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From Health Law Daily, May 31, 2013

First Circuit vacates dismissal of EMTALA screening claim related to pregnant woman, remands to district Court

By Kelly J. Rooney, JD

The complaint brought against a hospital for failing to properly screen a patient who presented at its emergency room with vaginal bleeding in her third trimester of pregnancy when the hospital had in place a protocol for screening just such a patient presented an issue sufficient to proceed to trial (Cruz-Vazquez v Mennonite General Hospital, May 29, 2013, Torruella, J). The dismissal of the patient’s disparate screening claim brought under the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 USC sec. 1395dd) by the U.S. District Court for the District of Puerto Rico is vacated and the matter is remanded to the district court for further proceedings.

The facts of the case. The patient, Hazel Cruz-Vazquez, in her third trimester of pregnancy, presented to the Mennonite General Hospital’s emergency room for treatment for vaginal discharge and spotting. Only a pelvic exam was performed, during which the physician found that the patient’s cervix was not dilated. The physician contacted the patient’s obstetrician who advised that she be discharged in stable condition and instructed to follow up with him the next morning, which the hospital’s physician did. The obstetrician found, when he performed a pelvic exam on Cruz-Vazquez the following morning, a pool of blood collected in her vagina, her cervix dilated seven centimeters, and the fetus in breech position. At that point, the obstetrician transferred her to another hospital in stable condition, where she underwent a cesarean section. The baby died two days later.

At the time of Cruz-Vazquez’s treatment at Mennonite, the hospital had a protocol in place requiring certain tests and examinations to be performed when a patient presented with bleeding in her third trimester. Beyond just a pelvic exam, a speculum exam was to be performed to see if membranes had ruptured, fetal movements and heart rate measured, as well as a number of laboratory tests run. Mennonite stipulated that it did not activate or follow the protocol in this case. Cruz-Vazquez filed suit in district court alleging that she presented to Mennonite with an emergency medical condition, that the hospital failed to screen her properly, and failed to stabilize or properly transfer her in accordance with EMTALA.

Prior proceedings. The case has seen an arduous history up until this point. First, the patient’s expert witness was dismissed and the hospital was granted judgment as a matter of law, and the district court said that she had failed to prove crucial elements of her case. On appeal to the First Circuit Court of Appeals, the court raised the issue of whether the district court could exercise federal jurisdiction under EMTALA. However, the First Circuit’s decision vacating the district court’s judgment for abusing its discretion in excluding the expert’s testimony based on his potential bias, which is a matter that should be left to the jury to decide, was silent on the jurisdiction issue. Instead of starting a new trial on remand, the hospital filed a motion for summary judgment based on the lack of federal jurisdiction, which was denied by the district court. Then, after the patient’s motion to appoint a new expert was granted and a date for trial was to be scheduled, and despite the fact that the jurisdictional issue was previously rejected by the district court and not addressed by the Court of Appeals (which should have been interpreted as meaning that there was no flaw), the court requested a briefing on the jurisdictional issue. The hospital at that time also filed a motion to dismiss for lack of federal jurisdiction under EMTALA, but its briefing, rather, attacked the merits of the patient’s claims instead of jurisdiction. The district court granted the hospital’s motion and vacated its prior denial of summary judgment. In its opinion, the district court also addressed the merits of the claims. Ultimately the district court dismissed Cruz-Vazquez’s complaint “as stating facts limited to a medical malpractice claim, and holding that ‘EMTALA does not create a federal cause of action for medical malpractice.’” On appeal, this matter is before the Court of Appeals for a second time.

Analysis by appeals court. Here, the Court of Appeals found that the use of jurisdictional framework to consider the merits of the patient’s EMTALA claim in the district court’s opinion and order were erroneous. This court, rather, reviewed the hospital’s motion to dismiss as raising challenges regarding the complaint’s sufficiency.

EMTALA elements. To establish a violation of EMTALA, a party must show that (1) the hospital is a participating hospital, covered by EMTALA, and operates an emergency department; (2) the party sought treatment at the hospital; (3) the hospital either did not appropriately screen the patient for an emergency medical condition or released the patient without stabilizing. For a screening violation, a party “need not prove that she actually suffered from an emergency medical condition when she first came through the portals of the defendant’s facility; the failure appropriately to screen, by itself, is sufficient to ground liability as long as the other elements of the cause of action are met.”

Appropriate screening. The court notes that EMTALA does not dictate what an appropriate screening is, only that there must be a screening procedure in place and it must be “administered even-handedly.” The court cites that if a hospital has an internal procedure for dealing with certain symptoms, those procedures “set the parameters for an appropriate screening.” To determine whether treatment is uniform (or “administered even-handedly”), the court must look to whether the hospital’s existing procedures are followed when triggered symptoms are identified.

This matter is distinguished from situations where there was no screening protocol in place, where screening procedures existed but were not followed because no triggering symptoms presented, and when screening was done but an improper diagnosis resulted. Both parties agreed that there was a protocol in place for this situation. This case is distinguishable from a situation where the triggering symptoms were not evident or were not complained of by the patient because Cruz-Vazquez clearly presented with the triggering symptoms for the protocol—vaginal bleeding in her third trimester. Further, the hospital admitted that it did not implement the protocol with the patient. It is also distinguishable from a situation where less screening was performed which led to an improper diagnosis. Here, there was no failure to properly diagnose based on a faulty screening, but rather, a failure to treat as they would other individuals presenting with the same symptoms. Further, her discharge based on the recommendation of her obstetrician did not relieve the hospital of own screening requirements. Sufficient evidence was presented by Cruz-Vazquez to proceed to trial. The matter was remanded and the district court’s judgment was vacated.

The case number is 11-2297.

Attorneys: Anselmo Irizarry-Irizarry (Matta & Matta PSC) for Mennonite General Hospital, Inc. Humberto R. Vazquez-Sandoval for Advanced Ob-Gyn, PCS. Gilda del C Cruz Martino for SIMED.

Companies: Mennonite General Hospital, Inc.; SIMED; Advanced Ob-Gyn, PCS

MainStory: TopStpry CaseDecisions EMTALANews MaineNews MassachusettsNews NewHampshireNews PuertoRicoNews RhodeIslandNews

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