Isaac-Burgos v. Rodriguez

Case 3:06-cv-01259-JP Document 102 Filed 05/02/2007 Page 1 of 14(cid:10)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO

YOLANDA ISAAC-BURGOS, et al.,
Plaintiffs
v.
DR. GILBERTO RODRIGUEZ, et al.,
Defendants

CIVIL NO. 06-1259 (JP)

OPINION AND ORDER

The plaintiffs filed the instant case against a hospital and two
doctors claiming medical malpractice and that the hospital violated
the Emergency Medical Treatment and Active Labor Act (EMTALA). The
defendants move for summary judgment dismissing the EMTALA claims
with prejudice. The defendants’ motions (Nos. 63, 68, 73) are
DENIED.
I. STANDARD
Summary judgment serves to assess the proof to determine if
there is a genuine need for trial. Garside v. Osco Drug, Inc.,
895 F.2d 46, 50 (1st Cir. 1990). Under Rule 56(c) of the Federal
Rules of Civil Procedure, summary judgment is appropriate when “the
record, including the pleadings, depositions, answers to
interrogatories, admissions on file, and affidavits, viewed in the
light most favorable to the nonmoving party, reveals no genuine issue
as to any material fact and the moving party is entitled to judgment

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as a matter of law.” Fed. R. Civ. P. 56(c); see also
Zambrana-Marrero v. Suárez-Cruz, 172 F.3d 122, 125 (1st Cir. 1999)
(stating that summary judgment is appropriate when, after evaluating
the record in the light most favorable to the non-moving party, the
evidence “fails to yield a trial worthy issue as to some material
fact”); Goldman v. First Nat’l Bank of Boston, 985 F.2d 1113, 1116
(1st Cir. 1993); Canal Ins. Co. v. Benner, 980 F.2d 23, 25
(1st Cir. 1992). The Supreme Court has stated that “only disputes
over facts that might affect the outcome of the suit under the
governing law will properly preclude the entry of summary judgment.
Factual disputes that are irrelevant or unnecessary will not be
counted.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248,
106 S. Ct. 2505, 2510, 91 L. Ed. 2d 202 (1986). In this way, a fact
is material if, based on the substantive law at issue, it might
affect the outcome of the case. See Mack v. Great Atl. and Pac. Tea
Co., Inc., 871 F.2d 179, 181 (1st Cir. 1989).
In a summary judgment motion, the movant bears the burden of
“informing the district court of the basis for its motion and
identifying those portions of the [record] which it believes
demonstrate the absence of a genuine issue of material fact.”
Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S. Ct. 2548, 2253,
91 L. Ed. 2d 265 (1986). Once the movant meets this burden, the
burden shifts to the opposing party who may not rest upon mere

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2.

allegations or denials of the pleadings, but must affirmatively show,
through the filing of supporting affidavits or otherwise, that there
is a genuine issue of material fact for trial. See Anderson,
477 U.S. at 248, 106 S. Ct. at 2510; Celotex, 477 U.S. at 324,
106 S. Ct. at 2553; Goldman, 985 F.2d at 1116.
II. MATERIAL FACTS NOT IN GENUINE ISSUE OR DISPUTE
The parties stipulated to the following facts at the Initial
Scheduling Conference held on August 28, 2006.
1.
Dr. Mario Acosta-Duarte is a physician licensed to
practice medicine in Puerto Rico.
At all time relevant Dr. Acosta had privileges extended by
Hospital Auxilio Mutuo de Puerto Rico, Inc. (“HAM”).
Dr. Gilberto Rodríguez is a physician with a specialty in
the field of internal medicine, and is authorized to
practice medicine in Puerto Rico. At all times relevant
he had medical privileges extended by HAM. He is married
to Ana Rivera.
The plaintiffs are not entitled to hedonic damages under
Puerto Rico law.
On March 8, 2002 Alfonso Domenech was admitted to HAM’s
Emergency Room due to a transient ischemic attack (TIA).
On March 13, 2004 Alfonso Domenech, a 64-year-old male,
was taken to the Emergency Room of HAM.

3.

4.

5.

6.

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7.

8.

9.

10.

11.

12.

13.

