WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20100013
OBJECTION BY: Worker
EMPLOYER: Participating
REPRESENTATIVES: Worker, Employer
HEARING DATE: November 27, 2009
ATTENDEES: Worker, Worker Representative, Employer, Observers
ISSUES
Entitlement to benefits for psychotraumatic disability
100 per cent loss of earnings (LOE) benefits from August 8, 2007
HOW THE ISSUES ARISE
The worker was a registered nurse for a community nursing agency. Her job duties involve providing nursing care for clients in the community. On March 14, 2006, while driving to a client’s home she encountered a sudden onset of white out conditions and due to poor visibility, a tractor trailer truck struck her pickup truck from behind. She went off the road into a ditch on the opposite side of the road and her vehicle was totally damaged. She sought immediate medical attention and was diagnosed with soft tissue injuries involving her left neck, right buttock, low back and chest. The claim was allowed and the worker received LOE benefits from March 15, 2006 to March 27, 2006.
The worker was involved in another motor vehicle accident (MVA) on July 18, 2007 while
on vacation. The worker developed a psychological condition and stopped work as of
August 8, 2007. She claimed the psychological condition was related to the work-related MVA
of March 14, 2006 and requested lost time benefits from August 8, 2007.
As outlined in a letter dated November 6, 2007, the case manager denied further entitlement based on the following reasons. The worker managed to continue working doing her regular job which involved driving, until August 8, 2007. At that point, she informed the employer she was unable to work due to a number of stressful events which occurred over the previous months including an MVA that happened while on vacation in July 2007. The employer was unaware of ongoing stress issues related to the work-related MVA of March 2006. Two co-workers who the worker felt could confirm she had ongoing issues related to stress did not provide the case manger with any information. Finally, the worker did not seek medical attention for stress and did not stop work until after the non-work-related MVA of July 2007. Consequently, the case manager denied entitlement for Traumatic Mental Stress and benefits for the lost time from August 2007.
The worker representative objected to the case manager’s decision of November 6, 2007 and the matter was referred to the Appeals Branch for further consideration.
Based on a preliminary review of the case record, I returned the claim file to the case manager to conduct further enquiries. Since the worker sustained physical injuries as a result of the
work-related MVA of March 2006, I directed the case manager to make a decision on entitlement to benefits for a psychotraumatic disability.
The case manager gathered additional information through a Workplace Safety and Insurance Board (WSIB) field investigation and reconsidered the previous decision based on new information obtained. As outlined in a letter dated February 12, 2009, the case manager denied entitlement to benefits for a psychotraumatic disability because the worker did not seek professional treatment and did not miss any time from work because of stress until after the
non-work-related MVA of July 2007.
The worker representative proceeded with the worker’s objection and the matter was returned to the Appeals Branch for further consideration.
AUTHORITY
15-04-02 Psychotraumatic Disability
15-03-01 Recurrences
EXHIBITS
#1 - Post Traumatic Stress Disorder - Discussion Paper prepared for the Workplace Safety and Insurance Appeals Tribunal May 2002 – by Dr. Diane Whitney
#2 - Global Assessment of Functioning
#3 - Five colour photograph’s of the worker’s pick up truck following the work related MVA of March 14, 2006
#4 - Three colour photograph’s of the worker’s vehicle following the non work related MVA of July 18, 2007
ASSESSMENT OF THE EVIDENCE
I reviewed the case record, the worker’s testimony, and the worker representative oral and written submissions, and I have taken into account relevant WSIB operational policies. In reaching a decision I considered all the evidence, but in particular the following.
Evidence Surrounding March 14, 2006 Workplace Incident:
The worker testified in detail about the work related MVA of March 14, 2006. She was driving a pickup truck in a rural area on County Road 3 on her way to a client’s home. She was travelling at a speed of about 30 kilometres because of the bad weather conditions. She suddenly encountered a white out situation so she slowed down further. As she was making a right turn onto a street, she was struck from behind by a tractor trailer truck. She thinks the driver did not see her vehicle because of the white out situation. She turned the steering wheel in order to avoid hitting a pole and went off the road into a ditch on the opposite side of the road. Her truck was totally damaged. (Exhibit #3) She stated she could not exit her truck on her own so the driver of the tractor trailer helped her out.
