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Come on. What is good, my son. That's good. Um, are you, do, do you want me to stick around or are you? Ok. I think we're, yeah. Ok. Well, I just thought sometimes the idea is that I'm just going to remind them that there is Judith who is doing a thing. Just hi, everyone. Right. Hi. Before Trevor and Sam get started. I'd just like to remind you that Judith is doing a two stage exam practice this afternoon in Ivy Gate building that's from, I think 2 to 4 don't have to attend, but it's very helpful, very useful revision practice. Thank you. Hello. My name is Sam. I am a GP trainee. That's my clinical work. But the university I am, my job is Waffle the academy's clinical teaching co ordinator. Essentially. I work with a lot of the CTF to make sure that while you guys are the academies, things are running well, Trev and I are going to be delivering this session today. We've got, we're going to be talking about sustainability in health care. And I mean, Trev, you've encountered a few times this week already and with Trev helping me out and doing this together. I think Trev has a finger in a pint of some sort here. Yes, I'm the co lead for sustainability for Bristol Medical School. Ok. So again, with all these jobs on my waff one, what does that actually mean? Like what your credentials credentials? Right. Well, I've got no qualifications in sustainability. I've never done a course in it, but I have run student choice projects for many years on this theme. And one of them was called Sustainable Health Care. And it led to this publication of this book which in Fairness, I did write most of and it gave me about a year of studying this stuff in quite a lot of detail. And so I also set up the green Impact for a health scheme which is active across the UK now in general practice. So a few bits and Bobs mainly just a clinician with an interest. Excellent. I think the same thing really applies to me is that I'm a clinician with an interest. I have no credentials in this. But I find quite interesting and I'm hoping that we can explore a bit more today. So in previous years, Trev delivered this session and I kind of been interested and that's why you brought me in today. So we can have a bit more of a discussion between us involving you guys about this topic with that in mind. Just go back to this if you haven't got on to a log on to that questions coming up throughout with this. So there's just one little thing I would like to mention if I may just use this space because we talked about some student choice projects earlier. This is one I've just heard since the lecture this morning that this is definitely going ahead now and it will involve seminars from international experts. There's, there's a, an academic center of migration studies at Bristol University which is internationally renowned. You're gonna have professor professors from that talking. Um We're going to try and get you placements in UK or probably Bristol Centers. And there's gonna be an evening cooking event with a charity called My Grateful. And 19 5% sure there's going to be a week in Calais working with an organization called Care for Calais, which is social rather than medical care to migrant communities in camps around Calais, which should be pretty interesting. And the other thing is there's a little bit of an opportunity for language development, maybe in the French language or possibly in other languages like Farsi and Arabic. So keep an eye out for that one in your catalogs. Thank you. So, I guess so when Trevor talked to me about this session, he said that you've actually covered things already. Is that right? So this is the, you may not have noticed this, but there is actually a lecture series here. The first one was on planetary physiology just looking at how planetary system is regulated in a surprisingly similar way to the body. And so, for instance, the body, the blood buffers CO2, the, um, the, the oceans buffer, atmospheric CO2, in fact, 40% of all the carbon dioxide that we ever emitted is currently in the ocean and dissolved in the water or in the bodies of marine organisms. And the second lectures sound was really about where that system has. Oh, I've hit the uh standing desk. That's clever. We were talking about this earlier. Oh OK. We could do that for our right. Yeah. So uh you know, and particularly in things like biodiversity, it's a bit of a car crash and as, as you probably are aware it, so it is with carbon dioxide. Yeah. So this is, this is really where all of that stuff meets the NHS. That's what we're about today. I mean, so all of my interests that I developed on this has been post graduate and I think, I guess I pursued in my personal time these guys got it covered now. Well, I mean, most of the issues that we're talking about have been known about for about 20 years, but it's only fairly recently that it's got into things like outcomes for graduates, which is the gmc's list of learning outcomes that medical schools need to cover. And the BMJ is like nuts about this like just about four weeks ago. That was the cover of the BMJ issues around the climate and nature crisis. So I think it's just, it's just because it's become so much more obvious and also the health implications are more obvious. And that's why it's getting into the curriculum for students. Surely if it's in the outcomes for graduates, they can be assessed on it. They can, they can, this is the good forward slash bad news, as I said this morning, well done for coming here this morning's lecture, I don't think was recorded, but we are actually, I think we're allowed to say yes, we are going to teach you an AY station which was OSC last year in 2023. And your