United States Court of Appeals
For the First Circuit
No. 10-1203
JOSÉ RAMOS-CRUZ and DEBORAH LÓPEZ-PAGÁN,
Plaintiffs, Appellants,
v.
CENTRO MÉDICO DEL TURABO d/b/a HOSPITAL HIMA SAN PABLO FAJARDO
and HIMA SAN PABLO CAPTIVE INSURANCE COMPANY LIMITED,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Jaime Pieras, Jr., U.S. District Judge]
Before
Torruella, Siler,* and Howard,
Circuit Judges.
John E. Mudd for appellants.
Orlando H. Martínez-Echeverría with whom Fernando E. Agrait,
was on brief for appellees.
April 8, 2011
*
Of the Sixth Circuit, sitting by designation.
SILER, Circuit Judge. José Ramos-Cruz and Deborah López-
Pagan (collectively “Plaintiffs”) filed suit under the Emergency
Medical Treatment and Active Labor Act (“EMTALA”) after their son
died following a hospital transfer. The district court granted
summary judgment in favor of the defendants. For the reasons stated
below, we AFFIRM.
I.
Plaintiffs filed suit under EMTALA, 42 U.S.C. § 1395dd,
against defendants Centro Médico del Turabo d/b/a Hospital HIMA San
Pablo Fajardo and the hospital’s insurer, HIMA San Pablo Captive
Insurance Company Limited (collectively “Hospital”). Plaintiffs
alleged the Hospital improperly transferred their son, Jose Ramos
Lopez (“Ramos”), when it failed to comply with EMTALA’s transfer
requirements. The district court granted summary judgment for the
Hospital, concluding Ramos’s transfer did not violate federal law.
On August 23, 2006, Ramos arrived at the Hospital with a
history of abdominal problems and anemia and experiencing abdominal
pain. He subsequently vomited blood and was diagnosed with upper
gastrointestinal bleeding. Because the Hospital did not have
gastroenterologic services available, the emergency room physician,
Dr. Ramon, arranged with a doctor from the San Juan Medical Center
(“SJMC”) to have Ramos transferred.
The physician then prepared and signed a “Clinical
Summary and Examination at the Moment of Transfer,” a section of
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which requires the transferring doctor to explain why the benefits
of the transfer outweigh its risks. In the space provided, he
wrote “Gastroenterologist.” Ramos and his medical records were then
transported to SJMC in an ambulance staffed with medical
technicians. Following a drop in Ramos’s hemoglobin level, a
gastroenterologic team at SJMC performed an endoscopic procedure
that stopped Ramos’s bleeding ulcer. Unfortunately, his bleeding
began again later, and blood transfusions and an attempted surgical
procedure were unsuccessful in saving his life. Ramos died on
August 25, 2006, approximately 36 hours after his arrival at SJMC.
II.
Plaintiffs contend the district court erred when it
granted summary judgment in favor of the Hospital, concluding as a
matter of law the Hospital’s transfer of Ramos complied with
EMTALA.
We review a district court’s grant of summary judgment de
novo. Triangle Trading Co. v. Robroy Indus., Inc., 200 F.3d 1, 2
(1st Cir. 1999). A district court should grant summary judgment
where “the movant shows that there is no genuine dispute as to any
material fact and the movant is entitled to judgment as a matter of
law.” Fed. R. Civ. P. 56(a).
Congress enacted EMTALA in 1996 in response to claims
that hospital emergency rooms were refusing to treat patients with
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emergency conditions but no medical insurance. Reynolds v.
MaineGeneral Health, 218 F.3d 78, 83 (1st Cir. 2000). EMTALA
therefore “is a limited anti-dumping statute, not a federal
malpractice statute.” Id. (internal citations and quotation marks
omitted). It creates private rights of action where hospitals
violate its mandates. Correa v. Hospital San Francisco, 69 F.3d
1184, 1190 (1st Cir. 1995); 42 U.S.C. § 1395dd(d)(2).
