Autopsy Report: Awal Gul, Guantanamo Bay (Natural) (Death Certificate Included)

 

ARMED FORCES MEDICAL EXAMINER SYSTEM

1413 RESEARCH BLVD, BLDG 102

ROCKVILLE, MD 20850

AMENDED*

FINAL AUTOPSY REPORT

Autopsy No.:

AMP No.:

Rank: Civilian (Detainee)

Place of Death: Guantanamo Bay

Place of Autopsy: US Naval Hospital

Guantanamo Bay, Cuba

(b)(7)(F) Name: GUL, Awal

ID No: ISN-782

Date of Birth: 1962 (48 years)

Date of Death: 01 FEB 2011 (2339 hours)

Date of Autopsy: 03 FEB 2011, 0700 hours

Date of Report: 23 FEB 2011

Date of Amended Report: 04 MAR 2011

(b)(7)(F)

Circumstances of Death:

Mr. Awal Gul, a 48 year-old detainee, collapsed in the shower room after 2230 hours.

Earlier he was exercising on the treadmill, and complained of being tired after 5 minutes.

He went to shower where he collapsed. He was noted with his back to the shower wall

foaming around the mouth. He was carried by other detainees to the cell block gate.

Code Yellow was called at 2238 and CPR was started immediately. He was noted

without spontaneous respiration or pulse and Code blue was called. He was transported

to the US Naval Hospital Guantanamo Bay (USNH GB) in asystole. He was pronounced

deceased at 2339 hours, on 2 FEB 2011.

Mr. Gul had a medical history of obesity and poorly controlled hypertension. He had

complained of chest pain on 28 Jan 2011. Laboratory tests on the 28 th revealed no

evidence of myocardial ischemia or significant abnormalities; see "Review of Medical

Records".

Authorization for Autopsy: Office of the Armed Forces Medical Examiner, TAW Title

10 US Code 1471

Identification:

Mr. Awal Gul, ISN 782, is identified by visual recognition and detainee's identification

tags. He is positively identified by fingerprints comparison by the FBI, Dover AFB on

08 FEB 2011. A tissue sample is collected for DNA identification.

Cause of Death:

Atherosclerotic Cardiovascular Disease

Manner of Death:

Natural

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F) 2

MEDICAL RECORDS REVIEW

The available medical health records am screened by the prosector and the observing

civilian medical examiner prior to the autopsy; see "Postmortem Examination".

Review of the medical records reveals the following in the more recent entries:

Mr. Gul was in an overall good health. He had past medical history of hypertension and

non-compliance with treatment, hypercholesterolemia, and obesity (BMI over 30.0). He

had also history of appendectomy in 10/2002, bilateral knee osteoarthritis, and latent TB

(positive PPD in Oct 2002; INH treatment was completed).

On 01 DEC 2009, he complained of upper chest pain for two weeks, with no signs of

distress, only when he eating or drinking. He believed that this pain is due to acid reflux

and requested diet recommendation.

On 28 JAN 2011, Mr. Gul was transported to the medical area complaining of a

localized, non-radiating, squeezing chest pain in the center of the chest. There were no

other associated symptoms or signs. EKG showed a normal sinus rhythm, minimal

criteria for left ventricular hypertrophy and no ST elevation/depression, wide QRS or

arrhythmias. Laboratory tests for Creatine Kinase (CK-MB) and Cardiac Troponin 1

(cTn1) were within normal limits. The differential diagnosis of his chest pain was

atypical chest pain vs. Gastro-esophageal Reflux Disease (GERD). He was to be seen

again in a week. He died on 01 FEB 2011 at 2339 hours.

POSTMORTEM EXAMINATION

The postmortem examination (b)(7)(F) on Awal Gul is performed at the US Naval

Hospital Guantanamo Bay (USNH GB), Cuba on 03 FEB 2011, starting at approximately

0700 hours. Full body CT-Scan is obtained at the USNH GB. Photographs are obtained

by (b)(6)

Assisting in the autopsy procedure

is (b)(6) Attending the au toss as medicole :al

observers are (b)(6 )

(b)(6)

(b)(7)(C)

EXTERNAL EXAMINATION

The body is that of a well-developed, unclad obese male covered by multiple white sheets.

