Don't Slouch on Surgeon Comfort

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Ergonomic solutions paired with physical preparation reduce the risks of debilitating and career-threatening repetitive strain injuries.


Surgeons undergo years of intense training to learn how to return patients to good health, yet receive little instruction on how to maintain their own well-being. After long days in the OR, their necks stiffen, backs ache and shoulders throb. They often shrug off the pain and hope it goes away, even though it usually doesn’t.

Graeme Rosenberg, MD, who’s in his last year of general surgery residency at Stanford (Calif.) Health Care, remains physically fit for surgery through stretches and — sketches?  “Early in my residency, I’d draw illustrations in my notebook of surgical steps so that I could remember the coaching I received in the OR, and refer back to it later,” explains Dr. Rosenberg. “I thought the drawings could be helpful to other surgeons, and started sharing them on Twitter.”

His sketches, brilliant in their simplicity, depict a variety of tips, tricks and lessons he’s learned during his early career, including how to position equipment and his body to mitigate the debilitating pain caused by standing in static positions for hours on end. He jots down important reminders in the margins about the essentials of surgical ergonomics: Position video monitors at eye level and straight ahead. Keep your shoulders down, arms loose and elbows in. Remember to breathe!

In his first year of residency, Dr. Rosenberg spent countless hours standing in ORs, watching surgeons in action and learning from their techniques. One of the biggest takeaways came from how he felt instead of what he saw. “You aren’t as focused on the patient as you would be if you were operating, so it’s easier to feel and be more aware of the discomfort in your shoulders, back, feet and legs,” he says.

Dr. Rosenberg began to experience chronic lower back pain, which he attempted to alleviate by trying five different types of footwear. The pain persisted, however, so he started doing yoga. That lessened his discomfort because he was becoming more flexible, and his core was getting stronger. “I try to do yoga every day, even if it’s for only 10 minutes in the morning,” he says.

No longer a young med student, Dr. Rosenberg is more hands-on in the OR, and more aware of ergonomics. He admits to already feeling the physical effects of long hours spent in surgery. He’ll be 35 years old when his residency ends later this year, and doesn’t want to begin his career as a thoracic surgeon feeling like it’s over before it starts.

“I’ve been very focused the last couple of years on how I stand and position my elbows, and where video monitors are placed to improve my ergonomics,” says Dr. Rosenberg. “As I start performing cases that last six, eight or even 10 hours, the little things I do to preserve my physical health will pay off down the road.”

 

LIKE HE DREW IT UP Graeme Rosenberg, MD, refers to his sketches for reminders of how to properly position himself and his equipment during surgery.  |  Louis Salamone, MD

The ergonomics of surgery is underdiscussed and isn’t properly addressed, according to Tom Nguyen, MD, FACS, FACC, chief of cardiothoracic surgery at the University of California, San Francisco. He believes surgeons are taught to be stoic and strong, and often don’t have or make the time to prepare their bodies for the physical rigors of surgery. “I know surgeons whose careers ended because of neck and back injuries, and that’s unfortunate,” he says.

Dr. Nguyen is all too familiar with the aches and pains associated with his profession. “Being a surgeon is mentally and physically taxing,” he says. “We perform long operations and contort ourselves  into a variety of very unnatural positions. Surgery puts a lot of strain on our bodies that we’re not always aware of and we don’t fully appreciate.”

Underestimating the physical toll of surgery causes many surgeons to endure chronic pain throughout their careers. “We don’t strengthen our bodies as much as we should,” says Dr. Nguyen. “There is some data to suggest that surgeons who exercise regularly, train the right muscles and get enough sleep minimize the negative consequences of surgery’s stressors.” 

He believes achieving healthy ergonomics requires proper body positioning during surgery, working with the right equipment, and proper preparation and recovery outside of the OR. He also admits that busy surgeons often don’t put enough energy into physically preparing for surgery or recovering from a long day in the OR. “This is the Catch-22. Our hours are long, and we have families we want to spend time with, but we also have to find a way to take care of ourselves.”

To help surgeons remain physically fit, Dr. Nguyen developed a simple but effective strengthening and stretching regimen that can be completed in less than 15 minutes (see “Finding Time for Fitness” ). His goal is to perform the exercises a couple times a week, but he sometimes can only fit it in his schedule about once a week. “Our careers are so demanding that sometimes we don’t have the time to exercise,” he says. “We still have to try to make it a priority.”

