Citation Nr: 0005253 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 96-43 084 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for residuals of a chest injury, to include chronic obstructive pulmonary disease. REPRESENTATION Appellant represented by: Earl C. Sheehan, Attorney ATTORNEY FOR THE BOARD Douglas E. Massey, Associate Counsel INTRODUCTION The veteran had active military service from February 1942 to January 1946. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a January 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In December 1997, the Board remanded the case to the RO for additional development. That development has been completed by the RO, and the case is once again before the Board for appellate review. In a letter dated in January 2000, the veteran's attorney argued that the veteran's lung condition was caused by tobacco use in service or nicotine dependence that began in service. As this matter has not been procedurally developed for appellate review, the Board refers it back to the RO for appropriate development and adjudication. FINDINGS OF FACT 1. All available evidence necessary for an equitable disposition of the appeal has been obtained by the RO. 2. The veteran's chronic obstructive pulmonary disease is not related to service, to include chest trauma therein. CONCLUSION OF LAW Residuals of a chest injury, to include chronic obstructive pulmonary disease, were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim for service connection is plausible and capable of substantiation and is therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a). The VA therefore has a duty to assist the veteran in developing facts that are pertinent to these claims. See 38 U.S.C.A. § 5107(a). The Board finds that all relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issue on appeal has been obtained. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. See 38 C.F.R. § 3.303(b). In this case, the veteran maintains that he currently suffers from residuals of a chest injury, to include chronic obstructive pulmonary disease (COPD), as a result of injuries incurred in an airplane accident in 1943 during his period of military service. For the following reasons, however, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for residuals of a chest injury, to include COPD. Service medical records reflect that the veteran was severely injured in an airplane accident in October 1943. Chest X- rays taken at that time revealed atelectasis of the left lower lobe. It was further noted that a diaphragmatic hernia would have to be ruled out. Physical examination showed both lung fields to be clear. The veteran was later seen in October 1944 for complaints of constant pain in his lower chest on the left side, with no objective findings shown. In November 1946, the veteran reported a burning sensation in the left upper quadrant since the airplane crash. He also reported shortness of breath. All studies were normal except for slight pleural reaction at the base of the left lung. Neither restrictive nor obstructive lung disease was shown to have been present at any time in service. Thus, service medical records show no evidence of a chronic respiratory disorder during the veteran's period of military service. The first documented post-service complaints of respiratory problems occurred many years after the veteran's separation from military service. Reports from Aultman Hospital dated from March to April of 1977 show that the veteran was initially treated by John S. Schuster, M.D., for chest congestion, shortness of breath and fatigue. Dr. Schuster recorded that the veteran was overweight and continued to smoke cigarettes. Chest X-rays revealed tenting of the left diaphragm, and a perfusion lung scan revealed no evidence of pulmonary emboli. Pulmonary function testing disclosed severe obstructive airway disease with hypoxia. Dr. Schuster concluded that the veteran had chest pain and fatigue of uncertain cause. He also said that the possibility of cardiac or pulmonary etiology was to be determined. In an August 1980 report, Dr. Schuster explained he had been treating the veteran for the past five years for severe emphysema, and that asthmatic bronchitis was superimposed on this condition. Dr. Schuster stated that X-rays found pleural scarring in the right lung which had been stable since 1975. Dr. Schuster believed that pleural scarring was related to the veteran's previous history of chest trauma from the airplane crash. Since his initial admission at Aultman Hospital in 1977, the veteran received ongoing treatment for various respiratory disorders, to include COPD, emphysema, respiratory insufficiency, respiratory failure, cor pulmonale, obstructive sleep apnea, and chronic bronchitis. Treatment reports show that these conditions had been treated by numerous health care providers, including Shrinivas Tonapi, M.D., Robert B. Miller, M.D., Stanley Benjamin, M.D., John Schuster, M.D., Sam O. Simmerman, M.D., Karen LeMiller, LPN. The Board stresses, however, that none of these reports (other than Dr. Schuster's August 1980 letter discussed above) includes an opinion as to the etiology of the veteran's respiratory disorders. Thus, none of these reports relates any of the veteran's respiratory disorders to the plane crash of 1943. In connection with this claim, the veteran underwent a general medical examination by the VA in August 1995. A report from that examination documents the veteran's history of sustaining right lung damage in a plane crash in 1943, as well as his history of COPD secondary to smoking. X-rays of the chest revealed chronic interstitial pulmonary disease, particularly in the left lung. The examiner concluded with diagnoses of (1) COPD, requiring home oxygenation and inhalers, stable at the current time; (2) obstructive sleep apnea, stable on home BIPAP with oxygen bled; and (3) history of right lung injury in 1943 from plane crash. No opinion as to the etiology of the veteran's COPD or obstructive sleep apnea was provided. Pursuant to the Board's December 1997 Remand, the veteran's claims file was referred to a VA pulmonary specialist who was requested to review all pertinent records and offer an opinion as to whether it is at least as likely as not that the veteran's current lung disorder is related to service. In an April 1998 report, a VA physician stated that blunt trauma to the chest could have resulted in the pattern of chest X-ray findings seen in 1977, which showed tenting of the right diaphragm and pleural thickening. The physician then hypothesized that the veteran may have suffered from a pulmonary embolus during his recovery period which caused problems such as airway obstruction. However, he explained that was unlikely that blunt trauma or pulmonary emboli had progressed