Tuesday, December 23, 2014

Ergonomics-A Call to Action-When Helping Others Harms the Surgeon

By: Celeste Hollands, MD, FACS 

Why was everyone shocked when shortly after my partner retired I told them he was only 62?  He had had a heart attack and back surgery during his career.  He walked with a limp and had to sit to operate due to years of standing in the operating room without regard to his own well being so he could provide outstanding surgical care to the children he served.  We give our time selflessly, our reimbursement is diminished, there are certain health hazards to a job where you stand on your feet, but must we sacrifice our health?  Isn’t there a better way to partner with industry to develop instruments and devices that are ergonomic or can be made ergonomic for all that use them?

We all remember our childhood and think back to what has changed as we have grown up and grown older.  I remember riding in the “way back” of our Volkswagen beetle-3 little kids delighted to be in that special secret place where only us kids would fit.  Did my parents love us? Of course they did.  Were they smart and educated? Yes.  Safety devices such as seatbelts were neither widely available nor used at that time. When safety devices were developed, they were designed for the 50th percentile male.  So seat belts, especially the 3-point restraint systems naturally did not “fit” many smaller men, most women and almost all children.  Car seats and booster seats were designed, kids were moved to the back seat to avoid injury from air bags which were the newest “safety” device and on and on it goes.

Surgical devices and surgical instruments are largely similar in design approach.  Those of us with smaller hands cannot operate many of the instruments in the manner that was intended.  We have adapted in many cases-that is what we do-to provide the best care for our patients.  Many of the adaptations result in work related injuries-either from misuse or repetitive use injuries in instruments that were not designed for small hands.  Some injuries are not related to hand size at all, just repetitive use of instruments or surgical systems that were not designed with the user-the surgeon-in mind.

Injuries related to the ergonomics of minimally invasive surgery (MIS) have been investigated and reported.  Youssef and colleagues (1) analyzed the risk to surgeons from side standing and between the leg standing positions during laparoscopic cholecystectomy. They concluded that the American side standing position posed risks of injury to the surgeon due to increased physical demand and effort resulting in ergonomically unsound conditions for the surgeon.   Esposito and colleagues (2) reported on work-related musculoskeletal disorders (WMS) of the upper extremity in pediatric laparoscopic surgery.  Their work parallels the work of Park and colleagues (3) in that the longer you have been performing MIS and the larger your caseload the more symptoms you report and experience. 

Women performing laparoscopic surgery report more hand and shoulder symptoms than men and seek treatment for these symptoms more often even though they have been in practice a shorter time.  This finding is from work by Sutton and colleagues (4).  These findings seemed to be independent of glove size and probably more related to instrument handle size and design and/or table height. 

A recent discussion thread on the ACS Women Surgeons community focused on flexible endoscopes and the lack of ergonomics for those with smaller hands.  A number of good suggestions came forth for adapting safely to this challenge.   These tips included how to best use an assistant; how to position yourself, the patient and  the table; and how to manage the dials and grip and manipulate the scope.  This is all very valuable information however the tips do not solve the issue for those with small hands.  One discussant brought forth the knowledge that there was an adapter available that could be obtained from the company rep that helped with manipulating the dials.

If surgeons are discussing ergonomics and these work related injuries at all, it is likely behind closed doors, in a more private, more intimate setting-like the locker room or lounge since that is often where you immediately feel the mental and physical strain of the operation or procedure you just completed.  It is when you have the time to readjust your focus for a moment to yourself that you are more likely to share your symptoms with those around you. 

Ergonomics and surgeons’ work related injuries are an important topic.  Some of the ergonomics are relative to all surgeons and some will be unique to those with smaller hands and of smaller stature.  Identifying the magnitude of the issue and then designing studies to document it while partnering with industry to fix it is the next step.

We can wear support stockings, “sit when you can”, adjust table height, assume good posture and be mindful of our physical and emotional health. I remember when I was a resident one of the cardiothoracic surgeons was taking off his support hose in the lounge after the case and he told me that if I stayed a surgeon long enough that eventually gravity and low pressure systems in the body would be my enemy.  He could wear support hose to help his legs but there were other things he could do little to manage.  After 16 years in practice following 9 years of training, Mark, I get it!  We can do our part to manage and control these ergonomic issues. We cannot remanufacture instruments and devices. 

I encourage you to share your experiences here on our blog.  Let’s have a very powerful conversation that leads to meaningful results.  If someone has already stated an issue you have experienced-acknowledge it and be counted.  There is power in numbers and we need power to begin to get industry to respond and partner with us. 

  1. Youseff Y, et al.  Laparoscopic cholecystectomy poses physical injury risk to surgeons: analysis of hand technique and standing position.  Surg Endosc (2011) 25:2168-2174
  2. Espositio, C et al.  Work-related upper limb musculoskeletal disorders in paediatric laparoscopic surgery.  A multicenter survey.  J Pediatr Surg (2013) 48:1750-1756
  3. Park et al.  Patients benefit while surgeons suffer: An impending epidemic.  J Am Coll Surg  (2010) 210:306-313
  4. Sutton et al.  The ergonomics of women in surgery.  Surg Endosc (2014) 28:1051-1055

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