Hoffman v. Tonnemacher, CIVF045714AWIDLB.

• Decision Date: 31 March 2006
• Docket Number: No. CIVF045714AWIDLB.,CIVF045714AWIDLB.
• Court: U.S. District Court — Eastern District of California
• Parties: Donna HOFFMAN, Plaintiff, v. Kent TONNEMACHER, M.D.; Unknown Physicians; Memorial Medical Center, Defendants.

Page 1120

425 F.Supp.2d 1120

Donna HOFFMAN, Plaintiff, v. Kent TONNEMACHER, M.D.; Unknown Physicians; Memorial Medical Center, Defendants.

No. CIVF045714AWIDLB.

United States District Court, E.D. California.

March 31, 2006.

COPYRIGHT MATERIAL OMITTED

Kevin Gerard Little, Law Office of Kevin G. Little, Fresno, CA, for Plaintiff.

C. Fredrick Meine, III, Richard Stephen Salinas, Baker, Manock & Jensen, Fresno, CA, Alan Louis Martini, Sheuerman, Martini & Tabari, San Jose, CA, for Defendants.

ORDER ON DEFENDANT MEMORIAL MEDICAL CENTER'S MOTION FOR PARTIAL SUMMARY JUDGMENT

ISHII, District Judge.

This case arises out of the May 22, 2003, visit by Plaintiff Donna Hoffman ("Hoffman") to the emergency department of Defendant Memorial Medical Center ("MMC") where she was seen by Co-Defendant Dr. Kent Tonnemacher. Dr. Tonnemacher diagnosed Hoffman as having bronchitis with a differential diagnosis of pneumonia and discharged her with antibiotics the same day. On May 23, 2003, Hoffman returned to MMC in an ambulance and went into septic shock. After a lengthy hospitalization, Hoffman survived her sepsis and was released. On May 14, 2004, she brought suit against MMC and Dr. Tonnemacher for violations 42 U.S.C. § 1395dd (the Emergency Medical Treatment and Active Labor Act ("EMTALA")), and California law medical malpractice. MMC moves for partial summary judgment on Hoffman's EMTALA claims and, in the event that partial summary judgment is granted, for this Court to decline to exercise jurisdiction over the state law malpractice claims. For the reasons that follow, MMC's motion will be GRANTED in part and DENIED in part.¹

FACTUAL BACKGROUND

On May 22, 2003, Hoffman presented to the Emergency Medical Department at MMC and was examined and treated by Dr. Tonnemacher, a board certified emergency department physician.² Defendant's Undisputed Material Fact ("DUMF") No. 1. Hoffman had a fever of 102.3°, a pulse of 126, respiration of 24, a blood pressure of 159/87, and it was reported that Hoffman had a temperature of 106° when she was with the ambulance crew shortly before admission. Plaintiffs Opposition to Undisputed Facts (hereinafter "PODUMF") at p. 6; Tonnemacher Declaration Exhibit A.³ Hoffman was noted to have a medical history of hypertension, hypothyroidism, Hodgkin's lymphoma, a prior splenectomy, and a heart murmur at the time of her admission. Id.; Tonnemacher Declaration at ¶ 4. The medical records indicate that Hoffman's chief complaints were chills with hyperventilation, nasal congestion, cough, chest pain, and numbness in her hands.⁴ PODUMF at p. 6; Tonnemacher Declaration at ¶ 4 & Exhibit A. Dr. Tonnemacher took a medical history, performed a physical examination, and ordered x-rays and a urinalysis for Hoffman. DUMF No. 2. No blood culture, urine culture, CBC, blood differential, or other type of test was administered. PODUMF at p. 6; Tonnemacher Declaration Exhibit A.

Based upon Dr. Tonnemacher's evaluation and work-up, and based upon Hoffman's medical history, his examination and x-ray studies, Dr. Tonnemacher diagnosed fever and bronchitis with a differential diagnosis⁵ of possible pneumonia and ordered medications to address Hoffman's condition. DUMF No. 3.⁶ Dr. Tonnemacher did not believe that Hoffman suffered from an emergency medical condition requiring further immediate medical attention, or any additional treatment prior to her discharge, and that in his considered medical opinion, Hoffman could be discharged without placing her overall health in jeopardy. DUMF No. 4.⁷ However, Dr. Tonnemacher testified that given Hoffman's history and symptoms, a bacterial illness/process was a potential concern. Tonnemacher Deposition at 37:14-38:2.⁸ Dr. Tonnemacher did not order additional tests. PODUMF at p. 6; Exhibit A to Tonnemacher Declaration; see also Tonnemacher Declaration at ¶¶ 4-7. Dr. Tonnemacher determined that Hoffman's condition improved while in the emergency department on May 22, 2003, and he discharged her with a prescription for an antibiotic. DUMF No. 5.⁹ Dr. Tonnemacher prescribed an antibiotic for Hoffman because, based on his course of treatment, he had not been able to rule out a bacterial process. Id. at 43:16-20. In the opinion of Dr. Tonnemacher, Hoffman was not suffering from an emergency medical condition on May 22, 2003, either at the time she presented in the emergency department or at the time of her discharge. DUMF No. 6.¹⁰ Hoffman was discharged at 10:45 p.m. on May 22, 2003, with a 102.5° fever and an elevated pulse of 124. PODUMF at p. 6; Tonnemacher Declaration Exhibit A.

