The authors of this booklet know the subject well. Margaret Doucette, D.O., is a physician who specializes in care of those with chronic disease/disability. James Boen, Ph.D., has much experience outdoors and has lived in snowbelt states for 36 years, as a quadri plegic since the age of 19. Physical therapist Jeanne Kogi, R.P.T., specializes in outdoor recreation and has over 25 years of experience in Minnesota. All three wish to express appreciation to Margaret Andrews, Marilyn Barton, Deborah Sampson, and Kathy Veilleux for their work in preparing this booklet.

© University of Minnesota School of Medicine Department of Physical Medicine and Rehabilitation and School of Public Health 1990 - Used with Permission

On Saturday morning, December 19,1989, Minnesota was nearing the end of a cold snap. It was still -20 degrees F, but Dean Clapp decided to go ice-fishing by himself. He opened the door of his car that was parked on the street, tossed his gloves onto the front seat near the passenger side, started to get into the car on the driver's side, slipped and fell. Dean Clapp is 34 and has been a paraplegic for 15 years. With his spinal cord severed at the T6 level, he has no feeling or use of his muscles below his chest. He gets around in a wheel chair.

When he slipped, his feet and legs were in the car. He tried for over ten minutes without success to reach the safety of either chair or car. The bitterly cold metal left his hands without feeling in four minutes, and his bare left hand was hurt in the fall. Each try tired him more, and he felt panic setting in. He knew he was in serious trouble. He had to get warm.

Dean Clapp lives in Zimmerman, a small town about an hour north of Minneapolis. No one drove by to see his predicament, but he very wisely decided to leave a signal. He left his car door open and his wheelchair in a conspicuous spot where a passing motorist might see it. Then he started "crawling" by sliding on his seat, a few inches at a time, to the door of his house a little over 100 feet away. His hands, completely numb, could no longer feel the damage from ice, snow, and rough concrete. After about half an hour he made it to the house and was able to open the door, crawl in, and shut the door. He found a blanket in the living room, wrapped himself in it, and fell asleep.

Four hours later, a neighbor spotted the empty wheelchair and found Dean on the floor of the house. The neighbor di- aled 911 and got an ambulance to take him to the hospital in nearby Princeton. The doctor saw the seriousness of Clapp's condition and had a helicopter fly him to Hennepin County Hospital in Minneapolis where he was rushed to the burn unit. The medical staff was not able to find a pulse in either leg below the knee, nor in the left hand. Over two months later, on February 22, 1990, Dean Clapp left that hospital. They had to amputate all the fingers on his left hand and the middle finger of his right. Of all his digits, only his right thumb now functions normally.

Dean Clapp's ordeal is not common, but it did happen and provides an excellent lesson. Frostbite and hypothermia can be especially serious for the physically challenged. Young, muscular, active people may not need much clothing to stay warm because their muscles and fat produce and retain heat, but body fat can reduce mobility for the disabled or elderly. Reduced circulation, low muscular heat, and the effects of some medications can speed the bad effects of being chilled. This booklet not only explains these processes, but describes ways to improve the safety and enjoyment of winter.

Getting Around on Snow and Ice

Moving from place to place over ice, through slush and snow can be a challenge. Slippery roads and heavy, deep, uneven snow make it hard for those with bad joints, bad hearts, or brittle bones to walk and to get in and out of cars, buses, or vans. In one situation, however, the challenge is in trying NOT to move, not to slide when transferring out of or into a vehicle (car to wheelchair or chair to car) on a slippery road. A chair sliding away on ice is worse than one out of control on a dry road. Only good athletes can get back in a chair after falling on ice. The cold will make matters worse.

The first principle in transfers on ice (or on loose gravel) is to anchor the chair solidly to the car somehow or, for those not in chairs, to provide a solid handhold. Boon uses a small chain that goes around a bar in the front seat of his car and can be quickly looped over a brake (see illustration). Anything that ties wheelchair to car will do the job: chain, belt, piece of rope.

The second principle is to prepare the surface of the road so that feet do not slip, if they are on the ground

during transfer. Use the sand carried in the car (or salt, or kitty-litter) to sprinkle on the ice for better footing. Or put down a mat (expanded metal or other heavy, rough surface that will not slip) like those used on entrances to houses, to eliminate slippage.

Mobility in wheelchairs is never made easier by snow and ice, and is sometimes impossible. There is snow... and then there is snow. Some is slippery, some quite sticky. Snow can be light and fluffy, sloppy and heavy, deep, or merely a light dusting. Some snow drops gently straight down, some comes horizontally in high winds.

Almost all modern manually-operated wheelchairs have big wheels in the back and little wheels in front. For big back wheels, a major problem is lack of traction, while little front wheels may dig in and get stuck. Very low foot pedals are also a problem if their height above the ground is less than the depth of the snow. Wheelchairs make terrible snowplows. In Minnesota, heavy snowfall is defined as over four inches. Only a skilled wheelchair atlilete can propel himself or herself forward in a manual wheelchair in 4" of snow, by propelling the chair while doing a "wheelie," tipped back and balanced on the back wheels.

