Category: Medical

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Medical

Day 845 and Fucked Fertility

A bit of discourse stirred up a lot of grief and sadness for me. Noah Smith did an analysis of the much discussed Atlantic piece “The Myth of the Broke Millennial.” His breakdown is excellent and I recommend the Twitter thread where several of my geriatric millennial friends weigh in on how late in life security has come for many of us and how precarious it still feels.

What jumped out at me most in Noah’s breakdown is whether millennials will feel financially secure enough to have kids if it’s indeed true that we are getting less precarious.

That matters as a question as having children appears to be a driving force towards conservative politics but also a general preference for less government involvement. Noah wondered if millennials will be less woke and less inclined to socialism if we don’t turn out to be downwardly mobile. The theory is we might be if, and it’s a big if, we feel secure enough to have children.

There is one age-related factor that appears to draw people to the right, however: having children. Fertility rates are down, and Twenge discusses some reasons for this in her article. But what really matters for politics is probably not the number of kids that get born, but the number of people who end up having any kids at all.

I’ve got bad news on this front as the first wave of elder millennials who haven’t already had kids probably can’t. Why? Our women are aging out of fertility before they find the security they feel they need to consider having kids.

By the time millennial women get to a place where it seems feasible we’ve long entered “geriatric pregnancy” territory. I froze my eggs right before it was considered a geriatric situation. Which is give or take 31-32 now as we redefine fertility. I am now 39.

Now that’s a longer story for me personally as freezing my eggs felt like a consumer decision, was marketed as insurance policy, and ended up being a life changing catastrophe. And I still don’t have kids.

The process of egg extraction triggered an inflammatory disease and I may never be able to carry to term. And I have complicated grief stricken emotions about the entire affair. And we spent a small fortune getting me healthy enough to go back work.

But my suspicion is that many millennials will learn that fertility isn’t as easy as they imagine if they try to deal with it past 35 let alone past 40.

And we simply cannot seem to discuss the issue in a way that is productive. The discourse is toxic as cultural warriors, often men weigh in with their complex emotions about what it means to have a family, support children and generally deal with women’s health.

Shaming and controlling women’s bodies doesn’t really do much for the cold hard reality that we failed many millennial women by assuring technology could solve for the hard questions on fertility. So we marketed these new medical options and sold it at premium. Silicon Valley mounted a whole campaign to freeze eggs for its female workforce.

I’m afraid we are too deeply entrenched in a culture war to discus this productively as most of the people I see with the message that fertility is complex tend to view things in a more traditional context.

I personally love playing a tradwife on Twitter because I’ve learned a lot about how reactionary feminists and baroque online misogyny views motherhood. They talk to me and I’ve listened.

But we need to get women of all politics and preferences and family structures involved in this conversation as a full decade of millennial women are going to need to consider their relationship to their own fertility and bodies in short order. And for many of us it’s too late.

Treatments like IVF and egg freezing & extraction are expensive and have considerably more risk than we are comfortable discussing. Surrogates are a quarter of a million dollar expense which disgustingly is for bureaucratic costs not the surrogate herself. If you want multiple children it’s not crazy to plan for a million dollars. And don’t get me started on how adoption plays into all of this.

A generation of fucked fertility with myriad corporate profit motives driving decision making sounds like the stuff of conspiracy and cranks but don’t be fooled by extremism. We’ve done a shitty job investing in women’s healthcare in America and it will have consequences.

I know it’s scary to look at head on. I regularly break down with my own grief on the matter. I’ve been looking at it for years. Having a serious health crisis brought on by family planning has been a blessing to my marriage but that blessing has enormous costs. I’d expect this process of addressing the fertility of a generation of women to be challenging for us all no matter your personal choices or politics.

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Medical

Day 836 and Medical Care & AI

I had a little bit of excitement in New York City when I encountered some type of gastrointestinal issue. We’d speculated it was food poisoning or norovirus with our doctor.

After getting it out of my system and speeding back to Montana; we’ve been pouring over the symptoms, timing, biometrics and medicines to see if we missed anything. It felt like an opportunity.

We had three doctors retire on us this year and after two years of rising premiums, we are naturally skittish about health care. Pandemic telehealth reimbursement being sunset is a hit to rural care as is the other policy roll backs as the of emergency winds down. Reciprocal licensing across all states sure seemed like it should have been a keeper. But alas American health care is a mess.

Thankfully we’ve got a doctor local to us in Montana who we’ve been slowly building up a relationship with over our first year here. After his star turn in this gastrointestinal saga, I am ready for a round of blood work and a look at the big picture with him.

