Case Title: Snelson v. Kamm

Citation: 

Docket Number: 91232, 91239

State: illinois

Court: Illinois Supreme Court

Date: 2003-03-20T00:00:00Z

Document:
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 against
defendants, Donald Kamm, M.D. (Kamm), and St. Mary's
Hospital of Decatur (St. Mary's). Following a jury trial in the
circuit court of Macon County, a verdict was returned in favor of
Snelson and against Kamm and St. Mary's in the amount of
$7 million. After a hearing on defendants' posttrial motions, the
trial court granted St. Mary's a judgment notwithstanding the
verdict (judgment n.o.v.) on the issue of proximate cause and
granted Kamm a new trial on the issue of damages, setting aside
the $7 million award. The appellate court consolidated the separate
appeals by Snelson and Kamm, and affirmed the orders of the trial
court. 319 Ill. App. 3d 116. We allowed Snelson's and Kamm's
petitions for leave to appeal (177 Ill. 2d R. 315) and also
consolidated the appeals.
	Before this court, Snelson contends that the trial court erred
by: (1) granting Kamm a new trial on the issue of damages; and
(2) granting St. Mary's motion for judgment n.o.v. Kamm
challenges certain of the trial court's rulings and the jury's verdict.
Specifically, Kamm claims: (1) he was improperly prevented from
examining Snelson's medical expert as to bias; (2) the testimony
of Snelson's medical expert should not have been admitted,
because it lacked foundation; (3) the jury was improperly
instructed; (4) certain medical bills of Snelson's were improperly
admitted into evidence; (5) the verdict was tainted by extraneous
information; (6) the verdict was against the manifest weight of the
evidence; and (7) the verdict is excessive.

BACKGROUND
	At the June 1999 jury trial, the following evidence was
adduced. In March 1994, Snelson was 58 years old and employed
as a clerk by the Illinois Central Gulf Railroad. Snelson was
referred to Kamm, a general surgeon, who suggested that Snelson
undergo a radiological procedure known as an aortogram or
arteriogram, to determine the location of arterial blockages in his
legs caused by arteriosclerosis, commonly referred to as hardening
of the arteries. Dr. Carlos Capati, a radiologist practicing at St.
Mary's, testified that, on March 2, 1999, while attempting to
perform a translumbar aortogram on Snelson, he experienced
difficulty navigating the guide wire into the thoracic aorta. It
appeared that the guide wire instead entered the superior
mesenteric artery, which supplies blood to the intestine. Capati
withdrew the translumbar needle and the guide wire and attempted
to reinsert the guide wire into the aorta. During the second attempt,
however, Snelson's blood pressure dropped, he complained of
abdominal and back pain and expressed an urge to have a bowel
movement. A portable commode was brought in and Capati
examined Snelson's stool, but did not notice any discoloration. At
that point, Capati terminated the procedure and informed Kamm
that he had been unable to complete the test and that Snelson was
complaining of back and abdominal pain.
	Snelson's son, James Snelson, testified that following the
unsuccessful aortogram, he saw his father being brought back to
his room on a stretcher, "screaming and yelling." Once in his bed,
Snelson began complaining of "a lot of pain in his stomach." He
was lying on his side "in a fetal position" with his eyes closed and
was sweating profusely. Snelson also complained of pressure in
his stomach and the need to use the bathroom. James stated that he
went to the nurses station and told them that his father needed a
catheter and one was provided at about 3 or 3:30 p.m. James
testified that he left St. Mary's late that afternoon to care for his
mother and, prior to his departure, did not see Kamm visit his
father. James stated that he spoke to his father by telephone that
evening at approximately 8 p.m., and that his father still
complained 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 at
trial had any independent recollection of the events. The nurses'
notes indicate that, following the unsuccessful aortogram, Snelson
was returned to his room at 12:40 p.m. He was complaining of
pain in his abdomen and cramping and requested a bedside
commode. A 12:44 p.m. shift assessment showed that Snelson was
alert and complaining of pain. According to the nurses' notes, the
pain rated "7" on a scale of 1 to 10. At 12:45 p.m., Snelson had a
large bowel movement and continued to complain of severe pain
across the middle of his abdomen radiating into his back. At this
point, the nurses notified Kamm of Snelson's complaints of
abdominal pain. In response, Kamm ordered by phone that
Snelson receive blood tests and pain medication, 50 milligrams
Demerol by muscular injection, every three hours as needed.
Kamm also ordered that Snelson's vital signs be taken every 15
minutes for two hours and then hourly thereafter.
	Snelson's vital signs were then checked every 15 minutes
from 12:45 p.m. to 2:30 p.m. During this period, plaintiff's
temperature stayed below normal, his respirations were normal
and remained constant. His pulse rose during the first hour and
then fell back to normal the second hour, while his blood pressure
dropped and rose throughout the period.
	The nurses charted in their flow sheet that a catheter was
inserted to empty Snelson's bladder around 3 p.m. A second shift
assessment at 3:35 p.m. showed Snelson's bowel sounds were
normal, but he continued to complain of abdominal pain. At 4
p.m., Snelson had a bowel movement with blood-tinged mucous.
The nurses immediately paged Dr. Kamm, and were advised that
he was in surgery at another hospital. Kamm called back at 4:30
p.m. and was advised by a nurse of the bloody bowel movement.
Kamm testified that he spoke with the nurse about Snelson's
condition at 4:30 p.m., and concluded that the bloody stool was
due to a mild hemorrhoid or fissure. Kamm told the nurse he
would quickly conclude his duties at the other hospital and would
proceed directly to St. Mary's.
	At 6 p.m., Kamm arrived at St. Mary's and examined Snelson
for 15 or 20 minutes. At this time, Kamm had access to the nurses'
notes, shift assessments, flow sheets and vital sign records which
had recorded Snelson's condition. Kamm noted that Snelson's
vital signs were stable, but he had passed several small blood-tinged stools and was complaining of abdominal pain and
difficulty urinating. Kamm found that Snelson's lower abdomen
was tender and distended, with diminished bowel sounds. Kamm's
notes further state the following: "Concerned about mesenteric
insufficiency or thrombo-embolus with ischemia. Will watch
closely." Kamm testified that he was not making a diagnosis of
mesenteric ischemia, or deficiency of blood circulation to the
intestinal system, but rather was "entertaining [it] as a one of the
rare possibilities" of arteriographic puncture complications.
Rather, at the time, Kamm thought that the most likely cause of
Snelson's pain was bleeding into his retroperitoneal area from the
puncture sites.
	Because Kamm believed that the fullness and tenderness in
Snelson's lower abdomen was consistent with a distended bladder,
he ordered a catheter inserted. Kamm noted that the catheter
caused 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 on
Snelson. However, the nurses' flow sheet, which Kamm had
available to him at the 6 p.m. examination, indicated that a
catheter had been inserted at 3 p.m. Kamm acknowledged that a
catheter could have been ordered before he arrived as part of a
postoperative order. At any rate, it was undisputed that the catheter
brought 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 was
therefore safe to increase his pain medication from 50 milligrams
to 100 milligrams of Demerol every four hours as needed. He
further ordered that Snelson have no food or liquids by mouth, that
the nurses check his vital signs every four hours, and that some
laboratory work be completed for the next morning. Kamm then
left St. Mary's for the evening.
	After Kamm's examination, the nurses observed Snelson at
least every hour. A nurse's notation for that evening indicates that
Snelson had a normal bowel movement and received Demerol at
7 p.m. It was also noted that Snelson slept most of the evening. He
was awake at 10 p.m., but was back asleep at 11 p.m. No
documentation exists showing that Snelson's vital signs were
taken at 10 p.m.
	Kamm conferred with the nurses before he went to bed around
10 p.m. and was advised that Snelson was stable and that they had
nothing new to report. At midnight, Snelson's vital signs were
taken. The section in the shift assessment to indicate level of pain
was not marked at that time. St. Mary's nurse Belinda Durbin
testified that at 12:45 a.m. on March 3, she administered 100
milligrams of Demerol to Snelson because he was having some
pain. She further noted, however, that if he had been experiencing
severe pain she would have made a notation of that fact in the
records. At 4 a.m., Snelson's vital signs were taken again.
	Kamm returned to the hospital on March 3, 1994, and
examined Snelson between 6 and 6:30 a.m. It appeared to Kamm
that Snelson had not improved over the prior 18 hours, and he had
an abnormally high white blood cell count. Over the next four
hours, a computerized tomography (CT) scan and abdominal X
rays were taken, which showed definite abnormalities, including
the presence of air in Snelson's small intestine. Capati, who
interpreted the CT scan and X rays, testified that the results were
consistent with "small and large bowel infarction," which meant
that parts of Snelson's small and large bowel loops were
gangrenous or dead. Capati further testified that the most likely
cause of that condition was "acute embolism and thrombosis
involving the superior mesenteric artery," meaning that a plaque
or clot moving within the blood vessel, or a preexisting plaque or
clot, had blocked the superior mesenteric artery. Capati opined that
the unsuccessful translumbar aortogram caused the death of
portions of Snelson's intestine.
