### F I LE D U. S . COURT OF AP PE ALS E LEVE NTH CI RCUI T June 18, 2004 T HOM AS K. KAHN C L E RK [ P UB L I S H] I N THE UN I TE D STATE S C OU RT OF APPE ALS F O R T H E E L E V E N T H C IR C U IT

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A n n e M a r ie N o le n ap p e a ls f r o m as u m m a ryju d g m e n t e n te r e d a g a in s t h e r . T he di stri ctcourthel d thatN ol en’ s c om pl ai nt , brou gh tun der both the E m er gency M e di c a l T r e a tm e nta nd A c t i ve L aborA c t( E M T A L A ) , 42 U . S . C . s e c t i on 1395dd, a n d F lo r id ala w , f

a ile d a s am a tte ro f

la w . W e a f

f irm ; th e d is tr ic t c o u rt p r o p e r ly grant ed sum m ary j ud gm enti n favor of the B oca R at on C om m un i ty H ospi t al , Inc. ( H o s p ita l) . I . F AC T S AN D P RO CE DU RA L HI S T OR Y No l e n wa s ap e d i a tr i c n u r s e a tth e Ho s p i t a l . S h e wa s ab o u ttwe n ty - two w e e ks pr e gna ntw i th tr i pl e t s a nd ha d i ns ur a nc e c ove r a ge . A tappr oxi m a t e l y5: 00 p. m . on M a y 4, 2000, N ol e n a rr i ve d a tthe H os pi t a l f oral aborc he c k a tthe di r e c t i on of

he rphy s i c i a n, D r . Z a nn. T he H os pi t a l a dm i tt e d N ol e n a s a n outpa t i e nt abouttw e nty m i nut e s l a t e r . S he c om pl a i ne d of c r a m pi ng a nd am uc ous di s c ha r ge th a t s h e f e a r e d s ig n a le d th e o n s e t o f lab o r . N ol e n w a s f

i r s ttr e a t e d by aH os pi t a l nur s e , R e i ns vol d, i n the l abora nd del i veryun i tof the H ospi t al , O ne F am i l y P l ac e. R ei nsvo l d u nd ert oo k p re l i m i nary c a r e pr oc e s s e s , i nc l udi ng the f ol l ow i ng m e a s ur e s : t a ki ng N ol e n’ s vi t a l s i gns , t a ki ng N ol en’ s m edi ca l hi st ory, l i st eni ng t o the un bo rn babi es ’ heart s, cond uct i ng a f et al m on i t or, and g i vi ng an i ni t i al exam i nat i on of N ol en’ s abd om en. N ol en w as a tt a c he d t o af

e t a l m oni t or , w hi c h de t e c t s ut e r i ne c ontr a c t i ons a nd ut e r i ne3

i rr i t abi l i ty, for m ore than an h ou r. R ei nsvo l d al so paged D r. Z ann t o see N ol en s h o rtlya f

te rN o le n ’s a d m is s io n to O n e F a m ilyP la c e . A f te rth e in itia l a s s e s s m e n t p e r f o rm e d b yR e in s v o ld , D r . Z a n n a rr iv e d to exam i ne N ol en, w ho w as st i l l on ou tpat i entst atus, abou tan ho ur and t en m i nu t es a f t e rs he w a s f

i r s tr e gi s t e r e d by the H os pi t a l . D r . Z a nn pe r f orm e d avi s ua l e xa m of N o le n ’s c e rv ix , to o kac u ltu r e o f h e rv a g in a , a n d f

