Abnormal nerve variant identified during carpal tunnel surgery

Nathan Pallace received a Citation of Merit in the Clinical category and the BCA Medical Education Award in the BioImages 2017 Salon for his image "Abnormal nerve variant identified during carpal tunnel surgery". Below, Nathan tells us about his job and tips for medical photographers.

“Photography around the sterile surgical field can be described as an odd kind of dance in which the lead does everything in their power to never make contact with their partner.” – Nathan Pallace

© Nathan Pallace

Please describe your primary line of work.

I’m a photographer working with the Mayo Clinic in Phoenix, AZ. My main responsibility within the organization’s media department is surgical photography and other related medical based digital imaging.

Tell us about your photography background? Were your formally trained?

I learned basic black and white film photography in high school during the early 90s. I didn’t do a lot with photography again until returning to college at SUNY Adirondack in the early 2000s after a somewhat successful career as a musician. I earned an AAS degree in media arts and communications with a concentration in photography in 2003. This was during the earlier stages of digital photography, so most of the training I received through this school was also film based and in a darkroom. In 2002 I started an internship for college credit with a daily newspaper in Upstate New York. I was hired as a part-time photojournalist in 2003 and was basically forced to go completely digital overnight. Most of the training I received in this transition happened though collaboration with my new colleagues and personal trial and error. I adjusted rather quickly though and continue to build my digital skillset to this day.

Changes in the print industry forced me to take a hard look at the future of my career as a photojournalist sometime in 2007. I witnessed my company’s stocks crash over the course of a few quarters and knew their value would probably never come back up to where they originally started. It was also around this time that I started to have an urge to continue my education. I started began researching different paths online because it seemed like a “now or never” time to act was fast approaching. Part of me wanted to get out of photography completely due to what I was experiencing in the newspaper/print world and another part thought I should find a specific niche inside photography. Then I came across the Biomedical Photographic Communications program at The Rochester Institute of Technology in Western New York and just went for it. I was accepted into the program over the winter of 2008 and began classes that Fall. It was at RIT that I fine-tuned my digital skillset and immersed myself into the more technical aspects of photography. I concentrated in high magnification imaging and studied standardized medical photography abroad as part of my degree requirements.

What first sparked your interest in medical/surgical photography? What advice would you give photographers who are just starting out in this field?

I was introduced to surgical photography through a one-of-a-kind class at RIT that was created during my second year as a student in the Biomedical Photography Certification program. This class was conceived through collaboration between Rochester General Hospital (RGH) and RIT in an effort to help student’s gain access to the hospital’s OR for the purpose of documenting surgical procedures under the guidance of RIT’s Michael Peres and RGH’s Dr. Ralph Pennino. The experience clicked right away for me. It felt like I had a job again immediately after my first time shooting.

My best advice to anyone starting out in the medical/surgical photography field is to understand that a very strong soft skillset is just as important as a strong foundation of technical hard skills. I always tell students that are interested in this type of work that only one-third of my job is photography and another third is customer service. It’s important to understand that a skilled photographer who does not have communication skills will not survive in this kind of environment (and vice versa). In my experience, I’ve seen more photographers fail in the medical field due to their lack of proper personal skills and how best to handle difficult situations that can arise. Not having the most advanced foundation of photographic knowledge is more acceptable compared to not having the personal skills to deal with people and problems that arise.

What are some of the challenges or technical issues you face in capturing clinical and surgical photographs?

The surgical field is always a challenge considering that the photographer is a liability to its integrity. It sometimes also limits the physical possibilities for getting certain types of shots. Keep in mind that the surgical field is not just limited to the patient, but includes the surgeons working on the case and the majority of the equipment that is being utilized by them.

Can you describe the level of difficulty in obtaining photographs in a surgical field?

