Harry Hall v. City of Richmond Heights, Missouri

(Affirming Award and Decision of Administrative Law Judge)

Employer: Harry Hall (Deceased)

Dependent: Tina Hall

Employer: City of Richmond Heights, Missouri

Insurer: St. Louis Area Insurance Trust

Injury No. 14-032369

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by § 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Law. Pursuant to § 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated November 18, 2020, and awards no compensation in the above-captioned case.

The award and decision of Administrative Law Judge Lee B. Schaefer, issued, is attached and incorporated by this reference.

Given at Jefferson City, State of Missouri, this ______ 2nd ______ day of July 2021.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

Robert W. Cornejo, Chairman

Reid K. Forrester, Member

DISSENTING OPINION FILED

Shalonn K. Curls, Member

Attest:

Secretary

I believe that the administrative law judge should have found that claimant sustained an occupational disease arising out of and in the course and scope of his employment that eventually resulted in his death.

Claimant was a police officer for nearly 50 years. The day to day job duties of a police officer are stressful, to the point that the Missouri legislature chose to include a special provision regarding police officers' stress, and occupational diseases by enacting §287.067.6. Furthermore, Drs. Schuman and Mankowitz agreed that the job duties of a police officer are stressful. Claimant dedicated more than half of his life to serving and protecting the public, and I believe that $\S 287.067 .6$ was enacted by the Missouri legislature specifically for individuals in claimant's position.

For these reasons, I would find employer to be liable to claimant for the occupational disease that arose out of and in the course of his employment. Because the majority of the commission has determined otherwise, I respectfully dissent.

Shalonn K. Curls

Shalonn K. Curls, Member

Employee: Dependents of Harry Hall

Injury No. 14-032369

Dependent: Tina Hall

Employer: City of Richmond Heights

Insurer: St. Louis Area Insurance Trust

Additional Party: N/A

Hearing Date: August 12, 2020

Before the

DIVISION OF

WORKERS'

COMPENSATION

Department of Labor and

Industrial

Relations of Missouri

Jefferson City, Missouri

Checked by: LBS

1. Are any benefits awarded herein? No
2. Was the injury or occupational disease compensable under Chapter 287? No
3. Was there an accident or incident of occupational disease under the law? No
4. Date of the alleged accident or onset of occupational disease: January 24, 2014
5. State location where accident occurred or occupational disease was contracted: St. Louis County
6. Was above employee in employ of above employer at time of alleged accident of occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of employment? No
9. Was claim for compensation filed within time required by law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: Employee allegedly sustained an occupational disease arising out of and in the course and scope of his employment that allegedly resulted in Employee's death.
12. Did accident or occupational disease allegedly cause death? Yes
13. Part(s) of body injured by accident or occupational disease: BAW - cardiac
14. Nature and extent of any permanent disability: N/A
15. Compensation paid to date for temporary disability: $\ 0
16. Value necessary medical aid paid to date by employer/insurer? $\ 0

1. Value necessary medical aid not furnished by employer/insurer? None
2. Employee's average weekly wages: $\ 1,273.00
3. Weekly compensation rate: $\ 851.80
4. Method wages computation: Stipulation between parties

1. Amount of compensation payable: None
2. Second Injury Fund liability: Dismissed at Hearing.
3. Future requirements awarded: N\A

Employee: Dependents of Harry Hall

Dependent: Tina Hall

Employer: City of Richmond Heights

Insurer: St. Louis Area Insurance Trust

Additional Party: N/A

Hearing Date: August 12, 2020

Injury No. 14-032369

Before the

DIVISION OF

WORKERS'

COMPENSATION

Department of Labor and Industrial Relations of Missouri Jefferson City, Missouri

Hearing Date: August 12, 2020

The parties appeared before the undersigned administrative law judge on August 12, 2020, for a Final Hearing in this matter. Attorney James Martin represented Tina Hall, Dependent of Harry Hall ("Claimant"). Harry Hall ("Employee") is deceased. Attorney Todd Hilliker represented the Employer, City of Richmond Heights ("Employer"), and its insurer, St. Louis Area Insurance Trust ("Insurer"). Claimant dismissed the Second Injury Fund at the time of the Hearing.

Claimant offered and had admitted into evidence the following Exhibits:

Exhibit 1: Autopsy report

Exhibit 2: Report of Dr. Whiting

Exhibit 3: Reports of Dr. Gupta

Exhibit 5: Medical records of Skaggs Community Hospital

Exhibit 6: Medical records of Dr. Carter

Exhibit 7: Medical records and reports of Dr. Harshman

Exhibit 8: Division of Workers' Compensation records for Injury Number 90-009746

Exhibit 9: Medical records of Dr. McCann

Exhibit 10: Medical records of Dr. Joseph Bodet

Exhibit 11: Medical records of Metro Health Group (Dr. Kancherla)

Exhibit 12a: Personnel records of St. Louis Police Department

Exhibit 12b: Medical division records of the St. Louis Police Department

Exhibit 13: Records of the Richmond Heights Police Department

Exhibit 14: Medical records of Dr. Purcell

Exhibit 15: Medical records of St. Clare/SSM Hospital

Exhibit 17: Division of Workers' Compensation records for Injury number 87-10342

Exhibit 18: Division of Workers' Compensation records for Injury number 88-137214

Exhibit 19: Medical records of St. Mary's Hospital

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Exhibit 20: Medical records of Midwest Sleep Diagnostics

Exhibit 21: Report and deposition of Dr. Stephen Schuman

Exhibit 23: Records of Police Officer Standards and Training (P.O.S.T.)

Exhibit 24: Marriage License of Harry and Tina Hall

Exhibit 25: Death Certificate of Harry Hall

Exhibit 26: Records of St. Louis County Police Department

Exhibit 27: Division of Workers' Compensation records

Exhibit 28: Claimants' Exhibit List

Employer/Insurer offered and had admitted into evidence the following Exhibits:

Exhibit A: Certified records of the Division of Workers' Compensation

Exhibit B: Medical records of Dr. Harshman

Exhibit C: Medical records of Midwest Sleep Diagnostics

Exhibit D: Medical records of Dr. Droege

Exhibit E: Medical records of Dr. Noda

Exhibit F: Medical records of BJC Christian Hospital

Exhibit G: Medical records of Dr. McCann

Exhibit H: Medical records of Dr. Purcell

Exhibit I: Medical records of Dr. Terkonda

Exhibit J: Medical records of St. Mary's Hospital

Exhibit K: Personnel records of St. Louis Metropolitan Police Department

Exhibit L: Medical records of St. Louis Metropolitan Police Department

Exhibit M: Medical records of St. Clare Hospital

Exhibit N: Medical records of Dr. Kancherla

Exhibit O: Death Certificate of Harry Hall

Exhibit P: Records of Richmond Heights Police Department

Exhibit Q: Deposition of Dr. Mankowitz

Exhibit R: Correspondence from Mr. Martin to Dr. Schuman

Exhibit S: Report of Dr. Shreim

Exhibit T: Autopsy report

Exhibit U: Records of St. Louis County Police Department

Exhibit V: Employer/Insurer's Exhibit List

**STIPULATIONS**

The parties stipulated to the following:

1. On or about January 24, 2014, Employee allegedly sustained an occupational disease allegedly arising out of and in the course and scope of his employment that allegedly resulted in his death;
2. Employee was an employee of Employer pursuant to Chapter 287;
3. Employee's dependent provided proper notice of his occupational disease to Employer;
4. Employee's dependent filed their Claim for Compensation within the time allowed by law;

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1. Employee's average weekly wage on the date of his occupational disease was 1,273.00, with a resulting rate of 851.80 for death benefits;

1. Employer has not paid any benefits to date;

1. Venue for this Hearing is proper in the City of Saint Louis.

The issues to be determined in this Hearing are:

1. Did Harry Hall sustain an occupational disease arising out of and in the course and scope of his employment?

1. Is Harry Hall's cardiac condition and death medically causally related to his alleged occupational disease?

Only evidence supporting the award will be summarized. Objections not ruled on during the hearing or in this award are overruled. Marks or highlights contained in the exhibits were made prior to being made part of this record and not placed thereon by the Administrative Law Judge.

**Terry Ford** ("Ford") was a Certified Law Enforcement Officer for 15 to 20 years. He met Employee when Ford worked for the Maplewood Police Department and Employee worked for Employer. Ford and Employee were both patrol officers. The areas that they patrolled shared a boundary. They would work a call together once or twice a week. Ford has worked in private security for the last 10 years.

As patrol officers, Ford and Employee would look for obvious crimes as they patrolled their cities, answer calls, and maintain safety and law and order.

Ford and Employee would discuss their jobs and the stress they experienced in their jobs. Ford developed stress as a result of his job. Ford had trouble sleeping due to stress. Ford developed heart disease that he relates to his job stress.

Ford reported that he and Employee discussed job stress that would arise during confrontations with their superiors. They also discussed stress that came from arrests with resistance and violence.

Ford and Employee responded to motor vehicle accidents together. They often responded to crimes together because they both patrolled high crime areas next to each other. The boundary of their cities was a violent area with a lot of drug use. When dealing with traffic

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matters or crimes, they often dealt with confrontations. The calls were so abundant in both jurisdictions that Ford and Employee were the only officers on the scene. In the evening, the number of officers working was "thin".

