Ingram v. Muskogee Regional Medical Center

F I L E D
United States Court of Appeals
Tenth Circuit
PUBLISH
DEC 18 2000
UNITED STATES COURT OF APPEALS
PATRICK FISHER
Clerk
TENTH CIRCUIT

HELEN INGRAM, Special
Administration of the Estate of
LaTasha Cherie Ingram, deceased,

Plaintiff-Appellant,

v. No. 99-7126

MUSKOGEE REGIONAL MEDICAL
CENTER,

Defendant-Appellee,

and

JAY A. GREGORY, M.D.;
RUSSELL T. SHEPHEARD, M.D.;
BERRY E. WINN, M.D., P.L.L.C.,

Defendants.

APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF OKLAHOMA
(D.C. No. 99-CV-262-S)

Submitted on the briefs:

John F. McCormick, Jr., Harry A. Parrish, of Pray, Walker, Jackman, Williamson
& Marlar, Tulsa, Oklahoma, for Plaintiff-Appellant.

Terry Todd, Leslie C. Weeks, Elizabeth K. Hall, of Rodolf & Todd, Tulsa,
Oklahoma, for Defendant-Appellee.
Before TACHA , EBEL , and BRISCOE , Circuit Judges.

EBEL , Circuit Judge.

This suit arises from the death of LaTasha Ingram after she suffered

a gunshot wound to the chest. The following facts are not disputed. Ms. Ingram

was shot in the early hours of the morning and taken to the emergency room at

Muskogee Regional Medical Center (MRMC) in Muskogee, Oklahoma. The

emergency room physician, Dr. Russell Shepheard, initiated treatment and called

the on-call surgeon, Dr. Jay Gregory. Dr. Gregory ordered Ms. Ingram transferred

to the intensive care unit over the phone, and determined later at the hospital that

she needed cardiovascular surgery. Because MRMC lacked the necessary

surgeons, Dr. Gregory arranged for Ms. Ingram to be transferred to St. Francis

Hospital in Tulsa. The risks were explained to plaintiff, Ms. Ingram’s mother,

who then requested the transfer in writing. Ms. Ingram died shortly after she was

transferred from MRMC.

Plaintiff sued MRMC and three physicians, asserting claims of wrongful

death under theories of common law medical malpractice and violation of the

Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C.

§ 1395dd. Plaintiff alleged that MRMC inappropriately transferred Ms. Ingram

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under EMTALA because defendants failed to first stabilize her condition and

minimize the risk of transfer by inserting chest tubes. The district court granted

summary judgment to MRMC on plaintiff’s EMTALA claim and dismissed the

pendent medical malpractice claims for lack of jurisdiction. Plaintiff appeals

from the grant of summary judgment to MRMC, but does not challenge the

dismissal of her pendent claims against defendants. We have jurisdiction under

28 U.S.C. § 1291, and affirm. 1

On appeal, plaintiff argues that the district court erred: (1) in granting

summary judgment to MRMC when plaintiff presented evidence that

Ms. Ingram’s transfer was not appropriate under EMTALA; (2) in holding that a

difference of opinion on appropriate treatment supported only a state medical

malpractice issue; and (3) in requiring plaintiff to present proof of a violation of

MRMC’s procedures or requirements regarding Dr. Gregory’s failure to insert

chest tubes to support her claim that Ms. Ingram’s transfer was not appropriate

under EMTALA.

We review the grant of summary judgment de novo, using the same

standard as the district court under Fed. R. Civ. P. 56(c). Ford v. West , 222 F.3d

1
After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument.

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767, 774 (10th Cir. 2000). A summary judgment is appropriate “if the pleadings,

depositions, answers 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.” Rule 56(c).

EMTALA was enacted to prevent hospitals from “dumping” patients that

they could treat but who could not pay for services. See, e.g. , Bryan v. Rectors &

Visitors of the Univ. of Va. , 95 F.3d 349, 351-52 (4th Cir. 1996); Summers v.

Baptist Med. Ctr. Arkadelphia , 91 F.3d 1132, 1136-37 (8th Cir. 1996); Delaney v.

