Ergonomics in the Cath Lab(or, how to save staff backs, necks, wrists...)

The application of the relatively new field of ergonomics has been a trial-and-error procedure for the last twenty years. Trying to actually define ergonomics is an interesting experiment, as it’s not located in any dictionary published before 1985. If you break down ergonomics into its root forms, you find: ERGO = Latin for therefore NOMY = Latin for a system of laws or body of knowledge about a field. (Clear as mud to me definitely sounds like something the government would come up with.) So what is ergonomics, and what does it have to do with the world of the cardiovascular professional? In July 2001, the U.S. Department of Labor, Occupational Safety & Health Administration (OSHA) held meetings asking presenters to define ergonomics. Thankfully, presenters came up with a much better answer to the question of ergonomics. The following definition is courtesy of Lt. Col. Mary Laedke, U.S. Army: Ergonomics involves the application of knowledge about human capacities and limitations to the design of workplaces, jobs, tasks, tools, equipment, and the environment.¹ Basically, that means we adapt the WORKPLACE to the WORKER, not the other way around. The old method of finding a job and learning how to physically work at that job, no matter if it hurts to do so, has proven too expensive in terms of workers’ compensation and overall productivity. At some point, the paradigm must shift. The new thought process of ergonomics is one of logic and wellness. Ergonomic-related injuries Poorly designed workplaces mean a higher risk of work-related musculoskeletal disorders (WMSDs). There is an increased risk of repetitive stress and strain injuries, cumulative trauma or force injuries, carpal tunnel syndrome, and of course, the companion to wearing lead aprons for a long day, low back pain. The list of work-related musculoskeletal disorders is very familiar to cath lab staff. Along with carpal tunnel syndrome and back injuries, there’s also tendonitis and rotator cuff injuries. We should throw in Raynaud’s syndrome for good measure, after having our hands in ice-cold saline in an ice-cold room for hours every day. These injuries can be worsened by our everyday normal living activities. In forums, OSHA asked both employers and employees to determine if the ergonomic injury was work-related or non-work related. Discussion centered on those injuries that could not always be defined as work or non-work, but there is also the injury that is a combination of the two, or synergistic damage (anyone who has ever gone home with a backache, then lifted a baby, will understand). Seven main risk factors for work-related musculoskeletal disorders (WMSDs) There are seven main risk factors for WMSDs: 1. Position and posture; 2. Repetition; 3. Force; 4. Compression or contact stress; 5. Vibration; 6. Temperature; 7. Duration. Good position and posture is drummed into every student nurse. They go to sleep thinking about good body mechanics. (Well, some of us do.) Good body mechanics are vital to good back health. A healthcare provider is not helping anyone by using bad technique; not the patient who might be jerked or dropped, and not themselves when they hurt their back, lifting with brute strength instead of good body mechanics. (There’s definitely a time, though, when the very strong men and women are handy to have around.) The ergonomic answer to this is to keep your body parts in good alignment. Place your ears over your shoulders, and your shoulders over your hips. Also, keep your arms close to you when you do your job. (How many times have you had to stretch way out in front of yourself to pan the table?) Remember… EARS SHOULDERS HIPS Arms close and about 90 degrees Repetition. Any task that you do the same way over and over will wear out the part being used. Both holding groins and injecting contrast are excellent examples of overuse risks. If you have to use force to move heavy objects (or heavy patients) or you have to exert manual force to get a device to cross a lesion (isn’t that why some doctors grunt and cheerlead as they move a stent millimeter by millimeter?), it takes a toll. What about when we have to stock supplies? Kit boxes, along with everything else, are not light. We move them over and over, patient by patient, and box by box. Use your tools even a surfboard or patient sled decreases the surface tension and makes moving stretcher to table and back easier. Stocking shelves so less bending and stretching is required to get supplies is much better than stacking them floor to ceiling. These are little things you can do without permission. Look over your stock room the next time you go into it. Think about good posture and repetitive use, and force injuries. Then rearrange the shelves for the best use of space. THEN and this is the big THEN, go to your boss and say: We just saved the hospital a lot of money by DECREASING the RISK of INJURY because we rethought how we stocked and stored our equipment. Then ask for a raise. It is always cheaper to do preventative maintenance than repair work. Compression and contact stress and the injuries they cause are a major cause of workers’ disability. The use of ergonomically-designed keyboards have helped decrease the carpal tunnel syndrome seen after hours of data entry, day by day. Remember that these keyboards offer a wrist REST, not a wrist HOLDER. That means you rest your wrist in a neutral position, then move it off. Your keyboard needs to be at the precision level for work, which is 2-4 below the elbow. Always seek neutral or normal body alignment. At that position, speed and dexterity are enhanced; it’s just physics at work. The concept of vibration is self-explanatory. We don’t see many vibration injuries in the interventional lab, but the risk is to the digits, because of the grip necessary to control devices. Duration of any motion or stress increases the risk of injury. The longer you have to fix that wire or hold that catheter right there, the greater the risk of muscle damage. It isn’t only that particular time, it’s the cumulative amount of times you repeat that motion. Once a month, once a day, once an hour, it all adds up. Lest we forget temperature, I saved it for last. There has to be a consensus on temperature. Forget the snickering about hot flashes, and that men have