Provider Discretion (LU in Healthcare)
(Lots of technical jargon in this one, lovelies, hope you don’t mind)
Something wasn’t right.
The patient herself was… okay. Mostly. She had called 911 because she’d had back pain that had just been getting worse, and she’d said she couldn’t even get around anymore.
Mo and Hyrule often exchanged a somewhat exasperated look when someone called an emergency line for something that had been an ongoing problem, but today this… was different. She just didn’t look well.
“I’m really sorry,” the patient apologized for the fourth time as Hyrule and Mo loaded the stretcher into the ambulance.
“It’s okay,” Hyrule quickly reassured her. His heart ached a little at how much this woman wanted to seem to shrink into oblivion. Even Mo, who, despite his big heart, often came across a little standoffish, had tried to make her smile multiple times. “This is what we’re here for.”
With a chief complaint of back pain, there wasn’t much to do outside of check vital signs. Mo could easily take this call. But Hyrule just… this felt wrong.
“Let’s get a 12-lead,” he said, already grabbing the cables for it while Mo got vitals. His partner didn’t argue, helping him place the leads in the right positions.
Vitals looked mostly fine. The patient’s blood pressure was high. She said she had a history of hypertension, so perhaps between that and her pain that would explain it. Though 180/98 did not make Hyrule particularly happy. But he couldn’t treat that.
The 12-lead showed normal sinus rhythm. Nothing wrong there. But something just didn’t feel right.
Grabbing the blood pressure cuff, Hyrule checked it again, but on the opposite side.
There was a discrepancy.
Hyrule and Mo looked at each other, eyebrows pinching. Mo took a manual on the left. Hyrule took a manual on the right.
They still didn’t match.
Feeling dread fill him, Hyrule told Mo, “I’m taking this call. Let’s get going. We don’t need lights but… just drive expediently, ok?”
The transport was blessedly uneventful. But the discrepancy remained. Her blood pressure was high, but higher on one side than the other. Coupling that with back pain…
Her aorta. Hyrule was worried about her aorta. The biggest artery in this woman’s entire body could getting ready to tear apart.
When Hyrule texted Warriors later, he got his answer.
Dissection. They rushed her to the OR. You pointing out the BP difference really tipped off the doc. Good catch.
Mo whistled. “Good thing she didn’t rupture in our truck.”
Hyrule blew out a breath. He was just thankful he trusted his gut.
XXX
The dispatch information had been for diabetic emergency. Fire had gotten there first, which Aurora was thankful for since she and Dawn were coming from the hospital and therefore farther away than if they’d responded from the station.
When they arrived, the house was a nightmare. The street was so narrow that the ambulance and fire truck blocked the road entirely, the stairs were so narrow Aurora felt like she had to squeeze her arms in just to climb up them, and the turns were so sharp she wasn’t sure how any kind of equipment could get up there. The patient was lying on his bed, altered, and unable to move.
According to the patient’s friend, he’d heard him fall and came up to check on him. He knew he was a diabetic and figured his blood glucose had to be low. Fire had already checked it, saying it was over two hundred. As the firefighter paramedic gave information to Aurora, he said, “He could be acting like this because of his sugar. Could be a stroke. We’re not sure.”
Honestly, Aurora couldn’t see the patient all that well from her vantage point. Dawn had already walked in and started assessing, they’d handed a reeves stretcher to the firemen, and they were working on loading him on to it. The girl went downstairs to prep the stretcher for their arrival. Once they managed to get the patient into the ambulance, Aurora stared.
This man’s entire right side of his face was noticeably drooping. He was moving his head a little to the left, eyes somewhat moving, pupils equal. Aurora quickly asked him to look at her, to follow her finger. While he could stare at her, he couldn’t track at all, and his eyes wouldn’t move to the right. He blinked once while attempting, and was only able to blink his left eye.
Who the hell thought this could be his sugar??
Once Dawn got in the truck, they were quick to get vitals and a 12-lead. He was hypertensive, all other vitals fine.
“We need to stroke alert this,” Aurora immediately said.
