                      COURT OF APPEALS OF VIRGINIA


Present: Judges Benton, Bray and Senior Judge Hodges
Argued at Norfolk, Virginia


PAPCO OIL COMPANY AND
 LIBERTY MUTUAL INSURANCE COMPANY
                                                  OPINION BY
v.       Record No. 0989-97-1              JUDGE WILLIAM H. HODGES
                                              NOVEMBER 18, 1997
WILLIAM KENNETH FARR


           FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION
              Bradford C. Jacob (Taylor & Walker, on
              brief), for appellants.

              Ralph Rabinowitz (Rabinowitz, Rafal, Swartz,
              Taliaferro & Gilbert, on brief), for
              appellee.



         Papco Oil Company and its insurer (hereinafter referred to

as "employer") appeal a decision of the Workers' Compensation

Commission (commission) holding employer responsible for the cost

of certain medical expenses incurred by William Farr (claimant).

 Employer contends that the commission erred in finding it

responsible for the cost of claimant's (1) June 26, 1994 through

July 5, 1994 and September 19, 1994 through September 27, 1994

medical treatment related to claimant's idiopathic
                       1
thrombocytopenia (ITP); (2) January 30, 1995 through
February 8, 1995 medical treatment related to his deep venous

thrombophlebitis (DVT) 2 and pulmonary embolism; (3) May 16, 1995
     1
     Thrombocytopenia is the decrease in the number of blood
platelets. See Dorland's Medical Dictionary, 27th Edition.
     2
     Thrombophlebitis is the inflammation of a vein associated
with thrombus formation, i.e., an aggregation of blood factors,
primarily platelets and fibrin with entrapment of cellular
through May 24, 1995 medical treatment related to his DVT and

pulmonary embolism; and (4) coumadin therapy.      Finding no error,

we affirm the commission's decision.

                                 Facts

        On March 7, 1994, claimant sustained a compensable back

injury. 3   On April 1, 1994, claimant underwent lumbar disc

surgery causally related to his compensable injury.      In June,

1994, claimant was scheduled for a second back surgery.      During a

routine work-up prior to that surgery, claimant's physicians

found that he suffered from ITP.       On June 22, 1994, Dr. Robert L.

Burger examined claimant with regard to his ITP.      On June 30,

1994, Dr. Burger admitted claimant to the hospital to undergo

treatment for his ITP.    On claimant's history and physical form,

Dr. Burger noted that "claimant had been told by Dr. Messer, the

orthopedic surgeon, that the platelet situation needed to be

clarified before surgery."    In a July 5, 1994 discharge summary,

Dr. Burger noted that claimant's platelet count had increased

from 15,000 to 210,000 after infusion of intravenous

gammaglobulin.    Dr. Burger opined that claimant could proceed

with surgery.

elements causing vascular obstruction at the point of its
formation. See Dorland's Medical Dictionary, 27th Edition.
    3
     The full commission refused to consider any medical evidence
filed by claimant with the commission after the February 8, 1996
hearing. Claimant did not appeal this ruling. Accordingly, on
appeal, we did not consider any medical records filed with the
commission after February 8, 1996.



                                   2
        On July 23, 1994, claimant underwent his second back

surgery.    Claimant was discharged from the hospital on July 24,

1994.    Three to four days after discharge, claimant developed

right-sided chest pain.

        On August 19, 1994, claimant was again admitted to the

hospital for treatment of pleural effusion and ITP.    He remained

in the hospital until August 27, 1994.    On August 19, 1994,

Dr. Chantal Brooks became claimant's treating physician.
        On September 19, 1994, claimant was admitted to the hospital

for treatment of his ITP before his third back surgery.    After

physicians corrected claimant's platelet count, he underwent his

third back surgery in September, 1994.

        After claimant's third back surgery, he developed DVT, which

required hospital treatment from January 30, 1995 through

February 8, 1995.    While in the hospital, claimant developed a

pulmonary embolism, a complication of his DVT.

        On May 8, 1995, claimant underwent an elective splenectomy

to treat his ITP.    Shortly after discharge from the hospital,

claimant was readmitted due to recurrent left lower extremity DVT

and pulmonary embolus.

        In a letter dated June 12, 1995, Dr. Brooks summarized

claimant's medical treatment beginning August 19, 1994.    Dr.

