                         IN THE NEBRASKA COURT OF APPEALS

               MEMORANDUM OPINION AND JUDGMENT ON APPEAL
                        (Memorandum Web Opinion)

                                     HOMSTAD V. BLOCK 21


  NOTICE: THIS OPINION IS NOT DESIGNATED FOR PERMANENT PUBLICATION
 AND MAY NOT BE CITED EXCEPT AS PROVIDED BY NEB. CT. R. APP. P. § 2-102(E).


                                TIMOTHY HOMSTAD, APPELLANT,
                                                V.

                    BLOCK 21, LLC/WOODBURRY MANAGEMENT COMPANY,
                    DOING BUSINESS AS COURTYARD MARRIOTT, APPELLEE.



                            Filed October 29, 2019.    No. A-19-191.


       Appeal from the Workers’ Compensation Court: J. MICHAEL FITZGERALD, Judge.
Affirmed.
       Eric B. Brown, of Atwood, Holsten, Brown, Deaver & Spier Law Firm, P.C., L.L.O., for
appellant.
      Patrick B. Donahue and Dennis R. Riekenberg, of Cassem, Tierney, Adams, Gotch &
Douglas, for appellee.


       MOORE, Chief Judge, and PIRTLE and WELCH, Judges.
       WELCH, Judge.
                                      I. INTRODUCTION
        Timothy Homstad appeals the determination of the Nebraska Workers’ Compensation
Court that the injuries to his knees, which he sustained in an accident occurring within the course
and scope of his employment, and his resulting surgeries did not cause a blood clot in his sinus
cavity. We affirm the judgment of the Workers’ Compensation Court.
                                  II. STATEMENT OF FACTS
       On August 20, 2015, Homstad suffered injuries to both of his knees which he sustained in
an accident occurring in the course and scope of his employment with Block 21, LLC/Woodbury



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Management Company, doing business as Courtyard Marriott (Block 21). Due to these injuries,
Homstad underwent surgery on both of his knees. Surgery on his left knee resulted in Homstad
developing deep venous thrombosis (DVT) in his left leg on February 1, 2016, and a pulmonary
embolism which was diagnosed on February 2, 2016. Surgery on his right knee resulted in DVT
diagnosed in August 2016.
       By February 2017, Homstad developed additional right lower extremity pain and swelling.
A Doppler ultrasound revealed “near occlusive thrombus” in his right leg and his medication was
changed. A repeat Doppler ultrasound conducted in March revealed the remaining presence of a
blood clot in his left leg. In July, Homstad had a third surgery to remove a tibial button from a
prior surgery. By September, Doppler ultrasound testing revealed the presence of partially
occlusive deep vein thrombosis, or blood clots, in both his right and left legs.
       As pertinent to Homstad’s clotting, Dr. Erik Avery, a hematologist who served as
Homstad’s primary care physician, opined in an October 2017 report:
       I have reviewed [Homstad]’s pertinent previous notes. Unfortunately, he continues to have
       difficulty with symptoms related to shortness of breath and additional symptoms related to
       his prior blood clots. I agree with previous assessments that the knee injury followed by
       surgery caused his DVT’s which ultimately caused a pulmonary embolism. Once a person
       has a blood clot, the risk of developing subsequent blood clots are significantly higher due
       to the first episode. He continues to have symptoms related to shortness of breath from his
       pulmonary embolism and I feel that his ongoing DVT issues and shortness of breath are
       most likely related to the inciting event. Previous workup has not shown any other
       pre-existing condition.

