#9 | The sustainability of anesthesia with CRNA Kelly Pucillo (Part 1)

Today, we have a very special episode for you with our #1 fan. (And please pardon the hammering that would not stop in time for the start of this episode. Construction on the weekends should not be allowed.)

Sadly, Hannah could not join us for this one, so I (Brandee) am flying solo. Well, not quite.

In today’s episode, I have a very impromptu chat with Kelly Pucillo, one of my closest friends, about healthcare and the sustainability struggles she faces as a CRNA (Certified Registered Nurse Anesthetist). 

We’ve been friends since nursing school, so while I have close to zero knowledge of anesthesia, we dive into the good and the bad of the anesthetic gas desflurane, the environmental impact of convenience, and the ever-present underlying theme of awareness and intentionality when it comes to sustainability.

So hit that play button and stay tuned for part 2 of this chat (all about sustainability and motherhood) in two weeks!

Links and resources:

#3 | Is plastic really that bad?
Desflurane
Methane
Environmental Implications of Anesthetic Gases
History of Instrument Sterilization
Joseph Lister, the Man who Sterilized Surgery
Sterilizing Practices
Why you shouldn't buy a plastic cutting board
What is a staphylococcal infection?
9 ways to cut down on medical waste
People, planet and profits: the case for greening operating rooms

Transcript

Note: This transcript is mostly unedited.

Brandee   0:04  

Hello and welcome to the tea on sustainable living podcast where your hosts, Hannah, and Brandee try and help each other navigate the big messy gray area of giving a shit about the planet and hopefully helping you along the way. Each episode we have honest chats about our sustainability fails, sometimes amongst ourselves and sometimes with guests, while also leaving you with a little sprinkle of hope and inspiration to keep on giving a shit. So go make yourself a cup of tea, get comfy, and let's dive into the episode.

Hello, Give-a-Shitters. This is Brandee, 

Kelly  0:36  

and Kelly. 

Brandee   0:37  

And you're listening to episode number nine of the tea on sustainable living podcast. So today Give-a-Shitters we have a special episode for you with probably our biggest fan Kelly, my friend from nursing school since nursing school, she always sends us sends me voice notes right after like an episode has gone live like letting me know your thoughts, which in the future, I think I will figure out a way to accept other voice notes and like maybe feature them in like future episodes. I think that would be really cool to like have it on a podcast and like, Have other people send voice notes. Sadly, Hannah is not with us today. She's moving house. And it's been so hard schedule wise to get the three of us in with the different time zones on Zoom. And I woke up sent Kelly or responded to a message from Kelly and then all of a sudden it was Hey, want to record a podcast. So here we are impromptu. And maybe in the future, we can get you back when Hannah is on. And yeah, welcome to the podcast.

Kelly  1:32  

Thank you for having me.

Brandee   1:33  

So yep. Today we'll talk about our sustainability struggles like we usually do. Our original idea was to have some sort of episode centered on motherhood and sustainability because I'm not a mom and is not a mom. Kelly is a mom. So we thought that would be a cool, like dynamic to have on, which we'll touch on. But that's not necessarily the central theme of the episode. And because it's so impromptu, sadly no tea time today. I'm drinking coffee and you're drinking something coffee. Yeah, it's another coffee episode. So apologies. Give a shooter's we'll have a tea time in the next one. Hopefully.

Kelly  2:09  

depends on the time of the morning.

Brandee   2:11  

Yeah, that's true time of the day. So seeing as how this is impromptu Kelly is actually at work. She is a well, I'll let you take it over. Tell tell the listeners a little bit about you. And yeah, the main thing that you wanted to talk about today,

Kelly  2:27  

hello. So I'm Kelly Pucillo. I live just outside of Philadelphia were very close to where I'm at Brandi. And I work in inner city, Philadelphia at a children's hospital, which I love so much. But we had initially like talked a lot about how being a mom kind of changes your like your thoughts on sustainability, and, you know, trying to protect the planet for your kids and how to be sustainable as mum. But then I was also thinking this morning about how terrible my job is for the environment, because I specifically am a nurse and anesthesia. So we were talking about that.

