ASGBI_4_sustainability_02.27.25

Hello and welcome to Behind the Knife. Once again, we have another awesome collaborative episode with our partners from across the pond through the Association of Surgeon in Great Britain and Ireland, where we take a deep dive into the many facets of surgery and compare how things are done here in the United States as well as in the United Kingdom.

If you've tuned into our earlier episodes, you know that we welcome expert guests from each country to enlighten us on what it's all like. At the end of the episode, you as the listeners, get to decide for yourself who does it better. I'm John Williams, one of the Behind the Knife Fellows, and I'm excited to once again have both Kelly Bateman and Jared Wget from A-S-G-B-I co-hosting with me, Kelly and Jared here to introduce our topic for today's episode.

Yeah, I'd love to. So I'm Kelly stay from A-H-G-B-I-A surgical trainee in Wales. And I'm really excited that today we're gonna be discussing sustainability and green surgery. We know it's becoming an evolving hot topic, especially in the uk and we know that healthcare contributes sort of four to 5% of greenhouse

emissions globally with our operating theaters.

Contributing over half of this. So there's definitely plenty of room for improvement there. So today we're going to explore what some of the issues are and hopefully find out some solutions to reduce the waste and emissions from both sides of the pond. And, hello, I'm Jared. Surgical trainee in Scotland, and I'm delighted to introduce our UK expert, Mrs.

Cleo Kennington. She is a big fan of the podcast, but more importantly, she is a consultant, emergency general, and trauma surgeon at St. George's Hospital, London. And was the recent A-S-G-B-I sustainability lead. In America, you'd call her Dr. Cleo Kennington or Professor Cleo Kennington. But in the UK we, we call Mr.

And Mrs. For our surgeons. She's a big advocate for practicing what she preaches, focusing on how we can reduce the environmental impact at all stages, including cycling to work, preventing complications and unnecessary

surgeries to reducing the use of disposable surgical components. Welcome to the podcast.

Thank you. Alright. And for our US based expert, we're excited to have Dr. Ben Miller with us. Dr. Miller is a general and minimally invasive surgeon at the Cleveland Clinic with a clinical focus on complex abdominal wall reconstruction. After earning his MD from University of Minnesota School of Medicine in 2011, Dr.

Miller went to Nashville to complete his general surgery residency at Vanderbilt University Medical Center. Following this, he became a MIS complex ABWA Fellow at the Cleveland Clinic under Dr. Rosen after which he joined faculty in 2023. In addition to his clinical interest, Dr. Miller also has a deep passion for sustainability efforts within surgical practice, carrying on the legacy of established sustainability efforts within surgical care at the Cleveland Clinic, and training the next generation of sustainable surgeons.

Dr. Miller, thanks so much for joining us. Thanks for having me. Lovely. So perhaps we can kick things off with some of the basics. Where, where do the emissions in

surgery come from, and what does sustainability in surgery look like? Where can we get started? Mrs. Kennington, why don't you start with what we know from the uk.

So what we know from the UK is the. Carbon emissions from an operation don't just come from the theater. There's everything around it including the patient's journey to the hospital, how many visits that they have before the the operation as well as. Even thinking about the staff travel and how staff get to the hospital, focusing on public transport and active travel.

But from when we are, if we are thinking more in this podcast about the actual operation itself, there are three main sources of carbon hotspots. That's the anesthetic gases. So the halogenated anesthetic gases actually have a global warming potential up to 2000 times. That of just CO2. And so a lot of work is undertaken, especially with anesthetists from the uk.

Looking at ways to reduce this. So an important thing we as surgeons can do

is to think about using local anesthetic. But also the gases used by the anesthetists are being looked at. We know that des fluorine is the worst anesthetic gas. So there's loads of work done in the UK to reduce the use of des fluorine and switch where possible to intravenous anesthesia.

The next carbon hotspot in the operating theater is energy use. We use a lot of devices in theater. There's a lot of, computer systems also with the anesthetic machines. But the biggest energy is from the HVAC system, the heating, ventilating and air conditioning system that keeps the operating theaters at the right temperature and with airflow.

