If I Never Hear That Again It Will Be Too Soon!

Here’s a tongue-in-cheek look at my top ten list of annoying things I hear as a medical photographer.

(From Medical Personnel)

1. “Yes, we are ready for you now, the dressings are down and the patient has consented”.

Meaning: I have not removed any dressings yet and the patient has absolutely no idea you are coming to take photographs.

2. “Yes, I will be able to assist you when you get here”.

Meaning: When you arrive they will be busy/on a break so you will have to spend the next ten minutes looking for some one else to help you.

3. “Do you need me to remove the dressings before you take the photographs?”

Erm, yes! I find it’s much easier to photograph a wound when I can actually see it!

4. “There’s a photographer here who wants to photograph your bottom”.

Erm, no! I don’t go round the hospital randomly selecting patients bums to photograph. You have a pressure sore and your doctor has requested I document it for your medical records.

5. “Oops, sorry they were given a suppository this morning”
.

This is an unfortunate (and all too common) consequence of number 4.

(In Theatres)

6. “Could you send a photographer now we will be ready for them in 15 minutes”.

Meaning: The patient has not even been  anaesthetized yet so it will be at least an hour before we are ready for the first photograph.

7. “No we won’t need a photographer for the full procedure, we will only need them for about ten minutes”.

Meaning: It will be at least five hours before you’re finished here so I hope you’ve had a drink, eaten lunch and been to the toilet.

(From Patients)

8. “I bet you’ve not seen anything this bad before”.

Well, no, not since last Tuesday anyway!

9. “Where do you put the photos? They won’t end up on Facebook will they?”

Erm, no! I don’t think your friends and family would appreciate seeing your clinical images appear in their newsfeed.

10. “Should I smile for the photo?”

You can if you like but I’m photographing your feet so it’s not essential!

It could only happen to a Medical Photographer!

This afternoon a lady attended our photographic studio to have full body mole mapping views taken. She had her young son with her who played happily with his toys in the corner for the half an hour or so it took to take all the photographs and dermascopic images.

After work I made my way to the busy tram stop when I heard a child shouting “hiya”, “hiya” from the opposite platform. I looked up to discover the same lady and child. I was just about to wave when the child shouted (rather loudly) “Mummy look there’s the woman who took the photos of you when you had all your clothes off”.

The poor lady went scarlet, luckily her tram arrived soon after and she bundled him on to it before he could say anything else. You can alway trust kids to say it how it is!

Infection Prevention is not relevant to Medical Illustration – or is it?

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A medical illustration department typically consists of medical artists, graphic designers, medical photographers and audio-visual technicians. All medical illustration staff need a basic awareness of infection prevention, however medical photographers require a more in-depth knowledge.

Graphic designers for example spend most of their time in the medical illustration department producing work on computers and don’t have regular contact with patients or routinely visit wards or clinics. Medical photographers on the other hand come into contact with patients on a daily basis and must transport their camera equipment to wards, clinics and operating theatres throughout the hospital.

As Medical photographers routinely photograph open wounds they are likely to come into contact with micro-organisms and body fluids, some of which may be infectious. It is therefore essential that medical photographers take precautions to ensure that they do not transmit these organisms to subsequent patients or hospital wards. Routine hand washing, decontamination of camera equipment and protective clothing is necessary to avoid any cross-contamination taking place. It is therefore essential that medical photographers rigorously adhere to infection prevention policies.

Hand washing

The most important thing a photographer should do before and after photographing each patient is wash their hands. This is necessary as it prevents the hands from becoming contaminated with micro-organisms. If the hands were not washed they would pose a risk to subsequent patients who have a weakened immune system and are more susceptible to infections.

Liquid un-medicated soap can be used for routine hand washing, when photographing patients in wards or clinics but a more effective antiseptic cleansing agent should be used before entering a sterile area for example an operating theatre.

Each ward should display posters explaining how to correctly wash hands, these are usually situated by the sink and soap dispensers. Paper towels should be used to dry the hands after washing to rub away any transient organisms left on them. An alcohol gel should then be applied to the hands after they have been washed to disinfect them.

The photographer should keep the skin on their hands in good condition as bacterial counts increase when skin is damaged. The NHS encourages healthcare workers to reduce the frequency of hand washing when their skin is sore or chapped.

Damaged skin on the hands should be covered with a waterproof impermeable dressing as broken skin is at an increased risk of exposure to blood borne pathogens. Gloves should also be worn on top of the dressing to ensure no contamination occurs.

Gloves

Gloves should be worn by a photographer when they are likely to come into contact with body fluids, for example when removing dressings, photographing open wounds, during surgical procedures or when performing invasive dental photography. I think this is really important as unsanitary hands could easily contaminate the photographer’s uniform and camera equipment.

Gloves protect the hands from contact with organic matter and micro-organisms and minimise cross-infection by preventing the transfer of organisms from patient to photographer or vice versa. Gloves should always be worn when photographing a patient who is known to be contagious or infectious. If they are not worn the photographer could inadvertently infect the next patient they photograph.

The photographer should wash their hands thoroughly when they have removed the gloves, as gloves don’t always provide an impermeable barrier. The gloves could have been punctured and hands can easily become re-contaminated when the gloves are removed. Used gloves should be immediately placed in a yellow clinical waste bin.

Disposable Aprons

Disposable aprons should be worn when the photographer’s uniform is likely to come into contact with body fluids, for example when leaning over a patient, removing dressings or when photographing open wounds or burn injuries.

