known financial disclosures I have, but likely there. Given the breadth of this problem and given the scope of the challenges, given that I exist in the world, I have money that comes from a government that goes into my wallet and goes to my house and mortgage. All of that money is intertwined with oil and gas and climate. And so, yes, I probably do have financial disclosures to make. I don't know what they are, though. I have two very small children, or smallish children now. And I worry deeply about this issue for them, for us, as well as adults in this room, but largely for our future generations. My clinical practice is pediatric critical care. And so, obviously, this is something that hits home. Disclaimers. I remain hopeful. And I think we can always have climate change talks that are doom and gloom and steeped in nihilism. We'll try and avoid that and try and have a hopeful approach going forward. And then, also, politics. There has to be politics discussed when discussing climate change. It's unavoidable. I'll try to avoid partisan things. I acknowledge I am Canadian and don't know the American landscape very well. But there has to be an addressing of the elephant in the room. Also, a land acknowledgment. I'm here on the Raimaton Olón land here in San Francisco. And I acknowledge that they're the traditional custodians of this land. And I'm grateful for that. OK. We're going to take two approaches here. The first approach is, is my ICU ready? We're also going to talk about how my ICU can help. And so, obviously, these are two separate things. And we'll delve deep into them. But as a clinical talk, we'll have a case presentation. This is maybe a bit of a stretched metaphor. But let's try it. We have a young patient who has been rapidly deteriorating over recent years. The patient continues to practice self-injurious behaviors, has multiple morbidities at this point, is admitted to the hospital, unable to accomplish activities of daily living at home. Every subspecialty is consulted. There's no clear management plan in place. Everyone is arguing in the hallway about what to do next. An ICU is called after a code is called on the patient on the ward. The metaphor, obviously, is Earth. It's a code read for humanity. I'm using code language, because that's the language that we know in ICU. And this is Antonio Gutierrez, the Secretary General of the UN, saying this is a code read for humanity. It's time to really escalate the conversations and the actions given the scope of the problem. So we'll talk about it from an ICU-type language perspective. And we always, in ICU and clinical practice, think about, when do we begin resuscitation? We have a deteriorating patient. We have problems happening. We know they are happening. When do we escalate our management so that we shift from a chronic disease management to an acute resuscitation approach? So this is NASA data, Global Land Ocean Temperature Index. Indexed 1940 to 1960 is zero. And you see, obviously, temperatures across land and ocean rapidly escalating over the past 40 years. This is ocean heat content since 1963. And that is a fairly steep slope upwards, looking at the heat content in our oceans globally. This is carbon dioxide over the last 800,000 years. And this is data that they get from looking at ice and ice content and carbon dioxide content within them. And you see that fluctuation, as people say, there's natural fluctuations in history as it relates to carbon dioxide content in the atmosphere. With various ice ages and various warm ages in the past 800,000 years, that arrow in the top right is where we are today, or last year, 415 parts per million. For reference, I was born at around 319 parts per million myself. My kids were born about 390 parts per million. And so things are rapidly getting out of control. And then I'm acknowledging that this talk is in California. This is slides from just last week with more rain and weather-beaten California, many dead and flood-ravaged communities. So clearly, the problem is escalating, and resuscitation is probably indicated. So then how? How do we resuscitate? And I'm at an ICU meeting. And so we talk about ICU-type things. And I always highlight crisis resource management and how we communicate during an acute decompensation of a patient. And a lot of the language of ICU is that team-based communication. I talk to you. You talk to me. We have a consensus plan. And we work together for a common good at managing a very, very sick patient. And we have these tenets of crisis resource management, things like situational awareness, things like leadership and followership skills, things like task management and assigning tasks, and things like communication strategies. And we have very clear frameworks for that. We've all been to codes. We've all been to acute resuscitations, where these things are established. There's a hierarchy. There's a conversation strategy. Everyone knows what they're supposed to do. And we do it. And I'll reflect and think that this is exactly what's required, given the scope of the problem globally with climate. Health. OK. Can my ICU help? Health care. Health care emits a lot. So this is data from the United States, looking at the proportions of where within health care we emit greenhouse gases. And so across health care facilities, it's only about 7%, the buildings themselves. But then you have to think about what's in those buildings, whether it's the electricity being used, people getting to work, the medical devices they're in, the plastics at those facilities, the pharmaceuticals, and so on. So there's all sorts of things in small slivers here that we could all work towards and work together at reducing. And as Gloria said, depending on the country, depending on the jurisdiction, health care works out to about 10% or so of our total carbon emissions. And so we know that we have to do things quickly. And we, in some way, shape, or form, are in charge of health care, at least within our local context and within our local ICUs. And so there are things that we can