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Hello, everyone. Um We are now in the sustainability and surgery um surgical training session. Um So our first speaker is um Mr Neil Neil Bangu, who is a senior lecturer and in surgery, the University of Birmingham and a consultant colorectal surgeon at the University Hospital Birmingham. His clinical practice includes management of colorectal cancer, common proctologic problems and a range of general and emergency conditions. Anil is based in the Institute of Cancer and Genomic Sciences with over 200 peer reviewed research publications. Annual H index is 40 for his achievements were recognized by the prestigious Young Cola Proctologists of the year 2018 award from the Association of Cola Proctology of Great Britain and Ireland. Without further a do, I'll introduce you to Mr Neil Banker. Okay, thank, thank you very much. It's a, it's a pleasure to be here. I think I first came to asset in 2012 and it did, it did shape my training and it shape my approach to academia and what I do now actually. So it's, it's a really important for um um Yeah, so I'm a, I'm a consultant colorectal surgeon. Uh I'm a senior lecturer so that means I, I've come through a sort of, the second half of my training was academic and now I'm 50% clinical and 50% academics. I'm employed by the University of Birmingham. Um, and it's a really good position. I feel like I get the best of both worlds. I probably have two jobs and I don't do either them properly, but it does keep me on my taste and it keeps me fresh. Um, so I'm here to talk to you about my, our journey towards environmentally sustainable surgery. Um, um, I was gonna look quick hands up for anyone who's, who's, who's awake this late in the day. Have you, who's seen this known unknowns business before? Who's done that sort of human factors stuff for those, for those who don't, it's an interesting thing. It's about what, you know, and what you don't know. So if you have no knowns, you're, you're pretty safe if you know, you don't know something, you know, you're, you're still pretty safe because you won't, you won't do it if you, if you sort of no something, but you're not very confident about it, believe it or not, you're pretty safe. I think we get a lot of that. You know, we actually know what to do but were under confident in certain things. Some people might call that partly imposter syndrome. But then there's this box of unknown unknowns. Those are blind spots. That's, that's what we, we don't know, we don't know. And that's where I am in this, in this field and other people in different places, other people further ahead than me, other people are sort of with me in this box. But, but I'm really talking about the unknown, unknowns. This is where I work. So this is the, this is the hospital. Yeah, it's a, it's a university hospital Birmingham. It's had a bad, bad press with trainees recently And there's definitely some things that, that, that could be improved. I like to think in the in the Department of Colorectal Surgery, you know, we're not necessarily part of that, but that aside, it's a really good place for me to work because it's integrated across the campus. Um And so we can find people to, to talk about the things we need to talk about really easily. We, we don't, we're not isolated somewhere outside of the realms of multidisciplinary academic teams and that's what the world sort of looks like as you develop some of these projects. Um And why me, why am I sort of here talking about you? So I'm not an environmentalist. I probably don't know that much about sustainability. What I do know is about network building and I do know about pragmatic change in the front line. So I started as a training, the training collaborative, I published a trial called Rocks in the Lancet in, in January 2020. Then, then COVID hit uh and we brought out the series of projects called COVID surge and they were rapid data collection. They were to um uh they really gave us the information we needed to change the front line. I'll come to that. So also it within this university were funded as a global surgery unit. So the NIH are the National Institute of Health Research that's like the nhs's research branch. They funded as 14 million pounds over a period of about eight years to deliver frontline research. So the, the Cheetah trial, which is about changing gloves and instruments before you close an abdominal fascia. Anyone operating on the abdomen? Do you do that routinely? If you don't read the paper because it will change your practice. Um The COVID search studies were based from this platform so I I don't make these decisions. Other people, we listen to the network, other people tell us what they want to do coming out of COVID. People said they wanted to talk about the environment as surgery revamps. You heard Dmitry talking about the elective recovery piece, which is a, which is a global as well. But we will, we work across 100 and 40 countries. We've got now over half a million patients' worth of data sitting with us, which we have published and we have a randomized trial network across seven low middle income countries. So I call that this is like the Amazon of surgical research. We can get things done relatively quickly because we have the links to the front line. Um And this was COVID search. So what COVID says did for me is it, it took me away from doing sort of left toenail research. And it taught me that I like topics that are cross cutting. I like topics that apply to, you know, who's into like E N t, who isn't there any neurosurgery trainees? Uh Once I got outside of my little colorectal box, it taught me that the generality of surgery is really interesting to me, infections, weight list, sustainability and things like that. So the network and what this says is that this is the media impact from COVID surge. The middle figure is what's called an out metric score that summarizes everything you've done. And that first COVID paper had a really high up metric score. I say that with humility, that first paper in the Lancet and COVID. So said that if you operate on someone with what was then COVID undifferentiated, there's a 25% mortality. That's the, that, that is the highest mortality from a case series you'll ever read. And that's a lot of death and misery around the world. This is to say that where patient's have surgery and how safe it is is important to the general public. It