United States Court of Appeals
For the First Circuit
____________________
No. 99-2153
CINDY REYNOLDS, INDIVIDUALLY, AND AS
PERSONAL REPRESENTATIVE OF THE ESTATE
OF WILLIAM D. REYNOLDS; TINA MOORE, AS NEXT
FRIEND OF KELLIANN RAE REYNOLDS, A MINOR;
Plaintiffs, Appellants,
v.
MAINEGENERAL HEALTH,
Defendant, Appellee.
____________________
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MAINE
[Hon. Eugene W. Beaulieu, U.S. Magistrate Judge]
____________________
Before
Torruella, Chief Judge,
Lipez, Circuit Judge,
and Keeton,* District Judge.
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Joseph M. Jabar, with whom Daviau, Jabar & Batten and David M.
Glasser were on brief, for appellants.
George C. Schelling, with whom Gross, Minsky, Mogul & Singal, P.A.
was on brief, for appellee.
* Of the District of Massachusetts, sitting by designation.
____________________
July 17, 2000
____________________
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KEETON, District Judge. This appeal requires us to interpret
the scope of coverage under the Emergency Medical Treatment and Active
Labor Act (EMTALA), 42 U.S.C. § 1395dd, for secondary risks associated
with emergency conditions. After reviewing the record in light of the
statutory scheme, we affirm the district court's summary judgment in
favor of defendant-appellee MaineGeneral Health.
I. The Facts
Because we are reviewing the district court's summary
judgment in favor of defendant-appellee, we recite the facts in the
light most favorable to the plaintiffs-appellants. See Fed. R. Civ. P.
56.
On September 8, 1996, William D. Reynolds was driving a car
that collided head-on with another vehicle. As a result of the
accident, Mr. Reynolds suffered various injuries including several
fractures of bones in his lower right leg and left foot. Mr. Reynolds
was taken immediately by ambulance from the accident scene to the
emergency room of Kennebec Valley Medical Center (now known as the
MaineGeneral Medical Center and referred to throughout this opinion for
convenience as "MaineGeneral" or the "hospital"). After an emergency
room nurse had triaged Mr. Reynolds, he was examined by Dr. Harry
Grimmnitz, the emergency room physician. Dr. Grimmnitz evaluated Mr.
Reynolds, took an oral medical history, and ordered a series of
laboratory tests, x-rays, and an abdominal CT scan. After considering
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this information, Dr. Grimmnitz determined that Mr. Reynolds suffered
from multiple trauma to his lower right leg, including a probable open
fracture of the right tibia and fibula and possible fracture of the
left foot, and from a possible intra-abdominal injury.
Dr. Grimmnitz then requested consultations from Dr. Alexander
Wall, a surgeon, and Dr. Anthony Mancini, an orthopedic surgeon. Dr.
Wall reported slight right upper quadrant tenderness with a negative CT
scan of the abdomen. Dr. Mancini examined Mr. Reynolds in the
emergency room and took another oral medical history. Dr. Mancini
determined that the injuries to Mr. Reynolds' lower extremities
required surgery. Mr. Reynolds was transferred to the operating room
where Dr. Mancini performed a closed reduction and intramedullary
rodding of the right tibia fracture and a closed reduction and
percutaneous pinning of the left second, third, and fourth metatarsal
neck and head fractures. Following surgery, Mr. Reynolds was admitted
to the hospital floor, where the hospital staff monitored his condition
and he began receiving physical therapy.
On September 13, 1996, Mr. Reynolds was returned to the
operating room for closure of his right lower leg wound. On September
14, 1996, he was discharged from the hospital. On September 19, 1996,
he died of a massive pulmonary embolism that emanated from deep veinous
thrombosis ("DVT") at the fracture site on his right leg.
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Plaintiffs proffered the affidavit of Mr. Reynolds' mother-
in-law, Shirley Kimball, who was in the emergency room at MaineGeneral
after the accident but before Mr. Reynolds had surgery. Ms. Kimball
states that she saw a man in a white lab coat ask Mr. Reynolds if he
had any allergies or medical problems of which the hospital should be
aware. Ms. Kimball alleges that Mr. Reynolds told the man "that his
family had a blood clotting problem on his father's and brothers' side
of the family whenever they had a trauma." Appendix to Appellants'
Brief at 130.
Plaintiffs proffered the affidavits of several family
members, each of whom alleges that he or she told a MaineGeneral
employee in the hospital room after Mr. Reynolds underwent surgery that
Mr. Reynolds had a family history of hypercoagulability.
