Court Opinion

ID: 4560498
Source: CourtListenerOpinion
Date Created: 2020-08-26 21:02:15.116882+00
Date Added: 2024-06-11T11:16:06.236616
License: Public Domain

FILED
                                                                                            Dec 04, 2019
                                                                                            04:05 PM(ET)
                                                                                        TENNESSEE COURT OF
                                                                                       WORKERS' COMPENSATION
                                                                                              CLAIMS

              TENNESSEE BUREAU OF WORKERS' COMPENSATION
                COURT OF WORKERS' COMPENSATION CLAIMS
                           AT CHATTANOOGA

    Johnny Johnston,                              )         Docket Nos.: 2015-01-0023
               Employee,                          )                      2018-01-0003
                                                  )                      2018-01-0008
    v.                                            )
                                                  )
    Siskin Steel & Supply Co./Reliance            )         State File Nos. 9602-2015
    Steel & Aluminum Co.,                         )                          266-2018
                  Employers,                      )                         1326-2018
                                                  )
    and                                           )
    Trumbull Insurance Co.,                       )         Judge Thomas Wyatt
                Carrier.

         COMPENSATION HEARING ORDER AWARDING MEDICAL AND
               PERMANENT PARTIAL DISABILITY BENEFITS

       On November 14, 2019, the undersigned held a Compensation Hearing in Johnny
Johnston's claim seeking benefits for exposure to heavy-metal contaminants at Siskin
Steel & Supply Co./Reliance Steel & Aluminum Company (Siskin). The primary issue
was whether Mr. Johnston's liver, cardiac, and kidney conditions arose primarily out of
and in the course and scope of employment. 1 For the reasons below, the Court holds they
did and awards Mr. Johnston medical and permanent partial disability benefits.

                                         History of Claim

      Mr. Johnston is sixty-one years old with almost forty years of service at Siskin.
He sawed, cut, grinded, and welded steel since 1996 and continues to do so today. Siskin
considers him an excellent employee. Mr. Johnston has never smoked, and he has not
consumed alcohol in the past twenty years.
1
  Mr. Johnston filed three separate claims with different dates of injury for each condition. Since each
condition allegedly arose from the same occupational exposure, the Court consolidated them into one
claim.

                                                   1
       Siskin first assigned Mr. Johnston as a laborer in its outdoor scrapyard for ten
years. He worked close to areas where aluminum and stainless steel were cut. He ran a
machine that bored holes in cast iron and worked in a small building operating machinery
that compressed scrap iron into bales. He testified that cutting and boring caused metal
chips and particles to attach to his clothing. He described his work in the scrapyard as
greasy and dirty and stated the air smelled like diesel exhaust. Mr. Johnston testified that
he did not wear respiratory protection on any job at Siskin until approximately three years
ago.

       Siskin next moved Mr. Johnston inside its large plant. The plant's ceiling stands
an estimated 100 feet above the floor, and trucks enter and exit through numerous large
bay doors. The plant is not climate-controlled but has fans. Some of the saws and
cutting machinery have exhaust fans that remove metal particles from the floor to the
atmosphere near the ceiling.

       During his first six years inside the plant, Mr. Johnston banded steel and loaded it
onto trucks with an overhead crane. He operated the crane in a cab located near the
ceiling. 2 In January 1996, Siskin assigned Mr. Johnston to cut steel products inside the
plant with various power saws, torches, and aT-splitter (a hot-cutting process.) He also
finished steel with a hand-grinder and performed welding. While doing so, Mr. Johnston
worked with his face close to the area where the apparatus he used cut, grinded, or
welded steel. These processes exposed him to metallic chips, dust, and fumes.

       Mr. Johnston testified that he sawed all steels and alloys Siskin manufactured. He
described the plant environment as smoky and "rotten," sometimes to the point of
burning his eyes. He testified that the smell consisted of fumes from diesel trucks, raw
diesel fuel used to clean rusty steel, and cutting fluid used to lubricate saws.

       Siskin produced documentation of air-sampling performed in its plant during Mr.
Johnston's period of employment. A 2002 study cited concerns that the plant ventilation
did not fully protect employees from airborne contaminants. The report recommended
improvements in the local exhaust systems and in protecting crane operators from
exposure to contaminants removed from the floor. 3 The report identified three primary
sources of airborne exposure: diesel exhaust, fumes from hot-cutting operations, and
particulates from grinding and sanding. The report noted that employees reported the
accumulation of acrid smoke during periods of peak production. It further noted that the
2002 testing was not conducted under worst-case conditions.

2
  Air-sampling reports suggested that air quality was worse in the crane cabs because of contaminants
lifted by exhaust fans from the floor.
3
  The Court heard no evidence whether the suggested improvements were made.

