Opinion ID: 763593
Heading Depth: 2
Heading Rank: 2

Heading: The Emergency Room Situation, The Transfer, and the

Text: Application of the Law to the Facts 18 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. 19 As soon as Dr. Cherukuri arrived, he spent about 30 minutes diagnosing the injuries. He found Crum to be nonresponsive with massive cranial injuries, very low blood pressure and fixed dilated pupils indicating that the brain may be near death. He made a small incision in Crum's stomach and found internal bleeding. He tentatively concluded that Crum might not survive but would need immediate blood and other liquid transfusions to stabilize his blood pressure. He set that treatment in motion. He also concluded at that time he would have to operate on Crum's abdomen to find and stop the bleeding before transferring him to Huntington for brain surgery. 20 He found Mills to be responsive but unconscious with a serious head injury and low blood pressure. A similar stomach incision showed internal bleeding. After taking similar steps to administer blood and liquids, he examined the other three patients. He tried unsuccessfully to find another surgeon to come in to help with the five patients. 21 After four hours of treatment, Crum and Mills, the two patients with cranial injuries, were transferred by ambulance to Huntington. Time was lost trying without success to get a helicopter in to transfer the two patients to Huntington. Due to heavy fog in the river valley where the Williamson Hospital is located, the helicopter pilots finally advised that they were afraid to land in this mountainous country. Transfer was also delayed because of difficulties in finding an anesthesiologist.
22 It is undisputed that Dr. Cherukuri determined by 4:00 A.M. that it would be best to operate on both Crum and Mills to stop the internal bleeding so that he could raise their blood pressure to assure a sufficient blood supply to the brain and other organs. But he was unable to do so for the next three hours because Dr. Thambi, the anesthesiologist on call, advised strongly against operating and did not come to the hospital. He testified that he advised Dr. Cherukuri and nurse White that the patients should be immediately transferred to St. Mary's Hospital in Huntington. He testified that he advised repeatedly and adamantly that administering anesthesia for the abdominal surgery was too risky because they had no equipment to monitor its effect on the pressure in the brain. Dr. Thambi himself testified that he would only have provided anesthesia under protest if ordered to do so. 23 Dr. Cherukuri and Pat White testified that over the next two hours each requested Dr. Thambi by phone several times to come to the hospital but he maintained that anesthesia was out of the question and did not come. They tried to locate other anesthesiologists during this period but were unsuccessful. Finally, when Dr. Thambi came two and a half hours later, he testified that he told the parents of the patients that they must be transferred to Huntington for surgery because it could not be performed at Williamson. He continued to advise the staff that anesthesiology on the brain injured patients was out of the question. All witnesses who heard and observed Dr. Thambi so testified. No one testified to the contrary. 24 While recognizing that Dr. Thambi had made his position very clear that he did not intend to provide anesthesiology because it might kill the brain injured patients, the ALJ concluded that EMTALA required the surgeon to force Dr. Thambi to perform by expressly ordering him to administer anesthesia. The ALJ states repeatedly throughout her long opinion that the law necessarily required Dr. Cherukuri to stop the bleeding for the patients to be considered stabilized under the statute and that this required Dr. Cherukuri to force Dr. Thambi against his will to administer anesthesia. Nothing in EMTALA demands such a confrontation, and for good reasons. 25 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. 26 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. 27
28 All witnesses in the case, as well as the ALJ, agreed that by the time the two patients were transferred by ambulance four hours after they arrived, the emergency room staff had normalized their blood pressure so that a sufficient blood supply was flowing to the organs of the body. But two witnesses, an emergency room doctor (Dr. Harrigan) and a general surgeon (Dr. Browning) testified for the government as experts that stabilization for transfer to another hospital could not occur, as a matter of definition, unless abdominal surgery was performed to stop the internal bleeding. They testified that the word stabilize in the statute has an intrinsic, a priori meaning requiring that patients not be transferred while internal bleeding remains. The ALJ accepted their testimony and adopted the inflexible meaning they gave to the word stabilize in the statute. 29 The two government experts, and the ALJ, viewed transfer with internal bleeding as improper because it was possible that the patients could start hemorrhaging during the 1-1/2 hour ambulance trip to Huntington. Even though attendants giving blood transfusions accompanied the patients, the two government witnesses believed that the risk of deterioration during travel was too great. All witnesses, as well as the ALJ, agreed that in this case the two patients in fact arrived at the Huntington Hospital without further injury or deterioration, that their blood pressure and breathing remained stable and did not deteriorate, and that the travel did not further exacerbate the patients' conditions. Although Crum died later of his injuries, the evidence was that there was nothing Dr. Cherukuri, or the staff in Huntington, could have done to save him. Mills survived, recovered from his injuries and was released. 30 Eight expert witnesses, including Dr. Cherukuri, testified either expressly, or in effect, that stabilize must be given a more flexible meaning and that the on-the-spot risk analysis of Dr. Cherukuri leading to transfer was appropriate under the circumstances. Among the witnesses, who so testified in addition to Dr. Cherukuri, were Dr. Sircus Arya, the receiving surgeon at Huntington who operated on Mills and Crum when they arrived; Dr. Thambi, the anesthesiologist, who testified that from the beginning he believed that Dr. Cherukuri had no choice but to transfer; and Dr. Hossein Sakhai, a Huntington-based, Vanderbilt-trained neurosurgeon with 31 years experience, who testified that he had carefully reviewed the hospital records at Williamson and Huntington and that the transfer should have been done when it was done and that there was good cause and good reason to transfer without an abdominal operation. After going over the blood pressures of the patients in detail, he testified repeatedly on direct and cross-examination that he could find no fault with the way Dr. Cherukuri handled the problem: 31 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. 32 In addition, Dr. William Aaron, a board certified quality assurance and peer review physician, Dr. Paul Fowler, specializing in legal medicine, R.N. Judy Hatfield, the emergency room nurse at Williamson, and Pat White, the nurse who attended Dr. Cherukuri, also testified as experts that the two patients were sufficiently stabilized to transfer and, like Drs. Arya, Sakhai, and Thambi, testified that Dr. Cherukuri had no other viable choice under the circumstances but to transfer. 33 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. 34 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. 35 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. 36 In our view Dr. Cherukuri acted properly under very trying and difficult circumstances and should be exonerated of any wrongdoing. Certainly any possible fault does not rise to the level prescribed by § (d) of EMTALA, which states that a civil penalty can only be imposed on a doctor who knew or should have known that the benefits [of transfer] did not outweigh the risks. 42 U.S.C. §§ 1395dd(d).
