Dr. Shannon Fernando is an intensivist at Lakeridge Health and a prolific researcher with over 150 publications. Known for his work in outcomes-based research across critical care, he joins us to discuss long-term outcomes after cardiogenic shock.

About the Episode:

This episode is part of our cardiovascular critical care series and explores what happens after the ICU for patients who survive cardiogenic shock. We unpack quality of life, functional outcomes, mental health, and the hidden burdens on both patients and caregivers. Dr. Fernando provides key data insights from his large cohort studies and shares reflections from ICU follow-up clinics. We also dive into the challenges of prognostication and how to communicate realistic expectations to families.

Topics Covered

Defining Long-Term Outcomes:

• Beyond survival: functional independence, mental health, cognition, and system resource use.

Key Findings from Ontario Cohort

• 42% of cardiogenic shock survivors require increased levels of care

• 15% die within a year post-discharge

• Modest impact of revascularization or mechanical support on long-term outcomes

Morbidity and Quality of Life

• Loss of independence and inability to return to work

• High incidence of PTSD, depression, and caregiver burden

• Delayed functional recovery and unmet expectations

Prognostic Factors and Predictive Markers

• Frailty as a key indicator

• Pre-existing mental health as a predictor of post-ICU mental health outcomes

• In-hospital arrest characteristics: rhythm, downtime, comorbidities

ICU Follow-Up Clinics

• Value in knowledge translation and emotional support

• Real-world insights on functional recovery and patient satisfaction

• Common patient sentiment: gratitude mixed with trauma

• Communication with Families

• Avoiding value imposition

Emphasizing trajectory over fixed timelines

• Balancing hope with realism

Rethinking Endpoints in Research

• Limitations of 28-day mortality

• Need for patient-centered, long-term functional outcomes

• Trajectory-based data over snapshot metrics

• Knowledge Translation as the Intervention

Equipping clinicians and patients with realistic expectations

• Normalizing psychological responses

• Shaping future research directions around lived experience

In this episode, recorded live at CCCF 2024, we sit down with Dr. Emilie Belley-Côté, a cardiac intensivist, researcher, and clinical trialist from McMaster University, to unpack cardiogenic shock: the SCAI classification.

Whether you're in the ED, cath lab, or ICU, the SCAI (Society for Cardiovascular Angiography and Interventions) stages offer a common language to describe the severity of cardiogenic shock, guide escalation of care, and improve outcomes through structured assessment.

Dr. Belley-Côté walks us through:

• The five SCAI stages (A through E): what they mean and how they’re used.

• How this classification system improves communication between specialties.

• The importance of recognizing patients in pre-shock (Stage B) before they deteriorate.

• Real-world application: how SCAI staging intersects with clinical signs, biomarkers, and hemodynamic monitoring.

• Where the SCAI classification fits in research, including trials evaluating mechanical circulatory support and advanced heart failure therapies.

With Dr. Belley-Côté’s clear explanations and insights from the front lines of cardiac critical care, this episode is essential listening for anyone managing unstable cardiac patients.

In this episode, we’re joined by Dr. James Downar, a leading Canadian voice in palliative and critical care, for a wide-ranging discussion on the emerging role of psychedelics in managing psychological and existential distress.

Psychedelics have gone from fringe to forefront in recent years, and we dig into what that shift might mean for patients facing critical illness or the end of life.

What psychedelics are and how they work

• Substances like psilocybin, LSD, ketamine, and MDMA

• Key effects: altered perception, ego dissolution, and emotional insight

• Risks and benefits in vulnerable populations

Psychedelic-assisted therapy: structure and process

• The three-phase model: preparation, the session itself, and integration

• Micro dosing vs. full therapeutic sessions

• Where current evidence stands

Potential applications in critical care and palliative medicine

• Helping patients process fear, isolation, and suffering

• How psychedelics differ from traditional symptom management tools like opioids

• Limitations in advanced illness due to physiological concerns

Research and implementation challenges

• Problems with study design and placebo controls

• The importance of ‘set and setting’

• Defining success in existential or spiritual distress

Ethical considerations and clinical integration

• Balancing innovation with compassion and caution

• Avoiding reductionism: why psychedelics should complement—not replace—human care

• The future role of these therapies in ICU and palliative settings

Recorded live at the Canadian Critical Care Forum 2024 in Toronto, this episode dives into the complex world of ischemia-reperfusion syndrome — the paradox where restoring blood flow causes further injury. We explore the underlying mechanisms, clinical implications, and future directions in managing this phenomenon.

