This case involves a fifteen-year-old male with past medical history of spinal surgery. He underwent further surgery to remove an infected spinal implant. The procedure was performed without complications and the patient was prescribed the antibiotic Gentamicin by the treating orthopedic surgeon post-operatively. The patient was not closely monitored by the treating surgeon following the operation. The patient began experiencing nausea and vomiting and complained of ringing in his ears. Blood tests conducted by the patient’s infusion service revealed declining renal function shortly after the prophylactic antibiotic treatment was administered. The infusion service recognized that the patient’s signs and symptoms could be related to his medication and wrote an urgent memo to the treating surgeon, who failed to reply. The following day, the patient’s infusion service followed up to advise that they would require authorization to continue the patient on the prescribed regimen – at which point he’d been vomiting for 9 consecutive days and was in poor condition. The doctor again failed to reply. Finally, the patient’s family followed up with the surgeon – who failed to reply – however, his nurse practitioner advised the patient’s family that he should be brought to the ER promptly. A toxicologist indicated that the patient’s Gentamicin level was greater than 12, and this was 17 hours after he’d last taken the drug. Despite conversion of the frequency and the dosage of the drug, and notwithstanding increasing BUN and creatinine value, there were no peak/trough levels obtained nor any consideration of Gentamicin toxicity given by the surgeon’s office – until the patient was already in kidney failure and had lost all vestibular nerve function. The patient’s vestibular injury is complete and permanent – he will require a lifetime of special care and treatment.