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CHAPTER FIVE
It hit without warning. It killed some victims and marked others for life.”
“
“IT HIT WITHOUT WARNING. IT KILLED SOME VICTIMS AND MARKED OTHERS FOR LIFE, LEAVING BEHIND VIVID REMINDERS FOR ALL TO SEE: wheelchairs, crutches, leg braces and deformed limbs. . . . Each June in America, like clockwork, came newspaper photos of jam-packed polio wards and eerily deserted beaches. Newspapers ran tallies of the victims—age, sex, type of paralysis—akin to baseball box scores. Children were warned not to jump into puddles or share a friend’s ice cream cone. Parents checked for every known symptom. . . . Some gave their children a daily ‘polio test.’ Did the neck swivel? Did the toes wiggle? Could the chin reach the chest?”1
In 1952, polio—the most feared disease in the country—peaked in the United States. More than 58,000 new cases left 20,000 victims paralyzed in some way and killed 3,000 others.2 Then came March 26, 1953, the day Dr. Jonas Salk announced on national radio that he had successfully tested a vaccine against the crippling disease. Soon after, parents—especially parents of young children, who were more likely to contract the disease—rejoiced.3 It was a worldwide celebration that never would have happened without the work of Frederick C. Robbins, MD.
Dr. Robbins came to City Hospital in 1952, in the middle of the worst of the epidemic, to oversee the contagious unit. In 1954, the National Foundation for Infantile Paralysis, now the March of Dimes, designated City Hospital as a National Respiratory Care Center, the third largest of 13 polio centers in the United States with as many as 32 iron lungs operating at the peak of the epidemic.4 Dr. Robbins, though, had started fighting infectious disease in 1940, when he graduated from Harvard Medical School and began a residency in bacteriology at The Children’s Hospital Medical Center in Boston, Massachusetts.
After serving in the US Army from 1942 to 1946, he returned to the lab at Boston’s Children’s Hospital, which was led by John Enders, MD. Over the next four years, Dr. Enders, Dr. Robbins, and Dr. Thomas Weller found a way to grow the polio virus in human skin and embryonic tissue in the lab. Before then, the virus had only been grown in live monkeys. With more virus to study, large-scale vaccine experiments and development became possible.5 The three doctors also discovered that antibodies in the blood of polio patients could be used to stop the virus from growing in others. Those advances gave Dr. Salk the scientific foundation he needed to develop his vaccine.
In April 1954, laboratories across the country began to test the vaccine by looking at blood samples from more than a million first-, second-, and third-grade children, known as “polio pioneers.” Researchers wanted to see if they were creating antibodies that protected them from the virus. It was Dr. Robbins’s lab at City Hospital that analyzed the samples from children in Indiana and Ohio. In the midst of that work, in October 1954, the Caroline Institute of Medicine announced that Dr. Robbins—along with Drs. Enders and Weller—had been awarded the Nobel Prize in Medicine.6 Unprepared for the news, Dr. Robbins rushed off to be fitted for a tuxedo. “What did you do?” the tailor asked. “Win a Nobel Prize?”7
Six months later, on April 12, 1955, the Salk vaccine was licensed for use. By August of that year, millions of children had been vaccinated. Quickly, new polio cases dropped from tens of thousands a year to just a few.8 And the method developed in the Enders lab went on to help develop vaccines against chicken pox, measles, and other diseases. As a leading member of that lab, Dr. Robbins helped prevent the deaths of thousands of children and launch the field of molecular virology.9
Many others at City Hospital contributed to the fight against polio. Robert Eiben, MD, served as Assistant Director of the Division of Contagious Diseases from 1945 to 1950 and as acting director before Dr. Robbins arrived. Dr. Eiben and his team were among the first physicians in the country to prescribe physical therapy to help polio patients maintain muscle tone and range of motion. Dr. Eiben also played a critical role in developing techniques and technologies that allowed those paralyzed by polio to stay physically active. Once City Hospital patients resumed 30 percent of their breathing capacity, they started working with physical and occupational therapists, using various bracing devices to make their way from bed rest to wheelchairs.10 Specially devised appliances allowed patients who had lost use of their arms and hands to feed themselves. One learned to write with a stylus using his teeth. Another gave birth in an iron lung.11
Dr. Eiben’s dedication to his patients was boundless. He flew to Maryland with one patient, who had faced multiple complications, and his team was at her home when she arrived to make sure her family and doctor understood how to use her iron lung and other equipment.12
From 1949 to 1956, City Hospital staff treated more than 2,000 polio patients from Cuyahoga County alone. In 1956, the first full year after the vaccine rollout, the hospital admitted fewer than eight polio patients. Because of Dr. Robbins, the United States has been free of polio since 1979, and the disease has been eradicated from nearly every other country in the world.13
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LESSONS IN HEALING FROM
DR. FRATIANNE
Establishing the Burn Unit, the Trauma Center, and Life Flight at MetroHealth
The Burn Care Center at MetroHealth, the only one in Cleveland, began in Galveston, Texas, home of the first burn unit of Shriners Hospital for Children in 1966. Soon after, Shriners looked to create a national burn care network and scouted locations in the Midwest, including Cleveland. At the time, the closest burn centers were in Pittsburgh, Pennsylvania, and Louisville, Kentucky.
