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<pre>                 United States Court of Appeals <br>                     For the First Circuit <br> <br> <br> <br> <br> <br>No. 98-1594 <br> <br>                    MAYDA LOPEZ-SOTO, ET AL., <br> <br>                     Plaintiffs, Appellants, <br> <br>                                v. <br> <br>                   JOSE HAWAYEK, M.D., ET AL., <br> <br>                      Defendants, Appellees. <br> <br> <br> <br>           APPEAL FROM THE UNITED STATES DISTRICT COURT <br> <br>                 FOR THE DISTRICT OF PUERTO RICO <br> <br>         [Hon. Salvador E. Casellas, U.S. District Judge] <br> <br> <br> <br>                              Before <br> <br>                      Selya, Circuit Judge, <br>                                 <br>             Coffin and Cyr, Senior Circuit Judges. <br>                                 <br>                                   <br>                                 <br>     Guillermo Ramos Luia, with whom Harry Anduze Montao was on <br>brief, for appellants. <br>     Jos A. Rivera Cordero, with whom Pedro Lugo Frank, Luis F. <br>Montijo and Mirta Rodriguez Mora were on brief, for appellees. <br>      <br> <br> <br> <br> <br>April 9, 1999 <br> <br> <br> <br> <br>

  SELYA, Circuit Judge.  This appeal presents a fundamental <br>question  concerning the interpretation of the Emergency Medical <br>Treatment and Active Labor Act (EMTALA), 42 U.S.C.  1395dd (1994) <br>(amended 1997).  We neither minimize the difficulty of the question <br>nor pretend that the answer is transpiciously clear.  Upon careful <br>perscrutation, however, we hold that EMTALA subsections (a) and (b) <br>are to be read disjunctively, not conjunctively.  Accordingly, we <br>reverse the district court's contrary ruling and reinstate the <br>plaintiffs' action. <br>I.  BACKGROUND <br>  We rehearse only those facts necessary to add a modicum <br>of texture to our statutory analysis, accepting as true the <br>appellants' version of events.  See Fed. R. Civ. P. 56.  For ready <br>reference, we reproduce EMTALA's pertinent provisions in an <br>Appendix. <br>  Experiencing normal labor pains, Mayda Lpez-Soto arrived <br>at Auxilio Mutuo Hospital (the Hospital) in the early morning hours <br>of June 12, 1993.  Hospital personnel brought her to the maternity <br>ward where she was examined and admitted.  Dr. Jos Hawayek, an <br>obstetrician, broke her water at approximately 7:30 a.m., revealing <br>the presence of thick "pea soup" meconium in the amniotic fluid.  <br>Rupturing the membranes of the amniotic sac failed to stimulate <br>dilation, so Dr. Hawayek ordered a cesarean section.  Lpez-Soto <br>gave birth to a baby boy at 1:50 p.m. (roughly 15 minutes after the <br>operation commenced).  The infant emerged in severe respiratory <br>distress due to meconium aspiration.  His condition presented a <br>medical emergency. <br>  Hospital staffers summoned Dr. Martn Garrido, the <br>pediatrician on call.  Dr. Garrido determined that the baby <br>required specialized care and began making arrangements to transfer <br>him to a hospital with a functioning neonatal intensive care unit.  <br>Before transport occurred, Dr. Garrido identified an additional <br>cause for medical concern:  the presence of a pulmonary <br>pneumothorax.  He nonetheless elected to send the infant to the <br>receiving hospital without first attempting to stabilize the <br>patient or to treat that exigent condition.  The baby was admitted <br>to the San Juan Pediatric Hospital that evening, but perished the <br>next day. <br>  Lpez-Soto and her husband brought suit on behalf of <br>themselves and the deceased child in Puerto Rico's federal district <br>court.  The complaint named as defendants the Hospital and several <br>caregivers, including Drs. Hawayek and Garrido.  Lpez-Soto <br>premised jurisdiction on the presence of a federal question, see 28 <br>U.S.C.  1331, that question being the existence of a putative <br>cause of action against the Hospital arising under federal law (to <br>wit, EMTALA).  She added supplemental claims for medical <br>malpractice under local law against all the defendants. <br>     Only the EMTALA claim is relevant here.  In her <br>complaint, Lpez-Soto posited that the Hospital violated EMTALA <br>because her baby was born "with a severe pulmonary condition that <br>required emergency and immediate medical care and treatment," but <br>the Hospital nonetheless transferred him to another  institution <br>without stabilizing this condition.  