Opinion ID: 2977728
Heading Depth: 2
Heading Rank: 4

Heading: Existence of an Emergency Medical Condition

Text: The district court’s reasoning in granting summary judgment was partially predicated on its finding that the hospital conducted an appropriate screening, and that “no emergency medical condition was recognized on the screening.” (J.A. at 216.) We believe that whether Howard had an emergency medical condition that the hospital recognized upon screening him is an issue of fact that the court should have left for a jury to decide. As an initial matter, “before summary judgment may be granted against a party, Fed. R. Civ. P. 56(c) mandates that the party opposing summary judgment be afforded notice and a reasonable opportunity to respond to all issues to be considered by the court.” Routman v. Automatic Data Processing, Inc., 873 F.2d 970, 971 (6th Cir. 1989). “Rule 56(c) requires at a minimum that an adverse party be extended at least ten days notice before summary judgment may be entered.” Id. “Noncompliance with the time provision of the rule deprives the court of authority to grant summary judgment, unless . . . [inter alia] there has been no prejudice to the opposing party by the court’s failure to comply with this provision of the rule.” Kistner v. Califano, 579 F.2d 1004, 1006 (6th Cir. 1978) (citations omitted). In this case, the district court granted summary judgment from the bench at the end of oral argument, and based its decision in part on the fact that the hospital never detected an emergency medical condition–a ground that Defendants had not raised prior to oral argument. Moreover, Defendants’ briefs in support of their summary judgment motion did not include any supporting evidence whatsoever, as their written arguments were based purely on statutory interpretation; to the extent that the district court relied on any evidence at all with respect to this ground, such evidence came from exhibits Defendants attached to previous filings. Although there is no rule prohibiting the district court from considering previously submitted evidence–see Fed. R. Civ. P. 56(c) (allowing court to consider “the pleadings, the discovery and disclosure materials on file” in resolving a motion for summary judgment) (emphasis added)–it is still difficult to discern how Plaintiff could have received sufficient notice of this argument, or a No. 07-2111 Moses v. Providence Hospital and Medical Ctrs., et al. Page 16 reasonable opportunity to oppose it with evidence, without being advised that this issue would determine the district court’s ruling on the motion. With respect to prejudice, Plaintiff argues that had she known Defendants would raise the absence of an emergency medical condition at oral argument, she would have included Dr. Bursztajn’s expert report in her opposition to Defendants’ motion. Defendants had notice of Dr. Bursztajn’s report, because it was filed in connection with a previous motion to compel during discovery. We therefore will consider Dr. Bursztajn’s report on appeal. In reviewing this report as well as the remainder of the evidence in the record, we find that issues of fact exist with respect to whether the hospital physicians actually believed Howard lacked an emergency medical condition. An “emergency medical condition” is “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 . . . [inter alia] placing the health of the individual . . . in serious jeopardy[.]” § 1395dd(e)(1)(A)(i). The language in the statute does not appear to preclude classifying a psychiatric condition as an emergency medical condition, and “the health of the individual” could certainly include the individual’s mental health. Moreover, we are not aware of any discussion of this issue in the legislative history. Without such guidance, we hold that a mental health emergency could qualify as an “emergency medical condition” under the plain language of the statute. A. Howard’s Condition Upon Arrival at the Hospital At the time he came to the hospital, Howard was experiencing slurred speech, disorientation, hallucinations and delusions, and was making threatening statements, including telling his wife that he had “bought caskets.” (J.A. at 150.) Howard’s condition included physical symptoms such as severe headaches, muscle soreness, high blood pressure and vomiting. Moreover, Dr. Bursztajn’s report, based on a review of Howard’s hospital records, concluded that Howard had an emergency medical condition upon arriving at the hospital. Thus, there is plenty of evidence in the record to create an issue of fact with respect to whether Howard’s condition was a mental health emergency. No. 07-2111 Moses v. Providence Hospital and Medical Ctrs., et al. Page 17 However, in order to trigger further EMTALA obligations, the hospital physicians must actually recognize that the patient has an emergency medical condition; if they do not believe an emergency medical condition exists because they wrongly