So you've spent half your life hacking at Orcs, obliterating
alien hordes, and dragging leisure-suited misfits around the world.
Now you're looking to do something useful for humanity. Well, your
timing is great. Toolworks General is looking for a few good surgeons
to assume the burden of a few appendectomies, infections, and vascular
grafts. No problem at all!
When you start the game, you'll need to sign in on the
receptionist's clipboard. She'll welcome you and prompt you to go to
the classroom, but let's not do that yet. Using whichever input device
you have (a mouse is ideal for this game), set your difficulty level
to Novice until you've successfully completed both operations. Erase
the scrawl in the box at the bottom of the option screen by clicking
on the small Erase checkbox; then draw your own initials in the space
provided. You can turn off the sound at this point, but don't unless
you absolutely have to: The sounds of the EKG and of the clamps
closing are extremely useful.
Click outside the box to signify you're done setting parameters.
Now you're ready to hand-pick your surgical staff and start seeing
patients. Since your first operation will be an appendectomy, let's go
into the Staff room and choose knowledgeable and cooperative
assistants. Otherwise they'll be of no help at all in the OR
Look over the six files by first clicking on the filing cabinet,
and then on each name (NOT in the small check-box). You'll get a photo
and brief description of each staff member. Gregory Danielson is a
must for appendectomies; click on his check-box. But that means that
you will NOT want Beverly Kabes on your staff, nor will you want
Laurelee Menzies (whose area of expertise is irrelevant to this
operation). Kim Brewer would be a good choice if you're looking for a
general nurse to assist; if you have trouble keeping your eye on the
EKG, then pick Ken Shepherd instead of Kim. If you're anticipating
trouble with incisions, David Manglier would also be a decent
alternative. My personal picks are Danielson and Brewer.
Click on the door of the Staff room to leave and head into the
Classroom. Watch the blackboard and listen closely; the advice is
basic (most can be found in the manual). When class is over, click on
the door and the receptionist will tell you where your patient is.
In the patient's room, there's no need to look at the clipboard
yet. The patients' complaints all sound the same, and your main
diagnostic tool is to palpate the abdomen, so click on the abdomen of
whoever's in bed. Click all around the area; be sure to get each
quadrant at least once or you'll be reprimanded further on down the
line. In this, the first half of the game, here are the guidelines for
diagnosing: If there is no pain response anywhere on the abdomen, that
signals intestinal gas and should be OBSERVED. If there is pain
response all over the abdomen, that signals an infection and should be
MEDICATED. If there is pain only in some parts of the abdomen, that
could be either appendicitis or kidney stones; you MUST take an X-RAY
(even if the pain is only on the patient's left side and thus unlikely
to be appendicitis). If there are kidney stones, they'll appear as a
clump of small white dots ABOVE the pelvis (surrounded by black). If
such stones appear, your action should be REFERRAL (since urology is
not the field you're in). If no stones are present, that's
appendicitis! Click on OPERATE on the clipboard and exit the patient's
If you've just booted up, you'll be advised to check in on the
phone (the copy protection). Do that if you need to; the receptionist
should then inform you that they're waiting for you in OR. Head for
the OR and here we go!
Life & Death
On the upper right is the section of the patient's body with
which you'll be working. Beneath the body is a message box (it may not
appear instantly) where words of encouragement, advice, and scorn will
appear from your two assistants. Next to it is a small bottle
representing the current fluid connected to the patient's IV. At the
left is the EKG and the anesthetic machinery, and below that are a
tray and two drawers (currently closed) with all the instruments
you'll need to operate. You can see that the anesthetic is OFF and the
breathing and heartbeat are regular. You'll want to learn to keep your
ears tuned to that EKG; if the pitch changes or if the constant
beeping stops, you'll have to turn your attention to the problem.
Although you have assistants who will be commenting along the way, I'm
going to assume you're in this alone.
