BTK Ergonomics V3
===

[00:00:00] Welcome back to Behind the Knife. I'm Steven Thornton, and I'm joined here by Agnes Prim Kumar. We're both behind the Knife Surgical Education Fellows, and today we're really excited to share another podcast with you. We're gonna be revisiting the topic of surgical ergonomics with a special focus on how to respond to injury during your career.

If you haven't already, be sure to check out our prior episodes on this important topic. Yes, your posture, your positioning, and your overall physical health in the or. Without are further ado, let's meet the team helping us explore this topic. First up, we have Dr. Cohen. Thanks so much for having me. I'm Dr.

Katie Cohen, an endocrine surgeon and associate professor at the Creighton University School of Medicine. Outside the or, I enjoy being active, playing golf, ice hockey, and hiking, all of which require a happy back. I am Dr. Anthea Powell. I'm a colorectal surgeon and I work at Renowned Health and the University of Nevada Reno.

Outside of the or, I have certifications in personal training as well as coaching for [00:01:00] nutrition, sleep and recovery, mobility and menopause. I am a former All-American in triathlon and aqua bike, which is swim bike Without the run. I do believe a lot in ergonomics, especially about how they can impact your surgical career.

Hello, I'm Danielle Tanner. I'm a PGY five at Creighton University School of Medicine in Phoenix, and I'm very passionate about ergonomics and excited to be here. Thank you for having me. So let's start at the top. What is ergonomics? When we talk about ergonomics, we often think about posture, but it's really much bigger than that.

Dr. Berger back in 1997, was the first to apply ergonomics to the field of surgery, and he described visualization, manipulation, posture, mental and physical workload and operating room environment. It's important to keep all of these components in mind in order to best optimize ergonomics for our jobs.

So how did each of you get interested in this topic? Spend a lot of time looking like a headlight, wearing vulture, just probably not so [00:02:00] ergonomical. But it can definitely lead to some back and neck pain. And a couple of years ago I actually had a disc herniation and can really attest how debilitating that can be and how much the, or impacts the feelings in my back and neck nowadays.

For me it's mainly it comes from triathlon. In triathlon we care about position and ergonomics a lot, and we talk about it all the time. Given the amount of time triathletes spend training, we are prone to overuse injuries. Specifically working on posture and position can prevent injuries as well as improve economy emotion, which in turn leads to better energy management and faster times.

I have long wondered why there's a huge market for ergonomics, especially in cycling for sport. But we expect surgeons to perform life-saving lengthy operations without any coaching or support. And I've really feel like this is a major gap in surgical education and support for practicing surgeons.

During my intern year, my dad actually kept calling me a turtle and made a comment about how poor my posture had become. He was wondering if I [00:03:00] really did a good job taking care of myself at work. That really inspired me to think about, you know, what I was doing at work to take care of myself, especially my posture in the OR when we have these long cases that we have to stand in.

I started to notice how most every resident and attending I worked with had terrible posture and chronic back pain and other pain complaints. It made me want to explore why we don't focus more on this topic and how we can improve. I totally relate to your story, Danielle. I have my own awkward poses and posture both inside and outside the OR, and that's something that I'm actively trying to work on improving.

Alright, let's start by discussing how ergonomics is often overlooked in the field of surgery. Unfortunately. We talk about the cognitive demand of surgery a lot, and we're starting to be more open, I think, to these days, especially after the pandemic about the emotional demand. But addressing the physical demands of surgery is still lagging quite a bit.

The literature is lagging and we, and we talk about it much less. Both energy management and ergonomic strategies need to [00:04:00] be incorporated into residency education and career support. We spent hours in uncomfortable positions, atic postures. Around patients and, and particularly like laparoscopy, you're in a, in often in sort of twister type positions.

These are really not ideal, obviously. And if you add in under fueling and under hydration for long cases, it is a recipe for musculoskeletal disorders, chronic pain, and even career ending injuries, although that is rare. Mostly people just exist in pain. And I, I think that also has impacts on surgery or on the operation itself that we're not addressing or acknowledging.

