Court Opinion

ID: 9365895
Source: CourtListenerOpinion
Date Created: 2023-01-25 16:00:37.800311+00
Date Added: 2024-06-11T17:15:48.216578
License: Public Domain

Appellate Case: 22-4033     Document: 010110803149      Date Filed: 01/25/2023   Page: 1
                                                                                 FILED
                                                                     United States Court of Appeals
                       UNITED STATES COURT OF APPEALS                        Tenth Circuit

                              FOR THE TENTH CIRCUIT                       January 25, 2023
                          _________________________________
                                                                        Christopher M. Wolpert
                                                                            Clerk of Court
  ESTATE OF ANGELO WRIGHT,

        Plaintiff - Appellant,

  v.                                                        No. 22-4033
                                                    (D.C. No. 4:18-CV-00084-DN)
  BRUCE BURNHAM,                                              (D. Utah)

        Defendant - Appellee.
                       _________________________________

                              ORDER AND JUDGMENT*
                          _________________________________

 Before HARTZ, TYMKOVICH, and MATHESON, Circuit Judges.
                  _________________________________

       Angelo Wright was an inmate with the Utah Department of Corrections

 (UDC). On December 22, 2016, he was transferred from the San Juan County (SJC)

 jail to the Central Utah Correction Facility (CUCF) due to slow healing ulcers on his

 right leg. On December 23, Nurse Jason Jackman evaluated Mr. Wright, found no

 infection, and reported his findings to prison physician Bruce Burnham, who

       *
         After examining the briefs and appellate record, this panel has determined
 unanimously that oral argument would not materially assist in the determination of
 this appeal. See Fed. R. App. P. 34(a)(2); 10th Cir. R. 34.1(G). The case is therefore
 ordered submitted without oral argument. This order and judgment is not binding
 precedent, except under the doctrines of law of the case, res judicata, and collateral
 estoppel. It may be cited, however, for its persuasive value consistent with
 Fed. R. App. P. 32.1 and 10th Cir. R. 32.1.
Appellate Case: 22-4033    Document: 010110803149        Date Filed: 01/25/2023    Page: 2

 formulated a treatment plan. On December 29, CUCF medical staff discovered the

 ulcers on his right leg had become infected. Mr. Wright was transferred to the

 hospital that same day, but the infection led to the amputation of his right leg below

 the knee.

       Mr. Wright sued Nurse Jackman and Dr. Burnham.1 His amended complaint

 sought relief under 42 U.S.C. § 1983, asserting that the defendants violated his rights

 under the Eighth and/or Fourteenth Amendments to be free from cruel and unusual

 punishment. He alleged that defendants’ deliberate indifference to his medical needs

 caused his leg to become so infected that it required amputation. He further alleged

 that the infection could have been diagnosed, treated, and stabilized before December

 29, 2016. Mr. Wright also brought a claim under the Utah Constitution.

       Defendants moved for summary judgment, arguing they provided appropriate

 treatment for Mr. Wright on December 23. Mr. Wright conceded summary judgment

 was proper as to Nurse Jackman but not for Dr. Burnham.

       The district court granted summary judgment for Dr. Burnham. It said that

 even if Dr. Burnham misinterpreted Mr. Wright’s symptoms, his conduct did not

       1
         The amended complaint also named John Does 1-5, alleging they were
 medical staff at CUCF, aware of Mr. Wright’s condition, and deliberately indifferent
 to his medical needs. But these unnamed defendants were never served. The district
 court’s summary-judgment decision is final. See Raiser v. Utah Cnty., 409 F.3d
 1243, 1245 n.2 (10th Cir. 2005); Bristol v. Fibreboard Corp., 789 F.2d 846, 847
 (10th Cir. 1986).

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 demonstrate deliberate indifference to Mr. Wright’s medical needs. Mr. Wright

 appeals.2 Exercising jurisdiction under 28 U.S.C. § 1291, we affirm.

                                 I. BACKGROUND

                                 A. Factual History

        Mr. Wright suffered from a chronic condition known as venous stasis ulcers,

 which are open wounds occurring around the ankle or lower leg and caused by poor

 circulation.

