On Feb. 27, 2011, plaintiff Chad Simmons, 50, a backhoe driver, experienced an episode of left-sided facial numbness, uncontrolled clenching of his left hand, and some weakness and skin irritation in his left leg. He also complained of a headache and dizziness. Simmons subsequently presented to the emergency room at Palo Alto VA Health Care System, in Palo Alto. Simmons previously presented to the emergency room at the Palo Alto VA Health Care System on Feb. 20, 2011. He complained of his “heart beating in [his] ears,” right-sided visual disturbance, a headache, jaw clenching, and an ongoing neck pain. Simmons was allegedly sent home with discharge instructions, noting a final diagnosis of acute sinusitis and otitis media, but there was no discharge note from an emergency room physician. Later that morning, Simmons saw an ophthalmologist, who noted that Simmons was experiencing light sensitivity and blurriness in his right eye, as well as haziness, like a film was over his eye. Simmons also complained of a mild, right-sided headache, which he described as pressure, not pain. As a result, Simmons was counseled on ocular migraines. Three days later, Simmons followed up with VA Internal Medicine Physician David Yao. This time, Simmons complained that he was unable to sleep much because when he lies down, he feels his heart pounding. As a result, he was sent home with a short course of pseudoephedrine and sinus wash. On Feb. 26, 2011, Simmons fainted when he tried to stand. As a result, the next day, he returned to the VA Medical Center in Palo Alto and was seen by Dr. James Connor, who noted a differential diagnosis of possible cerebrovascular accident (CVA) or transient ischemic attack (TIA) in his report. Connor claimed that he discussed the case on the phone with a neurologist, who felt that a TIA was unlikely and who recommended an EKG and perhaps an outpatient MRI through Simmons’ primary care physician. (However, there was no record of the phone conversation and the government could not identify the neurologist who spoke to Connor.) A non-contrast CT of Simmons’ head was performed and found to be normal, but no MRI, other diagnostic radiograph or ultrasound was taken to rule out a CVA or a TIA, or its cause. Connor’s emergency department report indicated that he “will recommend 1 ASA (aspirin) per day.” However, Simmons and his wife both do not recall receiving any instructions or counseling in regard to taking aspirin. The discharge instructions noted that Simmons received a final diagnosis of sinusitis and was instructed to see his primary care physician as soon as possible. On March 1, 2011, Simmons began having increased problems with his memory. As a result, he contacted the VA Advice Nurse and was told to return to the emergency room. The nurse explained that Simmons needed to see a doctor immediately or his condition could worsen and that Simmons should take ASA (aspirin), as directed. Simmons subsequently went to the emergency room at the VA Medical Center in Palo Alto on March 1, 2011, and was seen by Dr. Sanjiv Singh. There was no reference to aspirin in Simmons’ active medication. On physical exam, Simmons exhibited confusion with word choice, misdated some forms, and initially responded he had no siblings when he had four. A CT scan showed multifocal hypodensities, and Singh noted a need for an MRI/MRA of Simmons’ head and neck for further evaluation. The neurology resident was consulted, and it was noted that they “remained concerned for stroke.” At 3:43 p.m., Simmons was taken for an MRI, which revealed acute bilateral watershed infarcts and right carotid occlusion that was suggestive of right carotid dissection. While in the waiting area after his MRI was completed, Simmons became unresponsive and suffered a massive stroke. Simmons sued the owner and operator of the subject VA hospital, the United States of America. He alleged that the defendant failed to timely diagnosis and treat his condition and that these failures constituted medical malpractice. Plaintiff’s counsel contended that the differential on Feb. 27, 2011 clearly included a TIA or stroke, requiring an emergent work-up and prophylactic treatment with anticoagulation or antiplatelet therapy. Counsel contended that as a result, an MRI/MRA should have been completed within 48 hours of Simmons’ presentation to the VA Medical Center on Feb. 27, 2011, and that if MRI/MRA was not available, a carotid ultrasound or a CTA should have been ordered within that time frame. Counsel also contended that Simmons should have been admitted to the hospital for neurological consultation and monitoring, as well as for medical management. Plaintiff’s counsel asserted that if appropriate studies had been ordered within the standard 48-hour window, then the carotid dissections would have been identified, along with the fact that Simmons had hypoperfusion (decreased blood flow). Counsel also asserted that Simmons should have received medical management with antiplatelet or anticoagulation therapy, along with monitoring of his hypoperfusion starting on Feb. 27, 2011, and that the staff at the VA should have continued antiplatelet/anticoagulation therapy when Simmons returned to the emergency room on March 1, 2011. Plaintiff’s counsel noted that although a stroke/TIA was in the differential diagnosis on March 1, 2011, it was not immediately worked up or treated, no CTA or carotid duplex was ordered, an MRI/MRA was not scheduled until the next day, and Simmons received no anticoagulation or antiplatelet therapy at that time. Thus, counsel asserted that, more likely than not, if Simmons had been properly managed, the massive stroke suffered on March 2, 2011, would have been avoided and Simmons would have resumed his normal life. Defense counsel contended that the physicians at the VA acted within the standard of care at all times and that Simmons was advised to take aspirin on Feb. 27, 2011, as noted in Connor’s emergency department report. Counsel also contended that the VA Advice Nurse had instructed Simmons to take aspirin as instructed, as well as well as return to the emergency room. However, defense counsel asserted that aspirin is only effective in preventing strokes in one out five patients with TIA and that, more likely than not, the stroke would not have been prevented by aspirin therapy., Simmons suffered a massive stroke while in the waiting area after his MRI. A Code Blue was called and it was ultimately decided to initiate an IV tissue plasminogen activator, a stroke treatment that has the potential of reversing stroke effects. Following the stroke, Simmons was noted to be perfusion dependent and suffered an escalation of symptoms when his head was elevated at times. He now suffers from left-sided numbness, left facial droop, and an “alien hand” as a result of the stroke. He also suffers from pseudobulbar affect, which causes sudden and unprovoked episodes of crying. The long term effects of the stroke also include cognitive deficient and memory problems. Plaintiff’s counsel also contended that Simmons suffered behavioral changes as a direct consequence of the brain pathology of the stroke. Prior to the stroke, Simmons was self-employed as a backhoe driver. However, he now suffers a full loss of income as a result of the stroke. Defense counsel conceded that Simmons was unable to work post-stroke. However, defense counsel asserted that Simmons was not working much prior to the stroke due to the poor economy and other health problems. Counsel also asserted that, absent the stroke, Simmons would not have been able to return to work in construction due to the carotid dissections.