A 39-year-old man in Australia sought medical attention at Flinders Medical Centre in Adelaide for a foot injury and a painful, persistent erection known as priapism. While his foot injury was relatively minor, the four-hour-long priapism required immediate medical intervention. The patient had a history of similar episodes and had previously been successfully treated with lidocaine injections, a local anesthetic used to relax the muscles in the penis and reduce the rigidity of the erection. However, during this particular treatment, a critical error occurred: the medical staff administered ten times the required dose of lidocaine, 2000mg instead of the intended 200mg.
The overdose resulted in a severe adverse reaction known as local anesthetic systemic toxicity (LAST). The patient experienced hallucinations, vision loss, and paralysis, although he remained conscious and could hear his surroundings. The medical team recognized the gravity of the situation, initiating a “code black” emergency protocol. He was immediately transferred to the intensive care unit, where he received oxygen, intravenous fluids, and a lipid emulsion to counteract the lidocaine toxicity. Despite these efforts, the patient’s condition deteriorated, requiring intubation to assist with breathing due to increasing respiratory distress. The incident was described by the patient as the “worst day of my life.”
Concurrently with the treatment for LAST, the urology team addressed the patient’s priapism through blood aspiration to alleviate pressure within the penis. Following the incident, the hospital conducted a thorough review to identify the contributing factors to the medication error. The investigation revealed several critical issues, including the visual similarity between the 1% and 10% lidocaine vials, and the lack of a double-checking procedure before administering the medication. The hospital staff apologized to the patient for the potentially fatal error.
The patient’s recovery was complicated by the traumatic experience. The following day, he exhibited anxiety and re-experienced some of the LAST symptoms, including hallucinations, vision loss, and temporary paralysis, when anesthesia was attempted for a subsequent procedure. He was eventually discharged after a few days and, according to a one-month follow-up, was recovering well. The priapism had not recurred, and he regained normal erectile function.
This case highlights the importance of meticulous medication administration protocols and the potential for serious complications arising from medication errors. The near-fatal outcome underscores the need for clear labeling, double-checking procedures, and heightened awareness of the potential for visual confusion between different concentrations of medications. The patient’s experience also emphasizes the psychological impact of such traumatic medical events, particularly the potential for re-experiencing symptoms and anxieties related to the initial trauma.
The incident serves as a critical reminder for healthcare professionals to adhere to stringent medication safety practices to prevent similar adverse events. The visual similarity of medication vials, a factor identified in this case, necessitates extra vigilance during preparation and administration. The hospital’s subsequent review and implementation of improved procedures demonstrate a commitment to patient safety and a recognition of the systemic factors that contributed to the error. The patient’s eventual recovery, both physically and in terms of erectile function, emphasizes the resilience of the human body and the importance of timely and appropriate medical intervention in such critical situations.
