So I'm going to talk a little about ergonomics. And like I said, before six years ago, I thought I was pretty slick. And even though I was pediatrics, that I could go over to the adult side and at least not embarrass myself. And I really actually went, and I've gone to see lots of really good people do lots of interesting cases, but it wasn't until I went to see Kevin Washka, who is the past president of CAG, do eight or nine colonoscopies unsedated and using some of these techniques. And it really kind of transformed how I think about it. And then through SOP, Standards of Practice Committee, and some work we did locally really took an interest in ergonomics. And it's kind of like quality was 20 years ago. We were like, oh, god. And actually, Jen Lightdale, who's our guest faculty, she was doing quality research in peds before it was trendy. And I really was just like, I want no part of that. And what was I doing five, 10 years later? Working with Jen doing quality work. So I think ergonomics really is there. And Amadip Shergill has really been the primary person publishing in this area for the last decade. And so I'm hoping that some of this work will kind of inspire and stimulate some future work. OK. So I don't have any disclosures relevant to this, other than I've become very passionate about it. And so I really do think you have to, almost like a religion, become very pious about it and really believe strongly, because if you don't, again, in five years when you start having some injury, you'll be like, I remember a thing about this. And some of these slides you may have seen in some context before, even in a talk. But again, I wanted to, some of these were pre-done. But I think it's really important. So we're going to understand the scope of endoscopy, no pun intended, the related injuries in fellowship and things that will affect you beyond. Describe and prioritize potential ergonomics interventions. That includes what happens during the endoscopy, before and after. And then talk about some tips for minimizing injury risk during pregnancy. So injuries can occur during fellowship. A survey that SWATI did, up to 50% of GI trainees reported an ERI, or endoscopic related injury. A third of GI fellows are female, and injury is more common in women. It was also felt that 97% of GI fellows wanted mandatory training. The majority of us, in fact, I would be willing to say almost all of us, none of us had training until a few years ago. Less than a third of GI fellows got formal education or hands-on training, which is a little surprising. Poor ergonomics in pregnancy can lead to complication, both of the mom or the baby. There's certainly a lack of institutional safeguards for staff. You know, OSHA has certain requirements, but certainly not to the effect that you would think to protect both the physician and even the patient. Because some of these changes and things we're talking about have a translating effect for the family and the patient as well. Lack of training and evaluation of trainers by programs and governing bodies. So we don't have a set recommendation for how to train the trainers and how to teach those skills. So we're getting there. So there is a core curriculum for ergonomics and endoscopy that Catherine Walsh was a senior author on, published a couple of years ago now. And certainly you can scan this, but it's in GIE. I certainly encourage you to do that. But there's not any other formal curriculum. Some programs have some curriculum, but it's pretty limited, I would say. So how do we integrate our ergonomics and endoscopy training? And so what is ergonomics, right? It's the act of being functional, which translates into a safe and efficient endoscopy, right? And to minimize injury. But you get personalized feedback at every section of this, whether you're starting at the endoscopy, before the endoscopy, during the endoscopy, or after the endoscopy. And there's cognitive skills that go into this. And that's why I said at some point you actually have to go back and relearn, why are we doing the endoscopy? Think about the anatomy. Think about the room setup. So those are kind of the pre-things. There's technical skills. How do I actually do the endoscopy? How do I hold the scope? How do I, you know, if I'm using a device, am I doing it? Is the tech doing it? There's some very specific technical skills that become important. Then there's the non-technical skills, communication, things like that, during and after the scope. So what are the pre-interventions? So certainly education. Again, you could always go back, open up, you know, the Cotton Book, which I think is great. Again, it doesn't teach colonoscopy the way that I would teach it to you today, but lots of pearls about loops and lots of other things. So going back to the basics, open your Netter. Look at—they still use that book, right? No. Look at the anatomy. See where the mesentery is. Think about where your looping is going to occur. Those are the things that are going to kind of save you. Thinking about the type of anesthesia for the right patient. I think Doug gave some nice examples about when you should think about these types of certain situations. Set ergonomic-related goals, right? So for example, the technique I just showed you, yeah, I don't necessarily think you're going to start doing it tomorrow, but to say, hey, in one year my goal is to do 80 