Baltimore Co. v. Quinlan

Panel: Leahy, Reed, Shaw Geter, JJ. Leahy, J. ^{488 888} A jury in the Circuit Court for Baltimore County found that Mr. Michael Quinlan ("Appellee") suffered an occupational disease in the form of degenerative tears in the medial and lateral menisci in his right knee arising out of and in the course of his employment as a paramedic/firefighter for Baltimore County ("Appellant" or the "County"). The County appeals that decision, presenting a single issue for our review: "Whether right knee degenerative tears of the medial and lateral menisci and their underlying cause, osteoarthritis, constitute[ ] an occupational disease as defined by the Maryland's Workers' Compensation Act[.]" The Workers' Compensation Act (the "Act") provides that a covered employee may recover for an occupational disease that "is due to the nature of an employment in which hazards of the occupational disease exist and the covered employee was employed before the date of disablement." Maryland Code (1991, 2016 Repl. Vol.), Labor & Employment Article ("LE"), § 9-502(d)(1)(i).

Mr. Quinlan established through testimony presented at trial that repetitive kneeling and squatting is (1) a regular part of a paramedic's job and (2) a risk factor for ⁴⁸⁹ developing menisci tears and, in turn, osteoarthritis in the knees. We hold that Mr. Quinlan presented sufficient evidence at trial establishing that the degenerative menisci tears he suffered were an occupational disease for which he may recover under LE § 9-502(d)(1)(i). BACKGROUND A. Mr. Quinlan's Workers' Compensation Claim Mr. Quinlan filed an employee's claim with the Workers' Compensation Commission ("Commission") on October 19, 2015, asserting that he developed meniscal tears in his right knee due to his job duties as a paramedic/firefighter. The Commission held a hearing on March 31, 2016, on the following issues regarding Mr. Quinlan's claim: 1.

Did the employee sustain an occupational disease arising out of and in the course of employment? 2. Temporary Total Disability 3. Average Weekly Wage On April 5, 2016, the Commission found that Mr. Quinlan "did not sustain an occupational disease of Right Knee degenerative tears arising out and in the course of employment as alleged to have occurred on February 11, 2015," and issued an order disallowing Mr. Quinlan's claim. The Commission noted that the second issue (temporary total disability) was raised but not litigated and found Mr. Quinlan's average weekly wage to be $2,082.16.

Later that month, on April 29, he filed a petition in the Circuit Court for Baltimore County for review of the Commission's decision and requested a jury trial. B. Trial in Circuit Court The circuit court held a jury trial on April 19-20, 2017. Mr. Quinlan testified first. At the time of trial, he was 51 years old, 5'9? tall, and weighed between 230-240 lbs.

He explained that he has worked for the Baltimore County Fire Department as a paramedic since September 1994. The job requires him to work four days on followed by four days off; the first two days ⁴⁹⁰ on are ten-hour shifts and the second two are fourteen-hour shifts. Over those four days, he responds to about 26 to 30 calls that last an average of 60-90 minutes each. According to Mr. Quinlan, calls for paramedics range from "anything from patient assist, meaning like just helping somebody off the floor, to cardiac arrest to rescues to chest pain[.]" Because many of the calls are in response to people who are ⁸⁸⁹ in a heightened state of anxiety or pain and the patients may be on the floor, a couch, or a bed, and may be unconscious, Mr. Quinlan has to "kneel down to their level while [ ] talking to them instead of hovering over top of them." When he kneels, he'll often do so on his right knee.

In some situations, for example, if a patient is in cardiac arrest, he will "be on the floor for a little while, either doing compressions, airway managements," or "doing an I.V." While working, he also has to carry patients and equipment up and down steps. Aside from work, Mr. Quinlan testified that he golfs recreationally, lifts upper body weights, and occasionally rides a bike or goes sailing with friends. The County established on cross-examination that he has also posed for a picture squatting next to a dog and that he sometimes carries groceries or a laundry basket up the 10-20 stairs at his house. In 2005, Mr. Quinlan hurt his right knee on the job while assisting a patient down a set of stairs; he saw a doctor a few times for the pain at the suggestion of an officer at work.

Then, around 2014, Mr. Quinlan saw a doctor again for more problems associated with his right knee. He testified that after a shift, he was experiencing pain and "thought it was something that might just go away on its own" but the next day he noticed clicking when he walked. When he tried to pop his knee to alleviate the pain, "it just hurt more." Although he felt knee soreness and stiffness throughout his career, he indicated that this time felt more severe and consistent, and that the clicking was a new development. His personal physician told him to get an MRI and referred him to an orthopedic surgeon.