Ford enumerated several causes of stress on the job including the hours worked, low personnel numbers, difficult assignments, confrontations with supervisors, and poor eating habits. Ford noted that police officers worked a different shift every three weeks; which did not allow their bodies to adjust before changing shifts again. Constantly changing shifts also made it difficult to sleep and made it difficult to perform. Because of personnel shortages, officers often worked overtime. Ford believes all of the stressful factors could lead to heart disease.

On cross-examination, Ford testified he stopped working as a police officer in August of 2001. He had no on-duty interaction with Employee from 2001 through 2014. Ford did not know if the stressors he had at the Maplewood Police Department were the same as those at the Richmond Heights Police Department.

Tina Hall ("Tina") married Employee on June 6, 1980. (Exhibit 24). They had two children who are adults and independent.

When Tina and Employee met, he was already a police officer for the St. Louis City Police Department ("SLCPD"). Employee had a Bachelor degree from St. Louis University, and a Master degree from Lindenwood University. They discussed his job duties periodically. When they first married, Employee was working as a street patrol officer in the Evidence Technical Unit ("ETU"). When he worked in the ETU, Claimant would smoke cigars on duty.

When Employee first worked for Employer, he was Employer's Liaison with the Galleria. Employee told Tina he had conflicts with Larry Beerman who was the Head of Security for the Galleria. Employee also told Tina other officers at Employer teased him about having worked for the SLCPD. Employee also told Tina he got in trouble because his reports were not filed timely.

One time, when Employee was working for Employer, he became very agitated because he was accused of losing or stealing property. Even though he was exonerated, he was still mad that he was blamed.

While working for Employer, Employee also taught law enforcement at Sanford Brown. He taught criminal law and criminal justice. Tina said Employee saw teaching as a release and less stressful. Employee thrived and was calmer when he was teaching.

Employee applied to be an instructor with St. Louis County Police Department. Employee wanted to get off of the streets. Employee wrote letters and communicated with St. Louis County about the position. Two days after Employee died, a letter arrived offering Employee an interview for the position.

1 No disrespect is meant by calling the witness by her first name. Because she has the same last name as Employee, it is done to avoid confusion.

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Tina knew more wives of police officers in St. Louis City rather than in Richmond Heights. The wives would talk about the stress of their husbands' jobs. Specifically, they would discuss confrontations with supervisors over quotas for tickets and vacation checks on houses. Employee would discuss his confrontations with his supervisors with Tina.

When Employee got ready for work, he would "wind up", "get wired", and get nervous. He would need to get in the proper mindset for what might occur at work. Tina would see the stress in her husband. Employee would exercise to calm down. He would pace before going to work, and Tina would see a change in his body language before he went to work.

When Employee was stressed, Tina would notice he twitched, was nervous, and seemed fatigued. Tina could tell by Employee's body language when he was stressed. Employee would also suffer from night sweats and insomnia when he was stressed. When Employee was irritable or angry, Tina would give him space.

When he got home from work, Employee would pace and be angry. Employee would always give her a hug and she could immediately tell what kind of day he had. Sometimes Employee would go for a walk or read after work. He would do anything to disengage from the police work. Employee tried to keep his work and family separate.

When Employee was angry or irritable, Tina would give him space. Employee never got any medical treatment or counselling for his stress. Tina once mentioned counselling to Employee, but he did not want to do that. Employee said if he asked for help, he would be put on a desk job or be dumped by the force.

Tina made several suggestions to Employee to help him deal with his stress. She recommended that he exercise or walk. She recommended that he talk to her or seek counselling through Employer. She also encouraged Employee to go to Dr. Droege.

Employee would relax by going to Dr. Droege, reading, and watching YouTube. He would also go downstairs and have private time with his guns. Employee did seem to be helped by Dr. Droege. Dr. Droege helped with back pain and stress. Tina noticed that Employee seemed calmer and felt better after seeing Dr. Droege.

In 1990, Employee had a heart attack on their driveway. He was treated at St. Louis University Hospital. Employee filed a Workers' Compensation claim following his heart attack. Following this incident, Employee treated for his heart until his death.

Tina knew Employee had atrial fibrillation ("A-fib"), and regularly saw doctors for that, but Tina did not accompany him. Employee also used a CPAP machine.

In late 2013, Employee had surgery to replace an aortic valve. While Employee was in the hospital and before having surgery, two officers from Employer came to visit; one was a sergeant and one was a "white shirt". They asked Employee if he was going to return to work or if he was going to retire.

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Following his aortic valve surgery, Employee returned home. On January 22, 2014, Employee began having chest pain and Tina called an ambulance. Employee was taken to St. Clare Hospital. A surgeon was called and Employee was to have some tests, but they were never performed. Employee died the morning he was being released.

Tina spent more than $5,000.00 for Employee's funeral. The funeral was at Kutis. She flew her daughter and her husband in for the funeral. Tina also had to purchase an urn and pay for a reception after the funeral.

On cross-examination, Tina admitted Employee used a CPAP machine, but she was not aware he had severe sleep apnea or that he had 98 episodes where he stopped breathing in one hour. Tina was also aware Employee took medicine for high blood pressure. Tina did not know Employee had kidney disease. Tina knew Employee had A-fib, a bicuspid heart valve, and vasospasms of his heart.

In 1977, Employee was seen at St. Louis University Hospital for chest pain. Employee also had chest pain when they were in Branson and he was swimming in ice cold water. In 1999, Employee was treated at St. Mary's Hospital for chest pain and dizziness.

Tina agreed Employee chose to be a police officer and voluntarily worked as a police officer for 47 years. Tina testified that police officers "happen" to be put into harm's way; it is not voluntary. However, she agreed that being involved in bad things is a known risk of being a police officer.

Tina thought that working in the streets was the highest level of stress. Tina believed Employee had less exposure to violence and homicide working for Employer than when he worked for St. Louis City Police Department.

Employee never took any time off for stress or Post Traumatic Stress Disorder. Employee never had psychiatric treatment through work or on his own. Employee never went to a psychologist, got counselling, or contacted his Employee Assistance Program ("EAP").

Employee did not highlight the Galleria as being any more stressful than his other jobs. In fact, he worked secondary/seasonal work at the Galleria as security for Mark Shale and the Apple Store.

Tina did not know Employee applied to work in the Homicide Division of the St. Louis County Police Department. She did not know his application indicated he "feels good about profession" and "thrives on challenges".

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On January 4, 1977, Employee was treated at St. Louis University Hospital Emergency Room for complaints of chest pain. Employee had experienced an episode of sharp pain with nausea lasting several minutes. The pain had occurred one hour before reaching the hospital. Employee's blood pressure was 140/110. (Exhibits 12(b) & L).

On February 13, 1978, Employee was seen at St. Vincent's Hospital. Employee reported that he smoked 5-10 cigars a day and drank half a quart of whiskey a day for the past 1 to 2 months. Employee's father had cancer. Employee was experiencing marital problems; his wife wanted a divorce. Also, Employee and his wife had recently lost twins in a miscarriage. Employee had been drinking heavily. Dr. Lawrence diagnosed neurotic-level depression, which was partly reactive and aggravated by acute alcoholism. Employee was admitted to the hospital for treatment from February 14, 1978 through February 24, 1978. (Exhibits 12 & L).

Employee was on vacation with his family when he next treated for heart issues. Employee was seen at Skaggs Community Hospital Emergency Room on July 24, 1986, where he underwent an EKG. The EKG revealed atrial fibrillation with rapid ventricular response of approximately 160 beats per minute. Employee was admitted to the Hospital and diagnosed with atrial fibrillation and heart flutter. Employee remained in the hospital until July 27, 1986. (Exhibits 5, 12(b) & L).

Employee was working for the SLCPD and climbing steps on January 29, 1990 when he experienced severe left precordial chest pain. Employee was seen at St. Louis University Hospital where he was diagnosed with an inferior wall myocardial infarction. He was given intravenous TPA, with resolution of his chest pain. Employee remained in the ICU at St. Louis University Hospital for two days and then was transferred to St. Mary's Hospital. (Exhibit B & F).

When Employee was examined by Dr. Harshman, he reported experiencing severe substernal chest pain after walking up eight flights of stairs. Employee was diagnosed with a recent inferior myocardial infarction. On February 1, 1990, Employee underwent cardiac catheterization, during which he developed intense coronary spasm, which was relieved with nitroglycerin. Dr. Harshman determined Employee's myocardial infarction was related to coronary spasm. An electrocardiogram conducted the next day revealed spontaneous coronary spasm of the right coronary artery, resulting in an 85% to 90% stenosis of the artery. (Exhibits B & L).

Employee was again treated for his heart on April 21, 1991 when he was seen in the Emergency Room at St. Anthony's Medical Center with supraventricular tachycardia ("SVT").

2 The Exhibits in this case are voluminous (over 6,000 pages) and repetitive. Rather than comparing Exhibits to prevent duplicates, almost every Exhibit of each party has a duplicate with the other party. Further, many reports are duplicated within the different medical records. As an example, Exhibit 2 contains six copies of the same report.

