Favorable EMTALA Court Decisions in 1997
February 1, 1998 23 minutes read
Favorable EMTALA Court Decisions in 1997
By Paul A. Craig, RN, JD, Consultant, MMI Risk Management Resources, San Francisco, CA.
Few ED physicians would put "good news" and the Emergency Medical Treatment and Active Labor Act (EMTALA) in the same sentence. The past few years have seen activist administrative enforcement by certain regional Department of Health and Human Services (HHS) offices and state agencies based on wildly expansive interpretations of EMTALA regulations. As if the tension between the conflicting demands of managed care plans and these overbroad agency interpretations was not producing enough anxiety, HHS has promised that more is coming. A recent article in USA Today quotes an HHS spokesperson as saying, "The numbers [of enforcement actions] should be going up" because HHS has hired even more investigators.1
Is there any venue in which good news can be found about EMTALA? A recent computer search of EMTALA court opinions published in 1997 suggests that there may actually be good news coming from the state appellate courts and the federal court system. This article is a survey of EMTALA court decisions published in 1997 by both state appellate courts (including state supreme courts) and federal courts (both district courts and courts of appeal). This article does not attempt to capture the verdicts of all state trial courts, which are generally not published on computer legal databases, and which do not hold precedential value or determine legal issues that would apply to anyone other than the litigants in the particular case.
While the 1997 court opinions have not created any judicial safe harbors, the use of EMTALA by medical malpractice plaintiffs appears to be met with increasing disfavor from the appellate courts. In fact, all but two of the EMTALA court opinions published in 1997 were decided in favor of the defendants. As described below, some appellate courts appear to have bent over backward to let the defendant hospitals off the hook. The two cases that did rule in favor of, or affirm rulings for, the plaintiffs presented truly egregious facts pointing to hospital liability.
For years, observers feared the appellate courts would open a Pandora’s box of overbroad interpretations of EMTALA. In 1994, a federal court of appeals appeared to have confirmed these fears with the case of In the Matter of Baby K.2
In that case, a federal court of appeals ruled that a Virginia hospital was required to resuscitate an infant with an encephaly despite uncontradicted expert testimony that this was outside the medical standard of care and went beyond existing ethical requirements. The court alarmed hospitals across the country in ruling that EMTALA imposed duties that went beyond ethics and standards of care. In retrospect, the case has not been widely followed by other courts.
The majority of the 1997 court opinions are decidedly "pro-hospital" in their results and in their reasoning. In these cases, the courts decided legal issues in favor of the defendants that may have precedential value for other defendants down the road. For purposes of discussion, the cases have been grouped together according to the decisive or dominant legal issue. However, a number of the cases involve more than one issue of law.
Screening and Stabilization
The first generation of EMTALA cases often dealt with transfers of unstable patients to other facilities, or what is popularly known as "patient dumping." Most subsequent court cases have involved patients who were discharged from an ED. The 1997 EMTALA court opinions are no exception. In the majority of these cases, the plaintiffs have charged that the defendant hospitals violated both of EMTALA’s fundamental prongs: 1) that the hospital failed to provide an appropriate medical screening exam; and 2) it failed to stabilize an emergency medical condition (EMC). Most of the discussion and analysis in these opinions focuses on the screening exam prong. A cluster of legal issues surround EMTALA’s screening exam and stabilization requirements.
A hospital’s liability to a plaintiff who brings an EMTALA claim often rises or falls on the answer to the following questions: Was it malpractice or was it an EMTALA violation? Did the patient’s chief complaint actually rise to the level of an EMC at the time the patient was examined and treated? What kind of evidence is sufficient to prove a hospital failed to provide an appropriate screening exam? Must plaintiffs prove the hospital had actual awareness of an EMC in order to succeed on a failure to stabilize claim?
Malpractice or an EMTALA Violation?
