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Docket Nos. 91232, 91239 cons.-Agenda 27-November 2001.

ROBERT SNELSON, Appellee and Cross-Appellant, v. 
DONALD KAMM, M.D., et al. (Donald Kamm, M.D., Appellant
and Cross-Appellee).

Opinion filed March 20, 2003.

JUSTICE THOMAS delivered the opinion of the court:

Plaintiff, Robert Snelson, brought a negligence action againstdefendants, Donald Kamm, M.D. (Kamm), and St. Mary'sHospital of Decatur (St. Mary's). Following a jury trial in thecircuit court of Macon County, a verdict was returned in favor ofSnelson and against Kamm and St. Mary's in the amount of$7 million. After a hearing on defendants' posttrial motions, thetrial court granted St. Mary's a judgment notwithstanding theverdict (judgment n.o.v.) on the issue of proximate cause andgranted Kamm a new trial on the issue of damages, setting asidethe $7 million award. The appellate court consolidated the separateappeals by Snelson and Kamm, and affirmed the orders of the trialcourt. 319 Ill. App. 3d 116. We allowed Snelson's and Kamm'spetitions for leave to appeal (177 Ill. 2d R. 315) and alsoconsolidated the appeals.

Before this court, Snelson contends that the trial court erredby: (1) granting Kamm a new trial on the issue of damages; and(2) granting St. Mary's motion for judgment n.o.v. Kammchallenges certain of the trial court's rulings and the jury's verdict.Specifically, Kamm claims: (1) he was improperly prevented fromexamining Snelson's medical expert as to bias; (2) the testimonyof Snelson's medical expert should not have been admitted,because it lacked foundation; (3) the jury was improperlyinstructed; (4) certain medical bills of Snelson's were improperlyadmitted into evidence; (5) the verdict was tainted by extraneousinformation; (6) the verdict was against the manifest weight of theevidence; and (7) the verdict is excessive.

BACKGROUND

At the June 1999 jury trial, the following evidence wasadduced. In March 1994, Snelson was 58 years old and employedas a clerk by the Illinois Central Gulf Railroad. Snelson wasreferred to Kamm, a general surgeon, who suggested that Snelsonundergo a radiological procedure known as an aortogram orarteriogram, to determine the location of arterial blockages in hislegs caused by arteriosclerosis, commonly referred to as hardeningof the arteries. Dr. Carlos Capati, a radiologist practicing at St.Mary's, testified that, on March 2, 1999, while attempting toperform a translumbar aortogram on Snelson, he experienceddifficulty navigating the guide wire into the thoracic aorta. Itappeared that the guide wire instead entered the superiormesenteric artery, which supplies blood to the intestine. Capatiwithdrew the translumbar needle and the guide wire and attemptedto reinsert the guide wire into the aorta. During the second attempt,however, Snelson's blood pressure dropped, he complained ofabdominal and back pain and expressed an urge to have a bowelmovement. A portable commode was brought in and Capatiexamined Snelson's stool, but did not notice any discoloration. Atthat point, Capati terminated the procedure and informed Kammthat he had been unable to complete the test and that Snelson wascomplaining of back and abdominal pain.

Snelson's son, James Snelson, testified that following theunsuccessful aortogram, he saw his father being brought back tohis room on a stretcher, "screaming and yelling." Once in his bed,Snelson began complaining of "a lot of pain in his stomach." Hewas lying on his side "in a fetal position" with his eyes closed andwas sweating profusely. Snelson also complained of pressure inhis stomach and the need to use the bathroom. James stated that hewent to the nurses station and told them that his father needed acatheter and one was provided at about 3 or 3:30 p.m. Jamestestified that he left St. Mary's late that afternoon to care for hismother and, prior to his departure, did not see Kamm visit hisfather. James stated that he spoke to his father by telephone thatevening at approximately 8 p.m., and that his father stillcomplained of pain and was not making sense.