And one of the ways that you can save the most carbon within the operating theaters is to think about switching those up. That. Off when the operating theater's not in use because the it only takes 20 minutes for those machines to power on and get the operating theater go in, in action.

And often the theaters aren't working overnight. So, work is going on within the UK to be able to switch those machines off overnight. And then finally,

the edit, the, the third highest energy. Sorry, CO2 source is from the single use consumables, and we use loads of those in the operating theater.

So it's really looking at where you can switch from single use to reusables, so where that, whether that's with the drapes, the gowns and, and then many of the instruments and when you can't use reusable instrument may sometimes using hybrids. So, instruments that are partly, reusable and partly single use.

And I use those for my ports for laparoscopic operating. And then there is a small amount of energy use from heating the water for for scrubbing and for sterilizing of the instruments. But compared to those first three, that that's much less. Thank you very much for that. Mr. Kennington. I think that's really laid, the foundations of our understanding in some, some of the key issues that we face in surgery.

And Dr. Miller we know that the US has the highest healthcare emissions globally. And why do you think that is? How does that compare to the uk? What can we do about it and why, why should

ca surgeons care? So America does generate a lot of, of greenhouse gases and the health healthcare industry is, plays a big role in that.

I think we, the, you know, US healthcare generates somewhere between eight and nine or nine to 10% of our annual greenhouse gas emissions and surgery is a big contributor, right? But we don't actually know how much surgery contributes to that number. And so the, the, but to back up a little bit, your question about why American healthcare generates so many greenhouse gases compared to other countries is a good one.

I don't know how much, you know, the UK generates, or how much, how much less the United Kingdom generates than America, but I'd be curious to know. I think that, you know, Glo the. Of the global carbon healthcare footprint. America generates about a quarter of it, if I'm not mistaken. And we don't, you know, I don't think we have a quarter of the world's people, so it should be smaller than that.

First surgery is resource intensive,

right? We know that the operating room uses five to six times more energy per square foot than other areas of the hospital. We use half the hospital supplies. We generate. 30 to 70% of the hospitals waste. So anything that's going on in the operating room is using a lot of resources and generating a lot of greenhouse gases.

We are incentivized in America to do things, to do, especially to provide, to do healthcare stuff in general, and especially to do operations because that is how the hospital generates most of its revenue. And so we as surgeons are always asked to do more, to do more operations, to see more patients, and we generate.

More greenhouse gas is doing that. And so I think that that we don't, to be fair, we don't know exactly the carbon footprint of surgery, of American surgery. That number is unknown, although Woodson, they like to get to the bottom of it. But we do know that overall that the carbon footprint of healthcare is huge and a lot of that is

driven by surgeons in surgery.

And why should we care about this Because. This affects all of us, right? It affects Americans, it affects our communities, but it also affects people across the planet. The greenhouse gases that we emit here are felt everywhere. And so, and we know that greenhouse gas, you know, that greenhouse gases, the, that fossil fuels are burning and.

Sort of is supercharging greenhouse gas effect. And this affects patients across the world. And it, you know, it worsens outcomes of people who have cardiovascular pulmonary diseases. It changes the distribution of vector-borne diseases. It, there's even some evidence that, you know, we know that heat related illnesses are rising and there's some evidence even that.

That heat causes increased violence, even, even when accounting for seasonal variability. So I think that these, that we should care because we're, we're doctors and we're people, and we should care about other people around the world and how the delivery of surgical care in the United States is potentially worsening healthcare outcomes across the world.

Across. Okay, well, of course it's vitally important to consider the environmental impact of surgical care. It needs to be kept under the wraps of the broader context of cost. We could propose all sorts of green initiatives, but our managers won't approve of it unless it's cost effective or even cost saving compared to what we do at the moment.

So, Dr. Miller, maybe we should start with you. You've just described how, how expensive things are in states and how you're incentivized to do more. But how do you think healthcare economics. Influences sustainability and what are the implications of costs and attempts to make surgical care more sustainable?

I would say that luckily this is an area where they typically align often, so the. When you to make things more sustainable in general, we try to make them reusable, right? Like, you don't, every time you need to put a t-shirt on, you don't go buy a new t-shirt, you wash the T, you know, you wash your T-shirt and reuse it.

