Good evening. Thank you all for joining tonight's webinar. My name is Lori Lizansky. I'm the chairperson for the SVU eLearning Educational Committee. And it looks like the weather caused much of the country today was unpleasant, so let's spend some time being productive tonight earning a free CME. Before we begin, I have a couple of notes from the SVU office to share with any first-time attendees. Number one, the webinar will be recorded and available online after tonight for attendees through the SVU website at no charge. And then let's please take a moment to familiarize yourself with the GoToWebinar program. Everyone should see a question section along the side menu of your screen. It's near the bottom of the column just above the chat. So please type in any questions that come to mind during the presentation. And at the end of tonight's talk, we should have some time for discussion. To receive your CMEs from tonight's lecture, you need to wait for an email from the SVU office containing an evaluation. So you should get that email in about a week, so 7 to 10 days. And once you get the email, complete the evaluation, and your CME certificate will automatically pop up after you do the evaluation in 7 or 10 days. So before we begin, raise your virtual hand if you come home from work every day with sore, burning muscles somewhere on your body. And who's had a work-related injury which caused you to seek treatment? Or who's been injured at work but treatment was not an option or not covered, and you just had to drag yourself in the next day? So we should all strive to – or commit to better ergonomics in every aspect of our job moving forward. And maybe we should add this to our list of New Year's resolutions. So for this reason, I thought there was no better topic than ergonomics to start out with this year. And tonight, we are privileged to have Carolyn Coffin joining us to speak on the importance of work station design and sonography. A little bit about Carolyn. She's a multi-specialty technologist, board-certified in general cardiac and vascular sonography. She has a master's degree in public health from the University of Denver and a special interest in occupational ergonomics. Carolyn has been very active in SDMS over the years, holding several board positions and earning fellow status from the group in the year 2000, which recognizes a career lifetime of achievement and outstanding contribution to the field of sonography. And for the last 20 years, Carolyn has been a champion, lecturing around the world and publishing about sonographer injury and the importance of ergonomics prevention and self-care. She works to educate and consult with sites committed to improving workplace conditions for their sonographers. And now, if you would, please join me in welcoming Carolyn Coffin. Thank you, Lori. Hello, everyone. Today, I'd like to talk about how important the design of our ultrasound workstation is in helping us work more comfortably and in reducing injury risks. So, this presentation will review work postures and the changes that we can make in them. We'll look at the role of your workstation equipment and what that role plays in reducing injury risk. And then, we will discuss some of the newest designs and prototypes, along with possible injury risks that might be associated with them. These are our disclosures. Our focus on mitigating injury risks has changed over the years. Originally, the focus was on scanning postures and how changes could be made to them. That put the responsibility of reducing injuries on the sonographers. Then manufacturers started to design systems with multiple adjustable features. And that's making it a little easier for sonographers to use more comfortable postures. Now the focus is on the workstation as a whole, not just one piece of equipment in isolation. Everything in the exam room has to be compatible with each other and they all have to work together. Workspace design has also changed focus. Designs have been focused in the past on the impact that a building has on the planet, making it environmentally sustainable. Well, this led to the creation of a certification program known as LEED, which recognizes those buildings that are environmentally designed. Now the focus is more on the workers in those spaces. How are they affected? Healthy workers are more productive and workspaces are being designed with more measurable wellness benefits to them. The focus is now on human sustainability, which is considered just as important as environmental sustainability. And it has also led to new certification programs that are more people centric, such as well-building standards and fit well. Why do we care about our workspace in ultrasound? Why don't we just work in any room? And I'm sure we have with any exam table, poor lighting or too much lighting. Well, if you look at the statistics, you'll see that 56% of all occupational injuries across every industry reported to OSHA are musculoskeletal disorders. Surveys among sonographers have shown between 67 and 90% of them are scanning in pain and up to 14% have had to change their jobs. I know of at least one ultrasound educational program that teaches the students a second major because the students are told that there's a high injury rate in our field and they should be prepared in case they need to change jobs. So rather than teaching the students how to work more comfortably, they are teaching them an entirely different profession. These are the risk factors and we'll talk a little bit about how that applies to our field. Just because your job has risk factors though, doesn't mean you're going to develop an injury. In fact, a little bit of exposure to some risk factors can actually be good for you. Occasionally moving into an awkward position like reaching or bending will help stretch and exercise your muscles. Whether or not a risk factor will result in injury depends on the duration of your exposure to that risk factor or how long are you exposed to the risk factor. And for us, that's transducer time. It's also the frequency of the exposure. How often are you exposed to something and how much rest do you get in between? And that translates to the number of exams and a little bit of downtime in between them. And then the intensity of the exposure. And this is akin to how heavy an object is when you lift it, how much pushing you