Endoscopic ergonomics, this is a new topic that we wanted to talk about because it's something kind of like transportation that I think is in a lot of minds, no disclosure. So we'll talk about the prevalence of ergonomics-related injuries. We'll discuss ASGE guidance to prevent injuries and a couple other models that we can use as well as some other considerations. So a lot of what we'll talk about is centered on this ASGE guideline on the role of ergonomics for prevention of endoscopy-related injury. This is submitted by the Standards of Practice Committee in April of 2023. And we'll talk through, but a lot of it is still like transportation, not that much evidence, but really trying to go off of what we can learn from other areas. So the first poll, what is the overall rate of endoscopy-related injury? What do you think is the size of the problem? Yeah, this is a tough question, right? Well, you know, I think generally people are optimistic that the rates are low. Turns out that when this was evaluated in a meta-analysis, it estimates the overall rate to be about 57.7. So it ranged from like a high 40s to the mid 60s of endoscopists, depending on the trial, have had some sort of endoscopy-related injury. That's pretty darn prevalent. The sites, it wouldn't surprise you, for endoscopists specifically, there's a lot of injury in the hands and fingers, there's also in the back and neck, all in about 25 to 35%, you know, for each of those, to have injuries in those. And of course, multiple people have more than one, and that's what the number gets so high. Risk factors to be aware of. So not entirely surprisingly, it turns out that female endoscopists are at higher risk. This is because a lot of the studies are analyzing by glove size. And we do know that the endoscopy, the endoscopes were designed, you know, with a certain hand size involved in terms of turning the dials and stuff like that. And so it turned out that when analyzed by glove size attempt, it happens to map pretty strongly with female versus male. And that's why it turns out that it seems female endoscopists are at a higher risk. And that risk is 62% compared to about 45% with an odds ratio of about 1.8. So like 80% more likely end up with some sort of endoscopy-related injury. The second big category of risk factors, this is not going to be a surprise, greater exposure to endoscopy associated with higher rates of injury. And that, you know, that was analyzed in a few different ways. So greater than 15 years of practice. The second was in the number of endoscopes being done per week. So greater than 20 per week. And the third is by greater than 16 hours of endoscopy per week. So that means, you know, you might be doing either a few very long cases or a lot of short cases, but just having a scope in your hands for many hours per week is a risk factor for having an endoscopy-related injury. That part makes sense. So this was a great diagram, or this is the visual abstract from that paper that we discussed, the ASG guideline and ergonomics recommendation. We're going to spend a little bit of time talking this through. The first thing that I'll just note is if you look at all of them, you know, as you know, we often try to declare the strength of the recommendation as well as the strength of the quality of the evidence. And for all of them, it's either low quality of evidence or very low quality of evidence. But you know, they did the best that they could, reading for, you know, trends in the surgical literature, as well as what seemed to, you know, track from other areas of medicine, mainly from surgery. And I think this just highlights that there's more research needed, you know. I am by no means an expert in ergonomics and endoscopy, and frankly, there just aren't that many. But I think it's a topic that is important to think about, and hopefully we'll learn more as we go. So the goal here is to make everyone aware, and this group and this recommendation kind of highlighted in each of the recommendations, well, there's low risk to doing it, and we think it might be helpful, and there's some evidence for it. So we're going to make it a recommendation. So the first one is the ASG recommends ergonomic education to reduce the risk of ERI, kind of like in this talk right now, talking about ergonomics and making it something that you're thinking about when you're doing your procedures can be helpful to try to, you know, watch out for risk factors for injury and things like that. So that's, you know, picture number one. They're showing people watching a module, probably like you are right now watching the screen here. The second listed here is recommending a neutral monitor position during endoscopies to reduce the risk of ERI. So what they list here, and what was done in some of the studies, is that at the top of the screen is to be just 15 to 25 degrees lower than the line of sight for the endoscopist, and that's so it's not straining the eyes or you're not actually moving your neck up and down to try to see the screen, and the second component of the monitor placement is to have it 52 to 182 centimeters, or in our units, you know, 20 inches to about six feet, usually at the other side of the bed, and that's so it's not so close in your