So, I want to start off by congratulating you on starting your journey as a gastroenterologist. GI is a great field, and actually, of all the medical subspecialties, gastroenterologists have the highest professional satisfaction scores, but GIs also have the highest rates of work-related injuries, and that's because endoscopy is physically demanding. It puts unique strains on your body. So, essentially, the goal of this session is to make you aware of the problem and introduce you to the concept of ergonomics so that you can apply the principles of ergonomics to your practice to even during training, starting from training, to improve your well-being and prevent injuries. So, over the next 20 minutes, we'll go over the scope of endoscopy-related injuries during fellowship and describe and prioritize some ergonomics interventions that you can apply to pre-endoscopy, intra- and post-endoscopy phases of care delivery, and we'll go over some tips for minimizing injury risk during pregnancy as well. So, how big is the problem of ergonomics-related musculoskeletal injuries? There's been a lot of survey studies, and this is data from a study that was conducted by the Women's Committee of American College of Gastroenterology. And what they found was 75 percent of women and 79 percent of men in GI reported some sort of endoscopy-related injury. Women reported more upper extremity and upper back injuries, and men complained of more left – I'm sorry, lower back pain. What's also concerning was that women in GI who were pregnant during practice reported 79 – or 79 percent of them reported a new injury while they were pregnant, and 70 percent of them said that their pre-existing injuries got worse during that time. So, how about fellowship and fellows? So, more recently, within the last couple of years, we have data coming in that show that anywhere from 20 to 54 percent of GI fellows report pain and endoscopy-related injuries. So, this is a little concerning in many ways, but also because the demographics of our field are changing. Twenty percent of GIs in practice are women, but a third or more of GI fellows are female. And as we'll talk a little bit in the upcoming slides, our scopes aren't really ergonomically designed for women. What these studies also showed was that the majority of the fellows wanted mandatory ergonomics training, but only – actually, less than a third of them actually got formal ergonomic education or hands-on training in this regard. And there's several barriers, but probably lack of institutional safeguards for staff and lack of training and evaluation for your attendings might be playing a role in this. So, this slide shows you the common sites of endoscopy-related injuries and their contributing factors. So, most common – some of the most common injuries occur in the upper extremity, so your thumb, hand, wrist, elbow, shoulders. And for the most part, this is related to the biomechanics of scope handling. So, when you're scoping, you're grasping and stabilizing the control section in your left hand, you're holding the insertion tube in your right hand, you're constantly torquing. And all of these tasks involve repetitive motions with high forces, and these forces actually exceed safety thresholds set by occupational standards. And you're often, like, holding the scope in non-neutral joint postures. This is neutral wrist position. You might be holding the control section like this or this, and these non-neutral postures make you work harder to do the same job to increase the effort in your hand muscles and other connective tissues. So, that's one of the biggest reasons for injuries. And that, along with static loading of your muscles – so, static loading is when you're doing a job and you're not moving, so you're holding the scope and holding the scope in the same position for a long time. So, the muscles that are helping you bear the weight of the scope, they're not only activated throughout that task, but they're not getting enough blood supply either. So, that's one of the reasons why – I mean, you develop lactic acid in the muscles and you start having pain and injuries and so on. So, that's the reason behind upper extremity injuries. And in this context, one of the things to remember is that our scopes are a one-size-fits-all. So, they don't – the scope – the variation in hand size and grip strength is not taken into consideration. So, female endoscopists and those with smaller hands may be at greater risk of injury for this reason. Other common sites of injury are neck, shoulder, and back, and these are mostly related to non-neutral body postures. So, if you're looking up or looking down or twisting yourself, those might be reasons for neck, shoulder, and back pain, usually because your room is not set up properly. And then prolonged standing can lead to static loading in your lower extremities and that can cause pain and discomfort as well. So, what do we do about this? Can we do something to proactively prevent injuries rather than feel bad or complain afterwards? So, this is where ergonomics comes into play. So, ergonomics is essentially the science that helps you fit the job to the worker and not the other way. So, when you're fitting the job to the worker, you're taking into consideration the tools, the environment, and making it safe for the worker. And this slide shows something called the hierarchy of controls, and