Joining us for the third time is Prof. Mervyn Singer, ICU physician, researcher, and thought leader in critical care physiology. Known for challenging dogma and making complex science accessible, Prof. Singer unpacks this important topic with clarity and insight.

Dr. Mike Christian is a critical care and pre-hospital medicine specialist with extensive experience in aeromedical transport and military medicine. His diverse career spans work as a paramedic, internal medicine and critical care training, and roles as a flight physician with London Air Ambulance and the Canadian military. He is a leading advocate for integrating interprofessional teams and advancing physician-led pre-hospital care in Canada. Currently, he is involved in the MedResponse BC initiative, which aims to enhance critical care delivery outside of hospitals.

In this episode, Peter and Leon sit down with Mike to explore the evolving landscape of pre-hospital critical care. From his unconventional career path to the integration of AI in emergency response, he shares insights on improving outcomes in pre-hospital medicine and the lessons Canada can learn from global high-performance systems.

Key Topics & Chapters

Mike’s Career Journey

• From paramedic to physician: an unconventional path

• Military and aviation medicine experience
• The shift to leadership in pre-hospital care

Pre-Hospital Critical Care: Canada vs. The World

• How Canada’s HEMS (Helicopter Emergency Medical Services) differs from global models
• Lessons from the UK, Australia, and Denmark
• The role of AI in dispatch and triage

The Role of Physicians in Pre-Hospital Medicine

• The evolving need for physician-led care outside the hospital
• The impact of interprofessional teams on survival rates
• Mentorship, coaching, and cultural change in pre-hospital systems

The Role of the Physician in Pre Hospital Medicine.

• AI-powered dispatch and GoodSAM app in improving CPR and trauma response
• Scoop and run vs. stay and play: What actually saves lives?
• Addressing Canada’s geographical challenges with rural and remote care

Future Directions in Pre-Hospital Medicine

• The rise of telemedicine and virtual ICUs
• Developing triage physicians and training programs
• MedResponse BC: A new model for interprofessional pre-hospital care

Keywords:

Pre-hospital care, critical care transport, HEMS, trauma response, paramedics, physician-led pre-hospital medicine, telemedicine, AI in emergency medicine, interprofessional teams, rural emergency care, GoodSAM app, London Air Ambulance, MedResponse BC.

Links of Interest:

1. CCCF Presentation:  https://youtu.be/MVDHaYaZRSI  (Web view)
2. Recent Publication:  https://doi.org/10.1186/s13049  (Web view)

In this episode, hosts Leon Byker and Peter Brindley are joined by Dr. Elizabeth Viglianti, an assistant professor at the University of Michigan, Pulmonologist and Critical Care Specialist, to discuss the crucial issue of gender based harassment in medicine.

Gender-Based Harassment refers to any unwelcome behavior, comment, or conduct that demeans, intimidates, or disadvantages someone based on their gender or gender identity. This can include derogatory remarks, exclusion, stereotyping, unequal treatment, or threats, whether or not the behavior is sexual in nature. In the workplace, it undermines professional dignity and contributes to a hostile or inequitable environment.

Dr. Viglianti shares her personal experience that led her to study this field, detailing the prevalence and impact of such harassment. The discussion covers key findings from the National Academies of Science, Engineering, and Medicine's framework on addressing sexual and gender based harassment, gender disparities, organizational factors contributing to harassment, and her research on the topic. Practical steps and recommendations for institutions to mitigate harassment are also explored.