                                                  2
        The 2002 air-sampling revealed that tested employees4 were exposed to heavy-
metal contaminants in levels below OSHA limits during eight-hour testing periods. It
also revealed that the largest exposures, by volume, were to zinc oxide, iron oxide,
copper, aluminum, and manganese. Other exposures were to silver, cadmium, cobalt,
chromium, and lead. The report concluded that "it is clear that airborne contaminants
sometimes create an uncomfortable work environment for at least some of your
manufacturing personnel." Air-sampling reports from 2006 and 2019 revealed similar
results.

       In 2013, Mr. Johnston was diagnosed with granulomatous hepatitis with non-
alcoholic cirrhosis of the liver. A physician ordered hair testing in November 2014 that
revealed elevated heavy-metal contaminants in his system. As a result, the physician
recommended chelation treatment. Mr. Johnston presented the hair-testing results to
Rick English a management representative of Siskin,5 shortly after he received them and
requested that Siskin authorize the recommended treatment. Siskin denied the claim,
which led Mr. Johnston to file his first claim for benefits in 2015.

       Mr. Johnston had a cardiac event in 2016. 6 He was eventually diagnosed with a
heart attack caused by coronary artery disease and hypertension. He underwent surgeries
for five coronary-artery stents and a pacemaker and missed work for approximately six
months. Later, Mr. Johnston learned during an evaluation by Dr. Edward Workman that
he was previously diagnosed with chronic kidney disease. He filed claims on his cardiac
and kidney conditions shortly after becoming aware of them.

      The parties stipulated that the earliest date Mr. Johnston's metal-disease
manifested itself was January 20, 2015, and his average weekly wage on that date was
$976.41, or a $650.97 compensation rate.

       The bulk of the evidence at trial consisted of the deposition testimony of
consulting medical experts. No treating physician testified. Mr. Johnston relied on the
opinions of Dr. Workman, a Tennessee neuropsychiatrist with a clinical practice in pain
management, and Dr. Matthew Lee, a Virginia physician and pharmacist with a segment
of his practice devoted to toxicology.          Siskin presented the testimony of
gastroenterologist Dr. Jonathan Schneider, kidney specialist Dr. Doug Linfert, and
cardiologist Dr. William Fleet. They all hold Tennessee licenses and maintain clinical
practices.

4
  The records indicated Siskin never tested Mr. Johnston's personal exposure to airborne particulate.
5
  Mr. English attended the Compensation Hearing but did not testify.
6
  The event took place at Siskin but was unrelated to physical activity or unexpected mental stimulus.

                                                     3
                             Dr. Edward Workman's Testimony

        Dr. Workman's primary practice involves the operation of pain-management
clinics. He has long-participated in forensic evaluations, including for several
government agencies. He performed a physical examination, record review, and
impairment evaluation.

       Dr. Workman relied on the 2014 hair-testing results to conclude that Mr.
Johnston's system contained concentrations of heavy metals in significantly higher-than-
accepted levels. He testified he expected adverse health effects from elevated exposure
to heavy-metal contaminants. Dr. Workman preferred hair testing over blood or urine
testing to determine a patient's long-term, heavy-metal exposure because hair testing
quantifies accumulated contaminant levels, while blood and urine testing quantify only
acute contaminant levels. Dr. Workman testified the hair testing showed that Mr.
Johnston's system had slightly elevated levels of antimony and gadolinium, 4.7 times the
accepted level of cadmium, and 4.8 times the accepted level of lead.

       Dr. Workman testified that elevated levels of heavy metals were the primary cause
of Mr. Johnston's liver disease. However, at first his opinion as to Mr. Johnston's heart
and kidney diseases was equivocal. After further researching medical literature, Dr.
Workman concluded that metal exposure primarily caused Mr. Johnston's heart and
kidney diseases as well. Regarding Mr. Johnston's heart attack, Dr. Workman explained
that Mr. Johnston's metal-related liver damage caused systemic hypertension that
accounted for his cardiac hypertension, which contributed to his heart attack.

       Dr. Workman rated Mr. Johnston's renal impairment at 24%, liver impairment at
21%, and cardiac impairment at 17%, all to the whole body. 7 Dr. Workman testified that
Mr. Johnston's combined rating is 59% to the body. Dr. Workman was equivocal on Mr.
Johnston's maximum medical improvement date but used April 7, 2017, the date that Mr.
Johnston received his pacemaker. Siskin's expert testified that Dr. Workman placed one
of Mr. Johnston's diagnoses in an incorrect category, but otherwise, Siskin did not
challenge Dr. Workman's impairment ratings.

       Dr. Workman admitted he has does not practice gastroenterology, nephrology, or
cardiology. Siskin challenged the hair-test reliability based on a disclaimer printed onto
the test report stating that the hair test was a screen rather than a diagnostic test. Dr.
Workman countered that, standing alone, almost no medical test is diagnostic of any
particular condition. He stated he trusted the hair-test results and reiterated that he
preferred the hair test to blood or urine tests.

7
 Dr. Workman also rated Mr. Johnston for mental and erectile-dysfunction impairments. However, the
Court did not consider those ratings.

