Court Opinion

ID: 6221632
Source: CourtListenerOpinion
Date Created: 2022-02-14 22:01:36.364005+00
Date Added: 2024-06-11T08:57:23.182955
License: Public Domain

In the United States Court of Federal Claims
                                  OFFICE OF SPECIAL MASTERS
                                          No. 19-0733V
                                         UNPUBLISHED

    MICHAEL WILKINSON,                                         Chief Special Master Corcoran

                         Petitioner,
    v.                                                         Filed: January 14, 2022

    SECRETARY OF HEALTH AND                                    Special Processing Unit (SPU);
    HUMAN SERVICES,                                            Findings of Fact; Onset; Ruling on
                                                               Entitlement; Influenza (Flu); Shoulder
                        Respondent.                            Injury Related to Vaccine
                                                               Administration (SIRVA).

Ronald Craig Homer, Conway, Homer, P.C., Boston, MA, for Petitioner.

Mark Kim Hellie, U.S. Department of Justice, Washington, DC, for Respondent.

                                     RULING ON ENTITLEMENT1

       On May 17, 2019, Michael Wilkinson filed a petition for compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that as a result of the influenza (“flu”) vaccine on
November 20, 2017, he suffered a shoulder injury related to vaccination (“SIRVA”) as
defined on the Vaccine Injury Table (the “Table”). Petition (ECF No. 1) at Preamble. The
case was assigned to the Special Processing Unit of the Office of Special Masters (the
“SPU”).

1
  Because this unpublished opinion contains a reasoned explanation for the action in this case, I am
required to post it on the United States Court of Federal Claims' website in accordance with the E-
Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic
Government Services). This means the opinion will be available to anyone with access to the internet.
In accordance with Vaccine Rule 18(b), petitioner has 14 days to identify and move to redact medical or
other information, the disclosure of which would constitute an unwarranted invasion of privacy. If, upon
review, I agree that the identified material fits within this definition, I will redact such material from public
access.

2
 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2012).
       For the reasons discussed below, I GRANT Petitioner’s motion for a ruling on the
record (ECF No. 36), because Petitioner has established the elements of a Table SIRVA
claim.

     I.   Relevant Procedural History

        In May 2019, this case was assigned to the SPU after its activation. On May 15,
2020, Respondent noted the 50-day interval between Petitioner’s vaccination and his
initial treatment with his primary care provider as possibly suggesting the onset
requirement could not be met, but recommended that the case remain in the SPU
nevertheless. ECF No. 17. Respondent entered into settlement negotiations on July 14,
2020. ECF No. 20. Petitioner obtained updated medical records, then conveyed his
demand to Respondent on January 20, 2021. ECF No. 28.3 After exchanging proposals,
the parties advised that they had reached an impasse on May 21, 2021. ECF Nos. 29-
32.

       On August 24, 2021, Respondent filed his Rule 4(c) report in which he
recommended against compensation for Petitioner’s Table SIRVA claim. Respondent
only disputed that Petitioner had established onset within 48 hours of vaccination. Rule
4(c) Report (ECF No. 34) at 5-6. I then directed the parties to file briefs and any other
evidence that would assist my resolution of the disputed issues. ECF No. 35. On October
15, 2021, Petitioner filed a motion for a ruling on the record regarding onset and
entitlement more generally. ECF No. 36. On October 28, 2021, Respondent filed a
response, again addressing only onset. ECF No. 37. Petitioner did not file a reply. The
matter is now ripe for adjudication.

    II.   Relevant Factual Evidence

     I have fully reviewed the evidence, including all medical records and affidavits,
Respondent’s Rule 4(c) Report, and the parties’ briefs. I find most relevant the following:

             •   Upon receiving the subject vaccination, Petitioner was 73 years old. His
                 prior medical history was non-contributory. He sought medical care
                 infrequently.