have to do to scan. And if there's a combination of risk factors where you're exposed to more than one at a time, because the more risk factors that are present at one time, the more likely an injury will occur. And then there's some contributory factors. One factor is performing all the same type of exam back to back. And an example is too many standing reflex studies back to back. In general ultrasound, too many endovaginal exams, one after the other. Another contributory factor is the computerization of our work environment. Our ultrasound systems are computerized. All of our imaging storage and collection is computerized. Then if you have ergonomic features, they're often not used properly, or sometimes not at all. And there are some personal factors that contribute to injuries, such as previous injuries to joints, leisure activities, health issues. But the primary cause is the technical advances we've seen in medical imaging. The computer and filmless image storage have taken away our need to move, to do our job. We no longer have that darkroom break, where we walk down to the darkroom and have a few minutes to wait for the film to process. It was a time when we could rest our muscles and do other things. So moving from the ultrasound system to a reporting computer uses all the same muscles. We have now developed a frozen relationship with our equipment. Work processes changed with the Industrial Revolution. The more work that could be done using machines, the higher the productivity. Henry Ford stated that the work in his automobile production plant should be brought to the worker, rather than having the worker walk over to get the pieces they needed. This introduced a decreasing need for workers to move in order to perform their job, because the conveyor belt brought everything to them. Productivity may have improved, but injuries began to increase. Other machines to increase worker productivity, such as the cotton gin, also occurred during this time period. World War II brought about improvements in how workers interacted with airplanes and machines. Sometimes this was necessary to reduce actual physical injury or death. And NASA had to redesign controls in spacecrafts, because weightlessness affected how the astronauts viewed and interacted with their controls. Reducing the need for workers to move may increase productivity, but it has a negative effect on muscle health. There are two types of muscular effort, static and dynamic. During static muscular effort, blood vessels are compressed, resulting in decreased perfusion and poor removal of waste products. If this is sustained for any length of time, muscle fatigue and pain will occur. And the most frequent form of static effort in sonography is non-neutral positioning of the arms and the trunk. Dynamic muscle activity acts as a pump. The muscles contract and alternately relax, which allows oxygen-rich blood to be pumped in and waste to be pumped out. Dynamic effort, therefore, can be sustained longer before fatigue sets in. This is the principle behind exercise, and it's the reason why it's important for an ultrasound workstation to promote movement. Some of the injury-producing inactivities include force, particularly with the transducer. Awkward, non-neutral postures of the arms, the neck, the wrist, like reaching and abduction, if these are sustained for any length of time, they even become more injury-producing. Overuse of muscles and joints without enough time for them to recover contributes to injury, and gripping the transducer. The ideal ultrasound workstation will allow for natural postures of your spine, your head, and non-awkward postures of your upper extremities. The workstation should promote movement, and there should be muscular support, especially for your arms. Early systems were large, and some actually had articulated scanning arms, like the system on the left. These systems could be positioned on either side of the exam table, but the monitors were small, and they were fixed in place. The controls were mounted vertically, and the transducer had to be unscrewed when you wanted to change to another frequency, like you see in the red circle. There was a risk for injury due to electric shock when changing the transducers, especially if you were leaning against a metal exam table. Other risks were due to neck flexion and extension when trying to view the fixed monitor, and reaching with an abducted arm to access the controls, regardless of what side of the table it was placed on. But one advantage of these systems is that the worker had to be standing to use them, and had to do a fair amount of moving while scanning and changing imaging parameters. The compound B scanner system was paired with a fixed-height exam table, so the worker stood to perform the exams. This type of scanning allowed the sonographer to move frequently, which is good for you. However, since it's fixed, there was no way to change the height of the exam table or the height of the system itself. You can see in these photos that the risks for injury include arm abduction and neck twists, so that the sonographer can see around the scanner. Repetition of these work postures all day could definitely lead to neck and shoulder injury. Now, some of us may remember working on these systems in the late 1980s or early 1990s. They could be moved, but they were heavy. The monitors were fixed in height, although the ones on the right did swivel some. So in order to change the height, you had to add a second monitor on the top of the system on the left, so if the sonographer needed to stand up for any reason, he or she wouldn't have to bend over to see the monitor. The systems on the right had a retractable keyboard, and this is a bad design because it forces you to reach too far of the controls when the keyboard is extended, or if you were positioned comfortably and in a good neutral posture in front of the system, you have to back away from that position in order to extend the keyboard. Ultrasound exam rooms need tables that are unique to each exam type. These procedure tables may be okay for massage therapy or other types of procedures, but not for ultrasound. Any ultrasound table should have wheels. You should be able to move it around and reposition it in the room. Stretchers have way too many features that extend beyond the mattress, making it difficult for sonographers