Hands and feet were tied together with white ribbons with attached identification tags with

his name and ISN number. No clothing or personal effects accompanies the remains.

and Special Agents (b)(7)(C)

The body measures 68" and weighs an approximately 220 lbs, with no evidence of external

trauma or abnormalities. Rigor is present to an equal degree in all extremities. Lividity is

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F)

present and fixed on the posterior surface of the body, except in areas exposed to pressure.

Body temperature is cold due to refrigeration.

The scalp hair is black-gray with prominent male baldness. The facial hair consists of black

mustache and long beard. The eyes are unremarkable. The irides are brown. The corneae

are slightly cloudy. The conjunctivae appear injected with no petechiae. The sclerae are

white with a small area of hemorrhage on the right side. The external auditory canals,

external nares and oral cavity are free of foreign material and abnormal secretions. The

nasal skeleton is palpably intact. The tongue is unremarkable. The lips are without evident

injury. The frenula is unremarkable. The teeth are natural and unremarkable. Examination

of the neck reveals no evidence of trauma or abnormal mobility.

The chest is hairy and unremarkable. No injury of the ribs or sternum is evident externally.

The abdomen is markedly protuberant, but otherwise unremarkable with no evidence of

trauma. A surgical scar is noted on the right lower abdominal quadrant, consistent with a

remote appendectomy. No other scars are present. The posterior torso is unremarkable with

no evidence of trauma or abnormality. The external genitalia are those of a normal adult

circumcised male with unremarkable descended testes. The anus is unremarkable.

The upper and right lower extremities are unremarkable with no evidence of recent trauma.

Contusions of unknown etiology are noted on the distal left leg. The hands are

unremarkable with no trauma. The finger nails are clean and unremarkable. No tattoos,

other major surgical scars or identifying marks are noted.

EVIDENCE OF INJURY

Examination of the head reveals no evidence of external or intracranial trauma. A small

area of subgaleal hemorrhage is noted on the back of the head with no overlying trauma

of the scalp or underlying skull fracture; see "Opinion". A small area of hemorrhage is

noted in the tongue; see "Opinion".

Examination of the neck reveals no evidence of external trauma or ligature marks.

Examination of the strap muscles reveals small focal area of hemorrhage on the left

sternocleidomastoid muscle; see "opinion". The hyoid bone and thyroid cartilage are

intact. Posterior dissection of the neck reveals no evidence of muscular or spinal trauma.

Examination of the anterior chest wall reveals a small area of superficial hemorrhage of

the left serratus anterior muscle overlying a non-displaced fracture of rib # 3, anterolaterally.

Examination of the chest cage reveals fractured left ribs # 3, 4, 6 and 7

anteriorly, at the strno-chondral junction. The fractured ribs are associated with minimal

hemorrhage; see "Opinion". External and internal examination of the chest, abdomen

and genitalia reveals no other evidence of trauma.

AUTOPSY REPORT (b)(7)(F) 4

GUL, Awal (ISN 782)

Examination of the upper and right lower extremities reveals no evidence of trauma.

Examination of the left leg reveals two contusions on the anterior and medial distal leg,

well above the ankle.

Serial longitudinal incisions on the back and extremities reveal no evidence of recent or

remote injuries; photographed for documentation.

CLOTH: NG & PERSONAL EFFECTS

None received.

MEDICAL INTERVENTION

An endotracheal tube and a neck guard are noted. CT-scan and postmortem examination

reveals the endotracheal tube inserted in the esophagus; see "Opinion".

INTERNAL EXAMINATION

BODY CAVITIES:

Examination of the intact pericardial sac reveals 600 cc of fluid and clotted blood; see

"Cardiovascular System". No abnormal collection of fluid is present in the chest or

abdominal cavities. The amount of intra-abdominal fat is markedly increased. Mild

adhesions are noted of the cecum to the abdominal wall, consistent with the remote

appendectomy. All body organs are present in the normal anatomical position. The

subcutaneous fat layer of the abdominal wall is increased, measuring 2" thick at the

umbilicus. There is no internal evidence of blunt or sharp force injury to the thoracoabdominal

region.

