Archives for posts with tag: Brain Injury

If you’ve been reading this blog for a while now, you may have heard this story before. Here’s the short summary. Man is out and about doing something totally mundane– walking home from a friend’s house or ferrying garbage and laundry across a lake in a small boat at the end of a summer vacation– when he suddenly and violently strikes his head. He is rushed to the hospital and falls into a coma. Meanwhile, the wife, not present at the scene, rushes to her husband, and waits. Because that’s what you do when someone you love is in a coma. You wait. The patient either comes out of it or doesn’t. In our story, the man does eventually awaken from the coma. Although it’s straining credulity a little bit to say he is the same person as he was before.

This is the story of traumatic brain injury. It is what happened to Alan Forman in the summer of 1996. And it is what happened to me in the beginning of 2005. Where Is the Mango Princess? is a non-fiction account by humorist Cathy Crimmins. Alan is Crimmins’ husband. His head was run over by a speedboat while the family was on vacation in Canada. The book is an intimate account of the effects of traumatic brain injury, not only on the direct victim, but on her, their daughter and every aspect of their lives.

My friend, Princess, told me about the book when we were talking about her senior level physiology class she’s taking this quarter at Northwestern. Part of this class comprises a disease symposium. Students group up and research a given topic. She has chosen traumatic brain injury and using the Forman case to present for the symposium. I’m reading the book for more personal reasons. I have a strong personal interest in TBI. Whirl is concerned that it is causing me distress to read this book. I admit there are a peculiar number of similarities in the cases. The sections about recovery and therapy have been the most troublesome for me, bringing up echos of my own anger and sense of helplessness at the time. Crimmins writes with a voice that is at once deeply personal, gut-wrenching and often hilarious. I applaud her for that.

When I’m finished with this book, it will stand alongside My Stroke of Insight, The Diving Bell and the Butterfly, Brainlash and Your Miracle Brain as part of my ever-growing library about scrambled eggs.

Chihuly 6Five years have gone by since my brain injury. Five years. I’m more than a little amazed it has been that long. I mean, I know it has been that long, and I know I’ve been talking about it for the entire time. This journal is proof of that, if nothing else. The earliest entries chronicle the first few weeks and months after my emergence from the coma. I’ve tended to return to thinking about that injury around its anniversary. I don’t think that’s terribly unusual. I take stock of where I am today and try and compare to how I was feeling five years ago. And then there are the flights of fancy where I imagine some alternate timeline in which the injury never took place. I try to draw comparisons and form conclusions across that divide. As you might imagine, it doesn’t work out very well. My time traveling skills are fairly restricted. Fortunately that restriction keeps me more-or-less safe from paradox.

Ani at Bejing Noodle No. 9For the past five years my friends and I have traveled to Las Vegas on the anniversary of my injury. We drink. We gamble. We eat too much. We stay up too late. Generally we leave our responsibilities at home and enjoy the moment. This year was no different in that respect. We did have a smaller group out of Chicago than in years past: T., Smokes, Stingo, Sabz, Bitsy, Whirl and I were joined by some special guests. Frank and Shane joined us from the City of Angels. Whirl’s cousin, Ani, was coincidentally in Las Vegas organizing a conference at the Mirage for her company. And Bitsy’s friend, Jeanine, who lives in Las Vegas, came down to the Strip to hang out with us for at least some of the time.

As for gambling, I scratched that itch with some healthy doses of pai gow poker, craps and limit hold ’em. The highlight of my gambling this trip was the five hour session at the Bellagio playing low stakes pai gow. The fact that at the end of the marathon I walked away from the table up nearly double what I wagered is just gravy. What made this such a fun experience were our two dealers, Reza and Jeff. Whirl, Smokes, T., Sabz and I commandeered a five seat pai gow bonus table. Normally pai gow poker seats six. This version we found at the Bellagio featured a community dragon hand played the house way, limiting the number of actual players to five maximum. Anyone playing could decide to bet on the communal dragon hand as well. This differs from how the dragon hand is offered and played normally. In a more typical version of pai gow the dragon hand is only offered when there is an empty seat at the table and the dragon hand is played with a rotating right of first refusal. The dealer offers the hand sequentially around the table. If you want to play it, you match your original bet and set the second hand any way you desire within the restrictions of the game. At our table, with a maximum of five players the dragon hand was always available. You just had to bet. And everyone that bet, was betting on the same hand against the house. It was a nice twist.

