Blog Posts

primary care

Medical Missions Provide Relief to Developing Nations

Posted on Wed, Jan 25, 2017
Medical Missions Provide Relief to Developing Nations

By Mark A. Merlin, M.D., FACEP

When Hurricane Matthew wound its path through the Caribbean Sea in October, it dealt another blow to Haiti, a country already suffering. It caused $1.89 billion worth of damage and an estimated 1,600 deaths.

There’s no infrastructure in the western end of Haiti, no hospitals, no pharmacies. The residents use the same water they drink and cook with to bathe in, wash their dishes and relieve themselves. To help deliver healthcare to the struggling nation, I partnered with Stuart Hirsch from Operation Endeavor M99, a non-profit philanthropic organization, to organize a short medical mission. A partnership occurred between Jet911, a private air ambulance service; RWJBarnabas Health, a N.J.-based health system that treats 700,000 emergency department patients annually; St. Mary’s Hospital/Trinity Health New England in Waterbury, Conn., MONOC, a non-profit company comprised of 15 acute-care hospitals throughout New Jersey; and CentraState Medical Center, Freehold, N.J.

Joining me Oct. 26-27 on the 12-person team of EMS/disaster medicine physicians and paramedics and Eli Rowe, CEO of Jet911 on this special mission were EmCare-affiliated physicians Matthew Harris, M.D., Ije Akunyili, M.D., James Tanis, M.D., Navin Ariyaprakai, M.D., and Ernani Sadural, director of RWJBarnabas Global Health. We flew to Port Au Prince, the capital of Haiti, then helped move 4,000 pounds of lifesaving medications and equipment to Les Cayes. We then took a boat to the remote island of Ile A Vache, where we conducted clinic operations in the villages of Caille Coq and Madame Bernard.

We set up a mobile ED with EKG, ultrasound and blood-drawing capabilities. Our focus was on delivering primary care, which is a bit different from other medical missions, which typically seek to provide a specialty service, like dental care or vaccinations.

Within minutes of our arrival, hundreds of people gathered. Unfortunately we couldn’t help everyone, but we made a significant impact in these remote villages, where no medical care is available. These are places that many have forgotten about. Residents live in such extreme poverty that it’s difficult to describe. Many have no clothes, no bathroom, no medical care, no hospitals. Infant mortality is extremely high. We treated 600 patients, the majority of whom were children with pneumonia and low oxygen levels. Without the medications given to these children, about 25 percent would have died from infection. We also saw patients with fevers, coughs, acute phlegm, chest pain and shortness of breath. In our last stop during the mission outside of an orphanage, people were gathering and almost begging us for more care before we had to leave.

This was my first mission, and my first trip to a developing nation. It left a lasting impression on me, to say the least. I will always remember the 8-year-old girl who had stepped on a tack and had developed an infection that spread to her bone. We gave her antibiotics to treat it, although she really needed surgery, which just wasn’t possible. I’ll remember the baby with pneumonia who was struggling to breathe. I hope the antibiotics worked and that we prevented his respiratory failure. Most of all though, I’ll remember the kindness of the people that we met. Even under such a dire, bleak situation, they had smiles on their faces. A few even scaled towering palm trees to pick coconuts to give us as gifts.

Medical missions bring together people with different skills sets and experience, but with a common goal. It wasn’t an easy trip, because there’s no easy answer to truly changing access to healthcare in developing countries like Haiti. There’s only so much that we can do. We’re planning another mission in February, and I’m looking forward to continuing our progress in the region.

Mark A. Merlin, M.D., FACHE, is vice chairman and EMS fellowship director at Newark Beth Israel Medical Center, Newark, N.J.; associate professor at Rutgers School of Public Health/Rutgers Medical School; and system medical director and chief medical officer of MONOC.

EmCare supports providers who participate in international medical missions. The company has partnered with Operation Endeavor M99 and Global First Responder to coordinate non-denominational medical-relief missions.

Licensed EmCare-affiliated providers interested in participating in medical missions with an approved partner organization are eligible to receive 10 hours of credit each day of providing services in the designated country of the medical mission, up to 5 days per year toward meeting full-time hours.

For more information about EmCare’s medical mission benefit, contact Jim McMillin, National Director of Recruiting, at



Emergency Medicine’s Expanding Role in Population Health

Posted on Wed, Feb 03, 2016
Emergency Medicine’s Expanding Role in Population Health

By Nick Zenarosa, M.D., FACEP

Traditionally, population health management has fallen to primary care providers (PCPs), but as more patients opt for the ED instead of a PCP, the responsibility of population health management is shifting.

Becker’s Hospital Review reports that nearly 80 percent of adults ages 18 to 64 visited the ED due to lack of access to other providers. An estimated 56 percent of primary care delivered in EDs is based on preventable, non-urgent visits, according to the Network for Excellence in Health Innovation (NEHI). And, the American College of Emergency Physicians finds that more than 33 percent of all primary care is performed by emergency medicine providers, yet they make up less than 5 percent of the primary care workforce.

