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something for me, and I was asked to talk about unsustainable surgery. But I've been very conscious that as an equal, this is not We're not just organ to the surgeons, so I'm trying to keep it very broad relevant for all clinicians both I/O of the operating theater. So s, as was mentioned, I'm tilted in the notice. General surgery and major trauma. And at this and usually, hospital South London Since George's on you can see the helicopter on top. That brings out major trauma pay patients, but as a result of the 02 emissions from that. So we're gonna have to work very hard to get it next year. Uh, so on, then I'm also an active travel compainer. It's, um is the carbon footprint of surgery important? Even that it's recognized that surgery is necessary for quality quality care, but it is very possible Teo reduce the climate impacts. Surgery itself is a resource intensive because it involves a tick Whitman that we use sterilization process there many technologies that we use and the life support systems that the anesthetist use. And afterwards I have a big impact. So what can we do to reduce that? Um, yeah. Um and this is a interesting a publication by Chantelle Reason, who is one of the right right and lights in a reception to stay mobile surgery. She's in theanti training and working with Sustainable Healthcare Institute. She did a systematic review looking at what is the carbon footprint often operation on GI. Identify this wide range that the lowest that she found was a cataract operation at this center in India where they used I think the person you set it up use the concept from McDonald's of class foods to provide class healthcare. But he did everything super sis efficiently to provide really low cost surgery for the patients in India. But actually, from the way he does it, they actually have the best outcomes so they can do hundreds of cases in a day compared to where we would only do 2 10 in the UK but actually have much better outcomes, much lower infection rates. Um, it's it's somewhere we should really learn from on. It's also a much more sustainable way of of healthcare. On on the opposite extreme is this an operation from three US A robotic hysterectomy which has 815 kg on. There are certainly reasons why you would need to do both types of operations. So, for example, if you've got a super B patient who needs a hysterectomy, actually, doing it robotically can massively reduce your complication rates and therefore it over the long term will have lower so two emissions. So there are times when you would need to use both systems just because it's got high, See it a carbon footprint. It doesn't mean it's not the right way. We should be proceeding in half. But to me, the way to reduce the carbon footprint of surgery, not just to me this is, um, comes from sustainable principles is prevention. If we can reduce the need for an operation that is the best way to reduce the carbon footprint because the operation is always going to have a on impact. So think about every two every consultation we have A with the patient to think about prevention, talk about physical activity, stopping smoking. I think we already heard her talks this morning about diet things like Has the patient had their coding back kind of vaccine because you could if you stop patient's getting coated in their postoperative course. You convict, come on. Massive Reduce the health impacts. A Patrick surgery itself that's been shown to reduce health and out that should be focused is a prevention on. Then, once you decided the patient definitely need the operation, make sure the patient is optimized. The fourth surgery is a lot of new evidence coming through, showing how preoctive on optimization massively reduces complications with that that reduces the overall carbon footprint often operation. Um, another way of reducing the need for surgery is shared decision making on. Actually, if the patient really understands the impact of the operation and need for it the complications, the risks, quite often they may decide that that operation is not right on. It's too later, after the operation, have the complication. So it's really important that those those conversations I've had in advance so that the patients only have operations that I needed on then at the end of life is well, one of the operations are not involved with the emergency laparotomy on. But we're doing a lot of work now to identify how, actually, because you could say that sometimes you see a patient who's dying in front of you on the surgeon will come along, so yeah, but I can save the day by doing an operation on. Actually, you may save their life on the day, but it is that a benefit? I'm thinking about the whole process and not just the day of the operation on the on the top right topic of prevention. So this is just a on that's that's it's like from the making everyone contact count, which is where they highlight the importance off healthcare professionals in in Prevention is that actually we have a really privileged role and patients will listen to us and we can make a difference. So every time you have a have a contact with a patient, really think about health promotion on on, Did they say the brief advice left and 30 seconds I can make a difference on the patients. We've seen this from on uh, studies on and stop smoking is that the types of where it makes a difference is if you've got a on a non smoking health care professional who is a vitamin to stop smoking, that makes a a much more difference, but it but it healthcare professionals I met, much more likely to help people quit. So it's the same. It is a so assume that it would be similar between stopping smoking and other lifestyle factors. And I think these are the updated slow. Anyway, I don't flick through, and it's a couple of things at the end that has changed. But so I just wanted to talk a little bit about cycling, as I mentioned, is so as a major trauma surgeon, about a third of our work comes from Rhode trauma on. So if we're thinking about prevention for on for surgery, that the way to to do that for for my work in major trauma is tow, improve