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Employee reported that he was sitting, stood up, and then felt lightheaded and fell; he did not lose consciousness. Employee then developed mild chest discomfort. On the way to the Emergency Room, Employee converted to sinus rhythm. Employee no longer had chest discomfort in the Emergency Room. When he reached the ER, Employee was no longer having chest discomfort. (Exhibit B).

When Employee was seen by Dr. Harshman on May 9, 1991, he reported that he was experiencing a rush going up to his chest, associated with dizziness and lightheadedness. Dr. Harshman believed Employee was having more SVTs. (Exhibit B).

Employee saw Dr. Harshman on July 22, 1991, reporting occasional, brief sharp chest pains. Employee reported he was upset because his wife just found out she had miscarried after 7-1/2 weeks of pregnancy. (Exhibit B).

In an August 28, 1991 letter responding to an inquiry from Employer, Dr. Harshman stated the cardiac catheterization on February 1, 1990, demonstrated spasm of the right coronary artery. He noted that Employee treated at St. Anthony's in April 1991 for paroxysmal SVT. Employee was presently stable. Since Employee's myocardial infarction appeared to be related to coronary spasm, not obstructive coronary disease, no activity restrictions were necessary. (Exhibits 7, B, F & P).

Dr. Bodet examined Employee for Employer on September 4, 1991. He found Employee's cardiac status to be stable. He noted Employee's prior myocardial infarction was caught early, so there was little damage to his heart. Dr. Bodet noted Employee's diagnosis of coronary artery spasms and found Employee could work without restrictions. (Exhibits F & 10).

On September 14, 1991, Employee saw Dr. Harshman complaining of lightheadedness and dizziness. Dr. Harshman believed Employee was having paroxysmal SVTs. (Exhibit B). On October 4, 1991, Employee reported to Dr. Harshman that he was experiencing lightheadedness. Dr. Harshman believed Employee was having brief episodes of atrial fibrillation. (Exhibit B).

On September 1, 1993, Employee was working out after eating dinner when he developed palpitations and chest pressure. Employee stopped exercising, took a nitroglycerin, and his discomfort was relieved. On the next morning when Employee experienced similar chest pain, he went to the Emergency Room where his chest pain went away spontaneously. (Exhibits B & F).

When Employee underwent a treadmill stress test on September 16, 1996, he only walked 8 minutes and 40 seconds. Employee developed leg fatigue and pain during the test. Employee was admitted to St. Mary's Hospital. A peripheral Doppler suggested peripheral vascular disease in the superficial femoral region, bilaterally. (Exhibit B).

On May 19, 1997, Employee was found to have a systolic ejection murmur. Dr. Harshman diagnosed Employee with hypertension and probable aortic sclerosis. Dr. Harshman performed an echocardiogram Doppler on November 10, 1997, which revealed mild concentric

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left ventricular hypertrophy, a thickened and somewhat sclerotic aortic valve without significant stenosis, and aortic sclerosis. Employee was diagnosed with hypertension and aortic sclerosis. Employee also reported his wife had been diagnosed with breast cancer and was beginning chemotherapy. (Exhibit B).

Employee was seen in the Emergency Room of St. Mary's Hospital on June 7, 1999 with complaints of lightheadedness, dizziness, and chest pain. Employee's EKG and cardiac enzymes were normal. When Employee followed up with Dr. Harshman the next day, Employee believed he had a migraine the day before. After taking Midran, the discomfort went away. (Exhibit B). Employer completed a Report of Injury for the June 7, 1999 event. A report completed by Captain Wild stated while working St. Louis Galleria security, Employee felt dizziness and chest pain. After receiving first aid from Richmond Heights EMS, Employee treated at St. Mary's. Dr. Rill issued return-to-work instructions, discharging Employee from St. Mary's on June 7, 1999, and indicating Employee could return to work the next day without limitations. (Exhibits 13 & P).

When Employee saw Dr. Harshman on September 1, 1999, Employee complained of pounding in his chest, off and on, since the day before. Employee denied chest pain and shortness of breath, but reported that he felt "funny." Employee's blood pressure was 160/110. Employee began taking Atenolol for high blood pressure. (Exhibit B).

Employee experienced palpitations on October 8, 1999, after drinking an excessive amount of caffeine. Employee called paramedics to his home. He was told his heart rate was fast, but there were no rhythm abnormalities. The next day, Employee again experienced palpitations. Employee was admitted to St. Anthony's Hospital on October 10, 1999. A cardiac ultrasound showed left ventricular hypertrophy, mild left atrial dilatation, and a mildly thickened and calcified aortic valve without significant stenosis. Dr. Harshman performed a successful electrical cardioversion from atrial fibrillation to sinus rhythm. Employee was discharged from the hospital on October 12, 1999. (Exhibit B).

On October 14, 1999, Employee contacted Dr. Harshman's Office and requested a letter indicating his condition was not brought on by the job and was controlled by medicine. On October 19, 1999, Dr. Harshman wrote a note stating Employee was recently admitted to the hospital with cardiac arrhythmia, which was not work related. He also indicated that Employee could return to work, without restrictions. (Exhibits B & P).

On November 12, 1999, Employee reported a brief "rushing" feeling in his chest and lightheadedness the prior evening and twice that morning, Dr. Harshman found the "rushing" in Employee's chest was cardiac in nature. (Exhibit B).

On November 22, 1999, Dr. Harshman's office received a call from Employer's Human Resources Department asking for more information regarding Employee's health. The doctor's office declined to release any information because they did not have a release from Employee. When told about the request, Employee reported they were "out to get his job." (Exhibit B & F).

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On August 21, 2001, Employee contacted Dr. Harshman's office requesting something to calm him down because he was "having a lot of problems with his 16 year old." (Exhibit F). An echocardiogram on September 27, 2001, showed no evidence of stress-induced ischemia but Employee only reached 75% of age predicted maximum heart rate. Employee's exercise tolerance was not very good, and his heart rate response was somewhat blunted. (Exhibit B & F).

Employee presented to the Emergency Room on April 28, 2002, complaining of palpitations. Employee believed his heart beat was irregular. Employee was found to be in atrial fibrillation, with rapid ventricular response. A chest x-ray showed a tortuous aorta. Employee was diagnosed with: recent onset atrial fibrillation, previous history of atrial fibrillation, 1999; coronary artery disease s/p percutaneous transluminal coronary angioplasty of right coronary artery; electrocardiographic evidence of previous interior infarction; and history of hypertension. After Dr. Harshman performed a successful cardioversion, Employee was discharged from the hospital on April 29, 2002. (Exhibit B).

Employee was seen in the Emergency Room on June 7, 2002, where he was found to be in atrial fibrillation, with rapid ventricular response in the 120s. Employee was given Lopressor and Digoxin, which decreased his heart rate. Dr. Harshman performed cardioversion, after which Employee successfully returned to normal sinus rhythm. (Exhibit F).

Employee underwent an echocardiogram Doppler on September 23, 2002. The echocardiogram revealed: trivial aortic insufficiency, mild to moderate aortic stenosis with a calcified aortic valve, mild concentric left ventricular hypertrophy, mild tricuspid insufficiency, mild elevation of pulmonary artery pressures, and normal left ventricular systolic function. On September 26, 2002, Dr. Harshman diagnosed Employee with an aortic systolic murmur. (Exhibit B).

While treating with Dr. Harshman on July 15, 2003, Employee reported having palpitations for 2 to 3 weeks. An electrocardiogram showed atrial fibrillation. In August of 2003, Employee reported dizziness and blurred vision lasting fifteen to twenty minutes, one to two times a day. Employee had an EKG that showed atrial fibrillation. On September 16, 2003, Employee underwent a successful electrical cardioversion, which restored Employee to sinus rhythm. (Exhibit B).

During a February 10, 2004 appointment with Dr. Harshman, Employee reported he had been taken off work at the Galleria, and placed on the street with "a bunch of kids." He denied palpitations, but occasionally felt a "rush" up his chest. Employee had a grade 2/6 systolic ejection murmur. (Exhibits B & F).

Employee's March 18, 2004 Echo Doppler showed moderate aortic stenosis with a heavily calcified aortic valve, mild concentric left ventricular hypertrophy, and mild tricuspid insufficiency with evidence of elevation of pulmonary artery pressures. Later that month, Employee informed Dr. Harshman that earlier that morning he had two episodes of sharp chest pain radiating into his left arm that then resolved almost immediately. (Exhibits 19 & B).

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When Employee saw Dr. Harshman in October of 2004, Employee denied cardiac complaints but admitted he felt lightheaded and woozy at times. His blood pressure was 100/70. Dr. Harshman believed Employee had hypotension, and reduced his blood pressure medication. When Dr. Harshman examined Employee on April 12, 2005, he had an irregular heart rhythm; an EKG showed atrial fibrillation. (Exhibit B).

