The straightening of a scoliosis patient's spine using pedicle screws and rods

© Nathan Pallace

Nathan’s image won the BCA Medical Education Award in the Still Media Division from BioImages 2020.

Tell us something about you. What is your imaging background?

I started my imaging career as a photojournalist at a mid-sized daily newspaper in Upstate New York in the early 2000s. I covered everything from local high school sports to national news stories during my time of service there. I also won several state and national awards for my work, which was an amazing honor. In 2007-ish it became very hard not to notice the effects on the newspaper industry due ot the near immediacy that information could travel via the internet and the introduction of the smart phone. I watched our stocks plumet to single digits in a short amount of time and quickly began to realize that I was going to have to act fast or ride out this crash. So, I made the difficult decision to leave this career and continue my education. When I landed, I was enrolled in the Rochester Institute of Technology’s Biomedical Photographic Communications Program. It was probably one of the best decisions I have ever made. Here I learned the photographic fundamentals related to my current career and became a much more knowledgeable and skilled photographer. I studied high magnification as a concentration (specialization) and learned photomacrography, photomicrography, and several other niche imaging skills. I began to work with video and graphic design here too. In 2010, I received a contracting stint as a medical and public relations photographer at a National Health Service hospital in Cardiff, Wales as part of my course work. Thanks to these educational experiences I started my career in medical photography/imaging almost immediately after graduating from RIT’s Biomed program.

What was your concept when creating this image? Was it for a job or for personal creativity?

To be honest, I didn’t apply any hard conceptual approach when making this image. I’m currently employed as medical photographer and am specialized in surgical photography. These images were created while covering a call during a standard shift at my job. On any given day, I run around in between all the numerous rooms found inside of my hospital’s OR (operating rooms) making pictures of human anatomy, physiological issues, diseases, and pathological specimens. I can document dozens of surgeries in a single shift, which vary from case-to-case, and fill a spectrum that includes everything from minor routine procedures to major life saving events. As a result of the diversity found in this, I create my images with more of a philosophical approach, as opposed to a conceptual one. This philosophy centers around the decision-making processes needed to overcome the imaging challenges that present themselves and situational obstacles that I encounter as I jump from surgical scenario to surgical scenario. Some of these decisions are obviously about photography techniques, which are usually made after I’m able to view the subject matter. Regularly, these involve lens choices and the different qualities of light that I can create with the equipment that I have available to me. Some of the other types of decisions needed to be made have absolutely nothing to do with photography at all. They are normally related to environmental observations. Examples would be, but are not limited to: the mood in the room, or what side of the table the surgeon is standing on, or even, what position the patient is in on the table. When put together, all these observations help me make the proper choices that allow for the creation of the highest quality images possible, while maintaining a sharp focus on patient safety.

Tell us something about the creative process you use when coming up with a solution to a problem/assignment.

I tend to view every subject I come across as its own unique situation with its own unique imaging challenges, regardless of what it is. I then assess what those challenges are and how I can overcome them with the equipment that I have available to me, and how that equipment can be best utilized in the conditions that I find myself in. That’s basically it.

What technical issues did you have to work out to create this image?

On a technical level, these photos were rather easy to make. The biggest technical decision that needed to be made was related to the type of lighting that would benefit the subject the most. Once I was able to view the patient, I made the decision to use bounce flash, which I created using a standard speedlite fastened to the camera’s hot shoe mount. This would help to provide soft and even illumination to the entire subject matter at capture. Bounce flash lighting also creates subtle shadow details that help provide the illusion of depth in the final images too. A small sacrifice of resolution is often needed to configure a proper exposure when I use bounce flash though. This typically involves a subtle bump up in ISO in order to hold onto an adequate depth of field. This is usually necessary because of the distance between myself and the surface material I’m bouncing the light off. That surface was the ceiling in this scenario.

In my experiences with this type of work, I’ve found that many of the obstacle that a medical photographer encounters are not technically based. I refer to these as “mechanical issues”, but the word “mechanical” should be interpreted broadly. The central object that ties into most of these mechanical issues is the sterile field. This is the area inside of surgical set-up that has been sterilized of microbes and other pathogens to protect the patient from infections. The sterile field regularly include surfaces, instrument, and people. In theory, if this field becomes contaminated by anything that is unsterile it needs to be re-established, which is usually a very bad way to be if it occurs during the middle of a surgical case. A surgical photographer, and their gear, are not considered to be part of the sterile field, which basically makes them a liability to it. Our work requires us to regularly enter this sterile space though. The mechanics of this can become physically difficult and often nerve racking. The necessary focus then becomes a harmony between protecting the patient and documenting the necessary details of their condition. Being able to verbal communicate clearly with those inside the sterile field becomes as important of a skill for a medical photographer to have as knowing how to frame a shot is.

