Case History Webinar 2020
MD CONSULTING SERVICES LLC
5743 S. Genoa Court
Aurora, CO 80015
October 26, 2019
Perry Mason, J.D.
Law Office of Perry Mason & Assoc.
19 Rose Avenue
Denver, Colorado 80285
Re: E B
Dear Mr. Mason,
You have asked me to review an Independent Medical Examination report by Abraham Van Helsing, M.D. dated September 24, 2019 concerning your client E B. As you know, I observed the IME done by Dr. Van Helsing on September 24, 2019. I have also reviewed the medical records of Yuri Zhivago, M.D., Laurence Moreau, M.D., June Apple, Ph.D., and Billie Jean Barbee, Ph.D. Dr. Van Helsing’s report also summarizes some of Mr. B’s medical records.
In addition, I interviewed Mr. B by telephone on September 20 , 2019 to clarify the medical records, as well as Mr. B’s medical history and current symptoms.
Brief History of Events
Mr. B is a 30-year-old man who reports he was working as a bicycle repair technician. On April 14, 2017 Mr. B took a bicycle he repaired for a test drive and due to a faulty pedal was thrown over the handlebars of the bike landing on the top of his head. He was wearing a helmet, however, reports the helmet cracked on impact. Mr. B remembers “waking up” on the ground after the fall and states he was “dazed.” He had a lacerated scalp which was bleeding profusely. Mr. B is not certain if he lost consciousness, however, he did use the term “waking up” after falling, suggesting he may have lost consciousness.
Mr. B was seen later in the day at the Denver Hospital Emergency Department. Mr. B was diagnosed with a “concussion” and “lacerated scalp.” He returned home after the ED visit and on the advice of the treating ED physician was instructed to follow up with his Primary Care Physician, Yuri Zhivago, M.D.,
Mr. B reports the following ongoing medical problems starting after the April 14, 2017 bicycle crash.
Mr. B reports he currently experiences 2-3 severe headaches per week. He often experiences a headache on awakening. Mr. B reports the headache starts in the occipital (back of the head) region and progresses forward to his eyes. The headaches are accompanied by photophobia (sensitivity to light), sensitivity to sound, dizziness and occasional nausea & vomiting. Mr. B reports the headaches are severe enough to feel like “my head will explode.” He reports (with zero representing no pain and 10 representing pain severe enough to lose consciousness) that his headache pain averages 5-7/10 on an average day. The headaches can last up to 24 hours. The headaches are relieved by lying down in a darkened room protected from outside noise. He is currently treated with sumatriptan 50 mg at the onset of a headache which may repeated once.
The headaches started immediately after his accident. Mr. B did not have a history of headaches prior to the accident.
Mr. B reports significant cognitive loss. He has difficulty with immediate and short-term memory, decreased concentration & attention span, visual disturbance, difficulty organizing thoughts & activities and word finding difficulties. In addition, Mr. B has difficulty expressing the written word, for example an inability to fill out simple forms or to compose email. He also has tangential thinking and difficulty maintaining his train of thought in conversation. As well, Mr. B complains of rapid mental fatigue, reduced math skills, decreased word comprehension, difficulty reading and processing information.
Mr. B reports his cognitive difficulties have caused him difficulty carrying on tasks in the activities of daily living such as writing out bills or cleaning his house. He has stopped almost all social interaction. He states, “I’ve cut myself off from my friends and family.” Mr. B feels uncomfortable around others due to his difficulty tracking normal conversation. He reports people have difficulty understanding what he is saying due to speaking in disjointed sentences. These problems are corroborated by his fiancé with whom he lives.
Mr. B reports his relationship with his fiancé has suffered due to his cognitive difficulties. Mr. B and his fiancé were to be married August 2018, however, they delayed the marriage and they are now starting couples therapy due to stress in the relationship caused by Mr. B’s ongoing injuries.
The cognitive problems started immediately after his accident and have continued unabated since the crash. Mr. B did not have a history of cognitive loss prior to the accident.
