International agencies have traditionally focused on addressing global surgical care disparities through short-term mission trips. More recently, this approach has been criticized for lack of continuity of care, cultural appropriation, and incomplete buy-in from host countries. Cost-effectiveness and ethical considerations account for the most difficult challenges to overcome [1]. In response, focus has shifted toward local capacity building, emphasizing longer-term partnerships and educational initiatives [2]. Although essential to effective global surgery practice, this shift to sustainability is variable, time-consuming, and methodologically experimental given the availability of new technologies. Ideal outcomes may take years to manifest and have locally limited impact. It is necessary to adopt innovative and tailored approaches.

Critical care is a global surgery discipline that can be sustainably and feasibly adapted into daily practice using telemedicine. Complex clinical scenarios can be taught and learnt remotely using real-life cases; simultaneously, immediately helping patients in need. Using our experience of managing patients with severe acute respiratory distress syndrome (ARDS) including the use of interprofessional extracorporeal membrane oxygenation (ECMO) telerounding, we discuss a novel outlook to global surgery critical care delivery that represents a more sustainable approach to mission trips and fosters an ecosystem of real-time responsiveness in a logistically feasible and economical manner.

The senior author was contacted by physicians or patient families for his expertise in severe COVID-induced ARDS management. Specialized health professionals from the University of Michigan partnered with critical care physicians from multiple hospitals in India to facilitate the treatment of five patients with severe COVID-induced ARDS including three patients on ECMO, through daily interprofessional telerounding. The team designed a system using virtual platforms: WhatsApp and Zoom, through which telemedicine rounding was conducted with a multidisciplinary team of clinicians, surgeons, pharmacists, physical therapists, and families for ECMO-requiring patients. Rounds were conducted twice a day utilizing a multi-system approach. Pictures of daily chest x-rays and laboratory evaluations of arterial blood gasses, blood counts, and chemistries were shared. Live bedside evaluations were also conducted through tablets. Specific clinical evaluation included patient appearance and patient effort related to transition from controlled to spontaneous awakening and breathing trials. Treatment plans for the next twelve hours were formulated by the consulting physician through consensus. Round duration varied based on clinical improvement and lasted from an average of ten to forty days. Decannulation and transition to liberation from mechanical ventilation plans were addressed. Though the sample size is limited, two of three patients requiring ECMO survived. The consultant and local treating physicians perceived telerounds as similar to in-person rounding [3]. Additionally, the platforms provided a good avenue for pertinent literature sharing. We recommend adaptation and replication of this telerounding model in critical care efforts globally. From this experience, we believe that virtual platforms can support ethical, longitudinal, and clinically effective critical care capacity building.

This model’s adaptation requires specialized professionals’ availability and interprofessional communication. Management of severe ARDS and ECMO is a high acuity event requiring complex management decisions that are time and resource intensive to teach. Daily telerounds by subject-matter experts alongside primary physicians meant not only were critical patients receiving the highest quality care but also many physicians trained in critical care were able to learn a challenging skillset for easier future application. There is high critical care mortality and limited critical care providers globally, especially in lower-income and lower-middle income countries [4]. The current emphasis on training specialized physicians while vital is also decades in the making. Interprofessional telerounding is an instantaneous solution required in conjunction to formal capacity building efforts.

Reimagining global surgery efforts in critical care also results in greater logistic and economic feasibility. Current undertakings are prioritized based on cost-effectiveness and practicability [5]. These are predominantly substantial, expensive endeavors requiring on-ground personnel, infrastructure, resources, and access. This limits the nature and number of possible efforts and greatly restricts contribution in essential zones, such as war or disaster regions. Providing ECMO via telemedicine utilized free virtual communication platforms. A pre-existing rounding infrastructure was tapped into, and specialist physicians offered their time at no charge. No total costs were amounted aside from time spent engaged in treatment. With smartphones and technology being ubiquitous, scaling critical care delivery up through telerounds does not present a huge challenge. In regions with limited technological advancements, enabling telehealth systems will require a single investment with numerous, long-term benefits. Only possible consistent costs will be specialist physician time compensation.

Telerounding also exponentially increases the flexibility to tackle any patient’s care immediately—essential in critical care. Requisite specialized input or region are not limiting factors. This is in stark contrast to existing global surgery efforts which only allow for targeted, premeditated responses for specific issues. This mechanism also challenges the status quo of the top-down approach in global critical care delivery. The telerounding framework can be readily adapted both within and beyond low- and middle-income countries (LMICs) or high-income countries (HICs) and does not necessitate unidirectional care delivery from HICs to LMICs.

Potential telemedicine approach challenges include the limited availability of specialists willing to donate their time. Additionally, buy-in from the treatment team locally is imperative for complicated care delivery. Potential HIPAA violations and legal implications for consulting physicians remain problematic. We overcame these barriers as follows: (1) the family was instrumental in contacting the consulting physician and gave consent to patient personal data, (2) the local treatment team was fully on-board, and (3) it was clearly explained upfront that the treatment team was free to refuse any consulting physician recommendations. Therefore, successful telerounding mechanisms will require buy-in from local stakeholders for daily meetings, family members and hospital administration for data sharing, and specialist physicians for regular involvement in treatment plans. These are easily achievable through strong collegiate, institutional, and organizational partnerships.

Timely and safe critical care availability globally, that is rooted in ethical practice, needs a proficient ecosystem of health professionals in real-time and at low cost. Sporadic mission trips and traditional long-term capacity building do not suffice. Using interprofessional telerounding to capitalize on telehealth and reimagine critical care delivery worldwide will address existing gaps and help save lives.