WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
Decision Number: 20180006
OBJECTING PARTY: Worker
REPRESENTED by: Representative
RESPONDENT: Employer
REPRESENTED by: Self
HEARING: Hearing in Writing
HEARD by: L. Cirillo, Appeals Resolution Officer
Dated: March 15, 2018
ISSUE
The worker objects to the Eligibility Adjudicator’s (EA’s) decision dated January 10, 2017 which denied initial entitlement for a cardiac impairment which occurred on September 29, 2016.
BACKGROUND
The employer reported that on September 29, 2016 the worker was in a room installing cross wires when a pound of cross wires fell from a wall and struck him on the head. The worker suffered a laceration, which was cleaned; however, he declined any additional medical help. Two hours later the worker approached the security station in obvious distress and collapsed. He was transported to the hospital via ambulance. The worker was 58 years of age at the time and had been working for the employer as a Technician for 29 years.
The Emergency Room (ER) reports outline the chief complaint as cardiac arrest and that the worker was resuscitated after one shock for ventricular fibrillation (VF). The worker also had a small laceration to the right scalp.
In her October 8, 2016 discharge report, Dr. Ipekian outlined the final diagnoses as:
VF arrest – non-ischemic
Non-obstructive Coronary Artery Disease (CAD)
Preserved left ventricular systolic function
Paroxysmal atrial fibrillation post arrest, with reversion to sinus rhythm
The file was referred to the WSIB Occupational Medical Consultant (OMC) in order to obtain an opinion on whether or not any of the diagnoses listed in Dr. Ipekian’s report were compatible with the accident history.
It was eventually concluded that the worker’s VF arrest was not compatible with the mechanism of injury and as a result initial entitlement was denied. The decision was communicated to the worker in correspondence dated January 10, 2017.
On the Appeal Readiness Form (ARF) dated September 19, 2017 the worker’s representative argued that there is a causal link between the head injury sustained while working and the cardiac event. She stated that further consideration should have been given on the basis of significant contributing factor and aggravation of a pre-existing condition. In order to support her position the representative submitted a medical report from Dr. Joyner, Cardiologist dated
September 14, 2017.
Following receipt of the new medical report the operating area reconsidered initial entitlement; however; ultimately determined that the new report did not satisfy the requirement that the head injury significantly contributed to the condition of VF arrest. As a result initial entitlement remained denied.
The worker’s representative objected to the denial of initial entitlement; however, the decision remained unchanged and as a result the matter was referred to the Appeals Services Division for further consideration.
Worker’s Position:
In correspondence dated February 2, 2018 the worker’s representative provides a claim background and maintains that an accident arose out of and in the course of the worker’s employment on September 29, 2016 which resulted in a VF arrest.
The representative submits that the preponderance of evidence supports a causal link between the incident when the worker was struck on the head by a suspended jump wire holder, and a few hours later going into cardiac arrest. The representative refutes the decision maker’s assertion that the blow to the head was of no consequence. She states that while the worker attempted to remain at work, it is evident, based on the information on file that the worker was in obvious distress and shortly thereafter collapsed.
The representative further states that the worker had had a previous Arterial Septic Defect (ASD) repair in 1991. She goes on to provide a general definition of the condition which she obtained from the internet. It is her position that the blow to the worker’s head precipitated the cardiac arrest and the fact that the worker had had a previous ASD repair is not a basis to deny the claim.
The representative submits that the reporting on record supports that the worker was feeling fine that day and his activities were of a person who was fully functional. In order to support her position she explains that she wrote to Dr. Joyner, the worker’s treating Cardiologist, and in his report dated September 14, 2017 he confirms that the worker has been his patient since May 2011. She argues that his comments are compelling and more relevant than those of the WSIB OMC.
The worker’s representative argues that the contemporaneous medical evidence supports that it is more likely than not that the blow to the head contributed to the escalating symptoms and ultimate cardiac arrest. She explains that while the head injury is not the sole contributing factor, in her view, it was a significant contributing factor.
