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 blue 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.

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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.

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Chinese city is world's fireworks capital

LIUYANG, China — The Lunar New Year is fast approaching in China, and that means big business for fireworks sellers like Liu Zhicheng.

Liu is a wholesaler in this industrial city known as China's pyrotechnics capital, home to about a 1,000 companies churning out roman candles, spinners, bottle rockets, sparklers and more. Some of his bestsellers are red firecrackers the size of dynamite sticks. Called Thunder Kings, the noisemakers are so powerful they could easily trigger a block of car alarms.

A few miles away in the showroom of a manufacturer called Dancing Fireworks, the staff proudly shows off its top seller: a 66-pound cardboard box packed with 230 projectile tubes called Tonight Is So Beautiful. The $200 package fires red and green bursts several stories high.

"Every time we have customers visit, we explain this is a must-have," said Tang Caiying, a salesclerk.

No place on Earth loves fireworks more than China. The country has been crazy for huapao since a Chinese monk named Li Tian invented firecrackers in the 5th century. An estimated 90% of the globe's pyrotechnics are designed and produced in China, most of them here in Liuyang. The noisemakers have become an essential part of Chinese tradition. Popular as gifts, they're used to ward off evil spirits and usher in good fortune.

The difference between now and Li Tian's day is the sheer firepower of the displays. China's rising wealth has boosted demand for ever more spectacular explosives. Ordinary citizens, including children, can buy fireworks here that in the United States would be off limits to everyone but pyrotechnic professionals.

The result is some truly epic homemade fireworks shows in China, particularly around Chinese New Year. Starting Sunday, China will erupt in a combustible, two-week frenzy to ring in the Year of the Snake.

"It's just beautiful and awesome. It's something people in the U.S. don't have a clue about because it just seems so unreal," said Terry Winkle, a fireworks maker from Rochester, Minn., who spends most his year working with factories in Liuyang.

The downside is the carnage. Building fires, skin burns, mangled digits and deaths come with the territory. Last week, a truck carrying fireworks exploded on an elevated highway in central Henan province, killing 10 people. The blast toppled a section of the roadway about the length of a football field. Authorities say the fireworks were unlicensed and transported by untrained handlers — part of a shadow network of illegal manufacturers and sellers that spring up during the new year crush.

Even Liuyang's own fireworks museum caught fire in November. Locals were quick to attribute the accident to some smoldering incense. The fire was put out in about 10 minutes with no major damage. But folks here are keenly aware of the risks.

"This is dangerous work," said Zhong Ziqi, Dancing Fireworks' founder and chairman. "It's very easy for things to explode."

Fireworks were a lot tamer in the late 1980s when Zhong was just entering the business as an apprentice. A big showstopper then was a $20 fountain, a tubular device that sits on the ground and shoot streams of sparks about 10 feet in the air.

Zhong, a former soldier, opened his first factory in 1988 after studying the trade for just a year. He soon realized how much he had to learn. Within just a few months a storage area at his plant loaded with half-finished products exploded and killed four workers. A shaken Zhong quit and launched a wholesale company.

"That accident was a tragic lesson," said Zhong, 57.

But Zhong would return to manufacturing in 1996 after being persuaded to privatize a struggling state-owned fireworks mill. A shareholder named it Dancing Fireworks to evoke their effects.

The company quickly built a name for itself and was asked to put on a fireworks show over the Bund, a waterfront area in Shanghai, in 1999 for a global forum of world leaders. With dignitaries including Chinese President Jiang Zemin and U.S. President Bill Clinton looking on, the electrical ignition system suddenly malfunctioned. Zhong ordered his staff to light cigarettes and run down the line lighting fuses.

"It was like war, but that was our big break," said Zhong, whose company would later be hired to put on shows at the Shanghai Expo and Beijing Olympic Games. He said annual sales are about $48 million.

In recent weeks, Dancing's 1,600 employees have been hustling to finish orders for Chinese New Year. About a third of the company's revenue comes over the holiday fortnight. Clustered in small workshops, many dug like bomb shelters into the red clay hills as a precaution against explosions, workers carefully filled products with so-called flash powder, a cousin to gunpowder that produces a burst of light and smoke when ignited.

Safety slogans abound on the factory grounds: "Safety and quality are the lifelines of company survival and development."

