Kimberly Ruloph v. Lammico, doing business as LAMMICO Risk Retention Group, Inc.

United States Court of Appeals
For the Eighth Circuit
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No. 21-1572
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Kimberly Ruloph
lllllllllllllllllllllPlaintiff - Appellant
v.
LAMMICO, doing business as LAMMICO Risk Retention Group, Inc.
lllllllllllllllllllllDefendant - Appellee
Washington Regional Medical Center
lllllllllllllllllllllDefendant
Mercy Hospital-Fort Smith
lllllllllllllllllllllDefendant - Appellee
Jody A. Bradshaw; Kristin Pece, M.D.
lllllllllllllllllllllDefendants
Mercy Clinics Fort Smith Communities; Robert A. Irwin, M.D.
lllllllllllllllllllllDefendants - Appellees
John Does, 2-10, also known as John Does 1-10
lllllllllllllllllllllDefendant
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Appeal from United States District Court
for the Western District of Arkansas - Ft. Smith
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Submitted: February 17, 2022
Filed: October 7, 2022
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Before SMITH, Chief Judge, BENTON and KELLY, Circuit Judges.
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SMITH, Chief Judge.
Kimberly Ruloph brought suit against LAMMICO d/b/a Lammico Risk
Retension Group, Inc. (LAMMICO); Mercy Hospital-Fort Smith (Mercy); Jody A.
Bradshaw, M.D.; Kristen Pece, M.D.; Mercy Clinic Fort Smith Communities; Robert
A. Irwin, M.D.; and John Does 1-10, alleging liability under the Emergency Medical
Treatment and Active Labor Act (EMTALA), 42 U.S.C. § 1395dd. She now appeals
the district court1 grant of summary judgment to the defendants. We affirm.
I. Background
Ruloph alleges that Mercy violated the EMTALA in its handling of her transfer
from Mercy to Washington Regional Medical Center (WRMC) on April 15, 2018.
Shortly after noon that day, Ruloph arrived at Mercy’s emergency department having
injured her knee in a fall. Dr. Kristin Pece diagnosed the condition and noted that
Ruloph’s blood flow was obstructed to her foot, which showed no pulse. Dr. Jody
1The Honorable P.K. Holmes, III., United States District Judge for the Western
District of Arkansas.
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Bradshaw reduced2 Ruloph’s dislocated knee. Doppler studies, a way to evaluate the
body’s circulatory system, confirmed the lack of blood flow in her lower left leg.
Dr. Bradshaw concluded that Ruloph had suffered a vascular injury based on
the Doppler test results and missing pulse. He further concluded that Mercy was
incapable of providing Ruloph proper treatment for her injury and that she needed to
be transferred to a facility with a qualified vascular surgeon. The condition
constituted a medical emergency under EMTALA. Mercy then called the Arkansas
Trauma Communications Center (ATCC), “an arm of the Arkansas Department of
Health (ADH), of which Mercy is a member,” and notified it of Ruloph’s injury and
the situation necessitating a transfer. R. Doc. 84, at 8. ATCC facilitated a call with
Washington Regional Medical Center (WRMC) located in Fayetteville, Arkansas, as
that facility was available for a possible transfer. Around 1:20 p.m., Dr. Bradshaw
connected with Dr. Robert Irwin in Fayetteville. Dr. Irwin, on behalf of WRMC,
accepted Ruloph as a patient after receiving Ruloph’s medical condition information
from Mercy. Dr. Pece placed the transfer order at 1:37 p.m., stating, “External
Transfer To [W]ash [R]egional for va[s]cular surgery via trauma com
arrangemen[t]s.” R. Doc. 92-8, at 1.
Dr. Pece also noted in the Acute Care Transfer Note that WRMC “has available
space and qualified personnel for the treatment of the patient” and that transfer
benefits included “[a]vailability of specialty care,” specifically, “va[s]cular surgery.”
