Wild Iris Medical Education
COURSE PRICE: $18.00
CONTACT HOURS: 2
This course will expire or be updated on or before July 1, 2013.
ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
ACCREDITATION / APPROVAL
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. See our disclosures for more information.
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide an overview of the special needs of disabled travelers and the duties of healthcare providers who assist them.
Upon completion of this course, you will be able to:
Traveling beyond a person’s community, for business or pleasure, is often part of a cherished lifestyle. It can be both invigorating and a respite from the humdrum of daily life. For people traveling with disabilities, however, it can be full of challenges. Disabled travelers face a host of problems, both in planning and during the trip, that include:
While laws such as the Air Carrier Access Act (USDOT, 2010) have been implemented over the years to improve travel conditions for disabled persons, local and international issues still create unexpected difficulties for the disabled traveler. This course presents information for healthcare professionals who are assisting people with disabilities to overcome travel barriers.
Healthcare professionals may assist a disabled traveler in planning a trip based on special medical needs and they may travel as an assistant with a disabled person (Routson, 2007). Although healthcare professionals have traditionally functioned as advocates to improve health policy conditions, both in the hospital setting and in the community, they may not be familiar with the many issues disabled persons face—even in making a simple trip to a medical center. Frequent travelers, on the other hand, may not routinely consult their healthcare professional about travel issues unless they have had trouble on a recent trip.
The first step in determining the challenges a disabled person may face when traveling is to review their known disabilities and symptoms. Such a list may be a work in process, since both disabled clients and healthcare providers may not always realize ahead of time which symptom will seriously affect them when traveling.
For clients who are mentally and physically capable, the list of their symptoms and disabilities should also include the coping mechanisms they currently use when traveling. If the client is not able to cooperate in this review, collaborate with their primary caretakers or family members, as authorized by the client under United States HIPAA regulations or other appropriate government regulations (USDHHS, 2010). The vulnerability of children requires the planner to consider additional risk factors, including possible separation from the travel group and the child’s language skill level.
The second step involves planning for the trip. If you have been hired to accompany and assist a disabled traveler, the journey will be made easier for both if you are included in ordering transportation tickets, accommodations, and any special medical equipment. Many healthcare professionals are also asked to assist with immunizations or arrange for access to local medical transportation systems. The planning priority is for the client’s comfort, not the assistant’s. For example, on a flight, the client may require an aisle seat, with the assistant accepting a middle seat.
Planning must also include anticipating additional expenses, such as paying porters to help the client navigate challenges like long flights of steps. Visiting crowded venues for religious services, meetings, or sporting events can impact disabled travelers who are susceptible to illness, such as colds or influenza. It may be important to review travel advisories issued by the Centers for Disease Control and Prevention (2010).
It is less common to be involved in the lengthy process of planning a cross-country or international trip, but travel nursing or disabled group excursions are growing specialties (Gautret et al., 2009; Mizroch, 2009; Routson, 2007). When accompanying the traveler on a longer trip, the use of proper tools and planning may help both of you to cope if there is an unexpected medical emergency.
The goal is to complete the trip with minimal unexpected stress for both the traveler and the healthcare professional. At trip’s end, you should always follow up with the traveler about any aspects of the trip in which you were involved. This may range from asking about the trip at the next appointment to doing a written evaluation of the assignment. The traveler should also provide feedback making the next trip will be easier to plan.
The case of Maggie (mother) and Dana (daughter) will demonstrate the hazards of travel for people who are disabled. Theirs is a disability that is not evident or recognizable to many people and which presents many challenges to their travel. Maggie and Dana both have hypokalemic periodic paralysis (HKPP) with permanent muscle weakness. This rare autosomal dominant genetic disorder affects the ion channels supplying the muscles of the body (Periodic Paralysis Association, 2009).
Maggie lives more than 2,000 miles from her daughter Dana but travels frequently to see her and also travels for pleasure. Dana would like to travel to see her mother, but she also has multiple chemical sensitivities and food allergies that make travel extremely challenging. As Maggie’s leg muscles continue to weaken, many questions arise about how to plan future trips. She has asked for help in creating a medical documentation file and travel plan.
When Maggie told her physician that she wanted to plan an international cruise and land tour, the doctor was concerned about whether she could manage it with her level of physical problems. Maggie reassured the doctor that she usually flies with a companion or is met by her family at the destination airport. The use of a medical summary sheet for periodic paralysis, including Maggie’s current medications, and the submission of a medical notification form to the cruise line and tour company will be necessary items on Maggie’s planning list.
HKPP is either inherited or caused by a spontaneous gene mutation that presents as intermittent episodes of muscle weakness and/or paralysis alternating with periods of normal muscle function. The episodes of paralysis are temporary but can lead to permanent muscle weakness. People with this disorder experience very low or acute swings in blood potassium levels that cause episodes of weakness. Attacks usually begin in adolescence and continue through adulthood. These attacks may mimic hypoglycemia or a stroke, and many patients are misdiagnosed until a familial connection is made. (Dana was diagnosed in her twenties, several years before her mother was diagnosed.) The paralysis attacks may last for hours or days, with frequency ranging from daily to yearly (Periodic Paralysis News Desk, 2010).
A person with HKPP may experience a variety of symptoms and complications such as: weak and flaccid extremities; sensitivity to temperature changes; muscle aches; and pain, which is usually associated with certain foods (particularly those high in carbohydrates and salt), exercise, and arrhythmias. Weekly supervised exercise may be needed to prevent muscle atrophy, but it can also exacerbate attacks—requiring an increased potassium dose just to walk continuously for more than 5 minutes. Another of many potential complications associated with HKPP is fractures, which can occur during a fall.
