Bad backs and aching necks: Occupational hazards of the cath lab

February 16, 2005


Toronto, ON - In most labs, it is usually the patient whose long-term health is at risk. Blocked arteries requiring intervention or irregular heartbeats in need of a good electrophysiologist are typically the problem at hand. But for many interventional cardiologists, electrophysiologists, and even sonographers, there are occupational hazards that go along with the job. In fact, severe, sometimes debilitating, musculoskeletal injuries are a fact of life.

"There is a major concern that there is substantial occupational risk associated with performing radiological procedures, especially since we're standing around wearing lead," Dr James Goldstein, an interventional cardiologist at William Beaumont Hospital (Royal Oak, MI) told heart wire . "The orthopedic problems are fairly well substantiated to suggest that there are issues, and given the increasing length of some of these complex procedures that operators do and the increasing volume of procedures over the course of a year, and a career, I think many of us are concerned that if you start today and perform interventional procedures for 20 or 25 years, you're going to end up with major health problems, certainly orthopedic issues."

There is a major concern that there is substantial occupational risk associated with performing radiological procedures, especially since we're standing around wearing lead.

Goldstein called the occupational hazards of interventional cardiology one of the unspoken secrets of the field. He said it is a fact of life that operators, especially those over the age of 35, will develop orthopedic problems, such as aches and pains in the neck, back, hips, knees, and ankles that range in severity. He said he became aware of possible problems when his own neck began to hurt at the end of a long day.

"Everybody knows about the occupational hazards, and everybody knows somebody, friends or colleagues, who have not just minor but major problems with their spine," said Goldstein. "We all know people who have been out of the lab for months, people who have been operated on, and people who have had to leave interventional cardiology because of these problems."

Dr Lloyd Klein

Dr Lloyd Klein, an interventional cardiologist at Gottlieb Memorial Hospital (Melrose Park, IL), said that while most interventionalists leave the lab contented after a productive day making patients well, they often also leave physically exhausted, with aches and pains of their own. In some cases, a hard day in the cath lab actually makes them shrink.

"I first noticed a problem when I would get into my car and have to readjust the rearview mirror every single morning," Klein told heart wire . "I couldn't understand how the mirror kept falling down each night. Then I realized that I was constantly moving the mirror. After a day in the cath lab, I was coming back into the car at night and slouching in the front seat because my back and neck were hurting. I'd adjust the mirror down just to be able to see out the back."

Prevalent problem in interventional cardiology

Dr James Goldstein

Goldstein told heart wire that the issue has been largely ignored, both by professional societies and industry. In fairness, however, there were not much data to go on, with the exception of one study by Dr Allan Ross at George Washington University that first raised the issue.[1]] Taking that study further, Goldstein and Klein conducted a recent survey to determine the magnitude of the problem with the hope of being able to address it.[2]

In an online study of more than 400 interventional cardiologists, they found a striking incidence of orthopedic disease, including spine problems in 42% of responders. Problems related to the hips, knees, or ankles were also reported by 27% of all operators. Not surprisingly, Goldstein and Klein found that spine problems were related to the operator's annual procedural caseload and the number of years in practice. More than one third of all operators included in the study reported missing work because of back pain.

After a day in the cath lab, I was coming back into the car at night and slouching in the front seat because my back and neck were hurting. I'd adjust the mirror down just to be able to see out the back.

Most believe that one of the reasons for such large numbers of operators developing problems is the dramatic evolution of the workday lifestyle of busy interventionalists. In the era of percutaneous coronary intervention (PCI), invasive cardiologists are spending more time in the lab, especially as PCI is recommended for more and more patients, including those with complex lesions.

"I'm 54, and when I first started doing procedures a busy cath day was two or three diagnostic caths," said Goldstein. "You were in the cath lab doing a case that took maybe 45 minutesyou'd do two or three casesand it wasn't that big a deal. Now a busy interventionalist is doing seven, eight, or nine cases a day, one or more days a week, and in some cases those cases can be quite prolonged. I don't think it's a surprise that many of us walk out of the lab at the end of the day in some discomfort."

