                                                                         FILED
                                                             United States Court of Appeals
                                                                     Tenth Circuit

                        UNITED STATES COURT OF APPEALSFebruary 13, 2020
                                                                Christopher M. Wolpert
                                   TENTH CIRCUIT                    Clerk of Court



 SEIFULLAH CHAPMAN,

           Plaintiff - Appellee,

 v.                                                      No. 18-1117
                                            (D.C. No. 1:15-CV-00279-WYD-KLM)
 GEORGE SANTINI, MD,                                      (D. Colo.)
 individually; ANTHONY OSAGIE,
 PA, individually; RONALD
 CAMACHO, PA, individually,

           Defendants - Appellants,

 and

 FEDERAL BUREAU OF PRISONS,

           Defendant.


                              ORDER AND JUDGMENT *


Before HOLMES, McKAY, and CARSON, Circuit Judges.


       At all relevant times (approximately February 2013 to August 2015),

Seifullah Chapman was a prisoner at Administrative Maximum (“ADX”) in



       *
              This order and judgment is not binding precedent except under the
doctrines of law of the case, res judicata, and collateral estoppel. It may be cited,
however, for its persuasive value consistent with Fed. R. App. P. 32.1 and 10th
Cir. R. 32.1.
Florence, Colorado, reputedly the most secure and restrictive prison operated by

the Bureau of Prisons. Mr. Chapman has a severe form of Type 1 diabetes.

While incarcerated at ADX, he was treated by three prison medical professionals:

Dr. George Santini, Anthony Osagie, and Ronald Camacho (the “Medical

Professionals”). In this Bivens action, 1 Mr. Chapman alleges that each Medical

Professional violated the Eighth Amendment by acting with deliberate

indifference to his serious medical needs. The Medical Professionals deny any

wrongdoing and invoke qualified immunity.

      We must decide whether the Medical Professionals are entitled to qualified

immunity. In doing so, we must resolve two questions: (1) whether any of the

Medical Professionals violated the Eighth Amendment, and (2) if so, whether

then-extant law clearly established the unconstitutionality of their conduct. In

denying the Medical Professionals’ motion for summary judgment, the district

court answered both questions in the affirmative.

      The Medical Professionals appeal from that order. The parties are familiar

with the facts and the procedural history. As to such matters, we offer details




      1
             In Bivens v. Six Unknown Named Agents of Fed. Bureau of Narcotics,
403 U.S. 388 (1971), the Supreme Court “recognized for the first time an implied
private action for damages against federal officers alleged to have violated a
citizen’s constitutional rights.” Ashcroft v. Iqbal, 556 U.S. 662, 675 (2009)
(quoting Corr. Servs. Corp. v. Malesko, 534 U.S. 61, 66 (2001)).

                                         2
only in connection with our disposition of the issues presented in this appeal.

Exercising jurisdiction under 28 U.S.C. § 1291, we affirm.

                                          I

      Before we can turn to the merits of the Medical Professionals’ appeal, “we

must first ensure we have jurisdiction.” Perry v. Durborow, 892 F.3d 1116, 1119

(10th Cir. 2018). Mr. Chapman has moved to dismiss this appeal for lack of

appellate jurisdiction. The Medical Professionals respond that we do have

jurisdiction. We agree with the Medical Professionals: we do have jurisdiction.

      As a general rule, we lack jurisdiction over denials of summary judgment.

See Plumhoff v. Rickard, 572 U.S. 765, 771 (2014); accord Serna v. Colo. Dep’t

of Corr., 455 F.3d 1146, 1150 (10th Cir. 2006). The collateral-order doctrine is

an exception to that general rule; it allows appellate courts to review “a limited

set of district-court orders” even though the orders are “short of final judgment.”

Ashcroft v. Iqbal, 556 U.S. 662, 671 (2009) (quoting Behrens v. Pelletier, 516

U.S. 299, 305 (1996)). In particular, orders denying qualified immunity at the

summary-judgment stage qualify for this special jurisdictional treatment, see, e.g.,

Plumhoff, 572 U.S. at 771, but in appeals from such orders, we are limited to

review of “the district court’s abstract legal conclusions,” Felders ex rel. Smedley

v. Malcom, 755 F.3d 870, 878 (10th Cir. 2014); accord Fancher v. Barrientos,

723 F.3d 1191, 1198 (10th Cir. 2013).


                                          3
      Notably, we generally lack interlocutory jurisdiction when a district court

denies qualified immunity based on a determination that there are “genuine”

disputes of material fact for trial. Johnson v. Jones, 515 U.S. 304, 319-20 (1995);

see Cox v. Glanz, 800 F.3d 1231, 1242 (10th Cir. 2015) (noting that whether “‘the

pretrial record sets forth a “genuine” issue of fact for trial’ is not an abstract legal

question” (quoting Johnson, 515 U.S. at 320)). An exception to this general rule

applies when a district court fails to specify which factual disputes preclude the

grant of summary judgment based on qualified immunity. See Lewis v. Tripp, 604

F.3d 1221, 1225 (10th Cir. 2010) (“[W]hen the district court at summary

judgment fails to identify the particular charged conduct that it deemed

adequately supported by the record, we may look behind the order denying

summary judgment and review the entire record de novo to determine for

ourselves as a matter of law which factual inferences a reasonable jury could and

could not make.”).

