Artificial Intelligence in Emergency Medicine

Artificial Intelligence in Emergency Medicine

Progressing through my medical training, I have witnessed the progression of paper-based medical records, all the way to different forms of electronic medical records, let alone intelligence infused medical records. It is safe to say that health informatics has evaded the way we practice medicine in all its disciplines and all across health care systems.

Artificial intelligence (AI) describes the capability of a machine to learn human cognitive functions and learning. AI applications in healthcare have brought in a paradigm shift powered by data mapping, data aggregation, analytics, and algorithmic techniques that can simulate our decision making as clinicians.

Furthermore, it can predict and suggest clinical pathways, data-based prognosis, and outcomes. AI has already been incorporated in major disciplines such as genetics, diagnostic imaging, neurology, and cancer. Yet, its path into emergency medicine (EM) is still paving its way for vast integration.

EM is a unique field of medicine, as its rich with varying paces of practice, the criticality of conditions, acuity of diagnostic decisions, and a highly stressful environment. It puts their providers consistently on a stretched active clinical decision making and interventions. Hence it is worth to foresee how AI can help enhance and complement the emergency department (ED) functions and add significant benefits to the EM physician’s daily tasks.

One of the main applications of AI is triage. Efficient triage can significantly enhance patients flow, lengths of stay, resource allocations, and risk stratifications. A study published by the American College of Emergency Physicians evaluated electronic triage (E-Triage) systems based on machine learning as opposed to the Emergency Severity Index (ESI). They found out that E-Triage can more accurately classify ESI level 3 patients and highlight opportunities to use predictive analytics to support triage and decision making. (1) A lot more studies established the use of different forms of electronic triage algorithms in improving patient distribution by clinical outcomes, and improved acuity predictions.

Another application of AI was significantly noted in diagnostic imaging departments. Offering remote clinics with restricted resources access to tools for reading imaging needed for active clinical interventions. Feeding into these AI systems is a wealth of comparative studies to predict and describe abnormal studies, and enhance its predictions. Let alone how efficient it would be in a fast-paced ED, getting approximate quick predictions that can be overseen by supervising radiologists.

Additionally, AI has been used in monitoring patient’s vitals, and predicting deteriorating clinical course, requiring early resource utilization and critical decision making in a timely manner. One significant example where AI and machine learning is heavily invested in is Sepsis, and mortality prediction scores, aiding at early detection, guiding clinical course and interventions by using simple data trajectories and analysis.

Another utilization of AI in an ED setting is predictions of Acute Coronary Syndromes, predicting the urgent need for revascularization from reading 12 Lead electrocardiographs (ECGs). A Study done in Keio University Hospital developed an AI model enabled to detect patients requiring urgent revascularization within 48 hours from only 12 leads electrocardiogram. (2) This significantly helps fast pace a lot of the grey cases we see and monitor in our ED’s, especially if validated with risk stratification scores we are already utilizing.

It is worth saying that there are still some barriers to the vast adoption of AI integration to EDs as it’s still a new evolving technology, with restrictive access, ethical discussions, safety, and needed regulations.

I personally have always had a utopian vision of how far health informatics can take our clinical practice, specifically EM. Injecting machine learning and AI into healthcare curates the perfect system that could decrease lengths of stay, intelligently and safely triage our patients, predict clinical course, suggest evidence-based treatment pathways, reduce medication errors and improve clinical outcomes. A more utopian version of my vision is how such a system can help remote and restricted regions requiring extensive resources to aid the reach of its care to underserved populations. It goes without saying that most of these do exist in one way or another, some are still being enhanced, and some are under the works for the next stage. We would foresee its progress nonetheless and slow infusion into our daily practice.