A unique feature of HKPP is that a person may become temporarily unresponsive while fully conscious of the events going on around them. Maggie and Dana both experience this symptom, and they are acutely aware of both positive and negative comments about their paralysis attacks, especially those made by healthcare professionals. They have been accused of faking the symptoms to obtain attention even with medical evidence to the contrary.
Both of them have memories dating back to childhood of conversations around them that they could not respond to. When this happens on a school trip, a child may feel they have experienced a nightmare, but may not say anything later to the teacher or their parent, especially if they are undiagnosed with HKPP. Instead, they may refuse to participate in similar trips in the future without giving an adequate explanation.
Treatment of HKPP is focused on the relief of acute symptoms and the prevention of further attacks. Types of treatment include routine oral potassium administration or emergency intravenous therapy (in a crisis or a prolonged attack); a low-carbohydrate, low-sodium diet; medications, including acetozolamide and/or potassium-sparing diuretics; and avoidance of alcohol.
Maggie and Dana both require potassium supplements and must monitor their diet to prevent excessive carbohydrate and sodium intake. Planning for any outing includes determining whether they will need a wheelchair or can use an assistive walking device such as a cane. This is particularly important in the colder seasons, as the response time of their muscles is impacted by temperatures under 70°F. They have used the Quality of Life Assistant forms from the Periodic Paralysis News Desk (2005) to document their daily medication regime, food and beverage triggers, and tolerance levels for daily activity.
Each disability brings a different challenge. For example, Maggie and Dana have to plan for multiple problems related to their disabilities. Maggie’s issues are primarily due to lowered physical abilities. She has to deal with the potential issue of paralyzing at any point on her journey; she also has visual problems affecting her depth perception. Dana’s issues include lowered cognitive, physical, and social issues. She has to deal with periodic paralyzing, brain fog, food allergies, and sensory issues when traveling. Social issues are more apparent with full body paralysis, as these impair oral and facial communication.
DISABILITIES THAT AFFECT TRAVEL
Lowered Physical Abilities
Lowered Cognitive Abilities
Lowered Social Abilities
There are many travel challenges for people with lowered physical abilities. They may have problems moving around in strange locations. These can range from using crutches for a twisted ankle to requiring a specialized wheelchair due to quadriplegia. Mizroch (2009) describes a group of paraplegic travelers ascending and then riding on the back of an elephant as especially challenging. Airline travelers should be aware that cabins are only pressurized to 5,000 to 8,000 feet, which can exacerbate respiratory and cardiac conditions (Fenner, 2007). If a small oxygen cylinder is carried in a sling, this may impact the traveler’s stability due to additional weight on one side of the body. When planning a trip, the traveler and assistant should assess all potential mobility needs in advance.
Common mobility devices used by travelers include canes, crutches, walkers, and wheelchairs. Particularly bulky or heavy specialized equipment required by the traveler can sometimes be preshipped or rented at the destination site. With such equipment, the traveler should have an assistant or be willing to ask for assistance. Persons weighing over 250 pounds can obtain sturdier versions of mobility devices from a medical supply store. Larger or customized wheelchairs may not be as travel ready as a simple, standard-sized wheelchair. Advanced planning with the airline, bus line, or other transportation provider will decrease the traveler’s anxiety about possible equipment issues.
The size and shape of a mobility device must be considered for ease of storage when traveling. Collapsible canes will fold in thirds or quarters, making them small enough to stow in carry-on luggage, and some specialty canes have built-in flashlights or other helpful gadgets (Miller, 2010; Norman, 2007). About 5 million Americans use a cane as their preferred assistive device. Crutches and braces require custom fitting and are often made of metal. Power wheelchairs and scooters are now a common method of assistance, especially at popular vacation destinations. Power chairs are difficult to transport when traveling via airlines but can be rented by the day or week and delivered to the destination hotel.
A destination checklist should include any special equipment and any other requirements for individual needs. Some types of specialized equipment are (Albrecht, 2007):
A prior stroke, a shortened leg, or gait abnormalities such as ataxia may cause a person to walk with an uneven gait. These people often need more peripheral space when they walk because they swing their legs and arms widely to maintain balance. The wide-swinging gait may be a problem in a crowded space such as an airport or conference center. The person may not be able to walk through a security screening area without setting off the alarm system, which then triggers a personal security check. Some airports have started providing a plastic cane to assist passengers through the scanner, which can prevent the traveler from needing a secondary screening. Walkers with uneven gait may also tire easily when trying to deal with crowds or long distances such as an airport concourse or a multi-level museum.
Numerous medical conditions cause partial mobility. It is common for a person with hip or knee injuries to use a cane or walker. When trying to navigate a crowded facility, such as an airport, these clients may instead require wheelchair assistance to prevent unexpected falls. Bulky doors may also present a problem if the person has weak muscle function; restrooms, for instance, sometimes have heavy fire doors that preclude easy access. Electrically controlled doors provide the best access for disabled users.
Persons dependent on a wheelchair require fully handicap-accessible facilities. They may need assistance transferring to a seat in any kind of public transportation (taxi, bus, or plane). Access may be limited by the steepness of the ramp (incline should be 1 inch for every foot of steepness) (USDOJ, 2002). When traveling out of their home area, a wheelchair-dependent person may need an assistant to access ramps, elevators, and vehicles that are not fully operational or accessible. For example, subway systems may have poor wheelchair access at some stations (Twardowski & Twardowski, 2007).
Amputees, such as military personnel and people who have long-term diabetes, may appear to have full mobility but be unable to pass through a security screener without setting off the alarm system due to the metals used in their artificial limbs. Titanium, which is currently used to pin a broken leg, usually does not set off a metal detector, but older pins or plates may be made of materials that routinely set off the detector. The traveler should know these materials and carry a physician’s note (USDOT, 2004).
