What’s Important (Arts and Humanities): Shouldn’t Our GOAL! Be to Find a Better Way?

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"GOAL! is an artistic video highlighting the medical waste produced by the orthopaedic industry.","object-id":[{"pub-id-type":"doi","id":"10.2106/JBJS.23.00828.vid1"},{"pub-id-type":"other","content-type":"media-stream-id","id":"JBJS2300828V1"},{"pub-id-type":"other","content-type":"media-source","id":""}]} Orthopaedic surgery is one of the most energy- and resource-intensive fields in medicine, having a disproportionately large impact on health care’s unsustainable carbon footprint. It is our hope that this article and accompanying artistic video presentation will cause the readers of JBJS to pause in their busy daily routines to reflect, debate, question, and act to “find a better way.” The accompanying video presentation, GOAL!, was created by the Dutch artist Maria Koijck. This piece represents the fifth in a collection of 5 unique artistic creations made with use of medical waste collected from procedures in 5 different subspecialties: reconstructive surgery1, ophthalmology1, obstetrics2, emergency medicine3, and orthopaedic surgery. The surgical waste displayed in the accompanying GOAL! video was generated while performing a standard total knee arthroplasty procedure in a single operating room (OR) at Leiden University Medical Center in The Netherlands. Maria Koijck originally trained as a nurse in The Netherlands before going on to become an internationally recognized award-winning spatial artist4. In 2009, Maria was diagnosed with breast cancer and treated with a mastectomy and breast reconstruction at the University Medical Center Groningen in The Netherlands. Following this life-altering experience, Maria—through her art—turned this traumatic experience into something positive. Shocked by the amount of discarded single-use medical supplies and packaging utilized in her breast reconstruction, she asked the surgical staff to collect the preoperative, intraoperative, and postoperative waste, which she would later use to create her first work of art1. She hoped that her art would make others aware of the enormous amount of waste generated from a single surgery—her own surgery. In Maria’s words, “these creations are to raise awareness in the medical community of the shocking amount of waste used in surgery. Hopefully, by calling attention to this enormous amount of waste, my art will open people’s eyes and motivate them to reflect, question, and act to help reduce medical waste.”1 The health-care sector is one of the largest contributors to the world’s carbon footprint3,5, being responsible for almost 7% of global emissions of greenhouse gases6. Putting this into perspective, health care’s annual environmental footprint is equivalent to approximately 514 coal-fired power plants! Or, if the health-care sector were a country, it would be the world’s fifth largest emitter of greenhouse gasses after the U.S., China, India, and Russia7. The largest portion of carbon emissions comes from energy generated for heating, cooling, ventilation, and hot water production in health-care facilities8, followed by the manufacturing, delivery, servicing, and consumption and disposal of products9. A recent systematic review examining the carbon footprint of surgical services revealed that the primary sources of greenhouse gas emissions were energy consumption (for maintaining the OR environment), disposal of single-use items, and anesthetic gases10. ORs utilize 3 to 6 times more energy per square foot than the hospital as a whole, due to the demanding heating, ventilation, and air conditioning requirements, as well as lighting, patient-monitoring equipment, and long hours of use11. In addition to the large energy consumption, surgical services are responsible for approximately 20% to 30% of the total waste generated in hospitals10,12. Most of the waste generated in ORs is nonhazardous; however, such waste is often mistakenly disposed of as though it were hazardous, and therefore is processed with methods that cause substantially more emission of pollutants and thus a greater environmental footprint13. Finally, the use of anesthetic gases in surgery is an important contributor to greenhouse emissions. In the U.K., anesthetic gases represent 5% of the carbon footprint for all acute National Health Service organizations14. A 2005 study conducted in 1,100 Canadian hospitals estimated that anesthetic emissions were the equivalent of >1.1 million tons of CO2, equivalent to the total annual emissions of 68,000 Canadians15,16. Only 5% to 20% of anesthetic gases administered to patients are metabolized17, with the rest released into the atmosphere, where they can have warming effects on the atmosphere for many years. The