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And um as if you haven't had enough of my voice today, um I'm going to be talking to you for the next 15, 20 minutes or so about sustainability from the trainees point of view. Um I know that as the British Orthopedic Trainees Association, we're all sitting here thinking well, okay, but what does this mean from my perspective? Um So, hello, everyone. My name is Fran. You've heard a lot from me today. I'm an ST three in trauma orthopedics in the Wales Dean Ary. And this year I've taken on the role of being the sustainability lead for BOTHA. Now, what does this mean? Exactly. Well, I've organized this conference today with the help of our colleagues throughout the committee, uh with the BO A and with ORUK um involved in promoting sustainability within BOTHA and hopefully later on this year at the BO A congress, I'll be chairing the voter at BO A session on sustainability and alongside the British Orthopaedic Association, we've written a survey on sustainability within trauma orthopedics, but there will be more on this to come a little bit later on. So you're probably thinking, well, why sustainability, why is she banging on about this quite so much. And to be honest, I've always held an interest in environmental science and then thinking about global politics and then, well, not to be dramatic, but without it, we are all doomed. So let's put this into a little bit of context. Global temperatures this month for the month of June, ever since records have started, has been on average one degree Celsius warmer than all previous months recorded for June and recording started back in the 19 seventies. We know that global warming which is caused by fossil fuel use, global development and a growing population is an incredibly politically charged issue. It's a key priority of the United Nations where they aim to bring leaders together to help create international legislation so that we can help to slow or prevent the effects of climate change. And we know that climate change is one of the most significant health emergencies of our current time with the who estimating, but there's 250,000 fatalities per year as a result of climate change. And we know that there are extremes of temperature as a result of climate change are believed to be linked to increasingly frequent disaster events most frequent. Most recently, we can think about the floods that happened in northern Italy, which had consequences for both the economy and also in terms of cost of life with Italy being particularly susceptible to the effects of climate change with their geography and two very long coastlines. And it's been estimated that since between the year 2020 19, that extreme weather events have caused 9.4% of global deaths. 9.4%. That's huge. I think it's also important to know that we appreciate that healthcare is one of the largest global contributors to climate change. And when we narrow this down and we think about the NHS itself as we've already heard from some of our other speakers today, the NHS generates 25 mega tons of CO2 emissions. The NHS generates 500,000 tons of waste every year, which represents a quarter of all public sector waste. We know that operating theaters when we distill it down even further will generate between 2033% of the total amount of hospital waste. And then we know that about 90% of theater waste is thought to be inappropriately segregated and incinerated rather than being appropriately processed and, and recycled to its true potential. I think it's, it's important that we understand what sustainability is. But it's also important to know that as a trainee, it is hard to bring about change. As a trainee, you're potentially going to be rotating around between departments and hospitals every four months or six months as a registrar. And actually, where are you going to be able to find the ability to create change and then create a sustainable project that is able to continue long after you're gone as a trainee, I'm finding it is incredibly difficult because I have no control over processes or procurement within my department. We've then also got to think about the time that's spent actually doing the job over promoting that sustainable agenda. So when we're at work and we're thinking, gosh, I'm actually not been able to use the bathroom for more than 12 hours. Really is promoting that bit of recycling in the operating theater. Going to be your main concern. When you've got to get your 60 WBS per year, you're 300 plus operations per year as well as do your research, audit publications, presentations, prizes, you're teaching your leadership and managerial experience. How are you really going to be able to work on the sustainability agenda? And is that going to be one of your top priorities? It's really difficult to be able to say yes, it is going to be. But I think that this is then where it's important that we recognize the potential for using quality improvement as a tool to promote sustainability. Now, the improvement tool that I use is that IH I Institute for health improvement methodology. Appreciating that this isn't the only methodology that we can use out there. The reason that I use this method is that I think it's incredibly simple. We start every improvement project by thinking about the three qualifying questions. What are we trying to accomplish? How do we know that a change is going to be an improvement. And what change can we make that is going to result in an improvement? We're then able to utilize our plan do study act cycles so that we can make sequential