United States Court of Appeals
For the First Circuit
No. 08-2351
PROVIDENCIA ALVAREZ-TORRES et al.,
Plaintiffs, Appellants,
v.
RYDER MEMORIAL HOSPITAL, INC. et al.,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Francisco Besosa, U.S. District Judge]
Before
Lipez and Howard, Circuit Judges,
and Woodcock, District Judge.*
José Luis Ubarri, with whom Brown & Ubarri was on brief, for
appellant.
Teresa M. García-Moll for appellee Ryder Memorial Hospital,
Inc.
José A. Gonzalez Villamil on brief for appellees Dr. Enrique
Octavio Ortiz-Kidd, the conjugal partnership of Dr. Enrique Octavio
Ortiz-Kidd and his wife, and Triple-S, Inc.
José Miranda Daleccio on brief for appellee Juan Ramón Gómez
López.
Igor Domínguez Pérez on brief for appellee Dr. Griselle
Pastrana.
Luis R. Ramos Cartagena on brief for appellee Sindicato de
Aseguradores de Impericia Medico Hospitalaria.
September 4, 2009
*
Of the District of Maine, sitting by designation.
LIPEZ, Circuit Judge. The surviving family of Adalberto
Martínez López brought suit against a hospital and several
physicians, alleging a violation of the Emergency Medical Treatment
and Active Labor Act ("EMTALA"), 42 U.S.C. § 1395dd, and various
provisions of state law. The district court granted the
defendants' motion for summary judgment, concluding that
plaintiffs had failed to make out a claim under EMTALA and
declining to exercise supplemental jurisdiction over the state-law
claims.
Plaintiffs appeal, arguing, inter alia, that the evidence
supports a claim for failure to stabilize under EMTALA. Finding no
error, we affirm.
I.
A. Factual Background
On appeal from a grant of summary judgment, we state the
facts in the light most favorable to the non-movant. Levesque v.
Doocy, 560 F.3d 82, 84 (1st Cir. 2009).
At 6:45 p.m., on January 16, 2001, Adalberto Martínez
López ("Martínez") came to the Ryder Memorial Hospital, Inc.
("Ryder") Emergency Room complaining of chest pain and bleeding
from a femoral dialysis catheter site. Martínez was fifty-seven
years old at the time and an end-stage renal disease dialysis
patient. His vital signs were taken, and at 6:50 p.m. Martínez was
examined by Dr. Griselle Pastrana, an emergency room physician.
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Dr. Pastrana documented that Martínez was actively bleeding from
the catheter site and that he was weak and dizzy. She described
his general condition as "alert, oriented [and] mildly pale," and
noted his end-stage renal disease. Dr. Pastrana ordered a variety
of tests for Martínez, including a chest x-ray, an EKG, and a "type
and cross for four units of Packed Red Blood Cells."
At 7:30 p.m., Dr. Pastrana discussed Martínez's case with
Dr. Enrique Ortíz-Kidd, a nephrologist at Ryder. Dr. Ortíz-Kidd
then ordered Martínez's admission to Ryder's "Medicine Floor" and
the completion of the tests ordered by Dr. Pastrana. Martínez was
admitted to the Medicine Floor at 7:39 p.m., with orders for bed
rest, testing of vital signs every four hours, and hemodialysis and
a blood transfusion the next morning.
Martínez did not arrive in his room on the Medicine Floor
until 9:30 p.m. When he arrived, he was described as alert, but
pale, feverish, and complaining of chest pain. The catheter site
remained bloody. At 10 p.m., the on-duty nephrologist, Dr.
Baquero, was contacted and informed of Martínez's vital signs. Dr.
Baquero prescribed, among other things, an antibiotic and Tylenol,
which were administered at 10:20 p.m. At 12:15 a.m., January 17,
Dr. Ortíz-Kidd gave a telephone order to change the bandage on
Martínez's catheter site, apply pressure, and prepare for a blood
transfusion in the morning.
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However, Martínez continued to bleed throughout the
night, and his bandages had to be changed several times. At
4:55 a.m., a relative accompanying Martínez complained to the
nursing staff that the bleeding was "profuse[]." Staff contacted
Dr. Ortíz-Kidd, who requested a consultation with a Ryder surgeon,
Dr. Sotomayor. Vital signs taken at 5 a.m. reflected that
Martínez's blood pressure had dropped and his temperature had
increased. Nurses called an on-duty physician, Dr. Juan R. Gómez
López, who examined Martínez and ordered a blood transfusion. He
then discussed Martínez's condition with Dr. Ortíz-Kidd over the
phone.
