Hearing of environmental anxiety and distress, global warming and the implications of human activity on the world is common (Ojala et al, 2021). However, it is reassuring to have this concern surrounding the environment's health and sustainability.
With extensive publicity in the news and other media, it seems that, on an individual level, people are becoming aware of their actions and the potential repercussions of these (Ojala et al, 2021). Whether it's opting for reusable alternatives to single-use plastic items such as coffee cups and shopping bags or perhaps being travel conscious, such as driving less and walking or cycling more, people have been adopting a sustainable lifestyle.
However, large corporations such as the ambulance service, as well as healthcare organisations in general, still appear not to be following this trend (Spruell et al, 2021).
Individual experiences have swayed the author's perspective in line with striving towards environmental sustainability, most notably when moving from rural areas in Yorkshire and Cornwall to central Oxford. There are great discrepancies in how people live and in their attitudes and beliefs when it comes to holding themselves accountable for the environment (Steffen, 2021).
What is environmental sustainability?
This article discusses environmental sustainability in the context of paramedic practice through a literature review. This section will give the background to ensure a full understanding of the topic, which will then be explored further.
The term ‘environmental sustainability’ is often found in the context of human activity and the impact it has on natural systems (Morelli, 2011). However, this term appears to be uncommon within paramedic practice and in emergency care in general (Morelli, 2011).
The word ‘environmental’ concerns a broader perspective, such as for the ecological systems surrounding physical life rather than one's personal environment (Morelli, 2011; Place, 2018).
The drive towards eliminating the repercussions of any activity that could otherwise have a lasting negative impact is in line with sustainability; it is the practical implementation of values and understanding that has a lasting, positive effect (Costanza and Patten, 1995).
It can be argued that this has substantial relevance in our modern world, as the climate crisis is ever growing and requires rapid action against its development (United Nations, 2022).
In the context of this literature review, environmental sustainability contextualises the objectives that can be implemented to ensure paramedic practice has less of a negative impact on the natural world.
Relevance to paramedic practice
Emergency care is heavily relied on worldwide, with nearly 3000 critically ill people (category one) conveyed to hospital via emergency ambulance in the UK daily (House of Commons Library, 2025). On average, almost 50 000 people were admitted to accident and emergency units each day in one year, whether they were referred by themselves or a health professional or via ambulance conveyance (House of Commons Library, 2025).
This gives an understanding of the colossal impact the ambulance service has on the environment as a result of the thousands of miles driven, single-use plastics discarded, medicines wasted as well as medical equipment used improperly, perhaps in anticipation for use only for the care plan to be altered (Hazell and Robson, 2015). Given this, paramedic practice has a great role to play in caring for the planet and its environmental health.
Arguably, the greatest offender in this disregard for human activities' impact on the natural environment in Europe is the UK's NHS, with approximately 133 000 tonnes of single-use plastic discarded in a single year (Percival, 2021). In addition, a total of approximately 200 000 tonnes of recyclable materials are taken to landfill rather than properly recycled or repurposed (Nichols and Richardson, 2011). This accounts for 80% of the NHS's total wastage in one year (Nichols and Richardson, 2011).
This is only physical waste; a further 20 million tonnes of greenhouse gases (GHG) were emitted in a single year in the UK, largely contributed to by the NHS (The King's Fund, 2021). This is most notable in areas of emergency travel and inhaled analgesics (NHS England, 2021).
This environmental strain was highlighted at the UN Climate Change Conference of the Parties (COP26) held in the UK between October and November 2021 (UN Climate Change Conference, 2021).
With global concern for the environment's health becoming a popular topic in the media and conversation (World Meteorological Organization, 2021), it is arguably strange that environmental health legislation did not immediately follow this surge in ecological health concern.
Legislation, practice and understanding
The author noted, through initial research on the topic, that legislation surrounding environmental sustainability in the ambulance service is hard to come by.