As technology continues to develop, some prostheses or medical equipment may be so novel that any breakdown of the pieces cannot easily be repaired except at a specialized facility. The traveler may need to bring back-up parts or a second prosthesis (Fenner, 2007). This limits other luggage, and needed repairs can change the whole tenor of the trip. Travelers need to anticipate this potential problem by carrying emergency medical instructions on their person, along with the supplier’s information and customer service number.
Pacemakers can malfunction, especially near the end of their battery life. Travelers with heart pacemakers are usually familiar with these concerns. Patients with gastroparesis, commonly caused by diabetic complications, may have a pacemaker for their stomach, and for children with type 1 diabetes, they will need a knowledgeable assistant or family member with them in case of problems. Since pacemakers are a hidden device, knowledge of any potential issues should be a high priority for the traveler’s assistant.
Individuals with lowered cognitive abilities often have problems making themselves understood, understanding others, or figuring out where to go (Job Accommodation Network, 2010). It is important that people with cognitive disabilities have a detailed list of what they need to accomplish at each stop on their trip. This list will help the individual remember what they need to do and when they need to do it. Copies can be handed to others to ask for help or clarification of misunderstandings, and it can soothe a disabled individual when they get. This list should include:
Destination information must include an address and phone number for each stop. This is especially important when using public transportation, such as a taxi or medical transportation. Taxi companies may have cabs designated as accessible, but they are not always available (Twardowski & Twardowski, 2007). Numbered or color-coded index cards are useful tools to hand to a driver. With the popularity of Internet-based reservations, it is fairly simple to print out addresses and hotel confirmations that can be carried by the traveler in a folder that fits in carry-on luggage or in a large purse.
In addition to the destination, these cards should include the traveler’s name, any travel assistant’s name and phone number, and home contact information. The traveler should also have home address information both inside and outside all pieces of luggage in case they are misplaced.
Contact information includes a list of people important to notify when the destination is reached. If a local contact person is expecting the traveler, list that name and information first, then include a family member or contact person in the home area to reassure them that the traveler has arrived safely. In case of an emergency situation, the information on the contact list is a priceless asset in case the traveler cannot clearly state whom to call.
If the destination is a hotel or motel, the list may need to include details on how to register. Even if the traveler has a companion, many people prefer to maintain control of their environment as much as possible, and this list can be used to collaborate with the companion in completing the expected tasks. Collaboration may be as simple as giving the traveler a choice of what to do next on the task list.
A list of items brought with the person on a trip should include available space to identify new purchases, which will facilitate easier repacking upon leaving. For example, if the traveler needed a new swimsuit, it should be included on the revised packing list. The list should also include any carry-on items for airplanes.
Compartmental packing in the suitcase helps to keep contents organized. Commercial products, such as those used to organize a hiker’s backpack, are readily available. These may include pouches for shirts, slacks, or cosmetics. The contents can be packed by outfit (underwear through outerwear) and may even be labeled by which day the outfit is intended to be worn. The traveler may benefit from a diagram or photos of the original positions of the items in the suitcase.
Travelers should pack their medications in carry-on luggage in case of failed delivery of baggage, and this will affect both the space available for other items and the weight of the luggage (Albrecht, 2007). Another priority is a charger for the person’s cell phone.
Other items individuals may need to remember or request help for on a trip might include medications or information on a local pharmacy that would refill an out-of-area prescription. Considering the variety of insurance plans and coverage available, especially in the United States, the traveler needs to be familiar with their specific insurance coverage. Some insurance provides only domestic coverage, and an additional insurance policy may be needed for foreign travel (Fenner, 2007; Princess Cruises, 2010).
For the healthcare assistant, tasks to complete upon arrival may range from unpacking the suitcase at a family home to registering at a hotel to obtaining the rental power chair from the bell captain’s desk. The list might prioritize the activities that most directly impact the safety and comfort of the traveler. A reminder to eat some food or take medications may be a high priority item.
A person’s speech may be altered due to a physical deformity (cleft palate), medication, or neuromuscular problems (stroke). Sometimes the problem is intermittent and becomes worse when the person experiences a stressful event. When traveling to new areas, different languages or dialects may increase the challenges the traveler will have communicating with other people. Giving information to a cab driver may become difficult unless the traveler has clearly written information available. During the planning phase, it may help to create a short list of common phrases translated into the destination language.
Altered vision may range from misplaced glasses to permanent blindness. Travel plans might also need to include transportation for a service animal (Albrecht, 2007). Travelers with color blindness may have trouble recognizing or reading signs for freeway off-ramps. Temporary or permanent depth perception can challenge a traveler immensely, especially in crowded situations such as boarding an airplane or a bus. For example, a person with depth perception problems may have trouble stepping over the floor gap between the ramp and the airplane entrance, which then slows down the boarding time. This puts the traveler at a potential risk for injury when other passengers do not know there is a problem and they try to rush by when boarding or exiting the airplane.
Decreased auditory acuity is commonly experienced by older travelers, but a person can also be over-sensitive to sound. A poorly functioning hearing aid can cause significant problems for the traveler; the assistive device may even be affected by radio transmissions. Altered noise levels can cause interference with person-to-person communication, especially in crowds. For example, people with auditory disabilities may have problems understanding directions in an airport. Also, security personnel may address passengers from behind, but the person may not hear them or the metal detector alarm. This could be easily misinterpreted by security personnel and present a potentially serious problem that could delay the traveler’s journey.
