Opinion ID: 196369
Heading Depth: 2
Heading Rank: 1

Heading: sufficiency of the evidence

Text: 15 The Hospital's multi-pronged attack calls into play varying standards of appellate review. The first five claims of error all involve the sufficiency of the evidence, and, hence, are reviewed under a familiar set of rules. 16 The district court's denial of a motion for judgment as a matter of law poses a question of law and, therefore, this court's review of such a ruling is plenary. See Gibson v. City of Cranston, 37 F.3d 731, 735 (1st Cir.1994). In addressing such issues on appeal, we must approach the evidence from a coign of vantage identical to that employed by the district court in the first instance. See Rolon-Alvarado v. Municipality of San Juan, 1 F.3d 74, 77 (1st Cir.1993). This dictates that we take the record in the light most flattering to the nonmoving party, without probing the veracity of the witnesses, resolving conflicts in the testimony, or assaying the weight of the evidence. See Gibson, 37 F.3d at 735; Wagenmann, 829 F.2d at 200. We may reverse the denial of such a motion only if reasonable persons could not have reached the conclusion that the jury embraced. Sanchez, 37 F.3d at 716. 17 1. EMTALA Coverage. The Hospital starts its series of sufficiency sorties by solemnly stating that the survivors stumbled in failing to show that it is subject to EMTALA's suzerainty. We need not tarry. HSF tacitly concedes that, in general, federal courts have jurisdiction over EMTALA claims, see Thornton v. Southwest Detroit Hosp., 895 F.2d 1131, 1133 (6th Cir.1990), but argues that the plaintiffs did not prove a requisite predicate fact: that HSF had accepted the federal government's carrot and agreed to come under EMTALA. 6 This argument has the shrill ring of desperation. 18 The plaintiffs introduced into evidence, without objection, HSF's policy statement outlining for its employees and associates how the Hospital intended to ensure compliance with EMTALA in its emergency room. The Hospital solidified this proffer when, during the defense case, its health services administrator testified that he had dutifully instructed his staff regarding the fine points of EMTALA compliance. Evidence admitted without limitation can be used by the jury on any issue in the case. See, e.g., United States v. Castro-Lara, 970 F.2d 976, 981 (1st Cir.1992), cert. denied, --- U.S. ----, 113 S.Ct. 2935, 124 L.Ed.2d 684 (1993). Here, the policy statement and the executive's testimony, without more, formed a sturdy basis on which the jury could build an eminently reasonable inference that the Hospital considered itself to be--and was--covered by EMTALA. 19 HSF strives to topple this edifice, contending that the policy statement constituted inadmissible hearsay and that the plaintiffs did not lay a proper foundation for the document's introduction. But in the absence of plain error--and we discern none here--these objections, voiced for the first time on appeal, are deemed to have been waived. See Suarez-Matos v. Ashford Presbyterian Community Hosp., Inc., 4 F.3d 47, 50 (1st Cir.1993); Freeman v. Package Mach. Co., 865 F.2d 1331, 1336 (1st Cir.1988); see also Fed.R.Evid. 103. Hence, the jury had a rational basis on which to conclude that HSF is among the ninety-nine percent of American hospitals covered by EMTALA. 20 2. Failure to Provide Appropriate Screening. Three of the Hospital's remaining four sufficiency-of-the-evidence claims are inextricably intertwined. These three claims are designed to illustrate the purported lack of any foundation for a finding that HSF failed to provide Ms. Gonzalez with an appropriate screening upon her appearance at the emergency room. The final sufficiency claim is closely related to the first three initiatives. In it, HSF posits that, as long as a hospital is not motivated by crass economic considerations, any failure appropriately to screen does not run afoul of EMTALA. These importunings lack merit. 7 21
22 We begin this analytic segment by laying a straw man to rest. The Hospital asserts that it had no obligation to screen because Ms. Gonzalez did not have an emergency medical condition when she reported to its facility. This theory of defense is doubly flawed. For one thing, EMTALA requires participating hospitals to provide appropriate screening to all who enter the hospitals' emergency departments, whether or not they are in the throes of a medical emergency when they arrive. See supra note 5 and accompanying text. For another thing, the record does not compel a conclusion that the decedent's emergency condition developed only after she consulted Dr. Rojas. 23 Angel Correa testified that he told HSF's receptionist that his mother was experiencing chest pains, and HSF concedes that a patient of Ms. Gonzalez's age who suffered from chest pains would be regarded as having an emergency medical condition. Yet the Hospital asks us to ignore this evidence in deference to Dr. Rojas's testimony that Ms. Gonzalez did not develop chest pains until some time after she arrived at Hospmed. There is no principled way in which we can accommodate HSF's request. Credibility choices are generally for the jury, not for the court of appeals. See Cook v. Rhode Island Dep't of Mental Health, Retardation, and Hosps., 10 F.3d 17, 21 (1st Cir.1993). What is more, Dr. Rojas's testimony does not rule out a finding that Ms. Gonzalez exhibited an emergency medical condition when she arrived at HSF. The chest pains might well have spurted and later subsided, or, even if Ms. Gonzalez only complained of nausea and dizziness, that symptomatology (as Dr. Rojas explained) might well herald the onset of an emergency medical condition in the case of a hypertensive diabetic (such as Ms. Gonzalez). 24
