CLAIM NO. E510333
Before the Arkansas Workers’ Compensation Commission
OPINION FILED SEPTEMBER 23, 1997
Upon review before the FULL COMMISSION in Little Rock, Pulaski County, Arkansas.
Claimant represented by the HONORABLE JAMES SWINDOLL, Attorney at Law, Little Rock, Arkansas.
Respondents represented by the HONORABLE J. CHRIS BRADLEY, Attorney at Law, North Little Rock, Arkansas.
Decision of Administrative Law Judge: Reversed.
[1] OPINION AND ORDER
[2] The respondents appeal an opinion and order filed by the administrative law judge on January 22, 1997. In that opinion and order, the administrative law judge found that Randall Williford (the deceased claimant) sustained a compensable coronary accident on July 6, 1995, which arose out of and in the course of his employment. After conducting a de novo review of the entire record, we find that the claimant (claimant’s estate) failed to prove by a preponderance of the evidence that, in relation to other health factors, any accident that the claimant sustained on July 6, 1995, was the major cause of the claimant’s myocardial infarction which caused his death on July 9, 1995. Therefore, we find that the decision of the administrative law judge must be reversed.
[4] Mr. Williford died on July 9, 1995, at St. Vincent’s Medical Center at the age of 43 after sustaining a recent myocardial infarction. Mr. Williford’s wife filed the present claim asserting that Mr. Williford’s participation in FEATS testing on July 6, 1995, was the major cause of his myocardial infarction. [5] Dr. Michael Bierle testified that, when Mr. Williford presented through the emergency room at St. Vincent’s hospital without a treating physician on July 6, 1995, he was assigned as Mr. Williford’s treating physician. A History and Physical report dictated by Dr. Bierle on July 6, 1995, indicates that Mr. Williford was “awake” and “alert” during his examination. In addition, Dr. Bierle testified that he took a medical history from Mr. Williford in St. Vincent’s intensive care unit. [6] Dr. Bierle testified that Mr. Williford’s most pronounced complaint at that time was back pain. According to Dr. Bierle, Mr. Williford’s other complaints at that time included nausea and vomiting, with vomiting of blood over the prior 24 to 36 hour period and shortness of breath with a cough. According to Dr. Bierle, Mr. Williford indicated that the back pain which brought him to the hospital had started earlier in the day after pulling a sled of weights at work. [7] In addition to the back pain, nausea, vomiting, shortness of breath and cough, Dr. Bierle testified that he received a history from Mr. Williford of a 19 to 20 year history of insulin-dependent diabetes under poor control (i.e., sugars not within the normal range). Dr. Bierle testified that Mr. Williford also reported a history of hypertension requiring antihypertensive medication including Procardia and Monopril. In addition, Dr. Bierle testified that Mr. Williford had indicated a recent 5-7 pound weight loss. [8] Mr. Williford’s course of treatment between July 6 and July 9 is best summarized in a “Death Summary” prepared by Dr. Bierle on July 24-25, 1995:(a) A Cardiovascular, coronary, pulmonary, respiratory, or cerebrovascular accident or myocardial infarction causing injury, illness, or death is a compensable injury only if, in relation to other factors contributing to the physical harm, an accident is the major cause of the physical harm.
(b)(1) An injury or disease included in subsection (a) of this section shall not be deemed to be a compensable injury unless it is shown that the exertion of the work necessary to precipitate the disability or death was extraordinary and unusual in comparison to the employee’s usual work in the course of the employee’s regular employment or, alternatively, that some unusual and unpredicted incident occurred which is found to have been the major cause of the physical harm.
(2) Stress, physical or mental, shall not be considered in determining whether the employee or claimant has met his burden of proof.
In the present case, Mr. Williford was employed by the City of North Little Rock as a fire fighter. His primary job duty was to drive the truck. As a condition of his employment Mr. Williford was also required to pass an annual fire fighter’s encounter and agility test (FEATS testing).
