In January 2006, a fourteen-year-old named Uli broke his arm snowboarding in the Bavarian Alps. The repair was routine. The anesthetic was routine. Uli took hours to wake up, and when he did he was confused and vomiting. An MRI found two small white spots deep in his brain, in a region that helps control movement. Every test that followed came back negative.
His mother, Yaremy Hernández Castillo, is an internist. As Sarah Zhang tells it in a long piece in The Atlantic, she spent most of the next twenty years trying to understand what happened to her son, on her own time, while colleagues told her the theory forming in her head was absurd. She collected fragments as they came. Another mother in Caracas, picking up the same medication for her own son, mentioned a cluster of anesthesia injuries years earlier. An expert reviewing the case said the lesions looked like inherited mitochondrial disease. A genetic panel in Houston found no known mutation, only a short list of variants of unknown significance that drew little attention.
Then in 2020, her cousin’s thirteen-year-old son had knee surgery in Austin and struggled to wake up. His scan showed two spots in the same places. One case in a family can be bad luck. Two is a pattern. A variant on Uli’s old report turned out to run through their shared maternal line, and with researchers in Spain she assembled seven patients. Same rare change in their mitochondrial DNA. Same inhaled anesthetic, sevoflurane, one of the most widely used in the world. The study made the cover of Anesthesiology this June. Professional societies on several continents now recommend asking patients about maternal Venezuelan ancestry before anesthesia.
Zhang has a line about where Yaremy stood years before the answer arrived: “She already held key pieces of the puzzle.”
What slowed her down was that the pieces lived in different places. No hospital that treated those boys ever saw more than one of them. Uli’s anesthesiologist replayed the surgery in his mind and could find no mistake, because inside one operating room there was no mistake to find. The pattern only existed across sites.
I opened our clinical council’s fall retreat with that story last week. I chair the council for the anesthesia management company where I’m chief clinical officer, a group that provides anesthesia at about 150 sites, from academic centers to two-room surgery centers. Most of the people around the table see patients: physicians, chief CRNAs, medical directors. The council exists for a smaller version of the same problem. A group our size can see what no single site can. I’m also the one grading this meeting, and a company like mine has its own reasons to want standards. That is why the council, not management, has to own them.
That raises a harder question, and I had to answer it before the meeting started. Once you can see across 150 sites, how much do you tell them to do?
A frame, not a picture
Yaremy was working a puzzle with one right answer and no box to show the final picture. Setting standards for 150 sites is closer to a LEGO set. Anyone who has built a large LEGO set knows the moment. With ninety percent of the pieces in place, there is only one thing the set can become, and it’s printed on the box. Dump the same pieces on the floor, minus the picture on the box, and they can become almost anything.
Much of the standardization I have seen in healthcare runs like the nearly finished set. Someone senior arrives with the complete picture, a protocol or a policy already assembled, and asks the room to agree. The room agrees, or appears to, and the picture ships to sites that had no part in drawing it.
Hand people the picture on the box and they will build the picture on the box.
So, with one exception I’ll come to, I did not bring one. I brought a frame. The council decides. Management, which includes me, supports the work. Every standard the council endorses is a floor: the thing every site does unless there is a good clinical reason not to, with any site free to set a higher bar if it has the resources. When a clinician practices outside the standard, the conversation should come from a colleague, not an executive. Past that, the picture was theirs to draw.
What they drew surprised me. Handed authority to build and set standards for 150 sites, the room’s first instinct was restraint. In a change management session on the second day, the clinicians kept returning to the same guardrails. Don’t be overly prescriptive. Respect how different the sites are. Call it a recommendation where a recommendation will do. Protect the buy-in of the people who will have to carry the work. People who have spent careers on the receiving end of a finished picture know exactly what it costs.
What came out of that session was a deliverable for local facility governance, and it does not announce a standard. It invites each site’s feedback and asks what questions they want the council to take up. Floors go out. What the sites see comes back, and that return trip is how the next pattern gets seen.
The draft that did not pass
Motion after motion carried that day without opposition. We adopted a guideline for patients taking GLP-1 medications that the room reworked from my pre-read, adopted a policy on sterile compounding, and confirmed how we select patients for surgery centers. A unanimous room should make any leader suspicious, and it made me suspicious. Agreement is easy to get when the person chairing the meeting is also a respected or senior person in it. In my feedback after a break, I asked for more active engagement, and said I wanted to remove any sense, my own included, that I was driving the conversation toward a specific endpoint.
The clearest evidence that this room was collaborating rather than deferring came earlier that day, from the one finished picture I had brought.
I presented a perioperative glucose standard, merged from two existing protocols and aligned to national guidance, with a treatment threshold and a recheck cycle. The room took it apart. Does every operating room have a glucometer? What happens to the schedule when you recheck every thirty minutes? What do you do with the patient who has never needed insulin and whose sugar climbs after the steroid we gave to prevent nausea? Will the surgeons follow it? The point that ended the discussion came from across the table: a written standard we don’t follow is worse than no standard at all.
That was right. We did not adopt it. We formed a work group with a ninety-day clock, and I’m co-leading it with a CRNA colleague.
Had the room deferred to the picture I brought, we would have shipped a policy that read well and failed at the bedside. Instead, the people who would have to live with it showed me which pieces didn’t fit, before anyone had snapped them into place.
What an empty box costs
The strongest objection to all of this comes from the operating room itself. When a patient is crashing, you don’t convene a council. Someone takes charge, says what happens next, and the room executes. We train for that, and we are right to. Some decisions need the picture on the box, and they need it now.
There is a slower version of the same objection, and the council named it themselves. Without a picture, a room can talk without deciding. When the group mapped where change breaks down, missed deliverables for lack of a decision made their list. A floor can also harden into a ceiling if the council never comes back to raise it. And a glucose work group could easily become the place a hard question goes to wait.
My answer is that the frame has to carry a clock. Withholding the picture is different from withholding a decision. The glucose group reports in January. The guidelines that did not reach a vote move by email within a month or two rather than waiting a quarter. A council that never finishes anything has stopped collaborating and started stalling, and the clinicians at 150 sites will be able to tell the difference faster than I can.
Holding the picture back
Yaremy never had the box. She had a scan, a rumor, a line on a genetic report, and eventually a second boy with the same two spots. The answer came from putting pieces from different places on the same table.
Leaders in medicine are trained to do the opposite. We arrive with the plan, and most of the time that is what the moment needs. But when the work is setting how hundreds of clinicians will care for patients at sites I might never walk into, I’d argue the most useful thing I can do is set the frame, keep the clock, and hold the picture back long enough for the people closest to the work to see what the pieces can become.
They built something better than anything I would have drawn.