United States Court of Appeals
For the First Circuit
No. 01-2083
MARIA DEL CARMEN GUADALUPE, EFRAIN LABOY GUADALUPE, MARCELINA
FRANQUI FIGUEROA,
Plaintiffs, Appellants,
v.
DR. SAMUEL NEGRON AGOSTO; HOSPITAL INTERAMERICANO DE MEDICINA
AVANZADA, INC.-HUMACAO,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Juan M. Pérez-Giménez, U.S. District Judge]
Before
Torruella and Lipez, Circuit Judges,
Coffin, Senior Circuit Judge
Kevin G. Little, with whom Law Offices of David Efron was on
brief for appellants.
Fernando Agrait Betancourt for appellees.
August 7, 2002
LIPEZ, Circuit Judge. This case concerns the grounds for
establishing the liability of a hospital under the Emergency
Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.
§ 1395dd. EMTALA requires hospitals to provide emergency room
patients with an appropriate medical screening designed to identify
emergency conditions. Contending that Hospital Interamericano de
Medicina Avanzada, Inc.-Humacao (HIMA) provided such a minimal
screening for Narciso Figueroa that it could not be deemed
appropriate, the plaintiffs appeal the district court's grant of
summary judgment to HIMA. We affirm.
I. Background
In reviewing an award of summary judgment, we "view the
entire record in the light most hospitable to the party opposing
summary judgment, indulging all reasonable inferences in that
party's favor." Griggs-Ryan v. Smith, 904 F.2d 112, 115 (1st Cir.
1990). We state the facts accordingly.
On October 2, 1998, at approximately 9:50 P.M., Maria del
Carmen Guadalupe took her husband, Narciso Figueroa, to the Yabucoa
Diagnostic and Treatment Center (YDTC). Figueroa was suffering
from urinary retention, edema in his legs, high blood pressure, and
pain. The YDTC referred Figueroa to HIMA, where he arrived at 1:05
A.M. on October 3, 1998, accompanied by del Carmen Guadalupe. By
this time, Figueroa was also suffering from increased respiratory
difficulty, a dry cough, fever, and drowsiness.
When he arrived at HIMA, Figueroa was joined by his niece, a
nurse who worked at the hospital (but was off duty at the time).
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She spoke to the doctor on call, Dr. Samuel Negron Agosto. While
del Carmen Guadalupe filled out paperwork at the front desk of the
hospital, Dr. Negron Agosto examined Figueroa. Atlhough there
were other patients in the emergency room, Figueroa was examined
before them. At least two nurses also attended to Figueroa, taking
his vital signs, drawing blood, and arranging for an x-ray of his
chest. The nurses also checked the Foley catheter (designed to
drain urine) that had been attached to Figueroa before he arrived.
Figueroa was conscious the whole time, communicating to family
members and health care workers.
After reviewing an x-ray, Dr. Negron Agosto diagnosed Figueroa
with bronchial pneumonia. In her deposition, del Carmen Guadalupe
claimed that Dr. Negron Agosto told Figueroa's niece (the nurse)
that Figueroa could be discharged because "nobody dies from
[bronchial pneumonia]." Before del Carmen Guadalupe left with
Figueroa, Dr. Negron Agosto gave her some medicine and told her to
give it to Figueroa once they got home and to return to the
hospital the next day to pick up the x-ray. Figueroa was
discharged at about 3:00 A.M., and del Carmen Guadalupe drove him
back home by 5:00 A.M. He was conscious and speaking during the
journey, and did not complain about his treatment at the hospital.
After del Carmen Guadalupe and Figueroa returned to their
home, they looked for the medicine, but could not find it. Rather
than returning for a replacement, they decided to rest.
Unfortunately, Figueroa's condition continued to deteriorate,
prompting del Carmen Guadalupe to take him to another hospital,
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Ryder Memorial Hospital. Figueroa was pronounced dead upon arrival
at Ryder at 1:45 P.M. Dr. Yocasta Brugal of the Forensic Sciences
Institute of Puerto Rico performed an autopsy on Figueroa and
established the cause of death as bilateral bronchial pneumonia.