In February 2015, Mr. Quinlan underwent a partial meniscectomy on his right knee. After surgery, he returned to work. ⁴⁹¹ 1. Dr. Cochran's Testimony Following Mr. Quinlan's own testimony, he presented a video deposition of Dr. Barbara Cochran, who specializes in internal medicine, occupational medicine, psychiatry, and pulmonary medicine. Dr. Cochran testified that she evaluated Mr. Quinlan to determine whether his right knee issue was related to his occupation as a paramedic.

She explained that her evaluation procedure includes reviewing a patient's medical records and any medications he or she may be on, speaking to the patient, and looking at the patient's occupational history and job functions. She then reviews peer-reviewed medical literature to incorporate into her report. Dr. Cochran said that understanding the patient's job functions, shift work, and whether he or she takes breaks is vital to forming a reliable opinion relating to osteoarthritis. Dr. Cochran highlighted the functions of EMT/paramedic work that require paramedics like Mr. Quinlan to transport heavy patients, get them on stretchers or into the ambulance, and bend down to take vital signs, talk to, or triage patients.

Regarding lifting patients onto stretchers, she stated, "they're low to the ground. So you're in [a] squatting position, which puts a great deal of stress on the knee, because you know you're going to lift with your knees, you don't lift with your back." Mr. Quinlan had tears in his medial and lateral menisci when surgery was performed on his right knee. Dr. Cochran explained that tears of the menisci are "part of the continuum of osteoarthritis." She stated that "any type of motion or repetitive trauma" will cause "inflammation [of the] synovium, which is the covering over the bone[,] and then that progresses and so then you can get abnormal bone formation or you can get, again, changes in the meniscus." ⁸⁹⁰ As for risk factors, Dr. Cochran opined that age played a role in Mr. Quinlan's osteoarthritis in the sense that as you age you have that many more moments ... where you can [ ] injure your knee[.] ... [I]t's a risk factor in terms of how many times you were walking or how many ⁴⁹² times you were kneeling or bending. But his particular case, he developed this at a much earlier age than one would expect to see it.

Gender was not a risk factor for him because osteoarthritis occurs more frequently in women and Mr. Quinlan was diagnosed in only one of his knees, and no genetic factors have yet been identified as risk factors. Joint injuries were another risk factor, according to Dr. Cochran, but Mr. Quinlan did not appear to have any. Having reviewed Mr. Quinlan's medical records from 2005, Dr. Cochran testified that Mr. Quinlan's injury back then was not the type of joint injury contemplated as a potential risk factor: "He had a totally normal examination of his knee, there wasn't any infusion, there wasn't any swelling, there wasn't any laxity, there's nothing there that indicated he had any significant injury to his knee." Dr. Cochran explained that overuse or repetitive trauma is another risk factor. She then outlined the stress that squatting can put on the knees and observed that "as you come up and unbend you're exerting tremendous forces downward on the structures and they're going to again protect the ligaments and protect the joint integrity, but they're going to put pressure on the meniscus." She continued: When you do repetitive motions, ... what happens is that you have an inflammation and it doesn't have to be big inflammation, it can be a small inflammation.

But what happens is you get, the body will repair itself as long as there is enough time for the reparative molecules, which are called ... cytokines, but there's pro-inflammatory and they're healing and there's a number of different structures, or things that do that but, again, when you do this on a repetitive basis, the body does not have time to compensate and repair. So, you have inflammation, partial healing, inflammation, so it builds up. She then discussed one study that showed "repetitive kneeling and repetitive squatting" can "markedly increase[ ] risk" for osteoarthritis, which "is a cumulative injury," and another study that showed fire fighters have a "significant" relative ⁴⁹³ risk of osteoarthritis. Specific to Mr. Quinlan, Dr. Cochran opined that, based on two different types of causation analysis, including a six-step occupational-practice guideline documented in the American College of Occupational and Environmental Medicine, Mr. Quinlan's "essential job functions, which include considerable repetitive kneeling, bending, stress on the knee, [are] the cause of his knee osteoarthritis." She testified that the medical literature she reviewed supported her conclusion.

On cross-examination, the County elicited from Dr. Cochran that she never observed Mr. Quinlan physically and only spoke to him on the phone for around 30 minutes. She also testified that weight was a risk factor for osteoarthritis and would be a factor independent of Mr. Quinlan's employment. One study showed that patients over 197 pounds are more likely to suffer from osteoarthritis. Aside from weight posing a risk, Dr. Cochran did not consider Mr. Quinlan's weightlifting to factor in because he lifts weights with mostly upper extremities and not his legs.

Dr. Cochran also testified that she would not be surprised to learn that Mr. Quinlan experienced some soreness in his left knee because "he has an anatomically altered ⁸⁹¹ right knee, so that's going to create more stress on the contralateral knee." The County then spent a large part of its cross-examination parsing the findings of the studies on which Dr. Cochran relied. For instance, the County challenged the Framington Heart Study, contending that the sample size of male subjects was too small to sufficiently demonstrate a link between a person's occupation and being symptomatic for osteoarthritis. Dr. Cochran responded by explaining that she did not think the study's sample size impacted what the study was trying to show with respect to the physical demands of knee bending. Another study noted that meniscal damage and osteoarthritis occur frequently in the general population.