percent of my colonoscopies with the C technique, something like that. Create open communication among all team members. I think this is so critical, and I think it starts day one, even day zero, because the more communication you have with the team in the room and the more they understand what's going on, the easier your day goes. Talking about efficiency, but also in terms of you want everyone to be healthy at the end of the day, right? Your safety, the patient's safety, but actually your entire team, because this is a team you're going to work with for sometimes up to 15, 20, or your whole career. We have nurses in Texas that have been in our hospital for 30 plus years. So I think that's really important, and to demonstrate that you care about their health. In the same way, we can talk about scheduling endoscopy, which avoids overuse injury. And so Doug talked a little bit about how you can set up your schedule. Some of the recent ASG guidelines even suggest about taking both micro breaks and macro breaks. Well, micro breaks we'll talk about during the procedure, but macro breaks are really setting aside a time like lunch or in between lunch to actually let your body heal and get ready. Let the CO2 burn off, let your lactate burn off. So there are some benefits in theory physiologically to doing that. And then the other part about right before your procedure, just as you do your standard joint commission required timeout, to do an ergonomic timeout. So is the monitor in the right place? Am I standing in the right place? Is the fellow standing in the right place? Am I standing on a mat? Do I have lead? Do I have the right kind of lead? So all those kind of things, you can actually do a verbal timeout. And we've even done it, although my current team refuses to do it with me, but we do a little stretching beforehand. And if you noticed, this is business casual, but I come in my track shoes. And you really do need to be comfortable. And I have a picture from several years ago of one of our guest faculty here who was wearing a glove protecting her fancy shoes. And again, I think those might be ergonomically adapted shoes, but they're probably not. So I think if you're going to be on your feet all day for eight hours, you have to be comfortable. Okay. So what's in this ergonomic timeout checklist? So again, monitor should be 15 to 25 degrees below eye level. I've heard previously maybe above eye level, but it has to do with the level of your cervical spine. The bed should be positioned between elbow and 10 centimeters below the elbow height. And again, it probably should be the height of the learner, not the faculty. The faculty is doing it. You can either adjust the bed or suffer, depends on what percent of the case you're going to be doing. I think that question comes up a lot. The tower, again, I'll show some pictures, but it should be the stack, the endoscopy stack behind you, parallel to me, parallel to the orifice of the lumen you're scoping, parallel to the TV screen. In my mind, it's got to be basically fully parallel. Every room is maybe some permutations, but I think you have to really, that should be, if you don't start there, it alters a lot of factors, both for performing the endoscopy as well as your ergonomic safety. Foot pedal, you don't want to be dancing trying to find it. You also kind of, when you're in a situation like taking off a polyp, you don't want to be looking for it either. So it's always good to kind of be right where it's supposed to be. Same is true for a pedal for water, things like that. Cords and wires, again, a lot of our endoscopy rooms now have gone wireless, but there's still some things, suction tubing, and we have some other certain wires, things that just kind of are still on the floor. So you have to be careful, right? You don't want to trip on them, and that's a good way to get a new unit is to have enough people trip, but that hasn't worked yet. Cushion floor mats, certainly for longer cases. There gets to be an issue with how big do they have to be. I think that was Andy Storm's comment was, how do we clean them in between cases, right? Maybe that was somebody else. So that's certainly something to think about. Lead apron, there is minimal data, one versus two-piece, but enough to suggest that two-piece is probably better from a force standpoint on your body. Endoscopy position, again, neutral posture. The more you're bending or if you're sitting, the weight on your spine increases. So being in a very straight, legs apart, kind of shoulder length apart is ideally best. How do you hold the scope? Again, I shared with you the C position. That's ideal. And then basically using your fingers, not forcefully, but really just to hold in place like a pencil from 15 to 30 centimeters from the patient's rectum. Communication, again, you can never go wrong. I always tell my trainees, we do proctoring before people start procedures. Introduce yourself to the anesthesiologist even after the timeout and say, hey, I haven't worked with you before. And even at least once during the case, say, how's the patient doing? Maybe if you're doing EGD, maybe you're already done before that. But at least trigger some conversation. Then that way the next time they know if there is an issue that you actually care, that you're kind of focused on the same things that, hey, I heard the stats go from 94 to 87. Are we