Wheelchair Transportation Safety series: part 6: the role of parents and caregivers in providing safe transportation for occupants seated in wheelchairs.

The driver slammed his foot on the brake pedal, and the bus came to a sudden stop just in time to avoid a collision with a car that suddenly entered the street from a driveway. He heard a thud and turned around to see what it was. The wheelchair was still facing forward where he had secured it to the vehicle using the four tiedown straps, but the occupant of the wheelchair was on the floor with a broken leg and was bleeding from a deep cut to the forehead. All other passengers, including the driver, were still in their seats, uninjured.

What happened? Did the driver forget to fasten the seatbelt? Did something break?

Scenarios like this are becoming all too familiar to researchers at the Rehabilitation Engineering Research Center (RERC) on Wheelchair Transportation Safety who seek to provide safer transportation for people seated in wheelchairs during normal driving, emergency vehicle maneuvers, and more serious crashes. In particular, the evidence is mounting that serious and fatal injuries are occurring needlessly to travelers seated in wheelchairs during non-crash events such as emergency braking or vehicle turning.

When it comes to filing lawsuits following such events, parents, caregivers, and their attorneys are quick to place blame on transit providers and tiedown/restraint manufacturers. The immediate implication is that either the driver did something wrong or that the tiedown/restraint equipment failed. However, the responsibility for providing safe transportation for travelers seated in wheelchairs is shared by many stakeholders, including wheelchair and tiedown/restraint manufacturers, vehicle modifiers and equipment installers, transit providers, rehabilitation technology suppliers, wheelchair/seating clinicians, and even informed and responsible travelers and their caregivers. Just as buckling a seatbelt, placing a child in a properly secured child safety seat, or wearing a bicycle helmet are responsible actions based on response to knowledge of risk, there is much that parents and caregivers can do to ensure that occupants seated in wheelchairs are provided with the safest possible transportation.

It is, of course, not possible to remove all injury risk from motor-vehicle transportation, and there are many uncontrollable factors that can affect the likelihood and severity of occupant injuries, including the magnitude and direction of the crash and the age and physical condition of the occupant. However, there are some very specific things that can be done to minimize injury risk and particularly to prevent needless injuries to travelers seated in wheelchairs in non-crash and minor-crash situations. Family members and caregivers need to be informed about "best practice" in wheelchair transportation safety, and they need to be proactive with their knowledge in advocating on behalf of passengers seated in wheelchairs.

First and foremost, parents and caregivers should understand the fundamental principles of transportation safety and ensure that the transit provider consistently follows these principles. This means:

a) orienting the wheelchair occupant facing forward in the vehicle rather than sideways,

b) securing the wheelchair to the vehicle floor with a system of four tiedown straps that complies with the industry standard, SAE J2249 (soon to be renamed as ANSI/RESNA WC18), and

c) providing the wheelchair occupant with properly positioned upper (shoulder) and lower (lap) belt restraints.

As has been previously noted in this series of articles, it is best if the individual is seated in a WC19 crash-tested wheelchair that has four easily accessible securement points. Therefore, when a new wheelchair is needed, parents and caregivers should make every effort to obtain a WC19-compliant wheelchair. It is especially important to select a wheelchair that has a "good" or "excellent" rating for accommodating the proper use of vehicle-anchored belt restraints. These wheelchairs will increase the likelihood of proper seatbelt use, which is critical to effective occupant restraint in both crash and non-crash events.

While having a crashworthy WC19-compliant wheelchair that easily accommodates the proper placement of belt restraints makes providing safe transportation easier and more reliable, especially in higher-speed collisions, it is possible to provide effective wheelchair securement and occupant restraint for the majority of adverse vehicle events when the wheelchair does not comply with WC19. In these situations, parents and caregivers must work with the transit provider to:

* select and permanently mark four strong and easy-to-reach securement points on the frame of the wheelchair (e.g., junctions of the wheelchair frame),

* ensure that the wheelchair is always secured by four tiedown straps, and

* determine the best way to position the vehicle lap and shoulder belts between and around wheelchair components so that they contact the wheelchair occupant low on the pelvis and over the middle of the shoulder.

