I was tired, nearing the end of a long shift in the ER during my fourth year medical school rotation. I had spent the night busy suturing up cuts, evaluating stomach aches and helping with the occasional emergent trauma as they came through. Life in the ER, I had come to see, was a life fueled by adrenaline and built on a foundation of quick decisions based on limited data. You saw a person for only a few minutes, often with no previous hospital record, and shipped them out just as quickly, hopefully addressing their problems. This particular night, as I started eyeing the clock for shift change, I noticed a small group of residents and faculty huddling around a computer screen. As I wandered over to overhear my eye caught the the sight of what looked like a huge balloon inside a person’s chest. The aorta, a large artery that connects the heart to the entire body, had an enormous bulge in it that looked ready to burst at any moment. I huddled closer as the team went over the film.

“You should stay and follow this guy, Mike. This is a great case.” The attending said turning to me as I stepped toward him.. “His name is Bob Holly and he is in bay 4.” he motioned down the hall.

Bob’s story actually begins in 1979. Rheumatic fever as a child had damaged his aortic valve to the point that now his heart was failing before his fiftieth birthday. That year his life was saved with a mechanical valve replacement, done at a time when the procedure was still very much experimental.

He lived for many years after, slowly growing old into his 80’s with little trouble from his operation. An episode of bleeding in the early 2000’s made him discontinue his coumadin with luckily no negative consequence after. The years crept up, knees went bad, activity decreased, but he still enjoyed time with his wife, reading “Westerners” and watching the ball game (when asked which, he replied “all of them”). Unfortunately over the last few years an aneurysm had developed just above his mechanical valve on his aorta, likely due trauma from the original the surgery itself. His doctors had followed him through the years while it slowly but stably grew.

Then, on this particular night in May, he began to experience some mild chest pain while at a restaurant with his wife and some friends finishing dinner. Just to be safe, he and his wife decided to go to the ER where the pain slowly went away while sitting in triage. As he would find out later, the pain disappeared not because anything resolved, but because the mounting pressure had finally torn a small hole through his aorta and began leaking blood slowly into his pericardial sac and pleural space. Sitting in triage, he received a small IV fluid bolus, to which he quickly seemed to respond. On top of the valve replacement and known aneurysm, he had dealt with a-fib as well so it was decided that although he was doing well, he would be kept in observation for a brief period of monitoring.

The CT that was my first introduction to Bob was not ordered until long after he came in because he seemed to be doing so well and his minor initial complaint. But after much prodding, Bob admitting that the original pain miiiiight have radiated to his back (concerning for aneurysm), and because his kidneys were healthy and could tolerate the contrast used for the CT, the doctors decided to go ahead and get one. It was upon opening up the images that I stumbled into Bob’s life for the first and last time.

The giant leaking aneurysm that I was staring at was like a ticking bomb waiting to explode at an anytime and Bob’s only chance of survival was emergent surgery.  Unfortunately, his age, previous open heart surgery, declining functional status, and mechanical valve all made him a very high risk patient in an already difficult surgery.

I walked into the closed trauma bay to find Bob and his wife sitting chatting quietly and introduced myself as the medical student working in the ER. This small quiet room felt like a different world from the loud, chaotic hallway outside. It was only a minute later that the cardiothoracic surgeon came in and introduced himself. The ER doctor had already delivered the bad news and had let them know that the surgeon would be in to discuss the option of surgery, so they were already trying to process things as I and then the surgeon entered.

I watched intently, though melting into the background, as the surgeon began with some small talk. They talked seemingly casually about family, hobbies, recent experiences, all, as I soon understood, to get a sense of Bob’s quality of life before this incident. This major surgery would, without doubt, leave him weaker and slower mentally as well as physically. Without a reasonably active life before surgery there would be no hope after, and that would likely mean that even if he survived the surgery he could not withstand the recovery.

But more profoundly, the surgeon was trying to ascertain how meaningful Bob’s life was. Was he simply living out his last days ready for death, or engaging in and experiencing life? Without meaning to one’s life, or if one’s purpose has been accomplished, what benefit does a person have holding onto life? In trying to avoid the inevitable they have little to gain and much to lose–the ability to die with dignity and to say goodbye to loved ones.