The worker was off work from March 15, 2006 to March 27, 2006 because of the soft tissue injuries she sustained. She testified that over time her physical injuries resolved.
Continuity March 27, 2006 to August 8, 2007:
The worker testified she performed her regular duties between March 2006 and August 2007 with difficulty. Depending on her caseload she visited about 3 to 4 clients a day, but on a busy day she visited 10 to 11 clients.
The worker testified since the March 2006 MVA she is afraid of driving, in particular driving long distances in inclement weather. In January 2009 she told a WSIB investigator that during poor weather conditions she took advantage of the VON policy on poor weather and did not go out on calls but instead contacted her clients and advised them she would not be travelling in the poor weather conditions.
The worker testified about the difficulties she has had when driving. When she returned to work on March 28, 2006, she cancelled 5 appointments with clients because she was afraid of driving too far. She described an incident occurring in the winter of 2006 or 2007 where she was on her way home from work. She was in the Sauble Beach area and encountered a snow squall. She pulled over, became sick and wet herself. She called her husband and he talked to her over the telephone all the way home. She stated that sometimes on the weekends if there was bad weather her husband would drive her to her appointments and he would wait for her in the car. She described having difficulties when encountering trucks on the road or if there was poor visibility or weather conditions. In January 2009 the worker told a WSIB investigator that after the work-related MVA of March 2006 she avoided the portion of County Road 3 where the MVA happened and she took alternate routes instead.
The worker indicated that since the work-related MVA of March 2006, she had problems with her palliative care patients. She told the WSIB investigator that she got to know them well and got close to them. After the March 2006 MVA, she started having trouble visiting the homes of these people and would tend to drive around the block several times to “work up” the courage to go in to treat them. She explained this was never a problem for her prior to March 14, 2006.
The worker testified she started having nightmares about the work related March 2006 MVA soon after it happened, almost every night. She had nightmares about her palliative patients being in the vehicle with her. She was not sleeping well so she started taking Gravol to help her sleep. During this time, she initially started to diet to a certain extent because of concerns about a diabetic condition; however, she lost 70 to 74 pounds and her family physician became concerned about the amount of weight loss. The worker related this weight loss to her stress and lack of appetite because of it.
The employer submitted an Employer’s Continuity Report and letter dated September 21, 2007 stating the worker returned to work on March 27, 2006 with no functional limitations or required accommodations. She experienced occasional absences from work between March 2006 and August 2007 and requested time off to deal with personal circumstances. On August 8, 2007 the worker called a supervisor at VON explaining she was unable to complete her assignment and that she had experienced an episode that led her to seek care from her physician. She said she had a number of stressful events over the past months and recently she had been involved in an accident while travelling for personal reasons.
The worker explained she did not complain to the employer about her difficulties because she did not want to appear “wimpy” and was also embarrassed. She recalled on one occasion in May 2007 she told her supervisor DA that she was having a lot of trouble driving. She also told her that on one occasion she was caught in a snow squall and that she panicked and wet herself.
The WSIB investigator was unable to interview the worker’s supervisor DA because she was longer employed with VON. He interviewed two co-workers. Co-worker AH stated the worker was an anxious driver before the incident with the truck. She thought the worker was clearly more anxious about driving after the March 2006 MVA and in fact AH noticed the difference. AH explained that prior to the March 2006 MVA, whenever there were poor weather conditions, the worker was usually one of the first ones to call in to advise that she was cancelling her appointments. After the March 14, 2006 incident the worker seemed to cancel even more appointments than she had previously and seemed to even cancel them when there were just minor snow flurries. For this reason AH felt the worker was clearly more anxious about driving. She recalled that after the March 2006 MVA she would occasionally offer to drive the worker to some team meetings if the weather conditions were poor, as she knew the worker would not attend due to her fear of driving. During one particular occasion when AH was driving the worker to a team meeting, there were fairly severe snow flurries and whiteouts and the worker was so terribly nervous that “she nearly wet herself”. AH suggested to the worker that she should seek treatment for what AH described as a “post traumatic stress problem.” AH confirmed that during their drive together on the day they went to that particular team meeting, the worker mentioned to her that she was experiencing anxiety while driving.
