Creating clear, quality photographs of xrays, OR procedures and case evidence is an important skill for any hand surgeon to aquire. ASSH members have provided their tips and techniques for taking excellent high resolution pictures that they can use for presentations, article submissions and sharing in electronic forums.
Get started on taking your own professional pictures with tips from ASSH Member Barry Press, MD, FACS.
Choosing a Camera
Assuming that you are searching for a camera to use in your office/clinic and operating room, I believe that the most important consideration is size. A full-featured digital SLR (DSLR) may give you extreme flexibility and the ability to be very creative. However, it will be bulky and heavy. Medical photography is more like photojournalism: the object is to realistically and clearly portray what you saw and want the viewer to appreciate. A camera must be AVAILABLE to achieve this goal. For the vast majority of photos, the newer compact digital cameras will do the job nicely, and their small size and low weight will make them easy to carry in a pocket or bag.
Because you will be taking photos of small structures, it is mandatory to choose a camera with good macro capability (the ability to focus at close distances so small objects can nearly fill the viewfinder.)
Various memory card options are available and all function well. Prices for memory cards continue to fall, so look for a card that will hold a sufficient number of images to allow you to download them at your leisure, not when the card is full. Shooting at the highest quality setting will allow maximum flexibility in preparing images for printing or presentations, but will generate large files, so I recommend at least a 1 GB memory card. The most versatile shooting format is RAW, but this is generally only available on larger and DSLR cameras. Each manufacturer has a different name for its “highest quality” format.
More megapixels do not necessarily lead to better images. In fact, if too many pixels are crammed onto a small sensor, artifacts and loss of resolution can result. Digital cameras of 9-10 years ago with 2-3.5 megapixels took excellent clinical and OR photos. Most good contemporary cameras will have 8-14 megapixels.
There are many manufacturers and models of digital cameras available, and new models are constantly introduced. There are a number of good websites that rate digital cameras; some of my favorites are www.stevesdigicams.com, http://reviews.cnet.com/digital-cameras/, and http://www.dpreview.com.
Digital Photography in the Office
Attempt to keep the extremity flat, either horizontally or vertically, against the background. A medium blue background is felt to be optimal, but any solid color (e.g. a surgical towel) is satisfactory. If the extremity is away from the background, a shadow may be present from the flash, and it may be difficult to focus only on the area of interest. Filling the viewfinder with the area of interest will minimize both of these problems.
For views of the hand, forearm and fingers, the camera should be oriented horizontally. For orientation, include the wrist with views of the hand, include the elbow and fingertips with views of the forearm, and include the fingertip and the MCP joint with views of the finger.
Digital Photography in the Operating Room
Radiograph and MRI/CT photography is best done using a lightbox with the room lights off (this prevents reflections, which are very difficult to remove.) Turn the flash off and stabilize your hands to minimize motion artifact. Use the macro mode; most cameras focus best in the middle zoom range. Set the zoom to the middle of its range and then move closer or farther from the lightbox so that the image is centered and nearly fills the viewfinder. Take multiple images. When editing these, change the format to grayscale; this removes any color cast and decreases the file size. Take care to remove any patient identifying information from images that will be shown to others.
When you know you will be shooting intraoperative photos, have the OR pull several extra pairs of overgloves. Put these over your gloves, grab the camera, and shoot.
For photographs of the operative field, it is generally best to use the camera’s flash and turn off the OR lights or direct them away from the field. If you don’t like the looks of the photo, try it with the OR lights on the field and/or with the ambient light only.
Take a few moments to clean the skin edges of blood, and frame the area of interest with clean OR towels. If necessary, have an assistant hold a towel as a background. Removing distractions in this manner will significantly improve photo quality.
As in the office, attempt to keep the extremity flat and close to the background. Make sure your focusing is accurate. Locking the focus on a high contrast spot in the area of interest and then framing the desired photo can minimize focusing difficulties. Many cameras will “lock” focus by pushing the shutter release halfway down and holding it there until taking the picture.
Hand off the camera, remove the overgloves, redirect the OR lights and continue the case.
For intraoperative digital microphotography/microvideography with a standard consumer digital camera, please consult Yanni DS, Beshara M, Ebersole K et al. Surgical Neurology 72(2009) 153-156.
Preparing Images for Email, Web Publication, or PowerPoint Presentations
High quality images from a digital camera are large files. They can be 6-10 MB or more. These will take a long time to upload and download, even with a high-speed Internet connection. Used in a PowerPoint presentation, they will take too long to load to be practical. For these applications, the images must be compressed.
Note: always save your original image for archiving and later use. Save compressed images with a different file name.
Computer monitors have a resolution of 72 pixels per inch (ppi). Theoretically, any resolution higher than this will not improve the image quality but will increase the file size. There are many ways of compressing images for viewing on monitors; this is a method that has worked well for me. I use Adobe Photoshop, but these manipulations can be made with any photo imaging software, including the one that comes bundled with your camera. Irfanview (http://www.irfanview.com) is a free Windows program which can handle these issues.
JPEG (Joint Photographic Experts Group) is a format that allows for compression with minimal loss in quality, and is a standard format for the web, email, and presentations. My method:
- Perform any sharpening, brightness, contrast or color adjustments necessary.
- Go to the menu item that sets Image Size: set the longer dimension of the image to 5 inches and the resolution to 72-150 ppi. Some images will look better at higher resolutions than 72 ppi; experiment until you are satisfied with the appearance. Small images to be used for presentations should be set at 125-150 ppi.
- For radiographs or scans, change the mode to Grayscale.
- For color images, consider changing the mode from RGB to 256 colors. This will decrease the file size without an appreciable loss in quality.
- Save the image as a JPEG with a quality setting of 5-8/12 (higher setting: better quality and larger file size.
- Give it a descriptive name different from the original image.