The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Military's dogs of war also suffer post-traumatic stress disorder

LACKLAND AIR FORCE BASE, Texas — Not long after a Belgian Malinois named Cora went off to war, she earned a reputation for sniffing out the buried bombs that were the enemy's weapon of choice to kill or maim U.S. troops.

Cora could roam a hundred yards or more off her leash, detect an explosive and then lie down gently to signal danger. All she asked in return was a kind word or a biscuit, maybe a play session with a chew toy once the squad made it back to base.

"Cora always thought everything was a big game," said Air Force Tech. Sgt. Garry Laub, who trained Cora before she deployed. "She knew her job. She was a very squared-away dog."

PHOTOS: Military dogs

But after months in Iraq and dozens of combat patrols, Cora changed. The transformation was not the result of one traumatic moment, but possibly the accumulation of stress and uncertainty brought on by the sharp sounds, high emotion and ever-present death in a war zone.

Cora — deemed a "push-button" dog, one without much need for supervision — became reluctant to leave her handler's side. Loud noises startled her. The once amiable Cora growled frequently and picked fights with other military working dogs.

When Cora returned to the U.S. two years ago, there was not a term for the condition that had undercut her combat effectiveness and shattered her nerves. Now there is: canine post-traumatic stress disorder.

"Dogs experience combat just like humans," said Marine Staff Sgt. Thomas Gehring, a dog handler assigned to the canine training facility at Lackland Air Force Base, who works with Cora daily.

Veterinarians and senior dog handlers at Lackland have concluded that dogs, like humans, can require treatment for PTSD, including conditioning, retraining and possibly medication such as the anti-anxiety drug Xanax. Some dogs, like 5-year-old Cora, just need to be treated as honored combat veterans and allowed to lead less-stressful lives.

Walter Burghardt Jr., chief of behavioral medicine and military working-dog studies at Lackland, estimates that at least 10% of the hundreds of dogs sent to Iraq and Afghanistan to protect U.S. troops have developed canine PTSD.

Cora appears to have a mild case. Other dogs come home traumatized.

"They're essentially broken and can't work," Burghardt said.

There are no official statistics, but Burghardt estimates that half of the dogs that return with PTSD or other behavioral hitches can be retrained for "useful employment" with the military or law enforcement, such as police departments, the Border Patrol or the Homeland Security Department.

The others dogs are retired and made eligible for adoption as family pets.

The decision to officially label the dogs' condition as PTSD was made by a working group of dog trainers and other specialists at Lackland. In most cases, such labeling of animal behavior would be subjected to peer review and scrutiny in veterinary medical journals.

But Burghardt and others in the group decided that they could not wait for that kind of lengthy professional vetting — that a delay could endanger those who depend on the dogs.

Since the terrorist attacks of 2001, the military has added hundreds of canines and now has about 2,500 — Dutch and German shepherds, Belgian Malinois and Labrador retrievers — trained in bomb detection, guard duty or "controlled aggression" for patrolling.

Lackland trains dogs and dog handlers for all branches of the military. The huge base, located in San Antonio, has a $15-million veterinary hospital devoted to treating dogs working for the military or law enforcement, like a Border Patrol dog who lost a leg during a firefight between agents and a suspected drug smuggler.

"He's doing fine, much better," the handler yelled out when asked about the dog's condition.

Cora received her initial training here and then additional training with Laub at Moody Air Force Base in Georgia. Before they could deploy, however, Laub was transferred to Arkansas, and Cora shipped off to Iraq with a different handler, much to Laub's regret.

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Alt Text: How to Tell Real SEALs From Basement-Dwelling Posers

The White House recently congratulated the makers of Troop ID, a service designed to help online merchants securely identify members of the armed forces. This was a significant recommendation, the first software application to be publicly praised by the president since he canceled a 2009 press conference in order to play Doodle Jump.

While I’m happy that troops will be able to claim their 10 percent discount on water bottles and mock turtlenecks, I’m a bit disappointed that the service is apparently only being used in a retail context. After the whole Stolen Valor saga, you’d think there’d be a huge demand for a secure way to vet self-described vets.

Here’s a statistic: While there are only 2,500 active-duty Navy SEALs at any given time, there are approximately 4 million people claiming to be current or former Navy SEALs in various chat rooms and message boards on the internet. This is because any argument is 200 percent more convincing when presented by a Navy SEAL.

