Outdoor Adaptive Athletes Chapter 32 Outdoor Adaptive Athletes

Objectives 32.1 Define and contrast the following terms: disability handicap impairment 32.2 List and describe two disorders that cause intellectual disabilities. 32.3 List two disorders that cause progressive physical disabilities. continued

Objectives 32.4 Describe four elements of effective communication with a person who has an intellectual disability. 32.5 Describe how to assess and care for physically disabled athletes. 32.6 List the signs and symptoms of autonomic dysreflexia. 32.7 Describe and demonstrate how to assess an adaptive athlete. continued

Objectives 32.8 Describe and demonstrate how to care for an adaptive athlete who is injured or ill. 32.9 Describe and demonstrate how to manage an above-the-knee amputee with a femur fracture of the same leg.

Topics Common Disabilities Adaptive Equipment Assessment Management Chapter Summary

Case Presentation At a racing event for disabled athletes, one of the chaperones waves you over. The chaperone explains that the 14 year-old girl had a “few falls” during the day, and has not been acting right for the past 10 minutes. As you lean down to assess the patient, you notice that she does not make eye contact and is staring off to the side. She is unresponsive and does not follow verbal instructions. Discussion Points: What should you do while you are waiting for assistance? Discuss the impairment this girl may have.

Common Disabilities Americans with Disabilities (ADA) overview Terminology matters Handicap – substantial limitations of one or more ADL. Disability Physical or intellectual May be situational Discussion Points: The overview in the chapter raises topics not mentioned elsewhere in the text. It is important to know a bit of history and the ADA content helps students understand the prevalence of adaptive athletes on the slopes. A common vocabulary will be helpful as you discuss other parts of the chapter. continued

Common Disabilities Terminology matters Impairment Physical, physiological, or psychological

Intellectual/Physical Disabilities May have one or both disabilities Intellectual may be learning, cognitive, or psychological/personality related Communication may be difficult Most common physical are neurological, amputees, and muscular disease Discussion Points: Draw from the students’ background and experience regarding impairments. Discuss the concept that a disability is not always an inhibition– i.e., the successful businessman who is also dyslexic, the amputee who runs for fitness, etc. continued

Intellectual/Physical Disabilities Some have severe disability Some need modified sport with supervision Discussion Points: Draw from the students’ background and experience regarding impairments. Discuss the concept that a disability is not always an inhibition– i.e., the successful businessman who is also dyslexic, the amputee who runs for fitness, etc.

Intellectual Disabilities Learning disorders ADD, dyslexia Communication may be impaired Autism spectrum disorders Autism, Asperger’s, and Atypical Limits to effective communication Discussion Point: Note that all intellectual disabilities occur with degrees of severity. See text for additional details. continued

Intellectual Disabilities Cognitive TBI or loss of brain function Seizures, physical impairments, coordination issues Autonomic dysfunction, Mental illnesses Discussion Points: Raise awareness of stereotypes and prejudice with the class. Discuss the response OEC techs must display when dealing persons with disabilities. continued

Intellectual Disabilities Intellectual difficulties Genetic conditions, fetal alcohol syndrome, and other pre-natal causes Asphyxia, brain trauma, poisoning, meningitis among other causes Exhibit anxiety, hyperactivity/apathy, bad judgment, impulsiveness Kindness and caregiver help are vital Discussion Points: Raise awareness of stereotypes and prejudice with the class. Discuss the response OEC techs must display when dealing persons with disabilities.

Physical Disabilities Spinal cord injuries Adjunct devices may be used AD: Result from: Dangerous increase in BP Medical emergency Determine source Patient may assist Discussion Points: Emphasize the patient’s ability to help diagnose the problem– the OEC Technician needs to ask the right questions. Present inserting catheters and ostomy bags in a straightforward manner. continued

Physical Disabilities Cerebral Palsy Anoxic brain injury – Three patterns: Spastic, athetoid, dsytonic Extremity injuries likely: Patient’s cannot control during a fall Many sit to ski Treat in position of comfort: Spasms/rigidity are concerns in splinting Discussion Point: See text for additional details on cerebral palsy. continued

Physical Disabilities • A person with cerebral palsy is at increased risk of an extremity injury during a fall. • Muscular dystrophy causes skeletal muscles to become very weak. continued

