Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_05-cv-00499/USCOURTS-alsd-1_05-cv-00499-0/pdf.json

Nature of Suit Code: 360
Nature of Suit: Other Personal Injury
Cause of Action: 42:2651 Medical Care Recovery

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

BRENDA L. MORGAN, ) PUBLISH

 )

Plaintiff, )

 )

v. ) CIVIL NO. 05-0499-WS-B

 )

NORTH MISSISSIPPI MEDICAL )

CENTER, INC., )

 )

Defendant. )

ORDER

This matter is before the Court on defendant North Mississippi Medical Center, Inc.’s

Motion to Dismiss (doc. 5). The Motion has been briefed and is now ripe for disposition.

I. Background.

On August 26, 2005, plaintiff Brenda L. Morgan (“Morgan”) filed the instant Complaint

(doc. 1) in this District Court against defendant North Mississippi Medical Center, Inc.

(“NMMC”), alleging a state-law claim for outrage, as well as a cause of action for violation of

the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd (“EMTALA”). 

The well-pleaded allegations of the Complaint assert that on August 22, 2003, decedent Thomas

Henry Morgan, Sr. (“Mr. Morgan”) sustained serious injuries (including fractured ribs and

vertebrae, a dislocated shoulder, and a pulmonary contusion) in a fall from a tree stand at a

hunting camp near Calhoun City, Mississippi. (Complaint, ¶ 4.) Mr. Morgan, who did not have

medical insurance, was rushed to NMMC’s hospital in Tupelo, Mississippi (the “Hospital”),

where he received emergency trauma care and was admitted as a patient. (Id., ¶ 5.) Immediately

following Morgan’s arrival at the Hospital, Hospital personnel notified her that she would need

to make financial arrangements right away for her husband’s treatment. (Id.) After several

stalled attempts commencing within a day after his admission, the Hospital discharged Mr.

Morgan on August 31, 2003 (nine days after he was admitted), without conducting an MRI scan

of his badly injured back, and despite his serious ongoing medical difficulties. (Id., ¶¶ 6-10.) 

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 1 of 20
1 This recitation of background facts is not intended to be, nor should it be

construed as, a formal or binding set of factual findings. This matter is before the Court on a

Rule 12(b) motion, and plaintiff’s accounts of these events are nothing more than bare

allegations at this time. This Order accepts as true the well-pleaded allegations of the

Complaint, but expressly refrains from making any specific findings of fact at this juncture.

-2-

An ambulance owned and/or controlled by the Hospital transported Mr. Morgan to his home in

Foley, Alabama, where ambulance attendants physically carried him inside the house to his bed

on a stretcher. (Id., ¶¶ 10-11.) Approximately 12 hours later, Mr. Morgan died from untreated

injuries relating to his fall on August 22. (Id., ¶ 12.)1

In its Motion to Dismiss, NMMC contends that dismissal of the Complaint is warranted

on three distinct grounds. First, defendant maintains that this District Court lacks personal

jurisdiction over it because NMMC does not possess the requisite minimum contacts with the

State of Alabama to reasonably anticipate being haled into court here. Second, defendant argues

that venue does not properly lie in this District Court. Third, defendant states that the EMTALA

claim is not actionable, as a matter of law, and that in the absence of a viable EMTALA cause of

action there is no federal subject matter jurisdiction. Plaintiff contests each of these objections.

II. Analysis.

A. Personal Jurisdiction.

NMMC first contends that Morgan’s claims must be dismissed pursuant to Rule 12(b)(2),

Fed.R.Civ.P., because personal jurisdiction is nonexistent. In particular, defendant argues that it

is a non-profit Delaware corporation with its principal place of business in Tupelo, Mississippi,

and that it lacks the requisite minimum contacts with the State of Alabama to support exercise of

personal jurisdiction over it here in a manner consistent with constitutional and statutory

guarantees.

1. Legal Standard.

Where a district court in its discretion decides a personal jurisdiction issue without an

evidentiary hearing, it is the plaintiff’s burden to establish a prima facie case of personal

jurisdiction over a nonresident defendant. Meier ex rel. Meier v. Sun Int’l Hotels, Ltd., 288 F.3d

1264, 1269 (11th Cir. 2002); S.E.C. v. Carrillo, 115 F.3d 1540, 1542 (11th Cir. 1997). Such a

showing requires the presentation of evidence sufficient to withstand a motion for directed

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 2 of 20
-3-

verdict. Id. In considering the adequacy of a plaintiff’s proffer, district courts accept as true all

facts alleged in the complaint, to the extent they are uncontroverted by a defendant’s affidavits.

Id. If the complaint and the defendant’s affidavits conflict, then all reasonable inferences must

be construed in the plaintiff’s favor. Id. A dispositive motion alleging lack of personal

jurisdiction must be denied if the allegations of the complaint state a prima facie case of

jurisdiction. Ruiz de Molina v. Merritt & Furman Ins. Agency, Inc., 207 F.3d 1351, 1356 (11th

Cir. 2000).

“When a defendant challenges personal jurisdiction, the plaintiff has the twin burdens of

establishing that personal jurisdiction over the defendant comports with (1) the forum state’s

long-arm provision and (2) the requirements of the due-process clause of the Fourteenth

Amendment to the United States Constitution.” Lasalle Bank N.A. v. Mobile Hotel Properties,

LLC, 274 F. Supp.2d 1293, 1296 (S.D. Ala. 2003) (citations omitted); see also Horizon

Aggressive Growth, L.P. v. Rothstein-Kass, P.A., 421 F.3d 1162, 1166 (11th Cir. 2005) (similar). 

In Alabama, however, this two-pronged inquiry collapses into a single question because

Alabama’s long-arm provision permits its courts to exercise personal jurisdiction to the full

extent permitted by the Due Process Clause of the Fourteenth Amendment. See Molina, 207

F.3d at 1356; Lasalle Bank, 274 F. Supp.2d at 1296; Reliance Nat’l Indemnity Co. v. Pinnacle

Cas. Assur. Corp., 160 F. Supp.2d 1327, 1332 (M.D. Ala. 2001). Accordingly, the critical

question here is whether the exercise of personal jurisdiction over NMMC conforms with

constitutional safeguards.

