Cruz-Vázquez v. Mennonite Gen. Hosp., Inc.

• Decision Date: 29 May 2013
• Docket Number: No. 11–2297.,11–2297.
• Citation: 717 F.3d 63
• Parties: Hazel I. CRUZ–VÁZQUEZ; Raúl A. Cruz–Rivera; Lucy I. Vázquez–Rivera; Conjugal Partnership Cruz–Vázquez; Benjamín Martínez–Reyes; Benjamín Martínez–Morales; Nitza I. Reyes; Conjugal Partnership Martínez–Reyes, Plaintiffs, Appellants, v. MENNONITE GENERAL HOSPITAL, INC.; Dr. Brenda M. Torres–Pérez; John Doe; Conjugal Partnership Doe–Torres; Dr. Eduardo Gómez–Torres; Jane Doe; Conjugal Partnership Doe–Gómez; Advanced OB–GYN, PCS; Simed; Companies A–Z; Peter Poe; Mary Moe, Defendants, Appellees, Minerva Díaz–Aristud; Conjugal Partnership Gómez–Díaz, Defendants.
• Court: U.S. Court of Appeals — First Circuit

717 F.3d 63

Hazel I. CRUZ–VÁZQUEZ; Raúl A. Cruz–Rivera; Lucy I. Vázquez–Rivera; Conjugal Partnership Cruz–Vázquez; Benjamín Martínez–Reyes; Benjamín Martínez–Morales; Nitza I. Reyes; Conjugal Partnership Martínez–Reyes, Plaintiffs, Appellants,

v. MENNONITE GENERAL HOSPITAL, INC.; Dr. Brenda M. Torres–Pérez; John Doe; Conjugal Partnership Doe–Torres; Dr. Eduardo Gómez–Torres; Jane Doe; Conjugal Partnership Doe–Gómez; Advanced OB–GYN, PCS; Simed; Companies A–Z; Peter Poe; Mary Moe, Defendants, Appellees,Minerva Díaz–Aristud; Conjugal Partnership Gómez–Díaz, Defendants.

No. 11–2297.

United States Court of Appeals, First Circuit.

May 29, 2013.

Pedro F. Soler–Muñiz for appellants.

Anselmo Irizarry–Irizarry, with whom Matta & Matta, PSC, was on brief for appellees.

Before TORRUELLA, LIPEZ and HOWARD, Circuit Judges.

TORRUELLA, Circuit Judge.

This appeal concerns whether the district court erred in dismissing a disparate screening claim under the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. § 1395dd. After carefully reviewing the record, we vacate the district court's dismissal and remand for further proceedings.

I. Background

A. Factual Background

1. Cruz–Vázquez's Medical Treatment

At around 10:15 p.m. on January 4, 2007, Plaintiff–Appellant Hazel Cruz–Vázquez (“Cruz–Vázquez”), then in her third trimester of her first pregnancy, arrived at the emergency room of Defendant–Appellee Mennonite General Hospital (“Mennonite”) requesting medical services. She complained of vaginal discharge and blood spotting but denied experiencing pelvic pain, dysuria or feverishness. Cruz–Vázquez also felt fetal movement upon her arrival to the emergency room. She was evaluated by the on-duty emergency physician, Dr. Brenda M. Torres–Pérez (“Dr. Torres”), who performed a pelvic exam and found that Cruz–Vázquez's cervix was not dilated. No other exams were performed.

At around 10:55 p.m., Dr. Torres called Cruz–Vázquez's obstetrician, Dr. Eduardo Gómez–Torres (“Dr. Gómez”), who advised Dr. Torres to administer 0.25mg of Bretine and 50mg of Visatryl, to discharge Cruz–Vázquez in stable condition, and to instruct her to follow up at his private office the following morning at 8:00 a.m. Dr. Torres followed those instructions. Cruz–Vázquez was discharged and sent home on January 5, 2007, at 12:15 a.m., less than two hours after her arrival. Cruz–Vázquez's condition was recorded in the medical record as “discharge condition stable.”

Cruz–Vázquez was seen the following morning at 8:14 a.m. by Dr. Gómez in his private office. She complained of continued blood spotting but no pelvic pain. Dr. Gómez performed a pelvic exam which revealed a blood collection pool in her vagina and cervix dilation of seven centimeters. Cruz–Vázquez's fetus was floating in breech position. Dr. Gómez diagnosed Cruz–Vázquez as suffering from an incompetent cervix, and he recommended that she be transferred to another hospital.¹ Cruz–Vázquez agreed, and she was transferred in stable condition.

Following admission to the San Juan City Hospital that morning, Cruz–Vázquez underwent a cesarean section. Her baby was born a living baby girl at 12:12 p.m. The baby died on January 7, 2007, at 7:57 a.m., due to unspecified reasons.

2. Mennonite's Hospital Protocol

At the time of these facts, Mennonite had in place, and in full force and effect in all of its facilities, a “Gravid with 3rd Trimester Bleeding” protocol (the “Protocol”) which required that a number of tests and examinations be performed on a patient presenting bleeding in her third trimester of pregnancy. The Protocol indicated, for example, that a speculum exam and examination for a rupture of membranes be performed, and that a number of laboratory tests be conducted.²

Mennonite has stipulated that the Protocol was in place when Cruz–Vázquez was examined on January 4, 2007, and that it failed to activate or follow that Protocol in her case, including its requirement that certain tests and laboratory studies be performed on patients presenting vaginal bleeding in their third trimester.