atmospheric lifetime and consequently the degree to which a given anesthetic impacts global warming depends on its chemical composition. For instance, sevoflurane has an atmospheric lifetime of 1 to 5 years; isoflurane, 3 to 6 years; desflurane, 9 to 21 years; and nitrous oxide, 114 years18. Using nitrous oxide in a 1-hour surgery warms the atmosphere the same as 16 kg of CO2, and is equal to driving a car 106 km. A 1-hour surgery using desflurane anesthesia has >2,500 times more warming effect than CO2, warming the atmosphere the same as 30 to 60 kg of CO2, which is the equivalent of driving a car 200 to 400 km19. Of the 50 million major surgeries performed annually in the U.S., approximately 19 million are orthopaedic procedures20. Of these surgeries, total knee and hip arthroplasties are among the most commonly performed, and their procedure volume continues to grow by over 20% annually21. The accompanying video celebrates the successful recovery of an athlete from anterior cruciate ligament surgery, capturing the very positive attributes of orthopaedic surgery. Few studies have evaluated waste generation and the carbon footprint of individual surgical specialties; however, considering that orthopaedic surgery is one of the most, if not the most, resource-intensive surgical subspecialties, it makes sense that its carbon footprint is large. In a 2013 study, Southorn et al. reported that the average waste generated from total hip arthroplasty was 12.0 kg, half of which (5.8 kg) was recyclable22. Another study conducted by Stall et al. found that the average surgical waste generated per total knee arthroplasty procedure, excluding laundered linens, was 13.3 kg, of which 8.6 kg (64.7%) was general nonhazardous solid waste, 2.5 kg (18.8%) was hazardous waste, 1.6 kg (12.0%) was blue sterile wrap, 0.3 kg (2.3%) was recyclables, and 0.3 kg (2.3%) was sharps. The authors note in their article that a substantial amount of the total waste consisted of plastic wrappers, disposable surgical linens, and personal protective equipment23. In the total knee arthroplasty represented in the accompanying GOAL! video presentation, 12.8 kg of surgical waste was generated, including surgical drapes, triple-layered oversized boxes for sterile implants, tubes, gauzes, etc. Considering the inordinately large contribution that surgical procedures make to a hospital’s carbon emissions, measures taken to reduce carbon emissions in the OR can have an important impact on reducing a hospital’s overall environmental footprint. Numerous surgical specialties are beginning to adopt environmentally friendly and sustainable approaches10,24. Simple, common-sense, and inexpensive measures that follow the 4-R rules—reduce, reuse, recycle, and rethink—can be utilized in the OR, which when targeting the main culprits (i.e., energy consumption, reusable and recyclable products, and anesthetics) can have an immediate substantial impact. Simple measures that reduce energy consumption in the OR include switching to LED (light-emitting diode) lighting; adjusting heating, cooling, and air exchange levels; turning off lights; keeping doors closed; unplugging equipment; disconnecting vacuum and medical air lines; and putting computers and monitors in power-saving modes. For these changes to be carried out effectively, it is important to engage the OR staff and to reinforce the idea that energy and water are resources that are to be utilized only when needed11. Making single-use devices, such as saw blades, trocars, and catheters, suitable for reuse can substantially reduce waste as well as production and disposal costs. Reusable surgical linens, including gowns, drapes, and table covers, make up 2% of all hospital waste. These items are available as single-use or reusable products, and yet about 80% of hospitals in the U.S. still use single-use gowns25. Reprocessing medical equipment substantially reduces costs by allowing hospitals to “buy back” reprocessed medical devices at a 50% cost reduction16. According to a 2019 study, 28% of 398 Canadian hospitals reported that they reprocess single-use devices26. Private companies in the U.S. currently reprocess >100 types of single-use devices27. In 2020, the U.S.