Papco Oil Company, et al. v William Kenneth Farr

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COURT OF APPEALS OF VIRGINIA

Present: Judges Benton, Bray and Senior Judge Hodges
Argued at Norfolk, Virginia

PAPCO OIL COMPANY AND
LIBERTY MUTUAL INSURANCE COMPANY
OPINION BY
Vv. Record No. 0989-97-1 JUDGE WILLIAM H. HODGES
NOVEMBER 18, 1997
WILLIAM KENNETH FARR
FROM THE VIRGINIA WORKERS!' COMPENSATION COMMISSION

Bradford C. Jacob (Taylor & Walker, on
brief), for appellants.

Ralph Rabinowitz (Rabinowitz, Rafal, Swartz,

Taliaferro & Gilbert, on brief), for
appellee.

Papco Oil Company and its insurer (hereinafter referred to
as "employer") appeal a decision of the Workers' Compensation
Commission (commission) holding employer responsible for the cost
of certain medical expenses incurred by William Farr (claimant).

Employer contends that the commission erred in finding it
responsible for the cost of claimant's (1) June 26, 1994 through
July 5, 1994 and September 19, 1994 through September 27, 1994
medical treatment related to claimant's idiopathic
thrombocytopenia (ITP); (2) January 30, 1995 through
February 8, 1995 medical treatment related to his deep venous

thrombophlebitis (DVT)* and pulmonary embolism; (3) May 16, 1995

‘Thrombocytopenia is the decrease in the number of blood
platelets. See Dorland's Medical Dictionary, 27th Edition.

‘Thrombophlebitis is the inflammation of a vein associated
with thrombus formation, i.e., an aggregation of blood factors,
primarily platelets and fibrin with entrapment of cellular

2
through May 24, 1995 medical treatment related to his DVT and
pulmonary embolism; and (4) coumadin therapy. 	Finding no error,
we affirm the commission's decision.
Facts
On March 7, 1994, claimant sustained a compensable back
injury.3 On April 1, 1994, claimant underwent lumbar disc
surgery causally related to his compensable injury. 	In June,
1994, claimant was scheduled for a second back surgery. 	During a
routine work-up prior to that surgery, claimant's physicians
found that he suffered from ITP. 	On June 22, 1994, Dr. Robert L.
Burger examined claimant with regard to his ITP. 	On June 30,
1994, Dr. Burger admitted claimant to the hospital to undergo
treatment for his ITP. 	On claimant's history and physical form,
Dr. Burger noted that "claimant had been told by Dr. Messer, the
orthopedic surgeon, that the platelet situation needed to be
clarified before surgery." 	In a July 5, 1994 discharge summary,
Dr. Burger noted that claimant's platelet count had increased
from 15,000 to 210,000 after infusion of intravenous
gammaglobulin. 	Dr. Burger opined that claimant could proceed
with surgery.
elements causing vascular obstruction at the point of its
formation. 	See Dorland's Medical Dictionary, 27th Edition.
3
The full commission refused to consider any medical evidence
filed by claimant with the commission after the February 8, 1996
hearing. 	Claimant did not appeal this ruling. 	Accordingly, on
appeal, we did not consider any medical records filed with the
commission after February 8, 1996.

3
On July 23, 1994, claimant underwent his second back
surgery. 	Claimant was discharged from the hospital on July 24,
1994. 	Three to four days after discharge, claimant developed
right-sided chest pain.
On August 19, 1994, claimant was again admitted to the
hospital for treatment of pleural effusion and ITP. 	He remained
in the hospital until August 27, 1994. 	On August 19, 1994,
Dr. Chantal Brooks became claimant's treating physician.
On September 19, 1994, claimant was admitted to the hospital
for treatment of his ITP before his third back surgery. 	After
physicians corrected claimant's platelet count, he underwent his
third back surgery in September, 1994.
After claimant's third back surgery, he developed DVT, which
required hospital treatment from January 30, 1995 through
February 8, 1995. 	While in the hospital, claimant developed a
pulmonary embolism, a complication of his DVT.
On May 8, 1995, claimant underwent an elective splenectomy
to treat his ITP. 	Shortly after discharge from the hospital,
claimant was readmitted due to recurrent left lower extremity DVT
and pulmonary embolus.
In a letter dated June 12, 1995, Dr. Brooks summarized
claimant's medical treatment beginning August 19, 1994. 	Dr.
Brooks opined that the May, 1995 splenectomy markedly improved
claimant's platelet count. 	Dr. Brooks also noted the following:
[Claimant] returned to the office in
follow-up thereafter and was noted to become
again increasing thrombocytopenic. 	It was

