ÿWPC¯ BŽ7žÔôüê4Îê7žÔ((ÕàÇè !V Ômø+e‡‰`ºë¯j®íHT«Ãu`àseÜ÷5¾ðV™C@uôžòiùj>>±îäEÚkc ›ÄJ.Zж¤žÊ „ÆNÜ+üœ&»8ŒÜ}.Q®eLÓ)œüÍü®Ãr`Å'ÑÅÔ3øyjr½.H~¨¡ñ”ûU!gÖeùöëŠè¬phÀÅEžÚªÓ™ËˆíÙ0àO#ãê¹–&Z‚'¿)øè­…6KfÍj‡ZR‰q¾Ö¶²þ‚+ǾðuǬ'íY9¨ÖŽ‹­È‘f'ÄóÝžn¢pÅó%¯9ÆÌK(Vel•–|÷þÕÂ;š©–IçB ç@uÛd(O^n[÷¾³”xæ 5yA“ý„¬ñOuæ`¨^;ÏB‘ó‹rº-Â̬vhØ$óÓcÎ6bØú«¸„ …_P|pÃ3òUK]x&2W¡Qñ'2UßÞBËä¯ÇQWÒ¸>y( ^êËBPœ -s³ E6UÆú×–Â%«”yß°x‰5ûRE¬oÄÃØþ+ jä>ÃeY×RžëF˜ô‚qp8g]ú' >'CÛF9.¯ƒú…Ñ,4Þp!46U:ô %.4 0C³U@ö 0}6³n®ÃNq 0(s w@› 4Û ï mñ 0C n­K ø #!w n­˜ ªE ˆï w^  1u‹ 0cÆcN)) 0g++++++++++++++++++++++++ B’<þ6X9`("Courier 10cpiX uÝ ƒI)ÝÝ  ÝÔ_ÔÓ ÿÿ` °œXÓà@88)ìà„Ú  Ú1Ú  Ú„(2I$©©Ý ƒ !ÝÝ  Ý*Ͼ¦ `(CG TimesScalable(<2“ê$¤¤Ý ƒ !ÝÝ  ÝÓÓòòÓ  ÓÚ  Ú0Ú  Úóó#|xÅ«<þ6X9`("Courier 10cpiXôxþ6X@É“8Ç;X@*Ͼ¦ `(CG TimesScalable\\xϾ¦ P쉊7û\P*Ͼ¦ `(CG TimesScalable„„³Ï¾¦ P쉊7û„P*Ͼ¦ `(CG TimesScalable™Ï¾¦ P쉊7ûP($¡¡ ¼D½D¾D¿DÀÁDÂ[ÃDĀŷˆa()_R&P51\DOCS´…~ÿU‹ÿÀÀÀ(ÿÿ$òòÚ  ÚÚ  Úóó«<þ6X9`("Courier 10cpiXôxþ6X@É“8Ç;X@ uÝ ƒI)ÝÝ  ÝÔ_ÔÓ ÿÿ` °œXÓà@88)ìà„Ú  Ú1Ú  Ú„˜HP LaserJet 4,ü,,,,,ü0«<þ6X9`("Courier 10cpiXôxþ6X@É“8Ç;X@  Ý ƒ“ê$ÝÓÓòòÓ  ÓÚ  Ú*Ú  ÚóóÝ  ÝÔ_Ô€€Of€the€District€of€Massachusetts,€sitting€by€designation. ~Ý ƒI)ÝÝ  ÝÔ_ÔÓ'°X` P ¸ °œX'Óà@88)ìà„Ú  Ú2Ú  Ú„ô¡ñ(Æ3#37=CIQYag­­1.a.i.(1)(a)(i)1)a)(;3£$´´Ô2#ÔÚ  Ú0Ú  Ú.Ô3  Ôà0  àa, b, c,Level 1Level 2Level 3Level 4Level 56#-Î4Quick a. ÚƒÚÚ  Ú.à0 àÛ€Û dÝ ƒ !ÝÝ  ÝÔ_ÔÓ  ÓÓ ÿÿ` °œXÓÖ€ÿÿÖÑ = ÑÙ*ƒ !ÙÔ€X€çXXXÔà@  ìàÔ€°س°XX€çÔUnited€States€Court€of€AppealsˆÐ ° Ðà@ ìàÔ€„îÚ„°°سÔFor€the€First€CircuitˆÐ à ÐÔ€X€çX„„îÚÔÔ€X޳XXX€çÔÓ ÿÿ` ÿÿXÓà@<< ìà____________________ˆÐ øH ÐÓ ÿÿ` ÿÿXÓÖ€ÈÖÑ = ÑÌNo.€99„2153ÌÌà@| | ìàCINDY€REYNOLDS,€INDIVIDUALLY,€AND€ASˆÌà@@ @ ìàPERSONAL€REPRESENTATIVE€OF€THE€ESTATEˆÌà@Ø Ø ìàOF€WILLIAM€D.€REYNOLDS;€TINA€MOORE,€AS€NEXTˆÌà@P P ìàFRIEND€OF€Ô_ÔKELLIANNÔ_Ô€RAE€REYNOLDS,€A€MINOR;ˆÌà@ˆˆìàPlaintiffs,€Appellants,ˆÌÌà@tt)ìàv.ˆÌÌà@<< ìàÔ_ÔMAINEGENERALÔ_Ô€HEALTH,ˆÌà@<< ìàDefendant,€Appellee.ˆÌÌà@<< ìà____________________ˆÌÌà@œ œ ìàAPPEAL€FROM€THE€UNITED€STATES€DISTRICT€COURTˆÌÌà@ìàFOR€THE€DISTRICT€OF€MAINEˆÌÌà@¬¬ìà[Hon.€Eugene€W.€Ô_ÔBeaulieuÔ_Ô,€òòU.S.€Magistrate€Judgeóó]ˆÐ `° ÐÌà@<< ìà____________________ˆÌÌà@„„'ìàBeforeˆÌÌà@ˆˆìàÔ_ÔTorruellaÔ_Ô,€òòChief€Judgeóó,ˆÐ ` ÐÌà@ ìàÔ_ÔLipezÔ_Ô,€òòCircuit€Judgeóó,ˆÐ  ð ÐÌà@t t ìàand€Ô_ÔKeetonÔ_Ô,׃×Ý ƒÿÿÝòòÚ  Ú*Ú  ÚóóÝ  Ý×  ×€òòDistrict€Judgeóó.ˆÐ 0 €! ÐÌà@ ìà_____________________ˆÌÌà  àòòJoseph€M.€Ô_ÔJabarÔ_Ôóó,€with€whom€òòÔ_ÔDaviauÔ_Ô,€Ô_ÔJabarÔ_Ô€&€Battenóó€and€òòDavidM.Ð P# % ÐGlasseróó€were€on€brief,€for€appellants.Ð $h& Ðà  àòòGeorge€C.€Ô_ÔSchellingÔ_Ôóó,€with€whom€òòGross,€Ô_ÔMinskyÔ_Ô,€Mogul€&€Ô_ÔSingalÔ_Ô,Ð à$0 ' ÐP.A.óó€was€on€brief,€for€appellee.Ð ¨%ø ( ÐÌÌà@<< ìà____________________ˆÌÌñÄñà@àà$ìàñÄññÅñJuly€17,€2000ñÅñˆÌà@<< ìà____________________ˆÐ  X*¨%. ÐÔ_ÔÑ  ÑÓÓÓ °` P ÿÿXÓÖ€ÈÖÙ* !Ùà ` àò òKEETON,€òòDistrict€Judgeóó.€€ó óThis€appeal€requires€us€toÐ ° Ðinterpret€the€scope€of€coverage€under€the€Emergency€MedicalÏTreatment€and€Active€Labor€Act€(EMTALA),€42€U.S.C.€ðð€1395dd,€forÏsecondary€risks€associated€with€emergency€conditions.€€AfterÏreviewing€the€record€in€light€of€the€statutory€scheme,€we€affirmÏthe€district€court's€summary€judgment€in€favor€of€defendant„¼appellee€MaineGeneral€Health.Ìà@àà$ìàò òI.€€The€Factsó óˆÐ ð@  Ðà ` àBecause€we€are€reviewing€the€district€court's€summaryÏjudgment€in€favor€of€defendant„appellee,€we€recite€the€facts€in€theÏlight€most€favorable€to€the€plaintiffs„appellants.€€òòSeeóó€Fed.€R.Ð ð@ ÐCiv.€P.€56.Ìà ` àOn€September€8,€1996,€William€D.€Reynolds€was€driving€aÏcar€that€collided€head„on€with€another€vehicle.€€As€a€result€of€theÏaccident,€Mr.€Reynolds€suffered€various€injuries€including€severalÏfractures€of€bones€in€his€lower€right€leg€and€left€foot.