BCPHR Logo Horizontal

Forced Perspectives

Dr. Ryan Montoya

By Dr. Ryan Montoya​

Needle Point

In this short story, Dr. Montoya discusses how needles are what allow the wheels of the hospital to keep turning, and how sometimes the most complicated procedures can be when the needle isn’t in the healthcare provider’s hand.

Editorial Note: You have two options to read the story, which is 12 panels in length and is numbered at the bottom in yellow.

1) At the top, the story is formatted in a carousel. To review the panels, click the arrows to the left or right, or the buttons below. 

2) You also may review all of the panels at once in the gallery below. Clicking on the images will enlarge them. Arrows also will appear to allow you to advance through the story.  

Three comic panels. A black panel with a thin white curve of light along a magnified needle edge; captions read "A tiny metal straw with a beveled edge" and "That's really ALL a needle is." Below, a hugely enlarged needle tip with its bevel opening rendered like a dark eye against a grey wash, captioned that needles can seem an insignificant nuisance but are the meticulously rotating cogs of the hospital machine. Bottom, a full syringe angled across the frame, captioned that patients need blood drawn, IV drugs dosed, and vaccines given, and that a needle is there for all these stages. Created by Dr. Ryan Montoya
Two comic panels. Top: a masked, gowned clinician leans over a patient curled on their side on a procedure table, back exposed, with captions explaining that Mr. Amos may have meningitis and that a needle will withdraw cerebrospinal fluid to diagnose it. Bottom left: a high-contrast figure curled in the fetal position, spine drawn as a glowing blue segmented ladder, a labeled 22-gauge spinal needle pointing to the lower back. Bottom right: a cross-section of lumbar vertebrae labeled L3 through L6, with a handwritten pink arrow reading "Subarachnoid space, a.k.a. PAYDIRT," beside a caption listing every layer the needle pierces on the way in. Created by Dr. Ryan Montoya
Four comic panels. A needle tip breaks through a taut membrane with the gold sound effect "PFFT," captioned that breaching the ligamentum flavum brings pressure then an actual popping noise. Gloved hands hold a spinal needle against a draped back while captions describe advancing 2 millimeters at a time and pulling the stylet to check for CSF. A wide dark panel shows the needle deflecting off bone, captioned "Pull back, take a breath, and redirect." Bottom, a patient leans forward over a table against a hot pink background, her back covered in handwritten pink annotations marking the thoracentesis entry site, with a cutaway inset showing blue fluid trapped between lung and pleura. Created by Dr. Ryan Montoya
A comic page dominated by a patient with a distended abdomen. A circular ultrasound-style diagram of her belly is drawn as a blue ocean with cartoon waves, annotated in handwritten pink with "Ocean waves not to scale," "Hit inferior epigastrics equals win instant lawsuit," "Don't hit these," "Lateral to rectus sheath," and "Try here" pointing at a target in the left lower quadrant. Inset panels show the gowned doctor prepping the draped abdomen and gloved hands inserting a needle. Numbered captions walk through the paracentesis, ending as a nurse says "I'm sorry Dr. Montoya, we don't have any two-way vacuum bags." Created by Dr. Ryan Montoya
Five comic panels. At the bedside the team learns the hospital is out of two-way vacuum bags and settles for negative pressure bottles, wondering aloud how they will rule out SBP. Captions explain that negative pressure bottles require removing the needle to empty fluid manually and hold a lot of pressure. A gold splash bursts as fluid sprays into the nurse's face. The final large panel is a close-up of the nurse, mask and skin spattered with gold droplets, expression flat, captioned "To this day, our nurse will deny being angry at me for spilling potentially infected abdominal fluid on her face. I have my doubts." Created by Dr. Ryan Montoya
Six comic panels. Dr. Montoya walks a hospital corridor as his pager sounds in handwritten pink, then takes a call about Mr. Correia and asks whether Dr. Yates is around to curbside. At the ICU workstation a colleague jokes about family medicine being consulted for emergency vitamin D levels. Montoya presents Mr. Correia, a 52 year old with liver failure, ascites and persistent hypoglycemia after a failed therapeutic tap. He and the ICU physician face off over whether a central line is needed. She answers flatly, "You could watch him die of hypoglycemic shock." Created by Dr. Ryan Montoya
A dense comic page. Top left, a flat brightly colored anatomy-textbook illustration of the neck and chest with blue veins and red arteries, annotated in pink "Try one of these two sites" and "How it looks in anatomy books." Top right, the same patient in stark black and white, thrashing with his mouth open, annotated "In real life," as the doctor shouts in English and Spanish for him to stop moving. A strip of six small panels shows the kit, needle, blood, guide wire and draped patient while captions list every step of placing a central line, ending "Don't let go of that wire at any point, or it will slip into the patient's heart. Easy." A bottom strip of five blood-spattered panels: "Don't lose the guide wire!" "Push." "Shit, the needle escaped." "Pop." "Redirect." Created by Dr. Ryan Montoya
Five comic panels. At morning rounds the team presents Bart Perjalta, a 43 year old IV drug user with two artificial valves on Coumadin and two days of fever, noting the INR target conflict between the PICC line and the valves. A caption explains he introduced bacteria that destroyed his heart valves and that treatment will be prolonged. A large center panel is an extreme close-up of Perjalta, bearded and wide-eyed, shouting from his bed, "Antibiotics for HOW LONG???" Below, Montoya stumbles over his name at the bedside, asks if it is a Hispanic name, is told "It's not," and answers "Um, so it could take 4-6 weeks." Created by Dr. Ryan Montoya
Six comic panels. Captions explain that Perjalta needs at least four weeks of IV antibiotics through a PICC line, that nurses will not place it until his INR falls below 1.5 or he will bleed out, and that holding his blood thinner risks clots. At the bedside he traces the loop himself: to treat him they have to increase his risk of dying from something else. Montoya confirms it. Told he is a young guy, Perjalta shouts "How old are you??" Montoya realizes they are the exact same age and starts to make something of it. Perjalta cuts him off: "Stop. We are not the same." "Listen, if you died..." The last panel is Montoya's face in stark graphic black, white and halftone: "...it'd be a fucking tragedy." Caption: "Push." Created by Dr. Ryan Montoya
Three comic panels. Montoya leans over Perjalta's bed among IV lines, arguing that the PICC line's rewards outweigh its risks. Perjalta agrees to be kept going "a bit longer" and mentions doctors in Boston who said he should have been dead five years ago. A caption notes he uses 10 grams of heroin a day and sometimes injects under his tongue because his other veins have collapsed. A wide close-up of his mouth mid-sentence: "I'd say I'm doing pretty fucking well," captioned "Puncture." In the last panel Montoya is told security has found Perjalta in the bathroom shooting heroin into his PICC line, and a colleague says, "Told you dude. PICC lock." Created by Dr. Ryan Montoya
Final comic page, three panels. From a high distant angle Montoya stands small beside the bed, telling Perjalta they will stop treatment if he keeps shooting, and asking him to promise. In close-up, exhausted, Perjalta answers, "Honestly, doc?... I can't." At rounds the team learns he left against medical advice overnight on day 23 of 28 of antibiotics, with full capacity to decide, and that his endocarditis will almost certainly kill him. A huge close-up of Montoya's face fills the frame with a jagged shout, "WHAT THE FUCK, PERJALTA!!" Captions read "Pause," "Shit. I'm sorry," and "Redirect," as he asks who is next and the next case begins mid-sentence. Signed with the artist's monogram and "END." Created by Dr. Ryan Montoya

Like what you read?

More from Dr. Ryan Montoya here.

Stay Connected with Dr. Ryan Montoya

Linkedin-in