Court Opinion

ID: 4701565
Source: CourtListenerOpinion
Date Created: 2021-07-06 20:04:00.724798+00
Date Added: 2024-06-11T08:06:18.730412
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 19-0039V
                                          UNPUBLISHED

    SAUM ESHRAGHI,                                              Chief Special Master Corcoran

                         Petitioner,                            Filed: June 4, 2021
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Findings of Fact; Onset; Tetanus
    HUMAN SERVICES,                                             Diphtheria acellular Pertussis (Tdap)
                                                                Vaccine; Shoulder Injury Related to
                         Respondent.                            Vaccine Administration (SIRVA)

Leigh Finfer, Muller Brazil, LLP, Dresher, PA, for petitioner.

Traci R. Patton, U.S. Department of Justice, Washington, DC, for respondent.

                                           FINDINGS OF FACT 1

      On January 7, 2019, Saum Eshraghi 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 a Table claim for a shoulder injury related to vaccination
(“SIRVA”), or in the alternative a cause-in-fact claim of SIRVA caused by a Tdap vaccine
he received on November 1, 2016. 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   Because this unpublished fact ruling contains a reasoned explanation for the action in this case, I am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 Petitioner’s SIRVA Table claim must be
dismissed, because onset within the 48 hours following the administration of vaccination
(as required to establish a Table injury) cannot be established.

   I.     Relevant Procedural History

       After the case’s initiation, Respondent filed a status report identifying missing
and/or incomplete records and requesting insurance benefits statements from Petitioner’s
insurance providers, which Petitioner filed over the next several months. ECF 18.

        Respondent subsequently filed a status report indicating that he would be
“contesting this claim” and proposing a deadline for his Rule 4(c) report, which he filed on
June 29, 2020. ECF 32 and ECF 33. In it, Respondent asserted that there is not a
preponderance of evidence demonstrating the requisite facts necessary to establish a
Table SIRVA injury. In particular, Respondent claimed that “the most contemporaneous
documentation does not establish that the onset of [P]etitioner’s pain occurred within
forty-eight hours of the vaccination.” ECF 33 at 7. Respondent further argued that
Petitioner could not prove actual causation either, as he had failed to submit an expert
report or other preponderant evidence in support of causation sufficient to satisfy his
burden of proof. Id. at 8 (citing Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274,
1278 (Fed. Cir. 2005)).

       After holding a status conference with the parties to discuss Respondent’s
objections to entitlement, I ordered to Petitioner to file a brief to show cause as to why his
Table SIRVA claim should not be dismissed. Petitioner filed his brief on January 14, 2021.
ECF 35. Respondent filed his response on January 28, 2021. ECF 36. Therefore, this
matter is ripe for adjudication.

   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(c)(10)(ii).

   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 Vaccine Act
Section 11(c)(1). A special master must consider, but is not bound by, any diagnosis,

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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 & 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).

        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).

       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.

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       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.    Findings of Fact

        I make the following findings after a complete review of the record, including all
medical records, affidavits, the arguments in Respondent’s Rule 4 report and Petitioner’s
brief, and any additional evidence filed.

          •   Petitioner received a Tdap vaccination in his right arm on November 1,
              2016, following a head injury. Ex 1 at 8.

          •   In his affidavit, Petitioner averred that “[w]ithin two to three hours following
              vaccination, I felt pain in my right shoulder.” Ex 7 at 1. Petitioner reiterated
              this assertion in a supplemental affidavit. Ex 8 at 1.

          •   In a supplemental affidavit, Petitioner asserts that throughout the day
              following vaccination his “right shoulder felt sore and tender” and he was
              “unable to lift [his] arm up past a certain point without feeling pain.” Ex 8 at
              1.

          •   On December 21, 2016 (51 days after vaccination), Petitioner presented to
              his primary care physician (PCP) with a complaint of “back spasm.” Ex 3 at
              5-6. Petitioner did not report right-sided shoulder pain at this visit. Id.

          •   On February 1, 2017 (three months after vaccination), Petitioner left a
              phone message for his PCP, stating he “wants to discuss weakness in right
              arm; he ha[d] a tetnus [sic] shot several months ago in the same area.” Ex
              11 at 3. Petitioner left another message on April 3, 2017, stating “his
              shoulder continues to be uncomfortable; he spoke to you a month ago
              regarding shoulder pain from tetnaus [sic] shot.” Ex 11 at 5. He did not visit
              his PCP after either of these calls.

          •   On April 21, 2017, Petitioner visited urgent care with a complaint of
              “constant muscle pain in his neck and back” for two weeks and pain in his

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                right shoulder “since tetanus shot was given in November.” Ex 2 at 5. The
                Petitioner’s right shoulder was examined for the first time since his tetanus
                vaccination. The physical examination revealed tenderness in the
                subacromial bursa and decreased abduction. Id. X-rays showed no
                abnormalities and Petitioner was diagnosed with “unspecified sprain” of the
                right shoulder joint. Id.

            •   On May 1, 2017, Petitioner visited his PCP and complained of intermittent
                right shoulder pain for “many months.” Ex 3 at 3-4. Physical examination
                revealed findings within normal limits and Petitioner was diagnosed with
                “shoulder pain.” Id.

            •   On June 23, 2017, Petitioner presented for an initial visit with Dr. Russell
                Petrie, an orthopedist. Ex 3 at 20. Petitioner reported right shoulder
                discomfort beginning in “November 2016” and weakness starting “about a
                week” after vaccination, and physical examination showed weakness in the
                infraspinatus and supraspinatus tendons. Id. at 20-23.

            •   During an initial visit with a physical therapist on August 30, 2017, Petitioner
                complained of “shoulder pain beginning in November after receiving a tetnis
                [sic] shot.” Ex 5 at 63.

