Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event entitled Ergonomics and Endoscopy. My name is Marilyn Amador, and I will be your facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded, and we will post within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to hand over the presentation to our GI Fellow moderators, Dr. Nihal Karnak and Dr. Mohamed El-Mekdadi from SUNY Downstate Health Science University. Thank you. Thank you for that introduction. My name is Nihal Karnak, and Mohamed and I both come from Downstate over in Brooklyn. As someone who's interested in therapeutic endoscopy, I'm really excited to be a part of this discussion, and it is a real pleasure and honor to introduce our moderator and panelists. First up, we have Dr. Shergil. She comes from the University of California at San Francisco. She is currently the interim division chief of gastroenterology at the San Francisco VA. She's a professor of clinical medicine, and she's currently the director of endoscopy at the San Francisco VA Medical Center. Thank you, Marilyn, for the introduction. We also have our panelists. We have Dr. Shreya Patel, who's currently an assistant professor of medicine at UCSF in San Francisco and California. We also have Dr. Swati Pawar, who's associate professor at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. And finally, we also have Dr. Raju, who's the John Strolland distinguished professor of medicine in the Department of Gastroenterology at MD Anderson Cancer Center in Houston, Texas. Thank you so much for inviting me to moderate this session for a topic that I'm really passionate about. So by way of disclosures, I do have a financial relationship with Boston Scientific as well as Pentax, and the rest of my co-panelists do not have disclosures. Thank you again for my co-panelists for joining today and providing their expertise. So the overarching goals for today's session is to help provide some background and understanding of the prevalence of endoscopy-related injury in training and practice, to help you as trainees recognize the biomechanical risk factors for repetitive strain injury during endoscopy, and apply mitigation measures using something called the hierarchy of controls, apply ergonomic knowledge to the endoscopy suite, and then provide some tips for endoscopy ergonomics during pregnancy. We're hoping to make this an interactive session, and so we're going to be using Poll EV. So there's two ways to participate. One would be through the website, and the website's PollEV.com backslash AShareGill 001, or you can text AShareGill001 to 22333 to join. So please do participate, either through the online platform or via texting. So to start, I wanted to ask the question, please answer yes or no, learning how to use the endoscope is intuitive. Let's see if we get any answers coming through here to see if this is working. It was working a second ago. Right. So I don't know how many people are actually participating right now, but 100% of our respondents have reported that the using the endoscope is not intuitive. I don't know if many of you know how I became interested in ergonomics, but actually when I was a fellow, actually when I was a resident and had just been accepted into UCSF fellowship, a fellow in the class, it was a year ahead of me. So I knew her from residency and she was one of the smartest people in our residency class. After a year of being a GI fellow, she decided that GI fellowship wasn't for her and she left gastroenterology to become a radiologist. And sort of the word on the street was that she was having a lot of back, neck, shoulder pain and hand pain related to performing endoscopy. And when I became a GI fellow, you just had to take one look at the scope to know like we should absolutely be able to do better than this. The endoscope design really has not changed over the last 30 to 40 years. Whereas when you think about what's happened with cars and with telephones and our technology, how it's advanced, this is unfortunately one area where we have not seen the same kinds of advancements. The companies are all camera companies, Olympus, Pentax, Fujinon. But unfortunately, while we've gotten better, more beautiful pictures, more ability to do post and pre-processing, we haven't seen the same similar applications to actually the biomechanics of the scope and the ergonomics of the scope. So the next question is, have you experienced pain or discomfort when performing endoscopy? Okay, again, I don't exactly know what our denominator is, but just looking at the percentage, it looks like about 90% of those of you who are participating in this session today have experienced some pain or discomfort when performing endoscopy. So on this slide, if you guys can just using, I think the phone interface or on the computer interface, use your mouse or your finger to kind of indicate where have you experienced this pain or injury. So let's see, we're seeing left wrist, neck pain, shoulder pain. So a lot of hand finger pain, especially on that left side, also the right side, low back pain, upper back pain. So what we're seeing sort of on this slide here is very consistent with what we'll find from the survey-based studies, which Dr. Powell will review with us. But really there can be pain in multiple areas of the body. So the distal upper extremities, specifically the left and right wrists and hands, because of the way we have to hold and manipulate the scope. And then that neck, shoulder, and back pain related to how we're interfacing with our endoscopy suite in the room. I have shared my problem with my faculty or program director. All right, so it looks like maybe about 40% of you have shared this with your program director, other faculty in your program, but the majority of you have not. I have taken time off from endoscopy due to an endoscopy-related injury. Okay, looks like the overwhelming majority have not. Oh, there's a few people who have had to take some time off for endoscopy, it looks like. Certainly as fellows, as you're learning how to scope, oftentimes it's related to just how non-intuitive the endoscope is and how difficult it is to learn how to scope in the first place. But the risk for developing cumulative trauma injury, and especially if there are pre-existing injuries, is definitely real. All right, so we'd like to start off with Dr. Pawa. Thank you so much for joining and reviewing with us this important study that you had done, and I'm going to go ahead and I'll advance the slides for you as we're moving forward through your talk, okay? Thank you, Amandeep. Thank you for having me. Good evening, everyone. So, I'm going to start off with just some background on the prevalence of endoscopic-related injuries. As gastroenterologists, we are at risk for these injuries, and up to 89% of us have reported ERI at some time or the other based on the survey studies that I'll be talking to you about. And obviously, we have no published statements from any of our societies on how to prevent ERI. And I'll let Dr. Shergill speak more about that, but I think what we talk about when we talk about work-related injuries is when the external loads, which are our endoscope, so to speak, exceed our internal tolerance. And that can happen with an endoscope when we have repetitive motions, very awkward, non-neutral positions that my fellow is exhibiting right now in that picture, which she kindly agreed to share, long hours of standing, the sustained static loads that we endure, and the high forces that are generated during some of our twists and turns to see or to get to where we need to get to. For us who are interventionalists, we also have the added burden of a lead apron when we do ERCPs, which adds to the static load. And so what is the scope of the problem? The scope of the problem, as we all see it, is that there is increased demand for GI endoscopy. There is reduced age for colorectal cancer now. It's screening now at 45 years instead of 50, coupled with an increase in the adenoma detection rate, which will increase colonoscopy utilization, both as a screening tool and for post-polypectomy surveillance. We're seeing increasing utilization of advanced GI procedures for disease management, which were traditionally requiring surgery. And more women are now entering the field of gastroenterology. So it's not that we just woke up today and we decided that, oh, you know, we're getting affected, we're getting injured. Our history goes back to 1994 when the first survey study was done by Bush-Baffer and found that 57% of the study, which was a sample size of 265 ESG members, described reporting ERI in various areas. And over the years, many studies have come out talking about this, with as high as 89.1% of one study group reporting ERI out of, I think, Korea. So these are national and international studies that have been done thus far. And what have we learned from these slides? I think we've learned, I'm going to just keep going because I thought I'd gotten rid of it and I probably did not. What we've learned is that the higher procedure volumes and the more years that we put into endoscopy are considered risk factors for ERI. We've already discussed ERCP use of lead aprons. Some of these surveys were done on ERCP use that have been shown to increase risk of ERI. But more interestingly, lately, in the last couple of years, gender has come up as a risk factor for ERI, with some of the papers reporting female gender to be an independent risk factor for ERI, which is rather concerning. And so all these survey studies have shown that the common reported areas of injury, as you all pointed out to our hands and fingers, at the top of the list, followed by neck, shoulders, back, and elbows. There was an AGS survey in 2017, which never really saw a publication. So it remained an abstract form, which for the first time kind of, or not, but I think more critically for the first time mentioned that women were being more affected than men in the following areas, which were wrist, elbows, so more upper extremities. But the overall incidence or likelihood of injury for both men and women endoscopists remained the same. And so this was a study that we conducted in 2021. It actually was two or three years in the making, but got published in 2021. This is the largest sample to date of a study of prevalence of ERI in gastroenterologists. This catered to, or the first set of results that I'm going to present catered to the practicing gastroenterologists who were members of the American College of Gastroenterology. This was funded by the ACG. And what we sought to see was