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.

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.
figure-2

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.