Source: http://www.emtala.com/cherukuri.htm
Timestamp: 2018-01-18 17:26:22
Document Index: 11705824

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 1395', '§ 1395', '§ 1395', '§ 1395', '§ 1320']

ELECTRONIC CITATION: 1999 FED App. 0160P (6th Cir.)
File Name: 99a0160p.06
Theodore Cherukuri, M.D.,
Donna E. Shalala, Secretary of the Department of Health and Human Services,
No. 97-4464
On Appeal from a Final Decision of the Departmental Appeals Board, Department of Health and Human Services.
No. C-96-020
Decided and Filed: May 3, 1999
ARGUED: Gregory C. Lisa, JENNER & BLOCK, Washington, D.C., for Petitioner. Carl E. Goldfarb, U.S. DEPARTMENT OF JUSTICE, CIVIL DIVISION, APPELLATE STAFF, Washington, D.C., for Respondent. ON BRIEF: Gregory C. Lisa, Paul M. Smith, JENNER & BLOCK, Washington, D.C., John D. Preston, Chad G. Perry, III, PERRY, PRESTON & MILLER, Paintsville, Kentucky, for Petitioner. Carl E. Goldfarb, Barbara C. Biddle, U.S. DEPARTMENT OF JUSTICE, CIVIL DIVISION, APPELLATE STAFF, Washington, D.C., for Respondent. Paul M. Smith, JENNER & BLOCK, Washington, D.C., for Amicus Curiae.
MERRITT, Circuit Judge. This appeal by Dr. Cherukuri, a surgeon, arises from the decision of the Secretary of Health and Human Services that the transfer of two patients violates the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd, enacted in 1985, and now given the acronym, "EMTALA." EMTALA regulates emergency room care in hospitals that accept Medicare patients and was passed ostensibly to prevent "patient dumping" of the uninsured, although its literal language reaches well beyond its stated purpose. Both the enforcement power and the adjudicatory authority under the statute are lodged in one place, the Secretary.
The issue before us is more technical in nature. The question is whether Dr. Cherukuri, the emergency room surgeon on call that night at Williamson Hospital, should be found guilty of violating the "stabilization" language of § (b) of EMTALA because he transferred the two patients with head injuries to the trauma center at St. Mary's Hospital in Huntington (1) before operating on their stomach injuries to stop internal bleeding and (2) before receiving express consent to transfer from the physicians at the Huntington hospital. The Inspector General commenced an enforcement action to suspend the surgeon's license and assess the maximum "civil penalty" of $100,000. An administrative law judge employed by the Secretary wrote a 35,000-word opinion finding the surgeon guilty and imposing a fine of $100,000. The "Departmental Appeals Board" in the Office of the Secretary declined to review or comment on the decision and made it final and binding, subject to review in the Court of Appeals.(1)
(b) . . . the hospital must provide either -
Id. § 1395dd(b) (emphases added). Under subsection (c), a patient who "has not been stabilized" may be transferred (1) only upon "a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual . . . from effecting the transfer" and (2) only if "the receiving facility . . . has agreed to accept transfer of the individual and to provide appropriate medical treatment . . . ." Id. § 1395dd(c) (emphasis added). Only unstable patients require a certification and consent of the receiving hospital. A patient who has been "stabilized" in the emergency room of the transferring hospital may be transferred to a receiving hospital without a certification, as described above, and without obtaining the express agreement of the receiving hospital. "Stabilized" patients may be transferred without limitation under the language of the statute.
