Facts

On November 7, 2008, when Makenzie Pauly was approximately ten years old, she saw Dr. Gates at Sutter Hospital (Sutter) for abdominal pain she had been suffering from for two months. She had received a significant workup including ultrasound, colonoscopy, esophagogastroduodenoscopy, and CT scan, all of which were negative. After a physical examination, Dr. Gates performed a diagnostic laparoscopy and removed Pauly's appendix. Dr. Gates reported no complications. An MRI was conducted; no intracranial mass, hematoma, acute infarct, or enhancing lesions were found. On November 11, 2008, Pauly was discharged from Sutter with medication and instructions to follow up in 7-10 days. Her record noted that the family planned to call Stanford Health Care (SHC) "to see if they can be evaluated by their team."

On November 14, 2008, Pauly's mother took Pauly to the SHC emergency room for abdominal pain after the surgery. Her medical history was obtained, her vitals were taken by nursing, and she saw Dr. Stephanie Doniger for a physical exam. Dr. Doniger made a differential diagnosis "includ[ing] but not limited to post-op abscess (s/p neg appendectomy) vs gallbladder pathology (cholecystitis/cholelithiasis) vs UTI vs functional AP vs constipation vs abdominal migraines vs post-op pain." Pauly was given morphine and was evaluated with several labs and an ultrasound. The ultrasound showed a small amount of gallbladder sludge but was otherwise normal. Pauly was given more pain medication later that night. She left in stable condition with a prescription for Vicodin and instructions to return in the case of persistent vomiting, intolerance to liquids, or unbearable pain not controlled with Vicodin. On November 17, a nurse spoke with Pauly's mother about a positive urine culture, and a doctor sent a prescription for Augmentin.

On December 4, Pauly returned to Sutter reporting "persistent abdominal pain ... different in nature from the pain she originally presented with." She again saw Dr. Gates, who treated her on December 5 with a bupivacaine injection that "caused her excruciating pain." Dr. Gates sought a consultation by Dr. Falco, whose assessment notes indicated "nonspecific abdominal pain that despite a very extensive workup has no organic etiology" and a normal heart rate despite high pain levels. Dr. Falco recommended "more intensive psychiatric therapy" and "agree[d] with getting a pain consultation from UC Davis and/or transferring her to Stanford where there is a more extensive pain/psychiatric service." A consult was also performed by Dr. McDonald, who noted an "extremely extensive workup" with all labs and testing negative. Dr. McDonald assessed Pauly as having "chronic abdominal pain," recommended an MRI of the spine in case of a tumor, and noted Pauly's mother was "interested in a pain clinic in Stanford." In discharge notes Dr. Gates noted Pauly's pain was "inconsistent" with her abdominal examination and heart rate and suggested a "nonorganic etiology for her abdominal pain."

Dr. Gates' notes also indicated he sought an inpatient referral to SHC's pain clinic, "but they refused admission unless she failed their outpatient pain management service." Notes from December 7 indicated Pauly was "awaiting bed avail - Sford" but "no bed avail today" and stated intent to transfer "to Stanford as soon as bed avail." Notes from December 8 again mentioned a possible "transfer to Stanford peds." Notes from December 9 indicated an attempt to transfer her to SHC: "try to get her to Stanford pain clinic." Notes from December 10 indicated that doctors at Sutter were trying to transfer Pauly to SHC when a bed became available: "cont [illegible] bed avail @ Stanford;" "Waiting for Stanford pain clinic," "cont. @ current Doc. Tx to Stanford when bed avail," "P awaiting bed @ Stanford."

Notes from SHC's transfer log showed that they had no beds available on December 7 but recommended calling back the next day. Notes from December 8 noted no beds available "and not sure if they want to take pt." Notes from December 10 stated, "There is nothing that LPCH has to offer at this time bed control is aware."

On December 10, after Pauly was discharged from Sutter, her mother took her to SHC's emergency room. Pauly reported her pain was a 10/10 and a procedure at Sutter had made the pain worse. Nursing notes indicated Pauly had been in pain for a month and been seen at numerous hospitals for pain control without relief. Nurses triaged Pauly and then performed a nursing assessment. Topical cream and morphine were administered. Pauly's vitals were taken again. Pauly was seen by Dr. Grant Lipman, who received a medical history from Pauly's mother. The medical history included her laparoscopy in November and hospitalization at Sutter. Dr. Lipman noted the pain "started at the end of August and continued despite negative workup." Dr. Lipman noted "severe" pain not relieved by anything but "no anorexia, no diarrhea, no hematuria, no fever, no nausea, no vaginal bleeding, no cough, no vomiting, no vaginal discharge, no headaches, no constipation, no dysuria and no rash." Dr. Lipman also noted Pauly was seen by "psych at Sutter Hospital to [rule out] somatoform disorder."

Dr. Lipman conducted a physical examination including palpation of Pauly's abdomen. He consulted pain services, which said they would not "admit/consult unless medically indicated or seen as outpatient first." He made a differential diagnosis of "Chronic pain symptom v neuropathic pain v abdominal migraines v malingering." His notes on patient progress and condition on discharge stated: "Stable 8:17 PM." He also noted Pauly's mother was uncomfortable with leaving and would follow up as an outpatient with pain services. He noted at 9:10 p.m. that the patient was refusing to sign discharge papers, was "demanding admission for diagnostics" despite over 5 weeks of similar symptoms, and having a "good" follow-up scheduled in the morning.

From Pauly's perspective, the visit was stressful and perfunctory. Pauly submitted a declaration stating that she was "in severe pain" and unable to walk at the emergency department, and that the doctors were angry she had come and refused to admit her or treat her pain. She stated that the examination was rude and harsh, and Dr. Lipman "treated [her] like a nuisance." She stated that on-call specialists refused to come in, and she was discharged without stabilizing treatment despite her mother's insistence that she stay for the night. She
was traumatized by the experience and in severe pain for five more weeks. She used a wheelchair during that time due to the pain.

Pauly saw a naturopathic doctor, Dr. Suzanne Wang, the next day. Pauly believes her condition was caused by a myotoxic reaction to the bupivacaine she was administered at Sutter. She applied a topical cream "for about a week and the pain finally resolved five weeks" after the visit to SHC. In a deposition, Pauly's mother stated Pauly had no ongoing impairment to her bodily functions.

PLAINTIFF'S CONTENTIONS: Plaintiff alleged multiple violations of the Emergency Medical Treatment and Active Labor Act including: (1) failure to accept in transfer, (2) failure to provide an appropriate medical screening exam, (3) failure to provide on-call specialists, and (4) failure to treat her emergency medical condition.

DEFENDANT'S CONTENTIONS: (1) Plaintiff did not have an emergency medical condition and therefore EMTALA's stabilization requirement did not apply, (2) that the SHC did provide an appropriate medical screening exam, (3) there was no violation related to on-call specialists, (4) there was no failure to stabilize, (5) that there was no causation for Plaintiff's injuries, and (6) that California's MICRA law applied to Pauly's damages.

Result

The court granted Defendant's Motion for Summary Judgment finding (1) there were no beds available at SHC and Pauly's first claim for failing to accept her for transfer did not meet the requirements of EMTALA, (2) SHC's medical screening examination was appropriate, (3) EMTALA does not create a cause of action for failure to provide on-call specialists, and (4) Pauly did not have an emergency medical condition under EMTALA.