Veer Towers and TramI enjoy pai gow because it is such a social game. It plays slowly with a lot of pushes where neither the player nor the dealer win the hand. And players can help each other with strategy and advise on how to play. The actions of one player have no effect on the actions of other players. (This is true of many table games, but there are far too many perceptions and superstitions surrounding games like blackjack to act otherwise.) In pai gow you cannot “steal someone else’s ace”, for example. Whether this actually changes the probabilities or not is irrelevant. Perception and superstition are king and queen in gambling.

So. The five of us belly up to the table at the Bellagio and proceed to play and play and play. The afternoon starts slow, and we strike up a congenial conversation with our dealers. Over the course of the next five hours they would teach us strategies to pai gow, how to play banker and let us in on some of their collected stories in Las Vegas. Reza has been a dealer with MGM Mirage for twenty-two years. He’s dealt at the Golden Nugget, the Mirage and the Bellagio among others. Each time Steve Wynn would open a new casino, Reza would move to the new flagship. He amazed us with his ability to read seven card hands displayed for mere fractions of a second. MGM Mirage often deployed him to deal with high maintenance players. He would deal for 40 minute stretches and then take a 20 minute break. His relief was a phlegmatic dealer named Jeff. Jeff was the dealer who instructed Whirl and Smokes on the rewards and pitfalls of playing banker in pai gow and offered particular advice on just when to split pairs.

The two of them had plenty of stories of their experiences working as dealers at the Bellagio and elsewhere. They were always discreet, never compromising the identities of their customers or relating events that were particularly incriminating. Two of the most memorable stories concerned the particular characteristics of high rollers. One story detailed how the Bellagio appeased a particular baccarat player. The unnamed high roller could not suffer the clicking noise emitted when cards were pulled from the shoe. The Bellagio staff constructed a special shoe that did not click, and keeps it in storage just for this player. Another story was from some years ago at an unnamed casino when the largest chips on the floor were valued at $20000. A high roller was playing blackjack at $120000 a hand and had animatedly (and inadvertently) spilled the tray belonging to one of the cocktail waitresses. Drinks go everywhere. It’s a mess. The player brusquely asked the waitress what her mortgage was. She responded with the monthly payment value and was rejoined with: “No. That’s not what I asked. How much is your mortgage.” She thought for a moment and then told him it was $93000. The player immediately grabbed a stack of five of these $20000 chips and tips the waitress. This caused an uproar in the casino. The casino demanded that all markers be paid before tips were paid out. The casino refused to cash the waitress’ chips. The amount of money this player had dropped at the casino over the years was astronomical and eventually the casino saw reason and reached a passable resolution. The waitress ended up having to pay taxes on the tip, but she kept the money. The casino kept the player.

The recurring theme with these stories was that Las Vegas holds a magnifying glass to the the personalities that come there. People do not fundamentally change when they visit; instead the become that much more of who they are already. Kind people grow kinder; meanness becomes moreso. I appreciate this observation more and more as I think on it.

I coached Sabz and T. at craps, one of my other favorite games. Craps is the polar opposite of pai gow. Fast-paced, hectic action. Highly volatile, craps runs on streaks. I’m still not sure what that says about me that I count the slow-paced leisurely game of pai gow and the frenetic chaos of craps as two of my favorites.

Flamingo Flamingo FlamingoThe third game I played for any significant length of time was Texas Hold ’em poker. I played in one tournament, and spent the rest of my time playing cash games. This year I avoided no-limit hold ’em and opted for the limit tables as a change of pace. I did well. Not “big money” well, but well enough that I could pay for dinner and a show with my winnings. A couple of notable moments came while playing at the Flamingo. Smokes and Whirl were playing on the table next to me. Smokes has a singular laugh. For those of us who know him, it’s a beacon. We can always find him anywhere in the casino. It cuts through the noise of the slot machines, the cheers of the craps tables and the clatter of the roulette wheel. My poker table noticed it as well. I explained to them that it belonged to my friend and when Smokes came over to talk to me later, I introduced him to his fan club. Smokes has a way of making friends wherever he goes. That’s one of the things I love about him.