safety on the roads on. I think it's really important that health professionals are advocating for this because there is a lot of controversy out there when it when we when it comes to talking about cars and by special legs. And so this is data of mortality from 2020 where you can see the number of deaths across the UK from people in cars, pedestrians most like cycles, and you can see five times the number of possessions were hit like that were killed on the roads, a supposed to cypress on day. Or although that is because there are a lot more restaurants on the road. People talk a lot more about that, that the cyclist hills and it's important to realize is improving, although safety that's important, not just it likely so often treated. Absolutely. It and people don't like the cyclist, so they don't care. 100 cyclists died on, so they won't but often won't change things. But But if we need to highlight the fact, it's not just like a big hills, but because the deaths on what matters is the the carbon footprint of it and HS because they don't come to the hospital on before. They don't impact on our on our work. It's the ones who were seriously injured on this. Put about think a TC 15 times a many people who are seriously injured on there, they're the ones who come to us and be treated, and that the, uh and the expense and carbon footprint off the treatment of these patients majorly injured patients is massive. So if we could do something to reduce the number of patients injured on the road that would be have a have a big impact on on our on our health systems on. Is that possible? Well, actually, the answer is yes. So if you compare that high number of people killed on the roads in UK, this's a report on health thinking and Oslo and both those couple cities had no deaths in that city on on the roads off for pedestrians in a whole year on the way they did, it was they made a, um, uh, serious commitment to changing the way that cars use the space So they cut speed limits. They change the street design. They removed space for cars and generally made it much harder for motorists on they. With this, they shift the responsibility for crashes from the road uses to the design of the roads on. So it is possible that we can take away that massive of carbon footprint that's dedicated to looking after these patients by by by making a difference. Railroads on baby, then being a week. Um, it it is not that just changing the hospital, it's changing, changing the environment as well. But actually, it's not just the those trauma patients that will make a difference, too, if you if you design walking and cycling into your daily life, it's most effective way to increase physical activity on. But many of my patients through emergency service surgery and I'm sure for everyone are are impacted from physical in activity. So if we've designed in tile IVs, then we'll say, Well, that coming from the from their house can ease. I know it's over pollution because it's not something I know very much about it, but a lot of pollution comes from cars, so if we take those absolute city, we'll save a lot of these complications on then. Of course, what we're here for is the final change in carbon footprint and a large part of your problem. Footprint comes from travel. Um, so just and this is a really interesting study a couple of years ago in it was there was, ah, hypothesis that the number of deaths on the road, especially from cyclists, was directly related to the number of cyclists. And it doesn't didn't matter what what you did on the roads. If you had once you get beyond the critical member of cyclists, actually that was protected and that's all you needed to do what they did in the US They looked at 12 different US cities and they looked at the number of cyclists, but also the amount of infrastructure. Four. Cycling on day looked at the impact that had on death on what they found is that it's not just the right thing, but portion of the number of cyclists. You can have a many since I kisses a Z. You can. That's not what's protective. What protective is having good structure on, but the infrastructure that cycling infrastructure doesn't just protect the cyclists. The infrastructure projected the cyclist pedestrians most like it's on the drivers on. That's why it's really important that we need ta increasing amount of infrastructure we have out there. It's not all for these awful cyclists that nobody likes and and but I want to highlight. Being a cyclist isn't about like craft. I fight it here. Actually, I was very short. Son came in, but I I often cycle as I am now. You concisely in the suit on I like to use my electric. I still I think in electric by school is the future that that's you talk about you can travel many times further and But the important thing, um that I got a thing that I didn't think that mentioned too much is not just cycling as a way to get to work but actually doing our job. There are many community working within the NHS on, but there are not enough of them that do their visits on bicycles s. So this is a great group group from Dorsett. They set up that study was at least three or four years ago, and I'm really disappointed that I haven't heard of many, many, uh, district necessary of copy their work. But the other thing is the which is on line up there to slide story is the London Ambulance Service. And they've got a great, um, cycle, uh, service where they they have responders on bicycles, our electric bicycles so that they can have a whole load of kits, but they can get so much more places they can get into. It was a picture of them on the Millennium bridge. All sorts of places where in ambulance can't get to the bicycle can and they can treat a lot of patients just with their bicycles without having state nodules, so the any chest scan doesn't need to electrify it sleep. It doesn't need to do that as well, but what it also needs to do is on the pedal. It's Lisa's well, because these vehicles are a lot smaller than cars, so moving away from prevention on away and back TEO surgery. So once you've prevented your operation being many operations a little bit being happened, you are still gonna