Mr. B reports depression characterized by depressed mood, difficulty falling and staying asleep, 30# weight gain, irritability, feelings of hopelessness & helplessness, fatigue, loss of motivation, crying spells, low self-esteem, emotional lability and occasional suicidal ideation without intention.
Mr. B feels his depression is contributing to the difficulty in his relationship with his fiancé as well as interfering with his ability to conduct the tasks of everyday life. He also feels his depression is contributing to his need to isolate from others including former friends.
The depression started immediately after his accident. Mr. B did not have a history of depression prior to the accident. Mr. B is currently prescribed Remeron 15 mg twice daily for depression. He is also taking Ambien CR 12.5 mg at bedtime for sleep. He is prescribed Lamictal 50 mg twice daily for mood stabilization.
Traumatic Injuries Manifested as Pain
Mr. B reports ongoing bilateral jaw pain which has been diagnosed as Traumatic Temporomandibular Joint Disorder (TMJ). He has neck pain originating at the base of his skull and radiating to his shoulders and upper back. Mr. B also reports mid-line low back pain radiating into his buttocks and legs.
Based on his doctor’s advice, Mr. B is trying to reduce his overall pain level with increased activity and exercising with light weights. He reports he was extremely active prior to the accident and was involved in several sports. Mr. B was an avid disc golfer. He was able to play 9 holes of disc golf recently for the first time in 6 months. Mr. B states he is trying to increase his activity as well as working on improving his cognitive abilities.
The traumatic injuries to his jaws, neck and low back started immediately after his accident. Mr. B did not have a history of TMJ, neck or back problems prior to the accident. He is prescribed Topomax 50 mg twice daily for pain control along with Non-Steroidal Anti-inflammatory medication, specifically, diclofenac 25 mg up to four times per day.
Recovery from Iatrogenic Narcotic Medication Addiction
Mr. B was treated with various narcotic medications for pain and eventually became addicted to oxycodone and OxyContin. He underwent withdrawal treatment at St. Augustine Hospital in August 2018 and has remained off these narcotics since that time. Mr. B is taking Suboxone 8 mg twice daily. He reports his plan along with his prescribing physician is to gradually reduce the Suboxone dose until he is completely off the Suboxone.
It should be noted Mr. B states he did not abuse illicit or prescribed drugs prior to the accident. He also reports he took the prescribed oxycodone and OxyContin exactly according to the prescription directions.
I disagree with many of Dr. Van Helsing’s conclusions and diagnoses. I will outline my opinions.
Traumatic Brain Injury
Since the 2017 bicycle crash Mr. B has complained of symptoms well explained by having sustained a Mild traumatic Brain Injury (MTBI) followed by Post-Concussion Syndrome. Mr. B describes cognitive loss, emotional distress, specifically depression, and headaches since the accident. All of these problems are well described problems of MTBI. Dr. Van Helsing states “It is improbable that he got depressed due to an injury from 2017.” It should be noted that is not the history reported by Mr. B. In fact, depression is one of the most common problems of MTBI. Jorge et al. in Archives of General Psychiatry Vol. 61, No. 1, Jan. 2014 state “Major depressive disorder was observed in 30 (33%) of 91 patients during the first year after sustaining a TBI. Major depressive disorder was significantly more frequent among patients with TBI than among the controls… Major depression is a frequent complication of TBI that hinders a patient’s recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms. The neuropathological changes produced by TBI may lead to deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala.”
Dr. Van Helsing states “Mr. B had a fall off of a bicycle on April 14, 2017. At that time, he hit his head. In his history, as he presented to me, he had what appears to be a brief loss of consciousness, which would be diagnosed as a concussion. This was not severe enough to cause a post concussive disorder.” Dr. Van Helsing suggests that because Mr. B had a brief loss of consciousness his head injury was not severe. It is my medical opinion to a reasonable degree of medical probability Mr. B’s accident cannot be described as “not severe.” Even so, it is well described in the medical literature that in certain individuals even low impact accidents do cause significant brain damage resulting in MTBI with significant symptoms including cognitive loss and affective (emotional) pathology.
