Brooks v. Maryland General Hosp., Inc.

Decision Date21 June 1993
Docket NumberNo. 92-1852,92-1852
Citation996 F.2d 708
Parties, 41 Soc.Sec.Rep.Ser. 391, Medicare & Medicaid Guide P 41,486 Robert BROOKS, Plaintiff-Appellant, v. MARYLAND GENERAL HOSPITAL, INCORPORATED; John Doe Morritts; Hassan A. Ghandour; M. Floan; Allan Genut; David M. Cook; University of Maryland Medical System, Incorporated; Michael Salcman; D. Griffith, Defendants-Appellees.
CourtU.S. Court of Appeals — Fourth Circuit

Mark Eric Herman, Baltimore, MD, argued, for plaintiff-appellant.

Jeffrey Grant Cook, Miles & Stockbridge, Towson, MD, argued (Ronald U. Shaw, Miles & Stockbridge, Towson, MD, Donald L. DeVries, Jr., Susan T. Preston, Goodell, DeVries, Leech & Gray, Patti Gilman West, Smith, Somerville & Case, Baltimore, MD, on the brief), for defendants-appellees.

Before PHILLIPS and NIEMEYER, Circuit Judges, and HILL, Senior Circuit Judge of the United States Court of Appeals for the Eleventh Circuit, sitting by designation.


NIEMEYER, Circuit Judge:

Complaining of acute weakness and a sudden inability to walk, Robert Brooks presented himself at the emergency room of Maryland General Hospital in Baltimore on October 5, 1989, at 2:00 in the afternoon. At the time he had no medical insurance. Over six hours later he was first examined but received no treatment or evaluation; three and one-half hours later, he was transferred to the University of Maryland Medical System's emergency room; and three hours still later, at approximately 3:15 the following morning, he was given a pan-myelogram and a CAT scan. Medical personnel were not able to read the results of the CAT scan for three days due to technical difficulties. Brooks claims that the delay caused by the refusal of both hospitals and their professional personnel to diagnose and stabilize his condition caused him permanent spinal cord damage, requiring surgery and lengthy rehabilitation.

Brooks brought suit against both hospitals and the responsible professionals 1 alleging a claim under the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd (imposing on hospitals with emergency rooms duties to screen all individuals coming to the emergency room for emergency medical conditions and to stabilize any emergency medical condition found). The defendants moved to dismiss the complaint because Brooks had not first sought arbitration of his claims as mandated by the Maryland Health Care Malpractice Claims Act (the Maryland Malpractice Act), Md.Cts. & Jud.Proc.Code Ann. § 3-2A-01, et seq. The district court granted defendants' motion, holding that Brooks' claims are covered by the requirements of the Maryland Malpractice Act and accepting defendants' argument that EMTALA did not preempt state law requirements for arbitration. This appeal followed.

We must now decide a case of first impression and determine whether a plaintiff seeking relief under EMTALA must first pursue arbitration required by state law for medical malpractice claims. While we question whether any state law, substantive or procedural, can defeat a federally created cause of action absent some express or implied incorporation of the state law in the federal act, we conclude that a claim under EMTALA would not in any event be within the scope of the Maryland Malpractice Act and therefore would not need to be arbitrated in accordance with its terms. We vacate the judgment in favor of the hospitals only and remand the claims against them for further proceedings. The dismissals of the claims against the individual defendants are affirmed. 2


EMTALA was passed by Congress in 1986 in response to a growing concern that hospitals were "dumping" patients unable to pay, by either refusing to provide emergency medical treatment or transferring patients before their emergency conditions were stabilized. The Act was not designed to provide a federal remedy for misdiagnosis or general malpractice. Rather, Congress expressed concern that hospitals were abandoning the longstanding practice of providing emergency care to all due to increasing pressures to lower costs and maximize efficiency. Under traditional state tort law, hospitals are under no legal duty to provide this care. Accordingly, Congress enacted EMTALA to require hospitals to continue to provide it.

EMTALA imposes two duties on every hospital that has both a medicare provider agreement with the Secretary of Health and Human Services and an emergency room or department: (1) to provide to anyone presented for treatment "an appropriate medical screening ... to determine whether or not an emergency medical condition ... exists," and (2) to stabilize the condition or, if medically warranted, to transfer the person to another facility if the benefits of transfer outweigh its risks. See 42 U.S.C. § 1395dd(a)-(c). 3 A person injured by a breach of these duties may recover "those damages available for personal injury under the law of the State in which the hospital is located." 42 U.S.C. § 1395dd(d)(2)(A).