Retiring at 49 years old

One world-class clinician forced into premature retirement was Dr Geoffrey Hartzler, formerly of the Mid America Heart Institute (Kansas City, MO). In the mid-1980s, Hartzler suffered a ruptured disk. At the time he was essentially a lab doctor, performing both electrophysiology (EP) and interventional procedures.

Dr Geoffrey Hartzler (Source: Mid America Heart Institute)

"At the time I ruptured my diskL4/L5EP procedures were often hours long, so we were hunched over wearing the lead and kept bent over the patient. None of this was good ergonomically, " Hartzler told heart wire . "A variation of that, when we were doing coronary angiography and interventional procedures, basically involved standing on one leg. You'd put all of your weight on that one leg, run the pedal with the other, and move the table with your hands. Again, ergonomically, there were forces at work that were just not good."

Before joining Mid America, Hartzler had been a staff member at the Mayo Clinic, where he eventually served as the director of the diagnostic EP lab. Hartzler was also extensively involved in interventional cardiology, performing the first angioplasty at the Mayo Clinic in 1979. When he moved to Kansas City in 1980, he started the angioplasty program at the Mid America Heart Institute, one of the busiest programs in the country. Some weeks Hartzler put in 100 hours at the hospital.

After the first ruptured disk, however, it became obvious that the physical demands of his workload were taking their toll. After 1985, for every year and a half to two years, Hartzler suffered another ruptured disk, each resulting in a lumbar laminectomy. He had a fifth and final lumbar laminectomy in 1995, just after his retirement. His last spinal procedure was a cervical fusion in 1996, done to repair a ruptured cervical disk that was causing a great deal of pain.

I'm not a wimp, but there were days when simply doing a day's work was all I could do. I'd go home and go to bed, trying to recover for the next day.

"From about 1990, I had chronic, horrible back pain," he said. "The physical work in the lab, doing the things that I love to do, became overwhelmingly painful. I'm not a wimp, but there were days when simply doing a day's work was all I could do. I'd go home and go to bed, trying to recover for the next day."

After his first lumbar laminectomy in 1985, he and other colleagues tried modifying the labsitting while performing procedures, equipping the ceiling with hooks to suspend the leadbut eventually Hartzler just slowed down. In the end, he says, he "had to hang it up," retiring young at 49. He notes that he sustained no sports injuries as a kid and suffered no accidents that would account for his back pain. Nearly 10 years out of the lab, he still has a little bit of pain, but no regrets about his decision.

"I retired pretty much at the top of my game," said Hartzler. "I wanted to stop when I was still appreciated for doing good work. People may have a hard time understanding that when I started, interventional cardiology was just coming into being, and I was honored to be part of developing it. Being involved in some of the early EP procedures, we were still exploring the limits of what could and could not be done, as well as defining which patients would benefit from different treatments. It was such an exciting time and there was so much to learn that it was unreasonable not to do it. I mean I loved doing what I was doing. I loved every second of it. It felt like I was doing good for a lot of people."

Sonographers also hurting

Interventional cardiologists and electrophysiologists are not alone in their pain. Workers in the medical ultrasound community also have a disproportionately high musculoskeletal incidence rate, with many sonographers leaving the workforce early. According to Dr Linda Gillam, president of the American Society of Echocardiography, the high rate of injury compounds the existing shortage of trained sonographers.

Dr Linda Gillam (Source: Hartford Hospital)


"Sonographers wind up with a variety of musculoskeletal pains that typically involve the hand, wrist, arm, shoulder, neck, and the back," Gillam told heart wire . "There are a lot of places that can hurt, and this all translates to lost work days, both from acute disability and chronic disability. It is one of the leading reasons why a number of sonographers leave the workforce and begin to look to do other things, at a time when there already is a significant sonographer shortage. It is really critical that we mitigate these work-related musculoskeletal problems if we are going to keep good people in the field."

Gillam noted that some reports have found that more than 80% of sonographers experience some degree of work-related pain. She points out that some manufacturers are starting to pay attention to ergonomics and are providing solutions.

According to Gillam, though, there is still a real need to make hospitals aware about how necessary this equipment is. "There is a lot of attention that is being paid to ergonomics, but one of the problems is that institutions, whether it is a hospital or a doctor's office, don't always want to make the investment," noted Gillam. "If there were endless resources, then I think more sonographers would be able to scan in a better, more ergonomically friendly lab. But frequently, they are asked to make due with what's at hand. The most ergonomically friendly systems are often the most expensive echo systems. We're not doing as well as we should with work environments. We need to get the labs to make investments into what is really the long-term health of their workers."