We’ve even been dabbling in a few theories with our Large Language Model friends. While ChatGPT goes to a lot of trouble not to diagnose, we’ve been able to run down some leads on our own and bounce them off our doctor. I’m looking forward to getting a look at my liver panels and gallbladder. Maybe tweaking some of the pharmaceutical line up.

While it may seem a bit grim, I’m considering that with enough questions asked and enough clever inferences on our behalf from our new AI friends, maybe we can get further. Sure we are down 3 doctors and up 30% cost wise, but maybe these plucky kids can make do with a chatbot, a young doctor and a can do attitude.

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Medical

Day 834 and Inside Out

I had a really rough night last night. It’s entirely possible my original theory of industrial lettuce wasn’t the whole picture.

For a little timeline clarification. Yesterday, I woke up with stomach troubles after eating agribusiness salad chain for dinner on Wednesday. I had meetings on Thursday so I took some varied drug store tummy medicines and gutted it out. I even had a very fun time at my meetings. But then as the adrenaline of the day wained I was heading towards disaster. The nausea and had was getting worse.

I realized I couldn’t attended a dinner with some old friends but Alex was fine. I told him to pick up some Tums on the way home. As his dinner wore on my symptoms got worse and worse.

I felt like I was beach ball ready to pop. My stomach was distended so far I felt like I had back problems my stomach pushed out so far. I was tight Mike a drum. The pain and nausea consumed my focus. Around 7:30 or so I called Alex saying I needed a doctor or a visit to urgent care. I couldn’t tolerate it any longer.

Blessedly our doctor in Montana called back almost immediately. He had just personally had a case of stomach flu or norovirus himself and mentioned it was trending up nationwide. At that point I was mostly moaning and curled into a ball from the nausea and gas. He prescribed an antispasmodic called dicyclomine. It helps calm stomach cramping.

I had an hour of crying and praying waiting for it to kick in. I’m sure I scared the shit out of the other hotel guests with the moaning and crying. I was begging Alex to please fix it. To find something else I could take. To do literally anything to relieve me of this horror. Thankfully around 930pm or so it kicked in fully. How do I know?

I was able to vomit. A lot. Seven times over the course of half an hour. And then I was fine. My stomach deflated down to a normal size. The nausea abated. The pain and cramping subsided. Four hours of intense misery has passed with a drug that turned me inside out.

I spent all of Friday in bed sleeping it off. I missed all my meetings and couldn’t eat anything till dinner time came around. I’m having some soup and I suspect I’ll simply pass out. New York is an inside out kind of place sometimes and I’ll just have to live with it.

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Medical Travel

Day 833 and Industrial Romaine

I packed my day a little too full so I found myself ordering a salad from popular New York industrial salad chain Chopt at 8pm right as they closed.

The order was placed on an app so it was a crapshoot and I knew it. And sure enough I got something that wasn’t what I ordered but I’d been running around for 12 straight hours so I just said fuck it I’ll eat this weird burrito of industrial romaine and mayonnaise because I’d really rather be passed out.

Incredibly poor decision making on my part. I was up early and I was up often performing ablutions and praying to the gods of intestinal fortitude that this please pass swiftly.

I appear to have stopped with the worst of it and had about an hour or so before a meeting I really didn’t want to cancel. It’s not as if food poisoning is catching. So I groomed and put on something that would withstand the 88 degree heat of…checks notes… early April in Manhattan? And then I got on the subway.

Shockingly heat and the subway aren’t a great combination, but I was determined to gut it out. I’d left early so I could find my way to a drug store. Naturally nothing was available to purchase without someone unlocking a cabinet. Nothing more humiliating than asking if one could have a key to acquire GasEx, Tums and Imodium. A really stellar look all around.

I’m now comfortably in a lovely office of a venture capitalist hoping it all kicks in before I need to attempt socializing. Naturally I’m taking the time to write about it as I wait as it’s keeping my mind off the discomfort and misery of it all.

This isn’t the first run in I’ve had with agribusiness greens that’s gone awry for me. Many moons ago I got food poisoning from spinach I bought at a Trader Joe’s. A few blocks from where I am now. I had Gucci insurance (literally Gucci the luxury house I do not mean that it was particularly fancy) and spent the night in the emergency room. So maybe this is just a full circle experience. Ashes to ashes romaine lettuce to romaine lettuce to romaine lettuce.

I can feel the drugs kicking in and maybe I’m at the end of it. And hopefully this will just be an amusing anecdote that I recount on why we need to be more careful with food safety and industrial run off. But also I am loathe to cancel a commitment during a business trip. Showing up matters too.

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Medical Politics

Day 776 and Informed Consent

I’d really like to write about informed consent and whether it is a convenient fallacy to obfuscate the harsh reality that medicine isn’t as black and white as we have been led to believe.