And so I think the

same thing applies to, to surgery. I. And especially with textiles in the operating room. And so if something is reusable, you pay for it one time. Like we don't, you know, when we do a laparoscopic case, say we don't open all brand new laparoscopic instruments. We reuse the instruments we have, or even an open case, any case, and because it's cheaper that way, right?

We invest some capital in instruments and then we wash them and reuse them. Which makes sense. And so I think that a lot of these, a lot of the, the most impactful sustainability initiatives involve just simply reusing things instead of buying new things. Unfortunately, we live in what's often called a linear economy, right?

Where comp, where healthcare industries incentivized to sell you things forever and ever and ever. And so they want, they want devices and textiles to be disposable so that you have to buy new ones for your next case. And. So, but anyway the more we can get toward reusable things in the operating room, textiles and instruments, the

more money we save there.

There are other logistical supply chain issues with some reusables laundering sterilization, and I get that, but most of the time you save money by. Purchasing something up upfront, maybe a little more upfront cost with, you know, Dr. Kennington referred to trocars, right? So using reusable trocars, there is, you know, there's extra sterilization costs that may go into that.

But overall, the big picture overall is that in the long run, by using reusable devices and textiles and items you typically save money instead of spending more money. And the last thing I'll say is. When it comes to supply chain shocks, right, like we saw during the pandemic, you are much, your, your system, the healthcare system is much more resilient if you're not relying on disposable items.

If you have a, a system, a circular economy set up locally where you can use something and then clean it and reuse it, and you don't have to rely on something shipped in from overseas that are susceptible to, to supply chain disruption. So. It's another reason

to switch to reusables. It saves you money and makes your healthcare ecosystem more resilient.

That's really interesting. So you're basically saying you need to spend money to save money. But that implies you need money in the first place. Mrs. Cannington in the UK are, are we able to invest in capital in our hospitals, buying more surgical equipment that is reusable rather than. Maybe the case by case, cheaper alternative of making, buying single use items but the longer term expense of single use items.

Do you think we are good in the UK at reusing instruments and buying good kit? So I think every hospital is different, but I know at my hospital at the moment, we're doing a lot of work and what we're trying to do is. Yes, we need a little bit of money upfront, but each project we do, we then demonstrate how much money we're saving.

So for example, they bought a whole load of reusable theater hats for all the staff. And not only were they reusable, they also had the

staff's name on it, which helps a lot with team working. I dunno about anyone else, but I'm not very good with names and because there's so many people in the team, they all know my name 'cause I'm the boss, but I don't know their name.

So I found it really helpful having everyone having their name on their hat. But then that same saved us loads of money over a period of time on the re on disposable hats that we've then we've really made sure we calculate that. So we've then been able to reinvest the money that we've saved into the next project of doing and di different things.

So we just, it's a kind of self-fulfilling prophecy of saving money of each different project that we're changing on than, you know, than using the reusable instruments and things. Just a side question then. It was mentioned that in the u in the US there's a lot of incentive to do more operate, more specifically operate.

And the UK we don't have that same pressure, do we? I mean your, your wage, unless you know, private work aside, your wage doesn't go in, go up if you do more and more operating necessarily. So how would you approach that

conundrum? I mean, I feel not, not just for operations, but we can, we are, we are incentivized to re reduce costs.

So making kind of developing protocols that are very clear of when you need to intervene and when you don't, to try and identify when you don't. When you wouldn't need to in intervene. And because I know it I guess for me it's, I know I'm not gonna lose income from not doing the operations.

It's really it helps me to have those conversations without feeling pressured to make the patient I. To undergo the intervention. For example, there's a big push towards shared decision making where we're recommending to, to get to talk about benefits, risks, and alternatives and what will happen if we do nothing.

So the patient has a real understanding of the treatment needed and a lot of the time using this, this process, the patient then opts not to have the operation, which may be the best outcome for the patient because there's a lot of evidence that. A large number of patients have regrets of undergoing treatment.

So if you're gonna do an operation for a patient that then who then has

regrets, that's a real waste of carbon. So it's really important to make sure that we, we don't do operations when then they're not indicated. I think that's such a fascinating aspect that I've never really thought of through a sustainability lens, which is, you know, providing the correct care for the patient and having a, you know, a shared decision making conversation and things like that.

