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Uh Next up, we've got MS Victoria pregnant. Uh We'll give a, a speech on no excuse and that she'll tell you that you can be a sustainable surgeon and give you advice on how you can achieve that. Uh MS Bagna is an S T A colorectal surgery registrar in the K S S Dean Ary. She has biology BSC from U C L and MSC Neuroscience. Then studied medicine at Imperial College London, elected to Council in 2019, Victoria quickly co founded the S I S Sustainability and Surgery Comity on RCs, England Council and is currently a co chair and is an active environmentalist. She has been part of many sustainability projects including setting up the green surgery challenge and James Lynn Lyons priority setting partnership for sustainability. The floor is yours. Thank you for being us with us today. Thanks and thanks to an ill, I think, hopefully I'll be able to tackle some of the things that have been mentioned. Um And I think the one thing I wanted to say because obviously this is a trainee conference. Um everything I say or tips I give or things that I'm talking about or that I might have done, um I've done as a registrar, so you don't need to be a consultant to do these things. So it's really thinking about things that you can do as a trainee. And I think one of the things actually just on the opening slide to say is that um I got elected to the Royal College of Surgeons of England just nearly four years ago now. And one of the first things I did was I went, said to the Presidente, can I be on your environmental committee or whatever? And they didn't have one, they don't have a policy, didn't have anything. So one of the ways to change that is then to set something up. So I said, can I set it up? So then two of us set, set up the Sustainability and surgery group. So we obviously now chair it and then we've done everything on that to talk to you about um from that position. But as a registrar, so you don't need to be a consultant to do these things. Um uh uh from that, from being the chair of the Sustainability and Surgery Group, I've then spent the last three years trying to get all four Royal Colleges together to work together because that's another thing is that lots of the time all of us have got good intentions rule in our local hospitals, but you're not working in unison and it actually happens the same at the higher levels. You've got great hospital, doing great things. You might have the English College or whatever college, doing some good things. But if you're not doing it together, then really, we're not going to make big changes. So, after three years, I got the four Royal colleges to agree to declare a climate emergency. Um, that doesn't, that sounds like it would be an easy thing, but actually it wasn't an easy thing at all. But eventually in November last year they all declared a climate emergency. And what that means is that all the four Royal Colleges of Surgeons are recognizing that, that, that, that this is quite bad and that something needs to be done and that they're going to become, become more accountable and try to help guide practice a bit more. Um and actually take an interest. So, and then the other thing I want to say actually has been said before, sometimes you come to these talks, people come to these talks and they think, um I don't think I can do that as a trainee. No one's going to listen to me, but there are some things that you can do and I think it's better to do one or two things, not 61 like in that other study and, and even do them imperfectly rather than doing nothing at all because doing nothing at all is going to carry on with the climate emergency that we've got at the moment. Um I won't really well on this slide here, but it's so bad that we, you know, on death certificates. Now, we've seen a child die of pollution and it's such an important thing that we need to tackle because what's really important to remember here is that five, nearly 5% of greenhouse, our carbon footprint in England comes from the NHS. Uh And within that, within the NHS, some, about 50% of that comes from operating theaters that were all in every day. So even if we do one tiny thing in our operating theater, it actually has a really massive impact. Um So if you think you're not doing much, you are, and we'll talk about that in a second, a straightforward simple tonsillectomy that takes, let's say it takes 15, 20 minutes, something like that is the same carbon footprint is driving in your petrol car from here down to London and back again. So can you imagine what a robotic low anterior section would do or whatever your operation is? So, it's, it's a really, really huge carbon footprint that these operations have. Um the three areas that we've talked about that I won't dwell on this. Actually, we've talked about this or the, the single use items, the consumables, basically anesthetic gases, which is not really our domain. And then, and, and power supply, which actually we might have some implements on if we sort of listen onto the things that you can do and are single use instruments are the worst offenders. So, a bunch of us registrars came up with this green theater checklist and then we then presented it to the Royal Colleges who then looked at it and we're happy to endorse it. And the really good thing about this green theater checklist. I don't know if the QR code shows up on there and actually I did it on a Mac this and it hasn't translated very well, but the green theater checklist, um it's basically a tool for you to be able to go into your theaters and say, um this is what the Royal Colleges endorse. Uh And this is what we'd like to do. Um I won't talk too much about the anesthetic side. But what I do want to say is that every single I know that the, I know it's not translated very