Cruz-Vazquez et al v. Mennonite General Hospital, Inc. et al
Filing
132
OPINION AND ORDER denying 112 Motion for Summary Judgment as to Plaintiffs' EMTALA claims and denying Defendant's motion requesting dismissal of Plaintiffs' state law claims. Signed by Judge Jose A Fuste on 08/15/2011. (dv)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
HAZEL I. CRUZ-VAZQUEZ, et al.,
Plaintiffs
v.
CIVIL NO.
08-1236 (JP)
MENNONITE GENERAL HOSPITAL,
INC., et al.
Defendants
OPINION AND ORDER
Before the Court is Defendants’ motion for summary judgment (No.
112) and Plaintiffs’ opposition thereto (No. 116). On February 25,
2008, Plaintiffs brought the instant action pursuant to the Emergency
Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. §
1395dd, and Articles 1802 and 1803 of the Puerto Rico Civil Code,
P.R.
Laws
Ann.
tit.
31,
§§
5141-42.
Plaintiffs
allege
that
Defendants’ medical malpractice and violation of EMTALA caused
Plaintiff Hazel Cruz-Vazquez (“Cruz”) to give birth to a premature
baby girl whose incomplete development resulted in respiratory
complications that caused the baby’s death within two days after she
was born. For the reasons herein, Defendants’ motion is DENIED.
By way of background, a jury trial was held in this case
commencing on March 30, 2009. Plaintiffs presented the testimony of
several witnesses, including the testimony of Dr. Carlos E. Ramirez
(“Dr. Ramirez”), Plaintiffs’ expert witness. On April 2, 2009,
CIVIL NO. 08-1236 (JP)
-2-
Defendants moved to exclude the testimony of Dr. Ramirez, which the
Court
granted.
Thereafter,
Plaintiffs
rested
their
case,
and
Defendants moved for judgment as a matter of law pursuant to Rule
50(a) of the Federal Rules of Civil Procedure, which the Court also
granted (No. 93). On August 2, 2010, the First Circuit Court of
Appeals vacated the judgment of the Court and remanded the case for
further proceedings consistent with the Opinion (No. 103).
I.
MATERIAL FACTS NOT IN GENUINE ISSUE OR DISPUTE
The following material facts (“ISC UMF”) were deemed uncontested
by all parties hereto at the Initial Scheduling Conference held on
June 27, 2008 (No. 34).
1.
Defendant Mennonite General Hospital, Inc. (“Mennonite”)
is a medical institution subject to EMTALA.
2.
Plaintiffs sent a letter dated December 27, 2007, to
Defendants Mennonite and Defendant Dr. Eduardo Gomez (“Dr.
Gomez”) via certified mail, which was received on January
2, 2008.
3.
Defendant Dr. Brenda Torres (“Dr. Torres”) is a physician,
fully authorized to practice medicine in the Commonwealth
of Puerto Rico, who has been granted privileges to do work
in the emergency room by co-Defendant Mennonite. She is
employed by RMB Corp. Dr. Torres is of legal age, married
to Amílcar Vélez and resident of Road 176, Camino Dr.
Juliá, Cupey Alto, San Juan, Puerto Rico.
CIVIL NO. 08-1236 (JP)
4.
-3-
Defendant Dr. Gomez is an obstetrician and gynecologist
duly authorized to practice medicine in the Commonwealth
of Puerto Rico who had privileges to practice in all the
medical facilities of Defendant Mennonite at the times
subject of this case. Dr. Gomez is an obstetrician and
gynecologist with a private medical office located at El
Jíbaro
Avenue,
Parque
Industrial,
Centro
de
Salud
Menonita, Suite 101, Cidra, Puerto Rico.
5.
Defendant Dr. Gomez is Plaintiff Cruz’s primary OB-GYN
physician and was not an employee of Mennonite at the time
of the alleged facts.
6.
Defendant Advanced OB-GYN, PSC is a Professional Services
Corporation of which Defendant Dr. Gomez is an owner
and/or president and/or shareholder for the practice of
obstetrics and gynecology. It is a legal entity authorized
and with operations under the laws of the Commonwealth of
Puerto Rico.
7.