colleagues are missing that by not being here and it appears in the progress test factual knowledge. I wasn't assessed on that. Ok. So these are the learning outcomes. We're going to come today and let's just crack on with our first learning objective, which is the global environmental crisis and its health implications. These are all things that I think is familiar to this. Yeah, this is like a very quick resume of a few things. Ok. So you put this list of some of the the problems associated with climate change and their health impacts. So extreme weather, heatwaves, floods, storms, forest fires, they're all quite new. We're familiar with those flood to storms, forest fires are all quite bad. Why heatwaves so bad? There's new grapes that now been grown in Cornwall. Yeah. Apparently the people that make champagne, they make, they still, they have to make it in northern France. The grapes are increasingly coming from England. And the reason is because in France it's not getting cold enough at night in summer. And that's part of how the grapes get their taste. Anyway. Uh, you asked about heatwaves. Yes. Yeah. Ok. Heat waves of that list. They're the biggies in my view because um we've got, um, we've got a lot of parts of the world which are going to be quite difficult to live in once the temperature gets high enough in summer for prolonged periods. And that's going to trigger migration and that migration is going to be on a scale which we're not used to. And that's one of the things, for instance, we're going to be covering in this student choice project, which is climate migration. Ok. And does that then? I mean, food insecurity when we were planning this, you said that that's a biggie and I was aware that extreme weather. That's one for me. But why is, why is food insecurity such a biggie? Uh Let me see what we've got slide wise. Yeah. Um uh it's, it's really to do with the um it's the same issue really Sam, which is that the main, one of the main things that will make people migrate is inability to sustain their, their population with food production. There's quite a lot of reasons for this. So for instance, as sea levels rise, you get salination, you get salty water coming into the aquifers, particularly if the aquifers are exhausted by pumping. Um you get the sea level rising and flooding agricultural land. And most importantly, you get drought and uh you can this graph here just shows predictions for um global temperature against time. So when you guys are mid career, like a bit somewhere around a bit older than him and a bit younger than me, uh the climate, the the the global warming is probably going to be about 2.42 0.5 degrees. So I was lecturing to the students last week and I told them that the average global warming was 1.1 degrees. And I actually heard that now for a third of the days during 2023 the average global temperature was 1.5 above um pre industrial levels. And if you're just wondering why this graft trifurcates like that the different rcps depend on the actions taken by humanity. And I figure that we are doing some things that will not be the worst but will certainly not be the best. So by centuries end, I think it will be somewhere around 3.5 to 4 degrees. That's my guess. Great. All right, sunshine, rainbows. Thank you. So that extreme weather and food insecurity with the complication of biodiversity loss. I again, it's sad we all like Siberian tigers but humans are going to survive. And as doctors, we humans. Right. Yes, I agree. I mean, we are, we are very an about how we think about these things. And I did quote in the lecture a year ago about the South Subcontinent, Indian subcontinent issues with its, its vultures for instance. So that's a type of biodiversity loss because the vultures are very sensitive to diclofenac. The vultures have died. They were, they were dealing with the car and that niche has been filled with wild dogs and the wild dogs bring rabies and they reckon there's been 50,000 excess deaths in the subcontinent from rabies as a result. But even more anthropocentrically is the issue of medicine, particularly plant based medicines from the rainforests. And I think you may have remembered from our last lecture that's plant, which actually is an ornamental plant in British Gardens. As it happens, the periwinkle produces vinCRIStine and there must be dozens, 100s of other useful substances these plants make that we don't know about. So that's, that's a very anthropocentric case against losing our biodiversity, which I guess then relates to us working with human patients. Pollution. Yeah, that makes sense. And hopefully everyone's familiar with that one disease vector modification. That's about the area of where certain animals that carry disease might live, such as malaria, carrying mosquitoes. With there being a wider band of heat, they'll spread, they can spread malaria more. That's right. I believe So I think there was a case of malaria near Gatwick airport as an example. OK. Gosh. OK. Time to move up to Yorkshire then um climate change anxiety. So was this yes, I don't know whether everyone got to that but it's just a uh OK, so some of us are noticing this. Um So what, so what is this? Right? OK. So somebody called hog never met him but he's, he's relating um awareness of environmental challenges to classic symptoms of anxiety. I haven't really studied the, the, if you like the, the validation of his questionnaire or her questionnaire, but that's what it's trying to measure. It's trying to measure the extent to which the impending challenges that we face are themselves a source of mental ill health, right? OK. And it looks like we're causing some. So that's so, so OK, so that summarizes what's been covered, I