The UK government has released details of a consultation on environmental sustainability regulation; specifically, section 71 of this document displays details of how emissions can be reduced in the public health sector (Medicines and Healthcare products Regulatory Agency, 2022). However, the document's relevance to active change is minimal as there has been success in avoiding full implementation. In the last 50 years alone, the decline in the natural environment's health has been abundantly clear (Thompson, 2020).
The first Earth Day took place on 22 April 1970, serving as a reminder to celebrate the environment and to become more conscious of one's surroundings (Thompson, 2020). Although this is an annual, optimistic event, it ultimately failed to prompt any radical change. The recommendations place emphasis on individual changes, rather than on those that can be made by companies, corporations and governments, which likely impact the environment the most.
Methods
Formulating a research question and literature review
The population/problem, intervention/issue, context and outcome (PICO) framework is a widely used and valuable tool that assists in formulating research questions. The PICO process was used to develop the most appropriate research question (Eldawlatly et al, 2018) Appendix 1 (online): ‘can sustainability and paramedic practice coexist?’.
Keywords
For this literature review search, terms were chosen to identify the most relevant documents and research (Phelps et al, 2007).
Inclusion and exclusion criteria
Comprehensive inclusion/exclusion criteria were developed to ensure this literature review had relevant papers to analyse and discuss. Many inclusion and exclusion topics can be chosen, and precise search results allow the author to access the exact documents that will be relevant to the chosen topic (University of Melbourne, 2025).
The criteria include dates, areas of study and availability. By setting criteria, relevant papers of a high quality were found. Duplicates were removed.
Relevance is central to this literature review as the concepts of natural environment decline or environmental sustainability are relatively recent, with comprehensive research documents appearing to date back approximately 30 years (United Nations, 1987).
In this instance, inclusion and exclusion criteria presented certain barriers; this topic is so sparsely discussed that the author constantly reviewed and compared documents before the final review, which potentially created bias (Mare, 1992).
In spite of this and in recognition of selection bias, the author selected documents of varying topics, including those providing conflicting answers to the research question.
Ethical considerations
By only using documents that had previously been approved by an ethics committee or where the researcher had confirmed there was no conflict of interest, this entire document can be deemed ethically appropriate (Kara, 2019).
Databases
The author primarily employed the following databases for the study: the Allied and Complementary Medicine Database (AMED), British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), EMCARE, Health Management Information Consortium (HMIC), MEDLINE and PubMed.
Results and analysis
Following the search strategy previously described, six core studies were identified for their relevance to emergency paramedic practice. These papers were subsequently critically appraised and analysed.
The papers were predominantly qualitative studies, mixed-methods reviews, quantitative studies and life-cycle assessments. Results were collated to answer the question: ‘The environmental impacts of emergency care: can sustainability and paramedic practice coexist?’.
Six key papers were chosen for their consistency in exploring the theme of environmental sustainability in conjunction with emergency care. These were Ryan et al (2010), Dunphy (2014), Unger et al (2017), Sherman et al (2018), Sangkharat et al (2019) and Baid et al (2021). These papers were then appraised.
Thematic analysis
To identify themes throughout the six papers, the author analysed each study and carried out a comparative study to ascertain if themes arose from more than one paper. Reading and rereading the literature identified clear themes (Braun and Clarke, 2006).
The thematic analysis identified four pervasive themes: professional opinions on sustainability in healthcare, the impact of single-use plastics on the environment, greenhouse gas emissions in prehospital care, and the use of plastics in healthcare.
Discussion
Dunphy et al (2014) discuss health professionals' moral standpoint on the topic, while Sherman et al (2018) argue that there is a direct correlation between GHG emissions and single-use plastic medical devices/tools and a deterioration in the natural environment.
However, one study asserts that there is no direct correlation between emergency care and sustainability. Instead, it discussed the implications of GHG and physical health implications to service users, which could lead to an increase in ambulance journeys. It can be argued that a rise in GHG and air pollutants causes further emissions, as people in the UK whose health is damaged by them will require out-of-hospital emergency care.
