Court Opinion

ID: 6497197
Source: CourtListenerOpinion
Date Created: 2022-07-01 13:01:48.060352+00
Date Added: 2024-06-11T08:49:52.488909
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 20-0634V
                                          UNPUBLISHED

    DEBORAH PEEPLES,                                            Chief Special Master Corcoran

                         Petitioner,                            Filed: May 26, 2022
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Findings of Fact; Statutory Six Month
    HUMAN SERVICES,                                             Severity Requirement;
                                                                Pneumococcal Conjugate Vaccine;
                         Respondent.                            Shoulder Injury Related to Vaccine
                                                                Administration (SIRVA)

Howard Scott Gold, Howard S. Gold, Sudbury, MA, for Petitioner.

Althea Walker Davis, U.S. Department of Justice, Washington, DC, for Respondent.

                                           FINDINGS OF FACT1

      On May 21, 2020, Deborah Peeples 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 right shoulder injury related to
vaccine administration (“SIRVA”) caused-in-fact by the pneumococcal 13-valent vaccine3
she received on January 25, 2018. Petition at 1, ¶¶ 1-2, 22.

1 Because this unpublished Fact Ruling contains a reasoned explanation for the action in this case, I am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.

2National 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).
3The pneumococcal 13-valent vaccine is a pneumococcal conjugate vaccine - routinely administered to
children, and covered by the Vaccine Program. See Morrison v. Sec’y of Health & Hum. Servs., No. 04-
        Because Petitioner failed to seek treatment for her SIRVA injury during a greater
than 15-month period (from late May 2018 through early September 2019), Respondent
questioned whether Petitioner has satisfied the statutory six-month requirement. ECF No.
24. Petitioner maintains that the symptoms she experienced in September 2019 and later
reflect a continuation of her SIRVA injury. Petition at ¶ 15.

       For the reasons discussed below, I find the Petitioner continued to suffer the
residual effects of her alleged SIRVA for more than six months. See Section 11(c)(1)(D)(i)
(statutory six-month severity requirement).

            I.       Relevant Procedural History

       Within a month of filing her Petition, Ms. Peeples filed the medical records required
under the Vaccine Act. Exhibits 1, 3-5, filed June 18, 2020, ECF No. 7; see Section 11(c).
She also filed a declaration signed under penalty of perjury as required by 28 U.S.C.A. §
1746. Exhibit 2, ECF No. 7. On July 2, 2020, the case was activated and assigned to the
Special Processing Unit (OSM’s process for attempting to resolve certain, likely-to-settle
claims). ECF No. 9.

        No factual issues requiring further development were identified during the initial
status conference held on September 24, 2020, or in Respondent’s later status report.
Order, issued Sept. 25, 2020, at 1, ECF No. 12; Status Report, filed Dec. 22, 2020, at 2,
ECF No. 13. However, Respondent identified several medical records which appeared to
be outstanding. Status Report at 1. Over the subsequent one-month period, Petitioner
filed these additional medical records. Exhibits 6-7, ECF Nos. 15-16.

       On July 22, 2021, Respondent filed a status report raising severity as an
impediment to a favorable entitlement determination. Status Report at 1, ECF No. 24. I
therefore ordered the parties to file simultaneous briefing addressing the issue. Non-pdf
Order, issued July 28, 2021. Instead of briefing, however, on September 21, 2021,
Petitioner filed a motion for additional time indicating that Petitioner planned to file a
supplemental affidavit and the parties wanted time to discuss an informal settlement in
this case. ECF No. 25. Petitioner filed a signed statement4 on September 21, 2021.
Exhibit 9, ECF No. 26.

1683, 2005 WL 2008245, at *1 (Fed. Cl. Spec. Mstr. July 26, 2005) (describing how and when
pneumococcal conjugate vaccines were added to the Vaccine Table).
4 Although Petitioner refers to this statement as an affidavit, it is signed but not notarized. Additionally, it
does not contain a statement indicating it was signed under penalty of perjury as required by 28 U.S.C.A.
§ 1746. Id.

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       On December 2, 2021, Respondent filed a status report indicating “the parties were
unable to resolve the issue regarding the severity requirement for [P]etitioner’s alleged
SIRVA injury.” ECF No. 28. They requested that a new deadline be set for their
simultaneous briefing on the issue. Id.

