United States Court of Appeals

For the Eighth Circuit 

___________________________

No. 20-1274

___________________________ 

United States of America

 Plaintiff - Appellee

v.

Katie Louise Boll

 Defendant - Appellant

____________

Appeal from United States District Court 

for the Northern District of Iowa - Waterloo

____________ 

Submitted: January 15, 2021

Filed: July 8, 2021

____________ 

Before GRUENDER, BENTON, and STRAS, Circuit Judges. 

____________

STRAS, Circuit Judge.

While working as a hospice nurse, Katie Boll stole opioids and other pain 

medications from 14 patients. Is 14 a “large number”? U.S.S.G. § 3A1.1(b)(2)(B). 
-2- 

The district court1 said yes when it gave her a two-level enhancement for an “offense 

involv[ing] a large number of vulnerable victims.” Id. We affirm. 

I. 

One of Boll’s responsibilities was to make sure that her patients received their

pain medications. Instead, she decided to feed her drug addiction. Sometimes, she 

would just take the medications set aside for her patients. Other times, she would 

get extra and help herself to it. For particularly strong opioids like morphine, she 

would keep most of it and dilute what remained. In total, she tampered with or stole

the pain medications of 14 patients.

When Boll’s drug-pilfering scheme was discovered and she was confronted 

about it, she immediately confessed and expressed remorse. She later pleaded guilty 

to two of the 14 counts in the indictment. See 18 U.S.C. § 1365(a) (tampering with 

a consumer product); 21 U.S.C. § 843(a)(3) (acquiring controlled substances by 

misrepresentation, fraud, forgery, deception, or subterfuge). Although she agreed to

an enhancement for exploiting “vulnerable victim[s],” U.S.S.G. § 3A1.1(b)(1), the 

parties could not agree on whether 14 was a “large number,” id. § 3A1.1(b)(2)(B), 

which left an additional two-level enhancement in limbo. 

 The district court resolved the issue. It explained why, in its view, 14 was a 

“large number”: 

the defendant [was] hands-on with these patients, [she was] in the 

position to make the decision about what these patients [were] going to 

receive and in the context of a facility with . . . 97 potential victims, for 

her to [have made] the decision to either adulterate or not provide pain 

medication to 14 of those patients, under these contexts, I find [it] to be 

1

The Honorable C.J. Williams, United States District Judge for the Northern 

District of Iowa.
-3- 

a large number. Again, I wouldn’t necessarily find more than 10 to be 

a large number in other contexts with other types of crimes, but with 

this type of crime, with the defendant’s hands-on conduct with the 

individual patients, I find that more than 10, and particularly in this 

case, 14 patients, is a large number.

The sole issue on appeal is whether 14 is indeed a “large number.” Id.

II. 

We review the district court’s interpretation and application of the Sentencing 

Guidelines de novo and its factual findings for clear error. See United States v. 

Hackman, 630 F.3d 1078, 1081–82 (8th Cir. 2011). Figuring out whether 14 is a 

“large number” involves both interpretation and application. U.S.S.G. 

§ 3A1.1(b)(2)(B). 

A.

We start with interpretation. When an offense involves “vulnerable victims,” 

there are two enhancements available. Id. § 3A1.1(b). The first is a two-level 

enhancement when “the defendant knew or should have known that a victim of the 

offense” was vulnerable. Id. § 3A1.1(b)(1). The second tacks on two more levels 

when there were “a large number of vulnerable victims.” Id. § 3A1.1(b)(2). The 

Sentencing Guidelines define “vulnerable victim,” id. § 3A1.1 cmt. n.2, but not 

“large number.” See United States v. Anderson, 349 F.3d 568, 573 (8th Cir. 2003) 

(observing that the phrase “large number” as used in section 3A1.1(b)(2) of the 

Guidelines is “largely uninterpreted”).

Two possibilities exist. One is that “large” is relative, which is how the district 

court understood it. As one dictionary puts it, “large” can mean “exceeding most 

other things of like kind in . . . quantity.” Webster’s Third New International 

Dictionary 1272 (2002) (emphasis added); see also Wis. Cent. Ltd. v. United States, 
-4- 

138 S. Ct. 2067, 2070–71 (2018) (explaining that we “interpret . . . words consistent 

with their ordinary meaning,” and using dictionary definitions to aid in this task 

(internal quotation marks omitted)). The idea is that ten people might be a “large

number” for a dinner party, but not for a rock concert. Likewise, ten could be a 

“large number” of victims for a murder spree, but not for a telemarketing scheme. 