      Therefore, “[i]f a district court does not state the facts a reasonable jury

could find at summary judgment, ‘a court of appeals may have to undertake a

cumbersome review of the record to determine [those] facts.’” Id. (quoting

Johnson, 515 U.S. at 319); accord Roosevelt-Hennix v. Prickett, 717 F.3d 751,

756 n.8 (10th Cir. 2013); see Armijo ex rel. Chavez v. Wagon Mound Pub. Sch.,

159 F.3d 1253, 1259 (10th Cir. 1998) (noting that “if the district court concludes


                                            4
that a genuine issue of material fact exists in denying qualified immunity, but

does not set forth with specificity the facts presented by the plaintiff that support

a finding that the defendant violated a clearly established right, then we may look

behind the order denying summary judgment”). “In such circumstances, but only

in such circumstances, we may review the entire record, construing the evidence

in the light most favorable to the plaintiff, and determine de novo whether the

plaintiff in fact presented sufficient evidence to forestall summary judgment on

the issue of qualified immunity.” Armijo, 159 F.3d at 1259.

      This case requires such a record review. Although the district court denied

summary judgment because of “genuine issues of material facts,” Aplts.’ App.,

Vol. XX, at 3334–35 (Order Den. Summ. J., filed Jan. 25, 2018), it did not

explicitly identify the material facts in dispute. 2 Moreover, this is not a situation

where the defendants dispute our obligation to construe any facts found in the

light most favorable to the plaintiff. Cf. Castillo v. Day, 790 F.3d 1013, 1018

(10th Cir. 2015) (“Although [Defendant] attempts to characterize the issue on


      2
              The district court identified the following genuine issues of material
fact, without specifying the facts that precluded the grant of summary judgment:
(1) whether the Medical Professionals appropriately administered Mr. Chapman’s
insulin, (2) whether the Medical Professionals provided Mr. Chapman with
appropriate medical supplies to manage his diabetes, and (3) whether the Medical
Professionals appropriately responded to Mr. Chapman’s symptoms and
complaints regarding his Type 1 diabetes and whether Mr. Chapman suffered
serious harm or substantial risk of serious harm. The district court provided no
further detail.

                                           5
appeal as Plaintiffs’ failure to assert a violation of a constitutional right under

clearly established law, her argument is limited to a discussion of her version of

the facts and the inferences that can be drawn therefrom. Thus, [Defendant’s]

argument is actually a challenge to the district court’s conclusion Plaintiffs

presented sufficient evidence to survive summary judgment. As such, this court

lacks jurisdiction to review her appeal at the interlocutory stage.” (emphasis

added) (footnote omitted)). Indeed, the Medical Professionals expressly

acknowledge that “all disputed facts must be resolved in the light favorable to

[Mr. Chapman].” Aplts.’ Resp. to Aplee.’s Mot. to Dismiss at 4 (filed July 26,

2018). And they purport to do so in their opening brief. See Aplts.’ Opening Br.

at 6.

        In light of these circumstances, we do have jurisdiction over this

interlocutory appeal. Mr. Chapman’s motion to dismiss is denied. We proceed to

the merits.

                                           II

        Qualified immunity “shields officials from civil liability.” Mullenix v.

Luna, --- U.S. ----, 136 S. Ct. 305, 308 (2015) (per curiam). But it is more than

“a mere defense to liability”; it is also “an immunity from suit.” Plumhoff, 572

U.S. at 771–72 (quoting Pearson v. Callahan, 555 U.S. 223, 231 (2009)). Indeed,

qualified immunity exists largely “to ensure that ‘“insubstantial claims” against


                                           6
government officials [will] be resolved prior to discovery.’” Pearson, 555 U.S. at

231 (alteration in original) (quoting Anderson v. Creighton, 483 U.S. 635, 640 n.2

(1987)). That said, the qualified-immunity shield protects officials only when

their “conduct ‘does not violate clearly established statutory or constitutional

rights.’” White v. Pauly, --- U.S. ----, 137 S. Ct. 548, 551 (2017) (quoting

Mullenix, 136 S. Ct. at 308). More specifically, a plaintiff may defeat a claim of

qualified immunity by making two showings: First, that “the defendant violated a

constitutional right.” Redmond v. Crowther, 882 F.3d 927, 935 (10th Cir. 2018)

(quoting Koch v. City of Del City, 660 F.3d 1228, 1238 (10th Cir. 2011)). And

second, that “the constitutional right was clearly established.” Id. (quoting Koch,

660 F.3d at 1238).

      A constitutional right is clearly established if its contours are “‘sufficiently

clear’ that every ‘reasonable official would [have understood] that what he is

doing violates that right.’” Ashcroft v. al-Kidd, 563 U.S. 731, 741 (2011)

(alteration in original) (quoting Anderson, 483 U.S. at 640). Although the

Supreme Court does “not require a case directly on point, . . . existing precedent

must have placed the statutory or constitutional question beyond debate.” Id.

