United States Court of Appeals

For the First Circuit

No. 04-2375

EDGARDO JOSE CRUZ-QUEIPO; MARIA ISABEL PUIG-SANCHEZ; CONJUGAL

PARTNERSHIP CRUZ-PUIG,

Plaintiffs, Appellants,

v.

HOSPITAL ESPAÑOL AUXILIO MUTUO DE PUERTO RICO,

Defendant, Appellee;

AMERICAN INTERNATIONAL INSURANCE CO., a/k/a AIICO,

Defendant.

APPEAL FROM THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF PUERTO RICO

[Hon. Jay A. García-Gregory, U.S. District Judge]

Before

 Torruella, Lynch, and Lipez, Circuit Judges.

Rafael G. Martínez-Géigel, with whom Emilio E. Solé de la Paz

was on brief, for appellant.

Carlos E. Umpierre-Schuck, with whom Juan A. Pedrero-Lozada

was on brief, for appellee.

July 27, 2005
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LIPEZ, Circuit Judge. This case tests the scope of

hospital liability under the Emergency Medical Treatment and Active

Labor Act (EMTALA), 42 U.S.C. § 1395dd. EMTALA requires a hospital

to even-handedly administer an appropriate screening procedure to

all emergency room patients and, if it determines that an emergency

medical condition exists, to stabilize the patient's condition

before discharge or transfer to another hospital. See id.

Asserting that Hospital Español Auxilio Mutuo de Puerto Rico

(Auxilio Mutuo) did not comply with its own protocol in screening

Edgardo Cruz-Queipo (Cruz) and that it failed to stabilize him

prior to discharge, the plaintiffs appeal a grant of summary

judgment against them. For the reasons set forth below, we vacate

the district court's grant of summary judgment on both the

screening and stabilization claims and remand for further

proceedings.

I.

In reviewing a grant of summary judgment, we view the

record in the light most favorable to the nonmovant. See Del

Carmen Guadalupe v. Negron Agosto, 299 F.3d 15, 17 (1st Cir. 2002).

Accordingly, we draw the following facts from the summary judgment

record, "indulging all reasonable inferences in [the plaintiffs']

favor." Griggs-Ryan v. Smith, 904 F.2d 112, 115 (1st Cir. 1990).

At approximately 4 p.m. on August 31, 2001, Cruz visited

the Auxilio Mutuo emergency room complaining of pain in his chest,
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arm, and wrist. Pursuant to Auxilio Mutuo's written policy,

emergency room patients receive a screening examination upon

arrival to determine the severity of their conditions and are then

classified in one of four categories. Category I encompasses the

most serious conditions, including acute chest pain with unstable

vital signs, and Categories II, III, and IV encompass progressively

less serious conditions. Triage officer Dr. Miguel Rodríguez

performed an initial screening evaluation of Cruz pursuant to

Auxilio Mutuo's policy. After checking Cruz's vital signs and

noting that Cruz complained of pain in his left arm and warmth in

his wrist, Dr. Rodríguez placed Cruz in Category IV, which includes

back and muscle pain. Notes from the screening examination do not

indicate that Cruz complained of chest pain. For purposes of

summary judgment, however, we must credit Cruz's assertion that he

did, in fact, report such pain, and, drawing all reasonable

inferences in Cruz's favor, we must assume that the emergency room

doctors were aware of the chest pain.

A second physician, Dr. James Davison, performed a more

thorough examination of Cruz at approximately 5:30 p.m. Like Dr.

Rodríguez, Dr. Davison did not document a complaint of chest pain.

Finding that Cruz suffered from shoulder pain, however, Dr. Davison

ordered an electrocardiogram (EKG) and a cervical spinal x-ray. He

interpreted the results of both tests as negative. Based on his

examination and the test results, Dr. Davison diagnosed Cruz with
American International Insurance Company was dismissed as a 1

defendant on April 7, 2003 pursuant to an unopposed motion for

summary judgment on the grounds that it "did not have in effect an

insurance policy for Hospital Español Auxilio Mutuo covering the

damages claimed in the complaint."

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thoracic outlet syndrome, a non-emergency disorder that involves

the compression of blood vessels and nerves in the shoulder region.

See National Institute of Neurological Disorders and Stroke,

Thoracic Outlet Syndrome Information Page, at

http://www.ninds.nih.gov/disorders/thoracic/thoracic.htm (last

visited July 20, 2005). Dr. Davison prescribed Celebrex (an antiinflammatory) and Clonazepan (an anti-convulsant) and discharged

Cruz, encouraging him to follow up with a specialist.

The following day (September 1, 2001), Cruz returned to the

Auxilio Mutuo emergency room with severe chest pain radiating to

his left arm and jaw. Doctors determined that Cruz had suffered an

acute myocardial infarction (heart attack). He was admitted to the

coronary care unit, where he remained for approximately one week

before being transferred to another hospital where he underwent

sextuple bypass surgery. As a result of the infarction, Cruz

suffered permanent damage to his heart, including scarring and

decreased cardiac performance.

