Ergonomics in Endoscopy: A Fellow's Perspective

Abstract

Emotionally exhausted and fraught with cabin fever, I began running outdoors during the coronavirus disease 2019 pandemic. The meditative cadence and endorphin rush of a good run hooked me, and I started sprinting fast and for long distances, without paying adequate attention to form or rest. Soon, I started experiencing a sequence of musculoskeletal injuries—first my hamstrings, then my knee, then my foot. Exhausted with my misplaced enthusiasm, my partner (a life-long athlete) sat me down: “If you want to do this for a lifetime, train such that your body will be able to support you for a lifetime.” I started gastroenterology fellowship in 2021, eagerly awaiting my first endoscopy block. Like any new activity, I dove into it headlong, scoping long days without caring much for how I positioned myself or my scope. Sure enough, I started experiencing shoulder and wrist pain, even beyond the usual soreness that was to be expected while performing a new activity. That is when my partner's sage advice echoed in my mind—and I knew I had to understand and embrace endoscopic ergonomics. ERGONOMICS: DEFINITION AND IMPORTANCE Ergonomics is the study and design of equipment and devices to better fit the human body and its movement. Ergonomic design is present in almost every aspect of our life today, whether in the knives you use to make breakfast, the car you use to drive to work, or the chair you are sitting on in front of your desk. The importance of ergonomics in endoscopy cannot be stated enough. Endoscopy is a major component of training and workload for most gastroenterologists, with recent American Society for Gastrointestinal Endoscopy data showing that most practitioners spend >40% of their time performing endoscopy. However, endoscopists are particularly prone to sustaining musculoskeletal injuries from their practice. Data from various countries show that 39%–89% of practicing endoscopists have endoscopy-related pain and/or injuries.1 These injuries in some cases start as early as fellowship, with 1 of 5 gastrointestinal fellows developing endoscopy-related pain and/or injuries.2 This strong association with musculoskeletal injuries is because of microtrauma caused from the repetitive motions, prolonged awkward postures, and sustained high pinch force during endoscopy. The current endoscope, duodenoscope, and colonoscope were not designed to accommodate the range of physician hand sizes and strength in mind, making endoscopy a physically taxing career for many operators.3 The most commonly affected body parts include the back, neck, shoulders, and upper extremities, particularly the thumb, hand, wrist, and fingers. Several risk factors for injuries have been identified and described. These include higher procedure volume (>20 cases per week), more time doing endoscopy per week (>16 hours per week), cumulative years performing endoscopy, female sex, small hand and wrist size, low muscle strength, improper body posture, and lack of an ergonomic room design.4 Of these, a few are nonmodifiable. Speaking for myself, I certainly cannot change the fact that I am a woman wearing size “S” gloves. Being interested in an endoscopy-heavy career, it is highly likely that I will exceed the fairly low volumes that have been described to be risk factors for injuries. However, what I can attempt to modify is my own body posture and body strength and the design of the room I work in. This is where understanding the current state of and best practices in ergonomics in endoscopy comes in handy. PRACTICAL TIPS FOR INCORPORATING ERGONOMICS INTO YOUR PRACTICE The ergonomic or “athletic” stance is the easiest way I found to improve posture during endoscopy (Figure 1—adopted from the study by Singla et al).5 It consists of holding a neutral neck and back position without hyperextension or flexion with shoulders back and chest out, having even weight distribution between both legs, avoiding knee hyperextension, and keeping feet hip width apart pointed