Opinion
No. M2014-02455-SC-R3-WC
12-15-2015
KAREN ALFORD v. HCA HEALTH SERVICES OF TENNESSEE, INC., ET AL.
Catheryne L. Grant, Nashville, Tennessee, for the appellants, HCA Health Services of Tennessee, Inc., d/b/a Stonecrest Medical Center, and ACE American Insurance Co. R. Steven Waldron, Murfreesboro, Tennessee, for the appellee, Karen Alford.
Appeal from the Circuit Court for Rutherford County
No. 65629
Royce Taylor, Judge The plaintiff, a nurse, alleged that she sustained a hip injury in the course of her employment. She further alleged that she sustained an injury to the nerves of her leg as a result of treatment for the hip injury. In addition, she alleged a mental injury. Her employer contended that her hip problems were preexisting and that she failed to sustain her burden of proof as to the nerve and mental injuries. The trial court found that the hip and nerve injuries were compensable but the alleged mental injury was not. It also awarded certain medical expenses from unauthorized physicians. Employer has appealed, asserting that the evidence preponderates against the award of benefits. The appeal has been referred to the Special Workers' Compensation Appeals Panel for a hearing and a report of findings of fact and conclusions of law pursuant to Tennessee Supreme Court Rule 51. We reverse the award of medical expenses but otherwise affirm the judgment.
The employee has not appealed the trial court's ruling concerning the alleged mental injury. For that reason, we omit discussion of the evidence presented on the subject. --------
Tenn. Code Ann. § 50-6-225(a)(2) (2014) Appeal as of Right; Judgment of the Circuit Court Reversed in Part and Affirmed in Part
BEN H. CANTRELL, SR. J., delivered the opinion of the Court, in which JEFFREY S. BIVINS, J., and ANDY D. BENNETT, J., joined. Catheryne L. Grant, Nashville, Tennessee, for the appellants, HCA Health Services of Tennessee, Inc., d/b/a Stonecrest Medical Center, and ACE American Insurance Co. R. Steven Waldron, Murfreesboro, Tennessee, for the appellee, Karen Alford.
OPINION
Factual and Procedural History
Karen Alford ("Employee") is a registered nurse. On August 24, 2011, she was employed by Stonecrest Medical Center ("Employer") in the emergency department. She worked on a "prn," or "as needed," basis for Employer, averaging twenty-four hours per week. She also held a full-time position at Baptist Hospital as a transfer center coordinator. She described the latter position as an office job, in which she arranged the transfer of critical care patients to other hospitals. On August 24, at Stonecrest, Employee slipped on a wet substance while working with a patient. She described her movement as a "half-split" in which her right foot moved forward while her left foot stayed planted. She did not fall to the ground, but she felt immediate pain in her right groin. Employee reported the incident to her supervisor and was referred to Dr. Aaronson, a physician in Employer's emergency department.
Employee was subsequently provided with a panel of physicians and selected Dr. Mayfield, an orthopaedic surgeon. She had been treated by Dr. Mayfield for right hip pain earlier that summer. Dr. Mayfield had ordered an MRI, which revealed a possible labral tear, and referred her to Dr. Thomas Byrd, a hip specialist. Employee had not actually seen Dr. Byrd before her work injury but had been examined by his nurse practitioner, Beth Potter, on August 9, 2011. On that date, Ms. Potter gave Employee an intra-articular injection, which provided relief of her symptoms within three or four days.
When Employee first saw Dr. Mayfield for her work injury, he prescribed physical therapy and activity restrictions. Employee's condition did not improve, and she was referred again to Dr. Byrd for further evaluation. Employee was seen by Ms. Potter again on October 11, 2011. Employee described her hip pain as "similar to the pain she had at her last visit but with increased severity." Based on a physical examination and review of x-rays, Ms. Potter's impression was that Employee's problem "seems to still be an intra-articularissue. However, the severity of this particular episode is significantly worse than her last episode." Ms. Potter limited Employee to sedentary work, performed another intra-articular injection and ordered a high resolution MRI of the right hip.
Employee was seen by Dr. Byrd on November 4, 2011. She reported that she had received only temporary relief from the most recent injection by Ms. Potter. Dr. Byrd noted that the MRI "further substantiated evidence of labral damage" and that "[h]er MRI from July is most notable for posterolateralparalabral cyst. The more recentMRI more clearly shows evidence of accompanying labral pathology laterally and anterolaterally." He recommended arthroscopic surgery to repair the damage, but added that "[r]ealistically there is some of this that can't be reversed." By November 28, Employee called Dr. Byrd's office and reported that she was feeling better. However, by the time she returned to see Ms. Potter on December 12, 2011, she had suffered a flare-up after a physical therapy session. She expressed concern about her ability to continue as a floor nurse.
