Perioperative Medicine and the Environment: Are We Obsessed with ‘Clean’ but Oblivious to ‘Green’?

Brian, thank you for joining us. Please describe your current job and responsibilities.

Thanks for the invitation to join this conversation. Professionally, I wear two hats: on one hand, I am a private practice anesthesiologist in Portland, Oregon, with Oregon Anesthesiology Group, while on the other, I serve as the Oregon Region Medical Director of Environmental Stewardship for a large health system, Providence Health and Services. In this role, I navigate three pillars of stewardship: 1) mitigation of our health system impacts, 2) adaptation of our care delivery system in the face of environmental challenges, and 3) advocacy within (and beyond) Providence to increase individual and collective accountability in support of environmental and public well-being.

How did you get interested in the environmental impacts of medicine?

For me, environmental stewardship is a core value that was instilled early on, growing up on a ranch in Western Montana. Constantly working outside, we bore witness to the direct relationship between the health of the land, water, and air and the sustainability of our ranch. In medicine, a similar dynamic exists – healthy people require a healthy environment. We face this issue from multiple perspectives in health care. As an industry, health care is extremely polluting, but we are also called to care for those vulnerable communities suffering the effects of environmental degradation, be it the local impacts of air and water pollution or the larger-scale health impacts of climate change. Particularly troubling in all this is that those who contribute the least to these problems bear the disproportionate burdens of disease.

Let’s jump right into some controversial topics. What is better, disposable versus reusable, or does it depend?

On some level, everyone recognizes the vast amounts of waste generated through the widespread use of disposables. But not only are we filling up landfills and incinerators, we are also extracting and processing raw materials then transporting these manufactured supplies to our hospitals through our “just-in-time” supply chain. The environmental toll builds up quickly and pales in comparison to any negative impacts associated with reusable products. The vast majority of formal, published life-cycle assessments find that reusable items confer less environmental impact than disposable alternatives, including anesthesia-specific items such as laryngoscopes.

In addition, given its “just-in-time” nature, our global medical supply chain has little resilience and is prone to disruption during events such as Hurricane Maria in 2017, and currently the ongoing COVID pandemic. As climate change continues to drive more severe and frequent extreme weather events, these disruptions are likely to become frequent. Process engineering and (re)design of efficient systems to support a circular, reusable supply chain will reduce resource consumption and waste generation while also providing greater overall system resilience.

Do you see aggressive infection control standards and the proliferation of single-use items as a blessing or a curse?

Clearly, we must work diligently to reduce infectious transmission, but the widespread shift to disposable items is clinically unnecessary and is costly from both the financial and environmental perspectives. That being said, some disposable devices may be appropriate, particularly those that are difficult to clean effectively. In other cases, approaches such as the Spaulding criteria should be used to match cleaning practices and protocols with the level of invasiveness of each device, such that we minimize infectious risk while also reducing financial costs and environmental impacts. Many of our supplies can be durable, reusable, and safe. In the end, resources are finite and we cannot afford to continue on an inherently unsustainable path of resource extraction, manufacture, and disposal.

What is your view on the use of inhalational agents and their environmental impact?

For the individual anesthesiologist, there are few other facets of clinical activity that confer a larger greenhouse gas impact than the use of inhalational anesthetic agents. All three commonly used agents are potent greenhouse gases, but not all are equal in their radiative forcing effects. All have been used broadly enough to be measurable in the atmosphere above Antarctica, thousands of miles from the nearest anesthesia machine! However, of the three commonly used agents, desflurane is the most potent greenhouse gas, with a global warming potential (GWP) of 2,540, meaning that every pound of desflurane carries the equivalent atmospheric impact of 2,540 pounds of carbon dioxide. By comparison, the GWP of sevoflurane is 20-fold lower at 130. Nitrous oxide is also a potent GHG with a GWP 265, certainly not as high as that for desflurane, but given its relative lack of clinical potency, the total amount used and emitted during an anesthetic is quite high. Per capita within health care, anesthesiologists have a disproportionately large carbon footprint compared to other clinicians. Anesthesia-related emissions are estimated to account for 2%-5% of health care’s total.