u llye v a lu a te d N o le n ’s c e rv ix . N o le n ’s c e rv ix w a s f

o u n d to b e n e ith e rd ila te d n o rth in n e d . T h e lab o r a to ryr e s u lts f r om the c ul tur e w e r e ne ga t i ve . D r . Z a nn c onc l ude d tha tN ol e n’ s l ow e rut e r i ne s e g m e n t w a s c o n s is te n t w ith w h a t h e e x p e c te d f r o m an o rm a l p r e g n a n c yin th is ci rc um st ance . D r. Z ann p er form ed an ul tra soun d t o eval uat e e ac h o f the three fe t al he a rtr a t e s . H e di d notor de rf urthe rt e s t i ng. D r . Z a nn c onc l ude d tha tN ol e n w a s notdi l a t e d a nd tha ts he ha d onl yone concl usi ve epi sodi c c on tra ct i on , w hi ch occurre d at5: 32 p. m . A no ther pot ent i al epi sodi c c on tra ct i on occurre d at6: 04 p. m . , bu ti tw as i ncon cl usi ve because N ol en w as bei ng re po si t i on ed w hen the fe t al m on i t or re gi st er ed thatm ov em ent . S at i sf i ed thatN ol en had b ee n adequ at el y di agno se d and st abi l i ze d, D r. Z ann d i sc harged her fr om the H ospi t al at6: 48 p. m . H e order ed N ol en t o k ee p h ersc hedu l ed ap p o in tm e n t w ith h e rp e r in a to lo g is t, D r . S c o tt, th e n e x t m o rn in g . A f t e rl e a vi ng the H os pi t a l , N ol e n’ s c ondi t i on c ha nge d f orthe w or s e . S he4

t e s t i f i e d a tde pos i t i on tha ts he be ga n c r a m pi ng a f t e rl e a vi ng the H os pi t a l . S he m a d e n o e f

f o rt to c o n ta c t D r . Z a n n o rth e H o s p ita l a f te rth is c h a n g e in c o n d itio n . W hen she re ac hed D r. S cott ’ s off i ce the nextm orni ng , N ol en ful l y des cr i bed the e ve nt s of

the pr e vi ous da y . N ol e n a l s o t ol d D r . S c ottof the c ha nge i n c ondi t i on s he e xpe r i e nc e d a f

t e rl e a vi ng the H os pi t a l . D r . S c otte xa m i ne d N ol e n a nd c onc l ude d tha ts he m a y ha ve be e n e nt e r i ng pr e - t e rm l aboron tha tda ybe c aus e the part i al ef fa ce m entand d i l at i on of her c ervi x. D r. S cottdet erm i ned thatN ol en coul d n othave been ent er i ng pre- t erm l abor on the previ ou s dayw hen she w as at th e H o s p ita l in th e c a r e o f D r . Z a n n . D r . S c o tt s e n t N o le n b a c kto th e H o s p ita l to s u p p r e s s h e rp r e - te rm lab o r . N ol en st ay ed there un t i l M ay7, 20 00 , w hen she w as transfe rr ed t o B row ar d G ener al H ospi t al because i thad a superi or neon at al care un i t . N ol en w enti nt o p re te rm lab o r . H e rf

ir s t b ab y w a s s tillb o rn , a n d h e ro th e rtw o b ab ie s w e r e b o rn a liv e . N ei ther of her tw o l i ve bi rths survi ved p as tM ay24 , 20 00 , ho w ever . N ol e n f i l e d ac om pl a i ntunde r42 U . S . C . s e c t i on 1395dd on M a y3, 2002, a nd a l l e ge d tha tthe H os pi t a l ( 1) di d notpr ovi de he rw i th a n a de qua t e s c r e e ni ng e xa m i na t i on, ( 2) di d nots t abi l i z e he rl aborc ondi t i on a de qua t e l y , a nd ( 3) di s c ha r ge d he ri n vi ol a t i on of the E M T A L A . N ol e n r e c e i ve d l e a ve f r om the di stri ctcourtt o am end h ercom pl ai ntt o i ncl ud e s i x cou nt s of m edi ca l m alprac t i ce5

unde rF l or i dal a w . D r . Z a nn, R e i ns vol d, a nd S l a vi c e k, a nothe rnur s e f r om the H o s p ita l, w e r e a d d e d a s d e f e n d a n ts o n th o s e c la im s . T h e d is tr ic t c o u rt d e c lin e d to e x e r c is e ju r is d ic tio n o v e ra ll b u t o n e o f th e s ta te - la w c la im s . B oth pa rt i e s f

