What I’ve learned About Surgical Photography

For the last year or so I’ve been fortunate enough to make pictures for a medical product company on a regular basis. Their product is markedly better than the alternatives and my images are used for marketing and educating surgeons. I get to work with top surgeons in the field, and it’s a true privilege to be included as the surgeons employ their special skills and make life better for their patients.

Surgical photography is a special environment, just like sports or wildlife photography, and hopefully some of my experiences will help you somewhere down the road, even if you only use it for photographing the birth of your child.

You never know where a client may come from: I made new head shots for the doctors at the local hospital in Cache Valley, Utah, and when my current client called and asked who they use for medical photography, the hospital passed on my name. Fortunately, I had photographed a birth and so I had something medical related to show as samples.

Mind Your Manners

The first thing to know is that you’re a very privileged guest in a strange place. There are customs and rules you don’t know, and breaking them can threaten a life. Ask lots of questions well before you go into the surgical area and be knowledgeable about what you’re doing. Below I’ll talk about equipment and changes I’ve made to the surgical setup to accommodate photography better. These were all made with permission, and I asked very nicely. You mustn’t assume that you’ll be catered to. Be good guest and remember that you’re the least important person in the room.

Environmental Concerns

There’s the hospital, the surgical wing, the operating area, and the operating room. Anyone can go in the first two, only those in surgical clothing (scrubs) can enter the operating area, and entrance to the operating room is for the surgical team only. Before I take my equipment into the operating area, I have to wipe it with disinfectant wipes so that I don’t bring in any outside particles. The entire outside of bags and cases, and since I’m working with a videographer, too, we also wipe down his c-stands, lights, and even the power cords. I’ve got a cap on my head, mask on my face, and covers on my shoes, as well. Outside the cases isn’t all that gets wiped, however. My camera bodies, lenses, straps–everything. If your zoom lens extends in and out, you’ve got to extend it and clean the whole barrel. I’ve also had to have immunizations and screenings for diseases.

It’s a lot of trouble to do all this, but it’s imperative. The thing to remember is that photographs are just ones and zeros recorded on silicon chips, but there is a person–someone’s daughter or sister or mother–with her inner self literally exposed and any carelessness or mistake you make could actually lead to her death. That’s what I think about as I reach for another wipe to scrub the textured rubber on my camera’s grip.

Don’t plan on bringing lots of equipment in, either. Firstly, there isn’t room. I don’t get a table for my camera tools with an assistant handing me a change of lens on demand. Also, it’s less to clean and prepare. Lastly, once things get underway, you don’t get time to change lenses and tweak lighting; you use what you’ve got and you make it work for every shot.

Gear Considerations

Since there is little space in the operating room, and since things happen quickly without time to change lenses, I use one lens for the entire operation. When I’m in the OR I’m usually not sterile like the doctor is–he has an additional gown and gloves that are completely sterile from sealed packaging. Because I’m not sterile, I can’t touch the operating table or even get too close. That means I need a long lens to get a close view without getting physically close. A long lens is also great for candid portraits of the surgical team, eliminating distracting elements by cropping tight. Also, I’m often not able to see past the doctor or maybe the videographer, and I have to just reach my arm out, aim blindly and shoot. That means I need a wide lens that is forgiving in if I’m not aimed perfectly. The wide lens is also terrific for action shots with lots of depth and foreshortening. Fortunately, Nikon’s 28-300mm fits the bill perfectly on my full frame D800 (I don’t need the 36megapixels, but sure like them, especially when cropping those blind shots). If I didn’t have this lens! I would seriously consider Tamron’s 28-270mm, or any of the 18-200mm zooms for cropped bodies, and the new 18-300mms look promising, too.

The videographer and I spend most of the surgery on step stools so that we can shoot over the surgeon’s shoulder and see the action, and we are constantly moving our stools to the other side of the table as the surgeon works in different areas. That means a tripod is impossible. Still, I need to make useable pictures that are both sharp and have enough depth of field. I generally shoot at f/8, which is quite a small aperture. I also aim for a shutter speed of at least 1/160 so that I can make a sharp picture. I adjust my shutter speed when switching from shooting the surgical table to shooting the room or other details. I use a handheld light meter to measure the light at different places before the surgery begins so I know what the shutter speed needs to be in that area.

