A School Nurse Talks About the Spreadsheet No One Asked For

Tamsin Gale is a fictional composite, but the clinical reality she describes is drawn entirely from published research, documented school district events, and peer-reviewed nursing literature. There are thousands of school nurses living some version of her week. Almost none of them have been interviewed.

The school nurse's health office keeps a bodily record that almost no other room in American public education does. When wildfire smoke settles over a district, the emergency department eventually captures the worst asthma exacerbations — a 17% increase during the 2023 Canadian wildfire season, according to CDC data, with children aged 5–17 among the hardest hit.¹ But the ED only sees the cases that escalate. Upstream, in a room with a cot, a locked inhaler cabinet, and a box of tissues, the school nurse manages the cases that never make it to the hospital. In most districts, nobody is counting them.

Tamsin Gale has been a school nurse on Colorado's Front Range for twelve years. She covers two elementary schools in a suburban district, shuttling between buildings under the kind of cluster staffing model that the National Association of School Nurses has long argued is inadequate.² Three years ago, she started keeping a personal spreadsheet. Clinic visits logged against that day's AQI reading, pulled from AirNow on her phone. The district didn't ask her to do this. No one has asked to see it.

We spoke in her health office at the larger of her two schools during a Wednesday lunch period. A portable air quality monitor she bought herself — $130, out of pocket — sat on the windowsill next to a spider plant. The AQI that day was 42. She reported it the way she'd report a blood pressure reading: fine, but worth knowing.

You started keeping a spreadsheet three years ago. What prompted that?

Tamsin: Frustration. Pure frustration. I kept telling my principal, the district health coordinator: "I'm seeing more kids on smoke days, this is a pattern." And the response was always very polite and very... noncommittal. "Hmm, interesting, we'll keep an eye on it." So I thought, okay, I'll keep the eye on it. I started logging every clinic visit with the date, the complaint, and the AQI. It's not science. I know it's not science. But when you can show someone fourteen respiratory visits on a day the AQI was 158 and three the day before when it was 40, that's not nothing.

Has anyone in the district used that data?

Tamsin: No.

What does your district's protocol actually say about smoke days?

Tamsin: We have a general air quality protocol that follows the EPA tiers. AQI over 100, sensitive students stay inside. Over 150, everyone stays inside. Over 200, no outdoor activity.³ Fine as far as it goes. But it doesn't tell me what to do clinically. It tells the principal when to cancel recess. It doesn't address what happens when I've got six kids in my office at 10 a.m., three of them with asthma action plans and three who just "don't feel good," and I'm supposed to be at my other school by noon.

Walk me through a bad smoke morning. AQI 150, say.

Tamsin: I check AirNow before I leave the house. If it's already elevated, I'm mentally triaging before I've finished my coffee. I know my asthmatics. I've got their action plans, I know which ones have rescue inhalers at school and which ones are supposed to but the parents haven't brought one in since September. That's its own whole saga.

So I get to school and the first thing I'm doing is checking the inhaler cabinet. Do I have enough? Because I can administer a rescue inhaler under a standing order, but I can't conjure one. If a kid's inhaler is expired or empty and the parent hasn't replaced it, I'm calling the parent on a day when the parent is also dealing with the smoke.

Then kids start coming in. The asthmatics come first, usually. But then you get what I call the "smoke headaches." Kids who don't have a respiratory diagnosis but their head hurts, their eyes hurt, they feel "weird." And I have to decide: is this the smoke, is this dehydration, is this anxiety, is this a kid who didn't eat breakfast? Sometimes it's genuinely all four at once. I'm not running labs. I'm looking at a nine-year-old and making a judgment call with a pulse ox and twenty years of nursing instinct.

And then, the part that keeps me up at night: at 11:45, I'm supposed to drive to my other school. So whatever's happening at School A after lunch, I'm not there for it. The front office secretary becomes the health office. She's wonderful. She is not a nurse.

The NASN published a position statement this year formally naming climate-associated conditions as within the school nurse's clinical scope.⁴ Did that change anything for you practically?

Tamsin: I read it. I appreciated it. It changed nothing about my Tuesday.