        In April 2015, while in UDC custody, Mr. Wright developed ulcers on his left

 leg. In November 2015, when the ulcers had not improved, Dr. Burnham transferred

 Mr. Wright to CUCF for more intensive treatment that included daily dressing

 changes, compression hose, and occasional sitz baths. Nurse Jackman participated in

 this treatment. Over several months, the ulcers showed significant improvement.

 Once Dr. Burnham was satisfied the ulcers had improved enough, he agreed

 Mr. Wright could be transferred to SJC jail in May 2016.3

        On December 12, 2016, Mr. Wright filed a medical request form asking to see

 a doctor about ulcers on his right ankle. On December 15, he saw Physician

 Assistant (PA) Blen Freestone, who assessed the ulcers as slow healing but not

 showing signs of infection. PA Freestone recommended that Mr. Wright see a wound

        2
          Mr. Wright passed away in March 2021. His Estate was substituted as
 plaintiff in August 2021. We refer to the appellant as Mr. Wright.
        3
        Mr. Wright was housed at SJC jail as part of the UDC’s Inmate Placement
 Program (IPP).

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 care specialist. He explained at his deposition that any referral would be up to the

 prison physician.

       On December 19, an SJC jail staff member emailed Nurse Jackman, reporting

 that PA Freestone “does not feel that [Mr. Wright’s] leg wound is healing the way it

 should and would like him to see a specialist. We would request that he get

 transferred back to the prison to have this addressed.” Aplt. App., Vol. III at 518.

 On December 20, Mr. Wright filed another medical request form stating that he could

 “hardly put pressure on [his] right foot to walk.” Id. at 517.

       After PA Freestone saw Mr. Wright, he contacted Dr. Burnham and told him

 that “the ulcer[s] on Mr. Wright’s right leg were not improving and Mr. Wright

 should be seen by a provider who was more familiar with treating venous stasis

 ulcers.” Id., Vol. II at 482. Dr. Burnham explained in his declaration that “outside

 emergency situations, before sending any inmate in an IPP facility to a specialist, it is

 UDC practice to have a UDC medical provider evaluate the inmate.” Id.

       On December 22, Dr. Burnham ordered Mr. Wright to be transferred back to

 CUCF “so he could be evaluated by UDC medical staff who were familiar with

 Mr. Wright’s condition and who had the knowledge and experience to properly treat

 venous stasis ulcers.” Id. That same day, Mr. Wright was transferred. He arrived at

 CUCF in a wheelchair.

       Nurse Jackman briefly assessed Mr. Wright when he arrived at CUCF on the

 22nd. He ordered crutches for Mr. Wright because the ulcers were limiting his

 mobility. On December 23, Nurse Jackman performed a more thorough assessment.

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 In his notes, he indicated that the previously treated ulcers on the left ankle were

 almost completely healed, but four new, small ulcers appeared on the back of the

 right foot and that the area was “red [and] swollen.” Id., Vol. III at 520. He

 observed “[w]eeping” due to the swelling. Id. He also noted the area was “raw and

 macerated,” but that “[n]o infection is seen.” Id. In his declaration, Nurse Jackman

 said the ulcers were “discolored” and “the skin was friable and irritated.” Id. at 626.

 He also testified at his deposition that he did not see any “pus” on Mr. Wright’s

 ankle, and it was not “hot to the touch.” Id., Vol. I at 183.

       Nurse Jackman consulted with Dr. Burnham, who did not see Mr. Wright.4

 Dr. Burnham ordered dressing changes, compression socks, and crutches.

 Nurse Jackman also instructed Mr. Wright to keep his leg elevated. Dr. Burnham

 “believe[d] [Nurse] Jackman ha[d] the knowledge and experience to recognize signs

 and symptoms of an infection and . . . would have noted any signs of infection and

 reported them to [him].” Id., Vol. II at 483. Dr. Burnham’s rationale for his order

 was that “[d]aily dressing changes not only promote healing but allow for medical

 staff to assess the wound daily for changes and address signs of infection as they

 arise.” Id. The wound was cleaned with saline and covered with Xeroform gauze

 and a Telfa pad. Dr. Burnham then left on vacation for a week.

