Court Opinion

ID: 4588430
Source: CourtListenerOpinion
Date Created: 2020-11-20 17:03:19.763215+00
Date Added: 2024-06-11T07:50:04.346879
License: Public Domain

In the United States Court of Federal Claims
                              OFFICE OF SPECIAL MASTERS
                                   Filed: October 26, 2020

*************************
DIANE R. HECHT,             *
                            *                        UNPUBLISHED
                Petitioner, *
                            *                        No. 19-387V
v.                          *
                            *                        Special Master Nora Beth Dorsey
SECRETARY OF HEALTH         *
AND HUMAN SERVICES,         *                        Finding of Fact; Onset; Influenza (“Flu”)
                            *                        Vaccine; Shoulder Injury Related to
                Respondent. *                        Vaccine Administration (“SIRVA”).
                            *
*************************

Matthew F. Belanger, Faraci Lange, LLP, Rochester, NY, for petitioner.
Camille M. Collett, U.S. Department of Justice, Washington, DC, for respondent.

                                     RULING ON FACTS1

        On March 13, 2019, Diane R. Hecht (“petitioner”) filed a petition for compensation under
the National Vaccine Injury Compensation Program (“Vaccine Act” or “the Program”), 42
U.S.C. § 300aa-10 et seq. (2012).2 Petitioner alleged that she suffered a left shoulder injury as
the result of an influenza (“flu”) vaccination she received on September 26, 2016. Petition at 1
(ECF No. 1).

1
  Because this Ruling contains a reasoned explanation for the action in this case, the undersigned
is 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 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, the undersigned agrees that the
identified material fits within this definition, the undersigned will redact such material from
public access.
2
 The National Vaccine Injury Compensation Program is set forth in Part 2 of the National
Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755, codified as amended,
42 U.S.C. §§ 300aa-10 to -34 (2012). All citations in this Ruling to individual sections of the
Vaccine Act are to 42 U.S.C. § 300aa.

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        Prompting this fact ruling is Respondent’s Rule 4(c) Report, filed May 7, 2020, in which
respondent asserted that the petitioner had not “submitted independent objective evidence”
establishing that onset of petitioner’s pain “was within 48 hours of vaccination.” Respondent’s
Report (“Resp. Rept.”) at 4 (ECF No. 29). Thereafter, a status conference was held during which
the parties agreed to a fact hearing to determine the onset of petitioner’s shoulder injury. Order
dated May 19, 2020 (ECF No. 30). A fact hearing was held on October 6, 2020.

        After a review of the record as a whole, testimony given at the fact hearing, and for the
reasons set forth below, the undersigned finds by preponderant evidence that the onset of
petitioner’s shoulder injury occurred within 48 hours of her flu vaccination.

I.     PROCEDURAL HISTORY

        On March 13, 2019, petitioner filed a petition for compensation alleging a left shoulder
injury related to vaccination (“SIRVA”) as the result of her September 26, 2016 flu vaccination.
Petition at 1. Petitioner filed medical records shortly thereafter. Petitioner’s Exhibits (“Pet.
Exs.”) 1-10. This case was reassigned to the undersigned on October 7, 2019. Notice of
Reassignment dated Oct. 7, 2019 (ECF No. 14). Petitioner subsequently filed additional medical
records on October 18, 2019. Pet. Exs. 11-12.

        On May 7, 2020, respondent filed his Rule 4(c) Report arguing petitioner was not entitled
to compensation because she had not “submitted independent objective evidence” establishing
that onset of petitioner’s pain “was within 48 hours of vaccination.” Resp. Rept. at 4. After a
status conference on May 19, 2020 and party conversations about appropriate hearing dates, the
parties scheduled a fact hearing for October 6, 2020. See Order dated May 19, 2020 (ECF No.
30); Joint Status Rept., filed Sept. 4, 2020 (ECF No. 43). Prior to the hearing, petitioner filed
affidavits. Pet. Exs. 13-14.

II.    ABREVIATED MEDICAL HISTORY

       Petitioner is currently 55 years old and is employed as nurse practitioner at a skilled
nursing facility in Rochester, New York. Pet. Ex. 5 at 1; Pet. Ex. 13 at ¶ 2. Prior to her flu
vaccination on September 26, 2016, she had no prior medical history of left shoulder injury or
problem. Pet. Ex. 1 at ¶ 4; Transcript (“Tr.”) 30. She received her flu vaccine on September 26,
2016, in her left shoulder. Pet. Ex. 2 at 1.