At 5:30 a.m., staff contacted Dr. Ortíz-Kidd again and
informed him that Dr. Sotomayor was not available. Dr. Ortíz-Kidd
requested that Dr. Luis Canetti, another Ryder surgeon, evaluate
the patient. Nurses noted that when Dr. Cannetti removed the
bandages to examine Martínez, "bleeding continue[d] profusely and
abundantly." Dr. Canetti determined that Martínez required surgery
but that he could not perform it, and he recommended that Martínez
be immediately transferred to Auxilio Mutuo Hospital for an "A-V
fistula revision." At 7 a.m., Dr. Ortíz-Kidd was notified of the
recommendation and "order[ed] [the] patient to be transferred as
soon as possible." The blood transfusion ordered by Dr. Gómez
López began at 7:05 a.m.
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Sometime between 7 and 8 a.m., nurses discovered that
Martínez was not breathing. CPR was performed, but Martínez could
not be revived. He was pronounced dead at 8:15 a.m., January 17,
2001.
B. Proceedings in the District Court
On January 15, 2003, Martínez's surviving wife and
children, including Tony Martínez Taveras, a child from another
relationship, brought suit against Ryder, Dr. Pastrana, Dr. Ortíz-
Kidd, and an unnamed physician. The Second Amended Complaint,
which also named as defendants Dr. Gómez López and Dr. Cannetti,
alleged violations of EMTALA by Ryder; malpractice by Drs.
Pastrana, Ortíz-Kidd, Gómez López, and Cannetti; and several other
state-law claims.1
After defendants' motions to dismiss were, for the most
part,2 denied, a long and contentious period of discovery ensued.
At its completion, the district court granted defendants' motion
for summary judgment on November 19, 2007, on all of plaintiffs'
claims, concluding that the plaintiffs had failed to establish a
claim under EMTALA against Ryder for failure to screen or stabilize
1
Also named as defendants in the Second Amended Complaint
were the insurers and "conjugal partnerships" of Drs. Pastrana,
Ortíz-Kidd, Gómez López, and Cannetti. Because these defendants
are not material to the issues presented on appeal, we omit
reference to them below.
2
The district court dismissed claims against one of the
defendant insurers on the grounds that insurance coverage did not
extend to the alleged incident.
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and that EMTALA did not support claims against the individual
physicians who had treated Martínez. It declined to exercise
supplemental jurisdiction over the state law claims pursuant to 28
U.S.C. § 1367(c)(3).
Plaintiffs timely appealed. On appeal, they argue that
the district court erred in dismissing the EMTALA claim for failure
to stabilize, that no EMTALA claims were brought against individual
physicians, and that the district court retained jurisdiction over
state-law claims brought by Tony Martínez Taveras on the basis of
diversity jurisdiction.
II.
A. EMTALA claims against Ryder
EMTALA is designed to prevent hospital emergency rooms
from "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 1189, 1189 (1st Cir. 1995)
(internal quotation marks and citation omitted). To this end,
EMTALA imposes duties on covered facilities to: (a) provide an
"appropriate medical screening examination" for those who come to
an emergency room seeking treatment, and (b) provide, in certain
situations, "such further medical examination and such treatment as
may be required to stabilize the medical condition." 42 U.S.C. §
1395dd(a), (b)(1)(A); see López-Soto v. Hawayek, 175 F.3d 170, 172-
73 (1st Cir. 1999).
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To establish a violation of the screening or
stabilization provisions in EMTALA, a plaintiff must prove that:
(1) the hospital is a participating hospital,
covered by EMTALA, that operates an emergency
department (or an equivalent facility);
(2) the patient arrived at the facility
seeking treatment; and (3) the hospital either
(a) did not afford the patient an appropriate
screening in order to determine if she had an
emergency medical condition, or (b) bade
farewell to the patient (whether by turning
her away, discharging her, or improvidently
transferring her) without first stabilizing
the emergency medical condition.
Correa, 69 F.3d at 1190.
