Cruz-Vazquez et al v. Mennonite General Hospital, Inc. et al
Filing
154
OPINION AND ORDER - GRANTING 139 MOTION to Dismiss/Lack of Jurisdiction under EMTALA. The Court hereby VACATES 132 OPINION AND ORDER. The Court will enter a separate judgment dismissing with prejudice Plaintiffs'federal claims against Defendants and dismissing without prejudice Plaintiffs' state law claims. Signed by Judge Jose A Fuste on 9/20/11.(su)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
HAZEL I. CRUZ-VAZQUEZ, et al.,
Plaintiffs
v.
CIVIL NO. 08-1236 (JAF/JP)
MENNONITE GENERAL HOSPITAL, INC.,
et al.,
Defendants
OPINION AND ORDER
The Court held a hearing in this case on August 16, 2011. At the
hearing, the Court heard the parties on the issue of settlement of
the
case
and
the
issue
of
whether
the
Court
properly
had
jurisdiction. Pending before the Court is Defendants’ motion to
dismiss for lack of jurisdiction (Docket No. 139) and Plaintiffs’
memorandum in opposition (Docket No. 136). Upon reconsideration of
the Court’s previous Opinion and Order (Docket No.
132) and for the
reasons provided herein, the Court hereby GRANTS Defendants’ motion
to dismiss for lack of jurisdiction. Accordingly, the Court VACATES
its Opinion and Order at Docket No. 132.
I.
INTRODUCTION AND PROCEDURAL BACKGROUND
On August 15, 2011, the Court entered an Opinion and Order
denying Defendants’ motion for summary judgment (Docket No. 132). At
CIVIL NO. 08-1236 (JAF/JP)
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the hearing held on August 16, 2011 and in their motion for summary
judgment,
Defendants
argued
that
Plaintiffs
did
not
present
sufficient evidence to support a finding that Defendants failed to
provide an appropriate screening to Plaintiff Hazel I. Cruz-Vazquez
(“Cruz”) upon her arrival to Defendant Mennonite General Hospital,
Inc.’s (“Mennonite” or “Hospital”) emergency room as required by the
Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42
U.S.C. § 1395dd. Thus, Defendants argue that the Court should decline
to
exercise
jurisdiction
over
Plaintiffs’
state
law
medical
malpractice claims. After hearing the parties again on the issue of
jurisdiction, the Court ordered the parties to file supplemental
briefs on the issue of jurisdiction. The parties subsequently filed
supplemental briefs (Docket Nos. 136, 139), and Defendants moved to
dismiss for lack of federal jurisdiction (Docket No. 139).
In this case, Plaintiff Cruz arrived at the emergency room of
Mennonite around 10:15 p.m. on January 4, 2007 complaining of vaginal
discharge and blood spotting and requesting medical services. She
denied having pelvic pain or dysuria, did not have a fever, and was
feeling fetal movements. At that time, Cruz was in her third
trimester of pregnancy, at 27 4/7 weeks. Upon her arrival, Cruz was
evaluated by Dr. Brenda M. Torres-Perez (“Dr. Torres”) who performed
a vaginal or pelvic exam on Cruz; Dr. Torres found that Cruz’s cervix
was not dilated. Thereafter, around 10:55 p.m., Dr. Torres called
Cruz’s obstetrician, Dr. Eduardo Gomez-Torres (“Dr. Gomez”), who
CIVIL NO. 08-1236 (JAF/JP)
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advised that Dr. Torres should administer Bretine and Vistaryl so
that Cruz could be discharged in a stable condition. Dr. Gomez also
advised that Cruz should follow-up the next morning at Dr. Gomez’s
private office. The parties stipulate that these instructions were
followed. Cruz was sent home at 12:15 a.m., less than two hours after
her arrival at the emergency room.
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. Upon
examining Cruz, Dr. Gomez found a blood collection pool in Cruz’s
vagina, and found that Cruz was dilated seven (7) centimeters with
bulging membranes. He also found that the baby was floating in the
breach position and that the fetal cardiac rhythm was 142 beats per
minute. 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.
The baby died two days later on January 7, 2007.
II.
LEGAL STANDARD
EMTALA
is
an
“anti-dumping”
statute
which
was
enacted
by
Congress in response to concerns about the increasing number of
reports that emergency rooms were refusing to accept or treat
uninsured patients with emergency medical conditions. Correa v. Hosp.
CIVIL NO. 08-1236 (JAF/JP)
-4-
San Francisco, 69 F.3d 1184, 1189 (1st Cir. 1995) (internal citation
omitted).
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).
EMTALA was not intended to be a federal medical malpractice
statute, 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. MaineGeneral Health,
218 F.3d 78, 83 (1st Cir. 2000).
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
CIVIL NO. 08-1236 (JAF/JP)
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to all those who present substantially similar complaints.” Correa,
69 F.3d at 1192; see Guadalupe v. Negrón-Agosto, 299 F.3d 15, 20
(1st Cir. 2002).
The First Circuit Court of Appeals has explained that “a refusal
to follow regular screening procedures in a particular instance
contravenes the statute [], but faulty screening, in a particular
case, as opposed to disparate screening or refusing to screen at all,
does
not
contravene
the
statute.”
Correa,
69
F.3d
at
1192-93
(internal citation omitted). In Correa, the First Circuit found that
the hospital’s “delay in attending to the patient was so egregious
and lacking in justification” that it amounted “to an effective
denial of a screening examination.” Id. at 1193.
