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Position of the Patient and Examiner

  • There are various possible options when positioning the patient and examiner.
  • In particular, when performing rigid endoscopy the angle of the endoscope and the chosen position determines what you will see.
  • Various criteria should be considered:
    • The position of the patient (sitting or lying)
    • The instrumentation (flexible or rigid endoscope, handling preferences, type of camera)
    • Ensure comfortable examination body level
    • Does the patient have a pronounced gag reflex?
    • Are there features of special interest around the anterior commissure or posterior larynx?
    • The expected duration of the examination
    • For more: See Tips and Tricks/Special Positioning of Endoscope or Patient
Patient Examiner
Sitting     Standing opposite the patient
(Standing behind the patient)
Sitting higher than the patient
Sitting at the same level as the patient
Sitting lower than the patient
Standing  Standing
Sitting
Lying   Standing
Sitting
Standing at the head of the bed (rare cases)

Table 4.1: Possible variations of position of patient and examiner

Patient sitting, examiner sitting. Height of both chairs is adjustable, the head of the examiner is slightly higher.

Patient sitting, examiner standing. Note that the examiner’s left elbow is angled, his right arm adducted.
  • When choosing your position for examination ensure that the monitor is within easy line of sight - avoid extreme head rotation to either side for longer examinations.

  • Adjust the height of both chairs – it is usually more comfortable for the examiner to sit in a slightly higher position than the patient.

  • The examiner’s arms should be adducted during prolonged endoscopy procedures.

  • The examiner’s elbows should be comfortably flexed.

Position of the Patient and Examiner: Rigid Endoscopy

  • Rigid endoscopy with a 90° or with a 70° endoscope can be performed either from a standing or sitting position.

  • In some countries, it is common for both the examiner and patient to sit.

  • However, when using some cameras, it may be easier to stand while the patient remains seated.

  • While seeking a particular view, it may be necessary to alter the normal positions for examination.

The most comfortable position for the examiner will depend on the manner in which the endoscope is gripped:

Note that by holding the endoscope in this manner both sitting and standing are possible and convenient.

Gripping the camera as illustrated is easiest from a standing position.

Patient sitting, examiner sitting. Note the manner in which the endoscope is held from below.

Patient sitting, examiner standing. Note the manner in which the endoscope is held.

Position of the Patient and Examiner: Flexible Endoscopy

  • Examinations with flexible endoscopes can be performed while the examiner is either sitting or standing.

  • Especially for longer procedures, e.g. examination of swallowing, it is sometimes more comfortable for the examiner to stand in order to reduce the strain on their arms.

  • Another possibility for flexible endoscopy is to stand behind the patient so the examiner and patient can watch the monitor. We are not fond of this technique because the examiner cannot see the patient’s face, and is therefore unable to check their reactions, e.g. an impending vagal response.

Patient sitting, examiner standing: Two alternative styles for grasping the endoscope’s handpiece. Look at the levels of their heads: The head of the examiner is held in a slightly higher position than that of the patient.

A) Standard handling, right index finger controls tip deflection

B) Right thumb controls tip deflection in this examination.

Patient sitting, examiner standing: Three alternative ways to grasp the endoscope handpiece

A) Standard grip, index finger controls tip deflection

B) Endoscope rotated, thumb controls tip deflection

C) Endoscope held horizontally. This handling requires examination in a standing position.

The Patient in Supine Position

  • Flexible endoscopy is more ergonomic and thus easier to perform than rigid endoscopy when the patient is lying in a supine or semirecumbent position.

  • The examiner may sit or stand as appropriate, using whichever position is the most comfortable.

The semirecumbent patient with the examiner sitting on the edge of the bed. This arrangement is helpful when the bed is so wide that the examiner has to bend sidewards in order to reach the patient.

The semirecumbent patient with the examiner standing. This is a convenient position for the examination of swallowing. The examiner can watch both the patient and monitor easily.

When the patient is lying supine, the examiner may sit at the head end of the bed. In this position it may be helpful to rotate the endoscope and use the thumb to control the tip deflection. Note the repositioned monitor.

Posture of Examiner – How to Do It

  • For both rigid and flexible endoscopy it is important to find a neutral, comfortable (i.e. not tiring) position, especially for the arms, head, and back.

  • The examiner’s elbows should not be abducted, nor held any higher than necessary.

  • The examiner’s arms should be adducted during long endoscopy exams.

  • During protracted examinations, standing may be a more comfortable option for the examiner.

  • The distance between the examiner and patient should not be so great as to prevent the examiner from sitting or standing upright with a straight back and neck.

  • Make sure that the monitor is positioned so that the examiner can see the screen and the patient with a minimal amount of head turning.

Example of good ergonomic posture. The examiner has a straight back and his arms in a low, elbows-in position.

Note the examiner’s left elbow is angled and the distal part of the flexible endoscope is not straightened. The examiner’s right arm should be relaxed with the elbow dropped towards the body during protracted endoscopy exams.

Make sure that you can see the monitor and the patient with a minimal amount of head turning.

Note the examiner sits up straight. The distance between the patient and examiner should be reasonably short, as shown here.

Position of Examiner’s Legs and Feet

  • Foot pedals may be required during some examinations in order to operate recording, stroboscopy, laser, etc.

  • Be prepared to reach all necessary foot pedals.

  • Sit or stand up straight.

  • Avoid getting your feet tangled in cables.

  • There are several options for where to place your feet when sitting opposite a patient. When using a foot pedal, the patient’s knees should be facing the examiner, who can then arrange his own legs to the left or to either side of the patient’s knees.

  • Check that the distance between examiner and patient is small enough to permit both to sit upright.

Check the position of the standing and free leg

Check how easy it is to reach all the necessary foot pedals. Try to avoid getting the feet tangled in stray cables.

Position of the examiner’s legs on either side of the patient’s knees.

Position of the examiner’s legs to one side. Both are turned towards the monitor.

Examiner – How NOT to Do It

 

Example of nonergonomic posture:

  • Note the bent back and arms held high and abducted.

  • Note the distance between the examiner and the patient.

  • Also note the wide angular change in direction required to view either the patient or the monitor.

The distance between the examiner and patient is too great, causing unnecessary forward bending of the examiner’s back and neck.

Poor location of the monitor demands considerable and unnecessary head turning.

Examiner’s arms are both held too high with the elbows abducted

Once again the distance between the examiner and patient is too great, despite the back and neck not being bent. Both arms are abducted and too high.
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