James Copeland v. Gencom, Inc.

(Affirming Award and Decision of Administrative Law Judge)

**Injury No.:** 14-009289

**Employee:** James K. Copeland

**Employer:** Gencom, Inc.

**Insurer:** MO Employers Mutual Insurance Company

**Additional Party:** Treasurer of Missouri as Custodian of Second Injury Fund

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 June 2, 2021. The award and decision of Administrative Law Judge, Melodie A. Powell issued June 2, 2021, is attached and incorporated by this reference.

The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law.

Given at Jefferson City, State of Missouri, this 27th day of December, 2021.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

Robert W. Cornejo, Chairman

Reid K. Forrester, Member

DISSENTING OPINION FILED

Shalonn K. Curls, Member

Attest:

Secretary

Improve: James K. Copeland

- 2 -

I have reviewed and considered all of the competent and substantial evidence on the whole record. Based on my review of the evidence as well as my consideration of the relevant provisions of the Missouri Worker's Compensation Law, I believe the decision of the administrative law judge should be modified.

I find persuasive the opinion of Dr. Stephen Schuman that the accident was the prevailing factor in causing employee's injuries of arterial thrombosis, subsequent ischemia, and subsequent right leg amputation and bowel resection due to the fact that employee, a large and heavy man, was suspended in the air by his seatbelt for several minutes and then fell against the other side of the cab.

According to Dr. Schuman, the pressure on employee due to the seatbelt caused internal damage or trauma to employee's abdomen. This abdominal trauma led to trauma-induced pancreatitis, explaining employee's high lipase level. However, the emergency room staff failed to notice such trauma while palpitating employee's abdomen. Had they performed a CT scan, the emergency room staff probably would have noticed the damage in employee's abdomen. Unchecked and untreated, the abdominal damage resulted in blood clots (specifically a traumatic thrombosis of the mesenteric artery) that led to ischemia and the resultant bowel resection.

Dr. Schuman also opined that employee suffered trauma from the accident to his right leg, either from being suspended by his seat belt or from falling to the passenger side of the truck. This right-leg trauma resulted in traumatic thrombosis of the right femoral artery, ischemia, and a leg amputation above the right knee. Dr. Schuman noted that employee was able to use his right leg for walking and driving immediately prior to his accident, but unable to walk after his accident.

I also find Dr. Schuman's opinion persuasive that the evidence does not support a conclusion that employee's injuries were the result of his diabetes or erroneously presumed ketoacidosis. Dr. Schuman explained that there was no fruitiness on employee's breath in the emergency room and no evidence of ketoacids in his blood or urine. Employee was alert and fully oriented, without evidence of any altered mental status in the emergency room. The record even notes that employee was able to perform computations and relate abstract thoughts.

I also take note of Dr. Schuman's observations that employee complained about belly and leg pain on the way to the emergency room. Although the emergency room staff did not find any issues with employee's abdomen and leg, the pain in both areas increased over the subsequent days. There is no evidence of belly or leg pain prior to the accident. Dr. Schuman also noted that employee did not suffer from lower extremity neuropathy due to his diabetes. I find persuasive that the accident was the prevailing factor in causing both the resulting medical condition and disability.

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Accordingly, employer should be liable for past medical expenses related to the bowel resection and leg amputation, temporary total disability benefits, future medical benefits, and permanent total disability benefits as employee cannot compete in the open labor market. Because the Commission majority has decided otherwise, I respectfully dissent.

Shalonn K. Curls, Member

3315 WEST TRUMAN BLVD, P.O. BOX 58 JEFFERSON CITY, MO 65102 PHONE: (573) 526-8983

JUNE 02, 2021

Scan Copy


Injury No : 14-009289

Injury Date : 02-15-2014

Insurance No. : 20140001277

\# Denotes that the Division sent a copy of the Award by electronic mail to the email address that the party provided. The Certificate of Service for this document is maintained in the Division's records.

Enclosed is a copy of the Award on Hearing made in the above case.

Under the provisions of the Missouri Workers' Compensation Law, an Application for Review of the decision of the Administrative Law Judge may be made to the Missouri Labor and Industrial Relations Commission within twenty (20) days of the above date. If you wish to request a review by the Commission, application may be made by completing an Application for Review Form (MOIC-2567). The Application for Review should be sent directly to the Commission at the following address:

Labor and Industrial Relations Commission

PO Box 599

Jefferson City, MO 65102-0599

If an Application for Review (MOIC-2567) is not postmarked or received within twenty (20) days of the above date, the enclosed award becomes final and no appeal may be made to the Commission or to the courts.

Please reference the above Injury Number in any correspondence with the Division or Commission.

DIVISION OF WORKERS' COMPENSATION

Please visit our website at www.labor.mo.gov/DWC

MISSOURI

DEPARTMENT OF LABOR

& INDUSTRIAL RELATIONS

Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.

Employee: James K. Copeland

Dependents: N/A

Employer: Gencom, Inc.

Additional Party: N/A

Insurer: Missouri Employers Mutual Ins. Co.

Hearing Date: February 23, 2021

Injury No. 14 - 009289

Before the

**DIVISION OF WORKERS' COMPENSATION**

Department of Labor and Industrial Relations of Missouri

Jefferson City, Missouri

Referred by: MAP/sb

1. Are any benefits awarded herein? Yes

1. Was the injury or occupational disease compensable under Chapter 287? Yes

1. Was there an accident or incident of occupational disease under the Law? Yes

1. Date of accident or onset of occupational disease: February 15, 2014

1. State location where accident occurred or occupational disease was contracted: Newton County, Arkansas

1. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes

1. Did employer receive proper notice? Yes

1. Did accident or occupational disease arise out of and in the course of the employment? Yes

1. Was claim for compensation filed within time required by Law? Yes

1. Was employer insured by above insurer? Yes

1. Describe work employee was doing and how accident occurred or occupational disease contracted: Employee was in a motor vehicle accident

1. Did accident or occupational disease cause death? N/A Date of death?

1. Part(s) of body allegedly injured by accident or occupational disease: Pelvis/sacrum and right lower extremity with sequelae to internal organs

1. Nature and Extent of any permanent disability: 2 ½ % BAW referable to the sacrum

1. Compensation paid to date for temporary disability: $0.00

1. Value necessary medical aid paid to date by employer/insurer? $0.00

WC-32-R1 (6-81)

Page 1

Said payments to begin as outlined herein and subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25% of all payments hereunder in favor of the following attorney for necessary legal services rendered to the employee: Clare Behrle

Employee: James K. Copeland

Injury No: 14-009289

Dependents: N/A

Employer: Gencom, Inc.

Additional Party: N/A

Insurer: Missouri Employers Mutual Ins. Co.

Checked by: MAP/sb

On February 23, 2021, a final award hearing was conducted in this matter in Columbia, Missouri. Employee, James K. Copeland, appeared personally and by counsel, Clare Behrle. Employer/Insurer appeared through counsel, Eric T. Lanham. The parties were afforded an opportunity to submit proposed awards, resulting in the record being completed and submitted on March 23, 2021.

