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Life & Death 2


     Welcome to the classroom here at Toolworks General. This is where
the  Chief  Neurosurgeon  will explain the essentials in the diagnosis
and  treatment  of  various  neurological  dysfunctions  and  surgical
procedures.  It  is  best  to  come  here  with  your questions before
operating.  The  medical  community  frowns  on experimenting with the
patients, especially unto death.

     When  you botch an operating you will find yourself the object of
a  stern  lecture  from  the Chief Neurosurgeon. He will also send you
back  to  this  classroom  for  remedial course work and an occasional
visual aid.

     Just point and click your mouse or mouse substitute on the screen
when  you  are finished reading its contents. The page will appear, or
you  will  return  to  the  menu  to select another classroom subject.
Whenever  you  are  finished in the classroom, exit by clicking on the
door behind the chief neurosurgeon, or pressing ESC.

     While  making  your  rounds  or just exploring Toolworks General,
merely  point  and  click  on  your  room of choice. You have your own
office  next  to  the  chief  neurosurgeon's, where you can make staff
decisions  and hide from family members. You may even visit the morgue
to reminisce over your past mistakes.

     Once  inside  the  various rooms you may find help text, click on
various  objects  or observe the activities related to that room. Just
click  the  EXIT  sign to return to the main hospital screen. It isn't
quite as easy to leave the operating room when surgery is in progress.
To  change the parameters of the game just click on the receptionist's
clipboard.

     To exit Toolworks General (perhaps in embrassment on being yanked
from  surgery), point and click outside the hospital walls on the main
hospital  screen. Remember, brain surgery is always a matter of LIFE &
DEATH. Are your malpractice premiums paid up?

GENERAL DIAGNOSTIC PROCEDURES

     When  instructed to attend a patient in one of the four Toolworks
General private rooms, you will need to perform a physical examination
that  involves  a series of neurological tests. Those results and your
experience as a neurosurgeon will help you determine the proper course
of treatment.

     Once inside the patient's room, click the chart (Patients Orders)
for his or her vital information and symptoms. Click off the chart and
click  on  the  patient's  face, arms or legs to continue the physical
examination in those areas.

     For  the face, a close-up of the patient's eyes apper, and a tray
of  instruments  just below. Grab the pointer object in the upper left
of  the  tray  by  pointing hand cursor and clicking. Position pointer
over  face,  click left button (or equivalent) and hold as you move it
around the screen to test eye movement for any abnormalities.

     Replace  the  object  by  moving  over tray and clicking. Use the
penlight  to check pupils for light reactions and observe any abnormal
dilation.  Test  the patient's speech by grabbing the "SAY ALICE" card
and clicking it on the face area.

     Next, take the pin to check sensory response on both sides of the
patient's face. Don't stick it where it doesn't belong unless you want
to go back to med school.

     The  clipboard  at  the lower right will track the results of all
your  tests  for  future  reference.  Just  click on it if you want to
review  test  results.  Click  off  the image area to return to a room
view.

     Now  moving  to  the arms, click for the close-up and examine the
patient's  strength  by pointing your hand on the patient's left hand.
Lift  by  clicking, holding and dragging the mouse upward. Release the
mouse  button  to  observe  how  the patient's arm falls. It will fall
quickly if there are any weaknesses. Repeat for the right arm.

     Test the patient's reflexes with the hammer by tapping (clicking)
at the elbow for both arms. An appropriate sound will indicate whether
you  have  tapped  the  right  area.  Observe any absent or aggravated
responses. Again take the pin to test sensory response in both arms.

     Follow the same procedure for the legs as you did the arms. Don't
forget to lift each leg with your hand and observe weaknesses.

     Once  you  have finished your examination, click on the clipboard
next  to  the  tray  to  evaluate  the results. The handy neurological
textbook  will help you to determine which, if any, major tests may be
required,  or  confirm  your  diagnosis  for  a  prescribed  course of
treatment under the patient's clipboard.

     When  you  have  questions about medical imaging results, such as
CAT  scans,  MRI, x-ray and angiography, visit the imaging labs to see
some  sample  images. The labs are located in the back corridor of the
hospital.

     If  you order any major tests, order only those indicated by your
physical examination results. Study them carefully, then check off the
prescribed  treatment and initial (you do want credit if the treatment
is  a success). If you are headed for surgery, you may want to stop in
the cafeteria for a quick cup of coffee and the latest gossip.

INTERPRETING SKULL X-RAYS

     Skull X-Rays are a technique for providing images of the skull in
the  diagnosis  and  treatment  of  neurological  disorders.  After  a
complete  physical examination, it may be necessary to order X-rays of
the  skull  to  confirm  the presence of a fracture, and its severity,
when  a  head  injury  is  suspected  as  the  cause  of the patient's
symptoms.

     The  X-ray  may  provide  valuable  information  to  confirm  the
likelihood of a subdural hematoma when ambiguous symptoms are present.
The  image  will reveal a fracture where the head injury occurred that
led to the collection of blood between the dura mater and the brain.

