new scutmonkey: the 6 stages of overnight call

This may be a slight retread if you follow me on Twitter, but one particularly bad night on call about a month ago, I posted a poll surveying the worst overnight call phenomena. After that...well, after that it was just a matter of drawing the thing.

Here, panel by panel:

For those who are curious, I've been meaning to get back into cartooning for a while now (despite the long hiatus I've actually drawn comics...well, basically my whole life, since I was a very small odd child with too few friends and a bit of a defensive sense of humor to match), but as I noted previously, making these comics does take some significant amount of time. I mean, at least the way I do it, which is extremely analog and old school, it involves many inefficient, labor-intensive steps.

Joe actually got me one of those Wacom tablets about a year ago because I've been yammering about drawing more since forever. He thought, quite logically, that a tablet might be a good tool that could input the my drawings directly into the editing software. It was such a thoughtful gift, but...I don't know. There's something about the tactile sense and resistive friction of drawing with specific tools, and I'm picky enough as it is about my writing implements.

I did try to do a sort of quick and dirty YEARS ago, with this "colonoscopy face" comic...

...which I deliberately did on a yellow notecard just to force me to treat the exercise it casually. I briefly considered doing more things like that--just casual, tossed off, straight ink to paper, no erasing, no post-processing cleanup, nothing. But the fact is that I don't like things that are careless and tossed off. I want to do things how I want to do them, and how I want to do them necessarily takes a certain amount of time. It just does.

Anyway, everyone has their weird outlets. Writing and drawing stupid comics are mine. I hope you liked this one.

shiny new scutmonkey: patient allergy stratification

I don't even remember when the last time it was that I made a new comic (I suspect it was right before I submitted the manuscript for my book to the publisher,* so that would put me in the last few weeks of residency, roughly a lifetime ago), and I don't want to make a big thing about this, because the comics...are really pretty stupid. But anyway, here's a new one.

The comics really do take a lot of work, which is probably why I haven't made a new one in just about a decade. There's the sketching and the penciling and the inking and the erasing and the scanning and the cleaning up and the titles and cropping. To think, I used to go through this entire process every single weekend for three years when I was in college and the cartoonist for the Wellesley News. This makes me realize that back then, when I thought I was busy, and had so little free time? I had nothing but time. Kids...don't know stuff.

Anyway, it's many years later now, and I am old, and semi-responsible, so I feel the need as an attending to say: Allergies are real, and can be serious. Listen to your patients. Use common sense, but respect the histories they are giving you.

However, sometimes funny things are funny. Maybe this comic is one of those things. And maybe now you understand why I was on that fine point mechanical pencil bender.

And here, so you don't hurt your eyes (we're all a decade older now, aren't we?), I have it panel by panel.

Happy trails.

* My editor ultimately decided not to include the comics with the book, which...look. At the time, I was a little disappointed, because I'd worked hard on them. But even at the time, I knew it was absolutely the right call. Strong work, Emily Griffin.

one flew over

So we had this bird nest in our garage. Our nanny first noticed it a few weeks ago, high up on a shelf something like eight, nine feet up, propped on a shelf against a corner, atop of a pack of Costco bulk terry cloth towels. We've had a broken window in the garage for...I don't know, probably going on a year now (don't judge), and I suppose it was only natural that at some point, a bird might find its way indoors and make itself at home.

"What kind of bird?" a few people at work asked me when I brought it up, but I couldn't really say, since I never actually saw anyone in the nest. For all I knew, the nest could have been there for months, and I just never noticed it sitting there, high above my head.

However, the nest apparently did have an inhabitant, and around Mother's Day, she let us know.

This also gave me a slightly more specific answer to the "What kind of bird?" question, because at least now I could say, "The kind of bird that lays eggs that look like that." 

The consensus in the anesthesia lounge, both from the build of the nest and the speckling on the eggs, was that these were Carolina wrens. There were five little eggs tucked in there, the size of those Cadbury chocolate eggs with the candy shells sold around Easter (they're what M&Ms should ideally be, in my opinion--better chocolate, thicker shell), and while it certainly made me somewhat monstrous for thinking of this mother bird's clutch of eggs in terms of snack food, I'm sure in the wild, outside of the safety of the high shelf in our garage, the eggs would be a snack for someone.

I had no idea what the gestational age of a baby bird is, particularly when the species is unknown. So I checked on this clutch of eggs a few times, but not daily, as I didn't want to spook the mom (again, I'd never seen her in the nest, for all I knew she'd already abandoned the eggs that the creepy Chinese lady kept peeking at), and anyway, it's not like anything interesting was happening.

Then, one weekend about a week and a half ago while I was in New York, I got a picture text from Joe. 

