Joan Knutter v. American National Insurance

Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION

(Reversing Award and Decision of Administrative Law Judge)

**Injury No.:** 13-020414

**Employee:** Joan Knutter, deceased

**Dependent:** Karl Knutter, deceased

**Claimant:** Michael Knutter

**Employer:** American National Insurance

**Insurer:** Travelers Indemnity Company of America

This workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by § 287.480 RSMo. We have reviewed the evidence, read the parties' briefs, heard the parties' arguments, and considered the whole record. Pursuant to § 286.090 RSMo, the Commission reverses the award and decision of the administrative law judge (hereinafter "ALJ").

The parties asked the administrative law judge to resolve the following issues:

1. Whether the employee's March 25, 2013, injury was the prevailing factor in causing her death on May 9, 2013;
2. Whether there was an appropriate substitute of Michael Knutter for his deceased father Karl Knutter, employee's husband; and
3. A Motion for Costs filed on behalf of both employee and employer/insurer.¹

The ALJ determined that the claimant "failed to sustain his burden of proof that Joan Knutter died as the result of immobilization from the treatment of her March 25, 2013, injury resulting in a blood clot and pulmonary embolism."² Finding the issue of medical causation to be dispositive of the case, the ALJ addressed no other issues.

Both employee and employer/insurer filed timely applications for review with the Commission.

The employer/insurer allege that the ALJ's award was erroneous for the following reasons:

I. The Award failed to address all the issues presented for adjudication at the final hearing on August 18, 2017 and specifically the following:

¹ The ALJ's October 10, 2017, award references only the issue of "whether the employer/insurer are liable for the costs of an unreasonable defense." Award, 3. At hearing, the parties stipulated that motions for costs pursuant to §287.560 filed on behalf of both the employee and employer/insurer were in dispute. See Claimant's Exhibit 12, Transcript, 543, and Employer/Insurer's Exhibit F, Id. 1228.

² Award, 5.

Injury No.: 13-020414

Employee: Joan Knutter, deceased

- 2 -

(a) The Motion for Costs filed on behalf of Employer and Insurer; and

(b) Whether there was an appropriate substitution of Michael Knutter for his deceased father and husband of employee, Karl Knutter.

The attorney for claimant Michael Knutter alleged the ALJ's award was erroneous for the following reasons:

(a) The administrative law judge erred in that she failed to award $116.48 in TTD [temporary total disability] benefits not paid by the employer and insurer, because the parties stipulated at the hearing that the employer and insurer underpaid TTD benefits by $116.48.

(b) The administrative law judge misapplied the law in that she failed to find the death of Joan Knutter, caused by a pulmonary embolism according to every medical opinion in evidence, compensable because the parties stipulated that Joan Knutter sustained an accidental ankle fracture arising out of an[d] in the course and scope of her employment for the employer and as such ever[y] natural consequence that flows from her injury is compensable as a direct and natural result of the primary original injury.

For the reasons set forth below, we reverse the award and decision of the administrative law judge.

Findings of Fact

The Accident

On March 25, 2013, while in the course and scope of employment for employer, the employee slipped and fell on ice at work, twisting her right ankle. That day, she saw Dr. Thomas Corsolini, who reviewed an X-ray of employee's right ankle and identified a non-displaced fracture of the right distal fibula. Dr. Corsolini initially treated the employee's injury with a protective splint and crutches. However, after an evaluation on April 1, 2013, orthopedist Dr. Robert Bennett treated employee with a non-walking fiberglass cast and a wheelchair for ambulation. The employee received no further treatment from Dr. Bennett and was wheelchair dependent until the time of her death.

On May 9, 2013, the employee experienced shortness of breath while she was sitting on the toilet. Her husband contacted emergency medical service personnel who took the employee to the hospital. Employee's husband told EMS personnel that his wife had complained of dull chest pains for several days. Despite CPR and emergency intervention at Mercy Hospital Springfield, the employee suffered a severe anoxic brain injury due to a saddle pulmonary embolus and died on May 9, 2013.

Injury No.: 13-020414

Employee: Joan Knutter, deceased

- 3 -

Dr. Randall Cross, a family physician, summarized his findings based on a review of employee's medical records in a report dated October 22, 2014.

Dr. Cross found the employee had cardiac risk factors consisting of hypertension, hyperlipidemia, obesity, and a sedentary lifestyle, which predisposed her to vascular disease and increased risk of thrombosis. He considered the employee to have major risk factors for vascular disease including longstanding chronic renal insufficiency, obstructive sleep apnea, gastroesophageal reflux disease with esophagitis, and hemorrhoids. He considered her report of dull chest pain for two days followed by sudden onset of shortness of breath while on the toilet leading to cardiac arrest "very suspicious for an acute coronary event." Dr. Cross noted a hospital evaluation showed the employee had an elevated troponin level, which he also considered potentially indicative of myocardial damage. Dr. Cross surmised, based on a mass identified in the employee's left adrenal gland, that the employee also may have had undiagnosed cancer.

