Category Archives: Blog

From the Director’s Desk

Happy New Year.

We have updated our website to help families find their way after a loss. Some families experience a sudden loss; others experience a loss after a long illness. Still other families have questions related to specific experiences — like a surgery; and many come to us with strong feelings that “someone’s to blame.” Others wonder about specific conditions like Alzheimer’s disease. We are skilled at handling each situation. But starting the process can be overwhelming. We have simplified our website to help the family find a place that resonates with their experience. Check out our home page to see the update. A view of the interactive feature is provided below.

In keeping with our interest in public health, I am including a link on the Zika virus. You may have heard about this in the news. The virus is spread mainly through mosquito bites. It causes mild symptoms in infected adults. The main concern is birth defects occurring in children of infected women. The specific birth defect is “microcephaly” — or a small head, leading to developmental disability. The CDC has provided a list of countries with “travel alerts.” The territory is mainly in South and Central America. No cases of mosquito transmission have been reported in the continental United States.

Take a look at this month’s case about a ruptured coronary artery; and our follow-up to last month’s Sleuth-It. I hope you find the cases interesting and engaging.

Monthly Case: Coronary Artery Rupture

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What is shown?
The top image shows the heart sac opened in the chest. The sac is full of blood (cardiac tamponade). The bottom image shows the heart after the blood around it has been removed. The view is of the back of the heart. There is a T-shaped hemorrhage. The right coronary artery (RCA) wraps around from the front and is seen on the top right. The left circumflex coronary artery (LCX) also wraps around from the front and is seen the top left. The posterior descending coronary artery (PDA) branches off the RCA and travels down the middle of the back of the heart.

What was the story here?
The patient was a middle aged man who came in to the hospital short of breath for several days after getting through a cold. He had a coronary artery stent put in his right coronary artery. The procedure seemed to go well. Later in the afternoon, he became dizzy, collapsed and died. His wife spoke with the cardiologist who explained it was probably a “stroke.” The wife could not understand why, suddenly, there was a stroke right after the procedure. She also didn’t believe he had any blockages because the husband had been athletic. She requested an autopsy and retained a lawyer.

What caused the blood on the back of the heart?
The blood on the surface of the back of the heart tracks along the coronary arteries. (The coronary arteries travel over the surface of the heart). This suggests the blood came from the coronary artery itself. Because a stent was placed in the same area as the hemorrhage, this suggests that a coronary artery ruptured related to the placement of the stent. Other possibilities would be a CPR-related contusion (but that would not track along blood vessels); or a tear of the muscle heart muscle wall (but that did not happen either).

How did the person die?
After the vessel ruptured, the blood also leaked into the sac around the heart. When the heart sac fills with blood, there is no room for the heart to beat. The heart is squeezed by the blood in the sac. This can cause the patient to collapse and die. This is what happened here.

Could the rupture have happened on its own, unrelated to the procedure?
No. Spontaneous rupture of coronary arteries is documented but extremely rare. The rupture was right in the region where the stent was placed and indicated the procedure had a role in the rupture.

What else did the autopsy show?
The autopsy showed very little coronary blockage overall and a viral infection of the heart muscle (viral myocarditis).

How did the autopsy help?
The autopsy helped on a variety of levels. It determined the cause of death (coronary rupture with tamponade). It also provided information on the prior health of the heart (viral myocarditis). The patient’s shortness of breath was likely from his heart infection; and his heart infection was likely a complication from his recent viral illness (“cold”). The results also shed light on the role of the procedure in the patient’s death. Because the patient’s coronary arteries were “open,” the procedure was unnecessary. Moreover, it caused his death.

What was the impact of the autopsy results on the family’s emotions?
Difficult as the information was to consider that the death was intimately related to the care, the information from the autopsy helped the family move on from the painful restlessness of “not knowing.” At the same time the results deepened the wife’s concern regarding the cardiologist’s explanation and behavior. She began to suspect that her husband had been left to die at the time of the code (because the cardiologist did not seem to consider a diagnosis related to the heart). On top of this, she felt profoundly dismissed that there seemed to be no consideration that her husband’s death may have had any connection to a procedure hours before — a “common sense” consideration given the time frame. The autopsy results validated her concerns. Before the autopsy, the wife was left not knowing what had happened with the cardiologist telling her it was a stroke. After the autopsy, the wife knew what happened, which diminished her dependence on the cardiologist and seemed to have a liberating effect.