Photography around the sterile surgical field can be described as an odd kind of dance in which the lead does everything in their power to never make contact with their partner. The photographer cannot come into contact with anything in the field with their person or their gear -period. He or she has to be aware of the individuals preforming the surgery and the patient at all times, even when they are focused on a shot, which can be nerve wracking. If a mistake is made, the sterile integrity of the field has been compromised and will regularly need to be reestablished, meaning the entire field must be broken down and then reset again with the proper sterilization techniques and new uncompromised materials. This costs money and takes time, which means more money in the long run. I’ve been told that a major contamination mistake makes for a very bad day. If the actual surgical site is compromised, it could lead an infection for the patient, or worse.

Can you walk us through what camera and lighting gear you take on assignment?

I always carry a Domke F-2 bag that is full of a number of photographic tools that I use on a daily basis. My camera of choice at the moment is a Canon 80D, due to its live view shooting capability that includes a nearly 270 degree flip screen. This provides a number of additional opportunities for capturing difficult shots around the sterile filed without the photographer having to become that much of a liability to the patient’s safety. A Canon MR-14 EX II ring flash provides my default lighting, but I also carry a Canon 600 EX-RT speedlite for wider angle shots and situations that require reflected light. The lens I normally keep on the camera is a full frame 28 – 105 mm, which functions more like a 45 – 170 mm when you add in the crop factor of the 80D’s sensor size. My go-to lens is a 60 mm macro though, but it is much less versatile that the 28 – 105 mm, and therefore stays in the bag until I know exactly what kind of shot is expected of me. I also carry a 100 mm macro for the added working distance so that I can stand further away from subjects and still get higher magnified shots with edge-to-edge sharpness and a 10 – 22 mm to capture much larger objects and room documentation. I also carry portable storage media for when I need to remove data from numerous medical imaging machines that the surgeons use in my OR and that specific data needs to be included in the patient’s record.

Camera gear and lighting equipment are essential but what other skills does it take to work with physicians/surgeons and patients?

As I mentioned before, additional soft skills are key, especially communications skills. The OR is a very high stakes environment where time is precious and every minute usually counts. In most cases, a minute of surgical time provided to a photographer is very generous. Therefore, a photographer needs to learn how to own every second of that minute in order to efficiently, and safely, do what is expected of them. A level of trust must be developed between the photographer and the medical staff and the better an individual is at conducting themselves in these situations, the quicker that trust bond will form. Being skilled enough to create the best images possible is very important too, but if the surgical team can’t begin to trust a photographer this relationship tends to go nowhere.

What is the influence of digital technology on your photography?

Digital technology has cut out any form of chemical processing and a large amount of hardcopy printing, that has substantially cut down on image turnaround and made basic work protocols much faster. Nearly everything I do is now is outputted as a digital file, which means I can capture an image, edit it in digital software, archive it and then send it to another part of the building (or clear around the world for that matter) in a matter of minutes.

What has technology enabled you to do that you were not able to do before?

Digital technology has allowed me to view my images almost instantaneously and allows me to make on the spot exposure decisions and adjustments. This provides better results at capture, that reduces post production process time significantly and makes my overall workflow that much more efficient.

How helpful would you say your work is for patients, physicians, students, and researchers?

Medical/surgical photography work is very helpful for all of these groups. My final product is a form of visual documentation that normally can’t be obtained at any other time other than during a surgical procedure. Very few people would ever see this information without my services. My photos create a timeline for the physician related to progress (or decline) in a patient’s condition and allows them to revisit specific information associated with returning patients. The photographers can be used as proof of care/condition for insurance providers and evidence that may be used in a court of law for the benefit of either the patient or the doctor. Patient photographs are also beneficial to medical education and research communities as teaching tools and learning opportunities.

How do you find medical photography compares to, for example, journalism style photography? Or for example, nature photography is beautiful. How does that compare to the kinds of professional photography you do?

I’ve found that there’s definitely a parallel between journalistic photography and surgical photography primarily because the photographer is creating a document, or a record, of a specific event in both. The biggest difference is that a photojournalist takes photos and a medical photographer makes them. Photojournalism images are meant to be more artistic, or at least aesthetically pleasing, while visually telling a story, usually through emotion. These images are captured with the photographer being a standard observer that is not interfering with the subject matter in any way. Good instincts, knowledge of the subject at hand and a bit of luck all benefit the shooter.

