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My family practice clinic is in a small town. About 9000 people. The hospital is four blocks from my house and about a mile from my clinic.

We drive someone to the emergency room about once every 2 years.

Usually it is atrial fibrillation. They are newly in atrial fibrillation, they are reasonably stable, they drove themselves to clinic and they don't want us to call an ambulance. Worried about cost, embarrassed, maybe not quite sure that they believe me since I have only used my stethoscope and not a magical machine that plugs into the wall with stickers on your chest. How can I do that with only a stethoscope and feeling their pulse?

Anyhow, we had a different one recently. New patient P, short of breath when P sits in the chair. History of asthma and a smoking history. I get my thorough history and P is not short of breath and can answer in full sentences. P has some belly pain. Left lower quadrant. P has a history of diverticulosis and diverticulitis. Past medical history, allergies, medicines, surgeries, family history and I take P's blood pressure. Then ask P to get up on the exam table.

Uh-oh. P has difficulty getting out of the chair, splinting. Splinting by holding a hand to P's lower left side, and it's obviously painful. P is short of breath by the time P stands up and is pale once P is on the exam table.

I already know it's not asthma or an emphysema exacerbation because P was not short of breath after sitting for a bit. This is very worrisome for an acute abdomen. That's our term for peritonitis, this person needs surgery. I do my exam. P can barely lie back because it hurts so much. Damn.

The signs we look for: pain. Guarding is tightening the muscles from the pain during the exam and is not always voluntary. Rebound is when I press on another part of the abdomen, say, right upper quadrant and it hurts down on the left. A really bad abdomen is rigid. P is not rigid. Bowel sounds will also be decreased and I didn't bother: P is going to the emergency room. And not driving.

I drive P, hand over my note and leave.

I don't hear anything. Technically the hospital is supposed to send me the note, it's a national mandate, but well. Three days later we request it.

Ah. Life flighted to Seattle for not only diverticulitis but perforated diverticulitis with a large left lower quadrant abscess. The big Seattle hospital is also not sending me notes. We request them.

I call the home number the next day. I talk to the spouse. P is just home from Seattle, asleep, much better.

I talk to P a few days later. "Thank you." says P. "I didn't realize it was that bad."

It could have just been diverticulitis, in which case P would have gone home from the emergency room with antibiotics. I could not be sure without the imaging and would not have the priority outpatient. Sometimes outpatient is just not fast enough.

And prevent diverticulosis: eat more fiber. Vegetables and fruit and whole grains.

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