The parties stipulated as follows:

1. That on or about February 15, 2014, Gencom, Inc., was an employer operating under and subject to the Missouri Workers' Compensation Law, and during this time was fully insured by Missouri Employers Mutual Insurance Company.
2. That on or about February 15, 2014, James K. Copeland was an employee of the employer and was working under and subject to the Missouri Workers' Compensation Law.
3. That venue is proper in Boone County, Columbia, Missouri.
4. That Employee notified Employer of the alleged accident and injury as required by $\S 287.420$, RSMo.
5. That the Claim for Compensation was filed within the time prescribed by $\S 287.430$, RSMo.
6. That Employee's average weekly wage at the time of the alleged accident was $\ 536.53, resulting in a compensation rate of $\ 357.68 for temporary total, permanent partial, and permanent total disability.
7. That Employer/Insurer have paid no medical expenses.
8. That Employer/Insurer have paid no temporary total disability benefits.
9. That the attorney's fee being sought is 25 % of any benefits ordered to be paid.

1. Whether Employee sustained an accident arising out of and in the course of his employment.
2. Whether the accident was the prevailing factor in causing Employee's resulting medical condition and disability.
3. Whether Employee is entitled to past temporary total disability benefits.
4. Whether Employee is entitled to past medical expenses.
5. Whether Employee is entitled to future medical benefits.
6. The nature and extent of any permanent disability.

The following exhibits were offered and admitted into evidence:

1. Arkansas Uniform MV Collision Report
2. North Arkansas Regional Medical Center records
3. Boone Hospital records
4. JCH Medical Group/Dr. Voigts records
5. Jersey Community Hospital records
6. Hanger Clinic records
7. Passavant Area Hospital records
8. Rochelle Community Hospital records
9. Radiologists of Russellville records
10. Dr. Crabtree records
11. Medical Bills (Group Exhibit)
12. Deposition Transcript and Report of Dr. Stephen Schuman
13. Deposition Transcript and Report of Timothy Lalk
14. Dr. David Volarich reports dated August 30, 2016 and October 2, 2016
15. St. Mary's Regional Medical Center records
16. HyVee Pharmacy records
17. Midwest Heart, Dr. Enikova records
18. Hygienic Institute, Dr. Fess records
19. Swedish Health Systems records
20. Claim for Compensation

EMPLOYER/INSURER EXHIBITS

A. Answer to Claim for Compensation

B. Arkansas Uniform Motor Vehicle Collision Report

C. Deposition Transcript of Employee

D. Deposition Transcript, with Exhibits, of Dr. John S. Daniels

E. Deposition Transcript, with Exhibits, Thomas Karrow, M.Ed., CRC, CCM, CDMS

All exhibits appear as received and admitted into evidence at the evidentiary hearing.

There has been no alteration (including highlighting or underscoring) of any exhibit by the undersigned administrative law judge.

James Copeland ("Employee") testified at the hearing. He is 61 years old and began working for Gencom on May 18, 2011. He was responsible for hooking and unhooking trailers, picking up loads, and delivering loads, however, his job largely involved driving. He was paid by the mile, and if he was not on the road, he was not earning money.

On or about February 2, 2014, Employee testified he left Marshall, Missouri, with a loaded trailer to be delivered to Russellville, Arkansas. He arrived in Russellville that evening and dropped the loaded trailer then went to a truck stop to sleep. When he woke up on February 3,2014 , he noticed he was light-headed and did not feel very good. He developed a cough and what he thought was a cold, then began having diarrhea. Employee testified his condition worsened, he was unable to work, and he spent the next few days in his truck before seeking help at an Emergency Room at St. Mary's Regional Medical Center on February 7, 2014. Employee testified that they "really didn't do much" for him, but simply diagnosed him with a UTI and possible ear infection. They gave him antibiotics and an anti-diarrheal and discharged him. After this emergency room visit, he testified that he was not eating very well, so another truck driver brought him some soup or something to drink.

Employee spent the next eight days in his truck at a truck stop because he was concerned about the diarrhea and did not have a bathroom in his truck. By February 13 or 14, 2014, Employee testified he began feeling somewhat better, and on February 15, 2014, he left the truck stop near Russellville, Arkansas. He testified that he was still having symptoms on February 15, 2014, however, he felt he was capable of finishing the job.

Employee drove to a nearby Conagra Foods location where he picked up a loaded trailer for a Monday delivery in Illinois. Shortly after leaving Conagra, his truck developed a mechanical problem, and he spent approximately three hours at the top of a mountain near Harrison, Arkansas, while a mechanic repaired a busted hose.

Once the truck was fixed, Employee testified he proceeded downhill, pulled into a brake check area, but chose not to stop. He testified he was driving slowly but was unsure as to his exact speed. Employee testified he felt the back wheels of the trailer drag onto the edge of the asphalt, and he could not correct. As a result, the truck went off the road and rolled over onto the passenger side. Employee testified he was hanging by his seatbelt for a 15-20 minutes until he was able to roll the window down and relieve the pressure by sticking his arm out of the window. He then was able to release the seatbelt. He fell to the other side of the cab. According to Employee, first responders arrived within a half hour or less. Employee initially indicated he did not want to go to the emergency room, but after he complained of tailbone pain, he was taken by ambulance to the emergency room at North Arkansas Regional Medical Center in Harrison, Arkansas.

Employee was admitted to the emergency room at 8:29 p.m., approximately ninety minutes after the rollover occurred. (Exh. 2, p. 16). Upon admission, his complaints were coccyx pain and thirst. (Exh. 2, p. 16). The triage notes indicate that he voiced no other complaints at that time. It was noted that Employee's blood sugars had been read at $531 \mathrm{mg} / \mathrm{dl}$. After a short

**Employee:** James K. Copeland

**Injury No.:** 14-009289

evaluation period that revealed no diagnosis of serious trauma, he was discharged at 12:25 a.m. the morning of February 16, 2014, approximately 5 hours after the motor vehicle accident. After discharge, the Employee went to a hotel in Jasper, Arkansas. Employee said that he began having leg pain shortly after his arrival, which impacted his sleep, and by the next morning he could barely walk on the leg.

Employee testified at trial that he when he fell to the passenger side of the cab he hit his leg on the stick shift and had pain in his right foot. However, in his deposition taken four months after the accident, there was no testimony concerning foot or leg pain. Employee testified in his deposition that he felt he had a little sore on his pelvis and then noticed a bit of pain in his stomach. When asked if he had symptoms anywhere else besides the pelvis or stomach, Employee stated "no, not really". (Exh. C, p. 7).

There are no references to Employee's leg striking the stick shift or to any leg injuries in the traffic report, the ambulance report, or the emergency room records. (Exh. 2, p. 7).

Employee's dispatcher drove to Arkansas to bring him back to his home in Missouri. Employee testified he continued to have severe leg pain and was admitted to Boone Hospital Center on February 18, 2014, where he had surgery, including an above-knee amputation and a colon re-section.

Employee testified that he remained at Boone Hospital Center for over a month before his release on April 9, 2014. He testified that he moved back to Illinois where he had family and began treating with Dr. Voigts for a few months. He subsequently moved to another town and began treating with another physician.

Employee additionally testified concerning his hip surgery, a prostate cancer diagnosis, and conditions since the accident. He testified that he no longer receives treatment for his low back, pelvis, or abdominal complaints. He testified that he anticipates the need for additional care or replacements for his prosthetic device.

