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Roness v. Wal-Mart Stores, Inc.

Court of Appeals of Nebraska

August 27, 2013

Anna Marie Roness, appellee,
v.
Wal-Mart Stores, Inc., appellant.

1. Workers' Compensation: Judgments: Evidence: Appeal and Error. Under Neb. Rev. Stat. § 48-185 (Reissue 2010), a judgment of the Workers' Compensation Court may be modified, reversed, or set aside based on the ground that there is not sufficient competent evidence in the record to warrant the making of the order, judgment, or award.

2. Evidence: Words and Phrases. Competent evidence means evidence that tends to establish the fact in issue.

3. Workers' Compensation: Appeal and Error. In determining whether to affirm, modify, reverse, or set aside a judgment of the Workers' Compensation Court, an appellate court will not disturb the findings of fact of the trial judge unless clearly wrong.

4. Workers' Compensation: Evidence: Appeal and Error. In testing the sufficiency of the evidence to support the findings of fact by the Workers' Compensation Court, the evidence is considered in the light most favorable to the successful party, every controverted fact is resolved in favor of the successful party, and the successful party has the benefit of every inference that is reasonably deducible from the evidence.

5. Workers' Compensation: Proof: Expert Witnesses. To recover compensation benefits, an injured worker is required to prove by competent medical testimony a causal connection between the alleged injury, the employment, and the disability.

6. Workers' Compensation: Expert Witnesses. If the nature and effect of a claimant's injury are not plainly apparent, then the claimant must provide expert medical testimony showing a causal connection between the injury and the claimed disability.

7. Workers' Compensation: Expert Witnesses: Words and Phrases. Although expert medical testimony need not be couched in the magic words "reasonable medical certainty" or "reasonable probability, " it must be sufficient [21 Neb.App. 212] as examined in its entirety to establish the crucial causal link between the plaintiff's injuries and the accident occurring in the course and scope of the worker's employment.

8. Workers' Compensation: Rules of Evidence: Appeal and Error. The compensation court is not bound by the usual common-law or statutory rules of evidence; admission of evidence is within the discretion of the compensation court, whose determination in this regard will not be reversed upon appeal absent an abuse of discretion.

9. Workers' Compensation: Evidence: Due Process. The compensation court's discretion to admit evidence is subject to the limits of constitutional due process.

10. Workers' Compensation: Evidence. Workers' Comp. Ct. R. of Proc. 10 (2011) allows for the introduction into evidence of signed medical reports in place of live expert testimony; such reports would often be hearsay in trial courts.

11. ___: ___. Workers' Comp. Ct. R. of Proc. 10 (2011) allows the compensation court to admit into evidence medical reports that would not normally be admissible in trial courts, provided that those reports are signed.

Appeal from the Workers' Compensation Court: J. Michael Fitzgerald, Judge.

Jennifer S. Caswell, of Ritsema & Lyon, P.C., for appellant.

Michael W. Meister for appellee.

Inbody, Chief Judge, and Irwin and Moore, Judges.

Irwin, Judge.

I. INTRODUCTION

Wal-Mart Stores, Inc. (Wal-Mart), appeals an order of the Nebraska Workers' Compensation Court awarding temporary benefits and payment of medical bills in favor of Anna Marie Roness for an aggravation of carpal tunnel syndrome allegedly caused by Roness' employment with Wal-Mart. On appeal, Wal-Mart challenges the compensation court's admission of and reliance on reports and deposition testimony of a physician's assistant in lieu of live testimony and challenges the court's finding that Roness demonstrated with sufficient medical evidence that there was a compensable injury caused by her employment. We find that there was not sufficient evidence to support an award of benefits, without the need to resolve the question concerning the admissibility of depositions or reports of physician's assistants. We reverse.

[21 Neb.App. 213] II. BACKGROUND

In August 2011, Roness filed a petition in the Workers' Compensation Court, seeking benefits from an alleged work-related accident. Roness alleged that she had been injured on or about December 19, 2010, and alleged that the injury suffered was an aggravation of bilateral carpal tunnel syndrome.

