Medical Photography: a Trinidad Experience

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  • 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 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 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 womens

    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 womens 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

    moments 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: spencephoto@yahoo.com

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

    Journal of Audiovisual Media in Medicine, Vol. 27, No. 2, pp. 6871

    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 womens 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 Units 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 surgeons

    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 Facultys 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 inlaboratory 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 serv...