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Life & Death


Part 1

     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
(Operating Room).

     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
room.

     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

Part 2

     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
scalpel.

     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
retractor.

     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
golf.

     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
the past.

Life & Death

Part 3

     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
straight...neatness counts.

     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
Surgery's office.

     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!

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