The defendants denied the <br>material allegations of the complaint and contested jurisdiction, <br>saying that EMTALA did not apply.  After considerable jousting (not <br>relevant here), the district court, acting pursuant to Fed. R. Civ. <br>P. 56, accepted the defendants' jurisdictional argument and <br>dismissed the EMTALA claim.  At the same time, the court declined <br>to retain supplemental jurisdiction over the medical malpractice <br>claims, dismissing them without prejudice.  See 28 U.S.C.  <br>1367(c).  This appeal ensued. <br>II.  ANALYSIS <br>     Lpez-Soto's EMTALA claim hinges on the Hospital's <br>alleged failure to comply with the statute's stabilization and <br>transfer provisions.  See 42 U.S.C.  1395dd(b)-(c).  In a <br>thoughtful (though unpublished) opinion, the district court <br>concluded that Congress's isthmian concern with patient dumping   <br>the practice of refusing to accept or treat patients who are <br>uninsured or have no demonstrable means of payment   precluded <br>reading these provisions independently of 42 U.S.C.  1395dd(a).  <br>The court therefore adopted a conjunctive interpretation of all <br>three subsections and ruled that they create statutory duties for <br>a covered hospital solely with regard to persons who come to the <br>emergency department for assistance.  Only in that event must the <br>hospital  provide an appropriate medical screening, 42 U.S.C.  <br>1395dd(a); and, only if that screening uncovers an emergency <br>medical condition must the hospital stabilize the patient and <br>refrain from transferring him except in compliance with the <br>statutory commands, see 42 U.S.C.  1395dd(b)-(c). <br>     Superimposing this interpretation upon the scenario <br>depicted by Lpez-Soto, the district court reasoned that the <br>newborn had not come to the Hospital's emergency room seeking <br>treatment for his respiratory distress, but, rather, had come to <br>the Hospital via the operating room.  Consequently, the court <br>determined that EMTALA's stabilization and transfer obligations had <br>not been triggered and that Lpez-Soto had failed to state a <br>cognizable claim under federal law. <br>     We afford plenary review to the district court's <br>resolution of this unadulterated question of law.  See, e.g., <br>United States v. Gifford, 17 F.3d 462, 472 (1st Cir. 1994).  We <br>start our search for the meaning of the words that Congress wrote <br>with an appraisal of the statutory text and structure, see Inmates <br>of Suffolk Country Jail v. Rouse, 129 F.3d 649, 653 (1st Cir. <br>1997), mindful that if the plain language of the statute points <br>unerringly in a single direction, an inquiring court ordinarily <br>should look no further.  See United States v. Charles George <br>Trucking Co., 823 F.2d 685, 688 (1st Cir. 1987). <br>     EMTALA has a long reach.  It touches all acute care <br>hospitals that have executed Medicare provider agreements with the <br>federal government pursuant to 42 U.S.C.  1395cc.  See 42 U.S.C. <br> 1395dd(e)(2); see also Correa v. Hospital San Francisco, 69 F.3d <br>1184, 1189-90 (1st Cir. 1995).  Moreover, it imposes myriad duties <br>on these covered hospitals. <br>     For the most part, these duties reside in three principal <br>statutory silos.  The most familiar of these is subsection (a), <br>which imposes a duty to triage.  This duty takes the form of a  <br>requirement that a covered hospital perform an "appropriate medical <br>screening examination" on "any individual" who "comes to the <br>emergency department" seeking examination or treatment.  42 U.S.C. <br> 1395dd(a).  Clearly, this provision obligates hospitals to screen <br>only those individuals who present themselves at the emergency <br>department. <br>     Subsection (b) has a different focus.  It emphasizes <br>stabilization, not screening.  Thus, if "any individual . . . comes <br>to a hospital and the hospital determines that the individual has <br>an emergency medical condition," the hospital must try to stabilize <br>that condition, and can shift the patient to another institution <br>only in accordance with EMTALA's transfer provisions.  42 U.S.C.  <br>1395dd(b).  This language unambiguously imposes certain duties on <br>covered hospitals vis--vis any victim of a detected medical <br>emergency, regardless of how that person enters the institution or <br>where within the walls he may be when the hospital identifies the <br>problem.  