Plaintiff Cruz became a patient of Dr. Gomez for her
prenatal care on August 10, 2006. Cruz was further seen by
Dr. Gomez for prenatal care on August 24, August 26,
September 26, October 10, October 24, November 21, and
December 19, 2006; and on January 4, 2007.
CIVIL NO. 08-1236 (JP)
8.
Cruz’s
-4-
prenatal
care
and
progress
was
completely
uneventful, including her regular visit on January 4, 2007
at 2:00 p.m.
9.
At said visit, on January 4, 2007, Dr. Gomez wrote in a
progress note that Cruz had a blood pressure of 120/70,
the fetal cardiac rhythm was present, she was twenty-seven
weeks and four days pregnant, with a fundal height of
thirty centimeters, with no vaginal bleeding, no vaginal
“D/C,” no suprapubic pain, no lower back pain, and with an
active fetus.
10.
Cruz’s estimated date of labor was April 1, 2007, as per
Dr. Gomez’s medical record.
11.
As per the medical records, during prenatal care the
laboratory results were normal.
12.
On January 4, 2007, Plaintiff Cruz, the only plaintiff who
requested medical services on January 4, 2007 at Mennonite
in Cidra, arrived to the emergency room of Mennonite in
Cidra at 10:15 p.m. with complaints of vaginal discharge
and occasional blood spotting within the prior half hour.
Cruz
denied
pelvic
pain,
dysuria,
or
fever,
and
was
feeling fetal movements.
13.
Cruz was evaluated by Dr. Torres, who performed a vaginal
or pelvic exam on Plaintiff Cruz and found that the cervix
was not dilated.
CIVIL NO. 08-1236 (JP)
14.
-5-
Dr. Torres provided certain medical care and treatment to
Plaintiff Cruz on January 4 and 5, 2007, at Mennonite, as
per the medical record.
15.
Cruz was with 27 4/7 weeks of gestation and was in her
third trimester.
16.
As per the medical record, Dr. Torres called Dr. Gomez,
Cruz’s obstetrician, at 10:55 p.m. to speak to him about
Dr. Torres’ examination of Cruz. Dr. Gomez advised Dr.
Torres to administer Bretine 0.25 and Vistaryl 50mg, to
discharge Cruz in stable condition, and to instruct her to
follow-up at Dr. Gomez’s private office on the morning of
January 5, 2007 at 8:00 a.m., instructions which were
followed.
17.
As per Mennonite’s medical record, there is one annotation
stating “FHR = 160.” A nurse’s note in the medical record
states that Plaintiff Cruz was re-evaluated at 12:15 a.m.
by “M.D.” who ordered discharge on January 5, 2007, to
have a follow-up with OB-GYN.
18.
According to the medical record, Cruz was sent home on
January 5, 2007, at 12:15 a.m., less than two hours after
her arrival. Cruz’s condition was recorded on the medical
record as “discharge condition stable.”
CIVIL NO. 08-1236 (JP)
19.
-6-
On January 5, 2007 at 8:14 a.m., Cruz was seen by Dr.
Gomez at his office. She complained of blood spotting
since the previous night but no pain.
20.
A pelvic evaluation of Cruz revealed normal genitalia, no
masses in the bartolin urethra skinny gland, no infection,
no neoplasia, and no trauma.
21.
A blood collection (pool) was found in the vagina. Cruz
was also found to be dilated seven (7) centimeters with
bulging
membranes
and
the
baby
floating
in
breech
position. The fetal cardiac rhythm was 142 beats per
minute.
22.
Dr. Gomez determined that Cruz was suffering from an
incompetent cervix. Cruz and her mother, Plaintiff Lucy
Vázquez-Rivera, were oriented as to Cruz’s and the baby’s
condition, diagnosis and prognosis, and the need for
transfer to Puerto Rico Medical Center. Both agreed to the
transfer.
23.
Dr. Gomez was informed that Dr. Gracia at University
District Hospital, Puerto Rico Medical Center would accept
Cruz, and Cruz was transferred in stable condition from
Dr. Gomez’s office with orders.
24.
Plaintiff Cruz was admitted to the San Juan City Hospital,
where a cesarean section was done due to the prematurity
of the baby.
CIVIL NO. 08-1236 (JP)
25.
