No. 87-263

INTHE SUPREME COURT OF THE STATE OF MONTANA
1987

RITAMAE SNYDER,
Claimantand Appellant,-vsSAN FRANCISCO FEED & GRAIN, Employer, and EBI COMPANIES AND ORION GROUP,
Defendantand Respondent.

APPEAL FROM: TheWorkers' CompensationCourt, The HonorableTimothy Reardon, Judge presiding.
COUNSEL OF RECORD:
For Appellant:
TrieweilerLawFirm; TerryN. Trieweiler, Whitefish, Montana
For R.espondent: Garlington, Lohn & Robinson; LarryW. Jones, Missoul.a, Montana

Submittedon Briefs: Nov. 13, 1987
Decided: December 31, 1987
Filed:\ii 

## 1987

ClerkMr. Justice John C. Sheehy delivered the Opinion of the Court.

Rita Mae Snyder appeals the judgment of the Workers' Compensation Court finding that her evidence did not establish a compensable industrial accident. San Francisco cross-appeals on the issue of the propriety of certain hypothetical questions. We reverse. The issuesbefore the Court are: 1. Was there substantial credible evidence to support the Workers1 Compensation Court's judgment that Snyder did not suffer a compensable industrial accident? (a) Does a stress related injury require a "psychological reconstruction?" (b) Does a compensable injury require a showing of physical impact? (c) Does a compensable injury have to arise from a single incident? Is the testimony of a treatingphysician entitled to 

# -. greater evidentiaryweight? 3. Did Rita Mae's counsel pose improper hypothetical questions? Rita Mae was 47 years old at the time of her trial in August, 1986. She had been married to Vernon Snyder for 29 years and had six children. Her youngest remained in the familyhome. Rita Mae can no longer care for her husband or family,however. On December 31, 1984, Rita Mae suffered a ruptured basilar tip aneurysm while performing her duties at San Francisco Feed & Grain (San Francisco) in Ronan, Montana. As a result of the ruptured aneurysm, Rita Mae sufferedextensive brain damage; she is confined to awheelchair; she has vision deficiencies; her memory has been affected; her reasoning process has been impacted; she engages in inappropriate behavior and laughs or cries forno reason; and she has had a guardian appointed. Her condition is permanent. Prior to the date of injury,Rita Mae's family did not have ahistory of aneurysms. She did not consume alcoholnor
was she overweight. She had no history of high blood pressure. She alleges thather aneurysmruptured as a result of job stress. Rita Mae began her duties as a bookkeeper with San Francisco in May, 1982. Her duties included helping customers, recording the weight of trucks, answering the phone, balancing the cash register, doing daily sheets, posting receivables, helping with the statements, posting inventory, totaling inventory books, helping total the cost of sales, and occasionally helping proof the computer printouts. She shared these duties with her sister/co-employee,Helen Teigen. Rita Mae was a conscientious, hard working employee. She was described as dedicated and concerned that her work

was current and correct. She seemed.happy with her work and

never complained. The situation at San Francisco changed dramatically in June, 1984, however. At that time, a new general manager assumed control of the San Francisco operation in Ronan. San Francisco employees described the new manager's style as chaotic and antagonistic. The work place became disorganized. Management-employee relationsdeteriorated. A change in the procedure for dealing with customers resulted in slower service and unhappy customers. On one occasion, Rita Nae had to call the police to prevent violence betweenthe manager and a disgruntled customerwho had been forced to wait severalhours. Rita Mae'swork situation continued to deteriorate. The lack of organization and communication caused thework place to become more frantic. The changed procedures resulted in angry customers and employees. Although Rita Mae was the type of person who was bothered by bickering, she often had to deal with the unhappy customers and smooth employee dissatisfaction. The seasonal increase in feed purchases during the winter months and a fire at San Francisco's main competitor further exacerbated the situation. During November and December, 1984,Rita Mae began working through her lunch hour and staying after hours in an attempt to stay current with her work. Although the overtimewas not paid, she began to fear she would lose her job, the family's sole source of income. RitaMae's job situationbegan to take a toll. She lost her cheerfulness about her job. Friends and family noticed she lookedmore andmorewrung-out. She seemed tobe under a lotofpressure fromwork and always appearednervous. The day of her injurywas unusual. Since December 31

