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Dollard v. Allen

Application of EMTALA requirements to inpatients

In May 2003, the Federal District Court in Wyoming issued a decision addressing the recurring question of whether EMTALA applies to a person who is transferred while an inpatient.  We believe that this opinion is one of the better EMTALA analyses that we have seen on this issue.

The case involved a claim brought by an employee of defendant hospital, who originally sustained a back injury while assisting a patient in December 1998. She was followed by a local physician, a Dr. Allen, for several months.

On June 25, 2000, she telephoned Dr. Allen and told him that her pain was worse and that she was experiencing numbness in her buttocks for the first time.  (This symptom could be indicative of a major neurological problem.)  He prescribed pain medication and rest.  

On June 27, she was not better and called her doctor again.  He advised her that she should be admitted to the hospital for pain management.  She went to the hospital and presented directly to the medical-surgical floor, bypassing both the emergency room and the admitting desk.  She was admitted and was treated with IV pain medications.

On June 28, when he saw her on rounds, she told Dr. Allen that her complaints of pain had improved but that she had experienced an increase in the numbness.  Again, this could have been a "red flag" to her physician, indicative of an impending neurosurgical emergency that he overlooked.  He ordered that she be discharged home.  

On June 29, after a worsening of her symptoms, she was readmitted to the hospital and examined by another physician, who found a large ruptured disk.  He operated on June 30.  The nature of the residual problems or disabilities is not specified in the opinion.  

The defendant hospital moved for summary judgment on the EMTALA claim, stating that the fact that she never presented to the emergency room for examination precluded the claim.  Alternatively, it claimed that she had failed to establish that the hospital failed to follow its screening procedures.  

Before addressing these points, the court observed:

"Since EMTALA's enactment as part of the Consolidated Omnibus Budget Reconciliation Act, Pub. L. No. 99-272, § 9121 (1986), courts have struggled with the interpretation of the Act. It is safe to assume that § 1395dd has not made its way into any textbooks on statutory construction as a model of Congress' ability to draft a plain and unambiguous statute. Consequently, the Tenth Circuit has routinely resorted to, and emphasized the importance of, EMTALA's legislative history in construing the Act and explaining its limited purpose. See Phillips v. Hillcrest Med. Center. 244 F.3d 790, 798-99 (10th Cir. 2001); Ingram v. Muskogee Reg'1 Med. Center. 235 F.3d 550, 552 (10th Cir. 2000)."
  The court found with respect to the intent of the statute:
  • Congress' purpose in enacting EMTALA was to prevent patient dumping - the practice of refusing to treat uninsured patients.
  • EMTALA was not designed to function as a federal malpractice statute or to supplant state law medical malpractice suits.

After noting the two distinct obligations imposed by EMTALA - the screening requirement and the treat until stable requirement - the court observed that they could be considered either conjunctively or disjunctively:

"Under the conjunctive approach, EMTALA is construed as setting forth one cause of action based upon three sequential requirements. First, under subsection (a), the hospital has the duty to screen any individual who comes to the hospital emergency department to determine if an emergency medical condition exists. 42 U.S.C. § 1395dd(a). If the hospital determines through its standard screening procedures that the individual who presents himself in the emergency department has an emergency medical condition, then subsection (b) requires the hospital to treat and stabilize that condition, id. § 1395dd(b) (1) (A) , or to transfer that individual in accordance with subsection (c) , id. § 1395dd(b) (1) (B) . In turn, subsection (c) restricts the transfer of the unstabilized individual unless certain requirements are satisfied. Id. § 1395dd(c)(i)-(iii).

"Under this approach, subsections (a) , (b) , and (c) of EMTALA all relate to a single sequence of events; hence, the threshold issue is whether an individual came to the hospital's emergency department."

The court then described the alternative interpretation:
"Under the disjunctive approach, EMTALA is construed as setting forth distinct causes of action under its medical screening requirement in subsection (a) and its stabilization requirement in subsection (b)."