Employee presented to the Emergency Room at St. Mary's on May 7, 2005, reporting malaise. Employee had developed nausea and vague symptoms of discomfort as he went to work. Employee had a vague sensation of discomfort, stating it felt "like a cloud passes over me." Employee felt nauseated and clammy, but he denied chest pain and shortness of breath. Employee also reported he had been in atrial fibrillation for the past 4 to 5 weeks. Employee was diagnosed with: atrial fibrillation with a rapid ventricular response and brief pauses during sleep, probably due to sleep apnea. Employee was given Diltiazem which slowed his heart rate. The doctor opined that since Employee had obstructive sleep apnea, the episodes of myocardial arrhythmias may have been due to arterial hypoxia. (Exhibits 9, 19, B, G & J).

While he was in the hospital, Employee had episodes of bradycardia with atrial fibrillation. Dr. Garcia was called in for a pulmonary consultation because Employee experienced daytime sleepiness, took daytime naps, and snored loudly when sleeping. Dr. Garcia diagnosed sleep disorder, and atrial fibrillation with rapid ventricular response. Employee was to undergo nocturnal oximetry, to determine whether he qualified for oxygen, and take an outpatient sleep study for sleep apnea. Employee's discharge diagnoses included: atrial fibrillation with rapid ventricular response, history of hypertension, history of A-FIB cardioverted in the past, chronic renal insufficiency, and hypertension. (Exhibit 9 & B).

On May 16, 2005, Dr. Harshman completed a form allowing Employee to return to work without restrictions. When Employee dropped the form off at Dr. Harshman's office, he indicated he felt his department was "trying to get rid of him" before his retirement. (Exhibits B, F & G). Dr. McCann also completed a form allowing Employee to return to work with no restrictions. (Exhibit G).

On August 8, 2005, Employee reported lower extremity edema to Dr. Harshman. On September 9, 2005, Employee informed Dr. Harshman his lower extremity swelling had worsened, and was up to his knees. Employee had become increasingly lethargic, and had to pull over while driving because he was falling asleep. When treating with Dr. Harshman on September 27, 2005, Employee had extensive edema in both lower extremities, up to his knees. Dr. Harshman diagnosed peripheral edema of uncertain etiology. (Exhibit B).

A renal sonogram on October 10, 2005, showed a small left kidney with calcification and a 1.3 cm cyst in the right kidney. A renal ultrasound one week later revealed a functionally-absent left kidney and probable slight renal parenchymal dysfunction of the right kidney. There was almost total lateralization of the renal function to the right kidney. (Exhibit 14, G & J).

Employee underwent a split night polysomnography at Midwest Sleep Diagnostics on December 13, 2005. Employee reported loud snoring, trouble breathing at night, and daytime sleepiness. Dr. Masi diagnosed severe obstructive sleep apnea. Employee had an apnea

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hypopnea index of 93 events per hour (normal was less than 5 per hour), associated with nocturnal desaturations to 83%, hypersomnia, hypertension, and obesity. Employee was to return for a full night nasal CPAP/BIPAP titration study. As of January 6, 2006, Employee used a CPAP machine for sleep apnea. (Exhibits 20 & G).

Employee treated with Dr. Harshman on March 6, 2007. Employee had no cardiac complaints and his heart rhythm had been fairly stable. Employee had put in job applications for Heartland Security, and some teaching positions. He was still teaching at Sanford Brown. Dr. Harshman found Employee was stable. (Exhibit B).

When Employee treated with Dr. Purcell on May 17, 2007, his edema had improved. Employee had no shortness of breath, chest pain, or urinary difficulties. Dr. Purcell diagnosed hypertension nephrosclerosis, solitary kidney, and kidney disease. (Exhibits 14 & H).

In October of 2007, Employee cancelled a scheduled test because his wife's cancer had returned, and she was undergoing surgery. Employee later informed Dr. Harshman his wife was receiving chemotherapy. (Exhibits B & F).

Dr. Kancherla examined Employee on September 15, 2008. A treadmill stress test conducted in August was submaximal. An EKG was suggestive of a prior MI. A stress profusion study revealed no evidence of ischemia. Employee denied chest discomfort, shortness of breath, or palpitations. Employee had a murmur, which was suggestive of probable aortic sclerosis, and mild to moderate aortic stenosis. A Doppler echocardiogram showed sinus bradycardia, asymmetric septal hypertrophy, diastolic dysfunction, mild aortic stenosis, and mild dilation of the aortic root. (Exhibits 11 & N).

Employee returned to Dr. Kancherla on May 4, 2009. He had not experienced any palpitations or shortness of breath, but had occasional dizziness. Cardiovascular exam showed regular rhythm, without murmurs. Dr. Kancherla diagnosed history of paroxysmal atrial fibrillation, hypertension, mild aortic stenosis-stable, and abnormal EKG. (Exhibits 11 & N).

On March 11, 2010, Dr. Purcell noted Employee was having a stressful year because his wife had breast cancer. (Exhibit 14).

Employee saw Dr. Terkonda on June 18, 2010 for high blood pressure. Employee's cardiovascular exam showed normal rate and regular rhythm. Dr. Terkonda diagnosed high blood pressure, hyperlipidemia, and stable renal failure. (Exhibit I).

When Employee saw Dr. Terkonda in December of 2010, his blood pressure was 170/80. Employee stated he had been really stressed lately with his job, but provided no specifics. When he returned to Dr. Terkonda on April 14, 2011, his cardiovascular exam showed normal rate and regular rhythm. (Exhibit I).

While treating with Dr. Kancherla and Dr. Terkonda through the rest of 2011 and 2012, Employee had no cardiac complaints. He continued to be diagnosed with: atrial fibrillation-

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maintaining normal sinus rhythm, hypertension, benign and well-controlled on medication, renal failure, and high cholesterol. (Exhibits 11, I & N).

On May 3, 2012, Employee told Dr. Purcell he intended to get a spot in the Homicide Division in St. Louis County and retire from Richmond Heights. (Exhibit 14).

When Employee saw Dr. Kancherla on December 16, 2013, he was doing well, and was without palpitations. A review of systems was negative for chest pain, chest pressure, and diaphoresis. Cardiac exam showed no murmurs. Heart rhythm was regular, and heart sounds were normal. Dr. Kancherla diagnosed atrial fibrillation, high cholesterol and hypertension, well controlled on medical therapy. (Exhibits 11, M & N).

Dr. Terkonda examined Employee December 20, 2013, and determined he had a systolic murmur at the aorta. Dr. Terkonda diagnosed hypertension (stable), hyperlipidemia (stable), atrial fibrillation (controlled), renal failure (stable), and cardiac murmur. (Exhibit I). An echocardiogram revealed the left ventricle size was normal, as was systolic function. Doppler parameters were consistent with abnormal left ventricle relaxation (grade 1 systolic dysfunction). The aortic valve showed severe leaflet thickening and calcification, and a bicuspid valve. There was severe aortic stenosis. Pulmonary artery systolic pressure was rapidly increased. Right ventricle size was normal, as was systolic function. (Exhibits 15 & M).

When Employee returned to Dr. Kancherla on January 3, 2014, he reported chest tightness, which went away on its own, and edema. An echocardiogram showed severe aortic stenosis, along with severe leaflet thickening and calcification. On exam, Employee had a systolic ejection murmur at the right upper sternal border, and lower extremity edema. Dr. Kancherla diagnosed severe aortic stenosis. He recommended cardiac catheterization. (Exhibits 11 & N).

On January 6, 2014, Employee was admitted to St. Clare Hospital. A pre-procedural history stated Employee was seen by his primary care physician, who heard a murmur and ordered an echocardiogram. The echocardiogram revealed severe aortic stenosis, severe leaflet thickening, and calcification. Employee had been more tired than normal recently. He was to undergo cardiac catheterization for further evaluation of aortic stenosis. His co-existing diseases were dyslipidemia, hypertension and a history of atrial fibrillation. Coronary angiography performed on January 6, 2014, showed severe aortic stenosis. (Exhibits 15 & M).

Employee was admitted to St. Clare Hospital on January 14, 2014, with a diagnosis of severe aortic stenosis. On the day he was admitted, Dr. Noda performed an aortic valve replacement. Dr. Noda's post-operative diagnoses were critical aortic stenosis with a congenital bicuspid aortic valve. During that procedure, the aortic valve was visualized, and noted to be heavily calcified. There was a heavily diseased bicuspid congenital aortic valve. There were significant amounts of calcifications, which remained within the wall of the aorta. Employee was released from the hospital on January 20, 2014. (Exhibits 1, E & M).

Employee returned to St. Clare Hospital on January 22, 2014. In the Emergency Room, Employee reported he experienced 8/10 left-sided chest pain with palpations for one to two

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hours. The pain was present in the left chest, and Employee had chest pressure. Employee had elevated cardiac enzymes on admission. Physical exam showed regular rhythm and normal heart sounds. Employee was not in respiratory distress, but exhibited tenderness to the chest. An EKG was non-specific. It revealed normal sinus rhythm. (Exhibits 15 & M).

Dr. Terkonda examined Employee at St. Clare Hospital on January 22, 2014. Dr. Terkonda diagnosed chest pain. While he believed it to be skeletal pain, Employee had elevated cardiac enzymes. Additional diagnoses were aortic valve replaced, hypertension-stable, renal failure-at baseline creatine, and sleep apnea. (Exhibits 15 & M).

