Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_03-cv-06668/USCOURTS-caed-1_03-cv-06668-11/pdf.json

Nature of Suit Code: 362
Nature of Suit: Medical Malpractice
Cause of Action: 28:1331 Fed. Question: Medical Malpractice

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IN THE UNITED STATES DISTRICT COURT FOR THE

EASTERN DISTRICT OF CALIFORNIA

CHRISTINA ROMAR, a minor suing )

through her mother and legal )

representative, CORA ROMAR, )

)

Plaintiff, )

v. )

)

FRESNO COMMUNITY HOSPITAL )

AND MEDICAL CENTER, and )

DR. THOMAS MANSFIELD, )

)

Defendants. )

____________________________________)

CIV F 03-6668 AWI SMS

ORDER ON PLAINTIFF’S

MOTION FOR PARTIAL

SUMMARY JUDGMENT AND

THE HOSPITAL’S MOTION

FOR SUMMARY JUDGMENT

This case arises out of three presentations on December 10, 12 and 14, 2002, by minor

Plaintiff Christina Romar (“Christina”) to the emergency department of Defendant Fresno

Community Hospital (“FCH”). Initially Christina was diagnosed with an ear infection, but later

developed swelling around her eyes. On December 12 and 14, Christina was diagnosed as

having an allergic reaction. On December 17, 2002, Christina presented to Children’s Hospital,

where it was determined that she had a virulent bacterial infection. Christina’s course at

Children’s Hospital was lengthy and difficult because the infections spread. Christina was

eventually discharged but suffered permanent injury due to the bacterial processes. On

November 24, 2003, Christina, through her mother Cora Romar (“Cora”), brought suit against

FCH and Dr. Mansfield for violations of 42 U.S.C. § 1395dd (the Emergency Medical Treatment

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“PRDUMF” is “Plaintiff’s Response to Defendant’s Undisputed Material Facts.” 1

“DUMF” is “Defendant’s Undisputed Material Facts.” 2

Christina states that a sore throat was noted for this admission. From the Court’s review of the medical 3

records, at bates #000016 next to sore throat, there is the notation “+/-.” The same notation is found next to “fever”

on the same page. Since 99.5 is less than a full degree fever, the Court takes the notation to mean “more or less.”

2

and Active Labor Act (“EMTALA”)), and California law medical malpractice. Dr. Mansfield

has been granted summary judgment and is no longer a party to this suit. Both Christina and

FCH move for summary judgment. For the reasons that follow, the motions will be denied.

 FACTUAL BACKGROUND

On December10, 2002, Christina was brought to FCH by her daycare provider. See Cora

Deposition at 42:24-43:13. Christina’s mother, Cora, worked for FCH in the cafeteria. See id. at

8:9-9:1. Christina was taken to the ER because she had a fever. See id. at 40:3-7. From the

medical records, Christina had “cold symptoms” for several days, which appears to be

cough/congestion, fussiness, runny nose, and pulling at her ears. See Plaintiff’s Exhibit 1. 

Christina had a fever of 103, blood pressure of 134/94, a pulse of 108, respiration of 26, and

weight of 15 kg. See id.; PRDUMF No. 7. It was noted that Christina had tympanic membrane 1

erythema and loss of tympanic membrane landmarks. See Plaintiff’s Exhibit 1. Christina was

diagnosed with an ear infection (otitis media) and fever, given Amoxicillin , Tylenol, and

Pediacare, and discharged home. See Plaintiff’s Exhibit 1; DUMF No. 7; PRDUMF No. 7. 2

Christina returned to the ER on the morning of December 12, 2002, with a chief

complaint of peri-orbital bilateral swelling (swelling around both eyes) that had onset that day. 

See Plaintiff’s Exhibit 2. It was noted that Christina had a recent ear infection and had been to

the emergency room two days prior. See id. However, there does not appear to be an indication

of ear pulling, tympanic erythema, or continued loss of tympanic membrane landmarks. See id. 

The records indicate a temperature of 99.5, weight of 15 kg, respiration of 26, and possible sore

throat. See id. Christina was diagnosed as having a likely allergic reaction to Amoxicillin, was 3

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Not all of entries in the medical records are legible or decipherable to the Court. 4

The records also appear to indicate that Christina had been taking Tylenol. See Plaintiff’s Exhibit 3. 5

Christina indicates that the records show ear pain on December 14, 2002. See PRDUMF No. 9. However,

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the only notation of ear pain that the Court has found is at bates 000005 under the “Past History” section. See

Plaintiffs Exhibit 3. 

The second page of the Conditions Form is very similar to the first page, has five paragraphs, four of which 7

deal with insurance and financial matters and the fifth deals with consent to contact a patient’s employer. See

Gonzalez Declaration Exhibit A.

3

given decadron and Benadryl, told to stop the Amoxicillin, and to return later that night. See id. 

Christina was apparently prescribed Benadryl and Prelone. See id. PRDUMF No. 9. 4

Christina returned to FCH during the evening of December 14, 2002, again with a chief

complaint of eye swelling, but this time the swelling had moved over into her forehead. See

Plaintiff’s Exhibit 3; DUMF No. 9; PRDUMF No. 9. Christina’s temperature appears to have

been around 98 degrees (records unclear), her blood pressure was 124/94, her pulse was 132, her 5

respiration was 20, and she now weighed 16.5 kg. See Plaintiff’s Exhibit 3. It was also noted

that Christina had been lethargic, her eyes had a crusty discharge, that she had been to FCH on

December 10 and was given Amoxicillin, and had returned on December 12 and was given

Benadryl and told to stop the Amoxicillin. See id. Christina was again assessed as having an 6

allergic reaction to Amoxicillin. See id. Christina was told to continue taking Benadryl and

Prelone, return if her condition worsened, and to follow up with her primary physician. See id. 

FCH’s records for Christina’s admissions on December 10, 12, and 14 show that on none

of these presentations did Christina receive a complete blood count (“CBC”), a blood

differential, blood cultures, urine cultures, a CT scan, a sedimentation rate, or intravenous

antibiotics. See PUMF No. 1. Also, at each of these three presentations, Cora signed a

“Conditions of Admission or Service” form (hereinafter “Conditions Form”). See Gonzalez

Declaration Exhibit A. The Conditions Form is two pages, largely single spaced in 7

approximately 8 point font, and has large signature spaces on the bottom of both pages that take

up roughly one third of the page. See id. The third paragraph (out of seven) on the first page of

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There is a disputed regarding the results of the blood work done by Children’s Hospital on December 17, 8

2002. Cf. DUMF No. 10 with PRDUMF No. 10.

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the Conditions Form reads:

Legal Relationship Between Hospital and Physician: All physicians and

surgeons furnishing services to the patient, including the radiologist, pathologist,

anesthesiologist and the like are independent contractors with the patient and are

not employees or agents of the hospital. The patient is under the care and

supervision of his/her attending physician and it is the responsibility of the

hospital and its nursing staff to carry out the instructions of such physician. It is

the responsibility of the patient’s physician or surgeon to obtain the patient’s

informed consent, when required, for medical or surgical treatment, special

diagnostic or therapeutic procedures, or hospital services rendered the patient

under the general and special instructions of the physicians.

Id. (bold type and underlining in original). The Conditions Form’s signature block on both pages

reads in part that, “The undersigned certifies that he/she has read the foregoing, received a copy

thereof, and is . . . the patient’s legal representative . . . .” Id.

