Court Opinion

ID: 4656255
Source: CourtListenerOpinion
Date Created: 2021-02-01 14:06:38.345705+00
Date Added: 2024-06-11T08:00:48.984710
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 19-0241V
                                          UNPUBLISHED

    T                 R              ,                          Chief Special Master Corcoran

                          Petitioner,                           Filed: August 10, 2020
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Findings of Fact; Onset; Influenza
    HUMAN SERVICES,                                             (Flu) Vaccine; Shoulder Injury
                                                                Related to Vaccine Administration
                          Respondent.                           (SIRVA)

Carol L. Gallagher, Somers Point, NJ, for petitioner.

Camille Michelle Collett, U.S. Department of Justice, Washington, DC, for respondent.

                                           FINDINGS OF FACT1

       On February 12, 2019, T                R        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 she suffered a left shoulder injury after
receiving the influenza (“flu”) vaccine on October 2, 2017. Petition at 1. The case was
assigned to the Special Processing Unit of the Office of Special Masters.

       For the reasons discussed below, I find the onset of Petitioner’s shoulder injury
related to vaccine administration (“SIRVA”) occurred within 48 hours of vaccination.
Specifically, Petitioner more likely than not suffered pain immediately upon vaccination

1
   Because this unpublished fact ruling contains a reasoned explanation for the action in this case, I am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 fact ruling 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).
      I.     Relevant Procedural History

       On April 30, 2020, Petitioner filed the last of her required medical records and a
statement of completion. ECF Nos. 28-29. On June 5, 2020, Respondent filed a status
report indicating he “intends to continue to defend this case.” ECF No. 30. He requested
60 days to file his Rule 4(c) Report. Id. In that Report (filed on August 6, 2020),
Respondent argues that Petitioner’s injury does not meet the Table definition of SIRVA
because she has not established that the onset of her left shoulder pain occurred within
48 hours of vaccination. ECF No. 31.

      II.    Issue

       At issue is whether Petitioner’s first symptom or manifestation of onset after
vaccine administration (specifically pain) occurred within 48 hours as set forth in the
Vaccine Injury Table and Qualifications and Aids to Interpretation (“QAI”) for a Table
SIRVA. 42 C.F.R. § 100.3(a) XIV.B. (2017) (influenza vaccination); 42 C.F.R. §
100.3(c)(10)(ii) (required onset for pain listed in the Qualifications and aids to
interpretation (“QAI”)).

      III.   Authority

       Pursuant to Vaccine Act § 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act §
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.
§ 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).

       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.

      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

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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
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.       Finding of Fact

       I make these findings after a complete review of the record, including all medical
records, affidavits, testimony, expert reports, Respondent’s Rule 4(c) Report, and
additional evidence filed. They are as follows:

             •   Prior to vaccination, Petitioner was treated for some generalized aches and
                 pains, difficulty breathing, and an episode of chest pain in 2014 (Ex. 3 at
                 13-14), dermatitis and right knee pain in 2016 (Ex. 5), and varicose veins
                 and a heart murmur in 2016-17 (Ex. 3 at 5-12). There is no evidence she
                 experienced any prior left shoulder pain.

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•   Petitioner visited her primary care provider (“PCP”) for an annual physical
    on October 2, 2017, the same day she received the flu vaccine alleged as
    causal. Ex. 3 at 5-6. At that visit, she discussed some abnormal EKG results
    with her PCP and expressed concern regarding her varicose veins. Id. In
    her affidavit, Petitioner explained that she was administered the flu vaccine
    later that day at an area Walgreen’s Pharmacy because her PCP clinic had
    not yet received their flu vaccines. Ex. 2 at ¶¶ 2-3.

•    The vaccine record shows the flu vaccine was administered
    intramuscularly in Petitioner’s left deltoid on October 2, 2017. Exs. 1, 9.

•   On October 17, 2017, fifteen days after vaccination, Petitioner visited a
    vascular surgeon for leg pain and swelling she had experienced for the last
    eight years. Ex. 7 at 1-4. Venous duplex and vein reflux studies were
    ordered. Id. at 4. These studies were performed on October 20, 2017. Id. at
    5-9. There is a notation of “no pain” in the medical record from this October
    17, 2017 visit (id. at 3), but the information under extremities shows the
    vascular surgeon was focused on Petitioner’s lower extremities (id. at 4).
    There is also an entry under musculoskeletal which indicates Petitioner
    “[d]enies back pain, sciatica, arthritis, knee pain and foot pain,” but no entry
    regarding the lack or existence of shoulder pain. Id. at 2.

