Court Opinion

ID: 4880825
Source: CourtListenerOpinion
Date Created: 2021-09-01 20:06:27.397387+00
Date Added: 2024-06-11T08:03:04.311685
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 19-1537V
                                          UNPUBLISHED

    ROBERT PRUDE,                                               Chief Special Master Corcoran

                         Petitioner,                            Filed: July 29, 2021
    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)

David John Carney, Green & Schafle LLC, Philadelphia, PA, for petitioner.

Dhairya Divyakant Jani, U.S. Department of Justice, Washington, DC, for respondent.

    FINDINGS OF FACT, CONCLUSIONS OF LAW AND RULING ON ENTITLEMENT 1

       On October 3, 2019, Robert Prude 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 he suffered a shoulder injury related to vaccine
administration (“SIRVA”) caused by an influenza (“flu”) vaccine administered on October
17, 2017. Petition at 1. The case was assigned to the Special Processing Unit of the
Office of Special Masters.

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   Because this unpublished fact ruling contains a reasoned explanation for the action in this case, I am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 that there is a preponderance of evidence
that the onset of Petitioner’s injury (specifically shoulder pain) occurred within 48 hours
of his vaccination, and his pain was limited to his left shoulder. I otherwise find that
Petitioner is entitled to compensation for a left SIRVA.

      I.      Relevant Procedural History

        Shortly after the claim’s initiation, Petitioner filed a statement of completion on
October 14, 2019. ECF No. 7. However, on January 27, 2020, Petitioner was ordered to
file additional evidence addressing the onset of his injury. ECF No. 12.

        On February 22, 2021, Respondent filed a status report stating that he believed
the record was substantially complete, but that he intended to defend this case. ECF No.
24. Respondent proposed filing a Rule 4(c) Report by May 10, 2021. Petitioner thereafter
filed a status report on February 25, 2021, noting that this case has been pending for over
one year and asking me to expedite its resolution.

         On March 3, 2021, I ordered Petitioner to file a motion for a ruling on the record
(ECF No. 26), which Petitioner filed on March 24, 2021. ECF No. 27, Petitioner’s Motion
for Ruling on the Record and Brief in Support of Damages (“Mot.”). Petitioner argues that
he has established, by a preponderance of evidence, that he suffered a Table Injury. Mot.
at 17. 3

       Respondent filed a response on April 22, 2021. ECF No. 30, Respondent’s
Response to Petitioner’s Motion for Ruling on the Record and Rule 4(c) Memorandum
(“Res.”). Respondent argues in part that Petitioner has failed to establish a Table claim
because he had a history of left shoulder pain, the records do not established onset within
48 hours of Petitioner’s vaccination, and his pain was not limited to his left shoulder. Res.
at 10-12. 4

       Petitioner filed an amended petition (ECF No. 31), 5 supplemental affidavit (ECF
No. 32), and a reply on May 5, 2021. ECF No. 33, Petitioner’s Reply Brief in Support of
Petitioner’s Motion for Ruling on the Record (“Reply”). Petitioner addressed Respondent’s
positions and requested that I make a ruling on the record in favor of entitlement. Reply
at 1. This issue is now ripe for resolution.

3
    Petitioner also included briefing on damages.
4
    Respondent also argues that Petitioner has not established causation-in-fact. Res. at 12-13.
5
 Petitioner noted in his Reply that the original Petition did not specifically allege a Table Injury. Reply at 2.
Petitioner’s amended petition cures this issue but alleging both a Table injury and causation-in-fact. Id.

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      II.      Petitioner’s Medical Records

      Petitioner received the flu vaccine on October 17, 2017, in his left shoulder. Ex. 1
at 2. At that time, Petitioner was fifty-five years old with type II diabetes myelitis,
        6

hypertension, and chronic obstructive pulmonary disease. Ex. 3 at 251, 711.

