Digital Video in Medicine
Contents
1. Digital Video in Medicine How to capture edit and share video of surgeries and other medical procedures By Patrick Reardon M D Director Advanced Minimally Invasive Surgery Training Program The Methodist Hospital Houston White Paper Digital Video in Medicine Contents Page 3 Page 4 Page 6 Page 13 Page 22 Page 23 Page 24 Introduction Why Record Surgeries For Yourself To Train Others To Educate Referring Physicians Digital Video Options Scenario A Good Scenario B Better Scenario C Best Other Options Capturing and Editing Video Step by Step Planning Your Movie Capturing Video Importing Video from Tape Editing Video Transitions Text Audio Compositing Exporting Sharing Your Movies Conclusion For More Information Appendix Apple Video Production Software iMovie and iDVD Final Cut Express Mac OS X Server Final Cut Studio Final Cut Server Xsan White Paper 3 Digital Video in Medicine Introduction In my career as a surgeon I ve seen firsthand how recording surgeries has helped improve my technique and how effective video can be as an education tool for others from new doctors to longtime practitioners Thanks to advances in video technology we can now record just about anything we can see including both open and endoscopic surgeries Even raw unedited videos provide valuable documentation of our work editing and annotating them turns them into outst2. No one understands your operation and what you want to convey about it better than you do And no one cares more about presenting your work positively than you do Today s powerful yet easy to use video editing applications free your creativity by simplifying basic editing tasks If you re serious about creating educational videos it s well worth your time to acquire editing skills yourself Even if you later decide to let someone else produce your videos having a good knowledge base enables you to work with a professional editor more effectively and to judge whether the final product shows your work in the best light You can also read more about editing and sharing surgical videos on Apple s website at www apple com science medicine videosurgery look forward to seeing your videos at upcoming meetings White Paper 23 Digital Video in Medicine For More Information For more information on using Apple products in medicine and clinical practice please visit www apple com medicine Here are some specific Apple products that can assist you with creating and publishing professional quality medical procedure videos e Final Cut Studio www apple com finalcutstudio e Final Cut Express www apple com finalcutexpress e iMovie iWeb and iDVD www apple com ilife e Final Cut Server www apple com finalcutserver e Xsan www apple com xsan e Mac Pro Mac mini iMac and MacBook www apple com mac e Mac OS X Server www apple
3. After you have finished editing your video and have added text to it play it through in its entirety As the video proceeds make notes of what you want to say for each portion Then flesh out your rough draft into a typed double spaced script with large easy to read type Be sure your script has a conversational tone not an academic one When narrating your video it s important to speak clearly in a conversational manner using normal lively inflections Don t succumb to the temptation to read the script in a monotone If you make an error or stumble simply stop speaking briefly so that you leave an audio gap and then say the line again If you want to add commentary in a language other than your native language consider finding a narrator who can speak the desired language more naturally Again this can make the difference in having your video accepted for use at a meeting or medical institution If you have the Final Cut Studio suite you can use the included Soundtrack Pro software to remove unwanted background noise and otherwise clean up your audio track Compositing Compositing is the combining of visual elements from different sources into a single video image In the final composited image it will appear as though all of the elements were a part of the same scene Understanding and mastering compositing can allow your videos to stand out visually and that will make them more effective teaching tools When people find
4. at least one FireWire port You can use any of Apple s video editing applications such as iMovie described in the following section to transfer the footage from the camcorder to the computer How you should store your video depends on how much video you collect and how you intend to use it If you simply want to document certain surgeries then storing the tapes or memory cards from your camcorder in a safe place may suffice If however you want to build a library of video from which you can develop presentation or curriculum materials then you ll want to transfer your videos to a hard drive In that case an external drive will prevent you from filling up your computer s built in drive and make it easy for you to take the drive wherever you need it such as between the office and home As you ll see later once you have selected specific segments of your video for use in a movie the storage space needed will be much less and you can keep those files right on the computer you re using for editing Note that if your camcorder only has analog output you ll need to research your options for converting the video to a digital format for use by the computer If you discover that making videos of your work is valuable and you decide to keep doing it you should consider moving to a recording device other than the camcorder White Paper 8 Digital Video in Medicine Edit and annotate A MacBook Pro notebook provides editing power and the added
5. benefit of portability so recommend it as your initial video editing platform Apple s iMovie software part of the iLife suite that comes on every new Mac is ideal for physicians who want to begin recording and editing procedures It helps you quickly and easily import your video select the parts you want and add transitions text graphics and voiceover narration iMovie supports both HD and standard definition SD video have a portable system that consists of a MacBook Pro with a power adapter and two bus powered 500GB hard drives in a wheeled carry on bag It s a simple but invaluable system that can take anywhere to record surgeries from laparoscopic cameras and edit the resulting video If you ll be recording surgeries where you can t capture video directly from a medical imaging device you ll also want to carry a camcorder and a tripod Scenario B Better If you decide to make movies on a regular basis you ll want to consider more sophisticated capture solutions as well as more powerful hardware and software for editing your video 5 eexeH B fro oon 0 0 0O 5 lOl aO DVCAM tape deck i lt 7 V 1 i Fin It Final Cut Express Interface device Capture In this scenario you could still capture video with a camcorder mounted on a tripod But let s assume that you re now capt