Ice and hard-packed snow present problems of traction. Smooth, unrutted ice, especially wet glare ice, can make self- propulsion virtually impossible. Packed snow or uneven, rut- ted ice can cause one of the four wheels to be off the ground. When that wheel is a back wheel, self-propulsion is difficult. When both back wheels are off the ground, they are useless for motion.

At least one solution can make travel on ice and on most packed snow-or rutted grass lawns or even slightly rough fields-relatively easy. A pair of canes with sharp points can be used for self-propulsion. To construct these: cut heads off large nails, drill holes in the ends of the canes the size

of the headless nails, and drive the dull ends of the headless nails into the holes in the canes. The canes then have sharp points that stick out 2" and can be sharpened to any degree, preferably medium. Very sharp points dull easily and are dangerous. The sharpened nail points will pierce ice and packed snow, giving traction the wheels cannot provide.

Pushing forward with the canes works, but the method works better pushing backwards. Backing in a wheelchair, the occupant cannot see where he or she is going without much turning around or use of a rearview mirror. But there are also mechanical advantages in using the pointed canes to push backwards on ice or packed snow. When going backwards in a chair with curved front forks, the little front wheels are further forward and present a longer whcclbase with relatively more weight on the big back wheels than the troublesome little front wheels.

The second mechanical advantage lifts the little front wheels out of ruts with each push. How many or how deep a rut a user can manage depends on personal strength. One could tip over backwards doing this, but Boen's experience is that as soon as tipping is felt, one instinctively stops pushing. Anti-tip wheels on the back would provide extra protection for those whose sense of balance is impaired. The advan- tages of backwards self-propulsion also apply when there is help from able-bodied assistants. Going backwards creates a problem of seeing where you are going, but there is much less "digging in."

In very deep snow (12-18"), assistance with a wheelchair is required for all but the most skilled wheelchair athlete. Those in front each place one hand just above the footrest and tip the chair back to raise the front wheels. Those in back push the handles of the wheelchair. This permits going forward, so that the assistants can see better. With four assistants, one can also negotiate stairs that are wide enough, or steep hills-backwards going up, forwards going down.

  

Placement of assistants' hands is important. Many willing assistants do not naturally get the correct grip and need your clear instruction. Using the wrong hand or pointing it the wrong way will not maximize their strength and may even sprain their wrists. Going down (forwards), assistants on your left should use their right hand, those on your right their left hand. Going up (with the chair backwards), the same-side hand is used. In both cases, their thumbs should point in the direction of the travel.

Using an electric wheelchair in snow and on ice can be hazardous. Safety requires planning. The user or assistant needs to understand both the limitations of electric wheelchairs and some techniques that can ensure personal safety.

Proper maintenance is important in winter. Batteries are less effective at low temperatures and will drain faster in use. Following manufacturer's recommendations will reduce frequency of breakdowns. Weekly checks of fluid, avoiding over- charging batteries, and making sure that all connections are tight can prevent many problems.

An electric wheelchair has little clearance between battery and floor or road, sometimes 2" to 3". This may cause a chair to scrape bottom on snowbanks, ruts, bumps, and holes. Scraping bottom causes drag on a chair and may knock the battery off its supports. Although snow varies widely from light and fluffy to heavy slush, when more than 1" deep it can cause the front casters to bog down and strain the power. Snow more than 1" deep can build up in front of the battery case and may even push the battery off the gimbals and disconnect the wires.

Protect the control box and the module from getting wet. Wet control boxes can cause loss of control of the chair. Wet modules can cause electrical shorts. When they could get wet, cover both with temporary waterproofed wrapping. It is necessary to remove these wraps when the chair is indoors, to decrease the chance of the parts overheating.

To prevent the chair from getting stuck, it is helpful to have good treads on power tires. Without good treads, the chair will have poor traction. The user must consider the terrain and the construction of the electric wheelchair, to maneuver safely in snow and ice. Go slowly, to keep the chair from slipping out of control. Stop the chair completely when control is lost.

When traveling up an incline, the weight of the chair is greater on the rear wheels. This may cause a chair to tip backwards more easily. Using anti-tip bars can help prevent tipping back. Another solution is to add weight to front wheels or footrest. An incline slippery with snow or ice requires extreme care. Some inclines may require physical assistance.

Each is responsible for his or her own safety when out traveling in winter. Traveling alone in an electric wheelchair, it is important to let others know where you are going and when you plan to return. It is advisable to travel with others who can get help or aid you if you become stuck. Safety flags on a pole, a whistle, or brightly colored clothing may help someone stranded to be located more easily if help should become necessary.

Despite the cold and hazards, winter can be fun. Although snow and ice make moving in a wheelchair or on crutches difficult, they can also make a physically challenged person more mobile on equipment such as skis, sit-skis, and ice-sleds, either for fun or in competition, as the person desires. Traditional winter sports for the disabled have taken place indoors (wheelchair basketball, bowling, swimming), bnt some outdoor activities can be done almost as easily by the disabled as the able-bodied.

Ice-fishing, even inside an icehouse, increases the risks of hypothermia but done right, can be very enjoyable. Taking care against windchill or frostbite, snowmobiling can be fun. With proper equipment, clothing, and safety precautions winter camping, making caves in the snow, inner- tubing on snow, recreational or competitive alpine

(downhill) ski-sledding, cross-country sledding, dog- sledding, and ice-sledding can be enjoyable for people of any age.