       4
          The parties dispute whether Dr. Burnham saw Mr. Wright in person. But the
 district court determined this fact was not material to its decision. Viewing the facts
 in Mr. Wright’s favor, it assumed Dr. Burnham did not visit or see Mr. Wright on
 December 23. We make the same assumption.

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       On December 24, another nurse saw Mr. Wright and completed a dressing

 change, noting that Mr. Wright did not exhibit signs or symptoms of an infection.

 Mr. Wright declined medical treatment on December 25 and 26, saying he would

 change his dressing himself. On December 27, a medical technician cleaned

 Mr. Wright’s wound with saline and placed Xeroform gauze on the wound, covered

 by a Telfa pad. Mr. Wright refused dressing changes on December 28 and 29. But

 then later on December 29, he told the guards he was in significant pain, and he had a

 hole in his ankle that was oozing white liquid.

       Mr. Wright was brought to the clinic where Nurse Jackman saw an open

 wound with drainage mixed with blood and more discolored than it was before. He

 cleaned the wound with saline, administered a shot of antibiotics, and transferred

 Mr. Wright to the University Medical Center (UMC) that same day due to concerns

 Mr. Wright had an infection. Despite UMC’s best efforts, the infection ultimately led

 to a below-the-knee amputation of Mr. Wright’s right leg on January 21, 2017.

                                B. Procedural History

       Mr. Wright filed his complaint in state court in November 2018, and the

 defendants removed it to federal court. Mr. Wright filed an amended complaint in

 January 2020, bringing claims under § 1983 and the Utah Constitution.

       In December 2020, Mr. Wright’s expert, Dr. John Deacon, prepared a report.

 In it, he opined that: the x-ray report from December 29 showed that Mr. Wright had

 an infection on December 23; Nurse Jackman’s assessment violated the standard of

 care because Mr. Wright “had physical exam findings that were consistent with

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 infection,” but Nurse Jackman did “not recognize [a] likely infection with the

 constellation of findings present in this case,” Aplt. App., Vol. III at 533, 534;

 Dr. Burnham violated the standard of care because he should have conducted his own

 examination of Mr. Wright, but even if he didn’t examine Mr. Wright, he should have

 acknowledged infection as the most likely diagnosis based on the information

 Nurse Jackman provided; if the infection had been properly treated with antibiotic

 therapy, Mr. Wright would not have developed septic arthritis; and “[i]f not for the

 errors and omissions of Nurse Jackman and Dr. Burnham, Mr. Wright would have

 avoided below-knee amputation,” id. at 539 (boldface omitted).

        Dr. Burnham moved for summary judgment based on qualified immunity. The

 district court granted summary judgment in Dr. Burnham’s favor on the § 1983

 claim. It declined to exercise supplemental jurisdiction over Mr. Wright’s state-law

 claim, so it dismissed that claim without prejudice. Mr. Wright appeals from the

 district court’s decision.

                                   C. Legal Framework

 1. Qualified Immunity

        “The doctrine of qualified immunity shields officials from civil liability so

 long as their conduct does not violate clearly established statutory or constitutional

 rights of which a reasonable person would have known.” Crowson v. Washington

 Cnty., 983 F.3d 1166, 1177-78 (10th Cir. 2020) (quotations omitted). A defendant’s

 assertion of a qualified immunity affirmative defense “creates a presumption that the

 defendant is immune from suit.” Id. at 1178 (brackets and quotations omitted). To

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 overcome this presumption, the burden shifts to the plaintiff to “show (1) facts that

 demonstrate the [defendant] violated a federal constitutional or statutory right, which

 (2) was clearly established at the time of the defendant’s conduct.” Sawyers v.

 Norton, 962 F.3d 1270, 1282 (10th Cir. 2020).

 2. Deliberate Indifference

       “A prison official’s ‘deliberate indifference’ to a substantial risk of serious

 harm to an inmate violates the Eighth Amendment.” Farmer v. Brennan, 511 U.S.