	 Kamm performed emergency exploratory surgery on Snelson
later that morning and found that almost all of his small intestine
and half of his large intestine were dead due to lack of blood
circulation to the area. It was therefore necessary to remove
approximately 95% of Snelson's small intestine and the right half
of his large intestine. Snelson was discharged from St. Mary's on
March 21, 1994.
	With regard to this cause of action, Kamm testified that the
nurses had adequately observed Snelson and reported to him
everything that he needed to know about Snelson's condition
following the unsuccessful aortogram. He further stated that, if he
had wanted to perform surgery sooner, he would have; however,
he did not think it was indicated. On cross-examination, Kamm
admitted that, as with any disease, there are signs and symptoms,
and that 80% of patients with mesenteric insufficiency will exhibit
abdominal pain often described as out of proportion to the physical
findings. He further agreed that blood in the stool can be
considered 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 he
is a general and vascular surgeon familiar with intestinal surgery
and the translumbar arteriogram procedure, including its risks and
complications. Sarnelle opined that, during Snelson's unsuccessful
arteriogram, the guide wire had injured the lining of the superior
mesenteric artery, which caused a blood clot to form and,"[o]ver
time," led to the death of the intestines from a loss of circulation.
Sarnelle testified that he was familiar with the national standard of
care for a reasonably well-qualified general surgeon as it related
to a patient in Snelson's condition on March 2, 1994, and opined
that Kamm's treatment of Snelson following the unsuccessful
arteriogram breached the standard of care because Kamm "did not
take any action which was necessary to save [Snelson's] small
bowel." Sarnelle reasoned: "[Snelson] has all the signs of
mesenteric ischemia. In fact, [Kamm] even mentions it in his note
at 6 o'clock that he is concerned about ischemia or thrombosis and
yet he does nothing, just says will watch closely." According to
Sarnelle, Kamm should not have been watching Snelson closely
but instead should have immediately performed surgery to restore
circulation, which would have saved a large portion of Snelson's
intestine.
	According to Sarnelle, the following signs and symptoms
should have alerted Kamm to the mesenteric ischemia: (1)
Capati's indication that during the unsuccessful arteriogram the
guide line went into the superior mesenteric artery; (2) Snelson's
drop in blood pressure and abdominal pain during the procedure;
(3) Snelson's need to have an immediate bowel movement during
the procedure; (4) the bloody bowel movements following the
procedure; (5) abdominal pain that was severe enough for Kamm
to increase the Demerol; and (6) the distention and tenderness of
Snelson'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 6
p.m., Snelson was stable enough to have surgery, and Sarnelle
testified that, if revascularization surgery had been performed in
a timely fashion on March 2, a large portion of Snelson's intestine
could have been salvaged and he would not now be dependent on
intravenous supplemental nutrition. Sarnelle testified that the latest
point in time that Snelson's intestines could have been saved was
midnight on March 2, and "after that it was too late." Sarnelle
explained that, while the length of time that intestines will remain
viable once blood supply is lost is variable from patient to patient
and cannot be determined with 100% certainty, based on the
clinical data contained in Snelson's medical records, the latest
time his intestine could have been saved was around midnight.
	Sarnelle acknowledged that, generally, acute mesenteric
ischemia is very difficult to diagnose because the typical patient
has an onset of abdominal pain with no clear history of causation.
Additionally, the typical patient is elderly and has trouble
communicating. However, Sarnelle testified that Snelson's case
was different because, unlike the typical patient who is admitted
to the hospital several hours after the onset of pain: (1) Snelson
was in the hospital at the time the ischemia began; (2) the
problems that developed during the unsuccessful arteriogram
involved the superior mesenteric artery; and (3) Snelson developed
signs and symptoms quickly and did not just arrive at the hospital
with "some obscure things going on."
	Sarnelle opined that Kamm breached the appropriate standard
of care by ordering pain medication for Snelson. In that regard,
Sarnelle stated the following:
		"[Y]ou should not be giving a patient pain medicine if
you do not know what is going on. The problem with the
pain medicine is that you mask the findings, the person
may have a lot of problems going on in their abdomen,
especially mesenteric ischemia you may give pain
medicine and they could feel somewhat better, and you
don't know whether they are really getting better or I am
just thinking they are feeling better yet a catastrophe is
brewing."
	Finally, Sarnelle acknowledged that he has been involved in
approximately 200 medical malpractice cases as a consulting
expert and witness, testifying at trial about 20 times, and in all of
those cases he represented the plaintiffs. Sarnelle offered no
opinion regarding the conduct of St. Mary's nursing staff.
	On cross-examination, Sarnelle acknowledged that, depending
on the cause of mesenteric ischemia, it can sometimes take days
for a reasonably well-qualified surgeon to diagnose that death of
the bowels has occurred. Sarnelle also admitted that the medical
literature does not set out certain symptoms as "classic," but
explained that the literature does not differentiate between
arteriogram-induced mesenteric ischemia and other types, instead
looking at "all comers." Sarnelle testified that he has performed
intestinal revascularization surgery twice in his career, with one
patient living and one dying. He estimated the mortality rate for
such surgery to be more than 50%.
	Grace McCallum, Snelson's nursing expert, testified that
nurses are taught and practice the "nursing process," which is a
critical thinking process that defines the standard of care that a
nurse should follow. McCallum opined that the nursing process
was not followed by the St. Mary's nursing staff on March 2,
1994, as evidenced by: (1) the failure to initiate a nursing care plan
for Snelson; (2) the failure to request that another physician
examine Snelson on the afternoon of March 2, when Kamm was
unavailable and Snelson was experiencing abdominal pain; (3) the
failure to request a physician after Snelson had a bloody bowel
movement at 4 p.m.; (4) the failure to perform a new abdominal
assessment following the bloody bowel movement; (5) the failure
to 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 evening
of March 2; and (8) the failure to call Kamm after checking
Snelson's vital signs around midnight on March 2. McCallum
further opined that the failure to follow the nursing process
increases the likelihood of an unfavorable outcome. However,
McCallum testified that she had no opinion as to the proximate
cause of Snelson's injury.
	Dr. William Pyle, a cardiac, vascular and thoracic surgeon,
was one of two medical experts presented by Kamm. Pyle testified
that mesenteric ischemia is difficult to diagnose and that the
ultimate mortality rate for patients suffering a mesenteric
infarction is "in excess of 90 percent." Pyle opined that Kamm met
the standard of care in his treatment of Snelson, explaining that,
contrary to the assertions of Sarnelle, "there weren't enough
findings or symptoms to justify surgery" on March 2. Indeed, after
reading the radiologist's description of the procedure, Pyle
believed that an internal dissection of the mesenteric artery
occurred, rendering the artery like "wet tissue paper," and making
revascularization impossible. Pyle noted that revascularization
surgery was also not an option if the guide wire inserted during the
arteriogram had produced a "showering" of small pieces of plaque
and debris which gradually plugged up the artery.
	Pyle further opined that Kamm complied with the standard of
care in prescribing pain medication to Snelson, testifying that the
doses were not high and that, in his experience, patients with
mesenteric ischemia have excruciating pain that is intractable to
pain medication. Pyle stated that, regardless of what caused the
ischemia and regardless of when the revascularization surgery
occurred, Snelson's intestines most likely could not have been
saved. On cross-examination, Pyle agreed that abdominal pain out
of proportion to the physical examination findings is present in
many people with mesenteric ischemia. Other symptoms may be
abdominal distension and the urge to have a bowel movement, and
findings may include blood in the stools. Pyle believed that
Kamm's concern about mesenteric insufficiency at 6 p.m. was
appropriate because Snelson was then exhibiting some of the signs
and symptoms of the condition. Pyle also agreed that
revascularization was a known and practiced technique and that,
if possible causes of ischemia other than dissection were
considered, the probability of revascularization existed, but was
low.
	Dr. Philip Donahue, a general surgeon testifying as Kamm's
other medical expert, also concluded that Kamm did not breach
the standard of care in his treatment of Snelson by failing to
diagnose mesenteric ischemia, prescribing pain medication or
failing 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 acute
mesenteric ischemia, just a patient "with some non-specific
complaints." While Donahue testified it was "a possibility" that
the superior mesenteric artery was totally blocked immediately
following the arteriogram, he believed that it had occluded over
time, basing his opinion, in part, on the fact that Snelson's pain
diminished after the catheterization and overnight but reemerged
in the early morning.
