Correa v. Hospital San Francisco

Citation1995 WL 627505,69 F.3d 1184
Decision Date31 October 1995
Docket NumberNo. 95-1167,95-1167
PartiesGloria Ivette CORREA, a/k/a Gloria Ivette Correa Gonzalez, et al., Plaintiffs, Appellees, v. HOSPITAL SAN FRANCISCO, Defendant, Appellant.
CourtUnited States Courts of Appeals. United States Court of Appeals (1st Circuit)

Igor J. Dominguez, on brief, Hato Rey, PR, for appellant.

Kevin G. Little, Los Angeles, CA, and Law Offices of David Efron, Rio Piedras, PR, on brief, for appellees.

Before SELYA, Circuit Judge, COFFIN, Senior Circuit Judge, and BOUDIN, Circuit Judge.

SELYA, Circuit Judge.

This appeal requires us to interpret, for the first time, the Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. Sec. 1395dd (1988 & Supp. V 1993). 1 After scrutinizing the record and dovetailing the facts with the statutory scheme, we affirm a $700,000 jury verdict in favor of the heirs and survivors of Carmen Gloria Gonzalez Figueroa (Ms. Gonzalez) against defendant-appellant Hospital San Francisco (HSF or the Hospital).

I. THE FACTS

We are guided through the thicket of conflicting testimony and the chasmal gaps in the direct evidence by the rule that, when the losing party protests the sufficiency of the evidence, the court of appeals must take both the facts and the reasonable inferences therefrom in the light most hospitable to the jury's verdict. See Sanchez v. Puerto Rico Oil Co., 37 F.3d 712, 716 (1st Cir.1994); Wagenmann v. Adams, 829 F.2d 196, 200 (1st Cir.1987).

According to her son, Angel Correa, Ms. Gonzalez, a sixty-five-year-old widow, awoke on the morning of September 6, 1991 "feeling real bad," and experiencing "chills, cold sweat, dizziness, [and] chest pains." She requested that Angel take her to the emergency room at HSF (where she had been treated previously). She arrived there no later than 1:00 p.m.

The evidence is conflicted as to whom she saw and what that person was told about her condition. Angel testified that he implored the receptionist to have someone "take care of my mother, because she feels sick and has chest pains." The Hospital disagrees, maintaining that its personnel were told only that Ms. Gonzalez felt dizzy and nauseated. In any event, a Hospital employee assigned the patient a number (forty-seven), told her to bide her time, and checked her medical insurance card. 2 After waiting approximately one hour, Angel called his sister, Esther Correa, and asked her to relieve him. Esther arrived some fifteen minutes later and Angel left the premises. At that very moment (roughly 2:15 p.m.), he heard an attendant calling patient number twenty-four for treatment.

Now accompanied by her daughter, Ms. Gonzalez maintained her unproductive vigil for an additional forty-five to seventy-five minutes. The Hospital staff continued blithely to ignore her. Weary of waiting, the two women drove to the office of Dr. Acacia Rojas Davis (Dr. Rojas), the director of Hospmed, arriving there between 3:00 and 3:30 p.m. According to Dr. Rojas, a nurse called from HSF to advise her that the patient would be coming to Hospmed for treatment. Dr. Rojas said that this conversation probably occurred earlier that day (perhaps around 1:00 p.m.), a datum suggesting that HSF tried to shunt Ms. Gonzalez to Hospmed as soon as it scrutinized her insurance card.

Ms. Gonzalez informed Dr. Rojas that she was nauseated and had taken a double dose of her high blood pressure medication. Her blood pressure was very low (90/60), and, when she began vomiting, the physician immediately started intravenous infusions of fluids. She also dispensed medicine to control the emesis. Despite these ministrations, Ms. Gonzalez's condition steadily deteriorated. Dr. Rojas had to resuscitate her soon after her arrival. The doctor then attempted to transfer her to the Hato Rey Community Hospital, but could not commandeer an ambulance. As Dr. Rojas began preparations to transport Ms. Gonzalez by van, the patient expired. Her death, which occurred at around 4:30 p.m., was attributed to hypovolemic shock.