Ultimately, Employee decided to proceed with the surgery. She continued to work both of her jobs until that procedure occurred on January 12, 2012. She testified that she was in extreme pain immediately after the surgery. An anesthesiologist administered two nerve blocks to address Employee's pain. The first "didn't help." The second reduced her level of pain, but "deadened" her right leg. At her first post-operative visit, Employee's hip pain was improved. However, when she returned to Dr. Byrd on March 19, 2012, she reported a new problem. She stated that she had numbness from her right groin area to her mid-calf, along the inside of her leg. She told Dr. Byrd that she did not have "any external numbness or problems voiding but since her last visit she hashad intercourse and she relates that she has not been able to climax, and that had never been an issue forher beforehand."
Employee testified that she noticed numbness immediately after the nerve blocks were administered. She had not previously mentioned the issue to Ms. Potter or Dr. Byrd because she thought such problems were a normal part of the recovery process. She brought the issue up on March 19 because the symptoms had continued. Dr. Byrd referred her for a neurological consultation. She continued with physical therapy until July 2012, when Dr. Byrd determined she was at maximum medical improvement. He assigned 3% permanent anatomical impairment to the body as a whole for the hip injury. He also placed a twenty-five pound lifting and carrying restriction on her activities. Employer could not accommodate those restrictions, so Employee was unable to return to work. She also had been terminated from her position at Baptist Hospital because she had been off work for longer than the maximum permissible medical leave.
Employee was evaluated by Dr. Stephen Graham, a neurologist, on May 31, 2012. He concluded that she had no neurological deficits. Her motor examination was normal. Her sensory examination did not reveal "any specific, clear areas of diminished appreciationto sharp, light touch, cold, or vibration." He found no correlation between her reported symptoms and specific dermatomes. He stated that she did not require additional testing or treatment and that she retained no permanent impairment for nerve dysfunction.
Employee thereafter consulted Dr. Riley, a gynecologist, on her own. By report, Dr. Riley pinched her right labia with a surgical clamp, but she was unable to feel it. Dr. Riley thereafter referred her to Dr. Michael Edgeworth, a neurologist, for additional evaluation. Dr. Edgeworth first examined Employee on June 21, 2012. Prior to the examination, he spoke directly with Dr. Riley, who described the clamp episode. Dr. Edgeworth's examination disclosed diminished sensation in the right groin, inner thigh and back of the leg to an area four inches above the ankle. He found no sensation in her right labia. His diagnosis was that she had a peripheral nerve injury; however, he was unable to determine which nerves were injured. He ordered MRIs of the lumbar spine and pelvis. The result of the former was normal. The latter showed improvement in the tissue of the labrum. When Employee returned to him on July 25, she reported pain in her right leg from her hip to her toes. This was a new complaint. It did not follow the same pattern as her sensory loss. The results of her clinical examination were similar to those from the previous exam. Dr. Edgeworth added anorgasmia, paresthesia and neurogenic pain to his previous diagnoses. He believed "her injuries weresustained during her procedure for theright hip surgery." However, he was unable to state how the injury occurred. He based his opinion on the timing of the onset of her symptoms.
Over the next several months, Dr. Edgeworth prescribed Neurontin to attempt to control Employee's pain. A nerve conduction study was performed. The results of the study were normal. Dr. Edgeworth stated that Employee's pain and numbness were permanent. He restated that he was unable to identify or "map out" the specific nerves causing Employee's symptoms. He understood that the numbness appeared in the period immediately after the post-surgical nerve blocks. Dr. Edgeworth contacted the anesthesiologist who administered the nerve blocks. Neither doctor could "make sense" of the relationship between the blocks and Employee's symptoms. Dr. Edgeworth learned that the injections were not made directly to the nerves, but rather into surrounding tissue, permitting the medication to seep down into the nerves. While this method is safer than direct injection, because there is no contact between the needle and nerve tissue, it also makes it difficult to predict which nerves will get "bathed" by the medication. During cross-examination, he agreed that there were other possible causes of Employee's symptoms, including unknown etiologies. However, he stated: "My medical opinion is thatthat would be an incredible stretch ofa possibility to get such isolatednumbness and pain without any othersystemic injury. That would be really bizarre and highly coincidental."
