Tag Archives: pulmonary embolism

Do The Zen Diaries of Garry Shandling Yield Insight Into The Cause of His Death?

The skeptical cardiologist watched a little bit of the Judd Apatow HBO Documentary on Garry Shandling last night. For fans of the comedian like me, it is fascinating. As I watched I was reminded of two posts I had written about the cause of his death and the physician detective in me searched for clues to his ultimate demise.

Right after his sudden death at the age of 66, media sources reported that he had died of a massive heart attack “according to insiders.”

At the time, TMZ reported that  “Sources familiar with the situation tell TMZ Shandling died from a massive heart attack, with no prior warning whatsoever”

In a post I wrote entitled “Do You Know What is on Garry Shandling’s and Your Parent’s Death certificate?” I pointed out that his cause of death was unknown and that:

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

I wrote another post on this after his autopsy was released.

His autopsy revealed that he  died from a pulmonary embolism, the disease I had raised as a likely  alternative cause of his sudden death in my post in April, 2016. The actual death certificate can be viewed here.

The medical report on his death reveals that Shandling had a prior
history of clots in the leg (s) (DVT) and that previously he had had an IVC filter implanted.

An IVC filter is an umbrella shaped device that is inserted into the major vein draining blood from the the lower half of the body (the inferior vena cava) to physically obstruct the vein and thereby prevent clots from reaching the pulmonary artery. These are used in cases where the normal medical treatment for blood clots (anticoagulants or blood thinners) can’t be utilized due to bleeding risk or have proven ineffective.

Although effective 95% of the time in preventing legs clots from migrating to the pulmonary artery there are reported failures and Shandling was clearly one.

Risk factors for DVT and PE include cancer, surgery and immobility. Shandling, it appears, was recently in Hawaii and long plane flights like the one he must have taken back to LA are notorious causes of immobility that can lead to DVT.

What Can We Learn From Shandling’s Death

Some take home points

-When some one dies suddenly and unexpectedly  it is not automatically due to a massive heart attack. Do not assume your family member or spouse who  was found dead in bed suffered a myocardial infarction.

-Unless the victim was quite old or had advanced cancer consider asking for an autopsy to find out the true cause of death. Whatever disease caused the death could be  inherited by the victim’s offspring.

-Pulmonary embolism can be a rapidly lethal disease. Consider a medical evaluation for it if you are experiencing leg pain/swelling, sudden, unexplained shortness of breath or chest pain which worsens upon taking a breath. If you have risk factors for leg clots or prior leg clots be even more vigilant.

 

Watching the Zen Diaries of Garry Shandling gave me no further insights into his death. Sudden death typically happens without warning to the victim and even those who are closest to him/her.

Antithrombotically Yours

-ACP

 

N.B. In the second post I talked about Carrie Fisher’s death (also widely reported falsely as due to a “massive heart attack”) and speculated that we might never know the cause of her death because I anticipated that her autopsy (with toxicology) would not be released.

I was right about her not dying of a “massive heart attack” .

Her cause of death was listed as sleep apnea with other factors.

The other factors appear to be LOTS of drugs:

“Fisher’s toxicology review found evidence of cocaine, methadone, MDMA (better known as ecstasy), alcohol and opiates when she was rushed to Ronald Reagan UCLA Hospital on Dec. 23, a toxicology report showed.”

No autopsy was done per family request but CT scanning was performed.

What Really Caused Garry Shandling’s Death: The Exploding Heart That Wasn’t

In March , 2016, Garry Shandling died suddenly and unexpectedly. At the time, TMZ reported that  “Sources familiar with the situation tell TMZ Shandling died from a massive heart attack, with no prior warning whatsoever”

This alleged cause of death  was reported widely.

 Radar Online (a site I strongly recommend avoiding) wrote

“According to an insider close to the comedian, “We are hearing that Garry had a massive and sudden heart attack.” and

“The word is that his heart basically exploded.”

LAPD, LAFD, Shandling’s rep, and LA coroner Ed Winter all declined to comment on the specifics of Shandling’s passing.

