Torretti v. Main Line Hospitals, Inc.

• Decision Date: 02 September 2009
• Docket Number: No. 08-1525.,08-1525.
• Parties: Christopher TORRETTI; Honey Torretti, as parents & natural guardians of Christopher J. Torretti, a minor, and in their own right, Appellants v. MAIN LINE HOSPITALS, INC., d/b/a Paoli Memorial Hospital; Andrew Gerson, M.D.; Main Line Perinatal Associates; Mark Finnegan, M.D.; Patricia McConnell, M.D.; McConnell, Peden, Belden & Associates; Lankenau Hospital.
• Court: U.S. Court of Appeals — Third Circuit

580 F.3d 168

Christopher TORRETTI; Honey Torretti, as parents & natural guardians of Christopher J. Torretti, a minor, and in their own right, Appellants v. MAIN LINE HOSPITALS, INC., d/b/a Paoli Memorial Hospital; Andrew Gerson, M.D.; Main Line Perinatal Associates; Mark Finnegan, M.D.; Patricia McConnell, M.D.; McConnell, Peden, Belden & Associates; Lankenau Hospital.

No. 08-1525.

United States Court of Appeals, Third Circuit.

Argued January 28, 2009.

Opinion filed September 2, 2009.

Barbara R. Axelrod, Esquire, (Argued), James E. Beasley, Jr., Esquire, Dion G. Rassias, Esquire, The Beasley Firm, Philadelphia, PA, for Appellant.

Daniel F. Ryan, III, Esquire, O'Brien & Ryan, Plymouth Meeting, PA, Peter J. Hoffman, Esquire, (Argued), Eckert, Seamans, Cherin & Mellott, Philadelphia, PA, for Appellees.

Before SCIRICA, Chief Judge, AMBRO, and SMITH, Circuit Judges.

OPINION OF THE COURT

AMBRO, Circuit Judge.

This is our first opportunity to confront the Emergency Medical Treatment and Active Labor Act ("EMTALA" or the "Act"). 42 U.S.C. § 1395dd, et seq. Among other things, the Act forbids hospitals from refusing to treat individuals with emergency conditions, a practice often referred to as "patient dumping."

Appellants Christopher and Honey Torretti's son, Christopher, was born with severe brain damage after Mrs. Torretti's high-risk pregnancy went awry. On the morning of the birth, Mrs. Torretti went to her routine outpatient fetal monitoring appointment at a perinatal facility. The attending medical personnel at the facility directed her to her primary hospital for extended perinatal monitoring. She gave birth to Christopher shortly after arriving at the hospital. The Torrettis sued the hospitals and doctors involved under EMTALA, as well as state statutory and common-law claims. This appeal tests the boundaries of EMTALA, which is not a federal malpractice statute. Given these circumstances, relief for Christopher Torretti's traumatic brain injuries may be available in other forms, but is not provided under EMTALA. Thus, we affirm the District Court's grant of summary judgment.¹

I. Background

This case, like most cases brought under EMTALA, is tragic. This was Mrs. Torretti's second pregnancy. Her first child was born healthy. Both pregnancies were high-risk because she is an insulin-dependent diabetic. Her primary obstetrician was Dr. Patricia McConnell, a member of the Peden Group, an obstetrics practice group based out of Lankenau Hospital ("Lankenau"). Lankenau is part of the Main Line Health system and located in Wynnewood, Pennsylvania.

Because of Mrs. Torretti's diabetic condition (which can present complications during a pregnancy), Dr. McConnell referred her to the Paoli Hospital Perinatal Testing Center ("Paoli"), located in Paoli, Pennsylvania, for monitoring throughout both pregnancies. Paoli is a center for fetal monitoring and consultation only, and is located in a medical building adjacent to Paoli Hospital. It is also owned by Main Line Health. The two hospitals are approximately twenty miles apart.

In Mrs. Torretti's third trimester, she began to have complications, primarily involving premature contractions. During this period, the Peden Group increased Mrs. Torretti's monitoring appointments at Paoli to twice per week from once per month. The Peden Group also monitored her as an outpatient at Lankenau on one occasion in mid-April 2005. Two weeks later, when she went to Paoli for routine monitoring on April 30, the Paoli medical staff detected that she was experiencing pre-term labor and directed her to Lankenau where she was hospitalized for three days. On that occasion, she drove herself from Paoli to Lankenau.

