Citation Nr: 21076010 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 15-19 881 DATE: December 22, 2021 ORDER Entitlement to compensation under 38 U.S.C. § 1151 for bilateral amputations, lower leg below the knee, is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is granted. REMANDED Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound status is remanded. FINDINGS OF FACT 1. The Veteran's additional disability, to include bilateral below the knee amputations, is not related to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment. 2. The Veteran's additional disability, to include bilateral below the knee amputations was a reasonably foreseeable event. 3. The Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for compensation under the provisions of 38 U.S.C. § 1151 for bilateral amputations, lower leg below the knee, due to care provided by the VA have not been met. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. 2. The criteria for a TDIU are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1985 to March 1995. In January 2019, the Veteran, his wife, and his son testified before the undersigned Veterans Law Judge via video conference. A transcript of the hearing is associated with the claims file. The case was remanded in January 2020 and April 2021 for additional development. That development has been completed, and the case has since been returned to the Board for appellate review. 38 U.S.C. § 1151 Claims Under VA laws and regulations, when a veteran incurs an additional disability or death as a result of hospital care, medical or surgical treatment, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such disability or death was service-connected. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.358, 3.361. For claims filed after October 1, 1997, as in this case, the claimant is required to show fault or negligence in medical treatment. Specifically, that the proximate cause of the disability was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing medical care or was an event not reasonably foreseeable. 38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361. In determining that an additional disability exists, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program upon which the claim is based, to the veteran's condition after such care, treatment, examination, services, or program has stopped. 38 C.F.R. § 3.361(b). If an additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in the veteran's additional disability or death. Merely showing that the veteran received care, treatment, or examination and that the veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the 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(c)(2). Further, additional disability or death caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(3). 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). To establish that 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 proximately caused a veteran's additional disability or death, it must be shown that VA failed to exercise a degree of care that would be expected of a reasonable health care provider; or, that VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's informed consent. Id. Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. 38 C.F.R. § 3.361(d)(2). 1. Entitlement to compensation under 38 U.S.C. § 1151 for bilateral amputations, lower leg below the knee The Veteran contends that VA was negligent in prescribing heparin during the course of treatment he received during coronary artery bypass graft (CABG) surgery performed at VAMC Durham in January 2015 because he informed physicians of his family history of allergy to that particular medication. He testified that he had an allergic reaction to heparin, after which he experienced heparin-induced thrombocytopenia (HIT) and developed clots in his lower legs, which resulted in him having bilateral below-the-knee amputations as well as amputations in fingers of his right hand. The evidence of record shows that the Veteran was known to have multi-vessel coronary artery disease (CAD) in December 2014 with a CABG planned for January 2015 at the VA. The Veteran then presented to a private emergency room on January 24, 2015, with chest pain. He was diagnosed with NSTEMI (a type of heart attack) and heparin was initiated. The Veteran was then transferred to another private facility where he had a left heart catheterization and placed on a heparin drip. He was transferred to the VAMC while on a heparin drip and had the CABG procedure performed on January 26, 2015. He developed cardiogenic shock following the CABG procedure. While in the hospital he also developed HIT, a thrombotic event, and subsequent gangrenous and ischemic changes involving his bilateral lower extremities and right upper extremity. He then underwent bilateral lower extremity below the knee amputations on February 24, 2015, and amputation of his right long finger and right thumb on March 12, 2015. In September 2015, VA obtained a medical opinion regarding the 1151 claim. Notably, the examiner did