They found him in an abandoned warehouse just two weeks before Christmas. He was alone, dressed in a Santa costume. He was in a coma. He had no identification on him. I first saw “Santa” in the emergency room shortly after he had been admitted to my internal medicine team. His blood glucose was 32. Normal is anything above 90 and less than 120. When you get below 50, you’re approaching a comatose state. We had no idea how long he had been like this. I chose to admit him to the intensive care unit until we could get him stabilized. Shortly after bringing him to the ICU from the ER, he coded — medical jargon for cardiorespiratory arrest. In other words, his heart stopped and he died. We worked on him for a good hour and managed to get his heart beating again but he had trouble keeping his blood oxygen level up so I decided to put him on a ventilator. It was the last free ventilator in the hospital.

That was when the fun began. Let me elaborate.

Bed 1 contained a man weighing 780 pounds. We tied two hospital beds together to hold him. He had been admitted to surgery for removal of a hernia so large, he had carried it in a wheelbarrow. But, the surgeons had no idea how to maintain the fluid balance of a 780 pound man so he developed fluid on his lungs. He coded at this moment and my team of medical students and the other intern starting working on him. I remember one of the medical students literally perched on the huge man’s chest pumping on his heart with her knees!

Bed 2 contained a man with delirium tremens. As soon as Bed 1 turned south, the man decided to pull out his Foley catheter without deflating the balloon. He was whirling the catheter with its balloon the size of a grapefruit around his head like a lasso while chasing one of the nurses. He was spewing bright red blood from his, uh, privates all over the floor.

Bed 3 contained a prisoner from the local jail. He had “overdosed” and was now in a “coma”. He had been in a “coma” most of the day although we suspected he was faking it just to stay out of jail. He had overheard me talking to the psychiatrist earlier saying as soon as he woke up, instead of admitting him to the psychiatric ward for treatment of his “depression” we would send him immediately back to jail. In the developing chaos, he woke up, opened the window and climbed out on the seventh floor ledge to kill himself. He was going to prove he was suicidal.

Bed 4 contained a medical student in her mid twenties. She had “converted” her PPD, meaning that sometime since starting medical school she had been exposed to tuberculosis and her skin test proved it. She had been placed on prophylactic medication which had proceeded to destroy her liver. She was currently in “hepatic encephalopathy” meaning she was delirious from all the ammonia building up in her bloodstream from her failing liver. She started screaming at the top of her lungs and trying to tear out of her restraints.

Bed 5 contained an elderly woman dying from ovarian cancer with fluid buildup in her lungs and her abdomen. Her protein was so low in her blood, we had to keep her in ICU to build her protein back up. She was on a ventilator.

Bed 6 contained a man  recovering from a massive heart attack. As our CCU, or cardiac care unit, was full, he had been moved to the ICU and was also on a ventilator. He was only 38 and currently sedated so he wouldn’t fight the breathing mechanism of the ventilator.

Bed 7 was currently empty.

Bed 8 contained Santa.

The next two hours were the most chaotic I have ever experienced in my many years of medicine. The 780 pound man died. The fellow in DT’s slipped on his own blood, fell and was taken to surgery for a subdural hematoma, a blood clot on the brain. The medical student began vomiting blood and we had to call in the gastroenterologist to try and scope her and find the source of bleeding. The psychiatry resident closed the window on the prisoner after telling him if he was still on the ledge in the morning, we would send him back to prison assuming he didn’t freeze to death. Otherwise, he could climb back inside and get sent back to prison without frostbite.

It was now 3 in the morning and I went to check on Santa. His status had not changed. He had not awakened. We still had no idea as to his identity. It was then the next admit rolled into ICU, a young woman in diabetic ketoacidosis. This is a state where the blood sugar is so high the patient becomes delirious and is in serious danger of dying. To top it off, the young woman had developed a rare complication, ARDS. This affected her lungs which were filling up with a proteinaceous material. If we didn’t get her on a ventilator soon, she would die.

But, there were no ventilators left in the hospital. That meant I had to make a decision.

In that day’s medical environment, most people don’t realize the loneliness of being the doctor on the spot. We are trained to make these kinds of decisions; to weigh life and death scenarios in a split second. Our current medical environment has taken that choice away from doctors and placed it in the hands of administrative individuals whether in the government or with an insurance company. These faceless, sterile, uncaring individuals sit behind a computer screen scrolling through a “cookbook” of these scenarios and deciding whether or not the doctor can make the appropriate decision only the doctor is trained to make. But, back then, the doctor was the final decision maker. The doctor, whether he liked it or not, was God.

I stood there faced with the inevitable prospects of taking a ventilator away from one of my patients. Who would it be? And, I had to make the decision quickly. For the young woman to survive, someone would have to die. Who then?

I stepped into Santa’s cubicle. He was still wearing the red pants and his bare chest rose and fell with the ventilator. I shooed the nurses and medical students out of the room. This would be my decision and mine alone.

“Sir,” I said. “I do not know your name. I know nothing about your past. I have no idea why you were in that empty building dressed as Santa. The only thing I know is that I have to make a decision and, I’m sorry, but it is time for you to die. I know that God knows your mind and your heart and I only hope He ushers you into heaven with open arms. The only thing I can offer to you is that although you may have spent your last waking moments totally alone, you will not die alone. I will be here with you.”

I turned off the heart monitor and slowly removed all the wires and EKG patches. I pulled his red Santa coat up and buttoned it over his chest. I removed the IV lines from his arms and straightened his long, white beard down over his chest. He had been wearing a tiny set of reading glasses in the warehouse, and I put those gold hued glassed back on his nose. For all the world, he looked like a sleeping Santa Claus save for the tube coming out of his mouth. I reached over and turned off the ventilator and slid the tube out of his throat. The respiratory technologist whisked the ventilator away and I reached down and took the man’s hand in mine. I felt for his steady pulse and waited as it slowed until it vanished.

I will never know who this man was this side of heaven. I will never forget the pain of making that decision even now 31 years later. I will never forsake another human being in the moment of death. We come into this world alone and are instantly embraced by family. But, death is a lonely experience. Even surrounded by loved ones, only we can experience the ultimate journey. But, we are not alone. God sends his angels to usher us into heaven. I have heard so many stories of men and women seeing the divine at the moment of death. There is that comfort.

Two people died recently whose deaths are significant to me. One was Christopher Hitchens, a radical, outspoken atheist who wrote the bestseller “God is Not Great”. He now knows the ultimate truth. And the other was Steve Jobs. Steve Job’s sister tells of his final moment of life when he sat up in bed, looked over her shoulder and said, “Wow, wow, wow.” Did Christopher Hitchens say something similar? I do not know.

I only know this. The night I allowed “Santa” to die so that a young woman could live, I learned the most powerful lesson in the world. It is the lesson of Christmas. It is the heart of the Nativity story. It is the fulfillment of man’s journey through darkness and evil. It is this. Someone had to die so that we could live. Jesus was born to die. The babe in the manger was overshadowed by the cross from the moment he drew his first breath.

This Christmas season, pause and look around you. Notice the unnoticed. Feed the unfed. Bless the unblessed. Love the unloved. Find the babe in a manger that cries in hunger. And, ultimately, share a love that is so profound, so deep, so unfathomable that because of that love He drew a cold breath in a manger only to breath His last breath on a cross for all of us.