R. Doc. 92-9, at 2. At 2:05 p.m., Ruloph’s spouse, Gary Ruloph, signed a consent
form for Ruloph’s transfer to WRMC for vascular surgery. Dr. Irwin was updated on
2“[R]eduction” is “the replacement or realignment of a body part in normal
position or restoration of a bodily condition to normal.” Reduction, Merriam-Webster,
https://www.merriam-webster.com/dictionary/reduction#medicalDictionary (last
visited Aug. 19, 2022).
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Ruloph’s condition when he received a call from Dr. Pece around 2:44 p.m. During
the call, Dr. Irwin reaffirmed that WRMC would be able to treat Ruloph, stating,
“[G]o ahead and send her.” R. Doc. 92-6, at 2.
At 2:55 p.m., Ruloph left Mercy by ambulance for Fayetteville. Unfortunately,
after Ruloph’s departure from Mercy to WRMC, WRMC realized its facility did not
have an available vascular surgeon to treat Ruloph’s condition. Ruloph arrived safely
at WRMC. After receiving Ruloph into its emergency room, WRMC immediately
made arrangements for Ruloph to be transferred to Mercy Hospital-Springfield in
Springfield, Missouri. Ruloph arrived at Mercy Hospital-Springfield by helicopter,
and a peripheral vascular surgeon operated. Unfortunately, the surgery occurred too
late to save Ruloph’s leg.
Ruloph filed suit against the hospitals and physicians involved along with their
insurers under the EMTALA. Ruloph claimed that Mercy made an “inappropriate
transfer,” in violation of 42 U.S.C. § 1395dd(b). R. Doc. 84, at 11. Ruloph alleges
that the delay in receiving vascular surgery within a six-hour window after the injury
caused her leg to be amputated. Ruloph further alleged that “Mercy’s statutory duty
under EMTALA, and its liability for damages caused by a violation of EMTALA, is
strict or absolute.” Id. at 15.
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Mercy3 moved for summary judgment against Ruloph’s strict liability claim.
In its order granting Mercy’s motion, the district court reviewed the history of
EMTALA. The court noted that “[t]he purpose of EMTALA is to address the problem
of patient dumping, where hospitals refuse to treat patients in an emergency room if
the patients do not have health insurance.” Ruloph v. LAMMICO, No. 2:20-cv-02053-
PKH, 2021 WL 517044, at *2 (W.D. Ark. Feb. 11, 2021). The statute requires
hospitals to evaluate the medical condition of patients entering emergency rooms and
provide appropriate treatment to stabilize their medical condition and transfer them
only if an emergency condition supports transfer to another hospital with required
facilities and qualified personnel. 42 U.S.C. § 1395dd(b). The court identified the sole
issue as whether “Mercy effected an appropriate transfer of Ms. Ruloph under
EMTALA when WRMC represented it had qualified personnel and accepted the
transfer, leaving Mercy to learn when Ms. Ruloph was already in transit to WRMC
that WRMC did not in fact have qualified personnel to treat Ms. Ruloph.” Id. at *3.
The district court dismissed Ruloph’s claims against the defendants after concluding
that claims seeking relief for “EMTALA transfer violations must be predicated on a
hospital’s actual knowledge.” Id. at *4.
3The district court granted Ruloph’s motion to dismiss Dr. Pece, Dr. Bradshaw,
and Mercy Clinics Fort Smith Community without prejudice on November 24, 2020.
Ruloph filed motions to dismiss defendants John Does 1-10 on December 8, 2020 but
the district court did not make a specific ruling as to those two motions before the
judgment for which this appeal stems from. Subsequently, Ruloph filed an amended
third complaint on December 29, 2020 including the aforementioned defendants as
well as LAMMICO, Dr. Irwin, and Mercy-Fort Smith but not the John Does.
Although Mercy moved for summary judgment against Ruloph, the other defendants
did not make a formal motion before the district court ruled on Mercy and Ruloph’s
motions. The EMTALA claim against Mercy was dismissed with prejudice, while the
claims against all other defendants were summarily dismissed without prejudice on
February 11, 2021. This appeal followed.
