Lisa Stegman v. Grand River Regional Ambulance District

not include any findings to resolve the conflicting evidence. Further, the Court found we failed to clearly express the legal theory upon which we relied in determining that the accident did not arise out of and in the course of employee's employment. For the foregoing reasons, the Court of Appeals vacated the award and remanded the matter to the Commission for findings of fact and conclusions of law.

The primary issue before the Commission is whether the injury that occurred on March 31, 2002, arose out of and in the course of employee's employment. All other issues are dependent upon that determination.

Employee began working for Grand River Regional Ambulance District in 1993. In March 2002, employee was a full-time paramedic and the crew chief for the ambulance district's King City office. At the time of the alleged accident, employee lived approximately one-half mile from the King City ambulance barn.

During March 2002, employee's regular hours were from 8:30 a.m. until 5:00 p.m., and she was on call between 5:00 a.m. and 5:00 p.m. on weekdays. Employee was paid to be on call and if she was called out during on-call hours in the evenings or on weekends, she received full pay. Barbara Shupe, the District Administrator for the ambulance district, testified that during employee's on-call hours, her pay went from 4.25 per hour to 10.60 per hour upon receiving a page.

The ambulance district's policy suggests a response time of five minutes – between the time the page is received and the time the ambulance is en route. This policy is further supported by Ms. Shupe's testimony in which she stated that upon receiving a page, employees **must** respond and attempt to arrive at the ambulance barn within five minutes.

On March 31, 2002, which was Easter Sunday, employee went on call at 5:00 p.m. She had worked for employer the week before the Easter weekend. The evening of March 31, 2002, a page went off while employee was at home. It was a priority one call, which is the most important type of call, and employee learned there had been a rollover accident, and a person was trapped in a car between King City and Union Star, Missouri.

Employee was standing in her kitchen in her pajamas scooping ice cream for her family when the page came in. After the page came in, employee ran back to her bedroom, put on her clothes, and then ran back out through the hallway into the kitchen and out into the garage. After she put her shoes on, and while she was in the garage on the way to her vehicle to drive to the ambulance barn, she stepped around the front of her husband's pickup truck near the driver's side, twisted her right knee and fell backwards landing on a wheel of a bicycle. Employee was going as fast as she could when the

Improve: Lisa M. Stegman

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incident occurred. Employee was then taken to the emergency room at Heartland Regional Medical Center in St. Joseph, Missouri.

**Medical**

Prior to this March 31, 2002, incident, employee had a medical history of anemia. When employee was nine years old, she was examined and treated at the Mayo Clinic for anemia. Employee received blood transfusions at that time. She did not receive another blood transfusion for several years, but did receive at least one other blood transfusion prior to the March 31, 2002, incident.

After employee was released from the emergency room on March 31, 2002, she was advised to follow-up with her primary care physician, Dr. Miller. Employee eventually had right knee arthroscopic surgery on her torn ACL on April 18, 2002, which was performed by Dr. DiStefano. Employee was ordered to follow-up with physical therapy.

In May 2002, employee was seen by Dr. Miller with complaints of exertional shortness of breath, and was admitted to Gentry County Memorial Hospital on May 14, 2002. The next day she was transferred to North Kansas City Hospital, with a diagnosis of multiple pulmonary emboli. On discharge from North Kansas City Hospital, her discharge diagnosis also listed swelling of her right knee and back pain in addition to her shortness of breath. Before employee was released from the hospital, the swelling went down and an MRI revealed that her back pain was most consistent with her sacroiliac dysfunction.

Subsequent to her release from North Kansas City Hospital, employee experienced numerous venipunctures, CBC testing, and tests to measure the thickness of her blood. These tests were performed at Northwest Medical Center.

On September 4, 2002, employee had a bilateral leg venous duplex exam at the North Kansas City Hospital, and this testing was ordered by Dr. Henry. In October 2002, employee had further testing at North Kansas City Hospital and was admitted to that facility on October 20, 2002, for a four-day stay due to anemia. Employee's discharge summary listed a history of pulmonary emboli. She received a blood transfusion to correct her anemia and was stable at discharge.

