MICHELLE PISAREK, Employee, v. RIVERWOOD HEALTHCARE CTR. and AMERICAN COMP. INS. CO./RTW GROUP, Employer-Insurer/Appellants.
WORKERS= COMPENSATION COURT OF APPEALS
OCTOBER 2, 2008
CAUSATION - MEDICAL TREATMENT. Where it was supported by medical records and expert medical opinion, the compensation judge=s conclusion that the employee=s withdrawal from certain work-injury-related medications was a substantial contributing factor in her need for the hospitalization at issue was not clearly erroneous and unsupported by substantial evidence.
CAUSATION - INTERVENING CAUSE. Where the employer and insurer had denied the employee access to psychotropic medications that had been prescribed for her work-injury-related condition, where that denial had led to the employee=s hospitalization for symptoms of withdrawal from those medications, and where there was expert medical opinion reflecting that gambling was not normally an Aunreasonable, negligent, dangerous, or abnormal activity@ for the employee to have been participating in absent that denial, law and substantial evidence supported the compensation judge=s conclusion that the employee=s trauma over gambling losses while she was suffering symptoms of withdrawal from her work-related medications was not a superseding intervening cause of her need for the hospitalization at issue.
Determined by: Pederson, J., Johnson, C. J., and Rykken, J.
Compensation Judge: Cheryl LeClair-Sommer
Attorneys: Thomas D. Mottaz and David B. Kempston, Law Office of Thomas D. Mottaz, Coon Rapids, MN, for the Respondent. Mark A. Kleinschmidt and Whitney L. Teel, Cousineau McGuire, Minneapolis, MN, for the Appellants.
WILLIAM R. PEDERSON, Judge
The employer and insurer appeal from the compensation judge's conclusion that the employee=s June 17, 1999, work injury was a substantial contributing factor in her need for certain medical treatment and that stress from certain gambling losses was not a superseding intervening cause of that need. We affirm.
On June 17, 1999, Michelle Pisarek sustained a work-related injury to her cervical spine while she was assisting a resident use his walker in the course of her work as an activity director at Riverwood Healthcare Center. Ms. Pisarek [the employee] was forty-six years old on that date and was earning a weekly wage of $508.80. Riverwood Healthcare Center [the employer] and its insurer acknowledged liability for the injury and commenced payment of benefits. On February 15, 2000, consequent to her injury, the employee, who had previously undergone fusion surgery at C6-7 of her cervical spine, underwent additional fusion surgery at C5-6 of her spine.
The employee=s cervical condition subsequently resulted increasingly not only in persistent cervical symptoms but also in depression and anxiety with psychotic features, for which the employee was treated primarily by psychiatrist Dr. Elizabeth Delesante. On October 1, 2001, the employee filed a claim petition, in which she sought payment of permanent total disability benefits continuing from August 31, 2001, together with permanent partial disability benefits for a 15% whole body impairment, based upon a two-level cervical fusion, and approval of further cervical fusion surgery that had been recommended by Dr. Timothy Garvey. The matter was eventually resolved in a stipulation for settlement reached on March 7, 2002, pursuant to which all indemnity claims were closed out and the employee withdrew her request for surgery for the time being. Also pursuant to that stipulation, the employer and insurer agreed not to dispute the treatment regimen recommended by Dr. Delesante, which provided for bimonthly counseling sessions and utilization of certain medications throughout the calendar year 2002. An award on that stipulation was filed March 11, 2002. The employee=s neck-related complaints continued and increased, and on November 18, 2003, after further litigation and hearing before a compensation judge in March of that year, she underwent the previously requested cervical fusion after all - - this from C3 through C5.
In the years that followed, the employee=s condition continued to deteriorate, and on December 20, 2006, she began treating with anesthesiologist/pain specialist Dr. Todd Hess at the United Pain Clinic, on referral from her family physician, Dr. James Storlie, and Dr. Delesante, evidently for consolidation of her treatment. On January 12, 2007, the parties reached another stipulation for settlement, pursuant to which the employee agreed Ato attend, participate, and cooperate with the United Pain Clinic for purposes of overseeing patient care, directing patient care, and coordination of medication therapies.@ An award on that stipulation was filed January 17, 2007, by which date Dr. Hess had evidently assumed management of the employee=s pharmacological regimen, ultimately deferring to Dr. Delesante for continued prescription of the employee=s psychotropic medications, Seroquel and Cymbalta, and to Dr. Storlie for prescription of the employee=s opioid pain medications.