Dr. Thanigaraja performed a cardiology consultation on January 22, 2014. Employee's cardiovascular exam showed regular rate, rhythm, and a systolic ejection murmur over the aortic area. ECG showed normal sinus rhythm. Employee's chest pain was atypical in character. The doctor thought Employee's chest pain was most likely musculoskeletal in nature, and related to his recent sternotomy. Recent cardiac catheterization done prior to aortic valve replacement showed normal coronary arteries, without any significant coronary artery disease. (Exhibit M).

An echocardiogram showed the left ventricle was normal in size. Systolic function was normal. Doppler parameters were consistent with abnormal left ventricular relaxation (Grade I diastolic dysfunction). A bio-prosthesis was present in the aortic valve. There was no stenosis. The mitral valve showed mild annular calcification and mild regurgitation. The left atrium was moderately dilated. Right atrium was at upper limits of normal. Right ventricle was normal in size. Employee had elevated Troponin levels. A Doppler of the pulmonary artery showed systolic pressure was at the upper limits of normal. (Exhibits 15, M & N).

On January 24, 2014, Employee was walking down the hall at St. Clare Hospital, when he experienced ventricular tachycardia and arrhythmia. Resuscitation efforts were unsuccessful. CPR was discontinued, and Employee was pronounced dead at 8:45 a.m. (Exhibit 15, I & M).

A Missouri Certification of Death found Employee's death was due to ventricular tachycardia arrest. (Exhibits 25, J & O).

An autopsy was performed on January 27, 2014. Employee's heart showed cardiomegaly with left ventricular hypertrophy, a left ventricle lateral wall subacute myocardial infarction, a coronary artery showing mild arteriosclerosis, and moderate arteriosclerosis of the aorta. Employee had severe aortic stenosis, and had undergone an aortic valve replacement. The coronary arteries showed atherosclerosis. The lateral wall of the left ventricle had a hyperemic area, measuring 1.0 x 1.0 x 0.5 cm. (Exhibits 1, S & T)

An artificial aortic valve was identified. The bilateral carotid and bilateral inguinal arteries appeared mildly arteriosclerotic. Microscopic exam of sections of the heart showed hypertrophy of the heart muscle. There was an infarct involving approximately half the thickness of the left ventricle. This was a subacute infarct, estimated age of two weeks to three months. The sections of the left ventricular posterior wall showed evidence of extensive chronic interstitial fibrosis, indicative of an old myocardial infarction. (Exhibits 1, S & T).

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The features of a subacute and healed myocardial infarct and of left ventricular hypertrophy all provided an increased risk of fatal arrhythmia. Acute spasm of coronary vessels could also cause decreased blood supply to the heart. Decreased blood supply led to decreased oxygen supply to the cardiac muscle, and the death of muscle fibers. The death of cardiac muscle fibers led to heart failure and arrhythmia. Employee had hypertension, hyperlipidemia, a history of aortic valve stenosis, and a functional aortic valve prosthesis. The cause of Employee's death was myocardial infarction, leading to ventricular arrhythmia. (Exhibits 1, S & T).

Employment

Between 1967 and September 1991, Employee was employed by the SLCPD where he worked as both a patrol officer and evidence technician. Employee resigned from the SLCPD on February 23, 1977, indicating he had taken a job as a security officer at McDonnell Douglas. Employee took that job because it paid significantly more than the SLCPD. He then returned to SLCPD on March 11, 1977, because the job at McDonnell Douglas did not meet his expectations regarding law enforcement. (Exhibits 12a, 12b & K).

On June 24, 1991, Employee applied for a position as a police officer with Employer. Employee stated he was applying for a position with Richmond Heights because he desired to become more involved in police work with a smaller community. Employee began working for Employer as a patrol officer on September 23, 1991. In 1992, Employee was transferred by Employer to the St. Louis Galleria. From 1992 to 2003, Employee served as manager of patrol functions and security for Employer at the Galleria. In November 2003, Employee returned to street patrol for the City of Richmond Heights. (Exhibits 13 & P).

In April 2012, Employee applied to the St. Louis County Police Department. When asked why he wished to be a police officer with St. Louis County, Employee stated "I am an experienced police officer that still feels good about my chosen profession. I thrive on the challenges." As to the highlights of his qualifications, Employee stated he was able to "maintain composure, and perform effectively under extreme stress conditions." (Exhibit U). Employee also indicated he was interested in a change in assignments. (Exhibit 26).

In January of 2014, Employee submitted FMLA paperwork prior to undergoing heart surgery. Dr. Kancherla completed a Return-To-Work Authorization Form, stating Employee had a procedure on January 6, 2014, and was due to undergo surgery with Dr. Noda on January 14, 2014. Employee was to remain home from work until undergoing surgery with Dr. Noda. Dr. Noda would determine how long after surgery Employee was to remain off work. (Exhibit P).

Prior Cardiac Workers' Compensation Claim

Injury Number 90-009746

Following his heart attack in 1990, Employee filed a Claim for Compensation (Injury Number 90-009746) against the SLCPD. Employee settled his claim for a lump sum of

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$10,000.00, representing 14.4% permanent partial disability of the body as a whole, rated at the heart. (Exhibit 8 & A).

Dr. Whiting examined Employee in conjunction with his work-related heart attack. In his June 29, 1991 report, Dr. Whiting found the Employee still experienced supraventricular rhythms, which were very rapid at times. Dr. Whiting opined that Employee's coronary artery spasms were not caused by stress, but rather was caused by changes in the coronary arteries. (Exhibits 2, 8, 12 & L).

Dr. Gupta saw Employee for the purposes of rendering a causation opinion regarding Employee's work-related heart attack. Dr. Gupta noted Employee had been put in a "felony car" which was more stressful than regular street patrol. In addition, Employee had climbed several flights of stairs prior to his myocardial infarction. Dr. Gupta opined that stress "contributed" to Employee's coronary artery spasm leading to his myocardial infarction. (Exhibits 3 & A).

Dr. Alex Shreim also opined Employee's 1990 heart attack was caused by job stress. Dr. Shreim based his opinion on Employee's report that he was under significant stress at work, including pressure to write more tickets and make more arrests. Dr. Shreim also found Employee to be depressed. (Exhibits 8 & A).

Notably, in Employee's Workers' Compensation cases regarding injuries in 1987 and 1988, Employee alleged and received compensation from the Second Injury Fund for the pre-existing condition of hypertension.

Medical Opinions

Report and Testimony of Dr. Schuman

Dr. Schuman specializes in internal medicine with a subspecialty in cardiology. He is Board Certified in both Internal Medicine and Cardiology. He has practiced in those areas for 30 years. (Exhibit 21).

Dr. Schuman prepared a report after reviewing medical records from: Employee's admission to St. Vincent's Hospital on 2-14-78, Dr. Whiting's June 24, 1991 letter, Dr. Harshman's letter of August 28, 1991, Employee's April 1991 St. Anthony's ER treatment, Employee's May 7, 2005, records of Midwest Sleep Diagnostics, Dr. Purcell's May 17, 2007 note, Dr. Kancherla's note from September 15, 2008 and December 17, 2012, January 3, 2014 records from SSM Heart Institute, records from Employee's January 22, 2014 admission to St. Clare, and Employee's autopsy report. (Exhibit 21).

Dr. Schuman then testified regarding Employee's stressors.³ Those stressors included: confrontations with supervisors, problems with work schedules, repeated questioning by

³ All of the stressors identified by Dr. Schuman are taken directly from letters sent to him on May 10, 2016 and June 28, 2016, by Claimant's attorney.

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supervisors as to whether he was going to retire or how long he would be off work while recovering from heart surgery in January 2014, questions from his supervisors as to when he would be able to return to limited duty work or handle desk work, multiple physical and verbal confrontations on the job and arrest situations while patrolling, and inability to obtain employment to get away from street patrol duties.

Dr. Schuman testified Employee was under the delineated stressors and had a ventricular tachycardia arrest which resulted in his death. Dr. Schuman opined that Employee's ventricular tachycardia was bought on by Employee's prior subacute myocardial infarction in the lateral wall. (The subacute myocardial infarction Dr. Schuman referenced was discovered during Employee's autopsy. According to the autopsy report, it occurred between two weeks to three months before Employee's death.)

Dr. Schuman said that by putting it all together, it follows logically that the prevailing factor causing Employee's subacute myocardial infarction was his job stress, and since the subacute myocardial infarction caused the ventricular tachycardia which caused Employee's death, the job stress caused his death. Stated another way by Dr. Schuman, the cause of Employee's ventricular tachycardia, and cardiac arrest, was his job-related subacute myocardial infarction.

Coronary artery spasms could be treated from 1991 to 2016 without a reoccurrence, but it would depend on the stress the person was under. While the coronary artery spasms could be controlled with medication, stress could overcome the medicine. Dr. Schuman testified stress is a known risk factor for coronary artery spasms. Because Employee did not have significant artery arteriosclerosis, coronary artery spasm was the only possible cause of his prior subacute myocardial infarctions. Dr. Schuman noted stress and elevated adrenaline were major factors in causing coronary artery spasms.

