Of the Sixth Circuit, sitting by designation. *

United States Court of Appeals

For the First Circuit

No. 10-1203

JOSÉ RAMOS-CRUZ and DEBORAH LÓPEZ-PAGÁN, 

Plaintiffs, Appellants,

v.

CENTRO MÉDICO DEL TURABO d/b/a HOSPITAL HIMA SAN PABLO FAJARDO

and HIMA SAN PABLO CAPTIVE INSURANCE COMPANY LIMITED,

Defendants, Appellees.

APPEAL FROM THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF PUERTO RICO

[Hon. Jaime Pieras, Jr., U.S. District Judge]

Before

Torruella, Siler, and Howard, *

Circuit Judges.

John E. Mudd for appellants.

Orlando H. Martínez-Echeverría with whom Fernando E. Agrait,

was on brief for appellees.

April 8, 2011
-2-

SILER, Circuit Judge. José Ramos-Cruz and Deborah LópezPagan (collectively “Plaintiffs”) filed suit under the Emergency

Medical Treatment and Active Labor Act (“EMTALA”) after their son

died following a hospital transfer. The district court granted

summary judgment in favor of the defendants. For the reasons stated

below, we AFFIRM.

I.

Plaintiffs filed suit under EMTALA, 42 U.S.C. § 1395dd,

against defendants Centro Médico del Turabo d/b/a Hospital HIMA San

Pablo Fajardo and the hospital’s insurer, HIMA San Pablo Captive

Insurance Company Limited (collectively “Hospital”). Plaintiffs

alleged the Hospital improperly transferred their son, Jose Ramos

Lopez (“Ramos”), when it failed to comply with EMTALA’s transfer

requirements. The district court granted summary judgment for the

Hospital, concluding Ramos’s transfer did not violate federal law.

On August 23, 2006, Ramos arrived at the Hospital with a

history of abdominal problems and anemia and experiencing abdominal

pain. He subsequently vomited blood and was diagnosed with upper

gastrointestinal bleeding. Because the Hospital did not have

gastroenterologic services available, the emergency room physician,

Dr. Ramon, arranged with a doctor from the San Juan Medical Center

(“SJMC”) to have Ramos transferred. 

The physician then prepared and signed a “Clinical

Summary and Examination at the Moment of Transfer,” a section of
-3-

which requires the transferring doctor to explain why the benefits

of the transfer outweigh its risks. In the space provided, he

wrote “Gastroenterologist.” Ramos and his medical records were then

transported to SJMC in an ambulance staffed with medical

technicians. Following a drop in Ramos’s hemoglobin level, a

gastroenterologic team at SJMC performed an endoscopic procedure

that stopped Ramos’s bleeding ulcer. Unfortunately, his bleeding

began again later, and blood transfusions and an attempted surgical

procedure were unsuccessful in saving his life. Ramos died on

August 25, 2006, approximately 36 hours after his arrival at SJMC.

II.

Plaintiffs contend the district court erred when it

granted summary judgment in favor of the Hospital, concluding as a

matter of law the Hospital’s transfer of Ramos complied with

EMTALA.

We review a district court’s grant of summary judgment de

novo. Triangle Trading Co. v. Robroy Indus., Inc., 200 F.3d 1, 2

(1st Cir. 1999). A district court should grant summary judgment

where “the movant shows that there is no genuine dispute as to any

material fact and the movant is entitled to judgment as a matter of

law.” Fed. R. Civ. P. 56(a).

Congress enacted EMTALA in 1996 in response to claims

that hospital emergency rooms were refusing to treat patients with
-4-

emergency conditions but no medical insurance. Reynolds v.

MaineGeneral Health, 218 F.3d 78, 83 (1st Cir. 2000). EMTALA

therefore “is a limited anti-dumping statute, not a federal

malpractice statute.” Id. (internal citations and quotation marks

omitted). It creates private rights of action where hospitals

violate its mandates. Correa v. Hospital San Francisco, 69 F.3d

1184, 1190 (1st Cir. 1995); 42 U.S.C. § 1395dd(d)(2). 

