BRUCE SCHAAF, Deceased Employee, by JOAN SCHAAF, Petitioner/Appellant, v. BIFFS, and STATE FUND MUT. INS. CO., Employer-Insurer, and QUEEN OF PEACE HOSP., LIFE LINK III, BELLE PLAINE AMBULANCE, VA MED. CTR., and SOUTHERN METRO MED. CLINIC, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
OCTOBER 18, 2005
CAUSATION - HEART CONDITION. Substantial evidence, including expert medical opinion and medical records, supports the compensation judge=s finding that the employee=s work-related injury in 1998 did not represent a substantial contributing factor in the employee=s fatal myocardial infarction in 2002.
Determined by: Rykken, J., Johnson, C.J., and Pederson, J.
Compensation Judge: Peggy A. Brenden
Attorneys: Raymond R. Peterson, McCoy, Peterson & Jorstad, Minneapolis, MN, for the Petitioner/Appellant. John M. Hollick, Lynn, Scharfenberg & Associates, Minneapolis, MN, for the Respondents.
MIRIAM P. RYKKEN, Judge
The employee appeals from the compensation judge=s finding that the employee=s July 21, 1998, work injury was not a substantial contributing factor in his fatal myocardial infarction on November 27, 2002. We affirm.
On July 21, 1998, at age 47, Mr. Bruce Schaaf, sustained an admitted severe crush injury to his right foot and ankle while employed as a forklift operator by Biffs, the employer. He received emergency treatment, including surgery for wound debridement, and was hospitalized. The employee later developed an infection, and then a severe abscess and gangrene in his right leg, which necessitated amputation, in September 1998, of his right leg below his knee. The employee later was fitted with a prosthesis which provided him mobility; he underwent physical therapy and eventually was able to return to work for the employer in a supervisory position. The employee ultimately required medical treatment for his left ankle due to the additional pressure that had been placed on his left leg, and on November 22, 1999, he underwent a left ankle fusion. Following the employee=s left ankle surgery, he utilized a wheelchair for most of his movement, and was unable to return to work.
The employer and its insurer, State Fund Mutual Insurance Company, admitted liability for the employee=s left ankle condition and paid for medical expenses related to his left ankle. As a result of his work injuries, they paid temporary total disability and temporary partial disability benefits, permanent partial disability benefits based on ratings of 28% whole body impairment relative to his right leg and 8% relative to his left leg. They also provided rehabilitation assistance and later paid for expenses incurred for necessary remodeling of the employee=s residence, completed to facilitate his movement into and throughout his residence and to otherwise adequately accommodate his disability.
One issue on appeal is whether the employee=s weight gain following his work injury ultimately led to his death. The employee=s weight fluctuated after his injury and related surgeries. He was six feet tall, and for most of his adult life he weighed approximately 250 pounds. Following his 1998 injury, the employee=s weight increased; at the time of his death, he weighed approximately 290 pounds, even with a portion of his right leg removed by amputation. In addition, following the employee=s injury, the level of his smoking increased, and he was also treated for depression.
The employee had a history of extensive medical treatment prior to his July 1998 work injury. In August 1987, a few days before his 37th birthday, the employee suffered a myocardial infarction. He underwent a coronary angiography that showed mild disease in the right coronary artery with an ejection fraction - - a measurement of the heart=s pumping ability - - of 50 to 55%. Studies also showed dyskinesia of the distal one-third of the interior wall of the left ventricle. His medical records at that time noted that he had a 20-year smoking history of one pack per day. The employee sustained a recurrent myocardial infarction in March 1988, underwent an angioplasty of an occluded left anterior descending coronary artery, and had follow-up cardiac treatment in April 1988. In September 1990, the employee sustained an additional myocardial infarction; a coronary angiogram showed diffuse distal disease in the left anterior descending coronary artery. His physicians recommended conservative medical management at that time. In February 1991, the employee was again hospitalized with chest pain, was diagnosed as having unstable angina, and was released after a four-day hospitalization. The discharge summary referred to his athrosclerotic coronary artery disease. In July 1991, the employee was hospitalized after he experienced left hand weakness and left facial numbness as well as slurred speech. He was diagnosed as having experienced multiple cerebral emboli, and was treated with anticoagulant medication to limit the formation of blood clots.
