Petraeus’s Lower C.I.A. Profile Leaves Benghazi Void

WASHINGTON — In 14 months as C.I.A. director, David H. Petraeus has shunned the spotlight he once courted as America’s most famous general. His low-profile style has won the loyalty of the White House, easing old tensions with President Obama, and he has overcome some of the skepticism he faced from the agency’s work force, which is always wary of the military brass.

Brendan Smialowski/Getty Images

The low-profile style of David H. Petraeus, right, has won the loyalty of the White House, easing old tensions with President Obama.

Win Mcnamee/Getty Images

C.I.A. director, David H. Petraeus, right, appeared before the Senate Select Committee on Intelligence in Washington in January.

But since an attack killed four Americans seven weeks ago in Benghazi, Libya, his deliberately low profile, and the C.I.A.’s penchant for secrecy, have left a void that has been filled by a news media and Congressional furor over whether it could have been prevented. Rather than acknowledge the C.I.A.’s presence in Benghazi, Mr. Petraeus and other agency officials fought a losing battle to keep it secret, even as the events there became a point of contention in the presidential campaign.

Finally, on Thursday, with Mr. Petraeus away on a visit to the Middle East, pressure from critics prompted intelligence officials to give their own account of the chaotic night when two security officers died along with the American ambassador, J. Christopher Stevens, and another diplomat. The officials acknowledged for the first time that the security officers, both former members of the Navy SEALs, worked on contract for the C.I.A., which occupied one of the buildings that were attacked.

The Benghazi crisis is the biggest challenge so far in the first civilian job held by Mr. Petraeus, who retired from the Army and dropped the “General” when he went to the C.I.A. He gets mostly high marks from government colleagues and outside experts for his overall performance. But the transition has meant learning a markedly different culture, at an agency famously resistant to outsiders.

“I think he’s a brilliant man, but he’s also a four-star general,” said Senator Dianne Feinstein, the chairwoman of the Senate Intelligence Committee. “Four-stars are saluted, not questioned. He’s now running an agency where everything is questioned, whether you’re a four-star or a senator. It’s a culture change.”

Mr. Petraeus, who turns 60 next week, has had to learn that C.I.A. officers will not automatically defer to his judgments, as military subordinates often did. “The attitude at the agency is, ‘You may be the director, but I’m the Thailand analyst,’ ” said one C.I.A. veteran.

Long a media star as the most prominent military leader of his generation, Mr. Petraeus abruptly abandoned that style at the C.I.A. Operating amid widespread complaints about leaks of classified information, he has stopped giving interviews, speaks to Congress in closed sessions and travels the globe to consult with foreign spy services with little news media notice.

“He thinks he has to be very discreet and let others in the government do the talking,” said Michael E. O’Hanlon, a Brookings Institution scholar who is a friend of Mr. Petraeus’s and a member of the C.I.A.’s advisory board.

Mr. Petraeus’s no-news, no-nonsense style stands out especially starkly against that of his effusive predecessor, Leon E. Panetta, who is now the defense secretary.

Mr. Panetta, a gregarious politician by profession, was unusually open with Congress and sometimes with the public — to a fault, some might say, when he spoke candidly after leaving the C.I.A. about a Pakistani doctor’s role in helping hunt for Osama bin Laden, or about the agency’s drone operations.

Mr. Petraeus’s discretion and relentless work ethic have had a positive side for him: old tensions with Mr. Obama, which grew out of differing views on the wars in Iraq and Afghanistan, appear to be gone. Mr. Petraeus is at the White House several times a week, attending National Security Council sessions and meeting weekly with James R. Clapper Jr., the director of national intelligence, and Thomas E. Donilon, Mr. Obama’s national security adviser. Mr. Donilon said recently that the C.I.A. director “has done an exceptional job,” bringing “deep experience, intellectual rigor and enthusiasm” to his work.

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NYC Marathon is canceled following storm damage

NEW YORK (AP) — Gisela Clausen delivered the news to her fellow runners from Germany as they walked into the New Yorker Hotel.

"We spend a year on this. We don't eat what we want. We don't drink what we want. And we're on the streets for hours. We live for this marathon," she said, "but we understand."

Mayor Michael Bloomberg reversed himself Friday and yielded to mounting criticism that this was no time to run the New York City Marathon: runners were ready but weary residents were still recovering from a monster storm named Sandy.

And just like that, the race was scrapped.

