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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The fine line between legitimate businesses and pyramid schemes

Controversy is again casting a shadow over the multilevel marketing industry, as nutritional supplement company Herbalife Inc., which has thousands of distributors in the Chicago region, has been publicly called a pyramid scheme by a prominent investor — an allegation the company vigorously denies.

Meanwhile, a different multilevel marketer, Fortune Hi-Tech Marketing, was shut down in recent weeks after a lawsuit was brought by regulators and several states, including Illinois, alleging the company scammed consumers out of $169 million. The scheme affected an estimated 100,000 Americans, including some in Chicago, where it targeted Spanish-speaking consumers, the Federal Trade Commission alleged.

Most people outside the industry might have only a vague notion about multilevel marketing, also called network marketing and direct selling. It often involves personal sales of cosmetics, wellness products or home decor items — or as critics flippantly call it, "pills, potions and lotions" — usually sold through product parties hosted by friends or relatives.

For sellers, the companies offer the appeal of starting a business on the cheap with little training, working from home and being their own boss, if only for part-time money. Some might recruit friends and family to become sellers, which augments their own commissions and gives them a shot at the six-figure compensation many such marketing companies tout but few distributors attain.

The largest multilevel marketing companies, often known as MLMs, are household names: Avon, Mary Kay, Pampered Chef and Amway. MLMs have annual sales of about $30 billion, with about 16 million people in the United States selling their products, according to the industry group Direct Selling Association, which represents these firms and others.

The recent controversies might raise the question: What's the difference between a legitimate multilevel marketing company and an illegal pyramid scheme, in which only people who get in first — at the top of the pyramid-like structure — make money and everyone else is a dupe?

The harshest critics maintain there is no difference, that there's no such thing as a legitimate MLM and that the industry's secrets stay safe because of a cultlike mentality and a blind eye of regulators.

Jon M. Taylor, who was once a seller for an MLM company, said he has studied the industry for 18 years and analyzed more than 500 MLM companies. He maintains the website MLM-thetruth.com and offers a free e-book there.

"I have not yet found a good MLM — a good MLM is an oxymoron," Taylor said.

He said all MLM companies have the same flaw: They depend on endless chains of recruiting new members.  "There is no more unfair and deceptive practice than multilevel marketing," Taylor said.

Tracy Coenen, a forensic accountant and fraud investigator with Sequence Inc. in Chicago and Milwaukee, is author of the Fraud Files Blog. She is also a critic.

"Multilevel marketing companies are pyramid schemes that the government allows to operate," said Coenen. "The only difference is that Herbalife, or any multilevel marketing company, has a tangible product that they use to make their pyramid appear legitimate."

The Direct Selling Association says MLMs are legitimate businesses, and that the group has about 200 members carefully screened by the organization to ensure they are not pyramid schemes and don't use deceptive practices.

The Federal Trade Commission agrees there are legitimate MLMs. The difference between a legitimate business and pyramid scheme comes down to products.

If the company and its distributors make money primarily from the sale of products to end-users (and not boxes of product accumulating in a distributor's garage), it's OK.

By contrast, a pyramid scheme compensates those at the top of the pyramid with participation fees paid by those recruited at the bottom. It eventually collapses when the scheme can't recruit more people.

But identifying a pyramid scheme can be difficult because MLMs typically have product sales, along with recruitment fees and recruitment incentives.

"It gets cloudy when you have a situation where you have fees being paid for both," said Monica Vaca, assistant director of the FTC's division of marketing practices. "It's very nuanced."

While prosecuting an MLM can seem somewhat of a judgment call, cases have a common factor: deceptive promises about how much money distributors will earn, Vaca said.

In the Fortune Hi-Tech Marketing case filed last month, C. Steven Baker, director of the FTC's Midwest region, said, "These defendants were promising people that if they worked hard they could make lots of money. But it was a rigged game, and the vast majority of people lost money."

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Northeast blizzard: 5 dead, thousands without power

New York/Boston—

A record-breaking blizzard packing hurricane-force winds hammered the northeastern United States on Saturday, cutting power to 700,000 homes and businesses, shutting down travel and leaving at least five people dead.

The mammoth storm that stretched from the Great Lakes to the Atlantic dumped more than 3 feet of snow across the Northeast, the National Weather Service said.

