February 28, 2001

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PRESIDING JUSTICE STEIGMANN delivered the opinion of thecourt:

In January 1996, plaintiff, Robert L. Snelson, sueddefendants, Dr. Donald Kamm and St. Mary's Hospital of Decatur (St.Mary's), for medical malpractice. Following a June 1999 jurytrial, the jury returned a verdict in favor of Snelson and againstKamm and St. Mary's and awarded Snelson $7 million.

Following an April 2000 hearing on defendants' posttrialmotions, the trial court entered an order (1) granting St. Mary'smotion for judgment notwithstanding the verdict (judgment n.o.v.)and (2) setting aside the $7 million damage award against Kamm andgranting a retrial on the issue of damages.

This court granted separate petitions for leave to appealby Snelson (Nos. 4-00-0418, 4-00-0432) and Kamm (No. 4-00-0419). See 166 Ill. 2d R. 306(a)(1). On appeal, Snelson argues that thetrial court erred by (1) granting Kamm a new trial on the issue ofdamages and (2) granting St. Mary's motion for judgment n.o.v. Kamm argues in his appeal that (1) the trial court erred by (a)allowing the testimony of Snelson's medical expert because itlacked foundation, (b) ruling that Kamm could not cross-examineSnelson's medical expert regarding his potential bias, (c) givingcertain instructions to the jury, and (d) admitting into evidenceall of Snelson's medical bills incurred since the unsuccessfulaortogram; (2) the jury (a) considered extraneous information and(b) demonstrated impropriety in conducting its duties; and (3) thejury's verdict was against the manifest weight of the evidence. Weaffirm and remand with directions for a new trial on the issue ofdamages.

In Snelson's January 1996 complaint, he alleged thatfollowing an unsuccessful translumbar aortogram that anotherphysician had performed on him on March 2, 1994, Kamm negligently(1) failed to diagnose "the acute mesenteric occlusion andinfarction," (2) delayed diagnosis of the acute mesentericocclusion and infarction, (3) failed to perform sufficientdiagnostic tests immediately following the unsuccessful aortogram,despite "incidents of abdominal pain," (4) failed to monitorSnelson closely, and (5) failed to perform serial physicalexaminations of Snelson. Snelson also alleged that St. Mary's,through its nursing staff, negligently (1) failed to inform Kamm ofSnelson's symptoms immediately following the unsuccessfulaortogram, (2) failed to adequately monitor Snelson, and (3) failedto perform sufficient diagnostic tests immediately following theunsuccessful procedure, despite incidents of abdominal pain.

At the June 1999 jury trial, the evidence showed thefollowing.

In March 1994, Snelson, who was then 58 years old, wassuffering from severe peripheral vascular insufficiency (poor bloodcirculation) in his legs, which was caused by arteriosclerosis(commonly referred to as hardening of the arteries). Snelson'sfamily doctor had referred him to Kamm, a general surgeon, fortreatment. Kamm suggested that Snelson undergo an aortogram todetermine the exact locations of the arterial blockages. On March2, 1994, Snelson and his son, James, arrived at St. Mary's so thatSnelson could undergo a translumbar aortogram, a procedure in whichdye is introduced through the patient's back into the aorta tostudy the aorta itself and its branches. (An aortogram is alsoreferred to as an arteriogram.) Possible complications from sucha procedure include (1) bleeding from the puncture site; (2) thebreaking off of a clot from the aorta, which then blocks a bloodvessel; (3) an allergic reaction to the dye; (4) infection; and (5)kidney damage.

Dr. Carlos Capati, a radiologist, testified that aroundnoon on March 2, he attempted to perform a translumbar aortogram onSnelson. However, he had difficulty navigating the guide wire intothe thoracic aorta, and it appeared that the guide wire was insteadgoing into the superior mesenteric artery, which supplies blood tothe intestine. Capati took out the translumbar needle and theguide wire and attempted to reinsert the guide wire into the aorta;however, he again had problems doing so. During the secondattempt, Snelson's blood pressure began dropping and he complainedof abdominal and back pain. Capati stopped the procedure andSnelson's blood pressure returned to normal. Snelson thenexpressed an urge to have a bowel movement and a portable commodewas brought in. Capati examined Snelson's stool but did not seeany discoloration. At that point, Capati decided to stop theaortogram. He then informed Kamm that he had been unable tocomplete the aortogram and Snelson was complaining of back andabdominal pain.

Snelson's son, James, testified that following theunsuccessful aortogram, he saw his father being brought back to hishospital room on a stretcher. James stated that his father was"screaming and yelling." Once in Snelson's room, James assistedthe nurses in getting his father back in bed. At that point,Snelson began complaining about "a lot of pain in his stomach." Healso complained of "pressure" in his stomach and the need tourinate. Snelson asked that the nurses insert a catheter to emptyhis bladder, and around 3 or 3:30 p.m. they did so. James left thehospital that afternoon before Kamm checked in on Snelson. Around8 p.m., James spoke with his father, who was still complaining ofpain and talking like he "didn't know who, what, when or where wasgoing on."

