Citation Nr: 1024066 Decision Date: 06/28/10 Archive Date: 07/08/10 DOCKET NO. 07-23 288 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUE Entitlement to compensation under 38 U.S.C.A. § 1151 for conditions that include severe cardiorespiratory depression, depression, sleep apnea, and a seizure disorder as a result of medication/treatment received at VA facilities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant/Veteran ATTORNEY FOR THE BOARD T.S. Willie, Associate Counsel INTRODUCTION The Veteran had active service from November 1970 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Manila, the Republic of the Philippines. The Board first considered this matter in May 2009 and remanded for additional development of the medical record. All requested development was performed, as will be discussed in detail below, and the appeal is now properly returned to the Board for further appellate consideration. The Veteran appeared at a hearing before a local hearing officer at the RO in June 2008 and at a videoconference hearing at the RO before the Board in January 2009. Transcripts of the hearings are of record. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The Veteran does not have additional disability, to include severe cardiorespiratory depression, depression, sleep apnea, and a seizure disorder, as a result of medication prescribed and/or treatment received at VA facilities. CONCLUSION OF LAW Criteria for compensation for additional disability, to include severe cardiorespiratory depression, depression, sleep apnea, and a seizure disorder, due to hospital care, medical or surgical treatment, or examination furnished under any law administered by VA are not met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.358 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION At the outset of this decision, the Board must consider whether VA met its duties as set out in the Veterans Claims Assistance Act of 2000 (VCAA). VA has both duties to notify and assist claimants in substantiating a claim for benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the Veteran pre-adjudication notice by a letter dated in June 2005. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The RO provided the Veteran with additional notice in December 2008, subsequent to the July 2006 adjudication. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio, 16 Vet. App. 183, identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. While the December 2008 notice was not provided prior to the July 2006 adjudication, the Veteran's Section 1151 claim was readjudicated thereafter, thus making all notices preadjudicatory as per Mayfield. Consequently, the Board finds that VA has met its duty to notify the Veteran with respect to the issue being decided herein. VA also has a duty to assist the Veteran in substantiating his claim. A review of the record reveals that VA obtained identified records, assisted the Veteran in obtaining evidence, afforded the Veteran VA examinations in September 2005, January 2006, May 2007, September 2009 and October 2009, and afforded the Veteran the opportunity to give testimony before the RO in June 2008 and the Board in January 2009. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran and his representative have not contended otherwise. The Board remanded this matter for additional development of the medical record in May 2009. A very specific medical opinion was requested. In September, October and December 2009, the Veteran's claims folder was reviewed by medical professionals and the questions posed by the Board were addressed. Well-reasoned rationale was included with each opinion expressed. As such, the Board finds that its remand orders have been substantially complied with and the opinions provided are adequate for rating purposes. Therefore, the Board finds that VA has also complied with its assistance requirements and the Veteran is not prejudiced by a decision on his Section 1151 claim at this time. Accordingly, the Board turns to the merits of the claim. Laws and Regulations Formerly, 38 U.S.C.A. § 1151 provided that "[w]here any veteran suffers an injury or an aggravation of an injury, as a result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation . . . awarded under any of the laws administered by the Secretary, or as the result of having submitted to an examination under any such law, and not the result of such veteran's own willful misconduct, and such injury or aggravation results in additional disability to or the death of such veteran, disability or death compensation . . . shall be awarded in the same manner as if such disability, aggravation or death were service-connected." 