Jackson v. East Bay Hospital
O’Scannlain, Judge.
County. At Redbud, a nurse took Jackson’s medical history, vital signs, current medications and drug aller- gies. Half an hour later, Dr. Wolfgang Schug, a Redbud We must decide, among other questions, whether emergency room doctor, examined Jackson and or- a hospital violates the Emergency Medical Treatment dered blood tests. Dr. Schug noted that Jackson was and Active Labor Act (“EMTALA”) if it fails to diag- reporting hallucination, dizziness, and unsteadiness, nose the cause of a patient’s emergency condition, but and that he was taking Anafranil and Ativan. Dr. Schug treats the symptoms identified, and concludes that the then diagnosed Jackson as suffering from acute psy- chosis; neither he, nor any other Redbud physician or employee, diagnosed Jackson as suffering from an emergency medical (as opposed to a psychological or This appeal arises out of Robert Jackson (“Jack- son”)’s visits to the Redbud Community Hospital Redbud did not offer psychiatric care to its pa- (“Redbud”) emergency room on April 2, 4, and 5, tients, and the unwritten policy of the Redbud emer- 1996, in Clearlake, California. Redbud entered into an gency room was that when a patient presented to the “Association Agreement Regarding the Affiliation of emergency room with psychiatric complaints, the pa- Redbud Health Care District with Adventist Health tient would be examined to determine if there were any Systems/West” (the “Association Agreement”) which medical components to his problem. If a medical prob- became effective on July 5, 1995. This agreement stated lem was found, it would take precedence over the psy- that the parties anticipated a future affiliation, and that chiatric complaints. If no medical problem was found, Adventist Health Systems/West (“Adventist”) would the patient would be referred to a psychiatrist or to a provide Redbud with administrative and financial ser- mental health facility for an appropriate psychiatric vices. On July 1, 1997, Adventist and Redbud entered follow-up. Dr. Schug arranged for Lake County (which into an “Agreement for Purchase and Sale of Assets” provides psychiatric care) to see Jackson upon his re- (the “Purchase Agreement”). Adventist currently oper- lease, where he was evaluated by Dennis Skinner, a On April 2, 1996, Jackson visited the Lake County On April 4, 1996, Jackson returned to the Red- Mental Health Department (“Lake County”) to see a bud emergency room. A triage nurse took Jackson’s psychiatrist. Jackson previously had been diagnosed medical history, vital signs, and current medications. with psychotic disorder, borderline intellectual func- An hour later, Dr. Miguel Ollada, a Redbud emer- tioning, and pedophilia. The Lake County staff in- gency room doctor, took a separate medical history structed Jackson to go to the Redbud emergency room and evaluated Jackson, who complained of a sore to receive a medical clearance before returning to Lake throat, chest pain while breathing, and dry heaves. Dr. Ollada also observed Jackson talking to himself. Dr. a life-threatening condition, and that a transfer to East Ollada performed a complete physical exam, and or- Bay Hospital did not pose a risk to Jackson’s condition. dered a battery of tests including an electrocardio- At 9:15 a.m., Redbud transferred Jackson to East gram, a urine screening, and a blood gas test. The Bay, where he was seen by Dr. Spencer Steele, a psychia- urine analysis indicated the presence of a tricyclic an- trist who performed a psychiatric, but not a physical, tidepressant, such as the Anafranil Jackson was examination of Jackson. At the time of the transfer, Dr. known to be taking. Dr. Ollada diagnosed Jackson as Ollada believed that Jackson’s condition had been stabi- having chest contusions, hypertension, and psychosis, lized. Dr. Steele prescribed more Haldol for Jackson. but not drug toxicity. Dr. Ollada gave Jackson medi- Shortly before 2:00 p.m., the East Bay medical staff con- cations, and ordered a mental health consultation, to cluded that Jackson was so unable to control his own be conducted at Lake County. Lake County refused to movements that he posed a danger to himself and oth- evaluate Jackson, however, because he had been re- ers. At 2:00 p.m., Jackson went into cardiac arrest. East cently seen by its staff, who found him to be non- Bay staff began to perform CPR, and they ordered an suicidal. Believing Jackson to be non-suicidal, and his ambulance to transfer Jackson to Brookside Hospital condition to have stabilized, Dr. Ollada released Jack- (“Brookside”). Jackson arrived at Brookside’s emergency son from Redbud, and he instructed Jackson to return room at approximately 2:30 p.m. Jackson received emer- gency care at Brookside, but he was pronounced dead at At 3:45 a.m. on April 5, 1996, Jackson returned to 2:37 p.m. An autopsy determined that Jackson died from the Redbud emergency room after his wife found him sudden cardiac arrhythmia, caused by acute psychotic wandering in the road in the middle of the night. A delirium, which was in turn caused by clomipramine nurse performed an initial medical evaluation, and Dr. (Anafranil) toxicity. None of the doctors or nurses who Ollada performed another examination at 3:50 a.m. Dr. saw Jackson at Redbud diagnosed him as suffering from Ollada observed that Jackson was very agitated, but he also observed that Jackson had a regular heartbeat, and Barbara Jackson and Sandra Jackson, Jackson’s that he presented no other physical symptoms. Barbara wife and daughter (“Jackson’s survivors” or “the survi- Jackson told Dr. Ollada that she believed that her hus- vors”) filed suit against the physicians who treated band was suicidal, because she found him in the middle Jackson, East Bay Hospital, Redbud, and Adventist in of the road, waving his hands. Dr. Ollada determined the Northern District of California. Their complaint that Jackson was suffering from a psychological disor- asserted