these are measures that we can apply to the job, the tools, and the environment to reduce the risk of injury to the worker, and these can be applied in endoscopy as well. A top-down pyramid, the measures on the top are most effective, and the measures on the bottom are the least effective. The top two measures are elimination and substitution, which are really not options at this time. And then we have engineering controls, which is making a physical change to the tool or the environment, and in the context of endoscopy, it's about changing our examples or changing our endoscopy suite, or, you know, the previous speaker talked about using clear caps to increase the efficiency of your job, so those would be engineering controls. And administrative control is about changing our work culture, and examples are, you know, doing things like ergonomic timeouts, which we'll talk about in the upcoming slides, and making sure we all get ergonomic training and so on. Last measure is personal protection, which is the least effective but also the most readily available for us, and this is like optimizing your technique and doing stretches, micro-breaks, maintaining your physical fitness, and so on. So the next few slides, I'm going to talk about some of these, prioritize some of these interventions that you can apply in the pre-endoscopy phase, intra-endoscopy phase, and post-endoscopy phase. Some of these are cognitive skills, like gaining knowledge. Some are technical skills, like improving your technique and knowing what to do with the knowing and doing, or changing your room setup. And others are non-technical skills, like developing better communication and leadership skills so that you can have your team be on the same page as you. And from a point of fellowship training, it's very important that all of this is integrated into your training and that you set goals for ergonomics along with other parts of your endoscopy training with your trainers, and that you get feedback throughout for this aspect as well. So in the pre-endoscopy phase, education and empowerment are key. What we know from survey studies is that physicians who have had some level of education about ergonomics had lower risk of endoscopy-related injuries. And you know, we saw previously that less than a third of the fellows were getting formal education. We're trying to actively change that, and this talk is, you know, an example of a didactic that would help. The ASG training committee came up with a great core curriculum for ergonomics and endoscopy that you should look into and share with your co-fellows and program directors as well. There's also other didactics and lectures online and through other GI societies and on GILeap that you should be checking out. It might be very intimidating to walk into the endoscopy suite and start talking about ergonomics, but it is very important that you take ownership of your personal safety and your learning experience, and so to implement all of these changes, communication is key. As the previous speaker mentioned, you know, go out there, introduce yourself to your team, let them know that you're interested in ergonomics, and actually empower them into looking out into their personal safety and ergonomics as well. And as a team, you can perform an ergonomics timeout prior to each procedure, and we'll go over in upcoming slides what that would look like. Moving to the intra-endoscopy phase of care delivery, the three important things are room setup, technique, and solidifying teamwork again. So you heard about room setup a little bit in one of the previous slides, but this slide has a lot of information that will help you set up the room optimally. So why is room setup important in the first place, right? You want to maintain a neutral or ergonomic stance throughout the procedure, and a proper room setup should facilitate that. And what is a neutral stance, right? Some people call it ergonomic stance, athletic stance. So you're looking straight, the monitor's right in front of you, your shoulders are back, relaxed, down, and your back is in a neutral position as well, and your elbows are at 90 degrees to your axial body. And this is important because this posture allows you to be the most efficient, as well as have the lowest risk of injury. And to facilitate that, you have to position your monitor, your bed, and tower appropriately. So your monitors, and in this picture, the monitor is hooked up to the wall, but a lot of you might probably have screens that come off of booms. So the screen should be straight in front of you, square in front of you, and the center of the screen is where your resting gaze should fall. So that resting gaze is usually 15 to 25 degrees below your eye level or horizon. So adjust your screen so that your resting gaze hits the center of the screen. And the bed position's also important. The bed position should be at your elbow level to 10 centimeters below the elbow level, and that allows for neutral back and shoulders. In this context, patient positioning is also very important. Patient should be as close to your end of the bed as possible, and that way you're not leaning over or hunching over to get to the patient while you're sculpting. For other things, your legs should be hip-width apart, and you should be bearing weight equally on both sides and not shifting your weight onto one side. And in the endoscopy unit, you