	Mary Delaney, St. Mary's nursing expert, testified that she
was familiar with the standard of care applicable to nurses under
circumstances similar to those involved here. Delaney opined that
the nurses at St. Mary's did not violate the standard of care in
treating or monitoring Snelson.
	On the issue of damages, Snelson presented, inter alia, his
own testimony and that of his treating physician, Dr. Robert
Newlin. Newlin testified that the function of the small intestine is
to do a significant part of the digestion of food. As a result of the
March 3, 1994, surgery during which 95% of his small intestine
was removed, Snelson suffers from "short bowel syndrome," a
condition which creates diarrhea and a lack of ability to absorb
sufficient nutrition and calories. Snelson must therefore rely on
hyperalimentation, the intravenous infusion of a solution
containing sufficient nutrients to sustain him. The solution is
infused into a vein in Snelson's upper chest through a catheter; the
catheter is attached to a small machine that injects the nutrition
directly into his body. The catheter is a foreign body and bacteria
can easily grow on it. Snelson has therefore suffered repeated
infections of his catheter site, some of which required
hospitalization. Newlin opined that Snelson will continue to suffer
from diarrhea and require hyperalimentation for the rest of his life.
While Newlin could not say that Snelson's short bowel syndrome
had reduced his life expectancy "to a great degree," due to his
"various problems," including preexisting diabetes and
arteriosclerosis, Snelson "could live another ten years."
	Snelson testified that, after his release from the hospital, he
took medical retirement from the railroad. He must be attached to
the hyperalimentation device for 12 hours each day, usually from
9 p.m. to 9 a.m. When he unhooks the device, he must be close to
a bathroom and remain there for 1 to 1½ hours. Snelson testified
that he suffers from chronic diarrhea and must use the bathroom
15 to 20 times each day, consuming most of his waking hours. The
hyperalimentation bag weighs between 10 and 15 pounds and must
be kept refrigerated. There are numerous steps which must be
taken to prepare the bag on a daily basis, including the entering of
nutrients and vitamins; the preparation takes 20 to 30 minutes to
perform. Sometimes the nutrient solution causes him pain as it
enters the catheter, and he requires help from family members to
maintain the catheter and catheter site. Snelson has spent a total of
almost 1½ years in the hospital since June 1994, mostly for
infections of his catheter site. A typical infection which leads to a
hospital stay for a catheter change involves chills, a high fever and
vomiting. He has had his catheter changed approximately 20
times; the catheter removal can be painful, as are the intravenous
antibiotics used for these infections.
	 Snelson further testified that, because of the
hyperalimentation, he must "pretty well stay at home." Although
he can eat regular food, the portions must be small and he cannot
eat certain foods, such as salad, green beans or corn, or even enjoy
his favorite drink, Kool-Aid, because those items are eliminated
by his body quickly and mostly unchanged. Snelson acknowledged
that, even before the March 3, 1994, surgery, the arteriosclerosis
made it hard to walk, restricting his ability to engage in daily
activities. Snelson stated that he still hunts and travels to
Minnesota to fish and to Indiana to see his daughter. However, if
he chooses to do anything during the day, he must be attached to
the bag during that time and then have the elimination process
occur at night, possibly resulting in his soiling himself in bed.
	In addition to this testimony, Snelson presented as economic
damages a medical bill summary totaling $595,766.35, and a lost-wage claim of approximately 2½ years with a 1993 wage rate of
$32,130.85. For purposes of his disfigurement claim, Snelson
showed the jury the catheter site on his chest where the
hyperalimentation device attaches to his body.
	Based on this evidence, the jury returned a verdict in
Snelson's favor and against both Kamm and St. Mary's, awarding
$7 million. Because the completed verdict form contained only the
total damage award, the trial court instructed the jury to return to
its deliberations in order to itemize the verdict. Approximately 20
minutes later, the jury returned with a verdict in the same amount,
itemized as follows: (1) $600,000 for past medical expenses; (2)
$1.1 million for future medical expenses; (3) $3 million for pain
and suffering; (4) $2 million for loss of normal life; (5) $80,000
for lost earnings; and (6) $220,000 for disfigurement.
	The appellate court majority affirmed the trial court's grant of
a new trial on the issue of damages for Kamm and judgment n.o.v.
for St. Mary's. Justice Cook, in dissent, would have reinstated the
jury's award of $7 million in damages. The panel upheld the jury's
verdict in favor of Snelson and against Kamm, rejecting Kamm's
claims that a variety of trial errors had prejudiced him. This appeal
followed.

ANALYSIS
	We first address Kamm's claims of trial error. Kamm argues
that the trial court erred by granting Snelson's motion in limine
barring him from cross-examining Snelson's expert, Sarnelle,
regarding his relationship with a professional witness referral
agency, Sappanaro, Inc. It is true that, generally, opposing counsel
may probe bias, partisanship or financial interest of an expert
witness on cross-examination. Sears v. Rutishauser, 102 Ill. 2d 402, 407 (1984). However, we agree with the appellate court that
Kamm's failure to make an adequate offer of proof has resulted in
a waiver of this issue on appeal. See People v. Andrews, 146 Ill. 2d 413, 422 (1992); Sinclair v. Berlin, 325 Ill. App. 3d 458, 471
(2001).
	When a motion in limine is granted, the key to saving for
review an error in the exclusion of evidence is an adequate offer
of proof in the trial court. See Sinclair, 325 Ill. App. 3d at 471.
Counsel makes an adequate offer of proof if he informs the trial
court, with particularity, of the substance of the witness'
anticipated answer; an offer of proof that merely summarizes the
witness' testimony in a conclusory manner is inadequate. Andrews,
146 Ill. 2d  at 421. Here, a review of the record reveals no adequate
offer of proof, only the following statement from Kamm's written
response to the motion in limine: "The testimony of the experts for
[Snelson] is that they have received other referrals from
Sappanaro." Given this sparse information, there is no way for this
court to determine if the excluded evidence had any relevance to
the proceeding. See Andrews,146 Ill. 2d  at 421 (an offer of proof
serves no purpose if it does not demonstrate, both to the trial court
and to reviewing courts, the admissibility of the testimony which
was foreclosed). However, the record does show that the trial court
allowed Kamm to cross-examine Sarnelle as to the frequency of
his plaintiff-oriented testimony and to argue to the jury his alleged
bias and financial interest. Thus, where counsel failed to explicitly
state what the excluded testimony would reveal about Sarnelle's
relationship with Sappanaro, Inc., we have no basis upon which to
conclude that the trial court erred in restricting Kamm's cross-examination of Sarnelle. See Holder v. Caselton, 275 Ill. App. 3d
950, 955 (1995).
	Next, Kamm argues that Sarnelle's testimony should be
disregarded as lacking foundation. Kamm claims that Sarnelle
failed "to ground his opinions in generally-accepted scientific
principles."
	The decision of whether to admit expert testimony is within
the sound discretion of the trial court (People v. Miller, 173 Ill. 2d 167, 187 (1996)), and a ruling will not be reversed absent an abuse
of that discretion (People v. Reid, 179 Ill. 2d 297, 313 (1997)).
Expert testimony is admissible if the proffered expert is qualified
by knowledge, skill, experience, training, or education, and the
testimony will assist the trier of fact in understanding the evidence.
See Wiegman v. Hitch-Inn Post of Libertyville, Inc., 308 Ill. App.
3d 789, 799 (1999). Here, Sarnelle testified to his credentials and
Kamm admits that they were sufficient to qualify Sarnelle as an
expert.
	At trial, Kamm failed to either object to the admissibility of
Sarnelle's testimony or file a motion for an evidentiary hearing to
determine its admissibility under Frye v. United States, 293 F. 1013 (D.C. Cir. 1923). See Donaldson v. Central Illinois Public
Service Co., 199 Ill. 2d 63, 76-77 (2002) (the admission of expert
testimony is governed by the standards expressed in Frye, which
dictates that scientific evidence is only admissible at trial if the
methodology or scientific principle upon which the opinion is
based is " 'sufficiently established to have gained general
acceptance in the particular field in which it belongs' "), quoting
Frye, 293 F.  at 1014. Because the record shows that Kamm did not
object to the underlying foundation of Sarnelle's testimony at trial,
we find that this issue has been forfeited on appeal. See People v.
Moore, 171 Ill. 2d 74, 98 (1996) (defendant waived Frye issue by
failing to present expert testimony at Frye hearing); see also Reed
v. Northwestern Publishing Co., 124 Ill. 2d 495, 519 (1988) (a
party waives evidentiary issues by failing to object at trial).
