Back and Forth

On Tuesday, Adam came back to NewYork-Presbyterian to have an MRI and to have a shunt put in to drain the bubble under his scalp. It’s done wonders for his looks (sorry, I don't have a picture right now).

The MRI looked fine; the doctors say he’s doing great and they expect him to have a really strong recovery.

He had the shunt put in Thursday afternoon. It is a bit of tubing (with an anti-siphon valve) that runs from under his scalp (but outside of his skull) down to his abdomen, running just under his skin the whole way. It drains excess fluid, but it’s my understanding that when his surgical wounds fully heal, it will then be idle, as its source is outside of the skull. Putting it in was just a 20 minute operation.

As of Friday morning, he was cleared to leave NYP to return to the Rusk Institute and get his therapy restarted, but we ran into a bureaucratic foul-up; NYP & Rusk wasted the whole day not getting their act together, so we’re still in NYP’s pediatric wing as of Friday night. Last time we went to Rusk, we wasted two days on admitting and insurance paperwork and on actually getting over there. Right now, I fear we’ll repeat that experience, and not get therapy restarted until Wednesday; however, we’re trying to do all we can (with the help of some friends) to get down there over the weekend and get him going on Monday.

Adam is doing well; he seems more comfortable and he’s smiling a lot more. He apparently spent the day asking for pizza; it’s great to have him that engaged & expressive. His doctors all seem to be very happy with his recovery, and we’re hopeful as well.

Rehab (no, no, no)

It’s three weeks since Adam’s surgery, and he’s in the hospital for the 27th day.

Last Tuesday, Adam went from the hospital (NewYork Presbyterian) to the Rusk Institute, a hospital devoted to rehabilitation. We’ve gone from having a view of the East River to having a view of the Empire State Building. He’s an inpatient there, and he’s in various therapies each day: physical therapy, occupational therapy, speech therapy, etc.

Thus far, it’s hard to tell how much difference the therapy is making. Adam is improving, although that improvement has, for me, to some extent been balanced by a growing awareness of how far he has to go.

I’ve read a number of books about the brain, including books that investigate oddities, such as Oliver Sacks’ works. In those books, you frequently have people who can do one thing well, but can’t do something else: they can sing but not speak, or some other similar mix of capability and inability. But I’d never seen this in practice, and it’s surprising and unintuitive: since the surgery, Adam has always seemed quite functional: he speaks, and he has always successfully navigated the standard neurologist quiz: “Touch your nose. Now touch the doll’s nose.”, and so on. That capability, combined with his general crankiness, made it hard for me to recognize how many things he couldn’t do, or perhaps didn’t do, anymore. For many days, he didn’t smile, didn’t converse (although he could speak and communicate, he wasn’t very responsive and rarely said anything novel).

He is improving: he’s smiling now. And we have faith in the ability of the brain to adapt and heal, particularly in young kids. So we’re confident that he’ll be OK, but it may be a while.

As you can see, he has a big lump on his head where the sutures from his surgery are (also, I gave him a haircut, so it’s more visible). The bubble is cerebrospinal fluid communicating through the surgical opening in his skull. It’s been growing a little bit, and he’s due for another MRI to evaluate whether things are OK inside. He may well end up with a drain installed to let excess fluid drain off and relieve pressure on the brain; if they do that, we’ll be back at NYP for a few days.

Laura and I are swapping off spending nights at the hospital. A month in, this is all starting to stretch us a little thin. I’m back at work, at least mostly, and the kids are in school. Grandparents have come and gone, and my mom is here now. But the stress, the disruption, and the logistical complexity of the back and forth is wearing on us and on the kids. Our friends and neighbors have been great, with food, play dates, errand-running, etc.; thanks, all.

18 Days in Hospital

By my calculus, it’s our 18th day here, but hopefully Adam will leave in the next day or two.

Since my last update, it’s been a stretch of recovery for Adam: general progress, but with a number of smaller challenges or setbacks. He moved to the general pediatric ward last week. For a period of time, he was quite weak on his left side, and couldn’t look to that side; later, he had some small seizures. Most recently, he went through a day or so where he said little if anything original: instead, his speech was a continuous, inconsolable, series of phrases that had little connection to the situation or his desires (e.g. “Mommy lie down with me”). He also has a big bubble of cerebrospinal fluid (CSF) under the sutured area of his scalp.