Many of the 1997 EMTALA cases repeated the theme that plaintiffs must prove something other than negligence to bring a successful EMTALA claim, and that EMTALA liability is qualitatively distinct from medical malpractice liability. The case of Brown v. Christian Health Ministries3,4 illustrates this threshold distinction. In Brown, a woman who had a history of heart disease and a CVA received an ED screening exam that included cardiac monitoring, various lab tests, and a head CT scan. Two physicians attributed her symptoms to a conversion reaction, and she was transferred to a psychiatric hospital. Her condition began to deteriorate after she arrived at the psychiatric hospital and shortly thereafter she died of an acute MI. The plaintiff claimed the hospital failed to provide an appropriate medical screening exam. The court concluded the evidence "might show error, misdiagnosis, or malpractice" but ruled that the plaintiff failed to prove a violation of EMTALA.
The court applied a similar rationale in the case of Boudreaux v. The State of Louisiana.5 In that case, a plaintiff first filed a malpractice action against Charity Hospital in New Orleans for its alleged failure to diagnose and treat an acute myocardial infarction. After a medical review panel found malpractice, the plaintiff attempted to amend her complaint and add an EMTALA claim for both a failure to screen and a failure to stabilize. The court found that without evidence of intentional dumping, the plaintiff could not prove a failure to screen. The court observed that it seemed nonsensical to argue that a charity hospital had made a treatment decision based on indigence rather than on negligent malpractice. The plaintiff claimed she could prevail on an EMTALA failure-to-stabilize claim without proving the defendant was subjectively aware of the patient’s EMC. The court disagreed, finding the patient was discharged for the same reason she was not given emergency treatment, because of negligent misdiagnosis and not a violation of EMTALA.
Sufficient Proof of a True EMC
The Supreme Court of Louisiana extended considerable generosity to a defendant hospital, under the rationale that a plaintiff had failed to prove the existence of a true EMC in the case of Fleming v. HCA Health Services of Louisiana.6 In Fleming, a man suffering with psychiatric problems presented to the defendant hospital’s ED. According to a nurse, the man’s estranged wife merely requested a referral to a facility that would "admit and treat her husband who had no insurance, no money, and no job." The wife claimed she had informed the nurse that the man was suicidal and in need of immediate assessment. According to the wife, the nurse refused a request for treatment and gave the man directions to a public hospital. No physician ever examined the man and the following morning he jumped from an overpass and was killed by a truck. The Louisiana Supreme court found that the plaintiff had failed to meet her threshold burden of proving that the man was in need of emergency medical services. The court observed that the man had not attempted to commit suicide prior to his arrival at the ED, and that the only evidence that he was suicidal when he presented to the ED was the wife’s "self-serving attestations." This, the court concluded, was insufficient proof of an EMC.
The issue of what constitutes an EMC was discussed in two other cases that went in favor of defendant hospitals. The first case, Camp v. Harris Methodist Fort Worth Hospital,7 is a non-precedential trial court jury verdict. In this case, a jury found a hospital had not violated EMTALA when it discharged a woman who had presented to the ED with acute abdominal pain and profound anemia. The woman, who apparently developed GI bleeding following a prolonged course of Toradol, had settled with the other treating physicians prior to the trial against the hospital on the EMTALA claim. After ED screening revealed a hemoglobin of 4 and a hematocrit of 14, the ED physician recommended transfusion and admission. However, the on-call physician concluded the patient did not require admission and offered an office appointment the following morning. The woman failed to keep the appointment and died later the next day.
According to the verdict reporter, the jury distinguished between the actual definition of the patient’s presenting complaint (pain, not weakness or anemia) and her laboratory values and relied on the fact that there were no signs of acute bleeding at the time she was in the ED (a test for blood in the stool was negative). In addition, the judge made a very significant evidentiary ruling in favor of the hospital. The judge refused to allow a HCFA citation and statement of deficiencies into evidence that alleged improper care of this particular patient. The judge concluded that the administrative findings lacked sufficient reliability to be admitted in an action unrelated to the hospital’s Medicare certification.