is important to the taxpayers. So we looked into this topic, we saw it coming. Governments around the world are committing to what they're called net zero um healthcare net zero um systems, but no one really could define what that is and I don't think they still can. We did a really rapid scoping progress. Most hospitals don't have a clear environmental plan, but most surgeons are willing to change their practice and most surgeons they probably don't have the tools to, to take them there. I think you're gonna hear a bit about this later about how, how, how the community can start equipping interested surgeons with the tools. What I would this is a trial called epoch. Anyone heard of this? So this was, this is really important in my world that this was done by a team from Queen Mary University of London and led by Professor Rupert Pearce who is a professor of Rupert, is a professor of Perioperative medicine. So it was all to do with emergency laparotomy and they tried to bring in better practice in emergency laparotomy. Um I, I think there was something around 61 individual measures, what one could bring into your hospital. And the idea is pick, pick whichever one's work, whichever ones you can do. Let's see if it reduces emergency mortality, uh mortality of emergency surgery. How many? So from those 61 does anyone hazard a guess about how many, what was the average number of interventions someone put into place. It was zero. You know, if you give people too many options and you don't give them the time and you don't give them the tools, people don't do anything and that, that all people go back to what is essential and what is basic because that's behavioral change. So behavioral changes really important here, changing behavior of surgeons and surgical teams is everything in research and we're learning, it's great to publish papers. But unless you can get them into clinical practice, you're not achieving that much. So this is what, this is what I'm here to talk to you about. Um Believe it or not, we're coming to the end because this is about the limit of my knowledge. We I'm not allowed to say this in public. So don't tweet this bit out, but we have been funded by the NIH are in a program grant to try and scale environmentally sustainable surgery across the N H S. So we've been funded 2.4 million lbs to do say, um we've been funded because not because we environmentalist, but we're saying that we will identify basic measures that everyone can do. Um I'll talk about those domains. We don't exactly know what the measures are. Let me talk about the domains, but these are the core principles. And actually this is, there's a, there's a lot of learn from writing these grants and learning about the field that I apply to the other areas of my life. So identify and scale 3 to 4 measures. We're not going to try and do too much. We're gonna, if we can identify three things we can scale. That's a win. Um We want things that are relevant to everyone. So not just the enthusiastic in the well resourced hospital that, that anyone can bring in. Um No major capital investment. I don't if anyone's ever tried to go down a sort of major project in the hospital, but I think if you have to rebuild things, none of us are really going to get there anytime soon, especially where the NHS is at the moment. These are two key things. There's a lot of focus on what cannot be done in this field, what the problems are. So we're going to focus on what we can do. We're going to focus on areas that were likely to have an impact. Um We're not going to aim for perfect. We don't want to aim for like the least worst because equally that doesn't sound great. So we are going to aim for better. We're going to make things better but, but not best and not perfect the areas where I've identified. So increase reusable equipment, we're gonna bring a tropical dragon into place to implement that and give the evidence needed. I'll talk about that in a moment. We're going to change anesthetic practice. So Rupert Pearse is going to help us with that. That's a really complex piece. You know, the NHS is going to cut out this, there's flooring gas that's polluting, but you know, that's only 2% of anesthetics that you get this totally intravenous anesthesia piece. So that's changing as well. So there's a changing baseline. So how do we work with Denise? This is there to, to document map and improve that changing baseline, better waste management. So, waste management is really hard. I'm doing a deep dive into this. Does anyone routinely recycle from an operating theater? Uh I tried, it's really hard are sort of main recycling will not do it. The people who take the brown bins from outside your house, they don't want to take stuff from an operating theater and that's gone up to sort of chief executive of the A level and they are just not going to do it equally. Um You know, I was operating on, on Monday and everything got put into the orange bin bags, all the clean waste, all the plastics and stuff and I get that and, and they're taken off and incinerated. But, but in Birmingham they, that incinerator drives. Um I only found out recently that incinerator drives uh an electricity generator. So it generates a lot of electricity which is fed back into the grid. Whereas landfill in the UK is, is quite a scientific process, but I'm no longer. I have, I'm not entirely clear. The landfill is definitely better for the overall environment than it going into this incinerator. So I'm scratching beneath that surface. I need, I need to figure it out. My gut feeling is getting people to put their waste into the correct bags is going to help. But you know, this, have you, have you heard of this term? Wish cycling? You shove stuff in your, your brown bin and you, you feel good. But the reality is half of that can't be recycled. 