The two kinds of heart problems you'll run across are PVC and
Bradycardia. With PVC, the EKG will drop in pitch and the line will
plummet and bounce back (see the manual for a picture). The cure for
this is a quick injection of Lidocaine, already in a hypo in the
bottom drawer (marked with an "L"). PVC is easy to remember because it
will look like a "V" on the EKG. Bradycardia shows a relatively flat
EKG, and the beep will stop altogether; this requires an injection of
Atropine, marked with an "A" and sitting next to the Lidocaine. Think
of "A" going with "B" and you can easily recall Atropine going with
Bradycardia. (These sorts of mnemonics are exactly what help most
medical students get through school.)
Once in a while, the patient's blood pressure will drop. This
will happen without fail if you don't start the patient on IV blood
before you begin cutting. If the heart rate does drop, put blood in
the IV and quickly clamp and cauterize all bleeders. But if the rate
drops to 50, immediately inject the patient with Dopamine (in the
bottom drawer, marked "D"). You only have one hypo of Dopamine and
unlimited hypos of Atropine and Dopamine.
Since the patient's still awake, you're not likely to run into
EITHER problem! So let's get down to some hacking and slashing of an
entirely new kind.
Open the bottom drawer (just click the fingertips on the end of
the drawer), and open the top drawer. From the top drawer: Click on
soap to wash; click on gloves. Click on the large bottle with the "A"
on it (it's antiseptic). Holding the button down, move the antiseptic
cloth all over the skin; try not to leave any unwiped areas. The area
will be shaded with black dots to show where you've wiped. Return the
antiseptic to the drawer, and pick up the sterile drape (the folded
cloth on the left). The cursor will change to a square; place this
square all the way to the upper left corner of the abdominal window so
that the corner of the square fits neatly into the corner of the
window (don't leave any visible area in between) and click. You should
get a very thin, almost unnoticeable line around the abdomen --
virtually no drape at all. This is crucial since you'll need every
available millimeter of space with which to operate. If the square
cursor vanishes and is replaced by the hand, and the abdomen window
flickers slightly, you've done it right. (A comment in the message box
may confirm it.)
Close the top drawer. Turn on the gas. Pick up the hypo labeled
"B" (the antibiotics) in the bottom drawer, and move it over to the
skin; click to inject, and the hypo will vanish. Get a bottle of blood
(it LOOKS like blood) from the drawer, and click it on the full bottle
next to the message window; that bottle should change to blood. This
will prevent the patient's blood pressure from dropping as you make
your first incision. Close the bottom drawer, and pick up your
You'll be making a McBurney's incision (page 92 of Lindstrom's
notes). From your point of view, you'll be making a single, straight
cut from the upper left corner of the abdomen to the lower right
corner. Make the line as long a possible; this is also crucial because
it determines the size of the wound you're creating, and you need a
BIG wound to get at the appendix. So, start and end as close to the
very corners as you can (without cutting the drape). Incision
technique isn't easy; you'll need to learn to cut as straight as
possible while also cutting QUICKLY (which helps to keep the incision
neat). Practice is the only solution here.
Make that incision in the abdomen. Then drop the scalpel, pick up
the forceps (lying horizontally above the scissors) and clamp a
bleeder (the widening circles of red that will appear along the
incision). As you clamp, you should hear a "click" and you'll probably
get a comment affirming the action. Another forceps will have
appeared; clamp all the bleeders. When all the bleeders have stopped
spreading, pick up the cauterizer (looks like a soldering iron on the
left edge of the tray) and click once LIGHTLY on each bleeder. You may
need to do this 2 or 3 times on each, but eventually you'll have
cauterized them all. Then remove each clamp, one at a time, and using
either sponge or suction hos (S-shaped), remove the blood.
Pick up the skin spreader (the butterfly-shaped mechanism at the
bottom of the tray), and click it on the incision. The skin will peel
away and reveal a layer of subcutaneous fat. Congratulations! Get
somebody in the room to wipe your forehead.
