The COVID pandemic has taken a toll on everyone, including health professionals. We take a look at what we have learned over the past two years. In this episode, Alaina Rajagopal features Dr. Daryn Towle, a Southern California native and emergency medicine physician. We reflect on the pandemic and how her life has changed as an ER doctor over the last two years. We also discuss some of the science behind why vaccines are important, the Omicron variant, and how to stay safe over the holidays.
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COVID Reflections With Dr. Daryn Towle
In this episode, we’re talking to Dr. Daryn Towle. She is an LA native and was born and raised in Santa Monica, California. She graduated from Georgetown University with a degree in Biology and Public Health. She continued her studies at Georgetown School of Medicine before returning to California to attend UC Irvine Medical Center for residency training. She was selected as Chief Resident in her final year and won an award for Excellence in Pediatric Emergency Medicine. She enjoys skiing, wine tasting, and running in her spare time. Welcome, Dr. Towle.
Thanks. It’s a pleasure to be here.
It’s nice to have you. Tell me a little bit about your background. You grew up in this area so tell me about your childhood.
I grew up in Santa Monica, which is in West LA. I am 1 of 3 girls. I’m the middle daughter. I ended up going to an all-girls high school and then Georgetown for college. Eventually, I came back to Los Angeles. I lived with my parents for a year, which most Millennials do anyway. I was trying to figure out what I wanted to do. I got back into Georgetown and knew I loved it for undergrad, so I went back to med school. I came back because I love California and you can’t beat the weather. Here I am now. I am the only physician in my family. There is nobody in science and medicine. It is lawyers and business people. Nobody in our family is telling us how to do or what to do.
I feel like most of the advice is bad advice too, where they are like, “You don’t have to do that internship.” I’m like, “I’m pretty sure I was supposed to do that.” They are like, “Take the day off. Take the summer off.” I’m like, “I don’t think we’re having the same conversation.”
I had to reflect on one, “Are you sure you have to wake up at 7:00 AM every day for four weeks?”
You study until 2:00 in the morning. It was intense.
That’s me in a brief moment.
When did you know that you wanted to be a doctor? What inspired you to become a doctor?
As physicians, we are the worst patients.
There are two things when I think about how and when I want to become a doctor. The first is the first time I got hurt, which was when I was in fifth grade. I was playing soccer and I broke my arm. It was terrible. My arm was crooked. We ended up in an ER. I will never forget the ER doctor setting my arm. I had no pain. That was the first time I was like, “This is a cool job.” It felt so magical. It was the first time that I had been in a hospital setting.
That’s when I knew that I wanted to be a doctor. You say that when you are young. You are very little to go off of. As I got older, there wasn’t anything in particular that pushed me towards medicine. It was a couple of people who pushed me towards medicine. It was two of my doctors growing up, my pediatrician and my OB-GYN. My pediatrician was Dr. Lawson. He was the funniest guy. He always had tricks up his sleeve. He made you laugh and feel comfortable. He didn’t say anything that ever made you not want to come back.
I loved going to the pediatrician, which is so rare for kids. Everyone who went to Dr. Lawson loved him. He exposed me to how fun and nice the medical world could be. My OB-GYN was someone who I started going to 15 or 16. She is one of the most kind-hearted people and embodies what a physician is, where she cares about the whole person, body, mind, and everything. I thought to myself, “I want to be like her. I’m going to be a doctor.”
I love that you had multiple doctors growing up that helped influence your life that much. I often forget that we have the potential to have those interactions and make that impact on kids. That’s a cool story. Once you decided you wanted to go into medicine, how did you end up in Emergency Medicine?
Like every other medical student, I’m going down the list. You are a little bit in awe of the blingy specialties, plastics and orthopedics. I was interested in those kinds of things, but what I loved about emergencies was that you always were able to do something. A person comes in, they got a broken arm like when I was in fifth grade. I can do something about it. I can reduce and splint it. They are okay. When someone comes in with a heart attack, I can start heparin, give them nitro, get them to the cath lab and do something.