The nurses on staff at St. Mary's on March 2 and 3, 1994,recorded notes on Snelson's condition, but none who testified attrial had any independent recollection of the events. The nurses'notes indicate that, following the unsuccessful aortogram, Snelsonwas returned to his room at 12:40 p.m. He was complaining ofpain in his abdomen and cramping and requested a bedsidecommode. A 12:44 p.m. shift assessment showed that Snelson wasalert and complaining of pain. According to the nurses' notes, thepain rated "7" on a scale of 1 to 10. At 12:45 p.m., Snelson had alarge bowel movement and continued to complain of severe painacross the middle of his abdomen radiating into his back. At thispoint, the nurses notified Kamm of Snelson's complaints ofabdominal pain. In response, Kamm ordered by phone thatSnelson receive blood tests and pain medication, 50 milligramsDemerol by muscular injection, every three hours as needed.Kamm also ordered that Snelson's vital signs be taken every 15minutes for two hours and then hourly thereafter.

Snelson's vital signs were then checked every 15 minutesfrom 12:45 p.m. to 2:30 p.m. During this period, plaintiff'stemperature stayed below normal, his respirations were normaland remained constant. His pulse rose during the first hour andthen fell back to normal the second hour, while his blood pressuredropped and rose throughout the period.

The nurses charted in their flow sheet that a catheter wasinserted to empty Snelson's bladder around 3 p.m. A second shiftassessment at 3:35 p.m. showed Snelson's bowel sounds werenormal, but he continued to complain of abdominal pain. At 4p.m., Snelson had a bowel movement with blood-tinged mucous.The nurses immediately paged Dr. Kamm, and were advised thathe was in surgery at another hospital. Kamm called back at 4:30p.m. and was advised by a nurse of the bloody bowel movement.Kamm testified that he spoke with the nurse about Snelson'scondition at 4:30 p.m., and concluded that the bloody stool wasdue to a mild hemorrhoid or fissure. Kamm told the nurse hewould quickly conclude his duties at the other hospital and wouldproceed directly to St. Mary's.

At 6 p.m., Kamm arrived at St. Mary's and examined Snelsonfor 15 or 20 minutes. At this time, Kamm had access to the nurses'notes, shift assessments, flow sheets and vital sign records whichhad recorded Snelson's condition. Kamm noted that Snelson'svital signs were stable, but he had passed several small blood-tinged stools and was complaining of abdominal pain anddifficulty urinating. Kamm found that Snelson's lower abdomenwas tender and distended, with diminished bowel sounds. Kamm'snotes further state the following: "Concerned about mesentericinsufficiency or thrombo-embolus with ischemia. Will watchclosely." Kamm testified that he was not making a diagnosis ofmesenteric ischemia, or deficiency of blood circulation to theintestinal system, but rather was "entertaining [it] as a one of therare possibilities" of arteriographic puncture complications.Rather, at the time, Kamm thought that the most likely cause ofSnelson's pain was bleeding into his retroperitoneal area from thepuncture sites.

Because Kamm believed that the fullness and tenderness inSnelson's lower abdomen was consistent with a distended bladder,he ordered a catheter inserted. Kamm noted that the cathetercaused considerable relief in Snelson's discomfort at that point.Kamm believed that the catheter inserted after his 6 p.m.examination was the first time a catheter had been used onSnelson. However, the nurses' flow sheet, which Kamm hadavailable to him at the 6 p.m. examination, indicated that acatheter had been inserted at 3 p.m. Kamm acknowledged that acatheter could have been ordered before he arrived as part of apostoperative order. At any rate, it was undisputed that the catheterbrought pressure relief and lessened Snelson's discomfort.

Kamm further testified that, based on his 6 p.m. assessment,he believed Snelson's condition had stabilized, and that it wastherefore safe to increase his pain medication from 50 milligramsto 100 milligrams of Demerol every four hours as needed. Hefurther ordered that Snelson have no food or liquids by mouth, thatthe nurses check his vital signs every four hours, and that somelaboratory work be completed for the next morning. Kamm thenleft St. Mary's for the evening.