1. Factual Background

Roness testified that in 2005, prior to her employment with Wal-Mart, she had undergone surgery to relieve carpal tunnel syndrome in her right hand. She testified that the surgery had been successful and that she experienced no continuing problems after a period of 5 or 6 months' recovery time.

In September 2010, Roness began working for Wal-Mart. She worked the overnight shift in the dairy department. She testified that her job duties involved "offload[ing]" and "downstack[ing]" pallets, placing freight onto carts, and stocking shelves.

Roness testified that on or about December 19, 2010, she helped other employees unload "milk freight." This was not something that she normally did, but she helped out on this occasion. She testified that "milk freight" involved removing crates of milk from pallets and placing them into a cooler. She testified that the crates arrived "stacked five high, " that there were "nine stacks on a pallet, " and that each crate had to be removed from the pallet and stacked in the cooler. She testified that between 15 and 20 pallets of milk came in each shipment.

Roness testified that in December 2010, her "hands felt funny." She testified that "[t]hey felt different than they did the last time" and that she "wasn't sure what was wrong with them." She described the sensation as "buzzing, like you were holding onto something that vibrates." She testified that she experienced this sensation in both hands. According to Roness, the symptoms began before she did "milk freight, " but they became "significantly worse after [she] did milk freight."

Roness testified that she did not immediately report any issues to management, because other employees had told her that "as long as [she] could do [her] job, [she] probably should [21 Neb.App. 214] keep [her] mouth shut." She testified that she initially could still do her job, but that eventually, "[i]t got worse and worse and then it got painful and then [her hands] went completely numb, " causing her to start "dropping product."

In April 2011, Roness reported her injury to management and stopped working. She testified that she filled out an incident report, and Wal-Mart sent her to an urgent care facility for treatment.

At the urgent care facility, Roness was treated by a physician's assistant. The physician's assistant assessed Roness as having "[c]arpal tunnel bilaterally." The physician's assistant recommended that Roness wear "hand splint[s]" and released her to return to work. The physician's assistant did not impose any restrictions on Roness' ability to work.

The physician's assistant authored a letter, the admissibility of which was challenged at trial and is challenged on appeal. In the letter, the physician's assistant noted Roness' history of and prior surgery for right carpal tunnel syndrome, noted that Roness was now experiencing pain in her left wrist and radiating into her fingers, and diagnosed Roness with carpal tunnel syndrome. The physician's assistant specifically indicated, "I can not say that it was caused by her work but the repetitive motions that she does at work will cause this condition to be aggravated."

In a deposition, the admissibility of which is also in question, the physician's assistant testified that she does not regularly treat carpal tunnel syndrome, that she does not always work with orthopedic patients, and that she saw Roness on only the one occasion. She testified that she had indicated in the letter that she "cannot say" that Roness' injury was caused by work. She testified that an opinion on causation is complicated by Roness' history of carpal tunnel syndrome and because the physician's assistant did not know about Roness' lifestyle outside of work or whether she engaged in other activities that could also have caused the aggravation. She acknowledged that she did not know what Roness' work routine was, did not know how many hours Roness worked per week, and did not know the type of work Roness performed.

[21 Neb.App. 215] Roness returned to work, using the splints recommended by the physician's assistant. Roness testified that the splints helped prevent her from waking up "in excruciating pain" but that they "made it almost impossible for [her] to do [her] job like [she] was supposed to be doing it."

Roness was eventually referred to see an orthopedic specialist, Dr. Diane Gilles. She saw Dr. Gilles in June 2011. The history provided to Dr. Gilles was of "complaints of numbness and pain in both hands, right greater than left." Dr. Gilles' impression was of "[b]ilateral carpal tunnel syndrome, right greater than left." She recommended that "electrical studies" be done to further assess Roness' injury.