Employee has had longstanding treatment for his diabetes beginning in 2007.

He also had a history of hypertension with failure to take his medications. (Exh. 19, pp. 14, 23). On March 30, 2007, he presented to Rochelle Community Hospital and was transferred to Swedish American Health System where they discovered left ventricle thrombus. (Exh. 19, p. 16). Thrombus is a blood clot in the vascular system impeding blood flow. (Exh. D, pp. 18-19). He had dilated cardiomyopathy and had an angiogram performed with an ejection fraction of 20-25 per cent. (Exh., 19, pp. 2-3). Employee was additionally diagnosed with pneumonia, left ventricular thrombus, and diabetes mellitus with hemoglobin A1C of 9.2.

On June 11, 2008, Employee reported to Maryfrances Crist, APN of Hygienic Community Health Center, that his blood sugars were regularly between 120-130, though they had been up to 200. He reported that he was instructed to stop taking Metformin noting it may

WC-32-R1 (6-81)

Page 6

**Employee:** James K. Copeland

**Injury No.:** 14-009289

have something to do with his kidney function. (Exh. 18, p. 6). At that time, he started taking Glipizide 10mg, one tablet two times daily. He would follow up for his "diabetes mellitus without mention of complication: type II or unspecified type, uncontrolled" on a 3-month basis. On May 18, 2009, he presented with complaints of diabetes-related symptoms including numbness and tingling in the toes. On October 13, 2009, Employee had a goal of 7.0% A1C or about 155(mg/dl) average blood glucose. (Exh. 18, pp. 15, 48). On June 7, 2010, with the continued hypoglycemia (low blood sugar), Dr. Kara Fess indicated Employee would need less Glipizide and reduced the dosage to 5mg, two times daily (Exh. 18, p. 22).

Employee continued to treat his type II diabetes with Glipizide. Prior to the motor vehicle accident of February 15, 2014, he had refilled the medication on December 15, 2013, and January 10, 2014, receiving 30 tablets each time. (Exh. 16, p. 9).

Employee first sought treatment at St. Mary's Regional Medical Center's Emergency Department in Russellville, Arkansas, on Friday, February 7, 2014. (Exh. 15). He reported he had not been feeling well for nearly five days with decreased appetite and an onset of diarrhea since Monday, February 3, 2014. Lab tests demonstrated high blood urea nitrogen (BUN) and creatinine levels, leading to a disposition of elevated renal functions. The note recommended following up with a primary care physician in two to three days. The clinical impression was a UTI, dehydration, diarrhea, and renal insufficiency. His diagnoses also included diabetes mellitus without complications, type II or unspecific type, hypertension not otherwise specified (NOS), coronary atherosclerosis of native coronary vessel, and congestive heart failure NOS. (Exh. 15, p. 32).

He was prescribed ciprofloxacin, diphenoxylate-atropine, and ondansetron. (Exh. 15, p. 32). A chest x-ray revealed no acute cardiopulmonary abnormality. Employee spent approximately six hours in the Emergency Department on February 7, 2014. (Exh. 15, pp. 20-21).

Operator V1, James Copeland, was northbound on AR HWY 7, south of Jasper, when he failed to properly negotiate a curve. V1 veered off the north shoulder and into the ditch line. Upon entering the ditch with V1's right tires, V1 fell over onto its right side. Witness' stated V1 was north bound at a slow rate of speed, passed the brake check area, then drove off the road and rolled over onto its side. Operator V1 stated he did not know what happened, only that when V1's tires went off the roadway V1 rolled over. Operator V1 stated he did not stop at the brake check, south of the accident scene. (Exh. 1, p. 3).

WC-32-R1 (6-81)

Page 7

Issued by DIVISION OF WORKERS' COMPENSATION

Employee: James K. Copeland

Injury No. 14-009289

The accident occurred at 7:11 p.m., 0.9 miles south of Jasper, Arkansas. (Exh. 1, p. 1). Employee was issued two citations, (1) careless or prohibited driving § 27-51104 and (2) disregard traffic control device (brake check) § 27-52-103. The report further noted the atmospheric conditions were clear, the roadway was dry with no defects, and Employee's vision was not obscured.

Statements were taken from witnesses to the accident. Amber Welch stated she and her husband had been following Employee's vehicle for a while and noted that he passed the brake check. (Exh. 1, p. 11). Welch stated they pulled over due to Employee traveling at such a slow speed, to keep from getting their brakes hot and noted Employee's vehicle had rolled over. (Exh. 1, p. 11). Janet Watkins stated she pulled out behind Employee, just south of the accident scene. (Exh. 1, p. 12). She saw Employee slowly drive off the ditch and roll over. (Exh. 1, pp. 3, 11-12).

Employee's testimony regarding whether he stopped at the brake check was inconsistent. In his June 23, 2014, deposition, Employee testified that he pulled into the brake check area and stopped for a couple of minutes. (Exh. C, pp. 40-41). At trial, he admitted that he did not stop, but pulled over into the brake check area. As noted above, a witness stated that he "passed the brake check," and Employee told the officer on the scene that he did not stop at the brake check. (Exh. 1).

The ambulance record demonstrates that a call was received at 7:20 p.m., arrived to the scene at 7:28 p.m., and arrived to North Arkansas Regional Medical Center at 8:21 p.m. (Exh. 2, p. 9). Employee was admitted to the emergency room at 8:29 p.m., approximately ninety minutes after the rollover occurred. (Exh. 1, p. 1; Exh. 2, p. 16).

Per the North Arkansas Regional Medical Center Records EMT report, on February 15, 2014, they were called to respond to a tractor trailer rollover at Jasper, Arkansas. (Exh. 2, p. 7). Employee was found standing up in his truck that had rolled over on its side. He stated he was not hurt, and that he did not want to go to the hospital. The fire department removed the windshield and Employee walked out of the cab noting his tailbone hurt, and that was all. He agreed to be transported. (Exh. 2).

Employee reported that he had been wearing his seat belt, he was moving at approximately 15 miles per hour, and there was no major damage to the truck. (Exh. 2, p. 7). Employee stated he felt like he had a belly ache. The EMS checked his blood sugar with an ACCU check, which showed a reading of 531 mg/dL. When advised of this, Employee stated he had not been taking his medications.

The records noted Employee's behavior was anxious, guarded, and angry. (Exh. 2, p. 18). Dr. William Pittman noted Employee had been drinking a lot of water that day and urinating frequently. Employee advised the doctor he was a diabetic, but had been noncompliant with his medications. (Exh. 2, p. 30). The Employee was unclear how the accident occurred, and Dr. Pittman addressed multiple underlying problems including diabetes mellitus with symptoms of hyperglycemia. He was provided sodium chloride and short-acting insulin. A CT imaging report revealed a fracture of the sacrum with presacral hematoma. Employee was discharged from

WIC-32-83 (6-81)

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**Employee:** James K. Copeland

**Injury No.:** 14-009289

North Arkansas Regional Medical Center on February 16, 2014, at 12:25 a.m. with a note of diabetes with medication noncompliance. (Exh. 2, p. 26).