     If  an  injury  is suspected, or an fracture is found, a CAT scan
can also be performed to provide additional information. The X-ray, in
some  cases,  may  be  used to exclude hematoma when a fracture is not
found.  However,  exposing the patient to unnecessary risk and expense
is not considered good diagnostic form for a would-be brain surgeon.

     Other  significant  and serious brain disorders such as ane rysms
and  tumors will return a normal skull X-ray, therefore a normal skull
image does not rule out a brain disorder of those types.

INTERPRETING CAT SCANS

     A  CAT  (computerized  axial  tomographic)  scan  is a diagnostic
technique  which  combines  the  use  of  a computer and X rays passed
through  the  body  at  different  angles.  The  computer analyzes the
density of tissues and organs.

     It  produces  cross-sectional  images of the area being examined,
providing  clearer  and  more  detailed  information  than X-rays used
alone. CAT scanning tends to minimize the amount of radiation exposure
to the patient.

     The  scanned  images  reveal soft tissues (including tumors) more
clearly  than  normal X-ray pictures. The CAT scan images are valuable
in  brain  disorders  due  to  their  sharp  definition  of ventricles
(fluid-filled spaces).

     Because CAT scans utilize iodine dye to contrast various tissues,
patients allergic to iodine should not be subjected this test. !!!

     The  MRI  scan  should be used instead. Additionally, the dye can
further  damage  an  injured kidney. Patients subject to kidney damage
should not !!! be CAT scanned either.

     CAT scans are valuable in confirming the preliminary diagnosis of
aneurysms  (unless bleeding is very small), brain tumors, hematoma due
to  head  injury  (scan will show abnormal clot and skull indentation)
and  the  damaged  areas  of the brain due to infarction (stroke) when
balanced  against  information from the patient's history and physical
examination.

        INTERPRETING MRI SCANS

     Magnetic   Resonance  Imaging  (MRI)  is  a  valuable  diagnostic
technique  that provides the neurosurgeon high quality cross-sectional
images  of  brain  structures. The images produced by MRI scans fo not
employ  the  use  of  X-rays  or other radiation. While similar to CAT
scans,  the MRI scan usually gives greater contrast between normal and
abnormal tissue.

     During  imaging,  patients  are  exposed  to  short  bursts  of a
powerful  magnetic  field. The nuclei (protons) of the body's hydrogen
atoms  then line up in parallel to each other as opposed to the normal
random arrangement. When they are knocked out of alignment by a strong
pulse  of  radio  waves, they return a detectable radio signal as they
fall back in to place.

     The  computer  interprets  these  signals by the varying strength
returned  by different body tissues and convert the information into a
high  quality  image.  Because  of the strong magnetic field involved,
patients  fitted  with  a pacemaker or other electrical devices should
not  !!! undergo MRI scans. The CAT scan should be used instead. There
are no other known adverse effects.

     MRI  scans  are  particulary  valuable  in  studying the brain an
spinal  cord.  This technique reveals tumors vividly, indicating their
precise  extent.  MRI  scans  also give detailed images of vessels and
thus  reveal  aneurysms (unless bleeding is small), hematomas (showing
clotting and skull indentations), and brain damage due to infarctions.

INTERPRETING ANGIOGRAMS

        Angiography is the procedure where an angiogram is produced in
order to examine the integrity of blood vessels on film. It is used to
detect diseases that alter the appearance of the blood vessel channel
especialy aneurysms.

     A   contrast   medium   (dye)  is  injected  into  the  patient's
bloodstream  and  X-rays  are  then  taken  to look for abnormalities.
Digital subtraction angiography uses computer techniques to remove, or
subtract,  unwanted background information. This procedure is somewhat
safer because it uses smaller amounts of contrast medium.

     For the neurosurgeon, angiograms provide valuable information for
diagnosis of aneurysms by indicating the location of the dilated blood
vessel. CAT and MRI scans may miss aneurysms if the bleeding is small.

     In subdural hematoma, the angiogram will indicate displacement of
vessels  by  the  blood  clot.  For  patient's  suffering  infarction,
angiography  often  indicates  the occlusion. This procedure will also
reveal an invisible mass compressing the blood vessel in the case of a
brain tumor.

DIAGNOSING/TREATING ANEURYSMS

     Ballooning  of  an  artery  due  to the pressure of blood flowing
through  a  weakened  vessel is called an aneurysm. Cerebral aneurysms
may  persist  for  many  years  without  causing  symptoms,  but their
proximity  to  many  important  neurological structures make them very
dangerous.  These  dilations  may gradually enlarge until finally they
rupture and bleed into the brain.

     SYMPTOMS. Sudden enlargement and bursting of an aneurysm produces
obvious  symptoms and signs. Patient's may complain of severe headache
or experience unconsciouness (symptoms simlar to a stroke).

     Look for weakness of the arms and legs, along with abnormal pupil
dilation,  light  reaction,  and possible paralysis of eye movement on
the opposite side of the patient's body in relation to the aneurysm.

     DIAGNOSIS.  The  angiogram  produced through angiography provides
more  detailed and definitive information in the confirming tests than
skull  X-rays,  which  usually  appear  normal.  The dilation may also
appear  on  the  CAT  scan  or  MRI scan and offer additional valuable
information (unless the bleeding is very small).