According to Roness, Wal-Mart's workers' compensation carrier denied her request to have the electrical studies performed and paid for, and she lacked health insurance or any other way to pay for them. As a result, the studies were not performed.

Dr. Gilles authored a letter to Roness' counsel in May 2012. In the letter, Dr. Gilles noted that she had seen Roness on only one occasion and that Roness had "related her problems to an injury on 02/11/2011." Dr. Gilles noted her diagnosis of bilateral carpal tunnel syndrome, right greater than left. Dr. Gilles indicated that she "certainly [did] believe" that Roness' symptoms "could have likely aggravated [a] preexisting condition and that [Roness] probably had a tenosynovitis associated with it." She indicated, however, that "without further objective studies, [she] cannot give ... a better treatment plan or history course."

Roness was also seen for an independent medical examination in February 2012, by Dr. Jonathan Sollender. Dr. Sollender noted that the physician's assistant who first treated Roness had indicated Roness was to return for a followup in 2 weeks, but that Roness had not done so and had, instead, waited approximately 4 months to seek additional medical treatment. Dr. Sollender agreed with the diagnosis of bilateral carpal tunnel syndrome, but specifically opined that it was not work related. Dr. Sollender was of the opinion that Roness' prior carpal tunnel syndrome had not been adequately resolved [21 Neb.App. 216] prior to the current symptoms. He also opined that Roness' work was not sufficient to produce a causal relationship and noted a variety of perceived conflicts in Roness' reporting and description of her symptoms.

2. Compensation Court Hearings

The compensation court ultimately held two hearings in this case during which evidence was adduced concerning Roness' claim for workers' compensation benefits. At the first hearing, in May 2012, Roness offered a variety of exhibits, including medical records and medical bills. One of the exhibits offered was the April 2011 letter, authored by the physician's assistant who had first treated Roness at an urgent care facility in February 2011. Wal-Mart objected to the admission of this exhibit, arguing that it was hearsay, that there were foundation issues, and that its admission in lieu of live testimony was not authorized by the compensation court's rules of procedure. In response to the objection, Roness' counsel argued that the rules of evidence were not applicable in workers' compensation cases and argued that the compensation court had discretion to receive the evidence if it deemed the evidence to be relevant.

Roness' counsel argued that he had not been prepared for Wal-Mart to object to the evidence and that his only recourse was to seek a continuance, which he felt would be a waste of everyone's time. Wal-Mart's counsel indicated that she had expected Roness to present some evidence from a medical doctor concerning causation, not only the letter from the physician's assistant. Roness' counsel argued that requiring more than the physician's assistant's opinion, coupled with Roness' testimony that there were injuries and that she had an immediate onset of pain at work, was unreasonable.

The parties then engaged in some discussion about how Roness might remedy any problem caused by not having live testimony from the physician's assistant. Roness' counsel indicated that he could depose the physician's assistant, and the compensation court judge expressed a question about whether a deposition would remedy any problem with admissibility. Roness' attorney argued to the compensation court that "[a]n [21 Neb.App. 217] evidentiary objection does not apply in workers' compensation" court.

The court ultimately sustained Wal-Mart's objection and granted a continuance. The court indicated that the real question to be addressed was causation, because the diagnosis of carpal tunnel syndrome did not mean that the injury was work related.

The compensation court held a second hearing, in August 2012. At that hearing, Roness again offered the same exhibits that were offered in the prior hearing, and also offered the deposition of the physician's assistant and the letter from Dr. Gilles. Wal-Mart again objected to the April 2011 letter from the physician's assistant, restating the same objections made at the prior hearing and reminding the court that it had sustained those objections in the prior hearing. Wal-Mart also objected to the deposition of the physician's assistant, on the same grounds. Similarly, Wal-Mart objected to the physician's assistant's notes concerning treatment of Roness. The compensation court took the objections under advisement.