Coastal blizzard and flood warnings were in effect, but Massachusetts and Connecticut lifted vehicle travel bans as the storm slowly moved eastward on Saturday afternoon.

Stratford, Connecticut, Mayor John Harkins said he had never seen such a heavy snowfall, with rates reaching 6 inches an hour.

"Even the plows are getting stuck," Harkins told local WTNH television.

The storm centered its fury on Connecticut, Rhode Island and Massachusetts, with the highest snowfall total, 38 inches, in Milford, Connecticut.

About 2,200 flights were canceled on Saturday, according to FlightAware, which tracks airline delays. Boston's Logan International Airport and Bradley International Airport in Windsor Locks, Connecticut, were shut down.

The storm dumped 29.3 inches of snow on Portland, Maine, breaking a 1979 record, the weather service said. Winds gusted to 83 miles per hour (134 km per hour) at Cuttyhunk, New York, and brought down trees across the region.

The storm contributed to three deaths in Connecticut, Governor Dannel Malloy told a news conference.

An 80-year-old woman was killed by a hit-and-run driver while clearing her driveway, and a 40-year-old man collapsed while shoveling snow. One man, 73, slipped outside his home and was found dead on Saturday, Malloy said.

A Boston fire official said an 11-year-old boy died from carbon monoxide poisoning. He was overcome by fumes as he sat in a running car to keep warm.

In Poughkeepsie, New York, a man in his 70s was struck and killed on a snowy roadway, local media reported.

A 30-year-old motorist in New Hampshire also died when his car went off the road, but the man's health might have been a factor in the accident, state authorities said.

Police in New York's Suffolk County, some using snowmobiles, rescued hundreds of motorists stuck overnight on the Long Island Expressway, said police spokesman Rich Glanzer.

Even as the big storm's force was slackening, the National Weather Service forecast a possible blizzard in the Great Plains.

Snow and, in some areas, blizzard conditions were expected across parts of Colorado, Nebraska, North Dakota, Minnesota, South Dakota and Wyoming through the weekend into Monday, it said.

POWER LINES DOWN

Utility companies reported about 700,000 customers without electricity across nine states as the wet, heavy snow brought down tree branches and power lines.

The Pilgrim Nuclear Power Plant in Plymouth, Massachusetts, lost power and shut down automatically late on Friday, but there was no threat to the public, the Nuclear Regulatory Commission said.

As the storm tapered off, streets in Cambridge, Massachusetts, were largely quiet except for snowblowers and shoveling. Kevin Tierney, 41, struggled with a snowblower to carve out a parking space in more than 2 feet of snow.

"I had this all planned out, and I don't know who said it, but everybody goes into a boxing match with a plan until they get punched in the mouth," said Tierney, an attorney.

Massachusetts, Rhode Island, Connecticut, New York and Maine declared states of emergency before the storm. The U.S. Postal Service suspended mail delivery in parts of those five states plus New Hampshire and Vermont.

Although New York was hit by a foot of snow, Fashion Week went on unfazed as crowds arrived to watch the morning's shows by Ruffian and LaCoste.

Andrea Daney, a digital marketing senior manager for LaCoste, said she was trying to be discreet as she changed from snow boots to high-heeled crushed blue velvet ankle boots.

"I'm calling it the shoe storm of the century," she said. "You have to make adjustments to your outfit."

The snow delighted New England's ski industry after a dry winter that has left green grass visible across much of the region.

Greg Kwasnick, a spokesman for Loon Mountain in Lincoln, New Hampshire, said business was slightly slower than normal on Saturday but likely would pick up in coming days as roads cleared.

"Snow is what it's all about," he said.

(Additional reporting by Scott Malone in Boston, Kevin Gray in Miami, Ellen Wulfhorst in New York, Ian Simpson in Washington, Jason McLure in Maine, Dan Burns in Connecticut, and Dan Lovering and Zach Howard in Massachusetts; Writing by Ian Simpson; Editing by Vicki Allen and Eric Beech)

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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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Rosenthal: Chevrolet restores style to Impala name

Because a brand embedded in our subconsciousness can find a space in our garage, the Impala endures.

About 16 million Chevys named for an African antelope have hit the road since 1958. And even though the one you recently returned to the airport rental lot bore little resemblance the one whose "giddy-up" the Beach Boys sang of a half-century ago, General Motors is betting the bloodline still can claim hearts.