to get close enough to the patient to reduce their reach. And stretchers are usually manually adjustable, which results in sonographers not making any height adjustments during the exam because they don't want to stop and walk to the foot of the table to change the height. So with today's equipment, awkward work postures can be minimized, but these features have to be used and used correctly. These photos show sonographers with trunk twisting and trunk bending, twisting of their necks, and too much reach for the patient and the control panel. These two sonographers are demonstrating too much reach, but the sonographer on the left who's doing a carotid from the head of the table is reaching across her body, which definitely is twisting her trunk, but it's also putting pressure on the shoulder vessels and muscles. And the sonographer on the right is kneeling on the floor in order to do a standing venous reflux exam with her arm abducted to reach the control panel and looking up at the monitor. The problem with reach is that it affects your endurance. As reach goes up, the distance gets farther, your endurance goes down. So at 30 centimeters, which is close to your body, you can work for about 30 minutes without discomfort. But when you reach up to 50 centimeters, you can only work for about seven minutes. And 50 centimeters is a common work posture for sonographers, and I see it all the time. One of the common causes of neck twisting is sharing the monitor with your patient. The best way to avoid this is to have a second monitor mounted on the wall for the patient to view. These can be inexpensive ones, and they don't have to be medical grade. Leaning too far to the right or left also causes you to twist your neck back over your shoulder to view the monitor. The system should have monitors on articulated arms that can be positioned for better viewing without having to twist your neck. Neck flexion and extension are also a cause for injury, and this is usually due to incorrect monitor height. Now that monitors have several adjustable features, you can position them so you're working with your head straight. If your system has limited monitor adjustability, you can compensate for this by either standing to scan if it's too high or sitting if it's too low. The sonographer on the left is seated, and the monitor is much too high, and it's not adjustable except for swivel. So she should have either raised her chair or stood up to scan. The sonographer in the middle picture has a number of things that need fixing. She is twisted. She's reaching across. Her head is twisted back to look at the monitor, and it's way too far away. And the sonographer on the right is tall, and with a limited adjustability of his monitor, he has to bend over or look down, and he should have been seated to scan. These are another two examples of monitors that are too high. They are somewhat movable but not much in height. They pretty much just swivel. If the sonographers were to keep their head straight, they would be looking at the bottom of the monitor. You should place it so that you're looking at the top frame of the monitor with a straight neck, and this applies to your home computer as well. If the monitors, in this case, lacked sufficient adjustability, the sonographer should have stood up to scan. So the most neutral neck position is with your head straight or with a slight 20-degree forward flexion. There is nowhere in this scenario that neck extension or looking back and up is considered neutral. Arm abduction is one work posture that contributes to shoulder injury along with reach. On the left, the sonographer is leaning to the right with an abducted arm and a twisted neck to see the monitor. On the right, his arm is abducted, and he has no support for it. In addition, he's reaching too far to the control panel with his left arm. These are two other examples of arm abduction combined with reach. In both cases, the patients could have moved closer to the sonographer. And you can see on the photo on the left, the space between the sonographer and the patient. The patient could have slid over to the edge, and that would have reduced both reach and arm abduction significantly. The patient in the picture on the right could have been positioned diagonally on the table with her head toward the sonographer and her legs down toward the opposite corner of the exam table. As abduction angle increases, the time it takes for muscle fatigue to occur decreases. At 30 degrees abduction, you can work for 60 minutes comfortably. At 90 degrees, which is not an uncommon position that I see among sonographers, you can only work for 10 minutes without fatigue. Now, looking at this, you probably think that we would never use 120 degrees arm abduction to scan. But venous reflux studies have changed all that. Another issue with arm abduction is the loss of muscle strength as angle increases. So strength goes from about 95% of maximum at 30 degrees abduction to about 10% of maximum at 120 degrees abduction, which, as we mentioned, is what we see withstanding venous reflux exams. If you can't avoid arm abduction, and sometimes you can't, you can significantly reduce muscle firing by supporting your arm with either a cushion or a roll of towels. This will take the burden of arm support off of your shoulder muscles. Wrist position is important in preventing injury to the carpal tunnel. In three of these photos, you can see the sonographers are using too much wrist extension, and in the top right photo, too much wrist flexion. Flexion increases the pressure in the carpal tunnel to 60 millimeters of mercury, and extension increases it to 120 millimeters of mercury. And this puts excessive pressure on this little nerve, this little red nerve known as the median nerve that runs through the carpal tunnel. This nerve is both a sensory nerve and a motor nerve, and when it's injured, motion is limited. The hand can be painful, numb, and weak. Ideally, you should only flex or extend your wrist up to 15 degrees from a neutral position. This may require changing how you hold the transducer, and these sonographers are scanning with a much more neutral wrist position. Deviation of the wrist can also cause injury. You shouldn't deviate from neutral to the radial side more than 15 degrees, and no more than 25 degrees to the ulnar side. And these positions also apply