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Maybin v. Corizon Healthcare

United States District Court, E.D. Missouri, Eastern Division

August 4, 2017




         This matter is before the Court on the joint motion of defendants William McKinney, M.D., and Corizon, LLC for summary judgment pursuant to Federal Rule of Civil Procedure 56.[1] Plaintiff has responded in opposition and the issues are fully briefed.

         I. Background

         Plaintiff William Maybin brings this action under 42 U.S.C. § 1983, claiming that defendants were deliberately indifferent to his serious medical needs, in violation of the Eighth Amendment. At all relevant times, plaintiff was an inmate in the Missouri Department of Corrections (MDOC). He has been confined at the Potosi Correctional Center (PCC) since his transfer there in November 2014. William McKinney, M.D., is the sole acting physician at PCC. Corizon, LLC provides medical care to prison inmates.

         Treatment for Respiratory Conditions

         i. Pre-Transfer Treatment

         In November 2013 plaintiff reported blood in his sputum. In response, MDOC medical personnel conducted several tests in December 2013, including (1) a chest x-ray, (2) a tuberculosis skin test, and (3) an AFB smear of plaintiff's sputum (screening for tuberculosis or other mycobacteria). All of the tests yielded normal results.

         Plaintiff next received an exam from a MDOC physician in March 2014 after reporting a cough. He also relayed that he first developed respiratory symptoms following an influenza vaccination in October 2013. The physician ordered albuterol nebulization treatment, chest and sinus x-rays, and sputum testing.[2] Those x-rays revealed no chest abnormalities, but did show potential allergic rhinitis and sinusitis. Later that same month, an MDOC physician diagnosed plaintiff with allergic rhinitis and sinusitis; plaintiff received prescriptions for Cipro, Claritin, and saline spray.[3] During that visit, the MDOC physician noted that plaintiff's “respiration was even and unlabored, and his lungs were clear.” [Doc. #43-1 at 10].

         In April 2014, the bloody sputum issue resurfaced, and an MDOC physician subsequently renewed plaintiff's Cipro prescription to treat his recurrent sinus infection. Moreover, April 2014 records link pinkish mucous to plaintiff's unresolved sinusitis. Notes also state that “throat and nose regions are currently neg[ative] for traces of mucous or pink drainage, ” but that pink drainage might “eventually wind up in his airway and will need to be coughed out.” [Doc. #43-2 at 76].

         MDOC physicians took additional sinus x-rays in early July 2014. They noted several abnormalities. Later that month, plaintiff complained of “continuous pain in the chest, troubled breathing, ” and “coughing up blood.” [Doc. #54 at 10]. A physician opined that plaintiff might have microcytic hypochromic anemia[4]; records also reflect that plaintiff had hilar granulomas on a previous chest x-ray from March. The physician considered that plaintiff might have sarcoidosis or hypersensitivity pneumonitis.[5] Following this assessment, plaintiff received a prescription for Cetirizine (an antihistamine) and an albuterol nebulizer treatment for shortness of breath, in addition to further lab work and spirometry testing.[6] An August 2014 chest x-ray produced normal results. No pulmonary infiltrates were observed, though granulomas remained. Plaintiff then had a spirometry test in August 2014; McKinney contends that the spirometry test did not produce results because plaintiff talked through the attempted procedure. Plaintiff, for his part claims he was simply responding to the nurse. Plaintiff continued to report shortness of breath and blood in his sputum in late August 2014; upon examination a nurse observed no signs of respiratory distress.

         ii. Treatment after Transfer to PCC

         Plaintiff reported respiratory symptoms to nurses in November 2014 and December 2014. Specifically, he complained of burning in his chest, congestion when coughing up dark red sputum, and shortness of breath. The nurse administered a nebulizer treatment for plaintiff's wheezing in November 2014. Plaintiff returned in late December 2014 and a nurse provided a nebulizer treatment due to diminished sounds in one lung. Plaintiff also produced a sputum sample for testing in December 2014.

         In January and February 2015 plaintiff persisted in reporting chest pain, burning, and numbness on multiple occasions. McKinney evaluated plaintiff's respiratory conditions on February 4, 2015. Noting plaintiff's history of negative evaluations and lack of symptomology, McKinney ordered a spirometry test. Plaintiff reported doing pushups and other exercises three to four times each week. MDOC medical personnel conducted the aforementioned spirometry exams on February 20 and 23, 2015. Plaintiff “reported he did not have enough air to do the test, ” and “did not follow directions well.” [Doc. #43-1 at 17].

         McKinney saw plaintiff again on March 11, 2015. During that visit plaintiff reiterated that his respiratory symptoms originated from an influenza vaccination. Medical records indicate that plaintiff reported less coughing.[7] Plaintiff further averred that his symptoms generally included fatigue, weakness, chest pain, drainage of pink to red colored sputum, and shortness of breath. McKinney observed (1) good breath sounds, (2) no cough, (3) a normal diagnostic history including chest x-rays, labs, and an AFB smear, and (4) no indication of disease. McKinney also ordered additional lab work.

