You have been notified by the special education department that a new student has moved into your county and that you will need to start transporting the student immediately. You send the school bus out the next morning, and the driver and monitor are faced with a wheelchair they have never seen before. In addition, the student is on a ventilator that has been placed, unsecured, on a tray on the back of the chair. Adding to the confusion, the student's mother starts talking about the importance of disengaging the gears of the motorized wheel-chair. Panic overtakes your staff.
Scenarios like this one happen all too frequently. However, increased teamwork between the special education and transportation departments, as well as a keen understanding of best practices in loading and securing students in wheelchairs, can make situations such as this the exception rather than the rule.
When the special education department is having an Individualized Education Program (IEP) meeting for a new student who requires special transportation, the transportation department must become an integral part of the process. The transportation staff, the physical therapist (PT) and/or occupational therapist (OT), the parent and the student should meet and examine the student's wheelchair. Together, they should assess the student's position in the mobility device and determine if additional positioning adaptations are needed. They should also identify the best locations on the chair to use as securement sites. In addition, they must decide if add-on equipment, such as a suction machine or respirator, needs to be attached to the wheelchair.
During the meeting, it is important to locate the gears on the wheelchair and determine how to disengage them for loading procedures. It should also be de-cided whether the student will ride in his chair, or whether he will be transferred to a bus seat. Whenever reasonable, students should transfer from their wheelchairs to school bus seats, where they will be protected by compartmentalization. Students must be transferred out of some mobility systems (unless they have been dynamically crash-tested and approved for school bus use). These include lightweight strollers, sports-type wheelchairs (low-back, canvas-type seat and back system) and three-wheeled scooters. The students can be loaded onto the bus in these mobility systems with careful monitoring by the staff, but they must transfer out of them once they are on the bus.
Mobility devices that have been dynamically crash tested are continually being introduced on the market. The easiest way to visually identify a mobility device that meets ANSI/RESNA WC-19 crash-test standards is to look for four plastic coated D-ring securement sites on the chair's base.
Do not assume that because a chair has passed crash testing, it no longer requires assessment before it is used on the school bus. Many of these mobility devices can be disassembled to allow for transportation in the family vehicle and may not always be properly reassembled for use on the bus. Students who re-main in their wheelchairs or mobility devices during transportation should have an extended back or a head support on their wheelchair to minimize the potential for whiplash, even if they donÕt normally require head support outside the transportation environment.
Loading manual chairs
Students must always be loaded onto the lift facing outward, with their back to the bus. To encourage independence, they should be allowed to maneuver onto the lift with as little assistance as possible. Remember to treat students with sensitivity during the loading process, as riding the lift can be frightening. Verbal reassurance is important.
Once the chair is on the lift, be sure that the manual wheel locks are set. (These locks stop movement, unlike brakes, which are used to slow down movement). If the wheelchair locks are not holding or if the chair is not equipped with wheel locks, a decision will have to be made based on the individual situation, keeping safety and the student's access to education as top priorities. The transportation department should have procedures for notifying parents of problems with the wheel locks or other equipment.
All lift equipment should be used in accordance with manufacturer recommendations. There should always be an adult on the ground holding on to the mobility device to minimize its movement on the lift. Once the lift is level with the bus floor, the wheel locks should be released, and the student can wheel back into the bus and into position. If the student is not able to perform this function alone, assistance should be provided.
Note: Loading and securing students in motorized wheelchairs will be discussed in an upcoming issue.
Chairs with trays
If the wheelchair or mobility device has a tray, it should be removed during transportation, for the following reasons:
Should there be an accident, the tray could be pushed into the anterior aspect of the student's body, causing internal injuries. Trays have not been de-signed to withstand crash forces.
Should the tray ever become dislodged from the wheelchair, it would be a dangerous projectile within the bus.
Many students rely on trays to help support the upper trunk. The tray should not be removed without consulting the student's OT or PT. Some students may need to have some type of anterior chest support added to their wheelchair. Parents who are concerned about their child's tray being removed should be assured that the anterior chest support and the shoulder-positioning belt will protect the child. There may be some unique cases in which the student's tray cannot be removed. If that is the case, best practice in the industry suggests using a high-density foam tray.