I will never forget, there was this one time when I was in medical school, they asked for a doctor on board, and there was a dermatologist. The nicest person is a fish out of water. I was like, “I want to be the person that if they call for a physician, I know what to do.” In EM, there is a saying, “The jack of all trades, master of none.” The master of none part is silly because we are masters of doing things. We are bringing people back to life, fixing things immediately, and resuscitating. That is what pushed me to Emergency Medicine. I love procedures. That is always fun. I love seeing all walks of life. If I only see kids, adults, or pregnant women, based on my personality, I would get bored.
That reminded me of one of the first thoughts that I had about getting into medicine that I hadn’t thought about in forever. I remember that feeling of not being able to do something in a medical situation. I was studying abroad in Kenya and seeing patients in an HIV clinic. I felt like, as a student taking blood pressure, I couldn’t do anything. I wanted to be able to help and make a difference.
It came back to me at this moment. It’s one of the first things where I started thinking, “Medicine might be an interesting field to pursue.” A great thing about Emergency Medicine is there is almost any situation where we can figure out something to do, even if it means following a referral. We can, in most situations, figure out what needs to be done next. I love that about Emergency Medicine.
I love to be surrounded by Emergency Medicine Physicians, too, because I’m like, “If something goes wrong, one of us will be able to figure it out.”
I remember it was my first rotation in residency. Some of the Internal Medicine residents I was working with said, “Are you an Emergency Medicine resident?” I was like, “Yes.” They were like, “Do you drive a Jeep?” It’s the impression that all Emergency Medicine Physicians drive a Jeep. I was like, “Not now but I used to have one.” It’s a stereotype outfit right there. Do you have one favorite thing about Emergency Medicine or one thing that you love about it the most?
I already touched on this. It’s the variety, seeing all walks of life and then also the procedures. One of my favorite things is the central line. I love putting a central line. Something about it is satisfying.
I feel similarly. Doing a central line feels like you are doing something like helping.
If I have a patient who needs three different pressors and antibiotics and you’re running out of access, you put that central line, and you’re a hero. It was so good.
Do you have a least favorite thing about Emergency Medicine?
I’ll talk a little bit about where I work so that you can understand where I’m coming from. My first least favorite is the consultants. Sometimes, you get consultants who are straight-up mean, which I don’t blame them because you are calling them in the middle of the night about something. They don’t think it is that important but we understand how important it is. You’ve got the patient right in front of you. The consultant is in bed or wherever they are. Sometimes, they are nice but most of the time, they are not, and they don’t understand where we’re coming from, which is one of the more frustrating parts of the job.
My second least favorite part is one of the hospitals that I work at. That’s a community hospital. They don’t have that many specialties in-house, but they have a couple of sister hospitals that they can transfer to. Part of the transfer process is going through insurance and trying to figure out which insurance is covered at which hospital and how to transfer the patients. It becomes phone call after phone call to get a physician to get insurance to accept it.
To even find a physician who accepts it on the other side, all of those things combined and rolled up into one end up spending hours trying to transfer a patient who has an open jaw fracture. They are like, “They can’t stay here.” That is a pretty frustrating part. We understand the urgency as ER Physicians because we were sitting and looking at the patient. We know all the things that could go wrong if we don’t get them the right care, but the urgency doesn’t exist on the other side because it’s a lot more business and protocol-driven.
I hear that from people a lot, and I completely agree. It can be so difficult dealing with some of the more bureaucratic aspects of what we do. A lot of times, we will spend 5 or 10 minutes with a patient, and then 1.5 hours making phone calls on behalf of that patient. You walk in, see them again, and then they are like, “Why has it been so long since you have seen me, doc?” It’s like, “I have been on the phone with about 400 people trying to figure out what we need to do for your case.” I wish that something that patients could understand and see is how much time we are spending on trying to get them the right care. That is not always apparent.
If we are all vaccinated, we will prevent further mutations from happening because we couldn't spread the virus, and it couldn't change its gene sequence and become more transmissible and more severe.
Half the time, you spend all of that energy trying to do the right thing for the patient, finding the right consultant and the right place for them. They are mad because they have been sitting there for four hours and decide to leave against medical advice.
Do you have a memorable case that you can discuss anonymously that might have a good teaching point?
