Chapter One: The Medically Fragile or Technology Assisted

Children with Special Health Care Needs  12
Categories of Students with
    Special Health Care Needs 13
Students with Chronic Special Health Conditions  13
Students Whose Conditions Are Infectious 14
Students Who Are Technology Assisted 14
Students with Conditions That Cause Changes In
    Neurological Functioning 15
Students Who Are Medically Fragile 15
Students with Body and Skin Deformities 17
Students with Multiple Disabilities 18
The High- or Low-Functioning Multiply Disabled 18
Students with Other Health Impairments 20
Specially-Equipped School Buses 20
Transportation As A Related Service 21
The Vocational Rehabilitation Act
    of 1974: Section 504 22
Student Individualized Evaluation For Special
    Education and Transportation Services 24
A Decision Matrix For Transportation Services
    For the Medically Complex 25
A Continuum of Special Needs
    Transportation Services 29

Chapter Two Special Bus Handling For Specific Medical Conditions

Students Subject To Anaphylactic Reactions To Food 35
    Table 1-Anaphylactic Reactions To Food 37
Students Subject To Anaphylactic Reactions
    To Insect Bites 38
    Table 2-Anaphylactic Reactions To Insect Stings 40
Special Bus Handling For Students
    with Severe Asthma 41
   Table 3-Special Bus Handling For Students
    with Severe Asthma 43
Special Needs Bus Handling For Students
    with Infantile Autism 44
    Table 4-Special Bus Handling For Students
    with Severe Autism 47
Special Bus Handling For Students
    with Cerebral Palsy 48
    Cerebral Palsy By Affected Limbs 49
        Monoplegia 49
        Diplegia 49
        Hemiplegia 49
        Quadriplegia 49
        Triplegia 49
    Cerebral Palsy By Type of
        Body Movement Disturbance 50
        Spasticity 50
        Table 5-Special Bus Handling For Students
            with Cerebral Palsy-Spasticity 51
        Athetosis 52
        Ataxia 53
        Table 6-Special Bus Handling For Students
            with Cerebral Palsy-Athetosis 54
        Rigidity 55
        Tremor 55
        Dystonia 55
        Torsion Dystonia 56
        Spasmodic Torticollis 56
        Blepharospasm 56
        Cranial Dystonia 56
        Dopa-Responsive Dystonia (DRD) 56
        Huntington's Chorea 56
        Table 7-Special Bus Handling For Students
            with Cerebral Palsy-Ataxia 57
        Table 8-Special Bus Handling For Students
            with Cerebral Palsy-Dystonia 58
        Mixed Cerebral Palsy 59
        Friedreich's Ataxia (FRDA) 59
Special Needs Bus Handling For Students
    with Cystic Fibrosis 61
    Table 9-Special Bus Handling For Students
        with Cystic Fibrosis 63
Special Needs Bus Handling For Students
    with Congenital Heart Malformation 64
    Ventricular Septal Defect (VSD) 64
    Congestive Heart Failure (CHF) 65
    Blue Baby Syndrome 65
    Table 10-Special Bus Handling For Students with
        Congenital Heart Malformation 66
Special Bus Handling For Students
    with Diabetes (Diabetes Mellitus) 67
    Type I Diabetes 67
    Type II Diabetes 67
    Table 11-Special Bus Handling For Students
        with Juvenile Diabetes 69
Special Bus Handling For Students
    with Encephalitis 70
    Table 12-Special Bus Handling For Students
    with Encephalitis 71
Special Bus Handling For Students
    with Fetal Alcohol Sydrome (FAS) 73
    Table 13-Special Bus Handling For Students
        with Fetal Alcohol Syndrome 75
Special Bus Handling For Students
    with Guillain-Barre Syndrome 76
    Table 14-Special Bus Handling For Students
        with Guillain-Barre Syndrome 78
Special Bus Handling For Students
    with Hemophilia 79
    Table 15-Special Bus Handling For Students
        with Hemophilia 81
Special Bus Handling For Students
    with Hydrocephaly (The Shunt) 82
    Table 16-Special Bus Handling For Students
        with Hydrocephaly 84
Special Bus Handling For Students
    with IrriTable Bowel Syndrome (IBS) 85
    Table 17-Special Bus Handling For Students
        with IrriTable Bowel Syndrome 86
Special Bus Handling For Students
    with Juvenile Rheumatoid Arthritis (JRA) 87
    Table 18-Special Bus Handling for Students
        with Juvenile Arthritis 89
Special Bus Handling For Students
    with Lennox-Gastaut (LG) Syndrome 90
    Table 19-Special Bus Handling For Students
        with Lennox-Gastaut Syndrome 91
Special Bus Handling For Students
    with Lesch-Nyhan Syndrome 92
    Table 20-Special Bus Handling For Students
        with Lesch-Nyhan Syndrome 93
Special Bus Handling For Students
    with Marfan Syndrome 94
    Table 21-Special Bus Handling For Students
        with Marfan Syndrome 93
Special Bus Handling For Students
    with Osteogenesis Imperfecta 97
    Table 22-Special Bus Handling For Students
        with Osteogenesis Imperfecta 99
Special Bus Handling For Students
    with Multiple Sclerosis 100
    Table 23-Special Bus Handling For Students
        with Multiple Sclerosis 102
Special Bus Handling For Students with Muscular Dystrophy 103
    Myotonic Dystrophy (DM) 103
    Duchenne Muscular Dystrophy (DMD) 104
    Becker Muscular Dystrophy (BMD) 104
    Limb-Girdle Muscular Dystrophy 105
    Facio-Scapulo Humeral Dystrophy (FSH) 105
    Congenital Muscular Dystrophy (CMD) 106
    Oculopharyngeal Muscular Dystrophy (OPMD) 106
    Distal Muscular Dystrophy (DD) 106
    Emery-Dreifuss Muscular Dystrophy (EDMD) 106
    Table 24-Special Bus Handling For Students
        with Duchenne Muscular Dystrophy 107
Special Bus Handling For Students
    with Myasthenia Gravis 108
    Table 25-Special Bus Handling For Students
        with Myasthenia Gravis 109
Special Bus Handling For Students
    with Prader-Willi Syndrome 110
    Table 26-Special Bus Handling For Students
        with Prader-Willi Syndrome 111
Special Bus Handling For Students
    with Raynaud's Phenomenon 112
    Table 27-Special Bus Handling For Students
        with Raynaud's Phenomenon 114
Special Bus Handling For Students
    with Rett Syndrome 115
    Table 28-Special Bus Handling For Students
        with Rett Syndrome 118
Special Bus Handling For Students
    with Scoliosis 119
    Table 29-Special Bus Handling For Students
        with Scoliosis 120
Special Bus Handling For Students
    with Spina Bifida 121
    Table 30-Special Bus Handling For Students
       with Spina Bifida 122
Special Bus Handling For Students
    with Spinal Muscular Atrophy 123
    Table 31-Special Bus Handling For Students
        with Spinal Muscular Atrophy 124
Special Bus Handling For Students
    with Traumatic Brain Injury 125
    Table 32-Special Bus Handling For Students
        with Traumatic Brain Injury 126
Special Bus Handling For Students
    with Tuberous Sclerosis 127
    Table 33-Special Bus Handling For Students
    with Tuberous Sclerosis 128