do. OK, let's talk about things. So electricity. If you work out the math and how much an individual patient on an individual ICU exists, it works out to about 9 kilograms of carbon dioxide per bed per day. And it's not including travel, not including supplies, and all the things that get a patient there. And so just the electricity of the ventilators, the monitors, the dialysis machines, the ECMO circuits, and so on, works out to about 9 kilograms, which is about 5 liters of gasoline, which is sort of an easier way of thinking about it. So 5, I guess, 1.25 gallons, I apologize, of gasoline for carbon dioxide emissions, which is a lot. And obviously, in ICU, we can't unplug ventilators. We can't unplug monitors. We need to have this bit of electricity. So what can we do to think about electricity and its impact on greenhouse gas? This is the easy one. It's not the easy one. But the straightforward answer is advocate for clean electricity. And I think this is a fundamental thing that we in health care and we in ICU communities can really do and really work hard at. This is United States data showing where our United States electricity comes from across the country. And about 60% still comes from non-sustainable, non-renewable sources, so natural gas and coal. And that has, obviously, substantial greenhouse gas impact. Canada is not much better. We still have about 20% of our energy coming from natural gas or coal. I pulled up a random country, Denmark. It's about 22%. They have coal still at about 16%. But they have a lot more wind and bioenergy. And so obviously, this is a big problem. This is not just something within one local hospital. And advocating for clean electricity is hard, given the power structures that exist. But when we think about our patients and think about our future patients, it's something we can do. Next thing, drugs. We use a lot of drugs in intensive care and intensive care practice. We have no idea what their environmental impact are. When we think about how and which patient drug we use, we think about the randomized trials showing safety, the randomized trials showing effectiveness. Sometimes, we'll think about costs. And all of our health technology agencies will sort of integrate societal costs into that. With our ID friends, we'll think about antimicrobial resistance, and so system-wide decisions and system-wide impact for a thing that we use for the individual. But we almost never think about the larger scope of what each individual drug does for our larger community. And that's specifically related to environmental impact. So I ask you, next time you look at a drug and prescribe a drug in your intensive care unit, just to think. Think about the environmental impact of individual drugs. Some drugs, we know this. Some drugs, we have no idea. And this is something that a lot of agencies are starting to think about as they make decisions about how to pay for drugs and which drugs to pay for within a health system, acknowledging future costs of environmental impact. And I don't want to do comparative health system stuff, but the United Kingdom is always going to be ahead of everywhere else in the world on this, specifically because of their common drug review program, which incorporates things across the country. So in ICU practice, the things that sort of always are the hardest hitters are the anesthetic gases. Not necessarily directly in the ICU, but obviously in the operating theaters, and we'll often use them within ICU environments, at least. And the environmental implications of anesthetic gases are fairly well-established. We know these gases are substantial greenhouse gases themselves. If you look at a busy, mid-sized US hospital, uses about 1,000 liters of inhaled anesthetics per year, which works out to about 1,200 cars full-time use over the course of a year. And if you look at the individual gas chosen, so desflurane, which is a very common gas being used across anesthetics across the world, it's about 26 times more greenhouse gases than sevoflurane, and about 13 times more common than isoflurane. And so across our hospital systems in British Columbia, we've slowly, over the past couple of years, phased out desflurane use altogether. And we've done the math, and we've done substantial greenhouse gas savings. And our anesthesiologists don't really care. They think the clinical implications of that change are fairly minimal. And so just with a small policy change instituted at a hospital level, we're able to substantially reduce our greenhouse gas emission within the hospital sector. That's a reasonably low-hanging fruit. And you guys can all bring that home to your institutions and say, why are we using desflurane? We should be using sevoflurane, so it's much easier. And the United Kingdom, once again, ahead of the game here, within the next year or so, they just announced a couple of days ago they're going to no longer be using desflurane across the NHS, purely because of its greenhouse gas-related impacts. And this is in conjunction with the Association of Anesthetists and Royal College of Anesthetists in the UK. So ahead of the game, great to hear that. Propofol, propofol is a drug we always use, we love. And obviously, no one's going to say, don't use propofol. Because largely, its environmental and greenhouse gas-related impact is reasonably small. It's reasonably efficiently produced and reasonably efficiently shipped. Its main problem is that it's a toxin. And so when it's released into the environment undiluted and uncared for, it can cause damage to fish and other sort of animals therein. And so instituting a local policy whereby your propofol discards are sent off to a specific place for management can help mitigate that. And so in our operating theaters and our ICU, we've set up little buckets, basically. So any excess propofol that exists within a patient's bedside just gets shot into that. And then that gets discarded by some separate strategy that doesn't get released within the water supply. Not necessarily a greenhouse gas problem, but an environmental