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Law and Medicine Rounds

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
- John Powell

EMTALA
What is the
"Appropriate Medical Screening Examination"

Chances are if you are an emergency medicine physician or nurse you have probably heard of the acronym EMTALA. Even without knowing what it stands for, you likely shudder at the mere mention of the word, with its authoritative ring as if bellowed from a voice up above . . . E-M-T-A-L-A. If a senior physician tells you, “That violates EMTALA,” you don’t ask questions. You simply look down and respond “Yes, Sensai, it will not happen again.” If you have been in the emergency medicine field a few years, you probably know that EMTALA prohibits a hospital from turning patients away from the Emergency Department, and it also prohibits transferring unstable patients to another facility. You know that a violation of EMTALA means bad things will happen. What those bad things are, however, you are not sure. This is usually the extent of people’s knowledge because to know more would require reading the EMTALA statute, both boring and confusing, or court case opinions, more boring and more confusing.

This article introduces the basic concepts of EMTALA by providing a brief history of the statute with its original purpose, a discussion of the statute’s actual form, and subsequent interpretations of EMTALA based on cases. It is written in non-legal fashion, with details in the endnotes for those of you for whom “seeing is believing.” It then challenges your understanding of EMTALA by having you work through a real case before being given the Court’s rationale for its opinion. It will hopefully answer basic questions you have regarding the application of EMTALA, specifically the requirement to perform an “appropriate medical screening examination.” It does not discuss details regarding transferring unstable patients. Do not read this article if you think it will give you EMTALA peace. It will only lead to more questions, as any discussion of legal principles invariably leads to more questions than answers. For the obsessive-compulsive, welcome to the EMTALA black hole.

In the mid-80s, Congress became concerned with reports of emergency rooms refusing medical care to patients without insurance. Hospitals were turning patients away, and transferring unstable patients to other facilities, due to lack of insurance. The practice of refusing to administer medical care or transferring an unstable patient without insurance became referred to as “patient dumping. ” In response to these concerns, Congress enacted the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA). EMTALA imposes penalties on Medicare and Medicaid participating hospitals for: 1) failure to afford appropriate medical screening to any person who comes to its emergency room, or 2) if an emergency medical condition exists, the hospital fails to render the services necessary to stabilize the patient’s condition.

The keen eye will notice that the statute is not limited to protecting patients without insurance, despite its original intent. It states that an “appropriate medical screening” is required for “any individual [who] comes to the emergency department. ” As discussed above, and recognized by the Circuit Courts, EMTALA was initially enacted to prevent emergency departments from “refusing to accept or treat patients with emergency conditions if the patient does not have medical insurance. ” Perhaps Congress meant for the statute to only include patients without insurance, even though the statute was not written to that effect?

As EMTALA cases arose, hospital attorneys jumped on the above argument, claiming that a patient must demonstrate an “improper motive,” such as lack of insurance; indeed the initial impetus of EMTALA. This strategy, however, was almost universally rejected. Courts decided that despite the initial intent of EMTALA, the final statute does not state that an “improper motive” is required, and its protections are not limited to people without insurance. Not only does the statute specifically protect “any individual,” but also, if an “improper motive” was required, “proving the inner thoughts and prejudices of the attending medical staff” would be “virtually impossible. ” As it was drafted, “EMTALA was enacted to fill a lacuna in traditional state tort law by imposing on hospitals a legal duty (that the common law did not recognize) to provide emergency care to all. ” “[EMTALA’s] core purpose is to get patients into the system who might otherwise go untreated and be left without a remedy because traditional medical malpractice law affords no claim for failure to treat. "

The next hurdle that Courts faced was the definition of an “appropriate medical screening examination.” How would a patient show that a physician did not perform an “appropriate medical screening examination? If it was simply demonstrating that the doctor made an incorrect diagnosis, then federal EMTALA claims would appear very much like state medical malpractice claims, traditionally governed by state law. Was EMTALA giving patients two cracks at the same case, one in federal court under EMTALA and one in state court under malpractice principles? The Circuit Courts did not believe that it was the intention of Congress to “substitute state-law malpractice actions” or “duplicate preexisting legal protections. ” The Eighth Circuit Court explained: “Something more than, or different from, ordinary negligence in the emergency-room screening process must be shown to make out a federal claim under EMTALA. ” The Courts eventually came to the conclusion that to prevail on an EMTALA claim, the patient must demonstrate that there was some form of “disparate treatment,” or that the patient was not treated “uniformly” as other patients in the Emergency Department, not simply that there was a missed diagnosis. One Circuit Court defined an “appropriate medical screening examination” as an exam “reasonably calculated to identify critical medical conditions that may be afflicting symptomatic patients and provide that level of screening uniformly to all those who present substantially similar complaints. ”