Wal-Mart offered a variety of exhibits, including medical records related to Roness' prior treatment for carpal tunnel syndrome and medical reports from Dr. Sollender, who had performed the independent examination of Roness in relation to the present claim. Roness' counsel, despite his earlier arguments to the court concerning applicability of the rules of evidence, objected to various of these exhibits on the grounds of foundation, relevance, and "rule of evidence 403." The court overruled the objections, finding that Roness' prior treatment for carpal tunnel syndrome was relevant to the current claim of an aggravation of carpal tunnel syndrome.

Roness testified as set forth above. Roness was the only witness to provide live testimony to the compensation court.

3. Award

On September 18, 2012, the compensation court entered an award, granting Roness compensation benefits. That award included a variety of specific findings, conclusions, and explanations for the court's determination that Roness was entitled to benefits.

[21 Neb.App. 218] The compensation court noted that while the alleged accident occurred on or about December 19, 2010, Roness had not stopped working and sought treatment until February 21, 2011. The court indicated that this case would be treated like a repetitive trauma case and that therefore, the appropriate date of injury should be considered February 21.

The court specifically ruled that the notes, letter, and deposition of the physician's assistant were being admitted into evidence. In so ruling, the court specifically found that the physician's assistant's "treatment and treatment plan were reviewed by a physician who signed off on the treatment plan." The court also found that within the physician's assistant's notes was a referral to an orthopedic specialist, signed by a physician.

The court recounted that the physician's assistant's letter indicated the repetitive motions performed by Roness will aggravate carpal tunnel syndrome, but that the physician's assistant specifically indicated she "cannot state the cause of the carpal tunnel syndrome." The court noted that the physician's assistant indicated in the letter that Roness' employment "could have" aggravated her carpal tunnel syndrome.

The court also recounted that Dr. Gilles had opined that Roness' "symptoms likely could have aggravated [her] preexisting condition . . . and that she probably has tenosynovitis associated with it." The court found that "Dr. Gilles state[d] in [the] affirmative that [Roness] has tenosynovitis because of her work, and . . . added it could likely have aggravated the preexisting condition."

The compensation court narrowed the primary issue to the question of causation—there was really no dispute about the diagnosis of bilateral carpal tunnel syndrome, and the primary question was whether it was caused by Roness' employment. In that regard, the compensation court specifically recognized that the use of terms such as "could" and "could have likely" would be insufficient to establish causation.

Nonetheless, the court concluded that Roness had adduced sufficient medical support for a finding of causation. The court held that Roness was entitled to benefits "because the [21 Neb.App. 219] physician's assistant gave a sufficient definite opinion that the carpal tunnel syndrome was aggravated" and held that Roness "is surely entitled to benefits because Dr. Gilles finds [Roness] probably has tenosynovitis associated with her symptoms. That alone is sufficient to award benefits because 'probably' is sufficient."

The court thus awarded temporary benefits and directed payment of medical bills. This appeal followed.

III. ASSIGNMENTS OF ERROR

On appeal, Wal-Mart has assigned error to the compensation court's admission of and reliance on the deposition testimony, reports, and letter of the physician's assistant and to the compensation court's finding that Roness adduced sufficient medical evidence to support a finding of causation and an award of benefits.

IV. ANALYSIS

Wal-Mart challenges the compensation court's admission of and reliance on the deposition testimony, reports, and letter of the physician's assistant in lieu of requiring live testimony and also challenges the compensation court's conclusion that Roness adduced sufficient medical evidence to support a finding that her bilateral carpal tunnel syndrome was caused by her employment. We decline to determine the specific issue concerning the admission of a physician's assistant's records and deposition testimony in lieu of live testimony because, even assuming all evidence received by the compensation court was properly considered, there was no medical evidence opining in support of a finding that Roness' injury was caused by her employment.