€ÏMr.Reynolds€was€taken€immediately€by€ambulance€from€the€accidentÏscene€to€the€emergency€room€of€Kennebec€Valley€Medical€Center€(nowÏknown€as€the€MaineGeneral€Medical€Center€and€referred€to€throughoutÏthis€opinion€for€convenience€as€"MaineGeneral"€or€the€"hospital").€ÏAfter€an€emergency€room€nurse€had€triaged€Mr.€Reynolds,€he€wasÏexamined€by€Dr.€Harry€Grimmnitz,€the€emergency€room€physician.€ÏDr.Grimmnitz€evaluated€Mr.€Reynolds,€took€an€oral€medical€history,Ïand€ordered€a€series€of€laboratory€tests,€x„rays,€and€an€abdominalÏCT€scan.€€After€considering€this€information,€Dr.€GrimmnitzÏdetermined€that€Mr.€Reynolds€suffered€from€multiple€trauma€to€hisÐ `,°'2 Ðlower€right€leg,€including€a€probable€open€fracture€of€the€rightÏtibia€and€fibula€and€possible€fracture€of€the€left€foot,€and€fromÏa€possible€intra„abdominal€injury.Ìà ` àDr.€Grimmnitz€then€requested€consultations€fromÏDr.Alexander€Wall,€a€surgeon,€and€Dr.€Anthony€Mancini,€anÏorthopedic€surgeon.€€Dr.€Wall€reported€slight€right€upper€quadrantÏtenderness€with€a€negative€CT€scan€of€the€abdomen.€€Dr.€ManciniÏexamined€Mr.€Reynolds€in€the€emergency€room€and€took€another€oralÏmedical€history.€€Dr.€Mancini€determined€that€the€injuries€toÏMr.Reynolds'€lower€extremities€required€surgery.€€Mr.€Reynolds€wasÏtransferred€to€the€operating€room€where€Dr.€Mancini€performed€aÏclosed€reduction€and€intramedullary€rodding€of€the€right€tibiaÏfracture€and€a€closed€reduction€and€percutaneous€pinning€of€theÏleft€second,€third,€and€fourth€metatarsal€neck€and€head€fractures.€ÏFollowing€surgery,€Mr.€Reynolds€was€admitted€to€the€hospital€floor,Ïwhere€the€hospital€staff€monitored€his€condition€and€he€beganÏreceiving€physical€therapy.Ìà ` àOn€September€13,€1996,€Mr.€Reynolds€was€returned€to€theÏoperating€room€for€closure€of€his€right€lower€leg€wound.€€OnÏSeptember€14,€1996,€he€was€discharged€from€the€hospital.€€OnÏSeptember€19,€1996,€he€died€of€a€massive€pulmonary€embolism€thatÏemanated€from€deep€veinous€thrombosis€("DVT")€at€the€fracture€siteÏon€his€right€leg.Ìà ` àPlaintiffs€proffered€the€affidavit€of€Mr.€Reynolds'Ïmother„in„law,€Shirley€Kimball,€who€was€in€the€emergency€room€atÏMaineGeneral€after€the€accident€but€before€Mr.€Reynolds€hadÐ À+'2 Ðsurgery.€€Ms.€Kimball€states€that€she€saw€a€man€in€a€white€lab€coatÏask€Mr.€Reynolds€if€he€had€any€allergies€or€medical€problems€ofÏwhich€the€hospital€should€be€aware.€€Ms.€Kimball€alleges€thatÏMr.Reynolds€told€the€man€"that€his€family€had€a€blood€clottingÏproblem€on€his€father's€and€brothers'€side€of€the€family€wheneverÏthey€had€a€trauma."€€Appendix€to€Appellants'€Brief€at€130.Ìà ` àPlaintiffs€proffered€the€affidavits€of€several€familyÏmembers,€each€of€whom€alleges€that€he€or€she€told€a€MaineGeneralÏemployee€in€the€hospital€room€after€Mr.€Reynolds€underwent€surgeryÏthat€Mr.€Reynolds€had€a€family€history€of€hypercoagulability.Ìà@Ô Ô ìàò òII.€€Procedural€Backgroundó óˆÐ P  Ðà ` àOn€September€8,€1998,€plaintiff„appellant€Cindy€Reynolds,Ïwidow€of€the€decedent€William€D.€Reynolds,€filed€a€complaint€in€theÏUnited€States€District€Court€for€the€District€of€Maine€in€herÏpersonal€capacity€and€as€the€personal€representative€of€the€EstateÏof€the€decedent.€€Mr.€Reynolds'€minor€daughter,€Kelliann€Reynolds,Ïis€also€a€plaintiff„appellant.€€The€complaint€alleged€thatÏMr.Reynolds€presented€to€the€emergency€department€at€MaineGeneralÏon€September€8,€1996,€with€an€emergency€medical€condition€asÏdefined€by€EMTALA,€42€U.S.C.€ðð€1395dd(e)(1);€that€MaineGeneralÏfailed€to€screen€Mr.€Reynolds€appropriately€for€DVT,€as€requiredÏunder€42€U.S.C.