After Kamm's examination, the nurses observed Snelson atleast every hour. A nurse's notation for that evening indicates thatSnelson had a normal bowel movement and received Demerol at7 p.m. It was also noted that Snelson slept most of the evening. Hewas awake at 10 p.m., but was back asleep at 11 p.m. Nodocumentation exists showing that Snelson's vital signs weretaken at 10 p.m.

Kamm conferred with the nurses before he went to bed around10 p.m. and was advised that Snelson was stable and that they hadnothing new to report. At midnight, Snelson's vital signs weretaken. The section in the shift assessment to indicate level of painwas not marked at that time. St. Mary's nurse Belinda Durbintestified that at 12:45 a.m. on March 3, she administered 100milligrams of Demerol to Snelson because he was having somepain. She further noted, however, that if he had been experiencingsevere pain she would have made a notation of that fact in therecords. At 4 a.m., Snelson's vital signs were taken again.

Kamm returned to the hospital on March 3, 1994, andexamined Snelson between 6 and 6:30 a.m. It appeared to Kammthat Snelson had not improved over the prior 18 hours, and he hadan abnormally high white blood cell count. Over the next fourhours, a computerized tomography (CT) scan and abdominal Xrays were taken, which showed definite abnormalities, includingthe presence of air in Snelson's small intestine. Capati, whointerpreted the CT scan and X rays, testified that the results wereconsistent with "small and large bowel infarction," which meantthat parts of Snelson's small and large bowel loops weregangrenous or dead. Capati further testified that the most likelycause of that condition was "acute embolism and thrombosisinvolving the superior mesenteric artery," meaning that a plaqueor clot moving within the blood vessel, or a preexisting plaque orclot, had blocked the superior mesenteric artery. Capati opined thatthe unsuccessful translumbar aortogram caused the death ofportions of Snelson's intestine.

Kamm performed emergency exploratory surgery on Snelsonlater that morning and found that almost all of his small intestineand half of his large intestine were dead due to lack of bloodcirculation to the area. It was therefore necessary to removeapproximately 95% of Snelson's small intestine and the right halfof his large intestine. Snelson was discharged from St. Mary's onMarch 21, 1994.

With regard to this cause of action, Kamm testified that thenurses had adequately observed Snelson and reported to himeverything that he needed to know about Snelson's conditionfollowing the unsuccessful aortogram. He further stated that, if hehad wanted to perform surgery sooner, he would have; however,he did not think it was indicated. On cross-examination, Kammadmitted that, as with any disease, there are signs and symptoms,and that 80% of patients with mesenteric insufficiency will exhibitabdominal pain often described as out of proportion to the physicalfindings. He further agreed that blood in the stool can beconsidered a sign of mesenteric ischemia and that occult blood,not detectible by mere sight, could be found in 75% of such cases.

Dr. James Sarnelle, Snelson's medical expert, testified that heis a general and vascular surgeon familiar with intestinal surgeryand the translumbar arteriogram procedure, including its risks andcomplications. Sarnelle opined that, during Snelson's unsuccessfularteriogram, the guide wire had injured the lining of the superiormesenteric artery, which caused a blood clot to form and,"[o]vertime," led to the death of the intestines from a loss of circulation.Sarnelle testified that he was familiar with the national standard ofcare for a reasonably well-qualified general surgeon as it relatedto a patient in Snelson's condition on March 2, 1994, and opinedthat Kamm's treatment of Snelson following the unsuccessfularteriogram breached the standard of care because Kamm "did nottake any action which was necessary to save [Snelson's] smallbowel." Sarnelle reasoned: "[Snelson] has all the signs ofmesenteric ischemia. In fact, [Kamm] even mentions it in his noteat 6 o'clock that he is concerned about ischemia or thrombosis andyet he does nothing, just says will watch closely." According toSarnelle, Kamm should not have been watching Snelson closelybut instead should have immediately performed surgery to restorecirculation, which would have saved a large portion of Snelson'sintestine.

According to Sarnelle, the following signs and symptomsshould have alerted Kamm to the mesenteric ischemia: (1)Capati's indication that during the unsuccessful arteriogram theguide line went into the superior mesenteric artery; (2) Snelson'sdrop in blood pressure and abdominal pain during the procedure;(3) Snelson's need to have an immediate bowel movement duringthe procedure; (4) the bloody bowel movements following theprocedure; (5) abdominal pain that was severe enough for Kammto increase the Demerol; and (6) the distention and tenderness ofSnelson's lower abdomen during Kamm's 6 p.m. examination.