The WSIB investigator interviewed another co-worker JM. She was aware of the worker’s MVA in March 2006. She recalled one occasion after this MVA the worker mentioned that she and her husband were going to travel to Vancouver and she was not keen about driving on the mountain roads. Other than that she could not recollect any complaints from the worker with respect to fear of driving or bad weather.
The family physician submitted hand written clinical notes (difficult to read) which show that between March 27, 2006 and August 8, 2007, he saw the worker on 12 occasions; April 26, 2006, May 3, 2006, July 11, 2006, August 2, 2006, August 15, 2006, September 19, 2006, October 4, 2006, January 3, 2007, January 8, 2007, June 6, 2007, July 11, 2007 and August 8, 2007. Out of these 12 visits, the worker complained of stress/anxiety on 4 occasions; August 2, 2006, June 6, 2007, July 11, 2007 and August 8, 2007.
In a letter dated October 31, 2007, the family physician explained he saw the worker on April 26, 2006 – he noted she was still shaken after the MVA in March 2006. On July 11, 2007 she requested a prescription for a mild tranquilizer in anticipation of a motor vehicle trip she and her husband were planning on taking, as she was still feeling anxious whenever she was in a vehicle, following the MVA in March 2006.
The worker testified she did not complain to her family physician about the trouble she was experiencing with nightmares and sleeping because she did not want him to think less of her as a medical professional. She did not want him to think she could not assist her patients because of psychological problems. However her weight loss became a concern and she eventually told him she was not sleeping well and had trouble driving.
The worker testified she went to a hospital emergency room for panic attacks. She recalled going on one occasion prior to her layoff from work in August 2007 and two other visits after August 2007. However, there are no medical records on file indicating the worker sought medical attention at a hospital emergency room for stress related symptoms between
March 27, 2006 and August 8, 2007.
In January 2009 the worker informed a WSIB investigator that between March 27, 2006 and August 8, 2007, she experienced some stressful events. Her mother in law passed away in February 2007 after a prolonged battle with cancer. She took one week off after that to deal with her grief. Her father-in-law had a stroke about a week before her mother in law passed away and although he was in hospital for a time, he did not survive. She admitted there was a certain amount of stress from these incidents as there would be for anyone who loses a family member or whose family member has a serious illness.
The worker testified about the non work related MVA occurring on July 18, 2007. Her husband was driving and she was a passenger. They were driving on Highway 401 in rainy weather. The car in front of their vehicle suddenly stopped and they struck it. She described it as a fender bender. There were minor damages. (Exhibit # 4)
Medical Evidence:
The family physician submitted a Health Professional’s Report dated September 18, 2007.
He noted the worker was involved in 1 MVA in 2006 and 1 MVA in 2007. She came in on August 8, 2007 after “not being able to remember who she saw in the AM and could not start I.V. Petrified to drive.” He suspected she had post-traumatic stress disorder.
