As mentioned, Dr. Delatour is part of a new multi-society task force focused on green and sustainable endoscopy. And this is something just like the patient experience, just like diversity, equity, inclusion, this is something that is going to sort of permeate our futures in the endoscopy unit, something that needs to be at the forefront of our minds. So with that, I want to welcome Rabia back to give us an overview of this emerging but very important topic. Thanks Rabia. Thank you for having me again. Alright, so again, my name is Rabia, I spoke to you guys in the lecture earlier, and one title I wanted to add to this list of titles here is that I recently became the Chief Sustainability Officer for Bellevue Hospital, which is my primary site within NYU. And it's a role that I am going to be having a chunk of my time dedicated to, because this topic is very, very important to me. So I'm happy to answer any questions about that later on. But today I want to talk to you about environmental considerations for your endoscopy unit. So we're going to talk about some definitions, we'll discuss climate change, its health impacts and the interventions that you can do to improve our own carbon footprint, not only as a human, but also as an endoscopist and as a gastroenterologist or hepatologist. So all the different things that we do within our endoscopy units to try to improve our carbon footprint. Alright, so let's start with some definitions. So just to really lay it all out there, and you may know some of these, but I just wanted to really make sure that when I speak, I'm being very clear about what I'm saying. So in terms of definitions, weather is your atmospheric condition on a given day, like minutes, days, hours. It's raining today. That's an example of weather. Climate on the other hand is an average, usually long term, at least 30 years of a regional or even global average of the temperature, the humidity, the rainfall patterns over seasons, years and decades. So that's the difference between weather and climate. So fossil fuels, again, are examples of non-renewable energy sources. They are your coal, your propane, diesel, natural gas, oil. And this is in contrast to renewable energy sources, which do not emit greenhouse gases. And those are solar power, wind energy, geothermal, biofuels, hydropower. So those are good for the environment in terms of trying to harness their energy to give us the energy we need to energize our lives. But fossil fuels are not, because as we'll talk about more, when they're burned, they release a gas into the atmosphere that are known as greenhouse gases. So greenhouse gases include a lot of different gases that you've heard of, including carbon dioxide, methane, nitrous oxide, several different other chemical compounds that we don't have to go into detail on today. But as a gastroenterologist, I did have to share this one factoid of the several contentions class have with the cow industry is that the cow's enteric emissions, aka their farts and their burps are methane. And they contribute to about 2% of the U.S. carbon emissions. And since there's 1.5 billion cows, it's not an insignificant contributor to greenhouse gases. So why do we care about greenhouse gases? When fossil fuels are burned for energy, which we are very heavily reliant on, they release these greenhouse gases into the atmosphere. And the greenhouse effect is when these greenhouse gases, which absorb infrared radiation energy that would have otherwise escaped into space, they trap that radiation energy from the sun at higher than normal levels. So we actually rely on that trapping at a normal level to keep our climate the way it is, to warm our earth, to keep our summers hot, you know, to basically keep our climate the way it is, the way our flora and fauna thrive. But when we increase our greenhouse gases, that trapping of energy and radiation happens at a much higher level. And that is why we're becoming slowly warmer and warmer as a planet since pre-industrial period because of our own human activities. And we are burning fossil fuels at an unprecedented rate. And this is causing heat trapping of these gases into our atmosphere. So our CO2 levels, they can be seen in this graph, and they are higher than they ever have been in recorded history. And this here graph is from NASA, and it illustrates the change in our global surface temperature relative from 1951 to 1980. Average temperatures, you know, things seem somewhat stable from 1980 to now. We've seen a steady rise in average temperature with no dip in sight. So 2020 tied with 2016 for the hottest years on record on planet earth. So as long as we on earth are kind of reliant on fossil fuels, we're going to continue to contribute to global warming, and it's completely inevitable. So there are interventions you can make on a daily basis, not only as improve your carbon footprint. It's something that I feel extremely passionate about, and I know a lot of you do too. So let's talk about those. But the last definition I just want to mention is climate change. So climate change as opposed to global warming is just a long-term change in the average weather patterns. And climate change and global warming, they're not synonymous. So climate change could, you know, go in the other direction. It could be cooling every single year. Obviously, we're not seeing that, but global warming is this trend upwards as you see in this graph right here. Okay. So the last definition we'll discuss before we go into what things