Shooting Under the Knife
Posted May 9, 2005

For those wedding and event videographers who are having a difficult time filling the virtual abyss in between weekend work, delving into the medical videography field might just occupy the mid-week void. Before you jump off the couch and call all local area hospitals, however, perform a quick gut-check. Do you have the stomach to back up your new venture? Even a Fear Factor devotee or Exorcist fan might find the transition into the O.R. a little intense.

Consider the testimonial of a first-time medical videographer: "The very first thing that I ever shot was open-heart surgery and I mean they cut the chest right open, they split it," recalls Dan Welch of New York Video Crews. "We were doing a piece on alternative kinds of treatments, so while this person had his heart worked on, a healer was massaging his head. That was really the angle we were shooting. But I did go and stand over the guy and shoot down into his chest. There was a moment where I was saying to myself, ‘OK, how do I feel about this?' but I felt fine—so I just kept going."

If the preceding passage incited feelings of nausea, chances are you are not suited for life in the O.R. But if your curiosity has not waned, dabbling in the medical videography arena could keep you working during the week and bolster your off-season income.

DV in the O.R.
Medical videography projects may include outpatient documentaries or other non-surgical affairs, but when most in the field speak about their work, more often than not, they're talking about surgery. Routine procedures do not generally warrant the services of a medical videographer, but surgeons performing revolutionary procedures or testing new prototypes will often call in a professional camera crew to ensure a quality production.

The captured footage then can be used to train medical students or be presented at conferences, and the nature of the final product depends upon the function and the audience. Educational procedures can yield quite lengthy productions, since students or interns may be learning about the procedure for the first time and thus require more exhaustive coverage to understand it, while a conference piece to be shared among peers may not require the same degree of detail. Michael Killips, former LTE specialist at the School of Nursing and current manager of classroom and A/V services at the Health Sciences Learning Center at University of Wisconsin Hospital in Madison, Wisconsin, explains the differences. "If the surgeon was showing it to all of these other surgeons, they already know how to do the whole process up until that point. They obviously know how to make the first incision, so they don't need to see that. They just need to see the core difference of a procedure."

Yet, not all surgery-based footage targets those in the medical field. On occasion, a video may be created with the patient's perspective in mind. Greg Bukshowany of Crystal Clear Productions recently produced a piece that aimed to calm patient fears about a particular operation, "The point of the video was to show how easy the procedure was and that it's not painful," Bukshowany says. "We would take shots of the patient on the table talking on the cell phone, a very tight shot of her. Then the camera pulls back, and you see that she's getting liposuction while she's having a conversation!"

Back to School?
One of the barriers that event videographers tend to encounter when they try to break into legal videography is the learning curve (See Stephen F. Nathans' "Court DV," October 2004, pp. 42-48). While the video technique required is usually well within most pro videographers' comfort zones, the presumed familiarity with legal protocol and the admissibility of various types of video evidence is quite substantial. By the same token, filming a liposuction or open-heart surgery must require a host of medical expertise and prior knowledge, right?

Not so, medical videographers say. What makes the field of medical video inviting in comparison to other specialized disciplines like legal video, is the fact that very little medical knowledge is required. As Bukshowany quips, "When I first got into it, I didn't even know how to put on a band-aid."

Fortunately, for Bukshowany and others, most surgeons will become the acting director for the piece. The surgeons performing the procedure obviously know much more about human anatomy, and they know what aspects of the surgery the videographer need to be covered in the video. However, given the requisite shot list, it's the videographer who knows how best to capture the surgical procedure effectively. Therefore, a strong symbiotic relationship will ensure the correct footage is committed to tape. "You don't always have to understand the anatomy and that kind of thing," Killips says, "but you need to have an understanding of what the people are looking for."

Aside from hours of dedicated TV surgery viewing, the next-best way to understand the surgical procedure you've been hired to shoot is to schedule a meeting with the surgeons to outline the essential elements of the procedure. "We always have conversations with the surgeon or whoever is requesting the video to understand what it is they want to see" Killips says. "We need to understand what the key components of the surgery were."

After covering the essential logistics, the working environment requires special preparation prior to admittance. Because O.R. machinery costs roughly as much as a small ocean-view condo, most hospitals will check the grounds of your equipment, essentially ensuring you don't blow out theirs. "When I first enter the O.R.," Bukshowany explains, "I have to go to the biomedical department, and they check all of the grounds on all the pieces of my equipment that are using electricity. They don't want anything plugged into the O.R. that's not grounded." But properly grounded equipment alone is not enough to grant access into the O.R. Sterility, by far, accounts for the most vital piece of O.R. preparation. Once grounding issues are eliminated, all equipment, cameras, tripods, monitors, etc., must be wiped with sterile rags, to eliminate the presence of any contaminants. While O.R. dogma mandates the sterilizing of equipment, the procedure and hospital will determine the degree of sterility for the person behind the camera.