In 2022, the staff included doctors, nurses, therapists, a nutritionist, a medical ethicist, and a dietitian, and burn care at MetroHealth remains a T.E.A.M. effort.
Dr. Fratianne found his calling. He would restore his burn patients’ health and their sense of dignity.
Instead of coming to Cleveland, the Shriners opened a pediatric burn hospital in Cincinnati in 1968. But their visit to Cleveland inspired John Davis, MD, a trauma surgeon and director of surgery, to consider a burn unit at MetroHealth. Dr. Davis served in the Korean War and was said to be one of the inspirations for Hawkeye Pierce: the surgeon at the heart of the novel, film, and television series M*A*S*H. A dedicated burn unit would allow the hospital to provide care otherwise unavailable in the region, he argued, convincing the hospital’s board of trustees, including Cleveland Fire Chief John Gannon, to buy into the idea.
In 1969, though, Dr. Davis became Chief of Surgery at the Medical Center Hospital of Vermont, and the burn center at MetroHealth remained in limbo until colleagues convinced Richard B. Fratianne, MD, to give up his thriving practice of advanced cancer surgery to serve as its director.
He opened the MetroHealth burn center, one of the first in the country, in the summer of 1970 as its only staff member.
It was a good fit for Dr. Fratianne. During his years as a resident at City Hospital, he had studied the physiology of shock. The devout Catholic also idolized missionary physician Albert Schweitzer and had plans to work in rural east Asia—until his wife stepped in, on behalf of herself and their two young children. “She said, ‘We can go any place you want,’” Dr. Fratianne recalled, “‘but aren’t there enough poor people in Cleveland that you could take care of?’”14
In 1970, fewer than ten US hospitals had burn centers. Patients were treated instead in emergency rooms, and their medical care focused almost exclusively on survival. Like today, burn patients underwent surgery after surgery to graft skin from one part of the body to another. Treatment lasted for months and, no matter how skilled the surgeon, scarring was often permanent. In many cases, burn patients, ashamed of how they looked, were driven into the shadows. With that realization, Dr. Fratianne found his calling. He would restore his burn patients’ health and their sense of dignity.
Doing that began with a renewal of his Catholic faith in a Cursillo-led retreat in the summer of 1971. For Dr. Fratianne, the key lesson in Cursillo focused on the family as a model for teamwork. After the retreat, Dr. Fratianne developed the T.E.A.M. model of care (Together Each Accomplishes More) for the burn center staff, a model in which every participant, no matter what type of care they provided, was regarded with equal value. Using the T.E.A.M. model, the burn staff helped patients, step by step, in their physical journey, which included indescribable pain and immeasurable dread. Doctors, nurses, therapists, social and child life workers, and others provided family-like love to restore patients’ love for themselves. Like Dr. Fratianne, the staff affirmed the goodness in each of their patients and encouraged them to let go of shame, find their inner strength, affirm their worth, and speed their recovery.
More than 50 years after its founding, the John A. Gannon Center for Burns and Trauma remains a distinctive feature of MetroHealth.
Dr. Fratianne’s development of the social and psychological dimensions of burn recovery aided in the recovery of thousands of Cleveland residents, and his publications on the subject helped revolutionize care for burn patients across the country.15 More than 50 years after its founding, the John A. Gannon Center for Burns and Trauma remains a distinctive feature of MetroHealth. It is one of two centers in Ohio and continues to be one of the most advanced in the country. Its 14 inpatient beds, including five intensive care beds, treat about 200 patients a year. In 2022, the staff included doctors, nurses, therapists, a nutritionist, a medical ethicist, and a dietitian, and burn care at MetroHealth remains a T.E.A.M. effort.
Dr. Fratianne retired in 2002, after more than 30 years as a surgeon and director of the burn center.16 In 2011, he was inducted into the MetroHealth Medical Hall of Honor. And in 2022, at the age of 90, he continued to facilitate the weekly Adult Burn Survivor Support Group, which the staff created in 1983 after a former burn patient began visiting others to instill hope. The support group moved to Zoom meetings in 2020 when the COVID-19 pandemic hit and now includes burn survivors from around the world.
