United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

O.C., Appellant

and

DEPARTMENT OF HOMELAND SECURITY, 

CUSTOMS & BORDER PROTECTION, 

San Diego, CA, Employer

__________________________________________

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Docket No. 17-1175

Issued: October 29, 2018

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On May 8, 2017 appellant filed a timely appeal from a March 24, 2017 merit decision of 

the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal Employees’

Compensation Act1(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.

ISSUE

The issue is whether appellant has met his burden of proof to establish a left lung condition 

causally related to the accepted August 31, 2016 employment incident.

 

1 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY

On August 31, 2016 appellant, then a 40-year-old customs and border protection officer, 

filed a traumatic injury claim (Form CA-1) alleging that he developed a left lung injury earlier that 

evening while in the performance of duty due to inspecting merchandise, stretching, and lifting. 

On August 31, 2016 the employing establishment provided an authorization for 

examination and/or treatment (Form CA-16). Appellant was transported to the Scripps Mercy 

Hospital emergency department via ambulance and was later admitted to the hospital where he 

remained until discharged on September 11, 2016. 

In an August 31, 2016 hospital report, Dr. Martha D. Strauser, a Board-certified internist, 

indicated that appellant’s admission diagnosis included recurrent and spontaneous left 

pneumothorax and he presented with left-sided chest tightness, which happened while at work. 

Appellant became short of breath with severe chest pain and discomfort. He had similar symptoms 

six months prior to admission at which time he also had spontaneous pneumothorax treated with 

a chest tube. Appellant had video-assisted thoracoscopic surgery (VATS) on September 2, 2016, 

with partial resection of the left upper lobe due to multiple bullae requiring two chest tubes

postsurgery. On September 7, 2016 he developed a fever and Dr. Strauser found that an 

echocardiogram revealed a normal left ventricular function with an ejection fraction of 60 to 65

percent with no evidence of vegetations. 

In a second August 31, 2016 hospital report, Dr. Kirk Raeber, an osteopath Board-certified 

in emergency medicine, noted that appellant was at work when he felt pain in his left chest. He

reported that appellant had sustained a similar episode six months prior when he developed a 

pneumothorax and was hospitalized at Sharp Chula Vista, had a chest tube placed, and was 

hospitalized four to five days. Dr. Raeber found that a chest x-ray showed “a pneumothorax on 

the left side approximately 40 [percent]” and diagnosed left-sided pneumothorax. 

In a third August 31, 2016 hospital report, Dr. Amanda R. Defour, an internist, noted that 

appellant was at work when he suddenly felt shortness of breath and chest tightness, but he knew 

right away that he had a pneumothorax because he had a very similar incident six months prior 

when he went to Sharp Chula Vista Hospital. She opined that the etiology of appellant’s recurrent 

pneumothorax was unclear at that time. 

A September 1, 2016 computerized tomography of the chest revealed a small 

predominantly anterior left-sided pneumothorax and a chest x-ray dated September 1, 2016,

showed persistent left apical pneumothorax. 

In a September 1, 2016 report, Dr. Michael P. Koumjian, a Board-certified cardiovascular 

surgeon, noted that appellant had a left-sided pneumothorax six months prior and had a recurrence 

on August 31, 2016. He diagnosed recurrent left pneumothorax and scheduled a left video-assisted 

thoracoscopic resection, which he performed on September 2, 2016. 

A chest x-ray dated September 2, 2016, revealed a significant collapse of the left lung by 

approximately 60 percent of the left chest volume. 
3

A September 3, 2016 x-ray of the chest showed no significant residual pneumothorax status 

post-left-chest-wall surgery with chest-tube placement. 

A September 4, 2016 chest x-ray demonstrated postoperative thoracotomy with chest tubes 

and tiny apical residual right pneumothorax. 

A September 5, 2016 chest x-ray showed that the heart and mediastinum were within 

normal limits, left thoracotomy tubes were in place, there was a small left pneumothorax with mild 

interval increased in size, there was basilar subsegmental atelectasis, and a small left pleural

effusion. 

A September 7, 2016 chest x-ray revealed small apical left pneumothorax and bibasilar 

atelectasis. 

Two chest x-rays dated September 8, 2016, demonstrated residual tiny left apical 

pneumothorax measuring approximately 2.6 millimeter (mm) in diameter and left pneumothorax 

at the apex measuring 4.7 mm, previously measured at 2.6 mm. 