Brandee   3:15  

And I kind of I met in nursing school. So I was a nurse for a few years. And I think we touched on it in hand and I touched on it in the plastic episode that the waste that comes with working in healthcare and especially with the pandemic and more disposable personal protective equipment, etc, etc. And it was like a maybe a brief chat about how Yeah, maybe that's not the area we should focus on. Obviously, health is important. But Kelly brought up a good point that I hadn't thought about, of another very unsustainable aspect of health care.

Kelly  3:44  

So I am a CRNA. So a certified nurse registered or certified registered nurse anesthetist. And so basically like, it's not a thing and like all across Europe, and some places it is but essentially here, an anesthesiologist will over see three or four CRNAs. So I work inside of the operating room doing all the things with the patients and then an anesthesiologist is there kind of in a more managerial role. We talk about it a lot. We have an anesthesiologist who is like very involved in sustainability and the she just like loves all things environment and like researches it and is really good about all that stuff. And we talk about it a lot that like we generally work with four different anesthesia gases. And in our role in anesthesia, we obviously have to keep people asleep because that's like the primary goal. So we do that with one of these for anesthesia gases. However, the way that our equipment is set up is to get the gases out of the operator room, because obviously we don't want to make the staff fall asleep to do that would be bad at that, that would be really bad. So the way that we do it is there's like a vacuum essentially on the back of the anesthesia machine that brings it to a pipe that allows the anesthesia gas to exit through a pipe in the roof of hospitals. And so the gases just like go into the environment. And so in places like Philadelphia, where there's a hospital, like every four feet, apparently, our ozone layer like is being like, wildly affected by the fact that there's so many functioning operating rooms, and all of this gas just, it just gets disposed of in a way that's like we got to make the hospital and the operating room safe, it doesn't get disposed of in a way that's like we got to make sure the air in the atmosphere everybody else living in Yes. And so that's how all hospitals function like across the world is like they just have pipes on the top of their roofs that allow these vapors into the atmosphere. And it kind of wasn't that huge of a big deal. Until one of the anesthesia companies made this one called does fluorine, it is honestly like a miracle anesthesia guess like it's so fun to work with. Because it keeps the patient really asleep very well with very minimal use of gas like it doesn't use a lot. And then as soon as you turn it off, the patient is able to breathe it off very quickly. Like most anesthesia, gases re metabolize into like your fat and your muscles. So it takes a long time to breathe it off. And depending on like how musculature or how much adipose tissue you have, it could stick around for hours, which isn't good for the person. So this does fluorine medication like anesthetic is is fantastic for the patient. However, it's apparently extraordinarily detrimental to the environment, like it's not good for the environment. And there's all this talk that we have to recreate how we're disposing of anesthetic gases, because it's like really thinning the ozone layer. Oh, wow,

Brandee   7:26  

that when you're talking that made me think of methane, how everyone's talked talks about carbon dioxide, the methane is so much more potent, and I don't think it sticks around as long but it's with the amount of you know, factory farms, you have not a cows that we've that we brought into existence for our purposes. It's so much more potent, damaging.

Kelly  7:45  

So that's how, and it kind of seems, again, like I haven't personally done the research. But this answers out of who's extremely knowledgeable like she grew up was born in Iran lived in Sweden, which I feel like she learned all about being sustainable in Sweden, because, you know, Europeans seem to care more than Americans do. And then she moved to California, which is like, I feel like the most sustainable of all the safe. So she just has this not East Coast mindset about her. So she has actually kind of taught me to only use does fluorine with patients that it would like, you know, like with morbidly obese patients, where you really don't want your anesthesia gas to re metabolize through all of their adipose tissue, because that could genuinely be unsafe for the patient. So we really like it's kind of a push in our department to not use Dez as much as would be safe for the patient. Because when I tell you like it really does cut down operating room times, which if you work in the hospital, hospitals are businesses. And although we're like doing, like good for the community, it's still at the end of the day business. And so time in the operating room is like a thing that's talked about a lot like every minute you spend in the operating room the patient spends in an operating room is like hundreds of dollars, and they want to cut costs in every way possible. They being like the administrators don't do medicine, but control medicine. They always want to cut operating room time. So things like desflurane are pushed a lot because they cut operating room time. So our kind of push with this one as he's out as she's educating us all has been to like, do what is safe for our patient. Obviously patient takes priority, but then be very aware of like, what our impact is in a place like Philadelphia that has dozens of hospitals, and probably hundreds of does fluorine vaporizers and so we tried to like kind of balance it. I know I've stopped using it nearly as much as I used to. Just because I she told me