See Helton v. Phelps County Regional Med. Ctr., 794 F. <br>Supp. 332, 333 (E.D. Mo. 1992); Smith v. Richmond Mem'l Hosp., 243 <br>Va. 445, 451-52, 416 S.E.2d 689, 692 (1992).  Nothing in the <br>subsection's text suggests a necessary relationship between a <br>hospital's obligations and the identity of the department within <br>the hospital to which the afflicted individual presents himself. <br>     Subsection (c) seemingly has relevance to both of the <br>preceding subsections.  It provides that "[i]f an individual at a <br>hospital has an emergency medical condition which has not been <br>stabilized . . ., the hospital may not transfer the individual" <br>save upon compliance with certain stipulated conditions.  42 U.S.C. <br> 1395dd(c)(1).  This subsection does not distinguish between <br>patients whose conditions are diagnosed in the emergency room and <br>those whose conditions emerge in other hospital departments. <br>     We reject the district court's attempt to meld these <br>three duties together principally because doing so necessitates <br>eschewal of subsection (b)'s plain language   "comes to a hospital" <br>  in favor of a phrase   "comes to the emergency department"   that <br>appears only in subsection (a).  This compressed approach renders <br>the "comes to a hospital" language meaningless; after all, if <br>subsection (a)'s predicate requirement that an individual "come[] <br>to the emergency department" were understood to infiltrate <br>subsection (b), the latter's "comes to a hospital" requirement <br>would be altogether superfluous. It is a time-honored tenet that <br>"[a]ll words and provisions of statutes are intended to have <br>meaning and are to be given effect, and no construction should be <br>adopted which would render statutory words or phrases meaningless, <br>redundant, or superfluous."  United States v. Ven-Fuel, Inc., 758 <br>F.2d 741, 751-52 (1st Cir. 1985).  We are reluctant to disregard <br>this venerable canon of construction, especially since a sensible, <br>available interpretation of the statute   one that places the three <br>subsections side by side, rather than in lockstep   gives effect to <br>both phrases. <br>     A further canon of construction has relevance here.  The <br>fact that Congress used the "comes to an emergency department" <br>language in subsection (a) while employing different phraseology <br>("comes to a hospital") in subsection (b) serves to emphasize the <br>separateness of the statutory commands.  "[I]t is generally <br>presumed that Congress acts intentionally and purposely when it <br>includes particular language in one section of a statute but omits <br>it in another."  BFP v. Resolution Trust Corp., 511 U.S. 531, 537 <br>(1994) (citations and internal quotation marks omitted).  Courts <br>have an obligation to refrain from embellishing statutes by <br>inserting language that Congress opted to omit.  See Keene Corp. v. <br>United States, 508 U.S. 200, 208 (1993).  So it is here.  <br>Congress's decision to change the "emergency department" language <br>rather than to repeat it in subsection (b) is potent evidence that <br>Congress preferred to cast a wider net in respect to stabilization. <br>     Finally, a disjunctive approach draws strength from the <br>fact that subsection (b) mentions neither an emergency room locus <br>nor a medical screening as a precursor to a hospital's <br>stabilization obligations.  Rather, those obligations attach as <br>long as an individual enters any part of the hospital and the <br>hospital determines that an emergency medical condition exists.  <br>See 42 U.S.C.  1395d(b)(1).  As a practical matter, a hospital <br>more often than not will discover the existence of an emergency <br>medical condition by performing the screening required under <br>subsection (a)   but nothing in EMTALA's language or structure <br>makes subsection (b) an adjunct to subsection (a).  Moreover, <br>punctuation can provide valuable insights into statutory <br>interpretation, see United States v. Ron Pair Enters., Inc. 489 <br>U.S. 235, 241-42 (1989), and we cannot overlook that Congress chose <br>structurally to disconnect the three subsections, closing them off <br>from each other by periods, without any conjunctive links.  A <br>statute should be parsed as punctuated unless some good reason <br>exists to read it otherwise.  See 2A Sutherland, Statutes and <br>Statutory Construction  47.15, at 179 (5th ed. 1992). <br>     We are not the only court to conclude that EMTALA <br>requires such a disjunctive reading.  