 825, 828 (1994). This includes “deliberate indifference to an inmate’s serious

 medical need.” Mata v. Saiz, 427 F.3d 745, 749 (10th Cir. 2005).

       “To establish deliberate indifference based on prison officials failing to attend

 to an inmate’s serious medical needs, a plaintiff must satisfy an objective and

 subjective component.” Smith v. Allbaugh, 987 F.3d 905, 910 (10th Cir. 2021). “The

 objective component of deliberate indifference is met if the harm suffered rises to a

 level sufficiently serious to be cognizable under the Cruel and Unusual Punishment

 Clause.” Sawyers, 962 F.3d at 1283 (quotations omitted). “To satisfy the subjective

 component, the plaintiff must show the official knows of and disregards an excessive

 risk to inmate health or safety.” Id. (quotations omitted). “The official must both be

 aware of facts from which the inference could be drawn that a substantial risk of

 serious harm exists, and he must also draw the inference.” Id. (quotations omitted).

       In determining whether the subjective component has been established, we

 have recognized “two types of conduct constituting deliberate indifference”—failure

 to treat and failure to act as a gatekeeper. Sealock v. Colorado, 218 F.3d 1205, 1211

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 (10th Cir. 2000). The first and most common type is when a medical professional

 acts in a treating role and the “medical professional may fail to treat a serious

 medical condition properly.” Id. But “[w]here this sort of conduct is alleged, the

 medical professional has available the defense that he was merely negligent in

 diagnosing or treating the medical condition, rather than deliberately indifferent.” Id.

 The second type is when a prison official or medical professional knows that his role

 is to serve as a gatekeeper for other medical personnel capable of treating the

 condition, but “he delays or refuses to fulfill that gatekeeper role” and “prevent[s] an

 inmate from receiving treatment or den[ies] him access to medical personnel capable

 of evaluating the need for treatment.” Id.

       “In some circumstances there may be a clear difference between a provider

 and a gatekeeper. But . . . a physician’s role often involves treating the patient while

 simultaneously considering the need for referral to someone with more specialized

 training at the same time.” Lucas v. Turn Key Health Clinics, LLC, --- F.4th ---,

 No. 22-5002, 2023 WL 327846, at *9 (10th Cir. Jan. 20, 2023) (citation and

 quotations omitted). So a medical professional can act as both a provider and

 gatekeeper simultaneously, and can be liable under either or both theories. Id. at *9

 & nn. 4-5.

                               D. District Court Decision

       The district court determined that the first prong of the qualified immunity

 test—whether there was a constitutional violation—was dispositive, so it did not

 address the second prong—clearly established law. The court explained that

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  “[b]ecause Wright has not carried his qualified-immunity burden of providing

  evidence of material facts supporting his view that Defendant breached his federal

  constitutional right, Defendant is protected from further litigation in this matter,

  without consideration of whether the law was clearly established at the time of the

  defendant’s conduct.” Aplt. App., Vol. V at 1181 (quotations omitted).

        In deciding Mr. Wright had not shown a constitutional violation, the district

  court first found that Mr. Wright met the objective component of the

  deliberate-indifference test because his infection and amputation showed that he

  “endured an objectively serious harm.” Id. at 1175. But the court next determined

  that Mr. Wright had not satisfied the subjective component because he had not

  offered evidence that Dr. Burnham knew of and disregarded a substantial risk to

  Mr. Wright’s health.

        In reaching this conclusion, the district court relied on undisputed facts

  presented in Dr. Burnham’s motion for summary judgment showing that:

             Defendant was aware that Wright had been successfully treated at
              CUCF in the previous thirteen months for a similar past ulcer;
             Defendant had ordered Wright’s transfer back to CUCF from SJC
              jail (just as had happened about thirteen months before) for better
              treatment of his current ulcers;
             within three days of being notified by SJC that Wright needed better
              treatment, the same nurse (Jackman) who had contributed to the
              successful treatment of the past ulcer was assessing Wright in
              person, on December 23, 2016, upon Wright’s arrival back to
              CUCF;
             though Defendant did not see Wright in-person on December 23,
              2016, Defendant consulted with Jackman about Jackman’s in-person
              assessment of Wright as to Jackman’s perception that Wright’s foot

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                was painful, red, and swollen, the ulcers were not open but were
                weeping and raw-looking, but that Jackman did not see pus and feel
                heat coming from the ulcered area and did not believe Wright had an
                infection that day; [and]
             Jackman had the knowledge and experience to recognize signs and
              symptoms of an infection and would have noted any signs of
              infection and reported them to Burnham[.]