Dr. David Gaw, an orthopaedic surgeon, examined Employee on September 12, 2012, at the request of her attorney. He found that she had normal sensation and function of her left leg and that she had normal strength and range of motion of her right leg. However, he found dysesthesia on the inside of the right leg from the groin to the ankle, as well as the back of her right thigh. He stated that she had neuropathies of several nerves in the right leg. He identified the affected nerves as the "right posterior femoral cutaneous, the saphenous, obturator, iliohypogastric, ilioinguinal, pudendal, and genitofemoral nerves." He stated that Employee's hip injury was more likely than not related to the slip at work. He further stated her nerve dysfunction was related to the post-surgical nerve blocks. He assigned 5% impairment to the right leg for the hip injury and 11% to the leg for dysfunction of the femoral, sciatic and obturator nerves. These impairments combined to 15% permanent impairment to the leg or 6% to the body as a whole. In addition, he assigned 12% permanent impairment to the body as a whole for dysfunction of the genitofemoral, ilioinguinal, iliohypogastric and pudendal nerves. These impairments combined to 17% to the body as a whole. Dr. Gaw recommended that Employee observe "common sense" limitations on her activities.
During cross-examination, Dr. Gaw stated that his initial opinion about the cause of the hip injury was based on his understanding that Employee's previous hip complaints were several years prior to the work injury. During redirect, he testified that he subsequently reviewed the records about Employee's hip problems in the summer of 2011and that the information did not change his opinion. He thought she had a partial labral tear prior to the work injury that was worsened by that event.
Concerning Employee's nerve dysfunction, Dr. Gaw agreed that his opinion about its cause was based on the timing of the onset of symptoms. Dr. Gaw did not consider the subsequent normal nerve conduction study to conflict with his opinions because that type of test is not helpful in detecting sensory pathologies. He agreed that Employee had normal motor function in her right leg. He also agreed that testing for sensory loss was subjective. However, Employee's responses during the examination were consistent with normal sensation to pulling, touching, and pinching on the outside of the right leg and diminished sensation on the inner part of the leg. He did not think that a nurse would have sufficient knowledge of the dermatomes of the leg to manipulate the examination. Dr. Gawstated that the only functional loss resulting from Employee's hip and nerve injuries would be related to pain.
In July 2012, after being released from Dr. Byrd's care, Employee was hired by CHS, a medical services contractor, as an occupational nurse. She worked as a plant nurse at the Nissan facility in Smyrna. She continued in that job until October 2013, when she was terminated for having an inappropriate relationship with an employee of another Nissan contractor. She testified that she was out of work for two weeks before finding a job through a staffing agency as an occupational nurse at Shaw Industries in Winchester. At that time, she contacted Dr. Byrd to request that her lifting restriction be removed. She made the request because the lifting limitation excluded her from many desirable nursing jobs, such as trauma, emergency and critical care nursing. Dr. Byrd declined to change her restrictions without a new functional capacity evaluation. Employee had the evaluation, and Dr. Byrd then lifted her restrictions.
Employee then secured a six-week contract working in Helena, Arkansas. For that job, she traveled to Arkansas, stayed in a hotel, and worked seven consecutive twelve-hour shifts before returning home for a rest period. Employee then was hired by Vanderbilt University Medical Center as a surgical step-down nurse. She was in training for that position when the trial of this matter took place in June 2014.
Employee testified that her condition had not improved significantly since 2013. She continued to have numbness from her right groin down the inside of her leg, pain in her hip and leg, and sexual dysfunction. She stated that sitting and driving caused pain in her hip and leg. She had gone dancing, an activity she had previously engaged in regularly, only once in the seven months preceding the trial. She had been to the gym only twice in four months. During cross-examination, she agreed that she was earning a rate of pay equal to or greater than at the time of her injury. She also agreed that she had no physical restrictions or limitations.
Patricia McDonnell was Employee's nurse case manager beginning in September 2013. Ms. McDonnell testified that Employee never asked her to arrange an examination by a neurologist other than Dr. Graham, nor was there any record of such a request being made prior to September 2013. She also testified that Employee mentioned that her boyfriend was assisting her with workout sessions.