are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. And those are the results that I'm going to discuss with you in the next few slides. And so some of the things that we took home after the study was that there was no difference in the likelihood of injury in both male and female endoscopists. So the male endoscopist reported 78.6% injury rate and the females 74.5%. However, we did note that the number of areas that were affected by injury were more in the female endoscopist. So even though the likelihood of injury was the same, the female endoscopist was reporting more areas of injury. There was no difference between subspecialties, but also I would chalk that to low numbers of various subspecialties, be it IBD or advanced or hepatology or general. Colonoscopy was associated with greater likelihood of injury, and that was statistically significant. ERI was more common in practices in which greater than 50% of patient population was female. And more procedures and procedure hours per week were associated with greater reported ERI, again, reaching significance. There was also differences in reported ERI by gender. So in this bar graph, you can see that there was more upper extremity pain, be it thumb pain, hand finger pain, or carpal tunnel, which was reported in females than males. Interestingly, males reported more elbow pain than females, and all of this reached significance. When you looked at neck pain and upper lower back pain, we noted that the female endoscopist reported more upper back pain, while the male endoscopist reported more lower back pain, which reached significance. We also wanted to see if the difference in the mechanism of ERI reached significance, and so we asked both our male and female colleagues what they thought contributed to their endoscopic-related injury. You might have to go to the next one, but so in the male endoscopist groups, we know that they pointed more to use of lead aprons or use of the elevator on the duodenum. And in the female population, we noticed more twerking with the right hand or non-adjustable bed for a monitor that contributed to ERI. So again, in males, more lead aprons, elevators, which reached significance, and in females, they said they thought it was more twerking of their hands and the non-adjustable bed and monitor heights. And again, what we noticed was that even though it didn't really matter what you were practicing when you reported ERI, that one practice site was not superior to the other in relationship to injury, we did notice that as the number of hours increased, so did the percentage reporting of ERI did, so directly proportional to the number of hours that you're working or the number of years. There weren't many surveys that looked at hand size. I think there was a study a few years ago that was more a perception study where women perceived that their hands were smaller and hence were a hindrance to their ability to learn endoscopy. In our study, however, we did not see a significant difference when we compared small glove size to large glove size, or when we combined the extra small, small, and medium glove size and compared it with the large and extra large glove size, that it had no bearing on ERI. So we did not see significance of that in this study. What we did, however, see was a concept of micro breaks, which we asked in the survey, or any kind of break to break that day of yours, be it every 45 to 60. For micro breaks, we define micro breaks as one to two minute breaks every 45 to 60 minutes where you just kind of just took a break, just broke that static load where you were standing with a scope, but just went and either did some exercises or just kind of stretched yourself out or just sat down for a minute. The pictures that you see on the right are actually borrowed from laparoscopic literature where they did it for the surgeons who have longer times and surgeries where they took them out every few hours and made them do these targeted stretching exercises. And both in the laparoscopic study, which noticed an improvement in the injury scale as well as in focus and mental health, we noticed too that a lower likelihood of ERI was found in those who took breaks, whether they were scheduled lunch break of 30 minutes or 15 minutes or whether they were micro breaks every few minutes. So that was a significant finding in this survey. What was interesting to see was that more than half of our adult endoscopists, so to speak, or our practicing gastroenterologists had had no training in ERI prevention, so had no training in ergonomics, be it related to posture, bed monitor height or techniques for reducing injury. And also when we asked them whether they were using any specific strategies in their current practice, again, more than half said that they were utilizing none of those, which was very concerning as well. And so just to sum up our adult survey, we noticed that the likelihood of injury in both male and females were the same, that not one was more than the other, 74.5 and 78.6. We had about 1698 respondents, 583 of which were female. Again, areas of ERI differed with upper extremity and upper back pain more in the female group, elbow and lower back more in the male. And again, the mechanism of injury was differing as well with non-adjustable bed monitor and torquing more in the female and lead apron and elevator in the male. I didn't speak much about the pregnancy-related ERI, I think Shreya was talking about that, but we noticed that 79% injury rate was present in that population as well, so ours was a smaller number. So I wanted to kind of close this talk with a study that's right now in revision. It's going to be published shortly, and I hope we can make this available to all of you in the coming months, but this was our subset of what we did with our fellows. And so I just wanted to kind of end with some of those slides that is still unpublished work, but hoping to get it to all of you. These are some of the papers that have come out specifically looking at fellows in the last few years. And again, note that at least half the fellows, I'm sorry, half the respondents, at least in our study, reported injury. We had a good mix of both male and female fellows in our study. Some of the things that we noticed, and you could probably just tap on a few, what we noticed was that the reported prevalence of BLI, just like our adult study, we're going to call you our fellow study or our children's study, right, because you're still children in that sense. But in our adult study, the same thing we noticed with our fellows was that the reported prevalence of likelihood of injury was the same in both our male and female fellows, but the number of reported injuries or the number of reported parts was, again, significant. And the red part is covering that was significant in the female group, very similar to the adult study. Again, the male fellows were taller, weighed more, and had more BMI than the female fellows. We also noticed that as far as the location went, again, there was the elbow pain. So one more time, and we don't have a reason why, we just want our male colleagues to watch out for that. But that was significant, again, in the male group as opposed to the female group. And even though the thumb pain didn't reach any significance, I think both male and female fellows complained of thumb pain equally. If you go to the next slide, you notice that there was a trend, just a trend of more or less thumb pain in the female fellow group as opposed to the male. I think that's where I end on the leap in terms of what we've noticed thus far in our studies. The last slide here is where we asked our fellows about ERI prevention training, and the results were very encouraging, that almost more than half of you were aware of ergonomics, were aware of the different interventions. But despite that, the injury rate remained high. And also that less of you, or more than half of you, were not taking any breaks or micro-breaks for that matter. Thank you. Thank you, Dr. Pawa, for a wonderful overview. We're happy to take any questions for her at this point before I lunge into biomechanical risk factors, if there are any questions from the audience. Dr. Pawa, did you notice any differences in age, and do you think that's related to the number of procedures, or do you also think it could be a component that endoscopists who have been out in training for a long time maybe didn't have the opportunity to have ergonomics training during their fellowship experience? So there are studies that have reported that age could be a factor, but I think it's more related in our study to the number of endoscopy years that you've put in, and the number of years that you've spent doing endoscopy as a relative risk factor. Whether ergonomics is playing a role in that needs to be more dealt with more adequately. I think we need more vigorous, rigorous curriculums to figure out what's going to help us or not. Just case in point is we are doing more than half the fellows reported injury who were aware of this ergonomics training, but I'm pretty sure it played a role. It's just that we were looking for that curriculum which will make that difference as of now. Dr. Pawa, I have a question from the audience, actually. A lot of the journals, a lot of the articles that we see focus on the general posture and, you know, the shoulders really, and focuses more on the screen position and all that, but you mentioned like a few interesting points about the thumb, which I think, you know, me myself, I've had, you know, I've had thumb pain after endoscopies. Is there any specific exercise or specific things that focuses on kind of the, you know, more of these micro injuries rather than the general posture that you know of? So, I think there are, and I think Dr. Sheragel might have some, I don't know if you have videos out there which talk about injury, about specific targeted exercises, but I'm sure they're out there, at least in laparoscopic literature, which are targeting on various body parts. And again, this might have a lot to do with the way the endoscope is designed and what we can do to help prevent that. Yeah, for sure. Could I ask a question to Swati? Yeah, yeah. Swati, is it because fellows don't take a break because they don't know how to take a break, or is it because the programs don't allow them? Are they in a rush to get as many procedures under their belt as possible? So, we didn't ask for that. So, my answer is going to be very hypothetical. We didn't ask for any of that data, but I guess the general presumption is that they are in a rush to get