In a 2015 article in Medical Science Monitor titled Correlating Crash Severity with Injury Risk, Injury Severity, and Long-term Symptoms in Low Velocity Motor Vehicle Collisions Croft and Freeman discuss the fact that a “substantial number of injuries are reported in crashes of little or no property damage.” The correlation can be made with Mr. B’s bicycle accident. In fact, Castro et al. in an important 1997 article titled Do “whiplash injuries” occur in low-speed impacts? reports the limit of harmlessness for stresses arising from rear-end impacts with regard to velocity changes lies between 10 and 15 km/h (6-9 mph). In fact, Mr. B had a direct blow to the head after falling from a height of the bicycle handle bars.
It should be noted that Mr. B had a SPECT (brain imaging) scan of the brain on April 20 and 24, 2018. The SPECT report dated April 27, 2018 by Honus Wagner, M.D. states “Mr. B had evidence of abnormalities in his frontal, temporal and cerebellar lobes as well as his basal ganglia…The nature, location and pattern of the previous abnormalities (in the report-my addition) is most consistent with a past traumatic brain injury…Of particular note are the findings of cerebellar abnormalities which can correlate with his history of visual disturbance. Further, visual disturbances following traumatic brain injury have been shown to be immune to the effects of pain, disability, malingering or depression.” It is my further opinion the SPECT scan is further objective evidence of Mr. B’s MTBI.
It should also be noted that Mr. B was treated by psychiatrist Sigmund Freud, MD. In a report dated April 13, 2018 with addenda and revisions on May 10, 2018 Dr. Freud diagnosed Mr. B with Dementia due to Head Trauma with “Behavioral Disturbance and Depressive Disorder due to Head Trauma.”
Dr. Van Helsing points to the issue of whether or not Mr. B lost consciousness. It is well accepted in the medical literature that loss of consciousness is not necessary to sustain traumatic brain injury (TBI) resulting in a Post-Concussion Syndrome. Lovell et al. in a 2010 article in Clinical Journal of Sport Medicine titled Does Loss of Consciousness Predict Neuropsychological Decrements After Concussion report “there were no significant differences found between LOC, no LOC or uncertain LOC groups” referring to the severity of TBI symptoms.
It is also reported in the medical literature that not all MTBI symptoms always start immediately after impact and can be delayed by days or even weeks.
In addition, to make the diagnosis of MTBI with subsequent Post-Concussion Syndrome it is very well described in the medical literature that antegrade and/or retrograde amnesia may or may not be present; however, neither symptom is required to make the diagnosis.
Dr. Van Helsing states “Through 2017 and 2018, when one would expect a head injury to have the most serious sequelae, he was functioning well. It is improbable that post-concussive symptoms would start in 2017 and continue for two years after the injury.”
In fact, Mr. B reports the onset of cognitive loss, depression and headaches immediately or very shortly after the accident. By Mr. B’s report and the report of his fiancé, Mr. B was not “functioning well.” Mr. B reports his cognitive problems to have “gotten worse” in 2018. It is important to note this time frame correlates with when Mr. B was prescribed increasingly higher doses of narcotics for pain.
It is common for psychoactive drugs, particularly drugs that are sedating, to exacerbate impaired cognitive functioning. It is my opinion to a reasonable degree of medical probability that Mr. B’s cognitive functioning was more impaired in 2018 due to the narcotics, tranquilizers and hypnotics (sleeping pills) being prescribed for him. This time frame also correlates to when Mr. B had significant difficulty performing his duties at Denver Tea Company.
