A Conversation with the Respiratory Therapist Known as Smoke

Miguel "Smoke" Rodriguez has worked as a respiratory therapist in Los Angeles emergency departments for fifteen years. The nickname started as a joke among colleagues—he was always the one getting paged for smoke inhalation cases. Now it feels less like a joke and more like a job description. We met at a coffee shop in Glendale on a February afternoon when the air quality index was, mercifully, in the double digits.

Note: This interview represents a composite character drawn from reporting on healthcare workers' experiences during wildfire events, not a specific individual.

How did you end up specializing in smoke inhalation cases?

I didn't, really. Nobody sets out to become the smoke guy. I started in respiratory therapy because I liked the technical side—understanding gas exchange, ventilator management, that kind of thing. But around 2015, 2016, we started seeing these patterns. October would come around and suddenly we'd get slammed with respiratory distress cases. Coughing, wheezing, people who couldn't catch their breath. At first it was just part of the job, you know? But then it kept getting worse. More cases, longer seasons, sicker patients.

The nickname happened after the 2018 Camp Fire. I worked something like six doubles in two weeks. Every time I'd finally get home and collapse, my phone would buzz—another smoke case, they needed me back. My coworkers started calling me Smoke because I was basically living at the hospital, treating smoke patients. It stuck. Now when the air quality goes to shit, my phone starts blowing up before I even check the AQI.

Walk me through what happens when someone comes in with severe smoke exposure.

Okay, so first thing—and this surprises people—it's not always the people you'd expect. Yeah, we see a lot of elderly patients, kids with asthma, the usual vulnerable populations.¹ But we also get healthy thirty-year-olds who thought they could tough it out, maybe they were outside trying to protect their property or evacuate pets, and suddenly they can't breathe.

When they come in, we're looking at oxygen saturation first. If they're in the low 80s or below, that's bad. We get them on supplemental oxygen immediately—nasal cannula if they're not too bad, non-rebreather mask if they are. We're listening to their lungs, checking for wheezing, crackles, any sign of inflammation or fluid. The really scary ones are quiet—their airways are so constricted there's barely any air movement.

For moderate cases, we're doing nebulizer treatments—albuterol to open up the airways, sometimes ipratropium if they're really tight. You can see them start to breathe easier within minutes if it's working. But severe exposure? That's when I'm assisting with intubation, getting them on a ventilator.² We had a guy during the Palisades fire, came in talking, seemed okay-ish, and then just crashed. His airways were so inflamed they basically swelled shut. We got him tubed, but it was close.

The thing nobody tells you is how much it varies. Some people respond great to treatment, they're home in a few hours. Others, especially if they've got underlying COPD or heart conditions, they're with us for days. And carbon monoxide poisoning—that's a whole other nightmare. You can't see it, can't smell it, but it's binding to hemoglobin and basically suffocating people at the cellular level.

The January fires this year—what was different about those?

He stares at his coffee for a long moment.

Everything and nothing. We knew it was coming. We always know it's coming now. But the speed... the fires started January 7th, and by the time I got to work that morning, we were already seeing patients. Hurricane-force winds, forty thousand acres, and the smoke was everywhere.³ What made it worse was that it's January. We're supposed to be done with fire season. Everyone's guard was down.

And the personal shit—that was harder this time. I had colleagues who were evacuating their families between shifts. One of our nurses, her house in Altadena was in the evacuation zone. She's there helping people breathe while not knowing if her own home is burning. You try to stay professional, stay focused, but there's this underlying current of... I don't even know what to call it. Dread? Rage?

We had a pediatric patient, maybe seven years old, severe asthma exacerbation from the smoke. Her mom was crying, asking if they should leave LA entirely. And I'm standing there thinking, "Where would you even go?" The smoke from Canadian wildfires reached New York last year. There's no safe zone anymore.

You mentioned surge capacity issues. What does that actually look like on the ground?

So here's the thing—ICUs normally run at like 80-90% capacity anyway. They're expensive to staff, hospitals don't want empty beds. Then you get a wildfire event and suddenly you've got this wave of admissions. Young asthma patients hit the ICU immediately after smoke exposure, but cardiovascular patients show up days later.⁴ It's this rolling surge that just keeps coming.

We had to develop what they call a "virtual disaster pack"—basically a pre-set inventory of supplies we can deploy fast. Extra nebulizers, oxygen tanks, intubation equipment.⁵ But supplies are only part of it. You need people. Respiratory therapists, nurses, doctors. And we're already burned out—no pun intended—from COVID, from the regular chaos of emergency medicine. Now add these predictable but overwhelming wildfire surges.