On December 17, 2002, Christina was initially taken to Pediatrics Plus, and was later

taken to Children’s Hospital in Madera. See Cora Deposition at 99:1-18, 101:9-25. Christina

initially appeared non-toxic, but did have a fever of 105 degrees and diarrhea. See Martin

Declaration at ¶ 12; Weiss Declaration at ¶ 15. However, a CT scan and blood work later

revealed a virulent bacterial infection, which eventually spread through Christina’s body. See 8

Plaintiff’s Opposition at 3:8-16. Christina spent weeks in the hospital undergoing various

treatments, including surgeries, to combat the infectious processes afflicting her. See id. 

Christina eventually recovered and was discharged, but has suffered permanent injury because of

the infection and related treatment and complications. See id. 

During discovery, Christina requested that FCH produce “the emergency room records of

all patients treated for a fever, possible infection, or other condition you deem similar to

plaintiff’s in December 2002.” See PUMF No. 2; Plaintiff’s Exhibit 5. In response, FCH

objected that the terms “fever,” “possible infection,” and “other condition you deem similar to

plaintiff’s in December 2002” were vague and ambiguous. See Plaintiff’s Exhibit 5. FCH made

several other objections to the request for production. See id. However, FCH did respond, but

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without waiving objections, that it would “search for patients seen in the emergency department

within the 12 months prior to Christina Romar’s subject visits who were demonstrating the same

composite of symptoms as [Christina] on her separate visits to that emergency department in

December 2002 upon receipt of the required assurances, etc.; records regarding emergency

department visits for patients with the same composite of symptoms will then be de-identified as

required by law and produced.” Id.; see also PUMF No. 3. A motion to compel the disclosure of

patient records was filed by Christina on June 14, 2005, with Magistrate Judge Snyder. See

Court’s Docket Doc. No. 42. FCH filed an opposition to the motion, see id. at No. 45, and a

hearing was held on July 14, 2005. See id. at No. 49. Magistrate Judge Snyder granted in part

and denied in part Christina’s motion to compel. See id. at No. 56.

As part of her ruling, Magistrate Judge Snyder specifically found, “In anticipation of

Plaintiff’s motion and this order, [FCH] has already performed extensive work identifying,

pulling, reviewing, redacting, and copying potentially relevant, third-party patient, emergency

visit records for patients aged 22 months old to one [73 months] at the time of their visits

between December 1, 2001, to December 31, 2002.” Court’s Docket Doc No. 56 at p.2 ¶ 8

(emphasis added). Magistrate Judge Snyder limited the records that FCH was required to

produce to patients aged 22 months to 73 months of age. See id. at pp. 2-3 ¶ 2. Magistrate Judge

Snyder then in part held:

As [FCH] has already spent hundreds of man-hours and thousands of dollars to

identify potentially relevant emergency visits, the production of third-party patient

records under this order will be limited to the emergency visit records that [FCH]

has already identified in anticipation of this order;

. . . . . . .

As to the emergency visit records not included above, Plaintiff’s motion to

compel is denied without prejudice. If after review of the records ordered to be

produced herein should Plaintiff’s experts . . . believe that additional third-party,

toddler records are needed, Plaintiff shall prepare a new noticed motion supported

by a declaration from her experts regarding what specific records in addition to

the records previously produced are necessary to his/her analysis of this action and

why they are necessary. Further, all parties will be required to brief the issues of

the meaning of “similarly symptomed” under an EMTALA disparate screening

analysis and who should bear an additional production costs.

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Dr. Weiss also specifically opined that none of the nurses or employees of FCH or any of the 9

practitioners’s treatment of Christina breached the standard of care and nothing that any medical professional did

caused any harm to Christina. See Weiss Declaration at ¶¶ 12-14.

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Id. at p. 3 ¶¶ 3, 6 (emphasis added).

FCH produced 287 patient records (hereinafter “the 287 records”) in compliance with

Magistrate Judge Snyder’s order. See DRPUMF No. 5. Of the 287 records, Christina has

specially identified the records of 30 third party patients (hereinafter “the 30 records”). Christina

contends that these patients are similarly symptomed to herself, yet they received superior

screenings. 

Declaration of Dr. Eric Weiss

Dr. Weiss is FCH’s emergency medicine expert. In support of FCH’s motion for

summary judgment, Dr. Weiss declares:

9. Christina Romar was seen at FCH’s emergency department on December

10, December 12, and December 14, 2002. On each of these occasions she was

seen promptly by nurses and practitioners, received appropriate nursing

assessments, received appropriate screening examinations which found acute

symptoms, was diagnosed, and received treatment. . . . Nothing regarding the

subject emergency department visits indicates a violation of EMTALA’s

screening requirement.

10. Documentation in her medical records reveals that Christina Romar did

not have an emergency medical condition while at FCH in December 2002. 

Based upon the symptoms Christina presented and the impressions and findings of

the practitioners, there was no role for diagnostic studies as part of her screening

or a need for treatment different than that which was rendered. No diagnostic

studies were needed on December 10, December 12, or December 14 to comply

with EMTALA’s screening requirement.

11. Christina Romar was examined, diagnosed, and treated on each of her

December 2002 visits to FCH’s emergency department. There was no breach of

the standard of care on any of the visits.

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. . . . . . . . .

17. In addition, to the above, Christina Romar was screened no different than

other similar patients who were perceived to have the symptoms that Christina

displayed on anyone of her December 2002 FCH emergency department visits.

18. I received hundreds of medical records pertaining to other patients seen at

FCH’s emergency department. I am informed and believe that these 287 thirdparty patient visit records were produced pursuant to an order issued by

Magistrate Snyder in this action. Further, my understanding is that these records

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were redacted in accordance with HIPAA requirements, but are all of patients

aged 22 months-old to one month after their sixth birthdays at the time of their

emergency department visits between December 1, 2001 and December 31, 2002. 

As the various stages of development can lead to different screening and treatment

concerns, patients in the toddler stage of development are the relevant population

when comparing them to Christina Romar in December 2002. 

19. I have reviewed the third-party patient visit records and have found no

support for a claim of disparate screening. None of the hundreds of visits reveal a

similarly symptomed patient who was screened differently than Christina Romar. 

The medical screening examinations received by Christina Romar and other

similarly symptomed patients were fully compliant with the requirements of

EMTALA. There was no EMTALA screening violation.

Weiss Declaration at ¶¶ 9-11, 17-19.

Declaration and Deposition of Dr. Peggy Goldman Dated August 9, 2006

Dr. Goldman is Christina’s emergency medicine and infectious diseases expert. In

support of summary judgment, Dr. Goldman submitted a declaration which states in part:

3. I have reviewed and considered the records of plaintiff’s three emergency

admissions [at FCH] between December 10 and December 14, 2002. I have also

reviewed and considered the records provided by [FCH] as to the emergency

department that they deem similarly situated to plaintiff.

4. Based upon my review and consideration of these case materials in this

action, it is my opinion that the screening examinations plaintiff received at

[FCH] on December 10, 12, and 14, 2002, were inappropriate and therefore not in

compliance with [EMTALA]. Specifically, the above referenced records show

that numerous similarly situated patients received screening examinations that

were, in crucial respects, more extensive and superior to those received by the

plaintiff upon her three emergency admissions. 

5. Indeed, all of the thirty similarly situated patients whose treatment is

reflected in the table that also accompanies this declaration received one or more

of the screening measures that I identified in my declaration and report as required

as to plaintiff: a CBC, blood differential, blood and urine cultures, a CT scan,

sedimentation rate, and/or intravenous antibiotics. Therefore, it is apparent that

plaintiff did not receive the screening examination to which she was entitled under

EMTALA, i.e. the same screening examination that any and all other similarly

situated patients would have received. 