•   Petitioner first sought treatment for her left shoulder pain from her PCP on
    January 19, 2018, approximately three and one-half months after
    vaccination. Ex. 3 at 3-4. At this visit, she complained of left shoulder pain
    following her flu shot and a cyst on the right side of her neck. Id. at 3. Her
    PCP recommended that she take Tylenol and follow-up in a few months. Id.
    at 4.

•   Petitioner visited an orthopedist on June 11, 2018, now approximately eight
    months since vaccination. Ex. 4 at 8. At this visit, Petitioner indicated she
    “had left shoulder pain ever since a flu shot in October 2017.” Id. Petitioner
    was diagnosed with left shoulder impingement and administered a steroid
    injection. Id. Additionally, she was instructed to attend physical therapy
    (“PT”). Id. at 6.

•   Petitioner attended PT from July 2 through August 10, 2018. Ex. 11 at 1-6.
    On her intake form, she again indicated that her left shoulder pain started
    in October after the flu shot. Id. at 2.

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            •    Petitioner returned to the orthopedist on October 25, 2018. Ex. 4 at 7. She
                indicated she had obtained some relief from the cortisone injection but still
                had pain with daily activities and when sleeping. An MRI was ordered. Id.

            •   The MRI performed on November 13, 2018 revealed a “[h]igh-grade bursal
                surface tear of the supraspinatus tendon.” Ex. 4 at 9; Ex. 6 at 7 (record of
                MRI from directly from University Radiology).

            •   Petitioner was seen again by her PCP for her annual physical on November
                30, 2018. Ex. 3 at 1-2. He noted that she was receiving orthopedic treatment
                for her left shoulder pain which started after she received a flu shot on
                October 2, 2017. Id. at 1.

       The above medical entries show that Petitioner consistently associated the origin
of her left shoulder pain to the flu vaccine she received on October 2, 2017. Every time
she sought treatment for her left shoulder pain from her PCP, orthopedist, and physical
therapist, Petitioner described her pain as occurring contemporaneously with the flu shot.
In her affidavit, she described pain after receiving the flu shot which became significant
by that night. Ex. 2 at ¶¶ 4, 6.

       Respondent stresses that Petitioner did not complain of her left shoulder pain when
she visited a vascular surgeon on October 17, 2017. Rule 4(c) Report at 6. However, the
purpose of this visit was treatment for leg pain and swelling, which she has suffered from
over the last eight years. Given the length of time she had experienced these symptoms
and the specific expertise of this treating physician, Petitioner’s failure to mention left
shoulder pain related to a recently administered flu vaccine is understandable – as is this
treater’s focus on her leg rather than arm.

       Respondent also emphasizes that Petitioner did not seek medical care for her left
shoulder pain until three and one-half months after vaccination. Rule 4(c) Report at 5-6.
However, it is often common for a SIRVA petitioner to delay treatment, thinking his/her
injury will resolve on its own. As Respondent himself notes, when Petitioner did seek
medical treatment, in January 2018, it appears that the initial level of her pain was not yet
severe (even if persistent since vaccination). Id. at 6. Her PCP prescribed only Tylenol to
control her pain. Ex. 3 at 4. It is not unreasonable for Petitioner to have waited this amount
of time before seeking treatment for her SIRVA.

       Accordingly, I find there is preponderant evidence to establish the onset of
Petitioner’s pain occurred within 48 hours of vaccination. Specifically, I find the
onset of Petitioner’s pain immediately upon vaccination.

       V.       Scheduling Order

      In light of this fact ruling, Respondent should review the record in this case again
and should indicate whether he is willing to engage in settlement discussions, desires to

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file an amended Rule 4(c) Report conceding entitlement, or wishes to continue to defend
this case. If the later, he should indicate the bases for his continued objection to
compensation in this case.

      Respondent shall file a status report providing his tentative position given
my fact ruling by no later than Thursday, September 10, 2020.

      Petitioner should finalize a demand and should forward her demand and
supporting documentation to Respondent as soon as possible. She also should file any
updated medical records or other evidence needed to establish her current condition.

      Petitioner shall file a status report updating me on the status of her demand
and supporting documentation by no later than Thursday, September 10, 2020.

      IT IS SO ORDERED.

                                 s/Brian H. Corcoran
                                 Brian H. Corcoran
                                 Chief Special Master

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