00:00 Introduction and Welcome

01:08 Personal Experience with Sexual Harassment

03:06 Understanding Gender Based Harassment in Medicine

05:34 Organizational Factors and Solutions

07:50 Gender Disparities in Academic Medicine

17:42 Impact on Trainees and Reporting Challenges

24:46 Addressing Patient-Perpetrated Harassment

28:59 Practical Strategies and Training

32:26 Conclusion and Call to Action

We take another break as we are joined by Prof. Wendy Sligl, formidable ID and ICU doc, to discuss the critical topic of optimizing antibiotic prescribing in critical care settings.

The discussion covers various aspects of antibiotic use, including the importance of timely administration, the role of communication in ensuring effective treatment, and the nuances of dosing strategies such as loading doses and continuous infusions. The conversation also delves into the duration of antibiotic therapy, emphasizing the need for individualized treatment based on patient response.

Takeaways:

• Infections are common in intensive care units, and sepsis is a life-threatening condition.
• Identifying the clinical syndrome is crucial for appropriate antibiotic therapy.
• Empiric therapy is often necessary before culture data is available.
• Timely administration of antibiotics is linked to better patient outcomes.
• Communication among healthcare teams is essential for effective antibiotic delivery.
• Loading doses can help achieve therapeutic levels quickly in critically ill patients.
• Continuous infusions of certain antibiotics may improve clinical outcomes.
• Shorter courses of antibiotics can be as effective as longer ones.
• Monitoring patient response is key to adjusting antibiotic therapy.
• Consulting infectious disease specialists can enhance treatment strategies.

Chapters:

00:00

Introduction to Antibiotic Optimization

01:07

Understanding Infections and Sepsis

02:47

Emergency Room Protocols for Antibiotic Administration

04:56

Identifying Sepsis and Administering Antibiotics

06:33

Communication and Timeliness in Antibiotic Delivery

08:42

Optimizing Antibiotic Dosing Strategies

10:59

Pharmacodynamics and Continuous Infusions

12:44

Duration of Antibiotic Therapy

18:52

Monitoring and Adjusting Antibiotic Treatment

21:39

The Debate on Antibiotic Duration

26:37

Specific Infections and Treatment Duration

31:24

Practical Strategies for Antibiotic Stewardship

32:43

Rapid Fire Questions on Antibiotic Use

Following the discussion on ECLS in AMI and cardiogenic shock, we go on to discuss eCPR for cardiac arrest specifically. This episode was recorded live at the Critical Care Canada Forum 2024 as part of our special series on cardiac intensive care.

Our guest is Dr. Darryl Abrams, Associate Medical Director and Director of Research for the Medical ECMO Program at New York-Presbyterian/Columbia University. Dr. Abrams joins us for an in-depth discussion on the current state and future direction of extracorporeal cardiopulmonary resuscitation, or eCPR.

We dive into the complex world of eCPR in refractory cardiac arrest, starting with a breakdown of the three landmark trials that have shaped the field: the ARREST trial, the Prague OHCA trial, and the INCEPTION trial. Each study offers a unique perspective, from the dramatic early findings of ARREST to the pragmatic design of Prague OHCA and the sobering multicenter outcomes of INCEPTION.

A major theme throughout the episode is the role of system design. Dr. Abrams emphasizes the importance of minimizing low-flow time, rapid cannulation, and consistent team expertise—factors that can make or break the success of eCPR.

We also explore the ethical and practical considerations that come with rolling out such a resource-intensive intervention, including the balance between innovation and equity. Is it fair that access to eCPR may depend on geography or institutional resources? And how do we make meaningful improvements in survival when only a few centers can offer this advanced care?

The episode closes with a practical lens: how should clinicians approach building an ECMO program? What are the essential pieces that need to be in place before considering eCPR? And how do you select patients in a way that balances risk, benefit, and system capacity?

Chapters:

• Introduction and guest welcome

• Setting the scene: What is eCPR and why now?

• The ARREST trial: Small study, big impact

• The Prague OHCA trial: Early randomization, broader population

• The INCEPTION trial: Multicenter reality and negative results

• Comparing the evidence: Why do outcomes differ?