In September and October of 1994, the employee experienced another episode of chest pain and unstable angina, and EKG testing showed that he had an injection fraction of only 30 to 35%. He underwent a stress thallium test that showed defects in his left ventricle. In July 1998, before undergoing surgery to his right leg, the employee underwent a cardiac evaluation which showed fixed perfusion defects in four segments of the heart and showed his left ventricle to be significantly dilated and his left ventricular function to be severely decreased. By the time of his injury in July 1998, the employee=s physicians had diagnosed that his heart muscle was severely damaged and had a pumping ability - - an ejection fraction - - of roughly half of a normal level. The employee=s medical records from his treatment to his left and right lower extremities also include multiple references to his cardiac condition, as that condition required monitoring by the employee=s treating physicians.
At the request of the employer and insurer, Dr. Berman examined the employee on December 6, 2000. In his report prepared following that examination, Dr. Berman diagnosed the following:
1. Arteriosclerotic coronary heart disease with multiple previous myocardial infarctions, severely reduced left ventricular function, history of cerebral emboli, previous angioplasty of the left anterior descending coronary artery, and diffuse distal disease of the left anterior descending coronary artery.
2. Below the knee amputation of the right leg secondary to gangrene resulting form his crush injury to the right foot in July 1998.
3. Peripheral vascular disease with ischemic ulceration of the left ankle.
4. Multiple risk factors including high cholesterol, positive family history, history of cigarette smoking, overweight, and history of hypertension.
In 2001, the employee was treated for depression, posttraumatic stress disorder and sleep apnea; he had been diagnosed with sleep apnea by at least 1999. In May 2001, the employee was hospitalized after he had difficulty awakening and was confused, drowsy, and experienced twitching in his arms. He was diagnosed as having chronic obstructive pulmonary disease and sleep apnea syndrome, with the possibility of congestive failure. Pulmonary function testing indicated restrictive lung disease, possibly due to sleep apnea, and consistent with his obesity. He was discharged from the hospital with a prescription for a home oxygen tank.
The employee=s medical records in February 2002 refer to a diagnosis of depression and chronic anxiety. In April 2002, the employee was taken to the hospital when he became unresponsive and was experiencing shortness of breath. He was tested for respiratory failure and underwent cardiac testing that showed an ejection fraction of 15%. It was determined that the employee had not sustained a myocardial infarction at that time. In May 2002, the employee was treated for respiratory distress. Findings on chest x-rays were consistent with congestive heart failure and pulmonary edema. He was again hospitalized in August 2002 and was diagnosed with congestive heart failure and interstitial pulmonary edema, and was diagnosed with ischemic cardiomyopathy.
By claim petition filed in February 2001, and amended in July 2001, the employee sought payment for certain medical treatment he received from the Minneapolis Veterans Administration Medical Center between 1998 and 2002, including treatment for his left ankle, as well as treatment he received from various medical providers in 2001, largely for his pulmonary condition and sleep apnea. He contended that the treatment was causally related to his 1998 work injury. The employer and insurer denied that the employee=s injury substantially contributed to his need for the claimed medical treatment. The employee=s claim petition was addressed at a hearing at the Office of Administrative Hearings on October 3, 2002, held before Compensation Judge Peggy A. Brenden. The employee contended that his symptoms and need for treatment were the result of his weight gain he experienced after his 1998 work injury. In her Findings and Order served and filed November 5, 2002, the compensation judge denied the employee=s claim for medical expenses incurred in May 2001, concluding that no causal connection existed between the employee=s work injury and his need for treatment in May 2001. The compensation judge awarded a portion of the employee=s claims, however - - payment for particular expenses incurred for medical treatment at the VA Medical Center, including medical treatment to the employee=s left ankle and certain of his prescription medications. No appeal was taken from the November 5, 2002, findings and order.