Physical Disabilities Multiple sclerosis: Progressive degeneration of central and peripheral nerves Intermittent progression Impairments vary Function at high mental capacity Affect may change as disease progresses Discussion Point: Note for students that patients with MS can plateau for long periods of time, and then take a sudden downward turn. continued

Physical Disabilities Spinal bifida Malformation often at lumbar spine Sensory or motor deficits below Abnormal CSF circulation Shunt may be implanted Blockage may cause pressure/life threat May be allergic to latex Some have abnormal circulation of the CSF Discussion Point: Details regarding the shunt and blockage are in the text, should you want to include. continued

Physical Disabilities Muscular dystrophy Affects skeletal muscles Spinal curvature, lax joints, weak/wasted muscles Easily fatigues Normal mental status continued

Physical Disabilities Amputations Largest group of adaptive athletes Can be congenital, traumatic, or surgical Relative impairment based on amount of extremity lost Use adaptive equipment and prosthetics Type/location of lower extremity amputation determine equipment needs Discussion Point: Content regarding levels of involvement and caring for the equipment used by amputees is discussed later. continued

Physical Disabilities Visually/Hearing Impaired Blind skier: Higher incidence of injury; explain in detail when providing care Hearing impaired skier: Be sure they can see your mouth May sign or be able to speak May prefer written communication

Combined Physical and Intellectual Disabilities Down syndrome Physical and intellectual impairments vary widely. May be highly competitive, not complain about injury or illness Chance of musculoskeletal injuries increases due to laxity of ligaments May have upper c-spine ligament injuries (C1/C2 area) Discussion Points: These athletes will usually be accompanied by a companion or caregiver, and may participate through their school or group home. Their competitive nature may be seen in the Special Olympics which are held at ski areas throughout the country.

Adaptive Equipment Available for many sports Prosthetics Scale from no assistance required to complete control by helpers Some ‘generic’, some customized Understand “ins” and “outs” Chair evac modifications maybe needed Discussion Points: The chapter includes the history of the Special Olympics and Para Olympics, which you may choose to discuss, if time allows. The chapter also mentions equipment for sports other than skiing; this slide and others referring to adaptive equipment focus on skiing. If your resort also has other adaptive athlete sports, cover as needed. If your area regularly has adaptive athletes, you may be able to arrange for a “show and tell” of commonly used equipment and an explanation of the amount of help each typically requires. Chair lift evac procedures will be covered again in a later slide.

Adaptive Equipment Copyright Dorling Kindersley Media Library • A prosthetic is an artificial body part used as a substitute for a lost body part. • Artificial legs come in many shapes, sizes, and designs. Copyright Dorling Kindersley Media Library Copyright Image Source/PunchStock

Snow Sports Equipment 4 major classes Snow slider or bike Sit Down (Mono, Bi, or Sit Ski/Board) 4 track (3 track) Blind Guiding 2 track (Stand up) Snow slider or bike Tethers and outriggers Treat equipment with care Discussion Points: Chapter includes brief descriptions of the classes and equipment. Also mentions the expense of the equipment, care, and how the equipment should travel with the patient. Sledge hockey and warm weather sports not included here; however, feel free to discuss if these activities are common in your area.

Snow Sports Equipment Copyright David Johe Copyright Craig Brown • An outrigger. • A sit-ski. Copyright David Johe Copyright Craig Brown

Case Update You’ve established that her ABCDs appear to be intact. The chaperone listed the patient’s medications and described her known seizure disorder. As another patroller arrives with a fully loaded toboggan, the patient begins to have a tonic- clonic seizure. Discussion Points: What attempts to communicate are being made? What medical condition manifests during your assessment? What steps are taken to deal with it? What may be the cause? What is the next step? Review seizure information here, as students may need it. Note that the head is stabilized in deference to the fall the patient had earlier, rather than because of the seizure. Remind students that the main skill to learn for seizures is to protect the person from harming themselves, not to restrain them. Review that post-seizure, the airway should be checked and breathing assessed as well.

