In this episode, author Susan Lieu discusses her memoir, “The Manicurist’s Daughter,” which explores her mother’s death during an elective surgical procedure. Mayo Clinic physician Dr. Alyssa Janousek provides her anesthesiology expertise to help listeners navigate and make sense of surgical procedures. This episode was made possible by the generous support of Ken Stevens.
In this episode, author Susan Lieu discusses her memoir, “The Manicurist’s Daughter,” which explores her mother’s death during an elective surgical procedure. Mayo Clinic physician Dr. Alyssa Janousek provides her anesthesiology expertise to help listeners navigate and make sense of surgical procedures.
We talked with:
Susan Lieu, a Vietnamese-American author, playwright, and performer, tells stories that refuse to be forgotten. A daughter of nail salon workers, she took her autobiographical solo theater show 140 LBS: How Beauty Killed My Mother on a 10-city national tour with sold out premieres and accolades from L.A. Times, NPR, and American Theatre. Her debut memoir, The Manicurist’s Daughter has been featured on The New York Times, NPR Books, and The Washington Post. Also, Lieu is the co-host of The Model Minority Moms podcast and board member for international NGO Asylum Access. Susan and her sister co-founded Socola Chocolatier, an artisanal chocolate company based in San Francisco. Susan lives with her husband and son in Seattle where they enjoy mushroom hunting, croissants, and big family gatherings.
Alyssa Janousek, M.D., is an anesthesiologist at Mayo Clinic in Arizona. She received her Medical Degree from University of Arizona-Phoenix, followed by residency in Anesthesiology at University of Texas Medical Branch at Galveston with distinction as Chief Resident. She practiced at UTMB in Galveston until 2020 when she moved home to Phoenix and began a private practice career. She has been at Mayo Clinic since May 2023 and has a special interest in graduate medical education, clinical education research, and quality and safety. She is married to her husband, Derrick, and they have two daughters, Eleanor (5) and Clara (2).
Can't get enough?
Purchase “The Manicurist’s Daughter”
Information from Mayo Clinic about general anesthesia
Information from Mayo Clinic about cosmetic surgery
What to do — and avoid — before anesthesia
Anesthesia 101 – American Society of Anesthesiologists
Preparing for Surgery – American Society of Anesthesiologists
How to Make Peace with Your Belly Fat talk by Susan Lieu
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Dr. Denise Millstine:Welcome to the “Read. Talk. Grow” podcast, where we explore women's health topics through books. In the same way that books can transport us to a different time, place, or culture, “Read. Talk. Grow.” demonstrates how they can give us a new appreciation for health experiences. Books can provide understanding of health topics and provide a platform from which women's health can be discussed.
At “Read. Talk. Grow.,” we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you.
Our book today is “The Manicurist’s Daughter,” a memoir by Susan Lieu. Our topic is surgery risk and complications, especially for elective procedures. I am so excited about our guests today. Susan Lieu is a Vietnamese-American author, playwright and performer. She tells stories that refuse to be forgotten. She's the daughter of nail salon workers who took her autobiographical solo theater show “140 pounds: How Beauty Killed My Mother” on a national tour.
Her debut memoir is “The Manicurist’s Daughter,” which has been featured on “The New York Times,” “NPR Books,” and “The Washington Post.” Susan is the co-founder of Socola Chocolatier, an artisanal chocolate company in San Francisco. She lives with her husband and son in Seattle, where they enjoy mushroom hunting, croissants, and big family gatherings. Susan, welcome to the show.
Susan Lieu: I'm so excited to be here. Thank you for having me.
Dr. Denise Millstine: Our second guest is Dr. Alyssa Janousek. She's an anesthesiologist at Mayo Clinic in Arizona. She was in medical school at the University of Arizona, Phoenix, followed by her residency and anesthesiology at the University of Texas Medical Branch at Galveston, where she was also a chief resident. She has a special interest in education, clinical education research, and quality and safety. She's married and lives in the Phoenix area with two daughters. Alyssa, welcome to the show.
Dr. Alyssa Janousek: Thank you so much for having me. I'm excited to be here.
Dr. Denise Millstine: “The Manicurist’s Daughter” is Susan's memoir of her mother, their relationship, and her mother's avoidable death at the hands of an irresponsible plastic surgeon. The book explores their shared history and takes a deep dive into Susan's grief as an adult, as she re-opens her mother's story.
Susan, this was such a brave book to write, more terrifying because of your family's silence around your mother's death. How has it been now that the book and of course, the show have been released?
Susan Lieu: I mean, I think for me, on a personal level, when I was working on the show, it was all about focusing on intergenerational trauma. And writing this book and having a kid during the pandemic, I was able to start navigating intergenerational healing and what that means for me. How does that transform? And sharing it with the community, I get notes from fans every day about how this work is changing them and having them look at their own dysfunctional families and their own traumas and what do they want to do with it?
Now, the characters in this book are alive. They're living it, and some of them are proud of the work I do. Some of them pretend I don't do it. And have we still had a vulnerable conversation about what has happened? No, but that's also family.
Dr. Denise Millstine: That's family and that's grief. Everybody is doing grief in their own time, in their own way, in many ways. But again, I just applaud you for how brave and courageous it was to put this story out publicly, which I know resonates with a lot of people who have lost a loved one, especially a parent early in life.
I want to make sure that our listeners who haven't read the book yet, and if they haven't, they should, of course, know who your mother was before we talk about the surgery that led to her death at a very young age. She was really fierce. She ran nail salons, and she was really courageous too, even making it to the United States, finding success here. Can you give us a background about this force that was your mother?
Susan Lieu: Yeah. So my mother is the tenth of 12 children. She grew up in the Mekong Delta, met my father there in a rural area. Both of them didn't have a high school education, and she ran an underground lottery operation so that she could get enough money to buy these covert tickets to try to escape by boat after the Vietnam War. And she actually won the lottery three times, which is kind of nuts. Like when we think about the odds of everything happening here, and then my mother and father, and at the time, my two brothers had enough money to buy these one-way tickets. On the sixth attempt, they made it on the boats to a Malaysian refugee camp where my sister was born.