Did those definitions for an “appropriate medical screening examination” really distinguish EMTALA from malpractice claims? If a physician is careless with one patient, and is not careless with the rest, could it be both malpractice and an EMTALA violation? The answer is yes, there may be an overlap. The failure to perform an “appropriate medical screening examination” may be tantamount to malpractice, but not every malpractice claim is an EMTALA claim. One Court explained:

Consider a situation in which a hospital adheres to a standard requiring tests A, B, and C as part of an appropriate emergency room medical screening. In many instances, this standard will also be the malpractice standard of care. Thus, failure to perform test C, for example would violate both EMTALA and the standard of care applicable in a malpractice claim. But if tests A, B, and C are performed and the doctor evaluating the results draws an incorrect conclusion, a violation of EMTALA may not be established, but medical negligence may be.

In essence, EMTALA only requires that the appropriate tests are ordered and the appropriate history and examination performed. It does not require a correct conclusion from the results and examination performed.

In March 2008, the Department of Health and Human Services, Centers for Medicare and Medicaid Services, established guidelines for EMTALA. The guidelines incorporated the very ideas of uniformity among patients and the prevention of disparate treatment previously described by the Courts. The guidelines state that the screening exam “must be the same [exam] that the hospital would perform on any individual coming to the hospital’s dedicated emergency department with those signs and symptoms” and it must be “reasonably calculated to determine whether an Emergency Medical Condition exists. ”

So what are the repercussions for violating EMTALA? For a statute with so much attention, there must be dire consequences. To enforce the provisions, Congress predicated a hospital’s Medicare reimbursement on compliance with EMTALA. The loss of Medicare funding would pose an enormous financial burden on a hospital for an EMTALA violation. EMTALA also includes a $50,000.00 fine against a hospital and $50,000.00 fine against a treating physician for each EMTALA violation committed. In addition, EMTALA requires the hospital to compensate the patient and family for damages incurred. Individual physicians, on the other hand, while they may be fined, are not individually responsible for compensating a patient or family for damages under EMTALA. Of course, individual physicians may be liable for a patient’s damages based on malpractice principles.

Now consider a case based on the principles outlined above. This case was decided by the Fourth Circuit in Power v. Arlington Hospital Association, 42 F.3d 851 (4th Cir. 1994). Keep in mind that this case was decided prior to the promulgation of the 2008 Interpretive Guidelines of EMTALA cited above. Nevertheless, the new guidelines do not seem to contradict the reasoning of the Fourth Circuit here.

As per the Court, at 5:45 a.m. a 33-year-old unemployed and uninsured female from Great Britain was brought to an Emergency Department by her fiancé. Her lack of health insurance and unemployment were indicated on the front of the chart. She was complaining of pain in her left hip, left abdomen, and in her back running down her left leg. She stated that she was unable to walk, was shaking, and had severe chills. The patient also had a sizeable boil on her left face that was not seen by the medical staff, nor was it mentioned in the medical chart.

A nurse took a history, performed a nursing assessment, and also collected urine for a “dipstick” urinalysis. The Court’s opinion did not elaborate on the nursing assessment. A doctor then examined the patient. He spoke with the patient, ranged her hip, performed a motor exam, and also a leg extension test. In the chart, the exam of her hip was described as normal. The physician also ordered x-rays. Details regarding the rest of the physician’s physical findings were not provided in the Court’s opinion. A second nurse then completed the patient information data and took vital signs, including blood pressure. All of the vital signs were normal at that time.

According to the Court, at the change of shift at 7 a.m. a second doctor examined the patient. He did not review the patient intake information in the chart. He did note that the patient was complaining of left hip pain of unknown etiology. He performed a neurological examination, and concluded that her pain was localized to the left hip and was musculoskeletal in nature. He believed that the patient looked uncomfortable, but not toxic. He did not believe she was ill, and he did not believe that she had an infection. Nevertheless, he ordered an official urinalysis without any other blood work or diagnostic procedures.

The second physician discharged the patient before the results of the urinalysis. He prescribed her anti-inflammatory pain medication, and instructed the patient to return if her pain became worse. He failed to record the results of the x-ray on the chart. The results of the x-rays were also absent from the Court’s opinion. Later, after the patient was discharged, the physician followed up the results of the official urinalysis. It showed the possibility of a mild infection. The doctor then sent a urine culture from the same sample to verify the result.

