Medical Photography: a Trinidad Experience

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Medical Photography: a TrinidadExperienceRICHARD SPENCEIn 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 Universitys schools, clinics andmedia services, and has been instrumental in educatinga new generation of healthcare professionals.Trinidad and Tobago is a twin-island republic at thesouthern end of the Caribbean archipelago, just offthe South American mainland. Trinidad is home to theSt Augustine Campus of the University of the West Indies,a regional university whose other main campuses are inJamaica and Barbados. The St. Augustine Campusevolved from Imperial College of Tropical Agriculture,which was of world renown in its time. The MedicalFaculty at St. Augustine consisting of the Schools ofMedicine, Veterinary Medicine, Pharmacy and Dentistry initiated its degree programme in 1989, which coincidedwith the commissioning of a new multimillion-dollarmedical facility, known as the Eric Williams MedicalSciences Complex (Figure 1). This facility houses an 800-bed general hospital, a paediatric hospital, a womenshospital, a dental hospital and a veterinary hospital; itsstate-of-the-art facilities include the largest medical-sciences library in the English-speaking Caribbean.The Media Unit came into being in 1991, when agraphic artist and the author, as medical photographer,were first hired. The complement was subsequentlyincreased by hiring a second graphic artist, an audiovisualtechnician, an IT-specialist, a darkroom assistant, twoprint-room attendants, and two clerical staff. Staff learnedthe rudiments of the profession from a British medicalphotographer, D. A. Gibson, who became Director of theMedia Services Unit at Dalhousie University, Canada.Part of our mission in the early years was to set upaudiovisual facilities throughout all teaching areas; work-ing in a small institution like ours requires that you bemulti-faceted. Without the benefit of the Internet, we hadto procure equipment that was generally not availablelocally, install systems, and operate and service everythingcorrectly. Initially we deployed twenty-five projectors,along with screens and overhead monitors whereverneeded. It is safe to say we gained a lot of practicalexperience in quick time, and working practices have beentransformed in the intervening years. In order toappreciate the diversity of the workload of the MediaUnit fully, I shall offer a brief look at the services weprovide and the problems we have had to overcome insetting them up.The Medical SchoolThe Medical School requests clinical and operating roomphotography for the general and paediatric hospitals, aswell as the womens hospital, which also incorporates aneonatal unit. Most clinical photography is performed atthe bedside or in clinics, whilst surgeons operate from anyof six operating theatres, where we may be called at amoments notice to record a procedure.A major constraint on the service is the unavailability ofa patient studio. The planners of the Complex did foreseethis need, and even made provision: there is a wonderfulCorrespondence 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: spencephoto@yahoo.comFigure 1. The teaching facilities at the Eric WilliamsMedical Sciences Complex.Journal of Audiovisual Media in Medicine, Vol. 27, No. 2, pp. 6871ISSN 0140-511X printed/ISSN 1465-3494 online/04/020068-04 # 2004 Institute of Medical IllustratorsDOI: 10.1080/01405110410005110310J Vis Commun Med Downloaded from by Osaka University on 12/08/14For personal use only.suite of rooms, located conveniently on a ward for easyaccess, which consists of a large studio space, changingrooms, a darkroom, a finishing room, and two offices. Ihave tried relentlessly to convince the clinicians of the needto achieve standardization in our clinical photography, butdespite all efforts to acquire the suite, it continues to beused for the storage of out-dated computers andredundant biomedical equipment. This situation maybewilder some, but many will recognize that marriagesbetween universities and hospital-trust companies canoften become strained because there are not alwayscommon interests and goals. Nevertheless we have learntto make the best of the situation: patients are photo-graphed against walls in clinics and on wards, avoidingunwanted background details and shadows; often wedrape material to act as backgrounds when a more suitableone cannot be found. Generally, one has to assess eachsituation and determine the best approach for the shoot.Patients in the womens hospital do not have access to afemale photographer, but gynaecological photography isnever carried out without the presence of a nurse or adoctor as a chaperon, and consent rights are respected, asis the case with all our photography. Neonatal photo-graphy can be challenging because the delicate nature ofthe patients requires that the photographer work in asshort a time and with as little intervention as possible.A busy area is the autopsy room: individual cases arerecorded mainly for pathology grand-rounds, in which astudent can follow an entire