Due process authorizes the exercise of personal jurisdiction when “(1) the nonresident

defendant has purposefully established minimum contacts with the forum;” and “(2) the exercise

of jurisdiction will not offend traditional notions of fair play and substantial justice.” Carrillo,

115 F.3d at 1542 (quoting Francosteel Corp., Unimetal-Normandy v. M/V Charm, Tiki,

Mortensen & Lange, 19 F.3d 624, 627 (11th Cir. 1994)); see also Horizon, 421 F.3d at 1166;

Molina, 207 F.3d at 1356; Lasalle Bank, 274 F. Supp.2d at 1296-97.

The minimum contacts analysis varies depending on whether the type of jurisdiction

asserted is general or specific. Indeed, facts supporting “[p]ersonal jurisdiction may be general,

which arise from the party’s contacts with the forum state that are unrelated to the claim, or

specific, which arise from the party’s contacts with the forum state that are related to the claim.” 

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 3 of 20
2 The parties also spar as to whether NMMC-Hamilton, a 57-bed acute care

hospital with nursing home, home health and wellness center services located in Hamilton,

Alabama, is sufficient to establish general jurisdiction over this defendant. NMMC asserts that

the Hamilton facility is a separate and distinct corporation from NMMC, although both share the

same parent corporation. The Court’s resolution of the specific jurisdiction question renders it

unnecessary to explore the legal relationship between these two entities, much less the

ramifications of NMMC-Hamilton’s existence on the jurisdictional status of NMMC in this

litigation, in order to resolve this aspect of the Motion to Dismiss.

-4-

Nippon Credit Bank, Ltd. v. Matthews, 291 F.3d 738, 747 (11th Cir. 2002). Under general

jurisdiction, there must be a showing of “continuous and systematic” contacts between the

defendant and the forum state even if those contacts are unrelated to the plaintiff’s claims. Id.

By contrast, specific jurisdiction is proper where (i) the defendant’s contacts with the forum state

are related or give rise to the plaintiff’s cause of action, (ii) the contacts involve some act by

which the defendant purposefully avails itself of the privilege of conducting activities within the

forum, and (iii) the defendant’s contacts with the forum are such that the defendant should

reasonably anticipate being haled into court there. See, e.g., McGow v. McCurry, 412 F.3d 1207,

1214 (11th Cir. 2005); Carrillo, 115 F.3d at 1542; Vermeulen v. Renault, U.S.A., Inc., 985 F.2d

1534, 1546 (11th Cir. 1993); Lasalle Bank, 274 F. Supp.2d at 1297.

2. Application of Jurisdictional Analysis to NMMC.

Plaintiff argues that, notwithstanding NMMC’s lack of a business presence in Alabama,

this Court may properly exercise specific jurisdiction over it.2 To that end, the Complaint may

be fairly read as alleging that when NMMC discharged Mr. Morgan, it placed him in an NMMC

ambulance operated by NMMC personnel. (Complaint, ¶ 10.) That NMMC ambulance is

alleged to have driven Mr. Morgan from the Hospital in Tupelo, Mississippi to his home in

Foley, Alabama, at which time NMMC ambulance attendants removed Mr. Morgan from the

ambulance, carried him into his home by stretcher, and deposited him in his bed where he died

just hours later. (Id., ¶ 11.) Plaintiff’s opposition brief contends that these allegations

adequately establish the elements of specific jurisdiction over NMMC.

Curiously, defendant’s reply brief utterly ignores the ambulance allegations and makes

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 4 of 20
3 In lieu of doing so, NMMC’s reply brief simply offers an affidavit stating that

NMMC does business solely in Tupelo, Mississippi, and that it is not qualified, authorized or

licensed to do business in Alabama. (Reply Brief, at Exh. A.) At most, such allegations create a

factual dispute with Morgan’s assertion in the Complaint that a NMMC ambulance operated by

NMMC staff transported the decedent to his home in Alabama and left him there in an

unstabilized condition. As indicated supra, however, all reasonable inferences must be

construed in the plaintiff’s favor and the Motion to Dismiss must be denied if the Complaint

establishes a prima facie case of jurisdiction. Accordingly, NMMC’s blanket denial that it

engages in activities outside of Mississippi cannot overcome plaintiff’s specific allegations of

NMMC conduct in Alabama for purposes of the Rule 12(b)(2) Motion.

4 Moreover, defendant does not proffer evidence that it did not own or control the

ambulance, that it did not employ or control the ambulance attendants, or that the ambulance and

its crew were not performing official Hospital business by transporting Mr. Morgan to Alabama. 

As such, this analysis assumes that Mr. Morgan traveled in an NMMC ambulance driven by

NMMC personnel on NMMC business.

-5-

no attempt to rebut plaintiff’s invocation of specific jurisdiction principles.3

 Defendant adopts

this strategy at its peril, inasmuch as this Court will not formulate a party’s arguments for it. See

Resolution Trust Corp. v. Dunmar Corp., 43 F.3d 587, 599 (11th Cir. 1995) (“There is no burden

upon the district court to distill every potential argument that could be made based upon the

materials before it.”); Pinto v. Universidad De Puerto Rico, 895 F.2d 18, 19 (1st Cir. 1990) (“The

court is under no duty to exercise imagination and conjure what a plaintiff might have alleged,

but did not, and do counsel's work for him or her.”).4

Applying the three specific jurisdiction criteria to the facts asserted in the Complaint, it is

clear that plaintiff has sufficiently pleaded a basis for the exercise of personal jurisdiction over

NMMC in Alabama. First, NMMC’s alleged contacts with the forum state (namely, its acts of

transporting Mr. Morgan to his home in Foley, Alabama, physically carrying him inside the

house on a stretcher, and leaving him there) are unquestionably related to plaintiff’s causes of

action herein. Ultimately, this case is factually centered on the propriety of the Hospital’s

discharge decision and the ramifications of that decision for Mr. Morgan. The Hospital’s actions

in transferring the decedent from the Hospital to Alabama are inextricably intertwined with,

substantially related to, and ultimately form the factual predicate for plaintiff’s theories of

recovery. Second, when NMMC personnel traveled into Alabama in an NMMC vehicle on

NMMC official business, they were certainly purposefully availing themselves of the privilege

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 5 of 20
5 Even if the facts alleged in the Complaint were inadequate as to one or more of

the three prongs of the specific jurisdiction test, the Court finds that defendant has waived any

such arguments by virtue of its failure to offer any substantive response to plaintiff’s contention

that defendant’s in-state ambulance travel satisfies the prerequisites for specific jurisdiction. 

