Case Title: FRANCIS NUANES v. STATE OF WYOMING EX REL. WYOMING WORKER'S COMPENSATION DIVISION, LOWER & CO., INC.

Citation: 

Docket Number: 84-88

State: wyoming

Court: Wyoming Supreme Court

Date: 1985-01-23T00:00:00Z

Document:
FRANCIS NUANES v. STATE OF WYOMING EX REL. WYOMING WORKER'S COMPENSATION DIVISION, LOWER & CO., INC.1985 WY 9694 P.2d 86Case Number: 84-88Decided: 01/23/1985Supreme Court of Wyoming
FRANCIS NUANES, APPELLANT 
(EMPLOYEE-CLAIMANT), 

v. 

STATE OF WYOMING EX REL. WYOMING WORKER'S COMPENSATION DIVISION, 
APPELLEE (OBJECTOR-DEFENDANT), LOWER & CO., INC., 
(EMPLOYER-DEFENDANT).

 
 
Appeal from the District 
Court, ConverseCounty, William A. Taylor, 
J.

 
 
James A. Hardee, 
Douglas, for appellant.

A.G. McClintock, 
Atty. Gen., Gerald A. Stack, Deputy Atty. Gen., John W. Renneisen, Sr. Asst. 
Atty. Gen., and Terry J. Harris, Asst. Atty. Gen., Cheyenne, for appellee.

Before THOMAS, C.J., and 
ROSE, ROONEY, BROWN and CARDINE, JJ.

ROONEY, 
Justice.

[¶1.]     This is an appeal from 
an order of the district court denying the claim of appellant for benefits under 
the Wyoming Worker's Compensation Act. The issues raised by appellant are as 
follows:

"I. THAT THE TRIAL COURT 
ERRED IN DENYING THE CLAIM OF THE APPELLANT FOR THE REASON THAT THE TRIAL 
COURT'S FINDING THAT THERE WAS NO CAUSATIVE EXERTION IS UNSUPPORTED BY THE 
EVIDENCE AND IS ERRONEOUS AS A MATTER OF LAW.

"II. THE TRIAL COURT 
ERRED IN DENYING THE CLAIM OF THE APPELLANT IN THAT THE COURT'S FINDING THAT 
THERE WAS NO `DIRECT CAUSAL CONNECTION BETWEEN THE WORK BEING PERFORMED AND THE 
CARDIAC ATTACK', IS UNSUPPORTED BY THE EVIDENCE."

[¶2.]     Appellant had worked as 
a journeyman painter for the majority of his adult life. On July 21, 1983, 
appellant was employed, through his union, by appellee Lower and Co., Inc. at 
the Dave Johnson Power Plant at Glenrock, Wyoming. On April 18, 1983, after painting one 
wall of the office he had been assigned to paint, appellant found it necessary 
to move four filing cabinets away from another wall to paint it. Each cabinet 
weighed between 200 and 300 pounds. Approximately five minutes after moving the 
last cabinet, appellant experienced chest pains and difficulty in breathing. 
Because of his condition, it took appellant 45 minutes to cover a 600-foot 
distance to notify his supervisor. Thereafter appellant was taken for treatment, 
and the next day underwent arterial by-pass surgery. Appellant was diagnosed as 
having a 99% occlusion of the anterior descending artery and a 60% narrowing of 
the circumflex system. Three weeks prior to April 8, appellant had completed a 
physical which indicated no problems whatsoever, and appellant had experienced 
no prior symptoms.

[¶3.]     Appellant submitted his 
claim for benefits under the Wyoming Worker's Compensation Act,1 and the State of Wyoming ex rel. Wyoming 
Worker's Compensation Division objected. Lower and Co., Inc. later joined in 
this objection. The matter was tried to the court, which denied the claim of 
appellant for benefits, based on § 27-12-603(b), W.S. 1977, which reads as 
follows:

"(b) Benefits for 
employment-related coronary conditions except those directly and solely caused 
by an injury or disease are not payable unless the employee establishes by 
competent medical authority that there is a direct causal connection between the 
condition under which the work was performed and the cardiac condition, and then 
only if the causative exertion occurs during the actual period of employment 
stress clearly unusual to, or abnormal for, employees in that particular 
employment, and further that the acute symptoms of the cardiac condition are 
clearly manifested not later than four (4) hours after the alleged causative 
exertion."

