APPEALS RESOLUTION OFFICER DECISION
DECISION Number: 20220130
OBJECTING PARTY: WORKER
REPRESENTED by: worker representative
RESPONDENT: EMPLOYER, NOT PARTICIPATING
REPRESENTED by: employer representative
HEARING: VIDEOCONFERENCE HEARING, OCTOBER 19, 2022
HEARD by: L. Diaz, Appeals Resolution Officer
ISSUE
The worker is objecting to the Adjudicator’s January 11, 2022 decision which denied entitlement to a basal ganglia haemorrhagic stroke under the claim.
BACKGROUND
On November 4, 2021, while employed as a Dispatcher, the worker was returning to their desk from filing t-cards and run sheets when they fell to the ground and struck their head on the tiled floor. Later that evening, after arriving home from work, the worker suffered a stroke and was taken to hospital by ambulance.
Following admission at hospital, the worker was found to have had an intracranial haemorrhage and had sustained a basal ganglia haemorrhagic stroke. The worker is claiming that their fall at work caused their stroke.
The worker’s file was then referred to an external Occupational Medical Consultant (OMC) with a specialty in Neurology. Their opinion is on file, and is dated January 10, 2022.
Adjudicator’s decision
Further to the January 11, 2022 Adjudicator’s decision, following review of the OMC’s opinion, it was concluded that the location of the haemorrhage would not have been caused due to trauma, and that uncontrolled hypertension and a complication of anticoagulant therapy was the cause of the haemorrhage which led to the right leg weakness and consequent fall. As a result, the Adjudicator concluded that they were unable to identify a causal connection between the fall at work and the development of the basal ganglia haemorrhagic stroke. Entitlement to a basal ganglia haemorrhagic stroke was therefore denied.
Worker’s and Employer’s positions
The worker’s representative argued that the worker’s fall at work caused a head injury which led to their stroke, and as a result, entitlement in the claim ought to be accepted for a basal ganglia haemorrhagic stroke. The employer’s representative argued that the decision to deny entitlement to benefits ought to be upheld. Their submissions will be reviewed in greater detail in the decision below.
AUTHORITY
Operational Policy Manual
Published
11-01-01, Adjudicative Process
November 3, 2008
11-01-02, Decision-Making
October 12, 2004
ANALYSIS
I find the worker does not have entitlement to a basal ganglia haemorrhagic stroke. In arriving at this decision, I had regard for the worker’s testimony, the arguments presented, the relevant file information, and the applicable Policy.
Worker’s testimony
The worker testified that they were in their early 60 and had completed one year of college in Business and Administration. Although the worker had been employed with their employer for seven months, they confirmed having worked in waste management for a number of years. Their job as a Dispatcher involved dispatching drivers, dealing with customers, doing run sheets, and other duties.
The worker confirmed that their prior medical history included having had a DVT (deep vein thrombosis), which resulted after their bilateral ankle fracture a number of years earlier. The worker confirmed they had been taking Coumadin, an anti-coagulant. The worker advised they were taken off Coumadin in December 2021, after their stroke.
Prior to their stroke, the worker stated they were in good health – they did not smoke, they were not diabetic, and they had no prior heart attacks or stroke. The worker advised that they did ambulate with two canes due to bilateral hip muscle tears/issues.
Prior to their fall, the worker confirmed they were feeling great, that they had no problems, apart from a fall at home when they twisted awkwardly due to their right hip problems.
On November 4, 2021, the worker indicated they had walked to the back to do run sheets. They recall that their cane slipped when they opened the door to the dispatch room on their return. The worker then walked back to the desk – they had one hand on the table (as they had placed their cane to the side), the other cane slipped, causing the worker to fall down and strike the back of their head on the tiled floor.
The worker was then asked about the Employer’s Report of Injury/Disease which indicated that their arms had given out – the worker denied this was the case, though they did confirm that in the past, on occasion, their legs might give out due to the problem with their hips.
The worker indicated they tried to call other staff for help, but were unsuccessful in reaching them. The worker then called their son, who arrived 45 minutes later and helped them off the floor. The worker completed their work shift. Following the incident, the worker advised they had a headache.
Approximately ½ hour after arriving home, the worker stated they started experiencing weakness in their left side and experienced left facial drooping. The worker advised they had not previously experienced these symptoms. They were taken to hospital by ambulance following which the worker reported having fallen earlier. The worker was told they had sustained a brain bleed that was caused by the fall and that the physician advised them it was at the same spot where the worker had struck their head on the floor.
