This case takes place in New York and involves a male patient who presented to the ER with severe abdominal pain, bloating, and fatigue. An X-ray revealed free air in his abdomen suspicious for perforation of the colon or a ruptured ulcer. Despite these worrying findings, the patient received no further care or evaluation for hours. Eventually, A CT scan was performed, which confirmed a perforated colon. Again, the patient’s treatment was delayed, with several hours elapsing before he was brought into the operating room. The patient had become septic in that time and ultimately passed away a few days after the operation.