About one-third of Dancing's revenue is export sales. U.S. consumers can buy a less-potent version of the Chinese multi-shot fireworks trays, known as cakes, with names like Eagle King, Skulls & Bones and Iron Pyro.

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Tunisian opposition leader Chokri Belaid shot dead outside home

The Unified Democratic Nationalist Party says Chokri Belaid was shot as he left his house in the capital Tunis. Witnesses say he was taken to a nearby clinic and died. (Hassene Dridi / Associated Press / December 29, 2010)

By Jeffrey Fleishman

February 6, 2013, 3:41 a.m.

CAIRO -- A leading opponent of Tunisia's Islamist-led government was assassinated in front of his home Wednesday, raising fears of sharpening political turmoil in the country that ignited the Arab Spring movement but remains starkly divided between liberals and Islamists.

Chokri Belaid, head of the Unified Democratic Nationalist Party, was shot on his way to work in the capital, Tunis, according to authorities. No one claimed immediate responsibility for the attack, but it comes as Tunisia faces a troubled economy and a restive transition to democracy after decades of dictatorship.  

"This is a criminal act, and act of terrorism not only against Belaid but against the whole of Tunisia," Prime Minister Hamadi Jebali told a radio station. Shortly after the killing, hundreds of protesters gathered outside the Interior Ministry.

An outspoken liberal with a bushy mustache, Belaid often criticized Nahda, the dominant moderate Islamist party for failing to unite the country's political factions. He had accused Ennahda of not clamping down on increasingly violent ultraconservative Salafis from attacking movie houses, art galleries and institutions they deem as against Islam.

Belaid's family told Tunisian media that he had received repeated death threats.

"Chokri Belaid was killed today by four bullets to the head and chest ... doctors told us that he has died. This is a sad day for Tunisia," Ziad Lakhader, a leader of the Popular Front, was quoted as saying to Reuters.

Tunisian President President Moncef Marzouki who was traveling in France said he would cancel a planned trip to Cairo on Thursday and return home.

ALSO:

Bulgarian probe links Hezbollah to Israeli tourist bus attack

Bangladesh war crimes court jails Islamic party leader for life

Ahmadinejad ally linked to human rights abuses arrested in Iran

jeffrey.fleishman@latimes.com

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Disney working on stand-alone 'Star Wars' films

LOS ANGELES (AP) — Disney is mining The Force for even more new films.

Walt Disney Co. CEO Bob Iger said Tuesday that screenwriters Larry Kasdan and Simon Kinberg are working on stand-alone "Star Wars" movies that aren't part of the new trilogy that's in the works.

"There has been speculation about some standalone films that have been in development, and I can confirm to you today that in fact we are working on a few stand-alone films," Iger told CNBC.

Iger said the movies would be based on "great 'Star Wars' characters that are not part of the overall saga." The films would be released during the six-year period of the new trilogy, which starts in 2015 with "Star Wars: Episode VII."

Disney confirmed last month that "Star Trek" director J.J. Abrams will direct the seventh installment of the "Star Wars" saga.

Disney bought "Star Wars" maker Lucasfilm last year for more than $4 billion.

The last "Star Wars" trilogy, a prequel to the original films, was released from 1999 to 2005.

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Online:

http://www.starwars.com/

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Ipswich Journal: Paul Mason Is One-Third the Man He Used to Be

Paul Nixon Photography

Paul Mason in 2012, two years after gastric bypass surgery stripped him of the unofficial title of “the world’s fattest man.”

IPSWICH, England — Who knows what the worst moment was for Paul Mason — there were so many awful milestones, as he grew fatter and fatter — but a good bet might be when he became too vast to leave his room. To get him to the hospital for a hernia operation, the local fire department had to knock down a wall and extricate him with a forklift.

That was nearly a decade ago, when Mr. Mason weighed about 980 pounds, and the spectacle made him the object of fascinated horror, a freak-show exhibit. The British news media, which likes a superlative, appointed him “the world’s fattest man.”

Now the narrative has shifted to one of redemption and second chances. Since a gastric bypass operation in 2010, Mr. Mason, 52 years old and 6-foot-4, has lost nearly two-thirds of his body weight, putting him at about 336 pounds — still obese, but within the realm of plausibility. He is talking about starting a jewelry business.

