Greener, Cheaper Medicine: Surgeon, Spare That Clamp

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They’re shiny and sharp. They click reassuringly in your hand. You can twirl one like a six-gun or clip it on your coat. They have countless uses beside the ones for which they were made. But we have too many. And I just can’t throw them away.

Beautiful stainless steel clamps and scissors, clips and forceps are all over our house. In drawers, toolboxes, in my tacklebox. Disposable clamps, scissors and forceps that originally came in convenient plastic sterile trays, with a few gauze pads and a towel or two. They were handed to me in ERs to sew up lacerations, in hospital clinics to take out stitches or clean up wounds, sometimes even in the OR. Then I was supposed to throw them in the garbage. But I couldn’t. They were good tools. So I washed them, and took them home.

The throwaway surgical instruments I keep are stainless, meaning they will never rust away in a landfill. Though meant for only one use, they are fairly durable; I’ve had some for 20 years. The Pakistani disposables are not quite as nice as the Swiss and German “keepers” we use in surgery — if you’re using magnification you can see that the jaws don’t come together quite as accurately, they don’t have the wonderfully consistent springiness and perfect finish of fine surgical instruments. But they’re pretty darn good. I’ve taken out plenty of splinters with those forceps, cut everything with the scissors, tied flies with the clamps.

Iron is cheap, but how much energy did it take to mine and smelt the other expensive metals, like chromium and manganese, that are alloyed with the iron in that clamp to make it stainless steel? To ship and work the stock, to melt it, cast it, cut it, shape it, temper, polish, assemble, clean, package, sterilize, test, ship, store, inventory and then deliver it to the hand of any random doc who says, “Hey, do we have a hemostat?” I’m not exactly a treehugger but the waste of resources in single-use medical instruments is just plain ugly. Every doctor and nurse with whom I’ve talked about it sees this. But, like me, the medical professionals did not know who’s in charge of this sort of thing — nor who could stop it.

So I’ve asked around. The hospital purchasing people insist that they somehow save money buying disposables. The administrator intimated there’s a lot I don’t realize that makes disposables O.K. — but he couldn’t quite tell me what. It was an easy computer search to find out how much the throwaways cost. Just had to compare that to the total cost of reprocessing the keepers. So I went to the source.

The ladies in Central Sterile Supply were happy to discuss. Turns out that re-processing a non-disposable clamp is not so difficult. We send it downstairs to Central where they brush clean it, then wrap it in towels and put it through a cycle in a steam sterilizer, a machine that the hospital already owns and operates every day.

What would you guess it costs for the five minutes (max) of American labor that goes into reprocessing that keeper clamp, compared with all those offshore (and onshore) steps above — whose sum total costs are seen in the price my hospital pays? The ladies in Central told me what they are payed — it’s not that much. The electricity to run the machine? It’s running anyway. There’s the water and detergent, the brush, the towels to wrap it and the piece of special tape that turns color to show it’s sterile. Five dollars is the most I can see this all costing in any halfway efficient system. The disposable set? Anywhere from $6 to $30 when I search it.

Somewhere along the line the price of that disposable instrument will be added to America’s bloated annual health care bill. There will be, however, no public debate about Pakistani clamps. Probably not even a private one; administrators don’t take much purchasing advice from the doctors who actually use the stuff they buy.

There was similarly no debate when one of my hospitals announced it was spending $260 million (yes) on a new computer system. Even though we already have a computer system — and even though we already know from the actual experience of the hospitals that got the new system that it will take even more time away from patient care than the one we’re using now.

The environmental stupidity of throwing away a good tool after a single use is actually the thing my friends and I find more obnoxious than the excessive health care cost. But there is also no debate about our throwing all that polished stainless steel into bio-hazard landfill every day.

Getting doctors to agree on anything is like herding cats — we certainly do need professional leadership. But the vast networks of those who administer and regulate us have become too big and too powerful, out of touch with our mission and quite uninterested in taking “management” advice from clinicians. A practicing doc has no push-back. Yet we are particularly good at recognizing things going wrong — its our business — and every one of us sees the practice going one way right now: down.

Like overworked Cassandras, doctors feel helpless as our profession, our nation and our planet are degraded by bad decisions made at “higher levels.” Surely good people in other lines of work feel something similar. Surely it’s time to climb on up there, each, perhaps, with his or her own discarded Pakistani hemostat in hand, to stop the bleeding.

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