38 U.S.C.A. § 1151 (West 1991). Earlier interpretations of the pertinent statute and regulations required evidence of carelessness, negligence, lack of proper skill, error in judgment, or similar instances of indicated fault on the part of VA, or the occurrence of an accident or an otherwise unforeseen event, to establish entitlement to 38 U.S.C.A. § 1151 benefits. See, e.g., 38 C.F.R. § 3.358(c)(3) (1994). Those provisions were invalidated by the United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (Court), in Gardner v. Derwinski, 1 Vet. App. 584 (1991). The Gardner decision was affirmed by both the United States Court of Appeals for the Federal Circuit, see Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), and the United States Supreme Court, see Brown v. Gardner, 513 U.S. 115 (1994). The United States Supreme Court, in affirming the Court's decision, held that the statutory language of 38 U.S.C.A. § 1151 simply required a causal connection between VA hospitalization and additional disability, and that there need be no identification of "fault" on the part of VA. See Id. 38 C.F.R. § 3.358 was amended in 1995 to conform to the Supreme Court decision. The amendment was effective November 25, 1991, the date the Court issued the Gardner decision. 60 Fed. Reg. 14,222 (March 16, 1995). Subsequently, Congress amended 38 U.S.C.A. § 1151, effective for claims filed on or after October 1, 1997, to preclude benefits in the absence of evidence of VA carelessness, negligence, lack of proper skill, error in judgment or similar fault on the part of VA in furnishing care, or an unforeseen event. Pub. L. No. 104- 204, § 422(a), 110 Stat. 2926 (Sept. 26, 1996), codified at 38 U.S.C.A. § 1151 (West 2002). The revised provisions of 38 C.F.R. § 3.358 state that where it is determined that there is additional disability resulting from a disease or injury or an aggravation of an existing disease or injury suffered as a result of hospitalization or medical treatment, compensation will be payable for such additional disability. Compensation is not payable for the necessary consequences of medical or surgical treatment properly administered with the express or implied consent of the veteran. 38 C.F.R. § 3.358(c)(3). "Necessary consequences" are those that are certain or intended to result from the VA hospitalization or medical or surgical treatment. Id. Effective September 2, 2004, the regulations pertaining to claims for compensation pursuant to 38 U.S.C.A. § 1151 filed on or after October 1, 1997, were amended. See 69 Fed. Reg. 46,426 (Aug. 3, 2004) [adding 38 C.F.R. § 3.361]. Those regulations largely implemented the provisions of 38 U.S.C.A. § 1151. The Board notes that the current claim was received in May 2005 and, as such, the current statute and regulations are applied. In pertinent part, 38 C.F.R. § 3.361 provides as follows: In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment 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). 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 the hospital care or medical or surgical treatment caused the veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). 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. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Analysis The Veteran has appealed the denial of compensation under 38 U.S.C.A. § 1151 for conditions that include severe cardiorespiratory depression, depression, sleep apnea, and a seizure disorder as a result of medication/treatment received at VA facilities. After review of the evidence, the Board finds against the Veteran's claim. The evidence shows that Dr. L related in June 2002 that the Veteran suffered from a number of chronic medical conditions and that he was using high dose opioids for pain control. In an April 2005 discharge summary it was shown that the Veteran complained of difficulty breathing. It was noted that he was taking Oxycodone for severe pain, Diazepam for anxiety, Morphine for severe pain and Trazodone for insomnia. Impending respiratory failure probably tranquilizer induced, resolved, was diagnosed. In May 2005, Dr. E.D related that the Veteran had a history of chronic degenerative joint disease and was prescribed Morphine Sulfate and Oxycodone for the severe pain by VA doctors. He related that the Veteran was taking Trazodone for insomnia, Diazepam for anxiety and that lately the VA increased the Morphine dose to five tabs times 100 mg SR times three per day which equaled to 1500 mg of Morphine Sulfate a day. Additionally, he noted that the Veteran was advised to take Oxycodone five mg four tablets three times a day which totaled 60 mg per day. It was further noted that the Veteran was advised to take Trazodone 50 mg one tablet two times a day and Diazepam 10 mg four tablets a day for anxiety. Dr. E.D noted that the Veteran developed difficulty breathing and was found by a friend unconscious. Severe respiratory depression secondary to Morphine and Oxycodone intake (very high doses) aggravated by the intake of Trazodone and Diazepam was diagnosed. In the September 2005 VA compensation and pension examination, it was noted that the Veteran's dosage of Morphine and Percocet at that time was so high and that he had a very small safety index to reach a