“My meals are a lot different now than they used to be,” Mr. Mason said during a recent interview in his one-story apartment in a cheerful public housing complex here. For one thing, he no longer eats around the clock. “Food is a necessity, but now I don’t let it control my life anymore,” he said.

But the road to a new life is uphill and paved with sharp objects. When he answered the door, Mr. Mason did not walk; he glided in an electric wheelchair.

And though Mr. Mason looks perfectly normal from the chest up, horrible vestiges of his past stick to him, literally, in the form of a huge mass of loose skin choking him like a straitjacket. Folds and folds of it encircle his torso and sit on his lap, like an unwanted package someone has set there; more folds encase his legs. All told, he reckons, the excess weighs more than 100 pounds.

As he waits to see if anyone will agree to perform the complex operation to remove the skin, Mr. Mason has plenty of time to ponder how he got to where he is. He was born in Ipswich and had a childhood marked by two things, he says: the verbal and physical abuse of his father, a military policeman turned security guard; and three years of sexual abuse, starting when he was 6, by a relative in her 20s who lived in the house and shared his bed. He told no one until decades later.

After he left school, Mr. Mason took a job as a postal worker and became engaged to a woman more than 20 years older than him. “I thought it would be for life, but she just turned around one day and said, ‘No, I don’t want to see you anymore — goodbye,’ ” he said.

His father died, and he returned home to care for his arthritic mother, who was in a wheelchair. “I still had all these things going around in my head from my childhood,” he said. “Food replaced the love I didn’t get from my parents.” When he left the Royal Mail in 1986, he said, he weighed 364 pounds.

Then things spun out of control. Mr. Mason tried to eat himself into oblivion. He spent every available penny of his and his mother’s social security checks on food. He stopped paying the mortgage. The bank repossessed their house, and the council found them a smaller place to live. All the while, he ate the way a locust eats — indiscriminately, voraciously, ingesting perhaps 20,000 calories a day. First he could no longer manage the stairs; then he could no longer get out of his room. He stayed in bed, on and off, for most of the last decade.

Social service workers did everything for him, including changing his incontinence pads. A network of local convenience stores and fast-food restaurants kept the food coming nonstop — burgers, french fries, fish and chips, even about $22 worth of chocolate bars a day.

“They didn’t deliver bags of crisps,” he said of potato chips. “They delivered cartons.”

His life became a cycle: eat, doze, eat, eat, eat. “You didn’t sleep a normal sleep,” he said. “You’d be awake most of the night eating and snacking. You totally forgot about everything else. You lose all your dignity, all your self-respect. It all goes, and all you focus on is getting your next fix.”

He added, “It was quite a lonely time, really.”

He got infections a lot and was transported to the hospital — first in a laundry van, then on the back of a truck and finally on the forklift. For 18 months after a hernia operation in 2003, he lived in the hospital and in an old people’s home — where he was not allowed to leave his room — while the local government found him a house that could accommodate all the special equipment he needed.

This article has been revised to reflect the following correction:

Correction: February 6, 2013

The headline on an earlier version of this article misstated Paul Mason’s current weight relative to what he weighed nearly a decade ago. He is now about one-third, not two-thirds, the weight he was then.

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Congress' horse-and-buggy computer laws

As martyrs go, Aaron Swartz was an extraordinary example of the breed. A computer programming genius, he had helped develop the social networking site Reddit and became known as a leading advocate for easy and free information sharing on the Web.

When Swartz committed suicide in January, while awaiting trial on federal computer hacking charges that could have landed him in prison for 35 years and cost him fines of $1 million, his death was seen as a reproach to overzealous federal prosecutors in Boston. But the case raises a broader issue: Why is Congress so awful at writing computer and Internet laws?

Swartz was indicted in 2011 under the Computer Fraud and Abuse Act, a 1984 law that has struggled to keep up with the times. It's been amended seven times and is more outdated than ever. The charges stemmed from his efforts to allegedly break into MIT's computer network and use it to download millions of academic articles kept by JSTOR, a nonprofit, fee-based service. Legitimate MIT users could access JSTOR articles for free. (JSTOR advocated dropping the case, but MIT did not.)

The Computer Fraud and Abuse Act, or CFAA, may be the worst of the statutes Congress has passed or debated as ways to address what is vaguely shoveled into a bin labeled "computer crime." But others are nearly as frightful. The Digital Millennium Copyright Act, or DMCA, of 1998 imposes excessive civil and criminal penalties for activities engaged in by many users of digital books, movies and music in the real world.