Under Neb. Rev. Stat. § 48-185 (Reissue 2010), a judgment of the Workers' Compensation Court may be modified, reversed, or set aside based on the ground that there is not sufficient competent evidence in the record to warrant the making of the order, judgment, or award. Pearson v. Archer-Daniels-Midland Milling Co., 285 Neb. 568, 828 N.W.2d 154 (2013). Competent evidence means evidence that tends to establish the fact in issue. Id.

[21 Neb.App. 220] In determining whether to affirm, modify, reverse, or set aside a judgment of the Workers' Compensation Court, an appellate court will not disturb the findings of fact of the trial judge unless clearly wrong. See Hynes v. Good Samaritan Hosp., 285 Neb. 985, 830 N.W.2d 499 (2013). In testing the sufficiency of the evidence to support the findings of fact by the Workers' Compensation Court, the evidence is considered in the light most favorable to the successful party, every controverted fact is resolved in favor of the successful party, and the successful party has the benefit of every inference that is reasonably deducible from the evidence. See Pearson v. Archer-Daniels-Midland Milling Co., supra.

In the present case, the primary issue raised on appeal is the question of whether there was sufficient competent evidence to demonstrate that Roness' bilateral carpal tunnel syndrome was caused by her employment with Wal-Mart. To recover compensation benefits, an injured worker is required to prove by competent medical testimony a causal connection between the alleged injury, the employment, and the disability. Winn v. Geo. A. Hormel & Co., 252 Neb. 29, 560 N.W.2d 143 (1997). If the nature and effect of a claimant's injury are not plainly apparent, then the claimant must provide expert medical testimony showing a causal connection between the injury and the claimed disability. Frank v. A & L Insulation, 256 Neb. 898, 594 N.W.2d 586 (1999). Although expert medical testimony need not be couched in the magic words "reasonable medical certainty" or "reasonable probability, " it must be sufficient as examined in its entirety to establish the crucial causal link between the plaintiff's injuries and the accident occurring in the course and scope of the worker's employment. See id.

Roness' injury in this case—bilateral carpal tunnel syndrome—is one not plainly apparent. As a result, she was required to present expert medical testimony which was sufficiently definite and certain to permit drawing a conclusion that there was a causal connection between the accident and her disability. To carry this burden, Roness presented evidence in the form of records, a letter, and deposition testimony from a physician's assistant who treated Roness at an urgent care [21 Neb.App. 221] facility and records and a letter from a physician who provided followup care. Wal-Mart presented evidence in the form of a report from an independent physician who examined Roness and her medical records.

One of the primary disputes at trial, and one of Wal-Mart's primary assertions on appeal, concerns the admissibility of the evidence from the physician's assistant in lieu of requiring her to appear and provide live testimony. Wal-Mart objected to Roness' offer of the physician's assistant's records and letter during the first hearing held by the compensation court, and the court sustained the objection. Wal-Mart objected to Roness' offer of the records, the letter, and a deposition of the physician's assistant at the second hearing held by the compensation court, and the court overruled the objection.

Wal-Mart bases its challenge to the admissibility of the evidence on the basis of Workers' Comp. Ct. R. of Proc. 10(A) (2011), which provides in pertinent part as follows:

The Nebraska Workers' Compensation Court is not bound by the usual common law or statutory rules of evidence; and accordingly, with respect to medical evidence on hearings before a judge of said court, written reports by a physician or surgeon duly signed by him, her or them and itemized bills may, at the discretion of the court, be received in evidence in lieu of or in addition to the personal testimony of such physician or surgeon; with respect to evidence produced by vocational rehabilitation experts, physical therapists, and psychologists on hearings before a judge of said court, written reports by a vocational rehabilitation expert, physical therapist, or psychologist duly signed by him, her or them and itemized bills may, at the discretion of the court, be received in evidence in lieu of or in addition to . . . personal testimony .... A sworn statement or deposition transcribed by a person authorized to take depositions is a signed, written report for purposes of this rule.