It’s a complex topic so consider this my notebook of scraps and gently judge it’s content as it’s not a full cohesive argument so much as a collection of thoughts I’m working through here. If you feel you are reacting to it strongly please work through why on your own time.

I am on this topic as I am reaching a point of frustration with the discourse around transgender issues and who is responsible for informed consent. We’ve got a spiraling culture war where everyone is ignoring basic facts like children are below the age of consent and thus their parents are responsible.

Our entire legal system is based on the premise that before 18 you have not reached the age of reason and are not fully responsible for your actions. Yes it’s flawed and doesn’t always work that way and we try minors all the time but the fact remains parents are the guardians of their children.

I am oddly both well read and well cited on issues related to informed consent and substituted judgement as I was a medical ethics research assistant at the University of Chicago. I got paid $10 an hour for my troubles so you know my credentials check out (in sarcasm font). Seriously go look I’m an author on a few papers.

Making a choice to engage in almost any medical procedure is risky in ways no one, not even doctors, can fully articulate. Bodies are complicated and abiding by a simple principle like “first do no harm” turns out to be hard calculus.

Sure you can get awfully close to the right answer but you will be pretty far down the calculating differential equations path once it dawns on you that we can get infinitely close to certainty but certainly itself cannot be reached. Turns out math is useful in daily life.

Patients have a right to chose their own risk parameters. Doctors do their best to inform. But the grey area is so wide it’s practically an abyss. Add in making decisions for a minor and it’s all best guesses and other people’s facts. Believe the science means you’ve got to do your own math and it appears most people are innumerate.

I am willing to make big criticism of the transgender panic crowd because they’d prefer to pick and chose convenient narratives like “think of the children” as a defense. I’ve heard that tune before in every other moral panic. And yet it’s still not the government’s job or the doctors job to make the call. It is the parent’s call because children require the substituted judgement of their parents for informed consent.

If this is annoying or unsatisfying to you well that’s a bummer for you. I’d encourage you to read up on how we’ve scapegoated populations in the past to make sure the in-group’s priorities and social mores are sustained. Every moral panic has one. I’d recommend René Girard’s work here.

When we fixate on a vulnerable population the story is always the same. And I believe anyone who is reading this blog is smart enough to grasp that in good faith. And we’ve got a long history of scapegoating people who don’t conform to our majority population’s comforts.

The transgender issue is no different and trying to wedge it into a “but the children” argument runs up against two issues. Most of our American historical moral panics have scapegoated in this exact way. And medicine is simply not so concrete that any treatment for any condition is risk free.

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Emotional Work Medical Politics

Day 765 and Kobayashi Maru for Women

I woke up to a totally off handed tweet of mine going viral. I had done some googling on the cost of pregnancy surrogacy and learned that it would probably cost $200,000 a pop. I’d never really considered the cost as to be honest as I didn’t think I’d be having children that way. The responses to the tweet left me feeling despondent.

Five years ago I did IVF to freeze embryos (and eggs too) and it kicked off a massive health crisis that I only feel I’ve gotten under control recently. It took everything from me. I was on medical leave, I sold my startup, and my marriage got to learn what “in sickness and in health” really means. It was awful. I am crying just remembering.

It took years to get healthy again. Of course, I first had to get stable at all. I spent years, and a huge chunk of savings, biohacking my way back to a body healthy enough to work. I’m thrilled to be back doing what I love most which is working with early stage companies. But work wasn’t the only goal of getting healthy.

I’ve had a fantasy that if I just kept at my biohacking that one day I’d be off all these medications. That I could truly be healed. That all this trouble and heartache wouldn’t be permanent. That I could heal myself. Unsaid in all of that, is that I cannot be pregnant and on the medications that saved my life. How is that for a kick in the teeth.

I’ve got two embryos and ten eggs and a fleeting dying ember of hope that I could ever carry them. I don’t know if having them via a surrogate is my path forward. Maybe there is still hope I could be healthy enough. I frankly don’t know and I’m not ready to say where my fertility is headed.

All I know is that this feels like a no scenario. That having a child in America is a fraught and expensive endeavor even when everything goes right and you are healthy and young. There is no winning as a woman as any decision around family is going to upset someone.

It’s the Kobayashi Maru for American women. Juggling your partner (or partners), your money, your home, your health and your fertility means balls get dropped. You are going to lose somewhere. And it really hurts.

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Emotional Work Medical

Day 762 and If It’s Not A Yes Then It’s A No

I was supposed to drive my husband to an appointment today. I’d put it on my calendar and was prepared to make sure it happened because that’s what wives do right? It was an easy and obvious yes. I didn’t think anything of it.