to your non-scanning arm, what you're doing with your typing hand. Something a lot of sonographers do during an exam, and I don't think they're aware of it, is to reach behind midline while scanning. This is especially true when performing lower extremity exams, as you see in this photo. This puts too much pressure on the blood vessels of the shoulder. The shoulder is naturally a poorly perfused joint, which is why we have so much range of motion with our arms. So you don't wanna work in any position that compromises the flow to it. Another injury risk is gripping the transducer, and that's generally due to its size. A too narrow transducer forces you to pinch it while you're holding it, and a too wide one forces your hand to be overstretched, and both can cause strain on the forearm muscles. Early workmen had their tools designed specifically to fit them, and then they would take their tools with them from job to job. Since transducers can't be specifically designed for each one of us, they are basically a one-size-fits-all tool, and we have to compensate for that by changing how we hold the transducer when our grip becomes uncomfortable. Small transducers or other tools require you to hold them with a pinch grip. Your hand is four times stronger in a whole hand or a palmer grip than in a pinch grip, and it takes four to five times more muscle tendon, muscle and tendon force to pinch something rather than to grip it using your whole hand. So it's important to use a whole hand or power or palmer grip rather than a pinch grip whenever possible. This may require practicing with new ways to hold the transducer. One exam that's very challenging, as I've mentioned before, from an ergonomic perspective, is the standing venous reflux exam. Sonographers are forced to look up with an extended neck to view the monitor and to reach up for the control panel, hence the 120 degree abduction. Seems like when new exam types are introduced, little to no attention is given to how the sonographers will perform those exams, which seems to be the case with venous reflux studies. Changing your work postures is much easier to do with exam room equipment that has multiple adjustments and can be repositioned within the room. The features of the equipment should be specific to every exam specialty that you perform. Sorry. In these photos, the sonographer is performing a carotid artery exam from the head of the table, so he has a couple options for supporting his arm. He can use a cushion, he can rest on the arms of a chair, he can rest on the table itself. Scanning neck structures is really better done from the head of the table, and this may take some practice if you don't generally do it that way. You don't have to switch hands to scan the left side of the neck, you just move to that side of the table after you've scanned the right side. Or you can have the patient sit in a chair and you'd be able to support your arms on the patient's shoulders or the chair arms. These are a couple of options for scanning the lower extremity. In the top left photo, the sonographer is seated near the end of the table and has the patient close to her, so she doesn't have to use an extended reach to scan the left leg. The table's in a steep reverse Trendelenburg, which hopefully will demonstrate some reflux. In the bottom photo, the patient is seated on the exam table with her leg extended over the end. The sonographer can scan without an extended reach or arm abduction and can keep his head and neck straight. The adjustability of some of today's ultrasound systems may even allow us to scan the patient's left side from the left by swinging the control panel and the monitor across the patient. With our obese population, it seems hard to avoid using transducer pressure. I hear this a lot. But pushing doesn't really improve the image enough to make the wear and tear on your body worth it. You really can't decrease the distance to a structure that much, but you can significantly increase your risk for shoulder injury. So if you do have to push, you wanna use what I have here as whole body force, which means you stand up so that you're above the body part that you're scanning, like for instance, the lower extremity, and you're pushing down using your whole body rather than just your shoulder. Now, let's take a look at the exam room setup and how that's changed. This is made possible by the continuing development of the equipment in the exam room. With all the adjustability of that equipment, we no longer need to scan in a silo with the system parallel to the table and the sonographer facing forward. Sonographer's not looking at the patient. Everything is in straight lines. Today's systems can be moved into positions that allow us to avoid this kind of patient non-engagement position. Now we scan in what we call a patient engagement, sonographer neutral posture. The monitor can be adjusted so that the sonographer can view it with a straight neck and still be able to talk to the patient. The control panel can be swiveled out to the left so that the non-scanning arm is close to your body and close to the most frequently used keys. So we call this the magic triangle. Now let's look at some of the newer technologies. Sometimes products and procedures are developed before we really know what to do with them or even how to use them. I remember doing a cardiac ultrasound many years ago and we had just gotten color doppler on that system. And one of the cardiologists was watching the exam and I turned on the color and she said, well, you know, it's kind of neat, but I don't see a use for it. Well, of course we know what that technology is used for. The learning curve for a lot of these new procedures and products probably doesn't include teaching your comfortable work positions. And we may not know something will result in an increase in injuries until they start to occur. The evolution of ultrasound includes new types of exams, such as lung imaging, which we have seen an increase in with COVID, transcatheter aortic valve replacement guidance and guidance for transcarotid artery re-vascularization procedures. It also includes new users performing point of care exams and new transducer technology to better accommodate the obese population. The DACS or deep abdominal transducer has increased penetration, thus reducing our need to exert so much force, but it may