You're an emergency room doctor and the patient in front of you looks tired, but otherwise OK.
You've examined this patient and others and they don't seem to be physically displaying the symptoms that brought them to the hospital in the first place. They haven't given you permission to speak to their family and the individual is just one of about 280,000 patients physicians will see in Winnipeg emergency departments in a year.
Do you send the patient home, possibly by taxi? Do you let them stay longer in the emergency room or do you admit them to hospital?
It can be why medical treatment is called both an art and a science.
But it's also part of a grey area of emergency care, and it can lead to controversy if you make the wrong decision or if something happens out of the blue.
Take the two decisions physicians in the Grace Hospital's emergency department made in recent weeks. David Silver, 78, was sent home on Dec. 31 at 1:30 a.m., in a cab and with a coat over his pyjamas and slippers on his feet, but died before getting in his front door. He'd been sent home diagnosed with gallstones and kidney stones, but died of a heart attack.
Wayne Mill, 62, was discharged from the Grace on Dec. 29 at about 8:25 a.m. and sent home in a taxi. He was found by nearby residents lying unresponsive on the sidewalk. Media reports said he died of an aneurysm.
The incidents occurred days before a standing hearing was being held for an upcoming inquest into the 2012 death of Heather Brenan, 68. She went to the Seven Oaks General Hospital complaining of weakness, difficulty and pain when eating, and long-term weight loss, but was sent home by cab after three days of tests. She collapsed when she got home and died a day later in hospital.
Dr. Alan Drummond, chairman of the Canadian Association of Emergency Physicians, said it may come as a surprise to people there are no universal standards across the country for emergency room care, including who works there, how much training they get and how to relate one department to another. It is only recently, through hospital accreditation processes, that some guidelines are being put together.
"It will always be a judgment call," he said.
"Because there's no accredited standards, people just make it up as they go along. Our view is emergency care is a basic human right and Canadians should expect a uniform level of care across the country. It has never made sense to us there should be such a variation of care.
"Variability of care keeps on raising its ugly head."
Drummond said the deaths and others in Winnipeg are generating national headlines.
"You have (Brian) Sinclair, now this, and the suspension of STARS (helicopter) ambulance -- it seems everything that could fall upon an emergency department has happened in Manitoba in the last year," he said.
The circumstances surrounding Sinclair's death is currently before an inquest. He died in the Health Sciences Centre's ER waiting room after going 34 hours without being seen by doctors.
Drummond said he hopes the upcoming part of the inquest that examines issues in emergency rooms themselves address problem areas that can affect discharging.
"We think this is probably the most important inquest in a decade, and we hope it focuses on the issue of crowded emergency rooms," he said.
"The biggest impediment of emergency room care is overcrowding."
Drummond said overcrowding can come into the decision-making of physicians making the call whether to admit or discharge a patient.
"Thirty years ago, we would keep old ladies overnight, but the keeping of little old ladies isn't on anymore," he said.
"Just as you can at any time of day come to an emergency department, you can also be discharged at any time too. It's not the pressure of opening up beds, but it is certainly there.
"Without a bed, you can't examine other patients -- unless we want to start examining patients in the waiting room."
But Drummond said individual health care needs will always trump overcrowding.
The Winnipeg Regional Health Authority does have a four-page document entitled Safe Patient Discharge that was approved on May 28, 2012, and revised on Nov. 20, 2012. It provides "guidelines to optimize post-discharge safety for adult patients who present and are discharged from emergency departments 24 hours a day, seven days per week" and details what should be taken into account before making the decision.
Lori Lamont, the WRHA's vice-president and chief nursing officer, said the guideline was revised following the death of Brenan and will be reviewed again as part of the investigation into the latest deaths.
Lamont said depending on what brings a patient to emergency, their discharge planning "can be very simple or it can be very complicated."
She said a team approach is always used for discharging a patient, but the team could involve only the ER doctor, nurse and patient or also include home care personnel, social workers, occupational and physical therapists and family members.
Lamont said patients themselves, if competent, and their participation are among the most important pieces in discharge planning.
She said they are always encouraged to ask questions if there is anything they don't understand about their medical care, including discharge.
"If we're not paying attention to some of the issues of going home... they need to raise awareness," she said. "And we need to respond."
She added the hospital can't contact family members if the patient doesn't give consent.
"If I was told I couldn't leave the ER without my husband's permission, I'd be angry," she said.
Steven Lewis, a health-care consultant based in Saskatoon, said part of the problem for some patients is emergency room medical staff are focused on what brought them through the door in the first place.
"If the reason for going to the ER isn't related to that, it is hard to expect the emergency room to do a complete examination of every case," Lewis said.
"The ER is only going to have a very partial picture. They are busy places set up to deal with specific complaints and treat them as quickly as possible.
"It may be a perfectly reasonable step to send them home... it is a tragedy when people are sent home and die, but it doesn't mean the system did anything wrong.
"We can't conclude there's a systemic problem."
Prof. Arthur Schafer, director of the University of Manitoba's Centre for Professional and Applied Ethics, said the deaths bring up several issues, including competence, negligence and whether it was obvious these patients should not have been discharged.
"Obviously, this is something that will be investigated in a critical care inquiry," Schafer said.
"But if someone is discharged to go home, and the instant they go home they collapse of a heart attack, it doesn't necessarily mean the doctor made a mistake or is incompetent or negligent. Sometimes even the best doctor in the world couldn't be expected to know someone will die.
"Because they died very shortly after proves nothing. It raises a suspicious red flag but no one should jump to a conclusion. You may have presented with a skin rash and then they have a heart attack."
Schafer said it points out the need for creating firm criteria for admitting and discharging because beds are a scarce resource.
"Wherever you draw the line there will be risk, the question is where is the line?" he said.
"Has the scarcity of beds and personnel to treat patients caused us to put the line for hospital discharge in the wrong place? Should we spend even more?
"That's a judgment for society, for government and for hospital administrators."
But in the end it will always come back to dollars, he said.
Drummond said the whole issue culminates in a sad truth about how medical practices change in emergency rooms.
"Every major practice development in emergency care in the last 30 years has come on the back of an inquest," he said.
"It's too bad we are not proactive. We wait for somebody to die and then change the system."