HEAD: (CENTRAL NERVOUS SYSTEM)

The dura mater and falx cerebri are intact. There is no epidural, subdural or subarachnoid

hemorrhage present. The leptomeninges are thin and delicate. The cerebral hemispheres are

symmetrical. The structures at the base of the brain, including cranial nerves and blood

vessels, are intact. Corona] sections through the cerebral hemispheres reveal no lesions.

Transverse sections through the brain stem and cerebellum are unremarkable. The brain

weighs 1300 grams. Serial sectioning of the brain reveals unremarkable parenchyma and no

evidence of trauma.

NECK:

See "Evidence of Injury".

Examination of the soft tissues of the neck including strap muscles, thyroid gland and large

vessels are unremarkable and without traumatic abnormalities. The hyoid bone and thyroid

cartilage are intact.

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F)

CARDIOVASCULAR SYSTEM:

The pericardial surfaces are smooth, glistening and unremarkable; the pericardial sac is

distended with 600 CC of fluid and clotted blood.

The coronary arteries arise normally, follow the usual distribution and are widely patent

with no atherosclerotic changes, except for the left anterior descending artery (LAD).

Serial sections through the LAD reveal marked narrowing of its lumen, pin point shortly

after its take off the left main coronary artery. Focal calcifications are noted.

The heart weighs 440 grams and is mildly enlarged. Examination of the heart reveals a

perforation of the anterior left ventricular wall, near the base and the anterior interventricular

septum. The perforation measures 1.0 cm in length on the epicardial surface and 1 rh x 0.5

cm on the endocardial surface; photographed for documentation. The surrounding

myocardium is dark red-brown, firm and grossly unremarkable. The valves exhibit the

usual size, texture and position relationship and are unremarkable.

The aorta and its major branches arise normally, follow the usual course and are widely

patent. The aorta reveals fatty streaks with no apparent calcification and no ulceration. The

major arteries are free of significant atherosclerosis and other abnormality. The venae cavae

and their major tributaries return to the heart in the usual distribution and are free of

thrombi.

RESPIRATORY SYSTEM:

The upper airway is clear of debris and foreign material; the mucosal surfaces are smooth,

yellow-tan and unremarkable. The pleural surfaces are smooth with no adhesions present.

The pulmonary parenchyma is red-purple and exudes a moderate amount of bloody fluid

with no focal lesions identified. The pulmonary arteries are normally developed, patent and

without thrombus or embolus. The right and left lung weighs 580 grams and 490 grams,

respectively.

LIVER & BILIARY SYSTEM:

The hepatic capsule is smooth, glistening and intact, covering dark red-brown, moderately

congested parenchyma with no focal lesions noted. The gallbladder contains green-brown,

mucoid bile; the mucosa is velvety and unremarkable. The extrahepatic biliary tree is

patent, without evidence of calculi. The liver weighs 2300 grams.

ALIMENTARY TRACT:

See "Medical Intervention".

The esophagus is lined by gray-white, smooth mucosa. The stomach is distended with air

and 500 cc of dark green partially digested food, a sample of which is submitted for

toxicological testing. The stomach reveals no evidence of ulceration. The small and large

bowels are unremarkable. The pancreas has a normal pink-tan ]obulated appearance and the

ducts are patent. The appendix is absent (s/p appendectomy).

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F)

GENITOURINARY SYSTEM:

The renal capsules are smooth and thin, semi-transparent and strip with ease from the

underlying finely granular red-brown cortical surfaces. The cortices are sharply delineated

from the medullary pyramids, which are red-purple to tan and unremarkable. The calyces,

pelves and ureters are unremarkable. The urinary bladder is unremarkable and contains

clear slightly cloudy yellow urine. The right and left kidneys weigh 180 grams and 160

grams, respectively.

