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Heather Guski, Independent Administrator v. Asim Raja and Midwest

May 10, 2011


Appeal from of the Estate the Circuit Court of Cook County. No. 2006 L 001965 Honorable Daniel M. Locallo,Judge Presiding.

The opinion of the court was delivered by: Justice Connors

JUSTICE CONNORS delivered the judgment of the court.

Presiding Justice Cunningham and Justice Harris concur in the judgment.


Plaintiff Heather Guski brought wrongful death and survival actions against defendants Dr. Asim Raja, Midwest Emergency Associates, and Ingalls Memorial Hospital in her capacity as the independent administrator of the estate of her father, Gerald Parkison, who was found dead in his home four days after visiting the emergency room at Ingalls. After Ingalls settled with plaintiff, the remaining parties proceeded to trial. The circuit court entered a partial directed verdict in favor of defendants Raja and Midwest on one issue and a jury found in favor of the defendants on the remaining issues. Plaintiff now appeals, arguing that: (1) the circuit court erred in several of its rulings on motions in limine; (2) defense counsel's closing argument was "unfair" and warrants reversal; (3) the cumulative effect of those errors requires that she receive a new trial; and (4) the jury's verdict was against the manifest weight of the evidence. For the following reasons, we affirm the judgment of the circuit court.


On December 25, 1999, Gerald Parkison arrived at the emergency room at Ingalls Memorial Hospital. A triage nurse took information about Parkison's symptoms and Parkison then saw Raja, the emergency room doctor. Raja performed a medical examination of Parkison, diagnosed him with an upper respiratory infection, prescribed antibiotics, and sent Parkison home with instructions to follow up with his family doctor or return to the emergency room if his condition worsened. Four days later, Parkison was found dead in his home. Plaintiff theorized that Raja failed to take an adequate medical history of Parkison and failed to order a CT scan, which would have detected the subarachnoid hemorrhage, or bleeding in the brain, that induced Parkison's fatal cardiac arrhythmia. Defendants' theory of the case was that Parkison died of a myocardial infarction or arrhythmia caused by atherosclerosis and unrelated to a subarachnoid hemorrhage.

Before trial, each party filed numerous motions in limine seeking to exclude certain evidence. Of particular relevance in this case, defendants filed a motion in limine to exclude evidence demonstrating that on several occasions, Raja failed to pass the examination for board certification in internal medicine. They argued that Raja would testify as an occurrence witness and not an expert witness; thus, any evidence of his prior failed attempts at board certification in an unrelated field was irrelevant. The court granted defendants' motion.

Defendants also filed a motion in limine to exclude testimony by one of plaintiff's experts, criticizing Raja's documentation of Parkison's symptoms on his medical chart. They argued that none of plaintiff's other experts would testify that such a failure was a proximate cause of Parkison's death. Plaintiff responded that "[t]here is no testimony that a failure to chart anything caused the guy's death," but argued that "what Dr. Raja charted and what he didn't chart becomes evidence of what his thought process was." The court granted defendants' motion.

Defendants also sought to exclude hearsay testimony offered by Parkison's family members that purported to demonstrate the severity of Parkison's headaches before going to the emergency room. The court allowed Parkison's ex-wife to testify that Parkison had headaches, that she called his doctor, and that she took him to the emergency room, for the limited purpose of explaining why she took him to Ingalls. However, plaintiff could not use that testimony as proof that Parkison was in fact suffering from headaches.

Plaintiff filed a motion in limine seeking to bar defense counsel from soliciting testimony from her expert about Parkison's use of marijuana, arguing that it was irrelevant to any issues in the case and that it was overly prejudicial. Defendants argued that the testimony rebutted plaintiff's claim that the only explanation for Parkison's passing out was that he was suffering from an aneurysm. The court denied plaintiff's motion.

The case proceeded to trial and the following relevant facts were adduced. Plaintiffs first called Raja to testify as an adverse witness. He testified that he was employed by Midwest, which contracted with Ingalls to provide emergency room doctors. He stated that when a patient arrives in the emergency room, he first reviews the patient's medical chart, which contains information that the patient gave to the triage nurse. In this case, the triage nurse wrote that Parkison had been vomiting, experiencing dizziness and body aches, and had passed out twice over the previous three days. Parkison made similar complaints to an intake nurse.