A couple of examples:

Unconvincing: “As a mall food court assistant supervisor, I believe that our mission in Afghanistan is necessary to the stability of the Middle East.”
Convincing: “As a Navy SEAL, I believe that our mission in Afghanistan is necessary to the stability of the Middle East.”

Unconvincing: “As a teaching assistant in comparative literature, I believe that The Silmarillion is vastly overrated by Tolkien fans.”
Convincing: “As a Navy SEAL, I believe that The Silmarillion is vastly overrated by Tolkien fans.”

With results like that, it’s no wonder that people are attempting to fraudulently win arguments by pretending to be members of elite military squads like the SEALs, the Green Berets, the Army Rangers and occasionally G.I. Joe. It seems to me that Troop ID could be used to distinguish the Special Forces from the basement-dwelling posers.

Once we have that technology in place, we could easily expand it to ferret out other internet pretenders. For instance, before you claim that you’re going to show up at someone’s house and beat them up, or argue that you’d have a mugger in a headlock before he could say “hand over the cash,” you’d be expected to use the ToughGuy ID service to certify that you have actually, at some point, won a fight that wasn’t against a sibling at least four years younger than you.

Our founding fathers created the First Amendment protections on free speech for a good reason: because it’s freaking hilarious.

Or before you can declare that the solution to the “fiscal cliff” crisis is obvious to anyone who knows anything about economics, you’d be expected to provide proof to Expert ID that your main credentials in economics aren’t limited to having seen both Atlas Shrugged movies.

I say “expected to” because I’m not saying that you would have to sign up for these services. Goodness no, my ludicrous and improbable fantasies aren’t that tyrannical. I believe that our founding fathers created the First Amendment protections on free speech for a good reason: because it’s freaking hilarious. There’s nothing more fun than watching someone weave ever-more-desperate lies to cover up their unwillingness to either put, or shut, up.

However, I do think there’s one vital concern that overrides the right to free speech: Before commenting on a humor column on the web, everyone should be required to take a simple test that would confirm that they have the basic human ability to recognize sarcasm and hyperbole.

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Born helpless, naked and unable to provide for himself, Lore Sjöberg overcame these handicaps to become a commando, a commandant and a cormorant.

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Dog bite sidelines ‘Dirty Dozen’ trumpeter Towns

NEW ORLEANS (AP) — Dirty Dozen Brass Band trumpeter Efrem Towns is recovering at home in New Orleans from a vicious attack by a Rottweiler at an Atlanta motel.

He missed performances in Colorado and New Orleans after the attack on Nov. 18, and doesn’t know if he’ll make the band’s next scheduled gig on Dec. 28, The Times-Picayune (http://bit.ly/XOJoNr) reported.

He and baritone sax player Roger Lewis said the dog surged from an open motel room door after Towns knocked on the door of Lewis’ room.

“I didn’t know if it was a dog, wolverine, bear, mongoose or what. I just knew something had me,” Towns said.

He said the dog‘s owner came out of the next room, and they were able to subdue it.

At Atlanta’s Grady Hospital, he received 30 stitches in his groin. Towns, who has health insurance through his wife, Tracie, said he will be seeing a urologist this week.

The Dirty Dozen Brass Band formed in 1977, and is credited with creating the contemporary, funk-infused brass band sound. It’s been featured on albums with David Bowie, Elvis Costello and the Black Crowes.

Towns said he probably could practice while convalescing. “But I’m very uncomfortable right now,” he said Friday evening. “I’m basically immobilized — it’s hard getting around. I’m kind of miserable.”

The experience hasn’t soured Towns on dogs. He and his wife own three miniature schnauzers, a standard schnauzer and a mixed breed. On Friday, his daughter’s dachshund was visiting.

“I’m a dog person,” he said. “And even though I got bit, I hope they don’t put that dog to sleep.”

___

Information from: The Times-Picayune, http://www.nola.com

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Agency Investigates Deaths and Injuries Associated With Bed Rails

Thomas Patterson for The New York Times

Gloria Black’s mother died in her bed at a care facility.

In November 2006, when Clara Marshall began suffering from the effects of dementia, her family moved her into the Waterford at Fairway Village, an assisted living home in Vancouver, Wash. The facility offered round-the-clock care for Ms. Marshall, who had wandered away from home several times. Her husband Dan, 80 years old at the time, felt he could no longer care for her alone.