                                                4
        Siskin also questioned why Dr. Workman concluded that the primary cause of Mr.
Johnston's cardiac disease was his exposure to heavy-metal contaminants when he has
non-work-related cardiac risk factors such as hypertension, advanced age, diabetes,
obesity, and family history of heart disease. Dr. Workman stated that Mr. Johnston's
long-term metal exposure supported his opinion. He added that the reviewed medical
literature noted heavy metals accumulate in a patient's system and cause or contribute to
diabetes, hypertension, and myocardial dysfunction.

                               Dr. Matthew Lee's Testimony

       Dr. Lee is a clinical physician, pharmacist, and medical examiner in Richmond,
Virginia. His practices involve toxicology, which he defined as investigation of the
adverse health effects of substances that do not naturally occur in the human body. He
performed a record review without examining Mr. Johnston.

       Dr. Lee testified that Mr. Johnston's hair-testing results revealed elevated levels of
cadmium, lead, antimony, and arsenic. He described the cadmium and lead elevations as
"extreme." He reviewed Siskin's Material Safety Data Sheets and determined that the
alloys it manufactures contain the four metallic substances elevated in Mr. Johnston's
system. Dr. Lee testified that hair testing is the gold standard for determining the
presence oflong-term exposure to heavy metals and stated:

              Given Mr. Johnston's exposure, that he's been working with heavy
       metals for 39 years, 34 of those years without any sort of barrier protection;
       that he's cutting the metals, that he is creating dust. So that's-makes it the
       component of the given metal, so he's inhaling those. But also, he's using
       a torch to cut the metals, which is creating fumes, as well as using various
       chemicals on top of the metals to help with the process of cutting, so he's
       exposed to those fumes also.

       Dr. Lee added that cadmium, lead, antimony and arsenic are deposited in the liver,
kidneys, and spleen. He explained that the duration of a patient's exposure to heavy
metals is important because heavy metals have a "really long half-life," meaning the
metals are deposited in body tissue and not promptly excreted. He stated that, "[o]ver
time . . . a person is continued to be exposed to the heavy metals, the heavy metal will
accumulate in the body and become more toxic." Dr. Lee stated that the presence of
elevated levels of multiple metals in the system has a synergistic effect that enhances the
singular toxic effect of each metal in compromising the body's ability to metabolize and
excrete toxic substances.

      Dr. Lee found that Mr. Johnston's heavy-metal levels constituted the primary
cause of his liver, cardiac, and kidney damage. He also testified that heavy metals caused
Mr. Johnston to suffer pulmonary compromise and contributed to his development of

                                              5
diabetes. Dr. Lee supported his position with a number of scientific studies he reviewed
in connection with this case.

       On another point, Dr. Lee acknowledged that the hair-test report provided a
disclaimer about the possibility the results included contaminants that would not be toxic
because they accumulate on the external portion of the hair sample. He did not consider
the disclaimer to reduce the reliability of the hair-test results because the testing protocol
includes washing the hair sample to minimize external contaminants. Dr. Lee also stated
that Mr. Johnston's long occupational history of exposure supported the reliability of the
hair-testing results.

       Dr. Lee conceded he is not board-certified in, nor does he practice in, the fields of
gastroenterology, cardiology, or nephrology. He stated that he does not hold a Tennessee
medical license, nor did he review the Siskin air-sampling report. Dr. Lee stated he
consulted in only two heavy-metal exposure cases previously and testified in only one of
them. He stated, however, that he has evaluated patients for heavy-metal-related
conditions in his clinical practice.

       Dr. Lee testified that he did not review blood-test results in formulating his
opinions. He said that blood or urine testing is unnecessary in assessing heavy-metal
exposure because the contaminants in hair test travel through the blood before depositing
in the hair. Siskin asked Dr. Lee to consider a 2016 blood test that showed Mr. Johnston
had normal levels of arsenic, lead, and mercury in his blood. 8 Dr. Lee replied that the
blood test did not change his opinion, since Mr. Johnston had started using respiratory
protection by 2016. He also pointed out that the blood test showed only the level of
contaminant in Mr. Johnston's blood at the time the test was performed, and it did not test
for accumulated contaminant levels in the patient's system.

       Siskin also asked Dr. Lee why Mr. Johnston's age, cardiac disease, diabetes, and
family history were not the primary causes of his liver, cardiac, and kidney conditions.
Dr. Lee responded:

                 So the heavy metal exposure led to the other health conditions, yes.
          And as time went on, the development of those diseases, disease processes,
          further compromised it and made-and allowed for it to continue to get
          worse. But the primary inciting factor was the heavy metal exposure and
          the toxic burden and the effect of the heavy metals on the organ systems.

        Siskin established that the literature on which Dr. Lee relied was based on animal,
rather than human, testing. Dr. Lee stated the lack of human testing did not invalidate the
animal testing because medical investigators cannot ethically test toxic substances on

8
    The test did not screen for cadmiwn and antimony.

                                                        6
human beings.