-based health-care system Kaiser Permanente avoided >1,500 tons of plastic waste via their reusable sharps container program, collecting >400 tons of medical devices for reprocessing29. A 2019 survey conducted at the Mayo Clinic in the U.S. showed that 56.7% of 524 physicians were unclear on which OR items were recyclable, and 47.7% agreed that this lack of knowledge was the greatest barrier to recycling. Following that study, an educational program was implemented to address this issue, after which a cost savings of 10.3% in sharps waste disposal was observed compared with the previous year26. Over the past 10 years at Leiden University Medical Center in The Netherlands, greater awareness of the excessive waste produced preoperatively, intraoperatively, and postoperatively has led to the adoption of several initiatives that include preferences for reusable instead of single-use disposable devices. Additionally, surgical waste is collected and separated according to various categories, including recyclable versus nonrecyclable, hazardous versus nonhazardous, etc. Finally, the same problems (high energy use and a lack of reuse or recycling) occur with the use of anesthetic gases in the OR. The main barrier to implementing change is a lack of understanding about the environmental impacts associated with different anesthetic choices26,30. Anesthesiologists in several institutions are rethinking their choices by discontinuing the use of gases with a high environmental impact (e.g., desflurane and nitrous oxide) and instead utilizing intravenous and regional techniques, low fresh gas flows, and new scavenging devices designed to collect, capture, reuse, or destroy gases. The latter devices capture anesthetic gases that would otherwise be released into the atmosphere. One such recovery system was implemented in 21 ORs at Sunnybrook Health Sciences Centre in Canada and, over a period of 5 years, the hospital reported preventing emissions equivalent to the annual emissions of 205 automobiles16,26,30. In addition to the measures described above, many other simple steps can be taken by orthopaedic surgeons to improve their carbon footprint, including optimizing surgical trays (i.e., reducing the number of redundant or unnecessary instruments and decreasing the weight and number of trays that need to be processed) and recycling hardware such as external fixators. These simple measures are recommended by the American Association for Hand Surgery, American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery in their Lean and Green initiative, which is meant to “reduce surgical cost and waste without compromising patient care and safety.” This initiative has already been implemented at various institutions, and reportedly can result in a reduction in the time taken between cases by almost an hour. Additionally, the initiative can help to minimize the number of trays required, resulting in substantial cost savings for hospitals31. Another promising approach that could potentially reduce environmental impact is the use of patient-specific orthopaedic implants. Although the degree to which this new technology impacts the environment has not yet been measured, one would expect treatment using patient-specific implants to help reduce carbon emissions. By customizing implants to fit each patient’s unique anatomy, there should be a reduction in the number of trays used, the operative time, and the amount of excess material used, and generally less waste produced. This tailored operative approach can also potentially lead to improved surgical outcomes, lowering the need for revision surgeries and thereby reducing the environmental impact associated with additional procedures32. Regarding the use of anesthesia in orthopaedic procedures, neuraxial and peripheral nerve blocks are frequently employed, which both result in substantially lower carbon emissions. In 2019, a leading orthopaedic hospital in the U.S., the Hospital for Special Surgery, administered regional anesthesia in 96% of its primary arthroplasty procedures, resulting in a reduction of greenhouse gas emissions equivalent to 27,000 pounds of coal31. Given the large number of orthopaedic surgeries conducted each year worldwide, such measures taken by orthopaedic surgeons to promote environmentally sustainable practices can have an important impact. Orthopaedic surgeons have started discussing the carbon footprint of their field and exploring ways to reduce it, yet there remains a long way to go32. Efforts to reduce the environmental impact of health care in the OR are gaining momentum, with strategies focusing on energy reduction, waste management, and the promotion of reusable materials. It is crucial for health-care institutions and providers to continue working collaboratively, advancing sustainable practices, and further reducing the sector’s ecological footprint29. As physicians, our primary objective is to maintain, promote, and restore health in our patients. To do so, we must extend that care to our planet, since the health of our patients is inseparably linked with the health of our planet. We hope that this artistic presentation serves to inspire our fellow health-care professionals to take measures to care for our planet’s health with the same compassion and dedication they do for their patients.

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