Sarnelle further opined that "a window of opportunity"existed to prevent the permanent loss of Snelson's intestine. At 6p.m., Snelson was stable enough to have surgery, and Sarnelletestified that, if revascularization surgery had been performed ina timely fashion on March 2, a large portion of Snelson's intestinecould have been salvaged and he would not now be dependent onintravenous supplemental nutrition. Sarnelle testified that the latestpoint in time that Snelson's intestines could have been saved wasmidnight on March 2, and "after that it was too late." Sarnelleexplained that, while the length of time that intestines will remainviable once blood supply is lost is variable from patient to patientand cannot be determined with 100% certainty, based on theclinical data contained in Snelson's medical records, the latesttime his intestine could have been saved was around midnight.

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 causation.Additionally, the typical patient is elderly and has troublecommunicating. However, Sarnelle testified that Snelson's casewas different because, unlike the typical patient who is admittedto the hospital several hours after the onset of pain: (1) Snelsonwas in the hospital at the time the ischemia began; (2) theproblems that developed during the unsuccessful arteriograminvolved the superior mesenteric artery; and (3) Snelson developedsigns and symptoms quickly and did not just arrive at the hospitalwith "some obscure things going on."

Sarnelle opined that Kamm breached the appropriate standardof care by ordering pain medication for Snelson. In that regard,Sarnelle stated the following:

"[Y]ou should not be giving a patient pain medicine ifyou do not know what is going on. The problem with thepain medicine is that you mask the findings, the personmay have a lot of problems going on in their abdomen,especially mesenteric ischemia you may give painmedicine and they could feel somewhat better, and youdon't know whether they are really getting better or I amjust thinking they are feeling better yet a catastrophe isbrewing."

Finally, Sarnelle acknowledged that he has been involved inapproximately 200 medical malpractice cases as a consultingexpert and witness, testifying at trial about 20 times, and in all ofthose cases he represented the plaintiffs. Sarnelle offered noopinion regarding the conduct of St. Mary's nursing staff.

On cross-examination, Sarnelle acknowledged that, dependingon the cause of mesenteric ischemia, it can sometimes take daysfor a reasonably well-qualified surgeon to diagnose that death ofthe bowels has occurred. Sarnelle also admitted that the medicalliterature does not set out certain symptoms as "classic," butexplained that the literature does not differentiate betweenarteriogram-induced mesenteric ischemia and other types, insteadlooking at "all comers." Sarnelle testified that he has performedintestinal revascularization surgery twice in his career, with onepatient living and one dying. He estimated the mortality rate forsuch surgery to be more than 50%.

Grace McCallum, Snelson's nursing expert, testified thatnurses are taught and practice the "nursing process," which is acritical thinking process that defines the standard of care that anurse should follow. McCallum opined that the nursing processwas not followed by the St. Mary's nursing staff on March 2,1994, as evidenced by: (1) the failure to initiate a nursing care planfor Snelson; (2) the failure to request that another physicianexamine Snelson on the afternoon of March 2, when Kamm wasunavailable and Snelson was experiencing abdominal pain; (3) thefailure to request a physician after Snelson had a bloody bowelmovement at 4 p.m.; (4) the failure to perform a new abdominalassessment following the bloody bowel movement; (5) the failureto document the effectiveness of the pain medication Demerol; (6)the lack of nursing notes regarding Kamm's 6 p.m. examination;(7) the failure to check all ordered vital signs during the eveningof March 2; and (8) the failure to call Kamm after checkingSnelson's vital signs around midnight on March 2. McCallumfurther opined that the failure to follow the nursing processincreases the likelihood of an unfavorable outcome. However,McCallum testified that she had no opinion as to the proximatecause of Snelson's injury.