Bloomberg, who as late as Friday afternoon insisted the world's largest marathon should go on as scheduled Sunday, changed course shortly afterward amid intensifying opposition from the city comptroller, the Manhattan borough president and sanitation workers unhappy they had volunteered to help storm victims but were assigned to the race instead. The mayor said he would not want "a cloud to hang over the race or its participants."

"I'm shocked," said Clausen, who is from Munich. "Not at the situation, but at how short this decision is (in) coming."

Like Clausen, many of the runners understood the rationale behind the decision. The death toll in the city stood at 41 and thousands of people were shivering without electricity, making many New Yorkers recoil at the idea of police officers protecting a foot race and evicting storm victims from hotels to make way for runners.

But the suddenness of it all forced runners to deal with an unexpected twist: What to do with no race.

Nearly 40,000 athletes — well over half from out of town — were expected at the Staten Island start line on Sunday. Their entry fees were paid. Their airline tickets were purchased. Their friends and family had hotel rooms. And all week the race was a go — even after Sandy came ashore Monday and ripped up everything in its path.

"I understand why it cannot be held under the current circumstances," Meb Keflezighi, the 2009 men's champion and 2004 Olympic silver medalist, said in a statement. "Any inconveniences the cancellation causes me or the thousands of runners who trained and traveled for this race pales in comparison to the challenges faced by people in NYC and its vicinity."

The cancellation means there won't be another NYC Marathon until next year.

"We cannot allow a controversy over an athletic event — even one as meaningful as this — to distract attention away from all the critically important work that is being done to recover from the storm and get our city back on track," Bloomberg said.

The nationally televised marathon had been held annually since 1970, including 2001, about two months after the 9/11 terrorist attacks.

The 26.2-mile race had been scheduled to start in Staten Island, one of the storm's hardest-hit places, and wind through all of the city's five boroughs with 2 million spectators usually lining the route.

In Staten Island, Cynthia Spinner said, "Thank God, thank God," when she heard the marathon was canceled.

"More for our people in New York," she said. "They shouldn't take their police or ambulance services off of what they're doing now to go for the marathon. People need homes. They're in hotels; they need everything right now."

Across the metro area Friday, the recovery made slow progress. Companies turned the lights back on, and many employees returned to their desks. Many major retailers also reopened.

But patience was wearing thin among New Yorkers who had been without power for most of the week.

Gov. Andrew Cuomo told utilities to step up power repair work or risk losing business in the state. And officials said the cost of the storm could exceed $18 billion in New York alone.

From storm-scarred New Jersey to parts of Connecticut, a widespread lack of gasoline frustrated people who were just trying to get to work or pick up a load of groceries.

Lines of cars, and in many places queues of people on foot carrying bright red jerry cans, waited for hours for precious fuel. And those were the lucky ones. Other customers gave up after finding only closed stations or dry pumps marked with yellow tape or "No Gas" signs.

Bloomberg called the marathon an "integral part of New York City's life for 40 years" and insisted that holding the race would not require resources to be diverted from the recovery effort. But, he said, he understood the doubts.

City and race officials considered several alternatives: a modified course, postponement or an elite runners-only race. But they decided cancellation was the best option.

Organizers will donate various items that had been brought in for the race to relief efforts, from food, blankets and portable toilets to generators already set up on Staten Island.

Mary Wittenberg, president of the New York Road Runners, the group that organizes the marathon, said canceling was the right move.

"This is what we need to do and the right thing at this time," she said.

"It's been a week where we worked very closely with the mayor's office and felt very strongly, both of us together, that on Tuesday, it seemed that the best thing for New York on Sunday would be moving forward. As the days went on, just today it got to the point where that was no longer the case."

Patrick Lynch, president of the Patrolmen's Benevolent Association — the police department's largest union — called the decision to cancel the marathon "a wise choice."

"When you have a significant amount of people voicing real pain and unhappiness over its running, you have to hear that. You have to take that into consideration," said Howard Wolfson, deputy mayor for government affairs and communications.

"Something that is such a celebration of the best of New York can't become divisive," he said. "That is not good for the city now as we try to complete our recovery effort, and it is not good for the marathon in the long run."

ING, the financial company that is the title sponsor of the marathon, said it supported the decision to cancel. The firm's charitable giving arm has made a $500,000 contribution to help with relief and recovery efforts and is matching employee donations. Sponsor Poland Spring said it would donate the bottled water earmarked for the marathon to relief agencies, more than 200,000 bottles.