As of March 13, 2007, Dr. Delesante=s diagnosis of the employee remained depression with psychosis. The employee returned to see Dr. Delesante on May 23, 2007, on which date Dr. Delesante indicated that the employee=s depression had increased, noting that she had tried the last option for reducing the employee=s medications. The employee=s neck and forehead pain were also increasing, and on July 17, 2007, Dr. Hess referred her to Dr. Garvey for treatment of those problems. On that same date, July 17, 2007, the employee apparently filled, for the last time, at her Pamida pharmacy, a prescription by Dr. Delesante for a thirty-day refill of her Cymbalta and Seroquel medications. When the employee attempted to have her prescription for those medications filled again the following month, the pharmacy evidently refused to fill the prescription, on grounds that the insurer had refused to authorize payment. On August 20, 2007, at the request of the employee=s attorney, Dr. Delesante wrote an unaddressed letter ATo Whom It May Concern,@ in which she diagnosed the employee=s condition as Adepression with psychosis as a result of her injury sustained while working.@ She indicated further in her letter that the employee=s medications were Aabsolutely medically necessary for her health and well-being,@ explaining that Awithout Seroquel she develops terribly vivid hallucinations@ and that ACymbalta has provided some relief from her depression in that she no longer feels suicidal.@ The doctor went on to state in that letter that A[the employee] reports that she is out of medication, which is a very dangerous situation,@ imploring her reader Ato immediately authorize her medications so that further harm does not come to her.@ In treatment notes the following day, August 21, 2007, Dr. Delesante indicated that she had talked with the employee about the insurer=s refusal to cover her psychiatric medications, noting that the employee had Abeen o[ff] the meds for about 10 days, which is a terrible situation for her. She is having withdrawal from the Cymbalta.@ The doctor noted also that she had Aasked that [the employee] please contact the pharmacy and see if they will let her charge meds.@
The employee was accustomed to gambling once or twice a month at a casino some twenty-five miles away, and on the evening of Friday August 24, 2007, she rode with a friend to the casino and began a session of gambling that lasted into the wee hours of the morning, ultimately writing checks for her expenditures in the amount of $3,000. By that date, the employee had also accrued $23,000 in high interest credit card debt as a result of earlier gambling and other excess spending, and upon her return from the casino, on Saturday August 25, 2007, her husband and children met to discuss with her her gambling problem and her large debt. At about that same time, the employee began experiencing increasingly grotesque and frightening hallucinations, and on August 28, 2007, she called her husband at work and apparently asked him to come home. Upon his arrival at home, her husband found her sitting half naked in a corner, crying uncontrollably, and delirious with hallucinations of snakes and dead babies. Dr. Delesante was notified, and the employee was taken immediately to the emergency room at Cuyuna Regional Medical Center [CRMC].
At CRMC the employee was diagnosed with severe depression and hallucinations, and pharmacological treatment was commenced. A nurse=s inprocessing treatment note at CRMC indicates that the employee was A[r]ecently off Seroquel and Cymbalta due to issues [with] workmans comp.@ In a note about an hour later at that facility, Dr. Delesante diagnosed depression with psychosis and APath[ological] Gambling,@ going on to report that the employee
has been w/o Seroquel & Cymbalta for several weeks as WC refuses to fill. Also just told husband/kids she has gambled large quantities $ at casino over last 9 mosB$3000 on Fri/Sat. Now [increasing] hallucinations - - dead bodies, dead babies, etc. Seeing snakes in cabinet. Quite agitated. Not suicidal but is depressed.
A health officer=s statement completed that same hour by Dr. Delesante reported the employee to be Aactively psychotic (off meds due to workers comp).@ An initial drug screening on that same date was read to reveal positive results for cannabinoids and one other drug. The employee was subsequently transferred to St. Joseph=s Medical Center [ St. Joseph=s] for a seventy-two-hour hold.