The worker advised they were still bedridden and in physical therapy. The worker became extremely emotional and was clearly distressed, advising that they are trying to put their life back together again. The worker indicated their physician had not told them they were at risk for a stroke. The worker is currently in receipt of $xxxx per month in CPP disability benefits.
Upon questioning by the employer’s representative, the worker stated that they had not been tired prior to their fall, and that they had had no issues with their balance. The employer’s representative then referenced memo xx which documented information from the worker’s spouse. In the third paragraph, it is noted that the worker advised that prior to their fall they were in pain, were fatigued, lost their balance as their hip was painful and the hip gave out. The worker stated it had not happened in this manner. The worker advised that 4-5 weeks earlier, prior to their injury, they had sustained a fall at home in that manner.
I then asked the worker about Dr. Joo-Meng Soh’s November 4, 2021 medical report, and specifically, whether the worker recalled having had a left leg DVT 2 years prior to their ankle fracture – the worker testified that yes, they recalled the DVT.
I then advised the worker that I wished him to have the opportunity to respond to Dr. Joo-Meng Soh’s November 5, 2021 report which indicated on page 2 that “He was certain that his fall at work was due to his right leg giving out” and Dr. Saqqur’s November 5, 2021 report which stated “He relayed the events leading to this admission – states he was at work, his left leg gave out causing him to fall. He states he hit the back of his head on the floor and phoned his son to help him off the floor as he was unable to get in contact with his boss”. The worker denied these accident histories and indicated he had relayed to the health professionals what had occurred.
Analysis
Policy 11-01-01, Adjudicative Process, records the following in part:
All decision-makers use the same criteria for ruling on initial entitlement to WSIB benefits. This system is known as the "five point check system."
An allowable claim must have the following five points
an employer (see 12-01-01, Who is an Employer?)
a worker (see 12-02-01, Workers and Independent Operators)
personal work-related injury
proof of accident, and
compatibility of diagnosis to accident or disablement history.
In reviewing the above points for an allowable claim, it is clear that the first two points have been established, as there is an employer and a worker. In light of the fact that the worker is claiming that their basal ganglia haemorrhagic stroke is work-related, it is necessary review the fifth criterion first, i.e. whether the worker’s diagnosis is compatible with their accident history.
There does not appear to be any dispute as to whether the worker fell at work – the overwhelming information supports that they fell. However, there appears to be some disagreement with respect to the cause of the fall. As a result, I therefore reviewed all pertinent medical reports with respect to this issue and with respect to the cause of their stroke.
The worker was assessed by Dr. Joo-Meng Soh, Internal Medicine Specialist, at the hospital who recorded that the worker’s past medical history was significant for a pulmonary embolism 15 years earlier following an ankle fracture repair. However, two years prior to that, the worker had a left leg DVT which was felt to be unprovoked. The worker had been on lifelong Coumadin since their pulmonary embolism. The worker also had issues with their right hip and knee. Apart from these medical issues, the worker reported they were otherwise healthy, with no prior history of diabetes, hypertension, heart disease, and they did not smoke.
Dr. Joo-Meng Soh documented the worker reported working as a Dispatcher for a garbage company. The worker was at work alone, when their right leg gave out and they fell, striking the back of their head on the tiled floor. The worker then called their son to help them up. The worker was at home when they developed left leg weakness as well as slurred speech, following which they were brought to hospital by EMS. The worker had a headache and presented with blood pressure of 230/90. Examination revealed left-sided facial droop and weakness, with slurred speech. CT scan and CT angio of the head and neck showed a 1.8cm focal acute haemorrhage in the posterior right putamen.
Under ‘Impression’, Dr. Joo-Meng Soh documented the following:
In summary, this is a 60-year-old with a history of previous DVT and PE on long-term anticoagulant therapy in the form of Coumadin, now presenting to hospital with a fall and right putaminal intracerebral haemorrhage. I am not certain if this is trauma related or not. They were certain that their fall at work was due to their right leg giving out (emphasis added).
Dr. Joo-Meng Soh’s November 5, 2021 in-hospital medical report records the following, in part:
They relayed the events leading to this admission – states they were at work, their left leg gave out causing them to fall (emphasis added). States they hit the back of their head on the floor and phoned their son to help them off the floor as they say they were unable to get in contact with their boss.