as many as they can from at least my fellows that I've seen. And also, to give the impression that, at least in my practice, to use any kind of crutches, be it a device that helps them scope better because their hands are small or two, they don't want to show that they're not good enough. I think that tendency to kind of, at least in my experience where we had a fellow who did suffer through the consequences, just avoiding that, it's considered more of a taboo that you're going through this, which was kind of, again, an eye-opener and something that we need to dispel. I think, if I can make one comment, every program director should make it as part of the evaluation. Whenever they meet the fellow, in addition to learning the procedures, they should include what is happening to your well-being. I'm not sure that we actually do that. Yeah, no, at least I don't know of that. Yeah, that's a great point, Raju. I think that when we focus on fellows' well-being, it's more just burnout and are they exceeding work hours and this kind of gets lost. And I think what's important to highlight is the majority of the fellows who are on this call sound like they have experienced injury, but the minority of them have actually shared it with anybody in their program. And so we really want to normalize, unfortunately, that pain and the potential for injury is real. It's not your fault if it happens, but by sharing it with your faculty members, with your program director, hopefully they can give you tools, tips, and tricks so that you can have a longer endoscopy life as compared to if you were to just continue to struggle through this on your own. So we really want to just give everybody the power of knowing that you're not alone and ask for help. We may not necessarily be able to help you because, again, the scope has some inherent limitations, but it's important for you to be able to feel comfortable seeking out that help if you need it. Yeah, and for us, I think who have gone through this, I think our aim is if we can delve into it enough to develop a rigorous curriculum that actually helps all while we're trying to go where we know that the scope is a limitation. But if we can do that, I think that will be a step in the right direction as well. All right, so we're going to move on to the next section, which is reviewing biomechanical risk factors for repetitive strain injury and potential mitigation measures. So we talked about the scope being not very intuitive, but I'd love to get your guys' thoughts on if you could change one thing about the endoscope, what would it be? I mean, I'd say everything, but in the absence of everything. Dial size. So yes, right now it's a one size fits all design. And unfortunately, if you don't have a large enough hand to be able to reach over to especially that right left dial, you won't be able to manipulate the dial in the same way. Perhaps people are, let's see, joystick use instead of dials. So changing the way we're interfacing with the endoscope. Reach, so making it more accessible for the full spectrum of hands. Maneuverability. Reach, so people are talking about difficulty sort of handling the scope and the size of the scope and the size of the dials. Excessive maneuvering and torque that's required. The weight of the scope, that's certainly a factor that contributes to static loads. Okay. And how about what your guys' understanding of ergonomics is? When you hear ergonomics, what do you think? What is ergonomics? Loop. Okay. That's a new one. What does ergonomics mean to you? Posture. Safety. Safety-oriented. Improving the job durability. Posture, again, being a big one. So posture definitely is an important part of it, but really what posture gets to is designing work for the individual. So ergonomics is the study of how work affects people physically and cognitively. So it tries to quantify both human capabilities as well as human limitations, and then applies it to work. And so it's the science of fitting a job to the worker instead of forcing a worker to fit to the job. So instead of all of us having to come in and figure out how to use the scope, the scope in theory should be designed for one, to be able to be picked up and be very intuitive with very minimal training to be able to understand how it's supposed to be used, but also really to fill the full, to be able to be useful and comfortable for the full spectrum of workers. So for all workers to be able to efficiently and effectively use it. And in order to do that, ergonomics relies on multiple different sciences, but the two ones I'd like to highlight are anthropometrics and biomechanics. And so biomechanics, this is an important concept, is how the body produces force and generates movement. And this is why neutral postures or postures overall are so important, because a neutral posture is our position of maximum strength. So if you remember back from your med school days, muscle force is going to be influenced by the length tension relationship of a muscle. So that overlap of the actin and myosin filaments, and when you're in your neutral posture, that's when you have that maximum overlap of your actin and myosin filaments. So neutral posture is your position of maximum strength. And muscle force is also influenced by sheer muscle mass. And as we'll discuss in a And muscle force is also influenced by sheer muscle mass. And as we'll discuss in a few slides, this is where unfortunately female endoscopists may be at a disadvantage. Anthropometrics is the study of human dimensions. So it's the idea that workers come in all shapes and sizes, and we want to be able to design a worksite and design a tool so that smallest fifth percentile female to that largest 95th percentile male could all use that tool or, you know, use that worksite and be comfortable being able to work in their neutral postures in their position of maximum strength. So as you can see here in this picture, this cart has been designed so that even the smaller female as well as the larger male can push that cart with relatively the same posture. So if we were to apply this idea of neutral postures and anthropometrics, which tool would you guys consider to be more ergonomic? I know that picture just kind of flashed on the screen. All right, so the majority of us agree that it's the second tool that's more ergonomic and the reason for that is because you can see here that the wrist is actually able to maintain a neutral posture, whereas here the wrist is ulnarly deviated. And so anytime we deviate from neutral posture, we actually decrease our ability to generate force. So any degree of wrist flexion or wrist extension, any degree of radial and ulnar deviation decreases that maximum grip strength. And anytime we are in a smaller or larger grip than our optimal grip size, so if you have too small or too large a grip, that also in addition decreases your ability to maximally generate power in addition to if you're wearing gloves. And as I had talked about previously, sheer muscle mass, unfortunately there's a big difference between male and female endoscopists here. Female strength is approximately 60% of male strength overall. And when we specifically look at hand grip forces, gender is the most important predictor of strength. And so here in the red dotted line, you see women and here in the blue line is men. And you can see that even our most elite females, like female athletes who do hand intensive sports for a living, that they're as strong as about the 30th percentile average male. So this is a big problem for women endoscopists, especially as we're thinking how we interact with the scope. And unfortunately, women at their strongest are strongest in our 20s. And at our strongest, we're about equally as strong as 80 year old men. And so I'd like you guys to think about whether or not you know of any 80 year old male endoscopists who are still scoping. And the answer to that is probably no. So it's important for us to think about how hard then people are working when they're scoping. And this is the idea of percent maximum voluntary contraction. So anytime in ergonomic studies, when we're evaluating work, you're normalizing it to the individual, so their relative work. And so what you have them do is generate their maximum force. Then you look to see how much force is required to perform a task. And that's the percent MVC required to form that task. So for instance, if we were to look at turning the dial and say that the dial required 10 newtons of force to turn the dial. And if the average female endoscopist had a maximum pinch force of 40 newtons, and the average male endoscopist had a maximum pinch force of 80 newtons. And so remembering that your percent MVC is going to be the force required to do the task divided by the max force, who is working harder? Your average female endoscopist or your average male endoscopist? Unfortunately, yes. Your average female endoscopist using these values would be working at 25% of their maximum voluntary contraction versus the average male endoscopist who's only going to be working at about 12.5% of their maximum voluntary contraction. So all of these factors influence our ability to handle loads. So when we talk about and we think about biomechanical risk factors that are associated with repetitive strain injury, it's non-neutral postures. Anytime you're out of that position of maximum strength, it's high forces and excessive loads, especially in excess of what are established risk thresholds, especially if you're doing these things repetitively throughout a task. And what happens is these external loads, the way we're holding and manipulating the scope, the way we're interacting with our environment, depending on how long we're doing it for, how much force is required to do it, and how repetitively throughout the day we're doing it, can overcome the internal loads and tissue tolerances of our muscles, ligaments, and tendons leading first to pain and then to injury. And in the ergonomics literature, there's evidence for a causal relationship between physical work factors such as posture, high force, and repetition for the distal upper extremity, as well as for the neck, back, elbow, and lower extremity. So our group had looked to kind of establish whether or not there was actually these high forces being applied during endoscopy. You know, there's a whole very robust survey-based literature that demonstrated the high prevalence of endoscopy-related injury, and we wanted to document that it really was the endoscope that was causing these issues. So just to give an overview of the study sort of like