In response to the County's questioning, Dr. Cochran clarified that job stress is not the only cause of osteoarthritis in the knee. ⁴⁹⁴ On re-direct, Dr. Cochran clarified that the small sample size of the Framington study ha[d] nothing to do with the causation analysis or what occupational risk factors there are that put stress in the knee that leads to the development of chronic inflammation that exceeds the reparative capacity of the body leading to the degradation of the knee structure, starting with synovium, extending to the [ ] menisci, extending to the bones, I mean, again, along a continuum. Additionally, she testified that none of the non-occupational risk factors or studies explain why Mr. Quinlan would have osteoarthritis in only his right knee if it was not caused by his work. Finally, she testified that having reviewed the report of the County's expert, Dr. Richard Hinton, she "did not see any causation analysis at all." 2. Dr. Hinton's Testimony Trial resumed on April 20 with the video deposition of Dr. Hinton, an orthopedic surgeon who was qualified as an expert to testify on behalf of the County.

Dr. Hinton performed an independent medical exam on Mr. Quinlan on December 18, 2015. During that exam he observed that Mr. Quinlan "walked with a reciprocal gait without an obvious limp[,]" and "had a mild varus alignment or a mild bowing to both legs bilaterally." This bowing, he explained, could be the cause or the result of an injury to the knee. Dr. Hinton recalled that Mr. Quinlan's ranges of motion with his knee and hip were within the normal limits, but he did "have reproducible tenderness to palpation or pushing in the medial side of his knee on both the left and right knee." Dr. Hinton found him to have "had a gradual onset of medial knee pain." Mr. Quinlan's MRI, clinical exams, x-rays, and Dr. Hinton's exam were all "consistent with previous partial meniscectomy, lateral meniscectomy, early arthritis in the medial side of the knee and some mild arthritis behind the knee cap[.]" Although Mr. Quinlan had improved after his surgery, his medial knee pain had increased over the few months leading up to his exam, which Dr. ⁴⁹⁵ Hinton found to be "most consistent with early arthritis in the medial compartment." When asked to define Mr. Quinlan's condition, Dr. Hinton explained: [A]t the time of his [exam], I thought his primary complaints were related to arthritis on the inside of his knees and he had a history of a meniscus tear and meniscectomy, which is a risk factor for that. I thought his symptoms were most consistent when I saw him with arthritic complaints.

Dr. Hinton then responded as follows when the County asked whether Mr. Quinlan's work as an EMT paramedic caused his injury: I was asked whether I thought ... his work was a primary or direct cause of his meniscus issues, which I think contributed ⁸⁹² to his arthritis. He didn't give me a history of specific injury or specific incidents or cumulative symptomatic episodes on the job. So, I cannot relate the meniscus tears directly to his duties as a firefighter and EMT. Certainly, there is literature that suggests that people who are in firefighter/EMT positions have higher rates of both meniscus tears and of arthritis, as do people in many physically demanding job descriptions.

I would say that there is a debate about why that is and I think there's literature to support different ways of approaching that literature. My view of looking at it is that physically demanding workers ... have higher rates of injury and those injuries are recognizable, they are cumulative in nature but they're recognizable reportable injuries that then put them at risk for problems over the long term. I'm not convinced that asymptomatic use in this situation leads to a definable process later in life. The County then asked more directly whether Mr. Quinlan's job caused his injury and Dr. Hinton responded, "I do not think it is the primary cause of his problem or definably the primary cause of his problem, given mostly his history." Dr. Hinton also explained that Mr. Quinlan's weight was between ⁴⁹⁶ overweight and obese and that, as well as his age, were risk factors for arthritis and menisci tears.

On cross-examination, Dr. Hinton agreed that the medical literature showed that, as a population, people in more physically demanding jobs and people who do more squatting and kneeling-such as firefighters, farmers, warehouse workers, or EMTs-have a greater risk for osteoarthritis and problems in their knees. In Dr. Hinton's opinion, however, the medical research did not yet explain why that portion of the population was more at risk, but he speculated that it could be linked to more "definable injuries, ... less access to health care, ... they smoke more, ... [or] they're overweight, we don't know." Dr. Hinton did acknowledge that the CDC considered occupations involving repetitive knee bending and squatting to be a risk factor for osteoarthritis, along with "age, genetics, weight, injuries, [and] infections[.]" Dr. Hinton then stated that he would consider Mr. Quinlan's 2005 on-the-job injury one instance that could be considered a relevant symptom for cumulative trauma, which sparked the following exchange: [MR. QUINLAN'S COUNSEL]: Okay and so in, in the sense that he had other episodes of[ ] tripping or, you know, banging his knee or, you know, lifting a heavy patient and saying oh, I have pain, those would be things that would sway you to the conclusion in part, at least, or move you closer to the conclusion that his occupation did have a primary role in the, in the development of his osteoarthritis, right? DR.