                           Dr. Jonathan Schneider's Testimony

      Siskin hired board-certified gastroenterologist Dr. Schneider to perform an
examination and records review.

        Dr. Schneider testified that Mr. Johnston's liver biopsy showed significant
scarring plus cirrhosis at the stage right before "full-blown cirrhosis." He stated he
suspected that the cause of Mr. Johnston's liver condition was his underlying diabetes,
high cholesterol, and obesity. He declined to testify that Mr. Johnston's metal exposure
contributed to his liver condition, since no blood or urine test confirmed the hair-test
results. Dr. Schneider stated the medical articles he read did not establish a link between
Mr. Johnston's chronic liver condition and his lead, cadmium, antimony, or arsenic
exposure.

       Dr. Schneider acknowledged that he is not board-certified in occupational
medicine nor does he review medical literature on toxicology as a routine part of his
practice. Dr. Schneider testified that, had Mr. Johnston been his patient, "given he has
the top three risk factors for liver disease, my evaluation as far as cause would have
stopped right there."

                              Dr. William Fleet's Testimony

       Dr. Fleet is a board-certified cardiologist and internist. He performed a records
review. Dr. Fleet testified Mr. Johnston's records reflect a diabetes diagnosis in 2000 and
later diagnoses of hyperlipidemia (high cholesterol) and hypertension. He stated the
records showed that Mr. Johnston was severely obese, had untreated sleep apnea, and a
family history of coronary artery disease.

       Dr. Fleet testified that Mr. Johnston had several cardiac diagnoses, including
coronary artery disease, atrial fibrillation, congestive heart failure, a left bundle branch
block, and a heart attack in 2016. He stated that these diagnoses did not arise primarily
out of and in the course and scope of employment because Mr. Johnston had four of the
five traditional risk factors for coronary artery disease: diabetes, hyperlipidemia,
hypertension, and family history. He stated that Mr. Johnston was at very high risk (over
30%) of having a heart attack from the traditional risk factors irrespective of any
occupational exposure. Dr. Fleet stated that the presence of heavy metals in his system
only slightly increased his risk of heart attack, and that metal exposure, standing alone,
was not the primary cause for Mr. Johnston's cardiac diagnoses and heart attack.

       Dr. Fleet admitted he was not a toxicologist or occupational physician. He stated

                                             7
that he did not subscribe to or read the articles cited in support of Drs. Workman's and
Lee's causation opinions. He conceded that he did not often obtain detailed histories of
his patients' work activities and exposures.

                               Dr. Doug Linfert's Testimony

        Dr. Linfert is a licensed, board-certified kidney specialist who sees patients in his
office, a dialysis clinic, and the hospital. He examined Mr. Johnston and reviewed his
records.

       Dr. Linfert testified that Mr. Johnston's records contain evidence since 2013-
high creatine levels in the blood-upon which to base a diagnosis of stage-three kidney
disease. He stated he would not use the hair test as a diagnostic tool because the test
report recommended confirmation of the results by blood or urine testing. He added that
blood tests for arsenic, lead, and mercury in 2016 showed Mr. Johnston had normal levels
of those metals.

       Dr. Linfert testified that Mr. Johnston has three risk factors for kidney disease:
diabetes, hypertension, and coronary artery disease. He said that these risk factors rather
than metal exposure primarily caused Mr. Johnston's chronic kidney disease. Dr. Linfert
stated he did locate some medical literature linking heavy-metal exposure to kidney
disease. However, the literature suggested presentations (certain urine fmdings and/or
gout) that Mr. Johnson does not have.

       Dr. Linfert is not a toxicologist and has never ordered heavy-metal testing for a
patient. He did not investigate the manner in which heavy metals cause kidney damage,
nor did he read the articles relied upon by Drs. Workman and Lee. Further, he did not
read the Material Data Safety Sheets describing the components of the alloys Siskin
manufactured.

                    Findings of Fact and Conclusions of Law

                                     Preliminary Matters

                                i)     Constitutional Challenge

       Mr. Johnston moved to declare a certain portion of the Tennessee Workers'
Compensation Law unconstitutional. Siskin responded on the merits but also countered
that the Court of Workers' Compensation Claims lacks jurisdiction to decide a facial
constitutional challenge. The Court agrees.

       In Richardson v. Board of Dentistry, 913 S.W.2d 446, 454 (Tenn. 1995), the
Supreme Court held that "administrative tribunals 'have no authority to determine the

                                              8
facial constitutionality of a statute. '"9 The Supreme Court has held that the Court of
Workers' Compensation Claims is an administrative tribunal. Pope v. Nebco of
Cleveland, Inc., 2018 LEXIS 145, at *12 (Tenn. Workers' Comp. Panel Jan. 16, 2018).

       The Court holds it lacks authority to decide Mr. Johnston's facial constitutional
challenge. Consequently, the Court denies his motion.

