Episodes 

In this episode, we will explore the presentation of sexual abuse, sexual assault and sex trafficking in the pediatric setting and discuss trauma and violence informed care practices to guide paramedic care.

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.

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

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

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

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.

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 are the
incidence, epidemiology and
etiology of pediatric cardiac arrest. What are the risk factors, outcomes and sociodemographics.The differences between adult and pediatric cardiac arrest and the importance that scene time plays into running a successful resuscitation.

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

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.

On this month’s episode, we discuss acute coronary syndrome (ACS) with Dr. Jesse 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 Drs. Ariel Hendin & Derek Lanoue about all things anaphylaxis, an acute, life-threatening systemic allergic reaction that may have a wide range of clinical manifestations.

During our conversation, we discuss diagnostic criteria, compare/contrast to allergies, cover the definition of anaphylaxis, cover treatment, discuss disposition/discharge, and cover some of the other intricacies of the disease.

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, and 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.

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.

Links to the primary literature included.

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.

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 that 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 episode, we’re breaking down the landmark DOSE VF study – DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF) – that was recently published in the NEJM with lead investigator Dr. Sheldon Cheskes.
Study Design: Cluster randomized controlled trial
Research Question: The objective of this trial (Double Sequential External Defibrillation for Refractory Ventricular Fibrillation [DOSE VF]) was 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.

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

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!

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.

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

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.

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?

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.

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.

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.

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.

CVA are amongst the top 5 causes of death, and number 1 cause of disability in N.A. Given the associated morbidity and mortality, rapid recognition and aggressive management is of the utmost importance.

Join us as we chat with Dr. Grant Stotts to discuss all things in the prehospital world of stroke: What is a stroke? How do we diagnose it prehospitally? How should we be treating them? What happens once we get to the ED?

A vital part of Ontario’s health care system, Ornge provides high quality air ambulance service and medical transport to people who are ill or injured. In the air and on the ground, our job is to be there for patients, so they can get where they need to be.

Ornge serves more than 13 million people over one million square kilometres of land— the size of France, Spain and the Netherlands combined.

We have the largest air ambulance and critical care land ambulance fleet in Canada, and perform approximately 20,000 patient-related transports per year.

On June 8, 2021, the Honorable Justice Arrell gave his judgement finding two Hamilton Paramedics guilty of failing to provide the necessities of life in relation to a call they attended on December 2nd, 2017. This is potentially a precedent setting case not only for paramedics but for the greater health care community. On todays’ episode we analyze the case and what it means with former paramedic and current lawyer Chris Robertson.

Unlike any other health care professionals, paramedics have the unique opportunity in entering the homes of some of their patients. With this comes a certain responsibility and obligation to report any indications of risk, especially with pediatric populations. With pediatric populations sometimes it is difficult to determine what injuries can be caused by normal childhood behaviour, accidents, or child maltreatment.

In contrast to adult patients, pediatric patients do not follow simple rules and as such, there is no one “magic number” to use as a predictor for patient condition, such as SBP in adults. In contrast, the best predictor for pediatric patients is getting the whole picture. No one vital sign trumps, the other instead they all build on one another to provide a better picture of what is happening. The most important part of a pediatric call is knowing recognizing that they are sick and knowing which tools can be used to help them.

There are several theories that suggest why double sequential defibrillation and/or vector change defibrillation may be effective.

Energy theory: increased energy delivery allows for defibrillation of a critical mass of myocardium terminating the refractory VF.
Setting up theory: the first shock reduces the threshold and results in a more successful second shock.
Multiple vector theory: change in pads (or additional pads) changes the energy vector defibrillating parts of myocardium not adequately defibrillated in standard position.

high-quality BLS management of cardiac arrest is essential. This includes ensuring CPR and ventilation quality including the use of feedback devices and measuring and providing feedback of performance. Once the BLS stuff is taken care of, treatment/management should be dictated by the patient. This may or may not prioritize the airway.