that we can all do is your carbon footprint. So your carbon footprint is the amount of carbon dioxide and other carbon compounds emitted due to the consumption of fossil fuels by a particular person, a group, an endoscopy unit, a hospital. And because all of those gases I showed you in the first slide are different, we kind of equate. So we say, for example, methane is much worse at trapping, not worse, it's worse for the environment. It traps a lot more heat and radiation than carbon dioxide does. So, and it's about 80 times stronger in that sense, but we kind of grade your methane emissions as carbon dioxide emissions and kind of do the math. And so we use them as CO2 equivalents. So as you can imagine, this is a really hard thing to measure exactly, hence the paucity of data on this topic that feels truly exact. So there's a lot of estimates, but as you can imagine, it's really difficult to say what your exact carbon footprint is on a day-to-day basis, you know, even a minute by minute basis. So let alone over a decade. So it's hard to be exact, but we do know what the end result is, which is global warming. And that is a direct result of our fossil fuel derived energy consumption. And that includes the gas used in your car, the gas your patients use in their car, the electricity used in your home, the electricity used to run your endoscopy unit, and how you cook your food, how you travel, the cost of making the shoes that you're wearing, you know, the cost of making the plastic bottle that holds our sterile water for lavaging, you know, the upper and lower GI tracts when we're doing procedures, how you heat your home, how you heat your water, all those things are part of your carbon footprint. And because carbon dioxide accounts for 85% of the greenhouse gas total, other greenhouse gases, like I mentioned, are basically, they have differing potencies in half-lives. So we just kind of lump it all into CO2 equivalents, like I mentioned. So of the decisions you make on a daily basis, there's high, moderate, and low-impact emissions. Low-impact emissions are like the type of light bulbs you use. Upgrading to LED or light-emitting diodes can save you money on your energy bill and reduce your emissions by about 20%. Moderate impacts, like recycling and washing your clothes in cold water or hanging them to dry, are also things you can do. And high-impact, using green energy, switching to renewable energy, divorcing yourself from the toxic fossil fuel industry, eating plant-based, reducing the amount of flying you do, living car-free or using an electric vehicle, even having fewer children can be a high-impact emission. A plant-forward diet, including some chicken and fish, is healthier and has a lower carbon footprint than the typical American diet, which generates three tons of carbon dioxide annually per person. So what is being carbon neutral? We hear a lot about a person or an institution being carbon neutral, and what does this actually mean? Carbon neutrality just means that you have a balance between the amount of carbon that you're emitting and the amount that you're absorbing from the atmosphere in carbon sinks, which absorbs more carbon than they emit, such as forests, soils, and oceans. So removing carbon dioxide from the atmosphere and storing it is known as carbon sequestration. In order to achieve net zero emissions, which you hear all the time, is basically trying to offload or offset the amount of emissions that you have and counterbalance it by sequestration. So you can definitely make sure that you have planted enough trees to offset your emissions. That's something that you can do. So carbon offsets are controversial. It depends on calculations and methods used to offset the carbon. And a cost per ton of carbon offset varies. So that's something that you can consider as a company, but it is very controversial. So if you were to say that you're going to be carbon neutral and use a whole lot of energy that is not necessary and you're overusing it, but you planted trees, even though you may be net neutral, it's not necessarily good for the environment. You should be reducing your initial amount of usage as opposed to trying to do things to put Band-Aids on the problem. All right. So what's your carbon footprint? The average American has a very high carbon footprint, unfortunately. So in terms of average CO2 production calculated from the national production divided by population, by person within the United States, it's cited to be anywhere from 16 to 20 metric tons per person per year. And this is daily. Each American is responsible for an average of 80 to 100 pounds of carbon dioxide emissions per person per day, which is the equivalent of driving 113 miles in an average passenger vehicle. And this could be offset by recycling about two bags of trash versus sending them to a landfill. Recyclable trash, obviously. So the global average is four to five metric tons. So we are four to five times the rest of the world. So if the rest of the world lived like we live, it would take five planet Earths to basically account or be able to sustain that. So we in the most developed countries are much worse in terms of our carbon emissions compared to the rest of the world. So it's really important if we're going to try to stave off or avoid this two Celsius rise in global temperature in terms of global warming, each person would need to reduce their carbon footprint in America from 16 to 20 metric tons to about two per year per person by the year 2050. So if