They came over to the Bay area in 1983. We lived in government housing. She knew that if she didn't get off welfare, she could never sponsor over her three sisters and her parents and a cousin. And so she did everything she could trying to figure out how do you navigate America with — now me being born in 1985 — with four children on welfare. How do you do this and not know the language in this new country you're in?
My father was a newspaper boy. My mom starts as a seamstress and she does hair and then she realizes the money is in nails. She opens her first store, her first salon. She then sponsors over all the family to then build this fiefdom, this mini army of people to grow her nail salon. And we are 13 people in a four-bedroom house. She was a matriarch. She was the pillar. She always called the shots. She knew what to do. We then had two nail salons. We bought a house. This is all within eight years of coming to America. We had it all. She had the American dream. And then it all comes crumbling down.
I'm 11 years old. She's 38. She goes in for a tummy tuck, the narrowing of her nostrils and a chin implant. And then she thinks she's going to come home with her beautiful body. The next day, two hours in the operation, she loses oxygen to her brain. Five days later, she flatlines. And for the next two decades, to this day, my family has never, ever spoken about her or her death.
And so that is what you're supposed to do. You're supposed to respect your elders. You're supposed to obey. And I did for a long time. And I asked questions and they said, you're being too emotional. You're stuck in the past. I believe them. I thought there was something wrong with me. I thought it was my fault. But I had a reckoning.
I had a reckoning after I got married, I got pressure to have kids from my dad, my aunts, and I said, “How do I become a mother if I don't know my own?” And since they wouldn't talk, I tracked down the plastic surgeon’s family. I read thousands of pages of depositions, enlisted the help of spirit channelers, went back to Vietnam several times, and every time I learned something new, I put it on stage in a one woman show. The fifth “140 pounds,” I took on a national tour in my second trimester.
So this is my journey to know me, to know her, to know where I come from, what I'm capable of, and also how do we end intergenerational trauma? How do we transform it into healing? And when we can name our shame about the past, how can it also liberate us?
In that process, I read all these depositions, which I can't wait to talk to you about, because I wanted to understand what really happened to my mother. How rare of an incident was this? How negligent was the doctor? And how afraid should we be as patients when we go under the knife?
Dr. Denise Millstine: That is so powerful, and also the perfect segue. I wanted to turn to Alyssa and talk about what it is to even be an anesthesiologist. We should clarify that in your mother's procedure, there was not an anesthesiologist present, but for most surgeries and procedures that would be managed by somebody who is trained in anesthesiology. I just want to make sure that our listeners understand what your professional role is, what your responsibilities are, and why you're so well positioned to offer commentary on what happened to Susan's mother.
Dr. Alyssa Janousek: Sure. So as an anesthesiologist or any of us, after medical school, we go into a residency where we specialize in obviously what we call anesthesiology. And that is the practice of essentially sedating patients for painful procedures. And there's a whole breadth of things that we can do. But our main goal is to make sure that you are often, amnestic, meaning can't remember what has happened. We help treat pain during the procedure and afterwards, and we also have to make sure to keep a close eye on you throughout the entire procedure. So your vital signs, meaning your heart rate, your blood pressure, your oxygenation, to make sure that you as an individual are safe during a stressful period, during a procedure.
So opposite the surgeon we are up at the head of the bed on the other side of the drapes, monitoring you from second to second, administering the anesthesia and from second to second changing that anesthesia based on how your body responds. What you may need during that procedure depending, more pain control, less pain control, more amnesia, less amnesia. And then fluid management, meaning sometimes you have blood loss during a procedure, so we have to replace that or you haven't been eating and drinking, so we need to replace certain fluids within your vessels to make sure that everything stays in a physiologic equilibrium, so that you are safe during the procedure and comfortable during the procedure.
Dr. Denise Millstine: So it is literally minute by minute monitoring of the person. And while it's not your role entirely to comment on risk for a patient before they have a procedure, certainly as you're meeting a patient before the procedure, you are commenting on risks.
So to connect to Susan's question, which is, you see a 38-year-old woman who she knew at the time had had breast augmentation within the last several years and tolerated the procedures coming in for elective cosmetic surgery without any other known health condition. Would you agree that she should have been low risk for this procedure?
Dr. Alyssa Janousek: Absolutely. This is someone that I would meet ahead of time, do a history and physical, ask questions. And from what we knew, she was a young, healthy woman who should have tolerated this procedure very well, very safely. And as long as someone was there watching her minute to minute on the anesthesia side of things, should have gone without a hitch.
And that's something that we discuss, of course, with patients ahead of time, you get a few minutes to get to know your patient, assess their risks and speak with them about those risks, and then make plans for those potential risks. There's always risks when you undergo anesthesia, even as a young, healthy person. And of course, those risks increase depending on your physiology, your chronic diseases and the procedure itself. And those are things that we always discuss with our patients, but that we plan for. And you have a plan A and a plan B and a plan C, and often all the way down to a plan C, because unexpected things happen. But that's why we're there.
Dr. Denise Millstine: So I just want to restate what you said, which is that there is always risk with procedures. Whenever you have a procedure or anesthesia, even if 99 plus percent of the time it goes, well, there's always going to be a risk, which is important to weigh in as you proceed.
Susan, I'm just going to give you some space to react to what Alyssa said, because I know that's painful since your mom didn't have that professional anesthesiologist there to monitor at this moment-to-moment level.
Susan Lieu: Oh yeah, I'm like, Alyssa, I love your job and I wish you were there for my mom. And it's great to have a dedicated person to that role because it is so important. Now, what is complicated in my mother's surgery, is the doctor who's presiding over this is on probation. His nurse, for some reason, has medical malpractice insurance herself for unknown reasons. And then the scrub nurse is a former physician, a physician from the Philippines but she didn't get her license and she’s not boarded yet.
Dr. Denise Millstine: (She's not licensed)
Susan Lieu: Okay, so that's his team. That's his team in the operating room. He doesn't have an anesthesiologist there. And he makes a choice, instead of doing general anesthesia, he does dissociative anesthesia. Can you talk a little bit about that, just talk about the differences. And at the time in 1996, was that radical? Was that trendy? I read in his deposition, he saw a flyer about it, went to a workshop and started doing it. And now my mom is the 18th person that he's doing it on. So did he prefer this method because it's cheaper? Is it better for the patient? Break it down for me.