On November 27, 2002, the employee died as a result of an acute fatal myocardial infarction. His attending physician=s chart notes state that he experienced a witnessed arrest at home and collapsed after he became acutely short of breath. After attempts by emergency personnel and doctors at the hospital failed to revive him, the attending physician determined that the employee Asuffered a massive acute myocardial infarction causing ventricular arrhythmia and cardiovascular collapse.@ The employee=s surviving wife, Ms. Joan Schaaf, later filed a claim petition, seeking dependency benefits. The employer and insurer denied the claim, contending that no causal relationship existed between the employee=s 1998 injury and his fatal myocardial infarction.
The record contains opinions from two medical experts, Dr. James Zavoral and Dr. David Berman, both cardiologists, concerning the issue of whether there was a causal relationship between the employee=s injury and his death. Dr. Zavoral conducted a medical record review on behalf of the employee=s wife. Dr. Zavoral testified that, at the time of his first myocardial infarction in 1987, the employee had an unusually advanced level of heart disease for a person of his age. Dr. Zavoral concluded, however, that the employee=s work injury and the consequential changes to a sedentary life style, immobility and inability to work substantially contributed to the progression of his heart disease and death. In his report of March 16, 2004, Dr. Zavoral summarized his conclusions as follows:
It is my professional opinion that Mr. Schaaf=s crush injury at Biff=s and his subsequent amputation of his lower extremity and the stress from his traumatic injury and amputation and the subsequent weight gain experienced as a result of this work injury of approximately 50 pounds, were substantial, aggressive contributing factors to his ultimate death as a young man of 52 years of age in November of 2002.
Although Mr. Schaaf had pre-existing heart disease with prior admissions for ischemia and myocardial infarctions and had had a cerebral infarct and was a chronic smoker and had a family history of heart disease, he still was very young and I believe that his cardiac condition substantially and abruptly declined due to the aggravation of stress, weight gain and depression following his crush injury with the necessitated amputation of his lower extremity which ultimately led to his death.
It is clear that [as an amputee, his] decreased ability to mobilize and increased pain on the surviving limb and attendant depression, left Mr. Schaaf in a very sedentary position which led to his weight gain and, among other factors, to his accelerated premature death.
At his deposition, Dr. Zavoral referred to the employee=s weight gain following his injury and the development of his depression. Dr. Zavoral testified that Mr. Schaaf=s inability to effectively exercise significantly decreased his ability to control his stress and weight gain. Dr. Zavoral also believed that the employee=s depression contributed to his cardiac problems, in part, because depression can lead to Apoorer choices of taking medication, not eating properly, smoking, which further aggravate the other [cardiac] risk factors.@ (Zavoral Depo., Employee Exh. D, p. 23.) Dr. Zavoral concluded that those were all substantial contributing factors that aggravated the employee=s underlying risk for heart disease and early death. He explained that if Mr. Schaaf Ahad the ability to exercise and deal with stress, he would have been able to cope with the risk factors that he could change, such as smoking and obesity, and with medical management that he would have had somewhat of a longer, higher quality of life.@ (Zavoral Depo., Employee Exh. D, p. 39.)
Dr. Berman also conducted a medical record review following the employee=s death. In his report issued on June 14, 2004, Dr. Berman outlined his conclusions concerning the cause of the employee=s death. He referred to the severe damage to the employee=s heart muscle, incurred earlier, which had significantly impaired the pumping function of his heart. He concluded that the cause of death was A[v]entricular fibrillation cardiac arrest with sudden death secondary to severe ischemic cardiomyopathy due to multiple previous myocardial infarctions.@ He outlined his opinion concerning whether there was a causal relationship between the employee=s 1998 work injury and his death, as follows:
The work injury of July 21, 1998, and subsequent amputation were not, in my opinion, a substantial contributing factor in Mr. Schaaf=s death. The basis for this is that Mr. Schaaf had severe preexisting cardiac disease with multiple previous myocardial infarctions. The usual prognosis of coronary disease is natural progress and I find no evidence that the injury and amputation were an accelerating factor in his cardiac illness.