I have a pretty good case. This was, at the very beginning, when we were attending. It’s maybe 4 or 5 months after graduating from residency. I had a patient who came in with chest pain radiating to his back with a history of hypertension, diabetes, and a kidney transplant. Any emergency physician who hears chest pain radiating to the back gets concerned about a dissection. I think to myself, “Maybe it is a dissection but they are so rare. In residency, I saw one. Let’s get some blood work and an X-ray.” I got some blood work. It generally looks okay but this guy has got a kidney transplant. His creatinine was 2.7. The baseline was 1.5, so it’s going up.
For the readers, that is an indication that kidney function could be worsening. Sometimes, it can be a kidney injury or indicative of kidney failure. That is what Dr. Towle was looking at and saying, “Maybe something is going on here.”
I got his chest X-ray and looked at it. In the middle of the chest X-ray is an area we call the mediastinum that we look at. His mediastinum is a little bit wide, which any emergency physician gets a little bit concerned about talking about an aneurysm or dissection, which is badness in the chest. I think, “I need to scan this guy with a CT scan, but he has got a transplanted kidney and his kidney function is not good.” I decided I was going to scan him without any contrast to get a good indication of what was going on. In my head, “If it’s that bad, I’ll see it on a non-contrast CT scan.”
I got the non-contrast CT. The radiologist called me and said, “Can you do a contrast CT because I’m concerned about aneurysm and dissection?” I said, “Doc, I would love to get a contrast CT but I’m in a predicament. This guy has a transplanted kidney. If we give him the IV contrast, we might knock out his kidney.” Contrast-induced nephropathy is a whole other conversation, but in this case, it is a concern. He said, “Get a STAT echo.” I said, “I need to know if you are concerned enough. Do I need to be calling the CT surgeon?” He said, “I don’t know.”
I got a STAT echo, which was pretty unbelievable. I had an echo tech come into the ER. It was 9:00 PM. They did an echo and it showed concern for a flap, which meant that there was a concern for dissection. I called our CT surgeon at the hospital, and he said, “We don’t do aneurysms and dissections here. You have to transfer this patient out.” I said, “Okay.” I called another local hospital. They said, “This person is on-call. Call that person.” They said, “Just kidding. We are not on-call.” The local hospital didn’t have anyone for CT surgery on-call.
I called another hospital. They looked at the imaging with me. They said, “I’m not sure it is a dissection. You need to get IV contrast.” I gave them the whole issue of, “This is a transplanted kidney.” They said, “It’s either the kidney or the heart.” I said, “Can you help me out here a little bit? We have got the echo.” They said, “Even if it was a dissection, it’s too complicated for me. We can’t even accept him.” Finally, I called my third hospital and got ahold of a CT surgeon who agreed to accept him without IV contrast. With the Echo images and the CT images, he looked at both of them and said, “It’s pretty complicated but I can take care of this guy. Let’s get him transferred over there.”
I got the whole transfer process started. This is going back to my least favorite part of Emergency Medicine. His insurance denied the transfer. I’m not even kidding you. They called and said, “We’re sorry. We’re declining the transfer because we should have been your first call.” That made me very upset. This was five hours after my shift had ended, too, because I was so wrapped up in this case. It ended up working out where I talked to a bunch of people at the insurance company and I got them to okay the transfer process for this guy.
He ended up having a dissection. It was a Type A. He needed a repair. Unfortunately, he lost his kidneys even though he didn’t get the IV contrast. It’s poor perfusion. These cases never go well in the long run. There is a lot of hypoperfusion to the spinal cord, kidneys, gut, and those kinds of things. It is pretty common for them not to do that well after. He was on the list for a transplanted kidney again but he was doing well two months post-op getting dialysis.
With all things considered, that’s a pretty good outcome. When we were talking about aortic dissection, it means that when some layers of the aorta, which is that blood vessel that is the main blood vessel coming out of the heart, separate and impedes the flow of blood. That can lead to decreased blood flow to other parts of the body. When we say poor perfusion, we mean there is not enough blood getting to some of the other organs like the kidneys. That is why the kidneys failed.
That was a very memorable case for a couple of reasons. 1.) When your spidey senses go off in Emergency Medicine and someone says chest pain radiating to the back, you take it seriously. 2.) My learning point is sometimes, as an Emergency Physician, you are going to have to choose one organ system over the other. It is prioritizing. In my head, I didn’t want this guy to lose his kidney because I didn’t want to be responsible for giving him contrast or doing whatever.