                                      ii.)    Evidentiary Objections

       Shortly before trial, the parties filed dueling motions seeking to exclude or limit
the other's expert testimony. Siskin's motion sought exclusion of Mr. Johnston's expert
witnesses because they relied on medical articles that Mr. Johnston did not produce in
discovery responses. It sought to exclude certain cross-examination testimony of its
experts for the same reason.

       The Court asked Siskin's counsel exactly which discovery request required Mr.
Johnston to produce copies of medical articles reviewed by his experts. He directed the
Court to Request for Production 13 (RFP 13), which requests "[a]ll documents stating,
recognizing, listing or otherwise addressing the extent or existence of industrial
impairment alleged to have been suffered by the Employee . . . including any documents
created in connection with any vocational evaluation of the Employee."

       The articles Siskin complains of were those reviewed by Mr. Johnston's medical
experts in their causation investigation. The articles do not relate to "industrial
impairment" and "vocational evaluation" as referenced in RFP 13. For that reason, the
Court denies Siskin's motion in limine.

       Mr. Johnston moved to exclude the testimony of Siskin's expert witnesses because
they are not toxicologists and, thus, insufficiently qualified to testify in this case. The
Court located no legal authority, and none was cited, indicating that only toxicologists or
occupational disease physicians are competent to testify in an occupational disease claim.
Licensed physicians may testify as experts in workers' compensation cases. The specific
qualifications of a physician may go to the weight given the expert's testimony, but they
do not disqualify the physician from offering expert testimony. Thus, the Court overrules
Mr. Johnston's motion.

                                              Evidentiary Standard

      At this Compensation Hearing, Mr. Johnston must establish by a preponderance of
the evidence that he is entitled to the requested benefits. Tenn. Code Ann. § 50-6-

9
  A facial challenge is one based on the position that a statute is unconstitutionally no matter how the judge
interprets or applies it.

                                                      9
239(c)(6) (2019); Willis v. All Staff, 2015 TN Wrk. Comp. App. Bd. LEXIS 42, at *18
(Nov. 9, 2015).

                                        Causation

        Mr. Johnston bears the burden of proving by a preponderance of the evidence that
his alleged occupational disease arose primarily out of and in the course and scope of his
employment at Siskin. See Tenn. Code Ann.§ 50-6-102(14).

       The current Workers' Compensation Law does not specifically defme the term
"occupational disease." However, in Pool v. Jarman D & Q Transport, 2016 TN Wrk.
Comp. App. Bd. LEXIS 9, at *9 (Feb. 18, 2016), the Workers' Compensation Appeals
Board observed that an occupational disease develops slowly, and it is injury from the
disease, rather than the disease itself, that entitles the employee to benefits. Thus, Mr.
Johnston must prove by the preponderance of the evidence that he developed an
occupational disease related to his exposure to heavy metals at Siskin. The Court holds
that Mr. Johnston met his burden of proof.

       The Court fmds that Mr. Johnston credibly described the work he performed at
Siskin and his exposure to heavy-metal dust and other contaminants while performing the
work. Siskin did not present evidence to rebut Mr. Johnston's testimony other than
producing air-sampling reports documenting that tested employees received exposures of
heavy metals thatdid not exceed OSHA limits.

       The Court believes Mr. Johnston's testimony that he worked with his face in areas
where airborne heavy-metal contaminants were created by his application of saws,
torches, hot-cutting processes, hand grinders, and welding equipment in direct contact
with the metal alloys Siskin manufactured. The Court also believes Mr. Johnston's
testimony that he performed his work without respiratory protection until approximately
three years ago. Based on this evidence, the Court finds that Mr. Johnston has been
exposed to heavy-metal contaminants at Siskin for many years.

       The Court next considers whether the preponderance of the evidence establishes
that heavy-metal contaminants accumulated in Mr. Johnston's system. This issue turns
on the reliability of the 2014 hair test. Mr. Johnston's experts accepted the reliability of
the hair-test results. They testified that Mr. Johnston's lengthy heavy-metals exposure
history bolstered the reliability of the test results because heavy metals accumulate over
the duration of exposure. Drs. Workman and Lee also stated that hair-test results are
more helpful than blood and urine testing in detecting the long-term presence of heavy-
metal contaminants because blood and urine tests detect only the acute presence of
contaminants, while hair testing measures accumulated contaminant levels.

       Siskin's experts testified they would not have relied on the hair-test results without

                                             10
confirmation by blood and urine testing. Because the only blood-test results in Mr.
Johnston's records were negative, they concluded the record contained no evidence that
Mr. Johnston had elevated levels of heavy-metal contaminants in his system. The Court
noted, however, that the physician who ordered the hair test relied on its fmdings to
recommend treatment for heavy-metal exposure. Considering the evidence as a whole,
and giving due weight to Mr. Johnston's lengthy exposure to heavy-metal contaminants
at Siskin, the Court fmds that Mr. Johnston accumulated elevated levels of cadmium,
lead, antimony, and arsenic in his system during his employment at Siskin.

