Alvarez-Torres v. Ryder Memorial Hosp., Inc.

• Decision Date: 04 September 2009
• Docket Number: No. 08-2351.,08-2351.
• Citation: 582 F.3d 47
• Parties: Providencia ALVAREZ-TORRES et al., Plaintiffs, Appellants, v. RYDER MEMORIAL HOSPITAL, INC. et al., Defendants, Appellees.
• Court: U.S. Court of Appeals — First Circuit

582 F.3d 47

Providencia ALVAREZ-TORRES et al., Plaintiffs, Appellants, v. RYDER MEMORIAL HOSPITAL, INC. et al., Defendants, Appellees.

No. 08-2351.

United States Court of Appeals, First Circuit.

Heard June 2, 2009.

Decided September 4, 2009.

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.

Before LIPEZ and HOWARD, Circuit Judges, and WOODCOCK, District Judge.^*

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. 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.

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.

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 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 1184, 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).

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 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...