In conclusion, she submits that based on the legal principles and well established doctrines of the “thin skull theory” and the “crumbling clause” [sic], an accident arose out of and in the course of the worker’s employment and that Dr. Joyner’s opinion should prevail over the general opinion of the OMC. For these reasons she requests that initial entitlement be allowed.
Employer’s Position
The employer completed the Respondent Form (RF) on November 24, 2017; however, did not provide any additional argument.
AUTHORITY
Operational Policy:
15-03-10 – Heart Conditions
ANALYSIS
I have reviewed the record and considered the information and relevant operational policy in reaching this decision. In considering all of the evidence, including the arguments presented I find there is no entitlement for the worker’s cardiac condition. The rationale for my decision is as follows.
WSIB Operational Policy 15-03-10 states in part:
The WSIB accepts claims as work related when:
a causal relationship is shown between the cardiac condition and an accident at work, or
the cardiac condition is established as a disablement "arising out of and in the course of employment."
The WSIB accepts entitlement for cardiac conditions under any of the following circumstances:
traumatic injury, either penetrating or non-penetrating injuries to the chest wall
electric shock producing irregular cardiac rhythm
inhalation of smoke and various noxious gases and fumes, e.g., fire fighters, and
complication of treatment for a work-related injury, e.g., anaesthesia with an interval of hypotension, hypoxia or cardiac arrest.
or
- unusual physical exertion for the individual and/or acute emotional stress with no significant delay in the onset of symptoms.
NOTE
This instance is allowed on the basis of aggravation of a pre-existing non-work-related condition.
As outlined above the worker sustained a head injury on September 29, 2016 when he was struck on the head by a suspended jump wire holder. A few hours later he went into cardiac arrest.
In reviewing the record I note Dr. Gladstone’s consultation report dated September 29, 2016 states the worker suffered a witnessed cardiac arrest, was resuscitated, and brought to the Intensive Care Unit (ICU). Electrocardiogram (ECG) revealed sinus rhythm with non-specific repolarization changes. The worker underwent coronary angiography and was found to have essentially normal coronary arteries. Left Ventricular (LV) function was essentially normal; however, he had had a previous ASD repair surgically. No ischemic causes were apparent for his cardiac arrest therefore, it was concluded that a defibrillator was necessary as a secondary precaution.
Dr. Amiralli’s consult report of October 7, 2016 describes the workplace accident and states that three hours later while still at work, the worker collapsed. The worker was noted to be in VF and required shock to return him to a supraventricular rhythm. A CT scan revealed no skull fracture and no evidence of intracranial haemorrhage or other problems. EKG initially showed changes suggestive of an acute coronary syndrome and global ischemia. Cardiac catheterization was performed and there was a 60% lesion in the first diagonal but no other abnormalities. LV function was normal. Given the resuscitated sudden cardiac death, a secondary prevention of Implanted Cardioverter Defibrillator (ICD) was arranged. The worker was discharged on
October 8, 2016 with a final diagnosis of VF arrest (non-ischemic), non-obstructive Coronary Artery Disease (CAD), preserved left ventricular function and paroxysmal atrial fibrillation post arrest, with reversion to sinus rhythm.
Dr. Ipekian’s discharge report dated October 8, 2016 also outlines the most responsible diagnosis as VF arrest. Another significant diagnosis was non-obstructive CAD.
It is my understanding that VF is a heart rhythm problem that occurs when the heart beats with rapid, erratic electrical impulses. This causes pumping chambers in your heart (the ventricles) to quiver uselessly, instead of pumping blood. Sometimes triggered by a heart attack, VF causes one’s blood pressure to plummet, cutting off blood supply to vital organs.
The cause of VF isn't always known. The most common cause is a problem in the electrical impulses traveling through one’s heart after a first heart attack or problems resulting from a scar in one’s heart's muscle tissue from a previous heart attack.
