Feature
Cath Lab Ergonomics
February 2006
Ergonomics has always held an interest for me because of the potential life-changing injuries that could potentially affect the people with whom I worked as well as the effect an injury can have on factory productivity and product quality. If someone is feeling pain or discomfort doing an important task, they cannot be be totally focused on that task, and there is a potential for error due to their inattentiveness. I always believed that I could help improve conditions in my workplace by promoting ergonomically safe behaviors at work and at home.
Over the course of twelve years at HP and Agilent Technologies, we progressed from providing powered ergonomic torque-limiting screwdrivers, based on a conservative repetitive-motion matrix, to a no-lifting shipping and light-lifting receiving department, to having an ergonomic presence on new product design teams to ensure that their products were designed with ergonomics in mind. During this twelve-year period, there was a lot of time and money spent on new equipment, tools, process changes, and training to provide and foster an ergonomically-safe work environment.
There were metrics put in place to measure improvement in this health and safety arena. We performed ergonomic assessments on all processes to measure their injury potential and proactively tried to address all high-ergonomic-risk situations. We constantly monitored the OSHA Injury/Illness rates, and I'm proud to say that during this time we cut our rate in half. Towards the end, we were trying to reduce it even more by implementing a BSOF program (Behavioral Safety Observation and Feedback).
All training I helped create for employees and management included information on the relationship between work and home activities on ergonomic injuries. I was concerned about home activity behaviors because of the nature of the beasts RMI (repetitive motion injuries) or CTD (cumulative trauma disorders). It is rare that you do not use the same muscles and tendons at both work and home. That is why it can hurt doing activities in both arenas. I do not want to lessen the responsibility of organizations regarding the health and welfare of their employees, which is directly affected by the tasks employees must perform for those organizations. However, I also want to point out the responsibility we all have to try and work safely on the job, and work and play safely at home. Body Positions and Injuries To help with a better understanding of ergonomics, let's discuss neutral and awkward body positions. If we could totally relax all of the muscles in our body without giving any conscious input, and be suspended in a saline, water-filled tank, our body would take a shape similar to sitting in a chair elbows at our sides, arms at 90 degrees to our body, and hands and fingers straight out. It would look a lot like the fetal position. This is called a neutral body position.
Our bodies were designed to move our muscles and joints, within limits, for a lifetime. So what happens when we exceed the normal limits of body position? If you are slowly stretching to new limits to increase mobility, that is one thing, but when you are doing a task that causes you to apply an excessive force repeatedly, hold an awkward position for a long duration, impede circulation with a sharp edge, or add vibration or sudden shock, you can start muscle tendon degradation that can lead to an injury. Let's call these injuries a micro-injury incident. Let's also call an uncorrected and/or unhealed accumulation of micro-injury incidents a Repetitive Motion Injury, or RMI. Stressful Postures o Causes compression or stretching of certain tissues: Elbow above the shoulder Arm behind the body Extreme flexion at the elbow: i.e., touching right shoulder with right hand Forearm extreme outward and inward rotation: Screwdriver motion Extreme flexion or extension of the wrist: i.e., moving your palm up or down at the wrist Extreme radial or ulnar deviation: i.e., flexing your hand in the thumb or pinky direction o Requires more muscle and tendon force: Pinch grips Extreme horizontal reaches Multiple micro-incidents can easily turn into a full-fledged RMI. Our bodies have an injury incidence file for each of our muscles and tendons. Each of our muscle and tendon areas have different size injury incident files, and these files can be different sizes for each person. This affects our body’s tolerance to multiple injury incidences and our ability to heal from the injury incidences. When we repeatedly tweak a muscle or tendon area without giving it a rest, the injury incident file fills up to bursting with injury incidences. If we take steps to eliminate or reduce the causes of the micro injuries, we can thin out our injury incidence file. What keeps the file from getting too full is our body’s ability to heal itself. We can help this ability further by resting the affected area or by changing the way we perform a particular task.
Our body’s response to these micro-incidents or doses is usually an achy, tired feeling in a muscle or tendon area. This is our body’s first response or warning of a potential injury. Ergonomic injuries happen because we continue to ignore these signals and work through the discomfort. When this happens, we get the more extreme symptoms, such as loss of grip strength or tingling due to nerve damage, although these are just a few of the potential symptoms. We need to reduce and eliminate one or more of the multiple causes of the discomfort. If we can eliminate the awkward position, duration, force or some of the repetition, we can go a long way in reducing the chance of an ergonomic injury.
In my past work in the electronic manufacturing sector, I was concerned with the hundreds and thousands of repetitions workers performed each day in order to build products. Bent wrists, pinch grips, arms extended above the shoulder and backs were just a few of the issues I dealt with in the manufacturing processes. We found that pinch grips associated with different forces and awkward positions contributed the most to carpel tunnel-type symptoms and injuries.
