATOR They then rushed him to the hospital,

where he's immediately admitted to the ICU.

He had to get multiple IVs.

They did a lot of tests on him, and it looked

like he was going downhill.

NARRATOR Doctors run a battery of tests, hoping

to find something that might save him,

but they quickly run out of time.

He codes again in the ICU about

hours after he gets there.

NARRATOR And shortly before midnight, Stefano Medina dies.

The sudden loss devastates Leah and Victor.

A troubled child from a broken home, Stefano

ran away often in his youth, but he'd always found

refuge with his grandparents.

Now, they've lost him forever, and their only hope of finding

out why lies with one person--

Dr. G. Dr. G begins the autopsy by scanning through Stefano's

medical history.

For someone , he's got a pretty extensive history.

Been in the hospital for g*nsh*t would.

We also find out that he's been in the hospital

before for some recurrent pancreatitis, which is

inflammation of your pancreas.

NARRATOR About , Americans are diagnosed

with acute pancreatitis each year, most of whom

are treated successfully with little more than fluid IVs

and dietary restrictions.

JAN GARAVAGLIA He's had a couple times.

It sounded like they were always mild.

They resolved spontaneously on their own

with very little treatment.

So it certainly hinders your quality of life,

but you don't usually die from it.

NARRATOR Dr. G doesn't think a simple case of pancreatitis

could have landed Stefano in the morgue.

But then, she sees something in the report

that may explain what did.

This is a man that started some bad habits early.

He started drinking at an early age,

and drinking quite heavily at an early age.

He starts smoking at an early age.

And he starts doing illicit dr*gs at a fairly early

age, specifically cocaine.

NARRATOR In fact, looking at his charts from the hospital,

Dr. G sees that Stefano's urine tested positive for cocaine,

leading doctors to believe that the drug caused

his sudden arrest and, ultimately, his death.
[ … ]

My number one suspect is I'm going

to go with what the doctors felt in the hospital.

Cocaine can cause bleeding in the brain.

Cocaine can cause heart att*cks.

It can cause an arrhythmia, or the heart

to quiver from the stimulant effect.

NARRATOR She also knows that his heavy drinking

could have significantly increased

his risk of cardiac arrest.

When people both drink and use cocaine,

something really interesting happens.

There is a chemical that's formed in your body that's

called cocaethylene that only forms inside your body

when you've taken in alcohol and you've taken in cocaine.

And what's interesting about cocaethylene

is it actually probably even more of an irritant

to your heart than either cocaine or ethanol alone.

There's even more of a chance of having a sudden cardiac arrest

and an arrhythmia when you use those dr*gs together.

So there there's still other things it could be,

but sounds like cocaine caused his sudden arrest.

NARRATOR For Dr. G, drug-related deaths are,

unfortunately, a dime a dozen.

They've got to be extremely routine and really

not that interesting.

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NARRATOR When Dr. G approaches Stefano's body on the gurney,

she immediately notes the paraphernalia

left by his intensive care in the hospital.

The external examination is everything

you expect from somebody that's been in the hospital

even for hours.

He's got an endotracheal tube.

He's got intravenous lines where they're

giving him a lot of fluid.

NARRATOR But the key is whether, amidst

these artifacts, she can find what put him in the hospital

in the first place.

Dr. G begins her examination by looking for clues

of Stefano's cocaine use.

You know, with a history of illicit drug use,

I'm always wondering, does he sniff cocaine,

does he smoke cocaine, or does he inject cocaine?

All of which can cause different things to your body.

If you sniff a lot of cocaine, we'll look

for a nasal-septal defect--

the tissue between your two nostrils.

That's from sniffing cocaine.

Certainly, from skin-popping cocaine--

where you inject cocaine right under the skin--

you get these shallow ulcers.

They're often round.

You usually see them on your anterior thighs.

I look for those.

He doesn't really have any on his anterior thighs.

Certainly, from injecting cocaine,

you can find needle puncture marks that are healing.

So we look for needle puncture marks,

and healing needle puncture marks,

indicating that he's used cocaine.

NARRATOR But the only sign she finds of Stefano's cocaine use

is his general appearance.

For somebody years old, he really doesn't look that good.

He's kind of thin and scrawny, which goes along

with his cocaine habit, because cocaine is a stimulant,

and cocaine can be an appetite suppressant.

NARRATOR To Dr. G, he looks like a habitual user.

But that doesn't mean cocaine is what ultimately k*lled him.

She'll first need to find hard evidence of the drug's

effect inside Stefano's body, and she

knows just where to start.

OK, go for it.

The cocaine will cause your blood pressure to spike.

It can cause bleeding inside the brain.

It would really kind of makes sense with all his symptoms--

then him coding, arresting, and then

being comatose in the hospital.

So I think I'm going to go to where the money is.

