Richard F. Edlich

Dusting powders were first applied to gloves to facilitate donning. After 1980, manufacturers devised innovative techniques to manufacture gloves without dusting powders. It has been well documented that the powders on gloves present a health hazard to patients, as well as healthcare workers. First, these powders elicit tissue toxicity in every tissue in the body. Second, these powders serve as carriers of latex allergen and may precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powders have caused a growing number of emergency medical technicians, paramedics, firelighters, and hospitals to abandon the use of powdered emergency medical examination gloves, using only powder-free gloves. Powder-free latex as well as non-latex gloves are now available to emergency medical technicians, paramedics, firefighters, and emergency department personnel. The use of powder-free natural rubber latex-free gloves is especially important to emergency medical technicians, paramedics, firefighters, as well as emergency department personnel to avoid eliciting an allergic reaction in the latex sensitized patient. The majority of our emergency medical technicians, paramedics and firefighters are now wearing powder-free emergency medical examination gloves that comply with the stringent Codes and Standards established by the National Fire Protection Association (NFPA), while very few hospital emergency department personnel have been provided with NFPA approved gloves. It is the purpose of this report to review the stringent regulations for emergency medical examination gloves that are outlined by the NFPA. This design and performance Standard was devised by the NFPA to address protective clothing for emergency medical operations. The design and performance requirement of the emergency medical examination gloves were described in the NFPA 1999, Standard on Protective Clothing for Emergency Medical Operations, 1997 Edition. In September 2003, the emergency medical examination glove must meet the new design and performance requirements of emergency medical examination gloves discussed

The most frequently encountered neoplasm in the US is skin cancer. More than 600,000 new cases of malignant skin tumors are diagnosed in the US each year. One standard method of treatment of skin tumors is excisional biopsy. There are seven technical considerations involved in the excisional biopsy of skin tumors: (1) aseptic technique, (2) examination and demarcation of skin lesion, (3) skin biomechanical properties, (4) anesthesia, (5) excisional biopsy, (6) wound closure, and (7) postoperative care.The physician must use aseptic techniques and wear a cap, mask, and powder-free gloves. Hair is a source of wound contamination, and removal of hair prevents it from becoming entangled in suture and the wound during closure. Because surgical electric clippers cut hair close to the skin surface without nicking the skin, we now use only electric clippers to remove hair. The physician’s visualization of the wound can be enhanced by magnification (2.5x) loupes. The physician’s plan for excisional biopsy is dictated by the suspected pathology of the skin lesion. The ultimate appearance and function of a scar after closure of excisional biopsy can be predicted by the static and dynamic skin tensions on the surrounding skin. Infiltration anesthesia is preferred over regional nerve block because it does not interfere with the muscle movement that causes dynamic tensions, which elongate the configuration of the defect. Most skin lesions are amenable to a circular excision. In these instances, it is worthwhile to use circular-shaped excisions. The reusable metal trephines have been replaced by disposable trephines that have ribbed plastic handles attached to 316 stainless steel circular cutting blades. Wound closure is accomplished in the same direction as the long axis of the elliptical defect by first approximating the midportion of the defect with a 4-0 synthetic CAPROSYN* monofila-ment absorbable suture attached to the swage of the laser-drilled, compound-curved reverse cutting edge needle. Additional interrupted dermal (subcuticular) sutures are placed in each wound quadrant to approximate further the divided edges of the dermis. Compound-curved reverse cutting edge needles have been specifically designed for dermal closure. Reinforced Steri-Strips are then applied transversly across the incision to facilitate further skin edge approximation. Rigorous follow-up examination is essential for any patient with a history of a skin cancer to detect recurrence and prevent further actinic damage. The use of wide diameter trephine biopsy instruments are still not widely used by physicians because most physicians do not have the technical skills to approximate the defect with dermal sutures. Consequently, this need for a rapid dermal skin closure technique that can be used by a primary care physician must be devised before the trephine excisional biopsy technique is widely used by the primary care physician. This goal can be achieved by developing a disposable stapler for subcuticular closure of the skin.

Skin cancer is the most common cancer diagnosed in the United States, and its incidence continues to rise. Epidemiological studies have documented that excessive sun exposure increases the risk of developing nonmelanoma skin cancer. Consequently, it is mandatory that the skin be protected from the damage that occurs from ultraviolet (UV) exposure. It is the purpose of this report to review the scientific basis for photoprotection by sunscreens, topical antioxidants, and systemic antioxidants to minimize the harmful effect of sun exposure. The US Food and Drug Administration regulates sunscreen products as over-the-counter drugs. Sunscreens are chemical or organic UV absorbers and nonchemical or inorganic UV absorbers. Other important sunscreen considerations include the sunscreen vehicle, sunscreen photostability, sunscreen preservatives, and sunscreen photoallergy and phototoxicity. Topical and systemic antioxidants have now been shown to supplement the photoprotective effects of sunscreen. The Skin Cancer Foundation, the only national and international nonprofit organization concerned exclusively with cancer of the skin, is playing a leadership role in eliminating skin cancer in our world.