[¶4.]     Section 27-12-603(b), 
supra, outlines the criteria according to which an employee can receive 
compensation for a work-related coronary condition. In previous cases, we have 
recognized that § 27-12-603(b), supra, contains four basic requirements, 
to-wit:

"(1) The claimant must 
establish a period of employment stress unusual or abnormal for employees in 
claimant's occupations;

"(2) Claimant must show 
that he or she engaged in some exertion during the period of unusual or abnormal 
employment stress;

"(3) Claimant must 
establish by competent medical evidence a direct causal connection between such 
exertion and the myocardial infarction; and

"(4) Claimant must show 
that the acute symptoms of the cardiac difficulty were clearly manifested within 
four hours after the alleged causative exertion." Claim of McCarley, Wyo., 590 P.2d 1333, 1335-1336 
(1979).

Specifically, the 
district court found that:

"* * * [T]he testimony 
does not indicate to the court that Mr. Nuanes was engaged in an activity during 
the actual period of employment unusual or abnormal to his employment. Mr. 
Nuanes did slide file cabinets away from the wall, they were heavy but and there 
is no testimony that the cabinets were heavier or more difficult to move than 
various types of furniture and fixtures, such as desks, which he routinely moved 
as a regular part of is [sic] employment." Opinion Letter of February 16, 
1984.

In addition, the 
district court said in its Opinion Letter: 

"* * * [A]fter a careful 
reading of the Doctor's deposition I cannot find where he states specifically 
that the moving of the filing cabinets was the direct casual [sic] connection 
between the work being performed and the cardiac attack."

Thus, it found 
that two of the four statutory requirements were not met by appellant. 
AppelleeState of Wyoming categorized these requirements as 
proof of legal causation and proof of medical causation.

[¶5.]     We will first address 
appellant's second issue: whether there was a direct causal connection between 
the work being performed and the cardiac attack, or in other words, was the 
trial court correct in ruling that the evidence was insufficient to establish 
medical causation. We note here that on appeal we assume that the evidence in 
favor of the successful party is true, and leave out of consideration entirely 
the evidence presented by the appellant in conflict therewith, and we give the 
evidence of the successful party every reasonable inference that may be drawn 
therefrom. Distad v. Cubin, 
Wyo., 633 P.2d 167, 180 (1981); Brittain v. Booth, Wyo., 601 P.2d 532, 535 
(1979). We also note that the burden of proof in a worker's compensation case 
rests with the employee to show the essential elements of his claim by a 
preponderance of the evidence. Jim's 
Water Service v. Eayrs, 
Wyo., 590 P.2d 1346, 1351 
(1979).

[¶6.]     We have dealt with the 
issue of medical causation before. In Claim of McCarley, supra, we denied 
compensation for a worker's coronary condition because the record was devoid of 
any medical testimony establishing the necessary causative link, and in fact the 
doctor's statements led to the conclusion that the employee suffered a heart 
attack as a result of exertion occurring off the job, and removed from any 
work-related stress.

[¶7.]     In Jim's Water Service v. Eayrs, supra, 590 P.2d  at 1349, we stated that:

"* * * The question that 
needs to be answered is whether the work effort contributed to a material degree 
to the precipitation, aggravation or acceleration of the existing disease and 
the resulting death. Claim of Vondra, Wyo., 448 P.2d 313 (1968); Claim of Hill, Wyo., 451 P.2d 794 (1969); Claim of Brannan, Wyo., 
455 P.2d 241 (1969) * * *."

And, we upheld 
the award of compensation based on a doctor's testimony that the work-related 
stress was a "contributory factor" and that the arrhythmia "very likely" and 
"probably" was due to the physical exertion and strain of attempting to free his 
truck from a snow bank. In Wyoming State 
Treasurer ex rel. Wyoming Worker's Compensation Division v. Schwilke, Wyo., 
649 P.2d 218 (1982), we held that medical testimony such as "most likely" and 
"contributed to" is of sufficient certainty to establish the required causative 
link.