The other poker story reminded me that there’s always someone playing an angle, even among the low-rollers like me. I’d been playing limit hold ’em for a few hours, mostly unsuccessfully. My head was still above water, but I wasn’t making much headway and was starting to consider going and doing something else. Getting schooled on the improper use of the term “set” for what is accurately described as “trips” hadn’t helped my self-esteem and likely had gotten my thoughts of departure started. A woman sat down and flashed her platinum players club card to the dealer. He read her name and keyed her into the table. As the dealer handed the players club card back, he asked if she was Vietnamese. She said she was and asked the dealer how he knew. He stated her last name, pronouncing it correctly: Nguyen. The player feigned shock. Shock at two things: one, the dealer had pronounced her name correctly; and two, that he had drawn the conclusion that it was a Vietnamese name. At this point our dealer, Rock, pointed out that Scotty Nguyen is one of the best-known professional poker players currently active: a five-time WSOP bracelet winner, including the 1998 main event. Scott Nguyen is also from Vietnam. While Ms. Ngyuen sat there shuffling stacks of 8-10 chips simultaneously in each hand and claiming complete ignorance, I quietly packed up and headed for places east. Of course she’d never heard of Scotty Nguyen. That’s just absurd. — Fool me once, shame on you. Fool me twice, shame on me.

Chicken and WafflesIn years past our group has consisted of a number of friends who enjoy buffets. We’ve been to several of the top buffets in Las Vegas. But after a while, I have to admit that all buffets start to blend together and none of them leave me particularly satisfied. This year the vocal buffet-goers were unable to join us, and we set out on a new direction with food. Whirl enjoys breakfast and did some research on some of the best breakfasts in Las Vegas. She found it. One of the most incredible breakfast experiences I’ve ever had was the chicken and waffles at Hash House a Go-Go at Imperial Palace. Sage fried chicken stacked with bacon waffles, hot maple caramel reduction and crowned with fried leeks. Truly a breakfast of champions.

The Crystals Grand StaircaseOne of my other fascinations with Las Vegas — besides food and gambling — is how it continues to reinvent itself architecturally. In December 2009, several key elements of the huge CityCenter development officially opened. We were able to visit the Aria casino and the Crystals entertainment and retail complex. I attempted to photograph some of this development from various perspectives. I’m uncertain of my success. The project is immense, the largest privately funded construction project in the United States, costing over $11B. While touring the spaces and dodging a Porsche 997 GT3 and a Ferarri F430, I happened into the Dale Chihuly Gallery at Aria. Whirl reminded me several times this trip about how much I appreciate Dale Chihuly’s art. He is one of my favorite artists. He had pieces at the Museum of Science and Industry a few years ago as part of “The Glass Experience”. The 1997 documentary Inspirations takes a in-depth look at his particular creative process.

Like our experience at the Bellagio, the gallery was empty. I had the place to myself, having arrived just a couple hours before closing. I made the faux pas of asking the curator of the gallery, “Do you mind if I shoot?” “Shoot?” he repeated back to me skeptically, throwing a glance to the glass sculpture that surrounded us. “Yeah. Shoot,” I start, then pause and turn crimson. “With my camera,” I attempt to explain hastily, punctuating with very nervous laughter. Earlier in the evening, I’d been asked to move along by security in The Crystals while trying to shoot the Grand Staircase. The gallery curator was much more congenial and finally let me off the hook with a well-intended caution to consider a less alarming verb when talking about photography around glass. I couldn’t help but remember Sean Connery’s line in Hunting for Red October: “Most things in here do not react well to bullets.”

I stayed in the Chihuly gallery until closing. I spoke at length with the curators about the pieces — all of which are also for sale, if you’re interested. We also talked about “Fiori di Como” the 2000-piece installation that forms the ceiling of the Bellagio lobby. I learned that the glass weighs over 40000 pounds, with an additional 10000 pounds of steel armature to support it. It continues to amaze me how Las Vegas can make this sort of fantastic artwork available to be experienced. The next day I had a similar experience as I spent a few minutes talking to Jennifer, the curator of the Richard MacDonald gallery at the Bellagio. MacDonald’s sculpture is inspired by the human form and the broad range of human emotion. MacDonald had been commissioned by Cirque du Soleil founder Guy Laliberté to create several pieces inspired by the circus. I did not have my camera with me at the time, however some of the exhibit is available online.