Why would the cardiologist suggest the cause of death was a stroke?
The cardiologist’s comments are filtered through the wife and we can’t really know what he said. If the report is accurate, it is concerning. Was this “physician hubris” (“My procedure can’t have caused a problem. I know I did everything right!”)? Was he being dismissiveness of the wife’s intelligence? Was this fear of a medical error being discovered and an attempt to deflect the wife from the “truth”? Was he really suspicious of a stroke on clinical grounds? Which option, or some other, cannot be ascertained here. But, the possibility that truth dismissed caused the patient’s death (by inattention to a procedural complication during the code) is horrific.

Summary Comment:
The issues in this case are multiple. They include a missed initial diagnosis (myocarditis); an erroneous assessment of coronary blockages (open and not blocked); a procedural complication (coronary artery rupture related to stent placement); and, possibly, misdiagnosis of stroke during the patient’s code. Probably least in question here is the actual technique of placement of the stent — the reason being that the coronary artery wall into which the stent was placed was not firm with plaque, but a pliable normal vessel. It was possibly more easily damaged by a metal stent than one shored up by at least some firm cholesterol plaque. While seemingly remote, there is a possibility that standard of care was met at various points. It would take a review of the presenting data, angiograms, the operative note, the post-operative care, and so on. However, the autopsy served to secure the truth — of benefit to the clinicians and to the wife sorely in need of information.

From the Director’s Desk

Happy Holidays.

This late fall and past year have been full of concerning news over a number of police shootings. While our role at Autopsy Center is to focus on medical cause of death, we would be in remiss if we did not comment on the important events and changes taking place in our cities, including Chicago. Please take a look at my essay: Commentary: The Laquan McDonald Shooting for a perspective. Our common experience with the humanity behind communication gives us a perspective for working with families during a loss, regardless of the nature of the death. See what you think.

We have one more date before the New Year for our event, ‘The Autopsy Talks’ at Theater Wit. Join us December 30 at 7:30 pm and keep an eye out for new dates in 2016. Check out Fox News and DNAinfo coverage of the event. Scrambling for Christmas present last minute? Keep this acclaimed event in mind.

Best for a safe and happy New Year.


Ben Margolis, M.D.

Sleuth It – The Case Without Findings

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Click here to skip to discussion.

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A 44 year old man dies suddenly after a night of “partying.” The coroner has made her evaluation but declined to perform an autopsy. The two sons request an independent autopsy, which you perform. The body is thin, but well nourished. There is no evidence of trauma and the autopsy exam is entirely normal. You save some blood for toxicology, even though the family has not requested testing.

Afterwards, you meet with the sons. They explain that their father was drinking beer and doing “shots” of hard liquor, but wasn’t really “that drunk.” You talk though the pluses and minuses of testing the blood for alcohol: the sons already know their father was drinking, so the test wouldn’t add that; but the test might give a clearer sense of how much alcohol was “in the system.” The sons don’t want any toxicology testing, saying they know “how hard” their father partied.

Suddenly, they turn to one another, whisper, and then turn back. “Oh, yeah, our father also ….”

Which of these disclosures would help in this case?

Their father:

a. Had high blood pressure
b. Was depressed and took the antidepressant Zoloft
c. Did cocaine
d. Had a serious family history of high cholesterol
e. Just started taking Coumadin (blood thinner) for a problem with his heart rhythm.

Stay tuned next month for a discussion of the case.

January 9, 2016 Update:
Case Discussion.

It would help to know that the father used cocaine (choice c.). Cocaine can cause spasm (clamping down) of normal coronary arteries, block blood flow in the artery and cause a heart attack that way. It could certainly have caused the death.

It may also help to know if the father had an abnormal rhythm (choice e.). That might be explored more to see in what way the abnormal rhythm might have been a risk factor for sudden death.

Coumadin is a risk factor for bleeding into the head — but you performed the case and there was no bleeding. So the part of option e. that is helpful is the mention of an abnormal heart rhythm, not the use of Coumadin.

High blood pressure is a risk factor for a large heart and an abnormal rhythm — but you performed the case and the heart was normal.

Family history for high cholesterol is a risk factor for high cholesterol and blockages — but you performed the case and there were no blockages.

Zoloft is not commonly a drug that causes overdose.

