​​​​Josh deGuzman

Public Health Determinants and Trends

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Social Determinants in Health

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            There are numerous factors that contribute to an individual’s overall health. Many of the social determinants of health are centered on one’s environment. The daily living conditions, options for physical activity, availability for healthy eating, safety of transportation, safety from violence, and prevalence of alcohol and illicit drugs all have a significant effect on an individual’s health. At my internship site, the Greenville Health System (GHS) morgue, the primary medical service that we provided was performing autopsies. Each of these social determinants influenced the need for autopsies to be conducted. Through our work, we were able to see how these factors contributed to each death.

            One of the first things that the forensic pathologist does is asking the coroner to describe the scene of the case. Here, the pathologist gains information about the type of environment that the individual was in when he or she died. The coroner then provides more background information about the individual. This gives the medical examiner details about the kind of living conditions and socioeconomic status of the person. Those in the lower socioeconomic group may not have the healthiest living environment. They may not have access to healthy foods due to cost nor options for physical activity such as parks and sidewalks. Lack of availability to both of these is contributing factors to overweight and obesity. During an autopsy of a case of an obese person we observe many health problems, the biggest one being heart disease. The coronary arteries of the heart become hard due to the buildup of plaque and they reduce blood flow to the heart.

            The daily conditions and environment in which people live may also affect their safety of transportation. A majority of the cases involving traffic accidents are either motorcycle related or due to drivers or passengers not wearing a seat belt. For autopsies dealing with traffic cases, we conduct external autopsies. The forensic pathologist does not cut the body open and examine the organs. He examines the external body by checking for trauma and fractures. He also inspects the head for injury and tests for blood in the chest.

Environments with high rates of crime and violence present another negative social determinant of health. Cases involving violence are typically homicides and are either gun or knife related. These autopsies usually take longer than normal because a forensic team comes in during the autopsy to take photographs and to obtain clothing, fingerprints, hair, and nails. For gunshot wounds, we x-ray the body to check if the bullet is still present in the body. If we find it on the x-ray, we search for it during the autopsy when we open up the body. The pathologist measures the wounds and determines the entry and exit points. Organs that are hit by the bullet are greatly damaged with a large amount of dead tissue. In cases of stabbings, the examiner also measures the size of the wounds to determine what kind of blade was used and the size of the knife.

Individuals in theses living conditions may also have a greater exposure to alcohol and illicit drugs. In many cases we are able to detect alcohol abuse by examining the liver. The livers of alcoholics are usually enlarged and cirrhotic with scarring of the tissue. The majority of autopsies that we performed were drug related deaths. In autopsies of overdoses, many organs are damaged such as the liver, kidneys, heart, lungs, and brain. The forensic pathologist takes samples of blood, urine, and tissue for toxicology testing. This is used to determine the presence and amount of toxins and drugs in the body. The main drugs used were opioid pain relievers and heroin. Other common overdose drugs are over-the-counter drugs, methamphetamines, cocaine, sedatives, and combinations of drugs.

A large amount of the deaths that we examined were related to some social determinant of health. These determinants directly influenced the necessity of the medical services delivered by the autopsies we conducted. Using knowledge of the individuals’ environment, we were able to effectively perform autopsies to determine the causes of death. Some of the individuals that we autopsied may have not died if their places in which they lived were better and the environment around them were healthier.

 

Organizational Behavior and Governance

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            The primary services provided by the GHS morgue are autopsies. My preceptor, Dr. James Fulcher and his partner Dr. Mike Ward work together in their own private practice. However, they also work alongside the GHS Greenville Memorial Hospital and the Greenville County Coroner’s Office. They conduct autopsy cases for the coroners as well as the hospital. One interesting structure within this system is that they perform autopsies for free for the hospital. Families that have any individual pass away in the hospital are offered an autopsy at no charge. GHS requires the medical examiners to perform hospital autopsies for free if the family requests one.

Conversely, families rarely request an autopsy to be done today. Decades ago, hospital autopsies were done very frequently because doctors were unsure as to why some of their patients were dying. The autopsies provided the doctors an opportunity to learn about specific diseases and gave families a certain cause of death. Presently, only 3-5% of inpatient deaths are autopsied. One way to make the system more effective is to encourage families to allow the pathologists to perform the autopsy. This would not only benefit the doctors, but the families too as they would be receiving an absolute cause of death. Pathologists may learn something new from these cases, but the healthcare providers directly caring for that patient would gain much more. This is another area for improvement. Out of all of the hospital autopsies that we did during my internship, only one doctor came to observe the autopsy. Doctors should be required to follow up with their patients throughout the autopsy. This would be a valuable learning tool for the healthcare providers and they would be able to observe how the disease affected the body’s organs. Doctors can also benefit by using this to improve their own practice. My internship site at GHS is a teaching hospital and thus, autopsies should be used for this as well. Medical students at the Greenville campus should also observe autopsies for learning purposes. Increasing hospital inpatient autopsies allows for countless learning opportunities and an overall improved health system.

 

Pre-professional Concentration

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            Professionalism is an essential trait that great health care providers possess. These health professionals are not only excellent in their work within their medical fields, but their character is even more top class. They show maturity, responsibility, and respect when communicating with others. Throughout my internship at GHS, I had the pleasure of working with an extremely professional health care provider, Dr. Mike Ward.

            Dr. Ward is one of the medical examiners that I worked alongside at the morgue. He is exceedingly qualified, as he has been working in a morgue ever since he was in high school. He has been in practice for over 20 years and is very knowledgeable and highly experienced in this field. His work is thorough and detailed. He fully examines each organ and saves a piece of each in a stock jar and he is precise in his cuts when taking cross sections of them for histology. He is also neat by making sure to clean the body of blood before taking pictures. Dr. Ward takes time in his work, making sure to not miss any detail by rushing. He maintains a mild and focused demeanor during the autopsies and conducts himself well. He leads each autopsy and takes full responsibility for all of his actions. He shows the utmost respect when speaking with his assistants, coroners, families, other staff members, and me included. He always asks others how they are doing and about their lives. Others can sense his sincerity in his voice because he shows such genuine interest in them.

            Dr. Ward fully exemplifies what it means to show professionalism. By working together with him, I have been able to learn the proper way to conduct oneself in a professional setting. He told me to always be kind and considerate of others. One of my tasks at the morgue was to bring x-ray cassettes to radiology nursing for them to print off the x-rays. I was always respectful when asking them to print the x-rays for me and I let them know how much I appreciated their help, especially on days when they were busy and the machine and computers were not working. I believe that every “thank you” meant a lot to the radiology nurses. I also learned that body language is an important communication skill in professionalism. There were instances when some workers verbally communicated well with others, but their poor display of body language came across as disinterested and rude. Nonverbal communication can be stronger than verbally speaking at times. Dr. Ward epitomized professionalism and taught me how to appropriately present myself through his actions and his character. I will continue to utilize the lessons he showed me in order to further improve my professional growth.