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so I'll be presenting, uh, a slide about surgical economics. Let me just upload my slides. Give bear with me again. You have any questions? Please Do not hesitate to, uh, put them onto the chat or be interested about any of the work that Morita's doing for women in surgery with the college or with British hip society. And in a British ship, Society are really pushing being the leaders in this field within surgical subspecialties in orthopedics. Uh, because historically there there were less, uh, female surgeons in, uh, taking on hip surgery as a specialty. And I think they're really trying to change that and show that anyone can do, um, hip surgery being hip surgeon. So they really are trying to push it. And I think I know that Joana mags is a really big part of that. And they have a dedicated, called university, uh, subcommittee for that. So if you're interested, please, Please do link up. Um, everyone's really welcoming, uh, for enthusiastic individuals. So I'm gonna give you a brief talk now about, uh, surgical ergonomics, and this is a really hot topic right now, and I really hope you'll find this interesting I'm applicable for your day to day to day practice. Uh, the definition of ergonomics. Ergonomics is the application of psychological and physiological, uh, political principles to the engineering and designer products, processes and systems. And I say this is a hot topic at the moment. Because just this month, surgeons and ergonomics was published in the bulletin of the RCs talking about how poorly fitting protective clothing and equipment is actually causing, um, injury and occupational hazard to surgeons. In this article that, uh, one of the surgeons interview was Ms Jenny Brown Brick, a vascular surgeon down in cancer Sussex. And she talks about her experience of having require, um, cervical spine surgery due to the degenerative spine condition that she's developed over the years from using loops for her vascular surgery and also for being a very tall surgeon, meaning that she had too often be flexing her neck and crouching over to do her operations. Um, you know, luckily, she's, uh, now recovering from her second operation. But this is a real issue, as surgeons, Uh, and it's something that we need to start discussing about a bit more openly. So when we look at some of the data for Moscow. Skeeter Injury with Insurgents Studies have found that, um, this is common insurgents and and once I found that 77 to 100% of laproscopic surgeons have experienced physical symptoms or discomfort attributable to operating this, the surgeons are exposed to many risk factors for muscular through the discomfort and occupational injury and this can and and being a surgical trainee when you're inexperienced and you don't know how to work. Ergonomically, this may put you at additional risk for having musculus keto injury. This discomfort potential injury can have negative consequences on the same in terms of their performance, but this can also affect our patient's. This can result in, uh, lost time for the surgeons because they take time off and also can lead to surgeon burnout. Improving surgical economics can reduce discomfort and mitigate any negative consequences due to our job in the Operating theatre. This can include any Um, this can include awareness about body posture and having a proper operating room set up now outside of the operating theater. Surgeons can also reduce their comfort by improving their economics, so must go together. Injury. Um, that can be that can happen in surgeons can be two types, which can be either chronic injury due to cumulative trauma disorders. Um, due to prolonged exposure to organic risk factors such as, as you can see in this diagram here, uh, excessive neck flexion. Poor torso positioning, which can cause, uh, back pain and cumulatively cause, uh, degenerative conditions. They can also occur from acute injuries. Um, such as sprains and strains. Remember one instance where my previous consultant actually, uh, was trying to dislocate hip, and unfortunately, the hook slipped, and it very nearly took his eye out. Um, and so these injuries And I don't think this is, uh, one isolated, uh, event. If also hear of surgeons who have, uh, experience with the cuff tears because of trying to reduce the hip or, um, not position themselves properly, um, and not concerning their ergonomics. So this is something that we really need to consider, especially if we are at the start of the career like myself. So ergonomic risk factors can include a variety of variable such as static loading, um, posturing, awkward postures, repetitive use. Um, I think lots of you've ever had your hand accidentally caught in the eye eye and you see a both authorities developing in your thumb. You know, we are constantly using our hands for our jobs, and we are at risk of these repetitive injuries. Um and so how do we apply economics into our day to day practice so economics can be applied? Principles can be applied to many aspects of our work. This includes how we lay out our operating theater, the design of our equipment, um, and especially design equipment, which is diverse for a diverse workforce, the posture of the surgeon. And this is all to enhance the safety, productivity, effectiveness and quality of life