key: cord-0724766-kcdbxkvo
authors: Sinan, Wu; Renli, Qiao
title: PCCM at the battlefront against COVID-19 in Wuhan, China.
date: 2020-04-13
journal: Chest
DOI: 10.1016/j.chest.2020.04.007
sha: c4a2225dfb14193087d6552bd2c0710509f5f2ce
doc_id: 724766
cord_uid: kcdbxkvo

nan

With its abrupt outbreak and rapid spreading, COVID-19 put an unprecedented challenge to the healthcare system in China. Over 40,000 health workers from all over the country were called upon and dispatched to Wuhan metropolitan area, the origin and the center of the epidemic where the medical system was overwhelmed. Among the 78,064 confirmed cases at the time of this writing, more than 2/3 were from Wuhan, >8,000 are in serious condition, and >3,000 Wuhan healthcare workers were infected (1, 2, 3, 4) .

In this large-scale mobilization of medical resource that has been the focus of media coverage for months, a keyword frequently mentioned was that most physicians and nurses dispatched to Wuhan were from Department of "PCCM". PCCM stands for pulmonary and critical care medicine. The term remains somewhat unfamiliar and even foreign to Chinese people, and much of the rest of the world. PCCM as a combined concept has, for a long time, been a "peculiarly American hybrid" (5) .

Facing the sudden disastrous COVID-19 epidemic, characterized by lung infection rapidly leading to a critical condition, a well-trained PCCM specialist is the best suited professional to take on the challenge. The Chinese PCCM team has been undoubtedly serving as the mainstay from the very beginning, in the defending and winning of the fight against the humongous natural disaster. How did a "peculiarly American hybrid" become a well-established medical specialty and in fact pioneered in the subspecialty training (fellowship) in China? In this regard, the American College of Chest Physicians (CHEST) has made an unparalleled contribution.

After the SARS epidemic in 2003, Chinese leaders in the field began to recognize the importance of incorporating critical care into the practice of respiratory medicine. After careful consideration, they decided to adopt the US model of PCCM, which has proven successful both in terms of serving the need of real world and attracting promising candidates to the profession (6) . Meanwhile, the mission of CHEST encompass medical education and international collaboration. In 2013, the Chinese Thoracic Society (CTS) and CHEST published the historical joint statement, declaring collaboration in developing PCCM subspecialty in China (7) . The China-CHEST PCCM fellowship program was launched in 2014. Curriculum and rotation structure were thoroughly planned adapting the US model to the Chinese needs and culture. Seemingly coincident, the medical aspects required in the management of patients with COVID-19 encompass almost the entire curriculum content (7, 8, 9) .

Experts from CHEST visited and provided hands-on training to faculties at each participating hospital. Under the supervision of a joint steering committee consisting of leading experts from CHEST and China, 54 PCCM fellows from 12 leading hospitals have since graduated from the program (7, 8) . In December 2016, the National Health Commission of China (NHCC) announced that formal subspecialty training (National Fellowship) would become an integrated component of the post-graduate medical education system in China, and PCCM was selected as one of the three pilot subspecialties. The China-Chest PCCM Fellowship naturally transitioned to the Chinese national program. Currently, more than 900 PCCM fellows are enrolled in 79 programs across China (9) .

In line with the development of a PCCM fellowship program, a detailed standard for creation of a PCCM Department was established by CTS and Chinese Association of Chest Physicians (CACP) in 2018, consisting of six components: organization of the department, scope of practice, essential space and equipment, faculty and staff, administration body, and culture. Inclusion of MICU or RICU services was emphasized to be a main component of a PCCM Department. By September of 2019, more than 1,600 hospitals in China had participated and become compliant with requirements set forth by the PCCM Department Standardized Construction Program (9) .

Thus, before outbreak of the COVID-19 epidemic, the Chinese PCCM field had already become a well organized profession with highly respected leaders and a core team qualified by an established set of standards, attracting a large number of enthusiastic applicants.

Caught off guard by the epidemic toward the end of 2019, PCCM professionals held on and mobilized with a remarkable speed. Large teams of PCCM professionals went to the frontline and took charge in almost every ward and unit in every hospital in Wuhan. Several key leaders in PCCM have remained stationed in Wuhan, directing immediate action plans according to the rapidly changing situation. The following are some of the highlights that made a fundamental difference in turning the situation in Wuhan from turmoil into an organized counter attack.

