United States Court of Appeals
For the First Circuit
No. 04-2375
EDGARDO JOSE CRUZ-QUEIPO; MARIA ISABEL PUIG-SANCHEZ; CONJUGAL
PARTNERSHIP CRUZ-PUIG,
Plaintiffs, Appellants,
v.
HOSPITAL ESPAÑOL AUXILIO MUTUO DE PUERTO RICO,
Defendant, Appellee;
AMERICAN INTERNATIONAL INSURANCE CO., a/k/a AIICO,
Defendant.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Jay A. García-Gregory, U.S. District Judge]
Before
Torruella, Lynch, and Lipez, Circuit Judges.
Rafael G. Martínez-Géigel, with whom Emilio E. Solé de la Paz
was on brief, for appellant.
Carlos E. Umpierre-Schuck, with whom Juan A. Pedrero-Lozada
was on brief, for appellee.
July 27, 2005
LIPEZ, Circuit Judge. This case tests the scope of
hospital liability under the Emergency Medical Treatment and Active
Labor Act (EMTALA), 42 U.S.C. § 1395dd. EMTALA requires a hospital
to even-handedly administer an appropriate screening procedure to
all emergency room patients and, if it determines that an emergency
medical condition exists, to stabilize the patient's condition
before discharge or transfer to another hospital. See id.
Asserting that Hospital Español Auxilio Mutuo de Puerto Rico
(Auxilio Mutuo) did not comply with its own protocol in screening
Edgardo Cruz-Queipo (Cruz) and that it failed to stabilize him
prior to discharge, the plaintiffs appeal a grant of summary
judgment against them. For the reasons set forth below, we vacate
the district court's grant of summary judgment on both the
screening and stabilization claims and remand for further
proceedings.
I.
In reviewing a grant of summary judgment, we view the
record in the light most favorable to the nonmovant. See Del
Carmen Guadalupe v. Negron Agosto, 299 F.3d 15, 17 (1st Cir. 2002).
Accordingly, we draw the following facts from the summary judgment
record, "indulging all reasonable inferences in [the plaintiffs']
favor." Griggs-Ryan v. Smith, 904 F.2d 112, 115 (1st Cir. 1990).
At approximately 4 p.m. on August 31, 2001, Cruz visited
the Auxilio Mutuo emergency room complaining of pain in his chest,
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arm, and wrist. Pursuant to Auxilio Mutuo's written policy,
emergency room patients receive a screening examination upon
arrival to determine the severity of their conditions and are then
classified in one of four categories. Category I encompasses the
most serious conditions, including acute chest pain with unstable
vital signs, and Categories II, III, and IV encompass progressively
less serious conditions. Triage officer Dr. Miguel Rodríguez
performed an initial screening evaluation of Cruz pursuant to
Auxilio Mutuo's policy. After checking Cruz's vital signs and
noting that Cruz complained of pain in his left arm and warmth in
his wrist, Dr. Rodríguez placed Cruz in Category IV, which includes
back and muscle pain. Notes from the screening examination do not
indicate that Cruz complained of chest pain. For purposes of
summary judgment, however, we must credit Cruz's assertion that he
did, in fact, report such pain, and, drawing all reasonable
inferences in Cruz's favor, we must assume that the emergency room
doctors were aware of the chest pain.
A second physician, Dr. James Davison, performed a more
thorough examination of Cruz at approximately 5:30 p.m. Like Dr.
Rodríguez, Dr. Davison did not document a complaint of chest pain.
Finding that Cruz suffered from shoulder pain, however, Dr. Davison
ordered an electrocardiogram (EKG) and a cervical spinal x-ray. He
interpreted the results of both tests as negative. Based on his
examination and the test results, Dr. Davison diagnosed Cruz with
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thoracic outlet syndrome, a non-emergency disorder that involves
the compression of blood vessels and nerves in the shoulder region.
See National Institute of Neurological Disorders and Stroke,
Thoracic Outlet Syndrome Information Page, at
http://www.ninds.nih.gov/disorders/thoracic/thoracic.htm (last
visited July 20, 2005). Dr. Davison prescribed Celebrex (an anti-
inflammatory) and Clonazepan (an anti-convulsant) and discharged
Cruz, encouraging him to follow up with a specialist.
The following day (September 1, 2001), Cruz returned to the
Auxilio Mutuo emergency room with severe chest pain radiating to
his left arm and jaw. Doctors determined that Cruz had suffered an
acute myocardial infarction (heart attack). He was admitted to the
coronary care unit, where he remained for approximately one week
before being transferred to another hospital where he underwent
sextuple bypass surgery. As a result of the infarction, Cruz
suffered permanent damage to his heart, including scarring and
decreased cardiac performance.
