I hope I've been able to explain to you why we're at risk. This is of no fault of our own, it has to do with, again, our muscle mass, our ability to attain neutral postures in this misfit of tool and environment, but there are things that we can do by applying the hierarchy of controls to begin to control these risks. So the hierarchy of controls tells us what are the most effective to the least effective mitigation measures that we should start thinking about if we're having issues in the endoscopy unit. And this has to do with both the design of tools, which we don't have a lot of control of currently, but ideally are built with that fifth percentile female to that 95th percentile male in mind, allowing everybody to attain neutral postures and really work at very low forces within safe exposure limits. What we probably have the most control over is the design of our endoscopy suite, so thinking about, again, how can we accommodate that full breadth of users so that they can attain neutral postures? Elimination and substitution are the most effective hierarchy of control methods, but that really is, requires our device companies to consider prevention through design and user-centered design. So what we're really focusing on here is going to be engineering controls, which is like physical changes to the work or workplace, administrative controls, which change the way we work, and then our personal controls, but I would just point out that we're at the bottom of this upside-down pyramid, so anything that we do in isolation may potentially be the least effective, although, again, it's sometimes the only things that we have available to us. So I just offer this up as a reference. This is a top tips that was published in GIE earlier this year, which sort of reviews what I'm about to talk about in greater detail, which is if you are having pain in the neck, back, and shoulders, for instance, the risk factors for this are going to be non-neutral postures related to the room setup, potentially fixed monitors, non-adjustable beds, and the static loading of performing our procedures. And so when we think about engineering controls, this really requires adjustability, adjustable monitors, adjustable bed. The administrative controls is going to be ergonomic education, as well as this idea of an implementation of a pre-procedure ergonomic timeout, because, for one, we do need to ensure that adjustability, but once that adjustability exists, we need to make sure we're using it in the rooms to really optimize the room for ourselves. And so this is what you guys are going to be spending time with Dr. Wen-Jie Shen, as well as Karen Woods with. If you're having pain in the distal upper extremity, this is likely related to the non-neutral postures that we have to assume in order to interact with the scope, the repetitive high force exertions while holding and manipulating the scope, as well as the static load of just holding that scope, which can, after an hour-long colonoscopy, sometimes feel quite heavy. So again, thinking about engineering controls, while these are the most effective, there really are not a lot available to us. And so the interaction between the tool and the endoscopist continues to be quite poor. So these right-left dial adapters have been used by many endoscopists, especially female endoscopists. Unfortunately, Olympus recently discontinued theirs, so theirs is no longer available on the market. Pentax still has one available, and I believe Fuji has one that's currently in development, but it, in theory, is going to increase that reach for that right-left dial. We did a study looking at a support arm to relieve the static loads of the control section on the left distal extremity, and we were able to show a benefit, and currently we're finishing up a study looking at a scope stand to see if that can as well relieve these loads. Anything that decreases exposure time is going to be helpful in decreasing risk, and so there has now been a robust literature on the use of distal caps, and especially the newest generation, which not only decrease withdrawal time, but they can potentially increase ADR. But there's really not a lot we can do to the scope itself, and so we're left really with administrative controls, and here I would really like to have us focus on schedule endoscope maintenance. So this is a picture that was given to me by a participant in one of our training endoscopy trainer courses at DDW earlier this year, and this is the same scope. It's an upper EGD scope, and you can see here how different that angulation is between the two scopes. And imagine trying to retroflex and look at the GE junction with that first scope. How hard is that going to be? But we're not going to know unless we look at the scope beforehand that we may be in for a really difficult endoscopy, and so you're going to be sitting there doing everything you can to try and see in retroflexion, and you physically may not be able to because of the scope itself. And since we know that exposures to the biomechanical risk factors are high, even when scopes are performing at their best, over time, the angulation control wires can stretch, you can get that play in your dials, the responsiveness is going to decrease, and so you may need to work even harder to achieve a comparable or even lesser degree of tip deflection, and so we want to try and be proactive and avoid that as much as possible. So take a look at your scope before you start your procedures, and especially if you have a scope like the first one, don't even start the procedure with that scope. Send that back. In terms of endoscopy schedule, we have a lot of data in terms of patient-related outcomes like adenoma detection rate, and really no data on physician-related outcomes in terms of pain and injury. And so the best advice here is try not to stack your endoscopy days, and you should really not be starting a day of endoscopy still recovering from your last day. So if you are experiencing any pain or injury from endoscopy before you start your next session, you should be fully recovered, and you should figure