On the day that would change his life forever, Ryan Brown went on his regular morning run. He rode his bicycle the quick mile to work at the U.S. Trademark and Patent Office in Alexandria, Va., where he was an examiner for plant molecular biology patents. Late in the afternoon, he headed home to take his two sons to dinner while his wife finished teaching a piano lesson. He never made it.
Barely a block from the family's apartment — within sight of their back patio — an elderly woman ran a red light just as Brown was riding through the intersection. She hit him in the crosswalk, the collision throwing him 50 feet. He was critically injured and unconscious when an ambulance arrived.
Without his bike helmet, "I think he would be dead," says Babak Sarani, a trauma surgeon at George Washington University Hospital in the District.
The 16 months since the crash have taken Brown and his family on a wrenching loop of despair, hope and slow recovery. Tens of thousands of bicyclists in this country are hurt annually in traffic crashes, and too many face devastating injuries and uncertain futures. In 2015, the latest year for which federal data is available, 818 of these cyclists died. That number has been climbing of late.
Difficult as the Browns' experience has been, it also signals the progress made in recent years in treating traumatic brain injury. One mark of this is a drop in the nation's death rate for TBI from 2001 to 2013, according to the Centers for Disease Control and Prevention — from 18.5 deaths per 100,000 population to 17.0.
"These people, generally, get brilliant acute medical care in the hospital and they survive, whereas 10 or 15 or 20 years ago, they would have died," said Joseph Fins, a physician and professor at Weill Cornell Medical College in New York, who has written about the ethical issues that can arise with severe brain injury.
Improvements have come primarily because doctors now take a far more holistic view of the brain and surrounding organs during the acute phase of care. They carefully manage blood pressure, oxygen and carbon dioxide levels, and focus on nutrition to help support healing.
Yet increased survival offers no guarantees about recovery, as Brown and his wife, Jessica, have learned. Despite the significant distance he has traveled, he has not returned to work.
"Do you remember what you did this week?" Jessica asked him on a recent Saturday as they sat in their apartment. On a nearby desk sat the computer that Jessica had used for hours at a time to research brain injury. Ryan is on it these days to get reconnected with the Internet.
"I went to therapy this week, I think," he said.
"Well, yeah, but on Tuesday night —"
"I went out," Ryan finished.
"You went out with a friend of ours from church. What did you say about that experience?" Jessica asked.
"I liked that experience," Ryan said.
"Because it helped you to realize that . . . what?"
"I'm okay," Ryan said.
He had a broken leg, a broken shoulder and three fractured vertebrae. But those were the 41-year-old cyclist's lesser injuries.
His brain was very badly damaged. Upon impact, it had careened back and forth within his skull, shearing neurons and causing bleeding in several areas. Tissue immediately began to swell.
By the time Jessica got to the hospital on May 5, 2016, Ryan already was on a ventilator to help his breathing. Doctors inserted a probe through his skull to monitor the pressure on his brain, and over the next three days they gave him medication to reduce the swelling and sedate him further to minimize additional damage.
"The problem is, [the brain] is in a confined space," said Sarani, who led his care. "It's in the skull, and the skull's not going to give. One option is to call the neurosurgeon and just take off the skull. Then you've fixed the issue in that the brain cannot swell, but obviously you've got the very invasive, dire maneuver, which you would rather not do."
Jessica was both terrified and encouraged. The brain is a mystery, one doctor told her, and nobody really knows why it heals well in one person but not another. Someone with Ryan's kind of injury could be in a coma for many weeks and still make a full recovery.
"She said, 'It happens,' " Jessica recalled. "But what she didn't tell me at that time was, if they do have a full recovery, it takes years."
Ryan very gradually began to regain consciousness and awareness, a process that his wife learned can wax and wane. "When I talk about it, I say he was in a coma for three to four weeks. It's so hard to tell," she said.
He was confused, unable to speak and weak on his left side. He began nodding in response to questions and trying to move on command, prerequisites for transfer to a program specializing in brain-injury recovery. It took until June 1, however, before he would be moved to MedStar National Rehabilitation Hospital in Northwest Washington.
He would spend the next three months there, with intense speech, occupational and physical therapy. Within several weeks, he started eating solid foods and walking with assistance. But he had trouble understanding what was wrong with him.
"All he could ever talk about was 'Where are my kids?' and 'Why am I not home with them?' " Jessica said.
Nor had Ryan's short-term memory returned. He could not remember anything since a week before the crash, and he wasn't forming new memories of events and conversations.
"In a case like TBI, the idea is that it is a diffuse brain injury, and one of the structures that gets hit the hardest is the hippocampus," where the brain stores short-term memories, explains Moriel Zelikowsky, a postdoctoral scientist at the California Institute of Technology. Yet she has demonstrated that the brain can reallocate short-term memory function to the prefrontal cortex. "You have a lot of pieces to work with in terms of how flexible and plastic other parts of the brain are that can compensate for damage."
Ryan's physical progress continued, and in late July, when Jessica asked him why he thought he was in the rehab hospital, he answered, "I'm a survivor."
For months, Jessica had kept relatives in Utah and friends all over updated on Ryan's status via social media and a YouCaring page set up to help cover his medical expenses. "I'm so grateful for all the help we've received," she wrote on Instagram on Sept. 2, 2016, shortly before Ryan finally came home. "I couldn't have made it this far without all of you, but sometimes I can't believe he's been away this long."
"I can't do as much as I used to be able to do," Ryan said recently, sitting on his couch at home. "Like, I can't talk as well as I used to be able to." His voice, still affected by his brain injury, sounded strained and stilted.
"Anything else?" Jessica asked.
"I can't do the things I used to be able to do," he said again. "Like I used to do computer stuff."
"You're getting back on that," Jessica agreed. "But it's clunky."
Ryan spontaneously recovered his short-term memory within a few weeks of being discharged from the rehabilitation hospital. Soon, as he continued with outpatient therapy, he could walk with a walker, dress himself and make his own breakfast.
He remains on extended medical leave without pay, and finances have been tough even with donations of paid leave from colleagues and now Social Security disability assistance. The woman who hit him was not cited, and the Alexandria prosecutor decided that there was "insufficient evidence to conclude that the driver of the motor vehicle acted in a criminally negligent manner."
"I would like to be independent again," Ryan said. "[Go] back to work. Take care of the kids again." In March, his boss at the patent office had come to see him and brought some of his biology books.
Sons Peter and Ned, now 11 and 13, headed back to school this month. Over the summer, they'd hung out as much as possible with their dad, watching videos and eating frozen yogurt together, just as they did before the accident.
"I have a greater appreciation for life," Ryan said.
The unknown is where they all will be in another year. His health insurer extended his therapy visits through December, and it is likely that they could go until mid-2018. And even as the Browns have required less support over time, they have found more opportunities.
Ryan regularly attends ADAPT Clubhouse, a brain-injury day program hosted by Brain Injury Services, a Virginia-based nonprofit, and Jessica has set up transportation for him through the city of Alexandria.
His progress "is kind of like a tree," with some areas growing a lot and others less so, Jessica said. "He probably will never be exactly like he was before, so in some ways it is like watching this new person develop."
But in July, Ryan did something that both of them thought he might never do again: He rode. The rehab hospital's adaptive cycling program outfitted him with a recumbent bike, and one sunny afternoon he put on a helmet and took off on the grounds of the nearby Armed Forces Retirement Home. He pedaled across a small paved road, in and out of the shade thrown down by the trees.
He was happy to be back on a bike.