Returned to Class

The following triage log entries are from the student health office at Millard Fillmore Elementary during the week of May 11–15, 2026, when wildfire smoke from a fire complex 340 miles to the south held the Air Quality Index between 138 and 224. The school remained open all five days. Nurse Truesdale agreed to let us publish the log on the condition that student identifiers be reduced to age and grade, and that we print the Notes field, which she described as "the part where I write what the form doesn't have a box for." Her name is the one she chose for the record.

STUDENT HEALTH OFFICE — DAILY TRIAGE LOG Millard Fillmore Elementary School | Enrollment: 487 Documenting Clinician: Delia Truesdale, RN, BSN Week of May 11–15, 2026

Monday, May 11

8:47 AM — Patient: Age 7, Grade 2 CC: Wheezing, chest tight, "can't get a good breath" Assessment: Asthma exacerbation, mild-moderate. Bilateral expiratory wheeze. O2 sat 96%. Action: Albuterol 2 puffs MDI + spacer per asthma action plan on file. Monitored 20 min. Wheeze resolved. O2 sat 98%. Disposition: Returned to class. Notes: AQI 142 at morning bell. I pulled action plans for all twelve asthmatics Friday afternoon when the forecast came in. She was first through the door. She won't be last.

11:20 AM — Patient: Age 10, Grade 4 CC: Headache, says eyes "sting" Assessment: Tension-type headache, bilateral. Conjunctival irritation. No respiratory distress. Action: Acetaminophen per standing order. Eye rinse. Rest, hydration. Disposition: Returned to class after 25 min. Notes: No prior visits this year. Outdoor recess held this morning. AQI 148 at 10 AM, which is orange, which means "outdoor option available with reduced exertion."¹ He was playing kickball. I know because his shoes are muddy.

Tuesday, May 12

9:15 AM — Patient: Age 7, Grade 2 CC: Cough, chest "feels heavy again" Assessment: Asthma exacerbation, moderate. Audible wheeze without stethoscope. Intercostal retractions visible. O2 sat 94%. Action: Albuterol 2 puffs MDI + spacer. Monitored 30 min. Wheeze decreased, persistent. Repeat albuterol per action plan. O2 sat 97% post second treatment. Disposition: Parent called. Voicemail first attempt. Reached on second call 9:52. Student picked up 10:40. Notes: Second visit in two days. Action plan says if rescue inhaler needed more than every four hours, contact physician.² She used it at home last night. Mom told me on the phone. Mom asked if she should keep her home tomorrow. I said yes. Mom asked if she'd be marked absent. I said I'd talk to the front office. Mom works at the distribution center off Route 9. She gets three personal days a year.

11:00 AM — Patient: Age 8, Grade 3 CC: "Can't stop coughing" Assessment: Persistent dry cough. No wheeze on auscultation. No history of asthma or reactive airway disease. Lungs clear but cough productive on deep breath. Action: Rest, hydration. Monitored 20 min. Disposition: Returned to class. Notes: First health office visit this school year. Healthy kid. AQI 163 at 10 AM. Red. Sensitive groups stay inside, others "avoid prolonged outdoor exertion."³ She's not in a sensitive group. She is eight.

1:45 PM — Patient: Age 6, Grade 1 CC: Scratchy throat, runny nose, "my eyes are wet" Assessment: Upper respiratory irritation consistent with smoke exposure. No fever. No wheeze. Action: Rest, water, tissues. Disposition: Returned to class after 15 min. Notes: Walks to school from Orchard Park. About a mile. No car on file for the family.

Wednesday, May 13

8:22 AM — Patient: Age 8, Grade 3 CC: Cough — "same as yesterday" — now with headache Assessment: Persistent upper respiratory irritation. Smoke-related headache, bilateral. Cough worsening. Action: Acetaminophen per standing order. Rest, hydration. Disposition: Returned to class after 40 min. Notes: Second visit in two days. No respiratory history. She told me she couldn't sleep because of the coughing. Her mom gave her cough syrup but it didn't help. It wouldn't. There's no OTC medication that treats air-quality exposure.⁴ AQI 171 at 7 AM. I have water and rest and acetaminophen. Same as yesterday.

9:50 AM — Patient: Age 10, Grade 4 CC: Dizziness, nausea, headache Assessment: Likely smoke-related. No focal neurological signs. No fever. Action: Rest in health office, supine. Hydration. Monitored 45 min. Disposition: Parent called. No answer. Second call, no answer. Student returned to class at 10:50 per protocol. Third call 12:15 — parent unable to leave work. Notes: Phone number on file is the only one. I've called it nine times across three students this week.

10:30 AM — Patient: Age 9, Grade 3 CC: Eyes burning, headache, "it smells weird in our room" Assessment: Conjunctival irritation, smoke-related headache. Action: Eye rinse, acetaminophen, rest. Disposition: Returned to class. Notes: Fourth student from Room 112 this week. South-facing, windows original to the 1974 build. One doesn't close all the way. The HVAC in that wing runs MERV 8 filters.⁵ I've submitted work orders.

1:15 PM — Patient: Age 7, Grade 2 CC: Wheezing Assessment: Asthma exacerbation. Wheeze bilateral. Action: Albuterol MDI + spacer per action plan. Disposition: Parent called. Mom kept her home yesterday per my recommendation. Brought her back today. She can't miss another shift. Notes: Third visit in three days.

Thursday, May 14

8:15 AM – 11:30 AM — Nine students. Individual entries on supplemental log sheet (attached).

Summary CC: Cough (5), headache (3), eye irritation (4), scratchy throat (3), wheeze (2), nausea (1), "chest feels weird" (1). Multiple complaints per student. Three returning: Age 8/Grade 3 (third visit), Age 9/Grade 3 (second, Room 112 again), Age 6/Grade 1 (second, the walker from Orchard Park).