II. Procedural Background
On September 8, 1998, plaintiff-appellant Cindy Reynolds,
widow of the decedent William D. Reynolds, filed a complaint in the
United States District Court for the District of Maine in her personal
capacity and as the personal representative of the Estate of the
decedent. Mr. Reynolds' minor daughter, Kelliann Reynolds, is also a
plaintiff-appellant. The complaint alleged that Mr. Reynolds presented
to the emergency department at MaineGeneral on September 8, 1996, with
an emergency medical condition as defined by EMTALA, 42 U.S.C. §
1395dd(e)(1); that MaineGeneral failed to screen Mr. Reynolds
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appropriately for DVT, as required under 42 U.S.C. § 1395dd(a); and
that MaineGeneral failed to stabilize Mr. Reynolds for DVT before
releasing him on September 14, 1996, thus violating the requirements of
42 U.S.C § 1395dd(b).
In a memorandum of decision dated September 8, 1999,
Magistrate Judge Beaulieu granted defendant-appellee's motion for
summary judgment, having concluded that the facts did not support a
federal claim for failure to screen under EMTALA even though they
supported a state-law claim for negligent diagnosis and treatment.
Magistrate Judge Beaulieu further held that plaintiffs' claim for
failure to stabilize fails as a matter of law because the hospital was
not aware that Mr. Reynolds was suffering from DVT. Plaintiffs filed
their notice of appeal to this court on October 6, 1999.
III. Merits of the Appeal
A. Screening Claim
At issue in this case is the precise scope of a participating
hospital's duty to screen for risks or related conditions associated
with or aggravated by an emergency medical condition. In this
instance, MaineGeneral does not dispute that William Reynolds suffered
from an emergency medical condition at the time he arrived in the
emergency room. The parties agree that the injuries to Mr. Reynolds'
lower extremities constituted an emergency medical condition requiring
appropriate screening and stabilization before discharge or transfer.
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In dispute is the answer to the following question: Does the increased
risk of DVT associated with this type of injury, combined with Mr.
Reynolds' family history of hypercoagulability, trigger a duty to
screen for DVT?
Appellants argue that the risk of DVT constituted a discrete
"emergency medical condition," which required screening and
stabilization under EMTALA, just as the fractures of the lower
extremities required screening and stabilization. Appellee contends
that the increased risk of DVT was not an "emergency medical condition"
within the meaning of EMTALA and did not require particularized
screening or stabilization. Appellee argues generally that risks and
conditions associated with or following from emergency medical
conditions that do not constitute independent "emergency medical
conditions" within the meaning of EMTALA will not fall within the
requirements of EMTALA. In evaluating these arguments, we consider
three analytically separable propositions.
First. Appellants' first argument is premised on a meaning
of "symptom" that we cannot accept. Appellants argue that summary
judgment was not appropriate because Mr. Reynolds was exhibiting
symptoms of an emergency medical condition – DVT – when he came to the
emergency room. Appellants contend that this court should interpret
the word "symptom" in EMTALA's definition of "emergency medical
condition" to include any evidence or communication of information that
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an emergency medical condition may exist. Appellants allege first that
injuries to the lower extremities such as those suffered by Mr.
Reynolds create a substantial risk of the development of DVT. They
contend that the knowledge that Mr. Reynolds' injuries indicated a risk
of DVT should be construed as a "symptom" under EMTALA, warranting
further screening and stabilization. Appellants argue alternatively
that Mr. Reynolds' alleged statement that he had a family history of
hypercoagulability, combined with the particular injuries, constituted
a "symptom" of an emergency medical condition. The hospital's failure
to screen when confronted with these symptoms of DVT, appellants aver,
violates EMTALA's screening requirement.
Appellants' proposed interpretation of "symptoms" is contrary
to ordinary usage, not supported by statutory text or purpose, and not
supported in caselaw.
EMTALA defines "emergency medical condition" as follows, in
pertinent part:
(A) a medical condition manifesting itself by acute symptoms
of sufficient severity (including severe pain) such that the
absence of immediate medical attention could reasonably be
expected to result in–
(i) placing the health of the individual . . . in
serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part
. . . .
42 U.S.C. § 1395dd(e)(1). Appellee argues that information about
family history provided by a patient, without any accompanying
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psychological or physiological symptoms, cannot reasonably be
understood to be an "acute symptom[] of sufficient severity" that is
"manifest[ed]" by a "medical condition."