Goldman Declaration at ¶¶ 3-5. 

Attached as part of Dr. Goldman’s declaration is a summary of the 30 records of patients

who received additional tests as part of their emergency department presentation at FCH. See

Plaintiff’s Exhibit 6, Attachment No. 3. This attachment was prepared by Christina’s counsel

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includes a patient’s chief complaints and the clinical impression. 

In her deposition, Dr. Goldman testified in part:

There can never be an identical match because patients are different, so close

enough to warrant the same approach by a physician, I guess would be the criteria

that we could use, and there are some. Basically, fever is the essential portion. 

That’s the essential feature that is of greatest concern to an emergency physician

when seeing a child. 

The other symptoms can be variable depending on how important a part of the

primary problem they are. So, for example, with febrile illnesses, what you’re

concerned about is making a diagnosis of an infection and emesis can be a

variable presentation of an infection. So can fever, but in general fever is more

consistently present than emesis when there’s been an infection present. 

So if we use a functional definition, which is when you are concerned in a child

that a serious infection can be present or an emergency medical condition such as

an infection can be present, I would be looking for fever, vomiting, respiratory

symptoms, pulling at the ears, cold cough, diarrhea, pain any where in the body. 

Any of these areas I think would fall into the functional definition of trying to

separate out a child who has an emergency medical condition who has an

infection. 

. . . . . 

There is no one on this list that is exactly the same as Christina because the way

that Christina presented was with serious bilateral swelling around her eyes in the

setting of having had a fever two days before and otitis media. So in that clinical

context, orbital cellulitis which can be a life-threatening medical emergency needs

to be ruled out and there’s no patient on this list that’s exactly like her. 

However, the patients on this list are similar to her in the sense that they are all

patients who could have an emergency medical condition that is an infection. 

And in that sense, what the doctor – what the emergency medicine doctor is trying

to do is to separate out those patients with an emergency medical condition due to

an infection from those who don’t, and also trying to determine how serious that

condition can be. 

So in terms of using that definition as similar in terms of presentation which is

taking the essence of what the doctor is trying to do with the visit, all of these

patients are similar, although not exactly like her, and they have additional tests

performed to rule out an emergency medical condition that is life-threatening or

serious . . . And those things would include chest x-rays, IV antibiotics, blood

counts, unspecified labs and other interventions.

Goldman Deposition at pp. 34-35, 60-61. Dr. Goldman also indicated that she did not review

each of the individual 287 patient records produced by FCH, but did review 3 of the 30 patient

records in detail, and “flipped through” the remaining 27. See id. at 21:22-22:9, 27:12-25, 72:14-

73:11. Also, Dr. Goldman testified that no malpractice occurred on December 10, 2002. See id.

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at 31:20-32:6. 

 SUMMARY JUDGMENT STANDARD

Summary judgment is appropriate when it is demonstrated that there exists no genuine

issue as to any material fact, and that the moving party is entitled to judgment as a matter of law. 

Fed. R. Civ. P. 56(c); Adickes v. S.H. Kress & Co., 398 U.S. 144, 157 (1970); Fortyune v.

American Multi-Cinema, Inc., 364 F.3d 1075, 1080 (9th Cir. 2004); Jung v. FMC Corp., 755

F.2d 708, 710 (9th Cir. 1985). Where summary judgment requires the court to apply law to

undisputed facts, it is a mixed question of law and fact. See Sousa v.Unilab Corp. Class II (NonExempt) Members Group Benefit Plan, 252 F. Supp.2d 1046, 1049 (E.D. Cal. 2002). Where the

case turns on a mixed question of law and fact and the only dispute relates to the legal

significance of the undisputed facts, the controversy for trial collapses into a question of law that

is appropriate for disposition on summary judgment. See Union Sch. Dist. v. Smith, 15 F.3d

1519, 1523 (9th Cir. 1994); Sousa, 252 F.Supp.2d at 1049.

Under summary judgment practice, the moving party always bears the initial

responsibility of informing the district court of the basis for its motion, and

identifying those portions of “the pleadings, depositions, answers to

interrogatories, and admissions on file, together with the affidavits, if any,” which

it believes demonstrate the absence of a genuine issue of material fact.

Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). “[W]here the nonmoving party will bear the

burden of proof at trial on a dispositive issue, a summary judgment motion may properly be made

in reliance solely on the ‘pleadings, depositions, answers to interrogatories, and admissions on

file.’” Id. Indeed, summary judgment should be entered, after adequate time for discovery and

upon motion, against a party who fails to make a showing sufficient to establish the existence of

an element essential to that party’s case, and on which that party will bear the burden of proof at

trial. Id. at 322. “[A] complete failure of proof concerning an essential element of the

nonmoving party’s case necessarily renders all other facts immaterial.” Id. In such a

circumstance, summary judgment should be granted, “so long as whatever is before the district

court demonstrates that the standard for entry of summary judgment, as set forth in Rule 56(c), is

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satisfied.” Id. at 323.

If a moving party fails to carry its burden of production, then “the non-moving party has

no obligation to produce anything, even if the non-moving party would have the ultimate burden

of persuasion.” Nissan Fire & Marine Ins. Co. v. Fritz Companies, 210 F.3d 1099, 1102-03 (9th

Cir. 2000). If the moving party meets it initial burden, the burden then shifts to the opposing

party to establish that a genuine issue as to any material fact actually exists. See Matsushita Elec.

Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986); Nissan Fire & Marine Ins., 210 F.3d

at 1103; Nolan v. Cleland, 686 F.2d 806, 812 (9th Cir. 1982); Ruffin v. County of Los Angeles,

607 F.2d 1276, 1280 (9th Cir. 1979). A fact is “material” if it might affect the outcome of the

suit under the governing law. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248-49 (1986);

Thrifty Oil Co. v. Bank of America Nat’l Trust & Savings Assn, 322 F.3d 1039, 1046 (9th Cir.

2002). A “genuine issue of material fact” arises when the evidence is such that a reasonable jury

could return a verdict for the nonmoving party. See Anderson, 477 U.S. at 248-49; Thrifty Oil,

322 F.3d at 1046. 

In attempting to establish the existence of a factual dispute, the opposing party may not

rely upon the mere allegations or denials of its pleadings, but is required to tender evidence of

specific facts in the form of affidavits, and/or admissible discovery material, in support of its

contention that the dispute exists. Rule 56(e); Matsushita, 475 U.S. at 586 n.11; First Nat'l Bank,

391 U.S. at 289; Willis v. Pacific Maritime Ass’n, 244 F.3d 675, 682 (9th Cir. 2001). However,

the opposing party need not establish a material issue of fact conclusively in its favor. It is

sufficient that “the claimed factual dispute be shown to require a jury or judge to resolve the

parties’ differing versions of the truth at trial.” First Nat'l Bank, 391 U.S. at 290; Hopper v. City

of Pasco, 248 F.3d 1067, 1087 (9th Cir. 2001). Thus, the “purpose of summary judgment is to

‘pierce the pleadings and to assess the proof in order to see whether there is a genuine need for

trial.’” Matsushita, 475 U.S. at 587; Mende v. Dun & Bradstreet, Inc., 650 F.2d 129, 132 (9th

Cir. 1982).