       On December 8, 2021, Petitioner filed a second signed witness statement5 on her
own behalf, plus a statement from one of her treating physicians – an orthopedist, Robert
Dasilva, M.D., indicating that he believed her later symptoms were related to the shoulder
injury she suffered in late January 2018. Exhibits 10-11, ECF No. 29. On January 20,
2022, Petitioner filed a status report requesting a fact hearing regarding the issue of
severity and a copy of a late May/early June 2019 email exchange between Petitioner
and Petitioner’s counsel – accompanied by a declaration signed under penalty of perjury
by Petitioner’s counsel attesting to the email’s authenticity. Status Report, ECF No. 31;
Exhibit 12, ECF No. 32. On January 30 and 31, 2022, the parties filed their briefing. ECF
Nos. 33-34. The matter is now ripe for adjudication.

            II.     Issue

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

5This statement was (like the prior witness statement) signed but not notarized or signed under penalty of
perjury as required by 28 U.S.C.A. § 1746. Id.

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       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, this rule
does not always apply. “Written records which are, themselves, inconsistent, should be
accorded less deference than those which are internally consistent.” Murphy v. Sec’y of
Health & Hum. Servs., No. 90-882V, 1991 WL 74931, *4 (Fed. Cl. Spec. Mstr. April 25,
1991), quoted with approval in decision denying review, 23 Cl. Ct. 726, 733 (1991), aff'd
per curiam, 968 F.2d 1226 (Fed.Cir.1992)). 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 & Hum. Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).

        The United States Court of Federal Claims has 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).

       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 v. Sec’y
of Health & Hum. Servs., 42 Fed. Cl. 381, 391 (1998) (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 fact 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 Section 12(d)(3); Vaccine Rule 8); see also Burns v.

                                             4
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).

          IV.      Finding of Fact

       I make this severity finding after a complete review of the record to include all
medical records, statements, declarations, briefing, and additional evidence filed.
Specifically, I base the findings on the following evidence:

          •     Petitioner received the pneumococcal 13-valent vaccine alleged as causal
                in her right deltoid on January 25, 2018. Exhibit 1. The same day, she also
                received an influenza vaccine in her opposing left deltoid. Id.

          •     On February 20, 2018, less than one-month post-vaccination, Petitioner
                visited her primary care provider (“PCP”), complaining of right shoulder pain
                and limited range of motion (“ROM”). Exhibit 6 at 1. She reported that she
                had soreness in both arms the day after vaccination, but “[t]he left shoulder
                soreness dissipated over the next few days.” Id. In contrast, “the right
                shoulder pain intensified, and she noted pain on ROM.” Id. Indicating that
                heating pads and cold packs had not helped, Petitioner described pain “over
                the lateral shoulder and deltoid area.” Id. Observing pain with palpitation
                and at the ROM extremes, the PCP opined that Petitioner’s injury “[wa]s
                consistent with right subacromial-subdeltoid bursitis/supraspinatus
                tendinitis, . . . occurred immediately after a Prevnar 13 deltoid injection, . . .
                [and was] presumed to occur when the needle inadvertently is place into
                the bursae.” Id. at 2. Noting that Petitioner was currently taking Tramadol
                for her knee arthritis, the PCP referred her to an orthopedist and showed
                her how to perform exercises “to minimize the risk of frozen shoulder.” Id.

          •     On February 23, 2018, Petitioner visited the orthopedist, reporting aching
                sharp pain for one month following receipt of the pneumococcal vaccine in
                late January 2018. Exhibit 4 at 12. Describing the same soreness in both
                shoulders, then improvement in the left shoulder receiving the flu vaccine
                and worsening in the right shoulder, Petitioner reported that the Tramadol
                she took for her back and knee pain was not alleviating her right shoulder
                pain. Id. Observing a painful arc but full ROM, the orthopedist ordered x-
                rays, administered a steroid injection, and recommended physical therapy
                (“PT”) - which Petitioner declined. Id. at 12-13. The orthopedist opined that

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    he “believe[d] the likelihood is high that this will improve with time.” Id. at 13.
    The record from this visit indicates that Petitioner was a retired nurse Id. at
    12.

•   Despite the notation indicating Petitioner was declining PT (Exhibit 4 at 13),
    Petitioner attended four PT sessions in March 2018. Exhibit 7 at 13-25. At
    her first session on March 15th, she provided the same history of bilateral
    soreness after vaccination followed by a worsening of her right shoulder
    pain and reported that currently she was unable to elevate her right arm
    without pain. Id. at 21. Reporting pain levels which varied between zero and
    eight at her initial PT session (id. at 19, 21), Petitioner indicated increased
    soreness and pain at her next session on March 20th – which she attributed
    to the first PT session and a Pilates class she attended the same day (id. at
    17). At her third session, two days later, Petitioner reported a more severe
    level of pain - seven out of ten, which started that morning. Id. at 15. By her
    fourth session on March 27, she was experiencing decreased pain but
    continued pain and difficulties when performing overhead tasks. Id. at 13.