Dr. Berman concluded that the employee=s death was due to the natural progression of his cardiac and pulmonary disease, which was related substantially to risk factors of smoking, elevated cholesterol, obesity, hypertension, strongly positive family history, and preexisting coronary disease. Dr. Berman also concluded that although the employee=s work injury contributed to his weight gain, that gain was a very minimal contributing factor in his death and that the Aother risk factors were more important contributory causes of his coronary disease.@ At his deposition, Dr. Berman testified that the employee=s smoking history would have played a more significant role in the employee=s death. Dr. Berman also concluded that stress or depression did not play a clear role in Mr. Schaaf=s death.
The dependency claim, filed by Mr. Schaaf=s wife, was addressed at a hearing at the Office of Administrative Hearings on November 12, 2004. In her Findings and Order served and filed January 5, 2005, the compensation judge denied the claim for dependency benefits, concluding that the employee=s July 21, 1998, work injury did not represent a substantial contributing factor to the employee=s death. The compensation judge found that although the employee=s use of a wheelchair significantly reduced his ability to exercise, which in turn contributed to his weight gain following his injury, the evidence did not establish that the employee=s weight gain substantially contributed to his death. The compensation judge also concluded that although the employee=s July 21, 1998, work injury substantially contributed to the employee=s depression following his injury, the evidence did not establish that the employee=s depression caused, aggravated, or accelerated his death. The petitioner appeals.
On appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order are clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1 (2004). Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence is conflicting or more than one inference may reasonably be drawn from the evidence, the findings of the compensation judge are to be upheld as long as the evidence of record supports the compensation judge=s findings. Id. at 60, 37 W.C.D. at 240. See Redgate, 421 N.W.2d at 734, 40 W.C.D. at 957.
The petitioner argues that substantial evidence does not support the compensation judge=s finding that the employee=s work injury was not a substantial contributing factor in his fatal myocardial infarction on November 27, 2002. An employee=s injuries are compensable if the employment is a substantial contributing factor not only to the cause of the condition but also to the aggravation or acceleration of a preexisting condition. Wallace v. Hanson Silo Co., 305 Minn. 395, 235 N.W.2d 363, 28 W.C.D. 79 (1975). An employee need not prove that the employment was the sole cause, only a substantial contributing cause of the disability for which benefits are sought. See Swanson v. Medtronics, Inc., 443 N.W.2d 534, 536, 42 W.C.D. 91, 94-95 (Minn. 1989); see also Treazise v. United Hosp., 64 W.C.D. 160 (W.C.C.A. 2003), summarily aff=d (Minn. Feb. 25, 2004).
The petitioner argues that the employee=s work injury was a substantial contributing cause of the employee=s worsened cardiac condition, claiming that the employee=s preexisting condition and his injury-related weight gain and depression contributed to his death. In support of her argument, the petitioner points to the compensation judge=s findings that the employee=s injury contributed to his weight gain and depression. She also relies on Dr. Zavoral=s opinion that the employee=s work injury and its effects were substantial contributing causes in the acceleration of his heart disease and that, more likely than not, he would have lived longer had he been able to continue with his pre-injury active lifestyle. The petitioner also argues that Dr. Berman=s opinion supports this contention, citing to his opinions that weight gain and increased smoking can accelerate heart disease and that exercise and activity could slow the progression of the disease.
Medical causation is a Adistinct legal concept that concerns the connection between the primary injury and a later condition.@ Jackson v. Red Owl Stores, Inc., 375 N.W.2d 13, 18, 38 W.C.D. 170, 178 (Minn. 1985). In other words, the concept of medical causation concerns A>how far the range of compensable consequences is carried, once the primary injury is causally connected with the employment.=@ Id., quoting Wallace v. Judd Brown Const. Co., 269 Minn. 455, 459, 131 N.W.2d 540, 543, 23 W.C.D. 362, 367 (1964) (quoting 1 Larson, Workmen=s Compensation Law, ' 13.11). Where a personal injury causes or aggravates some independent medical condition such as an underlying cardiac condition, that condition may be compensable if medical causation exists. See, e.g., Hartman v. Cold Spring Granite Co., 243 Minn. 264, 67 N.W.2d 656, 18 W.C.D. 206 (1954); Dotolo v. FMC Corp., 375 N.W.2d 25, 38 W.C.D. 205 (Minn. 1985). In the present case, the petitioner does not contend the personal injury was the sole cause of the employee=s worsened cardiac condition. Rather, the petitioner asserts that the employee=s injury caused him to be inactive and restricted to a wheelchair, which in turn resulted in weight gain, depression and an increased level of smoking, which aggravated his cardiac condition. Thus, there are several intervening factors separating the work injury from the claimed compensable consequence. AThe more remote the claimed consequence is from the personal injury, the less likely it is the claimed consequence is compensable.@ Melartin v. Mavo Sys., Inc., 65 W.C.D. 405, 414 (W.C.C.A. 2005); see also Hendrickson v. Geo. Madsen Constr. Co., 281 N.W.2d 672, 31 W.C.D. 608 (Minn. 1979).
The record contains conflicting medical evidence concerning the issue of whether the employee=s 1998 work injury aggravated his underlying cardiac condition and cardiac risk factors and substantially contributed to his death on November 27, 2002. Dr. Zavoral concluded that the employee=s 1998 work injury aggravated his underlying cardiac condition and cardiac risk factors, by contributing to his weight gain due to inactivity and by contributing to his stress level resulting from his traumatic injury and depression resulting from inactivity, which in turn led to an increase in the level of his smoking. Dr. Berman determined that the employee=s work injury and subsequent amputation did not substantially contribute to nor accelerate the employee=s cardiac illness. Instead, he concluded that the employee=s death was due to the natural progression of his cardiac and pulmonary disease, and was related to the employee=s multiple risk factors, including smoking, elevated cholesterol, obesity, hypertension and strongly positive family history for cardiac disease.
Both doctors assessed the employee=s cardiac risk factors, yet they formulated varying opinions on the causal relationship between the employee=s work injury and his death. The compensation judge relied on the opinion of Dr. Berman, who concluded that the employee=s work injury did not substantially contribute to the employee=s death. In view of the expert medical opinions offered by both parties, it was the compensation judge=s role to choose between the conflicting medical opinions. See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985). As outlined in his findings and memorandum, the compensation judge found Dr. Berman=s opinion to be more persuasive on the issue of causation. We conclude that the record as a whole supports the compensation judge=s findings that the employee=s July 27, 1998, injury did not substantially contribute to the employee=s death, and, therefore, we affirm.
 At his deposition, Dr. David Berman explained that the Aejection fraction is the percentage of blood that=s pumped out with each heartbeat. Normally, the heart should eject about 60 percent of the blood every time it beats.@ He further explained that an ejection fraction of approximately 30-35% Ameans that there=s very severe damage to the pumping ability.@ (Berman Depo., Employer Exh. D, pp. 8-9.)
 Ischemic pertains to ischemia, which is defined as Adeficiency of blood in a part, usually due to functional constriction or actual obstruction of a blood vessel.@ Cardiomyopathy is Aa general diagnostic term designating primary noninflammatory disease of the heart muscle, often of obscure or unknown etiology and not the result of ischemic, hypertensive, congenital, valvular or pericardial disease.@ Ischemic cardiomyopathy is defined as Aheart failure with left ventricular dilatation resulting from ischemic heart disease; it does not meet the strict definition of a cardiomyopathy.@ See Dorland=s Illustrated Medical Dictionary, 287-288, 920 (29th ed., 2000).
 See also Ruether v. State of Minnesota, 455 N.W.2d 475, 478, 42 W.C.D. 1118, 1123-24 (Minn. 1990) (citing Fryhling v. Acrometal Products, Inc., 269 N.W.2d 744, 31 W.C.D. 85 (Minn. 1978) and Golob v. Buckingham Hotel, 244 Minn. 301, 304-05, 69 N.W.2d 636, 639, 18 W.C.D.
275, 278 (1955)).