This Court will not speculate as to how NMMC might have combated the specific jurisdiction

theory had it endeavored to do so.

6 The “fair play and substantial justice” analysis hinges on such factors as “the

burden on the defendant in defending the lawsuit, the forum state's interest in adjudicating the

dispute, the plaintiff's interest in obtaining convenient and effective relief, the interstate judicial

system's interest in obtaining the most efficient resolution of controversies and the shared

-6-

of conducting activities in Alabama. Had defendant’s ambulance been struck by another

motorist in Foley, Alabama, defendant would have had access to the protections of Alabama law

in connection with that incident. It would defy common sense to suggest that NMMC did not

intend to avail itself of the protections and benefits of Alabama law when it dispatched its agents

and equipment into this State to transfer Mr. Morgan to his home. Third, NMMC should

absolutely have reasonably anticipated being haled into court in Alabama in the event of any

problems in connection with its ambulance foray in this State. For instance, had defendant’s

ambulance wrongfully struck another motorist while traversing the streets of Foley, Alabama, it

would be foolhardy for defendant not to expect to be sued in Alabama for that transgression.

Simply put, the allegations of the Complaint reasonably support the inference that

defendant intentionally directed Hospital personnel to travel into Alabama in a Hospital vehicle

with a Hospital patient who had just been discharged. The only sensible construction of these

facts is that defendant purposefully aimed its official activities into the State of Alabama. In so

doing, it must have known that any difficulty that its agents encountered in Alabama might be

remediable in courts in the State of Alabama pursuant to Alabama law. Plaintiff’s claims against

NMMC arise directly from its acts of ejecting Mr. Morgan from the Hospital, carrying him to

Alabama, and abandoning him there. Nothing more is required to establish specific jurisdiction.5

Having ascertained that NMMC possesses the requisite minimum contacts with Alabama,

the undersigned now turns to the second element of the due process inquiry, to-wit: whether

asserting personal jurisdiction over NMMC would comport with traditional notions of fair play

and substantial justice. Carrillo, 115 F.3d at 1542.6

 There appears to be nothing intrinsically

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 6 of 20
interest of the states in furthering fundamental substantive social policies.” Horn v. Effort

Shipping Co., Ltd., 777 F. Supp. 927, 931 (S.D. Ala. 1991) (citations omitted).

7 In the course of its argument that venue is improper, NMMC protests that this

forum “will prove to be unreasonable and inconvenient” and that most “staff, witnesses and

records related to the screening and treatment decision that gave rise to this claim will be found

in Mississippi.” (Reply Brief, at 9.) Such arguments might resonate in the forum non

conveniens context of § 1404(a); however, they are not relevant to the legal issue raised by

NMMC, to-wit: whether venue is properly laid in this District Court pursuant to § 1391(b).

-7-

unfair or unjust about requiring a Mississippi hospital that engages in patient transport activities

in Alabama to defend a lawsuit in this state relating to and arising from such activities. Stated

differently, NMMC has minimum contacts with this forum, and is unable to meet its concomitant

burden “to show that the imposition of jurisdiction in the forum is unreasonable.” Ruiz de

Molina, 207 F.3d at 1358. Indeed, defendant offers no evidence that it will incur any meaningful

burden in defending this action in a neighboring state, much less that any such burden outweighs

the interests of Morgan and Alabama in having this dispute resolved here. Even if defendant had

demonstrated hardship, which it has not, the fact remains that “[w]hen minimum contacts have

been established, often the interests of the plaintiff and the forum will justify even the serious

burdens placed on the alien defendant.” Vermeulen, 985 F.2d at 1551 (citations omitted).

For all of the foregoing reasons, the Court finds that the exercise of personal jurisdiction

over NMMC in this forum may be achieved without infringing on its due process rights or

implicating the Alabama long-arm statute. On that basis, the Motion to Dismiss is denied

insofar as it rests on a Rule 12(b)(2) personal jurisdiction argument.

B. Venue.

As a secondary position, NMMC maintains that this action should be dismissed for

improper venue, pursuant to Rule 12(b)(3), Fed.R.Civ.P. Defendant’s Motion invokes 28 U.S.C.

§ 1391(b), and will therefore be assessed according to that statute’s standards for improper

venue, rather than the framework set forth in 28 U.S.C. § 1404(a) for inconvenient venue.7

Under § 1391(b), venue in a civil case wherein jurisdiction is not based solely on

diversity is proper in any of the following locations:

“(1) a judicial district where any defendant resides, if all defendants reside in the

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 7 of 20
-8-

same State, (2) a judicial district in which a substantial part of the events or

omissions giving rise to the claim occurred ..., or (3) a judicial district in which

any defendant may be found, if there is no district in which the action may

otherwise be brought.”

Id. Because the face of the Complaint demonstrates that neither (1) nor (3) are satisfied here, the

propriety of this District Court as a venue for the instant dispute turns on whether a substantial

part of the events giving rise to Morgan’s claims took place in this judicial district. 

NMMC asserts that no substantial portion of the events occurred in Alabama. According

to NMMC, “[t]he essential elements of the claim examine the initial screening and stabilization

treatment,” both of which occurred in Mississippi. (Reply Brief, at 10.) The transfer of Mr.

Morgan to Alabama, NMMC states, “pales in comparison to 8 days of care given in

Mississippi.” (Id.) This line of argument – that venue does not lie in Alabama because the most

substantial events took place in Mississippi – misapprehends the governing legal standard.

