Opinion ID: 163939
Heading Depth: 4
Heading Rank: 1

Heading: The Symptoms of HACE

Text: 29 The Railroad first argues that Dr. Teitelbaum's basic contention — that Mr. Goebel exhibited symptoms classically associated with HACE — is not supported by the cited literature. Aplt. Br. at 30. Among the many symptoms exhibited by Mr. Goebel were a severe headache, tightness in his chest, significant aches and soreness, shortness of breath, nausea and disorientation that rendered him unable to read. In the Railroad's view, the studies cited by Dr. Teitelbaum do not support a diagnosis of HACE based on these symptoms. After reviewing the Railroad's citations to various studies and uncovering no significant support for its position, we conclude that the district court did not abuse its discretion. 30 Dr. Teitelbaum's opinion — that Mr. Goebel suffered from acute mountain sickness (AMS) which developed into non-acute HACE, see II R. at 356, ¶ 8 — was supported by The Lake Louise Consensus on the Definition of Altitude Illness, available in Thomas E. Dietz, High Altitude Medicine Guide (2000), II R. at 398. That study indicates that in the setting of a recent altitude gain, a headache plus nausea is alone sufficient to support a diagnosis of AMS. Id. Mr. Goebel clearly satisfied this criteria. The study also states that in such a setting, the presence of a change in mental status in a person with AMS is sufficient to support a diagnosis of HACE. Id. The included Lake Louise Consensus worksheet makes it clear that Mr. Goebel's disorientation is also sufficient to constitute a change in mental status. Id. at 400. Thus, contrary to the Railroad's suggestion, the Lake Louise Consensus supports Dr. Teitelbaum's conclusions. 31 In support of its argument, the Railroad also directs us to an isolated statement in Thomas E. Dietz, Altitude Illness Clinical Guide for Physicians, High Altitude Medicine Guide (2000), II R. at 403-12, where the author notes that I have not yet seen a case of HACE in which the patient didn't ascend with AMS symptoms. Id. at 408. The Clinical Guide admittedly relies on the Lake Louise Consensus guidelines relating to symptoms and diagnosis of altitude illnesses. Id. at 403, 407. Because under those guidelines Mr. Goebel exhibited symptoms of AMS and HACE, the quoted statement relied upon by the Railroad is utterly irrelevant. When read as a whole, the portions of the High Altitude Medicine Guide contained in the record support Dr. Teitelbaum's opinion. See id. at 416-18 (discussing the symptoms associated with AMS and HACE and essentially echoing the conclusions of the Lake Louise Consensus ). 32 Another of the Railroad's contentions is that the chapter in Michael P. Ward et al., High Altitude Medicine and Physiology 412-18 (2d ed.1995), entitled High Altitude Cerebral Edema and Retinal Haemorrhage, II R. at 333, contradicts Dr. Teitelbaum's opinion. In fact, in discussing the typical symptoms associated with AMS and HACE, this chapter once again echoes the conclusions of the Lake Louise Consensus. Id. (symptoms of AMS include headache and nausea; clouding of consciousness indicates HACE). Contrary to the Railroad's suggestion, Aplt. Br. at 31, this chapter at no point states that loss of consciousness is among the  classic symptoms of HACE. Id. (emphasis in original). Although the chapter states that [o]ften there is also an element of pulmonary edema exhibited in HACE sufferers, II R. at 334, it is undisputed that Mr. Goebel did not exhibit signs of that condition. Nonetheless, this quite general and self-limited statement is insufficient to render Dr. Teitelbaum's conclusion unreliable given the obvious corollary that cases must exist where no signs of pulmonary edema are exhibited by a HACE sufferer. 33 A similar issue arises from the Railroad's citation to the Statement on High Altitude Illnesses, Canada Communicable Disease Report (Nov. 15, 1998), II R. at 424, which states that HACE rarely occurs without high altitude pulmonary edema. Id. at 430. Although this is a stronger statement than that made in the High Altitude Medicine and Physiology chapter just discussed, it still fails to contradict materially Dr. Teitelbaum's opinion. Once again, this statement is limited by its own terms, i.e., rarely. Id. In addition, the Statement continues by stating that HACE is characterized by symptoms including an altered level of consciousness in the form of confusion [and] impaired thinking. Id. at 431. Its discussion of AMS again relies on the parameters listed in the Lake Louise Consensus. Id. at 427. Therefore, when read as a whole, the Report does not cast serious doubt on Dr. Teitelbaum's opinion and is certainly insufficient as a basis for finding that the district court abused its discretion by concluding otherwise. 34 The Railroad's attempted reliance on isolated passages and concepts in the following sources is similarly unavailing: Peter H. Hackett, The Cerebral Etiology of High-Altitude Cerebral Edema and Acute Mountain Sickness, 10 Wilderness and Envtl. Med. 97 (1999), II R. at 446; M. Jay Porcelli & Gary M. Gugelchuk, A Trek to the Top: A Review of Acute Mountain Sickness, 95 J. Am. Osteopath Ass'n. 718 (1996), II R. at 309; and Phillip R. Yarnell et al., High-Altitude Cerebral Edema (HACE): The Denver/Front Range Experience, 20 Seminars in Neurology 209 (2000), II R. at 535. When read as a whole, none of these articles calls Dr. Teitelbaum's opinion into question. In fact, our review of them substantially buttressed Dr. Teitelbaum's analysis given their consistency with the Lake Louise Consensus parameters. Our review of Railroad expert Dr. Neil Rosenberg's affidavit, III R. at 599-609, likewise provides no additional evidence that Dr. Teitelbaum's opinion is not supported by the cited studies; Dr. Rosenberg's affidavit falls well short of a showing that would allow us to conclude that the district court abused its discretion. 35