Critical Levels (Critical Levels)

IVEGOTYOURBACK911 was started by paramedics Jill Foster & Shaun Taylor in 2014. The goal of the campaign is to spread social awareness worldwide in regards to First Responder mental health issues.

On this month’s episode of Critical Levels, we sit down with Jill & Shaun to learn a little bit more about how and why they started the company, and some of the amazing work that they’re doing to help first responders.

How do we make decisions? How does our bias impact patient care? Listen in to our conversation with Dr. Vanessa Bohn as we discuss cognitive errors, metacognition, and cognitive bias 

🔹 Key Topics:

🔸 Why medics need to understand K9 trauma care

• The overlap between human and canine emergency medicine
• Common injuries in police, military, and search-and-rescue dogs

🔸 MARCH for Canines—What’s Different?

• The first "M" stands for Muzzle—securing the dog’s “weapon” before treatment
• Understanding the similarities in trauma care between humans and dogs
• Key differences in how canines respond to injury and shock

🔸 Massive Hemorrhage Control—Why Tourniquets Don’t Work on Dogs

• Anatomical challenges—why dogs' limbs aren’t suited for tourniquets
• When to use direct pressure, wound packing, and hemostatic agents
• Junctional bleeding—where life-threatening hemorrhages happen in dogs

🔸 Airway & Breathing—Why Intubating a Dog Is Easier Than You Think

• How to recognize respiratory distress vs. normal panting
• Why dogs have larger, straighter airways than humans
• Needle decompression for pneumothorax—landmarks and technique

🔸 Transporting an Injured K9—Avoid These Mistakes

• Best positions and vehicles for safe transport
• What paramedics, police, and handlers need to plan for before an emergency

🔸 Shock & Fluid Resuscitation—The Critical Role of Femoral Pulse Checks

• How to assess perfusion in a dog without a blood pressure cuff
• Why EZ-IO is the best choice for vascular access in canines
• When and how to administer fluids, TXA, and blood products

🔸 CPR for Dogs—Does It Work?

• When CPR can save a dog—and when it won’t
• How to perform chest compressions correctly
• Naloxone for K9 opioid overdoses—it works, but dosing is different

🔸 Medications & Pain Management—What Paramedics Can Safely Use

• NSAIDs are dangerous for dogs—avoid them in trauma cases
• Opioids, TXA, ketamine, and antibiotics—what’s safe and effective?

On today’s episode we sit down with Dr. Sonny Dhanani, Chief of the Pediatric Intensive Care Unit (PICU) at the Children’s Hospital of Eastern Ontario (CHEO).

We discuss the approach and management of the critically ill child, with an in-depth discussion on the A-B-Cs.

With respect to airway, we chat tips/tricks for airway management, as well as intubation.

On the topic of breathing, we chat about bagging and some of the physiological cardio-respiratory concerns of our efforts. We also discuss the causes of arrest and how our interventions may have a role.

Lastly, with respect to the sick child, we cover circulation. Fluid resuscitation (physiology/type/volume/medical vs. trauma), IOs, the symptomatic bradycardic patient(pacing, pressors/medications, etc.), and shock are all topics on the table. 

From here, we pivot to how death is determined, and how organ donation works.

On this month’s episode, we’re joined by Dr. Katie Lin to discuss TBI and the crashing brain. 

During the episode, you’ll hear us cover:

head injury differentials and history gathering 

ischemic vs hemorrhagic 

head injury etiology 

head injury pathophysiology 

assessment

3 step neuro exam 

pupil assessments 

signs/symptoms of herniation 

ECG changes

management 

• avoid/manage the H bombs (hypoxia, hypotension, hyperventilation)
• airway management 
• ICP management 
• other medications 
• seizure management 

paediatrics 

neuroprognostication 

On this month’s episode, we’re joined by Dr. Steven Sanders to discuss heat related illnesses. 