Employee returned to the North Arkansas Regional Medical Center emergency room at about 10:34 a.m. on February 16, 2014, reporting right leg pain. (Exh. 2, pp. 77-78). He stated the leg pain had begun the night prior but had worsened that morning. He rated the pain as 10 on a scale of 1-10. X-rays revealed no acute fracture or dislocation at the knee, tibia, fibula, or ankle. An ultrasound of his right leg revealed fluid collection in the posterior upper calf which was noted as a hematoma. Dr. Chris Bennett noted Employee was negative for DVT. Employee was discharged from the emergency room at 12:49 p.m. and was instructed to see his primary care physician in a few days.

Employee testified a dispatcher drove to Arkansas to pick him up and bring him back to his home in Missouri. Employee stated in his deposition that the leg was better on the drive back to Missouri. Employee testified he continued to have severe leg pain. On the morning of February 18, 2014, Employee was taken to the emergency room at Boone Hospital Center in Columbia, Missouri. (Exh. 3, pp. 210, 432). He reported that he could not stand on his right leg. His right leg was found to be cool to touch and pulses in his right leg from the femoral artery down could not be obtained. (Exh. 3, p. 217). Employee also reported he had not been able to walk much due to the sacral pain. (Exh. 3, pp. 216-217).

The medical records document that, on February 18, 2014, Dr. Paul Humphrey treated Employee's severe lower extremity ischemia. (Exh. 3, p. 216) Ischemia means lack of blood flow. Dr. Humphrey noted Employee was not a very accurate historian altering exactly when his right leg pain began noting "he believes in the past 24 hours." (Exh. 3, p. 216). His right lower extremity was cool to touch, somewhat mottled, and he could not move the toes of his right foot. Dr. Humphrey noted (1) severe right lower extremity ischemia; (2) status post motor vehicle accident with a pelvic fracture; (3) diabetes mellitus; and, (4) hypertension. (Exh. 3, p. 217). Dr. Humphrey performed (1) right iliac and femoral thrombectomies; (2) right popliteal and tibial thrombectomies; (3) four-compartment right lower extremity fasciotomy; (4) intraoperative anteriogram; (5) extensive common femoral endarterectomy with path angioplasty closure. (Exh. 3, p. 426).

Employee was transferred to the ICU to the care of Dr. Mohammad Jarbou. (Exh. 3, p. 211). When transferred, Employee was in renal failure and was severely acidotic, secondary to diabetic ketoacidosis. He developed sepsis. (Exh. 3, pp. 211, 236). He was managed in the ICU with an insulin drip, broad coverage for an infection, and anticoagulation. By February 20, 2014, Employee had developed an ischemic bowel, compartment syndrome, and rhabdomyolysis and acute renal failure. (Exh. 3, pp. 211, 253). On February 21, 2014, an exploratory laparotomy and resection of his bowel was performed, and nearly half of the small bowel was ischemic. On February 27, 2014, an upper endoscopy was performed revealing a blood ulcer, which was clipped. (Exh. 3, pp. 212). Cardiology was consulted to help with atrial fibrillation. (Exh. 3, p. 212). He had GI bleeding requiring the need for blood transfusions. Employee remained in the ICU in critical condition, and it was becoming clearer the right leg would not be salvageable. (Exh. 3, pp. 313, 321). Dr. Humphrey recommended a right above-knee amputation which was performed on March 3, 2014. (Exh. 3, pp. 212, 318).

WC-32-R1 (6/81)

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Issued by DIVISION OF WORKERS' COMPENSATION

Employee: James K. Copeland

Injury No. 14-009289

After Employee stabilized from the above-knee amputation, he developed significant anemia secondary to blood loss and chronic disease. He was found to have a right upper lung abscess cavitary lesion during this work up, which was caused by an infection. He was diagnosed with funguria and dysphagia. (Exh. 3, pp. 212, 340, 385).

Joseph Muscato, M.D., of Boone Hospital Center noted that there were multiple areas of arterial thrombosis of uncertain source. He indicated this was obviously suggestive history of a cardiac source and possibly a small right-to-left shunt so he could have a venous thrombosis which was not seen and which could be causing this. It was noted that Employee's venous Dopplers were normal for clot. Dr. Muscato suspected that Mr. Copeland unfortunately just had significant vascular disease and he would need to life-long coagulopathy. There was no evidence of vasculitis on Employee's surgical resection. Dr. Muscato stated that given the life-threatening illness and the previous clot in 2007, there was no way to avoid long-term anticoagulation. (Exh. 3, p. 15).

Employee was informed that he would need to be on anticoagulation for the rest of his life because of two spontaneous arterial thromboses, leading to mesenteric ischemia and lower extremity ischemia. (Exh. 3, pp. 212, 340, 386). He was admitted to Boone County Hospital Rehab on March 21, 2014. It was reported that Employee did well with rehabilitation and was discharged on April 9, 2014. Employee reported he was going to live with his friend, Beverly, near Jacksonville, Illinois.

On May 25, 2014, Employee reported to Jersey Community Hospital PT for an evaluation to determine treatment with the prosthesis and therapy. (Exh. 4, p. 93).

Between June 4, 2014, and August 19, 2014, Employee treated for various conditions, including prostate cancer, a cavitary lesion in the right lung with unknown cause, and right wrist swelling.

Medical and Vocational Experts

John S. Daniels, M.D.

At the request of the Employer/Insurer, Dr. Daniels prepared a medical report on May 18, 2018. He also testified by deposition. (Exh. D). Dr. Daniels' specialty is Internal Medicine with board certifications in Endocrinology and Metabolism. (Exh. D, pp. 5-6). Since 1979, Dr. Daniels has been practicing as an internist as well as an endocrinologist primarily seeing patients with diabetes. Endocrinology is a subspecialty in internal medicine which deals with the various classical hormone diseases, the most common being diabetes. (Exh. D, pp. 7-8). Diabetes is a disease of glucose and insulin metabolism, basically involving elevated blood sugars. (Exh. D, p. 8). Dr. Daniels testified that a majority of his diabetic patients have type 2 diabetes, or non insulin-dependent, the same type of diabetes as Employee has. (Exh. D, pp. 8-9).

Dr. Daniels explained Employee's medical history and the basic meaning of terms. Employee has a history of peripheral neuropathy, or damage to the small nerves resulting in numbness, tingling, or loss of feeling in the feet as a consequence of uncontrolled diabetes.

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Page 10

**Employee:** James K. Copeland

**Injury No.:** 14-009289

(Exh. D, pp. 10-11). As it concerned the February 7, 2014, admission at St. Mary's Regional Medical Center, Employee had vital signs of: creatinine = 2.8; BUN = 88; blood glucose = 332; and CO2 = 18. (Exh. D, pp. 11-13). Dr. Daniels further explained that based on Employee's vital signs and lab results, including the creatinine, BUN, blood glucose, and carbon dioxide levels, Employee was very dehydrated, acidotic, and ill with ketoacidosis. (Exh. D, pp. 11-13). He then explained ketoacidosis. It is a state of uncontrolled diabetes where one breaks down fats into ketones and the blood becomes too acid. (Exh. D, pp. 12-13). In Dr. Daniels' opinion, ketoacidosis would be a reasonable diagnosis for Employee given the marked dehydration. (Exh. D, pp. 12-13). Dr. Daniels testified most hospital emergency rooms would have admitted Employee to the hospital, and he was shocked Employee was sent home. (Exh. D, p. 11).