In 2011, Congress contemplated a bill called the Stop Online Piracy Act, or SOPA, which would have given the owners of supposedly pirated or counterfeited property nuclear-scale weapons to use against websites they didn't like, by allowing them to simply assert rights infringement to shut down a site. SOPA was derailed by an online campaign spearheaded by, among others, Aaron Swartz.

The three laws had much in common. They were written broadly, in a fruitless effort to "future-proof" them against new technologies. They imposed excessive penalties, on the reasoning that if a crime is bad, it's much worse when committed with these mysterious devices called computers. And they offered special interests such as copyright claimants, corporations facing trade competition, and media conglomerates opportunities to assert new legal rights they were denied in the world of old technologies.

"Congress tries to write technology-neutral laws," says Jennifer Granick, an Internet law expert at Stanford, "but there's been a wholesale change in how we interact with computers" that renders these laws quickly anachronistic.

Clever lawyers and aggressive prosecutors often rush in to fill the gaps. The DMCA was originally aimed to discourage hackers from copying code-protected DVDs; but it's been cited by a garage door-opener company against a rival making universal clickers, and by desktop printer makers against knock-off toner cartridges. (Both those efforts failed in court, but the potential for expansive interpretation remains.) The recording industry threatened to prosecute Princeton computer expert Edward Felten under the DMCA if he reported publicly on how he had broken the industry's digital protection technology — an effort he undertook at the industry's invitation. The threat prompted Felten to withdraw a planned public presentation.

By imposing extra penalties for using a computer to do things that have traditionally been handled in civil court, "these broader laws have criminalized things that are of dubious criminality," Granick told me.

The CFAA is a perfect example. The measure was written as a cyberspace analogue to trespass laws. Its broadest provision says that anyone who intentionally "exceeds authorized access and thereby obtains information from any protected computer" has committed a federal crime.

This is a wide-open definition that prosecutors have used very aggressively. A "protected computer," by Justice Department definition, can be almost anything with a microchip, including your Internet-savvy refrigerator or your car. "Unauthorized access" could mean viewing a website in violation of its terms of use, that mass of impenetrable legalese that most of us click on blithely without reading, just to use the site. Do that to obtain or read any "information," and you've committed a federal crime.

If you think this is an alarmist interpretation, consider the Lori Drew case — the "poster child" for CFAA overreaching, in the words of Orin Kerr, a Georgetown University cyber-law expert who argued Drew's side. She was the Missouri mother who was accused of helping set up a fake Myspace page to bully a classmate of her daughter. The classmate later committed suicide. Since there is no federal cyber-bullying statute, prosecutors charged Drew under the CFAA for violating the Myspace terms of use, which requires users to provide only accurate information about themselves. A Los Angeles jury found her guilty.

Los Angeles District Judge George Wu overturned the verdict, observing that a website's term of use, which can be altered without notice, are too flimsy to carry the weight of criminal liability, and almost never enforced by the website. But as Kerr notes, federal prosecutors have not abandoned their expansive interpretation despite its obvious absurdities: Until they were changed in March 2012, Google's terms of service required users to be of "legal age," meaning that a middle school child conducting a Google search was theoretically committing a federal crime. So are users of dating websites who exaggerate their good points, in violation of terms of use requiring rigorous accuracy about their height, weight, physical condition and charm.

The law places a powerful weapon in the hands of employers, who routinely forbid workers from using their computers for personal business. "The computer gives employees new ways to procrastinate by chatting with friends, playing games, shopping or watching sports highlights," wrote Appellate Judge Alex Kosinski in a ringing denunciation of the CFAA last year. "Under the broad interpretation of the CFAA, such minor dalliances would become federal crimes." Kosinski's ruling upheld the dismissal of CFAA charges against a corporate headhunter who used information from his old employer's computer system to start a competing company.

Efforts are underway in Congress to pare back the CFAA. Rep. Zoe Lofgren (D-San Jose) has proposed a draft "Aaron's Law," which would ban prosecutions based strictly on violations of a website's terms of service or an employer's policies. She would also make clear that tweaking a computer's digital signature — as Swartz did to conceal his identity in a weeks-long cat-and-mouse game with MIT network overseers — is not in itself a crime.

