All right, that was a wonderful talk, and you know, colonoscopies are humbling. No matter where you are and how many you've done, they're humbling. And you know, I often tell this story, you know, I've had a long day, I've done ERCPs and ESD poem or something, and I come home, I'm tired, and my wife sometimes will still ask me, did you reach the C cup? So this is a true story. This is true. She does that. So they're quite humbling. So anyway, so let's move on to our next speaker. Our next speaker is going to be Dr. Lisa Cassani from Emory University and the Atlanta VA. She's going to be talking about another very important topic, often neglected, and that's going to be ergonomics. So we're looking forward to it. So thank you to ASGE and to our course directors for having me. I love this course. I'm so happy to be here. So I'm going to talk to you about ergonomics and endoscopy today. Ergonomics is about optimizing equipment, endoscopists, and your work environment in order to maximize your well-being and mitigate your risk of injury. I have no disclosures. So the objectives today are to understand the scope of endoscopy-related injuries and fellowship, and prioritize potential ergonomic interventions. And that can be pre-endoscopy, intra-endoscopy, or post-endoscopy, and we'll talk about all three of these. And then we'll discuss a little bit about minimizing injury risks during pregnancy. So endoscopic injuries in GI fellowship are common. Survey studies suggest that up to 50% of GI trainees report an endoscopy-related injury. Now, back when I was a fellow, I can feel my 10-year-old rolling his eyes while I say that, but we didn't talk about ergonomics at all. So we didn't talk about ergonomics, we didn't talk about endoscopic fitness, we didn't talk about well-being. And I was one of these fellows. I was one of the 50%. So about eight months into my first year, I had terrible back pain. And I spent about six months in physical therapy trying to get it better. And luckily, it did get better. But no one talks about it. No one told me to raise the bed. No one told me where to put my monitor. It's great that we're talking about this now. So about a third of GI fellows are female, and this is important because the endoscope was not made for a woman. And so our scopes that we use and the devices are not ergonomically designed for us. 97% of GI fellows would like mandatory ergonomic training, but less than a third of them receive formal training or hands-on, as far as dynactics or hands-on training. So we're starting here. Poor ergonomics in pregnancy can lead to complications such as preterm labor and low birth weights in the babies. There's lack of institutional safeguards for staff, and then there's lack of training and evaluation of trainers by programs and governing bodies. So although there's no standardized education at this point, ASGE has put out this core curriculum document. And I will mention that your fearless leaders are authors on this, increasing the pressure on me just a little bit to give a good talk today. But they're a fantastic paper, and it really goes over some nice topics about ergonomics. So integrating ergonomics into endoscopy training, like I said, that there are different phases, in which case we can look at how to incorporate ergonomics. You'll develop cognitive skills, the technical skills, and then the non-technical skills, which we'll talk a little bit about. And then personalized feedback throughout the whole thing. All of these portions really are key to developing good techniques. So pre-endoscopy interventions mainly focus around education and empowerment. So education like didactics and online tutorials, and then setting ergonomic-related goals in addition to the technical skills that you want as far as goals during your each day as you're deciding kind of what you want to work on. Initiating open communication among all team members, taking breaks to avoid overuse injury, and then considering an ergonomic timeout. So I don't, you know, announce this formally when I go to each, before each procedure, but I do this consciously or subconsciously every time a patient comes into my endoscopy room. So the bed rolls into the room, and I make sure that the monitor's in the right place directly in front of me, about 15 to 25 degrees below eye height, so you have a normal relaxed look. The bed is raised, positioned between elbow height and about 10 centimeters below elbow height. Your endoscopy tower, the insertion of the endoscope is in line with the orifice to be intubated, so either the bottom or the mouth, depending on what you're doing. Your foot pedal is slightly in front of your body, so you can be in a relaxed position when you go to use water. Your cords and wires shouldn't be all tangled around everywhere so that people can fall over them when they're trying to get devices or if, you know, unfortunately an emergency happens. I can't stress enough about having a cushioned floor mat. They are fantastic, really helpful, and can really help take kind of weight off of your or the kind of hardness of the floor against your