Perhaps most important, is early access and early drug administration. The evidence points that IV access may be better than IO and that medications are still useful, especially early during the resuscitation.

Tactical paramedicine is the provision of prehospital medicine within a hostile environment, that requires knowledge of tactics, special equipment, and specialized personalized protective equipment (PPE). The PPE and the training, is really what separates this team from regular operations.

Emergency medicine and paramedicine, one can argue, are highly cognitive professions. One of the pitfalls to this specialty however is the level of risk involved.

Medical error is the 6th leading cause of death in North America, and some studies have shown that cognitive error or some flaw in decision making – as opposed to lack of knowledge – is present in about 95% of cases where there was a medical error. Moreover, The most recent institute of medicine report says, that as a patient, it’s not if you’ll be subjected to a diagnostic error, but when.

“Pandemics are in a rare and stressful time for health care providers with overwhelming caseloads, rapidly evolving information, and competing priorities of self-protection, while maintaining a high level of patient care.”

In this episode of Critical Levels Jason Buick discusses his recent research article COVID-19: What Paramedics Need To Know and attempts explain and bring some clarity to the many changes Paramedics have faced since the pandemic started. 

Across the world, every death investigation system is different – some are municipal, or state-based, but in Canada, it’s a provincial system. In Ontario, the system is the Office of the Chief Coroner and the Ontario Forensic Pathology Service. In Ontario, all Coroners are licensed physicians (same with PEI), while in other provinces, they are not necessarily physicians

Importantly, the motto of The Office of the Chief Coroner for Ontario is: “We speak for the dead to protect the living”

Part 2 – Paramedics work in a an extremely unique clinical environment. We’re tasked with working in small ad-hoc teams, we’re required to make decisions that can have significant impacts on patient outcomes, and all of this often occurs in novel environments with many external stressors – making these decisions that much more difficult.

Paramedics work in a an extremely unique clinical environment. We’re tasked with working in small ad-hoc teams, we’re required to make decisions that can have significant impacts on patient outcomes, and all of this often occurs in novel environments with many external stressors – making these decisions that much more difficult.

In December 2019, cluster of cases of pneumonia was reported in Wuhan, China and the cause of this cluster was a new coronavirus not previously found in humans.

Coronaviruses are a large group of viruses, that are shaped like a crown. Crown in Latin is “corona”, hence the name coronavirus, and they have been around for decades. Generally, symptoms tend to be mild, and in fact coronaviruses are one of the main causes of the common cold. Every once in a while, we see a more severe strain of the virus, such as SARS (severe acute respiratory syndrome) which arose from civet cats in China in 2003, and MERS (Middle East respiratory syndrome), which was identified in Saudi Arabia in 2012, which are also coronavirus’.

Respiratory pathologies are the most common ED complaint, other than fever, and the most likely reason why children may deteriorate rapidly – In this episode we explore 3 common respiratory pathologies in paediatric patients: Croup, Bronchiolitis and Asthma.

Approximately 1000 kids come to CHEO each year (~3/day) with new concussions, and more kids are being diagnosed with concussion than ever before.

The number of kids diagnosed with concussions has quadrupled over the past 10 years. That doesn’t mean 4 x as many kids are having head injuries, but the awareness and the understanding that these kids need medical assessment/follow-up has increased. More kids are not necessarily getting hurt, but more kids are getting seen. Interestingly, there was a big spike in the number of ED visits related to concussion after Sidney Crosby’s concussion in 2011.

Hello everyone and welcome to “Critical Levels” - a new podcast dedicated to having critical conversations in paramedicine. This episode is a brief introduction to the new “Critical Levels” podcast series - a podcast directed at paramedics, for paramedics, with a Canadian and local bias. Please reach out – email us at info@criticallevels.ca, or connect via social media – I welcome any questions, comments, ideas, and any feedback you have so that we can make this...