Although not ultimately dispositive, the issue of whether an ankle fracture qualified as an EMC was discussed at length by a federal court of appeals in the case of Phipps v. Bristol Regional Medical Center.8 The plaintiff, who was a member of a state Medicaid managed care plan, was treated at the defendant hospital’s ED after a motor vehicle accident. X-rays revealed an ankle fracture. His ankle was splinted, he was given crutches and referred to the on-call orthopedic surgeon. The orthopedic surgeon refused to treat the plaintiff because the physician did not accept patients from the Medicaid managed care plan. It was later determined the plaintiff needed surgery, and he was eventually treated at a university hospital. The trial court determined the plaintiff did not have an EMC, as the term is defined by EMTALA, and granted summary judgment for the hospital. The court of appeals affirmed but under a different rationale.
The court of appeals concluded it was not clear whether or not the ankle fracture constituted an EMC. It assumed, without deciding, the fracture did constitute an EMC and found that the ED had properly stabilized the patient’s condition before discharge. The court ruled the hospital had appropriately screened the patient and that there was no evidence that the hospital refused to provide necessary treatment because the patient was unable to pay. Significantly, the court completely sidestepped the issue of whether the hospital violated EMTALA based on the on-call surgeon’s refusal to provide the patient with follow up treatment. There is a general consensus that on-call physicians have a statutory obligation to attend to all patients with respect to the completion of the screening exam and stabilizing treatment of any EMC. However, there is little consensus as to whether physicians who take an ED call have any obligation to treat indigent or uninsured patients whose EMC has been stabilized. This case was silent on that issue.
Legal Paradigms for Proving an EMTALA Violation
So what must a plaintiff prove to recover under EMTALA? How does a hospital defend against an EMTALA claim? Courts have devised two different legal formulas for determining whether a hospital may be liable to a plaintiff under EMTALA. The first test, used by a minority of courts, is known as the "improper motive" test.9 The second test, used by the majority of courts, is known as the "disparate treatment" test. In 1997, courts used both tests to knock a number of plaintiffs out of the box.
Improper Motive Test
The improper motive test is the more "hospital friendly" of the two legal tests. It requires a plaintiff to prove a hospital acted out of an "improper or impermissible motivation" and provided a substandard screening exam, or failed to stabilize a patient with a known EMC, based on factors such as lack of insurance, race, sexual orientation, disease state, or spite. This test is a remarkably high hurdle for a plaintiff to jump over. It requires the plaintiff to affirmatively prove the defendant’s specific intent or motivation for making particular medical decisions. As some of the following cases demonstrate, courts have rejected the adequacy of strong circumstantial evidence of what could reasonably be interpreted as impermissible motivation.
In the case of Adams v. Grace Hospital,10 an uninsured man was discharged from an ED via taxi cab after being examined for abdominal pain, with a note pinned to his shirt saying "If lost, send him home." Allegedly, he was in such distress that he crawled from the cab to his home. The ED evaluation was cursory and did not even include such basics as a blood count or a urinalysis. He returned to the ED the following day with urosepsis and subsequently died. Incredibly, the court concluded there was not enough evidence to find the patient’s discharge was motivated by his lack of insurance.
The case of Roberts v. Galen of Virginia11 applies the improper motive test to a decision to discharge a patient rather than to the issue of the screening exam. In this case, an uninsured woman was transferred to a long-term care facility after being hospitalized at the defendant hospital for weeks with severe head injuries. The day after she was transferred, her condition deteriorated significantly and she died after being readmitted to another acute care facility and incurring almost $400,000 in uncompensated bills. The plaintiff claimed the hospital violated EMTALA because it transferred the woman before she was stabilized.
