Citation Nr: 1806700 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-09 729 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for diabetes mellitus. REPRESENTATION Veteran represented by: Kenneth M. Carpenter, Attorney ATTORNEY FOR THE BOARD R. Scarduzio, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1982 to July 1985 and from January 1986 to March 1986, as well as service in the Mississippi Army National Guard with periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Board issued a decision denying the Veteran's claim. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2017 order, the Court vacated and remanded the Board's decision for compliance with the instructions in a Joint Motion for Remand (JMR) filed by the parties. The matter now returns to the Board for further adjudication consistent with the Court's order. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran filed a claim for service connection for his diabetes mellitus type II (DMII) in February 2009. He asserts that his DMII was permanently aggravated by a May 2000 episode of diabetic ketoacidosis and subsequent diabetic coma that occurred during a May 2000 period of INACDUTRA because it caused his DMII to become to insulin-dependent. The Board denied the Veteran's claim in August 2016. According to the JMR, the Board did not adequately address whether the May 2000 incident of dehydration was or was not an injury for the purposes of 38 U.S.C. § 101(24)(C). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). In the context of Reserve or National Guard service, active military service is defined to include any period of ACDUTRA in which the individual was disabled or died from a disease or injury incurred or aggravated in the line of duty and any period of INACDUTRA during which the individual was disabled by an injury (but not disease) that was incurred or aggravated in the line of duty. 38 U.S.C. § 101(24). The Board notes that "injury" is defined as harm resulting from some type of external trauma. VAOPGCPREC 4-2002. The Board in August 2016 found that there was no indication in the record that the Veteran's DMII and diabetic ketoacidosis resulted from external trauma. Citing Dorland's Illustrated Medical Dictionary, 535 (31st ed. 2007), which defines "disease" as any deviation from the normal structure or function of an organ as manifested by characteristic symptoms, the Board concluded that the Veteran's condition was properly categorized as a disease rather than injury. As previously noted, the Veteran subsequently appealed to the Court, which vacated and remanded the claim for compliance with the instructions in a JMR filed by the parties. The JMR determined that the Board failed to consider whether the Veteran's May 2000 episode of dehydration and subsequent treatment by National Guard medics was or was not an injury for the purposes of 38 U.S.C. § 101(24)(C). It is the Veteran's contention that during his initial treatment for dehydration prior to his May 2000 hospitalization, and while he warned the attending medic that he was diabetic, he was treated with Ringer's lactate solution which triggered his subsequent DKA and diabetic coma. Given the above, the Board finds that an additional medical opinion is warranted. By way of history, the Veteran was hospitalized at Gilmore Memorial Hospital (Gilmore) for a motor vehicle accident in March 1999, where he was also first diagnosed with adult onset diabetes. There was no reported prior history of diabetes. He was initially treated with insulin at the time but was taken off insulin prior to discharge, with his blood sugars noted as normal with diet. The final diagnosis upon discharge in May 1999 was hyperglycemia secondary to trauma "with no diagnosis of diabetes." The following May 2000, during a period of INACDUTRA, the Veteran began feeling ill and was treated for weakness and dehydration by National Guard medics, to include receiving Ringer's lactate solution. The Board notes again that the Veteran asserts this initial treatment - with Ringer's lactate solution despite his diabetes - is what triggered his subsequent diabetic coma and unresponsiveness. He was taken to the hospital where he was diagnosed with severe diabetic ketoacidosis (DKA) and dehydration. The Veteran would later be honorably discharged as being medically unfit for further military service in part due to his diabetes. A VA examiner's opinion was obtained for the Veteran's claim in June 2014. The examiner noted that 1) the Veteran had insulin-requiring DMII prior to the May 2000 incident because he was treated for DKA during his March 1999 hospitalization for a motor vehicle accident, 2) the DKA was corrected with intravenous insulin treatment, and 3) that the Veteran's second episode of DKA in May 2000 was also successfully treated with insulin. As such, the examiner opined that the Veteran's DMII was less likely than not permanently worsened by his May 2000 incident of dehydration and diabetic coma, explaining that the natural progression of insulin-dependent DMII in many cases is the potential occurrence of DKA when the body is physically stressed, and that such episodes are treated with insulin with usual return to the base line state. He further opined that the Veteran's subsequent poor diabetic control through the years is more likely than not due to documented poor compliance with treatment. In a May 2016 supporting statement from his representative, however, the Veteran alleged that he did not, in fact, have insulin-dependent DMII prior to the May 2000 incident of dehydration and diabetic coma. Although it was true that the Veteran was initially treated with insulin during his 1999 hospitalization at Gilmore, this was only because the Veteran was unable to swallow oral medication. As the Board previously noted, his discharge form in May 1999 stated that the Veteran was controlling his blood sugar through diet alone, with the final diagnosis at discharge being hyperglycemia secondary to trauma with no diagnosis of diabetes. The Veteran also contends the VA examiner's opinion that the potential occurrence of DKA when the body is stressed is the natural progression of insulin-dependent DMII is nonsensical, and provided without sufficient rationale or physical examination of the Veteran. The Veteran has also submitted various medical articles in support of the argument that that DKA is not the natural progression of diabetes, and is actually considered rare in people with DMII. Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify any remaining outstanding treatment records relevant to his claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After the above development has been completed to the extent possible, schedule the Veteran for a VA diabetes examination and obtain an opinion to determine whether the Veteran's diabetes mellitus was caused or aggravated by an injury incurred during the Veteran's May 2000 period of INACDUTRA. The entire claims file must be reviewed by the examiner and a detailed history should be obtained from the Veteran. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Following a review of the record, the examiner should respond to the following: a) Did the Veteran's diabetes preexist his May 2000 period of INACDUTRA? b) If diabetes preexisted the May 2000 period of INACDUTRA, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the diabetes was aggravated (i.e., permanently worsened beyond the normal progression of the disability) as a result of the Veteran's dehydration and treatment with Ringer's lactate solution. c) If diabetes did not preexist the May 2000 period of INACDUTRA, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the diabetes initially onset during that period of ACDUTRA as a direct result of the Veteran's dehydration and treatment with Ringer's lactate solution. The examiner's attention is directed to the Veteran's final discharge diagnosis of hyperglycemia secondary to trauma with no diagnosis of diabetes after his 1999 motor vehicle accident, his lack of a prior history of diabetes prior to the 1999 motor vehicle accident, the assertion that he was not insulin-dependent prior to the May 2000 incident, and his various medical articles in support of the argument that that diabetic ketoacidosis is not the natural progression of diabetes as opined by the June 2014 VA examiner. A complete rationale for all opinions must be provided. 3. After completing the above actions, and any other development deemed necessary, the AOJ should readjudicate the claim on appeal. If the benefit sought on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his attorney. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).