On October 2, 2002, the plaintiffs -- Cruz; his wife, Maria
Isabel Puig-Sanchez; and their conjugal partnership -- filed a
complaint against Auxilio Mutuo and American International
Insurance Company,1 charging violations of EMTALA. Specifically,
1
American International Insurance Company was dismissed as a
defendant on April 7, 2003 pursuant to an unopposed motion for
summary judgment on the grounds that it "did not have in effect an
insurance policy for Hospital Español Auxilio Mutuo covering the
damages claimed in the complaint."
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the plaintiffs asserted that Cruz had been suffering from acute
coronary syndrome during his August 31 hospital visit and that
hospital personnel failed to properly screen and stabilize him.
The plaintiffs also contended that these deficiencies led to the
permanent damage that Cruz suffered as a result of his heart attack
on September 1. After the close of discovery, Auxilio Mutuo filed
a motion for summary judgment on the grounds that the plaintiffs
failed to state a claim under EMTALA. It argued that Cruz had been
given an appropriate medical screening, that he was subjected to
the same procedures used for every patient who visits the emergency
room, that the August 31 visit did not implicate EMTALA's
stabilization requirement because the hospital did not detect an
emergency medical condition, and that there was no causal
relationship between the damages alleged and the purported EMTALA
violation. Over the plaintiffs' vigorous objections, the district
court granted Auxilio Mutuo's motion, finding that the plaintiffs'
claims "are more suited to a medical malpractice claim."2 The
plaintiffs appeal from this decision.
II.
We review the grant of summary judgment de novo. Littlefield
v. Acadia Ins. Co., 392 F.3d 1, 6 (1st Cir. 2004). Summary
judgment is appropriate where "the pleadings, depositions, answers
2
The plaintiffs filed a separate malpractice suit in the
Puerto Rico courts.
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to interrogatories, and admissions on file, together with the
affidavits, if any, show that there is no genuine issue as to any
material fact and that the moving party is entitled to a judgment
as a matter of law." Fed. R. Civ. P. 56(c).
A. The EMTALA statutory scheme
Congress enacted EMTALA in response to "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." Correa v. Hosp. San Francisco, 69 F.3d
1184, 1189 (1st Cir. 1995) (internal quotation marks omitted).
EMTALA imposes two primary requirements on participating
hospitals:3
First, it requires that a participating hospital afford
an appropriate medical screening to all persons who come
to its emergency room seeking medical assistance. See 42
U.S.C. § 1395dd(a). Second, it requires that, if an
emergency medical condition exists, the participating
hospital must render the services that are necessary to
stabilize the patient's condition, see id.
§ 1395dd(b)(1)(A) . . . .
Id. at 1190. As an enforcement mechanism for these requirements,
EMTALA creates a private right of action for violations. See 42
U.S.C. §§ 1395dd(d)(1), (2).
3
EMTALA defines a participating hospital as a "hospital that
has entered into a provider agreement under section 1395cc of this
title." 42 U.S.C. § 1395dd(e)(2). Neither side disputes that
Auxilio Mutuo is a participating hospital.
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B. EMTALA screening claim
Although EMTALA does not define an "appropriate medical
screening examination," our circuit law does:
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.
Correa, 69 F.3d at 1192. "The essence of this requirement is that
there be some screening procedure, and that it be administered
even-handedly." Id. When a hospital prescribes internal
procedures for a screening examination, those internal procedures
"set the parameters for an appropriate screening." Id.4 A
hospital thus must adhere to its own procedures in administering
the screening examination.
The plaintiffs do not dispute that Cruz received a screening
examination, nor do they contend that Auxilio Mutuo's screening
protocol was per se inappropriate. Rather, they argue that the
hospital failed to follow its own protocol when it placed Cruz in
4
This is the view of other circuits as well. See, e.g.,
Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1138 (8th
Cir. 1996) ("It is up to the hospital itself to determine what its
screening procedures will be. Having done so, it must apply them
alike to all patients."); Baber v. Hosp. Corp. of Am., 977 F.2d
872, 878 & 879 n.7 (4th Cir. 1992) ("EMTALA only requires hospitals
to apply their standard screening procedure for identification of
an emergency medical condition uniformly to all patients.").
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Category IV despite his complaint of chest pains that should have
placed him in Category II (acute chest pain with stable vital
signs), and that this departure from hospital protocol violated
EMTALA's appropriate screening requirement.5 In short, they
challenge the district court's conclusion that they "have no claim
under EMTALA" because "Cruz was screened and evaluated according to
Auxilio Mutuo protocol." There is more to this challenge than may
initially meet the eye.
