Surgeons Acknowledge Feelings of Detachment, Fatigue, and Hope about Waste

In a 2021 study in the Journal of Climate Change and Health, Hsu et al found that over 24 hours, a total of 255 kilograms of waste was produced in a community emergency department (ED). This predominantly consisted of solid waste, with only 1.8 percent meeting criteria for medical waste. Most of the waste was plastic, and 5.2 percent consisted of unopened items: boxes of gloves, surgical face masks, suturing material, and medications. In that single day, 418 Styrofoam cups were disposed; projected over a year, this would total 152,570 cups in that single ED.

Ultimately, it was estimated that just disposing of the cups created 304 kilograms of carbon dioxide equivalents per day—comparable to flying from New York to Denver. This figure does not begin to account for the extraction, manufacture, packaging, and transport of these disposable items. Similar statistics have been reported by other health systems.

Physicians across specialties have voiced interest in making environmentally sustainable choices, yet fewer than one-third ultimately do so. Awareness of the waste and greenhouse gas emissions associated with surgical and clinical care across the United States is growing, but feelings of despondency are commonplace. Many physicians take stock of existing practices and habits across their clinical and surgical work environments, and they conclude that their individual efforts to recycle clean packaging, use one less drape, or choose a reusable device over a disposable one feel seemingly inconsequential.

Some orthopaedic surgeons will have the opportunity to observe and perform surgery abroad. Visiting countries outside of the United States and Europe provides an opportunity to observe a range of surgeries performed without the exorbitant waste we perceive in our home systems. Such practices exemplify the principle of maximizing value: prioritizing outcomes while making efforts to reduce cost and waste. Experiences abroad can inspire great enthusiasm to implement changes to promote greater efficiency. In the authors’ personal experience, such efforts typically stall or dissolve after meeting resistance of many types: widespread perceptions that sorting waste will slow down turnovers; reusing items will cause infections; recycled items will wind up in a landfill anyway; and disposable items are cheaper than durable, reusable equivalents.

These claims are not supported by data, yet we lose to inertia. We are busy caring for our patients and balancing call and educational obligations, so we continue to watch as bags of garbage pile up outside our ORs during turnovers following minor procedures. We shake our heads rather than doggedly working toward actionable plans for change.

Opportunities for improvement
Small, tangible, and durable changes can be empowering and have a ripple effect of inspiring cultural shifts. For example, many surgeons are unable to directly edit their preference cards for high-volume procedures. Surgeons can, however, work with their OR teams to identify workarounds. Case requests can be modified to specify the exact equipment needed and—perhaps more importantly—what is expressly not needed or wanted for a case. Writing in “No bipolar, no suction, and no c-arm drape” is a start, but surgeons must also be physically present during room setup to communicate such deviations from standard practice. By arriving early and gently reminding and requesting that staff not open unnecessary items, such shifts can be modeled and reinforced by surgeons. Most surgeons will find they have allies in these efforts. Some staff will begin to feel inspired to proactively ask what is needed rather than opening everything “just in case.” Difficulties arise when case carts are picked in advance by teams that are not privy to preparatory notes and communications. OR team members must act in concert; each member plays their part.

There is hope, here is why
Individual surgeons are educating themselves, starting dialogue, and initiating quality -improvement and research projects across the country. Cost savings typically follow efforts to promote sustainability, reinforcing the benefits of such investments of time and energy. Networks of orthopaedic “sustainability champions” are emerging, and every practitioner should feel welcome to join their ranks and contribute in small and large ways. Within such groups, there is immense energy, positivity, and hope for the future. Such feelings often emerge out of feelings of isolation, despondency, and inefficacy at our own institutions. By joining the conversation and hearing of successful strategies from our peers, we can continue to contribute and build inertia in this area, which will most certainly be considered “mission critical” to our health systems and economies in the next decade.

Hilton P. Gottschalk, MD, FAAOS, FAOA, is a pediatric orthopaedic and hand surgeon at Dell Medical School at the University of Texas in Austin.

Verena Schreiber, MD, is a pediatric orthopaedic surgeon at Nicklaus Children’s Hospital in Miami, Florida.

Laura L. Bellaire, MD, FAAOS, is a pediatric orthopaedic and spine surgeon at the University of Utah in Salt Lake City.

Sonia Chaudhry, MD, FAAOS, FACS, is a pediatric hand and orthopaedic surgeon at Connecticut Children’s Medical Center and associate professor of orthopaedic surgery at the University of Connecticut. 

References

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