pathological examinationwithout having to endure the unpleasantness of theexamination itself. The Pathology Unit recently setabout establishing a pathology museum, which containsspecimens and case-notes of some of these cases. TheMedia Unit was responsible for producing laminated case-study reference manuals, which include both photographsand text. The photography would have been much lessdifficult if the specimens could have been photographedbefore their pots were sealed; nevertheless we were able tobounce light from the ceiling to minimize reflections andproduce reasonable slides, which we subsequently scannedand annotated.Later we were asked to photograph similar specimens inpots for the Anatomy Unit. This time we had the benefitof digital photography so a slightly different approach wastaken, employing tungsten video-lights instead of the on-camera flash. Black velvet was used as a background andlight was bounced off the ceiling from the rear. Thismodeling capability allowed us to position the lights so asto minimize reflections; being able to view the imageimmediately on the digital camera was a big plus. Theimages were retouched with the simple use of the smudgetool in Microsoft PhotoEditor, further removing reflec-tions off the pots (Figure 2). Plans are afoot to produce aninstructional CD using these images.Petri-dish photography, which is often requested by themicrobiologists, has specific lighting challenges: our copy-stand allows us to employ different lighting effects, whichare crucial to the final success of the photograph.The Media Units work has been integral to the successof the biochemistry postgraduate-research programme.The photographic record we make of their researchfindings, by means of electrophoresis-gel photography,has helped to produce five doctorates in ten years, aswell as numerous scientific publications. The ComplexOphthalmic Unit has never been opened so all ophthalmicwork is performed in another hospital. Unfortunately, thatinstitution lacks a fundus camera (there are only two in thecountry) so the author works in the ophthalmic surgeonsprivate clinic using an old but reliable Phillips camera torecord interesting cases used in teaching (Figure 3).The Dental SchoolThe Dental School runs a polyclinic, which allows patientsto access dental care at a reduced cost so the clinic is keptbusy. Under the supervision of practicing dentists,students are able to develop skills and gain exposure toa wide range of dental conditions. Requests for intra-oralphotographs arise on a regular basis; these are typically foruse in case-conferences and sometimes for publication(Figure 4). We are often called to photograph maxillo-facial cases, for which before-and-after comparison needsFigure 2. Photograph of a prosected specimen of theright foot.Medical Photography: a Trinidad Experience 69J Vis Commun Med Downloaded from by Osaka University on 12/08/14For personal use be available. Intricate head and neck surgeries arerecorded using still-photography as well as video. Assist-ance is given to oral pathology through photomicrographyas well as gross-specimen photography. We also do a lot ofsmall-object photography, particularly of dental modelsand casts. This service is in great demand to demonstratedental implant techniques.Video has proved to be a useful tool in dental education.In order to facilitate a request from Professor DouglasAllan, we set up a live television system that allowsstudents to follow procedures with a much closerperspective than was previously possible. In 1994 alonewe managed to produce forty-eight instructional tapeson topics such as stainless-steel wire manipulation indentistry; these tapes are used extensively by students sowe are hoping to update them and make them available onDVD format.The Veterinary SchoolThe multi-disciplinary approach of the Faculty is evidentin cases such as the heart surgery of a pig, whencardiovascular specialists and vets may share a commonpatient. Apart from slides taken for teaching purposes,there is often a need for video footage in both theoperating room and the field. Numerous surgical proce-dures are videotaped for use in teaching, and motionstudies are recorded for clinical evidence (Figure 5). Inaddition, there are frequent requests for radiographs to bereproduced for publication, so our in-house processinglaboratory is still in use despite the availability of digitaltechnology.Patients in the Veterinary Hospital and its clinics canvary drastically in anatomy, size and temperament, so it isnecessary for the photographer to be receptive to all theseparameters in order to photograph effectively. In theclinical situation, proper restraint of the patient is oftenthe key to success. Post-mortem photography can alsopresent a challenge because specimens can be so large thatthe photographer has to climb a ladder to establish asuitable working distance. However, many of our cases arepublished so good photography with proper anatomicalorientation is essential to the pathologists work.The Pharmacy SchoolWhen the Facultys pharmacy programme began a fewyears ago, the Media Unit