       Nearly two months later, Petitioner was seen in urgent care on December 13,
2017, complaining of coughing, fever, and congestion for six weeks. Ex. 3 at 274. 7
Thereafter, between December and March of 2018, Petitioner was in contact with his
medical providers at Kaiser Permanente for treatment of his diabetes and an upper
respiratory infection. See, e.g., Ex. 3 at 274 (seen for upper respiratory infection on
December 13, 2017), id. at 308 (Petitioner was contacted on February 9, 2018, for follow-
up regarding his diabetes), and id. at 325 (email correspondence on January 25, 2018,
with Petitioner on behalf of Dr. Tan regarding outreach related to diabetes test results).

       Petitioner subsequently saw Dr. Randall Tan on March 8, 2018, for a physical
exam. Ex. 3 at 349. He received two vaccinations during that visit: a tetanus-diphtheria-
acellular pertussis vaccine in his right shoulder, and a hepatitis B vaccine in his left
shoulder. Ex. 1 at 2. There are no documented complaints of left shoulder pain or a
physical examination of his shoulder, but he was assessed with left shoulder joint pain.
Ex. 3 at 349-362; 351.

       On May 9, 2018, Petitioner returned to Dr. Tan and reported left shoulder pain “for
a couple of months.” Ex. 3 at 421. This is the first medical record directly corroborating
Petitioner’s claim – but it was created nearly six months after the vaccination at issue,
and does not specify the vaccination date or onset of his pain. Petitioner’s shoulder
capsule was tender to palpitation. Id. at 422. He was diagnosed with “rotator cuff
syndrome” and received a steroid injection. Id.

       Two months later, on July 9, 2018, Petitioner again saw Dr. Tan. Ex. 3 at 434. He
reported an eight-month history of left shoulder pain (which would place onset in
November 2017), and an X-ray showed mild degenerative joint disease. Id. at 439.
Petitioner reported the cortisone injection received in May had helped when he again saw
Dr. Tan on July 31, 2018, but it had since worn off. Id. at 454.

6
  Petitioner’s medical record reflects that the flu shot was declined (Ex. 3 at 252), however this appears to
be in error. Ex. 3 at 833 (email from Petitioner to Dr. Tan requesting that Dr. Tan “correct” the medical
record noting that Petitioner declined the flu vaccine).
7
    It was also noted at that time that Petitioner’s diabetes was uncontrolled. Ex. 3 at 274.

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      During a follow-up visit on August 8, 2018, Petitioner complained of ongoing left
shoulder pain for eight months. Ex. 3 at 466. He thereafter began physical therapy that
same month, on August 13, 2018. Id. at 471. He reported mild symptoms of pain,
weakens, and stiffness that was present for nine months (placing onset again in
November), and advised the mechanism of injury was a flu vaccine. Id. at 471. Upon
examination, Petitioner exhibited reduced range of motion and weakness. Id. at 472. He
was diagnosed with “power deficits” and discharged after one visit with a home exercise
program. Id. at 472.

       Between August 24, 2018 and September 12, 2018, Petitioner was seen several
times for cardiac-related events. Ex. 3 at 482, 540, 698, 714, and 723. There is no
discussion of shoulder pain during these visits.

       On September 25, 2018, Petitioner again presented to physical therapy for left
shoulder pain. Id. at 750. Petitioner now reported “left shoulder pain since October 17,
2017 after receiving a flu vaccination” – the first record in which an association with the
prior vaccination was proposed. The physical therapist noted Petitioner showed
weakness, but a normal range of motion with signs of impingement. Id. at 750.

        Petitioner attended his third physical therapy appointment on November 26, 2018,
reporting slight improvement in his shoulder pain. At that time, his range of motion was
recorded as within normal limits, but he still experienced pain during flexion and
abduction. Ex. 3 at 892. Petitioner was discharged from physical therapy on December
13, 2018. Id. at 931-32. At that time, he reported only occasional pain that was
significantly reduced. Id. at 932.