still good? Good. Great. I can keep going. I think it's a good way to foster kind of a relationship. And again, you sometimes become friends with these people too. So communication 101, introduce your staff, as I said. Tell the staff you'd like to focus on ergonomics. Like I said, we've done some stretching. Sometimes they're good for it. Sometimes they're not. We ask for feedback. Invite everybody to speak up. If there's a question, like the monitor's in the wrong place, or the other day I was doing a procedure and the monitor was like this, and I was just kind of used to the room being in a way that I would not be perfect, but we wanted to get done. And someone asked if they'd like to move. I said, that's great. Thank you. I should have just done that. Closed loop communication. Right? So you ask for something. Hey, do you want the snare open? Yes. Please open the snare. And the tech says, OK, snare open. Yes. So you've got that closed loop. We asked for it. We repeated that we wanted it, and they said that it was done. OK. During the procedure, positioning of the tower, the monitor, the bed, the learner, the teacher. So if you think about where everything should be, this is a nice schematic, kind of almost showing everything. It also shows pretty good PPE. Before COVID, I am slightly embarrassed to say that I did cases without a mask. And eye protection now, I would never do that without. I certainly am not wearing an N95 for every case anymore. But again, you get a sense for where the hand position should be. So your elbows are in a somewhat neutral position. You're standing on a mat. And again, you have that stack, scope, or sorry, faculty, or learner. You have the scope in, the patient, you have the patient, and then the monitor all lined up. OK. You may need to change the monitor throughout the procedure, right? And so a lot of these things are on boom, so you can move them around. At our hospital, it took a while to get this enforced. But we've moved the bed 180 degrees, so we don't have to have the scope reaching over the bed. I implore you not to do that. It's not good for the ergonomics. It's not good for your back. It's not good for the patients. I think the other thing that we'll see is that a large patient may not be as important. But for a smaller patient, you find yourself reaching over. And you may need to bring the patient towards the edge of the bed, so you're not reaching over and leaning over. And again, you'll see a lot of people doing their endoscopy like this, or like this, or like this. And I'm usually coming into the room and straightening somebody out a little bit. I ask them if it's OK usually. But anyway, I think it's really important. So again, how to hold the scope. again, you should really not be using a ton of force on your right hand during colonoscopy. We talked, I showed you that C position. And again, I'm happy to refer you to this video that kind of shows some nice examples. And again, just another, when you have a trainee and a trainer, where are the best places for the trainer to stand? This is one location that allows the trainer to see your hands, can see the screen, and generally see the patient. You can see in this diagram, gives you another alternative because you have an anesthesiologist that can see the patient. And you wanna be able to, as the trainer, be able to help the learner be able to see all the things that they need to see. All right, what about other things during the procedure? Ergonomic focus instruction. So again, how to hold the scope actually makes the procedure go smoother for people to believe in ergonomics. So I think that's really important. We start with safety. We start with your safety and the patient's safety, right? First and foremost. Don't be afraid to speak up. You're the leader when you're holding the scope. We talk about in the trainer courses about the difficult learner and how do you gain control of the endoscope if you're not the one actually holding the scope? It starts there. We have rules. We have, if I say stop, it means stop. If I say slow down, it means slow down. You're gonna be teaching people very soon. So you're gonna need to gain control of that as well. So that becomes really important. And how do we mitigate risk for ergonomic-related injury? Short one to two minute micro break. So you're in a long case. Hey, we're gonna take a pause here for a second. Maybe you're doing a change of the CO2. Maybe there's something else. Use that to kind of stretch a little bit. That actually has been shown to be helpful for long-term ERI. Compression stockings. Actually, if you go out to the ASG store, they actually sell ASG stockings. So consider those, especially if you're gonna be working long days or long cases. The anti-fatigue mats. They're usually gel, but don't have to be. Some of the companies even have them if your hospital allows that, but you certainly can purchase them and they can be wiped down. We talked about the two-piece lead aprons. What about after the endoscopy? Performance-enhancing feedback. Again, that talks about be able to give accurate and good feedback that's timely. And again, the learner, if you're an instructor and this came up with a question that was on the chat earlier, what if you're not being taught by the faculty? You can say, hey, how did I do? Because we're not good about giving you feedback and in general, learners are