Court Opinion

ID: 5648530
Source: CourtListenerOpinion
Date Created: 2022-01-11 14:01:07.964897+00
Date Added: 2024-06-11T08:38:27.453598
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 20-0114V
                                          UNPUBLISHED

    TERESA WASHIINGTON-JENKINS,                                 Chief Special Master Corcoran

                         Petitioner,                            Filed: December 7, 2021
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Findings of Fact; Statutory Six Month
    HUMAN SERVICES,                                             Requirement Influenza (Flu)
                                                                Vaccine; Shoulder Injury Related to
                         Respondent.                            Vaccine Administration (SIRVA)

Jeffrey S. Pop, Jeffrey S. Pop & Associates, Beverly Hills, CA, for Petitioner.

Naseem Kourosh, U.S. Department of Justice, Washington, DC, for Respondent.

                                           FINDINGS OF FACT1

        On January 31, 2020, Teresa Washington-Jenkins 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 alleged that she suffered a left shoulder injury related to
vaccine administration (“SIRVA”), a defined Table Injury, after receiving the influenza
(“flu”) vaccine on September 18, 2017. Petition at 1, ¶ 5. In the alternative, Petitioner
alleged that her left shoulder injury was caused-in-fact by the flu vaccine she received.
Id. at 1. The case was assigned to the Special Processing Unit of the Office of Special
Masters (the “SPU”).

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  Because this unpublished Fact Ruling contains a reasoned explanation for the action in this case, I am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).
       For the reasons discussed below, I find Petitioner suffered the residual effects of
her alleged SIRVA for more than six months.

   I.        Relevant Procedural History

        Within a month of initiating the case, Petitioner filed the medical records required
under the Vaccine Act. Exhibits 1-8, filed Feb. 13, 2020, ECF No. 6; see Section 11(c).
On April 26, 2021, Respondent indicated that he intended to oppose compensation in this
case. ECF No. 18. Two months later, he filed his Rule 4(c) Report setting out his
objections to compensation. ECF No. 20. In it, he specifically maintained the six-month
severity requirement could not be met. Rule 4(c) Report at 6, filed June 28, 2021. Citing
a five-month gap in treatment - from late December 2017 until mid-June 2018 - and
arguing that the left shoulder pain Petitioner experienced in June 2018 was due to a new
injury, Respondent maintained that “the evidence in this case establishes that
[P]etitioner’s alleged injury lasted for less than four months.” Id. at 6-7.

        Petitioner maintains she can establish severity. Petitioner’s Brief Regarding the
Vaccine Ac’s Severity Requirement (“Pet. Brief”), filed Sept. 14, 2021, at 20, ECF No. 22.
Specifically, she stresses that she continued to attribute the onset of her left shoulder pain
to the flu vaccine she received during appointments more than six months post-
vaccination. She also maintains the medical record does not establish that she recovered
from her SIRVA, only to reinjure her shoulder in a different manner. Id. Along with her
brief, Petitioner filed a supplemental affidavit, affidavits from her son, two daughters, and
friend, and a copy of an October 9, 2017 text message she sent to one of her daughters
regarding her left shoulder pain. Exhibits 10-15, filed Sept. 14, 2021, ECF No. 21.

          The matter is now ripe for adjudication.

   II.       Issue

     At issue is whether Petitioner continued to suffer the residual effects of the alleged
SIRVA for more than six months. Section 11(c)(1)(D)(i) (statutory six-month requirement).

   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 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

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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).

       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).

       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

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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 Section 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 this fact finding after a complete review of the record, including all medical
records, affidavits, testimony, expert reports, Respondent’s Rule 4 Report, and additional
evidence filed. Specifically, I determine the following:

          •   On September 18, 2017, Petitioner was seen by her primary care provider
              (“PCP”) for lower back and left leg pain, specifically she reported
              experiencing pain in the back of her left thigh which travel down her calf into
              her foot. Exhibit 3 at 100, 104. Petitioner received the influenza vaccine
              alleged as causal in her left deltoid during this visit. Id. at 100; see also
              Exhibit 2.

          •   To treat her lower back and leg pain, Petitioner attended five physical
              therapy (“PT”) sessions during late September through early November
              2017. Exhibit 4 at 60-101. At her second PT session on October 11, 2017,
              Petitioner reported “left shoulder pain since getting the flu shot a couple of
              weeks ago.” Id. at 63. She added that she was going to the doctor for this
              pain. Id.

          •   In the records from initial PT sessions on September 28 and October 11,
              2017, it was noted that Petitioner’s blood pressure was measured at her left
              wrist, presumably to avoid exacerbating her left shoulder pain. Exhibit 4 at
              63, 67, 70, 74. This notation was not included in the records from PT
              sessions beginning on October 19 and 24, 2017. Id. at 80, 82, 87.

          •   The same day she mentioned her left shoulder pain to her physical
              therapist, Petitioner was seen by a physician’s assistant at her PCP clinic.
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    Exhibit 3 at 108-15. She reported left arm pain after receiving the flu vaccine
    in September 2017, which caused her difficulty when lifting her arm. Id. at
    112. The physician assistant opined Petitioner’s pain was related to her
    cervical radiculopathy and instructed Petitioner to apply heat, stretch, and
    ensure her posture was correct. Petitioner declined pain medication,
    steroids, and muscle relaxers. Id. at 114.