i l e d c r os s - m ot i ons f

ors um m a ryj udgm e nta f t e rthe c l os e of di s c ove ry . T he di s tr i c tc ourtgr a nt e d the m ot i ons m a de bythe H os pi t a l a nd the o th e rd e f e n d a n ts o n a ll th r e e c o u n ts u n d e rth e E M T A L A a n d th e r e m a in in g s ta te l aw cl ai m . N ol en do es no taddres s the grantof sum m ary j ud gm entby the di stri ct courton her s t at e- l aw cl ai m i n h erbri ef before thi s C ou rt , so any argum ent s on that cl ai m ar e w ai ved. F arrow v. W es t , 32 0 F . 3d 12 35 , 12 42 (11th C i r. 20 03 ); K el l i her v. V e ne m a n, 313 F . 3d 1270, 1274 n. 3 ( 11th C i r . 2002) ; G r e e nbr i a r , L t d. v. C i ty of A l abas t er , 88 1 F . 2d 15 70 , 15 73 n. 6 (11 th C i r. 19 89 ). I I . STA N D A R D O F R EVI EW S u m m ary j u d g m en ti s o n l y ap p ro p ri at e i f “ th e p l ead i n g s, d ep o si t i o n s, a n s w e r s to in te rr o g a to r ie s , a n d a d m is s io n s o n f ile , to g e th e rw ith th e a f

f id a v its , if a ny , s how tha tthe r e i s no ge nui ne i s s ue a s t o a nym a t e r i a l f a c ta nd tha tthe m ovi ng pa rty i s e nt i t l e d t o aj udgm e nta s am a tt e rof l a w . ” F e d. R . C i v. P . 56( c ) ; A nde r s on v. L i be rty L obby , I nc . , 477 U . S . 242, 247, 106 S . C t . 2505, 2510 ( 1986) ( quot i ng F ed. R . C i v. P . 56 (c )) . S um m ary j ud gm entshou l d b e grant ed w hen, af t eran ad eq u at e t i m e fo r d i sco v ery, a p arty fai l s t o m ak e a sh o w i n g su ffi ci en tt o est ab l i sh6

th e e x is te n c e o f

a n e s s e n tia l e le m e n t o f th a t p a rty ’s c a s e . C e lo te x C o rp . v . C a tr e tt, 4 7 7 U .S . 3 1 7 , 3 2 2 , 1 0 6 S . C t. 2 5 4 8 , 2 5 5 2 (1 9 8 6 ). “W e r ev iew th e d istrict co u rt’s rul i ng s on m ot i on for s um m ary j ud gm entde no vo , appl yi ng the sa m e l egal s t a nda r ds tha tbound the di s tr i c tc ourt . ” C a rt e rv. G a l l ow a y , 352 F . 3d 1346, 1348 ( 1 1 th C ir . 2 0 0 3 ) . III. A N A L Y S IS N ol en as se rt s tw o g roun ds on w hi ch the di stri ctcourterre d i n h ol di ng that the H os pi t a l ga ve he ra n appr opr i a t e s c r e e ni ng w he n s he e nt e r e d a s a n outpa t i e nt on M ay4, 20 00 . F i rs t , she c on t ends thatthe H ospi t al di d n othave a s t andard w r itte n s c r e e n in g p r o c e d u r e o r , a lte rn a tiv e ly , th a t th e H o s p ita l d id n o t f o llo w its s c r e e n in g p r o c e d u r e , e ith e ro f w h ic h , s h e c o n te n d s , v io la te d th e E M T A L A . S e c ond, N ol e n a r gue s tha tthe di s tr i c tc ourts houl d notha ve c ons i de r e d the evi dence s ub m i tt ed by the H ospi t al thatprov ed N ol en w as no t , i n fac t , i n p re -t erm l abor w hen she w as exam i ned atthe H ospi t al on M ay4, 20 00 , by her per sonal p h y s ic ia n , D r . Z a n n . E a c h o f th e s e a r g u m e n ts is a d d r e s s e d a n d r e je c te d b e lo w . A s w e h a v e p r e v io u s lys ta te d , I n 1 9 8 6 , C o n g r e s s e n a c te d E M T A L A in r e s p o n s e to w id e ly publ i c i z e d r e port s of

e m e r ge nc yc a r e pr ovi de r s tr a ns f e rr i ng i ndi ge nt pat i ent s f rom on e hospi t al t o the nextw hi l e the pat i ent s’ em er gency m e d ic a l c o n d itio n s w o r s e n e d . E M T A L A w a s d e s ig n e d s p e c if ic a llyto addres s thi s i m po rt antsoci et al concern; i tw as no ti nt ended t o b e a fe dera l m alprac t i ce st atut e. U nd erE M T A L A , ho spi t al em er gency7