3
  Petitioner has represented that the claim does not involve a Medicaid lien or a worker’s compensation
claim. ECF No. 12. He is seeking pain and suffering, reimbursement of past out-of-pocket expenses, and
a “modest” lost wages claim. ECF No 19.

                                                  2
•   On November 20, 2017, Mr. Wilkinson received the flu vaccine in his left
    deltoid at a pharmacy inside of his place of employment, a Target retail store
    in Edina, Minnesota. Ex. 1 at 1.

•   The next medical record is from fifty (50) days later, on January 9, 2018,
    when Petitioner presented to his primary care provider, nurse practitioner
    (“NP”) Monica Overkamp. Ex. 2 at 606-09. NP Overkamp recorded
    Petitioner’s history that “about two days prior to Thanksgiving,” he had
    received a flu vaccine “fairly high up on his arm, close to the bony part of
    his left shoulder.” Ex. 2 at 606-07. Petitioner reported that he had been
    experiencing pain and difficulty lifting his left shoulder, despite his efforts to
    self-treat including with heat, cold, and aspirin. Id. at 606-07. NP Overkamp
    documented that he had “full range of motion, no edema” (without specifying
    any particular extremities). Id. at 608. She offered orders for imaging and
    physical therapy, which Petitioner deferred while “consult[ing] an attorney
    regarding the placement of his flu shot this season.” Id. at 609.

•   Upon ordering the x-ray of Petitioner’s left shoulder conducted on March 20,
    2018, NP Overkamp wrote that the indication was “deltoid pain after vaccine
    several months ago,” which had become “chronic.” Ex. 5 at 17-18. This x-
    ray showed mild degenerative changes in the acromioclavicular joint. Id. at
    18. It also suggested possible narrowing of the inferior aspect of the
    glenohumeral joint, for which the radiologist recommended follow-up
    imaging. Id.

•   On June 12, 2018, NP Overkamp and Petitioner “followed up on his left
    shoulder discomfort following a flu shot in November.” Ex. 2 at 621.
    Petitioner was “suspicious that his influenza vaccine is the cause of his left
    shoulder pain” and he was in contact with a lawyer. Id. at 622. NP Overkamp
    referred Petitioner to an orthopedist. Id. at 624.

•   On June 20, 2018, Petitioner underwent a repeat x-ray of the left shoulder,
    which demonstrated an intact glenohumeral joint. Ex. 5 at 11-12.

•   Also on June 20, 2018, orthopedist Alicia Harrison, M.D., conducted an
    initial consultation. Dr. Harrison accepted Petitioner’s history of injury on
    “11/20/2017, got flu shot and has lingering pain ever since,” as well as his
    initial assumption that the pain would resolve quickly. Ex. 2 at 636-37. After
    reviewing the imaging and conducting a focused physical exam, Dr.
    Harrison assessed Petitioner with “left shoulder pain, likely long head biceps

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                   +/- cuff.” She referred Petitioner for physical therapy. If that did not
                   adequately address his symptoms, he should follow up for the potential of
                   more advanced imaging. Ex. 2 at 638-39.

              •    On June 25, 2018, at an initial evaluation, physical therapist (“PT”) Cynthia
                   Lunch accepted Petitioner’s history of receiving a flu vaccine on November
                   20, 2017, followed by “pain later that day anterior/lateral left shoulder which
                   has not resolved.” Ex. 4 at 1. PT Lunch documented that the left shoulder
                   had limited range of motion, a positive impingement signs, and tenderness
                   at the supraspinatus tendon. Id. at 2. PT Lunch planned a total of six weekly
                   sessions. Id. at 4.4

              •    By August 27, 2018, Petitioner had demonstrated improvements in his pain
                   levels and function, but his progress was slowed. He was discharged from
                   physical therapy to follow a home exercise program. Ex. 4 at 22-27.