very briefly, what we did is we calculated or we collected data on peak muscle forearm load, both the right and the left forearm, and we compared it to established risk threshold, and we looked at peak thumb pinch force, and compared it to a risk threshold of spending greater than 11% of your time in forceful pinch, or greater than 11% of your time in that 10-newton force, because this is what's been associated in prospective studies with the development of carpal tunnel syndrome. When we looked at the left wrist, we found that during all phases of colonoscopy, insertion into the right and left colon, withdrawal and retroflexion, that we exceeded the highest risk threshold, and what was quite surprising to us was to see that specifically those left extensor muscles in all endoscopists, but specifically in male endoscopists, actually exceeding 50% of maximum voluntary contraction. The right wrist muscle loads exceeded that moderate risk for all phases of colonoscopy with female endoscopists sort of crossing that high risk threshold, especially during insertion. And when we specifically looked at thumb pinch forces, that 11% of time spent in greater than 10-newtons force, again, all throughout the colonoscopy, we were exceeding this risk threshold, and the values were higher for female endoscopists as compared to male endoscopists, and especially on the right side as compared to the left side. And so, although, you know, we do have video data, but we didn't correlate it with what we were seeing, what this data suggests, and this kind of corroborates what Dr. Pawa just went over in the endoscopy survey-related studies, is that male endoscopists appear to guide the insertion tube with predominantly dial control by their left hand, using both their thumb and fingers, and what Dr. Satickna likes to call the all-finger method. And it appears that female endoscopists guide the insertion tube with dial control by their left thumb, as well as by torque control by the right hand, presumably because it's harder for smaller female hands to get over to that right-left dial. And when you have this cumulative injury, this is what results in first pain, and then if that pain isn't sort of realized and dealt with, that can lead to degeneration, eventually tendon weakening, and then failure, and so it's important to think about if you're having pain, where are you having the pain, and how can you trace that back to what's going on either with the endoscope or the endoscopy suite? So, especially that distal upper extremity pain is likely the biomechanics of the scope handling, but if you're having neck and back pain, that's probably related to posture, so where is your monitor position, what's the monitor and bed height, or if it's low back and leg pain, it's likely related to the static loads related to performing endoscopy. And so now, knowing that we have these high-risk exposures, the question is, what can we do to minimize the risk of injury in endoscopists? So, in ergonomics, there's something called the hierarchy of controls. This goes over what's the most effective to what's the least effective methods to control risks in a work environment, and what I'd like to point out is, you know, PPE is really what the endoscopist does. The endoscopist is at the bottom of this upside-down pyramid, so what we should really be focusing on is these higher elements of control, and so the most effective controls are going to be either elimination or substitution. So, as you guys had talked about, you know, what are the things that we could potentially change of the scope, and someone brought up joystick design. The idea would be design to the user and prevent injury through a smart design, and that really is going to require buy-in from endoscope and device companies. In the absence of getting endoscope and device company buy-in, though, we have to think about what engineering controls can we apply that might mitigate risk. So, engineering controls require a physical change to the workplace or the tool, and that would apply both to the endoscopy suite as well as to the endoscope. The next level of controls would be administrative controls. This changes the way we work. It requires the worker or employer to do something different, and often involves training in a safety culture, implementing things such as an ergonomic timeout, as well as thinking specifically about how much endoscopy time is in your schedule, and properly maintaining your scopes, and then the things that the endoscopist can do themselves are really, you know, what is the technique that you're using, and is there anything that you can do to optimize your technique to minimize your risk of injury, and implementing things, as Dr. Paola had discussed, like micro breaks and stretches, and importantly, maintaining physical fitness. So, unfortunately, when it comes to engineering controls and interacting with the endoscope, there's very, very few options that are available to us. So, here I have a picture of dial controls, but I'm very sad to report that the screen dial extender, which is developed by Olympus, is actually off the market now. So, I think that the last chance to bought this dial extender, if you're using it, would have been last month, but they're pulling this from the market. I spoke to the engineers, as well as the marketing groups, to let them know that this was a big mistake, because unfortunately, there are people who need these dial extenders in order to optimize that reach and the fit with their hand. Besides the dial extenders, there is a scope stand that Pentax is currently evaluating, and that's where my disclosure comes into play. I do have a Pentax research gift to study the scope stand, but can we reduce the static loads of the scope? More often than not, though, the only thing that we have control over is our work environment, and so really making sure that we have an adjustable work environment, which Dr. Raju will go over shortly. But it's important also for you as fellows to think about a timeout, your schedule, as well as, again, your technique in order to minimize your risk of injury. So, before we move on to Dr. Raju, are there any questions about biomechanical risk factors in the hierarchy of control? So, Amandeep, what do you do at UCSF with your fellows? In terms of ergonomics training? Yeah. So, they start out with a... Now, it's a week-long simulation session that we do in conjunction with Dr. Sotikno, but prior to that, I give them the basic sort of training on ergonomics. I really try and establish that safety culture with them, and then they go through and learn this all-hands technique, actually, with Dr. Sotikno, and we try and optimize their performance of... their familiarity with the scope, as well as, their performance during endoscopy. And then, specifically, when I'm scoping with them, I try and give them feedback on their postures, their monitor and bed height, as well as, their technique to minimize their risk of injury. Shreya, would you say that's accurate? Yep, absolutely. So, do your nurses and technicians know about the principles as well? Yes. I think that because it's something that I certainly harp on, they will automatically start moving monitors and optimizing the bed for the fellows, and then I come in and often will lower the monitor even further, because I'm the shortest person in the room, most often, because it's going to be easier for them to sort of, like, slightly look down with their eyes, as compared to me having to extend my neck out. So, the nurses and technicians definitely are our allies in the room, and there was an interesting study done at VCUrbine, where they had really brought in the technicians and the nurses to help them with implementing an ergonomics program, and really were able to show a benefit of having the whole team involved. Thank you. Dr. Shergo, I think there's a comment in the chat. I think that builds upon this very point. One of the participants tonight, or members of the audience, basically has written a nice paragraph that says it can be very challenging to get this culture of buy-in from everyone. That also includes attendings who may have certain preferences about various maneuvers, and then also about the setup of various things, such as travel cases, logistics of being in an ICU, or there's a ventilator. How have you sort of addressed those challenges? It sounds like you got your endoscopy staff to buy in as a team. You know, how can we as fellows or, you know, attendings get our endoscopy staff to be a part of this team effort, where it may be a little challenging to get it started? Yeah, I think the key is making sure, first off, the endoscopy suite itself is adjustable, and then teaching fellows and faculty as well how to optimize the endoscopy suite and adjust it to sort of maintain neutral postures throughout a procedure. I think cases where you are traveling to the ICU and you don't have control over that ICU environment, and when you're getting additional providers involved, such as anesthesia, always makes it more difficult to optimize the room because there's just more pieces of equipment. So even, you know, our room, which is dedicated to anesthesia, is not, you know, we're still trying to figure out what's the best adjustability that allows for the endoscopist to achieve the neutral postures for what might be a very long case. What I tell most folks is that, you know, whereas most other people in the room can leave during a case, you know, we're stuck there. So it's most important that you're kind of comfortable and you have access to the tools and techniques that you need to in order to be able to perform the case because, you know, the nurse may be able to leave, the anesthesiologist may be able to switch out, but you're going to be there the whole entire time. And so really just trying to advocate at the outset for making sure that room is set up as best as possible. In terms of a culture of safety, this really does require endoscopy program, you know, fellowship programs to really embrace both an ergonomics curriculum, as well as, you know, proactively kind of assess for these issues with fellows. You know, I try and do that as they're rotating through our site. I've certainly had fellows, you know, come and approach me and tell me about issues they're having. Oftentimes it does require an attending to pay attention to technique. You know, there's this particular kind of pain or injury that you're having, letting your attending know that so that they can watch your technique and give you some tips about how to minimize that strain or what