     TREATMENT.  Because  a  ruptured aneurysm can lead to fatal blood
loss  and  severe  damage to the brain structure, proper diagnosis and
decisive  action  is  imperative. Once confirmed through dianosis, the
patient  should  be  prepared for surgery immediately. Bone up on your
knowledge of procedures though this one is tough sledding.

DIAGNOSING/TREATING TUMORS

     A  tumor is an abnormal mass of tissue that forms when cells in a
specific  area  reproduce at an accelerated rate. Though tumors may be
malignant  or  benign,  all brain tumors are serious. Malignant tumors
invade   surrounding   tissues,  spread  through  the  bloodstream  or
lymphatic system to form a secondary growth.

     Benign  tumors tend to grow more slowly and remain within fibrous
capsule.  This makes surgery and removal more straightforward. Because
tumors  press  on  nearby  structures,  they are very dangerous in the
confined spaces of the skull.

     SYMPTOMS.  As  the tumor grows it presses on normal brain tissues
causing  headache  or  weakness  in the arms or legs. Reflexes will be
aggravated  accompanied  with a loss of sensation on the opposite side
from  the tumor. The patient's speech will be impaired if the tumor is
located on the left side of the brain.

     DIAGNOSIS.  To  further  confirm  the physical examination, brain
tumors  are  located primarily by the use of a CAT scan or MRI scan to
view  the  abnormality.  An  angiogram  may  reveal  an invisible mass
compressing  the  blood  vessels.  Skull X-rays are usually normal and
should be viewed as unnecessary if other symptoms preclude it.

     TREATMENT. The patient's outlook is very poor if the tumor is not
removed by opening the skull. The majority of cases will end in death.
Once  the  diagnosis is confirmed, proceed immediately to OR and don't
forget  to bring your patient with you. Refer to the classroom subject
"Excising Brain Tumors" to improve your changes for success.

DIAGNOSING/TREATING INFARCTIONS

     An infarction (stroke) occurs when a blood vessel that supplies a
part of the brain becomes blocked or leakage occurs outside the vessel
walls.  This loss of blood supply results in the death of that area of
tissue. Infarctions vary in their severity with one third of the cases
resulting in death.

     SYMPTOMS.  Infarctions  will  result  in  weakness  and  loss  of
sensation  on  the  opposite side of the body. Physical examination of
the  head area will reveal abnormal pupil dilation, light reaction and
lack of eye movement on the opposite side. If the infarction occurs on
the  left  side  of the brain, speech will be slurred. Reflexes may be
aggravated as well.

     DIAGNOSIS.  CAT  and MRI scanning will show a damaged area in the
brain,  showing that the symptoms were not caused by a tumor, subdural
hematoma or other brain disorder. The blockage will also appear on the
angiogram.

     A  stroke  parallels  some  symptoms  of  aneurysms,  tumors  and
migraines, but with significant differences. Be careful to compare all
results of examination before deciding on a course of treatment.

     TREATMENT.  In  tissue losses that are not immediately fatal, the
best  course  of action is to make every effort to restore impairments
through  physical  therapy, speech therapy and exercise. The degree of
recovery  will  vary patient to patient. Avoid extreme embarrasment by
not performing surgery on an otherwise normal brain.

DIAGNOSING/TREATING MIGRAINES

     Migraines  are  severe  headaches  lasting  from two hours to two
days.  Sufferers  may  experience  one  attack, but more commonly have
recurring attack at various intervals. They are caused by the dilation
or spasms of blood vessels in the brain.

     SYMPTOMS.  There  are  several types of migraine, and a number of
factors  may singly or in combination brain on an attack. One type can
cause  motor  weakness  of  the  arm and leg on one side, similar to a
stroke. Reflexes can be aggravated and speech wil often be impaired.

     DIAGNOSIS. Special tests are rarely needed. Diagnosis should come
from the patient's history and physical examination.

     TREATMENT.  Severe  migraines  often  require simple preventative
measures   that   avoid   any   known  trigger  factors.  If  that  is
unsuccessful,  it  may  be necessary to prescribe a more powerful drug
such as codeine.

DIAGNOSING/TREATING HEMATOMAS

     A  subdural  hematoma is the enlarging collection of blood in the
space  between  the  dura mater and the brain. The common cause is the
tearing  of  veins inside the dura mater following a blow to the head.
This  may  go  unnoticed  by  the  patient for weeks before the trauma
becomes sufficiently symptomatic.

     SYMPTOMS.  The  bleeding  occurs  slowly,  but increases pressure
within  the  skull, displacing and pressing on brain tissue. Headaches
and  confusion  may  follow, along with one-sided weakness on the same
side  as  the  injury.  Physical  examination will show abnormal pupil
dilation  and  light  reaction.  Speech may be slurred if the hematoma
occurs on the left side.

     DIAGNOSIS.  CAT  and  MRI scans will show abnormal blood clotting
and   indentation  of  the  skull.  Angiography  will  show  invisible
displacement  of  the  blood  vessels  by  the clotting. X-rays should
confirm location of injury by revealing a skull fracture.