EMTALA requires that “if an emergency medical condition
exists, the participating hospital must render the services that
are necessary to stabilize the patient’s condition . . . unless
transferring the patient to another facility is medically indicated
and can be accomplished with relative safety.” Correa, 69 F.3d at
1189 (internal citations and quotation marks omitted); 42 U.S.C. §
1395dd(b) and (c).
When transferring a patient, the physician must sign a
certification that “the medical benefits reasonably expected from
the provision of appropriate medical treatment at another medical
facility outweigh the increased risks to the individual.” 42
U.S.C. § 1395dd(c)(1)(A)(ii). This certification must contain a
summary of the risks and benefits of the transfer. 42 U.S.C. §
1395dd(c)(1).
Further, a transfer is only appropriate where 1) the
transferring hospital provides “the medical treatment within its
capacity which minimizes the risks to the individual’s health,” 2)
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the receiving facility has available space and qualified personnel,
as well as agrees to accept the transfer and provide the
appropriate treatment, 3) the transferring hospital sends all
medical records related to the condition available at the time of
transfer, and 4) the patient is transported through qualified
personnel and transportation equipment. 42 U.S.C. § 1395dd(c)(2).
Dr. Ramon signed a certification at the time of transfer.
Further, this certification contained a section entitled “EXPLAIN
why the benefits of the transfer for the patient . . . are greater
than the risks, if any for the transfer,” and, in the corresponding
space, the physician wrote “Gastroenterologist.” This was merely
a summary statement of the more explicit explanation that Ramos
needed a gastroenterologist, none was present at the Hospital, and,
therefore, he needed to be transferred, because the benefits of a
gastroenterologist outweighed the dangers of transportation.1
Moreover, the Hospital provided appropriate pre-transfer
treatment. What is required in this regard is an issue of first
impression in the First Circuit. The district court relied on
Tenth Circuit precedent in applying this requirement and held that
a hospital runs afoul of this provision only where it “violate[s]
1
Plaintiffs contend Dr. Ramon could not have made a
risk/benefit assessment because he testified he made the decision
the moment Ramos vomited blood. However, there is no statutory
requirement as to how long the doctor has to consider the risks and
benefits of a transfer.
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an existing hospital procedure or requirement.” Ingram v. Muskogee
Reg’l Med. Ctr., 235 F. 3d 550, 552 (10th Cir. 2000).
While Plaintiffs concede the Hospital followed standard
procedure when transferring Ramos, they sharply dispute the
district court’s statutory interpretation. Plaintiffs argue the
correct standard is provided by the statute itself when it dictates
the hospital provide “the medical treatment within its capacity
which minimizes the risks to the individual’s health.” According
to Plaintiffs, this means that if a hospital does not deliver the
feasible specific treatment that is best, whatever it may be in a
given circumstance, it violates EMTALA.
Plaintiffs’ position on this point of law is untenable.
First, the district court’s opinion conforms with our jurisprudence
interpreting the similar EMTALA phrase, “appropriate medical
screening examination within the capability of the hospital’s
emergency department.” 42 U.S.C. § 1395dd(a). In that context, we
held that “refusal to follow regular screening in a particular
instance contravenes the statute . . . but faulty screening, in a
particular case . . . does not contravene the statute.” Correa, 69
F.3d at 1192-93 (internal citations and quotation marks omitted).
Second, the Plaintiffs’ interpretation would create a federal
malpractice cause of action. Any time an unstabilized patient did
not receive the correct care prior to transfer, he could sue in
federal court. This is entirely inconsistent with our
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jurisprudence and Congressional intent, as we have previously
stated “EMTALA does not create a cause of action for medical
malpractice.” Correa, 69 F.3d at 1192.
The district court found that Plaintiffs produced
sufficient evidence for a trial on the question of whether Ramos
was stabilized prior to his transfer to SJMC under 42 U.S.C. §
1395dd(b). We need not decide that question, because we find that
the Hospital provided for the transfer in the best interests of the
patient under 42 U.S.C. § 1395dd(c)(1)(A)(ii).
The decision of the district court is therefore AFFIRMED.
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