think in lectures one and two. But then I guess thinking about how this relates to the NHS and the work we're doing in the Yes, yes, indeed. It does. Yeah. So we, what we wanted to do guys is we wanted to ponder the role of the NHS in mitigating this situation that we've described. And one of the first things to do is to grasp the carbon footprint of the NHS. Um cos it's 40% of the public sector which is believable and it's 4% or some say 5% of the overall footprint of the UK. So I think it's back to the old. Um Is it on fermenting now? It's back fermenting. So, with this ment slide, I think this is for everyone to submit some ideas. Is it 44 ideas of what are the lead causes or sources of carbon emissions in the NHS? And they'll pop up on the screen and we can chat through some of them. OK. Good to know that we're causing uh eco anxiety. Yes. So awesome. Suck them, don't you burping? Interesting. I'm worried about the Kaiser. The patients are seeing it. Burping is the big issue there. It's me there, isn't it? Yes, I don't know whether you can, we gotta scroll down or not. Ok. Come on back to the washing the OK. Travel to and from hospital. Yeah, you guys have been quite discerning there. So I guess we had quite a few there. Um Alongside burping, we had sux medium, other gasses uh traveled to and from the hospital. Has anyone got an idea of what they think the biggest source is of all of those things that came up. Clue stop burping. Just shout it out anyone the leading cause can't be brave. OK. I'm going to show the graph. OK. OK. So this is a chart of the NHS so called carbon footprint plus. And you can see sa that surprisingly or not surprisingly actually, medicines and chemicals are the biggest single category on that chart. Yeah. So so travel to and from staff commute here is four per cent in my trust where I work with Swindon Hospital. I regularly will get emails saying about, oh, we need to carpool to help our planet and so on. But actually that's four per cent compared to medicines and chemicals, which is 20%. That's a huge difference there. It is. Um, I'm just so surprised that that doesn't get more attention. We don't get any e mails about that. I see this chart. It's called the carbon footprint. Plus, we were talking about carbon footprints. Why? Carbon footprint Plus plus guys, this to get your head around these ideas, you need to listen carefully what I'm about to say because on that pie chart, you can see there's a bit that says NHS carbon footprint and then there's everything else and that's slightly confusing. So Sam asks me, what do we mean by carbon footprint plus? Well, that is actually the entire pie chart. And the, the point really is that the NHS carbon footprint is carbon that is released directly by the NHS itself or by its vehicles as they drive around the country. All the rest is, is, is carbon dioxide that is released elsewhere. Should I try the next slide? I think it might make it clearer. Ok. So there's a little bit of tech language that you wanna just get your head around here. And that is the notion of the different scopes of admission, admission and we talk about them in three categories. 12 and three. And this division is not just used in the NHS. It's used in fact in all sectors of all public sectors and indeed for major organizations as well. So I just would it be helpful just to explain that a little bit? Ok. So scope one is more or less what we've just talked about, which is the stuff that is released on premises. And you can imagine really like heating buildings, lighting buildings, powering all the equipment in the thing. That's slightly incorrect, isn't it? It's not lighting, it's not that scope two. Electricity on the, just to go back to scope one, it's saying anesthetics. So, and that came up, but anesthetics we're not pumping CO2 into our patients. Why is that? Ok. Well, anesthetics are interesting. They have very, very major impact on the atmosphere as greenhouse gasses you can see at the top there, Sam, there's a whole bunch of different greenhouse gasses. But generally we talk, we don't, we don't talk about the individual gasses. We have this concept called E CO2 equivalent to CO2. So each of the gasses has got a global warming potential which is expressed as its strength relative to carbon dioxide. Ok. And then scope one is everything we're doing on our site and the vehicles. Scope two, that's the electricity that we buy, right? Ok. So that's actually personally, Trevor Thompson, I I'm carbon, I'm carbon neutral for electricity. Not for gas, too carbon neutral. Yeah. Well, I guess I am because my scope one, my gas I'm burning on site. That's true. Yes. So I am, I also have solar panels which is quite good if you can afford them. But yeah, so that's it. And then scope three, that's just, that's all the plus, is it? Ok. So guys, just to understand this, you try and explain what scope three is. I think a really helpful way of doing that is just to think of it the next level up. So if you take a look at this slide here, for instance, uh that's the U K's carbon emissions against time. I've given it a tick because you can see it's actually halved over the last 30 years, which is actually, do you know why that is well done before we do that, we have actually invested considerably in renewables. And if I just go back a slide or two, it's a very, this thing called National Grid Live. That's actually yesterday morning and it wasn't very windy, but on windy days, the proportion of wind can go up beyond 50 per cent of Uk's energy. Well, electricity, I guess production yesterday morning, it was only 12.9 per cent. But so to explain this graph, it is to do with renewables investment and it's a lot to do with moving away from