A recent decision by the Seventh Circuit Court of Appeals reaffirms that EMTALA permits transfer of unstable patients under certain circumstances and that EMTALA requirements can be satisfied even if physicians misdiagnose a patient’s condition or if a patient suffers a bad outcome.
Martindale v. Indiana University Background
In Martindale v. Indiana University Health Bloomington (.pdf of the court’s decision can also be found here), a 50 year old patient presented to an Indiana emergency department with severe abdominal pain. She received IV fluids, lab tests, and a CT scan. The CT scan reflected that the patient may have mesenteric ischemia (lack of blood flow to the intestines) and that the ischemia could be related to an internal hernia or volvulus at the site of the patient’s prior gastric bypass surgery.
The emergency physician contacted the surgeon on call. The surgeon stated that he did not have any experience with gastric bypass patients and did not feel that he had the expertise to safely operate on the patient. The emergency physician then contacted the surgeon who performed the gastric bypass procedure and the physician agreed to accept the patient in transfer.
When the patient arrived at the receiving hospital, she was taken for emergency laparotomy where she did have mesenteric ischemia. However, the ischemia had nothing to do with the patient’s prior gastric bypass surgery. A small bowel resection was performed, but unfortunately the patient died from sepsis and multiple organ failure two days later.
The surgeon at the transferring hospital stated that had he known the mesenteric ischemia was not related to the patient’s prior gastric bypass surgery, he “probably” could have operated on her at the transferring facility. In total, there was an approximately three-hour delay in the patient’s treatment for emergency care due to the transfer.
Martindale v. Indiana University Legal Proceedings
The patient’s family sued the transferring hospital alleging an EMTALA violation because the hospital allegedly failed to stabilize the patient prior to transfer.
The District Court dismissed the case, stating that under certain circumstances EMTALA allows transfers of patients without meeting EMTALA’s stabilization requirement and in this case, the hospital fulfilled those statutory conditions. § 1395dd(b)(1)(b),(c)
On appeal, the Seventh Circuit Court of Appeals began by reiterating that EMTALA is not a medical malpractice statute and “cannot be used to challenge the quality of medical care.” Rather, monetary penalties are limited to damages flowing directly from violations of the statute.
The Court of Appeals then summarized EMTALA requirements: Hospital emergency departments must provide medical screening examinations reasonably calculated to determine whether a patient has an emergency medical condition.
Under 42 USC § 1395dd(e)(1), an emergency medical condition is defined as:
(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in— (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having contractions— (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.
If the medical examination reveals no emergency medical condition, any legal duty under EMTALA ends.
If a hospital does discover an emergency medical condition, it must stabilize the medical condition within the capabilities of the staff and facilities available or it must transfer the individual to another medical facility that can provide the appropriate level of medical care.
A hospital may also transfer unstable patients to another facility under limited circumstances. If a patient is in unstable condition, the patient may still be transferred to another facility if:
1. the patient requests the transfer or if a physician certifies in writing that the benefits from transfer outweigh the medical risks of transfer (see 42 USC § 1395dd(c)(1)) AND
2. if the transfer is “appropriate” (see 42 USC § 1395dd(c)(2))
Under 42 USC § 1395dd(c)(2), an “appropriate transfer” means that the transferring hospital has provided whatever medical treatment is within its capacity to minimize the risk to the individual’s health during transfer, the recipient hospital has agreed to accept transfer, there is available space and qualified personnel at the accepting hospital, the transferring hospital sends all medical records related to the emergency medical condition at the time of transfer, and that qualified personnel and transportation equipment are used to transport the patient.
Martindale v. Indiana University Plaintiff Allegations
The plaintiff in this case alleged that IUHB violated section 1395dd(c)(2)(A) of EMTALA which requires that a transferring hospital provide “medical treatment within its capacity which minimizes the risks to the individual’s health.” The plaintiff alleged that this section of EMTALA required IUHB to perform stabilizing surgery on the patient prior to transfer.