Yeah, I cannot agree with what Dr. Powell said more. I mean, I think honestly early in my career, no one even talked about this and you just kind of powered through. But especially with my own back issues, I really noticed the toll operating can take, especially at the end of the day. I think it's also important to remember that we train so hard to learn perfect operative techniques during our residency and fellowship years, but we're not trained to protect our own bodies.[00:05:00]

What Danielle said is key. We are not trained like high performance athletes, and yet that's what every surgeon is. We need to give these sur all of surgeons, the support that high performance athletes do. The stakes are higher, and yet we're giving much less support. There have been some really interesting studies about the pain and physical toll that surgery has on the surgeon's body.

Danielle, do you mind highlighting a few of these for us? Sure research has shown time and time again that operating causes pain. In fact, JAMA 2018 published a meta-analysis which reported the prevalence of spine disease among surgeons to have increased by 18% with about 12% requiring either a leave of absence, early retirement, or practice modification.

Sutton examined the unique stressors among female surgeons and found that female surgeons reported a significantly higher frequency of musculoskeletal pain and muscle fatigue compared to males with females being more likely to receive treatment for their hands. 78% of women reported that lapse staplers are [00:06:00] too big for their hands.

Even simple things such as the size and handling quality of surgical instruments can translate into affecting ergonomic and physical strain on the surgeon. This isn't just for open procedures. I think that's what's really key studies looking at robotic surgery versus laparoscopic and open operations have generally found decreased pain with robotic surgery, but it is still present, and this is particularly true for neck and finger complaints.

If you talk to a lot of the urologists who spend most of their time on the console, they at least my lived experience is that they will tell me a lot about thoracic pain because of the curvature required for the console. So my biggest pet peeve is the chair for the console. I was having pain the other day in my right hamstring and I couldn't figure out why.

And my scrub tech pointed out that I was sitting on a stool, not even a chair, I hadn't noticed 'cause I was so in the flow of the operation. But I switched to a chair. This was not much better as it was still an office chair, not specifically designed for the robotic console. I've worked in a lot of different hospitals and have yet to see a console specific chair.

So we have this beautiful in robot. And yet we don't have a chair. [00:07:00] And so this in itself shows the basic gap in ergonomic support for surgeons. Yes. I think this, this gap is clear. And, you know, I just wanna chime in to say that JAMA recently published a study this year at the end of July by Patel, they found that surgeons do have a higher mortality rate compared to non-surgeons physicians.

Now obviously we can't say that's solely due to poor posture, but I bet there is an influence of the bodily strain that we put ourselves through on surgeons as a, on a daily basis. Thanks for that great overview. I have to agree that paying attention to ergonomics is really gonna pay off in the long run.

And for our listeners, all the papers that we're mentioning in this discussion will be linked in the show notes for you to read further. Now that we've heard about the importance of ergonomics, what are some things that we can do? What are some tips that we can implement in the OR tomorrow? Let's start with the basics, and if you're sitting or able to join us to mimic these moves as we discuss them.

Imagine you're operating First, adjust the table [00:08:00] height. It should be around your elbow level. Additionally, the patient should be appropriately positioned for your operation. Keep your wrists and neutral, not flex or extended position. Use your core and legs when bending, not just your back. I can attest to this.

And minimize static positions. Shift weight and stretch when you can, which we'll talk more about later. If you have loops, make sure they're at the correct angle. Craning your neck is a fast tracked pain. And if you're doing laparoscopic surgery, make sure the monitors are at eye level. You wanna brace your instruments as you're able to.

Bracing in a surgical context, primarily refers to a technique to stabilize the hands and instruments by resting them against the patient's body or a fixed surface to minimize tremors. Resting your hands, relieves your back or neck and helps you with your posture overall. And what about during robotic surgery?