have a group of patients that do need the operation on. How can we optimize that? Those that that pathway on the first step, even before you get into the operating theater, is to think about streamlining pathways, so reducing the number of journalists, the hospital, one stop clinics, making sure your pre assessment and the surgical assessment done at the same time So the patient doesn't have come to a hospital to see the surgeon and then and reducing unnecessary IV prescribing. And I I think surgeons probably maybe they're the West, the other other fields. But I spend a lot of time trying to convince my colleagues that there are or Almeda cations that are as effective as the intravenous one so especially metronidazole. Does it float? Sin P I Z. They don't need to be given intravenously because intravenously there's a lot that plastic. There's the preparation of medication. It's sterile form because it's been a go straight into the vein. That, or has a much higher problem footprint on the tablet on on giving the minimum dose in a swell that there were many times where three doses are not better than one. So make sure that you only give the effective dose and not the dose that you think on the medicine braces. If that actually may cause home unnecessary investigations there so many times where my juniors will tell me that we've done a group and say, because just in case is the anesthetist wants it. Well, I don't care what the least it's once I want the right treatment for the patient and the optimum. The most efficient treatment on what we know is in almost all operations. You don't need a group and save on system, because if a patient's suddenly it sanguine, it's on the table. You'll give them the negative blood that's available in the fridge, and actually, most of the time, what happens is, it's a couple of days later when the patients have the blood tried institution, which time they're gonna have another group and save. So it's not off the vast majority of the time. It's not necessary preoperatively on then. So making sure that you've got many patients managed a day procedure because stay in the hospital often have a lot of waste with it all that's being in a bed as well as with the cost of the services being provided. So if you can have, um, A Z many patients is possible case halfway on, especially my interest is in emergency ambulatory care on. I know that a lot of work is happening in in pediatrics and medicine. With that, we're trying to copy those ideas into surgery on now getting into the operating theater. So this is, ah, a diagram that's produced by colleague of mine and people bleed from ms. But he says he edited it from, uh, article in the bulletin. The surgery. But this just shows where the the carbon footprint is on. That's it's and I think we've all seen the wheel from the green and I chest on. That shows where all our carbon footprint comes from, it's really important to know that to know where we can tell get the hot spots on, Do you concede on the left one's? It's the inpatient bed days and I said, We try and focus on day day surgery, the travel from the solution to that on and set it. Guess is the I'm not gonna cover too much on because I'm not in the slightest, but that it always amazes me what a massive amount of the operation comes from an anesthetic gases. And there are many changes that the dentists are working on two. So it improves that on Ben. There's a a quarter of the circle, which is actually a surgical procedure itself, and off that a large proportion is energy use on my right side. So I've got another picture, but they're a large part of that energy. Use is, it comes from the machines that do the heating and cut. That kind of climate control in the thirties was operating theaters. They need to be kept it. A lot of ideal temperature was good airflow through it to make reduce infections, but also keep the patient at the right temperature on. If they have it operated, it doesn't have the right temperature you can't operate on. But I've had a few days through my career where it's not been working and temperatures, but there is, in the wrong temperature, too cold or too hot, and you just had to cancel the whole day's operating. And that's a disaster for the patients on before, on for the hospital on. So everyone is really anxious about these machines on As a result, what happens is they get enough down to 24 7 because I was concerned if you switch them off off, they might not come back on again. But actually, that is not the right answer on. Um, uh, um, we know that you only have to turn him on about half an hour before your before they're ready that it's warmed up the theaters and you can start operating on go work is starting to go ahead on on making sure we could. We turn off the theaters on the things things device is, but it does involve a lot of work between the hospital Facilities team on the clinician's. Um, that's something that I've noticed over my career is that they've seen that there's always being them, a sort of sustained about bility person in hospitals put for many years. And they've done some really good work over the decades, reducing a carbon footprint of our hospitals. But they are very separate from the conditions, and they don't know what we do. We really need to go and talk to them and make sure you know your sustainability manager on so that they can understand. Way had a meeting recently, and they were so the set off Patrick in turn off free staters at about midnight for just during the weekends. We like No, we don't because they don't know what we're doing in our theaters, and they don't realize that the majority of the time we finish it five. On occasion, you will stay until eight, and there's any one or two theaters that will be opening through the night. So hopefully we're going to get because if you can save, turn those machines off when the cities are using you, you can reduce those energy costs a cut carbon by a significant amount. So moving on to some of the other things that we're using in theater. So from the anesthetic, this perspective, that something that we can do a surgeon's is think where possible to use a local