          In a February 12, 2018, treatment note, following an approximate 1-month period where
Homstad failed to take his anticoagulation blood thinner, Dr. Avery wrote “I stressed to [Homstad]
that it is imperative that he remain on anticoagulation everything all day without interruptions and
as previously discussed he understands that he needs to stay on anticoagulation for the rest of his
life.” Repeat Doppler ultrasounds completed in February 2018 revealed that the right- and left-leg
clot conditions remained unchanged in relation to the ultrasound studies taken in September 2017.
          On March 1, 2018, Homstad experienced seizure activity and went to the hospital. Shortly
thereafter, he returned to the hospital with similar symptoms and was admitted from March 6
through 10, during which time he was diagnosed with superior sagittal sinus thrombosis (SSST),
a type of blood clot in his sinus cavity. Upon his release from the hospital, Homstad had four
additional seizures related to his SSST and he was readmitted to the hospital from March 11
through 14. Following his discharge on March 14, Homstad continued to experience seizures.
                                               1. TRIAL
        Trial in this matter was held in May 2018. At trial, the parties stipulated to the following:
(1) Homstad sustained bilateral injures to his knees from an August 20, 2015, accident arising out
of and in the course of his employment with Block 21; (2) as a result of Homstad’s injuries, surgery
was necessitated for both of his knees bilaterally, first left, then right; (3) as a result of his first
knee surgery, Homstad developed blood clots in his left lower extremity and a pulmonary



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embolism; and (4) Homstad is entitled to ongoing and future medical care for his bilateral knee
injuries, as well as blood thinners for causally related clotting issues. The parties also generally
stipulated to notice, average weekly wage, periods of disability, that Homstad had not reached
maximum medical improvement regarding his blood clotting condition, and that Block 21 did not
have permanent work available for Homstad with his limitations.
        As relevant to this appeal, the issue tried to the court was whether Homstad’s SSST
condition and resulting seizures and treatment in March 2018 were causally linked to his
compensable injures. At trial, the Workers’ Compensation Court received opinions from three
doctors regarding the causation issue: Dr. Eric Avery, Dr. Cythia Lewis, and Dr. Peter Silberstein.
Relevant portions of the doctors’ opinions are noted below.
                                        (a) Dr. Eric Avery
        Dr. Avery, who we previously quoted as linking Homstad’s leg and prior blood clotting
issues to the 2015 accident opined as follows:
                The superior sagittal sinus thrombosis (SSST) etiology is less clear. Studies show
        these are often younger patients (mean around 40yo), female, or have pregnancy,
        malignancy, infection or associated with a hematologic predisposition or certain
        medications. But ballpark of <20% of the time, an etiology is not identified. Out of those
        typical risk factors, his main risk is his previous clots. SSST are associated with seizures
        in the literature, but I will defer to neurology’s opinion as to the cause and effect of this
        particular thrombosis based on the size, location, and other characteristics.
                In addition, [Homstad] stated his anticoagulation was not authorized by his
        insurance for a few weeks in Dec 2017 and into Jan 2018. When his blood was drawn on
        1/25/2018, it is noted that his Ddimer (a blood test showing breakdown of blood clot) was
        significantly elevated. Upon restarting the anticoagulation, his Ddimer was back to normal
        by 2/19/2018. The reason that is important is because he was at a very high risk of recurrent
        thrombosis. Not being on a blood thinner during that time increases the risk of blood clots,
        and they don’t have to appear in the same location. A SSST could occur because of his
        overall hematologic predisposition.
                His previous blood clots could be a factor in his SSST. He has multiple risks for
        recurrent blood clots, so he does need lifelong anticoagulation.


                                       (b) Dr. Cynthia Lewis
       Dr. Lewis, a hematologist at Heartland Hematology Oncology in Kearney, Nebraska,
opined as follows:
       Regarding the etiology of [Homstad’s] thrombosis, that is very difficult to determine.
       Although testosterone replacement therapy can be associated with a[n] elevated
       erythrocyte count which increases the Hematocrit. However, various blood draw at
       different times, has shown his HCT to be 49-50 which was in the laboratory normal range.
       [S]everal of these times, his testosterone level was in the low to lower normal range. He
       has been on testosterone since ~6/2012 and didn’t have any trouble with thrombosis from