We are describing a heretofore untold narrative description of the emergency medical plan that saved the life of President Reagan on March 30th 1981. In 1976, Dr. Richard Edlich, director of the Emergency Medical Services at the University of Virginia Medical Center, wrote an editorial on the need for an emergency medical plan for the President of the United States. One year later Dr. Edlich enlisted the help of five distinguished experts in emergency medical systems in our nation to develop an emergency medical plan for the President of the United States. This published emergency medical plan was coauthored by Dr. David Boyd, the Director of Emergency Medical Services of the Department of Public Health and Welfare. Dr. Boyd wisely alerted both the Department of Health and Welfare as well as the White House staff, including Secret Service, of this plan. Realizing the importance of immediate emergency care, the Secret Service agent wisely recommended that the wounded President Reagan be immediately transported to the George Washington University Health Center, which has skilled emergency physicians as well as trauma surgeons, who saved the President's life. Realizing the benefits of this emergency medical plan that saved the life of the President of the United States, Drs. Edlich, Britt, and Wish will now be coordinating a medical narrative report that describes the development of emergency medical systems in the United States as well as modern trauma care in our nation.

One of the goals of this manuscript is to celebrate the influential and productive careers of three leaders in Emergency Medical Systems: Drs. James Mills, R Adams Cowley, and David Boyd. Through his courageous efforts, Dr. James Mills established the specialty of emergency medicine, with its own educational training programs, credentialing process, as well as a recognized society, the American College of Emergency Physicians. Dr. R Adams Cowley was the preeminent leader in developing an organized approach in trauma care in the State of Maryland, with the creation of the R Adams Cowley Shock Trauma Center. Many of the components of his comprehensive trauma program in the State of Maryland have been replicated in every state in our nation. Dr. David Boyd championed the development of emergency medical systems throughout our nation as he served as Director of the Office of Emergency Medical Service Systems in the Department of Health, Education, and Welfare. Under the guidance of Drs. Mills, Cowley, and Boyd, Dr. Edlich was a leader in developing emergency medical systems in the Commonwealth of Virginia. Unlike the comprehensive trauma system in the State of Maryland, the Commonwealth of Virginia, as well as other states in our nation, still lack statewide helicopter aviation services that bring critically ill patients throughout the state from the scene of injury to separate and distinct trauma facilities in which life saving trauma care can be initiated without admission to an emergency department.

This collective review has the following purposes. First we will describe each of the components of the Maryland State Police Aviation Division. We will then provide detailed information about the Atlas and Database of Air Medical Services (ADAMS) compiled by the center for transportation and injury research (Buffalo, New York) in alliance with the Association of Air Medical Services (Alexandria, Virginia) that provides a unique opportunity for each state to evaluate the comprehensive nature of their air medical services. The concept "the golden hour" has been molded into the world's premier public service aviation unit, which has proudly served the citizens of Maryland for over 24 years. This effort was initially made possible through a cooperative effort between the Maryland State Police Aviation Division and Dr. R Adams Cowley at the University of Maryland Hospital as a public service to the citizens of the state. This arrangement added a unique, economical, and life-saving component to the regionalized Emergency Medical Services and Critical Care system coordinated by the Maryland Institute for Emergency Medical Services Systems (MIESS). The Maryland State Police Aviation Division has four components: (1) aircraft, (2) state troopers, (3) system communications (SYSCOM) center, and (4) level I adult and pediatric trauma centers, as well as a regional burn center. ADAMS is a compilation of information of Air Medical Services in the United States to respond to traumas and other emergencies. Specifically, ADAMS provides descriptive and geographic information on Air Medical Service base locations, communication centers, rotor wing (RW) assets, and the major hospitals and transports that receive scene transports. The database includes all types of provider organizations including nonprofit, commercial, and public service (fire, police) air medical service providers, as well as several military units that routinely provide transport in remote areas. ADAMS provides national and statewide maps indicating air transport systems, trauma centers, and geographic population density. To provide a greater perspective on emergency medical care in individual states using the carefully tabulated ADAMS data, we compared the air emergency medical systems in Maryland to those of Oregon. Regardless of population density, Maryland provides air medical transport throughout the entire state, with the exception of only three small geographic areas. Maryland's 15 helicopter bases provide quick access for the seriously injured patient to either a Level I or pediatric trauma center within the "golden hour." In contrast, the air medical transportation system in Oregon is restricted to only three small geographic regions, making it an invitation to death for many seriously injured patients. It should be a federal mandate that the injured patient should gain access either by air transport or ambulance service to a Level I trauma center within that "golden hour." This federal legislation should include new criteria to initiate the dispatch of a helicopter to the scene of an accident or injury.