On cross-examination, Dr. Schuman testified he also reviewed the reports of Drs. Gupta, Whiting and Shreim. In Dr. Gupta's report, he attributed Employee's 1990 myocardial infarction to climbing 8 flights of stairs. Dr. Shuman did not review any records from SLCPD, Richmond Heights, or St. Louis County. Dr. Schuman did not recall any records regarding arterial tortuosity or atrial fibrillation flutter.

Dr. Schuman agreed that 1978 records from St Vincent's mentioned several stressors in Employee's life, but did not mention work stress as an issue.

Dr. Schuman did not see anything in Employee's medical records where he referred to work stress or stressors from work. Dr. Schuman did not see anything in the records he reviewed indicating Employee left the SLCPD and moved to Employer to reduce his stress.

The letters from attorney Martin were Dr. Schuman's only source for his belief that Employee was stressed due to confrontations with his supervisors. Dr. Schuman did not discuss that alleged stressor with anyone from Employer nor did he see any documents concerning Employee's alleged confrontations with his supervisors. Dr. Schuman did not know if the alleged confrontations were verbal or physical, if they occurred in public or private, or how many

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confrontations occurred. Dr. Schuman agreed the confrontations with supervisors were not mentioned in Employee's medical records and further he said confrontations were "part of the job" and "not a big deal."

Dr. Schuman did not know the specifics of Employee's problems with his work schedules. Dr. Schuman did not know how long Employee's shifts were or which shifts he worked. Dr. Schuman indicated that rotating shifts are relevant because sleep schedules can be effected. Dr. Schuman did not know Employee worked extra jobs teaching and working private security. Dr. Schuman did not see anything in Employee's medical records indicating the shifts he worked, or rotating shifts, was a problem. Dr. Schuman later learned from attorney Martin that Employee did not rotate shifts and worked the same afternoon shift for Employer.

Dr. Schuman did not review any documentation demonstrating Employee was under pressure to return to work or retire. Attorney Martin's letters did not offer any specifics about the "repeated questioning" Employee received about his employment status. Dr. Schuman did not know how often the questioning occurred or whether it was in person, by telephone, or in writing. Dr. Schuman did not find anything in the records he reviewed about "repeated questioning" regarding Employee's employment status.

Dr. Schuman testified that Employee had "the general stress" of being a police officer. Dr. Schuman has treated firefighters and police officers. He is aware that dealing with confrontations in their jobs can cause stress. That includes stressors such as being involved in an arrest.

Dr. Schuman acknowledged Employee had paroxysmal SVTs over the years. By their nature, those type of SVTs begin suddenly and stop suddenly. This type of SVTs are caused by abnormal circuitry in the heart. Employee also suffered from atrial fibrillation caused by an electrical abnormality.

On many occasions, Employee mentioned to Dr. Purcell that his wife had breast cancer and was undergoing treatment. However, Dr. Schuman testified that was not as stressful as being a police officer.

Dr. Schuman did not see any evidence that Employee sought treatment for stress. Employee was not taking any medication for stress.

Dr. Schuman did not see any evidence that Employee's job duties were ever limited or restricted due to his cardiac conditions. Dr. Schuman did not believe Employee had any work restrictions due to any other health conditions.

Dr. Schuman testified Employee applied to work for the St. Louis County Police Department to get off of the street. Dr. Schuman was given that information by attorney Martin. When Dr. Schuman reviewed Employee's application with St. Louis County, he did not see that Employee said he wanted to get off of the street. Employee did state in his application that he was capable of making a forceful arrest.

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Attorney Martin wrote a reference letter for Employee when he applied to work for St. Louis County. Attorney Martin's reference letter did not mention any of Employee's health issues or about any of the stressors Employee alleged suffered while working for Employer.

**Testimony Of Dr. Mankowitz**

Dr. Mankowitz is board certified in cardiology and internal medicine. He reviewed multiple documents and medical records, including the July 1, 2016 report of Dr. Schuman and the depositions of Dr. Schuman, John Gaffigan, John Madden, and Terry Ford. Additionally, Dr. Mankowitz reviewed the autopsy report, sleep studies, the records of Drs. Droege, McCann, Harshman, Terkonda, Purcell, Whiting, Noda, Schreim, Gupta and Kancherla, and the records of St. Clare Health Center, and St. Mary's Hospital. (Exhibit Q).

Dr. Mankowitz noted Employee had multiple medical problems, including hypertension, hyperlipidemia, sleep apnea, chronic renal insufficiency, atrial fibrillation, supraventricular tachycardia, mitral valve prolapse, migraines, aortic stenosis, and arthritis. Many of these conditions, including Employee's kidney problems, migraines, and arthritis were unrelated to his heart condition.

On reviewing Employee's medical records, Dr. Mankowitz found Employee had a long history of cardiac events, and suffered from multiple cardiac conditions. Dr. Mankowitz noted Employee's aortic valve was significantly narrowed and not working properly, but his arteries were relatively clear. Employee's fatal heart attack was due to cardiac arrhythmia caused by coronary spasms.

Dr. Mankowitz noted Employee's atrial fibrillation was a result of an intrinsic genetic condition. Employee had a spasm of his artery in 1990 that caused his myocardial infarction. When Employee's doctors performed a cardiac cauterization, they saw the spasms of the artery.

In reviewing Employee's treatment records and autopsy report, Dr. Mankowitz noted Employee developed severe aortic stenosis due to having a bicuspid rather than the typical tricuspid valve. This is a condition from birth, and not due to environmental factors. Employee's chest pain complaints were often due to coronary vasospasms. Vasospasms can be caused by rapid heartbeat, exertion, or occur spontaneously.

Dr. Mankowitz testified that patients with vasospasms often suffer from chest pain, but then have normal stress tests and normal heat catheterizations. Unfortunately, patients that have regular spasms can trigger a ventricular arrhythmia which causes sudden death. Dr. Mankowitz testified that is what occurred to Employee.

Dr. Mankowitz testified that Employee's coronary spasms, atrial fibrillation, and bicuspid heart valve were all intrinsic genetic conditions that he was born with. Further, Employee's work for Employer had nothing to do with the development of these conditions. Therefore, Employee's work had nothing to do with his death.

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On cross-examination, Dr. Mankowitz noted Employee was born with a pre-disposition to have episodes of coronary artery spasms. Coronary artery spasms were caused by an intrinsic abnormality of Employee's coronary arteries; they were hyperactive. Stress did not cause Employee's coronary arteries to be hyperactive or chronically irritable. Dr. Mankowitz found there was something intrinsically wrong with Employee's coronary arteries. It is not normal for a person to have the degree and frequency of coronary spasm Employee had. Stress could "aggravate" the spasms.

Dr. Mankowitz testified that he believes being a police officer is a stressful occupation. Based on Claimant's deposition testimony, he assumed Employee was under stress, but that did not change his opinion. However, there was something intrinsically wrong with Employee's arteries. Dr. Mankowitz testified that it is not normal to develop the frequency and severity of spasms Employee had.

Dr. Mankowitz testified that even though he does not know the direct genetic link for having spasms, he has treated family members who all display the same type of spasms. Even though a precise gene has not been identified, through his own experience and treatment of patients, he has seen a familial linkage to having spasms. The fact that a gene has not been identified doesn't change the fact that some people are more prone to vasospasms than others.

Dr. Mankowitz testified that while stress can aggravate an artery, chronic stress does not cause the arteries to become irritable. Dr. Mankowitz explained that Employee's coronary spasm could occur either spontaneously, when he was sleeping, with exertion, or with or without stress. In people with coronary spasm, coronary spasm can wake them up in the middle of the night, or occur when they are sitting and watching TV; it is totally unpredictable. Spasms can be deadly in patients who developed heart attacks, and such patients could develop life threatening arrhythmias, which was what happened on the day of Employee's death.

Dr. Mankowitz did not doubt Employee had a lot of stress in his life. However, Employee's death was caused by an episode of coronary artery spasm, which triggered a ventricular arrhythmia, which caused sudden death. Emotional stress did not cause the intrinsic abnormality in Employee of hyperactive coronary arteries which caused his coronary spasm. This was something innate, a tendency Employee was born with.

Dr. Mankowitz found Employee had atrial fibrillation. Atrial fibrillation is an irregular heartbeat caused by an abnormal beating of the upper chambers of the heart. From 1990 until 2005, Employee had multiple episodes of atrial fibrillation, requiring cardioversion. Employee's work as a Richmond Heights police officer did not cause his atrial fibrillation. Rather, his atrial fibrillation was an intrinsic, idiopathic abnormality of Employee's body.

Dr. Mankowitz opined the prevailing factor causing Employee's death was spasms of the coronary arteries, which caused a heart attack and fatal ventricular arrhythmia. The coronary spasms were caused by Employee's innate, abnormal contractility of the coronary arteries. Employee's death was not work related. Harry Hall's employment as a Richmond Heights police officer did not cause his atrial fibrillation, bicuspid aortic valve, or coronary spasm. These heart conditions were idiopathic, intrinsic abnormalities of Employee's body.