-7-
Cruz’s baby was born at 12:12 p.m. on January 5, 2007 and
was a living baby girl, APGAR 3/5 with a weight of two
pounds fourteen ounces.
26.
The baby died on January 7, 2007 at 7:57 a.m.
27.
On the date of the facts of this case, Mennonite had in
place
and
in
full
force
and
effect
in
all
of
its
facilities a “Gravid with 3rd Trimester Bleeding” Protocol
requiring the following tests to be performed on the
patient:
A.
3rd trimester bleeding must be differentiated from
bloody show by speculum exam;
B.
The most likely diagnosis of 3rd trimester bleeding is
placenta previa or abruption;
C.
The gestational age must be determined;
D.
Look for rupture of membranes;
E.
Fetal movements;
F.
Fetal heart rate tones by Doppler must be measured;
G.
Vital signs as blood pressure, pulse, and temperature
must be acquired;
H.
The following laboratories must be practiced:
(1)
CBC
(2)
Urinalysis
(3)
Serology
(4)
PT, PTT
CIVIL NO. 08-1236 (JP)
-8-
(5)
Platelet count
(6)
T & Screen or T & Cross match
(7)
Serum
fibrinogen,
hemorrhage
only
fibrin
if
>
split
B/P
product
of
(preeclampsia,
eclampsia).
I.
J.
Start Ringer lactate at 125 cc/hr;
K.
28.
Open a vein with a catheter;
Send patient to LR in stretcher.
Mennonite failed to activate Mennonite’s “Gravid with 3rd
Trimester Bleeding” Protocol in this case.
29.
Cruz
visited
the
office
of
Dr.
Gomez
for
postpartum
management on January 18, 2007, with clean and dry wound
secondary
to
cesarean
section,
and
diagnosis
of
incompetent cervix, neonatal death, and for contraceptive
counseling. The diagnosis of incompetent cervix was made
by Dr. Gomez.
30.
Cruz again visited the office of Dr. Gomez for postpartum
management on February 15, 2007 for a postpartum routine
visit and contraceptive counseling and prescription.
31.
On March 1, 2007, Cruz visited the office of Dr. Gomez
when normal pap smear results were given.
The following facts are deemed uncontested (“UMF”) by the Court
because they were included in the motion for summary judgment and
CIVIL NO. 08-1236 (JP)
-9-
opposition and were either agreed upon, or they were properly
supported by evidence and not genuinely opposed.
1.
Incompetent cervix is a diagnosis that is given to the
patient who has had two or more pregnancy losses in the
second trimester of pregnancy.
2.
Incompetent cervix is the inability of the cervix to
retain a pregnancy in the absence of contractions or
labor.
3.
An incompetent cervix is a condition that can appear
suddenly.
4.
The patient Cruz denied having pelvic pain, dysuria nor
fever upon arrival at the Emergency Room of Mennonite.
5.
The patient Cruz felt fetal movement upon arrival at the
Emergency Room of Mennonite.
6.
The patient was alert and oriented in time, place and
space while at the Emergency Room of Mennonite in Cidra.
7.
Upon pelvic examination Dr. Torres found that the cervix
was not dilated.
8.
Dr. Torres called the patient’s obstetrician, and that was
the correct thing to do.
9.
Dr. Gomez was correct when he ordered Dr. Torres to give
Brethine .25, Vistaril and follow up in the morning. These
orders were carried out.
CIVIL NO. 08-1236 (JP)
10.
-10-
After her discharge from the Emergency Room, the patient
Cruz went home. That night, Cruz did not feel any pelvic
pain;
did
not
notice
any
bleeding;
and
felt
fetal
movement.
11.
Contractions are uterine movements, which are not always
accompanied by pain. However, they are more likely than
not painful.
12.
The patient Cruz never complained of having pain.
13.
A diagnosis of Incompetent Cervix is done after the fact,
and cannot be made on a patient’s first pregnancy.
14.
An obstetrician cannot anticipate that a patient will have
an incompetent cervix in her first pregnancy.
15.
A mucous vaginal discharge is not an hemorrhage.
16.
Cruz did not present any risk factor nor any medical
condition that would predict incompetent cervix.
II.
LEGAL STANDARD FOR A MOTION FOR SUMMARY JUDGMENT
Summary judgment serves to assess the proof to determine if
there is a genuine need for trial.