of our workforce. This is a few that is growing in terms of the research that's being done, so hand size is a significant determinant. Uh, the study found that hand size is a significant determinant of difficulty using laproscopic instruments. They found that individuals using a glove size of 6.5 or smaller experience significant more difficulty using common laproscopic instruments and in particular laproscopic staplers because it couldn't just quite grasp their hand around it. Uh, manufacturer's uh, for these equipment, the study suggests, should consider, uh, hand sizes when designing their future of surgical instruments. Looking at the economics of women in surgery, uh, this study by certain found that women surgeons are experiencing more discomfort and treatment in their hands compared to their male counterparts. Surgeons and also they recommended redesigning laproscopic instruments that can handle different ergonomic and different hand sizes. Uh, further, under this systematic review, I found that women in surgery demonstrated more muscular asleep til pain than men. And this is potentially, they speculated, Do the decides and design of theater equipment and tools for mail for are definitely more taller and male individuals with bigger hands specific to orthopedic women within orthopedics one. This survey found that 87.3% of females reported symptoms in relation to using the orthotics surgical instruments. So these, um, discomfort and injuries is very real. And it's now we're now collecting. We now have the data to show that, you know, previously we may have, uh, anecdotal evidence. Uh, one thing that was commonly talked about is about the cementing gun about how a woman's hands, man, if you're less than if you're 6.5, you will have a lot of difficulty trying to use cement gun. Um, and you end up spraining your hand or your wrist. Um, and it's about learning about how we can either adapt to this equipment or change the design of the equipment. This is a study, um, published by the Mayo Clinic, and it's a study that they performed on looking at the economic risk of surgery using, UH, sensor measurement units. So they were placed sensors on the surgeon to understand the risk factors of the high risk positions that they placed themselves in. And they would use the sensors to measure different body posture angles, as you can see it on this diagram, uh, the red being very high risk orange being high risk. The high risk classification was based on known occupational economic research exposure analysis, and these known economic research exposure have been shown to be clinically, clinically significant and related to musculoskeletal disorders and discomfort, and this is specifically in associated with exposure to different high risk positions in the neck, the torso and the arm. So the study also found that, you know, become para ergonomic risk procedures categories across different surgeries. They found that open laproscopic and endovascular surgeries are a high risk of ergonomic high risk of muscular injury. They also found that the use of objective equipment such as loops, headlamps and the lead apron also increased the ergonomic risk of risk factors. So we if anybody, any trainees, have, uh, been scrubbed into a long case wearing a gown for 34 hours, you come out of that case feeling pretty knackered. Um, and you know, you have to activate your core throughout the whole the procedure. So the physical demands on surgery are real, and in particular, the surgeons cervical spine is, uh, unacceptably elevated risk of, um, injury poor organ. Ah, mix can be a cause of chronic pain and disability, and it can also reduce the surgeons career and also threatening the public's access to healthcare if our surgeons are not well looked after, Um, this is the study that I mentioned by Mayo. Uh, they served 53 surgeons, and they found that overall surgeons spent 65% of the procedure time in high risk neck positions due to excessive flexion. They also found that the surgeons placed their torso and their shoulders in high risk positions in 30% of the time and 11% of the time, respectively. The highest risk, as mentioned before, was during open and laproscopic surgeries, and the risk factors for surgeon reported pain was was because of longer case length and increased years in practice and use of adjunctive equipment such as loops and headlights. In addition to posture and looking after ourselves in terms of economic considerations, we as orthopedic surgeons use, uh, ionizing radiation for our jobs to do many of our procedures and specific a lot in trauma, uh, surgery as well. And so we need to consider that radiation exposure is an occupational hazard to us. And there are now studies that are emerging, demonstrating that risk, too, and the helpless to orthopedic surgeons and other surgeons such as cardiothoracic six and intervention radiologists. So this study, published in America, compared cancer occurrence during a 25 year period in 100 and 58 workers who were routinely exposed to radiation. In this survey, there were 31 surgeons, um, and they match them with a cohort of 100 58 agent sex match workers, and from this report they found that there was a 29% incidence of cancer among orthopedic surgeons who are exposed to radiation. And this is compared to only a 4% incidence