EMTALA requires that “if an emergency medical condition

exists, the participating hospital must render the services that

are necessary to stabilize the patient’s condition . . . unless

transferring the patient to another facility is medically indicated

and can be accomplished with relative safety.” Correa, 69 F.3d at

1189 (internal citations and quotation marks omitted); 42 U.S.C. §

1395dd(b) and (c). 

When transferring a patient, the physician must sign a

certification that “the medical benefits reasonably expected from

the provision of appropriate medical treatment at another medical

facility outweigh the increased risks to the individual.” 42

U.S.C. § 1395dd(c)(1)(A)(ii). This certification must contain a

summary of the risks and benefits of the transfer. 42 U.S.C. §

1395dd(c)(1).

Further, a transfer is only appropriate where 1) the

transferring hospital provides “the medical treatment within its

capacity which minimizes the risks to the individual’s health,” 2)
Plaintiffs contend Dr. Ramon could not have made a 1

risk/benefit assessment because he testified he made the decision

the moment Ramos vomited blood. However, there is no statutory

requirement as to how long the doctor has to consider the risks and

benefits of a transfer.

-5-

the receiving facility has available space and qualified personnel,

as well as agrees to accept the transfer and provide the

appropriate treatment, 3) the transferring hospital sends all

medical records related to the condition available at the time of

transfer, and 4) the patient is transported through qualified

personnel and transportation equipment. 42 U.S.C. § 1395dd(c)(2).

Dr. Ramon signed a certification at the time of transfer.

Further, this certification contained a section entitled “EXPLAIN

why the benefits of the transfer for the patient . . . are greater

than the risks, if any for the transfer,” and, in the corresponding

space, the physician wrote “Gastroenterologist.” This was merely

a summary statement of the more explicit explanation that Ramos

needed a gastroenterologist, none was present at the Hospital, and,

therefore, he needed to be transferred, because the benefits of a

gastroenterologist outweighed the dangers of transportation.1

Moreover, the Hospital provided appropriate pre-transfer

treatment. What is required in this regard is an issue of first

impression in the First Circuit. The district court relied on

Tenth Circuit precedent in applying this requirement and held that

a hospital runs afoul of this provision only where it “violate[s]
-6-

an existing hospital procedure or requirement.” Ingram v. Muskogee

Reg’l Med. Ctr., 235 F. 3d 550, 552 (10th Cir. 2000). 

While Plaintiffs concede the Hospital followed standard

procedure when transferring Ramos, they sharply dispute the

district court’s statutory interpretation. Plaintiffs argue the

correct standard is provided by the statute itself when it dictates

the hospital provide “the medical treatment within its capacity

which minimizes the risks to the individual’s health.” According

to Plaintiffs, this means that if a hospital does not deliver the

feasible specific treatment that is best, whatever it may be in a

given circumstance, it violates EMTALA.

Plaintiffs’ position on this point of law is untenable.

First, the district court’s opinion conforms with our jurisprudence

interpreting the similar EMTALA phrase, “appropriate medical

screening examination within the capability of the hospital’s

emergency department.” 42 U.S.C. § 1395dd(a). In that context, we

held that “refusal to follow regular screening in a particular

instance contravenes the statute . . . but faulty screening, in a

particular case . . . does not contravene the statute.” Correa, 69

F.3d at 1192-93 (internal citations and quotation marks omitted).

Second, the Plaintiffs’ interpretation would create a federal

malpractice cause of action. Any time an unstabilized patient did

not receive the correct care prior to transfer, he could sue in

federal court. This is entirely inconsistent with our
-7-

jurisprudence and Congressional intent, as we have previously

stated “EMTALA does not create a cause of action for medical

malpractice.” Correa, 69 F.3d at 1192.

The district court found that Plaintiffs produced

sufficient evidence for a trial on the question of whether Ramos

was stabilized prior to his transfer to SJMC under 42 U.S.C. §

1395dd(b). We need not decide that question, because we find that

the Hospital provided for the transfer in the best interests of the

patient under 42 U.S.C. § 1395dd(c)(1)(A)(ii).

The decision of the district court is therefore AFFIRMED.