coal to gas. But as your colleague rightly says, people love to sort of give China a bit of a, a drubbing because it, it's carbon footprint has gone up and up and up and it's still rising. But of course, that's because it's responding in, in part, that's because it's responding to demand for goods in the west. So it's exactly the same with the scope three emissions, they're emissions that are somewhere else often in another country. So if I prescribe a medication today in general practice, the carbon that was needed to produce that medication was often released in another country. Some knowledge of where drugs are made. Yes, I talk about diuretics and bumetanide. Most bumetanide is made in India. So when we prescribe bumetanide that's traveled all that way. Whereas if we prescribe frusemide that's from is ok. That's interesting data. We never get hold of. I happened to OLANZapine. Do you know what type of drug that is? Major tranquilizer and antipsychotic it's made in Avonmouth? Ok. However, I've been to the factory for it. I don't know it's still open but each, I think it's a week or so, they produce like a cubic meter of OLANZapine. But that OLANZapine is sent somewhere else to be made into tablets and somewhere else to be packaged into packages to reach the western marketplace. So these things to travel around the world, how far is it somewhere else? I think it was, I think Taiwan, right. It's like the whole factory only produces a cubic meter a week. That that just seems insane that that happens. So, so I guess with all this scope stuff for, for what for these guys? And also for me working in the NHS scopes, this all seems quite nuanced. How does this relate to what these guys can do day to day? Well, I hopefully that yes, that comes to our, our next slide, our next learning outcome rather, which is what to do about this carbon footprint. And I think before we can really unpack that answer, Sam, we just need to be aware. Now, Samuel and I have something to say about targets, but these are the official NHS net zero targets. And you can see, I hope my previous explanation has helped you understand the difference between the NHS carbon footprint and the carbon footprint plus. And in my view, and it's obvious, isn't it that the carbon footprint plus ambition is far more difficult to achieve than the other one? Just because of the fact that it's all outsourced. These are classic targets from the ambitious Department of Health. Actually, no, these sorts of targets are a requirement of the Climate Change Act. So you know, those who are prone to disliking the conservative government. This act is an act of Parliament which is quite radical, but I'm not an old man, but I have become quite skeptical this these targets, just someone paying lip service. Like, are we actually any closer to reach them. Well, uh I II am, I wouldn't say I was a skeptic on this, but I would say that I am, I'm a sort of pragmatist on this. I'll show you this why if I put this slide up, anyone want to have a guess it's a weekend plan, isn't it? Ok. So this is, this is the smoking in the pub situation. Ok. This actually does not happen at all. Right. So this is a result of legislation. Now, um, the Climate Change Act as a piece of legislation creates targets are in my view, everybody's view unreachable. However, they, they, ok, I'm going to try this on you. They, they stop us not doing things that we wouldn't do if the act wasn't there. In other words, we would do them if the act didn't prevent us. So, for instance, the, the trusts all have to produce policies to decarbonise as a result of the act, even if that doesn't cause them to meet the targets, that's the effect of the target, right? Ok. So legislation being the most powerful way to enact that change, I think legislation is vital. Sure. Ok. So, so that's the, oh yeah, that's how difficult it's going to be guys because um, you can see how the, the bottom, the top dotted line is if you do nothing and the, the bottom dash line is the, what you would need to do in order to reach the targets and on the right, you've got actually a bunch of really interesting suggestions. But, yeah, that, that's how steep the drop is. Ok. So that, that again, seems quite ambitious. It is. How are we going to get there? Oh, that's a big question. Oh, so I think I would like to use a sort of motivational interviewing approach to this. Ok. So there's, we did this this morning, so there's how to make the change, how to, for instance, get more exercise, but people won't make those changes unless they're motivated to make them. And that's where knowledge of the climate science comes in. That's the stuff that was presented to you in the first two lectures, for instance, because as with any behavioral change, like problem drinking or gambling, a common response to that is either to suppress it or ridicule it or just completely deny it's happening whatsoever. And for each of you in this room, that's the kind of personal thing. It's a, it's a, it's perhaps a question of priorities. It's questions of ethics. I say priorities because there's lots of things wrong with this world of ours. And, you know, we've got wars now and we've got, there's lots of things that you could be concerned about, but how concerned you are about, this determines how seriously you get into it. And that truth applies not just to individuals, but to hospital trusts, to governments. And then this is where we had our plan to call on our room of brilliant minds here. Yes. Is that back onto the, let's, let's go on here first. So we've got a little bit of relief for you guys uh sometimes to talk to each other because what the ask is that you have been and this does happen, by the way, you've been