Yet nothing in Lofgren's bill would address the fundamental problem of Congress writing nonsensically broad laws to govern cyberspace and letting the Justice Department work out the kinks. But prosecutors always agitate for more discretion and stiffer penalties, Kerr says; that's how we end up with criminal penalties for lying about one's age on a dating site.

It's also how Swartz gets threatened with 35 years in jail for downloading academic papers that MIT students could access for free. The prosecutors' goal was to pressure him to take a plea, but the instrument was put in their hands by a Congress that couldn't be bothered to educate itself about the real world of computers and networks before legislating about it. That's the type of legislating that has to change to avoid more cases like Swartz's.

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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Friends, investigators seek answers in killing of O.C. couple

They met in college, two highly regarded basketball players who seemed to have the same winning touch on the court and off.

After blazing through high school and college with her outside shot, Monica Quan became the assistant women's basketball coach at Cal State Fullerton. Keith Lawrence, whose highlight shots are still there on his college website, became a campus officer at USC.

Now police in Irvine are scrambling for an explanation — and friends are looking for a way to express their shock — after Quan and Lawrence were found shot to death in their parked car on the top floor of a parking structure in an upscale, high-security condominium complex near UC Irvine.

The two had just announced their engagement and had recently moved into a condominium complex near Concordia University, where they played basketball and had gone on to earn their degrees.

Late Sunday, after a passerby noticed two people in the parked car, police said they found Lawrence slumped in the driver's side of his white Kia. Quan was next to him, also dead. The couple were shot multiple times, and authorities said they have tentatively ruled out the possibility of it being a murder-suicide or motivated by robbery. Nothing in the car, police said, seemed to be disturbed.

The couple's friends and family said they were shaken by the violent deaths of two people who seemed to have so much to offer.

Quan was a 2002 graduate of Walnut High School in the San Gabriel Valley, where she set school records for the most three-pointers in a season and a game. She played at Long Beach State and at Concordia, where she graduated in 2007. She went on to earn a master's degree before becoming the assistant coach at Fullerton.

Quan's father was the first Chinese American captain in the LAPD, and went on to become police chief at Cal Poly Pomona.

Quan was known for pulling students aside to offer encouragement, said Megan Richardson, a former player. Marcia Foster, the head basketball coach at Cal State Fullerton, described her assistant as a special person — "bright, passionate and empowering," she said.

Quan shared a love of basketball with her fiancee, Lawrence, whom she met at Concordia.

He too had been a standout basketball player, starting at Moorpark High, where he played point guard and shooting guard, said Tim Bednar, who coached Lawrence.

Bednar said that Lawrence, who came from a family of athletes, was talented, yet quiet and humble. After Lawrence graduated in 2003, he continued to participate in summer youth camps

When he returned for the camps, Bednar said, he was known as the "best basketball player that ever came through" the school.

"He was awesome with the kids," Bednar said. "They all wanted to be around Keith Lawrence."

Bednar heard from Lawrence when he needed a recommendation to become a police officer after graduating from the Ventura County Sheriff's Academy. In August, he was hired by USC's public safety department.

John Thomas, the executive director and chief of the department, said that Lawrence was an "honorable, compassionate and professional" member of the community.

"We are a better department and the USC campus community is a safer place as a result of his service," Thomas said in a statement.

On Monday night, Quan's friends gathered outside Walnut High School. One clutched a heart-shaped balloon, another carried a collage of her basketball playing days. Still another held a basketball.

Lawrence's friends and family put up a Facebook page. "RIP Keith Lawrence, you will be missed," it said simply. Within hours, 840 had left comments or indicated they "liked" it. Concordia put up a link to Lawrence's game-winning shot that carried the school into a post-season tournament.

Michelle Thibeault, 27, said in a Facebook message that she had known Quan for more than a decade. The two were on the same athletic teams and went to junior high and high school together. "Monica was loved by everyone," she said.

During a somber gathering at the Cal State Fullerton gymnasium Monday, Foster read a brief statement from Quan's brother Ryan.

"We just shared a moment of incredible joy on her recent engagement," he wrote, and then added: "A bright light was just put out."

nicole.santacruz@latimes.com

kate.mather@latimes.com

lauren.williams@latimes.com

Times staff writer John Canalis contributed to this report.