Great question. The console helps a lot, but before posture is still an issue there. You wanna make sure that you adjust the console to you and not the other way around and be very [00:09:00] conscious of how you're adjusting it. Particularly the, the DD five, the new newer robot is kind of finicky in that if your forehead isn't touching it completely, it won't let you operate.

And so that I have noticed has made me just so that feature doesn't go off, it has made me even want to sort of round my neck a little bit more. So just being aware of that is sort of half the battle, I feel like. Make sure that the chair that you're working with fits you, that you like it. It may be an office chair. It may be what you have, but hopefully it's an office chair that you like. I think most surgeons, and particularly women surgeons in particular in general, worry about being high maintenance. It's okay to ask for what you need to be comfortable because that allows you to operate at your highest potential, and that's what your patients expect.

I think other things due to the like sort of having to fit your body to the console, sometimes it's really important to take a standing break. The best time to do this so you're not interrupting your mental flow, I feel like, is when there's an instrument swap. Especially if you're efficient with your instrument swaps and you're not swapping repeatedly.

For instance, if you're better [00:10:00] with the suture cut needle than I am where I don't shred every single suture and can't use. That instrument all the time. I have to sometimes have to have a second s sitter 'cause I'm not so good with that. So when I'm swapping instruments, that's a good time for me to get up.

And also obviously if you're red docking for instance, if you're a colorectal surgeon and you have to redoc to get the flexor down, that's a great time to, to get back up. You may not have to, your assistant might be so good. Like our nurse practitioner is so amazing. I don't actually have to stand up.

But that's a good time to stand up and scrub back in and do and either scrub back in or talk to them. But chance to get up. The other thing that I think is really under acknowledged is make sure that you keep in mind what you're eating and drinking before going into the case. And this goes for any case.

Being under fueled and under hydrated is unavoidable with long cases, but it can be mitigated. And so paying attention to your pre-case nutrition, I feel like is really important. A mix of protein, fat, and slow absorption. Carbs can go a long way. And also keeping a quick source of energy in your pocket.

If you feel like you're really not [00:11:00] able to focus or you're crashing. A lot of us are just told to keep going. But if you keep something like a a hundred calorie cliff bar in your pocket that can be really helpful. There are 22 grams of carbs and they're quick acting enough to make, at least they make me feel better quickly.

But I also don't get a huge sugar crash afterwards, like the full Cliff bars because they have 45 grams of carbs or 44. So, just being, being mindful of your nutrition and your hydration will also make it easier for you to pay attention to your ergonomics 'cause you won't be feeling, sort of so lightheaded or just not feeling well.

There's also a lot of apps out there, like Ergo Droid. It's an app that helps you investigate the strain on your body. It doesn't really give you answers, but it's a great way to kind of start mapping out the different strains that you put on yourself when you're operating. I will say that understanding the unique positions that we personally adopt during surgery and the strain that it places on our joints is actually a great first step.

Understanding that just sets us perfectly to be more cognizant about those behaviors and [00:12:00] fix those positions moving forward. And another component of ergonomics in the OR is taking micro. Dr. Cohen is actually the champion of micro brakes and stretch breaks in the or. Can you tell us about them and how we can incorporate them?

Oh, absolutely. Agnes, I do love a micro break, as you know. So Dr. Greta law is a endocrine surgeon and big proponent of micro breaks. And so I was at a conference when she shared this with us and you know, as people know, there are natural parts of the case that are more or less stressful. I think micro breaks really allow us to take a short break between those stressful segments to recenter ourselves.

So, I do a mini stretch break during the surgery with just three simple moves including some neck mobility as well as shoulder shrugs and rotation, and then a torso twist. Ultimately, it takes less than a minute, and it definitely improves your posture and recognition of postural issues. It also gives you a short mental health break, which I cannot emphasize enough.