       The Court next considers whether Mr. Johnston proved that his liver, cardiac, and
kidney conditions arose primarily from his work-related exposure. This requires the
Court to assess conflicting expert witnesses. When confronted with conflicting expert
opinions, the Court has discretion to conclude which of the experts' positions contains the
more probable explanation and should govern the decision in the case. Ledford v. Mid-
Georgia Courier, Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 28, at *8 (June 4, 2018).
In evaluating the opinions, the Court may consider, among other things, the qualifications
of the experts, the circumstances of their evaluation, the information available to them,
and the evaluation of the importance of that information by other experts. Hollis v.
Komyo Amer., 2019 TN Wrk. Comp. App. Bd. LEXIS 4, at *11 (Jan. 22, 2019).

       All the medical experts were sufficiently trained, credentialed, and clinically
experienced. No one expert stood above the other. All the experts reviewed Mr.
Johnston's medical records. Some reviewed the air-sampling data and the Material
Safety Data Sheets, and others did not. Some examined Mr. Johnston in their offices, and
others solely reviewed his records. Despite the differences, the Court holds that all
experts had sufficient information to formulate their causation opinions.

        Where Mr. Johnston's and Siskin's experts differed was in the methodologies they
took in addressing causation. Drs. Workman and Lee concluded that Mr. Johnston had
elevated levels of heavy-metal contaminants in his system and then researched the
medical literature to determine if scientifically-documented links exist between liver,
cardiac, and kidney conditions and those metals. Both Drs. Workman and Lee testified in
detail as to the specific sources they read in researching causation. They supported their
opinions that Mr. Johnston's conditions arose primarily out of and in the course and
scope of employment with the literature they identified.

       In contrast, Siskin's experts focused on Mr. Johnston's diagnoses of diabetes,
coronary artery disease, hypertension, and family history of heart disease to determine the
primary cause of his conditions. Dr. Schneider stated that, if Mr. Johnston had presented
to him as a patient, his determination of the cause of his liver problems would end with
the knowledge that Mr. Johnston had those conditions. Drs. Fleet and Linfert performed
vaguely-described literature research for links between heavy-metal exposure and liver,
cardiac, and kidney conditions based on human testing. Siskin's experts minimalized the

                                            11
hair-test results and relied on the negative blood testing. They concluded that, even if
Mr. Johnston had elevated heavy-metal levels in his system, that exposure would only
slightly increase the chances of his liver, cardiac, and kidney diagnoses, given his non-
work-related risk factors.

        Considering the expert opinions and other evidence, the Court holds that the
causation opinions of Drs. Workman and Lee give the more probable explanation for the
development of Mr. Johnston's liver, cardiac, and kidney conditions. The Court fmds it
significant that Mr. Johnston's work exposed him without protection for more than two
decades to heavy-metal contaminants that accumulate in the body. The Court further
considered the improbability of Mr. Johnston developing non-alcoholic cirrhosis of the
liver, respiratory issues without smoking, and cardiac and kidney conditions without the
intervention of his exposure to heavy metals at Siskin. The Court holds that Mr. Johnston
proved by a preponderance of the evidence that his liver, cardiac, and kidney conditions
arose primarily out of and in the course and scope of employment.

                                     Medical Benefits

       The foundational benefit of the Workers' Compensation Law is medical treatment,
free of cost to the employee, for injuries and conditions that arise primarily out of and in
the course and scope of employment. See generally Tenn. Code Ann. § 50-6-204.
However, the injured worker shall receive treatment for his work-related condition by a
physician selected from an employer-provided panel. Tenn. Code Ann. § 50-6-
204(3)(A)(i). The Court holds Mr. Johnston is entitled to medical benefits for ongoing
treatment of his liver, cardiac, and kidney conditions.

       Siskin's denial of his claim required Mr. Johnston to obtain treatment on his own.
However, because Mr. Johnston developed evidence that his conditions are work-related
after he gave Siskin notice of his claim, the Court holds that Siskin shall provide panels
of qualified physicians in Mr. Johnston's community for ongoing treatment of his work-
related liver, cardiac, and kidney conditions.

                              Temporary Disability Benefits

        As to temporary total disability benefits, Mr. Johnston must prove by a
preponderance of the evidence: (1) a disability from working as the result of a
compensable injury; (2) a causal connection between the injury and the inability to work;
and (3) the duration of the period of disability. Shepherd v. Haren Const. Co., Inc., 2016
TN Wrk. Camp. App. Bd. LEXIS 15, at *13 (Mar. 30, 2016). Here, Mr. Johnston simply
testified that he missed work after his heart attack and did not prove the dates he was off
work following his heart attack. The evidence introduced at trial is insufficient to
establish the necessary elements for an award of temporary disability benefits, and the
Court declines to award them.