I think that's actually really contributes to a compelling argument for you know, thinking critically about the indications for a given intervention as Dr. Miller mentioned. Our system is built around a fee for service value system that, whether it's conscious or not does incentivize interventional therapy, but I do think that, you know.

If you add sustainability to the equation of also, you know, doing the right thing for the patient, not subjecting them to the obvious risks of a given operation as well. You know, you can do a lot more harm than good, but not just for the individual iteration of of care, but for the environment at large.

So this is really helpful. You know, I think we, we did. Talk quite a bit about this concept of reusable items and instruments and things like that in the or. I

do think that, you know, my humble experience as a trainee right now, it's pretty blatantly obvious that a lot of medical and surgical innovations.

Don't take that into primary consideration. At the same time, you know, you develop the fancy fenestrated endovascular device for aortic reconstruction, but that's a single use item and costs probably more than I make in a year. So, you know, just things that I think maybe should be more at the conscious forefront for.

Innovations as well. So when you, so one of my partners just came up with a device to help us with abdominal wall reconstruction, and he worked with the Cleveland Clinic to build this, this new device, and now he's working on patenting it and he is, he is showing this device to industry their, their question because we.

Industry works in a linear economy, works best for them in a linear economy. Their question for him was, what are any of these? The device is totally reusable, everything is totally sterilizable, totally reusable.

And they asked him as he's pitching this device to them, well, could we make any of these components disposable?

Because then every, every time you use it, then you, you have to pay. More to use it. So I think we're, our, our priorities are not aligned. I think they could be aligned better with industry. But that is, you know, may require policy changes or require a lot of work to get us all on the same page. But that's sort of the reality of the situation with, you know, surgery and.

And our industry partners, I, I don't know if this is going to work, but a big part of the NHS net zero kind of policy is working with industry and they have sort of a timeline where it, they won't, because the NHS is such a big organization for procure procurement, what they've said is that the industry has to comply with their.

Net zero goals for us to be able to buy from them. So it's a real push to industry to make more sustainable

equipment. Where I see that failing is where you've, what you've just said about, I think that industry is going to say, oh yes, we are producing it in a net zero way, but we are still making it as a single use.

So I, I, I dunno if it's going to work, but I, I'm, I'm hoping they're making progress on it. Yeah. There's something about the United States and having industry. Healthcare delivery and the government being all the same page. That seems to be particularly challenging. So, Mo moving on. I know we talked a lot about this concept of reusable items and also a really interesting take on indications for interventions versus you know, making shared decisions with the patient.

Also with the sustainability mindset. What are some other kind of core areas of sustainability to be gained that you see within surgical care? I, I think of this in sort of three domains, and I think of this in the operational domain where we practice clinically, and that's most of what I do. And then there is the educational domain where we teach medical students and

trainees and other staff about how to deliver surgery in a way that's more environmentally friendly and to care about these issues.

And it's one thing to learn about them, but it's another thing to change behavior and could have a whole podcast on that, I think. And then the third domain is research. And what are we doing to learn more about the intersection of climate change and surgery? And so I. I think that surgeons, academic surgeons in particular, are well positioned here because this is what we do every day, right?

I work in a clinical realm and educate trainees every day and do research as part of my job every day. And so I'm thinking about these three areas continuously, and so it's easy to, to transition sustainability into these three domains. And as far as the operational domain goes. There are easy ways and more difficult ways to transition to, to a greener operating room, and we can, we, we can talk about those things later on as far as education goes, I think, I think that, you know, it's.

The

department, the institute, the state I think there are like ma macro measle and micro levels of involvement here. And I think surgeons can play a role at each of these levels to get to, to build a culture of sustainability and to get engagement from trainees and other surgeons. And then as far as research goes, I don't know that there's gonna be much, you know, federal funding for climate change research research in the next few years.

But there are, there are there. There are still. The study's ongoing and we're part of those things. And we have a pretty robust research group here. And so I think, you know, questions to answer are, you know, for reprocess instruments, for example, like a reprocess surgical harmonic scalpel, those are available and some people are hesitant to use them because they worry maybe they're.

