The Value of
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Lauren C. Berkow, M.D.
in Anesthesia 8
Committee on Equipment and Facilities
Jodi D. Sherman, M.D.
Committee on Equipment and Facilities
Co-chair, Task Force on Environmental Sustainabllity
On this 38th anniversary of Earth Day (April 22),
several articles in this issue address the importance
of environmental sustainability in our practice as
anesthesiologists. Why does this matter? There is no
question that the health sector, which runs 24/7, consumes
significant amounts of energy and natural resources, generates
alarming amounts of waste, and is a major contributor to
pollution in the United States and globally. Pollution is
the largest environmental cause of disease and death in the
world today, responsible for an estimated 9 million premature
deaths. 1 That makes pollution prevention part of the
doctor's duty to "first, do no harm."
The U.S. health care sector contributes nearly
10 percent of national greenhouse gas emissions. If it
were a nation itself, it would rank 13th in the world for
greenhouse gas emissions. It also emits a significant fraction
of other environmental emissions, including 12 percent of
acidification, 10 percent of smog formation and 9 percent
of criteria air pollutants. Both greenhouse gas and non-
greenhouse gas emissions result in a combined 614,000
disability adjusted life years lost annually. This is on the
Lauren C. Berkow, M.D., is Associate
Professor of Neuroanesthesiology,
University of Florida College of
Medicine, Gainesville.
American Society or
Anesthesiologists·
same order of magnitude of disease burden that stems from
medical errors but is currently unattributed. 2 Hospitals use
billions of gallons of water per year and dispose of more
than 4 million tons of waste yearly. 3•4 The O.R. generates
20-30 percent of the total solid waste produced by hospitals. 5
Much of this waste is biohazardous, or "red bag" waste, which
has an increased financial and pollution cost for disposal,
as it requires long-distance transportation to approved
facilities for high-temperature incineration.
As physicians, we pledged in the Hippocratic Oath to
"do not harm." Why should this oath not extend to the
environment as well as to our patients? We can't have
healthy people on a sick planet, and so protecting environ-
mental health is an integral part of the practice of all
physicians. The impact on the environment from the
industry of health care directly and indirectly impacts both
ourselves and our patients, contributing to greenhouse gas
emissions, water and soil contamination, and patterns of
disease. Strategies that address the "triple bottom line" -
patient safety, community health, and for the least costs -
can reduce environmental impact.
Jodi D. Sherman, M.D., is Associate
Professor ofAnesthesiology and
Associate Professor of Epidemiology
in Environmental Health Sciences,
Yale University Schoof of Medicine
and Yale Schoof of Public Health,
New Haven, Connecticut.
8 www.asamonitor.org
 The series of articles in this issue discuss several
important sustainability topics: the use of reusable versus
disposable medical devices, intravenous drug waste
reduction, narcotic waste management, waste anesthetic
gas reduction, and how to engage staff and leadership in
health care pollution prevention.
"We can't have healthy people on a sick planet,
and so protecting environmental health is an
integral part of the practice of all physicians."
In "WAG Treatment and CO 2 Absorbers: New Tech-
nologies for Pollution and Waste Prevention," Drs. Barrick
and Snow discuss how waste anesthetic gases are released
from the O.R. directly to the atmosphere, and they describe
several new technologies that can be implemented to reduce
WAG emissions. Of note, WAG-capturing technology
does not treat N 2O, and volatile storage is a concern. WAG
destruction technology is currently employed to treat N 2O
waste; however, it has not yet been adapted for volatile
anesthetics. Newer CO 2 absorbers can permit low-flow
fresh gas flows, below the two-liters-per-minute required
minimum for sevoflurane, since no compound A is produced.
The potential for reducing WAG pollution begs the question,
why isn't new technology implementation required?
In "Pre-filled Syringes: Reducing Waste and Improving
Patient Safety," Drs. Bukanova and Tunceroglu discuss growing
concern for pharmaceutical waste in the environment and
suggest pre-filled syringes as a strategy to improve both patient
and public safety. Pre-filled syringes have been recommended
by the Anesthesia Patient Safety Foundation since 2010 as
a key strategy to help prevent medication errors. They can
also be good for public health by reducing waste.