                                             12
                          Permanent Partial Disability Benefits

       The Workers' Compensation Law provides for permanent partial disability
benefits. Tenn. Code Ann. § 50-6-207(3)(A). Here, Dr. Workman testified to the
permanency of Mr. Johnston's conditions and assigned a 59% whole-body impairment
rating based on the combined ratings. Siskin did not challenge Dr. Workman's
impairment rating, other than to offer the testimony that he placed one of Mr. Johnston's
conditions in the incorrect classification. The Court holds that the preponderance of the
evidence establishes that Mr. Johnston's liver, cardiac, and kidney conditions are
permanent and his combined impairment rating for the conditions is 59% to the body.

        The Court holds that Mr. Johnston sustained a single occupational disease from his
exposure to heavy-metal contaminants at Siskin that manifested in his development of
liver, cardiac, and kidney conditions. The parties stipulated that January 20, 2015, was
the earliest manifestation date for Mr. Johnston's heavy-metal-related diseases. The
parties further agreed that, on that date, Mr. Johnston's compensation rate was $650.97.

       Tennessee Code Annotated section 50-6-207(3)(A) provides that an employee
with a permanent work injury shall receive an original award of permanent partial
disability benefits "for the period of compensation" calculated by multiplying the
employee's impairment rating by 450 weeks. The payment of the award begins on the
date of maximum medical improvement. I d.

       The Court awards Mr. Johnston an original award of 265.5 weeks of benefits, or
$172,832.00. The Court makes no ruling on Mr. Johnston's entitlement to a resulting
award because his initial compensation does not expire until May 10, 2022. See Tenn.
Code Ann. § 50-6-207(3)(B). Benefits shall be paid in the amount of $650.97 per week.
Accrued benefits shall be paid to Mr. Johnston in a lump sum from the date of maximum
medical improvement-April 7, 20 17-until the date of the first payment under this
order. Afterward, Siskin shall pay Mr. Johnston weekly or biweekly until the fu11265.5
weeks of benefits are exhausted on May 10,2022.

      The Court does not address Mr. Johnston's counsel's attorney's fees and costs.
Mr. Johnston's counsel shall file a petition addressing these issues as soon as practicable.

        This Court taxes the filing fee of $150.00 to Siskin under Tennessee Compilation
Rules and Regulations Rule 0800-02-21-.06. Further, Siskin shall prepare and submit a
Statistical Data Form within ten days of the date of judgment. Absent an appeal, this
order shall become fmal in thirty days.

                                             13
       IT IS ORDERED.
       ENTERED December 4, 2019.

                                    Judge Thomas Wyatt

                                       APPENDIX

Technical record:

            1. Petition for Benefit Determination-Liver
            2. Petition for Benefit Determination-Heart
            3. Petition for Benefit Determination-Kidney
            4. Dispute Certification Notices
            5. Order of Consolidation
            6. Scheduling Order
            7. Discovery Order
            8. Order Denying Motion to Quash
            9. Joint Pre-Compensation Hearing Statements
            10.Employer's Motion in Limine
            11. Employer's Witness and Exhibit List
            12. Employee's Witness and Exhibit List
            13. Employee's Response to Motion in Limine
            14. Employee's Motion to Exclude Employer's Expert Witnesses
            15. Employer's Response to Motion to Exclude
            16.Employee's Motion to Declare "Primary Cause" Portion of Workers'
                Compensation Act Unconstitutional
            17. Employer's Response to Constitutionality Motion
            18. Employer Brief
            19. Employee Brief
Exhibits:

            1.   Employer's Discovery Requests (Request for Production of Documents 13)
            2.   Dr. Edward Workman's Deposition Transcript
            3.   Dr. Matthew Lee's Deposition Transcript
            4.   Dr. Doug Linfert's Deposition Transcript
            5.   Dr. William Fleet's Deposition Transcript
            6.   Dr. Jonathan Schneider's Deposition Transcript
            7.   Medical Records Submitted by Employee
            8.   Medical Records Submitted by Employer
                                             14
           9. Documentation ofMr. Johnston's Assignment as a Saw Operator
           10. TOSHA Records
           11. 2019 Air Sampling Records
           12.2002 Report About Ventilation at Siskin
           13.2002 Air Sampling Records
           14.2006 Air Sampling Records

                             CERTIFICATE OF SERVICE

 I certify that a copy of the Order was sent as indicated on December 4, 2019.

Name                        Certified     Email       Service sent to:
                            Mail
Linn Guerrero-Justice                         X       linn@loringjustice.com
Employee Attorney
John Barringer                                X       ibarringer@manierherod.com
Employer Attorney

                                             15
                          CompenSation Hearing Order .Right to Appeal:
     If you disagree with this Compensation Hearing Order, you may appeal to the Workers'
Compensation Appeals Board or the Tennessee Supreme Court. To appeal to the Workers'
Compensation Appeals Board, you must:

    1. Complete the enclosed form entitled: "Compensation Hearing Notice of Appeal,'' and file
       the form with the Clerk of the Court of Workers' Compensation Claims within thirty
       calendar days of the date the compensation hearing order was filed. When filing the
       Notice of Appeal, you must serve a copy upon the opposing party (or attorney, if
       represented).