Our clinical management decisions, primarily agent selection and efficiency of use, determine our emissions burden. From an environmental perspective, the take-home messages are: 1) high-impact agents (desflurane and nitrous oxide) should be reduced or eliminated from your practice, and 2) fresh gas flows should be minimized to improve efficiency and reduce unnecessary waste and associated emissions.

How has your personal practice changed to become more “green?”

In my clinical practice, I have completely eliminated desflurane and nitrous oxide. When using sevoflurane, I minimize fresh gas flow to reduce excess delivery and waste. I preferentially utilize total I.V. anesthesia with propofol and consciously try to minimize the amount of medication wasted. Regarding anesthesia-related supplies, I only open what I plan to use at the moment; preparing a large amount of backup supplies “just in case” is unnecessary. With respect to waste stream optimization, here in Oregon we are fortunate to have a co-mingled clinical plastics recycling program, so most of our supply packaging is locally recycled. On a larger scale, I work to apply a quality improvement perspective and framework to perioperative environmental stewardship by determining relevant metrics and designing CQI initiatives to improve our environmental and clinical outcomes.

How do you respond to the political polarization surrounding environmental issues?

I find the political polarization throughout society to be extremely disturbing, particularly with respect to scientific issues and problems. The mistrust of science and scientific experts and the deference to one’s own internet “research,” with confirmation bias and associated echo chambers, is a serious barrier to evidence-based problem-solving and progress.

With respect to the environment, scientific consensus is unequivocal: Climate change is happening now, and we are responsible. Tragically, reflexive tribalism has reduced the conversation to whether the problem even exists, as opposed to a discussion focused on the best possible solutions. Here in the Pacific Northwest, we are seeing people die from climate change. The megafires of 2020 and the extreme heat events this summer killed Democrats and Republicans, liberals and conservatives; the environment has neither bias nor political party affiliation.

We must all move forward, accept the science for what it is and shift the debate to potential solutions, rather than remain hijacked by seemingly endless delaying tactics. Globally, the injustice of suffering among those who contribute the least to these problems, the poor and vulnerable, is ethically unacceptable and demands action, not paralysis. We cannot afford the cost of doing nothing.

As clinicians, we have all cared for patients “informed” by dubious, biased internet searches who demand that we do X, Y, or Z for them. Gently, we acknowledge their fears and redirect their understanding toward one based in the science of medicine. Climate and environmental scientists are trying to provide a similar service to society via their work to understand and communicate our global diagnosis. So, as a society, we need to listen and become engaged patients, truly invested in our collective outcome and working toward solutions.

What can ASA members do to make their own practices more environmentally friendly?

I recommend that interested members start by reviewing the ASA document “Greening the Operating Room and the Perioperative Arena: Environmental Sustainability for Anesthesia Practice” on the ASA website for a detailed description of opportunities and recommended actions: www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-equipment-and-facilities/environmental-sustainability/greening-the-operating-room

Huge question, but an important one: How do you see the planet’s future? Good, bad, or indifferent?

Without question, the planetary challenge we face is immense. Yet in the end, I do believe that people can take widespread societal action in service to the common good. Early on during the COVID pandemic, we saw people across the globe come together and take necessary steps to protect themselves and each other. I am optimistic that we can again rise to the challenges facing our planet, but it will require sweeping collective action, whether by direct mitigation within one’s sphere of influence or by direct advocacy with our communities, leaders, employers, industries, and governments. We must prioritize our planet’s health in order to preserve our health and the health of future generations. Waiting for political solutions won’t work because politicians are going to follow our lead.

Anything else you would like to share with readers?

At times it feels like individual action is insignificant given the scale of our environmental challenges, but remember there is power in the action of many. Working within what you can influence is a great first step. Success builds upon success, thereby expanding your reach and impact. As physicians within the anchor institutions of our communities, our reach is broad and our voices are trusted. So let’s step forward, use our influence, and take action to support planetary health and to protect our children’s future.