Opinion ID: 4707703
Heading Depth: 2
Heading Rank: 1

Heading: October 2013: Emergency Room

Text: On October 24, 2013, Mr. Smith called the nurse triage line at the VA Medical Center and reported severe pain in the right side of his head, particularly behind his ear and eye, accompanied by tongue swelling that caused his speech to be slurred. A VA nurse relayed a message to Dr. Puppala and directed Mr. Smith to the emergency room. That day, Mr. Smith sought care at the Coliseum Medical Center Emergency Department (“ER”) in Macon, Georgia. The ER physician, 3 According to the VA’s “Process Guide” for Non-VA Care Coordination, “Non-VA Care Coordination activities . . . continue through the episode of non-VA care.” During this time, it may be necessary for the Care Coordinator to generate progress notes to “coordinate, facilitate, and document support services required by the Veteran.” 6 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 7 of 58 believing Mr. Smith’s symptoms were an adverse reaction to Neurontin, instructed him to stop taking Neurontin and to follow up with his VA physician. The very next day, October 25, 2013, Mr. Smith contacted Dr. Puppala’s office, but he was unable to secure a VA appointment with Dr. Puppala until December 16, 2013—nearly two months later. B. December 2013–January 2014: Diagnosis and CT Scans At the December 16 appointment, Mr. Smith reported to Dr. Puppala, his VA doctor, that his tongue had remained dry and swollen since the October 24 ER visit and that the right side of his neck had begun to swell in the weeks prior to this appointment. Dr. Puppala noted the ER evaluation, examined Mr. Smith, and confirmed the right “submandibular gland swelling.” Dr. Puppala ordered CT scans without contrast of Mr. Smith’s neck. The VA scans, however, did not occur until over a month later, on January 14, 2014. Predictably, the January 14 CT scans showed a tumor in Mr. Smith’s throat at the base of his tongue. At that point, the tumor had spread to three lymph nodes in his right neck. According to the VA radiologist’s report, the CT scans showed “an enlarged mass or lymph node” in Mr. Smith’s right neck, “abnormally enlarged and irregular appearing lymph nodes” also in his right neck, and “[q]uestionable increased soft tissue density in the right base of [his] tongue.” 7 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 8 of 58 Dr. Ferris testified that, given the extent of the swelling in Mr. Smith’s neck and the undisputed presence of a mass in his neck, there was a “joint duty on the part of the [VA] physician and radiology” teams to get Mr. Smith in for CT scans “[w]ithin days, a week at the most” of his December 16 visit and to then assess the results quickly to arrive at a diagnosis. According to Dr. Ferris, the urgency of Mr. Smith’s condition ought to have been apparent, since “a neck mass in an adult is cancer until proven otherwise.”4 Dr. Ferris opined that “Mr. Smith had initial symptoms of tongue malignancy in October 2013 and there were obvious findings of his tongue cancer on the CT scans on January 14, 2014.” Dr. Ferris also testified, based on his review of the January 14 CT scans, that Mr. Smith “appeared to be clinical stage IV,” given that there were “two or more metastatic lymph nodes” and also “a large tumor at the primary site.” Even the VA radiologist noted that the January 14 scans were “worrisome for underlying head and neck malignancy”—cancer. Despite all this, the VA radiologist, Dr. Matthew Dobbs, only recommended an outside “ENT consultation and visual inspection and possible PET/CT for biopsy of these nodes.” Dr. Ferris opined that, “[h]ad Mr. Smith’s malignancy 4 Dr. Ferris is a medical doctor licensed to practice medicine in the State of Pennsylvania. He holds a medical degree from the Johns Hopkins Medical School, and is board certified in otolaryngology. Since at least 2002, Dr. Ferris had been regularly engaged in the active practice and teaching of otolaryngology, immunology, and head and neck oncologic surgery. 8 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 9 of 58 been diagnosed in January 2014, as it should have been, it is more likely than not that the malignancy could have been resectable at the time.” Upon receiving the CT scans on January 16, 2014, Dr. Puppala informed VA personnel that Mr. Smith needed another appointment with Dr. Puppala “ASAP” to discuss the results. Receiving this ASAP direction from Dr. Puppala, VA personnel promptly scheduled Mr. Smith for an appointment a week later, on January 22, 2014, with Dr. Puppala. Apparently, when the VA doctor orders it, VA personnel can act and schedule quickly. Even before seeing Mr. Smith for the January 22 follow-up, Dr. Puppala, like the VA radiologist, recommended and ordered a “non-VA consult” for Mr. Smith with an ENT specialist and entered a “Non-VA Care Coordination Note” into Mr. Smith’s treatment record requesting the outside ENT consult. Although there were “obvious findings of [Mr. Smith’s] tongue cancer on the CT scan[s] [on] January 14, 2014,” no medical person on Mr. Smith’s medical team ordered, requested, or tried to facilitate an immediate or expedited consult. At the January 22 follow-up appointment, Dr. Puppala discussed the CT scans with Mr. Smith. Although the primary purpose of the visit was to discuss the scans, Dr. Puppala noted that Mr. Smith still had swelling on the right side of his neck and that the swelling was now causing pain in his right ear. Given Mr. Smith’s continued symptoms