Baker v. Adventist Health, Inc., SUCCESSOR-IN-INTEREST

• Decision Date: 06 August 2001
• Docket Number: PLAINTIFF-APPELLANT,No. 00-15273,SUCCESSOR-IN-INTEREST,DEFENDANTS-APPELLEES,00-15273
• Citation: 260 F.3d 987
• Parties: (9th Cir. 2001) SARAH BAKER, A MINOR, INDIVIDUALLY AND ASTO HENRY BAKER, DECEASED, BY AND THROUGH HER GUARDIAN AD LITEM, LORIE MCKINNON,, v. ADVENTIST HEALTH, INC.; REDBUD COMMUNITY HOSPITAL DISTRICT; WOLFGANG SCHUG, M.D.; JANZEN, JOHNSTON & ROCKWELL EMERGENCY MEDICAL GROUP OF CALIFORNIA, INC.,
• Court: U.S. Court of Appeals — Ninth Circuit

Page 987

260 F.3d 987 (9th Cir. 2001)

SARAH BAKER, A MINOR, INDIVIDUALLY AND AS SUCCESSOR-IN-INTEREST TO HENRY BAKER, DECEASED, BY AND THROUGH HER GUARDIAN AD LITEM, LORIE MCKINNON, PLAINTIFF-APPELLANT, v. ADVENTIST HEALTH, INC.; REDBUD COMMUNITY HOSPITAL DISTRICT; WOLFGANG SCHUG, M.D.; JANZEN, JOHNSTON & ROCKWELL EMERGENCY MEDICAL GROUP OF CALIFORNIA, INC., DEFENDANTS-APPELLEES.

No. 00-15273

UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT

Argued and Submitted June 12, 2001

Filed August 6, 2001

[Copyrighted Material Omitted]

[Copyrighted Material Omitted]

Richard J. Massa, Massa & Associates, Lakeport, California, for the plaintiff-appellant.

Michael Tilner and Orly Degani, Horvitz & Levy, Llp, Encino, California; John S. Gilmore, Goldsberry, Freeman & Swanson, Sacramento, California; and David A. Heck, Bradley, Curley, Asiano & McCarthy, PC, San Francisco, Califor-nia, for the defendants-appellees.

Appeal from the United States District Court for the Northern District of California

Saundra B. Armstrong, District Judge, Presiding D.C. No. CV-97-03537-SBA/ WDB

Before: Mary M. Schroeder, Chief Judge, Donald P. Lay,^* David R. Thompson, Circuit Judges.

Schroeder, Chief Judge.

This case arises out of the tragic death of Henry Baker, who committed suicide two days after being released from the Redbud Community Hospital emergency room. The primary issue is whether the hospital violated the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. § 1395dd, when it called in a crisis worker from the county mental health department to screen Baker for a psychiatric emergency. The district court granted summary judgment in favor of the defendants on the ground that EMTALA requires the hospital only to provide a screening examination that is within the capability of its emergency department, and therefore could not have violated the statute by calling in an out-side expert to perform a screening that was beyond the hospital's capabilities. We affirm.

BACKGROUND

Redbud Community Hospital ("Redbud") is a 40-bed rural hospital located in Clearlake, California. It operates an emergency room, but it does not offer psychiatric treatment and has no psychiatrists, psychologists, or any other mental health professionals on staff. The hospital has a written policy that directs emergency room personnel to consult with the Lake County Mental Health Department ("Lake County") when dealing with patients who present possible psychiatric emergencies.

On September 25, 1996, Henry Baker was brought to the hospital by his former sister-in-law and her fiance, with whom Baker lived. The nurse who triaged him recorded his chief complaint as "request mental health evaluation. " The nurse checked his vital signs, noted no obvious physical problems, and classified Baker's triage status as "delayed, " meaning that he was in a stable condition, was in no distress, and was entitled to less priority than patients with life-threatening or urgent needs.

About ninety minutes later, Baker was examined by Dr. Wolfgang Schug, an emergency room physician on Redbud's medical staff. Dr. Schug recorded a patient history that includes the notation, "Last 90 days `apathetic,' unable to communicate, depressed. Suicide `constantly' in back of mind." Dr. Schug concluded that Baker had no physical or medical condition requiring immediate care, and recorded his diagnosis as "(1) Depression (2) Medical clearance for Mental Health."

Redbud has a written policy requiring the emergency department to request a mental health evaluation from Lake County if the medical screening turns up evidence of a "psychiatric disturbance" or symptoms of substance abuse. Patients must be "medically cleared" before Lake County is called to perform a mental health evaluation. The policy provides that the emergency physician's examination must be "sufficient to rule out any organic causes of the aberrant behavior."