People are exposed to ambient solar ultraviolet (UV) radiation throughout their daily routine, intentionally and unintentionally. Cumulative and excessive exposure to UV radiation is the behavioral cause to skin cancers, skin damage, premature skin aging, and sun-related eye disorders. More than one million new cases of skin cancer were diagnosed in the United States this year. UV radiates directly and diffusely scattered by the various environmental and atmospheric conditions and has access to the skin from all directions. Because of this diffuse UV radiation, a person situated under a covering, such as the roof of a car or house, is not completely protected from the sun's rays. Because shade structures do not protect effectively against UV radiation, there have been major advances in photoprotection of glass by the development of specially designed photoprotective windows and films. It is the purpose of this collective review to highlight the photoprotective windows and films that should be incorporated into residential, commercial, and school glass windows to reduce sun exposure. Low-emittence (low-E) coatings are microscopically thin, virtually invisible, metal or metallic oxide layers deposited on a window or skylight glazing surface to reduce the U-factor by suppressing radiative heat flow as well as to limit UV radiation. The exclusive Thermaflect^® coating uses the most advanced, double-layer soft coat technology to continue to deliver top performance for UV protection as well as prevent heat loss in the home. This product blocks 87% of UV radiation and has an Energy Star^® certification in all climate zones. Tints and films have been another important advance in glass photoprotection, especially in automobiles. Quality widow film products are high-tech laminates of polyester and metallized coatings bonded by distortion-free adhesives. The International Window Film Association provides members with accreditation in solar control films, safety films, and automotive films in an effort to increase consumer awareness and demand for all professionally installed film window products. The Skin Cancer Foundation has also played a leadership role in certifying window films that limit UV transmission. The Panorama Designer & Safety Films are currently recommended for UV photoprotection by The Skin Cancer Foundation. On the basis of these innovative scientific and industrial advances in window and film photoprotective products, we recommend that they be used in all residential, commercial, and school facilities to provide photoprotection in an effort to reduce skin cancer.

The purpose of this collective review is to outline the predisposing factors in the development of pressure ulcers and to identify a pressure ulcer prevention program. The most frequent sites for pressure ulcers are areas of skin overlying bony prominences. There are four critical factors contributing to the development of pressure ulcers: pressure, shearing forces, friction, and moisture. Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation. Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer formation. Among the clinical assessment scales available, only two, the Braden Scale and Norton Scale, have been tested extensively for reliability and/or validity. The most commonly used risk assessment tools for pressure ulcer formation are computerized pressure monitoring and measurement of laser Doppler skin blood flow. Pressure ulcers can predispose the patient to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts. The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief. The pressure relief program must be individualized for non-weight-bearing individuals as well as those that can bear weight. For those that can not bear weight and passively stand, the RENAISSANCE^® Mattress Replacement System is recommended for the immobile patient who lies supine on the bed, the stretcher, or operating room table. This alternating pressure system is unique because it has three separate cells that are not interconnected. It is specifically designed so that deflation of each individual cell will reach a ZERO PRESSURE^® during each alternating pressure cycle. The superiority of this system has been documented by comprehensive clinical studies in which this system has been compared to the standard hospital bed as well as to two other commercially available pressure relief mattresses. The most recent advance in pressure ulcer prevention is the development of the ALTERN8* seating system. This seating system provides regular periods of pressure relief and stimulation of blood flow to skin areas while users are seated. By offering the combination of pressure relief therapy and an increase in blood flow, the ALTERN8* reportedly creates an optimum pressure ulcer healing environment. Foam is the most commonly used material for pressure reduction and pressure ulcer prevention and treatment for the mobile individual. For those immobilized individuals who can achieve a passive standing position, a powered wheelchair that allows the individual to achieve a passive standing position is recommended. The beneficial effects of passive standing have been documented by comprehensive scientific studies. These benefits include reduction of seating pressure, decreased bone demineralization, increased blander pressure, enhanced orthostatic circulatory regulation, reduction in muscular tone, decrease in upper extremity muscle stress, and enhanced functional status in general. In the absence of these dynamic alternating pressure seating systems and mattresses, there are enormous medicolegal implications to the healthcare facility. Because there is not sufficient staff to provide pressure relief to rotate the patient every 2 hours in a hospital setting, with the exception of the intensive care unit, the immobile patient is prone to develop pressure ulcers. The cost of caring for these preventable pressure ulcers may now be as high as $60,000 per patient. The occupational physical strain sustained by nursing personnel in rotating their patients has led to occupational back pain in nurses, a major source of morbidity in the healthcare environment.

