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UNPUBLISHED OPINION FILED: September 26, 2016 en rnp. —o rpv ro .!> O"1' -.->•••'

COcrSpearman, 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. Fouryears 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 notcaused 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 towithdrawal of hercounsel, appellant submitted a number ofdocuments including a letter, emailexchanges between her and PeaceHealth, medical records, and other documents. To the extentthese 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. Herduties 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 herforehead, writing on paper, and typing on a computer. 

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

### experiencing elbow discomfort, aggravated byrepetitive motion atwork. She had difficulty bending and extending her arms. The Department issued an order allowing herclaim 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 herwith 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. Thesewere performed onFebruary 9, 2007 andwere normal.3

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

### jurisdictional historytowhich the parties stipulated athearing "forjurisdictional purposes only" includesinformation about the Department's December 3, 2007 order. Clerk's Papers (CP) at 94. 3Anormal electrodiagnostic test does notrule outthoracic outlet syndrome. Thoracic outletsyndrome potentially shows up on anelectrodiagnostictestonly ifit isserious. Intermittent thoracic outlet syndrome canresult in a normal study. While anelectrodiagnostic test isfrequently used in thediagnostic process for thoracic outletsyndrome, itisnot, 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 itso to avoid extending her arm fully. Hullbegan 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. Hullwas 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 inher 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 ofseveral 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 inthe 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 ofthe 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 ofthe scalene block demonstrated that Hullhad 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, includingbalance problems, breathing problems, difficulty 

### swallowing, dry heaving, and emotional problems including adjustment disorder with depressed mood. 

### In2013, the Department issued three orders that directed PeaceHealth to 

### payfor complications from Hull's thoracic outlet syndrome surgery. Those orders, which are the subject of this litigation directed PeaceHealth to pay for post

### surgery complications including pulmonary conditions, balance problems, 

### dysphasia, cricopharyngeal spasms, and adjustment disorderwith depressed mood. They also directed PeaceHealth to pay for the psychiatric medicationNo. 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 ofHull 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, itwas 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 heremploymentwith 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 decisionNo. 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 ofservices associated with defendant's thoracic outlet syndrome under Evidence Rule 409 and as such evidence regarding payment ofsuch services is stricken from the record. 

### 3. Defendantwas subsequently diagnosed with a condition of thoracic outlet 

### syndrome forwhich 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 employmentwithPeaceHealth 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 includesjudicial review provisions that are 

### specifictoworkers' compensation determinations. The superiorcourt's review of a Board determination is de novo. RCW 51.52.115. The Board's decision is 

### primafacie correct, and aparty attacking thedecision must supportits challenge 

### by apreponderance ofthe evidence. Rogers v. Dep't ofLabor&Indus., 151 Wn. App. 174, 180, 210 P.3d 355 (2009) (citing Ruse v. Dep'tofLabor&Indus., 138 Wn.2d 1, 5, 977 P.2d 570(1999)). By contrast, thiscourt reviews the superior court'sdecision under the ordinary standard ofreview for civil cases. "We review whether substantial evidence supports the trial court's factualfindings and then 

### review, de novo, whether the trial court's conclusions oflaw flow from the

6The 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 ofemployment." 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 

### testimonywhich shows that the disease is probably, as opposed to possibly, 

### caused by the employment." Id at 477 (citing Ehmanv. Dep't of Labor&Indus., 33 Wn.2d 584, 206 P.2d 787 (1949)). The disease is not "proximate" ifthere is an 

### intervening, independent and sufficient cause fordisease, so that itwould not have been contracted but forworking conditions. Simpson Logging Co. v. Dep't of Labor &Indus., 32 Wn.2d 472, 202 P.2d 448 (1949). "Aphysician's opinion as to the cause ofthe claimant's disease is sufficient when it is based on reasonable 

### medical certaintyeven though the doctor cannot rule outall other possible

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

### 55, 833 P.2d 390 (1992) (citing Haiderv. Dep't of Labor&Indus., 44Wn.2d 537, 543-45, 268 P.2d 1020 (1954)). "The evidence is sufficientto prove causation if, from the facts and circumstances and the medical testimony given, a reasonableNo. 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 offact needn't give more weight or credibility to the attending physician's testimony, but must give itcareful thought, jd. at 571. Inthis case, the record shows that Hullbegan feeling symptoms ofwhat

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 aboutfive months after filing the claim for her elbow condition and that inthose 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 withthe work 

### activity that caused the condition. There is no evidence of an intervening cause ofher shoulder pain. 

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

### job duties caused thoracic outletsyndrome.8 Hetestified that repetitive outin front use of her arms and overhead work such as that performed by Hull is a

7Hull'swork history is incomplete in the record. She testified that she worked for St Joseph's startingin 1990 or 1991, and worked there for 19 years and 11 months.Therefore, she was an employee of St. Joseph's until 2010 or2011. 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 ofthoracic outlet syndrome. Hull's body habitus and height made her more susceptible to injury inthese 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 byforensic physicians that does not 

### provide substantial evidence that Hull's thoracic outlet syndrome wasnotcaused by herwork activity. Oneexpert, Dr. Madhani, deferred on the cause ofHull's thoracic outlet syndrome. Another expert, Dr. Kremer, testified that theworking conditions ofhairdressers 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. 

### Kremerpoints toelectrodiagnostictesting from February 2007 thatwasnegative for thoracic outlet syndrome. However, this test was before Hull reported 

### shoulderpain, and isnot reliabletorule outintermittentthoracic outlet syndrome.9 

### Ifthoracic outlet syndrome is an allowed occupational disease, then the 

### downstream complications ofHull's surgeries, the sequelae, are alsoallowed. Claimants must be reimbursed "[u]pon the occurrence of any injury to a worker

9PeaceHealth also argues thatHull's injury must have occurred priortowhen theclaim 

### was allowed by the Department, butthey erroneously cite December3, 2006 asthe date the claim wasallowed. In fact, itwasallowed onDecember 3,2007 andHull 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 treatmentfor her thoracic outlet syndrome, and as conditions secondary to thoracic outlet 

### syndrome, they are allowed. PeaceHealth does argue that Hull'sadjustment disorder withdepressed mood is not proximately related to her surgeries. They 

### supportthis argumentwith 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 iswell supported byexpert 

### medical testimony. All ofHull's downstream conditions listedin the orders appealed to the Department are allowed. 

### Lastly, Hull argued that the trial court erred byexcluding evidence that PeaceHealth paid forHull's surgeries. The trial court correctly excluded evidence 

### ofpayment under ER409 and ouranalysis does notincorporate 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 proximatelyfrom heremploymentwith PeaceHealth. As discussed above, the opinions ofPeaceHealth's experts are insufficientto support the trial

10No. 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 herwork activities caused thoracic outlet syndrome. And because the 

### thoracic outlet syndrome was proximatelycaused 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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