As Roness' counsel emphasized at trial in this matter, the compensation court is not bound by the usual common-law or statutory rules of evidence; admission of evidence is within the discretion of the compensation court, whose determination [21 Neb.App. 222] in this regard will not be reversed upon appeal absent an abuse of discretion. See Johnson v. Ford New Holland, 254 Neb. 182, 575 N.W.2d 392 (1998). The compensation court's discretion to admit evidence is subject to the limits of constitutional due process. See Zwiener v. Becton Dickinson-East, 285 Neb. 735, 829 N.W.2d 113 (2013).

Rule 10 is an evidentiary rule. Johnson v. Ford New Holland, supra. Rule 10 allows for the introduction into evidence of signed medical reports in place of live expert testimony; such reports would often be hearsay in trial courts. See Johnson v. Ford New Holland, supra. In Johnson v. Ford New Holland, the Nebraska Supreme Court held that rule 10 allows the compensation court to admit into evidence medical reports that would not normally be admissible in trial courts, provided that those reports are signed. The Johnson court affirmed the compensation court's refusal to accept a medical report of a physician into evidence because it was not signed, a requirement specifically indicated in the rule. See, also, Baucom v. Drivers Mgmt., Inc., 12 Neb.App. 790, 686 N.W.2d 98 (2004) (finding compensation court erred in admitting medical evidence that did not comply with rule 10 requirement of signature).

Wal-Mart asserts that the records, letter, and deposition of the physician's assistant were not properly admitted in lieu of live testimony because rule 10 specifically allows for the admission of such evidence only from physicians, surgeons, vocational rehabilitation experts, physical therapists, and psychologists. The rule makes no mention of physician's assistants. Wal-Mart also asserts that it was error for the compensation court to admit the evidence from the physician's assistant because of due process concerns about the physician's assistant' s foundation to qualify as an expert.

The question of whether evidence from a physician's assistant, a medical provider not specifically mentioned in the text of the rule, can be properly admissible in the compensation court pursuant to rule 10 appears to be one of first impression in Nebraska. Neither party has cited us to any authority concerning whether rule 10 should be limited to only the medical providers specifically mentioned or whether, because [21 Neb.App. 223] admission of evidence is largely discretionary in the compensation court, the compensation court could, within its discretion, receive similar evidence from other medical providers. On the record presented in this case, however, we conclude that we need not specifically resolve that issue.

Even assuming that all of the evidence received by the compensation court in this case was properly received—a finding we expressly decline to reach—we find that there was insufficient evidence adduced by Roness to satisfy her burden to prove that her injury and disability were caused by her employment. None of the medical evidence adduced includes a sufficient opinion to support the crucial causal link between her injury and employment.

1. Physician's Assistant's Opinion

First, even if admissible, the records, letter, and deposition of the physician's assistant did not contain a sufficient opinion to establish causation. The physician's assistant's records reflected that Roness was treated at an urgent care facility, reported that her hand had been numb "since working delivering milk, " and included an assessment of "[cjarpal tunnel bilaterally." The physician's assistant's records do not include any statement that could be considered any kind of an opinion that the carpal tunnel syndrome was caused by Roness' employment.

The letter authored by the physician's assistant similarly does not contain an opinion that Roness' injury was caused by her employment. In the letter, the physician's assistant related Roness' history and prior surgery for carpal tunnel syndrome and related the findings of tests performed at the urgent care facility. In the letter, the physician's assistant specifically indicated that "[i]t is in [her] opinion that [Roness] has carpal tunnel." However, the physician's assistant explicitly indicated that she "can not say that it was caused by [Roness'] work." The physician's assistant indicated that "the repetitive motions that [Roness] does at work will cause this condition to be aggravated."

Taken on its own, the letter of the physician's assistant amounts to an opinion that Roness has carpal tunnel syndrome [21 Neb.App. 224] (which is not even disputed by Wal-Mart) and a specific representation that the physician's assistant cannot opine that it was actually caused by work, but a recognition that the physician's assistant believes that Roness' job duties are consistent with actions that aggravate carpal tunnel syndrome. Taken on its own, this is insufficient as an expert opinion to establish causation—indeed, it specifically includes an assertion that it "can not" be an opinion on causation. When read in conjunction with the physician's assistant's deposition, however, the evidence becomes even less useful as an expert opinion to establish causation.