     TREATMENT.  If  the  diagnosis  is confirmed through major tests,
surgical  treatment should follow immediately. Time is of the essence.
Though  not the most complex of neurosurgeries, special care should be
taken  to drain clot, repair vessels and provide continued drainage so
that  the clot will not reform. Proper surgery usually allows complete
recovery.

DIAGNOSING/TESTING HYSTERICAL

     Hysteria  is  a  term  encompassing  a broad range of physical or
mental symptoms. This was originally thought to be a disorder confined
to  women. Many psychiatrists feel this term is not specific enough to
be useful in diagnosis. Hysterical paralysis is often seen in patients
suffering from such high anxiety, thus leading to some confusion about
whether or not the disorder is neurological in origin.

     SYMPTOMS.  A  physical  examination  of the patient will reveal a
weakness in the arms and legs on one side of some patients. Facial and
other sensory defects may also be present.

     DIAGNOSIS.  In  the  absence of any other telling symptoms during
physical  examination,  major tests should not be ordered. CAT and MRI
scans,  X-rays and angiograms will all be normal in patients suffering
hysterical paralysis.

     TREATMENT. In the case of hysterical paralysis the best course of
treatment  is  a  referral  to  a competent psychiatrist or counselor.
Ignoring  the  condition  will  not  make  it go away, and any further
deterioration in the patient could result in insanity, and non-payment
of your bill. A fate worse than death.

DIAGNOSING/TREATING NEUROPATHY

     Neuropathy  is  simply  a  disease, inflammation or damage to the
peripheral  nerves  which  connect  the  central nervous system to the
patient's extremities. In many cases there is no obvious cause. Nerves
may become acutely inflamed, often occurring after a viral infection.

     SYMPTOMS.  Depending on which nerves are affected, neuropathy can
be affected, neuropathy can be characterized by damage to nerve fibers
which  may  cause  motor  weakness  or lack of sensation in one of the
patient's limbs.

     DIAGNOSIS.  A  complete  physical  examination  is  necessary  to
determine  the  extent  of  nerve  damage. In the absence of any other
symptoms  than the ones cited above, major tests such as CAT scan, MRI
scan,  X-ray  and  angiogram  should  not be required for deciding the
course of treatment.

     TREATMENT. Neuropathy is best treated by exercise of the affected
extremities.  A  full  recovery is possible if the damaged nerve cells
have  not been destroyed. Your recovery is far less predictable if you
should subject your neuropathy patient to the knife.

DIAGNOSING/TREATING ADDICTION

     Drug  addictions  involve  the  compulsion  to continue to take a
narcotic to produce the desired effects, or to prevent the ill effects
that  occur  when  it  is  not taken. Cocaine was once used as a local
anesthetic,  but  because of its potential for abuse has been replaced
by other local anesthetics.

     Morphine  is  the  best  known  narcotic painkiller. Its euphoric
effects  have  led  to its abuse. Long-term abuse will produce craving
and tolerance, which requires greater amounts for the same effect.

     SYMPTOMS.  Patients  suffering  from  cocaine  overdose will show
dilated  pupils,  but  few,  if  any,  additional abnormalities. Those
patients suffering from morphine addiction can be easily identified by
their  narrowed,  non-reacting  pupils.  The  balance  of the physical
examination for neurological disorders will appear normal.

     DIAGNOSIS.   The   limitation   of   disorders  in  the  physical
examination  should  provide  ample  clues  pointing to the drug abuse
conclusion. In both the morphine and cocaine circumstance, CAT and MRI
scans, angiogram and X-rays are all normal.

     TREATMENT.  Effective  treatment  of  drug addictions involve the
breaking  of  physical  and  psychological  dependencies.  Refer these
patients to qualified psychiatric and counselor care.

        DIAGNOSING/TREATING HEADACHES

     Headaches  represent  one  of  the  most  common  types  of  pain
disorder,  and  are  rarely  associated  with  any  underlying serious
condition.  The  expression  of pain takes on varying characteristics,
localized  or  general.  Causes  can  range  from  food  types to poor
posture. A headache can be caused by brain tumors or aneurysms.

     SYMPTOMS.  The patient will complain of pain all over the head or
at  some specific part. The pain may be deep or superficial, throbbing
or sharp, and may move around during its course. In the case of simple
headaches,   symptoms   associated  with  more  severe  migraines  are
obviously not found.

     DIAGNOSIS.  Except  for  the  complaint, all other aspects of the
physical  neurological examination will be normal. Major tests such as
CAT  scan,  MRI  scan,  X-ray and angiogram should not be required and
will return normal results.

     TREATMENT.  Politely and patiently prescribe aspirin and have the
patient  call  you  the  following  day.  If  you  prescribe  anything
stronger, you may be seeing them as drug addiction patients at a later
time.  Make  immediate  arrangements for their discharge, and under no
circumstances practice your surgical technique on them.

GENERAL SURGICAL GUIDELINES

     Direct  physical  intervention with instrument (surgery) into the
brain  always  amounts to major risk for the patient. Hopefully you're
reading  this  because you want to be prepared for surgical realities,
not  because  you've  already botched a procedure in OR, and the chief
neurosurgeon har threatened your own life unless you go to class.

