The Brain That Wasn’t Supposed to Heal

Steve Mishkin's unexpected recovery is a case study in luck, split-second decisions, and the many, many things that need to go right for a trauma patient to get well.

Hungarian doctors carry out a brain surgery at the National Neurology Institute in Budapest. (Bernadett Szabo / Reuters)

When Steve Mishkin was brought into the emergency room in December 2014—his skull smashed in several places, his eyes bulging out of their sockets, his face discolored beyond recognition—he was not expected to live through the night. Over multiple surgeries, doctors removed sizeable chunks of his dominant frontal lobe and temporal lobe, including the areas that govern speech and movement. They told his wife, Amber, that even if he survived, he would never be himself again.

Less than a year after that horrific night, after a weekend of playing soccer with his children and socializing with friends, Steve returned to work full-time as a business analyst for a major bank.

True, he is not exactly the same as he once was: He’s more affectionate and effusive with Amber, more open with strangers, spilling his story to anyone who will listen. He occasionally struggles to find the word for, say, the toaster. But he has defied every prediction for what happens to a person after his brain has been severely, traumatically damaged.

Each year, in the U.S. alone, an estimated 1.7 million people sustain a traumatic brain injury, the leading cause of death in children and young adults. Who recovers, and why, is still a mystery to scientists. “Prognostication is something we do very poorly and we have very poor tools for it,” says Deborah Stein, a brain-injury expert at the University of Maryland School of Medicine. “There’s so much we don’t know.”

Steve’s path back to normalcy has not been easy. He has endured painful surgeries, weeks of intensive physical and cognitive rehabilitation in a hospital, and months more as an outpatient. He spent dozens of hours practicing social rules with Amber and playing brain-teaser games he had originally downloaded for his 6-year-old son. But many other people with similar injuries have tried all of these things, with much less effective results.

Ultimately, Steve’s recovery is a case study in all the ingredients, including luck, needed to restore a brain to its once-pristine state. Once he was injured, a series of events fell into place in just the right way: Paramedics brought him in from the train station where he fell to the hospital within minutes of his injury. The neurosurgeon on call that night happened to be one of the best in the state, and made bold decisions borne of her decades of experience. After Steve emerged from his coma, he gained admission into one of the best rehab facilities in the country, one that specializes in cognitive recovery. At the time of his injury, Steve was a 44-year-old mathematician in the best of health, and his body and brain responded beautifully to every treatment. For the crucial first six months after the injury, his job afforded him long-term disability and health insurance that kept his family free of financial stress. Amber had trained as a psychologist and redesigned their lives around Steve’s recovery. (Amber and I have been friends since our sons were 3, and I had met Steve a few times through her.)

“Everybody really did everything right, and he had a good result,” says Lauren Schwartz, the neurosurgeon who operated on Steve. “There may be people who should have had that result and didn’t. That’s what we can change.”

* * *

On December 13, 2014, the day of Steve’s injury, he said goodbye to his family at his Brooklyn home sometime around noon, and headed into Atlantic City for a day of gambling with four work colleagues. He had three or four drinks over the course of the afternoon, texted Amber silly pictures of himself smiling at the Borgata casino, and thinks he might have won money (she later found $1,000 in his wallet.) At some point, the men had dinner at Wolfgang Puck’s restaurant in the casino. Around midnight, they left the casino for the parking lot, but Steve went back in to use the bathroom and then returned to the car.

That’s the last thing he remembers.

Trying to piece together what happened next is an exercise in futility and frustration. Two of the four colleagues declined interviews, and have been uncommunicative with Steve and Amber. The other two offer variations of the same story. Both agree that the men drove through New Jersey in their rented car, listening to ‘80s music. Depending on who’s recalling it, Steve was either falling asleep and not tracking the passage of time, or awake and talking. The colleague who was driving dropped off one of the men, then drove the other three to the PATH train station in Newport, New Jersey, where they could take a train into Manhattan. At that point, they say, Steve was either asleep and had to be woken up, or was fully awake but tired. On the way down into the station, the men might have been running to catch the train. Or not. Steve might have fallen on the escalator. Or not. While on the platform, Steve might have tripped over backwards on a bag. Or not. He might have said, “Oh guys, I’m going to pass out.” Or not.