A revamped 10th-generation 2014 model is now on display at the just-opened 105th Chicago Auto Show as a prelude to its dealership debut in a few weeks, a bid to re-establish its good name.

"It's always been a great brand name," Russ Clark, director of Chevrolet marketing, said alongside one of the made-over Impalas on the Auto Show floor at McCormick Place. "In fact, when we did research on the name, we found Impala is one of the strongest in terms of consideration and favorable opinion of any name in the industry. A lot of that is heritage. A lot of it is the fact that people say, 'I know people who have had them, and everybody loved them.'"

The brand has been ubiquitous for decades, even if you don't remember the Beach Boys immortalizing the vintage growl of a "four-speed dual-quad Posi-Traction 409" or how Robert Blake's 1970s TV tough guy Baretta drove a rusted-out Impala from '66, the era when Chevrolet could move about 1 million Impala sedans and station wagons a year. My own first car was a four-door V-8 '72 Impala, a powerful and roomy hand-me-down whose weather-beaten body — like the brand's identity — clearly had seen better days by the late '70s and early '80s.

More recent Impalas have hardly been the stuff of song, and it's hard to imagine them inspiring nostalgia. They've been too dully utilitarian to be iconic.

Nonetheless, although sales have slowed, it has been the overall best-seller among big sedans. Three-quarters of those sales have been as fleet vehicles for corporate salespeople, government agencies and rental companies. That means the premium has been on space, reliability and keeping costs down rather than the kind of panache and extras that might foster pride of ownership.

The goal of this Impala overhaul in both four- and six-cylinder iterations — drafting on similar nameplate revivals for models such as Ford's Taurus, Dodge's Charger and Chrysler's 300 — is to flip that 75-25 ratio of fleet sales to retail on its head.

"It makes perfectly good sense on General Motors' part to finally put some style back in the Impala," auto industry analyst Art Spinella, president of CNW Research, explained. "If you have a great brand name, to almost toss it off, treat it as an orphan and send it off to the fleet sales department with bland styling and cheap interiors, that's a disgrace. What they've done is kind of salvage themselves with this.

"It's finally dawned on General Motors that you can sell a consumer car to fleets, but you can't sell a fleet car to consumers. You always keep fleet cars (looking) relatively obscure and you keep the price way down, and that's what General Motors had been doing for years to keep the (Impala sales) volume up. Now they're taking another look. I don't think they've necessarily gone far enough, but it's a step in the right direction."

To wander through the vast Auto Show, which runs through Feb. 18, is to be reminded of how deeply many of us connect to vehicles, starting as children playing with toy trucks and cars. There's a teenage rite of passage when car keys and a license expand the world. Certain makes and models mesh with what played on their radios, the places traveled in them, the stage of life they marked.

That emotional bond doesn't form so easily with a mere box with wheels.

"What was it that made us fall in love with cars in the first place?" Henrik Fisker, executive chairman and co-founder of high-end hybrid carmaker Fisker Automotive, asked the crowd at Thursday's Economic Club of Chicago luncheon. "It struck me that most of us, when we really start to get our heart pumping about cars, it's usually not the cars of today. It's usually the cars of the '50s and '60s."

Road salt, slush and rain were my old '72 Impala's kryptonite. In time, its front bench seat reclined like a La-Z-Boy whenever I hit the gas because the floor beneath had rusted through. Whatever my affection for the vehicle, I could see the road we were on — literally and figuratively — both looking ahead and glancing down.

Thirty years after I traded it in for a sporty red Pontiac with seats that reclined only how and when I wanted, I would not have expected my old flame to generate much heat.

Carmakers, like most marketers, know that even when a brand is disconnected from what it once represented, it still can resonate. The new Impala is neither the muscular car of old nor the generic conveyance of late. Yet Impala means something to would-be buyers, and good or bad, it gives them something to measure this latest version against.

"They have equity in the name and you never get rid of a brand that has a good reputation," Spinella said. "Some people will buy it because it's an Impala. Some people won't. But they'll look at it because it's an Impala and they remember the Impala. It's easier to reintroduce a name than to introduce a name nobody knows."