not identify the disability being claimed by the Veteran, any other additional disability that resulted from VA treatment, or the date of treatment at issue in this case. Nevertheless, the examiner noted there was no fault on VA's part in treating the Veteran and provided an explanation in support of this conclusion. The examiner stated that the Veteran arrived in the operating room with new and unexpected evidence of cardiogenic shock as demonstrated by invasive monitoring and the response to induction of anesthesia. The duration of this state prior to surgery is uncertain but was not appreciated by multiple physicians and monitoring in the CCU. All subsequent events relate to his pre-operative left ventricular dysfunction. The examiner stated that although the Veteran demonstrated increased severity of his coronary disease, presenting with increasing symptoms of ischemia, his preparation management and evaluation was consistent with a typical patient process, and it was not probable that he would develop clinically "occult" cardiogenic shock prior to surgery. The examiner explained that this unforeseen state underlies his prolonged period of cardiac functional insufficiency that required mechanical left ventricular support and resulted in a number of disabling complications that were all managed appropriately. See September 2015 VA medical opinion. In the January 2020 remand, the Board noted that the September 2015 opinion would support a grant of benefits under section 1151 because the examiner stated that there were a number of disabling complications that resulted from an event that was not reasonably foreseeable. However, because the examiner did not identify the complications the Board was unable to determine the scope of the opinion and requested additional development. In an October 2020 opinion, an examiner opined that VA diagnosis and treatment was appropriate and timely, accepted appropriate protocols were followed, and the standard of care was met in this case. The examiner opined that it is less likely as not that the claimed condition was caused by or became worse as a result of negligence on the part of VA. The examiner noted that a life-threatening myocardial infarction occurred in January 2015 followed by cardiopulmonary bypass surgery. HIT occurred followed by acidosis and cardiogenic shock. The Veteran then developed vascular thrombosis resulting in amputations. The examiner explained that HIT is a life-threatening immune response complication of exposure to heparin that occurs in a "small" percentage of patients exposed, regardless of the dose, schedule or route of administration. HIT results from an autoantibody directed against endogenous platelet factor 4 (PF4) in complex with heparin. This antibody activates platelets and can cause catastrophic arterial and venous thrombosis. The examiner stated that the diagnosis of HIT in patients undergoing CABG surgery is challenging because these patients receive large amounts of heparin and normally have a decrease in the platelet count of approximately 40 to 50 percent during the first 72 hours following surgery. In the April 2021 Board remand, the Board noted that the October 2020 opinion did not explain why a reasonable healthcare provider would have considered HIT to be an ordinary risk of treatment if it only occurs in a small percentage of patients and did not comment on the Veteran's reports that the physicians were notified of his drug allergy. As such, the Board requested additional development. In an August 2021 opinion, an examiner opined that the Veteran had an additional disability after the medical and surgical treatment he received at the Durham VAMC in conjunction with the CABG performed in January 2015 as he developed the rare complication of Heparin-Induced Thrombocytopenia and Thrombosis (Abbreviated HIT or HITT) after heparin administered at community facilities at VA. The examiner noted that the Veteran "required multiple surgical procedures due to the underlying cardiovascular disease as well as the clotting abnormalities and associated poor healing related to HITT," adding that "the Veteran developed multiple thromboses due to the heparin induced thrombocytopenia (HIT/HITT), requiring alternative anticoagulation and resulting in vascular compromise necessitating amputation of bilateral lower extremities below the knees and right 1st and 3rd digits." The examiner also explained that the "Veteran had advanced coronary artery disease before heparin ever administered, so cardiac ischemia and continued/progressing coronary artery disease for Veteran since 1/2015 due to the underlying cardiac condition, not due to heparin/any VA treatment." It was noted that the ischemic tissue loss in the lower extremities did not represent an "increased coronary disease" but rather a loss of blood flow in the lower extremities due to blood clots caused by the HIT/HITT and was not related to the underlying CAD. The examiner stated that the Veteran developed HITT related to Heparin administered at multiple facilities, including VA. However, he did not fully manifest HITT until days after the CABG and transfer to Duke Medical Center. This examiner agreed with the October 2020 medical opinion that HITT is a challenging and elusive diagnosis because the evolving immune process that manifests as HIT.HITT can develop over days without diagnostic evidence of the process until it is already established or the patient is symptomatic. In this case, the examiner noted that the Veteran's HIT blood panel was negative when he was transferred from the VAMC to Duke Medical Center, "suggesting that HIT [was] not the cause of the thrombocytopenia at that time, but rather CABG at VA 1/26/2015, [which was] not an unexpected outcome after CABG." After the Veteran developed a left ventricular clot and displayed evidence of vascular compromise in the extremities, another HIT blood panel was performed and was positive on 2/3/2015, confirming the diagnosis of HIT. The examiner explained that "heparin is the safest, most studied, and most reliable anticoagulant for CABG," noting that although alternatives exist for those with a sensitivity to heparin, "the reliability and effectiveness and safety profiles of the alternative anticoagulants have not been well established by quality medical studies given the rare need to use the alternatives." She stated that given that heparin sensitivity is rare, "the benefits of heparin in the vast majority of cases, including this one, with CAD, NSTEMI, and CABG, far outweigh risks of HIT/HITT." In addressing the Veteran's contention that he informed his healthcare providers of a familial allergy to heparin, the examiner noted that "there is no known hereditary component to HIT/HITT," and although the Veteran claimed that he or his mother informed the VA providers of his mother's "allergy," there were no notes in the private or VA medical treatment records noting such an "allergy" prior to the Veteran's heparin use. The examiner added that the "Veteran's Mother's heparin 'allergy' did not include any serious complications or thromboses associated for her," and it was also not in the record until June 2015, months after treatment. The examiner noted that "HIT/HITT has no known genetic association," adding that because the record did not support that any providers had any knowledge of the Veteran's mother's 'allergy,' "heparin still would have been considered the best option to initiate for Veteran's conditions as of 1/2015." The August 2021 VA examiner noted that even if VA had taken a HIT blood panel prior to the CABG on January 26, 2015, it would not have confirmed heparin sensitivity as the Veteran's initial HIT blood panel at Duke Medical Center on January 26, 2015, was negative. Additionally, the Veteran had already been receiving heparin since January 24, 2015, "without any adverse effects noted at time of transfer to VA." The examiner noted that the heparin reaction did not fully manifest prior to January 26, 2015, so it was "unlikely to be the cause of Veteran's cardiogenic shock following CABG." The examiner summarized by stating that the Veteran had a rare reaction to heparin which led to "thrombocytopenia, thromboses, poor healing, and amputations." The examiner noted that "the Veteran was given heparin at every facility where [he was] treated from 1/2015-3/2015 for NSTEMI, CAD, CABG, and complications, as appropriate for Veteran's conditions." In light of the "elusive nature of the Veteran's HIT/HITT that did not fully manifest until 2/1/2015 at Duke Medical Center" the examiner stated that "it cannot be established that any single facility that administered heparin to the Veteran is more responsible than any other for the Veteran's unfortunate outcome with multiple complications." The August 2021 VA examiner also opined that it is less likely than not that additional disability was proximately caused by carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA because there was no documentation of the Veteran having reported a family history of a heparin allergy prior to the CABG. Furthermore, the examiner noted that the mother's 'heparin allergy' was likely not even related to the "Veteran's reaction to heparin which is a specific type of immune response with no known hereditary or familial relationships." The examiner noted that as the Veteran's HIT panel did not indicate HIT until February 1, 2015, "it cannot be established that VA providers acted in any way negligent or careless in administering lifesaving treatments, including heparin, during an urgent cardiac situation for Veteran prior to 2/1/2015." The examiner added that the "VA proceeded as per cardiac protocols with heparin" prior to his CABG procedure on January 26, 2015. The Veteran's cardiogenic shock following CABG "is a known risk factor of the procedure itself, not necessarily representative of HIT/HITT which had not yet clinically manifested." The examiner found that the "VA providers acted in good faith, following standards of care for cardiac conditions, utilizing the safest and most recommended anticoagulation, heparin," adding that