cases williams versus dimensionless health mr gordon whenever you're ready first of all i want to say good morning we're here for a limited purpose and least in my opinion we're here because the district court found that we failed to present a defense off and to good faith in mission mr turns williams and as you know mr chance williams was injured in a row over a car accident and  believe that dimensions health care services validated the emtala rules by failing to stabilize him it was brought up during the reply brief of the mentions that they raise for the st time to good faith defense and we never had an opportunity to deal with that defense however i think the evidence i think that should have been a jury question as opposed to something that court would have decided see how would you deal with that now yes interim and now our argument now is that there was an absence of qualified staff at the time of this event as you know they're supposed to be on call within thirty minutes of a rival care and you may well have a compelling medical malpractise claim with respect the lack of staff and the refusal alleged refusal of the surgeon to conduct the surgery in time all of that sounds pretty compelling but i'm just not sure what that has to do with a statute that is not intended i don't think to apply on these facts well or court found that we had such presented enough evidence to show that there was failure to stabilize so i really didn't think it was necessary to get into that the only if he's not being stabilized during that period of time and he suffers harm as he did in this case then it is and i'm talking just a court found that because he had been admitted and there's no indication in the record at least a court of the district court that that that ends the claim you're now so you know you're not left without a remedy you're able to pursue the state medical malpractise action which is still pending is that right now we want to six million two hundred thousand dollars or well good for you  t so so then but ok so and that the debt statement medical malpractise action includes some of the allegations that are part of this case well i separate medical malpractise again from in tala because they have nothing to do with one another again that's why i'm referring to the moment of his presentation to the hospital to the moment of an mission which is at least ten hours later that's when he suffered harm your position that point he was being  and i thought assume that's what you're going to say but what he for all practical purposes admitted if you're in the operating room having surgery done to you not necessarily on and that's why there are rules that deal with the mission there has to be a formal the hospital but he wasn't admitted that doesn't make any sense well even if even if you accept the fact that he was in surgery some several hours later i didn't search but yes but that is that does not constitute an admission under in means that he went into surgery when you look at the time of admission and even if you take your position extra i think that's a jury question to determine rather than something that would be determined as a matter of law simply going into surgery does not mean you're it i think he has asked about your malpractise case and i understand your position that there are separate climbs but was the evidence that was presented they are the failure of the hospital to  proceed with surgery in a in the timely fashion in the absence of absence of doctors in accordance with the regulation was that the same evidence that you say constitutes a bad faith admission virtually i could say yes and no but it's more no than yes and let me explain the reason why we found the medical malpractise cases because my client developed compartment syndrome and they failed to perform a fa arm and so you have all these emergency medical conditions that did not receive attention during at the most critical times of these injuries with within the st couple hours of these injuries compartment syndrome is basically the build up of pressure you have to relieve that pressure by making an incision from the knee down to the ankle and so you do you have a is there a case that you're aware of that interprets this statute to talk about the type of situation we have here which is some claim that after he gets to the hospital is being treated it's not in your according to you and apparently according a malpractise theory adequate kater and that seems like that's what you're arguing is that he's at the hospital there doing stuff to when they're not doing enough and not do it or not doing it soon this about we've already established at least to the court's satisfaction that we made a claim for the failure to stabilize i'm still trying to understand where what's going on here  your argument is he was not admitted when they were doing surgery i'm correct correct and so your argument further is then that intel applies because he was an admitted  what's your but my are they argue on reply that we failed to show that his admission subsequent to everything else was in good faith so that was that was raised for the st time one reply and so we didn't get a chance to address it so at that he just backer asked us you know what is the basis of our claim here one of them was the absence of qualified well the absence of qualified staff you can't admit someone in good  evidence in the record that the problems you say existed you not have been the physicians not go into surgery sooner related one way or the other to admission because had he been properly dealt with the surgeons would have been in place within the st thirty minutes i hope i'm answering your question i don't understand that your argument sounds like it's your answer it sounds like you're answering the question of calls ation about that to your clients injuries but i don't