The court ruled that proof that the hospital transferred the patient before she was stabilized would be insufficient to recover under EMTALA without proof of improper motive. Evidence was offered that the social worker who arranged the transfer said she "was getting a lot of pressure to discharge this person due to they knew they weren’t going to get paid for this person" (sic). However, the resident who ordered the transfer claimed his order was not motivated by the woman’s financial status. The chief of surgery signed an affidavit stating the attending physicians and residents at the defendant hospital "never have any idea what the financial condition of the patient is." The court accepted the credibility of the physicians and found there was insufficient evidence of improper motive.
Disparate Treatment Test
The disparate treatment test is theoretically the less stringent of the two EMTALA legal paradigms. It allows a plaintiff to successfully mount an EMTALA claim by simply proving that a hospital subjected a patient to "disparate treatment" in failing to apply its own procedures uniformly. The test does not require proof of an impermissible motive or that substandard ED screening exam or stabilizing treatment was based on factors such as lack of insurance, race, sexual orientation, or spite. Proof that a hospital acted inconsistently with its own policies is often adequate to demonstrate the required disparate treatment.
Critics of the disparate treatment test claim that it is too much like a malpractice standard. Courts that employ the test claim that the appropriateness of a screening exam is not judged against a malpractice standard. Courts have explained the distinction between the disparate treatment test and a malpractice standard in terms of the underlying intent of the statute. EMTALA is intended to ensure that each ED patient receives the same level of medical services (screening and treatment) that the hospital provides to every other patient who presents with the same or similar symptoms. However, the statute does not entitle every ED patient to a correct diagnosis. As the following cases demonstrate, proof of disparate treatment is different than proof of a malpractice claim. The reader will note that although the test is more porous than the improper motive test, it can still be a difficult test to satisfy.
In the case of Casey v. Amarillo Hospital District,12 a child with a fever of 106.5° F was evaluated in the defendant hospital’s ED. The child was examined by the family’s pediatrician; labs and a chest x-ray were performed and the child’s fever decreased to 103.2° F. The pediatrician, after consulting with a member of the hospital’s pediatric house staff, concluded that the child "suffered from constipation" and was discharged home. The following day, the child had a seizure and stopped breathing. He was returned to the hospital by ambulance where he died of meningococcemia. The parents brought an EMTALA claim, alleging both failure to screen and failure to stabilize. The trial court granted summary judgment in favor of the hospital, ruling that the hospital’s treatment of the child was within acceptable parameters of EMTALA.
The appellate court expressly rejected the improper motive test stating an EMTALA claim could be brought by any individual who had received disparate treatment regardless of whether the plaintiff could prove an improper motive. The court stressed that the appropriateness of a screening exam is to be judged in terms of disparate treatment under a hospital’s existing policies not in terms of the medical quality of the policies themselves. The court concluded that the plaintiffs had the burden to prove either that the child had not received the same screening exam as every other patient with the same or similar condition, or that after the hospital had determined that an EMC existed, it failed to stabilize the child or failed to make an appropriate transfer. This second requirement was construed to require proof that the hospital had actual knowledge of an EMC.
Plaintiffs claimed that the hospital failed to provide an appropriate screening exam because a complete set of vital signs, including his blood pressure, were not taken. The hospital presented its triage policy as evidence of its screening policy. The policy stated only:
"Vital signs should be taken on all urgent patients at the time of triage (non-urgent patients may be asked to wait in the lobby until the triage nurse is available to take vital signs)."
The hospital’s trauma coordinator testified that all of the hospital’s relevant policies were followed and that the child received the same screening exam that any other patient would who presented with the same symptoms. The plaintiffs’ expert witness testified that the failure to measure the child’s blood pressure violated the standard of care for the triage nurse and the pediatrician; however, the expert did not contend that the hospital violated its own policy. The court found that the expert testimony may have shown that the hospital was negligent under a malpractice standard but did not demonstrate disparate treatment. It also found that, at most, plaintiff’s expert testimony established that the doctors should have known an EMC existed, but not that the hospital’s doctors actually knew that an EMC existed when the child was discharged. The court concluded that the testimony the physicians had considered the possibility of meningitis did not mean that the doctors had the requisite actual knowledge of an EMC.