Healthcare professional opinions on sustainability and healthcare
Within the two documents that concern health professionals' opinions, it is increasingly apparent that the general consensus is that sustainability in emergency care is not a topic that is accessible, as it is not frequently discussed by practitioners and many do not see it as relevant to their practice; instead, it appears to be more of a concern for those at higher board and corporate levels in healthcare (Dunphy, 2014; Unger et al, 2017).
In line with this, cost is an important factor when considering the environmental impact of healthcare, arguably the most significant. While the NHS spends approximately £176.4 billion a year (The King's Fund, 2025), a breakdown showing expenditure on sustainable healthcare is not given.
Given this, the personal accounts of staff are more pertinent as they contend with initiatives such as a Greener NHS (Timmins, 2021). There is an overwhelming sense of wanting to take action against the climate crisis present in these two studies (Dunphy, 2014; Unger et al, 2017). Potential for resistance from governing bodies can however make individual action feel almost irrelevant – but this should not sway individuals from making small efforts as they can in fact make a great cumulative impact (White et al, 2020).
The discussion at hand reflects the UK's contribution to environmental instability. Although Dunphy's (2014) study examines only Australian professionals' opinions, it can be applied to the UK as healthcare systems in the UK and Australia are similar (based on population, national income and annual healthcare budget) (Dhaliwal, 2018; Office for National Statistics, 2021; 2022).
The application of this understanding is further supported by a 2025 study of health professionals in Europe, which found that 70% of almost 500 participants surveyed had seriously thought about improving environmental sustainability in emergency medicine (Grannemann et al, 2025).
Impact of single-use plastics on the environment
There was an expectation before the background research was carried out and the literature appraised that plastic, especially single-use plastic, would be a huge factor when discussing sustainability in healthcare, mostly regarding its environmental impact.
Background research showed that approximately a quarter of healthcare waste produced in the US and the UK is plastic (Gamba et al, 2021). The literature suggested that reusable medical devices could be used (Sherman et al, 2018). Unger et al (2017) and Sherman et al (2018) contain valuable information, research and suggestions for environmental and sustainability improvements that could be considered by ambulance services not only in the UK but also worldwide as well as by companies and charities for improvement. Such suggestions could also be made at the Climate Change Conference of the Parties and to the Greener NHS programme (NHS England, 2021).
One way to address the overconsumption of single-use plastics in healthcare would be to consider the use of autoclaves. These machines are still used in hospitals to this day but are costly and inefficient in terms of water, time and energy as test tubes are sterilised one a time.
Thus, use of an autoclave instead rather than single-use plastic products may be beneficial if used effectively but may also be harmful to the natural environment by way of creating external pollutants, which are a bioproduct of non-renewable energy, in water sources local to the medical facility (i.e. fossil-fuelled rather than natural energy sources such as wind or solar).
Greenhouse gas emissions and emergency prehospital care
The amount of GHG in the atmosphere as well as the rate in which they are rising is exponential and has a great impact on every aspect of human activity (British Geological Survey, 2025). Unhealthy ecosystems, no matter the size, are destined to fail.
In addition to preconceptions of GHG, such as global warming and declines in air quality, it was found that they cause not only an increase in atmospheric decline, but also natural disasters owing to unpredictable weather (Nunez, 2019).
Acute presentations can arise as a result of GHG that would not be experienced otherwise. These include strokes and myocardial infarctions, as atherosclerosis is more likely to develop in areas of increased ambient air pollution (Sangkharat et al, 2019).
This could be seen as an incentive to take action against the climate crisis and implement sustainable practice into personal and professional lives. However, this has yet to be seen successfully applied as has found in the studies examining GHG impact and emergency care (Sangkharat et al, 2019; Ryan and Nielsen, 2010). This is a particular concern in light of the hypothesis that as more emergency health crises occur, more emergency ambulances will be dispatched, causing more damaging GHG to be emitted into the atmosphere and the cycle continues.
