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The OR can be a dangerous place for doctors

OR medical staff should be included in the design process.

Sharp objects. Cables to trip on. Loud noises. Gases. Slippery floors. Operating rooms (OR) are full of hazards to the people who work there.

And these hazards can lead to injuries such as repetitive strain and joint pain from drawing medications, chronic back and neck injuries from standing in awkward positions for long periods of time—such as when performing surgeries or delivering babies—lung disease and more. 

One ob-gyn told the Medical Post she developed chronic back pain from doing deliveries. The pain subsided after she took off several weeks off because of an unrelated injury. So, the back issues “are clearly work-related.”

There was also a report of an anesthesiologist “who slipped and had a fall in an operating room and struck a surface that was protruding, and lost an eye,” said Dr. Eric Greenwood, an anesthesiologist who consults on how to make ORs safer to work in. An assistant professor of medicine at the University of Toronto, he spoke at the recent annual Ontario Anesthesia meeting on hazards in the OR.

But many of these dangers can be solved with a redesign of ORs, along with equipment that is more ergonomic. 

“OR design focus is generally on patient care, patient movement, equipment required in the room and how many computers. How practitioners move and interact in the environment is frequently overlooked,” he said. 

For example, equipment with poor ergonomic designs abound. An example is anesthesia gas machines which have one or two monitors positioned on a static high shelf and a keyboard lower down. A short person has to tip their head back awkwardly to view the monitors and can develop neck strain, while a tall person has to bend forward to use the keyboard and could develop back pain—especially if the stations are used for extended periods of time and repeatedly. Making them adjustable could help prevent these issues.

Another problem is noise.

“Tools such as convective warmers, computers, lasers, electrocautery and ventilation all have fans that add to the background noise. Added to this, surgical instruments add increased spikes to the sound levels in the OR,” he said. While studies haven’t focused on hearing loss (which doesn’t mean it doesn’t happen), the noise can create distractions and impair communication. 

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But studies do show that excess or constant noise can contribute to stress, sleep disturbances and hypertension.

Studies on OR-based occupational injuries are few and far between, likely because many don’t seem to be reported. Especially if hospitals don’t have a good mechanism for dealing with reported injuries.

However, a survey of 1,645 orthopedic surgeons in the U.S. found that this group had a total of 2,702 work-related musculoskeletal injuries. Of these, 17.9% required surgical treatment. A total of 61 surgeons filed disability claims, and of these only 66% returned to work and 34% retired early. As well, 17.4% of respondents were diagnosed with cancer since starting practice, and 93.8% reported experiencing a finger stick at some point.

There is a high prevalence of work-related musculoskeletal injuries and pain among surgeons, according to a metanalysis which investigated differences in subspecialities. The study found surgeons commonly had neck, shoulders, upper back and lower back, and upper extremities problems. It also found that robotic-assisted surgery led to lower post-operative discomfort, but could lead to static neck positions resulting in back stiffness.

Gastroenterologists commonly experience colonoscopy related musculoskeletal injuries too, according to a study by researchers in the U.K.. A survey of 368 gastroenterologists found the most common work-related injuries were in the lower back, neck, and left thumb resulting from awkward positions and repetitive strain.

When it comes to puncture wounds, or ‘sharps injuries,’ a study in the Internation Journal of General Medicine conducted by a group of surgeons found that medical students and doctors were significantly less likely to report the injuries than nurses. 

Doctors were less likely to report puncture injuries if they perceived the patient as being low risk “Unfortunately, this perceived safety can be dangerous because patients may voluntarily or involuntarily withhold medical information,” the researchers wrote. 

Another common concern is infection of OR medical staff, from both puncture wounds and airborne disease. 

A review paper Dr. Greenwood coauthored stated it has long been recognized there can be disease transmission from patient to healthcare provider, but “effective means to reduce transmission risk, and compliance with recommendations continue to be less than optimal. For example, transmission of herpes simplex virus 1 (HSV-1) causing herpetic whitlow from patient to anesthesiologist was recognized in 1970, and despite this, infections continue to occur because of variable compliance with wearing gloves.” 

Contact dermatitis is a common complaint among OR staff, whether from allergic reactions to the latex in gloves, or irritation from soaps and hand sanitizers. Some of this can be alleviated by switching to non-latex gloves and medical grade and lotions, Dr. Greenwood said.

According to a review in the Asian Journal of Surgerygases and smoke in the OR can be hazardous too. Electric knives, ultrasonic scalpels and lasers can all lead to surgical smoke, some of which can be carcinogenic.

“Although 95% of surgical smoke is water vapor, the constituents of the other 5% may cause health hazards. These include several kinds of components, such as inactive particles, chemicals, pathogens and active cells,” it said.  

The authors stated that surgical masks, suction devices and portable smoke evacuation systems can reduce the risks, but added that often OR staff members do not protect themselves properly. Fans that remove smoke help.

In his talk, Dr. Greenwood argued that another risk that should be included on the list of OR risks is substance use disorder (SUD), especially among doctors who have easy access to powerful addictive medications.

One study of 44,736 U.S. anesthesiology residents between 1977-2013 found 601 (1.3%) developed SUD; 114 (19%) of those with SUD died from it, and of the 487 who survived their substance use, 32% relapsed once, and 11% relapsed multiple times. The most common substance abused were opioids 55%, alcohol 40% and propofol 20%.  

What can be done? “Become aware of signs and symptoms of substance use disorder in our workplace,” he said. These can include mood swings, withdrawal from friends, taking extra call shifts, frequent requests to work alone, refusal of breaks or even taking more breaks. Working with the pharmacy can offer safer access to medications.

When ORs are being updated or designed, medical staff who work in the OR should be included in the designed process, including from different specialties who use different equipment and may have different ergonomic needs.

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