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Decker v. Wexford Health Medical Department

United States District Court, D. Maryland

February 18, 2015

TIMOTHY M. DECKER, #368787, Plaintiff.
v.
WEXFORD HEALTH MEDICAL DEPARTMENT, AVA JOUBERT, MD, Defendants.

MEMORANDUM

PAUL W. GRIMM, District Judge.

Pending is defendants' motion to dismiss or, in the alternative, for summary judgment, which remains unopposed. ECF No. 11. Upon review of the pleadings filed, I find a hearing in this matter unnecessary. See Local Rule 105.6 (D. Md. 2014).

Background

Plaintiff, an inmate confined at Western Correctional Institution ("WCI"), alleges in his court-ordered supplemental complaint that he has had "multiple problems" getting adequate medical treatment for "unbearable" pain. He claims that he has been advised by defendants that any recommendations for a new prosthetic device or back surgery would not be carried out because of the costs and the short time left on his sentence. He complains that that defendants' actions constitute deliberate indifference as their treatment evinces a wish to "cut costs [and to] generate profits" over the need to provide him medical care. Plaintiff asserts that he receives pain medication, but the prescription does not alleviate his discomfort. ECF No. 3, at 3-6. He seeks injunctive relief so as to receive a new prosthetic leg, a referral to a neurosurgeon, back surgery and an undetermined amount of compensatory and punitive damages. Id. at 3, 6.

Defendants provided in excess of 280 pages of medical records and defendant Joubert's affidavit in support of their motion for summary judgment. ECF No. 11. They assert that Plaintiff is a 32-year-old male with a medical history significant for an above-the-knee amputation to his left leg, thoracic aortic stent placement, and chronic pain secondary to a trauma related to a 2006 motor vehicle accident. Id. at Exs. 1 & 2. He also has a medical history of a gunshot wound to the right hand resulting in a surgical repair in 2010, hypertension, chronic migraines, and back pain. Additionally, Plaintiff has a mental history significant for bipolar disorder, depression, and anxiety. Id.

Significant to the issues pending before the Court are records indicating that in 2011, plaintiff reported severe back pain related to five herniated discs. Diagnostic x-rays taken of the thoracic and lumbar spine in January of 2011, showed preserved disc space, a normal vertebrae body, and lordosis of the thoracic and lumbar spines.[1] Id., Ex. 1, at 272. Bilateral screws and plates in the lumbar spine were identified consistent with orthopedic trauma. Id., Ex. 2. Upon examination by a nurse on March 12, 2011, plaintiffs spine tested positive for muscle spasm and tenderness of the lumbar spine. He voiced subjective complaints of moderate pain at the lumbosacral spine radiating to his right leg which increased when walking. Id., Ex. 1, at 7-8. Plaintiff was prescribed Neurontin, Robaxin, and Naprosyn for his complaints.[2]

In May of 2011, plaintiff was transferred from the Baltimore prison region to WCI. He was seen by Dr. Joubert on June 6, 2011, and reported an amputation following a 2006 accident where he was hit by a drunk driver. He also reported five herniated discs and claimed that he used crutches for ambulation, but the right-hand gunshot injury was making it difficult for him to use them. ECF No. 11, Ex. 1, at 14-16, 223. Dr. Joubert requested an occupational therapy consult to determine the most appropriate device to assist with plaintiff's ambulation. Plaintiff was continued on his pain regimen of Neuron tin, Robaxin, and Naproxen.

On June 9, 2011, plaintiff was seen by an occupational therapist. Id., Ex. 1, at 17, 271. At that time plaintiff reported his gunshot wound made it challenging to use his crutches and he had increased back pain on ambulation over long distances. The therapist recommended issuing plaintiff a wheelchair for independent mobility over long distances and to decrease stress on plaintiff's hand and lessen his back pain. Id. In addition, physical therapy sessions were recommended to address plaintiffs back pain. Id., Ex. 1, at 18-19. The sessions commenced on June 22, 2011 and plaintiff later reported improvement to his lumbar strain and back pain. Id., Ex. 1, at 256-259. Additional therapy was ordered and, by July 25, 2011, plaintiff reported the resolution of pain. Id., Ex. 1, at 261-266. On July 18, 2011, however, plaintiff was evaluated by Physician's Assistant ("PA") Schindler and reported that he was relying on his wheelchair "most of the time" for ambulation because he was unable to walk with crutches due to back pain. Id., Ex. 1, at 26.