€ðð€1395dd(a);€and€that€MaineGeneral€failed€toÏstabilize€Mr.€Reynolds€for€DVT€before€releasing€him€onÏSeptember14,€1996,€thus€violating€the€requirements€of€42€U.S.CÏâ âðð1395dd(b).Ð €*Ð%0 Ðà ` àIn€a€memorandum€of€decision€dated€September€8,€1999,Ïâ âMagistrate€Judge€Ô_ÔBeaulieuÔ_Ô€granted€defendant„appellee's€motion€forÏsummary€judgment,€having€concluded€that€the€facts€did€not€supportÏa€federal€claim€for€failure€to€screen€under€Ô_ÔEMTALAÔ_Ô€even€though€theyÏsupported€a€state„law€claim€for€negligent€diagnosis€and€treatment.€ÏMagistrate€Judge€Ô_ÔBeaulieuÔ_Ô€further€held€that€plaintiffs'€claim€forÏfailure€to€stabilize€fails€as€a€matter€of€law€because€the€hospitalÏwas€not€aware€that€Mr.€Reynolds€was€suffering€from€Ô_ÔDVTÔ_Ô.€€PlaintiffsÏfiled€their€notice€of€appeal€to€this€court€on€October€6,€1999.Ìà@Ô Ô ìàò òIII.€€Merits€of€the€Appealó óˆÐ À Ðò òA.€€Screening€Claimó óÐ  ð Ðà ` àAt€issue€in€this€case€is€the€precise€scope€of€aÏparticipating€hospital's€duty€to€screen€for€risks€or€relatedÏconditions€associated€with€or€aggravated€by€an€emergency€medicalÏcondition.€€In€this€instance,€Ô_ÔMaineGeneralÔ_Ô€does€not€dispute€thatÏWilliam€Reynolds€suffered€from€an€emergency€medical€condition€atÏthe€time€he€arrived€in€the€emergency€room.€€The€parties€agree€thatÏthe€injuries€to€Mr.€Reynolds'€lower€extremities€constituted€anÏemergency€medical€condition€requiring€appropriate€screening€andÏstabilization€before€discharge€or€transfer.€€In€dispute€is€theÏanswer€to€the€following€question:€€Does€the€increased€risk€of€Ô_ÔDVTÔ_ÔÏassociated€with€this€type€of€injury,€combined€with€Mr.€Reynolds'Ïfamily€history€of€Ô_ÔhypercoagulabilityÔ_Ô,€trigger€a€duty€to€screen€forÏÔ_ÔDVTÔ_Ô?Ìà ` àAppellants€argue€that€the€risk€of€DVT€constituted€aÏdiscrete€"emergency€medical€condition,"€which€required€screeningÐ `,°'2 Ðand€stabilization€under€EMTALA,€just€as€the€fractures€of€the€lowerÏextremities€required€screening€and€stabilization.€€AppelleeÏcontends€that€the€increased€risk€of€DVT€was€not€an€"emergencyÏmedical€condition"€within€the€meaning€of€EMTALA€and€did€not€requireÏparticularized€screening€or€stabilization.€€Appellee€arguesÏgenerally€that€risks€and€conditions€associated€with€or€followingÏfrom€emergency€medical€conditions€that€do€not€constituteÏindependent€"emergency€medical€conditions"€within€the€meaning€ofÏEMTALA€will€not€fall€within€the€requirements€of€EMTALA.€€InÏevaluating€these€arguments,€we€consider€three€analyticallyÏseparable€propositions.Ìà ` àòòFirstóó.€€Appellants'€first€argument€is€premised€on€aÐ à0 Ðmeaning€of€"symptom"€that€we€cannot€accept.€€Appellants€argue€thatÏsummary€judgment€was€not€appropriate€because€Mr.€Reynolds€wasÏexhibiting€symptoms€of€an€emergency€medical€condition€ð!ð€DVT€ð!ð€whenÐ à Ðhe€came€to€the€emergency€room.€€Appellants€contend€that€this€courtÏshould€interpret€the€word€"symptom"€in€EMTALA's€definition€ofÏ"emergency€medical€condition"€to€include€any€evidence€orÏcommunication€of€information€that€an€emergency€medical€conditionÏmay€exist.€€Appellants€allege€first€that€injuries€to€the€lowerÏextremities€such€as€those€suffered€by€Mr.€Reynolds€create€aÏsubstantial€risk€of€the€development€of€DVT.€€They€contend€that€theÏknowledge€that€Mr.€Reynolds'€injuries€indicated€a€risk€of€DVTÏshould€be€construed€as€a€"symptom"€under€EMTALA,€warranting€furtherÏscreening€and€stabilization.€€Appellants€argue€alternatively€thatÏMr.€Reynolds'€alleged€statement€that€he€had€a€family€history€ofÐ À+'2 ÐÔ_ÔhypercoagulabilityÔ_Ô,€combined€with€the€particular€injuries,Ïconstituted€a€"symptom"€of€an€emergency€medical€condition.