4
elected therefore to start him on steroid
therapy in November of 1994 at which time his
platelet count was 20,000. 	In February of
1995, as a result of inactivity secondary to
the multiple lumbar surgeries and residual
low back pain and leg pain as well as the
Prednisone therapy, the patient had to be
admitted to Virginia Beach General Hospital
with deep venous thrombophlebitis of the left
lower extremity along with a pulmonary
embolus.
As of June 12, 1995, claimant remained on coumadin, an
anti-coagulant, to prevent pulmonary emboli that could be caused
by claimant's DVT.
On January 22, 1996, Dr. Lara L. Dimick, the surgeon who
performed claimant's splenectomy, opined that ITP's cause is
generally unknown. 	Dr. Dimick stated that she could not
determine exactly why claimant developed ITP. 	However, she
believed that it was "a definite possibility that [the ITP] could
be related to things that happened during his back surgery." 	On
January 31, 1996, Dr. Dimick wrote: 	"There is no way that we can
know whether [claimant] had [ITP] prior to his surgery or whether
this was a result from interventions that he received while he
was in the hospital for his original back surgery." 	Dr. Dimick
also opined:
I do not believe any physician could answer
your question of probabilities in this case.
However, given the fact that [claimant] was
healthy prior to his other surgeries and had
no clinical signs or symptoms of this disease
would certainly support the fact that he did
not have [ITP] earlier. 	I feel that it is
likely that he received some heparin flush
while he was in the hospital to flush out
intravenous lines. 	This would not
necessarily be documented in any records and

5
could possibly cause this disease process.
Therefore, all I can state with certainty is
that there is a possibility that [claimant's]
injuries were related to his hospital stay.
On March 20, 1996, Dr. Brooks wrote:
As clearly stated by Dr. Laura [sic] Dimick
from a strictly scientific standpoint, it is
impossible to say whether [claimant's]
injury on the job followed by his surgery
could in some way be responsible for his
[ITP] finally resulting in a splenectomy.
Clearly, there was no documentation prior to
the initial injury of the presence of any
thrombocytopenia, and it was only subsequent
to the surgery that this was clearly
documented and evaluated.
The injury and the surgery could have
aggravated a pre-existing condition; however,
I am unable to state this with certainty,
having no data with which to make this
suggestion.
I would have to therefore state that in my
opinion it is possible that the [ITP] that
finally resulted in a splenectomy was related
to the treatment or the aftermath of the
treatment that [claimant] received as a
result of his injury on the job.
On January 12, 1996, Dr. John C. Schaefer, who reviewed
claimant's medical records for employer, commented via letter
regarding Dr. Dimick's opinions. 	Dr. Schaefer noted that "[t]he
diagnosis of immune thrombocytopenia is often a primary event
without an apparent underlying disease. 	However, it can be
associated with among other things an underlying
immunoproliferative disorder, either malignant or non-malignant."
Dr. Schaefer also listed various other conditions and drugs,
including heparin, which might cause ITP. 	Dr. Schaefer did not

render his own opinion as to the cause of claimant's ITP.

7
Commission's Decision
The commission held that claimant failed to prove that his
compensable injury by accident or the treatment required for his
work-related back injury caused his ITP.4 However, because the
medical evidence proved that claimant's ITP had to be treated
before he could undergo the second and third back surgeries, the
commission held employer "liable for the cost of correcting, at
least temporarily, the ITP because this condition needed to be
resolved so that the work-related back injury could be treated by
surgery." 	In so ruling, the commission held employer responsible
for the cost of Dr. Burger's treatment, and the hospitalizations
on June 26, 1994, September 19, 1994, and September 26, 1994.
In addition, based upon Dr. Brooks' June 12, 1995 notes, the
commission held employer liable for the cost of the
hospitalization beginning on January 30, 1995 for treatment of
claimant's DVT and associated embolism and continued medical
treatment for same. 	The commission also held employer liable for
the May 16, 1995 through May 24, 1995 hospitalization on the
ground that it was precipitated by a recurrence of claimant's
DVT, which was initially caused by the work injury. 	Finally, the
commission held employer liable for claimant's coumadin therapy.
The commission did not hold employer liable for claimant's
hospitalization from August 19, 1994 through August 27, 1994,
finding that no medical evidence proved that this treatment for
4Claimant did not appeal this finding.