changes one after the other in a particular item or project or things that we're measuring so that we can create long term sustainable change in culture. So essentially, very simply we can say, find a thing, measure it, change it. And then did we improve that thing? And then can we think about whether we are able to measure change over time? I think it's really important then that we also appreciate that. And I think we've all been in that situation where, you know, you as an F one or your F one has written a fantastic project has been presented at your local audit meeting. But then once they've left at the end of their four month rotation, no one's picked up and no one's carried it on again. So then I have to think about how we're going to keep that culture of change going forwards. For example, I was involved in a quality improvement project surrounding induction processes in Morriston Hospital in the Trauma orthopedics Department. And because we had significant buy in from the department that project is still going three years later. And every 4 to 6 months, the lessons that we learned at the start of that project are still being implemented. Today. And I think we have to then think, well, what can we do? It seems like a huge battle and like there's nothing that I can do as a trainee to change things. But actually it's all about doing the small things, do the simple things. For example, you can ask questions, you can be curious, make friends. You know, we've been able to get together today, all of us with an interest in sustainability and think about what our next steps are. We can get involved in promoting the green agenda on social media and in our local audit meetings and at local teaching sessions, we can do the small things that will help to promote sustainability. I'm gonna allude to this in just a moment. You need to be able to also find a mentor, find someone who's interested, the consultant that I'm working for currently, he's hugely into sustainability. And actually, I've learned a significant amount from him over the last five months of working together just about how I can improve my practice and become more sustainable in what I'm doing. And I think that the very simple thing that we can do, if you want to implement change, you've got to be able to show the benefit of a project. You've got to be able to show the potential in it, in black and white. What are the financial savings? What are the time savings? What are the carbon footprint savings? What are we doing, that's going to make an improvement. Then you'll be able to get that buy in from your department. So when I said, let's think about the simple things. It's a little bit of a grandmother sucking eggs. Time does everyone here every single time they go into the operating theater? Use a reusable hat. Get some reusable hats. Support your local businesses. Buy some and then you don't need to be throwing a hat away every single case that you do. Think about how we get to and from work. Can we utilize lift shares a lot better? As we heard from Mr Magee earlier thinking about wide awake local anesthetic know, tourniquet lists. This is something that we're utilizing a lot in my current place of work. And we've actually managed to drastically reduce the amount of waste that we have from our simple couple tunnel or trigger finger list. Everyone loves their cup of coffee is everyone bringing they're reusable coffee cup into work every day? Stupid things. The simple things like thinking, can we turn off the lights at the end of the day? Does that computer need to be kept on standby? I think something that I've learned significantly over the last couple of weeks that not weeks months is actually how I can better utilize Piff Ooh. So patient initiated follow up where I'm working at the moment. I've got a significant catchment area and some of my patient's have to drive an hour and a half just to get to the hospital for me to review them. Can I better utilize Piff Ooh. So that I'm reducing their time and reducing the carbon footprint of them coming into the hospital and then thinking about your operations, getting your operation right the first time I know that I've been, and as we all have been foul of dropping things on the floor or of not measuring something to the correct length and then having to waste equipment, making sure that you're getting things right first time so that we're not wasting our resources. And I've got a couple of things here that I think are more difficult for us to do. But actually, from what we've seen today, these issues are not insurmountable. For example, where I work at the moment, we have one stop shop, couple tunnel clinics. I've got a neurophysiologist on site for our once a month. Carpal tunnel specific hand clinics. I can get my patient's in, I can assess them. I can get their neurophysiology done in that same clinic appointment and then I can get them consented and added to my waiting list in one stop shop. Thinking about the use of reusable drapes. I know that reusable drapes is potentially a contentious issue in the world of orthopedics, but it is something that we should be looking into and across the country. There are regional variations with this. We've been speaking a lot today about reducing water use. So how can we better um promote the use of alcohol based hand preparation for our operating lists? I'm not suggesting that we go in there and we're able to do the plumbing ourselves. But how can we think about reducing this finite resource, reducing the use of this finite resource? Something else is potentially