Plaintiffs, heirs of Figueroa, filed a complaint against HIMA
and Dr. Samuel Negron Agosto on September 22, 1999, charging them
with violations of EMTALA and medical malpractice under Puerto
Rican law. After discovery, HIMA filed a motion for summary
judgment and/or to dismiss, arguing that the plaintiffs failed to
state a claim under EMTALA. HIMA argued that summary judgment was
appropriate because undisputed facts demonstrated that the hospital
had given Figueroa an appropriate screening examination comparable
to the screening it would have given any patient with substantially
similar symptoms. It also moved the district court to dismiss
without prejudice the malpractice claims.
To oppose the summary judgment motion, the plaintiffs
submitted hospital reports, records, and policies, a deposition
from del Carmen Guadalupe, and a letter and deposition from their
expert, Dr. David R. Nateman, Medical Director of the Emergency
Services Department of the Baptist Hospital of Miami. Dr.
Nateman's report concluded that both the Hospital and Dr. Negron
Agosto
fell below the standards of medical care for failing to
diagnose a life-threatening medical condition which resulted
in the death of Narcisco [sic] Figueroa. In addition, by
providing an inadequate medical screening at [the hospital],
the patient was not afforded the right of determination of
medical stability and therefore was illegally transferred
which resulted in a violation of EMTALA.
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On June 22, 2001, the district court granted HIMA's motion for
summary judgment with respect to the plaintiffs' EMTALA claim, and
dismissed without prejudice their supplemental malpractice claims.
The plaintiffs appeal from this decision.
II. EMTALA Standards
The parties agree that HIMA provided Figueroa with a
screening; they disagree over whether it was an "appropriate
medical screening" under the terms of EMTALA. 42 U.S.C. §
1395dd(a). HIMA argues that a plaintiff can prevail under EMTALA
only if she can demonstrate that the hospital offered no screening
at all, or deviated from its standard screening procedures
applicable to other patients with similar conditions.1 As HIMA
puts it in its brief, "[w]hat EMTALA prohibits is disparate
screening or no screening at all." Although appellants agree with
the disparate screening standard, they also contend that a hospital
can violate EMTALA if its screening is so cursory or inadequate
that it is tantamount to no medical screening. As we explain,
neither party has it exactly right.
1
For the sake of convenience, in the remainder of this
opinion we will refer to HIMA as the only defendant in this case.
As a physician, Dr. Negron Agosto may be immune from EMTALA
liability. While we have "not decided the issue whether EMTALA
provides a cause of action against individual physicians, all
circuits that have done so have found that it does not." Lebron v.
Ashford Presbyterian Cmty. Hosp., 995 F. Supp. 241, 244 (D.P.R.
1998) (citing Eberhardt v. City of Los Angeles, 62 F.3d 1253 (9th
Cir. 1995); King v. Ahrens, 16 F.3d 265 (8th Cir. 1994); Delaney
v. Cade, 986 F.2d 387 (10th Cir. 1993); Baber v. Hosp. Corp. of
America, 977 F.2d 872 (4th Cir. 1992); Gatewood v. Washington
Healthcare Corp., 933 F.2d 1037 (D.C.Cir. 1991)). Since we decide
that EMTALA was not violated here, we need not decide the question
of physician liability in this case.
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By its terms, EMTALA is designed to assure that any person
visiting a covered hospital's emergency room is screened for an
emergency medical condition and is stabilized if such a condition
exists.2 With respect to screening, it requires the following:
In the case of a hospital that has a hospital emergency
department, if any individual . . . comes to the
emergency department and a request is made on the
individual's behalf for examination or treatment for a
medical condition, the hospital must provide for an
appropriate medical screening examination within the
capability of the hospital's emergency department,
including ancillary services routinely available to the
emergency department, to determine whether or not an
emergency medical condition (within the meaning of
subsection (e)(1) of this section) exists.
42 U.S.C. § 1395dd(a). EMTALA does not define the term
"appropriate medical screening examination." However, it does
indicate that the purpose of the screening is to identify an
"emergency medical condition." An emergency medical condition is
defined 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 (or, with
respect to a pregnant woman, the health of the
woman or her unborn child) 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)(A). To identify such conditions,
hospitals are expected to employ "ancillary services routinely
available to the emergency department." 42 U.S.C. § 1395dd(a).