None of the nurses who testified at the trial had anyindependent memory of the events of March 2 or 3, 1994. However,the nurses on staff during that time recorded notes on Snelson'scondition. Those notes indicated that, following the unsuccessfulaortogram, Snelson returned to his hospital room around 12:40 p.m. At that time, he was complaining of abdominal pain and cramping andinsisted that he needed to have a bowel movement. A 12:44 p.m.shift assessment showed that Snelson was alert and complaining ofpain that he rated as a "7" on a scale of 1 to 10. At 12:45 p.m.,he had a large bowel movement and continued to complain of severepain across the middle of his abdomen with pain radiating to hisback. At that point, the nurses notified Kamm of Snelson'scondition. Kamm gave verbal orders that Snelson receive ahemoglobin and hematocrit test and be given pain medication (50milligrams (mg) of Demerol by muscular injection) every three hoursas needed. Kamm also ordered that Snelson's vital signs be takenevery 15 minutes for two hours and then hourly thereafter.

From 12:45 p.m. until 2:30 p.m. on March 2, Snelson'svital signs were as follows: (1) his temperature stayed belownormal, (2) his respirations were normal, (3) his pulse rose from80 to 164 during the first hour then dropped to 88 during thesecond hour, and (4) his blood pressure varied from a low of 120/70at 1 p.m. to a high of 164/76 at 2:30 p.m.

At 3 p.m., Snelson's temperature had risen slightly to95.6 degrees Fahrenheit and his blood pressure had dropped to160/80. The nurses' flow sheet indicated that a nurse inserted acatheter in Snelson's bladder around 3 p.m. At 3:35 p.m., a secondshift assessment indicated that Snelson's bowel sounds were normal,but he continued to complain of abdominal pain. At 4 p.m.,Snelson's temperature was 96.2 degrees, his pulse was 116, and hisblood pressure was 186/98. Around that same time, he had a bowelmovement that appeared to contain bloody mucous. The nurses pagedKamm, who was in surgery, and left a message. At 4:30 p.m., Kammtelephoned and spoke with a nurse about Snelson's condition. Kammtestified that at that point, he believed that the bloody bowelmovement was due to a mild hemorrhoid. Kamm told the nurse that hewould examine Snelson as soon as he could.

At 6 p.m., Kamm arrived at St. Mary's and examinedSnelson. At that time, the nurses' notes, shift assessment, flowsheets, and vital sign records were all available to Kamm. Duringthe examination, Kamm noted that Snelson was complaining of mid-abdominal pain and had difficulty urinating. Kamm found thatSnelson's lower abdomen was tender and distended, that his bowelsounds were hypoactive (less than normal), and that he had passedseveral small blood-tinged stools. In his notes, Kamm recorded aconcern "about mesenteric insufficiency or thrombo-embolus withischemia" (essentially, a blockage of blood flow to the intestine). Kamm testified, however, that at that time, he believed that themost likely cause of Snelson's pain was bleeding into hisretroperitoneal area as a result of his aorta being puncturedduring the unsuccessful aortogram.

Kamm further testified that, based on his 6 p.m.assessment, he believed Snelson's condition had stabilized"considerably" from earlier in the afternoon. He thus ordered thatthe nurses check Snelson's vital signs only every four hours. Because he was concerned about Snelson's abdominal distention, heordered that Snelson have no food or liquids by mouth. He alsoincreased Snelson's pain medication from 50 mg to 100 mg of Demerolevery four hours as needed, ordered that a catheter be inserted,and ordered some laboratory work for the next morning. Kammthought the catheter was inserted after his 6 p.m. examination ofSnelson, but he acknowledged that it could have been ordered beforehe arrived at St. Mary's as part of a routine postprocedure order. Kamm also stated that the catheter "caused considerable relief" inSnelson's discomfort. Kamm then left St. Mary's for the evening.

Following Kamm's examination of Snelson, Snelson wasobserved by the nurses at least every hour. According to thenurses' notes, he was sleeping most of the time between 6:30 p.m.and midnight on March 2, although it was noted that he had a bowelmovement and received Demerol at 7 p.m. and was awake at 10 p.m.and back asleep at 11 p.m. No documentation exists showing thatSnelson's vital signs were taken between 4 p.m. and midnight. Kammconferred with the nurses before he went to bed around 10 p.m. andwas advised that Snelson was stable and nothing had happened worthcommenting on. At midnight, Snelson's temperature was 98.3degrees, his pulse was 128, and his blood pressure was 190/100. The section in the midnight shift assessment concerning level ofpain was left blank; however, at 12:45 a.m., on March 3, Snelsonreceived 100 mg. of Demerol. At 4 a.m., Snelson's temperature was99.3 degrees, his pulse was 124, and his blood pressure was 154/90.

Kamm next saw Snelson between 6 and 6:30 a.m. on March 3. At that time, Snelson had an abnormally high white blood cellcount. Over the next four hours, a computerized tomography (CT)scan and X rays were taken, which showed the presence of air inSnelson's small intestine. Capati testified that the test resultswere consistent with "small and large bowel infarction," whichmeant that parts of Snelson's small and large bowel loops weregangrenous or dead. He also explained that the most likely causeof that condition was "acute embolism and thrombosis involving thesuperior mesenteric artery," which meant that either an embolism (aclot or plaque that moves within a blood vessel) or a thrombosis (aplaque or blood clot "that has been in there" and gradually causesblockage) had blocked the superior mesenteric artery. Capatiopined that the unsuccessful translumbar aortogram caused the deathof portions of Snelson's intestine.

Later that morning, Kamm performed exploratory abdominalsurgery on Snelson and found that almost all of his small intestineand the right half of his large intestine were dead due to lack ofblood circulation to the area. Kamm removed about 95% of Snelson'ssmall intestine.