The external genitalia are those of a circumcised adult male with bilaterally descended

unremarkable testes.

RETICULOENDOTHELIAL SYSTEM:

The spleen has a smooth, intact capsule covering red-purple, moderately firm parenchyma;

the lymphoid follicles are unremarkable. The regional lymph nodes appear normal. The

spleen weighs 180 grams.

ENDOCRINE SYSTEM:

The pituitary, thyroid and right adrenal glands are unremarkable. A small well

circumscribed 0.5 cm adenoma is noted in the left adrenal gland.

MUSCULOSKELETAL SYSTEM:

See "Evidence of Injury".

Muscle development is normal. No non-traumatic bone or joint abnormalities are noted on

gross examination.

EVIDENCE

None collected.

RADIOLOGICAL STUDIES

Radiographs reveal no recent skeletal fractures or abnormalities. Verbal preliminary

report is obtained. The CT-Scan reveals distended pericardial sac and endotracheal tube

inserted into the esophagus.

MICROSCOPIC EXAMINATION

Representative sections of the major organs are retained with preparation of histological

slides.

Slides # 1-6 Heart:

1. Perforation site: Evident perforation site with surrounding hemorrhage, fibrin

deposition and surrounding area of infarction with prominent fibroblastic

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F)

proliferation consistent with over 7 days. The prominence of fibroblastic

proliferation suggests 1-2 weeks of age; see "Opinion".

2. Section close to perforation site: Multiple foci of prominent fibroblastic

proliferation consistent.

3. Section 2 cm distal to perforation site: Multiple foci of prominent fibroblastic

proliferation consistent. Mild myocyte hypertrophic changes are noted.

4. Left Ventricle: Mild myocyte hypertrophic changes and perivascular fibrosis

are noted.

5. Septum; Mild myocyte hypertrophic changes and perivascular fibrosis are

noted.

6. Right Ventricle: Fatty infiltration, mild.

Slide # 7: Left Anterior Descending Coronary Artery: Atherosclerotic changes of the

LAD coronary artery with over 75% focal narrowing of the lumen and focal calcification.

Slide # 8: Lungs: Postmortem changes and dark pigment-laden macrophages.

Slide # 9: Spleen & Pancreas: Postmortem changes. No significant pathological changes.

Slide # 10: Thyroid gland: No significant pathological changes.

Slide # 11: Liver: No significant pathological changes.

Slide # 12: Kidneys: No significant pathological changes.

Slide # 13: Left Adrenal gland: Benign adenoma.

Slide # 14: Right Adrenal gland: No significant pathological changes.

Slide # 15: Prostate gland: No significant pathological changes.

Slide # 16: Testes: No significant pathological changes.

Slide # 17-20: Brain: No significant pathological changes.

TOXICOLOGY

Carbon Monoxide:

- Carboxyhemoglobin saturation in blood is less than 1% (1-3% is expected in nonsmokers,

3010% is expected in smokers and Over 10% is considered elevated).

Volatiles (Blood and Vitreous fluid):

- No ethanol was detected.

Cyanide:

- There was no cyanide detected.

Screened medication and drugs of abuse (Urine):

None were found

ADDITIONAL PROCEDURES

1. Documental), photographs are taken by (b)(6)

2. Full body CT-Scan is obtained by Department of Radiology, Naval Hospital

Guantanamo Bay, Cuba.

3. Specimens retained for toxicological and/or DNA identification are: Blood

(peripheral and from the hemopericardium), vitreous fluid, bile, urine, stomach

contents, and tissue samples from liver, lung, kidney, spleen, brain, psoas, heart

muscle and adipose tissue.

7. Special Agents (b)(7)(C) attended the autopsy.

8. (b)(6)

AUTOPSY REPORT

GUL, Awal (ISN 782)

(b)(7)(F) 8

4. Vitreous fluid is submitted for electrolytes testing.

5. Representative sections of organs are retained in formalin with preparation of

histological slides. The histological slides of the heart and coronary arteries are

submitted for Cardiovascular Pathology Consultation; see "Opinion".