     Here  at  Toolworks General, descriptions of procedure will refer
to  the  on-screen locator as your "hand". To grab something, you move
your  hand over the object or instrument and "hold" it by pressing the
left  mouse  button (or equivalent). The locator is now the instrument
you have selected.

     You  will  have  to  pick  up  and replace instruments to perform
surgery  and  to  free  your  hands  for  other actions. You must move
objects back over the tray when changing procedure. Any click while an
instrument  is over the patient will constitute its use. If the action
is uncalled for you, you may experience disasterous results.

     Do  not ignore the occasional remark by your assisting team. They
are  there  to  help  you  succeed as a neurosurgeon. Always check the
dialog  box  in  the  lower  right  corner  during  an  operation  for
instructions and information on your patient's condition.

     Watch  the  CO2  levels  and blood pressure at regular intervals.
Always  be  ready  to  address  negative  changes with the appropriate
remedy  (see  Operational  Hazards).  Also  keep an eye on the EKG for
abnormalities   in   hearth  rhythm.  Your  knowledge  of  appropriate
treatment and quick response may be necessary to save a life.

     Clicking on the "Exit" button will quit the game, as will ESC.

OPERATIONAL HAZARDS

     Many  variables  and  life-threatening  hazards  can  affect  the
outcome of neurosurgery. That's why you can command such huge fees. If
your  patients are going to survive, you must be prepared to deal with
surgical hazards quickly and effectively.

     IV  BOTTLE: Remember do not let the IV go dry. IV bottles are !!!
located  in  the  lower  drawer.  Several  types  of  IV are available
depending on the patient's current condition. If everything is stable,
use saline or glucose to keep the drip going.

     RESPIRATION:  You  must  check  the arterial blood gas monitor at
regular  intervals throughout the operation. The patient's respiration
will  normally  be  kept  at  30/minute.  Occasionally, blood CO2 will
increase.  If it is above the 30 level, turn the respirator to "high".
!!!

     When the CO2 level goes down, turn the knob back to "low". If the
CO2  level  rises  above  45, then the patient's heart stops and death
follows. Be careful not to leave the respirator on "high" for too long
or the patient will hyperventilate.

     EKG  TRACE:  Occasionally a patient may experience abnormal heart
rhythms.  You  must  act  quickly,  and  in appropriate manner, or the
patient will die. If the patient's EKG has an upside down trace (PVC),
inject !!! Lidocaine into the patient's body. If the EKG has two blips
in it (bradycardia), inject Atropine into the patient. !!!

     Do  not administer either of these substances during a normal EKG
trace  or choose the wrong substance for an abnormal rhythm. If either
occurs, the patient will experience ventricular fibrillation and die.

     BLOOD  PRESSURE:  Normally the patient's blood pressure should be
110/70.  Something  may  occur during surgery to cause it to drop like
bleeding.  If  the  blood  pressure drops too low, the patient's heart
will stop.

A drop in pressure can be combated in one of several ways:

     -  Saline  drip  may  only  be temporary effective, especially if
patient is bleeding.
     -  Blood  transfusion  is  most  the  most  effective action. !!!
Transitory if bleeding is not stopped.
     - Administer dopamine is effective if the patient is not bleeding
(emergency use only.)

     URINE  OUTPUT:  Periodically  check  the patient's urine bag. Low
urine output can be corrected by adding mannitol to the IV. If not !!!
corrected, the patient will go into shock due to renal failure.

     BRAIN  TIGHTNESS:  Pressure  in the cranial cavity will sometimes
lead  to brain tightness. Click hand on the exposed brain to see if it
is  relaxed.  If it becomes tight, click on the spinal tap (next to IV
unit)  !!!  to  open it and remove cerebrospinal fluid. Click to close
when the brain relaxes.

INCISING AND OPENING THE SCALP

     Your  patient  has  been  wheeled  in and their head shaved. Your
staff is hand picked and ready to assist you. The EKG has a reassuring
regular  "blip"  sound, and all your instruments are sterile and ready
for  your  skilled  hands.  This is not the time to stare blankly into
space wishing you had studied harder.

     Always  scrub  first. Just grab the soap from the tray and you're
done.  Next  reach  for  your  surgical  gloves  for a very impressive
beginning.  Now  select  which  side  you will operate on and turn the
patient's head accordingly (very important).

     Reach   for   the  iodine  to  clean  the  patient's  scalp  with
antiseptic,  swabbing the entire head area above the eyes. The risk of
post-operative  infection  is  higher  if  the scalp is not completely
covered.

     Now  is  a  good time to inject the antibiotics. Grab the syringe
marked 'B' from the middle drawer and inject it into the patient. This
will also help prevent post-operative infection.

     Next,  select  the drape from the upper left of the tray, move it
over  patient's  head  and click to apply. You should now see only the
portion  of  scalp  necessary for the surgery, along with the incision
line.

     You can't put off the scapel much longer. Depending on how steady
your  hand  is,  you  may want to give the patient a blood transfusion
before  beginning  to  cut.  This  keeps  the  pressure  up during the
incision process. Grab a bottle of blood from the tray, move it to the
IV bottle and click.

