A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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DC Comics Turns the Occupy Movement Into a Superhero Title

Eighteen months after the phrase first entered the collective public consciousness, the plight of the 99 percent is coming to mainstream superhero comics — via a new series from the second biggest publisher in the American comic industry, which just happens to be a subsidiary of a multi-national corporation that makes around $12 billion a year. Irony, anybody?

In May, DC Comics will launch two new series taking place in their mainstream superhero universe that offer different insights into the class struggle in a world filled with superheroes, alien races and inexplicable events. The Green Team, written by Tiny Titans and Superman Family Adventures creators Art Baltazar and Franco, with art by Ig Guara, revives an obscure 1975 concept about teenage rich kids who try to make the world a better place with their outrageous wealth. In an interview promoting the series, Franco promised that it would address questions like “Can money make you happy?” and “If you had unlimited wealth, could you use that to make the lives of people better?”

Obviously, this is one of the more fanciful series DC will be publishing.

But while DC is promoting The Green Team series as the adventures of the “1%,” its companion title, The Movement, is teased as a chance for us to “Meet the 99%… They were the super-powered disenfranchised — now they’re the voice of the people!”

“It’s a book about power,” explained The Movement writer Gail Simone. “Who owns it, who uses it, who suffers from its abuse. As we increasingly move to an age where information is currency, you get these situations where a single viral video can cost a previously unassailable corporation billions, or can upset the power balance of entire governments. And because the sources of that information are so dispersed and nameless, it’s nearly impossible to shut it all down.”

“The thing I find fascinating and a little bit worrisome is, what happens when a hacktivist group whose politics you find completely repulsive has this same kind of power and influence,” she elaborated in an interview at Big Shiny Robot. “What if a racist or homophobic group rises up and organizes in the same manner?”

While the concept is ambitious, the idea that a comic capable of living up to the book’s populist inspiration could come from DC Entertainment still strikes some as unlikely. Matt Pizzolo, the editor of the Occupy Comics anthology, told Wired that “though DC Comics did help launch Alan Moore and David Lloyd’s seminal anarchist epic V For Vendetta over two decades ago, it’s unlikely they would do so today. Between dismantling Vertigo and frankensteining Watchmen, the past year has demonstrated DC isn’t a safe place for bold creators who want to tell the kinds of stories that would inspire things like Occupy, rather than just cash in on them.”

Still, Simone says that the use of the iconography and language of a real-world populist movement is deliberate, promising that the book will reflect today’s decentralized political world and offer ”a slice of rarity that we’re unlikely to see in most superhero books.”

This wouldn’t the first time that DC has attempted to offer pre-packaged populist rebellion, of course; in addition to the aforementioned publication of the anti-establishment V For Vendetta, the company’s Vertigo imprint also published Grant Morrison’s The Invisibles, a series centering around an international organization struggling against forces of authority and repression that included anti-corporate themes.

Only time will tell whether The Movement will live up to the subversive examples of these earlier books, or just end up a well-intentioned piece of topical super heroics that trades on, and commodifies, a real political movement.

The Movement #1 will be available in both print and digital formats on May 1, while The Green Team #1 will be released on May 22.

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Mary J. Blige honored by Vibe at pre-Grammy party

LOS ANGELES (AP) — Babyface called her an icon; Diddy said she was like a sister; and Anita Baker credited her for helping secure her latest Grammy nomination.

There was no shortage of superlatives bestowed on Mary J. Blige on Friday night as Vibe magazine celebrated the Queen of Hip-Hop Soul’s career, which has now spanned for more than two decades.

“She’s a musical soulmate, she’s my sister, she’s one of my best friends in the world,” said Diddy, who has worked with Blige since the beginning of her career. “Mary is our queen. … There is no one to come after her.”

Blige was feted during Vibe’s first Impact Awards, which coincided with the magazine’s 20th anniversary. The event included guests like MC Lyte, Jermaine Dupri and Queen Latifah. Blige appeared to wipe away tears at moments as she was lauded by one guest after another.

Babyface, who wrote one of Blige’s biggest hits, “Not Gon’ Cry,” recalled being a little intimidated by the idea of working with Blige, whom he saw as a tough New Yorker.

“Mary walked in and she was so sweet … and so respectful and totally melted me right there,” he said.

Diddy recalled how Blige worked with him after he got fired from one of his first high-profile jobs in the industry and when no else one would, and also said she was one of his best friends.

One of the more emotional tributes came from Baker, who was a childhood idol of Blige’s. Baker thanked Blige for seeking her out for collaborations and helping a new generation discover her music.

“That kind of generosity is non-existent in our business,” said Baker, who is nominated for a Grammy at Sunday’s awards. “This Grammy nomination that I have is in great part because you spoke my name into the 21st century.”

Latifah noted the personal transformation of Blige, who overcame substance abuse and other obstacles to become one of music’s leading role models.

“For me when I look back at you and the journey you’ve taken, I find you to be extremely inspirational and aspirational, especially to young women,” Latifah said.

When Blige got up to accept her honor, she thanked everyone for embracing her throughout her career, even during her very public missteps. She also thanked people for accepting her imperfections. She recounted a story about being sent to charm school early in her career by handlers who thought she needed to smooth over her rough edges. But Blige was not a good student.

“I just walked out and I never went back,” Blige said. “I’m glad I didn’t go back because I don’t think that I would have had an impact on anyone’s life had I lived someone else’s life.”

Blige recently starred as Betty Shabazz, the widow of Malcolm X, in the Lifetime movie “Betty & Coretta” co-starring Angela Bassett.

___

Online:

http://www.maryjblige.com

___

Follow Nekesa Mumbi Moody on Twitter at http://www.twitter.com/nekesamumbi

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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Degrees of Debt: College Costs, Battled a Paycheck at a Time

If Steve Boedefeld graduates from Appalachian State University without any student loan debt, it will be because of the money he earned fighting in Iraq and Afghanistan and the money he now saves by eating what he grows or kills.

Zack Tolmie managed to escape New York University with no debt — and a degree — by landing a job at Bubby’s, the brunch institution in TriBeCa, where he made $1,000 a week. And he had entered N.Y.U. with sophomore standing, thanks to Advanced Placement credits. All that hard work also yielded a $25,000 annual merit scholarship.

The two are part of a rare species on college campuses these days, as the nation’s collective student loan balance hits $1 trillion and continues to rise. While many students are trying to defray some of the costs, few can actually work their way through college in a normal amount of time without debt and little or no need-based financial aid unless they have an unusual combination of bravery, luck and discipline.

“I literally never went out,” Mr. Tolmie says. “There just was not time to do that.”

Plenty of influential people assume that teenagers can ask parents for loans if all else fails, as Mitt Romney suggested during the 2012 presidential campaign. Others recall working their way through college themselves, including Representative Virginia Foxx, a Republican from North Carolina who heads a House subcommittee on higher education and work force training. “I spent seven years getting my undergraduate degree and didn’t borrow a dime of money,” she once said at a subcommittee meeting, adding that she was bewildered, given her own experience, by tales of woe she had heard from people with $80,000 in debt.

But students nowadays who try to work their way through college without parental support or loans face a financial challenge of a different order than the one that Ms. Foxx, 69, confronted as a University of North Carolina undergraduate more than 40 years ago. Today, a bachelor’s degree from Appalachian State, the largest university in her district, can easily cost $80,000 for a state resident, including tuition, room, board and other costs. Back in her day, the total was about $550 a year. Even with inflation, that would translate to just over $4,000 for each year it takes to earn a degree.

And the paychecks that Mr. Tolmie managed in the big city are only a dream in towns like Boone, where employers have their pick of thousands of Appalachian State undergraduates. Even the most industrious, like Kelsey Manuel, a junior who drives 10 miles each way to a job in a resort where she earns $10 to $11 an hour, often cannot work enough to finish college debt-free.