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At Hearing, Claimant made an oral Motion in Limine to exclude Dr. Mankowitz's report. Claimant also filed a written Motion in Limine. Claimant argues that Dr. Mankowitz's clinical opinion that Employee was predisposed to coronary artery vasospasms is inadmissible. Claimant argues that because Dr. Mankowitz could not identify a specific genetic marker related to coronary artery vasospasms, either identified by research, found in the general public, or found in Employee, Dr. Mankowitz's testimony must be excluded.

Dr. Mankowitz is a Board Certified Cardiologist and has practiced in that area for thirty years. He is able to rely on his experience in his practice to reach a conclusion.

Claimant's arguments go to the strength of Dr. Mankowitz's opinions, not the admissibility of those opinions. Claimant can, and did, argue that Dr. Mankowitz's opinion should be discounted because of the shortcomings perceived by Claimant.

Regarding the testimony of an expert witness, the Courts have held:

The statute charges the Commission with determining (1) whether the expert is qualified; (2) whether the expert's testimony will assist the trier of fact; (3) whether the expert's testimony is based on facts or data reasonably relied on by experts in the field; and (4) whether the facts or data on which the expert relies are otherwise reasonably reliable. *Kivland v. Columbia Orthopedic Grp.*, 331 S.W.3d 299, 310-11 (Mo. banc 2011) (citing § 490.065). In deciding whether to admit an expert's testimony, the Commission is required to ensure, however, only that the statutory factors are met—not that they are met to any particular degree. *Id.* And whether expert opinion testimony satisfies the requirements of § 490.065 is a matter of discretion. *McGuire v. Seltsam*, 138 S.W.3d 718, 721 (Mo. banc 2004); *Nixon v. Lichtenstein*, 959 S.W.2d 854, 860 (Mo. App. E.D. 1997) ("Whether a witness's qualifications to state an opinion are sufficiently established rests largely in the discretion of the trial court and its ruling will not be disturbed on appeal unless there is a clear showing of abuse."). *Hogenmiller v. Mississippi Lime Company*, 574 S.W.3d 333, 336 338 (Mo. App. E.D. 2019).

Dr. Mankowitz is clearly qualified as an expert. He is a Board Certified Cardiologist and had practiced as a cardiologist for 30 years. Although he could not refer to a specific genetic marker for his opinion that Employee's cardiac vasospasms were intrinsic, he did refer to Employee's treatment history and his own experience as a doctor treating only cardiac patients. That is more than sufficient to render his testimony admissible. After the basis for his opinion is established, it is up to the trier of fact to determine the weight to be given to his testimony.

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Claimant argues Employer is responsible for Employee's death on a theory of an occupational disease. Specifically, Claimant argues stress brought on Employee's cardiac disease and ultimate death. An occupational disease is defined as an identifiable disease, arising with or without human fault, out of and in the course of the employment. Ordinary diseases of life to which the general public is exposed outside of the employment shall not be compensable, except where the diseases follow as an incident of an occupational disease, as defined in the statute. The disease need not to have been foreseen or expected, but after its contraction, it must appear to have had its origin in a risk connected with the employment, and to have flowed from that source as a rational consequence. §287.067.1. RSMo. An injury or death by occupational disease is compensable only if the occupational exposure was the prevailing factor causing both the resulting medical condition and disability. The "prevailing factor" is defined to be the primary factor, in relation to any other factor, causing the resulting medical condition. §287.067.2. RSMo.

For an occupational disease to be compensable under the Act, there must be a peculiar risk or hazard is inherent in the working conditions, and the occupational disease must follow as a natural result. *Moreland v. Eagle Picher Tech.*, 362 S.W.3d 491, 505 (Mo.App.S.D.2012). Whether a particular employment involves a peculiar risk is determined from two criteria: 1) whether there was an exposure to the disease, which was greater than or different from that which effects the public generally; and 2) whether there was a recognizable link between the disease and some distinctive feature of employee's job, which is common to all jobs of that sort. *Smith v. Capital Reg. Med. Ctr.*, 458 S.W.3d 406, 407 (Mo.App.W.D.2014) (to meet the burden of proof as to causation for an occupational disease claim, employee has to submit medical evidence establishing the probability the working conditions caused the disease).

While Section 287.067 addresses occupational diseases in general, subsection 6 of that section deals with certain enumerated diseases, which are compensable for firefighters and police officers. Claimants are seeking recovery under Section 287.067.6 RSMo, which reads:

> Disease of the lungs or respiratory tract, hypotension, hypertension, or disease of the heart or cardiovascular system, including carcinoma, may be recognized as occupational diseases for the purposes of this chapter and are defined to be disability due to exposure to smoke, gases, carcinogens, inadequate oxygen, of paid firefighters of a paid fire department or paid police officers of a paid police department certified under chapter 590 if a direct causal relationship is established, or psychological stress of firefighters of a paid fire department or paid peace officers of a police department who are certified under chapter 590 if a direct causal relationship is established.

4 Claimant was certified by Missouri as a commissioned peace officer both while working for SLCPD City and for Employer. (Exhibit 23).

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Because of the conjunctive "or" contained in Subsection 6, two different types of injuries are discussed. The first is diseases of the respiratory system, cardiovascular system, or carcinoma, resulting from exposure to smoke, gases, carcinogens, or inadequate oxygen. The second type of injury is "psychological stress". Claimant seems to be making a hybrid argument between these two types of injuries. Claimant alleges Employee's psychological stress led to the disease of his cardiovascular system and ultimately his death.

First, it must be determined if Employee's alleged work-related stress constitutes an occupational disease. That inquiry involves a determination of a "direct causal relationship" between Employee's "psychological stress" and his work as a police officer. This is the "arising out of and in the course and scope of employment" determination. Section 287.067.6 RSMo. Determining whether Claimant has proven that Employee had work-related stress is a fact question. Second, if that work-related stress is proven, then it must be determined if that alleged stress lead to Employee's death. This is a medical casual question. To determine if a link exists between Employee's alleged stress and his death, the medical records and experts are controlling.

Employee had three cardiac conditions: coronary spasm, atrial fibrillation, and a bicuspid aortic valve. In addition, he also had hypertension. To recover under Section 287.067.1 and .2, Claimant must show Employee's cardiac conditions had their origin in a risk associated with his employment as a Richmond Heights police officer, and flowed from that source as a rational consequence. §287.067 RSMo; George v. City of St. Louis & Treasurer of the State of Missouri, Custodian of the Second Injury Fund, 162 S.W.3d 26, 32 (Mo.App. E.D. 2005). Claimant has named the stress of Employee's job as the risk associated with his job leading to his cardiac condition and death. Claimant must prove that Employee's work activities/stress were the prevailing factor causing his cardiac conditions and subsequent death. Id.

The first difficulty in this case is the actual evidence of stress. In all of the treatment records reviewed, there is only one mention of stress on the job while working for Employer. Nothing more than "work is stressful" was recorded by the doctor. Employee did mention to his doctors that he felt the Employer was trying to fire him due to his health, but that is a circular argument. Many other stressors are mentioned throughout Employee's medical records. Those other stressors, which are mentioned several times in the medical records, include miscarriages suffered by his wife, his wife's battle with cancer, and issues and trouble with his son.

Claimant testified about the stressors Employee experienced at work. Those stressors were the exact same stressors provided by attorney Martin to Dr. Schuman. Claimant did not give particular circumstances or dates regarding the stress. Claimant did not differentiate between times Employee was more or less stressed. Claimant testified in general about what she observed. Therefore, to get an accurate account of Employee's stress, each of the allegations of stress should be considered separately to determine what evidence supports those allegations of stress.

Dr. Schuman's testimony regarding the Employee's stress was taken directly from letters he received from Claimant's attorney. Drawing directly from letters of May 10, 2016 and June

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Issued by DIVISION OF WORKERS' COMPENSATION

Injury No.: 14-032369

28, 2016, Dr. Schuman identified the sources of Employee's alleged work-related stress, while employed at the Richmond Heights Police Department, as: 1) confrontations with supervisors; 2) problems with work schedules; 3) repeated questioning by supervisors as to whether he was going to retire or how long he would be off work while recovering from heart surgery in January 2014; 4) questions from his supervisors as to when he would be able to return to limited duty work or handle desk work; 5) multiple physical and verbal confrontations on the job and arrest situations while patrolling; and 6) inability to obtain employment to get away from street patrol duties. Dr. Schuman admitted, all of the information he had about Employee's alleged stressors while working at Employer came from Claimant's attorney. (Exhibit 21).

Regarding confrontations with his supervisors, Dr. Schuman did not know when the confrontations occurred, or how many confrontations there were. Nor did he know the subject of those confrontations, since attorney Martin did not tell him. Dr. Schuman was not provided with, and did not see, any documentation regarding these confrontations. Dr. Schuman assumed these were verbal confrontations, but he did not know.

In reviewing Employee's personnel file, I could find only one piece of evidence regarding a confrontation. Employee received a review in 2005 that he considered less than favorable and filed a complaint. Employee's dissatisfaction was noted in a Memo attached to his review. Otherwise, Employee's Personnel File reflects that his evaluations routinely fell in the "Good" range which meant his work was: "Consistently dependable and competent performance of the job." Many of the reviews mention Employee's prior experience as a benefit, complimenting Employee for bringing balance to the force, and noting that Employee helped to train younger officers. There are some minor criticisms in his reviews, stating that he needed to learn employer's procedures, reporting Employee's difficulty with technology, and indicating Employee needed to write more thorough reports.