By the time the urine culture results were ready the next day, the patient had already returned to the emergency department. The patient was in severe septic shock. She required vasopressors for her low blood pressure, and antibiotics. She was eventually admitted to the Intensive Care Unit where she remained for four months. She was on life support equipment. She had both legs amputated below the knees due to loss of circulation secondary to sepsis. She also lost sight in one eye, and developed severe and permanent lung damage. She was eventually transferred to a hospital in her hometown in England.

An orthopedic surgeon testified at trial that the patient’s hip was not the problem. An infectious disease specialist concluded that the patient had a blood infection secondary to lancing the boil on her face 10 days prior to her initial visit. A qualified emergency medicine expert and an infectious disease expert testified that appropriate blood tests would have most likely revealed a blood infection.

Consider the following:

1) Is lack of insurance necessary for an EMTALA violation?
2) Did the medical staff violate EMTALA by not performing an “appropriate medical screening examination?”
3) Are the physicians responsible for the patient’s damages under EMTALA?
4) Is the hospital responsible for the patient’s damages under EMTALA?
5) What are the other potential consequences to the hospital for violating EMTALA?
6) Did the physicians commit medical malpractice?
7) If so, are the physicians responsible for damages to the patient based on medical malpractice principles?
8) Can a physician violate EMTALA and commit medical malpractice?

1) Is lack of insurance necessary for an EMTALA violation?
No. The Fourth Circuit stated, “there is nothing in the statute itself that requires proof of indigence, inability to pay, or any other improper motive on the part of a hospital as a prerequisite to recovery. ” The statute protects “any individual” who seeks emergency medical care.

2) Did the medical staff violate EMTALA by not performing an “appropriate medical screening examination?”
Yes. The jury at trial found that Arlington hospital violated EMTALA. The Fourth Circuit was unwilling to reverse this finding. The Court stated that a jury could have reasonably concluded “a blood test was a necessary component of an appropriate medical screening examination at Arlington Hospital, for a patient who presented at the emergency room with the patient’s symptoms.”

3) Are the physicians responsible for the patient’s damages under EMTALA?
No. EMTALA does not hold physicians responsible for patient damages under EMTALA. A physician may be fined up to $50,000 for an EMTALA violation, but the physician can not be sued by the patient for damages. Here, the trial court dismissed the physicians from the EMTALA case.

4) Is the hospital responsible for the patient’s damages under EMTALA?
Yes. A hospital is responsible for compensating a patient and family for damages under EMTALA. In this case, the jury returned a verdict of $5 million for the patient against Arlington Hospital. This amount, however, was eventually reduced because of the State of Virginia’s caps on damages in medical malpractice-related cases.

5) What are the other potential consequences to the hospital for violating EMTALA?
The hospital could lose its Medicare funding for violating EMTALA, which would pose an enormous financial burden. The hospital may also be fined $50,000.00 for every EMTALA violation. These penalties were not discussed in the civil action above.

6) Did the physicians commit medical malpractice?
Although not specifically decided by the Court, the answer is most likely yes. The physicians here failed to perform an “appropriate medical screening examination” and a patient was harmed as a result. The physicians are most likely liable under medical malpractice principles.
7) If so, are the physicians responsible for the damages to the patient based on medical malpractice principles?
Yes. Under medical malpractice principles, a physician is liable for damages to a patient as a result of the physician’s negligence.
8) Can the physician both violate EMTALA and commit medical malpractice?
Yes. EMTALA violations and medical malpractice principles can overlap. If a physician carelessly fails to perform an “appropriate medical examination,” the Court can also find that the physician committed medical malpractice

Please click here for the REFERENCES used for this article.

Dainius A. Drukteinis, M.D., J.D. is an Attending Physician at MetroHealth Medical Center in Framingham, MA and author of Law and Medicine Rounds. He may be contacted at ddrukteinis@gmail.com

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Skirting the Issue

By Dr. Linda Regan

“I have spent many years of my life in opposition, and I rather like the role."
- Eleanor Roosevelt

Sexism is Alive

Does talking about something make it an issue? I can vividly recall being told as a medical student that sexism was just something that women chose to see in everyday life. That is was not really an issue; it was one that we chose to use as an excuse every time things did not go our way.