well, you'll just have to try and read what it says. Sorry, because it's from um uh an Apple computer. The everything that we've got on these 16 points um has got compendium of evidence to back it up with the evidence that's available. Um So when a for example, someone says, oh, you can't do that because there's no guidelines for that, then you can look on this and see that there are and you can challenge it. So one of the first things to think about is do they even need this general anesthetic for the operation? Do they need to the amount of carbon footprint there that drives from here to London and back again in a petrol car. So, if they've got a back abscess, do you really need to do that under a general anesthetic? For example, my argument would be no, um, and these statist to use the total intravenous anesthesia, but that's not necessarily our domain. However, if you were to bring this up when you do your, who's checking in the mornings and say, oh, I just wondered what, you know, what, what Germany in setting you're using. It just gets the conversation going and I think that's how you get behavioral changes, the conversation, you don't have to be pushy, you just start the start chatting. Um, and then I think there are other things you can think about like the, these, those slide sheets, those massive slide sheets that a single use really thick, full plastic sheet that a cost the hospital loads of money. But b they don't really work any better than just a bed sheet that can be washed. And there's no, like it's not an infection control issue. It's just something that companies have got rich from. So there are little things that you can do. You can, uh, you know, and change over really easily overnight. Um, the other thing to think about is don't, don't use it if you don't need it, I'll come onto that in a minute and when you're trying to get ready for surgery. This is one of the biggest things I want everyone to take away from today actually is scrub caps, gowns and drapes. And at the moment there isn't evidence to say that surgical site infections are worse when we use washable scrubs and drapes. At the moment. There isn't, I don't know whether trial will show something different. The Dragon trial, but at the moment there isn't. So we should be using washable scrubs, uh, washable drapes. I mean, I've even seen people coming in single use scrubs. Uh, I mean, it's, it's, it's horrific. And theater hats, we should just be all wearing our own theater hats. They're made of plastic. It's really bad. There's no need to wear a plastic scrub cap. You can do that tomorrow when you go into theater. Um, uh, I think, uh, in the NHS guidelines it says as well that you can, you can use these, um, these items too. So there's none of this kind of infection control nurse is saying, oh, sorry. You know, we're not really allowed to do that that you are, you are so it needs to be challenged and that's us on the shop floor that can challenge this and get the infection control in your department check to change it or just do it, which is what I do. Um, this gives you a few, a few bits of information and it's all in the compendium of evidence as well. Um, and it shows you that, it just, just not using that Drake, that gown that day, uh, making a washable one. You know, you don't, it's the same as driving, driving 10 miles in your car just for that, just for that gown. So it's really important that are really silly, small things you can do that will be really helpful. Um, if you've got the alcohol based rub the wash in your, in your hospital. Great. Use it. You do the first wash of the day scrub up and then after that, you can just use this to really, um, gel. Um, if you don't have it asked the department why they don't have it and then you can show them from our compendium the evidence that shows that it saves water. I mean, to be quite honest, you don't really need the evidence to know that it saves water. Of course, it saves water. It, it saves hundreds of liters of water per day. So, but if they want the evidence, there's some evidence there, another really big thing here is that there was a big our ct done. Um, here you can see it at the bottom showing that the clot hex prep sticks there in those plastic ones that are like terrible for the environment. Single use. They are no better than just using it in a galley potter reusable galley part that's slashed in or, or a bit of Betadine in the galley pot that slashed in So why are we using these sticks? I tell you why, because the companies are providing them someone up in procurement in NHS England and said yes to it. And then it just becomes like the norm, it just becomes the practice, but there is no evidence that it's better. And what's actually happening is it gets then infiltrated into some guidelines somewhere. And then these low income countries then end up feeling like they need to use these single use plastic sticks and they can barely afford the surgical equipment. But they're being told by who guidelines that they need to use these single use ones. And when an RCT was an international multi multi country are CT was on, it showed that it was no better. So we really need to challenge these things and I don't, I refuse to use them in art when I do um operations in my theater now and generally that people are, people will go along with it. So if you can show them the evidence intraoperatively, um what, what can you do? So um if you get a consultant level, when you get to consultant level, you can ask for your equipment to be what you actually need rather than stuff that you don't need. So that it used to be that when you put a chest drain in, for example, there's a massive long metal trocar that in for the last 15 years, no one's used a massive long sharp metal trocar and chest drain for chest trains. And