EARL BEERS, Employee, v. GENERAL MILLS and LIBERTY MUT. INS. CO., Employer-Insurer/Appellants, and HEALTHPARTNERS and NORIDIAN/MEDICARE, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
OCTOBER 20, 2004
EVIDENCE - EXPERT MEDICAL OPINION; CAUSATION - SUBSTANTIAL EVIDENCE. Absolute certainty in the opinion of an expert medical witness is not essential to support a finding as to a relationship between a work injury and subsequent disability; a medical opinion is sufficient if it is probably true. The standard for expert opinion testimony is the Areasonable probability@ standard, that is, the expert testimony must demonstrate it was more likely than not that the personal injury was a substantial contributing cause of the disability. Considering the testimony of the employee=s cardiologist, Dr. Taylor, as a whole, along with the opinion of Dr. Wolters and the testimony of the employee, there is adequate support for the compensation judge=s finding of causation.
Determined by Johnson, C.J., Wilson, J., and Pederson, J.
Compensation Judge: Patricia J. Milun
Attorneys: David J. Odlaug and Jason L. Schimickle, Hansen, Dordell, Bradt, Odlaug & Bradt, St. Paul, MN, for the Appellants. Larry J. Peterson, Peterson, Logren & Kilbury, St. Paul, MN, for the Respondent.
THOMAS L. JOHNSON, Judge
The employer and insurer appeal the compensation judge=s finding that the employee=s work injury was a substantial contributing cause of syncopal episodes and appeal the compensation judge=s award of benefits. We affirm.
On January 14, 1997, Earl Beers, the employee, sustained a personal injury while working for General Mills, the employer, then insured by Liberty Mutual Insurance Company. Apparently, a metal access door on a pneumatic tube system blew off and struck the employee in the head, face, mouth and chest areas. The employer and insurer admitted liability for the employee=s personal injury.
As a result of his personal injury, the employee sustained an open skull fracture, multiple facial fractures, a chest injury and a traumatic brain injury. The employee was hospitalized at the Hennepin County Medical Center (HCMC) with compound frontal basilar skull fractures, multiple facial fractures and a chest wall wound. While hospitalized, the employee underwent a ventriculostomy to maintain intracranial pressure, a bifrontal craniotomy to repair compound skull fractures and an enucleation of the right eye. While recuperating in the hospital, the employee had complications of deep vein thrombosis in his right arm and both legs. A CT scan of the skull and brain revealed bifrontal encephalomalacia. The employee subsequently underwent extensive rehabilitation and multiple facial reconstructive surgeries.
On April 21, 2000, the employee saw Dr. Mark Wolters at the HCMC complaining of multiple episodes of syncope over the prior two weeks. The employee stated the episodes occurred three to four times a day when he moved his head. The doctor noted the employee sustained a traumatic brain injury in 1997 resulting in cognitive difficulties of function. Dr. Wolters initially felt the employee=s complaints were related to an eustachian tube dysfunction. In June 2001, the employee was referred to the cardiology clinic at the HCMC for evaluation of syncope. A CT scan of the head, autonomic testing and a cardiac ultrasound were essentially normal. Dr. Frederick Langendorf, a neurologist, examined the employee at the request of Dr. Wolters and concluded, Aeven in view of the head injury, there is little to suggest seizures as a mechanism.@ The doctor ordered an EEG which was normal.
In October 2002, the employee came under the care of Dr. Richard Taylor, a cardiologist and electrophysiologist at the HCMC. Dr. Taylor performed an electrophysiology study that was basically normal and showed no cause for the employee=s syncope. The doctor then implanted a loop recorder that demonstrated intermittent slowing of the employee=s heart rate or bradycardia which Dr. Taylor believed was neurogenic and very likely related to his personal injury. In December 2003, Dr. Taylor implanted a pacemaker and removed the loop recorder. The employee has not experienced any further episodes of syncope.
