THE UNKINDEST CUT

The intensive care unit has 15 beds, and every day at least 2-3 beds will be occupied by patients with tetanus. Tetanus is virtually unseen in the developed world because of well-established vaccination programme, but in Vietnam, elderly and the older generation with inadequate vaccination are still vulnerable to the potential lethal infection, often contracted via skin cuts and upon exposure to soil and rust. As patients often do not recognise the importance of receiving post-exposure prophylaxis (in this case, extra doses of vaccine, which contain the inactivated toxin), many did not go to emergency department to receive treatment and only presented to hospital when they are already experiencing "lockjaw", painful spasms and even respiratory difficulty caused by the neurotoxin produced by Clostridium tetani. They may often experience autonomic dysfunction (resulting in abnormally high or low blood pressure or body temperature) - Mortality can be up to 70% if untreated.

Here you would see patients (often farmers, or hawkers and rubbish collectors who spent hours on end treading on the streets) lying on the bed looking terrified and distressed, stiffed and twitching from muscle spasms caused by the tetanus toxins. They would have a tracheotomy (a breathing hole through the trachea via a cut in the neck) and be on mechanical ventilation for 3 to 4 weeks, followed by weaning off in a side room. Sedation is not a common practice in ICU here so you see patients obviously looking uncomfortable, being intubated wide-awake. There is also a general lack of knowledge of tetanus among the public - there was an instance where a female farmer stepped on a needle (probably discarded by intravenous drug users) in her allotment. She hurried to the local clinic to receive post-exposure prophylaxis for HIV (paid hundreds of dollars on end), only to be found to have tetanus days later and was in a critical condition for a long while.

I wonder if giving tetanus vaccine is a common practice here in A&E or in primary care setting if a patient present with open wound/injury/contact with soil or rust - that would be something to find out.

*

Tetanus: from Ancient Greek: τέτανος, tetanos "taut", and τείνειν teinein "to stretch"
Clostridium tetani: Gram-positive, rod-shaped, obligate anaerobic bacterium