Brandee   9:59  

I know it's like when you hear something and then it's like, then that voice is in the back of your head the next time you go to do it, you're like, oh, oh, maybe I should do it a little differently. No, but I'm really interested in what like the stats would be if there are stats on that, if I'll do a brief research, I'm not going to try to write like a scientific research paper on it. But I'll see what I can find like a quick Google search and include in the show notes, just for reference for people who are completely unfamiliar with what we're talking

Kelly  10:23  

about. There's a lot okay, there's a few good like senemo wrinkles. Apparently does. fluorine has a 10 year lifetime a sphere compared to ISO fluorine, which is a different one, that is 3.6 years, and then Siva fluorine, which is the one we use, like the most frequent, that has 1.2 years lifetime in the environment, okay, as your favorite drug sticks around a bit longer, like, over three times as much as the other ones. So it's super bad for the bad, like, really bad for the environment, wonderful for patients, really bad for the environment, which I feel like is the theme in hospitals.

Brandee   11:04  

I feel like even a broader theme of like, balancing what, whether it's good for people and bad environment or not, that's not what I want to say, whether it's improves people's lives, convenience, versus the effect on the environment, like there's always like a balance.

Kelly  11:21  

Yes. And I also like we recently switched to, they're called blades, they're not actually blades, but we use this this tool that helps us intubate people. It's like a big tool with a flashlight on the tip of it. And we just switched to disposable ones, which kind of put like a wave of First of all, we are healthcare providers, we are all type a human being. And we do not like change. So that's like, really number one. So if you change any equipment on any of us type A personalities, like there's always a wave of issues, I feel like especially with surgeons, oh surgeons, anesthesia providers, oh my life, we are not gonna change. So like that is a personality flaw, but like I can see in myself. But it was funny because a whole bunch of anesthesiologist who like no offense, but just don't really have like an inside scoop on how their brain works. kind of took this stance now they've never taken the stance ever before and their whole lives. But they took the stance of like, these are really bad for the environment. You just use them once and throw them away. And I was like, you've never you have never spoken about the environment. You eat lunch on the cafeteria every single day on styrofoam plates with plastic forks, like I've never

Brandee   12:42  

hurt and like how many gloves have they gone through?

Kelly  12:45  

Oh, it Yeah, something like I don't, you don't actually care about the environment like that your tools were changed. But they do make a good point that like these tools, which we used to have metal ones with metal handles that used to get reprocessed and sterilized and repackaged and given back to us have now been replaced with disposable ones. So one time use and you throw it away, which on one hand, I'm like, like if you talk to people who worked in health care, like 50 years ago, like they used to have reuse masks, they used to reuse like nasal cannulas. They used to like clean and reuse almost every single solitary thing that we now would frequently throw away like I could never imagine taking like an oxygen device that goes over somebody's face, cleaning it and putting it on another individual's face. But it was like common practice back then.

Brandee   13:46  

I want to change because of convenience or like research that it wasn't like the most clean.

Kelly  13:51  

Will. So that's why like, I don't know, my thought process is is that like I presume that it's because it couldn't have been clean? Like you're sticking things on people who are in the hospitals face. They're not in the hospital because they're healthy and well. And then you're like, who knows who's cleaning it? Who knows how long that they get cleaned for? Was there a specific protocol for how they get cleaned

Brandee   14:16  

up because there are still things that are like cleaned? When I say clean? I mean like sterilized, sterile and clean or not. Yeah, same thing in healthcare. So if there are certain things that are properly sterilized, they're still used, like sculpt. Like, I don't like sculptures and stuff. Yeah, yeah. Yeah, so I wonder like metal material.

Kelly  14:34  

Yeah, can easily be sterilized and reused, but I'm talking they used to reuse like plastic and rubber stuff. Yeah. Yeah. Which I don't know.

Brandee   14:43  

Plastic is yours unless I'm mistaken. Like, yeah, like plastic cutting more. They say don't put certain things on there because it'll absorb and that's not Yes, not very safe. And just

Kelly  14:55  

and I also think it must have been that it was getting dangerous or like It was unsafe for people, because there's no way hospitals would spend more money on stuff that's like you have to buy more of disposable things. And just like, baseline hospitals don't want to buy more things.