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       starting the replacement therapy until he had [his] leg surgically manipulated and
       immobilized. There is really no way to prove that his testosterone therapy caused his clots
       especially with his circumstances. [He] has had an extensive evaluation for thrombophilia
       including, factor v leiden, prothrombin gene mutation, JAK-2, PHN flow cytometry,
       protein C and S, and lupus anticoagulant. His IgM anticardiolipin antibody was mildly
       elevated in 8/2017 at 19, and I haven’t seen this repeated, however, I didn’t have all of his
       records. That being said, a level [of] 19 is not a significantly elevated value.
               Testosterone itself can cause thrombosis in pts without a high HCT, however, it is
       unclear if this population of patients had an underlying thrombotic disorder prior to starting
       testosterone.
               Reviewed the patient’s history and labs that were available to me with the patient.
       I do believe that his knee injury requiring immobilization and surgical intervention was the
       contributing factor in him developing his deep vein thrombosis and pulmonary embolism.
       After the first predisposed thrombotic episode, limited anticoagulation was reasonable.
       After the second thrombotic event even that he had predisposing event, lifetime
       anticoagulation was reasonable recommendation. Then after having a DVT in both legs
       that was incompletely dissolved, and the recurring thrombosis in his legs and especially
       with this recent event of sagittal sinus thrombosis, there is no question he will need
       indefinite anticoagulation.

As a supplement to that report, Dr. Lewis then issued the following opinion:
               It would be very difficult for me to find an association with the patient’s initial
       injury at work to him having seizures and developing a thrombosis in his sagittal sinus . . . .
       Within a reasonable degree of certainty, the seizures and the sagittal sinus thrombosis,
       [were] not caused by the patient’s injury dating back to August 2015 or the surgeries that
       were performed addressing those injuries subsequent to August 2015.


                                      (c) Dr. Peter Silberstein
       Dr. Silberstein, a professor of internal medicine and chief in hematology/oncology at
Creighton University, explained in his written opinion:
               1. I agree and concur with the opinion from all of the other doctors who have
       evaluated this issue that Mr. Homstad’s knee injury which required immobilization and
       surgical intervention was the major contributing factor for his initial development of blood
       clotting in the form of a deep vein thrombosis and a pulmonary embolus.
               2. Mr. Homstad’s history of clots stemming from the inciting surgical event to his
       knee was the most significant cause of the development of the recent superior sagittal sinus
       thrombosis and associated seizure activity that resulted in Mr. Homstad’s hospitalizations
       at Bryan in March 2018. Mr. Homstad had a negative hypercoaguable workup, thus he had
       no congenital or genetic cause to predispose him to having clots [sic] Moreover, prior to
       his knee injury, he never had a clot which shows that he developed clots only after the knee
       injury and not before. Additionally, once Mr. Homstad suffered clotting, his risk went up



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       significantly for additional clotting due to that history. This additional risk is the reason
       why blood thinners continued to be prescribed for Mr. Homstad after he first sustained
       clots. Subsequent and associated clotting does not always occur in the same place.
               3. Regarding his treatment and care moving forward, Mr. Homstad is over 120 kg.
       None of the new anticoagulant drugs such as Xarelto or Apixaban have been shown to be
       effective in patients of his weight. He weighs 343 lbs or 155 kg. The most effective drug
       would be Coumadin. But this is difficult drug to manage, which requires frequent blood
       monitoring as well a special diet.


                                     2. TRIAL COURT’S ORDER
        Following the trial, the Workers’ Compensation Court found that the work accident caused
or contributed to Homstad’s DVT’s in both legs which resulted in his pulmonary embolus and
permanent anticoagulation therapy. However, the court held that Homstad’s SSST and resulting
seizure activity were not causally linked by the compensable injuries. In so finding, the court held:
        With regards to the SSST, it was not caused by nor contributed to be caused by the accident
        of August 20, 2015. While Dr. Sil[b]erstein states that plaintiff had a history of blood clots
        stemming from the initial cervical (sic) event to his knees was the most significant cause
        of the development of the recent SSST and associated seizure activity, the contrary
        opinions of Dr. Clark and the lack of a clear opinion from Dr. Avery, there is insufficient
        evidence to find that the SSST was caused by or contributed to be caused by the accident
        on August 20, 2015.