In this case, the district court determined that
plaintiffs had failed to establish a violation of either the
screening or stabilization provisions. Plaintiffs appeal only the
stabilization ruling. They argue that, properly construed, EMTALA
"imposes an unqualified duty to stabilize once it is determined
that the patient has an emergency medical condition," and this duty
begins upon admission to the hospital and follows the patient to
any hospital department. They suggest that Ryder violated this
duty by failing to dispense any meaningful treatment to stabilize
Martínez's condition until it became apparent that he was about to
die. In the alternative, plaintiffs argue that even if the duty to
stabilize applies only when a patient is transferred, "transfer"
does not require a patient to physically leave the hospital, but
only for a physician to enter an order of transfer. Any other
interpretation, plaintiffs say, would undermine the purpose of
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EMTALA. Thus, on plaintiffs' view, Dr. Ortíz-Kidd triggered the
stabilization duty by entering an order of transfer for Martínez.
We agree with the district court that plaintiffs have
failed to establish a violation of the EMTALA stabilization
provision. The duty to stabilize under EMTALA "does not impose a
standard of care prescribing how physicians must treat a critical
patient's condition while he remains in the hospital, but merely
prescribes a precondition the hospital must satisfy before it may
undertake to transfer the patient." Fraticelli-Torres v. Hosp.
Hermanos, 300 Fed. Appx. 1, 4 (1st Cir. 2008) (unpublished). Thus,
a hospital cannot violate the duty to stabilize unless it transfers
a patient, as that procedure is defined in EMTALA. See Correa, 69
F.3d at 1190 (to establish a violation of the duty to stabilize,
the plaintiff must prove, inter alia, that the hospital "bade
farewell" to the patient).
As the Eleventh Circuit has explained, this conclusion
follows from the statutory definition of "to stabilize." Harry v.
Marchant, 291 F.3d 767, 770-72 (11th Cir. 2002) (en banc). The
stabilization provision requires a covered hospital, within its
staff and facilities, to provide an individual it determines has an
emergency medical condition with "such further medical examination
and such treatment as may be required to stabilize the medical
condition." 42 U.S.C. § 1395dd(b)(1)(A). EMTALA defines "to
stabilize" as "to provide such medical treatment of the condition
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as may be necessary to assure, within reasonable medical
probability, that no material deterioration of the condition is
likely to result from or occur during the transfer of the
individual from a facility." Id. § 1395dd(e)(3)(A) (emphasis
added). When this definition is inserted, the stabilization
provision requires "such further medical examination and such
treatment as may be required [to assure, within reasonable medical
probability, that no material deterioration of the condition is
likely to result from or occur during the transfer of the
individual from a facility]." Id. § 1395dd(b)(1). This directive
plainly applies only where transfer occurs. Otherwise, no effect
is given to the phrase "during the transfer." Harry, 291 F.3d at
771-72.3
Contrary to plaintiffs' suggestion, this interpretation
does not undermine the purposes of EMTALA by permitting hospitals
and physicians to provide substandard treatment. EMTALA is a
"limited 'anti-dumping' statute, not a federal malpractice
statute." Bryan v. Rectors & Visitors of the Univ. of Va., 95 F.3d
349, 351 (4th Cir. 1996); accord Harry, 291 F.3d at 770.
Congress's concern with patient dumping is clearly implicated when
3
Such an interpretation also makes sense of the larger
structure of the stabilization provision, which "set[s] forth two
options for transferring a patient with an emergency medical
condition": stabilizing the condition or transferring without
stabilizing where an exception applies. Harry, 291 F.3d at 771;
see 42 U.S.C. § 1395dd(b)(1).
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a hospital transfers a patient. Harry, 291 F.3d at 773 ("The
primary legislative goal of EMTALA was remedying the problem of
inappropriate patient transfers by hospitals." (citing S. Rep. No.
99-146, at 469-70 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 428-
29)). Interpreting the stabilization provision to apply where
transfer occurs is therefore fully consistent with EMTALA's
statutory purpose.
In this case, Ryder did not violate the stabilization
provision because Martínez was never transferred. The statute
defines "transfer" as "the movement (including the discharge) of an
individual outside a hospital's facilities at the direction of any
person employed by (or affiliated or associated, directly or
indirectly, with) the hospital." 42 U.S.C. § 1395dd(e)(4).
Therefore, Dr. Ortíz-Kidd's order that Martínez was "to be
transferred as soon as possible" did not effectuate a "transfer"
for purposes of EMTALA. The summary judgment record clearly
establishes that Martínez never left Ryder's facilities, and indeed
died in the room on the Medicine Floor where he was admitted the
night of January 16. Because no transfer occurred, plaintiffs have
not established a stabilization claim under EMTALA.