The record shows that during 2011 through 2013, plaintiff's sick-call complaints of back pain were responded to by healthcare personnel. He was prescribed Ultram[3] for pain and ordered to undergo repeat x-rays of the thoracic and cervical spine. ECF No. 11, Ex. 1, at 35-39, 43-45. The x-rays were unremarkable and showed no change from the previous completed study. Id., Ex. 1, at 274. However, plaintiff was referred for a physiatrist consult[4] for his complaints of continued back pain.

In September of 2011, Wexford Health received a request for an orthotic evaluation for a possible prosthesis. It was noted that plaintiff had a prosthetic leg at home and recommended that a security clearance be obtained to bring the prosthetic leg into the prison for use during plaintiffs confinement. ECF No. 11, Ex. 2 ΒΆ 9. The security clearance was granted in January of 2012. Id., Ex. 1, at 48.

On January 26, 2012, plaintiff was seen by physiatrist Cornell Shelton at Bon Secours Hospital and reported chronic back pain. Id., Ex. 1, at 227-29. On examination, plaintiffs muscle strength was normal on the left and right lower extremity. Straight-leg and Hoffman tests[5] were negative. Shelton's impression was that plaintiff had lumbar radiculitis[6] on the lower right side, low back pain and right lower extremity parenthesis due to amputation. Dr. Shelton recommended tapering down plaintiffs Neurontin, starting plaintiff on Lyrica, [7] increasing plaintiffs Baclofen, discontinuing the Naproxen and starting plaintiff on Mobic.[8] Shelton also recommended a lumbar epidural for pain management based on plaintiffs report that his prior physical therapy sessions had not been helpful. ECF No. 11, Ex. 1, at 227-28. The request for a lumbar epidural injection was approved and was scheduled. Plaintiff received the pre-operative lab work and examination. On March 8, 2012, he refused his scheduled medical trip to Dr. Shelton for the epidural injection because of the length of the ride and the need to stay at another prison. Id. at 60-62, 283.

On April 18, 2012, plaintiff was seen and evaluated by PA Flury. He advised Flury that his old prosthetic leg was loose-fitting around his thigh and was causing irritation. Flury noted that plaintiff was using a wheelchair to get around and wrote a consult request for an evaluation with Hanger Orthotics for an assessment. Id., Ex. 1, at 64-65. On April 26, 2012, PA Sparks examined plaintiff and issued orders to implement the medication recommendations made by Dr. Shelton to include Lyrica in plaintiffs regimen. Id., Ex. 1, at 66-69.

On May 20, 2012, plaintiff was transferred to the Jessup Pre-Release Unit and upon arrival was placed in the Chronic Care Clinic ("CCC") for pain management. Id., Ex. 1, at 74-76, 78-81. Dr. Onabajo maintained plaintiff on his existing pain regimen and considered sending plaintiff to an outside pain management clinic. Id. In August of 2012, plaintiff was seen at Hanger Orthotics for a "readjustment" to his prosthesis. Id., Ex. 1, at 234, 236; Ex. 2. On August 21, 2012, he was reevaluated by Dr. Onabajo, who referred plaintiff back to Dr. Shelton for a possible epidural. In the interim, plaintiff's medication regimen was modified to include Lyrica. ECF No. 11, Ex. 1, at 83-86.

On September 13, 2012, plaintiff was seen and evaluated by Dr. Shelton at Bon Secours Hospital. Id., Ex. 1, at 241-42. Plaintiff reported sharp pain and aches down his lower back radiating to his right leg. Shelton recommended increasing plaintiffs Lyrica and Baclofen dosages. He again recommended an epidural injection. Id., Ex. 1, at 241, 283. In October of 2012, Dr. Onabajo increased plaintiffs Baclofen and Lyrica dosages. Id., Ex. 1, at 87-89. Over the next several months, referral back to Dr. ...


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