|||United States Court of Appeals For the First Circuit
|||July 17, 2000
|||CINDY REYNOLDS, INDIVIDUALLY, AND AS PERSONAL REPRESENTATIVE OF THE ESTATE
OF WILLIAM D. REYNOLDS; TINA MOORE, AS NEXT FRIEND OF KELLIANN RAE REYNOLDS,
A MINOR; PLAINTIFFS, APPELLANTS,
MAINEGENERAL HEALTH, DEFENDANT, APPELLEE.
|||Joseph M. Jabar, with whom Daviau, Jabar & Batten and David M. Glasser
were on brief, for appellants. George C. Schelling, with whom Gross, Minsky,
Mogul & Singal, P.A. was on brief, for appellee.
|||Before Torruella, Chief Judge, Lipez, Circuit Judge, and Keeton, *fn1
|||The opinion of the court was delivered by: Keeton, District Judge.
|||APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MAINE
[Hon. Eugene W. Beaulieu, U.S. Magistrate Judge]
|||This appeal requires us to interpret the scope of coverage under the Emergency
Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd, for
secondary risks associated with emergency conditions. After reviewing the
record in light of the statutory scheme, we affirm the district court's
summary judgment in favor of defendant-appellee MaineGeneral Health.
|||I. The Facts
|||Because we are reviewing the district court's summary judgment in favor
of defendant-appellee, we recite the facts in the light most favorable to
the plaintiffs-appellants. See Fed. R. Civ. P. 56.
|||On September 8, 1996, William D. Reynolds was driving a car that collided
head-on with another vehicle. As a result of the accident, Mr. Reynolds
suffered various injuries including several fractures of bones in his lower
right leg and left foot. Mr. Reynolds was taken immediately by ambulance
from the accident scene to the emergency room of Kennebec Valley Medical
Center (now known as the MaineGeneral Medical Center and referred to throughout
this opinion for convenience as "MaineGeneral" or the "hospital").
After an emergency room nurse had triaged Mr. Reynolds, he was examined
by Dr. Harry Grimmnitz, the emergency room physician. Dr. Grimmnitz evaluated
Mr. Reynolds, took an oral medical history, and ordered a series of laboratory
tests, x-rays, and an abdominal CT scan. After considering this information,
Dr. Grimmnitz determined that Mr. Reynolds suffered from multiple trauma
to his lower right leg, including a probable open fracture of the right
tibia and fibula and possible fracture of the left foot, and from a possible
|||Dr. Grimmnitz then requested consultations from Dr. Alexander Wall, a
surgeon, and Dr. Anthony Mancini, an orthopedic surgeon. Dr. Wall reported
slight right upper quadrant tenderness with a negative CT scan of the abdomen.
Dr. Mancini examined Mr. Reynolds in the emergency room and took another
oral medical history. Dr. Mancini determined that the injuries to Mr. Reynolds'
lower extremities required surgery. Mr. Reynolds was transferred to the
operating room where Dr. Mancini performed a closed reduction and intramedullary
rodding of the right tibia fracture and a closed reduction and percutaneous
pinning of the left second, third, and fourth metatarsal neck and head fractures.
Following surgery, Mr. Reynolds was admitted to the hospital floor, where
the hospital staff monitored his condition and he began receiving physical
|||On September 13, 1996, Mr. Reynolds was returned to the operating room
for closure of his right lower leg wound. On September 14, 1996, he was
discharged from the hospital. On September 19, 1996, he died of a massive
pulmonary embolism that emanated from deep veinous thrombosis ("DVT")
at the fracture site on his right leg.
|||Plaintiffs proffered the affidavit of Mr. Reynolds' mother-in-law, Shirley
Kimball, who was in the emergency room at MaineGeneral after the accident
but before Mr. Reynolds had surgery. Ms. Kimball states that she saw a man
in a white lab coat ask Mr. Reynolds if he had any allergies or medical
problems of which the hospital should be aware. Ms. Kimball alleges that
Mr. Reynolds told the man "that his family had a blood clotting problem
on his father's and brothers' side of the family whenever they had a trauma."
