O'Connell v. Holy Family Hospital

                                             Fourth Division
                                             June 30, 1997







No. 1-96-2579

MICHAEL O'DONNELL AND KATHRYN HUNT,     )    APPEAL FROM THE
as Co-Administrators of the Estate      )    CIRCUIT COURT OF
OF RYAN O'DONNELL, Deceased,            )    COOK COUNTY.
                                        )
     Plaintiffs-Appellants,             )
                                        )
          v.                            )
                                        )
HOLY FAMILY HOSPITAL, a corporation,    )    HONORABLE
and DR. MUSTAFA KEMAL YON,              )    RONALD C. RILEY,
                                        )    JUDGE PRESIDING.
     Defendants-Appellees.              )
                                        

     PRESIDING JUSTICE WOLFSON delivered the opinion of the
court:
     The plaintiffs in this case say that 12 minutes was the
difference between life and death for their son, Ryan.  They also
say that the actions or omissions of Dr. Mustafa Kemal Yon during
that brief span of time are what caused Ryan's death.  The jury
found otherwise.  This court must decide, among other things,
whether the jury's verdict for the defendants was against the
manifest weight of the evidence.  We affirm.
FACTS
     In a third amended complaint, Michael O'Donnell and Kathryn
Hunt (Ryan's parents) alleged that Holy Family Hospital was
negligent because it failed to provide timely and competent
resuscitative care to Ryan; because the hospital failed to
provide a neonatologist within 30 minutes of the obstetrician's
decision to perform an emergency Caesarian section (C-section);
because the hospital violated its Maternity and Neonatal Service
Plan in several ways; and because the hospital failed to have in
place a reliable means of communicating with its on-call
neonatologists.  Plaintiffs further alleged that Dr. Yon, as
agent, and the hospital, as principal, were negligent because:
Dr. Yon failed to properly intubate and ventilate Ryan; Dr. Yon
failed to monitor or have others monitor Ryan's heart rate; Dr.
Yon failed to perform cardiac compressions on Ryan; Dr. Yon
failed to resuscitate Ryan; and Dr. Yon failed to timely
anesthetize Kathryn (Ryan's mother) in preparation for the C-
section.  
     Although the trial in this case lasted several days, much of
the evidence focused on the 12 minutes between 11:10 and 11:22
a.m. on May 22, 1991.  This time period was important because,
while there was some discrepancy in the records, it was generally
accepted that Kathryn Hunt gave birth to a son, Ryan, by
Caesarean section (C-section) at Holy Family Hospital at 11:09
a.m.; that Dr. Yon, Kathryn's anesthesiologist for the C-section,
took over resuscitation efforts on the infant at 11:10 a.m.; and
that Ryan was clinically dead when the neonatologist, Dr. Go,
arrived in the delivery room at 11:22 a.m.  Resuscitation efforts
continued for nearly two hours after Dr. Go arrived and Ryan was
not pronounced dead until 1:15 p.m.  But what transpired during
those 12 minutes and whether anything Dr. Yon did or did not do
during that time deviated from the standard of care and
proximately caused Ryan's death were the main issues at trial.
     Kathryn Hunt was 41« weeks pregnant when she arrived at Holy
Family Hospital in the early morning hours of May 22, 1991.  Her
amniotic sac already had ruptured.  Still, the progress of her
labor, as observed by the doctors attending her throughout that
morning, was slow.  When Dr. Carson, Kathryn's obstetrician, took
over Kathryn's care at 9:40 a.m., Kathryn's cervix had dilated
only 4 cm.   The fetal monitor strip up to this point, however,
showed that the baby's heart beat was stable and strong.
     Between 10:05 and 10:24 a.m. the fetal monitor strip began
to show that problems were developing.  There were deccelerations
in the fetal heart rate indicating that the baby was not getting
enough oxygen.  At 10:30 a.m., when Dr. Carson next checked
Kathryn, the doctor saw the strip and an unusually large amount
of blood in Kathryn's pelvic cavity.  The doctor concluded that
an abruption (a separation of the placenta from the uterine wall)
had occurred.  For this reason, she decided that an emergency C-
section was necessary.  The decision to perform a C-section was
made at approximately 10:36 or 10:37 a.m.
     The hospital delivery room personnel immediately went into
action.  A nurse called the surgical department and requested a
surgical assistant and an anesthesiologist.  Another nurse called
the nursery department and told the staff nurse there to notify
the on-call neonatologist that an emergency C-section was going
to be performed.  The nursery nurse paged Dr. Go.
     Dr. Go, the neonatologist, was driving in her car to another
hospital when she received the page.  Dr. Go called Holy Family
Hospital at about 10:55 a.m.  When she learned of the emergency,
she agreed to proceed to Holy Family Hospital immediately.