  Id. at 1176-77 (brackets, citations, ellipsis, and quotations omitted). The court also said it

  was undisputed that Dr. Burnham did not believe Mr. Wright had an infection that day,

  and that Dr. Burnham ordered treatment for Mr. Wright that was consistent with the need

  to heal the ulcers. And the court noted:

                       Once the consultation was over and Defendant had
                given the orders, he left on vacation, no doubt with the
                expectation that the orders would be carried out and daily
                assessments would alert on-duty medical staff to lack of
                healing of the wound, or signs of infection that might arise.
                This is exactly what happened, with the infection being
                discovered on December 29, 2016, and Wright being
                transferred to UMC that same day.

  Id. at 1177 (citation omitted).

         The district court acknowledged that Mr. Wright’s expert found “plenty of fault”

  with Dr. Burnham’s care of Mr. Wright and opined that Dr. Burnham did not observe

  “the standard of care for Wright’s situation.” Id. at 1178 (quotations omitted). But the

  court explained, “While it may be true that ‘the medical standard of care’ demanded more

  from Defendant, . . . Wright’s constitutional rights did not.” Id. at 1179. “Unfortunately,

  Wright’s symptoms were possibly misinterpreted by Defendant but this falls well below

  the culpable state of mind necessary to support a deliberate indifference allegation.” Id.

  at 1180 (quotations omitted).

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        The district court also rejected Mr. Wright’s attempts “to cast Defendant as a

  gatekeeper” when the evidence showed “he did not see that as his role.” Id. at 1181. The

  court explained that Dr. Burnham was primarily responsible for providing medical care,

  he was experienced in treating wounds, and there was no evidence he thought of his role

  as a gatekeeper for other medical professionals capable of treating Mr. Wright’s wounds.

                                     II. DISCUSSION

        We review de novo a grant of summary judgment based on qualified

  immunity. Mata, 427 F.3d at 749. Summary judgment is appropriate “if the movant

  shows that there is no genuine dispute as to any material fact and the movant is

  entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). “In applying this

  standard, we view the evidence and the reasonable inferences to be drawn from the

  evidence in the light most favorable to the nonmoving party.” Sawyers, 962 F.3d at

  1282 (quotations omitted).

                                      A. Gatekeeper

        Mr. Wright first argues that he “raised an issue of fact regarding Burnham’s

  subjective knowledge where Burnham never assessed [him] yet denied him access to

  a specialist referred by another physician.” Aplt. Opening Br. at 16 (boldface and

  underline omitted). He contends that Dr. Burnham committed deliberate indifference

  in his role “as gatekeeper to outside medical experts.” Id. at 17 (underline omitted).

        We first note that this argument contains factual inaccuracies. There was no

  other “physician” who referred Mr. Wright to a specialist. Although PA Freestone

  recommended that Mr. Wright see a specialist, he acknowledged that the prison

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  doctor would decide whether Mr. Wright should see a specialist. It is therefore not

  accurate to state that Dr. Burnham denied Mr. Wright access to a specialist that

  another physician had referred him to see.

        In support of his gatekeeper argument in district court, Mr. Wright presented

  evidence that prison policy generally required a doctor at CUCF to decide whether to

  refer a prisoner to a specialist. A jury might be able to infer from this evidence that

  Dr. Burnham acted simultaneously as a treating physician and a gatekeeper.5 But

  even if Dr. Burnham acted in part as a gatekeeper, there is no evidence that he

  consciously decided not to refer Mr. Wright to a wound specialist, and even if there

  were, there is no evidence that he did anything other than exercise his considered

  medical judgment, which is not deliberate indifference. See Self v. Crum, 439 F.3d

  1227, 1232 (10th Cir. 2006) (explaining that “the subjective component is not

  satisfied, absent an extraordinary degree of neglect, where a doctor merely exercises

  his considered medical judgment” and “[m]atters that traditionally fall within the

  scope of medical judgment are such decisions as whether to consult a specialist or

  undertake additional medical testing”).