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Commentary – The Laquan McDonald Shooting

On October 20, 2014, Laquan McDonald died after multiple gun shots from a Chicago police officer. A year later on November 24, 2015, a video of the event was released to the public.

How does a neutral service like Autopsy Center participate in the discussion of the Laquan McDonald shooting? By sharing truths. I’m going to emphasize some basic parts of the process we see in all death investigation cases — medical, civil and criminal — and which are at play here. I’m specifically going to talk about one piece of the story: the release of the video.

There is little talk of autopsy results. The results are the video. But the process is the same.

Who controls the results? Who decides when they are released? And who interprets them?

The family? The public? The “experts”? The “officials”? The community? The law?

Not everyone has the control or voice they wish for yet; and not everyone believes the other has a just amount. The push and pull between the many groups reflects that this case is about power and vulnerability: between two people on October 20, 2014; between communities and law enforcement; and between U.S. citizens and the justice system. The clamor generated by the release of the video creates two deafening sound tracks: one for the silent video with its silent officers and now-silent youth; and another for the many silent months prior to the video’s release.

This uproar over the delay in the release of the video reflects, more than anything, that there is a gap in the process. Because trust is built on communication and respect, lack of communication can become a symbol of disrespect or worse.

We see this all the time in health care. Physicians doing a good job and with good, fair intentions often meet their downfall by not communicating. When the patient dies and the relationship between the physician and the family has broken down, it can buy the doctor a law suit regardless of how good the care was and how sick the patient was. Doing a good job is not enough — they physician has to attend to the system, care for who’s vulnerable and understand what it means to be in a position of power.

It’s no different in the justice system. If delays in communication are clearly required by law, this may be understandable. If not, they should be accompanied by clear timelines, updates and reasoning. If the law is wrong, it should be changed. Otherwise, power steps on the vulnerable – creates obstacles, and then suspicion and then rage.

There are some efforts in some cities to update communication and “evidence-release” (e.g., video-release) laws. This is an important part of the solution here.

But regardless of how the law evolves, it will never be enough for the family despairing over the loss of their loved one; and it will never be enough for the “system” seeking to protect and isolate the legal process. There needs to be communication and transparency on top of it. That’s about attitudes and individuals, community and culture. It is right to talk about race relations and community relations in this case. It’s right to talk about patterns of behavior. The issues here are also social. Changing the law is only one part of the solution because we are more than our laws.

It’s that basic communication and respect for a relationship that will keep us together — officer and youth; community and police; U.S. citizens and our government. Let’s remember that to move forward. It’s the only way we can have a system and be free.

Ben Margolis, M.D.
Autopsy Center of Chicago

Updated Dec. 22, 2015

From the Director’s Desk

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Join us opening night, November 4, at Theater Wit to experience our critically acclaimed autopsy seminar. We are delighted to expand our seminar into our new theater space. The event is an interactive slideshow and discussion for the public, as seen in Time Out Chicago, AV Club, Life Matters Media and others. Wondering if it’s for you? Think psychology, health, families….Seen it already? Spread the word. We get artists, laywers, social workers, hospice workers, law enforcement, the generally curious and many others. Learn how an autopsy is peformed. And hear a story or two along the way will show you the humanity behind the science.

Looking for a lunch buddy on November 3? Join us online at noon for our next Q & A series for the public. The topic for this event is gastrointestinal death. If you know someone who has had died from colon cancer, c. difficile infection, or esophageal varices, have a question, or just want to following along with the conversation, feel free to login. As always, the event will begin with a short video (preview here) showing a dissection of an intestine. We look forward to your questions and participation this Tuesday. Just go to our Facebook page and the event will be right there.

This month’s newsletter includes my essay, “The Independent Autopsy and Private Autopsy – and Your Rights.” So much happens to a family when there’s a loss — from the emotional to the practical. A family can be pulled in different directions by all the individuals, institutions and laws that come into play during this vulnerable time. Take a look and see if you’re familiar with your rights when it comes to autopsies.

Our Live from the Morgue series is up and running. If you work with high schoolers, please feel free to be in touch.


Ben Margolis, M.D.

New event venue – Theater Wit

We are excited to expand our Autopsy Seminar into Chicago’s Theater Wit in Lakeview.

An exciting, professional presence in Chicago, Theater Wit will host our growing numbers of curious attendees — nearly 1000 to date.