6. best wouldn t rely on locally attached disk drives If you want to maximize the educational value of your surgeries you ll want maximum flexibility to access and edit the video That means implementing a video storage solution that allows access to the video files from any computer with editing software Therefore recommend that you connect the Mac Pro systems in your surgical suites to a centralized Promise RAID disk array over a Fibre Channel network Another excellent addition to your campuswide system would be Apple s Xsan software Xsan is a 64 bit cluster file system that enables multiple Mac computers to share RAID storage volumes over a Fibre Channel network Xsan allows each client to read and write directly to the centralized file system so it makes workgroup collaboration fast and efficient We ve tested Xsan at The Methodist Hospital and I m impressed with how quickly can retrieve video files on whatever Mac l m using no matter where I m physically located Edit and annotate For editing and annotating surgical videos use Apple s Final Cut Pro software which is part of the Final Cut Studio suite If you need a lower cost editing solution recom mend Final Cut Express which has most of the same functions as Final Cut Pro In the next section of this paper l Il give you an example of how used Final Cut Pro to turn raw video into a movie fit for presentation at national conventions The best editing system would ru
7. built in Media Browser you can quickly find and add the videos you need Keynote is part of Apple s iWork 09 applica tion suite which also gives you word processing and spreadsheet tools that let you create professional quality results with the legendary Mac ease of use QuickTime Pro is an upgrade that adds features to QuickTime Player including the ability to create podcasts The Movie to iPod option makes it a snap to convert your video for use on iPod You can also save videos in the optimum formats for iPhone and other devices Podcast Producer is an end to end solution for encoding publishing and distributing high quality podcasts Ideal for presentations university lectures and distance learning Podcast Producer simplifies the process of recording content encoding video and publishing podcasts for playback in iTunes and on iPod iPhone and Apple TV Podcast Producer is included with Mac OS X Server v10 5 Leopard iDVD part of iLife and DVD Studio Pro part of Final Cut Studio are Apple s DVD authoring programs DVDs offer an inexpensive widely supported way to distribute video content For example they make a great handout at conferences You can prepare your videos for DVD with any of Apple s video editing programs and then send the files to iDVD or DVD Studio Pro to create and burn DVDs White Paper 21 Digital Video in Medicine Websites Websites are a great way to share your videos because web br
8. busy physicians allowing them to maximize the use of their limited time White Paper 12 Digital Video in Medicine Other Options The equipment described in the preceding scenarios only skims the surface of the options available to make impressive videos of your surgeries and other procedures As you ve seen suitable recording devices range from low cost consumer products to high end professional equipment In addition to camcorders and video equipped medical instruments your choices include HD videotape recorders DVD or Blu ray Disc recorders standalone USB or FireWire drives the internal disk drives on your computer and RAID storage systems You may also want software that renders DICOM volumes DICOM Digital Imaging and Communications in Medicine is a standard for distributing and viewing data still and moving produced by medical imaging devices OsiriX is an open source image processing application that enables Mac users to view and manipulate DICOM dcm images For example OsiriX can be used to repurpose volumetric radiology Studies such as CT scans and MRI images to improve their teaching and diagnostic value including use as reference materials during surgeries White Paper 13 Digital Video in Medicine Capturing and Editing Video Step by Step This section gives an overview of an effective process for capturing and editing video of your surgeries The steps in this section refer to Apple s Final Cut Pro softwar
9. closing credits However music behind video of the actual opera tion is distracting and should be avoided Voiceover equipment You have several options for recording voiceover audio Built in microphone A simple and inexpensive way to add audio to your video record ings is to use the microphone built into all MacBook and MacBook Pro notebooks oo EEE Target Sequence 2 Track A2 Voice Over 4 at lt a 27 24 H 40 46 12 9 G6 3 d E Source Guit in Microphone 16 Offset 3 Frame 18 mout menai meoprore Rate 48000 Hz USB microphone For higher quality audio recording connect a USB microphone to your Mac Many USB microphones are designed specifically for recording voice Check the Music amp Audio section of the Macintosh Products Guide guide apple com or the Music Creation section of the Apple Store store apple com for information on Mac compatible USB microphones Recording studio For optimum audio quality record your annotations in a sound booth Many universities already have such a facility or you can rent time at a commer cial recording facility When you schedule a recording session be sure to inquire about your options for taking home the finished audio such as on a tape or flash drive Several vendors offer sound booths that are affordable even for small medical practices White Paper 18 Digital Video in Medicine Creating your narration
10. com server macosx e Podcast Producer www apple com server macosx features podcasts html e iTunes U www apple com education mobile learning Apple has created a number of video capture editing and sharing tutorials that you can view on the Apple website They include e iMovie www apple com ilife tutorials imovie e iDVD www apple com ilife tutorials idvd e iWeb www apple com ilife tutorials iweb e Final Cut Express www apple com finalcutexpress tutorials e Final Cut Studio www apple com finalcutstudio tutorials Peachpit Press www peachpit com offers a wide selection of books about creating movies with Apple software Here are a few titles you may want to consider Apple Training Series iLife 09 Final Cut Express 4 Visual QuickStart Guide e Apple Pro Training Series Final Cut Express 4 Final Cut Pro 6 Visual QuickPro Guide Final Cut Pro Basic Editing Video QuickStart Apple Pro Training Series Final Cut Pro 6 Edit Well Final Cut Studio Techniques from the Pros The Methodist Institute for Technology Innovation and Education MITIE is a comprehensive state of the art education and research center at The Methodist Hospital in Houston Texas White Paper 24 Digital Video in Medicine Appendix Apple Video Production Software Whether you want to learn about movie editing by using software that comes on every Mac computer set up a departmentwide video workflow system or anythi