Dr. William Pyle, a cardiac, vascular and thoracic surgeon,was one of two medical experts presented by Kamm. Pyle testifiedthat mesenteric ischemia is difficult to diagnose and that theultimate mortality rate for patients suffering a mesentericinfarction is "in excess of 90 percent." Pyle opined that Kamm metthe standard of care in his treatment of Snelson, explaining that,contrary to the assertions of Sarnelle, "there weren't enoughfindings or symptoms to justify surgery" on March 2. Indeed, afterreading the radiologist's description of the procedure, Pylebelieved that an internal dissection of the mesenteric arteryoccurred, rendering the artery like "wet tissue paper," and makingrevascularization impossible. Pyle noted that revascularizationsurgery was also not an option if the guide wire inserted during thearteriogram had produced a "showering" of small pieces of plaqueand debris which gradually plugged up the artery.

Pyle further opined that Kamm complied with the standard ofcare in prescribing pain medication to Snelson, testifying that thedoses were not high and that, in his experience, patients withmesenteric ischemia have excruciating pain that is intractable topain medication. Pyle stated that, regardless of what caused theischemia and regardless of when the revascularization surgeryoccurred, Snelson's intestines most likely could not have beensaved. On cross-examination, Pyle agreed that abdominal pain outof proportion to the physical examination findings is present inmany people with mesenteric ischemia. Other symptoms may beabdominal distension and the urge to have a bowel movement, andfindings may include blood in the stools. Pyle believed thatKamm's concern about mesenteric insufficiency at 6 p.m. wasappropriate because Snelson was then exhibiting some of the signsand symptoms of the condition. Pyle also agreed thatrevascularization was a known and practiced technique and that,if possible causes of ischemia other than dissection wereconsidered, the probability of revascularization existed, but waslow.

Dr. Philip Donahue, a general surgeon testifying as Kamm'sother medical expert, also concluded that Kamm did not breachthe standard of care in his treatment of Snelson by failing todiagnose mesenteric ischemia, prescribing pain medication orfailing to perform revascularization surgery on March 2, 1994.Donohue opined that earlier surgery was not warranted because,on the afternoon of March 2, there was "no evidence" of acutemesenteric ischemia, just a patient "with some non-specificcomplaints." While Donahue testified it was "a possibility" thatthe superior mesenteric artery was totally blocked immediatelyfollowing the arteriogram, he believed that it had occluded overtime, basing his opinion, in part, on the fact that Snelson's paindiminished after the catheterization and overnight but reemergedin the early morning.

Mary Delaney, St. Mary's nursing expert, testified that shewas familiar with the standard of care applicable to nurses undercircumstances similar to those involved here. Delaney opined thatthe nurses at St. Mary's did not violate the standard of care intreating or monitoring Snelson.

On the issue of damages, Snelson presented, inter alia, hisown testimony and that of his treating physician, Dr. RobertNewlin. Newlin testified that the function of the small intestine isto do a significant part of the digestion of food. As a result of theMarch 3, 1994, surgery during which 95% of his small intestinewas removed, Snelson suffers from "short bowel syndrome," acondition which creates diarrhea and a lack of ability to absorbsufficient nutrition and calories. Snelson must therefore rely onhyperalimentation, the intravenous infusion of a solutioncontaining sufficient nutrients to sustain him. The solution isinfused into a vein in Snelson's upper chest through a catheter; thecatheter is attached to a small machine that injects the nutritiondirectly into his body. The catheter is a foreign body and bacteriacan easily grow on it. Snelson has therefore suffered repeatedinfections of his catheter site, some of which requiredhospitalization. Newlin opined that Snelson will continue to sufferfrom diarrhea and require hyperalimentation for the rest of his life.While Newlin could not say that Snelson's short bowel syndromehad reduced his life expectancy "to a great degree," due to his"various problems," including preexisting diabetes andarteriosclerosis, Snelson "could live another ten years."

Snelson testified that, after his release from the hospital, hetook medical retirement from the railroad. He must be attached tothe hyperalimentation device for 12 hours each day, usually from9 p.m. to 9 a.m. When he unhooks the device, he must be close toa bathroom and remain there for 1 to 1