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In resolving a summary judgment motion, the court examines the pleadings, depositions,

answers to interrogatories, and admissions on file, together with the affidavits, if any. See Rule

56(c); Fortyune, 364 F.3d at 1079-80. The court has the discretion in appropriate circumstances

to consider materials that are not properly brought to its attention, but the court is not required to

examine the entire file for evidence establishing a genuine issue of material fact where the

evidence is not set forth in the opposing papers with adequate references. See Southern Cal. Gas

Co. v. City of Santa Ana, 336 F.3d 885, 889 (9th Cir. 2003); Carmen v. San Francisco Unified

Sch. Dist., 237 F.3d 1026, 1031 (9th Cir. 2001). The evidence of the opposing party is to be

believed, and all reasonable inferences that may be drawn from the facts placed before the court

must be drawn in favor of the opposing party. See Anderson, 477 U.S. at 255; Matsushita, 475

U.S. at 587; Stegall v. Citadel Broad, Inc., 350 F.3d 1061, 1065 (9th Cir. 2003). Nevertheless,

inferences are not drawn out of the air, and it is the opposing party’s obligation to produce a

factual predicate from which the inference may be drawn. See Mayweathers v. Terhune, 328

F.Supp.2d 1086, 1092-93 (E.D. Cal. 2004); UMG Recordings, Inc. v. Sinnott, 300 F.Supp.2d

993, 997 (E.D. Cal. 2004). “A genuine issue of material fact does not spring into being simply

because a litigant claims that one exists or promises to produce admissible evidence at trial.” Del

Carmen Guadalupe v. Agosto, 299 F.3d 15, 23 (1st Cir. 2002); see also Bryant v. Adventist

Health System/West, 289 F.3d 1162, 1167 (9th Cir. 2002).

Finally, to demonstrate a genuine issue, the opposing party “must do more than simply

show that there is some metaphysical doubt as to the material facts. . . . Where the record taken

as a whole could not lead a rational trier of fact to find for the nonmoving party, there is no

‘genuine issue for trial.’” Matsushita, 475 U.S. at 587 (citation omitted). If the nonmoving party

fails to produce evidence sufficient to create a genuine issue of material fact, the moving party is

entitled to summary judgment. See Nissan Fire & Marine, 210 F.3d at 1103.

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 CHRISTINA’S EMTALA CLAIM

Plaintiff’s Arguments

Christina argues that she is entitled to summary judgment on the issue of liability on her

EMTALA claim because the record shows that 30 other similarly symptomed patients received

superior screenings to Christina. Dr. Goldman’s declaration confirms that these 30 patients

received additional tests and thus, received superior screenings in comparison to Christina. 

Importantly, FCH itself selected and produced the 287 patient records from which the subset of

30 patients was taken. In producing these documents, FCH has admitted their authenticity and

responsiveness to Christina’s request. See Maljack Prods., Inc. v. GoodTimes Home Video

Corp., 81 F.3d 881, 889 n.12 (9th Cir. 1996); Snyder v. Whittaker Corp., 839 F.2d 1085, 1089

(5th Cir. 1988). Given Dr. Goldman’s opinions and FCH’s own production of these records,

there is no doubt that Christina received disparate screening, and summary judgment in her favor

on liability is warranted.

With respect to FCH’s motion, that motion is based on a faulty assumption. That is, FCH

incorrectly believes that Christina must provide evidence that patients with symptoms identical to

her own were screened materially different than she was. However, it is not required that

patients with identical symptoms be found, instead evidence must be presented that at least one

patient with a similar presentation was not screened identically. There are 30 other patients with

similar presentations who received medical screening exams superior to Christina in that they

received tests that would have helped to identify Christina’s virulent bacterial infection. Dr.

Goldman testified that the 30 records revealed conditions that, while not identical to Christina’s,

were similar in that they all exhibited symptoms that indicated a possible bacterial infection and

they all received additional tests that would likely have detected bacterial infections. Summary

judgment in favor of FCH must be denied. 

Defendant’s Arguments

FCH argues that it produced records that are “potentially relevant.” It did not produce

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records of patients that it deemed was “similarly symptomed” or similarly situated. Further, FCH

does not dispute the authenticity of the records. However, admitting authenticity of the records is

not the same as admitting that the records are all of patients who are similarly symptomed. FCH

has never deemed the 287 or the 30 identified by Christina as being similarly symptomed to

Christina. Further, of the 30 patients identified by Christina, the only patients who received

blood tests, urinalysis, x-ray or other screening procedures had symptoms in addition to

Christina’s, including vomiting, diarrhea, wheezing, and rales. Further, Christina and her

counsel represented to FCH and the Court that not one of the 287 records produced by FCH

reflected a patient with Christina’s symptoms who received a materially different screening. Dr.

Goldman has also admitted that there is not a patient with Christina’s exact symptoms. Finally,

the summary of the 30 patient records was prepared by Christina’s counsel, and the summary is

inaccurate in that it contains omissions and misrepresents. 

With respect to its own motion for summary judgment, FCH argues that there is no

evidence of disparate screening. A disparate screening requires that patients presenting with the

same symptoms were actually screened differently than plaintiff. There is no evidence that any

patient presented with the same symptoms as plaintiff, and even Dr. Goldman so admitted and

acknowledged that plaintiff’s presentation was unusual. Since there is no evidence of a patient

who presented with “symptoms identical to plaintiff,” summary judgment on the EMTALA

claim is appropriate.

Legal Standard

EMTALA is also known as the “Patient Anti-Dumping Act” and reflects the concern that

“hospitals were dumping patients who could not pay for care, either by refusing to provide

emergency treatment to these patients or by transferring [them] to other hospitals before [their]

conditions stabilized.” Jackson v. East Bay Hospital, 246 F.3d 1248, 1254 (9th Cir. 2001). 

Under EMTALA: 

[I]f any individual . . . comes to the emergency department [of a hospital that

participates in the Medicare program] and a request is made on the individual’s

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behalf for examination or treatment for a medical condition, the hospital must

provide for an appropriate medical screening examination within the capability of

the hospital’s emergency department, including ancillary services routinely

available to the emergency department, to determine whether or not an emergency

medical condition . . . exists. 

42 U.S.C. § 1395dd(a); see also Bryant v. Adventist Health System/West, 289 F.3d 1162, 1165

(9th Cir. 2002). An “emergency medical condition” is a condition “manifesting itself by acute

symptoms of sufficient severity (including severe pain) such that the absence of immediate

medical attention could reasonably be expected to result in -- (I) the placing of the health of the

individual . . . in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious

dysfunction of any bodily organ or part . . . .” 42 U.S.C. § 1395dd(1)(A); Jackson, 246 F.3d at

1254. 

“EMTALA imposes two duties on hospital emergency rooms: a duty to screen a patient

for an emergency medical condition, and, once an emergency condition is found, a duty to

stabilize the patient before transferring or discharging him.” Baker v. Adventist Health, Inc., 260

F.3d 987, 992 (9th Cir. 2001); see 42 U.S.C. § 1395dd(a), (b). A hospital meets its obligation to

provide an “appropriate medical screening” under EMTALA when it:

provides a patient with an examination comparable to the one offered to other

patients presenting similar symptoms, unless the examination is so cursory that it

is not designed to identify acute and severe symptoms that alert the physician of

the need for immediate medical attention to prevent serious bodily injury.

