(This is the second installment of a three-part series.)

Question: Emergency Medical Treatment and Labor Act (EMTALA) litigation has yielded which of the following rules of law?

A. The statute is applicable only when a patient is physically in the hospital’s emergency department (ED).

B. Directing an ambulance away from the ED is a violation of EMTALA.

C. All patients presenting to the ED must have an appropriate medical screening exam conforming to customary standard of care.

D. It is not what is performed in any medical screening exam, but whether it is applied evenly to all patients similarly situated.

E. The U.S. Supreme Court has held that an improper motive behind an unstable transfer is a prerequisite to an EMTALA violation.

Answer: D. In 1986, Congress enacted the Emergency Medical Treatment and Labor Act to ensure that all patients who present themselves to the emergency department are appropriately screened for an emergent medical condition, and if one is present, that they be stabilized prior to transfer or discharge.

In the 3 decades since its enactment, the statute has, as expected, spawned numerous lawsuits. Parts two and three of this series on EMTALA summarize the salient findings and rules of law in several interesting and impactful cases. These cases are neither encyclopedic nor necessarily representative of the types of litigation commonly encountered.

EMTALA is about events in the emergency department. They begin with the patient coming to the ED seeking treatment, and the statute specifically refers to “any individual … [who] comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition.”

But what if the patient has yet to arrive, e.g., in an ambulance en route, and was diverted elsewhere in an unstable condition? In Hawaii’s case of Arrington v. Wong ( 237 F.3d 1066 [9th Cir. 2001] ), the court was faced with whether the requirement that a patient must first “come to” the hospital means his or her literal physical presence in the hospital.

On May 5, 1996, Harold Arrington developed dyspnea while driving to his job as a security guard. En route to the closest medical facility, the Queen’s Medical Center, the ambulance personnel contacted Dr. Norbert Wong, the physician on call, describing the patient as being in severe respiratory distress, speaking one to two words at a time, and breathing about 50 times a minute.

Although Queen’s was not on diversionary status at the time, Dr. Wong thought it was okay for the ambulance to go instead to Tripler Hospital, a more distant hospital, as the patient’s doctor worked there. Unfortunately, by the time the ambulance arrived at Tripler, Mr. Arrington’s condition had deteriorated, and he was pronounced dead shortly after arrival.

The lower court ruled for the defendant, holding that the statute demanded an actual physical presence in the ED, but the 9th Circuit Court of Appeals reversed. It held that under EMTALA, a hospital may divert an ambulance that has contacted its emergency department and is on the way to that hospital only if the hospital is in diversionary status, because the diverting hospital then has a valid, treatment-related reason for doing so.

Such an interpretation of the law works no hardship on the hospital and is consistent with the Centers for Medicare & Medicaid Services’ regulation that “only requires hospitals that offer emergency services to provide screening and stabilizing treatment within the scope of their capabilities.” The 9th Circuit felt that this was consistent with the purpose and language of the EMTALA statute.

The next case, Summers v. Baptist Medical Center ( 91 F. 3d 1132 [8th Cir. 1996] ), addressed the screening aspect of EMTALA, specifically on the distinction between disparity and adequacy in screening procedures. In Summers, the plaintiff fell from a tree while hunting and sustained bilateral hemothoraces, vertebral, rib, and sternal fractures. Incredibly, the diagnosis in the first hospital ED was muscle spasms, and the diagnoses only became clear when he checked into a second hospital 2 days later.

Still, the court ruled that there was no EMTALA violation, and that allegations of substandard care should be addressed under a negligence theory in state courts and not under EMTALA. The court reasoned that under the statute, an “inappropriate” screening is one that is performed in a disparate manner to similarly situated patients, and the hospital itself is usually left to define for itself what is within its capabilities. It is up to the hospital itself to determine what its screening procedures will be and to apply them alike to all patients with comparable complaints.

Likewise, in Vickers v. Nash ( 78 F.3d 139 [4th Cir. 1996] ), an intoxicated patient who sustained a head injury following a fight died 4 days later from an epidural hematoma that was missed. He did have his head laceration treated in the ED, and was observed for 11 hours before discharge. The court ruled that the plaintiffs had failed to prove there was disparate treatment, and that hospitals can only be expected to stabilize emergency medical conditions known to them at the time.

Finally, in its first and thus far only EMTALA case, the U.S. Supreme Court in 1999 looked at whether an improper motive was a prerequisite for a finding of an EMTALA violation regarding stabilization and transfer.

In Roberts v. Galen of Virginia ( 119 S. Court 685 [1999] ), the patient, injured in a truck accident, required a splenectomy and ventilator support. After a prolonged hospital stay, she was about to be moved to a nearby nursing home when she developed a high fever from an infection, and had to be transferred to an acute care facility. Her guardian, Roberts, brought suit, asserting violations of EMTALA’s stabilization and transfer requirements. The hospital argued that no material deterioration of the condition was likely to result from or occur during the transfer, and the district court determined her transfer was not prompted by an improper motive.

On appeal, the 6th Circuit Court of Appeals affirmed, extending its earlier holding that a showing of improper motive was required to make out an inadequate screening claim under EMTALA.

The hospital raised a number of important defenses, which included the physician lacking actual knowledge that the patient had an emergency medical condition, that EMTALA did not apply to in-hospital treatment and discharge decisions, and denying that EMTALA imposes minimum substantive standards of medical care.

The U.S. Supreme Court granted certiorari on the single issue whether the improper motive test should apply to an allegedly wrongful transfer. Overturning the appeals court, it held that Section 1395dd(b) (stabilization and transfer) contained no express or implied “improper motive” requirement. The Supreme Court declined to resolve broader issues under the statute.

Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at siang@hawaii.edu .