              •    There are no further medical records until March 9, 2020, when sports
                   medicine specialist Siatta Dunbar, D.O., met with Petitioner for an initial
                   consultation. Ex. 11 at 48. Dr. Dunbar took down Petitioner’s history of “pain
                   in the left shoulder began after getting a flu shot in the left shoulder at a
                   pharmacy,” which had never subsided. Id. at 48-49. Dr. Dunbar observed
                   tenderness at the supraspinatus and limited range of motion. Id. at 49. She
                   assessed pain and osteoarthritis, for which she administered a steroid
                   injection into the left glenohumeral joint. Id. at 49-50.

              •    At their June 16, 2020, follow-up appointment, Dr. Dunbar recorded that
                   Petitioner had experienced one month of relief with the steroid injection, but
                   then his shoulder pain returned. Ex. 11 at 34. Dr. Dunbar assessed that
                   Petitioner’s pain appeared to be “multifactorial,” including both osteoarthritis
                   and dysfunction of the rotator cuff. Id. Dr. Dunbar recommended, “given that
                   Dr. Harrison is a shoulder specialist, that Petitioner follow up and defer to
                   her suggestions of next steps.” Id. at 39.5

4
 Petitioner attended PT sessions on June 25; July 2; July 9; July 18; and July 30, 2018. There was a one-
month gap before the final session on August 27, 2018.

5
    However, Petitioner has not filed any further records from Dr. Harrison.

                                                       4
              •   In an affidavit dated May 15, 2019, Petitioner recalls that the November 20,
                  2017, flu vaccine was initially “slightly more painful” than in past
                  experiences. Ex. 8 at ¶ 2. His arm was “sore” that afternoon, but he had
                  “experienced soreness in the past for just a day or two, so I tried to reassure
                  myself that this would be the same.” Id. However, the pain was still present
                  three days post-vaccination, on November 23, 2017 (Thanksgiving), and
                  over the ensuing weeks. Id. ¶¶ 2-3. He attempted to limit use of his left arm
                  and used over-the-counter pain relievers and ice packs. Id. at ¶ 3.

              •   Petitioner recalls that at Christmas 2017, his daughter (who is an attorney)
                  observed his shoulder pain and asked to remain informed if he did not start
                  to improve soon. Ex. 8 at ¶ 4.

              •   Petitioner states: “When my symptoms were unchanged by the end of
                  January 2018,6 I let [the daughter] know. She did some research and let me
                  know that this was not an uncommon occurrence following vaccination. I
                  decided to make an appointment with my primary care doctor for a few
                  reasons and felt I should bring my shoulder symptoms to their attention.”
                  Ex. 8 at ¶ 3.

    III.   Authority

         Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act
Section 11(c)(1). A special master must consider, but is not bound by, any diagnosis,
conclusion, judgment, test result, report, or summary concerning the nature, causation,
and aggravation of petitioner’s injury or illness that is contained in a medical record.
Section 13(b)(1). “Medical records, in general, warrant consideration as trustworthy
evidence. The records contain information supplied to or by health professionals to
facilitate diagnosis and treatment of medical conditions. With proper treatment hanging in
the balance, accuracy has an extra premium. These records are also generally
contemporaneous to the medical events.” Cucuras v. Sec’y of Health & Human Servs.,
993 F.2d 1525, 1528 (Fed. Cir. 1993).

6
 I presume that Mr. Wilkinson’s follow-up conversation with his daughter actually took place at the end of
December 2017, in light of his recollection that the conversation preceded – and in fact prompted – the
primary care appointment on January 9, 2018.

                                                    5
       Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this rule
does not always apply. In Lowrie, the special master wrote that “written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Lowrie, at *19. And the Federal Circuit recently “reject[ed] as
incorrect the presumption that medical records are accurate and complete as to all the
patient’s physical conditions.” Kirby v. Sec’y of Health & Human Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).