€€TheÏhospital's€failure€to€screen€when€confronted€with€these€symptoms€ofÏÔ_ÔDVTÔ_Ô,€appellants€aver,€violates€Ô_ÔEMTALAÔ_Ô's€screening€requirement.Ìà ` àAppellants'€proposed€interpretation€of€"symptoms"€isÏcontrary€to€ordinary€usage,€not€supported€by€statutory€text€orÏpurpose,€and€not€supported€in€Ô_ÔcaselawÔ_Ô.Ìà ` àÔ_ÔEMTALAÔ_Ô€defines€"emergency€medical€condition"€as€follows,Ïin€pertinent€part:ÌÒ°ÒÒ°ÒÓÓ(A)€a€medical€condition€manifesting€itself€by€acuteÏsymptoms€of€sufficient€severity€(including€severe€pain)Ïsuch€that€the€absence€of€immediate€medical€attentionÏcould€reasonably€be€expected€to€result€inð!ðÐ h Ðà ` à(i)€placing€the€health€of€the€individual€.€.€.€inÏserious€jeopardy,Ìà ` à(ii)€serious€impairment€to€bodily€functions,€orÌà ` à(iii)€serious€dysfunction€of€any€bodily€organ€orÏpart€.€.€.€.ÌÌÒ°ÒÒ°ÒÓÓ42€U.S.C.€ðð€1395dd(e)(1).€€Appellee€argues€that€information€aboutÏfamily€history€provided€by€a€patient,€without€any€accompanyingÏpsychological€or€physiological€symptoms,€cannot€reasonably€beÏunderstood€to€be€an€"acute€symptom[]€of€sufficient€severity"€thatÏis€"manifest[ed]"€by€a€"medical€condition."Ìà ` àWe€need€not€and€do€not€adopt€this€more€circuitous€path€ofÏreasoning€instead€of€the€direct€inference€that€the€words€of€theÏstatute,€in€their€literal€context,€do€not€support€appellants'Ïproposed€meanings€of€"symptoms."Ìà ` àCaselaw€provides€no€clear€answer€to€the€issue€ofÏâ âstatutory€interpretation€before€us.Ð 0*€%0 Ðà ` àA€patient€who€communicates€that€she€feels€nauseous€orÏâ âdizzy€could€be€describing€a€symptom€of€an€emergency€medicalÏcondition.€€òòSeeóó€òòCorreaóó€v.€òòHospital€San€Franciscoóó,€69€F.3d€1184,Ð Ð  Ð1192€(1st€Cir.€1995)€("[N]ausea€and€dizziness€...€might€well€heraldÏthe€onset€of€an€emergency€medical€condition€in€the€case€of€aÏhypertensive€diabetic.").€€In€such€a€case€the€condition€manifestsÏitself€by€the€dizziness€or€nausea,€a€symptom€that€is€thenÏcommunicated€verbally€by€the€patient.€€Information€about€risk„¼factors,€such€as€injuries€or€medical€history,€would€inform€aÏphysician's€interpretation€of€that€symptom.€€Nausea€and€dizzinessÏalone€do€not€necessarily€indicate€that€an€emergency€medicalÏcondition€exists€but,€when€coupled€with€a€history€of€hypertensionÏand€diabetes,€as€in€òòCorreaóó,€may€indicate€the€presence€of€anÐ pÀ Ðemergency€medical€condition.€€Several€important€differences€exist,Ïhowever,€between€the€facts€of€this€case€and€those€of€òòCorreaóó.€Ð à ÐFirst,€the€patient€in€òòCorreaóó€was€at€the€time€of€the€examinationÐ  p Ðexperiencing€physiological€symptoms€of€a€pathological€condition,Ïsymptoms€that€were€communicated€to€the€staff€of€the€emergencyÏdepartment.€€Here,€Mr.€Reynolds€was€not€experiencing€anyÏphysiological€symptoms€of€DVT€that€he€expressed€to€anyone€atÏMaineGeneral.€€Also,€the€patient€in€òòCorreaóó€came€to€the€emergencyÐ ð#@( Ðroom€complaining€of€these€symptoms€and€received€no€screening€orÏtreatment€for€any€condition€that€she€may€have€had.€€Here,ÏMr.Reynolds€was€brought€to€the€emergency€room€with€significantÏtrauma€to€his€lower€legs€for€which€he€received€extensive€screeningÏand€treatment.€€Although€appellants€ask€us€to€accept€as€compellingÐ À+'2 Ðan€analogy€between€the€absence€of€any€screening€and€treatment€inÏòòÔ_ÔCorreaÔ_Ôóó€and€the€lack€of€screening€and€treatment€for€Ô_ÔDVTÔ_Ô€here,€weÐ @ Ðfind€this€argument€unpersuasive.Ìà ` àòòSecondóó.€€Appellants€claim€that€a€court€(including€thisÐ ` ° Ðcourt)€should€hold€in€this€case€that,€for€purposes€of€applyingÏEMTALA's€screening€requirement,€Mr.€Reynolds€came€to€the€emergencyÏdepartment€twice.Ìà ` àAppellants€cite€òòÔ_ÔLð;ðpezÔ_Ô„Sotoóó€v.€òòHawayekóó,€175€F.3d€170€(1stÐ  ð  ÐCir.