Appendix to Appellants' Brief at 130.
|||Plaintiffs proffered the affidavits of several family members, each of
whom alleges that he or she told a MaineGeneral employee in the hospital
room after Mr. Reynolds underwent surgery that Mr. Reynolds had a family
history of hypercoagulability.
|||II. Procedural Background
|||On September 8, 1998, plaintiff-appellant Cindy Reynolds, widow of the
decedent William D. Reynolds, filed a complaint in the United States District
Court for the District of Maine in her personal capacity and as the personal
representative of the Estate of the decedent. Mr. Reynolds' minor daughter,
Kelliann Reynolds, is also a plaintiff-appellant. The complaint alleged
that Mr. Reynolds presented to the emergency department at MaineGeneral
on September 8, 1996, with an emergency medical condition as defined by
EMTALA, 42 U.S.C. § 1395dd(e)(1); that MaineGeneral failed to screen Mr.
Reynolds appropriately for DVT, as required under 42 U.S.C. § 1395dd(a);
and that MaineGeneral failed to stabilize Mr. Reynolds for DVT before releasing
him on September 14, 1996, thus violating the requirements of 42 U.S.C §
|||In a memorandum of decision dated September 8, 1999, Magistrate Judge
Beaulieu granted defendant-appellee's motion for summary judgment, having
concluded that the facts did not support a federal claim for failure to
screen under EMTALA even though they supported a state-law claim for negligent
diagnosis and treatment. Magistrate Judge Beaulieu further held that plaintiffs'
claim for failure to stabilize fails as a matter of law because the hospital
was not aware that Mr. Reynolds was suffering from DVT. Plaintiffs filed
their notice of appeal to this court on October 6, 1999.
|||III. Merits of the Appeal
|||A. Screening Claim
|||At issue in this case is the precise scope of a participating hospital's
duty to screen for risks or related conditions associated with or aggravated
by an emergency medical condition. In this instance, MaineGeneral does not
dispute that William Reynolds suffered from an emergency medical condition
at the time he arrived in the emergency room. The parties agree that the
injuries to Mr. Reynolds' lower extremities constituted an emergency medical
condition requiring appropriate screening and stabilization before discharge
or transfer. In dispute is the answer to the following question: Does the
increased risk of DVT associated with this type of injury, combined with
Mr. Reynolds' family history of hypercoagulability, trigger a duty to screen
|||Appellants argue that the risk of DVT constituted a discrete "emergency
medical condition," which required screening and stabilization under
EMTALA, just as the fractures of the lower extremities required screening
and stabilization. Appellee contends that the increased risk of DVT was
not an "emergency medical condition" within the meaning of EMTALA
and did not require particularized screening or stabilization. Appellee
argues generally that risks and conditions associated with or following
from emergency medical conditions that do not constitute independent "emergency
medical conditions" within the meaning of EMTALA will not fall within
the requirements of EMTALA. In evaluating these arguments, we consider three
analytically separable propositions.
|||First. Appellants' first argument is premised on a meaning of "symptom"
that we cannot accept. Appellants argue that summary judgment was not appropriate
because Mr. Reynolds was exhibiting symptoms of an emergency medical condition
- DVT - when he came to the emergency room. Appellants contend that this
court should interpret the word "symptom" in EMTALA's definition
of "emergency medical condition" to include any evidence or communication
of information that an emergency medical condition may exist. Appellants
allege first that injuries to the lower extremities such as those suffered
by Mr. Reynolds create a substantial risk of the development of DVT. They
contend that the knowledge that Mr. Reynolds' injuries indicated a risk
of DVT should be construed as a "symptom" under EMTALA, warranting
further screening and stabilization. Appellants argue alternatively that
Mr. Reynolds' alleged statement that he had a family history of hypercoagulability,
combined with the particular injuries, constituted a "symptom"
of an emergency medical condition. The hospital's failure to screen when
confronted with these symptoms of DVT, appellants aver, violates EMTALA's
|||Appellants' proposed interpretation of "symptoms" is contrary
to ordinary usage, not supported by statutory text or purpose, and not supported
|||EMTALA defines "emergency medical condition" as follows, in
pertinent part: (A) 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 . . . . 42 U.S.C.
|||Appellee argues that information about family history provided by a patient,
without any accompanying psychological or physiological symptoms, cannot
reasonably be understood to be an "acute symptom of sufficient severity"
that is "manifest[ed]" by a "medical condition."
|||We need not and do not adopt this more circuitous path of reasoning instead
of the direct inference that the words of the statute, in their literal
context, do not support appellants' proposed meanings of "symptoms."