No one tracks how many students are trying to work their way through without parental assistance or debt, but plenty work long hours while also attending classes full time. As of 2010, some 17 percent of full-time undergraduates of traditional age worked 20 to 34 hours a week, according to the National Center for Education Statistics. About 6 percent worked 35 hours or more.

Students who work fewer than 30 hours a week (excluding federal work-study jobs) while in college were 1.4 times more likely to graduate within six years than students who spent more than 30 hours a week in a job, according to an article by Pilar Mendoza, an assistant professor of higher education administration at the University of Florida, in The Journal of Student Financial Aid last year. Their grades are likely to be better, too, since they have more time to study.

But working less has financial consequences. “You have two choices,” Ms. Mendoza says of students whose families could not or would not contribute to their college costs. “You either work, or you acquire debt.”

Banking on Brunch

Zack Tolmie chose to work. He first caught sight of New York University on television when he was a freshman in high school in Altamont, N.Y., outside Albany. While his parents wanted him to attend college, their savings suffered in the 2001 recession.

So Mr. Tolmie got a job at a Johnny Rockets restaurant. By the time he started college in 2007, he had saved $8,000, four times as much as his parents had accumulated for him.

Impressed by the pluck he had demonstrated in passing so many Advanced Placement tests, N.Y.U. guaranteed Mr. Tolmie $25,000 in merit scholarships each year, which left him with about $75,000 that he needed to earn over three years. “I had a chart on my desk so that every time I sat down I would need to look at it,” he says. “Every two weeks I needed X amount. That first year, it would have been around $600 after taxes.”

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Big Bear locked down amid manhunt

The bustling winter resort of Big Bear took on the appearance of a ghost town Thursday as surveillance aircraft buzzed overhead and police in tactical gear and carrying rifles patrolled mountain roads in convoys of SUVs, while others stood guard along major intersections.

Even before authorities had confirmed that the torched pickup truck discovered on a quiet forest road belonged to suspected gunman Christopher Dorner, 33, officials had ordered an emergency lockdown of local businesses, homes and the town's popular ski resorts. Parents were told to pick up their children from school, as rolling yellow buses might pose a target to an unpredictable fugitive on the run.

By nightfall, many residents had barricaded their doors as they prepared for a long, anxious evening.

PHOTOS: A tense manhunt amid tragic deaths

"We're all just stressed," said Andrea Burtons as she stocked up on provisions at a convenience store. "I have to go pick up my brother and get him home where we're safe."

Police ordered the lockdown about 9:30 a.m. as authorities throughout Southern California launched an immense manhunt for the former lawman, who is accused of killing three people as part of a long-standing grudge against the LAPD. Dorner is believed to have penned a long, angry manifesto on Facebook saying that he was unfairly fired from the force and was now seeking vengeance.

Forest lands surrounding Big Bear Lake are cross-hatched with fire roads and trails leading in all directions, and the snow-capped mountains can provide both cover and extreme challenges to a fugitive on foot. It was unclear whether Dorner was prepared for such rugged terrain.

Footprints were found leading from Dorner's burned pickup truck into the snow off Forest Road 2N10 and Club View Drive in Big Bear Lake.

San Bernardino County Sheriff John McMahon said that although authorities had deployed 125 officers for tracking and door-to-door searches, officers had to be mindful that the suspect may have set a trap.

"Certainly. There's always that concern and we're extremely careful and we're worried about this individual," McMahon said. "We're taking every precaution we can."

PHOTOS: A fugitive's life on Facebook

Big Bear has roughly 400 homes, but authorities guessed that only 40% are occupied year-round.

The search will probably play out with the backdrop of a winter storm that is expected to hit the area after midnight.

Up to 6 inches of snow could blanket local mountains, the National Weather Service said.

FULL COVERAGE: Sweeping manhunt for rampaging ex-cop

Gusts up to 50 mph could hit the region, said National Weather Service meteorologist Mark Moede, creating a wind-chill factor of 15 to 20 degrees.