think you're answering how those alleged problems relate one way or the other to whether he was admitted or not or whether we he was admitted in good faith or not because but at a time he was admitted his injuries had deteriorated to a point when it cost him harm and so and the reason why he was in minute argument is for non medical reasons the reason why he was in minutes so late was for non medical reasons that is there was a refusal to treat when they could have been treated by one of the doctors there was absolute qualified staff within a period of time that he could have been treated whereby he would have suffered his entries and that there was a we believe that there was a consume it from his colleagues at the expense upon that was caused between the time of presentation and the time of admission and we also believe that he was being hoarded for financial gain because he had a premium insurance coverage the bottom line is the only issue here is again the good weather and that this was a good faith in patient mission we claim that it cannot be a good faith and patient mission when he was not being and when this emergency medical condition was not being treated from the moment of his mission i mean from the moment of his presentation to the moment of his admission is it your view mr gordon that all those claims you just talked about are not the types of things that can be litigated in a state medical malpractise action yeah but well the bottom line is when the defense was that it was that a so anything from my understand of entirely anything that occurs where this harm results from the moment a presentation to the moment of admission if you have this little window in that being treated you suffer harm then that's an say no because he should have been admitted earlier to prevent his injuries from occurring yet especially specific about one of the claims made hospital was hoarding him because of his insurance policy yes you have a case that says that  and maybe in there and i were looked at but it just seems to me that that seems so inconsistent with the whole purpose of the statute was is to prevent hospitals from refusing to treat patients primarily on the notion that they were not insured but again claiming it was in bad the ground let me just try to be more clear and these in my articulation of the issue we're not really challenging we're not challenging the law of course finding that dimensions your morning your honour's and please the court christian can tie on behalf of dimensions health doing business as prince george's hospital center your hours this is not an  pertains to transfers the only transfer that happened here was eleven days after this patient arrived at prince george's hospital center when he was transferred to university of maryland shock trauma in stable condition what is is an anti dumping statute that's why it was perceived and created by congress to correct the perceived failures of emergency rooms to provide treatment to patients that presented w inability to pay or for other non medical reasons there was a perceived failure there is a perceived problem with patients being turned away at the door not receiving treatment either of on active labor or while other emergency medical medical conditions presented so the statute was created to create what was perceived as a gap in state tort law to give patients a remedy where state tort law could afford an on the patient came into an emergency room with an emergency medical condition just sat around without being screened  treated the hospital could avoid liability sounds are you never undertook a duty to treat you don't you don't have any redress with us is this the gordons claim to be just that the hospital kind of sat around for a little while before deciding what to do with this klein's injuries well so to that point these are really issues of quality of care and correctness of care not emtala claims  there could be a dispute about that is the question is whether at seems to me the question is whether emtala covers that type of claim and what your position as to whether such a scenario i think one has to look at the facts of each case under this case this patient was admitted he was provided treatment over the course of eleven days before he was transferred in stable condition so the patient does have a remedy with the hospital under that scenario because the hospital has a duty to that patient in any delay in treatment when he arrives he's taken into the trauma bay the doctors are working on him if the patient perceives that history minutes delayed during the details of that claim but can you talk generally about whether or not these very issues that mr gordon talks about were part of the case they're so in medical malpractise tort obviously the case is dependent upon experts and if they don't have an expert that comes in to say that there was that the leg they don't get to present that issue their experts came into the state court to say we think the medical malpractise is with the quality of the initial surgery they receive they have the opportunity to have an expert come in and say this trauma surgeon did wrong immediately when he presented by not doing x y z they have the opportunity they have that redress because there is a duty of the hospital under those facts of the case the reason we have me let me i don't mean to divert us from that because i don't think we want to get into the necessarily into the details of that case but if i understood mr gordon's argument he's resting primarily on the timing of the admission here period up until the point of admission and it becomes a quality of care statute where you judge the quality of care during that time period you judge the correctness of care during that time period the dispute about the time  immaterial i believe it is your honor for two reasons number one counsel for the mr williams concedes in his brief that the patient was admitted there's formal admission orders in the chart on the st day and it is summary judgment is not a material fact the only reason the good face admission was even brought up or admission was even brought up because it is a complete defense to an impala claim and the reason it was brought up was the only conceivable way that this could potentially be an impala case would be if one were to take this case as this admission this eleven day horse with dozens of surgeries a plethora of care by teams of health care providers was somehow subterfuge for the hospital to avoid its and tala obligation in other words they did all this to so that they could dump this patient your honour's and they just didn't do that if this patient were dumped ten hours after he arrived if they brought him in and as take counsel's characterization he was just sitting around and nothing was happening and then the hospital decided well we're going to admit him and they admit him on paper and then three hours later they say you know what we got a transfer in the university of maryland and his emergency or his medical condition deteriorates during that transfer then potentially under those facts there's an line similarly if the patient was admitted in bad faith over the course of ten days and then on the th day he's transferred up to the university of maryland and his emergency medical condition deteriorates as a result of not receiving stabilizing treatment up until that time of transfer and there was indeed a subterfuge or lack of good faith that mission possibly could be an emtala case however the district court was quite thorough and you can read the record that it relied on there's absolutely not even a micron of that didn't of a lack of good faith of subterfuge to avoid impala because there is no dumping here your honour's counsel again then the mistake that he makes with that to be a federal malpractise case this these judges in this court will then be deciding whether or not shock trauma could have saved the patient's legs whether or not dr smith over at this hospital could have fixed this condition you're in no this course i no position to do that with the text of the statute it was never meant to do that and quite the opposite the courts of come down all across the country all across all circuits saying in thout a cli this is not a medical malpractise statute this statute is limited it limits what a hospital must do it's not a quality of care it's not a complete complete or correctness of care statute it's a statute that requires certain stabilizing treatment and certain screening treatments to be given to patients and in order to prevent dumping of patients so is it your position that if a hospital on begins treatment and negligently there's no there may be a malpractise calling i think it would turn on the facts of the case your honor but yes if a patient goes to a hospital and the hospital exception treats that patient a duty of care arises under state tort law whereby it paints a patient can redress those grievances under state tort law and that's what has been said only if they turn the patient away for no good reason is there an entitlement claim is that you're argument the courts have specifically stabilization treatment there have been courts in that this court in matter baby k in re baby k where the court did look to the facts after the time of an admission but again just to assure that there was a good faith admission in that case there was the hospital wanted to admit the patient you know you give lawyers a chance to interpret these laws they'll come up with a crafty way to get around in tal and they get to do that in baby k they tried to say hey you know we'll just admit this patient but we won't provide this stabilizing treatment and therefore you can't get us within tala well the court said this was before the good faith requirement of c m s they said not so fast you know you can't you can't refuse to provide stabilizing treatment under these facts because under those facts there what they were contemplating a transfer a transfer back to a nursing home under those facts no one no other treating facility would accept a transfer but the court again couched it in terms a contemplated transfer to provide the stabilising treatment necessary to send the baby back to the nursing home without a deterioration you're on your client's hospital was a level two trauma centers that right that's correct and he ultimately the patient in this case mr williams was transferred to a level one trauma silly right it's better standard of care so and the this is not exactly the facts of this case but just  understand your view of the reach of an tala if mr williams had a presented at your client's hospital and they had made that determination right away this is beyond our capacity to treat we need to get him transferred to this other level one trauma center but in the meantime they do nothing to stabilize him until the transfer is made that isn't and that's and tahlequah that would be under those facts as you present that there could possibly be in and telling that that's what  statute is about it's about requiring under that situation my hospital to do one of a couple things either stabilize him with enough treatment that would provide for a safe transfer if that's impossible sign off that the it does need to be successful stabilization or just an attempt well i guess if you know your o b would open up and colic can o worms for every patient around the country who couldn't be stabilized you would to use the text of this statue to judge whether or not a patient could have been stabilized versus whether dr smith at another hospital could have stabilized the patient and our brian case addressed that don't we say they are when you undertake to stabilize that's