	Citing Kleiss v. Cassida, 297 Ill. App. 3d 165, 174 (1998),
and Aguilera v. Mount Sinai Hospital Medical Center, 293 Ill.
App. 3d 967 (1997), Kamm argues that, despite his failure to
object to the complained-of testimony, the trial court should have
entered judgment n.o.v. in his favor because of the alleged
deficiencies in the testimony. We disagree. Both Kleiss and
Aguilera are distinguishable and do not support Kamm's position.
	In Kleiss, the plaintiff farmer alleged that his crops were
damaged by the defendant's spraying of herbicide on nearby
farms. The plaintiff's expert testified that the herbicide could have
traveled two miles in the air to the plaintiff's property. However,
the expert had no reasons whatsoever for his opinion other than
"20 to 30 years experience." In affirming judgment n.o.v. for the
defendant, the appellate court held that "[w]hen an expert testifies
simply that plaintiff should win but is unable to support that
conclusion with reasoned analysis, the expert's testimony is
worthless, provides no assistance to the jury, and should be
stricken." Kleiss, 297 Ill. App. 3d at 174. In contrast to the expert
in Kleiss, Sarnelle's testimony was replete with reasoned analysis
supporting his opinions. Sarnelle carefully explained that his
opinions were based on the clinical data contained in Snelson's
medical records such as the onset and severity of pain, the vital
signs, the appearance of blood in the stools, and that Snelson had
been in the hospital having a procedure done in the area of his
mesenteric artery when his problems began.
	In Aguilera, the plaintiff's decedent was taken to the
emergency room complaining of numbness on the right side of his
body. About six or seven hours later, a CT scan was taken,
revealing a brain hemorrhage. The patient died a few days later.
The plaintiff presented two experts who testified that the
emergency room physician's delay in taking the CT scan caused
the decedent's death. It was the plaintiff's theory that a diagnosis
of the condition would have triggered surgical intervention to
prevent the decedent's death. However, on cross-examination the
plaintiff's experts admitted that they would defer to a
neurosurgeon as to whether surgery should have even been
performed, yet the only neurosurgeons testifying in the case stated
that surgery would not have been appropriate. The appellate court
held that a directed verdict for the defendant was proper because,
without supporting testimony from a neurosurgeon, the plaintiff's
expert's testimony was insufficient to show that surgery would
have occurred absent defendant's conduct. Aguilera, 293 Ill. App.
3d at 975. Here, in contrast, there was no question that Sarnelle
was qualified to render the opinions he offered at trial, and there
was no missing link failing to establish all of the elements of
Snelson's case.
	While Kamm contends that Sarnelle's opinions were not
adequately supported, the basis for a witness' opinion generally
does not affect his standing as an expert; such matters go only to
the weight of the evidence, not its sufficiency. See National Bank
of Monticello v. Doss, 141 Ill. App. 3d 1065, 1072 (1986). Indeed,
the weight to be assigned to an expert opinion is for the jury to
determine in light of the expert's credentials and the factual basis
of his opinion. See Wiegman, 308 Ill. App. 3d at 799; Treadwell
v. Downey, 209 Ill. App. 3d 999, 1003 (1991).
	In Wilson v. Clark, 84 Ill. 2d 186, 194 (1981), this court held
that an expert may give an opinion without disclosing the
underlying facts or data. Rather, the burden is placed upon the
adverse party during cross-examination to elicit the facts
underlying the expert opinion. Wilson, 84 Ill. 2d  at 194. Here, as
the appellate court noted, "Kamm conducted a vigorous cross-examination of Sarnelle, challenging the bases and soundness of
his opinions." 319 Ill. App. 3d at 136. Thus, it was up to Kamm to
reveal any alleged deficiency in Sarnelle's testimony, a fact which
the trial court recognized in denying Kamm's motion for judgment
n.o.v., stating: "[T]he criticism of Dr. Sarnelle by [Kamm] really
goes to the weight of the evidence or testimony presented by him,
and I believe that was all argued to the jury at the time. I think
suffice it to say that the jury had the option of accepting the
testimony of either side's expert witnesses ***." The trial court
did not err in this regard.
	Kamm further contends that the trial court erred by giving
certain jury instructions at Snelson's request. However, the
plaintiff has the right to have the jury clearly and fairly instructed
on any theory supported by the evidence. Leonardi v. Loyola
University, 168 Ill. 2d 83, 100 (1995). This court, in Leonardi,
further stated:
		"The question of what issues have been raised by the
evidence is within the discretion of the trial court. The
evidence may be slight; a reviewing court may not
reweigh it or determine if it should lead to a particular
conclusion. [Citation.] The test in determining the
propriety of tendered instructions is whether the jury was
fairly, fully, and comprehensively informed as to the
relevant principles, considering the instructions in their
entirety." Leonardi, 168 Ill. 2d  at 100.
	Kamm first argues that Snelson's instruction No. 26, alleging
Kamm's negligence in "prescribing pain medication to Robert
Snelson once he was concerned with mesenteric insufficiency,"
was improper because Sarnelle never testified that Snelson
suffered any injury from the prescription of pain medication. It
was Snelson's theory at trial that administering pain medication in
his case was a deviation from the standard of care because such
medication made his condition more difficult to diagnose. Sarnelle
testified that, in his opinion, based on a reasonable degree of
medical and surgical certainty, no pain medication should have
been given to a patient in Snelson's condition because it "may
mask the findings." Additionally, Donahue and Kamm himself
testified that Demerol, the pain medication which Kamm
prescribed for Snelson, is a narcotic analgesic that can cause
sedation and that the patient's condition can be reassessed only
when the medication "wears off." Because the instant case
involved a failure to timely diagnose, we find that there was
sufficient support for Snelson's theory and that no abuse of the
trial court's discretion occurred in giving this instruction. See
Holton v. Memorial Hospital, 176 Ill. 2d 95, 119 (1997) (to the
extent a plaintiff's chance of recovery or survival is lessened by
the malpractice, he should be able to present evidence to a jury
that the defendant's malpractice, to a reasonable degree of medical
certainty, proximately caused the increased risk of harm or lost
chance of recovery).
	Kamm further argues that he was prejudiced when, over his
objection, the trial court gave Snelson's instructions based on
Illinois Pattern Jury Instructions, Civil, Nos. 1.03, 1.04, B45.03.A,
30.01 (1995) (hereinafter IPI Civil (1995)). We first address
Snelson's instruction No. 3, which provided: "A fact may be
proved by circumstantial evidence. Circumstantial evidence
consists of proof of facts or circumstances which give rise to a
reasonable inference of the truth of the facts sought to be proved."
IPI Civil (1995) No. 1.03. Kamm contends that there was no
circumstantial evidence concerning him presented in this case.
However, Kamm's expert, Donahue, testified that part of the basis
for his opinion that the occlusion of the blood supply was not
immediate was that Snelson's pain had diminished following the
catheterization and then reemerged the next morning. Therefore,
if Snelson's pain had not actually diminished overnight, the factual
basis for Donahue's opinion was weakened. To that end, and
because no direct evidence existed, Snelson presented
circumstantial evidence as to his level of pain after midnight on
March 2. Nurse Durbin testified that, while the medical records
did not show Snelson's level of pain during the midnight shift
assessment, at 12:45 a.m. Snelson received 100 milligrams of
Demerol and that Snelson was therefore in pain at that time. In
Illinois, in a civil case where any of the evidence is circumstantial
a party is entitled to an instruction on circumstantial evidence. See
Kane v. Northwest Special Recreation Ass'n, 155 Ill. App. 3d 624,
630 (1987). We therefore agree with the appellate court that the
trial court, in the case at bar, did not err in giving IPI Civil (1995)
No. 1.03.
	Kamm further argues that IPI Civil (1995) No. 1.04, regarding
a juror's life experiences, was improperly given. Snelson's
instruction No. 4 provided: "In considering the evidence in this
case you are not required to set aside your observation and
experience in the affairs of life but you have a right to consider all
the evidence in the light of your own observation and experience
in the affairs of life." IPI Civil (1995) No. 1.04. Kamm argues that
the jury should not have received this instruction because jurors
may not attempt to resolve issues of medical malpractice from any
personal knowledge they may possess. See IPI Civil (1995) No.
105.02. However, jurors are allowed to use their own observation
and experience in assessing damages. See Baird v. Chicago,
Burlington & Quincy R.R. Co., 63 Ill. 2d 463, 472-73 (1976).
Therefore, where the record clearly shows that the jurors were also
instructed that they could not use their personal knowledge to
determine the issues of professional negligence (see IPI Civil
(1995) No. 105.02), the trial court did not abuse its discretion in
giving IPI Civil (1995) No. 1.04.