I do have to say, just make sure that you spread out and don't contaminate the surgical field [00:13:00] or each other when attempting to stretch. Also, if you have a favorite sterile dance move, this is absolutely the time to incorporate that. I agree. Those breaks are great. I learned them from Dr. Cohen and I really appreciated it.

Actually, give me a stretching certificate when I left Creighton and moved to Reno. Unfortunately I am not honoring said certificate, but I'm going to try to do better. They, but the micro group breaks. One, they help you in many ways, but two, they also facilitate a team atmosphere in the or. Everyone participates in Dr.

Cohen's or, and she is an amazing team leader. The hardest part though is just remembering to do them each case when you do not have your own personal Dr. Cohen. In your operating room with you, which is sad every day. In any event we would, we, we also do need to talk about physical exercise. As I said, surgery is a sport, and if you're not really fit for your, for your sport the strains on your physical body can, can be more difficult to manage.

We all do not need to be doing hydrox or running an or doing an [00:14:00] Ironman every weekend. I think we need to be mindful of physical activity. Just a plug for Peloton which many physicians have, Andy Spear has one hour strength classes. They're called Total Strength 60 or TS 60. He does them on Sunday Live, and he has a whole library of about 120, maybe 130 classes.

Some of us even do the trifecta, which is three of those a week. And they incorporate everything you need for longevity. He includes mobility, balance, strength, power and conditioning. And so it's a full complete, you don't have to think about it, you just put it in, you just do what he tells you. And it's incredibly helpful, I feel like, and that format goes a long way especially as we get older and spend more time in the operating room.

Thanks for the reminder to prioritize physical exercise that's so important. We've talked a lot about the different steps to take both inside the OR and outside of it. But as residents, how exactly do you recommend we bring this up? Yeah, I think there's a couple phrasing things like, would it be okay if, or would you please adjust this, or can [00:15:00] I have a step stool?

Also asking for those things before the case starts, or grabbing them yourself, positioning them yourself so that you're not. Having to ask the nursing staff is another way to avoid some of those more awkward situations. I would also suggest documenting your pain, making a map or something like that so that you can look at your cases over time and see what you can do to improve those.

There are also a ton of things you can do outside the OR to practice good ergonomic technique. Everything from how you hold a needle driver or a hemostat can be game changing. There's a website called Black Belt Academy Surgical Skills that has great photos, videos, and documents that detail the hand techniques for each instrument that are best and most ergonomic for your hands.

You should totally check it out. Wow. Yeah, I'm glancing through their website now and it looks great. There's a lot of pictures and easy to read information on everything from even holding a scissor. I definitely wish I knew about these resources when I was starting residency and that [00:16:00] way I can build good habits in my techniques early on.

Some institutions I've heard are incorporating ergonomic education to do just that. And I know your institution has had ergonomics and wellness workshops in the past. How were those structured and what was the feedback? Yes. So we you know, we had an expert obviously in ergonomics, and so we actually had part of our annual lecture series, we incorporated ergonomics into our weekly didactics.

You know, similar to the podcast here, we really discussed the why it's important and then had some hands-on activity to allow folks to practice. And then. You know, be comfortable with feedbacking on your colleagues and peers of, you know, that doesn't really look comfortable or, you know, maybe you'd be a little bit easier on your back, shoulders, neck, et cetera, if you did this.

'cause I noticed that. So it's just like any habit, the more you do it, the more it becomes incorporated into your practice and culture. Speaking from a resident standpoint, that lecture was super helpful. I knew a little bit about ergonomics, but having us all discuss it together in [00:17:00] practice was really valuable.

Yeah. I think a key here is that, and this really speaking to faculty who might be listening, is that faculty need to empower residents. This really needs to come from the faculty to, to speak up in the or. My residents and students are very used to hearing me say, stand up straight or engage your core.

So encouraging your learners as a faculty member to put the table at the proper height from them when they're performing a key part of the procedure is really important. I once was on service with two very tall residents and we christened the steps after that. One was the little lower one and one was the higher one.