called as a what's called a stakeholder. They do have these stakeholder meetings. Uh and it's of a mixed primary and secondary care trust and you are there as yourself as a medical student. And we want you to make some feasible suggestions for how your trust can reduce its carbon footprint. And I'm gonna give you like 33 minutes on this. And then I would like you to type something into ment, which describes your idea. So that's the ask. So we, we put the scope slide back on. If everyone's happy with that task, just come up with a chat for a bit and then write that up on and we're trying to reduce the carbon footprint. Plus, I guess is, well, yeah, across the board because we're reducing scope one, scope two and scope three sort of emissions. So we'll leave that with you and then we'll round up in a few minutes, three months, take it on time. No, we started, we started late, finish it on the eye. I don't do that. Um Yeah, we started late. I know you probably slightly later, maybe 12 points, right. There. Yeah, here and I just, I just need to ok with the feedback as well. Ok. Just on time and the brands of time. Funny. Well, it's quite, it's quite convincing. I've seen it. I actually haven't see that now, see how we're doing on time because I think, I think are gonna, yes, that's true. Let's not, let's not rush the Aus. I've got the, um. Ok. Yeah. Nice. Ok. If you recline, you remember so great. It's been two minutes now. Give me another 30 seconds. One it's a good time, right? We'll give you guys a few more seconds. It's a good time now to start writing things on the mentee if you haven't done so already. Yeah. Yes, I hope that silence while you're typing on the silence waiting for you to say something. Hm. My big hospital compost. I mean I suggesting I don't instead of the more how I get solar criminals. Very small. Yeah. Ok. Mhm. Right. Yes. Who who put the comment about avocados out of interest? I'm not picking on you. I'm do you mind expanding on that please? And if Jesus says it's bad, we hate it. That's why we hate Camper vans as well, right? Caravans. Um ok and it all put who put solar panels, some of the cell panels people are now worried about expanding on their points because solar panels is an interesting one because hospitals, yes, all of the land around it is usually precious. That's car parking space. But they're big, usually flat buildings which is quite perfect for solar panels. Really? It's just that investment. Hm. Um What else have we got here? So power inhalers build more nuclear reactors. Is that NHS nuclear reactors? Ok. See your health secretary, things like that. Um, move away from gas anesthesia. Ok. Inhaler usage wind energy. So it was actually there was a hospital, I think down in cold that invested in a um a wind turbine, nuclear medicine in a hospital, invested in a wind turbine and they've got loads of people in the community to contribute towards putting that wind turbine in place and then any electricity that sold back the grid, the people who invested cash in on people engaging in that local community. One child policy. Hm somewhat, somewhat brutal. We don't get any sun, put wind turbines on top of hospitals and stairs. Ok. Nice. So the ax solar panels are becoming more effective now they are working all year round in the UK. Yeah, if you get the expensive types, but the NHS probably wouldn't get the expensive types who are right? Cool. Let's go back. Yeah. So I mean, as I mentioned with the wind turbine being used down at one of these hospitals in the South West, there's a lot of work that's going on to make it less carbon intensive. I think you've prepared a few examples. Yes, I mean, I have as a general rule with clinical activity, the more you do, the more money it costs and the more money it costs, the more carbon it tends to ait. So as a general rule, the more agile, the more lean, more evidence based and effective the health care, the lower its carbon impact. So what you don't want to do is things that are unnecessary. And, well, I just wondered, have you ever ordered a blood test that perhaps you didn't need? I didn't want you to ask me that in front of everyone. Yes, I have done that. Seriously. Why does, why does that happen as a junior consultant asked me to, that's a common one. And that same with Laing the Yeah, absolutely high behind the consultant as usual, I guess sometimes it just gives patients that peace of mind. Some of them say I don't feel ready to go home. But when you can say objectively these, your numbers, you're fine. Sometimes it's a blood test where you go. I just want to check the CRPS coming down for reassurance. That actually is irrelevant. You could achieve a final examination. You don't need to do it. So, yeah, I think maybe a cultural thing in hospitals that, what about in the community? What about investigations are expensive? Right. Yes, I mean, we do get patients come in wanting MRI scans and we're really told not to do them by the radiologists, but sometimes they do persuade us and what I've noticed some is there's a huge difference between the different doctors in my practice, Dr X. Like she's, she's a serious investigator and like, I have to deal with a lot of the investigations because of the way the work and when the results come back and I've just started sending them back to her saying, look, uh, you know, would you mind dealing with this? Like, I think that there are quite strong sociological reasons why not only why we investigate but why we prescribe and intervene. And I think that we have to be brave as clinicians to, to row back against some of that sort of stuff. May I show you an example? The BMJ as ever is onto this? Yeah. What about arthroscopy? II think in fact, actually, I