895 F.2d 46, 50 (1st Cir. 1990).
Garside v. Osco Drug, Inc.,
Pursuant to Rule 56(c) of the
Federal Rules of Civil Procedure, summary judgment is appropriate
when “the record, including the pleadings, depositions, answers to
interrogatories, admissions on file, and affidavits, viewed in the
light most favorable to the nonmoving party, reveals no genuine issue
as to any material fact and the moving party is entitled to judgment
CIVIL NO. 08-1236 (JP)
as
a
matter
of
-11-
law.”
Fed.
R.
Civ.
P.
56(c);
see
also
Zambrana-Marrero v. Suárez-Cruz, 172 F.3d 122, 125 (1st Cir. 1999)
(stating that summary judgment is appropriate when, after evaluating
the record in the light most favorable to the non-moving party, the
evidence “fails to yield a trial worthy issue as to some material
fact”); Goldman v. First Nat’l Bank of Boston, 985 F.2d 1113, 1116
(1st
Cir.
1993);
(1st Cir. 1992).
Canal
Ins.
Co.
v.
Benner,
980
F.2d
23,
25
The Supreme Court has stated that “only disputes
over facts that might affect the outcome of the suit under the
governing law will properly preclude the entry of summary judgment.
Factual disputes that are irrelevant or unnecessary will not be
counted.”
Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248,
106 S. Ct. 2505, 2510, 91 L. Ed. 2d 202 (1986).
In this way, a fact
is material if, based on the substantive law at issue, it might
affect the outcome of the case.
See Mack v. Great Atl. and Pac. Tea
Co., Inc., 871 F.2d 179, 181 (1st Cir. 1989).
On a summary judgment motion, the movant bears the burden of
“informing the district court of the basis for its motion and
identifying
those
portions
of
the
[record]
which
it
believes
demonstrate the absence of a genuine issue of material fact.”
Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S. Ct. 2548, 2253,
91 L. Ed. 2d 265 (1986).
Once the movant meets this burden, the
burden shifts to the opposing party who may not rest upon mere
allegations or denials of the pleadings, but must affirmatively show,
CIVIL NO. 08-1236 (JP)
-12-
through the filing of supporting affidavits or otherwise, that there
is a genuine issue of material fact for trial.
See Anderson,
477 U.S. at 248, 106 S. Ct. at 2510; Celotex, 477 U.S. at 324,
106 S. Ct. at 2553; Goldman, 985 F.2d at 1116.
III. ANALYSIS
Defendants argue that summary judgment is appropriate in this
case because Plaintiffs have not provided evidence sufficient to
support a finding that Defendants failed to provide an appropriate
medical screening to Cruz in violation of EMTALA. Defendants argue
that Cruz was appropriately evaluated by Dr. Torres, that Dr. Torres
consulted Cruz’s obstetrician, who recommended a treatment, which was
followed. Defendants also contend that Cruz did not have an emergency
medical condition upon arriving at the emergency room and that she
was discharged in a stable condition. The Court will consider
Defendants’ arguments in turn.
A.
Plaintiffs’ EMTALA Claims
Plaintiffs allege that Defendants violated EMTALA by failing to
provide Cruz with an appropriate medical screening. EMTALA is an
“anti-dumping” statute which was enacted by Congress in response to
concern about the increasing number of reports that emergency rooms
were refusing to accept or treat uninsured patients with emergency
medical
conditions.
Correa
v.
Hospital
San
Francisco,
69 F.3d 1184, 1189 (1st Cir. 1995) (internal citation omitted).
EMTALA was not intended to be a federal medical malpractice statute,
CIVIL NO. 08-1236 (JP)
-13-
but rather a federal law that provided a remedy for emergency care
patients where state malpractice provisions fell short.
Correa,
69 F.3d at 1192; see Reynolds v. Maine Gen. Health, 218 F.3d 78, 83
(1st Cir. 2000).
The
statute
imposes
two
categories
of
obligations
upon
hospitals. First, it requires that hospitals provide an appropriate
medical screening to all individuals who come to the hospital’s
emergency room seeking assistance.
69 F.3d at 1190.
42 U.S.C. § 1395dd(a); Correa,
Second, EMTALA requires that if an emergency
medical condition exists, the hospital must render the services that
are
necessary
to
stabilize
the
patient’s
condition,
unless
transferring the patient to another facility is medically indicated
and can be accomplished with relative safety.
