Barrett I. Woods, MD, FAAOS (right), explored the impact of noise exposure in the OR during the Instructional Course Lecture titled “Mitigating Occupational Exposures in Orthopaedic Surgery.” From left: Mary F. Carnduff, MD, MBA, FAAOS; Konrad I. Gruson, MD, FAAOS, FAOA; moderator Julie Balch Samora, MD, PhD, MPH, FAAOS; and Dr. Woods


Published 6/20/2024
Leah Lawrence

Improve Self-Care by Minimizing Occupational Hazards

More attention is being paid to the overall approach and changing culture of how orthopaedic surgeons approach their own safety in the OR. The AAOS Committee on Healthcare Safety was specifically created to support the dissemination of culture and processes that improve orthopaedic surgical safety. During the AAOS 2024 Annual Meeting, attendees were invited to learn more about this topic during the Instructional Course Lecture titled “Mitigating Occupational Exposures in Orthopaedic Surgery.”

Course moderator Julie Balch Samora, MD, PhD, MPH, FAAOS, pediatric hand surgeon at Nationwide Children’s Hospital and member of the AAOS Committee on Healthcare Safety, opened the session by detailing an online survey about occupational exposure that was sent to AAOS members. Survey results revealed that respondents felt that radiation exposure and a lack of ergonomics during work were among the most hazardous aspects of their profession. “On a weekly exposure basis, concerning hazards included surgical noise, radiation, Bovie/laser smoke, and anesthetic gases,” Dr. Samora said.

About one-third (34 percent) of respondents indicated that they had never received training on guidelines for hazardous exposures, and less than half (44 percent) received training at least once a year. Interestingly, although 56 percent of members indicated that it was standard practice to use a Bovie with suction at their institutions, 71 percent of candidate members reported use of this tool, indicating that “the next generation is going to be more attuned to these exposures,” Dr. Samora said.

Noise exposure
Noise exposure is something that Barrett I. Woods, MD, FAAOS, associate professor of spine surgery at Thomas Jefferson University Hospital, admitted he did not previously know a lot about. “Occupational exposure can lead to disability hearing loss in adults and has significant economic implications,” Dr. Woods said. The National Institute for Occupational Safety and Health (NIOSH) recommends that noise exposure not exceed 85 dB over an 8-hour period.

One contributing factor to occupational exposure to pathologic noise for orthopaedic surgeons is reliance on power tools to perform various procedures. Noise from these instruments was first quantified in the early 1990s, and many instruments emit noise >85 dB, contributing to cumulative effects on surgeons, Dr. Woods said.

Dr. Woods and colleagues recently conducted a study of noise-induced hearing loss in spine surgeons. They recorded procedures and found that maximum decibel levels averaged 102 dB for cervical spine procedures and 103 dB for lumbar spine procedures. “This level in and of itself is considered potentially harmful by the NIOSH committee, and the recommended exposure time for this noise level is less than 15 minutes per 8 hours,” Dr. Woods said.

Potential safeguards against this noise exposure include distance, which would be difficult in real-world practice; personal protective equipment, which could hinder communication in the OR; and use of modern instruments that result in lower noise exposure.

“Awareness is important, and surgeons must take steps to protect themselves from noise exposure,” Dr. Woods said.

Radiation exposure
Radiation-based imaging has revolutionized orthopaedic care, but it has increased surgeon exposure to ionizing radiation. During his discussion of intraoperative radiation exposure, Konrad I. Gruson, MD, FAAOS, FAOA, professor at Albert Einstein College of Medicine/Montefiore Medical Center, focused on a wide variety of topics, including the scope of the problem for orthopaedic surgeons.

One study published in PLOS One estimating occupational exposure to radiation for surgeons in the OR found that surgical residents had five-fold the radiation exposure as attending physicians, and orthopaedic surgeons had exposure more than six-fold the levels of general surgeons. Despite this increased exposure, the specialty lacks consistent formal radiation training, and according to Dr. Gruson, more education is needed.

There are myriad mitigation strategies to reduce unnecessary exposure, including improved recognition of the problem, consistent knowledge reinforcement, distance, and consistent use of personal protective equipment. “With all the available modalities, I think we can minimize the dose-dependent risk from ionizing radiation,” Dr. Gruson said.

Chemical exposure
The final speaker focused on chemical exposures that orthopaedic surgeons may be vulnerable to, specifically surgical smoke. “Surgical smoke is by far the most dangerous [chemical] exposure because of the composition of the smoke,” said Mary Carnduff, MD, MBA, FAAOS, director of surgical services and commander of the 316th Surgical Operations Squadron at Joint Base Andrews, Maryland. “Most of the particles in that smoke are nanoparticles, and our surgical masks do not filter those out.”

In addition, surgeons can potentially be exposed to viral pathogens, bacterial pathogens, and existing malignancies from patients. “Exposure is variable depending on the type of case, but it affects everyone in the room, and generally the surgeon is going to have the primary exposure,” Dr. Carnduff said. “We do know that using cautery in the OR all day is the same as smoking between 6 to 20 unfiltered cigarettes. If you can smell it, you are being exposed to it.”

Dr. Carnduff said that some of the best methods of mitigating surgical smoke—use of N95 masks and Bovie with suction—may be disliked, but they will reduce risk.

“We decided to be a part of taking care of other people, but we also have to take care of ourselves and our teams,” Dr. Carnduff said. “At the end of the day, as a surgeon in the room, you are leading the culture that is happening there. If you make taking care of yourself a priority, and you take an extra moment to make sure your team has everything they need, it will be better for everyone.”

Leah Lawrence is a freelance medical writer for AAOS Now.