it's just been in that pack year after year after year. So you just need to talk to, to the department's to make sure you've got what you want on your set, try to use stuff properly. So, I don't know if you notice sometimes like you'll have swabs handed to you in like a speck of blood goes on them and then that swab gets changed for a new, why just use it properly, make sure it's got blood on it and whatever else is on it, just use them properly, use them up. It's, you know, it's just common sense, this stuff try and try and um, talk to your scrub team about, can we use reusable stuff today? So the reusable drapes, can we use reusable galley pots? Um You don't need to open stuff that doesn't. So in your, when you put a catheter in, often in that set, the, the gloves are included in that set, but we all forget that and we all go and get a new pair of gloves, you know, which is in another packet. We use so many things doesn't necessarily, we just need to think about it a little bit more. Um One of my big bugbears is energy devices. So there's a really big company that's like the biggest company in the UK, probably in the world for energy devices that do you staplers across the colon. And um, in America, that company, um We'll re sterilize their, their single use stapler and they'll send it back to the hospital in the UK because the NHS just keeps buying them each time brand new single use because the NHS isn't very savvy when it comes to saving money. Um They, Ethicon I'm gonna, don't endorse just sorry, just said, um great, bring it on, bring it on, I'm ready. Know they know me, they blacklist to be on Twitter. Um um Anyway, Ethicon refused to endorse re stabilization in the UK. So there's a company called Vanguard, for example, that will re sterilize it and then, and, and, and approve it as well. So it's completely done properly. There's no, it's all been approved through proper guidelines. But Ethicon don't, don't endorse this because they make loads of money because it's 500 quid a stapler, whereas Vanguard will send it back to you for 200 lbs and then you get, you get paid 11 lbs to send it back to be re sterilized. So there's lots of really silly little things that as a trainee every huh hospital I've gone to, I've told the hospital department about this vanguard, for example, whatever, what it doesn't matter what, what, what it is. Um and other other equipment providers and it's that by the end of my year on that rotation, we've, I've saved the hospital tens of thousands of pounds. Um So it's really, so this and that's as a reg just mentioning it because when you're talking about money, people listen. So that's the way I think is the in for the environmental thing for me is to try and show that it will also saves money. Um And then I think, think about skin sutures and like when you close up just use sutures, why, why use clips unless there's really a clinical need, fine if there is great. But if there isn't use sutures, because otherwise they have to go and see a nurse have to drive to their GP, have to use a single use clip remover as well to get it removed and they have to have a dressing on. So just, just try and think of small things like that that you can do and change your behavior with. I'm not saying do everything open and don't do it minimally invasive because I'm very keen on minimally invasive operations. But, but I'm just demonstrating here that it's three times as bad in general for the carbon footprint of, of the, for the operation. If you do stuff either laparoscopically or robotically, so it's not going away minimally evasive is the future. So we need to try and think what we can do to reduce our carbon footprint whilst using minimally invasive stuff. So, can we use reusable ports? Can we use reusable clip? A pliers? Can we use reusable scissors every time you do an appendix, they open up a single, you scissor that I cut a suture with, and I cut the basic, you know, it's like one cut. So we just need to ask the department's to get in the reusable scissors. And then when people say, oh, but 20 years ago I use those reusable scissors and they weren't sharp, so I don't want to use them ever again. There's a company that just provides you with new Caesareans. So they are brand new. It's just the handles re sterilize herbal. Um And it's just, it, it's just this kind of, oh, we've tried this before and it doesn't work attitude. But we as the young trainees and the future of surgery don't need to have that attitude. We have the power to ask for things and to change things. And when you become consultants, you can then say no, I really do want that, please. Um And we have the, we get the conversation starting now during our training years. Um, when he was already said about recycling, it's great to recycle. It's got the lowest impact out of all the whole of the NHS footprint for surgery, but it's great to try and put things in their bags correctly. It's done really badly. It's also really bad every time an orthopedic surgeon washes out the knee with a single use squirter thing, it's got six batteries in it. The whole thing is single use. That kind of stuff is just crazy. There is a company that also takes in your energy devices and all the things that, um, that are long and metal and big and plastic and they will separate it out for you. So, not Viola, but there's another company that would, uh, um, so there are ways around it, but that's the slightly lower on, on, on big, big step improvements. Um, we need to repair things rather than just chuck them away. We need to turn off everything at the end of the day. So if you've got 20 operating theaters like where, like where I work at the moment, um And only one of them is see, pods, you only need one theater that's up and running for 24 hours all the time. The other 19 should have