of cancer among workers who are not exposed to radiation. Who are agents. Sex matched. So we are from this study. It shows that there we are potentially at a 20% increased risk of incidents of cancer, which may be related to our radiation exposure. This study uh, orthopedic, urology, urology and plastic surgeons, uh, where they studied their fluoroscopy history, medical history and history of cancer again found a high rate of cancer than expected in orthopedic surgeons. With breast cancer being reported at a 2.9 fold increased rate, they didn't find any difference between the observed, uh, incidence of cancer in urology and plastic surgeons. So, in terms of what we can do to protect ourselves from ionizing radiation, uh, we can wear lead aprons, which is, you know, when we do trauma, uh, and we use I I we must wear lead apron, and in general, the most common ones that we use, which is 0.2 25 millimeters 0.5 millimeter lead aprons can reduce the amount of radiation from 90 to 99%. We can also wear lead eyeglasses to reduce our exposure, and this can be reduced exposure by 90%. The risk of cataracts is not studied in orthopedic surgeons. However, multiple other studies looking at cataracts in interventional cardiologists have found that, um, posterior lung capacity's was found to be 38% versus 12% in a control group with a relative risk of 3.2%. Other ways we can reduce our radiation risk is through our CM positioning to avoid any backscatter with the use of a CM when we're in theater. The surgeon, uh, and the operating scrub stuff to try to stand on the intensifier side of the arm if possible, because by standing on the intensifier side, um, you if you so if you stand on the admitting side of the CM, then you may be exposing yourself to a 4 to 8 times higher increase of radiation exposure. Uh, compared to when you stand an intensifier side. In addition, but increasing the distance you stand from the beam can reduce your exposure and also not using your fill oscopy judiciously and not flashing through unnecessary, which is to reduce radiation exposure to yourself, your colleagues and also to the patient. So this is, um, a paper that has been talked about a lot very recently. And it's a paper published in the Journal of American Academy of Orthopedic Surgeons, um, which they sent it to, uh, female comic surgeons. And they collected results from 672 responses. And from this, they have found that there was a higher, significant, statistically significant increased risk of breast cancer and all cause cancer in females Orthopedic surgeons. They found that there was a increased risk of, uh, 2 to 3, uh, times risk of increasing breast cancer. And they speculate that this is due to the lead guns that we wear, which goes over our upper torso does not cover the axilla and the upper portion of the breast due to the breast tissue. That means that they're not well fitting for female orthopedic surgeons. So this is an increased risk of breast and all cause cancer. And this is a, uh, North Korea House said that we need to be that is being discussed increasingly more and for us trainees who are starting off in your career. You definitely need to consider so principles of surgeon ergonomics in terms of applying them to try to reduce the risks of the things that I have discussed in terms of muscular, skeletal injury, um, and being efficient and to protect yourself, Um, and to reduce your ionizing radiation, we can divide principles of surgical economics into three domains. Um, one is how we position our body to is the equipment that we use And three is how we prepare, um, ourselves and, um, inside operating theater and also what we do outside of work. Ultimately, surgical, economic, um, economics and the principles of it is to operate with as close as possible to a neutral body posture and using equipment that limits the physical stress on our bodies and to regularly strengthen and stretch our muscles and joints. So, the following, um, can these these principles can be used to improve mosquito issues outside of the, uh, inside the operating theater. So when next time you're in theater, you can start thinking about how you can perform most ergonomically for yourself. So studies, uh, ergonomics in surgical graphics have shown that to be at the most optimal how your table height should be about 70 to 80% of your elbow high. So the next time someone asks you if you want to lower the table, um, they are genuinely asking to try to try to protect you there. Experience scrub staff and surgeons and anesthetists who are looking out for you. And sometimes when you're in such deep concentration, um, in the task at hand, you may not notice that you're putting yourself in a high risk position, so be conscious of the table right next time you operate. If you were a loops, if you're involved in enhance surgery, try to wear ones that are as light as possible and to keep your head in a neutral position as much as possible. If you're doing our orthoscopic surgery and you're using monitors, these should be placed high and at a neutral I distance. The monitors should be around 8220 centimeters, uh, from your eye level and your hand level, and may and try to ensure that the definition and the focus of the of the camera, um, is appropriate so that you don't have to be straining your eyes. Um, sorry