“But he was last seen normal three hours ago,” Dawn said uncertainly. “Isn’t that outside the window? Or is the window four hours now?”
“I think it’s four,” Aurora answered. “And it doesn’t matter either way. This is absolutely a neuro issue. Drive us hot, okay?”
Dawn nodded, heading to the front. She drove to the hospital with the lights and sirens on, allowing them a faster transport time, while Aurora called it in to the hospital. As they progressed, she tried to get the patient to follow commands, but he couldn’t. He held up his right arm but couldn’t hold his left up at all, and he still didn’t really track any movement.
When they arrived at the hospital, they were placed in a major room, transferring him quickly to the hospital bed. Warriors was charge that night, working on coordinating all the help they’d need for this patient. The ED physician entered, looking the patient over, and then turned to Aurora, asking, “So what makes you think he’s having a stroke?”
Aurora stopped in mid motion, looking at him with the most enraged and bewildered expression. “I’m sorry, what?”
“Why do you think he’s having a stroke?” The doctor repeated.
“What makes you think he isn’t?!” Aurora snapped, completely mind blown that this was even a debate. “His face is drooping so low it’s hitting the earth’s fucking crust, he’s altered, not tracking movement, blinking with one eye, down on one side, is hypertensive, and you’re asking why I—do you even know what a stroke is??”
“Let’s just alert it,” Warriors said calmly as he walked into the room, clearly sensing that the paramedic was about to explode. “It’ll get us a CT to rule it out.”
Aurora was fuming, and she stormed out before she could hear a response. Dawn tried to gently check on her, only to be subjected to her ranting for the next hour.
Later, Warriors texted Hyrule, who relayed the message. “You were right.”
“OF FUCKING COURSE I WAS!”
XXX
Legend wasn’t particularly a fan of working triage.
There were aspects of it that were exciting - he was the one to make first contact with patients who didn’t come in via ambulance, and he determined their acuity. But there was also a public relations aspect to it, a patience dealing with impatient people, a kindness and sympathy for those who were genuinely hurting or needing help but had to wait anyway. It was understandable, but public relations… was not Legend’s forte.
There was a reason he was put in triage, though.
It wasn’t always obvious, what was wrong with someone. But there were times when a patient just didn’t look right. Legend saw the man limp over, listened to him as he explained that he had some leg pain that had been going on for the last few days, how he thought maybe he’d strained a muscle but the pain hadn’t improved.
There were always signs to look out for. Little things, cues that something was off. The man looked resigned, reluctant; he clearly had been talked in to coming to the hospital, and he commented that his wife insisted on it. Legend saw the clothes he wore, heard the accent he spoke with, saw his muscles, and pieced together that he was probably a farmer.
Farmers never came to the hospital.
“We’ll get you back as soon as we can,” he finally said after completing his assessment. Usually, this patient would be low on the acuity scale—a muscle spasm or strain was not nearly as important as a heart attack, pneumonia, sepsis, strokes, traumas—but Legend made him a yellow rather than a green. Just to be sure.
That higher acuity score got him a room far faster. That faster room made a doctor assess him and notice that his left leg was bigger than his right. That doctor made sure he got an ultrasound of his leg, found clots in his leg. She also learned the man was short of breath sometimes, which his wife insisted was new, and got a CT scan.
Legend glanced at his chart later to see him being admitted. Confused and curious, he did some digging.
The man had a pulmonary embolism.
Huffing with a small smile of satisfaction, Legend closed out of the chart as another patient approached.
XXX
Time had to admit, he did not spend as much time assessing his patients as he should. His hours were stolen away in the OR, unpredictable and chaotic as his line of work was. So sometimes he didn’t get to round, sometimes he didn’t have a chance to walk in and chat with the patients and the nurses and the licensed independent providers who took charge of their care.
Today he was glad he did.
The patient was actually calm and pleasant, had little complaint of anything except for some lower back pain. In the world of uncomfortable hospital beds, it wasn’t a huge surprise.