References and Further Reading

  1. Levin S, Toerper M, Hamrock E, et al. Machine-Learning-Based Electronic Triage More Accurately Differentiates Patients With Respect to Clinical Outcomes Compared With the Emergency Severity Index. Ann Emerg Med. 2018;71(5):565‐574.e2. doi:10.1016/j.annemergmed.2017.08.005
  2. Goto S, Kimura M, Katsumata Y, et al. Artificial intelligence to predict needs for urgent revascularization from 12-leads electrocardiography in emergency patients. PLoS One. 2019;14(1):e0210103. Published 2019 Jan 9. doi:10.1371/journal.pone.0210103
  3. McParland, Aidan. (2019). Applications of artificial intelligence in emergency medicine. University of Toronto medical journal. 96.
  4. Liu, Janny & Chen, Yongchun & Lan, Li & Lin, Boli & Chen, Weijian & Wang, Meihao & Li, Rui & Zhao, Bing & Hu, Zilong & Duan, Yuxia. (2018). Prediction of rupture risk in anterior communicating artery aneurysms with a feed-forward artificial neural network. European Radiology. 28. 10.1007/s00330-017-5300-3.
  5. Berlyand, Yosef & Raja, Ali & Dorner, Stephen & Prabhakar, Anand & Sonis, Jonathan & Gottumukkala, Ravi & Succi, Marc & Yun, Brian. (2018). How artificial intelligence could transform emergency department operations. The American Journal of Emergency Medicine. 36. 10.1016/j.ajem.2018.01.017.
  6. LIU, N., ZHANG, Z., WAH HO, A., HOCK ONG, M.. Artificial intelligence in emergency medicine. Journal of Emergency and Critical Care Medicine, North America, 2, oct. 2018. Available at: <http://jeccm.amegroups.com/article/view/4700&gt;. Date accessed: 22 May. 2020.
  7. Stewart J, Sprivulis P, Dwivedi G. Artificial intelligence and machine learning in emergency medicine. Emerg Med Australas. 2018;30(6):870‐874. doi:10.1111/1742-6723.13145
  8. Lee S, Mohr NM, Street WN, Nadkarni P. Machine Learning in Relation to Emergency Medicine Clinical and Operational Scenarios: An Overview. West J Emerg Med. 2019;20(2):219‐227. doi:10.5811/westjem.2019.1.41244
Cite this article as: Shaza Karrar, UAE, "Artificial Intelligence in Emergency Medicine," in International Emergency Medicine Education Project, June 5, 2020, https://iem-student.org/2020/06/05/artificial-intelligence-in-emergency-medicine/, date accessed: April 21, 2021

I woke up like that! – Bilateral Shoulder Pain

bilateral shoulder pain

Case Presentation

A 35-year-old male presented to fast track complaining of bilateral severe shoulder pain for one-day duration. He reports waking up like that, and not being able to move his shoulders much due to the pain.

He denied any recent falls, injuries, or direct trauma to his shoulders. He also denied any fever, rashes, skin changes, headaches, numbness or weakness. No further findings found upon review of systems. Past medical history revealed a history of epilepsy. Otherwise, he’s not on any medications and denies any known allergies.

Physical examination showed slim male, with flattened anterior shoulders and normal inspection of the skin overlying his shoulders. He had internally rotated upper extremities, flexed elbows, and arms held in adduction. Upon attempts on any passive or active test of the range of motion, he experienced reluctance and pain on external rotation or abduction of his shoulders. Bilateral Shoulder X-rays were obtained.

shoulder dislocation and fracture 1
shoulder dislocation and fracture 2

This patient had bilateral posterior shoulder dislocation, with associated fractures.

    • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
    • May go undiagnosed and often missed on physical exam and imaging
    • Epileptic seizures or electrical shocks, sports injuries are the most common causes.
    • Subtle signs on AP X-Ray include:
        • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
        • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
        • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
    • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.
    • Rounded posterior shoulder.
    • Prominent coracoid and acromion.
    • Palpable posterior humeral head.
    • Flattened anterior shoulder contour.
    • Neurovascular injuries
    • Rotator cuff tears
    • Osteonecrosis of the humeral head
    • Recurrent posterior shoulder instability or re-dislocation
    • Joint stiffness and post-traumatic osteoarthritis
    • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
    • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
    • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
    • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
    • Patients would require pre and post-reduction neurovascular examination and X-rays.
    • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
    • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
    • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.

Case Reflections

  • Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations.
  • Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature.
  • In the rare case of an asymmetrical bilateral dislocation, attention may be distracted to the more evident lesion, which is the anterior dislocation. This may lead to delayed diagnosis, especially in an unconscious patient in a post-ictal state.
  • In the present case, open reduction and internal fixation was performed.

References and Further Reading

  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53
  4. Wikem – Posterior Shoulder dislocation: https://www.wikem.org/wiki/Posterior_shoulder_dislocation
  5. Canadiem – Posterior Shoulder Dislocation: Radiographic Evidence : https://canadiem.org/posterior-shoulder-dislocation-radiographic-evidence/ 
  6. Meena S, Saini P, Singh V, Kumar R, Trikha V. Bilateral anterior shoulder dislocation. J Nat Sci Biol Med. 2013;4(2):499–501. doi:10.4103/0976-9668.117003S – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783813/
  7. Sharma A, Jindal S, Narula MS, Garg S, Sethi A. Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report. Malays Orthop J. 2017;11(1):74–76. doi:10.5704/MOJ.1703.011 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393121/

Acknowledgement

Credit and acknowledgment for Dr. Eelaf Elhassan for sharing the case.