Exercise Plan: Finding Time for Fitness
HEALTHY APPROACH Dr. Nguyen believes surgeons who work on their physical well-being are better prepared to perform surgery.
Even the busiest surgeons can squeeze in this strengthening and stretching routine created by Tom Nguyen, MD, FACS, FACC, chief of cardiothoracic surgery at the University of California, San Francisco. It takes about 15 minutes to complete and doesn’t require additional equipment. Rest for 30 seconds between each set and repeat the circuit three times. Afterward, you’ll feel refreshed and ready to return to the OR. — DBF

Set 1: Stretching
• Neck stretch: Tilt your ear to your shoulder and hold for five to 10 breaths on each side.
• Chin tucks: Keep your shoulders still, face forward and pull your chin to your chest. Release your chin, allowing it to float forward. Repeat five to 10 times.
• Shoulder stretch: Place one arm across your chest and push gently on your elbow with the other arm. Hold for two to five breaths on each side.

Set 2: Strength 
• Squats: Place your feet shoulder-width apart with your toes facing forward. Squat until your thighs are parallel to the floor. Do 15 reps with an optional hold.
• Mountain climbers: While in a plank position, engage your core and alternate bringing each knee up to your chest. Continue for 60 seconds. Consider increasing your speed to increase your heart rate.  
• Glute bridge: Lying on your back, bend your knees and keep your feet flat on the floor. Push your hips up until your knees, hips and shoulders are in a straight line. Do 15 reps.

Set 3: Stretching
• Trapezius stretch: While sitting on a chair, use one hand to hold the seat and the other to gently pull your head in the opposite direction. Hold for 15 seconds on each side. 
• Levator scapulae stretch: With arm bent, place your hand on the ipsilateral shoulder so your elbow is pointed upward. Look down toward your opposite hip. Place your opposite hand behind your head and gently pull down to deepen the stretch. Hold for 15 seconds on each side.
• Cat-cow: Start on your hands and knees with a neutral spine. Inhale and arch your back, looking up (cow position), then exhale and round your back (cat position). Repeat for 10 slow breaths.
SIT UP STRAIGHT Brian Shafer, MD, operates with the perfect posture that’s needed during ophthalmic procedures.  |  Vance Thompson Vision

Many surgeons are realizing they must find the time to take care of themselves physically if they want to keep operating. No one knows this more than ophthalmologists, who spend much of their careers in the clinic and OR hunched behind the oculars of a microscope.

“In a single day, most ophthalmologists will see more than 40 patients in the clinic or perform 20 surgeries,” says Brian Shafer, MD, who is completing his fellowship in cornea, refractive, glaucoma and cataract surgery at Vance Thompson Vision in Sioux Falls, S.D. “Over a 30-year career, that’s thousands of hours in a head-forward position, which can cause serious neck and back injuries.”

Ophthalmologists must maintain this head-forward position while also steadily manipulating instruments in a microscopic space. Performing the subtle movements over many years can put significant strain on their wrists and hands. Roughly 80% of ophthalmologists report having suffered such work-related injuries, according to Dr. Shafer.

He’s already feeling the first twinges of musculoskeletal pain due to poor posture in the OR. “I’m performing around 50 surgeries a week and beginning to experience discomfort in my upper back and neck,” he says. “I operate in a well-run, highly efficient and ergonomic-friendly ASC, but that does not prevent me from being my own worst enemy. I prioritize patient comfort over my own, and have suffered for it.”

Dr. Shafer points out that technology has responded to the demand for improving surgical ergonomics, particularly in ophthalmology. “The chairs surgeons sit in during surgery have improved lumbar support, which is essential,” he explains. “Surgeons can also adjust the heights of the surgical microscope and operating room bed to ensure their back is straight, their neck is upright and they can reach the patient without straining.”

Heads-up surgical displays free ophthalmic surgeons from the microscope’s oculars, allowing them to shift their body during surgery and operate in greater comfort. They wear 3D glasses and view the case on a large video monitor. This allows them to remain completely upright, and keep their shoulders and head back instead of slouched forward.

To avoid wrist and hand injuries, ophthalmic surgeons should utilize wrist rests attached to the head of the surgical bed. This is critical for their added comfort and helping to keep instruments steady in the eye, according to Dr. Shafer. He also points out that beds used for eye surgery must have a head support that extends beyond the main portion of the platform to allow for flexion and extension of the patient’s neck. This lets surgeons sit comfortably during surgery without their knees touching the patient.

“I’m hoping to operate for 30 more years, so if my colleagues see me operating with bad posture, I’m hoping they remind me to straighten up,” says Dr. Shafer.

Surgeons like Dr. Shafer who want to reduce the risks of debilitating repetitive strain injuries should take the time and make the effort to properly care for their bodies. They must prioritize personal wellness as if their career depends on it, because in many ways it does. OSM

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