	Kamm also contends that the trial court erred by giving
Snelson's instruction No. 20, a verdict form that provided, in
pertinent part, as follows:
			"We find that the total amount of damages suffered by
Robert Snelson as a proximate cause of the occurrence in
question is itemized as follows:
* * *
		The pain and suffering experienced and reasonably certain
to be experienced in the future as a result of the injuries
***." See IPI Civil (1995) Nos. B45.03.A, 30.05.
Kamm argues that there was no competent evidence to support an
award for future pain and suffering, "as no party testified that
[Snelson] was reasonably certain to experience pain and suffering
in the future as a result of injuries allegedly caused by Dr. Kamm."
However, at trial Snelson testified that he suffers from chronic
diarrhea, that he sometimes experiences pain when the nutrients
enter his body through the hyperalimentation catheter, and that he
has experienced sickness and pain in association with the repeated
infections and replacements of his catheter. This evidence was
sufficient to warrant giving Snelson's instruction No. 20, and we
therefore agree with the appellate court that the trial court did not
abuse its discretion by submitting it to the jury. See Leonardi, 168 Ill. 2d  at 100 (plaintiff has the right to have the jury clearly and
fairly instructed on any theory supported by the evidence).
	Finally, Kamm contends that the trial court erred by giving a
modified version of IPI Civil No. 30.01 that replaced "disability"
as an element of damages with "loss of a normal life." We note
that the portion of the instruction at issue is actually contained in
IPI Civil (1995) No. 30.04, which is one of a number of "element
of damages" phrases that may be inserted between the two
paragraphs of IPI Civil No. 30.01 to complete that general
damages instruction. See IPI Civil (1995) Nos. 30.01, 30.04, Notes
on Use. Kamm argues that it was error to use this modified
instruction, first proposed in Smith v. City of Evanston, 260 Ill.
App. 3d 925 (1994), because the Smith version was not an
approved instruction at the time of the instant trial, citing Supreme
Court Rule 239(a) (177 Ill. 2d R. 239(a)).
	Rule 239(a) provides that whenever IPI contains an
instruction applicable in a civil case, and the court determines that
the jury should be instructed on the subject, the IPI instruction
shall be used, unless the court determines that it does not
accurately state the law. 177 Ill. 2d R. 239(a). However, the notes
on use for IPI Civil (1995) No. 30.04, which were available at the
time of the 1999 trial, state: "If the trial court rules that the Smith
case is applicable, then the phrase 'loss of a normal life' may be
substituted for the term 'disability.' " IPI Civil (1995) No. 30.04,
Notes on Use. Indeed, since the instant case has been on appeal,
the IPI committee has formally adopted "loss of a normal life" as
an accepted alternative to "disability" where the trial court
determines that "loss of a normal life" more accurately describes
the element of damages claimed and would be less confusing to
the jury. See IPI Civil (2000) No. 30.04.01, Notes on Use. Here,
the trial court, after lengthy discussion at the instructions
conference, agreed with Snelson that the loss of a normal life
instruction was appropriate. Thus, the trial court complied with
Rule 239(a), because it gave the modified instruction believing it
to more accurately state the applicable law. Further, while the trial
judge later stated, in ruling on posttrial motions, that he believed
his decision to give the modified instruction was "in error," he
reasoned that this was because "loss of a normal life is merely a
component of a compensable damage element and not an
independent element in and of itself." To the contrary, loss of a
normal life has been recognized as a separate element of
compensable damages in Illinois. See Turner v. Williams, 326 Ill.
App. 3d 541, 551 (2001).
	Kamm also claims prejudice from the use of the loss of a
normal life instruction, arguing that "the extremely subjective
nature of this element may have allowed the jury to decide issues
in this case on the basis of sympathy rather than the testimony and
evidence." Not only is this argument speculative, but it is
repudiated by the addition of the element to the IPI instructions.
See Turner, 326 Ill. App. 3d at 551 (the addition of IPI Civil
(2000) No. 30.04.01, which allows either loss of a normal life or
disability to be given as an instruction, depending on the nature of
the evidence at trial, illustrates that the use of an instruction on
loss of a normal life is not contrary to Illinois law). Therefore,
where Kamm has failed to show error or prejudice in the giving of
the modified instruction, we see no abuse of the trial court's
discretion requiring reversal. See Thompson v. MCA Distributing,
Music Corp. of America, 257 Ill. App. 3d 988, 991 (1994) (a new
trial will be granted because of improper jury instructions only
where the party has suffered serious prejudice from the offending
instruction).
	We next address Kamm's contention that the trial court erred
by admitting into evidence Snelson's exhibit No. 16, a summary
of his medical bills covering five years and many different
providers, which totalled $595,766.35. Kamm claims that this
exhibit included "all" of Snelson's medical bills incurred since
entering St. Mary's on March 2, 1994, and that no attempt was
made to separate and distinguish the medical expenses he incurred
for treatment of his preexisting health problems. However, we
reject this claim based on Snelson's uncontradicted testimony that
the summary included only bills received for medical services
related to his intestinal problem, including those costs and
problems associated with hyperalimentation.
	Kamm also argues that the exhibit did not distinguish those
medical expenses Snelson claimed were due to Kamm's alleged
medical negligence from those Snelson would have incurred had
a successful revascularization occurred. While Kamm contends
that he objected to the "totality of the bills," we agree with the
appellate court that the record reveals he specifically objected to
only two bills contained in the summary: (1) the initial
hospitalization bill from St. Mary's, for $52,814.59; and (2) a bill
from Dr. Thomas Fulbright, a neurologist, for $471. The record
further shows that Snelson's counsel suggested that the summary
might be changed to delete Fulbright's bill and the objectionable
portions of the hospital bill, and then the following colloquy
occurred:
			"MR. KEHART [Kamm's counsel]: I just wanted to
preserve my objection.
			THE COURT: At this point it is going to be admitted
and then we will work out the details of what gets back to
[the jury] later."
However, neither the trial court nor any of the parties ever raised
the issue again and Snelson's exhibit No. 16 was admitted
unchanged.
	The admission of evidence is within the sound discretion of
the trial court and a reviewing court will not reverse the trial court
unless that discretion was clearly abused. Gill v. Foster, 157 Ill. 2d 304, 312-13 (1993). We acknowledge that,"[i]n proving damages,
the burden is on the plaintiff to establish a reasonable basis for
computing damages." Gill, 157 Ill. 2d  at 313. Here, however,
Snelson suggested deleting those medical charges that Kamm
claimed were not causally related to his alleged negligence, and
Kamm not only failed to accept this suggestion when it was made,
but failed to reassert his objection later, allowing the unaltered
exhibit to go to the jury. Accordingly, we hold that any valid
objection Kamm may have had for admitting the medical bills into
evidence was waived by his failure to make specific contemporary
objections at trial so that any defect could have been cured. See
Janisco v. Kozloski, 261 Ill. App. 3d 963, 966 (1994); see also
Simmons v. Garces, 198 Ill. 2d 541, 567 (2002) (failure to object
in a timely manner waives objections).
	Kamm also argues that the jury verdict was "irrevocably
tainted" because the jury considered "extra-judicial information."
We reject this contention, as it is not supported by the record and
is based solely on the jury's submission of the following question
to the trial court during deliberations: "Was it possible a Break
[sic] Brachial Arteriogram could have been preformed [sic] once
Dr. Kamm was concerned with mecenteric [sic] insufficiency? or
any procedure that could have shown blockage or reduced
circulations [sic]?"
	It is true that independent investigation by the jury may
constitute error so prejudicial as to require reversal. See People v.
Holmes, 69 Ill. 2d 507, 519 (1978); Johnson v. Danville Cash &
Carry Lumber Co., 200 Ill. App. 3d 196, 199 (1990). In order to
set aside a verdict, however, the losing party must show
"competent and credible evidence of an improper external
influence on the jury." Johnson, 200 Ill. App. 3d at 199. In the
instant case, we find, as did the appellate court, that Kamm does
not support his claim with any evidence that the jury acted
improperly. 319 Ill. App. 3d at 144. Rather, Kamm contends that
the jury's question shows that it considered extraneous
information because "[n]o witness, even Dr. Sarnelle, opined that
a second or 'brachial arteriogram' should have been attempted."
However, Sarnelle did testify that, rather than a translumbar
arteriogram, he preferred "a different route *** into the brachial
artery, which is in the arm." Sarnelle further testified that when
Kamm became concerned about ischemia following his
examination of Snelson on March 2, he could have done an
arteriogram where he would "go in through the arm to see the
circulation." Kamm's claim must therefore be rejected because it
is unsubstantiated by any "competent and credible" evidence and
the record shows that the jury could have formulated its question
based on the evidence presented at trial.