The admission evaluation at St. Joseph=s on that same date indicates that the employee reported having been without her Seroquel and Cymbalta medications for about three weeks, due to denial of payment for them by Aa new Worker=s Compensation rep.@ That evaluation indicates also that, in addition to the visual hallucinations, the employee reported hearing screaming and the breaking of windows in the course of her hallucinations, that her hallucinations had increased since she had been off her Seroquel medication, and that her depression had increased without her Cymbalta. The evaluation also reiterates that there had been a Aurine drug screen positive for benzodiazepine and cannabis.@ On August 29, 2007, the following day, a Aur[ine] drug confirm@ of the employee=s initial drug screen at CRMC was reported there to have yielded negative results for the cannabinoids. Although in his medical consultation report on that same date, August 29, 2007, Dr. James Gelbmann did make a brief, one-sentence reference to the fact that the employee had Agambled a lot of money away, $3000.00 just in the last weekend,@ nowhere in the detailed treatment records of the employee=s nurses over the course of the employee=s three-day stay at St. Joseph=s, or in her discharge summary from that facility, is there any reference to the employee=s gambling history. On August 30, 2007, the employee=s treatment records at St. Joseph=s indicate that the employee reported that ADr. Delesante will give her samples [of medications] when she has them.@ The employee was discharged from St. Joseph=s into the care of her family on August 31, 2007, with samples of Cymbalta and Seroquel and under a diagnosis of A[m]ajor depression disorder, recurrent, mild with psychotic features@ and A[p]ossible cannabis abuse.@
In treatment notes for September 10, 2007, Dr. Delesante indicated that she had inquired of the employee and her husband as to the positive drug screen for cannabis and that both the employee and her husband had been shocked by the report and knew nothing about it. In those same notes, Dr. Delesante indicated that she and the employee and the employee=s husband had noted Athat [the employee] can=t drive herself to the casino@ and that it was Aunderstood that no one else is going to drive her. Mostly she had gone with her daughter who wasn=t aware of how much she was gambling.@ The doctor went on to note, AI think the safety measures are in place. I think it was a case of sort of an opportunistic thing. I don=t think that sending her to gambling treatment, considering her level of psychosis and depression, is going to result in any significant improvement.@ In a subsequent note on that same date, Dr. Delesante indicated that she had located the record of the original drug screen, done at the CRMC emergency room, and found it to be reflecting no presence of marijuana. On that evidence, she indicated, she had placed a correction in the employee=s records, the employee and her husband having both also adamantly denied that the employee had ever used marijuana.
On that same date, September 10, 2007, the employee filed a medical request, seeking continuation of her psychiatric medications, including Cymbalta, Seroquel, and two others, payment for her treatment at CRMC, penalties for the employer and insurer=s raising of a frivolous defense pursuant to Minnesota Statutes section 176.225, and preapproval for a referral from Dr. Hess to Dr. Garvey. Unpaid bills at St. Joseph=s were apparently also subsequently added to the claim.
In treatment notes on September 18, 2007, Dr. Hess reported that the Ainsurer cut off Cymbalta and Seroquel cold turkey and the [employee] had severe withdrawal,@ adding that A[i]t is essential she get back on these medications.@ The employee was examined for the employer and insurer about two weeks later, on October 3, 2007, by psychiatrist Dr. Ronald Groat. In his report on October 11, 2007, after interview of the employee and review of various medical records, Dr. Groat diagnosed depressive disorder, psychotic disorder, cognitive disorder, and sleep disorder. He considered the employee=s currently prescribed psychiatric medications to be medically necessary though perhaps of too high a dosage, but he considered her pain medications to be unnecessary and, indeed, to be having serious and significant side effects, Athe worst of which could be hallucinatory activity and dysphoria.@ AIt would appear,@ he opined, Athat Seroquel reduction may be associated with the emergence of unusual hallucinatory activity, which is relatively difficult to explain, and I initially postulated that this may be a side-effect of her narcotic use and the Seroquel is addressing it.@ He recommended that, instead of so Asimply relying on medications and support from others= kindness,@ the employee should try Aseeing a therapist to help her identify what she is experiencing and learn coping mechanisms.@ Subsequently, in a responsive letter to the employee=s attorney dated November 9, 2007, Dr. Delesante expressed her opinion that the pain medication prescribed by Dr. Hess and the psychiatric medication that she herself was prescribing were both Aabsolutely imperative@ in the employee=s treatment.