Race organizers had been expecting about 47,500 runners before the storm.

For now, they are sticking to their policy of no refunds for runners, but they will guarantee entry to next year's marathon or the half-marathon in March. However, Wittenberg said the group would review the refund policy.

Steve Brune, a Manhattan entrepreneur, was set to run his fourth New York City Marathon.

"I'm disappointed, but I can understand why it's more important to use our resources for those who have lost a lot," he said.

Nikki Davies arrived from London on Friday, eager to race.

"I can understand not wanting to run through devastated parts of the city," she said. "I thought if they cancel it, they'd cancel it earlier."

Now, she had 10 days to fill. On her agenda?

"A lot of sightseeing," she said.

___

Associated Press writers Cara Anna, Ronald Blum, Verena Dobnik, Melissa Murphy, Christina Rexrode, Michael Rubinkam and Ted Shaffrey in New York contributed to this report.

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Second Illness Infects Meningitis Sufferers

Just when they might have thought they were in the clear, people recovering from meningitis in an outbreak caused by a contaminated steroid drug have been struck by a second illness.

The new problem, called an epidural abscess, is an infection near the spine at the site where the drug — contaminated by a fungus — was injected to treat back or neck pain. The abscesses are a localized infection, different from meningitis, which affects the membranes covering the brain and spinal cord. But in some cases, an untreated abscess can cause meningitis. The abscesses have formed even while patients were taking powerful antifungal medicines, putting them back in the hospital for more treatment, often with surgery.

The problem has just begun to emerge, so far mostly in Michigan, which has had more people sickened by the drug — 112 out of 404 nationwide — than any other state.

“We’re hearing about it in Michigan and other locations as well,” said Dr. Tom M. Chiller, the deputy chief of the mycotic diseases branch of the Centers for Disease Control and Prevention. “We don’t have a good handle on how many people are coming back.”

He added, “We are just learning about this and trying to assess how best to manage these patients. They’re very complicated.”

In the last few days, about a third of the 53 patients treated for meningitis at St. Joseph Mercy Hospital in Ann Arbor, Mich., have returned with abscesses, said Dr. Lakshmi K. Halasyamani, the chief medical officer.

“This is a significant shift in the presentation of this fungal infection, and quite concerning,” she said. “An epidural abscess is very serious. It’s not something we expected.”

She and other experts said they were especially puzzled that the infections could occur even though patients were taking drugs that, at least in tests, appeared to work against the fungus causing the infection, a type of black mold called Exserohilum.

The main symptom is severe pain near the injection site. But the abscesses are internal, with no visible signs on the skin, so it takes an M.R.I. scan to make the diagnosis. Some patients have more than one abscess. In some cases, the infection can be drained or cleaned out by a neurosurgeon.

But sometimes fungal strands and abnormal tissue are wrapped around nerves and cannot be surgically removed, said Dr. Carol A. Kauffman, an expert on fungal diseases at the University of Michigan. In such cases, all doctors can do is give a combination of antifungal drugs and hope for the best. They have very little experience with this type of infection.

Some patients have had epidural abscesses without meningitis; St. Joseph Mercy Hospital has had 34 such cases.

A spokesman for the health department in Tennessee, which has had 78 meningitis cases, said that a few cases of epidural abscess had also occurred there, and that the state was trying to assess the extent of the problem.

Dr. Chiller said doctors were also reporting that some patients exposed to the tainted drug had arachnoiditis, a nerve inflammation near the spine that can cause intense pain, bladder problems and numbness.

“Unfortunately, we know from the rare cases of fungal meningitis that occur, that you can have complicated courses for this disease, and it requires prolonged therapy and can have some devastating consequences,” he said.

The meningitis outbreak, first recognized in late September, is one of the worst public health disasters ever caused by a contaminated drug. So far, 29 people have died, often from strokes caused by the infection. The case count is continuing to rise. The drug was a steroid, methylprednisolone acetate, made by the New England Compounding Center in Framingham, Mass. Three contaminated lots of the drug, more than 17,000 vials, were shipped around the country, and about 14,000 people were injected with the drug, mostly for neck and back pain. But some received injections for arthritic joints and have developed joint infections.

Inspections of the compounding center have revealed extensive contamination. It has been shut down, as has another Massachusetts company, Ameridose, with some of the same owners. Both companies have had their products recalled.