think you know about this one. Also I know that arthroscopies are used to be done a lot more, but I think this was because there was evidence saying that actually they don't really do much in a lot of our patients. Yes. So these are people with painful knee and the standard thing was to just open up that knee, put a little camera in, have a look around, sneak, snuck out, wash out the joint effectively. And uh you know, they, they've, they've done a lot of controlled trials now and these findings do not support the practice of arthroscopic surgery for middle age or older patients with knee pain with or without the signs of osteoarthritis. And, uh, in fact, that's the data on what's happened to rates of arthroscopy. So, actually people do listen to this research. Yeah. And this is only one procedure that's actually been investigated. I'm sure there's lots of procedures that probably aren't as effective as we're led to believe. Yes. Or that we're requesting for patients that don't actually need them. That might be inappropriate. Yes. Inappropriate endoscopies. That happens. A lot of people with dyspepsia just go for endoscopies. Yeah, there's a lot of it going on and of course, you know, sometimes there's quite strong vested interests who don't want us not to do those procedures, particularly in sort of very fancy specialties like cardiology. Yeah, where the evidence base is sometimes surprisingly weak for things like stenting in people with stable angina. I guess that's something that these guys can take forward into their clinical work. Quite a few colleagues mentioned about anesthetic agents. So it's obviously out there in your mind that anesthetics are quite toxic to the global system. And desflurane is a widely used agent, but it's used a lot less than it was quite a bit of that movement has actually come from Bristol. I think there's a video that we could maybe send on to you. Um, we do it now. I mean, but, but an a it's interesting how many of you mentioned anesthetic gasses because anesthetic gasses is going to be beyond the scope of a lot of work now prescribed or used anesthetic gas. Is there something that's more relevant to the majority of? I just want to say a little word against anesthetics before we go on. Because I read somewhere that 50 per cent of the sort of carbon equivalent impact of a surgical procedure is, is from the anesthetics. That's fascinating. I never thought they could have so much impact. I also thought that hospitals find ways of holding those gasses within a system and reusing them rather than just letting them into the atmosphere, which I didn't realize. But you asked me, Sam, is there anything more practical? Yes. So here we come, this is if you're just about to leave before you get your teaching, but don't worry, the inhalers are what we're actually referring to and uh these inhalers. That's not example, that's, that's not a meter dose inhaler, but meter dose inhaler inhalers have what in them, they have a gas in them which propels the liquid into the respiratory tract and those gasses are very, they've got very high ec O twos. So we've in primary care, we've actually done a lot to change that. Ok. So, so what, so in your switching people? Yeah. So what happens is you get like you just get an inhaler switch and you get a text message saying we've switched you from the MDI metered dose inhaler to the dry powder inhaler. Um And this, this very thing Sam, I know it because I wrote the station was one of the ay stations in 2023. And because it's happened in the past, definitely does not mean that it won't happen in the future. It could be repeated. So it's worth knowing about. I just wondered whether we might just do a quick, have a quick go at this, give it a go. Trev. Sprung this on me yesterday. I've actually never had this conversation with a patient because I've only just started on GP. And this is, this is what happened, right? So I'll leave that for you. OK? For us. Yeah. Yeah. Uh Yeah, hi. So uh my name is Sam. I'm uh the uh F one currently on my GP rotation. Sure. Um You've come in today because you were asked to come. Yeah. Yeah, I got a face to face cause II just got this text through saying that I've been swapped from my usual inhaler uh to this new one. And I just, I just felt I just wanted to talk to somebody about it because basically my asthma for five years, I'd say it was really bad and I was even in the hospital once. It's been great and I'm just, I'm just nervous about making a change in case uh in case something goes wrong and you know, like in my asthma gets, gets bad again. Well, I'm sorry, we cause that anxiety. Hopefully you haven't been swapped yet. The idea is that we'd want to have a conversation with you before. Well, actually the text said that what had been swapped. Oh. Right. Well, I'm sorry that's happening. But it said I could contact if I was. Ok. Well, I'm glad that you have. Sure. So your asthma is well controlled from what you're saying? Yeah. Yeah. Ok. Well, that's great. If it's well controlled, that's great to hear. And with us swapping you with this different inhaler, there's motivations behind it, which I can come on to. But actually it's clinically equivalent. There's been lots of studies to investigate that. People who do well on the, probably the blue inhaler. Yeah. Yeah. Yeah. Yeah. It's just as good as that. It's just a slightly different formulation and delivery process. Ok. But like, why bother them? Like if they're just the same. Well, so it's actually, um, in the wider scheme of things, we're actually, we're looking in the NHS now towards the health and the impact we're having on the planet. And these are blue inhalers. They're actually, when you're just using one that