Wildfire smoke and NEMT: air quality levels, riders with lung disease, and protecting drivers

Check the AQI for fine particles at the start of every shift

Smoke days are judged by a number, not by how the sky looks. EPA’s Air Quality Index (AQI) runs from good to hazardous, and wildfire smoke shows up in its reading for fine particles, called PM2.5. EPA ties a value of 100 to the short-term national health standard. Above 100, the air is unhealthy, first for sensitive groups and then for everyone.

The levels a NEMT dispatcher acts on:

• 101 to 150, orange. Unhealthy for sensitive groups, who may feel effects while most people do not. Many NEMT riders fall in those groups.
• 151 to 200, red. Some healthy people now feel effects, and people in sensitive groups may have more serious ones.
• 201 to 300, purple. EPA calls this a health alert: the risk is higher for everyone.
• 301 and up, maroon. A health warning of emergency conditions.

Check the reading for each area you serve before the first trip leaves and again during the day. California and Oregon both make employers check when each shift starts and again as conditions change. AirNow shows the current reading for your area, and EPA points people to its Fire and Smoke Map to check smoke in their area. Smoke can also make the roads dangerous. EPA warns that it can cut visibility, and NWS issues a Dense Smoke Advisory when smoke brings visibility down to a quarter mile or less.

Which riders smoke hurts first

Many of the riders a NEMT company carries every week belong to the groups EPA lists as most at risk. Its wildfire smoke guide for public health officials names these groups:

• People with asthma or COPD. Smoke can set off breathing trouble and flare-ups. EPA notes that people with COPD face a higher risk of needing emergency care after exposure, because their lung capacity is already low.
• People with heart disease. After particle exposure, they may have palpitations, unusual fatigue, lightheadedness, shortness of breath, or pain or tightness in the chest, neck, or shoulder. Fine particles have been linked to heart attacks and strokes.
• Older adults. They have more heart and lung disease, and the body’s defenses weaken with age.
• Children and pregnant women. Children breathe in more air for their body weight than adults.

CDC adds people with diabetes and chronic kidney disease to its list of those at higher risk from smoke. That puts most dialysis riders on it, and a dialysis rider cannot skip treatment for a smoke day. The dialysis transport guide covers those runs in general.

For riders on the list, the goal is less time breathing outdoor air. Call or text a few minutes before the van arrives so the rider waits indoors, not at the curb. After the appointment, have will-call riders wait inside the clinic until the driver is at the door. CDC tells people with heart disease to call 911 for severe trouble breathing or chest pain, and that applies on the ride too. The steps for a rider in distress are in the medical emergency guide.

Keep the smoke out of the van

A closed van with filtered air is far better than outside air, but it is not a clean room. EPA’s guide gives the vehicle advice:

1. Close the windows and vents, and set the air to recirculate. Most vehicles can recirculate inside air, which keeps particle levels lower.
2. Know the filter’s limits. Ventilation in older vehicles removes only a small share of incoming particles. Newer vehicles may filter more, but EPA warns owners not to expect the protection of a dedicated clean room. Check the owner’s manual so the system is set to keep outdoor smoke out.
3. Watch for stale air on long runs. Studies cited by EPA found carbon dioxide from occupants’ breath can climb quickly, possibly above 2,500 parts per million, in newer cars on recirculate with the windows shut. EPA suggests opening windows or vents briefly now and then when smoke levels are lower.
4. Mind the heat. In hot weather a closed vehicle can heat up far beyond the outdoor temperature, and heat exhaustion can follow. A rider should never wait alone in a parked van. The heat safety guide covers hot days.
5. Use the van to move people, not to shelter them. EPA’s position is that vehicles get people to indoor places with cleaner air. They are not shelters.

The cabin filter also decides whether a state worker smoke rule applies to the van. All three state rules below exempt enclosed vehicles only when the air passes through a cabin filter, and Oregon and Washington require it to be properly maintained. Check each van’s filter interval and keep spares before fire season.

Loading is where most smoke gets in. Each wheelchair loading leaves a door open for minutes. Close doors between steps, and do not idle at a pickup with the side door open.