I can still remember driving around with my friends with no particular place to go, a song on the radio about a horse with no name. If there was a tune about a nameless car, I don't recall it.

philrosenthal@tribune.com

Twitter @phil_rosenthal

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Blizzard slams Northeast

A blizzard slammed into the northeastern United States on Friday, snarling traffic, disrupting thousands of flights and prompting five governors to declare states of emergency in the face of a fearsome snowstorm.

The storm caused a massive traffic pile-up in southern Maine. Organizers of the U.S. sledding championship in that state postponed a race scheduled for Saturday, fearing too much snow for the competition.

The blizzard left about 10,000 along the East Coast without power. Almost 3,500 flights were canceled and officials in Massachusetts and Connecticut closed roads.

Forecasters warned about 2 feet of snow would blanket most of the Boston area with some spots getting as much as 30 inches. The city's record snowfall, 27.6 inches, came in 2003.

"We're seeing heavier snow overspread the region from south to north," said Lance Franck, a meteorologist with the National Weather Service in Taunton, Massachusetts, outside Boston. "As the snow picks up in intensity, we're expecting it to fall at a rate of upwards of two to three inches per hour."

Early Friday evening, officials warned that the storm was just ramping up to full strength, and that heavy snow and high winds would continue through midday on Saturday. The governors of Massachusetts, Rhode Island, Connecticut, New York and Maine declared states of emergency and issued bans on driving by early Friday afternoon.

Authorities ordered nonessential government workers to stay home, urged private employers to do the same, told people to prepare for power outages and encouraged them to check on elderly or disabled neighbors.

People appeared to take the warnings seriously. Traffic on streets and public transportation services was significantly lighter than usual on Friday.

"This is a very large and powerful storm, however we are encouraged by the numbers of people who stayed home today," Boston Mayor Thomas Menino told reporters.

Even so, the storm caused a few accidents, including a 19-vehicle pile-up outside Portland, Maine, that sent one person to the hospital.

Winds were blowing at 35 to 40 miles per hour by Friday afternoon and forecasters expected gusts up to 60 miles per hour as the evening wore on.

Almost 3,500 flights were canceled on Friday, with more than 1,200 planned cancellations for Saturday, according to the website FlightAware.com.

The storm also posed a risk of flooding at high tide to areas still recovering from superstorm Sandy last fall.

"Many of the same communities that were inundated by Hurricane Sandy's tidal surge just about 100 days ago are likely to see some moderate coastal flooding this evening," said New York Mayor Michael Bloomberg.

About one foot of snow was forecast to land on New York City.

Brick Township in New Jersey had crews out building up sand dunes and berms ahead of a forecast storm surge, said Mayor Stephen Acropolis.

Travel became more difficult as the day progressed. Massachusetts started closing its public transportation system at 3:30 p.m. and ordered most drivers off roads by 4 p.m. Connecticut also closed its roads.

The Amtrak railroad suspended service between New York, Boston and points north on Friday afternoon.

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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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S&C relay at center of Super Bowl outage

An electrical relay device supplied by Rogers Park's S&C Electric Co. was found to be at the center of the Super Bowl power outage in New Orleans, the company said Friday.

S&C Electric Co. said the outage, which lasted for more than 30 minutes at Sunday's game, happened when the demand for Superdome power exceeding a "trip setting" for its electrical relay.

But the device didn't malfunction, S&C said. Instead, it said it found in testing that system operators didn't account for the amount of power needed at the Superdome. S&C doesn't control the power settings on its equipment.

S&C wouldn't go into more details, but the power provider for Sunday's game was Entergy New Orleans, a unit of Entergy Corp.

In a statement, Entergy said the relay device had functioned properly at other high-profile sporting events, including the Sugar Bowl.

The relay was designed to prevent an outage if a cable connection to the stadium failed.

"S&C continues to work with all those involved to get the system back online, and our customers can continue to rely on the quality and performance of our products," Spokesman Michael Edmonds said in a statement.

S&C equipment is commonly used where high reliability is critical, he said, including data centers for United Parcel Service Inc., drug manufacturing centers and hospitals. The company also works with other stadiums throughout the U.S. and Canada.

Entergy said in a statement that the Superdome relay has been removed and replacement equipment is being examined.

That statement came before a special meeting of the New Orleans City Council's Utility Committee Friday morning to discuss the root cause of the outage.

Immediately after the game, Entergy indicated its equipment was functional and the problem must have come from the Superdome, but later said it was launching an investigation to determine the source of the problem.