The medical records contain no information as to what time
Domenech arrived at HAM’s emergency room on March 13,
2004.
It was noted that Domenech arrived at the HAM by
stretcher.
Domenech was triaged at the HAM on March 13, 2004 at
1:43 p.m.
At the time of the triage Domenech’s blood pressure
was 184/94, temperature 37, heart rate 86, and
respirations 18. His complaints were hypoactivity,
dehydration, and generalized weakness. On a pain scale
of 0-10, 10 being the worst pain possible, the nurse
assessed Domenech’s pain at 7. Domenech was classified as
a “category 3″ patient.
Domenech was evaluated at the emergency room by
Dr. Acosta.
Dr. Acosta placed a verbal communication to Dr. Gilberto
Rodríguez at 3:15 p.m. on March 13, 2004.
Domenech had a history of high blood pressure, a history
of a previous brain infarct or CVA (cerebral vascular
accident), and a recent fall. This history was known by
the defendants by the time he was evaluated by Drs. Acosta

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14.

15.

16.

17.

18.

19.

20.

and Rodríguez. Domenech also had a history of new
prostate cancer.
HAM’s triage categories are from 1 to 4, with 1 the
emergency cases, and 4 the least urgent cases.
HAM’s triage protocol category defines, among others, that
a patient with acute chest pain and unstable vital signs
is a “category 1″ patient.
HAM’s triage protocol category defines, among others, that
a patient with suspicion of brain aneurism or other
vascular area is a “category 1″ patient.
HAM’s triage protocol category defines, among others, that
a patient with neurologic deficit of acute onset is a
“category 1″ patient.
HAM’s triage protocol category defines, among others, that
a patient with moderate to severe dehydration is a
“category 2″ patient.
On March 13, 2004 Dr. Acosta ordered the following tests:
CBC with differential, enzymes profile, cardiac profile,
arterial blood gases, chest X-ray, brain CT scan. The
orders were taken by the hospital nurse at 7:50 p.m.
An electrocardiogram (EKG) was performed on March 13, 2004
at 8:20 p.m. The printout results from the EKG stated
“Abnormal EKG,” “nonspecific diffuse ST-T abnormalities,”

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21.

22.

“consider anteroseptal infarct,” and “Preliminary-MD must
review.” The EKG printout results were evaluated by
Dr. Rodríguez.
An arterial blood gas result performed on March 13, 2004
at 9:00 p.m. reflected the patient’s PO2 at 81 mmHg, and
oxygenation levels at 96 percent.
The results of the cardiac profile ordered by Dr. Acosta
Duarte reflected a CPK enzyme of 911, and CKMB of 3. The
result was verified by the lab on March 13, 2004 at
9:07 p.m. The result was known by Dr. Rodríguez before
Domenech was discharged.
Domenech was not admitted to the hospital and remained at
the emergency room from his arrival until his discharge.
On the morning of March 14, 2004 Domenech was discharged
from HAM’s emergency room.
25.
The order of discharge was issued by Dr. Rodríguez.
26.
Domenech died on March 16, 2004.
The following material facts are properly supported, and are not
in genuine issue or dispute. The Court here exercises its authority
under Rule 56(d) to designate these facts as established in this
case.

23.

24.

27.

Domenech was examined at the triage area.

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28.

29.

30.

31.

32.

On the triage evaluation there are recorded several events
pertaining to Domenech such as his blood pressure,
temperature, respiration rate, heart rate weight, his mode
of arrival, the patient’s chief complaint, medications
taken, allergies, past medical history, pain, and whether
he had pain in the past days or weeks.
At the triage level of Emergency Room of Auxilio Mutuo
there are four different categories to establish a
priority system for patient care. The classification
system gives priority to the most severe conditions to
ensure immediate and appropriate treatment.
“Category 3″ includes, among others, chest pain
(non-cardiac, associated with cold symptoms), slight
dehydration for any reason, hypertension not complicated,
and headache not complicated.
On March 13, 2004 at approximately 2:45 p.m., Domenech was
examined by Dr. Mario Acosta-Duarte.
In the history taken and the assessment of Domenech’s
condition, Dr. Acosta noted the following:
Chief Complaint: Hypoactivity, dehydration,
weakness. Current Medications: Hyzaar. Patient
male, 64 years old with history of prostate
cancer. CVA two years ago. High blood
pressure.