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Join us for our informative, engaging discussion and slideshow on the autopsy. And be sure to take advantage of Theater Wit’s many other offerings.
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Opening night is Wednesday, November 4 at 7 pm.

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Top Viewed Post: Greenfield Filter with Clot

May Newsletter Covered

What is shown? Shown (right photo) is a piece of metal wiring with blood clot trapped in it. The device is called a Greenfield filter. It’s about two inches long altogether. The left picture shows the device where it was found – in the inferior vena cava (dashed lines). The inferior vena has been opened up along its length. The diagrammatic insert shows the filter without clot attached.

What is a Greenfield filter? A Greenfield filter is a device inserted into the inferior vena cava (the large vein returning blood to the heart). The filter traps clot that might travel up from the legs in some patients. It is inserted through the groin and threaded up the inferior vena cava to rest there.

How does the filter stay put? Little hooks at the ends of the wires keep it in place inside the vein. This keeps it from traveling up the vein closer to the heart

How does the filter help the patient? By trapping clots that travel in the blood stream up from the legs, the filter prevents them from traveling any farther. Specifically, the filter prevents them from reaching the lungs. The Greenfield filter saves lives.

Who gets a Greenfield filter? Patients with clots in their legs (deep venous thromboses – DVT’s) get a Greenfield filter.

What was the story here? This was a 32 year old man with cancer (lymphoma), DVT, and many infections. He spent the six months leading up to his death in the hospital.

Why did the family request and autopsy? The family was looking for closure and peace of mind. They were also concerned about the quality of care and the possibility of missed diagnoses. The family was dedicated and committed and had one member or another stay with him at all times. Their style was centered on control with extensive documentation and detailed note-taking of any medical information or conversations that came their way. Behind all this were deep feelings of grief over the loss of a son and brother.

How did the autopsy help? In the setting of deep grief, it was important to make use of any and all information from the autopsy to provide both a clear picture of the quality of care and the patient’s experience prior to death. The finding of a Greenfield filter with entrapped clot indicated the following:

Filter placement. The presence of the filter itself reflected appropriate clinical judgment and excellent quality care on the part of the providers. It is standard of care to place the filter, which is what this patient had. For a family with concerns about treatment, it was then helpful to objectively show that at least in one area (management of deep venous thrombosis), care had been appropriate. This then, could help the family feel a bit less angry about some of their concerns. It was not clear what, if anything, had already been discussed with the family about the filter’s placement. Its finding at autopsy presented another opportunity to review the clinical course.

Trapped clot. The presence of trapped clot indicated a disaster avoided. The amount of clot was significant. Without the filter the clot would have, without a doubt, traveled up the blood stream to the lungs and possibly caused the patient’s death, if not severe illness.

Conclusion. Therefore, for during a life cut short, when days and weeks had become precious to the patient and to the family, it was clear that the medical care had bought some time in this world for this patient. This was an important thing to share with a family dealing with loss; and a benefit of the autopsy.

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From the Director’s Desk

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Our on-line Q & A series for the public continues with another event scheduled for Tuesday, September 22 at 12 noon central time. Please join us for our live-response session held on our Facebook page. The topic for this event is infectious disease death. If you know someone who has died from a pneumonia or has had bed sore , or have other questions related to infections and the autopsy — or just want to follow along — please join us. The event will begin with a short video showing a dissection of a spleen, one of the organs participating in the body’s defense against infections. We look forward to your questions and participation this Tuesday. Just go to our Facebook page and the event will be right there.

Last month’s Q & A covered cardiac death. Thanks to everyone for participating. If you missed the on-line event, please feel free to check out our brief video showing a dissection of a coronary artery; and view the Q & A thread here. And be sure to join us on Tuesday, September 22 at noon to catch the next Q & A.

There is little in the medical literature written about the role of autopsy in bereavement. Usually, it’s just a few words — “provides closure” or “helps the family during grief” — in a more general article about the autopsy. The procedure developed historically from medical science and the explorations of inquisitive physicians. It makes sense that most written information about the autopsy centers on case medical findings. While the end-point of the autopsy – inventorying medical conditions and making sense of the cause of death — remains, the procedure’s meaning to the family penetrates deeply on an emotional level, often touching on a lifetime of relationships. Read my piece, The Autopsy: An Emotional Choice, which explores one son’s experience with an autopsy and see what you think.

Best for the fall.


Ben Margolis, M.D.