25 We next assess the Hospital's insistence that it gave Ms. Gonzalez the same (suitable) screening provided to all patients. EMTALA requires an appropriate medical screening, but does not explain what constitutes one. The adjectival phrase is not self-defining. See Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 271 (6th Cir.1990) ( 'Appropriate' is one of the most wonderful weasel words in the dictionary, and a great aid to the resolution of disputed issues in the drafting of legislation. Who, after all, can be found to stand up for 'inappropriate' treatment or actions of any sort?). In the last analysis, appropriateness, like nature, is a mutable cloud which is always and never the same. Ralph Waldo Emerson, Essays: First Series (1841). 26 Be that as it may, the courts have achieved a consensus on a method of assessing the appropriateness of a medical examination in the EMTALA context. 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. See Baber v. Hospital Corp. of Am., 977 F.2d 872, 879 (4th Cir.1992); Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C.Cir.1991). The essence of this requirement is that there be some screening procedure, and that it be administered even-handedly. 27 We add a caveat: EMTALA does not create a cause of action for medical malpractice. See Gatewood, 933 F.2d at 1041. Therefore, a refusal to follow regular screening procedures in a particular instance contravenes the statute, see Baber, 977 F.2d at 879, but faulty screening, in a particular case, as opposed to disparate screening or refusing to screen at all, does not contravene the statute. See Brooks v. Maryland Gen. Hosp., 996 F.2d 708, 711 (4th Cir.1993). In this case, HSF's delay in attending to the patient was so egregious and lacking in justification as to amount to an effective denial of a screening examination. Thus, we need not decide whether mere negligence in failing to expedite screening would itself violate the federal statute. 28 To illustrate our point, it should be recalled that HSF prescribed internal procedures which set the parameters for an appropriate screening. HSF's rules, as explicated in its policy statement, required its emergency room personnel, inter alia, promptly to take the vital signs of every patient who visited the facility, to make a written record of all such visits, to treat patients suffering from chest pains as critical cases, and to refer all critical cases to an in-house physician immediately. From the evidence adduced at trial, especially Angel Correa's recollections and the Hospital's utter inability to produce any records anent Ms. Gonzalez's visit, the jury reasonably could have inferred that the Hospital did not measure up to the parameters it had established, and that the decedent was denied the screening (monitoring of vital signs, compilation of a written chart, immediate referral to an in-house physician) that HSF customarily afforded to persons complaining of chest pains. 29 That ends the matter. Bearing in mind that, under EMTALA Sec. 1395dd(a), the same screening examination must be made available to all similarly situated patients, see Brooks, 996 F.2d at 710-11; Baber, 977 F.2d at 881, the jury's finding that HSF denied Ms. Gonzalez an appropriate screening examination is unimpugnable. 30
31 In an allied vein, the Hospital contends that it neither denied Ms. Gonzalez an initial screening nor refused her essential treatment. Its point is that it gave the patient a number, and would have ministered to her had she waited. This contention is spurious. 32 First, according to Dr. Rojas, HSF referred Ms. Gonzalez to Hospmed. If the jury believed the physician's testimony--and we note, as an aside, that HSF called Dr. Rojas as its witness--it could well have found that HSF never intended to treat the decedent, or, at the least, was itself responsible for truncating her wait. Second, we think that regardless of motive, a complete failure to attend a patient who presents a condition that practically everyone knows may indicate an immediate and acute threat to life can constitute a denial of an appropriate medical screening examination under section 1395dd(a). Much depends upon circumstances; we recognize that an emergency room cannot serve everyone simultaneously. But we agree with the court below that the jury could rationally conclude, absent any explanation or mitigating circumstances, that the Hospital's inaction here amounted to a deliberate denial of screening. EMTALA should be read to proscribe both actual and constructive dumping of patients. 33
34 HSF maintains that depriving a patient of an appropriate screening, in and of itself, will not support an EMTALA claim. It suggests that a hospital can be liable for transgressing the statute only if economic concerns, such as the suspicion that the patient will be unable adequately to pay her way, drive the hospital's actions. Since Ms. Gonzalez had insurance that permitted her hospital visit if an emergency existed, its thesis continues, its handling of her case could not have been motivated by concerns about her ability to pay. 8 As phrased, this contention raises a question of law, engendering de novo review. See Foster-Miller, Inc. v. Babcock & Wilcox Can., 46 F.3d 138, 147 (1st Cir.1995). 35 Every court of appeals that has considered this issue has concluded that a desire to shirk the burden of uncompensated care is not a necessary element of a cause of action under EMTALA. See, e.g., Power v. Arlington Hosp. Ass'n, 42 F.3d 851, 857 (4th Cir.1994); Collins v. DePaul Hosp., 963 F.2d 303, 308 (10th Cir.1992); Gatewood, 933 F.2d at 1040. 9 We think that these cases are correctly decided, and that EMTALA does not impose a motive requirement. The decision on which the Hospital relies, Nichols v. Estabrook, 741 F.Supp. 325 (D.N.H.1989), did not involve failure to screen, but merely a misdiagnosis. We hold, therefore, that EMTALA, by its terms, covers all patients who come to a hospital's emergency department, and requires that they be appropriately screened, regardless of insurance status or ability to pay. See 42 U.S.C. Sec. 1395dd(a). 36