175 F.3d 170 (1st Cir. 1999), 98-1594, Lopez-Soto v. Hawayek

Docket Nº:98-1594.
Citation:175 F.3d 170
Party Name:Mayda LOPEZ-SOTO, Et al., Plaintiffs, Appellants, v. Jose HAWAYEK, M.D., Et al., Defendants, Appellees.
Case Date:April 09, 1999
Court:United States Courts of Appeals, Court of Appeals for the First Circuit

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175 F.3d 170 (1st Cir. 1999)

Mayda LOPEZ-SOTO, Et al., Plaintiffs, Appellants,


Jose HAWAYEK, M.D., Et al., Defendants, Appellees.

No. 98-1594.

United States Court of Appeals, First Circuit

April 9, 1999

Heard March 2, 1999.

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Guillermo Ramos Luina, with whom Harry Anduze Montano was on brief, for appellants.

Jose A. Rivera Cordero, with whom Pedro Lugo Frank, Luis F. Montijo and Mirta Rodriguez Mora were on brief, for appellees.

Before SELYA, Circuit Judge, COFFIN and CYR, Senior Circuit Judges.

SELYA, Circuit Judge.

This appeal presents a fundamental question concerning the interpretation of the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd (1994) (amended 1997). We neither minimize the difficulty of the question nor pretend that the answer is transpiciously clear. Upon careful perscrutation, however, we hold that EMTALA subsections (a) and (b) are to be read disjunctively, not conjunctively. Accordingly, we reverse the district court's contrary ruling and reinstate the plaintiffs' action.


We rehearse only those facts necessary to add a modicum of texture to our statutory analysis, accepting as true the appellants' version of events. See Fed.R.Civ.P. 56. For ready reference, we reproduce EMTALA's pertinent provisions in an Appendix.

Experiencing normal labor pains, Mayda L¢pez-Soto arrived at Auxilio Mutuo Hospital (the Hospital) in the early morning hours of June 12, 1993. Hospital personnel brought her to the maternity ward where she was examined and admitted. Dr. Jose Hawayek, an obstetrician, broke her water at approximately 7:30 a.m., revealing the presence of thick "pea soup" meconium in the amniotic fluid. Rupturing the membranes of the amniotic sac failed to stimulate dilation, so Dr. Hawayek ordered a cesarean section. L¢pez-Soto gave birth to a baby boy at 1:50 p.m. (roughly 15 minutes after the operation commenced). The infant emerged in severe respiratory distress due to meconium aspiration. His condition presented a medical emergency.

Hospital staffers summoned Dr. Mart¡n Garrido, the pediatrician on call. Dr. Garrido determined that the baby required specialized care and began making arrangements to transfer him to a hospital with a functioning neonatal intensive care unit. Before transport occurred, Dr. Garrido identified an additional cause for medical concern: the presence of a pulmonary pneumothorax. He nonetheless elected to send the infant to the receiving hospital without first attempting to stabilize the patient or to treat that exigent condition. The baby was admitted to the San Juan Pediatric Hospital that evening, but perished the next day.

L¢pez-Soto and her husband brought suit on behalf of themselves and the deceased child in Puerto Rico's federal district court. 1 The complaint named as defendants the Hospital and several caregivers, including Drs. Hawayek and Garrido. L¢pez-Soto premised jurisdiction on the presence of a federal question, see 28 U.S.C. § 1331, that question being

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the existence of a putative cause of action against the Hospital arising under federal law (to wit, EMTALA). She added supplemental claims for medical malpractice under local law against all the defendants.

Only the EMTALA claim is relevant here. In her complaint, L¢pez-Soto posited that the Hospital violated EMTALA because her baby was born "with a severe pulmonary condition that required emergency and immediate medical care and treatment," but the Hospital nonetheless transferred him to another institution without stabilizing this condition. The defendants denied the material allegations of the complaint and contested jurisdiction, saying that EMTALA did not apply. After considerable jousting (not relevant here), the district court, acting pursuant to Fed.R.Civ.P. 56, accepted the defendants' jurisdictional argument and dismissed the EMTALA claim. At the same time, the court declined to retain supplemental jurisdiction over the medical malpractice claims, dismissing them without prejudice. See 28 U.S.C. § 1367(c). This appeal ensued.