you can imagine taking everything you do in a day and reducing it from 16 to 20 to two, that would mean a lot of sacrifices that I don't know that a lot of Americans are ready and willing to make. So it's just feels a little unfair to the rest of the world when they're suffering from the impacts of climate change much more than we are when we're the ones who are responsible among other countries for having the largest emissions. So the healthcare industry, again, it's a major contributor to greenhouse gases. We're cited to be responsible for 4.4% of our global carbon emissions and 8.5% of the U.S. national emissions. And if healthcare were a country, it'd be the fifth largest emitter on the planet, right up there with the U.S., Saudi Arabia, Australia, and China. There's a really well-known climate activist and journalist named Winston Choi Shugrin, who you should definitely follow. And some of the tweets that this person has put out have been very interesting about hospitals specifically. And one of the things that they mentioned were hospitals filled with computers, machinery, and lighting that run 24-7 are more than twice as energy-intensive as other commercials. And the largest source of carbon consumption, estimated 70%, comes from the supply chain and the energy required to manufacture, ship, and dispose of the pharmaceuticals, food, medicine, and plastic packaging used by hospitals every day. So why do hospital emissions matter? Human-caused climate change threatens to undo years of progress in public health to improve nutrition and access to clean water. And that is so important to note. We have spent so much time drilling in preventative care into our hearts and minds and instilling it into medical school education and practicing in real life. We are threatening to reverse all of that if we start to impact the health of the people surrounding our hospital systems, our waste incinerations, our landfills, because we are definitely producing a lot of waste and wasting a lot of plastic. So it's just something to note because our supply chain and the things that we use every day and that we use excessively are going to impact the health of the people that we're trying to protect. So on average, a US hospital generates around 29 to 43 pounds of trash per day per patient. That's a lot of trash. OK. All right. So similar to health care, I'll digress and get off my soapbox. But similar to health care emissions per capita in developed countries, our health care emissions by country mirror much of the same patterns. The per capita health care sector greenhouse gas emissions are also the highest in most of the developed countries, and the US is one of the largest culprits, as you can see here. So we're up there in terms of our health care being just as bad as we are as citizens of the world. OK. So in terms of greenhouse gas emissions and their sources in health care, we as sustainability folks look at it in three scopes. So there's scope one, scope two, and scope three. Scope one emissions are the type of energy your hospital building uses, your fleet vehicles, the anesthetic gases that are wasted, how you refrigerate things that need to be refrigerated and the refrigerants used. Scope two emissions are the purchased electricity. Where do you get your energy from? Is it from burning fossil fuels or is it from renewable energy sources? And your purchased steam. Very similar. So a lot of fossil fuels are converted into steam, and that steam is then used to heat things. But it's still essentially from fossil fuels. And scope three emissions are the largest source of emissions, right? And that's kind of represented in this graph because it's the widest one. So scope three emissions are the largest ones, and those are the things that we as clinicians can actually intervene and help with. And that's business travel for people going to conferences. So the fact that this conference went to hybrid, I was obviously sad I didn't get to meet a lot of people that I wanted to meet in terms of all of you guys and the other panelists. But I was appreciative of the fact that it reduces the amount of flights. And we're going to talk about how bad flights are. But business travel is a big contributor for scope three emissions. Employee commute, also the patient commutes, waste disposal, meat procurement for patient meals, pharmaceuticals, and then medical devices and equipment. And scope three emissions is kind of the target of all the work that I do and how we as clinicians can use clinician-driven initiatives to try to reduce our scope three emissions. All right. So what's the scope of the problem in GI? No pun intended. And I'll try to talk fast because I have a lot to say, and I don't want to go too over time. So Eden, please cut me off if I do. All right. So in 2020, a study came out where one, actually Swapnagiam, who I worked with on our multi-society task force, she looked at the, just the plastic that was kind of used per case in her endoscopy unit. And she found that every procedure generated 1.5 kilograms of plastic waste. And about 0.3 of that was recyclable, but they don't recycle at our hospital. So she calculated the effect that would have if you average 18 million endoscopies annually in the U.S. And what she found was that the U.S. endoscopy generates thousands, millions of tons of kilograms of plastic every single year, as you can see from the math here. And essentially a lot of this, if you don't have recycling capabilities in your endoscopy unit or, you