Maxine Kowalski—Max to everyone in the emergency department—has been an ER nurse in Portland for fifteen years. She moved from Michigan in 2010 specifically because the Pacific Northwest promised milder weather than the Midwest's temperature extremes. Then came June 2021, when Portland hit 116°F and her emergency room became what she describes as "a fucking triage tent in a disaster movie, except we were inside a hospital."

Max agreed to talk during her lunch break at a coffee shop near the hospital, though she checked her phone twice in the first five minutes. She's forty-three, with the particular kind of exhaustion that comes from years of emergency medicine. Not the dramatic collapse kind, but the steady erosion that makes you forget what it felt like to not be tired. We're meeting on a November afternoon that's unseasonably warm, and she keeps glancing at the thermometer display across the street.

This interview is a composite drawn from research on emergency nurses experiencing climate health impacts, though Max herself is not a real person—more like the conversation you'd have if you could distill the experiences of dozens of ER nurses into one very tired, very funny woman who moved to Portland for the wrong reasons.

So you moved here for the mild climate

Max: I know. The irony is not lost on me. I grew up outside Detroit, and I was so done with the weather whiplash. Negative twenty in January, ninety-five and humid in July. Portland sounded perfect. Temperate rainforest, they said. Mild year-round, they said. I bought a house without air conditioning because the real estate agent told me I wouldn't need it.

Then 2021 happened and I watched people die because they also didn't have air conditioning. Elderly folks, mostly. Low-income. The kind of patients where you're doing everything right medically and they're still coding because their core temperature is 106 and their body just gives up.

Walk me through that heat dome weekend

Max: Saturday we started seeing the uptick—people coming in confused, dizzy, the usual heat exhaustion stuff. By Sunday morning we knew it was going to be bad because the overnight low was still in the eighties. Your body needs cool nights to recover, and we weren't getting them.

By Sunday afternoon we had people lined up in the hallways, and I'm doing triage trying to figure out who's about to die versus who's just miserable.

Here's the thing. We train for mass casualty events—shootings, earthquakes, whatever. But this was different. Everyone was hot. Everyone was dehydrated. And we're running out of IV bags because—and I'm still mad about this—a hurricane hit a plant in Puerto Rico in 2017 and we never really recovered the supply chain.¹

So I'm looking at an eighty-year-old woman who's been lying in her apartment for two days with no AC, and I'm thinking about IV bag rationing protocols.

You had to ration hydration therapy during a heat emergency?

Max: We had to make decisions. That's the diplomatic way to put it.

The real way is: I had to look at patients and calculate who would survive without IV fluids versus who would die without them, and allocate accordingly. And then I went home—to my house with no AC—and couldn't sleep because it was ninety degrees at midnight, and I kept thinking about the patients we'd sent home because we didn't have beds.

The research says over half of us are experiencing high burnout now.² Yeah. No shit.

What changed after 2021?

Max: I bought a window unit. The hospital added some capacity but not enough. And every summer since then I watch the forecast like I'm planning a military operation.

When we get a heat warning now, I know we're going to see the surge—heat exhaustion, heat stroke, but also the weird stuff people don't think about. Ear infections spike during heat waves. Infectious diseases. Medications stop working right when people get too hot.³

Last summer we had a guy come in, regular patient, takes antidepressants. He's out doing yard work in ninety-five degree heat and ends up in our ER because his meds basically amplified the heat stress. His body couldn't regulate temperature properly. He's sitting there going "I was just mowing the lawn" and I'm explaining that his medication plus heat equals dangerous, and he's looking at me like I'm speaking another language.

How do you explain that to patients?

Max: I usually don't have time. That's the honest answer. I'm triaging fifteen people with five beds available, and I don't have time to explain the complex pharmacology of how SSRIs affect thermoregulation. I just tell them: stay inside when it's hot, drink water, if you feel weird come back.

But here's what keeps me up at night—and I mean this literally, because I'm losing sleep to heat too now⁴—we're seeing patients who are making reasonable decisions based on old information. "I've lived in Portland forty years, I never needed AC before."