A September 9, 2016 chest x-ray showed a stable to slightly smaller apical tiny left 

pneumothorax with chest tubes in place. 

A venous duplex of the left upper extremity dated September 9, 2016 revealed occlusive 

thrombus throughout the cephalic vein from the level of the wrist to the antecubital fossa. 

In a September 9, 2016 report, Dr. Shawn S. Koura, an internist, noted that appellant had 

a history of recurrent spontaneous pneumothoraxes “likely due to his body habitus who underwent 

VATS procedure and resection of his left superior segment with removal of blebs.” He found that 

appellant was doing well, but then developed fevers and shaking chills due to methicillin-sensitive 

Staph aureus bacteremia. Dr. Koura diagnosed sepsis, septic thrombophlebitis, and recurrent 

pneumothorax. 

A chest x-ray dated September 10, 2016, showed no pneumothorax status post chest tube 

removal and no significant change in airspace opacities. 

On September 12, 2016 Dr. Koumjian found that appellant’s left pneumothorax had 

resolved and discharged him home with antibiotics. 

In a September 19, 2016 work excuse note, Dr. Koumjian advised that appellant was under 

his care for post-thoracic surgery for pneumothorax and was disabled for work for the period 

August 31 to November 2, 2016. 

On October 3, 2016 Jerome Glincosky, a physician assistant, diagnosed bacteremia 

associated with intravascular line, recurrent spontaneous pneumothorax, essential and other 

specified form of tremor, and anxiety disorder due to a general medical condition with panic attack. 

In an October 6, 2016 report, Dr. Tifani Gleeson, a Board-certified occupational medicine 

specialist, indicated that she had reviewed available medical reports and claim documentation, but 

had not spoken with or examined appellant, who had reported a second spontaneous 
4

pneumothorax. She noted that appellant had an initial onset of chest pain at work on June 1, 2016

and that appellant reported that he continued to work and sought care in the emergency room after 

he left work for the day. Appellant was hospitalized until June 6, 2016, and returned to full duty 

on June 14, 2016. On August 31, 2016 he was at work inspecting merchandise when he had a 

second onset of chest pain and was diagnosed with recurrent spontaneous pneumothorax. 

Appellant underwent a VATS procedure for resection of multiple blebs and pleurodesis and was 

discharged home with home health and antibiotics to treat an infection of his intravenous line while 

in the hospital. Dr. Gleeson noted that a spontaneous pneumothorax occurred with a sudden onset 

of chest pain or shortness of breath without a precipitating event in an individual with no known 

lung disease, but most often occurred from the rupture of an unrecognized pleural bleb. Pleural 

blebs could occur in young, healthy individuals with no known risk factors or they could be 

attributed to risk factors such as smoking, family history, and certain systemic medical conditions. 

Dr. Gleeson found that there was no indication that appellant had any additional contributing 

medical conditions and he most reasonably had a spontaneous rupture of previously unrecognized 

pleural blebs that had since been treated appropriately. She opined that there was “no rationale 

provided by a treating physician to indicate any association with work” and there was “no 

indication that the underlying causative pathophysiology, (pleural blebs) and resultant condition”

was related to work activities. 

In an October 17, 2016 claim development letter, OWCP advised appellant of the 

deficiencies of his claim and afforded him 30 days to submit additional factual information and 

medical evidence.

In response, appellant submitted a June 2, 2016 chest x-ray and hospital report from

Dr. William Contreras, a Board-certified internist at Sharp Chula Vista Medical Center, who 

diagnosed spontaneous pneumothorax and history of essential tremor. 

Appellant also submitted two chest x-rays dated September 1, 2016, which revealed 

approximately 40 percent left-sided pneumothorax and a left-sided chest tube placed with 

improved left-sided pneumothorax and residual at the left apex. 

A September 6, 2016 chest x-ray showed a new second chest tube in the left hemi thorax 

with reduced left pneumothorax. 

On October 31, 2016 Dr. Koumjian released appellant to full-time, full-duty work effective 

November 2, 2016. 

By decision dated November 18, 2016, OWCP accepted that the August 31, 2016 

employment incident occurred as alleged, but denied the claim because the medical evidence of 

record failed to establish a causal relationship between appellant’s diagnosed conditions and the 

August 31, 2016 work incident. 

On December 27, 2016 appellant requested reconsideration. 

