Power v. Arlington Hosp. Ass’n, 42 F.3d 851, 1994 U.S. App. LEXIS 34586 (4th Cir. 1994)

This lengthy and detailed opinion involved a patient who came to the emergency room of the hospital with pain in her left hip, abdomen, and back. After being evaluated by two nurses and two physicians, she was discharged on pain medication and provided with the name of an orthopedist, with instructions to return to the hospital if the pain became worse. The chart reflected that the patient was “unemployed and uninsured.” Several tests were performed, and x-rays were ordered. The physician examined the patient and found her to be “uncomfortable” but that she did “not look ill in terms of toxic.” The physician ordered only a urinalysis, but believed the patient’s pain to be musculoskeletal.  The patient returned to the ER the next day with virtually no blood pressure. She was diagnosed as suffering from septic shock, was admitted to the ICU, where she remained for four months on life support. She had both of her legs amputated, lost sight in one eye, and experienced permanent lung damage.

The plaintiff brought a failure to screen claim and also alleged that she should not have been transferred to another hospital in an unstable condition. After a trial, the jury found in favor of the failure to screen claim and awarded $5 million. First, regarding the screening claim, the court found that the jury’s verdict was appropriate given that the plaintiff presented testimony that the patient had not been screened appropriately and according to other patients with similar symptoms.  The defendant argued, relying on Cleland from the Sixth Circuit, that there was no proof of improper motive and thus the screening claim could not stand. The court rejected this argument, and found that there is no improper motive requirement under EMTALA. The court was swayed primarily by the fact that it would be difficult, or impossible, for plaintiffs to prove this requirement, and the court did “not believe that proving the inner thoughts and prejudices of attending hospital personnel is required in order to recover under EMTALA.” Id. at 23. The court, clarifying the standard for such a claim, that the patient can show disparate treatment by showing non-conformity with a standard policy, and the hospital can then show ‘that a test or procedure was not given because the physician did not believe that the test was reasonable or necessary under the particular circumstances.” Id. at 25.

Second, the court also went on to analyze whether the plaintiff’s claim should be reduced in light of Virginia’s cap for medical malpractice damages ($1 million), and also a limit on damages in “tort” against a tax-exempt hospital (also $1 million). The court found specifically that Congress “explicitly directed federal courts to look to state law in the state where the hospital is located to determine both the type and amount of damages available in EMTALA actions.” Id. at 37. The question was whether the Virginia law would apply to a claim alleging disparate treatment, as opposed to a claim alleging breach in the standard of care. The court found that the law would apply, given that the claim was brought against medical health care providers, the receipt of “health care,” and the claim was based on the provision of such services. The court was persuaded by the language “damages available” under state law in the statute, and reasoned that the damages would not be available under a similar state law claim in Virginia due to the cap. The court reached the same conclusion regarding Virginia’s cap against tax-exempt hospitals, finding that the hospital was a non-profit under § 501(c)(3) of the internal revenue code. Because the EMTALA claim was essentially a tort action, the cap applied.

 

Notes: This case contains detailed and exhaustive analyses of the standards to prove a failure to screen claim and also an analysis of the application of state malpractice damage caps to EMTALA claims. A very good read for anyone looking for a discussion of the policy considerations behind the failure to screen claim and the subsequent decisions interpreting it.