In any case, at 3 a.m., Steve did fall while on the platform, because this last part can be seen in a PATH station video that Amber was later able to obtain. In the grainy video, you can see a man fall back, two men bending over him, and a few seconds later, one quickly running up the stairs.

This narrative would be unremarkable except for one thing: Nearly every medical professional associated with Steve’s case insists that his injuries are wholly inconsistent with a simple fall on the back of his head. He had multiple fractures, including some in the front of his face. Steve may have fallen, they say, but that is not all that happened that night.

“We don’t really know what happened to him, but I know what didn’t happen to him based on his injuries,” says Schwartz. “I’m 100 percent sure it wasn’t just a fall.”

Regardless, the men called 911. According to the police report, they said Steve had been drinking. The paramedics arrived promptly, and rushed Steve to the Jersey City Medical Center just a few minutes away. And that begins the string of events that swung fate clearly in Steve’s favor.

* * *

Despite rapid gentrification over the past decade, parts of Jersey City are decidedly seedy, and the center has a bustling trauma unit. (Even though Steve’s companions accompanied him to the hospital, for reasons that are unclear, Steve was not identified—in the medical records, he is referred to only by his trauma number.) Blood-alcohol levels indicated that Steve wasn’t drunk. In many cases of brain injury, the secondary damage from a lack of oxygen in the brain can doom the patient even before surgery. In Steve’s case, the trauma team immediately put him on a ventilator, delivering oxygen to his brain.

Still, while in the trauma center, he deteriorated rapidly—his score on a commonly used measure of brain functioning called the Glasgow Coma Scale plummeted from 13 when he first arrived to the minimum score of 3. A CAT scan showed that he had sustained fractures in the base of his skull (which led to a classic presentation of “raccoon eyes”), in the right temple, and on the roofs of both eye sockets. He had a massive bleed on the right side of his brain and a smaller one on the left. He had also herniated a disk.

Schwartz, the neurosurgeon on call, arrived within 20 minutes. It was her first night on call at this particular hospital. She is a pediatric neurosurgeon, but she trained at Temple University in Philadelphia and at Parkland Center in Dallas, both of which have busy trauma units. Her decisions that night might well have saved Steve’s life; they undoubtedly restored his brain’s function.

“From the moment he met that neurosurgeon, Steve’s entire life shifted in a positive direction,” says Amber.

Based on the CT scan, Schwartz decided to operate on the right side of his brain first. The scan had showed an epidural hematoma—bleeding from an artery between the dura, the thin membrane that covers the brain, and the bony skull. “Time is brain,” Schwartz likes to say, meaning that when handling the brain, speed is of the essence, and this is particularly true of epidural hematomas. The fix can be straightforward—removing the clot and repairing the torn blood vessel—but without it, death can come swiftly.

The surgical team anesthetized Steve, placed his head in a horseshoe head holder with the right side up, and shaved his head. Schwartz made an incision in the shape of an upside-down question mark and lifted his scalp flap, which was then held back by fish hooks. She drilled a small hole in the skull and stanched some of the blood to relieve the pressure. She then outlined and cut out a hand-sized wedge of bone, careful not to touch the dura beneath. The bone sat in a basin of antibiotic solution while she took out a small fractured shard, and used a pen-like device called a bipolar electrocautery to seal the lacerated artery.

If the brain below the dura is swollen, surgeons might opt to leave the bone off in a freezer for months. In Steve’s case, Schwartz made a small nick in the dura to check on the brain beneath it, and, satisfied that it looked healthy, she put the bone back on. She left in a tube to monitor the pressure in the brain and to drain any excess spinal fluid that might build up.

