Cesal v. Moats

• Decision Date: 20 March 2017
• Docket Number: No. 15-2562,15-2562
• Citation: 851 F.3d 714
• Parties: Craig J. CESAL, Plaintiff–Appellant, v. Scott MOATS, Defendant–Appellee.
• Court: U.S. Court of Appeals — Seventh Circuit

851 F.3d 714

Craig J. CESAL, Plaintiff–Appellant,

v.Scott MOATS, Defendant–Appellee.

No. 15-2562

United States Court of Appeals, Seventh Circuit.

Argued November 8, 2016

Decided March 20, 2017

Jory Hoffman, Barry Levenstam, Attorneys, Jenner & Block LLP, Chicago, IL, for Plaintiff–Appellant.

Lillian Stewart, Attorney, Office of the United States Attorney, Springfield, IL, for Defendants–Appellees.

Before Wood, Chief Judge, and Posner and Rovner, Circuit Judges.

Wood, Chief Judge.

While lifting a heavy door at his prison job at the Pekin Correctional Institution on March 21, 2008, Craig J. Cesal heard a "snap" in his back and felt pain in his leg and hip. He promptly sought treatment from the prison's medical staff, but he was dissatisfied with their response. He alleges that he received only a three-year long medical runaround during which his pain was ignored. Worse, he says, Pekin's Clinical Director, Dr. Scott Moats, canceled Cesal's insulin

prescription in retaliation for Cesal's filing of a complaint about the inadequate care for his back. Without the prescription, Cesal—an insulin-dependent diabetic—was unable to control his blood sugar and consequently suffered additional unnecessary pain and physical harm. He filed a second complaint with the prison about the insulin deprivation.

Cesal ultimately sued Dr. Moats and Dr. Andreas Molina, another Pekin physician, alleging that they exhibited deliberate indifference in the care they gave him. At the screening phase, see 28 U.S.C. § 1915A, the district court identified two claims in Cesal's pro se complaint: an Eighth Amendment deliberate-indifference claim regarding his back treatment, and a First Amendment retaliation claim related to the withholding of insulin. The district court granted summary judgment for the defendants on both issues, reasoning that the statute of limitations on his complaints had run and that, in any event, there was no question of material fact that would justify allowing his case to move forward. Cesal appeals only the judgment in favor of Dr. Moats, and so we largely disregard Dr. Molina's role in these events. Although Cesal's allegations are troublesome, we conclude in the end that the district court's judgment must be affirmed.

I

Because this is an appeal from the grant of summary judgment, our review is de novo . Conley v. Birch , 796 F.3d 742, 746 (7th Cir. 2015). At this stage of the litigation, we assume that the facts alleged by Cesal are true, and we draw all reasonable inferences in his favor. Dixon v. Cnty. of Cook , 819 F.3d 343, 346 (7th Cir. 2015). Summary judgment is appropriate when there are no genuine disputes of material fact and the movant is entitled to judgment as a matter of law. Fed. R. Civ. P. 56 ; Celotex Corp. v. Catrett , 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986).

Between March 21, 2006, and March 28, 2011, Cesal was serving a life sentence at the Pekin Federal Correctional Institution, which is run by the Bureau of Prisons (BOP). There, he worked as a welder—a physically demanding job that required him to move 320–pound doors. He was lifting one such door on Friday, March 21, 2008, when he heard a "snap" in his back and felt sharp pain in his left hip and knee. He immediately sought care at the medical unit, but was told that the facility was closing and instead to report to sick-call on Monday, March 24. He did so, meeting with a nurse that day. By then, Cesal had been given a wheelchair and was temporarily excused from his job. Dr. Moats gave him a verbal order for Motrin

(the active ingredient of which is ibuprofen ) but was not otherwise involved in his treatment that day.

Cesal was next seen by a physician assistant on March 27. Cesal reiterated his report of pain and numbness in his leg and hip. Although he still was using the wheelchair, the physician assistant noted that Cesal had "no difficulties getting up to sit on exam table" and that Cesal displayed normal gait and posture. During the exam, the physician assistant reviewed x-rays of Cesal's back. These x-rays had been taken on March 12, 2008—before Cesal's lifting accident—in response to his earlier reports of hip pain and numbness in his knee and thigh. The physician assistant prescribed Cesal ibuprofen

for another ten days.

Dr. Molina saw Cesal at a follow-up appointment on March 31, when Cesal reported having moderate low-back pain and some numbness in his leg. Four days later, on April 3, the medical staff took an x-ray of Cesal's lumbar spine, which is the area between the rib cage and pelvis. That x-ray showed that Cesal had degenerative joint disease

and disc disease, a diagnosis which previously had shown up in a different x-ray. Otherwise it revealed no problems.

The very next day Cesal filed an informal complaint—the first step in the administrative grievance process—about the treatment he was receiving for his back. In this complaint, Cesal reported that he had "acute pain in my hip and knee, also numbness along the front of my thigh" and that he could not "stand or walk for a worthwhile duration." He said that he "ha[d] been to Medical Dept. repeatedly, but examination or care have been denied." Cesal asked for a medical evaluation and appropriate treatment.

His complaint was rejected. On May 6, 2008, Cesal appealed this denial to the Warden—the proper next step for an inmate who is unsatisfied by the response to an informal complaint. Cesal alleged that he had been evaluated only superficially and never seen by a doctor for acute pain in his left hip and knee and numbness in his left thigh. He did not allege back pain. The Warden rejected Cesal's appeal on June 9, 2008, noting that Cesal's medical records indicated that he was receiving appropriate care.

The Warden's denial also noted that medical officials were awaiting the results of a June 4, 2008, MRI of Cesal's lumbar spine. This scan had been requested on April 15, and was approved sometime in the interim. By June 16, 2008, the results were in. The MRI revealed a few problems—mild stenosis (narrowing of the spinal canal) in one spot, and disc degeneration with mild bulging elsewhere without major stenosis. But this diagnosis did not assuage Cesal's concerns. He appealed the denial of his grievance on June 25, 2008, moving up another rung on BOP's grievance ladder.

Two days after Cesal filed that appeal, on June 27, Dr. Moats saw him in the prison's chronic care clinic for what Cesal describes as a "non-routine visit." As Cesal tells it, Dr. Moats had learned of Cesal's grievance for the treatment of his back issue and was angry. Dr. Moats told Cesal that he would "show him" what providing no medical care looked like, and then abruptly terminated Cesal's prescription for insulin

for no medical reason. Cesal is an insulin-dependent Type II diabetic; he had been taking sliding scale insulin. Without insulin, Cesal was left to manage his blood sugar through diet, exercise, and metformin, a prescription drug that Dr. Moats did not cancel, which is commonly used for type II diabetes

to control high blood sugar. Metformin, WEB MD, http://www.webmd.com/drugs/2/drug–112857061/metformin-oral/metformin ---oral/details (last visited March 20, 2017). "Metformin works by helping to restore your body's proper response to the insulin you naturally produce. It also decreases the amount of sugar that your liver makes and that your stomach/intestines absorb." Id. Cesal skipped meals or went for runs when his blood sugar level got too high. But despite these efforts, Cesal's blood sugar soared. As a result, he felt dizzy and saw stars, and his toenails fell off.

Cesal's back pain also continued to bother him. Dr. Moats requested a consultation for a "back specialist" for Cesal on October 6, 2008; his request was approved about a month later. In the meantime, Cesal appealed his back-pain grievance in accordance with BOP rules; he exhausted this process on November 25, 2008, when his last appeal was denied. He finally saw the specialist on March 31, 2009, some five months after the visit had been approved. Cesal told the consulting neurologist that his pain was moderate, but he also reported that he usually jogged two or three miles a day. The neurologist recommended no major changes to Cesal's current "conservative" treatment plan and indicated that he did not believe that surgery or steroid injections would help.

On December 23, 2008, after nearly six months without his sliding scale insulin, Cesal filed a second administrative grievance concerning his diabetes treatment. He specifically requested the restoration of his insulin prescription. Again, his grievance and related appeals were denied at each level of the BOP administrative process. The denial dated January 21, 2009, noted that Pekin's clinical director (presumably Dr. Moats) had discussed with Cesal a different diabetes

management program that was "tailored to prevent hyperglycemia, not to treat it after it occurs." A subsequent denial from March 6, 2009, noted that Cesal still had oral medication for his diabetes and concluded that "sound clinical judgment is being demonstrated" in Cesal's treatment. Cesal exhausted the prison grievance process for this claim on May 26, 2009, when his final appeal was denied.

Medical records show that Cesal had several visits with Dr. Moats in 2009 and 2010, but Dr. Moats did not re-prescribe him insulin

until October 29, 2010. On that date, Dr. Moats prescribed Cesal five units of insulin—half the dosage he had been receiving in June 2008, when his prescription had been cancelled. In the months following the insulin renewal, Dr. Moats stepped up Cesal's dosage incrementally. By February 22, 2011, Cesal was back on the same ten-unit dosage he had received in June 2008.

On March 28, 2011, Cesal was transferred from Pekin to the Federal Correctional Institution in Greenville, Illinois. His back pain worsened, and so he sought treatment there. An October 9, 2012 x-ray of Cesal's middle back revealed...