Around noon I noticed I was becoming intensely sound sensitive. I asked my husband if it felt really bright outside even though we had cloud cover. I felt a little bit nauseous but I’ve been taking some antibiotics so I dismissed the symptom.

It was only when some silverware clattered onto our wooden dining table I realized something was wrong. I full on screamed. I jumped and shrieked liked like a poisonous spider had just bit me. A massive overreaction to a noise that objectively was neither that loud or that threatening.

“Honey, is it possible you have a migraine?”

Alex Miller

Despite the litany of easy to diagnose symptoms, I had managed to ignore the obvious. I had a migraine. And from the looks of it a pretty severe one.

I’d woken up feeling amazing so I wanted to tackle the day with all the energy I had. But as it waned I got angry. If I’d bothered to look at the emotion I would have seen that underneath the steam of the anger was hurt. I felt betrayed by my body. I had a 95% recovery score on my Whoop. How dare it let me down? So I just ignored it.

The kicker to the story is I kept trying to ignore it. I took one Imitrax even though it seemed like a two Imitrax migraine. Alex asked me if I was sure I would be OK to still drive him this afternoon. I waffled a little bit and said I dunno I am sure it will be fine once the migraine medicine kicks in.

I don’t like to drive after taking Imitrax as it tends to make me a little sleepy. And I really wanted to help Alex by driving him. So I just took one and hoped for the best.

An hour later Alex came into the dark bedroom and said “honey you know if it’s not an immediate yes then it’s a no, right?”

Apparently I did not. I took another Imitrax and Alex found another ride. Hopefully I learned my lesson.

Categories
Medical Startups

Day 696 and Edge

I’m enjoying a migraine this weekend that was both strong and as of yet unbeaten. Perhaps I overdid things on Thanksgiving and Black Friday. But I’ve been stuck in bed in a dark room for the last 48 hours or so.

While this sounds a bit miserable, I can assure you it is also part of my edge. When my physical works shrinks my cognitive capacity unfurls. I very much liken it to the traditional super hero dilemma of being gifted with something that makes living a normal life a challenge.

I may be stuck inside struggling with light, noise and smell but I can still do most of my core deep work. I can’t take calls or go to meetings but I can be on my phone and my Kindle. I can intake information and I can synthesize that information when I’m in darkness.

And that is 90% of my job. Be informed and make the best decision you can. Those decisions are generally done when you are calm and fast. And I get the benefit of being in rest and digest as often as possible as it’s what keeps me alive.

I’ve got a generalized theory related to finding one’s edge. It’s pretty simple. If other people perceive it as a weakness but you understand how to wield it as a strength then your got an edge. People dismiss you sure. But being underestimated is one hell of a way to get on the better end of a trade.

And so while I’m here looking like I might not be worthy because of some set of heuristics that’s have typically worked well for you I’m actually the one that has a leg up on you. You would do well to think about all the ways in which you can leverage talent and insights that trade below their value. You can make a lot of money betting off of truly underestimated viewpoints.

Categories
Medical Politics

Day 656 and Genetic Material Storage

What feels like a lifetime ago, my husband and I pursued fertility treatments. I didn’t have any known issues but we wanted to freeze eggs and embryos while I was still young. At the time we didn’t feel stable or wealthy enough to predict when having children would be feasible. It seemed like the responsible choice to have a backup plan. Everyone we knew was doing it too.

I remember a gynecologist telling me off for considering freezing eggs as she managed medical school with a toddler so surely an easier career like startup CEO would have no trouble with resources for becoming a mother. I never saw her again after that incident. But knowing me the shame I felt from her judgement simply cemented my decision to free my eggs.

But I was equally poorly served by the fancy fertility clinic that glossed over risks and side effects. In hindsight I wish I’d been more concerned about ramifications. I also which I’d listened to my gut which was screaming that this felt more like a luxury shopping experience than a major life decision. The ease with which I was being sold a life where I could buy an insurance policy about a decision that I was ambivalent is almost shocking.

Now I’m faced with another choice. The genetic material needs to be moved to a safe state. In the wake of Roe v Wade being overturned, there is concern that fertilized eggs (embryos) might not be fully under our control as red states pursue stricter and stricter control policies. No one is quite sure how embryos will be treated. And frankly no one wants to find out.

Embryos that were stored in states like Texas and Florida are on the move. Clinics and storage facilities cannot guarantee their safety and usage as too much is still uncertain. Of the storage options we have, only two are in safe states unlikely to be impacted. Minnesota and Connecticut.

