EMTALA Stabilization
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         Article from ACEP EM Today
         August 23, 2000

   The Emergency Medical Treatment and Active Labor Act (EMTALA) requirement
that patients be stabilized before being transferred from one hospital to
another has been further defined in a recent ruling by The United States Court
of Appeals for the Sixth Circuit.
   In the case, Cherukuri v. Shalala, five patients involved in a car crash,
two with severe head injuries and internal abdominal injuries and bleeding,
were brought to the emergcncy department of Williamson Hospital, a small rural
facility in Kentucky. The hospital did not have a trauma center or equipment
for monitoring anesthesia during surgery. It also had a long-standing policy
of not performing neurosurgery on head injuries and patients with those types
of injuries were usually transferred to larger hospitals.
   Two of the patients were transferred to another hospital and eventually
sued Theodore Cherukuri, MD, the surgeon on call at Williamson that night.
   The Department of Health and Human Services (HHS), which oversees EMTALA,
questioned whether Dr. Cherukuri had violated EMTALA stabilization
requirements by transferring the two patients with head injuries before
operating to stop internal abdominal bleeding, and before receiving express
consent to transfer from the receiving hospital.
   An HHS administrative law judge found that Dr. Cherukuri had violated
EMTALA's stabilization requirements and imposed the maximum fine of $100,000.
   Dr. Cherukuri appealed and the Sixth Circuit reversed the action of the
administrative law judge. According to ruling, Dr. Cherukuri had sufficiently
stabilized the two patients to permit transfer. The Sixth Circuit also noted
that he did not have an anesthesiologist available so that he could operate.
   The court explained that, under EMTALA, a patient who has not been
stabilized may be transferred only if the medical benefits reasonably expected
from the provision of appropriate medical treatment at another medical
facility outweigh the increased risk to the individual from the transfer and
if the receiving facility agrees in advance to accept the transfer. But a
patient who has been stabilized may be transferred without obtaining the
express agreement of the receiving hospital.
   The Sixth Circuit also considered what type of standard is required under
EMTALA to determine whether a patient is stabilized. A number of witnesses,
including Dr. Cherukuri, testified that stabilized must be given a flexible
meaning and that the risk analysis by Dr. Cherukuri leading to transfer was
appropriate under the circumstances.
   The Sixth Circuit Court of Appeals agreed and ruled that the definition of
stabilized requires a flexible standard of reasonableness that depends on the
circumstances. In reversing the decision of HHS, the court concluded that the
administrative law judge did not apply the proper meaning of stabilization and
therefore the proper standard for transfer and seriously erred in concluding
that anesthesiology was available.
   ACEP along with the American Medical Association and the American College
of Surgeons, filed an amicus curiae brief in support of Dr. Cherukuri.