## Facts

- Dr. Theodore Cherukuri, a general surgeon and on-call emergency-room physician at a small rural Kentucky hospital, treated five automobile-accident victims brought to the emergency department.
- Two patients had severe head injuries and internal abdominal bleeding.
- The hospital lacked a trauma center, lacked equipment to monitor brain function during anesthesia, and had a standing practice of transferring severe head-injury cases to a larger hospital with appropriate capabilities.
- Dr. Cherukuri determined the two patients needed immediate abdominal surgery for internal bleeding.
- The on-call anesthesiologist refused to administer anesthesia due to safety concerns and the hospital’s lack of brain-monitoring equipment for patients with severe head injury.
- Unable to secure anesthesia services, Dr. Cherukuri arranged transfer to a higher-level hospital in Huntington, West Virginia.
- Physicians at the receiving hospital initially advised against transfer, but later reported Dr. Cherukuri to HHS for an alleged EMTALA stabilization violation; at a later hearing they testified they no longer believed an EMTALA violation occurred.
- The record reflected no discriminatory motive or “patient dumping,” and the patients’ conditions did not deteriorate during transfer.

## Issues

1. Whether EMTALA required Dr. Cherukuri to perform abdominal surgery to “stabilize” the patients before transfer, despite the hospital’s limited resources and anesthesia refusal.
2. Whether the ALJ’s findings—especially that anesthesia was “available” and that internal-bleeding patients are not stabilized until surgery—were supported by substantial evidence and consistent with EMTALA’s statutory standard for stabilization during transfer.

## Decision

- The Sixth Circuit granted the petition for review and set aside the Secretary’s final decision finding an EMTALA violation.
- The court held Dr. Cherukuri did not violate EMTALA by transferring the patients under the circumstances.
- The court rejected the agency’s rigid approach equating “stabilization” with definitive surgical treatment and questioned treating anesthesia as “available” when the anesthesiologist refused to proceed for patient-safety reasons.

## Legal Principles

- EMTALA’s stabilization requirement focuses on whether, within reasonable medical probability, treatment has been provided so that no material deterioration is likely to occur during transfer; it does not necessarily require definitive treatment of the underlying condition before transfer.
- EMTALA should not be applied to force high-risk procedures at facilities lacking necessary equipment and support when transfer to a capable hospital is the safer option.
- Substantial-evidence review does not permit agency liability determinations grounded in inflexible medical generalizations that conflict with EMTALA’s transfer-focused stabilization standard and the practical realities of emergency care.
- Absent discriminatory motive, EMTALA is not a general malpractice or punitive statute against physicians acting in good faith amid institutional limitations.

## Conclusion

The Sixth Circuit vacated HHS’s EMTALA sanctions against Dr. Cherukuri, concluding that EMTALA required assessment of stabilization for transfer, not completion of definitive surgery, and that transferring critically injured patients to a better-equipped hospital was consistent with the statute when the originating hospital could not safely provide the needed care.


Cherukuri v. Shalala, 175 F.3d 446 (6th Cir. 1999)