In subsection (e), EMTALA's definition subsection, the word "stabilized" is defined, but the definition is not given a fixed or intrinsic meaning. Its meaning is purely contextual or situational. The definition depends on the risks associated with the transfer and requires the transferring physician, faced with an emergency, to make a fast on-the-spot risk analysis. The definition says that "stabilized" means "that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual." Id. § 1395dd(d). The bottom line is that under the language of subsections (b) and (c), including the definition of "stabilized" in subsection (e), a physician may transfer any emergency room patient to another hospital without any certifications and without the express consent of the receiving hospital if he reasonably believes that the transfer is not likely to cause a "material deterioration of the patient's condition." Id. Obviously a surgeon in Dr. Cherukuri's position must weigh what he can do for the patient at his hospital versus the services available at the receiving hospital, as well as the present condition of the patient and the risk that he will get worse during the transfer.(2)
Section (d) defines the burden of proof for the government when prosecuting a physician in a civil penalty enforcement action. Subsection (d)(1)(B) provides for a "civil money penalty" against "any physician who is responsible for the . . . transfer of an individual . . . and who negligently violates a requirement of this section, including a physician who . . . signs a certification . . . that the medical benefits reasonably to be expected from a transfer to another facility outweigh the risks associated with the transfer, if the physician knew or should have known that the benefits did not outweigh the risks." Id. § 1395dd(d)(1)(B) (emphasis added). In order to prove a transfer violation under sections (b), (c) and (e), the government must show in a civil penalty case not only that the transferred patient was not "stabilized" and not accepted by the receiving hospital. It must show that the doctor was "negligent" in transferring the patient in the sense that, under the circumstances, "the physician knew or should have known that the benefits [of transfer] did not outweigh the risks."
Counsel for Dr. Cherukuri argue that he should be exonerated not only because he did not violate the literal language of the stabilization and transfer provisions of EMTALA, but also because this is a "patient dumping" statute and we should read into section (b) a requirement of discrimination based on insured status, ability to pay or other class based intent. The Supreme Court in Roberts v. Galen of Virginia, Inc., 119 S. Ct. 685 (1999), recently rejected the view that § (b) of EMTALA implicitly incorporates an "improper motive" test. The Supreme Court opinion says that the statutory text should not be read to include qualifications not imposed by its plain language, but we leave to another day the question whether the Roberts opinion precludes a reading of the statute that incorporates a discrimination requirement. We need not reach this issue because, as we explain below, Dr. Cherukuri did not violate the stabilization provision of EMTALA.
II. The Emergency Room Situation, The Transfer, and the Application of the Law to the Facts
At about 3:30 on Sunday morning, September 15, 1991, five injured auto accident victims were brought to the Williamson Hospital. Dr. Hani, the emergency room doctor, and registered nurse Judy Hatfield were then on duty in the emergency room. They immediately called Dr. Cherukuri, the general surgeon on-call that night, a man in his mid-50s with many years experience and with a good reputation in his profession prior to this prosecution.(3) He was originally trained in India and received extensive further training in surgery in the New York University medical system. He came immediately to the emergency room. Pat White, the senior nurse who was in charge of administration of all of the departments at the hospital that night, also came immediately. Dr. Cherukuri and nurses White and Hatfield were at the hospital for the next six hours dealing with the five patients. The two nurses both testified that the small emergency room was "almost overwhelmed" by the situation. Two of the accident victims, Crum and Mills, were critically injured, another very seriously injured and two more were hurt in the accident and needed treatment.
Special care must be exercised in sedating parties who have sustained head injuries, as the level of consciousness is an important diagnostic and prognostic sign. It is difficult to distinguish between a desirable drug effect and the progression of intracranial pathology. Even mild drug-induced respiratory depression with its associated hypercania can result in significant elevations of the intracranial pressure. Lewis A Coveler, Anesthesia, in Trauma 219 (Ernest E Moore et al., eds., 2d ed. 1991). We thus regard the ALJ's conclusions as erroneous. Dr. Thambi testified that he probably would have administered anesthesia, if ordered, but strongly opposed it, delayed coming to the hospital for 2-1/2 hours so that the patients could be transferred and personally advised the parents not to allow surgery at Williamson but to transfer to Huntington.
"If somebody had told me that there is this kind of blood pressure, even though the peritoneal lavage [operation which showed internal bleeding] was positive, I would have said that yes, let's take the risk of coming up here [to Huntington] rather than having surgery up there [at Williamson] because there could have been some serious problem in the head, that doing that [abdominal] surgery might have caused some problem."