	Kamm also argues that the jury's verdict was against the
manifest weight of the evidence, contending that "all of the
credible evidence on the applicable standard of care supported
only a verdict in favor of Dr. Kamm." Again, we disagree.
	It is well established that, in an appeal from a jury verdict, a
reviewing court may not simply reweigh the evidence and
substitute its judgment for that of the jury. Rhodes v. Illinois
Central Gulf R.R., 172 Ill. 2d 213, 242 (1996); Doser v. Savage
Manufacturing & Sales, Inc., 142 Ill. 2d 176, 189-90 (1990).
Indeed, a reviewing court may reverse a jury verdict only if it is
against the manifest weight of the evidence. Rhodes, 172 Ill. 2d  at
242. A verdict is against the manifest weight of the evidence
where the opposite conclusion is clearly evident or where the
findings of the jury are unreasonable, arbitrary, and not based upon
any of the evidence. Leonardi v. Loyola University of Chicago,
168 Ill. 2d 83, 106 (1995); Maple v. Gustafson, 151 Ill. 2d 445,
454 (1992).
	Here, Snelson's medical expert, Sarnelle, testified, inter alia,
that, based upon a reasonable degree of medical certainty, had
there been surgery in a timely fashion on March 2, a large portion
of Snelson's intestines could have been saved and he would not
require hyperalimentation to survive. In turn, Kamm's experts,
Pyle and Donahue, testified that, even had revascularization been
attempted on March 2, the surgery would not have been
successful. As we earlier found, and contrary to Kamm's assertion,
we see no "scientific poverty" in Sarnelle's testimony that would
put the jury's verdict in doubt. Rather, as the appellate court so
aptly stated:
			"This case involved a classic battle of the experts.
Witnesses qualified in their fields stated their opinions
and gave their reasons for those opinions. Not
surprisingly, the plaintiff's experts did not agree with the
defense experts. The jury needed to listen to the
conflicting evidence and use its best judgment to
determine where the truth could be found. The jury found
in favor of Snelson and against Kamm, and this court
'should not usurp the function of the jury and substitute
its judgment on questions of fact fairly submitted, tried,
and determined from the evidence which did not greatly
preponderate either way.' Maple, 151 Ill. 2d  at 452-53."
319 Ill. App. 3d at 145.
	We now address Snelson's argument that the trial court
abused its discretion by ordering a new trial on the issue of
damages. The determination of whether a new trial should be
granted rests within the sound discretion of the trial court, whose
ruling will not be reversed unless it reflects an abuse of that
discretion. Maple, 151 Ill. 2d  at 455; Reidelberger v. Highland
Body Shop, Inc., 83 Ill. 2d 545, 548 (1981). "If the trial judge, in
the exercise of his discretion, finds that the verdict is against the
manifest weight of the evidence, he should grant a new trial; on
the other hand, where there is sufficient evidence to support the
verdict of the jury, it constitutes an abuse of discretion for the trial
court to grant a motion for a new trial." Maple, 151 Ill. 2d  at 456.
	Illinois courts have repeatedly held that the amount of
damages to be assessed is peculiarly a question of fact for the jury
to determine (Lee v. Chicago Transit Authority, 152 Ill. 2d 432,
470 (1992); Baird v. Chicago, Burlington & Quincy R.R. Co., 63 Ill. 2d 463, 472-73 (1976)) and that great weight must be given to
the jury's decision (see Hastings v. Gulledge, 272 Ill. App. 3d 861,
863-64 (1995); McMahon v. Richard Gorazd, Inc., 135 Ill. App.
3d 211, 230 (1985)). The very nature of personal injury cases
makes it impossible to establish a precise formula to determine
whether a particular award is excessive or not. See McMahon, 135
Ill. App. 3d at 230. Additionally, judges are not free to reweigh the
evidence simply because they may have arrived at a different
verdict than the jury. Drews v. Gobel Freight Lines, Inc., 144 Ill. 2d 84, 97 (1991); see also Hulke v. International Manufacturing
Co., 14 Ill. App. 2d 5, 49 (1957) (the question of excessiveness is
not to be determined by what we as judges think the damages
should have been; the court has no right to substitute its judgment
for that of the jury). Indeed, a court reviewing a jury's assessment
of damages should not interfere unless a proven element of
damages was ignored, the verdict resulted from passion or
prejudice, or the award bears no reasonable relationship to the loss
suffered. Gill v. Foster, 157 Ill. 2d 304, 315 (1993). Given this
precedent, we believe the trial court, in the instant case, abused its
discretion in setting aside the jury's verdict as excessive.
	When reviewing a question as to the adequacy of damages,
the court must consider the record as a whole. See Hastings, 272
Ill. App. 3d at 864. Here, after reviewing the record in its entirety,
it is clear that not only did the record support the jury's verdict, but
the trial court's rationale for granting a new trial was, for the most
part, faulty. The trial court's stated reasons for granting a new trial
on damages may be summarized as follows: (1) there was error in
giving the "loss of normal life" instruction; (2) the jury's question
showed "[it was] attempting to base a decision on something other
than the evidence presented"; (3) the jury's rapid itemization of
the verdict indicated "there could not have been any meaningful
discussion as to the allocation"; (4) the pretrial settlement demand
showed that Snelson's $10 million request in closing "was not
made in good faith"; and (5) the amount of the verdict was based
"at least in part on sympathy" and was unreasonable given
Snelson's "surviving" and his "overall medical condition."
	As to the first two bases, we have already found that the
giving of the "loss of normal life" instruction was not error and
that the jury's question was insufficient to show it was improperly
considering extrajudicial information. Thus, contrary to the trial
court's belief, these were not legitimate reasons for overturning
the jury's verdict.
	Next, while the trial court believed the jury took only an
additional "five or ten minutes" to deliberate after the court
explained to the jury that it had failed to itemize the damages, the
record shows, and Kamm admits, that the jury actually took
approximately 20 minutes to complete the itemized verdict form.
The trial court's assumption that the lack of a lengthy delay meant
"there could not have been any meaningful discussion as to the
allocation" was speculation and ignored the possibility that the
jury had previously deliberated on the individual damage elements
but neglected to fill out that portion of the verdict form. Further,
we agree with Snelson that it appears the elements of damages
were itemized "in a thoughtful way," where the medical costs
awarded were rounded to the nearest large whole number, the
future medical awarded related to Snelson's current expenses of
$7,000 to $10,000 per month for hyperalimentation, which will
continue for the remainder of his 10-year life expectancy, and the
lost-wages amount was taken directly from the closing argument
suggestion. Therefore, because the calculations and proportions of
the award demonstrate a strong relation to the evidence presented,
the jury's determination cannot be against the manifest weight of
the evidence. See Jones v. Chicago Osteopathic Hospital, 316 Ill.
App. 3d 1121, 1138 (2000) (if a jury's award falls within the
flexible range of conclusions reasonably supported by the
evidence, it must stand).
	The trial court also stated that because Snelson had offered to
settle the case at the start of trial for $500,000, his closing
argument to the jury requesting $10 million was not made in good
faith. However, the actual amount of Snelson's pretrial settlement
offer was not $500,000, but rather $1 million, the limits of
Kamm's policy. Additionally, while the trial court assumed that
the settlement offer was based upon the predicted value of the case
as determined by Snelson's counsel, we agree with Justice Cook's
dissent that the demand for the policy limits and its subsequent
withdrawal on the record were most likely made to lay a
foundation for a possible "wrongful-refusal-to-settle claim." 319
Ill. App. 3d at 149 (Cook, J., dissenting). Thus, we believe the
basis for the trial court's finding that Snelson's $10 million
request was not made in good faith is erroneous.
	Finally, we address the trial court's belief that the verdict was
excessive given Snelson's medical condition and the sympathy it
engendered. In granting Kamm a new trial on damages, the trial
court stated, in pertinent part:
			"[T]he $7 million verdict *** under the circumstances
of this case is definitely outside the range as what is fair
and reasonable based on all of the evidence presented.
			The first reason that I believe that is the case is that the
$2 million which was attributed to the loss of a normal
life and the $3 million which was attributed to pain and
suffering are excessive when viewed in the light of the
plaintiff's overall medical condition which existed prior
to this occurrence and his ability to function after this
occurrence.
* * *
			Furthermore, I believe [the experts] all testified that the
condition suffered by the plaintiff *** [has] a very high
degree of fatality. Here we have the plaintiff surviving.
* * *
			I think in the context of this case and this case only,
with the plaintiff appearing in Court out of necessity as he
has and with the feeding unit, which I in no way criticize
plaintiff for because that's a fact of life, it is something
that he has to have. I just think under the circumstances it
was inevitable that the verdict was based at least in part
on sympathy was [sic] the result here."
