American Academy of Emergency Medicine

Legal Definition of a Medical Screening Exam

by Robert V. West, MD JD FAAEM

EMTALA case law usually complicates our duties in the Emergency Department and encumbers our already challenging practice responsibilities. The following case review serves to add an element of predictability to our triage role and helps to set some legal bounds to the nagging question as to the adequacy of a medical screening exam.

On April 19, the U.S. Court of Appeals for the Ninth Circuit held that, when a hospital wrongly diagnoses a patient's emergency condition but nonetheless provides an adequate medical screening, it does not breach the Emergency Medical Treatment and Active Labor Act. (Jackson v. East Bay Hospital, 9th Cir., No. 98-17152, 4/19/01). In the case, Robert Jackson, who had been diagnosed with and was taking medication for a psychotic disorder, visited a hospital emergency room in California three times in four days. He then died of a heart attack caused by a psychotic delirium brought on by a drug toxicity, according to the decision.

The doctors and nurses at the hospital emergency room did not diagnose a drug toxicity, and Jackson's family argued he did not receive an adequate EMTALA medical screening. The Ninth Circuit (which joined most other federal circuit courts) used the case to announce its adoption of a "comparative test" as the standard for judging compliance with EMTALA's requirement that all emergency room patients be given an appropriate medical screening, regardless of ability to pay (42 U.S. C., Section 1395dd(a).

A hospital generally satisfies EMTALA's screening mandate "if it provides a patient with an examination comparable to the one offered to other patients presenting similar symptoms," the court held. The relevance of this case to implementing and adopting triage protocols is undeniable. The implementation of a reasonably calculated triage protocol has been advocated by many authors, including Robert Derlet MD FAAEM for almost a decade. Evolving case law seems relatively clear and supportive of the fact, that a comparable test as outlined by a standard triage protocol would seem to satisfy this legal duty in an efficient and objective manner.