This purposefully “demanding standard protects ‘all but the plainly incompetent

or those who knowingly violate the law.’” District of Columbia v. Wesby, --- U.S.




                                          7
----, 138 S. Ct. 577, 589 (2018) (quoting Malley v. Briggs, 475 U.S. 335, 341

(1986)).

         The plaintiff bears the burden to meet each part of the qualified-immunity

test. See id. at 591; accord Riggins v. Goodman, 572 F.3d 1101, 1107 (10th Cir.

2009). We may take up either part first. See Pearson, 555 U.S. at 236. We

review the district court’s legal conclusions—such as whether the defendants

violated a constitutional right and whether that right was clearly established—de

novo. See, e.g., Felders, 755 F.3d at 877.

                                          III

         “[E]lementary principles” of humanity embodied in the Eighth Amendment

“establish the government’s obligation to provide medical care for those whom it

is punishing by incarceration.” Estelle v. Gamble, 429 U.S. 97, 102–03 (1976).

Prison officials betray that obligation by acting with “deliberate indifference to an

inmate’s serious medical needs.” Mata v. Saiz, 427 F.3d 745, 751 (10th Cir.

2005).

         Deliberate indifference has “both an objective and a subjective

component.” Id. (quoting Sealock v. Colorado, 218 F.3d 1205, 1209 (10th Cir.

2000)). To satisfy the objective component, a prisoner must prove that the

alleged deprivation was “sufficiently serious.” Id. (quoting Farmer v. Brennan,

511 U.S. 825, 834 (1994)). A delay in medical care is sufficiently serious if “the


                                           8
delay resulted in substantial harm.” Id. (quoting Oxendine v. Kaplan, 241 F.3d

1272, 1276 (10th Cir. 2001)). “[S]everal hours of untreated severe pain” counts

as substantial harm. Al-Turki v. Robinson, 762 F.3d 1188, 1194 (10th Cir. 2014).

The subjective component requires that a defendant act with “a sufficiently

culpable state of mind.” Redmond, 882 F.3d at 936 (quoting Giron v. Corr. Corp.

of Am., 191 F.3d 1281, 1289 (10th Cir. 1999)). A defendant has the necessary

state of mind if he knew an inmate “faced a substantial risk of harm and

disregarded that risk.” Id. at 939 (quoting Martinez v. Beggs, 563 F.3d 1082,

1088–89 (10th Cir. 2009)). An inmate need not prove the defendant had actual

knowledge of the danger or actually intended that harm befall the inmate. See

Mata, 427 F.3d at 752. Rather, it is enough that circumstantial evidence supports

an inference that a defendant failed to verify or confirm a “risk that he strongly

suspected to exist.” Id. (quoting Farmer, 511 U.S. at 843 n.8).

      Construing the record facts in the light most favorable to Mr. Chapman, we

conclude that each Medical Professional violated his Eighth Amendment rights.

By way of overview, Mr. Chapman has a severe form of Type 1 diabetes that

requires specialized medical care. His condition is so dire that his former military

doctor, Dr. Shakir, wrote a letter to future medical providers warning that “Mr.

Chapman is at a very high risk for diabetes ketoacidosis and hypoglycemia” and

that “these disorders have 10 to 15 % [sic] mortality rate[s] if not treated


                                          9
immediately.” Aplee.’s Suppl. App., Vol. VII, at 1021 (Dr. Shakir Letter, dated

Nov. 2, 2012). Adequate treatment, he added, requires at least three, and up to

six, shots of insulin every day. Id. Furthermore, an expert opined that, without

adequate care for his diabetes, Mr. Chapman’s “life is constantly in danger.” Id.,

Vol. VI, at 879 (Expert Report, dated Sept. 7, 2016).

      There is considerable record evidence that the Medical Professionals

provided Mr. Chapman with care “dramatically short of medically acceptable

standards of care, even for prisoners.” Id. While at ADX, Mr. Chapman suffered

serious bouts of hypoglycemia and hyperglycemia multiple times a week—often

several days in a row—as well as multiple life-threatening bouts of extreme

hypoglycemia. See id., Vol. XXII, at 2235–80 (BOP Health Services Report, filed

Oct. 10, 2017). 3 As one expert remarked, “[e]very physician knows . . . that

poorly controlled diabetes risks death.” Id. at 2285 (Expert Report, dated Oct. 4,