The case of Cuningham v. Fredonia Regional Hospital,13 decided in the fall of 1996, presents an interesting application of the disparate treatment test, which required the court to choose between two hospital policies. In Cuningham, a federal court of appeals ruled in favor of a hospital in a case brought by the family of a deceased woman who had been discharged from the hospital’s ED without examination by a physician. The woman was first evaluated at her family physician’s office for chest pain, nausea, and shortness of breath. Her physician sent her home. When her symptoms persisted, she phoned her physician and reached his partner. The partner directed her to go to the ED for a "pain shot" and telephoned an order in to the ED for the woman to receive medication. The patient was seen by an ED nurse who evaluated her, gave her the injection as ordered, and sent her home. The woman died later that evening of an MI.
The woman’s husband brought an EMTALA claim alleging that the hospital failed to follow its chest pain policy, which required a physician to examine patients who presented to the ED with "life threatening symptoms of chest pain." He contended that, under the hospital’s own policy, all patients with chest pain were to be evaluated by a physician. The hospital argued that the relevant screening policy was its emergency illness policy, which permitted a nurse to independently evaluate a patient, without a physician, if the nurse had been "in verbal contact" with a physician. The court observed that if all patients with chest pain were to be evaluated by a physician, then the "life-threatening" language would be superfluous.
The ED nurse admitted that if the woman had come to the ED without the physician’s orders she would have followed the chest pain policy. However, because the nurse had received the physician’s telephone order and because the nurse’s evaluation did not reveal an EMC, the trial court ruled that the hospital was only required to follow its emergency illness policy. It found that there was no evidence the hospital failed to comply with its standard screening procedures under the emergency illness policy. The court of appeals agreed and upheld the trial court’s grant of summary judgment for the hospital.
The above two cases can be contrasted with C.M. v. Tomball Regional Hospital,14 which is one of the two 1997 EMTALA cases that ruled against a hospital. The C.M. case, which was decided based on the application of the disparate treatment test, involved a 15-year-old girl who was brought to the ED by her mother the day after she was raped. The mother informed the ED nurse of the assault and that the girl was in severe pain. The ED nurse allegedly did not take any vital signs, prepare a rape kit, or permit the girl to be examined by an ED physician. She did ask questions about the rape. When the mother told the nurse that the girl had bathed after the assault, the nurse informed the mother there was nothing the hospital could do and that the girl should be taken to her family physician. The mother and girl left the defendant hospital and eventually had a rape exam performed at another hospital.
The plaintiffs brought suit under a number of theories including a violation of EMTALA’s screening exam requirement and the intentional infliction of emotional distress. The trial court granted defendant’s motion for summary judgment on all counts but the appellate court reversed on the EMTALA claim. Sections of the hospital’s procedure manual dealing with the medical investigation of cases of suspected sexual assault were offered as proof of the relevant screening exam policy. The appellate court found the plaintiff had raised ample evidence that the nurse did not follow the hospital’s standard policies for the exam and treatment of victims of suspected sexual assault and reversed the grant of summary judgment.
Application of EMTALA Outside the ED
Over the years, a number of cases have addressed the issue of whether EMTALA has any application outside of the ED. The 1997 case of Roberts v.Galen of Virginia, discussed previously (in the section on the improper motive test), applied concepts of EMTALA liability to patient care decisions made several weeks after ED treatment. However, the case does not directly confront the issue of whether, or how, EMTALA should be applied outside the ED. Two other 1997 cases, Scott v. Hutchinson15 and Lemuz v. Feiser,16 deal with this issue directly.