HINTON: The fact that he had an episode, it was definable and required treatment, makes me, I have to bring into the equation that injury on the job as potentially a risk factor for some of his knee complaints. * * * DR. HINTON: And again, it's one episode but it is [one] more episode than I had when I did my [exam] on him . * * * ⁴⁹⁷ DR. HINTON: So, it, it does [sic] into the equation a little bit more than it did when I saw him for my [exam]. I think he also has, again, other risk factors that are just as significant as that, but I didn't have that when I did my- [MR.

QUINLAN'S COUNSEL]: Okay. So, [ ] that episode, if I understand you correctly, moves you closer to supporting the, the idea that the occupation had a more than indirect role in [the] development ⁸⁹³ of his knee osteoarthritis, correct, if I understand you correctly? * * * DR. HINTON: ... [ I]t's important, the fact is he had an occupational injury that I think could contribute to long term knee problems. [MR. QUINLAN'S COUNSEL]: All right.

DR. HINTON: I'm not convinced that his occupation as an EMT/firefighter is any more injurious or risky for his knee th[a]n a bunch of other jobs out there. But he did have an on the job injury, which I have to put into the equation. (Emphasis added).

Dr. Hinton then testified that he believed weight was the biggest risk factor, followed by age, and "a history of definable injury on the job is next[,]" followed by body alignment and gender. Although he would not consider an occupational injury as the primary cause, he described it as a "potential cause" or "arguable cause." 3. The Verdict The jury returned a verdict finding that Mr. Quinlan "sustain[ed] an occupational disease of right knee degenerative tears of the medial and lateral menisci of the right knee, arising out of and in the course of his employment." Four days later, on April 24, 2017, the court, Judge Ruth Jakubowski, entered an order vacating the Commission's order and remanding the case for entry of an order consistent with the jury's verdict. The County noted its timely appeal to this Court on April 28, 2017. ⁴⁹⁸ DISCUSSION I. The County argues on appeal that "[t]here is absolutely no evidence that right knee degenerative tears of the medial and lateral menisci is an occupational disease." It asserts that to be compensable, "the disease must be an inherent risk of employment." According to the County, the testimony of Doctors Hinton and Cochran make clear that osteoarthritis and degenerative knee tears are "not [ ] disease[s] inherent in Mr. Quinlan's employment[.]" The County asserts: "Osteoarthritis is not a disease caused by employment, but is rather a disease of life.... [T]he mere happening of pain or discomfort while at work does not render these conditions work related, caused by work, or is [sic] an occupational disease." The County also challenges Dr. Cochran's reliance on the Framington Heart Study, "in which the authors agree they do not have enough subjects to reach a definitive opinion regarding the relationship between occupational stress and O/E/degenerative meniscus tears." Finally, after reiterating that Mr. Quinlan is overweight and lives in a house with stairs, the County asserts: "A disease cannot be occupational if it [is] wide spread in the population and is not inherent to the occupation." In response, Mr. Quinlan contends that "the proper analysis is not whether a disease is labeled occupational or not, ... but rather whether the basic job responsibilities exposed an individual to conditions that could lead to the disease." He asserts that he "provided the jury with more than enough evidence for them to find that his responsibilities as a paramedic led to his occupational disease of right knee degenerative tears." In addition to his own testimony about his job requirements and the aches and pains he felt regularly, Mr. Quinlan points to Dr. Cochran's testimony about the stresses his job responsibilities placed on his right knee and Dr. Hinton's acknowledgment that his job could have played a role in his degenerative tears.

Mr. Quinlan then argues that his occupational responsibilities need only contribute in part to his diagnosis. He says he does not, ⁸⁹⁴ nor has he ever "dispute[d] that there were ⁴⁹⁹ potentially other causes in addition to his work that could have led to the diagnosis because by law there can be more than one cause for the degenerative tears as long as his work as a paramedic contributed in part, which there is ample evidence that it did." A claimant appealing the Commission's denial of a claim retains the burden of proof before the circuit court. Keystone Masonry Corp. v. Hernandez , 156 Md. App. 496 , 505, 847 A.2d 493 (2004) (citations omitted). On an appeal of a jury verdict to this Court, we treat the jury's decision as conclusive on all issues of fact.

Id. at 506 , 847 A.2d 493 (citation omitted). We will not reweigh the evidence; we must determine simply whether the evidence presented at trial was legally sufficient to support the jury's decision. Id. Any issues of law, we review de novo.

See Reger