8
pleural effusion and ITP was causally related to the compensable
work injury.
Analysis
On appeal, we view the evidence in the light most favorable
to the prevailing party below. 	See Lynchburg Foundry Co. v.
Goad, 15 Va. App. 710, 712, 427 S.E.2d 215, 217 (1993). 	In
addition, the commission's factual findings will be upheld if
supported by credible evidence. 	See James v. Capitol Steel
Constr. Co., 8 Va. App. 512, 515, 382 S.E.2d 487, 488 (1989).
"However, the question of whether the disputed medical treatment
was necessary within the meaning of Code § 65.2-603 is a mixed
question of law and fact." 	Goad, 15 Va. App. at 712-13, 427
S.E.2d at 217. 	Accordingly, the commission's conclusions as to
the necessity of the disputed medical treatment are not binding
upon this Court. 	"However, both the purposes of the Workers'
Compensation Act and the equities of the situation guide us in
affirming the commission's award." 	Id. at 713, 427 S.E.2d at
217.
Code § 65.2-603(A)(1) provides in pertinent part as follows:
As long as necessary after an accident, the
employer shall furnish or cause to be
furnished, free of charge to the injured
employee, a physician . . . and such other
necessary medical attention.
"'So long as a causal relationship between the industrial
accident and the . . . [treatment rendered] is shown, the
employer is financially responsible for the medical attention

9
which the attending physician deems necessary, subject to review
by the Commission.'" 	Goad, 15 Va. App. at 714, 427 S.E.2d at
217-18 (quoting Jensen Press v. Ale, 1 Va. App. 153, 159, 336
S.E.2d 522, 525 (1985)). 	Moreover, Code § 65.2-603 should be
construed liberally in favor of the claimant, in harmony with the
Act's humane purpose. 	See Goad, 15 Va. App. at 713, 427 S.E.2d
at 217.
ITP Treatment
Credible medical evidence established that claimant's ITP
was diagnosed during medically necessary treatment of his
compensable back injury. 	To continue treatment of claimant's
back with further surgeries in July and September, 1994,
claimant's physicians required limited treatment of the ITP to
normalize his platelet count. 	Thus, treatment of the ITP was a
medically necessary adjunct to the successful completion of that
care required by claimant's work-related back injury.
Accordingly, under the facts of this case, the commission
did not err in holding employer responsible for Dr. Burger's
medical treatment and for medical expenses incurred by claimant
from June 26, 1994 through July 5, 1994 and from September 19,
1994 through September 27, 1994.
DVT and Pulmonary Embolic Treatment
Dr. Brooks' June 12, 1995 notes provide credible evidence to
support the commission's award of medical expenses incurred from
January 30, 1995 through February 8, 1995, and May 16, 1995

10
through May 24, 1995, for treatment of claimant's DVT and
pulmonary emboli. 	Dr. Brooks stated that in February 1995
claimant had to be hospitalized for DVT and pulmonary emboli as a
result of inactivity secondary to his multiple lumbar surgeries
and residual low back and leg pain. 	The May 1995 treatment was
necessitated by a recurrence of the DVT and pulmonary embolism,
which flowed from the compensable injury. 	Therefore, because the
DVT and pulmonary emboli followed as natural consequences of the
compensable back injury, the commission did not err in holding
employer responsible for medical expenses related to treatment of
those problems. 	See Morris v. Badger Powhatan/Figgie Int'l,
Inc., 3 Va. App. 276, 283, 348 S.E.2d 876, 879 (1986).
Even if claimant's prednisone therapy also contributed to
cause his DVT and pulmonary embolism, employer is still
responsible for the cost of medical treatment related to those
conditions under the "two causes rule." 	That rule provides that
a condition which has two causes, one related to a work injury,
and one not, is compensable and the treatment of that condition
will be the responsibility of the employer. 	See Shelton v. Ennis
Bus. Forms, Inc., 1 Va. App. 53, 55, 334 S.E.2d 297, 299 (1985).
Coumadin Therapy
The medical records established that Dr. Brooks prescribed
the coumadin therapy to prevent pulmonary emboli, which might be
caused by claimant's left lower extremity DVT. 	Because the DVT
flowed as a natural consequence of the compensable back injury,

11
employer is responsible for any necessary medical treatment
related to the DVT. 	Accordingly, the commission did not err in
holding employer responsible for the cost of the coumadin
therapy.
For these reasons, we affirm the commission's decision.
Affirmed.