An NEHI study identified the following five causes for patient use of the ED for primary care:

  • Patients have limited access to timely care services
  • The ED provides convenient after-hours and weekend care
  • The ED offers patients immediate reassurance about their medical conditions
  • Primary care providers refer patients to the ED
  • Hospitals have financial and legal obligations to treat all ED patients

The NEHI study further shows that increased insurance coverage under the Affordable Care Act will not drive patients to primary care. Findings indicate that the belief that ED overuse is the result of poor and uninsured seeking non-urgent care may be spurious – these populations were found to be a small subset of the overall population who were using EDs inappropriately. However, the Agency for Healthcare Research & Quality (AHRQ) indicates that if the ED staff encourages patients to an initial primary care visit, they will likely continue to see a PCP.

Disease Management Growing More Difficult, But There’s Hope

Particularly of concern for population health management is the management of chronic disease – especially the growth of Type 2 diabetes mellitus. It can lead to devastating complications such as renal disease, blindness, heart disease, stroke and impaired peripheral circulation. Blood glucose control, particularly decreased glycosylated hemoglobin, is associated with the delay or prevention of these complications. This type of control is achieved by close monitoring of diabetics’ blood glucose results, lifestyle management, diet and medication.
This close monitoring requires consistent, comprehensive care that is best offered in a primary care setting. However, access to primary care may be an issue for these patients.

If the trend of growing ED volumes continues, it could fall on emergency physicians to handle the proliferation of diabetes. Managing the disease requires knowing about it – screening high-risk individuals, actively looking for chronic conditions instead of passively finding out, discharging patients with long-acting insulin, oral hypoglycemic agents and diabetes education to get them started on a treatment plan. If the patient is not stable enough to go home, placement in the observation unit for medication initiation, including insulin and diabetes education, is a reality. He or she can follow up with a PCP, and return to the ED if unable to see PCP within the prescribed time. This approach could be applied to other chronic diseases.

Transitional care clinics, such as acute episodic care clinics, also offer a solution to chronic disease management. These clinics can be open seven days a week for 16 hours or 24 hours with the same triage processes as the ED. Between non-emergent patients and PCP patients looking for urgent care, this approach could save millions of dollars.

Coordinating Care through Established ED Demand Management Techniques

Emergency medicine professionals excel at demand management. Triaging, surge control and vertical flow are all tools that could have wider applications for population health and chronic disease management. ED staffs could improve clinical outcomes by coordinating patient care between the ED and primary care.

Emergency physicians can improve effectiveness and efficiency by coordinating care across the care team:
  • Communication with ED providers, ED nurses and others outside of the ED
  • ED flow rounds once a shift to ensure everyone on the multidisciplinary team is on the same page
  • Ensure successful transitions from the ED and plan for patients’ next steps
  • Engage patients as active participants in their care. Without patient and family involvement, the patient is unlikely to be able to manage their disease

A county-owned hospital with a Level-1 trauma center recently implemented some of these population health management techniques in its ED. The results aren’t scientific, just anecdotal, but they are promising:
  • A decrease of 28 to 49 hospital bed days per day
  • 3 percent decrease in inappropriate inpatient admissions related to diabetes
  • $158,000,000 in estimated expenses mitigated annually in aggregate
  • Tens of millions of estimated dollars at risk for Medicaid 1115 funding relative to ED process and access to primary care

Moving forward, the ED could use the following proposed metrics to measure success with Type 2 diabetes mellitus patients:
  • Number of patients initially diagnosed with Type 2 diabetes mellitus
  • Number of patients started on treatment plan
  • Number of patients transitioned to primary care clinics
  • Number of T2DM patients connected to a clinic who come to the ED for care before and three months after initiation of process
  • Decreased number of patients seen for medication refill

In this value-based purchasing environment, it’s more important than ever to keep the frequent ED visitors from doing what they’re used to doing – going straight to the ED when they don’t need emergency care. Getting out in front of population health by tapping the ED to help these “frequent flyers” formulate a more effective care plan could be the key to proactive, preventive care, less ED gridlock and fewer readmissions.

Nick Zenarosa

Nick Zenarosa, M.D., FACEP, is President of Integrative Emergency Services, an affiliate of EmCare. He currently serves as the System Medical Director of Emergency Services for Baylor Scott & White North Division. He also is Chairman of Emergency Medicine at John Peter Smith Hospital in Fort Worth, where he oversees the emergency department, the clinical decision unit, urgent care emergency department, and the emergency medicine residency program.

Dr. Zenarosa received his medical degree from the University of Illinois at Chicago College of Medicine. He completed an internal medicine residency at Parkland Memorial Hospital in Dallas and an emergency medicine residency at Carolinas Medical Center in Charlotte, N.C., where he was chief resident.