They impact that maybe, maybe the, they have higher failure rates or maybe they, their wound morbidity will be higher if they use one of those. And so, you know, what doesn't exist out there is like a, for example, like a clinical

trial comparing a reprocessed device to a new device. And does that have an impact on clinical outcomes?

Like, like wound complications. And so these are things that we can explore and should explore, but there's a lot of work to be done. This, this might be a complete sideline, but you know, even, even in the. Realms of solar panels electric vehicles, you know, for many years, for decades in Europe and America, there were incentivized government incentives to buy these things.

And now those government centers are decreasing and decreasing as the price of these things comes down. And eventually, and possibly it's already happening that, you know, the amount of. Government subsidies that is required for these things is essentially non-existent because they have become market viable compared to a non-sustainable alternative.

So, I dunno, hopefully we get to that point in male healthcare industry as well. Okay. And building from that particularly Ms. Kennington, what do you think that, how clinicians can help influence more industry and government

to get those more sustainable items and to think about the bigger picture?

Things from some of your experiences so far? I do think influencing industry can be very difficult because. They don't want their remanufactured instrument to be used. They want you to be using the, the single use one. So I think it's the clinic. It has, yeah. It, it has to come from the clinician want wanting these things.

The one thing that I haven't found on the market, which I to make sense to me, is a reusable stapler. So at the moment, the sta the staplers, they, they are reusable because on in the same patient, you can use the. The staple staple numerous times, you just get refill cartridges and I don't know why they can't make a stapler where the stapler is, can go for re sterilization.

And then you just, you get, you obviously have single use cartilage cartridges for the next patient. So. To me that that's where, that, that's one area that you could, you could make a low cost stapler may potentially,

there's a lot of talk about using it in, in these innovations in the developed world because they can't afford to buy these, the single use items I.

They are kind of wanting to do more healthcare. So maybe that's where these devices may become more used and tried and demonstrated that they are effective. And then we start using them more. In the developed world, I. I think Dr. Kenton is right. I think that surgeons have a lot of power here because the only things that are being used in the operating room are the things that we are asking for, and so we can be better about asking for reprocessed or reuse reusable devices.

I, I don't know how much influence I have over, you know, sort of macro level in Indus industrial and healthcare policies, but at a very micro level we do, we do have a lot of influence and I think that we can work with. With our supply chain as well. And to try to and the administrators in the hospital try to make more sustainable decisions.

And like we talked about before, most of these things, if you can, if you can show that there is a cost savings

and for a lot of these things, there is a cost savings even for using, you know, reprocess devices. The reprocess device is usually cheaper than the new device, and you can demonstrate.

Significant. You know, a place like the Cleveland Clinic, which is a huge enterprise, it can show significant cost savings by using reprocess devices, for example. So, so I don't wanna sound like, like, I don't want it to sound like surgeons can't have any impact here. There are a lot of things out of our control for sure.

But in the end, like it's you and the patient in the operating room with your team and, and you, you're making the decision whether or not to use, you know, a device. So I think that in the end, our choices matter and the teams we build matter and we can have an impact. Thank you. Yeah, I think it is focusing, isn't it, on some of the small things that we can do to sort of help feed into that bigger picture.

Particularly as surgeons, you know, sometimes we're a bit resistant to change. We like the quick wins. Focusing on that sort of clinical domain, have you practiced or got any other examples of sort of simple things that, that we can all do day to day to

improve sustainability in our, in our work?

So I have like a hierarchy of. Of things I think about from easy things to do in a hospital or hospital system, and then down to much harder things and the easy things to do. Dr. Kennington, she pointed out a lot of these already, so in, you know, if your, if your operating rooms have setbacks, so set them back when they're unoccupied, turn the air changes down.

Let the humidity and temperature drift out of their, out of their, you know, required ranges. So there are ways to save money in the HVAC system that way. And then you can reduce your red bag waste. I know this is a little controversial, but we found that just changing the size of the canister to a smaller canister instead of a giant canister that's convenient for everyone to fill, it gets people to think about putting less.

