This case involves a female patient in her mid-thirties who presented to the emergency room with persistent abdominal pain and gastric distress. A CT scan was ordered and several possible causes were suggested – the patient was discharged with a referral to a GI specialist but no diagnosis was made. For an extended period of time following this initial evaluation she was seen by a number of doctors, and was eventually diagnosed with severe sepsis and Crohn disease. Several drugs were prescribed including vasopressors. It was determined that a member of the hospital’s nursing staff gave the patient an exceptionally large dose of one of these medications, resulting in the amputation of both legs.