The worker underwent a Neurology consult by Dr. Saqqur on November 5, 2021 at the hospital, who recorded the following:
Very pleasant 60 year old who presented with acute onset of left-sided weakness. They suffered from right putaminal haemorrhage the likelihood due to hypertension and being on Coumadin with INR 3.2 for pulmonary embolism and DVT (emphasis added). Their INR (international normalized ration) was revised and the recent one 1.2. On admission their blood pressure was 230/90. …
Impression and Plan
60 y.o. who presented with left-sided weakness. The etiology of ICH (intracerebral haemorrhage) is most likely anticoagulations and possible underlying hypertension (emphasis added).
1. They will have blood pressure target is less than 140/90. They will receive laetalol. …
2. They will have a repeated CT in 24 hours. In 24 hours after repeat their head CT if there is no hematoma expansion seen then they will be started on LMWH (low molecular weight heparin) as DVT prevention.
The worker was assessed in-hospital on November 7, 2021 by Dr. Devaraj, who recorded the following:
This 60-year-old was seen on the Comprehensive Stroke Unit on Sunday, November 7, 2021, at the request of Dr. L. Milosevic for assessment/management. The patient was at work (they work as a truck dispatcher). They apparently stumbled and fell around 7:30 pm without suffering any injuries. Subsequently, they had trouble with slurred speech and left-sided weakness by about 9:45 pm. They were brought to the Emergency Room by ambulance at 10:30 pm as a code stroke and was admitted to the ICU for a 1.8 cm right putamen haemorrhage causing left hemiplegia while on Coumadin with an initial INR of 3.2.
Impression:
Right basal ganglia hemorrhage while on Coumadin causing left hemiplegia
History of recurrent DVT in the left leg with PE in 2015
3. High BMI (body mass index)
4. Hypertension
The worker was re-assessed by Dr. Saqqur on November 8, 2021, who once again indicated that the etiology of ICH was most likely anticoagulations and possible underlying hypertension.
The worker underwent assessment on November 15, 2021 by Dr. Fakhruddin Taher, Internal Medicine, who recorded the following impression:
This 60-year-old presents to the hospital with right basal ganglia haemorrhage, likely on the basis of hypertension while on oral anticoagulant therapy with Coumadin (emphasis added). I will request an echo to identify other changes that would suggest the chronicity of their hypertension. Their treatment for hypertension will be optimized. …
Dr. Fakhruddin Taher completed the November 23, 2011 Health Professional’s Report which confirmed the diagnosis of right basal ganglia haemorrhage, and documented the following as far as how the worker’s condition occurred:
Intracranial haemorrhage caused most likely by anticoagulation and possible underlying hypertension.
Following the worker’s claim for benefits for a basal ganglia haemorrhagic stroke, the WSIB Adjudicator obtained a Neurology opinion on the matter. Dr. Baskind, Neurologist, reviewed the worker’s file on January 10, 2022, and provided the following opinion:
On November 4, 2021 this now 60-year-old Dispatcher's fell, while at work, after their right knee reportedly "gave out" and they fell backwards, striking the back of their head on a hard tile floor. There was no reported loss of consciousness. According to the provided documentation, their son drove them home from work. Upon returning home they felt unwell, and EMS was contacted. They exhibited signs of left-sided weakness, slurred speech, as well as headache. They were taken to the hospital and admitted on November 5, 2021, at which time their blood pressure was noted to be critically high, 230/90. A CT of the brain evidenced a small acute hemorrhage in the posterior aspect of the right putamen, partly involving the posterior limb of the internal capsule. At the time of their admission, they were taking Coumadin with a supratherapeutic INR of 3.2, which required reversal with PCC and vitamin K. Their hypertension required treatment with labetalol in the ICU. CT of the head repeated on November 6 demonstrated a grossly unchanged intraparenchymal hematoma centered within the right lentiform nucleus, typical for a hypertensive hemorrage.
Of note, the worker's medical history is remarkable for pulmonary embolism following ankle fractures 15 years ago, and prior to that, they had an incidence of venous thromboembolism, for which they were recommended lifelong anticoagulant therapy. They reported a history of prior hypertension, but was not on any pharmacological therapy to manage their blood pressure.
Based on the information available for consideration, it is my opinion that this worker's intracranial hemorrhage was secondary to hypertension, as the location of the bleed was identified in a typical area for a hypertensive hemorrhage, and likely the thin blood with a supratherapeutic INR from their use of Coumadin, was a contributing factor. Their right leg likely became weak because of the hemorrhage, and this caused them to fall. Hemorrhage in this location would not be caused by trauma. As such, uncontrolled hypertension and a complication of anticoagulant therapy was the cause of the haemorrhage which led to right leg weakness and consequent fall.