have foot pedals of various sorts for water pump, your electrosurgical unit. You need to make sure that those are positioned right in front of you so that you're not, you know, twisting yourself or getting into awkward positions to get to the pedal in the middle of the procedure. And the tower, which is the part of the picture you see it right behind the endoscopist, and that's where the processor is, that should be behind the endoscopist, and the point of insertion of the scope into the tower should be in the same line as the orifice that you want to intubate. There's a few other things that you can do to improve your posture and comfort in the procedure room. One of them is cushion mats. And they may not be available everywhere because you have to, like, clean them up and stuff, so cushioned insoles might also be helpful. And compression stockings also can help you with that. And remember the, you know, once you start the procedure and you have to change, the patient has to change positions or, you know, for, you can actually, like, you should continue to maintain an ergonomic stance, and you get that by adjusting the equipment throughout the procedure. And we talked about equipment, so how about people? So obviously a nurse, and so this slide is showing you where different personnel and staff involved in the procedures can be stationed for upper endoscopy and lower endoscopy. One of the anesthesia nurse and technician usually are at the head of the bed. And your trainer attending should ideally be next to you on the same side of the bed, on the right side of you, and that way they're able to keep an eye on the patient and the scope monitor, make, you know, evaluate the procedure progression, but also see how you're handling the scope. And this is an example of ergonomic timeout checklist that you can use to get all of the things that we discussed previously. Make sure you have all of these in place before you start the procedure so you get the best out of it. In the intra-procedure interventions, technique is very important. And you heard a little bit about looping in the previous talk. So maintaining a straight scope is important for many reasons, one of them being you get the maximum tip deflection by moving the wheels or rotating the insertion tube when the scope is straight. If you have loops, you're going to have to work much harder to deflect the tip. And optimizing grip, that's another important thing. And all of these things are, you should pay attention right from the get-go because we start developing muzzle memory for these things very quickly and go into an unconscious phase of doing things. And how we do and what technique we adopt from the get-go is going to set us up for either success or failure from an ergonomic standpoint as well. So these are things we should be paying attention from the very beginning. So in terms of holding the scope, a lot of us, when we start, we have a death grasp on the shaft of the scope and we're torquing with our wrists. And that can lead to a lot of wrist discomfort and right-hand pain. And there's really no one best technique that's described. We don't have a consensus on what's best. But what I'm going to show you in this slide and the next is what's endorsed by experts in the literature and the ASG core curriculum. So in terms of holding the scope, there's three ways of holding the scope that you see on this slide. The first is a neutral thumb, where you're holding the scope very lightly. And your thumb is in a neutral position, not hyperextended, not hyperflexed. And it's an easy, comfortable grip. The second picture, what you're seeing is you're holding the scope with the washcloth or a rolled-up gauze. And the grip is a fist grip, where your fingers are turned towards the palm. And this is actually a very powerful grip. And also, holding the and using a washcloth or gauze increases the diameter of the scope. And that actually makes the grip more efficient and comfortable for you. The third picture is what we call the left-hand shaft grip. So this is Dr. Rext, who's one of our big colonoscopy experts, talks about this. But essentially, you're letting go of the shaft with your right hand, grasping it with the fingers of your left hand, and using the right hand to help you move the right-left angulation knob. I have short hands, small hands. And I personally feel that this is comfortable for me. So with all these techniques, the things that you need to consider or actually look into is what works best for you in terms of not only getting the job done, but also the comfort in your hands. So the ASGE core curriculum talks about the C technique for colonoscopy. This was developed in Europe to help their endoscopists with their ergonomic problems. So this is a way of holding the scope for colonoscopy. And essentially, so normally, we're holding the scope vertically. This technique, you're holding the scope horizontally. The control section is in your left hand, and the shaft is supported on the bed. You're holding the insertion tube about 15, 20 centimeters from the tip. And it's a finger grip. And instead of twerking from the right hand or the wrist, you're rolling the insertion tube like a cigar roll. And I'll show you a video that Dr. Walsh demonstrating this video, I mean, this technique. And essentially, what you see her doing is for twerking the scope, she's using the left hand to steer the