However, his physical tests (MRI & EEG) look good and his surgeons don’t think that he needs a shunt implanted to keep his pressure under control. He’s doing pretty well; neurology & neurosurgery are ready to discharge him. He’s eating well. He’s using both sides of his body (for example, he will eat with a fork using his left hand). He’s a lot less uncomfortable than he was a few days ago, although he’s still apparently pretty tired of being in the hospital.

The final pathology on his tumor came back, and it confirmed the good news that it’s not malignant; they’ll have another doctor give a second opinion as a triple-check, but we’re confident that it was a “benign” tumor, which is great news.

Before	After
(yes, that cauliflower blob is the tumor)

If life wasn’t complex enough, our au pair, Tabata, woke us at 3:30 last Sunday morning with bad abdominal pains; Laura took her to the emergency room, and that evening, she had her gallbladder removed. Thankfully, it’s a pretty straightforward operation (laparoscopic), she came home the next night, and she’s up & around now, although still regaining her energy. Also, a virus has swept through the family; it had me in bed for 24 hours and slowed me down for a few days; now, Laura is recuperating from her bout with it.

The current plan is that he’ll go from here in the hospital to an inpatient rehab facility, so he can get intensive physical therapy. We don’t yet know where (we’re hoping to go to one here in Manhattan associated with NYU, the Rusk Institute, but we’re not sure if we’re going to get a bed there), nor do we have any good idea how long he might be there (an offhand guess from a doctor here was 2-6 weeks).

So, it’s pretty challenging, but Adam’s improving. We have much to be thankful for.

Recovery: Two Days In

Adam is doing well. Of course, brain surgery is a Big Deal, and one doesn’t bounce out of bed the next morning. He’s feeling pretty crummy, but he’s recovering.

The surgery involved cutting a hole in the top-right of his skull, and they had to go past the right side of his brain, so his left side has been worse than his right, but it’s improving: on Tuesday, he couldn’t look left at all and his left hand was limp: now, he can look all over and he has some grip in his right hand.

Thursday was actually a little worse than Wednesday: Adam wasn’t communicating as well, just seemed a little less active, and had a couple incidents where his eyes rolled all the way back and to the right. The doctors here don’t think these were seizures, but we’re keeping a close watch on it.

He had his compression dressing taken off yesterday, and the drain in his skull removed. I think this will be a big help: the giant turban of a bandage was not only bulky and making it hard for him to lie comfortably, it was also squeezing his head, which couldn’t have been any fun. Plus, it means we now get to see his stitches.

He seems a little more aware this morning (asking for his stuffed doggy), but he slept turned to his right last night (I was sleeping next to him) and fluid puffed up the right side of his face. Again, looks ugly but apparently not very concerning to the staff here.

I don’t have a good idea of how much longer we’ll be in the ICU, or thereafter in the general pediatric ward. Here’s hoping we’ll be home by Thanksgiving.

After Adam’s Surgery

Adam was in surgery for about 6 hours yesterday. Afterwards, his surgeon said that it went very well: he was able to remove all the tumor very cleanly, and there was very little bleeding: in fact, Adam didn’t need a transfusion, either during the operation or afterwards—the surgeon said that it’s the first time he’s done such an operation without the patient needing any blood at all.

The initial indication (based on the test they did during the surgery) is that the tumor was benign, but they’ll do the determinative test over the next week.

He had an MRI this morning to confirm the results and take a look at how he’s doing, and everything looks great. The tumor is gone, there’s no bleeding, and no visible brain damage. It’s all good news; his surgeon described him as “a showoff”. They plan to take his drain out soon, as there’s no sign of problematic inter-cranial pressure.

He is still pretty under the weather from the operation: they had to push the right side of his brain out of the way, and he has weakness and sensory issues on his left side as a result, but that was expected, and he’s improving.

So, the kid’s luck holds.

An Update on Adam

Yesterday, Adam had a procedure where they did an angiogram and embolization of the tumor. They threaded a catheter through his arteries up to his brain and used x-rays and injected dye to map the blood supply of the tumor, then they injected a polymer which closed off the selected blood vessels and blocked about half of the blood supply to the tumor.