diagnose the patient, EMTALA does not apply. Roberts ex rel. Johnson v. Galen of Virginia, Inc., 325 F.3d 776, 786 (6th Cir. 2003).1 Yet while actual knowledge is required, “any hospital employee or agent that has knowledge of a patient’s emergency medical condition might potentially subject the hospital to liability under EMTALA.” Id. at 788. Howard was admitted to the hospital so that the hospital physicians could conduct further tests, including an MRI, a lumbar puncture and a psychiatric evaluation. On the first day of testing, Dr. Silverman’s note that “an acute psychotic episode [must] be ruled out” indicated both the possible seriousness of Howard’s condition and the need for further testing before a complete diagnosis could be made. (J.A. at 153, 158.) Dr. Lessem diagnosed Howard on December 17, 2002 as having “atypical psychosis,” determined that Howard should be transferred to 4 East, and instructed 4 East doctors to take “suicide precautions.” (J.A. at 173.) A legitimate possibility that the patient might commit suicide would appear to “place the health of the individual . . . in serious jeopardy,” and could thus fall under the category of “emergency medical condition.” See § 1395dd(e)(1)(A)(i). It is noteworthy that Dr. Lessem recommended Howard be transferred to 4 East, the unit for patients “who are acutely mentally ill.” (J.A. at 160.) This evidence supports Plaintiff’s claim that the hospital physicians believed Howard had an emergency medical condition upon his admission. B. Howard’s Condition Upon Discharge Defendants argue further that, to the extent that Howard had an emergency medical condition at the time of his admission, the hospital physicians no longer believed that he had such a condition when they released him–i.e., that he was stable upon 1 To the extent Plaintiff argues that the hospital’s physicians were negligent in failing to recognize that Howard had an emergency medical condition, such an allegation is reserved for state malpractice law. See, e.g., Bryant v. Adventist Health Sys., 289 F.3d 1162, 1166 (9th Cir. 2002). No. 07-2111 Moses v. Providence Hospital and Medical Ctrs., et al. Page 18 discharge. In Cleland, this Court, in affirming summary judgment for the defendant, explained why it was clear that the responsible doctors reasonably believed the patient had been stable upon discharge: To all appearances, the plaintiff’s condition was stable. He was not in acute distress, neither the doctors nor the patient or his parents made the slightest indication that the condition was worsening in any way, or that it presented any risk that might become life-threatening, or that it would worsen markedly by the next day. 917 F.2d at 271. Plaintiff has introduced evidence that challenges whether any of these signs of stability noted in Cleland existed with respect to Howard. First, the “final diagnosis” of Howard upon discharge of an “atypical psychosis [with] delusional disorder” was substantially the same as Dr. Lessem’s diagnosis on December 17, 2002, which included “atypical psychosis.” (J.A. at 169, 178.) Moreover, Dr. Bursztajn’s report concludes that “the symptoms and mental state described by Dr. Lessem could not be resolved in one to two days, yet the decision to discharge Mr. Howard was made one day later.” (J.A. at 68-69.) The doctors were aware on the day they released Howard that Howard’s wife did not think he had improved, and in fact still “fear[ed] him.” (J.A. at 219.) Finally, Dr. Lessem’s note dated December 17, 2002, in which he writes “will accept [Howard] to 4 east if [Howard]’s insurance will accept criteria” (J.A. at 172), creates at the very least a credibility issue with respect to whether the hospital physicians actually believed that no emergency condition existed upon Howard’s release. To support their argument, Defendants cite Dr. Mitchell’s progress note dated December 18, 2002, which states, “[Howard’s] affect is brighter. No physical symptoms now. [He] wishes to go home, wife fears him. Denies any suicidality.” (J.A. at 219.) Defendants also cite Dr. Mitchell’s progress report dated December 19, 2002 stating that Howard “cannot stay as he is medically stable and now does not need 4 [East].” (J.A. at 89.) First, these notes do not refute Plaintiff’s evidence that Dr. Lessem believed Howard was still unstable at the time of his release. But more importantly, while these notes may arguably provide a basis for a jury to find for Defendants, for the reasons No. 07-2111 Moses v. Providence Hospital and Medical Ctrs., et al. Page 19 discussed, Plaintiff’s evidence still raises a dispute of fact with respect to whether Howard had an emergency condition on the day of his release, and what the hospital’s doctors believed when they released him. Because issues of fact exist relating to Howard’s medical condition–upon his initial screening as well as prior to his release–the district court erred in granting summary judgment on this ground.