### , 1984 was a Monday sandwiched between two days on which the businesswas tobe closed,businesswas expected tobebrisk. Nevertheless, the work force was only 7, rather than the usual 10 employees. In addition, Rita Mae had end-of-the-month bookkeeping to complete. When she arrived at work that day, Rita Mae appeared fine. She soon looked fatigued,however. Shehad noted that

an upsetting customer was scheduled for servicing that day. She also was having difficulty deciphering one of the manager's incomplete invoices. The unfinished invoice appeared to upset her. Shortly thereafter, Rita Mae wasfound slumped over herdesk andwas later diagnosed ashaving

a ruptured aneurysm. The medical evidence received at trial consisted of the deposition testimony of 3 neurological specialists. The doctors were instructed to base all opinions on the medical standard of more likely than not. Generally, they are in agreement concerningRitaMae's injury. It is agreed that an aneurysm is aweak spot in ablood vessel analogous to a weak spot in an inner tube which expands and develops a balloon-like appearance; that Rita Mae's aneurysm developed sometime during her teenage years; that not all aneurysms rupture; that psychological stress elevatesblood pressure; that increased blood pressure places increased pressure on the aneurysm, often resulting in rupture; and that intracranial aneurysms can rupture spontaneously without change invascularpressure. Dr. Richard Dewey is a neurological surgeon. Dr. Dewey examined Rita Mae upon her arrival inMissoula and confirmed that shehad a ruptured aneurysm. Following aperiod of time necessary to stabilize Rita Mae's condition, Dr. Dewey performed a craniotomy in order to prevent a second rupture. Prior to his deposition, Dr. Dewey stated that in his opinion, "the claimant's work was not in any way causally related to [theruptured aneurysm]." Dr. Dewey'sopinionwas offered in response to a written request by counsel for San Franciso. At hisdeposition, however,Dr. Dewey indicated thatnew informationhad since come tohis attention. Q. And do you still hold that opinion today? A. Based on the information that I had as of 16 July '86 regarding Mrs. Snyder's work or what my impressions were of her job at that time, my opinion is still valid. It would be unfair for me--or not unfair, but inappropriate, I think to change that opinion. That is what T stated, andthat's what Ibelieved at that time. And based on that same information, I would arrive at the same conclusion.

Q. When you say "information", is that information--A. Well-- Q. --about Rita Mae Snyder's work? A. I have been informed of some circumstanceswhich,in fact, may have some causal relationship subsequenttomy dictating that letter.

In addition, Dr. Dewey indicated that Rita Mae1 s stressful work environment could have aggravated the aneurysm. Q. Did Mr. Jones mention any unusual changes in the work place or stressors in thework place when he asked foryour opinions?

A. Idonot see that [inthe letter].
Q. Did Mr. Jones inquire whether itwasmedically possible that an increased work load or increased stress in the work place aggravated or accelerated Rita Snyder'spre-existing condition?

A. No,he did not. Q. Would that informationpossibly have changed an opinion thatyouhad given toMr. Jones in response to his letter. A. I don't know. I guess it depends on what information he had given me. That's a question that's very difficult to answer even in retrospect. But, in practical terms, I think the more information that a physician has, the more appropriate and informed his answer may be. Q. Dr. Dewey, would you agree that the following work situations more likely than not cause workers to experience stress: One, a disorganized procedure for handling customers; two, angry customers; three, poor communications withmanagement; four, increased work load; five, unusual and unpaid for overtime; and six, job duties that cannotbe completed correctly?

