An excerpt from Box of Birds: What New Zealand taught me about life and the practice of medicine.

While dobutamine improves the strength of heart contractions and can thereby help raise blood pressure, it also has properties that dilate the arteries, which in this patient’s case dropped the blood pressure further. The patient’s blood pressure improved once her sepsis was identified and she began IV antibiotics.

Learning from clinical experience means being able to say: I won’t make that mistake again. Today, many American doctors live in dire fear of admitting mistakes, given the prevalence of lawsuits, but in truth becoming a doctor involves making many good decisions and the occasional wrong one due to unforeseeable circumstances. One learns from those errors, and the act of doing so is a key part of the acquisition of clinical experience. A culture in which one can neither make nor admit mistakes is not a healthy atmosphere. Another noteworthy incident occurred when I was assigned to the emergency room.

We used to get a lot of inner-city traumas, and they called our unit “the knife and gun club.” One evening, a young man presented with a stab wound to the chest. He proceeded quickly into cardiac arrest, and a nurse called a code. My job on the code team was to obtain an ECG to detect the pattern of his heart’s electrical activity. As I entered the room, I saw a young man lying unconscious with a large kitchen knife protruding from the left side of his chest. I had never seen anything like this before and can still recall the shock I felt at the sight of that big knife in his body. Nothing I had studied in medical school had prepared me for this harsh clinical reality.

I plugged in the ECG machine and a surgical resident began pumping on the man’s chest, but what the patient really needed was for his chest to be cracked open and the bleeding stopped. Soon the surgical team whisked the patient off to surgery to repair the knife wound. The patient didn’t survive, but I had learned a critical lesson. Not all cardiac arrest patients need a heart tracing, even though this is standard procedure. Sometimes you simply have to jump into action, crack open the chest, and stop the bleeding from a knife wound.

Following my internship, I decided to pursue cardiology and completed my two years of residency at a Yale-affiliated hospital in Danbury, Connecticut. My fondest memory of residency was making rounds at Yale New Haven Hospital with the world[1]renowned clinician Howard Spiro. One time he asked me to examine a patient who had a high-pitched systolic murmur and an enlarged liver that pulsated against my fingers when I pressed down on the abdomen. Dr. Spiro asked me what was causing the liver to pulsate. My mind went blank, as I had never seen a patient with a pulsating liver. Dr. Spiro smiled and gently explained that it was from tricuspid regurgitation. With each heartbeat, a valve on the right side of the heart called the tricuspid was leaking a jet of blood back into the liver, causing it to pulsate. Given that cardiology was my field of endeavor, I was embarrassed not to have known the answer, but afterward I felt determined to learn everything I could about tricuspid regurgitation. Dr. Spiro was an inspiration as a clinician and as a bedside teacher because he was able to transfer what we learned while reading about a disease to a real-life, in-person clinical presentation.

I chose to specialize in cardiology because I felt that was where the action was. Treating the heart was exciting and dynamic. Patients showed up exhibiting fast heartbeats, slow heartbeats, high blood pressure, and low blood pressure, meaning the clinical presentation was always changing. And perhaps I was influenced by having seen Dr. Topley save my grandfather’s life when my grandfather had a heart attack in our living room. I hoped to become a person who, like Dr. Topley, could intervene success[1]fully in the middle of an acute crisis.

Danbury, Connecticut is also where I met my wife-to-be, Bonny. We found each other at a Halloween party that took place during my residency, while bobbing for apples. She asked if I could give her a ride home, and on the way we stopped at a railroad crossing. As the train rumbled by, I let her bucket seat down and kissed her. Bonny has beautiful brown eyes, a heartwarming smile, and a wonderful sense of humor, and I fell in love with her straight away. We dated throughout the rest of my medical education. After completing my residency, I moved to Portland, Maine, where I worked in cardiology at Maine Medical Center, with the hope of becoming a primary-care cardiologist. When that year was done, however, I decided that I wanted more extensive training, so I began a two-year cardiology fellowship at George Washington University Hospital in Washington, DC.

I remember our chief of cardiology, Dr. Allan Ross, leading the weekly review of coronary angiograms we had performed during the week. The patients’ clinical histories, electrocardiograms, echocardiograms, and stress tests would all be put together. “With inferior ECG changes on stress test, what coronary artery do you expect to be involved, Steve?” asked Dr. Ross, at one of these gatherings. “Narrowing in the right coronary artery which supplies the inferior wall,” I replied. He made it all coherent, and it was a good learning experience.

Bonny was still living in Connecticut, and she would drive down to see me on the weekends. One weekend, the area had a severe snowstorm, and we cross-country skied down Wisconsin Avenue to the Washington Monument. Her car was buried in the snow for a week before we were able to dig it out. We got married that June, right after I finished my fellowship. Bobby Curtis, my pharmacist friend from Kansas City, flew east to serve as my best man, and then Bonny and I moved down to Florida, where I took a job with the University of Florida in Jacksonville.

Stephen Stowers is a cardiologist and author of Box of Birds: What New Zealand taught me about life and the practice of medicine.