37 At about 4:00 A.M., after Dr. Thambi advised Dr. Cherukuri that anesthesia should not be given to Crum and Mills, Dr. Cherukuri talked to the chief surgeon at Huntington, Dr. Arya, briefly describing the situation and his problem in finding an anesthesiologist. Dr. Arya advised him to try to find an anesthesiologist somehow and to perform an abdominal operation on each to stop the bleeding. Dr. Arya testified that he was irate when he learned later that morning that the patients were on their way by ambulance. He called Williamson and told Nurse White to recall the patients and perform the abdominal operations. He testified he was angry, suspected patient dumping and reported the incident as an improper transfer. The Administrator at the hospital in Huntington, Dr. Arya, and others who initially heard about what had happened thought that Dr. Cherukuri had violated EMTALA by transferring unstable patients without consent of the receiving hospital. On the basis of these initial complaints, the government undertook the investigation that led to this prosecution. 38 The Huntington Administrator and Dr. Arya both changed their minds completely once they learned the circumstances facing Dr. Cherukuri. They both had the courage to admit their error in sworn testimony and testified that their initial view was mistaken. Dr. Arya was a government witness, and the government does not seek to attack his credibility or expertise. The government argues, and the ALJ found, that Dr. Cherukuri lied when he told Nurse White that he had received permission from Dr. Arya to transfer the patients to St. John's in Huntington. Although it is true that Dr. Cherukuri did not have express permission to transfer, the record does not quite bear out a conclusion that he acted in bad faith and intentionally misrepresented the situation. In answer to a question by government counsel on direct examination, after having this conversation [about 4:00 A.M. with Dr. Cherukuri] what was your expectation of what should occur before transfer, Dr. Arya gave this answer: 39 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. 40 Trans. 310. This answer states, contrary to the finding of the ALJ, that Dr. Arya's expectation was that it is quite conceivable to me that Dr. Cherukuri might be so desperate as to send the patient over. This testimony from the government's own witness does not support the finding that Dr. Cherukuri lied. Dr. Arya then further testified: 41 Q. Now, if I understand it, both of these patients made it to you and were alive and you operated on both of them?A. Yeah. 42 Q. And you got good results with your abdominal surgery on both of them? 43 A. Yes. 44 Q. But that this Sean Crum was, as you explained to the Judge, in answer to her question, for all practical purposes, beyond help because of his brain damage? 45 A. That is correct, yeah. 46 Trans. 314. 47 On cross-examination, Dr. Arya testified that he is now sympathetic to him [Dr. Cherukuri] because after all the facts, I knew that he was in a tough situation, so it looked like he had no choice, what he did. (Trans. 318.) The ALJ then took over the questioning: 48 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. 49 It happened to me. I have a patient, anesthesia wouldn't put him to sleep, I cannot put him to sleep myself, I don't have the license. 50 JUDGE LEAH: But would you just transfer the patient? 51 DR. ARYA: You have to, you have to do something. 52 JUDGE LEAH: Wouldn't you get the consent of the surgeon who is supposed to be receiving, first? 53 DR. ARYA: Yeah, but that comes more like paperwork. Bear in mind, you have to do something with the patient, he is dying, and nobody wants to put him to sleep, and the other doctors say not to send the patient, you have to make the decision. And he made the decision to send the patient over. 54 It is not nice choices, but I don't know what other choice he had. 55 JUDGE LEAH: So you think the consent of the receiving surgeon and the receiving hospital are merely paperwork? 56 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. 57 So he couldn't find a way, and he sent the patient over. But, I mean, I wouldn't blame him for sending the patient over, because the patient would have died there without surgery. At least, if you send him over, we could operate and so on and so on. 58 (Trans. 323, emphasis added.) 59 The ALJ does not mention this exculpatory testimony in her long opinion repeatedly condemning Dr. Cherukuri, nor does she mention that Dr. Arya said he believes that Dr. Cherukuri saved Mills' life by keeping him alive and transferring him under extremely difficult circumstances. 60 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.