[¶8.]     Finally, in Kaan v. State ex rel. Wyoming Worker's Compensation Division, Wyo., 689 P.2d 1387, 1389 
(1984), we concluded that:

"* * * The causal 
connection requirement is satisfied if a medical expert testifies that it is 
more probable than not that work exertion or stress contributed in a material 
degree to the precipitation, aggravation or acceleration of a myocardial 
infarction."

[¶9.]     Applying those 
standards to the case at bar, it is clear that appellant did not meet his burden 
of proof on the issue of medical causation. Appellant's only medical expert, a 
cardiac surgeon, refused to say more than there "could have" been a causal 
connection between the moving of the filing cabinets and the attack, or that it 
is "certainly possible" that the effort precipitated, aggravated or accelerated 
the heart attack. He testified that:

"A. Okay. A myocardial 
infarction comes about, at least according to the best of our belief, as a 
result of an imbalance between supply and demand of the heart. If for some 
reason the blood supply to the heart is reduced, such as by an arthrosclerotic 
[sic] plaque, but excessive demands are made upon the heart, that can certainly 
precipitate an infarction. 

"Now, of course, if the 
person didn't have the pre-existing plaque, he could well sustain the amount of 
exertion required.

"Okay. But you know, to 
ask did exertion cause the heart attack, I don't think I am going to answer that 
yes or no. I will lay out the picture which we all have in our minds of a 
narrowed artery in a heart. And for some reason the patient exerts more than 
usual. Okay. And this is a strict supply-demand situation. Now, his supply of 
blood to that area is limited by the narrowing, but the demand on the muscle is 
more than the supply, and that's believed to be the way in which an infarction, 
death of muscle, can occur.

* * * * * 
*

"Q. In this particular 
instance given - I don't know how you want me to approach this. Hypothetically, 
let's assume that Mr. Nuanes was moving file cabinets and that type of thing. Is 
it possible or even probable that that type of activity would place this type of 
excess demand on that portion of the heart?

"A. It could have - first 
let me say that I don't know the particular -

"Q. I am saying 
hypothetically.

"A. I really don't know 
the circumstances under which he had immediate onset of 
pain.

"Q. 
Uh-huh.

"A. Yes, any type of 
exertion can increase the demand above the supply. Now, whether you call that 
demand excessive, what is excessive relative to the supply? I mean, I don't know 
what counts as an excessive exertion."

The doctor further 
testified:

"Q. Just as a point of 
clarification, and going back to our hypothetical, assuming that an individual 
was called upon to move file cabinets, and that onset occurred within ten to 
fifteen minutes after that. In your opinion is there a possibility or a degree 
of probability that that is the causative concept in patients with Mr. Nuanes' 
type of cardiac condition?

"A. Yes. If a person has 
pre-existing narrowing of his coronary arteries, then it's certainly possible 
that exertion can cause an excessive demand on the heart that cannot be met 
because of limitations in supply of blood to the heart."

This does no 
more than make the causal link a possibility. The district court was correct in 
holding that that is not enough.

[¶10.]  Inasmuch as compensation under the 
Worker's Compensation Act was properly denied on this basis, we need not address 
the other issue raised by appellant.

[¶11.]  Affirmed.

1 Sections 27-12-101 
through 27-12-804, W.S. 1977.

ROSE, Justice, 
dissenting.

[¶12.]  The evidence presented by appellant 
Francis Nuanes is sufficient to establish both medical and legal causative 
exertion under the standards developed in our cases concerning 
employment-related cardiac attacks. Therefore, I would have reversed the order 
of the district court denying recovery under the Wyoming Worker's Compensation 
Act.

