JC: Sustainability and Climate Change in Anaesthesia. St Emlyn’s

Healthcare has a huge environmental impact and contributes to climate change​1​. This appears to be irrefutable (Ed – there will be skeptics), with effects from transportation, greenhouse gases (notably Nitrous Oxide and other anaesthetic gases) and the high volume of single use items/packaging and production.

On a personal level it’s interesting to reflect that at home we recycle as much as we can, and yet at work there is far less impetus or encouragement to sort and recycle on a daily basis (although @drcjf pointed out that our hospital has won awards for environmental awareness and change). Vast amounts of plastics and paper are simply thrown into landfill or incineration. In some cases this will be unavoidable (contamination for example), but the point is that our behaviours within healthcare are not as overtly focused on recycling and the reduction of environmental impact.

The NHS has arguably made significant progress already with a carbon reduction strategy in place since 2009. Back then the carbon impact of the NHS was 21 Million tonnes of CO2 per year, larger than some medium sized countries. Since then some progress has been made but there is much to do.

This month the Cliff Shelton and colleagues describe how anaesthesia can impact on the environment and perhaps change to reduce that impact​2​. It’s well worth a read and a consideration of how other specialities can reduce their impact too. It’s well worth a read. In brief the editorial suggests that by changing our practice, by considering environmental impacts when we adopt new practices, by recycling and reviewing our equipment and through educating ourselves and our colleagues we may be able to reduce the impact of anaesthesia on the environment. A good example would be in reducing the use of Desflurane which is pretty awful as a greenhouse gas​3,4​.

Not everyone will agree with this of course. Recent twitter debates have questioned the need for medical students and doctors to receive training on environment and sustainability. ‘Teach them medicine’ is the retort to suggestions that climate should be part of the curriculum. This is a false dichotomy in my opinion. Healthcare outcomes and activity have always been intimately linked to world that we live in. Any change to our environment will impact the health of our patients, and ourselves. In the UK this is increasingly accepted. The NHS has a centre for sustainable healthcare (The sustainable development unit​5​), and ambitious targets to reduce the carbon footprint of healthcare​6​. The national regulator, the GMC, requires that

“newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice.​7​

GMC Outcomes for Graduates 2018

This is requiring schools to change their curricula. Other specialities are similarly looking to reduce the impact of their activities on the environment​8​.

Emergency Medicine and sustainability/environmental impact.

Climate change can certainly impact on the ED workflow. For example, natural disasters can significantly impact on emergency department use in the short to medium term, but global trends such as heatwaves also result in increased cardiorespiratory disease presentations​9​.

There are many, many examples of how what we do influences the environment and much that we can draw from this editorial. Reducing waste, avoiding high impact, recycling waste, reducing nitrous oxide use are all strategies that we could adopt.

Nitrous oxide is a good example as it has a very significant contribution to global warming. In healthcare it’s used a lot in anaesthesia, obstetrics and in emergency care. Alternatives exist with a lesser impact and this may be a reason to switch to other inhalational agents like methoxyflurane for some patients, or to non-inhalational agents for others. For more on that question and some technical facts have a look at the twitter trail below. However, this is a good example of where we need to think about the entire cycle of what we do in healthcare. Methoxyflurane (Penthrox) may be less impactful as a gas, but as it is produced in a non-recyclable plastic ‘whistle’ the argument is not as straightforward as it might seem.

The Royal College of Emergency Medicine recently announced that it is disinvesting from oil and gas producers in its investment portfolios in common with other healthcare organisations. It has been suggested that this was precipitated by concerns raised from a younger generation of clinicians who (perhaps) are more environmentally aware than the older generations.

#FOAMed and the environment.

There are clearly potential benefits from using #FOAMed resources in teaching and education to reduce the travel impacts of meetings. Sharing what we have as widely and as openly as possible can only be a good thing. However, many of us involved in #FOAMed also travel internationally to speak and take part in conferences. The impact of this should not be underestimated and as a result groups such as St Emlyn’s are not carbon neutral. Reducing travel, flying economy and/or carbon offsetting are options​10​, but we must recognise that clinical education is not exempt from considering our environmental impact.

Keep an eye on @codachange for more links on the environmental impact of healthcare and consider following some of the organisations linked in the tweet below.

Final thoughts.

There is no doubt that there is increasing awareness of sustainability and environmental impact around the world. Healthcare is no exception and I understand that this issue will increasingly be an issue for all of us in the next few years. This paper is a useful and timely reminder that climate change is a healthcare issue. It’s was open access (Ed – I don’t think it is anymore), so there is no reason not to read and share widely. Individually and organisationally we should all look for opportunities to reduce our impact, so on your next shift I invite you to keep a mental tally of the impact of healthcare, and to look for opportunities to make a change.

vb

S

References

  1. 1.
    King’s Fund U. Climate Change. King’s Fund. https://www.kingsfund.org.uk/projects/time-think-differently/trends-broader-determinants-health-climate-change. Published 2012. Accessed 2019.
  2. 2.
    Shelton CL, McBain SC, Mortimer F, White SM. A new role for anaesthetists in environmentally‐sustainable healthcare. Anaesthesia. March 2019:1091-1094. doi:10.1111/anae.14647
  3. 3.
    Alexander R, Poznikoff A, Malherbe S. Greenhouse gases: the choice of volatile anesthetic does matter. Can J Anesth/J Can Anesth. November 2017:221-222. doi:10.1007/s12630-017-1006-x
  4. 4.
    Charlesworth M, Swinton F. Anaesthetic gases, climate change, and sustainable practice. The Lancet Planetary Health. September 2017:e216-e217. doi:10.1016/s2542-5196(17)30040-2
  5. 5.
    SDU N. About us. Sustainable Development Unit. https://www.sduhealth.org.uk/. Published 2019. Accessed 2019.
  6. 6.
    SDU N. Natrual Resource Footprint. Sustainable Development Unit. https://www.sduhealth.org.uk/policy-strategy/reporting/natural-resource-footprint-2018.aspx. Published 2018. Accessed 2019.
  7. 7.
  8. 8.
    Tun MS (SanYuMay. Fulfilling a new obligation: Teaching and learning of sustainable healthcare in the medical education curriculum. Medical Teacher. June 2019:1-10. doi:10.1080/0142159x.2019.1623870
  9. 9.
    Cheng J, Xu Z, Bambrick H, et al. Cardiorespiratory effects of heatwaves: A systematic review and meta-analysis of global epidemiological evidence. Environmental Research. October 2019:108610. doi:10.1016/j.envres.2019.108610
  10. 10.

Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

Thanks so much for following. Viva la #FOAMed

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