        The medical records first document that petitioner experienced symptoms in her left
shoulder on March 9, 2017, when she saw Dr. Michael Bibighaus with complaints of left
shoulder pain. Pet. Ex. 3 at 1. Dr. Bibighaus’ differential diagnosis included possible rotator
cuff injury, bursitis, or muscle strain. Id.

        On August 24, 2017, petitioner saw orthopedist, Dr. Michael Yip, with complaints of left
shoulder pain and decreased range of motion (“ROM”) which she related the onset of her
shoulder pain back to her prior flu shot. Pet. Ex. 4 at 16-17; Pet. Ex. 5 at 5. At this visit
petitioner also stated her shoulder pain began approximately ten to eleven months earlier. Pet.
Ex. 4 at 17; Tr. 52. Petitioner indicated her pain was 8/10 at its worst. Pet. Ex. 4 at 17. The pain

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was aggravated by reaching, overhead lifting, and behind the back movements and she had
difficulty with activities of daily living such as dressing. Id. Exam showed negative Neer and
Hawkins impingement signs. Id. X-rays were unremarkable. Id. at 16. The impression was
adhesive capsulitis of left shoulder. Id. Dr. Yip recommended conservative treatment of oral
anti-inflammatories, activity modification, and physical therapy (“PT”). Id. Dr. Yip suggested a
follow up appointment in three months with consideration of a joint injection if petitioner was
not better. Id.; Pet. Ex. 5 at 3-7.

        On September 7, 2017, petitioner began PT with Judith Morale, PT, DPT, for adhesive
capsulitis. Pet. Ex. 7 at 1; Tr. 44. Petitioner described an insidious onset of pain approximately
one year prior. Pet. Ex. 7 at 1. She reported her pain was constant at a level of 3/10 to 8/10 and
was aggravated by driving, donning/doffing her bra, and shaving her left axilla. Id. at 1-2.
Petitioner indicated the pain disturbed her sleep three to four times per night. Id. at 1. An exam
showed limited ROM and weakness in several movements. Id. at 1-2. Petitioner attended PT
twenty-nine times with her last visit taking place on June 18, 2018. See Pet. Ex. 7; see also Pet.
Ex. 8. At that time of her last visit, petitioner was noted to be functioning well with minimal
symptoms and she had met her goals. Pet. Ex. 8 at 235.

        Petitioner returned for her follow-up appointment with Dr. Yip on September 15, 2017.
Pet. Ex. 5 at 1-2. Petitioner complained of pain at night despite attending PT as well as home
stretching and requested a steroid injection. Id. at 1. On exam, Dr. Yip’s impression of left
shoulder adhesive capsulitis remained unchanged. Id. at 2. Dr. Yip administered a glenohumeral
joint injection and petitioner reported immediate pain relief. Id.

        On October 9, 2017, petitioner saw Dr. Valerie Newman, her primary health provider, for
a preventative health visit. Pet. Ex. 4 at 5. Dr. Newman noted petitioner’s diagnosis of adhesive
capsulitis of the left shoulder. Id. A flu vaccine was administered at this visit. Id. at 10.

III.   TESTIMONY

        Ms. Pamela Rhoden testified during the hearing on October 6, 2020. Ms. Rhoden is the
employee Health and Wellness Coordinator at St. John’s nursing home where she and petitioner
currently work in their respective capacities. Tr. 6. Ms. Rhoden stated that after about a week
after her September 26, 2016 flu shot, petitioner came to her office to complain of arm pain. Tr.
9. Ms. Rhoden said she next saw petitioner in April 2017 for an annual health assessment and
noted petitioner continued to have arm pain and was going to PT. Tr. 11-12.

        Mr. Robert Hecht, petitioner’s husband, also testified at the hearing. Mr. Hecht recalled
the evening after petitioner’s vaccination, petitioner questioned the site of injection. Tr. 22. Mr.
Hecht reported petitioner said the pharmacist hit the shoulder high up in the joint versus into the
deltoid muscle which gave her immediate pain. Id. He stated petitioner complained of pain for
months after the vaccination. Tr. 23.

        Petitioner testified she felt immediate pain after the injection was given. Tr. 34. She
stated she visited Ms. Rhoden a few days after the vaccination to report her pain and then
contacted a telemedicine health care provider in March due to worsening shoulder symptoms.

