Koel v. Citizens Medical Center

128 F.4th 1329

• Court: Court of Appeals for the Tenth Circuit
• Decided: February 24, 2025
• Docket: 23-3232
• Status: Published

Opinion

Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 1 FILED United States Court of Appeals PUBLISH Tenth Circuit

UNITED STATES COURT OF APPEALS February 24, 2025 Christopher M. Wolpert FOR THE TENTH CIRCUIT Clerk of Court _________________________________

RICKY KOEL,

Plaintiff - Appellant,

v. No. 23-3232

CITIZENS MEDICAL CENTER, INC.; DANIEL P. KUHLMAN, M.D.; SAM RODGER FUNK, O.D.; SAM R. FUNK, O.D., P.A.,

Defendants - Appellees. _________________________________

Appeal from the United States District Court for the District of Kansas (D.C. No. 2:21-CV-02166-HLT) _________________________________

Jonathan Sternberg, Jonathan Sternberg, Attorney, P.C., Kansas City, Missouri (Michaela Shelton, Shelton Law Office, P.A., Overland Park, Kansas, on the briefs) for Plaintiff- Appellant.

Brian C. Wright, Wright Law Office, Chartered, Hays, Kansas, for Defendants-Appellees Citizens Medical Center, Inc., and Daniel P. Kuhlman, M.D. (Lawrence J. Logback and Brenna M. Lynch, Simpson Logback Lynch Norris, P.A., Overland Park, Kansas, with him on the brief, for Defendants-Appellees Sam Rodger Funk, O.D. and Sam R. Funk, O.D., P.A.), for Defendants-Appellees. _________________________________

Before TYMKOVICH, EBEL, and ROSSMAN, Circuit Judges. _________________________________

TYMKOVICH, Circuit Judge. _________________________________ Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 2

Ricky Koel sought emergency care and treatment at Citizens Medical Center,

Inc., a hospital in Colby, Kansas, after sustaining serious injuries to his right eye.

Citizens evaluated Mr. Koel and eventually released him with medication and

instructions to see an ophthalmologist the following morning. He visited the

ophthalmologist and received emergency surgery the next day, but eventually lost

vision in his injured eye.

Mr. Koel asserted state-law medical malpractice claims against Citizens and

several of Citizens’ medical staff. He also brought a federal claim against Citizens

under the Emergency Medical Treatment and Labor Act (EMTALA). The district

court dismissed Mr. Koel’s EMTALA claim, concluding that Citizens did not violate

the requirements under the Act.

We agree. EMTALA requires only that a covered hospital provide a medical

screening examination according to its capability and stabilize emergency medical

conditions that it has actual knowledge of. We therefore AFFIRM.

I. Background

On April 10, 2019, Mr. Koel injured his right eye while repairing a wire fence

on his farm in rural western Kansas. He and his wife sought emergency treatment at

Citizens. Mr. Koel’s right eye was bleeding, and he was vomiting due to the pain.

Mr. Koel was immediately seen by a triage nurse, who conducted a triage

examination and an initial nursing evaluation. A physician assistant then admitted

and evaluated Mr. Koel in Citizens’ emergency department. Citizens did not have an

2 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 3

eye specialist on-site, and thus the physician assistant called Dr. Luther Fry, an

ophthalmologist, for advice and left him a message.

Subsequently, Citizens’ on-call ER hospitalist, Dr. Daniel Kuhlman, examined

Mr. Koel with an ophthalmologic scope and ordered a CT scan. Dr. Kuhlman, who

has no training in ophthalmology, was concerned that Mr. Koel may have a globe

rupture, although it was not visible or apparent. A possible globe rupture was noted

in Mr. Koel’s differential diagnosis. 1 An open ruptured globe is clearly and readily

visible upon examination, while an occult ruptured globe is not obvious and cannot

be seen by the naked eye. A ruptured globe must be surgically closed as soon as

possible to avoid loss of vision.

A local optometrist, Dr. Sam Funk, was also called in to examine Mr. Koel.

Dr. Funk used a slit lamp to examine Mr. Koel’s injured eye, but an open globe

rupture was not visible. Dr. Funk performed what is called a Seidel test—a

diagnostic procedure used to detect ocular trauma—which did not rule out a possible

open globe rupture. At this point, Dr. Funk believed Mr. Koel had a closed globe,

not an open globe rupture. Citizens did not have the capabilities to surgically explore

Mr. Koel’s eye to confirm a suspected ruptured globe.

After a brief phone call with Dr. Funk, Dr. Fry agreed to see Mr. Koel the next

morning at his office in Garden City, approximately 100 miles away.

1 It is “common to describe injuries, both penetrating and blunt, as either open-globe or closed-globe injuries, depending on the integrity of the eyeball.” Open-globe versus closed-globe injuries, 5 ATTORNEYS MEDICAL ADVISOR § 36:378. 3 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 4

Dr. Kuhlman received the interpretation results of Mr. Koel’s CT scan after

Dr. Funk left the hospital. The radiologist opined that the CT scan showed a “right

intraocular hemorrhage and possible component of right globe rupture.” Dr.

Kuhlman did not share the CT scan results with Drs. Funk or Fry; he testified that the

results did not change or add anything to Mr. Koel’s diagnosis or treatment plan,

which noted that “some degree of right globe rupture [was] possible.” App. Vol. I,

57.

Dr. Kuhlman shared the CT scan results with Mr. Koel, including that he had a

possible globe rupture which, if correct, may result in loss of vision if it is not

immediately closed. He informed Mr. Koel that he had the option of being

transferred to a larger ER with more assessment capabilities for further evaluation.

Based on his professional judgment, Dr. Kuhlman did not recommend Mr. Koel

transfer to another facility because it was possible Mr. Koel may personally incur

financial costs for the transportation when he did not have a ruptured globe injury at

all. Mr. Koel, who was uninsured, declined to be transferred.

Mr. Koel was discharged from Citizens with multiple medications and

instructed to see Dr. Fry the next morning. Dr. Kuhlman recommended Mr. Koel

travel to Garden City that evening, even by private transport, for the following

morning’s appointment, but Mr. Koel and his wife stated that they could not afford

the overnight stay. Mr. Koel was informed that he should “return to care” if anything

arises before the next morning’s appointment.

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The next day, Dr. Fry examined Mr. Koel and sent him to see Dr. Nesmith, a

retina specialist in Wichita, who conducted surgery that same evening for an occult

ruptured globe. Despite his surgery, Mr. Koel ultimately lost vision in his injured

eye.

Mr. Koel asserted state-law medical malpractice claims against Citizens and

several of the medical professionals who treated him. He also brought a federal claim

against Citizens under EMTALA. After a period of discovery, the district court granted

summary judgment in favor of Citizens on the EMTALA claim and declined to exercise

supplemental jurisdiction for Mr. Koel’s remaining state-law claims. Mr. Koel’s

appeal is limited to the district court’s grant of summary judgment on the EMTALA

claim.

II. Discussion

A. Standard of Review

We review a summary judgment order de novo, applying the same standards

the district court would use in deciding whether to grant the motion. Ingram v.

Muskogee Reg’l Med. Ctr., 235 F.3d 550, 551 (10th Cir. 2000). Summary judgment

is appropriate “if the pleadings, depositions, answers to interrogatories, and

admissions on file, together with the affidavits, if any, show that there is no genuine

issue as to any material fact and that the moving party is entitled to a judgment as a

matter of law.” Id. (citing FED. R. CIV. P. 56(c)).

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We review the record in the light most favorable to the non-moving parties to

determine if there is a genuine issue of material fact, which would require the case to

go to trial. Urb. By & Through Urb. v. King, 43 F.3d 523, 525 (10th Cir. 1994).

B. EMTALA

“Congress enacted EMTALA in 1986 to address the problem of ‘dumping’

patients in need of medical care but without health insurance.” Phillips v. Hillcrest

Med. Ctr., 244 F.3d 790, 796 (10th Cir. 2001) (“the rights guaranteed under

EMTALA apply equally to all individuals whether or not they are insured”).

Dumping occurs when a hospital declines to treat or transfers patients because of

their inability to pay. At its core, EMTALA functions to “ensure all patients,

regardless of their perceived ability or inability to pay for medical care, are given

consistent attention.” Id. at 797.

Under EMTALA, 42 U.S.C. § 1395dd, a hospital that receives Medicare

payments and operates an emergency room has two requirements. “First, if an

individual arrives at the emergency room and requests treatment, the hospital must

‘provide for an appropriate medical screening examination . . . to determine whether

or not an emergency medical condition . . . exists.’” King, 43 F.3d at 523, 525 (citing

42 U.S.C. § 1395dd(a)). “Second, if the examination reveals the patient is suffering

from an emergency medical condition, the hospital usually must stabilize the patient

before getting into the business of trying to transfer him elsewhere.” Genova v.

Banner Health, 734 F.3d 1095, 1097 (10th Cir. 2013).

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Mr. Koel argues that Citizens violated both its first and second obligation

under EMTALA. We disagree for the reasons explained below.

1. Appropriate Medical Screening Examination

The first obligation under EMTALA requires hospitals to provide an

individual requesting treatment in its emergency room with “an appropriate medical

screening examination within the capability of the hospital’s emergency department,

including ancillary services routinely available to the emergency department, to

determine whether or not an emergency medical condition . . . exists.” 42 U.S.C.