A. Well, I don't think it requires a medical degree to answer those questions. Those all seem like stressful--thatall seems like collectively a stressful work environment.
Q. When a worker experiencesa stressful situation in their work place, is it medically possible and probable that that situation could cause them to suffer elevation inblood pressure?

A. Again, my feeling is that stress of any kind may lead to the transient--at least transient elevation of blood pressure. In our treatment of patients,once they arrive at thehospital,whenwe are attempting to reduce blood pressure, is to do the opposite. That is, to avoid all stressful circumstances. So, I can't say that a particular stress raises blood pressure; but it is possible and probable that stressful situations,regardless of their cause,may elevateblood pressure.

Q. Dr. Dewey, testimony at trial was offered to the following facts: That through the fall months of 1984, Rita Snyder worked progressively more unpaid overtime. That through the fall months of 1984, communication between the management and the employees at her place ofwork deteriorated. That during the fall months of 1984, the procedure for scheduling customers changed. The business operated in a less organized fashion, and further that one of Rita Snyder's job duties, that of balancing the till, became progressively more difficult because the manager would remove money from the till and not leave a note telling anyone how much or that he had done so. On December 6th, 1984, the business's closest competitor was destroyed by fire, and within aweek Rita Snyder's jobdutieswere increasedboth in customers shehad to wait on and the bookkeeping that shehad to do.About this point in time Rita Snydermade comments about the job being a rat race. That she feared she would lose her job.
If the Court finds as fact some or all of those incidents,as I have related them, do those sound like incidents that would causeRita to feel stress inher work place?
A. Those are, in my opinion and I think in most lay people's opinion--most lay people would agree are stressful. Q. Is it medically possible that that chain of incidents aggravated or accelerated the ultimate result of Rita Snyder's basilar artery aneurysm?

A. If those--if that chain of events caused any significant change in blood pressure, then they would have a bearing; and that is an acceleration of the stressof thewall of the aneurysm. Q. At the time of trial, testimony was offered concerning the following facts about December 31st, 1984: December 31st, 1984,was an unusually busy day. Rita Snyder's place of employment was short three or four employees of the normal number of ten. Rita had commented soon after coming towork that anunusually unpleasant customerwas scheduled to come in and do business at her place of employment. The other bookkeeper that Rita Snyder shared duties with was busy with another job and couldn't help Rita with her customers and her work up in the front of her business place. When Rita came towork in themorning, she looked normal and fresh. And after approximately anhour, she looked tired and wrung out. And shortly before Rita's syncopalepisode,Rita asked forhelp todeciferan invoice that had been incorrectly and incompletely filled out. Assuming the Court finds as fact some or all of those incidents, are those incidents occurrences that would cause Rita to suffer stress inher work place.A. What you're describing, again, sounds to me like it is entirely possible that that is a stressful circumstance, stressful situation. That that stressful situation could possibly have elevatedblood pressure. Q. Could the elevation of the blood pressure aggravateor accelerate the ultimate ruptureofher basilar artery aneurysm? A. Any elevationof the mean arterial pressure will accelerate the rupture of an aneurysm. Let me rephrase that. Any elevation in mean arterial pressure predispose--predisposes an aneurysm to rupture because it can be directly--it will directly reflect itself in tension of the wall of the aneurysm. Dr. Gary Cooney is a neurologist who practices in conjunction with Dr. Dewey. In his practice, Dr. Cooney regularly evaluates patients for stress-related conditions. He opined that he performs that type of evaluation more frequently than a neurosurgeon. Dr. Cooney initially reviewed Rita Mae's medical records at the request of a psychiatrist involved in Rita Mae's treatment. He also gathered additional informationand continued to take part in Rita Mae's treatment. In his opinion, the rupture of Rita Mae's aneurysmwas causallyrelated towork stress. Q. Dr. Cooney, do you have an opinion to a reasonable degree ofmedical certainty whether Rita Snyder's current problems are causally related to the ruptured aneurysmand its treatment? A. Ido. Q. What is your opinion? A. I believe that the rupture of the patient's aneurysm was related to the medical problems that she was experiencing at the time of the rupture which were exaggerated and aggravated by work stress which she had been experiencing for some time.