Kamm also testified that the nurses had adequatelyobserved Snelson and reported to him everything that he needed toknow about Snelson's condition following the unsuccessfularteriogram. He further stated that, if he had wanted to performsurgery sooner, he would have; however, he did not think it wasindicated.

Dr. James Sarnelle, Snelson's medical expert, testifiedthat he is a general and vascular surgeon and is familiar with thetranslumbar arteriogram procedure as well as with intestinalsurgery. Sarnelle opined that, in Snelson's case, a blood clot hadblocked the mesenteric artery during the unsuccessful arteriogram.

Sarnelle stated that he was familiar with the nationalstandard of care for a reasonably well-qualified surgeon as thatstandard related to a patient in Snelson's condition on March 2,1994. Sarnelle opined that Kamm breached the standard of care intreating Snelson following the unsuccessful arteriogram. Heelaborated that on March 2, Kamm "did not take any action which wasnecessary to save [Snelson's] small bowel." He further stated that"what [Snelson] really needed was an operation to restore thecirculation" (revascularization surgery). Sarnelle based hisopinion that Kamm should have performed surgery on March 2 on the"classic" signs and symptoms of ischemia (blockage of the bloodsupply) of the small intestine that existed during Kamm's 6 p.m.examination of Snelson. In that regard, he testified that Snelson"has all the signs and symptoms of mesenteric ischemia. In fact,[Kamm] even mentions it in his note at 6 o'clock that he isconcerned about ischemia or thrombosis and yet he does nothing,just says will watch closely." According to Sarnelle, thefollowing signs and symptoms should have alerted Kamm to themesenteric ischemia: (1) Capati's indication that during theunsuccessful translumbar arteriogram the guide line went into thesuperior mesenteric artery; (2) Snelson's drop in blood pressureand abdominal pain during the unsuccessful procedure; (3) Snelson'sneed to have an immediate bowel movement during the arteriogram;(4) the bloody bowel movements following the arteriogram; (5)abdominal pain that was severe enough for Kamm to increase theDemerol from 50 to 100 mg.; and (6) the distention and tendernessof Snelson's lower abdomen during Kamm's 6 p.m. examination ofSnelson on March 2.

According to Sarnelle, a small window of opportunityexisted to prevent the permanent loss of Snelson's intestine. At6 p.m. on March 2, Snelson's vital signs indicated that he wasstable enough to have surgery. Sarnelle opined that hadrevascularization surgery been performed in a timely fashion onMarch 2, a large portion of Snelson's intestine could have beensaved and Snelson would not need to depend on intravenous supplemental nutrition, as Snelson's condition now requires. The latesttime that Snelson's intestine could have been saved was aroundmidnight on March 2. Sarnelle based his time frame opinions on theclinical data contained in Snelson's medical records, such as theonset and severity of Snelson's pain, his vital signs, and theappearance of bloody bowel movements.

Sarnelle acknowledged that generally acute mesentericischemia is very difficult to diagnose because the typical patienthas an onset of abdominal pain with no clear history of the pain'scausation. In addition, the typical patient is often elderly andhas trouble communicating. Sarnelle stated that Snelson's case wasdifferent because, unlike the typical patient who is admitted tothe hospital several hours after the onset of pain, (1) Snelson wasin the hospital at the time the ischemia began; (2) the problemsthat developed during the unsuccessful arteriogram involved thesuperior mesenteric artery; and (3) Snelson developed signs andsymptoms quickly and did not just show up at the hospital with"some obscure things" going on.

Sarnelle also opined that Kamm breached the appropriatestandard of care by ordering pain medication for Snelson becausepain medications may mask a patient's symptoms and make ischemiamore difficult to diagnose.

Sarnelle had no opinion regarding the conduct of St.Mary's nursing staff.

During cross-examination, Sarnelle acknowledged thatdepending on the cause of mesenteric ischemia, it can sometimestake days for a well-qualified surgeon to diagnose the condition. He also acknowledged that the medical literature does not (1)differentiate between arteriogram-induced mesenteric ischemia andother types or (2) set out certain symptoms as "classic." Sarnellestated that the possibility that Snelson's intestine did not "die"until 6 or 7 a.m. on March 3 was "extremely remote." Sarnelle hasperformed intestinal revascularization surgery twice in his career. One of those patients lived and the other died. The mortality ratefor such a surgery is over 50%. Sarnelle further stated that hehas been involved in 200 medical malpractice cases as a consultingexpert and witness. In all of those cases, he worked for theplaintiffs.

Grace McCallum, Snelson's nursing expert, testified thatnurses utilize the "nursing process," which is a critical thinkingprocess that defines the standard of care that a nurse shouldfollow. McCallum opined that the nursing process was not followedby St. Mary's nursing staff on March 2, 1994. This failure tofollow the nursing process was evidenced by the following: (1) thefailure to initiate a nursing care plan for Snelson; (2) thefailure to consult with another physician after the nurses foundout that Kamm was in surgery at 4 p.m. on March 2; (3) the failureto request a physician after Snelson had a bloody bowel movement at4 p.m. on March 2; (4) the failure to perform another assessmentfollowing the bloody bowel movement; (5) the failure to perform afollow-up evaluation on the effectiveness of Demerol; (6) the lackof nursing notes regarding Kamm's March 2 examination; (7) thefailure to perform all ordered vital signs during the evening ofMarch 2; and (8) the failure to call Kamm after checking Snelson'svital signs around midnight on March 2. McCallum opined that thefailure to follow the nursing process increases the likelihood ofan unfavorable outcome. However, she had no opinion about whatultimately caused Snelson's injury and stated that she would leavethat for "medicine to decide."

