Citation Nr: 21002278 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 10-01 077 DATE: January 13, 2021 REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for additional disability of the right arm, hand, and hip as the result of VA medical treatment is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1962 to October 1963, from April 1966 to March 1968, and from February 1969 to August 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2009 rating decision. In August 2016, the Veteran participated in a videoconference hearing before the undersigned, and a transcript of this hearing has been associated with the record. The matter was remanded for development in January 2017 and November 2019. The Veteran’s petitions to reopen claims for service connection for a right hip disability (a distinct claim from the current claim for compensation under 38 U.S.C. § 1151) and a stomach disability were recently addressed by the Board in a separate Board decision. Notably, in December 2020, the issues were remanded for additional development. The Veteran claims that he suffers from disabilities of the right hand, arm, and hip as a result of a November 2008 injection that he received from the VA Medical Center (VAMC) in Mountain Home, Tennessee. On November 26, 2008, the Veteran sought emergency treatment for symptoms of aching hip pain. The Veteran requested pain medication, and he was administered a 4mg intramuscular injection of Decadron to treat his hip pain. The Veteran was discharged from emergency treatment later that day, at which time he reported that he had no pain. On November 27, 2008, the Veteran returned to emergency treatment with complaints of aching pain in his right arm, hand, and hip. A clinician noted that the Veteran’s right hand was slightly swollen, but the Veteran denied having experienced any trauma to the area. In December 2008, the Veteran argued that he was injured after an injection caused his hand and arm to swell. VA has obtained opinions addressing whether the Veteran suffered additional disability or an aggravation of an existing disability as the result of the November 2008 injection that he received at a VAMC. None of these opinions are adequate. In April 2017, a VA examiner opined that the Veteran did not suffer additional disability or an aggravation of an existing disability as the result of VAMC treatment. The examiner discussed an informed consent and medication associated with March 2013 VAMC treatment rather than November 2008 treatment. In January 2019, a VA orthopedist opined that the Veteran did not suffer additional disability or an aggravation of an existing disability as the result of VAMC treatment. However, the orthopedist incorrectly stated that the Veteran received an injection of Toradol on November 26, 2008. The Veteran did not receive a Toradol injection on November 26, 2008; instead, he received a Decadron injection on that date. In April 2020, an examiner opined that the Veteran did not suffer additional disability or an aggravation of an existing disability as the result of VAMC treatment. However, the examiner did not explain this conclusion. Thus, upon review of the evidence of record, the Board finds that none of the existing medical assessments adequately address the facts in this case. An examiner of appropriate expertise should again review the Veteran’s claims file and offer an opinion addressing whether the Veteran has disabilities of the right hand, hip, or arm that are etiologically related to VA treatment. Accordingly, the case is REMANDED for the following actions: Solicit the following opinions from a VA orthopedist to address whether the Veteran’s disabilities of the right hand, hip, or arm are etiologically related to VA treatment. The claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner, and the examination report should note that review. A physical examination of the Veteran should be conducted only if it is required in order for the examiner to offer the following opinions: (a.) Identify all disabilities of the right hand, arm, and hip that presently exist or that have existed at any time since the Veteran’s December 2008 claim. (b.) For any identified disability of the right hand, arm, and hip, is it at least as likely as not (that is, a 50 percent or greater likelihood) that the disability represents a permanent additional disability or aggravation of disability as a result of VAMC medical treatment, specifically the Decadron injection that was administered to the Veteran on November 26, 2008? (c.) If so, was any additional disability a risk that a reasonable health care provider would have disclosed in connection with the informed consent procedure for the care provided by VA? (d.) If so, is it at least as likely as not (that is, a 50 percent or greater likelihood) that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instances of fault in administering this injection to the Veteran? (e.) Is it at least as likely as not (that is, a 50 percent or greater likelihood) that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or furnished the prescribed medication or treatment? When answering these questions, the examiner must specifically discuss the Veteran’s contentions regarding the symptoms that he suffered after receiving the November 26, 2008 injection, and the VAMC records showing that on November 27, 2008, the Veteran sought emergency treatment for pain in his right arm, hand, and hip, and swelling of the right hand. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.A. Flynn, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.