be a little heavier with the current standard transducers. Point of care ultrasound presents a number of ergonomic challenges. These exams are done in a variety of settings, such as the ER, OR, or bedside. And these environments are not designed to be ultrasound rooms. Most likely they don't have ergonomic equipment, such as seating and ultrasound tables, and often the lighting isn't ideal. There may be other equipment in the room, such as ventilators or other large pieces of equipment that make it hard to reach the patient. Generally, these exams though are limited in length since the intent is just to answer a clinical question and provide information for treatment planning. So the amount of time that the practitioner works in an uncomfortable posture may be relatively short. Also, the ultrasound system may be smaller, making it easier to position in almost any room. But smaller is not particularly better when it comes to ergonomics. These providers are leaning over the bed rail to scan. They are bending their necks to view the screen, and the provider on the right has to look back over his shoulder to see the monitor. This probably means that there is other equipment in the room that makes it impossible to set the system up any other way. Some of these small systems may be handheld and may not be positioned at eye level. If there's a keyboard, it's usually attached to the screen itself. So either the keyboard or the monitor can be positioned correctly, but not both. You'll be looking up at the monitor if the keyboard is at a comfortable height, or reaching up for the keyboard if the monitor is properly positioned. Some of the point-of-care systems have wireless transducers, which may look like a good solution for issues related to the cable. But these transducers are heavy, and they can put strain on the hand and wrist. New technologies bring with them a new risk for different types of injuries. One type is called text neck, or anterior head syndrome. And this is caused by extensive neck flexion to view your cell phone screen. And you can see what it causes. It causes shoulder pain, headaches, and an abnormal spine curvature that you can see in these two pictures. And it's not just your cell phone. These smartphone ultrasound systems are increasingly being used in point-of-care exams. This graphic shows us how much weight is on the spine as we flex our head forward to view the screen. You'll go from 12 pounds of weight on your spine to 60 pounds with a 60 degree angle of flexion. Vertical screens force us to use mid-air arm gestures, which means your arm is unsupported and at shoulder height in order to access the screen. Touch screens don't wanna be vertical, and they are an ergonomic nightmare for longer interactions. They require a lot of strength and a lot of force involving a joint that is naturally poorly perfused. They can have a long-lasting impact on the body. Another option for a new design is an augmented or virtual reality headset currently used in gaming. But virtual reality is emerging in medicine as well, and it's bringing with it an increased risk for shoulder injuries. VR devices require unnatural arm positions, which are necessary because of the technology used to detect the user's movements. Optical motion sensors have to have an unobstructed view of your hand and arm, which means that your hand and arm are being held in mid-air and unsupported. In one study conducted on workers using VR, only 25% of them could work for 30 minutes in this position. The use of mid-air gestures to manipulate the VR image can lead to an injury called gorilla arm syndrome. And this is a syndrome that's become the touchscreen equivalent of carpal tunnel syndrome. The company that designed this system claims that it's intended to be more ergonomic than the screens on the standard ultrasound systems. It's true, you can view the image with a straight neck, but you're trading one injury for another one, which is the shoulder. Since the shoulder is the number one area of the body that gets injured, this just adds to the risks. I had an opportunity to try this system with this headset, and I was reaching out to manipulate the image, and within three minutes, I couldn't hold my arm out any longer, so it was really uncomfortable. It's called gorilla arm syndrome because it's named this way because of the way gorillas interact with vertical screens. They tend to reach out and touch them to manipulate things. But again, are we transferring the risk? We don't wanna go from one injured body part to another one. There are growing use of robots in our world. From anywhere from flipping hamburgers to preparing salads, they're entering the fast food workforce. They're increasingly being used to deliver items, such as meals in a restaurant, to packages to your home, and they can be found in the operating room. They bring along with them the associated risks for injury, such as neck flexion, as in this provider's position viewing his controls. Robots can assist the sonographer by reducing their need to apply force in gripping the transducer. You can see in this picture, there's a sensor for the amount of forces being exerted with this robotic arm. There's a handle for sonographers to comfortably hold it and hopefully keep their arms close to the body, and this is the transducer face itself. The role of sonographer with robotic arms is to guide them in order to get the images required. In the photo on the right, the sonographer is actually able to comfortably hold the transducer in a neutral position with her arms close to her body and her forearms parallel to the floor. Her neck and back are straight as she views the monitor, and that appears to be on the opposite side of the table, so she can look straight ahead. An ultrasound sticker is being developed by the engineers at MIT. It's about two centimeters square and can be worn by the patient for up to 48 hours. It is currently connected to an instrument that translates the returning echoes into an image, but the engineers are working on making it wireless. Obviously, there are some exams that you can't use this type of ultrasound system with because it's in a fixed position. These innovations could certainly reduce injury risk for sonographers during longer procedures by eliminating the need to hold the transducer for extended periods of time. Risk for injury may end up