•   When she returned to her orthopedist on March 30, 2018, Petitioner
    expressed frustration with her slow recovery – describing her pain as sharp
    and radiating at times. Exhibit 4 at 9-10. Reporting that she obtained only
    seven days relief from the steroid injection and no relief from PT, she
    requested the orthopedist prescribed Lidoderm patches for her pain.
    Observing that Petitioner had full ROM but “a painful impingement arc,” the
    orthopedist prescribed the requested Lidoderm patches and recommended
    Petitioner “discontinue formal therapy because it is not helping much and
    switch to a home program.” Id. at 9.

•   At her last PT session on April 3, 2018, Petitioner was described as
    “hav[ing] pain and difficulty using her R shoulder with daily activity.” Exhibit
    7 at 7. The cessation of PT was attributed to Petitioner “having financial
    difficulty along with the slow progress and concern of adverse reaction with
    physical therapy.” Id. It was noted that Petitioner had met only goals related
    to improved posture and less than 40 percent impairment, but Petitioner had
    failed to achieve less than 20 percent impairment. Id. at 8.

•   On April 27, 2018, Petitioner underwent an MRI, the results of which
    included no rotator cuff tear and a trace amount of subacromial/subdeltoid
    bursitis. Exhibit 4 at 14-15.

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•   On May 4, 2018, Petitioner visited her orthopedist to discuss the results of
    her MRI. Exhibit 4 at 7-8. Reporting “that the shoulder pain ‘[wa]s getting to
    her,’” Petitioner described difficulties sleeping, bathing, and performing
    caretaker duties for her mother. Id. at 7. Noting that Petitioner had arthritic
    changes but no symptoms prior to vaccination, the orthopedist theorizes
    that “her shoulder somehow got aggravated from the injection.” Id. He
    indicated that Petitioner had exhausted all conservative treatment but did
    not wish to pursue surgery. Instead, she preferred to “continue with her oral
    medications and activity modifications to manage her shoulder arthritis.” Id.

•   On May 29, 2018, Petitioner was seen by an orthopedic surgeon. Exhibit 5
    at 35-37. Providing the same consistent history, Petitioner described
    “aching; sharp; dull, constant; [and] worsening” pain, with a current level
    ranging from four to eight. Id. at 37. After discussing options which ranged
    from continued conservative care to a manipulation under general
    anesthesia, and noting that Petitioner would be going to Florida for six to
    eight weeks to care for her mother, the orthopedic surgeon indicated the
    tentative plan was a manipulation. Id.

•   Petitioner did not return to the orthopedic surgeon until September 10, 2019
    – over fifteen months from the date of her last 2018 treatment visit. Exhibit
    5 at 32-35. However, in response to an email inquiry by Petitioner’s counsel
    approximately three months earlier, Petitioner had reported that she
    continued to experience symptoms of her shoulder injury throughout the
    gap in treatment. Exhibit 12 at 3 (Counsel’s May 31, 2019 email and
    Petitioner’s June 3, 2019 response). Noting the length of time that had
    passed, she recalled that one of her physicians (thought to be her PCP) told
    her “it could take that long to recover.” Id. Attributing her delay in treatment
    to her reluctance to undergo surgery, Petitioner indicated that she planned
    to seek a current assessment from the orthopedic surgeon in late July/early
    August, and to pursue a surgical option. Id. It appears Petitioner called to
    schedule the September 10 appointment on August 13, 2019. Exhibit 5 at
    32.

•   At the September 10, 2019 appointment, the orthopedic surgeon assessed
    Petitioner as “continu[ing] to have pain in the shoulder really without much
    improvement.” Exhibit 5 at 34. He recommended arthroscopic surgery, and
    Petitioner agreed. Id.

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          •   During the October 2, 2019 surgery, it was revealed that Petitioner suffered
              from “[s]ignificant arthritis” and “a small partial thickness rotator cuff.” Exhibit
              5 at 32. In the clinical history section, Petitioner is described as having
              “continued shoulder pain despite conservative care.” Id.