 

 

 

 

Beware The Insider’s Information

In a post I wrote entitled “Do You Know What is on Garry Shandling’s and Your Parent’s Death certificate?” I pointed out that his cause of death was unknown and that:

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

What Did Shandling Die Of?

In a post dated 12/27/2016 (which I was unaware of until last week) TMZ reported the details of Shandling’s medical examination .

It turns out that Shandling did not die of a massive heart attack or an explosion of his heart.

His autopsy revealed that he  died from a pulmonary embolism, the disease I had raised as a likely  alternative cause of his sudden death in my post in April, 2016. The actual death certificate can be viewed here.

The medical report on his death reveals that Shandling had a prior
history of clots in the leg (s) (DVT) and that previously he had had an IVC filter implanted.

An IVC filter is an umbrella shaped device that is inserted into the major vein draining blood from the the lower half of the body (the inferior vena cava) to physically obstruct the vein and thereby prevent clots from reaching the pulmonary artery. These are used in cases where the normal medical treatment for blood clots (anticoagulants or blood thinners) can’t be utilized due to bleeding risk or have proven ineffective.

Although effective 95% of the time in preventing legs clots from migrating to the pulmonary artery there are reported failures and Shandling was clearly one.

Risk factors for DVT and PE include cancer, surgery and immobility. Shandling, it appears, was recently in Hawaii and long plane flights like the one he must have taken back to LA are notorious causes of immobility that can lead to DVT.

What Can We Learn From Shandling’s Death

Some take home points

-When some one dies suddenly and unexpectedly  it is not automatically due to a massive heart attack. Do not assume your family member or spouse who  was found dead in bed suffered a myocardial infarction.

-Unless the victim was quite old or had advanced cancer consider asking for an autopsy to find out the true cause of death. Whatever disease caused the death could be  inherited by the victim’s offspring.

-Pulmonary embolism can be a rapidly lethal disease. Consider a medical evaluation for it if you are experiencing leg pain/swelling, sudden, unexplained shortness of breath or chest pain which worsens upon taking a breath. If you have risk factors for leg clots or prior leg clots be even more vigilant.

Antithrombotically Yours

-ACP

N.B. Carrie Fisher was also reported to have suffered a “massive heart attack” by Radar Online (a most despicable website) and multiple other media outlets:

The Star Wars star, 60, suffered a massive heart attack on a United Airlines Flight from London on December 2, 2016, and was rushed to the hospital in LA upon landing, where she died four days later. Her death certificate was released by the Los Angeles County Department of Health and her cause of death was listed as “cardiac arrest/deferred,” which means it was likely a heart attack, but the final result is pending investigation.

No Radar Online! Cardiac arrest is the final mechanism of almost all deaths no matter what the cause. It does not mean she had a heart attack.

The CDC does not want cardiac arrest listed as a cause on death certificates:

In Part I, the immediate cause of death is reported on line (a). This is the final disease, injury, or complication directly causing the death. An imme­ diate cause of death must always be reported on line (a). It can be the sole entry in the cause-of-death section if that condition is the only condition causing the death.

The immediate cause does not mean the mechanism of death or terminal event (for example, cardiac arrest or respiratory arrest). The mechanism of death (for example, cardiac or respiratory arrest) should not be reported as the immediate cause of death as it is a statement not specifically related to the disease process, and it merely attests to the fact of death. Therefore, the mechanism of death provides no additional information on the cause of death.

We may never know the cause of carrie Fisher’s death because the autopsy (with accompanying toxicology) may never be released.

Do You Know What’s On Garry Shandling’s And Your Parent’s Death Certificate?

0324-garry-shandling-twitter-4
Better Call Saul’s Bob Odenkirk and Kathy Griffin “hanging” with an apparently healthy Larry Sanders on March 20. These two appeared on Shandling’s brilliant Larry Sanders TV show.

When someone who had appeared to be healthy dies suddenly, it is often assumed that he/she died of “a massive heart attack.” Certainly, this was the case in the recent unexpected sudden death of Garry Shandling, the actor and comedian.  Shandling, aged 66, died March 24 of this year.