Raja then conducted his own examination of Parkison, beginning with a conversation about Parkison's medical history. Raja acknowledged that Parkison did complain of vomiting, dizziness, and passing out, but he did not record that on Parkison's medical chart. Raja further testified that when he asked Parkison follow-up questions about those complaints, Parkison explained that he was no longer suffering from those symptoms, but that he had a cough, sinus pressure, and a sinus headache, which symptoms Raja also did not record on Parkison's medical chart. Raja testified that patients sometimes alter their statement of complaints between the time they arrive in the emergency room and the time they are seen by him. Raja said that Parkison told him that the coughing spells made him feel light-headed and dizzy, like he was going to pass out, but Parkison was not sure if he actually passed out.

Raja acknowledged that vomiting, dizziness, and passing out, collectively, could indicate that Parkison suffered from a serious intracranial condition. He acknowledged that under these circumstances, he was required to do a "neuro exam" and cranial nerve testing on Parkison, which included an examination of Parkison's eyes, ears, nose, throat, and facial muscles. Raja provided a detailed description of the "neuro exam" he performed on Parkison and described the results of that exam as normal. He documented that Parkison appeared normal. He also examined Parkison's lungs and found his breathing to be normal. He concluded that Parkison's clear nasal drainage, aches, chills, and cough indicated that he had a viral upper respiratory infection.

Raja testified that he did not record Parkison's respiratory infection symptoms on his medical chart because he was using a new computerized documentation system at that time and he did not think he also needed to write the symptoms down. However, he did write orders on Parkison's chart.

Raja was asked about aneurysms specifically. He acknowledged that a CT scan is an appropriate method of investigating and diagnosing an aneurysm or a hemorrhage in the subarachnoid space in the skull. He testified that in the past, he has ordered CT scans when he believed patients had neurological problems. While practicing emergency medicine, he has diagnosed an aneurysm or subarachnoid hemorrhage about five to seven times. However, in this case, he did not order a CT scan for Parkison because he believed that Parkison had an upper respiratory infection. He testified that in his experience and personal knowledge, the "cardinal symptom" of a ruptured aneurysm is an "excruciating headache, the most severe headache you ever had in your life," which is a patient's prominent complaint. He stated he had never heard that a subarachnoid hemorrhage following a ruptured aneurysm could induce a cardiac arrhythmia.

Plaintiff then called Dr. Paul Stiegler to testify as an expert on the standard of care for emergency medicine physicians. Steigler opined that Raja deviated from the standard of care by not taking an adequate medical history of Parkison. He testified that after reviewing the triage nurse's notes on Parkison's medical chart, a reasonably careful physician would have investigated Parkison's complaints of vomiting, dizziness, passing out, and body aches as symptoms of either a cardiac problem or a serious intracranial problem, like subarachnoid hemorrhage, encephalitis, or meningitis. Steigler testified that Raja's indications that Parkison had a cough and clear nasal discharge indicative of an upper respiratory infection were inconsistent with the symptoms Parkison reported to the triage nurse. However, pursuant to the court's ruling on a motion in limine, the court instructed the jury that any criticisms of Raja's documentation of symptoms could be considered for credibility purposes only and not as a deviation from the standard of care.

Steigler also opined that Raja deviated from the standard of care by failing to order a CT scan. He stated that the symptoms Parkison reported suggested a subarachnoid hemorrhage or another intracranial problem and a reasonably careful physician would have ordered a CT scan to investigate that possibility. He testified that the "neuro exam" conducted by Raja would not, by itself, detect a subarachnoid hemorrhage. Steigler ultimately concluded to a reasonable degree of medical certainty that Raja deviated from the standard of care by failing to take an adequate medical history and failing to order a CT scan.

On cross-examination, Steigler acknowledged that before his deposition, he had only reviewed Parkison's medical records, the autopsy report prepared by Dr. Young Kim, an incomplete deposition of Dr. Kim, and the depositions of Raja and Parkison's ex-wife. He also acknowledged that vomiting, dizziness, and passing out are not symptoms specific to a subarachnoid hemorrhage, but are present in other illnesses; specifically, an upper respiratory infection.