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NJ Gov. Christie, Letterman laugh about fat jokes

TRENTON, N.J. (AP) — New Jersey Gov. Chris Christie and David Letterman have shared some laughs about the many fat jokes the comedian has made about the lawmaker's ample girth.

Christie has termed his plumpness "fair game" for comedians. And during his first appearance on "Late Show with David Letterman" on Monday, the outspoken Republican and potential 2016 presidential contender read two of Letterman's jokes that he said were "some of my personal favorites."

The governor also drew loud laughs when he pulled out a doughnut and started eating it while Letterman asked him if he was bothered by the digs that have been made about his weight. Christie said he wasn't, noting that he laughs at the jokes if he finds them funny.

"Late Show" airs on CBS at 11:35 p.m. Eastern time.

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The New Old Age Blog: In Blended Families, Responsibility Blurs

Every year, Fran McDowell waited for the summer week when she would sing in a choral festival in the North Carolina mountains, then spend a few days in a lakeside cabin with close women friends.

That getaway grew more complicated to arrange — but perhaps more necessary — after her husband, Herb Beadle, was diagnosed with Alzheimer’s disease. They had a “gloriously happy” marriage — her first, his second — for 11 years, and she was more than willing to care for him in sickness as in health. But he could no longer manage alone in their Atlanta home.

For a few years, other family members pitched in to allow Ms. McDowell her cherished vacation. Eventually, though, she had to ask her husband’s daughter, a medical professional in another state, to take him into her home for a week.

She said no, then yes. Then, the day before Ms. McDowell was to drive him there, her stepdaughter again refused, leaving no time for alternate arrangements. If this had been her biological child, “I would have said, ‘Come on, don’t do this to me,’” Ms. McDowell said. Instead, reluctant to make waves, she canceled her trip.

“I think confrontation is riskier for stepparents,” she told me. “I was the compliant one who would bite my tongue rather than say what I thought.”

Ms. McDowell never told her stepdaughter, or anyone in the family, how angry and disappointed she was, or how difficult it was becoming to care for their father, who died three years ago at 86. She told the members of her dementia caregivers support group instead.

It was that group’s leader, Moira Keller, who e-mailed me to suggest this topic. A clinical social worker with the Sixty Plus program at Piedmont Atlanta Hospital, she wrote that “one of the biggest challenges I have is blended families in later life.”

Though I’ve written about the way the 1970s’ spike in divorces could complicate caregiving for adult children — more households to sustain, more siblings to either help or hinder — I hadn’t considered the impact on the older people themselves.

But Ms. Keller seems to be onto something. “The generation most likely to have stepchildren” — the boomers — “don’t need much care yet,” said Merril Silverstein, a Syracuse University sociologist co-editing a coming issue of the Journal of Marriage and the Family on stepfamilies in later life. “The crunch will come in 10 or 20 years.”

Initially, many adult children whose divorced or widowed parents remarry seem delighted, Ms. Keller said when we spoke. “They’re thrilled that Mom or Dad isn’t alone,” she said. “It’s a wonderful thing — until somebody gets sick.”

Then, she has found, “it gets really blurry. Who’s going to do what?” Grown children don’t have much history with these new spouses; they often feel less responsibility to intervene or help out, and stepparents may be unwilling to ask. Perhaps it’s unclear whether children or new spouses have decision-making authority.

“Older couples in this situation fall through the cracks,” Ms. Keller said.

Research shows that the ties which lead adult children to become caregivers — depending on how much contact they have with parents, how nearby they live, how obligated they feel — are weaker in stepchildren, Dr. Silverstein said. Money sometimes enters the equation too, Ms. Keller added, if biological children resent a parent’s spending their presumed inheritance on care for an ailing stepparent.

Adela Betsill, another of Ms. Keller’s support group members, married her longtime partner five years ago — her second marriage, his third. She has since given up her interior design business to care for Robert who, at 72, has also developed Alzheimer’s disease. His two children have had little involvement — perhaps because she’s just 49 and presumed able to handle everything.

Thus, though Robert’s son works from an office in their home, if Ms. Betsill needed to go out and asked him to remind his father to eat lunch, “he might, or he might not,” she said. “I don’t think he realizes it’s a burden.” So she has not asked.

