Dutch Put Electric Cars to the Test

AMSTERDAM — When Patrick Langevoort’s company issued him an electric vehicle two years ago, the first months were filled with misadventure: he found himself far from Amsterdam, with only a 25 percent charge remaining, unable to find the charging point listed on a map. Though the car was supposed to travel 100 miles on a full battery, he discovered that cold weather and fast driving decreased that range.

But electric vehicles have improved, the network of charging stations in the Netherlands has expanded and drivers like Mr. Langevoort are getting used to the particularities of electric driving. “I used to be a real petrol head,” said Mr. Langevoort, who works for a company that manages electricity networks. “Now, I’ve sold my petrol car.”

Although a number of European countries and a few American states are aggressively promoting the use of electric vehicles to reduce planet-warming emissions and pollution, the Netherlands provides perhaps the ultimate feasibility test. If electric vehicles catch on anywhere, it should be here: a small country — about 100 miles east to west — with gas prices of about $8.50 a gallon and a long tradition of environmental activism.

To encourage electric driving, the country is developing a rapidly expanding national grid of charging stations in cities and along highways; and Amsterdam offers owners of electric vehicles free street parking and charging. With hefty tax breaks, promotional leases and cheaper operating costs, the vehicles offer driving costs no more than those of conventional cars, some analysts say.

The number of plug-in electric vehicles in the Netherlands soared eightfold to about 7,500 last year, and charging posts dot the sidewalks. “In a few countries you’re starting to see a number of E.V.’s on the road, especially in capital cities; they’re very visible,” said Peder Jensen, a transportation expert at the European Environment Agency.

And yet, experiments with the cars in the Netherlands and Denmark also underscore the challenges facing this new technology. Sales have been lower than politicians and automakers hoped, representing under 1 percent of new vehicles, even here. “It seems that the industry has not convinced consumers that they can do this,” Mr. Jensen said. “If they fail over the next few years, I think investors will pull out, and that will be a problem.”

Last year 120,000 plug-in electric vehicles were sold globally, according to a recent report by Pike Research, an industry analyst group, which predicts 40 percent annual growth between now and 2020. In 2012, 52,000 were sold in the United States, which now has 12,000 charging stations, according to the automotive consulting firm J. D. Power; but they are dispersed over a large area. Those statistics include pure electric cars and plug-in hybrids, which can run on gas or propane once the battery loses power.

Though many analysts had assigned electric vehicles to the second-car niche, a 2012 survey of Dutch drivers of the cars by the consulting firm Accenture found that most of them ended up being used as a family’s primary vehicle.

Drivers learned to figure out how far they could drive on a charge, overcoming what has been dubbed “range anxiety.” They started off cautiously driving straight from home to the office, knowing they could charge at one or both sites. Over time, they expanded their driving repertoire, learning where to find charging points in garages and along highways — a smartphone app contains them all — much as people learn the locations of convenient A.T.M.’s. That task was made easier by the growing number of chain stores and restaurants offering parking spots with charging outlets, so that customers can refuel while they dine or shop.

Still, a layer of complexity limits acceptance. “There’s still some planning; it’s a bit like a puzzle,” said Maarten Noom, an Accenture consultant who drives an electric vehicle. “It’s not the same ease of mind as with a gas car.”

Mr. Noom, for example, charges at his office and overnight at home, but he switches to a gasoline car when his appointments are scattered around the Netherlands, since he sometimes drives hundreds of miles in a day. Charging at home uses low voltage and takes four to eight hours. New high-voltage rapid charging stations give an 80 percent charge in 20 to 30 minutes, but they are costly to install and still rare.

Mr. Langevoort, the electricity company manager, says he now leaves for work later because his Opel Ampera’s charge goes further as the day warms.

Some electric car leasing programs here provide free or discounted gas vehicles for those who want to take a weeklong driving vacation around Europe.

Many experts say the lack of a uniform business model in the fledgling market is also a hindrance. Contracts for charging are sometimes purchased along with the car and tied to a particular charging network, much as cellphones are linked to a certain carrier. What is more, the penetration of the various networks varies depending on the region, and technology is not always interchangeable.

In Europe, the charging network run by New Motion delivers electricity from pumplike devices. One rival, Better Place, offers swap stations where drivers get a fresh battery in addition to charging points. In the United States, SAE International, an organization of scientists and vehicle engineers, recently adopted a standard charging plug nationwide so that most electric vehicles can use any charging station. But some companies, like Tesla Motors, operate closed networks of high-performance “superchargers.”