Normal waste in the red bag waste. And so I think reducing red bag waste is all can, is a very, another easy way, another low hanging fruit to reduce your overall waste and emissions associated with disposing of red bag waste. And then you can start a recycling program where

you can recycle high value plastics and some cardboard and, and we have a program like that, but it's required a small grant.

So those are harder things to get started. And then you can, you can start a reprocessing program. I know that Stryker Sustainability would love to come into your hospital and start a reprocessing program just about anywhere they put a bin in your OR, and you collect all the reprocess items and they do it for free.

So, and it's up to you whether or not you wanna buy back those items, but it's an easy way to prevent them from going into the landfill. Then you can, you get to things like other things in maybe easier streamlining your surgical sets. Although you know, whether or not one or two instruments make a huge difference, I think is debatable.

I think you have to somehow shrink the size of the overall tray to make a big difference because of the sterilization processes is what's generating most of the greenhouse gases. In my experience, the hardest things to change are the textiles and not even the sterilized textiles, just the non-sterile textiles.

These things can be very difficult because of the logistics involved, right? The laundering, the getting them, the

transportation back to the hospital, getting them restocked. So on the, on the order of the hierarchy of. Easy things to do to hard things. I think that's kind of how I, how I look at it. But there are, there are tons of low hanging fruit in your hospital to take advantage of, and I would encourage people who are interested in this to start with something small, something easy, build a team and work on changing just one small thing.

Thank you. I think, yeah, that's very inspiring, giving us all a few ideas. And Mrs. Kennington, have you got any other ideas or, I know there's been a lot of college initiatives and college pushes for sort of rub, don't scrub. The green surgery checklist, would you like to expand on some of those? One.

So I, I think a lot, a lot of what the colleges have been working on are what Dr. Miller was giving examples on, there's, there's two, two examples that I'd like to describe which I. Seem sim simple ideas that can make a difference. The first one, it actually was started in Gray Ormond Street hospital, which is a pediatric hospital by the infection

control team.

So I've noticed especially coming through the pandemic that there's. Been an increased use of using non-sterile gloves for everything. Every time you go anywhere near a patient, or even if you're not near a patient, people put on a new pair of non-sterile gloves and actually they don't make any difference for infection control.

The important thing is to wash your hands. And so what the infection control team at Great Almond Street did was a campaign to say, you don't need to wear these non-sterile gloves. And I dunno how it works in the US but definitely in our operating theaters. The, every time the patient is moved from trolley to operating table back again, every time the.

The team around the operating theater do anything new. They put a new pair of non-sterile gloves on, and that is just not necessary unless you are touching the mucus membranes of the patient. Having these non-sterile gloves does not reduce infection. So this campaign in Great Almond Street, they massively reduce the amount of gloves they use.

Saving loads of plastic that they was avoided to going to landfill as

well as saving them loads of money. But I think one of the important things that they showed was that it actually made, it was good for the patients so that the, the kids were reporting that they were actually really scared of people coming at them with these blue gloves on.

And so when they were just normal people, you know, the, with a touch of their hands rather than the plastic. The patients had a much better experience. And so, so, you know, that's a sim, a simple change to reduce waste and and, and, and improve patient care. And so, this, this campaign from Great Ormond Street, it, it has been approved in many hospitals, so certainly within our, even in our intensive care unit now, we don't need to wear gloves when we're.

Going up to patients in the intensive care, we only only if we're going to be doing intimate examinations or getting in, in contact with bodily fluids. So I think that's, that's a simple change that can make a difference. The other one that is is maybe slightly less, less impactful, but a change that I've made recently is in the use of inco pads.

I, I dunno what they're known as in the us. I know in

Australia they call them. Bluey, but inco pads are quite big, bulky things that have plastic in them and they're single use and usually in each operation you use quite a few of them and they all get thrown away at the end of the operation. And so certainly for laparoscopic cases, you use them to wrap the arms round to the side of the patient.

They used, used once and thrown them bin Somebody showed me that they are actually the same size as a pillowcase. And so I've start, I've, I've asked the team to my theaters to use pillowcase instead. And so now instead of throwing these, the, these Inco pads away, every operation we use a, a Pi, a few pillowcase, and they get washed and then we can use 'em again for the next week.

