IN THE COURT OF APPEALS FOR THE STATE OF WASHINGTON

LORIANN HULL,

Appellant,

v.

PEACEHEALTH MEDICAL GROUP,

Respondent.

No. 74413-5-1

DIVISION ONE

UNPUBLISHED OPINION

FILED: September 26, 2016

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crSpearman, J. — While employed at St. Joseph Hospital PeaceHealth

Medical Group (PeaceHealth) or shortly thereafter, LoriAnn Hull began to feel

pain in her shoulders. This led to surgeries for thoracic outlet syndrome which

resulted in significant complications that continue to plague her. Four years after

the surgeries, PeaceHealth challenged the Department of Labor and Industries'

(Department) determination that Hull's employment caused thoracic outlet

syndrome. The trial court found that Hull's condition was not caused by her

employment. On appeal, Hull contends the trial court's finding is not supported by

substantial evidence. We agree and reverse.1

1 Subsequent to withdrawal of her counsel, appellant submitted a number ofdocuments

including a letter, emailexchanges between her and PeaceHealth, medical records, and other

documents. To the extent these documents were not already a part of the record on appeal, we

do not consider them because they are untimely.
No. 74413-5-1/2

FACTS

Appellant LoriAnn Hull worked for St. Joseph Hospital PeaceHealth for 20

years as an admitting representative in the emergency room. Her duties included

gathering patient information, inputting information, pulling forms and patient

charts, affixing labels to documents, assembling and breaking down charts,

sorting and stacking documents in piles, and cleaning name badges. These

duties involved reaching over an arm-length away at waist level, reaching for

items at or above her forehead, writing on paper, and typing on a computer.

Hull filed a worker's compensation claim on October 23, 2006 after

experiencing elbow discomfort, aggravated by repetitive motion at work. She had

difficulty bending and extending her arms. The Department issued an order

allowing her claim on December 3, 2007. It did notspecify the conditions

allowed.2

On November 7, 2006, Hull saw her primary care provider, Dr. Hughes,

who diagnosed her with left and right medial epicondylitis, a condition ofthe

tendons in the elbow. Dr. Hughes saw Hull again on January 12, 2007. The

elbow diagnosis remained the same and she was referred for electrodiagnostic

studies. These were performed on February 9, 2007 and were normal.3

2The record does not include Hull's claim or the Department's order. However, a

jurisdictional history towhich the parties stipulated at hearing "for jurisdictional purposes only"

includesinformation about the Department's December 3, 2007 order. Clerk's Papers (CP) at 94.

3Anormal electrodiagnostic test does notrule out thoracic outlet syndrome. Thoracic

outlet syndrome potentially shows up on an electrodiagnostic test only if it isserious. Intermittent

thoracic outlet syndrome can result in a normal study. While an electrodiagnostic test isfrequently

used in the diagnostic process for thoracic outlet syndrome, it is not, by itself, helpful in ruling in

or out the diagnosis.
No. 74413-5-1/3

Hull continued to work. To avoid pain, she adjusted her motions. To reach

for something, she twisted her shoulder towards it so to avoid extending her arm

fully. Hull began to feel pain in her left shoulder in March 2007. She continued to

work at PeaceHealth at least through that date.

Hull saw Dr. Hughes again on July 9 and 26, 2007, reporting that she had

pain in her left shoulder. Hull was referred to an orthopedic surgeon for the

shoulder problem. She tried non-invasive treatment such as physical therapy, but

ultimately had acromioplasty surgery on her left shoulder in October, 2007.4 It did

not resolve the problem. Hull attempted to return to work after that surgery.5 With

her left side immobilized from the surgery, she began feeling pain in her right

shoulder.

Because acromioplasty surgery did not resolve her pain, Hull was referred

to a thoracic outlet syndrome specialist. Thoracic outlet syndrome refers to three

separate types of conditions in which either the artery, the veins, or the nerve are

compressed at one of several sites in the body. Neurogenic thoracic outlet

syndrome, Hull's condition, arises where the nerves that pass through from the

spinal cord and the neck out to the arms are compressed. Neurogenic thoracic

outlet syndrome is characterized by steadily worsening pain, numbness, tingling,

and weakness in the shoulder, neck, arm, and hand.