you might be doing. But really it comes down to education. And I think through education, hopefully we can get buy-in. Could I make a comment here? Please. So, you know, it's very interesting. I think whoever has posted that comment on doing cases in the ICU, you know, most ICUs are not set up for endoscopy. And we go in and take care of the most difficult patient who is at very high risk for adverse events. And we do the procedures and with the most awkward position, right? So if a patient bleeds and you can't control the bleed, radiologists are not coming to the bedside and doing an angiogram. The patient goes to the angiogram suite. So we use the same logic and said that, shared with our group, and recommended that every ICU patient that needs an endoscopy, unless it's crashing, should come to the endoscopy unit. So they do come to the endoscopy unit. Even if they have a vent, they come to the endoscopy unit. And when you do your cases in the endoscopy unit, there you work in an environment where you know where things are. And if you get into trouble, hopefully there is somebody else or additional support from the technicians. So that's one thing that has made a huge difference in our practice by switching from going to the ICU and doing cases to bringing the patient to the endoscopy unit. It is something that, you know, depending upon where you practice, people may have a hard time to listen to what you're going to say, but it took almost six, seven months of working with everybody to make it happen. Yeah, it makes intuitive sense that the patient is stable enough to come down to the GI unit, that that's the preferred place for the procedure to be performed. That's where all of our tools are. That's our home environment, our home court advantage, so to speak. So I wholeheartedly agree. And just in having read that chat comment, it just makes me sad that someone gave up. Please don't give up. You just, you know, again, it requires education. And certainly there are faculty who will push a certain way of scoping. And what I tell fellows is learn from them, but don't necessarily, you know, take whatever works for your technique and learn from them. You don't necessarily need to do it exactly their way. It's hard when your attending is telling you to do it one way, not to listen to them. But if it becomes that it's actually painful for you to do it that way, then you just need to be empowered to try and speak up and hand the scope over to that faculty member to let them do it the technique way that seems that they seem to be pushing on you, but at the same time, trying to protect yourself from the injuries that may be related to that. All right, Dr. Raju, please take the floor. All right. First of all, I want to thank you, Amandeep. And I also want to thank Swati for a beautiful talk. I've just put this slide here because when you go out, not only as a fellow, but during fellowship, you don't have much control, but when you go out into practice, one thing that I suggest to you is make sure that you agree for breaks in between your procedures. And that will give you the time to heal, especially after a long day of doing cases. And the second one is lunch break. If you think about lunch break, think about it, you finish the case. After that, you have to go and put the report, then talk to the patient. If you actually talk to the patient, that's a good practice to talk to the patient and the family. Then you have to consent the next patient. And if you put a detailed, nice report, you hardly have any time for your lunch in that half an hour. So make sure that you have a one-hour lunch break. That will give you the time for you to rest. Otherwise, you're not, everybody will have their lunch break and you will be working like a crazy person and you'll be getting hurt. So something to keep in mind, having that break. If you're going into practice or wherever academic center, how you set up your schedule on day one of your practice makes a big difference. Once you get into a habit of taking half an hour lunch break and no lunch break, you'll not be able to change that because the institution likes you to do as many cases as possible. So if you don't want to listen in that thing, this is the most important thing that you should keep in mind. So if you look at this endoscopist and ask yourself what's going on, I think I see this with fellows. The moment the fellow is given a scope, he tries to get into either the mouth or into the colon without thinking about the configuration of the umbilical cord. So here the umbilical cord is twisted with a loop and that loop, I've not tested it. I hope Amandeep can actually test it. That loop adds extra strain on your left side and you need to make sure that you don't have a loop when you start your case. Something very important to keep in mind. So let us look at the procedure setup. And when it comes to procedure setup, you have three compartments here. The number one is the compartment where you stand and how you manage yourself. And number two is the compartment of the patient, the bed and the monitor. And the third compartment is your endoscope processor. Where is it located and how does the umbilical cord come to your left hand? And all these three components are very important so that you can do your procedures without getting injured or with the minimum amount of injuries, which can be compensated by taking those micro breaks and lunch breaks that are necessary. So let us talk about the procedure setup. All right. So if you look at it, there are two important things that both Amandeep and Swati have talked about. One is the the height of the patient's bed. If it is too low, you're going to lean forwards. When you lean forwards, you are going to put strain on your low back and you will eventually develop a low back pain. So that could be avoided by getting the stretcher to the height that we're going to talk about. The second one is if the monitor is too high, as Amandeep was saying that, hey, I've seen this monitor too high, I brought it down. So if the monitor is too high, you're going to look up and strain. And as you keep looking up, you're going to develop neck pain. I've known senior endoscopists who have developed severe cervical spondylosis and cervical myelopathy, to the point that they hated why they have taken up endoscopy as a profession. So you may not realize these small things. They all add up and increase the risk of your injury. So this is what I've learned from Amandeep, from her writings. I make it a point to adjust my bed to a height. The height is basically, instead of those centimeters, you should look at keeping your right arm at about right angles, or just a little bit down, that is so-called neutral position, so that you can enter into the mouth or into the colon. And that's the height of the bed that I would like to adjust. And I would like to adjust my monitor so that I could just look straight or a little bit down, so that it is easier on my neck. So these are the two most important things. You may have trouble if your monitor is not mobile, if it is fixed to a wall, or if it is sitting on a table where you cannot adjust the height. We have done those things in the past, but in modern endoscopy, you should have a monitor that can be moved up and down. And if you're planning to look at a practice and you don't have this thing, I suggest that you find another practice to join, because you will get injured eventually. Because your senior partner may have a different height, and if it is fixed to facilitate the senior partner's practice, if you're shot, you will pay a price. So think about that. The other one is, if the monitor is mobile, and if you have a mobile monitor, you want to make sure that you change the monitor position with the change of the patient's position. Say for example, you're doing a difficult colonoscopy, or in this picture, you see the patient from left lateral to supine. And now we do supine position when you're doing a peg, or a difficult endoscopy, or something like that. When you do that, what happens is, if you do not change the monitor, like the comment that I've seen, you may be standing straight, but you may be turning your head to the left. And if you keep doing that for a long period of time, and you keep doing that again and again, you are likely to develop injuries to the neck. So it's important when you change the position, you want to move the monitor so that you could look straight ahead. That is really very important to do. Whenever I'm doing a colonoscopy, if I actually, I tend to, as I'm coming back from the CECOM, I tend to put my patient from left lateral to a little bit supine position, so that the left colon distanced better. You can have a better examination of the left colon. You'll have more adenoma detection in the left colon if you just change the position from left lateral to supine. When you do that, then automatically, you may have to move your monitor to your left side so that when you're actually putting the scope in, you are not straining yourself. So those things, although they are small things, and you may be able to do the procedure in five minutes by straining your neck, avoid that temptation. Make sure you take the time to change the monitor so that you are aligned with the monitor. So here is the umbilical cord that I was talking about. I've actually seen this where I've felt by having the umbilical cord in a loop position, it tends to drag on your left hand much more, and that's not what you should be doing. You should disconnect the umbilical cord and take away the loop and then reinsert. So this is something that you want to do when you start your procedure. Sometimes when you have a very difficult colonoscopy with a lot of loops, with a very long mesocolon, you'll end up untangling the loops inside by getting the loop come from the insertion tube onto the umbilical cord. And once you create, take that loop from inside and put it on the umbilical cord, I do not proceed. I stop, I ask my assistant to disconnect my scope and take away the loop before I proceed. Because that's one thing that would actually minimize the amount of injury that you will have. Always take time, think about yourself, how to prevent injury. It is the feedback that helps you. So coming to the body mechanics. So we talked about the body mechanics. On the left side, you'll see an endoscopist who is stooping forwards. And if you think about it, look at where the patient is. The patient is in the center, in the middle of the bed. When I'm doing my colonoscopies, I tell my team that I want the patient