Opinion
Cause No. EV 00-248-C-T/H
December 14, 2001
ENTRY DENYING WBH EVANSVILLE, INC.'S MOTION TO DISMISS
Though this Entry is a matter of public record and is being made available to the public on the court's web site, it is not intended for commercial publication either electronically or in paper form. The reason for this caveat is to avoid adding to the research burden faced by litigants and courts. Under the law of the case doctrine, the ruling or rulings in this Entry will govern the case presently before this court. See, e.g., Trs. of Pension, Welfare, Vacation Fringe Benefit Funds of IBEW Local 701 v. Pyramid Elec., 223 F.3d 459, 468 n. 4 (7th Cir. 2000); Avitia v. Metro. Club of Chicago, Inc., 49 F.3d 1219, 1227 (7th Cir. 1995). However, a district judge's decision has no precedential authority and, therefore, is not binding on other courts, on other judges in this district, or even on other cases before the same judge. See, e.g., Howard v. Wal-Mart Stores, Inc., 160 F.3d 358, 359 (7th Cir. 1998) ("a district court's decision does not have precedential authority"); Malabarba v. Chicago Tribune Co., 149 F.3d 690, 697 (7th Cir. 1998) ("district court opinions are of little or no authoritative value"); United States v. Articles of Drug Consisting of 203 Paper Bags, 818 F.2d 569, 571 (7th Cir. 1987) ("A single district court decision . . . has little precedential effect. It is not binding on the circuit, or even on other district judges in the same district."). Consequently, though this Entry correctly disposes of the legal issues addressed, this court does not consider the discussion to be sufficiently novel or instructive to justify commercial publication of the Entry or the subsequent citation of it in other proceedings.
This matter is before the court on a Motion to Dismiss filed on February 20, 2001, by defendant WBH Evansville, Inc., d/b/a Welborn Baptist Hospital ("Welborn"). (Docket Items 17, 18.) The Plaintiff filed a responsive brief on March 26. (Docket Item 28.)
Welborn filed a reply brief on April 9. (Docket Item 33.)
I. Factual Background
The Plaintiff, Robert E. Hicklin, Jr. ("Hicklin"), as Personal Representative of the Estate of Millard H. Black, Deceased ("Black"), brings this action alleging Black incurred additional medical expenses, endured tremendous pain and suffering and a loss of quality of life during a fourteen-month period of time, and ultimately suffered an untimely death as a result of actions taken by emergency room physician Dennis L. Newberry, M.D. ("Newberry") and by Welborn's Emergency Room.
II. Motion to Dismiss Standard
Defendant claims that Plaintiff's Complaint must be dismissed under Federal Rule of Civil Procedure 12(b)(6). Under Rule 12(b)(6), a complaint may be dismissed for failure to state a claim upon which relief can be granted. Fed.R.Civ.P. 12(b)(6). A motion to dismiss tests the sufficiency of the complaint, not the merits of the suit. See Gibson v. City of Chicago, 910 F.2d 1510, 1520 (7th Cir. 1990).
Rule 8(a)(2) requires "a short and plain statement of the claim showing that the pleader is entitled to relief," that will "give the defendant fair notice of what the plaintiff's claim is and the grounds upon which it rests." Leatherman v. Tarrant County Narcotics Intelligence Coordination Unit, 507 U.S. 163, 168 (1993) (citation and quotations omitted). When considering a motion to dismiss, the complaint's allegations are accepted as true and viewed in the light most favorable to the plaintiff. See Hentosh v. Herman M. Finch Univ. of Health Sciences/The Chicago Med. Sch., 167 F.3d 1170, 1173 (7th Cir. 1999).
