Opinion ID: 3062135
Heading Depth: 1
Heading Rank: 2

Heading: facts

Text: On August 25, 2009, while he was assigned to a halfway house, Mr. Phillips fractured the fibula in his right leg. On August 26, 2009, Dr. David Matthews, an orthopedic surgeon, repaired the fracture using two metal plates and seven screws. One of those screws was a 4.5 mm cortical screw (the syndesmotic 1 42 U.S.C. §§ 12132, 12182, and Rehabilitation Act of 1973 (§ 504), 29 U.S.C. § 794. -2- screw) inserted across the syndesmosis (a wide sheet of ligament connecting the fibula to the tibia at the ankle) tying the fibula and tibia together. R. Vol. 4 at 222-23. After the operation, Mr. Phillips was taken to the El Paso County Jail. Dr. Matthews next saw Mr. Phillips for a follow-up visit on September 11, 2009, noting the fixation to be in proper position and that the “ankle wound [was] healing well.” Id. at 228-29. He prescribed Tylenol or Tylenol 3 for pain and directed corrections personnel at the El Paso County Jail to bring Mr. Phillips back “in about a month for an X-ray of his right ankle out of the cast. At that point we will make plans to remove the syndesmotic screw.” Id. at 228. Phillips was to “remain [non-weight-bearing] on crutches.” Id. at 229. The record suggests that the next appointment was scheduled for October 13, 2009. However, on October 8, 2009, Mr. Phillips was regressed to KCCC to continue serving his sentence. While Mr. Phillips was at the El Paso County Jail, doctors there additionally prescribed Neurontin for a thirty-day period. Mr. Phillips remained at KCCC for about two months, until his transfer to the state-operated Sterling Correctional Facility (“SCF”) on December 11, 2009. While at KCCC, he was under the medical supervision of defendants Dr. Susan M. Tiona, a physician employed by CCA to provide medical services to inmates housed in KCCC, and Jodi Gray, a Health Services Administrator at KCCC, as well as others. -3- During his two months at KCCC, Mr. Phillips mounted a vociferous, sometimes strident, and ongoing campaign to have the syndesmotic screw removed from his ankle. He submitted dozens of requests/demands by way of grievances, “kites” and other means to Dr. Tiona, Administrator Gray, Warden Brill and others (including the Governor, the Department of Corrections, and Doug Roberts, a Medical Monitor for the private Prisons Monitoring Unit of the Colorado Department of Corrections (“CDOC”)) contending that Dr. Matthews had directed that the screw be removed on October 8, the date of his arrival at KCCC. Failure to do so, Mr. Phillips asserted, would result in him walking with a limp. He also contended that Dr. Matthews wanted him to remain non-weightbearing until the screw was removed, so he apparently continued on crutches, or at least not using his right leg, although he was issued a walker on November 5. On November 10 he was told to start placing some weight on his right leg since the fracture had healed. On or about October 13, Dr. Tiona ordered an x-ray of Mr. Phillips’ ankle, to be taken at the next scheduled arrival of CCA’s portable x-ray equipment at KCCC. The x-ray was performed on October 28, 2009, and a diagnostic report was issued on October 29, 2009, by Dr. Benjamin Huang. Dr. Huang stated that the x-ray showed a “well fixated fracture of right distal fibula and without displacement.” Id. at 273. The doctor also noted that there was no dislocation and that the ankle mortise was intact. Id. -4- On October 28 and again on October 30, 2009, Administrator Gray responded to complaints by Mr. Phillips by advising him that the x-rays just taken were being evaluated by Dr. Tiona. Id. at 346, 366. Then, on November 5, 2009, Dr. Tiona removed Mr. Phillips’ cast and entered the following note in Mr. Phillips’ Ambulatory Health Record: “X-ray taken on 10/29/09 shows well healed fracture with hardware in place, including syndesmotic screw through fibula and tibia. Cast removed without difficulty. His surgical incision is nicely healed. Leg is thoroughly cleaned up. He received a walker to use in his cell until I hear back [exhibit indecipherable] . . . about ambulation.” Id. at 279. In her affidavit in support of her Motion for Summary Judgment, Dr. Tiona relates her actions and conclusions from that point, as follows: 6. Denver Health Medical Center is the referring facility used by Kit Carson Correctional Facility. 7. After identifying Plaintiff’s postsurgical status, I consulted with an Orthopedic PA at Denver Health Medical Center. The Orthopedic PA conveyed to me that the removal of the syndesmotic screw is elective and that his department does not routinely remove the screw. Further, it is expected that the screw will break after the patient starts weight-bearing. If persistent pain exists 3 to 6 months after the screw breaks, the screw can then be removed. 