     Now  reach  for the scapel, position it over the incision line to
the left, click and hold. You are now cutting. Drag scapel aldong line
carefully,  noting  the  bleeders, until you have gone about one third
the  distance.  Release the mouse button to finish cut, replace scapel
to tray and grab the Rainey's clips one at a time.

     Clip them over the bleeders on both sides of the incision to stop
the  bleeding.  Repeat  procedure until incision in complete and there
are  no  bleeders.  If you cut off the incision line accidentally, you
will  get a warning. Carve anywhere else intentionally, and you'll get
yanked from surgery.

     Now  you  get to see what's underneath. Place your hand above the
incision,  click  and  drag upward. Don't let the tearing sound get to
you,  it's  only  the  beginning.  Grab the fishhook from the tray and
click  on  the skin flap to keep it up and out of the way. It would be
very embarrassing to have it falling into your work.

     Now  that  the  scalp is open, you are ready to continue with the
procedure  specific  to your patient's disorder and you better hope he
or she isn't just suffering from a migraine.

TREATING SUBDURAL HEMATOMAS

     Preliminary  diagnosis  indicated,  and  the  X-ray  confirmed  a
subdural  hematoma.  You  have  successfully  retracted the scalp (see
Incising  and  Opening  the  Scalp),  and  there  should  be a visible
fracture underneath which lies the hematoma.

     If  there is no fracture, guess what - you either misdiagnosed or
turned  the  patient's  head  the  wrong  way.  Either  way, the chief
neurosurgeon  will  have  your  head. If you see the fracture, you can
briefly  breathe a sigh of relief. At least you've faked your way this
far.

     Check  respiration,  EKG  and  blood pressure immediately to make
sure  everything  is  within  safe limits. Select irrigation (the tube
with  a  bulb on the end) and position over the center of the fracture
and click. Make sure the irrigation tool begins to drip properly.

     Now  grab  the drill, move over to the fracture and click-hold on
the  center.  Listen to the sound. IMMEDIATELY release the button when
sound  goes  up  in  pitch.  You should have a cylindrical hole, not a
rounded  depression,  at  the  drill  point. One hole is sufficient so
replace the drill.

     Grasp the bone wax and click on the hole you just drilled to stop
bleeders.  Replace  the  wax and the drill to the tray if you have not
already  done  so.  Use the scapel to make an incision in the hole and
replace  it  on  the  tray. Select the suction instrument (tube with a
button) and click-hold in the hole.

     You  will  notice that the tube is red. When the tube turns white
IMMEDIATELY release and click on the tray to replace the suction.

     Now select the drain tube (with "u" hook on end) and click on the
hole.  The Drain should appear. Make sure it is placed properly. Grasp
the  suture (curved needle and thread) and click on the drain where it
lies on the scalp. Do not click on the bone or drape.

     Without  suturing  the  drain  tube  it  will  pull out after the
operation  and  be very messy. Replace suture on the tray. If you have
gotten  this  far,  you  might  have  what  it  takes  to close up the
operation successfully (see General Closing Procedures).

OPENING THE SKULL

     Neurosurgical  procedures  specific to aneurysms and brain tumors
require  opening  the  skull  for access and treatment of the affected
area. These two operations demand both caution and skill.

     Now  that  the  skin  and  muscle  layer  has been retracted (see
Incising  and  Opening  the  Scalp), you must drill four burr holes to
remove  the bone flap. Select irrigation tool (the tube with a bulb on
the end) and position over the extreme right edge of the exposed skull
and  click.  Make  sure the irrigation tool appears and begins to drip
properly.

     Now grab the drill, move over to where the irrigation is dripping
and click-hold right where the drops land. Drill anywhere else and the
patient's brain will overheat, and death follows. Listen to the sound.
IMMEDIATELY release the button when sound goes up in pitch.

     You  should have a cylindrical hole, not a rounded depression, at
the  drill  point. Replace the drill on the tray, select the bone wax,
wipe around edge of burr hole to stop bleeders, and then replace wax.

     Grasp  irrigation  to pick it up again, and repeat for three more
burr  holes  at the upper center, extreme left and lower center of the
exposed  skull,  and  at  reasonably equidistant points. When you have
completed those three burr holes, replace irrigation on the tray.

     Now  select  the  dissector (just under scapel) and click in each
burr  hole  to separate the dura from the bone flap. If you fail to do
this  for  each hole, the dura will stick to the bone flap and be torn
when it is removed. Replace the dissector when finished.

     Next,  click  on  the  saw  head  ("L" shaped) to place it on the
drill.  Select  drill  and drag between the adjacent holes to cut free
the  diamond-shaped  bone flap. Start the click inside a hole and drag
to  the  next adjacent hole, releasing when done. After connecting all
four burr holes, replace the drill.

     Place  your  "hand" onto the bone flap and click. Then drag it to
the lower left of the operating table once to set it out of the way of
your  surgery.  You now have bleeders to attend, unless you improperly
prepared  the  dura.  In  that  case you will be yanked into the chief
neurosurgeon's office.