The venue statute “contemplates some cases in which venue will be proper in two or

more districts.” Jenkins Brick Co. v. Bremer, 321 F.3d 1366, 1371 (11th Cir. 2003); see

also Mitrano v. Hawes, 377 F.3d 402, 405 (4th Cir. 2004) (“Under the amended statute, it is

possible for venue to be proper in more than one judicial district.”); Wright & Miller, Federal

Practice and Procedure § 3806 (explaining that “it is now absolutely clear that there can be

more than one district in which a substantial part of the events giving rise to the claim

occurred”); 28 U.S.C. § 1391, Commentary on 1988 and 1990 Revisions ( “there may be several

districts that qualify as a situs of such ‘substantial’ activities” ). Indeed, under § 1391 a plaintiff

does not have to select the venue with the most substantial nexus to the dispute, as long as she

chooses a venue where a substantial part of the events giving rise to the claim occurred. See

Country Home Products, Inc. v. Schiller-Pfeiffer, Inc., 350 F. Supp.2d 561, 568 (D. Vt. 2004)

(explaining that “the plaintiff is not required to establish that his chosen venue has the most

substantial contacts to the dispute; rather, it is sufficient that a substantial part of the events

occurred [here], even if a greater part of the events occurred elsewhere”); Greenblatt v. Gluck,

265 F. Supp.2d 346, 352 (S.D.N.Y. 2003) (similar); TruServ Corp. v. Neff, 6 F. Supp.2d 790, 792

(N.D. Ill. 1998) (“The test is not whether a majority of the activities pertaining to the case were

performed in a particular district, but whether a substantial portion of the activities giving rise to

the claim occurred in the particular district.”). Thus, the question confronting the undersigned is

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 8 of 20
8 This philosophy has not been embraced by all appellate courts in interpreting the

“substantial part” language. See, e.g., Mitrano, 377 F.3d at 405 (citing First and Sixth Circuit

authorities for proposition that “in determining whether events or omissions are sufficiently

substantial to support venue under the amended statute, a court should not focus only on those

matters that are in dispute or that directly led to the filing of the action,” but instead “should

review the entire sequence of events underlying the claim”).

-9-

not whether the lion’s share of the events at issue occurred in the Southern District of Alabama,

nor is it the relative magnitude and significance of the events occurring in this judicial district as

compared to those in the Northern District of Mississippi. Instead, the question is simply

whether “a substantial part” of the events transpired here.

In evaluating whether events or omissions support venue under § 1391(b), the Eleventh

Circuit has made clear that “[o]nly the events that directly give rise to a claim are relevant” and

that “only those acts and omissions that have a close nexus to the wrong” are properly weighed

in the “substantial part” analysis. Jenkins Brick, 321 F.3d at 1372; see also Daniel v. American

Bd. of Emergency Medicine, 428 F.3d 408 (2nd Cir. 2005) (“When material acts or omissions

within the forum bear a close nexus to the claims, they are properly deemed significant and, thus,

substantial, but when a close nexus is lacking, so too is the substantiality necessary to support

venue.”).8 In that regard, the Court finds a close nexus between the alleged acts and omissions

of NMMC in the Southern District of Alabama and the claims asserted by Morgan in this

lawsuit. The gravamen of plaintiff’s claims is that the Hospital admitted Mr. Morgan under false

pretenses, failed to stabilize his emergency medical condition, then shipped him via Hospital

ambulance to his home in this judicial district, where he died a short time later. The legal

elements of the alleged EMTALA violation may have been satisfied the moment that NMMC

wheeled Mr. Morgan out the front door of the Hospital and into a waiting ambulance. 

Nonetheless, NMMC’s alleged act of transporting him to and leaving him in Alabama bear a

“close nexus” to the alleged wrong under any reasonable construction of the term, from a logical,

temporal and sequential vantage point. Moreover, plaintiff will undoubtedly rely heavily on the

Alabama events to prove that Mr. Morgan was “transferred” for EMTALA purposes without

prior stabilization of his emergency medical condition, inasmuch as his rapid decline upon being

left in his home might support an inference that the Hospital failed to stabilize him (within the

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 9 of 20
9 In reaching this determination, the Court notes that defendant failed to offer any

legal authority or analysis in support of its conclusory suggestion that NMMC’s ambulance

transportation of Mr. Morgan into Alabama does not qualify as a “substantial part” of the events. 

Instead, defendant simply argued that the events in Alabama were less critical or important than

those events occurring in Mississippi. Such a relativist argument is unilluminating and unhelpful

in applying the Jenkins Brick framework.

-10-

statutory meaning of the term) before discharging him. Thus, the Alabama occurrences may

figure prominently in the proof at trial. On that basis, the undersigned is of the opinion that

venue properly lies in this judicial district. Defendant’s Motion to Dismiss for improper venue is

therefore denied pursuant to 28 U.S.C. § 1391(b)(2) and Jenkins Brick.

9

C. Viability of EMTALA Cause of Action.

Defendant’s third and final ground for relief is that plaintiff’s EMTALA claim fails to

state a claim upon which relief can be granted, such that dismissal is warranted pursuant to Rule

12(b)(6), Fed.R.Civ.P. The Court disagrees, at least in part.

1. Legal Standard for Rule 12(b)(6) Motion.

On a motion to dismiss, the Court must view the complaint in the light most favorable to

the plaintiff. Jenkins v. McKeithen, 395 U.S. 411, 421-22, 23 L. Ed. 2d 404, 89 S. Ct. 1843

(1969). A motion to dismiss may be granted only where “it appears beyond doubt that the

plaintiff can prove no set of facts in support of his claim which would entitle him to relief.” 

Conley v. Gibson, 355 U.S. 41, 45-46, 2 L. Ed. 2d 80, 78 S. Ct. 99 (1957); Bradberry v. Pinellas

County, 789 F.2d 1513, 1515 (11th Cir. 1986). The rules of pleading require only that a

complaint contain “a short and plain statement of the claim showing that the pleader is entitled to

relief.” Rule 8(a), Fed.R.Civ.P. Moreover, the Court must, “at this stage of the litigation, . . .

accept [plaintiff’s] allegations as true.” Hishon v. King & Spalding, 467 U.S. 69, 73, 81 L. Ed.