Factors that may increase the risk of VF include:
A previous episode of VF
A previous heart attack
A heart defect one is born with (congenital heart disease)
Heart muscle disease (cardiomyopathy)
Injuries that cause damage to the heart muscle, such as electrocution
Use of illegal drugs, such as cocaine or methamphetamine
Significant electrolyte abnormalities, such as with potassium or magnesium
The file was referred to the WSIB OMC who outlines that there are multiple risk factors for VF including congestive heart failure, prior myocardial infarction, hypertension, diabetes mellitus, excessive alcohol use, high cholesterol, obesity, positive family history, advancing age and other. He notes that there is fairly limited medical information on file pertaining to the worker’s past medical history; however, the available evidence indicates the worker is obese and had a remote ASD repair. He further opines that the accident details of September 29, 2016 suggest a minor injury when a 1 pound item fell and struck the worker on his head causing a small laceration. The OMC notes that while VF following a severe head injury has been reported in the past, the details in this case do not indicate a severe head injury. This was evidenced by the CT scan which did not reveal any skull fracture or intracranial haemorrhage or other problems. As a result the OMC opines that there is no compatibility between the head injury sustained while at work and the ultimate VF.
In response to the worker representative’s solicited request Dr. Joyner provided a report dated September 14, 2017. In that report he notes he has been treating the worker since May 2011. He explains that in 1991 the worker had surgical repair of a congenital defect, an ASD.
Dr. Joyner explains that it is not possible to be sure of the cause of the worker’s VF arrest. He states it is likely that the VF arrest was related to the head injury in the setting of his previous underlying structural heart disease with ASD repair and probable mild cardiomyopathy. He states that the timing of the arrest, several hours after the head injury makes it likely that the event was at least partially related to the head injury; however, there is no test that is able to answer that question definitively. Dr. Joyner further states that the accident did not aggravate the worker’s pre-existing heart disease.
While I acknowledge the arguments presented by the worker’s representative in that the head injury was a significant contributing factor in the development of the worker’s VF arrest and that the condition arose out of and in the course of the worker’s employment, I respectfully disagree.
I must rely on operational policy 15-03-10 which specifically states that entitlement can be accepted if there was a traumatic injury, either penetrating or non-penetrating injuries to the chest wall, electric shock producing irregular cardiac rhythm or unusual physical exertion for the individual and/or acute emotional stress with no significant delay in the onset of symptoms. This instance is allowed on the basis of an aggravation of a pre-existing non-work-related condition.
In considering the information, while there is evidence that a head injury occurred on
September 29, 2016, while in the course of the worker’s employment, I am in agreement with the OMC in that this was only a mild injury. This is supported by the fact that there was no skull fracture or intracranial haemorrhage. In addition, there is no evidence which suggests that this injury caused a direct injury to the chest or produced an irregular cardiac rhythm. Instead the medical literature supports that the factors that may increase the risk of VF include heart defects that one is born with, as is the case in this claim.
While I acknowledge the opinion expressed by Dr. Joyner in his report of September 14, 2017, he does not provide any objective evidence to support his statement that the timing of the arrest makes it likely that the event was at least partially related to the head injury. In fact the Cardiologist explains, that it is not possible to be sure of the cause of the worker’s VF and that there is no test that will be able to answer this question definitively.
In my view, the file evidence outlines that although the worker’s heart condition occurred while he was performing his regular work, there was no injury which would have precipitated the VF arrest that satisfies the entitlement criteria outlined in operational policy 15-03-10.
In weighing the evidence, I find that the preponderance of evidence supports a finding that the worker’s heart condition did not arise from his employment, and that it is more probable that the worker’s employment did not cause or significantly contribute to the heart condition.
As a result I find that on the balance of probabilities, the worker’s heart condition did not arise out of his employment and as a result there is no entitlement in this claim.
CONCLUSION
I conclude the worker does not have initial entitlement to benefits for a cardiac condition which occurred on September 29, 2016.
The worker’s objection is therefore, denied.
DATED March 5, 2018
L. Cirillo
Appeals Resolution Officer
Appeals Services Division