     Once when Dr. Carson checked the fetal monitor attached to
Kathryn it showed a "flat line" for two-four minutes, indicating
that the fetus was not getting any oxygen.  For this reason
Kathryn was given oxygen and turned on her side to improve
circulation to the fetus.
     The monitor was disconnected from 10:41 until 10:46 a.m.,
while Kathryn was moved to the delivery room.  When reconnected
at about 10:47 a.m., the monitor showed some improvement in the
fetus' heart rate.  At about 10:50 a.m., Kathryn was in the
delivery room and being prepped for surgery.  Dr. Yon, the
anesthesiologist, began to administer anesthesia to Kathryn.  By
11:02 or 11:03 a.m., less than 30 minutes from the time Dr.
Carson decided to perform the C-section, the first incision was
made by Dr. Carson.  According to the fetal monitor strip, Ryan
was born at 11:09 a.m.
     Dr. Carson determined, after Ryan's delivery, the placental
abruption had not been complete, but she categorized it as
"severe."  Dr. Carson assessed Ryan briefly as she passed him to
Dr. Zamirowski, a general practitioner who came to delivery to
help in this emergency.  Dr. Carson noted that Ryan was limp and
not breathing at birth.  As the other doctors worked on trying to
resuscitate Ryan, Dr. Carson never heard Ryan cry.
     Dr. Carson opined that the pain medications and anesthesia
administered to the mother had contributed to Ryan's depressed
condition at birth.  Dr. Carson also admitted that, after Ryan's
birth, Kathryn developed disseminated intravascular coagulation
(DIC), a condition in which the mother uses up much of the
clotting factors in the blood.  Also, a hematocrit done on the
blood in the cord going to Ryan showed that his blood count was
low, though not alarmingly so.  Still, the low blood count
indicated that he might have had some blood loss due to the
abruption.
     Despite Ryan's condition at birth, it was Dr. Carson's
opinion that neither the delivery, nor anything that occurred
before the delivery, was the proximate cause of Ryan's death. 
Her medical opinion was that Ryan died due to an inability to be
resuscitated after birth.  Why Ryan could not be resuscitated,
she could not explain.
     Plaintiff's expert, Dr. Kimble, agreed that Ryan died after
birth due to failed resuscitation attempts.  Dr. Kimble stated:
     "I think that Ryan's death resulted because of the
     failure on the part of Dr. Yon to be able to provide
     ventilation to this baby in the first very few minutes
     of life, and I think that why ventilation was not
     successful in Dr. Yon's hands is not entirely clear."
     It was his opinion, however, that Dr. Yon's inability to
resuscitate Ryan stemmed from one of three possibilities: (1)
that Dr. Yon put the endotracheal tube in the wrong place, (2)
that Dr. Yon never ventilated Ryan using the Ambu bag, or (3)
that Dr. Yon did not squeeze the Ambu bag sufficiently to fill
Ryan's lungs.
     Dr. Kimble identified some markings on an autopsy photograph
depicting Ryan's airway.  This picture, Dr. Kimble said, was
evidence of trauma to the esophagus caused by Dr. Yon's
misplacement of the endotracheal tube.  This theory was
discounted, however, by Dr. Yana, the pathologist.  Dr. Yana
testified that when he performed the autopsy on Ryan, he found
that Ryan's airway was "patent," i.e., that it showed no
hemorrhage, laceration, or other abnormality.  Dr. Yana said that
the markings identified by Dr. Kimble as evidence of laceration
were, in actuality, the incision site where Dr. Yana removed the
thyroid gland.
     Dr. Yana said that his examination of Ryan revealed that the
tracheal bifurcation (the bronchial tree leading to the two
branches of the lungs), both main bronchi, as well as the
bronchial bifurcation, were almost completely occluded by a
thick, yellow-ish tan mucoid material.
      The other two theories proposed by Dr. Kimble regarding Dr.
Yon's failure to resuscitate Ryan were discounted by the
testimony presented by other witnesses.  One witness in
particular was Dr. Zamirowski.
     After Ryan was born, he was handed over to Dr. Zamirowski
and Nurse DeLorge at 11:09.  Ryan was immediately placed on the
warming table, cleaned off, and his airway suctioned.  Dr.
Zamirowski testified that Ryan's mouth and nose contained a
bloody mucus, indicating that he had swallowed some of the
amniotic fluid.  This was not a good sign, said Dr. Zamirowski,
because "free" blood can be an irritant and can cause swelling of
the tissues.
     Though a normal baby's heart rate ranges between 150 and 160
beats per minute, Ryan's heart rate was only 60 beats per minute. 