again, with in terms of your equipment when you if you are using a headlight, um, we don't often use it in orthopedics, But I actually just used a couple weeks ago with the headlight make sure that the weight, um and the brain is is suitable for you and that it's attached on properly onto on top of your scrub cap. Make sure the lighting is optimal so that you don't have to be straining your eyes when doing the operation. If you have. If you are someone like me who requires a stepping stool because the person operating it with is about foot taller than me. Ensure you have sufficient stepping area so that you don't avoid compromising your foot balance and with lead aprons I've discussed before to protect yourself from ionizing radiation. And this is an area that we definitely need to look into more as, um, surgeons with female breast tissue and to protect ourselves from possible increased risk of cancer. Overall, the aim is to try to operate in, uh, as neutral position as possible. Um, you can see from this diagram, uh, that this patient, this, uh, surgeon here is on the right is excessively flexing flexing the cervical spine. Um, there their legs are not in their pelvis is not a neutral position. Um, and they're also bending their torso, which can increase the risk of neck pain, shoulder pain and back pain. So things to be aware of next time you operate just to make it more most efficient for yourself. In addition to protecting yourself from mosquito injury, surgical ergonomics actually can make us operate more efficiently. Um, if you were in the room, I'll ask you to demonstrate this. But the most efficient way for us to grip things is actually in our with our hands in slight, Uh, with our risk and slight extension, so allows us the most powerful grip. Holding your instruments with a flex risk actually makes it strains your wrist and also is really inefficient. In terms of biomechanically holding the equipment, you don't have much power, and you have you have difficulty controlling the equipment. So next time you do pick up a new equipment, have a feel of it and try to see whether you're holding it in the most economic way. So ergonomics is has been, you know, research is that the research is building, and what they also recommend is that, you know, we we do do quite a physically demanding job, and we need to look after ourselves outside of the operating theater. And this is all published in the Plastic Reconstruction Surgery Journal about strength, stretching and strength training to improve your posture and ergonomics while you're inside. Some of the other studies have also recommended that in between your breaks between cases, you should be doing regular stretching, uh, to ensure you're trying to avoid any injury specifically with your neck and your shoulders and also your back. We're also looking at how to take restful, uh, efficient breaks. So this study looked at having interruptive micro bakes micro breaks with targeted stretching to enhance surgeon physical function and mental focus. And they found that they by implementing at 1.5 minutes stretching program every 30 or 40 minutes. During the operation, they found that the surgeons reported 34% improvement in their mental focus and over 50% improvement in the fiscal performance time. Most importantly, they actually did not find any increase in the operating operating time when they implemented this program, and I think it's about taking tactical breaks at the right time and also reminding your colleagues to take breaks when they need to, so that they're looking after themselves in order to have a, uh, lengthy career. Furthermore, um, this is a table published from the Canadian Center for Occupational Health and Safety Um, they emphasizing the importance of a table height in decreasing the strain on your back muscles. And it minimizes neck flexion and the leaning over and reaching over that we sometimes I'm sure we all have participated in. So they also recommended that when and how to position yourself and the table height and your elbow when you're doing specific tasks, they said that if you're doing a precise task such as soft tissue dissection or mobilizing critical structures, then use the table. Height should be five centimeters about the level of your elbow. If you're doing light work such as inserting screws or stuttering, then the table height should be slightly lower. 5 to 10 7 is below your elbow height. If you're doing a heavy task that requires downward force such as drilling or impacting, Um, that would require maybe some of your body weight to push on to the, um, equipment. Then the the table should be a little bit lower, about 22 4 centimeters below your elbow height. Furthermore, they advise that if you're doing any precision tasks, um, you your elbow should be flexed at a about 100 and 10 degrees to improve your functionality. Uh, and also, if you're doing heavier tasks into effect it to 40 to 50 degrees to improve your functionality and to avoid fatigue putting this all together. Um, I mentioned previously earlier in the day our we held our very first tips and tricks course for the ergonomic orthopod this Saturday that just passed where we, in addition to doing giving students, uh, plastering workshops and total replacement workshop with sawbones, we also told them specific tips and