Compounding pharmacies, which mix their own drugs, have had little regulation from either states or the federal government, and several others have been shut down recently after inspections found sanitation problems.

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For Hourly Workers After the Storm, No Work, No Pay

Chantal Sainvilus, a home health aide in Brooklyn who makes $10 an hour, does not get paid if she does not show up. So it is no wonder that she joined the thousands of people taking extreme measures to get to work this week, even, in her case, hiking over the Williamsburg Bridge.

While salaried employees worked if they could, often from home after Hurricane Sandy, many of the poorest New Yorkers faced the prospect of losing days, even a crucial week, of pay on top of the economic ground they have lost since the recession.

Low-wage workers, more likely to be paid hourly and work at the whim of their employers, have fared worse in the recovery than those at the top of the income scale — in New York City the bottom 20 percent lost $463 in annual income from 2010 to 2011, in contrast to a gain of almost $2,000 for the top quintile. And there are an increasing number of part-time and hourly workers, the type that safety net programs like unemployment are not designed to serve. Since 2009, when the recovery began, 86 percent of the jobs added nationally have been hourly. Over all, about 60 percent of the nation’s jobs are hourly.

Even as the sluggish economy has accentuated this divide, Hurricane Sandy has acted as a further wedge, threatening to take a far greater toll on the have-littles who live from paycheck to paycheck.

“There’s a lot of people in our society that are living in a very precarious situation in terms of low wages or very insecure work,” said Arne L. Kalleberg, a sociologist at the University of North Carolina at Chapel Hill and author of “Good Jobs, Bad Jobs.” “That’s why it’s important to have a safety net that’s based on the idea of people working insecure jobs like this.”

On Friday, Gov. Andrew M. Cuomo announced that New York City and four suburban counties were eligible for disaster unemployment relief, which covers a broader spectrum of workers than regular unemployment benefits, including the self-employed like taxi drivers and street vendors as well as those who were unable to get to work.

New Jersey has also declared people in 10 counties eligible for disaster unemployment assistance. In Connecticut, residents of four counties and the Mashantucket Pequot Indian Reservation are eligible.

A New York Department of Labor spokesman emphasized that workers who lost wages should call to apply because the program is flexible and many eligibility issues would be determined on a case-by-case basis.

But the program might not help people whose commute simply lasted longer or cost more, like Ibezim Oki, a cabdriver who spent $50 on a cab to get from his Brooklyn home to Manhattan on Friday, rather than risk long bus delays, and “now I don’t know how long I’m going to have to wait for gas.”

The commute alone represented a hardship for workers whose jobs require a physical presence, while neighborhood coffee shops in the boroughs and suburbs overflowed with those who needed nothing more than a laptop and Wi-Fi to stay connected to work.

Ms. Sainvilus estimated that on Thursday, she had traveled eight hours to work for five, making her effective pay less than $4 an hour.

Others could not work because their place of business was closed. At a food distribution center in Chelsea, Mike Samuel, 55, a delivery man for a florist, was feeling the pain of five days of lost income. “We don’t work, we don’t get no tips, we don’t get no pay,” he said.

Muta Prather said the chemical company where he works in Newark was flooded, causing him to miss three days of work. He worked part of the day on Thursday helping to clean up, but worried about how he would pay for damage to his own roof.

“It hurts, you know,” said Mr. Prather, who is 49 and lives in West Orange, N.J. “I looked up at my roof, and it’s going to cost me like seven grand. I don’t make that kind of money.”

But at a playground in the Clinton Hill section of Brooklyn, Damien Carney stood with his baby daughter strapped to his chest and his toddler on a nearby swing, enjoying a surprise week off. For Mr. Carney, a salaried portfolio manager for a wine distributor that was closed because it had no power, the storm was amounting to something like a paid vacation with time for cooking and rearranging the living room. “They basically said, ‘Don’t worry about it,’ ” Mr. Carney said of his employers.

Federal labor laws include more protections for salaried workers than hourly workers when a disaster hits. Employers must continue to pay salaries if the worksite is closed for less than a week, even though they are allowed to require employees to use vacation or paid leave for the duration of the closure. Hourly workers, on the other hand, do not have to be paid if the worksite closes. If the workplace is open but salaried workers cannot get there, their pay may be reduced.