Q. Dr. Cooney, can you state whether or not the following situations more likely than not would cause a bookkeeper who also waits on customers toexperience stress: One, a disorganized procedure forhandling customers; two,unsatisfied customers; three,poor communicationwithmanagement; four,an increased work load; five, unusual and unpaid for overtime; and, six, job duties that cannot be completed correctly nor on time.

A. All of those conditions would probably increase an individual's levelof stress. Q. If each situation would increase an individual

### 's level of stress,would several or all of those situations at the same time add additional stress?

A. Theywould.

Q. At the time of trial,Dr. Cooney, testimonywas offered to the following facts concerningDecember 31, 1984: December 31, 1984,was anunusually busy day at Rita Snyder's place of employment. Rita Snyder'splace of employment normallyoperatedwith ten employees and had six or seven working on December 31. Early in the morning ofDecember 31, Rita commented that an unusually unpleasant customer was scheduled to come in and do business at her place of employment. The other bookkeeper who normally worked with Rita Snyderwasbusy with other job duties and was unable to help Rita with waiting on customers and some of the other job duties that Rita had to do. That December 31, 1984,was the day the end of the month bookkeeping was to be done on. The end of the month bookkeeping was an extra, additional duty in addition to Rita's normal job duties. When Rita Snyder came to work on themorning of December 31, she appeared normal. After one hour in the work place, she appeared wrung out. Shortly before Rita's syncopal episode at work, Rita asked for help from the other bookkeeper because she was unable todecipher somepaper work that themanager had incorrectly and incompletely filled out.Dr. Cooney, if the Court finds as fact those facts substantially as I have related them to you, is it--are those incidents such as would normally cause aworker to experience unusual stress?

A. Iwould think that those eventswould cause an unusual amountof stress.
Q. Is it medically possible that these incidents aggravated or accelerated the ultimate result of Rita Snyder's pre-existing basilar artery aneurysm?

A. Yes.

Q. Is it medically probable that Rita Snyder experienced a stress reaction to her work place generally after being exposed to stressful experiencesover aperiod of time?

A. It's certainly possible that that occurred.
Q. Dr. Cooney, do you have an opinion, to a reasonable degree of medical certainty, whether Rita Snyder's aneurysmwould have rupturedwhen it did if she had not been exposed to unusual work stress?

A. Ido.
Q. What is your opinion?

A. I believe that it is more likely that the aneurysm ruptured when it did, presuming that she was exposed to the stresses that we have been discussing, than would have occurred had she not experienced that sortof stressfulsituation.Dr. Albert Joern is a neurosurgeon and former medical school professor. Dr. Joern examined Rita Mae's records and concluded that it is more likely than not that there is a causal relationship between the unusual stress in her work place and the rupture ofRitaMae's aneurysm. The central issues in the case at hand concerns the sufficiency of evidence presented by the claimant. It is well settled that decisions of the Workers' Compensation Court will be upheld upon a finding of substantial credible evidence. Tocco v. City of Great Falls (Mont. 1986), 714 P.2d 160, 163, 43 St.Rep. 310, 314. "However, when the critical evidence,particularly medical evidence, is entered by deposition, we have held that 'this Court, although sitting in review, is in as good a position as the Workers' Compensation Court to judge the weight to be given record testimony 