feet can be really helpful. If you're using lead aprons for ERCP, trying to pick a two-piece apron instead of a full one-piece, and we'll talk about that a little bit more. Your position, it should be neutral posture with your back straight, upper extremities kind of neutral, square to the monitor, and your feet hip-width apart, and again, we'll talk about these things a little bit more. Your endoscope positioning should be horizontal positioning of the head of the colonoscope, shaft in a C position, and your finger grip about 15 to 30 centimeters from the patient's bottom. And then using communication to encourage team members to raise any concerns they have, and I would suggest going one step further than that, and being an advocate for your team, a happy team leads to a good day. So, you know, share your cushioned mat with your tech. If she's trying to, she or he is trying to get a biopsy forcep out of your scope, you know, bring it a little bit closer so they don't have to lean over, grab a wedge to prop up the patient so that every time, you know, they don't kind of roll back with sedation and then your nurse has to come over and push them back up, and then, you know, for goodness sakes, get anesthesia a chair, let them sit down. Introduce yourself to all the staff in the room, tell staff you like to focus on the ergonomics, at least tell your trainer, you know, I'd really like to think about this today, ask for feedback about it, you know, I'm just because of my history of this, I'm pretty conscious of saying things to fellows, I cannot tell you how frequently I say, stand up, stand straight, look up, you know, just to talk about it, just to, you don't notice it while you're doing it, but your trainer should. So intraendoscopy interventions, so this is more about technique, positioning of the tower, the monitor, the bed, the learner, and the teacher. Not all endoscopy suites are ergonomically designed, some of them obviously, you know, a lot of hospitals are on the older side, they're not something that you can modify, so you have to do, you know, if that's the case, you have to do what you can, but if you do have the opportunity to scope in an ergonomic environment, then that's really great. So again, your tower should be right behind you with the insertion of the scope in the tower in line with the orifice, your monitor should be directly in front of you at eye height or about 15 to 25 degrees below, your bed should be raised up to your elbows or about 10 centimeters below that so that you're in a comfortable place to put your arms. You should be in a neutral position, I promise you that standing on your tiptoes and craning your neck is not going to make the scope go up, I promise. It also, going like this and trying and looking, that does not make the scope go to the right, it doesn't, it's just going to hurt you. So try your best to not do those things, it's really hard, really hard, because I even think, sometimes I think to myself, I see myself going like this, I'm like, that's not helping. So just try and be as neutral as possible. And then remember, you can change your monitor or your position during the procedure, right? So if the patient needs to roll supine, you might need to raise the bed a little bit, you might need to move your monitor over so that you can look at it. So your body might change position and your patient might need to, or your positioning of the rest of the equipment in the room might need to change. So I'm not going to ask you to admit it, but I'm positive that most people in this room have a death grip on the shaft of the colonoscope with their right hand. Maybe because you are so terrified that the CO2 that you insulated the sigmoid with while you're trying to flail around in the rectum and get out of it is going to explode out of the anus, and the colonoscope is going to fly across the room, and then that's just not good. The chances of that happening are very small, okay? So you really, really don't need to hold on to the scope that hard, because you're going to hurt your hands, okay? So usually, so kind of what most people are going to recommend is using a finger grip with fingers and thumbs and be light. I don't actually do that. I use my hands, but I do it very lightly. Then the other thing is putting your colonoscope in a C position and starting in this neutral position so that you use the up-down wheel and more torque to get around and maneuver. So the position of the trainer is important mostly so they can provide feedback for you. So the trainer being on the side where they can see your hands, can see the patient, can see the monitor and both the monitor for the patient's vitals and things and the scope. This is kind of the setup with colon and with EGD. And so also within the intraendoscopy, the ergonomics-focused instruction, you can ask your trainer, hey, can you watch me and comment about this and give me feedback? Don't be afraid to speak up if you're uncomfortable. Like if you are twisted in a pretzel and you're like, oh, this hurts, I mean, say something. And then risk mitigation. So the concept of