2d 59, 104 S. Ct. 2229 (1984); Stephens v. HHS, 901 F.2d 1571, 1573 (11th Cir. 1990); cf. South

Florida Water Management Dist. v. Montalvo, 84 F.3d 402, 409 n.10 (11th Cir. 1996)

(conclusory allegations and unwarranted deductions of fact are not deemed true on a motion to

dismiss). The Court’s inquiry at this stage focuses on whether the challenged pleadings “give

the defendant fair notice of what the plaintiff's claim is and the grounds upon which it rests.”

Conley, 355 U.S. at 47. A plaintiff must meet only an “exceedingly low” threshold to withstand

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 10 of 20
-11-

a Rule 12(b)(6) motion. United States v. Baxter Int’l, Inc., 345 F.3d 866, 881 (11th Cir. 2003).

2. Overview of EMTALA.

EMTALA is a federal anti-dumping provision that was enacted in 1986 for the stated

purpose of preventing “patient dumping,” which is “the practice of some hospital emergency

rooms turning away or transferring indigents to public hospitals without prior assessment or

stabilization treatment.” Harry v. Marchant, 291 F.3d 767, 772 (11th Cir. 2002) (en banc); see

also Hunt ex rel. Hunt v. Lincoln County Memorial Hosp., 317 F.3d 891, 893 n.5 (8th Cir. 2003)

(“This law was enacted to address patient ‘dumping’ by hospitals of patients without the

appropriate amount of insurance.”); Holcomb v. Monahan, 30 F.3d 116, 117 n.2 (11th Cir. 1994)

(“Congress enacted EMTALA to prevent ‘patient dumping’ (the practice whereby private

hospital emergency rooms refuse to treat indigent patients by transferring them to public

hospitals or turning them away).”). Courts have universally recognized that EMTALA was not

conceived as a federal medical malpractice statute. See, e.g., Nolen v. Boca Raton Community

Hosp., Inc., 373 F.3d 1151, 1154 (11th Cir. 2004); Harry, 291 F.3d at 770; Hunt, 317 F.3d at 894;

Jakubiec v. Sacred Heart Health System, Inc., 2005 WL 1261443, *2 (N.D. Fla. May 27, 2005);

Bowden ex rel. Bowden v. Wal-Mart Stores, Inc., 2001 WL 617521, *4 n.4 (M.D. Ala. Feb. 20,

2001); Gardner v. Elmore Community Hosp., 64 F. Supp.2d 1195, 1201 (M.D. Ala. 1999).

EMTALA requires hospitals to satisfy two distinct obligations, which are commonly

labeled as the “appropriate medical screening requirement” and the “stabilization requirement.” 

Harry, 291 F.3d at 770. Pursuant to the former duty, if an individual comes to a hospital’s

emergency department and requests examination or treatment of a medical condition, “the

hospital must provide for an appropriate medical screening examination within the capability of

the hospital’s emergency department ... to determine whether or not an emergency medical

condition ... exists.” 42 U.S.C. § 1395dd(a). Under the latter, if an individual comes to a

hospital and the hospital determines that person to have an emergency medical condition, then

the hospital must either provide “such further medical examination and such treatment as may be

required to stabilize the medical condition” or “transfer ... the individual to another medical

facility” in accordance with EMTALA requirements. 42 U.S.C. § 1395dd(a); see also Harry,

291 F.3d at 770 (characterizing stabilization requirement as mandating that hospital provide

stabilization treatment before transferring patient with an emergency condition). Morgan’s

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 11 of 20
10 As a threshold matter, MMNC argues that EMTALA “applies only to persons

who present to hospital emergency departments.” (Motion, ¶ 4.) In support of this contention,

defendant relies heavily on Lopez-Soto v. Hawayek, 175 F.3d 170 (1st Cir. 1999). But LopezSoto actually stands for a proposition dramatically different than that ascribed to it by defendant. 

In Lopez-Soto, the First Circuit declared that, while the screening requirement is limited to

emergency departments, the stabilization requirement “unambiguously imposes certain duties on

covered hospitals vis-a-vis any victim of a detected medical emergency, regardless of how that

person enters the institution or where within the walls he may be when the hospital identifies the

problem.” Id. at 173; see also 42 U.S.C. § 1395dd(b) (imposing stabilization requirement

whenever individual “comes to a hospital and the hospital determines that the individual has an

emergency medical condition,” with no textual limitation to emergency departments). LopezSoto reasoned that the broad sweep of the stabilization requirement makes sense because

“stabilization is arguably the key to ensuring the health of those already admitted to the hospital

who develop emergency medical conditions.” 175 F.3d at 175. When the defendant asserted (as

does NMMC here) that interpreting the stabilization requirement so expansively would do

violence to the legislative purpose of EMTALA to clamp down on patient dumping, Lopez-Soto

rebuffed this objection by reasoning that “patient dumping is not a practice that is limited to

emergency rooms,” and that dumping admitted patients who develop emergency conditions “is

equally as pernicious as what occurs in emergency departments, and we are unprepared to say

that Congress did not seek to curb it.” Id. at 177. Thus, NMMC’s attempt to confine all

EMTALA obligations to emergency departments results from an incorrect reading of the statute

and the caselaw.

-12-

EMTALA claim purports to allege violations of both statutory requirements.10

3. The Appropriate Medical Screening Requirement.

Plaintiff maintains that the Hospital failed to comply with the screening requirement of

EMTALA “by failing to obtain an MRI scan of Mr. Morgan’s back ... to determine that an

emergency medical condition existed in the thoracic region of his spine” on August 30, 2003. 

(Complaint, ¶ 17.) Neither the Complaint nor plaintiff’s submission as to the Motion to Dismiss

supplies further amplification of the screening aspect of her EMTALA claim.