A WSIB Nurse Case Manager (NCM) referred the worker to a psychiatric assessment with
Dr. D. A. Jones. The assessment was completed on September 19, 2007. Among other things, he provided a detailed account of the March 2006 work-related MVA. He noted after the first MVA the worker had difficulty with anxiety while driving initially but she was able to manage her anxiety enough to drive to work. He also provided an account of the non-work-related MVA of July 2007 while the worker and her husband were travelling out west. Dr. Jones indicated the worker reported increasing levels of anxiety as they drove west, until her levels of anxiety became severe while driving on the mountain roads in British Columbia. She found that her anxiety was re-triggered by frequent sounds of transport trucks when they were sleeping in their trailer at nights and she began having frequent panic attacks. She reported attempting to return to work two days after their return from British Columbia and her symptoms were manageable while she remained in Port Elgin. However her symptoms escalated on August 8, 2007 when she attempted to drive outside of town on the highway and she found herself unable to drive after managing to get herself to her physician’s office without remembering how she got there...Based on the results, he diagnosed Axis I; Post traumatic Stress Disorder, Axis II: no diagnosis (some dependant and obsessive-compulsive personality features noted) Axis III: none, Axis IV: Occupational Problem (unable to work due to PTSD symptoms).
In a letter dated May 21, 2008, the psychiatrist Dr. Jones answered questions posed by the worker representative in a letter dated May 8, 2008.
Question 1: What was the worker’s current diagnosis under the DSM-IV? Dr. Jones responded, the worker was experiencing significant symptoms and meets DSM-IV criteria for a diagnosis of post traumatic stress disorder.
Question 2: What was her GAF score currently? Dr. Jones responded the worker’s current GAF score was only 46, which is virtually unchanged from her initial GAF score of 45 at the time of her initial assessment on September 19, 2007.
Question 3: Is her condition permanent or temporary? Dr. Jones responded her condition is temporary since her symptoms should respond to appropriate psychological treatment of PTSD.
Question 4: Are you of the opinion that she is currently working full or part-time? If not, are you able to indicate a potential timeline for return to work? Dr. Jones indicated because the worker continued to experience high levels of anxiety when travelling in vehicles further than a few blocks from her home, she was currently unable to work either part-time or full-time, since she is required to travel by vehicle as a requirement of her employment. Since she did not receive treatment initially, and since she had continued to experience anxiety when driving or riding as a passenger, he thought she would continue to require more treatment than he originally anticipated. He did not anticipate that she would be ready to return to work before autumn 2008, even if she received treatment over the summer. He anticipated that 15 to 20 treatment sessions would be necessary to reduce her symptoms.
Question 5: What restrictions would you suggest be appropriate given her current level of functioning? Dr. Jones responded, the worker was not to drive a vehicle or return to work until her symptoms have been reduced to a level where the risk of retriggering trauma is substantially reduced. She was at great risk of having her symptoms become worse if she experienced another related trauma.
Question 6: What is the cause of her psychological condition (PTSD if it applies) and does it, or how does it relate to her workplace accident in March 2006?
Dr. Jones responded, although the worker returned to work shortly after her March 2006 MVA, she had reported that she was experiencing some anxiety when driving and working but was able to keep that anxiety within manageable limits. However, due to the sudden and violent nature of the MVA, her nervous system became sensitized to stimuli related to driving, accidents, or storms, and she became extremely vulnerable to being re-traumatized by any stimulus related in any way to any aspect of the March 2006 MVA. Thus, the March 2006 MVA (which occurred while performing the duties of her employment) left her highly predisposed to being re-traumatized by almost any MVA related stimulus regardless of the degree of severity. In other words, her March 2006 MVA left her extremely vulnerable to being re-traumatized by a seemingly insignificant stimulus, such as the very minor “fender bender” experienced by her family while on vacation, which could be considered “the straw that broke the camel’s back” in this situation. The March 2006 MVA is the major contributor to her PTSD symptoms while the subsequent minor MVA in the summer of 2007 was a seemingly insignificant event that re-traumatized her and triggered and reinforced (strengthened) the massive PTSD fear reaction over the course of her road trip to B. C. in the summer of 2007.