know, in your ORs or in your procedural areas in general, a lot of that plastic that could be recyclable is going to waste. In addition, each procedure has a pretty significant energy consumption as well from your endocard, the lighting in the hospital, you know, just energy uses to run all the computers and all that stuff that often run 24-7. And what she found that it was using about 175 pounds of coal per day, and that's 39 million tons of coal per year. So this was an interesting kind of study, you know, somewhat bare bones in terms of just looking at the plastic and then using, looking at the energy consumption and what impact each endoscopy has, which makes you think of all the unindicated endoscopies that we do within the United States that are not guideline-based and how that's impacting our environment. Here's a picture of waste audit that we're doing in our hospital. We're actually doing life cycle assessments of every single piece of plastic, the lighting, the energy, and we're going to submit it pretty soon. Just collecting trash and going through it is also part of my job, which is very fun. Okay. So in terms of endoscopy waste, another study was done in 2022, just published with another person who's on a multi-society task force named Dr. Heiko. And they looked at a five-day audit and they just weighed the trash. Again, super simple, but they weighed the trash per case and found that each case was creating 2.1 kilograms of waste per case. 64% of that was going to landfill, 28% of it was in the biohazard or red bags, and 9% was recycled. And again, if you multiply this times 18 million procedures, they calculated that they were creating 38,000 metric tons of waste within GI per year. And that would weigh as much as about a little under 25,000 passenger cars and cover 117 soccer fields, one meter deep. You know, it's just a lot of waste. So something to consider, again, when we are performing these procedures, what is the actual impact it has on the environment, because it's not free. Okay. So we talked a lot about duodenoscopes in the last two lectures. You know, it's really important to know that duodenoscopes, the single-use duodenoscopes that have come out to combat the duodenoscope-related infections. We talked about whether or not that contamination is clinically relevant infection and if single-use duodenoscopes are really the solution. I don't know. The reusable scope uses 30 gallons of water per cycle, plus disinfectant, plus enzymatic solution, plus electricity to wash. A single-use scope is 20 times the carbon emissions of a reusable duodenoscope per one study, and 96% of that was from production. But that being said, the single-use duodenoscopes, if you ask for the bin from the manufacturer, you can actually send them back to have, I think it's over 90% of their parts reused. So it's not, you shouldn't, if you are going to use it, make sure you're not putting it in the trash. That's probably the most important point. And secondly, you should only use it for indicated cases. I am not a subscriber of using it for every single case. I'm not a fan of that idea, and I've heard of some people doing that, but again, it's not guideline-based. Okay, so why does any of this matter and how does this tie into actual health? In 2021, a really wonderful editorial was published by The Lancet and 200 other journals on every continent published it, targeting all disciplines, everyone from ophthalmology to vets, and just essentially making a call to arms about how we as healthcare providers should and must limit our carbon emissions to limit the effect of global warming. And it highlights the impacts it has on our health and our patient health, and I really recommend that you read this really short paper. All right, so the impact of climate change on human health. There are so many different impacts that climate change have on our health and our patients' health and different reasons, right? So there is extreme heat can cause health-related illness, heat-related illness, I'm sorry, and death, cardiovascular fever, weather can cause injuries, fatalities, mental health impacts, air pollution can cause asthma, cardiovascular disease, changes in vector ecology can cause all these infectious diseases that we've been seeing increased cases of, increasing allergens can contribute to respiratory allergies and asthma, water quality can increase risks of cholera, campylobacter, leptospirosis, and water and food supply can cause food insecurity and that can cause malnutrition, diarrheal disease. And lastly, environmental degradation can cause forced migration, civil conflict, and mental health impacts. And all of the mental health issues can cause worsening alcohol abuse and in turn liver disease. And so there's a lot of different GI issues that we see as well. It's not just like a global health issue, like globally, I mean, but adverse effects on GI health also exist. So when you don't have clean water access, that can impact your ability to hydrate properly, adequate nutrition, if you don't have it, you can have malnutrition. If you have rainfall and floods, there's increased risk of enteric infections and hepatitis, increased risk of cholera. You can have further limitations to your access and care as a result of all these. And like I mentioned, you can have increased risk of alcohol-related disease and in turn liver disease, alcohol-related liver disease, if you succumb to a lot of the stressors that come with climate change. All right, so what is our plan? There