you've probably gone through a lot in, in your lifetime, probably each, each, yeah, 100 each inhaler equates to 175 miles of a car driving. Really? Yeah. And that's the greenhouse gasses. That is polluting. It's equivalent to you. But it's like minute. Yeah. So it's not CO2 because obviously with your asthma we wouldn't want to put CO2 into your lungs. It's these alternate chemicals and they have, they're also greenhouse gasses and they have a significant impact, more of an impact than just CO2. So, for you to get in your car and drive 100 and 75 miles at the M five, that's the same as you're using your one inhaler. Ok. And you think if I take it, like my asthma will just be the same then? Yeah. Well, that's what we anticipate. Absolutely. Because what if it isn't then? Well, that, that's, we're going to be checking up on you following up to make sure. And we'd want you to perhaps leave that. Well, I've got this peak flow thing. So, yeah, peak flow you can monitor. So how do you use it? It just like you just press the button and, well, fortunately I have this one that I was just keeping right next to me. Um, so it's a little bit different. So you a bit like the other one, you know how, when you had to, you would sit up straight. Yeah, you breathe out and you, you press the button on the top and breathe in with it. Absolutely. I have a spacer thing actually. Oh, I don't know. Which is it. But yeah. Sure. Ok. With this one, you, we could try it um, just for now, just as this one. But how you set it up is you remove the, the cap on it. Yeah. Cap removed and then for the, so you need to prime it. So there's no prime it. Yes, there's no gas that's driving it out. You have to what drives the light. So it's you with this spring loading action in here. So you will turn that to the right. Yeah, the base here and then turn that back to the left and if you listen closely there's a click. Ok? And that click means that it's ready and then once it's ready, you then do things as normal. So sit up straight, breathe out and then breathe as you're breathing in, you then just put it to your lips and breathe in. You don't need to press a button because it's already ready to go. So, absolutely. And then you inhale and then hold your breath for 10 seconds and then just exhale a bit. OK. Does that make sense that good? Thank you. Well done. So I think you passed your oy, great that as well. Um But yeah, I mean, you've also say if that's true about the about the inhaler, that's, that's a fair bit over a lifetime. Yeah. No, definitely. And yeah, I mean, it's an argument also making sure when patients come and say, oh yeah, I use myself using my inhaler, you know, 10 times a day. It's like, well, there's another reason we should get you on a Labra as well or to inhale corticosteroids. Yeah, I think it's fair enough though to to, to, to get the person to voice their concerns and not just treat them like, you know. Ok, because people do worry about these things. Yes, definitely. Ok. All right. How are we doing? So, where are we up to now? So I'm in now an F one primary care headspace. Not, I'm presenting a lecture. Uh That's the, that's, that's ok. Final point. Oh, so, so we've looked at now, so we looked at the health impact from the consequences of climate change. We've looked at the environmental footprint of the UK actually includes that scope one to scope three, everything, all the sort of emission there with the key things that need to change for us to achieve a net zero and how ambitious those targets are been set. But right now, so rather than about when you're going to be qualified as and think about it as f one start thinking about it then, which is what I was doing instead now as medical students, what can you do? And I guess that's the next part we talk about. Yeah, so this is another brief intervention. We'll do it just for a couple of minutes and that is to try to get yourself into a little group there. And I want you to consider some pro sustainability changes that you could do. And we're thinking of two domains, the personal domain when you're a medical student, sort of feels easier in a way because that's what you have agency over but can impact in the professional sphere while a medical student. And I think you can. So when you've had that discussion, stick something on mental and we'll have a discussion and we'll still be, I think, finishing our lecture on time. How efficient is that? Ok. Sounds good. Two minutes and thank, yeah. Yeah. Ok. Yeah, he comes out regularly, doesn't it? It's always good. That was, you know, you information not cure. I think you still can and just be, be carefully afraid. It always no matter how much does it come. Do they do it on the computer? Yeah. Straight. Ok. Cancer. Like I quite enjoy the flight. Um You told that as well. It might be. Yes, you, yeah. So if everyone can now write up some of their answers um and then we can have a chat through some of them very quickly. Fine as, as well as preparing you for your sys and also other assessments where this stuff might come up. It's good for you guys to leave feeling empowered that you can do something to make a difference. Ok. Commit wire fraud and use the money to buy solar panels for my student house. You know what? I got solar panel quotes recently and they said 14 grand to get solar panels. And I was like, well, never mind then I'll not do that end capitalism. You guys are ambitious and I like it. Cry less or drink less if you think about this. Ok. Whoever puts start cycling south, we buy food out there. Thank you. Uh for that. That's valuable stuff. Breathing out. That laughter means you're breathing disapproval from that student there. Uh online parkings, buy less clothes, good fast