Ryan did not respond to initial attempts to resuscitate him.  For
these reasons, Dr. Zamirowski called for Dr. Yon's assistance. 
Dr. Yon took over Ryan's care at 11:10, when Ryan was one minute
old.
     At this one minute mark, Dr. Zamirowski evaluated Ryan as a
"3" on the APGAR scoring system.  A perfect APGAR score is "10,"
which represents a score of "2" in each of five categories.  Ryan
was given a score of zero for breathing because he was not making
any effort to breath; a score of zero for muscle tone because he
was "totally limp, like a rag doll"; a score of "1" for
responsiveness because he had a minimal reflexive response to
suctioning; a score of "1" for skin color because he was not
totally blue; and a score of "1" for heart rate because his heart
rate was 60 beats per minute.  This APGAR score reveals that Ryan
was extremely sick at the time he was born.
     The ABC's of resuscitation are Airway, Breathing, and
Circulation.  The most important thing, testified Dr. Zamirowski,
is to get an open airway.  According to Dr. Zamirowski's
testimony, Dr. Yon's initial actions were an attempt to open an
airway for Ryan.  Dr. Yon did some deep suctioning by placing an
endotracheal tube down Ryan's throat, past the vocal cords, using
a laryngoscope.  This process is called intubation.  After
suctioning through the tube, Dr. Yon attached the tube to an Ambu
bag and an oxygen source.  Dr. Yon then began to pump oxygen into
Ryan by compressing and releasing the Ambu bag.  This process is
referred to as "bagging" or "oxygenating."  Dr. Zamirowski
reported that he heard breath sounds from Ryan's chest as Dr. Yon
"bagged" Ryan using the Ambu bag.  He also watched as Ryan's
chest rose and fell.
     When Ryan was five minutes old, Dr. Zamirowski assessed
Ryan's APGAR scores again.  The 5-minute score of "5" showed that
Ryan was making only slight improvement.  Dr. Zamirowski gave
Ryan a "1" for skin color; a "1" for muscle tone; a "1" for
responsiveness; and a "2" for heart rate, because it had improved
to about 130 beats per minute.  This improvement was generally
believed to be due to some oxygen getting into Ryan's lungs.
     Dr. Zamirowski testified, too, that Dr. Yon began chest
compressions on Ryan to artificially pump the heart in an attempt
to circulate the oxygenated blood.  Ryan, however, remained
unresponsive.  Because Ryan was not breathing on his own, chest
compressions were futile.  Ryan's heart beat decreased again to
60 beats per minute and then, at about the seven minute mark, his
heart rate went to zero.  Dr. Yon continued his attempts at
suctioning in an effort to open the airway.  He intubated Ryan's
stomach using a nasogastric tube in an attempt to empty the
stomach of any fluid or air so that the lungs would have more
room to fill.
     At 11:22 a.m., Dr. Go, the neonatologist, entered the
delivery room and took over resuscitation efforts.  At the time
of her arrival, Ryan had not been breathing and had no pulse for
several minutes.  He was clinically dead.  Still, Dr. Go
continued her efforts to revive Ryan for another two hours. 
According to Dr. Go and two respiratory therapists who were
called to delivery to assist with the emergency, Ryan never
breathed on his own, and his skin color never changed, even
though it appeared that the lungs were inflating.  
     Dr. Yon testified about his efforts to resuscitate Ryan.  He
explained that he had been an anesthesiologist since 1958 and had
performed numerous resuscitations on both infants and adults.  In
fact, before the late 1960's or early 1970's, when neonatology
became a separate practice, anesthesiologists were in charge of
resuscitations at infant deliveries.
     Dr. Yon's paperwork indicated that Ryan was born at 11:19,
not 11:09, and he felt that he had not been attending to Ryan for
very long when Dr. Go took over.  However, he admitted that being
occupied with the resuscitation made his ability to recall actual
time spans impossible and that he would accept the records of
others on these matters.
     Dr. Yon claimed that he had not been able to oxygenate Ryan
successfully.  He testified that his attempts to "bag" Ryan were
met with resistance.  It was Dr. Yon's belief that there was an
obstruction in Ryan's airway which caused the resuscitation
efforts to be ineffectual.  Dr. Yon did not recall doing chest
compressions, but testified that they would have been of no use
since there was no movement of oxygen into the lungs.  Dr. Yon
recalled spending his entire time with Ryan attempting to open
his airway.
     Nurse DeLorge testified about her recollection of Ryan's
delivery.  She agreed that, upon delivery, Ryan was limp, his
skin color was blue, and he was not breathing.  She also agreed
that when she first received Ryan at the warming table he had a
thick bloody mucus in his mouth and nose.
