Background: The case is of an elderly man with sudden onset of left hip pain. He was diagnosed and treated for arthritis, but died two weeks later. The body is oriented diagonally in the photo. The head would be at the upper left and the feet at the lower right. The star shows the inside of the rib cage. The heart and lungs have been removed. Most of the abdominal organs have already been removed. What happened? What caused the man’s symptoms? Why did he die?

Discussion: The patient’s aorta ruptured just above where it branches near the pelvis. This branching is called the aortic bifurcation. The aorta ruptured (black oval) towards the left hip, sending blood (curved arrow) towards that side of the body and causing the patient’s discomfort around the hip.

Isn’t aortic rupture serious? Why didn’t this patient die right away from bleeding? The patient did not die suddenly because the rupture was partly contained inside the nearby tissue. The blood did not freely enter the abdominal cavity — which could have been an immediately life threatening event. Instead, the blood tracked and pushed into the pelvic tissue, the upper leg tissue and around the hip. The patient was mistakenly thought to have had arthritic pain, but the pain was, in fact, from the pressure of blood in the tissue around the hip.

What caused the rupture? The surface of the patient’s aorta (outlined in red) is rough and not smooth. This tells us, the patient’s aorta was covered in cholesterol build-up (plaque), a risk factor for the rupture. The aorta was also widened in this area (difficult to see in this view), so the patient had an aneurysm which ruptured.

Below is a diagram of the anatomy we are talking about.

Why did the patient die? The patient did not lose enough blood to die from bleeding. Instead, he developed an abdominal infection on top of the rupture and that caused him to die.

Diagnosis: Airway mucus plugging

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What is shown?
The photograph shows the large airway opened from behind. Seen are: the voice box (left, black arrow), trachea (center); two mainstem bronchi (right, white arrows). The airway is completely filled with mucus.

How did this happen?
This patient was very weak (from cancer and from an infection), had advanced Alzheimer’s disease, and could not “clear” the mucus. Normally, people can “clear” mucus by coughing it out of the airway (and then swallowing or spitting it out). The patient was too weak to do this. So the mucus built up and blocked the airway.

How did this patient die?
The mucus blocked the airway and gradually choked the patient, preventing airflow into the lungs.

How did the autopsy help the family?
The autopsy findings allowed the family to address specific, emotionally-charged and distressing medical-related issues:

The patient’s level of comfort. The family noticed gurgling sounds during breathing and was concerned this meant the loved one was uncomfortable or suffered near the time of death. The autopsy confirmed the presence of mucus but cannot specifically comment on suffering. However, an understanding of the specific effect of mucus on air flow helped the family feel more comfortable that the patient may not have suffered.

Here’s how that worked. Because mucus builds up gradually, the patient must have had a gradual decrease in air flow (rather than abrupt, as in sudden choking). This suggests the likelihood of a gradual and long term decrease in body oxygen. This means the brain likely also had a gradual decrease in oxygen supply. Low oxygen levels cause the brain to lose or decrease consciousness. An unconscious person cannot experience suffering. This means there was a high likelihood the patient did not suffer.

The patient’s level of care. The family worried that, with all that mucus, the patient should have been suctioned by nursing staff. The autopsy cannot comment on treatment options. However, by discussing the issues and findings, the family can consider alternate points of view. For this patient, the following questions had to be considered: Given her terminal condition, what were the treatment goals? Was full care the treatment plan? Or was hospice in place? What palliative measures (e.g. suctioning) were agreed upon? Was the treatment plan made clear to the family or, more importantly, made by the family?

A family that agrees to hospice but requests suctioning suggests an active and human struggle in accepting imminent death and letting go of the loved one. A family that requests full care (including suctioning) and does not see it suggests a different set of issues.

Summary.
In this particular case, the autopsy allowed the family to come to terms with the terminal nature of the cancer; understand that their observation (of breathing) reflected the process of dying; focus their energy on bereavement rather than anger (over perceived nursing issues); and thereby achieve a sense of peace.

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Listen to case discussion:

View accompanying image:

This month’s case features an audio discussion recorded live at our event Science to Humanity: The Autopsy.

April 1, 2015.

To learn more or attend the event, click here.

The case was of a middle aged man who died suddenly two weeks after a surgery. One of the photographs shows the cause of death. The other photograph from the same patient shows a similar process, but was not the cause of death.

Case discussion:
The photographs show grafts to the heart. These were grafts from a coronary artery bypass procedure. The grafts came from a vein in the leg (saphenous vein) and were attached to the heart to allow blood flow around blocked coronary arteries. The grafts have been cut open to see along the length of their insides.

The bottom graft shows the cause of the death. This graft is completely blocked by the clot seen at the right. The clot appears as a red tube inside the graft. It blocked blood flow from getting completely through the graft to where it needed to go – the heart muscle. It was as though the heart was functioning without this graft at all.

This was a sick heart with a recent serious heart attack that prompted the bypass surgery emergently. The graft was critical to the patient’s health and life.  Without the open graft and the blood flow to the heart, the patient died.

The top photographs shows a small amount of clot healing onto the inside of the graft.  It’s not enough clot to block the blood flow in the graft, but is the same process. This clot is brown and not red because it is starting to heal and scar, which changes the color.

To the left of the clot in the top photo is a hole surrounded by small sutures.  This is called a “side anastomosis.”  This graft was used twice.  Blood flow passed through the side anastomosis to a blood vessel there; and blood flow passed through the end of the graft (all the way at the right) to a blood vessel there.  Often, grafts can be used to bypass more than one blocked vessel.

Early graft closure from clot (thrombosis) is a known, but rare complication of coronary artery bypass grafts.  It’s unrelated to the technique of the surgery or any intraoperative factors, but just a part of the body’s reaction that can sometimes happen to the graft itself.

Meaning to the family:
In this case, while it was helpful to know that the graft closure was “no fault” of the surgeon, the patient had tell-tale signs of trouble during recovery after hospitalization (shortness of breath and fainting) that were not attended to. This was a complicated post-operative story to sort though. The autopsy was helpful to the family by clarifying the cause of death and its relationship to natural processes, the surgery and post-operative care.

The case was of a middle aged man treated with intravenous antiobiotics for a skin and muscle abscess which developed after an operation. The patient died suddenly months after the abscess healed. The normal organ is seen on the right.

Discussion: The patient developed kidney failure as a result of toxicity from intravenous antibiotics. The patient required short term dialysis. He was recovering from his kidney failure when he died suddenly. The metabolic and possibly immunologic consequences of kidney failure had taken a toll on the heart, although the kidneys themselves were recovering. Uremic pericarditis is a known but poorly understood complication of kidney failure. “Uremic” means “related to kidney failure.” The heart is covered in fibrin (a blood protein) and inflammation and had begun to scar onto the surrounding sac (pericardium). “Pericarditis” means “inflammation of the pericardium.”