# .

# .."' Jones v. St. Regis Paper Co. (1982), 196 Mont. 138, 146, 639 P.2d 1140, 1144, citing Hert v. J. J. Newberry Co. (1978), 178 Mont. 355, 584 P.2d 656. We find the medical evidence, together with other evidence is sufficient to establish a compensable injury within the meaning of the Montana Workers' CompensationAct. The Workers' Compensation Court found that Rita Mae was upset on the day in question; that stress causes an increase inblood pressure; and that an increase inblood pressure can
cause an aneurysm to rupture. The court concluded,however, that therewas insufficient evidenceofwork caused stress in the degree needed to elevate blood pressure. Such a conclusion is in stark contrast with the evidence presented at trial. Themedical experts unanimously agreed that the average person would deem Rita Mae's work place unusually stressful in the months immediatelypreceding her injury. The experts also agreed that the work environment on the day of theinjury was particularly stressful. San Francisco contends such evidence isnot significant,however. San Francisco places great reliance on the fact that human beings react differently to environmental stimuli. It is alleged that this variation and our decision in Campbell

v. Young Motor Company (Mont. 1984), 684 P.2d 1101, 41 St.Rep. 1218, requires that a psychologist perform a "psychological reconstruction" demonstrating that R-itaMae foundherwork environment stressful. We disagree. In Campbell, the issuewas whether suicide isper se an independent, intervening cause which precludes the award of death benefits to an injured workers beneficiary. We held that suicide is compensable if the on-the-job injuryproduces post-injury trauma which causes the suicide. 684 P.2d at 1103, 41 St.Rep. at 1220. We did not set forth an evidentiary rule requiring a "psychological reconstruction" if psychological factors are involved. The "psychological autopsy" performed in Campbell was merely recognized as a method of establishing a nexus between the injury and resulting suicide. In the instant case, Rita Mae's family and co-workers testified, inter alia, that Rita Mae was under a great deal of pressure from work; that she had been working progressively more unusual and unpaid overtime; thather job duties had become more difficult; that she had to dealwith angry customers and employees; that the work place was disorganized; that there was poor communication with management; and, that she feared she would lose her job. There is no evidence that Rita Mae was an emotional zombie. The record discloses quite the opposite. The medical experts agreed that Rita Mae's work environment was very stressful. Rita Mae's co-workers and family confirmed that Rita Mae was affected by the stress.The testimony showed she appeared nervous all the time; she

was thought to be under a great deal of pressure fromwork; and, she appeared wrung-out soon after arriving atwork. We find the evidence is sufficient to demonstrate that Rita Mae foundherwork environmentunusually stressful. As Dr. Dewey indicated, it does not take a medical degree to determine that thework environmentwasvery stressful. In the alternative, San Francisco contends that S 39-71-119, MCA (1983),which was controlling at the time of the rupture,precludes a finding of compensable injury absent

a showingofphysical impact. Itprovides: "Injury" or "injured" means: (1) a tangible happening of a traumatic nature from an unexpected cause or unusual strain resulting in either external or internal physical harm and such physical condition as a result therefrom and excluding disease not traceable to injury


# .. . By its terms, the statute does not require that an injuryarise froma specific instanceofphysical impact. "A tangible happening must be a perceptible happening 

# ... Some action or incident, or chain of actions or incidents, must be shownwhichmay be perceived as a contributing cause of the resulting injury." Erhartv. Great Western Sugar Co.

(1976)

## , 169Mont. 375, 381, 546 P.2d 1055, 1058. The stress induced increase in blood pressure which gradually expands a blood vessel to the point of rupture is such a chain of incidents. The fact that the injuryproducing stimulus is in the form of sustained emotional stress or strain does not make the impact on the body any less harmful or real. We hold that the unusual and unexpected mental strain of a stressful work environment which causes a pre-existing aneurysm to rupture is a tangible happening of a traumatic nature from an unusual strain. See Rathbun v. Tabor Tank Lines (1955)

### , 129 Mont. 121, 283 P.2d 966 (unusual stressand strainwhich causes injury is a compensableoccurrence); Hoehne v. Granite Lumber Co. (1980), 189Mont. 221, 615 P.2d 863 (tangible happening need not be a single, isolated incident); Jones, supra (claimant need not identify specific incident which causes injury);Wise v. Perkins (Mont. 1983)