However, in the manufacturing environment where I practiced ergonomics, there were always individuals who never seemed to get injured doing their job. I noticed that rather than the job and tools manipulating their movements, that these individuals used all of the flexibility available to them to use the tools and equipment to their ergonomic benefit.
I have also observed during my clinicals that there is usually someone that has not developed any back, wrist, or arm discomfort working in a cath or specials lab. I personally enjoyed talking to these professionals about how they perform certain activities so I myself can develop ergonomically safe work habits to avoid injury in my new career. As a result, I have learned about some ergonomic ways of holding pressure, and a way to reduce the pinch grip on a slippery glidewire by using a dry or damp 4x4.
At home, any activity like using a screwdriver forcefully, trying to open a tight jar or wringing out a wet cloth or towel, can tweak the hand or wrist. Most carpal tunnel injuries are an accumulation of the stresses received from pinch grips, awkward arm positions, high forces, repetition, and long duration stresses. There are similar body mechanics and stressors at work in our cath lab daily life.
Our hands are one of the most valuable assets in our chosen career. In the cath, EP or specials lab, we can collaborate with staff and have discussions about better ways to do required tasks , as well as make sure everyone knows about RMIs and CTDs. Some individuals may laugh and say, What’s the big deal?, while others are very intimately acquainted with these types of injuries. I encourage technologists to work with cardiologists and radiologists, because they seem to have a large say as to when a hemostasis device can and cannot be used. Although there are established contraindications for the use of Femostop® (Radi Medical Systems, Wilmington, MA), Perclose® (Abbott Vascular Devices, Redwood City, CA), or Angio-Seal (St. Jude Medical, Minnetonka, MN), I have observed physicians who readily request and use some of these devices on a regular basis. I have not asked why they frequently request their use, but I know it certainly can reduce the potential stress of holding manual pressure for fifteen or twenty minutes.
I have also noted in some of the labs I have visited that there are usually one or more technologists that are suffering some wrist discomfort, and several have had carpal tunnel surgery. Most of the time these professionals are very active, both in and out of work. I checked with a few of the specialists who track injuries at some of the clinical sites in Washington state and noticed that over the last two years there have not been any claims for carpal tunnel or other RMI-type injuries in the cath or specials labs. Conclusion In conclusion, remember that there are lots of things we can do collaboratively to reduce the chance of an ergonomic injury at work and home. Ergonomics is not just about health and safety. It is also about the quality and productivity of your processes! A Final Note I want to compliment Marsha Holton, RN, BS, CCRN, RCIS, Cardiovascular Orientation Programs (Indian Head, Maryland) for her articles and investigation into ergonomic injuries and incidence in cath labs. For more information, see Holton, M. Ergonomics in the Cath Lab (or, how to save staff backs, necks, wrists...). Cath Lab Digest May 2003;11(5):1-14, and Holton, M. Ergonomics Revisited: Carpal Tunnel Syndrome. Cath Lab Digest March 2005;13(3):48-53. Al Moglia can be contacted at RUBABYM @ peoplepc.com. References 1. Cumulative trauma disorders: Their recognition and ergonomic measures to avoid them. Applied Ergonomics 1989, K.H.E. Kroemer. 2. Work Factors Associated with Cumulative Trauma Disorders: Work Postures. Tom Armstrong, Ph. D. University of Michigan. 1990. I was also a manufacturing process technician/engineer during my 32 years with HP and Agilent Technologies. We continually evaluated the effectiveness of our manufacturing, shipping and receiving processes in relation to ergonomics, productivity and quality. We made changes if the processes revealed bottlenecks in the speed and quality of the overall process, working under the continuous improvement philosophy. I have seen some opportunity for similar types of improvement in the cath and specials labs where I have spent time in regards to their processes: for example, rooms may be set up differently even though the same procedures are performed in each. Process-wise, this setup has potential for mistakes and has bottlenecks in a potentially life-saving process. The focus of a heart procedure or a carotid stenting procedure is helping the patient in a timely manner. When circulating technologists need to quickly find catheters, balloons or wires, for example, it doesn’t help when the locations are different for each room. It is not intuative for our brains to learn and perfectly repeat these processes when equipment is stored and located differently for each room.
Over the course of twelve years at HP and Agilent Technologies, we progressed from providing powered ergonomic torque-limiting screwdrivers, based on a conservative repetitive-motion matrix, to a no-lifting shipping and light-lifting receiving department, to having an ergonomic presence on new product design teams to ensure that their products were designed with ergonomics in mind. During this twelve-year period, there was a lot of time and money spent on new equipment, tools, process changes, and training to provide and foster an ergonomically-safe work environment.