The lower one was the Steven step. 'cause he was about six two. I'm five nine. And the we step was about the higher one because he was six five. I used whichever one was needed so they could be comfortable as much as we could. And it just came to be, I need the Steven step, I need the wade step. And I think just having, saying to learners, if you're not comfortable and you're doing the key proportion of the procedure in part of your pre-case.

Discussion would be really helpful. And it just really feel like this has to come from the faculty so that learners feel [00:18:00] comfortable asking for what they need. And the more we model it as faculty, I think the more learners will feel comfortable asking for it. And then it sort of continues on as surgical education moves on.

Chris Cohen and Paul, you both mentioned this earlier, but can you share a little bit about how injuries have impacted you during your surgical careers? Yeah, so as I mentioned earlier, I have kind of a back herniation and some disc slippage issues that don't happen frequently, but when they do happen, they really are debilitating.

And so I, when those events occur, I have had to re even reschedule cases. So it obviously really impacts the surgical practice by having to move patients and, and change around your or schedule, which impacts a lot of people. Yeah, for me, I had to I had a biomechanical disturbance in my left leg, and after many, many years of running, I finally was having trouble walking and I was doing a pelvic exoneration one day with one of our senior colleagues.

And I just said to him, Kevin, I don't. I can keep doing this case. My knee hurts too much. Obviously I finished the [00:19:00] case, but that was the turning point where I knew I had to do something about injury because it was just I felt like my pain was becoming in my brain was becoming an, a competing issue with the patient, and that just was totally unacceptable to me from a surgical quality standpoint.

So that's when I started looking into having it replaced and did eventually have it replaced shortly thereafter. And if we find ourselves injured, where should we seek help or what can we do? You know, I think first is acknowledging that we're really all human and the pain is not weakness leaving the body.

It's not something we should just grin and bear. It really needs to be addressed, you know? And so I think talking to your colleagues, talking to your leadership, and then we all do work in a hospital. So having a t you have those resources around you. So I now have a neurosurgeon, a physical therapist, and a pm and r.

Doctor who are all supportive of that, including the, or schedulers who are willing to make some changes that are helpful to my longevity. Yeah. I mean, I couldn't agree [00:20:00] with Dr. Cohen Moore is that we need to accept that pain is not, I mean, we're always gonna have something, but, but having a degree of pain that may be interfering with operating is not normal.

And I think I sort of liken that to what's been going on in the endurance space with red s and female sacral or female stress bone injuries. They're, they're not okay. You know, they're not normal. Not menstruating because you're not eating, because you're, if pursuing your endurance sport is not normal.

And it, I think we have to start. That has really shifted, I think in the last five years in endurance sports. And I think we have to start seeing injuries in, in surgery in the same way. If you are operating with a high degree of pain, that it really is competing in your brain for the surgery. That, and hopefully it doesn't get to that point, but you need to be able to address it and feel safe addressing it before it gets to that point.

And that really is where I think we all need to sort of start speaking about this issue more so that it is not swept under the rug. And would you say that your specific institutions were supportive of you during this time? How did you navigate taking time [00:21:00] off? I've been fortunate that my institution and colleagues I couldn't ask for better folks have been extremely supportive, you know, and then now you know, I actively work to manage my schedule.

You know, and also patients, you know, were actually very supportive too when I had to reschedule their surgeries and that they also don't want someone in suboptimal conditions operating on them. So they were incredibly understanding in that we are all human. I, I mean, I think also Dr. Cohen was very honest and trans.

Parent with our patients. And I think that it just, again, acknowledging that we are not super human, that we're on a, that we are human. Really the transparency piece, I think is key to how she managed that situation. And why everyone? One of the reasons why everyone was very supportive. For me I.

Took three months off from my knee replacement. We were able to plan that because it was something that had been progressively getting worse. And so I sought multiple opinions and then we decided on a surgeon and, and I was able to schedule it at a date that worked for the practice. Also from a financial standpoint it was at a point where I [00:22:00] felt comfortable from a productivity standpoint, which these are things that we have to actually, unfortunately think about.