Scott v. Hutchinson involved a woman brought to the defendant hospital’s ED by ambulance. The woman, an insulin dependent diabetic, had fallen twice due to weakness and had a number of complaints, including left-sided chest, shoulder, and abdominal pain with nausea and vomiting. She was admitted to the ICU with an acute MI under the care of the on-call physician who ordered thrombolytic therapy. No cardiologist was available, and the defendant hospital did not have a cardiac catheterization lab. Shortly after the thrombolytic agent was administered, her blood pressure plummeted and she went into shock. The woman was transferred while in an acutely unstable condition to another hospital where a cardiologist could perform emergency balloon angioplasty. Transfer forms were completed but no written consent was obtained from the woman or her family. After arriving at the second hospital, and before any invasive procedures, the woman died of massive intra-abdominal bleeding. Neither the ED physician nor the admitting physician had diagnosed an abdominal aortic aneurysm.
The woman’s husband brought suit claiming the hospital violated EMTALA in three ways: 1) it failed to perform an appropriate screening exam; 2) it failed to provide adequate stabilizing treatment; and 3) it improperly transferred the patient prior to stabilizing her condition. The district court granted summary judgment to the hospital on each of the three theories of EMTALA liability. First, there was no evidence the hospital violated its own screening policy. Therefore, the court found no screening exam violation. Second, the hospital had attempted to treat the only EMC of which it was aware. The court said the hospital had no actual knowledge of the true EMC because neither physician had diagnosed an abdominal aortic aneurysm. Therefore, under EMTALA, no duty to treat the aneurysm arose.
The plaintiff made several allegations as to why the transfer was not appropriate, there was no written consent, the physician’s certification was improper, and the hospital failed to provide medical treatment within its capacity to minimize the risks from the cardiac condition and the aneurysm. The court did not address the substance of any of these arguments. Instead, it ruled that after a patient has been screened in an ED, admitted to the hospital, and is received treatment, EMTALA’s transfer provisions do not apply. The court reasoned that EMTALA’s duties to stabilize or transfer must be cut off at some point, and that it was appropriate to terminate liability after the establishment of a physician-patient relationship and the attachment of liability under state tort law.
Lemuz v. Feiser involved a woman who was admitted to the obstetrics floor of the defendant hospital without being seen in the ED. The woman gave birth to an infant who began to exhibit neurological symptoms the day after delivery. The admitting physician consulted with a pediatric neurologist and transferred the infant to a second hospital after certifying the benefits of transfer out-weighed the risks and obtaining the mother’s consent for transfer. The plaintiff brought an EMTALA claim, alleging the hospital failed to appropriately screen the mother and fetus for an EMC and failed to stabilize the neonate’s EMC. The court granted the hospital’s motion for summary judgment on both prongs of EMTALA liability.
The court first found that the hospital had no statutory duty to screen the mother for an EMC because she did not come through the ED. The court assumed, for the sake of the motion for summary judgment, the hospital had actual knowledge that the neonate suffered with an EMC at the time of transfer. However, the court concluded that once the hospital becomes aware of an EMC, it may discharge its duty under EMTALA in one of two alternative ways, it can either stabilize the condition or make an appropriate transfer. The court ruled that because the neonate was appropriately transferred, there could be no claim for a failure to stabilize.
Immunity
A handful of the 1997 EMTALA cases addressed the issue of statutory or constitutional immunity. The subject of legislative immunity is complex and beyond the scope of this article. However, a simplistic analogy to where EMTALA sits in the relevant legislative hierarchy might be the children’s game of rock-paper-scissors. Federal constitutional immunity defeats EMTALA liability. However, EMTALA preempts state statutory immunity. As a result, state hospitals, or hospitals owned and operated by state universities, may be immunized against EMTALA liability by the 11th Amendment of the U.S. Constitution. However, county or municipal hospitals do not enjoy the same immunity from EMTALA liability.