A clear finding was given in Sangkharat et al's (2019) study of air pollutants' impact on ambulance dispatches. In 2013, South Central Ambulance Service added 30 ambulances with solar panels to its fleet. Although the ambulances were not entirely electric, during points of standby they would not have to run idle to maintain internal equipment such as defibrillators and electronic patient records systems (BBC, 2013). This is a cost-effective step towards slowing the climate crisis and being more environmentally sustainable in emergency healthcare. Yorkshire Ambulance Service followed suit a year later, with 175 ambulances of the same type being added to its fleet (Brindusescu, 2014). It is hoped that developments of this nature will continue.
One of the most overt findings, which applies specifically to emergency care, is the use of unnecessary gases when attending patients in pain. Ryan et al (2010) found that nitrous oxide as a carrier gas for other anaesthetics increases the environmental impact as it has a 114-year atmospheric life, which has been somewhat dismissed by ambulance services as the impact is only realised long term (Ryan and Nielsen, 2010). Owing to the lack of time experiencing these effects and the fact that only hypothetical arguments can be made from current research regarding the positive correlation between GHG and global population health, it is not conducive to a budget well spent. It may therefore be dismissed in favour of more pressing matters such as progressive implementation of equality and diversity in healthcare (Coghill and Naqui, 2019).
The data show there are valuable lessons to be learned in emergency health care; there is potential to overhaul how emergency healthcare is delivered. Although neither Ryan and Nielsen (2010), nor Sangkharat et al (2019) explicitly discuss cost as a hindering factor, it is evident from the findings previously discussed in this literature review that a reassessment of budgeting could have a great impact on the planet's atmospheric health.
Further to this, low-flow nitrous oxide is arguably less impactful than high-flow, yet in emergency care there is no control over the amount administered in a single dose. Moreover, Greener NHS acknowledges the use of medical gases to be incongruent with long-term sustainability, in line with the findings in Ryan and Nielsen's (2010) study.
A shift in inhaled prescriptions is now taking place as GPs are advising patients to swap from metered dose inhalers to dry powder inhalers, which will greatly reduce the carbon footprint of non-emergency care. This move could be seen as having potential in emergency care (Asthma + Lung UK, 2023).
The use of plastics in healthcare
Plastic has had a prominent presence in modern history. It was developed to provide alternatives to naturally occurring polymers (such as those in silk), to phase out materials such as ivory and provide durability to everyday products, such as car parts and kitchenware (Obermeyer, 2021).
Nowadays, single-use plastic plagues the modern world in a myriad of ways alongside standard plastic. Before the early 1960s, single-use plastic would have been considered unimaginable as standard plastic was (and still is) durable. To create a shift in consumerism, single-use plastic was phased in with the rise of convenience (Miodownik, 2025). This inordinate shift leaked into every corner and soon single-use plastic was everywhere: supermarkets, cosmetics, hospitals and, most notably for this review, in emergency ambulances (Obermeyer, 2021). As with the theme of single-use plastics' impact on the natural environment, Unger et al (2017) and Sherman et al (2018) found the most commonality in this theme.
Reusable plastic, although having a large carbon footprint from manufacture, has some benefits (Joyce, 2019). This is especially in areas such as emergency healthcare, where items made from it are built to last and can withstand multiple uses (Ducharme, 2021).
The studies analysed are honest and detailed in their approach, with data that support realistic changes to the use of plastic in healthcare. A suggestion made after data analysis found that, in terms of cost, reliability and effectiveness for medical practice, reusable medical devices are better than single-use plastic in nearly every aspect. Ideally, these devices would be metal or completely recycled plastic to ensure the impact on the environment is not outweighed by initial manufacturing (Sherman et al, 2018). Two countries were assessed in these studies, one of which – the UK – is ranked for recognisably efficient and advanced healthcare.