There was one citizen complaint filed against Employee. It alleged he threatened a domestic abuse victim with calling the prosecutor and having her thrown out of her apartment because the police were being called there too often. A letter was placed in Employee's file stating threats such as that were not acceptable.

Employee filed a lawsuit against Valor Security Services, Paul Beerman, and Paul Poecker for tortious interference with a business relationship and slander. The lawsuit involved an incident at the Galleria on November 18, 2003 involving Rochelle Canion. Following the incident, Employee was taken out of the Galleria and placed back on the street. The events surrounding the lawsuit are never discussed in Employee's file, however deciding to initiate a lawsuit and being involved in litigation can be stressful. However, it was Employee's choice to do so.

On October 10, 2010, Employee received a Chief's Commendation for his handling of a call with a woman who was suicidal. Claimant also received a commendation in 1994 for the way he handled a burglary. He received another commendation for handling the consequences of a storm in 2000. I found at least 5 letters from citizens commending his work as a police officer.

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Issued by DIVISION OF WORKERS' COMPENSATION

Injury No.: 14-032369

I could find no evidence of Employee being demoted, disciplined, or punished while working for Employer. Certainly, in any job, employees have conflicts with their supervisors. Often, in reviews, employees are told to correct certain actions, or perform at a higher standard. However, that alone cannot create a stress claim, or every employee could make such a claim.

The next claim is that Employee was stressed due to his job schedule. Following the first part of Dr. Schuman's deposition, attorney Martin informed the doctor Employee had a steady shift while working for Richmond Heights; he did not work rotating shifts. After Employee completed his Galleria security detail in November 2003, he was placed on permanent afternoon watch from 3:00 p.m. to 11:00 p.m., through the date of his death. Thus, Employee worked regular shifts from 3:00 p.m. to 11:00 p.m. during his final years with Richmond Heights. Employee did not experience any stress from working rotating shifts or different work schedules because he always worked the same shift while employed by Employer.

The next two stressors involve his supervisors pressuring him to retire or asking when he could return to full duty. Employee's wife testified that two officers, including a "white shirt" visited Employee when he was in the hospital. While Employee may have felt pressure from this, it was not due to his job duties, but rather due to his medical condition. Dr. Schuman did not know whether this alleged questioning was in person, or done by telephone, voice mail, or in written form, such as email or letter. He did not know which supervisors were involved in the questioning, or when it occurred. He simply assumed it occurred in early 2014.

Dr. Schuman did not know how many times Employee was questioned about retirement or how long he would be off work after heart surgery, and whether those questions came from the same supervisor or different supervisors. He did not know the specifics of the questioning. Nor had he seen any documentation from Employee, where he contacted persons at Richmond Heights regarding the questioning, and asked it to cease. And as Dr. Schuman admitted, he saw nothing in the records from Employee's treating physicians regarding questions from his supervisors at Richmond Heights about Employee retiring, or how long he was going to be off work after surgery. Dr. Schuman did not see any documentation that Employee filed a grievance against Richmond Heights in regard to repeated questions. In fact, Dr. Schuman saw no documentation regarding this alleged questioning.

The next allegation of stress is stress due to multiple physical and verbal confrontations on the job and arrest situations while patrolling. Dr. Schuman did not know when these confrontations occurred, or the nature of the confrontations, whether they were physical or verbal, or whether there were any witnesses to these confrontations. Nor did he see any police reports documenting these confrontations. Dr. Schuman did not recall seeing any documentation that Employee requested help from his Employee Assistance Program for his occupational stress, and its effects on him. Nor did he see that any treating physician recommended Employee eliminate or limit his exposure to physical or verbal confrontations on the job.

While I have no doubt those confrontations occurred, there is no mention of them either in Employee's Personnel file or in his medical records. Inherently, being a police officer is a difficult job, but to prove a claim of stress related to Employee's job, Claimant must do more than just make general statements.

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Issued by DIVISION OF WORKERS' COMPENSATION

Injury No.: 14-032369

Last, Dr. Schuman noted Employee had applied to work with St. Louis County in an "off-the-street" type job. During his deposition, Dr. Schuman was provided with the application Employee filed with the St. Louis County Police Department. After reviewing the application, Dr. Schuman noted Employee stated the reason he was applying was for "changing assignments" and "variety". The application did not state that Employee no longer wanted to work as an on-the-street police officer or that he was seeking an off-the-street job in teaching or management. Dr. Schuman acknowledged Employee stated in the application he was capable of performing under extremely stressful situations.

Employee did not state he wanted to leave Richmond Heights because of job stress. Employee represented he was physically capable of making a forceful arrest, requiring physical strength and exertion. Indeed, Employee specifically applied to work in the Homicide Division of St. Louis County Police. The Homicide Division would certainly not be off of the street and presumably would be more stressful than his work with Employer. Employee's intent was clear as he also informed his doctor of his intent to work in the Homicide Division.

Thus, the evidence that Employee had "psychological stress" as a result of his job is lacking. Clearly, there is a level of stress in every job; everyone deals with supervisors, job requirements, and stress. Police officers have a higher level of stress because of the nature of their job duties. However, there must be some evidence that convinces the trier of fact that the particular police officer in question suffered job-related stress. It is not enough to simply enumerate stressors without citing specific facts. Otherwise, the statute would allow every firefighter and police officer to make a claim for job-related stress.

However, assuming arguendo that Claimant successfully proved sufficient work-related stress to meet the minimal statutory requirements, Claimant must then prove that stress caused Employee's cardiac event and death. The competent and substantial medical evidence and medical records demonstrate Employee's cardiac conditions do not constitute an "occupational disease", within the contemplation of the Act: a disease which is the natural incident or result of a particular employment, developing gradually from long, continued work in that employment, and serving to attach to that employment, a hazard distinguishing it from the ordinary run of occupations. *Renfro v. Pittsburg Plate Glass Co.*, 130 S.W.2d 165,170 (Mo.App. 1939).

For a condition to amount to an occupational disease, it must be due to causes and conditions inherent in, and characteristic of the particular employment. *Sanford v. Valier-Spies Milling Co.*, 235 S.W.2d 92, 95 (Mo.App. 1951). To establish a claim for occupational disease, there must be evidence of a direct causal connection between the conditions under which employee performed his work duties, and the alleged occupational disease. *Sellers v. TWA*, 752 S.W.2d 413,415-416 (Mo.App.W.D.1988); *Kelley v. Banta and Stude Constr.*, 1 S.W.3d 43, 48 (Mo.App. E.D.1999) (an employee or claimant must establish, through competent and substantial medical opinion, the probability the claimed occupational disease was caused by the conditions of the employment).

I find Dr. Mankowitz's opinion to be more persuasive than Dr. Schuman's. Dr. Schuman relied on alleged stressors that were not proven by Employee's medical records or personnel file.

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Issued by DIVISION OF WORKERS' COMPENSATION

Injury No.: 14-032369

If being a police officer in and of itself was enough to make a claim for stress that is how the statute would be written. All of the testimony regarding Employee's stress is nebulous and nonspecific. Further, other than Employee's 1990 myocardial infarction, there is no evidence any of Employee's vasospasms or atrial fibrillations were temporally related to something stressful happening at work.

Dr. Mankowitz's opinion that Employee's cardiac events were related to three intrinsic factors unrelated to work stress is borne out by the records. There are voluminous records of Employee developing SVTs or atrial fibrillation, not one of which are related to a stressful work event. Further, most of them are not related to any event, they came on suddenly with no apparent cause; which is exactly what Dr. Mankowitz testified would happen.

Even more persuasive than the experts' opinions is what is found in Employee's treatment records. Not one of Employee's treating doctors recommended that he stop being a police officer. None of his doctor found that police work was too stressful for Employee. None of his treating doctors linked any of his symptoms to stress, or taken further, work-related stress. Consistently, Employee's doctors found Employee could work full duty as a police officer with no restrictions. Further, in the medical records, none of the cardiac events were linked to Employee's employment with Employer. In fact, on October 14, 1999, Employee contacted Dr. Harshman's Office and specifically requested that Dr. Harshman write a letter indicating his cardiac condition was not brought on by his job and was controlled by medicine; Dr. Harshman issued that letter.

Therefore, Claimant's allegation that Employee's alleged stress, cardiac condition, and death were work-related must be denied.

CONCLUSION

Having given careful consideration to the testimony, medical evidence, and guidance from the statute and case law, I find that the evidence fails to support that Employee's alleged occupational disease was medically causally related to his work or arose out of and in the course of his employment. Therefore, Claimant failed to meet her burden to prove that Employee sustained a compensable occupational disease. Therefore, no benefits are awarded.

I certify that on 11-18-20 I delivered a copy of the foregoing award to the parties to the case. A complete record of the method of delivery and date of service upon each party is retained with the executed award in the Division's case file.

By:

Made by:

Lee B. Schaefer

Administrative Law Judge

Division of Workers' Compensation

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