      3
               “The normal range for blood sugar levels is between 70 and 180
milligrams per deciliter (mg/dl).” Aplee.’s Suppl. App., Vol. VI, at 869.
“Hyperglycemia occurs when blood sugar levels are too high.” Id. at 870. While
at ADX, Mr. Chapman’s blood sugar levels were frequently in the high 200s and
300s. See id., Vol. XXII, at 2235–80. “Hypoglycemia occurs when blood sugar
levels drop below 70 mg/dl.” Id., Vol. VI, at 869. For a person with Type 1
diabetes, blood sugar levels below 30 mg/dl are life-threatening. Id. at 870. At
this level, “brain damage, loss of consciousness, seizure, and death” may occur.
Id. In a little over two years at ADX, Mr. Chapman’s blood sugar levels were
measured at below 30 mg/dl on approximately ten separate occasions. See id.,
Vol. XXII, at 2235–80. His blood sugar level was measured in the 30s on
approximately twenty-two additional times. See id.

                                         10
2016). Yet, at ADX, Mr. Chapman’s diabetes was so “poorly controlled” that it

may have caused some “brain injury.” See id. In the end, the record strongly

suggests that Mr. Chapman’s care at ADX was “contrary to . . . basic human

rights and the community standards of care.” Id., Vol. VI, at 879. And the record

supports sufficient inferences that each Medical Professional acted with a

culpable state of mind by disregarding a substantial risk of harm to Mr. Chapman.

      To be sure, we are aware of the repeated suggestions of the Medical

Professionals that some of the failings of medical care Mr. Chapman complains of

were not attributable to their bad intentions, but, rather, to shortages of medical

staff and security considerations that are particularly acute in a high-security

penal facility like ADX. See, e.g., Aplts.’ Opening Br. at 5 (noting that ADX has

“an uncommon level of security and has unique security and control procedures”);

id. at 27 (“There were numerous issues outside of Osagie and Camacho’s control,

relating to the unique security protocols at ADX, which sometimes delayed pill

line.”); id. at 28 (“Both Osagie and Camacho stated that they never intentionally

delayed pill line and tried to complete pill line as soon as possible, but they

acknowledged that there were sometimes delays because of issues that were

outside of their control.”).

      Although we do not gainsay or diminish the seriousness of such

institutional considerations, we must construe the summary-judgment record in


                                          11
the light most favorable to Mr. Chapman. See, e.g., Armijo, 159 F.3d at 1259; see

also Zia v. Tr. Co. ex rel Causey v. Montoya, 597 F.3d 1150, 1155 (10th Cir.

2010) (“Our analysis of course [of the summary-judgment record] only accounts

for the plaintiffs’ version of events, a version which a jury may later reject.

However, under this version we agree with the district court that the plaintiffs

have met their burden of showing a constitutional violation.”). And, if the record

so construed raises triable inferences that each of the Medical Professionals acted

with the requisite culpable intent under the Eighth Amendment, then the alleged

institutional constraints of ADX will not preclude a denial of their qualified-

immunity defenses. Cf. Ramos v. Lamm, 639 F.2d 559, 578 (10th Cir. 1980)

(where prison-administrator defendants sued for injunctive relief blamed the

provision of allegedly inadequate prisoner medical care on staffing shortages,

holding that those shortages did not excuse such care; instead, they “evince[d] . . .

a deliberate indifference to the serious health needs of the prison population”); cf.

also Toussaint v. McCarthy, 801 F.2d 1080, 1093 (9th Cir. 1986) (“The state has

no right to subject a prisoner to cruel and unusual punishment. The [E]ighth

[A]mendment is not a ‘maybe’ or a ‘sometimes’ proposition. If conditions violate

the [E]ighth [A]mendment, all prisoners have the right to be free of such

conditions. The right does not vary depending on the threat that the individual

prisoner presents to institutional security.”), abrogated on other grounds, Sandin


                                          12
v. Conner, 515 U.S. 472 (1995). In other words, irrespective of the institutional

constraints associated with ADX, if the Medical Professionals acted with

deliberate indifference, within the meaning of our precedent, to Mr. Chapman’s

serious medical needs, they violated his Eighth Amendment rights.

      We recognize that Bivens liability is personal; Mr. Chapman must establish

that each Medical Professional personally violated his Eighth Amendment rights.

See, e.g., Pahls v. Thomas, 718 F.3d 1210, 1225–26 (10th Cir. 2013) (“Because

[42 U.S.C.] § 1983 and Bivens are vehicles for imposing personal liability on

government officials, we have stressed the need for careful attention to

particulars, especially in lawsuits involving multiple defendants. . . . [I]t is

incumbent upon a plaintiff to ‘identify specific actions taken by particular

defendants’ in order to make out a viable § 1983 or Bivens claim.” (citations

omitted) (quoting Tonkovich v. Kan. Bd. of Regents, 159 F.3d 504, 532 (10th Cir.

1998)); accord Glaser v. City and Cty. of Denver, 557 F. App’x 689, 702 (10th

Cir. 2014) (unpublished)). Examining the objective and subjective components of

the deliberate-indifference standard, we conclude that Mr. Chapman has made this

individualized showing of Eighth Amendment violations.