     Quickly  drag  bone  wax for all small bleeders along skull edge.
Electrocauterize  the  center  of  those  remaining  to  staunch their
bleeding  (the  two-pronged  instrument).  You  may need to swab heavy
bleeders  with  cotton  to  find  their center again. Replace swab and
electocauterizer when all bleeding is stopped.

     To  clean  jagged  edges  of the exposed skull bone, click on the
high-speed  grinder drill-head (ball-shaped) to place it on the drill.
Select  drill, click and drag it along the bone edge and over the dark
grey  sphenoid  ridge.  Be sure to get all the sphenoid ridge and bone
edges. Use bone wax to stop bleeders.

     Check  all  vital  signs and take a deep breath. Congratulations,
the  skull is now opened and you are ready for the next important step
(see Incising and Opening the Dura Mater).

INCISING/OPENING THE DURA MATER

     Assuming  you've gotten this far without a major mishap, the bone
flap  is  out,  all  bleeders  have  been  stanched,  the  patient  is
stabilized and you're ready to open the dura mater.

     Click  the  fine  drill  head  (needle-shaped) to place it on the
drill.  Select  the  metal ribbon (oval shaped strip) and click on the
bone  edge  running from upper left to lower middle. The ribbon should
appear  in  a  position  underneath the skull edge to protect the dura
mater from drilling.

     Now  select  the  drill  and  click on the bone edge running from
upper left to lower middle, about midway between the bone edge and the
edge  of  the drape. This creates suture holes in the rim of the skull
opening.

     IMPORTANT: make sure the drill is within the ribbon outline as it
would  continue  underneath  the  bone edge or you will drill into the
patient's  brain.  Click  on tray to replace drill. Repeat those exact
steps for the other three edges. Click hand on metal ribbon to pick it
up and click on the tray to replace it.

     Now  create  suture  holes  in the bone flap the same way. Select
drill  and  make sure it stil has the fine bit. Click and drill on the
bone  flap  once in the middle, and once near the center of each edge.
Replace the drill on the tray.

     Now  grasp the suture (upper tray, curved needle and thread), and
click  on  the  fine drill holes along the bone edge to insert suture.
Also  put  one suture in the center of the exposed dura mater. Replace
the suture on the tray.

     Place  your hand over the bone flap and click once. Drag the bone
flap to the tray and let go. The bone flap will now appear on the tray
out of your way for the tricky stuff.

     You  must now induce hypotension by injecting nitroprusside. Grab
the   syringe   marked  "N"  and  click  it  into  the  patient.  This
artificially  reduces  the patient's blood pressure to prevent massive
bleeding  when  cutting  or  retracting  the  brain. Do not attempt to
inject  dopamine to raise blood pressure while the brain is retracted,
or the patient may die from excessive bleeding.

     At  this  point  you  must relax the patient's brain. To do this,
place  your  hand  on  the brain and click. If the brain is tight, you
will  be told. At that point you must open the spinal tap and click on
the  brain  to relax it. Don't forget to close the spinal tap when you
are done.

     Incise  thye  dura  by  selecting  the scapel and clicking on the
exposed  dura near the bone edge, just a little to the left of the top
corner.  Click  and  drag counterclockwise hugging the bone edge until
you are just to the right of the top corner.

     DO  NOT  COMPLETELY CONNECT THE INCISION. If you cut off the dura
completely, that tissue will die. Cauterize any bleeders.

     Before  lifting  the dura mater, grab the gauze roll and click on
the  scalp flap to apply moistened gauze. You will then see a layer of
gauze  strips.  Place  your  hand on the dura and click. The flap will
fold up. If you foret the gauze, the will dry out and that tissue will
die.

     REMEMBER: the brain must be irrigated every five minutes while it
is  exposed, or it will dry out. You are ready for the next procedures
(see  Excising  Brain  Tumors or Treating Brain Aneurysms depending on
your patient's condition).

EXCISING BRAIN TUMORS

     Before  this  point  in surgery, you have succesfully removed the
bone  flap,  incised  the dural flap and lifted it out of the way. The
brain is exposed, and if irrigation is not used every minute or so the
brain will dry out. Now let's get that pesky tumor out.

     To locate the tumor, click the ultrascan button (the one with the
box  on  a  cable  end,  and  waves coming down). The tray area is now
covered  with  the ultrasound window. Pick up the sensor at the bottom
right  of  the  ultrascan  screen.  Click and hold the sensor over the
exposed brain while watching the display.

     If  you  don't  ding  the  tumor  on the first layer, look in the
second  by  replacing  the sensor and clicking the top right button of
the ultrascan unit. The button will change color to indicate you're on
a different layer. There are a maximum of three layers.

     When  you  fing  a large white blot, get it centered and note the
"X"  and  "Y"  coordinates  in  the upper left corner of the ultrascan
window. The top one is X, and the bottom one is Y. Also note the layer
on which you found the tumor, because it corresponds to the microscope
layer used later. Click on the ultrascan window to turn it off.

     During  ultrascan,  the  tools on the tray cannot be accessed. If
the   patient  develops  PVC's,  turn  off  ultrascan  before  getting
lidocaine.