being transferred, though, from the ultrasound system to the computer workstation as sonographers prepare the images for interpretation. So if the future role of sonographers includes more computer time to review and process images, then some of the focus has to be on the computer workstation and its ergonomics. That workstation has to have as many adjustable features as the ultrasound workstation. Monitors have to be height-adjustable. The keyboard and mouse have to be positioned close enough to avoid region abduction. There has to be desks that are intended for use with computers and that have room for the user's legs underneath them. Ideally, the desk should be height-adjustable electrically to accommodate different height users. And the desk chair should have some adjustable features as well. It should be different than the chair that is used in the ultrasound exam room. If these features aren't available, then all the progress made to reduce injury in the exam room will just be transferred to the computer workstation. Ergonomic workstation design definitely creates a more pleasant and more comfortable environment for workers. It adds value because it supports worker wellness and it's the most cost-effective way to create a healthy, productive workplace. Now let's look at cost and how we compare that to the cost of injury. Musculoskeletal disorders in healthcare cost about $7.4 billion annually, both in direct and indirect costs. And these include workers' comp, paying to replace your staff, the cost of legal fees, loss, income from productivity, and other administrative costs. So an average of one injury per year can be $34,377. An ergonomic workstation equipment, ergonomically equipped workstation, on the other hand, includes these costs. An exam table for about $9,000. A chair appropriate to the work you're doing, $975. Personal arm support cushions, about $250. An ultrasound system with lots of adjustable features, $100,000. So this is a total of $110,225. Now let's assume that the average lifespan of this equipment is eight years and let's amortize this cost over those eight years. That comes out to a total per year of $13,778. Now compare that to the $34,377 a year for an injury. Let's look at a hypothetical example. We have a hospital with 10 employees, 10 sonographers. Their average salary is $70,000 annually. That's a total payroll to this department of $700,000. Total cost of unplanned or extended absences is 9% of payroll or $63,000 per year. Loss of productivity is 9.7% as a percentage of the payroll or $46,900 in this example. Now compare that to the $13,778 per year for an ergonomic workstation. So there can't be an argument that it's cheaper to just suffer an injury for your department than to provide ergonomic equipment for your sonographers to be more comfortable. The return on investment is 100% through workplace and equipment design. An ergonomic workplace will have 100% return on your investment. There's only a 20% return on investment if worker behavior changes are used to decrease injury risks. And that was what we initially did to try to reduce those risks when we first started addressing it. So you can see there's a definite difference and a definite value to an ergonomically designed workstation. But it's important that you learn the various features of all the equipment in your workstation. You won't like it if you don't know how to use it to its maximum advantage. And you need to learn all the ways that you can use it. It's important that you identify good and bad designs when you're purchasing new items. Choosing the right equipment for the job enables the sonographers to work more comfortably. Each exam room purchase should be a joint decision between management and the sonographers who will be using it. Too often I hear that the sonographers have little or no input into all the pieces of the equipment that go into their room. Purchasing decisions should not be based solely on the price since any possible savings will eventually be offset by worker injury and the resulting reduction in productivity. There's a fourth component of the ultrasound workstation and that's the sonographer. Regardless of what ultrasound system, exam table, or chair that you have in your room, you should keep these core concepts in mind and make adaptations if the equipment isn't as adjustable as you'd like it to be. First you want to work at the proper height. Now this may mean that you're going to raise your chair, you are going to lower the exam table, do both, or stand up to scan. You should try to maintain neutral body posture. You want to avoid bending and reaching and you want to avoid neck twisting and trunk twisting. You want to reduce fatigue factors by using breaks to rest rather than working on the computer to answer emails. During longer exams, try to follow the 20-20-20 rule, which means you want to stop every 20 minutes and focus on an object 20 feet away. This will help reduce eye strain and just give you a really quick, brief minute to relax. Try to work in your reach zone and this is a half circle. When your elbows are next to your body, this is the half circle, which is your immediate work area and it keeps your arms close to your body. Notice that it's not reaching away from your body and it's not reaching out to the side or behind your back. Now there are times when you have to reach out away from you. There will always be times, but you shouldn't maintain that reach for any length of time and you shouldn't do it very often. There's plenty of exams that you can do comfortably. You can't do them all comfortably because there's going to be difficulties with the room that you're in, like if it's a patient's room or a difficult patient or limitations to some of your equipment. But the goal is to try to do everything comfortably as often as you can. And it's also not to make sweeping changes all at once. The goal is to make little changes and add to them a little bit until everything becomes habit. You'll have to fall back on uncomfortable postures if you are in a hurry or you have a difficult patient, but you want to try to focus on doing as many exams as you can in a more ergonomic and comfortable position. So once you have your ultrasound room set up for yourself, run through all these core concepts and see how you can make changes and how you can be part of the ergonomic