	The evidentiary basis for the award of damages for loss of a
normal life and pain and suffering was the loss of 95% of
Snelson's small intestine, which has necessitated his dependence
on hyperalimentation for survival and has resulted in his suffering
from numerous infections and chronic diarrhea. The appellate
court majority admits that "Snelson undeniably suffered a serious
injury" and states that "[t]his issue is a close one." 319 Ill. App. 3d
at 133. The majority nonetheless upholds the trial court's grant of
a new trial on the issue of damages because Snelson's injury did
not diminish his life expectancy, he acknowledged that his
restricted ability to engage in daily activities was largely
attributable to his preexisting physical problems, and he did not
present evidence that his condition was likely to deteriorate in the
future. 319 Ill. App. 3d at 133. We, however, believe that, even
taking into consideration the majority's concerns, the injuries
suffered by Snelson were shown by the evidence to be significant
and devastating, and nothing has been presented that would
compel us to conclude that the verdict was excessive.
	We agree with Snelson that "[i]t is a vast oversimplification
to state that [his] damages are limited because he still tries to live
by occasionally going fishing." It is indisputable that the loss of
Snelson's small intestine has radically affected his life and
subjected him to phenomenal suffering. He has lost the ability to
enjoy food and to consume many foods. He has had to endure
bouts of diarrhea 15 to 20 times a day, every day, for over eight
years and counting. As Snelson further argued: "Every decision-to
even leave the house-requires the trade-off to occur; must he have
immediate access to a bathroom, or must he take the bag with him
and then affect his ability to sleep that evening or, even worse, to
soil his bed." Therefore, we find that, regardless of his prior
medical condition, the jury's damage award for loss of a normal
life was clearly demonstrated and supported by the evidence
regarding the limitations on Snelson's freedom, mobility, and the
change in nearly every element of his daily routine caused by the
loss of his small intestine. Perhaps Snelson's own comment at trial
made the point most succinctly: "When you are hooked up 12
hours a day, you don't have no days left." Similarly, we find the
jury's award for pain and suffering was adequately supported by
evidence of the infections, diarrhea, and hospitalizations caused by
Snelson's "short bowel syndrome" and his need for
hyperalimentation.
	Additionally, we find that the trial court improperly
considered Snelson's survival in determining the verdict to be
excessive. The jury found that Kamm was guilty of negligence in
his treatment of Snelson and the trial court denied Kamm's motion
for judgment n.o.v. In determining whether the injuries Snelson
did suffer merit the jury's damage award, it is irrelevant that the
negligence did not cause Snelson's death.
	In sum, an abuse of discretion will be found where there is no
recognizable basis in the record to support the granting of a motion
for a new trial. See Greco v. Coleman, 138 Ill. App. 3d 317, 322
(1985). Here, the jury's damage award was not against the
manifest weight of the evidence. There were no trial errors that
occurred that persuade this court that the award in the instant case
was not fair and reasonable compensation for Snelson's injuries.
Additionally, we have carefully scrutinized the record and do not
find that the amount of the verdict is so large as to be a result of
passion and prejudice or a shock to the judicial conscience. See
Baird, 63 Ill. 2d  at 473. Therefore, we hold that the trial court
abused its discretion in granting a new trial on damages.
	Finally, we address Snelson's claim that the trial court erred
in granting judgment n.o.v. for St. Mary's on the issue of
proximate cause. Snelson acknowledges that he presented no
expert testimony indicating that St. Mary's conduct was a
proximate cause of his injury. He also acknowledges that Kamm
testified that no act or omission of the nursing staff affected his
course of treatment of Snelson. Nevertheless, Snelson argues that
a question of fact as to proximate cause was sufficiently
established by the evidence.
	A motion for judgment n.o.v. presents a question of law and
should be entered "in those cases in which all of the evidence,
when viewed in its aspect most favorable to the opponent, so
overwhelmingly favors [the] movant that no contrary verdict based
on that evidence could ever stand." Pedrick v. Peoria & Eastern
R.R. Co., 37 Ill. 2d 494, 510 (1967). A decision on a motion for
judgment n.o.v. is subject to de novo review by this court.
McClure v. Owens Corning Fiberglas Corp., 188 Ill. 2d 102, 132
(1999).
	In medical negligence cases against hospitals based on
vicarious liability for the conduct of its nurses, it is necessary for
a plaintiff to present expert testimony to establish the standard of
care and that its breach was the cause of the plaintiff's injury.
Jones v. Chicago HMO Ltd. of Illinois, 191 Ill. 2d 278, 296
(2000). The rationale for requiring expert testimony is that a lay
juror is not skilled in the profession and thus is not equipped to
determine what constitutes reasonable care in professional conduct
without the help of expert testimony. Jones, 191 Ill. 2d  at 295.
	Snelson in essence argues that St. Mary's nurses deviated
from the standard of care by failing to (1) advise Kamm at 6 p.m.
that they had inserted a catheter at 3 p.m. and (2) advise Kamm
that Snelson continued to experience some pain through the
evening after Kamm left at 6 p.m. The problem with Snelson's
argument is that there was no expert testimony presented at trial
that either of these matters constituted a deviation from the nursing
standard of care.
	Snelson's first expert, Dr. Sarnelle, had no opinions about the
nurses' conduct. Snelson's other expert, nurse McCallum, did not
testify that either of the cited omissions amounted to a deviation
from the standard of care. Although McCallum was critical of the
nurses' failure to document the effect of the Demerol, she did not
testify that this was a proximate cause of Snelson's injury in this
case. Moreover, she did not testify that a failure to inform Kamm
of pain before the closing of the "window of opportunity" was a
deviation from the standard of care. She also acknowledged that
she was not qualified to offer any opinion regarding the proximate
cause of Snelson's injury.
	McCallum testified about eight matters on which she was
critical of the nurses. Conspicuous by its absence is any mention
that it was a breach of the nursing standard of care to fail to orally
advise Kamm that a catheter had been inserted at 3 p.m. This may
be because the nurse notes and flow sheets to which Kamm had
access at his 6 p.m. visit listed that a catheter had been inserted. It
may also be because this was not something that was important for
Kamm to know or for the nurses to communicate. Indeed, this
theory of negligence based on what was or was not communicated
about the catheter was not even a theory relied upon by Snelson at
trial. At any rate, the general rule must be applied here-that except
in very simple cases, expert testimony is necessary in professional
negligence cases to establish the standard of care and that its
breach was the proximate cause of the plaintiff's injury. See Jones,
191 Ill. 2d  at 296; Addison v. Whittenberg, 124 Ill. 2d 287, 297
(1988); see also Natasi v. United Mine Workers of America Union
Hospital, 209 Ill. App. 3d 830, 837-38 (1991) (although nursing
experts testified that failure to notify doctor was a deviation from
standard of care and delays in diagnosis could cause "poorer
ultimate results," there was no medical testimony to substantiate
that omissions of nursing staff ultimately had any impact on
outcome of treatment and therefore directed verdict for hospital
was proper).
	Nurse McCallum also testified that she was critical of the
nursing staff's apparent failure to take Snelson's vital signs at 10
p.m. Snelson, however, does not explain how the failure to take
vital signs at 10 p.m. helped to cause his injury. More importantly,
there was no expert testimony that the conduct of the nurses on
this matter was a proximate cause of Snelson's injury.
	As previously mentioned, there was no expert testimony that
the nurses' failure to inform Kamm of Snelson's complaints of
pain constituted a breach of the standard of care and was a
proximate cause of Snelson's injury. Kamm knew about Snelson's
complaints of pain at the 6 p.m. visit. Kamm clearly anticipated
that Snelson would continue to experience more pain and so he
increased his dosage of Demerol from 50 milligrams to 100
milligrams, as needed. That Kamm was ordering Demerol instead
of watching Snelson for pain was the criticism leveled against
Kamm by Snelson's expert. That Kamm knew about Snelson's
pain and yet was unconcerned about it beyond his ordering of
Demerol means that the nurses' conduct on this matter could not
have been the proximate cause of Snelson's injury even if there
had been testimony that they deviated from the standard of care in
failing to advise of pain.
	The outcome of this case is controlled by our previous
decision in Gill v. Foster, 157 Ill. 2d 304 (1993). There, the
plaintiff was admitted to the hospital and surgery was performed.
Several days after the surgery and while still in the hospital, the
plaintiff complained to his surgeon that he was having chest pain.
Two days later at the time of his discharge, the plaintiff
complained to a nurse of chest pain. The discharge nurse, aware
that the plaintiff had complained of pain before, did her own
examination. She then told the plaintiff that something was wrong,
but did not inform the treating physician. At the time of his
discharge, the plaintiff actually had a herniation of his stomach
into his chest, which required surgery at another hospital two
weeks later.