III.
ANALYSIS
A.
Plaintiffs’ EMTALA Claim
In the instant case, Plaintiffs argue that Cruz was not given
an appropriate medical screening because Dr. Torres should have
conducted additional examinations and laboratory tests on Plaintiff
Cruz before releasing her as per the Hospital’s established protocol.
Plaintiffs point to the existence of the Hospital’s “Gravid with 3rd
Trimester Bleeding” protocol which required certain tests to be
performed. According to Plaintiffs, because the additional tests were
CIVIL NO. 08-1236 (JAF/JP)
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not
was
performed
on
Cruz,
Cruz
given
disparate
treatment
in
violation of EMTALA.
As to this particular patient, however, Dr. Torres made a
medical judgment not to perform additional tests after performing the
pelvic
examination
on
Cruz,
establishing
that
she
was
not
experiencing any pain, and consulting Cruz’s private physician. Dr.
Torres’ decision not to perform additional tests is not the same as
the denial of screening or egregious delay in screening identified
by the First Circuit in Correa. See Reynolds, 218 F.3d at 83-84
(finding that plaintiffs’ claim that the patient received disparate
treatment because the hospital did not take the patient’s “complete
medical history” as per the hospital’s written policy was “an attempt
to
bring
a
malpractice
standard
into
the
interpretation
and
application of [EMTALA]” and that “[i]t is not enough to proffer
expert testimony as to what treatment should have been provided to
a patient in [the plaintiff’s] condition”)(emphasis in original). Dr.
Torres’ decision not to conduct additional tests had nothing to do
with Cruz’ ability to pay but rather with her assessment of Cruz’s
medical condition. See Vickers v. Nash Gen. Hosp., Inc., 78 F.3d 139,
144 (4th Cir. 1996)(affirming district court’s grant of dismissal of
EMTALA disparate screening claim where doctor treated patient for
what he “‘perceived to be’ the [patient’s] medical condition” and
that in the doctor’s “medical judgment ... [the condition] did not
warrant testing for intracranial injury”).
CIVIL NO. 08-1236 (JAF/JP)
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Moreover, that Dr. Torres’ diagnosis of Cruz’s condition may
have been incorrect is not actionable under EMTALA. See id. at 143-44
(noting that “when an exercise in medical judgment produces a given
diagnosis, the decision to prescribe a treatment responding to the
diagnosis cannot form the basis of an EMTALA claim of inappropriate
screening” and finding that “treatment based on diagnostic medical
judgment [does] not violate [EMTALA]”); Brooks v. Maryland Gen. Hosp.
Inc., 996 F.2d 708, 710-11 (4th Cir. 1993)(noting that [EMTALA] does
not impose any duty on a hospital requiring that the screening result
in a correct diagnosis”); Baber v. Hosp. Corp. of America, 977 F.2d
872, 880 (4th Cir. 1992)(noting that the “avowed purpose of EMTALA
was not to guarantee that all patients are properly diagnosed, or
even to ensure that they receive adequate care”).
After examining
Cruz, Dr. Torres consulted Cruz’s private physician, Dr. Gomez, who
advised administering certain medications to Cruz and that Cruz
should visit Dr. Gomez’s office the following morning. Even if Dr.
Torres erroneously determined that further tests were unnecessary,
her error amounts only to a faulty screening, which is appropriately
dealt with under Puerto Rico’s medical malpractice laws. Thus, the
Court finds that Plaintiffs’ EMTALA claim fails.
In conclusion, too often, this Court has seen plaintiffs use
EMTALA to bring their medical malpractice claims to federal court in
CIVIL NO. 08-1236 (JAF/JP)
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order to have a jury hear their cases.1 In the instant case,
Plaintiffs are trying to do exactly that. There is no question that
Cruz had medical insurance, her own private physician, and that she
was not denied admission or treatment when she arrived at the
Hospital. Indeed, upon her admission to the emergency room of the
Hospital, Cruz was examined by Dr. Torres in a timely manner. On
reviewing the record of this case, the legislative purpose of EMTALA
- to prevent the “dumping” of uninsured patients - is not implicated.
EMTALA was designed to protect the uninsured. Neither EMTALA nor the
First Circuit has ever stated that plaintiffs can use EMTALA as a
jurisdictional door to bring to a federal court a case that is
strictly a state court case. The First Circuit has repeatedly
emphasized that EMTALA does not create a federal cause of action for
medical malpractice.
B.
Plaintiffs’ State Law Claims
Having dismissed Plaintiffs’ federal law EMTALA claim, the Court
declines to exercise supplemental jurisdiction over Plaintiffs’ state
law medical malpractice claims. 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”).
1.
In medical malpractice suits here in Puerto Rico, there is a consistent pattern
of trying to plead EMTALA to circumvent the unavailability of jury trials in
civil cases.
CIVIL NO. 08-1236 (JAF/JP)
-9IV.
CONCLUSION
After considering the arguments presented by the parties at the
hearing and the parties’ supplemental briefs as to the issue of
jurisdiction under EMTALA, the Court hereby VACATES its previous
decision and GRANTS Defendants’ motion to dismiss. The Court will
enter a separate judgment dismissing with prejudice Plaintiffs’
federal claims against Defendants and dismissing without prejudice
Plaintiffs’ state law claims.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 20th day of September, 2011.
s/José Antonio Fusté
JOSÉ ANTONIO FUSTÉ
UNITED STATES DISTRICT JUDGE
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