Like Dr. Fratianne, the staff affirmed the goodness in each of their patients and encouraged them to let go of shame, find their inner strength, affirm their worth, and speed their recovery.
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WHEN WORDS FAIL
"When words fail, music speaks"
Doctor Richard Fratianne, a recipient of the Albert Schweitzer Memorial Trophy, founder of Cleveland MetroHealth’s Burn Care and Level 1 Trauma Center, had been first at many, many things that matter. But, to quote Monty Python, this was something “completely different.” This caused him some concern. This was the first time he would expose his soul with his music, the first time to record. “Don’t laugh at me,” he insisted more than once. As if I could ever laugh at him about anything.
“Doc Frat” and I got to know each another [sic] in 1973 when he whispered in my left ear, “Joe, I’m Doctor Fratianne. You’re in the hospital and you’ve been hurt very badly. I’m going to have to take off your right hand, and probably your left one too, but I’ll try to save your left hand.” Forced by his calling to expose me to six-months of daily tortures, I was but one of more than 25,000 burn patients who came to owe him a debt of love.
Forty-five years later, I overheard him playing piano at one of the Adult Burn Survivor’s Retreats when he was seeking a moment of solace and thought no one was within earshot. Sitting at an old, upright piano standing against a brick wall, he found a few minutes for reflection. Self-taught, learning “by ear,” his style was intensely personal. He had no formal lessons, didn’t read music, didn’t know the names of all the chords he played. “I just know how I want it to sound.”
Encouraging him to record his favorite songs for family and friends, he finally came to feel it sounded like an idea who’s [sic] time had come. At 89 years of age, the time for this “first,” was now. For more than two hours, 22 tunes from the music of “The Great American Songbook” flowed from his fingers. I was in awe.
Watching his purposeful movement across the keys, I reflected on the fact that these were the same fingers that took my arm and other portions of my burned body; the same fingers that gave me, and so many others, life. For a moment, it was staggering, sucking the wind from my sails. I closed my eyes and, to quote Frank Sinatra at the end of “Angel Eyes,” one of Doc’s favorite songs, “I just disappeared.”
There comes an end to what words can say. That’s where the music begins. Doc only stopped playing long enough to chide himself for “thinking too much,” or playing from too much emotion. He just wanted to be a conduit, something through whom the art of it all might simply, flow. He was the same way when it came to the healing arts of Science.
As a conduit of Grace, he believes the “whole” person must be addressed; body, mind and spirit. “Cinders to Butterflies” is how he spiritualizes his mission to burn survivors. Pioneering new concepts in healing for more than 50 years, Doc’s insistence in ministering to the spirit of his broken patients caused him to “adopt” every one of them, revealing his true “art.”
Doc is one of those folks for whom being a Physician is more about calling than it ever was about vocation. In his youth, he wanted to serve the very poorest of the poor in places like Africa or India. His dear wife, Mary, asked, “Do we really need to go around the world to serve the poor? There are many, many poor right here in Cleveland.” There are 25,000 plus burn survivors who thank Mary for her gentle influence. Because of that, we are alive.
Reprinted with permission from Joe Markko [AllSavedFreakBand.com]
A Level 1 Trauma Center must have a trauma surgeon available 24 hours a day, seven days a week, every day of the year.
“It is a mechanism of healing the inner person after the wrapping on the gift has been destroyed,” Dr. Fratianne said. “They go from being unlovable to feeling that they are not only lovable, but they are capable of helping other people feel lovable. It’s the healing of others that heals themselves.”
The monumental expansion of services Dr. Fratianne brought to MetroHealth didn’t stop with burn care. He also founded MetroHealth’s Level 1 Trauma Center and served as the first Medical Director of its air ambulance service, Metro Life Flight.
Forty years after its founding, the Life Flight team transports about 4,000 patients a year.
In 1980, the American College of Surgeons appointed Dr. Fratianne state chairman, with duties that included informing hospitals of the requirements needed to become trauma centers. Dr. Fratianne went to the administration to pitch the idea of MetroHealth becoming a Level 1 Trauma Center, the highest level, so it could provide the most sophisticated care to the most seriously ill and injured.
Initially, hospital leaders balked at the cost.