	The plaintiff alleged in Gill that the hospital deviated from the
standard of care by failing to inform his treating physician that the
plaintiff was complaining of pain at the time of his discharge. This
court found, however, that even assuming that the nurse breached
the standard of care in failing to inform the doctor of the plaintiff's
complaint, it could not have been the proximate cause of delay in
the correct diagnosis of the plaintiff's condition because the doctor
had repeated contacts with the patient yet failed to diagnose the
problem or examine him more thoroughly. Gill, 157 Ill. 2d  at 310-311.
	Similar to Gill, there was no indication in the present case that
Kamm would have taken a different course of action had he been
informed that Snelson had some pain after Kamm left at 6 p.m.
Moreover, Snelson did not even allege that St. Mary's nurses
deviated from the standard of care in failing to apprise Kamm of
any further pain.
	Snelson's suggestion that it is impossible for a plaintiff to
prove causation where the doctor testifies that "he would not have
acted differently regardless of what information could have been
given him [by the nurses]" is a red herring for two reasons. First,
Snelson mistakenly assumes that a doctor will not be willing to tell
the truth about whether the conduct of hospital nurses affected his
decisionmaking ability. Second, a plaintiff would always be free
to present expert testimony as to what a reasonably qualified
physician would do with the undisclosed information and whether
the failure to disclose the information was a proximate cause of
the plaintiff's injury in order to discredit a doctor's assertion that
the nurse's omission did not affect his decisionmaking. See Seef
v. Ingalls Memorial Hospital, 311 Ill. App. 3d 7, 26-27 (1999)
(O'Mara Frossard, P.J., dissenting). In such a case, a factual
dispute as to proximate cause would be created sufficient for the
jury to resolve. We do not, of course, have such a factual dispute
in the present case.
	Snelson claims that he was "foreclosed" from presenting such
evidence due to the appellate court majority's decision in Seef. We
find no merit to this claim given that the trial in this case took
place in June 1999, while the Seef decision was not filed until
December 1999 (see Seef, 311 Ill. App. 3d 7).
 	To support his position that expert testimony establishing
causation is not required, Snelson relies upon Holton v. Memorial
Hospital, 176 Ill. 2d 95 (1997), and Suttle v. Lake Forest Hospital,
315 Ill. App. 3d 96 (2000). Neither of those cases, however,
supports Snelson's position. Holton and Suttle do not set aside the
requirement that a plaintiff present expert testimony asserting that
a defendant hospital deviated from the standard of care and that
that deviation was the proximate cause of the plaintiff's injury.
	In Holton, the hospital's nursing staff did not inform the
plaintiff's two treating physicians that the plaintiff's symptoms
had progressed to partial paralysis. Unlike the present case, there
was expert testimony in Holton to connect the nurses' particular
deviation from the standard of care to the plaintiff's injury. The
two treating doctors testified that they based their erroneous
diagnosis and treatment on the incomplete information supplied by
the nurses. Holton, 176 Ill. 2d  at 108-09.
	To define what evidence is necessary to establish a jury
question on proximate cause, Holton adopted the rule used by the
appellate court in Northern Trust Co. v. Louis A. Weiss Memorial
Hospital, 143 Ill. App. 3d 479, 487 (1986) (" '[e]vidence which
shows to a reasonable [degree of medical] certainty that negligent
delay in diagnosis or treatment *** lessened the effectiveness of
treatment is sufficient to establish proximate cause' "), quoting
James v. United States, 483 F. Supp. 581, 585 (N.D. Cal. 1980).
Holton, 176 Ill. 2d  at 115. In Northern Trust, the plaintiff's expert
specifically testified that the hospital breached the standard of care
in failing to have a "specially trained nurse" on call to monitor the
plaintiff's meconium baby. The plaintiff connected that breach to
the plaintiff's injury with expert testimony indicating that a
specially trained nurse would have notified the doctor of the
baby's problems, that if the doctor had been notified he would
have undertaken certain diagnostic steps and treatment, and that
the delay in treatment increased the probability of harm. Northern
Trust, 143 Ill. App. 3d at 486-88. Thus, the appellate court rejected
the hospital's argument that the jury verdict against the hospital
should be reversed for lack of a connection between the hospital's
omissions and the baby's brain injury. Northern Trust, 143 Ill.
App. 3d at 487.
	Neither Holton nor Northern Trust supports the notion that
Snelson in this case should be excused from presenting expert
testimony to show that the failure to notify Kamm of the insertion
of the catheter and of continued pain amounted to deviations from
the standard of care and that those deviations were a proximate
cause of Snelson's injury. Unlike the present case, the plaintiffs in
both of the cited cases presented expert evidence connecting a
particular breach of the standard of care to the plaintiffs' injuries.
Thus, neither case is helpful to Snelson.
	Snelson attempts to fit the circumstances of this case under
the shelter of the appellate court decision in Suttle, 315 Ill. App.
3d 96. There, the appellate court reversed a judgement n.o.v. for
a hospital, holding that the question of whether the doctor's
treatment of the plaintiff would have been the same if he had been
accurately informed of the plaintiff's true condition was a question
of fact for the jury. Suttle, however, is distinguishable and actually
supports the judgments of both lower courts in this case.
	In Suttle, the appellate court specifically noted that the
plaintiff had presented expert testimony establishing the standard
of care. The plaintiff also presented evidence of the hospital
nurses' violations of the various provisions of the Illinois
Administrative Code to establish the standard of care. The plaintiff
further presented expert testimony that, to a reasonable degree of
medical certainty, the hospital nurses' breaches of the standard of
care led to a delayed diagnosis that was one of the proximate
causes of the plaintiff's injuries. Moreover, the treating doctor
testified that the hospital's breach resulted in a delay in his taking
appropriate action. Suttle, 315 Ill. App. 3d at 104-05. Under these
circumstances, the court concluded that the issues regarding the
standard of care and proximate cause were questions of fact
properly to be decided by the jury. Suttle, 315 Ill. App. 3d at 105.
Unlike in Suttle, Snelson presented no expert testimony that the
hospital breached the standard of care, resulting in a proximate
cause of his injuries.
	Despite Snelson's suggestion to the contrary, Suttle did not
hold that a case should be submitted to the jury whenever a
plaintiff presents some evidence that hospital nurses failed to
communicate some information to a treating physician. Instead,
Suttle merely distinguished the case before it from this court's
decision in Gill, 157 Ill. 2d 304, noting that summary judgment for
the hospital in Gill was proper even though a nurse failed to
inform the doctor that the patient being discharged from the
hospital was complaining of chest pain because the doctor knew
of the plaintiff's pain. Suttle, 315 Ill. App. 3d at 104. Suttle further
noted, however, that unlike Gill, there was a factual dispute in the
case before it as to what the doctor would have done if he had
received the information assessing the patient's blood pressure.
Suttle, 315 Ill. App. 3d at 104. This was because the plaintiff's
expert explicitly testified that the lack of an assessment by the
nurses led to a delayed diagnosis that was a proximate cause of the
plaintiff's injury, while the treating doctor testified that his
treatment would have been the same even if he knew of the
condition of the placenta. Suttle, 315 Ill. App. 3d at 104.
	Given the complete absence of expert evidence connecting
any deviation from the standard of care by St. Mary's with
Snelson's injury, we conclude that the evidence so overwhelming
favored St. Mary's that no contrary verdict based on the evidence
could ever stand. In entering judgment n.o.v. for St. Mary's, the
trial judge stated that in his 21 years on the bench he had always
given great deference to jury verdicts and had never entered a
judgment n.o.v. before. He then explained that he was compelled
to enter judgment n.o.v. for St. Mary's because Snelson
completely failed to present any expert evidence that any of the
claimed deviations from the nursing standard of care were the
proximate cause of his injury. We agree with the judgments of the
trial and appellate courts on this point. Accordingly, we affirm the
judgment n.o.v. in favor of St. Mary's.

CONCLUSION
	For the foregoing reasons, the judgment of the appellate court,
rejecting Kamm's claims of error in No. 91232, is affirmed. As to
Snelson's appeal, No. 91239, the appellate court and circuit court
judgments are reversed with respect to Kamm and the cause is
remanded to the circuit court of Macon County with directions to
reinstate the $7 million award against Kamm. The trial court erred
in granting Kamm a new trial on damages, as the jury's verdict in
that regard was supported by the evidence, and we find no reason
to overturn it. However, the appellate court and circuit court
judgments with respect to the granting of judgment n.o.v. for St.
Mary's are affirmed.
No. 91232-Appellate court judgment affirmed.
No. 91239-Appellate court affirmed in part
and reversed in part;
circuit court affirmed in part
 and reversed in part;
cause remanded with directions.
	JUSTICE RARICK took no part in the consideration or
decision of this case.