When a wheelchair tray is removed, it must be stored securely on the bus. Some transportation departments secure trays against the bus walls, while others have made upholstery bags to fit over the school bus seat for tray storage. All other supportive equipment (crutches, walkers, etc.) must also be secured while being transported on the school bus. This equipment should be stowed in an area of the bus where it does not become an obstacle or a projectile. Best practice in the industry calls for any method that secures the equipment to sustain at least five times its weight, is not in the head impact area and does not project into the passenger area.
Follow manufacturer recommendations for use of securement systems. The following information is for general application and should not take precedence over manufacturer recommendations.
Wheelchair securement points must never be located on any removable part of the wheelchair (e.g., leg rests, arm rests, or removable wheels). With some newer wheelchairs, finding the strongest place for attaching the securement can be difficult. Generally, you can secure the chair on the frame, nearest the seat level, at a welded joint. Begin your securement with the wheelchair locks off so that a poor adjustment will not be masked.
When you secure the wheelchair, start with the front two belts. (Note: Some new retractor systems allow for rear attachment first.) Anchor the tie-downs to the floor track at as close to a 45-degree angle as possible (the angle should be no less than 40 degrees and no more than 60 degrees). Securement belts should be angled outward slightly for lateral stability.
Attach the rear belts to the frame of the wheelchair at the welded joint, close to where the chair back and seat meet. Attach the straps to the bus floor in a straight line inside the wheels. The preferred angle of rear attachment is 30 to 45 degrees.
When all securement belts are attached properly and adjusted, perform a "shake" test with the locks off to ensure that the securement is tight, with less than one inch of slack. Make final adjustments accordingly, and reapply the wheel-chair locks. This shake test should be done with a firm, but gentle shake. Do not alarm the student.
Positioning in the chair
Transportation staff must be instructed that the positioning belt and anterior chest supports on a wheelchair have not been dynamically tested and never take the place of the bus occupant restraining system. However, these positioning adaptations should hold the student in the most upright alignment possible. Work with parents to help them understand the importance of positioning the child properly in the wheelchair before the school bus arrives at the bus stop. Should there be a recurring problem with the child's position in the wheelchair, the PT and OT should be consulted, as additional wheelchair modifications might be needed.
The lap portion of the occupant restraining system should always be positioned over the pelvis, a bony area that can withstand a crash with minimal risk of internal injury. The lap portion of the retraining system must remain snug to the studentÕs body and should never be fed through the wheelchair arm rests. Also, the lap belt should not be placed over hip positioning pads. Instead, it should run under the hip positioning pads, snug to the student's body. Make sure the belt is not twisted in any way. This lap belt portion of the occupant restraining system should then be attached to the rear tie-downs of the wheelchair se-curement system. (If you are using an integrated system, check manufacturerÕs instructions.)
Applying the restraints
The shoulder portion of the occupant strap should then be attached, by positioning it across the midpoint of the shoulder and over the bony clavicle (collar-bone) -- never over the occupant's neck area. The shoulder strap should extend upward and rearward from the midpoint of the shoulder to prevent downward forces on the spine. The shoulder belt is then attached to the lap portion of the occupant restraint. The belt should be positioned so that it runs diagonally across the student's upper body and then attaches at a point directly over the pelvic bone.
For example, if the student is riding on the right side of the bus, the shoulder portion attaches directly over the left side of the pelvis. (Just think of how your three-point lap shoulder belt works in your own car. The shoulder portions attaches across your pelvic area, not across your stomach.) Adjust the shoulder strap so that it is snug, while still allowing slight movement.
Young children are often positioned in wheelchairs that are close to the ground so they are at eye level with their peers. These low-seating wheelchairs present a problem with the occupant shoulder strap, which has a tendency to cross over the child's face. In many cases, these students can easily be transferred to a school bus seat and then positioned in a safety restraint system for upper trunk support. However, when transferring the student is not possible, you must use a height adjuster system on the occupant shoulder strap to bring the shoulder strap down to the level of the student's clavicle.
Equipment assessment, loading and securement are challenges for the transportation team, no matter what type of mobility device a student is using. As medical science advances, students are coming to us with add-on equipment that we never dreamed of in the past. Pulling up to a student's home to discover a mobility device that wasn't planned for undermines the efforts of the team to provide students with the safest ride. Knowing best practices and meeting with the transportation team to evaluate student needs helps reduce risky surprises and increases safety for our special-needs passengers. Kathy Furneaux is a training specialist for the Pupil Transportation Safety Institute in Syracuse, N.Y. Jean M. Zimmerman is supervisor of occupational and physical therapy at Palm Beach County School District in West Palm Beach, Fla.