workstation. Thank you for listening. Thank you, Carolyn. That was a very thorough presentation. I mean, I think you covered almost every aspect of our day-to-day activities, like palm grip versus pinch grip info. That was very interesting and new developing technology, also some things that we've not seen before. We have a number of questions already. Please type any last-minute questions you might have using the side menu of the webinar menu here. And so let's try to discuss some of the questions we have so far. The first one is, do you think ergonomics should be included in curriculum to teach to new sonographers? Absolutely. It should be a part of every course. And I think the Joint Commission, I think, they don't mandate it, but they recommend it. So I think it should be a strong component of every single ultrasound program. Yeah. And I know you're right, because I'm part of an education program, and that's one of the bullets we have to hit through the curriculum. So it is, I can tell you. The next item is that we have a suggestion or comment from one of tonight's attendees. I'm just going to read it. Quote, just an opinion, but when I started as a vascular tech in 1981, I was aware of muscular strain injury, and therefore, I learned how to both scan and manipulate machine controls with both arms. So I forced myself to both scan and type or manipulate controls with both hands. This has kept me working without pain and without stopping my work schedule. Also, not all labs are set up the same way. Exam table and machines may be on opposing sides of the room, so the technologists must adjust accordingly. Any comments on that, Carolyn? Yeah. I do have a comment. People bring this up, and I can scan with both arms for some exams. But the point is that if you abduct your arm, both arms, in an unnatural position, you'll end up with two injured arms and not just one. So it's a great idea, but still keep those basic core concepts in mind and keep your arms close to your body. And I agree. There's different setups in different rooms, which is why the ultrasound manufacturers have done a great job of making the equipment so adjustable so that we can bring it across the table now. They're lightweight. You can move them around with one hand. So as you start to upgrade your equipment, you want to look for that. You want to look for stuff that has really extensive adjustability and can move around. But the key point with scanning with both arms is to make sure you're not abducting or reaching with both of them. OK. And the next question is, as a multi-specialty technologist yourself, do you have an opinion which modality is more difficult to scan, like cardiac, general, or vascular? By difficult, I'm thinking more difficult from an ergonomic standpoint? I believe so, yes. OK. So yes, I do have an opinion. Cardiac for sure. And dedicated OB. OK. And do you think it's more beneficial if you can scan like a general case followed by a vascular exam, or does it not make a difference? Is it worse if you work in a dedicated lab versus a more diverse lab? Well, it can be if the same exam within that lab, like for instance, let's take a vascular lab. If you do like a standing venous reflux exam, and you do another one, and another one, and another one, versus a reflux exam, and then maybe a carotid, and then maybe an upper extremity. Maybe just a DVT exam, not a venous reflux exam. So you can be in a dedicated lab as long as there's a, and the injury risk isn't as great, as long as there's a variety of exams within that specialty. But the difficult part comes for labs like fertility departments, where they do endovag after endovag after endovag, and that's all they do. Or cardiac, where you really don't have a lot of variety. So those are two of the higher ones. But you can get enough variety in a vascular lab, I think. I agree. The next question is, what percentage of sonographers have disability insurance, do you know? Can they even get disability policies today? You know, that's a good question. I would, yes. I mean, I think we had one at my hospital, University of Colorado, and we had the option to buy that. And I'm not sure, but you might see if SVU offers it or SDMS offers it as a benefit through a group policy. But they should be able to get them, but I don't know the percentage of sonographers that have them. A lot of times, disability insurance is tied to your employer. Okay. The next question is, do you have a preference or a specific exam chair you'd recommend? Or maybe the features it should have? I definitely have a preference, because when I first sat in it, I absolutely fell in love with it. And it was in my slides. That was the Capisco chair, the one where you saw the sonographer scanning the patient who was seated. He was sitting backwards on the chair, and he was resting his arms on the arm. The features are, it has a gentle saddle shape, and I'll explain why that's important. When you sit in a regular chair, and we're all probably doing it now, our spines curve, and that's taking away the natural, normal lordosis of your spine. But when you sit in a saddle seat type chair, and they discovered this among cowboys and little kids, they took out horseback riding, your spine ends up in its normal position. It's more neutral, natural position. So you don't have all that wear and tear on the intervertebral discs in the spine itself. And that's my favorite. It's light. It's easy to move around. It has just enough adjustable features to make it usable and not overwhelming. If you have something like eight controls on a chair to make changes, you can get 4,000 different positions out of it, and this has only a couple of things, height, seat depth, and that's really all. So that's my favorite chair. But anything that has a waterfall front pan or that gentle saddle is definitely the best for your spine. And they also promote a little bit more movement. All right. And then along those same lines, do you have a preference for an exam table? Well, I do. And I don't know how much of this I can tell you, but I do because I was part of the design team. I was asked to help design it. The other part of the question, maybe I want to read that as well. It says that they've seen some modality-specific tables, and I'd agree with this statement. The ones that have the drop-down pieces, they don't look comfortable, and at least the