My Dying Coronavirus Patient Was Concerned About Their Hospital Bill

Derrick Smith is a certified registered nurse anesthetist (CRNA) at a New York City hospital, typically covering the operating room. Usually his job involves putting people under anesthesia or sedation before various surgeries and, depending on the procedure, putting them on a ventilator. But recently, he's been working in the emergency room and the intensive care unit (ICU), responding to pages about COVID-19 patients who have trouble breathing and need help from breathing tubes or ventilators.

On Friday, he wrote on Facebook about a patient's "last words [he]’ll never forget." Smith said that, after explaining to a COVID-19 patient that they had to be placed on a ventilator to help them breathe, the gasping patient asked: "who's going to pay for it?" Smith and his colleagues then called the patient's spouse so they could talk for what could be the last time, as many patients don't recover after being intubated, he said.

"This situation is by far the worst thing I’ve witnessed in my collective 12 years of critical care & anesthesia," Smith wrote. "Next-level heartbreak = having to hear a dying patient use his last words to worry about healthcare finances." The post has been shared nearly 6,000 times.

VICE spoke to Smith about that gut-wrenching moment, and what it's like to treat a viral pandemic in a country that doesn't guarantee healthcare to all.

This conversation has been lightly edited for length and clarity.

How has your job changed in the past few weeks?
Since the crisis hit, initially we went from elective cases to only urgent or emergent cases, which was a statewide order. As of about a week and a half ago, our roles have shifted to where we now cover one of two sites: We actually function in an emergency department, which is somewhere I've never worked before so it's quite a new experience, and also an ICU consult, where we respond to any sort of emergency or code all throughout the hospital.

The patient you wrote about putting on a ventilator, the one who asked "who's going to pay for it?"—had you seen that patient before?
No, this was our first meeting.

Can you describe that moment?
This particular patient, we just quickly assessed them, saw the vital signs, it was someone who definitely required imminent intubation.

A lot of these patients present the same, they're usually pretty out of it at this point, and by that I mean, it's not easy to talk after you've spent X amount of time with difficulty breathing—you're just exhausted. I guess that's why it was even more remarkable that one of his first responses was in reference to healthcare finances.

Were you able to answer the question of who's going to pay for it in the moment or were you focused on letting them talk to their partner before the tube went in?
Focused on letting them talk to the partner. And I have to say, for me, it was especially jarring because I'm a clinician…you can look at the chart and you can see the patient's insurance information but that's something none of us in my position usually even look at. We kind of have the privilege of not even wanting to get into anyone's finances. When they asked that question I just diverted back to getting their partner on the phone so they could have some last words with her.

What was it like hearing them ask that question?
My first thought was this is someone who's possibly the head of their household, and they're not necessarily just worrying about their own finances but their ability to take care of themselves and, by extension, their family.

What made you decide to post about it online?
It's the most succinct and unfortunate representation of what's going on with our healthcare system. It's completely abhorrent that this question should even come up for a patient who's facing possible death. I think that speaks for itself.

Let's extend it in a variety of ways: We're not prepared. We haven't been prepared. It's gross negligence on a lot of levels, from federal to state and so forth. That extends from just ventilator availability, to mask availability, and so on. It's a fundamental, systemic [problem] that's gotten us to where we are right now.

You also wrote that once someone is intubated, they're not going to speak again until the tube comes out. There has been a lot of coverage of how, because of isolation rules, people very sick with COVID-19 are dying alone. But it feels like there isn't much discussion about how people on ventilators can't even talk to their families by phone or video chat. Do you think the general public understands that?
I don't think that they do. And I think that's what's unfortunate about, obviously we have wall-to-wall, 24/7 coverage on a lot of mainstream media networks, but the focus seems to be on the things that aren't most important. I think that speaks to why a lot of people don't even observe the physical or social distancing parameters.

I've been in critical care for about 12 years now and I've never seen, number one, a disease that's had such an impact. It affects almost every organ system so people are getting very sick very quickly. On top of that, again, the dying alone aspect, which is something I'm not quite used to. We abolished our visitor policy for all our safety, which is unfortunate but it's necessary. Even in the ICU setting [where I worked as a registered nurse for about five years], you at least could have visitors.

And even beyond that, any sort of grieving process afterward. We can't do organized funerals. And there are freezer trailers, tractor trailers, at certain hospitals because we've run out of morgue space. That is a whole other level of a new thing that we're trying to adapt to and get used to.

How are you adapting and getting used to it?
You just do what you can. Try to remain positive despite what's going on and just work to our capacity. On one hand, I definitely appreciate my job and what I'm able to do because as sad and as terrible as it was—I was emotionally hit after that particular shift with this patient, more than I think I've ever been—but despite that, I do definitely feel like I have a purpose when I have to get up and take the subway to my job. I live the purpose and I actually appreciate that in some strange way. Trying to get some sort of silver lining out of what's going on.

As someone who has to take the subway to their essential job, what are your thoughts on the people you mentioned who aren't following the social distancing guidelines?
It's strange, I try not to be too judgmental or scolding because, to be frank with you, we have a number of people who aren't able to adhere to that and that includes our unhoused population, our incarcerated population, our immigration detention system population. So I kind of try to stay away from any sort of chastising—even just for the "regular" person who has a house.

Instead of telling people "don't do this," I would be more interested in highlighting what's happening to these people [who get very sick], because maybe they'll take it a little bit more seriously when they see the fact that people are possibly having to die alone.

Your post has really gone viral. Have you written anything about your job before that has gotten shared so much?
No, this definitely reached a level that I didn't really anticipate. It's quite a rough topic obviously and it's been mostly overwhelming support. If anything, this pandemic has shined a really bright light on a lot of the inequities and the problems that have been systemic to our country and many countries. That includes the fact that we have more of a tertiary care system in our population. We don't really do public health and proactive efforts—people show up to ERs in the most critical stages of acute disease as opposed to a more primary [care] method.

With healthcare itself, I believe the Trump administration is working on something to cover COVID-related costs but [regarding] this patient in particular, it almost disincentivizes people from seeking care, which could also further contribute to the pandemic. People aren't going to want to come in until they're at the stage that this patient was. It's a negative feedback loop in a way.

Right, if more people had health insurance they wouldn't be as scared about getting care from a cost perspective.
Right. And an analysis just showed it's likely that insurance premiums could increase up to 40 percent next year. Not to mention, a lot of people just lost their jobs and lost their associated health insurance. It's just a multi-tiered problem.

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