Successful revival of a patient with cardiac arrest need vigilant effort on behalf of whole team but sometimes missing a small thing can create disaster. Here we present a case of 58?years old obese lady who was revived from a cardiac arrest secondary to septic shock. Obstruction due to proximal ureteric stone was relieved with JJ stent insertion. She required renal replacement therapy and invasive ventilation. Fever and inflammatory blood markers improved and she woke up after 6?days in intensive care unit (ICU). She developed another episode of sepsis but this time it was her shoulder that was hurting. Initially it was thought to be an iatrogenic skeletal injury during aggressive cardiopulmonary resuscitation (CPR) but radiographs came out to be normal. Magnetic resonance imaging (MRI) created more confusion by showing septic arthritis with proximal humeral osteomyelitis and gas formation. MRI suggested that it might be the sequelae of an intraosseous line insertion. All documented records were silent regarding the intraosseous line insertion. Resuscitation team was contacted and inquired. They confirmed the insertion of intraosseous line insertion during initial resuscitation which was removed after securing peripheral vascular access and before transferring the patient to ICU but they forgot to document. Her shoulder joint was washed out and debrided arthroscopically. She made a safe recovery without any other problem.
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