Citation Nr: 1323301 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 09-05 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C.A. § 1151, for additional disability of a below-knee amputation of the right extremity due to treatment in November and December 2005 and January 2006 by the Department of Veterans Affairs (VA). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran had service from February 1960 to February 1963. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision of the VA Regional Office (RO). The Veteran's claim was previously before the Board and remanded in May 2012. It is properly before the Board at this time. A review of the Virtual VA claims file reveals that it contains no pertinent evidence not already contained in the Veteran's paper claims file. FINDING OF FACT Additional disability of a below-knee amputation of the right extremity was not the result of carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on the part of VA, nor is it an event not reasonably foreseeable. CONCLUSION OF LAW The criteria for compensation pursuant to the provisions of 38 U.S.C.A. § 1151 for additional disability of a below-knee amputation of the right extremity have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the RO provided the Veteran with the notice required under the VCAA in a pre-rating letter dated in March 2006. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained all records of the VA treatment at issue in this claim. The Veteran submitted some records from a private hospitalization that occurred in January 2006. In addition, the Veteran was afforded a review of his claims file by a VA examiner, who provided an opinion with regard to whether the treatment he received by VA warranted a grant under the provisions of 38 U.S.C.A. § 1151. The VA physician reviewed the claims file, provided a thoroughly detailed history of the VA treatment received by the Veteran, and gave a definitive opinion on this matter that was supported by a stated rationale. The examiner noted the absence of evidence related to the home health care provided to the Veteran as well as the private hospitalization in January 2006. However, as stated below, the Veteran did not submit or cooperate in assisting VA to obtain these records. Therefore, the VA physician provided an opinion based upon the most accurate evidence the Veteran has permitted VA to obtain. As such, the Board finds that it is an adequate opinion. The Board notes, and the Veteran's representative pointed out in the June 2013 informal hearing presentation, that additional records of the Veteran's private hospitalization in January 2006 may exist and are not associated with the claims file. The representative requested a remand on this matter for the Board to obtain these records. However, the Board finds that one is not necessary. In the March 2006 letter, the Veteran was informed that, for VA to request any private evidence, he must submit a completed form that was enclosed with that letter. In addition, the Veteran submitted copies of some of the records from that hospitalization. Therefore, the Board can only conclude that the Veteran had access to additional records, if they exist. He had numerous opportunities and several years during the course of this appeal to submit these records and has not done so. The same is true of any possible records from the home health care he was provided with in November and December 2006. As the Veteran has not submitted any of these records and has not provided the appropriate releases for VA to request these records, the Board finds that VA's duty to assist with regard to obtaining this possibly relevant evidence has been met. Additionally, when the Veteran's claim was remanded in May 2012, it was to obtain an opinion with regard to the claim decided herein. The November 2012 opinion provided by a VA physician answered all questions asked by the Board in the May 2012 remand and addressed all matters referred therein. As such, the directives given in the remand have been complied with. Stegall v. West, 11 Vet. App. 268, 271 (1998). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claim for compensation under 38 U.C.S.A. § 1151 is thus ready to be considered on the merits. II. Analysis The law provides that compensation may be paid for a qualifying additional disability not the result of the Veteran's willful misconduct, caused by hospital care, medical or surgical treatment, or examination furnished the Veteran when the proximate cause of the disability was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not recently foreseeable. 38 U.S.C.A. § 1151 (2012). VA regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability due to hospital care, medical or surgical treatment, examination, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361 (2012). If additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran's additional disability. See 38 C.F.R. § 3.361(c)(1) (2012). In addition, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d) (2012). It must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the informed consent of the Veteran or the Veteran's representative. To establish the proximate cause of an additional disability or death, it must be shown that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination. Whether the proximate cause of a Veteran's additional disability or death was an event not recently foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d) (2012). The November 3, 2005 assessment indicates that the veteran complained of right heel ulcer with cellulitis that was chronic. He had chills since yesterday