Two of the 1997 EMTALA court opinions involve public hospitals in Puerto Rico and address the issue of federal constitutional immunity.17 In each of those cases, plaintiffs brought an EMTALA action against a number of defendants, including the University of Puerto Rico, which operates the Puerto Rico Medical Center and Piedras Medical Center, University Hospital (UPR). In both of the cases, the UPR filed a motion to dismiss the EMTALA claim. In one of the cases, the UPR was joined by another defendant, the Commonwealth of Puerto Rico, which owns the Yauco Area Hospital. These governmental bodies asserted that they were immune from EMTALA liability in the federal courts under the 11th Amendment.
Under U.S. constitutional legal doctrine, the federal courts are barred from hearing claims for money damages against the states, including Puerto Rico, under the 11th Amendment. This immunity does not extend to municipal corporations or other political subdivisions. As a result, application of 11th Amendment immunity to state run hospitals depends on whether they are treated as "an arm or alter ego" of the state or as another type of political institution. 11th Amendment immunity can be abrogated by Congress, under certain circumstances, if the language of a particular statute makes that intent unmistakably clear. The court granted the hospitals’ motions to dismiss. It found they were shielded from EMTALA liability by the 11th Amendment, and that EMTALA does not contain language that makes any intent to abrogate 11th Amendment immunity unmistakably clear.
A third case, Williams v. County of Cook,18 addresses the application of state statutory immunity to EMTALA claims. That case was brought against two physicians and Provident Hospital, which is a public hospital operated in Chicago, IL, by the County of Cook. The case, which presents some gruesome facts, involved a woman who was pregnant with twins and arrived at the hospital’s ED in active labor. For reasons that are unclear from the court’s opinion, neither the ED physician nor the on-call obstetrician examined the woman. Instead, the physicians planned to transfer the woman to another hospital and told her to wait in the ED waiting room.
After waiting three hours for transfer, the woman began to deliver the first twin in the waiting room. The ED physician and the obstetrician attempted an emergent breech vaginal delivery, during which the first twin was decapitated. At the time the woman was admitted to the hospital, the second twin was undiagnosed. Afterward, labor was induced to deliver the first twin’s placenta. As a result, the undiagnosed second twin was born and died later that day. The plaintiffs brought suit charging, among other things, medical malpractice, infliction of emotional distress, and violations of EMTALA.
The defendants brought motions to dismiss under a number of legal theories, two of which directly addressed EMTALA. First, the physicians successfully argued that private individuals cannot make a claim against individual physicians under EMTALA. The court agreed that EMTALA’s plain language only permitted private lawsuits against hospitals and it criticized the one published court opinion which has permitted an EMTALA suit to go forward against a physician.
The hospital unsuccessfully argued that, as a public hospital, it was immune from EMTALA liability under the Illinois Tort Immunity Act (ITIA). ITIA provides, in relevant part, that public entities are not liable for injuries caused by a failure to make a physical exam, the failure to diagnose or treat, and the failure to admit a person to a medical facility. However, EMTALA does contain language that it preempts state law that directly conflicts with its requirements. As a result, the court found that EMTALA preempted ITIA and that the EMTALA claim could proceed against the hospital.
Conclusion
It would be premature to uncork the champagne and declare the state appellate courts and the federal court system fast friends of emergency physicians or hospitals in general. However, as the cases surveyed in this article demonstrate, the decisions these courts published in 1997 have been predominantly pro-defense. In some cases, the court’s interpretations of both facts and law appear to have generously favored the medical defendants. The cases that ruled in favor of plaintiffs did not stretch or expand any existing interpretations of EMTALA’s requirements or create "bad law" for future litigants. In short, in 1997, the lid to Pandora’s box seems to have remained tightly sealed.