       There is a subsequent gap in the records filed in this case of almost one year.
Petitioner was next seen at the San Jacinto Family & Urgent Care on October 30, 2019,
and again complained of shoulder pain that “has been there for more than 3 years and
recalls it started after immunization.” Ex. 4 at 4.

   III.   Affidavits

       Five affidavits were filed in support of this claim, including an affidavit from
Petitioner (Ex. 2); an affidavit from his sister, Deborah Prude (Ex. 5), a coworker, Regina
Winston (Ex. 6); his girlfriend, Beverly Kralik (Ex. 7), and a supplemental affidavit from
Petitioner. Ex. 8.

      In Petitioner’s affidavit, he asserts that he received a flu vaccine on October 17,
2017, on his way through the lobby to his annual diabetic retinopathy screening. Ex. 2 at

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2-3. Petitioner also stated that his shoulder was sore and painful the day he received his
flu vaccination, and the pain increased the next day. Petitioner acknowledges delaying
treatment for the pain, but explains this was due to the need to reschedule an appointment
with his physician, Dr. Tan, who was unavailable until March 2018. Ex. 2 at 5.

       Petitioner’s sister, Deborah Prude, also provided an affidavit. Ex. 5. Ms. Prude
stated that she recalled when Petitioner received his vaccine because he was planning
on mowing her lawn the following Saturday (October 21, 2017). Ex. 5 at 2. However, due
to shoulder pain, he was unable to do so. Ms. Prude also recalls numerous instances in
October 2017 that Petitioner was unable to participate in activities such as cleaning his
home in preparation for sale and landscaping due to his shoulder pain. Ex. 5 at 2-3.

       Petitioner’s coworker, Regina Winston, submitted an affidavit. Ms. Winston stated
that she and Petitioner worked together beginning in 2010, and would often take walks
together during their work breaks. Ex. 6 at 1. Starting in Mid-October of 2017 the walks
began to slow and were less frequent due to Petitioner’s shoulder pain. Ex. 6 at 2. Ms.
Winston also recalled a project that involved taking reference books on and off shelves in
October of 2017. Ms. Winston described how she saw Petitioner struggle to reach
shelves, take books down, and return them to shelves, due to shoulder pain. Ex. 6 at 3.

       Petitioner’s girlfriend, Ms. Beverly Kralik, submitted an affidavit as well. Ex. 7. Ms.
Kralik described how Petitioner was unable to participate in certain activities, including
cleaning his home in preparation for sale on October 21, 2017, due to shoulder pain. Ms.
Kralik also described how she observed that Petitioner’s shoulder pain interfered with his
sleep. Ex. 7 at 2.

       Finally, Petitioner submitted a supplemental affidavit explaining that the reference
to “severe and unrelenting pain from September 2016 to present” in his original affidavit
was in error. Ex. 8 at 1. According to him, the sentence should read “I endured severe
and unrelenting pain from October 2017 to the present.” Ex. 8 at 1 (emphasis added).

   IV.    Issue

       At issue is whether the onset of Petitioner’s symptoms (specifically pain) occurred
within 48 hours, and whether his pain was limited to his left shoulder 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(c)(10)(ii) (required onset for pain listed in the QAI); §
100.3(c)(10)(iii) (requiring pain and reduced range of motion be limited to the shoulder in
which the vaccine was administered).

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   V.     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 & Hum. 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 & Hum. Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, the
Federal Circuit has recently “reject[ed] as incorrect the presumption that medical records
are always accurate and complete as to all of the patient’s physical conditions.” Kirby v.
Sec'y of Health & Hum. Servs., 997 F.3d 1378, 1383 (Fed. Cir. 2021). Medical
professionals may not “accurately record everything” that they observe or may “record
only a fraction of all that occurs.” Id. In Kirby, the Federal Circuit emphasized that the
medical records in question were “silent” about the existence or nonexistence of
symptoms that would render the petitioner's injury sufficiently severe to receive
compensation under the Vaccine Act. Id. (citing Shapiro v. Sec'y of Health & Hum. Servs.,
101 Fed. Cl. 532, 538 (2011) (itself citing Murphy v. Sec'y of Health & Hum. Servs., 23
Cl. Ct. 726, 733 (1991) (holding that “the absence of a reference to a condition or
circumstance is much less significant than a reference which negates the existence of the
condition or circumstance”).