In accordance with hospital policy, Dr. Schug contacted Lake County to request a mental health evaluation of Baker. In his telephone call to Lake County, Dr. Schug reported that Baker was not saying that he was suicidal, according to the undisputed facts. Dr. Schug testified in his deposition that he could not tell whether Baker was a danger to himself, and called Lake County to have them make that determination.

Within one half hour of Dr. Schug's call, Lake County crisis worker Dennis Skinner and a trainee arrived at Redbud. Skinner had an M.S. degree in counseling psychology. He examined Baker and concluded that he did not meet the criteria for an involuntary hold under the applicable state statute, California Welfare & Institutions Code § 5150, because Baker did not constitute a danger to himself or others.

Baker was discharged from Redbud after he agreed to go to Lake County the following day to complete paperwork in order to qualify for medical expenses and social services, and to receive an assessment by a clinician for possible referral to a psychiatrist for the treatment of depression. Both Dr. Schug and Baker signed the discharge record, which noted that there was to be a mental health follow-up. Baker's body was found two days later after he had hanged himself from a tree.

This suit was filed on behalf of Baker's minor daughter in 1997. She sought damages and injunctive relief for violations of EMTALA and California Health & Safety Code § 1317, as well as for medical negligence under state law. After discovery, the district court granted summary judgment in 1999 for the defendants on the EMTALA and § 1317 claims. The district court declined to exercise supplemental jurisdiction over the remaining state law claims and dismissed the action. This appeal followed.

DISCUSSION

A. EMTALA

The essence of plaintiff's case is that Redbud was required under EMTALA to provide a psychiatric examination with the hospital's own personnel, and that it violated the statute by calling in Lake County to screen Baker for a psychiatric emergency. The plaintiff further contends that the hospital violated EMTALA by failing to stabilize an emergency medical condition, by disparately applying its mental health policy to Baker, by discriminating against persons who have psychiatric as opposed to physical emergency conditions, and by improperly transferring Baker to Lake County before he was stabilized.

EMTALA imposes two duties on hospital emergency rooms: a duty to screen a patient for an emergency medical condition, and, once an emergency condition is found, a duty to stabilize the patient before transferring or discharging him. See 42 U.S.C. § 1395dd; Jackson v. East Bay Hospital, 246 F.3d 1248, 1254-55 (9th Cir. 2001). The statute requires the emergency department to "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, to determine whether or not an emergency medical condition . . . exists. " 42 U.S.C. § 1395dd(a).¹ If the hospital determines that an individual has an emergency medical condition, it must provide"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." 42 U.S.C. § 1395dd(b)(1)(A).

The hospital's duty to stabilize arises only when it actually detects an emergency medical condition. Jackson , 246 F.3d at 1257. If the patient's condition has not been stabilized,² the hospital may not transfer³ the patient to another medical facility unless (1) the patient or her proxy requests a transfer in writing, or (2) a physician or other medical professional certifies that the medical benefits available at the other facility outweigh the risks of transfer. See 42 U.S.C. § 1395dd(c)(1). Any transfer of a patient whose emergency medical condition has not been stabilized must comply with additional requirements set forth in the statute in order to qualify as an "appropriate transfer." See 42 U.S.C. § 1395dd(c)(2).

Congress enacted EMTALA to respond to the specific problem of hospital emergency rooms refusing to treat patients who were uninsured or who could otherwise not pay for treatment. In such situations, emergency rooms would either decline to provide treatment or transfer patients in an unstable condition to other hospitals, thereby jeopardizing patients' health. See H.R. Rep. No. 99-241, pt. I, at 27 (1985), reprinted in 1986 U.S.C.C.A.N. 579, 605; Jackson, 246 F.3d at 1254.

The statute is not intended to create a national standard of care for hospitals or to provide a federal cause of action akin to a state law claim for medical malpractice. See Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1258 (9th Cir. 1995). The statute expressly contains a non-preemption provision for state remedies. See 42 U.S.C. § 1395dd(f). Indeed, we recently held, in a case that ironically also involved Redbud, that the hospital did not violate EMTALA even though it misdiagnosed an emergency condition as a psychiatric rather than a medical condition. See Jackson, 246 F.3d at 1256-57.

The novel argument plaintiff makes in this case is that the hospital should have provided a mental health screening itself rather than calling in the county mental health department. This is not a tenable position under the statute, however, for the statute explicitly limits the screening examination that the hospital is required to provide to one that is "within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department." The hospital did not have the capability to perform a mental health screening. Nor are mental health services listed in Redbud's written policy detailing ancillary services available to the emergency department. Redbud therefore did not have any duty to provide Baker with a mental health screening. For purposes of our EMTALA...