everything turned off at six PM. Whatever time they finished at the end of the day, the gas scavenging systems need, turning off the lights need, turning off the computers need turning off. You could save your energy bill for that theater departments 70% by just turning off everything. Now that is tricky for us as trainees because obviously how do we go around doing that? But we can certainly do projects, quality improvement projects, audit, show financial implications if you want to do that as well. Presented the department and show them how much money they will save if they use gel gel wash, turn off a few lights and a few air conditioning systems. But we, we need behavioral change we actually need policies in place to have this done. But that is a really big energy saving, money saving and environmental savings. We do that and then gloves. I don't, I don't really want to get me started on gloves, but basically everyone puts on a glove to shake a patient's hand. Do you do that when you're in the street? Shake someone's hand, you don't put a glove on. So why do we do it in the hospital? Why do we examine patients' arms with a glove on? Why do we, why do we put a set of gloves on the 10 people that are in theater, put on a set of gloves to move the patient 30 centimeters on a bed. It is just madness. We're about to wash our hands anyway to do the operation. So there are so many things that we can do differently. In addition to that, in addition to that, the gloves are all made in slave labor conditions by Children in Malaysia. The world's gloves provided by basically two providers provide about 80% of them, all of which all the time they get shut down for slave labor conditions. Children Rohingya meant refugees, working, having their passports taken away. And there we are checking, putting a pair of gloves on to shake a patient's hand or to touch there to touch their arm. So there are things like that, that tomorrow you can change, not, not do that because it's having such a impact financially on the NHS, but also on the ethical trade of these, these items that the NHS buys. Um And one thing I just would say is that it's great that we've showed that if you change your gloves, when you're closing a wound helps reduce surgical site infections, it might be helpful to also look at whether we just put a bit of iodine on that wound and maybe put some iodine on our gloves and on our, our instruments as well. Would that give us the same, the same outcomes for surgical site infections rather than everybody changing their gloves for, for sterile gloves, especially if you're in a country that's a low income country that can't really afford all these extra gloves, but they might be able to afford a slush of iodine instead. So I think, I think it's great to show that it's great to use gloves and change gloves. But actually, are there alternatives out there that might be a little bit more helpful for saving money in the NHS? But also saving the low income countries, um, money and wasted as well. So lots of things you can do tomorrow. I really hope that I've helped to make you think about a few of these things, but put your own scrub cap on, choose the scrubs that are washable and the drapes that washable and the gowns that are washable and don't put a pair of gloves on every single time you do, you walk into a hospital ward and if you've got any questions, I'm happy to take them. Thank you very much for such a powerful speech. I think a lot of us have got a lot to take home and we know what we can do when we go back to our day to day work, how to start the change and how to make a difference in terms of moving towards more sustainability. We have got uh not that much time. I'll have one quick question from the audience. Do we have a question? Yes, absolutely. What? See that because I just, no. Uh Yeah, I'm scared of them. Can you hear me now? Yes. Good. Right. I'm taking a risk here and declaring that I am an intensive care and anesthetic consultant by background and especially I'm on stage tomorrow. Doctor. Hello. Right. First of all, just to say, I do hope that if you do engage in this conversation in the, in the states that they will be receptive. Certainly in my own hospital with band Desflurane will stop. Um Second of all, just a question about your training, your curricula going forward. Do you think this should be a subject of all surgical curricula going forward or should be even be putting in the G P C S? So yes, I do think it should be a subject. We've already lobbied the parties that need to be involved to put it on the curricula and there have already been some mutterings that basically they are in support of that and they will, it's a really, really long process as is everything with that kind of thing. And I want to like hit my head against the wall sometimes, but yes, we are trying to do that. I hope that we see it. And on the shop floor, there are lots of universities that are now starting to include in part as part of their medical school training. I'm I was based at Brighton and actually brighter medical score really partners in this. And actually I talked the other day on of course, the medical students, I did the sustainability part. Um it was part of their curriculum. So yes to that. And secondly, an East tests are brilliant because they are way ahead of the game. When it comes to sustainability. We are so behind in surgery and we need to take a leaf out of your book and actually most of the evidence we've had to use to, to research the compendium has actually come from an East is that have done it. So I actually hope that we um it's not, it's not asked making the conversation within East. It's really, it's, it's the other way around. So yeah, you guys are way ahead. Brilliant. Thank you so much, MS Beckner. Thank you for your time.