“That type of uncertainty is also unsettling to customers,” said Mike Omotoso, a senior manager of forecasting at LMC Automotive, a market research firm. “There’s a Wild West feel, with a lot of companies jumping in. But ultimately there will be a shakeout and consolidation.”

In many European countries there is a good financial case for driving electric. In Denmark, taxes on new luxury cars can be 200 percent of the sticker price, whereas electric vehicles come tax-free. In the Netherlands, gas costs about five times as much as the electricity needed for a similar journey.

While there are some tax breaks for electric vehicle purchases in the United States, the Obama administration has relied more on exhortation to make electric vehicles “as affordable and convenient as gasoline-powered cars in the next 10 years.” Last month, the Energy Department announced its Workplace Charging Challenge, in which Google, Verizon, Eli Lilly, Nissan and other companies pledged to put charging infrastructure in at least one major office.

Mr. Jensen, of the European Environment Agency, said that a big infusion of money could be needed to improve infrastructure in those countries seeking to increase the use of electric vehicles.

When he looked into buying an electric car, the charging system would not fit in his garage, Mr. Jensen said, and few are willing to drive around Europe with a trunk full of adapters. “I think the companies who will win are not necessarily the ones that have the best technology, but the ones that form the best alliances,” he said. “It you have a mobile phone — and even more a car — the most important thing is that you can use it wherever you go.”

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Media Decoder Blog: Macmillan Settles With Justice Department on E-book Pricing

11:58 a.m. | Updated Macmillan said Friday it had agreed to settle a lawsuit brought by the Department of Justice over the pricing of e-books, asserting that the potential costs of continuing to fight the action were too high.

The agreement means that all five major publishing houses have settled the charges brought by the government last spring.

Apple Inc., which is also a defendant, will continue to trial in June, according to the Department of Justice. A spokesperson said Friday it was declining comment.

In a letter addressed to authors, illustrators and agents, Macmillan’s chief executive, John Sargent, said the risks were too great to go it alone.
“Our company is not large enough to risk a worst case judgment,” he said. “In this action the government accused five publishers and Apple of conspiring to raise prices. As each publisher settled, the remaining defendants became responsible not only for their own treble damages, but also possibly for the treble damages of the settling publishers (minus what they settled for). A few weeks ago I got an estimate of the maximum possible damage figure. I cannot share the breathtaking amount with you, but it was much more than the entire equity of our company.”

In a suit filed last April, the Justice Department accused five major publishers and Apple of conspiring in e-mails and over lavish dinners to set the price of e-books at an artificially high level. The publishers had moved from a wholesale pricing model, which allowed retailers to charge what they wanted, to a system that allowed publishers to begin setting their own e-book prices, a model known as “agency pricing.”

The defendants said they were trying to protect themselves from Amazon, which was pricing e-books books below their actual cost, putting financial pressure on the publishers that they said would drive them out of business over time.

Nevertheless, three big publishing houses – HarperCollins, Simon & Schuster and Hachette – settled with the government immediately. Penguin, Macmillan and Apple decided to fight the charges. But in December, to clear the way for its merger with Random House, Penguin settled too.

The terms of the Macmillian settlement mirrors that agreed to by the other publishers. Macmillan will immediately lift restrictions it has imposed on discounting and other promotions by e-book retailers and will be prohibited until December 2014 from entering into new agreements with similar restrictions. The publisher must also provide the government advance notification to the of any e-book ventures it plans to undertake jointly with other publishers.

Macmillian had been holding firm that it wouldn’t settle, and analysts offered varying explanations for the sudden turnabout. James McQuivey, an analyst for Forrester Research, said that potential merger talks might be one motivation. The publishing industry has begun to consolidate in order to respond to the threat from Amazon, and when Penguin and Random House announced last October that they would merge, it fueled speculation that more alliances would follow.

“This was a fight not worth fighting in the first place,” Mr. McQuivey said of the lawsuit, “and given the likely nature of merger conversations behind the scenes, that’s where you finally decide the litigation is an obstacle to those talks, which are much more important.”

But Mike Shatzkin, the founder and chief executive of the Idea Logical Company, a publishing consultant, downplayed the role of a potential merger. “There have been no rumors and no signs that Macmillan is merging,” he said. “I would actually take their statement at face value.”

He said he thought it was more likely that Macmillan realized that their stand on pricing was having no effect on the market. E-book prices have been declining steadily but not precipitously since the settlement with the first three publishers went into effect last September. “Their settling doesn’t change the overall market, and it looks much more that way to them now than when they were originally fighting,” Mr. Shatzkin said.

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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

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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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The New Old Age: The Executor's Assistant

I’m serving as executor for my father’s estate, a role few of us are prepared for until we’re playing it, so I was grateful when the mail brought “The American Bar Association Guide to Wills and Estates” — the fourth edition of a handbook the A.B.A. began publishing in 1995.