Consistency is critical. Having the right equipment and knowledge of the basic principles of transportation safety are of little value if the vehicle driver or attendant does not apply these principles on a daily basis. For this to occur, the transit provider must have an active and thorough training program. The training should instruct drivers and attendants on specific details for securing different types of wheelchairs and on how to position lap and shoulder belts for different wheelchair designs and configurations. Parents and caregivers should inquire about the transit provider's training program and make sure that it includes hands-on skills training and demonstrations with different wheelchair and occupant situations, as well as regular, ongoing monitoring of driver performance in using the tiedown/restraint equipment. They should also check to make sure that their particular wheelchair is being properly secured and that the seatbelt is being properly positioned on the wheelchair occupant.

There are also a couple of things that parents and caregivers are in a unique position to do that can be very important to preventing needless injuries in events such as the emergency braking incident at the outset of this article. One of these is to equip the wheelchair with a postural lap belt and ensure that it is used during transportation. While postural belts should not be relied on for restraint in motor-vehicle crashes (see photo above of a peak-of-action crash test with restraint provided only by postural belts), a properly positioned postural belt will keep a person in their wheelchair in non-collision or minor crash events. It will also enable improved placement of vehicle seatbelts by improving sitting posture.

[ILLUSTRATION OMITTED]

The second thing that parents and caregivers can do is to make sure that removable seat cushions are attached to the seat surface by Velcro or other comparable method that will keep the cushion in place if the vehicle decelerates quickly in a sudden stop or frontal impact. If the cushion slides forward when the vehicle decelerates, this can significantly increase the likelihood that the occupant will slide under (i.e., submarine) the lap belt, especially if the lap belt is not correctly positioned low on the pelvis and upper thighs. Such lap-belt submarining can result in serious injuries to the abdomen and chest from belt loading, as well as injuries to other parts of the body from contact with the vehicle interior.

While parents and caregivers should be able to look to the transportation provider to provide a reasonable level of safe transportation for travelers seated in wheelchairs, knowledgeable and educated caregivers can make an important contribution to reducing injury risk. Understanding the basic principles of transportation safety and occupant crash protection enables parents and caregivers to become part of the team working for safer transportation.

Parents and caregivers should express their concerns about following best practice to the transportation provider and should work with them to ensure that these best practice principles are regularly followed. In cases of school transportation, they should work with the school district to assure that the best practice principles are included in the Individualized Educational Program (IEP), detailing how students in wheelchairs are to be transported. Resources like the RideSafe brochure (HYPERLINK "http://www.travelsafer.org" www.travelsafer.org), Guidelines for Use of Secondary Postural Support Devices by Wheelchair Users During Travel in Motor Vehicles, examples of wheelchair crash videos, and a list of products that comply with current safety standards are available at www.rercwts.org/info and can help parents and caregivers in creating safer travel environments.

Lawrence W. Schneider, Ph.D., is a Research Professor and Head of the Biosciences Division of the University of Michigan Transportation Research Institute. He is also the Director of the RERC on Wheelchair Transportation Safety.

Miriam A. Manary, M.S.E, is a Senior Engineering Research Associate in the Biosciences Division of the University of Michigan's Transportation Research Institute.

Gina E. Bertocci, Ph.D., is an Associate Professor of Mechanical Engineering, Bioengineering, and Pediatrics at the University of Louisville, where she is Director of the Injury Risk Assessment and Prevention Laboratory. She is also an Associate Director of the RERC on Wheelchair Transportation Safety.

As the leader in providing mobility options for those with special needs, the National Mobility Equipment Dealers Association applauds EP, and its partner UMTRI, on the Wheelchair Transportation Safety series as an invaluable source of information for those who use a wheelchair as a seat in a motor vehicle.