Hearing deficiencies are addressed in the United States Department of Transportation (2004) New Horizons brochure. “Any carrier that provides telephone service for the purpose of making reservations or offering general information must provide comparable services for hearing-impaired individuals, utilizing telecommunications devices for the deaf (TDDs), or text telephones (TTs).” The brochure also includes information about onboard communication and safety briefings.
Travelers who tire easily may experience some impaired thinking, especially after a long day of travel, which can affect physical stamina as well (Fenner, 2007). When a person has an underlying cognitive problem, fatigue can make social interactions even more difficult. Registering for a hotel room may become a major challenge. The traveler may forget they have the information in written format. Even with written information, the person must be able to double-check the room rate before signing in or they may be charged a different rate than they had budgeted. Another high-risk time is when transferring to a new mode of transportation. If travelers have to use a taxi to the airport or transfer vehicles to reach their destination, they can easily become confused or miss their connections.
A common problem for older travelers experiencing the beginning stages of impaired memory due to a dementia disorder is misplacing a companion in a crowd (Wicklund et al., 2007). The person may not be aware of a problem until they are lost in an unfamiliar setting, such as a crowded bus station. To increase their visibility to other passengers in their group, the traveler should wear a piece of distinctive jewelry or clothing that is not easily removed. The companion or a contact person can then provide a description of it to security personnel, if necessary.
Individuals with lowered social abilities often have problems understanding their surroundings. They interpret social situations differently than others perceive them and may not be able to interface easily with the people around them (Job Accommodation Network, 2010). It is recommended that an individual or group with social disabilities have an assistant to help smooth over communication differences. If an assistant is not available, it is vital that the individual’s needs and communication issues are clearly documented in an obvious place.
This document should identify the individual’s disability and recommend strategies for strangers interacting with the traveler. Such travelers are more likely to be exploited, since (1) they have a tough time realizing that there is a problem in the first place, and (2) they have trouble making another person understand that there is a problem (Flyer Talk Forums, 2007). Some examples of strategies:
CASE
Maggie and her husband John once went on a trip to the Middle East with a group of elderly passengers. One member of the group, Jerry, had early-stage Alzheimer’s and was traveling with an attendant to help make sure that his memory and processing problems did not affect his trip too much. Jerry’s special identification clothing item was the tour group’s colorful hat, which he wore everywhere. A secondary identification item was a fanny pack for money and documents to decrease possible thefts. The attendant also carried an itemized list of Jerry’s clothing to further keep track of him throughout the tour.
One day the group visited a bazaar and Jerry became separated from his attendant. Jerry found himself in a location he did not recognize, surrounded by many people having conversations in a language he could not understand. He had also lost his tour hat. He started to panic, yelling at everyone to help him. His attendant was able to find him quickly by being aware of Jerry’s clothing for that day. By speaking to Jerry with prearranged phrases and gestures, he helped Jerry realize he was not alone and that someone knew where he belonged.
People with developmental disabilities or memory impairment may not have a good grasp of monetary matters. They often do well with preset quantities of cash or money arranged in a certain pattern (tens folded to the right, twenties folded to the left). Otherwise, they may need to travel with a companion, especially when dealing with foreign currencies. Storing foreign currencies separately will assist the traveler when using it for local purchases. This also makes the currency easier to exchange at the end of the journey.
Persons with attention deficits or those with visual or hearing impairments may have trouble communicating in new environments. This can cause the traveler severe distress, especially when interacting with security personnel or with local service personnel about problems with their travel arrangements or accommodations. These travelers would also face challenges in other cultures, especially those whose communication depends upon nuances or nonverbal cues such as facial expressions. If the person’s condition is severe, it is essential to plan strategies before leaving home to prevent confusion or confrontations. Pre-investigation of local cultural responses will help the traveler with communication challenges.
Many cultures have preconceived understandings about acceptable boundaries. A person assuming that their own culture’s boundaries are accepted anywhere they travel could experience conflict when communicating with a person of another culture. For example, a child who is used to greeting adults with a hug may become confused when adults reject this affectionate response.
A disabled person with sensory issues may need extreme physical touch, or conversely, to avoid even the lightest of touches. An individual with extreme physical touch needs is more likely to touch a stranger aggressively and violate their personal space. An individual sensitive to touch may react badly if touched when they did not expect it. Chemical sensitivities can stimulate a reaction if the traveler is allergic to the fabric of the glove touching the skin. Although these are physical disabilities, they appear to others as lowered social abilities because of the verbal and nonverbal cues the traveler exhibits.
Any person with anger issues has the potential to experience confrontations with security personnel or other persons in authority. In addition, some medical disorders cause angry outbursts when a person feels threatened or stressed. The traveler and any assistant should be well aware of this issue and plan strategies to cope with unexpected stress the disabled person may encounter, such as a delay in the arrival time of a plane.
A travel file containing medical documentation should be prepared by the traveler with the assistance of any traveling companion(s) and healthcare providers. All medical documentation files should include, at a minimum:
Additional information may include a brief summary of the traveler’s medical issues and the basic emergency care needed for their specific disorder. The most important information should be made as concise as possible, since there is less chance of losing the information if it is on one or two type-written pages.
Medical emergencies can occur anywhere. When a person is traveling in a foreign country, their insurance may not cover emergency care or medical evacuation to a facility that can handle the individual’s disability. For this reason, medical vacation insurance is highly recommended for disabled individuals.
The traveler should be wearing a medical alert tag. (Some people prefer a necklace over a bracelet.) The site of the medical alert tag should be noted in the paperwork (Fenner, 2007). Medic alert tags list the most immediate health concern and state where to find more medical information.
In addition, full medical treatment information for rare disorders or treatments should be carried with the person at all times. Some healthcare agencies will provide a person’s medical information on a flash drive for easy computer access, but it must be ordered well in advance of the trip. If appropriate, the information should be translated into the language of the country being visited. Another option is to include a website for emergency personnel to access.
MEDICAL DOCUMENTATION FILE
The following items may also be included in the medical documentation file:
Most emergency departments do not have access to a central patient database. Having specific medical information readily available prevents the traveler from struggling to provide a general history from memory when acutely ill.
Developing the medical information file may seem overwhelming at first. Reassure the traveler that it is a work in progress.
One of the most confusing parts of any long-distance trip is adjusting the medication schedule to the new time zone in order to maintain therapeutic values for each drug. The traveler must factor in both the time-zone difference and the duration of time to reach the destination time zones. If travel is slower by ship, train, bus, or car, there will be fewer adjustments than when by airplane.
Each person should identify the best times to administer their medications. Medication schedules ordered for a specific time of day, such as a sleep aid, should be discussed with the traveler’s primary physician to prevent incorrect dosing based on time-zone differences. Special attention should be given to a child’s medication schedule, a child may not adapt well to disruptions in their daily activities. A plan compensating for altered meal times should also be created if any of the medications must be taken in conjunction with food.
The following table includes suggestions for adapting medication schedules for domestic and international travel.
| Medication | Dose/Frequency | Origin Times | Destination Times |
|---|---|---|---|
| Crosscountry (e.g., from California to New York, a 3-hour time difference) |
|||
| Klor Con | 20 mEqs/2X daily | 7 am & 7 pm PST* | Day 1: 8:30 am & 8:30 pm EST* Day 2: 7 am & 7 pm EST |
| Lisinopril | 5 mg/1X daily (pm dose) | 7 pm PST | Day 1: 8:30 pm EST Day 2: 7 pm EST |
| Long-Distance International (e.g., from San Francisco to London, an 8-hour time difference and a 12-hour flight) |
|||
| Klor Con | 20 mEqs/2X daily | 7 am & 7 pm PST | Day 1: Extra dose 12 hours after previous dose, then 7 pm & 7 am GMT* |
| Lisinopril | 5 mg/1X daily (pm dose) | 7 pm | Day 1: Extra dose at 1 pm GMT, then a second dose at 11 pm Day 2: 7 pm GMT |
| * PST = Pacific Standard Time; EST = Eastern Standard Time; GMT = Greenwich Mean Time | |||
Air travel challenges may begin with the basic planning for the trip. One problem is disabled seating when marking reservations online. Most people can choose their seats when booking their ticket; disabled travelers may need to call the airline by phone because online sites may not allow disabled passengers to select special seating. Disabled travelers may have to request a seat change at the airport, which takes more time; such seats may also not be available because there are often a limited number on the plane.
When requiring assistive devices such as oxygen or wheelchairs, a disabled traveler may also need to communicate their special needs by phone. An airline can require up to 48 hours advanced notice for respirator hook-ups or storage space for an electric wheelchair (USDOT, 2010). Federal Aviation Administration (FAA) regulations restrict the assistive devices allowed onboard, but aircraft with 60 or more passenger seats must provide an onboard wheelchair for lavatory access. There are very specific requirements for oxygen, and airlines can charge an extra fee (USDOT, 2004).
Some people with disabilities also have chemical sensitivities and food allergies. Anticipating problems may alleviate their travel stress. Both of these conditions can add weight and content to a traveler’s luggage if special food or clothing is required to prevent anaphylactic reactions. An EpiPen autoinjector for allergies, if prescribed by the healthcare provider, should be placed in the person’s purse or carry-on luggage. This medication should also be highlighted in their medical documentation travel file and can be brought through airport security with a Labeled Medication Letter.
People with chemical sensitivities have problems being around others who are wearing perfumes, scented shampoos, or even deodorant. They may be sensitized to various common environmental stimuli and respond with symptoms similar to an allergic reaction; this is possibly due to an autoimmune injury (Multiple Chemical Sensitivities, 2007). If the traveler is seated near someone using strong fragrances, they may have to request a seat reassignment, which can be difficult on a crowded plane, train, or bus. Chemical sensitivities can be so disabling that the individual is required to bring all their own bed sheets and towels in order to avoid the chemicals often found in laundry detergents used by hotels.
With food allergies, eating out may be an unsafe option, especially if the restaurant is unwilling to consider special orders, such as cooking without peanut oil. Travelers may wish to carry a “chef card” listing safe ingredients for common dishes that may help them to negotiate their meal at a restaurant. Some travelers must bring all their own safe food in a portable refrigeration unit. Or they may be required to buy food at the destination and use a kitchen in which they can safely cook their meals. Having an accessible microwave oven has helped some travelers with food allergies feel more comfortable planning meals. Buying and cooking food after spending all day traveling can be difficult, especially after a long trip.
People traveling with food allergies face an additional challenge at security checkpoints. They may have to travel a long distance by plane and carry certain types of food with them due to their dietary restrictions. Carrying this food on the plane increases carry-on luggage and may be challenged by security (Food Allergy News, 2007), especially liquids such as cooking oils.
For many disabled persons, traveling alone may not be an option. A person may travel with family and friends or hire a medical professional as an assistant (Routson, 2007). The assistant’s scope may be limited to providing companionship except for emergency care, or be all-inclusive, covering both the physical and mental care of the traveler. It is imperative that the medical professional understand the traveler’s goals for the trip and work with the traveler to facilitate a positive experience.
When a medical professional will be assisting the traveler, a written contract should be developed and agreed upon before the start of the journey. The contract should clearly identify expected daily duties, how possible extra activities would be assigned, and any specific tasks that are not routinely part of the medical professional’s job description. With a clear contract, the traveler can prevent stress in an unexpected situation and expect basic care to be performed per the agreement.