€1999),€to€support€the€proposition€that€the€duty€to€screen€doesÏnot€arise€only€at€the€moment€a€patient€first€comes€to€the€emergencyÏroom,€but€may€arise€later€in€the€face€of€new€information€or€changedÏcircumstances.€€Appellants€materially€misread€this€court's€holdingÏin€òòÔ_ÔLð;ðpezÔ_Ô„Sotoóó.€€The€circumstances€in€òòÔ_ÔLð;ðpezÔ_Ô„Sotoóó€involved€a€womanÐ pÀ Ðwho€came€to€the€hospital€to€deliver€her€baby€and€was€admitted€toÏthe€maternity€ward.€€Problems€developed€during€delivery€and€theÏchild€was€born€in€severe€respiratory€distress€and€later€died€afterÏbeing€transferred€to€a€different€hospital.€€Defendant€in€òòÔ_ÔLð;ðpezÔ_Ô„SotoóóÐ °  Ðargued€that€the€infant€did€not€"[come]€to€the€emergency€room"€andÏthat€the€hospital,€therefore,€was€not€under€an€obligation€toÏstabilize€his€emergency€medical€condition€before€transferring€himÏto€another€hospital.€€In€ruling€against€defendant,€this€courtÏdetermined€that€subsection€(a)€and€subsection€(b)€of€42€U.S.C.Ïðð1395dd€are€to€be€read€disjunctively.€€òòSeeóó€òòid.óó€at€173.€€That€is,Ð '`", Ðthe€phrase€"comes€to€the€emergency€room"€relates€only€to€the€dutyÏto€screen€embodied€in€subsection€(a).€€Subsection€(b),€on€the€otherÏhand,€provides€that€if€any€individual€"comes€to€a€hospital"€and€theÐ À+'2 Ðhospital€determines€that€the€individual€has€an€emergency€medicalÏcondition,€the€hospital€has€a€duty€to€stabilize€that€condition.€€InÏòòÔ_ÔLð;ðpezÔ_Ô„Sotoóó€the€court€concluded€that€the€duty€to€stabilize€beforeÐ Ð  Ðtransfer€attaches€"as€long€as€an€individual€enters€any€part€of€theÏhospital€and€the€hospital€determines€that€an€emergency€medicalÏcondition€exists."€€òòId.óó€at€174€(citation€omitted).€€Because€theÐ € Ð  Ðcourt€clearly€distinguished€the€requirements€imposed€by€subsectionÏ(a),€which€are€triggered€by€a€patient's€coming€to€the€emergencyÏdepartment,€from€those€imposed€by€subsections€(b)€and€(c),€whichÏare€triggered€by€a€patient's€coming€to€the€hospital,€appellants'Ïreliance€on€òòÔ_ÔLð;ðpezÔ_Ô„Sotoóó€is€misplaced.Ð P  Ðà ` àAppellants€try€a€somewhat€different,€but€related,€tack€inÏarguing€that€the€hospital€room€should€be€treated€as€the€functionalÏequivalent€of€the€emergency€department€for€purposes€of€this€case.€ÏAppellants€acknowledge€that€the€need€to€treat€immediately€theÏtraumatic€injuries€to€Mr.€Reynolds'€lower€extremities€postponedÏfull€screening€for€and€treatment€of€Ô_ÔDVTÔ_Ô€until€after€Mr.€Reynolds'Ïtraumatic€injuries€had€been€treated.€€Appellants€also€note€thatÏMr.Reynolds€may€not€have€had€Ô_ÔDVTÔ_Ô€when€he€first€arrived€atÏÔ_ÔMaineGeneralÔ_Ô,€but€may€have€developed€Ô_ÔDVTÔ_Ô€while€at€the€hospital.€ÏThey€propose€that€because€of€these€circumstances,€the€duty€toÏscreen€should€be€tolled,€in€effect,€until€after€the€traumaticÏinjuries€had€been€treated€and€clotting€was€more€likely€to€haveÏbegun.€€Appellants€argue€that€it€would€be€unreasonable€for€thisÏcourt€to€interpret€42€U.S.C.€ðð€1395dd(a)€in€a€way€that€requiresÏMr.Reynolds€to€leave€the€hospital€and€reenter€the€emergency€roomÐ À+'2 Ða€second€time€in€order€to€receive€screening€and€treatment€forÏpotential€Ô_ÔDVTÔ_Ô.€€Not€only€does€the€text€of€the€statute€fail€toÏsupport€appellants'€contention,€but€neither€does€the€purpose€of€theÏstatute€as€manifested€by€Congress.Ìà ` àAs€numerous€courts€have€noted,€including€this€one,Ï"Ô_ÔEMTALAÔ_Ô€is€a€limited€'anti„dumping'€statute,€not€a€federalÏmalpractice€statute."€€òòBryanóó€v.€òòRectors€and€Visitors€of€the€Univ.Ð `  Ðof€Va.óó,€95€F.3d€349,€351€(4th€Cir.€1996)€(citation€omitted);€òòseeóóÐ  ð  ÐòòÔ_ÔCorreaÔ_Ôóó,€òòsupraóó,€69€F.3d€at€1192;€òòSummersóó€v.€òòBaptist€Med.€Ctr.Ð 0€  ÐÔ_ÔArkadelphiaÔ_Ôóó,€91€F.3d€1132,€1137€(8th€Cir.