Aprons should always be worn when photographing a patient who is known to be contagious or infectious, this is important as it is often the front of the uniform which becomes most contaminated with micro-organisms. Used aprons should also be put in yellow clinical waste bins before the gloves are removed and hands are washed thoroughly.

Surgical masks

Medical photographers should wear masks when photographing patients in operating theatres, or when they are in close contact with patients undergoing any form of surgical procedure, this includes invasive dental photography. This is necessary as masks trap any organisms exhaled by the photographer.

A fresh mask should be worn for each procedure and masks should be replaced when they become damp, as damp masks no longer deflect organisms. At the end of the procedure the mask should be removed and placed in a yellow clinical waste bin.

Decontamination of camera equipment

Medical photographers have a responsibility to their patients and other healthcare workers to ensure that their camera equipment is clean and not contaminated with body fluids or micro-organisms, it is therefore imperative that photographers de-contaminate their lenses and camera equipment by wiping them down with alcohol wipes on a daily basis.

It is necessary as photographers transport their photographic equipment to wards, clinics and operating theatres throughout the hospital and are often required to photograph patients whose immune system has been compromised.

Lenses and camera equipment should also be wiped down with alcohol wipes every time a photographer is required to wear gloves, for example when removing dressings, photographing open wounds, during surgical procedures or when performing invasive dental photography. This will prevent secondary contamination from gloves to camera, lens and cable release.

The photographer should also be conscious of where they place their camera bag as this could also become contaminated. Camera bags, if possible should be left outside the patients room or cubicle and the photographer should only bring into the room the camera equipment which is required to photograph the patient at that time.

Operating theatre procedures

Operating theatres are sterile areas and medical photographers must follow special infection control protocols. All healthcare workers must change out of their uniforms and put on clean, un-contaminated clothes before entering the theatre. The use of protective clothing such as gloves, surgical mask, clogs and hair net is essential to avoid contaminating the theatre or incision site.

Camera bags must be left outside and the photographer should only bring the camera equipment which is needed into the theatre. It is imperative that the photographer decontaminates this camera equipment with alcohol wipes before entering the theatre. If the photographer doesn’t disinfect their equipment they could inadvertently introduce micro-organisms into the incision site.

Close-up views of the surgical procedures are often requested, the photographer must ensure they don’t touch or rub against any of the sterile green areas in the theatre, for example the instrument table, surgeon or patient. If the photographer does touch a sterile green area they must tell the surgeon and the greens or instruments can be replaced.

Barrier nursing procedures

Some micro-organisms cause infections which can spread easily from person to person. Barrier nursing is implemented to prevent contagious or infectious diseases spreading throughout the hospital. It is the responsibility of the nurse or doctor in charge to inform the photographer if the patient they are about to photograph has a contagious or infectious disease.

The patient will be situated in an isolated room and a notice should be fixed to the door informing visitors of the precautions they must take before entering the room. Visitors are required to put on gloves, mask and a disposable apron. This protective clothing should be worn by all medical photographers at it will reduce the risk of contamination to their hands and uniform.

The camera bag must be left outside and the photographer should only bring the camera equipment which is required into the room. The door to the room should remain shut while any wound dressings are removed and the photographs are being taken as this minimises the spread of infection and maintains the patient’s privacy.

When the photographs have been taken the photographer should dispose of the gloves, mask and apron, wash their hands thoroughly and apply alcohol gel before leaving the room. The photographer should also decontaminate the camera equipment with alcohol wipes.

“…When a patient, however, is highly contagious, the room is so posted and safety precautions are listed. These usually require gowns and masks to be worn by all visitors. When a photographer is called to the room it is essential that all posted precautions be observed. Transmission of infection from the patient to a visitor can occur via three primary routes: (1.) Direct contact, which represents the greatest opportunity for transmission… … (2.) Indirect contact, which would involve touching something which has been contaminated by the patient… … (3.) Via respiratory droplets. This refers to contamination of the air from the patients sneezing and/or coughing. (LeBeau 1992:502).”

Infectious diseases

MRSA (Methicillin Resistant Staphylococcus Aureus) is a strain of Staphylococcus Aureus which is resistant to the group of antibiotics which include methicillin, flucloacillin and cloaxacillin. MRSA infections are increasing in prevalence in UK hospitals, It is therefore essential that medical photographers adhere to infection prevention guidelines when photographing patients who have tested MRSA positive. Barrier nursing should have been implemented and gloves, masks and disposable aprons must be worn by the photographer to prevent contact with any infectious secretions.

HIV (Human Immunodeficiency Virus), AIDS (Acquired Immune Deficiency Syndrome) and Hepatitis B are blood borne viruses which are not easily transmitted in a hospital setting. The viruses are not airborne and cannot penetrate healthy intact skin. They are spread via contact with body fluids and not by close social contact. Hepatitis B is more infectious than HIV and all healthcare workers (including medical photographers) should be vaccinated against it.

Medical photographers should wear gloves and cover any damaged skin with an impermeable dressing before photographing a HIV or Hep B positive patient. A mask and plastic eye shield should also be worn as it is theoretically possible that the HIV virus could transmit across intact mucous membranes in the nose, mouth or eyes, though this has never been recorded. This protective clothing is necessary when photographing open wounds or during surgical procedures where blood and body fluids are present. If protective clothing is not worn the photographer could be put themselves at risk.

The most common way for health care workers to become infected is through needle stick injuries. Medical photographers do not administer injections but they must insure they do not come into contact with discarded needles when photographing infectious patients in a surgical setting. If the photographer is careless they could accidental stick themselves with a needle. In the event of a needle stick injury the photographer should encourage bleeding but without pressing or sucking on the wound. Any incident should be immediately reported to the occupational health department and a HIRS report should be completed recording the source of the contamination, type of fluid and how the injury occurred.