more challenging. How can we switch to paperless system? I know that I'm particularly guilty of it. I love my paper list and I love being able to write down my jobs on it. And actually there are issues with data governance and information protection. But how can we go to a paperless system across the NHS and working on a more sustainable um set up here. I know that across the country we've got virtual fracture clinics and they're used to fantastic effect patient's who've got orthopedic issues, but they don't necessarily need to come in to see us and we can direct them straight to, for example, the physiotherapists or back to the general practitioner from our VFC S. We know that they work across the country and we know they're fantastic ways of saving money as well as helping to reduce our carbon footprint. We've heard today from Mr Donaldson about surgical tray rationalization. How can we reduce the amount of kit that we're using so that we can be more efficient? We can save money and we can save energy that's used in sterilizing these pieces of equipment, something that is a particular bugbear of mine at the moment. The individually packaged screws. When did we make that transition from having a caddy of screws on our operating sets to the individually packaged screws? I shudder at how much time it takes and the amount of waste that comes in when we're using these screws and small pieces of equipment. When it used to be on my operating tray, it used to be on my caddy. And then for us, registrars every single week, we have Friday afternoon teaching. That's in a centralized location for me personally, if I weren't able to attend my teaching virtually, that would be 100 and 60 mile round trip for me to attend in person teaching. I wonder what the setup is across the country in different Dean Aries and whether you're utilizing a virtual platform or a hybrid platform so that we're not reducing the quality of our teaching and training programs. But we are also taking into account the sustainability elements of it. I think that within orthopedics, it's also really important for us to understand that there are a number of things that we all do just because it's the way that it's always been done. We know that there are dogmas out there. And I think it's important that we work out how we best able to challenge these, how can we make our practice more sustainable? In my opinion, that's going to come from conducting good quality research which will either show that there's noninferiority or indeed superiority to more sustainable practices. And we need to know how this can affect our choices of treatment or how we practice. For example, I know that this is a contentious one. But the draft trial from a couple of years ago showed that actually, there's equivalence with K wire fixation for distal radius fractures over volar plating. It showed that it was a quicker, faster and cheaper operation. We've also seen with the aim trial for ankle fractures in the over 65 year old population that close contact casting is equivalent to open reduction, internal fixation. And we know that with the smart protocol from Swansea with tender achilles ruptures that we've got equivalent outcomes with conservative management of these treatments. We've also seen that wall int operating techniques of wide awake local anesthesia, no tourniquet has successfully challenged the dogma and we're seeing more and more elective hand surgery is able to be done within a clinic setting rather than in a theater setting. I think that it's also really important for us to appreciate that sustainability isn't just about reduce reuse recycle. Whilst that is a significant part of the challenge going forwards, there are other more pressing issues we know that the definition of sustainability is that we need to meet the ability of the needs of the present generation without compromising the ability of future generations to meet their needs. When we think about the most recent NHS staff survey, one in three of NHS staff felt burnt out. And rcs England publication from 2021 showed that rates of burnout in surgeons was between 29 and 41% with surgical trainees themselves reporting a 59% rate of burn out. I mean, what does, what does that mean? It's a word that a lot of us here brandished around and it's really difficult to understand what that is. So burnout is when you've got a state of physical and emotional exhaustion, you got feelings of being tired, drained, feeling hopeless, trapped or defeated, feeling detached, feeling alone, having a cynical or a negative outlook, feeling that you've got self doubt or feeling overwhelmed. It's a really wide ranging feeling and a number of emotions that we will be feeling. And I don't think that it would be a shock that anyone says that they've experienced these burnout symptoms. I know that I have felt these and I've been incredibly close to quitting medicine all together because of the symptoms of burnout. And I think it's really important that we work out how we can look after ourselves. Big disclaimer here. I do not have all of the answers, but I think we need to understand the support systems within where we work. You need to be able to understand what those symptoms are of burn out within yourself and your colleagues. I think we are all need to get better at communicating, you need to be able to take time for yourself. We work long hours and our job is demanding. You need your lunch, you need to go to the bathroom, you need to take your leave and you need to enjoy your free time and you need to not feel guilty about that. I