and the “worrisome” findings of “head and neck 9 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 10 of 58 malignancy” on the CT scans, Dr. Puppala entered another Care Coordination Note ordering an outside ENT consult. As detailed above, once Dr. Puppala ordered the outside ENT consult, a VA Clinical Care Coordinator, here Nurse Ekwueme, was responsible for conducting an administrative and clinical review of Dr. Puppala’s ENT consult order to determine Mr. Smith’s eligibility and approve the ENT consult. Mr. Smith’s treatment record indicates that on January 24, 2014, two days after Dr. Puppala entered the second Care Coordination Note, Nurse Ekwueme approved the ENT consult. Specifically, Nurse Ekwueme made a note in Mr. Smith’s treatment record that the ENT consult Dr. Puppala ordered was “authorized by Fee,” and the consult was given to the Fee PSA (Program Support Assistant) for processing. On the same day, the Fee PSA acknowledged receipt of Nurse Ekwueme’s authorization note. In short, as of January 24, 2014, the VA had completed its administrative and clinical review and determined that Mr. Smith was eligible for an outside ENT consult and that the consult was medically necessary. There was no benefits issue as to the outside ENT consult then or at any time. C. January 24–March 11, 2014: No Medical Follow Up on Outside ENT Care Despite the obvious findings of tongue cancer shown in the January 14 CT scans and the urgency of Mr. Smith’s cancer condition, the VA’s medical staff 10 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 11 of 58 took no further action for almost a month. There is no indication in the record of any management, coordination, monitoring, or follow-up as to Mr. Smith’s medical care by any of his VA medical professionals or their supporting personnel. It took until February 21, 2014, for the VA to even send information to the ENT Center of Central Georgia, an outside private medical group. This one-month delay was not due to any dispute about whether Mr. Smith was entitled to benefits. To the contrary, once Nurse Ekwueme indicated in the treatment record on January 24 that Mr. Smith’s outside ENT care was approved, there were no concerns with whether Mr. Smith was eligible for the outside medical care ordered by Dr. Puppala or whether that outside medical care was medically necessary. Meanwhile, the private clinic, the ENT Center of Central Georgia, informed Mr. Smith that they were still awaiting notice of the VA’s approval for his visit. It appears that despite the indications in the VA record that the outside care was already approved, the ENT Center had not yet received anything from the VA. Again, from January 24 to March 6, there appears to have been no medical follow up or care coordination by any VA medical professionals or their supporting personnel. So, on March 6, 2014, Mr. Smith contacted the VA Medical Center about his outside ENT consult. In response, VA Nurse Ekwueme, as Care Coordinator, intervened the following day. On March 7, Nurse Ekwueme faxed an authorization to the private 11 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 12 of 58 ENT Center and scheduled an appointment for March 11, 2014, almost two months after the January 14 CT scans and almost three months after Dr. Puppala examined Mr. Smith on December 16. The private ENT Center saw Mr. Smith promptly on March 11. In fact, once the VA faxed the authorization on March 6, the ENT specialist saw Mr. Smith a mere five days later (March 11). If anything, this again demonstrates how the VA’s medical personnel are able to get a VA patient with serious cancer seen immediately and are able to manage and coordinate medical care. At the March 11 appointment, Dr. Sanford Duke, the private ENT, examined Mr. Smith and confirmed he had a palpable mass on his right neck and the base of his tongue. Mr. Smith again presented with symptoms including dysphagia (difficulty swallowing), dry mouth, mucous after drinking, and affected speech. After reviewing the January 14 CT scans, Dr. Duke immediately performed a fine needle aspiration of the mass for pathological examination. Predictably, the pathology results indicated “Malignant Cells present, poorly differentiated carcinoma”—cancer. Two days later, on March 13, 2014, Dr. Duke saw Mr. Smith again, at which point he advised Mr. Smith that he needed immediate surgery for his cancer. Dr. Duke noted the need for a set of scans with contrast and a PET scan before he could surgically remove Mr. Smith’s tumor. VA policies and procedures, 12 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 13 of 58 however, required that the scans be performed back at a VA facility. Again, there is no dispute that Mr. Smith was eligible for these scans and that they were medically necessary. D. March 13–April 24, 2014: No Medical Follow-Up on PET Scan Despite the urgency and seriousness of Mr. Smith’s cancer diagnosis and the need for immediate surgery on March 13, the VA medical team did not manage, coordinate, monitor, or follow-up as to Mr. Smith’s medical care. Rather, it took weeks to do the new scans. The CT scans with contrast were not performed until March 28, 2014, over two weeks after they were ordered, and the PET scan was not done until April 7, 2014, over three weeks after it was ordered. The CT scans with contrast showed enlarged nodes in the right neck and a questionable soft tissue density in the base of the tongue. But, as of April 14, 2014 (a month after the scans were ordered), Mr. Smith still