On October 2, 2002, the plaintiffs -- Cruz; his wife, Maria

Isabel Puig-Sanchez; and their conjugal partnership -- filed a

complaint against Auxilio Mutuo and American International

Insurance Company, charging violations of EMTALA. Specifically, 1
The plaintiffs filed a separate malpractice suit in the 2

Puerto Rico courts.

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the plaintiffs asserted that Cruz had been suffering from acute

coronary syndrome during his August 31 hospital visit and that

hospital personnel failed to properly screen and stabilize him.

The plaintiffs also contended that these deficiencies led to the

permanent damage that Cruz suffered as a result of his heart attack

on September 1. After the close of discovery, Auxilio Mutuo filed

a motion for summary judgment on the grounds that the plaintiffs

failed to state a claim under EMTALA. It argued that Cruz had been

given an appropriate medical screening, that he was subjected to

the same procedures used for every patient who visits the emergency

room, that the August 31 visit did not implicate EMTALA's

stabilization requirement because the hospital did not detect an

emergency medical condition, and that there was no causal

relationship between the damages alleged and the purported EMTALA

violation. Over the plaintiffs' vigorous objections, the district

court granted Auxilio Mutuo's motion, finding that the plaintiffs'

claims "are more suited to a medical malpractice claim." The 2

plaintiffs appeal from this decision.

II.

We review the grant of summary judgment de novo. Littlefield

v. Acadia Ins. Co., 392 F.3d 1, 6 (1st Cir. 2004). Summary

judgment is appropriate where "the pleadings, depositions, answers
EMTALA defines a participating hospital as a "hospital that 3

has entered into a provider agreement under section 1395cc of this

title." 42 U.S.C. § 1395dd(e)(2). Neither side disputes that

Auxilio Mutuo is a participating hospital.

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to interrogatories, and admissions on file, together with the

affidavits, if any, show that there is no genuine issue as to any

material fact and that the moving party is entitled to a judgment

as a matter of law." Fed. R. Civ. P. 56(c).

A. The EMTALA statutory scheme

Congress enacted EMTALA in response to "the increasing number

of reports that hospital emergency rooms are refusing to accept or

treat patients with emergency conditions if the patient does not

have medical insurance." Correa v. Hosp. San Francisco, 69 F.3d

1184, 1189 (1st Cir. 1995) (internal quotation marks omitted).

EMTALA imposes two primary requirements on participating

hospitals:3

First, it requires that a participating hospital afford

an appropriate medical screening to all persons who come

to its emergency room seeking medical assistance. See 42

U.S.C. § 1395dd(a). Second, it requires that, if an

emergency medical condition exists, the participating

hospital must render the services that are necessary to

stabilize the patient's condition, see id.

§ 1395dd(b)(1)(A) . . . .

Id. at 1190. As an enforcement mechanism for these requirements,

EMTALA creates a private right of action for violations. See 42

U.S.C. §§ 1395dd(d)(1), (2).
This is the view of other circuits as well. See, e.g., 4

Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1138 (8th

Cir. 1996) ("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."); Baber v. Hosp. Corp. of Am., 977 F.2d

872, 878 & 879 n.7 (4th Cir. 1992) ("EMTALA only requires hospitals

to apply their standard screening procedure for identification of

an emergency medical condition uniformly to all patients.").

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B. EMTALA screening claim

Although EMTALA does not define an "appropriate medical

screening examination," our circuit law does: 

A hospital fulfills its statutory duty to screen patients

in its emergency room if it provides for a screening

examination reasonably calculated to identify critical

medical conditions that may be afflicting symptomatic

patients and provides that level of screening uniformly

to all those who present substantially similar

complaints. 

Correa, 69 F.3d at 1192. "The essence of this requirement is that

there be some screening procedure, and that it be administered

even-handedly." Id. When a hospital prescribes internal

procedures for a screening examination, those internal procedures

"set the parameters for an appropriate screening." Id. A 4

hospital thus must adhere to its own procedures in administering

the screening examination.

The plaintiffs do not dispute that Cruz received a screening

examination, nor do they contend that Auxilio Mutuo's screening

protocol was per se inappropriate. Rather, they argue that the

hospital failed to follow its own protocol when it placed Cruz in
Plaintiffs contend that Cruz should have been placed in 5

either Category I or II, emphasizing that both categories include

acute chest pain. Category I, however, applies specifically to

acute chest pain with unstable vital signs. The triage officer

determined that Cruz's vital signs were stable, and Cruz does not

dispute that determination. Therefore, he did not meet the

requirements for Category I.

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Category IV despite his complaint of chest pains that should have

placed him in Category II (acute chest pain with stable vital

signs), and that this departure from hospital protocol violated

EMTALA's appropriate screening requirement. In short, they 5

challenge the district court's conclusion that they "have no claim

under EMTALA" because "Cruz was screened and evaluated according to

Auxilio Mutuo protocol." There is more to this challenge than may

initially meet the eye.