We need not and do not adopt this more circuitous path of
reasoning instead of the direct inference that the words of the
statute, in their literal context, do not support appellants' proposed
meanings of "symptoms."
Caselaw provides no clear answer to the issue of statutory
interpretation before us.
A patient who communicates that she feels nauseous or dizzy
could be describing a symptom of an emergency medical condition. See
Correa v. Hospital San Francisco, 69 F.3d 1184, 1192 (1st Cir. 1995)
("[N]ausea and dizziness ... might well herald the onset of an
emergency medical condition in the case of a hypertensive diabetic.").
In such a case the condition manifests itself by the dizziness or
nausea, a symptom that is then communicated verbally by the patient.
Information about risk-factors, such as injuries or medical history,
would inform a physician's interpretation of that symptom. Nausea and
dizziness alone do not necessarily indicate that an emergency medical
condition exists but, when coupled with a history of hypertension and
diabetes, as in Correa, may indicate the presence of an emergency
medical condition. Several important differences exist, however,
between the facts of this case and those of Correa. First, the patient
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in Correa was at the time of the examination experiencing physiological
symptoms of a pathological condition, symptoms that were communicated
to the staff of the emergency department. Here, Mr. Reynolds was not
experiencing any physiological symptoms of DVT that he expressed to
anyone at MaineGeneral. Also, the patient in Correa came to the
emergency room complaining of these symptoms and received no screening
or treatment for any condition that she may have had. Here,
Mr. Reynolds was brought to the emergency room with significant trauma
to his lower legs for which he received extensive screening and
treatment. Although appellants ask us to accept as compelling an
analogy between the absence of any screening and treatment in Correa
and the lack of screening and treatment for DVT here, we find this
argument unpersuasive.
Second. Appellants claim that a court (including this court)
should hold in this case that, for purposes of applying EMTALA's
screening requirement, Mr. Reynolds came to the emergency department
twice.
Appellants cite López-Soto v. Hawayek, 175 F.3d 170 (1st Cir.
1999), to support the proposition that the duty to screen does not
arise only at the moment a patient first comes to the emergency room,
but may arise later in the face of new information or changed
circumstances. Appellants materially misread this court's holding in
López-Soto. The circumstances in López-Soto involved a woman who came
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to the hospital to deliver her baby and was admitted to the maternity
ward. Problems developed during delivery and the child was born in
severe respiratory distress and later died after being transferred to
a different hospital. Defendant in López-Soto argued that the infant
did not "[come] to the emergency room" and that the hospital,
therefore, was not under an obligation to stabilize his emergency
medical condition before transferring him to another hospital. In
ruling against defendant, this court determined that subsection (a) and
subsection (b) of 42 U.S.C. § 1395dd are to be read disjunctively. See
id. at 173. That is, the phrase "comes to the emergency room" relates
only to the duty to screen embodied in subsection (a). Subsection (b),
on the other hand, provides that if any individual "comes to a
hospital" and the hospital determines that the individual has an
emergency medical condition, the hospital has a duty to stabilize that
condition. In López-Soto the court concluded that the duty to
stabilize before transfer attaches "as long as an individual enters any
part of the hospital and the hospital determines that an emergency
medical condition exists." Id. at 174 (citation omitted). Because the
court clearly distinguished the requirements imposed by subsection (a),
which are triggered by a patient's coming to the emergency department,
from those imposed by subsections (b) and (c), which are triggered by
a patient's coming to the hospital, appellants' reliance on López-Soto
is misplaced.
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Appellants try a somewhat different, but related, tack in
arguing that the hospital room should be treated as the functional
equivalent of the emergency department for purposes of this case.
Appellants acknowledge that the need to treat immediately the traumatic
injuries to Mr. Reynolds' lower extremities postponed full screening
for and treatment of DVT until after Mr. Reynolds' traumatic injuries
had been treated. Appellants also note that Mr. Reynolds may not have
had DVT when he first arrived at MaineGeneral, but may have developed
DVT while at the hospital. They propose that because of these
circumstances, the duty to screen should be tolled, in effect, until
after the traumatic injuries had been treated and clotting was more
likely to have begun. Appellants argue that it would be unreasonable
for this court to interpret 42 U.S.C. § 1395dd(a) in a way that
requires Mr. Reynolds to leave the hospital and reenter the emergency
room a second time in order to receive screening and treatment for
potential DVT. Not only does the text of the statute fail to support
appellants' contention, but neither does the purpose of the statute as
manifested by Congress.