The procedure lasted about an hour and a half; it went well and he came through it fine. When he woke up, he was aware & fairly happy (although somewhat uncomfortable and annoyed with being trapped in the hospital and in his bed). This morning, he was a little tired and cranky, but generally in good shape.

Today, he’s having surgery to actually remove the tumor. (He’s in the operating room as I write this). The tumor is about the size of a golf ball; his surgeon describes it as large. I’m not sure of the precise procedure, but apparently they can get access via a relatively small incision; they’re going to get to the tumor by pushing past the left side of his brain, which will give him some temporary physical weakness on his right side. They’ll then cut the tumor out; the primary risk in this operation is the bleeding from cutting the tumor away. The surgery is scheduled for four hours, but it may take longer (which doesn’t imply a serious problem). There’s some possibility that they won’t be able to get all the tumor out in this operation and they’ll have to do another one; this also doesn’t imply a worse outcome; it’s just possible that they won’t be able to get it all from this direction.

After removing the tumor, they’ll test it to determine if it’s malignant or not; that test should take close to a week. (They also, as a matter of procedure, get a second opinion on that diagnosis).

He’ll continue to be in the pediatric ICU for at least a couple or three days after the surgery, and then remain in the hospital for a couple days more, so we expect to possibly be here for another week (plus or minus). The staff here have all been great with Adam and with us; informative, supportive, and helpful.

Henry and Lucy are doing well. It's all a little above Henry’s head, but Lucy’s been concerned for Adam. My father, Peter, arrived Sunday and has been helping out with the kids. Laura's mom, Barbara, came in on Friday and has also been very helpful, more here at the hospital; she's a nurse, so she knows her way around a hospital bed.

Adam's Tumor

Some bad news: we found out on Thursday that Adam has a serious brain tumor. He’s in the hospital now and is going to have at least two operations in the next few days.

Some background: when we adopted Adam in Ethiopia last June, he was somewhat delayed, due to being in orphanages for about a year. At the time, he could barely crawl. After bringing him home, he advanced quite quickly, and was walking by the end of the year. He’s always been a little unsteady, and never learned to run or jump, but we chalked this up to his delayed development.

However, a few months ago, while he was going up & down stairs well, we became more concerned that he wasn’t making as much progress as we hoped; he was also noticeably shaky (wobbly, having trouble standing still), particularly right after waking in the morning or after his nap. However, other than that, he was doing well; in particular, his speech has continued to develop.

A few weeks ago, we took him to his pediatrician, who agreed that his symptoms called for him to be seen by a neurologist; when we saw the neurologist, she recommended some tests, including an EEG and an MRI. When he had the MRI on Thursday, it was clear that he has a large tumor in his brain’s ventricles; the tumor is causing overproduction of cerebrospinal fluid, which is causing hydrocephalus.

Thankfully, he thus far hasn’t had any acute symptoms (no seizures or other obvious neurological issues). However, out of fear that acute symptoms could develop, he’s been admitted to the hospital (Weill Cornell / NewYork-Presbyterian in Manhattan).

On Monday, he’ll have a procedure where they will thread a catheter up to his brain and inject a dye to take detailed images of the tumor (an angiogram); they may also close off some of the blood vessels serving it (embolization), and I believe they’ll install a drain to allow taking off some of the fluid pressure.

On Tuesday, he’ll have surgery to remove the tumor. Then they’ll biopsy the tumor to determine if it’s benign or malignant; that will tell us more about what the future will hold for him.

He’s in the hospital as a precautionary measure, not because he’s noticably ill: he’s the same happy, active kid he was a few days ago, although a little tired of being stuck in bed all day and hooked up to monitors. (Not to mention the hospital food.)

While this is tragic, let’s remember that Adam’s a very lucky kid: I think that if you’re going to have a brain tumor, New York City is as good a place as any to have it, at least presuming you have good insurance (certainly better than Addis Ababa). His surgeon is a world-class pediatric neurosurgeon, a specialist in removal of intraventricular tumors. (He’s also got a room with a beautiful view of the East River.)

Lucy & Henry are dealing with it well so far; they’re sending their love and their drawings.

Thanks for all your offers of help & support. We’ll be happy to take you up on your offers of play dates, etc.; right now, we have two grandparents in town, so we have enough pairs of hands for watching kids, etc.