Brandee   15:11  

Yeah, but I also wonder what like the process and involved in like cleaning and sterilizing is like the resources involved in that. Like, how is that compared to like getting getting new stuff, but especially today with like, plastic being so cheap? It makes sense. Yeah, that convenience would also play a role in it. But yeah, like I'm, I'm all for it. If there's if it's like safer, cleaner. Yeah, go for it by the disposables. If it improves patient, patients will be

Kelly  15:38  

yet like, even as far as syringes for medications, like there's a big like, ONE syringe, one patient campaign that's been going on for the last 10 years. Because it was before the 1980s. This what I do actually know like what the history of it is, before the 1980s, it was not unusual for a nurse or doctor to use the same syringe over and over and over again, thinking if they change change the needle hub that they weren't transmitting anything. So they would use like the same syringe for the same medication on different patients. And then like HIV broke out in the 80s. And we know how that was handled really poorly. But one of the things that was looked at was like how health care providers, our health care providers were a big part of transmission of HIV and hepatitis because of how they were reusing materials. And one of the materials that they kind of pinpoint was the reusing of syringes. So now it's one syringe, one patient gone, which, like we graduated nursing school in 2011. So to me, I'm like it, I would imagine you're standing at a clinic and somebody gets a flu shot next to you and they like take off the needle and then come at you with this it like you would freak out in the 21st century be like Get away from me, you're just yesterday.

Brandee   17:04  

Oh, I think I told you my experience getting the COVID vaccine in Spain, I went to get it and they didn't like clean my arm with an alcohol swab first before injecting it and it exactly. I remember I left thinking okay, well, next time, I'm good to bring my own alcohol swab and just cleaned my arm really quick. Because in I mean, in the states in nursing school and working in hospitals, like you, you don't like break the patient's skin without, you know, sterilizing it first cleaning it like when an alcohol swab or other material or other oh my god, or sorry, wipes. Yeah, thing depending on what you're doing. And then I thought more about it was like, Well, why do we do that? Like, is there? I mean, in nursing, they talk a lot about evidence based practice. But I feel like sometimes that's not always the case. Sometimes it's like, why do we do things, like for example, tangent length, turning off a patient's two feet before laying them flat before boosting them up in bed. Two seconds before you lay them flat. The idea is that they're that they're what's in their stomach will come back up and they'll it'll go down there. But they didn't when I did that fast. Exactly, you would have to pause it 30 minutes ahead of time. Anyways, so I thought more about this alcohol swab thing is cool. Maybe it's like not really a thing because like the needle so tiny. So what are the odds of you like it like pushing some path, that bad pathogen into your, like, into the blood? I don't know.

Kelly  18:21  

Well, and also I feel like the only time that would be so staff lives on your skin, but we literally eat staff, we it's like we have to be our bodies has to be comfortable with staff, right? Like, because it lives all over the surface of our skin. So if you were to like, accidentally give like an intravascular, like inject a vaccine into your blood vessels, which would also not be great. But like, maybe I can understand not wanting to have because if you think about it, all alcohol wipes do is clean the surface of staph off of that part of your body. But then you think of I think about all this like, I don't know, I could go down this lane.

Brandee   19:04  

Yeah, I think when you get an injection like a COVID vaccine, or most vaccines is in the muscle. And then how we were taught in school is to kind of like you're supposed to like draw back a little bit, make sure you're not accidentally in a bloodstream. I haven't experienced anyone doing that in Spanish, because I think the odds are so low. So the likelihood of it happening is so low. I wonder if there was a case at some point that it happened so that like change the rules for everyone.

Kelly  19:30  

Meanwhile, in the United States, we alcohol swab before giving an IV to somebody receiving the lethal injection, because that is how foul Wow. Which just makes me laugh.

Brandee   19:44  

Yeah, that can be a whole other thing.

Kelly  19:47  

I just think that that's like in a state and they're like, Yeah, you can get this flu shot without it. And in America, they're like, just going to make sure the guy getting the lethal injection doesn't sue us. world we live in what America is just a weird place. Like I love it. But

Brandee   20:06  

it's a weird place because it's such a massive country, but it's really a collection of 50 small countries.