25% of that is going to end up on a boat going somewhere. You know, you're luckier for third or 20% is recycled. So we feel good about these things, but we got to make sure it's going to the right place and not actually making the problem worse. So that's a really hard one to scale. So for waste management, what we're aiming to do something really simple, if we can change behaviors, then the people who come in afterwards, the companies, the industry and they can do these things better and they can take the recycling away and these companies are going to do this in the next 10 years. They can take the contaminated waste away. What we've already done is provided a framework where the behaviors and operating theaters are aligned to that and people are ready to put the waist in the right place and they moved away from dump it all into one bag and energy management. That that's, that's another behavioral change. Lights are still left on in operating theaters. I'm not an east this but I'm told there's this, I don't know if you guys know better than me, there's this scavenger thing at the back of the anesthetic machine that's left on all night. You'll come to that. And what's really interesting is what you're here is, is my interest is implementing all this into wide scale practice. It's not the individual measures, other, other people are better at that. So this is a really interesting piece. Um, just to finish Dragon and this is sort of where I need your help. Dragon is going to be a trial which is going to test reusable drapes and gowns. 50% of practice in the UK is still with disposable gowns and drapes. And that's because people believe that they reduce infection. The World Health Organization makes no recommendations because there's not good evidence out there. So to really change practice, to change guidelines, to get this into everyday practice, we'll do a very fast randomized control trial. So 5000 patient's, we can get that done quickly across all specialties. Um test the reusable and disposables, but we'll have this combined outcome measure of surgical site infections. So we'll prove things are safer. Patient's costs and carbon bit. Technical, carbon outcome measures are not fit for policymakers at the moment. So we're trying to come up with a metric that works for, for everyday people. What's the effect on patients' for every ton of carbon saved? And that, that sort of makes sense to me. Recruitment is trials post COVID is really dire. It's really bad. The NIH are know this. So the normal networks are not going to recruit to this trial and the trial will fail because of that. What we'd really like to do. I'm happy to collaborate with acid and, and build, build a wider team. I think the trainees will deliver this trial. I think there's something about um the topic, there's something about trainees, there's something about being in every operating theater. I think we need this concept of upward mentors. So the trainees uh the agents for change and they can go in and just tell the consultants and tell the theater team what to do. I think that all works for me and I think they're the ones who will deliver this. So it would be really interested to collaborate with people here and for any enthusiasts. Um We would like to. So here's a sort of project launch. We we'd really like to do a little pilot in five hospitals and figure out if we can get information on what happens to your orange bin bags, information on on the recycling pathways and just two or three key questions that it involves people may be going to the head of estates and stuff like that. So that's quite different, that's quite novel, but would be really good to get there. Um We will be hosting a meeting for about 300 people on November the second in, in Birmingham to launch some of these research projects into clinical practice. So please keep your eyes open for that. I'm going to stop there. Thank you very much. Thank you Mr Bangu for a really insightful talk. Um We would welcome any questions, but just in the interest of time, um can we just get one question if anyone has one and then we'll move on. Can you guys see some hands over there? Yeah, go for it. Uh I'm on time. Thank you. Very interesting talk. Um I was just wondering about their usable drapes that you mentioned. Um Is the chemicals that are used for re washing the reusable ones still better for the environment than using single use? I'm sorry the other way around. I'll get you a get you look that, that, that is a brilliant question and that, that goes to one of the and you can get the others will comment that number one, this isn't just about carbon, it's definitely about the environment. I and that's what you're saying, you know what the wider environmental impacts. And number two, I came to in the outcome measures that this is all going to be a trade off, isn't it? As with everything in life? You know, we're a bit used to thinking about Brexit. Yes and no, but I think there will be a trade off. So what we'd like to have at the end of all, this is the information to answer that question, but in a way that's digestible, I think some of that information is out there and you'll hear about that, but it needs to be done in a way that the policymakers can really make decisions on it and we can make decisions. And I think transmission of information is, is not perfect at the moment. So, uh you've, you've asked quite a hard question and I'll sort of dodge saying yes and no, because I think that all needs to come together in a piece that allows you to make decisions for the future and, and the policymakers. So the World Health Organization will want to know about this. NHS England, I'm sure will want to know about this as the results come out. Okay. Thank you for your very detailed answer. Uh I have a question myself. What would you name as three main barriers to achieving more sustainable surgery and how we can tackle them as junior doctors and trainees? Um, behavioral changes. Number one, you got to bring the whole operating theater along with you. I did this Net zero operation um as a proof of principle, it was a bit gimmicky, but I liked, I do this research, but my clinical practice, I like to do what everyone else does. I'm like a really average surgeon. So I did, I didn't, I didn't force it down. People's next. I just, I just kept going and all the behaviors that I changed for that day. It took me four months to get there. They all disappeared, you know, three days later, everyone was just like back to two standard practice. So number one is, number one is definitely behavioral change. Number two is knowing what to do I think, you know, and even I struggle to know what to do sometimes with, with this stuff. And number three is, I think as a trainee, yes, we need to upward mental. That's when you go and tell people what to do, but you'll need some downward support. You've got to find the enthusiastic consultant who's just going to open a few doors that will allow you to, to bring change in. Okay. Thank you very much.