The biggest mechanical issue that I encountered when making the images that we are talking about was in relation to camera placement. I needed to figure out how I could get the camera high enough above the patient to create the necessary working distance needed to capture the entirety of the exposed spine in one frame. I also needed to evade coming into physical contact with the sterile field while doing this. My solution was to create additional height by stacking two metal steps, on top of one another, at one edge of the field. This allowed me to place the camera where it had to be after I climbed up on top of them. It might sound like this was a simple fix, but I assure you, it is a very difficult position to be in. When this must be done, the room regularly becomes dead quiet as the camera and photographer loom over the field. Time seems to stop when you are up there too, and it often feels as if a spotlight has been placed on you because you can feel every eye in the room. It’s a moment of very condensed and intense stress. I’ve witnessed other photographers physically get the shakes from the pressure that a situation like this can create. Luckily, the camera model that I use has a live view capture mode with a rotational LCD flip screen that helps make situations like this safer and a bit more comfortable. It’s a great tool that gives the photographer new levels of control in certain scenarios. It sometimes also makes impossible angles possible and can even remove potential contamination liability from the field almost entirely.

Tell us something about the subject of this image.

The general subject matter in these images is a spinal condition call scoliosis that can be described as a sideways curvature of the spine. It’s normally diagnosed early in life. I remember being annually checked for it in gym class when I was in grade school. The surgical correction of this condition is represented here in a two-image series. The first image clearly shows the curved spine through a large incision in the back of the patient. The second image shows the corrected spine after the insertion of pedicle screws and rods that have been utilized to help straighten the curve. I shot a third intra-operative image early in the case that I decided I not to include in my BioImages contest submission. That image depicted what the patient’s spine looked like before the incision was made but was not as visually potent because their back had been covered in a bright yellowish antimicrobial adhesive drape. This material is rather saturated in color and canceled out a lot of finer details of the subject.

What elements are important to you when you judge or critique your work or the work of other professionals?

I tend to be hard on myself when I critique my own work. It helps me to recognize my mistakes and to learn from them. It also helps to keep me humble. In my opinion, a big part of becoming a better photographer is making a lot of mistakes and working out the problems that were created by them. Personally, this allows me to be a forever student inside of this discipline and keeps my ego in check in the process.

When I critique other professionals work, I always try to be constructive and lean my focus more towards the technical issues that I feel could have benefitted from different approaches. In the past, I’ve witnessed more subjectively based critiques get ugly and have always found them to be more damaging than anything else. A technical critique tends to involve problem solving and solution-based thinking, which allows the end results to be more productive and educationally based. My general goal is to provide the individual I am critiquing with additional options that they could potentially use help them make higher quality images with, regardless of what their image content is.

Who are some of your favorite image makers?

Medical photographers do not tend to become famous because our work is protected by HIPAA patient safety legislation. Therefore, our images cannot normally be used for personal promotion reasons. I always say that I have an amazing portfolio that I’m legally not allowed to show people, unless it is under the umbrella of medical education. Therefore, most of my imaging heros are based in the art and journalism worlds. For instance, I’m a huge fan of Richard Avedon and Diane Arbus portraits. I also fell in love with the grimy 1940s nightlife photography captured by Weegee while managing a black and white student darkroom in the early 2000s. I also have a huge appreciation for more contemporary photographers that emerged during the 80s and 90s, like Glen E. Friedman and Charles Peterson. Their documentation of American underground subcultures from my generation always takes me back to a good place in time.

What images or image makers inspire or influence you?

Photomicrographs completely inspire me and have changed the way that I look at the world. I became completely obsessed with the unseen world while studying how to make these types of images at RIT. They have a unique ability to make other subjects seem a little boring to me now. When done well, the results can be completely mesmerizing, regardless of what the subject matter appears like at life size. For instance, I gifted my parents a large print of a re-crystallization for Christmas several years ago. It was captured using cross polarization photomicroscopy techniques and the image is very angular, sharp, and dominated by vibrant colors. It still hangs in a very visible place in their home to this day. I don’t think I’ve ever told them that it was created using a sample of bovine urea.

Do you have any advice for people interested in an imaging career in biomedical/life sciences.

Get educated and do the work! Seek out any kind of relevant experience as soon as you can, even if it involves volunteering. Most employers are looking for applicants with one to five years of professional experience. Often, it doesn’t matter if this experience is rooted in science, medial, or technical photography, but if it is, it can help open a lot more doors. I’ve seen a lot of extremely talented people miss out on opportunities when they were first getting started because they couldn’t meet this requirement on their resume. So, the harder you work now, the easier it will be for you later.

Are you a member of BCA and if so how has your membership in the BCA helped you?

I’ve been a member of the BCA for around a decade and the organization has helped me in numerous ways during my time as a student, and within my career. I received EFFE grant money through a BCA application process while I was a student that help with the lodging expenses associated with my previously mentioned UK work/study experience. I’ve also received countless amounts of recognition, on a global level, for my involvement with the BCA’s BioImages contests over the years. Additionally, the BCA has provided me with a larger network of industry professionals that I’ve been able to learn from and share information with.