to produce chronic obstructive lung disease. Another etiological hypothesis proposed was the veteran's history of cigarette smoking. The physician then concluded that it was unlikely that the lung injury sustained in the 1943 airplane crash could itself explain all of the features in 1977. The veteran underwent a pulmonary examination by the VA in June 1998. At that time, the examiner recorded the veteran's history of sustaining a chest injury in 1943, cigarette smoking from age 18 until age 45, and COPD since 1973. X-ray examination revealed chronic elevation of the right diaphragm with adhesions, chronic interstitial fibrosis, with no acute disease. Pulmonary function testing indicated a severe obstructive ventilatory impairment. The examiner concluded with a diagnosis of COPD, but offered no opinion as to the etiology of this condition. The Board subsequently requested an additional VA expert medical examiner to review the claims file and provide an opinion as to whether it is at least as likely as not that the veteran's 1943 chest injury either caused or aggravated any current lung/chest condition the veteran may have. In a November 1999 report, a VA pulmonary specialist concluded that "[t]he veteran's current lung/chest condition was not caused or aggravated by the chest injury suffered during a plane crash in 1943." In reaching that conclusion, the physician said that he agreed with most of the information contained in the April 1998 VA examination report, except the information concerning the veteran's smoking history. The physician went on to state that blunt chest trauma would be expected to cause restrictive impairment of lung function, which was never documented. He related that radiographic evidence of pleural thickening was observed, which usually results in a reduction of the vital capacity with maintenance of the FEV1 value. It was further noted that pulmonary functions performed over a period of time indicated that the veteran had hyperinflation and that the reduction in the vital capacity was related to COPD with air trapping rather than to restrictive impairment from an old injury to the chest wall. The physician explained that the veteran's history of 37 packs of cigarettes a year and continuing smoking while suffering from severe obstructive airflow disease strongly points to cigarettes as the major cause of the veteran's pulmonary disability. Applying the applicable criteria to the facts of this case, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for residuals of a chest injury, to include COPD. While the veteran suffered chest trauma in 1943 and was subsequently treated for respiratory problems in service, no chronic respiratory disorder was diagnosed in service. The Board also places significant weight on the fact that no post-service respiratory problems were documented unit 1977, over thirty years after the veteran left service. The Board also notes that only one medical opinion of record suggests that the veteran's current respiratory disorder was incurred in service. As noted, Dr. Schuster stated in an August 1982 report that the veteran's right pleural effusion and pleural scarring were related to chest trauma from an airplane accident. This opinion, however, does not appear to be based on a review of the veteran's claims file. In Swann v. Brown, 5 Vet. App. 177, 180 (1993), the United States Court of Appeals for Veterans Claim (Court) held that, without a review of the claims file, any opinion as to etiology of an underlying condition can be no better than the facts alleged by the veteran. As such, Dr. Schuster's opinion relating the veteran's pleural effusion and scarring to an in-service chest injury can be considered no more than mere speculation. See Black v. Brown, 5 Vet. App. 177, 180 (1993); see also Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (rejecting a medical opinion as "immaterial" where there was no indication that the physician reviewed the claimant's service medical records or any other relevant documents which would have enabled him to form an opinion on service connection on an independent basis). The only medical opinions of record based on a review of the claims file are those contained in the VA medical reports of April 1998 and November 1999, both of which declined to relate the veteran's current respiratory disorder to service. The April 1998 report includes a medical opinion that blunt trauma to the chest could result in the pattern of chest X- ray findings seen in 1977, which showed tenting of the right diaphragm and pleural thickening. It was further noted that the veteran may have suffered from a pulmonary embolus during his recovery period in service which resulted in problems such as airway obstruction. Nevertheless, the physician opined that is was unlikely that blunt trauma or pulmonary emboli had progressed to produce chronic obstructive lung disease. The physician then proposed that the veteran's history of cigarette smoking was an etiological factor. Although the physician did not attempt to rule out whether the veteran's current respiratory disorder was aggravated by chest trauma sustained in service, the November 1999 report contained an opinion which unequivocally ruled this out. That report notes that the veteran's current respiratory disorder was not caused or aggravated by the chest injury suffered during a plane crash in 1943. As these opinions were rendered following a review of the record, the Board affords them greater probative value than the opinion provided by Dr. Schuster. In addition, both opinions are supported and explained by sound bases and rationale. No such rationale or bases were provided by Dr. Schuster. Under these circumstances, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for residuals of a chest injury, to include COPD. The Board has also considered the veteran's own lay statements concerning the etiology of his respiratory disorder. However, where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1991). Since the record does not reflect that the veteran possesses the medical training and expertise necessary to render an opinion as to either the cause or diagnosis of a respiratory disorder, his lay statements are of little probative value and cannot serve as a basis for granting service connection for this condition. See Heuer v. Brown, 7 Vet. App. 379, 384 (1995) (citing Grottveit v. Brown, 5 Vet. App. 91, 93 (1993)). In conclusion, the Board finds that the preponderance of the evidence is against the veteran's claim of entitlement to service connection for residuals of a chest injury, to include COPD. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for residuals of a chest injury, to include chronic obstructive pulmonary disease, is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals