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.

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.