N95s for riders who can wear them

An N95 can help a rider who has to be outside in smoke, but it is not right for everyone. EPA advises people with heart or lung disease and older adults to check with their health care provider before using one, because a respirator can make breathing harder. That is exactly the group most likely to be in the van, so offer a mask and let the rider decide.

What makes a mask work, from EPA’s guide:

• The right marking. The facepiece is printed with “NIOSH” and either “N95” or “P100”. An N95 filter captures 95 percent of test particles.
• A tight seal. It fits over the nose and under the chin. One strap goes at the back of the neck below the ears, the other at the crown of the head. Misplaced straps are a common mistake.
• A clean-shaven face. A beard or heavy stubble where the mask meets the skin breaks the seal.

EPA warns that one-strap dust masks and surgical masks are not respirators and will not protect against smoke, and that bandanas, handkerchiefs, and tissues should not be relied on. CDC notes that approved respirator sizes are not made for very young children. Keep a box of N95s in each van, in more than one size. In California, Oregon, and Washington, the company has to provide them to drivers the smoke rule covers once the air reaches its levels, so the supply is already there.

Trips that can wait, and trips that cannot

On a purple or maroon day, the safest ride for many riders is the one that does not happen. EPA’s main advice to people at higher risk is to stay indoors and limit time outside, and to think about leaving the smoky area for a while if the smoke is expected to last.

• Routine visits. Offer to reschedule, and let the rider and the clinic decide. Follow your broker’s rules for cancelling a booked trip, covered in trip cancellations.
• Life-sustaining treatment. Dialysis, chemotherapy, and similar trips keep running. Tighten the timing so the rider spends as little time outdoors as possible.
• Riders getting worse. CDC tells people with chronic conditions to think about evacuating if they have trouble breathing or other symptoms that do not improve. A rider who is struggling to breathe needs 911, not a routine trip.

Pickups near an evacuation zone

An evacuation order changes who is in charge of the roads. Ready.gov says to leave right away when authorities order an evacuation and to follow local instructions. CAL FIRE notes that fire officials decide when and where people evacuate, that police enforce the orders, and that leaving early keeps roads clear for firefighters.

• Do not send a van into an order zone for a routine pickup. Call the rider, and point a rider who is trapped to 911. Ready.gov warns that emergency response could be delayed or impossible.
• Warning zones are different. CAL FIRE advises people not to wait for an evacuation order if they feel at risk. A rider in a warning zone may ask for an early ride out. Whether you take it depends on what your company has agreed to; the emergency preparedness guide covers evacuation agreements with facilities.
• Phones get busy. Ready.gov says phone systems are often overloaded after a disaster and suggests texts over calls.

State rules that protect drivers from smoke

Three West Coast states have written wildfire smoke rules for workers, and each can apply to NEMT drivers who work in smoke. Each starts at a fine particle level, then adds training, communication, and respirator steps as the air gets worse.

The details that matter for a van fleet:

• The vehicle exemption is narrow. All three exempt enclosed vehicles with filtered air only while windows, doors, and other openings stay closed except to get in or out. Oregon and Washington write “briefly” and leave out buses and other transit vehicles whose doors open often to board passengers. A NEMT driver who runs a lift and walks riders to doors spends real time outside at every stop, so the safer plan is to act as if the rule applies.
• Short exposures. California exempts workers exposed for a total of one hour or less in a shift. Oregon applies only its training and voluntary mask parts to work with less than 15 minutes of exposure in an hour and under one hour in 24 hours.
• Oregon’s numbers changed labels. Oregon wrote its rule before EPA revised the AQI in May 2024. Its guidance says the particle limits are unchanged, and that the required-respirator step written as AQI 251 now starts at 277 on the current scale.
• Symptoms and reporting. Washington’s rule lists symptoms that need immediate medical attention, including wheezing, chest pain, and sudden numbness or confusion, and bars retaliation against workers who seek care. Oregon’s training covers burning eyes, cough, headache, and an irregular heartbeat.

A fleet’s other workplace safety duties are in OSHA for NEMT.

Keeping riders indoors until the van arrives

HealthRide texts riders before the ride and again once the driver is headed their way, and the link in that text shows the driver’s arrival time, so a rider with lung disease can stay indoors until the van is close. Dispatch sees every vehicle on the live map and can message each driver from the map when the air turns purple.