So you, you brought up before, you know, only doing necessary operations, and I totally agree with you, and I think that this is, this is a kind of a controversial area of minimizing. Unnecessary operations and I think, you know, if we take a step back, if we all just stopped operating, we would drive down the greenhouse gases emitted by surgery to zero.

And if we just did, if we only did absolutely necessary operations for people with free air or bleeding or whatever, then it would increase a little bit. But you know, for me, most of what I do are hernia repairs and. Those are our quality of life operation. And so I, I think that we have to be a little careful about this, this idea that we only do necessary operations and stop doing unnecessary operations.

I think it's hard to define an unnecessary operation sometimes, and I think that really only I would hope really that I. That, that only the most unscrupulous surgeons would be the ones doing operations that are not indicated. I think that even surgeons who are doing a lot of operations, even in America, are doing operations that are indicated and a lot of those operations here are for quality of life.

Another, another area to look at is to, is to think about. Reducing, not necessarily reducing the, the number of operations or not, or only doing necessary operations. But I think another way to consider this is to talk about reducing, and I think Dr. Kenton

referred to this earlier, reducing low value care and improving quality of our care.

Right? And so we, we, as we improve the quality of our care, we drive down complications. And complications are expensive, not only to the hospital and to the patient, but they also generate a lot. They have a huge environmental impact. And if we can reduce low value care, things that we do, like preoperative testing, preoperative or postoperative imaging, or even in-person visits sometimes where we ask people to drive a really long way so that we can look at them and you know, do a cursory exam, that maybe something that's more easily accomplished with a virtual visit, something like that.

So I think that there are ways to improve the value of our care and drive down our carbon footprint, but at the same time. Providing high quality care to patients who can really benefit from operations, even if it's a quality of life operation. I think you've both alluded to it a little bit, which is another aspect is having sustainability champions or individuals who are, you know,

minded towards sustainability.

So surgeons who just have a passion for this and share this with, with their colleagues. I think that is one of the things in, in the cur her current hospital that I work in at the moment, EX, is extremely effective. There's one surgeon in particular. Who she'll kill me if I say her name, but she's, she's brilliant.

She, she has made huge changes in our institution, including introducing reusable gowns and reducing all sorts of waste. She's also focused on reducing single use gloves and single-use, use instruments. And even when she's not there, people will say, you know. Don't let such and such know that you're doing this or that you've used second gloves and so on.

So, you know, putting a poster on the wall of the latest checklist or going through a checklist could be useful, I suppose. But putting, putting signage up doesn't always work. People will just ignore it. But having an individual who people know is passionate about this, I, in my experience so far, it's, it's worked really well at keeping everyone in

line and in check.

I think you're right, Jared. I think that having a champion changes the culture of your hospital, and when the culture changes to one that prioritizes and normalizes sustainability, that's when you get engagement from I. Everyone from more staff, from trainees, from administrators, from the allied health personnel, like, like the scrub techs and the nurses and the CRNAs, everyone else involved in the care.

If you have someone who, who values this and makes this vis like a visible priority and is interested in this and is motivating people to change their behavior, I think you can change the culture in a place. And that, that I think is what makes. Sustainability, more sustainable is changing the culture.

Oh, well, great. It's great to hear all that's being done to improve sustainability, both in here in the UK and also across the pond. I think a key question is where do we go from here? What do you think the future of sustainability in surgery

looks like and how can we grow these efforts? So, so I think it's putting all these ideas into action, making sure that we do think about all of these things every time when we're operating a and although I agree with Dr.

Miller there, I just because it's a lifestyle operation doesn't mean we shouldn't be doing it. But I think we need to be very careful about thinking about o only doing operations when, when they are beneficial and the patient understands the, the benefits that they might get from the operation. But also thinking about how we can prevent the patient from needing the operation and when, so for me, as an emergency surgeon, often when the patients come in as a.

As an emergency, it's a real teachable moment. They're in, they're, they're very scared and it they have a lot of respect for us as doctors and surgeons, and they listen to the advice that we give them. So really using that moment to advise them to stop smoking and increase exercise and and, and, and improve their diet.