more muscle, and whatever else. It is cold in the labs. The computers do not have to live at 68 degrees. Just think a minute. Your body temperature is around 98. The room is now 30 degrees colder. Yes, you have on layers of clothing and lead, but the stainless steel bowl of saline does not. The patient does not. The equipment does not, and it gets as cold as the room. You can trigger an attack of Raynaud's by extreme fluctuations in temperature. We cannot give our nurses nitro to vasodilate that finger and expect them to remain standing! Compromise, people, compromise, and ask the biomedical people how cool the room really needs to be. Then work it out. Buy one of those blanket warmers and maybe even a Bearhugger, the warm air-filled wrap used in the OR. (A little warning: if you wrap the staff in one of these, they will fall asleep.) A discussion of ways we can modify the workplace.There are not enough trained staff in our field. We have to find ways to keep those we do have from being injured on the job. Why go through these changes? Why rock the boat, and the bosses who have always done things this way, and people who have just learned how to do the job? Well, because it is the right thing to do. OSHA, in 1999, reported that $1.00 of every $3.00 spent on worker’s compensation costs were related to work-related musculoskeletal disorders. That’s 33%, which cost the government $15-20 billion dollars (those are just 1999 figures)! These figures don’t even take into account those employees who don’t report their injuries for fear of reprisal or ostracizing. (Almost done are you tired yet? Have you been sitting too long? Do you need a stretch break, and to use different muscles for a minute?) Alternative & positive mechanisms we can beg for in our labs. Consider preventive maintenance for our bodies as well as machines. Let’s take another look at our workplaces. There are expensive ways to fix things, and there are less costly ways. The most efficient way is to work with engineers as they rebuild or build your labs. By this I mean the staff working with the engineers, not the administrators! Who, bless their pocketbooks, have probably never been in the lab except to say hi, if they even have had a chance to do that lately. It goes without saying that the cook should have the most say as to how the kitchen is set up. The labs are our kitchens (and for considerably longer than we are in our real kitchens at home). We redid one of our labs a few years ago with the caveat that staff could not add to the budget with their requests. Instead, they talked to the engineer and biomedical engineer as they placed things. You can do a lot once the floor is broken up. For example, our staff put a slave monitor at the end of the table; they pan, so it decreases the turning of the neck and panning in the other direction. After this exercise of opinion, they could not be stopped. CD speakers and wires were hung and hidden, and as a result, the guided imagery in that room is wonderful. Staff changed the angle of the x-ray table so that in case of emergency there is a 360 access to the patient (totally different than originally planned). Then they changed the angle again to protect the patient’s privacy when the door was opened. None of these changes added to the cost of the room. We are an adaptable people. The 5’0 staff will adapt themselves to the same workspace at the 6’4’’ staff person. Ideally, the fixed table heights should be for the tallest (mean) and the shortest should have steps or platforms. That is the Army or OSHA way. Unfortunately, it will not work in the lab, since we work in the dark with things underfoot already. Look around, remember the rule of neutral positioning, and change the things that you can. Is it possible for the biomedical or carpenter staff to add a footrest to the area around the table? Are you sure it isn’t possible? Have you asked? Remember: EARS SHOULDERS HIPS Arms close and about 90 degrees We work fastest and are strongest in a neutral position. It minimizes stress and maximizes circulation. The angle of the elbow in particular needs to be discussed. Acute angles or 90 degrees give the best visibility and fine motor speed. Angles that increase 110-120 degrees, or 4-6 inches below the elbow, have more strength, and are better for putting things together or for when you need more intensive manual labor. Angles larger than 4-6 inches below the elbow are where brute strength comes into play. You don’t need brute strength to thread a wire in a balloon, so work closer and higher. CPR is a time when you might need the table height lowered, so remember to be considerate of your friends doing compressions or bagging. Why not? Why not offer staff hand and arm massages and paraffin wax treatments after a hard day’s work? (A note: ask if the staff has osteoarthritis, as the heat will aggravate it). Neck and shoulder massages would also help after wearing lead all day. (A note: all of the doctors will line up; this should be first for the staff, then the doc). Of course, you must get releases from staff just in case the wax is too warm, or you massage too strong, or whatever the lawyers and risk management want on paper. Yes, you also must get the time to do this on a consistent pattern; preventative maintenance is repetitive, just like the injuries that the lack of prevention will cause. There are many alternative and complementary practices in place around the world today. There is definitely a place for some less orthodox preventative measures in the interventional world of lead, freezing rooms, long hours, and repetitive-use tasks. The point of an ergonomics program and the savings it can bring about are in the prevention of injury to employees. Isn’t that worth working for? More information can be downloaded from OSHA’s website (www.osha.gov).

1. Laedke, Mary Lt.Col. USMC. "Ergonomics Readiness Through Design." Ergonomics for the APTA, March 31, 2001.

2. OSHA: Ergonomics Current Public Forums/Request for Comments. July 16, 2001. www.osha-slc.gov/ergonomics-standard/index.html

3. Piasecki D. OSHA’s Ergonomics Program Standard. 6-28-01. p. 2-3.

4. The American Heritage Dictionary, Second College Edition. 1983; pp. 239, 464.

5. Braumberg, Mark President ErgoPro. OFFICE ATHLETE, Program. New Version for Windows 95-98-NT. 2001. Permission to use and supplied by Mark Bramberg, Pres.