Dr. William Pyle, one of Kamm's medical experts,testified that mesenteric ischemia is difficult to diagnose and theultimate mortality rate is "in excess of 90 percent." Pyle opinedthat Kamm met the standard of care in his treatment of Snelson onMarch 2 and 3, 1994. Pyle also opined that "there weren't enoughfindings or symptoms to justify surgery" on March 2. Pyle furtheropined that revascularization surgery was not an option because themesenteric ischemia was most likely caused by a dissection of theartery, as opposed to a sudden blockage due to a blood clot. Inaddition, he opined that regardless of what caused the ischemia andregardless of when the revascularization surgery occurred,Snelson's intestine most likely could not have been saved.

Dr. Philip Donahue, another of Kamm's medical experts,opined that Kamm did not breach the standard of care by failing todiagnose mesenteric ischemia or failing to perform revascu-larization surgery on March 2, 1994. He reasoned that earliersurgery was not warranted by the medical evidence and would nothave made any difference in Snelson's outcome. Donahue also statedthat the "classic" signs of ischemia about which Sarnelle testifiedwere not "classic of anything." Instead, they "were justnon[]specific signs." Donahue further opined that the death ofSnelson's intestine did not occur until sometime around 6 a.m. onMarch 3.

Mary Delaney, St. Mary's nursing expert, testified thatthe nurses did not violate the standard of care in treating ormonitoring Snelson.

Dr. Robert Newlin, Snelson's treating physician,testified that as a result of the March 3, 1994, surgery, Snelsonsuffers from "short bowel syndrome." Because Snelson no longer hasmost of his small intestine, he must rely on hyperalimentation toprovide him with nutrients. (Hyperalimentation is the intravenousinfusion of a solution that contains sufficient nutrients.) Thesolution is infused into one of Snelson's veins in his upper chestvia a catheter. The catheter is a foreign body and bacteria caneasily grow on it. Snelson has suffered several infections of hiscatheter site, some of which required hospitalization. Newlinopined that Snelson will require hyperalimentation for the rest ofhis life. Newlin estimated that Snelson could live another 10years. He acknowledged that Snelson's preexisting health problems,including diabetes, high blood pressure, arteriosclerosis,arthritis, and a history of smoking, would considerably shortenSnelson's life expectancy by themselves.

Snelson testified that he must be attached to thehyperalimentation device for 12 hours each day. Sometimes thenutrient solution causes him pain as it enters through thecatheter, and he requires help to maintain the catheter and thecatheter site. Although Snelson can eat regular food, the portionsmust be small. He suffers from chronic diarrhea, and he must usethe bathroom 15 to 20 times a day. Because of thehyperalimentation, he decided not to return to work and took earlyretirement. Snelson also presented a medical bill summary,totaling $595,766.35 and prior income tax returns from 1990 through1994, showing total wages ranging from $16,970 to $40,838.04.

Snelson acknowledged that even before the March 3, 1994,surgery, the arteriosclerosis made it hard to walk and he had touse a wheelchair. Snelson stated that he still hunts, fishes, andtravels to Minnesota to fish and to Indiana to see his daughter. He also acknowledged that his restricted ability to engage in dailyactivities was largely attributable to his preexisting physicalproblems.

On this evidence, the jury returned a verdict inSnelson's favor and against both Kamm and St. Mary's and awarded $7million. Because the completed verdict form contained only thetotal damage award, the trial court instructed the jury to returnto deliberations and itemize the verdict. Shortly thereafter, thejury returned with a verdict in the same amount, itemized asfollows: (1) $600,000 for past medical expenses; (2) $1.1 millionfor future medical expenses; (3) $3 million for pain and suffering;(4) $2 million for loss of normal life; (5) $80,000 for lostearnings; and (6) $220,000 for disfigurement.

As earlier stated, following an April 2000 hearing ondefendants' posttrial motions, the trial court entered an order (1)granting St. Mary's motion for judgment n.o.v. and (2) granting aretrial on the issue of damages. This appeal followed.

Snelson first argues that the trial court erred bygranting St. Mary's motion for judgment n.o.v. because sufficientevidence existed that the actions of St. Mary's nursing staffproximately caused his injuries. We disagree.

A judgment n.o.v. is properly entered in those limitedcases where "all of the evidence, when viewed in its aspect mostfavorable to the opponent, so overwhelmingly favors movant that nocontrary verdict based on that evidence could ever stand." Pedrickv. Peoria & Eastern R.R. Co., 37 Ill. 2d 494, 510, 229 N.E.2d 504,513-14 (1967). We review de novo a trial court's decision on amotion for judgment n.o.v. McClure v. Owens Corning FiberglasCorp., 188 Ill. 2d 102, 132, 720 N.E.2d 242, 257 (1999).

"In a medical malpractice case, Illinois mandates aplaintiff prove (1) the proper standard of care by which to measurethe defendant's conduct, (2) a negligent breach of the standard ofcare, and (3) resulting injury proximately caused by the defendant's lack of skill or care." Higgens v. House, 288 Ill. App. 3d543, 546, 680 N.E.2d 1089, 1092 (1997). Except in very simplecases, the issue of causation in a medical malpractice case isbeyond the common knowledge of laypersons. See Addison v.Whittenberg, 124 Ill. 2d 287, 297, 529 N.E.2d 552, 556 (1988)(noting that examples of this exception include cases in which "thetreatment is so common, or the act so grossly negligent, that alayman would be able to make a proper evaluation of the challengedconduct"). Thus, a plaintiff generally must present "experttestimony to establish the applicable standard of care, a deviationfrom the standard, and the resulting injury to the plaintiff." Higgens, 288 Ill. App. 3d at 546, 680 N.E.2d at 1092.