It was then his niece entered the room, tearfully embracing Bob and his wife. She appeared to be in her early 50’s and was the only family living in the area. She weakly smiled at the surgeon and I, and after a brief exchange, stood quietly next to the bed holding Bob’s hand tightly as the surgeon continued.

The surgeon let Bob know about the procedure. It would involve stopping his heart, cooling his body to minimize trauma, and rerouting his blood supply through an pumping machine while his entire aorta, from his heart down to his naval, would be removed and replaced with an artificial one. “Even if the surgery is successful, you will likely have some permanent mental and physical impairment from these steps alone. I would guess you have about a 20% chance of making it through the surgery, but I can’t begin to guess the extent of the other effects of the surgery. They could range from mild forgetfulness to being unable to feed or take care of yourself. However if you do nothing, your chance of death increases by about 2% every hour. You may have a few hours or a few days to spend with your family, but if we decide to do surgery you will have to prepare to say goodbye now.”

Bob looked searchingly into his wife’s eyes for an answer. “It sounds like you have to do the surgery. Do you really have any other choice?” his niece implored and wife nodded in assent.

“We will step out and give you all a little time to think it over.” the surgeon said as he motioned us toward the door.

I stood outside the door taking in the enormity of the decision as the surgeon made some calls to make sure the OR staff were readying things in case of surgery. Heroic efforts had saved this man’s life over four decades ago, but at what point does the will to live become detrimental or foolish? What value does the option of dying peacefully and dignified in ones own bed have?

We walked back into the room as the family was finishing up their conversation. “I have to try… for my family.” Bob coaxed the words from his mouth.

“I’ll let the OR team know. We will probably wheel you back in about 15 minutes.” The surgeon said stepping toward the door.

“Can I go to the bathroom first?” Bob suddenly asked. He had IV’s hooked into both arms and was somewhat frail, so this would not be a simple request. Plus, the fear that the rip in his aneurysm could worsen made this, or any movement, seem like a daunting request. However, it could also be his last and a simple one at that to oblige.

“Sure, as long as Mike can help you.” the surgeon said as everyone turned to me for the first time since I  introduced myself. I ducked out and grabbed a wheelchair and rolled it next to the bed. Bob slowly stepped down and sat while I untangled the mess of lines from his IV’s. I wheeled him into the bathroom down the hall amid curious stares. I closed the door behind us and helped him to the toilet seat. For the first time I noticed his intense shivering as I held onto his arm. There he sat, in what could be his last few moments alive and conscious on earth, cold, shivering and half naked in a busy ER restroom without even the ability to be alone to contemplate his decision. I stood silent, uncertain of what to say, as he sat wringing his hands with his head buried in his chest or fumbling with the IV lines streaming from him. The rapidity with which this scenario had unfolded and the fact that he was currently without any symptoms that you might expect from an imminent danger must have been overwhelming.

“A lot of people are praying for you right now,” I said, uneasy with the silence. This was my feeble attempt to help him maintain hope, though it just as likely served to make me feel better. He began to sob, bringing me frighteningly close to this man’s experience with death, yet at the same time a world away. Mostly, I prayed that he would not fall down dead in the bathroom.

Finally, he finished, just as the nurse knocked “it’s time to go to the OR.” I wheeled him back to his room. The family gathered what few belongings they had brought and I watched as the OR nurse wheeled him off toward his last hope of survival with his family following closely behind. I wonder what his last words to his family were? “Goodbye?” or “See you soon?” Perhaps simply, “I love you.”

The next day I came in a little early to look up the surgery note written in his chart. As I read I imagined the surgeon, tired and sad, dictating the words I now read into a phone while sitting outside of the OR in the early morning hours. He explained how he had successfully replaced the aorta and reconnected all of the vessels to the new graft. But as the heart was restarted the junctures between the graft and his blood vessels continued to bleed. They tried for three hours to stop the bleeding but in the end could not. They sewed the patient back up and called the family into the OR to share his last unconscious minutes with him while his pulse slowly faded. Bob Holly passed into eternity, beyond the edge of a life he ultimately put in the hands of his surgeon.