All the while, of course, you'll be listening to the EKG and
injecting the proper fluid when necessary. Also keep your eye on that
bottle; when the blood is about to run out (don't wait till the last
moment), put in a bottle of Glucose from the bottom drawer.
Now do the same thing to the subcutaneous fat that you did to the
skin; incise at the same angle, clamp bleeders, cauterize, remove
clamps, and wipe clean. Again, be sure to go to the very corners for
your incision, but be careful not to cut _beyond_ the corners to the
skin above. Retract the fat to reveal the oblique muscle tissue.
The oblique muscle (and the transversus muscle below) has no
blood vessels and will not cause bleeders. Cut the oblique muscle
layer exactly as in the last two layers, going from corner to corner
and making a straight, neat incision. The next layer -- the
transversus muscle -- is striated in the oth direction. Don't cut at
the usual angle; cut "with the grain" from upper right to lower left.
Keep making those incisions as long as possible. Retracting the
transversus will reveal the peritoneum, through which you can vaguely
see the end of the large intestine (which covers the appendix).
The peritoneum calls for very delicate incising. Unless you have
version 1.03 of the program (or better), forget what the manual tells
you about incising the peritoneum and listen carefully. You're going
to cut diagonally from upper left to lower right with the scissors.
FIRST, pick the spot where you're going to start the incision. Pick up
the scalpel and click once just at that point; you're scraping the
peritoneum but not cutting it. Don't draw a line, just click once and
let go. Put the scalpel down and get the forceps; clamp the forceps
just a pixel or two below where you just scraped. With the forceps in
place, pick up the scalpel again and click once more on the same point
you scraped; a large black dot should appear. Drop the scalpel, remove
the forceps, pick up the scissors and start clicking. Make each click
a little farther down and to the right of the last, but not too far or
the program will think you've started a new incision. Don't make your
first snip right on the black dot; make it a bit further down/right.
Continue all the way to the lower right corner and use the skin
Voila! There's that lovely large intestine, covered with infected
fluid (the black shading). From the bottom drawer, take the test tube,
and click it on the abdomen to get a fluid sample. Close the drawer
and get the suction tube start to suction off the liquid, and it'll
come right up. Put down the hose.
Click the fingertips at the bottom of the large intestine.
Provided you've made the incisions long enough, the cecum will flip up
into sight. If the incisions aren't as large as they need to be, you
won't be able to get at this area, and you'll have to abandon the
operation. But let's hope for the best.
Open the top drawer and get the roll of gauze. Click the gauze at
the base of the cecum, and the cecum becomes packed and immobilized.
Close the drawer. I assume you're still watching the IV and the EKG?
Of course you are.
Once again, click the fingertips at the base of the cecum to
expose more intestine. Click the fingertips at the base of this new
intestine, and the appendix pops up, pointing to the right. Take a
clamp, the L-shaped object in the center of the tray. Clamp the tip of
the appendix, all the way to the right and just above the bottom edge.
If you clamp in the wrong spot, the appendix may rupture; in that
case, take the drainer from the top drawer (the red bulb) and drain
the appendix before continuing. If you've clamped the appendix
correctly, it will be lifted and the underside exposed. You're doing
great if you're still with me; put the game on pause and play some
You're going to nick the mesoappendix membrane. Pick up the
scalpel. There's a red line, or shadow, running the length of the
appendix. You'll nick -- a quick click -- at a point slightly to the
right and about a fifth of the way up that red line. If you mess up,
you'll know it...and they'll show you in class the proper place to
nick. Assuming you've clicked in the right place, you'll get another
big black dot with a small white dot in the center. Put down the
scalpel and take the needle and thread. Click once at the center of
that dot to suture the mesoappendix artery.