        The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Human Servs., 42 Fed.
Cl. 381, 391 (1998). The Court later outlined four possible explanations for
inconsistencies between contemporaneously created medical records and later
testimony: (1) a person’s failure to recount to the medical professional everything that
happened during the relevant time period; (2) the medical professional’s failure to
document everything reported to her or him; (3) a person’s faulty recollection of the events
when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did
not exist. La Londe v. Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013),
aff’d, 746 F.3d 1335 (Fed. Cir. 2014).

       The Court has also said that medical records may be outweighed by testimony that
is given later in time that is “consistent, clear, cogent, and compelling.” Camery, 42 Fed.
Cl. at 391 (citing Blutstein v. Sec’y of Health & Human Servs., No. 90-2808, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998). The credibility of the individual offering
such testimony must also be determined. Andreu v. Sec’y of Health & Human Servs., 569
F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Human Servs., 991 F.2d
1570, 1575 (Fed. Cir. 1993).

        A special master may find that the first symptom or manifestation of onset of an
injury occurred “within the time period described in the Vaccine Injury Table even though
the occurrence of such symptom or manifestation was not recorded or was incorrectly
recorded as having occurred outside such period.” Section 13(b)(2). “Such a finding may
be made only upon demonstration by a preponderance of the evidence that the onset [of
the injury] ... did in fact occur within the time period described in the Vaccine Injury Table.”
Id.

       The special master is obligated to fully consider and compare the medical records,
testimony, and all other “relevant and reliable evidence contained in the record.” La
Londe, 110 Fed. Cl. at 204 (citing § 12(d)(3); Vaccine Rule 8); see also Burns v. Sec’y of

                                               6
Health & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within the
special master's discretion to determine whether to afford greater weight to medical
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).

IV.     Findings of Fact Regarding Onset

       Respondent argues that “although Petitioner claims that the onset of his symptoms
was immediate, these claims are not corroborated by the contemporaneous medical
records.” Rule 4(c) Report at 5-6. In effect, Respondent is questioning the fact that there
are no close-in-time (perhaps as close as within 48 hours) records of pain complaints.

       This reasoning suggests that to establish a Table injury, Petitioner must obtain
medical care for his shoulder pain within the first 48 hours after vaccination. But the
Vaccine Act does not impose such a requirement. See Section 13(b)(2) (permitting a
special master to find onset “even though the occurrence of such symptom was not
recorded or was incorrectly recorded as having occurred outside such time period,” and
only requiring a preponderance of the evidence) (emphasis added); see also Stevens v.
Sec’y of Health & Human Servs., No. 90-221V, 1990 WL 608693, at *3 (Fed. Cl. Spec.
Mstr. 1990) (noting that clear, cogent, and consistent testimony can overcome missing or
even contradictory medical records). Moreover, Petitioner’s medical records, affidavit,
and motion demonstrate that he initially believed that he was experiencing typical
vaccination site pain, which would resolve without medical treatment. It is also consistent
with many past successful cases.7

7
 See, e.g., Tenneson v. Sec’y of Health & Human Servs., No. 16-1664V, 2018 WL 3082140, at *5 (Fed.
Cl. Spec. Mstr. March 30, 2018), review denied, 142 Fed. Cl. 329 (2019); Deutsch v. Sec’y of Health &
Human Servs., No. 18-527V, 2021 WL 4995076 (Fed. Cl. Spec. Mstr. Sept. 24, 2021); Winkle v. Sec’y of
Heath & Human Servs., No. 20-485, 2021 WL 2808993 (Fed. Cl. Spec. Mstr. June 3, 2021); Williams v.
Sec’y of Health & Human Servs., No. 17-830V, 2019 WL 1040410, at *9 (Fed. Cl. Spec. Mstr. Jan. 31,
2019); Knauss v. Sec’y of Health & Human Servs., No.16-1372V, 2018 WL 3432906 (Fed. Cl. Spec. Mstr.
May 23, 2018).