Chapter Three: Transporting the Technology Assisted

Transporting Students Using Oxygen Support
    On The Special Needs Bus 134
    Oxygen By Nasal Catheter 134
    Oxygen By Nasal Prongs 134
    Oxygen By Face Masks 135
    Oxygen By Trachea Masks 135
    Home/School Oxygen 135
    Oxygen Safety 136
    Table 34-Special Bus Handling For Students
        Using Oxygen Support 137
Transporting Students Using Home or Portable
    Ventilators On The Special Needs Bus 138
    Table 35-Special Bus Handling For Students
        Using Ventilator Support 139
Transporting Students with A Tracheostomy
    On The Special Needs Bus 140
    When To Suction 140
    Types of Tracheostomy Tubes 141
    Communication with Student Riders
        Using a Tracheostomy 142
    Clothing, Overcoats, Winter Dress On The Bus 142
    Tracheostomy Tube Suctioning 143
    Table 36-Special Bus Handling For Students
        Using Tracheostomy Support 145
Transporting Students Using Nasal Feeding Tubes
    (Nasogastric Tubes) 146
    Table 37-Special Bus Handling For Students
        Using Nasogastric Tube Support 148
Transporting Students Using
    Gastronomy Feeding Tubes 149
    Table 38-Special Bus Handling For Students
        Using G-Tube Support 151
Transporting Special Needs Students
    Requiring Ostomy Care 152
    Types of Ostomies 152
        Colostomy 152
        Ileostomy 153
        Continent Ileostomy 153
        Ileoanal Reservoir 154
    Ostomies in the Urinary System 154
    Table 39-Special Bus Handling For Students
        Requiring Ostomy Support 155
Transporting Special Needs Students
    Requiring Catheterization 156
    The Tatro Decision 156
    Condom/Collection Bag 157
    Indwelling Catheter 157
    Table 40-Special Bus Handling
        For Students Requiring Catheterization 158
Transporting Special Needs Students
    Requiring Dialysis 159
    Hemodialysis 159
    Peritoneal Dialysis 160
    Kidney (Renal) Transplant 161
    Table 41-Special Bus Handling
        For Students Requiring Dialysis 162
Transporting Students Requiring
    Assistive Technology 163
    Table 42-Special Bus Handling
        For Students Requiring Assistive Technology 166
Transporting Students Requiring Scooter Technology 167
    Rear Wheel Drive Scooters 167
    Front Wheel Drive Scooters 168
Transporting Students Requiring
    Wheelchair Technology 169
    Powered Wheelchairs 170
    Wheelchair Components 170
    Wheelchair Frames 171
    Wheelchair Upholstery 171
    Wheelchair Seating Systems 171
    Wheelchair Brakes 172
    Wheelchair Wheels and Tires 172
    Wheelchair Footrests 172
    Wheelchair Armrests 172
    Wheelchair Controls 172
    Wheelchair Drive Systems 173
    Wheelchair Batteries 173
    Special Powered Features 173
    Purchasing A Wheelchair 173