April 2018 ■ Volume 82 ■ Number 4
In "Disposal and Treatment of Controlled Substances
from the O.R.," Drs. Gordon and McGarry discuss the
complex regulations surrounding the handling of controlled
substances waste. They describe how different pharmaceutical
disposal methods each have their own environmental
concerns and that the safest method of handling involves
wasting liquid into a solidifier and then incinerating it. 8
The authors further stress the importance of reducing drug
waste upstream, prior to use and disposal. 9
In "Reusable vs. Disposable Equipment: Procurement
Considerations," Drs. Warrier and Hopf discuss how the
general trend toward single-use disposable medical devices is
concerning for environmental health. Initial purchase costs
of reusables tend to be higher than disposable supplies, but
this focus may be short-sighted. Concern for infection
prevention is critical to procurement decision-making;
however, lack of risk stratification and over-reliance on
single-use disposables can result in higher environmental
pollution and facility costs. While public health consideration
is not the first thing that occurs to supply managers, it ought
to be a consideration.
Finally, in "Leadership in O.R. Environmental Sustain-
ability: Methods and Metrics for Engagement," Drs. Zuegge
and Berkow discuss the importance of engaging both
frontline staff and leadership to drive and maintain pollution
prevention initiatives. Safety, infection control, efficiency
and process standardization are all important goals of
perioperative services. Improving the environmental and
economic sustainability of the O.R. can be achieved without
jeopardizing these goals. They stress that lack of education
and engagement are major barriers to staff participation
and provide some metrics and recommendations to overcome
these barriers.6•7
Continued on page I 0
American Society or
9 Anesthesiologists·
 Continued from page 9

We as clinicians can do our part by incorporating
pollution prevention into our daily practice. Although it
may seem to the individual anesthesiologist that his or her
efforts may not make a difference, when magnified over the
entire health sector, individuals can have a tangible impact -
especially when working together.
Several hospitals and anesthesia departments have
already begun to "step up to the plate" to do their part to
improve health care sustainability performance. Gunderson
Health System in Wisconsin has achieved the impressive
goal of becoming the first (and only) carbon-neutral health
system in the country. 10 Several hospitals, such as Yale, the
University of Florida and others, have removed desflurane -
the inhaled anesthetic with the highest global warming
potential - from their O.R.s. Many other hospitals, such as
Johns Hopkins, Beth Israel Deaconess and the University of
Maryland and Yale, have each saved millions of dollars via
waste reduction, management of pharmaceutical waste,
recycling and reprocessing. 11 ,12
We hope the articles in this issue inspire you to bring
our specialty of anesthesia to the forefront of sustainable
medical practice. The ASA Task Force on Environmental
Sustainability has many useful resources, including a greening
the O.R. manual and checklist to help guide providers. 13
Anesthesiologists have been leaders in patient safety. It is time
to become leaders in environmental stewardship, as public
health is also a matter of patient safety.
References:
I. Landrigan PJ, Fuller R, Acosta NJR, et al. The Lancet Commission on
pollution and health. Lancet. 2018;391(10119):462-512.
2. Eckelman MJ, Sherman]. Environmental impacts ofthe US health care
system and effects on public health. PLos ONE. 2016;11(6):e01570l4.
3. US Energy Information Administration. Energy characteristics and
energy consumed in large hospital buildings in the United States
in 2007. https://www.eia.gov/consumption/commercial/reports/
2007/large-hospital.php. Published August 17, 2012. Last accessed
February 8, 2018.
4. Practice Green health. 20 IS Sustainable operations survey.
htt ps ://p ract icegre en h ea Ith. o rg/ about/press/news/
2015-sustainable-operations-survey. Published October 12, 2015.
Last accessed February 8, 2018.
5. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on
global climate: a carbon footprinting study of operating theatres in
three health systems. Lancet Planet Health. 2017;1:e381-e388.
6. Kagoma Y, Stall N, Rubenstein E, Naudie D. People, planet and
profits: the case for greening operating rooms. CMAJ. 2012;
l84(17):1905-191 I.
7. Sherman JD, Ryan S. Ecological responsibility in anesthesia practice.
Int Anesthesia/ Clin. 20 I0;48(3): 139-151.
A complete list ofreferences can be found in the online version of this
article at monitor.pubs.asahq.org.

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