and a history of diabetes mellitus. He denied fever, nausea, and vomiting. Examination revealed a right heel ulcer with erythema to the ankle. There was no pus expressed. There was a foul odor noted. The treatment plan was intravenous antibiotic with local wound care. November 4 and November 5, 2005 hospitalization records show that the malodor of the Veteran's wound continued to be present with no evidence of pus. A November 7, 2005 VA surgery request indicates that the Veteran was to undergo right foot debridement with possible partial foot amputation for right heel ulceration. Loss of a limb was included as an uncommon risk. Infection of the soft tissue or bones was listed as a common risk. A November 8, 2005 VA record shows that the Veteran was doing well, and his wound had no odor. A November 11, 2005 VA outpatient record shows that the Veteran was admitted one week ago with complained of fever and chills. He was found to have a right heel infected ulcer (DM). A separate note dated that same day indicated that the Veteran needed to have a foot amputation. There was a notation that the Veteran's wound was not improving. A November 14, 2005 VA report indicates that the Veteran had right foot and ankle abscess and underwent incision and drainage and devitalized tissue of the right foot and ankle. The findings included pus drainage of the right ankle and foot. The surgery request indicated that the planned procedure was right foot debridement with possible partial amputation for right foot infection. A November 15, 2005 VA report shows that the Veteran was resting comfortably with no complaints. He denied fever, cough, nausea, vomiting, diarrhea, chest pain, or shortness of breath. A November 16, 2005 VA record demonstrates that the Veteran reported developing a blister on his right foot in March. A November 18, 2005 VA record shows that the Veteran underwent right foot debridement. The diagnosis was right foot open wounds status post incision and drainage with necrotic tissue. While the plan had been for debridement, it was noted that it was possible that there would be amputation of the toes and/or partial amputation of the foot, which was also listed as an uncommon risk of the procedure. A November 19, 2005 VA report demonstrates that the Veteran had right heel ulcer with cellulitis and abscess. He was resting comfortably with no complaints. He denied fever, cough, nausea, vomiting, diarrhea, chest pain, or shortness of breath. The wound vacuum-assisted closure (VAC) was intact with no maceration, erythema, or edema. He had been admitted for twenty days for vancomycin-resistant enterococci infection of the right foot. The November 23, 2005 VA hospitalization discharge report shows that the Veteran was admitted on November 3, 2005 for foul smelling heel ulcer with an increase in drainage and cellulitis to the ankle. He had three incision and drainage surgeries and cultures grew out vancomycin-resistant enterococci bacteria. After the third debridement and linexolid was started, the Veteran began to improve rapidly. He was put on a wound VAC to stimulate granulation tissue and was now ready to be followed as an outpatient with home wound VAC therapy and oral linexolid. He was improving on discharge, and he was expected to recover. A November 28, 2005 VA record shows that the Veteran returned for treatment due to developing new blisters after sitting to close to a space heater. On examination, there were large open wounds of the right foot and additional blistering of the toes. The digits started turning dark from skin loss. The assessment was non-healing right heel wound with new burns to the forefoot. The Veteran was to continue medication for infection control, along with dressing changes, and VAC therapy. A December 9, 2005 VA record indicates that the Veteran had diagnoses of first, second, and third right toe gangrene, dry and calcaneal major nonhealing defects. The day before, he underwent right lower extremity diagnostic angiography via antegrade access, right proximal posterior tibial angioplasty with balloons, and right tibial peroneal truck angioplasty and stenting. The Veteran was discharged on December 10, 2005. A December 15, 2005 VA treatment record shows that the Veteran was returning for follow up status post right proximal posterior tibial angioplasty and right tibial peroneal trunk angioplasty and stenting for toe gangrene and calcaneal tissue loss. His right lower extremity temperature was warm. He had a venous ulcer, digital gangrene and a heel ulcer. There was no pus and minimal draining of serosanguinous fluid. The plan was for the Veteran to return in two months and continue treatment with podiatry as well as continue to change his wet dressings to dry twice a day. He was to return to the limb preservation clinic in one month. A December 21, 2005 clinical note indicates that the Veteran returned for follow-up for his right foot ulceration and dry gangrene. He denied fever, cough, nausea, vomiting, diarrhea, or much pain. The right foot wound VAC was in place and functioning. There were larger, full thickness ulcerations on the planter right heel and lateral foot. There was a fibrotic and fibrinous base with good underlying granular tissue. There was periwound maceration. The foam in the wound appeared only to partially cover the wound area. There was no erythema or purulence noted. The one, two, and three distal toes and dorsal foot proximal to those toes had dry, black, eschar. The second toe was completely mummified. There was no erythema, malodor or drainage noted. The assessment was right foot ulcerations, and the Veteran