The employee filed a Medical Request seeking payment of certain medical expenses incurred due to his syncope condition. The employer and insurer denied a causal relationship between the employee=s personal injury and syncope. In preparation for the hearing, the deposition of Dr. Taylor was obtained. The doctor testified the loop recorder data showed the employee had several asystole episodes during which he had no heart beat for approximately five seconds which was distinctly abnormal. Dr. Taylor concluded the employee=s syncope was related to an intermittently slow heart beat which required a pacemaker. The doctor stated he believed the cause for the employee=s slow heart rate was an interconnection between the autonomic nervous system and the cardiovascular system. Dr. Taylor opined the employee=s personal injury caused autonomic imbalance that could lead to syncope. The doctor also stated the psychological impact of the post-traumatic stress could have affected the autonomic nervous system leading to bradycardia which caused the syncope.
Dr. Bruce Van Dyne, a neurologist, examined the employee on behalf of the employer and insurer, and his deposition was obtained prior to the hearing. In his deposition, the doctor testified as follows:
It is my opinion that there is absolutely no connection whatsoever between the cardiac events that have caused him to have syncopal episodes and his brain injury of 1997. I am not aware of - in my own personal experience of neurology for many years-of any instance in which a delayed effect on the cardiac=s autonomic functioning has been brought about by a prior head injury months or years prior to that time.
Secondly, I=m not aware of any place in the neurologic literature where there has been even a passing reference to the fact that such an event might be caused by a head injury many years beforehand.
It=s my opinion that Mr. Beers= syncopal episodes are occurring solely as a result of the fact that he is a 70-year old man, who likely has some [aging] effects, degenerative changes on conduction qualities of his heart, and that the changes noted on his revealed loop recorder, in which he had three events in three days, are not - have not been influenced and are not influenced by his prior head injury. There simply is no connection, there=s no reasonable way in which that might have occurred to have caused such a condition.
(Resp. Ex. 2 at 16-17.)
The employee=s Medical Request was heard by a compensation judge at the Office of Administrative Hearings. In the Findings and Order, the compensation judge accepted the medical opinions of Dr. Taylor over those of Dr. Van Dyne, and found the employee=s disputed treatment at the Hennepin County Medical Center was causally related to the employee=s personal injury. The employer and insurer appeal.
On appeal, the appellants cite the following testimony of Dr. Taylor:
A: . . . I also believe that the pain that Mr. Beers had suffered could have a profound effect on the autonomic nervous system and could be a factor in some of these neurocardio-genic causes for syncope. And I also believe, if I may add, that the psychological trauma that he suffered could have a profound effect on his autonomic nervous system and may also be a contributing factor. The trauma that Mr. Beers suffered I think would - although again I=m not an expert in neurology and I=m not an expert in psychiatry, but I believe that he suffers from post-traumatic stress disorder based upon what he - what he - what he endured at the time of the injury and what he=s endured subsequently over the last seven years.
Q: So what=s triggering this slowing heart rate is something in his system external to the heart organ itself?
A: That=s my assumption. I can=t really prove that. You know, there are other possibilities, but I believe that it has to do with the interconnections that we talked about between the autonomic nervous system and the cardiovascular system.
Q: Maybe you could just state the connection between Mr. Beers= injuries and what you believe was an impact, if any, on the autonomic system.
A: I believe that Mr. Beers= injuries and the resulting pain and psychological trauma could very well have impacted his autonomic nervous system and that may in fact have caused the bradycardia that we=ve documented and that may be a cause for his syncope.
Q: Wouldn=t you expect that if this man=s brain injury on January 14 of 1997 caused some defect in the autonomic nervous system that he would experience syncopal episodes shortly after that injury?
A: I can=t answer that. I don=t really know, you know, what the balance and imbalances that would be created by such an injury and what effect it would have on the autonomic nervous system. It=s way too complex for me to say if he had an injury that it - if he had a brain injury that resulted in his - an imbalance in his autonomic nervous system that one would expect him to pass out between a certain date. I couldn=t say that.