€1996)€("So€far€as€we€canÐ À Ðtell,€every€court€that€has€considered€Ô_ÔEMTALAÔ_Ô€has€disclaimed€anyÏnotion€that€it€creates€a€general€federal€cause€of€action€forÏmedical€malpractice€in€emergency€rooms.");€òòUrbanóó€v.€òòKingóó,€43€F.3dÐ pÀ Ð523,€525€(10th€Cir.€1994).€€Congress€enacted€Ô_ÔEMTALAÔ_Ô€in€1996,€in€theÏface€of€"the€increasing€number€of€reports€that€hospital€emergencyÏrooms€are€refusing€to€accept€or€treat€patients€with€emergencyÏconditions€if€the€patient€does€not€have€medical€insurance."€€H.R.ÏRep.€No.€241(I),€99th€Cong.,€1st€Sess.€27€(1986),€reprinted€in€1986ÏÔ_ÔU.S.C.C.A.N.Ô_Ô€42,€605.€€Ô_ÔEMTALAÔ_Ô€created€a€remedy€for€patients€inÏcertain€contexts€in€which€a€claim€under€state€medical€malpracticeÏlaw€was€not€available.€€Although€the€exact€scope€of€the€rightsÏguaranteed€to€patients€by€Ô_ÔEMTALAÔ_Ô€is€still€not€fully€defined,€it€isÏclear€that€at€a€minimum€Congress€manifested€an€intent€that€allÏpatients€be€treated€fairly€when€they€arrive€in€the€emergencyÏdepartment€of€a€participating€hospital€and€that€all€patients€whoÏneed€some€treatment€will€get€a€first€response€at€minimum€and€willÐ À+'2 Ðnot€simply€be€turned€away.€€òòSeeóó€òòÔ_ÔBaberÔ_Ôóó€v.€òòHospital€Corp.€of€Americaóó,Ð ° Ð977€F.2d€872,€880€(4th€Cir.€1992)€("The€avowed€purpose€of€Ô_ÔEMTALAÔ_ÔÏwas€not€to€guarantee€that€all€patients€are€properly€diagnosed,€orÏeven€to€ensure€that€they€receive€adequate€care,€but€instead€toÏprovide€an€'adequate€first€response€to€a€medical€crisis'€for€allÏpatients€and€'send€a€clear€signal€to€the€hospital€community€.€.€.Ïthat€all€Americans,€regardless€of€wealth€or€status,€should€knowÏthat€a€hospital€will€provide€what€services€it€can€when€they€areÏtruly€in€physical€distress.'")€(òòquotingóó€131€Cong.€Rec.€S13904Ð 0€  Ð(Oct.23,€1985)€(statement€of€Sen.€Ô_ÔDurenbergerÔ_Ô)).€€Appellants'Ïargument€that€because€Mr.€Reynolds€was€in€a€hospital€room€receivingÏtreatment€for€his€injuries€when€the€risk€of€Ô_ÔDVTÔ_Ô€became€manifest,€itÏwould€be€unreasonable€to€deny€him€the€protections€of€subsection€(a)Ïis€unpersuasive.€€The€fact€that€Mr.€Reynolds€was€in€the€hospitalÏreceiving€treatment€is€a€òòprimaóó€òòfacieóó€showing€that€the€purpose€ofÐ à Ðsubsection€(a)€was€satisfied;€any€failures€of€diagnosis€orÏtreatment€were€then€remediable€under€state€medical€malpractice€law.Ìà ` àòòThirdóó.€€Appellants€argue€that€Ô_ÔMaineGeneralÔ_Ô€screenedÐ @" ÐMr.Reynolds€differently€than€it€did€other€patients€exhibitingÏsimilar€symptoms.€€Appellants€contend€that€a€complete€medicalÏhistory,€under€Ô_ÔMaineGeneralÔ_Ô's€hospital€policy,€includes€questioningÏpatients€concerning€any€family€history€of€Ô_ÔhypercoagulabilityÔ_Ô.€€TheyÏaver€that€because€Mr.€Reynolds€was€not€asked€questions€about€hisÏfamily€history€of€blood„clotting,€he€received€disparate€treatment.Ìà ` àAppellants€proffered€evidence€that€Ô_ÔMaineGeneralÔ_Ô's€onlyÏwritten€policy€regarding€the€taking€of€medical€histories€fromÐ À+'2 Ðpatients€required€that€a€"complete€history"€be€taken€from€allÏpatients.€€Appellants€proffered€expert€testimony€to€support€theÏproposition€that€a€"complete€history"€in€Mr.€Reynolds'€contextÏnecessarily€included€asking€questions€about€any€family€history€ofÏÔ_ÔhypercoagulabilityÔ_Ô.€€Appellants€aver€that€this€expert€testimony,€inÏconjunction€with€the€absence€of€any€more€detailed€hospitalÏpolicies,€compels€an€inference€that€Ô_ÔMaineGeneralÔ_Ô€gave€disparateÏtreatment€to€Mr.€Reynolds€when€it€did€not€ask€him€questionsÏconcerning€his€family€history€of€Ô_ÔhypercoagulabilityÔ_Ô.Ìà ` àAppellants'€argument€attempts€again€to€bring€aÏmalpractice€standard€into€the€interpretation€and€application€of€aÏstatute€designed€to€complement€and€not€incorporate€stateÏmalpractice€law.