"To get through the hardest journey, we need only one step at a time, but we must keep stepping." — Chinese Proverb

As a first-year Penn cardiology fellow, I had just finished work rounds in the VA CCU when a staccato message displayed across my iPhone, "New consult: Patient with known HFrEF, concerns for shock." I immediately went down to see the patient on the medicine floor. He was altered from his normal baseline, his extremities were cool, his radial/brachial pulses were weak and thready, and his blood pressure was 108/54 mmHg.

Over the past 24 hours of his admission, he had been treated for altered mental status from presumed sepsis due to an unclear source. Following the sepsis treatment pathway, his weak heart was given a volume challenge it was incapable of handling, breaking his Starling curve, and placing him into a tailspin resulting in global tissue hypoperfusion.

The next few minutes were punctuated by a flurry of activity and phone calls, including calling his family for collateral, reviewing his goals of care and formulating a plan. After discussing the case with the CCU attending, Raj Jain, MD, and our interventionalist, Paul Fiorilli, MD, both former Penn fellows, we decided on the most prudent course of action. We would bring our patient to the cardiac catheterization lab, place a Swan-Ganz catheter and examine his hemodynamics to guide our care.

As I walked into the cath lab, Fiorilli looked at me and said, "Scrub in Brian, your patient, your procedure." While this seems like a traditional academic interaction, this moment represents the culmination of 17 years of work.

In my former life, I was a registered cardiovascular invasive specialist, known colloquially as a "cath tech." After departing the U.S. Air Force, where I served as a medic for six years, the Hospital of the University of Pennsylvania took a chance on me and trained me on the job as a technologist.

Over the next 10 years, I grew to love everything cardiology, especially all that interventional cardiology had to offer. I was in the lab when drug-eluting stents became the main stay of coronary interventions. I watched as we tackled more complex lesions and developed hybridized approaches to therapy. I bore witness to the birthing transcatheter treatment of the structural heart disease, privileged to watch both Howard C. Herrmann, MD, FACC, and Frank E. Silvestry, MD, FACC, partner together to achieve amazing results.

During this time, Penn's cardiology fellows both inspired and pushed me toward my goal of becoming an interventionalist. When I had moments of doubt, they reassured me. They guided me through the process of becoming a physician, helped lighten the load of my hardships and celebrated my achievements along the way. Penn's cardiology fellows from 2002 until present represent the single most influential body of people in my life, and I owe them all a tremendous debt of gratitude.

As the patient lay before me, prepped for discovery, I smiled through my surgical mask. My journey to this moment, although arduous, was one of the most rewarding of my life. Today begins the first steps of a new sojourn, a trip 17 years in the planning with a final destination as yet unclear. All I know is that I will take it one step at a time and just keep stepping.

Thank you to everyone who played a role in getting me here, including my wife, Tammy, and our children and families. Thank you to the aforementioned physicians, as well as Jeffrey M. Testani, MD; Paul Forfia, MD; Antony F. Chu, MD, FACC; Andrea M. Russo, MD, FACC; Saif Anwarrudin, MD; Jay S. Giri, MD; John W. Hirshfeld, Jr., MD, FACC; Taisei J. Kobayashi, MD, FACC; Daniel M. Kolansky, MD, FACC; Robert L. Wilensky, MD, FACC; Cooper Medical School of Rowan University; my Brown University GIM family; and my Penn mentors, coworkers and friends.

This article was authored by Brian D. McCauley, MD, MPH, RCIS, first-year cardiology Fellow in Training (FIT) at the Hospital of the University of Pennsylvania in Philadelphia, PA.