One thing we figured out is that we need specific staffing plans for wildfire events. Not just "call in extra people" but actual protocols for who gets called, in what order, with what roles.⁶ During the January fires, we had respiratory therapy students helping with basic treatments under supervision. It worked, but it's not ideal. You're essentially training people during a crisis.

Do you see patterns in who's most affected?

Yeah, and it's not always who you'd think. Obviously kids, elderly, people with pre-existing respiratory or cardiovascular conditions—they're high risk.⁷ But we're also seeing effects on people with diabetes, kidney disease, even cognitive impacts. The research is still emerging on some of this, but we're seeing it clinically.⁸

There's also a huge socioeconomic component nobody wants to talk about. People in newer buildings with good HVAC systems, they can seal themselves in with filtered air. People in older apartments, working outdoor jobs, no air conditioning? They're getting hammered. We had a landscaping crew come in during the fires—they'd been working outside because they couldn't afford to miss days. All of them needed treatment.

And here's something dark: we're starting to see what I call "smoke literacy." People who've been through this before know to come in early, ask for nebulizer treatments before it gets bad. But new residents, people who just moved to LA, they wait too long. They don't realize that "just a little smoke inhalation" can send you to the hospital.⁹

How has your own relationship with living in LA changed?

He laughs, but there's no humor in it.

I check the AQI more than I check the weather. I have N95 masks in my car, my apartment, my locker at work. I bought two HEPA air purifiers for my place—they run constantly during fire season. Which is now like six months long instead of two.

The weird part is the cognitive dissonance. I'm treating people for smoke exposure, I know exactly how dangerous it is, and then I'm driving home through the same smoke. You can't avoid it. Even with the windows up, recirculation on, it gets in. Your eyes burn, your throat gets scratchy. You shower and you can smell smoke in your hair.

I've thought about leaving. But where? The Pacific Northwest has fires now. Colorado has fires. Even places that didn't historically have wildfire smoke are getting it from hundreds of miles away. And this is my community, you know? These are my neighbors coming into the ED. Feels wrong to bail.

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Plus—and this sounds insane—there's something about knowing you're useful. When the fires hit, I know exactly what to do. I can help people breathe again. That matters. Even when everything else feels out of control, that matters.

What do you wish people understood about wildfire smoke and health?

That it's not just an inconvenience. People see the AQI hit 150 and they're like, "Oh, it's hazy out." But we're seeing increased ED visits for respiratory and cardiovascular conditions during and after wildfire smoke exposure.¹⁰ The particles in wildfire smoke are different from regular air pollution—they're smaller, they carry different chemicals depending on what's burning, and they penetrate deep into your lungs.¹¹

Also, the effects aren't always immediate. You might feel fine during the smoke, then have a heart attack three days later. The cardiovascular impacts are real and they're delayed. We see it in the admission patterns.

And for healthcare workers—we need people to understand we're not superhuman. We're breathing the same air, dealing with the same anxiety about our homes and families, and then we're supposed to show up and be calm and competent and reassuring. It's exhausting. After the January fires, I slept for like 16 hours straight. Just completely crashed.

Do you think the healthcare system is adapting fast enough?

He exhales slowly, like he's measuring his lung capacity.

No. But also, how could it? The speed of change is outpacing our ability to adapt. We're developing protocols for wildfire surge capacity, we're training people, we're trying to build resilience. But every year it gets worse. More fires, longer seasons, more intense smoke.

The healthcare sector itself is part of the problem—we're responsible for like 9% of national greenhouse gas emissions.¹² There's this irony where we're treating climate-related health impacts while contributing to the problem. Some hospitals are trying to reduce emissions, become more energy efficient, but it's slow.

What worries me is that we're normalizing this. New respiratory therapists coming in, this is just... normal to them. They've never known a fire season that wasn't intense. They don't remember when October was quiet. And I guess that's adaptation in a way, but it's also tragic. This shouldn't be normal.

What keeps you doing this work?

Honestly? Some days I don't know. The pay isn't great, the hours are brutal, and I'm inhaling smoke particles while trying to help other people not inhale smoke particles. It's absurd.

But then you get someone who comes in barely breathing, terrified, and you help them. You get them on oxygen, give them a treatment, and you watch their O2 sat climb back up, watch them relax as they can breathe again. That moment—that's real. That matters.

And the dark humor helps. My coworkers are the only people who get it. We joke about needing hazard pay for breathing hazardous air. We have a running bet on when the first "fire season" patient will show up each year—winner gets a beer. It's gallows humor, but it keeps you sane.

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I don't know if I'll still be doing this in five years. Some days I think about moving to Minnesota or something, somewhere cold and wet. But for now, this is where I am. Someone's got to be the smoke guy.