And, and those are some of the things that will imp I reduce complications and reduce the need for surgery.

But also, I know in the US. They do a lot more than we do in the UK about optimizing pre-surgery to to, to reduce complications. And I hope that we can do more of that in the NHS, especially as we have such long, long waiting lists.

So use the time when the patient's on the waiting list to make sure that they're optimized and they're fit for their operation to reduce complications. So hopefully we can do more of that in the future. I think Dr. Ken is exactly right. I think if we can improve the quality of care we deliver and reduce low value care, it improves patients' outcomes, improves their satisfaction, and drives down the cost of care and drives down the environmental impact of the delivery of surgical care.

And then, you know, beyond that, how do we get everyone interested in this? I think that in a perfect world, everyone rides their bike to work. All the patients ride their right. They ride their bikes to the hospital and we use all reusable instruments, reusable textiles, and the operations are short and everybody goes home the same day without staying in the hospital.

But, you know, I think that that's not totally realistic in the next, in my

lifetime, but I, one thing I will say is that I, I think that as the, as the effects of climate change become more apparent. In the United States and globally, I think people will become more interested in learning how to mitigate this.

And we've, like we talked about in the beginning, we're seeing a rise in interest in this, even among surgeons, which I think maybe the last group on earth to care about this. So it's, so, it is reassuring that, that surgeons are finally caring about this and, and are motivated to make some changes. And so I think we just we keep working to, you know.

To find ways to reduce our greenhouse gas emissions, to work with industry, to develop policy, to work among our societies. I know that Sages and EAES have taken position statements on this recently, and the American College of Surgeons is is interested in writing a position statement on this as well.

So, so, so I think that we get people on board and we stay motivated and, and make changes in our, in our hospitals at the local level. Make changes nationally and internationally. We'll continue to move the needle on this. Well,

this has been an incredibly enlightening discussion, so thank you both for all of your, your expert input on that.

You know, you both of you mentioned that you know, this growing interest in the sustainability concepts are, are certainly occurring and prudent. So for our listeners out there, or anyone else that's. Early in their career, whether it's a, a current trainee or just outta training who might have found this or other sustainability efforts as inspiring as we have.

Do you have any words of wisdom for folks that are interested in sustainability and surgery for kind of getting involved in this space maybe for the first time? I think that you can, you can start by, by building a small project at your hospital, making a team, and if you want help, there are tons of resources out there, so healthcare without harm.

Is, is definitely willing to help you get started. Practice Green Health is a consultant group and they can help you get started. And there at the society level, there are people interested in helping you as well. So if, if you're a general surgeon involved in sages, there is a sustainability committee.

And if you're part of the American College of Surgeons, there's a sustaina. There's at the, the college has all these communities that you can be a part of and there's a sustainability community Now. And I think more than anything, like just talking to people who are interested in this and finding a community of people to collaborate with, you know, both in your hospital but also across the country in your, in your discipline is important as well.

And you can share ideas, share successes, share things that didn't work so well, and changes you could have made. And so I think that there are, there are lots of ways to get involved from, you know, in a society and a kind of a micro level. Yeah. And within the uk and on a si similar level within the A-S-G-B-I and within your societies, but also within your hospital, like Jared was suggesting, find, find a champion within your hospital to help you with your projects.

And there are lots of ideas other sources of the green surgery report has lots of ideas of, of, of su sustainable projects that you can do as well as looking at the green theater checklist from the Royal College of Surgeons.

Well, that wraps up our deep dive into sustainability efforts in surgery in both the United Kingdom and the us.

I hope that all of our listeners found this is informative and inspiring as we certainly did. Now that you've heard both sides, you as the listener get to decide who does it better, the UK or the us. Of course, I. We'll leave it up to you. Thank you, Mrs. Kennington, and, and thank you Dr. Miller again for spending your time with us and, and for sharing your experience and expertise.

We certainly do appreciate it. For the listeners out there, stay tuned for more Behind the Knife as SGBI collaborative content coming soon. And as always, if you have any thoughts, questions, feelings or comments, please feel free to reach out to us at hello@behindtheknife.org. Mrs. Kennington, do you care to do the honors to send us off, dominate the day?