to be close to the edge of the bed. That way I don't have to lean forwards. And I always stand a little bit away from the patient in a neutral position. A neutral position is you have a straight back, a little bit of your feet at shoulder width and your knees a little bit bent slightly and your neck a little bit, slightly flex with less pressure on different portions of your body. And that is always, you have to keep thinking if you are doing a part, if you're taking up a wrong posture, you should be able to correct it. Sometimes we get into the wrong posture, but having that feedback loop to correct it is very important for you to develop. So on the right side, on the left side, you know, one of you actually pointed out, right? You know, somebody is using too much of torque and that puts a lot of strain on your wrists. And I want to share with you something and I would like to actually record the video and put it out there. You could avoid torquing by actually doing one thing, that is stepping away from the patient. And I mean, stepping away from the bed will give you a lot of freedom to move your insertion tube. Instead of talking right, left, you can actually swing. If you swing, you can actually achieve the same effect as talking. The swing is easy because you're using large joints and talking is putting a lot of strain on your wrist. And I would like to show you what I mean by that in the next slide. As the endoscopist stands back, you're able to swing your insertion tube to the right or left without putting too much strain on your body or on your joints. When you're, in terms of holding your colonoscope, whether it's an EGD scope or colonoscope, if you hold as if you're holding the insertion tube with a pen grip, you can easily do the scope without the need for the torque. And the pen grip will work if you distance yourself and you hold the scope away from the bottom. If you hold your scope close to the bottom, the scope becomes like a rigid tube and you have to apply a lot more torque. But on the other hand, if you hold your scope a little bit away, it becomes much more easy and you can manage the insertion much more easily without putting strain. On the way back, get into the habit of using a towel or a gauze and loosely gripping on that so that the strain on your hands becomes less. You know, if you look at, go to a geriatric floor, you know, older people are using larger handles to hold so that it is not that difficult. Think about that. There is less strain on your hands if you get into the habit of using a washcloth or a gauze to hold and you don't have to pinch. So in summary, although it's important for us to have the bed height at the appropriate level, the monitor at the appropriate level, and how you hold the scope, avoiding the loop in the umbilical cord, I always want to share with you one thing. If you go to the gym and you're exercising, one of the things that the exercise physiologist or the physical therapist will tell you or a personal trainer will tell you is listen to your body. And if you feel that you're straining your body, you may have to change the way you do things. And that feedback of listening to your body and making appropriate changes will help you a long way. Thank you. Thank you, Dr. Raju for sharing all of that wisdom, really trying to give again, all of the fellows on the call, the importance of being able to pay attention to the signs and symptoms that you may be experiencing. Pain is a really important symptom. And if you're having pain, really recognizing that something needs to be done differently to prevent you from that pain to progress onto injury. And again, advocating for yourself. You guys know best what's going on. It sounds like there may be some units that are not set up with adjustability, but as Dr. Raju points out, if you're looking at jobs and they haven't set that room up to be adjustable to you, as I was told when I was looking for jobs for like the best you're ever gonna be get treated is during your interview day. If on your interview day, they haven't even made any attempt to accommodate you as an endoscopist, that's likely not the practice for you. Thank you, Dr. Raju. Are there any questions for Dr. Raju? Yeah, there was one question in regards to an earlier point about moving patients from the ICU to the endosuite. Would you consider moving patients who are on pressors or hemodynamically unstable? So when it comes to doing these cases, these cases are all done with the help of an anesthesiologist. So the anesthesiologist feels uncomfortable, then we go to the ICU. If the anesthesiologist feels comfortable that they can manage, then they come to the endoscopy suite. There's also one more question regarding disability insurance and us as fellows, is there anything we should be aware of? Should we be all getting disability insurance given all this kind of high risk of injury? I think I'll let Amandeep answer that question. I think she has written quite a bit about that. The answer is definitely yes. We should have time to just go over a short primer on disability insurance, but it's actually going to be the cheapest for you guys to be able to buy it now. And it's gonna be very important for you to protect your future to get that disability insurance. And there's many different types and most programs do offer some training on helping fellows pick out their best type for themselves, but definitely it's something that you should be looking into securing right now. There's one last question. The question is, are there any recommendations to empirically wear wrist splints while learning how to scope early on, similar to wearing wrist splints while lifting or exercising? I'm not aware of any recommendations specifically to wear wrist splints, but I think that gets to just making sure that you're trying to keep neutral postures while you're performing endoscopy. I think wrist splints can get a little bit tricky just in terms of keeping them clean between procedures and the like, but if you can just make sure that you're paying attention to how you're holding the scope and the insertion to trying to make sure that you have a neutral posture so that you're not extending or flexing, that's the most important piece. Certainly if you do develop symptoms that may be consistent with carpal tunnel syndrome, that's where the wrist splints are going to become more important. And at that point, hopefully you've been connected with a physical therapist or occupational medicine physician to help facilitate how that should be worn during work hours and off work hours. So I want to make one comment that, so we have seen a lot of people complain about left thumb pain. And if you ask yourself, left thumb pain comes when you're moving up and down your up down knob. And it's important to, before you take the scope and start the procedure, check your up down knob tightness. So if your scope has gone for repair and come back, your technician may not check what is happening. You'll just go and bring the scope and you set it up and you're in a rush to do the case. And imagine that it's a difficult, long, tortuous colon, right? And you start the case and that up down knob has been tightened too much. And then you are moving almost like a hard rock up and down, every small movement. I'll tell you, you do that, your thumb will be gone for a few weeks. So imagine that scenario and get into the habit of checking your right, left, up down knobs, whether they're loose enough. If they're too tight, you'll cause more damage to your thumb because you have to, like Amandeep talks about, how much of force do you generate and how long do you generate will actually determine how much of injury you're going to have for a sustained period of time. If you keep doing that for a sustained period of time, you're going to get it. Yeah, I think that's a really important point and we'll talk a little bit about it during the ergonomics timeout in a bit, but checking your scope is a really important piece of it. And sometimes, when I take the scope from fellows, when they haven't been able to do what I'm asking them to do, it turns out that the scope actually, the right, left dials or the up down dials are not able to turn in that direction or require too much force in order to turn in that direction. So sometimes when you can't do something, it's not you actually, it's the scope. And you guys are at too young an age to know that the scope can be that big of a problem, but there've been studies that have looked at scopes that have actually just come back after maintenance and still actually not meeting manufactured specified angulations. And so that's a really important piece is to make sure you've optimized your instrument as much as you can before you start and checking your scope like Dr. Raju is talking about is an important part of that pre-procedure timeout. All right, with that, I'll give the floor to Dr. Patel. Thank you so much, Dr. Patel, for talking about endoscopy ergonomics during pregnancy. Okay, thank you. Thank you so much for having me. So I'm just going to briefly cover this kind of micro topic within ergonomics. I'm going to go over why this is an issue, some of the physiologic changes of pregnancy that affect us as endoscopists. I'm going to briefly talk about radiation exposure because I know that was an issue for me and for other fellows. And then I'm going to end with some tips for maintaining good ergonomics during pregnancy. So women in medicine often delay pregnancy, and that often means that we are having babies either throughout fellowship or in our early career hood. When they've done studies of this, they show that female gastroenterology fellows are actually more likely to remain childless or have fewer children at the end of training despite marital status. And so a lot of us are putting our training first, and that leaves us as full gastroenterologists or gastroenterology fellows by the time that we are starting our practice. And so with childbearing, often falling during training or early career hood, you're going to often be in a position where you're learning how to do endoscopy or refining your technique and dealing with pregnancy at the same time. So going over some of the physiologic changes in pregnancy, as anyone can tell you who's been pregnant, there's a lot of changes that occur in a woman's body. So many of these are hormonal. So starting right off in the very first trimester, they increase estrogen, actually leads to a lot of nausea and vomiting, fatigue, electrolyte imbalances, and these can directly affect us during endoscopy. As