2
A covered hospital is defined as a "hospital that has
entered into a provider agreement under section 1395cc of this
title." 42 U.S.C. § 1395dd(e)(2). Both sides agree that HIMA is
covered by EMTALA.
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However, they are not liable for failing to conduct examinations
(or parts thereof) that are not "within the capability of the
hospital's emergency department." 42 U.S.C. § 1395dd(a).
With the statutory language as a guide, we have said
previously that "[t]he essence of [EMTALA's] screening requirement
is that there be some screening procedure, and that it be
administered even-handedly." Correa v. Hosp. San Francisco, 69
F.3d 1184, 1192 (1st Cir. 1995). Thus, there is both a substantive
and a procedural component to an appropriate medical screening
under EMTALA: "[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." Id.; see also Jackson v. East
Bay Hosp., 246 F.3d 1248, 1256 (9th Cir. 2001) ("We hold that a
hospital satisfies EMTALA's 'appropriate medical screening'
requirement if it provides a patient with an examination comparable
to the one offered to other patients presenting similar symptoms,
unless the examination is so cursory that it is not 'designed to
identify acute and severe symptoms that alert the physician of the
need for immediate medical attention to prevent serious bodily
injury.'" (quoting Eberhardt v. City of Los Angeles, 62 F.3d 1253,
1257 (9th Cir. 1995))).
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III. Applying the Legal Standards
A. Reasonably Calculated to Identify Critical Medical Conditions
In pressing their claim that HIMA failed to provide Figueroa
with an appropriate medical screening under the terms of EMTALA,
plaintiffs argued that "[t]he medical examination and treatment
[offered to Figueroa] . . . was totally inadequate and
inappropriate for a man in his condition." In moving for summary
judgment in response to this claim, HIMA focused on concessions
elicited from the plaintiffs' expert witness, Dr. Nateman, during
his deposition. Although Dr. Nateman concluded that there had been
an "improper screening," he also conceded that he could not be
certain whether Figueroa suffered from a "life-threatening
condition" when he arrived at HIMA. Dr. Nateman also admitted that
Figueroa was treated rapidly at the hospital, noting that Figueroa
"was triaged, [had] some vital signs done, had a physical exam by
the doctor, and chest x-rays [and] laboratory tests were ordered."
Figueroa's wife, del Carmen Guadalupe, confirmed this
testimony in her deposition. She also testified that Figueroa was
given medication at the emergency room. She stated that, at the
close of their visit, she was given a prescription and told to come
back in the morning for the x-rays. Del Carmen Guadalupe also
stated at the deposition that her husband did not appear to be in
critical condition when he left the hospital with her:
Q: [B]y five in the morning . . . your husband was doing well
in the car.
A: Yes.
Q: That is, conscious and talking and all that.
A: Yes.
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Q. Did he express any complaints about the way he was attended
in there?
A: No.
Q: Some sort of malcontent?
A: No.
Q: You personally, did you feel you were attended?
A: Yes.
Given the concessions of Dr. Nateman and del Carmen Guadalupe, HIMA
argues that it was clear that HIMA's screening of Figueroa was
reasonably calculated to identify critical medical conditions
afflicting him.
In response, the plaintiffs argue that, while this screening
examination may have been adequate for many emergency room
patients, it was "totally inadequate and inappropriate for a man in
[Figueroa's] condition." According to Dr. Nateman, Figueroa's co-
morbid conditions--his obesity, age (51), edematous legs,
catheterization, and high respiration rate--made him a "vascular
nightmare waiting to happen," a man with an obvious "potential for
death." Dr. Nateman concluded that an appropriate screening
examination would have included, at a minimum, an
electrocardiogram, a fuller assessment of Figueroa's respiratory
function, and an immediate reading of the chest x-ray by a
radiologist.3 At the very least, say the plaintiffs, these
3
Dr. Nateman's deposition suggests that Figueroa's chest x-
rays were examined twice--once at about 2:00 A.M. (by the doctor on
call), and then again at 11:05 A.M. (by a radiologist). Dr.