toxin problem. Inhalers. Lots of conversations about metered dose inhalers. And so we, as sort of an ICU community, use a lot of inhalers with our patients with bronchoconstrictions and other diseases. The impact of metered dose inhalers are substantial compared to an alternative dry powder inhaler. One of the challenges within ICU communities is that we sort of have to give these medications through ventilators and through circuits. And they often, with the dry powder, can deposit on the circuit themselves without actually getting to the lower airways of the patients. We don't know that. We think that. And so we've made sort of blanket recommendations to just use metered dose inhalers within critical care communities and environments. We don't know that. And so having some studies to say that dry powder inhalers are equivalent to metered dose inhalers for critical care would be great. Looking at specific environmental impacts, but also patient outcomes themselves. In the community, say, for example, if a patient's on a metered dose inhaler compared to a dry powdered inhaler, the annual CO2 equivalent's about, I can't do math, 180 kilograms more, which works out to about 30 gallons of gas per patient. Which is a lot. And so when you think about the number of metered dose inhalers that are out there in our communities. Plastic. We've all worked in ICUs where the amount of plastic that is present is tremendous. And remember, plastic as we use it takes energy to make, primarily. Obviously, there's a discard problem with plastic. All the plastic is hard to recycle. And anyone who claims that their city recycles plastic probably isn't accurate, because plastic recycling is very challenging to do, especially the soft plastics. And so when you think about the math here, about 2.2 kilograms of plastic waste per hospitalized patients per day. And so for the generation of that plastic, it works out to be for a 20-bed ICU, 90% occupancy, back of the envelope math, about half a million kilometers in a normal gas car for one ICU. It's a lot of plastic. How do you solve this problem? This is a tricky one. With our infection control colleagues, and the manufacturers, and so on, it's very hard to minimize the use of plastic. Every central line kit with 400 gallons of plastic on it, and hard plastic, and soft plastic, and peeling off things everywhere. Every IV bag with all sorts of different plastics around each IV bag and everything else, it's hard. But we can work with our suppliers. There are novel approaches to this. Each hospital is thinking about this. And you can advocate within your own hospital about how you can reduce the use of single-use products. Obviously, the sterile things need to have appropriate sterility. But at the same time, many of the things that are single use don't need to be sterile. And they have all sorts of plastic layers that can be minimized. And talking to your hospital supplier about where they get their things and whether they can do different things is something we can all do at home. So breaking down areas for change. We have clinical care, medications, consumables, linens. Don't get me started on yellow gowns that we have to change into 40 times during an ICU round. And whether they're valuable or not, obviously it's a huge burden. Administrative, paper use, commuting. These are low hanging fruit that we can all think about, less paper use, better commuting strategies, or building. Professional, travel costs. This is all awkward right now. We're here. Many of us flew here to San Francisco. It's lovely to be here, obviously, and see people. But there are substantial greenhouse gas implications of many people flying to a city for a meeting. I'm not going to layer on the guilt. I think this is not the place for that, nor is that the right approach to climate change mitigation. We really need to think about systemic problems, not individual ones, but still acknowledge that travel is a major contributor to greenhouse gas. And the last thing from a can my ICU help perspective is really finding like-minded individuals. I think every ICU is a large community of people who all have different perspectives and can all bring them to a common problem. And so finding those people within your ICU and finding those people within your hospital, setting up. We all have quality review committees. We all have morbidity committees. We don't have climate committees or greening ICU committees within our hospitals. It's very easy to set up. And just finding those right people, and then working on those small problems, and then collectively working on the big problems. And obviously, this is a political problem. We talked about clean electricity and clean energy being the fundamental thing. And using your voices as doctors and health care providers and other people who are respected within your community to really sort of advocate for the local and national changes required. There are some hopes. There are a lot of UN conferences specifically related to health and its impacts. And many countries have now signed on to this, specifically at COP26 last year, where many countries signed on to develop climate smart health care relating to health care itself as a major contributor to our climate crisis. So Canada and the United States have signed on to it. Whether they should have been more specific in their language, yes. And so more advocacy is definitely required. Canada and the United States both have said we're going to build these climate resilient health systems. We're going to build a low carbon health system. But neither of them made a net zero commitment, which was what a lot of folks were advocating for from a health system perspective. So a lot of work still left to be done. OK. Then next we're going to move on to, is my ICU ready? And this is trickier, because we're not really sure what to be ready for. And preparedness work is really hard, because you're preparing for everything while having to solve the things that are coming in your door all the time. And so taking an already strained system