References
1. Associated Press. Hospitals accused of dumping’ patients. USA Today December 16, 1997:10A.
2. In the Matter of Baby K, 16 F.3d 590 (4th Cir. 1994).
3. Brown v. Christian Health Ministries, La., August 22, 1997 (1997 U.S. Dist. LEXIS 13303); See e.g., Williams v. County of Cook, N.D. Ill., No. 97 C 1069, July 24, 1997, (1997 U.S. Dist LEXIS 10971);
4. Boudreaux v. State, 687 So.2d 596 (La. Ct. App. 1997).
5. Boudreaux v. The State of Louisiana, 687 So.2d 596 (La. Ct. App. 1997).
6. Fleming v. HCA Health Services of Louisiana, 691 So.2d 1216 (La. Sup. Ct. 1997).
7. Camp v. Harris Methodist Fort Worth Hospital, No. 352-155902-94 (Tarrant County Judicial District, TX, January 23, 1997).
8. Phipps v. Bristol Regional Medical Center, U.S. Ct. App. 6th Cir., July 14, 1997 (1997 U.S. App. LEXIS 17919).
9. This test is used by only one federal court of appeals, the U.S. Court of Appeals for the Sixth Circuit. It was first articulated in the case of Cleland v. Bronson Health Care Group, 917 F.2d 266 (6th Cir. 1990). In May of 1997 the U.S. Supreme Court declined to address this apparent conflict between the 6th Circuit’s use of this legal standard and the remainder of the federal circuit courts’ use of the disparate treatment’ standard when the Supreme Court denied the plaintiff’s petition to grant a writ of certiorari in the case of Hutton v. Three Rivers Area Hospital, 1997 U.S. LEXIS 3262 (U.S. Sup. Ct, 1997). By refusing to hear the Hutton appeal, the Supreme Court left the courts divided on the issue of which legal standard to use.
10. Adams v. Grace Hospital, 962 F.Supp. 101 (S. Dist. Mich. 1997).
11. Roberts v. Galen of Virginia, 111 F.3d 405 (6th Cir. 1997).
12. Casey v. Amarillo Hospital District, 947 S.W.2d 303 (Tex. App. 1997).
13. Cuningham v. Fredonia Regional Hospital, 1996 U.S. App. LEXIS 26661 (10th Cir. 1996)(subsequently reported in table case format at 98 F.3d 1349).
14. C.M. v. Tomball Regional Hospital, TX Ct. App., 1st Dist., (1997 Tex. App. LEXIS 2012).
15. Scott v. Hutchinson, 959 F.Supp. 1351 ( U.S.Dist. Ct., Kansas, 1997).
16. Lemuz v. Feiser, U.S. Dist. Ct., Kansas, No. 94-1513-FGT, July 3, 1997 (1997 U.S. Dist. 11385).
17. Lebron v. Ashford Presbyterian Community Hospital, U.S. Dist Ct. Puerto Rico, No. 96-13424, Aug. 20, 1997 (1997 U.S. Dist. LEXIS 13424); Morales v. Estado Libre Asociado De Puerto Rico, 967 F.Supp 42 (U.S. Dist Ct. Puerto Rico, 1997).
18. Williams v. County of Cook, N.D. Ill. 1997, No 97 C 1069, July 24, 1997 (1997 U.S. Dist.)
Physician CME Questions
20. Transfers of unstable patients to other facilities, or "patient dumping," were:
a. rarely seen in early EMTALA cases.
b. often seen in early EMTALA cases.
c. never seen.
d. occuring on a daily basis.
21. The improper motive test requires a plaintiff to prove a hospital acted out of an "improper or impermissible motivation" and provided a substandard screening exam, or failed to stabilize a patient with a known EMC, based on factors such as:
a. lack of insurance.
b. race or sexual orientation.
c. disease state.
d. spite.
e. all of the above.
22. In order to mount an EMTALA claim of "disparate treatment," what proof is often adequate?
a. Impermissible motive
b. Lack of insurance and spite.
c. Racial and sexual discrimination.
d. A hospital acting inconsistently with its own policies.
23. EMTALA is intended to ensure that each ED patient receives the same level of medical services (screening and treatment) that the hospital provides to every other patient who presents with the same or similar symptoms.
a. True
b. False
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