The court must review the plaintiff's statement of the claim to determine whether the plaintiff has set forth facts supporting a cause of action that would entitle them to relief. Conley v. Gibson, 355 U.S. 41, 45-46 (1957); Beam v. IPCO Corp., 838 F.2d 242, 244 (7th Cir. 1988). However, the court is not required to accept legal conclusions, inferences, or allegations unwarranted by the facts as presented in the pleadings. Mid-Am. Reg'l Bargaining Ass'n v. Will County Carpenters Dist. Council, 675 F.2d 881, 883 (7th Cir. 1982). The accepted standard for determining the sufficiency of the complaint does not permit dismissal "unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief." Conley, 355 U.S. at 45-46. This is a technical determination not based upon the veracity of the facts alleged. The court cannot dismiss a complaint merely because it doubts that the plaintiff can prove the facts it alleges. Neitzke v. Williams, 490 U.S. 319, 327 (1989). Thus, a defendant's motion to dismiss can only be granted if the plaintiff has failed to allege sufficient facts to entitle the plaintiff to relief if the facts alleged are taken as true. "[I]f the plaintiff . . . pleads facts, and the facts show that he is entitled to no relief, the complaint should be dismissed. There would be no point in allowing such a lawsuit to go any further; its doom is foretold." Am. Nurses' Ass'n v. Illinois, 783 F.2d 716, 727 (7th Cir. 1986).
III. EMTALA
Hicklin brings this action pursuant to the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd ("EMTALA"). This federal statute became effective in 1986 as a part of the Consolidated Budget Recommendation Act of 1986, often referred to as "COBRA." See Pub.L. No. 99-272, 100 Stat. 82, 164-67 (1986). Welborn suggests, and cases which have discussed this statute seem to agree, that at least one of the primary purposes of the statute was to prevent hospitals from "Patient Dumping" — the practice of refusing to accept or treat patients with emergency conditions if that patient does not have insurance. See Correa v. Hospital San Francisco, 69 F.3d 1184 (1st Cir. 1995) (citing to H.R. Rep. No. 241(I) (1986), reprinted in 1986 U.S.C.C.A.N. 42, 605); see also Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 268 (6th Cir. 1990). Congress responded to this concern by conditioning hospitals' continued participation in the Medicare program on accepting certain duties under the Act.
Fifteen years have passed since the enactment of this statute, but there is surprisingly little authority addressing the effect of the Act. The United States Supreme Court has touched upon the statute but once; only one case in this circuit has briefly discussed the Act; and district court decisions within this circuit have come to different conclusions about the effect of the statute.
Johnson v. University of Chicago Hospitals., 982 F.2d 230 (7th Cir. 1992), did not discuss any portion of the Act germane to this case.
The cases which have analyzed the statute seem to conclude that EMTALA imposes two duties, the first of which is stated as follows:
In the case of a hospital that has a hospital emergency department, if any individual . . . 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 . . . to determine whether or not an emergency medical condition . . . exists.42 U.S.C. § 1395dd(a). This requirement is commonly referred to in the case law as the "Screening Requirement."
The second requirement, referred to as the "Stabilization Requirement," is stated as follows:
(b) Necessary stabilizing treatment for emergency medical conditions and labor
(1) In general
If any individual . . . 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.
. . . .
(C) Restricting transfers until individual stabilized
(1) Rule
If an individual at a hospital has an emergency medical condition which has not been stabilized . . ., the hospital may not transfer the individual unless —
(A)(i) the individual . . . in writing requests transfer . . .,
(ii) a physician . . . has signed a certification that . . . the medical benefits . . . from . . . the provision of appropriate medical treatment at another medical facility outweigh increased risks . . .; or
(B) the transfer is an appropriate transfer
. . . .
A participating hospital who negligently fails to comply with this statute may be made to pay a civil penalty. Id. § 1395dd(d)(A). A physician who is responsible for the examination, treatment, or transfer of the patient and who negligently violates this statute may also be assessed a civil penalty. Id. § 1395dd(d)(B). In addition, a private individual may enforce the statute through a civil suit. In this regard, the statute provides:
(A) Personal harm
Any individual who suffers personal harm as a direct result of a participating hospital's violation of a requirement of this section may, in a civil action against the participating hospital, obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate.42 U.S.C. § 1395dd(d)(2).