Up to this point, her choices were smart, but conventional. Typical protocols suggest waiting six hours after a surgery for the next CAT scan, to give the brain a chance to rest. But Schwartz was uneasy about a seizure Steve had during the surgery. She also remembered the small bleed on the left side. “The last thing you really want to do when you finish is do more surgery. You want to go home and go to sleep, or go on rounds,” she says. “But I was concerned that the other side was getting worse.” She asked the surgical team to leave the operating room running, and took Steve for another CAT scan.

The scan confirmed her hunch. The bruise on the left had ‘blossomed’ into a subdural hematoma, blood oozing from a vein in the brain under the dura. This was particularly worrisome because in most people, the left side of the brain is dominant, holding the centers for speech, memory, movement.

The team rushed back into the OR and into Steve’s brain, this time on the left side. Schwartz opened up the dura and took out the blood clots. The brain itself was a black-and-blue mess of bruises rather than its normal dull gray, and swollen out of all semblance of its normal shape.

Without any landmarks to rely on, Schwartz felt her way as best she could, suctioning up damaged chunks of the frontal and temporal lobes with a small vacuum. In all, she estimates she might have taken out between 15 and 25 percent of those lobes, hoping she hadn’t stripped him of his ability to talk or walk.

When the brain is swollen, its folds can stretch tight as a drum. Once the swelling subsided and the brain began to pulse again with a healthy rhythm, she packed it with a cotton candy-like material to prevent further bleeding, and closed him back up.

Steve stayed in a coma for 10 days. Because he had no other internal injuries, the medical team could focus on maintaining his brain’s health, monitoring him for seizures, infections and brain pressure.

The drains for his cerebrospinal fluid still seemed clogged, so Schwartz replaced the tube in his brain with a shunt that evacuates the fluid through his chest and into his abdomen, where it is absorbed. (The shunt is still there—“let sleeping bears lie” is Schwartz’s mantra.)

* * *

Around 6 a.m., possibly as Schwartz was drilling through Steve’s skull, his two colleagues arrived at his home in Brooklyn. They knocked on the window. When Amber didn’t respond, they went to a Dunkin Donuts at the corner and called her to let them in. Back at the apartment, they told her, “Steve was in an accident.” (Days later, Amber’s mother found Steve’s bag, with his glasses, wallet, cell phone and keys, tucked into a corner of the kitchen; Amber says the men never told her about the bag.)

Amber reached the trauma center in New Jersey in time to talk to Schwartz between surgeries. “She told me that night that his IQ would plummet, that he would never be the same again, that he might never speak, or understand language, or interact with the world in a meaningful way,” Amber recalls, tears streaming down her face.

The first couple of weeks after Steve came out of his coma, he tried to talk, but the sounds he made did not resemble language. He was physically restless and often needed to be restrained. Like many people with brain injury, he went through a phase, mercifully short-lived, where he was disinhibited and hypersexual, groping the nurses and exposing himself.

But very quickly, he began to show improvement. The first six months are considered crucial for anyone with a brain injury, and Steve showed promise within the first few weeks. Schwartz says she first realized he might make a full recovery when, after three weeks at the hospital, he could reach across his body. That was a sign that the two sides of his brain were communicating.

Amber was constantly planning ahead. “I knew early on that the clock was ticking fast for Steve,” she says. “If he was going to have any chance at recovering, he needed to have as much deliberate and planned therapy under his belt before the six-month mark as possible.” For rehab, she had her sights set on NYU Langone Medical Center’s Rusk Rehabilitation, where she had once been a psychology intern (she later switched careers and became an elementary-school teacher). Rusk is one of 16 federally funded centers in the TBI model systems program, which sponsors research on various aspects of brain injury. Rusk specializes in neuro-rehab and employs seven doctors who are board-certified in brain-injury medicine, a relatively new subspecialty.

