Court Opinion

ID: 4585217
Source: CourtListenerOpinion
Date Created: 2020-11-10 18:01:41.628336+00
Date Added: 2024-06-11T13:42:47.852345
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 19-1771V
                                          UNPUBLISHED

    KRISTI A. BAKER,                                            Chief Special Master Corcoran

                         Petitioner,                            Filed: October 9, 2020
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Findings of Fact; Site of Vaccination
    HUMAN SERVICES,                                             Influenza (Flu) Vaccine; Shoulder
                                                                Injury Related to Vaccine
                         Respondent.                            Administration (SIRVA)

Simina Vourlis, Law Offices of Simina Vourlis, Columbus, OH, for petitioner.

Lynn Christina Schlie, U.S. Department of Justice, Washington, DC, for respondent.

                                              FACT RULING1

       On November 18, 2019, Kristi A. Baker 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 right shoulder injuries related to
vaccination (“SIRVA”) pursuant to the Vaccine Injury Table, or caused in fact by an
influenza (“flu”) vaccine administered on November 23, 2017. Petition at 1, 7. The case
was assigned to the Special Processing Unit (“SPU”) of the Office of Special Masters.

     For the reasons discussed below, I find that the flu vaccine Petitioner received on
November 23, 2017, was more likely than not administered in her right shoulder.

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   Because this unpublished fact ruling contains a reasoned explanation for the action in this case, I am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).
   I.     Relevant Procedural History

       Ms. Baker filed her petition on November 18, 2019. On November 19, 2019,
Petitioner filed Exhibits 1-11 and a Statement of Completion (ECF Nos. 5-11). The case
went through the pre-assignment review process and was thereafter assigned to the SPU
on November 26, 2019 (ECF No. 13).

      The initial status conference was held on March 2, 2020 (ECF No. 16). On March
24, 2020, Petitioner filed additional medical records as Exhibit 12 (ECF No. 17). On April
28, 2020, Ms. Baker filed a status report (ECF No. 18) and Statement of Completion (ECF
No. 19).

      On May 15, 2020, Respondent filed a status report (ECF. No. 20) noting that he
had not identified missing medical records or medical issues beyond what is normally
addressed in the SPU. However, counsel identified an issue that may require additional
development or support: the record established that Petitioner received a flu vaccine on
November 23, 2017, but did not indicate which arm was the site of vaccine administration.

        A telephonic status conference was held on June 4, 2020 to discuss how to resolve
the issue of the vaccination situs (ECF No. 21). Petitioner’s counsel stated that she
thought the record contained sufficient evidence to support her contention that she
received the vaccine in her right arm. Respondent’s counsel noted that an affidavit from
the person who administered the vaccine could be helpful. Petitioner agreed to look into
whether any additional evidence was available. Neither party objected to the possibility
of a ruling on the written record concerning the vaccination site after Petitioner filed either
additional evidence or a status report.

       On August 6, 2020, Petitioner filed a status report stating that she did not intend to
file additional evidence concerning the site of vaccine administration (ECF No. 24).
Rather, she cited medical records relevant to the vaccination situs, and noted that her
affidavit provided further explanation. Petitioner reported that a letter was sent to the
nurse who administered the November 23, 2017 vaccine, but no response was received
and the letter was not returned undelivered. Attached to Petitioner’s August 6, 2020 status
report is a letter dated June 29, 2020 from Petitioner’s counsel to the nurse identified in
the status report requesting the nurse to respond concerning the vaccination site (ECF
No. 24 at 4). This issue is now ripe for resolution.

   II.    Issue

        At issue is whether Petitioner received the vaccination alleged as causal in her
right arm. 42 C.F.R. § 100.3(a) XIV.B. (2017) (influenza vaccination).

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   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
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, 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.

        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 & 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, 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).

       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

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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

       Based upon a review of the entire record, I find that Petitioner’s November 23,
2017 flu vaccine was likely administered in her right arm, as she contends. I make this
finding after a complete review of the record to include all medical records, affidavits, and
additional evidence filed. Specifically, I base my finding on the following evidence:

          •   Exs. 1 at 1 and 3 at 615, 709 document that an intramuscular flu vaccine
              was administered to Petitioner on the morning of November 23, 2017,
              although they do not establish the situs of vaccine administration;

          •   Ex. 4 at 25, a record of a December 13, 2017 appointment with Nurse
              Practitioner Tonnette Hoffman for right shoulder pain notes that Petitioner
              reported that she “was being discharged from the hospital on Thanksgiving
              day and was given a flu vaccine. She said the shot was given [too] high in
              her right arm and has hurt ever since”;

          •   Ex. 5 at 1, a record of a December 19, 2017 appointment with orthopedist
              Dr. Stanley Tao for right shoulder pain, noting “acute onset (11/23/17) pt
              states started after receiving flu shot . . . pt state[s] flu shot was given
              exceptionally high region of arm and did hurt worse than usual” and noting
              an onset date of 11/23/17. This record also documents that Petitioner’s
              dominant hand is her left hand. Id;