"I'm not sure if they're dead," his text read, "they're not moving. Maybe the garage was too hot for them?"

Since I was not there, I couldn't really weigh in, and I certainly couldn't tell from the photo. What could we have done, anyway? Put a little mirror under their beaks to see if it fogged up? Put on teeny tiny EKG leads? Put them on ECMO?

"Don't touch them," is all I could think of to reply, "and don't show the kids, it'll make them sad." It was a still photo, but Joe assured me that a video would look no different. And hell, babies that you can't see moving or breathing at all? Sounded pretty dead to me.

When I got home at the end of the weekend, the first thing I did (well, in truth it was maybe the third thing, after putting down my luggage and going to the bathroom) was stand on a chair, put my camera on a selfie stick telescoped out as long as it would go, and take a picture of the nest.

They were not dead. 

I exhaled a long breath I didn't realize I'd been holding in up until that moment.

When I took the MCATs back in--good lord, I think it was the summer of 1997--I remember this one section in the "critical analysis and reasoning" section. This is the part of the test where they give you some deathly dense and deliberately boring excerpt of technical writing and ask you a lot of questions about it afterwards to ascertain that you were able to not only stay awake, but actually retain and synthesize the information. (While this might be a reasonable test for how you would fare in med school, I will venture to say that it has only marginal bearing determining how good of a doctor you might eventually become.) Anyway, most of the sections were, as I said, deliberately inscrutable--an excerpt from a technical manual about how to extract aluminum via electrolysis, for example--but some reading selections were sort of interesting, probably by accident. 

This one I recall was about the breeding habits of certain birds in which "obligate sibicide" was the norm. Meaning: the bird will lay two or more eggs, and as a necessary evolutionary flourish, survival of the fittest, the stronger siblings will kill one or more of the weaker ones. Always. As a rule. I obviously didn't retain too much of what else I had read (though, to be fair, it was more than 20 years ago), but I figured, hey, five eggs is a lot of eggs. Probably by design. It was probably normal to lose a few by attrition. It's likely what we should expect, in fact.

I checked the nest every day (at this point Joe had set up our tallest ladder by the shelving and just left it there because apparently I was becoming the goddamn Birdman of Alcatraz and the ladder was heavy) but I would always approach with this vague, atavistic dread that at some point I'd happen onto one or two or five dead baby birds.

But there were no dead baby birds. Every time I peeked at them (just peeked, never touched), I did a quick head count. I couldn't tell them apart, I didn't name them or anything, I wasn't crazy--but just a quick head count. One, two, three, four, five. Every day, all five were there. 

Sometimes they would be in a different order, sometimes a few of them would be hiding in the back, but always, every day, five of them. They grew.

And grew.

And grew, until their ceiling hung with vines, and the walls become the world all around.

Yesterday, when I went to peek at the birds, it started to look a bit crowded. There was that adolescent gangliness to the brood--they still all seemed content to stay inside, they had a few tufts of baby down showing through, but the nest suddenly seemed like all arms and legs. 

And then this morning, just like that...

...they were gone. 

Joe caught a glimpse of one of the no-longer-babies early this morning, hopping around on a cardboard box by the recycling bin, virtually indistinguishable from the adult birds we'd seen about, but for the few sprigs of downy fuzz it had yet to shed. But by the time I got home from work, none of them were left. The garage was suddenly very quiet.

I'm not totally sure why I'm telling this non-story. After all, it's not really that interesting--lots of people find birds nests near their houses, baby animals come and go all spring and summer, the "empty nest" analogy as applied to human children is trite and hoary, and something I honestly don't really know about yet. (Soon, yes. But not yet.)

I think it was my reaction to the birds. The way I automatically assumed the worst. I think this happens at work a lot--in fact, I think the reason I sometimes assume the worst is because of the work I do. It's like a protective mechanism. You learn the statistics, you recognize patterns, you make predictions, you prepare yourself. Hope for the best, sure; but always, always, always prepare for the worst. Prepare yourself for the bad outcome and you'll never be surprised or disappointed. It's the bad outcomes you allow to blindside you that will truly break your heart.

But you don't always get a bad outcome. Even sometimes, when you should get a bad outcome, when you fully expect it...you don't. You're surprised the other way. People beat incredible odds. Genuine miracles happen. 

When I was a resident doing a rotation in the cardiothoracic ICU, there was a saying we'd murmur to each other back and forth on rounds, under our breath. Well, it was maybe not even so much a saying so much as it was a known phenomenon. "You fly or you die." Patients who had major cardiac surgery seemed to have two paths. Either they would do great--they would fly--or they would limp out of their moment of crisis, hobble through the next few days and weeks, accruing one complication after another, and eventually, succumb. It wasn't absolute, but it held true enough that it was accepted as near uniform fact. You fly or you die.