Dr. Daniels testified that Employee's glucose level had been high (531), per the EMT report, and the labs demonstrated a markedly elevated white blood cell count indicating severe stress or infection. (Exh. D, pp. 16-17). Dr. Daniels testified that Employee was malnourished and acidotic, which indicated an inflammation of the pancreas consistent with someone who is in ketoacidosis. Dr. Daniels testified that Employee had the classic symptoms of someone with out-of-control diabetes. (Exh. D, p. 17).

According to Dr. Daniels, Employee developed arterial blood clots in his right femoral and iliac arteries, which are the main arteries that supply blood to the lower extremities. (Exh. D, pp. 18-19). As a result, Employee lost blood flow to the leg and it died. When addressing the cause for these types of blood clots, Dr. Daniels testified there are a number of reasons including intermittent atrial fibrillation. (Exh. D, pp. 19-20). He suggested Employee was at a high risk for developing a deep vein thrombosis because of his obesity and uncontrolled diabetes combined with having been sedentary for a week prior to the accident. (Exh. D, pp. 19-20). Additionally, because of the markedly out-of-control diabetes and dehydration, Employee was at a much greater risk for arterial thrombosis and developing blood clots in his arteries. (Exh. D, pp. 19-20).

Dr. Daniels explained how the doctors at Boone Hospital attempted to rescue the leg by removing blood clots from the femoral and iliac arteries. (Exh. D, pp. 20-21). However, there was no improvement in blood flow and the leg had to be amputated. (Exh. D, pp. 20-22).

Dr. Daniels did not have a good explanation for why the right leg femoral and iliac arteries were affected as opposed to the left. However, because the thrombosis also occurred in the mesenteric artery resulting in the small intestine dying, it was Dr. Daniels' opinion that what happened to Employee was a systemic problem related to his uncontrolled diabetes. (Exh. D, pp. 22-23).

Dr. Daniels went on to state that Employee was a very ill individual for the week prior to the accident as evidenced by the two emergency room visits, and should have been admitted to the hospital. Dr. Daniels opined that Employee was very prone to developing arterial blood clots as a result of his illness, his uncontrolled diabetes, being overweight, and having heart abnormalities including a right to left shunt and atrial fibrillation. In Dr. Daniels' opinion, Employee's arterial thrombosis resulted from these conditions. Dr. Daniels testified that the pelvic fracture sustained in the motor vehicle accident did not cause or contribute to any of Employee's subsequent medical conditions. (Exh. D, pp. 23-24).

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Page 11

**Employee:** James K. Copeland

**Injury No.:** 14-009289

Dr. Stephen Schuman performed an IME on behalf of Employee on August 30, 2016. (Exh. 12, pp. 6-7). Dr. Schuman specializes in internal medicine with a subspecialty of cardiology. (Exh. 12, p. 4). He currently has a private practice in internal medicine/cardiology in Chesterfield, Missouri.

Dr. Schuman provided the following diagnoses from the truck accident:

1. Comminuted sacral fracture
2. Mesenteric ischemia with bowel perforation-status post extensive intestinal resection due to the bowel ischemia, in turn caused by thromboembolism of branches of the superior mesenteric artery
3. Right lower extremity ischemia due to thromboembolism of the right femoral artery necessitating above-the-knee amputation
4. Chronic diarrhea due to the extensive intestinal resection

(Exh. 12, pp. 40-41).

It was Dr. Schuman's opinion, based on a reasonable degree of medical certainty, that the accident of February 15, 2014, was the prevailing factor in these diagnoses and that the treatment provided was reasonable, necessary, and causally related to the motor vehicle accident of February 15, 2014. He felt Employee's prognosis was poor and found him to be permanently and totally disabled due to his multiple injuries. (Exh. 12, pp. 41-42, 46-47).

Dr. Schuman's deposition was taken on March 18, 2020. (Exh. 12, p. 2). His testimony was largely consistent with his August 30, 2016 report.

He recounted Employee's illness beginning February 6, 2014, where Employee had diarrhea, loss of appetite, and dizziness. (Exh. 12, p. 10). He explained Employee only had enough medication (including Glipizide), to treat his diabetes for a two or three-day trip. (Exh. 12, p. 11). Dr. Schuman acknowledged that Employee ran out of medication because he planned to be gone for three days but was instead gone for ten days. (Exh. 12, p. 55). Concerning the accident itself, Dr. Schuman testified the truck rolled over on its right side, and Employee was caught on his seatbelt causing a severe abdominal injury. (Exh. 12, pp. 41-43). Dr. Schumann suggested this rollover could cause ischemia into the right leg and traumatic thrombosis of the right femoral artery. (Exh. 12, pp. 41-43). He testified Employee's thromboses were a result of trauma.

Dr. Schuman testified Employee's bedside glucose from February 15, 2014, was 378 mg/dL., but admitted the ACCU check reading at the scene was 531 mg/dL. (Exh. 12, p. 26) He acknowledged the Employee demonstrated an elevated lipase level of 522 U/L, but felt that was from acute pancreatitis directly attributable to the Employee's abdomen injury from the seatbelt. (Exh. 12, pp. 29, 43). He was unable to say how or why the acute injuries and

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Page 12

**Employee:** James K. Copeland

**Injury No.:** 14-009289

trauma he diagnosed were neither diagnosed or treated by either the emergency room or hospital personnel, nor could he explain why the Employee failed to complain to those providers of any problems other than a sore tailbone and being thirsty. He was unsure whether Employee's diabetes was uncontrolled on February 15, 2014. (Exh. 12, pp. 49-50).

Dr. Schuman considered himself an expert on blood glucose levels, but only as it concerned internal medicine and not as it pertained to diabetes. (Exh. 12, p. 52). He testified that normal blood glucose levels are 70 - 100 while fasting, and anything less than 140 while non-fasting. (Exh. 12, p. 52). He testified someone is considered to be diabetic if their fasting blood glucose level is greater than 125. (Exh. 12, pp. 52-53). Dr. Schuman acknowledged that Employee's blood glucose level when taken by the paramedics was noted to be 531, however, he was unsure why he did not include that in his report. (Exh. 12, pp. 54-55). Dr. Schuman testified he was uncertain whether Employee was on the verge of a diabetic coma at the time the accident occurred and stated that would mostly depend on how quickly Employee's blood sugar level rose. (Exh. 12, p. 55).

Dr. Schuman acknowledged that Employee had a history of left ventricular thrombus. (Exh. 12, pp. 59-60). He testified that Employee had previously been prescribed Coumadin, a blood thinner. Dr. Schuman said Coumadin is prescribed to patients because they are at risk of blood clotting. He testified that, if an individual stops taking the prescribed Coumadin, a blood clot could develop. (Exh. 12, pp. 59-60).

Dr. Schuman also testified about the right-to-left cardiac shunt. (Exh. 12, pp. 60-62). He testified a cardiac shunt does not necessarily put someone at an increased risk of arterial thrombosis, however, he acknowledged that atrial fibrillation could put someone at an increased risk for a blood clot. (Exh. 12, pp. 62-63). He also acknowledged that being sedentary for a week would increase the likelihood of developing a venous thrombosis.