out ways to either have half days of endoscopy or build in time between endoscopy to ensure complete recovery before you start your next shift. There is a lot of talk on different techniques for holding and manipulating the scope, and there's really only out of the U.K. and Canada do we have a formalized technique that's taught. Here in the U.S., we kind of learn from our mentors and figure out what works for us and apply that to our practice that way. So two different schools of thought. One is holding the scope horizontally, as you can see in this first picture. And the idea is that by holding the scope horizontally with the umbilical cord behind you that the weight of the control section is perfectly balanced and actually can be balanced as they're trying to demonstrate here on just one finger. So in theory, this is taking off some of that static load of the control section versus the all-fingers technique where the umbilical cord goes in front of the wrist. This is actually used by a lot of advanced endoscopists, I've noticed. This allows better, in theory, reach for that right-left dial with all fingers. I've never been able to reach the right-left dial, so this is not a technique that I can use. In terms of holding the insertion tube, we do have a sense that the power grip is going to be a more comfortable grip as well as a more sustainable grip than a pinch grip. So the pinch grip is when the fingers are flexed towards the tip of the thumb, and it's estimated that a pinch grip can be three to five times more stressful on the tendons as compared to a power grip, which is when your fingers are flexed towards the palm. And the power grip is the strongest human grip, it's 75% stronger than a pinch grip. So you want to see how you can convert your grip into a power grip either using gauze, some people use towels in order to be able to increase their grip size, but that power grip is going to be our more comfortable and powerful grip. So again, I'll just direct you to this website from the Canadian GI Association where they talk, where they demonstrate this technique called the C-technique, and actually Dr. Woods and Dr. Law are both experts in this, and so people to potentially talk to. But the idea is that you're leveraging your larger muscle groups for tip deflection instead of the smaller muscle groups of the hand. So you can see by moving the biceps and even to some extent the torso, that that's what's resulting in tip deflection here. In terms of personal practice, I would really encourage all of you to implement micro-breaks. So during procedures, this may be resting your scope during withdrawal or when you get to seek them, or if you're waiting for biceps, really taking a second to just shake out your hands, that's sort of like paying back the lactic acid debt during the procedure and helping you to start the recovery process. And in the survey of ACG endoscopists by Dr. Powa, they were able to show that there was a lower likelihood of endoscopy-related injury in those who took breaks and micro-breaks, and the length of break didn't really matter, you just needed to be taking them. And post-procedure, again, consider these stretching exercises, which will be the next session. If you're experiencing pain in the lower extremities, this is likely related to just the static loads of standing during our procedures. In terms of engineering controls, there are anti-fatigue mats. For administrative controls, it's again the pre-procedure ergonomic timeout and ergonomic education. I think an important concept here is just what is the difference between static loads and what are we trying to accomplish with the anti-fatigue mats or cushioned insoles. So a static load is when the muscles are contracted, and because they're contracted, blood flow is needed, but because they're contracted, the blood can't get in. So there's a mismatch between the blood needed and the blood flowing through. If you're at rest and your muscles aren't contracting, you don't need significant blood flow, blood flow isn't coming in. But when you have a dynamic load, the muscles are contracting, there's a good amount of blood that's needed, but because the muscles are contracting and relaxing, the blood flow can match the blood that's needed. So what we're trying to do is convert these static loads, where we're just taking one posture and not moving, and converting them into more dynamic loads so that we can track the muscles and bring blood back into muscle groups that are contracting. So this is where the anti-fatigue mats as well as the cushioned insoles, they both essentially achieve the same thing. So they're helping to introduce some degree of postural instability so that you're kind of forced to move and forced to have some dynamic movement. Compression stockings are helpful, especially if you're experiencing any lower extremity edema. There are people who actually sit during procedures, although the main issue with sitting is just making sure that your monitor can lower low enough that you're maintaining a neutral neck posture. And again, stretching may play a role here. I'd say a key concept in all of the, whenever you're applying ergonomics to your practice is the idea that you do need management commitment, especially as you're thinking about engineering controls or administrative controls, you kind of need that management buy-in. There are many resources available, so depending upon where you're at. If you're at a big academic institution, there may be an ergonomist on staff, an occupational medicine physician as well. If you don't have access to ergonomists or occupational medicine physicians, then physical therapists can offer some benefit in terms of being able to help you with overall postures. And there was a nice GIE study that showed a benefit of that. And as a last resort, hopefully you never have to go here, but you are, you have the right to a safe workplace, and so OSHA is a resource if you're not able to get the leverage that you need within your own practice.

endoscopists

non-neutral postures

high forces

hierarchy of controls

engineering controls