In the event of splashing from body fluids the photographer should wash off splashes with plenty of soap and water. Splashes to the eyes, nose or mouth should be wash out with lots of water, sterile water should be used on the eyes. Any incident should be reported immediately to the occupational health department and a HIRS report should be completed recording the source of the contamination, type of fluid and how the incident occurred.

Intra oral dental photography

Medical photographers are also required to photograph intra oral dental views. This can be quite invasive as dental retractors, tongue depressors and mirrors must be inserted into the patient’s mouth. It is important that gloves are worn during this procedure as saliva and gingival fluids can be infectious.

After the patient’s pictures have been taken the photographer should pack up the used retractors and mirrors and soak them in a germicidal solution or send them away to the sterile services department to be sterilized. The gloves should be removed and the photographer should wash their hands thoroughly.

Specimen photography

The transport of organs and tissue samples to the Medical Illustration Department where I work was discontinued in 2000, this was due to concerns about infection control. Now photographs of specimen are taken in theatre, pathology or the mortuary and photographs of culture plates are taken in microbiology.

“…When an organ or piece of tissue is removed from the body, a process known as autolysis or breaking down of cell structure takes place. This alteration in cell structure can so change the microscopic appearance that diagnosis can be uncertain or even impossible… …Therefore on occasion when both colour and shape are to be recorded accurately, the specimen has to be photographed fresh (Cardew, Lunnon, Tredinnick and Turnbull 1975:7a-2).”

Medical photographers should always wear gloves and an apron when handling specimens as they can be infectious. When the specimen has been positioned the photographer should remove the gloves before handling the camera to avoid any cross-contamination occurring.

Medical photographers also need to be aware of infection control when photographing culture plates. The photographer should put on a full-length white coat and gloves before entering the laboratory to protect their uniform against contamination from micro-organisms. A mask should also be worn to protect the photographer from inhaling any potentially dangerous bacterial spores.

“…Agar plate cultures of bacteria or moulds and tissue cultures of viruses are particularly dangerous because of the high concentration of organisms that they contain. It should be remembered that the simple action of opening a culture plate can create an aerosol or cloud of spores in the air around the photographer. It is routine practice to photograph culture plates with the top section of the plate removed, but one should first consult a laboratory technician to be certain that this is a safe practice. (LeBeau 1992:502).”

Conclusions

I think infection prevention is very relevant to medical illustration, particularly to medical photographers. I believe they need a good working knowledge of infection control to carry out their duties safely and effectively.

Medical photographers have a responsibility to their patients and other healthcare workers to ensure their hands are washed between patients, their camera equipment is decontaminated regularly and the correct protective clothing is worn. If the photographer does not carry out these procedures they could put themselves or the patient at risk. It is therefore essential that medical photographers rigorously adhere to infection prevention policies.

 


References

  1. Cardew, P.N., Lunnon, R.J., Tredinnick, W.D. and Turnbull, P.M. (Eds.) (3rd Edition) .1975. Photography,The sudy guide of the London School of Medical Photography. The London School of Medical Photography Limited.
  2. LeBeau, L.J.1992. From: Health Hazards in Biomedical Photography. In Vetter, J.P. (Ed.) ‘Biomedical Photography’. Focal Press.

References

  1. Cardew, P.N., Lunnon, R.J., Tredinnick, W.D., Turnbull, P.M. (Eds.). (3rd Edition).1975. The Study Guide of the London School of Medical Photography. The
  2. London School of Medical Photography Limited.
  3. Damani, N. N. (2nd Edition).2003. Manual of Infection Control Procedures. Greenwich Medical Media Limited.
  4. Hansell, P (Ed.).1979. A Guide to Medical Photography. MPT Press Limited.
  5. HIV and AIDS Policy and Control of Infection Guidelines. South Manchester Health Authority.
  6. McCulloch, J. (Ed.).2000. Infection Control: Science, Management and Practice. Whurr Publishers.
  7. Meers, P., McPherson, M., Sedgwick, J. (Eds.) (2nd Edition).1997. Infection Control in Health Care. Stanley Thornes (Publishers) Limited.
  8. MRSA Explained. South Manchester University Hospital Trust leaflet.
  9. Shackelford Breckenridge, E.M., Halpert, B. 1953. The Photography of Gross Specimens. Journal of the Biological Photographic Association. 21:1.
  10. Vetter, J.P (Ed.). 1992. Biomedical Photography. Focal Press.
  11. Wilson, J. (2nd Edition).2001. Infection Control in Clinical Practice. Harcourt Publishers Limited.

A tough week to be a medical photographer

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Monday the 22nd of May 2017 is a date that I will never forget, a suicide bomber detonated a bomb he was carrying at the Manchester arena. The bomb had been filled with screws, nuts and bolts intended to act as shrapnel and cause as much physical harm as possible. The device killed 22 adults and children and injured 119, 23 of those critically. I was just getting ready for bed that evening when the news broke; I sat watching the 24 hour news channel in shock trying to process what was happening. How could somebody do this? And in my own city?! Why target innocent children? I watched the stream of ambulances arrive at the scene and became acutely aware that some of the casualties would be taken to the hospital I work at and that I would be required to document their injuries.