€€To€recover€for€disparate€treatment,€appellantsÏmust€proffer€evidence€sufficient€to€support€a€finding€thatÏMr.Reynolds€received€materially€different€screening€than€thatÏprovided€to€others€in€his€condition.€€It€is€not€enough€to€profferÏexpert€testimony€as€to€what€treatment€òòshould€óóhave€been€provided€toÐ °  Ða€patient€in€Mr.€Reynolds'€condition.€€Appellants€have€notÏproffered€evidence€sufficient€to€support€a€finding€thatÏMr.Reynolds€received€materially€different€screening€than€did€otherÏpatients€in€his€condition.Ìà ` àInsofar€as€appellants€are€continuing€to€make€a€generalÏcase€for€interpreting€Ô_ÔEMTALAÔ_Ô€as€providing€a€federal„law€remedy€forÏany€inappropriate€treatment€in€a€hospital€to€which€a€patient€inÏneed€of€emergency€attention€is€brought,€this€attempt€fails€for€theÏreasons€explained€above.€€In€òòÔ_ÔCorreaÔ_Ôóó,€this€court€recognizedÐ ,`'2 Ðappropriate€emergency€screening€as€the€Ô_ÔEMTALAÔ_Ô€objective€andÏsketched€out€the€contours€of€appropriate€screening€under€Ô_ÔEMTALAÔ_Ô:ÌÒ°ÒÒ°ÒÓÓA€hospital€fulfills€its€statutory€duty€to€screen€patientsÏin€its€emergency€room€if€it€provides€for€a€screeningÏexamination€reasonably€calculated€to€identify€criticalÏmedical€conditions€that€may€be€afflicting€òòsymptomaticóóÐ ( x Ðpatients€and€provides€that€level€of€screening€uniformlyÏto€all€those€who€present€substantially€similarÏcomplaints.€.€.€.€€The€essence€of€this€requirement€isÏthat€there€be€some€screening€procedure,€and€that€it€beÏadministered€even„handedly.ÌÌÒ°ÒÒ°ÒÓÓòòÔ_ÔCorreaÔ_Ôóó,€69€F.3d€at€1192€(emphasis€added)€(internal€citationsÐ È  Ðomitted).€€Because€we€conclude,€based€on€the€record€before€us,€thatÏappellants€failed€to€proffer€evidence€sufficient€to€support€aÏfinding€that€Mr.€Reynolds€was€"symptomatic"€for€Ô_ÔDVTÔ_Ô,€within€theÏmeaning€of€the€statute,€the€hospital€was€not€required€under€theÏstatute€to€screen€for€Ô_ÔDVTÔ_Ô.Ìò òB.€€Stabilization€Claimó óÐ (x Ðà ` àIn€addition€to€their€claim€for€failure€to€screenÏMr.Reynolds€appropriately€for€Ô_ÔDVTÔ_Ô,€appellants€argue€that€a€genuineÏdispute€of€material€fact€exists€as€to€whether€Ô_ÔMaineGeneralÔ_ÔÏstabilized€Mr.€Reynolds€for€Ô_ÔDVTÔ_Ô€before€releasing€him.€€AppellantsÏargue€extensively€about€the€nature€of€the€stabilizationÏrequirements€under€Ô_ÔEMTALAÔ_Ô€in€support€of€their€contention€thatÏMr.Reynolds€was€not€stabilized€before€release.€€A€critical€flaw€inÏthis€claim€of€appellants€under€ðð€1395dd(b)(1),€however,€is€thatÏappellants€have€failed€to€demonstrate€that€Mr.€Reynolds€had€anÏemergency€medical€condition€at€the€time€of€his€discharge€fromÏâ âÔ_ÔMaineGeneralÔ_Ô.Ð ¨*ø%0 Ðà ` àAs€a€corollary€to€the€right€to€be€appropriately€screened,Ïâ âÔ_ÔEMTALAÔ_Ô€guarantees€patients€the€right,€if€an€emergency€medicalÏcondition€is€determined€to€exist,€to€have€that€condition€stabilizedÏbefore€discharge€or€transfer€to€another€hospital.€€The€statuteÏprovides,€in€pertinent€part:ÌÒ°ÒÒ°ÒÓÓIf€any€individual€.€.€.€comes€to€a€hospital€and€theÏhospital€òòdetermines€that€the€individual€has€an€emergencyÐ H ˜  Ðmedical€conditionóó,€the€hospital€must€provide€eitherð!ð€Ð 8ˆ  Ðà ` à(A)€within€the€staff€and€facilities€available€at€theÏhospital,€for€such€further€medical€examination€and€suchÏtreatment€as€may€be€required€to€stabilize€the€medicalÏcondition,€orÌà ` à(B)€for€transfer€of€the€individual€to€anotherÏmedical€facility€in€accordance€with€subsection€(c).ÌÌÒ°ÒÒ°ÒÓÓ42€U.S.C.€ðð€1395dd(b)(1)€(emphasis€added).€€This€court€need€notÏreach€any€questions€about€the€nature€of€stabilization€if€weÏdetermine€that€the€predicates€to€stabilization€have€not€beenÏsatisfied.