Jerry H. Siegel, MD, MACG, for ACG Women in GI Committee
Orthopedic injuries are very commonly reported among endoscopists resulting from repetitive actions. We shouldn’t forget injuries sustained from falls, lifting patients off of stretchers, or even injuring one’s hands and arms pushing a stretcher through a narrow doorway. The more-serious problems are those occurring from repetitive use, i.e., torqueing and “jiggling” the endoscope, manipulating the control wheels, and assuming sustained awkward body positions. Serious injuries affect the neck, shoulders, arms, hands, thumbs, wrists, lumbosacral spine, hips, legs and feet. In my own experience, I have suffered many of these injuries.
When I began performing endoscopy in the 1960s, we used optical instruments, those which had an eye piece through which the endoscopist visualized the internal components of the organs being examined. This meant that the endoscope was held up to the endoscopist’s eye, which resulted in the endoscopist’s head and neck held at acute angles for extended periods of time. Ultimately such positions caused injury to the neck and shoulders. In addition, the endoscopist’s body often was bent in awkward positions, too, resulting in injuries to one’s back and hips. Obviously, standing and bending caused injuries to the hips, legs and feet. Remember, many procedures during the evolution of endoscopy lasted much longer than they do now, with video instruments. To add to assuming unusual body positions, those of us doing ERCP wore very heavy and stiff one-piece lead aprons, adding pressure to the already injury-prone skeletal structures. When endoscopists performed ERCP using optical endoscopes held to an eye, the endoscopist had to extend his/her neck to see the fluoroscopic images, another position straining the upper body structures. Obviously, with today’s video endoscopes, one’s head is held upright, and the video and fluoroscope monitors are adjusted to eye level to avoid extension of the neck. New Fellows entering training programs are fortunate that they use video instruments, which obviously avoid many of these problems. Our experience may help to prevent some of these injuries in those beginning their fellowships.
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I performed many endoscopic procedures, including thousands of ERCPs with optical instruments (video endoscopy only became universal in the 1990s), and carried instruments, light sources, cautery units and other equipment to many different hospitals on a hand truck, which only added to my injuries (very few endoscopists were performing ERCPs in the 1970s and 1980s. I volunteered to come to their hospitals to work with them in advancing their techniques). In those days we, the endoscopists, assisted the staff in moving patients off of the stretchers, onto the fluoroscopy table, and back onto their stretchers. Because of the awkward positions I assumed for so many years using optical endoscopes, in 2000 I began to experience paresis (weakness) in my arms and legs, loss of proprioception and balance, paresthesia when extending my neck, and difficulty standing upright. After visiting six neurosurgeons and undergoing nerve conduction studies, EMGs, many imaging studies and a myelogram, I was found to have cervical cord compression. Four of the six surgeons refused to operate because I was a physician, a little older and, considering the work I was doing, they were afraid they would make things worse if they operated. But, in 2001 I did have surgery on my cervical spine, with fusion of cervical vertebrae three to five and titanium plates inserted (Figure 1). Recovery and rehabilitation required a long hiatus from work. When I returned, I was told to limit my physical activities and to avoid lifting and assuming awkward positions, and definitely not to perform ERCP examinations for an extended period of time. Occasionally I would do some procedures when my partners were unavailable. I finally returned to full-time work after two years.
The cervical spine was OK, but then I began to have back pain. I went for an x-ray series to facilitate physical therapy. When the images came up on the monitor, I asked the radiology technician to whom these awful back malformations belonged. When he told me the images were of my back, I couldn’t believe it. I had kyphoscoliosis affecting my thoracic and lumbar spines. The vertebrae were angulated, trapezoid in shape and compressed, resulting in a loss of five inches in my height (Figure 2). I continued to have difficulty walking and balancing. I underwent physical therapy but no surgery, and my problem persists. Along with these injuries I was treated for bilateral rotator cuff injuries, carpal tunnel syndrome, bursitis of my hips, knee pain, and plantar fasciitis.
In addition, I described what I call a “stent associated enlargement of my index finger knuckle” of my right hand (Figure 3), resulting from repetitive actions from trauma associated with forcefully pushing thousands of stents through obstructions of the biliary tree and pancreatic duct. My thumbs were spared. On more than one occasion when using an optical endoscope and applying tension to a basket attached to a biliary stone, I sustained lacerations above my eye when the stone I was trying to remove suddenly yielded to the tension, releasing the endoscope and allowing the eye piece to strike my forehead. Many endoscopists had a red ring around the eye they held to the optical head, and some sustained retinal damage from the halogen light. I used a teaching head most of the time, which diffused the intensity of the light, thus saving my eyesight.
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Other problems I developed over the years included a severe allergic dermatitis to latex gloves, which began as vesicular eruptions on the palmar surfaces of my hands. These vesicles would open up, leaving fissures that bled at times and were very painful. This happened during the AIDS epidemic. In order to avoid contact such as handshakes, etc., I wore white cotton gloves all the time. I underwent PUVA treatment and used steroids topically, but none worked. After being treated with lose dose radiation, the dermatitis healed. Since then I use vinyl gloves and, when I perform endoscopy on a patient at high risk, I place a latex glove over the vinyl glove to avoid latex contact. In the past, when the technicians physically washed the endoscopes, they were placed into an open tub containing glutaraldehyde which was located in our endoscopy room. Under these conditions, the glutaraldehyde vaporized, and we were breathing in the vapors. From this I developed asthma, for which I use medications to this day—this started more than 25 years ago. Our technicians were always coughing and complaining of their eyes burning, dermatitis, etc. Subsequently, as we all know now, the endoscopes are disinfected in a special ventilated room to avoid inhalation of the vapors.
The moral of this story is to prevent acute or chronic injuries associated with repetitive use injuries by resting, using ergonomically designed facilities, avoiding unnecessary straining or lifting, using a two-piece, lightweight lead apron (fluoroscopy is not only used for ERCP, but also for dilating enteral strictures, placing enteral stents, performing rendezvous procedures (EUS-ERCP combined), etc. One might need to wear an orthopedic back, knee or ankle brace to support these areas. Make sure to avoid liquid spills on the floors to prevent falls. It would be helpful to strengthen your bodies, following prescribed exercises for your upper and lower muscle groups. In addition to wearing comfortable shoes, it is recommended that a soft mat be placed on the floor for more comfort. Some experts have recommended using a short stool—four to six inches high—so that you can shift your weight intermittently from one foot to the other on the stool. Others have suggested sitting on a stool, which I found difficult to do. And certainly, avoid hyperextending one’s neck by adjusting the monitors to your height.