As numerous courts have noted, including this one, "EMTALA
is a limited 'anti-dumping' statute, not a federal malpractice
statute." Bryan v. Rectors and Visitors of the Univ. of Va., 95 F.3d
349, 351 (4th Cir. 1996) (citation omitted); see Correa, supra, 69 F.3d
at 1192; Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1137
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(8th Cir. 1996) ("So far as we can tell, every court that has
considered EMTALA has disclaimed any notion that it creates a general
federal cause of action for medical malpractice in emergency rooms.");
Urban v. King, 43 F.3d 523, 525 (10th Cir. 1994). Congress enacted
EMTALA in 1996, in the face of "the increasing number of reports that
hospital emergency rooms are refusing to accept or treat patients with
emergency conditions if the patient does not have medical insurance."
H.R. Rep. No. 241(I), 99th Cong., 1st Sess. 27 (1986), reprinted in
1986 U.S.C.C.A.N. 42, 605. EMTALA created a remedy for patients in
certain contexts in which a claim under state medical malpractice law
was not available. Although the exact scope of the rights guaranteed
to patients by EMTALA is still not fully defined, it is clear that at
a minimum Congress manifested an intent that all patients be treated
fairly when they arrive in the emergency department of a participating
hospital and that all patients who need some treatment will get a first
response at minimum and will not simply be turned away. See Baber v.
Hospital Corp. of America, 977 F.2d 872, 880 (4th Cir. 1992) ("The
avowed purpose of EMTALA was not to guarantee that all patients are
properly diagnosed, or even to ensure that they receive adequate care,
but instead to provide an 'adequate first response to a medical crisis'
for all patients and 'send a clear signal to the hospital community .
. . that all Americans, regardless of wealth or status, should know
that a hospital will provide what services it can when they are truly
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in physical distress.'") ( quoting 131 Cong. Rec. S13904 (Oct. 23, 1985)
(statement of Sen. Durenberger)). Appellants' argument that because
Mr. Reynolds was in a hospital room receiving treatment for his
injuries when the risk of DVT became manifest, it would be unreasonable
to deny him the protections of subsection (a) is unpersuasive. The
fact that Mr. Reynolds was in the hospital receiving treatment is a
prima facie showing that the purpose of subsection (a) was satisfied;
any failures of diagnosis or treatment were then remediable under state
medical malpractice law.
Third. Appellants argue that MaineGeneral screened
Mr. Reynolds differently than it did other patients exhibiting similar
symptoms. Appellants contend that a complete medical history, under
MaineGeneral's hospital policy, includes questioning patients
concerning any family history of hypercoagulability. They aver that
because Mr. Reynolds was not asked questions about his family history
of blood-clotting, he received disparate treatment.
Appellants proffered evidence that MaineGeneral's only
written policy regarding the taking of medical histories from patients
required that a "complete history" be taken from all patients.
Appellants proffered expert testimony to support the proposition that
a "complete history" in Mr. Reynolds' context necessarily included
asking questions about any family history of hypercoagulability.
Appellants aver that this expert testimony, in conjunction with the
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absence of any more detailed hospital policies, compels an inference
that MaineGeneral gave disparate treatment to Mr. Reynolds when it did
not ask him questions concerning his family history of
hypercoagulability.
Appellants' argument attempts again to bring a malpractice
standard into the interpretation and application of a statute designed
to complement and not incorporate state malpractice law. To recover
for disparate treatment, appellants must proffer evidence sufficient to
support a finding that Mr. Reynolds received materially different
screening than that provided to others in his condition. It is not
enough to proffer expert testimony as to what treatment should have
been provided to a patient in Mr. Reynolds' condition. Appellants have
not proffered evidence sufficient to support a finding that
Mr. Reynolds received materially different screening than did other
patients in his condition.
Insofar as appellants are continuing to make a general case
for interpreting EMTALA as providing a federal-law remedy for any
inappropriate treatment in a hospital to which a patient in need of
emergency attention is brought, this attempt fails for the reasons
explained above. In Correa, this court recognized appropriate
emergency screening as the EMTALA objective and sketched out the
contours of appropriate screening under EMTALA:
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A hospital fulfills its statutory duty to screen patients in
its emergency room if it provides for a screening
examination reasonably calculated to identify critical
medical conditions that may be afflicting symptomatic
patients and provides that level of screening uniformly to
all those who present substantially similar complaints. . .
. The essence of this requirement is that there be some
screening procedure, and that it be administered even-
handedly.
Correa, 69 F.3d at 1192 (emphasis added) (internal citations omitted).