did not have the results from the PET scan, so he called the VA Medical Center. On April 24, 2014, Mr. Smith emailed Dr. Puppala about his “serious malignancy,” stating that he had not received the results of the April 7 PET scan: I am very concerned about the cancer on my neck and tongue that you and the radiologist diagnosed in January 2014. I had experienced symptoms of ear pressure, headache, and problems with movement of my tongue since about October 2013. It is now almost May, and I have not been contacted by . . . [the VA Medical Center] . . . with an interpretation of my PET scan results . . . . And since Dr. Dukes’ [sic] office has informed me that VA has not authorized him to provide further care (presumably surgery and radiation), I have a serious 13 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 14 of 58 malignancy but do not yet have a plan of care from any medical professional at VA. Am I missing something here, or is treatment of my cancer not an urgent matter? E. April 25, 2014: PET Scan Results On April 25, 2014, apparently in response to Mr. Smith’s email, Dr. Puppala noted the findings of Mr. Smith’s PET scan and stated that Mr. Smith needed to “follow up with [his] ENT . . . who requested the PET scan.” Consistent with the January 14 CT scans, the PET scan showed evidence of a primary malignancy of the tongue, as well as evidence of right cervical lymph node metastases. That very same day, Dr. Puppala also called and emailed the VA’s fee department to gain approval for Mr. Smith’s follow-up care—including surgery to remove his throat tumor—with Dr. Duke. According to the notes in Mr. Smith’s patient record, Dr. Puppala was unsure why Mr. Smith’s follow-up with Dr. Duke needed approval, since “[u]sually the consutls [sic] we submit are approved for a year.” Dr. Puppala herself stated that the VA (specifically the “fee dep[artmen]t” where Nurse Ekwueme worked) should have been coordinating with the private ENT center to set up Mr. Smith’s follow-up appointments with Dr. Duke. Unfortunately for Mr. Smith, this apparently did not occur between March 13 and May 13. 14 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 15 of 58 F. May 19, 2014: Surgery It was not until Mr. Smith obtained legal counsel who contacted Congressman John Barrow, who in turn contacted the VA on May 12, 2014, that Mr. Smith’s surgery and other follow-up care was approved on May 13, 2014. The treatment record reflects that on May 13, 2014, the VA’s Acting Chief of Staff, Dr. Shauna S. Kincheloe-Zaren, entered a note in response to Congressman Barrow’s letter stating that “[a] new consult [order] was required to evaluate and treat the patient and it was placed on 5/12/201[4],” and that “the appointment [was] scheduled with the ENT on 5/13/2014.” Apparently, this VA doctor knew how to order, or have someone enter an order for, an immediate ENT consult and have it occur the next day. By the time Mr. Smith’s surgery was approved on May 13, 2014, it had been five months since he saw Dr. Puppala on December 16, 2013, with symptoms and swelling that Dr. Ferris says indicated adult cancer, and four months since the January 14, 2014 CT scans had confirmed the malignant mass in Mr. Smith’s throat. Once the VA’s Dr. Kincheloe-Zaren intervened, Dr. Duke was able to perform the surgery six days later. On May 19, 2014, Mr. Smith underwent surgery to remove the tumor mass in his neck. By that time (five months after his December 16 visit) the tumor had grown, and, because it now involved Mr. Smith’s carotid artery, Dr. Duke was 15 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 16 of 58 unable to remove the entire mass through surgery. As a result, Mr. Smith was required to undergo a more intensive chemotherapy and radiation regimen, thereby reducing his chances of survival. According to Dr. Ferris, Mr. Smith’s medical expert, “there is a standard of care for an adult with a mass in the neck,” regardless of whether the medical care is within or outside the VA. Dr. Ferris opined that, given the symptoms Mr. Smith presented with during his December VA appointment, a reasonable timeframe from when he “walk[ed] in the door” to “getting on the OR table” would have been a “two-to-three month timeframe.” Dr. Ferris added that Mr. Smith’s care was “below the standard of [medical] care.” Additionally, Nurse Rose opined, based on her experience as an RN and a VA care manager, her education, and her professional knowledge on the standards of care for nurse care managers, that “Mr. Smith’s care was mismanaged from the beginning” and that, “had Mr. Smith’s medical condition been properly managed and [his] care coordinated early on and through his illness, his outcome” would have been better. G. Subsequent Developments On May 29, 2014, Dr. Duke, along with Mr. Smith’s oncologists, confirmed a plan of care, which was to begin a few days later on June 3. It was only after Mr. Smith and his counsel held a press conference that the VA finally started his 16 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 17 of 58 treatments on June 25. Mr. Smith then underwent chemotherapy and radiation treatments. By early 2015, Mr. Smith’s doctors believed his cancer was in remission, and for the next two and a half years, Dr. Duke continued to see and monitor Mr. Smith. A routine PET scan in September 2017 revealed a nodule on Mr. Smith’s lung, which was the same type of cancer as in his throat. In May 2018, Mr. Smith had surgery to remove the new tumor and a portion of his left lung.