See 42 U.S.C.
§ 1395dd(b); Correa, 69 F.3d at 1190.
A plaintiff can bring a cause of action under either the
screening or stabilization provisions of EMTALA, or both.
See
Benítez-Rodríguez v. Hosp. Pavía Hato Rey, Inc., 588 F. Supp. 2d 210,
214 (D.P.R. 2008).
The United States Court of Appeals for the First
Circuit has outlined a three-pronged standard to establish an EMTALA
violation.
Correa, 69 F.3d at 1190.
In order to prevail on an
EMTALA claim, a plaintiff must show that (1) the hospital is a
participating hospital, covered by EMTALA, that operates an emergency
department;
(2)
the
plaintiff
arrived
at
the
facility
seeking
treatment; and (3) the hospital either (a) did not afford the patient
CIVIL NO. 08-1236 (JP)
-14-
an appropriate screening in order to determine if she had an
emergency medical condition, or (b) bade farewell to the patient
(whether by turning her away, discharging her, or improvidently
transferring her) without first stabilizing the emergency medical
condition.
Id.
(citing
Miller
v.
Med
Ctr.
of
S.W.
La.,
22 F.3d 626, 628 (5th Cir. 1994); Stevison v. Enid Health Sys., Inc.,
920 F.2d 710, 712 (10th Cir. 1990)).
The parties hereto do not contest the first two requirements.
That
is,
Cruz
arrived
at
the
emergency
room
of
participating EMTALA facility, seeking medical care.
Mennonite,
a
Plaintiffs’
claims turn on the third prong: whether Mennonite failed to provide
an appropriate screening.
1.
Appropriate Medical Screening
Although
EMTALA
does
not
define
what
appropriate
medical
screening entails, the case law has defined this duty as providing
an examination “reasonably calculated to identify critical medical
conditions that may be afflicting symptomatic patients and provides
that
level
of
screening
uniformly
substantially similar complaints.”
to
all
those
who
present
Correa, 69 F.3d at 1192; see
Guadalupe v. Negrón-Agosto, 299 F.3d 15, 20 (1st Cir. 2002).
A plaintiff must show that the screening that he or she received
failed to comply with the standard screening policy that the hospital
“regularly
follows
for
similar conditions.”
other
patients
presenting
substantially
Malavé Sastre v. Hospital Doctor’s Ctr.,
CIVIL NO. 08-1236 (JP)
-15-
93 F. Supp. 2d 105, 109-10 (D.P.R. 2000) (Pieras, J.) (noting that
“an ‘appropriate’ screening is properly determined not by reference
to particular outcomes, but instead by reference to a hospital’s
standard screening procedures”); see Correa, 69 F.3d at 1192 (“[t]he
essence of this requirement is that there be some screening, and that
it be administered evenhandedly”).
In this case, Plaintiff Cruz arrived at the emergency room of
Mennonite around 10:15 p.m. complaining of vaginal discharge and
blood spotting and requesting medical services (ISC UMF 12). At that
time, Cruz was in her third trimester of pregnancy, at 27 4/7 weeks
(ISC UMF 15). Upon her arrival, Cruz was evaluated by Dr. Torres who
performed a vaginal or pelvic exam on Cruz; Dr. Torres found that
Cruz’s cervix was not dilated (ISC UMF 13). Thereafter, Dr. Torres
called Cruz’s obstetrician, Dr. Gomez, who advised that Dr. Torres
should
administer
Bretine
and
Vistaryl
so
that
Cruz
could
be
discharged in a stable condition (ISC UMF 16). Dr. Gomez also advised
that Cruz should follow-up the next morning at Dr. Gomez’s private
office (ISC UMF 16). The parties stipulate that these instructions
were followed (ISC UMF 16). Cruz was sent home at 12:15 a.m., less
than two hours after her arrival at the emergency room (ISC UMF 18).
The next morning, the record shows that Cruz was examined by Dr.
