Wednesday, August 28, 2013

Death on the Job... as a result of the job?... or just Happenstance?

Death on the Job... as a result of the job?... or just happenstance?

A Compensable work injury is defined as an injury to an employee, regardless of his previous condition, arising in the course of his employment and (is) related thereto.
A compensable work injury may include "death resulting from such injury and its resultant effects".
See the Section 301 (c)(1) definition of "injury".

In the instance where an employee falls, the injury sustained as a result of the fall may be the significant event.
In the instance where the employee faints, collapses or passes out, the resultant injury may be a compensable disabling injury, if it is caused by the work duties or condition of the work premises.

Where the employee suffers a fatal condition... a question of medical causation is presented.
Employee has the burden of proof to establish a relationship of the death to the work duties or condition of the work premises.

The Manitowoc Company Inc. v. WCAB (Cowan), No. 472 C.D. 2013, an opinion of a panel of Commonwealth Court of Pennsylvania, authored by Judge Friedman on August 20, 2013, addressed these medical causation causation questions in a fatal claim petition.

Factual & Procedural Background

Employee and Co-worker were working on an elevated crane platform without any harnesses. The platform was 6 feet off the ground and had no handrails.
While in a crouched position, employee said "Hold it. Wait a minute". Co-worker saw employee's eyes roll back, he fell off the platform, he struck his head on the floor.
Within seconds employee began turning blue and blood came from his mouth. He was breathing slowly and had a faint pulse. Soon his breathing stopped and first responders administered rescue breathing and chest compressions.
Diagnostic tests, later that day, showed Employee was brain dead.
He was disconnected from life support.
Autopsy report stated cause of death was cardiac dysrhythmia due to mitral valve prolapse.

A Fatal Claim petition was filed in the name of Employee's 3 year old son.

Claimant Medical Expert Opinion

He could not be certain of Employee's state of consciousness at the time of the fall... as he was not hooked up to any monitoring devices. [did the eyewitness account provide any information?].

He concluded employee did not experience cardiac arrest at the time of the fall, as he has a pulse and was breathing when on the ground. He was not agonal. [gasping for breathe]
[based upon eyewitness accounts].

He opined employee's death was a direct result of falling on his head, which caused a closed-head injury with massive concussion and diffuse axonal injury [diffuse traumatic brain injury], leading to a anoxic brain injury [brain cell death due to inadequate oxygen]  and cerebral edema.

He opined Employee did not die from mitral regurgitation or heart disease.
[autopsy cause of death].
Thomas R. Stoner, D.O. Board Certified in Internal Medicine.

Employer Medical Expert Opinion
He opined Employee lost consciousness before he fell, as employee went limp and fell, without trying to catch himself.

He believed it was highly possible that a cardiac event caused employee to lose consciousness, based upon the pre-existing mitral valve disease and fact that he turned blue quickly.

He did not believe employee's airway was blocked, despite a moderate amount of blood when EMT's intubated employee.
He opined the brain injury resulted primarily from the cardiac arrhyythmia and secondarily from the head striking the floor.

He believed the head trauma had little impact upon the cause of death as it did not cause bleeding in the brain and employee would have died whether or not he struck his head.
Paul M. Shipkin, M.D. Board Certified in Neurology.

Employee had mitral value prolapse and mitral regurgitation.
He experienced ventricular fibrillation because of the mitral valve regurgitation.
This lead to anoxic brain injury and death.
Ventricular fibrillation does not commonly result from head trauma unless there is bleeding in the brain.
He concluded Employee's diffuse brain swelling and anoxic encephalopathy were consistent with a cardiac event.
Joseph Gascho, M.D. Board Certified Cardiologist

WCJ Decision
WCJ found Employee was injured in the course of his employment as his death was caused by the fall and resulting head trauma. Employee medical expert was found credible.

Employer appealed the WCJ award of benefits.

Employer Argument

Employer argued that Claimant medical expert evidence was not unequivocal medical evidence to support an award of benefits. Claimant medical expert was equivocal as he offered 4 alternative theories regarding the exact cause of death.

Commonwealth Court Reasoning
WCJ decision was supported by unequivocal medical evidence, as under each of the scenarios offered by Claimant medical expert, the fall and blunt force trauma caused the employee death.
Absent the head trauma, employee would still be alive. slip opinion page 7.

Claimant has the burden of proof to establish the work injury was a substantial contributing cause of employee's death.

 Where the causal connection is not obvious, claimant must present unequivocal medical evidence which establishes that connection.

The question of whether unequivocal medical evidence proves causation, is a question of law, reviewable on appeal.

The offering of alternative analyses does not render the medical expert testimony equivocal.
Medical expert testimony is competent, even if the witness admits to uncertainty, doubt, reservation or lack of information with regard to certain medical details... as long as the medical expert does not recant the opinion expressed.

***Despite the uncertainty as to the exact chain of physiological events, Claimant medical expert opined that the work fall and head trauma caused Employee's death.

Practice Pointers:
1. This fact pattern demonstrates the difficulty of review and analysis of complex medical issues, such as "causation" where there are multiple factors present.
2. This fact pattern also demonstrates the role that the testimony of "fact" witnesses may play in assessment of the case and support of a medical expert opinion.
3. One must obtain and review all pertinent medical records, such that the reviewing medical expert can assess pre-existing and non-occupational factors. The work event must be the significant or substantial contributing factor, to establish a compensable work injury. Are there significant or substantial non-occupational factors?
4. Often there are competing theories of causation. The best practice is to present this medical expert opinion evidence, together with the complete medical records and fact witness testimony to convince the fact-finder of the logic of one particular theory.
5. One must also assess the "non-legal" factors, recognizing a certain level of sympathy arises in fatal claims litigation. This can be unavoidable. In the instant case, the fatal claim was filed in the name of the 3 year old son of the employee. Is there any evidence of other financial remedies to the surviving family members? Is it relevant or admissible? Is there any third party liability?

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