    2. You must pay, via check, money order, or credit card, a $75.00 filin1 fee within ten
       calendar doys after filing of the Notice of Appeal. Payments can be made in-person at
       any Bureau office or by U.S. mail, hand-delivery, or other delivery service. In the
       alternative, you may file an Affidavit of Indigency (form available on the Bureau's
       website or any Bureau office) seeking a waiver of the filing fee. You must file the fully-
       completed Affidavit of Indigency within ten calendar days of filing the Notice of
       Appeal. Failure to timely pay the fding fee or file the Affidavit of lndigeney will
       result in dismissal of your appeal.

    3. You bear the responsibility of ensuring a complete record on appeal. You may request
       fiom the court clerk the audio recording of the hearing for a $25.00 fee. A licensed court
       reporter must prepare a transcript and file it with the court clerk within fifteen calendar
       days of the filing the Notice of Appeal. Alternatively, you may file a statement of the
       evidence prepared jointly by both parties within fifteen calendar days of the filing of the
       Notice of Appeal. The statement of the evidence must convey a complete and accurate
       account of the hearing. The Workers' Compensation Judge must approve the statement
       of the evidence before the record is submitted to the Appeals Board. If the Appeals
       Board is called upon to review testimony or other proof concerning factual matters, the
       absence of a transcript or statement of the evidence can be a significant obstacle to
       meaningful appellate review.

   4. After the Workers' Compensation Judge approves the record and the court clerk transmits
      it to the Appeals Board, a docketing notice will be sent to the parties. The appealing
      party has fifteen calendar days after the date of that notice to submit a brief to the
      Appeals Board. See the Practices and Procedures of the Workers' Compensation
      Appeals Board

To appeal your case direetly to the Tennessee Supreme Court, the Compensation Hearing
Order must be final and you must comply with the Tennessee Rules of Appellate
Procedure. If aeitber party timely files aa appeal with the Appeals Board, the trial c:o•rt's
Order will beeome final by operation of law thirty allendar days after entry. S~e Tenn.
Code Ann. § 50-6·239(c)(7).
For self-represented litigants: Help from an Ombudsman is avt~ilable aJ 800-.1.32-2667.
                                                               ~
                                                               w
                                        COMPENSATION HEARING NOTICE OF APPEAL
                                                Tenni!SSee Division of Wo~kers' Compensation
                                                    www.rnJ!ovDnbor·wfdlwr.om AAhtmi
                                                            wc.courtderk@ltn.gov
                                                               1-800..332-2667

                                                                                                     Docket#: -------~
                                                                                                     State File #/YR: ------"-------,--

                         Employee

                         v.

                         Employer

           Notlr:e
           Notice is given that--- - - - - - - - - - - - - - -- - - - - - - - - - - - - - - -
                                [Ust name(s) of all appealing party(ies) on separate sheet If necessary]

           appeals the order(s) of the Court of Workers' Compensation Claims at
                                                                                           ------~-----------

            - - - - - - - - - - - - - - - ----"to the Workers' Compensation Appeals Board.
            [Ust the date(s) the order(s) was filed in the court clerk's office]

          Judge._ _ _~~=------------------

          Statement of the Issues
          Provide a short and plain statement of the Issues on appeal or basts for relief on appeal:

          list of Parties

          Appellant (Requesting Party)~,~--------'At Hearing: []EmployerOEmployee

          Address:__~-----~--------~---~-----------------------
          Party's Phone:._ __,..._________________,Emall:______________._____

          AttorneysName :~-----------------------~-------- BPR#:                                        _____________
          Attorneys Address:.___________________________                                               Phone:
          Attorneys City, State & Zip code:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-=------
          Attorney's Email:._ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
                                      • Attach an uddltJonDI sheet for each additional AppeiiDnt •
LB-1103   I'I!V. 10/18                                   Page 1 of 2                                                           ROA 11082
 Employee Name:._ _ _ _ _ __        _ __    _     sn·, ________ _.;:;._             DOl: _ _ _ __      _

Appe!leefsl
Appellee (Opposing Party):'---------·At Hearlng:[}mployerC]Employee

Appellee's Address: -------~~--------------------
Appellee's Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _E.mail:._ _ _ _ _ __ _ __ _ __ _

Attorney's Name: - - - - -- -- -- -- - --:-- ---'--- BPR#: - - - - - - - -
Attorney's Address: - - - -- - ' - - - -- - - -- - - " - - - - - ·Phone; ....____,..,___ _ _~
Attorney's City, State & Zip coder. _ _ _ _....__ _ _ _ _ _ _ _ __ _ __ _ _ _ _ __

Attorney's Email:
                        --------------------------------------
                                                  al sheet for each additional Appellee *
                           "' Attoch an atldlt1o.;_

CERTIRCATE Of: SERVICE

1,                                            ; certify that I have forwarded a true and exact copy of this
Corriperisatlon Hearing Notice of Appeal'by