Cite this article as: Shaza Karrar, UAE, "I woke up like that! – Bilateral Shoulder Pain," in International Emergency Medicine Education Project, December 13, 2019, https://iem-student.org/2019/12/13/bilateral-shoulder-pain/, date accessed: April 21, 2021

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Purple Rain: A Rare Spot Diagnosis

Purple rain urine

Case Presentation

A 70-year-old pleasant elderly male was brought in by his son, surprisingly complaining of purple-colored urine. The son got worried once he saw the purple urine bag and rushed his dad to the Emergency Department.

Upon further questioning, he reports a sweet elderly gentleman, known with previous cerebrovascular accidents, dysphasia and neurogenic bladder, that he has a urinary catheter inserted for. He claims that his dad has been having low appetite and passing less stool in the past week. Otherwise, he didn’t notice any other alarming symptoms. Furthermore, he denied noticing any fever, vomiting, behavioral changes indicating any pain, or recent change in his medications or diet. He had no known allergies as well. Upon full review of symptoms, chronic constipation was appreciated, otherwise, it was unremarkable.

Physical Exam

The patient was lying in bed, a bit uncomfortable, with an attached urinary catheter bag. He was afebrile and vitally stable. Proceeding with a focused physical examination, his chest was clear, and abdomen was soft, lax and nontender, furthermore, his skin had no rashes, and limbs were non-edematous. Inspecting the Urine Catheter Collection Bag, it did reveal Purple Urine Sediment.

Purple Urine in the Urinary Catheter Bag
Purple Urine in the Urinary Catheter Bag

Differential Diagnosis and Workup

Thinking of differential diagnoses of discolored urine, a purple urine bag is almost a spot diagnosis in our practice, definitely after ruling out any possible confounders if any.

We reassured the family and explained to them that we would order some blood and urine tests to confirm the diagnosis and start the appropriate treatment plan.

Case Management and Disposition

Laboratory test revealed mild leukocytosis with neutrophilia and mild elevated CRP. Otherwise, his urea, creatinine, liver function tests and electrolytes were reported normal.

Furthermore, a urine dipstick was done in the ED that reported positive for leukocytes, nitrites, and consequently sent to the lab for culture and full analysis which confirmed the diagnosis of a urinary tract infection (UTI).

We informed the son of the workup results, and a diagnosis of a UTI, given his leukocytosis, positive urine dipstick and the presence of a urinary catheter putting him at risk UTI. We reassured him about the urine color and explained the need to start antibiotics to cover the UTI, and changes the urinary catheter, which left us to explain only why was the urine purple unlike usual cases of UTI’s.

Critical Thinking and Take-home Tips

What is PUBS?

  • PUBS stands for Purple Urinary Bag Syndrome, first described in 1978.(1)
  • It is characterized by purple-colored urine collecting in urinary catheterization bags in patients known to prolonged urinary catheters. 
  • It presents asymptomatically and it is associated with urinary tract infections.
  • PUBS presents alarmingly to patients and family members, yet it is a benign phenomenon.

What causes the purplish discoloration of the urine in PUBS?

  • PUBS is associated with alkaline urine with a high bacterial load. 
  • It results due to UTI with certain bacteria producing sulphatases and phosphatases, which lead tryptophan metabolism to produce indigo (blue) and indirubin (red) pigments, a mixture of which becomes purple. (2)
  • Several bacterial species have been reported in association with PUBS including Providencia stuartii, Providencia rettgeri, Klebsiella pneumoniae, Proteus species, Escherichia coli, Enterococcus species, Morganella morganii, and Pseudomonas aeruginosa. (3)

What are the PUBS risk factors?

  • Female gender
  • Bedridden status or immobility
  • Chronic constipation leading to bacterial overgrowth
  • Renal disease
  • Prolonged urinary catheterization

What is PUBS management?

  • The reassurance of patient and family
  • Regular changing of urinary catheter
  • UTI Antibiotics coverage

What other urine colors should we be aware of?

  • Urine discoloration if a fairly common sign and indicates a certain pathology often that would need your attention as a physician.
  • Most urine discoloration is caused by food intakes, medications, dyes, or specific disease pathologies.
  • Red-colored urine is often related to hematuria, caused by multiple pathologies, including kidney stones, urinary tract injury or infection or cancer, amongst others.
  • Pink colored urine is often related to certain medications or dietary intake, i.e. beetroots and berries.
  • Brown or tea-colored urine indicates hepatobiliary disease or obstruction.
  • Green Urine can result due to medications such as Propofol.

What should I do when I encounter a discolored urine finding in my patient?