lethal dose. The examiner related that the Veteran was very much dependent on high doses of Morphine and Percocet for pain control and that he had taken these for years and at the present. In September 2005, Dr. E.D related that the Veteran is always suffering from respiratory depression because of intake of high doses of narcotic medications and that he is prone to respiratory failure. He further noted that month that the Veteran had severe signs/symptoms and side effects of high doses of narcotic pain killers, sedatives/hypnotics and antidepressant drugs and that such render him unable to function normally. In the January 2006 VA compensation and pension opinion, Dr. C.V.C indicated that he had reviewed the entire claims folder and following review opined that the Veteran's intake of narcotics and sedatives was at least as likely as not related to an overdose in April 2005 but was less likely as not an episode of severe respiratory depression. He stated that over dosage was not foreseeable and did not result in carelessness by VA. Dr. C.V.C noted that the Veteran was diagnosed with arthritis and was mentioned to have done moderately well with moderate pain control and minimal side effects. He related that narcotic pain medications and sedatives had been prescribed since 2000 to address the Veteran's complaints of pain and inactivity in the absence of adequate pain control. It was noted that over dosage is always a possibility for patients who are dependent on multiple narcotics and sedatives but the drug information sheets given after each refill and the presence of drowsiness at any time should alert him and his attendant that precautions should be exercised and the reporting of such side effects be done immediately to the nearest VA facility. In March 2006, the Veteran's private physician, Dr. E.D, indicated that the Veteran taking very high doses of narcotics, tranquilizers and anti-depressant medications at the same time made him chronically or perennially susceptible to the dangers of toxicity from cumulative effects of narcotic intake. He noted that chronic respiratory depression or failure can be produced by narcotic overdose when the patient has been taking the drug for a long time. He related that the Veteran's hospitalization in April 2005 with complaints of severe difficulty of breathing, pinpoint pupils and respiratory rate of seven per minute are objective findings of Morphine/Oxycodone or narcotic overdose. Dr. E.D related that respiratory depression is classic and known side effects of Morphine/Oxycodone overdose or toxicity. In an undated report, Dr. E. E indicated that the combination of morphine and Oxycodone could result in the fatal side effect of respiratory depression. In November 2006, Dr. J.D stated that the Veteran's intake of high doses of narcotic and anti- depression medication had resulted in respiratory depression. The Veteran was advised to gradually taper off intake of his medication to the lowest possible dose and least amount of medications. In December 2006, Dr. A.G.P related that the Veteran was suffering from hypoventilation syndrome induced by synergistic effect of his current medications. He related that opioids, as well as Benzodiazepines, can cause respiratory depression and that these side effects are more prominent if high doses of the above medications are given. The Veteran was afforded a VA compensation and pension examination in May 2007. The examination was conducted by Dr. C.V.C. A history of CABG in 1998 with respiratory depression related to intake of sedative, opioids in 2005 was noted. Drug induced respiratory depression, bronchial asthma and sleep apnea syndrome was diagnosed. With regard to the question of what was the effect of the Veteran's respiratory depression on his lungs, the examiner indicated that the Veteran had bronchial asthma and a sleep disorder with both conditions aggravated by his repeated drug induced respiratory depression. Dr. C.V.C related that the Veteran's lung function showed a sleep disorder and that this condition together with his asthma symptoms are worsened by the repetitive episodes of drug induced respiratory depression. He noted that there were episodic hypoxemia during sleep study but 2d echo findings did not show any right sided cardiac involvement. In an October 2007 statement, Dr. J.B.M related that he believed that the Veteran had seizure episodes and sleep apnea syndrome as a result of his chronic intake of opiates and benzodiazepines. He related that the Veteran developed tolerance with the medications over the years but the depressant effects of the medications on the respiratory drive and cognitive functions are still present. He related that at high dosages and acting synergistically, such can produce both temporary and permanent damage in the central nervous system. In an April 2008 letter, Dr. E.D noted that the constant and continuous increases in dosages of Morphine, Diazepam, Trazodone, and Percocet