Dr. Schuman opined that the rollover accident caused a severe abdominal injury, leading to the right lower extremity and abdominal ischemia and subsequent injuries. (Exh. 12, pp. 41-44). He testified that Employee was permanently and totally disabled due to his multiple injuries, including his right lower extremity, which necessitated an above-the-knee amputation, chronic diarrhea and incontinence due to the extensive bowel resection, and chronic right limb phantom pain. (Exh. 12, pp. 41-47).

**David T. Volarich, D.O.**

On August 30, 2016, Dr. Volarich performed an independent medical examination at the request of Employee's attorney. (Exh. 14). Dr. Volarich routinely provides IMEs on behalf of employees in workers' compensation cases.

Employee gave a history to Dr. Volarich regarding the truck accident. Employee told Dr. Volarich that due to his multiple other injuries, he was kept on bedrest and his sacral fracture healed. He reported he was not receiving any active treatment for the sacral fracture. (Exh. 14, p. 4). Employee's complaints when he saw Dr. Volarich were "some" pain in his sacrum, which

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Page 13

Issued by DIVISION OF WORKERS' COMPENSATION

Employee: James K. Copeland

Injury No. 14-009289

he described as a tension in his hips and sacrum. He stated the pain worsened with sitting too long. (Exh. 14, p. 4). Dr. Volarich's examination was limited to the low back/pelvis and associated neurologic examination. (Exh. 14, p. 5). On physical examination, Dr. Volarich noted discomfort with lumbar extension and discomfort over the sacrum and gluteal muscles bilaterally, with palpation. (Exh. 14, pp. 5-6). Dr. Volarich stated that Employee was at MMI with regard to the sacral fracture. (Exh. 14, p. 6).

Dr. Volarich indicated that Employee was using crutches upon presentment as the prosthesis was being adjusted by his therapist. He diagnosed the injury of February 15, 2014, as a comminuted sacral fracture status post non-operative treatment. (Exh. 14, p. 6). It was Dr. Volarich's opinion that the accident of February 15, 2014, was the primary and prevailing factor in causing the comminuted sacral fracture that required non operative treatment. The work injury was the prevailing factor causing his symptoms, need for treatment, and resulting disabilities. (Exh. 14, 6). Dr. Volarich provided a 22.5% permanent partial disability rating to the body as a whole at the lumbosacral spine due to the comminuted sacral fracture.

Dr. Volarich did not opine in his initial report that the accident was the prevailing factor in causing the arterial issues that led to the multiple surgical procedures. Dr. Volarich initially opined only that the accident was the prevailing factor in causing a lumbar spine injury and a sacral fracture, and his rating only addressed those body parts. However, on October 12, 2016, Dr. Volarich provided an addendum to his above opinion in which he agreed with Dr. Schuman's opinion as to causation and permanent total disability.

There is no indication that Dr. Volarich reviewed Dr. Daniels' report or deposition testimony.

Timothy G. Lalk

At the request of Employee, vocational rehabilitation counselor, Timothy Lalk, issued a report on August 28, 2020. (Exh. 13). He is a certified by the Commission on Rehabilitation Counselor Certification. For Missouri workers' compensation cases, he testified 60-65% of his practice is on behalf of Employees.

Mr. Lalk's report concluded the right above-knee amputation and use of a prosthesis would not prevent Employee from returning to some type of work. (Exh. 13, p. 77). He would instead require an unskilled, sedentary type of employment. (Exh. 13, p. 77). However, based on the prognosis of Dr. Schuman, Employee would not be able to attempt any type of work with the persistence and pace expected by any reasonable employer due to his need to leave his workstation and utilize a restroom as a result of the problems Employee has with his bowels. (Exh. 13, p. 78).

The deposition of Mr. Lalk was taken on December 1, 2020. Mr. Lalk testified in line with his report. (Exh. 13). He indicated Employee's primary problem limiting his ability to function was frequent bowel movements occurring as often as ten times per day. (Exh. 13, pp. 14-15).

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Page 14

**Employee:** James K. Copeland

**Injury No.:** 14-009289

Employee has a GED and basic computer skills. (Exh. 13, pp. 19-20). His vocational skills pointed towards his extensive experience as a truck-driver. However, Mr. Lalk pointed to the bowel problem as the rationale Employee could not continue in this role. (Exh. 13, pp. 20-23). Mr. Lalk relied on Dr. Schuman's restrictions and opinion that Employee was permanently and totally disabled. (Exh. 13, p. 26). Mr. Lalk testified that Employee's prosthesis would not prevent Employee from returning to some type of work. He might be able to secure a job as a dispatcher, but he would not be able to continue working due to the problems he is experiencing with bowel frequency and incontinence. (Exh. 13, p. 28).

Mr. Lalk testified that Employee still goes to movies, goes to restaurants, and drives his car. Mr. Lalk agreed that all three of those situations put Employee far away from a restroom. (Exh. 13, pp. 41-44).

**Thomas S. Karrow, M.Ed., CRC, CCM, CDMS**

At the request of the Employer and Insurer, vocational rehabilitation consultant Thomas Karrow issued a report on January 11, 2021. (Exh. E). Mr. Karrow is certified to work Social Security Disability Cases, workers' compensation programs on the federal level, ailroad cases, and Longshoreman and Jones Act cases. His current case load would be about 65-70% on behalf of plaintiffs. (Exh. E, pp. 7-8).

Mr. Karrow's report was based upon a review of file materials, a phone interview with Employee, and information concerning the local labor market. (Exh. E, pp. 10-11). Employee indicated to Mr. Karrow that he can drive using his left foot for both pedals, that he uses the restroom up to 12 times a day, that he does not take medication for his restroom problem, and that he can access the internet. (Exh. E, p. 13). Mr. Karrow concluded Employee could perform light work as exhibited by his daily activities, indicating he is employable. (Exh. E, pp. 14-16). Using a job matching system in conjunction with the U.S. Department of Labor Standards, Mr. Karrow found Employee could either (1) do nothing - in accord with Dr. Volarich and Schuman or (2) perform sedentary to light duty activities per the restrictions of Dr. Daniels. (Exh. E, pp. 20-23). With Dr. Daniels' restrictions, Mr. Karrow testified that many entry level jobs were available for Employee such as cashier, sales associate, counter clerk, check cashing clerk, customer service representative, truck dispatcher, truck company recruiter. There are even opportunities for him to get a commercial truck driving position if he can pass a skilled performance evaluation.

Mr. Karrow testified that if Employee had diarrhea and incontinence requiring Employee's use of the restroom on an urgent basis 12-15 times during a day, that would be an issue and he would not be employable. (Exh. E, p. 40). He indicated there may be a possibility of temporary work at best. Mr. Karrow agreed that if the Employee was able to space out his bathroom breaks using his regular breaks, a lunch break, and a couple of other non-scheduled breaks throughout the day, he would be able to be employed. (Exh. E, p. 52). Ultimately, Mr. Karrow found employment opportunities for Employee based on sedentary to light duty activities. This would depend upon Employee's diarrhea and incontinence.