At the same time, I knew something had to be done because if he lost his aorta, that would be a bigger deal. I felt like that was a huge learning point for me at the beginning of being an attending and figuring out every procedure. The scan and lab you do is a risk-benefit. Trying to figure out the least amount of risk with the most amount of benefit is something that you will only learn with time.
We face these challenges fairly regularly in the emergency department. Often, I’ll try to talk to the patients about it if it’s not an immediate life-threatening situation and say, “These are the risks and benefits. Do you have a preference on what choice we make?” In the era of COVID, there has been even more of that risk versus benefit decision-making. What has been the most difficult thing for you as a Physician during the pandemic, speaking of COVID?
COVID was and still is something that has contributed to my emotional exhaustion and burnout. That has been the most difficult thing for me. Part of the emotional exhaustion and burnout was mostly because we were surrounded by so much unknown and so many deaths. As ER Physicians, I don’t want to say we were used to death, but we know how to handle it. We can handle loss much better than other people can, but we’re not trained to handle mass casualty loss.
I’m not saying that COVID came in as a mass casualty, but at certain points in the pandemic, it felt like that, especially when we were at least in Los Angeles in our surges when we had so many patients that we weren’t accepting EMS transfers for cardiac arrest patients. That is something that haunts me because the amount of times that I had to call a death over the radio because they couldn’t transfer the cardiac arrest patient is not ideal. Why did I go into this? I went into this because I always want to be able to do something. For the first time in years, you feel hopeless and helpless.
You hit the key point by saying helpless. Most Emergency Medicine Physicians and doctors in general don’t like to feel helpless. We went into medicine so that we could make a difference. When there’s that much mortality, morbidity and so much that is out of your control, you feel helpless, and that affects mental health often.
I would be lying if I said my mental health was super strong for the entire pandemic. What people don’t understand, or at least they think they may understand firsthand, is the emotional toll that that took on us. We were seen as soldiers. We should be able to continue our job, keep going and march on, but you can’t when you feel like you’re overrun.
If you're having a gathering, just make sure that everyone knows and understands the risks and make sure that everyone's on the same page.
There are a lot of times where I remember losing a patient and then you have been in a room with that patient trying to save them for over an hour in most cases. The second you call that patient or lose that patient, you have to turn around and run back to all of your other patients immediately because you haven’t been able to do anything for them in the entire time you were in the room with that patient.
You have all of these other patients who are angry with you because you haven’t done anything for them over the last hour. There is no time to process mentally and emotionally the loss of the patient that you had. Any one of us can handle that every once in a while, but when it’s happening multiple times a shift or when the frequency of that happening is so much, you never have the time to process and it takes a toll.
We have all been pushing the ability to process and it has come to a breaking point. You will see it in hospitals where it is not just Physicians. It’s all staff. We have pushed it aside and kept going because we don’t have time to process it. People are getting to the point where they are so burned out. They are running on fumes emotionally that people are leaving. They are either taking a medical leave of absence or completely changing careers, which is terrible and sad.
Especially after everything that you have to go through to become a Physician, leaving the field is not something anyone takes lightly. The fact that so many people are leaving suggests that we need to do more to look at mental health and how to better help all clinicians cope.
Part of being a Physician is we feel like we always know what is right. As Physicians, we are the worst patients. You can say to yourself, “I’m anxious and sad. I have a lot on my plate but I’m not suicidal and homicidal. I’m not having auditory and visual hallucinations. Therefore, I don’t need to get professional help just yet.” We know what to look for so we can reason our way on it.
We often view everything through the lens of, “Is this admittable? No, then I don’t need any medical help.” The lens of the Emergency Medicine Physician is so different than many people. What do you think has been the most difficult thing for your patients during the pandemic?
What I have noticed is access to care. In the beginning, all the offices were closed. Nobody was getting the preventative care they needed. They were not getting the medication refills, blood glucose checks, and blood pressure checks. Offices were starting to open, but people were still too scared to go to the doctor. I feel like it swung even more the other way where people are backlogged in primary care that people are not able to get in. They are saying, “I can’t get an appointment for three months.” They become complacent. That access to care has been a huge detriment to all patients.