In its brief, Auxilio Mutuo devotes a great deal of attention

to the aspects of its triage protocol that were followed in this

case. It points out that Cruz was examined and placed in a triage

category upon his appearance in the emergency room, and that he was

subsequently evaluated by the emergency room physician. Auxilio

Mutuo asserts that Cruz's screening therefore did not deviate from

the standard hospital protocol and that, at bottom, the plaintiffs'

claim is really one of medical malpractice rather than of an EMTALA

violation. See id. at 1192-93 ("EMTALA does not create a cause of

action for medical malpractice. Therefore, a refusal to follow

regular screening procedures in a particular instance contravenes

the statute, but faulty screening, in a particular case, as opposed
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to disparate screening or refusing to screen at all, does not

contravene the statute." (internal citations omitted)).

Auxilio Mutuo's reasoning overlooks one key factor -- namely,

our inference, for purposes of summary judgment, that emergency

room doctors were aware that Cruz was suffering from chest pain.

Under Auxilio Mutuo's written triage policy, a patient with stable

vital signs who complains of chest pain must be assigned to triage

Category II. Indeed, the hospital conceded in its motion for

summary judgment that, under its own standards, "[i]f the patient

[had] referred a complaint of chest pains, he would have been

placed in Category I or II with an emergency condition." Cruz's

placement in Category IV despite a complaint of chest pains thus

marked a departure from the hospital's standards, which "set the

parameters for an appropriate screening." Id. at 1193; see also

id. ("under EMTALA § 1395dd(a), the same screening examination must

be made available to all similarly situated patients").

Accordingly, Auxilio Mutuo is not entitled to summary judgment on

the plaintiffs' claim that Cruz was denied an appropriate screening

in violation of EMTALA.

C. EMTALA stabilization claim

The plaintiffs also assert a claim under EMTALA's

stabilization requirement, which provides that

[i]f any individual . . . comes to a hospital and the

hospital determines that the individual has an emergency

medical condition, the hospital must provide . . .
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(A) within the staff and facilities available at the

hospital, for such further medical examination and such

treatment as may be required to stabilize the medical

condition.

42 U.S.C. § 1395dd(b)(1)(A). The statute defines an emergency

medical condition (for an individual not in active labor) as

a medical 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) placing the

health of the individual . . . in serious jeopardy, (ii)

serious impairment to bodily functions, or (iii) serious

dysfunction of any bodily organ or part. 

Id. § 1395dd(e)(1)(A).

In support of their stabilization claim, the plaintiffs point

to Auxilio Mutuo's acknowledgment, in its motion for summary

judgment, that "[i]f the patient [had] referred a complaint of

chest pains, he would have [had] . . . an emergency condition,

[and] therefore the hospital [would have been] obliged to stabilize

the patient." Emphasizing this concession, the plaintiffs assert

that if we accept that Cruz complained of chest pains during his

August 31 visit, we must also conclude that the hospital had a duty

to stabilize the heart condition that culminated in a heart attack

on September 1. We agree.

At this stage of the proceedings, as we have already

explained, we must draw the inference that the hospital knew that

Cruz was suffering from chest pain. By its own admission, then,

the hospital also knew that Cruz was suffering from an emergency
Auxilio Mutuo also asserts that it is entitled to summary 6

judgment on the ground that "there is no causal relation[ship]

between the damages alleged and the purported EMTALA violation."

See 42 U.S.C. § 1395dd(d)(2)(A) ("Any individual who suffers

personal harm as a direct result of a participating hospital's

violation of a requirement of [EMTALA] may, in a civil action

against the participating hospital, obtain those damages available

for personal injury under the law of the State in which the

hospital is located . . . ."); 31 P.R. Laws Ann. § 5141 (damages

available under Puerto Rico law when "[a] person who by an act or

omission causes damage to another through fault or negligence"

(emphasis added)). Specifically, Auxilio Mutuo claims that Cruz's

heart condition was attributable to his "inability to adequately

care for his physical condition" by controlling his cholesterol and

blood pressure, rather than to any action or omission of the

hospital. This argument is a non-starter. Hospitals generally do

not cause the emergency conditions that they are called upon to

stabilize under EMTALA. That does not mean, however, that a

hospital's failure to stabilize a condition bears no causal

relationship to the damages suffered by a patient as a result of a

deterioration in his condition that could have been avoided by

stabilization. 

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medical condition and had a duty to stabilize that condition.

Auxilio Mutuo therefore was not entitled to summary judgment on the

plaintiffs' stabilization claim.6

III.

Although a jury ultimately may determine that the hospital's

treatment of Cruz did not violate EMTALA, the summary judgment

record, viewed in the light most favorable to the plaintiffs, does

not permit that conclusion as a matter of law. In light of Cruz's

claim that he complained of chest pain during his August 31 visit

to the emergency room and the hospital's concession regarding its

own standards for handling such a complaint, we must vacate the

grant of summary judgment to Auxilio Mutuo and remand to the
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district court for further proceedings consistent with this

opinion.

So ordered.