Brooks opined that the May, 1995 splenectomy markedly improved

claimant's platelet count. Dr. Brooks also noted the following:
          [Claimant] returned to the office in
          follow-up thereafter and was noted to become
          again increasing thrombocytopenic. It was



                                   3
          elected therefore to start him on steroid
          therapy in November of 1994 at which time his
          platelet count was 20,000. In February of
          1995, as a result of inactivity secondary to
          the multiple lumbar surgeries and residual
          low back pain and leg pain as well as the
          Prednisone therapy, the patient had to be
          admitted to Virginia Beach General Hospital
          with deep venous thrombophlebitis of the left
          lower extremity along with a pulmonary
          embolus.


As of June 12, 1995, claimant remained on coumadin, an

anti-coagulant, to prevent pulmonary emboli that could be caused

by claimant's DVT.
     On January 22, 1996, Dr. Lara L. Dimick, the surgeon who

performed claimant's splenectomy, opined that ITP's cause is

generally unknown.   Dr. Dimick stated that she could not

determine exactly why claimant developed ITP.   However, she

believed that it was "a definite possibility that [the ITP] could

be related to things that happened during his back surgery."    On

January 31, 1996, Dr. Dimick wrote:   "There is no way that we can

know whether [claimant] had [ITP] prior to his surgery or whether

this was a result from interventions that he received while he

was in the hospital for his original back surgery."   Dr. Dimick

also opined:
          I do not believe any physician could answer
          your question of probabilities in this case.
           However, given the fact that [claimant] was
          healthy prior to his other surgeries and had
          no clinical signs or symptoms of this disease
          would certainly support the fact that he did
          not have [ITP] earlier. I feel that it is
          likely that he received some heparin flush
          while he was in the hospital to flush out
          intravenous lines. This would not
          necessarily be documented in any records and



                                 4
          could possibly cause this disease process.

          Therefore, all I can state with certainty is
          that there is a possibility that [claimant's]
          injuries were related to his hospital stay.


     On March 20, 1996, Dr. Brooks wrote:
          As clearly stated by Dr. Laura [sic] Dimick
          from a strictly scientific standpoint, it is
           impossible to say whether [claimant's]
          injury on the job followed by his surgery
          could in some way be responsible for his
          [ITP] finally resulting in a splenectomy.
          Clearly, there was no documentation prior to
          the initial injury of the presence of any
          thrombocytopenia, and it was only subsequent
          to the surgery that this was clearly
          documented and evaluated.
          The injury and the surgery could have
          aggravated a pre-existing condition; however,
          I am unable to state this with certainty,
          having no data with which to make this
          suggestion.

          I would have to therefore state that in my
          opinion it is possible that the [ITP] that
          finally resulted in a splenectomy was related
          to the treatment or the aftermath of the
          treatment that [claimant] received as a
          result of his injury on the job.


     On January 12, 1996, Dr. John C. Schaefer, who reviewed

claimant's medical records for employer, commented via letter

regarding Dr. Dimick's opinions.       Dr. Schaefer noted that "[t]he

diagnosis of immune thrombocytopenia is often a primary event

without an apparent underlying disease.      However, it can be

associated with among other things an underlying

immunoproliferative disorder, either malignant or non-malignant."

Dr. Schaefer also listed various other conditions and drugs,

including heparin, which might cause ITP.      Dr. Schaefer did not


                                   5
render his own opinion as to the cause of claimant's ITP.




                                6
                         Commission's Decision

        The commission held that claimant failed to prove that his

compensable injury by accident or the treatment required for his

work-related back injury caused his ITP. 4      However, because the

medical evidence proved that claimant's ITP had to be treated

before he could undergo the second and third back surgeries, the

commission held employer "liable for the cost of correcting, at

least temporarily, the ITP because this condition needed to be

resolved so that the work-related back injury could be treated by

surgery."     In so ruling, the commission held employer responsible

for the cost of Dr. Burger's treatment, and the hospitalizations

on June 26, 1994, September 19, 1994, and September 26, 1994.
        In addition, based upon Dr. Brooks' June 12, 1995 notes, the

commission held employer liable for the cost of the

hospitalization beginning on January 30, 1995 for treatment of

claimant's DVT and associated embolism and continued medical

treatment for same.     The commission also held employer liable for

the May 16, 1995 through May 24, 1995 hospitalization on the

ground that it was precipitated by a recurrence of claimant's

DVT, which was initially caused by the work injury.       Finally, the

commission held employer liable for claimant's coumadin therapy.

        The commission did not hold employer liable for claimant's

hospitalization from August 19, 1994 through August 27, 1994,

finding that no medical evidence proved that this treatment for
    4
        Claimant did not appeal this finding.