But it, it sort of, everything aligned for me for coverage. I had two partners who were wonderful and able to cover, even though I kind of had a solo practice at the cancer center at the time. And so, it was really about planning and about, again, being transparent and explaining why it needed to be done and that it wasn't a three month vacation.

And then on the three months I treated rehab like a job. I did rehab. I went to rehab three times a week with a. A, a special physical therapist who does endurance work. And then I, I did probably four to six hours of rehab a day. I was in pain a lot of that time but it was really important to get the rehab done so that I would have full function in the knee afterwards.

So I did not waste that time at all. It was extremely careful with it. What was it like when you came back to your clinical roles? Did your case mix change? Did your volume change? Did you have to do any refreshers to get ready to be back in the operating room? You know, fortunately my time off was [00:23:00] relatively limited.

But I can say now I really prophylactically try to address and avoid injury by adjusting my case mixes on operating days and that I don't try to schedule multiple back to back high intense surgeries and spread those out throughout the week or month as able. I think that's a key point that Dr.

Cohen just brought up. And I also just wanna bring that up for young surgeons. You know, you don't have to stack really difficult cases to do three a day because that's what the operating room gives you. And I think in the beginning there's really temptation to just say, oh, I finally got operating time.

I have to put these cases on. I was actually talking with a a more junior surgeon recently about, about doing exact. That I think it's not just from your physical being, but from your mental health standpoint is trying to be a little bit cautious about how you get things scheduled. It's not always possible, but if you can, especially when you're starting your practice, like make sure that you have not days where you're, you're operating for 12 to 15 hours a day on really difficult cases.

If you can try to minimize that it can, or at least spread it out, it can be really [00:24:00] helpful. For me at the time, my practice was mainly a deep pelvic reve practice, and so my surgeon actually told me that I could go back a little bit earlier and I did not want to because I was concerned that I would end up doing a pelvic ex degeneration the day I came back.

And in fact, that is what happened. One of my partners got sick and I ended up taking his pelvic ex degeneration on day three of returning. It was still painful. There's no getting around it, but it was manageable that day because I had done all the work and now the key to operating pain. I'm now completely pain-free.

I'm back to a hundred, not a hundred percent on that leg, but I think 80%. I'm not sure I'm ever gonna get back to a hundred percent. The orthopedic surgeons will tell you that you will at three months. That's not correct for anyone who's contemplating a knee replacement. You hopefully will be back to that at a year.

But the key to operating pain free for me has been really careful rehab and strength training. So I used to really feel like my threshold sessions, my VO two max sessions were the most important sessions that I was doing in the week, but now they're my strength sessions and really making sure that those strength [00:25:00] sessions include mobility and balance are all the things that have really two years out, it was the best decision I made.

But it does require attention to it and to the strength training on a regular basis. Thank you both for being vulnerable and sharing your stories on navigating this, often challenging but not well talked about realm, I think, in surgery regarding dealing with injuries in our career. Well, I think we've covered a lot of ground here.

So as we wrap up, what are some quick hits that you would like our listeners to take away regarding ergonomics? No, I, I would say that a really ignoring pain doesn't make you tough. It just makes you injured. Yeah, I would say investing in your own physical wellbeing is not selfish. It's essential for high performance surgery, which is what we all aspire to.

For me, every OR setup is negotiable. If you speak up, stretching and movement count as part of the work, not an afterthought. That's great. Thank you. All surgery really is so demanding and our [00:26:00] longevity matters. Our hands and our posture, those are instruments as well, so thanks for helping us to understand how we can treat them that way.

A huge thank you to our guests for joining us and providing their invaluable insight to this topic. Once again, all the studies and apps that we reference can be found in our show notes. And thank you to all of our listeners. May your postures be perfect and your backs be pain free. Until next time, dominate the day.