Some surgeons may want the camera person to remain outside the sterile field and rely on zoom lenses, while others may ask you to use a mobile camcorder. Mark Charrette, videographer and editor at Digital Video-Done Right!, filmed two first-ever surgical procedures in Canada and remembers, "I never had to scrub in. The operating room was not huge, but there was room to move," he says. "But I was told to stay on the other side of the table with all of the surgical tools." Killips relates a similar experience. "We're always outside the sterile field," he says. "Our lens is sufficient enough that we can zoom into the surgery site without having to get close to the surgery."

While Killips and Charrette were usually able to remain outside the sterile field, New York Video Crews' Welch has generally found himself and his crew working in much tighter quarters with stricter adherence to surgery protocol. "Just like the surgeons, we cleaned our hands and we wore booties, scrubs, even a mask or goggles if need be." Why goggles, you ask? "When they're drilling stuff," Welch says, "particles are flying. You know stuff gets on your equipment."

You have been prepped by the O.R. staff, your equipment has been scrubbed down, you might even be dawning human-particle defense clothing, but you are far from being ready to capture the footage. Setting up for the procedure requires thorough foresight and compliance with surgical staff requests. Some surgeons may want the camera person to remain outside the sterile field and rely on zoom lenses, while others may ask you to use a mobile camcorder. 

Whether you're stationed behind a tripod or moving around the operating table, ensuring that you do not accidentally touch any tools or members of the surgical team is of vital importance. "If I were to go in there and my hand was to touch the doctor," Bukshowany says, "they would probably throw me out. Depending on how strict the hospital is, they might ask the doctor to rescrub. If you need something moved you have to ask a nurse to do it; you don't have the freedom to move things around yourself."

That said, you're the videographer, and movement restrictions aside, you know what it will take to get a given shot. To make the surgeon see that you can't capture the procedure from the proper vantage point because something or someone is in the way, ask him or her to view the footage as you're capturing it.. To enable this type of real-time review, most medical videographers arrange to have monitors in the O.R. to keep the doctors apprised of the shots you're getting or not getting, and allow them to continue to function in their director's role as they operate. "We leave it up to them and give them explicit directions," Killips says, "letting them know that they need to check the monitor when they have something that they want to see for sure. They certainly understand the anatomy better than we do. There might be some small component of the surgery that they absolutely need to see," Killick says, that he and his crew might otherwise miss.

But sometimes it's not the surgeon or surrounding staff that impedes a potential shot—it's the lighting. The overhead lights that surgeons activate when they are going into an incision create a host of problems for videographers attempting to capturing usable images on camera. O.R. lights equate to a high-powered concentration light, which illuminates the surgical area but hardly provides the type of lighting scheme that's optimal for indoor shooting. "If you were shooting in auto iris," Welch says, "it would stop the camera completely down and you would have a bunch of silhouetted doctors. When you go in for close-ups you have to re-expose your camera. You might even have to put a neutral density filter in to stop the camera down because it's such an extreme. It's like shooting into the sun."

Bukshowany agrees. "The light tends to give a washed-out look," he says. "The remedy is to set your shutter speed to 1,000 and zoom in on the lit area."

While this may serve as a makeshift solution, it's still far from ideal, so Bukshowany often asks the surgeons if he can replace the obtrusive O.R. lighting with proper video lighting. In fact, he has devised a specialized lighting mount, which he says is patented by his studio, Crystal Clear Productions. The lighting apparatus mounts to the tripod and holds two halogen lights on either side of the lens on his Sony DSR 300 camera. This eliminates the doctors' or nurses' shadows from protruding onto the patient from the other lights set up throughout the room. Although he is not always able to use his own lighting instruments, Bukshowany says, "Doctors who are more video-savvy will allow video lighting to be brought into the O.R."

Sound Check
Interestingly, while light plays a major consideration during production, capturing sound does not create the same sort of challenges, and most medical videographers use ambient sound inside the O.R. In some cases, when surgeons are narrating the procedure as they go, videographers will equip them with surgeons will be equipped with wireless or lavaliere microphones. Notably, depending on the function of the film—specifically presentation material—whatever sound the camera captures may not be used at all. Killips explains, "For the most part, surgeons do not want any kind of audio. If they aren't going to use it in their presentations, they find no need for it."

Bukshowany, likewise, does not use sound captured captured during a medical shoot; rather, he uses voice-over technology during post-production to finish the video. He explains, "They have music on, the radio is playing, people are talking, and audio is really not used."