Nateman stated that the doctor on call clearly misdiagnosed
Figueroa, in part because "his chest x-rays were not normal."
However, Dr. Nateman also admitted that he did not have the x-rays
with him at the deposition, and therefore could not answer an
attorney's question as to whether "the reading by the emergency
room doctor [was] obviously wrong, or . . . [was] reasonably
misread [by a non-radiologist]."
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contentions created a "genuine issue of material fact" regarding
the appropriateness of the screening examination offered to
Figueroa.
Although plaintiffs' arguments have some force, they ignore
the important distinction between an EMTALA claim and a malpractice
claim. EMTALA does not "create a cause of action for medical
malpractice," and "faulty screening, in a particular
case . . . does not contravene the statute. " Correa, 69 F.3d at
1192-93. Dr. Nateman's criticisms of HIMA's diagnosis of Figueroa
in the emergency room are indistinguishable from the standard of
care criticisms that one would hear from an expert in a malpractice
case triggered by a misdiagnosis. Under EMTALA the issue is not
what deficiencies in the standard of emergency room care
contributed to a misdiagnosis. See Gatewood, 933 F.2d at 1041
(observing that EMTALA is not intended "to ensure each emergency
room patient a correct diagnosis"). Rather, the issue is whether
the procedures followed in the emergency room, even if they
resulted in a misdiagnosis, were reasonably calculated to identify
the patient’s critical medical condition. Dr. Nateman's criticisms
do not address this precisely formulated EMTALA standard.
Moreover, whereas malpractice liability usually attaches when
a health care provider fails to adhere to a "general professional
standard" of care, W. Page Keeton et al., Prosser and Keeton on the
Law of Torts § 32, at 188 (1984), EMTALA only requires "an
appropriate medical screening examination within the capability of
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the hospital's emergency department." 42 U.S.C. § 1395dd(a). As
the Fourth Circuit has observed:
This section establishes a standard which will of
necessity be individualized for each hospital, since
hospital emergency departments have varying capabilities.
Had Congress intended to require hospitals to provide a
screening examination which comported with generally
accepted medical standards, it could have clearly
specified a national standard. Nor do we believe
Congress intended to create a negligence standard based
on each hospital's capability. EMTALA is no substitute
for state law medical malpractice actions.
Baber, 977 F.2d at 879-80. Although Dr. Nateman criticized HIMA
for failing to perform certain tests for Figueroa, plaintiffs
offered no evidence indicating that such tests were within HIMA's
capability. For example, Dr. Nateman stated during his deposition
that, at his hospital, he would test "oxygen saturation [for]
anybody who comes in with any kind of respiratory complaints."
However, he also admitted that he did not know "if [HIMA has] the
machine necessary for such a test." Dr. Nateman suggested that
HIMA should have had a radiologist examine Figueroa's x-rays as
soon as they were developed. However, he also said that he had "no
idea" whether the hospital's radiology department was in full
operation at that time. Plaintiffs offered no evidence that HIMA
had an electrocardiogram machine available, or had staff on hand
qualified to perform a "respiratory differential"--two other items
Dr. Nateman deemed essential to an "appropriate medical screening
examination." A claim of inappropriate medical screening based on
a failure to provide certain diagnostic tests must at least address
whether the hospital was capable of performing such tests. Because
plaintiffs failed to present such evidence or evidence that HIMA's
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screening was not "reasonably calculated to identify critical
medical conditions," Correa, 69 F.3d at 1192, summary judgment for
HIMA on the substantive component of EMTALA was appropriate.
B. Disparate Treatment
The district court concluded that the plaintiffs’ failure to
"submit any . . . policies on the initial screening standards of
Defendant HIMA" was "a fatal flaw in their case." Without that
evidence, the district court concluded, the plaintiffs could not
demonstrate that HIMA gave Figueroa a more cursory screening than
it gave to other patients with substantially similar symptoms.
