Del Carmen Guadalupe v. Negron Agosto

• Decision Date: 07 August 2002
• Docket Number: No. 01-2083.,01-2083.
• Citation: 299 F.3d 15
• Parties: Maria DEL CARMEN GUADALUPE, Efrain Laboy Guadalupe, Marcelina Franqui Figueroa, Plaintiffs, Appellants, v. Dr. Samuel NEGRON AGOSTO; Hospital Interamericano de Medicina Avanzada, Inc.-Humacao, Defendants, Appellees.
• Court: U.S. Court of Appeals — First Circuit

299 F.3d 15

Maria DEL CARMEN GUADALUPE, Efrain Laboy Guadalupe, Marcelina Franqui Figueroa, Plaintiffs, Appellants, v. Dr. Samuel NEGRON AGOSTO; Hospital Interamericano de Medicina Avanzada, Inc.-Humacao, Defendants, Appellees.

No. 01-2083.

United States Court of Appeals, First Circuit.

Heard March 7, 2002.

Decided August 7, 2002.

COPYRIGHT MATERIAL OMITTED

Kevin G. Little, with whom Law Offices of David Efron was on brief for appellants.

Fernando Agrait Betancourt for appellees.

Before TORRUELLA and LIPEZ, Circuit Judges, COFFIN, Senior Circuit Judge

LIPEZ, Circuit Judge.

This case concerns the grounds for establishing the liability of a hospital under the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd. EMTALA requires hospitals to provide emergency room patients with an appropriate medical screening designed to identify emergency conditions. Contending that Hospital Interamericano de Medicina Avanzada, Inc.-Humacao (HIMA) provided such a minimal screening for Narciso Figueroa that it could not be deemed appropriate, the plaintiffs appeal the district court's grant of summary judgment to HIMA. We affirm.

I. Background

In reviewing an award of summary judgment, we "view the entire record in the light most hospitable to the party opposing summary judgment, indulging all reasonable inferences in that party's favor." Griggs-Ryan v. Smith, 904 F.2d 112, 115 (1st Cir.1990). We state the facts accordingly.

On October 2, 1998, at approximately 9:50 P.M., Maria del Carmen Guadalupe took her husband, Narciso Figueroa, to the Yabucoa Diagnostic and Treatment Center (YDTC). Figueroa was suffering from urinary retention, edema in his legs, high blood pressure, and pain. The YDTC referred Figueroa to HIMA, where he arrived at 1:05 A.M. on October 3, 1998, accompanied by del Carmen Guadalupe. By this time, Figueroa was also suffering from increased respiratory difficulty, a dry cough, fever, and drowsiness.

When he arrived at HIMA, Figueroa was joined by his niece, a nurse who worked at the hospital (but was off duty at the time). She spoke to the doctor on call, Dr. Samuel Negron Agosto. While del Carmen Guadalupe filled out paperwork at the front desk of the hospital, Dr. Negron Agosto examined Figueroa. Although there were other patients in the emergency room, Figueroa was examined before them. At least two nurses also attended to Figueroa, taking his vital signs, drawing blood, and arranging for an x-ray of his chest. The nurses also checked the Foley catheter (designed to drain urine) that had been attached to Figueroa before he arrived. Figueroa was conscious the whole time, communicating to family members and health care workers.

After reviewing an x-ray, Dr. Negron Agosto diagnosed Figueroa with bronchial pneumonia. In her deposition, del Carmen Guadalupe claimed that Dr. Negron Agosto told Figueroa's niece (the nurse) that Figueroa could be discharged because "nobody dies from [bronchial pneumonia]." Before del Carmen Guadalupe left with Figueroa, Dr. Negron Agosto gave her some medicine and told her to give it to Figueroa once they got home and to return to the hospital the next day to pick up the x-ray. Figueroa was discharged at about 3:00 A.M., and del Carmen Guadalupe drove him back home by 5:00 A.M. He was conscious and speaking during the journey, and did not complain about his treatment at the hospital.

After del Carmen Guadalupe and Figueroa returned to their home, they looked for the medicine, but could not find it. Rather than returning for a replacement, they decided to rest. Unfortunately, Figueroa's condition continued to deteriorate, prompting del Carmen Guadalupe to take him to another hospital, Ryder Memorial Hospital. Figueroa was pronounced dead upon arrival at Ryder at 1:45 P.M. Dr. Yocasta Brugal of the Forensic Sciences Institute of Puerto Rico performed an autopsy on Figueroa and established the cause of death as bilateral bronchial pneumonia.