During the episode, you’ll hear us cover:

Health impacts of temperature increase 

Physics/physiology of temperature vs heat

Spectrum of heat related illness

• heat rash
• heat cramps
• heat edema
• heat syncope
• heat exhaustion 
• heat stroke
• exertional vs classic

Comorbidities/confounders/risk factors

Temperature assessment

Disease management & treatment

On this episode, we’re joined by Dr. James Gilbertson with the Ottawa Hospital, and Cst. Caroline Gallant with The Ottawa Police Marine, Dive and Trails (MDT) Unit.

We take a dive into drowning and cover:

• What drowning is
• The scale of the problem
• Drowning pathophysiology
• The medical management of drowning patients
• Prognostication

Lastly, we speak to drowning prevention 

In British Columbia 7 people per day are dying as a result of a highly contaminated toxic supply of drugs. Since the announcement of the public health crisis related to illicit drug toxicity deaths in 2016 over 12,000 people have lost their lives.

Despite previous misconceptions that the toxic drug crisis is confined to Vancouver’s lower mainland and the downtown east side, Jen is sounding the alarm that not a square inch of the province of BC has been unaffected by the crisis. Working on the frontlines of a provincial organization means every patient and every paramedic is being affected, and as a service provider the organization is burdened with the monumental task of meeting the demand for emergency health services in rural communities that otherwise have never required such a response.

Jen emphasizes the importance of the paramedic role given the frequency at which they interact with people who use drugs. She proffers that paramedics are uniquely positioned to offer alternative models of care that aim to reduce harm, but that the window of opportunity to offer these tools is narrowing.

In this episode Jen speaks to some of the things paramedics can be doing to reduce harm in their approach, and in pathways that their organizations can be offering to patients. You can learn more about what the literature is saying about the paramedic role in caring for people who use drugs in Jen’s scoping review.

You can contact Jen on twitter at @jlynnbolster or e-mail her directly at jennifer.bolster@bcehs.ca

Welcome to the first episode of 2025! This month, we’re diving into the critical role of Tranexamic Acid (TXA) in pre-hospital trauma care. Dr. Erik Vu, a critical care flight paramedic, emergency physician, and intensivist, joins us to discuss the latest insights and applications of TXA, particularly in dynamic and tactical environments.

From its role in stabilizing clots to its use in mass casualty scenarios, we break down everything you need to know about this cost-effective and life-saving medication. Learn about the benefits of intramuscular (IM) administration, the importance of timely intervention, and how TXA fits into modern trauma care systems.

What You’ll Learn in This Episode:

What TXA is and how it works.
The history and research behind its pre-hospital use.
Why IM administration is a game-changer in tactical and unpredictable environments.
Best practices for dosing and administration.
TXA’s role in mitigating hemorrhagic shock and improving patient outcomes.
Practical tips for integrating TXA into your trauma care toolkit.

In part 2 of our conversation with Will Johnston about Calming the Chaos, we discuss the importance of a pre-brief, the zero-point survey, communication/language, graded assertiveness, debriefing, and working with our allied partners. 

Tune in with Jon Lee, formerly from the ORNGE Pediatric Critical Care Transport Team as he discusses his approach to the critically ill child

On today’s episode, we carry on last month’s conversation about cardiac arrest management and care. 

Recorded at the Paramedicine Across Canada Expo (PACE) Conference in Saskatoon in September 2022, we’re sitting down with Mike Humphrey and Adam Perrett of Lethbridge Fire and Emergency Services to talk about how they’ve revolutionized the care provided to the citizens of Lethbridge, Alberta. 

We walk through how they train, evaluate, and feedback data with respect to cardiac arrests; how they use a culture of excellence to deliver high performance CPR leading to improved ROSC rates; and they use real time data to track opiate overdoses in their community.  

On this month’s episode, we’re joined by Dr. Bonnie Snyder to discuss BVM as well her recently published paper in Resuscitation: Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. 