Sit-Ski Sledding

Sit-skiing on sleds, introduced several years ago, is now established as the first official outdoor sport for the mobility- impaired and is becoming increasingly popular. Sled-skiing began with a specially designed sled called a "pulk." It required a specially packed trail and was thus impractical and inefficient. Now many modifications in design and in training have increased the performance and efficiency of ski-sleds. With training, tlie physically challenged can use ski-sleds for downhill skiing, cross-country skiing, ice-hockey, dog-sledding, and ice-luging.

Sit-skiing cross-country (Nordic skiing) can be good aerobic exercise for those with disabilities as it is for the able- bodied. After the initial cost of equipment, it is relatively cheap and can be done anywhere, so that many nature-trails previously inaccessible to disabled people have been opened to them through cross-country skiing. To cross-country ski independently, those with limited strength in arms and hands

may need adaptive equipment (see appendix) or sled dogs. To downhill (alpine) sit-ski, there must be a ski area. Besides accessible parking and an accessible lodge, the skier should look for wide trails and lifts to the top of the mountain or hill:

rope or cable tows, poma lifts, T-bar lifts, chairs, gondolas, or a large tram.

 

Sit-skiing in a pulk sled should be preceded by indoor training for safety, proper equipment, and appropriate dress (see appendix). Check for: (1) adequate padding, to protect the skin; (2) straps to keep the skier in the sled and provide

efficient performance; (3) leg coverings to keep the skier dry and warm; and (4) back supports at proper heights.

A tether-line is attached to the rear of the sit-ski to let an instructor assist the beginner, who needs help to learn turns and stops as well as how to get into the sled. Moving both arms and poles together, called double-poling, increases forward motion. Braking is done by dragging the hand in the snow or by leaning on 7"-24" poles. Tipping the sled stops it.

Cross-country sit-skiing outdoors requires warm-up and cool-down exercises before and after, to prevent injuries to muscles and joints. Beginners start out on a flat trail until they develop good techniques and can maximize strength and endurance in the arms. Each skier needs to learn to ski within his or her own limitations. Many ski areas provide safety instructions for sit-skicrs. When first attempting to sit-ski sled, physically challenged persons should attend a school that addressess their needs (see appendix). Certifying exams in sit-skiing are offered by the National Handicapped Sport and Recreation Association (see appendix). The NHSRA also offers teaching clinics to improve the abilities of skiers who ski for fun or in competitive races.

Some special safety techniques should be observed by both downhill and cross-country disabled sit-skiers. A sit-skier is low to the ground and may not be visible to other skiers on the slopes. Some ski areas are concerned about liability for the skier and for their own personnel. The sit-skier needs two lifters to assist entry to the sled or a lift. Loading on a lift should be done without slowing the liftline. Downhill sit-skiers should wear helmets (see appendix). "Unbreakable" sunglasses or goggles should protect the eyes from sun and snow-glare, and waterproof mittens or gloves should be worn.

For those with immobile legs, particular attention must be paid to keeping the feet warm. When the temperature is below 30 F (-1.1 C), extra insulation around the legs

is necessary. Wrapping the legs in a sleeping bag works well. Temperatures below 10 F (-12.3 C) may necessitate a body-warmer of the stick or wicked type, a hand-warmer like that used by hunters, or heated bricks wrapped in a blanket. Warmers with open flames are dangerous. Keep the body- warmer insulated so it does not touch the body in areas with poor sensation, at high risk for burns.

Physically challenged persons should not undertake snow- based activities alone. Besides the difficulty in getting into and out of sleds and lifts, the sit-skier can become stranded in deep snow banks. Upright companions can be seen by others who cannot see the sled. With sufficient safety precautions, however, sit-ski sleds can provide pleasant recreation and exercise.

Downhill Skiing on Outriggers or On a Single Ski

Some who are more nearly able-bodied, especially those who are young, may be able to down-hill ski in a standing position. Such a skier can develop good mastery of the slopes using skis and outriggers rather than regular poles, to add stability. In the first stages, outriggers with an attached armbracket and a short ski-tip attached to the bottom of the pole are helpful, and some skiers will always use this equipment. Some poles have retractable spikes to let a skier move on flat surfaces. Techniques and equipment continue to be developed and refined to make this sport more enjoyable.

HYPOTHERMIA

Becoming Chilled

The term for exposure, hypothermia, meaning low body temperature, comes from Greek (hypo- below, thermia tem- perature). If this condition is left untreated, temperatures in a body continue to drop until functions cease and flesh is damaged. Hypothermia can occur on cool days in spring or fall, even while sitting inside-any time the surrounding temperature is cool-in those not dressed properly who are inactive. Wet skin or clothes make it worse. In some people it occurs more easily due to illness, disability, medications, not eating right, or old age.

The temperature of the inner body and its vital organs (heart, lungs, stomach) is called the "core temperature." Normally in healthy people it is about 98.6 Fahrenheit (37.3 C). A center in the brain works like a thermostat to control core temperature automatically using two techniques: control of blood flow, and shivering.