and thinking about things that may or may not happen in 10 or 20 years is going to be hard. And as we've all been through with COVID-19, and we've realized the importance of resiliency and the importance of preparedness with dealing with future health emergencies. So what are the problems? Floods. Floods are a problem. I think we've appreciated that in California. And some folks have done studies looking at where our hospitals are in the United States and other places that are especially flood prone. There's going to be many more floods over the next decades. And thinking about how our hospitals are ready for them and whether they are ready for them. And particularly, say, in the eastern United States, about a third of all cities have about half or more of their hospitals at high risk of flooding from relatively weak hurricanes. And so when you think about resilient health systems to future health emergencies, putting our hospitals directly in a place where they're at high risk for flooding does not constitute that. And so there's a lot of work to think about how we think about resiliency at future emergencies. Disaster readiness. Herc and Sandy really brought that out as to how our ICUs specifically are going to be ready for future disasters. And how whether or not we have the capacity to surge, whether we have the capacity to evacuate patients, whether we have the capacity to move them to a different hospital based on accepting hospitals and politics and money and so on. All of these issues need to be thought about upfront to make sure our hospitals are disaster ready. Because there will be more opportunities for hospitals to be stressed, given the future crisis. Two years ago, or a year and a half ago in British Columbia, which is where I live, we had a heat dome, which I'm not going to explain the weather or the meteorology of that. But it was very hot temperatures for about four days. And Celsius works out to about 45 to 50 degrees in a place where that really experience was not present at all. Most of the houses were not air conditioned because it's the Pacific Northwest. We don't usually have these hot temperatures. And even though the weather forecast predicted this, the preparedness efforts were not there. Meaning that people weren't reached out to, there weren't appropriate cooling centers everywhere, and so on. And hundreds of people died. And thousands of people presented to the emergency rooms with various heat related problems within the span of about 48 hours. Typically elderly individuals, typically people who lived at home, who didn't have air conditioning, and so on. And so the ICUs were overwhelmed for about 48 hours of rapid surges of heat related issues. Were we ready? No. Could we have been better prepared? Yes, of course, with the prevention of the problem, with air conditioning, and access to cooling centers, and so on. But thinking about diseases that will happen more and more often going forward over the next couple of decades, heat related problems are going to be more and more often. This is Newfoundland, where I'm from, on the east coast of Canada. And this is after a hurricane just a couple of months ago. New infectious diseases. And so even after the disasters themselves, infectious diseases after these disasters are frequent. And they're going to become more common. And so making sure you're aware of which infectious diseases are endemic in your communities, and how you can respond to them accordingly. And then new ones. And so with climate change globally, you're going to see different vectors in different parts of the world that were not previously exposed to those vectors. And so dengue is the greatest example therein, where 20 years ago there was no documentation of dengue in parts of the world, which are now seeing it now in southern Europe, southern United States, and so on. Largely because as the mosquito vector moves upward with warming climate, we'll likely see different disease dynamics in different parts of the world. Are people ready for that necessarily? Not necessarily, in the sense that knowing those diseases are out there and preparing for them accordingly. COVID-19. Is COVID-19 a vector borne disease, or a zoonosis, or anything like that? Difficult to say. But we do know that the deforestation in the regions where it emerged are likely contributing to it having emerged in the first place. And so thinking about how we intersect with our natural environment relates to how we think about new infectious diseases. And now in the Pacific Northwest at least, we have a fifth season after summer, spring, winter, and fall, which is wildfire season, which usually late July, August constitutes large swaths of the forested areas burning. And that leads to lots of problems. Specifically, it relates to fine particulate matter. And more and more studies are emerging about the cardiorespiratory effects of those. And so if you look at where you live as it relates to your exposure of particulate matter, your risk of respiratory disease goes up proportionally, particularly if you're directly exposed to this. And so any respiratory disease, specifically, this is California data showing that obviously risk goes up with higher exposures to particulate matter, which is becoming more and more common. Even COVID-19, and this is a very cool study, showing they looked at particulate matter exposure during the wildfires in 2020 and basically used time-based data where they had COVID-19 data and COVID-19 death-related data and found a direct correlation between exposure to high levels of particulate matter, incidence of COVID-19 within those counties, and deaths within those counties. And so as we think about cardiorespiratory health and as we think about preventing patients from getting sick, particularly with new infectious diseases like COVID-19, you really have to think about those upstream causes. And so that causal pathway, more wildfires, increases in particulate matter, and greater transmissibility and severity of airborne respiratory diseases. And then acute effects of