B. Procedural History

Cruz–Vázquez ³ filed a complaint in the United States District Court for the District of Puerto Rico alleging that she arrived at the emergency department of Mennonite on January 4, 2007, with an emergency medical condition as defined by EMTALA, 42 U.S.C. § 1395dd(e)(1); that Mennonite failed to screen her appropriately, as required under 42 U.S.C. § 1395dd(a); and that Mennonite failed to stabilize or properly transfer her before release on January 5, 2007, thus violating the requirements of 42 U.S.C. § 1395dd(b).

This case has followed a tortured history subsequent to that filing. In March 2009, over a year after the original complaint was filed, Cruz–Vázquez's case proceeded to trial. The trial was truncated by the dismissal of Cruz–Vázquez's expert, Dr. Carlos Ramírez, on the trial's fourth day, following Mennonite's oral Daubert challenge and an evidentiary hearing. See Daubert v. Merrell Dow Pharms., Inc., 509 U.S. 579, 592–93, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993). After granting Mennonite's motion to exclude Dr. Ramírez's expert testimony, the district court went on to grant Mennonite's Rule 50 motion for judgment as a matter of law; the court held that plaintiffs failed to offer proof of crucial elements of their case. See Cruz–Vázquez v. Mennonite Gen. Hosp., Inc., 613 F.Supp.2d 202 (D.P.R.2009).

Cruz–Vázquez appealed to this court, and at oral argument, the issue of subject matter jurisdiction was raised. Specifically, the undersigned inquired whether, under the facts as stated in the amended complaint, the district court could properly exercise federal jurisdiction under EMTALA. Following our request for supplemental briefing on jurisdiction, we issued an opinion vacating the district court's judgment and remanding for further proceedings. Specifically, we found that the district court had abused its discretion when it excluded the expert testimony because its “reasoning had nothing to do with the scientific validity of the opinion that Dr. Ramírez proposed to offer or the principles that underlie it.” Cruz–Vázquez v. Mennonite Gen. Hosp., 613 F.3d 54, 59 (1st Cir.2010). Rather, we found, the district court assessed the expert's potential bias, “a task that is ‘properly left to the jury.’ ” Id. (quoting United States v. Carbone, 798 F.2d 21, 25 (1st Cir.1986)). Our opinion did not address the jurisdictional issue.

In light of the advanced stage of the proceedings below, the natural progression on remand should have been for the case to proceed to a new trial. However, shortly after the case was remanded, Mennonite filed a motion for summary judgment “for lack of federal jurisdiction under EMTALA.” The district court denied Mennonite's motion, finding that “Mennonite had a standard screening procedure, its ‘Gravid with 3rd Trimester Bleeding’ protocol, which required certain tests to be performed and which Mennonite denied to Cruz.” Cruz–Vázquez v. Mennonite Gen. Hosp., Inc., No. 08–1236(JP), 2011 WL 3607669, at *7 (D.P.R. Aug. 15, 2011). The court concluded that Plaintiffs “have presentedsufficient evidence for a reasonable jury to conclude that Defendants' conduct in failing to apply its ‘Gravid with 3rd Trimester Bleeding’ protocol to Cruz violated EMTALA.” Id.

On the same day summary judgment was denied, Cruz–Vázquez filed a motion to appoint a new expert, Dr. Frederick González. On the following day, the district court granted that motion, ordering that the expert be available to the parties within ten days. The district court also set a date for the jury trial. However, despite the fact that the district court in a prior motion had already considered and rejected the jurisdiction challenge, and that our opinion had been silent as to the issue, which could only be reasonably interpreted to mean that we found no jurisdiction flaw, the district court requested additional briefing “on the issue of jurisdiction within 10 days.” Mennonite took advantage of the newly afforded chance to raise the jurisdictional issue and filed a motion to dismiss “for lack of federal jurisdiction under EMTALA.” Mennonite's briefing, while framed in name as a motion to dismiss on jurisdictional grounds, attacked the merits of Cruz–Vázquez's EMTALA claim, arguing that she had failed to allege sufficient facts to state an EMTALA claim.

The district court granted Mennonite's motion and vacated its prior order denying summary judgment. In its opinion, the court labeled Mennonite's motion as a “motion to dismiss for lack of jurisdiction,” but proceeded to address Cruz–Vázquez's EMTALA claim on its merits. It found that Dr. Torres' “decision not to perform additional tests [on Cruz–Vázquez was] not the same as the denial of screening or egregious delay in screening identified by the First Circuit in Correa [v. Hosp. San Francisco, 69 F.3d 1184, 1189 (1st Cir.1995) ],” relying on a Fourth Circuit case to hold that plaintiffs' claims were as to a “faulty” screening rather than a “disparate” screening. Cruz–Vázquez v. Mennonite Gen. Hosp., Inc., No. 08–1236 (JAF/JP), 2011 WL 4381888, at *3 (D.P.R. Sept. 20, 2011) (citing Vickers v. Nash Gen. Hosp., 78 F.3d 139, 144 (4th Cir.1996)). It proceeded to dismiss Cruz–Vázquez's complaint as stating facts limited to a medical malpractice claim, and holding that “EMTALA does not create a federal cause of action for medical malpractice.” Id.

II. Discussion

A. Cruz–Vázquez's EMTALA Claim

We first address the procedural and briefing peculiarities we have inherited on appeal. The district court requested that the parties brief “the issue of EMTALA jurisdiction” well after a four-day trial on the merits, a first appeal vacating the granting of Mennonite's Rule 50 motion, and all deadlines for filing dispositive motions. Cruz–Vázquez v. Mennonite Gen. Hosp., No. 08–1236(JP) (D.P.R. July 9, 2008) (setting deadline for dispositive motions for January 12,...