was to continue home health care by changing dressings and continuing the wound VAC. Regarding the wound VAC placement, there was too much maceration. Home healthcare was to use a larger VAC foam during application to cover the entire wound and to consider using stomahesive or other skin barrier to help prevent maceration or change the VAC more often. A January 4, 2006 VA outpatient record shows that the Veteran denied fever, cough, nausea, vomiting, diarrhea or pain. His dressing had been changed daily. Examination revealed full thickness ulcerations of the plantar right heel and lateral foot. There was a fibrotic and fibrinous base with good underlying granular tissue. There was no foul odor. There was localized mild erythema at the periwound. There was no pus formation. There was no clinical sign of infection. There was no erythema, malodor or drainage of the toes. The assessment was right foot ulcerations. The wound and periwound had been debrided, and the Veteran was to continue avoiding weight bearing of the right foot. The Veteran was to return on January 25, 2006. A January 17, 2006 private hospital discharge report shows that the Veteran was admitted with a diagnosis of gangrene of the right foot with ulceration over the right heel, rule out sepsis and slight osteomyelitis. During his stay, the Veteran underwent bone scan that revealed the presence of osteomyelitis. The Veteran was transfused blood due to being anemic. Because of osteomyelitis and ongoing heel ulceration for the last three years, it was advised that the Veteran undergo below-knee amputation, which was done on January 14, 2006. The discharge diagnosis was osteomyelitis of the right foot, status post below-knee amputation of the right leg. A January 20, 2006 private hospital report shows that the Veteran had gangrene of the right foot and was to undergo right below knee amputation. The gangrene of the foot was secondary to severe atherosclerosis. In his February 2006 written statement, the Veteran contended that he was treated at the VA facility in Linda Loma from November 3, 2005 to November 23, 2005. During that time, he underwent surgery on his right foot caused by a pair of shoes that caused an ulcer. He had home health care from November 24, 2005 to December 1, 2005. He had a wound VAC that did not do any good. He returned to VA on December 1, 2005 and was there until December 8, 2005, during which he received blood. He asserts that he also got "VRE" while in the hospital and was alternatively staying in a four-bed room and then a dirty private room. On January 5, 2006, he was told that his foot looked good. While he informed his doctors that he felt sick, they ignored him. He had home health care on January 10, 2006 and was told his foot looked good. That same night, he was feeling so sick that he went to the St. Mary Medical Center and was given blood. They told him that he had four infections in his right foot, and on January 14, 2006, he underwent surgery to remove his right foot. He blames VA for his amputation and wonders how they could have missed his infection. An April 2006 VA outpatient record shows that the Veteran had diabetes mellitus for about thirty years. In a May 2006 written statements, the Veteran asserts that, if the VA facility had caught his infection, he would not have lost his right leg. In a December 2006 written statement, the Veteran wondered why he had no pus or foul odor of his foot or any sign of infection if he had gangrene in three toes. He also asked why he was not hospitalized for surgery when he was first told about his problem on November 7, 2005. In a September 2007 written statement, the Veteran alleged that his right leg was amputated due to misdiagnosis and substandard care at VA. In a January 2009 written statement, the Veteran wondered why he continued to received treatment when it was noted on November 11, 2005 that he needed a foot amputation. He questioned why a VA record dated on January 4, 2006 showed no sign of infection but he was so sick on January 10, 2006 that he fell out of his wheelchair and had to go to the private hospital. In August 2012, the Veteran's claims file was submitted to a VA physician for review. The physician checked a box that stated that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the Veteran presented to the VA hospital with a right foot infection that was treated appropriately with prompt incision and debridement of the infected and necrotic tissue. He received multiple debridements in November 2005. At that time, he was found to have vancomycin-resistant enterococci, which was treated appropriately with linezolid and infectious disease involvement. His wound was vacuumed. When non-healing was noted, appropriate vascular surgical consultation was requested. After the appropriate studies were ordered and reviewed, vascular surgical intervention was performed, consisting of angioplasty. The Veteran had peripheral artery disease, which compromised his ability to heal. He was treated with appropriate surgery, antibiotic treatment, and when healing was not progressing, vascular surgery involvement was added. There was a low possibility of the viability of his right foot with significant infection and peripheral artery disease to compromise not only healing, but deliver of antibiotics. The VA physician believed that appropriate and appropriately timed interventions were performed. In November 2012, the Veteran's claims file was review by another VA physician. He noted that records from private treatment dated in January 2006, with the exception of a pathology report, were not available for review. The