     Nurse DeLorge also testified, however, that after Dr. Yon
came over to assist in the resuscitation, he was unable to
intubate Ryan and that he struggled to intubate Ryan until 11:14. 
After Dr. Yon intubated Ryan, Nurse DeLorge did not remember Dr.
Yon, or anyone else, doing anything for Ryan for the next eight
minutes, until Dr. Go arrived.  Nurse DeLorge did not recall Dr.
Yon "bagging" Ryan or giving him oxygen.
     Though she claimed to have witnessed everything Dr. Yon did
for Ryan, Nurse DeLorge admitted on cross-examination that she
was not present when the APGAR scores were determined, that she
prepared an injection of Narcan for Ryan at Dr. Carson's
suggestion, and she was "in and out."
     Nurse Toni Daker testified that she did not see Dr. Yon
"bag" Ryan, but admitted that his back was toward her,
obstructing her view.  According to notes she made, Ryan was
initially intubated and given "free flow" oxygen.  Ryan's heart
rate was recorded at 60 beats per minute, increasing to 100, then
decreasing.  Narcan, she recorded, was given to Ryan by injection
at 11:15 a.m.  She also had a note indicating that oxygen was
given "by face mask" at 11:12 a.m.
     Nurse Daker admitted that she did not see everything that
Dr. Yon did while he was working on Ryan.  She could not say if
chest compressions were started before Dr. Go arrived.  Once Dr.
Go arrived Dr. Yon went back to attending Kathryn and her
anesthesia for the C-section operation, which was not completed
until 11:50.  Nurse Daker did not ask Dr. Yon for his input when
she was filling out her notes after the operation was over.
     Dr. Go testified that when she arrived in the delivery room
at 11:22 a.m. Ryan had no pulse, was not breathing, and was blue. 
There was no endotracheal tube in place, but Dr. Yon had the ambu
bag in hand.
     Dr. Go intubated Ryan and tried to pump air into Ryan's
lungs.  She said that she heard air entering the lungs.  However,
sometime after 11:35 a.m., Dr. Go "needled" (placed a needle into
the plural cavity) both sides of Ryan's chest and was able to
extract 25 cc. of air on the right.  This indicated that Ryan had
a right pneumothorax, i.e., a collapsed lung due to the lung
"bursting" from the resuscitation efforts and causing air leakage
into the chest.  Pneumothorax, said Dr. Go, is a very common
complication from prolonged resuscitation efforts.
     Dr. Go also testified that whenever chest compressions were
stopped, Ryan's heart rate stopped, indicating there was no
response from Ryan.  Ryan was clinically dead at the time Dr. Go
came into the delivery room and, despite her efforts, she was
unable to revive him.
     Both the hospital and Dr. Yon presented their own expert
witnesses, who testified regarding their theories on the cause of
Ryan's death.  Dr. Muraskas, the hospital's expert witness,
testified that he believed that, ultimately, Ryan was unable to
be resuscitated due to bilateral pneumothoraces, which resulted
from the continued efforts to ventilate Ryan.  Dr. Muraskas also
opined that there were many contributing factors to Ryan's
condition which caused the resuscitation efforts to fail.  These
conditions were: the abrupted placenta, aspirated bloody amniotic
fluid, hypovolemia (loss of blood), as well as the mother's
fever, infection, and DIC.
     Dr. Vender, who was Dr. Yon's expert witness, testified that
he believed the resuscitation efforts failed because of "mucoid
plugs," which obstructed the airway and made successful
ventilation impossible.
     After hearing all of the testimony, the jury found that
neither Dr. Yon nor the Holy Family Hospital was responsible for
Ryan's death.  The plaintiffs appeal the jury's decision,
claiming: (1) the judgment was against the manifest weight of the
evidence; (2) the trial court erred by allowing the jury to hear
certain evidence; (3) an improper proximate cause instruction was
used; (4) the trial court improperly removed the issue of the
neonatologist's response time from the jury's consideration; (5)
the trial court improperly excluded certain evidence; (6) during
jury selection, the trial court improperly denied certain
challenges for cause; and (7) closing argument by defense counsel
was unfairly prejudicial.
OPINION
     1. Manifest Weight of the Evidence
     Plaintiffs contend that the jury's finding in favor of the
defendants was against the manifest weight of the evidence and,
for this reason, the motion for new trial should have been
granted by the trial court.
     All parties agree that the standard by which a reviewing
court determines whether the jury's findings are against the
manifest weight of the evidence is one of deference.
     "A trial court cannot reweigh the evidence and set
     aside a verdict merely because the jury could have
     drawn different inferences or conclusions, or because
     the court feels that other results are more reasonable. 
