The woman arrived at the emergency department on the third day of the heat wave, her daughter supporting her weight. Seventy-two years old, living in a third-floor walkup on Chicago's South Side where temperatures had hit 96 degrees inside. She'd felt dizzy that morning but didn't want to bother anyone. By afternoon, her heart was racing, her breathing shallow. The triage nurse recognized the pattern immediately—not heat stroke, but cardiac stress exacerbated by sustained heat exposure.

Heat causes heat stroke. It also worsens cardiac, respiratory, renal, and mental health conditions. The actual climate health burden exceeds what gets coded as "heat-related." Between 2000 and 2023, Chicago saw 151 heat-related deaths, with deaths higher among non-Latiné Blacks and older adults. Those numbers miss the cardiac events, the kidney failures, the respiratory crises that heat triggered but didn't officially cause.

The emergency department nurse treating her had no standardized protocol to follow. No heat illness screening questions during triage. No climate risk assessment integrated into patient history-taking. She improvised—IV fluids, cardiac monitoring, cooling measures—based on her own pattern recognition from three summers of watching these cases surge. Every June through September, heat-related visits spike across the Midwest. Every wildfire season, respiratory cases flood in—emergency room visits for asthma nearly double during major smoke events. Every spring, Lyme disease cases climb as tick territory expands across Indiana, Illinois, Michigan, Ohio.

She knows what's coming through the doors before the surveillance systems catch up. She also knows that every patient's care depends on whether their particular provider recognizes climate-related symptoms. The healthcare system stays perpetually reactive.

So she's been pushing for institutional protocols. Heat illness screening during triage. Air quality monitoring that triggers clinical responses. "Environmental determinants of health" as a standard category, not an afterthought. Standardized treatment algorithms for heat emergencies instead of ad hoc responses when someone collapses.

The organizational backing exists. The Nurses Climate Challenge is mobilizing nurses to educate 50,000 health professionals on climate health impacts. A 2024 scoping review identified nurses' roles in climate change as encompassing research, education, advocacy, leadership, and clinical practice.

Correctness doesn't budge bureaucracies. Funding models lack mechanisms to recognize environmental health risk assessment. She's expected to integrate climate resilience work into an already overstretched role, without remuneration or recognition. The regulatory frameworks were built around traditional models of acute, physician-led care. They struggle to adapt to climate realities.

The data collection itself reveals institutional resistance. Chicago's Department of Public Health doesn't track heat-related hospitalizations. Illinois discontinued the emergency department surveillance data it collected from 2012-2014. A Heat Vulnerability Index developed by Northwestern researchers in partnership with Chicago remains hidden from the public nearly four years after the project began. Officials offer contradictory explanations that leave no one accountable.

Many heat deaths go unrecognized because heat kills indirectly. Deaths get recorded as cardiac events rather than climate-related. The invisibility is structural—built into how deaths get recorded and what counts as climate impact. It protects institutions from accountability for the populations they're failing to protect.

She's in her fourth committee meeting this year about climate health preparedness. The hospital administrators agree that protocols are needed. Everyone nods when she presents the data. Then the conversation shifts to budget constraints, staffing shortages, competing priorities. The meeting ends with a promise to revisit the issue next quarter.

Meanwhile, patients keep arriving. The woman went home after twelve hours in the ED, her cardiac rhythm stabilized, her daughter promising to check on her daily. But the heat wave continued for another week. The apartment stayed hot. The woman knew to drink water, to rest, to watch for warning signs. What she didn't have was air conditioning. AC use varies significantly by race, ethnicity, and poverty level in Chicago. On the hottest days, non-Latiné Black adults use AC less than other groups. The gap between what the nurse can treat and what the patient can survive at home widens every summer.

Focusing on institutional change is a calculation: without standardized approaches, every nurse improvises responses to climate health emergencies. The woman with cardiac stress got good care because her particular nurse recognized the pattern. The construction worker who collapsed last July got sent home with Gatorade because his provider didn't connect heat exposure to his kidney values. The kid with asthma during the June 2025 wildfire smoke got nebulizer treatments but no education about air quality monitoring because his ED physician didn't know to provide it.

Individual competence breaks down without infrastructure. In these committee meetings, she argues for adaptations that everyone agrees are necessary but no one has figured out how to resource.

The tradeoff is time. Time in meetings and policy discussions instead of direct patient care. Time arguing for changes that might take years while the climate health burden increases now.

Colleagues have decided that patient education is more valuable than waiting for comprehensive system change. They're teaching people to protect themselves with the tools they control. She understands their choice. She's just betting differently.

If hospitals don't have protocols for recognizing and managing heat emergencies, if triage doesn't screen for climate-related risk factors, if air quality monitoring doesn't trigger clinical interventions, then nurses will keep treating symptoms of institutional unpreparedness as much as patient illness.

The next committee meeting is scheduled for March. She's already preparing her presentation, knowing it will sound familiar to everyone in the room. Knowing they'll agree with her analysis. Knowing that agreement doesn't guarantee change.

Whether that infrastructure will arrive before the next heat wave, the next smoke event, the next surge of patients whose symptoms the system wasn't designed to recognize—that remains the open question.