Plaintiffs, heirs of Figueroa, filed a complaint against HIMA and Dr. Samuel Negron Agosto on September 22, 1999, charging them with violations of EMTALA and medical malpractice under Puerto Rican law. After discovery, HIMA filed a motion for summary judgment and/or to dismiss, arguing that the plaintiffs failed to state a claim under EMTALA. HIMA argued that summary judgment was appropriate because undisputed facts demonstrated that the hospital had given Figueroa an appropriate screening examination comparable to the screening it would have given any patient with substantially similar symptoms. It also moved the district court to dismiss without prejudice the malpractice claims.

To oppose the summary judgment motion, the plaintiffs submitted hospital reports, records, and policies, a deposition from del Carmen Guadalupe, and a letter and deposition from their expert, Dr. David R. Nateman, Medical Director of the Emergency Services Department of the Baptist Hospital of Miami. Dr. Nateman's report concluded that both the Hospital and Dr. Negron Agosto

fell below the standards of medical care for failing to diagnose a life-threatening medical condition which resulted in the death of Narcisco [sic] Figueroa. In addition, by providing an inadequate medical screening at [the hospital], the patient was not afforded the right of determination of medical stability and therefore was illegally transferred which resulted in a violation of EMTALA.

On June 22, 2001, the district court granted HIMA's motion for summary judgment with respect to the plaintiffs' EMTALA claim, and dismissed without prejudice their supplemental malpractice claims. The plaintiffs appeal from this decision.

II. EMTALA Standards

The parties agree that HIMA provided Figueroa with a screening; they disagree over whether it was an "appropriate medical screening" under the terms of EMTALA. 42 U.S.C. § 1395dd(a). HIMA argues that a plaintiff can prevail under EMTALA only if she can demonstrate that the hospital offered no screening at all, or deviated from its standard screening procedures applicable to other patients with similar conditions.¹ As HIMA puts it in its brief, "[w]hat EMTALA prohibits is disparate screening or no screening at all." Although appellants agree with the disparate screening standard, they also contend that a hospital can violate EMTALA if its screening is so cursory or inadequate that it is tantamount to no medical screening. As we explain, neither party has it exactly right.

By its terms, EMTALA is designed to assure that any person visiting a covered hospital's emergency room is screened for an emergency medical condition and is stabilized if such a condition exists.² With respect to screening, it requires the following:

In the case of a hospital that has a hospital emergency department, if any individual ... comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must 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 (within the meaning of subsection (e)(1) of this section) exists.

42 U.S.C. § 1395dd(a). EMTALA does not define the term "appropriate medical screening examination." However, it does indicate that the purpose of the screening is to identify an "emergency medical condition." An emergency medical condition is defined as

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 (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

(ii) serious impairment to bodily functions, or

(iii) serious dysfunction of any bodily organ or part[.]

42 U.S.C. § 1395dd(e)(1)(A). To identify such conditions, hospitals are expected to employ "ancillary services routinely available to the emergency department." 42 U.S.C. § 1395dd(a). However, they are not liable for failing to conduct examinations (or parts thereof) that are not "within the capability of the hospital's emergency department." 42 U.S.C. § 1395dd(a).

With the statutory language as a guide, we have said previously that "[t]he essence of [EMTALA's] screening requirement is that there be some screening procedure, and that it be administered even-handedly." Correa v. Hosp. San Francisco, 69 F.3d 1184, 1192 (1st Cir.1995). Thus, there is both a substantive and a procedural component to an appropriate medical 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." Id.; see also Jackson v. East Bay Hosp., 246 F.3d 1248, 1256 (9th Cir.2001) ("We hold that a hospital satisfies EMTALA's `appropriate medical screening' requirement if it provides a patient with an examination comparable to the one offered to other patients presenting similar symptoms, unless the examination is so cursory that it is not `designed to identify acute and severe symptoms that alert the physician of the need for immediate medical attention to prevent serious bodily injury.'" (quoting Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1257 (9th Cir.1995))).

III. Applying the Legal Standards

A. Reasonably Calculated to Identify Critical Medical Conditions

In pressing their claim that HIMA failed to provide Figueroa with an appropriate medical screening under the terms of EMTALA, plaintiffs argued that "[t]he medical examination and treatment [offered to Figueroa]...