In today's episode we discuss the story of a man who fell off a ladder, landed on his knee, and walked—or so he thought—into an ER for what seemed to be a straightforward injury. He was diagnosed with a muscle tear… but just three days later, he underwent an above-the-knee amputation.

What went wrong? Could it have been prevented? And most importantly—how do we as clinicians, nurses, and providers ensure we never miss something so critical in our own practice?

Let’s break down the timeline, the clinical decision-making, the communication gaps, and what this case teaches us about responsibility, humility, and patient safety.

It started with a simple ankle injury. A young man sought care for what seemed like a routine contusion, but his provider suspected cellulitis—and that’s where things took a disastrous turn. What followed was a cascade of missteps that ultimately led to a colectomy and a grueling seven-week hospital stay.

Where did things go wrong? Could this outcome have been prevented? In this episode, we dissect the key moments in his care, identify the red flags that were missed, and discuss how we can sharpen our clinical judgment to avoid similar outcomes in the future.

Don’t miss this gripping case study—because one misstep can change everything.