[music playing]

NARRATOR Dr. G prepares to examine the cranium

of -year-old Stefano Medina.

I'm hoping, when I do the head,

this is going to give me the answers.

Because it really would make sense with all his symptoms--

then him coding, arresting, and then being in the hospital.

He uses cocaine, and then has that elevated blood pressure,

and he has a bleed inside his brain.

That would kind of off off-fit this.

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NARRATOR Dr. G's morgue technician,

Brian Machulski, guides the oscillating

saw through the skull.

For him, this has been a difficult tool to master.

BRIAN MACHULSKI It's similar to sawing through a piece of wood."], index ,…}

The only problem-- as you're doing it,

you're realizing that it was once alive,

and it was a human being.

See, I have very heavy hands, and I'm notorious for breaking

everything.

So when I first learned how to do it,
[ … ]

sometimes I have a tendency to go right through the skull

real fast, real heavy, and it goes into the brain.

You got to slow it down.

You got to ease up on your pressure.

It's definitely something that you're not used to.

Probably one of the most awkward experiences of my life.

NARRATOR If Stefano's blood pressure had skyrocketed

to the point where it burst a vessel,

she would expect to see a collection of blood,

known as an intracerebral hemorrhage

that is congealed into a clot.

So we remove the calvarium, but when I cut that brain,

he's got no hemorrhage.

There's nothing there.

Well, I'm thinking, well, the cocaine didn't

cause the bleed in his brain.

But there are other ways you can die from cocaine,

and I'm still expecting to find some.

Cocaine can cause heart att*cks, an arrhythmia.

It can actually cause heart muscle damage,

and that's what my thinking is.

[music playing]

WOMAN You got another new one up there when you name them.

NARRATOR Dr. G makes the Y incision from Stefano's

shoulders down to his abdomen.

Then, she reflects the skin and fat

to expose the ribs, a technique that also

reveals his abdominal cavity.

And there, she sees something unexpected.

Something else is going on here.

There's blood mixed with some fluid collection

inside his abdominal cavity.

But why is there some blood in his abdominal cavity?

Let's see.

So I immediately look around at his liver, his spleen,

for any type of trauma.

But all of those look fine.

There's no evidence of trauma.

NARRATOR What she does see is more blood

in the area underneath the organs,

called the retroperitoneal space.

Dr. G suspects that this massive internal bleeding may have been"], index ,…}

caused by an aortic aneurysm--

a tear in the body's largest blood vessel.

Chronic cocaine users will have spikes of blood pressure,

which can cause aortic dissections, which is what I'm

really thinking is going to be his mechanism

of death at this point.

NARRATOR The aorta originates at the heart

and extends into the retroperitoneal space

behind the abdominal organs.

JAN GARAVAGLIA And in that space are your kidneys,

your pancreas, your aorta.

NARRATOR Unfortunately, at this point in the autopsy,

she's unable to access this area.

It's a space I can't get to until all of the organs

in the abdomen are taken out.

And honestly, I can't wait to get to that.

It gets kind of tedious, but I would like to now go in

to figure out what is causing that blood

in that retroperitoneal space.

And I can't do that until I look in the heart and lungs,

so I start with his heart.

NARRATOR She pries open the rib cage

and removes the heart for closer inspection.

So I'm surprised that his heart looked completely normal.

I really didn't see any chronic effects of cocaine

on his heart.

NARRATOR Next, she examines the top portion of Stefano's aorta,"], index ,…}

the section that's connected to his heart.

And here, she's surprised by what she doesn't find.

And there's no tearing of the aorta,

so I don't really see anything in the first part of the aorta.

But I can't get to the lower part of the aorta

until I take all of the abdominal organs out.

NARRATOR She begins by removing the lungs.

I don't see any acute diseases, except that he's got

a lot of edema to his lungs.

He's got a lot of fluid buildup.

But I think that is a result, probably, of him just

being in the hospital, because he's

clearly been on a respirator.

All righty, you know what?

Just leave the bowel out like that for me.

OK.

NARRATOR She finds no abnormalities in the lungs,

liver, stomach, or bowels.

With the chest and abdominal cavities clear,

Dr. G can finally access the retroperitoneal space

where she hopes to pinpoint what has caused

Stefano's massive bleeding.

JAN GARAVAGLIA He clearly d*ed from the loss of blood,

but I don't really see the source of that blood.

And it's very difficult to dissect what's going on.

Let me get some of this out of here.

NARRATOR To get a closer look, she clears

out the blood with a ladle.

When we go into that retroperitoneal space,

his aorta really actually looks pretty good.

NARRATOR The intact aorta brings
[ … ]

Dr. G to a baffling dead end.

Stefano clearly d*ed from massive internal bleeding.

But where was the blood coming from?