|||Caselaw provides no clear answer to the issue of statutory interpretation
|||A patient who communicates that she feels nauseous or dizzy could be describing
a symptom of an emergency medical condition. See Correa v. Hospital San
Francisco, 69 F.3d 1184, 1192 (1st Cir. 1995) ("[N]ausea and dizziness
... might well herald the onset of an emergency medical condition in the
case of a hypertensive diabetic."). In such a case the condition manifests
itself by the dizziness or nausea, a symptom that is then communicated verbally
by the patient. Information about risk-factors, such as injuries or medical
history, would inform a physician's interpretation of that symptom. Nausea
and dizziness alone do not necessarily indicate that an emergency medical
condition exists but, when coupled with a history of hypertension and diabetes,
as in Correa, may indicate the presence of an emergency medical condition.
Several important differences exist, however, between the facts of this
case and those of Correa. First, the patient in Correa was at the time of
the examination experiencing physiological symptoms of a pathological condition,
symptoms that were communicated to the staff of the emergency department.
Here, Mr. Reynolds was not experiencing any physiological symptoms of DVT
that he expressed to anyone at MaineGeneral. Also, the patient in Correa
came to the emergency room complaining of these symptoms and received no
screening or treatment for any condition that she may have had. Here, Mr.
Reynolds was brought to the emergency room with significant trauma to his
lower legs for which he received extensive screening and treatment. Although
appellants ask us to accept as compelling an analogy between the absence
of any screening and treatment in Correa and the lack of screening and treatment
for DVT here, we find this argument unpersuasive.
|||Second. Appellants claim that a court (including this court) should hold
in this case that, for purposes of applying EMTALA's screening requirement,
Mr. Reynolds came to the emergency department twice.
|||Appellants cite López-Soto v. Hawayek, 175 F.3d 170 (1st Cir. 1999), to
support the proposition that the duty to screen does not arise only at the
moment a patient first comes to the emergency room, but may arise later
in the face of new information or changed circumstances. Appellants materially
misread this court's holding in López-Soto. The circumstances in López-Soto
involved a woman who came to the hospital to deliver her baby and was admitted
to the maternity ward. Problems developed during delivery and the child
was born in severe respiratory distress and later died after being transferred
to a different hospital. Defendant in López-Soto argued that the infant
did not "[come] to the emergency room" and that the hospital,
therefore, was not under an obligation to stabilize his emergency medical
condition before transferring him to another hospital. In ruling against
defendant, this court determined that subsection (a) and subsection (b)
of 42 U.S.C. § 1395dd are to be read disjunctively. See id. at 173. That
is, the phrase "comes to the emergency room" relates only to the
duty to screen embodied in subsection (a). Subsection (b), on the other
hand, provides that if any individual "comes to a hospital" and
the hospital determines that the individual has an emergency medical condition,
the hospital has a duty to stabilize that condition. In López-Soto the court
concluded that the duty to stabilize before transfer attaches "as long
as an individual enters any part of the hospital and the hospital determines
that an emergency medical condition exists." Id. at 174 (citation omitted).
Because the court clearly distinguished the requirements imposed by subsection
(a), which are triggered by a patient's coming to the emergency department,
from those imposed by subsections (b) and (c), which are triggered by a
patient's coming to the hospital, appellants' reliance on López-Soto is
|||Appellants try a somewhat different, but related, tack in arguing that
the hospital room should be treated as the functional equivalent of the
emergency department for purposes of this case. Appellants acknowledge that
the need to treat immediately the traumatic injuries to Mr. Reynolds' lower
extremities postponed full screening for and treatment of DVT until after
Mr. Reynolds' traumatic injuries had been treated. Appellants also note
that Mr. Reynolds may not have had DVT when he first arrived at MaineGeneral,
but may have developed DVT while at the hospital. They propose that because
of these circumstances, the duty to screen should be tolled, in effect,
until after the traumatic injuries had been treated and clotting was more
likely to have begun. Appellants argue that it would be unreasonable for
this court to interpret 42 U.S.C. § 1395dd(a) in a way that requires Mr.
Reynolds to leave the hospital and re-enter the emergency room a second
time in order to receive screening and treatment for potential DVT. Not
only does the text of the statute fail to support appellants' contention,
but neither does the purpose of the statute as manifested by Congress.
|||As numerous courts have noted, including this one, "EMTALA is a limited
'anti-dumping' statute, not a federal malpractice statute." Bryan v.