know that a number of people will utilize apps like headspace or calm and that we've got to be better able that looking after ourselves in terms of taking the rest that we need, but also being fit and active and moving in appropriate amounts that we get those endorphins pumping, that we feel fit and active. And I think really importantly, we need to get beyond those barriers that we put in front of ourselves. You know, the perceived shame, the thought that admitting you're struggling is going to affect your career or thinking that the team isn't going to cope. Something that someone told me a few months ago was from the hospital was here before you arrived and it will be here long after you are gone. So you need to look after yourselves. I think it's really important, but we also look out for those members of our team. You need to understand the dynamics of your team. And unfortunately, as much as we all hate, it were all leaders, whether we like it or not. And actually, it takes a very strong leader to understand the needs of their team and making sure that their team is well looked out for. Um, and that can be as simple as let's go have a coffee break. Has everyone had their lunch? Have you had any water today? Why don't you take five minutes and then we'll go and see that next patient. It's difficult to see these things within yourself, but then it's even more difficult to appreciate that for the people around you as well. I think sustainability isn't just something that we need to kick down the road. It's incredibly easy for us as trainees to think. Well, I'm not in a position of power. There's nothing that I can do here, but actually, there is a significant amount that you can do. There is a lot that we can do as trainees and to be honest, we're going to become the future leaders. So change needs to start with us and then as we go through the system and as we get more senior into leadership positions were then able to implement that change a lot easier. Something that you can do again, I'll talk about this in a second is to get involved in the new bo a Boater Sustainable orthopedic Systems questionnaire that's going to be landing into your inbox is in the next couple of weeks. You can make small positive changes to your practice. You can, and I've seen it within my own practice and it does make a difference, you can do the simple things like buying some washable hats. That can be your number one thing you can do this afternoon, get onto ebay and buy yourself some reusable hats. You can talk to your reps, talk to your bosses, talk to your scrub technician is about things like reintroducing caddies about the sets that were using the, the reps that we're using and the equipment that we're using, try to get as much information as you can. As Mr Donaldson was suggesting earlier. Actually, it's all about observation and being curious asking why do we use this and how can we make it better when we're doing our own operations? Think about what we're doing. I know that we all get taught when we're doing our operations. Have your plan A, your plan B and your plan. See, you want to make sure that your plan A works and think about, well, what equipment do I want? Making sure that you're getting those measurements correct that you can save waste going through and that's utilizing our gift principles. So getting it right. First time measure, once, put that screw in, once, don't change it. Now, I'm gonna finish off talking today by mentioning our sustainable orthopedic systems questionnaire proof Eastwood and a group from Mallya. And I, we've been working very hard over the last few months to develop a questionnaire that's going to be looking at the thoughts and opinions of both botha and the bo a membership on sustainability. We want to be able to get as much information as we possibly can about different people's thoughts, ideas and what your agenda is. So we can distill the priorities of our members with regard to sustainability. And this is going to be coming out to you very soon to your email inbox. You're gonna be spammed all over Twitter and Instagram with this. It shouldn't take more than 10 minutes to complete and it's going to really help to inform the direction that the bo A and that botha takes with regard sustainability in the coming years. So please fill it out when you get the invitation. And I'd like to say a huge thank you to everyone for coming and joining us today. A huge thank you to all of our speakers and to every single one of you for coming and joining us and for taking up your, your Thursday to learn a little bit more about orthopedic sustainability. Thanks very much, everyone. Uh Let me just stop share ing my screen and if there's any questions, I'd be more than happy to have a chat with anyone about it. Francesca. I think that was a great sort of roundup about sustainability and it covered a lot of important topic that I think are applicable to all of us. Thank you very much. Thank you. I wanted it to, I wanted to be able to sum up everything that we've kind of thought about today and thinking about how we as trainees are able to make that step forward and how we can get involved because I think it, it is a very daunting subject and thinking, oh, gosh, I can't get involved here. I don't know what I'm doing, but I actually think we can make small changes and actually, I think that's where the most significant changes come from by making the small ones because all of the small changes amount to bigger ones. Yep. Um, there are no, there's no questions in the chat so I don't see any, what you say.