It is not uncommon for an individual to under report cognitive loss in the days, weeks or even months after a traumatic brain injury. The symptoms themselves can be confusing to the patient and misinterpreted by the patient and doctors alike. As many of the symptoms in PCS are common to, or exacerbated by, other disorders, there is a risk of misdiagnosis. LM Ryan and DL Warden in a 2003 article in International Review of Psychiatry 15 (4): 310-316 titled Post Concussion Syndrome report “symptoms such as noise sensitivity, problems with concentration and memory, irritability, depression, anxiety, fatigue and poor judgment may be called ‘late symptoms’ because they generally do not occur immediately after the injury, but rather days or weeks after the accident.”
MTBI symptoms in some individuals can become permanent. In the 2005 book Forensic Neuropsychology Sweet et al. state “…over 1,300,000 (in the US-my addition) individuals sustain an MTBI…Although the majority will make a full recovery a minority suffer from more chronic difficulties. However, the size of the minority who become chronically symptomatic varies from one study to another from 7-8% to 10-20% to even a higher estimate to approximately one third.” Depending on which journal articles one reads approximately 8%-30% of individuals with TBI do not recover. Permanent brain injury is usually defined as MTBI symptoms that persist longer than one year.
In a 2009 paper by P. Karzmark; K. Hall; and J. Englander titled Late-Onset Post-Concussion Symptoms after Mild Brain Injury: The Role of Premorbid, Injury-Related, Environmental, and Personality Factors the authors discuss the factors that contribute to late onset symptoms.
Report of Drug and Medication Usage
Dr. Van Helsing states “Mr. B’s depression was maintained by his substance abuse and dependence.” He goes on to state “Though he blames his life circumstances on the injury, his downhill spiral, including employment and relationship issue, were related to drug use.” It is my opinion to a reasonable degree of medical probability that Mr. B’s iatrogenic addiction to opiates actually made his traumatic brain injury symptoms worse. The problems most affected by his use of prescribed psychoactive medications were depression and cognitive impairment.
Unfortunately, now that Mr. B has significantly decreased his use of psychoactive drugs his cognitive impairment continues. It is my further opinion now that Mr. B is no longer taking opiates other than Suboxone, he should undergo repeat neuropsychological testing. It is my opinion neuropsychological testing is another objective way to measure Mr. B’s cognitive condition.
Claim of Misrepresentation of History
Dr. Van Helsing reports “Mr. B’s presentation is complicated by misrepresentation.” Dr. Van Helsing makes assumptions concerning Mr. B’s job history that really is nothing more than speculation. For example, Dr. Van Helsing states “He held a job at Denver Tea Company with no evidence that he performed poorly though Mr. B infers that he did not do well.” I do not know if Dr. Lee interviewed Mr. B’s boss to confirm his speculation. There is no such indication in his IME report.
In addition, Dr. Van Helsing makes a case that because Mr. B went on vacation trips he could not be significantly injured. It is my opinion individuals with depression and/or cognitive loss can still move about and be active enough to engage in activities like travel. Mr. B’s condition has not made him bedridden. Dr. Van Helsing’s conclusion here is somewhat incredulous.
It is my opinion to a reasonable degree of medical probability that E B sustained a Mild Traumatic Brain Injury with subsequent Post-Concussion Syndrome in his April 14, 2017 bicycle accident. His ongoing medical problems are best explained by this diagnosis. As noted, Mr. B has ongoing problems, specifically cognitive impairment, depression and headaches, all very common to MTBI. It is my further opinion that the diagnosis of MTBI is now more definitive given Mr. B no longer takes opiates, has reduced his use of other medications and still presents with cognitive loss and other symptoms outlined.
In, addition an April 2018 SPECT scan gives objective evidence of MTBI. It is also my opinion Mr. B needs to have repeat neuropsychological testing. Unfortunately, I suspect the testing will also give objective evidence regarding the MTBI diagnosis.
It is my opinion to a reasonable degree of medical probability there is not a better alternative medical explanation that fits his current condition more closely.
Armin Feldman, M.D.
MD Consulting Services LLC