        The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Hum. 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 & Hum. Servs., 110 Fed. Cl. 184, 203-04 (2013), aff’d, 746 F.3d 1335 (Fed. Cir.
2014).

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       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 & Hum. 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 & Hum. Servs., 569
F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Hum. 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 & Hum. 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).

   VI.     Finding of Fact

         Respondent argues in his Rule 4(c) Report that Petitioner has failed to show he
suffered a Table claim, because onset of his pain was not within 48 hours of his
vaccination, that his pain was not limited to his left shoulder, and that he had a prior history
of left shoulder pain. Res. at 10-12.

           a. Onset of Petitioner’s Injury was within Forty-eight Hours of his Flu
              Vaccination

       The following finding of fact is based on a complete review of the record, including
all medical records, affidavits, and additional evidence filed. Specifically, I highlight the
following:

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          •   Petitioner received a flu vaccination in his left shoulder on October 17, 2017.
              Ex. 1 at 2.

          •   On March 8, 2018, Petitioner was assessed with left shoulder joint pain,
              although the record in question gives no details about the temporal period
              in which the pain began, and/or how long Petitioner suffered with it. Ex. 3 at
              349-362.

          •   On May 9, 2018, Petitioner reported continued left shoulder pain, and was
              diagnosed with rotator cuff syndrome. Ex. 3 at 422.

          •   On August 13, 2018, Petitioner began physical therapy and reported
              shoulder pain, stiffness, reduced range of motion, and weakness. Ex. 3 at
              471. Petitioner also reported now (for the first time) that he believed the
              cause of injury was a flu vaccine. Id.

          •   A record from September 25, 2018 states reported Petitioner had “left
              shoulder pain since October 17, 2017 after receiving a flu vaccination.” Ex.
              3 at 750.

          •   On October 30, 2019, Petitioner complained of shoulder pain that started
              after an immunization. Ex. 4 at 4.

       Additionally, the affidavits submitted by Petitioner provide further corroborating
evidence including specific events close-in-time to Petitioner’s vaccination. The affidavit
of Ms. Prude, for example, describes numerous instances in October 2017 that Petitioner
was unable to participate in activities due to shoulder pain. Ex. 5 at 2-3. She also provided
specific instances, such as when Petitioner was unable to assist her with lawn care due
to shoulder pain on October 21, 2017, just three days after his vaccine. Ms. Winston’s
affidavit is also helpful in this case, as it describes Petitioner’s struggles to move books
during a work project in October of 2017. Ex. 6 at 3.

       Based on the above medical entries and corroborating affidavits, the
preponderance of the evidence supports – if barely - a finding that onset of Petitioner’s
injury was within 48 hours of his October 17, 2017 flu vaccine.

       The record alone offers fairly weak support for Petitioner’s onset assertions.
Petitioner never complained of shoulder pain for nearly six months, despite a number of
intervening medical treatment visits – and even when he first was assessed with such
pain (at his visit with Dr. Tan in March 2018) he did not report pain since vaccination. He

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also provided varying onsets, some of which could have occurred outside of the 48-hour
period for the Table claim. For example, on May 9, 2018 Petitioner reported to Dr. Tan
that he had been experiencing shoulder pain “for a couple of months”, which would have
put onset of his injury in late January or early February. Ex. 3 at 421. Later, he reported
what would be a November onset ( on July 9, 2018 (Ex. 3 at 434), August 8, 2018 (Ex. 3
at 466), and August 13, 2018 (Ex. 3 at 471)), and did not specify vaccination onset until
the start of his physical therapy. Id. at 750.