The PCCM experts participated and led the first three groups of expert inspectors entering epidemic area and assessing the situation. Prof. Nanshan Zhong, former president of CTS, and the leader of the 3 rd group, firmly declared the human-to-human transmission and the extremely high contagion of the new coronavirus on January 20 th , which led to the development and roll out of a strict social distancing policy by the government, which included the closure down of all public transportation, schools, and factories in affected areas (4).

Within 2 months, a management guideline was developed and repeatedly revised based on the rapid change and accumulation of knowledge as the situation evolved. A standard guideline is vitally important in the management of a novel viral disease that injures human body through unknown mechanisms and for which no specific curing agent is available. More than 100 clinical trials have been approved to test various treatment options, including the highly controversial use of corticosteroid and the efficacy of the promising anti-viral agent, remdesivir.

The clinical presentation of COVID-19 is diverse, but the central issues in its management mirror those encountered on daily basis in the PCCM, including isolation techniques for respiratory contagious diseases, hypoxemia, respiratory failure, sepsis, hemodynamic instability, and multiorgan failure. The Chinese PCCM fellows and faculty have been trained and equipped with structured, cutting edge knowledge plus repeated experience in oxygen therapy, rational use of antibiotics, ventilator management, hemodynamic monitoring and support, and ECMO.

Stemming transmission is the single most important tactic that can reverse epidemics. With huge number of asymptomatic potential virus carriers, the initial policy of home isolation was not sufficiently effective and was complicated by growing fear and helplessness. Prof. Chen Wang, current president of CACP and former president of CTS, firmly and decisively initiated the construction of converted hospitals for purpose of isolation and monitoring. Large public venues like stadiums and college/school dorms were converted into preliminary medical facilities to admit suspected carriers and verified patients who remained asymptomatic or only mildly symptomatic. The facilities were named Fang Cang hospital, a name derived from the concept of military container shelter. The goal was to admit at earliest time all those who should be isolated or monitored. Within a matter of days, 16 such facilities were functioning at capacity with 13,000 admissions in Wuhan alone. The facilities are staffed with medical professionals who can identify clinical deterioration at the earliest stage and immediately initiate necessary responses including transferring to higher-level hospitals designated for treating COVID-19. Supplies are provided by the government agents and daily activities of the in-patients are organized to minimize psychological stress. Establishment of Fang Cang hospital is the crucial measure that has begun to curb the rapidly uprising trend in the curve of accumulated cases.

Outside Wuhan city and Hubei Province, PCCM departments in the rest of the country are the backup for the front fighters and assumed the responsibility left by their colleagues. Besides, the Standardized Construction process has greatly enhanced the staffing and equipment of PCCM Departments and enabled PCCM Departments to function as the designated treating center for COVID-19, in collaboration with other departments, in almost all the hospitals cross China.

No one would have foreseen an outbreak of COVID-19 during the years of effort in the development of PCCM subspecialty, but with its designed professional scope, what has been very clear is the key role of PCCM subspecialty in such epidemics or any other epidemics characterized by respiratory disease leading to critical conditions. PCCM in China is an excellent model for collaboration among international professional societies. While COVID-19 epidemic has seriously challenged China, it has proven a common threat worldwide that warrants collaboration.

CHEST, as a long-time close ally, has written to the PCCM colleagues in China to express support in this extraordinary time. In the heart-felt letter is the following statement: "You are fighting not only for the Chinese people, but for the human of the world.... We firmly believe, with the well established PCCM team we have built together over years of effort as the main force, we will definitely win this battle."

National Health Commission of the People's Republic of China: Updates on the epidemic

COVID-19 control in China during mass population movements at New Year. LANCET

Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia

The People's Government of Hubei Province. The announcement from the Hubei Provincial Novel Coronavirus Pneumonia Prevention and Control Headquarter

Pulmonary and critical care medicine: a peculiarly American hybrid?

Establishing Pulmonary and Critical Care Medicine As a Subspecialty in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians

on behalf of the China-CHEST PCCM Program Steering Committee. Establishing Pulmonary and Critical Care Medicine in China: 2016 Report on Implementation and Government Recognition

The Strategic Establishment of Pulmonary and Critical Care Medicine (PCCM) as a subspecialty in China: 3rd report from the China-CHEST PCCM Fellowship project