is a precious commodity in health care and with the court so i'll get straight to the crux of what we're here to discuss today the district court opinion on page sure and in the act it says the transfer must be appropriate and it's our argument then that up under who did lie would then be inappropriate time that because the statute is silent on time and that any time a crime on a patient transfer would be an appropriate time whether it was four hours four day as four weeks because the e here's here's my concern about what you're suggesting the way i read is that it was enacted to avoid the practice of one hospital dumping his patient prematurely before they had been screened and just so that they would not have to deal with the patient and we construe appropriate transfer the way you've suggested then we're going to create exactly the problem that it seems to me that the legislation was designed to prevent i wonder if you want to address that sure just present i'm you're you're correct the statute was clearly focused on and sure that the other secondary hospital rest is to take the patient however what the purpose of the legislation to avoid patient dumping certainly been the statute couldn't possibly mean that you could take however long that you wanted to and i'm not asking the court to issue a bright line rule and tie and four hours is too long but i w what i would like to see is some cracked eerier of what determines that the life so that then we could be kicked back to the district court for further discovery and the court could rule whether or not we had reached that threshold i'm certainly not suggesting that the court should be running a time clock and saying that thirty minutes is too long or four hours is too long because that's not the purpose of the court but it it's almost like in an employment discrimination case and when you've got under mcdonnell douglas when you've got a bright line on things that you've got to check off on your boss i would state law and when there is a difference of opinion on how you could determine things then you can always look at state law as in  friend because the crux of the matter is that it took too long yes but isn't that a claim under state law that's where i'm having i'm having difficulty understanding you say that you understand and you're conceding that this is not a federal malpracti issue are trigger so the only way you're going to affect real change on guidelines about how long you're going to hold somebody at the hospital before you transfer is you're going to have to then have an e m t l i change and that's why that this particular statute talla was designed to do that and that's where i'm having a problem in other words the federal government does not have to direct legislation and every problem that there is it can be selective in what it chooses to direct legislation now it could have determined or maybe sort of negatively determined rather that it wasn't going to address this particular problem instead leave it to the state to address and that's where i'm having the problem why is that not the case is this the problem you're talking about is addressed only by the state it causes of action like medical malpractise as opposed to by the federal statute which appears designed instead to address exactly the opposite problem that is premature so called patient  the way the statute is light out and if you interpret it that doesn't matter then technically then you could hold a patient indefinitely that you never had to transfer and isn't that really the same as patient if you never asking the court to interpret appropriate under state law but not on a bride law and ruling if there were a series of guidelines so that the district court then could this had been was and in fact the transfer appropriate we never made it to discovery in this case just because you said in the case that for further review it doesn't mean that we can it just means there are discovery and the court will still have to rule or there will be a jury question on whether or not  good morning and may have please the court my name is david hanson i represent crisp regional hospital the short story here is that and how was not created to form a federal medical malpractise law it was created to prevent dumping of patients and it was narrowly tailored and crafted specific to that purpose the statute has two primary requirements st a screening requirement and nd a stabilization requirement and then there are provisions regarding transfer that apply if the patient cannot be stabilized so unstabilized transfers although those provisions regarding transfer are somewhat subsumed within the concept of stabilization here we're really faced with the single question which your honour's have have highlighted in which appellant highlights is whether the timeliness of transfer is contemplated as something that and paolo regulates the short answer is no to get straight to the crux of the matter there is no language within the statute which could be interpreted to impose a timeliness requirement on transfer miss smith referenced the phrase appropriate transfer which appears in some sections to of the statute appropriate transfer is actually defined as judge andersen athlete pointed out there are five  an appropriate transfer to a three d each of those requirements is a bit technical requirement you have to provide the medical records the new receiving facility has to accept the patient you have to use  have to use an ambulance you can't send them be a private car or if you've got to use an air flight you've got to use therefore you have to have an appropriate transfer mechanism in none of those requirements does there appear any language which could impose a timeliness requirement upon the transfer congress certainly knew how to define what an appropriate transfer was they did so within the statute subsection c two and in none of that definition did they include any suggestion that timel one of the requirements for transfer and that makes sense because timeliness is a question that is left to the medical discretion of the medical professionals providing care and so thus would be something regulated under state law practice well when you start talking about did you do it quick enough should you have stabilized more should you have given another round of id another whatever the underlying fact might be in this case we're talking about a child and diabetic  acidosis should they have given insulin for example and should they have waited for another dozen from before transferring or should they have transferred before giving another doesn't want those level of questions are best left  standard of care which is what georgia usually uses to refer to medical malpractise cases if appropriate is interpreted as such those things would be grafted onto and how the the problem with interpret ing  appropriate transfer to include all those things is that congress specifically delineated what an appropriate transfer was in the statute they didn't just say to appropriate transfer or an appropriate transfer to a medical facility must occur and put a period they said an appropriate transfer to a medical facility is a transfer and then they listed five different things one of which has some parts which are required for an appropriate transfer in other words congress defined what an appropriate transfer was and they did not choose to include timeliness as one of the factors they did not choose to include appropriate medical decision making regarding the patient as one of those factors in other words they did not include the phrase the one which complies with the standard of care if that was what they intended to do if congress intended to bring transfer within and tap excuse me to bring medical malpractise claims related to transfer within the realm of them talent they could have added a subsection to this to the definition appropriate transfer which said a transfer subsection f could have said one that complies with the standard of care that would have clearly and easily brought transfer within the realm of emtala that does not exist and thus there's no linguistic there's no there's no ambiguity in the statute which would cause us to turn to medical malpractise on georgia to interpret what georgia says and why does georgia recognize a right to transfer or something like that there's no hook to bring in state level law here on in the cases that the appellant cites are entirely and opposite on this point specifically st anthony from i believe it was the th circuit of the only part of the opinion which references state laws regarding state agency to determine whether the individual who denied accepting the transfer had the ability to act on behalf of the hospital in other words were they an agent under state law that's a state law question it's not contemplated by emtala here transfer is that and palin does not impose a timeliness requirement upon transfer and remains an anti dumping statute and not a federal medical malpractise statute i'm happy to answer any further questions that the justices and the judges might that the time is not contemplated surely that's not what it was intended by the statute  i understand that this is a narrow issue of the law but i would ask that the court allow the it to be more like progress in sight and that there are great issues of the law and that we interpret those to clear up that ambiguity