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.