big muscles of the left hand are helping with the twerk. And that reduces the strain on the right wrist. And the other advantage of this technique is that you see her holding the scope horizontally. That position of the control section allows your thumb to reach the dials more easily. It's also seems to be better for weight bearing. To be honest, this is not a technique that I was trained in, but I did learn this technique from her during a recent train-the-trainers course. And I do find it helpful, not only from an ergonomic standpoint, but also keeping the scope straight. A few other things, risk mitigation. Try to take micro breaks during your procedures. We talked about static loads. You're holding the scope in the same position for a long time. So if you have a few seconds, even a few seconds, when you're waiting for your technician to hand over a biopsy forceps or snare, let go of the scope for a little bit, change your position, shake your hands. And that'll help your blood circulation and relieve your muscles off of those static loads. And two-piece aprons are better than one-piece aprons if you're doing fluoroscopy procedures. So if you're wearing a one-piece lead apron, there's a lot of pressure that the lead puts on your shoulders and the discs in your vertebral column. And now if you're wearing two-piece, that'll help distribute the weight equally between your upper body and your lower body. And again, throughout, it's important that you have your trainers give you instruction in ergonomics as well. And endoscopy is a team sport, so you should involve your team. Talk to them about what's working, what's not working. And also consider the fact that ergonomics is for everyone. In general, all health care workers, including our endoscopy nurses and staff, are at high risk of developing work-related injuries. So if you're asked for pressure or help with moving a patient, make sure that they're not getting hurt. As soon as you don't need that pressure, be cognizant of the effort that they're putting as well and ask them to let go. And post-endoscopy, it's about feedback. We talked about that and recovery. So the survey studies that I alluded to previously show that taking breaks between procedures, regardless of the length of the break, help with reducing the risk of endoscopy-related injuries. So micro-breaks, two minutes, up to two minutes, meaningful movement break. Or you could do targeted stretching micro-breaks, where you incorporate stretches, endoscopy-specific stretches into those breaks. And then macro-breaks are longer breaks that have to be built into your schedule. So I have two resources listed on this slide. One is from ASGGI-LEAP, and the other one is from VideoGIE. And they're both excellent resources for stretching and strengthening of the muscles involved in doing an endoscopy. And then in pregnancy, as we heard about before, there's an increased risk of endoscopy-related injuries. And that's partly because of the physiological changes of pregnancy, where the ligaments are laxer and the center of gravity is changing. So you have to make room position adjustments accordingly, according to the changes in your center of gravity. And in the later stages of pregnancy, seated endoscopy might be helpful. You should make sure that if you are pregnant during fellowship or even after, make sure that you have enough breaks between your procedures where you can eat and hydrate. And then things like wearing compression stockings and support devices can be helpful. And then during pregnancy, but also anyone in general, talk to your radiation safety officer and familiarize yourself with what your institution safety, radiation safety protocols are. And make sure you're wearing appropriate lead protection, as well as personal fetal dosimeters during pregnancy to measure your radiation exposure. So to sum it up, make sure that your room setup is endoscopy-centric so that you are maintaining a neutral stance throughout by adjusting your monitor and bed positions. Focus on your technique and try to use things like cushioned mats and compression socks for your comfort. Consider doing an ergonomic timeout. Try to take some micro breaks during procedures and some breaks between procedures. And do some stretching and focus on your physical fitness. So we have a lot to do in the field of endoscopy, I'm sorry, endoscopy ergonomics. And I urge all of you to become ergonomics advocates in your programs. You should make sure that your fellowship programs are giving you enough instruction and speak up if you see anything that would cause poor ergonomics. Gaps are always an opportunity. So there's a lot of opportunity if any of you is interested to do research in this field, collaborate with your physical therapist and occupational therapy colleagues to start new programs in your institutions and participate in curriculum development. You should also consider doing advocacy efforts on social media. Appeal to your GI societies, appeal to industry for better design of scopes, or like Dr. Christie said at the beginning, you could develop your own new scope that would help with ergonomics. So that's all I have to say. Thank you, Dr. Dunleavy and Dr. Walsh for the content in this slide. And I'll take any comments or questions at this time. Thank you.

ergonomics

gastroenterology

work-related injuries

endoscopy procedures

ergonomics training

prevention