"While some further analysis remains, we believe we have identified and remedied the cause of the power outage and regret the interruption that occurred during what was a showcase event for the city and state," Entergy New Orleans President and CEO Charles Rice said.

sbomkamp@tribune.com | Twitter: @SamWillTravel

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Snow to hit evening commute

A winter storm warning has been issued for Lake and McHenry counties, with heavy wet snow falling at the rate of one to two inches an hour in some northern suburbs.

Some areas, such as Gurneee, had 5 inches by 4 p.m. Those areas are expected to get 6 to 8 inches of snow by the time the storm moves out overnight, according to National Weather Service meteorologist Bill Nelson..

“Parts of Cook and DuPage counties will see around 2 to 5 inches,” Nelson said. Areas farther south will see only an inch or two.

As of 4:30 p.m. the Chicago put out 199 of its snow and salt trucks and expected to patrol main streets throughout the evening rush.

The Illinois Tollway also has mobilized its full fleet of 182 snowplows during rush hour and throughout the evening across the 286-mile system, according to a release.

By 4 p.m., Gurnee had 5 inches, Beach Park 4.6 inches, Wadsworth 4.5 inches, Kenosha 4.3 inches, Spring Grove 4 inches, Beach Park 3.1 inches, Antioch 2.8 inches and Bull Valley 2.1 inches.

North and northwest suburbs were seeing numerous accidents, from Barrington to Antioch, according to Traffic.com.

In McHenry County, police were warning motorists to avoid U.S. Route 31 between Crystal Lake and McHenry because the road was "impassable" where it crosses over a hill.

State police said expressways were largely clear but the weather service warned of a slow evening commute.

"The threat for a period of heavy snow could result in reduced visibilities under a mile at times and rapid accumulation on area roads during the evening commute," the weather service warned.

Photos: Chicago winter 2012-13

Still, the storm was nothing like the one barreling toward New England with forecasts of up to two feet of snow. A blizzard warning has been issued for New York City, Connecticut and the Boston area.

Forecasters warned the snow would begin lightly on Friday morning but ramp up to blizzard conditions by afternoon, leading Boston Mayor Thomas Menino to order the city's schools closed Friday. He asked businesses to consider allowing staff to stay home.

"We are hardy New Englanders, let me tell you, and used to these types of storms. But I also want to remind everyone to use common sense and stay off the streets of our city. Basically, stay home," Menino told reporters. "Stay put after noontime tomorrow."

The National Weather Service said Boston could get one to two feet of snow on Friday and Saturday, which would be its first major snow fall in about two years. Light snow is expected to begin falling around 7 a.m. EST on Friday, with heavier snow and winds gusting as high as 60 to 75 miles per hour as the day progresses.

"It's the afternoon rush-hour time frame into the evening and overnight when the height of the storm will be," said Kim Buttrick, a meteorologist at the National Weather Service in Taunton, Massachusetts. "That's when we expect the storm to begin in earnest."

The heaviest snow was expected around Boston, the region's most populous city, with cities from Hartford, Connecticut to Portland, Maine, expected to see at least a foot.

If more than 18.2 inches of snow fall in Boston, the storm will rank among the 10 biggest snowfalls on record in the city. The heaviest snowfall ever recorded in Boston was a 27.6 inch dump that accompanied the blizzard of February 17-18, 2003.

The storm's timing brought back memories of the blizzard of 1978, Boston's second-heaviest recorded snow fall, which roared in on an afternoon, dropping 27.1 inches of snow, trapping commuters on roadways and leaving dozens dead across the region, largely as a result of downed electrical lines.

Peter Judge, a spokesman for the Massachusetts Emergency Management Agency, said one of the state's biggest worry is power outages.

"It being winter, folks losing their power means they're also losing their heat, and if you lose heat during the middle of the storm, you're not going to be able to go out to get to a shelter," he said, adding that the agency would begin 24-hour operations at its emergency compound at noon (1700 GMT) on Friday and would be in close contact with local utilities.

Unlike the 1978 blizzard, which had been forecast to drop far less snow than it actually did, he said he hoped several days of news coverage about this storm would prompt people to stay off the roads.

"People have been warned, they have been told what the issues are," Judge said. "We don't expect people to be surprised."

Reuters contributed to this report.

chicagobreaking@tribune.com

Twitter: @chicagobreaking

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

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Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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