In Gill v. Foster, 157 Ill. 2d 304, 310-11, 626 N.E.2d190, 193 (1993), the supreme court affirmed summary judgment forthe defendant hospital where a discharge nurse's failure to notifyan attending physician of the plaintiff's complaints of chest painwas not the proximate cause of plaintiff's injury because thedoctor already knew of the pain and thought it was a normalbyproduct of surgery. The court concluded that "even assuming thenurse had breached a duty to inform the treating physician of thepatient's complaint, this breach did not proximately cause thedelay in the correct diagnosis of the plaintiff's condition." Gill, 157 Ill. 2d at 311, 626 N.E.2d at 193.

In Seef v. Ingalls Memorial Hospital, 311 Ill. App. 3d 7,18-19, 724 N.E.2d 115, 124 (1999), the appellate court affirmed thetrial court's dismissal of the defendant hospital from theplaintiff's action for wrongful death of a stillborn infant becausethe nurses' failure to earlier notify the physician of certainabnormalities did not cause the delay in performing a cesareansection. In reaching that decision, the Seef court stated, inpertinent part, as follows:

"Assuming arguendo that the nurses had notified [the physician] several hours earlier,[the physician] admitted that he would havemisinterpreted the data on the monitor stripsin the same way. *** By his own admission,the nurses' failure to notify [him] earliermade no difference in this case." Seef, 311Ill. App. 3d at 17, 724 N.E.2d at 122-23.

Similarly, in this case, the evidence showed that thefailure of St. Mary's nurses to notify Kamm about Snelson'ssymptoms and vital signs did not delay Kamm's diagnosis of themesenteric ischemia or his surgical intervention. In that regard,Kamm testified that (1) by 6 p.m. on March 2, 1994, he was awarethat Snelson's condition could possibly be mesenteric ischemia; (2)the fact that the nursing staff did not take Snelson's vital signsat 10 p.m. on March 2, did not affect his ability to treat Snelson;(3) if he had wanted to do surgery sooner, he would have; however,he did not think it was indicated; and (4) the nurses had adequately observed Snelson and reported to Kamm everything that heneeded to know to treat Snelson. Based on Kamm's testimony, thenurses did not have any information which, if communicated to Kamm,would have changed his diagnosis or treatment of Snelson.

In the cases upon which Snelson relies, Holton v.Memorial Hospital, 176 Ill. 2d 95, 679 N.E.2d 1202 (1997), andSuttle v. Lake Forest Hospital, 315 Ill. App. 3d 96, 733 N.E.2d 726(2000), evidence was presented showing that if the nurses hadcommunicated specific information to the patient's physician, thephysician would have acted differently. See Holton, 176 Ill. 2d at109, 679 N.E.2d at 1208 ("there is testimony in the instant casethat the doctors would have undertaken a different course oftreatment had they been accurately and promptly apprised of theirpatient's progressive paresis"); Suttle, 315 Ill. App. 3d at 104,733 N.E.2d at 732-33 ("In the instant case, there is testimony that[the physician] diagnosed [the patient] as suffering from respiratory distress syndrome, rather than hypovolemic shock, because hewas unaware of [the patient's] velamentous insertion" (emphasis inoriginal); also noting that the physician testified that if he hadknown of the patient's low blood pressure earlier, he would havecalled a transplant team).

Despite the lack of such evidence in this case, Snelsoncontends that the nurses' deviations from the standard of care--bythemselves--comprise sufficient evidence that those deviations werea proximate cause of his injuries. We disagree.

As earlier discussed, a medical malpractice plaintiffmust present expert testimony to establish the standard of care andthat its breach was the cause of the plaintiff's injury. Snelsondid not provide the requisite proximate causation testimony to linkthe nurses' deviations from the standard of care to his injuries. Snelson's nursing expert, McCallum, could not testify regardingproximate cause since she was not a medical expert (see Seef, 311Ill. App. 3d at 20-21, 724 N.E.2d at 125). Indeed, McCallumacknowledged that she did not have the medical expertise to form anopinion regarding proximate causation. Even assuming McCallumqualified as a medical expert, her vague assertions that failure tofollow steps in the nursing process "increases the likelihood" ofan unfavorable outcome was insufficient to establish proximatecausation. In Nastasi v. United Mine Workers of America UnionHospital, 209 Ill. App. 3d 830, 837-38, 567 N.E.2d 1358, 1364(1991), the appellate court affirmed a directed verdict in favor ofa hospital, reasoning as follows:

"Although plaintiff's nursing expert ***did testify that the Hospital's nursing staffdid deviate from the proper standard of carewhen it failed to promptly notify [the physician] *** and although *** plaintiff's medicalexpert[] did testify that delays in promptdiagnosis and treatment could cause poorerultimate results in patients suffering fromplaintiff's condition, there was no medicaltestimony to substantiate that the acts oromissions of the nursing staff ultimately hadany impact at all on the outcome of plaintiff's treatment."