The District Court held that it was an “untenable” position to suggest that a hospital may never transfer a patient prior to stabilization based on facts such as the one in this case. The Court noted that using this logic would mean that any time evidence showed any medical probability that the hospital *might* have been able to stabilize a patient, then pre-stabilization transfer could never be deemed “appropriate” under EMTALA.
In this case, the emergency physician at the original hospital certified that the benefits of transfer outweighed the medical risks since at the time of transfer, there was no available surgeon at the transferring facility capable of safely operating on the patient. In hindsight, the surgeon might have been able to operate on the patient, but the Court stressed that EMTALA specifically states that a decision to transfer must be warranted “based on the information available at the time of transfer.” 42 USC § 1395dd(c)(1)(A)(ii).
The Court seemed skeptical of the plaintiff’s “purported expert,” Dr. Martin Schrieber, who alleged that the emergency physician made an inappropriate determination that the benefits of transfer outweighed the risk of harm. However, the Court noted that even if this testimony was true, it amounted to more of a medical malpractice issue rather than an EMTALA violation.
Finally, the Court noted that EMTALA did not define what it meant for a hospital to “minimize [ ] the risks” of pre-stabilization transfer within the meaning of § 1395dd(c)(2)(A), but left that issue unaddressed as the issues in this case clearly showed that there was no EMTALA violation. The Court also noted that the plaintiff was free to file a state malpractice claim against defendants and it “expressed no views on the merits of such a claim.”
Discussion
Although the outcome in this case is heartbreaking, bad outcomes don’t necessarily mean that an EMTALA violation occurred nor do tragic outcomes equate to medical malpractice. Mesenteric ischemia is a devastating diagnosis. Patients diagnosed with mesenteric ischemia have a mortality rate up to 80%. In other words, up to 80% of patients diagnosed with mesenteric ischemia will die from the disease. A delay of three hours in performing surgery would likely not have affected this patient’s outcome.
The Court of Appeals noted that the plaintiff in this case was free to file a state medical malpractice claim against the defendants. There may be benefits in filing a federal EMTALA claim rather than a state medical malpractice lawsuit. State caps on medical malpractice judgments may not apply to federal EMTALA claims. This is a state-by-state determination. CMS investigations often occur in cases alleging EMTALA violations. Those investigations may be used as an enhanced discovery tool. If CMS issues any hospital EDs a citation for deficiencies in emergency care, those citations are publicly available. In some cases these citations can be introduced as evidence of alleged wrongdoing in a medical malpractice case.
Ultimately, it appears that the plaintiff’s attorney was attempting to use hindsight bias to bolster claims of failure to stabilize. In other words, because surgery at the receiving hospital showed that the patient did not require specialty surgery care, the plaintiff alleged that the physicians at the original hospital should have “known it all along” and should have performed surgery prior to transfer. Hindsight bias is sometimes difficult to overcome, especially when a patient suffers a bad outcome. Fortunately both the district court and the Court of Appeals recognized that EMTALA requirements are based on what was known at the time of transfer.
This opinion provided a good summary of EMTALA requirements, an excellent discussion of the issues pertinent to this case, and a well supported conclusion.
Takeaways
- Most emergency physicians are aware of EMTALA requirements for providing medical screening examinations and stabilizing treatment of patients. Statutory requirements for effecting an “appropriate” transfer may not be as apparent. Fortunately, most pre-printed hospital transfer forms contain the requirements for an appropriate transfer outlined within EMTALA. Fully completing hospital forms prior to transfer will help physicians meet those requirements.
- EMTALA imposes few duties on physicians. Instead, Medicare-participating hospitals are the entities that must comply with almost all EMTALA mandates. The only EMTALA violations physicians can commit under 42 § 1395dd(D)(1) (which may subject them to civil monetary penalties of up to $50,000) are if a physician falsely certifies that the benefits of transfer outweigh the medical risks of transfer, if the physician misrepresents an individual’s condition or other information, or if an on-call physician refuses to come to the emergency department at the emergency physician’s request.
- Most importantly, EMTALA does allow transfer of unstable patients. Completely safe transfers are not always possible. Before completing the transfer, the responsible physician just must attest that benefits of transfer outweigh the risks and that the transfer is “appropriate.”
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