Thumb, hand, shoulder pain and low back pain are some of the musculoskeletal injuries reported by Gastroenterologists, Endoscopists-Mehnaz Shafi

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 Ergonomics of Endoscopy & injuries to endoscopists

Thumb, hand, shoulder pain and low back pain are
some of the musculoskeletal injuries reported by
Gastroenterologists, Endoscopists- Mehnaz Shafi

EUS guided biliary drainage has a potential but it
should be used by 
experienced persons-Khalid Hassan

KARACHI: Dr. Mehnaz Shafi from United States who made numerous presentations at the Pakistan Society of Gastroenterology’s 33rd Annual Conference also discussed Ergonomics of Endoscopy and injury to the endoscopists at one of the sessions on March 11, 2017.  She was of the view that we must always have our focus on patient safety, practicing Gastroenterologists and Endoscopists. Ergonomics deals with long standing in awkward position and work related stress. The gastroenterologists and endoscopists often work in awkward positions which results in musculoskeletal problems which we can develop.

These musculoskeletal problems include low back pain which has been very well documented in USA and Canada associated with loss, muscle over use, tiny scars besides over exertion. Frequency of postures and use of force is related to all this. A survey among four hundred gastroenterologists, endoscopists done in 2010 revealed that 72% had thumb, hand and elbow pain. Other disorders included low back pain, shoulder pain, carpel tunnel syndrome and numbness in index finger.  As compared to internists, gastroenterologists who do procedures suffer from these disorders more. GI group had more musculoskeletal disorders including thumb discomfort, pain in hands and low backache. American Society of Gastroenterology has come up with guidelines on managing occupational hazards. Radiation safety, personal protection are also important. Those who do up to twenty or more procedures per week are at a higher risk of developing these disorders. About 10% of gastroenterologists develop upper extremities injury after ten years. They also report pressure on left thumb.


Dr. Mehnaz Shafi presenting a memento to one of the presenters at the
Gastroenterology conference. Prof. Baddar Fayaz Zuberi is
also seen in the picture on extreme right.

Speaking about the precautions she mentioned maintaining natural position of spine, minimizing change in neck position, monitor should be high at elbow level. Bed position of the patient should be such which avoids low back pain. Cushioned floor mats should be used. Engineers should be involved in designing the Operation theatres and designing of other electro medical equipment. There should be correlation between works while high volume of work is associated with pain.  The survey also showed that about 10% of those surveyed were aware of the ergonomics. Another survey done in Japan between 275 endoscopists and 173 non-endoscopists had 70% response rate. Frequency of pain in hand was much more as compared to other parts of the body. The studies have further showed that with increasing age the pain worsens.

She referred to yet another study about prevalence and risk factors of musculoskeletal injuries in Endoscopists. It showed that almost 67% needed time off from endoscopy, 52% perceived injury, 54% had modified their practice. Thumb, hand, shoulder pain and low back pain besides elbow pain were reported.

Talking about treatment, she pointed out that OTC products, pain killers and NSAIDs are most often used. About 20% of them also reported use of steroid injections while 33% needed rest. Stretching during work, break during work, adjusted table higher than the endoscopists, standing on rubber mat or use of orthopedic shoes is helpful. Yet another survey among gastroenterologists an endoscopists showed that they had complex timings and three had to take more than one month leave due to injury.

Women Endoscopists

Speaking about endoscopic procedures among women, Dr. Mehnaz Shafi said that doing colonoscopy in women is very difficult. It is important that endoscopy unit is not a hazardous place. Women wish to consult women endoscopists and the pressure is also more common in women, only 4% of women endoscopists had training in ergonomics. Studies also showed that micro breaks were low. Pain in thumb and low back pain were common in men and women both. She suggested that one must use gown, gloves, face shield and stand on gel mat, maintain erect posture during the procedure. Shoulders should be relaxed, wear comfortable shoes and socks. Keep weight evenly balanced. Make sure that during the procedure the position of the monitor is in front of your eyes. Keep upper arm close to the body. Wrist should be in natural position. Minimize long grip tight, switch hands to relieve tension. Use towel to grip endoscope. Move monitor position to keep neck in comfortable position. Micro breaks helps prevent muscle fatigue. Do regular stretch exercises. She also talked about optimal work load wherein kind of procedures do not matter.  Prevention and training should be focused. Design in endoscopy was also important. She also revealed that the American Gastroenterologists Association has formed a Task Force in Ergonomics in 2017 to look into these issues.

EUS guided Hepatic biliary interventions

Dr. Muhammad Khalid Hassan’s presentation in this session was on EUS Guided Hepatic Biliary Interventions. Speaking about failure of ERCP he said, it accounts for 3-6%. He then discussed in detail the efficacy and safety of EUS besides guided biliary drainage. He also discussed EUS guided vs. PTC drainage.  Adverse events he mentioned included bleeding and  bile leakage. The purpose of dilatation is to move the stent easily. Fully covered stents are used. There are technical issues like scope position which were also discussed in detail.


Prof. Munir presenting cerrtificate to the speakers at the recently held 33rd Annual conference of
Pakistan Socity of Gastroenterology and GI Endoscopy at Karachi durning March 2017.

Continuing Dr. Khalid Hassan said that during the procedure it is likely that one may break the wire. One should adjust the scope and make sure there is no more than four mm dilatation. Avoid needle knife. Be careful with stent placement and cystic duct. Use appropriate length of stent. EUS guided Hepatic Biliary drainage is taxing but not ready for takeoff. It should be used only by experts. Gallbladder drainage has been performed. He further stated that over one thousand ERCPs are performed at their Center  every year and about 10% fail outside. In 88% cases standard technique is used and only in 12% advanced technical is used. Needle knife should not be used for more than 10-12% of the time. ERCP is cheaper as compared to EUs guided drainage.

He concluded his presentation by stating that our first and foremost objective should to do no harm to the patient. Technique needs further simplification.  EUS guided biliary drainage has a potential but it should be used by experienced persons.

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