This was a unique situation for me as ordinarily I am not aware of the cause of a patient’s injuries before I photograph them. I also consciously avoid, wherever possible, finding out afterwards what caused them. I think, in some respects, this is a coping strategy I have developed, It ensures that I don’t become upset by the trauma I photograph, or get emotionally involved. This detachment makes it easier to document traumatic injuries on a daily basis. I think the camera also separates me from the patient, I only see what I observe through the viewfinder, I see the wound in great detail, but not the patient.

The Manchester terror attack turned my coping strategy on its head; I knew what had happened before I went to work. I knew who I would be photographing and the types of injuries they would have sustained. I was also already emotionally involved and affected by what had happened. It was my city and I was upset and grieving for all the innocent people who had lost their lives or were caught up in this madness. Despite this I was determined to go to work, be professional and get the job done.

That week at work was a blur; we were extremely busy which helped as I didn’t have time to reflect on what I was photographing. Everybody went above and beyond what was expected of them, working extra hours, staying late and going without lunch and tea breaks. It didn’t matter whether they were a surgeon, a doctor, a nurse, a porter or a cleaner everybody had an equally important job to do and they did it well! That weekend I went to pay my respects and lay flowers at St Anne’s Square in Manchester and I finally allowed myself to grieve for the victims and my city and reflect on what I’d photographed.

So what have I learned from this terrible incident? I’ve learned that its okay to adopt coping mechanisms as it helps me be a medical photographer long term; I have also discovered that I can still do my job effectively when forced to work without them. Most importantly, I now have even more admiration and respect for my colleagues and all the NHS staff in Manchester and London who have performed their duties diligently and with such dedication and professionalism in the face of such difficult and sad circumstances.

Dental Photography and the Medical Photographer

dental_photography

Dentistry is a branch of medicine concerned with the prevention and treatment of tooth and gum disorders. Dentistry is divided into several highly specialized areas; endodontics is a branch of dentistry concerned with the treatment and diagnosis of diseases which affect the pulp and roots of the teeth, orthodontics is concerned with the prevention and correction of abnormally aligned teeth and periodontics is concerned with the treatment of abnormal conditions of the gingivae (gums).

Dental photography has emerged as a specialized field within medical photography. Clinical photographs of the oral cavity and teeth are useful to practitioners of all dental specialities as well as to oral and plastic surgeons. External facial views and intra-oral views can be used to document and monitor a number of conditions including malformations of the oral cavity, dental disease, reconstructive surgery and corrective procedures to the teeth. As with all aspects of medical photography standardization is essential to produce consistent, high quality, repeatable images.

Anatomy of the Oral Cavity

It is important that the medical photographer has a good working knowledge of the anatomy and physiology of the oral cavity and teeth. This knowledge enables them to produce accurate, repeatable records of a dental patient’s condition or treatment. The medical photographer should have a good understanding of teeth notation and be aware of common dental terminology. This allows them to accurately locate and document a variety of anatomical structures and pathological conditions within the oral cavity.

Extra-Oral Photography

Most conditions of the face and mouth can be demonstrated by photographing anterior posterior (AP), oblique (45°) and lateral views. An AP and right and left lateral of the patient’s head and shoulders are generally all that are required for extra-oral views, although some consultants may also request oblique views. It is however important that both lateral views are taken to ensure any facial asymmetry shows clearly.

Extra-oral views can be taken with a standard camera and lens set-up using studio lighting. It is essential that the camera plane remains parallel to the anatomical plane and that the patient’s head remains straight when extra-oral views are photographed, otherwise distortion will occur. The photographer will also make sure that the orbito-helix line (outer canthus of the eye to the point on the junction of the helix of the ear to the head) is horizontal when photographing the AP and lateral views.
Figure-1

Intra-Oral Photography and ring flash/point source systems

Macro lenses are required when photographing intra-oral views as the teeth need to be photographed at high magnifications. Typical magnification ratios used for teeth are 1:1 and 1:2. Intra-oral views require maximum depth of field to ensure the entire dentition is sharply focused, therefore the highest aperture should be used.

The oral cavity cannot be lit sufficiently using standard studio lighting, for intra-oral views the source of illumination must be near to the lens axis and mounted at the front of the lens. There are two main methods of lighting the oral cavity, point source and ring flash. Point source is a short straight flash tube, it is called point source as its illumination is directional. The flash unit is mounted near the front of the lens on a flash bracket, this technique illuminates the oral cavity well but can cause shadowing.

Ring flashes have one or more curved flash tubes (the shape of a circle) built into the end of the lens. Ring flashes provide even, shadow-free illumination which is ideal for lighting the oral cavity. The only disadvantage to ring flashes is the distracting reflections which can occur on wet tooth enamel. These reflections can be reduced by asking the patient to swallow their excess saliva or by drying their teeth and gums on a piece of gauze before each photograph.
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Dental retractors and mirrors

Views of the dentition can only be achieved using dental retractors as it is necessary to retract the cheeks and lips from the field of view in order to obtain clear intra-oral pictures. Dental retractors are available in metal, wire and plastic and come in paediatric and adult sizes. Dental retractors (if used properly) should provide both vertical clearance as well as horizontal retraction of the lips.

Dental mirrors can be used alongside retractors, the mirrors are available in glass and plastic and also in paediatric and adult sizes. There are two main types of dental mirrors, occlusal mirrors are designed to fit inside the patient’s mouth. The occlusal mirror can be tilted until the reflection of either the upper or lower dentition is visible, the photographer can then photograph the reflected image of the maxillary or mandibular arch.

Buccal mirrors are used when photographing the buccal surfaces of the posterior teeth. Buccal mirrors are often double ended and the smaller side can be used to photograph the lingual surfaces of the posterior and anterior teeth.

