Williams v. Dimensions Health Corp.

• Decision Date: 13 March 2020
• Docket Number: No. 18-2139,18-2139
• Citation: 952 F.3d 531
• Parties: Terence WILLIAMS, Plaintiff – Appellant, v. DIMENSIONS HEALTH CORPORATION, trading as Prince George’s Hospital Center, Defendant – Appellee.
• Court: U.S. Court of Appeals — Fourth Circuit

952 F.3d 531

Terence WILLIAMS, Plaintiff – Appellant,

v.DIMENSIONS HEALTH CORPORATION, trading as Prince George’s Hospital Center, Defendant – Appellee.

No. 18-2139

United States Court of Appeals, Fourth Circuit.

Argued: January 28, 2020

Decided: March 13, 2020

ARGUED: Jon Wyndal Gordon, LAW OFFICE OF J. WYNDAL GORDON, PA, Baltimore, Maryland, for Appellant. Christian W. Kintigh, DOWNS WARD BENDER HAUPTMANN & HERZOG, P.A., Hunt Valley, Maryland, for Appellee. ON BRIEF: Mary Alane Downs, DOWNS WARD BENDER HAUPTMANN & HERZOG P.A., Hunt Valley, Maryland, for Appellee.

Before DIAZ, THACKER, and QUATTLEBAUM, Circuit Judges.

Affirmed by published opinion. Judge Quattlebaum wrote the opinion in which Judge Diaz and Judge Thacker joined.

QUATTLEBAUM, Circuit Judge:

Shortly after midnight on May 3, 2014, Terence Williams was seriously injured when his vehicle rolled over in a single-vehicle accident. Williams’ most serious injuries were to his lower body. He was subsequently transported to Prince George’s Hospital Center (the "Hospital") in Prince George County, Maryland. He arrived at the Hospital at 1:33 A.M., and Hospital staff began screening procedures. Within twenty minutes, he was intubated to protect his airway, and a trauma surgeon performed a right antecubital cutdown to insert a catheter to infuse large volumes of fluid and blood quickly. After the insertion of the catheter, Williams was repeatedly given blood for the next several hours. Between 2:21 A.M. and 2:57 A.M., various CT scans

were performed on his head, chest and spine. At 3:23 A.M., Williams was removed off the back board provided by paramedics in the field. At the same time, he was given additional units of blood and plasma. Twenty minutes later, x-rays were performed on his chest, abdomen, pelvis, forearm, femur, spine, tibia and fibula. After the x-rays, Williams was transported to the operating room and began receiving anesthesia. At 5:13 A.M., Williams’ first surgery began and lasted more than six hours. Although the formal documentation is ambiguous, at some point on May 3, Williams concedes he was admitted to the Hospital.

For the next eleven days, Hospital staff performed a variety of surgeries and medical treatments on Williams. On May 13, 2014, he was transferred to the University of Maryland Medical Center. Despite the treatment he received at the Hospital and at the University of Maryland, the injuries to Williams’ lower body required amputating both of Williams’ legs.

Williams sued the Hospital in state court, alleging it violated the Emergency Medical Treatment and Active Labor Act ("EMTALA") by failing to properly screen him and stabilize his condition. The Hospital removed the case to federal court and then moved to dismiss Williams’ complaint.

The district court granted in part and denied in part the Hospital’s motion. It treated the motion as a motion for summary judgment because Williams attached exhibits to his opposition that were not attached or referenced in his complaint. It then held that the Hospital was entitled to judgment as a matter of law on Williams’ failure to screen claim: "[The hospital] followed its own standard screening procedures when it provided an initial screening for Williams. Whatever shortcomings Williams may perceive in the physician assistant’s screening or the physicians’ involvement, those are matters for a medical malpractice action, and outside the scope of an EMTALA action." J.A. 153. The district court denied the Hospital’s motion with respect to Williams’ failure to stabilize claim, holding "until a patient is transferred, discharged, or admitted, ‘the Hospital must provide that treatment necessary to prevent the material deterioration of each patient’s emergency medical condition.’ " J.A. 155 (citing In the Matter of Baby K , 16 F.3d 590, 596 (4th Cir. 1994) ). As the district court explained, "[a]t some point, ... Williams was admitted to the hospital. Thus, [Williams] has stated a claim for failure to stabilize, given that it is plausible that the Hospital failed to stabilize his emergency medical condition before it admitted him, such that his condition materially deteriorated." J.A. 157 (emphasis added).