Get the scalpel. To sever and remove the artery and membrane, you
click once directly on that long red shadow, a pixel or so below the
bottom edge of the clamp. The clamp appears spread; use the lower of
the two clamp ends as a reference point. Click just below that end,
and the membrane vanishes. Now get another clamp and clamp the base of
that long, red shadow; Danielson should confirm that the LOWER clamp
is in place. Get another clamp and clamp at about the middle of the
shadow; Danielson will remark that the HIGHER clamp is in place. Get
the needle and thread, click once between the two clamps, and a small
"purse string" suture should appear. Click the scalpel just above the
suture, and off it goes. The appendix is gone. All the clamps except
one will vanish. Remove that clamp and click the fingers on the cecum
to tuck in the wound. A small hole appears on the cecum; click the
needle on that once to make a Z-string suture across the hole. Put
away the needle, and click the fingertips on the base of the cecum.
That'll instantly remove the gauze and tuck everything back into
place. You're ready to close!
To close each layer, pick up the skin retractor. Move it all the
way to the right of the window; it will be almost entirely off the
screen. Click it once and the peritoneum closes. Put down the
retractor, pick up the needle, and place sutures along the closed
incision. They don't have to be touching, but they should be fairly
close together. You'll need to make a lot of them.
Once you've finished suturing the peritoneum, take the spreader
and click it all the way on the right as you did just before. The
transversus muscle layer closes; suture it the same way. Now close and
suture the oblique muscle layer and the subcutaneous fat layer. Close
the skin layer, but don't suture it. Secure it with the X-shaped skin
clips in the upper left corner of the tray. Put them close enough
together to touch. Turn off the gas, and let the patient go to
Recovery. Congratulations! This was the hard part.
When the program evaluates the surgery, you'll be told to go to
Medical School if your performance was not perfect. If it was perfect,
you'll be congratulated for having performed an appendectomy and sent
to medical school anyway! But now you'll be promoted to deal with a
different set of problems, and appendectomies will become a thing of
Life & Death
Your new crop of patients will have one of three possible
conditions: arthritis, immature aneurysms, and mature aneurysms. The
diagnosis is just nearly as straightforward as in the previous part of
the game. Carefully palpate all areas of each patient's abdomen. Be
certain to palpate several times just below the navel. If the patient
has pain all over the abdomen, take an X-RAY. You'll probably find
that the spine is practically a solid white mass; this indicates
arthritis and requires MEDICATION. If the patient's response to
palpation under the navel is "That feels like a lump" or some mention
of a lump, that's probably an aneurysm. Do an ULTRASOUND SCAN to
determine its size. If it's less than "5 cm" in diameter (use the
ruler up above the ultrascan screen to judge), it's immature and
should not be operated upon. Check OBSERVE. If the aneurysm is 5 cm or
larger (as it probably will be), you'll have to OPERATE!
Before you go into the OR, though, you'll want to readjust your
staff. Be sure to include Laurelee Menzies, the resident expert on
aneurysms. Your other assistant should be either Kim Brewer, Bev
Kabes, or Ken Shepherd. Head into the OR. You'll note a few new items
on the trays, but don't be intimidated. Next to conquering the
appendix, this one's almost a cakewalk.
Open the bottom and top drawers. Use the soap and the gloves (in
that order please!). Apply the antiseptic (this time you have a whole
abdomen to work with). Put on the drape, and as before, you're going
to leave as much room to operate with as possible. Close the top
drawer, turn on the gas, inject with the "B" hypo (there's a new one
marked "H" for Heparin, which you'll need in a bit). Hang a bottle of
blood on the IV and pick up your scalpel.
This time you won't be making any McBurney's incisions. Cutting
smoothly, incise the abdomen straight down the middle from as far on
top to as close to the bottom as you can without touching the drape.
There shouldn't be much drape there, anyway...only a line or two on
top and bottom. Work quickly to clamp all the bleeders with the
forceps. The cauterizer is gone; we now have a ligator -- a
pretzel-shaped loop on the tray. Pick it up and center it over each
bleeder; click once to ligate each bleeder. When you've gotten them
all, remove the forceps and wipe the area clean. Separate the skin
with the skin retractor. Do the same with the rippling subcutaneous
fat layer. Always be vigilant for problems with the EKG; act quickly
with Atropine, Lidocaine, and Dopamine when necessary.
