At the Transporting Students with Disabilities & Preschoolers conference this past March in Phoenix, Jean Zimmerman, supervisor of occupational/physical therapy at the School District of Palm Beach County (Fla.), spoke on complex medical procedures that school bus drivers are being asked to perform on special-needs students.

Zimmerman raised this question: In life-threatening situations, should bus personnel be required to tend to medically complex passengers, or should this be reserved for qualified medical professionals such as nurses?

SBF Associate Editor Albert Neal spoke with Zimmerman about the complexities involved in tending to these passengers.

SBF: What constitutes an invasive procedure?
JEAN ZIMMERMAN: It is a medical or surgical procedure that requires the skin to be cut open and/or an object is inserted into the body. A medication is injected or inserted into the body.

When would a person have to execute such a procedure?
All of these procedures depend on the child. In some cases, they are performed on a routine basis. Other times, the procedures are needed on an emergency basis.

What are drivers being asked to perform?
More and more students are requiring the use of an EpiPen when they are having an allergic reaction. For students with uncontrolled seizure activity, one procedure is the Vagus Nerve Stimulator and the administration of the medication Diastat. Also, students with a tracheostomy may need suctioning.

Would you say that some of these procedures are outside drivers’ scope?
I think it’s beyond the driver to be expected to drive the bus plus look at the medical reactions and conditions of children. The driver’s scope is to drive the bus. If there’s a need for a medical procedure, that’s where the IEP team comes in.

The IEP should include members of the transportation staff, medical professionals, the occupational and physical therapist, school staff and parents. These people should be familiar with the environment of the bus that the child would be riding. The IEP team should determine if a nurse is necessary on the bus or if someone else can be taught and safely do the medical procedure.

Is the interior of a bus conducive to executing these procedures?
Sometimes you have to put a child who is having a seizure down on the floor to be able to give them Diastat, which is a rectal suppository. If you only have a 12-inch aisle in a school bus, then you really can’t do that. There’s not enough space. Plus, you have the hard floors and the anchor points of the bus seats, on which children could hit and injure their heads. Then there’s the whole privacy issue.

The IEP team should consult the child’s physical about the possibility of another medication being given until the paramedics arrive. If this is not at all possible, the bus environment will need to be modified, including removal of seats, placing a mat on the floor and planning for privacy.

Can drivers be properly trained to perform invasive procedures?
It’s different with each procedure. Intense training is not always enough, because sometimes you need to have additional medical knowledge. It’s not only knowing how to do the procedure — it’s knowing when to do it and what, if any, side effects to expect. Some procedures include the use of medications that could slow down respiration. Therefore, the driver would also need CPR training.

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What should transportation departments do when asked to perform an invasive procedure?
First of all, transportation departments should take this opportunity to be proactive. We are transporting more and more medically complex students on our school buses. Be proactive. Form a task force in your area. Familiarize yourself with your state’s Nurse Practice Act — your state may say that only a nurse can perform certain medical procedures. Have policies and procedures in place before you need them. Have your school board attorney review your policies and procedures.

Invasive Procedures

EpiPen
Many children and adults are allergic to certain medications, food, insect bites/stings and latex. The result of exposure to one of these irritants could be anaphylaxis. This is a sudden, severe and potentially fatal systemic allergic reaction.

The EpiPen auto injector is commonly prescribed for individuals who have had prior severe allergic reactions. The EpiPen is an emergency injection of the medication epinephrine. Epinephrine constricts blood vessels, relaxes smooth muscle in the lungs to improve breathing and stimulates the heartbeat. The effects of epinephrine usually last 10 to 20 minutes, so it is still necessary to call 911 or proceed to the hospital. The child may need additional medication, cardiac or respiratory care.

Vagus Nerve Stimulation
Vagus Nerve Stimulation is a relatively new treatment for uncontrolled seizure. It is a type of treatment in which short bursts of electrical energy are transmitted into the brain via the vagus nerve, which is a large nerve in the neck. The energy comes from a small generator, which is surgically implanted under the skin, usually on the chest. Leads are threaded under the skin and attached to the vagus nerve in this same procedure. The physician programs the device to deliver small electrical stimulation bursts every few minutes. This electrical stimulation travels via the vagus nerve to influence parts of the brain that control seizures.

The second way Vagus Nerve Stimulation is delivered is when a patient, a family member or a caregiver senses a seizure coming on and passes the magnet over the area in the chest where the generator is implanted to activate an extra, on-demand stimulation. In addition to preventing the seizures, the stimulation can also decrease the severity of the seizure and decrease the recovery time after the seizure. School bus drivers are often asked to use this magnet.

Diastat
Many children experience seizure activity that can be controlled by oral medications. However, some children have seizure clusters, which are episodes of multiple seizures that are different from the child’s usual pattern. These seizures may progress to status epilepticus (a state of non-stop seizures), which carries an increased risk of brain damage or even death. Diastat (diazepam rectal gel) is an acute at-home treatment for patients two years and older who are on stable anti-epileptic medications and experience bouts of increased seizure activity. The literature states that both medical and non-medical care providers can easily administer Diastat in the school setting.

However, there is also a warning in the literature that reads that Diastat “should only be administered by caregivers which in the opinion of the prescribing physician, i) can distinguish between a cluster seizure and the patient’s ordinary seizure patterns ii) have been instructed on how to administer Diastat and judge competent to do so, iii) understand explicitly which seizures may or may not be treated and iv) are able to monitor clinical response and recognize when the response mandates professional medical evaluation.”