Elizabeth Yates

Next Generation is a Brigham Clinical & Research News column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email us. This month’s column is written by Elizabeth Yates, MD, a general surgery resident and research fellow in the Center for Surgery and Public Health.

As any resident who has tried to safely discharge an uninsured or homeless patient knows, resource inequities can affect health. Over the course of our careers, climate change will make this problem worse.

I came to this realization during medical school, while my younger brother was studying environmental science at the same institution. Talking my ear off about greenhouse gas emissions and the carbon cycle, he made me wonder how much our institution was contributing to the climate change problem. Over brunch, we would discuss how the downstream effects of climate change he learned about in class would impact the health of my patients. He was almost prescient. Over the past five to ten years, more and more data has demonstrated how extreme heat and air pollution exacerbate pediatric asthma, worsen pregnancy outcomes and increase the risk of myocardial infarction. In many cases, the additive risk is worst for patients from low-income or minority communities.

Greening the Operating Room

As of 2018, the health care industry is responsible for approximately 9 percent of our national greenhouse gas emissions. Hospitals, which house waste- and energy-intensive operating rooms (ORs), represent the largest chunk of that emissions burden. As greenhouse gases accumulate in the atmosphere and drive climate change, the resultant extreme temperatures, sea level rise and more frequent storms can have major consequences for health. In service to our patients, organizations like Practice Greenhealth and Healthcare without Harm are leading the charge to help healthcare institutions implement initiatives to reduce their environmental impact.

Such initiatives are often slowest to permeate surgical practice, likely because clinical practitioners lack the bandwidth to initiate interventions. In collaboration with my mentor, Louis L. Nguyen, MD, MPH, MBA, we aim to leverage behavioral economics theory to guide data-driven, system-level solutions to optimize environmental sustainability without further burdening the overworked surgical practitioner.

Our first project tackles OR waste streams. Prior case studies have found that “red bags,” which are intended only for materials saturated with blood/bodily fluids, are overused. If the red bag happens to be the closest trash can in the room, you can see why a busy OR team member might throw plastic wrapping or extra drapes into the nearest bag. But after that red bag leaves the OR, it undergoes extra autoclaving or incineration – two energy intensive processes. In theory, avoiding inappropriate red bag use could lessen the environmental impact of our OR waste production.

We are starting to test that theory with our Watching our Waste initiative. Through a collaborative audit with our waste management contractor, SteriCycle, and our dedicated Environmental Services staff, we identified multiple areas where we can systematically improve our waste streams. Starting with improving “red bag” use, we plan to measure the direct impact of our interventions on waste production. Ultimately, we hope to share our return on investment and environmental impact data for hospitals hoping to follow in our footsteps.

Climate Pressures and Surgical Outcome Disparities

I believe in our capacity to tackle big problems when armed with the appropriate tools. One of the most crucial tools to address climate change is information, but the data on the impact of climate change on surgical outcomes is sorely lacking.

To that end, the other half of my research focuses on defining how the environmental effects of climate change (e.g. extreme temperatures, severe weather patterns, sea level rise, etc.) can affect patients undergoing surgery. My first project examines how increasingly frequent heatwaves impact surgical outcomes. Will there be higher rates of readmission or wound infection? Will patients who can afford air conditioning fare better than those who cannot? Generating answers to these questions could help inform surgical care delivery across the country.

The Bigger Picture

From this perspective, climate change can be conceptualized as a “threat multiplier”; patients who are already vulnerable from undergoing the stress of a major surgery could be more affected by extreme temperatures. At a population level, the health effects of climate change will multiply existing health and wealth disparities, both nationally and globally. Those least prepared to cope will face the most intensely compounded threats.

As physicians-in-training, we are charged to “do no harm.” In our careers, fulfilling that call means practicing medicine with an awareness of how our environmental impact contributes to the “threat multiplier” effect of climate change, and how convergent threats may affect our patients’ outcomes.


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