SCCM Pod-487: The Intersection of Climate Change and Critical Care

According to the United Nations, climate change is the defining crisis of our time and is happening more quickly than anticipated. Can critical care professionals be the spark that lights the fire of change? Kyle B. Enfield, MD, FSHEA, FCCM, was joined by Srinivas Murthy, MD, MDCM, MHSc, at the 2023 Critical Care Congress to discuss the intersection of climate change and critical care. Dr. Murthy is a pediatric infectious diseases and intensive care physician at the University of British Columbia in Vancouver British Columbia, Canada. His academic and clinical interests are in emerging and severe infections, innovative clinical trials, and global public health.

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Transcript:

Dr. Enfield: Hello and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care Medicine’s podcast. I am your host, Dr. Kyle Enfield. We all know that healthcare contributes, depending on your location, to 5 to 10% of a location’s greenhouse gases. Sitting down with me today to discuss climate change and critical care is Dr. Srin Murthy. Dr. Murthy is a clinical associate professor in the Department of Pediatrics at the University of British Columbia in Vancouver, British Columbia, Canada. As you did this afternoon, I want to acknowledge that we are having this Congress on the lands of the Muwekma Ohlone people, and I want to welcome you and thank you for taking the time out of Congress to sit down with me. Before we start, Dr. Murthy, do you have anything you would like to disclose?

Dr. Murthy: Thanks, Kyle. I have no personal financial disclosures. I will say, though, that we’re all sort of intertwined with oil and gas and the finances therein. So I may have some disclosures, but I’m not really sure what they are.

Dr. Enfield: I think that’s a great way to start. I guess I should say my disclosure is my father worked for the United States Environmental Protection Agency, so my entire education has been funded in one way or another by the EPA. This year’s Congress is called Better Together, and I wanted to start with asking you how you think climate change relates to this theme.

Dr. Murthy: If there’s any issue in the world right now that requires us to work together and to work better together, it’s our fight against the climate crisis. Doing things by ourselves, working in isolation, is not going to solve this problem. This is the definition of a collective problem that can only get better together.

Dr. Enfield: That’s great. But I’m a critical care ICU doctor, so why should I concern myself with climate change?

Dr. Murthy: There are a couple of ways of looking at that. Your patients are going to change. Already we’re seeing different patient populations within our ICUs, whether it’s new infections that they get, we’re seeing more dengue in the southern United States, whether it’s the particulate matter they’re being exposed to because of wildfires, whether it’s extreme heat events, or whether it’s disasters that have happened because of hurricanes that are more frequent because of climate change. You, as an ICU provider, are going to have to be ready for all of these different physiologies and different case mix that’s inevitably going to land up in your ICU.

Also, you’re a cause of climate change, not you directly, Kyle, but you within the space of critical care. We use a lot of energy in critical care. We use a lot of greenhouse gases in critical care. We can do a lot of things to help minimize the impact of climate change, so that our patients don’t change into those disaster-prone patients and with new infections and so on.

Dr. Enfield: You started to mention this with the change in the diseases you are seeing around the country and around the world in our patient populations. But today, what do you think the biggest climate change threats are to our patients?

Dr. Murthy: I think the biggest climate change threats, and I guess “our” is a loose term there, if you look at “our” in the context of the United States, critical care, or global critical care. Globally, I think people are seeing a lot of different diseases, whether it’s because people are migrating because they don’t have access to resources because of climate change or whether it’s because of extreme heat. I think there’s going to be more and more global problems because of climate change. I think, locally, the biggest problem, the biggest threat, is probably the disasters that we’re all seeing. Just this week in California, dozens died secondary to floods after heavy rainfall, which was almost definitely caused by climate change. So, thinking about those immediate threats and how they link up to the bigger problem of how we can mitigate the climate emergency.

Dr. Enfield: You really got into the fact that this is a global problem. But even as a global problem, the things that I’m seeing in my ICU and the things that people are seeing in ICUs in India are going to be very different. It gets a little bit to thinking about what climate resiliency is, but it’s not a term that people use a lot or are very familiar with. Would you take a moment and explain what climate resiliency is?

Dr. Murthy: Sure. It’s an ability to withstand rapid change. You can think of resiliency like a piece of wood that’s not going to break when it’s strained. You can think of resiliency to pandemics and a health system that can respond to, say, COVID-19 and future threats, and you can think of a resilient system as it relates to the climate emergency as a system that knows what’s coming and knows what’s likely to be coming and has capacity to respond and has capacity to mitigate whatever happens in as robust a way as possible. I wouldn’t say there are many climate-resilient health systems out there, but we need to work toward building that system so that we’re ready for what will come.