the Veteran's unfortunate complications were due to his "underlying cardiac condition and rare reaction to heparin administration, not due to any negligence/carelessness on part of VA." Regarding whether this was an event not reasonably foreseeable, the examiner noted that "while HIT/HITT is a known risk any time heparin is administered, HIT/HITT is an extremely rare reaction to heparin." While the examiner explained that this was a technically foreseeable complication, "HIT/HITT would not be considered an 'ordinary' risk, but rather an extraordinary possible outcome." She added that "bleeding and clotting abnormalities in general ARE ordinary/common risks with the use of any anticoagulants, including heparin, so such risks are included in the Informed Consent discussions prior to anticoagulant use/procedures." Thus, the examiner concluded that "a reasonable healthcare provider can foresee and discusses the risks of bleeding and/or clotting difficulties after anticoagulation/procedure, but that the same provider would not consider HIT/HITT to a be a significant risk, though possible." See August 2021 VA medical opinion. The Board acknowledges the Veteran's lay statements that he notified the medical providers of his mother's heparin allergy prior to his CABG surgery. However, the objective contemporaneous medical evidence of record in this case is considered more probative than the Veteran's lay statements regarding his actions prior to his surgery in January 2015. The evidence of record does not mention any heparin allergies in the family or for the Veteran until March 2015, when VA treatment records indicate a heparin allergy following the Veteran's diagnosis for HIT. The Board notes that after a complete review of the claims file, the August 2021 VA examiner opined that the Veteran's additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on part of VA. The August 2021 examiner explained that the Veteran developed unfortunate complications following his NSTEMI, CAND, and CABG management due to his rare reaction to heparin, and not through any negligence or carelessness on part of the VA. The examiner also noted that HIT is a known risk any time heparin is administered, and although it would not have been considered a significant risk, a reasonable provider could have foreseen the risks of bleeding or clotting difficulties following anticoagulation or a procedure. While rare, the examiner stated that it is a foreseeable complication of heparin use. The August 2021 VA examiner explained that there was always a chance of bleeding and clotting abnormalities when anticoagulants like heparin are administered and a reasonable healthcare provider can foresee and discusses the risk of bleeding and/or clotting difficulties after anticoagulation procedures. Furthermore, to whatever extent the Veteran has attempted to establish his entitlement to compensation under U.S.C. § 1151 on the basis of lay assertions, alone, such attempt must fail. The Board acknowledges that lay assertions may serve to support a claim with respect to the occurrence of lay observable events or the presence of disability or symptoms of disability subject to lay observation (see, e.g., Jandreau v. Nicholson, 492 F.3d. 1372 (2007)), and that lay persons may be competent to provide opinions on some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)). However, in this case, the specific matter of whether the Veteran's complications following a CABG procedure and heparin administration were the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA physicians, or an event not reasonably foreseeable, falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377. As the Veteran is not shown to have appropriate medical training and expertise, he is not competent to render a probative and persuasive opinion on the complex medical matters upon which this claim turns. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998). Hence, lay assertions in this regard have no probative value. After reviewing the record, the Board finds that the August 2021 medical opinion is adequate and is the most probative evidence. In contrast, and has highlighted above, the September 2015 and October 2020 medical opinions were incomplete and did not contain a reasoned medical judgment or sufficient explanation which would allow the Board to compare the opinions against other contrary reports. Although portions of these opinions appeared favorable to the Veteran's claim, the opinions were not as fully articulated as the August 2021 opinion. Because the August 2021 medical opinion supports its conclusion with an analysis that the Board can consider against contrary opinions, and contains a reasoned medical judgement, the Board finds it to be the most probative medical opinion of record. Consequently, when comparing the Veteran's condition immediately before his VA hospital care with the condition after such care, the Board finds that an additional disability is present. With respect to causation, the Veteran received heparin at VA and non-VA facilities. Although