when and tala liability ends it seems to me that lying would suggest that it's the effort to do that as a in it  successful hope that maybe not day and if it's not and it's below the standard of care then your remedy is malpractise if you undertake to do to do that unless you do it bad certainly brian was quite similar in this case you had a patient who was a brought to the hospital stayed there for twelve days was admitted to the hospital and then possible decided we're not going to provide more stabilizing treatment to the patient i think the patient died and under those facts you know there is no inappropriate transfer there's no faired stabilize prior to the transfer the redresses medical malpractise is a duty under state law to the patient by the health care provider in the redresses isn't based on state tort laws again i think those scenarios if you find the term tala claims they set up this court to you know decide medical malpractise quality of care and correctness of care issues which clearly  i think counsel misstates the law pursuant to intolerant if an emergency medical condition exists the hospital must stabilize the condition if medically warrant to transfer to pace a person to another facility if the benefit of the transfer outweigh hospital stabilize the patient when it provides such medical treatment of the condition as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occurred during the instead of discharging or transferring the patient the hospital admits in the visual as an inpatient for further treatment the hospital's obligation under emtala so from the time of presentation as i indicated earlier to the time of admission which they were treating the harm that he suffered before he was admit it while in the hospital and that is compartment syndrome counsel read from they'd be ok yes and i appreciate you doing that but after baby k the brian decision from this court more more you know precedent lease that we're working with and it fairly yeah narrowly the baby k to the medical conditions at play they are correct and it talks about that once and tala has met the purpose of ensuring that the hospital undertake stabilising treatment for a patient then liability a mission so and i don't want to get to arguing about those dueling orders but i'm really try and ask you how you can square your claim with brian in terms of the admission again brian i believe it wasn't a emtala matter because he was in minot subsequently and during that period of time they were challenging the treatment went with challenging again the windows between presentation and it mission that the mission failure to participate in surgery or for the hospital's failure to have the required doctors there i realize that may or may not square up with what you did that could be a malpractise calling it could it could be but it's also an m taluk claim because it was not that mission then i mean it just you just said admission was the key fact it sounds like you're backing off that and saying well this could be well what i'm saying is that once you admit it the hospital takes responsibility for the care emtala comes around and thomas is ok you guys a bump in patient is patients in this across this country is causing a problem we need to deal with something that deals with the point of presentation when you come to a hospital in requesting medical services and a point of  mission before because before then there was no patient relationship emtala feels in that gap in this case prince george's hospital dropped the ball because between presentation and admission my client suffered harm they he did not have when he came into the hospital the harm suffered because he did not get the treatment that he would that he needed to stabilize this injury so when you say that that this was something that the judge found on a motion to dismiss and or for a summary judgment it was the same thing we present documentation we presented medical records and things that nature that weren't objected to and that's what the court found they found another motion for summary judgment submitting the same documentation but saying on reply which makes which is deemed inappropriate in the st place that even though perhaps that you found in your earlier they said because you didn't reverse itself he didn't say i was i'm most respected i didn't see him say i was wrong he just said you haven't jumped this last hurdle of saying that this admission was like good faith and i'm saying that ok they didn't raise that last hurdle until reply after we found our opposition so now here's our argument in lack of faith because you can't have a good faith a mission when the in your own in tal a policy says that you must have physicians in this hospital within thirty minutes of your presentation to go to work when you especially when you're in hype of the name of shot you have these very bad injuries that the care because time is  undertakes stabilising treatment for a patient you don't read that as simply an undertaking you say that the hospital must succeed in stable now and that i'm saying you must undertake but you have to understand between the time between the time  presentation they didn't treat as emergency medical condition even when they'd perform surgery within that st period of time they didn't treat performed exploratory surgery ok so if you can see that the that they don't necessarily need a guarantee stabilizing treatment the rest of the language and brian says this and the legal adequacy of that care is then govern not by emtala right but by the state medical malpractise law ok so again what i'm arguing to this court is when emergency medical condition you cannot if you give them air of re transfused them you have to treat the injury the only way to treat this injury is surgery there's no other way to treat these types of injuries and at the time that