When dental mirrors are placed into the mouth misting can occur which can obscure the reflected image, this problem can be minimised by placing the mirror in a jar of warm water prior to use. It also helps if the patient breathes through their nose and not through their mouth during the procedure.

Medical photographers should be familiar with dental retractors and mirrors and have experience using them on themselves before they attempt to photograph any patients. This is important as retractors and mirrors can be uncomfortable or painful, particularly if the patient has limited jaw movement or mouth lesions. With experience the photographer can take intra-oral photographs quickly and with a minimum of discomfort to the patient. Where mirrors have been used the finished photographs will be a mirror image of the patient’s actual teeth so the photographer must manually reverse the image in photo editing software.

Health and safety issues

Medical photographers have a responsibility to their patients and other healthcare workers to ensure that their camera and dental equipment is sterile and safe to use. They must adhere to infection prevention policies rigorously when performing dental photography. Hands should be washed before and after patient contact and gloves should be worn to prevent the transfer of organisms from patient to photographer or vice versa.

Saliva and blood are both carriers of potentially infectious micro-organisms which can be transferred from the mouth onto dental mirrors and retractors. It is therefore essential that dental retractors and mirrors are sterilized after use to ensure no cross-contamination takes place. After the clinical photographs have been taken the used retractors and mirrors should be placed in a secure container and sent to a sterile services department to be cleaned. If this is not possible the equipment must be thoroughly sterilized in the medical illustration department before it can be reused.

 


Bibliography

Vetter, J.P (Ed.). 1992. Biomedical Photography. Focal Press.
Wander, P., Gordon, P.1987. Dental Photography. The British Dental Association.
Cardew, P.N., Lunnon, R.J., Tredinnick, W.D., Turnbull, P.M. (Eds.). (3rd Edition)
.1975. The Study Guide of the London School of Medical Photography. The London School of Medical Photography Limited.
Hansell, P (Ed.).1979. A Guide to Medical Photography. MPT Press Limited.
Tortora, G.J., Grabowski, S.R. 2003. (10th Edition) Principles of Anatomy & Physiology. John Wiley & Sons, Inc.
Delly, J.G (Ed.). (1st Edition) .1976. Biomedical photography- a Kodak seminar in print. Eastman Kodak Company.
Aldred. M.J., Bagg. J., Hartles. F.R. 1990. Colour teaching aids in oral pathology. JAMM. 13:1 9-11.
Merin. L.M., Mills. R.A. 1995. Intraoral and intranasal photography using a retinal fundus camera. JAMM. 18:1 23-25.
Hyland. G.J. 1986. Photographic planning for maxillary mandibular osteotomies. JAMM. 9:1 10-11.
Damani, N. N. (2nd Edition).2003. Manual of Infection Control Procedures. Greenwich Medical Media Limited.
McCulloch, J. (Ed.).2000. Infection Control: Science, Management and Practice. Whurr Publishers.
Meers, P., McPherson, M., Sedgwick, J. (Eds.) (2nd Edition).1997. Infection Control in Health Care. Stanley Thornes (Publishers) Limited.
Wilson, J. (2nd Edition).2001. Infection Control in Clinical Practice. Harcourt Publishers Limited.

Medical photography and escaping the confines of standardisation

The main role of a medical photographer is to record and document injuries, disease and medical procedures in clinics, on wards, in theatres and in the photographic studio. Adhering to the Institute of Medical Illustrator’s national guidelines enables the photographer to produce views that are standardised and consistent in hospitals up and down the country.

For example, a wound can be photographed on several occasions over a period of time by different medical photographers and each will take the same views at the same magnification. This ensures that an accurate record of the wound’s healing can be documented. Standardisation leaves the clinical images devoid of any artistic input thus guaranteeing a true and accurate representation which can be replicated and repeated. This is why I jump at the opportunity to be a little creative with my photography in other areas of my work.

Clinical photography makes up about 90% of my overall workload but I do have the opportunity to whet my artistic appetite occasionally, memento photography of babies is one example. The death of an infant is devastating and photographs are a tangible and lasting memento that parents can cherish. Each memento session is unique and tailored to the wishes of the family, for example the choice of clothes, blankets and toys photographed with the child. It is one of the most difficult, yet rewarding parts of my job but I get great satisfaction knowing the photographs help bereaved families come to terms with their loss and help in the healing process.

Hospital PR photography gives me another opportunity to be free from the confines of standardisation. Documenting the wards and departments, as well as special events taking place within the hospital can be a pleasant change from the clinical workload. It is also a good source of revenue for medical illustration departments and the proceeds can be used to buy new photographic and lighting equipment.

I recently had the opportunity to take a series of informal staff portraits for a ward and out-patient department. The brief was to capture the doctors, nurses and medical personnel in their working environment. The portraits were designed to present the staff in a friendly, familiar and approachable manner, thereby putting the patients at ease. I really enjoyed this project as I got to be creative with the lighting and composition and I was really happy with the end results.

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The role of the medical photographer in an operating theatre environment

“Photography in the operating theatre is only a small part of a wide field, but it demands not only solidly based technical competence but also the full commitment of the photographer and good co-operation with the surgical personnel” 1

Surgical photography has emerged as a specialized field within medical photography. Clinical photographs taken in operating theatres provide surgeons with precise visual records of surgical procedures and new surgical techniques.

Surgical images are useful for a number of reasons, they can be used for teaching purposes, for publication and for documentary evidence in the patient’s case notes.