Although we affirm the decision to grant summary judgment on the
disparate treatment claim, we do not agree that the claim
necessarily failed because the plaintiffs did not submit the
screening policies of HIMA. Although they are effective for
demonstrating disparate treatment, written hospital screening
policies may not exist, and therefore cannot be necessary to a
disparate treatment determination.4
Moreover, "'we may affirm [a summary judgment] order on any
ground revealed by the record.'" McGurn v. Bell Microproducts,
284 F.3d 86, 91 (1st Cir. 2002) (quoting Houlton Citizens'
Coalition v. Town of Houlton, 175 F.3d 178, 184 (1st Cir. 1999)).
4
If evidence of such written screening policies were
indispensable to EMTALA liability, a hospital could avoid liability
simply by failing to generate them. A "hospital cannot simply hide
behind [a] lack of standard emergency room procedures." Power v.
Arlington Hosp. Assoc., 42 F.3d 851, 858 (4th Cir. 1994) (internal
quotation marks omitted).
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Plaintiffs failed to submit any evidence establishing that HIMA
treated Figueroa any differently than it treated other patients
with substantially similar symptoms. HIMA submitted an affidavit
from its president, Carlos Pineiro Crespo, stating that "there were
no deviations on Mr. Figueroa's case from the standard treatment
HIMA offers persons in Mr. Figueroa's condition." The plaintiffs
cannot contradict this assertion because they have not addressed
the baseline level of screening prevailing at HIMA. At his
deposition, Dr. Nateman was asked whether "there was [sic] any
deviations of the standard treatment that [HIMA] gives to people in
the condition of Mr. Figueroa," and he replied "I can't comment on
that. I'm not sure." The plaintiffs made no effort to compare
Figueroa's screening with screenings of other HIMA patients
suffering from substantially similar symptoms. By submitting no
testimony regarding the baseline of care which the hospital
provides, the plaintiffs failed to raise a genuine question of
material fact on the issue of differential treatment.
The plaintiffs argue that the hospital may not have revealed
its screening procedures during discovery, and that subsequent
fact-finding might reveal this crucial evidence. They claim that
"[w]hen Defendants control the information, in essence controlling
the keys to the dismissal, the dismissal should not be granted,"
Ortiz v. Mennonite Gen. Hosp., 106 F. Supp. 2d 327, 331 (D.P.R.
2000). However, in Ortiz, the hospital clearly gave evasive
answers to interrogatories--something the plaintiffs here do not
allege. Id. Moreover, while they now imply that HIMA may be
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concealing the relevant documents, the plaintiffs assured the
district court on October 27, 2000, that "Defendant HIMA-Humacao
has answered all discovery submitted by the plaintiffs." Given
their failure to press for the relevant documentation at that
time, they cannot now claim that the mere allegation of disparate
treatment raises a genuine issue of material fact over whether
disparate treatment actually occurred. "A genuine issue of
material fact does not spring into being simply because a litigant
claims that one exists [or] 'promise[s] to produce admissible
evidence at trial.'" Griggs, 904 F.2d at 115 (quoting Garside v.
Osco Drug, Inc., 895 F.2d 46, 49 (1st Cir. 1990)).
IV. Stabilization
In addition to a medical screening requirement, EMTALA
mandates that hospitals stabilize patients with emergency medical
conditions before releasing them. See 42 U.S.C. § 1395dd(b)
(requiring "stabilizing treatment for emergency medical conditions
and labor"). In a footnote at the conclusion of their brief, the
plaintiffs claim that, although they charged HIMA with violating
the stabilization requirement in their complaint, "the district
court did not address [whether HIMA complied with] EMTALA's
stabilization requirement." However, the district court did
explain why the stabilization requirement does not apply to this
case: "If no emergency condition is detected, there is no duty to
stabilize." The district court's inquiry properly ended after it
determined that Figueroa's screening was neither inadequate nor
inequitable, and that the screening revealed no emergency
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condition. A hospital is only "required to stabilize" an
individual if "the hospital determines that the individual has an
emergency medical condition." 42 U.S.C. § 1395dd(b)(1). The
district court correctly applied the statute to this case.
V. Conclusion
For the foregoing reasons, the decision of the district court
is affirmed. Each side shall bear its own costs.
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del Carmen Guadalupe v. Negron-Agosto
Court: Court of Appeals for the First Circuit
Date filed: 2002-08-07
Citations: 299 F.3d 15
Copy CitationsCombined Opinion