Near the end of Mrs. Torretti's pregnancy, in her 34th week, she had a routine monitoring appointment scheduled at Paoli on Monday, May 23. Two days before the appointment, she called Dr. McConnell twice. First, she complained of contractions. Dr. McConnell told her to put her feet up and relax. The second time Mrs. Torretti called, the contractions had lessened, but she explained that she was very uncomfortable because of her large size and had noticed a decrease in fetal movement. She asked about the possibility of receiving a therapeutic amniocentesis, a treatment to reduce her discomfort by removing some of the excess amniotic fluid. Dr. McConnell advised her to drink a glass of ice water to try and stir the baby; thereafter, for whatever reason, Mrs. Torretti detected increased movement. The doctor also told her that she could come to Lankenau if she preferred, but that nothing could be done until Monday. Mrs. Torretti chose not to go the hospital that weekend and did not believe that her condition was emergent.²

On May 23, the Torrettis drove to Paoli for the appointment, which included a routine ultrasound and a fetal non-stress test.³ When Mrs. Torretti arrived at Paoli, she was feeling general discomfort, primarily because of the strain on her back from the large size of her abdomen. She was not alarmed about her condition and did not feel that she was in an emergent state.⁴ She told Dr. Andrew Gerson, a perinatologoist on Paoli's staff, about her conversation with Dr. McConnell over the weekend—that she was having a great deal of discomfort mainly due to her large size and had noticed a decrease in fetal movement, but that there was still some movement.

Dr. Gerson sat Mrs. Torretti in a chair and began the non-stress test. Over a 28-minute period, the test did not show expected fetal heart rate variability—normal accelerations and decelerations. Lack of variability in a non-stress test could be explained by a normal variant, such as a prolonged sleep cycle, or could be the sign of a problem. About the same time Mrs. Torretti began the non-stress test, her contractions returned. She indicated the "pain was so bad" that she was "grasping either the arm of the chair or both arms of the chair at once, and either almost grunting or to a degree yelling." The non-stress test indicated that she had 16 contractions in the 28 minutes of fetal monitoring—her contractions lasted approximately 50 to 70 seconds and were 1½ to 2½ minutes apart.

Dr. Gerson was aware of Mrs. Torretti's diabetic condition. He noted in her medical documents that her abdominal circumference was large—"off the charts." The fetus weighed approximately eleven pounds. Also, the ultrasound test indicated that she had excess amniotic fluid, but that the fetus "was moving its limbs and body."

Based on these preliminary test results and Mrs. Torretti's diabetic condition, Dr. Gerson terminated the non-stress test and sent her to Lankenau for longer-term monitoring of the baby.⁵ In directing Mrs. Torretti to Lankenau, he also consulted with her regular doctor, Dr. McConnell, by telephone. Dr. Gerson testified that this plan appeared to be "perfectly safe" based on the "best information we had." He further testified that, even though she was having contractions, which had been commonplace throughout her third trimester, "delivery wasn't necessarily going to be imminent or need to be imminent and [] it was appropriate for her to go to Lankenau Hospital."⁶ The nurse assisting Dr. Gerson commented to Mrs. Torretti that she believed Mrs. Torretti might deliver the baby sometime that day, but gave no indication of an emergency or imminency.

Mrs. Torretti testified that, while at Paoli, nothing in the statements or demeanor of anyone on Paoli's staff, including Dr. Gerson, indicated to her that her condition was emergent. For example, Mrs. Torretti stated that "[t]here was no [] urgency, though, as far as I was concerned. [The nurse] seemed pretty calm, and that's usually a pretty good indicator" because "I could usually read [the nurse] pretty well, I had known her since I had been pregnant with my first child." In addition, when Dr. Gerson discontinued the monitoring and sent her to Lankenau for prolonged monitoring, Mr. Torretti asked whether it was an emergency and if they should go in an ambulance. Dr. Gerson replied that it was not that urgent and that an ambulance was not necessary. Nonetheless, he requested that they go directly to Lankenau. En route to Lankenau, however, they stopped at their home. With the stop, the 20-mile trip took them approximately 45 minutes door-to-door.

As is customary, Dr. Gerson sent an explanatory letter to the Lankenau medical personnel along with the Torrettis. When Mrs. Torretti arrived, she had to wait approximately 15 to 20 minutes for a room. She stated that when she was first connected to the monitor, her condition seemed to be about the same as it had been at Paoli, but then "it worsened very quickly." Shortly thereafter, another doctor with the Peden Group checked on her. When he looked at the preliminary results, he exclaimed "oh shit!" The doctors immediately rushed Mrs. Torretti into surgery and she gave birth via caesarean section. The baby, Christopher Torretti, was born with severe brain damage.

Defendants moved for summary judgment on the EMTALA claim. The District Court ruled that the Torrettis did not offer sufficient evidence to raise a reasonable inference that defendants, specifically Dr. Gerson, knew Mrs. Torretti presented a medical emergency, and thus failed to sustain their burden under EMTALA. Torretti v. Paoli Mem. Hosp., No. 06-3003, 2008 WL 268066, at *1 (E.D.Pa. Jan.29, 2008). Accordingly, it granted the motion for summary judgment, dismissing the only federal claim. It also declined to exercise supplemental jurisdiction over the Torrettis' remaining state claims.

II. Standard of Review

When the District Court grants a motion for summary judgment, our review is plenary. See Elsmere Park Club, L.P. v. Town of Elsmere, 542 F.3d 412, 416 (3d Cir.2008) (citation omitted). Summary judgment is appropriate when no genuine issues of material fact exist and the moving party is entitled to judgment as a matter of law. See Celotex Corp. v....