     Likewise, the appellate 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 v. Gustafson, 151 Ill. 2d 445, 452-53, 603 N.E.2d 508 (1992).
     A new trial should be granted only when the opposite
conclusion is clearly apparent to the reviewing court or the
jury's findings are unreasonable, arbitrary, and not based on the
evidence.  Maple v. Gustafson, 151 Ill. 2d  at 454.  In Hajian v.
Holy Family Hospital, 273 Ill. App. 3d 932, 940, 652 N.E.2d 1132
(1995), the court said, "Reviewing courts are required to
scrutinize the evidence but not sit as a second jury and reweigh
the evidence or reevaluate the credibility of the witnesses,
especially where conflicting expert testimony is introduced at
trial."
     In this case it was uncontested that Ryan was not breathing
when he was born, that he never began to breath spontaneously,
and he died because Dr. Yon was unable to resuscitate him. 
However, many theories were offered on the question of why Dr.
Yon was unable to resuscitate Ryan.
     It was plaintiff's theory that Dr. Yon's failure to
resuscitate Ryan was due to some act or omission on Dr. Yon's
part.  But even plaintiff's expert witness could not identify
exactly what that act or omission was.  Several alternative
hypotheses were proposed.  These hypotheses, however, amounted to
mere speculation.  In essence, plaintiffs would have Dr. Yon be
liable because Dr. Yon was in charge of Ryan's resuscitation and
he failed.
     However, there must be something violative of the standard
of care that Dr. Yon did, or failed to do, that proximately
caused Ryan's death, before liability attaches.  The jury refused
the plaintiff's invitation to speculate on what that "something"
might be.  The jury decided that the plaintiffs did not meet
their burden of proving that the actions or omissions of Dr. Yon
and the hospital constituted negligence or were the proximate
cause of Ryan's death.  There was ample evidence presented at
trial to support this determination.
     As outlined above, Ryan was lifeless and not breathing at
birth.  There was evidence from the fetal monitor strips that
Ryan had been deprived of oxygen for several minutes in utero. 
Medications given to the mother for the delivery further
"depressed" Ryan's status.  There was evidence that Ryan
swallowed amniotic fluid which contained blood due to the
"severe" abruption.  Dr. Zamirowski testified that "free" blood
causes tissues to swell.  Finally, the pathologist, when
performing Ryan's autopsy, discovered a thick mucous coating
Ryan's lungs.
     Whether any one of the conditions, or all of them together,
caused Ryan to be unresuscitatable will never be known.  We
cannot say the evidence overwhelmingly pointed to anything Dr.
Yon did or failed to do, violative of the standard of care, as
the proximate cause of Ryan's death.  The jury's finding as to
Dr. Yon was not unreasonable, arbitrary, or against the manifest
weight of the evidence.  We find no cause to discard the verdict
that was entered or to order a new trial.
     As to the hospital, plaintiffs contend that the hospital was
negligent because it did not comply with its Maternity and
Neonatal Plan which "required a neonatologist at all Caesarean
section births, and that the neonatologist would be present
within 30 minutes of when the section was ordered."
     The evidence does not support these allegations.  A careful
reading of the Maternity and Neonatal Plan shows that, concerning
Caesarean Section deliveries, the plan requires the department to
be equipped to perform emergency Caesarean deliveries within 30
minutes from the time the obstetrician makes the definite
decision to operate.  An anesthesiologist and other necessary
personnel, other than a neonatologist, are in-house on a 24-hour
basis.  The anesthesiologist, says the plan, is available "to
initiate Caesarean sections within 20-30 minutes.  It further
provides:
     "Identification and resuscitation of distressed
     neonates is the responsibility of the anesthesiologist. 
     A neonatologist is available within 30 minutes."
     We do not interpret these passages in the plan to mean that
the hospital required a neonatologist to be present at the start
of an emergency Caesarean section that has begun within 20-30
minutes of the obstetrician's decision to operate.  The plan
clearly contemplates that an anesthesiologist, who is available
24-hours, will take responsibility for the resuscitation of
depressed neonates until the neonatologist arrives, which should
be within 30 minutes from the time the neonatologist is informed
of the emergency.
     In this case the first incision for the Caesarean section
occurred between 25 and 27 minutes from the time that the
obstetrician decided to perform the operation.  The evidence was
unclear as to the time that Dr. Go, the neonatologist, was paged. 
According to her recollection, she called Holy Family Hospital at
10:55 a.m., after receiving the page.  We do know she arrived at
Holy Family at 11:20 and was in the delivery room by 11:22.  This
evidence tends to support a finding that Dr. Go responded within
30 minutes of the time she was notified that she was needed.