          •   Ex. 5 at 28, a Scott Orthopedic Center Injury form dated December 19, 2017
              and signed by Petitioner reporting that the injury happened to her right
              shoulder on November 23, 2017, at approximately 10 am and explaining
              that she “[r]eceived flu shot too high on shoulder”;

          •   Ex. 6 at 2, a January 3, 2018 physical therapy initial evaluation noting a date
              of onset/injury of November 23, 2017 and “a six week history of right
              shoulder pain that she conveys began after a flu shot on 11/23/17”;

          •   Ex. 3 at 339, a record of a February 28, 2018 appointment with radiation
              oncologist Dr. Sanjeev Sharma noting that Petitioner had “a little bit of
              limited range of motion with her right arm; this has occurred after she had
              her flu shot. She has been diagnosed with a frozen shoulder and she
              attributes it more to the flu shot”;

          •   Ex. 3 at 340, a record of a May 7, 2018 appointment with Dr. Sharma noting
              that Petitioner had undergone arthroscopic surgery of her right shoulder due
              to a partial tear of a rotator cuff tendon secondary to a flu vaccine received
              while she was hospitalized:

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            •   Ex. 9 at 1, a January 11, 2019 letter from Sally B. Oxley of HPT Physical
                Therapy Specialists, documenting a January 11, 2019 evaluation of
                Petitioner’s functional abilities and noting that Petitioner reported right
                shoulder pain associated with a November 23, 2017 flu vaccine. This record
                also confirms that Petitioner “is left hand dominant.” Ex. 9 at 3;

       The above-referenced evidence supports a finding that Petitioner’s November 23,
2017 vaccination was likely administered in her right shoulder. In seeking care for her
right shoulder injury (beginning less than a month from the date of administration),
Petitioner reported that the vaccine had been administered in her right arm. Thereafter,
she consistently related her right shoulder injury to the November 23, 2017 flu vaccine.
Accordingly, there is record support for her contention about the situs of administration,
beyond her own allegations. In addition, Ms. Baker has provided a logical explanation for
why the vaccine would have been administered in her right arm, since her affidavit asserts
that she wanted it administered in her “non-dominant right arm.” Ex. 2 at ¶¶ 3-7. This
explanation is consistent with the medical records documenting that Petitioner is left hand
dominant. Thus, while there may not be a record from the date of administration that
conclusively establishes the issue in Petitioner’s favor, sufficient preponderant evidence
supports her favored conclusion.

      I therefore find it more likely than not that the vaccination alleged as causal in this
case was administered to Petitioner in the right shoulder on November 23, 2017.

    V.      Scheduling Order

        The issue of the vaccination site is the only issued Respondent’s counsel identified
as requiring additional development. Petitioner shall thus proceed with preparing a
demand, with supporting documentation, for Respondent’s consideration. This should
include lost wage documentation if Petitioner seeks damages for lost wages. I understand
that Respondent cannot provide a response to this demand until he has obtained formally
his client’s position.3 However, the parties should strive to be in a position to immediately
discuss damages once Respondent indicates he is amenable to consideration of
Petitioner’s demand after Respondent’s review is complete. In addition, it is sensible for
Petitioner to calculate her likely damages as quickly as possible in any case pending in
SPU.

         Accordingly:
    •    Petitioner shall file, by no later than Wednesday, December 02, 2020, a status
         report providing the following information:

3
  If Respondent’s position on this case remains undetermined subsequent to the provision of a demand by
Petitioner’s counsel, I will nonetheless direct Respondent’s counsel to provide Respondent with a copy of
the demand and to file a Status Report confirming provision of Petitioner’s demand to Respondent.

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          o Whether and when Petitioner provided a demand for damages with
            supporting documentation to Respondent’s counsel;
          o Whether there is a Medicaid lien in this case and, if so, when Petitioner
            anticipates providing documentation of the lien to Respondent;
          o Petitioner’s current treatment status and condition;
          o Whether all updated medical records have been filed; and
          o A list of each component of damages allegedly suffered by Petitioner.

   •   Respondent shall file a status report indicating how he intends to proceed in
       this case by Wednesday, January 06, 2021. At a minimum, the status report
       shall indicate whether he is willing to engage in tentative discussions regarding
       settlement or proffer, is opposed to negotiating at this time, or that the Secretary
       has not yet determined his position. In the event Respondent wishes to file a Rule
       4(c) report, he may propose a date for filing it, but shall indicate his position on
       entering into negotiations regardless of whether he wishes to file a Rule 4(c) report.

      Any questions about this order or about this case may be directed to OSM staff
attorney Eileen Vachher at (202) 357-6388 or Eileen_Vachher@cfc.uscourts.gov.

IT IS SO ORDERED.

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

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