When working hard contracting large muscles, the body generates heat; excess heat is carried by blood to skin surfaces and lost into the air. In cool air with a body not heated by moving, less blood flows to extremities, to save heat for heart and brain. Blood vessels near the skin become narrower. As the body tries to warm itself, it begins shivering, an involuntary muscular contraction that generates heat using both contractions and friction.

The sensation of being cold comes partly from nerveendings acting as pain receptors in skin. As it cools, the sensation of cold detected in the skin lessens, and the person may relax. The large muscles then do not contract, and production of heat stops. Loss of the sensation of cold starts a downward spiral to hypothermia.

Interferences with Temperature Control

a poorly protected body, or there is a change in efficiency of the body in controlling core temperature. The ability to pro- tect oneself from cold can be affected by medications, alcohol, illness, disability, and not eating right. There may be actual disruption of regulation of body temperature, or there may be decreased awareness of cold.

Medications can affect awareness of cold or impair response to cold. Tranquilizers, sleeping pills, or barbiturates can decrease awareness of cold, while medications such as phenothiazine or lithium may actually slow metabolism or make the body less able to generate enough heat. If you are on one of these drugs, please discuss with your doctor whether changes should be made or precautions taken in winter.

The common myth that alcohol can warm a cold person is false and dangerous; it does the opposite. Many people mistakenly believe alcoholic beverages act like antifreeze in a car radiator. They cause expansion of blood vessels near the skin, so alcoholic drinks give an initial warm feeling, but this increased blood flow causes sensors in the skin to signal the brain that the skin is not cold. Loss of heat increases as heat radiates from vessels near the skin. Warm blood is directed away from vital organs, not to them. Alcohol acts on the brain to dull awareness of cold, decreases ability to act appropriately in an emergency, and slows reaction time in getting help. Far from protection from freezing, alcohol can be a lethal contributor to hypothermia.

Like alcohol, tobacco interferes with the ability to regulate blood flow and direct warmth to organs that need it. Unlike alcohol, tobacco acts to narrow or even close blood vessels. It may narrow vessels and decrease blood flow to extremities so much that flesh is damaged, so smokers with frostbite risk amputation more often. The constriction may also interfere with sending blood to heart and brain, and the blood that is carried may have less ability to carry oxygen.

In a person who is hypothermia and confused, this lack of oxygen may worsen the confusion.

An injury high up on the spinal cord disrupts con- trol of and results in larger swings in body temperature. If you have quadriplcgia or a high paraplegia, your body is more likely to be cold in cold environments, too warm in warm environments. Core temperature may vary from season to season or even indoors to outdoors, much more than temperatures of able-bodied people. Injury to the spinal cord may decrease the ability to feel cold, too. Connection between receptors in skin and control-center in brain is disrupted. The body may be very cold, but the brain may not get that information and may think it is comfortable despite having frozen feet! Any type of major injury (trauma) to the head, or stroke, or brain tumor has the potential to affect the part of the brain where the control center for temperature is located. There is little that can be done once the damage occurs.

Several types of illness can change the ability of the body to respond to cold. Some change occurs slowly over a period of time, so gradual worsening may go unnoticed. It is important to check with your physician to sec if anything can be done to prevent changes and protect yourself.

Metabolism can be reduced, reducing the ability to gen- erate adequate body heat, in hypopltuitary or hypothy- roid conditions, or with adrenal insufficiency. The con- trol center of the brain may be impaired-by stroke, closed injuries of the head, brain tumors, or multiple sclerosis. Peripheral neuropathy (nerve damage) may decrease ability to sense cold, and peripheral vascular disease (hardening arteries) may decrease blood supply to arms and legs, increasing risk of frostbite or gangrene. Both of these can accompany diabetes mellitus.

Most people with multiple sclerosis actually show an improvement in symptoms when they are in cool temperatures. Severe cold, however, is still life-threatening, and there is nothing protective about the patient's response to

cold. The central temperature control in the brain may be affected by the process of the disease.

Old folks may be at increased risk for hypothermia because of bodily changes due to aging and because of social factors like living alone or having income too low to buy fuel or housing with inadequate insulation or heaters. If no help is available after a fall, an elderly person may lie on a cold floor long enough to become hypothermic. Ability to detect cold decreases as a nervous system ages. Ability to produce heat by activity and to prevent heat loss decreases. Elders do not start to shiver until a lower body temperature is reached, and shiver less strongly with less muscle-mass. There is less effec- tive control of narrowing of blood vessels to prevent loss of heat or of widening of vessels to regain heat in hands and feet. There may be peripheral vascular disease (hardening of the arteries). Stroke or diseases of blood vessels in the brain that affect the control center are more common in older people, and most have slower metabolism, some further reduced by medications or illnesses (such as infection or thyroid disease) that directly affect metabolism.

Those who do not get proper nutrition or have enough body fat may risk hypothermia. Food is fuel for the body, fat is insulation. In severe cold, fat is a main source of energy, producing heat to help rewarm persons who get chilled. Undernourished or thin people are less able to increase metabolic rate in response to cold, and a lower core temperature may result.