Homstad appeals from this portion of the judgment of the court.
                                 III. ASSIGNMENT OF ERROR
      Homstad contends that the trial court erred in finding that his treatment on and after
March 1, 2018, for a blood clot in his sinus cavity, and associated seizure symptoms, was
noncompensable.
                                  IV. STANDARD OF REVIEW
        Under Neb. Rev. Stat. § 48-185 (Cum. Supp. 2018), the judgment made by the
compensation court shall have the same force and effect as a jury verdict in a civil case and may
be modified, reversed, or set aside only upon the grounds that (1) the compensation court acted
without or in excess of its powers; (2) the judgment, order, or award was procured by fraud; (3)
there is not sufficient competent evidence in the record to warrant the making of the order,
judgment, or award; or (4) the findings of fact by the compensation court do not support the order
or award. Bower v. Eaton Corp., 301 Neb. 311, 918 N.W.2d 249 (2018); Coughlin v. County of
Colfax, 27 Neb. App. 41, 926 N.W.2d 675 (2019).
        Determinations by a trial judge of the Workers’ Compensation Court will not be disturbed
on appeal unless they are contrary to law or depend on findings of fact which are clearly wrong in
light of the evidence. Gimple v. Student Transp. of America, 300 Neb. 708, 915 N.W.2d 606




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(2018); Coughlin v. County of Colfax, supra. In reviewing workers’ compensation cases, this court
is not free to weigh the facts anew; rather, we accord to the findings of the compensation court the
same force and effect as a jury verdict in a civil case. Bower v. Eaton Corp., supra; Coughlin v.
County of Colfax, supra. In testing the sufficiency of the evidence to support the findings of fact,
an appellate court considers the evidence in the light most favorable to the successful party, every
controverted fact must be resolved in favor of the successful party, and the appellate court gives
the successful party the benefit of every inference reasonably deducible from the evidence.
Coughlin v. County of Colfax, supra; Kaiser v. Metropolitan Util. Dist., 26 Neb. App. 38, 916
N.W.2d 448 (2018).
                                          V. ANALYSIS
         Homstad challenges the finding of the Workers’ Compensation Court that his SSST
condition and associated seizures first arising in March 2018 were not caused by the 2015 injury
to Homstad’s knees. A finding in regard to causation of an injury is one for determination by the
compensation court as the finder of fact. Weyerman v. Freeman Expositions, 26 Neb. App. 692,
922 N.W.2d 246 (2018).
         The trial judge in a workers’ compensation case is entitled to accept the opinion of one
expert over another. Michie v. Anderson Builders, 22 Neb. App. 731, 859 N.W.2d 906 (2015). See
Lowe v. Drivers Mgmt., Inc., 274 Neb. 732, 743 N.W.2d 82 (2007). We will not substitute our
findings of fact for those of the compensation court when its findings are substantiated by the
record. Michie v. Anderson Builders, supra. See Clark v. Alegent Health Neb., 285 Neb. 60, 825
N.W.2d 195 (2013). Accordingly, in connection with this specific assignment of error, this
appellate court is limited to determining whether the court’s causation determination is supported
by the evidence. We find that there is support for the court’s factual determination.
         In short, the court was asked to determine whether Homstad’s 2015 knee injuries, surgeries,
and resulting blood clots caused or contributed to Homstad’s 2018 sinus condition and associated
seizures. In connection with like causation questions, the Nebraska Supreme Court in Hohnstein
v. W.C. Frank, 237 Neb. 974, 980, 468 N.W.2d 597, 602 (1991), previously held: “It is well
established that ‘unless the character of an injury is plainly apparent, an injury is a subjective
condition, and an expert opinion is required to establish the causal relationship between an incident
and the injury as well as any claimed disability consequent to such injury.’” Clearly, the issue of
whether a sinus clotting condition suffered over 2½ years after Homstad’s knee injuries required
expert analysis in order to establish causation.
         In connection therewith, the court received and reviewed three separate medical opinions
on the subject. Dr. Silberstein opined that the sinus clotting was caused or linked to the 2015 knee
injuries and resulting clotting conditions. Conversely, Dr. Lewis specifically opined that, to a
reasonable degree of medical certainty, Homstad’s sinus condition was not related. And finally,
Dr. Avery, Homstad’s treating physician, opined that the issue presented a difficult question and
that, although he believed the condition “could” have been caused by the original accident and
injuries, it was “very difficult to determine.” Regardless of whether Dr. Avery’s opinion could be
read to provide support for Homstad’s position, there is no question that Dr. Lewis affirmatively
opined that the sinus condition was not linked to the original accident and injury. At a minimum,