are multiple international agreements in place. The first meaningful agreement was reached in a historic meeting in Paris in 2015, with all nations agreeing to reduce their greenhouse gas emissions. And the target was to set a global, hold global warming to two degrees Celsius and a possible 1.5 degrees Celsius. So that was first. And we also had COP26. So we have a lot of promises. I just hope for future generations sake that these aren't empty promises and people actually fulfill what they agreed to do. Okay, so in terms of healthcare, what's our plan? So there's things we can do in a large scale and also in a smaller scale, which I'm gonna talk to you more about. So there's some high impact actions you can make like ensuring that the healthcare is energy that we use and the power we use is 100% clean renewable energy. So switching over from the fossil fuel industry to renewable energy sources in terms of your hospital and where it gets its energy from. Investing in zero emission buildings and infrastructure, transitioning to zero emissions, sustainable travel and transport, providing healthy and sustainable food to your patients. And also the healthcare workers themselves should be eating healthy, sustainable food and what's served in the hospital to the residents to in the cafeterias, et cetera. Should incentivize and produce low carbon pharmaceuticals and implement circular healthcare and sustainable healthcare management. Also establish greater healthcare system effectiveness. In terms of GI, there's also several things we can do. So there's advocacy, there's research, there's education, what we're doing today, what we're talking about today. The four societies have teamed up and we created a multi-society task force with two representatives from each one. I represent the ACG with Swapna and we have eight of us and we just wrote a paper that is going to be published pretty soon on different interventions that we can make. And we're gonna continue working within the societies to further our message and make sure that it reaches as many people as possible. Another thing you can do is work with industry, right? So there's a lot of questions I had when I first started as a gastroenterologist, like why does this metal stent that is going into this patient who has terminal cancer, why does a stent expire? Like if it expires tomorrow, how come I can put it in the patient today and it expires in the patient? What does the expiration date actually mean? And just working with industry about these types of questions is something that's important because you'll never affect change if you don't question the system at hand. So it's really important to question things and work with industry, not against industry, because they're not our enemies. They're going to do what they're going to do regardless, but you can try your best to try to influence the best you can if this is something you're passionate about. So 51 nations have signed to decarbonize your healthcare industries. And that's just a good thing moving forward in terms of what we can do. Several papers have been put out on this topic. There's about 10 and they're really easy reads. And I hope that this lecture is easy to listen to because it's not so detailed in terms of the science, but it's just things that you can do. And a paper that I wrote myself was in the ACG toolbox for practice management on improving your endoscopy and its carbon footprint. So just a plug for my own paper. All right, so what can you do in your endoscopy unit? When we talk about the old adage, recycle, reduce, reuse, it actually should be reduced, reuse, recycle because reduction is the most effective way to reduce your carbon footprint. Recycle is actually the least effective way, but it doesn't mean you shouldn't do it. So in terms of reduction, right? Limiting the amount of patients that come and physically see you, that's a scope three emission. Telemedicine has been obviously a side effect of the pandemic, which of course was not great, but it's one of the silver linings is that we are seeing more telemedicine and more telemedicine, exclusive telemedicine providers. And that's actually great for the environment because not all patients need to physically come into the hospital just to have a med refill visit or discuss a symptom that doesn't necessarily require a physical examination, let's say like a psychiatrist, for example. So telemedicine has been really wonderful for carbon footprint and scope three emissions. Something we mentioned earlier, and I want to talk about again, avoiding unnecessary procedures. So we do thousands and thousands of endoscopies at our hospital every year, and you always run into the cases, you're like, is this really indicated? So it's just something to consider as we move forward and we see worsening and worsening like emissions from healthcare, we must consider reducing the unnecessary procedures. And that can be anything from changing the guidelines for Barrett's for something like esophageal carcinoma that evolves so slowly from Barrett's, asking yourself a question if these patients need to be scoped as frequently. I was very happy to see the change in the colon polyp surveillance guidelines from every five to 10 years to every seven years for those polyps. So using a plant-based menu is really wonderful. We're going to talk about that more. Double basin washers are more energy efficient than single basin washers for scope cleaning, which is something we just talked about. Environment and