• Low-flow time and speed of cannulation

• The role of meta-analyses and what they do (and don’t) tell us

• Opportunity cost: What are we giving up to fund eCPR?

• Duration of support: How long is too long?

• Will there be another trial? Challenges of equipoise

• Building a responsible eCPR program

• Patient selection: Who qualifies and why?

• Cannulation techniques and adjunct devices

• System design: U.S. vs. Canada vs. U.K.

• Ethical concerns and access inequities

• Guidelines and final takeaways

In this episode, recorded live at the Critical Care Canada Forum in Toronto, we dive into extracorporeal life support (ECLS) in cardiogenic shock, with Dr Sean van Diepen.

He is an Associate Professor at the University of Alberta, Co-Director of the CCU at the Mazankowski Alberta Heart Institute, and a leading voice in cardiac critical care.

Join us as we explore the evolving landscape of mechanical circulatory support, the latest evidence from the DANGER and ECLS-SHOCK trials, and the complexities of patient selection.

Key Topics Covered:

1. The Evolution of ECLS in Cardiogenic Shock

• The 25-year gap since the last positive cardiogenic shock trial.

• How mechanical circulatory support expanded despite limited evidence.

2. The DANGER Trial – Impella in AMI-Associated Cardiogenic Shock

• Mechanism and function of the Impella device.

• Trial results: 20% mortality reduction at 180 days.

• Complications: Limb ischemia, hemolysis, and high costs.

• Real-world application: Who actually qualifies?

3. ECLS-SHOCK Trial – ECMO for Cardiogenic Shock

• A "negative" trial, but a crucial wake-up call.

• No mortality benefit but significantly higher complication rates.

• Controversies: Inclusion of cardiac arrest patients and transition to destination therapy.

• Future directions: Can patient selection improve outcomes?

4. ECPR – Extracorporeal Support in Refractory Cardiac Arrest

• Review of the ARREST, PRAGUE, and INCEPTION trials.

• Why the evidence remains unclear and institution-dependent.

• The role of high-volume ECMO centers and standardized pathways.

5. The Future of ECLS – Cost, Ethics, and Decision-Making

• How should institutions decide who gets ECMO?

• The role of cardiogenic shock teams.

• Could AI play a role in decision-making?

• The challenge of resource allocation in a single-payer system.

Key Takeaways:

✅ Impella shows promise in carefully selected AMI shock patients but is costly and high-risk.

✅ ECMO for cardiogenic shock remains controversial—patient selection is key.

✅ ECPR is promising but needs further trials and structured implementation.

✅ Cardiogenic shock management should be a team decision, not an individual one.

🔊 Listen now and join the conversation on the future of cardiac critical care!

We’re taking a break from our Cardiac Critical Care series to bring you a conversation with one of the most influential figures in medicine.

Peter had the huge privilege of interviewing Major General Tim Hodgetts, the recently retired, most senior medical advisor in the UK forces.

Hodgetts shares his remarkable journey in transforming emergency medicine from its infancy to maturity, detailing poignant experiences from his early career that steered him towards this specialty. The discussion ranges from Hodgetts' pioneering efforts in combat casualty care, the evolution of battlefield first aid, and innovative medical practices in conflict zones, to his concepts on leadership, international collaborations, and coping with trauma.

The segment also touches on Hodgetts' recent retirement and his ongoing contributions to medical and military communities through teaching, charity work, and writing.

Chapters:

00:00 Introduction and Guest Overview

02:56 Early Career and Influences

06:25 Pioneering Emergency Medicine in the Military

08:13 Revolutionizing Combat Casualty Care

17:55 International Collaboration and Cultural Insights

30:31 Leadership in Crisis

35:35 Coping with Trauma and Personal Reflections

39:43 Retirement and Legacy

42:29 Conclusion and Final Thoughts

This has been one of my absolute favorite podcasts to produce! What an honor to have Major General Tim Hodgetts join us on the Critical Care Commute!