In summary, although the worker’s representative submitted in their post-hearing same-day submission of October 19, 2022 that the worker slipped on tiles at work and fell, the contemporaneous file information does not support this was the cause of the worker’s fall. I acknowledge the worker testified that they slipped on tiles, however, the contemporaneous medical reports referenced above overwhelmingly document that the worker’s leg gave away, which was the cause of the fall. This information was provided by the worker directly to the treating medical professionals.
Furthermore, as was noted by the employer’s representative in closing, the worker’s spouse indicated to the Adjudicator in a memo, dated November 16, 2021 that “They state they told them they were in pain, fatigued and lost their balance as their hip was in pain, and gave out”. This accident history is consistent with the contemporaneous information provided by the worker to the health professionals at the hospital.
Consequently, having regard for all of the above, I accept that the worker’s leg gave way, causing them to fall and strike their head. The issue now turns on whether the worker striking their head on the floor precipitated their stroke.
Although the worker’s representative disputes that the worker had uncontrolled hypertension, based mostly on the worker’s testimony which did not support a history of hypertension, the file medical reports confirm the worker had dangerously elevated blood pressure on hospital admission, i.e. it was 230/90.
Medical literature confirms that many people with high blood pressure (hypertension) have no symptoms, and may even be unaware that they have high blood pressure. Some symptoms may include headaches, shortness of breath, and sometimes nosebleeds – however, these symptoms don’t typically occur until high blood pressure has reached a severe or life-threatening stage. Additionally, medical literature confirms that risk factors for the development of high blood pressure include physical inactivity, being overweight or obese, diet, smoking, family history, age, alcohol consumption, and stress. The worker’s history is significant for at least two of these risk factors, i.e. inactivity (given the sedentary nature of their job, and their difficulty with ambulating), and the documented obesity (with a high BMI, according to Dr. Devaraj).
As a result, while I fully accept the worker’s testimony that they believe they were healthy prior to their fall, based upon the medical information reviewed above, I find it is more likely than not that the worker already had hypertension prior to their fall.
In support of the above, I note that both specialists who assessed the worker in hospital, i.e. Dr. Saqqur, Neurologist, and Dr. Dr. Fakhruddin Taher, Internal Medicine Specialist, were of the opinion that the worker’s right basal ganglia haemorrhage was likely on the basis of hypertension while on oral anticoagulant therapy.
Furthermore, the opinion of the specialists above is also corroborated by the opinion of Dr. Baskind, a Neurologist, who was of the view, as documented above, that the worker's intracranial haemorrhage was secondary to hypertension, as the location of the bleed was identified in a typical area for a hypertensive haemorrhage. Dr. Baskind further indicated that the thin blood with a supratherapeutic INR from the worker’s use of Coumadin, was also a contributing factor.
Consequently, having particular regard for the opinions provided by the Specialists, as documented above, I do not accept the worker representative’s argument that the worker striking their head on the floor resulted in a haemorrhage which led to their basal ganglia haemorrhagic stroke. Of importance, there has been no specialist’s opinion submitted to file to support that the cause of the worker’s basal ganglia haemorrhagic stroke occurred due to striking their head on the floor.
In summary, although I sympathise greatly with the worker’s distress related to sustaining a basal ganglia haemorrhagic stroke, I find the file evidence, and in particular, the opinions provided by the worker’s treating specialists, confirm that the worker’s basal ganglia haemorrhagic stroke was likely caused due to hypertension while on oral anticoagulant therapy, and not as a result of striking their head on the floor.
Consequently, given my finding above that the worker’s basal ganglia haemorrhagic stroke was likely related to hypertension while on oral anticoagulant therapy and not due to striking their head, I therefore find the worker has not met the fifth criterion in the five-point check policy, i.e. compatibility of diagnosis to accident or disablement history. In light of this finding, I therefore also conclude the worker has not met the third and fourth criteria as well, i.e. ‘personal work-related injury, and ‘proof of accident’.
Given that the worker has not met 3 of the five criteria in the five-point check system for an allowable claim, I therefore conclude the worker does not have initial entitlement to a basal ganglia haemorrhagic stroke under the claim.
CONCLUSION
I conclude the worker does not have initial entitlement to a basal ganglia haemorrhagic stroke under the claim.
The worker’s objection is therefore denied.
DATED October 23, 2022
L. Diaz Appeals Resolution Officer Appeals Services Division