Rectors and Visitors of the Univ. of Va., 95 F.3d 349, 351 (4th Cir. 1996)
(citation omitted); see Correa, supra, 69 F.3d at 1192; Summers v. Baptist
Med. Ctr. Arkadelphia, 91 F.3d 1132, 1137 (8th Cir. 1996) ("So far
as we can tell, every court that has considered EMTALA has disclaimed any
notion that it creates a general federal cause of action for medical malpractice
in emergency rooms."); Urban v. King, 43 F.3d 523, 525 (10th Cir. 1994).
Congress enacted EMTALA in 1996, in the face of "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." H.R. Rep. No. 241(I), 99th Cong., 1st Sess. 27 (1986),
reprinted in 1986 U.S.C.C.A.N. 42, 605. EMTALA created a remedy for patients
in certain contexts in which a claim under state medical malpractice law
was not available. Although the exact scope of the rights guaranteed to
patients by EMTALA is still not fully defined, it is clear that at a minimum
Congress manifested an intent that all patients be treated fairly when they
arrive in the emergency department of a participating hospital and that
all patients who need some treatment will get a first response at minimum
and will not simply be turned away. See Baber v. Hospital Corp. of America,
977 F.2d 872, 880 (4th Cir. 1992) ("The avowed purpose of EMTALA was
not to guarantee that all patients are properly diagnosed, or even to ensure
that they receive adequate care, but instead to provide an 'adequate first
response to a medical crisis' for all patients and 'send a clear signal
to the hospital community . . . that all Americans, regardless of wealth
or status, should know that a hospital will provide what services it can
when they are truly in physical distress.'") (quoting 131 Cong. Rec.
S13904 (Oct. 23, 1985) (statement of Sen. Durenberger)). Appellants' argument
that because Mr. Reynolds was in a hospital room receiving treatment for
his injuries when the risk of DVT became manifest, it would be unreasonable
to deny him the protections of subsection (a) is unpersuasive. The fact
that Mr. Reynolds was in the hospital receiving treatment is a prima facie
showing that the purpose of subsection (a) was satisfied; any failures of
diagnosis or treatment were then remediable under state medical malpractice
|||Third. Appellants argue that MaineGeneral screened Mr. Reynolds differently
than it did other patients exhibiting similar symptoms. Appellants contend
that a complete medical history, under MaineGeneral's hospital policy, includes
questioning patients concerning any family history of hypercoagulability.
They aver that because Mr. Reynolds was not asked questions about his family
history of blood-clotting, he received disparate treatment.
|||Appellants proffered evidence that MaineGeneral's only written policy
regarding the taking of medical histories from patients required that a
"complete history" be taken from all patients. Appellants proffered
expert testimony to support the proposition that a "complete history"
in Mr. Reynolds' context necessarily included asking questions about any
family history of hypercoagulability. Appellants aver that this expert testimony,
in conjunction with the absence of any more detailed hospital policies,
compels an inference that MaineGeneral gave disparate treatment to Mr. Reynolds
when it did not ask him questions concerning his family history of hypercoagulability.
|||Appellants' argument attempts again to bring a malpractice standard into
the interpretation and application of a statute designed to complement and
not incorporate state malpractice law. To recover for disparate treatment,
appellants must proffer evidence sufficient to support a finding that Mr.
Reynolds received materially different screening than that provided to others
in his condition. It is not enough to proffer expert testimony as to what
treatment should have been provided to a patient in Mr. Reynolds' condition.
Appellants have not proffered evidence sufficient to support a finding that
Mr. Reynolds received materially different screening than did other patients
in his condition.
|||Insofar as appellants are continuing to make a general case for interpreting
EMTALA as providing a federal-law remedy for any inappropriate treatment
in a hospital to which a patient in need of emergency attention is brought,
this attempt fails for the reasons explained above. In Correa, this court
recognized appropriate emergency screening as the EMTALA objective and sketched
out the contours of appropriate 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. . . . The essence of this requirement is that there be some
screening procedure, and that it be administered even-handedly. Correa,
69 F.3d at 1192 (emphasis added) (internal citations omitted).
|||Because we conclude, based on the record before us, that appellants failed
to proffer evidence sufficient to support a finding that Mr. Reynolds was
"symptomatic" for DVT, within the meaning of the statute, the
hospital was not required under the statute to screen for DVT.