In a November 7, 2016 response to OWCP’s factual questionnaire, appellant indicated that 

at around 4:00 p.m. on August 31, 2016 he conducted a routine inspection of the cab of a 

commercial truck and lifted a bed frame and mattress weighing approximately 40 pounds above 

his head while kneeling on the floor. As he lifted it overhead, he felt a sharp pain on the left side 
5

of his chest. Appellant continued to work, but after beginning a shift in traffic control, the pain 

became unbearable and he experienced shortness of breath. At that time, he left work and went to 

the hospital via ambulance. 

A September 8, 2016 echocardiogram revealed that the left ventricle was grossly normal 

in size and the ejection fraction was 60 to 65 percent by visual estimation. In a December 7, 2016 

report, Dr. Jose Lira, a Board-certified pulmonary disease specialist, diagnosed recurrent 

spontaneous pneumothorax, lung bullae, and history of thoracotomy. He indicated that, in June 

2016, appellant was hospitalized at Sharp Chula Vista Hospital with complete left lung collapse 

due to spontaneous pneumothorax and was treated with chest tube drainage for two days. A month 

later, appellant again developed shortness of breath, and this time he underwent resection of bulla 

and decortication of the left lung at Scripps Chula Vista Hospital. Dr. Lira found that appellant’s 

complete pulmonary function testing was within normal limits. He opined that exposure to truck 

fumes for 10 years “may have trigger[ed] rupture of bullae.” 

By decision dated March 24, 2017, OWCP denied modification of its prior decision. 

LEGAL PRECEDENT

A claimant seeking benefits under FECA2 has the burden of proof to establish the essential 

elements of his or her claim by the weight of the reliable, probative, and substantial evidence,

including that an injury was sustained in the performance of duty as alleged and that any specific 

condition or disability claimed is causally related to the employment injury.3

To determine if an employee sustained a traumatic injury in the performance of duty, 

OWCP begins with an analysis of whether “fact of injury” has been established. Generally, fact 

of injury consists of two components that must be considered in conjunction with one another. 

The first component is whether the employee actually experienced the employment incident that 

allegedly occurred.4 The second component is whether the employment incident caused a personal 

injury.5 An employee may establish that an injury occurred in the performance of duty as alleged, 

but fail to establish that the disability or specific condition for which compensation is being 

claimed is causally related to the injury.6

Causal relationship is a medical question that generally requires rationalized medical 

opinion evidence to resolve the issue.7 A physician’s opinion on whether there is a causal 

relationship between the diagnosed condition and the implicated employment factor(s) must be 

 

2

Id.

3 20 C.F.R. § 10.115(e), (f); see Jacquelyn L. Oliver, 48 ECAB 232, 235-36 (1996).

4 Elaine Pendleton, 40 ECAB 1143 (1989).

5

John J. Carlone, 41 ECAB 354 (1989).

6 Shirley A. Temple, 48 ECAB 404, 407 (1997).

7 Robert G. Morris, 48 ECAB 238 (1996).
6

based on a complete factual and medical background.8 Additionally, the physician’s opinion must 

be expressed in terms of a reasonable degree of medical certainty, and must be supported by 

medical rationale, explaining the nature of the relationship between the diagnosed condition and 

appellant’s specific employment factor(s).9

In any case where a preexisting condition involving the same part of the body is present 

and the issue of causal relationship therefore involves aggravation, acceleration, or precipitation, 

the physician must provide a rationalized medical opinion that differentiates between the effects 

of the work-related injury or disease and the preexisting condition.10

Certain healthcare providers such as physician assistants, nurse practitioners, physical 

therapists, and social workers are not considered “physician[s]” as defined under FECA.11 

Consequently, their medical findings and/or opinions will not suffice for purposes of establishing 

entitlement to FECA benefits.12

ANALYSIS

OWCP accepted that the August 31, 2016 employment incident occurred as alleged, and 

also accepted that there was a medical diagnosis in connection with the employment incident. 

However, it denied appellant’s traumatic injury claim as the medical evidence of record was 

insufficient to establish a causal relationship between the diagnosed condition(s) and the accepted 

employment exposure. The issue is whether appellant’s left lung condition resulted from the 

accepted August 31, 2016 employment incident. The Board finds that appellant has not met his

burden of proof to establish causal relationship.

The diagnostic testing of record confirmed the diagnosis of left-sided pneumothorax. 

However, the diagnostic studies do not address the etiology of appellant’s left lung condition and 

are thus insufficient to meet appellant’s burden of proof.