not great about asking for it. And so you almost have to create that conversation and that's a whole nother talk probably for another day, but it gets at also you can do that within the ergonomic realm. And it gets to, in many ways, about how do you hold the scope? How is your looping? What is the torque? How much torque are you applying into a patient? Things like that. Again, breaks between procedures to promote muscle recovery. Again, it's this delicate balance. We have to be very efficient. We're trying to generate these RBUs, but I also need to take care of my body, right? And I think Doug's, one of his way to mitigate is to wear a brace. It's not just to prevent, I'm not sure if you recommend it for preventative care, but also if you already know you have an injury. And again, I didn't start doing much of this ergonomic discussion until, or I at least noticed that I felt a lot better once I started changing my strategy, but I also was having some numbness and tingling in my left arm. So anyway, so I think that becomes really important. And again, you're like, I'm young, I'm 30, what? If you start now, it will give you another 15, 20 years of being able to do this. So stretching, there's a nice ASG video GIE that I alert you to. It shows some stretches for the wrist, fingers, shoulders, and back. And then we talk about the hierarchy of controls and this came from a Shergill and something that Catherine Walsh put together in the curriculum, but kind of the most effective things that you can kind of easily do are kind of red, but it affects the smallest number of people, but wearing the right PPE, working on your technique, stretching, but the hardest thing to do is take away the exposure, right? So if you didn't do any endoscopy, you wouldn't have any endoscopy related injury. And there's everything in between. You can make some substitutions, you can use different equipment. And again, you could think about prevention and maybe designing a better endoscope or there's a special dials that you can attach to the scope, things like that. There's engineering controls that might separate you from the hazard. Again, using a stand, assisted devices like a cap and adjustable monitors in bed. So I think that certainly those things are all important and certainly at each level, there are different ways on a daily basis and also longitudinally that you can think about these. Okay, what about pregnancy? Well, hydration is important. It's important to have a radiation safety officer meeting. They can give you a badge. They actually give you two badges, usually one for your belly and one for yourself. Lead aprons and curtains and shields certainly should be used. We have a lot of discussion. We all have done fluoroscopy training. There's some nice CME that's available for it. But I think it really makes everybody think about what's going on. But certainly if you have a patient that's potentially pregnant or pregnant, I think it changes the conversation. But they definitely should be wearing both personal and fatal dosimeters. So we talked about compression stockings, but obviously pregnant patients are at greater risk for DVT and related thromboses. And certainly there may be a role for wearing supportive devices on the wrist and the back even before there's an injury. Pregnancy positioning. Again, even though I said earlier that sitting, if you're at 90 degrees, your spine, but the belly kind of gets in the way. So again, certainly thinking about where to move the bed, your eye position, to maintain that eye position, you may need to lower the bed and consider sitting. But certainly it is a known issue and there's certainly some ways to mitigate that. So again, you're finishing your fellowship, but there's certainly roles that you have. But one is to say, hey, I heard this talk and I heard a couple things, but why don't we try this? And you can't, Rome wasn't built in a day, but become an advocate for ergonomics. Ask for direct hands-on ergonomic feedback. So ask your attending as part of, if they said, hey, you did a great job on that polyp and you say, but how was I holding my, were my hands right? I noticed that I felt like I was leaning forward. Am I still doing that? You have to have a little introspection. And like I said, even as a more senior faculty, still asking, I'm still looking down every once in a while to see what my body's doing. I kind of have a pretty good sense, but I think that's really important. If you see poor ergonomics, speak up, right? There's wires all over, things that can injure you or the patient or your team, speak about it. So many education campaigns, you can check that out, that hashtag, participate in ergonomics curriculum development, ASGE, our PEED society, AGA, certainly we all need it. Collaborate with your physical therapists. I'm married one, so that makes life a little bit easier. Research to understand impact of interventions. We're just starting that. Ask the GI societies for standardized training and assessment. We had a lot of discussion when we worked on the ergonomics standard of practice guideline of do we think it's important? Is there data behind it? And if we don't, why are we doing this in the first place? But we do need to appeal to industry for better design of scopes and you're the next generation. So this guideline will be formally published in October, but I think it was a pre-print