Examples of newer systems designed with ergonomics in mind are the iU22 and iU33 ultrasound systems (Phillips Medical Systems, Andover, MA). With the iU22 and iU33, the sonographer is able to manipulate the position of the chair, exam table, the ultrasound system, and the patient. The monitor can be moved independently from the control panel, allowing users to optimize their position and maintain an upright spine. It even comes equipped with a voice command system that allows the sonographer to access nearly all the system functions. Jim Hutchins, a spokesperson for Phillips, told heart wire the iU33 system costs between $150K and $250K, in line with other premium systems.

Solutions in EP and interventional cardiology

A universal agreement among EPs and interventional cardiologists is that the lead vests and thyroid collars are a necessary evil if they help prevent certain cancers caused by radiation. Fortunately, the technology has advanced to the point where the radiation is not as much of a concern as it once was, with the advent of more protective, lighter lead and smaller X-ray doses. Operators have also gotten better at the procedures, leading to shortened case times.

Some companies have even attempted to address the ergonomic issues in PCI. NaviCath Ltd (Haifa, Israel) is one of the first companies to develop and test a remote-control PCI system. The system offers radiation safety for the operator and a convenient and precise operation mode, say its creators. So far, it has been tested successfully in patients with single-vessel disease.

Dr Rafael Beyar (Source: Technion-Israel Institute of Technology)

"PCI is becoming the major route for revascularization, with the majority of these being drug-eluting stent implantations," Dr Rafael Beyar (Technion-Israel Institute of Technology, Haifa, Israel), a cofounder of the NaviCath company, told heart wire . "We suggested the development of a system where the physician could operate stent implantation from a remote location. This would increase the accuracy of stent implantation and provide a friendlier working environment for the physician, which in turn will prevent human errors and improve results."

The remote-control PCI system comprises a bedside medical unit used to advance the guidewire and/or stent and an operator control unit, made up of a joystick, viewing screen, and touch-screen for discrete adjustments. In its current stage of development, balloon inflation is still performed manually, but guidewire navigation and stent placement can be conducted using the remote-control system. Early results suggest the system is capable of successfully advancing and positioning the stent, as previously reported by heart wire .

Another company, Stereotaxis (St Louis, MO), is also addressing the issue with the development of its magnetic guidance system for EP and interventional procedures. Two large magnets, external to the patient, create a magnetic field and generate sufficient force to steer magnetically tipped interventional devices through the vasculature. As heart wire reported earlier, for some procedures EPs with this system are now able to sit down in the control room, allowing them to map and ablate tricky arrhythmias outside the radiation field.

Patient comes first

Still, while most agree that there are better ways of doing things in the lab, not all are sure what those improvements should be. The interventional cardiologists heart wire spoke to said that these novel systems are likely to have greater use in EP rather than interventional cardiology.

It never would have entered my mind relative to taking care of a patient. I was going to do whatever I could offer them. It doesn't matter if you get a backache out of it. That was immaterial.

"For coronary procedures where you're doing multiple exchanges of catheters, from a left diagnostic to a right diagnostic to a pigtail, and then you're doing multiple exchanges of balloons, stents, postdilatation balloons, and other instruments, I'd have a hard time seeing anytime in the near future where a robot can replace all those delicate maneuvers," said Goldstein. In the future, a cath lab where the operators wouldn't be exposed to radiation and wouldn't have to wear lead aprons would obviate the reasons for having to have somebody in a distant room use a robot, he said.

Hartzler told heart wire that he expects to see changes in the lab, although these should not come at the expense of patient care. He believes it will always be easier to have a doctor to advance and torque a wire rather than have a magnet or robotic system perform such tasks.

"Still, I don't want to be naïve," he said. "I think 50 years from now things will be different from how we do them today. Things should get easier on the operator, but to me that is a secondary consideration. It never would have entered my mind relative to taking care of a patient. I was going to do whatever I could offer them. It doesn't matter if you get a backache out of it. That was immaterial."


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