Kelly  20:13  

Yes. Oh, yeah. And none of them agree with what it honestly like. It's every single one of them has a different personality. So,

Brandee   20:24  

yep. And we won't get into all the current legislation happening and, and several of them. Anyway, before we go off on, is there anything else you wanted to touch on about healthcare anesthesia?

Kelly  20:38  

I don't think just like, I find it to be, as with the gray area that you can always talk about. It's just a constant gray matter in my life gray area in my life of like, would this patient benefit from this? Or am I doing something more convenient for myself, or even as far as like I work with airways. And something that like I think about regularly, I work in a hospital that doesn't have a lot of money, it doesn't have a lot of resources, it's in an underfunded part of the city. So like, just as far as like saving resources for the environment, and saving resources for this community are pretty important parts of my daily setup. But there are some cases where I know the patient's not going to tolerate our medications very well. Or like I know the patient is like super unstable. And so I open up all of my like an A tracheal tubes and emergency airway stuff ahead of time, because I want to make sure that I don't waste a second opening a package. But then afterwards, if I don't, if I use it, and it's like, it really did go poorly, and I really didn't need everything that I opened, then I'm like, Oh, well, thank God, I was prepared. But if it doesn't go poorly, and I have all this open medical equipment, then I always feel so guilty. I'm like, oh, man, but then I then I think like, if it was my kid under anesthesia, I would want them to be super prepared, because screw the environment, if my kid doesn't survive this surgery, and there's the gray spiral. And there's the gray spiral where I go, like, I don't want the anaesthetic to go poorly, and US need the emergency airway equipment. But I don't like don't want to be not prepared, because every second matters when a person is not tolerating an anesthetic.

Brandee   22:38  

Yeah, I think that's the key own it is that it's someone's life, and you have a reason for it. You're not just doing it without thought. And I think that's yes, that is, but it's a struggle thrown away. Like for endotracheal tubes.

Kelly  22:52  

A man like, I'm like, Oh, this so bad.

Brandee   22:57  

How many times would you say out like that you end up like one out of five, one out of 10 that you end up in? Like needing it?

Kelly  23:03  

I would like I always open up like four different options for like a neonatal ICU kid. And I would say like 10 to 20% of the time we actually need it. Because we probably are I think even if it's one out of just 111 year yeah, just one guy not out of anything that like yeah, those second one little tiny baby. Yes. Yeah, that's Yeah. And they have no, it's the it's the issue of like, they have no reserve. If you have like a premature one kilo baby. Like we just have everything ready. Because you have no time to open supplies or find supplies. If a one kilo baby starts to like, cycle the dream, baby, you just want to die, which is a good cycle into motherhood. But babies are just like a whip to die. I don't know how humankind has really gotten this far. But like, equipped to die. Um, so yeah, just get everything prepared. And then I apologize to the environment and mother nature what I'm throwing it all the way at the end because we were really good at our jobs.

Brandee   24:15  

I mean, yeah, I wouldn't beat yourself up over that you're doing it with intention, with the intention of saving, saving a life. And I think that's kind of my conclusion. With healthcare in general. If you're there's like a reason behind it and intention, which hopefully is, you know, helping people live healthier, longer lives. But I think if you're just doing it for the sake of convenience, or if there's no research, there's no thought behind it. Like I think that's the difference. So yeah, healthcare for me as far as sustainability and like waste, whether it's the medications, the gases, the materials. I'm sure there are ways to improve it, but I don't think that's where, I don't know. That's where the bulk of people's time and energy should necessarily be going when I think there are other things that are more

Kelly  24:59  

like rocket ships to space? Yes, exactly.

Brandee   25:02  

So, as we're talking and I know you have you do have some more time I think this would be a great episode to split into two parts. So this is probably where I will start to introduce some music and fade out and conclude this episode and then we will Yeah, transition into motherhood. Thank you so much for listening to this episode of the tea on sustainable living podcast.

Hannah  25:26  

If you made it to the end, we can only assume that you've enjoyed this episode.

Brandee   25:30  

Please consider sharing this with a friend or family member who could use some support on their sustainability journey. And find

Hannah  25:36  

Find us on Instagram at the tea on sustainable living and let us know what you liked about the episode.

Brandee   25:42  

Alright, Give-a-Shitters, tea you later. Get it? Tea you later? As in, see you later? So punny.  

Hannah  25:48  

Whyyy?

Transcribed by https://otter.ai