As a cap to the trip, Whirl and I took in the Cirque du Soleil show Mystère at Treasure Island. I have seen several shows over the past years and this one was quite impressive. We both had a great time taking in some breathtaking performances.

So now I head back to the real world, refreshed, relaxed and inspired. After five years of hard-fought reflection, I suspect that’s exactly as it should be.

What is stress? We talk about it all the time. We talk about ways to treat stress. We devise methods for avoiding stress. We plan possibilities for contending with stress. We seek a myriad of ways to relieve stress. There are very detailed medical, physical and psychological definitions of the concept. I do not intend to go into that level of discussion. I am more interested—and capable—of writing about stress in the broad strokes. I contend that stress can include a hegemony of concepts: anxiety, antagonism, exhaustion, frustration, despair, overwork, over-focusing, confusion, mourning, fear.

But when I look carefully at this collection of experiences, I have come to realize that what I commonly call stress actually has two main components. There exist stressful events, situations and relationships that urge me forward, cause me to thrive or give me a real sense of fulfillment. Good stress. Eustress. This is contrasted with the litany of stressors we commonly talk about in our life—those that have a negative impact. Bad stress. Distress.

I believe the stressors vary from individual to individual as to their categorization. I believe the same exact stressor can be considered both eustress and distress depending on the victim. Examine this example: a constantly ringing telephone. For a salesman busy at work on the Glengarry leads this stressor fosters happiness—likely exhaustion, too, but the good kind of exhaustion. Our hypothetical Ricky Roma feels he has accomplished something. And he probably has. He has probably closed the big deal, or better yet, a series of big deals. And even if he did not, the fact that the phone continues to ring brings the promise that the big “always be closing” moment is imminent. Contrast this with the quiet architect who views the constantly ringing phone as an unmanageable series of interruptions. It disturbs his concentration; it retards his ability to focus—it confuses him.

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Thus, the Fool may indicate the whole range of mental phases between mere excitement and madness, but the particular phase in each divination must be judged by considering the general trend of the cards, and in this naturally the intuitive faculty plays an important part.
~ Arthur E. Waite, occultist and co-creator of the Rider-Waite Tarot

I recently got the following message via email. It has been some time since I have thought in great detail on what happened to me, last year. And while I answered the letter, it caused me to reflect on my own experiences. The letter was short and to the point:

A friend of mine who has suffered from severe depression and who has had ECT is facing neuropsych testing to assess his work fitness and is rather anxious. Can you lead me to online sample test questions I can share with him (he’s not online)?

The tests I underwent were a modified version of the Halstead-Reitan test battery designed by the rehabilitation hospital to which I was admitted. The hospital specializes in brain trauma. I wrote some of my thoughts about the tests. In those entries I have given a couple of vague examples. I came to realize I have not truly described what these tests were like.

I do not mean to suggest by describing these tests that there is some way to be prepared for them. That is one of the elements I found the most frustrating about these tests: I could not study for them—by design. Unlike so many other tests, these tests did not seem to focus on what I had—or had not—learned. Rather they looked at whether I was capable of learning and to what degree. To that end they measure psychological functions known to be linked to particular brain structures or pathways. Before the injury I may have argued that this sort of testing was merely an updated version of phrenology. I do not argue that now.

Do not misunderstand. I still tend to consider psychology a form of augury. It is that with some time and perspective that I begin to see a method. And occasionally I see some results. Not always. Not about everything. But some of these experiences have proven occasionally helpful.

The tests are based on what I consider a somewhat unsteady presupposition. A neuropsychologist compares my raw score on a test to a comparable sample of other people. Before the tests even begin, there is an extensive interview to determine my age, level of education, background and ethnicity. These variables then come into play when trying to interpret my results. My raw score is compared to a group of people just like me—minus the brain injury. I suppose the ideal would be to have a baseline evaluation before the injury and then after. That scenario has some unfortunate impracticality associated with it. So we are left with the unsteady presupposition that a group of similar people can accurately represent me in my pre-morbid state. Such are the challenge of divination, I suppose.