On January 7, Steve transferred by ambulance to Rusk. Amber had pinned her hopes on this move as the start of Steve’s return to normalcy. At first, progress was slow. Physically Steve quickly became strong, but cognitively, he was in what’s called a post-traumatic amnesia state—he couldn’t carry over information from day to day or grasp why he was in the hospital. “He really couldn’t understand why he still needed to be in the inpatient setting, why he needed to be taken care of by nurses, why we wouldn’t let him get up and walk around on his own,” recalls Brian Im, the director of brain-injury rehabilitation at Rusk.

Paradoxically, the sooner someone with a brain injury can understand and acknowledge their deficits, the better their chances for long-term recovery. At first, “he just kept wanting to talk and talk and talk, and he would go in circles,” Im says. “But during his stay with us, he started to show signs of better carry-over, better awareness of what was going on. It was a good sign that he was starting to recover.”

Rusk specializes in rehab after a brain injury, and unlike many other centers, its therapists focus on the cognitive and behavioral aspects of recovery as much as the physical. Each week, all of the therapists discuss every patient’s progress with a neurologist and chart out a roadmap for recovery.

In the four weeks Steve spent at Rusk, he learned to plan and execute simple tasks he’d taken for granted before: bathing, dressing himself, brushing his teeth, making tea. He worked on his speech, reading, writing, and math. He also had an emergency surgery to repair the herniated disk.

His relative youth, good health, and prior education were all in his favor, as was the fact that his insurance covered his medical bills. Im’s research suggests that unsurprisingly, the quality of care at private hospitals is often far superior to that at public ones. The people who seek care at public hospitals tend to belong to “vulnerable groups,” Im says: They are more likely to be minorities, to have been homeless, have other physical and mental illnesses, alcoholism or other addictions, or a history of incarceration. “All these things speak to a less favorable prognosis for recovery in general in the case of traumatic brain injury,” he says.

Soon as he could talk, Steve told anyone who would listen that all he wanted was to go home, get back to work, and support his wife and kids. This single-minded focus may have helped him, says Felicia Connor, Steve’s psychologist at Rusk. “People who have long-term goals of returning to work and who are aggressive about reaching that goal, I find that that grit, that determination really helps to drive their recovery,” she says.

Steve had one more, incredibly powerful, ingredient on his side—the support of his family. For someone with memory issues, not knowing whom to trust can be disorienting. The transition from the structured rehab environment back to a newly unfamiliar home can also be stressful. The anxiety and stress can further erode confidence, spiraling into depression.

The Mishkin family, a few weeks before Steve’s injury (Courtesy of Amber Carlin Mishkin)
The Mishkin family in 2015, following Steve’s injury (Courtesy of Amber Carlin Mishkin)

Forestalling this cycle requires infinite stores of patience, understanding — and time. Often, a brain injury can force a spouse to go to work or even take on a second job. In Steve’s case, the family was financially secure enough to have Amber take a break from work and dedicate her days to his recovery. Marshaling her training as a psychologist, she structured their home like a rehab center.

To help him feel a sense of control, she bought a dry-erase board, like the ones at Rusk, and on it wrote every item in his day — therapy appointments, visits from friends, walks to grocery stores, meal menus, calls to the insurance company, projects with their kids. She created an anxiety journal to help Steve track his feelings and their intensity, and his physical response to those feelings. “I chose this method because Steve is a data guy. He understands numbers and charts and finds comfort in seeing that things are predictable and controllable,” she says. “He could see he was getting better because the data supported that.”

She also helped him rehearse social situations. Before meeting friends at a restaurant, for example, they went to a coffee shop and practiced placing an order, taking turns in conversation, and paying the check.

The kids got right into helping Steve, too. When they first saw him, on January 10, he was still Frankenstein-like, with his stitched up scalp and tubes everywhere. Four-year-old Mirabel held back, but Henry, 6, jumped up on the bed and touched Steve’s head. “It was just such good therapy for both of them and they were just so calm in that moment together,” recalls Amber.

She told the kids Steve would need to learn to do everything, just as they were doing at school. Mirabel sang and drew pictures with her dad. Henry created Lego kits and packets of logic and math problems.