13

 Appellant also submitted evidence from 

a physician assistant. This document does not constitute competent medical evidence because a 

physician assistant is not considered a “physician” as defined under FECA.14 In her October 6, 

2016 report, Dr. Gleeson found that appellant had been diagnosed with recurrent spontaneous 

pneumothorax, but no rationale was provided by a treating physician to indicate that his condition 

 

8 Victor J. Woodhams, 41 ECAB 345, 352 (1989).

9

Id.

10 Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal Relationship, Chapter 2.805.3e (January 2013).

11 5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t).

12 K.W., 59 ECAB 271, 279 (2007); David P. Sawchuk, 57 ECAB 316, 320 n.11 (2006). A report from a physician 

assistant or certified nurse practitioner will be considered medical evidence if countersigned by a qualified physician. 

Supra note 10 at Chapter 2.805.3a(1) (January 2013).

13 See L.C., Docket No. 17-1788 (issued September 19, 2018).

14 See supra notes 11-12.
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was related to work activities. Consequently, the above-noted evidence is insufficient to satisfy 

appellant’s burden of proof with respect to causal relationship.15

Dr. Koumjian noted that appellant had a left-sided pneumothorax six months prior and a 

recurrence on August 31, 2016. He diagnosed recurrent left pneumothorax and performed a VATS 

procedure on September 2, 2016. Dr. Koumjian found that appellant’s left pneumothorax had 

resolved as of September 12, 2016, and discharged him home with antibiotics. He advised that 

appellant was disabled for work for the period August 31 to November 2, 2016, and then released 

him to full-time, full-duty work effective November 2, 2016. The Board finds that Dr. Koumjian 

did not provide any medical rationale explaining how appellant’s left lung condition was caused 

or aggravated by inspecting merchandise on August 31, 2016. The need for rationale is 

particularly important as the evidence indicates that appellant had a preexisting condition.16 

Therefore, the Board finds that the reports from Dr. Koumjian are insufficient to establish causal 

relationship.

In his September 9, 2016 report, Dr. Koura noted that appellant had a history of recurrent 

spontaneous pneumothoraxes “likely due to his body habitus.” In his December 7, 2016 report,

Dr. Lira diagnosed recurrent spontaneous pneumothorax, lung bullae, and history of thoracotomy

and opined that exposure to truck fumes for 10 years “may have trigger[ed] rupture of bullae.” 

The Board finds that the opinions of Drs. Koura and Lira regarding the cause of appellant’s left 

lung condition are speculative and equivocal in nature.17 They fail to sufficiently explain the 

reasons why diagnostic testing and examination findings led them to conclude that appellant’s left 

lung condition was employment related. A physician’s opinion must be supported by medical 

rationale, explaining the nature of the relationship between the diagnosed condition and appellant’s 

specific employment factor(s).18 The fact that a condition manifests itself during a period of 

employment is insufficient to establish causal relationship.19 Temporal relationship alone will not 

suffice.20 Thus, the Board finds that the reports from Drs. Koura and Lira fail to establish that 

appellant sustained a left lung condition causally related to the August 31, 2016 employment 

incident.

In their reports, Drs. Contreras, Strauser, Raeber, and Defour diagnosed left-sided 

pneumothorax. Nevertheless, the Board finds that these reports are of limited probative value 

because they all fail to address whether the accepted August 31, 2016 employment incident caused 

the diagnosed condition. The Board has held that medical evidence that does not offer any opinion 

regarding the cause of an employee’s condition is of no probative value on the issue of causal 

 

15 See supra notes 6-9, 11-12.

16 See supra note 10.

17 Medical opinions that are speculative or equivocal in character are of little probative value. See Kathy A. Kelley, 

55 ECAB 206 n.8 (2004).

18 Supra note 8.

19 20 C.F.R. § 10.115(e).

20 See D.I., 59 ECAB 158, 162 (2007).
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relationship.21 Therefore, this evidence is insufficient to establish that appellant sustained an 

employment-related injury.

As appellant has not submitted any rationalized medical evidence to support his claim that 

he sustained a left lung injury causally related to the August 31, 2016 employment incident, he has 

failed to meet his burden of proof to establish entitlement to compensation benefits.

Appellant may submit new evidence or argument with a written request for reconsideration 

to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R. 

§§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant has not met his burden of proof to establish that his left lung 

condition is causally related to the accepted August 31, 2016 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the March 24, 2017 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: October 29, 2018

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board

 

21 See L.B., Docket No. 18-0533 (issued August 27, 2018); D.K., Docket No. 17-1549 (issued July 6, 2018).