There were metrics put in place to measure improvement in this health and safety arena. We performed ergonomic assessments on all processes to measure their injury potential and proactively tried to address all high-ergonomic-risk situations. We constantly monitored the OSHA Injury/Illness rates, and I'm proud to say that during this time we cut our rate in half. Towards the end, we were trying to reduce it even more by implementing a BSOF program (Behavioral Safety Observation and Feedback).
All training I helped create for employees and management included information on the relationship between work and home activities on ergonomic injuries. I was concerned about home activity behaviors because of the nature of the beasts RMI (repetitive motion injuries) or CTD (cumulative trauma disorders). It is rare that you do not use the same muscles and tendons at both work and home. That is why it can hurt doing activities in both arenas. I do not want to lessen the responsibility of organizations regarding the health and welfare of their employees, which is directly affected by the tasks employees must perform for those organizations. However, I also want to point out the responsibility we all have to try and work safely on the job, and work and play safely at home. Body Positions and Injuries To help with a better understanding of ergonomics, let's discuss neutral and awkward body positions. If we could totally relax all of the muscles in our body without giving any conscious input, and be suspended in a saline, water-filled tank, our body would take a shape similar to sitting in a chair elbows at our sides, arms at 90 degrees to our body, and hands and fingers straight out. It would look a lot like the fetal position. This is called a neutral body position.
Our bodies were designed to move our muscles and joints, within limits, for a lifetime. So what happens when we exceed the normal limits of body position? If you are slowly stretching to new limits to increase mobility, that is one thing, but when you are doing a task that causes you to apply an excessive force repeatedly, hold an awkward position for a long duration, impede circulation with a sharp edge, or add vibration or sudden shock, you can start muscle tendon degradation that can lead to an injury. Let's call these injuries a micro-injury incident. Let's also call an uncorrected and/or unhealed accumulation of micro-injury incidents a Repetitive Motion Injury, or RMI. Stressful Postures o Causes compression or stretching of certain tissues: Elbow above the shoulder Arm behind the body Extreme flexion at the elbow: i.e., touching right shoulder with right hand Forearm extreme outward and inward rotation: Screwdriver motion Extreme flexion or extension of the wrist: i.e., moving your palm up or down at the wrist Extreme radial or ulnar deviation: i.e., flexing your hand in the thumb or pinky direction o Requires more muscle and tendon force: Pinch grips Extreme horizontal reaches Multiple micro-incidents can easily turn into a full-fledged RMI. Our bodies have an injury incidence file for each of our muscles and tendons. Each of our muscle and tendon areas have different size injury incident files, and these files can be different sizes for each person. This affects our body’s tolerance to multiple injury incidences and our ability to heal from the injury incidences. When we repeatedly tweak a muscle or tendon area without giving it a rest, the injury incident file fills up to bursting with injury incidences. If we take steps to eliminate or reduce the causes of the micro injuries, we can thin out our injury incidence file. What keeps the file from getting too full is our body’s ability to heal itself. We can help this ability further by resting the affected area or by changing the way we perform a particular task.
Our body’s response to these micro-incidents or doses is usually an achy, tired feeling in a muscle or tendon area. This is our body’s first response or warning of a potential injury. Ergonomic injuries happen because we continue to ignore these signals and work through the discomfort. When this happens, we get the more extreme symptoms, such as loss of grip strength or tingling due to nerve damage, although these are just a few of the potential symptoms. We need to reduce and eliminate one or more of the multiple causes of the discomfort. If we can eliminate the awkward position, duration, force or some of the repetition, we can go a long way in reducing the chance of an ergonomic injury.
In my past work in the electronic manufacturing sector, I was concerned with the hundreds and thousands of repetitions workers performed each day in order to build products. Bent wrists, pinch grips, arms extended above the shoulder and backs were just a few of the issues I dealt with in the manufacturing processes. We found that pinch grips associated with different forces and awkward positions contributed the most to carpel tunnel-type symptoms and injuries.
However, in the manufacturing environment where I practiced ergonomics, there were always individuals who never seemed to get injured doing their job. I noticed that rather than the job and tools manipulating their movements, that these individuals used all of the flexibility available to them to use the tools and equipment to their ergonomic benefit.
I have also observed during my clinicals that there is usually someone that has not developed any back, wrist, or arm discomfort working in a cath or specials lab. I personally enjoyed talking to these professionals about how they perform certain activities so I myself can develop ergonomically safe work habits to avoid injury in my new career. As a result, I have learned about some ergonomic ways of holding pressure, and a way to reduce the pinch grip on a slippery glidewire by using a dry or damp 4x4.
At home, any activity like using a screwdriver forcefully, trying to open a tight jar or wringing out a wet cloth or towel, can tweak the hand or wrist. Most carpal tunnel injuries are an accumulation of the stresses received from pinch grips, awkward arm positions, high forces, repetition, and long duration stresses. There are similar body mechanics and stressors at work in our cath lab daily life.