claims under EMTALA [and California state der which caused his agitation, but that he was not suf- fering from any physical disorders. Dr. Ollada EMTALA imposes a series of obligations on a hos- prescribed and administered Haldol and Benadryl in an pital emergency department. First, the hospital must effort to sedate Jackson and to stabilize his condition. provide an “appropriate medical screening examination Dr. Ollada ordered that Lake County be contacted re- within the capability of the hospital’s emergency depart- ment.” . . . If the hospital detects an emergency medical Later in the morning of April 5, Susan Smith, a condition, the hospital must provide “either (A) within Lake County crisis worker, evaluated Jackson. Smith the staff and facilities available at the hospital, for such found that Jackson’s condition met the criteria for in- medical examination and such treatment as may be re- voluntary psychiatric commitment, and she concluded quired to stabilize the medical condition, or (B) for the that he suffered from a psychological disorder, anxiety, transfer of the individual to another medical facility. . . .” and a dependent personality. Smith then asked Dr. “If an individual at a hospital has an emergency medical Ollada to clear Jackson for a transfer to East Bay Hos- condition which has not been stabilized . . . the hospital pital (“East Bay”), which functioned almost exclusively may not transfer the individual unless . . . a physician has as a psychiatric hospital. Dr. Ollada found that Jack- signed a certification that based upon the information son’s condition had stabilized (he was no longer agi- available at the time of transfer, the medical benefits tated, and was sleeping), that he was not suffering from reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh according to Redbud guidelines, and that Jackson was the increased risks to the individual. . . .” triaged by a nurse and examined by a doctor during Jackson’s survivors argue that Redbud violated each of his visits to the Redbud emergency room. Dur- EMTALA’s screening requirements by providing medi- ing these visits, the physicians performed several physi- cally inadequate screening examinations and by failing to cal examinations and ordered multiple laboratory tests. order additional tests on April 5, when, they allege, it was The district court also concluded that Jackson’s survi- obvious that Jackson was suffering from a physical dis- vors failed to create a genuine issue of material fact that order, and not a psychological one. The survivors also these examinations were so substandard or of such low argue that the examinations performed by Redbud’s quality as to violate EMTALA, and that the Jackson’s doctors and nurses were so wanting as to be “inappro- survivors’ expert witnesses established nothing more priate” medical screening examinations. Acknowledging than a failure to properly diagnose Jackson’s symptoms, the weight of authority supporting the district court’s an error which might result in state tort liability, but not conclusion that an examination does not have to be in EMTALA liability. The district court also rejected as “medically adequate” to satisfy EMTALA’s require- groundless the argument that Jackson was treated dif- ments, they ask us to overrule those precedents. In addi- ferently from other patients because he exhibited psy- tion, they argue, without evidentiary support, that there chiatric, and not just physical, symptoms. It also is a material possibility that the doctors acted in bad faith rejected the argument that the Redbud physicians de- because their diagnoses were “inherently implausible.” parted from their own procedures when they consulted We reject all of these arguments, and hold that Redbud satisfied its EMTALA screening obligations. The district court properly concluded that Redbud “The statutory language of the EMTALA clearly complied with EMTALA’s screening requirements. . . . declines to impose on hospitals a national standard of Jackson’s survivors also argue that Redbud failed care in screening patients.” . . . Seven of our sister cir- to stabilize Jackson’s emergency medical condition cuits have held that to comply with this requirement, a prior to his transfer to East Bay . . . As we have previ- hospital only must provide a screening examination ously explained, a “hospital’s duty to stabilize the pa- that is comparable to that offered to other patients with tient does not arise until the hospital first detects an emergency medical condition.” In Eberhardt, the plain- In Eberhardt, we did not explicitly adopt this com- tiff claimed that the hospital violated EMTALA’s stabi- parative test as the standard . . . We now adopt this lization requirements by failing to treat his son’s comparative test. We hold that a hospital satisfies suicidal tendency, and that this failure led to his son’s EMTALA’s “appropriate medical screening” require- death. We rejected this argument, and held that the ment if it provides a patient with an examination com- hospital had no obligation to stabilize the son’s suicidal parable to the one offered to other patients presenting tendency, because the hospital never detected it. This similar symptoms, unless the examination is so cursory “actual detection” rule comports with the law of five that it is not “designed to identify acute and severe symptoms that alert the physician of the need for im- . . . Redbud stabilized the only emergency condi- mediate medical attention to prevent serious bodily tion its doctors detected: agitation which posed a risk injury.” This standard is consistent with Congress’s purpose in enacting EMTALA, which was to limit the The parties agree that Dr. Ollada believed that he ability of hospitals to avoid treating poor or uninsured had stabilized Jackson’s condition at the time of his transfer to East Bay, and that he believed that Jackson The district court concluded that there was no was no longer