This is a legal universe, I’m learning, in which every step — even with a small, simple estate that owes no taxes and includes no real estate or trusts — turns out to be at least 30 percent more complicated than expected.

If my dad had been wealthy or owned a business, or if we faced a challenge to his will, I would have turned the whole matter over to an estate lawyer by now. But even then, it would be helpful to know what the lawyer was talking about. The A.B.A. guide would help.

Written with surprising clarity (hey, they’re lawyers), it maps out all kinds of questions and decisions to consider and explains the many ways to leave property to one’s heirs. Updated from the third edition in 2009, the guide not only talks taxes and trusts, but also offers counsel for same-sex couples and unconventional families.

If you want to permit your second husband to live in the family home until he dies, but then guarantee that the house reverts to the children of your first marriage, the guide tells you how a “life estate” works. It explains what is taxable and what isn’t, and discusses how to choose executors and trustees. It lists lots of resources and concludes with an estate-planning checklist.

In general, the A.B.A. intends its guide for the person trying to put his or her affairs in order, more than for family members trying to figure out how to proceed after someone has died. But many of us will play both these parts at some point (and if you are already an executor, or have been, please tell us how that has gone, and mention your state). We’ll need this information.

---

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

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DealBook: Helping Start-Ups With Local Support and National Networks

When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

A version of this article appeared in print on 02/08/2013, on page B5 of the NewYork edition with the headline: Helping Start-Ups With Local Support and National Networks.

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IHT Rendezvous: 'Downton Abbey' vs. 'Girls': Who's Happier?

BROOKLYN — Can we have too much freedom?

Page Two

Posts written by the IHT’s Page Two columnists.

That’s the question behind my latest Currents column, where I discuss what “Downton Abbey” and “Girls,” two wildly popular television shows set 100 years apart, have to tell us about ourselves and our society — especially when it comes to personal freedom and its consequences.

What begins on ‘‘Downton’’ as a new liberty to follow your heart, to dare love that others find unwise, has culminated in ‘‘Girls’’ in romantic pursuits that are dully mercenary and often unwise. The daughters of the sexual revolution are depicted without much agency: far from being conquerors, initiators, even equals, the girls of ‘‘Girls’’ are reactors, giving in to an ex who changes his mind, or a gay man wanting to try something, or a financier seeking a threesome that he manages to upgrade to (traditionally twosome) marriage.

I discussed the dangers of today’s freedoms with Rendezvous’s editor, Marcus Mabry, in this video, here and below. (I also argue that today’s India is “Downton.”)

Do you agree with my analysis of the drawbacks of what we call Western-style freedom? Is there a happy medium between the strictures of “Downton Abbey” and the ceaseless longing of “Girls”? In the video, I suggest Latin America is a modern society that, in places, has found the balance between personal freedoms and a collective sense of belonging. What society or country or group would you nominee?

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TIMESCAST: PC Industry Shifts as Dell Goes Private

February 6, 2013By Fritzie Andrade, Zena Barakat, Emily B. Hager, Erica Berenstein, Krishnan Vasudevan, Kriston Lewis, Abe Sater and Robin Lindsay

TimesCast Media+Tech: The effects of Dell’s landmark deal. | Kit Eaton reviews video editing apps. | The entrepreneur and inventor James Dyson.

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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.

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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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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.

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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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Gadgetwise Blog: This Robot Does Do Windows

The robots at this year’s Consumer Electronics Show fell largely into two categories: floor cleaners and toys. But there was an exception.

That was a robot taken cleaning to new heights – literally. It is the Winbot 7 Series from Ecovacs, and this robot does do windows.

The Winbot works much like any of the floor cleaning robots, only it works on vertical surfaces. Stick it outside on your window glass and it figures out the size of your window, then travels in a zigzag pattern to clean the surface.

The Winbot has to be plugged into an electrical outlet that feeds a powerful vacuum motor that keeps it stuck to the glass as it creeps around. There is a safety tether to keep the Winbot from bombing pedestrians below if it were to lose power. If the Winbot encounters a problem it sounds an alarm.

The Winbot has a damp cleaning pad on its leading edge that is followed by a squeegee and a drying pad in back. The reusable pads could require machine washing after a single large dirty window, but more typically the company said they needed a wash every few months.

The price of replacement parts and cleaning solution have not been yet determined. The Winbot becomes available in April at a list price of $200 for the 710 model that cleans framed windows, and $300 for the 730 model that cleans framed and frameless windows.

They will be available through the Ecovacs Web site.

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