Yeah, well, Portland forty years ago is not Portland now. Heat-related mortality in elderly patients is up 167% compared to the nineties.⁵ That's not a rounding error. That's a different city.

Do you think about leaving?

Max: Every nurse I know thinks about leaving. Forty-two percent of inpatient nurses, fifty percent of us in emergency.⁶ The burnout surveys keep coming out and we keep filling them out and nothing changes.

Well, that's not true. Things change—they get worse.

She laughs, but it's the kind of laugh that could easily become something else.

What does a break without interruption even mean in an ER?

Max: It means I get to pee and eat a granola bar without someone coding. It means fifteen minutes where I'm not making life-and-death decisions. It means—

Her phone buzzes. She glances at it, then puts it face-down on the table.

It means something that doesn't happen.

Look, I'm not trying to be dramatic. This is just the job now. Climate-related events are disrupting care at eighty percent of frontline clinics.⁸ We're all dealing with this. Supply chain issues, staff shortages, patient surges. After Hurricane Helene hit another IV plant last year, we were back to the same rationing conversations.⁹

How do you cope?

Max: I don't know if I do. I mean, I show up. I do the job. I'm good at it—I'm really good at emergency medicine, and I like the work when I'm actually able to do it properly.

But there's this constant background hum of dread. Or maybe anticipation. I check the weather forecast and I'm not thinking "oh good, beach day." I'm thinking "okay, ninety-eight degrees on Thursday, we'll see the surge Friday, make sure we're stocked on cooling supplies."

My therapist says I have anticipatory anxiety about climate events. I told her that's not anxiety, that's pattern recognition.

Do you think it's going to get better?

Max: Long pause.

No. I think it's going to get worse, and we're going to adapt, and it's going to get worse again, and we'll adapt again, until maybe we can't anymore.

The hospital is building some resilience—backup power, some cooling capacity. But we're adapting to a moving target. Dengue cases hit ten million globally last year, highest ever.¹⁰ Those mosquitoes are moving north. We're going to start seeing diseases here that we didn't train for. And I'll learn to treat them, because that's what we do.

But I didn't sign up to be a tropical disease nurse in Portland, Oregon.

She checks her phone again.

I need to head back. We're short-staffed today—someone called out sick. Heat exhaustion, actually. It's seventy-two degrees in November and my colleague has heat exhaustion.

Last question. Do you regret moving here?

Max: Some days. But where would I go? Michigan's getting tornado warnings now. Texas is Texas. Everywhere is becoming somewhere else. At least here I know which ER is going to be overwhelmed when the next heat wave hits.

She stands, drains her coffee, and heads for the door. Through the window I watch her check the thermometer display across the street one more time before walking back toward the hospital.

Footnotes

1. https://salatainstitute.harvard.edu/climate-change-is-threatening-patient-care/ ↩

2. https://www.ena.org/press-room/2024/01/10/ed-nurses-report-higher-work-dissatisfaction-than-inpatient-colleagues ↩

3. https://healthjournalism.org/blog/2025/01/climate-and-health-stories-to-watch-in-2025/ ↩

4. https://healthjournalism.org/blog/2025/01/climate-and-health-stories-to-watch-in-2025/ ↩

5. https://healthjournalism.org/blog/2025/01/climate-and-health-stories-to-watch-in-2025/ ↩

6. https://www.ena.org/press-room/2024/01/10/ed-nurses-report-higher-work-dissatisfaction-than-inpatient-colleagues ↩

7. https://www.ena.org/press-room/2024/01/10/ed-nurses-report-higher-work-dissatisfaction-than-inpatient-colleagues ↩

8. https://salatainstitute.harvard.edu/climate-change-is-threatening-patient-care/ ↩

9. https://salatainstitute.harvard.edu/climate-change-is-threatening-patient-care/ ↩

10. https://healthjournalism.org/blog/2025/01/climate-and-health-stories-to-watch-in-2025/ ↩