Opinion ID: 1772923
Heading Depth: 1
Heading Rank: 2

Heading: Plaintiff's Evidence Establishing Presumption of Causation

Text: Sidney Walton testified that before the accident he led a normal life, characterizing himself as a workaholic. He gave himself daily insulin injections, but experienced no disabling symptoms. The testimony of the plaintiff's wife, Deborah Walton, confirms his normal and active lifestyle prior to the accident. They both testified that after his treatment at the emergency room, Walton returned to work, but could only perform office duties. Both also testified that after his hospitalization from April 29 through May 3, 1981, Walton experienced continuing nausea, diarrhea and loss of weight, leading to further hospitalization on June 4 through 5, 1981. Mrs. Walton added that the plaintiff was very lethargic, spending most of his time at home in bed. The two further testified that the gastrointestinal and weight loss problems returned after the June hospitalization, eventually leading Dr. Herold to refer the plaintiff to the nephrologists. After the kidney transplant the plaintiff's gastrointestinal problems disappeared, and he has been able to engage in more activities. Dr. A.A. Herold, plaintiff's principal treating physician, is an internist specializing in the treatment of diabetes. He is a diabetic. He treats diabetic patients for all aspects of kidney problems associated with the disease, up until the time patients require dialysis or transplant. He had practiced medicine in his speciality for thirty-five years. He was clinical Associate Professor of Medicine, LSU School of Medicine, Shreveport, and a guest lecturer in diabetes. He had served as former president of the Louisiana Diabetes Association and was a member of the Southern Sugar Club, and the American Diabetes Association. As well as his daily practice, his teaching and association activities, Dr. Herold testified that he kept abreast of developments in the treatment of diabetes by reading pertinent medical journals and other literature on the subject. Nephrology was among the subjects of which he kept abreast, due to the frequency of kidney problems in diabetics. Dr. Herold testified that he had treated Walton since Walton developed diabetes at six years of age. He also treated Walton for the injuries he received in his work accident on April 23, 1981. At this time, Dr. Herold said Walton had extensive loss of blood into tissues of the low back, left buttock and left upper thigh with blood extravasated out into the tissues. At this time he also had a sharp elevation of his body's waste products, normally filtered out of the body by the kidneys into the bloodstream, which Dr. Herold said was by far the highest that Walton had experienced and indicated progressing renal dysfunction. After Walton's hospitalization, he failed to regain the kidney function that Dr. Herold felt that he should. Dr. Herold added that Walton's recovery was slow; he had continued soreness and weakness if he stayed at work for any significant period of time, ultimately becoming too weak to work. Dr. Herold later referred him to the nephrologists for transplant or dialysis evaluation. Dr. Herold has continued to treat Walton after his kidney transplant. He stated that Walton has made a significant improvement in his renal function, has continued to have some elevation of blood pressure, but less than before the transplant. Because Walton must take immuno-suppressive agents in order to prevent rejection of the transplanted kidney, he has less resistance to infection or trauma. Therefore, Dr. Herold advised that Walton should not engage in the work he was doing before as a general supervisor, general maintenance man at the apartment project which required some manual labor. He said even a simple cut or a simple upset stomach in a person whose immune system is compromised is a serious problem. Dr. Herold testified that there was a causal relationship between the fall and the injuries he had received and his disability due to the aggravation of his kidney dysfunction. Dr. Herold based this opinion on the fact that Mr. Walton was working and was gainfully employed prior to the fall but was unable to work after the fall and subsequently went into rather rapidly progressive renal failure. Another basis for the doctor's conclusion was that immediately after Walton's fall, laboratory tests indicated a substantial elevation of the creatinine content in Walton's blood. There were two possible ways in which the trauma which Walton received in the fall could have affected his kidneys, according to Dr. Herold. He said that with a fall of that magnitude it is quite likely that Walton's kidneys received a direct trauma from the fall. Secondly, the breakdown products of blood caused by the fall as they were absorbed and excreted from the tissues could have clogged the part of Walton's kidney that is involved in the excretion of wastes and could have prevented that excretion. Dr. Herold in part based his opinion that the accident causally contributed to the progressing renal failure on measurements of the creatinine level in Walton's blood during the period before and immediately after the fall. Dr. Herold explained that the most reliable test for evaluating renal function is measurement of creatinine. This is a measurement of waste products which are primarily produced by muscle activity in the body that must be filtered out through the kidneys. As the kidneys fail progressively, the creatinine backs up into the blood stream. Thus, the degree of kidney failure may be estimated by measuring the creatinine in the patient's blood. Dr. Herold noted that 1.5 milligrams per deciliter is considered normal and that Walton had a creatinine level of 2.3 in September of 1980, 2.9 in January of 1981, and 4.1 one week after the April 23, 1981 accident. He testified that the creatinine levels through January, 1981, reflected a fairly typical progression of renal failure, but that the rise in creatinine to 4.1 immediately after the accident indicated a sudden worsening of Walton's condition precipitated by the fall, especially considering the short time between the 2.9 level in January, 1981, and the 4.1 level just after the accident. Dr. Jose Barbosa, Associate Professor of Medicine, Division of Endocrinology and Metabolism, at the University of Minnesota, specializes in endocrinology, metabolism and particularly diabetes, and participated in Walton's diabetic care while Walton was at the University for his kidney transplant. Dr. Barbosa, testifying by interrogatories, agreed that plaintiff's accident had a considerable effect in speeding up the progression of his renal failure. Dr. Barbosa added that there are at least two ways such trauma could have accelerated renal failure, one being dehydration of the body and another being internal bleeding. Dr. David Sutherland, Associate Professor of Medicine at the University of Minnesota, specialized in general and transplant surgery, and performed Walton's transplant. Through interrogatory answers, Dr. Sutherland also agreed that Walton's accident accelerated the progression of his renal failure, necessitating transplant surgery much earlier than would have been required had the fall not occurred. Dr. Sutherland stated that such acceleration could have been caused directly by trauma to the kidneys in the fall, or indirectly by clogging the glomeruli (the kidneys' filtering mechanism) with hemaglobins released into the blood in response to the hemorrhaging into body tissues caused by the impact of the fall. He also stated that another way this hemorrhaging could cause acceleration of renal failure is by inducing a lower blood flow volume, depriving the kidneys of optimal blood flow for that period of time and consequently leading to a further loss of kidney function. Thus, Walton satisfactorily proved that before the accident he was fully performing all of the duties of his job without any disabling symptoms, that commencing with the accident he has been disabled continuously to perform his physical labor duties, and that there is both medical and circumstantial evidence indicating a reasonable possibility that his work injury aggravated, accelerated or combined with his preexisting diabetic kidney disease to produce his disability. Consequently, it became the burden of the defendants to prove the absence of any causal relationship between the accident and the aggravation or progression of the plaintiff's kidney dysfunction.