Professional Documents
Culture Documents
Filed: Patrick Fisher
Filed: Patrick Fisher
PUBLISH
MAR 26 2001
No. 00-5013
Defendant - Appellee,
and
CAROLYN COBB, a physician;
EMERGENCY PHYSICIANS, INC.,
an Oklahoma corporation doing
business in the State of Oklahoma,
Defendants.
_______________________
PATRICK FISHER
Clerk
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his friend and co-worker Mike Lulka, walked into the emergency room of
Hillcrest Medical Center (HMC). Phillips complained of severe chest pain and
pneumonia-like symptoms. Prior to examining Phillips, HMC staff took
background information from Phillips, including whether he was covered under
any health insurance plan. Phillips claimed he was covered but could not locate
his insurance card. Lulka, who was covered under the same plan from their
mutual employer, offered his card to provide HMC administrative staff with the
generic information that was equally applicable to the co-workers. HMC staff
allegedly indicated on his file that Phillips was not insured.
After initial processing, Phillips was triaged by Lugenia Cue, 1 a
registered nurse, and then examined by Dr. Carolyn Cobb in the minor care side
of the emergency room. After the examination, Phillips was given two
prescriptions, discharged from the emergency room, and referred to an Oklahoma
medical clinic for follow-up treatment. Though his symptoms failed to subside,
Phillips was seen at work on the two days (Thursday and Friday) following his
discharge from HMC. Based upon all accounts, his condition was rapidly
deteriorating through Saturday and Sunday.
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Act (EMTALA) and also brought a claim for wrongful death under Oklahoma
medical malpractice law for failing to properly treat Phillips.
Prior to trial, the district court dismissed the EMTALA claim against Dr.
Cobb and TEP. The remaining claims were presented to a jury. At the close of
evidence, the district court sustained HMCs Rule 50 motion, holding no
EMTALA claim existed as a matter of law, and sustained appellants Rule 50
motion that Dr. Cobb was the agent of HMC. 3 The district court submitted the
issue of medical malpractice/wrongful death to the jury and a verdict in favor of
HMC was returned. Plaintiffs filed this appeal.
C. Summary of Issues on Appeal
On appeal, appellants raise four issues. Appellants allege the district court
erred in (1) granting HMCs Rule 50 motion as to the EMTALA claim, (2)
admitting allegations of Phillips drug use, (3) excluding plaintiffs expert
testimony regarding the cause of bacterial endocarditis, and (4) refusing to allow
cross-examination of HMCs nurse regarding Exhibit 25 and Exhibit 26.
II. ANALYSIS
A. EMTALA
Appellants argued at trial that HMC treated Phillips differently than
similarly situated patients because he was alleged to be uninsured and that HMCs
3
established procedures were not followed. The district court ruled no evidence of
differential treatment was presented and, at most, the complained of conduct
amounted to negligence. See Vol. II, pp. 844-45. At the invitation of the district
court, 4 appellants are now pressing similar argument before this court.
1. Standard of Review
This court reviews the grant of judgment as a matter of law de novo, sitting
in the same position as the trial court. See Tyler v. Re/Max Mountain States, Inc.,
232 F.3d 808, 812 (10th Cir. 2000). Pursuant to Rule 50 of the Federal Rules of
Civil Procedure, a trial judge may grant a motion for judgment as a matter of law
if, after a party has been fully heard on an issue, there is no legally sufficient
evidentiary basis for a reasonable jury to find for the party on that issue. See
Tyler, 232 F.3d at 812; Finley v. United States, 82 F.3d 966, 968 (10th Cir. 1996).
This court has read FRCP 50(a) to mean judgments as a matter of law may be
granted only if the evidence points but one way and is susceptible to no
reasonable inferences which may support the opposing partys position. Finley,
82 F.3d at 968; see also Tyler, 232 F.3d at 812 (relying upon Reeves v. Sanderson
Plumbing Prods., Inc., 530 U.S. 133 (2000)) . As such, the facts and all
reasonable inferences from them are viewed in the light most favorable to the
The court stated to appellants counsel you certainly can amplify [your
argument] many pages over in Denver, but youve certainly got a record here. Vol. II, p.
852, lns. 3-4.
4
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the hospital must conduct an initial medical examination to determine whether the
patient is suffering from an emergency medical condition. See Abercrombie, 950
F.2d at 680. The second obligation requires the hospital, if an emergency medical
condition exists, to stabilize the patient before transporting him or her elsewhere.