§ 1395dd(a) (emphasis added).

We have held 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.” Phillips, 244 F.3d at 797. A hospital sets forth

which procedures are within its EMTALA capabilities when it establishes a standard

screening policy, such as through its rules or bylaws. Repp v. Anadarko Mun. Hosp.,

43 F.3d 519, 522 (10th Cir. 1994).

Our review is limited. “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.” Phillips, 244

F.3d at 797 (citing Repp, 43 F.3d at 522). Accordingly, we inquire only whether the

hospital adhered to its own procedures; we do not assess the adequacy of such

procedures. Repp, 43 F.3d at 522 & n.4; see also id. at 523 (Mere de minimis

variations or “slight deviations by a hospital from its standard screening policy” do

7 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 8

not violate EMTALA); Phillips, 244 F.3d at 798 (“EMTALA does not set a federal

standard of care or replace pre-existing state medical negligence laws.”).

Applying those standards, Citizens provided all services and care within its

capabilities as required by its bylaws and rules. We look to Citizens’ relevant

policies, rules, and practices as provided in the record by Citizens’ Rules and

Regulations, as well as Citizens’ Bylaws. See App. Vol. III, 61–138 (Medical Staff

Rules and Regulations); id. at 140–221 (Amended and Revised Medical Staff

Bylaws). 2 The two documents describe rules and regulations for Citizens’ medical

staff, including, but not limited to, physician procedures and administrative duties.

Section 13.1 of Article XIII of Citizens’ Rules and Regulations provides

definitions relevant under EMTALA. There, “capabilities” is defined as “the

hospital’s physical space, equipment, and supplies, as well as services made available

by the hospital such as . . . surgery.” App. Vol. III, 122. It provides that “[t]he

hospital’s capabilities to provide a medical screening examination and/or stabilizing

treatment may be impacted by the availability of specialist and sub-specialists at any

particular time.” Id. Relatedly, evidence in the record indicates that Citizens

followed its own standard procedures but lacked the capability—such as the

availability to conduct a B-Scan or surgery, or the availability of a specialist—to

identify and confirm Mr. Koel’s occult globe rupture. App. Vol. VII, 11-12.

2 The district court opinion provides an in-depth description of Citizens’ relevant policies, rules, and practices included in the two documents. See App. Vol. XX, 121–23. We only discuss those that are relevant to this appeal. 8 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 9

Although Mr. Koel argues that Citizens violated its own rules and procedures,

he provides no specific, supporting citations. In fact, much of Mr. Koel’s arguments

conflate standard or adequacy of care with EMTALA requirements. But it is not the

court’s function to delve into the adequacy of Citizens’ capabilities or Citizens’

failure to correctly diagnose Mr. Koel in considering his EMTALA claim. Phillips,

244 F.3d at 798. While it may have been beneficial for Mr. Koel if Citizens had the

capabilities to confirm his occult globe rupture, such an inquiry is irrelevant because

EMTALA, unlike traditional state negligence or medical malpractice law, does not

provide a remedy for an inadequate or inaccurate diagnosis. Id.

Even so, Mr. Koel contends that Citizens failed to: (1) consult a qualified

ophthalmologist regarding his injury, and (2) have a qualified ophthalmologist

examine him. Neither is required by Citizens’ standard procedure nor is it a part of

Citizens’ ancillary services routinely available to its emergency department. Section

3.4 of Citizens’ Bylaws, titled “Consulting Medical Staff,” only notes the

qualifications, prerogatives, and obligations of consulting medical staff—there is no

obligation that Citizens must consult a specialist. App. Vol. III, 168. Similarly,

Section 10.4 of Citizens’ Bylaws, titled “Emergency Medical Treatment Exam,”

provides that a medical screening examination may be conducted by physicians (i.e.,

Drs. Kuhlman and Funk), resident physicians, nurse practitioners, or physicians’

assistants. App. Vol. III, 200. Again, there is no requirement that a specialist be

available to conduct an individual’s medical screening examination.

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Mr. Koel also argues that Citizens, specifically Dr. Kuhlman, failed to forward

his CT scan results to Drs. Funk or Fry in violation of its “standard practices” that

require “ER staff . . . to forward the patient’s information and CT results to a

specialist to ask the next step.” App. Br. 18. But Citizens’ rules and bylaws require

no such thing, and Mr. Koel does not provide any record support for this contention. 3

Alternatively, Mr. Koel appears to allege that Dr. Kuhlman’s own standard

procedure is to defer eye emergencies to a specialist, and also share available

information, such as CT scan results, with relevant doctors or specialists. But

whether a doctor adhered to his own standard procedure or protocol is irrelevant for

purposes of EMTALA. Indeed, case law is clear that violations of EMTALA depend

upon whether a hospital adhered to its own standard procedures. Phillips, 244 F.3d

at 797; Repp, 43 F.3d at 522.

Finally, to the extent Mr. Koel argues that Citizens was biased against him for

being uninsured, that argument fails because EMTALA only considers the hospital’s

actions, not motives. Phillips, 244 F.3d at 798 (“Appellants’ repeated attempts to

introduce evidence regarding [the hospital’s] motives are irrelevant to whether [the

patient] was treated in a manner consistent with [the hospital’s] existing

procedures.”). Here, Citizens’ actions do not demonstrate a violation of EMTALA’s

requirement of uniform treatment for patients in similar medical circumstances. Nor

3 The district court held that Dr. Kuhlman’s decision not to forward Mr. Koel’s CT results, if anything, was no more than a de minimis deviation from Citizens’ standard procedure. App. Vol. XX, 132. 10 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 11

has Mr. Koel adequately alleged why Citizens would financially benefit from the

steps it took.

In sum, we agree with the district court’s conclusion that Citizens provided

Mr. Koel with an appropriate medical screening within its capability and in

adherence to its own standard procedures.

2. Stabilization and Transfer

The second requirement under EMTALA provides that “if an individual at a

hospital has an emergency medical condition which has not been stabilized . . . , the

hospital may not transfer the individual unless” certain conditions are met. King, 43

F.3d at 525 (citing 42 U.S.C. § 1395dd(c)(1)). We have previously held that “[a]

plain reading of the statute reveals actual knowledge of an unstabilized emergency

medical condition as a requirement to establish liability.” Id. (emphasis added) (“The

hospital cannot be held to stabilize an emergency situation without knowing an

emergency exists.”). In other words, EMTALA’s stabilization and transfer

requirements do not apply until the hospital determines and has actual knowledge of

the individual’s unstabilized emergency medical condition. Id. at 526.

Mr. Koel argues that he was improperly discharged under EMTALA because

he was not stabilized before the discharge. This issue turns on whether Citizens had

actual knowledge of Mr. Koel’s occult globe rupture.

Based on the record, we find no reasonable jury could find Citizens had actual

knowledge of Mr. Koel’s specific emergency medical condition—an occult globe

rupture. Dr. Funk opined that Mr. Koel did not have an open globe rupture but had a

11 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 12

closed globe, for which Citizens provided stabilizing measures. Importantly, as

noted above, Citizens did not have the capability (i.e., surgical exploration) to

affirmatively identify whether Mr. Koel had an occult globe rupture. Accordingly,

Citizens could not have had actual knowledge of Mr. Koel’s specific, unstabilized

emergency medical condition. And in turn, Citizens could not have been under an

obligation to stabilize Mr. Koel for an occult globe rupture before discharging or

transferring him because Citizens did not have actual knowledge of Mr. Koel’s

specific, unstabilized emergency medical condition.

Mr. Koel points to his differential diagnosis to argue that Citizens did know he

had a possible globe rupture. But knowledge of a possible diagnosis does not equate

to having actual knowledge of a diagnosis. 4 Simply put, EMTALA does not require

hospitals to provide stabilizing measures to any and all possible emergency medical

conditions.

Similarly, Mr. Koel argues that he should not have been discharged or

transferred because Citizens had actual knowledge that Mr. Koel had some medical

condition in his injured eye. That argument is unconvincing. First, the stabilization

and transfer requirement is only triggered for emergency medical conditions. See 42

U.S.C. § 1395dd. Second, according to Mr. Koel’s logic, hospitals could escape

EMTALA liability as long as they provide some sort of stabilizing measure for an

4 Mr. Koel does not point to any case law suggesting otherwise. At oral argument, Mr. Koel furthered the argument by stating that Citizens had actual knowledge of relevant symptoms of a globe rupture. But multiple diagnoses, emergency conditions or not, often exhibit the same or similar symptoms. 12 Appellate Case: 23-3232 Document: 75-1 Date Filed: 02/24/2025 Page: 13

injury, even if that stabilizing measure does not address the individual’s emergency

medical condition that the hospital has actual knowledge of. The result would create

a loophole that runs contrary to EMTALA’s purpose of not “dumping” uninsured

patients. See Phillips, 244 F.3d at 796.

Finally, any argument that Citizens should have known of Mr. Koel’s specific

condition is unavailing because EMTALA does not impose a federal standard of

medical care. Id. at 798.

In sum, the district court did not err in granting summary judgment on Mr.

Koel’s stabilization and transfer claims.

III. Conclusion

For the foregoing reasons, we affirm the district court’s summary judgment of

Mr. Koel’s EMTALA claims for Citizens.