Based on the testimony of David Martinez ("employee") and the medical records and reports admitted, I find as follows:
At the time of the hearing, the employee was 44 years old and lived in Park Hills at his current address for the past twenty years. He is currently married to Glenda Martinez and has three adult children and two grandchildren. In 1983, the employee graduated North County High School. Although he received his diploma, the employee was in special education classes throughout high school and was far behind his peers (Employee Exhibits O \& P). Following his graduation, the employee worked in law care, at a green house, and at a grocery store.
In 1988, the employee began working for NPC Acquisitions Corp. DBA Bidco Sealants, Inc. ("employer"). The employee's primary job was a roller where he would apply spacers and cores and then roll the sheet metal up with the use of a machine. Additionally, he would also cut up batches, clean floors, clean machines, and box up fiber strings. The employee left the employer for a short time to work at Killark, a big factory in St. Louis. After three days, the employee quit since he could not complete the paperwork and the amount of people made him nervous. After a few months, the employee returned to employment with the employer.
On October 30, 2003, the employee was working for the employer and went to retrieve a box of the cores to do his job. The core boxes were stacked in the space between the wall and ramp. In order to get a box, the employee had to stand on the ramp railing and lean out. At that time, the ramp railings were made of wood and broke under the employee's weight. As a result, the employee twisted and fell onto the concrete ramp and onto the floor injuring his head, right eyebrow, and left shoulder. The employee was immediately taken to Parkland Health Center in Bonne Terre for treatment. While at the emergency room, the employee provided the details of the work accident and was given sutures and medication. Additionally, the employee was taken off work and followed up with Dr. Laurence Lum on the next day. Dr. Lum examined the employee and kept the employee off work for another week. After the employee returned to work, he was able to work for three or four days until he had to return to the emergency room at Mineral Area Regional Medical Center on November 14, 2003. At that time, the emergency room doctor noted that the employee has obvious deformity of left shoulder and has reported pain in shoulder is getting worse (Employee Exhibit CC).
After following up with Dr. Lum and having an MRI completed, the employee was referred to Dr. Scott VanNess who examined him on December 17, 2003. Dr. VanNess diagnosed brachial plexopathy as a result of traction neuropraxia and subsequent axillary nerve palsy and deltoid atrophy of the left shoulder. In addition to placing the employee on light duty restriction, sedentary work, right handed work only avoiding any climbing or use of the left arm, Dr. VanNess referred the employee to physical therapy and to Dr. Howard for an upper extremity second opinion. On his next visit, Dr. VanNess deferred all further treatment to Dr. Howard (Employee Exhibit D, Part 2).
On January 19, 2004, Dr. Richard Howard examined the employee, noted the MRI was unremarkable, diagnosed the employee with Left C5-6 brachial plexus palsy with partial recovery, and ordered an EMG/Nerve Conduction Study (Employee Exhibit D, Part 3). The EMG/Nerve Conduction Study was completed by Dr. Daniel Phillips on February 2, 2004, and was consistent with left brachial plexopathy involving predominately the left axillary and suprascapular distributions. Additionally, Dr. Phillips noted that there was mild left median neuropathy across the carpal tunnel. A repeat EMG/Nerve Conduction Study was completed on March 2, 2004, and showed no evidence of suprascapular reinnervation (Employee Exhibit E). Later that day, Dr. Howard reviewed the study and recommended doing a nerve transfer for a suprascapular nerve most likely with a branch of the spinal accessory and then neuritization of his axillary nerve with the triceps branch. Further, Dr. Howard noted that it is unlikely that he will be able to return to the same job that he performed previously, although not impossible (Employee Exhibit D, Part 2).