SAMPLE RESPONSIBILITIES
A checklist of daily duties may include the following:
The professional should be comfortable traveling in any type of vehicle, using various accommodations, and addressing the traveler’s specific medical issues and care. If you are uncomfortable flying or communicating with service providers, especially in a different culture, you should reconsider taking the assignment.
Travel by a major commercial transportation system (airplane, train, cruise ship) or visiting tourist sites may involve security screenings. The disabled traveler should be prepared for the screening process. The traveler should try to accommodate the screeners by wearing easily removable shoes and jackets and carry only a lightweight bag or purse containing medications and medical documentation. Any additional items should be restricted to those needed before arriving at the next destination.
The security area provides challenges for people with mobility aids like braces, canes, and crutches. Collapsible canes work better than rigid or wooden canes because they can be folded down and placed in the security bucket. Canes and crutches can be passed through the luggage scanner, but braces must be wand-checked like wheelchairs.
A person bringing any metal mobility devices, including their personal wheelchair, should anticipate that they will be screened for gunpowder residue, as the hollow metal tubing is seen as a place to store explosives. An unusual walking aid may be taken from the person because it could be considered a weapon. For example, security has at times challenged Dana’s walking stick (4-foot, non-collapsible), which she needs for balance. (She carries a medical authorization letter, and it fits through the scanner.)
A person with metal in their body may need to have a medical certificate from their doctor stating the type of metal, where it is located, and how it might interfere with a security scanner (USDOT, 2004). Otherwise, the individual might not be allowed through security. This issue might be compounded if the person has lowered cognitive or social abilities. Proper documentation with their personal healthcare practitioner’s contact number becomes even more critical when the disabled individual has problems communicating their difficulties.
According to the latest airline regulations, passengers may take liquids on a flight if they are in containers of no more than 3 ounces and in a sealed plastic 1-quart bag (USDOT, 2004). Maggie and Dana both require a 16-ounce dilution of their potassium medicine, which is always challenged by security even when properly labeled. The solution to this problem has been to carry a “Labeled Medication Letter” from their primary care physician that includes the language: “It is imperative this patient has this medication with him/her at all times. Without treatment, this patient is at great risk for injury.”
Maggie has now tried to drink the last of a dose just before the security screen, then asking the wheelchair assistant to stop at a shop to obtain a new water bottle after the security screen. This is better received by security but may cause a delay in getting to the gate, which can be stressful for the traveler.
Disabled people in wheelchairs are not exempt from the requirement to remove additional layers of clothing, such as a sweater, jacket, and shoes. They are also encouraged to walk through the scanner “if at all possible,” or endure a full-body search by a security person of the same sex. This can be especially distressing for disabled children who may not be able to verbalize their discomfort (e.g., a child with severe cerebral palsy). Even though disabled persons are sent through the short line at the security station, the procedure may still take at least 15 minutes due to the full-body search and wheelchair check.
CASE
Security screening machines are often kept in a cool area, which may trigger problems for a cold-sensitive traveler. Maggie and Dana turn into “statues” (major muscle groups paralyze) when they are hit by cold air, and their muscles will not move well until they are out of the cold. During this time they may become nonresponsive and “floppy” if moved but will be able to hear and understand conversations. Maggie’s speech may become incoherent when her facial muscles paralyze after being exposed to a high intensity air-conditioning unit. Dana has fallen out of the wheelchair many times in security areas, even when security screeners were warned about her condition. Screeners have expressed suspicion that she’s hiding something because she springs back to life once out of the cold security area. Dana was almost kept from going on her plane by security because they witnessed this event, even though her medical conditions were explained, documented, and available to security.
The airline can require a travel attendant if the traveler has significant physical or mental impairments and would need assistance evacuating the plane in an emergency (Flyer Talk Forums, 2007; USDOT, 2004). Airplane staff may have trouble bringing out a transport chair mid-flight for a passenger, so restroom time must be preplanned. This has caused people with mobility issues to compromise by using diapers or catheters plus eating and drinking as lightly as possible prior to the flight.
Disabled passengers may use transportation devices until they get to the gate and then check them through to the destination. It may be preferable for disabled passengers to use a manual wheelchair with an assistant. Fenner (2007) recommends bringing a personal manual chair for proper size and support. Power chairs must have nonspillable batteries or the ability to remove spillable ones (USDOT, 2010). Batteries may drain on the flight and are difficult to recharge. Battery use and potential damage to the specialized equipment are two big issues with motorized wheelchairs.
Two factors that influence the number of available wheelchairs and attendants are (1) the seasonal fluctuation of tourists and (2) whether the wheelchair subcontractor has received adequate information from the airlines on the anticipated number of handicapped travelers. With connecting flights, a disabled traveler needs to include a long enough stopover to ensure they will make their next flight even if they must wait 15 to 30 minutes for a wheelchair to become available.
In the United States, public train and bus service should meet the national Americans with Disabilities Act (ADA) accessibility mandates (USDOJ, 2008). The traveler may experience challenges similar to air travel when reserving tickets, such as availability to accessible seating. Movement across crowded platforms and down narrow isles must be considered when determining the best mobility device to use. The traveler must also be prepared for the possibility of an elevator service not working or the facilities not being fully accessible despite assurances from a train or bus representative.
Private tour services both within the United States and internationally may not have the same level of accommodations required of public providers. A person using a wheelchair should verify that the train or bus system is accessible before the trip; for example, when booking bus tours on an international cruise, special tour accommodations may need to be arranged through the cruise line because not all buses are equipped with lifts. Such needs will limit the available tours unless the traveler is willing to pay for a private car service (Twardowski & Twardowski, 2007). Even within the United States, tours are planned for the use of a manual wheelchair. The tour company may define safe ground as a gravel parking lot, which is less easy to navigate in an electric wheelchair due to traction issues.