microbreaks is really interesting. So I obviously probably not with like a 10-minute EGD that you don't have to do this. But as a therapeutic endoscopist, I get referrals for a number of incomplete or difficult colons. And so often, getting to the CECM is pretty difficult and requires my text to be provided with a lot of abdominal pressure. We have to do position changes. And so for me, a natural break, this microbreak is when we get to the CECM, to take a minute pause and just kind of regroup. And everyone kind of takes a break and rests. And we make sure that I'm in a good ergonomic space. And then we refocus. And that way, we can have time to kind of regroup. And everyone is fresh to come back and actually do the work that we're there for, which is to screen and find polyps. A lot of people really rave about compression stockings. I don't personally wear them, but I know a lot of people that have had really nice relief from them. Again, the anti-fatigue mats, I think you guys know I'm a lover of those by now. And then two-piece lead aprons, which is what I use for ERCP. It's really helpful to take weight off the shoulders. And it more centralizes things onto the hips. Post-endoscopy, this is really about feedback, figuring out what you can do differently and better, and then taking breaks between procedures to promote your muscle recovery. Also stretching and then exercises for your fingers and wrists and shoulders and back can be really helpful. So this is a hierarchy of controls that's developed by the National Institute of Occupational Safety and Health. And this basically talks about what kind of changes we can make to minimize risk. And so the top part of the upside-down pyramid is the most effective, but actually the hardest to implement because it requires buy-in from industry. And that is changing the endoscopes and changing your endoscopy suite, which is not really something that necessarily you can do on your own. The bottom half of the upside-down pyramid is not necessarily as effective, but is more readily available for you to do. So personal changes, like changing your techniques, doing stretches, having physical fitness goals, and then doing the training of ergonomics. And then I can't emphasize enough making sure your endoscopes are maintained because wear and tear on them can make it harder for you to do your work, too. So we're also going to talk a little bit about pregnancy tips. I know this doesn't apply to everyone in the room, but I have three kids. I had my first kid as a third-year fellow, and then the second two as an attending. I did endoscopy throughout all of my pregnancies. I'm happy to speak with anyone, either here or offline, about it. I cannot emphasize a lot of these things enough. So hydration, really, really important to stay hydrated. If you are going to be having exposure to radiation, I did ERCP through both of my second two children's pregnancies. There is something called pregnancy lead. I didn't know about it until a couple years ago, but it's effectively like double lead. So I actually wore a second set of lead on top of my regular lead. And then you can get fetal monitors that go under the lead. And then compression stockings can be really helpful in pregnancy. Support devices when your ligaments get more lax, and they make kind of like belly bands that can help. I know people that have sat during pregnancy, although I also know people that sit for endoscopy as well. And I also know of some people, I didn't have to do this luckily, but who have felt so unstable that they've kind of put their pregnant belly on the bed kind of as support and then scoped it that way. So figuring out how you can manage in a comfortable way that is safe and doesn't cause more injury is really important. So the role of GI fellows is wide. So there are lots of things that you can get involved with, with ergonomics. And be someone at your institution that really promotes this, because it's very important. And so just to summarize the different things, so make sure you have your monitor position in front of you, bed up, neutral position, athletic stance, proper grip, cushion floor mats, compression stockings if you want to wear them. Do that ergonomics timeout, take a break and just kind of make sure that all of these things are set up in your room right. Take those micro breaks and stretches. I want to acknowledge these two ladies for helping with this slide set. And then any comments or questions? So the question is, is there any evidence to support a specific daily endoscopic rehab or mobility routine? Gosh, not that I'm aware of. If there is, I'd really like that. I don't think, I think, you know, with this is kind of more on the newish side. I think that there are a lot of these studies that are happening, trying to figure out what might be the best exercises and things that we can do to try and minimize our ergonomic or our risk with endoscopic procedures. But yeah, I don't know anything in particular that's been published. Most of the data has come from surveys.

ergonomics

endoscopy

injury prevention

training

equipment setup