At an administrative conference on November 20, 2007, the employer and insurer agreed to pay for the psychiatric medications, for a psychiatric evaluation, and for a drug test recommended by Dr. Groat. On that same date, November 20, 2007, after reviewing certain CRMC, St. Joseph=s, and other additional records, Dr. Groat amended his report of October 11, 2007, most essentially to include the following opinions: (1) that the employee=s symptoms at the time of her hospitalization might well be related to her gambling and financial concerns, which he noted Awere not discussed at the time that I saw her@; (2) that those symptoms might also be related to her positive test for cannabis while she was hospitalized, concerning which he asserted a presumption that Aa confirmatory test was not completed@; and (3) that the employee=s condition during her hospitalization in question could and should have been mitigated in that Ashe could have gotten samples of [the Seroquel and Cymbalta from which she was arguably in withdrawal] from her treating physician, but she did not pursue this alternative.@
In a decision and order filed December 19, 2007, the mediator/arbitrator presiding at the November 20, 2007, administrative conference determined that the medical condition resulting in the employee=s hospitalization at CRMC on August 28, 2007, was a consequence of the employee=s June 17, 1999, work injury, and on that basis she ordered the employer and insurer to pay the medical costs at issue and to pay for the employee=s consultation with Dr. Garvey as recommended by Dr. Hess. On January 7, 2008, the employer and insurer filed a request for formal hearing.
On February 14, 2008, after reviewing a letter from Dr. Delesante, Dr. Groat clarified once more his earlier opinions. In a letter on that date to counsel for the employer and insurer, Dr. Groat indicated that it was not his opinion that the employee=s medications were prescribed or used inappropriately. He explained that it was his opinion, however, that it was Anot crystal clear@ to him Awhat . . . stopping the medications, whether it is inadvertent or not, for [the employee] led to, in terms of a change in her clinical state,@ given the timeline of relevant events. Moreover, he indicated,
there was no discreet withdrawal phenomenon associated with the discontinuation of Cymbalta or Seroquel to the best of my knowledge. It is not described that [the employee] had symptoms within 24 to 72 hours of discontinuing these medications and the usual withdrawal symptoms associated with Cymbalta relate to flu-like symptoms or unusual neurologic sensations in a person not with the appearance of confusion, agitation or psychosis. Likewise, Seroquel withdrawal is also usually described in a manner of physical symptoms of a flu-like nature, not in a delirium, confusional state, agitation or hallucinations clearly attributable to a withdrawal phenomenon.
AIt is my opinion,@ Dr. Groat went on, that while the discontinuation of Cymbalta and Seroquel may have left [the employee] more vulnerable to the return of her previously experienced symptoms of psychosis, it is significantly possible that the stress [related to her gambling and financial losses] led to the recurrence of those symptoms at that particular time.@ AIt is also my opinion,@ Dr. Groat subsequently continued, Athat the gambling behavior that [the employee] had demonstrated, does not show any relation to the prescribed medication use, her psychiatric conditions, her current medication use or any medication discontinuation.@
On February 19, 2008, Dr. Hess testified by deposition, in part that the employee had followed his treatment regimen Awithin a degree of excellence actually.@ Dr. Hess testified that, in his opinion, the hallucination symptoms manifested by the employee just before her hospitalization on August 28, 2007, were not ones to be anticipated from gambling stress. He testified that suicidal or homicidal tendencies would be more likely consequences of such stress and that hallucination was far more likely to result from rapid withdrawal from medication. He noted in support of that opinion the fact that Athere wasn=t one bit of the gambling mentioned in [hospital records of the employee=s] talking to the nurses who have very strong documentation.@ It was Dr. Hess=s opinion that the employee=s hospitalizations at CRMC and St. Joseph=s Awere clearly in regard to the fact that her [Cymbalta and Seroquel] meds were stopped abruptly@ and that therefore it was his Astrong@ opinion that the work injury was a substantial contributing factor in those hospitalizations, Abecause the meds were used to treat the side effects and the problems that the work-related injury caused.