[¶13.]  The trial court imposed a standard of 
proof with respect to medical causation, unsupported by our recent decisions. 
According to the judge's opinion letter, benefits would not be awarded absent an 
unqualified statement from the cardiac surgeon that the work effort had caused 
the attack:

"First, after a careful 
reading of the Doctor's deposition I cannot find where he states specifically 
that the moving of the filing cabinets was the direct casual [sic] connection 
between the work being performed and the cardiac attack."

We have said, 
however, that a medical expert can establish causation under § 27-12-603(b), 
W.S. 1977 (majority opinion at 88) with less degree of certainty than may be 
required in other cases. Wyoming State Treasurer ex rel. Wyoming Worker's Compensation Division v. Schwilke, Wyo., 
649 P.2d 218, 222 (1982). In Jim's Water Service v. Eayrs, Wyo., 590 P.2d 1346, 1349 
(1979), we said: 

"* * * [The pathologist] 
declined to say that he could determine to a reasonable medical certainty that 
the stress caused or precipitated the death and stated that James could have 
died in his sleep just as easily as on the job. However, he also testified that 
the stress was a `contributing factor' and that the arrhythmia `very likely' and 
`probably' was due to the physical exertion and strain. That is sufficient 
evidence of the causal connection."

From these and 
other cases we distilled the proper test of medical causation in Kaan v. State ex rel. Wyoming Worker's 
Compensation Division, Wyo., 689 P.2d 1387, 1389 
(1984):

"* * * The causal 
connection requirement is satisfied if a medical expert testifies that it is 
more probable than not that work exertion or stress contributed in a material 
degree to the precipitation, aggravation, or acceleration of a myocardial 
infarction."

[¶14.]  Since the trial court in the instant case 
analyzed the expert's testimony under an erroneous test of medical causation, 
our usual, deferential standard of review concerning factual matters is 
inappropriate. We have the duty under these circumstances to examine the 
deposition of the medical expert and reach our own conclusion concerning 
causation, based upon this substantial evidence in the record. Scott v. Fagan, Wyo., 
684 P.2d 805, 811 (1984). Dr. Robert M. Ristroph, the cardiac surgeon who 
treated appellant, testified concerning the causal relationship between the work 
effort and the subsequent heart attack. Although no statement pinpoints 
appellant's moving of the file cabinets as the sole causative factor, the 
totality of the doctor's testimony establishes that the exertion contributed in 
a material degree to the precipitation of the 
attack.

[¶15.]  Portions of the expert's responses to 
direct examination are set out in the majority opinion. This testimony describes 
the causes of myocardial infarctions, in general, and establishes that any type 
of exertion by atherosclerotic individuals can place excessive demands on the 
heart muscle. The quoted testimony also affirms the possibility or probability 
of a causative connection between the moving of file cabinets and the cardiac 
attack within 15 minutes.

[¶16.]  On cross-examination, counsel inquired as 
to whether Mr. Nuanes, in light of his occluded arteries, was predisposed to a 
heart attack, the only question being when. Dr. Ristroph estimated the constant 
known risk of a heart attack to be 3% to 5% per year for someone such as Mr. 
Nuanes with a double vessel disease. He further testified that Mr. Nuanes' risk 
might be above the 3% to 5% figure, given the 99% narrowing of his anterior 
descending artery. The doctor then concluded:

"A. Now, I don't know 
whether I could say would he have had it if he had not been employed and hadn't 
moved this hypothetical file cabinet. That type of thing is really, you know, 
asking for the mind of God, you know."

The final 
session of cross-examination produced the following:

"Q. As I understood your 
answer to a question Mr. Harris just asked you, there really isn't any way to 
testify today within any reasonable medical certainty whether the exertion that 
this patient had was or was not the cause of his heart attack, is that correct, 
from your standpoint, from your own knowledge of what you know about 
it?

"A. The exertion - I 
mean, it is general medical knowledge that exertion can produce a heart attack 
given that the person already has narrowing of his coronary arteries. Whether 
it's fair to say that the exertion causes the heart attack, is not clear to me. 
All right. Because the same exertion with someone without the narrowing of the 
coronary arteries, would obviously not cause a heart 
attack."