cleaning from solutions, making use proper waste allocation, which we'll talk about. Surgical preference cards, this is more of an OR thing, but if you're in a unit that has a lot of gastroenterologists, sometimes there are preference cards that can be used so that not every single thing is open for every single gastroenterologist. Okay, reusing. You can food compost, reusable gowns are a really wonderful thing you can do. Use your scope buttons, reuse washcloths if they're washable, consider biodegradable packaging, donating expired medical goods, something I do at my hospital, reusing surgical and medical products when appropriate and not going against any infection control guidelines. And then lastly, if in the unit, there's several different things that you can recycle if you have the resources to do it and the support from your sustainability team. All right, so let's talk a little bit about travel. Again, we're at a remote conference, so pat on the back to us because we're reducing our carbon footprint. Well, meetings like ACG and DDW. So obviously they're really wonderful meetings, but they have a huge impact on our collective carbon footprint. The choice of meeting location has a very big impact on differences in carbon emissions. Societies really should consider the site of the meeting to reduce the number of in-person attendees if they wish to reduce their carbon footprint. Hybrid models should be considered. It's a great idea for people who can't travel or people who don't wish to travel because they're being conscientious about how much travel impacts the environment. So the average per capita distance traveled to a Toronto meeting, which was studied in the study with this graph right here, was 2,845 kilometers. And that resulted in 0.5 tons, so half a ton of CO2 equivalents emitted per person. So again, this is a lot, a lot, a lot of carbon emissions per different, in this study right here on the left, per person, per flight. And it's not okay to just say, oh, well, the plane is going there anyways, I might as well join. Because the more that people buy flights, the more airline industries are prompted to increase their number of flights. But we know that air travel is unavoidable, but just being conscientious of it is important. JetBlue is great because they actually do carbon offsets with every flight, and that's included in the purchase price and you can also purchase carbon offsets separately. And you can consider combining trips or going on Zoom like we are today. This may not apply to all of us, but like avoiding private jets and picking options with lower CO2 carbon emissions, and you can lower CO2 emissions. And you've seen nowadays on Kayak and other websites to buy flights that they actually list the carbon emissions, which is really lovely. Okay, so let's talk about regulated medical waste. I know that I'm probably running low on time, so I'm going to make these next few slides quick. Part of my job is educating people on regulated medical waste. So regulated medical waste is that red bag waste. And it's really important to know that not everything that has ever touched the patient needs to go into this. At our hospital, about five years ago, I started a group that focuses on sustainability. And what I found was you'd walk through the OR and you'd see people throwing their gowns and their gloves into these red bags, and these often get incinerated. It's so much worse for the environment. It's more expensive for the hospital to get rid of it. So appropriate allotment is 6% to 15% of your trash should go into the red bags, but the CDC recommends even lower, 3% to 5%. But some hospitals have as much as 70% of their trash going into the red bag. So it's really important to educate what goes in there, what doesn't. And this is a separate lecture because I'm running low on time, but it's just really important to know, unless something is drenched with blood and it's dripping off of it, it doesn't necessarily need to go into the red bag waste, just like your Band-Aid at home doesn't go into regulated medical waste and get incinerated. So I made a video that is now on all of our educational sites for NYU and soon hopefully at Bellevue on regulated medical waste, which has been a really good educational tool. So we talked about single-use duodenoscopes and their impact, I'm sorry, single-use disposables. And so, sorry, not single-use duodenoscopes, forgive me. So single-use disposables are things that we use that we throw away after using once. A lot of this stuff has done the name of infection prevention, and that's the biggest driver for single-use disposables. Single-use disposables make up a large portion of our trash. Every time you use a syringe to administer, a plastic syringe to administer any medication, it goes in the trash. Every time you use your bite block for a patient, it goes in the trash. So many of these reusable, many of these items do have reusable options like gowns and surgical equipment. And so finding those and utilizing those is really important to consider reducing your carbon footprint. I mentioned preference cards earlier. This is more of an OR thing, but it's been found to have a significant reduction in the amount of waste for surgical cases. So that's important to note. If you say, well, this surgeon only uses these materials, she doesn't like X, Y, and Z, you eliminate that entire panel of things being open and eventually thrown away because they were in an OR and they don't necessarily get reused in the name of