The ALJ treatment of the testimony of Drs. Sakhai, Aaron and Fowler is clearly erroneous and must be rejected. She rules out their testimony as irrelevant because "they did not have the opportunity to observe the patients' condition," deriving "their opinions solely from a review of the medical records." JA 24-25. Yet the ALJ appears to accept fully the testimony of government witnesses Harrigan and Browning -- who also "did not have the opportunity to observe the patient's condition" -- that the patients remained "unstable" so long as no abdominal operation was performed. No explanation is given for the inconsistent treatment of the two government experts and the three defense experts.
Nor does the ALJ give any credence to any of the five experts on the scene who observed the patients - Drs. Cherukuri, Thambi, Arya and Nurses White and Hatfield - and who all testified, either expressly or in effect, that after blood pressure was restored the patients were sufficiently stable and that transfer was the only reasonable choice.
We agree with the eight witnesses -- Drs. Cherukuri, Thambi, Arya, Sakhai, Aaron, Fowler, and Nurses White and Hatfield. The statutory definition of "stabilize" requires a flexible standard of reasonableness that depends on the circumstances. The two government witnesses and the ALJ erred in giving the concept a fixed meaning which necessarily, and in all events, requires an abdominal operation before transfer. Nothing in the statute so requires, and the rigidity of the representatives of the Office of the Secretary on this subject is misplaced.
"Difficult for me to say what was going on in the other side. I thought that he would probably find a way to take care of the patient [by operating]. At the same time it is conceivable he was so desperate to do something, he sent the patient over. That is quite conceivable to me."
Q. Now, if I understand it, both of these patients made it to you and were alive and you operated on both of them?
DR. ARYA: . . . . You have a patient, and you need to operate, but anesthesia doesn't want to put him to sleep, I don't know what choice you have. I kept saying that.
DR. ARYA: No, in fact, they are very, very important. But he is in the position - you have the patient, you need a surgeon, anesthesia people don't want to put him to sleep, what can he do? He could have gone one more time to the phone, but the problem was that I thought after our conversation, maybe he [should] find a way to operate.
Therefore, we conclude that the ALJ did not apply the proper meaning of "stabilization" and hence the proper standard for transfer and seriously erred in concluding that anesthesiology was available. It is unfortunate that the errors we have uncovered were not caught earlier in the administrative process. When the administrative "Review Board" established to administer EMTALA cases chooses without explanation to make an ALJ decision in an important case binding without review, the burden on the Court of Appeals to comb the record is substantially increased. We respectfully suggest that the Board should review cases like this one closely and should not simply pass them on to a federal appellate court without providing a reasoned disposition of the objections raised by the parties. Our own close review of the record clearly shows that the decision is not supported by substantial evidence on the record as a whole, does not justify the legal conclusion made by the ALJ that Dr. Cherukuri "knew or should have known that the benefits [of transfer] did not outweigh the risks" (§ 1395dd(d)(1)(B)), and accordingly must be set aside.
1. EMTALA calls for a review by the Court of Appeals of decisions to impose a penalty. The "court shall have jurisdiction . . . to make . . . a decree affirming, modifying, remanding for further consideration, or setting aside, in whole or in part, the determination of the Secretary and enforcing the same to the extent that such order is affirmed or modified . . . . The findings of the Secretary with respect to questions of fact, if supported by substantial evidence on the record considered as a whole, shall be conclusive." Subsection (d) of EMTALA incorporates the above review procedures from 42 U.S.C. § 1320a-7a(e).
2. The Fourth Circuit, in an opinion by Judge Phillips, has reached a similar conclusion that to "stabilize" for purposes of "transfer" is a relative concept that depends on the situation:
"The stabilization requirement is thus defined entirely in connection with a possible transfer and without any reference to the patient's long-term care within the system. It seems manifest to us that the stabilization requirement was intended to regulate the hospital's care of the patient only in the immediate aftermath of the act of admitting her for emergency treatment and while it considered whether it would undertake longer-term full treatment or instead transfer the patient to a hospital that could and would undertake that treatment."
Bryant v. Rectors & Visitors of the Univ. of Virginia, 95 F.3d 349, 352 (1996).
3. Williamson Hospital Administrator Charles Glover stated that over the many years he served as Administrator "no disciplinary action or derogatory information on Dr. Cherukuri" came to his attention and the Doctor was "a caring, prompt responding, well trained general surgeon."