agitated at that time. The parties’ dis- genuine issue of material fact that Jackson received agreement concerns medical conditions which re- initial screening examinations which satisfied Redbud’s mained undetected by the Redbud medical staff. . . . EMTALA obligations. The court noted that the Red- The survivors also contend that Redbud violated bud doctors and nurses performed these screenings EMTALA’s certification requirements because Dr. Ollada did not “sign[ ] a certification . . . that based judgment on the EMTALA claim. The district court upon the information available at the time of transfer, found that the Redbud doctors provided medical the medical benefits reasonably expected from the pro- screenings, examinations, and evaluations designed to vision of appropriate medical treatment outweigh the determine whether Jackson had an emergency condi- risks to the individual.” . . . The survivors argue that the tion, and the court found that Redbud provided the certification form signed by Dr. Ollada was deficient care and treatment required to eliminate the emer- because the form did not contain specific written de- gency condition Dr. Ollada identified (Jackson’s agita- scriptions of each of those risks and benefits. We con- clude, however, that EMTALA’s certification The survivors . . . contend that the provision in requirement does not apply in the circumstances of this [the statute] precluding liability “if a refusal to render case. The certification provision applies only when a emergency services or care . . . is based on the deter- hospital has detected an emergency medical condition mination, using reasonable care, that the person is not and thereafter elects to transfer the patient, rather than suffering from an emergency condition” establishes a reasonable care standard for liability . . . . They further argue that the opinions provided by their medical experts constitute material evidence supporting the California Heath and Safety Code imposes on Cali- conclusion that Redbud doctors did not act reasona- fornia hospitals an obligation to tend to all patients bly when they determined that Jackson was suffering from a psychological, and not a physical, condition. Emergency services and care shall be provided The logical reading of [the statute], which we to any person requesting the services or care, or adopt, is that its duty of reasonable care only applies for whom services or care is requested, for any in two situations: First, it applies when the hospital condition in which the person is in danger of does not provide a medical screening, examination, or loss of life, or serious injury or illness, at any evaluation to determine if the patient presents an health facility licensed under this chapter that emergency medical condition. Such a failure consti- maintains and operates an emergency depart- tutes “a refusal to render emergency services and ment to provide emergency services to the care.” There is no dispute that Redbud provided public when the facility has appropriate facili- medical screenings and examinations designed to de- ties and qualified personnel available to provide termine if Jackson suffered from an emergency medi- The statute defines “emergency services and care” Second, [its] duty of reasonable care applies when as “medical screening, examination, and evaluation by a a doctor diagnoses a condition, but declines to provide physician . . . to determine if an emergency medical treatment because he determines either that the condi- condition or active labor exists and, if it does, the care, tion is not an “emergency medical condition” or that treatment, and surgery by a physician necessary to re- the hospital does not have the appropriate facilities or lieve or eliminate the emergency medical condition, personnel to provide care. . . . If a hospital does not within the capability of the facility.” diagnose an emergency condition, it cannot “refus[e] to [The statute] also provides a safe harbor for hospi- render emergency care,” because one cannot “refuse” tals and doctors who refuse to render care, provided to treat a condition one does not detect. . . . that their refusal is based on a determination that the person is not suffering from an emergency condition or that they cannot treat the emergency condition afflict- Noting that the non-statutory claims against Ad- ventist were tort claims, the district court held that The district court granted Redbud summary judg- Adventist’s liability, if any, could only arise out of its ment . . . for the same reasons it granted it summary contractual relationship with Redbud under a joint venture or joint tortfeasor theory of liability. The dis- The survivors also argue that the district court trict court then held that Adventist and Redbud were erred when it concluded that Adventist and Redbud neither joint venturers nor joint tortfeasors. On ap- were not joint tortfeasors. . . . In light of the limited peal, the survivors argue that Adventist is directly role Adventist played in the provision of patient care, liable under EMTALA, and that the district court the district court properly concluded that Adventist’s erroneously concluded that Adventist and Redbud connection to Jackson’s injury was too tenuous to were neither joint venturers nor joint tortfeasors. support a conclusion that Adventist owed Jackson a The argument that Adventist is directly liable un- duty of care. The district court properly determined der EMTALA contradicts our precedents and the that Adventist was not Redbud’s joint tortfeasor. statutory definition of a “hospital.” . . . The district court properly granted summary judg- The survivors next argue that the Association ment to Redbud and Adventist on Jackson’s survivors’ Agreement created a joint venture or joint enterprise EMTALA and [state law] claims. The district court also properly held that Adventist was not liable, as a matter of



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