Signs and Symptoms of Hypothermia

Hypothermia can occur at any time of year. It may happen quickly, as when falling into cold water, or it may take hours or days to develop, depending on temperature of the air, velocity of the wind, age, weight, sex, and physical/mental condition of the person, type of clothing worn, and amount of activity. When it develops gradually, the per- son may not realize it until it is too late. Prompt action is needed for persons at any stage of hypothermia.

Normal (97.5 to 98.6 F or 35.6 to 37.3 C)

Mild (90 to 92 F or 32.5 to 33.6 C)
 Poor coordination, clumsiness, moving slowly
 Numb hands and feet, lost ability to feel cold
 Shivering (except high para- or quadriplegics)
 Slow. slurred speech but person is conscious
 Lesser attention span, forgetful, confused
 Change in personality, irrational or combative
 behavior including "paradoxical undressing,"
 an insistence on undressing despite the cold

Moderate (80 to 90 F or 26.9 to 32.5 C)

 Person is unresponsive but can be aroused
 Pupils are dilated
 Pulse and breathing are slow

Severe (70 to 80 F or 21.3 to 26.9 C)
 (Life-threatening)
 Person is unresponsive and cannot be aroused
  (in a coma, looks dead)
 Pulse, breathing very slow, hard to detect

Treatment of Hypothermia

Treatment varies with degree of hypothermia and under- lying condition of the person. Adequate treatment depends on recognizing signs and symptoms and responding quickly. The guidelines below are intended to provide specific steps you can take to initiate help. More complete treatment by a doctor or emergency room is often necessary. It is impor- tant to check temperature rectally with special thermometers that register low readings-otherwise the reading may be an inaccurate "normal." This is most easily done at a hospital. Careful observation of color and texture of skin will help avoid missed signs of frostbite, particularly in disabled or elderly who may not have adequate sensitivity to touch, or in those who were unconscious for a while.

Mild
At the Scene
1. Move the person to a dry, warm shelter.
2. Remove wet clothing.
3. Wrap person in dry blankets, sleeping bag, extra clothing, or
4. Place hypothermic person in sleeping bag with warm person or between two warm people.
5. If the person is alert, give warm fluids (not hot).

At Home
1. Check temperature (rectally with thermometer that registers low readings).
2. Give warm liquids if the person is appropriately alert and speech is not slurred.
3. Place warm-packs or hot water bottles at armpit, groin, neck where blood vessels are closest to the skin.
4. Wait for an hour before giving warm bath (100 F or 38.1 C), then keep arms and legs out of tub.

Moderate to Severe

1. Gently move the person to warm shelter.
2. Do not encourage activity.
3. Transport to medical facility/hospital.
4. Monitor heart rate and breathing.
Transport to the hospital any person who is cold, unresponsive or confused when found, is elderly or disabled, or is suspected of having frostbite.
At the Hospital

Health care personnel will check carefully for frostbite and monitor temperature and heart rate while beginning techniques for rewarming the "core." Treatment may include intravenous fluids, flushing the abdomen with warm fluids, warmed oxygen to breathe, and use of special techniques to warm the blood or inner organs selectively (active internal rewarming).

Problems Common in the Treatment of Hypothermia
1. Rewarming too rapidly.
2. Irritable response by the heart.
3. Frostbite that is overlooked.
4. Inaccurately measured temperature or missed hypothermia.<

br> Rewarming may be passive, the body rewarming itself in extra blankets or dry clothes, or active external, the body being immersed in warm water, wrapped with warm packs, or padded with hot-water bottles; or active internal, done at a hospital for cases of severe hypothermia. There is a risk of too rapidly rewarming the entire body and causing "afterdrop" or rewarming shock: blood vessels at the surface dilate and bring cold blood back to vital organs, causing shock. The heart is liable to becoming "irritable" during rewarming of moderate to severe hypothermia. Blood pressure may also fall too quickly, due to dilation of vessels in the arms and legs.

Following the guidelines should help you initiate safe and effective treatment for a person with hypothermia, and help you decide when to transport to a hospital for medical care. If in doubt, it is better to have the person seen by a health care provider than to risk complications that can occur with untreated or improperly treated hypothermia.

FROSTBITE

"Frostbite" means that either the skin or the flesh of some part of the body is actually frozen. Superficial frostbite involves just the skin itself. Severe frostbite involves muscle, blood vessels, and nerves of the frozen area. Most commonly affected are hands, feet, cheeks, cars, and nose, because these areas are the most exposed and farthest from the heart. Frostbite occurs when temperature of skin or flesh drops to -2 F (-19 C). Fingers exposed to wind may get frostbite, while covered parts of the body will not be frozen. Frostbite and hypothermia, can occur together or separately.

When a part of the body freezes, permanent damage can occur for several reasons: (1) supply of blood and its oxygen is limited as vessels freeze; (2) crystals of ice formed in skin or flesh damage cells; (3) damage occurs both as the part freezes and as it thaws. Because damage is worse if refreezing follows thawing, it is important to make no attempt to rewarm until the person is safely inside or in medical care.