Review of pertinent case authorities confirms that EMTALA’s medical screening

requirement is far too narrow to sustain plaintiff’s claim. Contrary to plaintiff’s contention, the

screening duty is not triggered whenever a hospital neglects to perform a screening test that the

plaintiff believes should have been done, or even one that any reasonably diligent hospital would

have performed. Rather, EMTALA’s screening obligation is focused exclusively on ensuring

that a hospital applies the same screening procedures for indigent patients who present at its

emergency room that it does for similarly situated patients who have insurance or are otherwise

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 12 of 20
11 A veritable avalanche of appellate and district court authority in this Circuit

confirms the validity of that interpretation of § 1395dd(a). See Nolen, 373 F.3d at 1155 (“So

long as the Hospital gave to [the plaintiff] the same quality screening that it would have given a

similarly situated outpatient, there is no violation of the EMTALA.”); Jakubiec, 2005 WL

1261443, at *2 (following Holcomb and Nolen); Williamson v. Roth, 120 F. Supp.2d 1327,

*1333 (M.D. Fla. 2000) (“As long as a hospital applies the same screening procedures to

indigent patients which it applies to paying patients, the hospital does not violate this section of

EMTALA.”); see also Gardner, 64 F. Supp.2d at 1201 (hospital satisfies EMTALA’s screening

requirement if “it utilizes identical screening procedures for all patients complaining of the same

condition or exhibiting the same symptoms”).

12 As one district court cogently and correctly observed, “[t]he essence of this

requirement is that there be some screening procedure, and that it be administered

even-handedly. Therefore, 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.” Gardner, 64 F. Supp.2d

at 1202; see also Summers v. Baptist Medical Center Arkadelphia, 91 F.3d 1132, 1138 (8th Cir.

1996) (“Patients are entitled under EMTALA, not to correct or non-negligent treatment in all

circumstances, but to be treated as other similarly situated patients are treated, within the

hospital's capabilities. It is up to the hospital itself to determine what its screening procedures

will be. Having done so, it must apply them alike to all patients.”).

-13-

well-heeled. See, e.g., Holcomb, 30 F.3d at 117 (explaining that statute’s appropriate medical

screening requirement “only requires a hospital to provide indigent patients with a medical

screening similar to one which they would provide any other patient”).11 Simply put, “[a]s long

as a hospital applies the same screening procedures to indigent patients which it applies to

paying patients, the hospital does not violate” the screening section of EMTALA. Holcomb, 30

F.3d at 117. Thus, failing to perform even a medically advisable screening test in no way

implicates EMTALA unless the Hospital treated Mr. Morgan differently in that regard than it

would have treated a similarly situated paying patient. See Hunt, 317 F.3d at 894 (affirming

dismissal of EMTALA screening claim where plaintiff’s claim was not that he received nonuniform treatment, but that he received incorrect treatment).12 

The Complaint is devoid of any suggestion that the Hospital engaged in disparate

treatment of Mr. Morgan vis a vis insured customers, or that it violated its own screening

protocols in neglecting to give him an MRI; rather, the crux of the “screening” portion of the

claim is simply that Mr. Morgan needed an MRI, but the Hospital failed to provide one for him. 

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 13 of 20
-14-

This aspect of plaintiff’s EMTALA claim bears the unmistakable tincture of a malpractice or

negligence claim in disguise. As demonstrated by the foregoing authorities, such a theory, not

rooted in any disparate treatment formulation, is not cognizable under EMTALA.

Even if Morgan had properly alleged a theory of disparate treatment sufficient to invoke

the appropriate medical screening requirement (which she has not), this obligation is

inapplicable here because § 1395dd(a) is confined on its face to Hospital emergency

departments. The statute itself restricts the screening obligation to circumstances where an

individual “comes to the emergency department,” and requires “an appropriate medical

screening examination within the capability of the hospital’s emergency department.” 42

U.S.C. § 1395dd(a) (emphasis added). This language is bolstered by appellate decisions that

have limited the screening requirement to the emergency room setting. See Harry, 291 F.3d at

770 (“The appropriate medical screening requirement obligates hospital emergency rooms to

provide an appropriate medical screening ....”); Lopez-Soto v. Hawayek, 175 F.3d 170, 173 (1st

Cir. 1999) (construing § 1395dd(a) as “obligat[ing] hospitals to screen only those individuals

who present themselves at the emergency department”). The Court’s research has disclosed no

authorities, and plaintiff has cited none, in which EMTALA’s screening duty has been extended

to an inpatient some eight days post-admission to the hospital. Inasmuch as such a construction

of the statute would contravene its express language and does not appear to be supported by any

interpretive case law, this Court declines to engraft EMTALA’s screening duty to encompass a

hospital’s failure to perform certain desired tests more than a week after a patient is admitted for

treatment.

In short, plaintiff’s contention that the Hospital should have performed an MRI on Mr.

Morgan’s back on August 30, 2003, some eight days after his admission, may well be actionable

through various state law vehicles. It is not, however, in violation of EMTALA’s screening

requirements, inasmuch as: (a) plaintiff has not alleged that the Hospital treated Mr. Morgan

differently than similarly situated insured patients in that regard; and (b) even if such an

allegation had been made, the screening requirement is limited to emergency rooms and does not

extend to other, non-emergency departments of a hospital post-admission of a patient. 

Therefore, the Court finds that plaintiff’s EMTALA claim is actionable, if at all, only on a

failure to stabilize theory, not on a failure to perform appropriate medical screening.

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 14 of 20
13 The statute also provides that, as an alternative to stabilization, a hospital may

transfer a patient to another medical facility under certain circumstances (i.e., a patient’s

informed written request to be transferred, certification by a physician or other qualified medical

person that the medical benefits of transfer outweigh patient risks, etc.). That provision of

EMTALA is not at issue here.

-15-

4. The Stabilization Requirement.

The Complaint also alleges that NMMC failed to comply with EMTALA’s stabilization

requirement, asserting that the Hospital “failed to provide the medical treatment necessary to

stabilize Mr. Morgan and, further, discharged him in an unstable medical condition.” 