ET online reported:

“His publicist Alan Nierob told the ET that Shandling had no history of heart problems, but that doctors believe he died as the result of a heart attack.”

Although a heart attack resulting in ventricular fibrillation is the most common cause of a sudden, unexpected death in individuals over the age of 40, it is not the only one.

In fact, People  magazine reported that Sanders experienced shortness of breath and pain in his legs just a day before his death, and that he spoke to a doctor friend about his symptoms, who stopped by that night to check on him,

Shortness of breath and pain in the legs raise the possibility of a clot or DVT in the leg, which can break loose and embolize into the pulmonary arteries. Such a pulmonary embolism, if massive, can result in swift and sudden death.

The LA Coroner’s office could not get Sanders’ physician to sign his death certificate and the cause of death has still apparently not been determined, pending toxicology testing which typically takes 6 weeks.

What’s On Your Parent’s Death Certificate

More important than what is on Garry Shandling’s death certificate is what is on your parent’s death certificate, and whether it is accurate. If one of your parents died prematurely and suddenly, it is  important to know with precision what caused it. If the cause was an heritable cardiovascular condition, hopefully, appropriate testing can determine if you have that condition, and steps can be taken to prevent your premature demise.

Examples of inherited cardiovascular conditions (in addition to heart attack (myocardial infarction) or pulmonary embolism) that can cause sudden and unexpected death include aortic aneurysm dissection, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasis, and long QT syndrome.

Unfortunately I find that, at least in my patients, uncertainty about the cause of death of one’s parents is the norm.

Many of my patients, for example, tell me one of their parents died of a “massive heart attack” and they assume that they are at increased risk of the same fate. When I press for details, typically no autopsy was performed.  Mom or dad may have been found dead at home, or they may have suddenly keeled over but not survived to make it to the hospital for a definitive diagnosis.

Without an autopsy in such circumstances, it is not possible to be sure of the cause of death.

Even if you have a cause of death listed on your parent’s death certificate, there is no guarantee that it is accurate.  The doctor that filled it out, without an autopsy in many circumstances, is just speculating on the cause based on what he/she knew about prior medical conditions and the circumstances surrounding the death.

I was recently asked to fill out the death certificate of an elderly patient of mine who had atrial fibrillation and congestive heart failure and was living in a nursing home.

One night she was noted by the staff to be very short of breath and was taken to a local  emergency room where she was pronounced dead.

Based on the information available to me, I had no idea what caused her death. Although she had quite signifiant cardiac problems, when I last saw her she was stable and I have numerous patients with the same conditions who live for decades.

I filled out the death certificate, listing all of her conditions, and entered in that the cause of death was unknown.

Although the CDC guide for physicians filling out death certificates clearly states that this is acceptable, I was subsequently informed that the funeral home did not accept unknown cause of death and that they had found another doctor to fill in a cause  of death.

I guarantee you, whatever he put on as the cause of death was total speculation.

Jerry Seinfeld was good friends with Garry Shandling and, oddly enough, not too long ago, featured him in an episode of his internet series “Comedians in Cars Getting Coffee” entitled “It’s Great That Garry Shandling Is Still Alive.

Screen Shot 2016-07-03 at 7.04.14 AM

Shandling mentions “I had hyperparathyroidism,” making a joke that “the symptoms are so much like being an older Jewish man, no one noticed!”

James Fallows, the excellent The Atlantic writer, highlights his own experience with hyperparathyroidism (a disease that leads to high calcium levels and is easily treated with surgery), in a recent Atlantic article. The subtitle of this article, “a rare and under-publicized condition that can sometimes be fatal,” suggests that hyperhyperparathyroidism might have led to Shandling’s death.

I don’t think this is likely because Shandling suggests that the disease is in the past tense (i.e. he has already had the surgery), and sudden death from hyperparathyroidism would be extremely unlikely.

Fortunately, Shandling is getting a full examination and autopsy to fully determine the cause of his death. If he has offspring, this will be extremely helpful to them in understanding what medical conditions they can expect later in life.

If he was not a celebrity, his death, like many of your parents’, most likely would have been ascribed to a “massive heart attack.”