I can actually remember thinking that this MUST be true. I mean, here I was, a woman in a class of medical students where HALF of us were women! How could sexism really exist? It certainly wasn’t holding me down! I thought that women who were victims to this were just that--victims--weak women who were victims of their own personalities or fears. At the time, I refused to join AMWA or get a key to the ‘women’s room’ that women students, residents and faculty could seek out as a private ‘sexist’ refuge. I told myself that if I segregated myself from men by reminding them that I was a woman, I would be contributing to the problem.

I am not sure when my beliefs changed. Maybe it was when a chief resident opened the top button of my shirt in hopes that it would help the chauvinistic interventional radiologist give me our study. Maybe it was when I realized that a lot of the female nurses DID treat me differently than my classmates who were male. The realism that sexism could also come from women was an eye-opening and depressing experience. Or maybe it was just the natural progression of realizing that male faculty whom I KNOW believe in me and support me still DON’T REALLY understand the challenges that women face. In fact, they often, albeit unintentionally, place them in our way.

Whatever the reason, I know that sexism exists. It is not because I choose to see it where it isn’t. It is not because I talk about it. It is because the world in which we live has socialized us to believe that men and women SHOULD be different. And when we, as women, try to take on stereotypically “male” roles, attitudes or personality traits, I think it makes people uncomfortable. This is the inherent reason why strong women are considered to be too aggressive or pushy or, god-forbid, the B-word, while men are just doing their job and somehow gain respect.

We need to accept that there is a double standard. There SHOULDN’T be! But there is. It’s there. Now. . what are we going to do about it?

Linda Regan, M.D. is an Attending physician at Johns Hopkins University Hospital and author of the blog column, Skirting the Issue, which discusses issues facing women in the field of medicine. She may be contacted at: skirtingtheissue@gmail.com

Vol 1:2

Supraventricular Tachycardia

Patients who present with a supraventricular tachycardia (SVT) may have potentially life-threatening disease, and their outcome is often directly related to the care they receive in the ED. In a matter of minutes, the emergency physician must quickly and confidently assess and support the “ABC’s” and determine the need for interventions. The search for an underlying condition must be initiated while immediately addressing the patient’s stability. Synchronized cardioversion is often indicated for unstable patients, while a more sophisticated approach is needed to decipher and manage the stable patient. Although SVTs are a frequent cause of ED1 and primary care office2 visits, they are infrequently the primary reason for hospital admission.1-3

Common pitfalls in dealing with SVTs
How you can avoid them

1. “ I have a lot of experience differentiating SVT with aberrancy from VT – I’m really on top of the various criteria you can use to tell one from the other.”

That’s great! Until the 54-year-old male who you were “sure” had SVT drops his blood pressure to 50/30 after you give him diltiazem and requires aggressive resuscitation and ICU admission. There are no criteria that are foolproof in differentiating SVT with aberrancy from VT. When the diagnosis is not 100% known to be SVT, a wide complex arrhythmia must be treated as VT. Medications used to treat SVT (diltiazem, verapamil) can be lethal in a patient with VT.

2. “I can’t believe that patient submitted a complaint. Adenosine was the indicated treatment for his SVT and I administered it right after he rolled in the door.”

It’s true that adenosine was an appropriate treatment, but patients appreciate forewarning of the side effects of medications. It is good practice to initiate treatment promptly, but take a minute to include patients in the overall plan and prepare them before administering medications that cause a sense of impending doom or death.

3. “That lady had “psych” written all over her – a history of depression, anxiety, and frequent ED visits for palpitations.”

Palpitations should not routinely be attributed to anxiety. Often, an ECG and telemetry monitoring in the ED will not document a dysrhythmia but Holter monitoring or event recorders might. It has been well documented that many patients, especially females, with SVT are initially misdiagnosed with anxiety. Referring these patients for additional testing may ultimately lead to a diagnosis, treatment that controls symptoms, and fewer visits to the ED.

4. “Young people can tolerate rapid heart rates; I never use electrical cardioversion because those young whipper-snappers never seem unstable – a blood pressure of 95/50 is normal for them.”

While younger patients may be better able to tolerate rapid ventricular response in SVT, there is still potential for precipitous deterioration. Atrial fibrillation in WPW syndrome is an inherently unstable rhythm where heart rates may be 300 bpm and the potential for deterioration to ventricular fibrillation is real. If there is a history of WPW syndrome or ECG findings consistent with WPW syndrome and atrial fibrillation, do not hesitate to cardiovert if there is any hint of hemodynamic instability.