But Time saw something. Some staining, bruising, around the patient’s groin. He peeked around their gown, turned them a little, and saw it.
Their groin was purple. He asked the nurse, who said they were told this had been baseline for a day or two, and that the independent providers over them had acknowledged the finding and moved on.
Time walked into the doc box where the providers were. “I want a CT abdomen for room 3. She’s got some bruising that’s concerning. Her H&H has been down trending steadily.”
“Her JP drains haven’t put out much,” the physician assistant noted, looking over the patient’s chart.
“She might have a retroperitoneal bleed,” Time pointed out. “Let’s just be sure.”
Years of education and even more years of experience had taught the trauma surgeon well. The war was especially humbling and educational. So when he got a text from the PA that the patient did indeed have a retroperitoneal, he wasn’t surprised. But he was disappointed that he had to be the one to notice it.
Sometimes, he supposed, it took the leader to point out the problem.
XXX
Four… didn’t like this.
Report had been bad enough. The day shift nurse spoke of how the patient had been previously septic and was recuperating well before her pressor demand had gone up during the day. She looked… not great. She was so edematous they were constantly changing the sheets underneath her arms because her body was leaking fluid from every inch of itself - they had dumped fluids into her over the last few days just to maintain her blood pressure. She was on a lasix drip to get her lot o pee off the fluid as best as possible, and her kidney function was… decent, but not great.
As Four assessed her, the clenching his chest only worsened. She was alert, oriented, a little miserable but trying to be in good spirits, bless her. She was peeing a decent amount, her pulses were present despite the swelling, her lung sounds were a little coarse but overall mostly clear. Her abdomen was soft and non-tender, her pupils were equal and reactive, and she didn’t have much complaint of pain aside from being sick of laying in bed, which Four could understand.
But still. This just… didn’t look great.
As the night progressed, the woman’s pressor need climbed. Four continued to increase epinephrine, increase norepinephrine. He tried not to increase the vasopressin too much as it had such a profound effect on vasoconstriction that it could cause necrosis. Also, the woman had a history of heart failure and had a pretty weak heart.
Four eventually went to the resident in charge of the patient for the night. “Hey. Can we maybe give 11 some albumin? She has plenty of fluid to give, but clearly it isn’t in her vasculature - she’s peeing ok but her pressure isn’t tolerating it. I feel like it could help.”
The resident shuffled on his feet uncertainly. “The surgeon really wants to make sure we can get this fluid off. I’d rather keep her negative and not give her more fluid, you know?”
“Yeah, I get that,” Four greed before continuing, “But albumin is only 250mL, and if it helps suck in the fluid that’s third spacing, it’ll still help. We’re dumping fluid in her through the pressors anyway.”
The resident continued to waffle, before the night attending asked, “She’s on vaso, right?”
“Yes.”
“Just go up on that.”
Four stared a moment longer, starting to doubt himself. He hadn’t been a nurse for long, and if an attending physician was saying this, then… it had to be true, right?
Sighing, he went back to the room and did as he was told. The patient’s blood pressure improved well enough, and the night progressed fine.
The next night was not as fine. At rounds, Four suggested that perhaps she should be lined for CRRT, a continuous dialysis that would allow for Four to control how much fluid they were pulling and would likely be better for the patient to tolerate. The night doctors shrugged, saying they’d mention it to the day team.
Again, the woman’s blood pressure was tanking. Again, Four had to increase pressors. Vaso had been turned down and was told to be left alone because the woman’s systemic vascular resistance was so high the attending was worried about her heart. (Four couldn’t help but feel a little bitter about it, because he knew that was going to happen)
This time, though, she went into atrial fibrillation as well. As Four called the resident and attending into the room, they deliberated the matter, muttering, “Maybe we should line her for CRRT.”
Four blinked. Stared. Was he… losing his mind?? Was he invisible? He’d suggested this earlier!
Ultimately, Four had managed to keep the patient stable enough so that it wasn’t needed. Ultimately, the shift ended uneventfully.
