GARY F. WHITMORE, Employee, v. HOLM BROS. CONSTR., INC., and FEDERATED MUT. GROUP, Employer-Insurer/Appellants, and UNIVERSITY OF MINN. PHYSICIANS, J.C. CHRISTENSEN & ASSOCS., FAIRVIEW RED WING HEALTH SERVS.-CLINIC, and FAIRVIEW RED WING HEALTH SERVS.-HOSP., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
APRIL 11, 2007
CAUSATION - MEDICAL TREATMENT. Under the circumstances of this case, the record as a whole, including the records of one of the employee=s treating physicians, adequately supported the compensation judge=s award of medical expenses related to cardiac and visual testing and treatment, despite the fact that the employee=s treating physicians had reached no firm conclusions as to the cause of the employee=s ongoing symptoms.
Affirmed as modified.
Determined by: Wilson, J., Rykken, J., and Stofferahn, J.
Compensation Judge: Janice M. Culnane
Attorneys: Karl F. von Reuter, Minneapolis, MN, for the Respondent. David O. Nirenstein and Ryan J. Courtney, Fitch, Johnson, Larson & Held, Minneapolis, MN, for the Appellants.
DEBRA A. WILSON, Judge
The employer and insurer appeal from the compensation judge=s findings concerning the nature and extent of the employee=s work-related injuries. We affirm, as modified.
The employee began working for Holm Brothers Construction [the employer] in May of 2002, driving a 22-wheel Mack truck with a Abelly dump@ trailer. On December 8, 2003, the employee was involved in a work-related accident while driving the truck. The employee testified that he remembers coming to a bend, driving at about 50 miles an hour; the next thing he remembers is walking down a road, where he was picked up by a stranger and taken to the hospital. Apparently, the employee=s truck went off the highway and stopped abruptly when the belly dump trailer became hung up on a grassy incline or field road. However, the employee has no memory of the accident.
The employee was admitted to the intensive care unit of Fairview Red Wing Medical Center, where he was diagnosed with a closed head injury, with concussion, and a nondisplaced sternal fracture. A CT scan of the employee=s head was normal; a chest CT revealed the sternal fracture along with Asome soft tissue density seen posterior to the distal sternum probably representing a hemorrhage.@ The employee was noted to have pain with deep inspiratory motion and some swelling over the right head of the clavicle. Lab tests were basically normal.
The employee was discharged from the hospital on December 11, 2003, with instructions not to drive while on pain medication and to follow up in one week. Notes from that follow up, on December 17, 2003, indicate that the employee was reporting rib tenderness Abut otherwise is without complaint.@ However, those same notes reflect that the employee was Adizzy, seeing some spots this a.m.@ The employee was advised that his pain would subside as he healed and that no further follow up was necessary, except for elevated blood pressure.
Over the next several months, the employee complained of and was evaluated for a variety of symptoms, including right eye visual disturbances, fatigue, lack of stamina, dizziness, difficulty breathing, left ankle pain, headaches, chest pain, palpitations, and a feeling of flushing. Tests eventually disclosed a healed posterior rib fracture, a near-complete tendon tear in the employee=s left ankle, and a posterior vitreous separation in the employee=s right eye. The employee underwent additional visual, cardiac, and pulmonary function testing in an attempt to ascertain the cause of his continuing symptoms. Physicians who treated the employee included Dr. Anthony Novak, for vision problems, Dr. Gladwin Das, for possible cardiac symptoms, Dr. Isam Habib, for pulmonary symptoms, and Dr. Matthew Eich, for the left ankle injury. Dr. Thomas Meyer, the employee=s treating internist, eventually referred the employee to Dr. Mark Sprangers, the medical director of the occupational medicine department at Fairview Red Wing Medical Center.
On June 1, 2004, Dr. Eich performed surgery to repair the tendon in the employee=s left ankle. The employer and insurer accepted liability for the employee=s ankle condition and paid various benefits. However, a dispute arose concerning the work-relatedness of the employee=s reported vision problems and alleged cardiopulmonary symptoms. As a consequence, the employee did not undergo certain additional eye and cardiac testing and treatment recommended by Dr. Sprangers.
The matter came on for hearing before a compensation judge on August 29, 2006, for resolution of the employee=s claim for wage loss benefits and medical expenses for certain treatment rendered after the employee=s December 8, 2003, injury and for the additional treatment recommended by Dr. Sprangers. The primary issue was the nature and extent of the employee=s work-related injuries, particularly with regard to the compensability of treatment for the employee=s alleged continuing right eye and cardiopulmonary symptoms. The employer and insurer maintained, in essence, that the effects of the December 8, 2003, accident had completely resolved by September 1, 2004. Evidence included the employee=s testimony, his treatment records, and reports from Drs. Samuel Hall, Thomas Beniak, and Alan Weingarden, the employer and insurer=s independent examiners.