and regional anesthesia on. But it's really important with with when, when you're using the Lantus at 36. But it's the whole patient journey because the patient has to have confidence in in what, what what your hip you're doing on so often. If I come to a patient who's already been told they're going to have a general anesthetic. If I try and say something different, then then they don't want it and they'll be free towers that on over. The other consultants said that I needed a general anesthetic own, and I have to have it so you can't. If you try and do it under local, then they they, um, much less less likely to be effective. So it's it may entering the whole team are singing on same some sheet. But actually, when it's operations, being done under local can be much better, because if the key, if you're that keeps the success, is a speedy recovery. It So, for example, having a hernia done in one or hernia done under local anesthetic. It's often done in the private sector because you recover quicker, you wake up quicker, you get home quicker. Your overall pain needs are better because you've never had the pain is if you have your operation under general anesthetic, you still, even though your ties I don't only suspended, is it it might be able to correct. But you still feel that way. Whereas if you use a local anesthetic that pain is locked right from the start on they, there's definitely evidence of any use less and juice afterwards. So So it is. Um, they wished that that I've heard people say that on the the sustainable health is good for the planet and good for the patient. And this is another example off that is, just because you're doing on the local anesthetic doesn't mean it's second best. Um, then what? So within the operating through that, it's important that we focus on that the higher, sensitive and sustainability the waist high rocky it's called on on. I always know when a drug company, not a drug company but a device company tries to greenwashing your name off and say, Oh, yeah, we're really sustainable company. We are recycling all our products. We've got great initiatives on to make sure that our plastic it's center recycling something on. If they start with the word recycling, you know that they're not just greenwashing you. The important thing is to start with reduced, so not using it in the first place on then, which is what I've come on stuff gone away from the start of not doing an operation. But once you actually need something, is to use reusable kits. So I don't know how many of you are here for the talk about the reusable hats, but actually, there's lots of things that we can use it in the operating theater, which are just as effective when they're being reused on eat a lot. I think the reason that we don't use it so much he's partly is the 19 nineties. There was concern about Priam's on on infection, which is no longer there on our infection control kind of practice. Is that the in order to get kind marked to be able to produce reusable kits, they have very quick, quick, clear, strict criteria, so actually the infection control is is not an issue, but also the reps that produce the single use kits. They make more money at a single use kits on so it they will always be there promoting that promoting it. So it's really important, as clinicians were there, to say No to say, That's not what we want until Teo insist on reusable on. Fortunately, my hospital, we've always since I've been there. We've always used reusable Ganz on We're Working On and Company, the company, same company that makes the reasonable and Ganz is going to be supplying us with readable drapes. But it's never that straightforward. Unfortunately, the drapes that we use that moment, the single use ones come in a big set, which has also had the whole load of other stuff in it. So we need to open that set for the operation. And so if we use the reusable drapes, will then just have the social drapes and throw them in the bed, which would be really silly. So we're doing a load of work with the company that makes that pack to get the drapes out to get on a 12. The whole lot of other stuff that is in there is No, it's not used to make sure that we're reducing the amount of firm, single use stuff during operations. But it's not easy. For example, syringes. They use several and that you can't. You can't with it with a syringe. It's really difficult to resettle like that. So the syringes and the needles were always the single use. But if you open them all individually, they're all individually wrapped. That's also a whole load of waste on. So you do want them in the pack and you can't. There's a limit, the number of different packs. You can't have one pack for my operation, one packed full, each different surgeons operation. So it's really important that we said we have to standardize the PACs and have what everyone needs without having to much wasted in there as well. And but they're not. But after all of that, there is still a place for recycling in the operating theater on, but it's important to know because eat up. Until recently, it was standard that everything in the operating theater went clinical. Waste on technical waist is high temperature. Incineration on that by its nature takes a lot, but it produces a lot of Oh two on down there eating different phases of clinical waist is infectious, clinical waste on. Then stand a clinical waste on, then standard waist and then recycling on. But so most of the stuff in it, it doesn't need to go to infectious clinical waste on backing to try and get it recognised to go to the non infectious clinical way to just slightly less, you know, to. But what happened is we did a whole lot of work. Got everyone to change over to. These is We call them Tiger Striped bags on. Actually, I have to credit because she might be listening online and the evidence here with our lead for on theaters. And so the PSA Test. Houston. Most of the work that's and George's, but we got We got all the surfaces trained, changed over from the orange infectious, faxed the type strike bags on the waist Company didn't trust us on, so they did a Nordic and is now is now for putting it all through