Freelance photographer Jitendra Shirpurkar has witnessed doctors fixing bones, breaking skulls and suturing wounds. Forty seven-year-old Shirpurkar has been hired many times by doctors to take photographs of surgeries. While the doctors and nurses in the operation theatre prepare the patient for the surgery, Shirpurkar adjusts his camera to the set-up and lighting in the operation theatre.

“Once, I was shocked to see the doctor using a drilling machine to break inside the skull for a brain surgery,” said Shirpurkar. “If I had to choose between shooting a fashion show and an operation, I would gladly do the former.”

While many hospitals record surgeries in their entirety on video, photographers like Shirpurkar get called in when doctors want to document new surgical techniques, rare medical conditions, or test new equipment. Sometimes photographers are even hired at the behest of the medical device maker as proof that their product works. Doctors and hospitals prefer to have professional photographers do the job so that they have high-quality photographs to use in medical papers and brochures or share with colleagues at conferences.

Twenty nine-year-old Swapnali Palande has just finished her first assignment of medical photography. Last month, Palande donned green scrubs like the ones doctors and nurses wear. She scrubbed her hands and entered the operation theatre at a hospital in Thane. “My hands were shaking for the first five minutes,” recalled Palande. “I had to pacify myself. I decided to look at the operation as a theme and proceeded with the photography.”

Palande spent an hour in the operation theatre taking photographs of doctors performing an angioplasty procedure. While the cardiologist was placing stents in the hardened heart vessels of a patient, Palande was making sure that she got candid photographs of the doctor.

“Usually, I can ask my subjects to hold a pose but I couldn’t ask the doctors to do so,” said the young photographer.

About 15 years ago when Shirpurkar landed his first assignment for shooting a surgery, he was thoroughly interviewed by the doctor. The doctor asked Shirpurkar if he would be able to stand the sight of blood. “You won’t faint in the operation theatre?” the doctor had asked Shirpurkar.

Since then Shirpukar has witnessed some 250 surgeries up close and claims to have seen nearly seen all human organs with the naked eye, a privilege only medical professionals have.

“The most challenging part of being in the operation theatre is the stench,” he says. “When the doctor uses the cautery, there is burning of the skin which results in a foul smell.”

The negatives

More is not merrier in an operation theatre.

Every additional person in the operation room increases the risk of infection to the patient and medical norms restrict people in the surgical space to the lowest necessary number. Hospital infection control experts said that the bacterial count in the operation theatre is directly proportional to the number of people in the theatre.

“Overcrowding in the operation theatre is already an issue,” said Dr Rohini Kelkar, vice president of the Hospital Infection Society of India. “I wouldn’t allow such photography in my operation theatre. There are some etiquettes to be followed while in the theatre. How can you expect a non-medical professional to know and abide to it?”

Dr Shishir Shetty, a cancer surgeon from Fortis Hospital in Mumbai said that photographers, like any other operation theatre staff, are expected to undergo a MRSA screening – a procedure to detect if the person is a carrier of the resistant bacteria methicillin resistant staphylococcus aureus.

But Kelkar, who is also the head of microbiology department at Tata Memorial Hospital, said that no outsider should be allowed in operating theatres. “You might as well perform the surgery on the road," she said emphatically. "The camera equipment and cords enter the operation theatre from the outside world, it can bring infections along.”

One photographer said that camera equipment is rarely cleaned before it is brought in the operation theatre. “Only one hospital in Mumbai had asked me to clean my camera and tripod with a solution they gave me," claimed the photographer. "Others, especially government hospitals don’t really care.”

Some surgeons who think it is important to document their work visually keep the outsiders out but ask their operating staff to take pictures. Cosmetic surgeon Dr Debraj Shome has trained a staff nurse in his operation theatre to do the job. “It is very important to document the improvement in cosmetic procedure and that can be best done by photographs,” explained Shome.

Who's picture is it anyway?

While photographers are hired by doctors, do patients get a say?

A year ago, Shetty from Fortis Hospital hired a photographer to shoot a rare surgery he was going to perform. “We were using the 3D technology to print a jaw bone for a reconstruction surgery,” recalled Shetty. “Though we called the photographer it was only for the purpose of documenting the surgery and use the videos and photographs for presenting at medical conferences.”

Shetty said that he took the permission of the patient before calling in the photographer. “We have to take the consent of the patient," he said. "If the patient is not comfortable, we have to respect it.”

However, a freelance photographer on condition of anonymity admitted to having entered an operation theatre without the consent of a patient’s family. “In one case, the family had not consented and hence, the doctor asked me to enter the operation theatre from the other gate (not visible to relatives)," said the photographer. "Especially when the patient is a woman, the family as well as the patient have apprehension of having a photographer inside the operation theatre.”

Senior spine surgeon Dr PS Ramani said that photography is integral for the purpose of training medical students. “We use these photographs to teach our students," he said. "Consent of the patient is always taken.”

Shetty insists that though he finds it useful to have photographs and videos of his procedures he would never share them on social media. “The idea is of documenting, not showing off," he said. "We never click a selfie in the operation theatre. It is a place of serious work."

And yet, it is not uncommon for pictures of fibroids and tumors exposed during surgery finding their way to Facebook. On several occasions doctors themselves have posted pictures of “huge tumours” they have excavated from a patient’s body.

In July, a gynaecologist and pediatrician from NKP Salve Institute of Medical Science in Nagpur were suspended after they took photographs of a baby born with a rare congenital condition called Harlequin ichthyosis in which a thick, hard skin covers the infant's body. In one of the pictures the doctor was holding the baby. The photographs were widely circulated on social media websites and messaging applications.

A month before that, a picture of doctors at the Punjab Institute of Medical Sciences in Jalandhar sparked public outrage. The photograph showed the doctors turning to pose for the camera while in the middle of a surgery, with their surgical instruments still inside the patients body.

Mobile phone photography

If the ethics of medical photography were not quite black and white earlier, the now ubiquitous mobile phone camera has made things even more grey.

Reji Pinto has been a photographer for 27 years and has been shooting surgeries for over two decades. “Earlier, we would be called quite regularly but now doctors shot their own pictures using their phone cameras,” said Pinto

A senior doctor said that a patient, once under anesthesia, is at the mercy of the doctor. “How can one be sure that the surgeon is not clicking photographs using camera," asked the doctor who wants a ban on cellphones in operating rooms. "There have been instances, where doctors are found answering calls while they are in the theatre.”

Even so, professional medical photographers aren't going anyway any time soon. Pinto considers himself to be half a doctor given all the surgeries he has worked through, many of them of childbirths and knee replacements. But he also knows to be very careful inside the operation theatre. "I make sure, that I am not close to the plate they (doctors) use to keep the organs, while they are operating," he said. "I have seen a beating heart. I am sure some people might faint seeing the photographs, we take.”