In a decision issued on October 30, 2006, the compensation judge resolved all issues in the employee=s favor, ordering the employer and insurer to pay for all of the disputed treatment as well as temporary total disability benefits through November 2, 2005. The employer and insurer appeal.
STANDARD OF REVIEW
On appeal, the Workers' Compensation Court of Appeals must determine whether "the 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 (2006). Substantial evidence supports the findings if, in the context of the entire record, "they 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 conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, "unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
1. Eye Condition
It is undisputed that the employee has a right eye condition described as a Aposterior vitreous separation,@ or vitreous detachment with Avitreous syneresis or liquefaction.@ Dr. Weingarden, the employer and insurer=s independent medical examiner, acknowledges that this condition is the result of the employee=s December 8, 2003, accident. However, it is Dr. Weingarden=s opinion that this condition is Anot visually significant,@ that the employee sustained no other injury to his eye during the accident, that the employee=s vision, with correction, is normal, and that the employee needs no additional care or testing for his eye as a result of his work-related injury. The compensation judge rejected Dr. Weingarden=s opinion, concluding that, A[a]s a result of the employee=s work-related injury to his right eye, the employee continues to have right eye vision diminution and problems with his tear duct.@ The judge further concluded that ADr. Novak=s referral@ for reevaluation and tear duct irrigation is Areasonable and necessary to cure and relieve the effects of this employee=s work-related injury.@ In her memorandum, the judge explained her decision on this issue as follows:
The employee complains of persistent visual problems in his right eye. The employee was examined by Dr. Weingarden, on behalf of the employer/insurer. Although Weingarden acknowledged Mr. Whitmore had a posterior vitreous detachment with syneresis or liquefaction of the vitreous body, he does not believe this condition results in any visual impairment. At hearing, the employee described the visual problems which he currently has, which affect his field of vision in his right eye on the far right side. The employee=s description was consistent with visual problems reported in the medical records. The employee has consistently noted problems with his vision and eye following the work-related injury of December 8, 2003. The medical records and the testimony of the employee both indicate the employee did not have these types of problems prior to his work-related injury. Although the reason for the employee=s problems has not been fully explained and understood, the Court is convinced the problems exist and began after the employee=s work-related injury. In addition to the visual problems, the employee has had continuing tear duct irrigation problems which need continued monitoring also as a result of this injury. The employee supplied convincing testimony and medical evidence that his ongoing vision and tear duct problems which began following his work-related injury, are related to the work-related right eye injury which he sustained in his motor vehicle accident of December 8, 2003.
On appeal, the employer and insurer contend that the record as a whole does not support the compensation judge=s conclusion that the employee=s ongoing eye complaints are causally related to the December 8, 2003, accident. More specifically, the employer and insurer contend that Dr. Sprangers, the only physician to tie the employee=s vision and tearing problems to the employee=s work injury, lacks foundation for his opinion, because he is not a vision specialist.
We acknowledge that the medical evidence supporting the employee=s claim is not particularly strong. Dr. Novak, the employee=s treating ophthalmologist, has never expressly indicated that the employee=s visual disturbances and tearing symptoms are work-related; rather, he indicated only that the vitreous separation was the result of the accident, and he expected no permanent partial disability to result from that condition. However, we cannot say that the compensation judge erred as a matter of law in ordering the employer and insurer to pay for the treatment at issue. As the judge noted, the employee did in fact injure his right eye in the accident, and he had no history of right eye vision or tearing problems before the accident. As for the employer and insurer=s argument about Dr. Sprangers= expertise, that was for the compensation judge to weigh.
The etiology of the employee=s eye symptoms has not yet been ascertained, possibly in part because the employer and insurer declined to pay for the treatment and testing recommended by Dr. Sprangers in the summer and fall of 2004. Under the circumstances of this case, the compensation judge reasonably concluded that treatment at issue was compensable, at least for purposes of ascertaining the nature and cause of the employee=s continuing right eye complaints. See, e.g., Sether v. Wherly Motors, Inc., slip op. (W.C.C.A. Dec. 30, 1999); Klaven v. Northwest Medical Ctr., slip op. (W.C.C.A. Sept. 24, 1991) (medical treatment and diagnostic tests performed to investigate possible alternative causes of an employee=s continued symptoms may be compensable, even if the employee=s condition is ultimately found to be nonwork-related). However, we do not construe the judge=s decision to represent a finding of a permanent injury to the employee=s right eye, and the employer and insurer are free to contest causation for any treatment or benefit claims beyond those awarded by the judge in the most recent proceedings. The judge=s decision is affirmed on that basis.