|||B. Stabilization Claim
|||In addition to their claim for failure to screen Mr. Reynolds appropriately
for DVT, appellants argue that a genuine dispute of material fact exists
as to whether MaineGeneral stabilized Mr. Reynolds for DVT before releasing
him. Appellants argue extensively about the nature of the stabilization
requirements under EMTALA in support of their contention that Mr. Reynolds
was not stabilized before release. A critical flaw in this claim of appellants
under § 1395dd(b)(1), however, is that appellants have failed to demonstrate
that Mr. Reynolds had an emergency medical condition at the time of his
discharge from MaineGeneral.
|||As a corollary to the right to be appropriately screened, EMTALA guarantees
patients the right, if an emergency medical condition is determined to exist,
to have that condition stabilized before discharge or transfer to another
hospital. The statute provides, in pertinent part: If any individual . .
. comes to a hospital and the hospital determines that the individual has
an emergency medical condition, the hospital must provide either-
|||(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, or
|||(B) for transfer of the individual to another medical facility in accordance
with subsection (c).
|||42 U.S.C. § 1395dd(b)(1) (emphasis added). This court need not reach any
questions about the nature of stabilization if we determine that the predicates
to stabilization have not been satisfied. Appellants proffered expert testimony
that it was likely that the clot that later became the pulmonary embolism
that caused Mr. Reynolds' death formed before Mr. Reynolds was discharged
from MaineGeneral. Appellants' expert further testified that a 17 to 30%
likelihood existed that Mr. Reynolds had formed blood clots at the time
of his discharge. Appellants' expert also proffered testimony that some
research indicates a 2% mortality rate in cases of untreated DVT. Evidence
of one expert that it is more likely than not in his opinion that the blood
clot that eventually caused Mr. Reynolds' death had formed by the time of
his discharge, combined with the evidence that 2% of untreated DVT cases
result in death, is not sufficient to support a determination that Mr. Reynolds
had an emergency medical condition at the time of his discharge. To invoke
subsection (b), appellants must proffer more than evidence of a possibility
of the existence of a blood clot at the time of Mr. Reynolds' discharge.
They must proffer evidence sufficient to support a finding, reasoned from
evidence, that an emergency medical condition, within the meaning of the
statute, was already in existence at the time of Mr. Reynolds' discharge.
Appellants have not proffered evidence sufficient to support a finding that
Mr. Reynolds had an emergency medical condition at that time, and for this
reason have failed to satisfy a necessary predicate to the duty to stabilize.
|||Furthermore, as noted by Magistrate Judge Beaulieu, appellants' case is
centered on the asserted fact that MaineGeneral did not take steps to determine
whether Mr. Reynolds was at risk of developing DVT. It is doubtful that
the text of the statute would support liability under the stabilization
provision for a patient who had DVT, absent evidence sufficient to support
a finding that the hospital knew of his DVT. See Marshall v. East Carroll
Parish Hosp. Serv. Dist., 134 F.3d 319, 325 (5th Cir. 1998); Summers, supra,
91 F.3d at 1140 (no duty to stabilize unless hospital "has actual knowledge
of the individual's unstabilized emergency medical condition"); Vickers
v. Nash Gen. Hosp., Inc., 78 F.3d 139, 145 (4th Cir. 1996) ("The Act
does not hold hospitals accountable for failing to stabilize conditions
of which they are not aware, or even conditions of which they should have
been aware."). It appears quite likely that one important respect in
which EMTALA's requirements are narrower than those imposed by state law
concerns prophylactic care. Subsection (b) requires stabilization of only
those conditions that a participating hospital has determined to be emergencies.
It may be that in exceptional circumstances of proof of an existing emergency
need for immediate stabilization, a hospital would have a duty of stabilization
under EMTALA. We need not and do not reach that issue, however, since it
is not presented by the record before us in this case.
|||Because appellants' claims essentially are claims that MaineGeneral misdiagnosed
and negligently treated William Reynolds, we believe the district court
appropriately granted defendant's motion for summary judgment on plaintiffs'
EMTALA claims. For the reasons stated in this opinion, the judgment of the
district court is AFFIRMED.
|||*fn1 Of the District of Massachusetts, sitting by designation.
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