made recommendations for theinstallation of a television system which could be used tomonitor the laboratory as well as the over-the-counterpractices of students. Sessions are edited, then reviewedand critiqued by lecturers and students. We now maintainthe system, and train pharmacy technicians to carry outbasic analogue editing.In-House ProductionRegardless of the discipline, there has always been ademand for teaching material. Initially our main outputwas copy slides: most teaching was done with diazo-typeVericolor slides, which could be produced easily andinexpensively from type or line drawings, and also withpublished material copied onto Ektachrome film. We weresoon producing over 10,000 slides per year. Towards themid-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 SpenceJ Vis Commun Med Downloaded from by Osaka University on 12/08/14For personal use the country, we adopted an unorthodox method ofrecording: with a sturdy tripod and the lights out, wemastered how to copy the images from computer screens.At the millennium, the Faculty invested in a local-areanetwork based on Dell computers; training courses inMicrosoft PowerPoint were provided, and lecturers andclinicians became more self-sufficient. This development,along with the acquisition of a high-end Nikon D1Xdigital-camera, has resulted in an 84% reduction inlaboratory costs over four years; even those who initiallyresisted now use laptops and multimedia projectors forteaching, and our slide-projectors have almost becomeobsolete. We still do a lot of copy work but most is nowdone digitally and delivered in CD-format.The digital camera has also had a significant impacton our student-ID database: previously we would photo-graph students with colour-negative film, then mountand 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 availablethe day after registration. A new marketing strategyrecently adopted by the University has resulted in amarked increase in calls for promotional photography,both for the Faculty and the campus; the author alsocontributes photography for the in-house magazine, StAugustine News (Figure 6).Video as a Teaching ToolAt its inception the Media Unit recognized the importanceof video as a teaching tool in the medical sciences, andinvested so as to be able to produce near broadcast-qualityvideos in house. An elaborate editing suite was ordered,and technicians travelled from the United States to installit; but they could not get it to work and decided to forfeittheir final payment rather than continue trying. The MediaUnit was lumbered with a big white elephant. For manyyears consultants were brought into advise us about howto make it function. In the meantime technology waschanging, so it was decided to make the suite compatiblefor both analogue and digital video. We have now come tothe point where we should simply throw most of thisequipment out and replace it with a Macintosh G5computer and the latest version of Final Cut Pro. Weexpect to move into web-based teaching during the comingyears, so have obtained provisional approval to purchase acouple of high-end DV-cameras. This time we are hopingthat the cameras arrive before the technology leaves us.Audio-visual SupportThe Media Unit has worked relentlessly to ensure that wedeliver audio-visual support, which can compare with thatof any international university. The service would normallymake staff available to set up sound-systems and operateas a projectionist and/or videographer. Apart from servicinglecture theatres for teaching, we provide this service formedical fraternities throughout the country, and havesuccessfully run major international medical conferences.Until recently the major challenge was to switch fromslide-projection to dual-slide projection, then to MicrosoftPowerPoint, then back to slides again. Thankfully, theplaying field seems to have been levelled and everybodyuses PowerPoint; now we typically worry about whetheror not the video-file will open and, of course, always havea back-up multimedia projector close by.SummaryMedical Illustration has been so encrypted into thepractice of medicine in the developed world that theidea of a university hospital without medical photographyservices at its disposal may seem unimaginable. However,prior to the establishment of the Media Unit, the reality inTrinidad was that photography of medical cases wasdependent upon the relevant clinicians own expertise andinterest or lack thereof. For example, in Trinidad in the1930s Dr. Lennox Pawan conducted globally importantresearch on the transmission of rabies by vampire bats, butthere are few useful photographs of this work. Perhapstoday his research would be captured on video: throughthe Media Unit, the University of the West Indies has beenable to set national standards in medical photography.However, the pressure to stay on top of appropriatetechnological change, if we are to maintain thesestandards, cannot be underestimated. Then again, if thegoing 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 71J Vis Commun Med Downloaded from by Osaka University on 12/08/14For personal use only.