Travel plans must include transportation at the destination. The traveler may require an accessible cab or medical transportation van to pick them up. If there is a train or plane delay, there must be a way to notify the cab or medical transportation company. Porters are very helpful in transferring luggage if travelers have problems lifting or carrying weights over 10 pounds, but they expect to be tipped extra for this service. Porters may also insist that a disabled traveler wait for an accessible taxicab even though the traveler is capable of transferring to a regular cab seat.
Unexpected physical activity may be necessary on a cruise excursion. The tender or bus transportation to any land-based excursions may be a significant distance from the ship. In some ports, the tenders may dock several miles from the cruise ship, and there may not be clear directions for those returning passengers who are not on an organized excursion. When taking a taxi, there still may be a long walk or uneven pavement for a wheelchair. This can be especially exhausting, frustrating, and upsetting to a disabled individual not expecting these additional challenges. The traveler should plan any off-ship excursions to end an hour before the ship’s departure time in order to reboard on time.
When traveling by car, truck, van, or mobile home, there is no guarantee that the locations along the way will be accessible to all disabled individuals. Basic accessibility in the United States should include designated parking spaces, some form of ramp to the sidewalk, and a larger restroom stall with grab bars by the toilet (USDOT, 2004).
Designated handicap parking spaces often fill up quickly, or the adjacent access area may have a car illegally parked in it, forcing the disabled traveller to park further away. Similarly, other vehicles may block the access area of the disabled person’s already parked vehicle, thereby obstructing access. This can mean the disabled person will trapped until the other vehicle owners return to move their cars. Local law enforcement authorities will ticket illegally parked vehicles in handicap zones, but they typically rely on individuals to call them about the violations.
Handicap access ramps at rest stops may be nonexistent or blocked by an obstacle, such as foliage debris. Parking in campgrounds or at rural rest stops may be in a dirt lot with uneven terrain. Some wheelchair users bring along two wooden planks that tie to the back of their wheelchair so they can use the planks as an impromptu ramp. This generally requires the assistance of a companion and is potentially dangerous because the traveler could fall off the impromptu ramp. In high country (e.g., towns high in the Rockies) the sidewalks are raised for access during deep winter snow, but may only have two planks side by side for wheelchair access. Stores in high snow country may also have a raised grab bar in the entryway, which makes wheelchair access difficult if a person has poor muscle function.
Restrooms also often have accessibility issues. Sometimes the larger stall is in use or out of order, so the traveler should have a contingency plan, such as using a portable cane to access a smaller stall. The larger restroom stalls are often used as the family stall, with the changing table placed just before the grab bars. If a family leaves the changing table in the down position, it may be hard to position the wheelchair correctly to access the grab bars. Restroom doors are constructed as fire doors and are fairly heavy.
CASE
Maggie’s depth perception issues were increasing, and she scheduled an appointment with a specialist in optometry. The specialist was located in a crowded urban area, and there was minimal parking near the clinic. She and her husband, John, decided to travel by public transportation using a manual wheelchair. They planned an extra hour each way for the trip.
They drove first to the subway system by car, but there were no accessible spaces available to let down the wheelchair ramp on the side of their van. John dropped Maggie in the wheelchair off at the loading zone and then left to find parking, which took ten minutes. When he returned, they discovered that the elevator to the subway was not working, and they had to use the escalator. This took an additional five minutes since Maggie had trouble seeing the steps. They boarded the train without problems by backing the wheelchair over the open space between the platform and the train. At the transfer station, the elevator did work, but both John and Maggie had trouble finding it due to the small print on the directional signs.
The transfer bus arrived 20 minutes late. Maggie became very cold and paralyzed while waiting for the bus. John kept talking to her so she would not get too scared. The bus had a lift for the wheelchair, but neither the bus nor the subway had a way to secure the wheelchair, so it slid from side-to-side on turns even with the chair’s brakes on.
When they reached their destination, Maggie was still paralyzed and John was very upset. The staff had to warm Maggie up and calm John down while also helping the other clients. John then arranged for a taxi to take them back to their van.
Overnight stays in a location away from home can be difficult and challenging for people with disabilities. Many sites are not as accessible as the traveler may have anticipated (e.g., lacking 24-hour access to a food source for the diabetic traveler). It is important to call the location ahead of time and find out if the individual’s specific concerns can be met.
A hotel room with two double beds and an accessible bathroom may not offer enough space to maneuver the wheelchair to or through the bathroom door. A traveler may need to ask the hotel staff to move or remove furniture to accommodate the wheelchair. Hotels built after 1993 must meet current ADA design standards (USDOJ, 1999), but only to the minimum standards, which may not be adequate for all disabled travelers. As an assistant, you may need to be an advocate for the traveler when the accommodations are unacceptable and ask for a different room.
If the person is planning to stay in a private home, it is imperative that issues with steps and bathroom access be discussed ahead of time with the host family. Private homes do not need to meet ADA standards, and the family may not be aware that even two stairs at the front door may make it difficult for the traveler to enter the house. The bathing area should have either grab bars or a shower chair, especially if there is only a bathtub available. All allergies and pertinent medical information should be reviewed with the family also. Sending them a copy of the medical documentation file may prevent miscommunication or misunderstandings during the visit.
One commonly overlooked need is enough accessible power outlets. A power wheelchair requires frequent recharging and generally requires a grounded outlet (three-prong), which is not always available in older homes. Power outlets in rooms are often hard to reach, even for the able-bodied. Hotels frequently place desks or other furniture in front of power outlets. A newer feature in hotels is the energy-saver switch. This switch turns off all the lights and the power outlets in the room. Maggie was not aware of this feature at one hotel, and her power wheelchair did not charge overnight, causing a loss of battery power by lunchtime the next day.
