Transcript
Page 1: Medical Photography: a Trinidad Experience

Medical Photography: a TrinidadExperience

RICHARD SPENCE

In 1991, the creation of the Media Unit at the St.Augustine Campus, University of West Indies, firstestablished medical illustration as an organized profes-sion within the public healthcare provision of Trinidadand Tobago. Since then the Unit has overcome manydifficulties, some of them unusual for medical illustra-tors in the developed world, not least in obtainingequipment unavailable in the country, in findingsuitable working facilities, and in developing practicesfor veterinary work. Today the Media Unit services awide range of the University’s schools, clinics andmedia services, and has been instrumental in educatinga new generation of healthcare professionals.

Trinidad and Tobago is a twin-island republic at the

southern end of the Caribbean archipelago, just off

the South American mainland. Trinidad is home to the

St Augustine Campus of the University of the West Indies,

a regional university whose other main campuses are in

Jamaica and Barbados. The St. Augustine Campus

evolved from Imperial College of Tropical Agriculture,

which was of world renown in its time. The Medical

Faculty at St. Augustine – consisting of the Schools of

Medicine, Veterinary Medicine, Pharmacy and Dentistry –

initiated its degree programme in 1989, which coincided

with the commissioning of a new multimillion-dollar

medical facility, known as the Eric Williams Medical

Sciences Complex (Figure 1). This facility houses an 800-

bed general hospital, a paediatric hospital, a women’s

hospital, a dental hospital and a veterinary hospital; its

state-of-the-art facilities include the largest medical-

sciences library in the English-speaking Caribbean.

The Media Unit came into being in 1991, when a

graphic artist and the author, as medical photographer,

were first hired. The complement was subsequently

increased by hiring a second graphic artist, an audiovisual

technician, an IT-specialist, a darkroom assistant, two

print-room attendants, and two clerical staff. Staff learned

the rudiments of the profession from a British medical

photographer, D. A. Gibson, who became Director of the

Media Services Unit at Dalhousie University, Canada.

Part of our mission in the early years was to set up

audiovisual facilities throughout all teaching areas; work-

ing in a small institution like ours requires that you be

multi-faceted. Without the benefit of the Internet, we had

to procure equipment that was generally not available

locally, install systems, and operate and service everything

correctly. Initially we deployed twenty-five projectors,

along with screens and overhead monitors wherever

needed. It is safe to say we gained a lot of practical

experience in quick time, and working practices have been

transformed in the intervening years. In order to

appreciate the diversity of the workload of the Media

Unit fully, I shall offer a brief look at the services we

provide and the problems we have had to overcome in

setting them up.

The Medical School

The Medical School requests clinical and operating room

photography for the general and paediatric hospitals, as

well as the women’s hospital, which also incorporates a

neonatal unit. Most clinical photography is performed at

the bedside or in clinics, whilst surgeons operate from any

of six operating theatres, where we may be called at a

moment’s notice to record a procedure.

A major constraint on the service is the unavailability of

a patient studio. The planners of the Complex did foresee

this need, and even made provision: there is a wonderful

Correspondence author: Richard Spence, Medical Photographer, Centerfor Medical Education, Faculty of Medical Sciences, University of WestIndies, Eric Williams Medical Sciences Complex, St. Augustine,Trinidad. E-mail: [email protected]

Figure 1. The teaching facilities at the Eric WilliamsMedical Sciences Complex.

Journal of Audiovisual Media in Medicine, Vol. 27, No. 2, pp. 68–71

ISSN 0140-511X printed/ISSN 1465-3494 online/04/020068-04 # 2004 Institute of Medical Illustrators

DOI: 10.1080/01405110410005110310

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Page 2: Medical Photography: a Trinidad Experience

suite of rooms, located conveniently on a ward for easy

access, which consists of a large studio space, changing

rooms, a darkroom, a finishing room, and two offices. I

have tried relentlessly to convince the clinicians of the need

to achieve standardization in our clinical photography, but

despite all efforts to acquire the suite, it continues to be

used for the storage of out-dated computers and

redundant biomedical equipment. This situation may

bewilder some, but many will recognize that marriages

between universities and hospital-trust companies can

often become strained because there are not always

common interests and goals. Nevertheless we have learnt

to make the best of the situation: patients are photo-

graphed against walls in clinics and on wards, avoiding

unwanted background details and shadows; often we

drape material to act as backgrounds when a more suitable

one cannot be found. Generally, one has to assess each

situation and determine the best approach for the shoot.

Patients in the women’s hospital do not have access to a

female photographer, but gynaecological photography is

never carried out without the presence of a nurse or a

doctor as a chaperon, and consent rights are respected, as

is the case with all our photography. Neonatal photo-

graphy can be challenging because the delicate nature of

the patients requires that the photographer work in as

short a time and with as little intervention as possible.

A busy area is the autopsy room: individual cases are

recorded mainly for pathology grand-rounds, in which a

student can follow an entire pathological examination

without having to endure the unpleasantness of the

examination itself. The Pathology Unit recently set

about establishing a pathology museum, which contains

specimens and case-notes of some of these cases. The

Media Unit was responsible for producing laminated case-

study reference manuals, which include both photographs

and text. The photography would have been much less

difficult if the specimens could have been photographed

before their pots were sealed; nevertheless we were able to

bounce light from the ceiling to minimize reflections and

produce reasonable slides, which we subsequently scanned

and annotated.

Later we were asked to photograph similar specimens in

pots for the Anatomy Unit. This time we had the benefit

of digital photography so a slightly different approach was

taken, employing tungsten video-lights instead of the on-

camera flash. Black velvet was used as a background and

light was bounced off the ceiling from the rear. This

modeling capability allowed us to position the lights so as

to minimize reflections; being able to view the image

immediately on the digital camera was a big plus. The

images were retouched with the simple use of the smudge

tool in Microsoft PhotoEditor, further removing reflec-

tions off the pots (Figure 2). Plans are afoot to produce an

instructional CD using these images.

Petri-dish photography, which is often requested by the

microbiologists, has specific lighting challenges: our copy-

stand allows us to employ different lighting effects, which

are crucial to the final success of the photograph.

The Media Unit’s work has been integral to the success

of the biochemistry postgraduate-research programme.

The photographic record we make of their research

findings, by means of electrophoresis-gel photography,

has helped to produce five doctorates in ten years, as

well as numerous scientific publications. The Complex

Ophthalmic Unit has never been opened so all ophthalmic

work is performed in another hospital. Unfortunately, that

institution lacks a fundus camera (there are only two in the

country) so the author works in the ophthalmic surgeon’s

private clinic using an old but reliable Phillips camera to

record interesting cases used in teaching (Figure 3).

The Dental School

The Dental School runs a polyclinic, which allows patients

to access dental care at a reduced cost so the clinic is kept

busy. Under the supervision of practicing dentists,

students are able to develop skills and gain exposure to

a wide range of dental conditions. Requests for intra-oral

photographs arise on a regular basis; these are typically for

use in case-conferences and sometimes for publication

(Figure 4). We are often called to photograph maxillo-

facial cases, for which before-and-after comparison needs

Figure 2. Photograph of a prosected specimen of theright foot.

Medical Photography: a Trinidad Experience 69

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to be available. Intricate head and neck surgeries are

recorded using still-photography as well as video. Assist-

ance is given to oral pathology through photomicrography

as well as gross-specimen photography. We also do a lot of

small-object photography, particularly of dental models

and casts. This service is in great demand to demonstrate

dental implant techniques.

Video has proved to be a useful tool in dental education.

In order to facilitate a request from Professor Douglas

Allan, we set up a live television system that allows

students to follow procedures with a much closer

perspective than was previously possible. In 1994 alone

we managed to produce forty-eight instructional tapes

on topics such as stainless-steel wire manipulation in

dentistry; these tapes are used extensively by students so

we are hoping to update them and make them available on

DVD format.

The Veterinary School

The multi-disciplinary approach of the Faculty is evident

in cases such as the heart surgery of a pig, when

cardiovascular specialists and vets may share a common

patient. Apart from slides taken for teaching purposes,

there is often a need for video footage in both the

operating room and the field. Numerous surgical proce-

dures are videotaped for use in teaching, and motion

studies are recorded for clinical evidence (Figure 5). In

addition, there are frequent requests for radiographs to be

reproduced for publication, so our in-house processing

laboratory is still in use despite the availability of digital

technology.

Patients in the Veterinary Hospital and its clinics can

vary drastically in anatomy, size and temperament, so it is

necessary for the photographer to be receptive to all these

parameters in order to photograph effectively. In the

clinical situation, proper restraint of the patient is often

the key to success. Post-mortem photography can also

present a challenge because specimens can be so large that

the photographer has to climb a ladder to establish a

suitable working distance. However, many of our cases are

published so good photography with proper anatomical

orientation is essential to the pathologists’ work.