Dr. Alyssa Janousek: So fantastic question. There are obviously different depths of anesthesia that we can use for certain procedures. So for an abdominoplasty or a tummy tuck, like your mom underwent, I have always, every single time provided general anesthesia for that, where I can help control airway and breathing, because it is a painful procedure. It's a very stimulating type of surgery. And so to be able to tolerate that as a patient, you need to be under a deep anesthesia.
And it sounds like your mom was under something that her surgeon called dissociative anesthesia, which is when we use ketamine and kind of pull the patient out of their own consciousness, if that makes sense. But I think in reading through all of the medications that your mother received, she was very close to a general anesthetic without a protected airway, which we do as anesthesiologists often in endoscopy procedures. We get a patient deep enough that they aren't responding to pain or stimuli and watch their airway very closely, and we're there to manage it if we need to be.
Susan Lieu: When you say protected airway, do you mean an oxygen mask? Because she didn't have an oxygen mask and yeah. I don't understand what that means.
Dr. Alyssa Janousek: So from our standpoint, a protected airway is one where we can take control of the airway should we need to. So having some sort of airway device in place beyond oxygenation. Your mother should have had oxygenation during this procedure in my opinion. But under a general anesthetic without a protected airway means that you're breathing spontaneously as a patient on your own, but we're there to provide help if need be. A protected airway would be a device like something called a laryngeal mask airway or an intubation, where we place a tube through your mouth and into your windpipe to help you breathe or assist your breathing, should we need to.
Dr. Denise Millstine: Well, I just want to slow that down for one second for our listeners, about what you said with endoscopy, because maybe many of our listeners have had colonoscopy for screening, which they should if they're 45 or above or an upper endoscopy and it's not always necessary for those procedures to do general anesthesia, but it is in a setting where the airway can be protected should something go wrong. But the distinction here is you are talking about a major surgery, where at least standard of care, modern standard of care, because I don't think either of us can comment on what the 1990s standard of care was, but I suspect it wasn't very different. The modern standard of care is to have the patient have what you've just described in terms of a protected airway. Did I misstate any of that?
Dr. Alyssa Janousek: I agree, modern standards for this procedure, for the stimulating and invasive of a procedure is a general anesthetic, meaning a completely asleep, patient unaware of what's going on with a protected airway. So some sort of device in place to ensure ventilation and oxygenation. So essentially just ensure that the patient is breathing appropriately.
Susan Lieu: Do you know like the ratio of, how much cheaper it is to do dissociative versus general, like how much was this guy saving?
Dr. Alyssa Janousek: So he was probably saving quite a bit, not necessarily on the medication itself, but on not paying a provider, not paying an anesthesiologist for their time. Because of the risk of anesthesia and the training that we go through, it's not inexpensive to hire an anesthesiologist or anesthesia provider to provide anesthesia during a procedure. So often the savings is not paying an anesthesiologist and also not having certain rescue equipment that we require in the room or close by to save a patient, should something go awry, be it a strange reaction to the anesthetic medication itself, or to help ventilate and oxygenate that patient.
Dr. Denise Millstine: Well, I want to comment on maybe it wasn't a cost decision, because I think the setting of your mom's procedure is also really important. I know you've written about how people will often ask, well, like, was this a back-alley procedure? And indeed it was not. It was in what, for all appearances, seemed to be a respected plastic surgeon’s office. But also different types of anesthesia can be provided in different settings easier. Alyssa, can you just clarify what I'm talking about there?
Dr. Alyssa Janousek: Sure. So there's many settings in which we can sedate or anesthetize a patient for a procedure, being it an office-based procedure or an outpatient surgical procedure, or an inpatient surgical procedure in a hospital with more resources. Usually those are either bigger procedures, more invasive procedures with more risk of complications or patients who are riskier to undergo even a simple procedure given their disease state, or their just personal risks to undergo anesthesia.
So from what I read, it sounds like this was an outpatient surgery type center, not office based. And often in those and in regulations and making sure that these are safe, there's many things you have to have in place to give a certain type of sedation. So a certain depth of anesthesia, be it moderate, to deep, to general anesthetic. There's different requirements to ensure safety of your patients undergoing those procedures in different settings.
Susan Lieu: So here's my question, if you're a patient and you're going to do a consult with someone, should you ask, hey, are you hiring an anesthesiologist? Or hey, are you on probation? Like, is this just actually an outlier situation? And most of the time you would expect that or should patients actively ask these types of questions?
Dr. Alyssa Janousek: So you should absolutely be asking those questions, even if you know nothing about the specifics of it. You need to ask what type of sedation will I be receiving? Who is providing that sedation? And who is monitoring me during that sedation?
Those are all very important questions that don't always have a clear answer. And you want that to be a safe procedure for yourself, for your family member. Unfortunately, it is, I wouldn't say common, but more common than it should be that you ask those questions and they don't have a good answer for you. You don't have an anesthesiologist nearby or directing the care or in the room with you when you should.
Susan Lieu: I just think as a consumer, like you don't think to ask these questions. You think, oh, this doctor is operating, they're going to do it right. They have a license. I think that's what's so troubling to me is that, I assume this to be actually a given. And I was born in America. I natively speak English. And so now I'm thinking about my mother, where Vietnamese is her primary language and she didn't have a high school diploma. And even though there was a Vietnamese translator there, I don't think at the time and I think even for now, in our day and age, do people have the wherewithal to even know to ask these questions unless they've already been through the wringer of the healthcare system?
Dr. Denise Millstine: Well, in your mother's case, she had been through a surgery that had gone so smoothly. So it's very possible we would never know but that she came into it maybe overconfident that just like it went, again, it was a big surgery. She had breast augmentation. She had to recover from it. But you barely even remembered that she was able to hide it so well. And here she is entering into this second plastic surgery, maybe assuming, like you said, that the boxes have all been checked because she didn't know to ask. And we shouldn't forget that this is 1996 where there was no Google to go back to and look up. But now you do have that information at your fingertips. If you seek it. But if you don't seek it, you don't maybe know to do that, which I think Alyssa is going to comment on whether you should before you undergo a surgery.