11. flexible or a rigid endoscope In addition moving digital images can be captured from the cardiac catheterization suite the digital angiography suite laryngoscopy equipment or even radiology scanning equipment such as CT scans or MRIs The open source OsiriX software allows you to process DICOM images on a Mac system On the back end capture options would include HDV decks hard drive recording solutions such as AIDA or AJA and network based capture solutions such as Apple s Final Cut Server You may also want to use an AJA lo HD box which makes it easy to connect your Mac to external video sources The lo HD supports Apple s ProRes 422 codecs allowing you to do production quality HD editing even on a notebook such as a MacBook Pro White Paper 11 Digital Video in Medicine Transfer and store In this scenario unlike the camcorder tapes we used in the first example data transfer and storage are already part of the capture solution But particularly with large HD video files storage becomes a critical point to consider As mentioned in the previous scenario if you plan to capture video directly to a hard drive recommend that at minimum you use a large high speed peripheral drive Depending on the length of the procedure and whether you re recording in HD or SD you may need more than one drive An ideal setup would be a Mac Pro with at least 4TB of disk storage in each operating theater However a system that is truly the
12. practice Such videos can reside on your own computer a local server a distant server via the Internet a CD a DVD an iPod touch or an iPhone Why learn video editing yourself You could pay others to edit your surgical videos for you However you would still have to review the entire unedited video first choosing the relevant segments and not ing their beginning and ending times You would then have to take the time to review rough cuts at various stages of the editing process And most important you would have to trust the editing service to edit the operation just right to clearly depict the relevant scenes and to make your work look its best Without an understanding of the editing process yourself it would be difficult to know what to ask for from the editor or whether the final product was all that it could have been On the other hand if you have editing skills yourself then you have two good options for creating effective videos You can choose to edit your videos yourself particularly if you find the creative process enjoyable Or you can knowledgeably engage others to do the work for you confident that you ll be giving them the instructions they need to do the best possible job White Paper 5 Digital Video in Medicine For example videos can be distributed throughout the medical school of a university or among the hospitals of a far flung hospital system Many journals now offer videos on their web
13. that particular oncologist send me his cases but so did other doctors in the room who were influenced by his unprompted remarks Previously my attempts to convince them that this surgery was a good oncologic procedure had fallen on deaf ears Once they were able to see it for themselves their thinking changed 180 degrees This was a great example of using a simple well edited video to convince referring physicians of the value of a particular procedure White Paper 6 Digital Video in Medicine Digital Video Options The workflow of creating surgical videos is straightforward e Capture the video If you are not capturing it directly transfer the video to a computer Edit the raw video down to the most important parts Add text voice and graphics as appropriate to improve the educational value of the video and give it a finished look The equipment you will need to carry out these tasks depends on the type of surgery or procedure you re doing the intended use of the video and what resources you want to devote to the project In this section l Il describe three typical systems in good better and best scenarios Scenario A Good First I ll describe a simple setup for getting started with digital video on an open surgery You can get your feet wet with your personal camcorder an Apple notebook and Apple s iMovie software Digital Camcorder MacBook Pro iMovie Capture Wi
14. way to share manage and use data on your network Specifically designed for computing environments that demand the highest level of data availability this powerful 64 bit cluster file system enables multiple Mac desktop and Xserve systems to share RAID storage volumes over a high speed Fibre Channel network Each client can read and write directly to the centralized file system accelerating user productivity while improving workgroup collaboration iTunes U is a free service available to qualifying institutions entering a service agreement with Apple Individuals looking to contribute content via iTunes U must do so through an iTunes U content provider 2009 Apple Inc All rights reserved Apple the Apple logo Apple Cinema Display Apple TV DVD Studio Pro Final Cut Final Cut Pro Final Cut Studio FireWire iDVD iLife iMac iMovie iPod iPod touch iTunes iWork Keynote Leopard Mac Mac OS MacBook Macintosh Products Guide QuickTime Soundtrack Xsan and Xserve are trademarks of Apple Inc registered in the U S and other countries iPhone and iWeb are trademarks of Apple Inc iTunes Store is a service mark of Apple Inc registered in the U S and other countries iDisk and MobileMe are service marks of Apple Inc Other product and company names mentioned herein may be trademarks of their respective companies May 2009 L404777A
15. with actual videos of your work could have much greater impact Let me give you a demonstration of that impact from my own experience Several years ago presented an interesting case at a meeting attended by all physicians who treat gastrointestinal disease at The Methodist Hospital showed a video of a laparoscopic right hemicolectomy at a time when many doctors felt this might not be a good operation for colon cancer Visually the patient was an ideal case to present Her tumor had been tattooed with India ink to highlight its location in the colon The ink had spread throughout the lymphatic drainage bed of her right colon so ink stained lymphatics as well as arteries and veins were easily visible and laid out as though they were illustrations in an anatomy book As the video progressed described each phase of the operation When the lights came back up an oncologist raised his hand He declared that prior to seeing my video he had refused to send colon cancer patients to surgeons who might attempt a laparoscopic resection because he believed the operation to be inferior from an oncologic standpoint He had assumed that sacrifices to standard oncologic principles would be necessary in order to do the operation laparoscopically He then stated that he had just witnessed as good an oncologic procedure as could be per formed in any manner and that he intended to refer patients for this type of surgery henceforth Not only did