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The true peculiarity of philosophy lies in the interesting individuality which is the organic shape that Reason has built for itself out of the materials of a particular age. The particular speculative Reason (of a later time) finds in it spirit of its spirit, flesh of its flesh, it intuits itself in it as one and the same and yet as another living being. Every philosophy is complete in itself, and like an authentic work of art, carries the totality within itself. Just as the work of Apelles or Sophocles would not have appeared to Raphael and Shakespeare — had they ever known them — as mere preparatory studies, but as a kindred force of the spirit, so Reason cannot regard its former shapes as merely useful preludes to itself.

— G. W. F. Hegel, The Difference Between Fichte’s and Schelling’s System of Philosophy

I promised myself that I wasn’t going to devolve this column into a series of complaints and recriminations. And now looking back over what I have written in the past several months, I am coming to the conclusion that that is exactly what I have done. It is troubling.

I am having trouble responding to unforeseen setbacks. Something goes wrong – plumbing, a work process, my sense of balance – and I seem unable to compensate adequately or appropriately. This is disturbing, because my very livelihood is predicated on the need for me to step up and solve unforeseen problems when they arise. Because they will arise. They always do.
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It has been approximately a month since I took the battery of neuropsychology tests to help determine if and when and how my injury has affected my ability to do things with my brain. No, I’m not talking about telepathy or pyrokinesis or any such powers. Despite some encouragement to the contrary, those abilities have not manifested. I suspect that they are, in fact, better off inside of a Stephen King novel than my head.

I’m talking about the simultaneously ordinary and amazing things that most human brains do: cognition, perception, emotion, reasoning, language, memory, learning. The big question was: Does Bingo’s brain do these things as well as it did in its premorbid state? I had to read the report a couple times to get past that description, too—premorbid state.

If this experience has taught me anything, it has underlined my belief that psychology is significantly closer to the traditions of divination than those of science as I understand it. Let me pause to mention that I don’t mean to offend any psychologists in the audience. My experience has been that those treating me with a more scientific approach have been considerably more capable in putting my head and life back together than the psychologists. And for that I am more thankful.

For example, at one point I told anyone who would listen that I had severe, recurring headaches. The scientifically-minded took a picture of my brain with a camera they had invented just for that purpose. They found a pool of blood exerting pressure on my frontal lobe. They cut a hole in my skull and siphoned the blood out. The headaches stopped.

The psychology camp asked me to repeat a random series of letters and numbers back to them in alphabetical and numerical order. This did not help. As further evidence against the psychologists I present this item: merely recalling the previously mentioned neuropsychology exams gives me a headache.

So when I went in to get my results on Tuesday, I was not particularly surprised at what they told me. Most of the test results corresponded closely to what I have been able to observe in my day-to-day life. My perception, cognition and problem-solving skills all scored highly—particularly on those tests that were verbally based. There was a small, but repeatable and statistically significant break in these scores when the tests were repeated in a non-verbal manner. This disparity was even more noticeable in the results of the memory tests.
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I’ve been back to work for three weeks. I think things are starting to catch up with me. When I first came back to work, I was excited about the possibility of getting back into the routine of things. I had been out for a long time. But more than that, I had been excited by the promise that I might return to something close to “normal” – the clichéd light at the end of the tunnel.

I think I believed that things were normal, when I came back. At least certainly after I had put the memories of the neuropsychology test battery out of my mind I was doing a pretty good job of thinking I has recovered completely.

I don’t think I can still say that. More and more, I am noticing the types of symptoms about which my doctors and therapists had talked to me at length. In most of the cases the symptoms do not seem to be having a strong effect on my day-to-day life. But they are there. I am aware of them. Memory problems, headaches, lack of attention, contending with large amounts of stimuli, fatigue, anger, and anomia: these things are with me, now.

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So as it turns out – and you might have gleaned from the title of this entry – the test I took on Tuesday was not the Halstead-Reitan test. After doing all the get-to-know-you parts of the interview before the test, my psychologist asked me if I had any questions about the test. So I took the opportunity to ask him if that was, in fact, what was going on. He laughed a little bit. I think I caught him off guard with the question as he responding by asking whether I had done research on the subject or something. I admitted that I had, and that was the name that kept coming up and seemed to fit the description I had been given by my therapists.

