In Exhibit B, the records of St. John's Mercy Hospital Emergency Room, the records of March 15, 2008 contain entries from two separate persons, the doctor and the person who performed the triage assessment. Neither of them records a history of a work related injury. In fact, the ER doctor noted the pain started " 2 weeks ago." In a separate entry, it is noted "Fell 2 weeks ago." The doctor's notes also indicate "earlier this week was moving furniture," and in the section which asks where the injury happened, the box marked "home" is checked. In the
triage records, it indicates Claimant complained of low back pain " 3 weeks on \& off" and "moved furniture this week, now worse."
In Exhibit C, the records of Dr. Kunkel, Claimant was first seen on April 4, 2008. Dr. Kunkel notes "no specific injury." In Exhibit D, Claimant saw Dr. Forget for the first time on April 28, 2008. Dr. Forget records a history of a fall on ice approximately two months prior. Although the history recorded by both Dr. Kunkel and Dr. Forget are inconsistent, the records of Dr. Forget are consistent with the history recorded by the ER doctor two days after the alleged injury. None of the histories recorded in these records are consistent with the testimony provided by Claimant. In fact, the history to which Claimant testified does not appear in any records until May 19, 2008, in the records of Dr. Curylo (Exhibit F). Even part of that history is inconsistent with Claimant's testimony, as Dr. Curylo notes that after Claimant injured his back, he was unable to work the rest of the day. However, Claimant testified he worked the rest of his shift, and did not present to the ER until March 15, 2008.
In order to believe Claimant injured his back at work, that the condition in his back is from the work injury, and that he gave that information to his medical providers, one would have to believe that four different people disregarded what Claimant told them, and recorded erroneous information in the treatment records. Additionally, some of them would have recorded identical erroneous medical histories independent of one another.
The claim for compensation is denied. The claim against the Second Injury Fund is denied. All other issues are moot.
Made by: /s/ GRANT C. GORMAN
GRANT C. GORMAN
Chief Administrative Law Judge
Division of Workers' Compensation