16. 3D from Sequence 3 slsls Video Y Controls V Filters V Motion Ehi 00 00 10 00 White Paper 17 Digital Video in Medicine All of Apple s video editing applications make it easy to add text You can set your preferred font color size and other aspects of the text and place it wherever you want it on the image Final Cut Pro and Final Cut Express even include text generators that allow text to crawl horizontally across the screen scroll up the screen or display other attributes iMovie also offers scrolling text and a number of other text animation options Audio Unless you plan to present your video in person it s useful to add an audio commentary In fact it s a good idea to add one anyway you can always mute the audio on playback if you re on hand to describe the procedure All of Apple s video editing solutions iMovie Final Cut Express and Final Cut Pro include the ability to add voiceovers and other audio elements A great operative video can be rendered forgettable by poor narration In fact the quality of the voiceover may determine whether your video is accepted for presentation at a professional meeting or for use at a medical school The competition for presenta tion time and teaching selection is fierce so any aspect of your video that can help it stand out is critically important You may also wish to use a short musical soundtrack during the opening titles of the video and during any
17. Last Cross Dissolve Make Favorite Effect XF Media Stat I coe WI Coy a Video Transitions ia Last Cross Dissolve a Favorites b Bore eb 00 Default Cross Dissolve 38T 3D Simulation Dp Lewes m Set Default Dissolve J Additive Dissolve on a Clear Default Iris gt Beste eres i 3 Map p Dip to Cotor Dissolve ee eee Video Filters lt Page Peel b Dither Dissolve Pa Favorites P QuickTime gt Fade In Fade Out Dissolve ao 00 00 00 of Audio Transitions b Slide gt Non Additive Dissolve 00 00 00 00 A Favorites gt Stretch b Ripple Dissolve Wipe gt 00 00 00 00 Default None XT Set Default Clear Default Audio Filters Favorites b Make Favorite Motion NE Motion Favorites Master Templates Favorites v vv v Effect Availability Cross Dissolve can be your workhorse transition for surgical videos Other transitions may be used effectively to transition to and from text based images X ray images introduction images and the like but use them sparingly Sequence 3 ARTE 01 00 08 19 opido u rewrrprrrre Sma SES Ferry Opina e Text Text can serve many purposes in a video At the very least you ll want to put a title and your name at the beginning You may also want to have credits at the end Text is also valuable especially in teaching situations to clarify the spelling of unfamiliar terms such as organ parts and medical procedures 808 Viewer Title
18. VDs and other output options that you can simply drag into the Compressor job window Or you can create your own custom compression settings Compressor then creates a video file that s ready for your intended use Final Cut Pro JG Edit Effects Tools View Mark Modify Sequence 2 OO New gt a J New Project OWN ame dig Barrett s_Esophagus jpg Open 0 00 00 00 00 00 02 10 00 Compositing_video Open Recent gt 00 00 00 00 00 00 06 08 Motion Mapping seque Close Window 38W 01 00 00 00 01 00 065 08 Ci Tab AW ose ia 01 00 00 00 01 00 06 08 00 00 00 00 01 00 00 00 01 00 10 17 Motion Mapping seque EJ Motion Mapping seque Close Project 00 00 05 08 h k a Sae Project oe ee oe Patholagy Mask motn n Ay ect As nae 00 00 00 00 00 00 09 29 Practice video lift E3 Practice video lift E Practice video lift motn Practice video lift motn 01 00 00 00 01 00 05 08 01 00 00 00 01 00 06 08 00 00 00 00 00 00 06 08 00 00 00 00 00 00 06 08 Revert Project Restore Project Import EE Sequence 1 EF Video Lift QuickTime Movie we Send To gt TA Batch Export Ny Using Compressor Ea video 1ifto2 Using QuickTime Conversion on Batch Capture Log and Capture Log and Transfer 2 8 For Soundtrack 388 For LiveType Media Manage
19. anding educational tools The ability to capture and edit video footage of surgeries and other medical procedures is now within the grasp of the physician Endoscopes both flexible and rigid now routinely have video output capability A rigid endoscope may be used in both laparo scopic and open procedures Consumer grade camcorders may also be used during open surgeries A rigid endoscope such as those utilized for laparoscopy can be securely mounted in a sterile fashion into an open operative field This has advantages over a camcorder The recording source may be placed directly into the operative field near the subject to be recorded The view will not be blocked by the surgeon s head and it also brings its own light into the operative field By adding an Apple MacBook Pro notebook which includes the iMovie application for basic movie editing or a Mac Pro desktop system with Apple s Final Cut software you can quickly and easily build a first rate system for creating compelling surgical videos In this white paper l Il explain the benefits to today s physicians of capturing videos of their work Then l Il outline the equipment you will need and discuss how you can edit and share your video using Apple hardware and software invite you to learn more about this exceptional way to keep your own practice up to date and to share your expertise with other physicians A personal recollection At one point in my career as a surgeon fe
20. d using the Log and Capture import option because it allows you to capture only the video that you deem important which saves storage space on your drive This method also lets you give each individual clip a descriptive name Final Cut Pro zi Edit View Mark Mo eee ees New gt CETA New Project TEN gt C Ad Open 20 T T Open Recent gt gt Fo s ilis Close Window W gt Video Close Tab SWN Close Project Save Project S Save Project As TES Save All KES Revert Project Restore Project Import gt Export gt Send To gt Batch Export Batch Capture SE Log and Capture 38 Log and Transfer 388 Media Manager Reconnect Media Set Logging Bin Print to Video M Edit to Tape One of the most useful features of Final Cut Server is that users can have their video automatically rendered into the format that they prefer to work with use the Apple ProRes format but even if users edit on a PC Final Cut Server can automatically render their video files into the format they wish to use Xi Q White Paper 15 Digital Video in Medicine As the tape plays you tell the software when to start and stop capturing video by setting in points and out points Each in out combination creates a separate video clip recommend that you take time to give each clip a descriptive name Choose a name that will help you remember exactly which part of the operation is