Surgical images usually consist of a series of close-up views of an incision site taken at different stages of the procedure. A medical photographer will endeavour to document each stage from the same viewpoint and at the same magnification. This will ensure that the each photograph in the sequence is taken at the same scale. A knowledge and understanding of anatomy and pathology is also needed to help the photographer locate and record the correct features in the incision site.

Surgical photographic techniques

Surgical photography can be more technical than other aspects of clinical photography and specialized lenses and lighting equipment are often required. Close-up views are frequently requested, so a macro lens is essential, this will enable the photographer to record minute features in great detail.

Specialized lighting equipment is also needed when photographing deep into the body as conventional camera flashes are unable to evenly illuminate cavities. In this situation the source of illumination must be near to the lens axis and mounted at the front of the lens. There are two main methods for lighting cavities, point source and ring flash. Point source and ring flash systems provide an even illumination which is ideal for lighting deep body cavities.

Directional theatre lights are very bright and can affect the exposure of the image, they can also create un-wanted colour casts on the final photograph. The photographer will ask for the theatre lights to be turned off each time a photograph is taken to minimise these problems.

The photographer will also ask the surgeon to staunch the blood flow from vessels and mop up any excess blood prior to a photograph being taken. If this blood is not removed it may obscure the underlying anatomy and create distracting reflections on the final image.

Metal retractors and clamps are used by the surgeon to gain access to the incision site. These instruments can also create distracting reflections, sometimes it is not possible for them to be removed for the photograph. In this situation the photographer will ask the surgeon to tilt the instruments as this can often minimise the reflections.

A medical photographer will, wherever possible avoid photographing an untidy surgical field as it can appear distracting on the final image. Unnecessary surgical instruments and used swabs should be removed from the field of view. The replacement of bloody and wet drapes is also preferred.

Consent

“Patients have a fundamental legal and ethical right to determine what happens to their own bodies. Valid consent to treatment is therefore absolutely central in all forms of healthcare, from providing personal care to undertaking major surgery. Seeking consent is also a matter of common courtesy between healthcare professionals and patients.” 2

Clinical photographs can only be taken if the patient has given their consent. The patient can only give informed consent if they are fully aware of the reason for the photographs and know what the photographs will be used for.

Photographs which are taken for the patient’s case notes cannot be used for publication or research purposes unless specific written consent is given by the patient. Photographic images may be used within the clinical setting for teaching purposes without specific consent if there is no possibility of the patient being recognised.

Specific written consent must always be sought if the photographs are to be used for publication. The patient should be informed that they can view the images that have been taken before deciding whether to give consent for the photographs to be published. The patient must receive information on the possible future uses of the photographs and be made aware that it may not be possible to withdraw their consent once the images are in the public domain. If the patient then decides they are not happy for the images to be used for publication the images must be destroyed.

The patient is usually unconscious when surgical photographs are requested. The photographer may take the photographs in the operating theatre without the patient’s consent but must seek written consent as soon as the patient is conscious. If the patient then refuses consent, the surgical images must be destroyed.

Sterile and non-sterile areas

Operating theatres contain sterile areas and special infection control protocols must be observed before entering. Theatres are subject to meticulous daily cleaning regimes, they must be kept clean at all times and have a working ventilation system to keep the theatre dust free. Decontamination and aseptic procedures must be strictly adhered to.

The theatre floor should be cleaned thoroughly on a daily basis and floors and surfaces should be damp-dusted between operations to remove any spillages of blood or body fluids. To reduce airborne contamination the movement of people in and out of the theatre should be kept to a minimum and the theatre door should be kept closed where possible to ensure the efficiency of the ventilation system.

All healthcare workers must change out of their uniforms and put on clean, un-contaminated clothes before entering an operating theatre. This clothing protects the patient and healthcare workers from potential infection from pathological micro-organisms.

There are two main types of theatre clothing (sterile and non-sterile). Sterile gowns should be worn by the surgeons and the scrub nurses as they have direct contact with the sterile field, i.e. the draped patient and the instrument table. The sterile long sleeved gowns are designed to resist wetting, tearing and bacterial penetration. Surgeons and scrub nurses must also observe strict hand washing procedures and wear sterile gloves.

Healthcare workers (including medical photographers) don’t have direct contact with the surgical field and can wear non-sterile clothing which usually consists of trousers and a short sleeved top.

Non-sterile clothing is usually made of a poly-cotton material, it is not as effective as sterile gowns and, if soiled, can allow bacteria and body fluids to penetrate the weave. If non-sterile clothing does get contaminated with body fluids it is advisable to remove it and put on a clean outfit as soon as possible. When the procedure is complete all theatre clothing should be removed and placed in a specified dirty linen bin.

It is usual practice for the sterile drapes and gowns to be green and the non-sterile clothing to be a different colour. This makes the sterile field easier to identify, and therefore easier to avoid.

As close-up views of the surgical procedure are often requested, the photographer must stand next to the sterile field. The photographer must ensure they don’t touch or rub against any sterile areas, for example the instrument table, surgeons, scrub nurses or patient. If the photographer does touch a sterile area they must tell the surgeon immediately and the drapes, clothing or instruments can be replaced.

Safe working practices

The most important thing a medical photographer should do before and after photographing each patient is wash their hands. This is necessary as it prevents the hands from becoming contaminated with micro-organisms. If the hands were not washed cross-contamination could occur. This is especially important when photographing a surgical procedure in an operating theatre environment.

The use of protective clothing such as a surgical mask, theatre clogs and hair net is also essential to avoid contaminating the theatre or incision site. Outside shoes should never be worn in an operating theatre as they harbour bacteria and could contaminate the floor. The hospital should supply non-slip, anti-static theatre clogs which can be washed after use. Hair nets should also be worn to prevent loose hair and skin from falling on the incision site or sterile areas.

