Ergonomics, the proper positioning that aligns with the natural movements of the body, significantly impacts gastroenterologists and their trainees in delivering quality care to their patients and contributes to possible injury during routine procedures such as colonoscopies.
There is an unmet need in the medical curriculum to address the principles of ergonomic positioning, equipment, and techniques to mitigate adverse effects and improve health outcomes for physicians and their patients. The American Society of Gastrointestinal Endoscopy or ASGE convened and developed recommendations to emphasize the importance of ergonomic equipment. Endoscopic Related Injury (ERI) or tissue microtrauma were found among 39% to 89% of gastroenterologists.
ERIs have short-term and long-term complications. Stiffness and pain of the forearm, fingers, neck, and back are associated with short-term complications, whereas long-term complications result in early retirement, disability, and loss of skilled labor. In fact, there is an expected shortage of surgeons by 2025 because of workplace injuries.
Ergonomic principles are vital in reducing the occurrence of musculoskeletal fatigue which is common among practitioners due to their professions. These impairments can lead to decreased productivity and even early retirement.
A lack of research about ergonomics and gastroenterology does not preclude its importance. Approximately 60% of gastroenterologists spend 40% of their time conducting endoscopic procedures.
By prioritizing ergonomics, the field can significantly enhance procedural efficiency, reducing the physical toll on gastroenterologists and ensuring a focus remains on delivering high-quality patient care.
This approach is the reciprocal relationship between the well-being of the healthcare provider and the quality of care provided, defining the importance of ergonomics in developing a positive outcome for both.
So, how can gastroenterology adopt the necessary methods that ensure the safest workplace environment possible?
For this, we can turn to the “hierarchy of controls,” a pyramidal schematic recommended by the Occupational Safety and Health Administration (OSHA), which provides a hierarchy of effectiveness of interventions for ergonomic changes, that prioritizes the most effective at the top and the least effective at the bottom (Fig. 1).
Figure 1. The “hierarchy of controls,” adapted from the Occupational Safety and Health Administration by Shergill in GIE.
Within the endoscopy suite, “elimination” and “substitution” would apply to the scope itself, or other medical devices, with a focus on prevention through design. “Engineering controls” would include adjustable monitors and beds as well as support strands, caps, right/left dial assist. Ergonomic training/safety culture and “time out” would fall under “administrative controls,” along with endoscopy schedule and maintenance. Lastly, endoscopists’ technique, microbreaks/stretches, and physical fitness would be considered “PPE” modifications.
As medical professionals and ergonomic experts learn more about creating the most ergonomically sound endoscopy department, a number of best practices and recommendations have come to light.
Endoscopist-Centered Room Layout
The bed should be in front of the endoscopist and the monitor in front of the bed. The patient’s anorectum should be positioned and aligned with the colonoscope. The endoscope tower should be behind the practitioner and the monitor positioned in front.
Monitor
In comparing three published studies, the ASGE found that the neck strain was lowered with the monitor positioned in front of the surgeon.
The consensus is that the top of the monitor should be visible without spine rotation, placed directly in front of the surgeon, within six feet, with the upper portion of the monitor at eye level and the center slightly below eye level. The center of the screen should be at a resting position, 15 to 25 degrees below the horizon, to prevent additional strain on the neck muscles.
Bed Height
The bed height should be between 10 cm of elbow height to allow for a necessary right and left arm range of movement between 0 to 10 degrees below the elbows.
Compression Stockings
The use of compression stockings appears to mitigate muscle fatigue occurring after a long workday; physiologically explained by the K+ ions balance in the muscle and the circulation system improving intramuscular pressure with the application of compression stockings.
Cushioned Floor Mat
This reduces pressure on joints and muscles; since each colonoscopy can range between 30-60 minutes, and GIs typically do up to 20 procedures a week, a cushioned floor mat helps to alleviate the pressure on the plantar muscles from prolonged standing.
Ergonomic Time Out
When the opportunity arises, taking a moment to pause periodically and survey the current setup, while making any modifications as necessary, is important for ergonomic optimization.
Micro-Breaks
Breaks don’t have to be lengthy. Very short breaks, especially in a very mentally and physically focused process, are crucial for performance and health. A study showed that inaccuracies using a star tracing test with Metzenbaum scissors increased by 7-fold for a typical non break day versus one with micro-breaks. This is further evidenced in a survey in which most surgeons (87%) indicated that they would like to incorporate micro-breaks into their work routine.
Intermittent Stretching
The repetitive movements of finger grip and the use of the larger muscles on the left side to assist with torque steering to mobilize the angles needed to visualize the entire colon can stress the muscles of the hand, notably the abductor pollicis and extensor carpi radialis.
The forces applied on the hand and loads is associated with increased thumb injury and exceeds the recommendation of the American Conference of Industrial Hygienists.
Intermittent stretching helps alleviate the strain on those repetitive movements, giving tired muscles new energy.
Universal Cord on Medial Left Forearm
As mentioned above in Intermittent Stretching, the left forearm is recommended for torque steering and the right side is preferred for the endoscope shaft.
Light "Bow" Grip
The “cigar rolling” method is preferable to the fist grip due to the excessive pressure that is placed on the wrist with the latter. This method relies on the thumb and fingers to guide the endoscope instead of the wrist.
It’s often been said that “necessity is the mother of invention.” As humans, we strive to constantly improve on what our predecessors have created in an attempt to design new products that eliminate unnecessary stress and strain.
With this focus on creating safer experiences through new product development, we are constantly seeing these ergonomically-inspired products make their way to the market.
Just as frustrated practitioners in their respective fields find the status quo unacceptable, so too did gastroenterologist, Dr. Marybeth Spanarkel, after her career-ending neck injury led to an almost paralyzed right arm. This injury fueled her passion to develop a new, specialized medical device that would save endoscopy professionals from unnecessary physical stress and strain.
Since Dr. Spanarkel’s injury was most likely due to the physical nature of the twisting and torquing of the scope for multiple colonoscopies a day for decades, she was well aware that the most likely culprit was looping. Looping is the phenomenon in which the colonoscope fails to advance, stretching and distending the colon as the physician’s attempts to push the scope forward.
Looping occurs in 90% of all colonoscopies and is the main cause of patient pain as well as failed and prolonged procedures.
The overall goal is to greatly eliminate manual pressure and repositioning needed to manage looping by substituting the manual pressure applied by endoscopy professionals with the ColoWrap device itself.
ColoWrap uses a proprietary neoprene-based, latex free, primary band to provide the necessary splinting of the sigmoid and transverse colons.
Once applied and the effective concavity established, the two secondary straps can be used to provide safe, targeted pressure to both the sigmoid and transverse colon. Each secondary strap can be attached and reattached as needed.
This greatly reduces looping, oftentimes up to 90% in some cases. From an ergonomic perspective, this means far less manual pressure, repositioning, twisting, and torquing, saving endoscopy staff from much of the physicality of the job often assumed to be inherent to the field.
With 20% of the cases generating 80% of the problems, proper ergonomics is of the greatest importance among these most challenging and difficult colonoscopies. This is where ColoWrap is most effective, particularly for those who meet the patient criteria.
At ColoWrap, our ultimate goal is to achieve a zero harm endoscopy unit. This begins with creating the most ergonomically sound endoscopy department possible. Feel free to reach out to us with any questions you may have.