Chapter Four Support Personnel for the Medically Fragile/Technology Assisted

Parents On the Special Needs Bus 176
Personal or Home Care Attendants 176
Respite Care Providers 178
Health Care Attendants 179
Physical Therapists
    and The Special Needs Bus Driver Team 180
Occupational Therapists
    and The Special Needs Bus Driver Team 182
Respiratory Therapists
    On The Special Needs Bus 185
Private Duty Nurses
    On The Special Needs Bus 186
School Nurses
    On The Special Needs Bus and
    The Special Needs Bus Driver Team 188
    Table 43-Specialized Health Care Provided
    By Driver Teams On The Special Needs Bus 189-191
Social Work Services (Case Management)
    For The Medically Fragile 192
Wheelchair Repair and Maintenance Technicians 194
Rehabilitation Technologists 196
Assistive Technologists 197
Other Medical Specialists Who Are A Part
    Of The Driver Support Team 199

Chapter Five: Students Requiring Extreme Special Handling

Medically Fragile Student Privacy
    vs. The Driver Team's Need To Know 202
Loading The Medically Fragile On The Special Needs Bus 204
    Loading Procedures-Up To The Home Door 204
    Loading Procedures-In-Home Service 204
    Lift Operation For the Medically Fragile 205
    Wheelchair Seating Assignments 206
    Nursing or Attendant Seating Assignments 206
    Wheelchair Tiedowns 206
    Prolonged Special Needs Bus Loading Times 207
Bus Routing For The Medically Fragile 207
    Modified Routes and Bus Schedules 208
    Emergency Room Procedures 208
    Alternative Bus Routes For Emergency Service 208
    Air Conditioning (Cooling, Heating, Humidity Control) 209
    Equipment Backup On The Bus 209
    Spare Lift Buses 210
    Support Personnel Backup On The Bus 210
    Backup Or Emergency Bus Communication Systems 210
School Loading Zone Procedures
    For The Medically Fragile 211
    Parent, Regular & Special Needs
        Bus Mix At The School Loading Zone 211
    Travel Distances At School Loading Zones
        For The Medically Fragile 211
    Transfer Of Custody Between Driver Team
    & Special Education Building Personnel 212
    Inclement Weather Planning
        At The School Loading Zone 212
    Avoiding Interactions with Other Students
        At The School Loading Zone 213
Supplemental Runs For The Medically Fragile 213
    Supplemental Route Driver Teams 213
    Supplemental Route Bus Equipment 214
    Supplemental Route Procedures 214
Home Drop Off Procedures On The Special Needs Bus 215
   Changing The PM Home Drop Off Service 215
    Maintaining The Student Daily Log
        Or Notebook Exchange 215
    Logging Behavior Or Health Incidents
        In The Notebook 216
    Transporting Empty Wheelchairs
        & Associated Student Technology 216
Transporting Essential Medications
    On The Special Needs Bus 217
    Transporting Student Medications 217
    Administering Medications To Students
        On The Special Needs Bus 217
Documentation Of Special Needs Bus Services 217
    Special Needs Transportation Eligibility
        For The Medically Fragile 217
    The Transitional Plan--From Hospital To Home 218
    The Transitional Plan--From Home To School 218
    The Special Needs Transportation Request Form 219
    The Special Needs Student Transportation Folder 219
    Emergency Student Documentation On The Bus 220
Bus Behavior Management For The Medically
    Fragile/Technology Assisted 220
    Fragile Student Special Handling
    On The Special Needs Bus 220
    Special Needs Student Incident
        Report Documentation 221
    Controlling Student Self-Abuse 221
Individual Student Emergency Plans 222
    Emergency Plan Development 222
    Technology Power Failure Emergency Plan 222
    Student Physiological Emergency Plan 222
    Emergency Care Plans For Natural Disasters
        & The Technology Assisted 223
    Emergency Communications For
        Specially-Equipped School Buses 223
    Emergency School Bus Routes 224
    Emergency Route Plans 224
Bus Evacuation For The Medically
    Fragile/Technology Assisted 225
Emergency Conditions Warranting Bus
    Evacuation Of All Students 225
Emergency Conditions Warranting
    Evacuation Of A Specific Fragile
    or Technology Assisted Student 225
    Loss Of Air Conditioning 225
    Loss Of Heating 226
    Loss Of Humidity Control 226
    Loss Of Interior Air Quality 336
    Anaphylactic Reaction Substances 226
    Insects Causing Anaphylactic Reactions 226
    Loss Of Battery Backup 226
    Loss Of Personal Attendant Or Ride-Along Nurse 226
Emergency Destination Choices 226
    Stay On The Special Needs Bus 227
    Return To The Home 227
    Return To The School 227
    Move To An Ambulance 228
    Move To A Fire Station 228
    Move To A Hospital Emergency Room 228
    Move To A Public Emergency Shelter 229
    Move To Child Protective Services 229
    Move To Emergency Respite Care Services 229
Physical Removal From The Special Needs Bus By
    Non-Conventional Means 230
    Special Needs Bus Stairwell
        Emergency Evacuation 230
    Special Needs Bus Rear Exit Emergency Evacuation--
        The Child Carry Strategy 231
    Special Needs Bus Rear Exit Doorway
        Emergency Evacuation--The Blanket Pull 232
    Special Needs Lift Doorway Emergency Evacuation
        Without Lift Powered Operation 233
    Special Needs Student Evacuation From
        A Side Exit Doorway 234
    Special Needs Bus Roof Hatch Evacuation 235
    Roof Hatch Emergency Exit with Bus Overturned 235
    Special Needs Bus Side Window Exit 236
Medical Emergencies On The Special Needs Bus 236
    Emergency Care Services Options 237
    Emergency Room Preparation For The Driver Team 238
Inclement Weather Procedures
    For The Medically Fragile/Technology Assisted 241
    Weather Emergencies Before School Opening 242
    Weather Emergencies Arising During School Hours 242
Disaster Preparations On The Special Needs Bus 243
Severe Weather Warning (Tornado, High Winds, Hurricanes) 243