Baker, 260 F.3d at 995; Jackson, 246 F.3d at 1256; Eberhardt v. City of Los Angeles, 62 F.3d

1253, 1258-59 (9th Cir. 1995); see also Correa v. Hospital San Francisco, 69 F.3d 1184, 1192

(1st Cir. 1995). “The essence of this requirement is that there be some screening procedure, and

that it be administered even-handedly.” Correa, 69 F.3d at 1192. EMTALA does not require

hospitals to provide identical screening to patients presenting with different symptoms and does

not require hospitals to provide screenings that are beyond their capabilities. Baker, 260 F.3d at

995; Hoffman v. Tonnemacher, 425 F.Supp.2d 1120, 1130 (E.D. Cal. 2006). 

Conversely, a failure to provide any screening, the provision of a “cursory screening” that

amounts to no screening at all in that it is not designed to detect acute and severe symptoms, and

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disparate treatment such as the hospital’s failure to follow its own screening procedures, may all

constitute a breach of the hospital’s duty to provide an appropriate medical screening to a patient

seeking emergency treatment. See 42 U.S.C. § 1395dd(a); Bryant, 289 F.3d at 1166; Baker, 260

F.3d at 994-95; Jackson, 246 F.3d at 1256; Correa, 69 F.3d at 1192-93; Eberhardt, 62 F.3d at

1258-59. 

To recover for disparate treatment, the plaintiff must proffer evidence “sufficient to

support a finding that she received materially different screening than that provided to others in

her condition. It is not enough to proffer expert testimony as to what treatment should have been

provided to a patient in the plaintiff’s position.” Reynolds v. Mainegeneral Health, 218 F.3d 78,

84 (1st Cir. 2000). “It is the plaintiff’s burden to show that the hospital treated her differently

from other patients; a hospital is not required to show that it had a uniform screening procedure.”

Marshall v. East Carroll Parish Hosp. Serv., 134 F.3d 319, 323-24 (5th Cir. 1998). However, a

de minimus deviation from a hospital’s standard screening policy is insufficient to establish a

violation of EMTALA. Repp v. Anadarko Municipal Hospital, 43 F.3d 519, 523 (10th Cir.

1994); see also Vargas by & through Gallardo v. Del Puerto Hosp., 98 F.3d 1202, 1205 (9th Cir.

1996). Further, where a claim of inappropriate screening is based on a “failure to provide certain

diagnostic tests,” a plaintiff “must at least address whether the hospital was capable of

performing such tests.” Agosto, 299 F.3d at 22. However, negligence in the screening process

or the provision of a merely faulty screening, as opposed to refusing to screen or disparate

screening, does not violate EMTALA, although it may implicate state malpractice law. See

Agosto, 299 F.3d at 21; Marshall, 134 F.3d at 323-24; Correa, 69 F.3d at 1192-93; see also

Jackson, 246 F.3d at 1255-56.

Discussion

With respect to Christina’s contention that FCH has deemed the 287 patient records, and

in particular the 30 records, to be similarly symptomed to Christina, the Court cannot agree. 

Christina’s requests for production included one request that in part requested the redacted

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The Court agrees that documents produced by a party in discovery are deemed authentic when offered by 10

the party-opponent. See Orr v. Bank of Am., 285 F.3d 764, 777 n.20 (9th Cir. 2002); Maljack Prods., 81 F.3d at 889

n.12; Snyder, 839 F.2d at 1089. “Authentication is a condition precedent to admissibility, and this condition is

satisfied by evidence sufficient to support a finding that the matter in question is what its proponent claims.” Orr,

285 F.3d at 773 (quoting Fed. R. Evid. 901). Authentication is not at issue since FCH admits that the 287 patient

records are medical records, in addition to having produced the records now offered by Christina.

Definition of “similar” taken from Merriam Webster On Line Dictionary (www.m-w.com). 11

16

records of any patients FCH deemed to have similar symptoms to Christina. However,

objections were made to that request and a motion to compel had to be filed and heard. The

resolution of the motion to compel, and thus the request for production, required FCH to produce

records that it had already identified as “potentially relevant.” See Court’s Docket Doc. No. 56 at

p. 3, ¶ 3. Thus, when FCH complied with the order on the motion to compel, and therefore the

request for production, it produced 287 “potentially relevant” records. “Potentially relevant” is

not the same as “similarly symptomed.” Moreover, the order on the motion to compel itself does

not contemplate settling the issue of similarly symptomed. The last sentence of the last

paragraph states that the parties “will be required to brief the issues of the meaning of ‘similarly

symptomed’ under an EMTALA disparate screening analysis . . . .” Id. at p.3, ¶ 6. The issue of 

“similarly symptomed” required further briefing and obviously had not been resolved by the

motion to compel, which was the mechanism for Christina obtaining the 287 records. Thus, the

287 records produced by FCH are “potentially relevant” only, and by their production, FCH has

not admitted that these patients are all “similarly symptomed” to Christina.10

Production of the 287 records aside, there is a disagreement between the parties regarding

what constitutes “similarly situated” or “similarly symptomed” patients. From the moving and

opposition papers, FCH’s position is that “identical symptoms” are required. The Court does not

agree with this view of EMTALA. The Ninth Circuit requires a plaintiff to receive “an

examination comparable to the one offered to other patients presenting similar symptoms.” 

Baker, 260 F.3d at 995 (emphasis added); Jackson, 246 F.3d at 1256. “Similar” means “having

characteristics in common . . . alike in substance or essentials,” it is not the same as “identical.” 11

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Thus, to show a disparate screening, Christina is not required to identify patients who are

identically symptomed to her, rather, she need only identify patients with “similar symptoms.” 

Since “similar” is not the same as “identical,” similarly symptomed or similarly situated

patients will not necessarily have identical symptoms. The question then becomes how similar to

Christina do other patients need to be in order to be considered “similarly symptomed” or

“similarly situated.” Both parties have cited Hoffman v. Tonnemacher. In Hoffman, the plaintiff

alleged inter alia that she had received a disparate screening. See Hoffman, 425 F.Supp.2d at

1135-37. To show disparate screening, Hoffman relied on the deposition testimony of Dr.

Tonnemacher. See id. Dr. Tonnemacher had indicated that, in the last 3 years, he had ordered

blood cultures on approximately six non-elderly patients whom he suspected as having a

bacterial infection (Hoffman had a bacterial infection). See id. at 1136-37. However, Dr.

Tonnemacher testified that the six patients had open sores, cellulitis, erythema, and/or possibly a

methecillin resistant bacteria, that Hoffman had none of these conditions, and that there was

nothing about Hoffman’s presentation that indicated a need for blood tests. See id. This court

recognized that EMTALA does not require differently symptomed patients to receive the same

screening, and then held that, since “Hoffman did not have the same ‘dispositive’ symptoms as

the six other patients, as explained by Dr. Tonnemacher, EMTALA did not mandate that

Hoffman receive the same treatment/screening as the other six.” Id. at 1137. The six patients

had different key symptoms and thus, were not in a similar condition as Hoffman, see Jackson,

246 F.3d at 1256; Reynolds, 218 F.3d at 84, that is, there was no showing that Hoffman was

similarly situated to Dr. Tonnemacher’s other six patients. See Hoffman, 425 F.Supp.2d at 1143.