tricks that we, as surgeons, have picked up throughout our career. Um uh, in terms of finding ways that work best in doing procedures, I myself, um, and Caribbean ST for registrar, and I love the tips and tricks that I that I was teaching in the course. I really wish someone told me when I was a medical student, a junior doctor so that I can understand the best way to perform these procedures that we all have to do in in any in terms of joint dislocation reduction and fracture reduction. Um, these tips are we We are anecdotically picking them up through our career. However, you know, we should be teaching these early so that the the increasing diverse workforce that come in know how to use their use, their body an ergonomic fashion so that they're most efficient and protecting themselves. So, for example, uh, in this station, we were doing ankle reduction with multiple, and you can see how many people are involved in an ankle reduction. And if you're a trainee or medical student and you haven't done one before, this is the minimum. This is about the minimum number of people you do You need to do an, uh, an ankle reduction. This is tricks that tips and tricks that we would probably not taught in a plastering course because when the plastering course, they just want to teach you how to put a plaster on. But in this course, specifically, want to teach you how to put a plaster on but also teach you how to reduce it in the most efficient way possible so that you it's best for the patient. And also you're protecting yourself. So in summary, economic principles can be applied to many aspects of surgeons work, and this can be included in terms of operating theater layout, the design of the equipment that we use and even surgeon posture. And this is all to try to enhance the safety, productivity, effectiveness and equality of life and work that we do. We talked I didn't touch upon equipment design, But Botha and the Bor currently working on a work stream called Diverse in Design, which is looking specifically at the equipment that we use and how we can increase its ergonomic, um, is ergonomic design so that a more increasingly diverse range of surgeons can use it effectively and prevent injury. We need to work with industry to do this, and a lot of research needs to go into to understand how they couldn't that we use, uh, may not be well suited for a diverse range of, uh, surgeons. If we can have glove sizes that range from 5.5 to 8.5 and nine, then our equipment should also consider this difference in hand size. It may not. It may be. We need to have more modular components, the equipment that we use or that industry can try to push to reduce the size and the and the strain that the equipment requires when we're using it. Surgeons are exposed to many risk factors for muscular disco, muscular skeletal discomfort and occupational injury. Uh, not only through physical discomfort and injury, but also through ionizing radiation. So when next time you you scrub into a case, please do consider this and protect yourselves as trainees, we may be an additional risk because we may not be aware of these occupational hazards. And so, hopefully, through this course and through increasing awareness of surgical economics, we can try to reduce that risk as you, uh, embark on a training career. Lastly, having surgeons, um, injured surgeons is not good for the public, and it will result in negative consequences, know only for the surgeon and their their performance and their career, but also result in negative patient outcomes. A few, um, last minute some of these for you to think about next time you're going to the operating theater, Remember, try to work in a neutral position, reduce excessive force, make sure you're working at a proper table height. We cannot emphasize enough how important the table height being at the right height for you is you'll be operating for 123 hours. You need to make sure that the environment you place yourself in is safe and comfortable outside of the operating theater. Um, multiple studies have shown that you need to keep your size. Keep yourself healthy, moving, exercising and stretching, and and to ensure that you have the right equipment when you're operating quick. Summary. Um, we want to try to aim for as much neutral position as possible. As here on the right, make sure that you're not straining your neck. Your forms are neutral position, which not only makes it more comfortable for you but actually makes it more efficient and precise. This is a talk, um, delayed by Suresh, our West junior culture and diversity champion, and she came up with the hashtag drop the table because next time, because she is a surgeon who is a 5 ft two, so for her, the table height and She's often operating with someone who's much taller than her. And she's previously been afraid to ask for the table to be the right height for. But really, in order for you to be efficient, safe and to be to provide the best outcomes for your patient, you really need to table at the right height. So hashtag drop the table is what she came up with. And I thought that was quite a quite a nice summary to our course. Thank you. Have any questions? Um, please do feel free to play on the chat and you're interested in, uh, participating in the research in this area. Please feel free to contact me.