@ Dr. Hess opined that the employee=s gambling activity A[a]bsolutely [did] not@ sever the causal link between the work injury and the employee=s need for the hospitalization at issue, because the employee=s lack of access to her medication Awasn=t [just] a withdrawal.@ A[T]he root cause [of her hallucinations] is still the fact that the meds were stopped abruptly.@ Dr. Hess also took important issue with Dr. Groat=s opinion that the employee=s pain medications may have been capable of inducing the employee=s hallucinations. Dr. Hess emphasized that he had reviewed the employee=s records thoroughly and that A[t]here is not one shred of evidence in her past history that there was ever a problem with her opioid medication in this capacity.@ He emphasized that the employee=s chronic pain Ais not a fictitious illness. This is not malingering. There are physical findings on this patient.@ He acknowledged that the employee had not mentioned her gambling when he met with her on September 18, 2007, but he testified that neither the employee=s own nor Dr. Delesante=s mentioning of it to him would have brought him to a different opinion, because A[i]t=s not the point here. [Gambling is] not going to cause somebody to hallucinate in my opinion.@ Finally, Dr. Hess emphasized that the drug confirm test of the employee=s initial drug screening at CRMC had evidently proved negative after all, based on the same urine sample.
The following day, in a letter to the employee=s attorney dated February 20, 2008, having been forwarded a copy of Dr. Groat=s report, Dr. Delesante opined unequivocally, AI think not having medications is definitely a substantial contributing factor for the [employee=s CRMC and St. Joseph=s] hospitalization. It is my opinion that the hospitalization would not have occurred at all had her medications been continued.@ In another letter on that same date, responding to another letter of the employee=s attorney, Dr. Delesante defended herself against the suggestion that she should have provided medications to the employee when the employer and insurer would not. She explained in part,
I don=t always have samples available of all medications. When [the employee] and I talked about that on August 11 she was going to contact the pharmacy to see whether they would advance her some medications. She does not live in the same town as my office and getting medications is sometimes difficult since she isn=t able to drive. . . . I would have provided samples if I had them and if I had known that the pharmacy didn=t provide her with medication.
The matter came on for formal hearing on February 27, 2008. Issues at hearing were (1) whether or not the employee=s June 17, 1999, work injury was a substantial contributing factor in the employee=s need for her emergency medical treatment at CRMC on August 28, 2007, or for her subsequent medical treatment at St. Joseph=s from August 28, 2007, through August 31, 2007, and (2) whether or not stress resulting from the employee=s gambling experience on August 24 and 25, 2007, was a superseding intervening cause of that need. Evidence submitted at hearing included the testimony of the employee, in part that her Pamida pharmacy had refused to allow her to charge her medications. Although finding that that testimony was not credible, the compensation judge concluded, in findings and order filed March 28, 2008, both that the employee=s June 1999 work injury was a substantial contributing factor in her need for the treatment at issue and that stress resulting from her gambling experience in August of 2007 was not a superseding intervening factor in that need. On those findings, the compensation judge ordered the employer and insurer to pay for the treatment at issue at CRMC, billed in the amount of $2,498.20, and for the treatment at issue at St. Joseph=s, billed in the amount of $5,601.75. The employer and insurer appeal.
STANDARD OF REVIEW
In reviewing cases 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. 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 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, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless 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.@ Id.
The compensation judge found that the employee=s June 17, 1999, work injury was a substantial contributing factor in the necessity of her medical treatment at CRMC and St. Joseph=s from August 28 through August 31, 2007, and that stress consequent to her gambling losses on August 24 and 25, 2007, was not a superseding intervening cause of that necessity. The employer and insurer contend that both of these conclusions are unsupported by substantial evidence, in that the opinions of Drs. Delesante and Hess, relied upon by the judge, are deficient in foundation and factual support.