         Plaintiff's respiratory symptoms were again reviewed by a nurse in April 2015, when he complained of shortness of breath. The nurse noted no shortness of breath, cough, or distress; plaintiff had 99 percent oxygen saturation level. Plaintiff gave a nurse a sample of his bloody sputum on May 18, 2015, which was preserved and then “showed” to McKinney in the morning. [Doc. #43-3 at 41]. The nurse also examined plaintiff's respiratory status on that date, and found that plaintiff had “easy and regular respirations, ” clear lungs, and oxygen saturation at 98 percent. [Doc. #43-1 at 20]. On May 21, 2015, plaintiff returned to a nurse to inquire about the testing of his sputum sample. He was informed at that time that the sample was “inconsistent with any chronic illness.” [Doc. #43-3 at 41].

         On August 26, 2015, plaintiff reported “subtle fatigue and a burning sensation in his chest and abdomen.” [Doc. #43-1 at 24]. The parties disagree as to plaintiff's last episode of bloody sputum. McKinney noted that plaintiff had good breath sounds.

         In an appointment with McKinney on October 5, 2015, plaintiff's lungs demonstrated good air movement and clarity. Spirometry testing showed normal results. Plaintiff's declaration reflects visits to complain of bloody sputum and provide further samples in October and November 2016.

         Treatment for Podiatry Complaints

         i. Pre-Transfer Treatment

         Plaintiff saw a physician at Truman Medical Center in 2006, while incarcerated in the Jackson County Jail. He does not provide records of this visit but states that a podiatrist instructed him to wear “soft sole orthopedic shoes.” [Doc. #54 at 3].[8] An MDOC doctor noted that plaintiff had “significant bunion deformit[ies]” on both feet in January 2012; the physician did not observe any tenderness or tissue breakdown. [Doc. #43-2 at 13]. Notes indicate that plaintiff had not been approved for shoes in the past, but that he had bunion splints. Records also indicate the potential for “amputation of foot deformity” as part of a treatment plan. [Doc. #57 at 1].

         Plaintiff filed numerous treatment requests for bunion-related pain from April 2012, to January 2013. Notes from an MDOC physician in May 2012 state that plaintiff had “difficulty getting wider shoes from custody to accommodate his bunion deformity, ” and that his bunions were “impressive.” [Doc. #57 at 3]. Because plaintiff was in administrative segregation, the physician stated that accommodation was “a moot point.” Id. During a November 11, 2012, appointment an MDOC physician recommended that plaintiff avoid running, conduct x-rays of both feet, and use bilateral bunion splints. And the November 12, 2012, x-ray of plaintiff's right foot revealed “subtle bony sclerosis” in the first metatarsophalangeal articulations; the impression was “hallux valgus with subtle periarticular soft tissue swelling” and mild degenerative changes of the first metatarsophalangeal articulation. [Doc. #43-2 at 33-34].

         In multiple visits in February 2013, doctors emphasized the prominence of plaintiff's bunions. Records from a February 4, 2013, doctor encounter state that “the bunion deformity is not viewed as an indication for special shoes, but [his] feet have impressive degree of bunion.” [Doc. #57 at 7]. The shoe committee determined that medical shoes should be prescribed upon plaintiff's release to the general population. He instead received bunion splints in April 2013. Plaintiff then requested surgery for his foot issues in September 2013, during a nursing encounter.

         Plaintiff received his medical shoes in October 2013. And he had an evaluation of his feet in May 2014; that visit resulted in diagnoses of bunions and mild degenerative joint disease.

         ii. Treatment after Transfer to PCC

         In November 2014, plaintiff submitted a request for new medical shoes. He did not receive them. McKinney examined plaintiff's feet in January 2015. McKinney noted a normal gait, no limping, obvious bilateral flat feet with pronation, and bilateral bunions. But he did not observe any “abrasions or changes to [p]laintiff's feet which would indicate that [plaintiff's] shower shoes were rubbing.” [Doc. #43 at 11]. McKinney recommended that plaintiff use arch support once released from administrative segregation. He also recommended wider shoes to accommodate plaintiff's bunions. He did not believe that medical shoes were merited.

         On June 10, 2015, plaintiff saw McKinney and requested surgery for his bunions. McKinney did not observe redness, soft tissue swelling, or open areas; he had superficial callouses on his right foot, as well as a “fluid gait with no limp.” [Doc. #43-1 at 21]. Plaintiff stepped down from the examination table without discomfort. McKinney determined that surgery was not medically indicated, and that shoes of the appropriate width would be the prudent treatment.

