Conclusion and Common Curveballs
As a final conclusion to the information I’ve presented in this book, I have some parting words of advice:
(1) dress conservatively, (2) don’t appear hesitant,
(3) don’t quote the textbooks or the literature,
(4) never mention a test or procedure you can’t fully describe and
(5) remember that the stress of the exam will do strange things to you.
I recommend a single dose of Immodium, a good movie, and possibly a “shot” of alcohol the night before.
I’ve also included a list of the most common curveballs to anticipate. We all see these in real life and know how to manage them, but it’s easy to end up with a swing and a miss when one comes at you on the exam. The examiners are trying to determine whether or not you are a safe sur- geon. Keeping that in mind, anticipate the following ahead of time and you won’t get shelled in anyone scenario and you may avoid a return trip to the Oral Exam:
The pt with a bowel obstruction will have had a recent MI
The incarcerated/strangulated hernia will reduce on induction of anesthesia
The trauma pt will have multi-system injury especially abdominal and neurologic trauma
Consultants will never be available
Pts needing laparotomy will often have had prior abdominal surgery
There will be a synchronous mass in the colon cancer patient
The obstructing left colon cancer will have a cecal perforation
The pt will have a cervical leak after a Zenker’s diverticulectomy
The pt will perforate after upper/lower endoscopy Percutaneous drains won’t work
The pt will be hypotensive/hypoxic in the recovery room The pt will have multiple GSWs
The pt will have neurologic findings after a GSW to the abdomen
The chest tube placed for a hemothorax will clot off and make you think the output has truly decreased The AAA will have post-op: MI, colonic ischemia,
renal failure
The pt started on Heparin will develop HIT The low anterior resection will leak
Medical therapy will always fail
The MI pt will throw a clot to the SMA 6 weeks post- op
The pt will develop a pseudoaneurysm
The pt will develop a enterocutaneous fistula after extensive LOA
The FNA will not be definitive in any solid mass The sarcoma will involve an artery/nerve
The colon cancer will have a colovesical fistula
Dissection in the pelvis for diverticulitis/cancer will injure the ureter
The colon cancer will involve the ureters
The rectal cancer pt will present with large bowel obstruction
The young pt with HTN will have an MEN syndrome The ERCP will fail to remove an impacted stone or
diagnose malignancy
The uneventful lap chole will develop post-op jaundice The gallstone ileus will have more than one stone in the
small intestine
The pregnant pt will need surgical intervention
The pre-op lymphoscintigraphy for a SLN in melanoma will light up two lymph node basins
Sarcoma will locally recur A.fib complicating any scenario
Gastric MALT-oma won’t respond to H. pylori treat- ment
Lung resection pt will have continued air-leak Abscess will complicate every operation
The ex lap/splenectomy/lap chole will have an unantici- pated ovarian mass
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Mobilizing the right colon will injure the ureter/IVC The colostomy will become ischemic post-op
The post-op thyroidectomy will have parathyroid or laryngeal nerve injury
Vascular prosthetic grafts will thrombose/get infected The DVT will fail medical therapy or develop phlegmasia Post-op trauma pt will get abdominal compartment
syndrome
Excisional biopsy for DCIS will have positive margins
Stomach cancer will be high on lesser curve adjacent to GEJ
Post-op Whipple will have pancreatic leak Duodenal stump will blow out on BII Pancreatic necrosis will get infected
Pseudocyst will erode into adjacent structures (stom- ach, colon, splenic vessels)
Results of percutaneous biopsies will always be incon- clusive
Strikeouts 157
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