See also Pumala v. Sipos, 163 Ill. App. 3d 1093, 1099, 517 N.E.2d295, 298-99 (1987) (expert's testimony that the earlier theplaintiff's disease was detected, "the better were the chances tocure it" was "insufficient to present a question for the jury"). Moreover, Snelson's medical expert, Sarnelle, did not provide thenecessary proximate cause testimony because he admittedly had noopinion concerning the conduct of St. Mary's nursing staff.

On this record, we conclude that all of the proximatecausation evidence, when viewed in its aspect most favorable toKamm, so overwhelmingly favors St. Mary's that no contrary verdictbased on that evidence could ever stand. We thus hold that thetrial court did not err by granting St. Mary's motion for judgmentn.o.v.

Snelson also argues that the trial court abused itsdiscretion by ordering a new trial on the issue of damages. Wedisagree.

"In determining whether an award is excessive, the testto be used is 'whether *** [the award] falls within the necessarilyflexible limits of fair and reasonable compensation or is so largeas to shock the judicial conscience.'" Tierney v. CommunityMemorial General Hospital, 268 Ill. App. 3d 1050, 1063, 645 N.E.2d284, 293 (1994), quoting Northern Trust Co. v. County of Cook, 135Ill. App. 3d 329, 334, 481 N.E.2d 957, 961 (1985). The factors acourt must consider in assessing whether the verdict is excessiveinclude: (1) the permanency and extent of the injuries suffered,(2) the plaintiff's age, (3) the possibility of deterioration inthe future, (4) the medical expenses incurred, (5) past and futurelost wages, and (6) any restrictions that the injury may haveplaced on the plaintiff's daily activities. Tierney, 268 Ill. App.3d at 1064, 645 N.E.2d at 293-94. If, after considering all theevidence, the trial court concludes that the jury verdict isexcessive, the court "may not allow the verdict to stand but mustact to correct the injustice." Haid v. Tingle, 219 Ill. App. 3d406, 410, 579 N.E.2d 913, 916 (1991).

In Maple v. Gustafson, 151 Ill. 2d 445, 455-56, 603N.E.2d 508, 513 (1992), the supreme court discussed the appropriatestandard to apply when reviewing a trial court's ruling on a motionfor a new trial as follows:

"Next, we must determine whether thetrial court erred in denying the motion for anew trial. The standard that was mistakenlyutilized by the appellate court in determiningwhether to enter a judgment n.o.v., that thejury's verdict was against the manifest weightof the evidence, is instead to be used indetermining whether to grant a new trial[citation], the application of which is addressed to the sound discretion of the trialcourt [citations]. A court's ruling on amotion for a new trial will not be reversedexcept in those instances where it is affirmatively shown that it clearly abused its discretion. [Citations.] In determining whetherthe trial court abused its discretion, thereviewing court should consider whether thejury's verdict was supported by the evidenceand whether the losing party was denied a fairtrial. [Citation.] Furthermore, it is important to keep in mind that '"[t]he presidingjudge in passing upon the motion for a newtrial has the benefit of his previous observation on the appearance of the witnesses, theirmanner in testifying, and of the circumstancesaiding in the determination of credibility."' (Buer v. Hamilton (1964), 48 Ill. App. 2d 171,173-74, [199 N.E.2d 256, 257-58,] quotingHulke v. International Manufacturing Co.(1957), 14 Ill. App. 2d 5, 47, [142 N.E.2d717, 739].) If the trial judge, in the exercise of his discretion, finds that the verdictis against the manifest weight of the evidence, he should grant a new trial; on theother hand, where there is sufficient evidenceto support the verdict of the jury, it constitutes an abuse of discretion for the trialcourt to grant a motion for a new trial." (Emphasis in original.)

In addition, in Craigmiles v. Egan, 248 Ill. App. 3d 911, 926-27,618 N.E.2d 1242, 1252-53 (1993), this court discussed the appropriate standard of review on appeal from a trial court's grant of anew trial on the issue of damages as follows:

"In Greco[ v. Coleman, 138 Ill. App. 3d 317,485 N.E.2d 1118 (1985)], as here, the issuewas whether the trial court properly granted anew trial on damages because of inadequacy orinconsistency of the award of damages.

The Greco court stated:

'It is well established thatwhether a motion for a new trial isto be granted is within the sounddiscretion of the trial court andshould not be disturbed unless aclear abuse of discretion appears inthe record. [Citations.] Since, asa general rule, a new trial will notbe granted on the ground that damages in personal injury actions areconsidered to be inadequate, appellate review of the granting of a newtrial limited solely to the issue ofdamages is essentially a review ofthe trial court's discretion. Anabuse of discretion will be foundwhere there is no recognizable basisin the record to support the granting of a motion for a new trial. [Citation.] ***' (Greco, 138 Ill.App. 3d at 322, 485 N.E.2d at1121.)"

Moreover, in Netzel v. United Parcel Service, Inc., 181 Ill. App.3d 808, 817, 537 N.E.2d 1348, 1354 (1989), the court stated asfollows:

"The amount of damages awarded generallyis within the discretion of the jury. [Citation.] Nevertheless, a reviewing court canorder a new trial if the damages are manifestly inadequate, if proved elements ofdamages have been ignored, or if the awarddoes not bear a reasonable relation to theplaintiff's loss."