face, but also not so far that you're squinting to see some of the details of the image that you're looking at. I think part of what's important to realize here, and I'll talk about also later, is making sure that the equipment is able to do this, right, so making sure you have a monitor that's able to go up and down so you can be adjusted to the height of the person, to the endoscopist, as well as, you know, maybe even tilt to face the person depending on where they are. So recommendation number three is to use neutral bed height, and that again means that the bed is able to be adjustable up and down based on the height of the endoscopist, as well as the width of the patient when they're on the bed. I think what, so what they list here is, you know, to be adjustable from 85 to 120 centimeters from the ground so that the arm, the wrist of the endoscopist, or the arm is, you know, is about at elbow height, so you're not really like pointing up and not necessarily pointing really far down and not leaning over to be able to advance the scope or pull it out and reduce loops and things like that. Some common things to be looking for is, you know, is the endoscopist bending over to reach the scope, or are they like lifting their shoulders to try to get their arms up? I've seen fellows standing on their tiptoes, and, you know, those are probably signs that someone's just not comfortable. We might be able to adjust the bed height to help. The fourth is to use anti-fatigue mats to reduce the risk of injuries. This one is also, you know, it says conditional, and it's very low quality of evidence. In the discussion, it was really like these mats are inexpensive, and in the surgical literature in terms of short procedures, it's been seen to reduce pain and discomfort. And so the idea was it's not that expensive, they're easy to put in place, maybe it's worth doing, but they gave it a conditional recommendation acknowledging the limited information that we have about how it impacts endoscopy-related injuries specifically. The last one is taking micro breaks and scheduled macro breaks to reduce the risk of these injuries. So by definition, they said macro breaks is 30 to 120 seconds, so this is like when you're in the middle of a procedure, taking a quick break to maybe flex your wrist and give it a chance to recover from some really heavy torque. The second is to do targeted stretching every 20 to 40 minutes, and, you know, in the picture here, they show someone bending to their sides, or maybe just bending their neck forward doing some flexion exercises, and the idea with that is that it doesn't have to be for a very long period of time, but it's just between cases, for example, doing some short stretches. I'll mention that there are exercises on the GILEAP website, and the Mayo Clinic has like a PDF that's available that's targeted to surgeons, but, you know, is still applicable to endoscopists. The third is to have macro breaks, which are 15 to 45-minute breaks built into the schedule. This, of course, is a structural change, you know? Sometimes people have long turnover times, and that might end up being some of the macro breaks. Some endoscopists do half days, and then, you know, you have kind of a built-in break, or the length of endoscopy is not as long, so those are, you know, structural ways, but I think the idea here is to think about how you can incorporate breaks of different lengths and at different times through endoscopy so that you're not, you know, straining your muscles or components of any particular muscle group for an extended period of time. As mentioned here, you know, things to be thinking about, and I'll have in a future slide is, you know, what are the changes that are made structurally, and what do you do in designing your unit, versus what are the things that individuals are doing to check and be aware of their ergonomics? So with all that in mind, something that was proposed by a team from a VA, from the San Francisco VA, they talked about this at DDW this past year, is to do what's called like an ergonomic timeout. So they labeled it with an acronym, MYSELF, where, you know, it's covering a lot of things we discussed, which is M is to look at the monitor height, Y, an upside-down Y, is to hold your feet kind of shoulder-width apart and straight, so they're not bearing much on one leg or the other, S is to make sure that your scope is actually, has good knobs and doesn't require too much effort to be able to turn, E is elbows, so again, with the bed height, making sure that you have easy mobility of your elbow and not straining to go up or down, L is lower extremities, meaning that your, you know, your weight is balanced and maybe you have an anti-fatigue mat to keep you moving around and not keeping your knees hyper-flexed, and then F is free, which is that there's free mobility of your processor and your scopes, you're not like, you're kind of like not stuck in a particular rotation to try to torque your scope one way or the other. So, you know, here they built this nice mnemonic, and the point would be that the endoscopes might be able to check in with themselves right before starting a scope to see if they're set up ergonomically. I think it highlights that, you know, the really