2. Cardiopulmonary Condition
Physicians suspected that the employee had sustained a cardiac contusion, or perhaps bruising to his lungs, as a result of the December 8, 2003, accident. For this reason, the employee was referred for cardiac and pulmonary testing, some of which was performed in the spring and summer of 2004. Cardiac testing appeared to eliminate the cardiac contusion theory, at least according to Dr. Das. However, as late as the fall of 2004, Dr. Sprangers was of the opinion that the employee was in need of additional cardiac evaluation, and cardiac rehabilitation, as a result of his work-related accident. The employer and insurer denied liability for both the cardiac and pulmonary testing actually performed and the additional treatment recommended by Dr. Sprangers, relying in part on the opinion of Dr. Hall, who reported that any clinically significant myocardial contusion had been ruled out by the diagnostic studies already performed.
The compensation judge was unpersuaded by Dr. Hall=s opinion, finding that the employee has Aresidual chest pain and symptomatology requiring further testing@ and that the cardiac referrals made by Dr. Sprangers were reasonable, necessary, and causally related to the employee=s work accident. In her memorandum, the compensation judge explained this conclusion, in part, as follows:
The employee offered credible and convincing testimony of ongoing problems and symptomatology in his chest. The timing of these problems, which began to occur after his work-related injury, and the severity of the employee=s accident, reliably support the employee=s claim that he began experiencing chest problems, including heart symptomatology, following his work-related injury. Dr. Hall=s opinion that the diagnostic tests were negative is insufficient to reach a determination that the work-related injury is not a substantial contributing factor. This is especially true since the employee=s treating doctor, Dr. Sprangers, is seeking a referral for further cardiac treatment and evaluation. The [employee] sustained his burden in proving the work-related injury of December 8, 2003, was a substantial contributing factor in the cardiac and chest problems he began experiencing after his injury.
The employer and insurer=s argument with respect to this issue is similar to the argument advanced with respect to the employee=s eye injury claim; that is, Dr. Sprangers= opinion lacks foundation and is inadequate to support the judge=s award. We are not convinced.
The employee fractured his sternum, and had a probable related hematoma, as a result of the December 8, 2003, accident. Subsequent cardiac and pulmonary testing was clearly reasonable, and compensable, for purposes of investigating symptoms that might well have been caused by the admitted work injury. At the same time, treating specialists have come to no firm conclusions as to any physiologic basis for the employee=s continued complaints of fatigue, shortness of breath, chest pain, and the like. Further cardiac evaluation and rehabilitation, recommended by Dr. Sprangers in the summer and fall of 2004, have not yet been performed. As was the case with the employee=s eye symptoms, it was reasonable for the compensation judge to conclude that the recommended additional cardiac treatment is reasonable and necessary as a result of the employee=s work injury. However, again, because there has been no definitive diagnosis, and the judge did not find that the employee had sustained any permanent cardiac or pulmonary injury, the employer and insurer may contest causation with regard to any treatment or benefit claims not specifically covered by the compensation judge=s decision.
3. Ankle Injury
The parties stipulated that the employee had sustained an injury to his left ankle in the December 8, 2003, work accident. In her findings, the compensation judge indicated that the employee had injured his right ankle. The employee agrees that the judge erred in this regard. We therefore modify the judge=s decision to conform to the parties= stipulation.
 A belly dump trailer has gates on the bottom, which may be opened to discharge the load.
 The employer and insurer had already paid or agreed to pay temporary total disability benefits through September 1, 2004. The claim was for benefits through November 2, 2005.
 It is not completely clear from the record whether the undated slip containing reference to the recommended eye treatment was written by Dr. Novak or was written by Dr. Sprangers to Dr. Novak.
 Dr. Das was Anot sure as to the reason for [the employee=s] shortness of breath@ or the basis for the employee=s chest symptoms, because there was Ano evidence of traumatic cardiac injury@ or significant cardiac disease. Pulmonary function tests, conducted by Dr. Habib, were suggestive of bronchial asthma, although underlying COPD could not be ruled out. The employee is a former longtime smoker.
 The employer and insurer also argue that the opinion of Dr. Thomas Witt is insufficient to support the employee=s claim. The value of Dr. Witt=s opinion is questionable at best, at least with respect to the employee=s possible cardiac complaints. In a June 6, 2006, letter discussing the employee=s exercise intolerance, palpitations, shortness of breath, neck pain, and other assorted symptoms, Dr. Witt recommended evaluation at the Traumatic Brain Injury Clinic at Mayo and concluded by writing, AAgain, at this time, I think his symptoms are certainly temporally related to his accident.@ (Emphasis added). In another record, Dr. Witt wrote that the etiology of the employee=s exercise intolerance was Aundetermined.@
 In her memorandum, the compensation judge explained that Afurther evaluation is necessary for a proper determination of the full extent of this employee=s work-related injury@ and for a Adetermination as to when the effects of this employee=s work-related injury may be deemed resolved.@