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II. Discussion
On appeal, Ruloph argues that the district court erred in granting summary
judgment to the defendants.“We review de novo a district court’s grant of summary
judgment.” Avenoso v. Reliance Standard Life Ins. Co., 19 F.4th 1020, 1024 (8th Cir.
2021) (quoting Riedl v. Gen. Am. Life Ins., 248 F.3d 753, 756 (8th Cir. 2001)). Only
in instances where the “there is no genuine issue as to any material fact” and “the
moving party is entitled to judgment as a matter of law” do we find summary
judgment to be proper. Id.
On appeal, Ruloph argues that EMTALA imposes a strict liability standard for
noncompliance with its directions. Ruloph relies on Summers v. Baptist Medical
Center Arkadelphia, 91 F.3d 1132 (8th Cir. 1996) (en banc), and Abercrombie v.
Osteopathic Hospital Founders Ass’n, 950 F.2d 676 (10th Cir. 1991), to support the
contention that EMTALA imposes a strict liability standard. That reliance is
misplaced.
Mercy urges us to reject Ruloph’s argument because it “finds no support in the
text of the [A]ct or in this [c]ourt’s interpretation of the [A]ct.” Mercy’s Br. at 10.
Ruloph concedes that Summers concerned “compliance with the screening
requirement under EMTALA,” not the duty to provide an appropriate transfer.
Appellant’s Br. at 16. Summers concerns 1395dd(a)’s screening process for patients,
not a health care facility’s transfer of patients under 1395dd(b)(1):
[W]e h[e]ld that instances of “dumping,” or improper screening of
patients for a discriminatory reason, or failure to screen at all, or
screening a patient differently from other patients perceived to have the
same condition, all are actionable under EMTALA. But instances of
negligence in the screening or diagnostic process, or of mere faulty
screening, are not.
91 F.3d at 1139.
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Ruloph’s proposed reading of EMTALA would extend the duty to provide for
an appropriate transfer to include responsibility for the accuracy of the
representations of expertise made by the receiving hospital. We conclude that
EMTALA does not go that far. The statute delineates the mandatory duties of a
subject hospital. It provides:
(1) In general
If any individual . . . comes to a hospital and the hospital determines that the
individual has an emergency medical condition, the hospital must provide
either—
(A) within the staff and facilities available at the hospital, for
such further medical examination and such treatment as may be
required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in
accordance with subsection (c).
42 U.S.C. § 1395dd(b)(1) (emphasis added).
Section 1395dd(c), “Restricting transfers until individual stabilized,” defines
an appropriate transfer. Such a transfer occurs when a “transferring hospital provides
the medical treatment within its capacity” and “the receiving facility . . . (i) has
available space and qualified personnel for the treatment of the individual, and (ii)
has agreed to accept transfer of the individual and to provide appropriate medical
treatment.” 42 U.S.C. § 1395dd(c)(2).
We interpret “a statute according to its plain meaning unless context requires
otherwise.” In re Cotter Corp., (N.S.L.), 22 F.4th 788, 795 (8th Cir. 2022). Here, the
requirement in subsection (c) that the “receiving facility” have “qualified personnel
for the treatment” would appear to impose strict liability under its plain meaning.
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However, context requires a different interpretation because this reading would lead
to results wholly at odds with the statute’s purpose. EMTALA sought to (1) prevent
“the ‘dumping’ of uninsured, underinsured, or indigent patients by hospitals who did
not want to treat them,” Summers, 91 F.3d at 1136, and (2) “create a new cause of
action . . . for what amounts to failure to treat,” id. at 1137 (internal quotation marks
omitted).
EMTALA’s aim is to discourage bad-faith hospitals from dumping patients.
Imposing liability upon a hospital’s good-faith effort to secure appropriate care for
a patient that is beyond its capabilities is off the mark. Such liability would run
contrary to EMTALA’s purpose and would undermine the express target of securing
adequate care for patients who could not otherwise afford it.
For example, if a hospital takes a patient, provides all the care within its
capabilities, discovers it cannot render further adequate care with its personnel,
confirms that a receiving hospital has the specialized doctor who can provide the
necessary treatment, and then transfers the patient, its EMTALA’s duties should, at
that point, be fulfilled. If, for reasons beyond its control, the specialist becomes
unavailable after the first hospital transferred the patient, holding the transferring
hospital liable under EMTALA unreasonably extends the statute’s reach. In such a
case, despite the hospital’s best efforts, the patient now would be heading to a
receiving hospital without the “qualified personnel.” We conclude that the statute
does not impose this type of strict liability.
Here, Mercy’s doctor explained to WRMC’s doctor that Ruloph dislocated her
knee, but had a pulseless foot even after her knee was reduced, and that Mercy did not
“have a vascular surgeon capable of repairing” the injury. R. Doc. 92-4, at 6. She
stated that Mercy did not yet have more detailed imaging, but WRMC nonetheless
accepted Ruloph, stating, “[S]end her imaging with you [sic] . . . , but that’s fine
. . . we’ll take her.” Id. at 7 (second ellipsis in original). WRMC never suggested that
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its personnel would not be qualified to handle her injury, or that its assessment could
change depending on her imaging and the complexity of the injury. Mercy then
conducted the transfer, sending Ruloph in an ambulance to WRMC. It was not until
two hours later—while Ruloph was en route—that WRMC’s surgeon reviewed the
imaging and concluded that the necessary treatment “was way more complicated and
in depth than [WRMC would] be able to do.” Id. at 9.
When Mercy sent Ruloph to WRMC, it acted in good faith, under the
reasonable impression—caused by WRMC—that WRMC had adequate, “qualified
personnel for the treatment of” Ruloph. See 42 U.S.C § 13955dd(c)(2)(B)(i). Mercy
did not attempt to dump Ruloph; it fulfilled its EMTALA obligations. Mercy’s
reliance on WRMC’s errant assessment of its own capabilities does not violate
EMTALA.
Further, EMTALA does not define the time at which the “appropriate transfer”
should be measured: whether at the moment the first hospital effects the transfer,
when the patient arrives at the receiving hospital, or at some other time. In light of
EMTALA’s purpose of discouraging bad actors from “dumping” patients, EMTALA
implies that the “appropriate transfer” inquiry should focus on the knowledge of the
transferring hospital at the time that it effects the transfer—the moment when the two
hospitals have agreed to the transfer and the patient departs for the receiving hospital.
Measuring knowledge at a different time—as Ruloph proposes—may produce absurd
outcomes in which a good-faith transferring hospital is held liable for relying on
information exclusively in control of the recipient hospital.
Thus, EMTALA’s “appropriate transfer” requirement should be assessed from
the perspective of a reasonable transferring hospital at the time the hospitals agreed
to the transfer and the patient departed the transferring hospital. Cf. Burditt v. U.S.
Dep’t of Health & Hum. Servs., 934 F.2d 1362, 1372 (5th Cir. 1991) (interpreting “‘as
required’ in 42 U.S.C. § 1395dd(c)(2)(C) to limit the scope of the requirement of
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qualified personnel and equipment to those conditions known to the transferring
physician” and applying a “reasonable physician” standard).
Under this standard, Mercy effected an “appropriate transfer”: it sent Ruloph
to a hospital that, based on the information conveyed to it by the hospital, had
“qualified personnel” for her treatment. There is no genuine issue of material fact
about the information that Mercy had at that moment or whether its reliance on that
information was reasonable. Thus, the district court properly concluded that Mercy
could not be held liable for violating § 1395dd(b) based on subsection (c)’s “qualified
personnel” requirement.
The district court applied EMTALA to the facts in this case and concluded that
Mercy’s obligations were not in the nature of a strict liability duty and that Mercy
acted reasonably given the knowledge that it had at the time that it made the transfer
to WRMC. With no genuine factual dispute present, we hold that the district court
properly granted summary judgment.
III. Conclusion
Accordingly, we affirm the district court.
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