The reasoning of Morales v. Sociedad Española de Auxilio
Mutuo y Beneficiencia, 524 F.3d 54 (1st Cir. 2008), does not aid
plaintiffs. In Morales, we held that where an individual is en
route to a hospital in an ambulance, and the paramedics contact the
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hospital and discuss the individual's ability to pay, the
individual has "come[] to" the hospital emergency department for
purposes of triggering EMTALA's screening requirement. Id. at 60
(alteration in original). EMTALA did not define "comes to," and
the implementing regulations were ambiguous with regards to
individuals en route to a hospital in an ambulance. Id. at 58, 60.
"Given the imprecision of the statute and the regulation and the
absence of reliable guidance from the agency," we interpreted
"comes to" in a way that prevented hospitals from undermining
EMTALA's statutory intent. Id. at 60-61. In this case, EMTALA
does define the critical expression, "to stabilize." That
definition clearly shows that the duty to stabilize attaches when
a hospital transfers a patient. Moreover, this interpretation is
fully in keeping with the statutory intent, since transfer is where
the danger of patient dumping often arises. Plaintiffs' view of
EMTALA, in contrast, would go beyond the statutory intent and
create a duty of care for medical services provided while a patient
remains in the hospital.
B. EMTALA Claims Against the Physicians
In its Summary Judgment order, the district court stated
that "[p]laintiffs bring their EMTALA claims not only against Ryder
but also against individual physicians." The court then dismissed
these claims on the grounds that "EMTALA applies only to
participating hospitals." On appeal, plaintiffs argue that the
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court wrongly characterized their claims against the physicians who
treated Martínez, and suggest that these claims are based on Puerto
Rico law.
We agree that plaintiffs' claims against Drs. Pastrana,
Ortíz-Kidd, Gómez López, and Cannetti, as reflected in the Second
Amended Complaint, are based, at least in part, on Puerto Rico law.
Nevertheless, the district court also dismissed without prejudice
"plaintiffs' state law claims against defendants," which plainly
includes state-law claims against the individual physicians. The
district court was entitled to do this. 28 U.S.C. § 1367(c)(3)
(permitting district court to decline to exercise supplemental
jurisdiction where it has "dismissed all claims over which it has
original jurisdiction").
C. Claims brought by Tony Martínez Taveras
Lastly, plaintiffs argue that the district court erred in
dismissing state-law claims brought by plaintiff Tony Martínez
Taveras, since there was an alternative basis of jurisdiction over
those claims. Because Martínez Taveras is a citizen of Germany,
plaintiffs argue, the district court has diversity jurisdiction
over his state-law claims against defendants.
We note that plaintiffs did not move to amend the Second
Amended Complaint to reflect a claim of diversity jurisdiction, as
is preferable. See 28 U.S.C. § 1653; Com. of Mass. v. U.S.
Veterans Admin., 541 F.2d 119, 122 (1st Cir. 1976). However,
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plaintiffs did raise the issue below in a proposed Pretrial Order
submitted to the district court, and the defendants had an
opportunity to respond to plaintiffs' claim. Because we can easily
resolve plaintiffs' argument, we need not decide whether they
properly raised the alternative basis of jurisdiction on appeal.
See Futura Dev. of P.R. v. Estado Libre Asociado de P.R., 144 F.3d
7, 12 n.4 (1st Cir. 1998).
Where it applies, diversity jurisdiction requires
"complete diversity of citizenship as between all plaintiffs and
all defendants." Connectu LLC v. Zuckerberg, 522 F.3d 82, 91 (1st
Cir. 2008); Gabriel v. Preble, 396 F.3d 10, 13 (1st Cir. 2005).
This means that diversity jurisdiction does not exist where any
plaintiff is a citizen of the same state as any defendant. Díaz-
Rodríguez v. Pep Boys Corp., 410 F.3d 56, 58 (1st Cir. 2005); see
Strawbridge v. Curtiss, 7 U.S. (3 Cranch) 267, 267 (1806),
overruled on other grounds, Louisville, Cincinnati & Charleston
R.R. Co. v. Letson, 43 U.S. (2 How.) 497, 554-55 (1844). According
to the Second Amended Complaint, several of the plaintiffs and the
defendants are citizens of Puerto Rico. See 28 U.S.C. § 1332(e)
(defining "States" in the diversity jurisdiction statute to include
the Commonwealth of Puerto Rico). Therefore, no diversity
jurisdiction exists.
Affirmed.
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