Although he noted that the employee had been in a wheelchair during much of the forty-five days from the time of her ankle fracture until the day of her demise, Dr. Cross concluded:

> Taking all of the medical facts into consideration, this woman had multiple risk factors for the development of thrombosis and there is no way with any reasonable medical certainty to conclude that her 45-day old ankle fracture was the prevailing factor in the development of a pulmonary embolus leaded to her cardiac arrest and ultimate demise.

Dr. Cross noted that the employee's cremation precluded an autopsy, which would have answered questions relating to the cause of her death.

Internist and registered vascular technologist, Dr. Thomas Wright, set out his opinions regarding medical causation in a letter dated October 22, 2014.

Dr. Wright noted that the employee had multiple underlying risk factors for venous thromboembolism (VTE), including age, obesity, renal insufficiency, and obstructive sleep apnea. However, Dr. Wright found that the key precipitating event and direct proximal cause of the employee's saddle pulmonary embolism was immobility secondary to fracture of her right ankle. He noted employee's prolonged lack of ambulation due to delay in planned removal of her cast at five and six weeks after her

3 Employer/Insurer's Exhibit A, Transcript, 557.

4 Id. 558.

Injury No.: 13-020414

Employee: Joan Knutter, deceased

- 4 -

fracture and the recommendation that she remain completely non-weight bearing and using only a wheelchair.

Dr. Wright considered the employee's immobility attributable to the March 25, 2013, work injury to be "the tipping point", proximate cause and "the final contributing factor" of her fatal pulmonary embolism.5 He observed that though the employee was sedentary, she was mobile and actively ambulating without assistance prior to her fall on March 25, 2013.

Using mathematical calculations that involved multiplying the employee's independent risk factors, Dr. Wright concluded that the employee's risk of deep vein thrombosis and pulmonary embolism (DVT/PE) was 52.2% if she remained immobile for greater than several days after her March 25, 2013, ankle fracture.

Dr. Wright concluded, "In this setting of significantly elevated risk, based on my experience and knowledge of the pathophysiology of venous thromboembolic disease, that fracture of the ankle was the inciting cause of Ms. Knutter's fatal PE."6

Dr. Mitchell Mullins

Dr. Mitchell Mullins, an emergency medicine osteopathic physician, reviewed the employee's medical records and summarized his findings in a report dated March 24, 2015.

Dr. Mullins noted employee's confinement to a wheelchair for much of forty-five days after her work-related ankle fracture. He stated that immobilization interferes with normal blood circulation, which leads to venous stasis; that thrombi or blood clots grow especially when blood flow is not normal; and that one in five pulmonary embolism occurs longer than fourteen days after a trauma.

Dr. Mullins noted that the employee did not have cardiovascular disease and had no history of heart failure. He opined it would "clearly be against logical medical reasoning to diagnose someone's death due to a cardiac event in light of a massive saddle embolus."7

Dr. Mullins acknowledged that the employee's age (sixty-nine) and obesity were factors that increased her risk for pulmonary embolus. He considered obesity to be a minor risk factor.

Dr. Mullins found that employee exhibited no symptoms of cancer nor was there any indication she had cancer. He did not consider the employee's elevated troponin level at the time of hospital evaluation to be a factor that increased her risk for pulmonary embolism.

5 Claimant's Exhibit 2, Transcript, 20, 22.

6 Id. 23.

7 Id. 10.

Injury No.: 13-020414

Employee: Joan Knutter, deceased

- 5 -

Dr. Mullins concluded that the most likely cause of the employee's pulmonary embolus was trauma from her March 25, 2013, work injury and resulting immobilization. Dr. Mullins specifically disputed Dr. Cross' opinion that the employee's ankle fracture was not, within any degree of medical certainty the prevailing factor in her development of a pulmonary embolism. He concluded:

> [I]t is within a reasonable degree of medical certainty that the ankle fracture lead [sic] to venous stasis which ultimately led to a saddle embolism. Although other factors are possible, it is not reasonable to consider them with the weight that a recent trauma has in the development of pulmonary emboli.

Dr. J. Randolf Mullins

Employer produced two undated letters from vascular surgeon Dr. J. Randolf Mullins (hereinafter Dr. J. Mullins). Dr. J. Mullins stated he firmly agreed with Dr. Cross' conclusions and opinion regarding the issue of medical causation. He further opined that the employee "had a 99.78% likelihood of not suffering a PE following her ankle fracture."

Dr. J. Mullins summarized:

> This exceedingly low risk occurs in the context of pre-existing risk factors (obstructive sleep apnea, obesity, sedentary lifestyle, sedentary profession, chronic kidney disease), likely co-morbid diseases (adrenal tumor, venous disease) and lack of clinical evidence for a DVT. Of the many people who have died of PE while on the toilet, my inability to find a single example of such a person who simultaneously had an ankle fracture is instructive.

Given the above, it is simply impossible to suggest that the predominant cause of Mrs. Knutter's PE was her ankle fracture.

Our Findings

We do not dismiss the ALJ's observation that because there was no autopsy, no medical records document the specific location of the employee's blood clot or deep vein thrombosis. However, we disagree with the ALJ's conclusion that it is purely speculative to link the employee's work-related right ankle injury and her fatal saddle pulmonary. Neither Dr. Cross' identification of a multitude of other risk factors based the employee's medical history and hospital records, nor Dr. J. Mullins' inability to find examples in medical literat