(Pet. Ex. C at 14-16-, 19, 37-38, emphasis added by appellants.)
In Grunst v. Immanuel-St. Joseph Hosp., 424 N.W.2d 66, 40 W.C.D. 1130 (Minn. 1988), the Supreme Court stated, AIf an opinion by a medical expert in a respected, recognized field of medicine is given with reasonable medical certainty, that opinion may, if the finder of fact chooses to rely on it, support a causal link between the worker=s disability and the job.@ The appellants here contend Dr. Taylor=s opinions fall short of any reasonable medical certainty. At no point in his testimony, the appellants argue, does Dr. Taylor ever provide an opinion unqualified by words such as Acould@ or Amay.@ Accordingly, the appellants argue, the compensation judge=s reliance on the opinions of Dr. Taylor was legally erroneous and must be reversed. We are not persuaded.
Since the law is not an exact science, Minnesota courts have never required medical experts to testify in terms of absolute or mathematical certainty. In Hiber v. City of St. Paul, 219 Minn. 87, 16 N.W.2d 878, 13 W.C.D. 302 (1944), the Supreme Court stated the standard of certainty necessary for expert opinion testimony as follows:
It is not necessary that the truth of an expert=s opinion be capable of demonstration; it is sufficient that it is probably true.
In Powers v. Eddy=s Baking Co., 261 Minn. 363, 112 N.W.2d 625, 22 W.C.D. 71 (1961), the court stated:
We have frequently held that absolute certainty in the opinion of expert medical witnesses is not essential to support a finding as to the relationship between an industrial accident and subsequent disability.
To establish causation, it is not necessary to establish absolute medical certainty; a medical opinion is sufficient if it is probably true. Pommeranz v. State, Dep't of Public Welfare, 261 N.W.2d 90, 91, 30 W.C.D. 174, 176-77 (Minn. 1977). In Walton v. Jones, 286 N.W.2d 710 (Minn. 1979), the court reiterated the standard for expert opinion testimony was the Areasonable probability@ standard, that is, the expert testimony must demonstrate Ait was more likely than not@ that the employee=s injury was a substantial contributing cause of the disability. Id. at 715.
When asked whether the employee=s personal injury was one of the substantial causes of his bradycardia condition, Dr. Taylor responded,
I believe that, you know, that both directly and indirectly the answer to your question is yes. I believe that the trauma that occurred could well have caused autonomic insufficiency B or not autonomic insufficiency. Let me rephrase that. Autonomic imbalance that could lead to syncope. And I also believe that the psychological impact in the form of posttraumatic stress could have affected the autonomic nervous system in a way that could have led to the bradycardia and caused a syncope. And finally, I=d like to say that the pain that he suffers from on a chronic recurring basis which is a result of the accident could impact on his autonomic nervous system and have led to syncope. So I believe that there is a direct relationship and an indirect relationship between the injury and the syncope.
(Pet. Ex. C at 16-17.)
By report dated November 8, 2002, Dr. Wolters stated,
[I]t would become apparent that the patient=s syncopal episodes are almost definitively associated with the traumatic brain injury that he had in 1997, although we have not been able to capture any significant neurologic events to justify this etiology completely. (Pet. Ex. A.)
Admittedly, Dr. Taylor was not quite definite and positive in his opinions as to the causal relationship between the employee=s injury and the syncopal episodes. Likely, the doctor=s lack of absolute certainty was due to the inability to record any abnormality on any of the neurologic or electrophysiologic tests. On balance however, we conclude the opinions of Dr. Taylor meet the reasonable probability standard. Despite his use of the words Acould@ and Amay,@ Dr. Taylor=s testimony considered in its entirety evidences an opinion that the employee=s syncopal episodes, more likely than not, were caused in substantial part by his personal injury. Dr. Taylor=s testimony, together with that of the employee and the opinion of Dr. Wolters, adequately support the compensation judge=s decision. The compensation judge=s decision must, therefore, be affirmed. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984).