Dr. Richard Howard operated on the employee on March 17, 2004, and performed an exploration of brachial plexus and neurotization of the suprascapular nerve with a branch of the spinal accessory and neurotization of the axillary nerve with a branch of the radial nerve to the triceps. The post operative diagnosis was left C5 nerve root avulsion (Employee Exhibit F). Following the first operation, the employee returned to physical therapy and was observed to have significant muscle atrophy thoughout the left shoulder joint and parascapular region along the supraspinatus, infraspinatus, deltoid musculature, and teres musculature (Employee Exhibit D, Part 6). After several follow up visits, Dr. Howard noted that the employee is not showing any function in the deltoid and cannot hold his arm out at all. As a result, Dr. Howard referred the employee to Dr. Rotman for a second opinion regarding further treatment recommendations (Employee Exhibit D, Part 3). On November 29, 2004, Dr. Mitchell B. Rotman examined the employee and recommended proceeding with a shoulder fusion (Employee Exhibit G). At the request of the employer-insurer, a second independent medical examination was performed by Dr. James Emanuel on January 11, 2005. Dr. Emanuel opined that the employee's current condition is directly and causally related to his injury of October 30, 2003, and that the left shoulder fusion would be an appropriate option (Employee Exhibit H).
On February 2, 2005, Dr. Howard performed the left shoulder fusion noting that the employee has an unstable painful shoulder which is a flail shoulder due to his complete C6 palsy (Employee Exhibit I). During the operation, Dr. Howard inserted several screws and plates (Employee Exhibit GG). After several follow up visits and more physical therapy, Dr. Howard found that the employee was at maximum medical improvement on July 14, 2005. He released the employee back to work and placed him on permanent restrictions of lifting no more than fifty pounds and no overhead use of his arm. Although the employee continued to complain of soreness and pain following his return to work, Dr. Howard opined on August 8, 2005, that some of his complaints were just going to be permanent and that the employee does not require any other treatment (Employee Exhibit D, Parts 3 \& 6).
After his release from Dr. Howard, the employee returned to Dr. Lum for follow up care for pain management and depression which he continued until the date of the hearing (Employee Exhibit CC). On January 31, 2006, the employee was examined by Dr. Bruce Schlafly at the request of his attorney. As a result of his examination, Dr. Schlafly did not recommend any
further surgeries and opined that the employee will require future medical care with prescription medication for pain control. Dr. Schlafly also recommended sedentary work and placed restrictions on the employee of no performing work with the left arm at the level of the chest or higher, no lifting of greater than ten pounds with the left arm, and no climbing ladders. With regard to the work injury of October 30, 2003, Dr. Schlafly rated the employee at eighty percent permanent partial disability of the left upper extremity at the level of the shoulder with an additional twenty percent permanent partial disability of the body as a whole referable to the upper back. Additionally, Dr. Schlafly noted that the employee's long term prognosis for working at the factory is poor and that the employee may be permanently totally disabled, but he would defer to a vocational rehabilitation counselor (Employee Exhibit A). At his deposition, Dr. Schlafly testified that the work injury of October 30, 2003 was not only the substantial factor, but also the primary factor in the employee's need for future medical treatment, his permanent partial disability, and his restrictions (Employee Exhibit X, Page 31).
The employee returned for another independent medical evaluation with Dr. Emanuel on October 17, 2006. Following his examination of the employee, Dr. Emanuel noted that he agrees with Dr. Schlafly with regards to his current work and work restrictions. Further, he recommended additional restrictions of no repetitive use of the left arm even at waist height, no lifting of any weight from waist to chest height, no crawling, no pushing or pulling greater than fifty pounds on a cart, and no pushing or pulling of greater than ten pounds without a cart (Employee Exhibit J). At his deposition, Dr. Emanuel noted that the employee does not necessarily require a pain management expert to follow him, but that the medications he was taking was appropriate. Further, Dr. Emanuel noted that if the employee was still having pain then the medical prescriptions and doctor follow ups would be medically necessary (EmployerInsurer Exhibit 2, Pages 22-24).
On November 14, 2006, the employee was evaluated by James England, a vocational rehabilitation counselor. Mr. England administered the Wide-Range Achievement Test Revision 3, the reading comprehension portion of the Adult Basic Learning Examination - Level 1, and the Wechsler Adult Intelligence Scale revised. The employee scored at the first grade level on word recognition, beginning of fourth-grade level on arithmetic, third grade fifth month on reading comprehension, a verbal IQ of 73, a performance IQ of 77, and a full-scale IQ of 74 (Employee Exhibits K, Q, R \& S). After his examination, Mr. England opined that the employee would not be able to successfully compete for alternative employment in the open labor market. Mr. England further noted that the employee would not be able to even perform sedentary work on a consistent basis due to a combination of his physical problems and pre-existing limited intellectual ability and poor academic abilities as a whole. Consequently, Mr. England stated that the employee was a good candidate for Social Security Disability benefits (Employee Exhibit K). At his deposition, Mr. England indicated that the employee could do retail sales, cashiering, and a wide variety of service employment if he had just the shoulder restrictions (Employee Exhibit Z).