Dr. Enfield: As all of us listening to this podcast are critical care providers, do you think there are any unique skills that our training helps lend itself to addressing this problem?

Dr. Murthy: Of course. When you go to a code or resuscitation and you’re called to the bedside, the residents are there, you’re there, nurses, and everyone’s there, it’s chaos, it’s noise. What you provide as an ICU provider is you provide leadership, you provide structure. We have a very clear framework as to how we communicate during these crisis situations. We’re able to successfully, in some cases, resuscitate patients. I think climate’s sort of an apt metaphor there, whereby there are lots of things happening right now, lots of different conversations, lots of avenues of communication that aren’t necessarily clear for everybody. I think what ICU providers do best is bring people together and work toward a common goal, even though it may seem chaotic at first, bringing structure to that chaos. I think we do an excellent job of that. That’s a skill set that ICU can really bring to this next fight.

Dr. Enfield: When we think about that in our own health system, you made the point during your talk at Congress today about the amount of waste that each individual health system creates. I think, for a lot of us, going back to our ICUs, our hospitals, it can seem really overwhelming to think, what can I do? I think a lot of us often think about the fact, “I do all this work to sort my recycling, yet there are industries that recycle nothing.” Are there any small three to five or just a few things that we could each do when we go back to really make an impact on climate change?

Dr. Murthy: Those are great points. I think that second point where like, are we really going to make a difference in critical care when there’s so much stuff out there that’s already worse than what we’re doing, whether it’s fossil fuel combustion in the world or coal burning and so on? I’d argue that all change starts somewhere, and we really need to be a leader in this space to make sure we can demonstrate that things are possible. So, the three to five things. Let’s think about your day-to-day practice in the ICU and what you can do differently to mitigate climate. We use a lot of paper in ICUs still, even though we’re all in electronic systems; paper still just spits out somewhere, whether it’s faxes or whether it’s printouts from lab results or so on. It’s a very simple thing that you can reduce, and reducing paper will obviously reduce taking down trees and subsequently improve climate.

There are things like choices of drugs you use; we don’t think about which drugs we use and their climate impact. The operating rooms are much ahead of us on this because a lot of their inhaled anesthetics are direct greenhouse gases. Some theaters and some health authorities are switching entirely away from some inhaled anesthetics, an example is desflurane, so that they can minimize their greenhouse gas directly related to that. We don’t think about, say, which types of inhalers we use for our patients, the metered-dose inhaler versus dry powder inhalers. But the greenhouse gases related to the MDIs are much higher than from the dry powder inhalers so, thinking about those drugs.

Then, just more broadly, from a less-is-more perspective, as we think about ICU practice more broadly, we do a lot of things that we probably don’t need, so always taking that sustainability approach to all of our decisions that we make in critical care is a very easy pathway in thinking about how that impacts both the patient and the broader system.

Dr. Enfield: Thinking about that a little bit from my own practice, one of the things that I notice a lot, I think this gets into something you also brought up, which is advocacy, is that there is a lot of plastic that is used in the ICU, whether it’s the wrapping within the wrapping within the wrapping to get the one dose of the one vial you need. Is there anything we can do as providers to address that issue?

Dr. Murthy: Yeah, we always think we’re at the very bottom of that chain, whereby the hospital buys something from a supplier who buys something from another supplier, and we just end up using it. But really, we have a lot of power in that conversation, like just bringing your hospital supplier into a room and having a conversation about which products they’re purchasing and why they’re purchasing those ones. There are viable alternatives for many of the single-use products that we currently have to make them multi-use or have less plastic supplying around them. Even those very small things can make large differences.

At home, at our houses, we’re very careful about recycling and making sure everything goes in the right bin. But at the hospital, we have all these piles and piles of plastic for everything that we just pile into a garbage can. It never really gets recycled and it’s always just going to go to a landfill. Remember, plastic is a big problem because its production requires a lot of greenhouse gases, not to mention its landfills that it just sits in forever.

Dr. Enfield: One of the things that I think a lot of us think about being at the bottom of the food chain is really being able to speak to our hospital administration. Do you think there is a business case that we can make for working on climate change? Is there a return on investment that we can show the people above us?

Dr. Murthy: Yeah, there’s the short-term and there’s the long-term stuff. I think, long term, the high expenses that we’ll make right now to fight the climate crisis will pay off in spades, given the health impacts that the climate crisis will have for the reasons mentioned earlier. In the short term, if we buy less single-use stuff, if we use less energy, if we’re able to print less paper, if we use better drugs, all of these things at the bottom line are going to be cheaper. So there are two ways that we can really convince our administrators, both from a reduction of climate crisis burden and also reduction in climate crisis because of our reduced use.