21. demanding services and applications Its multiple built in collabora i tion technologies include full featured web hosting wiki distributed computing email A IM file sharing and directory capabilities And its Podcast Producer software lets users A capture encode publish and distribute podcasts White Paper 25 Digital Video in Medicine Final Cut Studio Apple s flagship video editing suite Final Cut Studio includes six post production applications that work together seamlessly The heart of the suite is Final Cut Pro which lets you edit quickly and accurately The first choice of professional editors worldwide Final Cut Pro delivers high performance digital nonlinear editing native support for virtually any video format and facility class extensibility and interoperability Final Cut Pro integrates with Motion for stunning 2D and 3D motion graphics Soundtrack Pro to create the perfect soundtrack for your video and other applications for color grading high quality video compression and DVD authoring in either HD or SD DVD Studio Pro is a professional quality DVD authoring program Final Cut Server Final Cut Server is Apple s media asset management and workflow automation Final Cut Server software for collaborative video production It helps you and your colleagues find assets instantly share work seamlessly and automate routine tasks so that you can focus on being creative Xsan Xsan offers the best
22. deo from laparoscopic equipment directly onto a Mac Pro computer Transfer and store In this better scenario we ll stay with the external disk drive recommended as a storage solution in the good scenario Of course depending on how long your surgeries last and whether you want to record them in SD or HD you may need more than one disk drive for a single operation One interesting and versatile option at this level is to set up a video capture kiosk in each operating room consisting of a MacBook Pro with Apple s Final Cut Express application Doctors then bring their own removable drive for each operation hooking up both to the MacBook Pro and using Final Cut Express to control the camcorder and send the resulting video to the external drive Edit and annotate Final Cut Express software is a great option for those who don t need the full capabilities of the Final Cut Studio 2 suite It offers nearly all the same editing capabilities without the additional software to create more advanced animations audio editing and so on Final Cut Express will run just fine on a MacBook Pro notebook as many professional moviemakers can attest However at this level of video production a Mac Pro desktop system might meet your needs better Scenario C Best Our best example builds on the previous system As before it involves capturing video directly from medical imaging equipment But this scenario uses larger and more sophis
23. e Most of the same functions are built into Final Cut Express and many are also available in iMovie Refer to the websites listed at the end of this paper for more information on all of Apple s video editing solutions Planning Your Movie If you ve decided to record a surgery for educational purposes preoperative planning is just as important for your video as it is for your patient Consider which steps of the operation are most critical how you want to perform them and how you want to depict them in your video It may help to think about how you would describe this surgery to residents or during your oral board exams Plan ahead to record the most important details at the time of the surgery and you will have the best starting point for editing Check the recording equipment the day before the procedure to ensure that it is in good working order This gives you time to repair any problems or come up with an alternative method of recording Bring enough tapes to cover the longest period of time that the operation could possibly take then add one or two more If you will be capturing the video directly to a portable hard drive make sure that you have it ready When you capture surgical video that will be used to educate other physicians it s vital that you select your team members carefully It is important for every member of the operating team to know the planned procedure its important steps and what you want to achieve by recordin
24. even act as a repository for email discussions about a particular case or department iDisk One of the MobileMe online tools iDisk allows you and your colleagues to access your shared files from any web browser running on any type of computer wherever and whenever you need them iDisk gives you plenty of storage space so even large medical video files are no problem And with its familiar intuitive interface uploading and organizing files is as simple as drag and drop If you allow it your colleagues can also post their own files to your MobileMe iDisk iTunes U iTunes U is an innovative service that places the power of the iTunes Store in the hands of hundreds of colleges universities and cultural institutions making their educational content available free to students and educators Search the Medicine and Health category in iTunes U to find a wide variety of medical courses lectures and procedure videos all available for viewing and downloading for free on a Mac a PC or an iPod All content on iTunes U is available free to anyone who has iTunes White Paper 22 Digital Video in Medicine Conclusion Creating digital videos for those in the medical profession is all about education e Educating colleagues and trainees on how to perform procedures and operations e Educating referring doctors about how you can help their patients e Educating yourself on exactly what you re doing in the operating room and how you might improve it
25. g it For example the person running the camera needs to know how to follow the action smoothly and how to use an angled laparoscope with facility To create more powerful images we even teach our camera drivers the rule of thirds a rule for pleasing image composition that is familiar to both still and film video photographers SAGES has published its own set of video production guidelines These guidelines are somewhat dated now in their discussion of available formats connection types and peripherals but they still provide good suggestions for improving the quality of your video capture in the operating room For example no amount of digital editing will make up for video that doesn t capture the essential steps of the procedure or for shaky camera work or a blood smeared lens The SAGES guidelines are available online at www sages org publication id VID White Paper 14 Digital Video in Medicine Capturing Video Before the operation begins make sure that your cinematographer understands the proper technique The arm holding the camera should be held tightly against the person s trunk to shorten the lever arm distance between the stable platform and the camera This helps keep the image steady Incidentally both iMovie and Final Cut Pro have stabilization capabilities that can reduce the shaking in a video image Leave the tape recorder or hard drive running from skin cut to skin closure to ensure that you d