In what appears to have been <br>the first case addressing the issue, the Virginia Supreme Court <br>found "nothing in the language of the Act which limits application <br>of [subsections (b) and (c)] solely to a patient who initially <br>arrives at the emergency room."  Smith, 243 Va. at 452, 416 S.E.2d <br>at 692.  Consequently, the court concluded that a plaintiff who had <br>not come to the defendant hospital's emergency room nonetheless <br>could sue under subsection (c) for an allegedly improper transfer.  <br>See id.; see also Reynolds v. Mercy Hosp., 861 F. Supp. 214, 222 <br>(W.D.N.Y. 1994); Helton, 794 F. Supp. at 333. <br>     The Tenth Circuit also has accepted the disjunction <br>between subsections (a) and (b).  In Urban v. King, 43 F.3d 523 <br>(10th Cir. 1994), a pregnant woman went to the hospital for a <br>stress test (not conducted in the emergency department).  Despite <br>warning signs, the hospital sent her home.  When she returned the <br>following day, the hospital belatedly determined that she had an <br>emergency condition and began efforts to stabilize her.  The woman <br>sued, claiming that the hospital violated EMTALA on the first dayby sending her home without stabilizing her emergency condition.  <br>Although the case was decided on a different ground, the court said <br>that subsection (a) was beside the point.  See id. at 525 n.2.  <br>This dictum can only mean that the court did not consider emergency <br>room arrival to be a prerequisite to liability under either <br>subsection (b) or (c). <br>     We find further support for our interpretation in Robertsv. Galen of Va., Inc., 119 S. Ct. 685 (1999).  In the underlying <br>opinion, the Sixth Circuit imported an intent requirement from <br>subsection (a) into subsection (b), and ruled that, in a subsection <br>(b) case, a plaintiff must show that the hospital acted with an <br>improper motive in failing to stabilize.  See Roberts v. Galen of <br>Va., Inc., 111 F.3d 405, 410 n.3, 411 (6th Cir. 1997); see also  <br>Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 272 (6th <br>Cir. 1990) (holding that to prove  inappropriateness under <br>subsection (a), a plaintiff must show an improper motive <br>undergirding the hospital's actions).  The Supreme Court rejected <br>on textual grounds this attempt to transplant a standard from <br>subsection (a) into subsection (b).  See Roberts, 119 S. Ct. at <br>686.  Taking a similar textual approach, we find that subsection <br>(b), unlike subsection (a), contains no requirement of entry <br>through the portals of the emergency department.  Thus, by analogy <br>to Roberts, the plain language of the statute militates against <br>importation of the "emergency department" requirement from <br>subsection (a) into subsection (b). <br>     To these marshaled authorities, we add that a disjunctive <br>"plain language" reading of the statute works no fatuity.  <br>Subsection (a) requires hospitals to provide appropriate screening <br>for individuals who seek assistance at an emergency department of <br>a covered hospital, whereas subsection (b) serves a different <br>purpose   obligating hospitals to stabilize individuals (wherever <br>in the hospital they may be) when emergency medical conditions are <br>detected.  In short, these two provisions create distinct <br>obligations and apply to different classes of individuals.  SeeSmith, 243 Va. at 451, 416 S.E.2d at 692.  Moreover, it makes good <br>sense to restrict subsection (a) screenings to emergency room <br>arrivals, given the peculiar set of problems associated with <br>treatment in such facilities.  By contrast, the broader, hospital- <br>wide sweep of subsection (b) makes equally good sense.  While <br>screening is arguably the key to ensuring the health of itinerants <br>who arrive at an emergency room, stabilization is arguably the key <br>to ensuring the health of those already admitted to the hospital <br>who develop emergency medical conditions. <br>     To be sure, the proponents of a conjunctive reading <br>possess some ammunition   but, for the most part, they are shooting <br>blanks.  The appellees prominently mention several cases <br>interpreting subsection (c) to impose liability only upon a prior <br>subsection (b) determination that the transferee patient suffers <br>from an emergency medical condition.  See, e.g., Vickers v. Nash <br>Gen'l Hosp., Inc., 78 F.3d 139, 145 (4th Cir. 1996); Urban, 43 F.3d <br>at 525; Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, <br>1041 (D.C. Cir. 1991).  