The conjunctive approach, it noted, had been adopted by four different circuit courts in the following cases:

  • Harry v. Marchant. 291 F.3d 767, 770 (llth Cir. 2002) (noting that under EMTALA, emergency rooms are subject to two principal obligations, commonly referred to as the appropriate medical screening requirement and the stabilization requirement);
  • Bryan v. Rectors and Visitors of the Univ. of Va.. 95 F.3d 349, 352 (4th Cir. 1996) (holding that the stabilization requirement was intended to regulate the hospital's care only after emergency treatment);
  • Thornton v. Southwest Detroit Hosp.. 895 F.3d 1131, 1134 (6th Cir. 1990)(noting that once a patient is found to suffer from an emergency medical condition in the emergency room, she cannot be discharged until the condition is stabilized).
  • James v. Sunrise Hosp.. 86 F.3d 885, 889 (9th Cir. 1996).

The disjunctive approach, it found, had been adopted only by the First Circuit, in the case of Lopez-Soto v. Hawayek. M.D.. 175 F.3d 170 (1st Cir. 1999), and by District Courts in the following cases:

  • Reynolds v. Mercy Hosp.. 861 F. Supp. 214, 222 (W.D. N.Y. 1994);
  • Mclntyre v. Schick. 795 F. Supp. 777, 780 (E.D. Va. 1992);
  • Helton v. Phelps County Regional Med. Center. 794 F. Supp. 332, 333 (E.D. Mo. 1992).

The court noted that the 10th Circuit had issued nine EMTALA cases, but did not find any where a preference between these approaches had been expressly adopted.  On analyzing the facts of a couple of cases, particularly Urban v. King, 43 F.3d 523 (10th Cir. 1994), the Court considered that the 10th Circuit had implicitly accepted the disjunctive approach.  

Applying these considerations to the case before it, the court noted:

"A plaintiff may maintain an action under EMTALA by showing a 'violation of either § 1395dd(a) or § 1395dd(c); [the plaintiff] need not show a violation of both subsections.' Urban. 43 F.3d at 525 (emphasis added). However, a plaintiff must demonstrate a violation of EMTALA's stabilization requirement, § 1395dd(b), as a condition precedent to recovering under EMTALA's transfer provision, §1395dd(c)."

As to the screening claim, the court found that the plain language of the statute compels a conclusion that it applies only to patients who have presented to the emergency department.  

The applicable language is:

". . . 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. . ."

The court concluded that the obligation to provide stabilizing treatment did not arise because "Plaintiff has failed to present any evidence that LVMC had actual knowledge of her unstabilized emergency medical condition when it discharged her".

Further, the court concluded that LVMC did not violate EMTALA's stabilization before transfer requirement because that provision does not apply to individuals that have been admitted to the hospital for inpatient care.

This holding would seem to follow the "conjunctive approach", but this court's innovation was its conclusion that this result was compelled on Federalism grounds.  The court decided that its interpretation was supported by EMTALA's preemption provisions, and a ruling to the contrary would make those provisions meaningless.  The court analyzed the scenario thus:

  • While presenting to the emergency room for examination, the hospital's obligations are governed by EMTALA.
  • After she is admitted, by contrast, EMTALA ceases to govern and the hospital assumes liability under state law for any negligence in the course of treatment.  

This analysis, the court found, was most consistent with Congress' intent to ensure that EMTALA occupied only a narrow area and to avoid enacting a substantive malpractice requirement as a matter of Federal law.  Limiting EMTALA in this way meant that state and Federal requirements occupied their own separate ground:

"This interpretation makes EMTALA's stabilization before transfer requirement only applicable when state tort law does not apply and precludes the adoption of a standard tantamount to a federal malpractice statute."

After dismissing the Federal claims under EMTALA, the court scheduled the case for trial on the state law claims, exercising pendent jurisdiction over those claims.

Thus, the Wyoming District Court has carefully analyzed the distinction between two possible interpretations of the statute and has delineated a reasonable point of separation based on the purpose to be accomplished by EMTALA, as balanced against the need to avoid infringing on the issues that are properly within the purview of state-created malpractice law.  We believe that its approach is persuasive and should be carefully reviewed and considered by any litigant or court facing a similar issue.