26. in that clip just by reading the title For multiple clips that represent a single part of an operation such as a particular anastomosis you can log and name the first clip and then let Final Cut automatically number subsequent clips anastomosis 01 anastomosis 02 and so on When you move to a different portion of the operation start a new naming sequence When editing with tape you can go through your entire tape assign all of your in and out points log your clips and give them names and then instruct Final Cut Pro to capture those clips Final Cut will then go from one end of the tape to the other digitizing the segments you selected This process may take a while because the tape has to play at its normal speed while the video is captured and digitized This is one of the tremendous advantages of using the Final Cut Server system At The Methodist Hospital can send my captured video from the AIDA device to the Final Cut Server system with a few taps on a touch screen monitor By the time get to my office Final Cut Server has converted my video into Apple ProRes files based on my own set of preferences Users can choose the file type for their converted video Final Cut Server also creates a high resolution thumbnail video which I can preview Using the Gigabit Ethernet backbone at our hospital the video can be downloaded rapidly to my office computer Once there it is immediately available for editing Editing Video The Fi
27. lt that was beginning to mature in my technique Then looked back at some of my old laparoscopic 360 degree fundoplication videos realized that had not been as good a surgeon as thought was at the time What this taught me was that no matter how good you think you are at performing medical procedures there is usually still room for improvement As professionals physicians are expected to engage in lifelong learning and self improvement Recording and viewing our own procedures is an excellent way to help us do so White Paper 4 Digital Video in Medicine Why Record Surgeries believe that physicians who perform surgeries and other medical procedures can help themselves their students and their colleagues by making videos of their work And with today s technology it s easy Here are a few reasons to consider filming your work For Yourself Reviewing your own surgeries or other procedures with a critical eye toward your tech nique can be very beneficial In fact Practice based Learning and Improvement is one of the six core competencies defined by the American Board of Medical Specialties For physicians who perform procedures there is no better way to put that guideline into practice than to record and review your work Organizations such as the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons SAGES already make available peer reviewed videos on various
28. n Final Cut Studio on at least one Mac Pro in each department Each Mac Pro would have access to Final Cut Server for managing and editing the digital assets stored on the RAID disk array Final Cut Server acts as a system to gather and store digital assets from across the enterprise It then serves as an asset manager allowing access to the assets though an easy to use interface that Mac users expect At The Methodist Hospital we use Final Cut Server This asset manager goes well beyond simply managing digital video and still images it allows us to store our captured digital assets from different capture devices to a centralized location using our network Customized metadata tags can be used to search for a video or a still image using keywords The software then automatically generates a small rapidly viewable proxy video that users can quickly play or scrub to verify if it s the same video that they searched for The quality of these proxies is so good that when this software was demonstrated to some of our physicians they incorrectly thought they were viewing the actual video file Final Cut Server is Java based and can be used by both Mac computers and PCs Each user can have preferences so that Final Cut Server delivers video in just about any codec for editing on either a Mac or a PC The software even notifies physicians by email when their video is ready for download in the requested format This is a great feature for
29. nal Cut Timeline is where you assemble your movie from the captured video clips As its name implies the Timeline is a linear window that determines the sequence in which events will happen For your first simple Final Cut project the Timeline will primarily contain video clips plus audio clips and transition effects if you like Advanced Final Cut projects can contain hundreds of compositing and graphics effects but the Timeline is still what holds everything together In order to begin editing you simply drag the appropriate video clips into the Timeline window Once all the desired clips are in the Timeline most of your editing can be accomplished with just two tools in the Tool palette the arrow to select a clip in the Timeline and the Razor Blade to cut out unwanted parts of it Incidentally you can bring in any of your video clips plus supporting media such as still photos and diagrams to create a single Final Cut project the clips don t have to be from the same file folder of the same surgery For example you could show in a single movie how you dealt with several different tricky colon cancer resections White Paper 16 Digital Video in Medicine Transitions When you view your rough cut where the unwanted parts have been edited out the changes from one clip to the next will be abrupt In most cases you ll want to use Video Transitions to make the changes happen more smoothly Sequence figa Tools Window Help
30. ng in between Apple has software to meet your needs iMovie and iDVD iMovie makes viewing editing and sharing video intuitive First review the video of your medical procedure to select and extract the sections you want Drag your selec tions into the project area and arrange them as you wish Then add text annotations transitions and if you like a voiceover narration In just a few more steps you can upload your movie to a website create versions for iPod and iPhone devices or send the file to iDVD to create ready to view DVDs iDVD lets you incorporate sophisticated features such as scene selection menus on your DVDs cos gm D iMovie and iDVD come with every Mac They re part of the iLife 09 suite which also includes applications to help you organize photos design web pages and more Final Cut Express For more advanced video editing Final Cut Express delivers a powerful professional toolset that s great for editing raw footage or putting the final touches on an iMovie project Use it to capture the most popular formats from a camcorder including DVD and HDV You can even mix different video formats in the same movie Final Cut Express also lets you add dynamic animated text sophisticated transitions and other professional quality effects Mac OS X Server Ja 6 7 a by Apple s powerful operating system offers the reliability stability and performance you Server U E 7 need for the most