Thomas Patterson for The New York Times

Gloria Black, visiting her mother’s grave in Portland, Ore. She has documented hundreds of deaths associated with bed rails and said families should be informed of their possible risks.

But just five months into her stay, Ms. Marshall, 81, was found dead in her room apparently strangled after getting her neck caught in side rails used to prevent her from rolling out of bed.

After Ms. Marshall’s death, her daughter Gloria Black, who lives in Portland, Ore., began writing to the Consumer Product Safety Commission and the Food and Drug Administration. What she discovered was that both agencies had known for more than a decade about deaths from bed rails but had done little to crack down on the companies that make them. Ms. Black conducted her own research and exchanged letters with local and state officials. Finally, a letter she wrote in 2010 to the federal consumer safety commission helped prompt a review of bed rail deaths.

Ms. Black applauds the decision to study the issue. “But I wish it was done years ago,” she said. “Maybe my mother would still be alive.” Now the government is studying a problem it has known about for years.

Data compiled by the consumer agency from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults — about 4,000 a year — were treated in emergency rooms with bed rail injuries. Officials at the F.D.A. and the commission said the data probably understated the problem since bed rails are not always listed as a cause of death by nursing homes and coroners, or as a cause of injury by emergency room doctors.

Experts who have studied the deaths say they are avoidable. While the F.D.A. issued safety warnings about the devices in 1995, it shied away from requiring manufacturers to put safety labels on them because of industry resistance and because the mood in Congress then was for less regulation. Instead only “voluntary guidelines” were adopted in 2006.

More warnings are needed, experts say, but there is a technical question over which regulator is responsible for some bed rails. Are they medical devices under the purview of the F.D.A., or are they consumer products regulated by the commission?

“This is an entirely preventable problem,” said Dr. Steven Miles, a professor at the Center for Bioethics at the University of Minnesota, who first alerted federal regulators to deaths involving bed rails in 1995. The government at the time declined to recall any bed rails and opted instead for a safety alert to nursing homes and home health care agencies.

Forcing the industry to improve designs and replace older models could have potentially cost bed rail makers and health care facilities hundreds of million of dollars, said Larry Kessler, a former F.D.A. official who headed its medical device office. “Quite frankly, none of the bed rails in use at that time would have passed the suggested design standards in the guidelines if we had made them mandatory,” he said. No analysis has been done to determine how much it would cost the manufacturers to reduce the hazards.

Bed rails are metal bars used on hospital beds and in home care to assist patients in pulling themselves up or helping them out of bed. They can also prevent people from rolling out of bed. But sometimes patients — particularly those suffering from Alzheimer’s — can get confused and trapped between a bed rail and a mattress, which can lead to serious injury or even death.

While the use of the devices by hospitals and nursing homes has declined as professional caregivers have grown aware of the dangers, experts say dozens of older adults continue to die each year as more rails are used in home care and many health care facilities continue to use older rail models.

Since those first warnings in 1995, about 550 bed rail-related deaths have occurred, a review by The New York Times of F.D.A. data, lawsuits, state nursing home inspection reports and interviews, found. Last year alone, the F.D.A. data shows, 27 people died.

As deaths continued after the F.D.A. warning, a working group put together in 1999 and made up of medical device makers, researchers, patient advocates and F.D.A. officials considered requiring bed rail makers to add warning labels.

But the F.D.A. decided against it after manufacturers resisted, citing legal issues. The agency said added cost to small manufacturers and difficulties of getting regulations through layers of government approval, were factors against tougher standards, according to a meeting log of the group in 2000 and interviews.

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Solar power plants burden the counties that host them

When it comes to attracting business to California's eastern deserts, Inyo County is none too choosy.

Since the 19th century the sparsely populated county has worked to attract industries shunned by others, including gold, tungsten and salt mining. The message: Your business may be messy, but if you plan to hire our residents, the welcome mat is out.

So the county grew giddy last year as it began to consider hosting a huge, clean industry. BrightSource Energy, developer of the proposed $2.7-billion Hidden Hills solar power plant 230 miles northeast of Los Angeles, promised a bounty of jobs and a windfall in tax receipts. In a county that issued just six building permits in 2011, Inyo officials first estimated that property taxes from the facility would boost the general fund 17%.