Life is not nearly as uniform or algorithmic as we would sometimes like it to be, of course. The comfort of a logically predicated outcome and the inurement against heartbreak can sometimes close you off to the possibility of an improbable result. Worse yet, sometimes one becomes so jaded against good things happening that the possibility of a good result seems less likely than it should.

I'm not saying that having five baby birds born in our garage and having all of them survive to leave the nest is an improbable result. From most of my limited conversations with other people who've had firsthand experience in such matters (so...two conversations, then) this in fact seems par for the course. 

But maybe that's not the point either. Maybe the point is just that surprise and delight can sometimes go hand in hand. And that delight can be found in the most improbable places, exactly when you least expect it.

vintage scutmonkey: doctor id

This is a rare bird indeed, in that it is the one Scutmonkey comic that I never disseminated widely. I in fact never completed this strip. This string of panels originally ran with the tag line, "To Be Continued..." but I never followed it up, because...I don't know. I think it just never felt very funny to me. Don't get me wrong, for someone who has worked in the Peds ER, there is a decent dose of acerbic humor in there, but on the whole, when taken with the other comics I wrote, it felt...kind of darkly bitter. A little too much dark, and a little too much bitter.

In retrospect--and I don't think I needed that much distance from that time to realize this, I think I even realized it at the time--there was a point in my first year of Peds residency when I was likely borderline clinically depressed. It was circumstantial depression, certainly--I think many of us were at the time--but nonetheless it was a period of my life that both imprinted deeply and which I don't remember well. Day blended into night, one rotation blended into the next, there was very little time, very little spontaneity, very few genuine sparks of joy that I can recall. This had very little to do with my residency program per se (to this day I have nothing but good things to say about my Pediatrics residency, which turned out some of the finest doctors I know), but had everything to do with the nature of residency itself, which somehow, despite all best intentions, tends to bleed the humanity out of the young people training to take care of human beings at their most needy and vulnerable. It's quite a paradox, when you think about it.

So despite the fact that I cringe a bit reading this now, remember the place I was in when I wrote this, I'll republish this nubbin of a comic from the archives anyway. But I will also link these two things.

One is this older blog entry I wrote seven years ago, entitled, "It Gets Better."

The lowest point in my residency was in January of my intern year. I was a Pediatrics resident back then, doing a month-long rotation on "Team 2," which is what we called the general inpatient pediatric team, with a focus on the patients on our liver transplant service. 

It was a very long month.

I'd get to work at around 5:45 every morning to pre-round, and invariably leave after dark every night--not difficult, considering that, in January, it seemed like it started to get dark around 3:30pm every day. I was there much later than that, of course--most nights I'd leave around 7:00pm, unless I was on call, in which case I'd leave at around 10:00am the following morning. We'd have pre-rounds and then rounds, then attending rounds and work rounds, followed by teaching rounds and radiology rounds, with time at the end of the day for sign-out rounds. Twice a week we'd have Grand Rounds and Chief of Service Rounds. How we ever got anything done with all this rounding, I'll never know. How I ever got to spend time with any patients in between all these rounds is even more of a mystery. It just felt like a day of endless, endless scut. Losing the forest for the trees. It would be a day full of writing down numbers and pagers beeping and phone calls and faxes and entering computer orders, and not nearly enough time practicing medicine or spending time with patients. And then I'd go home and collapse and wake up at 4:15 the next morning to go in and do it all again... 

And let's get this straight. I liked residency. Really, I did. Yes, it was hard, and yes, I was tired basically all the time, but I expected that, and now that it's over, most of my memories are affectionate. Residency, like medical school, was full of stories, and many of them, in retrospect, are funny--not at the expense of patients, but at my own expense, because Lord, how serious and inexperienced and bumblingly well-intentioned I was! But that first January of my intern year, I was very close to being clinically depressed. It just all felt so grim and featureless and endless, and I felt more and more like I was just some kind of task-programmed automaton, not like the doctor that I thought I was supposed to be at this point.

I wanted to quit. Not just quit being a Pediatrics resident, but quit medicine altogether. I was unhappy. I didn't like my life. I wanted to be done. I know that this comic was intended to be a joke, but there were time, real times, when I passed by a Gap or a Starbucks or whatever, saw that they were hiring, and seriously considered stopping by to fill out an application. At least they don't make you take call at The Gap, folding chambray button-down shirts at 2:00am. 

Now I'm going to tell you a secret. Everyone who has been through a residency has felt this way at some point. Everyone. 

Maybe you're feeling this way right now. So here's another secret. There's more to life than this. Even though it feels like residency is your life, it's not. There's more to life. There's more to you. And it gets better.

It gets better.

