A man cut his hand while using scissors to open a bottle of glue. He wrapped his hand in a towel and was driven to the nearest emergency room. The receptionist told him he would have to wait. He went home. Later that day he was driven to the same emergency room. Again, the receptionist told him he would have to wait. A few minutes later, a nurse noticed the man waiting, removed the towel, and blood spurted from his wound.
The nurse took the man into the emergency room for treatment. Staff arrested the bleeding and decided he needed to be airlifted to the University of Kentucky Hospital (UK Hospital) for more treatment. Doctors at UK Hospital stopped the bleeding and stitched the wound. The next morning, a hand surgeon replaced the stitches with sutures. The man was told that during his four-week recovery he could not work.
The man sued the hospital responsible for the emergency room for violating the Emergency Medical Treatment and Active Labor Act (“EMTALA”), 42 U.S.C. § 1395dd, by failing to provide him with an appropriate medical screening and by failing to stabilize his injury. Following the close of discovery, the hospital filed a motion for summary judgment.
The U.S. District Court for the Eastern District of Kentucky granted the hospital's motion for summary judgment. The district court found that the man had failed to adduce evidence sufficient to establish the causal nexus between the alleged violation and his injury. Alternatively, the district court found that the man's failure to adduce evidence that the hospital acted with an improper motive was also a basis for granting summary judgment. On appeal, the man argued that both of those findings were erroneous and that the district court erred in failing to give preclusive effect to a preliminary determination letter issued by the Centers for Medicare and Medicaid Services (CMS).
The Sixth Circuit U.S. Court of Appeals affirmed the district court. The court found that (1) there was no evidence in the record to allow a jury to decide how much harm was caused by the initial laceration and how much was caused by the treatment delay, (2) the man did not explain how the hospital’s failure to provide a certain quality of emergency care had any bearing on its motive, and (3) the CMS preliminary determination letter did not meet the Chevron deference test. The Sixth Circuit did not address the man's stabilization claim because he failed to make any argument related to the claim on appeal.
First, the man failed to adduce evidence sufficient to establish the causal nexus between the alleged violation and his injury. In EMTALA cases, there is no bright line rule that a plaintiff must adduce expert testimony to satisfy the causation burden. However, a technical medical question requiring expert testimony is presented where a jury must determine whether the failure to screen, not the natural progress of a plaintiff's significant medical condition, caused the harm. The man’s severe laceration was in no way caused by the hospital or its staff. To the extent that the man suffered harm from the hospital's delay in treating him, there was no evidence in the record to allow a jury to decide how much harm was caused by the initial laceration and how much was caused by the treatment delay. If he had provided testimony from a physician that but for the delay he would have missed only two weeks of work, a jury would have an evidentiary basis for finding the hospital caused harm in excess of that caused by the laceration. Without such evidence, the jury's only recourse to differentiate the harm caused by the laceration from the harm caused by inadequate treatment would be impermissible speculation. Discovery ended without the man having adduced any medical expert testimony, leaving him no way to satisfy his burden to prove causation at trial.
Second, the man failed to adduce evidence that the hospital acted with an improper motive. For an EMTALA plaintiff in the Sixth Circuit to show that he or she did not receive an appropriate screening, the plaintiff must adduce some evidence that the screening differed in some way from that given to other patients, and the difference was improperly motivated. In this case, the man did not explain how the hospital’s failure to provide a certain quality of emergency care had any bearing on its motive.
Third, the CMS preliminary determination letter had no preclusive effect. Though courts generally give deference to agency adjudications under Chevron, the man cited no decisions in which a court adjudicating an EMTALA action gave preclusive effect to a CMS preliminary determination letter or any CMS decision. The court found that nothing remotely approaching an adjudication with an opportunity to litigate had occurred at the point that the hospital entered into a corrective plan of action to address the violation referenced in the CMS letter.
See: Romine v. St. Joseph Health System, 2013 WL 5750095 (C.A.6 (Ky.), October 24, 2013) (not designated for publication).
See also Medical Law Perspectives, December 2012 Report: When Urgency Leads to Errors: Liability for Emergency Care