Would it be different if she were his biological mother and he saw her wearing out under the strain? She thinks so, but it’s hard to know. After all, biological families also experience plenty of conflict and avoidance as elders age.

Still, that sense of reciprocity we often hear from caregivers — she took care of me when I was young, so I need to help out now that she’s old — doesn’t apply in late-life stepfamilies. Ms. Betsill didn’t raise this man, or his half sister.

Older couples who marry or remarry often discuss their finances, Ms. Keller has found. (An elder attorney, Craig Reaves, discussed the legal consequences here.) But illness and dependence may prove even more difficult subjects to broach.

“If I could yell one thing from a mountaintop,” Ms. Keller said, “it’s to talk about this stuff, too. Who’s going to take care of you if you become sick? Talk about that while you’re still healthy.”

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Justice Department sues S&P over mortgage bond ratings

The federal government is embarking on one of its most ambitious efforts to assign blame for the financial crisis, going after Wall Street's biggest credit rating firm for its role in pumping up the housing bubble.

The Justice Department filed a lawsuit late Monday in Los Angeles federal court against Standard & Poor's Corp. The suit accuses the company's analysts of issuing glowing reviews on troubled mortgage securities whose subsequent failure helped cause the worst financial crisis since the Great Depression.

The action marks the first federal crackdown against a major credit rater, and it signals an untested legal tack after limited success in holding the nation's banks accountable for the part they played in the crisis.

The government selected Los Angeles as the venue to file the lawsuit in part because it was one of the regions hardest hit when the bottom fell out of the housing market. Hundreds of thousands of California residents lost their homes to foreclosure, and others saw their wealth evaporate as properties plummeted in value.

"The DOJ is playing hardball and they're coming at the ratings agency in a very different direction with a potentially very powerful weapon to push S&P to the settlement table," said Jeffrey Manns, a law professor at George Washington University.

In addition to the Justice Department, several state attorneys general are investigating the ratings agency. States such as California and New York are expected to pursue their own investigations and legal action, people familiar with the matter said.

S&P has faced other lawsuits from investors and the states of Illinois and Connecticut.

California is expected to sue S&P under the state's False Claims Act, one person familiar with the matter said. The law makes it a crime to defraud the state, and damages of up to three times the amount of the claim can be awarded if the victim was an institutional investor, such as one of the state's pension funds.

The federal action does not involve any criminal allegations. Critics have complained that the government has yet to send any senior bankers or Wall Street executives to jail for potential illegal behavior that led to the crisis.

But civil actions typically require a much lower burden of proof.

Investors rely in part on rating agencies to decide what stocks, bonds or other securities to buy based on the agencies' recommendations about their safety. The three major raters – S&P, Moody's Investors Service and Fitch Ratings — have all been criticized for giving perfect AAA ratings to complex bonds in 2007 that later turned out to be nearly worthless.

It was not known why Standard & Poor's was singled out in the federal lawsuit.

The government and S&P have tangled before. The rating agency in August 2011 issued a historic downgrade of U.S. creditworthiness and threatened to lower it even further.

The two sides were reportedly in settlement talks that broke down during the past week. The ratings firm could face hundreds of millions of dollars in fines and new restrictions on its business model if found liable of civil violations.

S&P, which is a unit of publisher McGraw Hill, denounced the lawsuit in a detailed and strongly worded response. The company said the claims were unjustified, adding that it acted in "good faith" to warn the world about some of the securities that went belly up.

"A DOJ lawsuit would be entirely without factual or legal merit," the company said, adding that even the U.S. government "publicly stated that problems in the subprime market appeared to be contained."

The rating firm has steadfastly maintained that it was protected under the 1st Amendment to state an opinion about certain financial products. That argument may not hold up if federal or state investigators are able to prove that the ratings agency knowingly gave improper evaluations.

The lawsuit zeros in on a series of collateralized debt obligations that were created at the height of the housing boom in 2007, according to S&P. The value of these exotic mortgage securities was nearly wiped out when the subprime mortgages they were tied to imploded.

Lawrence J. White, an economics professor at New York University's business school, believes that the housing crisis could have been more contained if ratings agencies had been more careful.

"If they had been more conservative in their ratings, fewer bonds would have been sold, the interest rates would have been higher, fewer mortgages would have been granted," White said. "There would still have been a housing bubble, but it might not have been quite so severe."

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