This is the third installment of a three-part series.
Question: Based on case law, which of the following statements is most appropriate regarding EMTALA?
A. Prior to updated regulations, jurisdictions were divided as to whether the Emergency Medical Treatment and Labor Act (EMTALA) covered in-hospital patients.
B. CMS (Centers for Medicare & Medicaid Services) has since clarified that EMTALA does not apply to the in-hospital situation absent bad faith, and all courts now abide by this rule.
C. Stabilization and transfer refer only to moving a patient to another hospital or discharging a patient from the emergency department (ED).
D. Stabilization means a patient may never be transferred while unstable.
E. There is an EMTALA exception for futile treatment in the ED.
Answer: A.
Most cases under EMTALA, the federal anti-dumping statute, deal with the failure to screen or to stabilize patients presenting to the emergency department (ED) of a hospital. For a while, jurisdictions were split as to whether the EMTALA statute was equally applicable to inpatients. A typical case concerned Carol James, a renal-failure patient who complained that she developed an emergency vein-graft malfunction in the hospital but was discharged in violation of EMTALA. The condition was not stabilized before discharge, which caused her to have her hand amputated. However, the Ninth Circuit Court dismissed for failure to state a claim, reasoning that this federal statute could not be and was not based upon a claim of medical malpractice. The Court wrote: “Hospitals are often big buildings or complexes of multiple big buildings. It would make no sense for the authority of physicians proposing to transfer a patient from the eleventh floor of building III to be affected by whether a physician was physically present in the emergency room on the first floor of building I. Congress must have been contemplating patients who were in the emergency room …”1
In Dollard v. Allen,2 the Federal District Court in Wyoming addressed a claim brought by an employee of the defendant hospital alleging an EMTALA violation for an improper transfer. The claimant originally sustained a back injury while assisting a patient. Her pain became worse, and she was experiencing numbness in her buttocks for the first time. She went to the hospital and presented directly to the medical-surgical floor, bypassing both the ED and the admitting desk. Upon discharge, she was experienced increasing numbness and had to be readmitted with a large ruptured disk.
The defendant hospital moved for summary judgment on the basis that she never presented to the ED for examination in the first place. The Court ruled that EMTALA’s “stabilization before transfer” requirement does not apply to individuals that have been admitted to the hospital for inpatient care, reinforcing the rule that EMTALA’s limited purpose was to eliminate patient dumping and not to federalize medical malpractice. The court also held that she had failed to present any evidence that the hospital had actual knowledge of her emergency medical condition when it discharged her, as she had told the doctor that she was “okay,” “fine,” “comfortable,” and “ready to go home.” Under the statute, a plaintiff must first prove the hospital had actual knowledge of an individual’s unstabilized emergency medical condition to succeed on a claim.
On the other hand, in Thornton v. Southwest Detroit Hospital,3 the Sixth Circuit Court deemed the EMTALA stabilization requirement to extend to the inpatient situation. The patient had been in the hospital for an extended stay for treatment of a stroke before being discharged to home care, where her condition worsened. This was a 1990 case, but even after CMS’ revised rule in 2003 clarifying that EMTALA’s obligation ends upon hospital admission, the same Court chose to ignore the regulation. In Moses v. Providence Hospital and Medical Center,4 a hospitalized psychotic patient was discharged in an arguably unstabilized condition and went on to murder his wife some 10 days later. The Sixth Circuit Court ruled that EMTALA was nonetheless applicable.
Litigation over transfer propriety does not always involve another hospital. For example, in Carlisle v. Frisbie Memorial Hospital,5 an intoxicated and suicidal ED patient refused to see a psychiatrist and was handed over to the police and sent to jail. The court ruled that the hospital was in violation of EMTALA by failing to stabilize the patient prior to “transfer.”
Under EMTALA, an unstable patient may still be transferred so long as certain criteria are met, principally if the original hospital lacks the facilities to provide proper treatment, and the benefits of a transfer outweigh the risks. In Cherukuri v. Shalala,6 Dr. Cherukuri, a surgeon, faced suspension of his license and a civil penalty of $100,000 for allegedly violating the stabilization language of EMTALA. He had transferred two patients with head injuries to the trauma center at St. Mary’s Hospital in Huntington without first stopping intra-abdominal hemorrhage and before receiving express consent from the receiving institution. The patients were victims of an auto accident and were initially brought by ambulance in the early morning hours to Williamson Hospital, a small rural hospital in south Williamson, Kentucky, which had no trauma center and no equipment for neuro-monitoring during anesthesia.
Dr. Cherukuri was the on-call ED surgeon that night. An expert testified that stabilization of internal bleeding required an abdominal operation by the surgeon prior to transfer. Dr. Cherukuri was initially found liable, based on the legal conclusion that he “knew or should have known that the benefits [of transfer] did not outweigh the risks.” However, it was undisputed that the condition of the two patients did not deteriorate during transfer. On appeal, the Sixth Circuit Court reversed, finding that Dr. Cherukuri sufficiently stabilized the two patients to permit transfer and alternatively, that he did not have an anesthesiologist available in order for him to operate.
Probably the most unusual and unexpected challenge to EMTALA faced the Fourth Circuit Court when Baby K, an anencephalic infant, presented repeatedly to a hospital ED with respiratory distress.7 Her physicians and the hospital had petitioned withdrawal of ventilator support, arguing that a requirement to provide respiratory assistance would exceed the prevailing standard of medical care, i.e., provision of warmth, nutrition and hydration, because any treatment of the baby’s condition was futile. The baby’s mother however, insisted that respirator care must be continued, invoking the hospital’s obligations under EMTALA’s stabilization requirement. Citing the statute, the Court ruled that EMTALA required all EDs to provide treatment necessary to prevent the material deterioration of the individual’s condition, and that the statute does not contain a “standard of care” exception. The Court wrote: “We recognize the dilemma facing physicians who are requested to provide treatment they consider morally and ethically inappropriate, but we cannot ignore the plain language of the statute because to do so would transcend our judicial function …”
References
1. James v. Sunrise Hospital, 86 F.3d 885 (9th Cir. 1996) .
2. Dollard v. Allen, 260 F. Supp. 2d 1127 (D. Wyo. 2003) .
3. Thornton v. Southwest Detroit Hospital, 895 F.2d 1131 (6th Cir. 1990) .
4. Moses v. Providence Hospital and Medical Center, 561 F.3d 573 (6th Cir. 2009) .
5. Carlisle v. Frisbie Memorial Hospital, 888 A.2d 405 (N.H. 2005) .
6. Cherukuri v. Shalala, 175 F.3d 446 (6th Cir. 1999) .
7. In re Baby K, 16 F.3d 590 (4th Cir. 1994) .
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu.