But upon closer inspection, the picture didn't seem so rosy.

An economic consultant hired by the county found that property tax revenue would be a fraction of the customary amount because portions of the plant qualifiy for a solar tax exclusion. Fewer than 10 local workers would land permanent positions — and just 5% of the construction jobs would be filled by county residents. And construction workers are likely to spend their money across the nearby state line, in Nevada.

Worse, the project would cost the county $11 million to $12 million during the 30-month construction phase, with much of the money going to upgrade a historic two-lane road to the plant. Once the plant begins operation, the county estimates taxpayers will foot the bill for nearly $2 million a year in additional public safety and other services.

Two of California's other Mojave Desert counties, Riverside and San Bernardino, have made similar discoveries. Like Inyo, they are now pushing back against solar developers, asking them to cover the costs of servicing the new industry.

"Southern California is going to become the home to the state's ability to meet its solar goals," said Gerry Newcombe, public works director for San Bernardino County. "That's great, but where are the benefits to the county?"

Desert counties also are anticipating costly shifts in land use, including the conversion of taxable private property into habitat for endangered species. Solar developers are required to buy land to offset the loss of habitat caused by their projects. Once the property is acquired, it cannot be developed, which reduces its potential for tax revenue.

Two of the largest solar plants in the world are under construction in San Bernardino County. But county officials are not sure if revenue from the projects will offset the cost of additional fire and safety services, which analysts say will amount to millions of dollars a year.

For example, the $2.2-billion Ivanpah solar project at the county's eastern border has agreed to pay $377,000 annually, but that may not be enough to cover the county's new costs related to the plant. The county doesn't know how much solar plants will drain from its budget because the projects are being planned and approved too quickly for adequate analysis, officials say.

"We really support private development and generating jobs," Newcombe said. "On the other hand, I am concerned that it's going too fast. I don't know that we've had a chance to appreciate the long-term impacts."

The county is also worried because most of the land inside its borders is owned by the federal government, and up to 1 million acres of that — nearly 8% of the county — could be set aside for solar development, removing it from public access and recreational opportunities, Newcombe said.

Counties that object to the pace of development, however, have been scolded for standing in the way of progress. Not only is renewable energy a priority of the Obama administration, it is also the darling of California's chief executive.

Gov. Jerry Brown has vowed to "crush" opponents of solar projects. At the launch of a solar farm near Sacramento, the governor pledged: "It's not easy. There are gonna be screw-ups. There are gonna be bankruptcies. There'll be indictments and there'll be deaths. But we're gonna keep going — and nothing's gonna stop me."

Counties have little say because the state controls planning and licensing of large-scale projects. The California Energy Commission issues the permits for utility-scale solar farms, and counties depend on the commission's staff to look out for their interests.

To the extent that California counties are pushing back against industrial solar, the rebellion began in Riverside County more than a year ago.

Some 20 utility-scale solar farms are proposed in the eastern stretch of the county on 118,000 acres of federal land along the Interstate 10 corridor between Desert Center and Blythe.

The Riverside County Board of Supervisors considered charging companies a franchise fee to offset the effects on roads and public services and to compensate for the loss of recreation and tourism access to the 185 square miles of federal land. Local officials saw it as a matter of fairness. Public utilities pay 2% of gross receipts to the county, for example.

"The solar companies are the beneficiaries of huge government loans, tax credits and, most critically for me, property tax exemptions, at the expense of taxpayers," said county Supervisor John Benoit, referring to a variety of taxpayer-supported loans and grants available to large solar projects as part of the Obama administration's renewable energy initiative. "I came to the conclusion that my taxpayers need to get something back."

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Tracking Mars: Curiosity Makes Its Mark on the Red Planet

Since Curiosity landed on mars on Aug. 6, the rover has traveled hundreds of feet over the Martian surface. In the process, it has tracked up the sandy, dusty terrain, leaving tire marks, scoop divots, Morse code and one tiny piece of itself behind.

Unlike the Apollo astronauts' footprints on the moon, Curiosity's trails will probably be wiped away by the planet's frequent wind and sand storms. But there is still something so incredible about these little ephemeral marks we are making on another world.