A. Screening
Welborn's Motion to Dismiss (Docket Items 17, 18) argues that Hicklin's complaint fails to state a cause of action because the complaint merely alleges malpractice by Newberry. Welborn argues that EMTALA does not provide a federal remedy for misdiagnosis or inadequate treatment by a physician. (Brief at 3.) Welborn further contends that it has not violated EMTALA because the Act requires only that a "screening" be given, and in this case Black received such a screening. If the screening was negligently performed, Welborn argues, that matter is to be resolved under a state medical malpractice claim and not under EMTALA.
It must be noted that EMTALA requires hospitals to provide "an appropriate medical screening examination within the capability of the hospital's emergency department." § 1395dd(a). "Appropriate" is not defined in the statute. However, Correa aptly summarizes the holdings of several courts in these words:
Be that as it may, the courts have achieved a consensus on a method of assessing the appropriateness of a medical examination in the EMTALA context. A hospital fulfills its statutory duty to screen patients in its emergency room if it provides for a screening examination reasonably calculated to identify critical medical conditions that may be afflicting symptomatic patients and provides that level of screening uniformly to all those who present substantially similar complaints. See Baber v. Hospital Corp. of Am., 977 F.2d 872, 879 (4th Cir. 1992); Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991). The essence of this requirement is that there be some screening procedure, and that it be administered even-handedly.
We add a caveat: EMTALA does not create a cause of action for medical malpractice. See Gatewood, 933 F.2d at 1041. Therefore, a refusal to follow regular screening procedures in a particular instance contravenes the statute, see Baber, 977 F.2d at 879, but faulty screening, in a particular case, as opposed to disparate screening or refusing to screen at all, does not contravene the statute. See Brooks v. Maryland Gen. Hosp., 996 F.2d 708, 711 (4th Cir. 1993). In this case, HSF's delay in attending to the patient was so egregious and lacking in justification as to amount to an effective denial of a screening examination.
Correa, 69 F.3d at 1192-93.
As pled in the complaint, which facts must be accepted as true in a Federal Rule of Civil Procedure 12 analysis, Black presented himself at the Welborn Emergency Room with an emergency medical condition that evolved into a "substantial right parietal frontal temporal subdural hematoma." (Compl. ¶ 13.) The nurse examining Black noted that he hit his head on the windshield as a result of an automobile collision and complained of a headache. The nurse also noted an abrasion on the forehead and an injury to his right index finger. She noted Black's history of atrial fibrillation, a recent stroke, a pacemaker, and that he was taking a blood thinning medication. (Compl. ¶ 9.) Newberry conducted a fourteen-minute examination. In his report of the examination, he failed to note the head abrasion, the injury to the hand, and did not discuss any of Black's other prior medical conditions. (Compl. ¶ 10.) The physician ordered no further examination, testing, or observation, and immediately released Black to return home. (Compl. ¶ 11.)
This court concludes that these facts could conceivably be construed to suggest that the screening procedures employed here were not "reasonably calculated to identify critical medical conditions that may be afflicting symptomatic patients." Correa, 69 F.3d at 1192. Welborn could be liable under EMTALA even if the screening procedure used in this instance (a less than fifteen-minute examination with no tests, follow up, or other observations) is the normal screening procedure used by the hospital, provided the Plaintiff produces evidence to show that such a procedure is not reasonably calculated to discover serious medical conditions. Alternatively, if these screening procedures used for Black were not the "normal" procedures used by the hospital, then the hospital may be liable because it used other than its "normal" procedures. Although Hicklin has not explicitly pleaded a disparate screening procedure theory, notice pleading requires the court to infer such a theory from the present complaint. As a result, it is not beyond imagination that the Plaintiff could produce evidence to support such a theory. If the hospital does not provide its screening procedure "even-handedly," then Hicklin has a claim under EMTALA. This is not to say that the hospital is liable under EMTALA for a screening process that misses some injuries in Plaintiff that were diagnosed in other patients. Rather, the question is whether individuals who are perceived to have the same medical conditions receive disparate screening and treatment. See Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1139 (8th Cir. 1996) (en banc).