4The record does not explain the nature of this procedure.

5 Hull's full work history is not in the record.
No. 74413-5-1/4

Hull saw a thoracic outlet specialist, Dr. Johansen, on March 24, 2009.

She reported steadily worsening pain, numbness, tingling, and weakness in her

left arm and described her working conditions and onset of symptoms. Dr.

Johansen reviewed prior testing and did a physical examination. One of the prior

tests that he considered was a scalene block - an anesthetic procedure that

temporarily relieved Hull's symptoms - which is an accurate and specific test for

thoracic outlet syndrome. The effectiveness of the scalene block demonstrated

that Hull had thoracic outlet syndrome. Dr. Johansen diagnosed Hull with

neurogenic thoracic outlet syndrome based on workplace repetitive motion injury,

appropriate story, symptoms, physical examination findings, and a strongly

positive scalene block.

On April 22, 2009, Dr. Johansen performed surgery on Hull to correct the

thoracic outlet syndrome. It did not resolve the symptoms. He performed a

second surgery on December 21, 2009. This surgery resulted in significant

complications, including balance problems, breathing problems, difficulty

swallowing, dry heaving, and emotional problems including adjustment disorder

with depressed mood.

In 2013, the Department issued three orders that directed PeaceHealth to

pay for complications from Hull's thoracic outlet syndrome surgery. Those orders,

which are the subject of this litigation directed PeaceHealth to pay for postsurgery complications including pulmonary conditions, balance problems,

dysphasia, cricopharyngeal spasms, and adjustment disorder with depressed

mood. They also directed PeaceHealth to pay for the psychiatric medication
No. 74413-5-1/5

Cymbalta. PeaceHealth appealed these orders to the Board of Industrial

Insurance Appeals (Board).

The appeal proceeded to an evidentiary hearing before an Industrial

Appeals Judge (IAJ) on May 23, 2014. Hull's attending physician, Dr. Johansen,

testified in support of Hull's claim. PeaceHealth presented testimony by several

physicians, including Dr. Kremer, a retired vascular surgeon. He reviewed Hull's

medical records and performed a one-time partial evaluation of Hull in

September 2012, nearly three years after her second thoracic outlet syndrome

surgery. Dr. Kremer testified that Hull never had thoracic outlet syndrome and

even ifshe did, it was not caused by her working conditions.

The IAJ issued a proposed decision and order on October 6, 2014

upholding the Department's orders directing PeaceHealth to pay for

complications from Hull's thoracic outlet syndrome. PeaceHealth filed a petition

for review. The Board denied the petition for review and adopted the lAJ's

proposed decision. The decision and order upheld the Department's

determination that Hull's thoracic outlet syndrome arose naturally and

proximately out ofthe distinctive conditions of her employment with PeaceHealth,

thereby allowing the downstream consequences of her surgeries.

PeaceHealth appealed this decision to Whatcom County Superior Court,

which held a bench trial on August 25, 2015 and issued a memorandum decision
No. 74413-5-1/6

overturning the Board and finding in favor of PeaceHealth.6 The court issued an

order on December 2, 2015 which included the following "Conclusion of Law":

1. The Board of Industrial Insurance Appeals erred in admitting evidence

regarding payment of services associated with defendant's thoracic outlet

syndrome under Evidence Rule 409 and as such evidence regarding

payment of such services is stricken from the record.

3. Defendant was subsequently diagnosed with a condition of thoracic outlet

syndrome for which surgery was recommended and performed April 22,

2009 and December 21, 2009. Defendant's thoracic outlet syndrome did

not arise naturally and proximately from the distinctive conditions of her

employment with PeaceHealth Medical Group.

8. The Board of Industrial Insurance Appeals' decision dated December 8,

2014, is reversed.

CP at 823-30. Hull appeals.