31. on t miss any important portions of the operation There is nothing more frustrating than missing a superb example of a surgical procedure because you turned off the recording device to save tape or drive space and then forgot to turn it back on Recordings of rare clinical findings only happen if you are prepared To give an example was once able to videotape two cases of true left sided gallbladder in a 45 day period The odds of finding the gallbladder located under segment III of the liver are one in ten thousand was able to record both of these cases for posterity because our operating room facilities are always ready to capture what we see on the screen By the way during the operation make sure that you capture a good example of each step even if that sometimes means doing another take Importing Video from Tape Once you ve captured the video of the surgery or other procedure you re ready to import it to your Mac editing application If you ve already stored the video on an external hard drive or a network server you can call up the files directly from that device But if you are importing video from a camcorder you would follow the steps below To import the video you can connect your camcorder directly to your Mac through a FireWire connection if available otherwise with USB and then control playback of the tape with the software itself If you re editing with Final Cut Express or Final Cut Pro recommen
32. owser applications come with new computers so people don t have to obtain any special software to view your videos Personal website If you have your own website on Apple s MobileMe or another hosting service and an Internet account that gives you sufficient monthly bandwidth you can host your surgical videos there Medical websites As medical journals and associations recognize the value of educational videos they are increasingly adding them to their websites either accompanying an article or as standalone offerings Many institutions such as medical schools are doing the same In the commercial arena the WebSurg site www websurg com is devoted to laparoscopic surgery education It features hundreds of surgeries lectures and other videos which can be viewed on a desktop computer iPhone or video capable iPod iWeb part of the iLife suite that comes on every new Mac helps you quickly and easily design web pages including images and videos Then with a click you can upload the finished pages to your MobileMe account or other website Wiki Server which is built into Mac OS X Server enables you and your colleagues to collaborate and share information about your surgical movies When you post movies Slides papers or other content it can be tagged with relevant keywords Subscribers to specific topics will automatically be notified about new material via RSS Users can also add comments about the movies Wiki Server can
33. procedures that have been created by experts in their respective fields Other practitioners can compare these videos to their own techniques to ensure that they are exercising their skills at a high level Even the very act of planning to record a procedure can improve your performance Before the operation you ll want to decide which parts of it are critical and worthy of recording and how you ll perform those steps during the operation in order to create the most useful video Thinking about an operation you have done many times before in this new way can be very instructive for you as a surgeon To Train Others There is no better way to train residents fellows and other individuals in how to carry out a videoendoscopic surgery or other procedure than by recording digital video of the procedure and then editing and annotating it for maximum educational effectiveness If you write an article about how you perform a certain procedure other physicians may be able to duplicate your approach with some degree of accuracy If you illustrate the steps with medical drawings or photographs people may follow your example even more accurately However because humans are so visually oriented the ultimate teaching tool is a well edited video A video that depicts the critical steps of a procedure with clear images and high quality voiceover narration becomes an expert in a can instructional video that can train physicians no matter where they
34. r Audio to AIFF s Reconnect Media Audio to OMF Set Logging Bin Batch List Print to Video AM Cinema Tools Audio EDL Cinema Tools Change List Cinema Tools Film Lists Cinema Tools XML Film Lists EDL XML Edit to Tape k Motion Mapping sequence White Paper 20 Digital Video in Medicine Sharing Your Movies Once you have created a video it can be repurposed for many different uses Here are a few ideas on how to share your completed movies Meetings and courses Try out a new video first at local meetings or grand rounds Then after any tweaking prompted by feedback from those presentations submit it to a national event such as the SAGES annual meeting or the American College of Surgeons Clinical Congress You can use your videos in courses you teach at your own institution or health system as a guest lecturer at another site or at a regional national or international medical conference As a Mac user you have excellent solutions available for presenting your finished videos to audiences Keynote 09 the latest version of Apple s powerful presentation software helps you tell your story effectively and dramatically More than 35 Apple designed themes let you create a cinema quality presentation in minutes with coordinated fonts textures and layouts for different types of slides The Slide Navigator and Light Table make it easy to organize your presentation and using the
35. s a great tool that should be in every video educator s armamentarium Head mounted cameras are another option for capturing video of an open surgery See Apple s profile of London s Great Ormond Street Hospital www apple com science profiles gosh for a great example of that method If your procedure is apt to last longer than the capacity of a single tape you may want to capture video directly to a hard drive rather than having to change tapes midway You can use a regular camcorder with a large high speed peripheral drive I use a 500GB FireWire 800 drive that s powered by the device it is plugged into Video files require large amounts of hard drive space and rapidly consume the free space on the main hard drive of your computer External drives are easier to carry from place to place and they eliminate the need to bring the computer itself into the operating theater You will assemble your final movie on your computer s own hard drive later As an alternative you can use an AVCHD system that records to an internal hard drive or to flash memory For example an AVCHD camcorder with a 120GB internal drive can store about 10 hours of HD quality video Transfer and store Camcorders offer a selection of interfaces that allow you to transfer your video to a computer Look for a USB or FireWire connection You may see the terms i Link or IEEE 1394 instead of FireWire All Apple computers have at least one USB 2 0 port and almost all have