We question the relevance of these <br>precedents.  The linkage of subsections (b) and (c) finds explicit <br>support in the text of subsection (b)(1), which ties the need for <br>stabilization of discerned emergency medical conditions to the <br>transfer restrictions imposed by subsection (c).  See 42 U.S.C.  <br>1395dd(b)(1)(B) (explaining that, if a hospital determines that an <br>emergency medical condition exists, it either must stabilize the <br>individual or transfer him "in accordance with subsection (c)").  <br>This furnishes a sound reason, embedded in the statute's text, to <br>read subsection (c)'s qualified prohibition on unstabilized <br>transfers in tandem with subsection (b)'s requirement that the <br>hospital actually detect the emergency medical condition. <br>     Although conjoining subsections (b) and (c) therefore <br>makes linguistic and structural sense, no similar justification <br>exists for marrying subsection (a) to subsection (b).  The mere <br>fact that two pieces of a statutory puzzle may be interdependent in <br>a particular way does not mean that all the pieces must fit <br>together in the same manner.  As we have said, the language and <br>structure of subsections (a) and (b) counsel in favor of a <br>disjunctive interpretation.  The district court's attempt to merge <br>these two provisions renders nugatory key language pertaining to <br>the scope of the statute.  We see no compelling reason to sacrifice <br>the statute's plain language on the altar of interdependence in <br>order artificially to interlock subsections (a) and (b). <br>     Even though the case law bundling subsections (b) and (c) <br>is off point, there are some other straws in the wind that blow in <br>the appellees' direction.  For example, in James v. Sunrise Hosp., <br>86 F.3d 885 (9th Cir. 1996), a Ninth Circuit panel stated that <br>subsection (c)'s transfer restrictions "apply only when an <br>individual comes to the emergency room, and after an appropriate <br>screening examination, the hospital determines that the individual <br>has an emergency medical condition."  Id. at 889 (emphasis <br>supplied; internal quotation marks omitted).  In making this <br>statement, the James panel, like the court below, construed <br>subsections (a), (b), and (c) as relating to a single sequence of <br>events.  See id.  The court forged this link largely on the basis <br>of a phrase found in 42 U.S.C.  1395dd(c)(1)(A)(iii).  With <br>respect, we think that this cross-reference cannot carry the weight <br>that James placed upon it. <br>     Subsection (c) generally prohibits transfers of <br>unstabilized patients unless the patient has so requested in <br>writing, see id.  1395dd(c)(1)(A)(i), a physician has certified <br>that the medical benefits of an appropriate transfer outweigh the <br>attendant risks, see id.  1395dd(c)(1)(A)(ii), or, "if a physician <br>is not physically present in the emergency department at the time <br>an individual is transferred, a qualified medical person" has <br>signed the certificate after consulting with a physician who has <br>made the transfer decision and who subsequently countersigns, id. 1395dd(c)(1)(A)(iii).  James fastens onto this "not physically <br>present in the emergency department" language, overlooking that the <br>provision addresses only a discrete subset of transfer <br>circumstances   the physical inability of a physician to sign the <br>requisite certificate when time is of the essence    that Congress <br>likely associated with emergency room "on call" arrangements.  <br>Indeed, Congress's intention not to ensconce the certification <br>procedure within the exclusive domain of the emergency department <br>is made manifest by the language of 42 U.S.C.  <br>1395dd(c)(1)(A)(ii), which prescribes an independent procedure for <br>effecting unstabilized transfers without imposing any limitation on <br>where certification decisions must be made.  That same intent is <br>also evinced in 42 U.S.C.  1395dd(b)(1)(A), which directs use of <br>the staff and resources of the entire hospital facility to <br>stabilize a patient once an emergency medical condition <br>determination has been made.  Since the James court's reading of <br>the transfer restrictions flies in the teeth both of EMTALA's <br>physician-wide certification option and its hospital-wide <br>stabilization requirement, we decline to follow it. <br>     In settling upon a conjunctive reading of subsections (a) <br>and (b), the district court fretted most over legislative purpose.  <br>It cannot be gainsaid that, in enacting EMTALA, Congress was driven <br>by a concern that hospitals were refusing to admit and treat <br>uninsured patients. See H.R. Rep. No. 99-241(I), at 27 (1986), <br>reprinted in 1986 U.S.C.C.A.N. 579, 605; see also Correa,  69 F.3d <br>at 1189.  The lower court believed that allowing EMTALA's <br>stabilization and transfer obligations to apply outside the context <br>of emergency room arrivals would extend the statute's reach beyond <br>this particularized concern with patient dumping.  For three <br>reasons, we think that this is too cramped a view. <br>     In the first place, courts interpret statutes primarily <br>through detailed analysis of concrete statutory language, not by <br>reference to abstract notions of generalized legislative intent.  <br>See Connecticut Nat'l Bank v. Germain, 503 U.S. 249, 253-54 (1992) <br>(reiterating "that courts must presume that a legislature says in <br>a statute what it means and means in a statute what it says <br>there"); see also Correa, 69 F.3d at 1194 (concluding that, <br>notwithstanding Congress's focus on patient dumping, an <br>individual's financial status plays no part in determining the <br>reach of subsection (a)).  Put another way, although legislative <br>purpose can shed light upon congressional intent where Congress has <br>blown an uncertain trumpet, it cannot serve as the baseline for <br>statutory construction. <br>     In the second place, Congress obviously had a horizon <br>broader than the emergency room in mind when it enacted EMTALA.  <br>The statute explicitly embraces women in labor, see 42 U.S.C.  <br>1395dd(e)(1)(B) (defining emergency medical condition)   yet most <br>gravid women go to maternity wards, not emergency rooms, when they <br>are ready to give birth. <br>     Last, but surely not least, Congress's preoccupation with <br>patient dumping is served, not undermined, by forbidding the <br>dumping of any hospital patient with a known, unstabilized, <br>emergency condition.  After all, patient dumping is not a practice <br>that is limited to emergency rooms.  If a hospital determines that <br>a patient on a ward has developed an emergency medical condition, <br>it may fear that the costs of treatment will outstrip the patient's <br>resources, and seek to move the patient elsewhere.  That strain of <br>patient dumping is equally as pernicious as what occurs in <br>emergency departments, and we are unprepared to say that Congress <br>did not seek to curb it.  Accord Smith, 243 Va. at 452, 416 S.E.2d <br>at 692. <br>     The district court also worried that, without an <br>emergency room arrival limitation, EMTALA might be converted into <br>a federal cause of action for medical malpractice.  We agree that <br>Congress did not intend such a result, see Correa, 69 F.3d at 1192, <br>but we suspect that the district court's fears are overblown.  Cf.William Shakespeare, Macbeth, act 1, sc. 3 (1605) (warning that <br>present fears may be "less than horrible imaginings").  In all <br>events, the paradigmatic EMTALA circumstances of the instant case <br>give us no occasion to address such looming issues.  Here, the <br>newborn's emergency condition was apparent upon presentment and the <br>corresponding decision to transfer was made immediately. <br>III.  CONCLUSION <br>     We need go no further.  Because subsections (a) and (b) <br>of EMTALA operate disjunctively rather than conjunctively, the <br>infant decedent's arrival in the operating room and the Hospital's <br>prompt detection of an emergency medical condition, if proven, will <br>suffice to engage the gears of EMTALA's stabilization and transfer <br>obligations.  See 42 U.S.C.  1395dd(b).  It follows that the <br>district court erred in dismissing the complaint on jurisdictional <br>grounds.  Whether Lpez-Soto has made out the other elements of  an <br>EMTALA claim is, of course, a different question   and one that is <br>not now before us.  At this stage of the litigation we conclude <br>only that the absence of emergency room presentment does not <br>preclude prosecution of this suit under 42 U.S.C.  1395dd(b). <br>     In light of this conclusion, we reverse the district <br>court's dispositive order and remand for further proceedings.  The <br>district court must, inter alia, reinstate the pendent claims which <br>it previously dismissed. <br>Reversed and remanded.