patients that I've done in those tables, they say, no, they're not comfortable having to lay there for one hour. OK. So the drop-down section, is this cardiac that we're talking about? Yeah. I mean, we work in a, like, there's a couple of modalities in our department, and, you know, they just bought one type of table for... Yeah. Yeah. And that's typical. I'm glad to see that because it's not fair to you guys, and it's certainly not fair to the patients. But I was engaged by, from all my work, both as a sonographer in multi-specialties and in ergonomics, I was engaged to help design a table, and that's the one I like because it has features that make sense to me. Like we have, and it's been redesigned, and it's got a new design now, which even adds more to it. It's completely all electrically adjustable, which is what I like, what I recommend. Everything can be done with a hand control and a foot control. And it has an electrically controlled footboard and retractable stirrups, and it has, instead of a drop-down section for cardiac, it has a panel that slides up toward the head of the table. So you can open it only as far as you need to, to reach the cardiac apex without the patient feeling like they're going to fall through. Okay. And it has access panels, and there was a picture of it in my slides, and there's pictures of it, and they're exam-specific. There's a vascular table that's different than a cardiac table that's different than a general table. And some of the features can be added to all of them, but more information on that you can get from soundergonomics.com. Okay. Next question is, or comment is, I work at a facility that has limited space, so we do all exams bedside with a full-size equipment. What do you recommend to ease difficulties, and how do you stress to administration that this is putting us at risk? Well, to the person who asked the question, I think you should get a job where you don't have to do that, but yeah, I see that more often than I'd like to. The one thing that I recommend is, well, first of all, you can just present all the data on injuries. There's plenty of published articles on injuries, and how bedside's not the, you know, and even some of the point-of-care comments I made are not the ideal way to work. The solution for that is a difficult one, because what I recommend is that sonographers have asked the team to, or the floors, each floor, to dedicate one small room with an ergonomic exam table and an ergonomic chair on each floor that you do bedside studies on. And, you know, that's a big ask, because, you know, it takes up rooms, but you saw the cost of injury, and that's just going to cost them more than to put in a small room or to dedicate a small room, and then the patient can be moved down to that room. And each floor that you do portables, with the exception, of course, of ICU, could have that room. And, you know, the patients, a lot of them are asked to get up and walk on a regular basis so they can get ready to go home, so they can walk down to the room. And then if you have limited ultrasound systems, you just push the machine up to those rooms, but you at least have all the ergonomic pieces of a room with a dimmer and a table and a chair. But bedside exams are just a definite, a definite ergonomic nightmare, there's just no way to do them comfortably, because the beds, the patient's beds are too wide. And the only thing you can do is move them all the way over to the side of the bed and see the next time that they replace equipment, see if you can convince them to go with some smaller, lighter weight systems that are increasingly becoming more popular. Got it. All right, let's, let's ask one more question here. If you could go to administration and they're only going to buy one piece of equipment or something that would be ergonomically friendly, what should we ask for? One thing, one thing, as opposed to the ultrasound, like we can only get one thing off our wish list. What would be the most important thing to concentrate on? I would concentrate on the exam table. Okay. Okay. Yeah. Yeah. And then if I were, if they were in the market to buy an ultrasound system, I would definitely, if that was their wish, a new system, I would definitely look at the more than one provide what more than one manufacturer. I know everybody gets a favorite, you know, you may be in a GE lab, and that's all you want to buy. But, you know, there's up and coming systems that are really phenomenal, like the one that extends over the patient. So you can go to the left side. And you can use that in a really small room, because you don't, you just have the footprint of the of the system, and you don't have to roll it to the other side. So I encourage people replacing equipment systems in particular, to look at, at size and all the adjustability, but to really look at a variety of systems and what they offer. But exam tables and chairs are just as important. But I think if you were doing just one piece of equipment to make yourself more comfortable, start with a table because that has a lot of adjustable features and make sure that it's a table that's dedicated to ultrasound. Okay. All right. That's great. Well, thank you, everybody for all the questions and for joining us tonight. Thank you, Carolyn. Before we sign off, I want to remind everyone again that this webinar was recorded and will be available online through the SVU website at no charge for attendees. If you joined us late, I want to say one more time, you need to watch your inbox for the email from SVU in the next seven to 10 days. So you got to wait and follow the instructions in the email in order to get your CMH certificate. Finally, we have several webinars in the works covering new topics, including Doppler and color optimization and connecting practice to theory. And we'll review the new carotid consensus criteria later this year, name a few of the upcoming talks. Our next webinar will be in early March on fibromuscular dysplasia. So please look out for communication from SVU regarding upcoming events. And with that, thank you again, everyone, for joining us tonight. Until next time, take care and stay well. Thank you. Good night.

ergonomics

ultrasound workstations

injury prevention

musculoskeletal disorders

workstation design

new technologies

virtual reality headsets

education

proper posture

risk reduction