Transcending Borders with Remote ICUs: Indonesia and Mexico

An Intensive Care Unit in an Indonesian university hospital.

Critical patients whose lives are at risk are treated with the latest medical equipment.

The COVID-19 pandemic continues to strain this ICU's capacity.

ICU needs have risen
but there's not enough beds.

Indonesia is large
and ICU capacity is limited.

At the same time, there simply aren't enough doctors and nurses with ICU certifications.

Many other developing countries are facing similar circumstances.

One Japanese medical startup is looking to tackle the problem.

It connects ICUs in developing nations with Japanese ICU professionals through an online remote ICU support system, allowing them to share records and images.

What do you suggest to prevent increase the gastric emptying in patients with Parkinsonism?

We often use an endoscope to guide a
tube to the small intestines.

The remote ICU sessions were the brainchild of ICU doctor Nakanishi Tomoyuki.

ICU medics and nurses around Japan responded to his call to take part in the project.

Telemedicine can
be provided anywhere.

This remote system allows us to
assist in many different areas.

It's a project determined to bring ICU treatment to everyone, everywhere.

Depok is a city of 2.46 million, neighboring Indonesia's capital of Jakarta.

The University of Indonesia Hospital opened here in 2019.

It's a general hospital with 300 beds and ten departments.

Built with Japanese aid, it has some of the most cutting-edge equipment in Indonesia.

But although the ICU has 22 beds, the hospital has only three certified ICU doctors.

It isn't enough for the 24-hour, dedicated care required for critical patients.

Chief Doctor Dita Aditianingsih is an ICU specialist.

She's led the ICU here since its creation.

Dr. Noor Hafidz has been a specialist for three years.

This is his first hospital ICU.

The team has taken part in a remote ICU project with Japan since January 2022.

Hello, Yusuf. How are you?

63-year-old Yusuf was brought into the unit unconscious by an ambulance two weeks ago.

I know it's itchy. Try not to scratch.

His arm injury had worsened and was on the verge of necrosis.

The infection had reached multiple organs, his breathing was unstable, and his liver was not functioning well.

Although ICU treatment has improved his condition, he's still in a delicate state.

Infection and trouble swallowing
makes treatment difficult.

I'll discuss infection control
on our remote session with Japan.

The remote ICU sessions happen once a week.

Hello, Nice to meeting you all again.

About 20 people take part each time.

They include Japanese doctors examining the symptoms, as well as young Indonesian medics hoping to specialize.

Today, the case is being handled by Hoshino Kota, an ICU specialist at Fukuoka University Hospital.

He takes part outside of his regular working hours.

During the remote ICU meetings, local doctors share patients' data with their Japanese counterparts.

The Japanese team draws on specialist experience to advise on treatment and nursing.

Patient information such as digital records and CT scans can be examined along with real-time footage of Yusuf as the team discusses his case.

High-quality cameras and other necessary equipment were sent over from Japan for the project.

Dr. Hafidz hopes the remote ICU system can help him learn about the latest Japanese medical technology.

Maybe from me... The patient also developing some kind of symptom of Dysphagia.

Do you have an experience on this, Hoshino sensei? Thank you.

Sometimes thin liquids like water
can be tough to swallow.

Use contrast studies or an endoscope
to look at the dysphagia.

Evaluate the situation as
you work towards rehab.

To ensure accuracy, the Japanese team use an interpreter with an understanding of medical terminology who can translate any details.

ICU treatment is so dynamic.

I had doubts about a remote system.

But it works. No problem.

I've found it very useful.

Dr. Dita has eleven years of experience as an ICU doctor.

But the remote support from Japan has given her insight into the newest practices.

Indonesian and Japanese ICUs
have different equipment.

We can't implement all the advice.

But Japan is advanced and
the teams are experienced.

I think it will help us
provide better ICU care.

The remote ICU startup works out of Kobe, in Japan's west.

Leading the firm is CEO Nakanishi Tomoyuki, an ICU doctor with over ten years' experience.