     Even if we were to agree with plaintiff's interpretation and
find that the plan called for a neonatologist to be present
within 30 minutes of a decision to perform an emergency C-
section, the violation of this provision does not necessarily
demonstrate the hospital deviated from the standard of care, nor
was it shown that the violation was a proximate cause of Ryan's
death.
     It is clear that Dr. Go arrived in the delivery room within
45 minutes of the obstetrician's decision to operate.  A
qualified anesthesiologist was present at the start of the
delivery and available to begin resuscitation efforts, as called
for in the hospital's plan.  While it is undeniably a tragedy
that Ryan was unable to be resuscitated, we can find no evidence
to suggest that Ryan died as a result of the hospital's failure
to have a neonatologist present, or that Dr. Go's response time
was a factor.
     2. Evidence of Other Medical Conditions
     Plaintiffs contend that the trial court erred in admitting
evidence of other medical conditions.  The medical conditions
that plaintiffs would have had excluded are: abrupted placenta;
maternal infection, fever, and sepsis; fetal hypovolemia,
maternal DIC, and amniotic fluid aspiration by the fetus. 
Plaintiffs argue that these conditions should have been excluded
because they "were not causally related to Ryan's death."
     The problem with this argument is that the proximate cause
of Ryan's death was one of the issues at trial.  If we were to
accept plaintiffs' argument, we would necessarily be adopting
plaintiffs' position that Dr. Yon's conduct was the proximate
cause of Ryan's death.  We cannot.
     The situation here is distinguishable from the "other
medical condition" cases cited by plaintiff.  Those cases
involved prior injuries or pre-existing conditions.  See for
example, Tate v. Coonse, 97 Ill. App. 3d 145, 421 N.E.2d 1385
(1981)(prior injury held inadmissible); Rehak v. City of Joliet,
52 Ill. App. 3d 724, 367 N.E.2d 1070 (1977)(pre-existing
arthritis, diabetes, and arteriosclerosis not relevant).
     In the present case, had the trial court excluded evidence
of medical conditions present at the time of Ryan's birth, the
jury would have been deprived of relevant and material evidence
on the issue of proximate causation.  As plaintiffs concede, at
least one defense expert testified that these conditions
contributed to Ryan's death.  Since it was the jury's function to
determine the proximate cause of Ryan's death, this evidence was
admissible.  The trial court did not abuse its discretion by
admitting this evidence.  Leonardi v. Loyola University of
Chicago, 168 Ill. 2d 83, 92, 658 N.E.2d 450 (1995)(the relevance
and admissibility of evidence is committed to the sound
discretion of the trial court, and its decisions will not be
reversed absent a clear abuse of discretion); Moore v. Anchor
Organization for Health Maintenance, 284 Ill. App. 3d 874, 672 N.E.2d 826 (1996).
     3. Long Form Proximate Cause Instruction
     Plaintiffs contend they did not receive a fair trial because
the long form proximate cause instruction they tendered was
rejected in favor of a modified version of the short form
proximate cause instruction.  Specifically, the court instructed
the jury:
     "When I use the expression "proximate cause," I mean
     any cause which, in the natural or probable sequence,
     produced the injury complained of." (Emphasis added.)
     We find the giving of this short form instruction was not
reversible error.
     In Hajian v. Holy Family Hospital, 273 Ill. App. 3d 932, 652 N.E.2d 1132 (1995), the court found that modifying the "that
cause" phrase in the short form proximate cause instruction to "a
cause" adequately informed the jurors that they were not limited
to determining a single cause for plaintiff's injury."
     In Schlueter v. Barbeau, 262 Ill App. 3d 629, 635, 634 N.E.2d 1325 (1994), the court found it was error to use the
unmodified short form proximate cause instruction because the use
of the term "that cause" rather than modifying the instruction to
use the phrase "a cause" or "any cause" "suggested to the jury
that they were limited to finding a single cause of plaintiff's
injuries."
     In the present case the trial court instructed the jury
using a modified short form proximate cause instruction
containing the term "any cause."  We cannot say that the trial
court abused its discretion by using this short form instruction. 
The instructions, taken as a whole, fully and adequately informed
the jury of the applicable legal principles.  Ostry v. Chateau
Ltd. Partnership, 241 Ill. App. 3d 436, 608 N.E.2d 1351 (1993).
     4. Plaintiffs' Issues Instruction
     The next question is whether the trial court erred when it
struck plaintiffs' issues instruction on the hospital's alleged
violation of its plan to provide a neonatologist within 30-
minutes of the obstetrician's decision to perform an emergency C-
section.  The trial court removed this issue from the jury's
consideration because it found there had been no evidence
presented to indicate that the failure to have a neonatologist
present in the delivery room within 30 minutes of the decision to
perform a C-section proximately caused Ryan's death.  We agree.