We picked Connecticut. Even if Republicans take it over we are banking they will be of the WASPy moderate types who see value in family planning for nice white married couples. Our privilege is at maximum there and that’s worth a premium.

I am so conflicted on even addressing the issue of what we are supposed to do with our generic material. Is this the moment we give up and admit it’s not a life path that we want? The chances of Alex and I have children together are getting slimmer. It’s not impossible but it’s also not looking likely.

My health is stable but I use several pharmaceuticals that shouldn’t be used during a pregnancy. I’d need to be on bed rest and dosed off everything to proceed with a pregnancy. I’ve been warned I could lose my progress on controlling my autoimmune disorder, the worst case scenario is I’d have to repeat the last four years of stabilizing treatment. I would be in a lot pain that couldn’t be treated for the duration.

Needless to say I’d not be able to work during the pregnancy and possibly for an extended time after. It feels perilously close to a choice between living my life and organizing my entire life and healthcare for a child I don’t even know if I want. It might be a permanent off ramp from work as the recovery would be significant. Everyone says you will regret not having children but I’ve only ever met people who regret having children.

At which point I have to admit to myself I don’t want children so badly that I am willing to be physically debilitated for another five years. I am so excited to be living a semi-normal life where I can pursue my personal and professional goals. The last few were hard. Perhaps we could pursue surrogacy but that suggests a level of wanting children that I just don’t think either Alex or I have. Because neither one of us strongly desires children this additional effort and cost simply to preserve our own genetic material isn’t under consideration. If later on in life we find our preferences changed we are both comfortable adopting or raising children not related to us genetically.

Perhaps the problem was that we never strongly wanted children in the first place. Maybe that shitty gynecologist was right. If we’d wanted kids we would have found a way. Instead we bought an insurance policy. And now that insurance policy is a scary liability with an uncertain political future.

With the way America is headed if we don’t move the embryos to a safe state now it’s entirely possible the government will decide we actually already have children. Unborn children. Who might have more right to life than I do. To be honest that’s an ethical question I don’t have an answer to. All I know is that I am absolutely not willing to let the government decide if it is my life or the embryos. That’s between Alex, myself and God.

Categories
Medical Preparedness

Day 630 and Sympathetic Nervous Response

One of the downsides of having any kind of medical bullshit is having to keep an eye on yourself. If you over do shit you’ve got no one to blame but yourself.

I’ve been doing a wilderness medical incident first responder course this week. I initially went into it slightly concerned with my ability to physically keep up given my ankylosis. I was easily the odd duck out in a group of former military folks, paramedics and wild land firefighters. If I’m honest I didn’t want to embarrass myself by showing too much frailty. I was already the only woman in the class. I didn’t need to be the cripple on top of that.

But over four days I’ve managed just fine. I did wound packing and splints. I did a number of incident scenario responses ranging from anaphylactic shock to heart attacks. I even did multiple mass casualty response drills. Today I managed one as a triage incident deputy and comported myself quite well.

I was feeling pretty cocky about how well I’d managed through the week. I was enjoying that sense of accomplishment right up until 5pm or so today when we had our last assignment of the day. We’d just finished up a drill with five patients who had been caught in a tornado. It was an hour of field work and triage outside. I was thinking alright maybe I’m getting the hang of thing. But no I was about to embarrass myself on one of the easiest tasks in the course.

It was time to pack up our own medical kits. We got a big baggie with all the supplies we could possibly need for our our first aid kits and dumped it out on the desk. Our instructor began going over all the items and how to pack them up into the bright orange brick that serves as your kit bag. I was doing my best to follow along but my brain was just not having it. I kept trying to figure out what items went where and how it was meant to go. And I was not remotely keeping up with the class or the instructions.

I’m starting to feel overheated and I’m struggling to concentrate. And it’s then I realize “oh shit I’m in a bunch of pain” and I realize I haven’t taken my pain medication for hours and it is starting to show. I just ran around in a big field doing triage for an hour. So I think to myself well I’m having a sympathetic nervous system spazz out. The pain and fatigue is sending me into fight or flight and I’m losing decent coordination and fine motor skills. I am becoming one of my own patients.

I didn’t finish packing out my kit. I had to excuse myself. I briefly considered if it would be funny to have a medical incident in a first responder course. But I was fully capable of treating my own acute stress response. I was getting worked up by an inflammatory response from my ankylosis and low and behold the pain in my spine was going to spike.

The end of the story is that I’m in bed and the non-steroidal anti-inflammatory drugs have kicked in. My pulse and respiration are fine. I’m no longer in fight or flight. And yes I’m a little embarrassed that packing a bag is what did me in. But on the other hand, that’s a very “Julie” way to learn a lesson.