Help for Ethiopian orphans

We adopted a son, Adam Abera, from Ethiopia this year. He's a gift and a delight, and our good fortune in adding him to our family is far greater than his good fortune in being added to ours. However, it is true that we brought him home to material support, comfort, security, and opportunity far greater than what he left behind, and of Ethiopia's five million orphans, only a tiny fraction can or should be supported by adoption into first-world nations.

While we were there, we met the remarkable Dr. Tsegaye Berhe, the director of Wide Horizons for Children's program in Ethiopia—a man who truly loves and strives on behalf of children. He impressed upon us how deep the need there is and told us of their program to offer support to the vast number of children there for whom the proper path is not adoption—orphaned children who have family to care for them in Ethiopia, but who need support.

WHFC's program not only provides basic material support for the children you sponsor, it also makes an investment so their families can found viable, profitable businesses, and so, enable them to progress towards self-sufficiency. You can read more about the program here, including a brochure and FAQ.

This season, I would like to ask you to make a commitment and contribution to sponsor a child. $420/year can pull not only a single child, but a family out of poverty. Right now, go to WHFC's Child Sponsorship site and sign up. $420/year is $1.15 per day.

After you've contributed, please let me know. I've made a commitment that I and my companions in group 79, who brought home a double handful of kids this summer, will sponsor 79 children, and I'd like for your support to count towards that goal.

Thank you!

Tim, Laura, Adam, Lucile and Henry.

Missing the point

Benjamin Black has a service called the tls report that grades web sites based on the quality of their SSL configuration: points are taken off for SSL 2 support, support for shorter keys, etc. While I respect the effort and I value the concern for better security, this is just silly. Extending cryptographic key length is the least valuable thing any site can do to improve the security of people's data. Gene Spafford got it right when he said:

Using encryption on the Internet is the equivalent of arranging an armored car to deliver credit card information from someone living in a cardboard box to someone living on a park bench.

Worrying about whether the keys are 40-bit, 56-bit, 128-bit, or larger is the equivalent of worrying about whether the armored car guards are carrying revolvers or machine guns: it entirely misses the point. I'm not aware of a single case, ever, where an attacker stole data from a commercial site by cracking an SSL key of any length. Note also that SSL/TLS has mechanisms to prevent an attacker from forcing you to negotiate a lower grade of security than you ask for, so if you turn off 40 bit ciphers in your browser, an attacker cannot force a downgrade (other than by cracking the server's private key), so a site that supports 40-bit keys does you no harm at all. As such, in addition to measuring something not particularly relevant to security, these grades are irrelevant to the security of users paranoid and well-informed enough to know about them and care. If you're concerned about the security of your data, you should be concerned with how a site handles your account password and your data at rest. Of course, this is harder to observe than SSL settings, so Mr. Black appears to fall into a trap that catches a lot of the security community: thinking about problems that are easier to see and measure, even if they're not the truly significant security problems.

More Important than Excellence

What's the most important skill in playing poker, if you're looking to make the most money?

When I ask other poker players this, I get answers like "bluffing", "reading other players" or "knowing the probabilities".

They're all wrong. The most important skill is table selection—choosing what game to play and who to play against. You could be the 20th best poker player in the world, but if you spend all your time playing against the top ten players, you're going to lose money. Similarly, you can be a mediocre player and still be rolling in dough if you find and play against players you can beat. "Better" and "worse" isn't the only measure. Some people play well against certain styles of play (for example, you might play well in a game where your opponents bet and raise a lot, but not have the skills to adjust to players who play tighter). The most important thing you can do is put yourself into a situation that optimizes your chances for success. Only after does it become important to execute well. Only then do the skills of the game of poker come into play.

This isn't just a lesson for poker; it's also true in business. One of the tenets of venture capital is that it's better to have a bad company in a good market than a good company in a bad market. I know that while I think I'm an excellent software engineer, I've made more money by being in the right place at the right time than I have solely through engineering skill. (Of course, an excellent track record of success has given me the opportunity to be in the right place at the right time.)

I think this is also a valuable reminder that it's frequently not obvious what the rules that govern success are. For example, you might invest in a company because you think their product is insanely great, but it turns out that the important skill they needed to be successful was actually business development, not creating great products. Sigh.