During the episode, you’ll hear us cover:

There is nothing basic about the BVM - it is not a benign intervention

Rate and volume based on the guidelines 

• Consequences of excessive rate/volume
• Consequences of under ventilation 

General airway management

• positioning 
• suction
• airway adjuncts
• mask seal
• C-E technique
• 2 person technique 
• waveform capnography and other real time feedback
• importance of proper volume
• importance of proper pressure 

BVM sizing 

Dr. Snyder’s study 

• research question/impetus
• P-I-C-O
• results
• feedback 
• next steps

Join Dr. Allan Shefrin, a pediatric emergency physician at the Children's Hospital of Eastern Ontario (CHEO) discuss pediatric respiratory illnesses.

Detailed show notes can be found on our website: www.criticallevels.ca

In this episode of Critical Levels, we dive into the cutting-edge strategies shaping pre-hospital and emergency department care. Our guests discuss how data-driven decision-making, high-performance CPR, and improved handover processes are revolutionizing patient outcomes.

Key Topics Covered:
✅ High-Performance CPR: The role of real-time feedback, mechanical CPR devices, and quality metrics in improving survival rates.
✅ Data-Driven Protocols: How data influences resuscitation techniques, including push-dose epinephrine, early vasopressor administration, and optimizing CPR pauses.
✅ Seamless Transitions of Care: Addressing the challenges of pre-hospital to hospital handover, minimizing interruptions, and ensuring continuity of life-saving interventions.
✅ Training & Coaching: The impact of structured CPR coaching, debriefing sessions, and real-time monitoring in refining paramedic performance.
✅ Future Directions: Exploring nurse-led ACLS, multidisciplinary teamwork, and technology-driven improvements in emergency medicine.

Key Takeaways:
🔹 Data analysis is critical in refining protocols and enhancing patient survival.
🔹 Effective communication and structured handovers reduce adverse events.
🔹 Continuous training and feedback loops lead to better resuscitation outcomes.

Join us as we explore how collaboration, innovation, and data are shaping the future of emergency medical care.

On today’s episode, we chat with Dr. Brodie Nolan, an emergency physician and trauma team leader at St. Michael's Hospital (one of Canada’s largest trauma centres), and a transport medicine physician for ORNGE.

We discuss what trauma is, and how we define hemorrhagic shock. We discuss that trauma triad of death, and why it’s important to get these patients to a lead trauma centre.

These patients ultimately need blood products, so Dr. Nolan walks us through blood/fluid resuscitation, as well as the massive hemorrhage protocol.

Lastly, we cover the prehospital care of these patients: the field trauma triage and air ambulance utilization standards; A-B-Cs (the importance of de-prioritizing intubation and allowing for permissive HYPOtension); the on-scene interventions we should and shouldn’t perform; and what the future looks like for the care of these patients

Join us as we chat with Jason Buick, the lead author of the recent article published in the Canadian Journal of Emergency Medicine (CJEM) - COVID 19: What Paramedics Need to Know! 

Join us this month as we chat with Dr. Simon Hatcher, psychiatrist at the Ottawa Hospital and Ottawa Inner City Health, about First Responder Mental Health
 
Who gets PTSD, what’s the pathway/differences to mental health professionals, how do we heal, and how do we get people back to work are all topics we cover, plus more!

On this month’s episode, we’re joined by Dr. Louisa Marion-Bellemare to discuss Suboxone (buprenorphine/naloxone) and managing patients who use illicit and controlled drugs. During the episode, you’ll hear us cover:

• history of the drug crisis 
• lay of the land of the current drug crisis
• historical treatments
• opiate pharmacology 
• healthcare utilization 
• stigma 
• suboxone use 
• patient advocacy

Tune in as we chat with Dr. Vera Etches, Medical Officer of Health from Ottawa Public Health about coronavirus, how OPH is preparing, and how local healthcare partners are working together

Not all paramedics respond to just 911 calls. On today’s episode, we’re chatting with Matt Cruchet and Sgt. Gregory Hudson

Matt is a key member of the Country of Renfrew Paramedic Service’s Sierra Team – essentially their special operations arm.

