The opinion of the court was delivered by: Justice Cousins
APPEAL FROM THE ILLINOIS CIRCUIT COURT OF COOK COUNTY,
THE HONORABLE FRANK ORLANDO, JUDGE PRESIDING.
Plaintiffs, Pauline and Paul Wojcik, filed a medical malpractice suit against defendants, City of Chicago and Patrick McGuinness, a paramedic employed by the City of Chicago fire department, for willful and wanton misconduct resulting in injuries to Pauline Wojcik. A jury returned a verdict in favor of defendants and against plaintiffs. On appeal, plaintiffs contend that: (1) the trial court improperly admitted evidence that St. Anthony Hospital was the sole proximate cause of the plaintiffs' injuries; (2) the trial court improperly instructed the jury regarding proximate cause; (3) a variety of other trial court evidentiary rulings were incorrect; and (4) the plaintiffs were entitled to a judgment non obstante veredicto or a new trial.
On March 11, 1990, Pauline Wojcik, a diabetic, was treated for hypoglycemia by paramedics employed by the City of Chicago (the City). Hypoglycemia is a condition that results when glucose or blood sugar in a person's body is depleted. The evidence in the record established that at or around 5 a.m. Paul Wojcik dialed 911 because Pauline was sweaty and unresponsive. The paramedics, Patrick McGuinness and John Scheuneman *fn1 , arrived at the Wojciks' apartment at approximately 5:30 a.m. and tested Pauline's blood sugar, which they found was quite low. Scheuneman connected an intravenous (IV) line to the back of Pauline's right hand and administered an ampule of 50 cc's of a 50% dextrose solution (D50) into the vein. The method of administering D50 is to begin an IV line with 5% dextrose (D5W) and, when the IV is patent, administer a push of D50 until the patient is responsive. D5W is an isotonic solution, meaning that it is approximately the same density as blood and body fluids. However, D50 is hypotonic, meaning it is more dense and concentrated than body fluids.
Pauline was transported by ambulance to St. Anthony Hospital, arriving at approximately 6:08 a.m. St. Anthony Hospital continued the treatment and administered an additional 500 cc's of D5W into the IV set up by Scheuneman.
The Wojciks arranged for a private ambulance service to transfer Pauline from St. Anthony Hospital to Mount Sinai Hospital, where her attending physician was located. Reliance Ambulance paramedics Osmar Orozco and Juan Mejia transferred Pauline approximately three to four hours after her arrival at St. Anthony Hospital. Mejia noticed that Pauline's right hand was red and swollen, and he documented that the swelling was a result of infiltration of D50 administered by paramedics McGuinness and Scheuneman into Pauline's right hand. Infiltration occurs when the fluid intended for the vein goes into the surrounding tissues instead. As a result, the body sends fluids to dilute the tissues and swelling occurs. Once at Mount Sinai Hospital, Pauline was seen, examined, and admitted for further care.
On March 12, 1990, the day after the incident, Dr. Orhan Kaymakcalan, a specialist in hand surgery and microsurgery, noticed marked swelling of Pauline's right upper extremity and determined that she had compartment syndrome. Compartment syndrome occurs when there is increased pressure in a limited space and insufficient blood flow into the area, depriving nerves and muscles in the area of the oxygen needed in order to function correctly. If six hours elapse after the compartment syndrome occurs, surgery will generally be required to decompress the area.
Dr. Kaymakcalan performed an emergency fasciotomy to decompress the dorsum of Pauline's right hand and forearm. Following that surgery, another procedure was done to graft skin taken from her hip to close the wound on her right forearm. Pauline was discharged from Mount Sinai Hospital on March 20, 1990, and underwent occupational therapy until August 24, 1990, to help with her diminished sense of touch. She also had permanent damage and scarring of the right forearm, top of the hand between the thumb and index finger, and hip.
During trial, plaintiffs presented opinion testimony from two experts to establish that the conduct of McGuinness and Scheuneman, the City paramedics, was willful and wanton. Both experts testified that a minimal national standard of care applied to the care in issue.
Richard Hansson, a former emergency medical technician and paramedic, testified that the normal course of treatment for hypoglycemia is to administer D50 through an IV. Hansson noted that one should use as large a vein as possible for the IV because the treatment requires the infusion of a large volume of liquid. Hansson asserted that the larger vein reduces the risk of infiltration, which occurs when the fluid intended for the vein goes into the surrounding tissues instead. He further noted that infiltration is not infrequent and can be avoided by observation. Consequently, if medical personnel see swelling at the site of the IV, they should discontinue the IV and search for another site.
According to Hansson, McGuinness and Scheuneman did not meet the standard of care when they were treating Pauline because they selected a vein that was too small and failed to discontinue the IV when infiltration and swelling occurred. Further, Hansson opined that the conduct showed a conscious disregard for a known risk.
Dr. Albert Frankel, a specialist in emergency medicine who is also trained in orthopedic surgery, was the plaintiffs' second expert. Dr. Frankel testified that, in 1990, paramedics would treat hypoglycemia by starting an IV in a vein and then giving a D50 push through the IV. Because infiltration is noticeable when it occurs, Dr. Frankel opined that the paramedics should have noticed the infiltration of Pauline's hand. Dr. Frankel felt that in failing to observe the local swelling and discontinue the IV immediately, the defendants failed to exercise the skill and care of reasonably well-qualified paramedics. However, he did not believe the paramedics consciously disregarded a known risk to Pauline in doing so. Dr. Frankel opined that the infiltration of D50 given by the defendants caused Pauline's injuries.
The defendants presented opinion testimony from two expert witnesses. Dr. Joseph Mitton, a specialist in emergency medicine, opined that Pauline's compartment syndrome was not a result of infiltration of D50 administered by defendants. Rather, he believed the infiltration that led to compartment syndrome was more likely caused by the later infiltration of D5W administered through the IV line at St. Anthony Hospital.
Dr. Mitton testified that if D50 was infiltrating when first administered, Pauline would not have responded as quickly. Moreover, he opined that a person with peripheral vascular disease is more likely than a person without the disease to get compartment syndrome from an IV because a person with the disease has decreased blood flow in the small blood vessels in the extremities. Further, Dr. Mitton asserted that one cannot tell if someone has peripheral vascular disease by looking at him or her.
The defendants' second expert was Janis Sanchez, a nurse manager of the emergency room at Ravenswood Hospital who trains paramedics. Sanchez explained that standing medical orders are step-by-step instructions used by paramedics directing them how to treat particular conditions. The orders are written by physicians and establish the standard of care for treating injured patients in Chicago.
The standing medical orders in effect in March 1990 allowed for paramedics to give a D50 push through an IV once they tested the patient's blood sugar and found it to be low. Sanchez explained that if the fluid did not flow into the vein when the IV was attached, it would cause visible swelling around the site. Further, she testified that paramedics were trained to look and make sure there was no swelling at the site. If swelling was observed, they were to immediately stop the IV and look for another site.
On February 26, 1997, following trial, the jury returned a verdict in favor of defendants and against plaintiffs. Plaintiffs appeal.
Plaintiffs first contend that the circuit court abused its discretion in allowing the admission of evidence that St. Anthony Hospital was the sole proximate cause of Pauline's injuries. Specifically, they allege that the evidence of fault by non parties was not at issue and was highly prejudicial.
Plaintiffs correctly note that defendants were jointly and severally liable under section 2~1118 of the Illinois Code of Civil Procedure (735 ILCS 5/2~1118 (West 1994)). However, their reliance on the statute is misplaced as comparative fault was not an issue in the case. Defendants denied that they were even partly a proximate cause of Pauline's injuries. Rather, the defense theory was that the hospital was the sole proximate cause of Pauline's injuries.
The present case accords with Leonardi v. Loyola University, 168 Ill. 2d 83, 658 N.E.2d 450 (1995). In Leonardi, the estate of a deceased patient brought a medical malpractice suit against the decedent's hospital and physicians following an emergency pulmonary embolectomy which resulted in irreversible brain damage to decedent. Leonardi, 168 Ill. 2d at 90, 658 N.E.2d at 454. In ruling on the admissibility of evidence relating to defendant's sole proximate cause argument, our supreme court noted that "[t]he sole proximate cause defense merely focuses the attention of a properly instructed jury *** on the plaintiff's duty to prove that the defendant's conduct was a proximate cause of plaintiff's injury." Leonardi, 168 Ill. 2d at 94, 658 N.E.2d at 456. "A defendant has the right not only to rebut evidence tending to show that defendant's acts are negligent and the proximate cause of claimed injuries, but also has the right to endeavor to establish by competent evidence that the conduct of a third person, or some other causative factor, is the sole proximate cause of plaintiff's injuries." Leonardi, 168 Ill. 2d at 101, 658 N.E.2d at 459.
Consequently, defendants' general denial of liability even without an affirmative defense, counterclaim, or third-party action is sufficient to permit them, in support of their position, to present evidence that the injury to Pauline was the result of another cause. See Leonardi, 168 Ill. 2d at 94, 658 N.E.2d at 455.
Plaintiffs further contend that their motion in limine to exclude opinion testimony regarding non party fault should have been granted in that neither the factual evidence nor opinion testimony supported the defense's theory that St. Anthony Hospital was the sole proximate cause. As a rule, however, the relevance and admissibility of evidence at trial is committed to the sound discretion of the trial court and its determination will not be overturned absent a showing of clear abuse of that discretion resulting in substantial prejudice affecting the outcome of the trial. Leonardi, 168 Ill. 2d at 92, 658 N.E.2d at 454-55; People v. Hayes, 139 Ill. 2d 89, 130, 564 N.E.2d 803, 820 (1990).
"Relevant evidence" means evidence having any tendency to make the existence of any fact that is of consequence to the determination of the action more or less probable than it would be without the evidence. Fed. R. Evid. 401; People v. Free, 94 Ill. 2d 378, 413, 447 N.E.2d 218, 235 (1983). Further, questions of negligence, due care and proximate cause are ordinarily questions of fact for the jury to decide and become questions of law only when the facts are undisputed or there can be no difference in the inference a jury could draw from the ...