He originally launched the medical venture to help alleviate a shortage of expert ICU doctors in his home of Japan.

Working with critical patients is very different from regular medical care.

A certified ICU doctor makes all the difference in a patient's recovery.

The data shows us how important
ICU specialists are.

They lead to shorter ICU stays.

And better recovery rates.

To try and address the shortage, Nakanishi set up his company in 2016 with a mission to bring an ICU medic to every hospital.

Experienced ICU doctors and nurses took part from across the country, connecting to hospitals in need of remote ICUs.

In 2022, the firm built an ICU simulation to research and develop a functional and intuitive remote system.

It also provides training to those taking part in the program.

In 2021, after the pandemic had made painfully clear the global shortage of ICUs, Nakanishi decided the remote system should be borderless.

He worked with the Japanese government's international cooperation agency to provide support to developing countries.

So many places have
fewer ICU medics than Japan.

Or they have no remote ICU system
in place, so we wanted to support them.

Telemedicine can be provided anywhere.
So why not make the most of that?

Fukuoka University Hospital, Japan.

One of the medics who works with the University of Indonesia Hospital - Dr. Hoshino.

He's worked in ICUs for twelve years.

Despite a busy schedule, he makes time to take part in remote ICU sessions.

I've wanted to work internationally
since I was a med student.

But over the years, I've gained
responsibilities. I have a family.

I can't just travel abroad.

Then I heard I could help
other countries online.

It was a second chance at
my dream. I jumped at it.

The University of Indonesia Hospital nurses also meet with their Japanese counterparts to improve their medical skills.

Today, Nurse Zumaidah is discussing the timing of removing ventilators.

The question is... Is there any specific criteria for patient to be trialed for extubation in Japan?

Answering their questions is Naito Aki, who has worked for 17 years as a certified ICU nurse in Japan.

Has it been some time?

After 2 weeks we often perform
a tracheostomy.

From there we focus on rehabilitation.

In this patient, that have pulmonary embolism, what nursing care plan we can do and monitoring?

Naito advises the team to closely monitor for changes in vital signs such as blood pressure and pulse.

Tracking changes in vital signs is key.

It gives you great insight into
how your patient is improving.

Thank you very much for this discussion.

I hope what we discussed today will be good... and we can perform the advice from sensei in our hospital.

For the less experienced Indonesian nurses, the advice from Japan is a crucial help.

Remote ICUs have been
hugely beneficial to us.

It's shown us a different
approach to nursing.

I want to share what we've
learned from Japan...

...with other Indonesian ICU nurses.

Naito has spent her entire nursing career in ICUs.

I've only worked in ICUs.

Now I can use that knowledge
and experience to help others.

I want to work with the local
team on an equal footing.

How do we best care for patients
with limited staff and gear?

It's been two weeks since Yusuf's arm injury was examined at the remote ICU.

He's being treated with antibiotics following advice on timing and dosage.

We followed last week's
advice on infection care.

Appropriate antibiotics have
produced a good result.

The remote ICU is very useful.

I hope it will continue.

The remote ICU project has also partnered with hospitals in other regions with even fewer medical resources.

This is Valladolid, in Mexico.

It's a key city on the route to Mayan ruins.

Valladolid has just one hospital serving the 56,000 people living in the region.

It has just sixty beds.

The hospital's COVID-19 ward is this cluster of pre-fabs.

The hospital served as a regional treatment hub during the pandemic...

...and has accepted over five thousand patients so far.

One of the pre-fabs serves as an ICU.

It has six beds, which are continually occupied.

Specialist doctor Mario Aguilar has seven years' experience in ICUs.

He's painfully aware that many in rural Mexico can't access the bare minimum specialist medical aid.

Sadly many doctors in this region
only provide primary care.

I'm the only ICU specialist.
Despite serving such　a large population.

I worry about how to plug
this specialist gap.

It's very difficult.

The hospital has decided to join the remote ICU project.