I had one woman who had a ventral hernia that popped out at the beginning of COVID. She never saw a Physician for it. It had never been reduced, which meant that she had never pushed the hernia back in. It became strangulated, which means that it loses its blood flow and becomes a surgical emergency. I think to myself, “If she had gone to her Physician at the beginning of COVID with the ventral hernia that was causing symptoms, she could have gotten a preventative surgery and prevented that from happening, but it did not happen.”
I have seen a couple of cases of cancer as well where people were like, “I didn’t want to get checked because I was worried about COVID. I couldn’t get an appointment,” or any number of reasons. By the time I see them, they are experiencing significant symptoms, and the disease has advanced a lot more than it would have if they had gone early, which was their initial inclination. That is hard to deal with sometimes when you see those cases, and you were like, “I wish I had been there sooner. I wish there was more I could have done.”
It is back to that feeling of always wanting to be able to do something.
What is one thing you wish everyone knew about COVID-19?
One thing I wish everyone knew about COVID is the emotional rollercoaster that it has taken on all Physicians. We went from being heroes to people who were clapping outside their windows and cheering for us at 8:00 PM to severe turmoil and anguish at work and trying to figure out how to handle all these patients, to then dealing with anger from the community about how we were handling the pandemic and vaccines to burn out. You can imagine that anybody who has gone through all of those emotions was not going to be at our best.
Something that I have struggled with is the anger sometimes toward the medical community and science. It’s hard for me to understand and process. It has caused a lot of stress and concern even with this show, where I’m trying to get reliable medical information out there to combat some of the misinformation that has been. It seems like it’s growing over the years. It has taken some intestinal fortitude to push through some of the anger and negative emotions sometimes. What is one thing you wish you had known earlier in the pandemic?
One is probably every ER Physician is going to say the same thing, “I wish we knew how to treat it earlier.” It’s not necessarily the monoclonal antibodies, inhaled budesonide, and corticosteroids. It’s more the simple act of when and when not to intubate. We were intubating hypoxic patients as soon as they hit the door because we thought that that was right.
I will never forget looking at these patients thinking, “They are talking to me. They don’t look great but they don’t look like they are on death’s doorstep with low oxygen to 70%, but I am supposed to intubate them, so that’s what I do.” One thing that I wish we had known earlier was that we weren’t supposed to intubate them because that would have taken out a lot of anxiety, in the beginning, knowing that supplemental oxygen with the nasal cannula and BiPAP machine was good enough.
We have pushed away from BiPAP for a while because of the concern for aerosols. One of my biggest regrets is I wish, as a medical community, we could have maintained the use of BiPAP earlier for these patients. Unless somebody is imminently going into a respiratory arrest or something, we were intubating too early on in the pandemic. BiPAP would have been a great way to avoid that in a lot of patients, but we were very worried about the aerosols and probably rightly so. It does generate aerosols.
That goes back to our risk-versus-benefit conversation where you are trying to balance all of these risks and benefits for the patients, nurses, X-ray techs, Physicians, and everybody in the hospital as well as the other patients next door. It is difficult to know what the right choice is. In a lot of those cases, there is not necessarily a right choice. It’s a learn.
We were doing the best we could with the information we had. It is frustrating and hindsight is always 2020, but it is something I always think about. When I see a hypoxic patient and put them on BiPAP, I think, “Years ago, I would have intubated this patient.”
If you have any friends who are in healthcare, make sure you give them a hug. They need it. They deserve it.
It’s funny too because I look at my O2 sets when I climb mountains and there are some times where I’m like, “I’m at a nice 70%. If I saw myself in the ER, I would intubate myself, but I’m fine.” It’s funny how perspective changes sometimes. What is one lesson you think we can take from this pandemic to prepare for future outbreaks and pandemics?
The lesson that I would like everyone to learn is that early vaccination rates are the best thing to prevent the spread of any disease. We can look at history, polio, and measles and say the same thing about those vaccines. Early vaccination would prevent the spread, which would cause further mutations of the virus that would then cause new variants of interest and variants of concern. I wish that people will learn for the future that, in years when there is another pandemic, there is one way out of it. If you do it right, it will work.
Is that one way being vaccination?
Yes. It’s not mass casualty but vaccination.
We were doing this episode on December 2nd, 2021. The Omicron variant has been a topic of conversation and a variant of concern. We don’t know a lot about Omicron yet, but scientists all over the world are working on that. Let’s talk a little bit about what Omicron is and how herd immunity will help prevent future variants. You talked about this, but I want to make sure that we were clear.