[9] Dr. Bierle’s final diagnosis included:The patient was admitted to the intensive care unit, underwent diuresis, started on Proventil updrafts and started on an insulin drip to control his sugars. He had a very nice diuresis initially. Cardiologic consultation was obtained with Dr. Westerfield and it was felt this patient had an acute myocardial infarction with subsequent congestive heart failure. In addition he has chronic obstructive pulmonary disease and acute bronchitis. He as [sic] febrile and was started on antibiotic therapy. He seemed to respond the initial 48 hours. His creatine phosphokinase totals were elevated and he had evidence of positive MB fractions confirming the diagnosis of myocardial infarction. The patient continued to improve on July 8, 1995, was much less dyspneic [labored breathing], his sugars were under better control. His nausea and vomiting and hematemesis [vomiting blood] had resolved at this point in time. His diet was advanced a little bit. He was maintained on antibiotic therapy and monitored in the intensive care unit. However, the following day on July 9, 1995, the patient was significantly worse, being more short of breath with a productive cough. He had never had anginal symptoms. The blood pressure was stable. His chest x-ray however showed worsening congestive heart failure. His azotemia [excess nitrogen compounds in blood] was a bit worse. It was felt that he likely had ongoing myocardia ischemia at this time. His diuretics were adjusted, oxygen was increased. However, late the afternoon July 9, 1995, the patient had a cardiac arrest. Cardiopulmonary resuscitation was instituted as per the ACLS protocol and continued for a total of 40 minutes but he had absolutely no response but subsequently pronounce expired at 8:40 p.m.
[10] Mr. Williford’s body was later exhumed for an autopsy performed by Dr. Frank Peretti, a forensic pathologist, on April 13, 1996. Dr. Peretti’s autopsy report indicated that Mr. Williford’s “cause of death” was an acute myocardial infarction due to hypertensive arteriosclerotic heart disease with “contributory causes” being diabetes mellitus and chronic obstructive pulmonary disease. Dr. Peretti testified, in part, that:Acute myocardial infarction with congestive heart failure and subsequent cardiac failure, complicated by diabetes, renal failure, hypertension and chronic obstructive pulmonary disease. [Emphasis Added]
[11] In addition, Dr. Thomas Robinson, the Director of the Emergency Department of Baptist Memorial Medical Center in North Little Rock drafted the following “Memorandum” to the Arkansas State Claims Commission dated November 21, 1995:Well, you have to take the whole situation in perspective. Here you have a man before he began his testing allegedly had no cardiovascular complaints, such as chest pains, okay? He goes in there, he’s under the stress doing all these exercises for the agility test, and then develops all the symptomology.
The heart attack is clearly within twenty-four hours, it’s an evolving heart attack. And I think, you know, my opinion is, with a reasonable degree of medical certainty, is that the strenuous workout was about ninety-five to a hundred percent (95-100%) contributed to it, because he was fine beforehand. He was fine. He was walking around, no chest pains, no complaints.
[12] As we interpret the administrative law judge’s opinion and order, the administrative law judge apparently placed very significant weight on that portion of Dr. Peretti’s deposition testimony quoted above and on Dr. Robinson’s “Memorandum” opinion quoted above. In addition, the administrative law judge’s decision concludes in part:This letter is being written on behalf of Randy Williford. As you may know, Randy was a North Little Rock firefighter. Mr. Williford was undergoing the North Little Rock firefighter’s physical activity testing at the time of his death. His cause of death was an acute myocardial infarction. This M.I. was almost certainly a result of the strenuous activity required during the test.
[13] However, as we interpret Dr. Bierle’s deposition testimony, Dr. Bierle concluded from the claimant’s initial laboratory test data that the data did not support a diagnosis of myocardial infarction on admission, contrary to the administrative law judge’s discussion in that regard. Specifically, Dr. Bierle testified as follows regarding relevant laboratory data as to when the claimant’s myocardial infarction occurred:On the day that the claimant was brought to the emergency room Dr. Bierle was the physician on call at St. Vincent’s Medical Center. Dr. Bierle, in conjunction with the on call cardiologist determined that the claimant was suffering from an acute myocardial infarction at the time he was brought to the hospital.