                                           A

      The record shows that each Medical Professional caused Mr. Chapman

substantial harm, thereby satisfying the objective component. Mr. Osagie did so


                                           13
on March 18, 2013. By the time Mr. Osagie arrived with Mr. Chapman’s insulin,

Mr. Chapman was having an episode of severe hyperglycemia. When his blood

sugar is that high, Mr. Chapman says his “blood feels like it’s on fire.” Aplee.’s

Suppl. App., Vol. VI, at 848 (Expert Report, dated Nov. 21, 2016). And as Mr.

Osagie admitted, hyperglycemia can cause a diabetic to “go into a coma. They

can die from it, ultimately.” Id. at 656 (Tr. of Osagie Dep., dated May 17, 2016).

To alleviate the pain and lower his blood sugar to a safe level, Mr. Chapman

needed sliding scale insulin. See Aplts.’ Opening Br. at 25. But Mr. Osagie did

not bring the sliding scale insulin. And he waited over two hours before returning

with it. See Aplts.’ App., Vol. XI, at 1694–95 (Pl.’s Narrative Note, dated

Mar. 18, 2013). When Mr. Osagie did return and Mr. Chapman complained, Mr.

Osagie replied, “It’s not my problem, it’s not my fault.” Aplts.’ Opening Br.

at 26. Yet, for those two hours and twenty minutes, Mr. Chapman was in

substantial pain. By prolonging that pain and exacerbating the risk of coma and

death, Mr. Osagie inflicted substantial harm on Mr. Chapman sufficient to satisfy

the objective component. Cf. Al-Turki, 762 F.3d at 1193 (holding that prolonging

severe abdominal pain satisfied objective component); Sealock, 218 F.3d at 1210

(holding that delay in treating chest pain satisfied objective component).

      Mr. Camacho, too, inflicted substantial harm. On one occasion, Mr.

Chapman twice complained to guards that he was “in pain” or “in serious pain”


                                         14
from severe hyperglycemia. Aplts.’ App., Vol. XVI, at 2322 (Pl.’s Narrative

Note, dated June 6, 2013). When Mr. Camacho arrived—about two hours and

forty-five minutes after Mr. Chapman’s initial complaint—Mr. Chapman

explained that he experiences “extreme pain” when his blood sugar is high and

that he “had been asking for help for hours.” Id. Unmoved, Mr. Camacho replied

that he was not “worried about” Mr. Chapman’s blood sugar “being high” because

he knew someone who had extremely high blood sugar (i.e., multiple times the

threshold for hyperglycemia) who “survived.” Id. Those hours of “unnecessary

pain” satisfy “the objective component.” Mata, 427 F.3d at 755; see Lolli v.

County of Orange, 351 F.3d 410, 419–20 (9th Cir. 2003) (noting that diabetes

“can produce harmful consequences if left untreated for even a relatively short

period of time” and “join[ing] our sister circuits in acknowledging that a

constitutional violation may take place when the government does not respond to

the legitimate medical needs of a detainee whom it has reason to believe is

diabetic”).

      The records shows that Dr. Santini also caused Mr. Chapman substantial

harm. “Every physician knows . . . that poorly controlled diabetes risks death.”

Aplee.’s Suppl. App., Vol. XXII, at 2285. Under Dr. Santini’s care, Mr.

Chapman’s severe diabetes was “poorly controlled.” Id. As is clearly reflected in

his medical records, Mr. Chapman suffered serious bouts of hypoglycemia and


                                         15
hyperglycemia multiple times a week, as well as several bouts of hypoglycemia

that were life-threatening. See id. at 2235–80. Dr. Shakir warned that Mr.

Chapman “[wa]s at a very high risk for diabetes ketoacidosis and hypoglycemia”

and needed up to six shots of insulin every day. Id., Vol. VII, at 1021. Dr.

Santini, however, provided a level of care that one expert called “dramatically

short of medically acceptable standards . . . , even for prisoners.” Id., Vol. VI, at

879. Such shoddy care exposed Mr. Chapman to possible “brain injury” and

“vision problems,” and contributed to painful hyperglycemia and life-threatening

hypoglycemia. Id., Vol. XXII, at 2285; id., Vol. VI, at 877; id. at 870; id., Vol.

XXII, at 2235–80.

      Simply put, the record suggests that Dr. Santini caused Mr. Chapman

substantial harm. See Scinto v. Stansberry, 841 F.3d 219, 229 (4th Cir. 2016)

(“Plaintiff has created a genuine issue of material fact regarding whether Dr.