The trial court issued a written memorandum decision. It found that Employee had sustained compensable injuries to her hip and the nerves of her right leg. For those injuries, it adopted Dr. Gaw's impairment rating of 17% to the body as a whole. Based on that impairment, it awarded 25.5% permanent partial disability benefits. It also awarded employee medical expenses for treatment by Dr. Edgeworth and other unauthorized physicians. Finally, it found that Employee had not sustained a compensable mental injury. Employee filed a motion for clarification and modification, arguing that the trial court had incorrectly limited her award of permanent disability benefits to one and one-half times the anatomical impairment. Employer filed a response, agreeing that the "cap" set out in Tennessee Code Annotated section 50-6-241(d)(1)(A) did not apply but arguing that the award of 25.5% accurately reflected Employee's disability. The trial court granted Employee's motion and revised its award of benefits to 45% to the body as a whole. Judgment was entered in accordance with the court's findings. Employer has appealed, asserting that (1) the evidence preponderates against the trial court's finding that Employee sustained a compensable injury to her hip; (2) in the alternative, the evidence preponderates against the trial court's finding that Employee sustained compensable nerve damage; (3) in the alternative, the award of 45% permanent partial disability is excessive; and (4) the trial court erred by awarding expenses for unauthorized medical treatment.
Analysis
A trial court's findings of fact in a workers' compensation case are reviewed de novo, accompanied by a presumption of correctness, unless the preponderance of the evidence is otherwise. Tenn. Code Ann. § 50-6-225(a)(2) (2014); see also Tenn. R. App. P. 13(d). "'This standard of review requires us to examine, in depth, a trial court's factual findings and conclusions.'" Williamson v. Baptist Hosp. of Cocke Cnty., Inc., 361 S.W.3d 483, 487 (Tenn. 2012) (quoting Galloway v. Memphis Drum Serv., 822 S.W.2d 584, 586 (Tenn. 1991)). When the trial court has seen and heard the witnesses, considerable deference must be afforded to the trial court's findings of credibility and the weight that it assessed to those witnesses' testimony. Tryon v. Saturn Corp., 254 S.W.3d 321, 327 (Tenn. 2008) (citing Whirlpool Corp. v. Nakhoneinh, 69 S.W.3d 164, 167 (Tenn. 2002)).
"When the issues involve expert medical testimony that is contained in the record by deposition, determination of the weight and credibility of the evidence necessarily must be drawn from the contents of the depositions, and the reviewing court may draw its own conclusions with regard to those issues." Foreman v. Automatic Sys., Inc., 272 S.W.3d 560, 571 (Tenn. 2008) (citing Orrick v. Bestway Trucking, Inc., 184 S.W.3d 211, 216 (Tenn. 2006)). In this regard, we may make our own assessment of the evidence to determine where the preponderance of the evidence lies. Crew v. First Source Furniture Grp., 259 S.W.3d 656, 665 (Tenn. 2008); Wilhelm v. Krogers, 235 S.W.3d 122, 127 (Tenn. 2007). Further, on questions of law, our standard of review is de novo with no presumption of correctness. Wilhelm, 235 S.W.3d at 126 (citing Perrin v. Gaylord Entm't Co., 120 S.W.3d 823, 826 (Tenn. 2003)).
Compensability of Hip Injury
Employer points out, correctly, that the evidence showed that Employee had documented symptoms in her right hip in the months immediately preceding the work injury. An MRI scan had been performed, and Dr. Mayfield had diagnosed a labral tear. Ms. Potter, Dr. Byrd's assistant, noted on August 9, 2011, that the study showed "some labral abnormality on the right side with a fluid collection around her superior lateral labrum." However, Ms. Potter pointed out in the same note that the MRI contained "no isolated views of her right hip so the results are somewhatlimited." Employer points out that no evidence was introduced of a comparison between the pre-injury and post-injury MRI studies. It argues that the facts are similar to those in Foreman, in which the Supreme Court affirmed a trial court's finding that an employee's work injury had caused only a temporary aggravation of a pre-existing lower back condition. 272 S.W.3d at 574-75. In Foreman, an orthopaedic surgeon who treated the employee both before and after her injury affirmatively testified that her work injury did not advance the severity of her pre-existing condition. Id. at 574. In the instant case, the treating physician did not testify but provided a C-32 that affirmatively stated Employee's hip condition was related to her work injury. The evaluating physician, Dr. Gaw, testified that the work injury caused a worsening of her pre-existing labral damage. In contrast to Foreman, Employer in this case presented no evidence that the work injury caused only a temporary aggravation of Employee's already-damaged hip. Under the circumstances, we conclude that the evidence does not preponderate against the trial court's finding on this issue.
Compensability of Nerve Damage
Employer next contends that the evidence preponderates against the trial court's finding that Employee sustained a compensable injury to the nerves of her right leg. In this instance, Employer presented evidence, through Dr. Graham, who testified that Employee had no nerve abnormalities in her leg and that there was no objective correlation for her subjective complaints. As outlined above, Employee presented testimony from Dr. Edgeworth and Dr. Gaw that she had nerve dysfunction which was more likely than not related to the nerve blocks administered to her shortly after Dr. Byrd's January 2012 surgery. Neither doctor was able to provide a medical or scientific explanation of the process that caused Employee's numbness. Both doctors based their opinions on the timing of the onset of the symptoms in relation to the nerve blocks. Employee testified that her leg was "deadened" after the second nerve block and remained so thereafter. She explained that she assumed this was a normalpost-surgical course and, for that reason, did not mention it to Dr. Byrd until her second post-surgical visit.
"Although causation in a workers' compensation case cannot be based upon speculative or conjectural proof, absolute certainty is not required because medical proof can rarely be certain. . ." Clark v. Nashville Mach. Elevator Co., 129 S.W.3d 42, 47 (Tenn.2004); see also Glisson v. Mohon Int'l, Inc./Campbell Ray, 185 S.W.3d 348, 354 (Tenn.2006). All reasonable doubts as to the causation of an injury and whether the injury arose out of the employment should be resolved in favor of the employee. Phillips v.A&H Constr. Co., 134 S.W.3d 145, 150 (Tenn.2004).The element of causation is satisfied where the "injury has a rational, causal connection to the work," Braden v. Sears, Roebuck & Co., 833 S.W.2d 496, 498 (Tenn. 1992).
The evidence in this record shows that Employee underwent surgery for a compensable hip injury. Two nerve blocks were administered to treat severe pain after the procedure. Employee testified that her symptoms began after those injections and continued to the day of trial. The trial court specifically accredited her testimony. Her reports of her symptoms to Dr. Byrd, Dr. Edgeworth, and Dr. Gaw were consistent over time. Dr. Gaw was confident that the results of his sensory examination were accurate. He found that the symptoms followed certain dermatomes, and he considered it unlikely that even a sophisticated patient could deliberately misrepresent such symptoms. Dr. Edgeworth agreed that there were other potential causes for Employee's condition but considered that possibility bizarre and unlikely in light of all the circumstances.
Although Employee's proof of causation is far from certain, we find no basis to conclude that the evidence as a whole preponderates against the trial court's finding that her nerve dysfunction was related to the surgery and subsequent nerve blocks.
Extent of Permanent Disability
Employer next asserts that the award of 45% permanent partial disability to the body as a whole is contrary to the weight of the evidence. Employer points out that, as to her hip injury, Employee was working without medical limitation when the trial occurred. She had asked Dr. Byrd to lift the restrictions he had placed on her activities. Indeed, he lifted the restrictions only after she completed a functional capacity evaluation that demonstrated her ability to work without limitations. Dr. Gaw, the evaluating physician, testified that Employee had normal strength and motion in her right hip. After being released to return to work in July 2012, she was able to find work as an occupational nurse for Nissan within a short period of time. She held that position for longer than a year and was terminated for reasons unrelated to the effects of her injury. Thereafter, she was able to find jobs within her field on two occasions and had started working at Vanderbilt shortly before the trial. In addition, she had entered a Master's degree program, which she expected to complete in May 2015.
Further, the primary effects of Employee's nerve injury did not greatly reduce her employability. She sustained some level of sexual dysfunction. She reported minor urinary problems. The numbness in her right leg interfered with exercise and dancing, activities that she had frequently engaged in prior to her surgery. For these reasons, Employer argues that that the award of permanent disability benefits is excessive.
The trial court explained its decision in the October 7, 2014 memorandumgranting Employee's motion for clarification and modification of its original findings. It referred to Dr. Byrd's notes of October 23, 2012, March 25, 2013 and July 1, 2013, which documented continuing pain at "end ranges of motion," "residual dysfunction," "inflammation" and "irritability" of the hip joint. The court further noted Dr. Gaw's statement that Employee's activities would be somewhat limited by pain and that she was at increased risk of arthritis in the joint. The court then stated: "[Employee] is a nurse who is now employed at a higher paying nursingposition that is more sedentary than a floor nurse. Her limitations make itdifficult to work full time as a floor nurse, thereby leaving her with few optionsin the nursing field." The court's assessment of her disability was based on those concerns.