Question 7: Is it possible, and if so how, that the worker was able to work from March 2006 to August 2007 without medical or psychological attention if she has/had PTSD? That is, can you explain the delay in the traumatic event of the March 2006 accident and the onset of her symptoms in August 2007, which prevented her from working? Dr. Jones responded as noted above, the worker was sensitized by the March 2006 MVA but not affected quite severely enough that she could not manage her symptoms. Furthermore, she was not aware of the dangerously predisposed condition she was in, nor that a relatively minor MVA related stimulus could trigger a massive PTSD response, nor that she should receive immediate treatment to prevent having a major PTSD response. She did the best she could at managing her symptoms during this period of time, as most responsible employees would do in similar circumstances. The delay in symptom onset is simply explained by the amount of time elapsed between the original major trauma in March 2006 and the final re-triggering of that trauma in August 2007 when the proper conditions for triggering a full-blown PTSD episode occurred.
Question 8: Are there contributing factors to her condition that are work related, and if so, how are they related? For example, her nursing duties with palliative care patients and the necessity of driving from patient to patient, often out of town. Dr. Jones responded, obviously any driving related stimulus is a trigger of
post-traumatic symptoms of fear of dying in an accident. However, there is a more subtle, but insidious, fear present as well. The worker major fear of being hurt or dying is of being separated from her family (death being the ultimate form of separation.) After her March 2006 MVA she became much more sensitive to seeing patients who were dying, as it became a stimulus that represented separation from family, and which triggered her own anxiety that was related to her near-death experience in the March 2006 MVA, and her own heightened fear of separation from loved ones. Although less obvious, the worker’s intense fear of separation from loved ones is the major underlying fear that was triggered by the series of MVAs beginning with her major MVA in March 2006 and this fear was being triggered regularly when she was working with patients who were dying.
Question 9: The WSIB has concluded, in its decision of November 6, 2007, that there was “no evidence that the worker had a traumatic response or reaction to the accident of March 2006”. The WSIB then related her inability to work to the July 2007 MVA. Do you concur with this assessment and what is your rationale for your opinion? Dr. Jones responded, the WSIB decision is based on an incomplete understanding of the nature of PTSD, and the types of circumstances that can either pre-dispose people to later trauma or trigger an acute or post traumatic stress response. It is therefore, in error because it is based on the erroneous assumption that the worker should display significant PTSD symptoms immediately after the March 2006 MVA, if it was the source of her PTSD symptoms. The WSIB decision is incorrect because it does not take into account the manner in which her March 2006 MVA sensitized her nervous symptom, predisposing her to future trauma and making her “an accident waiting to happen” when she was exposed to any sort of MVA related trauma, as happened the following summer in August 2007.
In a letter dated July 30, 2008, Dr. Jones stated he was treating the worker for severe symptoms of post traumatic stress disorder (PTSD) which she continued to experience as a direct result of a motor vehicle accident she sustained in the course of her workplace duties. She continued to receive treatment for her symptoms but still required a great deal more treatment before she would be ready to return to work. Therefore he was unable to provide a return to work date at this time...
In a letter dated September 9, 2009, Dr. Jones indicated he was providing psychological treatment to the worker for symptoms of post traumatic stress disorder (PTSD). She continued to suffer from significant symptoms of PTSD which are directly related to a motor vehicle accident in which she was involved while performing the duties of her employment. Dr. Jones saw her for one treatment session per month (far less than adequate) as the worker was paying for treatment with limited funding from her husband’s extended health care benefits or at her own expense. He stated the worker’s improvement would continue to be slow until such time as she has adequate funding for more frequent treatment. He did not expect her to be returning to work within the foreseeable future.
In a letter dated September 23, 2009 to the medical adjudicator (Service Canada), Dr. Jones reiterated his opinion concerning the worker’s inability to return to work because of PTSD symptoms.