Signs and Symptoms of Frostbite

Anyone exposed to cold, wet, or wind for an extended time has risked frostbite and should be carefully and repeatedly checked for it until they can be judged safe. When frostbite has occurred, that part of the body will be hard, cold, and insensitive to touch. It may look pale and waxy. The person with frostbite may tell you that his or her ears or hands hurt a lot for a while but then stopped hurting.

As skin or flesh thaws, its color may remain white or yellowish white, or it may turn purple. It may develop blisters full of clear fluid or blood, in more severe cases. There will usually be great pain as the part thaws. Long-term damage can range from extra sensitivity to cold and more pain when that parts gets cold, to permanently damaged flesh, and amputation.

Treatment of Frostbite

DO NOT ATTEMPT TO THAW the frozen part. Mis- guided attempts to thaw may result in more damaged flesh. DO NOT MASSAGE the limb or rub it with snow, as this may cause more damage. The most important step is getting suspected frostbite to medical treatment. It is important to control the rate of thawing to minimize permanent damage, and the person should be absolutely away from risk of further freezing.

When taking the person to medical care, leave boots and gloves on, for protection. If hands and feet are already exposed, gently separate fingers or toes from each other using cotton or clean cloth. Keep the person away from a heater, and keep the vehicle cool. If rewarming during travel cannot be avoided, or if medical help is hours away, it is better to rewarm rapidly by immersing the affected part in warm (not hot) water and maintaining water temperature close to normal body temperature (100 F or 38.1 C).

If there is both frostbite and hypothermia, warming the core takes priority over warming skin or hands, feet, nose, ears. Remember that frostbite is not always easy to recognize. It may take days or weeks to identify clearly the extent of injuries. This should be done under care of medical personnel. Persons who are not sensitive to touch, or at risk for frostbite and hypothermia because of a medical condition, should be looked over at a hospital if you suspect they were seriously exposed to cold. The short checkup at a hospital may bring treatment that can prevent significant complications.

WARMTH

Dressing for Warmth

We humans can live in hot deserts and jungles and on wind-swept arctic mountain tops, but at only a small range of internal temperatures can we be comfortable and function fully, so our bodies have to be good at adapting. We adapt to heat by perspiring, becoming lethargic; evaporating per- spiration cools the body and inactivity keeps heat-producing muscular contractions down. In response to cold we hunch up shoulders, reducing surface area that loses heat, and we contract muscles in our backs, shivering to produce heat.

Physical disabilities and aging may interfere with natural responses that help us keep warm. Young, plump, muscular folks who are active do not need much clothing to stay warm. Healthy teens eat a lot of high-calorie food and arc often so active they can run around outside in very cold weather with light jackets and no caps, even no socks. The less muscle or fat you have, the less active and young you are, and the less warmth in your immediate environment, indoors or out, the more you need to dress warmly. These factors interact, so the physically disabled and old arc just the opposite of active healthy teens, but there are priorities to retaining heat in any human body.

The two main ways to save heat are body fat and warm clothes. Despite its effectiveness for seals and walruses in the Arctic, body fat has drawbacks in appearance, function, and effects on health. Physically disabled people find fat reduces both mobility and the ability to gauge how much clothing they need for insulation. There is much to know about dressing for warmth, especially on a tight budget. Physically weak people need warm clothing that is also light-weight and not bulky.

^

To live, the body must keep brain and vital organs, especially the heart and lungs, warm enough.

Hands, feet, and tips of noses and ears are not as important and are the first to be sacrificed when trunk and brain are running short of heat. Misunderstanding these priorities can result in mistakes in choosing clothing. When hands are cold, people may think they need mittens, when the cause may be a bare head. As a bare liead loses heat, the body allocates warm blood to this high-priority area rather than to low- priority hands. Putting on a warm cap-one that covers ears, neck, and forehead-slows heat loss from scalp over the brain allowing surplus warm blood to flow to the hands. A face-mask or scarf up to the eyes is good protection.

With head and trunk warmly dressed, hands can be lightly covered with thin gloves or mittens to allow max- imum dexterity. If feet do not need dexterity, they can be warmly covered too. Much heat can be lost through the soles by standing on cold ground or carrying the feet on metal footpedals of wheelchairs. Standing compresses the soles of shoes and boots, reducing their ability to insulate. It may be quite eifective to add felt insoles.

It helps to think of the body as a furnace producing heat, and clothes as the walls, floor, and ceiling of the house. Think of the areas of skin not covered by clothes as open windows, and clothes as insulation. The worse the insulation and the more windows open, the more the furnace has to burn fuel. If a furnace is not muscular and cannot produce much heat, it can warm only a well-insulated house with the windows closed. Thin, disabled, or frail people need to cover (insulate) as much of the body (furnace) as possible, with clothing, to prevent "drafts" caused by gaps that allow escape of warm air. Cold air, especially wind, will draw heat out of the body fastest in areas where skin is exposed.

. An open collar effectively lets warm air out, drawing like a chimney as it pulls cold air into openings at the ankles, wrists, or waist. Turtle-necked tops can prevent escape of rising air and air-tight wristlets help. If wristbands are too loose, rubber-band-like bindings can help to make them warmly airtight-but be careful not to reduce circulation by binding them too tightly. To keep warm, as much skin as possible should be covered. Cold air, especially wind, will draw heat out of the body fastest in areas where skin is exposed.