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Page 15

The claimant in a workers' compensation case has the burden to prove all the essential elements of the claim, including the causal connection between the injury and work. Jefferson City Country Club v. Pace, 500 S.W. 3d 305, 313 (Mo.App., W.D. 2016). The claimant does not have to establish the elements of the case on the basis of absolute certainty; it is sufficient if the claimant shows them by reasonable probability. Moreland v. Eagle Picher Techs., LLC, 362 S.W.3d. 491, 504 (Mo.App., S.D. 2012). Probable means founded on reason and experience, which inclines the mind to believe but leaves room for doubt. Id. (citations omitted). All provisions of Chapter 287, RSMo. shall be strictly construed.

"Accident" is defined in $\S 287.020 .2$, RSMo, as "an unexpected or traumatic event or unusual strain identifiable by time and place of occurrence and producing at the time objective symptoms of an injury caused by a specific event during a single work shift." "Injury" is defined as "an injury which has arisen out of and in the course of employment". §287.020.3 RSMo.

Injuries are only deemed to arise out of and in the course of employment if:

(a) It is reasonably apparent, upon consideration of all the circumstances, that the accident is the prevailing factor in causing the injury; and

(b) It does not come from a hazard or risk unrelated to the employment to which workers would have been equally exposed outside of and unrelated to the employment in normal non-employment life.

§287.020.3(2), RSMo. Any injury resulting directly or indirectly from idiopathic causes is not compensable. $\S 287.020 .3(3)$.

'The prevailing factor' is defined to be "the primary factor, in relation to any other factor, causing both the resulting medical condition and disability." 287.020.3(1) RSMo.

The employee in a workers' compensation case has the burden to prove a causal connection between the injury and the job. Royal v. Advantica Rest. Group, Inc., 194 S.W.3d 371, 376 (Mo. App. W.D. 2006) (citations omitted). "Medical causation, which is not within common knowledge or experience, must be established by scientific or medical evidence showing the relationship between the complained of condition and the asserted cause." Lingo v. Midwest Block \& Brick, Inc., 307 S.W.3d 233, 236 (Mo. App. W.D. 2010) (quoting Gordon, 268 S.W.3d at 461 ).

I find that an accident occurred on February 15, 2014. Employee was driving his tractortrailer when the back tires did not maneuver a curve and went off the pavement, causing the truck to overturn. However, the only injury that arose out of and in the course of employment is an injury to Employee's pelvis, or sacrum. (The medical records and experts refer to both almost interchangeably.) The medical records of North Arkansas Regional Medical Center on the date

**Employee:** James K. Copeland

**Injury No.:** 14-009289

of the accident contain a CT imaging report revealing a fracture of the sacrum with a pre-sacral hematoma. The medical experts were all in agreement that a sacral or pelvic fracture was sustained as a result of the truck rollover. The accident was the prevailing factor in causing only the sacrum fracture.

I find that the accident of February 15, 2014, was not the prevailing factor in causing Employee's arterial thrombosis, subsequent ischemia, and subsequent injuries and conditions including the leg amputation and bowel resection with sequelae. Rather, these injuries are idiopathic or personal conditions.

An idiopathic injury is "one that is 'peculiar to the individual: innate.'" *Taylor v. Contract Freighters, Inc.*, 315 S.W.3d 379, 381 (Mo. App., S.D. 2010) (quoting *Alexander v. D.L. Sitton Motor Lines*, 851 S.W.2d 525, 527 n.3 (Mo. banc 1993). This is an affirmative defense and the Employer must prove the injury was more likely than not, at least indirectly, due to an idiopathic cause. *Gleason v. Treasurer of the State of Missouri*, 455 S.W.3d 494, at 501-502 (Mo. App., W.D. 2015). Examples of idiopathic causes are seizures and diabetic conditions. *Ahern v. P&H, LLC*, 254 S.W.3d 129, 133 (Mo. App., E.D. 2008); *Crumpler v. Wal-Mart Assoc., Inc.*, 286 S.W.3d 270, 272-73 (Mo. App., S.D. 2009). Employee's expert, Dr. Schuman acknowledged Employee's diabetes is peculiar to him as an individual, an innate condition. (Exh. 12, p. 50).

Employee was in poor condition and ill for about two weeks prior to his accident on February 15, 2014. Employee testified that he had run out of his medication. He was failing to take both his Glipizide to control his diabetes and, most likely, other medication to treat his high blood pressure since he testified he only had a few days' worth of medications with him. He admitted that he felt bad enough that he had to rest in his truck the days before his February 7, 2014, visit to St. Mary's Regional Medical Center. After this emergency room visit, he remained in his truck for eight more days and was eating poorly. At one point, he required another truck driver to bring him food. Employee testified his symptoms were present on both February 7 and February 15, 2014, the day he began his trip back to Missouri and had the rollover accident.

As an endocrinologist, Dr. Daniels was the most persuasive and knowledgeable expert concerning Employee's diabetes. He has authored publications concerning diabetes, diabetic ketoacidosis, pathogenesis, and treatment of obesity. (Exh. 4, p. 26). Aside from his specialty as an endocrinologist, I find the opinion of Dr. Daniels most persuasive because he explained the impact of Employee's out-of-control diabetes combined with his failure to take his medication; the significance of his illness in the weeks prior to the rollover (dehydration, diarrhea, and inactivity); and how the low-impact rollover does not support the development of arterial thrombus.

Dr. Daniels testified concerning Employee's state of dehydration, explaining the excess urination from his St. Mary's Regional Medical Center and North Arkansas Regional Medical Center visits which led him to believe Employee was acidotic: "You wouldn't see excessive urination, so the key there is that he was urinating excessively and somebody who's dehydrated, you know, urine excretion decreases markedly. You only would have excessive urination in somebody who's dehydrated if the blood sugars were markedly elevated." (Exh. 4, pp. 38-39). In

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**Employee:** James K. Copeland

**Injury No.:** 14-009289

addition to the noncompliance with his medication, Dr. Daniels noted Employee's carbon dioxide level of 18 was below normal limits of 24 to 28. (Exh. 4, p. 13). This was another indication Employee was acidotic. (Exh. 4, p. 13). Dr. Daniels' opinion is supported by the medical records from Boone Hospital Center. Three days after the accident, those records note Employee was severely acidotic, secondary to diabetic ketoacidosis. (Exh. 3, pp. 211, 236).

Employee has a history of diabetes and cardiac issues (with a previous thrombus) which caused significant atherosclerosis in his arteries. This was well-documented in the pathology reports from the surgical procedures done while he was at Boone Hospital Center. Per Dr. Daniels, Employee was in diabetic ketoacidosis before the accident occurred, and this was because of the infection and his failure to take his diabetes medications. His condition deteriorated leading to the initial surgery on February 18, 2014, attempting to remove the thrombus from the upper leg, a second surgery on February 21, 2014, to remove the thrombus from his bowel, and a third surgery on March 3, 2014, to amputate his leg.

Dr. Daniels explained that Mr. Copeland's arterial thromboses developed from his underlying medical problems. These arterial blood clots developed in his right femoral and iliac arteries, the main arteries that supply blood to the lower extremity, and he lost blood flow to his leg. (Exh. D, pp. 18-19). According to Dr. Daniels, the records demonstrated no complaints of leg pain at the time of the emergency room visit just following the accident on February 15, 2014. Had Employee had trauma to the calf directly resulting in a hematoma, it would have happened right at the time of the accident and would certainly have resulted in him complaining of a lot of pain. No calf or leg pain was ever described or documented by the emergency responders or the emergency room providers. (Exh. D, pp. 53-54). Additionally, the history given by Employee on February 15, 2014, was that his tailbone was a little sore and his belly ached. He made no mention of acute leg pain.

