Critical Levels

In this episode of Critical Levels, Zach sits down with Dr. Anna-Maria Carvalho, a Royal College–certified emergency physician with a subspecialty in aviation medicine, to unpack what really happens when someone asks, "Is there a medical professional on board?" From the physiology of flying at 36,000 feet to the realities of managing cardiac arrest in a cramped aircraft cabin, this episode tackles the fears, logistics, and practical considerations of in-flight medical emergencies—especially for paramedics, nurses, and physicians who may be called upon to help. ✈️ What We Cover 🫁 The Physiology of Flight Why cabin altitude means we're all mildly hypoxic (normal sats ~92–93%) How hypoxia increases heart rate, blood pressure, and sympathetic tone Why alcohol hits harder in the air Why tomato juice tastes better at altitude The risk of DVTs and who's most vulnerable Barotrauma, ear pain, and when a perforated eardrum can occur 🚨 In-Flight Medical Emergencies Incidence: ~1 in 600 flights Most common categories: Neurologic Cardiac Respiratory Gastrointestinal The realities of flying with chronic disease Why more emergencies are happening as more people travel 🧰 What's in the Emergency Medical Kit? AED (separate from the medical kit) Oxygen & Ambu bag Oral airways (intubation equipment varies by airline) IV supplies (limited fluids, but enough for medication administration) Medications: epinephrine, steroids, bronchodilators, benzodiazepines, antipsychotics, glucose agents, and more BP cuff (palpated pressures only—too noisy to auscultate!) Pulse oximeter (remember: 93% can be normal) 📡 Ground-Based Medical Support Most airlines consult 24/7 emergency physicians on the ground Volunteers don't make diversion decisions—the captain does Diversions involve significant operational and logistical consequences In-flight volunteers are there to assess, stabilize, and communicate 🫀 Cardiac Arrest at 36,000 Feet Move to a bulkhead/galley if possible Call for additional medical volunteers Early AED use CPR until ROSC, exhaustion, or medical futility Diversion decisions are collaborative and situational ⚖️ The Legal Question Good Samaritan protections apply Act within scope No gross negligence or willful misconduct No one has ever been successfully sued for assisting with an in-flight medical emergency You are not responsible for diversion decisions 🕊️ When Death Occurs In Flight Resuscitation attempts may cease when appropriate Diversion is not automatic Flight crew are trained to manage these situations professionally and discreetly 🔑 Key Takeaways You already have the skills. The environment is different—but the fundamentals are the same. Recognizing sick vs. not sick is incredibly valuable. Most in-flight volunteer diagnoses are ultimately confirmed in hospital. About 60% of passengers improve with basic stabilization. You are protected when acting in good faith and within scope. If you've ever hesitated to answer that overhead call, this episode may change your perspective.

In this episode, Zach sits down with Dr. Ian Drennan and Dr. Sheldon Cheskes to dissect the newly released 2025 AHA and ILCOR resuscitation guidelines. They break down the evidence, controversies, and real-world implications for paramedic practice. Key Topics Covered 🔹 How guidelines are actually created 🔹 Mechanical CPR 🔹 Heads-Up CPR 🔹 IV vs IO Access 🔹 Medications 🔹 Defibrillation Science 🔹 Airway Management 🔹 Post Cardiac Arrest Care

Delta Air Crash: Paramedics on the Frontline of a Mass Casualty Incident In this gripping episode of Critical Levels, host Zach Cantor sits down with Ornge Critical Care paramedics Colin and Darren to discuss their response to the February 2025 Delta crash at Toronto's Pearson International Airport. From the initial plume of smoke spotted mid-flight to interagency coordination on the ground, they share how training, adaptability, and teamwork guided decisions under extreme pressure. Key Topics: • First impressions from the air and immediate decision-making • Mass casualty triage in an unpredictable environment • The challenges of communication across multiple agencies • The value of leadership, adaptability, and humility under stress • Interdisciplinary and interagency debriefs: lessons learned • Mental health, recovery, and supporting paramedics after major incidents Takeaway: Mass casualty incidents test every part of the emergency response system. Preparation, communication, and collaboration—not just within one service, but across all responders—make the difference.

Neonates are one of the most feared patient populations in EMS—and for good reason. In this episode, Zach Cantor talks with Anthony Iacolucci, a pediatric respiratory therapist and paramedic, about how to confidently approach neonatal calls. Anthony introduces NEO SECRETS, a practical acronym covering the top 10 causes of neonatal illness, and offers insight into assessment, common pitfalls, and key treatment considerations. NEO SECRETS Breakdown: • N – Inborn errors of metabolism • E – Electrolyte abnormalities • O – Overdose or toxic exposure • S – Sepsis (the leading cause of neonatal mortality) • E – Endocrine crisis (e.g., hypoglycemia, adrenal insufficiency) • C – Cardiac conditions (cyanotic vs. acyanotic presentations) • R – Recipe or formula mishaps (e.g., dilution errors leading to hyponatremia) • E – Enteric emergencies (e.g., malrotation with volvulus, gastroenteritis) • T – Trauma, including accidental and non-accidental injuries • S – Seizures (often subtle and hard to recognize in neonates) Key Takeaways: • Neonates are not small adults or even small pediatric patients—they are physiologically distinct and highly vulnerable. • Early identification of sepsis, cardiac issues, and metabolic errors can save lives. • Paramedics should rely on strong assessment skills, detailed history-taking, and high suspicion for uncommon causes. • Videos, glucose checks, pre-ductal saturations, and detailed caregiver interviews are essential field tools. • Understanding neonatal physiology, presentation timelines, and risk factors improves both confidence and outcomes. Why Listen: If you've ever felt unprepared when faced with a neonatal call, this episode provides a clear, practical, and memorable guide to the top threats to neonates—and how to recognize and respond to them in the field.

🔹 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?

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.

How prepared do you feel to care for children and youth who have experienced abuse or assault? 1 in 10 Canadians (7.8%) over 15 report at least one instance of sexual abuse before age 15 (Stats Canada) Up to 88% of people being trafficked access health care (Polaris Project) - many don't disclose they are being trafficked Highest rates of intimate partner violence occur between age 12-24 (Stats Canada) Young people aged 15-24 years have the highest rate of sexual assault (Gov't of Canada) 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. We will also discuss: - gaps and barriers to care in this population - practical tips to guide trauma and violence informed care including what not to ask - role of the Sexual Assault Nurse Examiner and care available in Ontario through the Network of Sexual Assault and Domestic Violence Treatment Centers (SADVTC's) - mandatory and consent based reporting - prevelence and risks of strangulation in the context of sexual assault and intimate partner violence and the importance of thorough assessment and imaging

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'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

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

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.

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