But when Four came back for his third night, he could hear the woman’s breathing from the door, he could hear how she was drowning in fluid because she couldn’t tolerate losing fluid but had too much for her lungs and heart to handle. The day team had lined her for CRRT, but her pressors were almost maxed out at their dosage, and she was so hypotensive that the renal nurse who had set up the machine was hesitant to start it up, saying it would further bottom out her pressure.
Tonight was different, though. Tonight, the provider in charge of making decisions and orders was a nurse practitioner, someone who was used to this unit. She walked in, saw the issues Four had seen, and she walked right back out, making a call.
Four struggled to keep the patient alive long enough for the ECMO team to arrive as the patient fell apart. He felt frustration boil his blood as he had to hand off her care after fighting for her, had to watch as the CV ICU nurse came in to take over while surgeons put large cannulas into the patient’s body to redirect blood flow around her heart so she could still perfuse her organs. He watched as they wheeled her out of the trauma ICU to go to the cardiac ICU where she would remain while on such extreme support, and he threw his pen on the desk, burying his face in his hands, fuming.
They should have listened to him.
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Okay fine I’ll do it
[rattles you]
Tell me your thoughts on Bishop!!!!!!! I wanna hear!!!
— Trauma
[Is rattled!!]
Oh boy I am so sorry my dear friend but as it happens pushing the Bishop button is even worse than pushing the OC button. I have done extensive historical research for this asshole, and I am totally using this ask as an excuse to infodump about it. God Forgive Me for the length this post is about to be.
Anyway before I get into all that, first the catalyst! The thing that got the part of my brain dedicated to analyzing Agent Bishop turning in the first place: in the post I tagged, you brought up the idea of how much power Bishop actually has, which is something I find super interesting! To me, there are two especially relevant pieces of evidence to consider, and they are as follows:
The first and most compelling to me is that Bishop seems to report directly to the president, which suggests-- as far as I can tell-- that he is pretty high-ranking within the government, or at least takes some priority in getting meetings with important people. It was also shown, briefly, that Bishop worked directly with at least one other president in the past, very early in America's development iirc. However, we know for a fact he does not outrank the president and relies on them for funding, so we can at least draw a hard line there. (There is another discussion to be had from Bishop's relationship to the presidents, which I'll come back around to after this point.)
Second, the level of technology at EPF's disposal. Now, some of it can be said to come from scrapped alien tech and indeed I think some of it is very much implied to be so. But it's clear from the numerous bases, modes of transport and level of defenses that EPF is and has been well-funded. The amount of resources at Bishop's disposal is kinda crazy, and he is also able to fund his own research projects, when the money's not used on the field.
There might also be something to be said of Bishop plausibly being head of EPF for 200 years, and being implied to have founded it. It could suggest a high level of trust and effectiveness, though that's more speculation than evidence. Otherwise, that's mostly why I feel Bishop and EPF do indeed have pretty strong influence within America and its government (wish I could say I had any solid thoughts on his influence outside of the US but tbh what we have suggests he absolutely does not lmao)
As for how Bishop may view the Justice Force, I think your read on it-- him not having much concern because they originate from Earth-- is pretty accurate. Bishop's main priority is protecting Earth from forces outside of it. When it comes to strife within, he doesn't seem too bothered. Despite his greater goals aligning morally good in theory, he very much believes the ends justify the means, and we've seen him dismissive of possibly causing the deaths of innocents because there would be overall long-term benefits. (Which is also why I think an invalid reasoning would be that he leaves JF be because they help people; he doesn't really care about the plight of the individual.)
Them appearing clearly humanoid helps, of course. He is definitely also xenophobic.
On that note, actually! It's also worth noting his interest in the turtles wanes a little after getting their DNA. After that first confrontation most subsequent run-ins with him tend to be the turtles crashing in on an unrelated op. Would he be chill with them getting endorsed by JF, though, that I'm not so sure ghdgdg. There might be a case to be made that vigilantes who regularly screw with government operations should not be getting a JF stamp of approval, and I think he's vindictive enough to press that.
