Sorry, We're Closed

Cleveland Clinic’s plan to shut down a trauma center counts dollars saved but not crucial minutes lost

In May, East Cleveland fire fighter Jonathan Alexander had just finished a 48-hour shift when he arrived at his Catalpa Road home to find a strange car in his driveway. He blocked the vehicle with his own, noticed that the keys were in the ignition, and started to investigate. That's when he saw one of three robbers coming from the back of the house. He raced to the car, grabbing for the keys while struggling with the man. Then, holding the keys, he ran back to his own car to call police, glancing back just in time to see the robber pull out a gun and aim it at him.

Alexander turned away as the bullet struck him in the lower back, ripping through his spleen and rendering his legs useless. He dropped to the ground as a second man came over to demand the keys. "I thought it was the man with the gun," he remembers thinking. "I thought he was going to kill me."

The second man found the keys as Alexander began screaming for help. Then a third joined the other two, and they drove across the lawn to escape as Alexander's brother and several neighbors arrived.

"As I'm laying on the ground in my yard, I'm feeling around. I didn't have any external bleeding, and I was kind of surprised," Alexander remembers thinking. "I know I got shot, so what's going on? What was hit? And how much time do I have before I begin to feel the effects of what happened? It was crazy."

By the time the fire department and EMS arrived, there was a good chance Alexander would die from his internal bleeding. The only hope was to access the nearest Level II trauma center — Cleveland Clinic's Huron Hospital.

Cleveland has three such centers: Huron Hospital, Hillcrest in Mayfield Heights, and Fairview on the West Side, along with the region's only Level I trauma center at MetroHealth. If plans announced by the Clinic in October do not change, Huron's trauma center will be closed, likely next year.

Alexander, who is on the mend and hopeful for a return to full duty, says that if his encounter with home invaders would have happened in 2011, without the option of Huron Hospital, his family would likely be mourning his death rather than celebrating his recovery.

The fear of losing Huron Hospital's trauma center has created justifiable concern on many levels. Cleveland Councilman Jeff Johnson, aware that the area affected most heavily by a loss of care at Huron is low income, calls the proposed closing "unacceptable." He says the poor are being disenfranchised from the fastest-possible, highest-quality medical care — at the same time the Clinic is announcing plans for a posh Center for Brain Health to be built in Las Vegas.

"It's a clash of cultures, of income, of race," Johnson says. While the Clinic claims this is not the case, it appears guilty at the very least of trying to keep secret a decision that potentially affects all Clevelanders.

Dr. Toby Cosgrove, President and CEO of Cleveland Clinic, announced the plan to close Huron's trauma center on Friday, October 22, though it was well known to Clinic insiders before that. Two hours before Cosgrove met with fire and EMS officials, council members, and others, news of the closure had been accidentally leaked. A trauma surgeon inadvertently mentioned what was happening to a Huron staffer, and word spread immediately.

Perhaps it would have been wisest to allow for the dissemination of critical information early enough in deliberations so that the affected cities and medical-response units could plan for it. Instead, the initial announcement was delivered as a statement of fact minimized only slightly when Cosgrove noted that "We do not plan on implementing this until we have managed the logistics to continue to provide the quality of care and to in fact enhance the quality of care for the patients and trauma patients of Northeast Ohio."

The quote struck some in attendance as odd, given that the proposed action — which would affect the residents of two cities — was being taken without discussion with city officials, the public, or even the first responders, especially paramedics and fire fighters, who must live with the consequences of the closing each day.

Cosgrove tried to soften the news by explaining why the shutdown was apparently out of the Clinic's control. The population needs have changed, he said; Cleveland and East Cleveland have fewer residents than in the past, and the number of trauma cases coming to Huron Hospital has fallen.

In 2006, a Huron Hospital study of the volume of serious trauma indicated that an estimated 1,400 patients would need Level I and Level II care over the course of the year. That was double the number handled by Huron in 2004.

Also in 2006, the overall numbers and growth of demand for trauma care were so great that Cosgrove asked the county commissioners to upgrade Huron Hospital to Level I, the equal of MetroHealth. The commissioners refused the costly change. So far this year, Huron has treated approximately 1,060 trauma patients out of 28,000 overall emergency visits, according to Clinic spokeswoman Eileen Sheil.

At the October 22 announcement, Cosgrove noted that the trauma center at Huron was understaffed. Four of the six trauma surgeons had left, he said, and as a result, "We do not think we will get a Level II trauma certification. Even if we wanted to, I don't think we could get it." One week later, on October 29, the trauma center passed its tests, and its national certification was renewed.

Ask local EMS workers to describe the importance of Huron Hospital to the region's level of trauma care, and they will point to the source of most of Cleveland's trauma runs.

"About 60 percent of the trauma that Cleveland EMS sees is on the east of the city, roughly from downtown to the East Cleveland border; from St. Clair/Superior neighborhood south to the Miles/Union neighborhood," says Cleveland EMS Commissioner Ed Eckart, the man in charge of the city's emergency medical services. "Huron Hospital is right in the middle of that area that I just described." It is a reality that seems to reinforce Councilman Johnson's claims of socioeconomic bias.

Just as troubling was the fact the decision to close Huron's trauma center had been made without prior consultation with the first responders from Cleveland and East Cleveland, who race the seriously ill and injured to the East Side hospital on a daily basis. Eckart is among the knowledgeable sources who seemingly should have been consulted about changes but is only now being brought to the table.

Amid the Clinic's talk of reduced need for a trauma center and understaffing at Huron, a more obvious concern being studiously ignored in comments to the public is the issue of who will die as a result of the shutdown.