Of course, policies vary from workplace to workplace, and some hourly workers were luckier than others. Cassandra Williams, 54, waiting for the bus from Brooklyn to Manhattan with her 6-year-old granddaughter, said the family for whom she keeps house would pay her full wages despite her missing three days of work. Tinash Makots, a 24-year-old salesman at the Nike store in Midtown Manhattan, said he would be paid for the days missed as well.

One nanny in the bus line said she would be paid her regular wages, while another said she would not be compensated for hours missed.

A financial district worker who would identify himself only as William S. said he did not strictly need to go into Manhattan to do his job, but felt that he should make an appearance after one of his staff members showed up every day at 6 a.m. and another paid $40 a day to get to a distant office in Queens.

But Anthony Howell, a 42-year-old hair stylist in Chelsea, said he hadn’t worked all week because his salon, like his high-rise apartment, has no electricity.

“That’s the brutal part,” he said. “The hair industry is like that. You don’t do the work, you don’t get the money.”

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U.S. Airman Is Suspected of Punching Japanese Boy

TOKYO — Japanese leaders reacted angrily on Friday after the police on Okinawa said an American Air Force serviceman was suspected of breaking into an apartment while drunk and punching a 13-year-old boy, just weeks after two American sailors were accused of raping a woman on the same island.

Japan’s foreign minister, Koichiro Gemba, called the suspected attack “outrageous,” and said hitting a boy was “completely unforgivable.”

The assault took place early Friday morning, the police said. The airman was apparently in violation of a curfew imposed just last month by the American military on all of its roughly 50,000 military personnel in Japan following the rape accusation. The police did not release the name of the 24-year-old airman, who was in the hospital after apparently falling from a third-story window.

The back-to-back episodes have stirred outrage on Okinawa, the southern island that hosts three-quarters of the American bases in Japan. The episodes also threaten to complicate ties between the United States and its closest Asian ally at a time when both nations are trying to work together to face an increasingly assertive China.

The episodes have added to the increasingly vocal opposition on Okinawa to carrying what many residents see as a disproportionate burden in hosting so many of the American troops in Japan. Japanese officials fear Okinawan anger could grow strong enough to disrupt their nation’s overall security alliance with the United States, on which Japan has relied for its defense since the end of World War II.

Okinawan opposition has already blocked a 16-year-old deal to relocate a United States Marine Corps air field to the island and forced the Marines to place restrictions on flights by a new aircraft, the tilt-rotor Osprey. Japanese leaders have been trying to convince Okinawans that they are working to lighten the island’s base burden, while also reassuring the Americans that they remain committed alliance partners.

The governor of Okinawa, Hirokazu Nakaima, warned that the suspected actions by American servicemen threatened the entire United States-Japan alliance.

“You can only conclude that they are fracturing the alliance,” Mr. Nakaima was quoted as saying by the daily newspaper Asahi Shimbun.

American officials said they would cooperate with the investigation.

“We are very upset, and we pledge complete cooperation with the government of Japan in getting to the bottom of this, and preventing future occurrences,” the American ambassador to Japan, John V. Roos, said in a statement.

Crimes by American military personnel are an emotional issue on Okinawa, especially since the rape of a girl by three servicemen in 1995. They top a list of Okinawan complaints about the bases that also includes noise and pollution.

The police said the American airman was suspected of entering the apartment about 1 a.m. Friday as two schoolboys inside were sleeping. The American woke them up and punched one of them in the face, the police said, before kicking in a television set and then trying to flee through the third-story window.

They said the American had apparently been drinking at a bar on the ground floor of the same building, where he began shouting and acting violently before going upstairs to the apartment. The police said the door of the apartment, which was rented by a 41-year-old woman, was unlocked, as is still common in parts of low-crime Japan.

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Norv's Bolts beat staggering Chiefs 31-13

SAN DIEGO (AP) — It took a win against arguably the worst team in the NFL to get Norv Turner off the hot seat, at least for 10 days.

And if things have been bad for the embattled Turner, imagine what Romeo Crennel is going through.

Antonio Gates caught a 14-yard yard scoring pass from Philip Rivers on the game's opening drive to snap a streak of six straight quarters without a touchdown and the San Diego Chargers went on to a 31-13 victory Thursday night over the woeful Kansas City Chiefs.

The Chiefs committed four turnovers and lost their fifth straight game.

