The Supreme Court of Tennessee’s Special Workers’ Compensation Appeals Panel recently affirmed a decision by a state trial court awarding an X-ray technician permanent and total disability benefits because of migraine headaches that the trial court had found were exacerbated by the technician’s exposure to chemical odors at her employer’s medical clinic [see Patton v. Paris Henry Cnty. Med. Clinic, 2016 Tenn. LEXIS 858 (Nov. 30, 2016)]. The special panel acknowledged deep conflict between and among the medical experts as to causation, but the panel reiterated that it was the trial court’s responsibility to assign the relative weight to be given such opinion testimony. The panel also found that the trial court did not err when it gave “little weight” to the AMA Guides (6th edition)—which assign a maximum 5 percent impairment for migraines. The appeals panel concluded that the evidence did not preponderate against the trial court’s finding that the technician was permanently and totally disabled.
In January 2008, Patton began working at Paris Henry County Medical Clinic (“the clinic”) as an X-ray technician. As a part of Patton’s job of taking and processing X-rays, she worked with chemicals in the X-ray development process. In June 2008, a clinic physician treated her for a migraine headache. By September and October 2010, Patton’s headaches became more frequent and severe, occurring sometimes occur three to four days a week and included blurred vision, floaters, and light sensitivity that required her to wear sunglasses. Patton was referred to Dr. Thomas Head, a neurologist in Jackson, Tennessee. Patton was also treated at several other hospitals for her headaches and on January 2, 2011, Patton had a migraine headache that required her to leave work. That was the last day she worked at the clinic.
Dr. Head eventually referred Patton to Dr. Merle Diamond at Diamond Headache Clinic in Chicago, Illinois. Dr. Diamond began treating Ms. Patton in January 2011 with frequent inpatient and outpatient care. Patton was also seen by several other physicians at various area medical centers and hospitals. In February 2011, Patton sought workers’ compensation benefits. After an unsuccessful benefit review conference, she sued the clinic.
Long History of Headaches
At trial, Patton testified that she has had a history of headaches since she was sixteen years old, but that the headaches she experienced after she began working at the clinic differed from her previous headaches in both intensity and frequency. Patton explained that her first serious migraine headache occurred in June 2008, about five months after she started working at the clinic.
At the time of trial, Patton was having migraine headaches three to four days per week. The pain generally required her to lie in bed in a darkened room. She frequently had to wear sunglasses and she could not drive when taking her medications. She said she did not believe she could sustain a full-time job because she never knew when her next headache might occur. Pepperoni and bleach were examples of problem odors that would trigger a migraine for her, and stress was also a trigger. Patton testified that she visited her obstetrician/gynecologist regularly and was not menopausal. In August 2009, hormone tests verified she was not menopausal.
Patton’s Treating Physician
Dr. Diamond—Patton’s treating physician—testified by deposition. Dr. Diamond has a subspecialty certification for headache medicine. She specializes almost exclusively in the treatment of headaches. Her Diamond Headache clinic is the oldest and largest private headache clinic in the United States and one of two places that has an inpatient treatment unit for patients with debilitating migraine headaches.
In her deposition, Dr. Diamond indicated she had treated Ms. Patton for several years, that even with a variety of preventative medications, Ms. Patton intermittently had a “status migraine”—a prolonged, severe headache that required extensive hospitalization. Prior to treatment by Dr. Diamond and during the time she has been treated by Dr. Diamond, Ms. Patton had taken 50 to 60 preventive medicines. By the date of the trial, Dr. Diamond was prescribing a cocktail of medications that were somewhat effective.
Diamond Disagreed with AMA Guides (6th Ed.)
Dr. Diamond indicated Patton’s chronic migraines were now a permanent condition. Dr. Diamond opined that Patton was 100% vocationally impaired because of her condition. Dr. Diamond explained that under the Migraine Disability Assessment (“MIDAS”) rating system, Ms. Patton would be considered highly disabled, which would correlate with a MIDAS score of 21. A MIDAS score of 21 often equated to having over twenty-five days of severe headaches per month. The MIDAS system was developed for clinical research but had been proposed to be used to measure disability. Dr. Diamond indicated that she had not previously been familiar with the AMA Guides, 6th edition, and that she disagreed that a MIDAS score of 21 would equate with a 5% impairment rating under the AMA Guides, stating that a 5% impairment rating for Ms. Patton would be illogical.