36. sites that supplement the information provided in the print version of the journal Clearly the potential value of these educational resources is immense As mentioned in the previous section the very act of creating a procedure video can be a self improvement process in itself Preparing to record a procedure for educational purposes forces you to critically evaluate your technique Creating a training video for other physicians can therefore benefit you too To Educate Referring Physicians Many physicians mistakenly believe that procedure videos are useful only in academic environments or to show at national meetings within their own specialty In fact such videos can be important outside of your immediate medical community A well edited video of one of your procedures presented at a local or regional meeting allows potential referring physicians to see your skills firsthand Many times these doctors have no other way to assess the quality of procedure performing physicians All proceduralists say they do a great job and the physicians who are competing with you for referrals are not likely to speak on your behalf So how can a potential referrer select the best proceduralist for each situation Video allows you to record and carefully edit your best work for presentation to this important group of referring physicians Many new physicians send out brochures announcing the opening of their practice and touting their skills A CD or DVD
37. th an open surgery the easiest capture method is to set up a camcorder on a tripod Of course you must place the tripod where it will not interfere with the surgical team and it may be difficult to find a location where the surgeon and assistant will not block the camera s view But camcorders can t be beat for price If you don t already own one models that support the popular MiniDV tape format can be purchased for only 200 300 High definition HD camcorders currently start at several hundred dollars but they provide a level of detail that can be valuable in analyzing the minute details of an organ Be sure to check out camcorders that support HDV or AVCHD the latest high definition formats White Paper 7 Digital Video in Medicine A better solution for open surgeries if you have access to the necessary equipment is a laparoscope laparoscopic camera and recording device We currently use Karl Storz products at The Methodist Hospital With a table mounted holder you can bring a sterile laparoscope right into the operative field And unlike a traditional video camera an angled laparoscope can get a good view of the operation without obscuring the surgeon s view The light source that s part of the laparoscope even has the benefit of improving the lighting of the operative field My colleagues and have used this technique to film aortic valve replacements Whipple procedures open hernia repairs and other open procedures It
38. ticated solutions that would likely be affordable only by hospitals or groups of physicians rather than individuals Below is a diagram of a system that would allow a hospital to capture and store video from multiple procedure rooms Deploying such a versatile system would provide doc tors with a wealth of video footage from which they could create compelling learning aids This example system includes A Mac Pro computer in each procedure room to capture HD video from the endoscope via an AJA Kona card OsiriX software may also be added to view DICOM images A centralized editing station consisting of a Mac Pro with Final Cut Pro software and its own Promise RAID storage A data storage room containing a Promise RAID picture archiving and communications system PACS plus an Apple Xsan collaboration server that communicates with Xsan client software on the Mac Pro systems in the endoscopy rooms White Paper 10 Digital Video in Medicine Endoscopy procedure room Interface device Endoscope Fibre Channel Editing suite and primary storage room 30 inch Apple Cinema Display Promise RAID Mac Pro Final Cut Studio SAN Central storage Promise RAID picture archiving and Apple Xsan communications system PACS collaboration server Capture As in the previous scenario the image source may be a
39. uring it directly from medical imaging equipment such as a laparoscope or a flexible endoscope Flexible and rigid endoscopes of many different types and from many different vendors Karl Storz Olympus Fuji Stryker and so on can be used to capture video for later editing One option for capturing video is to connect a camcorder to the endoscope via FireWire Karl Storz sells endoscopes that support FireWire and many HDV camcorders support it as well You ll see the FireWire interface called i LINK on Sony products You can then start and stop the recording directly from the device control module in your hand Even better than recording to a camcorder would be having your endoscopic camera feed a video tape recorder An HDV tape deck connected to a medical imaging device will give you excellent video to work with White Paper 9 Digital Video in Medicine You can also use video capture hardware to save the incoming video directly from the medical imaging equipment to your Mac In this situation you ll need an interface device to convert the video format codec coming from the camera into a format compatible with video editing software Here are two recommended options for such a device AIDA is a standalone image management system from Karl Storz Imaging After it captures and translates video from your laparoscopic camera you can transfer the video file to your Mac for editing AJA s Kona cards can capture both SD and HD vi
40. your video visually interesting they will stay focused on it When they stay focused on it they are more likely to assimilate the information contained in it White Paper 19 Digital Video in Medicine In the Final Cut Studio suite Apple s Motion software provides sophisticated compositing capabilities For example it allows you to add arrows to point to important visual elements in your video such as the location of a small hard to see lesion Your arrow can even rotate around the point of interest or move up and down on the screen Another handy effect is masking part of an image such as a group of suspicious looking cells to highlight it against the rest of the image Consult the SAGES document or the Final Cut Pro User Manual for instructions on those techniques Final Cut Express and iMovie also include compositing features Exporting Generally you don t want to show your video from within Final Cut Pro Once you have assembled all its elements video text and audio in their final form you will want to prepare your video for other viewing options If you want to put the video on a tape for someone to view connect a FireWire tape deck to your Mac and then use the Print to Video command in Final Cut Pro to record your edited video on tape For digital media your final product is output with Compressor another component of the Final Cut Studio suite Compressor offers presets for the web iPod devices D
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