In granting Kamm's motion for a new trial on the issue ofdamages, the trial court stated, in pertinent part, as follows:

"I am going to grant a new trial to thedefendant Kamm on the issue of damages only. The reason for that is that the $7 millionverdict in this particular--under the circumstances of this case is definitely outside therange as what is fair and reasonable based onall of the evidence presented."

Although the court set forth additional factors in reaching itsdecision, we need not discuss those factors. See In re Estate ofFerguson, 313 Ill. App. 3d 931, 936, 730 N.E.2d 1205, 1209 (2000)("A lower court's judgment, not its reasoning, is the crux ofappellate review").

The evidence showed that at the time of the failedarteriogram, Snelson was an overweight 58-year-old man, with ahistory of smoking, diabetes, hypertension, arthritis, and severearteriosclerosis, which affected his ability to walk. Snelsonundeniably suffered a serious injury as a result of the failedarteriogram--namely, the loss of most of his small intestine--andmust receive nutrients through a hyperalimentation catheter for therest of his life. He also suffers from chronic diarrhea. However,his injury did not diminish his life expectancy. In addition,Snelson acknowledged that his restricted ability to engage in dailyactivities was largely attributable to his preexisting physicalproblems. Snelson had to have his hyperalimentation catheterreplaced on several occasions; however, at the time of trial, hehad gone as long as 19 months without special medical assistance. Snelson did not present evidence that his condition was likely todeteriorate in the future. He submitted a summary of his medicalbills incurred since March 2, 1994, totaling $595,766.35, whichincluded some bills from physicians who treated him for preexistingproblems. Further, as Kamm correctly points out, the jury awarded(1) $1.1 million for future medical expenses in the absence ofevidence regarding such expenses, and (2) $600,000 for past medicalexpenses, which slightly exceeded the amount submitted by Snelson.

This issue is a close one, and this court may have cometo a different conclusion on the same facts. However, reviewingthe trial court's decision in accordance with the appropriatestandard of review, we hold that the trial court did not clearlyabuse its discretion by granting a new trial on the issue ofdamages. We therefore remand this case for a new trial on theissue of damages.

Last, Snelson argues, without citation to authority, thatif this court remands for a new trial on the issue of damages, weshould instruct the trial court that Snelson is only required tosubmit evidence of damages stemming from the loss of 95% of hissmall intestine. In response, Kamm asks this court to followCancio v. White, 297 Ill. App. 3d 422, 428, 697 N.E.2d 749, 753(1998), in which the First District Appellate Court held that,during a new trial on the issue of damages, the plaintiff mustprove both injury and proximate cause. We agree with Kamm.

In Cancio, 297 Ill. App. 3d at 428, 697 N.E.2d at 753,the appellate court stated, in pertinent part, as follows:

"We find that while plaintiffs were not required to prove liability on the part ofdefendant, *** plaintiffs were neverthelessstill required to prove actual damages beforethey could recover. As defendant notes, ajury cannot determine the nature, extent[,]and duration of an alleged injury, withoutfirst assessing what, if any, injury theplaintiffs suffered as a result of the accident and the extent and duration of any alleged injury."

The Cancio court relied, in part, on Robertson v. Smith, 40 Ill.App. 3d 174, 351 N.E.2d 576 (1976), in which the plaintiff's actionarose out of a car accident. At the outset of the trial, thedefendant admitted liability but contested the issue of damages,and the jury found no damages. Robertson, 40 Ill. App. 3d at 175,351 N.E.2d at 577. On appeal, the plaintiff argued that (1) "theverdict of no damages cannot stand because defendant admittedliability at the outset of the trial," and (2) "defendant, byadmitting liability, admitted proximate cause and injury becausethese are elements of negligence liability." Robertson, 40 Ill.App. 3d at 177, 351 N.E.2d at 578. The appellate court disagreedfor the following reason:

"In Jeffrey v. Chicago Transit Authority, [37Ill. App. 2d 327, 336, 185 N.E.2d 384, 389(1962),] the court *** specifically held thateven if a defendant's liability is established, a plaintiff must prove actual damagesbefore he can recover.

Applying this rule to the facts of thiscase, we hold that by his admission of liability[,] defendant admitted that the accidentresulted from his negligent operation of hisvehicle, and that plaintiff was free fromcontributory negligence. The mere fact thatthe accident occurred as a result of defendant's negligence does not, in any way, establish that plaintiff sustained physical injuries. While plaintiff was relieved, underdefendant's admission of liability, fromproving defendant's negligence and her freedomfrom contributory negligence, she was requiredto establish damages occasioned by physicalinjury." Robertson, 40 Ill. App. 3d at 177,351 N.E.2d at 578-79.

We agree with Cancio, Jeffrey, and Robertson, and wetherefore hold that at the new trial on the issue of damages,Snelson must prove injury and proximate cause.

Kamm first argues that the trial court abused itsdiscretion by allowing Sarnelle's testimony because it lackedfoundation. Specifically, he contends that (1) no medicalliterature supported Sarnelle's contention that certain signs ofmesenteric ischemia are "classic"; (2) Sarnelle had no clinicalexperience that "would allow him to conclude the existence of'classic symptoms' which would make immediate surgery the standardof care"; (3) Sarnelle based his opinion regarding the time linefor successful surgical intervention on "general principles"; and(4) Sarnelle had testified only for plaintiffs.