VA physician noted the Veteran's admission on November 3, 2005 for a non-healing ulcer of the right heel since March 2005. Surrounding cellulitis and wound infection were noted. An x-ray was negative for evidence of osteomyelitis. He was admitted to the hospital and intravenous medication was started empirically. When the wound failed to improve, the infectious diseases and vascular surgery services were consulted. Infectious diseases recommended change in antibiotics and vascular surgery recommended vascular and tissue perfusion studies. The Veteran underwent debridement of his heel wound on November 15 and November 19, 2005, at which time he was noted to have an infection and was begun on intravenous antibiotics. By November 23, his wound was improving and his wife was given the option of nursing home care or home nursing care and requested that he come home. He was released on November 24 with home nursing care, intravenous antibiotics, and a wound VAC. Vascular studies showed a 90 percent obstruction of the right popliteal artery at the knee and moderate peripheral vascular disease distally. The Veteran returned for care on November 28, 2005 after developing burns on his right toes. His ulcer was noted to be stable and without evidence of infection. He returned home and the home health agency was again contacted about wound care. He underwent percutaneous angioplasty of his right popliteal artery on December 8, 2005. This was performed without complication. Examination revealed transition to dry gangrene of the right toes. During this admission, the Veteran was noted to be severely anemic due to chronic disease and underwent blood transfusion. He was discharged on December 10, 2005. Regular follow-up with the limb preservation clinic on December 15, 2005, December 21, 2005, and January 4, 2005, revealed that the wound was not infected and was slowly improving with home care. The January 19, 2005 pathology report from the private hospital that performed the below the knee amputation on January 14, 2005 indicates that the gangrene of the toes was noted as was the peripheral vascular disease. Neither osteomyelitis of the calcaneus or other bones nor evidence of infection or abscess or wet gangrene involving the heal wound was noted. The clinical history noted is gangrene of the right foot. Per the Veteran's report, he became ill on January 10, 2006 and was taken to the hospital. The VA physician opined that it was less likely than not that the Veteran's right below knee amputation resulted from carelessness, negligence, lack of proper skill, error in judgment, or other instance of fault on the part of his care providers at VA. The physician opined that amputation was the most likely and definitive endpoint in the care of the right heal ulcer, which had been present for over six months before he presented in November 2005. The goal of his VA care providers was limb preservation, which is the avoidance of amputation. His care, which involved podiatry, vascular surgery, and infectious disease was appropriate and met general standards of care. Frequent follow-up was maintained, which demonstrated at least wound stability and the absence of infection. Proper protocol was followed with the discharge of the Veteran on November 24, 2005, as his wound was improving and home intravenous antibiotics and wound care had been established, and home care rather than continued inpatient care had been specifically requested by the Veteran's wife. It was not noted whether the Veteran was presented with the option of amputation at the time of his presentation in November 2005 as an alternative to conservative therapy aimed at limb preservation, though this omission in documentation does not constitute negligence. Communication between VA and the home care agency reveals documented stability of the wound. There was no mention of purulence, infection, abscess, or osteomyelitis in the pathology report of the Veteran's right lower leg in January 2006. The final outcome of a below knee amputation was not an unforeseeable event but rather the likely endpoint which the efforts of the providers at the VA hoped to avert. In a March 2013 written statement, the Veteran's representative questioned what measures were used to prevent maceration with the VAC therapy and whether the therapy should have continued. He also questioned what caused the Veteran's anemia, why osteomyelitis was not diagnosed at the VA, and the rapid decline in the Veteran's health, leading to his private hospital admission. At the outset, the Board notes that the Veteran is competent to describe what he has personally experienced, including the symptoms he has experienced. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The threshold question in this case is whether additional disability was the result of VA treatment that was characterized by carelessness, negligence, lack of proper skill, error in judgment, other instance of fault on the part of VA prior to an in furnishing surgical treatment, or was an even not reasonably foreseeable. The Board acknowledges that there are various opinions of record with respect this question and it is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). Furthermore, laypersons, in many instances, are competent to provided opinions with regard to etiology and other medical matters. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As such, while the Board will consider the opinions of both the Veteran and his representative, the Board finds that the opinion provided by the VA physician in November 2012 is more probative evidence on this matter for several reasons. First, the VA physician has medical expertise, training, and experience that neither the Veteran nor his representative have been shown to possess. In this case, the matter turns, in part, on what is the appropriate treatment for the Veteran's particular diagnosis and symptomatology, a matter for which an opinion provided by a medical professional such as the VA physician is more probative than lay statements. A physician certainly has more expertise about the practice of his own profession than non-medical professionals. In addition, the VA physician thoroughly reviewed the treatment afforded to the Veteran and provided opinions based on that treatment that answered the question of whether the treatment was appropriate for the Veteran's diagnosis and symptomatology. Rationales were provided for the conclusions given that were consistent with the record and treatment. Given all of this, the Board finds that the November 2012 VA physician's opinion is the most probative opinion of record and is given more weight than either the Veteran's or his representative's opinion. As stated above, the November 2012 opinion provided by the VA physician determined that the care provided to the Veteran was appropriate given the circumstances of his illness, and the below-knee amputation was not the result of carelessness, negligence, lack of proper skill, error in judgment, or other instance of fault on the part of his care providers at VA. He also determined, based upon an extensive review of the evidence, that the amputation of the Veteran's right lower leg was an event that was reasonably foreseeable, given the condition of his limb when he initially sought treatment in November 2005. As discussed above, this opinion is thorough, reasoned, detailed, and consistent with the record. In his February 2006 written statement, the Veteran appears to blame VA treatment for misusing the VAC therapy, for allowing him to get an infection while in the hospital, for missing signs of an infection, and for causing him to have to have his foot amputated. As stated above, with regard to whether proper care was administered with regard to the Veteran's treatment, the opinion provided in November 2012 by a VA physician is more probative than the Veteran's lay statements. In addition, an infection of the bones or tissues was noted twice in the record as a common risk of the surgeries the Veteran underwent. Finally, while the Veteran implies that VA missed signs of an infection, he does not provide reasoning as to why he believes that the infection found by the private hospital was caused by or present when he was treated at VA. In a January 2009 written statement, the Veteran questions why it was noted in his record on November 11, 2005 that he needed a foot amputation, when VA did not perform one and continued to treat him. It is clear from the record and the opinion provided by the VA physician that VA providers knew that an amputation of the right foot was likely but attempted conservative treatment to preserve the limb. The record notes that the Veteran attended the limb preservation clinic. There is no lay or medical evidence to suggest that such conservative treatment amounts to carelessness, negligence, lack of proper skill, error in judgment or other instance of fault on the part of VA providers. The argument that VA should have performed an amputation at the earliest possible stage instead of attempting to preserve the limb is specious. In a March 2012 written statement, the Veteran's representative questioned whether VAC therapy was properly used, what caused the Veteran's anemia, why osteomyelitis was not found until the Veteran was treated at the private hospital, and what led to the Veteran's rapid worsening of health just prior to his private hospitalization. Again, as stated above, with regard to whether the Veteran received appropriate care at the VA hospital, the November 2012 VA physician's opinion is the most probative of record and outweighs that of the representative. We again note that the possibility of the need for amputation was established at an early stage. Nothing in the record establishes that there was improper VAC therapy. The implied argument of some form of fault is unsupported by any evidence. With regard to anemia, the Veteran has not alleged that this is additional disability due to his VA treatment, and neither the Veteran nor his representative has provided any basis for a contention that anemia is somehow related to the below-knee amputation. Furthermore, the record shows that the Veteran underwent examination, including x-rays, while treated by VA, and osteomyelitis was not present or diagnosed. It was not present or diagnosed until he was admitted to the private hospital in January 2006, and neither the Veteran nor his representative has provided any competent evidence to suggest that it was present during his VA treatment. To the extent that there was a change in his condition due to his exposure to a space heater, such exposure and the consequences (to include gangrene of toes and additional wounds) were unrelated to the care provided by VA. Therefore, weighing the evidence of record, after careful consideration of all procurable and assembled data, the Board finds that the preponderance of the evidence is against compensation under 38 U.S.C.A. § 1151 for additional disability of the right below-knee amputation. There is no doubt to resolve. Accordingly, the claim is denied. ORDER Compensation under 38 U.S.C. § 1151 for additional disability of a below-knee amputation of the right extremity is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs