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The prefrontal cortices areas play an important part in memory, intelligence, concentration, temper and personality. They are distinguished from the occipital lobes by the parieto-occipital sulci on their medial surfaces. The occipital lobes are located at the back of the brain, and are the smallest lobes. The occipital lobes enable humans to receive and process visual information, influencing how we process shapes and colors. The right occipital lobe interprets visual signals from the left visual space, and the left occipital lobe performs that function for the right visual space. The temporal lobes are located at the level of the ears, separated from the frontal and parietal lobes by the lateral sulci. An area in the left temporal lobe is involved in verbal memory and helps humans remember and understand language. It is made up of densely packed collections of the myelinated projections of neurons (nerve cells) that course between the widely dispersed areas of gray matter. It appears that white matter provides the essential connectivity in the brain, uniting these different regions into networks that perform various mental operations. If this connectivity is disrupted by disease or other damage to white matter, the result is often a dramatic disturbance of normal mental function. White matter is so named due to the appearance and composition of its nerve fibers. At the cellular level, brain functions are carried out by nerve cells called neurons. Attached to the body of each neuron are multiple short dendrites, which receive information from other neurons through electro-chemical impulses. The neuron body processes the information, then uses another electro-chemical impulse to send the information on to another cell via its axon. Axons are the longer nerve fibers (up to three feet in length), and each neuron generally has only one. Axons are lined with myelin, which serves as electrical insulation, and increases the speed of conduction of information. The white matter areas of the brain are mainly composed of axons coated with myelin, while the gray matter areas are predominantly the cell bodies of the neurons. Figure 3 Diagram of a neuron the myelinated axons cluster together to form thicker bundles or fibers. The fibers are arranged in tracts within the white matter that serve to connect one part of the brain to another and to the spinal cord. Projection tracts extend vertically between the higher and lower brain and spinal cord centers, and carry information between the cerebrum and the rest of the body. Association tracts connect structures in different regions within the same cerebral hemisphere. Long association fibers connect different lobes of a hemisphere to each other, while shorter association fibers connect different gyri within a single lobe. One of the roles of association tracts is to link perceptual and memory centers of the brain. Commissural tracts cross from one cerebral hemisphere to the other through bridges called commissures. These tracts enable the left and right hemispheres of the cerebrum to communicate with each other. The great majority of commissural tracts pass through the large corpus callosum, which is a collection of white matter fibers that joins the two cerebral hemispheres inferiorly. Smaller anterior and posterior commissures are present and accommodate a few commissural tracts. In the cerebrum, messages for movement and sensation cross to the other side of the brain, and cause the opposite limb to move or feel sensation.

An 8 year-old is much more likely to tear the house apart because of underlying psychiatric illness. Provided that they are reasonably calm, collected and able to be of assistance, family is your greatest asset. These patients are generally extremely agitated and present with bizarre and potentially violent behavior. A stereotypical case would be the middle-aged male who, after stripping naked, is a bloody mess from breaking out all of the windows in his house and is now running through traffic or wandering aimlessly in an unusual location. Law enforcement officers are often called upon to confront and control these patients. Some patients may fall victim to a phenomenon known as sudden, unexpected, in-custody death if excited delirium goes unrecognized and untreated. Constant motion Effective 1/27/2020 Replaces 7/1/19 Behavioral Emergencies Page 3 of 6 4. Paranoia Attraction to shiny objects / lights / glass Superhuman strength Decreased pain sensation Hyperthermia, tachycardia, hypertension, often dilated pupils D. It is not unusual for an Excited Delirium patient, once they are subdued, to "crash" and exhibit difficulty breathing, hyperthermia, unresponsiveness, or other signs and symptoms of a medical emergency. Without prompt intervention and treatment, a certain number of these patients may progress to sudden, unexpected, in-custody death. Underlying Health Problems - put the patient at an increased risk of sudden death after such extreme exertion. Metabolic Acidosis - these patients tend to be functioning at a very high metabolic rate. They will eventually "burn out" and suffer an unsurvivable metabolic acidosis, which will lead to end-organ damage and death. Sympathomimetic overload ­ Patients tend to have hyperpyrexia (elevated body temperature, though their "fever" is not necessarily from an underlying infection), tachycardia, hypertension, and often dilated pupils. Psychiatric Illness - Certain psychiatric illnesses or conditions can lead to a hyper manic state and again cause metabolic acidosis. Ventilation Problems - the primary means by which the body corrects metabolic acidosis is through (hyper)ventilation. It is debatable, but many believe that certain restraint devices or positions limit adequate ventilation and may exacerbate metabolic acidosis. Patients who are in a state of Excited Delirium are at risk for sudden death and require medical intervention. To prevent the sympathetic overdrive from killing them, the patient must be sedated with benzodiazepines. Versed) to stop the hyperactive "fight or flight" response that will lead to neurologic excitatory-toxicity and death. Even with aggressive interventions, you must be prepared for the patient to suddenly "crash" and become dyspneic and/or unresponsive. Be ready to support ventilation and resuscitate from respiratory or cardiac arrest. Effective 1/27/2020 Replaces 7/1/19 Behavioral Emergencies Page 4 of 6 Paramedic A. It is prudent to back away after ketamine has been administered for several minutes until the medication has taken effect. Once patient is sedated, giving them more only increases side-effects; it will not make them "more sedated". Ketamine is a dissociative that will "pause" the excited delirium problem, not stop it. If using Midazolam in addition to Ketamine, recommend giving the Midazolam as the patient is starting to wake up from the Ketamine. This will both keep them sedated for safe transportation and help stop the underlying excited delirium b. Assessment of a patient who has been "hit" with a taser shall include evaluating: 1.

Additionally, around 9,000 premature births have been recorded among Syrian refugees since 2015, amounting to a total of at least 18,000 documented premature births per year (10). All patients require appropriate financial health coverage to support their medical management, very costly for admitted neonates. Soon, only the upper class will be able to afford the estimated $30,000 in costs for the care of a premature baby (10). Although not studied in this specific context, rural areas have a higher prevalence of births with inborn errors of metabolism, likely due to more frequent consanguineous marriage. With the population in these areas being largely workingclass, access to high-quality neonatal intensive care is particularly challenging, the crisis making it even worse. Lebanese is host to the second-largest Syrian refugee population and third largest Palestinian refugee population in the world. Unable to be employed as a result of their refugee status, most do not have access to either public or private health coverage. The last protest picture shows how "female-dominated" these protests were, led by strong women. Robert Sacy, next to the Karantina Hospital he built and invested in for the last 4 years only to see it blown away by the blast. These organizations have been essential to the survival of many newborns in this population, especially that they suffer a higher prevalence of neonatal complications due to inconsistent prenatal care, as well as higher rates of consanguinity (4). These organizations rely entirely on donations and grants, and their ability to cater to their beneficiaries has been severely impacted after the donations they depended on contracted as a result of the ongoing global economic crisis. Since 2017, six babies found in trash bins and more than twenty-two "undocumented" children have been taken in and treated by the Karantina team (2). Adding fuel to the fire, this center was heavily damaged by the Beirut Port explosion, nearing total collapse. Inside their incubators, babies sheltered from the debris were evacuated within 3 hours. The remains of paintings of trees, suns, and smiles are now covered with blood on the few walls still standing. The daily positivity rate fluctuates between 10 and 20%, and the death toll is 970+ since February 2020. The pandemic appears to be mostly affecting adults, with the case-fatality of children under nine years of age at 0. She did contend, however, that it is too early to draw any conclusions regarding this matter. What was once a haven for over 1,000 children per year has now been nearly razed to the ground. For physicians around the world, and particularly in Lebanon, working conditions have become increasingly difficult. Indeed, the pandemic has led many parents - those who have not migrated yet - to opt-out of vaccination programs and avoid routine follow-ups out of fear of exposure. Additionally, due to currency devaluation, consultation fees, still generally fixed at the same price in Lebanese pounds, are much less profitable to the physician (dropping from the equivalent of $60/patient to less than $12/ patient) while still being largely unaffordable for the larger patient population. Highly qualified and trained physicians, overworked and underpaid, have decided to immigrate for better opportunities abroad. Indeed, over 400 physicians have immigrated in the last couple of months, with more expected to follow suit (8). This exodus of physicians and the shortage of medications and medical equipment (hospital suppliers demanding to be paid in hard currency, largely unavailable on the market) has significantly reduced the quality of healthcare in Beirut, once a regional health hub in the Middle East. The pandemic has highlighted wide disparities and brought to the fore existing inequalities in developed countries, exposing the need to fill large healthcare delivery gaps to marginalized communities. In a country like Lebanon, shaken by financial precariousness, famine, civil unrest, a large explosion, a mass exodus, and a global pandemic, these disparities have become even more apparent and alarming. This eventful year has highlighted the lack of a national emergency preparedness plan, inadequate infection prevention and control practices, and the absence of an effective healthcare safety net for the uninsured in Lebanon. It is crucial to address these deficiencies for a better-equipped healthcare system in the face of the next blow in order to be able to , at least, give the newborns the gift of time. Consanguinity rates among Syrian refugees in Lebanon: A study on genetic awareness. Membership is available to physicians, nurses, and other caregivers in neonatal and perinatal medicine. Conference announcements and other news of interest to members may be posted here.

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