Medical photographers should wear masks when photographing patients in operating theatres, or when they are in close contact with patients undergoing any form of surgical procedure. This is necessary as masks trap any organisms exhaled by the photographer. A fresh mask should be worn for each procedure and masks should be replaced when they become damp, as damp masks no longer deflect organisms. At the end of the procedure the mask should be removed and placed in a yellow clinical waste bin.

The photographer’s camera bag should be left outside the theatre and the photographer should only bring in the camera equipment which is needed. It is imperative that the photographer decontaminates this camera equipment with alcohol wipes before entering the theatre. If the photographer doesn’t disinfect their equipment they could inadvertently introduce micro-organisms into the incision site.

The photographer should display their identity badge clearly so that the other theatre staff know who they are and will not ask them to perform tasks they are not trained to do, for example help transfer the patient from the bed to the operating table.

The photographer should always let the surgeon know when they are about to take a photograph and should never deploy the flash without warning. If they do they might distract the surgeon at a critical point in the procedure. The photographer should also make sure they are not in the way and should only step up to the table when a photograph is being taken. This will prevent the surgeons and scrub nurses from bumping into the photographer and contaminating their sterile clothing.

X-rays and lasers

Portable x-ray machines are often used in operating theatres as they are a useful diagnostic tool. An image is produced on photographic film by passing electromagnetic radiation through parts of the body. Dense structures such as bone absorb the x-rays and appear as lighter regions on the developed film.

Precautions should be taken to protect theatre staff from the damaging effects of occupational exposure to x-rays as radiation has the potential to cause mutations in the germ cells that may then be passed on to future generations. Pregnant theatre staff should avoid all exposure to x-rays as the radiation can also cause foetal abnormalities. Theatre staff can limit their exposure by wearing special protective clothing such as a lead apron.

Lead aprons are very effective at absorbing diagnostic x-rays to the parts of the body shielded by the apron. The aprons contain lead and often other metals such as tin, tungsten, antimony and barium. These metals are mixed with synthetic rubber or polyvinyl chloride (PVC). Sheets of the metal impregnated rubber/PVC are placed between sheets of nylon fabric which has been coated with urethane. This material is then cut into a pattern and sewn together to form the protective apron.

When an x-ray is taken the number of people present in the theatre should be limited to those performing the procedure, all other theatre staff, including medical photographers should leave the theatre. If the photographer needs to be present for any reason a lead apron must be worn.

Laser surgery is also performed in operating theatres. A laser is a device which absorbs electromagnetic energy and re-radiates it as a highly focused beam of single wavelength radiation. The wavelength of the beam determines its colour and different wavelengths have distinct effects on the body.

Carbon dioxide and infra-red lasers have a long wavelength which is easily absorbed by water in the cells. Long wavelengths are very effective at cutting through tissue. Argon lasers have a shorter wavelength which is not readily absorbed by water. Argon lasers are used in ophthalmic surgery to shine through the liquid in the eyeball and treat the retina.

Laser surgery can be hazardous for theatre staff. If the light from a laser is transmitted directly or reflected into the eye it could burn the retina causing a permanent blind spot. If the beam of light hits the head of the optic nerve it could cause partial or total blindness. Infra-red lasers can be more hazardous to theatre staff as the beam of light cannot be seen by the naked eye.

Theatre staff must wear well fitting eye protection for all laser procedures. The type of goggles required depends on the wavelength of the laser. The glass in the goggles consists of alternate layers of two different optical materials (Bragg mirrors). Each optical layer reflects a certain wavelength. This stops the harmful wavelengths from entering the eye and damaging it.

Modern laser safety goggles are labelled with the wavelengths that the goggles protect from and the strength of the goggles. This information should correspond exactly with the information on the laser. It is vital that the correct goggles are worn, if the wrong ones are selected they will offer no protection from the laser beam.

Conclusion

Medical photographers have a responsibility to the patient and other healthcare workers to ensure that they wear the correct protective clothing. The photographer must also have a working knowledge of sterile and non-sterile areas within the theatre. If the photographer is not aware of the correct protocols they could put themselves, the patient and surgical staff at risk. It is therefore essential that medical photographers rigorously adhere to theatre protocols when photographing surgical procedures.

 


References

  1. Hansell, P., (Ed.) 1979. A Guide to Medical Photography. MPT Press Limited.
  2. South Manchester University Hospital NHS Trust. 2006. Consent to examination or treatment policy. SMUHT.

Healing Histories: An Exhibition of Medical Marvels and Curative Curiosities.

Yesterday I attended a pop-up exhibition at the Central library in Manchester displaying some of the rarest objects from The Manchester Museum of Medicine and Health archives 1. The exhibition was curated by students in the Art Gallery and Museum Studies Master programme, with help from staff at the Museum.

“Healing Histories explores the curious and inspiring past of health and medicine, celebrating discoveries, exploring the unappreciated and highlighting important objects that tell our collective stories.” 2

Exhibition space.

healing_histories_exhibition_space

The exhibition was divided into six different themed areas:

  1. Medical Milestones.
  2. Unpacking the Doctor’s Bag.
  3. Toils of Labour: A Brief Social History of Childbirth
    and Women’s Health.
  4. School of Curiosities.
  5. Healthcare at Home: Fact or Fiction?
  6. Take Care.