They lacked the necessary cameras and monitoring devices, so they were sent from Japan.

Today, the team is discussing the case of 23-year-old Victor.

An abscess on his liver was treated at a local clinic, but his prognosis wasn't good.

He was brought to the hospital in critical condition.

Dr. Aguilar is assisted by Dr. Rocio Mosqueda, who graduated medical school two years ago.

She hopes to become an ICU medic.

Platelets at 11k. Before?

- 12k.
- Still low.

- Hear breathing?
- Yes.

We need him breathing.

It's okay, Victor. You're getting better.

Victor's mother has come to see him.

It's over half a day on foot and by car from their village.

Can you hear Mom?

You're getting better now.

Me and Dad are waiting
for you to come home.

He's slowly getting better
thanks to the doctors here.

Back in Tokyo.

ICU medic Suzuki Morio is part of Victor's remote team.

Since reading a book as a high-school student about a doctor treating patients in Latin America, Suzuki has dreamed of providing support to countries in the region.

After joining the project, Suzuki visited five Latin American countries to explain the system to local doctors and nurses in preparation for remote ICU consultations.

The remote monitoring takes place in one corner of the Valladolid hospital's ICU.

May I see the screen?

Suzuki checks the patient's vital data to see his condition.

Gracias Doc!

May I see the patient?

He examines details of the affected site.

So there's no pain or redness?
No sign of infection?

He's bloated with gas
but no pain when touched.

Dr. Suzuki suggests taking a CT scan with contrast dye to investigate the problem.

A contrast CT and proper drainage.

Might be hepatic encephalopathy
so let's focus on the liver.

It might help with
his consciousness.

We plan on a CT today.

It'll give us a better idea
of the abscess.

Suzuki is painfully aware that crucial tests and specialist exams are often delayed in regions without the necessary equipment.

We don't see many young patients
in such critical conditions in Japan.

They need to be treated at
Valladolid Hospital sooner.

Or at least get advice from their
specialist ICU doctor sooner.

Then it wouldn't be so bad.
Valladolid has many cases like this.

It's a serious issue.

Once a patient enters an ICU anywhere,
a specialist must get involved.

Mexican nurses also ask their Japanese counterparts for advice over the remote ICU system.

Today, nurse Luis Perez has questions.

Connecting from Japan is ICU nurse Nakamaru Makoto.

He's spent 14 years working in ICUs in Tokyo.

Victor is suffering hypothermia.

Perez wants to know how best to care for him.

How do Japanese nurses care
for hypothermic patients?

We warm the whole body.

Electric blankets, for example.

Or thermal blankets.

Occasionally we warm
the transfusion itself.

Can you explain exactly
how to warm the liquid?

We use a special machine.

It warms the liquid as it moves
along the transfusion tubes.

Thank you.

Many Latin American countries
don't have this kind of device.

Valladolid hospital doesn't have this machine either.

So the nurses warm Victor using available thermal sheets and blankets.

Almost there.

You cold? Okay? No pain?

You're getting better.
Don't worry.

It was interesting to discuss
Japanese and Mexican techniques.

Maintaining patient temperatures
with what you have.

It's vital, no matter the gear on hand.

Several days pass.

Victor is recovering well, and is able to breathe independently.

His ventilator has been removed.

In Mexico, where ICUs are in short supply, the remote sessions are a stroke of luck for Dr. Mosqueda and her specialist ambitions.

I've learned much about
ventilators and high-risk meds.

All new information for me
as an ICU doctor.

The remote sessions
have taught me a lot.

I've learned how to help
critical patients.

It's thanks to the Japanese
tech and remote support.

It helped Victor recover.

We've removed many tubes
and the ventilator.

I'm happy with this result.

The new remote ICU system is overcoming long distances and language barriers alike, opening new doors along the way.

I feel confident we can keep
helping abroad with remote ICUs.

I know this system is needed.
I want to keep rolling it out.

An ICU specialist doctor in every hospital around the world: The team continues to work towards this goal.