On cross-examination, Steigler testified that marijuana usage could also cause a person to pass out, although it was rare. Steigler was then presented with Parkison's toxicology report that accompanied his autopsy report. Steigler stated that he had not previously reviewed that report. He acknowledged that it showed that Parkison had marijuana metabolites in his system at the time of his death. Plaintiff did not object to this testimony at trial. The toxicology report also showed that Parkison had the chemical PPA in his blood stream, which Steigler acknowledged could cause cardiac arrhythmia, heart rhythm disturbances, and elevated blood pressure when taken in toxic amounts.

Plaintiff then called Dr. Colin Bloor, a pathologist, to testify as an expert witness on the cause of Parkison's death. He concluded that Parkison died of a cardiac arrhythmia that was induced by a subarachnoid hemorrhage. He explained that when the subarachnoid space fills with blood, that puts pressure on the brain, which triggers a sympathetic nervous system response, and leads to a fatal cardiac arrhythmia. He stated that subarachnoid hemorrhage is commonly caused by a ruptured aneurysm. He also stated that the autopsy report noted that blood clots were present around the hemorrhage, which indicated to him that the blood had been in that area for one or two days and that the patient was alive when the clotting occurred.

He also testified that Parkison did not die of a heart attack, known as a myocardial infarction. He acknowledged that Parkison suffered from extensive coronary artery disease, but stated that the autopsy provided no indication that Parkison suffered a heart attack. However, he acknowledged on cross-examination that if a patient does not survive a sudden heart attack for at least four hours, there would be no physical indication that a heart attack occurred and, thus, Kim's failure to document changes in the heart did not rule out sudden death by heart attack.

On direct examination, Bloor testified that he rendered his opinions on cause of death with a reasonable degree of medical certainty, which he later acknowledged to be "95 percent or more true." However, on cross-examination, he admitted that he rendered his opinions with a "degree of medical probability," which is "greater than 51 percent" true. He testified that he could not testify to a reasonable degree of medical certainty because, despite looking for it, Kim found no evidence of a ruptured aneurysm during the autopsy. Bloor also acknowledged that as a pathologist specializing in cardiology, he would not be "called in" if the primary cause of death was a subarachnoid hemorrhage, but he might discover the hemorrhage while examining a patient's cardiac system.

On cross-examination, Bloor testified that if Parkison had a ruptured aneurysm in his brain, he would expect to see a hole in the blood vessel during the autopsy. Bloor acknowledged that Kim did not report any ruptured or unruptured aneurysms in his autopsy report. In forming his opinions, Bloor also considered the fact that Kim testified in his deposition that he did not believe that Parkison had a ruptured aneurysm. Bloor also acknowledged that Kim did not account for the source of the blood he found in Parkison's brain in his autopsy report. Bloor agreed that Kim's report did not indicate the presence of the three signs of a subarachnoid hemorrhage: blood pooled across the back of the brain, herniation, and cerebral edema. Bloor also recognized that Kim did not perform a microscopic evaluation of the heart and, thus, there was no physical evidence to support his theory that a sympathetic nervous system response caused Parkison's arrhythmia.

Dr. Ronald Young testified as an expert in neurosurgery. He testified that the symptoms of a subarachnoid hemorrhage include headache, nausea, vomiting, dizziness, loss of consciousness, and neurologic symptoms like paralysis and loss of feeling. He opined that Parkison's subarachnoid hemorrhage was caused by a ruptured aneurysm, although he acknowledged that Kim did not report finding one. He believed, based on Parkison's reported symptoms, that Parkison's aneurysm ruptured between one and four days before he reported to the hospital. Young stated that although there are other causes of subarachnoid hemorrhage, there was no evidence to support those other causes.

Young testified that the first step in diagnosing a subarachnoid hemorrhage is performing a CT scan. He stated that a CT scan is in the "90 percent plus range" of accuracy in detecting subarachnoid hemorrhages. In his opinion, a CT scan would have revealed that Parkison had a subarachnoid hemorrhage at the time he was in the emergency room. Young stated that if the hemorrhage had been detected, Parkison would have been admitted to the hospital and undergone an angiogram to determine the source of the bleeding. He determined that had an angiogram been performed, the aneurysm would have been discovered. He then described the process by which an aneurysm is treated to prevent ...

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