(Complaint, ¶ 18.) Plaintiff argues that these allegations plead a violation of EMTALA, which

requires a hospital, when it becomes aware of an individual’s emergency medical condition, to

provide “such further medical examination and such treatment as may be required to stabilize the

medical condition.” 42 U.S.C. § 1395dd(b)(1)(A).13 The statute defines the term “stabilize” as

requiring such treatment of an emergency medical condition “as may be necessary to assure,

within reasonable medical probability, that no material deterioration of the condition is likely to

result from or occur during the transfer of the individual from a facility.” Id. § 1395dd(e)(3)(A);

see also Bowden ex rel. Bowden v. Wal-Mart Stores, Inc., 124 F. Supp.2d 1228, 1237 (M.D. Ala.

2000) (“A patient's condition is stabilized if no material deterioration of the condition is likely,

within reasonable medical probability, to result from or occur during the transfer of the

individual.”) (citing Cherukuri v. Shalala, 175 F.3d 446, 450 (6th Cir. 1999)). “Transfer” is also

a term of art in EMTALA. It is not confined to inter-hospital patient swaps, but is instead

defined as “the movement (including the discharge) of an individual outside a hospital’s

facilities at the direction of any person employed by ... the hospital.” 42 U.S.C. § 1395dd(e)(4).

Construing these statutory provisions in unison reveals that § 1395dd(b) is violated if a

hospital discharges a patient with knowledge of his emergency medical condition and without

engaging in such medical examination and treatment as may be necessary to assure that no

material deterioration of the patient’s condition will likely result from such discharge. The case

law is consistent with this construction. For example, one district court has opined that “a viable

Section 1395dd(b) claim requires plaintiffs to plead that: (1) they had an emergency medical

condition; (2) the hospital knew of the condition; and (3) the patient was not stabilized before

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 15 of 20
-16-

being discharged or transferred.” Kizzire v. Baptist Health Systems, Inc., 343 F. Supp.2d 1074,

1084 (N.D. Ala. 2004); see also Williamson v. Roth, 120 F. Supp.2d 1327, 1334 (M.D. Fla.

2000) (“Section 1395dd(b) of EMTALA requires that after a hospital determines that a patient is

experiencing an ‘emergency medical condition’ it must provide ‘whatever treatment, within its

capabilities, is needed to stabilize the condition before transferring or discharging the patient.’”). 

The Eleventh Circuit has emphasized that “the triggering mechanism for stabilization treatment

under EMTALA is transfer,” which plainly includes discharge. Harry, 291 F.3d at 772.

NMMC contends that the nine-day interval between Mr. Morgan’s arrival at the Hospital

and his discharge places this case outside the temporal parameters of the stabilization

requirement. (Motion, ¶ 4.) But nothing in § 1395dd(b) would restrict the scope of the

stabilization requirement to a maximum number of minutes, hours or days after a person with an

emergency medical condition presents at a hospital. To be sure, some courts in other

jurisdictions have soldered judicially-crafted limitations onto this requirement; however, others

have declined to do so. The Eleventh Circuit appears never to have entered this fray, but

research canvassing appellate decisions on this question identifies three distinct approaches. The

Fourth Circuit has imputed a fuzzy, ill-defined temporal limitation on all § 1395dd(b) claims,

such that the stabilization requirement is confined to “the hospital’s care of the patient only in

the immediate aftermath of the act of admitting her for emergency treatment and while it

considered whether it would undertake longer-term full treatment or instead transfer the patient.” 

Bryan v. Rectors and Visitors of University of Virginia, 95 F.3d 349, 352 (4th Cir. 1996) (holding

that EMTALA was not violated where patient had been admitted to hospital for 12 days, during

which time she received stabilizing treatment). The Bryan approach is unsatisfying because (a)

by effectively limiting the stabilization duty to emergency departments, it seemingly disregards

statutory language extending the stabilization requirement to entire hospitals but limiting the

screening requirement to emergency departments; (b) the undersigned would have no idea how

to apply the nebulous “immediate aftermath” concept to a specific set of facts; (c) the

“immediate aftermath” constraint was cut from whole cloth by the appellate court, and lacks any

underpinnings in the statute or its accompanying regulations; and (d) such a holding suggests

that hospitals could receive a “free pass” from EMTALA liability simply by admitting patients

whom they had no intention of treating, then unscrupulously dumping them a short time later by

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 16 of 20
-17-

discharging them without providing necessary stabilizing treatment. Thus, far from vindicating

the statutory purposes, Bryan appears to conflict with them by imbuing admission with

talismanic significance as a “cure-all” that guarantees freedom from EMTALA liability,

regardless of what chicanery a hospital might engage in post-admission to unload an indigent,

unprofitable patient with an emergency health condition.

On the other end of the spectrum, the Sixth Circuit has endorsed a position that

EMTALA’s stabilization requirements can apply well after the patient is admitted to a hospital. 

In Thornton v. Southwest Detroit Hosp., 895 F.2d 1131 (6th Cir. 1990), the panel interpreted §

1395dd(b) as meaning that “once a patient is found to suffer from an emergency medical

condition in the emergency room, she cannot be discharged until the condition is stabilized,

regardless of whether the patient stays in the emergency room.” Id. at 1134. The Thornton court

expressed concern that if the law were otherwise, hospitals might circumvent EMTALA by

admitting emergency room patients then immediately discharging them. On that basis, the Sixth

Circuit refused to draw a black-line distinction between emergency room care and inpatient care

for purposes of the stabilization requirement, but instead construed EMTALA as creating a

blanket requirement that “[e]mergency care must be given until the patient's emergency medical

condition is stabilized,” whenever and wherever that might occur. Id. at 1135; see

generally Lopez-Soto, 175 F.3d at 175 (interpreting stabilization requirement as “obligating

hospitals to stabilize individuals (wherever in the hospital they may be) when emergency

medical conditions are detected,” with no clear temporal constraint). This approach also seems

vulnerable to abuse, inasmuch as it would allow for an open-ended, uncabined duration of the

stabilization requirement with no logical limiting principle. Under this line of reasoning, then,

the stabilization duty could be imputed as extending indefinitely after a patient’s admission and

potentially poaching on regulatory territory patrolled by state malpractice law, an outcome which

runs directly counter to the stated purpose of EMTALA. See Lopez-Soto, 175 F.3d at 177 n.4

(“If stabilization were mandated by EMTALA without limit of time, it might well encroach upon

the province of state malpractice law.”).