air pollutants directly. This is data from Thailand showing if you're exposed to seasonal air pollutants, you're going to have higher mortality. So not necessarily wildfire related, but just living in an area where there's higher levels of air pollution, you're going to have higher mortality. So once again, increased fossil fuel combustion, increases in particulate matter, greater rates of cardiovascular and respiratory diseases. So where is this problem? It's in North America, obviously. But the bulk of this problem is in places of the world where their exposure to air pollution with fine particulate matter is very, very high. And so North America, you see, and Australia, New Zealand, they're very, very white on that scale for very minimal fine particulate matter exposure. And that's including wildfire data. But if you look at places like Northern Africa, South Asia, East Asia, their exposures are substantial. And a lot of that is from fossil fuel combustion. And a lot of that is from something that we can modify with reducing fossil fuel combustion. Obviously, the end results of that lead to all of these problems. And so the heat waves that have emerged over the past number of years, specifically in Pakistan and India, where they're getting temperatures of upwards of 50, 55 degrees. And I can't do the math to Fahrenheit. I apologize. But thinking about how we as an ICU community need to think about the solidarity required with our colleagues around the world as they struggle with extreme, extreme heat and as they struggle to recover from historic flooding. Pakistan remains underwater in many parts of it, even floods that happened about five months ago. So when we think about ICU and whether my ICU is ready and can my ICU help, of course. Your ICU can help. And of course, your ICU needs to think about being ready. And a lot of these problems are political. A lot of these problems relate to advocacy that you and all of us can do, both at the local and global and national levels, to think about how to solve this problem. So remember, the code red for humanity, as Antonio Gutierrez said. But in the end, this is my Star Wars quote, rebellions are built on hope. It's important to think about the hopeful parts of all of this. This isn't just doom and gloom. There are people in this room who are thinking about this issue and thoughtful about this issue and are here in this talk and thinking about how to solve the problem locally and how to solve the problem globally. And it's through that sort of community that we really build these, quote unquote, rebellions. Lots of journals are starting to pay attention to this. This is the New England Journal saying, putting health inequity at the center of the climate movement. Countries are committing to resilient and low carbon health systems. Lots of protesters at the latest COP were calling for climate reparations and human rights, specifically as it relates to health. And so yes, there is signs of hope. And a lot of that hope is with that building of community that people have done around this issue, because they've all realized the importance of it and trying to really work together to solve it. So can my ICU help? We ran through a bunch of things. So working with your hospital suppliers for single use products, thinking about your environmental impact of your drugs, changing your choice of inhaled agents, advocacy for clean electricity, all these sort of smaller things, and then finding those people around you who can work on this project with you. I can't emphasize that enough. Doing things by yourself is hard, requires a lot of work, and requires a lot of sacrifice. Doing things with people around you who are commonly working towards a common problem is easy, or at least easier. And finding those people around you in your local communities is really important. And then really bringing our ICU skills to this fight. As I said at the beginning, we deal with crises. We deal with how to communicate, how to task manage, how to deal on acute situations. And I'd argue that the critical care community is kind of uniquely impacted by, but also can uniquely impact the climate emergency. We have these spheres of influence. We have our ICU, our hospital, people around us directly. We see them every day. We have our university. We have our institution. We have our community. We have our professional societies, like SCCM. We have our local politicians. We have our national politicians. We have global policies. We, in this room and in our community, have these abilities to influence these local folks. And thinking about how best to do that, obviously requires a lot of conversations and a lot of thought, but making sure that we really impact those things. I'm gonna near the end, a couple of cartoons. This is Earth fighting COVID-19. In the background, waiting for that, is climate change. We've struggled over these past three years. We've had a lot of challenges, a lot of death, a lot of dying, a lot of stress, a lot of strain, a lot of burnout, and acknowledge that this all is basically a warmup fight for the bigger one to come, and acknowledge that we all need to work together there. A Margaret Mead quote, never doubt that a small group of thoughtful, committed individuals can change the world. In fact, it's the only thing that ever has. So I'm gonna stop there. I've talked for the past 35 minutes or so. I'm happy to engage with you guys to think about what you guys are doing locally, what you think we need to do better as a society, as a community, as your local provider, or whatever, and any ideas that you may have that you're willing to share, because I think it's a great conversation to have to really think about how we can move this forward. I'll end with, this is the sickest patient any of us have ever dealt with, but I think we can still save it, and I think it requires, I underline that, the unique skillset of critical care clinicians. Thanks. Thank you.

climate change

healthcare

intensive care units

clean electricity

medications

anesthetic gases

preparedness