       The above medical entries do not corroborate Petitioner’s statements regarding
onset of his shoulder pain within 48 hours of vaccination. Despite seeking treatment for
other musculoskeletal pain 3 at his December 21, 2016 visit with his PCP, Petitioner did
not mention his alleged shoulder pain at that time. To explain the omission, he avers that
he “thought [he] was having a similar reaction to the shot as [his] mother,” who had
apparently experienced similar symptoms for months following a tetanus vaccine in 2011.
Ex 8 at 2. However, Petitioner also reported in his affidavit that he was suffering
“excruciating” shoulder pain at night and that his pain was interfering with his ability to
perform many simple, everyday tasks. Id. Even if Petitioner expected the pain to
eventually diminish, it is unlikely he would have failed to even mention his excruciating
shoulder pain (which he alleges was occurring on a daily basis) while seeking care for
back pain that he described as occurring only “on and off.” Ex 3 at 5-6.

       Furthermore, despite Petitioner’s allegations regarding the severity of his pain, he
did not visit his PCP until more than 5 ½ months after vaccination, and more than 2 ½

3
 Petitioner reported back, hip, and buttock pain and back spasms “on and off” since a fall in July 2016. Ex
3 at 5-6.

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months after his last phone call to his PCP. Ex 2 at 5-8. While some delay in seeking
treatment is relatively common in SIRVA cases, 4 I have also noted that persistent delays
established in the medical record can undermine a Petitioner’s onset contentions. Pitts v.
Sec’y Health & Human Servs., 18-1512V, 2020 WL 2959421 (Fed. Cl. Spec. Mstr. Apr.
29, 2020). Specifically, “[i]t is reasonable to expect that the average Program claimant
might seek medical treatment sooner if in fact the person was experiencing sudden post-
vaccination pain.” Pitts, 2020 WL 2959421, at *5. Given the disabling pain Petitioner
describes, it would be reasonable to expect that he would have sought treatment earlier,
or at a minimum, would have mentioned his pain at the December 21, 2016 visit with his
PCP.

        Moreover, while Petitioner maintains that the onset of his pain occurred within 2-3
hours of vaccination, his treatment records consistently make generalized references to
his shoulder pain beginning after vaccination but without specifying a more precise onset.
During his first phone call to his PCP, for example, Petitioner did not make any reference
to the onset of his symptoms, instead only stating that he had a tetanus shot “several
months ago.” Petitioner has also reported pain “from” a tetanus shot, discomfort
“beginning” in November, and “since” his shot in November. While such language
certainly supports a finding that Petitioner suffered right-sided shoulder pain not long after
after his receipt of the Tdap vaccination, it does not support a finding that he more likely
than not suffered onset of his condition within 48 hours of his vaccination.

         I acknowledge that the standard applied to SIRVA claims on the onset issue is
fairly liberal. Even in the absence of a direct record, the standard will often permit a
determination that onset began within the 48-hour timeframe set by the Table, based on
records prepared a few months after vaccination, and/or corroborated by sworn witness
statements intended to amplify otherwise-vague records. There are many situations in
which compelling testimony may be more persuasive than written records, such as where
records are deemed to be incomplete or inaccurate. Campbell v. Sec'y of Health & Human
Servs., 69 Fed. Cl. 775, 779 (2006) (“like any norm based upon common sense and
experience, this rule should not be treated as an absolute and must yield where the factual
predicates for its application are weak or lacking”); Lowrie v. Sec'y of Health & Human
Servs., No. 03-1585V, 2005 WL 6117475, at *19 (Fed. Cl. Spec. Mstr. Dec. 12, 2005)
(“[w]ritten records which are, themselves, inconsistent, should be accorded less
deference than those which are internally consistent”) (quoting Murphy v. Sec'y of Health
& Human Servs., 23 Cl. Ct. 726, 733 (1991), aff'd per curiam, 968 F.2d 1226 (Fed. Cir.
1992)). But not every SIRVA claim can be so preponderantly established, and certainly

4
 See, e.g. Cooper v. Sec’y of Health & Human Servs., 16-1387V, 2018 WL 1835179 (Fed. Cl. Spec.
Mstr. Jan. 18, 2018); Marino v. Sec’y of Health & Human Servs., 16-622V, 2018 WL 2224736 (Fed. Cl.
Spec. Mstr. Mar. 26, 2018).

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not where the sequential and contemporaneous record does not lend overall support to
the Petitioner’s allegations.

       Petitioner has provided no reason for me not to conclude that the medical records
are correct, and he has otherwise failed to show cause, or provide any argument or
explanation in response to my Order to Show Cause, as to the onset of his SIRVA and
why his Table claim should not be dismissed. Accordingly, I find there is not preponderant
evidence to establish that Petitioner suffered the onset of symptoms within 48 hours of
his Tdap vaccination as required by the Vaccine Injury Table. 42 C.F.R. § 100.3(a)(I)(C).
However, I also note that the other Table indicia of a valid SIRVA claim do seem to exist
– meaning that this is likely a viable non-Table claim. To that end, I urge the parties to
make one final brief attempt at settlement – as I would anticipate that even after transfer,
Petitioner’s claim will likely be seen favorably by the special master who receives it.

   V.     Scheduling Order

        Petitioner has not preponderantly established that onset of his pain occurred within
48 hours of vaccination. Accordingly, Petitioner’s Table SIRVA claim is dismissed. The
parties shall file a final settlement status report on or before Tuesday, July 6, 2021.
The matter shall be transferred thereafter if the parties do not report progress in these
efforts.

IT IS SO ORDERED.

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

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