          •   After surgery, Petitioner began PT on October 9, 2019. Exhibit 5 at 24-27.
              There is evidence that Petitioner may have aggravated her right shoulder
              condition on in November 2019, which resulted in an increase in her pain.
              Id. at 8. Additionally, she may have suffered an unrelated injury in the fall of
              2020 when reaching out to put a dog in a kennel. Exhibit 8 at 10. Petitioner
              recalled feeling a pop in her shoulder at that time. Id.

          •   In a December 6, 2021 letter, Petitioner’s orthopedic surgeon opined that
              the right shoulder pain Petitioner experienced in September 2019 was a
              continuation of the pain she suffered in May 2018. Exhibit 11.

          •   In her most recent signed statement, Petitioner avers that her “decision to
              delay surgery until October 2019 was a result of financial constraints, family
              obligations, [her] desire to avoid surgery, and most importantly exhausting
              more conservative care including steroid injections, exercises and time.”
              Exhibit 10 at ¶ 10. Petitioner specifically reported that, given a $45 co-pay
              for each PT session, the monthly cost of her pre-surgery PT would have
              been almost $400. Id. at ¶¶ 7-8.

       In this case, to satisfy the Vaccine Act’s severity requirement Petitioner must show
that she suffered symptoms of her alleged SIRVA beyond July 25, 2018. Thus, Petitioner
must establish that the symptoms she complained of in September 2019 were a
continuation of her 2018 SIRVA injury - or that, at a minimum, that the symptoms she
reported in May 2018 continued through at least until July 25th of the same year.

       The above medical entries show that Petitioner was clearly experiencing
symptoms of her alleged right shoulder injury in late May 2018, approximately four months
post-vaccination. And they underscore the extent to which she obtained little relief from
the conservative treatment she received during that time. The cortisone injection
administered in late February provided only seven days of relief, and the PT sessions in
March and early April appeared to aggravate, rather than relieve, Petitioner’s symptoms.
At the last orthopedic appointment on May 27, 2018 (just before the start of the lengthy
treatment gap), Petitioner described her continuing symptoms and expressed her desire
to undergo a manipulation under general anesthesia after an extended trip to Florida to
care for her mother. Given the constant nature of Petitioner’s symptoms from vaccination

                                               8
through late May 2018, and the lack of relief she obtained from the conservative treatment
she pursued, it highly likely that her symptoms continued at least through the end of July
2018.

       My conclusion is bolstered by the symptoms Petitioner reported in September
2019, which reasonably appear to relate to those she experienced in 2018. The medical
records contain evidence which clearly supports the reasons Petitioner provided for the
15-month gap in treatment - financial constraints, family concerns, and a reluctance to
undergo surgery. And it is reasonable for Petitioner, a retired nurse, to attempt to treat
herself with conservative measures before undergoing surgery. Petitioner stated that she
was informed, by at least one treating physician, that it could take at least 18 months for
her injury to resolve.

        Most compelling is the opinion of the orthopedic surgeon, who saw Petitioner just
prior to and following this gap in treatment. He has opined that the later symptoms were
a continuation of Petitioner’s earlier injury. And the symptoms Petitioner complained of in
2019 mirrored those she reported in 2018.

       The overall record in this case shows that the right shoulder pain and limited ROM
Petitioner complained of following her January 25, 2018 vaccination continued at least
through her October 2019 surgery and early post-surgical PT. Accordingly, I find there is
preponderant evidence to establish Petitioner suffered the residual effects of her alleged
SIRVA for more than six months. Of course, the lengthy gap in treatment is highly relevant
to damages, as it not only supports the conclusion that Petitioner’s SIRVA was mild
enough to tolerate for a long period, but also that intervening circumstances could explain
some degree of severity thereafter. But this does not mean I cannot find the basic
requirement of six months severity met. A treatment gap that includes within it the
“expiration date” for severity does not automatically mean severity cannot be established.

   V.     Later Sequelae and Scheduling Order

        As stated in the previous section, there is evidence indicating that Petitioner may
have aggravated her right shoulder condition in November 2019, and may have suffered
an unrelated injury in the fall of 2020. However, these matters are relevant when
determining the appropriate amount of compensation, as noted above. I need not address
their connection to Petitioner’s earlier condition when determining whether Petitioner has
satisfied the severity requirement.

      In light of my finding regarding the Vaccine Act’s severity requirement, Respondent
should consider his tentative position in this case. Respondent shall file a status report

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indicating how he intends to proceed following my ruling by no later than Monday,
June 27, 2022.

     IT IS SO ORDERED.
                                                 s/Brian H. Corcoran
                                                 Brian H. Corcoran
                                                 Chief Special Master

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