DISCUSSION

The Industrial Insurance Act includes judicial review provisions that are

specific toworkers' compensation determinations. The superior court's review of

a Board determination is de novo. RCW 51.52.115. The Board's decision is

prima facie correct, and a party attacking the decision must support its challenge

by a preponderance of the evidence. Rogers v. Dep't of Labor &Indus., 151 Wn.

App. 174, 180, 210 P.3d 355 (2009) (citing Ruse v. Dep't of Labor &Indus., 138

Wn.2d 1, 5, 977 P.2d 570 (1999)). By contrast, this court reviews the superior

court's decision under the ordinary standard of review for civil cases. "We review

whether substantial evidence supports the trial court's factual findings and then

review, de novo, whether the trial court's conclusions of law flow from the

6 The memorandum decision is not in the record.
No. 74413-5-1/7

findings." Watson v. Dep't of Labor & Indus., 133 Wn. App. 903, 909, 138 P.3d

177 (2006) (citing Ruse, 138 Wn.2d at 5; RCW 51.52.115).

The Industrial Insurance Act (MA) provides that a worker suffering disability

from an occupational disease shall receive benefits under the Act. RCW

51.32.180. An occupational disease is defined as "such disease or infection as

arises naturally and proximately out of employment." RCW 51.08.140. "[A] worker

must establish that his or her occupational disease came about as a matter of

course as a natural consequence or incident of distinctive conditions of his or her

particular employment." Dennis v. Dep't of Labor &Indus., 109 Wn.2d 467, 481,

745 P.2d 1295 (1987). "The causal connection between a claimant's physical

condition and his or her employment must be established by competent medical

testimony which shows that the disease is probably, as opposed to possibly,

caused by the employment." Id at 477 (citing Ehman v. Dep't of Labor&Indus.,

33 Wn.2d 584, 206 P.2d 787 (1949)). The disease is not "proximate" if there is an

intervening, independent and sufficient cause for disease, so that itwould not

have been contracted but for working conditions. Simpson Logging Co. v. Dep't

of Labor & Indus., 32 Wn.2d 472, 202 P.2d 448 (1949). "A physician's opinion as

to the cause of the claimant's disease is sufficient when it is based on reasonable

medical certaintyeven though the doctor cannot rule out all other possible

causes. . . ." Intalco Aluminum v. Dep't of Labor & Indus., 66 Wn. App. 644, 654-

55, 833 P.2d 390 (1992) (citing Haider v. Dep't of Labor&Indus., 44 Wn.2d 537,

543-45, 268 P.2d 1020 (1954)). "The evidence is sufficient to prove causation if,

from the facts and circumstances and the medical testimony given, a reasonable
No. 74413-5-1/8

person can infer that a causal connection exists." jd. at 655 (citing Douglas v.

Freeman, 117 Wn.2d 242, 252, 814 P.2d 1160(1991)). In a worker's

compensation dispute, special consideration should be given to the opinion of a

worker's attending physician. Hamilton v. Dep't of Labor & Indus., 111 Wn.2d

569, 761 P.2d 618 (1988). The trier of fact needn't give more weight or credibility

to the attending physician's testimony, but must give it careful thought, jd. at 571.

In this case, the record shows that Hull began feeling symptoms of what

was eventually diagnosed as thoracic outlet syndrome either during, or

immediately following, her employment with PeaceHealth. She testified that she

began feeling pain in her shoulder about five months after filing the claim for her

elbow condition and that in those five months she continued to work.7 During this

time at work, she used her shoulders more in order to reduce the pain in her

elbows caused by extending her arms. Expert medical testimony confirms that

Hull should feel thoracic outlet syndrome symptoms concurrently with the work

activity that caused the condition. There is no evidence of an intervening cause

of her shoulder pain.

Hull's attending physician, Dr. Johansen, explained how Hull's particular

job duties caused thoracic outletsyndrome.8 He testified that repetitive out in

front use of her arms and overhead work such as that performed by Hull is a

7 Hull'swork history is incomplete in the record. She testified that she worked for St

Joseph's starting in 1990 or 1991, and worked there for 19 years and 11 months. Therefore, she

was an employee of St. Joseph's until 2010 or 2011. Once she started feeling symptoms in her

shoulder, there is no information in the record about whether she worked continuously.