Phillip’s failure to provide him with insulin was an ‘extreme deprivation’

resulting in ‘a serious or significant physical or emotional injury’ or ‘a substantial

risk’ thereof actionable under the Eighth Amendment.”); cf. Derfiny v. Pontiac

Osteopathic Hosp., 106 F. App’x 929, 934–35 (6th Cir. 2004) (unpublished)

(remanding to district court to consider defendants’ request for qualified

immunity, but opining that physicians’ continuation of inmate’s standard insulin

regimen—without measuring his blood sugar levels—presented a genuine dispute


                                          16
of material fact as to objective component, because it was “well known” that

inmate had Type I diabetes, and his “history of erratic blood sugar levels” was

documented).

                                          B

      Now for the subjective component. Recall that this component requires

that a defendant act with “a sufficiently culpable state of mind.” Redmond, 882

F.3d at 936 (quoting Giron, 191 F.3d at 1289). A defendant has the necessary

state of mind if he knew an inmate “faced a substantial risk of harm and

disregarded that risk.” Id. at 939 (quoting Beggs, 563 F.3d at 1088–89). An

inmate need not prove that the defendant had actual knowledge of the danger or

actually intended that harm befall the inmate. See Mata, 427 F.3d at 752. Rather,

it is enough that circumstantial evidence supports an inference that a defendant

failed to verify or confirm a “risk that he strongly suspected to exist.” Id.

(quoting Farmer, 511 U.S. at 843 n.8).

      The record supports sufficient inferences that each Medical Professional

acted with a culpable state of mind by disregarding a substantial risk of harm to

Mr. Chapman. Mr. Osagie knew that diabetics “can go into a coma” and “die

from” severe hyperglycemia. Aplee.’s Suppl. App., Vol. VI, at 656. Mr.

Camacho knew that hyperglycemia carries risks of slower blood flow to “several

vital organs,” including the brain, heart, and kidneys, and can cause diminished


                                         17
functioning in each of these organs. Id. at 629–30 (Tr. of Camacho Dep., dated

July 25, 2016). Both men knew “that hypoglycemia can be dangerous in the

short-term due to the possibility of . . . coma or potentially death.” Id., Vol. XV,

at 1825 (Camacho Decl., dated July 19, 2017); see also id., Vol. VI, at 653.

Furthermore, they knew that Mr. Chapman’s “sugars go stupid” when his insulin

is delivered outside of the normal schedule. See Aplts.’ App., Vol. X, at 1253

(Email from Osagie to Camacho and Others, sent Apr. 1, 2013). But they still

delivered Mr. Chapman’s insulin late. See id. at 1247–48 (Osagie Decl., dated

July 19, 2017); Aplee.’s Suppl. App., Vol. XV, at 1822–25. And when they found

Mr. Chapman in the throes of severe bouts of hyperglycemia, they waited hours to

bring the insulin necessary to alleviate Mr. Chapman’s pain. See Aplts.’ App.,

Vol. XI, at 1694–95; id., Vol. XVI, at 2322. Their inaction in the face of this

known danger is deliberate indifference. See Mata, 427 F.3d at 759.

      Dr. Santini also acted with a culpable state of mind by disregarding a

substantial risk of harm to Mr. Chapman. Dr. Santini, like “[e]very physician,”

knew “that poorly controlled diabetes risks death.” Aplee.’s Suppl. App., Vol.

XXII, at 2285. Dr. Santini knew “Mr. Chapman’s blood [sugar levels] were all

over the board.” Id. at 2307 (Tr. of Santini Dep., dated May 9, 2016). But Dr.

Santini failed to prescribe more insulin shots or otherwise adjust Mr. Chapman’s

treatment. Id. at 2303. The reason for this inaction? Dr. Santini claimed that


                                          18
“had any serious issues been brought to [his] attention . . . , [he] would have

taken steps to address [them].” Aplts.’ App., Vol. X, at 1272 (Santini Decl.,

dated July 19, 2017). But the record proves that Mr. Chapman had brought

serious issues to Dr. Santini’s attention. He told Dr. Santini about his “out of

control blood sugar.” Id., Vol. XVI, at 2283–84 (Chapman Decl., dated Sept. 15,

2017). He even “tried to show [Dr. Santini] [his] blood sugar logs but [Dr.

Santini] refused to look at them.” Id. at 2284. What’s more, Dr. Santini admitted

that he reviewed Mr. Chapman’s official medical records before each

appointment. Aplee.’s Suppl. App., Vol. XXII, at 2309. Those records clearly

reveal that Mr. Chapman repeatedly experienced life-threatening bouts of

hypoglycemia and serious bouts of hyperglycemia. See id. at 2235–80.

       In short, Mr. Chapman told Dr. Santini about a serious problem, and the

medical records that Dr. Santini acknowledged reviewing confirmed that problem.