He set me straight. It turns out that the Halstead-Reitan test was developed almost fifty years ago with the goal of determining where in the brain injury or disease damage might have occurred. At the time, this was a useful thing to know and there were few non-intrusive ways to determine it. Now most neurologists rely on CT and MRI scans to do that work for them – more quickly and more accurately. There are still psychologists who see the Halstead-Reitan test as ‘the one true test’ (his words, not mine), but most psychologists have moved away from it to concern themselves with working on behaviors and skills rather than focusing on what is basically a medical diagnosis. What these psychologists find important is determining problems with cognition or memory, recognition or attention. My psychologist understandably found himself firmly in that latter camp: I don’t need to know where the injury is; what I need to know is how it affects his life. My life, as it turns out.

In the end, he conceded that some of the tests I was to take had been derived from the Halstead-Reitan battery. Of course, he did not tell me which ones.

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Today is my second day back at the office. I came in and worked a full day on Friday, had the weekend off and am now back today. I won’t be back in until Wednesday, however. Tomorrow I will spend most of the day talking with neuropsychologists and completing the Halstead-Reitan Neuropsychological Test Battery. Yeah. Six hours of testing to make sure that my brain works correctly.

The pessimistic side of me is looking at this test battery and saying to myself, “No good news can come of this.” I mean I’m already back at work and doing pretty well with that. I’ve made some good strides in the other areas. I haven’t seen anything overly strange with respect to my reasoning ability or general cognition. I have noticed an increase in anomia — difficulty in finding the right words or names – and am working to rectify that as best I can. But that is really about it as far as the things the test is looking at goes.

The optimistic side of me looks at the test and says to myself, “Well, at least we’ll know and be able to maybe treat it or at least work around it more easily.” For example, if the test were to show that I had suffered a loss in my ability to concentrate or my short term memory, my therapists explained that I might teach myself ways to work around that – writing things down and the like.

I’m still grappling with what has happened to me. At the same time I get angry about the damage, the strange behaviors – the missing days! – the same time I get angry about that, I struggle to try and understand what it means for me moving forward.

I just want things back the way they were before. – And I know that’s something I can’t have.

St. Patrick’s Day news came in the form of an approval by my neurosurgeon to return to work. Earlier this week I had been discharged from out-patient therapy. They said I’d made the sort of recovery one just does not see with that type of injury. What type of injury is that, exactly? Well, now after all of this, I can tell you with some degree of understanding.

There are three general bits of information most commonly used to evaluate the severity of a head injury: Glasgow Coma Score, time spent unconscious, and a CT or MRI score.

The GCS was devised by doctors to assess head trauma and, importantly, to help keep track of patients’ progress over a period of time. The scale is comprised of three tests: one for eyes, one for verbal response and one for motor response. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma) whilst the highest is 15 (fully awake person). When this test was first administered to me in the emergency room, I scored a 7.

Doctors use time spent unconscious to rate the severity of a head injury. Generally speaking, longer time spent unconscious means a more severe injury. Anything over about twenty-five (25) minutes is considered at least a moderate injury. In my case I was knocked out at the scene, and stayed that way for at least a couple days. At some point I started to wake up, but the doctors decided it was best to keep me in a drug-induced coma for a longer period of time, to aid the recovery. All together I was in that coma for nine days.

CT and MRI scans are often employed to examine the brain and skull. It is possible for nothing to show on these scan and for a patient to have symptoms of a brain injury. But usually, if a scan shows a hematoma or other type of injury the likelihood of brain injury symptoms also occurring grows considerably. In my case, a large subdural hematoma was clearly visible on the first CT scan.

About that time is when they drilled into my skull to try and reduce it.

So, the initial diagnosis — which does not change — is that of a severe traumatic brain injury. Serious stuff. Whirl had several conversations with doctors about long-term care for me. But I seem to have broken the odds. Most of the symptoms I was suffering — and it was a long list, let me tell you — are now gone. What ones I’m still experiencing, are certainly at a level where they’re not interfering with a normal day. At least not most of the time. I can walk and talk. I can even do those things at the same time. My sense of balance that had been knocked for a loop is steadily returning thanks to some rigorous therapy and a double set of exercises I do.

So here I am. I shouldn’t be here. But here I am. — And I got to tell you, it’s good to be here.

We’ll see how work goes, tomorrow.