MMC argues that, at the time of her discharge on May 22, 2003, Hoffman was discharged in a stable condition with an appropriate antibiotic prescription and no additional medical screening or diagnostic testing was indicated at that time. DUMF No. 7.¹¹ Further, that the screening, examination, and treatment provided to Hoffman at MMC on May 22, 2003, was the same screening, examination, and treatment that any similarly situated patient presenting to the emergency department at MMC would have received at that time. DUMF No. 8. Dr. Tonnemacher's care and treatment rendered to Hoffman in the emergency department on May 22, 2003, was appropriate and designed to identify all signs and symptoms that would indicate the need for immediate medical attention to prevent serious bodily injury, and was in full compliance with EMTALA. DUMF No. 9. Dr. Tonnemacher's examination, assessment, and treatment of Hoffman on May 22, 2003, complied with the MMC guidelines and protocols relating to examination and treatment of patients in the emergency department presenting with similar symptoms. DUMF No. 10.

Hoffman disputes DUMF Numbers 7, 8, 9, and 10. Hoffman submits that Dr. Tonnemacher testified that, of the approximately six patients who were non-elderly individuals and whom he suspected had an ongoing bacterial process, Hoffman was the only one who was discharged without receiving a blood test. Plaintiff's Opposition to DUMF Nos. 8-10; Tonnemacher Deposition at 43-46, 52-53, 93, 97. Further, Hoffman submits that Dr. Tonnemacher failed to comply with MMC's ETALA compliance policy because he did not tailor his emergency screening to address the emergency conditions that he considered possibilities, i.e. he discharged Hoffman even though he suspected she had an ongoing bacterial process. Plaintiff s Opposition to DUMF Nos. 8-10; Hastie Deposition at 29-30. Finally, since Tonnemacher did not order a blood culture, CBC, blood differential, and/or an echocardiogram, which were within MMC's capabilities, his screening was inappropriate in that it was not reasonably calculated to identify the emergency condition he himself admitted to suspecting. Plaintiff's Opposition to DUMF Nos. 7-10; Bronston Declaration at ¶¶ 4-6;¹² Goldman Declaration at ¶¶ 4-6.¹³

After the May 22, 2003, discharge, Hoffman returned to MMC's emergency room via ambulance seventeen hours later on May 23, 2003, at approximately 4:00 p.m., in a septic condition and went into septic shock. PODUMF at p. 6; Tonnemacher Declaration Exhibit B. At 6:02 p.m. blood cultures were delivered to MMC's laboratory, and the results came back on May 24, 2003, at 4:12 a.m., ten hours later; and showed that Hoffman had a virulent bacterial infection, with the streptococcus pneumonia bacterial identified. Id.; see also Olson Deposition at 25:11-13. Dr. Olson, an infectious diseases physician who treated Hoffman, opined that the blood culture becoming positive in a relatively short period of time suggested a very serious problem and showed that the amount of bacteria in her bloodstream was quite high.¹⁴ Olson Deposition at 25:7-21. At the time Hoffman returned to the emergency department on May 23, 2003, her condition had changed and Hoffman presented with additional and different symptoms from those of her May 22, 2003 presentation. DUMF No. 11.¹⁵ For instance, on May 23, 2003, Hoffman presented with new symptoms, including diarrhea, diaphoresis, oral cyanosis, and gray skin appearance; additionally, her blood pressure was markedly abnormal and her heart rate was higher than it was on May 22, 2003, and she was in respiratory distress. DUMF No. 12.¹⁶ Following her presentation to the emergency department on May 23, 2003, Hoffman was admitted to the intensive care unit at the hospital in critical condition. DUMF No. 13. Hoffman survived her sepsis, but suffered permanent physical damage, and was apparently discharged on July 30, 2003. On May 14, 2004, Hoffman brought suit against MMC and Dr. Tonnemacher for violations of EMTALA and state law medical malpractice.

Plaintiff's Experts's Declarations

Both parties rely on the declarations of Hoffman's expert witnesses, Dr. Peggy Goldman and Dr. Paul Bronston. In pertinent part, Dr. Goldman declares:

4. [I]t is my opinion that the screening examination and emergency treatment received from Dr. Tonnemacher and [MMC] on May 22, 2003, departed from the applicable standards of care and were inappropriate as that term is defined under [EMTALA]. Specifically, the history obtained from the plaintiff by the triage nurse and Dr. Tonnemacher on May 22, 2003, raised a significant possibility that she could be suffering from a bacterial infection, including bacterial endocartis, a most serious emergency condition. This possibility should have been recognized by a competent emergency medical practitioner based on the history obtained from plaintiff and her presentation upon being examined. Under these circumstances, an acceptable and appropriate medical screening had to include, at a minimum, a CBC, blood differential, blood cultures, and an echocardiogram, none of which was ordered or done as part of the plaintiff's emergency screening examination. These necessary screening measures are clearly within the capability of any hospital having an emergency department and had to be ordered and done without delay.

5. The plaintiff also did...