Because we conclude, based on the record before us, that appellants
failed to proffer evidence sufficient to support a finding that Mr.
Reynolds was "symptomatic" for DVT, within the meaning of the statute,
the hospital was not required under the statute to screen for DVT.
B. Stabilization Claim
In addition to their claim for failure to screen Mr. Reynolds
appropriately for DVT, appellants argue that a genuine dispute of
material fact exists as to whether MaineGeneral stabilized Mr. Reynolds
for DVT before releasing him. Appellants argue extensively about the
nature of the stabilization requirements under EMTALA in support of
their contention that Mr. Reynolds was not stabilized before release.
A critical flaw in this claim of appellants under § 1395dd(b)(1),
however, is that appellants have failed to demonstrate that Mr.
Reynolds had an emergency medical condition at the time of his
discharge from MaineGeneral.
As a corollary to the right to be appropriately screened,
EMTALA guarantees patients the right, if an emergency medical condition
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is determined to exist, to have that condition stabilized before
discharge or transfer to another hospital. The statute provides, in
pertinent part:
If any individual . . . comes to a hospital and the hospital
determines that the individual has an emergency medical
condition, the hospital must provide either–
(A) within the staff and facilities available at the
hospital, for such further medical examination and such
treatment as may be required to stabilize the medical
condition, or
(B) for transfer of the individual to another medical
facility in accordance with subsection (c).
42 U.S.C. § 1395dd(b)(1) (emphasis added). This court need not reach
any questions about the nature of stabilization if we determine that
the predicates to stabilization have not been satisfied. Appellants
proffered expert testimony that it was likely that the clot that later
became the pulmonary embolism that caused Mr. Reynolds' death formed
before Mr. Reynolds was discharged from MaineGeneral. Appellants'
expert further testified that a 17 to 30% likelihood existed that Mr.
Reynolds had formed blood clots at the time of his discharge.
Appellants' expert also proffered testimony that some research
indicates a 2% mortality rate in cases of untreated DVT. Evidence of
one expert that it is more likely than not in his opinion that the
blood clot that eventually caused Mr. Reynolds' death had formed by the
time of his discharge, combined with the evidence that 2% of untreated
DVT cases result in death, is not sufficient to support a determination
that Mr. Reynolds had an emergency medical condition at the time of his
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discharge. To invoke subsection (b), appellants must proffer more than
evidence of a possibility of the existence of a blood clot at the time
of Mr. Reynolds' discharge. They must proffer evidence sufficient to
support a finding, reasoned from evidence, that an emergency medical
condition, within the meaning of the statute, was already in existence
at the time of Mr. Reynolds' discharge. Appellants have not proffered
evidence sufficient to support a finding that Mr. Reynolds had an
emergency medical condition at that time, and for this reason have
failed to satisfy a necessary predicate to the duty to stabilize.
Furthermore, as noted by Magistrate Judge Beaulieu,
appellants' case is centered on the asserted fact that MaineGeneral did
not take steps to determine whether Mr. Reynolds was at risk of
developing DVT. It is doubtful that the text of the statute would
support liability under the stabilization provision for a patient who
had DVT, absent evidence sufficient to support a finding that the
hospital knew of his DVT. See Marshall v. East Carroll Parish Hosp.
Serv. Dist., 134 F.3d 319, 325 (5th Cir. 1998); Summers, supra, 91 F.3d
at 1140 (no duty to stabilize unless hospital "has actual knowledge of
the individual's unstabilized emergency medical condition"); Vickers v.
Nash Gen. Hosp., Inc., 78 F.3d 139, 145 (4th Cir. 1996) ("The Act does
not hold hospitals accountable for failing to stabilize conditions of
which they are not aware, or even conditions of which they should have
been aware."). It appears quite likely that one important respect in
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which EMTALA's requirements are narrower than those imposed by state
law concerns prophylactic care. Subsection (b) requires stabilization
of only those conditions that a participating hospital has determined
to be emergencies. It may be that in exceptional circumstances of
proof of an existing emergency need for immediate stabilization, a
hospital would have a duty of stabilization under EMTALA. We need not
and do not reach that issue, however, since it is not presented by the
record before us in this case.
IV. Conclusion
Because appellants' claims essentially are claims that
MaineGeneral misdiagnosed and negligently treated William Reynolds, we
believe the district court appropriately granted defendant's motion for
summary judgment on plaintiffs' EMTALA claims. For the reasons stated
in this opinion, the judgment of the district court is AFFIRMED.
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