•   When seen for a check of her diabetes on December 28, 2017, Petitioner
    again complained of left shoulder pain since receiving the flu vaccine in
    September 2017, noting that it hurt to move her arm. Exhibit 3 at 116, 121.
    Observing non-specific discomfort upon palpitation, mildly decreased range
    of motion (“ROM”), and normal strength, Petitioner’s PCP prescribed home
    exercises for her left shoulder pain. Id. at 122-23.

•   In early 2018, Petitioner sought medical treatment on February 15, 2018,
    from an urgent care clinic for pink eye and on March 29, 2018, from her
    PCP for a rash on her hands. Exhibit 6 at 28; Exhibit 3 at 126 (respectively).
    There is no mention of left shoulder pain in the records from these two visits.
    Exhibit 6 at 24-31; Exhibit 3 at 126-34.

•   In her affidavit, Petitioner admitted that she did not mention her left shoulder
    pain during the February 2018 appointment at the urgent care clinic, but
    maintains that she reported continued left shoulder pain when seen by her
    PCP in late March 2018. Exhibit 10 at ¶¶ 6-7. She posited that this was not
    included in the medical record from that visit because her PCP did not
    address the complaint, adding that she felt her complaint was not being
    taken seriously. Id. at ¶ 7.

•   On June 18, 2018, more than nine months post-vaccination, Petitioner
    visited her PCP for a diabetes check and left shoulder pain and decreased
    ROM - present since receiving the flu shot but recently worsening after
    pulling a suitcase while traveling. Exhibit 3 at 135. Although she previously
    refused PT - opting instead for a home exercise program which she
    indicated had helped, Petitioner stated that she now was willing to attend
    PT. Id. at 135, 140. Petitioner reported that she started taking Fosamax
    along with a calcium supplement, and had increased her vitamin D
    supplement after experiencing left arm pain since her flu shot. She added
    that she had been “lifting a lot” prior to the appointment. Id. at 141. Her PCP
    diagnosed Petitioner with rotator cuff strain which had been unresponsive
    to home exercises and prescribed PT. Id. at 143.

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          •   Petitioner insists that her “left shoulder pain never went away [and that she]
              never reinjured [her] shoulder.” Exhibit 10 at ¶ 12. Petitioner’s children
              echoed this assertion in their affidavits. Exhibit 11 at ¶ 12; Exhibit 13 at ¶
              12; Exhibit 14 at ¶ 9.

          •   From late August through mid-October 2018, Petitioner attended twelve PT
              sessions. Exhibit 4 at 105-75. At her initial evaluation, she reported constant
              upper left arm pain since her flu vaccine with intermittent flare-ups. She
              estimated the level of her pain as three out of ten. Id. at 106. The physical
              therapist observed pain with palpitation over the left deltoid, weakness, and
              decreased ROM. Id. at 106-07. Her DASH score was noted to be 48. Id, at
              107. At her last PT session on October 15, 2018, Petitioner was noted to be
              progressing well - exhibiting improved ROM and increased strength. Noted
              as meeting all PT goals, Petitioner was discharge with instructions to
              continue her HEP. Id. at 173.

          •   The medical records show Petitioner sought medical treatment from her
              PCP on two occasions during January and February 2019. They do not
              contain any complaints of left shoulder pain. Exhibit 7 at 9-16; Exhibit 5 at
              50-61 (respectively).

       The above medical entries show that Petitioner experienced relatively mild left
shoulder pain and limitations in ROM after receiving the flu vaccine on September 18,
2017. Although she experienced intermittent flare-ups and appears to have aggravated
her injury during travel and exercise in early 2018, the evidence supports Petitioner’s
assertion that she experienced this low level of pain since vaccination.

       Throughout the medical records, Petitioner consistently attributed her left shoulder
pain to the flu vaccine she received. And when she reported pain after pulling a suitcase
and lifting at the gym, she clearly characterized the effects of these activities as a
worsening of already-existing pain.

        Petitioner’s failure to report her left shoulder pain when seen for pink eye at an
urgent care clinic in February 2018 is understandable, given that the appointment was for
an acute condition and did not occur with her normal provider. The lack of any mention of
left shoulder pain in the record from her March 2018 visit to her PCP is a more significant
omission, but not sufficient to counter the numerous other entries supporting Petitioner’s
claims of ongoing, albeit mild, pain.

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       Accordingly, I find there is preponderant evidence to establish Petitioner suffered
the residual effects of her injury for more than six months.

   V.     Scheduling Order

       Given the mild nature of Petitioner’s injury, which appears to have resolved by mid-
October 2018, and the impact of the non-vaccine related activities which may have
exacerbated her condition, I do not expect a high level of compensation in this case.
Petitioner previously submitted a demand, which included an amount to satisfy the
Medicaid lien in this case, on January 20, 2021. The parties should discuss the amount
Petitioner seeks and determine their preferred next step(s) in this case.

      The parties shall file a status report updating me their efforts to informally
resolve this SPU case and informing me of their preferred next step(s) by no later
than Friday, January 07, 2022.

IT IS SO ORDERED.

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

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