  • Remember always to have a systematic approach. 
  • Take a full history, including types or changes in medications history, diet changes, past medical history, and a full review of systems.
  • Keep in mind, some patients who are bedridden or elderly, communication and history taking might be limited; hence you will have to do your due diligence in gathering all the information you can get from family members, or available medical charts.
  • Your physical exam is a great asset as well in collecting information that can help you 

References and Further Reading

  1. Khan F, Chaudhry MA, Qureshi N, Cowley B. Purple urine bag syndrome: An Alarming Hue? A Brief Review of the Literature. Int J Nephrol 2011. 2011 419213. [PMC free article] [PubMed] [Google Scholar]
  2. Kalsi DS, Ward J, Lee R, Handa A. Purple Urine Bag Syndrome: A Rare Spot Diagnosis. Dis Markers. 2017;2017:9131872. doi:10.1155/2017/9131872
  3. Dilraj S. Kalsi, Joel Ward, Regent Lee, and Ashok Handa, “Purple Urine Bag Syndrome: A Rare Spot Diagnosis,” Disease Markers, vol. 2017, Article ID 9131872, 6 pages, 2017. https://doi.org/10.1155/2017/9131872.
  4. Al Montasir A, Al Mustaque A. Purple urine bag syndrome. J Family Med Prim Care. 2013;2(1):104–105. doi:10.4103/2249-4863.109970
  5. Traynor B P, Pomeroy E, Niall D. Purple urine bag syndrome: a case report and review of the literature. Oxford Medical Case Reports, Volume 2017, Issue 11, November 2017, omx059, https://doi.org/10.1093/omcr/omx059
  6. Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW. Purple urine bag syndrome in nursing homes: Ten elderly case reports and a literature review. Clin Interv Aging. 2008;3:729–34. [PMC free article] [PubMed] [Google Scholar]
Cite this article as: Shaza Karrar, UAE, "Purple Rain: A Rare Spot Diagnosis," in International Emergency Medicine Education Project, September 20, 2019, https://iem-student.org/2019/09/20/purple-rain-a-rare-spot-diagnosis/, date accessed: April 21, 2021

A Farmer’s Dilemma

Farmer's Dilemma

Case Presentation

It was a rainy night preceding my morning shift as a year 3 EM resident at one of our training centers in Abu Dhabi. The paramedics barged in with an agitated patient, who was found soaking wet in a farm field.

According to brief history that we got from the paramedics, the patient works at a farm and his boss found him collapsed, cold to touch and confused in the early morning hours. Paramedics also reported a confused, hypothermic, and tachycardic patient. They brought him directly to the ED, with no accompanying friends or family.

As we proceeded to resuscitate the patient, we noted that his initial vital signs did confirm hypothermia of 32 Celsius measured rectally, tachycardia, hypertension, and normal O2 saturation. We hooked him to the monitor, removed his wet clothing, gained IV access, started him on warm IV fluids, and covered him with blankets and a warming Bair Hugger (a warming blanket system).

Physical Exam

The patient was confused, agitated and uttering incomprehensive words, with a GCS of 11 (E3 V3 M5). I proceeded to examine him looking for more clues of why he was laying semiconscious under the rain all night. Systematic physical examination revealed pinpoint pupils, frothing and excessive salivations. Furthermore, diffuse mild crackles were noted on chest auscultation, and he was tachycardic with a regular rate and rhythm. Remaining physical exam was unremarkable, and a complete neurological exam was challenging.

Differential Diagnosis and Workup

Thinking of a broad differential diagnosis of altered mental status, systematic consideration of all possible etiologies similar to our patient presentation was reviewed. We have considered metabolic derangements, head trauma, CNS causes such as seizures and post-ictal status, infectious causes such as pneumonia or meningitis, and toxicologic causes, such as alcohol withdrawal, or medications overdose.

You may find useful this mnemonic for altered mental status!

ALTERED MENTAL STATUS

Further management plan included giving him benzodiazepines for the agitation and possible post-ictal status. We collected basic blood work and proceeded for a head CT to rule out traumatic or atraumatic intracranial pathologies. Blood workup was inclusive of an alcohol level, Aspirin, Acetaminophen level, and a urine toxicology screen.

As the patient returned from the CT, he apparently had passed the copious amount of loose stools, that smelled surprisingly like garlic that studded the ED with its smell.

The head CT was normal, and most of his blood workup came back unremarkable. But, he remained confused and agitated as the benzodiazepines were wearing off and despite all the warming measures. ECG showed only sinus tachycardia, and a chest X-Ray was unremarkable.

smells like garlic!

