About a month ago, Flea wrote about some of the vaccine preventable diseases and what actually happens when one contracts polio, diptheria and tetanus. I had no idea what diptheria was before I read that post, but tetanus is a disease I have some experience with.

I’ve personally taken care of two tetanus patients within the last few years. One was an IV drug user in his 30’s and contracted it through one of the many abscesses he had on his arms and legs. He went downhill fairly quickly and was intubated and put on a ventilator. Usually when a patient is intubated on a vent, we give them about 2 weeks to get off the vent before we start talking about a tracheostomy. Tetanus patients, I learned, get trached and peg’d after only a few days. It’s understood that they are going to have a rocky course of illness and a very long recovery time and will have these procedures done sooner or later.

Tetanus is treated with antibiotics, anti-seizure meds and “supportive care.” This means life support, intravenous or tube feeding, etc. It’s intended to support a person’s vital life functions while the patient fights off the disease. Tetanus is also treated with muscle relaxers, but in this guy’s case, those weren’t controlling his extreme muscle spasms. He was already in a “medically-induced” coma, meaning that we were sedating the heck out of him, so the only other option we had was chemically paralyzing him.

Paralyzing patients is a balancing act. Too much paralytic can affect a patient’s heart rate (too fast, irregular) and cause them to spike high fevers. Not enough and you’re stuck with the muscle spasms and unstable blood pressures. To determine if we are giving the correct dose, we use a “peripheral nerve stimulator.” We put electrodes on the patients’ wrist (thumb side) or along their temple. We then hook up this little box that sends electrical impulses. We set it to give 4 pulses at varying strengths. The doctor determines how deep he wants the patient. If the patient is not paralyzed enough, you’ll get 4 muscle twitches at the eyebrow or thumb in time with the 4 pulses. If they are too paralyzed, you get no muscle twitches. We usually aim for 2 twitches out of 4 pulses at a moderate strength.

The other tetanus patient I took care of was in his 70’s and was a carpenter. He actually acquired a big splinter in his arm, which was the supposed mode of entry. He came in with muscle stiffness but was talking and awake when he got to CCU. Within 24 hours, he was intubated on a vent due to respiratory distress and 24 hours after that he was trached and peg’d.

He was one of the most difficult patients I’ve ever taken care of.

This man’s hemodynamics defined instability. In Flea’s post about tetanus, he states, “The slightest stimulation can trigger muscle spasms: the ringing of a cell phone, the flash of a digital camera, or someone in the room burping.” That isn’t an exaggeration. It was very difficult to titrate the paralytics for this patient, even with the nerve stimulator. I’d check his twitches at a dose and find the dose adequate; an hour later I’d check again and find that the dose was way off in one way or the other.

Literally the slightest stimulation – conversation in the room, barely brushing the sheet that was covering him, an IV pump beeping – would send his muscles into tight tight knots. One could literally see them tensing. In addition to this, his blood pressure would skyrocket!! One moment he’d be at 80’s/40’s and you could literally watch it rise to 240/130 in a matter of seconds. It would stay there until it was dealt with, which meant giving boluses of paralytic or sedation (Propofol, the drug we use for sedation, will cause transient hypotension when given as a bolus). If given too little of whatever drug I decided to play with, he’d stay well over 200/100, but if given too much, he’d drop to 60/30. The difference between “too much” and “too little” was so negligible. If I actually managed to find the sweet spot dosage-wise one time, that same dose wouldn’t work the next time. It got to the point where one nurse would have to bolus with paralytic or Propofol to ease the muscle tension while another was simultaneously titrating the Dopamine (a vasopressor) to prevent hypotension.

By the end of a 12 hour shift with that patient, I felt like my muscles were afflicted with tetanus. I was that high-strung afterwards.

Eventually, the wide swings in blood pressure abated and sneezing in the patient’s room no longer elicited a body-wide charley horse. This last patient was eventually weaned from the sedation, paralytic and ventilator. A few months after he was transferred out of our unit, we asked one of the social workers how he ended up. I’m happy to say that he made a full recovery and was able to walk out of the hospital after a lot of physical therapy.

I like the happy endings.