Cade , 986 F.2d 387, 391 n.5 (10th Cir. 1993); Thornton v. S.W. Detroit Hosp. ,

895 F.2d 1131, 1134 (6th Cir. 1990); see generally 131 Cong. Rec. 28568-28570.

A hospital governed by EMTALA is faced with two basic requirements. First,

“the hospital must provide for an appropriate medical screening . . . to determine

whether or not an emergency medical condition . . . exists.” 42 U.S.C.

§ 1395dd(a). Plaintiff did not allege that MRMC’s initial medical screening was

not appropriate.

Second, EMTALA also requires that “[i]f an individual at a hospital has an

emergency medical condition which has not been stabilized . . ., the hospital may

not transfer the individual unless” certain conditions are met. § 1395dd(c)(1).

An initial condition is that the individual, or a responsible person acting on his or

her behalf, after being informed of the hospital’s EMTALA obligations, must

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request a transfer in writing, § 1395dd(c)(1)(A)(i), or a physician must determine

that the risks of transfer are outweighed by the medical benefits reasonably

expected to be provided at another medical facility, and this determination must

be documented in a signed certification, § 1395dd(c)(1)(A)(ii), (iii).

In addition, however, the transfer must be “appropriate,” as defined by the

statute. § 1395dd(c)(1)(B). “An appropriate transfer to a medical facility is a

transfer--(A) in which the transferring hospital provides the medical treatment

within its capacity which minimizes the risks to the individual’s health.”

§ 1395dd(c)(2).

The district court determined that there is a dispute of material fact as to

whether Ms. Ingram’s condition was stable when she was transferred. Because

summary judgment was sought against plaintiff, the district court therefore

appropriately completed its analysis under EMTALA assuming that Ms. Ingram’s

condition was not stable and that the limitations of § 1395dd(c) on transferring

her to another hospital applied. The court correctly determined that defendants

had satisfied the written request and signed certification conditions for transfer

under § 1395dd(c)(1)(A). The parties dispute whether the transfer was

“appropriate” within the meaning of § 1395dd(c)(2)(A).

There was no dispute that MRMC could have inserted chest tubes prior to

transfer. However, there was a sharp dispute as to whether insertion of chest

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tubes would have been helpful or harmful. The court noted that plaintiff

produced evidence that the insertion of chest tubes prior to Ms. Ingram’s transfer

would have reduced the risks of transfer, while MRMC presented evidence that

insertion of chest tubes would have created the possibility that Ms. Ingram would

bleed to death. Thus, the question is whether plaintiff raised a factual dispute as

to whether MRMC “provide[d] the medical treatment within its capacity [to]

minimize[] the risks to [Ms. Ingram’s] health.” § 1395dd(c)(2)(A).

We hold that plaintiff’s evidence is insufficient to create a material dispute

of fact within the meaning of the statute. We have found no cases from any

jurisdiction interpreting § 1395dd(c)(2)(A). However, in Repp v. Anadarko

Municipal Hospital , 43 F.3d 519, 522 (10th Cir. 1994), this court construed

similar language in EMTALA’s screening provision, § 1395dd(a). Section

1395dd(a) states that “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.” We stated that the phrase “appropriate medical screening” was

ambiguous, and then concluded that each hospital determines its own capabilities

by establishing a standard procedure, which is all the hospital needs to follow to

avoid liability under EMTALA. 43 F.3d at 522. This narrow interpretation ties

the statute to its limited purpose, which was to eliminate patient-dumping and not

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to federalize medical malpractice. See, e.g. , Bryan , 95 F.3d at 351-52; Summers ,

91 F.3d at 1136-37; Thornton , 895 F.2d at 1134; see generally 131 Cong. Rec.

28568-28570.

We conclude that sections (a) and (c)(2)(A) should be interpreted similarly,

considering the similarity of the language in those sections and the lack of any

meaningful distinction between the terms “capability” and “capacity.” Therefore,

in light of this court’s prior decision in Repp , MRMC’s capacity to provide

medical treatment to minimize the risks of transfer should be measured by its

standard practices, and plaintiff was required to produce evidence that

Dr. Gregory violated an existing hospital procedure or requirement by failing to

insert chest tubes in order to show that the transfer was not appropriate under

§ 1395dd(c)(2)(A). Because she did not, the grant of summary judgment to

MRMC was proper, and the district court judgment is affirmed.

AFFIRMED.

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