“It is this hospital’s tradition to provide services that others are not willing or able to provide,” Dr. Fratianne explained. The board and CEO Henry Manning agreed, and Dr. Fratianne went to work making sure MetroHealth met the long list of qualifications. A Level 1 Trauma Center must have a trauma surgeon available 24 hours a day, seven days a week, every day of the year. It also must offer a wide spectrum of specialty services such as neurosurgery, orthopedics, and pediatric orthopedics. Education, too, is critically important, as is response time. At Level 1 Trauma Centers, surgeons must be in the emergency department as the patient arrives.
As MetroHealth went to work meeting the qualifications to become a Level 1 Trauma Center, Dr. Fratianne knew the hospital also needed an air transport service to make sure patients arrived at the hospital within the “golden hour,” the 60 minutes after a traumatic injury when doctors are most likely to save a life.
“If you want this to be a success, this has to be a community service in which you are willing to have our vehicle transport patients to any hospital,” Dr. Fratianne remembered telling Mr. Manning. “And there’s one other thing, if you want to make this an absolutely phenomenal service, you’ll have a physician on every flight and a nurse trained in critical care on every flight.”
Again, Mr. Manning worried about cost. But he was interested. As a certified pilot, Mr. Manning knew key figures in air transportation and often flew his own plane to conferences in the region. He also knew the importance of the “golden hour.” Through his contacts in aviation, he purchased, then upfitted, a helicopter with oxygen and other critical care necessities. And, on September 1, 1982, Metro Life Flight began operating with one helicopter based at the West 25th Street hospital. The American College of Surgeons officially verified MetroHealth as a Level 1 Trauma Center in 1992.
Today, MetroHealth’s trauma team is the most experienced in the area, with a staff that includes 18 board-certified surgeons and 14 physician assistants and nurse practitioners. Most of the patients it treats are injured in falls or car accidents. Severely injured patients, on average, are treated by 50 to 100 specialists during their course of care.
Life Flight stands out, too, for its sophisticated equipment, its operations, and its personnel. Most medical evacuation helicopters employ one pilot. But every Metro Life Flight operates with two pilots and two medical staff: either doctor and nurse, or nurse practitioner and nurse. Nurses must have five years of experience in the intensive care unit, the emergency department, or a combination of the two and must become emergency medical technicians within a year of being hired. Its three twin-engine helicopters can fly in almost any weather and typically serve patients throughout Northeast and Central Ohio. Each helicopter carries supplies and equipment needed to provide critical care, including an ultrasound machine, mechanical ventilator, blood products, and IV pumps.
Life Flight also operates four ground units—critical care or advanced life support ambulances—which are used when a patient isn’t sick enough to require flight or when weather prevents helicopters from flying.
Forty years after its founding, the Life Flight team transports about 4,000 patients a year. The Level 1 Trauma Center cares for close to 6,000 patients a year, more than 16 a day. And Dr. Fratianne continues to be proud of the way each team fulfills the mission of MetroHealth. “If you can give your best care to those who can’t pay for it, then you’re a dedicated healthcare professional,” he said. “You’re in it for the sake of the patient. . . . The people that I worked with, I never found anyone that didn’t share my passion. I just didn’t.”
Each helicopter carries supplies and equipment needed to provide critical care, including an ultrasound machine, mechanical ventilator, blood products, and IV pumps.
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Life Flight also operates four ground units— critical care or advanced life support ambulances.
SAFETY FIRST
Quality Care at the MetroHealth
Correctional Health Program
“We purposefully don’t inquire why a person is incarcerated. We focus on the individual’s clinical and behavioral health needs.”
Bugs on the shower walls. Mice in food storage areas. Pregnant women sleeping on mats on the floor. Inmates who were denied toilet paper using clothing instead. The inhumane conditions at the Cuyahoga County jail in 2018 also included overcapacity by 25 percent, 55 suicide attempts in the previous 12 months, and seven deaths in a four-month stretch—three by suicide.18 On November 23, 2018, Peter J. Elliott, the US Marshal for the Northern District of Ohio, provided county jail staff with 30 days to correct the deficiencies. “My personal opinion is that the problems are very, very long-standing,” Mr. Elliott said. “They’ve been going on for decades.”19
Any progress made by the county did not come fast enough for Brenden Kiekisz. On Christmas, Mr. Kiekisz started his day in a mental health facility to address his suicidal thoughts. That evening, police officers detained him for panhandling and found that the 27-year-old Mr. Kiekisz was wanted on a warrant for missing a probation meeting. That evening, Mr. Kiekisz told the booking officer at the jail that he suffered from bipolar disorder and depression and provided a list of his medications. Even so, the booking officer did not refer Mr. Kiekisz to mental health professionals at the jail clinic. Two days later, when Thomas Tallman, DO, MetroHealth Director of Correctional Medicine, learned what happened, he e-mailed jail officials—again—about the need for immediate, effective change. “Please, please please . . .” Dr. Tallman wrote. “My patience is gone.”20 That same day, a month after the Marshals’ report was released, Mr. Kiekisz hanged himself in his jail cell. Finally, things began to change.