The Hospital later moved for summary judgment on the remaining stabilization claim. The district court granted the Hospital’s motion noting that "contrary to [its] understanding when [it] considered the parties’ argument for the Hospital’s first dispositive motion," the timing of a patient’s admission to the hospital is not essential because the good faith admission of an individual as an inpatient is a complete defense to an EMTALA failure to stabilize claim. J.A. 237. Without determining the exact time, the district court found that Williams was in fact admitted and held that Williams failed to present evidence that created a genuine issue of material fact about the Hospital’s good faith in admitting Williams. Thus, the district court granted the Hospital’s motion for summary judgment.

Williams filed a timely notice of appeal on June 29, 2018, and we have jurisdiction under 28 U.S.C. § 1291. On appeal, Williams raises a single, narrow issue, arguing that his admission to the Hospital lacked good faith.¹ For the reasons set forth below, we affirm the district court.

I.

Before analyzing the good faith admission issue presented here, we briefly describe EMTALA and its requirements. Congress enacted EMTALA in 1986 to prevent patient dumping, a practice by which hospitals would either refuse to provide emergency medical treatment to patients unable to pay for treatment or transfer those patients before their emergency medical conditions were stabilized. Vickers v. Nash Gen. Hosp., Inc ., 78 F.3d 139, 142 (4th Cir. 1996) ; Bryan v. Rectors and Visitors of Univ. of Va. , 95 F.3d 349, 351 (4th Cir. 1996).

In keeping with this purpose, EMTALA imposes two main obligations on hospitals with emergency rooms. First, EMTALA requires a hospital to screen an individual to determine whether he has an emergency medical condition. 42 U.S.C. § 1395dd(a) provides:

In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) 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 defines emergency medical condition as:

(A) 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).

Second, EMTALA requires a hospital to stabilize an individual’s emergency medical condition in certain limited circumstances. 42 U.S.C. § 1395dd(b)(1) provides:

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either--

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

42 U.S.C. § 1395dd(b)(1).

Critically, EMTALA defines "to stabilize" as "to provide such medical treatment of the [emergency medical condition] as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility ...." 42 U.S.C. § 1395dd(e)(3) (emphasis added). EMTALA defines transfer as "the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person." 42 U.S.C. § 1395dd(e)(4). Thus, under the statute itself, "the stabilization requirement only sets forth standards for transferring a patient in either a stabilized or unstabilized condition. By its own terms, the statute does not set forth guidelines for the care and treatment of patients who are not transferred." Harry v. Marchant , 291 F.3d 767, 771 (11th Cir. 2002) (emphasis in original).

Consistent with this definition, this Court in Bryan v. Rectors and Visitors of University of Virginia , 95 F.3d 349 (4th Cir. 1996), held that EMTALA’s stabilization requirement is "defined entirely in connection with a possible transfer and without any reference to the patient’s long-term care within the system." Id . at 352. Elaborating on the scope of the requirement, this Court held:

It seems manifest to us that the stabilization requirement was intended to regulate the hospital’s care of the patient only in the immediate aftermath of the act of admitting her for emergency treatment and while it considered whether it would undertake longer-term full treatment or instead transfer the patient to a hospital that could and would undertake that treatment. It cannot plausibly be interpreted to regulate medical and ethical decisions outside that narrow context.

Id . (emphasis added).²

Subsequent...