In its brief, Auxilio Mutuo devotes a great deal of attention
to the aspects of its triage protocol that were followed in this
case. It points out that Cruz was examined and placed in a triage
category upon his appearance in the emergency room, and that he was
subsequently evaluated by the emergency room physician. Auxilio
Mutuo asserts that Cruz's screening therefore did not deviate from
the standard hospital protocol and that, at bottom, the plaintiffs'
claim is really one of medical malpractice rather than of an EMTALA
violation. See id. at 1192-93 ("EMTALA does not create a cause of
action for medical malpractice. Therefore, a refusal to follow
regular screening procedures in a particular instance contravenes
the statute, but faulty screening, in a particular case, as opposed
5
Plaintiffs contend that Cruz should have been placed in
either Category I or II, emphasizing that both categories include
acute chest pain. Category I, however, applies specifically to
acute chest pain with unstable vital signs. The triage officer
determined that Cruz's vital signs were stable, and Cruz does not
dispute that determination. Therefore, he did not meet the
requirements for Category I.
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to disparate screening or refusing to screen at all, does not
contravene the statute." (internal citations omitted)).
Auxilio Mutuo's reasoning overlooks one key factor -- namely,
our inference, for purposes of summary judgment, that emergency
room doctors were aware that Cruz was suffering from chest pain.
Under Auxilio Mutuo's written triage policy, a patient with stable
vital signs who complains of chest pain must be assigned to triage
Category II. Indeed, the hospital conceded in its motion for
summary judgment that, under its own standards, "[i]f the patient
[had] referred a complaint of chest pains, he would have been
placed in Category I or II with an emergency condition." Cruz's
placement in Category IV despite a complaint of chest pains thus
marked a departure from the hospital's standards, which "set the
parameters for an appropriate screening." Id. at 1193; see also
id. ("under EMTALA § 1395dd(a), the same screening examination must
be made available to all similarly situated patients").
Accordingly, Auxilio Mutuo is not entitled to summary judgment on
the plaintiffs' claim that Cruz was denied an appropriate screening
in violation of EMTALA.
C. EMTALA stabilization claim
The plaintiffs also assert a claim under EMTALA's
stabilization requirement, which provides that
[i]f any individual . . . comes to a hospital and the
hospital determines that the individual has an emergency
medical condition, the hospital must provide . . .
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(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.
42 U.S.C. § 1395dd(b)(1)(A). The statute defines an emergency
medical condition (for an individual not in active labor) as
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.
Id. § 1395dd(e)(1)(A).
In support of their stabilization claim, the plaintiffs point
to Auxilio Mutuo's acknowledgment, in its motion for summary
judgment, that "[i]f the patient [had] referred a complaint of
chest pains, he would have [had] . . . an emergency condition,
[and] therefore the hospital [would have been] obliged to stabilize
the patient." Emphasizing this concession, the plaintiffs assert
that if we accept that Cruz complained of chest pains during his
August 31 visit, we must also conclude that the hospital had a duty
to stabilize the heart condition that culminated in a heart attack
on September 1. We agree.
At this stage of the proceedings, as we have already
explained, we must draw the inference that the hospital knew that
Cruz was suffering from chest pain. By its own admission, then,
the hospital also knew that Cruz was suffering from an emergency
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medical condition and had a duty to stabilize that condition.
Auxilio Mutuo therefore was not entitled to summary judgment on the
plaintiffs' stabilization claim.6
III.
Although a jury ultimately may determine that the hospital's
treatment of Cruz did not violate EMTALA, the summary judgment
record, viewed in the light most favorable to the plaintiffs, does
not permit that conclusion as a matter of law. In light of Cruz's
claim that he complained of chest pain during his August 31 visit
to the emergency room and the hospital's concession regarding its
own standards for handling such a complaint, we must vacate the
grant of summary judgment to Auxilio Mutuo and remand to the
6
Auxilio Mutuo also asserts that it is entitled to summary
judgment on the ground that "there is no causal relation[ship]
between the damages alleged and the purported EMTALA violation."
See 42 U.S.C. § 1395dd(d)(2)(A) ("Any individual who suffers
personal harm as a direct result of a participating hospital's
violation of a requirement of [EMTALA] may, in a civil action
against the participating hospital, obtain those damages available
for personal injury under the law of the State in which the
hospital is located . . . ."); 31 P.R. Laws Ann. § 5141 (damages
available under Puerto Rico law when "[a] person who by an act or
omission causes damage to another through fault or negligence"
(emphasis added)). Specifically, Auxilio Mutuo claims that Cruz's
heart condition was attributable to his "inability to adequately
care for his physical condition" by controlling his cholesterol and
blood pressure, rather than to any action or omission of the
hospital. This argument is a non-starter. Hospitals generally do
not cause the emergency conditions that they are called upon to
stabilize under EMTALA. That does not mean, however, that a
hospital's failure to stabilize a condition bears no causal
relationship to the damages suffered by a patient as a result of a
deterioration in his condition that could have been avoided by
stabilization.
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district court for further proceedings consistent with this
opinion.
So ordered.
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