Summary Action: Albuterol x2 per action plans. Acetaminophen x4 per standing order. Eye rinse x3. Rest and hydration x9. One parent reached, student picked up. Two parents unreachable.

Summary Disposition: Seven returned to class. One awaiting pickup. One in health office through lunch — no one available, student requested to stay, I let her.

Notes: I'm writing this at lunch because I couldn't document in real time. Nine students in three hours. I have 487 students in this building and one health office with one cot and four chairs and a mini-fridge with water bottles I buy at Costco because the health office supply budget is $200 for the year and that goes to bandages and ice packs and thermometer batteries.

The fire is 340 miles from here. There is no ash. The sky is a color I'd call dishwater if I were writing a novel, which I'm not, I'm writing a triage log. AQI hit 201 at 10 AM. Purple. Shelter-in-place, doors and windows shut, students and staff move freely inside, teaching continues.⁶ The kids are inside. They're breathing inside air.

The 8-year-old is back. Third visit. No asthma, healthy last week. I gave her water again. She said "thank you" like I'd done something. A study came through my listserv last month: wildfire PM2.5 is up to ten times more harmful to children's respiratory systems than PM2.5 from other sources.⁷ Ten times. There are 33.5 million children in this country living in areas that got a failing air quality grade this year.⁸ Nearly 2.4 million kids with asthma in counties that got an F.⁹ I don't know what to do with those numbers in this room. I know what to do with the kid in front of me, which is: water, rest, acetaminophen if she has a headache, albuterol if she has an action plan on file, and if she doesn't have any of those things, I have a chair and twenty minutes and the same air she'll walk back to.

The headache kids worry me. There's research showing children are less likely to go to the ER for headache during smoke events.¹⁰ They stay home, or they come here. A week ago these headaches would have gone to urgent care. Now they're coming to me because the ER feels like too much and home doesn't feel like enough, and I am the room in between.

Room 112's window is still open a quarter inch. I can see it from the hall.

Friday, May 15

9:00 AM — Patient: Age 8, Grade 3 CC: Cough. Headache. "I just wanted to come here." Assessment: Persistent upper respiratory irritation, day four. Smoke-related headache. Cough now productive, mucus clear. Action: Acetaminophen. Rest. Water. Disposition: Returned to class at 9:45. Notes: Fourth visit this week. I've documented the same assessment four times for the same child and each entry is accurate and each intervention is appropriate and each disposition is the same. She goes back to class. The air in the classroom is the air in the classroom. AQI 164, which is red, which is the same color it was Monday at a different number that meant the same thing. She said "I just wanted to come here" and I wrote it on the chief complaint line because I didn't know where else it went.

2:20 PM — Patient: Age 5, Grade K CC: Cough, first episode. Teacher reports student "couldn't catch her breath" during story time. Assessment: New-onset cough, no prior history. Mild tachypnea, resolved with rest. No wheeze. O2 sat 97%. Action: Rest, hydration. Monitored 20 min. Parent notified. Disposition: Returned to class. Notes: New patient. Five years old. Monday I start the log again.

Triage log continues. Week of May 18 not yet filed.

Footnotes

1. EPA/AirNow, "Air Quality and Outdoor Activity Guidance for Schools," https://document.airnow.gov/air-quality-and-outdoor-guidance-for-schools.pdf. At AQI 101–150 (orange), schools are advised to provide indoor and outdoor options, with sensitive individuals exercising indoors. ↩

2. American Academy of Pediatrics, "Asthma Management in Schools," https://www.aap.org/en/patient-care/school-health/management-of-chronic-conditions-in-schools/asthma-management-in-schools/. Needing rescue medications more than every four hours is a sign to seek medical care. ↩

3. At AQI 151–200 (red), the EPA recommends sensitive groups remain indoors and others avoid prolonged outdoor exertion. Schools typically keep doors and windows closed and move PE indoors. See also Palo Alto USD Air Quality Protocols, https://www.pausd.org/school-life/air-quality-protocols. ↩

4. Children's Hospital Colorado, "Wildfire Smoke and Kids," https://www.childrenscolorado.org/just-ask-childrens/articles/wildfire-smoke/. "No over-the-counter medication will treat exposure to low-quality air." ↩

5. MERV 8 filters, common in older school HVAC systems, capture significantly less fine particulate matter than MERV 13 or HEPA filters. See PerryWeather, "Why Is Air Quality in Schools So Bad?" https://perryweather.com/resources/air-quality-in-schools/. ↩

6. At AQI 201+ (purple/very unhealthy), schools implement shelter-in-place: students and staff move freely inside buildings, teaching continues. No established AQI threshold triggers school closure. See Clark County Public Health, https://clark.wa.gov/public-health/wildfire-smoke-resources-schools. ↩

7. American Academy of Pediatrics. Wildfire PM2.5 is up to 10 times more harmful to children's respiratory health than PM2.5 from other sources, with greatest impact in children under five. See also PMC12887139, https://pmc.ncbi.nlm.nih.gov/articles/PMC12887139/. ↩

8. American Lung Association, 2026 State of the Air Report. 33.5 million children live in areas receiving a failing grade on at least one major air pollution measure. Wildfire smoke, dust storms, and ground-level ozone are the primary drivers. ↩

9. American Lung Association, 2026 State of the Air Report. Nearly 2.4 million children with asthma live in counties receiving an "F" for at least one pollutant; more than half a million live in counties failing all three measures. ↩

10. Shapiro et al., "Association between wildfire smoke exposure and pediatric emergency department visits for headache," Headache, 2025, https://pubmed.ncbi.nlm.nih.gov/41013892/. Children were less likely to seek emergency care for primary headache in the days following wildfire smoke exposure. ↩