         On November 23, 2015, plaintiff met with McKinney regarding his bunions. McKinney noted that plaintiff was currently in administrative segregation and that he “still wants surgery.” [Doc. #43-3 at 69]. McKinney noted plaintiff's smooth step off exam table. He determined that “surgery is not currently medically necessary.” Id.

         Treatment for Knee Instability and Pain

         i. Pre-Transfer Treatment

         In July and August 2012, nurses evaluated plaintiff's knee pain. Plaintiff requested a knee brace during those visits. In particular he “reported he fell without a brace for his right leg.” [Doc. #43-1 at 4]. However, medical personnel did not observe swelling or popping sounds, and plaintiff exhibited a full range of motion. Plaintiff and McKinney disagree about whether plaintiff had been approved for surgery at that time. Plaintiff did not report to appointments regarding a potential operation. The parties dispute whether plaintiff knew about the appointments and intentionally missed them.

         In October and November 2012 plaintiff again complained of knee pain and requested surgery. A nurse evaluated plaintiff's knee on November 15, 2012. She found that he had full range of motion in his knee. And he received a similar referral to a physician for his knee pain in November 2012, but failed to attend the appointment; plaintiff states that he was not notified of the appointment.

         In September and October of 2013, plaintiff continued to report knee pain and a need for surgery on his right knee to nurses. On October 28, 2013, a physician noted plaintiff had “a good gait with ambulation, ” but that he sat “gingerly” and was “careful about bending his knee.” [Doc. #43-2 at 48]. Although the MDOC physician did not observe obvious swelling or gross abnormalities, plaintiff demonstrated tenderness and slight crepitus with palpation. The physician recommended Meloxicam and a knee sleeve for the left knee pain and instability. Plaintiff received a knee sleeve in December 2013.

         A nurse evaluated plaintiff in January 2014 for bilateral knee pain, knee “popping, ” as well as request for a bottom bunk. [Doc. #43-1 at 8]. The nurse's review indicated that he did not have any deformities, swelling, or discoloration, although he wore a knee sleeve.

         An MDOC physician examined plaintiff's knees in May 2014, pursuant to plaintiff's bottom bunk lay-in request. An exam of plaintiff's knees revealed “tenderness along the medial and lateral joint line of the right knee, ” and “trace swelling and some tenderness in the right ankle, ” but no tears. [Doc. #42 at 4]. X-rays of plaintiff's right knee in May 2014 showed no abnormalities. Later that month, an MDOC physician diagnosed chronic knee and ankle strains; he prescribed Indomethacin (Indocin), analgesic balm, continued use of a right knee sleeve, and the issuance of a right ankle sleeve. The physician recommended steroid injections and imaging of the right ankle if plaintiff's knee pain, ankle instability, and sciatica did not improve. Subsequent x-rays of plaintiff's ankle showed no abnormalities and plaintiff received a prescription for arch supports.

         In August 2014 a nurse observed that plaintiff had a mild limp, slightly more swelling of the right knee, and wincing on palpation of the right knee. Plaintiff requested a knee support on September 30, 2014; he told a nurse that MDOC officials held it in impound.

         ii. Treatment after Transfer to PCC

         McKinney evaluated plaintiff's knee pain (among other complaints) on April 12, 2015. Plaintiff told McKinney that he suffered right knee pain while jogging in place. McKinney prescribed Indocin and continued plaintiff's Pamelor prescription to treat plaintiff's general joint pain. In June 2015, a nurse referred plaintiff to McKinney for “slight swelling below” plaintiff's knee; plaintiff continued to request a knee sleeve at that time. [Doc. #43-3 at 52].

         McKinney evaluated plaintiff on July 6, 2015. McKinney determined that plaintiff did not require a neoprene sleeve; in particular he noted plaintiff's prior normal x-ray. He did observe increased movement in plaintiff's knees, which demonstrated some instability; but he also stated that plaintiff had no warmth, diffusion, palpable defect or any other abnormality in his knees. Moreover, plaintiff did not limp and easily climbed on and off the exam table without discomfort. Therefore, McKinney prescribed quad and hamstring exercises.

         Plaintiff reported knee pain to a nurse again several weeks later. He requested a knee sleeve and reported swelling while doing jumping jacks. On August 26, 2015, plaintiff also reported right knee pain to McKinney. Plaintiff told McKinney that he had done pushups, sit-ups and calisthenics, until custody removed his tennis shoes. McKinney also noted plaintiff's fluid gate and ability to climb on and off the exam table. On September 19, 2014, plaintiff complained of bilateral knee pain during a nurse encounter.

         McKinney examined plaintiff on October 9, 2015, for knee pain. Plaintiff expressed his desire to play basketball. During the appointment, McKinney noted a fluid gait and normal heel strike and stride. Plaintiff told McKinney that he experienced pain when walking on his ...

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