Critical Levels

Shift work is a core part of paramedicine, but growing evidence shows it carries real long-term health risks.

In this episode, with Dr. James Gilbertson, we explore the science behind circadian rhythm disruption, the impacts of sleep deprivation, and how lifestyle and longevity medicine can help mitigate risk.

Key Topics Covered:

• Why shift work affects lifespan and health outcomes
• Circadian rhythm disruption explained
• Links between shift work and:
  • Cardiovascular disease
  • Cancer risk
  • Mental health challenges
• Sleep optimization strategies for shift workers
• Exercise and longevity evidence
• Nutrition approaches that work on shift
• Social connection and cognitive health
• Practical, realistic habits for paramedics

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.

🫁 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

• 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.

On this unique episode, we attend the First60 Toronto Resuscitation Conference and interview several of the speakers. For more detailed information, check out our website, criticallevels.ca

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.

🔹 How guidelines are actually created 🔹 Mechanical CPR 🔹 Heads-Up CPR

🔹 IV vs IO Access

🔹 Medications 🔹 Defibrillation Science

🔹 Airway Management 🔹 Post Cardiac Arrest Care

In this episode, we explore the science, history, and frontline application of End-Tidal CO₂ (ETCO₂) — a tool that offers real-time insight into ventilation, perfusion, and metabolism. Danny and Rance from DnR explain how paramedics can use ETCO₂ to assess and guide care across multiple patient presentations.

Key Takeaways:

• ETCO₂ is the sixth vital sign — reflecting ventilation, perfusion, and metabolism in real time.

• Capnography vs. Oximetry: SpO₂ shows what was happening; ETCO₂ shows what's happening now.

• Waveform interpretation: Alpha and beta angles reveal underlying pathology like bronchospasm, obstruction, or air trapping.

• Clinical uses:

  • Tube confirmation: Real-time verification in 6 breaths or less.

  • CPR: Values

  • Ventilation: Real-time feedback for rate and volume.

  • Head injuries: Maintain normocapnia; hyperventilate only during herniation.

  • Sepsis, trauma, PE, and DKA: Trending ETCO₂ helps identify metabolic and perfusion problems.

• Practical tips:

  • "Filter first, end-tidal to the sky."

  • Inline sensors outperform sidestream for accuracy.

  • End-tidal is not just for intubated patients — use it with nasal prongs for sedation and respiratory monitoring.

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.

What is a paramedic — really?

In this thought-provoking episode of Critical Levels, Zach sits down with Dr. Alan Batt to unpack the evolving identity, responsibilities, and future of the paramedic profession. Together, they explore the disconnect between what paramedics are trained for versus what they actually do, the consequences of outdated education models, and the urgent need for professionalization and system-level change.

They discuss:

• Why current training doesn't match real-world workload

• How we define scope, identity, and autonomy in modern paramedicine

• The concept of career pathways beyond clinical work

• What regulatory independence could look like

• And why it might finally be time for paramedics to "move out of their parents' basement"

Whether you're a frontline clinician, educator, leader, or student, this episode challenges assumptions and sparks a critical conversation about the future of paramedicine in Canada and beyond.

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.

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.

🔸 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?