I really enjoyed the exhibition and found the objects on display fascinating. The six distinct areas were well laid out and visually engaging and there were plenty of knowledgeable students around to answer questions as well as informative, well designed leaflets and postcards. Here are some of my highlights:

 

Leather Gladstone bag c.1910-1920.

healing_histories_doctor_bag

Unpacking the Doctor’s Bag looked at the iconic image of the doctor and his Gladstone bag. It let us explore the world of the twentieth century doctor and the medical instruments they took with them on home visits.

 

Forceps – 1791-1876.

healing_histories_forceps

I also really enjoyed the Toils of Labour exhibit which consisted of obstetric and gynaecology instruments from the nineteenth and twentieth centuries. It explored the changing relationship between male doctors and female patients during childbirth in the nineteenth century.

“The emergence of modern obstetrics and gynaecology in the newly industrialising western cities of the 19th century is inseparable from the invention of new forms of male heroism: the gentlemanly, urban physician was now expected to apply not only force but also reason to the body of his patient. However, for the woman in childbirth, the first experience often remained pain. Which now without the exclusive, female solidarity of the “midwife”, often had to remain silent.” 3

 

The Embryonic Development of the Human Eye Lens – Late 19th Century.

healing_histories_embryo_retinal_models

The School of Curiosities exhibit included a rare set of late nineteenth century plaster models which represented the growth of the eye in a foetus from 37 days to six months. They were made by Dr Otto Becker, a professor of ophthalmology in Germany. They were made as gifts for honoured guests that attended the Heidelberg ophthalmology congress in 1888.

 

Lantern slides – late 19th / early 20th Century.

healing_histories_slides

Lantern slides were used by medical lecturers as teaching aids, they were the precursor to modern digital presentations. The slides on display were used by Dr William Stirling in his lectures whilst he was a professor of Physiology at Victoria University in Manchester from 1886-1919.

 

Nurse Annabelle.

healing_histories_nurse_annabelle

The Take Care theme was based on a fictitious nurse called Annabelle Bolland who wrote a diary spanning her career in nursing. It cleverly introduced the items on display in an interesting and unique way.

Nurse Annabelle had her own twitter account which I followed in the weeks leading up to the exhibition. Her tweets included excerpts from her diary and witty, amusing insights.

“Do you like my profile pic? My friend Margaret did it! I wish Instagram already exsisted in the 20th century.
#takecare #nurse” 4

The way the event utilised social media to generate interest was one of the most fascinating and enjoyable aspects for me. I first heard about the exhibition on twitter5 two months before it took place. Every few days I was given a sneaky glimpse of an object that would be going on display asking me to guess its use or purpose. The tweets also gave an insight into what it was like to curate and install an exhibition. It was a brilliant way to advertise the event and I was really excited to see it by the time the day arrived!

I’m really pleased this exhibition gave me the opportunity to see some of the rare and wonderful medical artefacts housed in The Manchester Museum of Medicine and Health archives, especially as the museum doesn’t have any permanent displays or galleries and isn’t open to the public. This brilliant exhibition has whet my appetite and I would love to have to opportunity to explore the archives more!

 


References

  1. Manchester Museum of Medicine and Health website (http://sites.bmh.manchester.ac.uk/museum).
  2. Healing Histories website (https://healinghistories.wordpress.com/).
  3. Quoted from exhibit display.
  4. Quoted from the Nurse Annabelle twitter account (https://www.twitter.com/@Nurse_Annabelle).
  5. Healing Histories Exhibition twitter page (https://twitter.com/HHistoriesPopup).

Top 5 Christmas Anatomy Themed Gifts

Greg A Dunn Fine Art Prints

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Greg Dunn earned a PhD in neuroscience in 2011 before becoming a professional artist and devoting his time to painting. The patterns of branching neurons he saw through the microscope reminded him of the aesthetic principles of Asian art.

While much of his work focuses on neurons he also explores other tissue types, such as glia and non-neuronal brain cells. This print focuses on the layered structure of the retina which is designed to both collect light and integrate basic visual information before it is sent to higher order cortical structures for detailed processing.

Retina in Inks Print 16″  X 24″  (40.6cm X 61cm) – $150.00 See it ›

 

The Sick Rose (or; Disease and the Art of Medical Illustration)

the_sick_rose_book

‘A beautifully gruesome and strangely enthralling visual tour through disease in the age before colour photography’

A book of exquisitely detailed medical illustrations from some of the worlds rarest medical books compiled by Richard Barnett and including historic maps, charts, medical instruments and case notes.

ISBN 9780500517345 – £19.95 See it ›

 

Histology Plates (set of four)

plates

This set comprises of histology plates of the testicle, thyroid, oesophagus and liver. The plates are 21cm in diameter and handmade from bone china.

Set of four – £110.00 See it ›

 

The Anatomical Venus

anatomical-venus-spread-2

Clemente Susini’s wax Anatomical Venus (c.1790) lies in a Venetian glass and rosewood case at La Specola, Florence. She was created as a means to teach human anatomy without the need for dissection. She can be dismembered into dozens of parts until finally revealing a foetus in her womb. Shortly after Susini’s wax Venus was introduced many anatomical Venus’ started appearing throughout Europe.

In this book Joanna Ebenstein explores these female wax models and reveals their evolution from medical teaching aid to fetish figure. Looking at the intersection between life, death, science, religion, body and soul.

ISBN 9780500252185 – £19.95 See it ›

 

Plush Organs

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These plush organs were created by anatomically obsessed illustrator Wendy Bryan Lazar. There are 30 different organs to choose from, I have shown three of my favourites: lungs, uterus and skin plush.

$20.00 each See it ›