Turner had been heavily criticized by fans after the Chargers (4-4) blew double-digit, second-half leads in losses to New Orleans and Denver, and then lost 7-6 at Cleveland on Sunday.

At the start of halftime, some fans in one end zone unfurled a big yellow banner that read: "Mr. Spanos, please fire A.J. & Norv."

Team president Dean Spanos decided in January to bring back both Turner and general manager A.J. Smith even though the Chargers missed the playoffs for the second straight year and have only one postseason win in four seasons.

Spanos probably wasn't inclined to fire Turner during the season, although a loss to the Chiefs (1-7) would have been more than embarrassing.

"We didn't talk about it specifically, but we want to win for him every week," Rivers said. "You play for a lot of things, but we play for our coach. I think that has been evident over the years when we have struggled."

Rivers, who looked shaky during the losing streak, did his part by completing 18 of 20 passes, or 90 percent, for 220 yards and two touchdowns, with one interception. It was the sixth time in NFL history a quarterback had completed 90 percent or more of his passes, and tied Steve Young for fifth on that list.

Rivers also threw a 13-yard TD pass to Malcom Floyd early in the fourth quarter.

"It was good to play well, but more importantly, it was good to win a game. We needed a win in the worst way," Rivers said. "Game like this, wins like this can jump start us."

The Chiefs' NFL-high 29 turnovers have led to 104 points.

"Similar to what's been happening throughout the course of this year, we shoot ourselves in the foot," Crennel said. "We're in a hole and we have to fight our way out. ... It wasn't very good overall, but we're going to keep coaching and keep fighting and play our way out of it."

The Chiefs had six turnovers in a 37-20 home loss to the Chargers on Sept. 30.

"We fought hard, played hard, but at the end of the game it came down to the turnovers," said quarterback Matt Cassel, whose fumble and interception both led to a Chargers TD.

The Chiefs still haven't led in regulation this season. Their only victory came when Ryan Succop kicked the winning field goal against the Saints in overtime.

In just more than two minutes, the Chargers' defense scored as many touchdowns as the offense had in 10 quarters.

With the Chiefs trailing 17-6, Cassel fumbled as he was sacked by Jarret Johnson in the end zone and Shaun Phillips recovered for a touchdown early in the fourth quarter. On the next drive, Cassel's high pass deflected off Dexter McCluster's hands and was intercepted by Demorrio Williams, who returned it 59 yards for a touchdown.

"I don't know If someone stepped in front of him and tipped the ball, but thank God I was there to make the play," Williams said.

In the loss to New Orleans, Williams had an interception return for a touchdown that was nullified after rookie Melvin Ingram was flagged for a late hit on Drew Brees.

Williams, who played for the Chiefs the last four seasons, forced a fumble in the first quarter.

Gates' first-quarter score was San Diego's first touchdown since the star tight end caught an 11-yard pass in the first half against Denver on Oct. 15. That score gave San Diego a 24-0 lead, but Peyton Manning rallied the Broncos to a 35-24 win.

The Chargers got only two field goals from Nick Novak in a 7-6 loss at Cleveland on Sunday, their third straight defeat.

After San Diego scored on the opening drive, Kansas City went on a 17-play drive, converting four third downs, but Dwayne Bowe fumbled after a 10-yard reception. Williams caused the fumble and Quentin Jammer recovered.

Bowe's fumble set up Novak's 25-yard field goal with 9:10 left in the second quarter.

After Kansas City decided not to go for it on fourth-and-1 from the San Diego 31, Succop kicked a 49-yard field goal with 2:51 left before halftime.

The Chargers had a third-and-goal from the 1 in the closing seconds of the half when Rivers was intercepted by Eric Berry.

Succop had a 41-yard field goal in the third quarter.

NOTES: K.C.'s Jamaal Charles was hurt when he was hit in the side of the head by Donald Butler. He said he would have gone back in, "but they told me to just relax." Charles said he was tested for a concussion but was cleared. ... San Diego's Ryan Mathews appeared to sprain his left ankle early in the second quarter and was in and out of the game after that. ... Chiefs LG Jeff Allen left with what was described as a head injury, and defensive end Glenn Dorsey left with a calf injury.

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The New Old Age Blog: How to Bypass the Revolving Door

Last week, I wrote about older people in nursing homes who are transferred to hospitals when their health takes a turn for the worse, even if they don’t want aggressive medical interventions. And you responded with dozens of stories about relatives who had had these experiences.