What do you think? What are the causes for this?

agents smells like garlic

phosphorus, tellurium, inorganic arsenicals and arsine gas, organophosphates, selenium, thallium, dimethyl sulfoxide
Learn More

The garlic smell did give us a lead though, we thought further of possible toxic agents that may give such a smell, along with a consistent similar clinical picture.

Case Management and Disposition

Collecting our clues once more, we had pinpoint pupils, frothing, salivation, wet lungs, vomiting and loose motions. Patient’s collective symptoms and signs indicated a Cholinergic Toxidrome, possibly due to Organophosphates ingestion.

The patient was already decontaminated with removal of all his clothes. All healthcare providers were equipped with personal protective equipment.

This was confirmed an hour later when his farm owner showed up with a Pesticides Bottle that he found near him in the early morning hours before calling an ambulance. Pesticide is shown in Figure. The content of the bottle is consistent with Organophosphates Toxicity, and hence his Cholinergic Toxidrome.

Pesticide Bottle Found Next To The Patient.
Pesticide Bottle Found Next To The Patient.

He was started on Atropine, and Pralidoxime, assessed and admitted to the ICU with arranged psychiatric consult to assess his suicidal ideations once he stabilizes.

Critical Thinking and Take-home Tips

A collection of symptoms and physical signs caused by a certain toxic agent.

Cholinergic
Anticholinergic
Sedative/Hypnotic
Sympatholytic
Sympathomimetics

Cholinergic toxicity represents a cholinesterase inhibitor poisoning. It results from the accumulation of excessive levels of acetylcholine in synapses. Clinical picture resulting from the Acetylcholine build up depends on the type of receptors that it stimulates and where is it found in the body. It can stimulate the nicotinic and muscarinic receptors. The balance of these stimulations reflects such clinical presentations.

Think of the symptoms that can be caused depending on the type of receptors affected by the buildup of acetylcholine.

Muscarinic Receptors – SLUDGE(M)

  • Salivation
  • Lacrimation
  • Urination
  • Diarrhea
  • Gastrointestinal pain
  • Emesis
  • Miosis

Nicotinic Receptors (NMJ) – MTWThF

  • Mydriasis/Muscle cramps
  • Tachycardia
  • Weakness
  • Twitching
  • Hypertension
  • Hyperglycemia
  • Fasciculations

These are called the Killers B’s which consist of Bradycardia, Bronchorrhea and Bronchospasm.

Decontamination should always be considered first in all cases with possible hazardous exposure from the patient and his environment to all health care providers in contact with him. All caregivers should wear appropriate personal protective equipment’s and make sure to remove all clothing and possible objects with the suspected contaminant.

Supportive care is a cornerstone to all unstable patients, make sure that they are monitored, with proper IV access and supplemental oxygen as needed.

Furthermore, airway management is lifesaving in similar patients, as bronchorrhea is one of the killer B’s and can lead to high fatality.

Antidotes such as Atropine and Pralidoxime in Cholinergic toxicity are paramount, as they help reverse the etiology, and prevent further worsening of the toxicity.

Make sure that such patients are admitted under needed specialty care with proper observation and reassessment for the patient.

Consult a toxicologist if feasible in your center to provide you with further management details and interventions that can help your patients better.

Conclusion

Organophosphates can be found in pesticides, chemical weapons such as nerve gases, and few medications as well such as neostigmine or edrophonium. They are highly lipid soluble making them easily absorbed via breathing and skin contact as well. Encountering similar patients, it is quite important to always be systematic in your approach, resuscitate your patient first, and make sure to use your history taking as feasible and physical examination to collect all the clues needed to narrow down your differentials and find the most appropriate treatment needed for your patient.

References and Further Reading

  1. Organophosphate toxicity on WikEM: https://www.wikem.org/wiki/Organophosphate_toxicity
  2. Das RN, Parajuli S. Cypermethrin poisoning and anti-cholinergic medication- a case report. Internet J Med Update. 2006;1:42–4.
  3. Aggarwal, Praveen et al. “Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department.” Journal of emergencies, trauma, and shock vol. 8,2 (2015): 123-5. doi:10.4103/0974-2700.145424
  4. Lekei EE, Ngowi AV, London L. Farmers’ knowledge, practices and injuries associated with pesticide exposure in rural farming villages in Tanzania. BMC Public Health. 2014;14:389. Published 2014 Apr 23. doi:10.1186/1471-2458-14-389

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Cite this article as: Shaza Karrar, UAE, "A Farmer’s Dilemma," in International Emergency Medicine Education Project, July 19, 2019, https://iem-student.org/2019/07/19/a-farmers-dilemma/, date accessed: April 21, 2021