Also on that note I just wish we got to see Bishop's thoughts on those more fantastical parts of the 03 universe more. How much is he aware of the Y'Lyntians and other non-human races native to earth? How aware is he of other dimensions, and did his knowledge and/or protocols change following the events of Turtles Forever? How about time travel and Time Keepers and all that? Given s5 I'm inclined to say he has some awareness of chi, mystics, and/or spirits because he's armed and ready with an arsenal of weapons that are effective against True Shredder's ghost demon army. Things to consider.
Also also! To loop back around on the presidents point: one thing I found really interesting about that is that it suggests the American government has Bishop on record as being alive for 200+ years and counting. So I think it's funny to imagine that after a certain point, every new president has to be sworn to secrecy and let in on the fact that yeah, one of the black ops leaders is functionally immortal, he reports directly to you, have fun.
Anyway those are all the thoughts I had based on that one segment from the radio post ghdvshs I warned you I warned you it's ridiculous
At this juncture I will now be rambling about various other observations, until the event that tumblr forcibly stills my hand:
-Bishop will chameleon into whatever his job requires of him. This is something that became obvious to me (and my captive audience of friends left to suffer my liveblogging my watchthroughs on discord,) after finally learning what the fuck was up with Bishop in Fast Forward. When I originally watched through, I was having trouble reconciling this Bishop with the one I knew and loved, even with the explanation we were given to why he changed his tune. So I posed my issue to The Gang (captive audience) and we stumbled upon a Great Truth on the nature of Agent John Bishop
Bishop, at his core, is fueled by the trauma he experienced when he was abducted so long ago, and it turned into a strong motivation to keep Earth safe so no one would ever have to experience that again (and also revenge. Revenge was a big part of it, too. But I digress.) At the core, Bishop's motivations are morally-good. And here's the other thing about Bishop, he's willing to throw away ANYTHING to achieve his goals. Nothing is sacred, not even human lives. As such, it follows Bishop will become whatever is most needed of him to accomplish his goals, too, including overhauling his behavior. This has likely already taken place numerous times in the "present," given Bishop comes from a different time period and would have to be constantly adapting to modern etiquettes and sensibilities. But this becomes even more likely in the event that he wanted to achieve and maintain an elected position, like the presidency he holds in Fast Forward. And indeed he succeeds, as we hear through Cody that he's extremely well-respected and beloved by the public.
I think it is very likely a majority of the Bishop we see in FF is a well-practiced act to become as personable as possible. He decided the best way to protect Earth was to ally with other planets, and chameleoned himself into the perfect ambassador in order to achieve this. So because his ultimate goal aligns morally-good, he became good in pursuit of it, despite his true nature (which is a sadistic mfer.) I also think it's way funnier to think FF Bishop is constantly surpressing urges to choose violence.
And piggybacking off of that, the other really interesting idea here is that Bishop's ultimate goal will create a world were people like himself will have no place. Bishop is, again, a sadistic fuck, he enjoys inflicting suffering on others. And here he's so effectively created an era of peace that even staged wrestling is considered violent and barbaric. How bored out of his mind must he be on the regular? How must he feel knowing he can never sate those violent tendencies or the world he built will turn on him in a heartbeat? What keeps him working for the same goals regardless?
(I still think the execution was clunky in FF despite how great the ideas behind it are. Are you telling me Bishop isn't internally obsessing over how the fuck the turtles just showed up 100 years in the future looking like teenagers still? You telling me the turtles don't listen to Bishop go 'hey guys I'm good now want to work with me :)' and don't immediately have 20 million alarm bells going off cuz that is DEFINITELY A TRAP and HOW IS BISHOP HERE if he has access to time travel that's REALLY BAD)
-Despite being an antagonist, Bishop almost always succeeds. THIS RIGHT HERE is one of the things I find most fascinating about Bishop as a character. Motherfucker can't stop winning. And it's especially interesting because as an agent in the story he is aligned to nobody but himself; he's just as likely to come into conflict with the turtles as he is to pick a fight with one of their enemies. Sometimes he does both at once!