Chapter Six Related Medical and Health Issues On The Special Needs Bus

Cleaning Procedures On The Special Needs Bus 247
    Hand Washing On The Special Needs Bus 247
    Housekeeping On The Special Needs Bus 248
    Decontamination of The Special Needs
        Bus Interior 248
    Decontaminating Cleaning Equipment 249
    Sharps Containers 250
Universal Precautions On The Special Needs Bus 251
    Universal Precautions Compliance Requirements 251
    Table 44A-Body Fluids Source Of Infectious Agents
        On The Special Needs Bus 252
    Disciplinary Action Against Driver Teams 253
Handling Body Fluids On The Special Needs Bus 253
Encopresis 253
Protective Equipment On The Special Needs Bus 254
    Protective Equipment Use 254
    Uniform Cleaning, Laundering and Disposal 255
    Repair and Replacement 255
    Gloves 255
    Laundry 256
    Table 44B-Routine Procedures
        For Handling Body Fluids 257
Communicable Diseases On The Special Needs Bus 258
    Table 45-Communicable Diseases
        On The Special Needs Bus 259
    Table 45A-Communicable Diseases
        On The Special Needs Bus 260
Cold Exposure Guidelines For The
    Special Needs Bus 261
    First Aid For Hypothermia 261
    First Aid For Frostbite 262
Special Needs Students On The Bus
    with Heat Exhaustion 263
Heat Control Guidelines For the Special Needs Bus 264
    Heat Related Illness 266
    Heat Cramps 267
    Heat Exhaustion 267
    Heat Stroke 268
Do Not Resuscitate Orders On The Special Needs Bus 269
    School Districts Basically Refusing To Comply 269
    School Districts, Special Needs Driver Teams Are Not EMS 269
    School Districts & Emergency Medical Services DNR Policy 270
    School Districts Are Not Hospitals Or Emergency Rooms 270
    Respecting The Rights and Legal Requests of the Parents 270
    Allowing The Child To Die At School 270
    Allowing The Child with A DNR Order To Die
        On The Special Needs Bus 271
    Providing Comfort Care Only On The Special Needs Bus 272
    Overriding The Comfort Care Only Order
        On The Special Needs Bus 273

Chapter Seven Transporting The Medically Complex: A Driver Team Self-Assessment Guide For The Special Needs Bus

Using The Self-Assessment Test Instruments 276
Decision Matrix For Transportation Services
    for the Medically Complex: A School District
    Self-Assessment Instrument 277-285
ADAAG Accessibility Checklist For Determining
    Physical Access Barriers To Special Needs Bus
    Transportation At School Buildings 286-292
Lift Driver Team and Ride-Along Nurse Procedures
    For The Medically Complex: School District
    Self-Assessment Instrument 293-303
Subject Index 305

Glossary 340