Q. Would you agree or disagree that to a reasonable degree of medical certainty Mr. Williford sustained his myocardial infarction during the physical workout based upon his initial clinical presentation?
A. No. Reviewing the records, I cannot say that the exercise induced his myocardial infarction. And I say that because the initial laboratory data, looking at whether or not he had a myocardial infarction within the time frame, did not support the diagnosis of that myocardial infarction.
Q. Okay.
[14] Moreover, we find that Dr. Bierle’s testimony regarding the claimant’s initial heart-related laboratory data raises serious doubt as to whether Mr. Williford’s myocardial infarction was in any way due to the physical exertion Mr. Williford underwent on July 6th, much less that the physical exertion on July 6, 1996, was the major cause of the subsequent myocardial infarction which caused a cardiac arrest on July 9, 1996. [15] In assessing the testimony of Dr. Bierle (Mr. Williford’s treating physician) and the testimony of Dr. Peretti (the pathologist who performed the autopsy) on the issue of causation, we note that Dr. Peretti testified that the coronary arteries supply blood to the heart, and a myocardial infarction occurs when blood flow to the heart is disrupted. Dr. Peretti testified that his autopsy indicated that heart disease (atherosclerosis) had caused a 70-80% occlusion of Mr. Williford’s right coronary artery, and that heart disease had caused such a severe occlusion of the left coronary artery so that the blood flow was restricted to only a pinpoint lumen (i.e., nearly complete artery blockage). [16] Dr. Peretti testified that Mr. Williford’s heart problems were also compounded by a congenital abnormality of the aortic valve (i.e., two valve flaps instead of the normal three valve flaps), and that his physical measurements indicated that Mr. Williford’s heart was very enlarged at the time of his death, as compared to the heart of a normal individual, due to the effects of hypertensive cardiovascular disease. In addition, Dr. Peretti testified that Mr. Williford’s diabetes had caused moderate atherosclerosis of the intramural (smaller) coronary arteries of the heart. Dr. Peretti also testified that his autopsy indicated that Mr. Williford’s heart had experienced changes which were indicative of two heart attacks, the first occurring at least 6 months prior to death and the second near the time of death but at least 24 hours prior to his cardiac arrest on July 9, 1995. [17] In a significant contradiction to his testimony that the claimant’s exertion was likely a 95-100% contributing factor to the claimant’s “evolving heart attack”, Dr Peretti also testified that:A. In that the review — let me get to that (consulting records) — in that the laboratory data that was done over the 24 hours after he was admitted, and specific [sic] the CPK and the LDH, did not show the pattern that you would see with acute myocardial infarction in that 24 hours after he was first admitted.
Q. All right. Have you had an opportunity to review the autopsy report?
A. I reviewed the autopsy report, and I understand what the autopsy report says. Okay? I’m looking at it, just based on the laboratory findings that I have that we used to support whether or not indeed a myocardial infarction occurred. Okay?
He presented on the 6th. Laboratory data was done from the 6th through the 7th to document whether indeed any myocardial infarction had occurred at the time he had presented to the emergency room, and the CPK and the LDH do not support the fact that he would have had a myocardial infarction at that time.
Now, that’s not to say that after he had — what caused his cardiac arrest wasn’t a myocardial infarction at the time of his cardiac arrest. Okay?
With his left main coronary vessel being occluded like that and the amount of exercise, we all know when you have to go out and jog or do some strenuous work you’re going to get out of breath pretty fast. His left main is occluded, he has a congenital bicuspid valve, he has an enlarged heart, he has emphysema. All that puts considerable stress on your body.
And another thing, too, is the fact that he is a diabetic, he does have a high blood glucose, or hypoglycemia, and that’s putting an additional stress on his body, because he has to maintain.
Q. What stress is that putting on his body, on a hundred percent scale?
A. Well, you’re probably about ninety (90%), ninety-five percent (95%), because what happens is your body needs glucose, sugar, and he’s got to produce it.