Let’s talk about the variants. Everyone was aware of Delta being the major variant of concern. Let’s define a variant of interest and variant of concern. When there is a virus, it has a certain sequence. When some of the genes change, it becomes a variant of that virus. When the genes change, it could go one way or the other. It could become more severe, more transmissible or completely fail. With variants of interest, that means we have identified that there have been variations in the virus that we are looking at. When we have a variant of concern, what we see are true mutations in that virus that are making it so that it concerns for higher transmission rates or increased severity of the disease.
With Delta, we knew that it was more highly transmissible than our original SARS-COV-2. With Omicron, we don’t have the information just yet as to the transmissibility and severity. What we do know with the little info is that it seems to be spreading rapidly. One thing that seems to be coming out of South Africa is that despite it being highly transmissible, the vaccines still do seem to be working to protect us against severe disease hospitalizations, ICU stay, and death. Using these vaccines, if we are all vaccinated, we will prevent further mutations from happening because we couldn’t spread the virus. It couldn’t change its gene sequence, become more transmissible and severe.
That is one thing that I want to emphasize because the mutations only happen when the virus can replicate. If we stop the virus from replicating by stopping the virus from infecting new people, then those mutations can never happen. The more people who are vaccinated, the less spread there is, the less reproduction of the virus, and the less chance of mutation happens. Therefore, the pandemic ends, and we can go back to the old normal.
There is still a lot for us to learn with the Delta variant as well. If we can emphasize one thing, it is vaccines do work. Despite having these mutations, the vaccines are still saving people. We, as a society, can move forward if we all get vaccinated.
We are right in the middle of the holidays. Do you have any advice on how people can stay safe over the holidays with family gatherings again?
Taking a page out of our books from 2020 would be a good idea for everybody. We know that masking works, but purely being outside is helpful as well. If you have family members that you are concerned about that are not vaccinated, I would recommend that they get vaccinated. If you have family members who are vaccinated but are immunocompromised, such as cancer patients, people who are undergoing chemotherapy, severe diabetes, pregnancy, and those kinds of things, I would highly recommend that you get tested before you see your friends and family that you are concerned about. You can do antigen tests, which are not as sensitive as PCR tests, but they are helpful to know whether or not you are going to be contagious at that time. These at-home tests are widely available. It is not 100% but it is better than nothing.
I love using them. There is a lot of peace of mind that you can gain from having a quick test. If you are having symptoms, you should back that up with a PCR test.
If you are having symptoms, it is okay to sit out at a family dinner and stay away. Wear your mask and be outside. There is nothing wrong with that.
If you are feeling sick and there is any concern for COVID, the recommendation at this time is to not go to those family gatherings and not be around other people for sure. I love all of the advice that you had in continuing to wear masks and gathering outside if possible. We live in Southern California, so it is easy for us to say that. It is not so easy for some other people in the rest of the country. If you can, outside is always safest, and then doing the pretesting and the post-testing if you do have a family gathering.
One other thing is you don’t want to be responsible for a super-spreader event. If you are having a gathering, make sure that everyone knows and understands the risks and everyone is on the same page.
Thank you so much for all of that wonderful advice and for sharing all of your experiences. Do you have any final thoughts or advice before we wrap this up?
My final thought is if you have any friends who are in healthcare, make sure you hug them. It has been tough years. Make sure you have your mask on. Give someone that you know who is in healthcare a big hug. They need and deserve it.
I’m sending a hug to you. That is it for this episode. If you like what you read, please give us a five-star rating, subscribe or send this episode to someone you know who might enjoy it. Feel free to connect with us on our website, TheEmergencyDocs.com or Instagram, @TheEmergencyDocs. Until next time.
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About Daryn Towle
Dr. Towle is an LA native, born and raised in Santa Monica, CA. She graduated from Georgetown University with a degree in Biology of PUblic Health. She continued her studies at Georgetown University School of Medicine before returning to California to attend UC Irvine Medical Center for residency training. She was selected as Chief Resident in her final year and won an award for excellence in Pediatric Emergency Medicine. She enjoys skiing, wine tasting and running in her spare time.