The second thing I would like to say is this. I am not a great person, and I know this. The people who work in the Peds ER are...incredible. Phenomenal. Superhuman. It is one of the rotations during my residency--both residencies--where I learned the most, and one of the rotations from which I have retained the most indelible memories. There's a chapter from my book, and though this is one of the less sensational excerpts (you would have never centered an episode of ER around it, for example), it's still the one that sticks with me the most.

...[T]here are some subtle changes of the twenty-four hour cycle that, to the experienced eye, can give some clue as to what time of day it is, but otherwise, days and nights in the ER are all pretty much the same, a constant stream of low-grade urgencies punctuated by the occasional heart-stopping emergency. 

In fact, the only event that allows me to reliably tell time in the ER is the 3:00 a.m. sandwich drop, wherein a café across the street, just prior to receiving their bakery-fresh goods for the morning, drops off heaping mounds of day-olds for the patients and staff of the Peds ER to pick through. Walk through the Peds ER at three thirty in the morning and you will find leftover yogurt cups lined with soggy scrims of granola, see patient attacking chicken salad wraps, and watch ward clerks turn away from their work stations to deal with a mouthful of cheese danish. "Try the turkey sandwich," the attending urges a floridly tattooed teenager with the air of insider knowledge, "the bread is really good." 

At these times, the ER feels like it could be anyplace where unlikely company is trapped together for an interminable wait. The DMV, the passport office, an airport terminal after all outgoing flights have been canceled due to a storm.

Anyway. Dr. Id. We don't often immortalize the worst of ourselves in amber, but it's still important to remember that there was a time when that person was there. Is still there at times. And to remember the small moments of happiness and good humor, no matter how inconsequential. And to know that it gets better. To know that you get better too.

It gets better, and you get better too.

vintage scutmonkey: surgery

So starting in 2000, and for more than a decade thereafter, I used to have part of my blog hosted on a platform called Homestead. (The fuck, you say? Shut up, it was the early 2000s, we didn't have nice things back then.) Homestead was clunky and hard to navigate and ugly as sin, and they also charged me upwards of $400 a year in annual hosting fees. As a resident I paid this. I mean, my God. Every July they would extort me remind me to cough up this renewal fee, and every July I would put off the payment as late as possible until they threatened to wipe all my data, at which point I'd pay and they'd keep my files online for another year. Anyway, one summer, many years ago, I just decided not to renew, they made good with their promise, and anyway, that's why the oldest strata of archives on this seventeen year-old blog have been fittingly lost in the ether. (That's an anesthesia joke for you. Not a good one, I admit, but...there really aren't that many great anesthesia jokes.)

Anyway, I do mourn the loss of those first three years of archives (as much for their Web 1.0-tackiness as for the content itself), but one thing that I didn't count on happening was that I would lose the scans of the first three long-form Scutmonkey comics I ever made, about three third-year clinical rotations I did in medical school: Psych, OB-Gyn, and Surgery. I am certain that the original hard copies remain somewhere in my possession, but I've moved 5 different times since then, and whatever logical location they once were stored is unclear. (I had also scanned them at some point, but, again, that was five hard drives and fifteen years ago--not every file has migrated intact.) So while I somewhat regret the archival loss of proto-me in medical school (only somewhat because let's be real--between the ages of 21 and 24, I was even stupider than I am now), what I really regret is the loss of the cached images of those first three long-form Scutmonkey comics.

I'm going to continue to look for the original hard copies, as I'm certain that they are merely displaced, though hopefully not irrevocably. But in my search, I did find something close--the two remaining copies of the handmade booklets I made and sold of the Scutmonkey comics, optimistically named "Issue #1" of the series. In truth it was the only issue I ever made. I wrote a dozen more comics in various forms for Scutmonkey, but that scan and Xerox, cardstock and staple zine-form of publication was on its way out, if it hadn't already become well extinct even before I cranked out "Issue #1." But in this form, the three original long-form Scutmonkey comics still exist.

Here's the last one of those, entitled (rather straightforwardly): Surgery. The images below are janky, because they are very "your mom texting you a photo of a photo," but I'm doing this quick and dirty, and it gets the point across. Forgive the slight image bleed-through, it was printed on cheap paper, both because I myself was cheap, but because the booklet had to be thin enough to be stapled through. (#thepast)

Mack, looking through this comic book earlier today, asked, a little puzzled: "Is this, like, supposed to be...for humor?" I don't know, son. I really don't know.

May all your dressings remain clean, dry, and intact. I'll post the Ob-Gyn comic once I summon the will to rotate and crop all those photos of photos too.

EDITED TO ADD: Thanks to Daisy Porter in the comments, I have found cached copies of the super old archives and extracted clean images from the Wayback Machine, thus enabling me to un-jank these images. Thanks, Daisy!