All along, Steve continued to go to speech, cognitive, and occupational therapy at Rusk three or four times a week. “Steve took homework and assignments in session very seriously and worked nonstop to perfect those skills,” says Connor.

By July, the Rusk staff, accustomed to delivering difficult news, instead granted Steve his biggest wish: He was ready to return to work part-time. But when Steve told his employers, he says, he didn’t receive a response for a few weeks. Then, he recalls, they abruptly terminated his employment over the phone, for reasons they said were unrelated to his injury.

* * *

If, until this point, Steve had been on a steadily rising curve, the termination flung him, hard, into an abyss. Stripped of his singular goal, he became deeply, intensely depressed, and even Amber couldn’t comfort him. Given everything he had been through, says Connor, this was not at all surprising. “It’s very common after traumatic brain injury for some people to feel emotions more strongly than they would have before,” she says.

When he emerged from his slump a month later, Steve began working his professional network, carefully navigating when to reveal his health status and how. Within weeks, he had two separate offers. He accepted a full-time job at a Canadian bank, and on the first Monday of November, began his new job (his new supervisor knows about the injury). The work is challenging, he says, but no more so than any new job ever is.

On the first anniversary of his fall, a month after he started the job, he seemed almost like his old self. He had a full head of hair, was not on any medications, and—physically, at least—showed no signs of his long ordeal. A missing Amazon package had sent him into a panic earlier in the day, but the episode had lasted 20 minutes, not two weeks or even two hours as it would have months before. He and Amber talked about ordinary things, like fixing the door on their summer house. “Right now the impact of [the injury] has really shrunk to a point where I think a lot less about what has happened to me,” Steve said that night. “I think more now about how do I move forward with my life.”

He proudly described his many spreadsheets of family expenditures and financial goals, which he has always maintained, but which now match every account to a penny—something he does because he says he is more aware of how fragile life is. Before his injury, he kept a tighter lid on his emotions, and he still does at work, but at home, “sometimes I get madder, maybe hold it more. I just can’t throw it away as easily,” he says. “But it gets better all the time.”

From the perspective of people close to Steve, in some ways, things might even be better than they used to be before his injury. He is funnier now, sings a bit louder and dances, Amber says, “like one of those solar-powered hula girls that you put on the dashboard.” The first time he held Amber’s hand walking down the street, the first time he kicked a ball again with Henry, the first time he felt the cool water of a lake—each new experience reminds him how grateful he is to be alive and back with his family.

“I don’t know if it’s because of the accident or it’s the vulnerable space he’s in, but he’s more open. He talks more freely about his stresses,” says Jenara Prieto, who met Amber when their children were toddlers. “I knew Steve as my friend’s husband, whereas now I think of him as a friend; to me that’s been really wonderful.”

Seeing him rediscover memories can be strangely emotional and eerie — like taking a walk through his brain and watching his neurons find their way back to familiar destinations. He talks with delight about how, after months of indifference to ‘80s songs, he suddenly regained his near-encyclopedic memory for lyrics. In his conversations, there are dozens of examples like this one:

Steve: I knew Ben Affleck left his wife. I’ll tell you her name. Starts with a J. It’s not Jennifer Aniston, I know who that is. I can picture her. First of all, she’s a lot taller than Jennifer Aniston, she has a skinnier face, she has brownish-black hair. Jennifer Cornice? I’m trying to think of the last name. Gor. I can’t remember, what’s her name? Jennifer Garner. Is that her name? Oh my God, I don’t know how that came out of my head. That’s wasting space in my head.

Amber: Not that much, you had to really pull it out.

Steve: No, but I have a lot less brain now.

Besides the jokes and the occasional over-sharing, Steve has only one small new tic, which he indulges when Amber isn’t around. He gently taps the right side of his head, behind his ear, where there used to be a huge dent.

“You’re talking with a person who for a year would always feel his head and never want to touch it, and also fear to touch it,” he says. “And now I feel my head, and the bumps and all the big craters have been diminishing. It’s all going away.”