Despite their differences, data in Sherman et al (2018) and Unger et al (2017) studies correlated so there are sustainable alternative symmetrical devices available that could be implemented. Arguably, it's a question of when, not if; the climate crisis is rapidly becoming more serious, changes have been developed and could be used to positively affect the natural environment.
The conjunction between sustainability and emergency prehospital care underpins the argument that development in environmental sustainability should be at the forefront of all healthcare providers globally. In addition, there is a clear correlation between plastic use and GHG emissions into the atmosphere (Unger et al, 2017).
Because the studies analysed had large teams, reducing the likelihood of bias, and the clear direction and evaluations they included, they can be relied on for direction when implementing sustainable change in emergency health care. While the studies are not all specifically about paramedic practice, owing to the crossover in the use of medical devices in both hospital and ambulance settings, it can be acknowledged that the data and findings are universal.
All four themes individually highlight areas of prospective development within emergency care in order to achieve environmental sustainability. The scale of their impact shows there is a definite requirement for a drastic change in the UK's health sector, with potential for leading global change in environmental sustainability in emergency care.
Limitations
The main limitation found while carrying out this literature review was the lack of research available to analyse and appraise.
Although there is a wealth of research publicly documented by news outlets and the like, the amount of academic research on paramedic practice's environmental impact is minuscule.
Rather than this limitation being seen as a deterrent for further research, it spurred a desire for more research. It is evident this is an area that desperately needs mass recognition and understanding.
Conclusion and recommendations
This literature review began with an expectation of developing an in-depth understanding of environmental sustainability as it applies to emergency paramedic practice.
By critically analysing, appraising and discussing six relevant studies, the author has detailed areas of healthcare's harmful impact to the environment and acknowledged suggestions for the future that could lead to a positive outcome in slowing climate change and improving the UK's perspective on sustainable healthcare.
The review has taught the author more than expected. Before starting it, the author had a passion for environmental sustainability and paramedic practice yet the data collected and research analysed provided enormous amounts of further education. That said, there are endless amounts of public, accessible spaces for change towards environmental sustainability; an individual's perspective can be altered with ease and minimal impact on day-to-day life.
The background research and six studies complement each other well and the result was an agreement that emergency medical practice can be perceived as likely to be unsustainable in consideration for the natural world, or at least not as sustainable as it has the potential to be.
With constant changes in the modern age and technological advances taking place every day, it is not an uneducated suggestion that emergency healthcare accepts responsibility for its environmental impact and takes steps towards nurturing the environment in which its clinicians practise.
The literature review has found suggestions that have the potential to radically change the system of emergency paramedic practice. Addressing the environmental impact of emergency care, most notably, could involve reducing the use of inhaled analgesics (specifically nitrous oxide) and abolishing the use of single-use plastics and replacing them with durable alternatives that can be sterilised.
Moreover, viewing these changes from a long term rather than an immediate perspective will allow their greater impact to be understood. Even though immediate costs may be impacted by changing materials or fitting emergency vehicles with renewable energy sources, the long term will see a decline in costs as fossil fuels and single-use plastics are relied on less.
From this literature review, there is anticipation that this issue will be reflected on through the eyes of the future: how different could a future with renewable energy-powered, sustainable healthcare look? A decline in cases of ambulance conveyance to hospital owing to better air quality should result in fewer ambulances on the roads, quieter accident and emergency units and quicker treatment times. Perhaps, if paramedics practised using alternatives to single-use personal protective equipment, such as masks, aprons and gloves, there would be a colossal shift in NHS landfill statistics.
Fundamentally, this review has collected research and data and considered how they could be applied to address the climate crisis and improve general understanding of environmental sustainability both in and outside emergency paramedic practice.
It is vital that systemic and personal changes are made in out-of-hospital emergency care, not only to ensure the planet's environmental and atmospheric health but also so essential practice can continue to be carried out. Equilibrium and understanding must be achieved to sustain longevity in prehospital care and the demand it faces every day.