Initially, we note that our review of the recordindicates that Kamm has forfeited this issue on appeal by failingto object to either the foundation of Sarnelle's testimony orSarnelle's qualifications at trial. Wingo v. Rockford MemorialHospital, 292 Ill. App. 3d 896, 909, 686 N.E.2d 722, 731 (1997). Moreover, even assuming that Kamm had not forfeited this issue, weconclude that the trial court did not abuse its discretion byallowing Sarnelle's testimony.

An expert's opinion is only as valid as the reasonsunderlying it. Thus, when an expert's opinion is totally lackingin factual support, it constitutes nothing more than conjecture andguess and should not be admitted. Harris Trust & Savings Bank v.Otis Elevator Co., 297 Ill. App. 3d 383, 393, 696 N.E.2d 697, 705(1998). "Although opinion witnesses may not base their testimonyon conjecture or speculation [citation], they may testify in termsof what 'might or could' have caused the plaintiff's injury." Hawnv. Fritcher, 301 Ill. App. 3d 248, 253, 703 N.E.2d 109, 112 (1998);Hajian v. Holy Family Hospital, 273 Ill. App. 3d 932, 942, 652N.E.2d 1132, 1139 (1995) (expert testimony may be based on areasonable degree of medical certainty). The decision to admitopinion testimony lies within the trial court's sound discretion,and a reviewing court will not reverse its decision absent an abuseof discretion. Van Holt v. National R.R. Passenger Corp., 283 Ill.App. 3d 62, 70, 669 N.E.2d 1288, 1295 (1996).

Sarnelle did indicate that he based some of his opinionson Snelson's "classic symptoms" and "general principles." However,he also stated that he based his opinions on the clinical datafound in the medical records from Snelson's March 2 and 3, 1994,admission to St. Mary's, including the following: (1) Kamm'sreport on Snelson's admission history and physical examination; (2)progress notes written by Kamm, Capati, and nurses who attendedSnelson; (3) physicians' order sheets; (4) radiology reports; (5)abdominal CT scan reports; (6) a March 3, 1994, operative report;(7) a surgical pathology report; and (8) a discharge summary. Sarnelle also reviewed the discovery depositions of Kamm andDonahue prior to testifying.

In denying Kamm's motion for judgment n.o.v., the trialcourt stated, in relevant part, as follows:

"[T]he criticism of Dr. Sarnelle by [Kamm]really goes to the weight of the evidence ortestimony presented by him, and I believe thatwas all argued to the jury at the time. Ithink suffice it to say that the jury had theoption of accepting the testimony of eitherside's expert witnesses which [was] presentedat trial ***."

Given the trial court's discretion in admitting expert testimony,we conclude that the court did not abuse its discretion byadmitting Sarnelle's testimony.

Although Kamm has alleged several ways in whichSarnelle's opinion is flawed, he has not demonstrated thatSarnelle's opinion included "so many varying and uncertain factors"that he was required to guess to reach his conclusions. Instead,Kamm's concerns constitute appropriate topics for cross-examination. As the Supreme Court stated in Daubert v. Merrell DowPharmaceuticals, Inc., 509 U.S. 579, 596, 125 L. Ed. 2d 469, 484,113 S. Ct. 2786, 2798 (1993), "[v]igorous cross-examination,presentation of contrary evidence, and careful instruction on theburden of proof are the traditional and appropriate means ofattacking shaky but admissible evidence." See also Halleck v.Coastal Building Maintenance Co., 269 Ill. App. 3d 887, 897, 647N.E.2d 618, 627 (1995) (on cross-examination, counsel may probe theweaknesses in the bases of an expert's opinion as well as thegeneral soundness of his opinion). Moreover, the determination ofthe precise bases for Sarnelle's opinions was exactly the type offactual question that a jury should resolve. See Maple, 151 Ill.2d at 452, 603 N.E.2d at 511 ("Unquestionably, it is the provinceof the jury to resolve conflicts in the evidence ***").

In this case, Kamm conducted a vigorous cross-examinationof Sarnelle, challenging the bases and soundness of his opinions. In addition, one of Kamm's medical experts testified that Snelson'ssymptoms were not "classic of anything."

B. The Trial Court's Refusal To Allow Kamm To Cross-Examine Sarnelle Regarding Potential Bias

Kamm next argues that the trial court erred by grantingSnelson's motion in limine, thus barring any evidence relating toa professional witness referral agency, Guy Sappanaro or Sappanaro,Inc. (hereinafter Sappanaro). Specifically, Kamm contends that thecourt's ruling (1) barred him from cross-examining Sarnelleregarding his relationship with Sappanaro; and (2) prevented thejury from considering "a true and complete picture of Dr.Sarnelle's financial interest in giving testimony favorable toparties referred to him by Sappanaro."

We agree with Kamm's assertion that parties must beallowed to demonstrate an expert's bias or financial interestthrough cross-examination. The supreme court has long recognizedthat "the principal safeguard against errant expert testimony isthe opportunity of opposing counsel to cross-examine, whichincludes the opportunity to probe bias, partisanship[,] orfinancial interest." Trower v. Jones, 121 Ill. 2d 211, 217, 520N.E.2d 297, 300 (1988). In Chicago City Ry. Co. v. Handy, 208 Ill.81, 83, 69 N.E. 917, 918 (1904), the supreme court stated:

"It is competent to show that a witness*** is in the employ of one of the litigantsregularly or frequently as an expert witness,or to prove facts and circumstances whichwould naturally create a bias in the mind ofthe witness for or against the cause of eitherof the litigants." (Emphasis added.)

See also M. Graham, Cleary & Graham's Handbook of Illinois Evidence