exacerbated all the following complications of treatment: chronic respiratory depression, central apnea, major depression, psychological dependence on drugs, psychiatric disorder (depression), and seizures. He indicated that all the complications from Morphine and Opiates overdose were very foreseeable and predictable and, therefore, preventable. He stated that not foreseeing all of these complications was tantamount to gross negligence and carelessness. He noted that the VA doctors should have foreseen the complications of Morphine and Opiates. He opined that all the above medical disabilities were clearly and irrefutably doctor-induced or iatrogenic conditions. In a statement received in October 2008, Dr. R.G.L stated that in all patient-physician relationships any form of treatment prescribed by a physician should be discussed with the patient. She related that the decision to accept the treatment lies in the patient after informed consent of his medical condition/s and treatment options that are available for his illness. She related that the Veteran's acceptance of the treatment for 5-6 years could mean that he agreed/consented to the management plan from the MD, a plan that was later said to be inappropriate/ careless only after he had hospital admission in 2005. Dr. R.G.L stated that records show that the MD continuously refilled the said medication, this however should not bring one to a conclusion that he never exercised caution in prescribing the said medication. It was noted that when the Veteran reported to the MD he had problems with the medication, the MD advised him to "stand on it" because "withdrawals can be bad." She related that it is very important at this point that medical record pertaining to the initiation and continued prescription of the said medication be looked into to determine whether the involved MD committed gross negligence. No such documentation were seen in the medical records reviewed she noted. At the January 2009 Board hearing, the Veteran reiterated that he sought treatment for arthritis from the VA and was prescribed drugs. He related that they continued to add drugs and at higher dosages. The Veteran testified that he took 1500 mg of Morphine a day plus 12 Percocet, plus 40 mg of Valium and 250 mg of Trazodone to help him sleep. He related that he has since been weaned off the drugs. The Veteran reported that he went into respiratory distress in 2005. He stated that he told his physician about the coma from the medication but was advised by his physician to continue on the medication. He related that such continued until 2006 and after 2006 he stopped taking the medication because his private physician helped him wean off of the drugs. In August 2009, Dr. E.D related the Veteran was given very high doses of Morphine and Opiates and the dose was equivalent to 15 times the normal dose. Dr. E.D noted that the increment of increased disability has increased many folds because VA doctors prescribed massive doses of Morphine and Opiates. Dr. E.D related that the way the VA doctors gave the Veteran massive doses of Morphine and Opiates is proximate cause of increased or additional disability of the Veteran. He noted that it showed gross negligence, carelessness, and error in judgment on the part of the VA doctors, and that the degree of increased disability was foreseeable because it was very obvious that they were giving massive doses of Morphine and Opiates. Dr. E.D related that the Veteran has suffered seizures, chronic respiratory depression and central apnea as a result of taking massive doses of Morphine and Opiates as prescribed by VA doctors. He noted that the Veteran is suffering from iatrogenic conditions (over dosage of Opiates, Morphine, Diazepam, Trazodone and the combination of all) and that review of his medical history will reveal excessive intake of abnormally very high dosage of the said medications for at least five years as prescribed by VA doctors. Dr. E.D related that the Veteran was also being treated for mitral valve stenosis and that such was a very dangerous heart condition in which high dosage of Opiates and Morphine are contraindicated because Morphine and Opiates can cause respiratory depression and cardiac depression which might lead to cardiac respiratory arrest and death. He related that all complications of Morphine and Opiates overdose are very foreseeable and predictable. Therefore, he opined that not foreseeing all these complications is tantamount to gross negligence and carelessness. Dr. E.D noted that the constant and continuous increase in dosages of Morphine, Diazepam, Trazodone and Percocet exacerbated chronic respiratory depression, central apnea, major depression, psychological dependence on the drugs, psychiatric disorder (depression) and seizures. The Veteran was afforded a VA compensation and pension examination for the brain and spinal cord in September 2009. The examination was conducted by Dr. R.S.J. During this examination, the