Dr. Alyssa Janousek: I think we're at a great advantage having that knowledge kind of at our fingertips. When you're researching a physician or a surgeon's office or how many procedures they've done. But it is very important to know that about a procedure. I make sure I ask, and I know all the ins and outs of the anesthesia and the risks and what my risk to undergo anesthesia for a major or a minor procedure is. But I always ask, and you can be sure that my family members always ask. I am on top of them about it because you just don't know and it's good to be vigilant and ensure that you're in a safe situation when you're undergoing something that carries risk.
Susan Lieu: You know, I got to tell you, I never knew to be a patient advocate until all this happened. And I started meeting people in the space around it where they're like, this is what you must do. Because guess what, I did it when I was giving birth. The anesthesiologist came in and I said, hey, are you on probation? And, like, they look like they were, like kind of shocked and I was like, can you give me your name, and can you come back when I'm ready for you to come back? Like I went to go look it up. I went to look it up. My husband was kind of like rolling his eyes, being like, are you serious?
But even before, like, I had an induction or induction, yeah. Induction. Right. I was like, that sounds like a stovetop cooker. But yes, I have an induction and I remember when we were scheduling the appointment, I was like, okay, who's operating? Who's going to be there? Are they on probation? What are their names? And like I kind of felt energetically from the other people that were like, “Whoa, lady, high maintenance,” right? Because I don't think people are asking and I have to ask because if I knew it was preventable, then I'm like, wow. It's like my mother's karma, you know? Like I knew better. But the problem is, it's actually kind of awkward to ask.
Dr. Alyssa Janousek: It is and I like your comment on “Whoa, this patient is high maintenance,” because you're often met with that when you ask those questions. I very recently was evaluated for a very minor procedure, but they often sedate for it and I asked all those questions and they were taken aback and had to offer that I was an anesthesiologist and this is why I'm asking these questions. But that shouldn't be something that gives your physician pause or makes them think that you're high maintenance. That's important. It's your life, and you're putting it in their hands.
Susan Lieu: Yeah.
Dr. Denise Millstine: It's possible. We maybe want to just pause there and think about the language for asking those questions. No, because if you say to a physician, are you on probation? And they were on probation until last month, they could say no. So I think it's probably a good idea to think about this in an open ended way, which is to say something along the lines of, you know, whether or not there have been any concerns about your care in the past, and these things you can find online, you know, through the state licensing board.
In the case of your mom's surgeon, I think he'd been the defendant in, was it 19 cases and he was currently on probation. So I think these are questions that you can ask, and you can kind of ask them on the global level too. So we have the privilege of working at Mayo Clinic. And I think as you come in, you could say, can I be assured that none of my treating physicians and health care professionals are currently being investigated for any concerns related to their practice and their licenses? And I can assure you, at Mayo Clinic, the answer to that is that you can be assured. And then I think it's when you get into these one offs where you're in maybe an outpatient surgical center, where the staff is rotating, right? They don't necessarily work there; they just use that space and so you might not even know who your anesthesiologist is until you're gowned and ready to go back. And so I would just encourage that conversation. I think also if I have never been on probation and somebody said, are you on probation? I'd be like, no. Why? You know, I think I would find that question jarring, when really what the question is, can I be assured that I will be at lowest risk possible, which means you're an experienced health care professional. And listen, bad outcomes happen, particularly in people who do complicated procedures on complicated patients. So we have to be a little careful about that. But we just want to make sure. Do I need to be concerned and how experienced are you?
So that's one thing I wanted to raise. And Alyssa maybe can comment on this. Surgeons who do procedures successfully more often do lower risk procedures and they get really good at it. And it's good to know that, too. If you're going in for abdominoplasty, tummy tuck, you would want to know if this is the person's first or this is their 550th?
Dr. Alyssa Janousek: Right. And that's a very important thing to know about your surgeon. It's often difficult to find that ahead of time about your anesthesiologist, because you're often just meeting them a few minutes before your procedure, like you were saying. But the risk for a procedure is much less, and becomes much less, the more that your proceduralist, or surgeon, does that particular procedure. So every time you're looking in to have a procedure done, find out how many different procedures your surgeon does and how often they are done. And what you can often find out maybe what their complication rate is, or speak with them about what the complications can be and how often that happens. Because like we were saying, there's always risks associated with any procedure and things do happen. You can do a perfect job and risks happen or complications happen. But it's good to know how much your proceduralist has done and is continuing to do.
Susan Lieu: Okay, is there like a cheat sheet somewhere where you're like, knee surgery, open heart surgery, tummy tuck? Where? Because I don't know, 500. That sounds good. A thousand that's I mean, how many is good and what is the complication hit rate should I be concerned about? I know things happen. I know things are situational. I just, I guess like if they give me a number, I actually don't even know how to react to it.
Dr. Alyssa Janousek: Understandable. So often surgeons who do the same procedure over and over, advertise how many they've done, which is actually a great advertisement and also helps reassure you that they know what they're doing with that particular procedure. You can always ask how many they've done. It depends on the procedure. So if it's a big, complicated surgery that takes all day, that surgeon is not going to have 20,000 of those surgeries under their belt.
If it's a small procedure, like a cataract surgery, you can do tens of thousands of those in a career. So it depends on the procedure itself. And then complication rate, any proceduralist or anesthesiologist that you talk to, you should know relatively about what the complication rate is in the general population for minor events, like an oral injury, when we're placing an airway or major events, like a heart attack under anesthesia.
You can ask those they should know at least relatively specific numbers. And the more major the complication, the less there should be of that. And if you're undergoing a large procedure, a major procedure, often the complication rate can be high. But that should be told to you ahead of time. And that's a decision that you make with your provider about whether that risk for you is worth the reward at the end of that procedure.
Dr. Denise Millstine: And a lot of this gets done in the preoperative evaluation, and so we can post to some of the Mayo Clinic content that's available for free for people to look at things like surgical risk score. And who do I talk to about this? Because many parts feed into this; it isn't just the surgeon’s complication rate, for example.
I want to highlight one other part of the procedure that I think is crucial to what happened to your mom, Susan. Which is who is watching and reacting to when things occur? Because like we said, there's risk for any procedure and so if you know that, then somebody has to be there and respond. And part of the devastating effect of what happened to your mom is that there was a delay in initiating the next level of care.