difficult part is just remembering to check on these things, and, you know, however many of these that you can do routinely through the day is protective as opposed to not thinking about it at all. So we've talked about some of the guidance, and I do want to discuss some other considerations. So I'll do a quick poll here. Your unit was designed with ergonomics in mind, if you know the answer. You know, that's pretty great. So more than half the people here think that their units were designed with ergonomics in mind, which is great. Sometimes I know they'll say that they did, but, you know, every once in a while, you're like, was it? You know, something doesn't quite seem right. So in practice, things may vary from how things were designed, but it's great that this really is something that at least half the units here are talking about this, it had been discussed. So great. All right. So I want to talk about how this relates to other team members as well. You know, all of this was about the endoscopist, but obviously everyone in the room should be thinking about their ergonomics. So monitor height, we should be thinking about it for all computers, not just the endoscopist. You know, obviously nurses are there ferociously documenting, techs are looking at things as well. So we want to make sure we're looking at the height of everything in the room. We want to make sure that the adjustable bed height is used for positioning and other activities as well. So the right position for the endoscopist might not be the same position as when the team is getting the patient into position. So, you know, again, a useful time to be adjusting the bed for any of them. We have a, you know, I'm 5'2 and working with a fellow who's 6'5, you know, we got to really make sure that we use the dials as we need to during a case. Optimize patient positioning and team member positioning. And this is really something that often is overlooked. It's not even in the acronym. So, you know, making sure that the bum is as close to the edge as possible so that the endoscopist doesn't have to lean over to reach. Right. So that's one of the things. That's really difficult in real life is you have, you know, the anesthesia room and where the nurse is going to sit. And depending on how your room is structured, it might be really difficult to get that monitor to be exactly in front of you or have it at the right height. And so just kind of working with everyone in the team to make sure that we're optimized as much as can be. And sometimes that's being creative with the angles in the room. You know, also like making sure the nurse isn't going to hit their head on the monitor or, you know, have to dig for the IV, things like that. Have step stools for team members as needed. You know, I've seen techs really leaning up and on their tiptoes to try to get to the top of a tower when they're cleaning the scope after procedure. So like having step tubes available or making sure we're aware of the height of the towers and things like that is really useful. And then, of course, design the booms and towers also for varied heights as much as that's possible is good. Really important back to the knobs that were discussed in the MICELF acronym, Endoscopy Maintenance Program. So, you know, after a while, it takes more effort to turn those dials and making sure that your scopes are actually updated and maintained so that they're not requiring more and more effort as they go out of spec. All right, so some practical and structural steps. The first is, you know, really just having a team approach, right? Everyone looks out for everyone else. Sometimes you know, I'll see a nurse at the station, I'll say, hey, sit up straight. And sometimes the nurse will say to the fellow, hey, your foot's in the air, you know? So they're just kind of being aware of each other and helping each other realize because when you're doing the scope and you're like, you know, knee deep and trying to get into that TI, you might not realize that you're twerking your head a certain way or you're bending your back. And so having other people there is really helpful. And the same for other ways around noticing when the tech is, you know, really leaning up to try to reach something or not comfortably handing you the snare and things like that. And I think a big thing here, and I hope that the leaders of the endoscopy units here can really take this away. And then also consider ergonomics when designing or purchasing equipment. So looking for those adjustable height monitors, thinking about the use of those anti-fatigue mats, positioning with anesthesia and other team members in the design of your room and the positioning of the towers, all of these components to really help, you know, make your place as ergonomically friendly as possible. So in summary, endoscopy related injuries are common. Individuals can use frameworks to try to protect themselves. As we showed in the picture today, units can make structural changes to support avoidant techniques. And, you know, consider support from all team members is again, a team support and we look out for each other. All right. With that, thank you.

endoscopic ergonomics

injury prevention

ASGE guidelines

ergonomic education

equipment design