1. The Work Injury as a Substantial Contributing Factor in the Medical Treatment
As the employer and insurer have acknowledged, where an injury or condition is found to have arisen out of and in the course of employment, the employer and its workers= compensation insurer are liable not only for treatment of that injury or condition but also for treatment of any natural consequence that flows from that injury or condition in the normal activities of the injured employee=s life. Nelsen v. American Lutheran Church, 420 N.W. 2d 588, 590, 40, W.C.D. 849, 851 (Minn. 1988) (A[w]here a work-injury creates a permanently weakened physical condition which an employee=s subsequent normal physical activities may aggravate to the extent of requiring additional medical care, such additional care is compensable@); Rohr v. Knutson Constr. Co., 305 Minn. 26, 28-29, 232 N.W.2d 233, 235, 28 W.C.D. 23, 25 (1975) (Aa disability resulting from an accident which aggravates an existing [work-caused] infirmity is compensable even though the subsequent accident would have caused no injury to a normal person@) (citation omitted). The employer and insurer contend, based on the opinions of Dr. Groat, that the employee did not prove that her treatment at CRMC and St. Joseph=s between August 28 and August 31, 2007, was due to any withdrawal from Seroquel or Cymbalta but was instead a consequence of her stress over her gambling losses. They contend that the employee=s treating doctors had insufficient foundation for their opinions that the employee=s hallucinations were a natural consequence of her inability to obtain her psychotropic medications, particularly her Seroquel, in the days immediately preceding her hospitalization. They argue in this regard that Dr. Hess had no expertise in the field of psychotropic medication, that Dr. Groat did have such psychiatric expertise, and that A[t]here is no foundational support in any of [Dr. Delesante=s] opinions as to the withdrawal symptoms from the Cymbalta and Seroquel.@ We are not persuaded.
With regard to Dr. Hess=s expertise, we note that it was by the parties= express agreement, in their stipulation of January 12, 2007, that Dr. Hess would supervise and coordinate the employee=s treatment and medication, precisely in order to ensure her integrated care. For the employer and insurer to question now Dr. Hess=s competence to render an opinion in this very related matter is disingenuous. We grant that the compensation judge was entitled to weigh Dr. Hess=s opinion either more or less than Dr. Groat=s, but Dr. Hess=s specific expertise in the areas of anesthesiology and chronic pain, in addition to his basic medical credentials, clearly rendered him competent to offer a creditable opinion in the psychiatric treatment that the employer and insurer themselves authorized him to coordinate. As for the issue of foundational support for Dr. Delesante=s opinions as to the symptoms of withdrawal from Cymbalta and Seroquel, we note that, in that doctor=s letter of August 20, 2007, four days before the employee=s traumatic casino experience and subsequent hallucinatory symptomology, Dr. Delesante noted expressly that, A[i]n the past, without Seroquel [the employee] develops terribly vivid hallucinations and is unable to sleep@ and that A[t]he Cymbalta has provided some relief from her depression.@ Clearly Dr. Delesante, a psychiatrist like Dr. Groat, was anticipating - - based on the employee=s own past experience - - the very sort of symptoms of withdrawal that the employee actually manifested as the period of her withdrawal lengthened. We conclude that it was not unreasonable for the compensation judge to find, in reliance on the opinions of the employee=s treating physicians, that the employee=s treatment for hallucinations during the hospitalizations here at issue was reasonably related to her involuntary withdrawal from the medications that she was taking in treatment of her work injury and so reasonably related to that work injury. See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) (a trier of fact's choice between experts whose testimony conflicts is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence); Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
2. Gambling Losses as a Superseding Intervening Cause of the Medical Treatment
As the employer and insurer have argued, the legal relationship between a work injury and its reasonable consequences, including medical treatment, is broken where the consequence is also a result of Asuch unreasonable, negligent, dangerous, or abnormal activity on the part of the employee that it can be said that such additional care was not a natural consequence flowing from the primary injury.@ Eide v. Whirlpool Seeger Corp., 260 Minn. 98, 102, 109 N.W.2d 47, 49-50, 21 W.C.D. 437, 441 (1961); Nelsen, 420 N.W.2d at 590, 40 W.C.D. at 851 (AIf . . . a subsequent aggravation of the initial injury arises from an independent intervening cause not attributable to the employee=s customary activity in light of the employee=s condition, then . . . additional medical care for the aggravation is not compensable.@) (citations omitted). The original work injury in such circumstances is, in effect, no longer a substantial contributing factor in the need for the care at issue. The employer and insurer contend that, given the employee=s susceptibility to depression and anxiety and her dependence on psychotropic medications, the employee=s gambling activity on the evening of August 24 and morning of August 25, 2007, was clearly just the sort of Aunreasonable, negligent, dangerous, or abnormal activity@ on her part as would, under our law, break any causal relationship between her hospitalization on August 28, 2007, and any effects of treatment by or withdrawal from the medications that she was taking consequent to her work injury. They support this argument by noting that Dr. Delesante herself diagnosed APath[ological] Gambling@ at the onset of the hospitalization here at issue. Moreover, they argue, having found the employee=s withdrawal from her medications a substantial contributing factor in her need for the hospitalization at CRMC and St. Joseph=s, the compensation judge Anever addressed the second issue of whether gambling was a super[s]eding, intervening cause@ of that need. We are not persuaded.