Veteran reported bouts of loss of consciousness every now and then. Examination revealed no clinical evidence of seizures. Dr. R.S.J related that a medical opinion would not be given because the diagnosis was that there was no seizure disorder in the first place. He related that what the Veteran is experiencing does not fit into any of the epileptic, seizure or paroxysmal disorders that is due to or a result of morphine dosage. The Veteran was afforded a VA compensation and pension examination for mental disorders in September 2009. The examination was conducted by Dr. A.E.D. During this examination, Dr. A.E.D noted that review of the claims folders and CPRS notes revealed a history of CABG in 1998 with respiratory depression related to intake of sedatives, opioids in 2005. It was noted that the taking of Morphine at 1500mg/day, Percocet 12 tablets/day, Trazodone 100 mg daily and Valium 10mg four times a day, the Veteran related that he still gets depressed and that his anxiety attacks occur daily. The Veteran reported being unproductive at home and that he spent time by watching television, talking to his wife and doing Internet stuff. The Veteran related that he did not have a life and that this memory has dwindled. He related that he was unsure if his memory problems were part of his depression or his long term medication use. An impression was given of major depression. Depression secondary to medical condition (chronic pain syndrome second to degenerative joint disease) was also diagnosed. In December 2009, Dr. A.E.D opined that the Veteran's claimed depression is not caused by or a result of that of the VA treatment. Dr. A.E.D noted that the Veteran had already been given medications for his depression secondary to his chronic pain syndrome thus we cannot attribute the depression as secondary to his VA physician at the VAMC committing gross negligence or carelessness in prescribing massive doses of Morphine and opiates. Dr. A.E.D stated that, in fact, the physician was aware of the depression due to the chronic pain syndrome and thus prescribed the Veteran the Trazodone at 50mgs BID which is the average dose being given to individuals diagnosed with depression. The Veteran was afforded a VA compensation and pension examination for the respiratory system in October 2009. The examination was conducted by Dr. R.G.L. During this examination, the Veteran reported that he was diagnosed with lung problems 15 years ago. The Veteran reported that as a result of his joint pains he was given 450 tabs of Morphine, 360 tabs of Oxycodone, 120 tabs of Valium and 60 pills of Trazodone refilled monthly for 5-6 years. He reported still having episodes of shortness of breath. Opioids with secondary effect on the lungs were noted. Chronic respiratory depression and central apnea were diagnosed. Dr. R.G.L related that there were no effects of problems on usual daily activities. She noted that it would not have any significant effect since the acute problem has been resolved. Dr. R.G.L related that given the fact that opioids are known to cause respiratory depression and that the Veteran has existing cardiopulmonary problems, it is at least as likely as not that these medications (Morphine and Oxycodone) could be related to the impending respiratory failure that the Veteran had. Dr. R.G.L. related that there are two types of respiratory depression/failure and that the examinations performed on the Veteran showed normal spirometry/hypoxemia on ABG/on CO2 retention and mild OSA on sleep studies. She noted that these are not compatible with a diagnosis of either acute or chronic respiratory depression. It was noted that the hypoxemia could be a result of the previous smoking/bronchitis and/or the recent pneumonia seen on the chest x-ray. Dr. R.G.L stated that she did not think that it was possible to determine the "increment of increased or additional disability" primarily because the "impending respiratory depression/failure" that the Veteran had has now resolved and was present only during the time that the medication was still in his system causing its effect on the lungs. After review of the evidence, the Board finds against the Veteran's claim. The Board finds that it is clear that this Veteran believes that he has additional disability as a result of what he calls over dosage of medication by a VA doctor. The more probative evidence, however, shows that treatment at VA facilities did not result in additional disability. While the amounts of medications certainly on its face seems quite high, the Board is bound by the medical evidence of record which includes the examination reported in September 2009 that reveals no clinical evidence of seizures, and the in October 2009, Dr. R.G.L statement that the "impending respiratory depression/failure" that the Veteran had has now resolved and was present only during the time that the medication was still in his system causing its effect on the lungs. Chronic respiratory