But still Dr. Santini did nothing. This inaction would permit a finding that the

subjective component was satisfied. See Hunt v. Uphoff, 199 F.3d 1220, 1223–24

(10th Cir. 1999) (holding that a prisoner sufficiently alleged deliberate

indifference—as opposed to a mere disagreement over proper medical

treatment—where a prison doctor refused to prescribe him insulin, and ultimately,

the inadequate treatment of his diabetes and hypertension caused him to suffer a

heart attack); see also Leavitt v. Corr. Med. Servs., Inc., 645 F.3d 484, 498–501

                                          19
(1st Cir. 2011) (holding that medical professional’s conduct satisfied the

subjective component where he knew prisoner suffered from HIV and various

HIV symptoms, but failed to read critical report relating to inmate’s “viral load”

in order to avoid the obligation to provide the inmate appropriate—but

costly—medical care); cf. Derfiny, 106 F. App’x at 936 (“Despite [physician]

Defendants’ knowledge of the available information, by administering drugs to a

patient without assessing his need, [physician] Defendants Johnson and Purchase

acted with deliberate indifference to Plaintiff’s substantial risks.”).

       Furthermore, recall that Dr. Shakir had written a letter warning future

medical providers, such as Dr. Santini, that Mr. Chapman “is at a very high risk

for diabetes ketoacidosis and hypoglycemia” and that he needs up to six shots of

insulin every day. Aplee.’s Suppl. App., Vol. VII, at 1021. This warning letter

should have bolstered the credibility of Mr. Chapman’s own reports of his

serious, diabetes-related health problems and, along with all of the other red flags

outlined above, strongly suggested to Dr. Santini that Mr. Chapman was

experiencing serious ongoing harm. And, because of these many red flags, we

cannot say that Mr. Chapman’s complaints about Dr. Santini’s care amounted to

nothing more than “a mere disagreement as to his medical treatment.” Hunt, 199

F.3d at 1223.




                                          20
       In sum, viewing his conduct in the totality, we conclude that, as to Dr.

Santini, the subjective component is satisfied. Scinto, 841 F.3d at 229 (holding

that refusing to prescribe supplemental insulin while aware of prisoner’s diabetes

diagnosis, blood sugar levels, and need for insulin met subjective component); Cf.

Oxendine, 241 F.3d at 1278–79 (prison doctor’s two-week delay in obtaining

specialized treatment—after personally recording evidence that prisoner’s

reattached finger was decaying—met subjective component).

                                         IV

       Thus, each Medical Professional violated the Eighth Amendment by acting

with deliberate indifference to Mr. Chapman’s serious medical needs. But did

they violate clearly established law? Yes. Our existing precedent put the

unconstitutionality of each Medical Professional’s conduct beyond debate. See,

e.g., al-Kidd, 563 U.S. at 741 (“A Government official’s conduct violates clearly

established law when, at the time of the challenged conduct, ‘[t]he contours of [a]

right [are] sufficiently clear’ that every ‘reasonable official would have

understood that what he is doing violates that right.’ We do not require a case

directly on point, but existing precedent must have placed the statutory or

constitutional question beyond debate.” (alteration in original) (quoting Anderson,

483 U.S. at 640)).




                                         21
       As it relates to the liability of Dr. Santini, our decision in Hunt is most on-

point. There, a prison doctor had prescribed insulin for an inmate with diabetes

and hypertension. Hunt, 199 F.3d at 1223. Despite the previous prescription,

another doctor “did not believe” that the inmate needed insulin and thus did not

provide it for over a year. Id. But the inmate was not totally denied treatment; he

saw doctors, got prescriptions, and had medical procedures. Id. at 1222–23.

Even so, the inmate eventually died “of acute blockage of [his] coronary artery

bypass graft.” Id. at 1223. The district court concluded that the second doctor

did not act with deliberate indifference. Id. We reversed that order. Id. at 1224.

Although that doctor believed (wrongly) that the inmate did not need insulin, we

could “not agree with the district court that the facts as alleged . . . reflect[ed] a

‘mere disagreement with [the] medical treatment.’” Id. (emphasis added) (quoting

the appellate record).

       So too here. As in Hunt, one doctor (i.e., Dr. Shakir) thought an inmate

needed a certain insulin prescription. Aplee.’s Suppl. App., Vol. VII, at 1021.

Like Hunt, another doctor (i.e., Dr. Santini) disagreed and withheld the necessary

amount of insulin, id., Vol. XXII, at 2303, though the inmate did receive other

medical treatment over that period. As in Hunt, the inmate suffered adverse

health consequences due to a lack of sufficient insulin. See id. at 2235–80.

Simply put, given Mr. Chapman’s wild swings in blood sugar—of which Dr.

                                           22
Santini was aware—a reasonable official in Dr. Santini’s position would have

known that denying Mr. Chapman adequate insulin violated the Eighth

Amendment. Hunt clearly established as much. See Lolli, 351 F.3d at 420 (citing

Hunt for proposition that an official who fails to “respond to the legitimate

medical needs of a [prisoner] whom it has reason to believe is diabetic” violates

the Eighth Amendment).