earlier in the summer. But the five major recommendations that came out of the guideline, number one was recommending education to reduce ERI. Again, we're doing that today. We recommend a neutral monitor position during endoscopy to reduce ERI. Again, 15 to 25 degrees below eye level. The ASG recommends use of neutral bed height. Again, keeping your hand position. Again, strong recommendation. Again, many of these things have very low or low quality of evidence based on one or two papers or taken from the surgical literature frequently. Recommended use of anti-fatigue mats to reduce ERI. There were a few papers on that. Conditional recommendation very low. Again, there's obviously some issues about how many do you buy? How do you clean them? When do you change them? All those things. And then finally, we recommend, suggest, not recommend, but suggest taking micro breaks. Again, these little mini breaks during the procedure and then even scheduling, considering changing macro breaks to reduce the risk. So those are the major things that came out of this document, but I encourage you to take a look at it and some of the data that went in behind it. This is all at once looking at it, bed position, monitor position, your technique, having an athletic stance, holding the scope appropriately with a proper grip, using a cushion floor mat, compression stockings. Again, ergonomic timeout, micro break, stretching, that probably gets the biggest bang for your buck are those three things. And again, just having active conversation about it, honestly. And like I said, it made a huge impact on how I do things on a day-to-day basis. And again, you just need a couple of disciples and people to start doing it and thinking about it and talking about it. And now it's a thing. So I think that really has been really impactful for my career and I wish I had done it sooner, so. And you can scan these for the teaching ergonomics through ASGE as well as the core curriculum that I mentioned earlier, if you wanna take a second to do that. And Doug and or I will take some questions before Andy gives his talk. Hi, I have a couple of questions. First of all, is with efficiency during procedures. Dr. Adler, is there a certain number of like small polyps you take out during colonoscopies? Let's say you're doing a colonoscopy on a busy day and you go in and this patient is riddled with multiple polyps. And for the sake of time efficiency, at what point do you say, okay, we have to bring back this patient for a second procedure? And secondly, what is like, in my experience in the county hospital, a lot of our colonoscopies are not adequate preps. And sometimes you spend quite significant time cleaning. Is there like a estimate for your Boston preparation scale you use? Like when do you totally give up or try to finish it? I love your question, Chris. On that first patient that had a lot of polyps, you wanted to just get them all out and it's whatever it takes to get them all out. They prep, they took a day off from work, they have their spouse to drive them. I think that that's fair. But on the other hand, if you're hitting the 60 minute mark and you've got a lot to go, you can stop recognizing that that's much more favorable for you than for the person, right? Like imagine that was your mom on the table, not your mother-in-law, but like your mother on that table. You would want them to get it all done in one shot. And then the other side of the coin is the prep issue. Different people have different tolerances for it. I think the bigger issue of doing colonoscopy in less than ideal prep is liability, right? Because if you keep going and finish the case, you're kind of saying between the lines, the prep was adequate for me. And then you're responsible for anything you missed. And I will tell you that as time went on, I went from doing a lot of washing and cleaning and suctioning to, nope, not your day. Come back when you're prepped. Because I felt like I was accepting too much risk. Like I was too worried about what I wasn't seeing. But everybody's different. And I also think, and I got into this the other day on a patient with polyposis, that I told the person who was working with me, I was like, don't let me take out anything smaller than a centimeter and a half. Like today, this patient literally had 30 large things, larger than two centimeters. I said, we're gonna do this today. There's a lot of sequel load. We're gonna deal with that and we'll come back. Like I'm not, I start taking out, unless the snare literally falls on a polyp, which happened a couple of times, I'm not taking them out. So I think it's, you have to be balanced and thinking about what you're gonna do, especially in someone who's got a significant burden of disease, and say, you know what, we've been in here for four hours. Again, I don't know if this is Doug's practice, but if you have a huge sequel polyp and they have two or three others, like today may not be the day to be messing with those other ones. I don't know how you approach that. Yeah, no, I think that's totally fair. And maybe if it's something really big, maybe you either need to refer it out or bring them back on a day in a different block where you're like, well, this is gonna take me 60 minutes to get this out. Just this one problem. Do you want that person to be good?

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