We would note initially that the judge does appear to us to have addressed the issue of whether the employee=s gambling constituted a superseding intervening cause by being an Aunreasonable, negligent, dangerous, or abnormal activity,@ both expressly in Finding 10 and at least indirectly in her memorandum, when she stated that, under our law, Athe contributory negligence of an injured employee is not a bar to his right to compensation.@ The employer and insurer argue that A[t]he memorandum never addressed the legal standard for a super[s]eding, intervening cause,@ that it never addressed Athe legal analysis as put forth by Eide/Wallace and their progeny.@ In this regard, they repeatedly draw a distinction between Amedical causation@ and Alegal causation.@ We see no dispositive difficulty in the judge=s handling of this issue. Whether express or implicit, her finding was clearly that the hallucinations that compelled the treatment at issue were at least a substantial, if not a direct, consequence of the employee=s withdrawal from her work-injury-warranted medications and that that treatment was at most only indirectly related to the employee=s stress over her gambling and financial woes. Notwithstanding Dr. Delesante=s one-time diagnosis of APath[ological] Gambling@ at the time the employee was suffering symptoms of withdrawal from the work-injury-related medications that had been denied her, and notwithstanding the employer and insurer=s contention that Dr. Delesante Aordered@ the employee to refrain from gambling while she was recovering after treatment of those symptoms, we find no evidence in the opinions of the two treating doctors upon whom the judge relied that the employee=s customary gambling entertainment was an Aunreasonable, negligent, dangerous, or abnormal activity@ for her to have been participating in absent the employer and insurer=s denial of the medications on which she normally depended.
In the end, the employer and insurer=s argument on this issue of superseding, intervening cause is even relevant only to the extent that there is any potential causal relationship in the first place between stress over gambling losses and specifically hallucinatory behavior such as that for which the employee was primarily hospitalized. It was Dr. Hess=s express testimony that, even if the trauma of her gambling losses might have increased the employee=s anxiety in the days following August 24, 2007, it was extremely unlikely that such trauma and such anxiety would ever result in hallucinatory behavior, and Dr. Delesante appears to have been of a similar opinion, as evident by her statement on February 20, 2008, Athat the hospitalization would not have occurred at all had her medications been continued.@ That stress might perhaps have resulted in homicidal or suicidal behavior, Dr. Hess opined, but not in hallucinatory behavior, a more common consequence of drug withdrawal in Dr. Hess=s opinion. The compensation judge evidently accepted Dr. Hess=s opinion over that of Dr. Groat, and we have already addressed the employer and insurer=s argument that Dr. Groat may have more specific credentials in the areas of psychiatry than does Dr. Hess. Moreover, Dr. Groat=s opinion on the relationship between the employee=s gambling trauma and her hospitalization was only that it was Asignificantly possible@ (underscoring added) that stress from gambling and financial problems led to the symptomology for which the employee was hospitalized. We conclude that it was not unreasonable for the compensation judge to find that the employee=s August 24-25, 2007, gambling trauma was not a superseding intervening cause of her need for the hospitalization here at issue, and therefore we affirm that conclusion. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
The compensation judge=s March 28, 2008, findings and order in this matter are affirmed in their entirety.
 Dr. Delesante is presumably referring to the Adrug confirm@ report dated August 29, 2007.