Sgt. Hudson is a Search and Rescue Technician (SAR Tech) with the 424 Transport and Rescue Squadron based out of CFB Trenton. Covering more than 10 million sq km, the 424 Transport and Rescue Squadron has a huge responsibility for maritime and aeronautical SAR 

We hear about their own unique prehospital roles and responsibilities, then tie it all together using a real case study.

We claim to practice evidence-based medicine, but what does the evidence actually say about how we manage our cardiac arrests? Tune in to our discussion to find out

On this month’s episode, we are going to talk about prehospital blood administration with Dr. Peter Antevy

Some topics covered are:

Historical trauma management 

Blood

• why 
• blood components 
• administration ratios 
• blood type 

Blood administration

• who do we give blood to
• medical vs trauma (blunt vs penetrating) 
• elderly vs peds 
• vital sign parameters
• when do we administer it 
• how do we give it
• IO vs IV (size matters…)
• temperature 

Logistics

• how do we get it patient side
• cold chain storage
• temperature management 
• training (initial and ongoing)
• minimizing waste

Challenges

• consent
• religion
• administering to females of child bearing age
• transfusion reaction

Blood Adjuncts 

• TXA 
• calcium 
• other

What’s the data showing? Next steps 

In this episode of Critical Levels, we tackle frostbite with Dr. Maria Doubova, exploring its pathophysiology, symptoms, and treatment. From outdoor enthusiasts to vulnerable populations, frostbite affects diverse groups. Learn about early early recognition and management of frostbite - from mild frostnip to severe cases requiring advanced interventions - and the latest classification system to improve outcomes in this insightful discussion.

What You’ll Learn in This Episode:

What frostbite is and who is most at risk.

Symptoms and early detection techniques.

Frostbite classifications and their significance for prognosis.

Practical pre-hospital and hospital management strategies.

How frostbite overlaps with hypothermia and what to watch for.

Check out our first episode - a brief introduction to the new "Critical Levels" podcast series - a podcast directed at paramedics, for paramedics, with a Canadian and local bias.

Join us as we sit down with Critical Care Paramedic Natalie Lavergne with ORNGE - to discuss exactly that: critical care paramedicine and ORNGE, the Ontario air ambulance service.

In this episode, we cover:

What is a critical care paramedic and how are they different? 

What type of training/continuing education do they receive? 

What is ORNGE?

What types of calls do they attend? How do they attend? 

Optimizing the patient and scene for an ORNGE arrival 

How is the patient physiology changed by air transport? 

Scene calls vs. inter-facility transports. What do they do on route to prepare and what do they do once they’ve arrived?

Differences between ORNGE and other critical care providers

FAQs

More information about Ornge at 

https://www.ornge.ca/home

Join Dr. Roger Zemek, a pediatric emergency physician at the Children's Hospital of Eastern Ontario (CHEO) and researcher at the CHEO Research Institute discuss pediatric concussion. 

Detailed show notes can be found on our website: www.criticallevels.ca

Obstetrics. Arguably one of the scarier and uncomfortable things we do as paramedics, at least that’s what I think. 

If you’re looking for a way to make this tremendously stressful call just a little bit easier, then I think you’ve come to the right spot.

On this engaging episode of Critical Levels, we’re talking with Dr. Glenn Posner about the prehospital OB assessment, the uncomplicated birth, and how to handle some of the more complicated presentations in the field.

On this month’s episode, we discuss acute coronary syndrome (ACS) with Dr. Jess McLaren

We define ACS, we cover pathophysiology, and some common causes. Importantly we discuss the assessment of this patient population - paying attending to both objective and subjectives signs and symptoms. We spend some time talking about electrocardiograms, and perhaps most importantly, we chat about the management of this patient. 

On today's episode, we chat with Dr. Sheldon Cheskes, principal investigator of the landmark DOSE VF trial. 

In this study, published in the New England Journal of Medicine, Dr. Cheskes and his team wanted to evaluate DSED and VC defibrillation as compared with standard defibrillation in patients who remain in refractory ventricular fibrillation during out-of-hospital cardiac arrest.