If the Fourth Circuit’s construction of the temporal limits of § 1395dd(b) is too

draconian, and if the Sixth Circuit’s is too permissive, then, much like Goldilocks in the famed

fairy tale, the Ninth Circuit’s approach may be just right. In Bryant v. Adventist Health

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 17 of 20
14 The Bryant holding and its explicit limitation is echoed in the implementing

regulations for EMTALA. Those regulations provide, in pertinent part, that “[i]f a hospital has

screened an individual under paragraph (a) of this section and found the individual to have an

emergency medical condition, and admits that individual as an inpatient in good faith in order to

stabilize the emergency medical condition, the hospital has satisfied its special responsibilities”

under EMTALA. 42 CFR § 489.24(d)(2)(i) (emphasis added). This regulation confirms that

admission of a patient cuts off a hospital’s stabilization duty under EMTALA only if that patient

has been admitted in good faith. Defendant quoted this regulation in its reply brief, but curiously

omitted the critically important “in good faith” qualifier from the regulatory language. (See

Reply Brief, at 2-3.)

-18-

Systems/West, 289 F.3d 1162 (9th Cir. 2002), the court weighed both the Fourth and Sixth Circuit

alternatives before holding “that EMTALA’s stabilization requirement ends when an individual

is admitted for inpatient care.” Id. at 1168. Lest one conclude that the Bryant court merely aped

the Fourth Circuit’s Bryan decision, the Ninth Circuit tempered this holding by recognizing the

wisdom of the Sixth Circuit’s concern that a hospital might attempt to evade EMTALA liability

by admitting a patient under false pretenses to cut off his stabilization rights, then

unceremoniously dumping him as soon as the coast was clear. In that regard, Bryant added an

important caveat to its inpatient rule, stating that “[i]f a patient demonstrates in a particular case

that inpatient admission was a ruse to avoid EMTALA’s requirements, then liability under

EMTALA may attach,” notwithstanding such admission. Id. at 1169; see also Mazurkiewicz v.

Doylestown Hosp., 305 F. Supp.2d 437, 447 (E.D. Pa. 2004) (“the most persuasive synthesis of

the law on admission as a defense to EMTALA liability is that admission is a defense so long as

admission is not a subterfuge”).14

The undersigned is of the opinion that the rule announced by the Ninth Circuit in Bryant

most accurately captures the letter and spirit of EMTALA and its attendant regulations, while

also remedying the inherent defects in the Fourth and Sixth Circuit constructions of § 1395dd(b). 

In light of these principles, and in the absence of any guidance from the Eleventh Circuit, the

Court finds that the EMTALA obligation to stabilize a patient ceases at the time of the patient’s

admission as an inpatient, unless the hospital fails to admit the patient in good faith or does so as

a subterfuge to avert EMTALA liability.

A fair reading of the Complaint supports a subterfuge theory of liability. Plaintiff alleges

that the Hospital demanded that she make financial arrangements to pay for her husband’s

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 18 of 20
15 Because the stabilization claim passes Rule 12(b)(6) muster, plaintiff’s EMTALA

claim confers upon the Court federal question jurisdiction pursuant to 28 U.S.C. § 1331. The

requisite jurisdiction plainly exists, and defendant’s argument that this action should be

dismissed for want of subject matter jurisdiction is unfounded.

-19-

treatment immediately after his arrival at the emergency department, then announced its

intention to discharge him the very next day, despite knowledge of the compression fractures of

his thoracic vertebrae, his intense back pain, his inability to walk, his pulmonary contusions and

the blood in his lungs. These allegations, accepted as true for Rule 12(b)(6) purposes, could

reasonably support a conclusion that the Hospital’s admission of Mr. Morgan was a mere façade,

a charade undertaken for risk management purposes even though the Hospital had no intention of

stabilizing his injuries before transferring him. Of course, Morgan will be required to prove this

subterfuge theory at trial by competent evidence. For now, however, she has adequately alleged

a violation of § 1395dd(b) inasmuch as her Complaint states or fairly implies that: (a) Mr.

Morgan presented at the Hospital for treatment of an emergency medical condition; (b) the

Hospital had actual knowledge that Mr. Morgan had an emergency medical condition; (c) the

Hospital admitted Mr. Morgan as an inpatient, but never intended to provide him stabilizing

care; (d) the Hospital discharged Mr. Morgan without providing him such medical treatment of

his emergency medical conditions as was necessary to assure, within reasonable medical

probability, that no material deterioration of his condition was likely to result from or occur

during his transfer from the Hospital; and (e) mere hours after the transfer was completed, Mr.

Morgan died in his home from the emergency medical condition in question. Defendant’s

Motion to Dismiss is therefore denied as to the EMTALA stabilization claim.15

This conclusion is not altered by NMMC’s attempt to recharacterize plaintiff’s EMTALA

stabilization cause of action as a concealed negligence or malpractice claim. (Motion, ¶ 6.) The

Complaint alleges nothing of the sort. Rather, the EMTALA claim alleges that the Hospital

discharged Mr. Morgan without stabilizing a known emergency medical condition. Such a

theory of liability plainly sounds under § 1395dd(b), and presents a colorable claim under that

statute notwithstanding defendant’s attempts to relabel it as something else.

III. Conclusion.

For all of the foregoing reasons, the Motion to Dismiss (doc. 5) is granted in part, and

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 19 of 20
-20-

denied in part. In particular, the Motion is granted as to the EMTALA claim predicated on

violation of the appropriate medical screening requirement, and that aspect of Count One is

dismissed without prejudice. In all other respects, the Motion is denied. The Court finds that

the exercise of personal jurisdiction over NMMC is proper, that venue lies in this judicial

district, and that federal subject matter jurisdiction is present.

DONE and ORDERED this 2nd day of December, 2005.

s/ WILLIAM H. STEELE 

UNITED STATES DISTRICT JUDGE

Case 1:05-cv-00499-WS-B Document 17 Filed 12/05/05 Page 20 of 20