The evidence in this case is different from the evidence presented in Hoffman. The only

testimony in Hoffman about the allegedly similarly symptomed six patients was uncontradicted

testimony from Dr. Tonnemacher himself. See id. at 1135-37. Dr. Tonnemacher testified that

there were additional symptoms that the six patients had, but that Hoffman did not, and that it

was the presence of those particular or peculiar symptoms that made the six patients materially

different from Hoffman. The six patients had key or dispositive symptoms that were different

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Dr. Goldman’s declaration and deposition are somewhat ambiguous as to whether she reached her own

12

independent conclusion that the 30 records are similarly situated to Christina, or whether she simply relied on the

fact that FCH produced records and believed that FCH itself decided who was similarly symptomed. See Goldman

Declaration at ¶ 2; Goldman Deposition at pp. 29-35. At oral argument, the Court requested clarification from

Christina’s counsel. Christina’s counsel replied that Dr. Goldman was not relying only on the fact that FCH

produced the records. Resolving the ambiguities in Christina’s favor, and given Christina’s counsel’s

representations, the Court assumes that Dr. Goldman has concluded, and concluded not solely on the basis that FCH

produced the 287 records, that the 30 records are patients who are similarly symptomed to Christina. 

18

from Hoffman, and those symptoms caused the additional diagnostic tests to be utilized. See id.

at 1136-37. In this case, by contrast, there is contradictory medical testimony. Dr. Weiss has

reviewed all of the 287 records and is of the opinion that none reflect a patient who was similarly

symptomed to Christina and who received a better screening than Christina. See Weiss

Declaration at ¶ 19. Dr. Goldman, on the other hand, is of the opinion that the 30 records reveal

similarly symptomed patients who received superior screenings compared to Christina. See

Goldman Declaration at ¶ 5; Goldman Deposition at pp. 29-35, 60-61. Dr. Goldman’s opinion 12

is based on classifying Christina and the 30 records as reflecting patients who possibly had

bacterial infections. Dr. Goldman’s key symptom for Christina appears to be fever with other

cold symptoms, including a prior diagnosed otitis media. See Goldman Deposition at pp. 34-35,

60-61. At oral argument, Christina characterized Dr. Goldman as identifying fever and cold

symptoms as the key or dispositive symptoms. The periorbital swelling was identified as

Christina’s chief complaints in the medical records for December 12 and 14, and, from a lay

perspective, would appear to be the key symptom, but Dr. Goldman’s expert medical testimony

suggests that the periorbital swelling is not the key or dispositive symptom. Although it does not

appear that all 30 records actually reflect Dr. Goldman’s understanding of a similarly symptomed

patient, e.g. Record 111 (patient had an insect bite that apparently caused eye swelling and had

no fever), some records do fit her opinion. E.g. Records 24, 205. Nevertheless, there is a

conflict of opinions between Dr. Goldman and Dr. Weiss. A jury will determine what weight

and credibility to give to Dr. Goldman’s and Dr. Weiss’s respective opinions, and will resolve

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FCH has objected to Attachment 3 of Plaintiff’s Exhibit 6 (“Attachment 3”), which is a summary of the 30 13

records. The summary consists of a record number, priority status, chief complaint, clinical impression, and

ancillary services utilized. FCH essentially objects that the summary was prepared by Christina’s counsel and is

inaccurate and incomplete. Christina has submitted the actual records of all 30 patients. The information contained

in Attachment 3 generally appears to be accurate, although there are exceptions. E.g. Record 87 (summary states

that patient 87 had fever, but actual record shows that fever was denied and the recorded temperature was less than

98.6). Attachment 3 lists chief complaints, which corresponds to a specific section of a particular form within the

medical records. FCH’s objections that not all symptoms are identified also appears to be correct, but the additional

symptoms identified by FCH generally are found in other parts of the medical records. Thus, the information that is

summarized in Attachment 3 is generally accurate for what it contains, but is not necessarily complete in terms of

identifying all symptoms found within the medical records. Since most of the information actually contained in

Attachment 3 appears to be correct, and many of the actual records themselves, apart from the summaries embodied

in Attachment 3, appear to fall within Dr. Goldman’s opinions, Attachment 3 in and of itself will not change the

result of this motion. Accordingly, for purposes of this motion, FCH’s objections are overruled. 

However, to the extent that Dr. Goldman relies on Attachment 3, any inaccuracies or incompleteness will

likely affect the weight and not the admissibility of Dr. Goldman’s opinions and are a proper subject for cross

examination. See Bergen v. F/V St. Patrick, 816 F.2d 1345, 1352 n.5 (9th Cir. 1987) (noting that weaknesses in the

underpinnings of an expert’s conclusion go to the weight of the evidence and may be explored during cross

examination). Further, there is a dispute whether some of the 30 patients received lab work or lab orders. This

dispute will have to be clarified through competent testimony explaining the records and the entries made. 

FCH relies on the Vickers case to argue that, for EMTALA, the proper comparison group is between a

14

plaintiff and patients who are perceived to have the same condition; not between patients who have what the plaintiff

eventually turns out to actually have. See Vickers v. Nash General Hosp., Inc., 78 F.3d 139, 144-45 (4th Cir. 1995). 

The test adopted by the Ninth Circuit uses the term “symptoms” rather than the term “condition.” See Baker, 260

F.3d at 995; Jackson, 246 F.3d at 1256. The term “condition” can be used in reference to symptoms, but “condition”

can also be used in reference to a diagnosis. As the Court understands the Ninth Circuit cases, disparate screening

claims are evaluated either by comparing a plaintiff to a hospital’s express guidelines or by comparing a plaintiff to

what amounts to a hospital’s “de facto” guidelines, which are in turn found by comparing the screenings received by

patients who had similar symptoms to the plaintiff. When a plaintiff’s symptoms are sufficiently similar to other

patients, the plaintiff and the other patients may be said to be in a similar condition. Cf. Jackson, 246 F.3d at 1256;

Reynolds, 218 F.3d at 84. In the absence of further clarification by the Ninth Circuit, the test for disparate screening

is based on patients with similar symptoms, not similar diagnoses. See Baker, 260 F.3d at 995; Jackson, 246 F.3d at

1256. 

19

what symptoms are key, whether the 30 records are sufficiently similar, and whether Christina 13

was disparately screened. Both Christina and FCH’s motions for summary judgment on 14

Christina’s EMTALA claim are denied.

CHRISTINA’S MEDICAL MALPRACTICE CLAIM

Defendant’s Argument

FCH’s nursing care expert, Nurse Bernadette Martin, has opined that none of FCH’s

nursing staff breached the standard of care. Neither plaintiff nor Dr. Goldman have identified

specific employees who were negligent. Dr. Goldman’s criticisms relate to the medical

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practitioners who screened, diagnosed, and treated plaintiff on December 12 and 14; she does not

criticize the nurses or other hospital employees. Although the complaint does not allege agency,

it is anticipated that plaintiff may rely on some form of agency theory. Because California

prohibits the corporate practice of medicine, FCH does not employee anyone to practice

medicine, including nurse practitioners, physician assistants, and physicians. Further, through a

conditions of admission and services form, FCH informs patients that FCH only provides general

nursing care and does not employ or exist in any agency relationship with the medical

practitioners. Cora received and signed this form on each of the three admissions to FCH. 

Finally, even if FCH is liable for the alleged breaches, there is insufficient evidence that

the breaches, to a medical probability, caused harm to plaintiff. Nurse Martin opines that nothing

that the nursing staff did caused injury, and Dr. Weiss opines that, even if some of the tests had

been performed, those tests would not have revealed the infection or caused plaintiff to be treated

differently. 

Plaintiff’s Opposition

Dr. Goldman identified conduct on December 12 and 14 that breached the applicable

standard of care, specifically that the standard of care required Christina to receive various

ancillary laboratory tests, the administration of intravenous antibiotics, a consultation with a

specialist, and a replacement antibiotic for the Amoxicillin. See Goldman Deposition at pp. 41-

42, 49-51, 63.