r o o m s a r e s u b

je c t to tw o p r in c ip a l o b lig a tio n s , c o m m o n lyr e f e rr e d to a s the appr opr i a t e m e di c a l s c r e e ni ng r e qui r e m e nta nd the s t abi l i z a t i on r e qui r e m e nt . . . . T he appr opr i a t e m e di c a l s c r e e ni ng r e qui r e m e nt ob l i gat es ho spi t al em er gency r oo m s t o p rovi de an approp ri at e m edi ca l s c r e e ni ng t o a ny i ndi vi dua l s e e ki ng tr e a tm e nti n or de rt o de t e rm i ne w hether the i nd i vi du al has an em er gency m edi ca l cond i t i on . . . . If an e m e r g e n c y m e d ic a l c o n d itio n e x is ts , th e h o s p ita l is r e q u ir e d to p r o v id e s tab iliz a tio n tr e a tm e n t b e f o r e tr a n s f

e rr in g th e in d iv id u a l. H a rry v . M a r c h a n t, 2 9 1 F .3 d 7 6 7 , 7 7 0 ( 1 1 th C ir . 2 0 0 2 ) ( e n b a n c ) . F i rs t , w e a dd re ss N ol en’ s c on t ent i on thatthe H ospi t al w as re qu i re d t o h ave a w r itte n s c r e e n in g p r o c e d u r e . A s im ila ra r g u m e n t w a s r e je c te d b yth e E ig h th C ir c u it. S u m m e r s v . B ap tis t M e d . C e n te rA rk a d e lp h ia , 9 1 F .3 d 1 1 3 2 , 1 1 4 0 ( 8 th C i r. 19 96 ) ( en banc). T he E i gh th C i rc ui thel d thata hospi t al w i th em er gency s c r e e ni ng pr oc e dur e s tha tw e r e unw r i tt e n, i n w hol e ori n pa rt , di d notvi ol a t e the E M T A L A . I d . ( s ta tin g th a t “th e h o s p ita l d id h a v e as c r e e n in g p r o c e d u r e , e v e n if u n w ritt en in p ar t, an d th e s tatu te m ak es n o ad d it io n al re q u irem en t”). N o len ’s arg u m en tth atth e H o sp i t al w as req u i red t o h av e a w ri tt en screen i n g p ro ced u re al so fa i l s bec ause a w ri tt en procedure i s notre qu i re d b y the t erm s of s ec t i on 13 95 dd (a ). N ol e n a l t e rna t i ve l y c ont e nds tha tthe H os pi t a l di d notf ol l ow i t s pol i c i e s f

or sc re eni ng pat i ent s i n p re -t erm l abor si tuat i on s. N ol en re l i es on se vera l po l i ci es pr opa ga t e d by the H os pi t a l t o c r e a t e doubtaboutthe qua l i tyof s c r e e ni ng s he r e c e i ve d. A s l ong a s the H os pi t a l s c r e e ne d N ol e n i n am a nne rc ons i s t e ntw i th the s c r e e ni ng tha ta ny othe rpa t i e nti n the c a r e of apr i va t e phy s i c i a n w oul d ha ve8

re ce i ved, there can b e no l i abi l i ty und erthe E M T A L A . T he H ospi t al pres ent ed un di sput ed evi dence thatR ei nsvo l d p er form ed exact l y the type of s cr ee ni ng that w oul d ha ve be e n gi ve n t o a ny othe routpa t i e nti n N ol e n’ s pos i t i on a c c or di ng t o the on l y pol i cythatappl i ed t o N ol en’ s c as e. B ec ause the H ospi t al m eti t s i ni t i al b u r d e n o f

d is p r o v in g th e ap p lic ab ilityo f th e E M T A L A , th e b u r d e n s h if ts b a c kto N ol en t o sho w the exi st ence of a genui ne i ss ue of m at er i al fa ct . H am m erv. S l at er , 2 0 F .3 d 1 1 3 7 , 1 1 4 1 ( 1 1 th C ir . 1 9 9 4 ) . N o le n d id n o t m e e t th a t b u r d e n . T he un di sput ed re cord show s thatN ol en, i f anythi ng , re ce i ved sup er i or care f r om the H os pi t a l . R e i ns vol d pr om pt l ys um m one d D r . Z a nn t o pe r f orm a n i np e r s o n e x a m o f