Though the physical traces won't last, their impact lives on in the images the rover is sending back to Earth. Here are some of our favorite shots of Curiosity's tracks on Mars.

Image: NASA/JPL-Caltech

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‘Gangnam Style’ most watched YouTube video ever

SEOUL, South Korea (AP) — South Korean rapper PSY‘s “Gangnam Style” has become YouTube’s most viewed video of all time.

YouTube says in a posting on its Trends blog that “Gangnam Style” had been viewed 805 million times as of Saturday afternoon, surpassing Justin Bieber‘s “Baby,” which has had 803 million views.

The blog says the “velocity of popularity for PSY’s outlandish video is unprecedented.”

PSY’s video featuring his horse-riding dance was posted on YouTube in July, while “Baby” was uploaded in February 2010.

PSY’s video has become a global sensation, with many people around the world mimicking his “Gangnam Style” dance. In their October meeting, U.N. Secretary-General Ban Ki-moon, a South Korean, joked that he had to relinquish his title as “the most famous Korean,” and tried a few of PSY’s dance moves.

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Dave Roberts brings diversity to the San Diego County supervisors

DEL MAR — In January, when he joins the San Diego County Board of Supervisors, Dave Roberts will be the only Democrat among four Republicans, the first Democrat on the board in more than two decades.

He will also be the first new supervisor in 18 years. And he will be the only one who is not a graduate of San Diego State. He has three degrees from American University in Washington, D.C.

He's also gay and married to a retired Air Force master sergeant. The two are adoptive parents to five former foster children, ages 4 to 17, who call them Daddy Dave and Daddy Wally.

With Roberts' election to a district representing a portion of San Diego and several seaside communities north of the city, diversity has arrived for the Board of Supervisors, long one of the region's most homogenous governing bodies.

"I'm going to bring some unique characteristics," Roberts, 51, said with a laugh during a family outing on the beach here.

Roberts hopes to concentrate on the same issues he focused on while serving on the Solana Beach City Council, where he is currently deputy mayor: regional fire protection, expansion of the San Dieguito River Park and "sensible" growth.

Roberts is a Democrat in the style of Republican-leaning northern San Diego County: fiscally conservative. He worked as a budget analyst for the Department of Defense and as a corporate vice president for the La Jolla-based defense contractor SAIC. He was a Republican until some in the GOP took exception to a gay man working in the Pentagon.

"The Republicans wanted me to be fired," Roberts said. "That's when I changed political parties."

Some of his first experience in government came from working as a staffer to Sen. Lowell Weicker, a Republican from Connecticut. "I learned from working for Sen. Weicker that you can make change if you're in the right place," Roberts said.

In 2009, Democratic party officials encouraged Roberts to seek the party's nomination to face incumbent Brian Bilbray (R-Carlsbad) in the 50th Congressional District.

On the verge of declaring his candidacy, Roberts was alerted by social workers about two children who needed a "forever" home. He decided that the adoption process took precedence over his political career.

Now there are five children in the two-story home in Solana Beach once owned by singer Patti Page: Robert, 17; Alex, 12; Julian, 8; Joe, 5; and Natalee, 4. Three of the children have taken the last name Roberts, and two took his spouse's last name, Oliver.

"We don't like double names," Roberts said.

Roberts and Wally Oliver, 55, have been together for 14 years. They had a commitment ceremony in 1998 and married in July 2008 in the brief period when county clerks in California were allowed to issue same-sex marriage licenses.

The family may soon expand.

"Wally would like a baby," Roberts said. "We're not Jewish, but we believe in the Jewish proverb: 'If you can save one soul, you can save the world.'"

During his race against a Republican opponent, Roberts was endorsed by the retiring incumbent, Pam Slater-Price. He has also begun discussions with Supervisor Dianne Jacob, possibly the most fiscally conservative member of the board.

He also looks forward to working with Supervisor Bill Horn, an ex-Marine who supported Proposition 8, the measure to ban same-sex marriage, and has said he opposes gays in the military. "He says things from time to time that remind me of my father," Roberts said.

For all of their fiscal conservatism, the supervisors have not dabbled much in social issues in a way that might satisfy some elements in the GOP. The board took no position on Proposition 8. Health clinics in gay neighborhoods and AIDS prevention programs are funded without controversy.