FCH is really arguing that it is not responsible for the acts of those who provided care to

Christina based on the boilerplate recitations of a form. However, Cora has declared that she is

minimally educated, does not know what an “independent contractor” is, did not have the

documents explained to her before signing, and felt that she had to sign the documents as a

condition of the emergency treatment she thought Christina immediately required. Cora was

likely required to sign the documents only after the care had been rendered. Also, Cora sought

emergency care at FCH in the first instance and had no preexisting relationship with any

physician at FCH. Under Mejia, there is an issue as to ostensible agency and summary judgment

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is inappropriate unless the evidence conclusively shows that Christina should have known that

the treating physician was not an agent of the hospital. Also, courts scrutinize and strike down

agreements for medical treatment that seek to relieve a hospital of liability. See Tunkl v. Regents

of University of Cal., 60 Cal.2d 92 (Cal. 1963). Finally, FCH’s attack on the complaint is

untimely, but in any event, the complaint alleges that Christina went to FCH seeking emergency

care, she was in need of immediate medical attention on all occasions, that FCH was a medical

provider who provided Christina with emergency care, that FCH provided substandard medical

treatment, which under applicable law could only occur if it were responsible for the medical

provider’s actions. There is no requirement that agency be specially pled.

With respect to causation, Dr. Goldman opined that a blood differential done on

December 14 would more likely than not have also shown abnormalities indicative of a bacterial

infection, and that, but for FCH’s misconduct, plaintiff had a reasonable medical probability of a

better outcome. Further, Dr. Weiss is an emergency medicine physician, not an infectious

diseases physician; he is therefore unqualified to render causation opinions.

Discussion

There does not appear to be a dispute regarding FCH’s nurses, that is, the nurses did not

commit malpractice. See DUMF No. 16; PRDUMF No. 16. FCH does not move for summary

judgment on the basis that the “medical practitioners” who treated Christina did not breach the

standard of care on December 12 and December 14. Instead, the dispute centers around whether

FCH may be held responsible for the conduct of the “medical providers” who treated Christina

and whether breaches identified by Dr. Goldman caused Christina’s injuries. The term “medical

providers” apparently embraces physicians, physician assistants, and nurse practitioners. See

FCH’s Motion at p. 9:19-21; Gonzalez Declaration at ¶ 3. 

As an initial matter, a defense of failure to state a claim upon which relief may be granted

may be raised as late as trial. See Fed. R. Civ. Pro. 12(h)(2). Because the defense can be raised

at trial, the Court will examine the allegations in Christina’s complaint to determine whether

FCH had reasonable notice of an agency theory. The active complaint alleges that Christina

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presented to FCH three times and on each occasion she was in need of immediate medical

treatment. See Complaint at ¶¶ 7, 9, 13, 16. Under the medical malpractice cause of action,

Christina alleges: 

25. As health care providers, [FCH] and Dr. Mansfield both had a duty to

engage in the non-negligent provision of medical treatment. This duty required

them to provide Christina with medical care that met or exceeded the pertinent

standards of treatment.

26. [FCH] and Dr. Mansfield breached their respective duties to provide

medical treatment in a non-negligent manner. Specifically, [FCH] breached this

duty by providing substandard emergency medical treatment to Christina on

December 10, 12, and 14, 2002. Dr. Mansfield violated this duty through his

actions on December 12, 2002, as alleged above.

 

27. [FCH] and Dr. Mansfield’s breaches of their respective duties to provide

medical treatment in a non-negligent manner caused Christina’s damages, as

alleged herein above.

28. Therefore, as a result of their breaching their duties to provide Christina

medical treatment in a non-negligent manner, [FCH] and Dr. Mansfield are liable

in this action.

Id. at ¶¶ 25-28. Also, Christina incorporated by reference the preceding paragraphs. In those

paragraphs, Christina alleges in some detail the care and treatment that she received from the

nurse practitioners and physician assistants on her three presentations. See id. at ¶¶ 9, 10, 14-15. 

With respect to agency and Dr. Mansfield, the Court has granted Dr. Mansfield’s motion

for summary judgment on the ground that there is insufficient evidence to show that he breached

the standard of care. Because principal/agent liability is derivative and Dr. Mansfield’s conduct

did not breach the standard of care, FCH cannot be liable for Dr. Mansfield’s conduct

irrespective of the complaint’s allegations. See Perez v. City of Huntington Park, 7 Cal.App.4th

817, 819-20 (1992). 

With respect to the nurse practitioners and physician assistants identified in the

complaint, Dr. Goldman has testified that there were no breaches of the standard of care on

December 10. See Goldman Deposition at 31:20-32:6. Thus, FCH could not be liable for the

care rendered by the physician assistant on December 10. See Perez, 7 Cal.App.4th at 819-20. 

Dr. Goldman, however, has opined that the standard of care was breached on December 12 and

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Since summary judgment has been granted in favor of Dr. Mansfield and FCH cannot be liable for his 15

conduct, see Perez, 7 Cal.App.4th at 819-20, it is unnecessary to decide whether Christina’s complaint gives fair

notice of some form of agency claim as to Dr. Mansfield, or whether the allegations have so separated FCH and Dr.

Mansfield that fair notice of an agency claim is absent. 

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December 14. Christina alleged conduct by unnamed nurse practitioners on both December 12

and December 14. Unlike the allegations against Dr. Mansfield, Christina’s complaint does not

separately account for the physician assistants and nurse practitioners under the medical

malpractice allegations. This suggests that Christina is attempting to make FCH responsible for 15

the nurse practitioners’s conduct. Moreover, that FCH addressed the issue of ostensible agency

in its motion for summary judgment suggests that it had notice of Christina’s theory and is not

surprised by Christina’s reliance on the theory. Given the allegations in the complaint and FCH’s

motion for summary judgment, FCH has received sufficiently fair notice that Christina is

attempting to make FCH responsible for the nurse practitioners’s conduct, which implies an

employment or agency claim. 

The issue then is what effect the notice in the Conditions Form has on Christina’s

malpractice claim. “An agency is ostensible when the principal intentionally, or by want of

ordinary care, causes a third person to believe another to be his agent who is not really employed

by him.” Cal. Civ. Code § 2300. Generally, there are three requirements necessary before

recovery may be had against a principal for the act of an ostensible agent: (1) the person dealing

with the agent must do so with belief in the agent’s authority and this belief must be a reasonable

one; (2) such belief must be generated by some act or neglect of the principal sought to be

charged; and (3) the third person in relying on the agent’s apparent authority must not be guilty

of negligence. Hill v. Citizens Nat. Trust & Sav. Bank, 9 Cal.2d. 172, 176 (1939); Seneca Ins.

Co. v. County of Orange, 117 Cal.App.4th 611, 620 (2004). In a hospital setting, one California

court has held that “the heart” of the three usual ostensible agency requirements are two

elements: (1) conduct by the hospital that would cause a reasonable person to believe there was

an agency relationship and (2) reliance on that apparent agency relationship by the plaintiff. See

Mejia v. Community Hosp. of Bernardino, 99 Cal.App.4th 1448, 1457 (2002). “Regarding the

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first element, courts generally conclude that it is satisfied when the hospital ‘holds itself out’ to

the public as a provider of care.” Id. at 1454. “[A] hospital is generally deemed to have held

itself out as the provider of care, unless it gave the patient contrary notice.” Id. “The second

element, reliance, is established when the plaintiff ‘looks to’ the hospital for services, rather than

to an individual physician.” Id. “[U]nless the patient had some reason to know of the true

relationship between the hospital and the physician--i.e., because the hospital gave the patient

actual notice or because the patient was treated by his or her personal physician--ostensible

agency is readily inferred.” Id. at 1454-55. The question of ostensible agency is generally a

question for the trier of fact unless the evidence conclusively establishes that the patient knew or

should have known that the treating physician was not an agent of the hospital. Id. at 1458.