Conversely, it is reasonable to expect that an average individual will seek medical attention for sudden pain
following a vaccination, particularly if the pain is severe. See, e.g., Pitts v. Sec’y of Health & Human Servs.,
No. 18-1512v, 2020 WL 2959421, at *5 (Fed. Cl. Spec. Mstr. April 29, 2020); see also Eshraghi v. Sec’y of
Health & Human Servs., No. 19-39V, 2021 WL 2809590, at *3 (Fed. Cl. Spec. Mstr. June 4, 2021) (in which
the petitioner claimed “excruciating” pain that prevented him from performing many simple, everyday tasks).

Therefore, the length of time before a petitioner seeks medical treatment may help to illustrate the severity
of injury, therefore bearing on the potential award for pain and suffering (in the event that entitlement is
established).

                                                       7
        Respondent also argues that the later medical records represent only Petitioner’s
own claims regarding onset. Rule 4(c) Report at 6; Response at 1-2 (citing Section
13(a)(1); Lett v. Sec’y of Health & Human Servs., 39 Fed. Cl. 259 (1997)). As I have
previously recognized,8 however, Lett is inapposite, because the petitioners therein failed
to obtain any medical records that demonstrated that their minor child had experienced
the alleged injury at any time, much less within the timeframe for a Table injury. 39 Fed.
Cl. at 262. Moreover in Lett, the petitioners’ expert neurologist conceded that he could
not identify any events that could have represented seizures, based on either the Table
definition or his own medical knowledge. Id. In denying the petitioners’ motion for review,
the Court of Federal Claims stressed that there was “no corroborating evidence that [their
minor child] ever suffered a seizure.” Id. at 262-63. This is distinguishable from a medical
provider’s later documentation of the injury alleged and acceptance of the petitioner’s
history of the inciting circumstances. Such “information supplied to… health
professionals” is presumed to be trustworthy, especially in the absence of evidence
supporting a different onset or a different precipitating event. Cucuras, 993 F.2d at 1528.

      For the foregoing reasons, Mr. Wilkinson has established that he suffered the
onset of shoulder pain within 48 hours after vaccination.

    V.   Other Table Requirements and Entitlement

        In light of the lack of other objections and my own review of the record, I find that
Petitioner has established the other requirements for a Table SIRVA claim. Specifically,
there is not a history of prior shoulder pathology that would explain her injury. 42 C.F.R.
§ 100.3(c)(3)(10)(i). There is no evidence of any other condition or abnormality that
represents an alternative cause. 42 C.F.R. § 100.3(c)(3)(10)(iii). The medical records and
affidavits support that his shoulder pain and reduced range of motion were limited to the
left shoulder. C.F.R. § 100.3(c)(3)(10)(iv). The contemporaneous vaccination record
reflects the site of administration as his left deltoid. Ex. 1; Sections 11(c)(1)(A) and (B)(i).
Petitioner has not pursued a civil action or other compensation. Ex. 1 at ¶ 12; Section
11(c)(1)(E). Finally, Petitioner suffered the residual effects for more than six months after
vaccination. Thus, Petitioner has satisfied all requirements for entitlement under the
Vaccine Act.

8
 Smith v. Sec’y of Health & Human Servs., No. 19-1384V, 2021 WL 6285638 (Fed. Cl. Spec. Mstr. Dec. 2,
2021); Hartman v. Sec’y of Health & Human Servs., No. 19-1106V, 2021 WL 4823549, at *4 (Fed. Cl. Spec.
Mstr. Sept. 14, 2021).

                                                  8
VI.   Conclusion

      Based on the entire record, I find that Petitioner has provided preponderant
evidence satisfying all requirements for a Table SIRVA. Petitioner is entitled to
compensation. A subsequent order will set further proceedings towards resolving
damages.

      IT IS SO ORDERED.
                                                  s/Brian H. Corcoran
                                                  Brian H. Corcoran
                                                  Chief Special Master

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