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33.

Today shows hypoactivity, can’t walk without
help, no history of fever, but has some history
of fall down four days ago.
General Appearance: bed ridden, hypoactive,
somnolent, follows orders but falls sleep again.
Lungs are clear as auscultation. Heart regular
rate, no murmur.
Neurologic: sleepy but moves the four
extremities.
Labs ordered: CBC with differential, emergency
profile, cardiac profile, arterial blood gases,
chest x-ray; brain CT; normal saline solution to
keep vein open.
Diagnosis: Hypoactivity rule out CVA. Prostate
carcinoma. High blood pressure.
Later
that
date,
after
verbal
request
by
Dr. Acosta-Duarte, Domenech was examined by Dr. Gilberto
Rodríguez-Rodríguez, an internal medicine specialist.
Dr. Rodríguez’s consultation note dated March 13, 2004 at
3:45 p.m. states:
Male 64 years old with history of prostate
cancer, high blood pressure, treatment Hyzaar,
CVA two years ago without residual deficit.
Came because of hypoactivity, cough scanty
sputum, low grade fever. Refer history fell
down days ago. Negative dysuria, focal deficit.
Physical examination: 170/80 (blood pressure),
20 (respirations), 37 (temperature). Thorax
symmetrical, no use . . . lungs are clear at
regular rhythm, abdomen soft, pressurable, bowel
positive, extremities no edema; CT Scan of the
brain done.
Assessment:
tract
respiratory
Out
Rule
infection, high blood pressure, prostate cancer.

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34.

35.

36.

37.

38.

As a result of such evaluation on a note written by
Dr. Rodríguez at 7:50 p.m. on March 13, 2004, he placed
several medical orders for the patient. The orders were:
to administer .45% of saline solution 1000 cc every
8 hours; CBC (complete blood count) with differentials,
SMA 7, arterial blood gases, electrocardiogram,
urinalysis, chest x-ray, administration of rocephin (an
antibiotic), and oxygen 3 liters.
When the patient was taken to Auxilio Mutuo he was
evaluated and multiple studies were done.
The specific enzyme test to determine if a patient is
undergoing a heart problem is known as the CPKMB. To rule
out heart disease the test needed is a CPKMB.
If the patient started to suffer a heart problem prior to
arriving to the hospital, it would be possible that when
the enzyme test was done an abnormality would have been
found on the CPKMB.
Yolanda Isaac-Burgos noticed that her husband was
complaining of chest pain during the morning of March 13,
2004. On that same morning she made arrangements to take
Domenech to HAM via ambulance. The ambulance arrived to
pick up Domenech at around 11:00 a.m.

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39.

40.

41.

After the onset of symptoms, CPK values are expected to
rise after six to eight hours.
On March 13, 2004 at 9:00 p.m. the Arterial Blood Gas
analysis was reported.
The progress note on the morning of March 14, 2004 written
by Dr. Rodríguez states the following:
Physical examination: Unremarkable. Feel
better. Chest x-ray negative. Brain Ct.
negative. Electrocardiogram normal sinus
rhythm. CK above 900. No focal neurologic
deficit.
Diagnosis: Acute bronchitis.
CK (CTBD) [Cause to be determined]
Plan: Follow up CK and work-up.
Tequin
Tussar
When Domenech arrived at the hospital he was given
IV fluids for hydration.
On March 14, 2004 at 8:00 a.m. Dr. Rodríguez ordered the
patient’s discharge home.
III. ANALYSIS
Congress enacted EMTALA in response to “the increasing number
of reports that hospital emergency rooms are refusing to accept or
treat patients with emergency conditions if the patient does not have
medical insurance.” Cruz-Queipo v. Hospital Espanol Auxilio Mutuo
de P.R., 417 F.3d 67, 69 (1st Cir. 2005). To establish an EMTALA
violation, a plaintiff must show that (1) the hospital is a

42.

43.