But like, when it comes to the greater goals Bishop sets out to accomplish his success rate is pretty damn high. The Slayer might be the most overt failure, he got skewered and his creation ran off to live with the rats so rip to that one. But like, he succeeds in getting the turtles' DNA samples, he succeeds in tricking the president into giving him more funding, he's able to blackmail fuckin Oroku Saki, he's able to trick the turtles into doing his dirty work, and so on and so forth. This goes hand-in-hand with his chameleon abilities. He is ruthless, willing to sacrifice anything to win, and he has been shown very capable of thinking outside the box. I think the fact that he's from a different time and lived through so many cultural shifts has a big part in the latter.
Also, this guy takes on 6+v1 odds multiple times and holds his own. Like what the hell. I could go into a whole other thing about his fighting style but this is gonna be long enough as it is-- all I'll say on that point for now is that Splinter is the only character shown to consistently give him trouble in a fight, which has an amazing effect of hyping both of them up.
-Bishop must have some level of medical background. This is mostly just speculation based on the fact that, when we're first introduced to Bishop and he's trying to perform vivisection on the guys, he's the only one in the room. I imagine you don't want to screw up your samples with something like a vivsection? Though I can't say I'm terribly knowledgable on the subject, considering the vested interest he has in actually getting the samples, I doubt he cleared the room without knowing he'd be able to do so. (The other reason is definitely just for his own sadistic thrills, of course.)
-I mentioned before, but Bishop seems to be lenient with scientists, even those not under his employ. Obv he's pretty indulgent with Stockman despite his attitude (at least, as close as Bishop can get to Not Terrible,) and he remains as loyal to keeping Stockman employed as Stockman is willing to stay in EPF. Bishop is also shown to have some level of respect or acknowledgment for both Donny and Leatherhead's intelligence, and iirc he's also seen to have some investment in Dr Chaplin Not Dying in s5.
This also could suggest Bishop is just a good employer in general, which I think would be a funny contrast to how we usually see him portrayed.
-Bishop's current accent is probably not his original one. This has no bearing on anything, but John Bishop was born in 1773 and they did not talk like we do, now. I'm not sure if he would develop a contemporary accent naturally, since he has been alive and actively working with people this entire time, or if this would be something he'd had to have worked to change intentionally.
-After running the math, Bishop was probably about 43 when he stopped aging.
-Who tf is the monster to Bishop?? Seriously this is going to haunt me forever we never get any closure on that and it's the closest we see to Bishop having a personal life or connections outside of just his work. One thing I've extrapolated from this, though, is that he was probably working on a way to reverse whatever transformed that man, and this meant he actually had a bit of a head-start on a formula to reverse mutations when the outbreak happened.
-Despite my opining for more Bishop content, I actually love how ambiguous a lot of his personal information is. It makes him stand out as an audience member, especially before they reveal anything about him and we see this dude just get up and walk off being impaled through the chest. It also just enforces a sense that nobody really knows him. We're only even privy to the fact that he's from the 18th century because it's an opening stinger for an episode, none of the other characters are aware of it. I love that.
-If you ever need some vibes for playing out a scene with Bishop, I cannot recommend the Utopia soundtrack enough. Monarch's Pyramid, To You All Kids Will Come, Meditative Chaos, and Jessica Gets Off are the ones I give the most listens.
-Given how very little we're shown of Bishop outside the context of EPF, I'm partial to thinking he literally never takes a break. Every waking moment he's working, he hasn't had a vacation day in 200 years. That's just a headcanon, though.
-Whenever Bishop appears on-screen, you can usually bet the show is about to dip 20 shades darker. This is initially what got me so invested in him, he's a harbinger for when the show's like Get Fucking Ready.
Anyway. I think about him too much. I intend to rewatch 03 after finishing my binge of 87 and compile even more observations, too, so maybe I'll have even more to say by then, who knows loL. In the meantime please take some extra Bishop doodles from my sketchbook and this moodboard of what my discord ramble box has looked like for the past few months
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