The Pharmacy School

When the Faculty’s pharmacy programme began a few

years ago, the Media Unit made recommendations for the

installation of a television system which could be used to

monitor the laboratory as well as the over-the-counter

practices of students. Sessions are edited, then reviewed

and critiqued by lecturers and students. We now maintain

the system, and train pharmacy technicians to carry out

basic analogue editing.

In-House Production

Regardless of the discipline, there has always been a

demand for teaching material. Initially our main output

was copy slides: most teaching was done with diazo-type

Vericolor slides, which could be produced easily and

inexpensively from type or line drawings, and also with

published material copied onto Ektachrome film. We were

soon producing over 10,000 slides per year. Towards the

mid-1990s, clients began to demand elaborate computer-

generated slides. However, with no film-recorder availableFigure 4. Intra-oral view.

Figure 5. Videotaping an equine surgical procedure inthe large animal theatre.

Figure 3. Clinical photograph showing a conjunctivalnaevus of the right eye (15-year-old patient).

70 Richard Spence

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Page 4: Medical Photography: a Trinidad Experience

in the country, we adopted an unorthodox method of

recording: with a sturdy tripod and the lights out, we

mastered how to copy the images from computer screens.

At the millennium, the Faculty invested in a local-area

network based on Dell computers; training courses in

Microsoft PowerPoint were provided, and lecturers and

clinicians became more self-sufficient. This development,

along with the acquisition of a high-end Nikon D1X

digital-camera, has resulted in an 84% reduction in

laboratory costs over four years; even those who initially

resisted now use laptops and multimedia projectors for

teaching, and our slide-projectors have almost become

obsolete. We still do a lot of copy work but most is now

done digitally and delivered in CD-format.

The digital camera has also had a significant impact

on our student-ID database: previously we would photo-

graph students with colour-negative film, then mount

and scan each frame to be processed in Adobe Photo-

Shop, a job that would take at least two weeks. Now,

with digital technology, photographs of all new students,

with names in alphabetical order, can be made available

the day after registration. A new marketing strategy

recently adopted by the University has resulted in a

marked increase in calls for promotional photography,

both for the Faculty and the campus; the author also

contributes photography for the in-house magazine, ‘St

Augustine News’ (Figure 6).

Video as a Teaching Tool

At its inception the Media Unit recognized the importance

of video as a teaching tool in the medical sciences, and

invested so as to be able to produce near broadcast-quality

videos in house. An elaborate editing suite was ordered,

and technicians travelled from the United States to install

it; but they could not get it to work and decided to forfeit

their final payment rather than continue trying. The Media

Unit was lumbered with a big white elephant. For many

years consultants were brought into advise us about how

to make it function. In the meantime technology was

changing, so it was decided to make the suite compatible

for both analogue and digital video. We have now come to

the point where we should simply throw most of this

equipment out and replace it with a Macintosh G5

computer and the latest version of Final Cut Pro. We

expect to move into web-based teaching during the coming

years, so have obtained provisional approval to purchase a

couple of high-end DV-cameras. This time we are hoping

that the cameras arrive before the technology leaves us.

Audio-visual Support

The Media Unit has worked relentlessly to ensure that we

deliver audio-visual support, which can compare with that

of any international university. The service would normally

make staff available to set up sound-systems and operate

as a projectionist and/or videographer. Apart from servicing

lecture theatres for teaching, we provide this service for

medical fraternities throughout the country, and have

successfully run major international medical conferences.

Until recently the major challenge was to switch from

slide-projection to dual-slide projection, then to Microsoft

PowerPoint, then back to slides again. Thankfully, the

playing field seems to have been levelled and everybody

uses PowerPoint; now we typically worry about whether

or not the video-file will open and, of course, always have

a back-up multimedia projector close by.

Summary

Medical Illustration has been so encrypted into the

practice of medicine in the developed world that the

idea of a university hospital without medical photography

services at its disposal may seem unimaginable. However,

prior to the establishment of the Media Unit, the reality in

Trinidad was that photography of medical cases was

dependent upon the relevant clinician’s own expertise and

interest – or lack thereof. For example, in Trinidad in the

1930s Dr. Lennox Pawan conducted globally important

research on the transmission of rabies by vampire bats, but

there are few useful photographs of this work. Perhaps

today his research would be captured on video: through

the Media Unit, the University of the West Indies has been

able to set national standards in medical photography.

However, the pressure to stay on top of appropriate

technological change, if we are to maintain these

standards, cannot be underestimated. Then again, if the

going gets tough, I can always head to the beach.Figure 6. The Media Unit assits in the design of the in-house magazine ‘STAN’.

Medical Photography: a Trinidad Experience 71

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