       As for Messrs. Osagie and Camacho, let’s consider Al-Turki. In that case,

an inmate with Type 2 diabetes “began to feel severe pain in his left side.” Al-

Turki, 762 F.3d at 1191. The inmate sent multiple correctional officers to tell a

prison nurse about his pain. Id. But the nurse refused to see him “because it was

too late and because [his] complaint was not an emergency.” Id. As a result, the

inmate endured “several hours of untreated severe pain.” Id. at 1194. We held

that the nurse violated clearly established law by prolonging the inmate’s pain and

leaving him without care for hours during a potential “medical emergency.” Id. at

1195 (quoting Self v. Crum, 439 F.3d 1227, 1232 (10th Cir. 2006)).

       Mr. Osagie and Mr. Camacho did something similar. They encountered

Mr. Chapman during bouts of severe hyperglycemia, a medical emergency which,

if left untreated, can result in a coma or death. See, e.g., Aplee.’s Suppl. App.,

Vol. VI, at 656. But rather than treat that emergency promptly, they delayed for

hours. See Aplts.’ App., Vol. XI, at 1694–95; id., Vol. XVI, at 2322. As in Al-

                                          23
Turki, their conduct violated clearly established law. See Al-Turki, 762 F.3d at

1194–95 (holding that “[i]t has been clearly established in this circuit since at

least 2006 that a deliberate indifference claim will arise when ‘a medical

professional completely denies care although presented with recognizable

symptoms which potentially create a medical emergency,’” and that defendant’s

actions constituted such behavior (quoting Self, 439 F.3d at 1232)).

      Sealock also put the constitutional question facing Mr. Osagie and Mr.

Camacho beyond debate. There, the inmate awoke with “a crushing pain in his

chest.” 218 F.3d at 1208. The inmate told Sergeant Barrett about his pain and

fear that he was “having a heart attack.” Id. Sergeant Barrett “refused to

transport [the inmate] immediately to a doctor or a hospital because it was

snowing outside and it would take time to warm up the prison van for

transportation.” Id. at 1210. He then told the inmate “not to die on his shift.” Id.

“Barrett’s failure to get [the inmate] treatment” caused him “several hours” of

“pain and suffering.” Id. Thinking the inmate could not “show that the delay in

receiving medical treatment caused him any injury,” the district court granted

Sergeant Barrett’s motion for summary judgment. Id. at 1209–10. We reversed.

Id. at 1211. Although Sergeant Barrett did not cause the pain, there was evidence

to show that “the delay occasioned by his inaction unnecessarily prolonged [the

inmate’s] pain and suffering.” Id. at 1210 n.5. And we held that Sergeant

                                          24
Barrett’s delay in the face of “symptoms consistent with a heart attack” violated

the Eighth Amendment. Id. at 1210–11.

      The same principle applies here. Mr. Osagie and Mr. Camacho each found

Mr. Chapman in the midst of a medical emergency that could result in a coma or

death, Aplee.’s Suppl. App., Vol. VI, at 656, but delayed treating him for hours,

see Aplts.’ App., Vol. XI, at 1694–95; id., Vol. XVI, at 2322. Mr. Osagie

dismissed Mr. Chapman’s predicament, saying, “It’s not my problem.” Aplts.’

Opening Br. at 26. Mr. Camacho responded that he was “not worried about” Mr.

Chapman’s blood sugar “being high” because he knew someone who had

extremely high blood sugar (i.e., multiple times the threshold for hyperglycemia)

who “survived.” Aplts.’ App., Vol. XVI, at 2322. Under our clearly established

law, this conduct is unconstitutional.

      In sum, each Medical Professional violated clearly established law. Our

precedent put the constitutional question facing each Medical Professional beyond

debate. And looking outside our circuit confirms that conclusion. See, e.g.,

Garretson v. City of Madison Heights, 407 F.3d 789, 798–99 (6th Cir. 2005)

(holding that officer who knew of detainee’s diabetes and delayed insulin violated

clearly established law); Lolli, 351 F.3d at 420–22 (holding that officers who

withheld insulin from diabetic violated clearly established law); Roberson v.

Bradshaw, 198 F.3d 645, 648 (8th Cir. 1999) (holding that prison official and

                                         25
doctor violated Eighth Amendment by delaying diabetic’s doctor visit and keeping

inmate on medication despite complaints about adverse reactions, respectively).

                                          * * *

      It goes without saying that “[t]he Constitution ‘does not mandate

comfortable prisons.’” Farmer, 511 U.S. at 832 (quoting Rhodes v. Chapman,

452 U.S. 337, 349 (1981)). But nor “does it permit inhumane ones.” Id. It is our

job to judge when the facts in the record indicate that the line separating

uncomfortable from inhumane has been crossed. At a later stage in this

proceeding, a factfinder may well conclude that the line was not crossed. But, at

the summary-judgment stage, we conclude that under our precedent each of the

Medical Professionals violated Mr. Chapman’s Eighth Amendment rights under

clearly established law. Accordingly, we AFFIRM the district court’s judgment.




                                               ENTERED FOR THE COURT



                                               Jerome A. Holmes
                                               Circuit Judge




                                          26