L¢pez-Soto's EMTALA claim hinges on the Hospital's alleged failure to comply with the statute's stabilization and transfer provisions. See 42 U.S.C. § 1395dd(b)-(c). In a thoughtful opinion, the district court concluded that Congress's isthmian concern with patient dumping--the practice of refusing to accept or treat patients who are uninsured or have no demonstrable means of payment--precluded reading these provisions independently of 42 U.S.C. § 1395dd(a). See L¢pez- Soto v. Hawayek, 988 F.Supp. 41, 45 (D.P.R.1997). The court therefore adopted a conjunctive interpretation of all three subsections and ruled that they create statutory duties for a covered hospital solely with regard to persons who come to the emergency department for assistance. See id. Only in that event must the hospital provide an appropriate medical screening, 42 U.S.C. § 1395dd(a); and, only if that screening uncovers an emergency medical condition must the hospital stabilize the patient and refrain from transferring him except in compliance with the statutory commands, see 42 U.S.C. § 1395dd(b)-(c).

Superimposing this interpretation upon the scenario depicted by L¢pez-Soto, the district court reasoned that the newborn had not come to the Hospital's emergency room seeking treatment for his respiratory distress, but, rather, had come to the Hospital via the operating room. See L¢pez- Soto, 988 F.Supp. at 46. Consequently, the court determined that EMTALA's stabilization and transfer obligations had not been triggered and that L¢pez-Soto had failed to state a cognizable claim under federal law. See id.

We afford plenary review to the district court's resolution of this unadulterated question of law. See, e.g., United States v. Gifford, 17 F.3d 462, 472 (1st Cir.1994). We start our search for the meaning of the words that Congress wrote with an appraisal of the statutory text and structure, see Inmates of Suffolk County Jail v. Rouse, 129 F.3d 649, 653 (1st Cir.1997), mindful that if the plain language of the statute points unerringly in a single direction, an inquiring court ordinarily should look no further. See United States v. Charles George Trucking Co., 823 F.2d 685, 688 (1st Cir.1987).

EMTALA has a long reach. It touches all acute care hospitals that have executed Medicare provider agreements with the federal government pursuant to 42 U.S.C. § 1395cc. See 42 U.S.C. § 1395dd(e)(2); see also Correa v. Hospital San Francisco, 69 F.3d 1184, 1189-90 (1st Cir.1995). Moreover, it imposes myriad duties on these covered hospitals.

For the most part, these duties reside in three principal statutory silos. The most familiar of these is subsection (a), which imposes a duty to triage. This duty takes the form of a requirement that a covered hospital perform an "appropriate medical screening examination" on "any individual"

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who "comes to the emergency department" seeking examination or treatment. 42 U.S.C. § 1395dd(a). Clearly, this provision obligates hospitals to screen only those individuals who present themselves at the emergency department.

Subsection (b) has a different focus. It emphasizes stabilization, not screening. Thus, if "any individual ... comes to a hospital and the hospital determines that the individual has an emergency medical condition," the hospital must try to stabilize that condition, and can shift the patient to another institution only in accordance with EMTALA's transfer provisions. 42 U.S.C. § 1395dd(b). This language unambiguously imposes certain duties on covered hospitals vis-a-vis any victim of a detected medical emergency, regardless of how that person enters the institution or where within the walls he may be when the hospital identifies the problem. See Helton v. Phelps County Regional Med. Ctr., 794 F.Supp. 332, 333 (E.D.Mo.1992); Smith v. Richmond Mem'l Hosp., 243 Va. 445, 451-52, 416 S.E.2d 689, 692 (1992). Nothing in the subsection's text suggests a necessary relationship between a hospital's obligations and the identity of the department within the hospital to which the afflicted individual presents himself.

Subsection (c) seemingly has relevance to both of the preceding subsections. It provides 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" save upon compliance with certain stipulated conditions. 42 U.S.C. § 1395dd(c)(1). This subsection does not distinguish between patients whose conditions are diagnosed in the emergency room and those whose conditions emerge in other hospital departments.

We reject the district court's attempt to meld these three duties together principally because doing so necessitates eschewal of subsection (b)'s plain language--"comes to a hospital"--in favor of a phrase--"comes to the emergency department"--that appears only in subsection (a). This compressed approach renders the "comes to a hospital" language meaningless; after all, if subsection (a)'s predicate requirement that an individual "come[ ] to the emergency department" were understood to infiltrate subsection (b), the latter's "comes to a hospital" requirement would be altogether superfluous. It is a time-honored tenet that "[a]ll words and provisions of statutes are intended to have meaning and are to be given effect, and no construction should be adopted which would render statutory words or phrases meaningless, redundant, or superfluous." United States v. Ven-Fuel, Inc., 758 F.2d 741, 751-52 (1st Cir.1985). We are reluctant to disregard this venerable canon of construction, especially since a sensible, available interpretation of the statute--one that places the three...

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