In her deposition, the physician's assistant again related the history of her treatment of Roness at the urgent care facility and Roness' history of prior carpal tunnel syndrome. Roness' counsel referred the physician's assistant to her letter and specifically asked, "[I]n that letter you indicate that your opinion is that [Roness'] having carpal tunnel and the repetitive motions at work caused the condition to be aggravated, is that fair?" The physician's assistant again specifically iterated that she said she "cannot say that it was caused by [Roness'] work."

The physician's assistant explained that an opinion on causation was complicated because of Roness' history of carpal tunnel syndrome and also because the physician's assistant did not "know what [Roness' ] other . . . lifestyle is outside of work." She continued, "So if [Roness] does a lot of typing, those kinds of things could have aggravated it too." Roness' counsel then asked if "it's reasonable to conclude that the work aggravated the symptoms." The physician's assistant answered, "Possibly."

The physician's assistant's opinion is, again, not sufficient to establish a crucial causal connection between Roness' employment and her aggravated bilateral carpal tunnel syndrome. The physician's assistant's deposition testimony establishes that she was not able to opine to such causation and that she was not opining to such causation.

In addition, although she had indicated in her letter and in her deposition testimony that "the repetitive motions" Roness [21 Neb.App. 225] performed at work would cause the carpal tunnel syndrome to be aggravated, she testified on cross-examination that she was unaware of what Roness' routine at work was, was unaware of what type of work she performed, was unaware of how many hours she worked on a weekly basis, and was unaware of how long she had worked at Wal-Mart. The physician's assistant also testified that she did not regularly treat carpal tunnel syndrome.

A review of the evidence from the physician's assistant reveals that she never provided an opinion that Roness' bilateral carpal tunnel syndrome was caused by her work. At most, she indicated that it was "[p]ossibl[e], " but she specifically declined to give an opinion on causation and specifically indicated that she lacked sufficient information to do so. Her testimony further indicates that she lacked sufficient foundation about Roness' employment responsibilities to be able to give such an opinion.

In addition to finding that the physician's assistant did not give a sufficient opinion to establish causation, we also conclude that the compensation court was clearly wrong with respect to its factual findings concerning the physician's assistant's records in this case. The court specifically ruled that the notes, letter, and deposition of the physician's assistant were being admitted into evidence. In so ruling, the court specifically found that the physician's assistant's "treatment and treatment plan were reviewed by a physician who signed off on the treatment plan." The court also found that within the physician's assistant's notes was a referral to an orthopedic specialist, signed by a physician. These findings are clearly wrong.

There is no evidence in the record to suggest that the physician's assistant's treatment of Roness or treatment plan for Roness was reviewed by a physician or signed off on by a physician. The medical records include intake notes which were signed by the physician's assistant and which also contained a line designated to be for a "NURSE SIGNATURE." That line contains a signature of an individual, followed by a series of initials that appear to be "R-T. MA." There is nothing in our [21 Neb.App. 226] record to indicate who this person was or that it was a physician, and the signature does not appear to correspond to any physician referred to in the record.

Similarly, there is no evidence in the record to suggest that the referral contained within the physician's assistant's notes was signed by a physician. The referral is on what appears to be a prescription form and indicates that "[Roness] was seen at Urgent Care. She is recommended to see an ortho specialist." The referral then includes the signature of somebody on a line, and the end of the line includes a preprinted "MD." The signature is not legible, but the first two letters of the first name appear to be "Sh" and the first two letters of the last name appear to be "St." The left side of the referral includes a listing of physicians, physician's assistants, and nurses of the urgent care facility. None of the physicians has a name that would appear to correspond to the signature; one of the other physician's assistants, however, is named "Sheila Sterkel, " which does appear to correspond to the signature.