Even with the bright surgical lights, the ISO is never less than 800, and often up to 2500 when I need to see into a cavity. Fortunately, this is not a problem for most any DSLR made in the last few years. You need to know how to use high ISO’s to your advantage (here’s an article about that).

It’s also imperative that you know how to set a custom white balance on your camera. The surgical light is never the same color as the room lights, and sometimes each of the surgical lights may be different colors. The only way to compensate is by setting a custom white balance. There are plenty of white surfaces to use, and Rich has already given us a tutorial on setting custom white balance right here.

Lighting Compromises

As with all my clients, great lighting helps me to continue getting hired. My genius director of photography friend, Craig Feldman of Manhattan, and I have gotten pretty good at making the most of the operating room’s lighting. In addition to the articulating surgical lights, Craig sets up two LED panels at either end of the table and matches the color to that of the overheads. These help brighten the shadows cast by the surgical lights, thus reducing contrast. That means there are fewer really dark shadows distracting the eye in the footage and photographs. Craig’s lights have a color adjustment knob, but sometimes we have to use additional sheets of colored gels to get things right. Custom white balance is good, but it only works on one color of light; do your best to get consistent light color on your subject and your pictures will look much better.

Also, the surgical lights are focussed into a spot light, which is a hard light and casts hard shadows and very shiny highlights, both of which are detrimental to surgical photography. Craig and I use a sheet of diffusion material to cover the lights and soften them. This diffusion is like a gel, but it’s colorless, and slightly opaque. It widens the spot and makes the pictures much better.

Recently, Craig and I shot two surgeries in a row. There is a cleaning team who comes in between and gets the room ready for the next patient, and we took a quick lunch break while they cleaned. That cleaning team must make the room completely sterile again. Much to our surprise, they threw away the diffusion we had put on the lights, and we didn’t have any extra. We were pretty anxious because without it the surgical lights were just too harsh; the shiny highlights make my pictures almost unusable, and the video is also much harder to work with. Fortunately, nurses had let us into the room the night before to scout and they had given us disposable white jumpsuits to put over our street cloths so we wouldn’t have to change into scrubs. These “bunny suits” are made of translucent white polyethylene…not unlike our diffusion! We hunted down the nurse and asked for more suits, which we cut up and taped to the lights. It wasn’t as good as the diffusion from Rosco, but it worked in a pinch.

Habitual Changes

My last tip for working in a surgery is that you’ve got to change some pretty basic habits for the safety of the patient. You can’t brush against the table with instruments on it–it’s a sterile place, and simply brushing your trousers against it means the nurse has to re-drape it with a new sterile sheet, and she has better things to do than clean up after you (the last thing you want to do is annoy the nurses). You’ve also got to get the shot the first time. Occasionally I’ve been able to ask the surgeon to repeat a motion or even pose a tool in a particular position. But you can never say, “Could you make that incision again? My focus was off.” Doctors may practice medicine, but you can’t be practicing photography in the OR.

The toughest habit for me to change is that I have to bury my inner Boy Scout a little and be less helpful. When the surgeon says, “Could I have a clamp, please,” he’s not talking to me! If I were to be helpful and reach down and hand him a tool, it would mean a whole lot of work getting new sterile instruments, and could endanger the patient’s life. I have to put both hands on my camera and stand still. A Scout may be helpful, but a photographer in a surgery is not.

Conclusion

Scott Bourne has often remarked that only the medical industry has done more for humanity than photography, and I am so blessed to be involved in both. Photographing the miraculous work I’ve seen has changed my view of the world and my outlook on life, and I hope you get the opportunity, as well. Hopefully these tips will help make it easier when you do.

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Levi Sim

Levi Sim is passionate about making photographs and helping others make their pictures better, too. He's a full-time photographer making business portraits and marketing and branding pictures for a living. He spends the rest of his time practicing all other kinds of photography. Read more of his articles here. And you can see more of Levi's portfolio here.

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