       However, the record must be viewed in the entirety - and in conjunction with the
affidavit evidence, which the Federal Circuit instructs deserves evidentiary weight. Kirby,
997 F.3d at 1382. Here, unrebutted affidavit evidence establishes Petitioner did likely
experience pain in close proximity to vaccination. And it is also understood in the Program
that individuals who have experienced a SIRVA injury often misconstrue its character,
and may delay treatment – either in the false hope that the pain will prove transitory, or in
order to see a particular kind of treater. See, e.g., Tenneson v. Sec'y of Health & Hum.
Servs., No. 16-1664V, 2018 WL 3083140, at *5 (Fed. Cl. Spec. Mstr. Mar. 30, 2018),
review denied, 142 Fed. Cl. 329 (2019), (finding a 48-hour onset of shoulder pain despite
a nearly six-month delay in seeking treatment); Williams v. Sec'y of Health & Hum. Servs.,
17-830V, 2019 WL 1040410, at *9 (Fed. Cl. Spec. Mstr. Jan. 31, 2019) (noting a delay in
seeking treatment for five-and-a-half months because petitioner underestimated the
severity of her shoulder injury); Knauss v. Sec'y of Health & Hum. Servs., 16-1372V, 2018
WL 3432906 (Fed. Cl. Spec. Mstr. May 23, 2018) (noting a three-month delay in seeking
treatment). It is unreasonable to expect claimants to tell one kind of specialist about a
possible shoulder injury when the specialist does not have expertise in that medical field.

       Again, the facts of this case present a very close call – and while Program law
does counsel to decide such matters in favor of the petitioner, the facts of a case like this
do not support more than a very modest damages award. Petitioner should especially be
mindful that his barely-preponderant showing on onset means he cannot expect (and
should not request) a high-dollar-figure pain and suffering award – since a claimant who
was able to tolerate SIRVA pain for so long without treatment is not a person who
experienced a severe injury. Regardless, the evidence presented herein supports a
finding that Petitioner’s pain “more likely than not” began within 48 hours of his vaccine.

          b. Pain was limited to Petitioner’s Left Shoulder

       I also find that there is a preponderance of evidence that Petitioner’s pain was
limited to his left shoulder. The following finding of fact is based on a complete review of
the record, including all medical records, affidavits, and additional evidence filed.
Specifically, I highlight the following:

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          •   Petitioner was assessed with left shoulder joint pain on March 8, 2018. Ex.
              3 at 349.

          •   On May 9, 2018, Petitioner reported left shoulder pain, exhibited a tender
              shoulder capsule, and was diagnosed with rotator cuff syndrome. Ex. 3 at
              421-22.

          •   On July 9, 2018, Petitioner was seen again for left shoulder pain and had
              an x-ray of that shoulder. Ex. 3 at 439.

          •   On September 25, 2018, Petitioner presented to physical therapy for left
              shoulder pain. Ex. 3 at 750. At that time, Petitioner showed signs of
              impingement and weakness. Id.

       Based on the above medical entries, the preponderance of the evidence supports
a finding that Petitioner’s injury was more likely than not limited to his left shoulder.
Petitioner’s records consistently report shoulder pain and loss of range of motion, which
are specific and consistent with other SIRVA cases.

        I acknowledge that there are references to pain radiating down Petitioner’s left arm
and weakness in his hand. Ex. 2 at 6 (reporting pain through Petitioner’s neckline).
However, the majority of other records support a finding that Petitioner’s pain was limited
to his left shoulder.

        Accordingly, preponderant evidence establishes that Petitioner’s pain was limited
to his left shoulder.

   VII.   Conclusion

       In view of the evidence of record, I find that there is preponderant evidence
that the onset of Petitioner’s injury, specifically shoulder pain, was within 48 hours
of his vaccine and his pain was limited to his left shoulder. Further, based on the
evidence of record, I find that Petitioner is entitled to compensation.

IT IS SO ORDERED.

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

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