the orange. Wait until we can prove that. Actually, there's no clinical waste in there, so it's a slow process, and it's not easy, and it takes a lot of work and determination on bogus on this. And then it's been brilliant having regular meetings every month since Kobe since before covered, really to try to slowly making this time changes. It's coming on. And then we've talked about the theater hats. I had a really nice picture of me and my bicycle hats. What I like about the personalized there's a hat. Since you can choose a hat that right foot with it represents you. It's like way consider running are both. Today we went me two things records that represents us. Where is in in the work environment, Especially when you're in scrubs world for me, you could have a little bit of difference in your hat. Um, on, Um So this is just a picture of what was done by the orthopedic team that doing couple panel operations on. They didn't identified on that sets on the top that there was a massive amount of stuff that got given to them each case and very little of it that they use. So they kind of rationalized it down and through meeting with all the different people involved, got assets just then on that had the much smaller number of instruments at the bottom. Um, so then talking about a few innovations in in the surgical field. So there are, um um, several things. I've hinted at that aunt. It's not possible that they could make them. It's reusable because there are really advantages to having them. Single use on dexamphetamine is the ports that we use for lap scopic surgery. So the in the olden days we use we use for what, What went on the time these trocar got blunt on. You can get it through the tissues and you have to push very hard should they're not enough giving way into something on the thing. The gas, the 02 would leak through the through the top of it every time you put an instrument in and they were just really off, which is why every all surgeons switched to having the reusable ones. But actually, there's a great company, so to clean of evasions, if I don't, if I'd actually you don't need to throw away the whole Not if If if those are your two floors, you can you can you could just have the top of the instrument a zoo disposable on. The rest of it can be reusable and they call it Hybrid on diet. Think there is a lot of scope for hybrids, instruments within surgery? A two moment. These are the only real ones that are being marketed it And I'd love to see a lot more being developed. One of things I can really think of is sacred. So state the surgical staplers were used in the bowel on now, I believe used in them another bits of surgery as well. But they are. They are officially single use. So you finished the patient with doing the operation and throw away. But actually it confused several times on that patient. So it is reusable. You just need a different cartridge. But they're not made in such a way that you can then send them and the sterilized. Or as I think it, if you that the the the instrument should be reusable and then you just have this this disposable cartridge that is single you see each time, that would be a great other hybrid instrument to reduce our waste on down. The other thing is medical device in that manner of that factory So I talked about these complicated and instruments at high energy instruments that used in surgery on disses An example. And I'm not going to use its name is highlighting a brand, but they put their kind of they use high energy, feels to quite elected tissues on they. And the instrument itself costs about 1000 lbs or what I think, over 1000 on. Actually, it was originally made in the U. S. And they're the law said that they could re manufacturer match that remanufacturing it on. So they were They were sent back to the company that made it completely taken apart, completely cleaned and completely put back together again, like as new. And they have to be re kind of tested and kite Marchish say there is new on that was done it by this company in the U. S. Five times. But the laws in the UK up until 2016, when this single used to medical devices remanufacturing guys came out was that that wasn't the case in the UK, So this company was marketing it in the UK a single use only. So even though the law has changed in UK and it can be really infected. Company has watery manufacturer because they make less money on, so they're trying to stop it. But there's a company from Germany called Vanguard who does the manufacturer, and we're trying to do that. But there's all sorts of rumors things read about the vanguard. Don't don't sterilize it effectively, and then it doesn't work so well. No time around. I don't know. I use my God. That's the only one. I love you. So I get a stroke with it so they can't find a vanguard. And it it works perfectly well. They I think we're using able in faces and so that and I just want to finish with thie. But I had the the details of it that does Aziz consider a lot of work meeting in research for a sustainable surgery on we're having a gentle and alliance uh, evaluation off a sustainable surgery. Research on it would be great toe. Have some copay people, contributes to it if you Google Green or operations and it's the James in the Wind Alliance on the deadline is the thirties of May. Just ti give us in support on what? What? Where are research should be targeted in surgery. Theo, thanks for that made me think I already tried it on guys. Any questions? Dear Bones from And I just got one about when you mentioned about know things that aren't necessary. How do you obviously kind of really was more defensive master than the price comes from being tense? Just do a blanket. So requesting a set of things, the suspects that condition ensure with us in too much, then that's that's what's it's accidents, I think, using guidelines. So if you have clear guidelines of in this situation, if you're concerned about this, you should do these things. Which means that you're only getting two Aleves evident for evidence on there. Whether it is yeah, Creeping said, It's really back there and the intervention waist up. Carbon interesting project