American Farmers Confront a Mental Health Crisis

From Bloomberg:

The worst agricultural downturn since the 1980s is taking its toll on the emotional well-being of American farmers.

In Kentucky, Montana and Florida, operators at Farm Aid’s hotline have seen a doubling of contacts for everything from financial counseling to crisis assistance. In Wisconsin, Dale Meyer has started holding monthly forums in the basement of his Loganville church following the suicide of a fellow parishioner, a farmer who’d fallen on hard times. In Minnesota, rural counselor Ted Matthews says he’s getting more and more calls.

“Can you imagine doing your job and having your boss say ‘well you know things are bad this year, so not only are we not going to pay you, but you owe us’,” Matthews said by telephone. “That’s what’s happened with farmers.’’

Rural Hospital Closures Rise to Ninety-Eight

From Rural Health Voices:

After a brief break in rural hospital closures, the numbers began to rapidly rise this summer. The rash of closures has only continued as temperatures have dropped, leaving hundreds more rural American out in the cold. Just last week, two more rural hospitals closed, bringing the number of rural hospital closures up to 98 since 2010. Hundreds more are likely to follow. Currently, 46% of rural hospitals operate at a loss, compared to 44% in 2018 and 40% in 2017. Due to financial strains, nearly 700 rural hospitals are financially vulnerable and at high risk of closure.

Reducing Emergency Department Length of Stay

From JAMA:

Bottom Line

  1. Multidisciplinary engagement of both frontline and executive staff by ED leadership, coupled with clear standards and real-time data, are essential to the success and sustainability of any improvement work.

  2. Separating patients with low- and high-acuity conditions in the ED can enhance the efficiency of managing both groups.

  3. Frequent review of performance metrics by frontline staff and hospital leadership facilitates real-time recognition of problems and evaluation of changes.

Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US

From the AAP:

BACKGROUND: Visits to the emergency department (ED) for psychiatric purposes are an indicator of chronic and acute unmet mental health needs. In the current study, we examined if psychiatric ED visits among individuals 6 to 24 years of age are increasing nationwide.

METHODS: ED data came from the 2011–2015 National Hospital Ambulatory Medical Care Survey, a national survey of ED visits across the United States. Psychiatric ED visits were identified by using the International Classification of Diseases, Ninth Revision and reason-for-visit codes. Survey-weighted logistic regression analyses were employed to examine trends in as well as correlates of psychiatric ED visits. Data from the US Census Bureau were used to examine population rates.

RESULTS: Between 2011 and 2015, there was a 28% overall increase (from 31.3 to 40.2) in psychiatric ED visits per 1000 youth in the United States. The largest increases in psychiatric ED visits per 1000 US youth were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A large increase in suicide-related visits (by 2.5-fold) was observed among adolescents (4.6–11.7 visits per 1000 US youth). Although psychiatric ED visits were long (51% were ≥3 hours in length), few (16%) patients were seen by a mental health professional during their visit.

CONCLUSIONS: Visits to the ED for psychiatric purposes among youth are rising across the United States. Psychiatric expertise and effective mental health treatment options, particular those used to address the rising suicide epidemic among adolescents, are needed in the ED.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department

From the Annals of EM:

Study objective

Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department.


This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%.


We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction.


ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.

Vermont state trooper revived after apparent drug exposure

From NBC:

Flansburg stopped a vehicle late Friday night for a traffic violation in Leicester, about 40 miles south of Burlington. Flansburg later observed a passenger swallow a small bag he later said contained cocaine.

In searching the car, Flansburg located and collected as evidence a small quantity of heroin in a baggie, an empty plastic baggie and a syringe. The passenger, who was checked out by doctors, but needed no medical care, was taken into custody by other troopers and later charged with heroin possession.

While transporting evidence, Flansburg began to feel ill and he collapsed in the parking lot of the barracks. Troopers administered two doses of Narcan. He received a third dose on the way to the hospital.

The ER was closed. The ambulance wasn’t close. This is how you die in rural Mississippi.

From the Clarion Ledger:

Shyteria Shardae “Shy” Shoemaker was sitting on a bed in her Chickasaw County home when it happened.

The 23-year-old mother, who family members say could talk to just about anyone she met and who loved to argue, couldn’t breathe.

Shoemaker gasped for air, stood up and opened the bedroom door.

Then, she collapsed.

Shoemaker, who was pregnant with her second child, was only an eight-minute drive from Trace Regional Hospital in Houston when 911 was first dialed. But that didn’t matter since the hospital shuttered its emergency room in 2014.

The only ambulance in the county that night was almost a half-hour away.

More than an hour later, in a neighboring county, Shoemaker was pronounced dead.