                        STATUTORY APPENDIX <br> 1395dd.  Examination and treatment for emergency medical <br>conditions and women in labor <br>     (a) Medical screening requirement <br>        In the case of a hospital that has a hospital <br>     emergency department, if any individual . . . comes to <br>     the emergency department and a request is made on the <br>     individual's behalf for examination or treatment for a <br>     medical condition, the hospital must provide for an <br>     appropriate medical screening examination within the <br>     capability of the hospital's emergency department, <br>     including ancillary services routinely available to the <br>     emergency department, to determine whether or not an <br>     emergency medical condition (within the meaning of <br>     subsection (e)(1) of this section) exists. <br>     (b) Necessary stabilizing treatment for emergency medical <br>     conditions and labor <br>          (1) In general <br>             If any individual . . . comes to a hospital <br>          and the hospital determines that the individual <br>          has an emergency medical condition, the hospital <br>          must provide either    <br>               (A) within the staff and facilities <br>               available at the hospital, for such further <br>               medical examination and such treatment as <br>               may be required to stabilize the medical <br>               condition, or <br>               (B) for transfer of the individual to <br>               another medical facility in accordance with <br>               subsection (c) of this section. <br>          . . . <br>     (c) Restricting transfers until individual stabilized <br>          (1) Rule <br>            If an individual at a hospital has an emergency <br>          medical condition which has not been stabilized <br>          (within the meaning of subsection (e)(3)(B) of <br>          this section), the hospital may not transfer the <br>          individual unless    <br>               (A)(i) the individual (or a legally <br>               responsible person acting on the <br>               individual's behalf) after being informed of <br>               the hospital's obligations under this <br>               section and of the risk of transfer, in <br>               writing requests transfer to another <br>               facility, <br>               (ii) a physician . . . has signed a <br>               certification that based upon the <br>               information available at the time of <br>               transfer, the medical benefits reasonably <br>               expected from the provision of appropriate <br>               medical treatment at another medical <br>               facility outweigh the increased risks to the <br>               individual and, in the case of labor, to the <br>               unborn child from effecting the transfer, or  <br>               (iii) if a physician is not physically <br>               present in the emergency department at the <br>               time an individual is transferred, a <br>               qualified medical person (as defined by the <br>               Secretary in regulations) has signed a <br>               certification described in clause (ii) after <br>               a physician . . ., in consultation with the <br>               person, has made the determination described <br>               in such clause, and subsequently <br>               countersigns the certification; and  <br>               (B) the transfer is an appropriate transfer <br>               (within the meaning of paragraph (2)) to <br>               that facility. <br>          A certification described in clause (ii) or (iii) <br>          of subparagraph (A) shall include a summary of <br>          the risks and benefits upon which the <br>          certification is based. <br> <br>                       *        *        * <br> <br>42 U.S.C.  1395dd (1994) (amended 1997).</pre>

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