There was no testimony adduced by anyone concerning the signatures, whose they were, or whether any physician reviewed and signed off on anything contained in the physician's assistant's records of Roness' treatment. The compensation court was clearly wrong in finding otherwise.

2. Dr. Gilles' Opinion

Dr. Gilles' medical records and letter similarly are not sufficient to establish the crucial causal link between Roness' employment and her carpal tunnel syndrome. Our review of the evidence adduced from Dr. Gilles reveals no indication of Roness' employment's causing her injury.

The medical records from Dr. Gilles' treatment of Roness include the "History of Present Illness" section which indicates that Roness related her work at Wal-Mart, the symptoms, and the prior history of carpal tunnel syndrome. The medical records include Dr. Gilles' impression of "[b]ilateral carpal tunnel syndrome, right greater than left" and "[s]tatus post previous right carpal tunnel release." The medical records from Dr. Gilles contain no statement on her behalf that appear to [21 Neb.App. 227] be any kind of an opinion as to causation of Rones s' bilateral carpal tunnel syndrome.

In the letter authored by Dr. Gilles, she indicated that she saw Roness on only one occasion and that Roness "related her problems to an injury on 02/11/2011." Dr. Gilles restated her diagnoses of "bilateral carpal tunnel syndrome, right greater than left, " and "status post previous right carpal tunnel release." Dr. Gilles then specifically indicated as follows: "I certainly do believe that [Roness' ] symptoms could have likely aggravated [a] preexisting condition and that she probably had a tenosynovitis associated with it but without further objective studies, I cannot give you a better treatment plan or history course." (Emphasis supplied.)

The court found that "Dr. Gilles state[d] in [the] affirmative that [Roness] has tenosynovitis because of her work, and . . . added it could likely have aggravated the preexisting condition" and held that Roness "is surely entitled to benefits because Dr. Gilles finds [Roness] probably has tenosynovitis associated with her symptoms. That alone is sufficient to award benefits because 'probably' is sufficient." These findings are clearly wrong.

Contrary to the compensation court's finding that Dr. Gilles stated that Roness has tenosynovitis "because of her work, " Dr. Gilles never expressed any opinion relating any of Roness' injuries to her work. Dr. Gilles opined that Roness' "symptoms" could have aggravated her preexisting condition—but Dr. Gilles never related those symptoms to employment in any way. Similarly, Dr. Gilles opined that Roness probably had tenosynovitis associated with "it, " but there is no indication that "it" referred to employment in any way. Rather, "it" would appear to refer to either Roness' preexisting condition or her symptoms. Dr. Gilles' opinion contains no reference to Roness' employment whatsoever. Dr. Gilles also specifically indicated that without further information, she could not provide more information.

As a result, Dr. Gilles' opinion appears, at most, to be that Roness has suffered an aggravation of her prior carpal tunnel syndrome. But that opinion does not provide the crucial causal [21 Neb.App. 228] connection between Roness' employment and her carpal tunnel syndrome. The compensation court was clearly wrong with respect to its specific findings about what Dr. Gilles actually opined and with respect to its finding that Dr. Gilles' opinion was sufficient for the award of benefits.

3. Dr. Sollender's Opinion

The only other medical evidence in our record was adduced on behalf of Wal-Mart, in the form of the report of Dr. Sollender, an independent physician who examined Roness and her medical records. Dr. Sollender's opinion was specifically that Roness' current bilateral carpal tunnel syndrome was not caused by her employment.

V. CONCLUSION

In this case, Roness had the burden to adduce sufficient medical testimony to establish a causal connection between the alleged injury, the employment, and the disability. The evidence adduced establishes that she suffered bilateral carpal tunnel syndrome, but does not include any medical testimony opining that her injury was caused by her employment. As such, the compensation court was clearly wrong in finding the evidence sufficient to support an award of benefits. We reverse.

Reversed.


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