Other Medical Evidence
Patton produced other medical evidence supporting her position. The employer offered testimony from five witnesses. One physician, a family practitioner, Dr. Harrison, testified he treated Ms. Patton for migraine headaches on a number of occasions. According to Dr. Harrison, Ms. Patton never complained that her migraines were triggered by exposure to chemicals at the clinic. Dr. Harrison, whose office is next door to the X-ray developing room, said he had never smelled heavy fumes or chemical odors emanating from the room.
Dr. Head, who referred Patton to Dr. Diamond, testified by deposition. He said Patton had not indicated anything specific as to triggering her headaches and had indicated a family history of migraines. Dr. Head agreed that Patton had a significant medical problem. Dr. Head gave no actual opinion as to the cause of Patton’s headaches. He posited that if Ms. Patton was no better now than she was when she was being exposed to the chemicals, it would be hard to say that the chemicals were playing a major role. Dr. Head agreed, however, that Dr. Diamond would know more about the cause and prognosis of migraine headaches than he would.
Another physician, Dr. Kalnas, an occupational medicine specialist, was deposed. He concluded that while odors from X-ray chemicals might act as a trigger of migraine headaches, Ms. Patton’s exposure to the chemicals caused no permanent worsening or aggravation of her migraine condition, and it did not cause her to develop chronic migraine headaches. The doctor found no evidence in the medical literature supporting the conclusion that exposure to chemicals or their odors would cause a person to become a migraine headache patient. Instead, the doctor indicated the propensity for migraine headaches was an inherited trait.
Five Percent Rating
Dr. Kalnas explained that a five percent impairment was the highest rating provided by the AMA Guides (6th Ed.) for a migraine headache condition. Dr. Kalnas stated that while it is premature to assign an impairment rating given Ms. Patton’s potential for improvement with certain treatments, Ms. Patton’s impairment rating would not be more than 5%.
Trial Court Said Everyone Was Credible
The trial court found all of the witnesses to be credible, but noted, however, that the testimony of Dr. Diamond and Dr. Head carried additional weight because each had treated Ms. Patton and had considerable experience in caring for patients suffering from disabling headaches. The trial court further noted that Dr. Diamond’s testimony showed no indicia of bias, whereas Dr. Kalnas, whose practice is limited to performing evaluations and not treatment, rendered his opinion in response to a referral by the clinic’s workers’ compensation insurance carrier. Further, the trial court noted that, unlike Dr. Diamond, Dr. Kalnas’s medical specialty was not in the diagnosis and treatment of headaches. The trial court afforded Dr. Kalnas’s testimony less weight than that of Dr. Diamond.
The trial court ruled that Ms. Patton’s migraine headaches were exacerbated by her exposure to the chemical odors at the clinic and resulted in a chronic disabling condition. The trial court ruled that Ms. Patton was permanently and totally disabled and gave little weight to the maximum five percent impairment rating provided under the AMA Guides, stating that the rating was “not at all representative of what the disabling [e]ffects of migraine headaches can be and certainly are in [Ms. Patton’s case].”
Appeal Panel’s: Employer Takes Employee “As Is”
The panel reminded that an employer generally takes an employee “as is,” assuming the responsibility for any work-related injury that might not affect an otherwise healthy person, but which aggravated a preexisting injury or condition. It was for the trial court to assign the weight to the evidence. The panel added that although the medical experts in this case were all well-qualified, the trial court did not err in placing more weight on Dr. Diamond’s testimony. The trial court was also free to consider Patton’s own testimony. The evidence did not preponderate against the trial court’s finding that Ms. Patton’s migraine condition was exacerbated by her exposure to chemical odors and resulted from her employment at the clinic.
Level of Disability
The panel noted that the trial court had assessed whether Ms. Patton was totally incapacitated from working at an occupation that could generate an income. The trial court considered Ms. Patton’s age, education, work history, and physical condition and the expert medical testimony that Ms. Patton’s headaches were permanent, highly disabling, and resulted in her inability to sustain gainful employment. Finding the five percent impairment rating under the AMA Guides not to be representative of the disabling effects of Ms. Patton’s migraine headache, it had found, by clear and convincing evidence, that Ms. Patton was permanently and totally disabled. The appeal panel said the evidence did not preponderate against the trial court’s finding.