The other possibility is that “large” is absolute. As the same dictionary says, 

“large” can also mean “dealing in great numbers or quantities,” which suggests that 

no comparison is necessary. Webster’s Third, supra, at 1272. The notion is that a 

number becomes large once it surpasses some specific cutoff. The cutoff may be 

10, 100, or 1,000, but it is always the same, regardless of the crime. 

Although both meanings are common, the Sentencing Guidelines leave us a 

few clues about which usage is at play here. See Hackman, 630 F.3d at 1083 (“We 

employ basic rules of statutory construction when interpreting the Guidelines . . . .”). 

Elsewhere, when setting crime-specific enhancements or departures, the Guidelines 

provide rigid cutoffs. See Smith v. United States, 508 U.S. 223, 235–36 (1993) 

(interpreting the phrase “uses . . . a firearm” by comparing it to other provisions that 

refer to firearms “involved in” an offense). For crimes involving slavery or 

involuntary servitude, for example, having “more than ten victims” makes a 

defendant eligible for an upward departure. U.S.S.G. § 2H4.1, cmt. n.3. For fraud 

crimes, “substantial financial hardship to five or more victims” is enough to trigger 

an enhancement. Id. § 2B1.1(b)(2)(B). The point is that, when the Sentencing 

Commission settles on a fixed number, it says so. It does not use the type of openended language we have here. Cf. Jama v. ICE, 543 U.S. 335, 341 (2005) (“We do 

not lightly assume that Congress has omitted from its adopted text requirements that 

it nonetheless intends to apply, and our reluctance is even greater when Congress 

has shown elsewhere in the same statute that it knows how to make such a 

requirement manifest.”). The better interpretation, in other words, is that the word 

“large” is used in its relative, context-specific sense. 
-5- 

We now know that context matters, but what circumstances are fair game to 

consider? Fortunately, the text itself provides an answer. Recall that the 

enhancement applies only when “the offense involved a large number of vulnerable 

victims.” U.S.S.G. § 3A1.1(b)(2)(B) (emphasis added). By “offense,” the 

Sentencing Guidelines mean both “the offense of conviction and all relevant 

conduct.” Id. § 1B1.1 cmt. n.1(I); see id. § 1B1.3(a) (defining “relevant conduct” to 

include “all acts and omissions . . . willfully caused by the defendant . . . that 

occurred during the commission of the offense of conviction” and “all harm that 

resulted”). So putting all the pieces together, the enhancement applies when, taking 

into account the defendant’s “offense of conviction and all relevant conduct,” the 

number of vulnerable victims exceeds the typical number involved in offenses of 

like kind. Id. § 1B1.1 cmt. n.1(I); see id. § 3A1.1(b)(2). But cf. United States v. 

Mooty, 25 F. App’x 501 (8th Cir. 2002) (unpublished per curiam) (concluding, 

without analysis, that “seven is not, as a matter of law, a ‘large number’ within the 

meaning of section 3A1.1(b)(2)”); United States v. Kentz, 251 F.3d 835, 843 (9th 

Cir. 2001) (rejecting the idea that the large-number enhancement should only be 

applied to a telemarketing offense when the number of vulnerable victims was 

“larger than the average telemarketing fraud”).

B. 

Now we move on to application. The district court concluded that “with this 

type of crime,” meaning one involving tampering with a consumer product and 

acquiring a controlled substance by misrepresentation, fraud, deception, or 

subterfuge, “14 . . . [was] a large number.” Among other things, it emphasized 

Boll’s “hands-on conduct” and the fact that she had a special responsibility as a nurse 

to give her patients the pain medication they needed.

Taking into account the “relevant conduct” that the district court identified, 

U.S.S.G. § 1B1.1 cmt. n.1(I), we agree with its conclusion that 14 was “a large 

number of vulnerable victims,” id. § 3A1.1(b)(2)(B). Even if, as it recognized, 14 
-6- 

“may not be a ‘large number’” in other circumstances, such as when an offense 

involves only “indirect contact” or is committed in a completely different “way,” 

this crime exceeded the number of vulnerable victims typically found in offenses of 

like kind.

III. 

We accordingly affirm the judgment of the district court.

______________________________