. Fingers and ears are good radiators for losing heat: they have a lot of surface for their size. This is why mittens are warmer than gloves. The fingers warm each other in mittens, but are separated and cannot, in gloves.

Most Minnesotans know about a principle called "layering". Pockets of trapped air are good insulators. (It is these pockets that make hand-knit sweaters and afghans warm.) It is easier to make and hold warm pockets of air when wearing several layers of clothing than with just one layer.

. A bottom layer of long underwear, in as high a percentage of wool as you can stand, is an excellent investment in warmth.

. A turtle-necked knit under a wool sweater can insulate against the wind, particularly if wrists and neck are sealed.

. An outer layer helps protect against wind that would blow heat away from the body. Nylon coverings on modern fabrics, or very tightly woven wool, can stop wind. One way to check the ability of a piece of clothing to protect against the wind is to put your hand on one side of the material, press it against your mouth, and try to blow through it. Material that prevents the heat of your breath from being felt on your hand will block out wind. If your hand can feel the warmth of your breath, the material will let wind through.

. Geese and ducks live outdoors comfortably in winter because they have natural insulation provided by downy underfeathers. People have worn goose- and duck-down for cen- turies, and it is now available to many. In Minnesota, ablebodied young people stand outdoors watching a Winter Carnival with windchill at -50 wearing so much down they look round! We now also have light, comfortable and warm clothing of synthetics like Dacron(tm) and Thinsulate(tm) to keep us warm without the weight of wool or the bulk of down.

To keep warm, you must stay dry. Moisture from any source-including perspiration-that gets trapped against the skin can spoil the insulating quality of the clothing. Rubber boots can trap perspiration, leading to cold wet feet. When wet, neither cotton nor down insulates well, but wool insulates amazingly well even when wet. Wool has natu- ral "pockets" of air and absorbs and carries away from the skin moisture that causes dampness and cold. Similarly, absorbent silk or cotton underwear may provide more warmth than that made of some man-made fibers that do not let moisture escape.

Outdoor cold is more severe and may be windy, but many people spend life indoors being cold, when disability or age combines with limited money. In very cold weather (0 F [-17.9 C] or lower) even well-insulated buildings may be cold on lower floors and near windows and outside walls. In states with milder climates, buildings may be less well-insulated and cold when outside temperatures reach 30 F (-1.1 C). Dressing for warmth indoors may also be necessary in unlikely places such as New Orleans in August, when it may be cold in conference rooms in lower floors of hotels because of excess air conditioning. Thin or frail old folks may need rooms at about 80 F (26.9 C) to be comfortable. Being cold most of the time can be unpleasant to miserable. It may be too expensive to turn up heat in homes, so those who live or work in cool buildings may need to dress warmly.

Dressing for warmth in one's own home saves on heat- ing bills and lessens need for humidity. Cold air drawn in from outside to replace warm air leaking out of a house is made drier by the heating process. Hot, overly dry air in a house dries out nasal passages, reducing resistance to colds and flu. Hot air also permits a virus to live longer on household surfaces, which may make it easier to catch from others. So, dressing warmly in a. cool house can have economic and health advantages over dressing lightly for a hot, dry indoors environment.

Keeping Warm Without Sensation

Understanding heat loss is especially important to the disabled who have lost feeling. The traumatic paraplegic without sensation below the chest loses just as much heat through the feet, legs, and uncovered waist as anyone else, but doesn't know that by feeling it. The paraplegic has to know it by thinking about it, and is wise to dress especially well those areas of the body not required for getting around or dexterity. People who are not so able-bodied or young -- less likely to generate heat by muscular contractions -- need to save the heat they do produce.

Keeping less-used parts (such as lower body) warmer allows more-used parts (such as arms and hands) to be less en- cumbered by bulky clothes. Warmer covering on paralyzed parts also ensures against gaps that might lose heat from places where drafts cannot be felt. For example, the upper body of a paraplegic would be mobile and comfortable at 10 F (-12.3 C) in no wind, or at 30 F (-1.1 C) with a strong wind, while wearing a light undergarment, wool sweater, light wind-breaker jacket, neck scarf, good gloves, and fully covering cap. The lower limbs that do not need mobility should be more warmly covered.

Sleeping Warmly

It is unpleasant to be cold during the day, but being cold in bed at night is miserable. One of the worst ways to sleep

warmly can be seen in old western movies where a cowboy bunks on bare ground, one blanket on top of him, his bare head on a saddle. The cold ground would draw away more heat than cold air would, so the blanket should be under him as well as on top, although his weight on the blanket would compress it and provide little insulation. It would help if he put his Stetson hat over his head or face.

The physical laws that apply to being warm while sleeping in a cool room are the same as those that apply to dressing warmly, but many people do not know how to apply those principles.

. Keeping the head well covered is just as important in keeping warm while sleeping as it is while awake. Any comfortable cap that covers forehead, neck, and ears will help. Blankets, sheets, even pillows over the head will help, if they allow enough exchange of air for breathing.

. Long, thick woolen socks for the feet and woolen mittens for the hands, and three layers of blankets (preferably wool, down, or flannel) will give a warm night's sleep in a cold room for all but the very frail.