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participating hospital covered by EMTALA that operates an emergency
department or equivalent treatment facility; (2) the patient arrived
at the facility seeking treatment; and (3) the hospital either
(a) did not afford the patient an appropriate screening in order to
determine if he had an emergency medical condition, or (b) bade
farewell to the patient (whether by turning him away, discharging
him, or improvidently transferring him) without first stabilizing the
emergency medical condition. Correa v. Hospital San Francisco,
69 F.3d 1184, 1190 (1st Cir. 1995). The defendants argue they are
entitled to summary judgment, because there is no genuine issue as
to whether HAM appropriately screened Domenech or discharged him
without first stabilizing emergency medical conditions. The Court
disagrees.
A.
EMTALA Screening Claim
The First Circuit defines the screening required under EMTALA
as follows:
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.
Cruz-Queipo, 417 F.3d at 70; Correa, 69 F.3d at 1192. When a
hospital prescribes internal procedures for a screening examination,
those internal procedures set the parameters for an appropriate
screening, and the hospital must adhere to its own procedures in

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administering the screening examination. Cruz-Queipo, 417 F.3d
at 70.
HAM is not entitled to summary judgment on the plaintiffs’
EMTALA screening claims, because there is a genuine issue as to
whether HAM followed its own established procedures when it screened
Domenech. The parties agree that Domenech was triaged at 1:43 p.m.
on the day of his arrival at HAM’s emergency department. Although
the only reference to chest pain complaints in Domenech’s medical
record of his March 13, 2004 visit to HAM appears in interpretations
of lab results, the plaintiffs produced their affidavits in which
they affirmed that Domenech’s wife, plaintiff Yolanda Isaac-Burgos,
told the screener, Dr. Acosta, and Dr. Rodríguez that Domenech had
chest pain, and had suffered a transient ischemic attack two years
before. Therefore the Court must draw the inference that HAM knew
Domenech was suffering from chest pain. The parties agree that a
patient with acute chest pain and unstable vital signs is a
“category 1″ patient. The plaintiffs demonstrated that if HAM had
classified Domenech as a “category 1″ patient, rather than as a
“category 3″ patient, he would have been placed on the “chest pain
protocol,” and tests to rule out heart disease would have been
repeated. The plaintiffs also raised an issue as to whether HAM
violated its policies regarding the triage screener’s qualifications.
HAM’s emergency department manual provides that triage screening must

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be performed by a registered nurse or a “physician.” Domenech was
screened by Charles Balbuena, who attended a foreign medical school,
but was not licensed to perform medicine in Puerto Rico. As the
non-movants, the plaintiffs are entitled to the reasonable inference
that HAM’s policy requires screening to be performed by either a
registered nurse or “physician,” licensed as such in Puerto Rico.
Because there are genuine issues as to whether HAM followed its own
screening procedures, the defendants are not entitled to summary
judgment on the plaintiffs’ EMTALA screening claims.
B.
EMTALA Stabilization Claim
In addition to a medical screening requirement, EMTALA mandates
that hospitals stabilize patients with emergency medical conditions
before releasing them. See 42 U.S.C. § 1395dd(b). A hospital’s duty
to stabilize a patient’s condition only arises if the hospital
determines that the patient has an emergency medical condition.
Del Carmen Guadalupe v. Negron Agosto, 299 F.3d 15, 23
(1st Cir. 2002). HAM ordered Domenech’s discharge at 8:00 a.m. on
March 14, 2004. As stated above, the Court must draw the inference
that HAM knew Domenech was suffering from chest pain, and must also
infer that HAM had the obligation to stabilize the medical condition
causing the chest pain. Although HAM performed tests, there is no
indication on the record that HAM treated Domenech’s chest pain or
underlying heart condition. Also, the plaintiffs produced evidence

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that when Domenech left HAM he was urinating uncontrollably,
disoriented, and “could hardly walk.” HAM does not argue that such
symptoms do not indicate an emergency medical condition which HAM was
obligated to stabilize under EMTALA. Accordingly the Court denies
HAM summary judgment on the plaintiffs’ EMTALA stabilization claims.
IV. CONCLUSION
The defendants are denied summary judgment on the plaintiffs’
EMTALA screening and stabilization claims.
IT IS SO ORDERED.
In San Juan, Puerto Rico, this 1 day of May, 2007.
st

s/Jaime Pieras, Jr.
JAIME PIERAS, JR.
U.S. SENIOR DISTRICT JUDGE