So I think that's the other part is that if you have an anesthesiologist or an anesthesia professional, literally on the other side of that curtain who, like Alyssa described earlier, is second to second monitoring. I'm not even joking. Right. Heart rate, breathing, oxygenation. How you can see the patient is responding to stimuli. Are they grimacing? You comment from the records about how your mom was feeling it, even when she got to the hospital, they could see that. Right.
I'm sorry to talk about this so clinically, but I want our listeners to hear that many of these things, if you have a professional present, even if they did happen, which is a low risk of happening, having somebody ready to respond can prevent, which is why I called your mom's death avoidable. So we can at some point talk about, did she need to have the surgery at all? But since she chose to have the surgery, how do you do your best to confirm that you in the safest hands possible and if escalation of care is needed, meaning you need to go to the hospital, you need critical care or similar, that is in place to happen quickly and that wasn't the case here.
Susan Lieu: That's right.
Dr. Alyssa Janousek: I think that was a major factor in your mom's procedure and surgery and complications that came along with it. For a procedure like your mom underwent in an operating room, there should be a surgeon, someone assisting the surgeon, often a scrub nurse, scrub tech, a circulating nurse to help grab things if need be, and also help respond to things. And an anesthesiologist, anesthesia provider.
The scrub nurse or the circulating nurse in your mom's procedure was tasked with too many things. It's too difficult to monitor a patient under that level of sedation, and also chart the anesthesia, chart the surgery, and run and get things, if need be. And I imagine that played into the delay in the response to your mom's urgent situation during her procedure.
Susan Lieu: Yeah. As you read in the California medical board report, there was charting that happened later in darker ink, several days later after she passed. That's an interesting thing.
And I want to break down what happened; So she goes in for surgery and two hours later she loses oxygen to her brain. In that period of the two hours, she's given different dosages of medication, they perform the surgery. At one point, the, I guess there's some machine that is monitoring your oxygen levels, it goes below 94 or something and an alarm goes off. So that's when the nurse springs into action and then everyone on the team is trying to help my mom have oxygen to her brain. In that period, there's 14 minutes that passes where they're trying to do everything they can, and at the 14 minute mark, that's when the surgeon calls 911, make the 911 call.
In general, if you do not have oxygen to your brain for four minutes, that's permanent brain damage right there. What is happening is the alarm goes off. It goes off in the room. It also goes off in the front desk area. So the front desk receptionist also hears it. They're not moving back and forth, like no one communicating with each other to possibly make the 911 call. The doctor’s doing everything he can and the 14 minutes passes.
So once the 911 call is made, the ambulance folks come in, they try to intubate her twice and they succeed on the second time and she has oxygen. Now guess how far away the hospital is that they take her to? It's two blocks away. It's two blocks away, friends. And then she's in a coma. And at the time when she arrives in the hospital, I think the nurses were talking to our nurse, and they actually thought she was going to be okay, but there was they had to remove the staples on her stomach. They saw the grimacing. There is tearing.
Dr. Denise Millstine: There's no excuse for it. I mean, it is malpractice at its very heart. And I think we both are so sorry for your loss and so moved by that you were brave enough to put this into the world.
I do want to talk about a couple other aspects, because I think it's really important for people listening to talk about consent. So we mentioned that there was an interpreter available for your mother, but that it's possible she sort of read through the form in the same way we run through technical forms. There was an interesting line that you pulled out that said, by signing this contract, you’re agreeing to have any issue of medical malpractice decided by a neutral arbitration, and you are giving up your right to a jury or court trial. That type of language should have set off alarm bells. But of course, either she didn't understand it, she didn't understand that it wasn't standard language.
Susan Lieu: Is it? Is it not standard? I thought that's like terms and conditions, like Apple, like you just accept it. No, no
Dr. Alyssa Janousek: I have not come across a consent or given a consent that has that clause in it.
Susan Lieu: Dear God.
Dr. Denise Millstine: I mean, you always have a right to litigate what happened. Why would you give up your right on the front end? I don't think that's standard. I'm not saying it doesn't happen.
Susan Lieu: Yeah, yeah, yeah.
Dr. Denise Millstine: I haven’t read thousands of consent forms, but it would not be considered standard.
Susan Lieu: Okay, so here's the kicker; all right, so the form is like, have you ever had a surgery, like open heart surgery, mammoplasty, like have you had all these like intense conditions? So she goes no, no, no, no, no, no, no, no, no. And then it goes, do you understand the risk associated with this? And she goes, no. Right. And then there was two more questions where she was supposed to say yes, where she says no. So then even though there's a Vietnamese interpreter there, I'm kind of like this feels like a slaughterhouse. Like a factory. They're just moving bodies through, right? Like they're not even checking their own forms or even talking about the forms. It's like, get it done, let's get it processed. And that was also troubling to me, right? She didn't even fill it out right and they didn't also make a point to talk about it.
Dr. Denise Millstine: They're looking for her to check boxes and sign the bottom. Sorry, Alyssa, go ahead.
Dr. Alyssa Janousek: No. It's okay. It sounds like she was not actually given informed consent. If she checked about, now whether she knew she checked that box saying that or not, she checked the box saying she doesn't know the risks of this procedure, which is the definition of informed consent, is we're going to do this to you and for you, and you need to know what could happen. We'll do our best for you, but it's important to know what you're getting yourself into.
Dr. Denise Millstine: So we've hit on, know your risks. Know how you mitigate those risks by understanding the professionals who are in the room with you and then actually consenting, not doing the consent in that “run through, here, just sign on this line.” Read the form, ask your questions. You have a legal right to having, never mind a moral right as well, but to having your questions answered so you understand what you are stepping into.
I really want to talk to about your perspective when you were in the emergency room yourself for your own health issue, and it occurred to you how your father, also native Vietnamese speaker, had limited agency to ask questions about what was happening or what had happened to your mom. Can you tell our listeners about that, because I think advocacy is so critically important when you have a health issue.
Susan Lieu: Yeah, so my father came to America with limited English, right? It was just some English he learned in the refugee camp. And so he has a basic understanding of English. He can operate his nail salon. But in terms of talking about cerebral anoxia, in terms of talking about the cocktail dosage of the anesthesia, like he didn't. In his deposition, they asked him, do you actually know what your wife died of? Do you actually know what happened? And he said, no.