. Keeping blankets tucked tightly around the body allows as small a volume of heat as possible to escape. Those who are active while asleep can accidentally open gaps around neck or feet, allowing escape of warm air and its replacement with cold air from the room. Sleeping bags can trap air and not allow gaps. The efficient use of blankets is one that simulates sleeping bags.

. A woolen mattress pad can add insulation; besides being soft and comfortable, they are cool in summer too.

¯ Electric blankets and heating pads add warmth but heating pads can cause burns and are especially dangerous to those without normal feeling. Our ancestors used hot bricks;

we may use a hot water bottle. It may leak, resulting in

wetness and then cold, but it cannot start a fire or get hotter as the night goes on. A hot water bottle that is not hot enough to burn at the start of the night cannot cause a burn later as you sleep, and so is safer than electric blankets or pads.

Maintaining Muscles in Winter

Muscle provides heat through voluntary contractions and involuntary (shivering). This is one good reason for "being in shape" in winter, by whatever means. Building and maintain- ing muscle anywhere-arms, legs, back, neck-helps. The

It is also surprising how much more muscle and endurance are needed for a person with marginal strength to get dressed in winter. That extra layer such a.s long underwear takes more pulling and tugging. Heavy boots and coats make movement cumbersome and require more strength. Pushing a cold wheelchair, its grease thick and slowed by cold, over rutted snow or ice, gripping cold and slippery handrims, folding a stiff and cold chair, is a lot of work. Breathing deeply while working this hard makes the body heat more air that enters the lungs, taking heat from the "furnace" and further sapping energy. Try to optimize both muscle and body fat, which is your insulation and reserve energy supply. One way to do this is to turn back to "recreation" and learn to enjoy winter.

FIGHTING WINTER DIRT

One unacknowledged burden of winter is dirt: the crud! Snow looks lovely falling gently as on a greeting card, but it forms the base for ghastly messes on automobiles, wheelchairs, clothes, and rugs. Salt. put on roads to keep them open for driving adds to the mess and hastens the rusting of car and wheelchair. Salty road-slime is splashed by passing cars and big trucks, on everything and everyone within range.

A wheelchair going only six feet through winter crud picks up enough slop to dirty shoes, socks, and pants legs and crawl up the sleeves of the occupant pushing a chair. Transferring in and out of cars and wheelchairs moves crud to the clothes. Able-bodied helpers who lift crud-laden wheelchairs into car trunks prepare their clothes for a nice cleaning bill. The encrusted chair deposits dirt, sand, and salt into the trunk. The salt hastens the rusting of a trunk, and if not dried out a wet trunk will help salt speed the rust. On entering a public or private building, the encrusted wheelchair will deposit a trail of salt, sand, and mud to be smeared for many feet before the wheels clean themselves off on the floor. Tires with treads are very good at carrying crud, leaving dirty pools of water as long as 20 minutes after entering a building.

The physically disabled who go outdoors in a wheelchair in the snowbelt add winter dirt to death and taxes as an unavoidable burden. There arc, however, some ways to minimize its impact. First, keep at hand cleaning rags and whisk broom-at home, in the office, and in your vehicle. The more you can wipe off the side of your car where your shoes, socks, pants legs, or dress will touch it, the less often you will need the dry cleaners, laundry, or shoe cleaning. Suggest to anyone who puts your wheelchair into a trunk that they use your whisk broom or rag to clean the chair some before brushing it against their clothes or depositing hunks of snow, sand, and salt in the trunk. Cleaning the chair is easier than removing salt and sand from the trunk.

Upon entering a home, yours or someone else's, it is easier to clean what you can off wheels than to clean floors after tracking in. When visiting, take your cleaning rags or broom. It takes a long time, 15 minutes or so, to wait for snow and ice to melt while parked on an old rug. The less snow to melt, the faster it will melt.

When choosing tires for wheelchairs, remember that tires with deep treads get good traction on snow and ice, but are impossibly hard to clean. A tire without treads can be cleaned well enough with a rag so that after a minute to dry it will not leave trails on carpets of even light color. Treads require 15 minutes to thaw and dry; they may leave sand and dirt for yards on light rugs.

The mess is picked up on sleeves of those who manually wheel a chair. Hands, gloved or not, and sleeves pick up crud from wheels especially at the forward end of strokes. Any long-sleeved shirt, sweater, or coat is at risk. Plastic sleeve covers for jackets or coats may be bought or made. Anything (such as elastic) that keeps sleeves high up on the forearm keeps clothes off dirty wheels. Wheels will also soil any clothes that stick out sides of a wheelchair, so it has side-panels called "skirt guards."

Snow, fluffy or slushy, sticks well to wheels and foot ped- als when wheelchairs are too warm, as when leaving a warm building or vehicle. When a warm chair is rolled through cold snow, it packs on like hard tight snowballs made in bare hands. To prevent sticking, let the chair cool to outside temperatures before rolling out. When snow is clean and you can sit on a snowless surface to let the tires get cold, tires and pedals will gather little snow that will brush off easily. Tires cool more slowly than frames: rubber conducts heat away more slowly than metal.