Worker Representative’s Main Argument:
The worker representative provided extensive closing oral submissions. She noted the worker did not have psychological symptoms prior to the March 2006 MVA. She had 25 years experience as a nurse and was able to perform her full nursing duties with no difficulties prior to the work related March 2006 MVA. The worker representative noted the worker had difficulties after the March 2006 MVA with driving and caring for her palliative patients. She also noted a co-worker was aware of the worker’s increased anxiety with driving after the March 2006 MVA. She referenced Dr. Jones’ medical opinion which supported their position that the worker’s PTSD symptoms were related the significant work related March 2006 MVA which left her vulnerable to re-trauma. She noted the worker experienced a series of events occurring between March 2006 and August 2007 such as; the death of her mother and father in law and a minor non work related MVA in July 2007 however these events were triggers causing re-traumatization but the work related March 2006 MVA was the major contributor to her PTSD symptoms.
Analysis/Decision:
In summary, I note the following evidence;
There is no medical evidence indicating the worker suffered from PTSD symptoms or other psychological condition(s) prior to the work related MVA of March 14, 2006.
Although the worker did not sustain any serious physical injuries as a result of the work related MVA of March 14, 2006, the incident itself was traumatic in nature noting that while driving in inclement weather the worker suddenly encountered a white out situation and was rear ended by a tractor trailer truck. She went off the road into a ditch on the opposite side of the road. Her truck was totally damaged and she needed assistance in existing the vehicle.
Although the worker performed her regular duties as a community nurse between March 27, 2006 and August 8, 2007, there is some evidence suggesting the effects of the work related MVA of March 14, 2006 caused the worker to experience anxiety while driving especially in bad weather, she had difficulty caring for palliative clients (did not have this problem before), she had trouble sleeping and she lost about 75 pounds some of which she related to stress and this became a medical concern. One co-worker confirmed the worker was clearly more anxious about driving since the work related MVA of March 2006. Another co-worker confirmed that on one occasion, the worker mentioned to her she was anxious about driving on mountain roads in an upcoming vacation. The worker sought medical attention for stress related issues on only a few occasions during the 18 month period following the work related MVA of March 2006. The worker’s family physician confirmed that on July 11, 2007 he prescribed the worker a mild tranquillizer in anticipation of a motor vehicle trip she and her husband were planning on taking as she was still feeling anxious when she was in a vehicle since the work related MVA of March 2006. This evidence demonstrates the fact the worker was experiencing anxiety symptoms after the traumatic work-related MVA of March 2006 but before the minor non-work-related MVA of July 2007.
The WSIB made arrangements for the worker to be assessed by a psychologist
Dr. Jones. As detailed in a report dated May 21, 2008, he describes the work-related MVA of March 2006 and the events leading up to the worker’s layoff on
August 8, 2007. He clearly supports medical compatibility between the traumatic work-related MVA of March 2006 and the diagnosis of PTSD which the worker was diagnosed with after she stopped working on August 8, 2007. There are no medical opinions on file which contradict Dr. Jones’ opinion.
- Dr. Jones has treated the worker since the initial assessment in September 2007. Based on his most recent report of September 23, 2009 he still considered her totally impaired and unable to resume any kind of work because of her psychological state.
Based on the evidence on record and in accepting Dr. Jones’ medical opinion, I am satisfied the traumatic work related MVA of March 2006 was a significant contributing factor to the development of PTSD diagnosed in August 2007. The worker is entitled to 100 per cent LOE benefits from August 8, 2007 when she stopped working because of PTSD. 100 per cent LOE benefits are to be paid to September 23, 2009 as Dr. Jones has submitted reports; the most recent dated September 23, 2009 indicating the worker has been incapable of returning to work in any capacity because of her psychological condition. The worker has co-operated in the prescribed healthcare measures, consisting of monthly therapy sessions with Dr. Jones.
CONCLUSION
For reasons outlined above, entitlement to benefits is granted for a psychotraumatic disability. In addition, 100 per cent LOE benefits are granted from August 8, 2007 to September 23, 2009.
The case manager is to obtain updated medical information concerning the worker’s psychological condition and is to decide on the level and duration of additional benefits including whether the worker has a permanent psychological impairment.
The worker’s objection is granted.
DATED February 8, 2010
F. Pansino
Appeals Resolution Officer
Appeals Branch