As India experienced its first COVID waves, the phone in Krishnan Raghavendran’s Michigan Medicine office began to ring.
Because the illness peaked in different places at different times, the Professor of Surgery and his UMMS colleagues by then had months of experience caring for COVID patients. Collaborators, acquaintances, and even friends of friends in India were reaching out for advice on how best to treat their most acute patients. The system he devised—real-time virtual rounding using videoconferencing and secure messaging apps—helped keep patients half a world away alive and is the subject of a recent article in the World Journal of Surgery.
“Telemedicine is not novel, but I think what is novel was applying these tools in a critical care setting and being involved remotely in care on a continuous, real-time basis,” Raghavendran said. “What surprised me was how beautifully the system worked.”
From late 2020 and into 2021, Raghavendran became part of the care teams for nearly a dozen COVID patients across multiple hospitals in India. All were on ventilation, and most were on ECMO (extracorporeal membrane oxygenation), the heart-and-lung bypass machines reserved for the most acute patients.
“With COVID, there was suddenly a huge amount of interest in ECMO across India. The pandemic prompted lots of ECMO centers to open around the country,” he said. “We at U-M have a lot of prior experience with it, and I was being contacted by many people for help and advice.”
Physicians in India would share with Raghavendran their patients’ x-ray images and laboratory values. After a review, Raghavendran would join the multi-disciplinary care team on their rounds using Zoom, conducting bedside evaluations and consulting about near-future treatment plans.
“I would walk them through what I would do based on the labs, the images, and what I was seeing in real-time,” he said. “In the end, I was an advisor. For any system like this to work, it has to have buy-in from the physicians on the other side.”
Raghavendran saw some patients for as few as 10 days. For others, he was involved for a month or longer, rounding twice a day via Zoom and offering guidance based on his experience. The majority of the patients survived, including an 80-year-old man who had been on ECMO and whom Raghavendran had the opportunity to meet on a subsequent trip to India.
“He and his family were incredibly appreciative, and I was grateful to meet him,” he said. “Personally, and professionally, this is why I got into medicine: using my expertise to help people.”
The article in World Journal of Surgery details the processes by which Raghavendran assisted the on-the-ground care teams with their COVID patients but suggests a potential for broader applications and benefits.
“We believe that virtual platforms can support ethical, longitudinal, and clinically effective critical care capacity building,” Raghavendran and his co-authors write. “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. 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,” they note.