the fetus starts to grow throughout the second and third trimesters, there's very significant changes that happen to the spine, including increased lordosis and kyphosis, as you can see in the diagram here, increased pelvic tilt and an altered center of gravity. With an average weight gain of about 25 or 35 pounds, that's really putting most of that force on your hips and on your knee joints, which when we're standing all day during endoscopy, that's an extra 20 to 30 pounds to be carrying around. The sacroiliac joint itself widens, and there's increased mobility, which leads to instability. That can lead to strained paraspinal muscles and round ligament pain. As we focus a lot of today's discussion on wrist and hand injuries, they are definitely more common in pregnancy, and this is due to fluid retention and hormonal changes. Throughout the course of a woman's pregnancy, there's actually been data to show that there's decreased hand-grip strength and increased wrist and hand strain, and as an endoscopist, you can tell that's going to directly affect your practice. Out of all pregnancies anyway, carpal tunnel affects almost a third, and so you can imagine in a career where we're using our hands daily, that number is just going to go up. De Quervain's tenosynovitis is another thing that we commented on. It's interesting to me when I did this literature search, it's also called a colonoscopist thumb or a mommy thumb, so when you're a mom and a colonoscopist, you get kind of a double hit there, and referencing Dr. Kala's study that she recently did that was excellent and really did bring to light numbers in pregnancy-related ERI, so 79%, just to go over that number, had new-onset ERI during their pregnancy, and as you can see in the table, 93% still performed endoscopies during pregnancy without really any alterations, and so there's a lot to go between understanding and recognizing these risks to women and actually feeling empowered to be able to make those changes. So to quickly touch on radiation exposure during pregnancy, this is a slightly side note from ergonomics, but certainly falls within the realm of being space and performing endoscopy. So the data really actually does support that there is a very minimal exposure of the fetus to radiation, even during endoscopic procedures, so the data is quite limited. So the two main institutions are the National Council on Radiation Protection along with the American College of Obstetrics and Gynecology, and they really recommend limiting occupational radiation to the fetus, obviously, and these are the numbers that they've set forth. In some small studies, they've looked at one directly within GI. They followed five endoscopists over two months, and they estimated that their annual abdominal dose was at maximum 3.6 MSEB, and they recommend that five is really the maximum to hit for the entire pregnancy, so you can see how someone would be underneath that. Studies out of IR have shown similar effects using one millimeter of lead, and in another kind of multidisciplinary study where they followed various kinds of physicians who are exposed to radiation, 30 out of 32 of them had just the background level throughout their pregnancy, and the two that had higher than background level were still less than 10% of the recommended levels. So in terms of how to kind of progress through a pregnancy while still scoping, and especially as a fellow, I think it's really important to understand the various kinds of symptoms that you might have and how to address them. So in terms of nausea, which can be quite severe for some women, especially if you develop more severe symptoms, you can use different medications and products, certainly, and keep them with you in the endoscopy suite. I think this often occurs in a first trimester when perhaps a pregnancy is not yet disclosed, and I think being candid with your staff or at least a technician or a nurse that you feel comfortable with, but what's going on is that they might need to take part in the case, that can be very helpful. And then in terms of helping with things like back pain and wrist pain, there's limited data, but there's certainly anecdotal support to using things like pelvic support bands and wrist supports, which I know came up earlier. Anti-fatigue masks and supportive footwear that we recommend anyway become all that more important. While this has not really been studied, there is support outside of pregnancy to try to perform endoscopy spinning on an adjustable stool, and I'll show you some figures of that. And then really using a lot of the same great techniques that we know are important throughout a regular endoscopist career, such as maintaining neutral posture, everything that we've talked about up until now, using breaks throughout your procedure. And then in terms of the more specific symptoms like lower extremity edema, compression stockings can be helpful in elevating legs between procedures. And with radiation exposure, I think it's really important to understand the resources that are available. So almost every hospital by mandate has to have a radiation safety officer, and they can meet with you privately to discuss a plan if you plan to be doing procedures that expose you and the fetus to radiation. Using appropriate lead and a fetal distemmer can be helpful as well to really make sure that you feel comfortable throughout the pregnancy about the radiation exposure to the baby. And using lead or protective shields that aren't physically on your body, so curtains and maneuverable shields can be another option as well. So this is just an example of some of the changes that need to occur when a woman is pregnant. So you can see maintaining that same neutral posture when standing just becomes all that more important when there's a growing fetus kind of between you and the patient. And some women may find it helpful to use a stool that's adjustable. And again, this becomes really vital when you have a setup that allows for that with an adjustable bed and an adjustable monitor as well. So I just, this hits near and dear to my heart. This was on the left. You can see Dr. Struggle in the background. That was my first pregnancy when I was a fellow. And the point I actually wanted to make is my second pregnancy on the right was while I was an attendee. In my first pregnancy, I developed thick varicose veins tenosynovitis. I had to get steroid injections, and I was really cognizant of that going into my second pregnancy. And even though my scoping volume was much higher as an attendee, I've been able to avoid any thick varicose veins with this pregnancy. And so I think really taking to heart and implementing some of those ergonomic strategies that I've learned can actually directly make an impact on your life. Thank you, Dr. Patel. Are there any questions for Dr. Patel in the chat or Q&A? There was one question, which I think you kind of answered already. Somebody was asking about, would you recommend sitting while scoping, especially in like third trimester pregnancy? Yeah, I recommend certainly trying. You know, this is definitely one of those situations where you have to listen to your body. And for some people it might be more comfortable, and some people it might be more uncomfortable. But if you have a unit that allows for it, so if you have adjustable beds, adjustable monitors, it's definitely something that is worth trying. Thank you so much for that important overview. I think this isn't a topic that we talk enough about. And I think the key point is again to empower fellows to really try and advocate for the things you need to be able to both survive an endoscopy day while, you know, even in your first trimester of pregnancy, and as it progresses, giving you the tools to be able to try and overcome the issues that are going to be compounded by the pregnancy itself. Thank you so much, Dr. Patel. So we're going to try and bring together everything that we've learned with these couple of next Polivy questions. So what's wrong with this picture? Can you guys click on what you see as an issue here? Yes, so that monitor. So this is unfortunately a real picture from the real endoscopy suite where the monitor was set this far high up and fixed and was not adjustable for the endoscopists. And so there was quite a few faculty members who were actually developing neck pain because of this monitor height. Okay, here, what's the issue? The bed, right, is too low, and because of that, I'm leaning forward. So anytime that bed is too low and you're leaning forward, that's going to put strain on that low back as Dr. Raju had talked about. Okay, so what's the issue here? Can you guys click on what you see as an issue here? Yes, so that monitor was set this far high up I don't know if this one's working because I'm not seeing anything show up, but this is an example of what happens when the bed is too high. So for instance, for me, when I take the scope from fellows, sometimes I may not adjust the bed immediately. And I've learned to because even just a few minutes of having the bed too high and really abducting your shoulders can lead to shoulder pain. So again, just highlighting the importance of having that monitor right in front of you so that you don't have any cervical neck rotation. The monitor should be situated so that your resting eye angle, which is about 15 to 25 degrees below the horizon falls to the middle of the screen. So again, having an adjustable monitor is key. And then adjusting that bed so that you can really have a neutral posture of your shoulder and elbows. So that's at about elbow height or about 10 centimeters below elbow height. So those are the most important things when you start out during a procedure, making sure that that monitor position, monitor height and bed height are optimized for your neutral postures. Sometimes like myself, the attending may come in and change the monitor position to accommodate everyone in the room, but certainly you guys should get into the habit of doing this at the outset. Okay, what's wrong with this picture? Exactly, so to Dr. Raju's point, that umbilical cord position is so important and you want to kind of line up where that umbilicus is to the orifice that you're going to be scoping. And here that's too far lateral for the colonoscopy it's going to be performed. So there's a lot of tension on that umbilical cord. And when there's tension on that umbilical cord that adds the tension on the scope itself. Okay, how about here? What's wrong with this image? Again, to Dr. Raju's point, that coil and the umbilical cord can really add additional