Who is actually advising him? As the nurses and doctors now at UCSF Mount Zion, who's trying to take care of my mom in a coma, who's advising him? My 19-year-old brother. He has now become the interpreter for the family and is talking to the doctors and trying to understand what happens and trying to advise my father to make calls. 19.
Dr. Denise Millstine: A legal adult but effectively is still a child, and your brother ends up having to make the decision to withdraw care, which it sounds like was the correct decision in terms of the likelihood that your mother was going to recover from this brain insult, but the whole thing is broken on so many levels. Which is why I think it's so important that you put the story out so people can have these conversations and can understand why, even when somebody's talking at you quickly and you're not understanding, you have to say, stop, tell me what you're talking about. Put it in terms I understand, and if you can't, get somebody who can. Because there is always somebody at a quality medical center who can come and go through it with you as slowly and in whatever language you need that to be done.
Susan Lieu: Yeah, depending on what state you're in, you can actually ask the doctor if you can record what they're going to say. Sometimes they can say yes and they can say no. But the information is coming really quickly. And as I talk about in my prologue. So spoiler alert, I went to the E.R. two times in an effort to finish my book and hit the deadline so I could publish when I was still 38. Like the stress got to me; I had abdominal pain, I couldn't stand, I couldn't walk, and so I go to the E.R. twice and that's when I'm realizing the pressure that my father went through. Because even I feel intimidated to talk to a doctor. I feel like it's a celebrity. I've been standing in line all night to talk to you. And finally I get like, 4 to 8 minutes with them. I forget all my questions, but I knew someone, a patient advocate had to tell me to write down the questions. I did in advance because when they're finally here, there's so much urgency to the situation. I drew a blank. I had to go back to my questions, but even then she was speaking so quickly to me that I was like, wait, there's no solution. There's nothing to prevent this in the future. There's no next step. And she's like, no. And I remember at that time I said, well, I knew my OB-GYN organization was also in the Swedish care. And I said, can I get a second opinion? Can I have them talk to me? She was so annoyed with me that I asked. She was so annoyed and she just grumbled and she's like, fine, she's just going to tell you the same thing and walks away. And then the folks from my OB-GYN come and we talk about it, and they give me actually different perspectives and different ways to follow up.
It is so scary to wait for so long and then you're googling all the things that it could be. And I was like, do I have liver cancer? You know? And she's like, stop, stop, you know, but because there's nobody there, it becomes terrifying that you are really the only advocate because then the doctor comes in and they're like, “Okay, are we done? Are we here? Are we good?” And you don't know if you're good.
Dr. Denise Millstine: Yeah. I think you've said a lot of really important tips there, which is, write down your questions on the front end and have a second set of ears, whether that's another person who can accompany you or a recording that you asked permission to take. Or even, I've had many patients call a loved one if they can't come with them, and we just have them on their phone while they're in the office with me. So again, that second set of ears is really critically important. And then you always have a right to advocate for yourself, even when that's met with unfortunate responses that might feel like you are pushing, but it's your health, so if you don't push, who will?
Susan Lieu: So can we role play this a little bit because she was spicy with me at the time. Like what are okay advocating questions. You know what I mean? Give it to me in real question form.
Dr. Denise Millstine: Alyssa, I'm going to let you go for it.
Dr. Alyssa Janousek: It can be difficult when you're faced with an attitude or preconceived, who knows what anybody had been saying, this patient is difficult, we often get that. Hey, she's been, you know, asking a lot of questions. And so you go in with a preconceived bias, which is terrible but we're human. And that happens sometimes and everybody is different of course. Invite questions, I appreciate when there's a family member there because they often will ask the question that the patient forgets. I don't think that it's inappropriate to be blunt with your provider if they're not answering the question that you're asking. It can be difficult. It can seem confrontational and it may off put the provider a little bit, which can make it difficult like you were saying, it makes it. I wish that I had a perfect scenario for you, or a perfect way to say, hey, this is a great way to get to what you're actually trying to get to. It depends. We're all human. We react to different questions differently, and we should have the clinical expertise to be able to answer your question and sometimes you have to ask that question a few times, or maybe circle back and ask it in a different way. If you aren't hearing or getting the answer that you're looking for.
Dr. Denise Millstine: So there's actually, sorry, a technique that's called the teach back method. So it's fair to say to your physician or health care professional, let me tell you what I heard you say. You said I have an ovarian cyst that is caused by this, that can be treated by this and my next steps are to follow up with this test or this person. Did I get that right? And if they say, oh no, no no no no no no no, you didn't hear that exactly right. And then that gives them a chance to understand. So, that is always a technique that, you know, in a lot of like telemedicine, you'll see if you talk to a health nurse, for example, when you call with an urgent issue, she might tell you, he or she might tell you, do these things and then they'll literally say to you, tell me what I just told you to do. So that they understand that you heard. I go pick up this prescription. I stop taking this medication. I need to come next week to see so-and-so.
That's called the teach-back method. Because any situation could have any number of variables as part of it, like that would be the best advice I could give somebody is that you always have the ability, or your family member can have the ability to say, here's what I heard. And correct the parts I didn't get or the parts that I got wrong. And there should be nothing threatening about that. Right? Because you're not saying, are you saying there's nothing I can do, right? Which can be read as threatening, right. And so now we're at odds versus are you saying, you know, “Here's what I heard you just say,” right? I think that also can go a long way for the attitude.
Susan Lieu: And one thing I wanted to add about the teach back method, which I really love. That's paraphrasing to understand what the provider is saying. But here's the sticking point. Do you know what questions to ask? And so when you can call in a friend, this kind of goes back to a question of class and privilege. Do you have any doctors in your circle that you can call and get on the line with, for them to also ask, you know, they can do their doctor speak to each other, but also they're going to help you actually understand what questions to ask, right? Like earlier I said, most people wouldn't ask, hey, are you on probation, right? Or have you had any concerns in your medical record that would threaten my standard of care or whatever? Like we don't know to ask these things. And so the other tool here is, is there someone who has medical training in your sphere that can support you?