Now you're down to the muscle layer, the rectus abdominus. This
one won't bleed. Cut down the linea alba, the thick white portion at
the center. Spread using the retractor. You'll be looking at the
preperitoneum, which is incised the same way the peritoneum was: Click
with the scalpel to scrape, elevate just below with forceps, click
again with scalpel to nick a hole, remove forceps and snip all the way
down with the scissors. Be cautious not to make your snips so far
apart that you appear to be making a separate incision; this will
puncture the intestines. But do try to make the incision
After snipping the preperitoneum, spread it. Using your
fingertips, click on the bottom of the chest to push the intestines
out of the way. In the top drawer you'll see a small bag (called the
gut bag). Click the bag on the intestines at the top of the screen to
keep them clean, tidy, and out of the way. Underneath the intestines
is the postperitoneum, and underneath that, the murky shape of the
aneurysm. Scrape, elevate, nick and snip the postperitoneum exactly as
you did with the preperitoneum. Spread it and there's the aneurysm,
the swelling just above where the two iliac arteries merge.
In the bottom drawer, take the Heparin and inject it before
proceeding. This prevents embolisms in 100% of my cases so far! I
wouldn't know what to do if there WAS an embolism. Click the
fingertips at the base of the aneurysm and rubber tubing will appear
in place. The aneurysm is now immobilized and ready for action!
Take a clamp (NOT a hemostat) and clamp either of the iliac
arteries, then clamp the other one. Put another clamp on the small
vessel (mesenteric artery) extending from the center of the aorta,
close to where they come together. Then put a clamp at the top of the
aneurysm, right where it comes into view. Work quickly at this point;
you've cut off the blood supply to the legs!
Take the scalpel and nick the mesenteric artery just above the
clamp (not between the clamp and the aorta). A bleeder will appear;
ligate it. You're going to incise the aorta with the scalpel. Don't
start right at the top! Start about a quarter of the way down the
aneurysm or the incision will be too long, and you'll have to abort
the operation. Make the incision straight and clean; don't bring it
quite all the way to the bottom. Use the skin retractor to expose the
clot. Remove the clot with your fingertips; take the Y-shaped dacron
graft from the bottom drawer and put it in place.
The graft has to be sutured into place. Take the needle and put
three sutures into each of the graft's three ends (nine sutures
altogether). You should be able to see each of the three sutures
connecting the graft to the artery walls. Put down the needle.
Before you can complete the suturing, you have to close the
artery walls around the graft. With your fingertips, click at the
junctures of the graft (the three ends) until the flaps of vessel
tissue close around them. Then take the needle up and suture three
times at each juncture again, for a total of six sutures in each of
the three branches. Pick up the retractor and close the aorta around
the graft. Suture the aortal incision with close stitches.
The next step is a test of your previous work. Remove one of the
iliac clamps. Then remove the next. Finally remove the clamp at the
top, re-establishing the flow of blood through the aorta. If no
bleeders appear, you've made it! If bleeders do appear, replace the
three clamps, starting wit the two iliac clamps. Resuture the incision
and try again.
Once the aorta is repaired, remove the rubber tubing. Then
un-retract the postperitoneum. Suture it. Remove the gut bag and
replace the intestines. Un-retract the preperitoneum and suture it.
Un-retract the next two layers (chest muscle and subcutaneous fat).
After un-retracting the skin, close it with skin clips instead of
stitches. Turn off the gas, and pick up your diploma in the Chief of
You retire wealthy, and your name will vanish from the
receptionist's clipboard. Should you want to relive past glories, head
into the Staff room and click on the file cabinet. Again, hearty
congratulations: I'll catch you on the back 9!