8. In addition to the consultation with Denver Medical Health Centers, I reviewed orthopedic literature about weight-bearing and screw removal. 9. From the recommendation of my consulting specialist, as well as the support from the current orthopedic literature, there was no medical necessity to remove the syndesmotic screw during the -5- time that Plaintiff was under my care at Kit Carson Correctional Center. Id. at 82. Based on information she had received and researched, as well as her experience, 2 and her conclusions, Dr. Tiona then reported to the Medical Monitor, Doug Roberts, by e-mail on November 6, 2009: Briefly .... removed his cast on Thursday. Surgical site looks good. X-ray showed well-healed distal fib fracture with stable hardware. I e-mailed DHMC Ortho about the necessity for screw removal – as I suspected, there is no need to have the syndesmotic screw removed. It will naturally break (the screw, that is) when the patient starts to bear weight. The fact is that he is being treated quite appropriately. I will follow-up with a phone call to you next week, though, in case you have any other questions. Id. at 91. Dr. Tiona conveyed this information to Mr. Phillips on November 10, noting the following information in his Ambulatory Health Record: Visited Mr. Phillips in segregation. Discussed with him that I had communicated with orthopedics at DHMC and that the syndesmotic screw does not need to be removed. He can start his ROM [range of motion] exercises (I reviewed these with him verbally), and can bear weight as tolerated, using the walker for support as needed for the next couple of weeks until his ankle gets stronger. Id. at 280. Subsequently Dr. Tiona examined Mr. Phillips on December 1, 2009, and made the following notation in the Ambulatory Health Record: I took his right ankle in my hands and started working with it. Initially, there was basically zero ROM–both voluntary and 2 In her answers to interrogatories, Dr. Tiona stated that she had “managed the post-surgical care of several other inmates over the past 6 years with the same ORIF procedure.” Id. at 473. -6- involuntary stiffness of the ankle. After working with it for a few minutes, and talking with Mr. Phillips to distract him, I was able to get several millimeters of motion in all planes. When I pointed out to him how much better his foot and ankle looked with just this limited amount of therapy, he said “but I can’t do that in my cell.” I showed him that he can, indeed, put his right leg across his left leg, grab his ankle with his hands, and work it just like I was doing. He says that he will try, and I told him that my nurses were going to be bugging him about doing his therapy regularly. I also demonstrated how to use his walker to better support his ankle while still encouraging weight bearing and ROM. Id. at 306. In a letter dated December 3, 2009, Dr. Matthews responded to inquiries from Mr. Phillips as follows: Dear Mr. Phillips: I received your letter. As we discussed when you were in my office, we typically remove the syndesmotic screw six weeks after the surgery. I can’t comment on the symptoms you are having now, as I have not seen you or gotten any other X-rays. If you have been walking on the ankle a fair amount then the screw may already be broken. That is not the end of the world but it is difficult to remove and may give you symptoms if it is broken. Id. at 319 (emphasis added). On December 11, 2009, Mr. Roberts, the Medical Monitor, entered the following note in his Contact Management folder: 12/11/2009 I have communicated with the mother several times, both by phone and email. The offender has received appropriate care. It is not essential that the screws be removed. The offender has not been following the recommendations of the MD at KCCC to start weight bearing and PT. However, the offender has been in Seg, and his opportunities to exercise and use his ankle are limited. I spoke w/him 12/09, and told him I think that the best thing would be to get him moved ASAP, so that he will be allowed greater movement. The offender has been wait-listed to be transferred out of KCCC. I spoke to Offender Services and this move will be done immediately. I told Offender Services that SCF would be a good choice b/c of their new -7- PA. The mother has been informed. (note: the offender was moved today, 12/11/09) /dcr Id. at 287 (emphasis added). As indicated by Mr. Roberts’ memo for the file, Mr. Phillips was moved that same day, December 11, to SCF, a state-operated prison, and thereafter was in the care of health care providers other than Dr. Tiona. X-rays taken at SCF on December 17, 2009, showed “good healing and no loosening of hardware.” Id. at 309. The physician’s assistant, Kathleen Melloh, noted: “He has not been putting wt on the R foot since that time [August 25] using crutches. Only exercise he has done