Extra patrols were brought in to check vehicles coming and going from Big Bear, McMahon said, but no vehicles had been reported stolen.

"He could be anywhere at this point," McMahon said. When asked if the burned truck was a possible diversion, McMahon replied: "Anything's possible."

Dorner had no known connection to the area, authorities said.

Craig and Christine Winnegar, of Murrieta, found themselves caught up in the lockdown by accident. Craig brought his wife to Big Bear as a surprise to celebrate their 28th wedding anniversary. Their prearranged dinner was canceled when restaurant owners closed their doors out of fear.

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Watch Pirate Bay Documentary <em>TPB AFK</em> Here (Or on Pirate Bay, Naturally)

Get ready to pirate the pirates — legally. DIY indie documentary The Pirate Bay — Away From Keyboard (aka TPB AFK) premiered Friday at the Berlin International Film Festival, and quickly became available for viewing via YouTube, paid digital download, and, naturally, the torrent-based file-sharing site The Pirate Bay.

Partially funded by Kickstarter, where director Simon Klose raised more than $50,000 for the film, TPB AFK documents the hectic trial of Pirate Bay administrators Fredrik Neij, Gottfrid Svartholm Warg, and Peter Sunde, who were eventually convicted in a civil and criminal copyright case in Sweden in 2009 that pitted them against the government and the entertainment industry. The men were given jail sentences and millions of dollars in fines for their work with the torrent-based site.

True to the spirit of his subjects, Klose is offering his movie in almost every online format there is; you can pay to download the film, watch a YouTube stream, or (naturally) torrent it for free via the Pirate Bay. (There’s also a DVD pre-order for those who want to keep it old-school.) The director is encouraging fans to share and remix his movie however they like, with a Creative Commons license.

“The cool thing is that you guys are going to be part of the premiere.… We’re streaming the film online, for free. You can download it, you can share it, you can remix it – it’s all up to you,” Klose said in a video announcing the premiere on the movie’s website. “I’m doing this because I believe, from a personal perspective, I want my films to be seen by as many people as possible, so my problem is that a normal copyright would become an obstacle between me and my audience.”

As of this writing, the film’s site reports that it’s already processed some 2,000 paid downloads, bringing in a little over $22,000 (the base price is $10, but buyers can opt to donate more). TPB AFK will have its North American premiere at the South by Southwest Film Conference and Festival in March.

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Well: Think Like a Doctor: A Confused and Terrified Patient

The Challenge: Can you solve the mystery of a middle-aged man recovering from a serious illness who suddenly becomes frightened and confused?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult case and solve a diagnostic riddle. Below you will find a summary of a case involving a 55-year-old man well on his way to recovering from a series of illnesses when he suddenly becomes confused and paranoid. I will provide you with the main medical notes, labs and imaging results available to the doctor who made the diagnosis.

The first reader to figure out this case will get a signed copy of my book, “Every Patient Tells a Story,” along with the satisfaction of knowing you solved a case of Sherlockian complexity. Good luck.

The Presenting Problem:

A 55-year-old man who is recovering from a devastating injury in a rehabilitation facility suddenly becomes confused, frightened and paranoid.

The Patient’s Story:

The patient, who was recovering from a terrible injury and was too weak to walk, had been found on the floor of his room at the extended care facility, raving that there were people out to get him. He was taken to the emergency room at the Waterbury Hospital in Connecticut, where he was diagnosed with a urinary tract infection and admitted to the hospital for treatment. Doctors thought his delirium was caused by the infection, but after 24 hours, despite receiving the appropriate antibiotics, the patient remained disoriented and frightened.

A Sister’s Visit:

The man’s sister came to visit him on his second day in the hospital. As she walked into the room she was immediately struck by her brother’s distress.

“Get me out of here!” the man shouted from his hospital bed. “They are coming to get me. I gotta get out of here!”

His brown eyes darted from side to side as if searching for his would-be attackers. His arms and legs shook with fear. He looked terrified.