Although the duty to screen is imposed only within the hospital's capabilities, the hospital must apply its standard of screening uniformly to all emergency room patients, regardless of whether they are insured or can pay. 4 The Act does not impose any duty on a hospital requiring that the screening result in a correct diagnosis. We have noted previously that EMTALA is not a malpractice statute and its "avowed purpose ... was not to guarantee that all patients are properly diagnosed, or even to ensure that they receive adequate care." Baber v. Hospital Corp. of America, 977 F.2d 872, 880 (4th Cir.1992). Rather, Congress deliberately left the establishment of malpractice liability to state law, limiting EMTALA's role to imposing on a hospital's emergency room the duty to screen all patients as any paying patient would be screened and to stabilize any emergency condition discovered. Id. at 879; see also Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1039 (D.C.Cir.1991) ("[A]n 'appropriate' screening is properly determined not by reference to particular outcomes, but instead by reference to a hospital's standard screening procedures."); Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 272 (6th Cir.1990) ("If [the hospital] acts in the same manner as it would have for the usual paying patient, then the screening provided is 'appropriate' within the meaning of the statute.").

In response to Brooks' complaint, which was tailored to allege solely an EMTALA claim, the defendants filed a motion to dismiss, contending that (1) EMTALA does not preempt state malpractice law, including the requirements of the Maryland Malpractice Act, and (2) the Maryland Act requires that a claimant proceed through arbitration as a condition precedent to initiating any claim against a health care provider for medical injury. Since Brooks failed to seek arbitration, the defendants contend that the district court was without jurisdiction to proceed. See Tranen v. Aziz, 304 Md. 605, 612, 500 A.2d 636 (1985); cf. Jewell v. Malamet, 322 Md. 262, 276, 587 A.2d 474 (1991) (refusing to dismiss case pending arbitration to prevent running of statute of limitations).

Defendants' contentions raise the unresolved issue of whether, as a matter of federal law, a state may impose arbitration as a condition precedent to filing suit under EMTALA. Before engaging that issue, however, we must determine first whether Maryland even purports to impose such a requirement for bringing claims such as the present one, a question which depends on whether Brooks' EMTALA claim is a malpractice claim under the terms of the Maryland Malpractice Act.


The Maryland Health Care Malpractice Claims Act was enacted in 1976, ten years before EMTALA, in response to a crisis in health care different from that later addressed by the federal statute. By the early 1970's, an increase in medical malpractice suits in Maryland and elsewhere led to an increase in malpractice insurance premiums and created concern that some health care providers, particularly those in high-risk disciplines, would not be able to continue to practice. One major insurer ceased writing medical malpractice insurance in Maryland and no new company entered Maryland to fill the void. The nature of this crisis is described in St. Paul Fire & Marine Ins. Co. v. Insurance Commissioner, 275 Md. 130, 133-34, 339 A.2d 291 (1975).

The Maryland legislature enacted several pieces of legislation to facilitate access to insurance by health care providers and to lessen the cost of health care. One measure was the Maryland Malpractice Act, which requires, as a condition precedent to filing a malpractice claim in court, that the claimant pursue arbitration. Although the arbitration is not binding, the legislature's purpose was "to reduce the number of medical malpractice court suits by screening out frivolous claims at the arbitration level." Newell v. Richards, 323 Md. 717, 732, 594 A.2d 1152 (1991); see also Attorney General v. Johnson, 282 Md. 274, 308, 385 A.2d 57 (1978) (the Act was intended to encourage more rapid resolution of claims and therefore to lower both costs and insurance premiums), appeal dismissed, 439 U.S. 805, 99 S.Ct. 60, 58 L.Ed.2d 97 (1978), overruled in part on a different point in Newell v. Richards, supra.

More specifically, the Act provides that "[a]ll claims, suits, and actions ... by a person against a health care provider for medical injury" must proceed through arbitration if the amount of damages meets the jurisdictional requirements, which is not at issue in this case. Md.Cts. & Jud.Proc.Code Ann. § 3-2A-02. The term "health care provider" is defined broadly, including, in part, hospitals, physicians, and nurses, id. at § 3-2A-01(e), and "medical injury" is defined as "injury arising or resulting from the rendering or failure to render health care," id. at § 3-2A-01(f).

Unless arbitration is waived by all parties, the...

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