Dr. Denise Millstine: Well, and let me advocate there for not just who you know personally, but also your primary care physician. As a primary care physician, I take it very seriously that I help my patients when they would like, to navigate some of these decisions and some of these risks, and to assist. So it doesn't necessary have to be a social connection. It could also be somebody on your health care team who you perhaps haven't considered bringing into the loop. For example, for your orthopedic surgeon, because you think that's just my knee surgery, so why does my primary care physician need to be involved? Well, he or she doesn't need to be involved, but they certainly could be if you are feeling like you need to talk it out and hash it out and understanding. And there's also your anesthesiologist, really, if you're in the immediate time just before, if it's a procedure.
Your anesthesiologist has a lot of knowledge. They've seen a lot of things go right and go in a way that needed intervention. And so they're also a person that when they're in a rush, you can say, can I just ask you a few more questions or can you just really tell me. Alyssa, jump in if there's a better, more broad question, but I understand you think this is going to go smoothly, but like if there was something that's going to go wrong or something I need to be aware of, since you've done this so many times, what am I not thinking about? I think that's a fair question. Alyssa, do you agree?
Dr. Alyssa Janousek: Absolutely. And I've had a few patients ask me that broad question. Hey, I'm concerned about what doctor whatever my surgeon said. Can you explain that part to me a little bit? And I often will answer, at least to the best of my knowledge and I say that I'm not your surgeon, but I do see abdominoplasty’s all the time. So I can tell you from my perspective, I can answer this question from my perspective. So often I will get asked questions about the surgery itself, and I always answer to the best of my knowledge. And it is very appropriate to ask your anesthesiologist because we are present during the procedures. We see them all the time about either a risk or a small question that wasn't answered. Often we are the last person that you meet or see before going back to the operating room. So you've had this 15 or 20 or 30 or however many minutes to process all of the answers that you've heard from your proceduralist or your surgeon, and then you still have a few questions. You're always welcome to call the surgeon back in, but often they're in the operating room and if your anesthesiologist is there, the last person to speak to you. We're happy to answer those questions as much as we can.
Susan Lieu: I love these tips. I never knew that I could ask the anesthesiologist or go back to my PCP because honestly, I always felt like I was bothering them because their time is so limited, because of how modern healthcare is. I like this reassurance because I had no idea I could.
Dr. Denise Millstine: It's possible that your primary care physician might say we need to make an appointment to talk about this. Because you're right, if you want them to really get their head wrapped around it and have a thoughtful conversation, then it probably does need to be an appointment or, you know, at least a virtual or a phone conversation, etc. But that is going to be covered by your insurance if you're privileged enough to be insured and probably money well spent, especially if something is worrying you or causing a level of concern.
Susan Lieu: Yeah, I want to make a cultural point here, which is something about the respecting of doctors. As Vietnamese people, doctors are so high on the social ladder and so challenging them, asking them questions, all of that is kind of taboo. It's seen as like, “Oh, you don't trust them.” You would never do that. And so I think back to my father, when my mother was in a coma, he was just receiving information as truth. There was no idea of a second opinion or clarifying things. Right. And so I guess my urge to anyone who is a provider out there listening is that be aware of that cultural context too. Some folks don't even know what questions to ask, let alone, will find that as I don't want to threaten and challenge you as if I don't trust you, because actually, I think everything you said is right.
Dr. Alyssa Janousek: Right. I really appreciate you saying that because that's something that I do my best to try and understand culturally where my patient is coming from and how I can kind of bridge that gap if need be. That's difficult sometimes in such a short interaction. So it's helpful to know what may certain cultures be feeling when I'm saying this or explaining this, or not feeling like they can ask a question.
Dr. Denise Millstine: And my hope would be that is something that's shifting. Now, to continue to restate but not only is your father, your father, but this was the 1990s, where this paternalistic, is how we frame it, paternalistic practice of medicine; “You do this because it's what I said,” was probably much more the vibe than in the 2020s, where there's a lot more collaboration in care and shared decision making, and there absolutely should be.
And again, not to be a broken record, but asking a question doesn't have to be a challenge. It can be just an ask for clarification. And then except for in emergency situations, asking for a second opinion, it's really never threatening. And if somebody is threatened that you went for a second opinion, that should raise some red flags for you as well. So again, when your mother got care in the hospital, this is not the time to ask for a second opinion. These people are trying to save her life and they're two blocks away and you're lucky enough to have a major medical center right there where you could get intervention. But if you're saying, I'm interested in having abdominoplasty, tummy tuck, it's not a bad idea if you can, to talk to some different surgeons. This is a little easier, particularly when you're looking at something that is medically indicated covered by your insurance. A knee replacement, you can meet with more than one orthopedic surgeon, and you can get all of that information. Who's your team? How do I feel when I'm around you? Can I ask you questions? Have you done this a lot of times? All those things and then you can weigh those side by side to decide. Who am I going to go forward with? Which anesthesia group do you work with? Right. This is important.
Susan Lieu: Here's another kicker friends. When my mother goes to UCSF Mount Zion for care, two decades later, I'm going through the depositions, I'm going through the medical report only to find out that her operating plastic surgeon had lost care privileges at Mount Zion. You know what I mean? Like patients don't know to ask; have you ever lost your privileges anywhere? Right.
Dr. Alyssa Janousek: And another important thing, if you're having an outpatient procedure is to ask, if there is an emergency, what are your next steps? At this outpatient freestanding, meaning not attached to a hospital or a major medical center. Where do we go from here? Do you have privileges at a hospital? Do you call 911? Who comes to help if you guys need help or your team needs help and I need to be in a higher level of care? Also, an important question to ask.
Dr. Denise Millstine: Should we talk about the beauty standard and how your mother, fierce, at the beginning of the episode, we talked about this fierce force, successful matriarch, business owner, just an amazing woman. Beautiful, for those of you who haven't read the book, look at the pictures, decided to have plastic surgery in the first place.
Susan Lieu: Boy was it heartbreaking to only learn through the medical records that she had had plastic surgery before. That she had breast implants years prior, and actually another chin implant and an eyelid surgery. I didn't know all those things when I was 11, and it's heartbreaking. In one of my one woman shows, I think it was the second one. I said, you know Ma, if I saw you on the street, I probably wouldn't want be friends with you, you know?
Because like in my world, I've put people in categories, right. Oh, you're into plastic surgery. You're vain. You know, where are your values? And yet, I have to live with this complexity that her values were very much centered on the family. So much so that she worked seven days a week. Everything was always for the family. She sent money back to home to Vietnam. And only after I have now had a kid, as I have aged in my female body, I'm like, I get it. I get that she wanted something for herself. She had no time for self-care. She had no time for exercise.
