Reynolds v. Secretary of Health and Human Services

United States Court of Federal Claims·Decided August 12, 2024·No. 19-1683V·Unpublished

Opinion

In the United States Court of Federal Claims OFFICE OF SPECIAL MASTERS No. 19-1683V

HANNA REYNOLDS, Chief Special Master Corcoran

Petitioner, Filed: July 11, 2024 v.

SECRETARY OF HEALTH AND HUMAN SERVICES,

Respondent.

Jeffrey S. Pop, Jeffrey S. Pop & Associates, Beverly Hills, CA, for Petitioner.

Sarah Black Rifkin, U.S. Department of Justice, Washington, DC, for Respondent.

DECISION AWARDING DAMAGES1

On October 30, 2019, Hanna Reynolds 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 alleged that that she suffered a left shoulder injury related to vaccine administration (“SIRVA”) as a result of an influenza (“flu”) vaccine received on October 28, 2018. The case was assigned to the Special Processing Unit of the Office of Special Masters (the “SPU”).

For the reasons set forth below, I find that Petitioner is entitled to a damages award of $110,000.00 for actual pain and suffering, plus $2,647.14 in actual unreimbursable expenses.

1 Because this Decision contains a reasoned explanation for the action taken in this case, it must be made

publicly accessible and will be posted on the United States Court of Federal Claims' website , and/or at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government Services). This means the Decision 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 (2018). I. Relevant Procedural History

The case was activated on November 13, 2019 (ECF No. 7). On February 2, 2021, Respondent indicated that he was willing to engage in settlement discussions (ECF No. 19). The parties negotiated for six months, but reached an impasse (ECF No. 28). After Respondent filed his Rule 4(c) Report, which he later amended, the parties again attempted negotiations, without success (ECF Nos. 29-33).

After briefing, I ruled that Petitioner was entitled to compensation on April 28, 2023 (ECF No. 39). The parties then attempted to negotiate damages, but again reached an impasse (ECF Nos. 42-44). The parties have now briefed damages (ECF Nos. 45, 46, 48). The matter is ripe for resolution.

II. Relevant Medical History

On October 28, 2018,3 Petitioner received a flu vaccine intramuscularly in her left arm at a Publix Pharmacy. Ex. 2 at 1.

Two months later, on December 27, 2018, Petitioner reported to Dr. Marc Hammerman of the Broward Institute of Orthopaedic Specialties, LLC for left shoulder pain after her flu vaccination. Ex. 3 at 8. She reported pain levels ranging from five to seven out of ten depending on activities. Id. Her pain limited her motion and interfered with her work activities as an accountant. Id. It also severely restricted her sports activities. Id. On examination, she had full passive range of motion (“ROM”) but painful active ROM. Dr. Hammerman assessed Petitioner with pain of the left shoulder joint on movement and tendonitis of the left rotator cuff. Id. at 9.

On January 28, 2019, Petitioner returned to Dr. Hammerman. Ex. 3 at 6. Her left shoulder pain was slightly better, but she still experienced discomfort, especially at nighttime. Id. Her active ROM continued to be painful. Id. Dr. Hammerman prescribed a Medrol dosepak, instructing Petitioner to take Zantac as well for gastrointestinal side effects from Medrol. Id. If her pain continued, he planned to order an MRI. Id.

Three weeks later (February 18, 2019), Petitioner underwent a left shoulder MRI. Ex. 4 at 1. The MRI showed a moderate degree of rotator cuff tendinosis with low grade partial thickness tearing involving the supraspinatus tendon, mild infraspinatus and subscapularis tendinosis, moderate biceps tendinosis, mild subdeltoid bursitis,

3 While the record indicates that the flu vaccine was given on October 28, 2018, Petitioner erroneously dated the form October 27th (instead of the 28th). Ex. 2 at 1.

2 degenerative changes with edema, mild labral blunting and fraying, and small joint effusion. Id. at 1-2.

Petitioner saw Dr. Hammerman to review the MRI on February 25, 2019. Ex. 3 at 3. She stated that in the morning her pain ranged from one to four out of ten, but as the day progressed her pain increased to six to eight out of ten. Id. Her pain was not affecting her work activities any longer. Id. On examination, she displayed “satisfactory” shoulder ROM, but “obvious pain” with abduction and internal rotation. Id. During the examination, her pain ranged from one to three out of ten. Id. Dr. Hammerman assessed her with a partial rotator cuff tear, and prescribed Mobic and physical therapy (“PT”). Id. at 4.

Petitioner underwent a PT evaluation on March 5, 2019. Ex. 5 at 5. She reported a current pain level of two out of ten, ranging to eight out of ten at worst. Id. On examination, her left shoulder active ROM was reduced compared to her right shoulder. Id. at 6. A treatment plan of three visits a week for four weeks was established. Id. at 7.

Petitioner returned to Dr. Hammerman on April 18, 2019. Ex. 3 at 1. She had seen improvement in strength after six weeks of PT, but was still in pain, especially with activity during the daytime. Id. Her left shoulder ROM was 170 degrees in abduction and forward flexion, with a pain level of five out of ten. Id. Dr. Hammerman recommended that she continue working on her home exercise program and return as needed. Id.

Petitioner attended a total of 12 PT sessions between March 5 and May 10, 2019. Ex. 5 at 5-45. By March 17th, her pain had decreased to three to six out of ten, and she had slight improvements in her left shoulder active ROM. Id. at 19-20. However, by April 5th, her pain had worsened, now ranging from five to eight out of ten, with no further improvements in ROM. Id. at 36. At her discharge on May 10th, her pain level remained between five and eight out of ten. Id. at 45.

Petitioner told Dr. Hammerman on June 24, 2019 that PT had helped with her strength and motion, but pain was impacting her quality of life and she was considering surgery. Ex. 6 at 1. She described her pain as three out of ten. Id. On examination, she had satisfactory ROM, but pain with abduction and internal rotation, and tenderness in the subacromial area. Id. Dr. Hammerman and Petitioner reviewed the risks and benefits of surgery, with Petitioner deciding to take time to contemplate her choices. Id. at 1-2.

Petitioner established care with Dr. Nancy Pyram-Bernard in August 2019, and underwent an annual physical examination. Ex. 14 at 9. Petitioner complained of left shoulder pain, explaining that she had been in constant pain for 11 months and that it was “very disruptive and bothersome.” Id. The pain was aggravated by movement and relieved by rest. Id. She was scheduled for surgery in October 2019 and wanted to make

3 sure she was healthy. Id.

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