Assessment Standard assessment procedures – ABCDs, SAMPLE, and vitals Be aware of communication issues Speak to the athlete Use input from the companion/guide Pain/stress may impact ability to communicate If sensation is absent, do not prolong exposure to cold/heat Discussion Points: The challenges outlined in the chapter focus mainly on the communication aspect of the assessment – the physical exams are standard. Emphasize that since these patients may not be able to communicate well, it is vital that OEC techs use MOI and S&S to guide their index of suspicion regarding injuries/illnesses. Additionally, the information from the ‘able bodied’ person (parent, friend, caregiver, companion, guide, etc) should be taken into account and noted on the documentation for the incident. It is possible that the patient and companion may give opposing answers to questions – it is up to the OEC tech to determine which is reliable information. Patients with impaired sensation need to be monitored and transported before hypothermia, frostbite, etc. become an issue.

Assessing Athletes with Intellectual Disabilities Anticipate behavior anomalies Remain calm, manage distractions Ask direct, clear questions - give simple explanations/directions Be aware of minimized complaints Be aware of autonomic dysfunction (AD) Discussion Points: If you have a class member who has had the experience of addressing someone who has an intellectual disability, allow them to share their insights. Additional details are included in the chapter. Typically, we do not involve non-patrollers in our assessment and care, but these situations may be best resolved with their help. Refer back to slide 10 for the info on AD.

Assessing Athletes with Physical Disabilities Modify communication style with sensory impairments Lip reading/written Verbal cues/explanations If stroke or TBI, muscle wasting or flexor tendon contractures may be present and risk for injury Equipment, prosthetics, ostomy bags/tubing may be involved

Management Notify base, request help Demo/explain what you will do to reduce anxiety Anticipate unusual reactions Stabilize in position of comfort, modify splints/strapping when splinting Pad areas without sensation Discussion Points: This slide covers the management of the disability, not the treatment of the specific injuries. Normal care would be given for injuries with the modifications noted. continued

Management continued Copyright Greg Bala It can be better to leave injured adaptive athletes in their adaptive devices until their arrival at an aid room. continued Copyright Greg Bala

Management Ensure adequate help when removing adaptive equipment Care for and transport with patient Keep service animals with patients Be aware of wheelchair needs Discussion Point: This section mentions the expense of adaptive equipment and the need to care for it. continued

Management Give priority in lift evacuation Evacuate first – athletes & companion Give extra coaching as needed Know how sit skis attach to evac equipment Discussion Point: Another major point here is lift evacuation. If your yearly lift evac refresher deals with this issue you may wish to give this topic only minimal coverage at this time, telling students they will learn more about it later.

Case Disposition Because you suspect that trauma is a factor in this case, you apply a cervical collar while the patient is still on the ski slope. Because she has remained confused and unresponsive to questioning, you and your partner elect to transport her in the toboggan on a long spine board with the cervical collar in place. Discussion Points: What treatment decisions were made? Why? What pre-transport communications were made? What role did the family member and chaperone play? If your area does not have a clinic you will want to discuss the transport issues you will encounter. Also, if a companion, but not a parent/legal guardian is on scene you will need to cover notification guidelines. continued

Case Disposition You maintain high-flow oxygen during transport to the clinic, checked alertness and radioed ahead about the seizure. A family member and the chaperone meet the patient at the clinic and describe the patient’s gradual return to baseline mental status. X-rays of the patient’s cervical spine show no evidence of injury, but a CAT scan of her brain shows a small subdural hematoma.

Chapter Summary Assume that altered mental status is the result of a new injury or illness. Adaptive athletes with sensory and movement disorders are at higher risk for cold-weather injuries. Ask adaptive athletes how you can assist them. Discussion Points: Use the summary to discuss the main points of the chapter. How are disabilities classified? How do they impact the potential for injury to adaptive athletes? What special assessment considerations are needed? How is management different for adaptive athletes? continued

Chapter Summary Ask the athlete’s skiing guide or chaperone for information and assistance. Describe and demonstrate how you will help an adaptive athlete before doing a procedure. Ask about medications and medical history. Look for medical alert jewelry or other alerts to help identify preexisting conditions. continued

Chapter Summary Request additional rescuers when caring for athletes with disabilities. Collect an adaptive athlete’s equipment, and transport it with the athlete. Paraplegics are at an increased risk for hypothermia and frostbite. Patients with spina bifida are allergic to latex. Always use latex-free gloves when treating these patients to avoid an anaphylactic reaction.