On November 19,1945, President Truman outlined a Prepaid Medical Insurance Plan for all people through the Social Security System. Because of its comprehensive nature, it was coined "National Health Insurance." On July 30,1965, President Johnson signed the Medicare and Medicaid bill (Title XVII & Title XIX of the Social Security Act). Today, many groups of people are covered by Medicaid. However, there are strict requirements that may vary from state to state. Medicare offers the following types of medical heath care plans to include the original Medicare plan that is a "fee for service" plan. The individual may stay in the original plan unless he/she chooses to join a Medicare+ Choice Plan or a Medigap Plan. Most individuals will receive Medicare Part A when they are 65 without paying a premium because it has been deducted annually through their tax payments before the age of 65. Medicare Part A helps pay for the following: inpatient hospital care, skilled nursing facility, hospice care, and some home health care. Medicare Part B, however, must be paid by the individual through premiums to the Federal government. Medicare Part B medical insurance pays for doctors' services, outpatient services, and some other services that Medicare Part A doesn't cover. In an effort to supplement one's health care coverage, the individual may select either a Medicare+ Choice Plan or a Medigap Policy. The Medicare+ Choice Plan has four different types: Medicare Managed Care Plans, Medicare Private Fee for Service Plan, Medicare Preferred Provider Plans, and Medicare Specialty Plans. If one selects a Medigap policy, one may choose either a Medigap SELECT Policy or the standard Medigap policy. The front of a Medigap Policy must clearly identify it as a "Medicare Supplement Insurance." One must be carefully advised of the selection of the Medigap Policy. The Medicare Part B has a wide range of preventative services, including tests for breast cancer, cervical cancer, vaginal cancer, and colorectal cancer; bone mass measurements; diabetes monitoring and diabetes self-management; flu, pneumonia, Hepatitis B shots, and prostate cancer screening tests. It is important to emphasize that Medicare and Medicare supplemental insurance policies do not pay for home health care, such as durable medical equipment. Because of the enormous complexity of the wide variety of health insurance plans and their billing strategies, many physicians are electing to charge their patients an additional fee for being part of their practice. In return for their annual fee, their patients receive immediate cell phone access to their doctor 24 hours a day, 7 days a week. In addition, they receive same-day appointments and on-time appointments. They also spend as much time with their doctors as they wish. It is not surprising that there is growing evidence that the privately insured patient with a life-threatening illness will live longer than those individuals who have the same disease but have public insurance only. Legislatures are well aware of this crisis in medical care that must be corrected immediately.

Australia has developed a national health care policy that has made prevention of the occurrence of skin cancer a societal responsibility. Its strategies for skin cancer control have included careful documentation of the incidence of skin cancer over the last two decades. After realizing that the magnitude of sun exposure during childhood is a major risk factor in the development of skin cancer, Australia provides successful strategies to monitor and reduce the frequency of skin cancer. Early in the 1970s, education campaigns for the public as well as the healthcare worker were implemented that included booklets, posters, and teaching materials. This educational program allowed the public as well as healthcare workers to diagnose accurately the presence of skin cancer. In addition to identifying tumors at an early stage, Australia managed an exciting educational program on photodamage prevention. Australian standards governing ultraviolet radiation protection were incorporated into numerous comprehensive legislative bills that set standards for a wide variety of sun protective products to include sunscreens, photoprotective apparel, sunglasses, and occupational standards for sun exposure. On the basis of these comprehensive standards, the epidemic of skin cancer has been curbed, as documented. In contrast to Australia, the United States has relatively few comprehensive skin cancer prevention programs. These programs include the National Skin Cancer Prevention Educational Program, National Skin Cancer Prevention and Detection Month, The Skin Cancer Foundation's Self-Examination Program, and the State of California and US Food and Drug Administration Sunscreen legislation. It is difficult to measure the impact of these innovative efforts because there is not an accurate monitoring system for all skin cancers in the United States. However, the National Cancer Institute does determine the incidence of melanoma, which is reported annually by the American Cancer Society in their January/February issue of CA Journal for Clinicians. Statistics on other skin cancers are only projective. In the absence of an accurate, comprehensive statistical monitoring system for the frequency of skin cancer in the United States, as well as the limited legislative initiatives, it is difficult for organizations such as the American Academy of Dermatology, the American Cancer Society, the Centers for Disease Control and Prevention, and The Skin Cancer Foundation to ascertain the results of their efforts to prevent skin cancer. Consequently, the prevention of skin cancer in the United States is a personal rather than a societal responsibility.