Look, it matters that the professional organization says "this is your job." But I already knew it was my job. What I need is a second nurse, or a protocol that accounts for the fact that smoke days generate three times the clinic traffic, or, honestly? I'd settle for a charting system that lets me code the environmental context. Right now, when a kid comes in on a smoke day, I chart "headache" or "respiratory distress" or "anxiety." The smoke disappears from the record. It just becomes a headache.⁵

So the environmental trigger is invisible in the data.

Tamsin: Completely invisible. The ER sees the kid who went home from my office and got worse at 2 a.m. The ER codes it as an asthma exacerbation. My visit, the one where I gave the rescue inhaler and called the parent and said "watch her tonight," that visit doesn't exist in any dataset anyone's looking at.

Wisconsin reported over 2,000 severe asthma ED visits in July 2026 during a wildfire smoke event, up from an average of 1,600.⁶ What do you think the school nurse clinic numbers looked like upstream of that?

Tamsin: I'd bet my spider plant they were enormous. And nobody counted them.

You mentioned anxiety. Are you seeing more of it?

Tamsin: Yeah. And it's the hardest thing I deal with, because a stomachache I can assess. An inhaler I can administer. But a ten-year-old who comes in and says "my stomach hurts" and when you talk to her for a minute, what's actually happening is she saw footage of a wildfire on the news and she's scared it's coming here. What do I chart? There's no code for that. There's no referral pathway for "climate-anxious fifth grader" in my district.

The research says school nurses should be part of the support system for climate-related mental health.⁷ Great. I'm one nurse for 847 kids across two buildings. My "support system" is me, a box of tissues, and the school counselor who's also covering two buildings. Between us we've got the therapeutic bandwidth of a very tired golden retriever.

What would you tell a parent who asks whether their asthmatic child is safe at school on an orange AQI day?

Tamsin: I'd tell them what I know: we keep the kids inside, we have the inhaler, I'm watching for symptoms. And then I'd tell them what I can't guarantee, which is that I'll be in the building all day.

I'd also want them to know the research picture is genuinely mixed. Some studies show clear increases in pediatric asthma visits on smoke days. A New York City study across five hospitals found wildfire smoke was not associated with pediatric asthma visits in that population.⁸ It probably depends on the building, the ventilation system, how much time the kid spent outside before school. I'd say: trust the action plan, keep the inhaler current, and if you can check on your kid after school, do it. I can see her until 3:15. After that, she's yours.

Is there something you wish the public understood about what you do on these days?

I've got twelve years of watching this change. I've got a spreadsheet no one's asked for. And next August, when the smoke comes back, I'll be in the same room with the same spider plant, counting inhalers.

Tamsin Gale's two schools have been on the same AQI exposure corridor for six consecutive smoke seasons. Her spreadsheet now contains over 1,400 entries. The district's electronic health record system still does not include a field for environmental context.

Footnotes

1. McArdle et al., "Asthma-Associated Emergency Department Visits During the Canadian Wildfire Smoke Episodes," MMWR 72:34, August 2023. https://www.cdc.gov/mmwr/volumes/72/wr/mm7234a5.htm ↩

2. Advocates for Justice and Education, "The School Nurse Shortage in D.C.," June 2025. https://www.aje-dc.org/2025/06/17/the-school-nurse-shortage-in-d-c-whats-broken-and-what-congress-could-fix/ ↩

3. EPA AirNow guidance on school outdoor activity thresholds, based on the Air Quality Index tier system. https://www.airnow.gov/aqi/aqi-basics/ ↩

4. NASN, "Position Statement: Environmental Health," NASN School Nurse, 2026. DOI: 10.1177/10598405261453093 ↩

5. The disappearance of environmental context from clinical health records is a documented problem across care settings. School health records, which are typically maintained in standalone systems without environmental data fields, are particularly susceptible. ↩

6. WXPR Public Radio, "Air quality monitoring will take on increased importance due to wildfire events," September 29, 2026. https://wxpr.org/energy-environment/2026-09-29/air-quality-monitoring-will-take-on-increased-importance-due-to-wildfire-events ↩

7. Léger-Goodes et al., "Integrating mental health into climate change education," Frontiers in Psychology, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10800611/ ↩

8. Liu et al., study across five New York City hospitals finding wildfire smoke was not associated with pediatric asthma ED visits in that population, contrasting with national CDC data and Wisconsin 2026 figures showing clear increases elsewhere. PMC, 2025. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12666338/ ↩