tension to the scope. So making sure that you're starting out and providing yourself with every advantage before you start scoping. And to that end, what do you guys think are the essential components of an ergonomic timeout? So bed position is key. Stretching, making sure you're optimized. Monitor is a big one, yes. Monitor height and monitor position. Making sure you're in a neutral posture. And what I would add to this is the instrument as just popped up here, excellent. So for your ergonomic timeout, again, think about that monitor and bed heights that you can develop those neutral postures. And as Dr. Raju pointed out, think about where that patient is because does that patient need to be brought to that edge of the bed so that you're not having to bend over? Check your endoscope. So do that endoscopic procedure. Part of that timeout should be checking your up-down dials and your right-left dials and making sure that you have good tip deflection without too much force that's required to turn those dials. And then check your processor position. So again, thinking about those three zones that Dr. Raju talked about, the patient, the processor, yourself, and then the scope itself. So in the interest of time, I'm gonna skip these two questions because I did wanna just give a broad overview of disability insurance because I do think that this is critical for you as trainees. So disability insurance is important because it replaces a portion of your income, 50 to 70% depending upon what you buy when you're unable to work due to injury or illness. There's short-term coverage, which can get implemented almost immediately after an incident and can last between nine to 52 weeks, depending on the specific policy. And then there's long-term disability that doesn't take effect until after short-term policies end or after a pre-specified period of time after an acute injury, and then can last anywhere from several years to whenever the person turns 65. A key distinction to make is own occupation versus any occupation disability insurance. And as gastroenterologists, although it may be more expensive, most of us wanna get our own occupation disability insurance because we want to be able to cover our income if we're not able to function as gastroenterologists versus any occupation would be, can you function as a physician in any sort of setting? So understanding the difference between own occupation versus any occupation, really considering paying that premium for the own occupation is gonna be important to protect your salary. There's lots of different riders that may go along with the insurance. And again, this is sort of outside the scope of us to be able to go over everything, except for to say, just like we all sub-specialize in different fields within GI, there are many people who sub-specialize with this, and it's important to align yourself with an expert who could help guide you through all these different decisions. But there is, for instance, a partial or residual disability benefit that pays benefits in the event of a partial loss of income. So for instance, if you suffer an injury, you're maybe able to work, but not at 100% capacity, maybe at 70% capacity, this partial or residual disability benefit will cover that difference in your income. A future increase option is an important one to consider. This allows you to apply for additional disability insurance coverage, regardless of your health, as your income rises. So you'll find that at your first disability insurance appointment, they're often gonna require a physical exam and some baseline labs. And these future increase options don't require a check-in for your health, basically. It automatically will give you the ability to increase your coverage if your salary qualifies for it. And then a cost of living adjustment is something else that you can also build into your disability insurance. Again, there's lots of potential riders and having an expert on your side to help guide you through that is gonna be an important aspect of that. So I know we're right up against time, but are there any additional questions either through the audience, the chat, or comments from the panelists before we close? You know, Amandeep, I had one for Dr. Raju. I was quite fascinated that he was able to convince and talk to ICU and get the patients down to endoscopy if it permitted, if the health permitted. I had a question, kind of a follow-up question. We're often in the OR on-call doing procedures and fairly ergonomically challenging positions. In my case, probably biliary disease. So ERCPs at the OR are not fun at all for anybody who's done them there. Have you been able to do anything, have you been able to negotiate anything in that realm, Dr. Raju? So Swati, your question is about doing cases in the OR? Yeah, especially when we're on-call. No, we do all our emergency calls, even on the weekends in our own endoscopy unit. There you go. You know, the thing is, if you look at it, I'm hoping that when you're on an emergency call, you're using anesthesia to support, right? And as endoscopists, we work very closely with anesthesiologists. And we actually suggested to them that every case that is done, unless the patient cannot make it, we do it in the endoscopy suite. And the other thing is when I do a case in the ICU, sometimes what happens is the ICU faculty will try to give you the sedation or whatever because the patient is already intubated. I insist that the anesthesia be there, at least in our hospital, anesthesia will come and help support that patient because I had to deal with a very sick patient and the ICU faculty are good in giving propofol to put the patient to sleep, but they don't have the same skillset like an anesthesiologist can manage as you're dealing with a complicated problem. So we make it a point to have anesthesia available in the ICU setting and also bring all the patients to the endoscopy suite. It makes a big difference from the patient's outcome. I don't think anybody has studied this, but if anybody studies the type of endoscopic care that is provided in the ICU, my guess is not going to be optimal. You don't have space. You are in a very small room and you may not have all the equipment there. Somebody has to run to the endoscopy unit if you don't have a piece of equipment. Imagine all those things. Thank you. But if you talk to them, I'm sure, for the amount of work they do in the endoscopy unit, it is worth exploring that. Thank you. I would like to share one thing. I want to share this observation that I made when I was in Japan. This is regarding Shreya's talk. Women endoscopists, women physicians who become gastroenterologists delay their pregnancy until they get into gastroenterology or maybe even a little bit later. And they are actually putting themselves at a lot of risk on many fronts by doing that. When I was in Japan, I was really pleased to see this. One, the whole endoscopy unit takes a break. Between morning and afternoon session, there is a complete break. They all go for their lunch and a leisurely lunch, okay? The second one is, I've also learned that after the delivery of a baby, the endoscopist is given time off for one year, paid, paid. Fully paid. And they are not on call. If that endoscopist is a therapeutic endoscopist, they're not on call for five years because they value the importance of taking care of kids. Wow. I had a baby four months ago and I've already been on call, so. No, no, no. But you know, if you look at it, we think about and talk about wellness, but we don't do a damn thing. As a mother, you must be up all night and then you have to go back to work the next day. Yeah. I'm just thankful for the VA now is actually supporting maternity leave because previously it was, you had to use your own vacation and sick time and there wasn't the paid parental leave. So that's been huge that the VA finally does that as a government institution. And I was also- That's how far behind we are. Yeah. I was also quite disappointed to see that the hospitals do not really support moms who are breastfeeding their kids when they come to work. Whatever. Yeah, I didn't cover that myself in this talk, but it is another challenge coming back and having a full schedule for endoscopy and having time to be able to pump twice or three times a day is difficult. Yeah. You know, one comment I want to make and share with the fellows as they graduate is how you set up your practice in the first week will determine what's going to happen to you. If you are in a rush to outdo all your faculty, colleagues or partners to show that you can outwork them, that is going to be your standard. Nobody is going to bring that standard down. That's what you need to reach. So make sure that you plan your time in the endoscopy unit the way you should so that you can practice endoscopy for a long time. By the time you become an endoscopist, you're in your mid thirties and you don't want to burn out in another 10 years. I want to thank everybody. I know we're over time, but a really big thank you to all of my co-panelists today. I think that this is just such an important topic for us to make sure that our fellows are aware of how to protect themselves and how to advocate for themselves. So thank you all so much. I know that there was going to be some final housekeeping items. Is Marilyn on? Yes, I'm on. I just want to say thank you again to all our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASG educational events, especially if you're going to DDW in San Diego, or if you want to view it virtually as well. We have a lot of offerings coming up for fellows at discounted pricing and actually complimentary as well. So check those out on our website. Next ENDL Hangout session will take place on Thursday, May 5th at 7 p.m. central time. Management of esophageal strictures, simplex and complex. And then at the conclusion of this webinar, you will receive a short survey. We would appreciate your feedback. And as a final reminder, if you haven't signed up yet, membership for fellows is only $25 a year. Make sure you take advantage of those offerings that ASG has. And in closing again, thank you again to all our panelists and moderators for tonight's excellent presentation. And thank you to our audience for making the session as interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a good night. Thank you, everyone.

repetitive strain injury

ergonomics

endoscopy

injury prevention

upper extremities

training

endoscopists

patient outcomes

proper posture

monitor height adjustments

pregnancy

supportive gear

disability insurance