is drawing the alphabet so consequently he cannot dorsiflex foot past neutral. Plantar flexion is only approx 15 degrees. I did see him in office yesterday and started on ROM exercises, but cannot start any weight-bearing exercises until syndesmotic screw is removed.” Id. (emphasis added). Subsequently, on January 13, 2010, the syndesmotic screw was removed from Mr. Phillips’ ankle, intact. The surgeon’s notes state that “[s]crew head was cleared and backed out. Wound was closed with Steri-Strips. . . . He can weight bear as tolerated. Ankle was stressed and stable.” Id. at 435. On April 22, 2010, following Mr. Phillips’ continuing complaints of pain, he underwent further surgery. After inspection of the prior surgery site, a surgeon removed the right fibular plate (one of the two plates inserted on August 26, 2009), noting: -8- The area of swelling that bothered the patient was secondary to muscle impingement over the proximal end of the plate. There was no sign of infection. No sign of necrotic tissue. No tissues, fluid plains or anything noted to suggest infection. All tissue looked healthy. Screws were removed. Plate removed. Where the syndesmotic screw had been we did take a tissue block from that. However, this showed just normal characteristics and no obvious concern of infection. It was felt that the proximal muscle plate interface was what had been irritated. Id. at 321. Mr. Phillips constantly complained of pain. At KCCC he demanded the Neurontin that had been prescribed at the El Paso County Jail, but that was denied by Dr. Tiona because it was considered a restricted drug for which Mr. Phillips did not qualify. Dr. Tiona at first prescribed Ibuprofen (to which Mr. Phillips objected because Dr. Matthews initially did not want him to take NSAIDs), then several days later, on October 13, she prescribed large doses of Tylenol and, later, combined doses of Tylenol and Ibuprofen. On October 18, 2009, Mr. Phillips wrote to Dr. Tiona thanking her for the 1000-mg Tylenol prescription. Id. at 463. With the possible exception of a few days at the El Paso County Jail in September 2009, the record does not show Mr. Phillips receiving anything but Tylenol and Ibuprofen for pain 3 from the date of his surgery on August 26, 2009, through at least 2010. That period includes his incarceration at SCF after December 11, 2009, and two surgical procedures in 2010. 3 The record does disclose the administration of medications related to other conditions; but those prescriptions were not linked to complaints of ankle pain. -9- During his two months at KCCC, Mr. Phillips refused to put any weight on his right foot, despite advice to the contrary from Dr. Tiona beginning on November 5. As a result, he maintained that the only way he could balance himself on one leg and still access food delivered through the slot in his cell door was to place the food tray on the floor and slide it to the table or bed where he could lift the tray to an eating position. He particularly objected to the traysliding technique due to the alleged presence of old dried urine stains on the floor from past occupants. Accordingly, he demanded a wheelchair, to use in his cell, so he could put food trays on his lap. Likewise, Mr. Phillips demanded a handicap shower facility having grab bars and a fold-down bench. But the one available handicap shower was not working, so he was directed to the regular shower. From October 8 through November 2, 2009, the prison gave Mr. Phillips a plastic chair to assist him in showering. The chair was discontinued on November 2 after Mr. Phillips fell off it. For the next month or so, Mr. Phillips alleges that to undress and dress for his shower, he was forced to sit on the shower floor which he described in lurid detail, not repeated here, as being covered with human wastes of all kinds. He did not complain at the prison and does not assert anywhere in his pleadings that he was unable to shower as such. His complaints are confined to having to dress sitting on a contaminated floor. -10- Mr. Phillips brought this action alleging that the defendants (1) violated his Eighth Amendment rights by not removing or delaying removal of the syndesmotic screw contrary to Dr. Matthews’ treatment plan, resulting in pain and a permanent limp; and (2) violated Titles II and III of the ADA and § 504 by not furnishing a handicap shower or a wheelchair, thus forcing him to sit on a dirty shower floor to dress and to slide his food tray over the dirty cell floor from the door to his bed or table. The district court, adopting the recommendation of the magistrate judge, dismissed the Eighth Amendment claim against CCA and Warden Brill pursuant to Fed. R. Civ. P. 12(b)(6) and, likewise, the § 504 claim as to all defendants. Subsequently, the court granted summary judgment in favor of the defendants on all remaining claims.