Download - 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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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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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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