Tennessee Code Annotated section 50-6-241(d) sets out a non-exclusive list of factors to be considered in determining the extent of permanent partial disability: "the employee' s age, education, skills and training, local job opportunities and capacity to work at types of employment available in claimant's disabled condition." "The trial court is not bound to accept physicians' opinions regarding the extent of the plaintiff's disability, but should consider all the evidence, both expert and lay testimony, to decide the extent of an employee's disability." Walker v. Saturn Corp., 986 S.W.2d 204, 208 (Tenn. 1998) (citingHinson v. Wal-Mart Stores, Inc., 654 S.W.2d 675, 677 (Tenn.1983)). Further, "the claimant's own assessment of her physical condition and resulting disabilities must also be evaluated." Whirlpool Corp. v. Nakhoneinh, 69 S.W.3d 164, 170 (Tenn. 2002) (citing Uptain Constr. Co. v. McClain, 526 S.W.2d 458, 459 (Tenn.1975)). Employee testified that she had continuing pain that interfered with her daily activities. Her testimony was consistent with statements contained in Dr. Byrd's notes and with Dr. Gaw's testimony. The trial court had the opportunity to observe Employee as she gave this testimony. As Employer points out, there are several factors that would have permitted the trial court to make a smaller award in this case. However, to reverse or modify the trial court's finding, it would be necessary for us to conclude that the evidence preponderates against it. We are unable to do so.
Unauthorized Medical Expenses
Finally, Employer asserts that the trial court erred by ordering it to hold Employee harmless for medical expenses associated with treatment from unauthorized physicians. The expenses at issue are those associated with Dr. Edgeworth and two other neurologists, Drs. Clark and Lee. It is not disputed that Employer provided a panel of neurologists from which Employee selected Dr. Graham. Employee testified that Dr. Graham's examination was cursory. She was dissatisfied with the experience. Thereafter, she sought treatment with her gynecologist, Dr. Riley, who referred her to Dr. Edgeworth. She did this on her own, without consulting Employer. The testimony of Ms. McDonnell confirmed that Employee did not make any effort to communicate her dissatisfaction with Dr. Graham or request an additional neurological evaluation. In general, an employee who is dissatisfied with the services of a physician provided by her employer has three options: "(1) move the court to appoint a neutral physician... (2) consult with his employer and make other arrangements... or (3) go to a physician of his own choice, without consulting with the employer, and thus be liable for such services." Consolidation Coal Co. v. Pride, 452 S.W.2d 349, 354 (Tenn. 1970).SeealsoBuchanan v. Mission Ins. Co., 713 S.W.2d 654, 658 (Tenn. 1986). In this case, Employee chose to seek additional medical treatment without consulting Employer. She is therefore liable for the cost of that treatment. In addition, we note that no evidence was presented concerning the reasonableness of the charges for which reimbursement was sought. An injured employee "has the burden of establishing the necessity and reasonableness of charges incurred under physicians not designated or otherwise approved by the employer." Russell v. Genesco, Inc., 651 S.W.2d 206, 211 (Tenn. 1983).
Based on the foregoing, we reverse that portion of the judgment requiring Employer to hold Employee harmless for the cost of unauthorized medical treatment.
Conclusion
The award of unauthorized medical expenses is reversed. The judgment is affirmed in all other respects. The case is remanded to the trial court for entry of an order consistent with this opinion. Costs are taxed to HCA Health Services of Tennessee, Inc., d/b/a Stonecrest Medical Center, and ACE American Insurance Co. and their surety, for which execution may issue if necessary.
/s/_________
Ben H. Cantrell, Senior Judge
JUDGMENT
This case is before the Court upon the entire record, including the order of referral to the Special Workers' Compensation Appeals Panel, and the Panel's Memorandum Opinion setting forth its findings of fact and conclusions of law, which are incorporated herein by reference.
Whereupon, it appears to the Court that the Memorandum Opinion of the Panel should be accepted and approved; and
It is, therefore, ordered that the Panel's findings of fact and conclusions of law are adopted and affirmed, and the decision of the Panel is made the judgment of the Court.
Costs will be paid by HCA Health Services of Tennessee, Inc., d/b/a Stonecrest Medical Center, and ACE American Insurance Co. and their surety, for which execution may issue if necessary.
PER CURIAM