II. THE PROCEEDINGS BELOW

The plaintiffs--Ms. Gonzalez's three adult children and four of her grandchildren (the progeny of her late son, Felix Correa, who had predeceased her)--brought suit against the Hospital in the United States District Court for the District of Puerto Rico. 3 They alleged two violations of EMTALA--inappropriate screening and improper transfer--and a pendent claim of medical malpractice under local law. Following a trial, the plaintiffs' case went to the jury on the two theories of EMTALA liability. 4 The jury returned a series of special written findings, Fed.R.Civ.P. 49(a), assessed $200,000 in damages on the decedent's account (payable to the heirs), and assessed $500,000 in damages for the pain, suffering, and mental anguish experienced by the survivors--$100,000 apiece for the three children (Angel, Esther, and Gloria), and $50,000 apiece for the four grandchildren (Glendalis, Glorimar, Angelis, and Sarai). The district court denied the Hospital's post-trial motions for judgment as a matter of law, a new trial, and remission of damages. This appeal ensued.

III. THE STATUTORY SCHEME

We delineate EMTALA's requirements in order to give definition to the statutory cause of action and place some of its nuances into perspective.

As health-care costs spiralled upward and third-party payments assumed increased importance, Congress became concerned "about the increasing number of reports that hospital emergency rooms are refusing to accept or treat patients with emergency conditions if the patient does not have medical insurance." H.R.Rep. No. 241(I), 99th Cong., 1st Sess. 27 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 605. Congress enacted EMTALA to allay this concern. Needing a carrot to make health-care providers more receptive to the stick, Congress simultaneously amended the Social Security Act, conditioning hospitals' continued participation in the federal Medicare program--a lucrative source of institutional revenue--on acceptance of the duties imposed by the new law. See 42 U.S.C. Sec. 1395dd(a-b), (e)(2); see also Abercrombie v. Osteopathic Hosp. Founders Ass'n, 950 F.2d 676, 680 (10th Cir.1991); Brooker v. Desert Hosp. Corp., 947 F.2d 412, 414 (9th Cir.1991).

We have set out the portions of the statute that are most germane to this appeal in an appendix. For purposes of patients such as Ms. Gonzalez, EMTALA has two linchpin provisions. First, it requires that a participating hospital afford an appropriate medical screening to all persons who come to its emergency room seeking medical assistance. See 42 U.S.C. Sec. 1395dd(a). Second, it requires that, if an emergency medical condition exists, the participating hospital must render the services that are necessary to stabilize the patient's condition, see id. Sec. 1395dd(b)(1)(A), unless transferring the patient to another facility is medically indicated and can be accomplished with relative safety, see id. Sec. 1395dd(b)(1)(B), (c)(1). To add bite to its provisions, EMTALA establishes monetary penalties for noncompliance, see id. Sec. 1395dd(d)(1), and authorizes private rights of action against those who transgress its mandates, see id. Sec. 1395dd(d)(2).

To establish an EMTALA violation, a plaintiff must show that (1) the hospital is a participating hospital, covered by EMTALA, that operates an emergency department (or an equivalent treatment 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. See Miller v. Medical Ctr. of S.W. La., 22 F.3d 626, 628 (5th Cir.1994); Stevison v. Enid Health Sys., Inc., 920 F.2d 710, 712 (10th Cir.1990).

HSF attempts to read into section 1395dd(a) an additional requirement: that the patient show that she in fact suffered from an emergency medical condition when she arrived at the emergency room. But EMTALA imposes no such requirement. The statute by its terms directs a participating hospital to provide an appropriate screening to all who come to its emergency department. Thus, to prove a violation of EMTALA's screening provisions, a plaintiff need not prove that she actually suffered from an emergency medical condition when she first came through the portals of the defendant's facility; the failure appropriately to screen, by itself, is sufficient to ground liability as long as the other elements of the cause of action are met. 5

IV. ANALYSIS

HSF assigns error in no fewer than eight iterations. It debunks the sufficiency of the evidence in five respects. It then hypothesizes that, even if the evidence on these points can withstand an instructed verdict, it is so anemic that the district court should have repudiated the jury's findings on liability and ordered a new trial. The climax of the Hospital's asseverational array denigrates the award of damages in two respects. After careful perscrutation of both the record and the rich variety of challenges marshalled by HSF, we affirm.

A. Sufficiency of the Evidence.

The Hospital's multi-pronged attack calls into play varying standards of appellate review. The first five claims of error all involve the sufficiency of the evidence, and, hence, are reviewed under a familiar set of rules.

The district court's denial of a motion for judgment as a matter of law poses a question of law and, therefore, this court's review of such a ruling is plenary. See Gibson v. City of Cranston, 37 F.3d 731, 735 (1st Cir.1994). In addressing such issues on appeal, we must approach the evidence from a coign of vantage identical to that employed by the district court in the first instance. See Rolon-Alvarado v. Municipality of San Juan, 1 F.3d 74, 77 (1st Cir.1993)....

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