5. “The elderly gentleman with a history of myocardial infarction (MI) had shortness of breath and an irregular rhythm on ECG with a rate of 120. I knew he wouldn’t tolerate a heart rate of 120 for very long so I administered metoprolol for rate control.”

Unfortunately, that patient had a history of severe COPD in addition to coronary artery disease; the ECG showed MAT (not atrial fibrillation) and the patient had profound bronchospasm in response to treatment with a β-blocker. In both MAT and NPJT, the best course of action is to treat the underlying precipitant of the SVT rather than the heart rate and to avoid medications that are relatively contraindicated. In this case, treatment of the underlying COPD may have relieved the patient’s symptoms of shortness of breath and terminated or slowed the MAT.

6. “It was a really busy shift; she was a healthy young woman who was just coming in for a refill on her allergy medication. She was tachycardic in triage, but didn’t mention any specific complaints.”

Vital signs are vital; sinus tachycardia needs to be addressed and underlying causes considered. Further history would have revealed that the patient’s “allergy symptoms” were actually shortness of breath due to her significant anemia in the setting of dysfunctional uterine bleeding.

7. “I wasn’t sure what to do with that kid…he was 4-years-old with a history of Ebstein’s anomaly and heart failure. He was slightly tachypneic with a blood pressure on the low-normal side. His ECG was difficult to interpret but it looked like he was in a preexcited SVT.”

When faced with a diagnostic dilemma or complicated case, don’t forget that you have back-up. Consult cardiology early and get expert guidance.

8. “It was a regular narrow complex tachycardia on the monitor and I couldn’t see any P waves. While the nurse was pulling adenosine, I figured it couldn’t hurt to try carotid sinus massage.”

Do no harm – even a simple vagal maneuver like carotid sinus massage can be disastrous in patients with a history of cerebrovascular accident or presence of a carotid bruit on examination. To avoid neurologic complications, it’s imperative to get a quick medical history and listen for carotid bruit before initiating carotid sinus massage. If you want to try a vagal maneuver, ask the patient to valsalva.

9. “The young woman had a history of SVT and presented with her usual symptoms of palpitations and lightheadedness. When I spoke with her cardiologist, he recommended amiodarone; the first dose was given in the ED.”

That young woman was pregnant and in her first trimester. Very few medications used to treat SVT are contraindicated in pregnancy, but amiodarone is one of them. While it is very useful to have specialist input, the emergency medicine provider must obtain routine tests that may alter management, even if the specialist does not suggest them – a urine pregnancy test should be ordered in all females of childbearing age, especially if a medication is to be given.

10. “The elderly diabetic woman was on digoxin for previously diagnosed atrial fibrillation. Today she presented with fatigue. Her ECG demonstrated NPJT and I sent a digoxin level which came back mildly elevated. I admitted her to the hospital for close monitoring.”

Her digoxin level wasn’t the only laboratory value that was high, her troponin I was 20. It’s true that she was in NPJT, but she was also having an inferior MI. On further review, her ECG also demonstrated inferior T wave inversions. It’s important to review the entire ECG in a thorough and systematic way. The diagnosis of an SVT does not exclude other more serious diagnoses.

References
1. Murman DH, McDonald AJ, Pelletier AJ, et al. U.S. Emergency Department Visits for Supraventricular Tachycardia, 1993-2003. Acad Emerg Med. 2007;14(6):578-581. (Retrospective; 550,000 visits related to SVT)
2. Luderitz B, Manz M. Pharmacological Treatment of Supraventricular Tachycardia - the German Experience. Am J Cardiol. Aug 1992;70(5):A66-A74. (Review)
3. Baine WB, Yu W, Weis KA. Trends and outcomes in the hospitalization of older Americans for cardiac conduction disorders or arrhythmias, 1991-1998. J Am Geriatr Soc. Jun 2001;49(6):763-770. (Retrospective; 144,512 discharges)

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Answer: VizD Challenge Week of 3/17/08

Kingellakoko is the winner of this week's VizD!

Thank you to everyone who participated!

Kingellakoko is the winner of $5

Recap:
A 32-year-old woman presents to your ED 2-days after falling off a bar stool and hitting her head on the floor. She complains of persistent headache.

(click on image to enlarge)

Questions:
1. What is the diagnosis?
2. Which nerves are injured?

Answer:
1. Claw Hand and atrophy of the thenar eminences
2. Ulnar and Median nerve injury

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient. For more information please refer to the following link.