Here, there is no dispute that Cora signed the Conditions Form on each of Christina’s

three presentations. There is further no dispute as to the content of the Conditions Form. Thus,

on three separate occasions, Cora, acting on behalf of Christina, was given written notice that all

“physicians and surgeons furnishing services to the patient, including the radiologist, pathologist,

anesthesiologist and the like are independent contractors with the patient and are not employees

or agents of the hospital.” Gonzalez Declaration Exhibit A. 

Cora has declared that she is a high school graduate, has never been a very good student,

and has attended some college level classes. See Romar Declaration at ¶ 2. Further, Cora

declared that she does not know what an independent contractor is, or why that term is important. 

See id. at ¶ 3. However, the notice in the Conditions Form does not simply use the term

“independent contractor.” Following the term “independent contractor,” the notice continues that

the physicians “are not employees or agents of the hospital.” Gonzalez Declaration Exhibit A. 

Cora’s declaration does not indicate that she did not read the Conditions Form, or more to the

point, that she did not read that physicians are not employees or agents of FCH. Cora does

declare that she did not have the Conditions Form explained to her before she signed them, but

her declaration only addresses the term “independent contractor.” Cora’s declaration does not

address the clause that the physicians “are not employees or agents of the hospital,” which

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Christina’s citation to Tunkl v. Regents of University of Cal., 60 Cal. 2d 92 (Cal. 1963), is not persuasive. 

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In that case, the California Supreme Court struck down a clause that read in part, “the patient or his legal

representative agrees to and hereby releases [the hospital] from any and all liability for the negligent or wrongful acts

or omissions of its employees, if the hospital has used due care in selecting its employees.” Tunkl, 60 Cal.2d at 94. 

In this case, there is no such release found in the Conditions Form signed by Cora. Cf. Gonzalez Declaration Exhibit

A. The paragraph in the Conditions Form that is at issue merely seeks to notify patients that physicians are not

employees or agents of the hospital. A notice of the agency status of the physicians is not the same as requiring

patients to release a hospital for the negligence of its employees.

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immediately follows the term “independent contractor.” See id. The statement that physicians

“are not employees or agents of the hospital” is a clear statement that does not require specialized

knowledge to understand and Cora’s declaration does not state that she did not understand that

the physicians were not employees or agents of FCH. Further, the Conditions Form itself

indicates that Cora read the form, which includes notice regarding the physicians’s employment

and agency status. See Gonzalez Declaration Exhibit A. Also, whether Cora signed the

Conditions Form before or after services were rendered to Christina does not matter in this case. 

As FCH points out, Cora signed the form on December 10, 12 and 14, and Dr. Goldman has

opined that there was no negligence on December 10. Given the notice in the Conditions Form,

as of December 10, Cora knew or should have known that the physicians were not agents or

employees of FCH because FCH told her through the Conditions Form. See Mejia, 99 16

Cal.App.4th at 1454-55.

However, more than just physicians were involved in Christina’s care. There is no

dispute that physician assistants and nurse practitioners were involved in Christina’s treatment. 

FCH argues that the notice in the Conditions Form covers “medical providers.” However, the

Conditions Form states that “physicians . . . are not employees or agents of the hospital.” The

Conditions Form does not state that “medical providers” or “nurse practitioners” or “physician

assistants” are not employees or agents of the hospital. At best there is an ambiguity whether the

Conditions Form reasonably informs patients that nurse practitioners and physician assistants are

not employees or agents of FCH. Given the language of the notice in the Conditions Form, the

Court cannot say as a matter of law that Cora and Christina knew or should have known that the

nurse practitioners and physician assistants were not agents or employees of FCH. Since FCH

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moves for summary judgment with respect to the medical practitioners, which includes nurse

practitioners and physician assistants, on the grounds that there is no ostensible agency due to the

notice in the Conditions Form, summary judgment is inappropriate.

Finally, with respect to FCH’s causation argument, FCH’s proposed undisputed fact on

this point is supported by the declaration of Dr. Eric Weiss, who is an emergency medicine

expert. See DUMF No. 17; Boggs Declaration at ¶ 14. Christina has objected to reliance on Dr.

Weiss’s causation opinions on the ground that he is not an infectious diseases expert and thus, is

not qualified to offer these opinions. FCH’s reply memorandum does not address this objection,

or the causation issue in general. Further, FCH did not raise causation or address Christina’s

objection at the hearing on these motions. For purposes of this motion, FCH has not adequately

shown that Dr. Weiss is qualified to render causation opinions and Christina’s objection is

sustained. Since Dr. Weiss is the only support for summary judgment on this claim under FCH’s

proposed undisputed facts, and FCH has not adequately shown Dr. Weiss’s qualifications to give

causation opinions, there is no longer a basis for this portion of FCH’s motion. Summary

judgment on the issue of medical malpractice causation is denied.

 CONCLUSION

Christina and FCH have moved for summary judgment on Christina’s EMTALA claim,

and FCH has further moved for summary judgment on Christina’s medical malpractice claim. 

The evidence presented shows a dispute with respect to whether Christina received disparate

screening. Christina’s expert has found 30 patients who she contends are similarly situated to

Christina, yet received superior screenings. FCH’s expert has opined that he has reviewed all

287 records produced by FCH and that none reflect patients who are similarly situated to

Christina and who received a superior screenings. Thus, whether the 30 patients are similarly

situated to Christina, whether Christina received a disparate screening in comparison to those

patients, and the credibility of the parties’s experts will be determined by a jury. The parties’s

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In a footnote in her opposition, Christina argues that Judge Coyle’s decision on a motion to dismiss and 17

Magistrate Judge Snyder’s decision to not allow an amended complaint were erroneous. However, it is inappropriate

to raise disagreement with previous orders in a footnote as part of an opposition. The propriety of prior decisions in

this case is not before the Court and it express no opinion on the issue.

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respective motions for summary judgment on this claim are denied.17

As to Christina’s medical malpractice claim, Christina is proceeding under an ostensible

agency theory. On each presentation to FCH, Cora signed a Conditions Form that stated the

physicians are not employees or agents of FCH. Although Cora either knew or should have

known that the physicians are not employees or agents of FCH, the Conditions Form does not

discuss physician assistants or nurse practitioners. The notice in the Conditions Form focuses on

physicians. The Conditions Form is sufficiently ambiguous with respect to nurse practitioners

and physician assistants that the Court cannot say as a matter of law that Christina knew or

should have known that the nurse practitioners and physician assistants were not the agents of

FCH. Further, FCH’s causation challenge is based on the testimony of Dr. Weiss. However,

FCH has not answered Christina’s objection to Dr. Weiss’s qualifications to render causation

opinions in this case. Christina’s objection to Dr. Weiss’s causation opinion is sustained and

thus, there is no longer a sufficient basis for FCH’s motion as to causation. Therefore, summary

judgment on this claim will be denied.

Accordingly, IT IS HEREBY ORDERED that:

1. Plaintiff’s motion for partial summary judgment is DENIED; and

2. Defendant FCH’s motion for summary judgment is DENIED.

IT IS SO ORDERED.

Dated: March 21, 2007 /s/ Anthony W. Ishii 

0m8i78 UNITED STATES DISTRICT JUDGE

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