Tetanus. Like so many
things here I’ve read about it, but never treated it. Malaria, filariasis, typhoid fever, PJP
pneumonia, and now tetanus. I was off
duty when a 12 year old girl was admitted to the children’s ward for prolonged
muscle spasms/contraction, and a positive malaria test. It’s important to note that these aren’t
muscle spasms like one might experience with a “Charlie horse” or dehydration;
these muscle spasms are about as tight as possible, and the muscles stay
contracted for hours at a time. The girl
couldn’t open her mouth due to “lock jaw,” which is a prolonged contraction of
the chewing muscles. She couldn’t bend
her arms or legs. Most painful of all
she had a condition called opisthotonus.
This is when the muscles around the spine become so contracted that the
person can keep everything but their head and ankles off the floor if laying on
their back. I think a picture from Dr.
Google might help here:
(Dr Google warned me that this might be copy-written, but
since the website is displayed, I am quoting the source). So imagine maintaining this position for
hours at a time, and just when you start to relax something (light, sound, etc)
causes your muscles to spasm again.
So how
do you treat tetanus? Well, you give
tons of muscle relaxers like diazepam, pain medicine like morphine, tetanus
toxoid if available to try and counteract some of the tetanus poison that the
bacteria has released, and antibiotics to kill off the tetanus bacteria remaining
(Clostridium tetani for the nerds in
the audience). The admitting house
officer had ordered the correct medications, but as is not uncommon our
pharmacy was out of them (metronidazole preferably, or aqueous penicillin if
metro is not available). At least we had
lots of diazepam and morphine, which I increased rather rapidly trying to
relieve her pain while at the same time not killing her (which would have made
the whole hospital visit kind of counter-productive). I mentioned earlier that she also had malaria
(lucky girl), and fortunately one of the medications to treat severe malaria is
Clindamycin (along with Artemesin, which we were also out of, but Arthemeter
was available so close enough). But
wait! Clindamycin also treat Clostridium difficile and Clonstridium perferingens. Could it be that it also treats tetanus? Hooray!
That actually is among the acceptable medications. It costs more per dose than most people make
in a week, but when that’s your only option you go with it. We only had to give that for a couple of days
as we got more metronidazole. Luckily
her fever reduced, and gradually the spasms became less and less. We were able to transition her over to oral
diazepam and tramadol, and when she went home she was just having the
occasional mildly irritating spasms that were short lived.
So the
missionary part? Her father only spoke
French, and I discovered that the family was Muslim. Our chaplaincy did not have any information
on Christianity in French, and had I tried with my broken French it would have
translated something like “you Muslim, God only one, I’m Jesus, may interest
for learn more?” Thank goodness one of
our wonderful French-speaking psychiatric nurses was able to translate one of
the informational tracts into French. I
wish that I could have reviewed it with him (although, again, “here paper,
Muslim for Christian. You read for learn
Jesus. Maybe stop one?”).
All-in-all
this was a great case for me to learn from.
Tetanus generally has a 30-50% mortality rate in the developing world. Let that be yet another reason to vaccinate you children! I thank God that she pulled through. Just hoping I didn’t make her a Valium and
opiate addict in the process.
~Bryan
~Bryan
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