The employee quit work on April 14, 2007 due to his inability to properly perform his work and the associated pain as a result of the work. On June 25, 2007, Dr. Lum filled out a physician's statement of ability to work or disability and noted that the employee will be on chronic pain medication for life (Employee Exhibit BB). The employee formally made a request
for all medically necessary treatment and pain management medications by his attorney's letter dated July 12, 2007 and requested a written response to the letter (Employee Exhibit AA). Mr. England's letter on August 22, 2007, reiterated his belief that the employee was permanently and totally disabled as a result of a combination of pre-existing problems and the work related injury (Employee Exhibit L).
On March 10, 2008, Dr. Wayne A. Stillings examined the employee and opined that the October 3, 2003 work injury is a substantial factor in causing the employee to suffer a mood disorder with an associated twenty percent permanent partial psychiatric disability and a pain disorder with an associated twenty percent permanent partial psychiatric disability. With regard to pre-existing psychiatric disabilities, Dr. Stillings noted a five percent permanent partial psychiatric disability for parent-child relational problem, a ten percent permanent partial psychiatric disability for social phobia, a twenty percent permanent partial psychiatric disability for mild mental retardation, and a five percent permanent partial psychiatric disability for avoidant personality traits. Dr. Stillings then opined that the employee was permanently and totally disabled from gainful employment on a psychiatric basis a result of a combination of the pre-existing and work related psychiatric problems (Employee Exhibit T). At his deposition, Dr. Stillings further testified that the employee would need further psychiatric treatment for the work injury to prevent deterioration in his clinical psychiatric condition specifically directed at his mood disorder (Employee Exhibit Y, Page 31).
The employer-insurer sent the employee to see Dr. Evan Bassett for an independent medical evaluation of his mental condition on June 28, 2008. Dr. Bassett opined that the work injury was a substantial factor in the employee's development of a major depressive disorder. Further, Dr. Bassett noted that the employee will benefit from treatment with antidepressant medication and that his depressive symptoms are potentially manageable by an informed attentive primary care physician, psychiatrist, or pain management physician. With regard to pre-existing psychiatric disabilities, Dr. Bassett noted a five to ten percent impairment due to the employee's learning disorder. Dr. Bassett opined that the employee had a five to ten percent impairment for the October 30, 2003 injury related depression (Employer-Insurer Exhibit 1).
On March 5, 2009, Dr. Robert F. Morgan reviewed the employee's records at the request of the Second Injury Fund. Following his review he opined that the employee was permanently and totally disabled as a result of the October 30, 2003 work related injury (Second Injury Fund Exhibit III). At his deposition, Dr. Morgan did not feel that the mild retardation explained why the employee was totally disabled (Second Injury Fund Exhibit I).
On April 7, 2009, the employee sought treatment at Southeast Missouri Community Treatment Center, Inc. At that time, the employee's medication was adjusted. At his follow up visit on June 4, 2009, the employee's medication was again adjusted (Employee Exhibit DD). According to the employee at the hearing, this treatment has been provided by Dr. Jintendra M. Patel at the employee's cost. Additionally, the follow up maintenance treatment by Dr. Lum and a large number of prescriptions were also paid by the employee (Employee Exhibits EE \& FF). At the time of the hearing, the employer-insurer stipulated to paying for the employee's out of pocket expenses in Employee Exhibits EE \& FF.
At the time of the hearing, the employee continued to take medication for treatment of the work related injury in the form of Percocet, Cymbalta, Cyclobenzaprine, Trazadone, and Ibuprofen. The employee has constant pain which is aggravated by any movement, vibration, or impact. As a result of his problems, the employee no longer goes fishing, hunting, bowling, or performs any yard work. Most of the employee's day is spent watching television, staying in his bedroom, and listening to the radio. With regard to disfigurement, the employee has a two inch scar below his eyebrow with a dime sized scar above his eyebrow. In addition to the top part of his left arm having a significant scar that runs down the back of his arm, the employee also has significant noticeable atrophy from his elbow up his arm.