With medical photography, the photographer is making scientific documents (that are also usually aesthetically pleasing and often tell a different type of story), which can be presented as evidence, or data. The subject of these images should not be manipulated at all by the photographer at the time of capture or during post-production (beyond global edits). A strong set of technical photography skills, knowledge of light behaviors and a base knowledge of anatomy and pathology will benefit the photographer when making medical images.

What photographers inspire or influence you?

When I started my journalism career I loved (and still love) the dark honesty of the images created by Weegee and Diane Arbus and the raw power found in Richard Avedon’s studio portraits. I also felt a parallel to more contemporary photographers like Glen E. Friedman and Charles Peterson, who were young people that found themselves immersed inside of two very different, and very potent, subculture scenarios that eventually helped give definition to America’s underground youth in the 90s.

Due to HIPAA legislation it is very hard for medical photographers publish, or even display their work. Therefore, my influences in the medical and science imaging tend to be derived from those who I have learned from and directly worked under. Michael Peres, from RIT, and Paul Crompton, from the University Hospital of Wales, have both been very strong mentors in my training. Both of these gentlemen are also BCA members. Michael was chair of the BPC during my time at RIT and Paul contracted me to work in his department for a summer while I was working towards my degree at RIT.

Why did you choose to submit this particular image?

I chose this image because it really stuck out when I was narrowing down the images I was considering for submission to this year’s contest. I just had a feeling about it. To tell the truth, the case was not that significant. So much so, that the surgeon was surprised when I contacted her for the description information for the submission form, and then even more surprised when I contacted her again to tell her that this image had won an award. It originally started as a standard laparoscopic carpal tunnel, but she had to open the wrist when she found the nerve situation. That’s when she requested that I take the photograph.

Overall, it was pretty easy image to make. I decided to use the ring portion of the macro light as a hand held strobe to provide some shadow detail, which really gave a pop to the depth in the end and is also a big reason why the image turned out so well. There’s one main technical issue, which is the shine on the metal instruments blowing out a bit to the left of the frame. It makes sense because that is where I was holding the light source, but the image comes together with a great amount of detail around the incision. The lighting and overall color made for a really striking image that was just too hard to place in my “NO” pile.

Why did you enter BioImages competition? What do you think of the competition?

I’ve been participating in the BioImages competition for the past 7 or 8 years. The first time I entered I was a student at RIT. The department I was in covered the fees, so I really had nothing to lose. I ended up winning the best student entry award that year, which was huge for me at the time. I’ve continued to enter ever since because I’ve had a wealth of fresh content to choose from every year and BioImages is the one of the only situations in which I can showcase my work in front of an audience of peers, or anyone else for that matter. It’s also a good source of feedback in a very niche field that doesn’t receive a lot of feedback. Winning an award will never hurt your resume either.

Do you have any advice for photographers who are interested in a career in biomedical/life sciences?

For younger photographers and students: employers in the surgical/medical field are regularly looking for a four-year college degree and 1 to 5 years of professional photographic experience. The more that you can align these 2 elements with standardized medical photography training, the easier it is going to be to get you’re your resume through HR and onto a department director’s desk. Internships in medical photography and job experience with other types of medical imaging, like ophthalmic photography, are a great benefit to fill these requirements. Be sure to tighten up your resume and get your portfolio online as well.

For anyone looking for a career in surgical medical photography: be sure that you have a strong understanding of macro lenses, especially the reproduction ratio scale. Flash photography also becomes and everyday thing, so practice with both macro ring lights and speedlites on every kind of surface. It also doesn’t hurt to have experience with alternative lights sources and their associated camera filters. Be sure to study up on legitimate reference materials that explain standardized studio positioning protocols and become familiar with their content and practice capturing these protocols correctly (i.e. Photographic Standards In Plastic Surgery by Plastic Surgery Educational Foundation). All of these elements can be considered a good technical foundation for the work a job in surgical photography entails.

Lastly, always work on polishing your communications skills.