On December 26, 2002, employee went to Gentry County Memorial Hospital for abdominal pain and was transferred to Heartland Regional Medical Center (Heartland). Employee was admitted at Heartland on December 26, 2002, and was discharged on December 28, 2002. Employee's final diagnosis was iliac/pelvic vein thrombosis, acute and chronic.

After being discharged from Heartland, employee was subsequently life-flighted to the Mayo Clinic in Rochester, Minnesota. The admitting diagnosis was abdominal pain, extensive venous thrombosis, and chronic anemia requiring transfusions. Employee was released from the Mayo Clinic the first part of January of 2003.

**Improvement in the care of the patient**

On December 15, 2005, Dr. Brent Koprivica provided an independent medical evaluation on behalf of employee. Dr. Koprivica noted employee's past history of anemia, which required transfusions, her ongoing back pain complaints, and numbness in her leg. Dr. Koprivica listed her ongoing complaints as right knee pain and grinding, severe problems with swelling (left greater than right), and ongoing back pain as well. Dr. Koprivica also noted that an MRI had been ordered with regard to employee's back pain and she had been diagnosed with Grade 1 spondylolisthesis and degenerative disk disease of L5 and S1. There was also bulging of the L5-S1 disk with annular tear and a central protrusion at L1-L2.

Dr. Koprivica concluded that employee sustained permanent injury to her right knee and developed deep venous thrombosis (DVT) as a direct result of the March 31, 2002, incident and resulting surgery. Dr. Koprivica also concluded that due to the March 31, 2002, incident, employee sustained an aggravating injury to her degenerative disease in her lumbar spine with the development of mechanical back pain.

Dr. Koprivica concluded that employee is at maximum medical improvement. He further opined that she was temporarily totally disabled for nearly a year as a result of the March 31, 2002, incident, and the medical treatment she received was medically reasonable and a direct result of the March 31, 2002, incident. Dr. Koprivica stated that she will need future monitoring, as well as blood transfusions and that this treatment is causally connected to the injury date of March 31, 2002.

Dr. Koprivica also provided permanent partial disability ratings. Dr. Koprivica opined that as a direct result of the March 31, 2002, injury, employee is 25% permanently partially disabled of the right lower extremity at the level of the knee, 10% permanently partially disabled of the body as a whole due to sacroiliac and chronic back pain, and 25% permanently partially disabled of the body as a whole for severe problems with DVT. Globally, Dr. Koprivica assigned a 50% permanent partial disability of the body as a whole.

Dr. Koprivica testified that DVT is a known complication of surgery, especially employee's surgery because they put a thigh cuff on which occludes the blood flow in the thigh area, and this is known to cause blood clots.

On July 17, 2006, Dr. John Gragnani provided an independent medical evaluation on behalf of employer. Dr. Gragnani opined that the injuries to employee's right knee and surgical intervention were definitely caused by the March 31, 2002, incident. He stated that the DVT in the right leg "was most likely triggered as a result of the immobilization and subsequent surgical treatment to the right knee." Dr. Gragnani went on to opine that the DVT complications related to the blood transfusions and so forth were "more likely" related to medical conditions that have been poorly defined but may be hypercoagulability due to possible protein S deficiency or some other deficiency that may be inherent in employee. Dr. Gragnani stated that there are a number of hypercoagulability states, and included, as an example that employee was over 200 pounds at the time of this occurrence, putting her at a greater risk.

Dr. Gragnani stated that while the first instance of DVT may be related to the fall that occurred on March 31, 2002, and resulting surgery, the subsequent DVT, blood transfusions, and hospitalizations and treatment for anemia have nothing to do with employee's incident of March 31, 2002.

Dr. Gragnani concluded that employee did not suffe