When the system turns on you (plot twist, I became the case study)

By Danielle Gibbs Koenitzer, RN

What I didn’t expect was to end up starring in the exact story I’d been shouting about. 

I’m a nurse. I’ve worked in emergency, critical care and rural communities, and I’ve seen what happens when care is delayed. But nothing prepared me for what happened to me in September 2025. 

That morning, around 3 a.m., I woke up in excruciating pain. It wasn’t cramping or discomfort. It was sharp, deep and completely immobilizing. My spouse had to call EMS because I couldn’t walk. I arrived at my local emergency department (ED) around 6:30 a.m., barely able to speak through the pain. 

I told them right away that I’d had an egg retrieval just the day before. That’s a big red flag in gynecology. I was at high risk for ovarian torsion, cyst rupture or hyperstimulation. My heart rate was over 110, my blood pressure elevated, respiratory rate 30, and I was in documented 10-out-of-10 pain and crying. My abdomen was tender, rigid and guarded. In emergency medicine, this is what we call a “surgical belly.” 

And yet, nothing urgent happened. 

Between 6:30 a.m. and noon, I received only 2 mg of hydromorphone and one dose of ketorolac. No gynecology consult. No urgent ultrasound. Just a quick bedside scan and the message that there were “no urgent ultrasound slots” available. I was advised to drive an hour to the next city to see my fertility specialist. In that state. With abnormal vitals. 

By noon, I left the hospital still in acute pain. At 2 p.m., my fertility specialist confirmed what should have been suspected from the start: ovarian torsion. He sent me back to the ED with documentation urging urgent imaging and consultation. 

But the delays continued. 

I finally received a hospital ultrasound 10 hours after I first arrived. Gynecology wasn’t even consulted until after 5 p.m. I didn’t get proper pain relief until I was already being wheeled to the operating room (OR). In total, I spent more than 14 hours in escalating pain, with more than 11 of those hours under-medicated and under-treated for a surgical emergency. 

My fertility specialist told me point-blank: the pain management I received was subpar. He said any clinician should have recognized the signs and acted swiftly. Time matters with ovarian torsion. Every hour matters for ovarian viability, for future fertility, for preventing irreversible damage. 

And there’s another piece to this story that can’t be ignored. 

I’m a woman of colour.

There is strong evidence that patients of colour are less likely to receive adequate pain management in emergency settings. Research has shown these patients are also 34 per cent less likely to receive opioids for the same symptoms compared to white patients. Studies show medical trainees often hold false beliefs about biological differences between ethnic and non-ethnic patients. Those biases have real, life-altering consequences. 

Despite my abnormal vitals. Despite my classic presentation. Despite being a nurse who knew exactly what was happening to my body, my pain was minimized, my emergency was downplayed, and I was discharged to fend for myself. And if I couldn’t advocate for myself, what happens to other people who can’t? 

The one moment of gratitude in this entire ordeal came when I finally reached the OR. The locum OBGYN surgeon was exceptional. They were able to save my ovary when others might not have. For that, I am deeply grateful. 

But what happened before that was a profound failure in emergency care. And it can’t be dismissed as a scheduling issue. This is about delayed care, systemic bias, and disregard for pain when it’s coming from women and women of colour. 

My trust in emergency care is damaged. But I’m telling this story because I refuse to let it end here. I didn’t ask to be the case study, but since I am, the lesson’s about to be loud.