She was sitting in her salon chair all day long. And so in a way, this tummy tuck was this fast track to having her pre-kid body after four kids. I lost my mom to a botched tummy tuck and I still squeeze my belly fat wishing, man, just come on 15 pounds. I've been wanting to lose these 15 pounds for 15 years. Okay. And it's like, so I guess I just want to say there's one element of I get it now, now I get it right, I, I get how the worthiness of your self is tied to your body. And it's not just the media, it's not just looking at the Kardashians that do this. It's also culturally what we reinforce as a family. Small comments here and there about how you look. That's the first thing my family always says, “Oh, you, you’re fat.” You know, right after my mom died a few months later, they were like, hey, don't eat that second bowl of rice. If you eat too much, no more will ever love you again and you'll die alone. So don't become a spinster. Lose some weight, you know? And I wasn't even. I was a little pudgy, but I wasn't that, like, obese. There wasn't something significant here. Maybe I was born in America and wasn't malnourished like the rest of my family, right. I grew up in America, so that's the first difference. But the second one is there is an expectation for the female body to fit in our traditional outfit called the ao dai. It's a long tunic. It's form fitting, actually, and there's little slits that you can just see, like an inch of skin on your waist, like it's like scandalous. But because I did not have that body type, I was reminded day in and day out that I'm not enough and I believe them. And I still, hear it in my brain, because now I have inherited that voice and I beat myself up all the time.
I did this TEDx Talk. It's called “How to Make Peace with Your Belly Fat.” Check that out. Right. So I what I'm trying to say is I'm still doing the work around that. And so when I had categorize my mom as this, like vain woman who is so selfish and she could have prevented this. And why did she do this to me? Why did she leave me? There is now this empathy as I age of this understanding of why.
Dr. Alyssa Janousek: Honestly, no matter how you grow up or no matter what your influences are growing up, there is always that beauty pressure. I am very fortunate to have a mother who never mentioned body image to us. But I grew up in America around other females and I have very similar post-baby issues with body. I am fortunate to have my mom's voice in the back of my brain saying, you know, it's okay, but it's always in the forefront. It's not always media. It's just people around you and you always judge yourself based on that person next to you. And the beauty standard, I think anywhere, but in America, in my experience, is impossible. It's impossible to be perfect to whatever standard you build up in your brain or whoever is around you builds up to you. And so coming from little bit more of, definitely a different background, I still struggle with that stuff. That beauty standard is impossible.
Dr. Denise Millstine: I want to be cautious that we are not making a blanket statement that plastic surgery should not be done, because for many people, I see mostly women, so I'm going to say for many women, but truly for many people, the plastic surgery is something that adds to their confidence, adds to the way they feel about their own body.
At Mayo Clinic, in many ways, plastic surgery is to correct some changes that have happened from other surgeries or to correct an asymmetry, or to help with a part of the body that's causing symptoms. So I think we have to be really cautious about making sure if you are considering an elective surgery, that you're doing it as safely as possible. So this is not something to get at a bargain price. You don't go for the discount plastic surgery basically ever. And also to make sure that you're doing it for the right reasons. Meaning it's for you, it's for your body, it's for feeling better in your body. Not for some other person's appreciation of your body, whether that's society or a partner or who it might be. There are many people for whom plastic surgery absolutely is the right choice. But then if you make that choice, make sure that you're doing it carefully.
Susan Lieu: With my mother's example, it's the most egregious. Right. The man was on probation, had so many lawsuits against him, no malpractice insurance, like lost privileges. This was, the writing was in a way, on the wall. This is not going to be every single provider that you run into at all. I think he's an anomaly, but he's my unfortunate anomaly for the rest of my life. And so I just really want to encourage listeners do their research and to do their due diligence. And I mean, going back to the tummy tuck and around eating and exercising. You know, maybe unpack eating and emotional eating and maybe there's going to be a breakthrough there. Right? I just wonder is the tummy tuck the only solution. Because I think around worthiness, that is an ongoing thing. Right. And the desires I think of perfection perhaps will never end. Like there's always something to correct in a way. Like I guess I just want to delineate too, like there's many types of plastic surgeries, I get it. But like, did she really have to get it? You know?
Dr. Denise Millstine: And it turns out that was her choice to make.
Susan Lieu: It is her choice and she is an adult and she wanted it for herself. That's what I'm trying to do with the memoir, is that my mother's an anti-hero. She's complex. The people who hold your hands when they do your nails, they can be all things. So I just wanted to humanize her and humanize this experience.
Dr. Denise Millstine: And it shouldn't be lost that she's working in the beauty industry. She's literally creating hands for people that are not natural. You know, the putting the nails and decorating them. That's not just going to grow that way. Right? So she's about this esthetic. It was her world, her professional world anyways.
Susan Lieu: I mean, and we can unpack all of that too, right? Like this was a career she could easily segue into with limited English and a number of Vietnamese people were teaching each other how to do it. Like that was what was available at the time. In terms of would be more of a cash cow than being a seamstress, right. That's its own socio economic, political thing that we can address too. But at the end of the day, how necessary is a procedure? Are there other potential solutions? And have you done the research?
Dr. Denise Millstine: Coming in with your eyes open and with agency and knowing that you can advocate for yourself or bringing somebody alongside you as an advocate and an extra set of ears. It's critically important.
This was such a powerful conversation. I want to thank you both for being here with me and talking about “The Manicurist’s Daughter.”
Susan Lieu: Thanks so much for having me. I think when we can talk about uncomfortable things, we can talk about shameful things, we have liberation and freedom from that. So thank you for having me.
Dr. Alyssa Janousek: And thank you for having me as well. I really enjoyed this conversation.
Dr. Denise Millstine: “Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. Our producer is Lisa Speckhard-Pasque and our recording engineer is Rick Andresen. This episode was made possible with the generous support of Ken Stevens.
The podcast is for informational purposes only and is not designed to replace a physician's medical assessment and judgment. Information presented should not be relied upon as medical advice. Please contact a health care professional for medical assistance if needed and with specific questions pertaining to your own health.
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