Ergonomics

Ergonomics is a relatively new word and practice, which appropriately fits right into our field of interventional cardiology. We are a new field less than 25 years old, and this is a new term less than 25 years old. Just like our desire to explore cardiology, we should also be open to exploring the field of ergonomics, because it does indeed hold value. History has shown that worry and concern regarding workers, working conditions, and the injuries that a poorly designed workplace have brought about have been societal concerns for a long time. Does anyone remember the Ten Commandments with Charlton Heston? He was so concerned with a slave woman who was going to be crushed that he stopped production of the Pharaoh s pyramid. Again, during the Industrial Revolution and the era of "sweat shops," the lives of factory workers were taken just as easily as they were in early work zones. Thankfully in today's cath lab we have no reason to fear loosing your life at work. We probably do however, have concerns about our body s health in regards to the long-term effects that our work can inflict on us every day. So what is ergonomics and what does it have to do with the world of the cardiovascular staff? This one is the bugger. OSHA, in July 2001, held meetings in Washington, D.C., as well as Chicago, asking the same question: Define ergonomics. The following is one of the best definitions I found, courtesy of Lt. Col. Mary Laedke, United States Army. "Ergonomics involves the application of knowledge about human capacities and limitations to the design of workplaces, jobs, tasks, tools, equipment, and the environment." Basically that means we adapt the workplace to the worker, and not the other way around. At some point, the paradigm must evolve from the understanding that a worker finds a job, and then decides how to perform that job, no matter the physical cost. This new thought process involved in the definition of ergonomics is one of logic and wellness. Poorly designed workplaces lead to a higher risk of work-related musculoskeletal disorders (this year s buzzword), or WMSD s. There is increased risk of repetitive stress and strain injuries, cumulative trauma or force injuries, carpal tunnel syndrome, and, the nemesis of wearing lead aprons all day: low back pain. The list of work-related musculoskeletal disorders for the cath lab staff is very similar. In addition to the previously mentioned, staff have to worry about tendonitis, rotator cuff injuries, and Raynaud s sign after having your hands in ice cold saline, in an ice cold room, for hours a day. These injuries can be worsened by our activities of everyday living. OSHA held forums and asked both the employers and employees to determine if their ergonomic injuries were work-related or non work-related. At these forums, discussion centered on those injuries that could not always be defined as work-related or non work-related. OSHA discussed the possibility of injuries that are a combination of the two: synergistic damage. (Has anyone ever gone home with a backache, then lifted a baby?) Six Main Factors for WMSD s 1. Position and Posture The ideas of good posture are drummed into every employee. We go to sleep thinking about good body mechanics. (Well some of us do.) These practices are vital to good back health. A healthcare provider is not helping anyone by using poor technique. Often employees hurt their backs when lifting with strength instead of proper posture. (Although there are times when the really strong men and women are handy to have around.) The solution is to keep your body parts in good alignment: ears over shoulders over hips, and arms close to you when you do your job. Call it repetitive use, call it "over and over," or call it what you willæany task that you do the same way all day long will wear out the part being used. After all, even solid rubber tires wear thin. We must be aware of activities that involve repetition. Holding groins and injecting contrast are both excellent examples of over-use risks. In addition, 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 more you are at risk for muscle damage. Duration doesn't only deal with single events either. Along with repetition, duration deals with the cumulative amount of times you perform an action; once a month, once a day, once and hour; it all adds up. If you have to use force to move an object, be it heavy objects or heavy patients, you put strain on your body. If you have to exert manual force to get a device to cross a lesion (isn t that why some doctors grunt and cheer as they move a stent millimeter by millimeter?) you put strain on your body, and it all takes its toll. Even stocking supplies can induce strain; those boxes and kits and everything are not light. You strain yourself all day long, over and over, patient by patient, box by box. The solution is to use the tools at your disposal. Even things like the surfboard or patient sled decrease the amount of bending and stretching you have to perform. Better yet…look over your stock room. Think about good posture, repetitive use, and force injuries. Then, rearrange the shelves for the best use of space. Then, and this is a 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. Remember that preventative maintenance is always cheaper than repair work. Compression and contact stress and its injuries, are major causes of worker s disability. The uses of "ergonomically" designed keyboards have helped decrease the amount of carpal tunnel syndrome in employees, but remember this pearl: wrist rest, not wrist holder! This means that you rest your wrist in a neutral position, then move it off. Also remember to have your keyboard positioned at the proper level of work: two to four inches below the