        Moreover, the undisputed facts show that when Nurse Jackman evaluated

  Mr. Wright on December 23 and communicated his assessment to Dr. Burnham, he

        5
          We recently clarified that a doctor can act as both a provider and a
  gatekeeper and that a plaintiff need not show the doctor was acting “solely” as a
  gatekeeper to establish liability under a gatekeeper theory. Lucas, 2023 WL 327846,
  at *9 & n.5.

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  did not indicate any concerns that Mr. Wright’s condition required emergency and/or

  specialty care. After consulting with Nurse Jackman, Dr. Burnham ordered a

  treatment plan consistent with Mr. Wright’s symptoms, and consistent with the

  treatment plan he had successfully implemented for the ulcers on Mr. Wright’s other

  leg. Mr. Wright’s expert did not say that Dr. Burnham was not capable of treating

  Mr. Wright’s condition or that Dr. Burnham should have referred Mr. Wright to a

  specialist or for emergency care on December 23. Instead, the expert opined that

  Nurse Jackman and Dr. Burnham could have provided the proper care on that day but

  failed to do so.

         We therefore agree with the district court that Dr. Burnham was entitled to

  summary judgment on Mr. Wright’s gatekeeper theory.

                                  B. Treating Physician

         Mr. Wright next asserts that, even if Dr. Burnham was not a gatekeeper, “there

  is still a dispute of fact as to subjective indifference where Dr. Burnham failed to

  both properly assess and treat Wright’s condition.” Aplt. Opening Br. at 21

  (underline omitted). We disagree. We have explained that “the negligent failure to

  provide adequate medical care, even one constituting medical malpractice, does not

  give rise to a constitutional violation.” Self, 439 F.3d at 1233 (quotations omitted).

  We have further explained that “[s]o long as a medical professional provides a level

  of care consistent with the symptoms presented by the inmate, absent evidence of

  actual knowledge or recklessness, the requisite state of mind cannot be met.” Id.

  “Indeed, our subjective inquiry is limited to consideration of the doctor’s knowledge

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  at the time he prescribed treatment for the symptoms presented, not to the ultimate

  treatment necessary.” Id.

        Mr. Wright contends that Dr. Burnham failed to treat his condition properly

  because Dr. Burnham “never assessed” him in person. Aplt. Opening Br. at 21. But

  Dr. Burnham did assess Mr. Wright’s condition based on his knowledge of

  Mr. Wright’s medical history and the information Nurse Jackman relayed to him

  from Nurse Jackman’s physical examination of Mr. Wright. Although Mr. Wright’s

  expert opined that Dr. Burnham’s conduct in not examining Mr. Wright in person fell

  below the standard of care, negligence or medical malpractice does not give rise to a

  constitutional violation. See Self, 439 F.3d at 1233.

        The undisputed evidence shows Dr. Burnham did not believe there was an

  infection when he prescribed treatment for Mr. Wright, and “[h]e prescribed care

  consistent with Wright’s symptoms on December 23—care that had successfully

  treated the ulcers in Wright’s other leg.” Aplee. Br. at 14. As the district court

  noted, it is possible that Dr. Burnham misinterpreted Mr. Wright’s symptoms, but

  Dr. Burnham did provide a treatment plan for the condition he believed was causing

  Mr. Wright’s symptoms, a treatment plan that worked successfully in the previous

  year. We therefore agree that because Dr. Burnham “promptly ordered a reasonable

  treatment plan, the district court correctly concluded that Dr. Burnham did not

  consciously disregard Wright’s medical needs.” Id.

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                                 III. CONCLUSION

        We affirm the district court’s judgment.

                                                   Entered for the Court

                                                   Scott M. Matheson, Jr.
                                                   Circuit Judge

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