                                   7
pleural effusion and ITP was causally related to the compensable

work injury.

                              Analysis

       On appeal, we view the evidence in the light most favorable

to the prevailing party below.    See Lynchburg Foundry Co. v.

Goad, 15 Va. App. 710, 712, 427 S.E.2d 215, 217 (1993).      In

addition, the commission's factual findings will be upheld if

supported by credible evidence.       See James v. Capitol Steel
Constr. Co., 8 Va. App. 512, 515, 382 S.E.2d 487, 488 (1989).

"However, the question of whether the disputed medical treatment

was necessary within the meaning of Code § 65.2-603 is a mixed

question of law and fact."    Goad, 15 Va. App. at 712-13, 427

S.E.2d at 217.   Accordingly, the commission's conclusions as to

the necessity of the disputed medical treatment are not binding

upon this Court.   "However, both the purposes of the Workers'

Compensation Act and the equities of the situation guide us in

affirming the commission's award."       Id. at 713, 427 S.E.2d at

217.

       Code § 65.2-603(A)(1) provides in pertinent part as follows:
            As long as necessary after an accident, the
            employer shall furnish or cause to be
            furnished, free of charge to the injured
            employee, a physician . . . and such other
            necessary medical attention.


"'So long as a causal relationship between the industrial

accident and the . . . [treatment rendered] is shown, the

employer is financially responsible for the medical attention



                                  8
which the attending physician deems necessary, subject to review

by the Commission.'"    Goad, 15 Va. App. at 714, 427 S.E.2d at

217-18 (quoting Jensen Press v. Ale, 1 Va. App. 153, 159, 336

S.E.2d 522, 525 (1985)).   Moreover, Code § 65.2-603 should be

construed liberally in favor of the claimant, in harmony with the

Act's humane purpose.    See Goad, 15 Va. App. at 713, 427 S.E.2d

at 217.

                            ITP Treatment
     Credible medical evidence established that claimant's ITP

was diagnosed during medically necessary treatment of his

compensable back injury.   To continue treatment of claimant's

back with further surgeries in July and September, 1994,

claimant's physicians required limited treatment of the ITP to

normalize his platelet count.   Thus, treatment of the ITP was a

medically necessary adjunct to the successful completion of that

care required by claimant's work-related back injury.

     Accordingly, under the facts of this case, the commission

did not err in holding employer responsible for Dr. Burger's

medical treatment and for medical expenses incurred by claimant

from June 26, 1994 through July 5, 1994 and from September 19,

1994 through September 27, 1994.
               DVT and Pulmonary Embolic Treatment

     Dr. Brooks' June 12, 1995 notes provide credible evidence to

support the commission's award of medical expenses incurred from

January 30, 1995 through February 8, 1995, and May 16, 1995



                                   9
through May 24, 1995, for treatment of claimant's DVT and

pulmonary emboli.    Dr. Brooks stated that in February 1995

claimant had to be hospitalized for DVT and pulmonary emboli as a

result of inactivity secondary to his multiple lumbar surgeries

and residual low back and leg pain.    The May 1995 treatment was

necessitated by a recurrence of the DVT and pulmonary embolism,

which flowed from the compensable injury.    Therefore, because the

DVT and pulmonary emboli followed as natural consequences of the

compensable back injury, the commission did not err in holding

employer responsible for medical expenses related to treatment of

those problems.     See Morris v. Badger Powhatan/Figgie Int'l,

Inc., 3 Va. App. 276, 283, 348 S.E.2d 876, 879 (1986).

     Even if claimant's prednisone therapy also contributed to

cause his DVT and pulmonary embolism, employer is still

responsible for the cost of medical treatment related to those

conditions under the "two causes rule."    That rule provides that

a condition which has two causes, one related to a work injury,

and one not, is compensable and the treatment of that condition

will be the responsibility of the employer.     See Shelton v. Ennis

Bus. Forms, Inc., 1 Va. App. 53, 55, 334 S.E.2d 297, 299 (1985).

     Coumadin Therapy

     The medical records established that Dr. Brooks prescribed

the coumadin therapy to prevent pulmonary emboli, which might be

caused by claimant's left lower extremity DVT.    Because the DVT

flowed as a natural consequence of the compensable back injury,




                                  10
employer is responsible for any necessary medical treatment

related to the DVT.   Accordingly, the commission did not err in

holding employer responsible for the cost of the coumadin

therapy.

     For these reasons, we affirm the commission's decision.

                                                        Affirmed.




                                11