Roberts may be different in another respect from his colleagues: He will not be assigning a staff member to send out his Twitter messages. He sends out his own tweets — lots of them, on topics political and personal.

Last week, among many tweets, was one announcing that he has hired his predecessor's chief-of-staff, praising him for his "broad experience, management style and network of contacts."

And the next tweet: "Took the kids out for frozen yogurt at Seaside Yogurt in Del Mar for a treat."

tony.perry@latimes.com

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How One <em>Myst</em> Fan Made Himself a Real-Life Linking Book

The classic PC game Myst was known for drawing people in to its massive, surreal world. But maker Mike Ando took a little piece of that world and drew it into ours. He made a lovingly authentic replica of the Linking Book that helps the main character — you — navigate the world.

Myst was a ground-breaking point-and-click adventure game created by Cyan Worlds, made of hundreds of beautifully rendered scenes whose combined size made the game so big that it needed a CD-ROM to play, back when many computers didn’t have them. It was the first breakout hit in PC gaming and from its release in 1993 it held the title of best-selling PC game until 2002 when The Sims surpassed it.

The game spawned four sequels, along with novels, music, and an MMO that is still online and being powered by donations from the fan base. The games have been widely ported and the game — once so huge that you needed special hardware to run it — is now available for download on iOS (among other places). In other words, it’s a pretty big deal.

At the core of Myst’s story was a mystical technology called Linking Books that pulled players into other realms, called Ages. They were these beautiful old tomes that, when opened, showed an animated preview of the Age to which you’d be linked.

“Ever since I first played the game, I always wanted my own linking book,” says Ando, “Of course, there was no way my old bulky 486 would fit within a book, but as time marched on technology advanced and computers became smaller. Eventually technology caught up and it was possible to shrink everything down to fit inside the book.”

Ando says his drive to make this project began six years ago when he learned where Cyan got the texture reference for the books — Harper’s New Monthly Magazine, Volume LIV, Issue 312, December 1876 to May 1877. “My mind hatched all sorts of plans about what I’d do once I had the book,” he says, “and finally I decided to set the bar as high as I could — all the Myst games, all playable, and playable well, even the 3-D ones at 30fps.”

To do this, Ando needed to perform two main feats. First, he needed to find the parts to make a computer that would fit in an extremely limited space. Then, he needed to restore the antique book, customize it to look like the ones from Myst, and gut it to make room for the compact computer that would power the game.

“Research was the main skill involved,” says Ando, “I spent hundreds of hours, literally, trying to find suitable components to meet all my requirements.”

To build the tiny computer that powers the Linking Book, Ando needed to find a X86 board that could fit inside. Most mobile devices run on ARM, but Ando wanted to run the original releases of each game, so porting wouldn’t do. It had to be X86.

“To give you an idea of how uncommon it is to shrink an X86 computer down this small,” he says, “the smallest X86 computer made by Apple, the Mac Mini, is 17 cm — this book is only 12 cm, plus I had to squeeze in my own power source and screen.”

The parts that made up the computer came from specialist vendors that ordinarily sell to aerospace and other niche enterprise customers. Ando ended up ordering a mixture of store-bought parts, and custom PCB layouts, soldering the whole thing together and switching out components between a bunch of boards to get the most efficient versions. He says he designed the touchscreen controller himself.

And as for the touchscreen itself? At one point in his search, he found himself talking to a vendor in China to arrange for a custom design. “His English skills were so poor I suggested we talk in Chinese and I used Google Translate, so I guess you could add that to my skills,” he says. “I suspect he just found one already to size and charged me as if they made it. If so, good for him — I couldn’t find one anywhere.”

For restoration and preparation of the book, Ando turned to Ian Bates, the president of the Australian Bookbinding Association. Bates handled the restoration of the cover, along with cutting the pages and embossing the book with the Myst logotype (but only after Ando had picked which of the several versions of the Myst font they should use).

If you find yourself gasping in horror at the idea that a book restorer would destroy a beautiful old book for a strange electronics project, Ando wants to assure you that nothing of value was lost. “The book I used is basically a cross between a Reader’s Digest & a gossip magazine and many of the articles are incomplete,” he says, “Today, books like this are sold to interior designers literally by the meter without any care given to their contents, author or title. Their main value rests on the aesthetics of their spine.”

Photos courtesy of Mike Ando.

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