fashion. Yeah, that has a big impact. No gloves. That's a really big one actually. Yes. Love the glove was a campaign we had for a while. Really? Is that a community one? Cause in a hospital they've got one in Swin as well, which is to not use the glove. Yeah, and there's increase over time, right? Ok. Can I just ask, uh, I'm just interested about, uh, travel to the out academies. My understanding is that if we had a slightly more efficient system of linking people up and more efficient in terms of the, the driver of the car getting properly paid in terms of their costs, do you think it might, there will be more lift sharing done than there is at the moment? Yeah, that's bad, Trevor, right? It's happening. It's going to happen. I bet it does. Ok. Excellent. Really good lists. Really good thoughts. So funny as well. Some really good ones with the personal ideas though. Why, why, what, why is that relevant to us? Why are we having that discussion about personal? Because I think you guys, I assume are well enough informed that, you know, to be doing things in your personal lives. Why is it relevant now in this talk. Well, II like this graph, it's a amazing that people actually listen to doctors. So like for instance, when I turn up at a home visit on my bike, I know that that is conveying various messages to my patients around lifestyle. And if you look, you know, we're the second most trusted profession. It's always amazed me that government ministers score as highly as that. Yeah, but this is 2020. That's before COVID before COVID. So yes, that was, yeah. So, so it, it it's, it's, it's a by example. Yeah, lead by example. OK. And then professionally so get properly informed, which we're doing right now. Speak truth to power with PHRC um Planetary Health Report card, every medical school in Europe and in North America is ranked for their sustainability credentials. And um we are sort of mid table and getting better and it's uh it's a the ranking system allows people like me to go to, to the academies and say, you know, have you thought about helping your students travel more efficiently? Say, ok, excellent. But students can do all of that and you've got a year five elective and elective flight plan on that. Why, why elective? Ok. So the elective thing is something that you haven't probably thought about much but and it's probably on its way out but not for you. And that is as you probably well know at the end, at the beginning of the fifth year you have this opportunity to, I think it's eight weeks, it's called an elective. You can elect to go really at the moment wherever you like. And this student is not unti that's, you know, that, that is 11 flights. Uh It's not quite as bad as the so bi Continental, which is four weeks in Africa, four weeks in Australia. Ok. So I think that where we're coming to with this stuff as a med school is if you want to do a journey like that, which is actually as far as you can get because it's the opposite side of the world. Then you need to explain to us why that is why that's gonna help you, er, educationally. And I think that, you know, some of you will just want to do electives closer to the UK or in the UK, but I don't think any time soon we're going to be banning this sort of activity, but we do want it to be justified and, you know, perhaps even just everybody is going to be required to give a carbon account of their elective. So this amount of flying use emits the same amount of carbon as the average citizen of a middle income country like Lebanon or Morocco or Turkey or Mexico doesn't an entire year. So it's quite a big, quite a big impact. What some students do in 88 weeks. Yeah. Oh, yeah, that, that particular student will have done more than that. That's about 7000 kg. That one. Wow. Ok. So we're not saying that they can't do their electors uh abroad. We're just saying no, no, not at all. Ok. So this is just the final slide. So I guess just to go back to this one, it's worth saying with personal lives. I think you all switched on enough and you've got some ideas on what you can do individually. But professionally qi projects are a really good way that if you spot something in a healthcare setting that you think this is wasteful, maybe something could be done. You that's positive role as a medical student is that you have that really valuable insight, see loads of different environments and you say, why is it that we're always doing that? And I've worked on an acute medical unit hull where people would go to take bloods, they take additional needles and kit with them in case they miss and then they just tip it all in the bin afterwards. And then that prompts a QR project that I did while well, the ment for you put your needle back if you don't use it. Yeah, absolutely. Sadly, it didn't get finished. And then COVID happened. Everyone's using loads of a lo of gloves but still really important. You guys have that in inside and that's really valuable. Um Yes. So please on the ward, think, think about those things, observer and taking your hands off, like going, using, not using gloves when examining you if you don't need to. Yeah, that's just the climate. That's just the temperature versus the NHS Skills graph. I think that's it. So, so, I mean, I hope that's given these guys some food for thought. Like every time I talk to you about the, gives me food for thought and hopefully, I mean, I don't think the GP practice I work at has been doing that inhaler switch. So I take that back on Monday. Ok. It's been a long morning for you. Thanks for you who came and well done. If you kept attending, we'll, uh, we'll be sending around that video on the anesthetic gasses and also a feedback form. Uh, if you guys could fill that.