Our hands are one of the most valuable assets in our chosen career. In the cath, EP or specials lab, we can collaborate with staff and have discussions about better ways to do required tasks , as well as make sure everyone knows about RMIs and CTDs. Some individuals may laugh and say, What’s the big deal?, while others are very intimately acquainted with these types of injuries. I encourage technologists to work with cardiologists and radiologists, because they seem to have a large say as to when a hemostasis device can and cannot be used. Although there are established contraindications for the use of Femostop® (Radi Medical Systems, Wilmington, MA), Perclose® (Abbott Vascular Devices, Redwood City, CA), or Angio-Seal (St. Jude Medical, Minnetonka, MN), I have observed physicians who readily request and use some of these devices on a regular basis. I have not asked why they frequently request their use, but I know it certainly can reduce the potential stress of holding manual pressure for fifteen or twenty minutes.
I have also noted in some of the labs I have visited that there are usually one or more technologists that are suffering some wrist discomfort, and several have had carpal tunnel surgery. Most of the time these professionals are very active, both in and out of work. I checked with a few of the specialists who track injuries at some of the clinical sites in Washington state and noticed that over the last two years there have not been any claims for carpal tunnel or other RMI-type injuries in the cath or specials labs. Conclusion In conclusion, remember that there are lots of things we can do collaboratively to reduce the chance of an ergonomic injury at work and home. Ergonomics is not just about health and safety. It is also about the quality and productivity of your processes! A Final Note I want to compliment Marsha Holton, RN, BS, CCRN, RCIS, Cardiovascular Orientation Programs (Indian Head, Maryland) for her articles and investigation into ergonomic injuries and incidence in cath labs. For more information, see Holton, M. Ergonomics in the Cath Lab (or, how to save staff backs, necks, wrists...). Cath Lab Digest May 2003;11(5):1-14, and Holton, M. Ergonomics Revisited: Carpal Tunnel Syndrome. Cath Lab Digest March 2005;13(3):48-53. Al Moglia can be contacted at RUBABYM @ peoplepc.com. References 1. Cumulative trauma disorders: Their recognition and ergonomic measures to avoid them. Applied Ergonomics 1989, K.H.E. Kroemer. 2. Work Factors Associated with Cumulative Trauma Disorders: Work Postures. Tom Armstrong, Ph. D. University of Michigan. 1990. I was also a manufacturing process technician/engineer during my 32 years with HP and Agilent Technologies. We continually evaluated the effectiveness of our manufacturing, shipping and receiving processes in relation to ergonomics, productivity and quality. We made changes if the processes revealed bottlenecks in the speed and quality of the overall process, working under the continuous improvement philosophy. I have seen some opportunity for similar types of improvement in the cath and specials labs where I have spent time in regards to their processes: for example, rooms may be set up differently even though the same procedures are performed in each. Process-wise, this setup has potential for mistakes and has bottlenecks in a potentially life-saving process. The focus of a heart procedure or a carotid stenting procedure is helping the patient in a timely manner. When circulating technologists need to quickly find catheters, balloons or wires, for example, it doesn’t help when the locations are different for each room. It is not intuative for our brains to learn and perfectly repeat these processes when equipment is stored and located differently for each room.
Observations in the Lab
Following each observation are some examples of potential problems and solutions. Example (no picture): Holding pressure on a groin with sheath removal. Problem: High forces and awkward hand arm positions. Potential solution: Suggest to physicians the use of an alternative hemostasis device. A post-procedure department can pull sheaths using a Femostop or QuicKlamp (TZ Medical, Portland, OR) with disposable pressure pads to reduce costs. (Note: It is important that the patient and this process is continually monitored, as well as maintaining a progressive release of pressure to ensure there are no peripheral circulation issues.) Example (no picture): Moving patient to and from exam table. Problem: Awkward back positions. Potential solution: Use arms and tighten stomach muscles. Do not over-reach. Use lifting help as needed. (Over-reaching can put you into the zone of seldom-used muscles: an added injury potential.) *Anthropometric data has info on body dimensions and strengths for different body motions. A material storage matrix can show what weight and frequency of access items should be stored at what height. Frequency of access and weight are the most important considerations for location. It is not a perfect method, but you can aim to accommodate 95% of the U.S. working population, which essentially ignores the very short and the very tall (note that the anthropometric data would be different for Asian countries). In the past, I have utilized data from the following source: Diffrient N, Tilley AR, Bardagjy J. Humanscale 1-9. Cambridge, Mass.: MIT Press, January 1991. Humanscale data was predominately taken from huge studies of people in the armed forces.NULL