For the past few months, the man had been in and out of the hospital, but he had been getting better — at least he had been improving the last time his sister saw him, the week before. She hurried into the bustling hallway and found a nurse. “What the hell is going on with my brother?” she demanded.

A Long Series of Illnesses:

Three months earlier, the patient had been admitted to that same hospital with delirium tremens. After years of alcohol abuse, he had suddenly stopped drinking a couple of days before, and his body was wracked by the sudden loss of the chemical he had become addicted to. He’d spent an entire week in the hospital but finally recovered. He was sent home, but he didn’t stay there for long.

The following week, when his sister hadn’t heard from him for a couple of days, she forced her way into his home. There she found him, unconscious, in the basement, at the bottom of his staircase. He had fallen, and it looked as if he may have been there for two, possibly three, days. He was close to death. Indeed, in the ambulance on the way to the hospital, his heart had stopped. Rapid action by the E.M.T.’s brought his heart back to life, and he made it to the hospital.

There the extent of the damage became clear. The man’s kidneys had stopped working, and his body chemistry was completely out of whack. He had a severe concussion. And he’d had a heart attack.

He remained in the intensive care unit for nearly three weeks, and in the hospital another two weeks. Even after these weeks of care and recovery, the toll of his injury was terrible. His kidneys were not working, so he required dialysis three times a week. He had needed a machine to help him breathe for so long that he now had to get oxygen through a hole that had been cut into his throat. His arms and legs were so weak that he could not even lift them, and because he was unable even to swallow, he had to be fed through a tube that went directly into his stomach.

Finally, after five weeks in the hospital, he was well enough to be moved to a short-term rehabilitation hospital to complete the long road to recovery. But he was still far from healthy. The laughing, swaggering, Harley-riding man his sister had known until that terrible fall seemed a distant memory, though she saw that he was slowly getting better. He had even started to smile and make jokes. He was confident, he had told her, that with a lot of hard work he could get back to normal. So was she; she knew he was tough.

Back to the Hospital:

The patient had been at the rehab facility for just over two weeks when the staff noticed a sudden change in him. He had stopped smiling and was no longer making jokes. Instead, he talked about people that no one else could see. And he was worried that they wanted to harm him. When he remained confused for a second day, they sent him to the emergency room.

You can see the records from that E.R. visit here.

The man told the E.R. doctor that he knew he was having hallucinations. He thought they had started when he had begun taking a pill to help him sleep a couple of days earlier. It seemed a reasonable explanation, since the medication was known to cause delirium in some people. The hospital psychiatrist took him off that medication and sent him back to rehab that evening with a different sleeping pill.

Back to the Hospital, Again:

Two days later, the patient was back in the emergency room. He was still seeing things that weren’t there, but now he was quite confused as well. He knew his name but couldn’t remember what day or month it was, or even what year. And he had no idea where he was, or where he had just come from.

When the medical team saw the patient after he had been admitted, he was unable to provide any useful medical history. His medical records outlined his earlier hospitalizations, and records from the nursing home filled in additional details. The patient had a history of high blood pressure, depression and alcoholism. He was on a long list of medications. And he had been confused for the past several days.

On examination, he had no fever, although a couple of hours earlier his temperature had been 100.0 degrees. His heart was racing, and his blood pressure was sky high. His arms and legs were weak and swollen. His legs were shaking, and his reflexes were very brisk. Indeed, when his ankle was flexed suddenly, it continued to jerk back and forth on its own three or four times before stopping, a phenomenon known as clonus.

His labs were unchanged from the previous visit except for his urine, which showed signs of a serious infection. A CT scan of the brain was unremarkable, as was a chest X-ray. He was started on an intravenous antibiotic to treat the infection. The thinking was that perhaps the infection was causing the patient’s confusion.

You can see the notes from that second hospital visit here.

His sister had come to visit him the next day, when he was as confused as he had ever been. He was now trembling all over and looked scared to death, terrified. He was certain he was being pursued.

That is when she confronted the nurse, demanding to know what was going on with her brother. The nurse didn’t know. No one did. His urinary tract infection was being treated with antibiotics, but he continued to have a rapid heart rate and elevated blood pressure, along with terrifying hallucinations.

Solving the Mystery:

Can you figure out why this man was so confused and tremulous? I have provided you with all the data available to the doctor who made the diagnosis. The case is not easy — that is why it is here. I’ll post the answer on Friday.

Friday Feb. 8 4:13 p.m. | Updated Thanks for all your responses. You can read about the winner at “Think Like a Doctor: A Confused and Terrified Patient Solved.”

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Rules and Regulations: Post your questions and diagnosis in the comments section below.. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Correction: The patient’s eyes were brown, not blue.

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European Union Leaders Agree to Slimmer Budget

BRUSSELS — As European Union leaders began their 14th hour of budget negotiations after a sleepless night, Valdis Dombrovskis, the prime minister of Latvia, took the floor early Friday to address what, for his Baltic nation of around just two million people, is a vital question: Why should a Latvian cow deserve less money than a French, Dutch and even Romanian one?

In a system that requires unanimous approval of budget decisions, what Latvia wants for its dairy farmers — or Estonia for its railways, Hungary for its poorer regions and Spain for its fishermen — is no small matter. It is this cacophony of local concerns that explains why, despite the outsize role in decision-making of Germany, the European Union has such trouble reaching an agreement on something as basic as a budget.

And if simply agreeing to a basic budget — the first decrease in its history — is so daunting to member countries, it also raised serious questions about the limits of political and economic integration that have long been the master plan for champions of European unity.

After a failed attempt to fix spending targets at the summit meeting in November and a 24-hour marathon of talks this week, European leaders finally agreed late Friday to a common budget for the next seven years. Slightly smaller than its predecessor, the new budget plan reflects the climate of austerity across a continent still struggling to emerge from a crippling debt crisis.

The colossal effort that was required to agree to a sum amounting to about €960 billion, or $1.28 trillion, or a mere 1 percent of the bloc’s gross domestic product, again exposed the stubborn attachment to national priorities that have made reaching agreements on how to save the euro so painful in recent years.

“We need to agree and to agree we need to take into account all countries,” said Mr. Dombrovskis in an interview. The Latvian leader, who rushed to his hotel for a shave, shower and change of shirt in the middle of the night, described the ordeal as “not a pleasant experience,” but said “it only happens every seven years so we can tolerate it.”

But toleration is not the same thing as cooperation.

“What we’re seeing is that European integration is very important to European leaders as long as it doesn’t imply that someone has to be paying for someone else,” said Daniel Gros, director for the Center for European Policy Studies, a research organization in Brussels.

“Sharing a European budget is not going to be the essence of the E.U., but crafting the rule books for open borders and stable banking systems will be,” said Mr. Gros.

For other observers, the spectacle of European leaders haggling through the night over amounts of money representing rounding errors in their national accounts once again demonstrated their reluctance to make policies together that erode their nations’ sovereignty.

“The budget negotiations are most visible sign of member states winning and losing from the European Union,” said Hugo Brady, a senior research fellow at the Center for European Reform, a research organization. “The result is a totally parochial budget that is poorly adapted to rapidly changing times,” he said.

The deal faces yet another hurdle before it becomes law at the European Parliament, which has the power to veto the budget.

Some of the most influential figures in Parliament have already signaled that they are prepared to reject a budget that foresees spending less on Europe in the years ahead.

Martin Schulz, the president of the Parliament, said this week he would not approve a budget that ended up widening the overall gap between the cash paid up-front by governments and the somewhat higher amounts, known as commitments, which make up the overall budget.

Britain, Sweden and the Netherlands were among the Northern European nations that fought hard to squeeze agricultural subsidies and increase spending on research and development to boost the bloc’s global competitiveness.

This article has been revised to reflect the following correction:

Correction: February 8, 2013

An earlier version of this article misspelled, on one reference, the last name of the Latvian prime minister. It is Dombrovskis, not Domobrovskis.

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Ex-cop at center of manhunt called 'depraved,' 'cowardly'

The fired LAPD officer suspected of terrorizing Southern California in a bloody rampage opened fire on two Riverside police officers with a rifle in a "cowardly ambush" early Thursday morning, Riverside police Chief Sergio Diaz told reporters at a morning news conference.

A 34-year-old officer who was an 11-year veteran of the department was killed in the attack. He was training a 27-year-old officer, who was shot in the upper body but survived, Diaz said. Their names were not released.

Diaz, a former Los Angeles Police Department deputy chief, said he believed the attack was random, coming less than 20 minutes after the suspect -- identified as Christopher Jordan Dorner -- had opened fire on two LAPD officers in Corona near the Magnolia Street exit ramp on Interstate 15.

PHOTOS: The Manhunt

Those officers were among 41 special details dispatched to protect LAPD officers whom Dorner, in an online manifesto, allegedly threatened to hunt down in revenge for being dismissed from the force.

"My opinion of the suspect is unprintable,'' Diaz said. "The manifesto I think speaks for itself as evidence enough of a depraved and abandoned mind and heart.''

The suspect allegedly opened fire as the Riverside officers were stopped at red light at the intersection of Magnolia Avenue and Arlington Boulevard around 1:35 p.m. Bullets pierced the patrol car's windshield, hitting both officers in the chest, Diaz said.

Law enforcement officers from agencies around the Inland Empire descended on Riverside after the shooting to assist with the manhunt. Officers tooting rifles and shotguns stood vigil outside the Riverside police station, which has been placed on "high alert.''

Diaz described the situation as surreal.

"We're hoping to wake up and find this is a bad dream,'' he said

Corona police Chief Michael Abel said the suspect opened fire on two LAPD officers after they were flagged down by a resident who recognized Dorner's Nissan Titan pickup truck. After a short pursuit, Dorner shot at the officers with a rifle, grazing one on the head. The LAPD officers returned fire but their patrol car was disabled and they could not continue the pursuit.

The LAPD officer who was shot was hospitalized and a full recovery is expected, said LAPD Dep. Chief Jose Perez. He was not identified.

Diaz's news conference, held in a Riverside police station near the Tyler Mall, was flooded with television news crews and other media.

Diaz said the department decided to delay releasing the names of the slain and wounded officers because of fears that Dorner, in his quest to hunt down police officers and their relatives, may target their families.

With the city on edge, Diaz urged parents to continue sending their children to school -- which he said was the safest place for them -- and for local businesses to stay open. There's no evidence that Dorner remained in Riverside, or that that he was targeting anyone in the city, Diaz said.

Diaz said he did not know the suspect while he was with the LAPD, and did not have any role in the grievance proceeding that led to Dorner's dismissal in 2009.

"We're going to find him. You can't have this many people looking for you and not be found,'' Diaz said.

Some schools in the area were closed.

A note posted on the Notre Dame Catholic High School website said the school was closed because of the shooting. The school is not far from the scene of the attack.

Meanwhile, a spokeswoman with the Riverside Unified School District said officials were trying to reassure parents that the district's campuses were safe and that they were working closely with authorities.

"Of course, we are being vigilant, even more extra than we normally do," said district spokeswoman Jacquie Paul.

Despite the outreach some parents have chosen to keep their children at home, she said.

PHOTOS: The Manhunt

The district oversees about 42,000 students from kindergarten through high school. She said students would be excused if their parents decided to keep them home. 

"We're very understanding of parents who are nervous, because we understand where they are coming from."

Assistant Supt. David Hansen of the Corona Norco Unified School District said some parents in his district had also kept their students home.

Hansen said all schools were operating normally. He said a automatic phone message was sent to parents telling them that officials were aware if the shootings, and to ensure them they were working closely with police.

"There's anxiety all around because this has been on the news," Hansen said.

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