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Tr. 36. When asked why she waited so long to get treatment she responded, “[b]eing a nurse
practitioner, I knew what a healthcare professional would say about treating.” Tr. 36-37.
Instead, petitioner self-treated with heat, ice, ibuprofen, Tylenol. Tr. 37. Petitioner stated that
when she did call a provider about worsening pain, he said to continue what she was doing. Tr.
38.

IV.    PARTIES’ CONTENTIONS

        In her affidavit, petitioner alleged she received her annual flu shot from a Wegmans’
pharmacist on September 26, 2016. Pet. Ex. 13 at ¶ 4. As he placed the needle in her left
shoulder, she saw it was just under her AC joint rather than in her deltoid muscle. Id. She
averred she “felt an immediate deep pain in [her] left shoulder that was more severe that the
post-injection pain [she] had had in the past.” Id. at ¶ 5. Over the next 48 hours petitioner had a
constant ache in her shoulder and after a few weeks the pain ranged from 4-5/10. Id. at ¶ 7-8.
Petitioner told her Health and Wellness Coordinator, Pamela Rhoden, about her pain when she
was reaching over her head and behind her back. Id. at ¶ 8. Petitioner stated that because she is
“a trained nurse practitioner, [she] chose not to seek outside medical care at that time, but rather
to take the conservative measures [she] would have advised a patient . . . with similar
symptoms.” Id. at ¶ 9. After a few months of conservative measures that did not alleviate her
left shoulder pain or loss of motion, she used her employer’s telemedicine program on March 9,
2017 to contact a doctor. Id. at ¶ 11. She then decided to see an orthopedist specializing in
shoulder pain on August 24, 2017. Id. at ¶ 12.

       In his Rule 4(c) Report, respondent argued that petitioner was not entitled to
compensation. Resp. Rept. at 1. Respondent argued that petitioner “ha[d] not submitted
independent objective evidence that specifically establishes that the onset of her pain occurred
within 48 hours of vaccination” as required for SIRVA injuries. Id. at 4; see 42 C.F.R. §
100.3(c)(10). Respondent contended that while petitioner’s affidavit asserts that she felt pain
immediately after injection, her claims are not corroborated by contemporaneous medical
records, nor did she seek treatment for her shoulder pain for almost six months. Id. at 4.

V.     DISCUSSION

           a. Applicable Legal Standard

        A petitioner must prove, by a preponderance of the evidence, the factual circumstances
surrounding her claim. 13(a)(1)(A). To resolve factual issues, the special master must weigh the
evidence presented, which may include contemporaneous medical records and testimony. See
Burns v. Sec’y of Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (explaining that a
special master must decide what weight to give evidence including oral testimony and
contemporaneous medical records). Contemporaneous medical records are presumed to be
accurate. See Cucuras v. Sec’y of Health & Hum. Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).
To overcome the presumptive accuracy of medical records testimony, a petitioner may present
testimony which is “consistent, clear, cogent, and compelling.” Sanchez v. Sec’y of Health &
Hum. Servs., No. 11-0685V, 2013 WL 1880825, at *3 (Fed. Cl. Spec. Mstr. Apr. 10, 2013)

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(citing Blustein v. Sec’y of Health & Hum. Servs., No. 90-2808V, 1998 WL 408611, at *5 (Fed.
Cl. Spec. Mstr. June 30, 1998)).

           b. Evaluation of the Evidence

        At the conclusion of the proceeding, the undersigned informed the parties that she
intended to issue a ruling from the bench. See Tr. 56-57. Both parties agreed to this proposed
action. Id. After a short recess, the undersigned returned and read her ruling into the record. Tr.
at 57-60.

        The undersigned stated that the issue to be resolved was a determination of onset of
petitioner’s symptoms of left shoulder pain. Tr. 57. With regard to the onset of symptoms, the
undersigned found that petitioner experienced pain “at the time of her vaccination and that she
continued to have pain for the next 48 hours and then continued to have pain consistent with her
testimony today.” Id. The reasons for the ruling are set forth in the transcript from the hearing at
pages 57 to 60, and incorporated herein by reference as if fully set forth.

VI.    CONCLUSION

      The undersigned finds, based on the record as a whole, that the onset of petitioner’s
symptoms occurred within 48 hours of petitioner’s flu shot on September 26, 2016.

       The following is ORDERED:

        Respondent shall file an Amended Rule 4(c) report, reflecting the Fact Ruling, in forty-
five (45) days, or by Thursday, December 10, 2020.

       IT IS SO ORDERED.

                                              s/Nora Beth Dorsey
                                                Nora Beth Dorsey
                                                Special Master

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