The Green Intensivist - Is that an Oxymoron?

Chris Poynter on 22-07-2014

Today I’d like to discuss environmental sustainability in critical care. Can such a thing exist? As we move towards a culture of increased personal responsibility at home for our environmental footprint, how does this impact on our practice at work?  Is there any point in trying to address this at work or is this a job for managers and can we have any effect on the climate change problem? If so, how? 


These are all questions which I’ve grappled with for several years now.


Firstly I should disclose that I am not your typical greenie.  I have 3 wonderful, but resource intensive children, I love to travel, have long hot showers and eat meat.  Anaesthesia and Intensive care are both extremely resource intensive areas within medicine, which is a resource intensive industry in a resource intensive society. 


This was not a great starting point for taking an interest in one’s environmental footprint.  However, several years ago, a combination of factors forced me to examine environmental sustainability and alter my approach.  My wife took an environmental health paper as part of her Public Health training and started discussing environmental issues with me.  At about the same time, Al Gore’s “Inconvenient Truth” came out and, although criticised for being somewhat melodramatic, brought environmentalism onto the public agenda. Most importantly, my first child was born and I started to consider what kind of world she (and subsequently her siblings) would inherit and how I would justify my actions during this period of climate change awareness.


It is surprisingly easy to get overwhelmed by this problem on first appraisal. This is the defining problem of our generation. It is a global problem and there is the sense that the problem is just so enormous and has progressed so far already.  This is within a societal structure that is set up for unsustainable and wasteful practices.  There is no easy starting point to fix the problem, sacrifices are required and there is no sense that personal action will lead to meaningful positive endpoints.  It can seem hypocritical to embrace environmentalism but only change some unsustainable practices.


However, upon closer inspection, this combination seems perfectly placed for intensivists to provide input. It parallels well with many of the clinical scenarios we are given. We are commonly asked to fix problems which seem overwhelming for others and have progressed to the point where damage is inevitable and the minimisation of that damage becomes the goal.  


The main issue seems to be how to institute the change that is required and who should be responsible for it.  


Firstly, I would like to point out that everyone is responsible for solving this problem.  There is no point spending unnecessary energy finger pointing.  Initially I raged against my parent’s generation for their supposed excesses until I realised that they had no knowledge that the economies they were building would lead to this, and were busy fighting the important social issues of their time such as racial and gender inequality.  


We may not all have the same influence on the process, but without a coordinated approach involving action and advocacy at all levels, the substantial change that is required cannot occur.  Lawmakers and managers rely on a clear mandate from the people they govern in order to write policy so waiting for the response to come from above without being part of the culture change that is required risks inaction at all levels.


So what can be done from within intensive care to improve environmental sustainability.  Initially I was paralysed by the enormity of what needed to change to become environmentally sustainable.  It felt hypocritical just attacking a few small, easy areas.  However, due to the size of the problem, the change that is required should be approached in a stepwise, sustainable fashion. The good news is that this makes it pretty easy to start making improvements given how generally resource intensive critical care is.  


The general areas to target can be categorised into waste, power, water, transport and procurement.  The important action points can be divided up into several single word categories:


-Reduce.  Generally, the principle here should be to consider every time you are using resources, whether they are really necessary. Easy targets in intensive care could be such things as reducing “routine” lab and radiology tests; double sided paper settings for printers; reducing power usage with motion sensor lights or shut down of unused equipment. 


-Reuse.  If resources must be used, it is much more desirable to reuse rather than have single use items. None of us base our practices on single use equipment at home, but this is easier to justify in the clinical setting when the money spent is not our own.  The trend towards single use items is driven by industry preying upon fear of prion or other infective diseases and based on little evidence of benefit.  Although often these options seem cheaper, fuller analysis (including life cycle analysis from production until disposal) rarely stands up to scrutiny.  Cheaper manufacturing leads to quality compromise. Easy examples to target are such items as cups and cutlery; gowns, hats and equipment for procedures.


-Recycle.  This is an area we generally all address and do well at home.  That is because the supporting infrastructure has been provided and this is the key to improvements at work.  Recycling needs to be the easier choice.  This will save the institution money as other forms of waste are more expensive.


-Rethink.  We need to think differently about how our job is done. Currently most hospital decisions seem to be based on the clinical and economic bottom lines. However, the concept of the “triple bottom line” is catching on and should be how the health system works. Economic, environmental and social consequences of decisions should be considered along with the clinical picture.  Environmentally preferential purchasing is a concept considering the environmental consequences of industry (similar to how the “fair trade” concept covers the social consequences).  Better education on environmental issues will also help to dispel many myths which seem to dog the environmental movement.


-Research.  There is a lack of hard science in medicine on this issue.  Adding some of the above practices to unit audit cycles and performing research on environmental sustainability will help further the cause.  Some have studied life cycle analyses of some basic medical equipment in order to elucidate true costs.  Research enables policy to be driven by science and dialogue with clinicians to occur using a language which is known and understood.


-Advocate.  Locally, the best plan is to set up a multidisciplinary environmental committee within the department and a network within the hospital, and to engage with the management of the hospital.  At Wellington Hospital we have a sustainability steering group at management level and a Green Initiative Group coordinating interested staff. We are working towards getting a sustainability officer position created to coordinate all of the ideas and activity in a more efficient manner.  This role is cropping up in more and more hospitals and early indications are that it is very cost effective.  Further advocacy can be at hospital policy level; in discussion with industry; within local and national politics; or in discussion with the press.  Environmental initiatives are a great opportunity for positive press for the hospital.  Within New Zealand we have an environmental advocacy group for health professionals called Ora Taiao. I’m pretty sure similar groups exist elsewhere.


The big question is why do all of this?  Any change within a hospital requires a lot of hard work and the cultural change described here means plenty of barriers will need to be overcome and so lots of time and energy will be required to achieve the desired outcome.



My main driver is my guilt and the knowledge that I will need to explain my actions to my children as they grow older and start asking tough questions.  Fortunately there are a lot more positive reasons than guilt to drive action in environmental sustainability: 


-   Environmental sustainability often is cheaper than less sustainable options. 


It enables the entire system to be looked at in a different light and other institutional gains may be made by this. 


Staff morale can improve as a result of working towards positive change. A happy worker is a better worker.


As mentioned above, this is an area which can lead to positive press.  


Coupled with that, it enables us to provide leadership to the community which we serve in an area of social importance.  As health professionals, we are looked to as leaders in society and as a common interface between science and the community.  


Environmental sustainability is the challenge for our generation and by acting in a positive fashion to institute change, we have the opportunity to leave a legacy of which we can be proud.


Surely that is motivation enough.  


I’m interested in your views. What do you think about this issue? What happens in your neck of the woods? Do you have anything to add? Please comment below.


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Mahesh from Australia wrote 08-03-2014 05:46:23 pm
This is an excellent discussion of one of the biggest challenges faced by our generation.

As far as hospitals and ICU's are concerned, the first step I would advocate for is converting to paperless medical records. The technology has been available for years but the inertia in the system is such that we have been extremely slow adopters. For example, At the place where I currently work, we order radiology and pathology "electronically"....but we then have to print out the form and fax it to the appropriate department. Also, for daily progress notes, medications charts etc there is no good reason they cannot be entirely electronic.

I'm no expert in this area, but air conditioning must be one of the biggest sources of energy expenditure in most modern hospitals. I wonder whether technologies such as tri-generation would be effective in decreasing energy consumption, particularly for larger hospitals co-located with research facilities and university campuses.




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