     Now  click  on  microscope  button  and  the microscope view will
appear. Note the X and Y scales. The top one is X and the right one is
Y. Click on the arrow buttons until the coordinates match the ones you
got  from  the ultrascan. The tumor should be near the center, about a
half  inch  in  diameter,  though  you  cannot  see  it at this point.
REMEMBER, keep irrigating.

     Pay attention. This is a matter of life and death. There are five
layers  of  brain  tissue,  the  tumor will be settled into one of the
first  three  layers, corresponding to the ultrascan layer. Each layer
of  brain  tissue is a different pattern and color; the tumor layer is
solid black.

     Select  the suction instrument. You will use this to bore down to
the tumor and remove it. When you click and hold the suction, it makes
a  small  circular region. Every hole inside becomes one layer deeper,
and you will notice the holes change appearance as you drill deeper.

     Suck  up all the black tumor on its layer while getting as little
excess  brain  matter as possible. When the tumor is gone, replace the
suction  onto  the tray. Click on the microscope button and prepare to
close (see General Closing Procedures).

TREATING BRAIN ANEURYSMS

     Before  this  point in surgery, you have successfully removed the
bone  flap,  incised  the dural flap and lifted it out of the way. The
brain  is  exposed,  and if irrigation is not used every minute or so,
the brain will dry out. Now for the hard part.

     Click  on  the  microscope  button (the button next to respirator
switch),  to  insure  you  do  not  injure  healthy  brain  tissue.  A
microscope view will appear.

     If  you  do not see a vague line running down the center, you did
not  remove enough of the sphenoid ridge. Click the micro button, fold
down  flap,  and  select the drill with high-speed grinder attachment.
Now run the grinder over the entire area of the sphenoid ridge.

     Fold up the flap and hit the micro button again. Your view should
now be in position over the arachnoid membrane (you may need to repeat
this procedure until you're sure that the sphenoid ridge is completely
gone.)

     Elevate the arachnoid membrane by selecting the jeweler's forceps
(tweezers)  and  click  to the left of the line (which is known as the
sylvan   fissure.)   This   will  prevent  damage  to  the  underlying
structures.

     Now  select  the arachnoid knife (or the microscissors) to incise
the  membrane. Move them to a position near the forceps and drag along
the sylvan fissure, then release. Replace both the arachnoid knife (or
microscissors) and the forceps before continuing.

     Retract  and  separate the frontal and temporal lobes by grabbing
the  retractors  (the  strip  of  metal  with  a  curl  on  the  end),
positioning  them  over  each  lobe.  Click and drag on the brain lobe
which appears to the left of the fissure. Do not drag too far (about a
half inch) just enough to expose the connecting vessels.

     You must cut the connecting vessels with the microscissors before
continuing  the  retraction  process. Immediately electrocauterize any
resultant bleeders. Continue retraction carefully and by degrees until
second  arachnoid  membrane  is visible. This will be the dark area to
one side of the large artery.

     Incise  with  arachnoid knife as before, being doubly careful, as
the internal carotid artery and optic nerve are just beneath.

     Use  arrow  buttons to move right or left, depending on where the
aneurysm  is located. Drag the right or left retractor, again based on
the anerurysm location, until thickening is exposed.

     Use  the  rhoton  dissector (in the trio of black tools, with the
teardrop on the end) to click and drag over the thickening twice. This
retracts the two layers of tissue covering the aneurysm.

     Now  the  forked artery with the ball (the aneurysm) is revealed.
Replace  the  dissector  and  select  the  rhoton hook (of the trio of
tools,  it  has  the  bend on the end). Move it to the middle of ball,
hooking it over the veins which cross the aneurysm.

     Click  and  drag  the  veins  down  so  that  they  are no longer
obscuring  the  ball.  Replace  the  hook  on  the tray. Re-select the
dissector and click on the ball. Replace and re-select the rhoton hook
and  click  and drag across the tissue under ball. The aneurysm should
elevate (this may take a few attempts.)

     Replace  the  hook.  Apply  the  aneurysm clip to the neck of the
dilation  by  selecting,  positioning  correctly  over the neck of the
aneurysm and clicking.

     Now  remove  both  retractors  and  replace  on  the tray so both
temporal  and frontal lobes can relax back into position. Click on the
microscope button and close (see General Closing Procedures).

GENERAL CLOSING PROCEDURES

     The  worst  is  over  the rest is a piece of cake. Close the dura
flap (Tumor and Aneurysm operations only) by placing your hand over it
and  clicking.  Stitch,  don't staple the dura by selecting the suture
and clicking at least ten times around the incision.

     Pick  up the bone flap (Tumor and Aneurysm operations only.) Drag
it  until  it fills the hole, click again and it should drop in. Click
hand on each of the bone edge holes and center hole. This will tie off
all the sutures, attaching the bone flap to the skull.

     Click  on  the fishhooks to remove them, and click on the tray to
replace. The scalp flap will fall back into place.

     Remove  the  rainey  clips one at a time and replace on the tray.
Finally,  and  don't  get  trigger happy, grab the staple gun tool and
click  on  the incision to apply staples. When enough are applied, you
are  finished  unless  one of your contacts falpl out between the dura
and the bone flap, in which case you have to start all over again!

The end

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