infection control. We reprocess a lot of devices at our hospital. Ended up with Stryker and we reprocess all of our endomechanics from the OR. So these again are for a lot of laparoscopic cases. Some of these items in the past were not single-use, but now they are. So we can make money off of this, but it's just something that you're also doing something that's really environment. So EKG leads, pulse oxes, the bed alarms, tourniquet cuffs, pressure infuser bags, those things that pressure bags, saline, and other things, those can all be reprocessed. Reprocessing saves money. And so that's just something I'm going to breeze through, but it saves a lot of money for the hospital and you make money, you're selling it back to the company. We also have started Iris starter pilot in our ORs. It's now expanded to 38 ORs. And basically we started with a single item, these plastic saline bottles that were used for every single case. And we now recycle all rigid plastics in our ORs at NYU and soon to be Bellevue. And then of course, there's examples of non-recyclable plastics that need to make sure you don't sully your recycling stream by placing those in there. And those are those soft plastics that are recite for recycling and other small ticket items that you don't necessarily, you can't recycle. So you have to make sure you don't mess up your stream and put those in the bin as well. We expire expired devices, we donate them. So I don't have a lot of help with this. It's myself and my tech who just retired. So now it's just me. We basically collect all our expired items in the hospital and then we donate them to a company that I found. And this has been really wonderful because otherwise they were going into the trash. All right. Now, another thing for those of you who work with anesthesiologists, it's really important to note that these inhaled anesthetic gases are, some of them are horrible for the environment. And we were successful in actually getting rid of desfluorine at NYU, which is one of the worst in terms of its global warming potential, as you can see here in this chart. And here again, that same journalist said, it may be surprising, but the propellant gases in inhalers or in anesthetic gases are greenhouse gases. So nitrous oxide or laughing gas is 300 times the warming potential of carbon dioxide. It's said to be 80 to 300, but she might've exaggerated a little here. And the main ingredient in inhaler is hydrofluorocarbon, the class of powerful greenhouse gases used in AC and fridges. So again, it's really important to note these things have impacts too. You know, your inhaler, which some people use after having reactive airway disease from a bad cold, those are really bad for the environment and can cause a lot of problems. So limiting the administration of those, which are definitely over prescribed is important. All right, turning off your lights. If you do not have LED light bulbs in your hospital, you would be surprised at how much energy our lighting sucks up and costs the hospital. LED light bulbs are wonderful and it's very energy efficient. 95% of the energy in LED light bulbs is used for the actual lighting. And so they don't get as hot. So there's less heat emitted. So they're much more efficient in terms of their energy use. So it's really important to ask your hospital switch if they haven't already. A little plug for plant-based menus, not only plant-based patient menus, but also education to try to get your patients in outpatient settings to eat plant-based. So as you can see in this graph on the left, the carbon emissions from lamb, beef, pork, even fish and chicken are much higher than plants. That's down to the lamb that needs to be cleared for these cows and lambs to roam around, the type of farming that's done to make food for them, the type of water that they require. They just have a much larger carbon footprint. And with the cows, we mentioned their farts and their burps create a lot of methane. So it's really important to try to switch over as much as you can be plant forward. We actually have a clinic at our hospital that is a plant-based lifestyle medicine education program. And it's been really wonderful to help patients who have certain medical conditions try to be more plant-based. And it's just so much better for the environment to try to limit the amount of meat that you intake, meat and fish that you intake because of the carbon footprint of all these. All right, so in summary, what can you do? We talked about a bunch of different things that you can do, but most important is reducing, reusing and recycling and aiming towards carbon neutrality, not necessarily by offsets, by trying to reduce your waste as much as possible and reducing what you might need. I am very, they call me, I'm very stingy in my endoscopy unit and that's because I think about each piece of plastic that we're using, you know, so wires are not wasted in my room. We don't like accidentally open things. We're very clear about what we might open and use and if we're going to use it. We talk about that out loud in closed loop communication to make sure that nothing is accidentally opened and wasted. We don't throw away anything into the sharps container before we're done with it for sake of losing and having to open another. We're very careful about that stuff. All right, thank you so much.

green and sustainable endoscopy

patient experience

diversity equity and inclusion

environmental considerations

carbon footprint

telemedicine

healthcare industry