15 minutes of intense muscle contractions: an unexpected medical experience in the middle of the street

An unexpected scene upon leaving a restaurant

I had just left a restaurant and was walking down the street when I noticed a young man, approximately 25 years old, sitting on the ground and surrounded by several people.

Something was not right.

I approached to try to help him and, after identifying myself as a doctor, I began to assess his condition.

The young man was experiencing extremely intense muscle contractions. His hands were completely locked, his arms rigid, and his jaw tightly clenched. He appeared to be in very significant pain.

His eyes remained shut so forcefully that I had to separate his eyelids to observe his pupils. I could see that they were dilated, although that finding alone did not allow for any diagnosis to be established.

His breathing was irregular and labored.

However, there was one crucial detail: the patient remained conscious.

He could hear my questions, appeared to understand them, and was able to respond, albeit with great difficulty due to the intensity of the episode.

I did not observe a complete loss of consciousness.

My first suspicion: a tetany attack

Given those muscle contractions — especially the locking of the hands and arms — my first hypothesis was a tetany attack.

Tetany is a syndrome characterized by increased neuromuscular excitability that can cause spasms, sustained contractions, rigidity, and pain.

One of its best-known signs is carpopedal spasm, which produces a characteristic posture of the hands, sometimes referred to as the “accoucheur’s hand”.

But a tetany attack does not, in itself, constitute a definitive diagnosis.

It can arise through different mechanisms, including disturbances in calcium or magnesium levels, or significant changes in the body's acid-base balance.

What is the relationship between breathing and calcium?

When a person hyperventilates, they expel excess carbon dioxide. This can trigger respiratory alkalosis — that is, an increase in blood pH.

In that context, calcium binding to plasma proteins, particularly albumin, increases, and the ionized calcium fraction transiently decreases.

Ionized calcium is directly involved in the functioning of nerve and muscle cells.

A decrease in ionized calcium can increase neuromuscular excitability and trigger painful spasms, even when the total calcium concentration in the blood is normal.

However, at that moment I did not have access to a blood gas analysis or an ionized calcium measurement. Therefore, I could not confirm that mechanism.

What if it wasn't a tetany attack?

This is precisely where one of the most important aspects of clinical reasoning comes into play: symptoms that appear similar may correspond to very different conditions.

In this young man, there were several possibilities that deserved to be investigated.

1. Paroxysmal dystonia

Dystonias are movement disorders characterized by involuntary muscle contractions that can cause abnormal postures, repetitive movements, and sometimes intense pain.

Some paroxysmal forms occur in episodes, with periods of relative normality between attacks.

They can affect the limbs, neck, face, or various muscle groups. Consciousness may remain completely intact.

In the case I witnessed, the intense contraction of the hands, jaw, and eyelids made it necessary to consider this possibility.

2. A metabolic disturbance

Hypocalcemia and hypomagnesemia can cause neuromuscular hyperexcitability and involuntary contractions.

Certain potassium imbalances can also cause episodes of weakness or paralysis, although their presentation is usually different from painful muscle spasms.

Without blood work, it is impossible to rule out these causes.

3. A focal seizure with preserved consciousness

There is a widespread misconception: the belief that all epileptic seizures cause loss of consciousness and generalized convulsive movements.

That is not the case.

Some focal motor seizures can manifest as contractions or tonic posturing, while the patient remains conscious.

For this reason, the fact that a person can hear and respond during an episode does not automatically rule out an epileptic seizure.

4. A functional neurological episode

There are also functional non-epileptic seizures that can produce involuntary movements, rigidity, respiratory disturbances, and prolonged episodes.

The duration of a seizure, preserved consciousness, or forceful eye closure can provide useful information to the specialist, but none of these signs in isolation is enough to establish a diagnosis.

And it is important to clarify this: the fact that a disorder is functional does not mean the patient is faking it or that their symptoms are imaginary.

Between ten and fifteen minutes of uncertainty

While I was observing the young man, his family members explained to me that this had happened before.

According to what they told me, the seizures occurred spontaneously, without any obvious trigger, and generally lasted between ten and fifteen minutes.

Then they would disappear.

My initial intention was to call for emergency services.

However, his parents asked me not to do so. They explained that they were familiar with these episodes and that, in their experience, the young man would eventually recover on his own.

That presented a delicate situation.

On one hand, there was the medical concern over an intense, prolonged episode of unknown origin. On the other, the trust of a family who had witnessed similar situations on previous occasions.

In the end, the episode resolved spontaneously, just as the parents had anticipated.

But that recovery did not answer the most important question: what disease or mechanism was causing these episodes?

Patient consent and medical emergencies

This experience also invites reflection on a fundamental principle of medicine: respect for patient autonomy.

Healthcare must respect, as a general rule, the wishes of a competent adult who has received the necessary information and has the capacity to make decisions.

However, there is an essential distinction between the patient's own wishes and the opinion of their family members.

In Spain, Law 41/2002 governs patient autonomy and provides for exceptional situations in which essential interventions may be carried out without consent when there is a serious and immediate risk and it is not possible to obtain valid authorisation.

Therefore, the opposition of family members does not necessarily prevent emergency assistance from being sought.

In a public setting, without monitoring equipment and in the face of a potentially serious episode, contacting emergency services may be a prudent measure, even when the family states that these episodes are a recurring occurrence.

What investigations should be carried out?

An episode of this nature warrants a thorough medical evaluation.

Among the initial tests that may prove useful are:

• Electrocardiogram.

• Blood glucose.

• Total calcium and ionized calcium.

• Magnesium, sodium, potassium, and phosphorus.

• Renal function.

• Blood gas analysis, especially if hyperventilation is present.

• Neurological examination.

Depending on the results and the characteristics of the episodes, the specialist may consider an electroencephalogram, a brain MRI, or specific studies for movement disorders.

In certain cases, a recording of the episode, carried out safely and with full respect for the patient's privacy, can provide very valuable diagnostic information.

What should we do if we witness a similar situation?

The first priority is to protect the person and make sure they are breathing adequately.

We should not attempt to forcibly straighten their limbs, open their jaw, or place any objects in their mouth.

We should also refrain from administering any medications or supplements without knowing the underlying cause.

Severe hypocalcemia may require intravenous treatment in a hospital setting. A prolonged epileptic seizure requires a different protocol altogether. Acute dystonia may call for a completely different approach.

That is why the correct treatment depends on the diagnosis.

My reflection as a physician

After that experience, I kept thinking about that young man.

I did not know his medical history, I did not know what tests had been carried out on him previously, nor whether an established diagnosis existed.

All I could do was assess the signs in front of me, formulate hypotheses, and recommend an appropriate medical investigation.

My first impression was a tetany attack. But I also felt that a possible neurological cause should be investigated.

I recommended that his family seek a thorough neurological evaluation.

Today I would add an idea that I consider fundamental: before attributing these episodes to a specific neurological disease, it is also necessary to rule out potentially treatable metabolic and cardiovascular causes.

I do not know what that young man's diagnosis was. And it would be wrong to claim that I do.

But that experience reminded me of something I consider essential in our profession.

In medicine, recognising our diagnostic limits is not a weakness. It is a way of protecting the patient.

And I want to close with a message directed especially to families who live with recurrent episodes:

The fact that a crisis has occurred many times and has always ended by resolving does not necessarily mean it is harmless.

Recurrent symptoms deserve a diagnosis, not simply getting used to them.