A positive feature in upgraded handicap accessible bathrooms is the roll-in shower area. Instead of a ledge, there is a sloped area directly into the shower. The negative impact is that the water may retrograde to the rest of the bathroom if the drainage is not properly designed. The traveler may need to request extra towels and definitely should notify the hotel staff of the problem.
When traveling to a variety of destinations it is important to keep in mind the different kinds of hazards the disabled individual may face. Examples include an excursion that requires more physical, mental, or social ability than was originally anticipated; special issues when traveling with children; and inclement weather, such as a thunderstorm or heat wave.
CASE
Dana’s nieces and nephew came to visit her with their mother. Everyone wanted to take a trip to the zoo. On a previous trip to the zoo, the children tired and wanted to be carried after a few hours, but since only one adult was available to carry them, this caused fighting among the children. This time they decided to hire a professional assistant. They brought a portable scooter for Dana and a foldable stroller for the young nephew, and they rented a wagon at the zoo for the older nieces. The zoo was handicap accessible, so the scooter and stroller could enter the majority of buildings. With the help of the assistant, Dana and her family were able to enjoy their outing.
CASE
Heat waves or other inclement weather may affect disabled and elderly travelers. On John and Maggie’s Middle East tour, the temperature remained above 100°F for several days, and even though the tour guide encouraged the travelers to stay hydrated, Maggie and several others became dehydrated. The tour guide arranged for treatment at a local hospital, and the tour was delayed a full day.
When assisting a disabled traveler in planning and implementing safe travel it is important to fully understand their disabilities, have all relevant medical information available in a readable format, help break down each challenge into manageable parts, and have anticipated challenges (with their solutions) clearly documented. The traveler should consider the potential safety issues for any excursion and should always consider personal safety needs when considering new sites or alternative methods of transportation. Achieving these goals will support the travelers and help them enjoy their vacation or trip.
Albrecht DG. (2007). Cleared for takeoff: Navigating airline baggage restrictions. Quest 14(5), 54–56.
Fenner P. (2007). Fitness to travel: Assessment in the elderly and medically impaired. Australian Family Physician 36(5), 312–15.
Flyer Talk Forums. (2007). Discussion on flying with mental disability. Retrieved on January 9, 2010, from http://www.flyertalk.com/forum/showthread.php?t=306002.
Food Allergy News. (2007). Traveling with food allergies. Retrieved on January 9, 2010 from http://www.foodallergy.org/downloads/SampleNL.pdf.
Gautret P, Soula G, Selmont J, Parola P, & Brouquil P. (2009). Common health hazards in French pilgrims during the hajj of 2007: A prospective cohort study. Journal of Travel Medicine 16(6), 377–81.
Job Accommodation Network. (2010). Accommodation information by disability. Retrieved on January 9, 2010, from http://www.jan.wva.edu/media/atoz.htm.
Miller J. (2010). How to choose and use a cane. San Leandro Times, January 7, 2010.
Mizroch A. (2009). A triumph of the spirit. International Jerusalem Post, December 4, 2009.
Multiple Chemical Sensitivities. (2007). The symptoms of multiple chemical sensitivity. Retrieved on January 9, 2010, from http://www.multiplechemicalsensitivity.org/.
Norman B. (2007). Canes, crutches, and walkers: A triple option for ambulation. Quest 14(6), 48–52.
Periodic Paralysis News Desk. (2010). Hypokalemic periodic paralysis FAQ. Retrieved on January 9, 2010, from http://www.hkpp.org/faq/hypokalemic_periodic_paralysis.html.
Periodic Paralysis News Desk. (2005). Welcome to the quality of life assistant. Retrieved on January 9, 2010, from http://www.hkpp.org/qla/index.html.
Periodic Paralysis Association. (2009). Retrieved on January 9, 2010, from http://www.periodicparalysis.org/english/view.asp?x=1.
Princess Cruises. (2010). FAQ: Cruise answer place. Princess vacation protection. Retrieved on February 8, 2010, from http://www.princess.com/learn/faq_answer/pre_cruise/prepare.jsp.
Routson J. (2007). Going places. NurseWeek 20(23), 28–29.
Twardowski B & Twardowski J. (2007). New York, New York, it’s a wonderful town. Quest 14(6), 63–65.
United States Department of Health and Human Services (USDHHS). (2010). Health Care Information Privacy. Retrieved on January 9, 2010, from http://www.hhs.gov/ocr/privacy/index.html.
United States Department of Justice (USDOJ). (2008). American with Disabilities Act, ADA home page. Retrieved on January 9, 2010, from http://wwwusdoj.gov/crt/ada/adahom1.htm.
United States Department of Justice (USDOJ). (2002). ADA Standards for acceptable design. Retrieved on January 9, 2010, from http://www.usdoj.gov/crt/ada/stdspdf.htm.
United States Department of Justice (USDOJ). (1999). ADA Checklist for new lodging facilities. Retrieved on January 9, 2010, from http://wwwada.gov/hsurvey.pdf.
United States Department of Transportation (USDOT). (2010). Passengers with Disabilities. Retrieved on January 9, 2010, from http://airconsumer.ost.dot.gov/publications/disabled.htm.
United States Department of Transportation (USDOT). (2004). New horizons. Information for the air traveler with disabilities.
Wicklund AH, Johnson N, Rademaker A, et al. (2007). Profiles of decline in activities of daily living in non-Alzheimer dementia. Alzheimer Disease & Associated Disorders, 21(1), 8–13.
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