"Cleveland Clinic is committed to providing the highest quality of care and safety for our patients," spokeswoman Sheil stresses in an e-mail about the closing of Huron's trauma center. Indeed, quality of care has never been an issue for those being rushed to any of the area hospitals in question. But the Clinic's professionals are concerned with the delivery of medical care after a patient arrives. What happens before patients reach that point is out of their hands, but is crucial to the overall success of the rescue effort.

It also was why outrage from the community came pouring in when the planned elimination of Huron's trauma center was announced. Without the trauma center, rescuers must turn to one of the region's other trauma options: Level II centers at Hillcrest (which would have been the next closest option for Alexander and others on the East Side) and Fairview, or Metro.

The concern of Alexander and others revolves around the time between a 911 call and transport to the hospital. Among the dozens of emergency runs made to Huron Hospital every day are instances like Alexander's, in which a delay of even five minutes can make the difference between life and death, or partial vs. full recovery. Close Huron Hospital's Level II center, and that five-minute delay would be far preferable to the remaining options.

Cleveland EMS produced a study of changes in run time if Huron Hospital ceases operations as a Level II center. A run from East 152nd Street and St. Clair Avenue (Cleveland's Ward 11), for instance, takes a maximum of six minutes when made to Huron Hospital. Without Huron in the picture? Add 14 minutes in each direction to Metro and 15 minutes to Hillcrest. Runs from the other affected wards are similarly time-consuming.

"Due to the location and travel time from the City of Cleveland to Hillcrest Hospital, their facility will provide virtually no assistance to trauma patients from the City of Cleveland," the city wrote in a prepared statement shared with Scene.

A secondary part of the problem is "really not about trauma, though we're talking about the loss of a trauma service," says Eckart. "It's about the ripple effect, about how it's going to affect all 911 calls and not just EMS. It's going to affect fire-service availability as well as police service."

Eckart uses the police as an example. "If someone is the victim of a gunshot wound over there in the Fifth District and we transport that victim to Huron Hospital, the Fifth District zone car can just drive over to Huron Hospital to conduct their investigation. Now if we're transporting that patient all the way over to Metro, that Fifth District zone car is going to be a lot farther out of their district to be available to handle other 911 calls."

The same can happen with other departments. Fire fighters and their trucks can be taken out of service with trauma calls that will require longer runs than they do now. "We utilize the Division of Fire as our first responders," says Eckart, noting that all fire fighters are also certified emergency medical technicians. "Frequently, they will have to assist taking a patient to the nearest Level II trauma center, either by driving the ambulance while both paramedics work on the critical patient or by assisting one of the paramedics during the drive. Again, this means a longer time away from the fire fighter's area of emergency coverage."

The cities of Cleveland and East Cleveland, desperate to stop the abrupt loss of a trauma center they deem critical to the community, brought a lawsuit against Cleveland Clinic to halt the planned closure. Within weeks, both sides seemed to recognize that the onset of litigation did little more than generate additional negative publicity. On November 15, a joint release was issued by the parties involved stressing that the goal was "... to reach an agreement which builds a trauma system that best serves the needs of our residents. If an agreement cannot be reached, the Cities and the Cleveland Clinic retain their respective rights."

And if Huron Hospital loses its fight?

"What's going to happen now is that you're going to have more patients going to fewer hospitals," Eckart says. "It's like an airport. An airport can only handle so many takeoffs and landings a day based on weather conditions and the number of available runways. Well, the same thing with hospitals. You're going to have the same physical structure at the hospital — five ambulance bays and 20 emergency room beds. Under normal circumstances, three of those ambulance bays and 15 of those patient beds are going to be used today. Now by taking those extra patients who would normally go to Huron, all of the ambulance bays are going to be tied up and all of the beds are going to be tied up, which creates a longer time before the paramedics can transfer those patients and get back out of the hospital and back into service.

"The hospital still has the same number of staff to deal with this, so instead of a nurse being able to come up to us in five minutes and say, 'Give me the report on the patient,' the nurse is probably going to be tied up with another patient now, which is going to force the paramedic staff to wait, so exponentially the time increases."

Sadness still permeates the voice of Jonathan Alexander when he relives the day he was shot. Half a year removed from the incident, he finds himself endlessly frustrated by the long road to recovery. He has logged more than eight years with the East Cleveland Fire Department, and he is proud of his career and the lives he has helped save along the way.

He speaks of one 911 call that came in two years before his own ordeal. A woman driving on Euclid Avenue had a heart attack, lost control of her car, and slammed into the back of a truck. Alexander was one of the first rescuers called to the scene.

"We got her, packaged her with a backboard and collar, got her into the back of the squad, and began our CPR on her," he recalls. She was hooked up to a monitor to analyze her rhythms, to see what the technicians were working with. As they navigated the streets to the trauma center at Huron Hospital, the efforts of Alexander and the others began to take effect. The woman's pulse returned. "We got an IV line going, assisted ventilations until we got to the hospital," he says. The medical staff agreed that, without the care administered at the scene and at Huron's trauma center, she would have died. Instead, she recovered and was sent home.

In August 2008, Alexander and his colleagues were presented with a Distinguished Service Award for helping save a life that probably would have been lost if not for their skill and the availability of the Level II trauma center at Huron Hospital. The same Distinguished Service Award was given to the first responders who took care of Alexander on the day he was struck down at his home.

And which organization administers the program honoring the quality of care received from first responders who work in conjunction with the staff of the Level 2 trauma center and emergency room services at Huron Hospital?

Cleveland Clinic.

Ted Schwarz is a freelance writer in Cleveland. Send feedback to [email protected].

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