At the time, healthcare at the jail was split between MetroHealth and the county: MetroHealth employees included a physician director, other doctors, and two advanced practice providers—physician assistants or nurse practitioners. But the majority of the staff, including the nurses, continued to report to county officials. And when MetroHealth staff—including Dr. Tallman—brought their concerns to the county, little, if anything, was done.
It was Cuyahoga County Council President Dan Brady who, after seeing the Marshals’ report, called MetroHealth CEO Akram Boutros, MD, and asked if the health system would take over all healthcare at the jail. Before MetroHealth would say yes, it reached out to the National Commission on Correctional Health Care to determine what had to be done to bring care up to national standards. “The only way we’ll do this,” Dr. Boutros told county officials, “is if we can provide this high standard of care.”
In January 2019, the county officially announced that MetroHealth would take over—and improve—all care at the jail, including the hiring of nurses. And Julia Bruner, MD, Physician Executive for Ambulatory Operations at MetroHealth, was tapped to oversee that care. The changes were immediate. Every single inmate, upon intake, would now receive a medical evaluation. No exceptions. Daily safety briefings were held and mental health services expanded.21 Then, Dr. Bruner and her staff began hiring to fill the dozens of job openings at the jail’s medical clinic.
“How would you want to be treated?’” Dr. Bruner asked applicants. “‘How would you expect your son to be treated at the jail?’”22
“Individuals end up at the doorsteps of the county jail for a variety of reasons,” Dr. Bruner explained. “Some due to a misstep or miscalculation; others due to a significant charge. As clinical team members, we purposefully don’t inquire why a person is incarcerated. We focus on the individual’s clinical and behavioral health needs.”23
In April, the Cuyahoga County Council officially approved a contract with MetroHealth, agreeing, unanimously, to pay $42 million for three years of comprehensive healthcare at the jail beginning May 1. MetroHealth continued to make improvements, updating electronic medical records to ensure patients at the jail received the proper medication. In addition, all inmates were screened for suicide risk upon arrival and, if a patient in the jail attempted suicide, he or she received immediate treatment. To prevent copycat behavior, other inmates did, too, and follow-up counseling sessions were prescribed for anyone identified at risk. Starting that September, MetroHealth also began providing care to all inmates with opioid use disorder, including counseling and medication to stop their cravings. In its first year, 95 percent of eligible inmates participated, and 99 percent of them connected with medication-assisted treatment in the community after they were released.24
Then, in 2020, COVID hit. As soon as it did, Dr. Bruner began working to protect the one-third of jail patients diagnosed with chronic diseases, which put them at a higher risk of COVID complications, including death. Quickly, she met with Judge Brendan J. Sheehan, the common pleas judge who oversaw court operations, and explained that a COVID crisis was absolutely certain unless something was done. On her advice, judges began working fast to release those charged with non-violent and low-level felonies. On March 11, 2020, the county jail held 1,978 people—12 percent above capacity.25 By March 25, that number was down to about 1,000.
For those still behind bars, Dr. Bruner’s team provided masks and COVID tests and implemented social distancing rules. Isolation was enforced for anyone testing positive—and anyone exposed to anyone who tested positive. Those who were isolated saw a nurse twice a day; a doctor, physician assistant, or advanced care nurse once a day; and a mental health specialist every other day.
In July 2021, the New York Times reported more than 2,700 people had died of COVID in US prisons, jails, and immigration detention centers.26 In Cuyahoga County, only one patient at the jail needed hospitalization in the first year of the pandemic and no inmate died of COVID. The Cuyahoga County jail did report one COVID inmate death the following December, but no others as of April 2022.
“What became clear,” said Dr. Boutros, “is that the Cuyahoga County jail is not a short-term incarceration facility for folks who are otherwise healthy. It is a long-term facility that incarcerates individuals with significant medical, behavioral, and addiction issues who have already faced a lifetime of trauma. The humane thing to do was to treat each of these individuals with a holistic approach to their care. They are our neighbors and our family members. We had to assume responsibility for their care.”27
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MetroHealth employees included a physician director, other doctors, and two advanced practice providers—physician assistants or nurse practitioners.
Those who were isolated saw a nurse twice a day; a doctor, physician assistant, or advanced care nurse once a day; and a mental health specialist every other day.
For those still behind bars, Dr. Bruner’s team provided masks and COVID tests and implemented social distancing rules.