the August 2021 examiner stated that "it cannot be established that any single faculty that administered heparin to the Veteran is more responsible than any other" it is undisputed that he received this drug from VA and experienced an adverse reaction resulting in multiple amputations. Resolving reasonable doubt in his favor, the Board finds that the causation element has been met. With respect to proximate cause, the Board finds that the August 2021 examiner's opinion is persuasive in establishing that the Veteran's additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on part of VA. It was noted that the Veteran developed unfortunate complications following his NSTEMI, CAND, and CABG management due to his rare reaction to heparin, and not through any negligence or carelessness on part of the VA. It was noted that the Veteran had already been on a Heparin drip when he arrived at VA with no evidence of adverse effects. The examiner walked through the timing and results of the Veteran's bloodwork and explained why HIT/HITT would not have been expected. The examiner also explained the difficulty in diagnosing HIT/HITT and how it is often identified only after a patient has become symptomatic. It was noted that VA providers followed the standards of care for cardiac conditions and used the safest and most recommended anticoagulation, heparin, for the Veteran. The examiner considered the Veteran's statement that he informed his healthcare provider of a family history of adverse reactions to heparin, but the examiner noted that this was not documented in the 1/24-25 private treatment records. Further it was noted that a reaction to heparin is not specific and has no known heredity or familial relationship. Finally, with respect to whether the additional disability was reasonably foreseeable, the record contains conflicting evidence. However, as discussed above, the Board finds that the August 2021 opinion is the most probative evidence of record because it contains sufficient detail for the Board to make a fully informed decision. As discussed, it was noted that while HIT is an extremely rare reaction to heparin it is a foreseeable complication and that bleeding and clotting abnormalities are ordinary/common risks with the use of any anticoagulant, including heparin, so such risks are included in informed consent discussions. Based on the foregoing, entitlement to compensation under 38 U.S.C. § 1151 for bilateral amputations, lower leg below the knee, is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In arriving at a conclusion, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The United States Court of Appeals for Veterans Claims (Court) has held that the term unable to secure and follow a substantially gainful occupation in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to follow and secure employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58 (2019). As sedentary is defined as "doing or requiring much sitting" the Board finds that sedentary employment is a job where the worker primarily sits down. MERRIAM-WEBSTER'S COLLEGEIATE DICTIONARY 1123 (2003). If there is only one service-connected disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). VA's policy is to grant TDIU in all cases where a service-connected disability causes unemployability regardless of the percentage evaluations. 38 C.F.R. § 4.16(b). In situations where the percentage evaluations do not allow TDIU under § 4.16(a), an extraschedular TDIU may be awarded under § 4.16(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 4.16 in the first instance. The Board, however, is not precluded from considering whether the case should be referred to the Director of VA's Compensation Service for consideration of an extraschedular TDIU rating. When determining whether the criteria for a TDIU are met, the Board is required to include a full statement as to the veteran's service-connected disabilities, employment history, educational and vocational attainment and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16(b). 2. Entitlement to a TDIU The Veteran contends that he is unable to obtain substantially gainful employment as a result of his service-connected disabilities. The Veteran has been awarded service connection for posttraumatic stress disorder (PTSD) at 30 percent disabling from July 1, 2015, and 50 percent disabling from February 12, 2018; chronic left knee strain at 10 percent disabling from April 27, 2006, and 40 percent disabling from February 12, 2018; dislocation, left shoulder at a noncompensable rate from March 4, 1995 and 20 percent from October 10, 2008; degenerative joint disease (DJD) of the lumbar spine and intervertebral disc syndrome (IVDS) at the L5/S1 at a noncompensable rate form March 4, 1995, at 20 percent from October 10, 2008, at 10 percent from August 16, 2010, and at 20 percent from November 17, 2011; sensory deficit sciatic nerve, right lower extremity associated with DJD of the lumbar spine and IVDS at the L5/S1 at 10 percent disabling from August 16, 2010, and 20 percent from November 17, 2011; sensory deficit sciatic nerve, left lower extremity associated with DJD of the lumbar spine and IVDS at the L5/S1 at 10 percent disabling from August 16, 2010, and 20 percent from November 17, 2011; bilateral plantar fasciitis with calluses at 10 percent disabling from March 4, 1995; tinnitus at a noncompensable rate from March 4, 1995, and 10 percent from April 27, 2005; fracture, left thumb at a noncompensable rate from March 4, 1995; hearing loss, left ear, at a noncompensable rate from March 4, 1995; and limitation of flexion, chronic left knee strain at a noncompensable rate from November 17, 2011 to February 12, 2018. The record reveals that the Veteran has not worked full time since January 2015 when he worked as a correctional lieutenant for the North Carolina Department of Public Safety. He had worked in this job for 20 years. See May 2021 VA Form 21-8940. The evidence of record includes VA knee examinations from October 2014, March 2018, and September 2021 indicating that the Veteran's left knee disability impacted his ability to work as it made it "difficult for him to do a job that requires prolonged periods of walking or standing or squatting," he is "unable to kneel or squat on firing range, trouble standing and getting back up off the ground," and "he cannot stand for more than a few minutes or walk more than a few yards without significant left knee pain and or swelling." VA back examinations from February 2018 and August 2021 indicate that the Veteran's back disability impacts his ability to work by making it difficult for him to "defend himself in the event of being attacked," and that he had "difficulty sitting, standing, walking for extended periods of time due to pain in mid lower back." The February 2018 VA examiner noted that the Veteran was attacked six times in the 20 years he worked as a prison guard, adding that his back disability "often prevented him from being able to bring the prisoner down, but would just hold on the best he could until help arrived." VA hearing loss and tinnitus examinations in September 2013, March 2018, June 2021, and September 2021 indicate that the Veteran's hearing loss and tinnitus impact his conditions of daily life, including the ability to work due to difficulty hearing and understanding people; difficulty with hearing over distances, with background noise, or without visual cues; crippling headaches that occasionally accompany his tinnitus; and interference with communication. After a careful review of the evidence of record, the Board finds that the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. The Veteran has a long history of working as a correctional officer for the North Carolina state prison system. The Board finds that his inability to walk, stand, or squat for long periods of time due to his left knee disability; inability to defend himself due to his back disability; and difficulty with hearing, headaches, and interference with communication due to his hearing loss and tinnitus preclude him from obtaining or maintaining substantially gainful employment. Thus, the Board finds that the criteria for entitlement to a TDIU have been met in this case and the claim may be granted. REASONS FOR REMAND 1. Entitlement to SMC based on aid and attendance/housebound status The Veteran contends that he is in the need of aid and attendance of another as a result of his service-connected disabilities. A March 2016 examination for housebound status or permanent need for regular aid and attendance revealed that the Veteran's DM II, amputation of finger, bilateral amputation of lower extremities, stage 4 pressure ulcers, hypertension, coronary atherosclerosis, depression, sleep apnea, and lumbago prevented him from preparing his own meals, required assistance in bathing and tending to other hygiene needs, required assistance with medication management, and did not allow him to manage his own financial affairs. The Veteran was also noted to be confined to a wheelchair "due to his medical conditions." The Board notes that the Veteran is service connected for PTSD (of which a depressed mood is a symptom) and a low back disability. Based on the foregoing, it is unclear whether the Veteran's service-connected disabilities alone would require the aid and attendance of another. As such, the Board finds that a new medical opinion is needed in order to determine whether his service-connected disabilities alone require the aid and attendance of another. The matters are REMANDED for the following action: 1. Arrange for an appropriate health care provider to review the Veteran's claims file and render an opinion on whether he requires regular aid and attendance due to the limitation of function resulting from his service-connected disabilities. If so, the examiner should determine, to the extent possible, when the need for regular aid and attendance arose and explain why. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. 2. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morrad, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.