See Urban v. King, 43 F.3d 523, 525 (10th Cir. 1994). To ensure compliance
with these obligations, Congress created a private cause of action. See 42 U.S.C.
1395dd(d); Repp v. Anadarko Mun. Hosp., 43 F.3d 519, 521-22 (10th Cir.
1994). Appellants only claim under EMTALA is for an alleged failure to
provide an appropriate screening as required by section 1395dd(a).
Pursuant to section 1395dd(a), HMC was required to conduct an
appropriate medical screening examination . . . to determine whether or not an
emergency medical condition . . . exists. 42 U.S.C. 1395dd(a). 6 This court
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has stated that whether a given hospital has performed an appropriate medical
screening examination, as defined by EMTALA, varies with the unique
capabilities of the specific hospital. See Repp, 43 F.3d at 522. Further, we give
appropriate deference to the existing screening procedures utilized by the
hospital, because it, not a reviewing court, is in a superior position to determine
its own capabilities and limitations.
only whether the hospital adhered to its own procedures, not whether the
procedures were adequate if followed.). Based upon those pre-existing
procedures, 7 adopted and employed by a hospital, the Repp court held EMTALAs
screening requirement is violated when it does not follow its own standard
procedures. See id. at 522.
The underlying principle behind section 1395dd(a) is to ensure all patients,
regardless of their perceived ability or inability to pay for medical care, are given
consistent attention. EMTALAs requirement of an appropriate screening
examination undeniably requires HMC to apply uniform screening procedures
to all individuals coming to the emergency room. Vickers v. Nash Gen. Hosp.
(...continued)
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Inc., 78 F.3d 139, 143 (4th Cir. 1996) (stating uniform treatment for all patients,
regardless of ability to pay, is considered the linchpin of an EMTALA claim).
While this court has never expressly described the obligation under EMTALA in
terms of uniform or disparate treatment, several of our sister circuits, as well as
numerous district courts within this circuit, have. See id.; Marshall v. East
Carroll Parish Hosp. Serv. Dist., 134 F.3d 319, 323 (5th Cir. 1998); Summers, 91
F.3d at 1138; Holcomb v. Monahan, 30 F.3d 116, 117 (11th Cir. 1994); Scott v.
Hutchinson Hosp., 959 F. Supp. 1351, 1357 (D. Kan. 1997) (A hospital satisfies
the requirements of 1395dd(a) if its standard screening procedure is applied
uniformly to all patients in similar medical circumstances.); Tank v. Chronister,
941 F. Supp. 969, 972 (D. Kan. 1996) (quoting Vickers, 78 F.3d at 144)
(EMTALA is implicated only when individuals who are perceived to have the
same medical condition receive disparate treatment . . . .). To the extent it was
unclear before, this court holds, as it implicitly did in Repp, a hospitals
obligation under EMTALA is measured by whether it treats every patient
perceived to have the same medical condition in the same manner. Disparate
treatment is simply another term for describing or measuring a hospitals duty to
abide by its established procedures. Unless each patient, regardless of perceived
ability or inability to pay, is treated in a uniform manner in accordance with the
existing procedures, EMTALA liability attaches. See Repp, 43 F.3d at 522.
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3. Appellants Claims
Appellants argued to the district court, as they have here, that evidence of a
bias towards those who are uninsured is sufficient to state an EMTALA claim.
They point to the testimony of Mike Lulka regarding the initial intake procedures
HMC undertook and attempt to extrapolate an intolerance towards those perceived
to be uninsured. 8 They also look for support in Christina Daczewitzs testimony
that she saw, some time after Phillips death, a notation of no insurance on
Phillips medical records at HMC. Appellants repeated attempts to introduce
evidence regarding HMCs motives are irrelevant to whether Phillips was treated
in a manner consistent with HMCs existing procedures. This circuit, like many
others, does not require any particular motive for EMTALA liability to attach.
See Repp, 43 F.3d at 522 n.5 (stating EMTALA imposes strict liability).
EMTALA looks only at the participating hospitals actions, not motives. See
Stevison, 920 F.2d at 713 (We construe [section 1395dd(a)] as imposing a strict
liability standard subject to those defenses available in the act.); see also Roberts
v. Galen of Virginia, 525 U.S. 249, 252 (1999) (stating the Sixth Circuits
requirement of an improper motive is in conflict with several circuits, including
the First, Fourth, Eighth, and D.C. Circuit). While testimony regarding a
Interestingly, however, Lulka further stated the fact that Phillips did not have on
his person the insurance card was not a problem and did not appear to affect the care of
Phillips.
8
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They did and the jury returned a verdict in favor of HMC and Dr. Cobb.
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appellants argue that the evidence was irrelevant and unduly prejudicial.
1. Standard of Review
Though appellants moved, in limine, to exclude evidence of drug testimony,
they failed to renew their objection at trial. HMC admits this has sufficiently
preserved the issue for appellate review. See United States v. Mejia-Alarcon, 995
F.2d 982, 986 (10th Cir. 1993) (stating a motion in limine may preserve the ruling
for review when the issue (1) has been fairly presented to the trial court, (2) is the
type of issue that can be finally decided in a pretrial hearing, and (3) is ruled upon
without equivocation). By presenting the issue to the district court and receiving
a definitive ruling, appellants were entitled to rely upon the ruling as the law of
the case and to have this court review the decision under an abuse of discretion
standard. See id. Under this standard, we will not reverse unless there has been
a distinct showing it was based on a clearly erroneous finding of fact or an
erroneous conclusion of law or manifests a clear error of judgment. United
States v. Mitchell, 113 F.3d 1528, 1531 (10th Cir. 1997) (internal quotations
omitted).
2. Relevance
In Oklahoma, evidence of a patients failure to provide an accurate medical
history is relevant to the defense of contributory negligence in a medical
malpractice claim. See O KLA . S TAT . tit. 23, 13, 14; Graham v. Keuchel, 847
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P.2d 342, 358 & n.78 (Okla. 1993) (stating patients failure to inform the medical
staff about her rare blood type may be considered by the jury as an indication of
her contributory negligence). In Bointy-Tsotigh v. United States, for example, the
plaintiff claimed [p]hysicians at the defendant facilities did not perform the
appropriate diagnostic tests to determine the source of plaintiffs medical
condition. Bointy-Tsotigh, 953 F. Supp. 358, 362 (W.D. Okla. 1996) Despite the
defendants failure to adequately test (or perform diagnostic tests), the court
reduced plaintiffs damages because she failed to give her accurate medical
history to the treating physicians. See id. at 362 (applying Oklahoma law). Based
upon Oklahoma law, there can be little doubt Phillips failure to inform HMC
and/or Dr. Cobb of his medical history was relevant and necessary to the defense
of contributory negligence. 10
3. Unfair Prejudice
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Even assuming Phillips failure to inform HMC of his prior drug use was
relevant, appellants claim the district court erred because evidence of Phillips
drug use was unfairly prejudicial. Pursuant to Rule 403, the district court must
determine whether the admission of relevant evidence would cause unfair
prejudice. See F ED . R. E VID . 403. Due to the district courts superior position to
gauge the testimonys prejudicial impact in light of the evidence presented
throughout trial and the jurors perception of the case as a whole, we give the
district courts determination a large degree of deference. See, e.g., Joseph v.
Terminix Intl Co., 17 F.3d 1282, 1284 (10th Cir. 1994).
Under Rule 403, relevant evidence may be excluded if its probative value
is substantially outweighed by the danger of unfair prejudice. F ED . R. E VID . 403.
According to the literal language of the rule, ordinary prejudice alone is
insufficient to exclude relevant evidence. The prejudice must be unfair, such that
we may conclude the jurors made their decision based not upon the evidence
presented but upon their confusion, passion, or emotion. See, e.g., Stump v.
Gates, 211 F.3d 527, 534 (10th Cir. 2000); see also Securities and Exchange
Commn v. Peters, 978 F.2d 1162, 1171 (10th Cir. 1992) (noting the unfair
prejudice must substantially outweigh the probative value).
Based upon a review of the proceedings appellants have identified as most
egregious, we are unable to conclude any unfair prejudice occurred. The
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testimony from HMC and Dr. Cobbs expert simply noted the obvious drug use
is an important indicator of a patients physical condition and is crucial to
determining whether to undertake additional testing. See Vol. II, p. 945. 11 While
plaintiffs would have preferred evidence of Phillips drug use not be presented to
the jury, simple prejudice alone is insufficient to warrant exclusion. See Peters,
978 F.2d at 1171 (noting almost all evidence, in the eyes of one party or the other,
will be perceived as prejudicial).
C. Causation Testimony
Appellants next contend the district court erroneously excluded testimony
of their expert, Dr. Benjamin E. Zola. Dr. Zola apparently would have testified
that Phillips alleged drug use did not cause bacterial endocarditis. The district
11
A:
Vol. II, p. 945, lns. 8-16. In addition, counsel for Dr. Cobb, in opening statement,
claimed drug use was relevant to the case because, for diagnostic purposes the clinician
needs to know that because its well known that [the use of] street drugs is a well known
predisposing factor for various infections including bacterial endocarditis, and they need
to know that. Vol. I, p. 56, lns. 8-13.
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court, however, ruled that evidence of what caused plaintiffs fatal condition was
not at issue. See Vol. II, p. 755-56. The court stated the issue was whether Dr.
Cobb negligently treated Phillips on September 23, 1998 and whether Phillips
contributed, by withholding pertinent health information, to the alleged negligent
care. See id. As such, what actually caused bacterial endocarditis was irrelevant
to whether Dr. Cobbs treatment fell below the recognized standard of care.
1. Standard of Review
Ordinarily, this court would review the exclusion of expert testimony under
the standards set forth in Daubert v. Merrell Dow Pharmaceuticals, Incorporated,
509 U.S. 579, 589 (1993) . See, e.g., Hynes v. Energy West, 211 F.3d 1193,1202
(10th Cir. 2000) (citing Kumho Tire Co. v. Carmichael, 526 U.S. 137, 152
(1999)). Here, however, the district court did not exclude Dr. Zolas testimony
based upon the merits of his expert opinion but rather because the proffered
testimony was irrelevant to the issue at hand. This court reviews rulings
excluding testimony under an abuse of discretion standard. See Dodoo v. Seagate
Tech., Inc., 235 F.3d 522, 528 (10th Cir. 2000). We will not overturn the trial
court unless it has made an arbitrary, capricious, whimsical, or manifestly
unreasonable judgment[.] Id. (citing Woodworkers Supply, Inc. v. Principal
Mut. Life Ins. Co., 170 F.3d 985, 992 (10th Cir. 1999)).
2. Causation of Disease
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Appellants made a proffer that Dr. Zola would testify that, based upon a
reasonable degree of medical certainty, Phillips drug use did not cause bacterial
endocarditis. See Vol. II, p. 753-55. This testimony was necessary, appellants
argue, to rebut arguments or evidence that HMC or Dr. Cobb might present to the
effect Phillips caused his own death. The district court stated that the cause of
Phillips bacterial endocarditis was irrelevant to the negligence claim at issue and
that Phillips use of drugs was relevant only to the extent that he failed to inform
Dr. Cobb of a pertinent medical condition. See id. at 755. While counsel for
HMC and Dr. Cobb were free to argue Phillips withheld pertinent information, the
district court rule that if [counsel for HMC or Dr. Cobb] start even for a moment
suggesting that the cause of death was drug use, then there will be serious old
testament stuff. Id.
Because appellant has failed to indicate any events contrary to this ruling
actually occurred, we are assured all arguments fell well within this ruling.
Without evidence alleging Phillips caused his own death, appellants sole
justification for Dr. Zolas testimony vanishes. Accordingly, we hold the district
courts decision fell well within his wide discretion. Furthermore, while it may
have been appropriate to offer a limiting instruction to the jury, there is no
indication appellants requested one. Given appellants failure, we can not say
plain error occurred. See Gilbert v. Cosco Inc., 989 F.2d 399, 404 (10th Cir.
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1993); see also United States v. Pedraza, 27 F.3d 1515, 1526 (10th Cir. 1994)
(stating the failure to seek a limiting instruction, in a criminal case, may be the
result of a tactical decision).
D. Cross-examination
In their fourth and final point, appellants allege evidence of disparate
treatment (applicable only to the EMTALA claim) would have been shown if the
district court had allowed them to cross-examine HMCs triage nurse, Lugenia
Cue, with Exhibits 25 and 26. These exhibits were summaries, prepared by
HMCs counsel at the request of appellants, indicating the number of patients
admitted to the emergency room (Exhibit 25) and the minor care area of HMC
(Exhibit 26) on September 28, 1998. See Vol. IV, Exs. 25 and 26. The
information contained in these exhibits showed the time the unnamed patients
were admitted and released, a one to two word description of their symptoms, and
which side of the hospital they were sent to after initial triaging. Upon
consulting the record, it appears appellants sought to submit these two documents
to the jury as definitive proof of differential treatment by HMC. See Vol. I, p.
370-77. The district court ruled this method was unduly confusing to the jurors
but invited appellants to question Cue as to Phillips condition and whether, as a
general matter, more patients with those symptoms were triaged to the emergency
room on that day or otherwise. See id. at pp. 375-78. Appellants then asked Cue
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whether she typically sent more people with chest pain to the minor side or to the
emergency side, but when she responded she could make no categorical statement,
the issue was pressed no further. See id. at 378.
1. Standard of Review
As an initial matter, the parties disagree as to what standard of review this
court should use to analyze appellants claim of error. HMC contends no offer of
proof was made as to the content of these exhibits and therefore this court may
review only for plain error. As we have stated before, [e]rror may not be based
on a ruling excluding evidence unless the substance of the evidence was made
known to the court by offer [of proof] or was apparent from the context within
which questions were asked. Inselman v. S & J Operating Co., 44 F.3d 894, 896
(10th Cir. 1995) (quoting F ED . R. E VID . 103(a)(2)); United States v. Janusz, 135
F.3d 1319, 1323 (10th Cir. 1998) (quoting F ED . R. E VID . 103(a)(2)). The purpose
of this rule is obvious it allows the district court to make an informed
evidentiary ruling and creates an adequate record for appellate review to
determine whether the trial courts ruling was reversible error. See Inselman, 44
F.3d at 896.
In order to satisfy Rule 103(a)(2), we have held that merely telling the
court the content of . . . proposed testimony is not an offer of proof. Polys v.
Trans-Colorado Airlines, Inc., 941 F.2d 1404, 1407 (10th Cir. 1991) (quoting
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Gates v. United States, 707 F.2d 1141, 1145 (10th Cir. 1983)). Rather, the
proponent of the excluded evidence must explain what he expects the evidence to
show and the grounds for which he believes the evidence is admissible. See
Polys, 941 F.2d at 1407. If appellants have failed to meet this hurdle, this court
can reverse the district courts ruling only if there was plain error that affected
appellants substantial rights. See id. at 1408; F ED . R. E VID . 103(d). The plain
error exception in civil cases has been limited to errors which seriously affect
the fairness, integrity or public reputation of judicial proceedings. Polys, 941
F.2d at 1408 (internal quotation omitted). It is an extraordinary, nearly
insurmountable burden. See id. at 1408 n.5 (collecting cases).
Based upon a review of the record, appellants have sufficiently preserved
this issue for appeal. Specifically, the exhibits were identified, their contents and
origins discussed, and argument as to their admissibility was made. See Vol. I,
pp. 369-76. We hold this more than sufficiently met the demands of Polys. As
such, appellants allegation of error will be reviewed under the less stringent
abuse of discretion standard. See Polys, 941 F.2d at 1407. Even under this more
lenient standard, however, appellants argument is unavailing.
2. Exclusion of Testimony
The district courts rationale for excluding the exhibits is that they were
rough summaries made by HMCs counsel, were utterly ambiguous, and, without
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The colloquy between appellants counsel and the district court went as follows:
Court: Right. So the question I mean, you can ask her why it is that
she chose, in the face of chest pain, to send him to minor care. And
you can even ask her if in more circumstances than not, chest pain
goes to the emergency room. But your goal here is to talk about what
she saw and heard and what decision she made and why she made
them, and whether or not those decisions in the normal course were
different than what she normally does.
Counsel: Is Your Honor saying I can ask her typically do more people
go to the emergency side with chest pain?
Court: Does she send more people to the emergency side.
Counsel: Yes sir.
Court: And what was it about this patient that caused her not to do
that.
...
Court: [] The point is, is that with that the one word entry doesnt tell
us anything about whether or not somebody should go to the minor
care side or ER side; right?
Counsel: Well, I mean, I think thats something that the witness would
certainly be able to explain. But I understand. With my objection
noted, Your Honor, I understand the courts ruling.
Court: No. I understand your objection. All Right.
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