Gomez at his office around 8:14 a.m. and was complaining of blood
spotting, which had been occurring since the previous night (ISC UMF
19). Upon examining Cruz, Dr. Gomez found a blood collection pool in
CIVIL NO. 08-1236 (JP)
-16-
Cruz’s vagina, and found that Cruz was dilated seven (7) centimeters
with bulging membranes (ISC UMF 21). He also found that the baby was
floating in the breach position and that the fetal cardiac rhythm was
142 beats per minute (ISC UMF 21). Thereafter, Cruz was transferred
to the San Juan City Hospital where a cesarean section was performed
and Cruz’s baby was born prematurely, with a weight of two pounds and
fourteen ounces (ISC UMFs 24, 25).
The baby died two days later on
January 7, 2007 (ISC UMF 26).
In their motion, Defendants argue that Cruz did not have an
emergency medical condition as defined by EMTALA when she arrived at
the emergency room, and therefore, summary judgment is appropriate.
The Court finds this argument untenable. To prevail on an EMTALA
claim for failure to provide appropriate screening, Plaintiffs need
only prove that Defendants did not afford Cruz an appropriate
screening in order to determine if she had an emergency medical
condition, and not whether or not she actually had an emergency
medical condition. See 42 U.S.C. § 1395dd(a); Correa, 69 F.3d at
1190. As the First Circuit clarified, “[t]he failure appropriately
to screen, by itself, is sufficient to ground liability as long as
the other elements of the cause of action are met.”
Correa, 69 F.3d
at 1190.
According to the facts stipulated to by the parties, Mennonite
had in place a “Gravid with 3rd Trimester Bleeding” protocol, which
required certain tests to be performed (ISC UMF 27). The protocol
CIVIL NO. 08-1236 (JP)
-17-
explicitly stated that “3rd trimester bleeding must be differentiated
from bloody show by speculum exam.” From the facts presented, it
appears that no such exam was performed on Cruz. Dr. Gomez performed
only a pelvic exam. Moreover, the protocol specified that certain
laboratory studies must be performed, including CBC, urinalysis,
serology, platelet count, among other laboratory studies (ISC UMF
27). Plaintiffs’ expert witness, Dr. Ramirez, found that Cruz did not
receive a CBC as required by Mennonite’s “Gravid with 3rd Trimester
Bleeding” protocol (Pl.’s Exh. 5). Dr. Ramirez concluded that, in his
opinion, Cruz’s preterm labor was caused by decidual or placental
infection and that this would have been detected and prevented if a
CBC had been done (Pl.’s Exh. 5).
The Court finds that, in this case, Defendant Mennonite had a
standard
screening
procedure,
its
“Gravid
with
3rd
Trimester
Bleeding” protocol, which required certain tests to be performed and
which Mennonite denied to Cruz. The protocol specified that a likely
diagnosis of 3rd trimester bleeding is placenta previa or abruption
and that the doctor should look for rupture of the membranes (ISC UMF
27). Cruz was given a cursory pelvic examination and, less than two
hours after being admitted to the emergency room for complaints of
bleeding during her third trimester, she was given some medications
and sent home.
After
considering
the
evidence
presented
and
Defendants’
arguments, the Court finds that Plaintiffs have presented sufficient
CIVIL NO. 08-1236 (JP)
-18-
evidence for a reasonable jury to conclude that Defendants’ conduct
in failing to apply its “Gravid with 3rd Trimester Bleeding” protocol
to Cruz violated EMTALA.
B.
Plaintiffs’ State Law Claims
Defendants also move for the dismissal of Plaintiffs’ state law
claims. The Court will exercise supplemental jurisdiction over
Plaintiffs’ state law medical malpractice claims because Plaintiffs’
federal law EMTALA claims are still appropriately before this Court.
See Newman v. Burgin, 930 F.2d 955, 963 (1st Cir. 1991) (“[t]he power
of a federal court to hear and determine state law claims in
non-diversity cases depends upon the presence of at least one
substantial federal claim in the lawsuit”).
IV.
CONCLUSION
In conclusion, the Court DENIES Defendants’ motion for summary
judgment as to Plaintiffs’ EMTALA claims and DENIES Defendant’s
motion requesting dismissal of Plaintiffs’ state law claims.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 15th day of August, 2011.
S/ JOSÉ ANTONIO FUSTÉ
JOSÉ ANTONIO FUSTÉ
UNITED STATES DISTRICT JUDGE
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