To hunt down the culprit, she turns back

to examine the remaining organs in the retroperitoneal space--

the pancreas and the kidneys.

And there, she suddenly spots a major abnormality.

Oh, gosh.

He clearly had a serious problem.

His body is basically digesting itself.

[music playing]

NARRATOR Dr. G is on a mission to find out

what k*lled -year-old Stefano Medina, beloved grandson

of Leah and Victor.

She knows that he d*ed of massive internal bleeding,

but she hasn't been able to pinpoint

what caused the bleeding in the first place, until now.

His pancreas does not look good.

Whoa, whoa, whoa.

There is a large amount of hemorrhage

surrounding the pancreas.

In fact, I can't see where the pancreas ends, because it's

kind of one big clump of blood.

NARRATOR But as she examines the organ more closely,

it becomes all too clear.

Stefano has suffered the worst possible complication

of pancreatitis.

The biggest part of the pancreas

is the formation of digestive juices

that then get emptied into your duodenum--

your small intestine-- to help digest food.

Now, pancreatitis is when you get an inflammation

of your pancreas.

And what's happened is he's got severe pancreatitis.

NARRATOR Severe, acute pancreatitis

causes the pancreas to leak digestive juices

into the surrounding tissues.

His body is basically digesting itself.

Those enzymes, which should be digesting and breaking down

your food, are actually digesting

and breaking down the tissues of the pancreas itself.

NARRATOR And it's not just the pancreas.

The enzymes were also eating away

at a major blood vessel called the superior mesenteric artery.

The superior mesenteric artery runs right next

to that head of the pancreas.

And in his case, that artery became weaker and weaker

as it was exposed to those digestive enzymes

that were leaking out.

NARRATOR The result?

The superior mesenteric artery balloons

until, finally, it bursts.

The source of the bleeding is clearly

when that superior mesenteric artery blew

and just digested away.

OK.

You know, what's happening to this guy is actually very rare.

First of all, pancreatitis--

% is not going to cause you any trouble.

But it's really rare to have a digestion of the blood vessel.

And of those that do occur, it's really rare

to have the superior mesenteric be the one.

So we have a very, very rare complication of pancreatitis.

NARRATOR Now Dr. G is finally able to explain

to Stefano's grandparents what cut his life

so tragically short.

All righty.

NARRATOR Stefano has been working

hard for hours, cleaning up his grandparents' backyard.

But he's not feeling well, for good reason.

A deadly chain reaction is unfolding deep within his body,

but it's not because of cocaine, as Dr. G first suspected.

When I get his toxicology back,

he wasn't high on cocaine at all.

It was just a small amount of metabolite

of the cocaine that was being picked up in his urine.

He probably had taken that cocaine

at least several days earlier, not when

the acute event was occurring.

NARRATOR But Dr. G believes another substance is to blame.

Because of his chronic alcohol use,

he started to get pancreatitis.

The number one cause in Western civilization is alcohol.

The alcohol ends up affecting his pancreas

intermittently in life.

In this episode, he probably started

to get a much more severe case and he'd had before.

NARRATOR At some point, Stefano's inflamed pancreas

begins leaking digestive juices that

consume the tissue of the organ itself, causing it to bleed.

That probably caused the initial collapse at home.

NARRATOR But at the hospital, while doctors

struggled to diagnose him, the digestive enzymes

continue their rampage.

JAN GARAVAGLIA That pancreas continued

to leak digestive juices.

These enzymes kind of just go into the surrounding tissues.

And unfortunately, adjacent to those enzymes being released

was the superior mesenteric artery.

NARRATOR As the enzymes eat away at this artery,
[ … ]

the wall becomes weaker and expands

until, finally, it explodes.

The blood could not be held, and the blood

just rushed in to the retroperitoneal space.

And he, subsequently, d*ed.

NARRATOR While painful to hear, the final autopsy results

helped Stefano's family to accept

what they never could before--

that he was a deeply troubled soul

whose addictions ultimately got the better of him.

We can talk about his cause of death, and it seems very neat.

His cause of death is due to pancreatitis, which caused

a pseudoaneurysm-- or a weakening

of the wall-- of the mesentery, which then

caused him to bleed internally.

Did you need any more of these?

Because I have some. WOMAN I got some.

You got some?

But the real cause of death--

the real cause of death on this man--

is his chronic alcoholism.

NARRATOR For Dr. G, the case reminds her

that each autopsy can be unique and unpredictable.

JAN GARAVAGLIA When I started this case,

I was not too thrilled about it.

I thought it was going to be a run-of-the-mill

drudgery type of case that I just have to get through.

But it turned out to be actually a fascinating case for me.

And it just goes to show you, you don't always

know what that autopsy is going to show,

and that's what makes this job so exciting.

[music playing]

[techno effects]

MAN Atlas.