[¶17.]  In sum, the doctor testified repeatedly 
that an infarction can occur when a person with atherosclerotic arteries exerts 
more than usual, thereby placing an excessive demand on the heart muscle. He 
confirmed the possibility or probability of a causal connectiion between the 
moving of the file cabinets and Mr. Nuanes' attack 15 minutes later. When asked 
specifically whether that exertion was or was not the cause of the heart attack, 
Dr. Ristroph answered:

"* * * [I]t is general 
medical knowledge that exertion can produce a heart attack given that the person 
already has narrowing of his coronary arteries."

[¶18.]  Dr. Ristroph's complete testimony 
establishes that Mr. Nuanes' work effort contributed in a material degree to the 
precipitation of the heart attack. The majority, perhaps as a result of some of 
the language in our earlier cases, focus on select phrases in this testimony and 
conclude that it establishes no more than a possible causal link between the 
exertion and the attack. In my view, however, the expert's meaning should be 
gleaned from the totality of the information produced during direct and 
cross-examination. Considered in this manner, the evidence is sufficient to 
satisfy the requirement of medical causation under our worker's compensation 
statutes.

[¶19.]  In addition to medical causation, the 
trial court based its holding on an absence of sufficient evidence to establish 
legal causation. That is, the court found no indication that the moving of heavy 
file cabinets by Mr. Nuanes constituted the unusual or abnormal stress required 
by § 27-12-603(b), supra.

[¶20.]  We first delineated the proper rule for 
proof of unusual or abnormal exertion in Mor, Inc. v. Haverlock, Wyo., 566 P.2d 219, 222 (1977):

"* * * [T]he exertion in 
question must only be unusual to the 
employee - it need not necessarily be unusual to others engaged in the same 
employment. [Citations.] To sustain his burden of proof, as to legal causation, 
the statute requires that the employee show that the causative exertion was 
clearly something beyond his normal routine - something more than the worker's 
usual work."

We reaffirmed 
the validity of this rule in Jim's Water 
Service v. Eayrs, supra, 590 P.2d  at 1349; Wyoming State Treasurer ex rel. Wyoming 
Worker's Compensation Division v. Schwilke, supra, 649 P.2d  at 221; Yost v. Wyoming State Treasurer ex rel. 
Wyoming Worker's Compensation Division, Wyo., 654 P.2d 137 (1982); and Creek v. Town of Hulett, Wyo., 657 P.2d 353 (1983). We said in Jim's Water 
Service v. Eayrs, supra, that the test is satisfied when the exertion, 
although not different in kind from the employee's regular work, is greater in 
degree than normal.

[¶21.]  When judged against this standard, the 
evidence in the present case supports only a finding that the moving of loaded 
file cabinets amounted to an unusual exertion for Mr. Nuanes. The uncontradicted 
testimony of appellant establishes that he typically moved furniture and 
equipment with the help of an apprentice or a laborer. He said that as a 
journeyman painter he was entitled to an apprentice to assist in the preparation 
of rooms for painting. He testified that the inadequate number of available 
laborers at the time of his heart attack necessitated his moving office 
furniture unassisted. A superintendent for the employer, the only other person 
to testify at trial, said that appellant was to contact him when helpers were 
needed to move furniture.

[¶22.]  We faced an almost identical situation in 
Mor, Inc. v. Haverlock, supra. There 
the employee usually carried cement with the assistance of helpers or a hoisting 
device. On the day of his heart attack, he had no helpers, nor did he use a 
hoist. We held this evidence sufficient to establish unusual 
exertion.

[¶23.]  The record in the present case 
establishes that appellant typically moved heavy objects with the aid of an 
apprentice or laborer. Prior to his heart attack, he moved four filing cabinets, 
each weighing 200 to 300 pounds, without help. This activity amounted to unusual 
exertion under § 27-12-603(b) and our prior cases.

[¶24.]  The evidence of Mr. Nuanes' exertion on 
the day of his heart attack and the expert medical testimony concerning 
causation, when measured against the proper standards, establish appellant's 
entitlement to worker's compensation benefits. I would have reversed the order 
of the district court.