In fact, researchers who have studied the revolving door between nursing homes and hospitals think that as many as 45 percent of hospitalizations for nursing home patients (those covered by both Medicare and Medicaid) are avoidable or unnecessary.

So why do they occur? Often, nursing homes aides aren’t adequately trained to identify the early signs of deterioration in a resident’s condition and to act promptly to help prevent a medical crisis. Doctors typically aren’t present in facilities full time, and those on call often would rather be safe than sorry.

Frequently, nursing home patients’ wishes — what kind of treatment they’d like to have and under what conditions — aren’t known or included in their medical records. So aggressive care is given as a matter of course.

A new pilot program in seven states that is sponsored by the federal Centers for Medicare and Medicaid Services aims to address these issues. The effort involves so-called long-stay residents (those who live in homes for 100 days or longer) in 145 nursing homes. It gets up and running later this year.

I spoke with experts from three sites – Nevada, Indiana and New York City – at length. All are trying different models but share some common elements. Notably, each program will send extra providers (nurse practitioners, registered nurses or physician assistants) into nursing homes to teach front-line staff (certified nursing assistants and others) how to better recognize and respond to changes in an older resident’s health.

“Keep in mind that these long-stay residents are very frail, with multiple chronic medical conditions that can flare up at any time,” said Dr. Greg Sachs, chief of the division of general internal medicine and geriatrics at Indiana University’s School of Medicine. “By intervening upstream, hopefully we can interrupt a cascade of medical complications that can lead to a hospitalization.”

HealthInsight of Nevada, working with 25 nursing homes, will be implementing a “green, yellow and red light” system. For each of the colors, extensive protocols – what clinical signs to watch for, how to react – have been created and will be taught to nursing home staff members. (The protocols were developed by Dr. Joseph Ouslander of Florida Atlantic University and are being used by several programs.)

Green means “something has changed but the patient is stable and it’s O.K. to keep her here,” said Dr. Jerry Reeves, HealthInsight’s medical director. An example: An older person with congestive heart failure who develops swollen ankles, a sign that her circulatory system is under stress, will get a stronger diuretic and be monitored more closely.

Yellow means the patient is unstable but “it’s still within the ability of the facility to care for Mrs. Jones,” said Dr. Reeves. This could be a patient who’s stopped eating and is now vomiting but otherwise isn’t acutely ill. Again, a medical intervention and more frequent checks will be in order.

Red signals a major change like chest pain, blood pressure that’s hard to measure or a stroke that requires immediate attention from a doctor, nurse practitioner or physician assistant. In some cases, patients will need to be transferred to the hospital; in other cases, they may remain in place at the nursing home with extra assistance.

In Indiana, the pilot will help 20 nursing homes establish nonpharmaceutical interventions for older patients with dementia. Too often, these patients are medicated with antipsychotic drugs, which puts them at risk of falls, fractures and strokes, which then land them in the hospital, Dr. Sachs said.

Other priorities will be integrating symptom-relieving palliative care more fully into the nursing home setting and better managing transfers of nursing home residents to and from hospitals when these admissions are necessary. Making sure that information about patients is transferred between settings and that medical providers communicate with one another is an important part of that.

In and around New York City, the Greater New York Hospital Foundation will be working with 30 nursing homes to ensure that older patients and their families have in-depth discussions about “goals of care” and palliative care and incorporate the substance of these discussions in medical decision-making. That involves educating caregivers about the consequences of various interventions and treatments.

“Caregivers need realistic expectations about what a hospitalization means to a person living in a nursing home,” said Roxanne Tena-Nelson, executive vice president at the foundation’s long-term care unit.

Given the enormous cultural diversity of New York and the sensitivity of the topic, “we don’t pretend this is going to be simple,” said Tim Johnson, executive director of the foundation.

Also, the New York pilot will create an “electronic dashboard” for nursing homes that eases communication among doctors and nurses, enables front-line staff to more readily identify emerging medical problems, and standardizes information that passes back and forth between nursing homes and hospitals when a patient is transferred. Most nursing homes rely on paper-based medical records currently.

The bottom line is that frail older people “should not be going to the emergency room when their care could be better delivered in another setting,” Mr. Johnson said. “We really have to take this on and make things better for this vulnerable population.”

I’m sure many readers here would second the sentiment. I’ll check back to see how these pilot programs are doing, after they have some experience under their belt.

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