Q. Right.
A. And he can’t do it.
Q. So?
A. He needs, his body needs to put more — His organs, I should say, are under more stress to produce it.
Q. Right.
A. Because it’s already severely compromised.
Q. Right. How severely compromised, on a hundred point scale?
A. Well, his, are you talking about his diet, from his —
Q. Well, in terms of his obstructive disease, his diabetes, his occlusion, how compromised is his body, off the norm?
A. I would say he is severely compromised. I mean, he’s a very ill man. I would say, you know —
Q. You could have knocked him over with a feather, so to speak?
[18] In addition, we place significant weight on the heart-related laboratory data collected beginning with the claimant’s hospital admission, and we place significant weight on Dr. Bierle’s testimony regarding the significance of that data from a diagnostic standpoint in assessing whether or not Mr. Williford was even experiencing cardiac-related symptoms when he first presented on July 6th with primary complaints of back pain. [19] As we interpret Dr. Peretti’s deposition testimony in its entirety, we understand Dr. Peretti’s autopsy to have indicated that Mr. Williford’s health in general (and the condition of his heart and his coronary arteries specifically) was so far compromised by preexisting medical conditions by July 6, 1995, that Mr. Williford was likely to experience a myocardial infarction at any time with no precipitating event, and that his condition was so far compromised even the slightest exertion could induce an infarction. [20] In reaching our decision, we note that Mrs. Williford’s testimony regarding Mr. Williford’s general health and his medical condition on July 6, 1996, deviates substantially from the history that Dr. Bierle testified that he took from the claimant after being assigned the claimant’s treating physician at St. Vincent’s. In light of corroborating medical records indicating that Mr. Williford was in fact “awake” and “alert” when Dr. Bierle took a history from Mr. Williford, we find that the contemporaneous medical history taken by Dr. Bierle is entitled to substantially greater weight than Mrs. Williford’s recollection at the hearing regarding her husband’s health and medical condition on July 6, 1995. [21] In short, we find that the greater weight of the credible evidence establishes that Mr. Williford experienced a number of preexisting coronary conditions (atherosclerosis, congenital valve abnormality, enlarged heart) and other risk factors (diabetes, hypertension, pulmonary disease) prior to July 6, 1995. In light of Dr. Bierle’s testimony that he could not agree (in light of laboratory data) that Mr. Williford sustained a myocardial infarction during the course of his activities on July 6, 1996, and in light of Dr. Peretti’s testimony that the claimant’s preexisting abnormalities rendered his health so compromised that Mr. Williford could have had a coronary event walking down the street, we find that the claimant failed to establish that, in relation to other factors contributing to the physical harm, any alleged coronary accident on July 6, 1995, was the major cause of Mr. Williford’s myocardial infarction. Therefore, we find that the decision of the administrative law judge must be, and hereby is, reversed. [22] IT IS SO ORDERED.A. Well, he could have been walking down the street and he may have had a coronary.
In assessing the weight to be accorded Dr. Robinson’s Memorandum opinion prepared on November 21, 1995 (before the autopsy which revealed findings of severe left coronary artery occlusion, an enlarged heart, and a congenital valve abnormality), we note that Dr. Robinson’s Memorandum does not in any way indicate a basis for his concluding that Mr. Williford’s myocardial infarction was “almost certainly a result” of work-related strenuous activity. In addition, we note that the only evidence linking Dr. Robinson to this case in any way (other than his Memorandum opinion) is Mrs. Williford’s testimony that she believed that Dr. Robinson had performed a stress test on her husband in June of 1995, just days before the FEATS testing. In assessing the relative weight to be accorded Dr. Robinson’s November 21, 1995, Memorandum, we also note that Dr. Peretti testified that it was hard to conceive how the claimant’s stress test in June of 1995 failed to reveal evidence of Mr. Williford’s prior heart attack. For these reasons, we find that Dr. Robinson’s Memorandum opinion is entitled to relatively little weight.
ELDON F. COFFMAN, Chairman MIKE WILSON, Commissioner
[23] Commissioner Humphrey dissents.