depression and central apnea were noted at that time. However, Dr. R.G.L related that the acute problem has been resolved. Regarding depression, Dr. A.E.D noted in September 2009 that the Veteran had already been given medications for his depression secondary to his chronic pain syndrome, thus, he could not attribute the depression as secondary to his VA physician at the VAMC committing gross negligence or carelessness in prescribing massive does of Morphine and opiates. For claims for compensation under 38 U.S.C.A. Section 1151, the claimant must show that the VA treatment in question resulted in additional disability (or death) and that the proximate cause of the disability (or death) was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability (or death) was an event which was not reasonably foreseeable. See VAOPGCPREC 40-97; 38 U.S.C.A. § 1151. There is no such showing in this case. The Board is mindful of the opinions rendered by the various private physicians on this issue and the prior examination results and acknowledges the Veteran's statements that he received additional disabilities because of the over dosage of medication by a VA physician. However, it has been determined that any acute problems involving chronic respiratory depression and central apnea have since resolved and there is no additional disability. Furthermore, examination reveals no evidence of seizures or an additional depression disability. The Board finds these medical findings to be competent and probative as they are based on a full review of the record evidence and examination of the Veteran. The opinions of no additional disability are accorded great weight as they are well-reasoned and supported in the objective medical evidence of record. The Board recognizes that the Veteran has submitted Wikipedia articles on seizures, depression and sleep apnea. Although the Veteran has submitted the above to support his 1151 claim, the Board notes that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, crucially, the evidence which has been submitted by the Veteran is general in nature and does not specifically relate to the facts and circumstances surrounding this particular case. More importantly, the Board reiterates that additional disability has not been found by medical professionals and the Veteran's statements and independent research simply cannot be given more weight than the well-reasoned opinions of the medical experts. The Board notes that the Veteran and his representative have challenged the adequacy of the opinions rendered by Dr. R.S.J in September 2009, Dr. R.G.L in October 2009 and Dr. A.E.D in December 2009. The Veteran has indicated that the medical opinions were not addressed with specificity, were without factual basis and/or did not include a discussion of all the medications prescribed to the Veteran. The Board disagrees. Although the Veteran has challenged the opinions given, the Board notes that the VA examiners have found no additional disability upon examination. The Board notes that the VA examinations are adequate and are reflective of the Veteran's current state of health. All the VA examinations reflect a pertinent review of medical history, clinical findings, and a diagnosis or lack thereof. The Board further notes that, with the exception of the examination for seizures, the examinations also contains opinions supported by medical rationale. Lastly, the Board recognizes that the Veteran has quoted Dr. R.G.L's notation regarding foreseeability. In the October 2009 VA compensation and pension, Dr. R.G.L discussed foreseeability as it relates to respiratory depression and drugs that are known to be respiratory depressants. However, the Board notes that given that Dr. R.G.L opined that any acute problems involving chronic respiratory depression has since resolved and was present only during the time that the medication was still in his system causing its effect on the lungs, there is no need to address foreseeability given the lack of an additional disability. The Board must find that entitlement to compensation under 38 U.S.C.A. § 1151 for conditions that include severe cardiorespiratory depression, depression, sleep apnea, and a seizure disorder as a result of medication/treatment received at VA facilities is not warranted. There is no competent evidence showing that the Veteran suffers from additional disability due to an unforeseen event or carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part. Thus, a preponderance of the probative evidence is against the Veteran's claim for 38 U.S.C.A. § 1151 compensation. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b) ORDER Compensation under 38 U.S.C.A. § 1151 for conditions that include severe cardiorespiratory depression, sleep apnea, and a seizure disorder as a result of medication/treatment received at VA facilities is denied. ____________________________________________ Kristi Barlow Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs