For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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18 accused in huge credit card scam were patient, authorities say

NEWARK, N.J. — Many scam artists are looking for ways to get rich quick.

Then there are the 18 people authorities said spent years meticulously creating fake identities, building up their credit scores and credit card limits, and borrowing money they never repaid in what may be one of the nation's largest credit card fraud rings.

The 18 were charged last week in what authorities said was a sprawling international scam in which at least $200 million was stolen using at least 7,000 identities and 25,000 credit cards. The enterprise spanned 28 states and eight countries, authorities said.

The elaborate fraud involved an outlay of patience and meticulous planning rarely seen in such a large credit card fraud case, authorities and industry analysts said.

"What they did was very painstaking, very sophisticated and took a lot of time," said Paul Fishman, the U.S. attorney in Newark, who announced the arrests Tuesday.

The scam started at least as early as 2007, Fishman said. The group created thousands of fake identities, sometimes using real Social Security numbers. One credit card was opened with the identity of a 6-year-old boy; others used Social Security numbers of people who were willing to leave the United States for a fee, Fishman said.

"You have to pull a lot of stuff together. You have to have a phone service and address where you're paying bills," said Avivah Litan, a vice president and analyst at Gartner Research. "They have to do a lot of background work to look like a real person."

The group then opened credit cards with small credit limits. The users purchased everyday items like groceries and paid off the bills so they could increase their credit score. That way, they were able to give the impression that they were a trusted customer, giving them access to a higher credit limit and cash advance checks.

Litan said one of the most impressive aspects of the scam was that the defendants were able to access so much credit during the financial crisis. They probably had to appear to be sterling customers in order to pump up their credit limits so high.

"They did this the last few years when credit was hard to come by," Litan said. "The banks don't give you $50,000 right away."

Authorities allege the defendants added one another and sham businesses as authorized users on credit card accounts, giving more people access to good credit. They received credit card machines with the scam businesses and paid themselves with the cards, Fishman said, and three jewelry stores in Jersey City were allegedly complicit in the scheme.

The defendants then maxed out the cards, buying electronics, jewelry and luxury cars. They also took out loans or cashed the checks and never paid back the money, authorities said.

Authorities did not directly say how the fraud came to light, but a co-conspirator was named in court documents, indicating that someone may have been cooperating.

Al Pascual, senior analyst at Javelin Strategy and Research, said it would be very unlikely for credit bureaus to have caught such a fraud if the cards were initially being used responsibly and paid off. Red flags also would not have been raised if accounts were opened using legitimate Social Security numbers that did not have any prior credit accounts, like a child.

"The activity itself shouldn't have garnered any notice until they stopped paying the bills," Pascual said.

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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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Beyonce, Jay-Z, Rihanna hang at Roc Nation brunch

LOS ANGELES (AP) — Jay-Z and Beyonce sat tightly with Solange. Kelly Rowland embraced Beyonce with a huge hug. And Rihanna spilled some of her drink laughing with Rowland.

Music's top stars attended the annual pre-Grammy Roc Nation and Nokia brunch Saturday at the Soho House.

Grammy nominee Miguel, Timbaland, Jill Scott and Kylie Mingoue also attended the exclusive event.

Jay-Z is one of six acts nominated for six awards at Sunday's Grammys. Rihanna is up for three trophies, and Beyonce is nominated for one award.

The crowd Saturday was full of members of music industry, who mingled with performers like The-Dream, Jordin Sparks, Melanie Fiona, Diane Warren, Christina Milian, MC Lyte and Santigold.

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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Boeing 787 Dreamliner takes test flight to assess batteries

SEATTLE — Aerospace giant Boeing Co. sent a 787 Dreamliner passenger jet on a test flight Saturday, the first since the new airliner was grounded three weeks ago because of a battery fire.

The aircraft took off from Boeing Field in Seattle and spent more than two hours flying back and forth over the inland Columbia Plateau. It landed at Boeing Field shortly before 3 p.m. Pacific Time. According to flight-tracking website FlightAware, the aircraft flew 1,131 miles, slightly more than the 919 planned.

The Federal Aviation Administration granted permission for test flights Thursday.

The 787 is the first commercial airliner to rely heavily on lithium-ion batteries, the same kind used in cellphones. Each plane has two of the 63-pound blue power bricks, one near the front to provide power to the cockpit if the engines stop and one near the back to start up the auxiliary power unit, which is essentially a backup generator.

On Jan. 7, a battery on a plane that had recently landed in Boston short-circuited and caught fire. Nine days later, a battery on an All Nippon Airways plane started smoking, leading to an emergency landing in Japan.

Boeing said Saturday's flight was to assess the in-flight performance of the batteries. Data would be used to support continuing investigations of the recent incidents.

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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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Kiefer Sutherland honored by Harvard theater group

CAMBRIDGE, Mass. (AP) — Golden Globe-winning actor Keifer Sutherland has been awarded the pudding pot after being honored as Man of the Year by Harvard's Hasty Pudding Theatricals.

The roast for the actor took place despite a massive snowstorm hitting the Boston area. The Friday evening event, including presentation of the traditional pudding pot, was moved to the Charles Hotel in Cambridge.

The 46-year-old Sutherland has been in dozens of films. He's perhaps best known for his role as Jack Bauer in the television series "24," for which he won Golden Globe and Primetime Emmy awards. He is currently starring in the television show "Touch."

Last year's Man of the Year was Jason Segel.

The 2013 Woman of the Year, Marion Cotillard (koh-tee-YAR'), was honored last week.

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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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Execs off the hook at S&P

You may have heard last week about a couple of big lawsuits brought by federal and state governments, alleging that the credit rating agency Standard & Poor's concocted a fraudulent scheme that contributed to trillions of dollars in investment losses and the cratering of pretty much the entire world financial system.

Those are serious charges, and the federal government's demand for $5 billion in penalties isn't peanuts. Yet there's something bloodless about the lawsuits, for the simple reason that they don't point the finger at any particular person who was responsible for these dastardly doings.

For example, you won't find the name Harold McGraw III anywhere in the court papers. Who?

McGraw was chairman, chief executive and president of McGraw-Hill, S&P's parent company, in the period at issue, 2004 to 2007. (He's still in place today.) Did he profit from S&P's wrongdoing? Let's assume so: he not only owns 10 million company shares but received $44.5 million in compensation over those years, according to corporate disclosures. Did he know or care about what was happening at S&P? One would hope so because it was by far the most profitable domain in his empire, contributing an average of more than 70% of McGraw-Hill's operating profit.

Harold McGraw's largest business unit engaged in an "egregious" fraud that "goes to the very heart" of the financial crisis, Atty. Gen. Eric H. Holder Jr. said. But prosecutors have made no effort to hold him, or anyone else, directly responsible for what was done at S&P.

These new lawsuits replay the only story uglier than the financial meltdown itself, which is the government's pathetic record at prosecuting the crimes that produced it.

For companies can't do things like manipulate numbers on spreadsheets, lie about their "independent" judgment, and fire employees who try to rectify such errors. Only people can.

In accordance with the government's standard approach to financial crisis justice, no flesh-and-blood people are on the hook in these cases. Only companies, which (more's the pity) can't be put in jail for their wrongdoing. Yet it's only people who can profit from such conniving.

The lawsuits name a few executives here and there, and identify others by initials (presumably they're the ones who cooperated with regulators). But the overall impression is that something happened at S&P, and some individuals were involved, but they were all swept up in some inchoate historical event that requires, nevertheless, that S&P fork over $5 billion. That's what makes reading these legal papers resemble getting through all of "War and Peace" without ever meeting Napoleon.

"We've had the greatest explosion of elite white collar crime in history and the weakest criminal justice response," observes William K. Black, who helped put financial wrongdoers behind bars as a thrift regulator after the savings-and-loan collapse of the 1980s. "There's reason to believe they're not unrelated."

To be fair, the S&P lawsuits — they include the federal case filed in Los Angeles and actions by more than a dozen states, including California — amount to a more aggressive regulatory attack than any mounted thus far. Their target is an indisputably major player in the meltdown.

The $5-billion penalty sought by the U.S. Justice Department would be a pittance compared with the damage done to investors and the general economy by S&P. But as the equivalent of about six years of corporate profits, it would be enough to reduce McGraw-Hill's Manhattan headquarters to a smoking hole in the ground — if you think there's any chance the government can make the claim stick. California Atty. Gen. Kamala Harris seeks redress of at least $1.4 billion in investment losses incurred by the California Public Employees' Retirement System and other state agencies on S&P-rated securities.

The essence of the governments' fraud claim is that S&P held itself out to be an independent and objective appraiser of investment securities, especially the residential mortgage-backed bonds that were hot investment vehicles during the housing bubble. But it wasn't.

To a great extent, the investors who took S&P at its word knew they were acting on faith. The firm, like the other major credit agencies, Moody's and Fitch, were paid for their ratings by the investment banks issuing the securities, a flagrant conflict of interest. S&P charged the bankers up to $750,000 to rate really oddball paper.

The lawsuits allege that as early as 2004, S&P began tailoring its ratings to keep those clients happy by exaggerating the safety of their securities. S&P allegedly allowed issuing bankers to browbeat analysts for better ratings. The firm delayed or suppressed changes in its analytical software that would reveal that huge swaths of the high-rated deals were heading south. It cheaped out on hiring enough analysts to keep up with the mounting need for accurate updates. Analysts emailed each other with complaints about the corrupting of their objectivity, while executives signaled, essentially, that they should put a sock in it.

Nevertheless, McGraw-Hill's annual reports every year from 2004 through 2007 touted S&P's stature as a "provider of independent credit ratings," even though it was then allegedly tailoring its procedures for the issuers' benefit.

When the firm could no longer delay the inevitable, it downgraded hundreds of billions of dollars worth of mortgage securities in a torrent — 9,000 in the second half of 2007, an additional 6,300 in early 2008, including some deals it had graced with AAA ratings only a few months before. Many investors were bound by law to rely on these ratings in choosing securities for their portfolios. The flood of downgrades made a bad market much, much worse.

None of this is news. The role of the rating agencies in the meltdown was documented thoroughly by the Financial Crisis Inquiry Commission, headed by former California Treasurer Phil Angelides, in January 2011 and by a Senate subcommittee under Sen. Carl Levin (D-Mich.) a few months later. Any aficionado of our financial train wreck can repeat many of the emails cited in the lawsuit from memory.

S&P's response to the lawsuits is standard: The firm wasn't cooking its numbers but was relying on "the same ... mortgage data available to the rest of the market," it said last week. Yet S&P held itself out to be experts — if all it was doing was repeating what everybody else knew, than who needed its opinion? Any investment bank could have dragged any nimrods off the street and gotten an opinion for —I'd wager —a lot less than $750,000.

No one should doubt that the federal and state prosecutors poured their souls into these cases. The California lawsuit followed nearly two years of investigation, interrogation and compiling of documents. And there are hints that investigations of Moody's may be continuing.

But the key question sidestepped by the new lawsuits is why no individuals are being brought to book for what were, in every way, the plots and designs of individual people, acting to slake their own greed and ambition. This is another example of what UC Irvine criminologist Henry Pontell calls "the trivialization of criminal fraud."

"This is essentially a criminal fraud case," Pontell told me. "The only difference between civil and criminal cases is that they [the prosecutors] can spend a lot less on civil cases because the burden of proof is lower."

That speaks to the impoverishment of our white collar prosecutorial corps since 9/11, when the best and brightest were diverted to anti-terrorism cases and not replaced. By normalizing major corporate fraud cases as merely matters for civil fines, however, this trend has destroyed the deterrent effect of the justice system.

"Persuasive anecdotal evidence exists that the prospect of criminal penalties is an effective deterrent" to wrongdoing in the corporate suite, Pontell said. "Upper-class businesspersons fear shame and fear incarceration. Paying fines? No problem — that's a cost of doing business. If anything, it's anti-deterrence."

That's true. It's a good bet that after fighting the government to a draw, McGraw-Hill will settle these lawsuits for much less than $5 billion and S&P will retain its plausible deniability in the next meltdown. The deterrent effect will be zero.

What would really deter wrongdoing? It would be an outcome that prompts a CEO of the future to instruct his underlings: "You better be on the straight and narrow, because the last thing in the world I want is to end up in jail like Harold McGraw."

That might work.

Michael Hiltzik's column appears Sundays and Wednesdays. Reach him at mhiltzik@latimes.com, read past columns at latimes.com/hiltzik, check out facebook.com/hiltzik and follow @latimeshiltzik on Twitter.

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