€€Appellants€proffered€expert€testimony€that€it€wasÏlikely€that€the€clot€that€later€became€the€pulmonary€embolism€thatÏcaused€Mr.€Reynolds'€death€formed€before€Mr.€Reynolds€wasÏdischarged€from€Ô_ÔMaineGeneralÔ_Ô.€€Appellants'€expert€further€testifiedÏthat€a€17€to€30%€likelihood€existed€that€Mr.€Reynolds€had€formedÏblood€clots€at€the€time€of€his€discharge.€€Appellants'€expert€alsoÏproffered€testimony€that€some€research€indicates€a€2%€mortalityÏrate€in€cases€of€untreated€Ô_ÔDVTÔ_Ô.€€Evidence€of€one€expert€that€it€isÏmore€likely€than€not€in€his€opinion€that€the€blood€clot€thatÏeventually€caused€Mr.€Reynolds'€death€had€formed€by€the€time€of€hisÏdischarge,€combined€with€the€evidence€that€2%€of€untreated€Ô_ÔDVTÔ_ÔÏcases€result€in€death,€is€not€sufficient€to€support€a€determinationÏthat€Mr.€Reynolds€had€an€emergency€medical€condition€at€the€time€ofÐ ,`'2 Ðhis€discharge.€€To€invoke€subsection€(b),€appellants€must€profferÏmore€than€evidence€of€a€possibility€of€the€existence€of€a€bloodÏclot€at€the€time€of€Mr.€Reynolds'€discharge.€€They€must€profferÏevidence€sufficient€to€support€a€finding,€reasoned€from€evidence,Ïthat€an€emergency€medical€condition,€within€the€meaning€of€theÏstatute,€was€already€in€existence€at€the€time€of€Mr.€Reynolds'Ïdischarge.€€Appellants€have€not€proffered€evidence€sufficient€toÏsupport€a€finding€that€Mr.€Reynolds€had€an€emergency€medicalÏcondition€at€that€time,€and€for€this€reason€have€failed€to€satisfyÏa€necessary€predicate€to€the€duty€to€stabilize.ñ¼ñ€€ñ¼ñÌñ½ñà ` àñ½ñà ` àFurthermore,€as€noted€by€Magistrate€Judge€Ô_ÔBeaulieuÔ_Ô,Ïappellants'€case€is€centered€on€the€asserted€fact€that€Ô_ÔMaineGeneralÔ_ÔÏdid€not€take€steps€to€determine€whether€Mr.€Reynolds€was€at€risk€ofÏdeveloping€Ô_ÔDVTÔ_Ô.€€It€is€doubtful€that€the€text€of€the€statute€wouldÏsupport€liability€under€the€stabilization€provision€for€a€patientÏwho€had€Ô_ÔDVTÔ_Ô,€absent€evidence€sufficient€to€support€a€finding€thatÏthe€hospital€knew€of€his€Ô_ÔDVTÔ_Ô.€€òòSeeóó€òòMarshallóó€v.€òòEast€Carroll€ParishÐ °  ÐHosp.€Serv.€Dist.óó,€134€F.3d€319,€325€(5th€Cir.€1998);€òòSummersóó,Ð @" Ðòòsupraóó,€91€F.3d€at€1140€(no€duty€to€stabilize€unless€hospital€"hasÐ Ð $ Ðactual€knowledge€of€the€individual's€Ô_ÔunstabilizedÔ_Ô€emergency€medicalÏcondition");€òòVickersóó€v.€òòNash€Gen.€Hosp.,€Inc.óó,€78€F.3d€139,€145Ð ð#@( Ð(4th€Cir.€1996)€("The€Act€does€not€hold€hospitals€accountable€forÏfailing€to€stabilize€conditions€of€which€they€are€not€aware,€orÏeven€conditions€of€which€they€should€have€been€aware.").€€ItÏappears€quite€likely€that€one€important€respect€in€which€Ô_ÔEMTALAÔ_Ô'sÏrequirements€are€narrower€than€those€imposed€by€state€law€concernsÐ À+'2 Ðprophylactic€care.€€Subsection€(b)€requires€stabilization€of€onlyÏthose€conditions€that€a€participating€hospital€has€determined€to€beÏemergencies.€€It€may€be€that€in€exceptional€circumstances€of€proofÏof€an€existing€emergency€need€for€immediate€stabilization,€aÏhospital€would€have€a€duty€of€stabilization€under€Ô_ÔEMTALAÔ_Ô.€€We€needÏnot€and€do€not€reach€that€issue,€however,€since€it€is€not€presentedÏby€the€record€before€us€in€this€case.Ìñ¾ñÌñ¾ñà@hh#ìàò òIV.€€Conclusionó óˆÐ  ð  Ðñ¿ñà ` àñ¿ñà ` àBecause€appellants'€claims€essentially€are€claims€thatÏÔ_ÔMaineGeneralÔ_Ô€Ô_ÔmisdiagnosedÔ_Ô€and€negligently€treated€William€Reynolds,Ïwe€believe€the€district€court€appropriately€granted€defendant'sÏmotion€for€summary€judgment€on€plaintiffs'€Ô_ÔEMTALAÔ_Ô€claims.€€For€theÏreasons€stated€in€this€opinion,€the€judgment€of€the€district€courtÏisñÀñ€ñÀññÁñÌÌñÁññÂñò òñÂñAFFIRMEDñÂñó óñÂñ.ñÃñ€ñÃñÔ_ÔÔ_ÔñÃñ€ñÃñÔ_Ô