6. No Evidence recovered.

attended the autopsy as an independent observer.

FINAL AUTOPSY DIAGNOSIS

I. Atherosclerotic Cardiovascular Disease:

A. Ruptured recent myocardial infarction (age over 7 days); No evidence of

myocardial scaring.

B. Cardiac tamponade, 600 cc of fluid and cloned blood.

C. Fatty infiltration of the right ventricle

D. Marked atherosclerotic narrowing, pin point, of the LAD with focal

calcification (over 75% stenosis on microscopic examination).

E. Finely granular renal capsules consistent with history of hypertension.

F. Atheromatous changes of the aorta.

IL Other Findings:

A. Left adrenal adenoma.

III. Evidence of Injury:

A. Focal subgaleal hemorrhage.

B. Multiple left rib fractures and associated minimal muscle hemorrhage.

C. Superficial hemorrhage of the left sternocleidomastoid and left anterior

serratus anterior.

D. Two contusions on the distal left leg.

M. Toxicology:

A. Volatiles: No ethanol was detected.

B. Screened drugs of abuse and medications: None were found.

C. Carbon Monoxide and Cyanide: Not detected.

D. Electrolytes of the Vitreous Fluid: No findings of clinical significance.

OPINION

Mr. Awal Gul, a 48 year-old detainee died from atherosclerotic cardiovascular disease.

The heart reveals a ruptured myocardial infarction of the anterior wall of the left

ventricle, resulting in 600 cc cardiac tamponade. Other atherosclerotic changes are: a

severely stenosed LAD (over 75% on microscopic examination) with focal calcification,

AUTOPSY REPORT (b)(7)(F)

GUL, Awal ()ESN 782)

atheromatus changes of the abdominal aorta, and finely granular renal capsules consistent

with a poorly controlled hypertension. The heart reveals mild hypertrophic changes.

Microscopic examination of sections from the heart reveals myocardial ischemic changes

consistent with over 7 days of age. Histological sections of the heart and coronary artery

are submitted for Cardiovascular Pathology Consultation for more definitive

determination of the age of the myocardial infarction. After review, the age of the

cardiac lesions is consistent with 1-2 weeks old. No evidence of remote myocardial

infarctions.

The subgaleal hemorrhage, hemorrhage of the left stemocleidomastoid and multiple left

rib fractures (with minimal surrounding hemorrhage) is consistent with resuscitation

efforts and intubation. The esophageal intubation is non-contributory to the cause and

manner of death.

Mr. Gul was obese (BMI over 30.0), had a history of hypertension with poor compliance,

hypercholesterolemia, and obesity; all are indicators of potential myocardial events. He

complained of localized squeezing chest pain on the 28 JAN. The chest pain had no other

associated signs or symptoms. The chest pain was reportedly associated with eating

raising the possibility of GERD. CK-MB and cNtl testing were negative. Mr. Gul was

to have a follow up within a week. He was exercising on a treadmill when he did not feel

well, stopped his exercise, and went to shower where he collapsed.

Microscopic examination of sections from the heart reveals myocardial ischemic changes

consistent with over 7 days of age. The prominent fibroblastic proliferation noted is

usually associated with myocardial infarctions of 1-2 weeks age. Sections of the LAD

reveal over 75% stenosis. Sections from the lungs, liver, spleen and kidney reveal no

significant pathological changes. A benign adrenal adenoma is noted in the left adrenal

gland.

Toxicological tests are negative for carbon monoxide, cyanide, ethanol and screened

medications and illicit drugs of abuse. Testing of the vitreous fluid for electrolytes

imbalance reveals no clinically significant chan es ort is attached

(b)(6)

Manner of death is "Natural".

(b)(6)

(b)(6)

* Report is amended to reflect the following:

I. Date of Death is 01 FEB at 2339 hours and not 02 FEB 2011.

2. History of chest pain is on the 28 of JAN only. No chest pain is reported on the 21' 4.

3. Heart sections are reviewed. The age of the myocardial lesion is 1-2 weeks.

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