## , 656 P.2d 816,40 St.Rep. 1 (excessive work weekwhich results in phlebitis constitutes a tangible happening of a traumatic nature from an unusual strain); Tocco, supra, (emotional stress contributing causeof injury). By soholding,we join the overwhelming majority of jurisdictions which recognize aggravationof an aneurysmas a compensable injury. We note, however, that this opinion may be unique in light of the Legislature's subsequent modification of the injury statute. SeeS 39-71-119(3)(a). The second issue before the Court concerns the evidentiary weight to be given the testimony of the treating physician. Rita Mae contends that theWorkers' Compensation Court improperly gave the deposition testimonyof Dr. Dewey, the treating physician, greater weight. As a general rule,

we agree that the testimony of a treating physician is entitled to greater evidentiary weight. See generally Drescher 

### v. Liberty Mutual Fire Insurance Co., WCC No. 8509-3254, decided February 11, 1986; Goodman v. Liberty Mutual, WCC No. 8502-2897,decided September 3, 1985. Logic indicates that the treating physicianwill normally have had more contact with, and greater knowledge of, the injured worker. As a result,the treatingphysician shouldgenerally be in the bestposition to give an informed opinion. However, the treating physician rule is not cast in stone. In the instant case, Dr. Dewey indicated that his initial opinion was, in effect, based on incomplete knowledge. The court ignored Dr. Dewey's subsequent acknowledgement that it is possible and probable that theunusually stressful work environment resulted in elevated blood pressure and that elevated blood pressure can cause an aneurysm to rupture. In addition, Dr. Cooney also took part in the care and treatment of Rita Mae. He concluded that Rita Mae's unusually stressful work environment was causally connected to the subsequent rupture of the aneurysm. His opinion, which was affirmed by Dr. Joern,was also ignored,however. Under these circumstances,we agree that the court improperly relied uponDr. Dewey's initialconclusion. The final issue before the Court is thepropriety of the hypothetical questions posed to the medical experts by Rita Mae

### 's counsel. Although San Francisco objected to the hypothetical questions, the Workers

## ' Compensation Court did not rule on the matter in light of its decision on the merits. We address the issue in the interests of judicial economy and finalresolutionof the controversy. Although the Workers' Compensation Court was not generally bound by the rules of evidence at the time in question, the court has often looked to theMontana Rules of Evidence for guidance. San Francisco contends that the hypothetical questions, reproduced infra, were improper because the questions contained improper characterizationsof the evidence,the facts reliedupon were notproven at trial, and Dr. Joernrelied upon information not communicated to the Court. Assuming, argumendo, that the stricter standard of the Montana Rules of Evidence did apply,we find no error. A review of the record indicates that the alleged mischaracterization of the record did not occur. The facts contained in the hypothetical questions posed by counsel accurately reflect the testimony presented. We will not require counsel to engage in a verbatim regurgitation of prior testimony. See Gra.ham

### v. Rolandson (1967), 150 Mont.270, 435 P.2d 263. San Francisco's contention that the facts relied upon were notproven is similarlywithoutmerit. Finally,we call San Francisco's attention to Rule 705, M.R.Evid. Itprovides: Disclosure of facts or data underlying expert 

### -- opinion. The expert may testify in terms of opinion or inference and give his reasons therefor withoutprior disclosureof theunderlying factsor data, unless the court requires otherwise. The expert may in any event be required to disclose of the underlying facts or data on cross-examination.

As Rule 705 indicates,an expert need not delineate the complete basis forhis orher opinionprior to offering that opinion. Counsel for San Francisco thoroughly investigated the matter on cross-examination. We findno error. The judgment of the Workers' Compensation Court is reversed with instructionsto enter judgment in favorofRita 

# - Mae Snyder.

We Concur: /