Therefore, in conclusion on the "screening" claim under § 1395dd(a), Welborn's Motion to Dismiss must be DENIED. Two conceivable sets of facts exist under which Hicklin can recover under EMTALA. First, Hicklin may show that the screening procedures Black received were the hospital's standard procedures, and that these standard procedures were not reasonably calculated to identify critical medical needs. Alternatively, if Hicklin can prove that the normal hospital screening procedures are significantly different from those received by Black, then Hicklin may also recover under EMTALA.
B. Stabilization
Hicklin also claims that the hospital failed to stabilize Black before his transfer home. (Compl. ¶ 14.) As to this claim, Roberts v. Galen of Virginia, Inc. holds that EMTALA imposes upon hospitals the duty to provide "such further medical examination and such treatment as may be required to stabilize the medical condition." 525 U.S. 249, 253 (1999). Roberts also holds that the cause of action brought under the "stabilization" component of the Act does not require a showing of improper motive by the hospital. Id.
In a footnote in Roberts, the Supreme Court discussed the hospital's argument that as long as the hospital did not have actual knowledge of the patient's condition, the hospital did not violate EMTALA. The Supreme Court expressed "no opinion as to the factual correctness or legal dispositiveness of th[is] claim" and left the resolution of it to the court below. Although the Supreme Court has not expressly concluded that actual knowledge of the patient's condition is a prerequisite to liability under EMTALA, a common sense reading of the statute requires it. To read the statute otherwise would render some words in the statute meaningless.
Specifically, § 1395dd(b) provides: "[if] any individual . . . comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either . . . [stabilization or transfer]." (emphasis added). This court concludes that a cause of action for improper stabilization may exist under EMTALA so long as: (1) the hospital has actual knowledge of the condition; (2) an individual came to a hospital with an emergency medical condition; and (3) the hospital fails to provide further medical examination and such treatment as may be required to stabilize the medical condition (so long as that examination and treatment can be done within the staff and facilities available at the hospital). This understanding of the stabilization requirement is widely followed in other circuits. Jackson v. East Bay Hosp., 246 F.3d 1248, 1257 (9th Cir. 2001); Summers, 91 F.3d at 1140; Vickers v. Nash Gen. Hosp., Inc., 78 F.3d 139, 140 (4th Cir. 1996); Urban v. King, 43 F.3d 523, 525-26 (10th Cir. 1994); Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 268-69 (6th Cir. 1990); Gatewood v. Wash. Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991).
An interesting problem arises from this interpretation, namely that a hospital which has an inadequate screening will never have knowledge of a patient's emergency medical condition and will never be liable under the stabilization portion of the Act. This apparent inconsistency is resolved when one examines the damages provision of EMTALA. EMTALA is a strict liability statute of sorts; once it is determined that a hospital violated the Act, the plaintiff need not prove negligence. However, the damages for a violation of either provision of EMTALA are the "damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate." 42 U.S.C. § 1395dd(d)(2)(A). It is not clear to this court how a plaintiff could receive greater damages for a violation of both provisions of the statute than for just a violation of one of the provisions. Either way the damages are limited to the damages available for personal injury. In this way, the knowledge requirement does not create an anomaly. A plaintiff can sue under both provisions, but if she establishes that the hospital has an inadequate screening provision that did not provide it with knowledge of her injury, she will still recover the full amount of her injury.
In this case, although it appears that Newberry did not have knowledge of his emergency medical condition, the nurse noted that Black hit his head on the windshield and had injuries on his head and hands. (Compl. ¶ ¶ 9,10.) If the nurse's observations can be imputed to the hospital, this would satisfy the knowledge requirement. Because at this stage of the proceedings, this court must accept all of the Plaintiff's facts as true and it is possible that Plaintiff could prove facts that state a claim under EMTALA, this court will decline to dismiss this claim.
IV. Conclusion
For the foregoing reasons, Welborn's Motion to Dismiss is DENIED. ALL OF WHICH IS ORDERED.