Patient in. Cataract removed. IOL implanted. Patient out. Again. And again. And again. The best cataract teams thrive on repetition, relying on muscle memory to speed patients through a well-orchestrated surgical track. But those highly trained muscles sometimes remember that they hurt. From the nurse who pushes and pulls patients through the facility to the surgeon who remains locked behind a microscope for hours on end, those who work in ophthalmology are prime candidates for a repetitive strain injury. Most surgeons and nurses don't consider that possibility until backs tighten or wrists ache. Luckily, some manufacturers have taken to designing their products with an eye on ergonomic safety (see "8 Ergonomic Products" on page 32).
8 Ergonomic Products
Edited by Beth Hurley, RN, CSN, CRNO, COE
"It's hard to focus on ergonomics when you're repeating the same process with little time to rest," says Beth Hurley, RN, CSN, CRNO, COE, president of the Phoenix, Ariz.-based consulting firm Ophthalmic Surgery Resources. "We are so focused understandably so on quality patient care that we don't think about our own safety or even remember to take care of ourselves."
Consider the story of Phoenix ophthalmologist Daniel Feller, MD, who spent 15 years behind a surgical microscope. At 55, today he's eight years removed from his last cataract case, unable to operate because of lingering neurological damage resulting from a botched procedure to correct his herniated C5 and C6 vertebrae. He spends his time in the clinic, his days in the OR a distant memory.
"It's my impression that my injury was caused by sitting firmly upright, with my neck flexed forward," says Dr. Feller. "You do that for several hours, two to three days a week, over many years and you'll put undue stress on your body."
Even without the expected regret over losing part of his professional identity he says the letters to the right of the comma are what he does, the letters to the left define who he is Dr. Feller cautions against taking a surgeon's comfort for granted. He knows of several ophthalmologists who've experienced similar injures, including a colleague whose work-related injury ended his ability to see patients. He can't even work in his practice's clinic. "He's absolutely crushed," says Dr. Feller.
So some might say the stool behind the surgical microscope is the toughest seat in the house. "Keep in mind that cataract surgery is microsurgery," says Terry Devine, MD, a surgeon at the Guthrie Clinic in Sayre, Pa. "We're looking through the scope and operating with both hands and feet. Once the case begins, our bodies are locked in position."
That stool, then, better be comfortable. Offering adequate support to the surgeon's lumbar region is a common and important consideration. But don't forget about his neck, reminds Dr. Feller. He says the many ergonomically designed stools currently available let you match the stool's primary support to the surgeon's preferred operating position. Does your surgeon lean far forward when looking through the scope? Perhaps a support bar across his upper chest would work well. Does he tend to sit in a slightly reclined position? Strong lumbar support is key for that doc.
Surgeons should first position themselves in a comfortable position and set the equipment around that comfort zone, says Dr. Feller. The placement of the foot pedals, stool and bed should ultimately let the physician sit comfortably behind the surgical scope.
"It's essential," says David F. Chang, MD, a cataract surgeon based in Los Altos, Calif., in reference to the scope's placement. "Surgeons need to work in such a way so as they're not leaning in an awkward position." He refers to his scope's magnetic clutch as an important feature. It lets him re-adjust the scope at any time during the case, putting it in a comfortable position without having to reset the position coordinates. Many scope manufacturers also offer ocular extensions, says Dr. Chang, which let surgeons set the eyepieces away from the illumination beam and sit in a more upright and ergonomic position.
8 Ergonomic Products Continued
4. M820 F19 Microscope With OptiChrome
During cataract cases, the surgeon's feet manipulate two multi-function foot pedals that control the surgical microscope and phaco handpiece. Dr. Devine actually operates without shoes he wears a scrub shoe cover over a sock to better feel the various movements of the pedals and side switches.
The pedals have a dual-linear movement. They move up and down like a gas pedal but also yaw like an airplane's control stick. Going shoeless it may not be the norm, but it's not uncommon highlights a surgeon's desire to maintain precise control over the delicate positioning of the surgical scope and the power of the phaco's fluidics.
Dr. Devine says, "Having the pedals fit the foot properly, at the right height with the right amount of tension, is important in being accurate during surgery and puts us in position to respond quickly to changes during the procedure." Something as subtle as the angle of the pedal while it's in the neutral position can affect a surgeon's comfort, he adds. A physician who sets his scope just so, aligns his stool just right, may soon discover that his carefully planned settings are rendered useless by foot pedals placed in the wrong position.
Build your cataract equipment purchases around a well-designed surgical bed, suggests Dr. Chang, ideally one designed specifically for ophthalmology. "Surgeons sit temporal to patients during procedures and traditional OR tables have bars or struts angled to support the patient's head," he says. Dr. Chang works next to a table that is without support structures below the patient's head, allowing the six-foot-one surgeon plenty of legroom.
The table's height can be finely tuned using a foot control, meaning Dr. Chang can raise the bed a fraction of an inch if he feels himself hunched over the surgical site. That, he says, adds to his comfort control without requiring him to sacrifice valuable minutes by resetting the position of the surgical scope.
Dr. Chang took the concept of an ergonomically designed OR bed one step further, patenting a unique patient headrest to improve the comfort of the surgeon and his subject. Unlike the low profile of a standard headrest, Dr. Chang's horseshoe-shaped model features a deep well for placement of the patient's head and a wide, flat-surfaced top. The broad top serves as a resting place for the surgeon's wrist, letting him manipulate instruments with adequate support similar to the keyboard extensions some office workers use to avoid the nasty effects of carpal tunnel syndrome.
With both feet and both hands often working in unison, your surgeons need to keep their hands and wrists comfortable throughout a packed cataract schedule. Dr. Chang's headrest helps. So do the new generations of phaco machines. One system boasts an ergonomically designed handpiece, a lightweight device that is tapered at the end, wider where a surgeon's fingers typically rest and able to take on a contoured shape like the rubber grip on a comfortable writing pen, says Dr. Devine.
Improvements to the tubing that connect the handpiece to the system's tower add to both surgeon comfort and patient safety. The two tubes one brings fluid to the eye, the other removes chopped cataract debris from the surgical site were designed with sufficient stiffness to keep the handpiece stable during fluidic surges and flexible enough to allow for easy and precise maneuverability in the eye. "Thicker and stiffer tubing offers some advantages to controlling the surge," says Dr. Devine, "but we can encounter a noticeable difficulty in turning the handpiece." Not a small consideration, he says, because of the forward, backward and 90-degree rotations performed during surgery.
What about nurses and surgical techs? They're anything but stationary, spending hours on their feet passing instruments or transporting patients. When moving patients around her facility, Vikki Pearce, RN, the clinical director of the Peninsula Eye Surgery Center in Mountain View, Calif., is fully aware of the impact on her small frame. "I can't transport patients by myself," she says, adding that all her nurses move patients in tandem.
Some OR beds and stretcher chairs help by offering self-driving mechanisms, electronic braking devices and hydraulic lifts. Ms. Pearce can set her beds to numerous positions, ranging from reclined to upright, but she had to educate her staff and anesthesiologists to use only certain position settings for transport. If the patient's feet are lower than her waist, she says, reaching down to grab the bed strains her back.
The reward for outfitting your center with ergonomically designed equipment and educating your surgeons and staff on their use might go beyond making your facility a comfortable place to work. A busy surgeon's ability to concentrate on the task at hand and smoothly manipulate instruments in and around the eye may be compromised by his discomfort. "Case efficiency is hindered without proper ergonomics," says Dr. Devine, "but so is patient safety. The two are interrelated."