N o le n , w h ic h o n ly6 p e r c e n t o f s im ila r lys itu a te d p a tie n ts r e c e iv e . T h e u n c o n tr o v e rte d e v id e n c e s h o w e d th a t 9 4 p e r c e n t o f o th e rp a tie n ts w h o c a m e to the H os pi t a l f

oral aborc he c k di d notr e c e i ve a s e xt e ns i ve as c r e e ni ng a s the one N o le n r e c e iv e d . A s th e F o u rth C ir c u it h a s e x p la in e d , ah o s p ita l h a s e v e ryr ig h t to t ai l or i t s s cr ee ni ng procedures t o a pat i entt o acc ou ntfor hercond i t i on , st at ed s y m pt om s , a nd the de t e rm i na t i ons m a de byhe rpe r s ona l phy s i c i a n. B abe rv. H os p. C o rp . o f A m . , 9 7 7 F . 2 d 8 7 2 , 8 7 9 n . 6 (4 th C i r. 1 9 9 2 ); see al so B ak er v . A d v en t i st H e a lth , I n c ., 2 6 0 F .3 d 9 8 7 , 9 9 5 ( 9 th C ir . 2 0 0 1 ) ( “H o s p ita ls a r e n o t r e q u ir e d to p r o v id e p a tie n ts p r e s e n tin g d if f e r e n t s y m p to m s w ith id e n tic a l s c r e e n in g s .” ) . N ol e n’ s tr e a tm e ntw a s pr ovi de d pr i m a r i l ybyhe rpr i va t e phy s i c i a n, w ho w a s i n a9

b e tte rp o s itio n to p r o v id e c a r e b e y o n d th e s c r e e n in g m a n d a te d b yth e E M T A L A . S o lo n g a s th e H o s p ita l g a v e to N o le n th e s a m e q u a litys c r e e n in g th a t it w o u ld h a v e g iv e n as im ila r lys itu a te d o u tp a tie n t, th e r e is n o v io la tio n o f th e E M T A L A . H a rry , 291 F . 3d a t770. S e c o n d , w e tu rn to N o le n ’s a r g u m e n t th a t th e d is tr ic t c o u rt im p e rm is s ib ly w ei gh ed evi dence and usurped the f un ct i on of a j ury. W e di sa gree . T he H ospi t al proffe re d evi dence fr om expert s and the pri nci pal s thatconfi rm ed thatN ol en r e c e i ve d a n a de qua t e s c r e e ni ng. I tw a s N ol e n’ s r e s pons i bi l i tythe n t o pr e s e nt evi dence of a genui ne i ss ue of m at er i al fa ct , w hi ch w ou l d h ave prec l ud ed sum m ary j udgm e nt . C e l ot e x, 477 U . S . a t322- 24, 106 S . C t . a t2552- 54. N ol e n di d not s a tis f y th a t b u r d e n , a n d th e d is tr ic t c o u rt p r o p e r lyg r a n te d s u m m a ryju d g m e n t. B aberi s a l so i nstruct i ve on thi s poi nt . T he F ou rth C i rc ui thel d i n B aberthat one c ur s ory a f

f i da vi tf r om aphy s i c i a n w a s i ns uf f i c i e ntt o c r e a t e age nui ne i s s ue of m a t e r i a l f

a c ta s t o the a de qua c y of the s c r e e ni ng tha tthe pa t i e ntr e c e i ve d. 977 F . 2d a t 8 8 1 - 8 2 . N o le n h a s f

a ile d to p r e s e n t e v e n as in g le a f f id a v it o f ap h y s ic ia n to d is p u te th e a d e q u a c y o f th e s c r e e n in g p r o v id e d b yth e H o s p ita l. A cco rd i n g l y, th e su m m ary j u d g m en ten t ered b y th e d i stri ctco u rti s AF F I RME D.