Dr. Enfield: One of the things I think that I also thought about when you were talking this afternoon is really how far ahead the British are with thinking about their medications and not just thinking about the cost of the medication frontline, but really incorporating all those costs. It leads into something that came up toward the end of that session, when John Marshall got up and asked the question of how we really motivate our own society, the Society of Critical Care Medicine’s membership, to engage in addressing the climate crisis.

Dr. Murthy: That’s the trillion-dollar question at this point. How do we organize across our communities to make this something that we all believe in and all push for? Because that’s what it’s going to take. It’s going to take people, a lot of people, pushing in various directions to make the changes required. I think, in critical care, we’re always focused on the individual patient in front of us, which is what we do, what we do best. We don’t always think about the broader problem across the world.

I think meetings like this, bringing people together, if you really think about these issues thoughtfully and providing them resources to take back home to start working on, whether we should come up with a five-item list that you can go back and benchmark yourself to the next ICU down the street and say, “I do this better from a green perspective and it doesn’t have any negative impact on patient-level outcomes and only improves things at the population level and only improves things at the environmental level,” that’d be great to have that small list of things. A lot of people are working on that and it’d be great to move that forward and endorse things like that, sort of like a climate bundle that you can easily incorporate into your ICU practice.

Dr. Enfield: I love the concept of a climate bundle and I hope that once we have one, it gets as much attention as the ICU Liberation Bundle and our sepsis bundle and our central line bundles because that really has helped us move the needle on a lot of quality initiatives. I guess I want to close out. This has been a great conference in many ways, and I loved your talk, and you ended with one of my favorite movie quotes, which was “Rebellions are built on hope.” During that talk, you talked about the need for hope and how you have hope for the future. But I wanted to focus on the other part of that, which is the rebellion. What kind of rebellion do you think we need to move the needle?

Dr. Murthy: It’s always good when people notice the Rogue One quotes in my presentation, so thank you, Kyle. What kind of rebellion do we need? I think, given the trajectory the world is on right now as it relates to the climate crisis, we need a substantial one. We need one across every level of government. We need one across every level of our institutions. We need one across every level of our societies. Organizations like SCCM, for example, could take a political stance, it’s a well-respected organization, and speak to our governments and decision-makers about what the important thing is for our community members, and that’s to minimize the impact of the climate crisis on our patients. There are clear policies that our government can implement that do that, and they have those levers to pull. SCCM and other organizations like it can definitely help pull those, and I think its membership can help with that.

Dr. Enfield: Before I wrap up, I just wanted to also ask you, there are probably people out there who are listening and saying to themselves they want to do more. Are there resources out there right now that a nurse at the front line or a resident or fellow who’s thinking about a career in critical care medicine can use right now to learn more about the ICU’s impact on climate change and where medicine needs to go to help the climate crisis?

Dr. Murthy: Sure. There are a few peer-reviewed articles in the literature. I wrote one a couple of years ago. The Australian and New Zealand Intensive Care Society has a sustainability toolkit, sort of a long list of things that you can bring back to your ICU practice to think about. There are all sorts of greening healthcare initiatives that exist across different countries and across different institutions, they’re easily googleable, about things you can do across healthcare. Many of them are at the hospital level or at the outpatient level, about EMR use and so on. It may not be as specific toward critical care, but they’re always useful and the themes resonate. I think, within critical care itself, it’s a burgeoning field. I think we, as a collective, need to come up with those lists of things and start implementing them. So if anyone is interested, start thinking about it.

Dr. Enfield: That’s great. If they want to reach out to you more, are you reachable through the normal means of Twitter, etc.?

Dr. Murthy: I do have a Twitter account. I’m not good at it, but it’s there, @SrinMurthy99. I also have an email address.

Dr. Enfield: Well, Srin, thank you so much for taking time out of your day. I know you have things to do with the Society and with your family, so I appreciate you taking time to talk to me today. I really appreciate the work you’ve already done and also your presentation today. I hope those people who didn’t get a chance to go see it will take time to look it up on the online sessions from the Critical Care Congress. This will conclude another edition of the Society of Critical Care Medicine Podcast. For the Society of Critical Care Medicine Podcast, I’m Kyle Enfield.

Kyle B. Enfield, MD, FSHEA, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care and medical director of the medical ICU at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complementary access to Congress Digital. To learn more, visit sccm.org/congressdigital.

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