elbow. Always remember neutral or normal body alignment. At that position, speed and dexterity are enhanced; it s just physics at work. Vibration is self-explanatory. We don t see many vibration injuries in the interventional lab, but the risks are associated with the digits, due to the grip necessary to control the device. Lest we forget temperature, I ve saved it for last. There has to be a general consensus for temperatures in a lab. Forget the snickering about hot flashes, men having more muscle, or whatever else; it s cold in the labs. The computers do not have to live at 68 degrees. Just think for a minute. Your body temperature is around 98 degrees. The room is pretty much 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 everything in the room gets as cold as the room. You can trigger an attack of Raynaud s sign by extreme fluctuations in temperature. In addition, we cannot give our nurses nitro for vasodilation and expect them to remain standing! It s all about compromise. Ask the biomedical people how cool the room really needs to be and work it out. Then buy one of those blanket warmers or maybe even those warm air-filled wraps used in the OR). A little suggestion though, if you wrap the staff in one, they will fall asleep. Why go through with these changes? Why rock the boat? Why bother the bosses who have always done things this way? Why change the methods used by employees who have just learned how to do the job? Why? Because it is the right thing to do. OSHA reported in 1999 that one dollar of every three dollars spent on worker s compensation costs were related to WMSD s. That s 33% of worker s compensation. Using their figures, this costs the government $15 to $20 billion, and that was in 1999! In addition, those figures don t take into account the patients who do not report their injuries for fear of reprisal or ostracizing. You can pick whichever reason you need to convince your administration, or perhaps it is like the science of ergonomics that all things are cumulative. Almost done, are you tired yet? Have you been sitting too long? Do you need a stretch break to use different muscles for a minute? It all works along the same principles. Let s take another look at the workplace. Remember that there are expensive ways to fix things, and there are less costly ways to fix things. The most efficient way is to work with the engineers as they rebuild your labs. That means 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 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. We in the labs are in our "kitchens" considerably longer than we are in our own kitchens at home. We redid a lab a few years ago with the caveat that we could not add to the budget with requests. So we talked to the engineer and biomedical engineer as they set up the room. You can do a lot once the floor is broken up. For example, our staff placed a slave monitor at the end of the table. The monitor pans, so it decreases the turning of the neck and panning in the other direction. CD speakers and wire were hung and hidden, and the "guided imagery" in the room is wonderful. They changed the angle of the x-ray table so in case of an emergency, there is a 360-degree access to the patient. They also changed the angle again to protect the patient s privacy when the door was opened. All these changes and it didn't add to the cost of the room. It s all about adaptability. We are an adaptable race; the 5 0" staff person will adapt themselves to the same workplace as the 6 4" staff people. However, nothing has to be in stone. The fixed table heights should be for the tallest (mean) and the shortest should have steps or platforms. That is the OSHA way. Unfortunately, it will not quite work in the lab. 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, and arms close at about 90 degrees? We as a race work fastest and are strongest in a neutral position. It minimizes stress and maximizes circulation. The angle of the elbow needs to be discussed. It is like physics and art together. Acute angles or 90 degrees give the best visibility and finest motor speed. Angles that are increased by 110 to 120 degrees, or four to six inches below the elbow, have more strength and are better for putting things together, but are more manual labor intensive. You don t need brute strength to thread a wire in a balloon, so work close and higher. CPR is a time when you might need the table height lowered, so remember to be considerate of your co-workers doing compressions or bagging. The last thing I want you to consider is an area that is near and dear to my sense of well being in the workplace. There are many alternative and complimentary practices being done around the world today. There is a place for some of these less orthodox preventative measures in the interventional world of lead, freezing rooms, long hours, and repetitive use tasks. Remember that the point is in prevention. Give hand and arm massages and paraffin wax treatments after a hard day's work. (Note: watch for osteoarthritis, the heat will aggravate it.) Give neck and shoulder massages after wearing lead all day. (Note: all of the doctors will line up; staff should be first, then the doctors.) Yes, you must get releases from the staff in case the wax is too warm, you massage too strong, or whatever the lawyers and risk management people want on paper. Yes, you must get the time to do this on a consistent pattern; but remember, preventative maintenance is repetitive, just like the injuries that the lack of this will cause. In closing, take time to evaluate your workstation in the future. Perhaps you can modify and save yourself and your coworkers an injury. Perhaps with the addition of preventative medicine practices, you can go home not exhausted.