But for all the lighting and sound considerations, attaining the right shot, ultimately, may hinge on the rapport developed between videographer and surgeon. Killips recalls one instance when problems arose because a surgeon was simply unaware of proper focal-length spacing. "The surgeon wanted to show me a gallstone he had removed from the patient. He kept walking towards me and I had to say, ‘You need to stop so I can shoot this.' And I backed up and he stepped towards me and said, ‘What's the matter, does this make you sick?'" The issue, in fact, was not revulsion, but the distance required for a usable shot. "And I said, ‘No, I can't shoot this.'"

Yet, most surgeons understand that they are the feature for the piece, and it is in everyone's best interest to leave shooting decisions to the video professional. Regarding a gynecologist he works with regularly, Bukshowany says, "I have to hand it to the doctor. He caters to the camera. He is very conscious of getting a great video and he allows me to tell him to move his hand, or move this, move that."

After stomaching a day-long surgery, what better way to unwind than open up your favorite non-linear software and relive the same fleshy footage? Indeed, few should be so lucky. But what may make things frustrating for the editor, aside from constantly viewing human innards, is that while hours of surgery may be recorded, only five to ten minutes of actual footage may make the final cut.

The function of the piece will usually dictate its length, but in either a longer educational video or shorter presentation piece, hours of footage will generally be removed. To ensure that he has created a film in accordance with the surgeon's needs, Killips often first makes a timecode-window copy of the procedure for the physician on his Mac-based Avid software. "The doctors goes through and indicate which segments they want. Then I go through the list given to us and I edit those pieces together," Killips says.

But aside from the annoyance of sifting through hours of sutured human flesh, medical projects require little or no specialized editing software tools or techniques. Although narration is often used to interweave the surgeon's explanation of a procedure (provided sound was captured), most other special features often used in training videos, such as green screen and chromakey, are sparingly used.

Sometimes, due to the live nature of the footage, surgeons may ask producers to cut out footage that reveals a patient's name or reveals other information that would violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which spells out a patient's rights regarding the privacy of personal health information and the accordant responsibilities of medical professionals to protect it. Charrette recalls a hair transplant procedure he produced on his Mac Final Cut 3 software when he was working in Canada that created such a conflict. "The doctor, the nurse, and even the patient were talking," he says. "The patient was talking about a bad experience in the U.S. and I think he, in fact, named the surgeon involved and they asked me to edit that out."

To avoid unanticipated sound-editing issues altogether, Bukshowany actually writes a script for each video he produces. The scripts are written prior to or after the surgery (but before the edit), depending on the nature of the procedure. He then hires voice-over talent to read the script blind. To interweave the narrated script over the footage, Bukshowany performs nearly all of his edits on MacroSystem's Casablanca Kron standalone editing system. He then, like most medical videographers, creates DVDs of his final product. "Now everything is DVD," he says, "A doctor is doing a lecture somewhere, he or she likes to do it off his laptop or overhead projector," and the portability and near-universal playback compatibility of DVD-Video thus makes it an ideal delivery medium.

Breaking into the Business
For the adventurous videographer looking to diversify his or her workload, the realm of medical videography is well worth exploring. In fact, marketing oneself in the medical community may be as simple as sending out a local mailing or inquiring at area hospitals to see if they require the type services you're prepared to offer. But as a cautionary note, the medical videography field may be rapidly changing—and possibly shrinking. Lathroscopic (Liz -- please check with Tom whether this should be lathrsocopic or laparoscopic) surgeries are becoming more popular for routine procedures, which by internally inserting a camera, eliminate the need to "open-up" a patient. Even more daunting is the fact that the cameras have the ability to record the procedure.

But until lathroscopic surgery completely dominates the surgical setting—which is many years away in most hospitals—physicians will still require the services of video professionals to document new and innovative procedures. If you find yourself with lulls in business or wanting to branch out your services, medical videography represents a ready-made opportunity, given the modest nature of the learning curve compared to legal videography. Moreover, you may well find yourselfon the cutting edge of revolutionary procedures, helping to advance medicine, a prospect most find very rewarding.

So, if you are willing to view open cavities and bloody tourniquets, opportunities await, as there remains a need for skilled videographers to capture the footage. But for many of us, that's a big "if," and a question that only experience (or extensive viewing of your local surgery cable channel) may answer. As Charrette says, "Just make sure that you can, in fact, stomach it. There is money to be made, but be prepared."

In the Spotlight

Crystal Clear Productions, Inc. (Greg Bukshowany)

Digital Video-Done Right! (Mark Charrette)

New York Video Crews (Dan Welch)

University of Wisconsin Health Sciences Learning Center (Michael Killips)