In this episode, we walk through the study design, methodology, results, and perhaps most importantly, critically appraise the study to see how it works in the real world!

Timestamps:

02:48: Dr. Cheskes Intro

06:15: Study Intro

16:45: Patients

18:18: Intervention – Vector Change

25:45: Intervention – DSED

37:12: Comparison/Outcome

40:23: Results

54:15: Critical Appraisal

Tactical paramedicine, rescue task force, tourniquets, and massive life-threatening hemorrhage. Tune in to our conversation about these topics with Ben Jolicoeur of the Ottawa Paramedic Service Paramedic Tactical Unit 

Is it an accident or is it abuse? Tune in with Dr. Michelle Ward,  Division Head of Child and Youth Protection at the Children's Hospital of Eastern Ontario, as we discuss what paramedics need to know about child & youth maltreatment

Continue our conversation with Dr. Drennan about cardiac arrest care. We've reached the end of our algorithms - what can we do next? 

On this month’s episode, we dive deep into the world of military medicine with special forces paramedics, pulling back the veil of secrecy surrounding their vital work. Join us as we explore the unique challenges and high-stakes scenarios these elite medics faced on the front lines.

From advanced trauma care in combat zones to the mental resilience required for their demanding roles, our guests share their incredible experiences and insights.

What is CANSOFCOM/JTF 2?

What is your role within the team? What does training look like?

Medical vs trauma treatment

TCCC

MARCHE management 

Blood

Challenges of providing austere medicine 

Attributes of a great SOF medic

Equipment selection 

Mindset/attitude/standards

Relationship building

Paramedics receive little education on grief and bereavement. As paramedicine integrates palliative approaches to care, it has become very apparent paramedics are under-prepared for the crucial role they play in supporting patients and families in grief and recognizing and responding to their own grief reactions.

In this episode we talk to Cheryl Cameron and Tyne Lunn about how paramedicine is evolving to include the provision of palliative care. We start by defining palliative care and talk about how paramedics are well positioned to support patients with palliative care needs, already seeing this patient population in our routine 911 caseload, but needs to do better to align the care we provide with people’s wishes.

·      MyGriefToolbox as one strategy and tool to address gaps in education/supports for paramedics

·      Scale and spread of this approach across Canada

·      Importance of person, family and caregiver centered approach

·      Psychosocial support, system navigation, and compassion can be provided by all levels of paramedics

·      De-bunking some myths about providing palliative care

They’ll introduce us to MyGriefToolbox, a set of free resources that have been developed in collaboration with Canadian Virtual Hospice to support paramedics as we provide a palliative care approach and psychosocial support to grieving individuals, families, and caregivers.

On this month’s episode, we’re joined by Dr. Justin Mausz to discuss violence against paramedics. 

During the episode, you’ll hear us cover:

• How often are we seeing violence against paramedics
• What is violence? Is it different from harassment? Does intent matter? 
• Incident reporting
• How does it compare to other industries?
• What does violence against paramedics look like?
• How do we balance paramedic and patient safety?
• What do we do with this?
• PPE
• Policy development 
• External vs internal violence
• The value of research

On this month's episode, we chat with Matt Smith about wilderness medicine. 

As we shift from a high resource to a low resource setting, there are 3 main concepts to consider:

- Ideal to real

- High risk to low risk

- Stable to unstable

These concepts are important as we shift our practice and prepare ourselves. 

For this patient context, we need to focus on the things we can't replace, and learn to manage that.

Our approach to these patients need to be algorithmic, and focus on doing the basics well. Two mnemonics (H-E-M-P; A-B-C-D-E) are presented to help with our approach.

Lastly, hypothermia assessment and management is discussed.

In this episode, we sit down with Dr. Louis McNaughton-Filion, Regional Supervision Coroner for Eastern Ontario. We cover death investigations, what paramedics need to be aware of on suspicious scenes, and some of the pathophysiology/body changes after death.

“No statistical difference”

On today’s episode of Critical Levels, we chat with Dr. Ken Milne of the Skeptics’ Guide to Emergency Medicine (https://thesgem.com; @thesgem).