     Plaintiffs equate the issue of whether there was evidence
that the hospital's alleged violation of its plan provision was
negligence that proximately caused Ryan's death with the issue of
whether Dr. Go was more competent that Dr. Yon.  Whether Dr. Go
performed competently, or more competently than Dr. Yon, is not 
the issue here.  The issue is whether the hospital's failure to
provide any neonatologist within 30 minutes of the decision to
perform the C-section was a deviation from the standard of care
which proximately caused Ryan's death.
     The evidence showed that Dr. Go, a neonatologist, arrived in
delivery within 45 minutes of the decision to perform the C-
section and 13 minutes after Ryan's birth.  Dr. Yon, an
anesthesiologist qualified in neonate resuscitation, attended to
Ryan in the absence of a neonatologist.  The APGAR scores showed
that Ryan, though never capable of breathing on his own, had a
heart rate of 130 when he was five minutes old.  According to Dr.
Zamirowski's testimony, at the seven minute mark Ryan's heart
rate dropped to zero.  Thus, Dr. Go arrived in the delivery room
within six minutes of the time that Ryan was deemed "clinically
dead."  Plaintiffs never have claimed that Dr. Go was negligent,
despite the fact that Dr. Go was unsuccessful in her attempts,
over the course of the next two hours, to revive Ryan.  Instead,
plaintiffs argue that the evidence presented indicates that Dr.
Go was able to intubate Ryan, perform chest compressions, and
"bag" Ryan without difficulty.  This, plaintiffs say, was 
evidence of Dr. Go's competence and Dr. Yon's incompetence, and
indicates that had Dr. Go been present at the time of Ryan's
birth Ryan would have lived.  From this conclusion, plaintiffs
reason, there was evidence that the hospital's failure to supply
a neonatologist within 30 minutes was evidence of the hospital's
negligence.  We are not prepared to make this factual leap.
     The failure to provide a neonatologist would be negligence
on the part of the hospital only if a neonatologist was the only
person qualified in neonate resuscitation.  It is undisputed,
however, that anesthesiologists were qualified in neonate
resuscitation and, according to the hospital's plan, responsible
for neonate resuscitations in the absence of a neonatologist.
     We agree with the trial court that the evidence presented at
trial did not support plaintiffs' claim that the hospital's
alleged violation of its plan provision to have a neonatologist
on the scene of a C-section within 30 minutes constituted an act
of negligence which proximately caused Ryan's death.
     5.  Evidentiary Errors
     As further reasons in their pursuit of a new trial,
plaintiffs allege nine separate instances where the trial court
erred in its evidentiary rulings.  When reviewing these claims we
are mindful that 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 a
clear abuse of that discretion resulting in substantial prejudice
affecting the outcome of the trial.  Leonardi v. Loyola
University of Chicago, 168 Ill. 2d 83, 658 N.E.2d 450 (1995);
Holston v. Sisters of Third Order of St. Francis, 165 Ill. 2d 150, 650 N.E.2d 985 (1995).
     Plaintiffs assign error to the following: (1) not allowing
the jury to hear that Dr. Yon failed his board certification exam
and was not board eligible; (2) barring plaintiff from asking Dr.
Go or Dr. Kimble questions about Ryan's prognosis had he been
timely resuscitated; (3) allowing Dr. Go to give her opinion on
whether the hospital complied with its plan for distressed
neonates; (4) defense counsel's reference to Kathryn Hunt as
"Mrs. Hunt" or "Mrs. Kuzniar" (her maiden name), rather than "Ms.
Hunt"; (5) exclusion of evidence that other area hospitals
offered 24-hour neonatology services; (6) improperly limiting
cross-examination of Dr. Yana; (7) Dr. Yon's single mention of
the term "Good Samaritan"; (8) Dr. Yon's reference to Dr. Kimble
in his testimony regarding difficulties in intubating; and (9)
exclusion of certain damages exhibits.
     We have considered each claim and find no grounds for
granting a new trial.  The record shows that the trial court made
thoughtful and reasoned determinations when ruling on the
admission or exclusion of the various matters.  We cannot say
that the record evidences a clear abuse of discretion or that the
outcome of the trial was substantially affected due to these
rulings.
     6.  Denial of Challenges for Cause
     Plaintiffs claim that two members of the venire who
indicated that they were incapable of awarding millions of
dollars in damages, regardless of the evidence, should have been
dismissed for cause.  The trial court's refusal to excuse these
two persons for cause, say plaintiffs, necessitated the use of
two of plaintiffs' peremptory challenges.  Plaintiffs now allege,
without any explanation or illustration, that they were forced to
exhaust all of their peremptory challenges and compelled to
accept two objectionable jurors.  This claim, however, must fail.
     It is left to the sound discretion of the trial court to
decide, based on the venireperson's entire voir dire examination,
whether that venire member can be impartial.  People v. Williams,
173 Ill. 2d 48, 67, 670 N.E.2d 638 (1996).  Unless that decision
is against the manifest weight of the evidence, it should be
upheld.  Williams, 173 Ill. 2d  at 69.  
     We need not decide whether refusal to dismiss the two jurors
for cause was error.  Plaintiffs' counsel never requested
additional preemptories or informed the court that plaintiffs
were being forced to accept objectionable jurors.  Nor do
plaintiffs attempt to explain why the jurors they were forced to
accept were objectionable.  Plaintiffs' simple assertion of
prejudice is insufficient grounds for finding reversible error. 
People v. Pendleton, 279 Ill. App. 3d 669, 665 N.E.2d 350 (1996).
     7.  Unfair Closing Argument 
     The final issue raised on appeal is whether defense
counsel's attacks on the credibility of plaintiffs' expert
witness in closing argument were unfairly prejudicial and warrant
a new trial.  Plaintiffs contend that they were unduly prejudiced
because defense counsel said:
     "But Dr. Kimble at $500 per will get up and say
     whatever it takes  . . . Dr. Kimble accepts wholesale
     whatever Mr. Pfaff asks him to accept."
and
     "No one supports Dr. Kimble's last theory but Dr.
     Kimble.  I submit to you that Dr. Kimble will say
     whatever it takes for the paycheck he picks up."
and
     "Our quarrel in this case is with Dr. Kimble.  Our
     quarrel is with his honesty.  Our quarrel is with
     someone taking money in exchange for whatever it takes
     to get it to you folks."
Although counsel objected to these remarks, the trial court
overruled the objections.
     An attorney is given broad latitude in closing argument to
argue the evidence and any reasonable inferences that may be
drawn from it.  Hajian v. Holy Family Hospital, 273 Ill. App. 3d
932, 652 N.E.2d 1132 (1995).  Reversal will be warranted only
when the attorney's remarks are clearly improper and prejudicial.
Kwon v. M.T.D. Products, Inc., 285 Ill. App. 3d 192, 673 N.E.2d 408 (1996).  The scope of closing argument is left to the sound
discretion of the trial court.  O'Neil v. Continental Bank, N.A.,
278 Ill. App. 3d 327, 662 N.E.2d 489 (1996).
     In this case defense counsel's references to Dr. Kimble
related to his testimony regarding the theory that Dr. Yon had
punctured or perforated Ryan's esophagus when intubating Ryan. 
Evidence was presented at trial that this theory was developed
after Dr. Kimble's deposition testimony, at the suggestion of
plaintiff's trial counsel, in light of certain autopsy photos. 
Dr. Yana, who performed the autopsy, testified at trial, however,
that there had been no damage to the esophagus and the alleged
"hole" depicted in the autopsy photo was the site where Dr. Yana
had severed Ryan's thyroid gland for examination and analysis.
     Even under these provocative circumstances, plaintiffs'
counsel's comments regarding Dr. Kimble and defense counsel were
improper and unprofessional.  See Regan v. Vizza, 65 Ill. App. 3d
50, 382 N.E.2d 409 (1978)(likening expert medical witness to
"hired gun" was improper); Cecil v. Gibson, 37 Ill. App. 3d 710,
346 N.E.2d 448 (1976)(reference to plaintiff's expert as a
"sidekick" and "righthand man" was improper; but see Ellington v.
Bilsel, 255 Ill. App. 3d 233, 626 N.E.2d 386 (1993)(reference to
expert as "polished" and "a performer" were not as inflammatory
as the "hired gun" line of cases); Moore v. Centreville Township
Hospital, 246 Ill. App. 3d 579, 616 N.E.2d 1321 (1993)("hired
gun" type of argument not improper).  Under the circumstances of
this case, however, we cannot say plaintiffs were so unfairly
prejudiced that a new trial is warranted.
                                CONCLUSION
     For all the reasons stated above, we affirm the judgment
entered in the circuit court.
     AFFIRMED.
     CERDA, JJ., concurs.
     McNAMARA, J., specially concurring:
     I agree with the result reached by the majority.  However, 
I do not believe that the comments of defense counsel during
closing argument about plaintiff's expert witness were improper. 
See Moore v. Centreville Township Hospital, 246 Ill.App.3d 579,
616 N.E.2d 1321 (1993).