Dr. Daniels testified that it is common to have a hematoma around a fracture site, but it is not reasonable to suggest a fracture could cause a blood clot in an artery or have anything to do with a thromboembolus. (Exh. D, p. 52). Hematoma is not in a blood vessel. It is outside a blood vessel, so it would not go into the blood vessel and cause an arterial thrombus such as what Employee had. (Exh. D, p. 52).

One of the leading problems identified per Doppler exam at Boone County Hospital was right to left cardiac shunt and atrial fibrillation, per Dr. Daniels. (Exh. D, pp. 19, 48-49). Atrial fibrillation is often intermittent; thus, it was likely not the first time Employee experienced atrial fibrillation. (Exh. D, pp. 19, 48-49). The pelvic fracture would not have caused a problem to his right to left shunt because the leg ischemia occurred shortly after the accident. This would not have been enough time to develop a deep vein thrombosis strictly as a result of the accident. The severe right lower extremity ischemia would not be caused by a sacral fracture. It was due to a thromboembolic phenomenon. It was from a blood clot that came from somewhere and stopped in the femoral and iliac artery. In his 40+ years, Dr. Daniels had never heard of a thromboembolism resulting from a pelvic fracture. (Exh. D, p. 31).

Dr. Daniels explained that Employee had a week of being sedentary and it is likely that was the mechanism of Employee developing the thromboembolism, the week prior to the

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Page 18

**Employee:** James K. Copeland

**Injury No.:** 14-009289

accident. The thromboembolism would have occurred because Employee was sedentary, his diabetes was out of control, he was dehydrated, and overweight. According to Dr. Daniels, all these things made Employee prone to blood clots. (Exh. D, p. 51). His problems appeared to be systemic because blood clots occurred in his mesenteric artery as well, requiring the removal of part of his small intestine.

I find that the evidence presented by Dr. Schuman is not persuasive, as he failed to adequately explain his findings and opinions. In his deposition, he mentions pancreatitis and severe abdominal trauma sustained in the accident as the cause of Employee's conditions. The medical records do not document a diagnosis of pancreatitis. No severe abdominal trauma was noted in the emergency room records.

Dr. Volarich is not persuasive as he merely concurs with the opinion of Dr. Schuman, without explanation and without having seen the opinions of Dr. Daniels. Additionally, Dr. Volarich's initial report mentions only the sacral fracture being caused by the rollover accident. He mentions the other diagnoses but did not address causation for those conditions in his initial report. I find his two reports to be inconsistent.

Employee is not the best historian. Discrepancies exist among his trial testimony, deposition testimony, and statements recorded by medical personnel in the records. At trial, Employee testified his main problem following the accident was a stomachache and right foot pain. He did not mention his tailbone. However, he told first responders that "his tailbone hurt, and that was all". He subsequently mentioned a belly ache. (Exh. 2, p. 7).

At trial, Employee testified he hit his right leg on the stick shift when he fell to the other side of the cab and had right foot pain. In his deposition taken just four months after the accident, there was no testimony concerning hitting the stick shift or having right foot or leg pain. In his deposition, he denied symptoms anywhere except his pelvis and stomach. Additionally, there are no references to Employee's leg striking the stick shift or any leg injury in the traffic report, the ambulance records, or the emergency room records.

Employee reported to Mr. Lalk that he hung from his seatbelt for a half hour. Employee's trial testimony was that he hung from the seatbelt for 15-20 minutes. In his deposition, Employee stated that once he released the seatbelt, he stood and waited for 15-20 minutes for the ambulance to arrive. The collision report documents the accident occurred at 7:11 p.m. The ambulance arrived at 7:29 p.m. and first responders found Employee already standing in his truck.

Employee's various statements concerning whether he stopped at the brake check were also inconsistent.

I do not find Employee to be particularly credible.

I find that the Employer/Insurer has met its burden to prove that Employee's injuries and conditions, other than the sacral fracture, are idiopathic in nature. I conclude the arterial

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Page 19

**Employee:** James K. Copeland

**Injury No.:** 14-009289

Thromboses and subsequent injuries which were treated at Boone Hospital Center and thereafter resulted directly or indirectly from an idiopathic cause and are, therefore, not compensable.

Having found that the accident was not the prevailing factor in causing Employee's arterial thromboses and subsequent injuries and conditions, the nature and extent of permanent disability for those conditions is moot and will not be addressed.

The only opinion regarding permanent disability to the pelvis/sacrum is from Dr. Volarich. I have found Dr. Volarich's two reports to be inconsistent since one assesses permanent partial disability only and the other merely agrees with Dr. Schuman's assessment of permanent total disability based on all of Employee's injuries and conditions. I note from Dr. Volarich's initial report that the physical examination did not contain any objective physical findings. He only noted "discomfort" when he palpated Employee's low back and sacral areas. This is a subjective finding. Employee himself told Dr. Volarich that, because he was bedridden due to the multiple other injuries, his tailbone fracture healed. Dr. Volarich went on to assess 22.5% BAW referable to the low back and pelvis which I do not find to be supported by the medical records. Additionally, Employee testified that he has no problems sleeping and no functional problems as it pertains to his pelvis fracture. He testified he gets "uncomfortable" if he sits or lays down too long. He is taking no medication for his pelvis/sacrum injury. I find that Employee sustained 2.5% PPD to the body as a whole as a result of the sacral fracture.

Having found that the accident was not the prevailing factor in causing Employee's arterial thromboses and subsequent injuries and conditions requiring multiple surgeries and the amputation of Employee's right leg, past temporary total, past medical, and future medical issues as it concerns these conditions, are moot. No benefits are awarded for medical or temporary total pertaining to the arterial thromboses and subsequent injuries and conditions.

Employee has met his burden to prove that medical treatment from the North Arkansas Regional Medical Center on the date of the accident is related to his pelvis/sacrum injury. Exhibit 11 contains bills from North Arkansas Regional Medical Center. Employee reviewed Exhibit 11 and testified it reflects the charges he has incurred for treatment. An award of past medical is appropriate when this type of testimony is accompanied by corresponding medical bills related to professional services rendered as shown within the medical records in evidence. *Martin v. Mid-America Farm Lines, Inc.,* 769 S.W. 2d 105, at 111-112 (Mo. banc 1989). I award Employee $9,440.60 for the medical bills from North Arkansas Regional Medical Center.

Employee is awarded $9,440.60 in medical expenses related to treatment received on February 15, 2014, at North Arkansas Regional Medical Center. Employee is awarded $3,576.80.

*WC-32-81 (6-81)*

*Page 20*

**Employee:** James K. Copeland

**Injury No.:** 14-009289

or 2.5% PPD to the body as a whole as it relates to his sacral fracture, for a total award of $13,017.40.

The compensation awarded Employee shall be subject to a lien in the amount of 25% of payments hereunder in favor of attorney Clare Behrle, for necessary legal services rendered.

I certify that on **6.2.21**, 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 **Angela**

**Made by:**

**Melodie A. Powell**

Administrative Law Judge

Division of Workers' Compensation