We start with a high-level discussion and literature and evidence, and then apply these concepts to ‘lyse’ and ‘bust’ some of the predominate prehospital myths.

Find links to the primary literature on our website.

We examine:

2:00 - The importance of primary literature

4:10 - Why? 

10:10 – Literature, critically appraising articles, & levels of evidence

13:20 – Evidence Based Medicine

17:30 – Guidelines & Protocols

22:22 – Epinephrine in Cardiac Arrest

28:30 – Sodium Bicarbonate in Cardiac Arrest

32:10 – Advanced Airways

36:10 – “Treat the patient, not the monitor”

42:05 – TTM (Targeted Temperature Management)

48:22 – “Be Skeptical”

51:15 – TBI Management/TXA

61:05 – Final Thoughts

After the War in Afghanistan, the Chief of Defence Staff of the Canadian Armed Forces decided to create a brand new forward aeromedical evacuation capability.

This is where our episode’s guest comes in. We speak with Dr. Leilani Doyle, Lt. Col. with the Canadian Armed Forces about her role in the creation of CMERT - the Canadian Medical Emergency Response Team.

Not only are we going to cover the development, roles, training, and capabilities of the team, we’re also going to discuss how to optimize battlefield medicine, and the challenges of providing high quality medical care from the resus bay in the back of the helicopter to the most austere military environments.

Lastly, we cover how the work being done in the military is impacting civilian prehospital care (e.g blood, TXA, invasive procedures, etc.).

On June 8th 2021, The Honourable Mr. Justice H.S. Arrell gave his judgment finding 2 Hamilton paramedics, Christopher Marchant & Steven Snively, guilty of failing to provide the necessaries of life to Yosif Al-Hasnawi (19), who died on December 2 2017.

In this episode, we chat with former paramedic and current lawyer Christopher Robertson, where we cover the background, the legal analysis, and what this precedent means to the profession.

On this month’s episode, we’re joined by Dr. Janice Tijssen to discuss pediatric cardiac arrest. During the episode, you’ll hear us cover:

The importance of our early interventions

What is cardiac arrest

• incidence/epidemiology
• etiology 
• risk factors/past medical history
• outcomes
• sociodemographics

Differences between adult and pediatric cardiac arrest

Simplifying our response

Symptomatic bradycardia

The importance of scene time

The importance of CPR/ventilation

IV vs IO, SGA vs ETT

Epinephrine  

PRIME study

Family presence during arrest 

Disposition

Pain is a condition that we often see in the prehospital world, yet for a variety of reasons, we're bad at treating it.

On today's episode with pain expert Dr. Samina Ali, we go through what pain is, pain assessment, barriers to providing analgesia, and then discuss how we actually treat pain, using both non-pharmacologic and pharmacologic interventions

The United Nations (UN) defines human trafficking (HT) as “the recruitment, transport, transfer, harbouring, or receipt of a person by such means as threat or use of force or other forms of coercion, abduction, fraud, or deception for the purpose of exploitation“.

What is human trafficking? How prevalent is it? What are the red flags? How can I use the history and assessment to raise my index of suspicion? How do I advocate for my patient?

Join our conversation with Dr. Lindsay Cheskes, EM Resident at The Ottawa Hospital, to learn the answers to these questions, and more!

Human trafficking: what do paramedics need to know?

On today's episode with Dr. Kyeremanteng, we're covering all things ROSC: what is ROSC? How do we optimize our patient's physiology (the A-B-Cs) post-arrest? What happens next - what's TTM, how does neuroprognostication happen? Lastly, we cover what is the impact to the healthcare system at large.

Thanks to Zoll Medical for sponsoring this episode!

Listen to part 1 of our conversation with Will Johnston about Calming the Chaos. In this episode, we cover some of the physiological responses to stress and it's the impact on team performance as well as individual performance, as well as how to mitigate that response. We also covered what makes up highly competent teams. Tune in soon for part 2 to continue the chat :)