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Dr. Avery’s testimony establishes that the issue presents a difficult medical question lending some
credence to Dr. Lewis’ ultimate opinion in the matter. Although the Workers’ Compensation Court
refers in its order to the opinion of “Dr. Clark” as supporting its finding, we find that was a
scrivener’s error in that the opinion referenced by the court was offered by Dr. Lewis. Because we
find that there is adequate support in the record from Dr. Lewis to substantiate the factual
conclusion reached by the trial court, we are precluded from substituting our own view of the facts
for that of the Workers’ Compensation Court.
        Homstad argues that this issue should be controlled by the Nebraska Supreme Court’s
pronouncement in Rosemann v. County of Sarpy, 237 Neb. 252, 466 N.W.2d 59 (1991). In
Rosemann, the Supreme Court referenced the claimant’s reliance on the following proposition
expressed in 1 A. Larson, The Law of Workmen’s Compensation § 13.00 at 3-502 (1900): “When
the primary injury is shown to have arisen out of and in the course of employment, every natural
consequence that flows from the injury likewise arises out of the employment, unless it is the result
of an independent intervening cause attributable to claimant’s own intentional conduct.”
Rosemann v. County of Sarpy, 237 Neb. at 258, 466 N.W.2d at 63. In that regard, Homstad argues
that there was no evidence of an independent intervening cause which led to Homstad’s sinus
condition and, consequently, there was an insufficient factual record to support the court’s
decision. However, the Nebraska Supreme Court, in relation to the same principle, went on to
explain:
                In his treatise, Professor Larson notes a group of medical-causation cases “in which
        the existence of the primary compensable injury in some way exacerbates the effects of an
        independent medical weakness or disease. The causal sequence in these cases may be more
        indirect or complex, but as long as the causal connection is in fact present the
        compensability of the subsequent condition is beyond question.” 1 A. Larson, supra,
        § 13.11(b) at 3-523 to 3-524.

Rosemann v. County of Sarpy, 237 Neb. at 258-59, 466 N.W.2d at 63.
        Accordingly, contrary to Homstad’s argument, even when ascertaining the compensability
of natural consequences that follow from an injury, the claimant remains obligated to establish the
causal connection of the subsequent condition. As such, in order to recover for Homstad’s sinus
condition, as a “natural consequence that follows from injury,” it remained Homstad’s burden to
show that the causal connection was present. Here, there was conflicting evidence as to whether
that condition was, in fact, a natural consequence of Homstad’s original injury and as we
previously explained, the court’s finding that Homstad’s sinus condition was not a natural
consequence that followed from the 2015 injury was adequately supported by the record. As such,
Homstad’s assignment of error fails.
                                        VI. CONCLUSION
       Having found that the record supports the Workers’ Compensation Court’s factual
determination that Homstad’s sinus condition was not linked to his original accident and injury,
the order of the Workers’ Compensation Court is affirmed.
                                                                                     AFFIRMED.



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