8Dr. Johansen performs the majority of thoracic outlet syndrome surgeries inWashington

State and authored chapters in a medical textbook on neurogenic thoracic outlet syndrome.
No. 74413-5-1/9

cause of thoracic outlet syndrome. Hull's body habitus and height made her more

susceptible to injury in these work conditions. Her elbow problems indicated that

her work activities were causing repetitive motion injuries. Under Hamilton,

"special consideration" should be given to Dr. Johansen's testimony as Hull's

attending physician. There is no indication that the trial court gave such special

consideration. It did not make a finding that PeaceHealth's experts were

persuasive or that Dr. Johansen was not credible.

PeaceHealth offered testimony by forensic physicians that does not

provide substantial evidence that Hull's thoracic outlet syndrome was not caused

by herwork activity. One expert, Dr. Madhani, deferred on the cause ofHull's

thoracic outlet syndrome. Another expert, Dr. Kremer, testified that the working

conditions of hairdressers and carpenters would cause thoracic outlet syndrome,

but he denied that Hull's out in front and overhead use of her arms caused it. Dr.

Kremer points to electrodiagnostic testing from February 2007 thatwas negative

for thoracic outlet syndrome. However, this test was before Hull reported

shoulder pain, and is not reliable to rule out intermittent thoracic outlet

syndrome.9

If thoracic outlet syndrome is an allowed occupational disease, then the

downstream complications of Hull's surgeries, the sequelae, are also allowed.

Claimants must be reimbursed "[u]pon the occurrence of any injury to a worker

9PeaceHealth also argues that Hull's injury must have occurred prior towhen the claim

was allowed by the Department, but they erroneously cite December 3, 2006 asthe date the

claim was allowed. In fact, itwas allowed on December 3, 2007 and Hull did complain ofshoulder

problems prior to that date.
No. 74413-5-1/10

entitled to compensation. . . ." RCW 51.36.010(2)(a). Compensation is required

for all "proper and necessary medical and surgical services. . . ." jd. Proper and

necessary treatment encompasses conditions secondary to the occupational

disease, such as complications from surgery. See Anderson v. Allison, 12 Wn.2d

487, 122 P.2d 484 (1942).

PeaceHealth concedes that Hull's balance problems, pulmonary condition,

dysphagia, and cricopharyngeal spasms are proximately related to treatment for

her thoracic outlet syndrome, and as conditions secondary to thoracic outlet

syndrome, they are allowed. PeaceHealth does argue that Hull's adjustment

disorder with depressed mood is not proximately related to her surgeries. They

support this argument with Dr. Friedman's testimony. However, Dr. Friedman

testified that Hull's mental health conditions were not caused by her elbow

condition. That is not at issue. The issue is whether her mental health condition

was secondary to thoracic outlet syndrome, which is well supported by expert

medical testimony. All of Hull's downstream conditions listed in the orders

appealed to the Department are allowed.

Lastly, Hull argued that the trial court erred by excluding evidence that

PeaceHealth paid for Hull's surgeries. The trial court correctly excluded evidence

of payment under ER409 and our analysis does not incorporate this fact.

We conclude that there is not substantial evidence to support the trial

court's finding that Hull's thoracic outlet syndrome and itssequelae did not arise

naturally and proximately from her employment with PeaceHealth. As discussed

above, the opinions of PeaceHealth's experts are insufficient to support the trial

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No. 74413-5-1/11

court's conclusion. In addition, the timeline of Hull's symptoms, her work history

and the testimony of her attending physicians strongly support the conclusion

that her work activities caused thoracic outlet syndrome. And because the

thoracic outlet syndrome was proximately caused by Hull's working conditions,

the downstream consequences of her surgery are also covered.

The trial court's order is reversed, the Board's Decision and Order is

affirmed and the case is remanded.

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WE CONCUR:

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