Life & Death
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O P Q
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U V W
X Y Z
Part 1
So you've spent half your life slashing at Orcs, obliterating alienhordes, and dragging leisure-suited misfits around the world. Now you'relooking to do something useful for humanity. Well, your timing is great.Toolworks General is looking for a few good surgeons to assume theburden of a few appendectomies, infections, and vascular grafts. Noproblem at all! When you start the game, you'll need to sign in on the receptionist'sclipboard. She'll welcome you and prompt you to go to the classroom, butlet's not do that yet. Using whichever input device you have (a mouse isideal for this game), set your difficulty level to Novice until you'vesuccessfully completed both operations. Erase the scrawl in the box atthe 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 thesound at this point, but don't unless you absolutely have to: The soundsof the EKG and of the clamps closing are extremely useful. Click outside the box to signify you're done setting parameters. Nowyou're ready to hand-pick your surgical staff and start seeing patients.Since your first operation will be an appendectomy, let's go into theStaff 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, andthen on each name (NOT in the small check-box). You'll get a photo andbrief description of each staff member. Gregory Danielson is a must forappendectomies; click on his check-box. But that means that you will NOTwant Beverly Kabes on your staff, nor will you want Laurelee Menzies(whose area of expertise is irrelevant to this operation). Kim Brewerwould 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 Shepherdinstead of Kim. If you're anticipating trouble with incisions, DavidManglier would also be a decent alternative. My personal picks areDanielson and Brewer. Click on the door of the Staff room to leave and head into theClassroom. Watch the blackboard and listen closely; the advice is basic(most can be found in the manual). When class is over, click on the doorand 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 diagnostictool is to palpate the abdomen, so click on the abdomen of whoever's inbed. Click all around the area; be sure to get each quadrant at leastonce or you'll be reprimanded further on down the line. In this, thefirst half of the game, here are the guidelines for diagnosing: If thereis no pain response anywhere on the abdomen, that signals intestinal gasand should be OBSERVED. If there is pain response all over the abdomen,that signals an infection and should be MEDICATED. If there is pain onlyin some parts of the abdomen, that could be either appendicitis orkidney stones; you MUST take an X-RAY (even if the pain is only on thepatient's left side and thus unlikely to be appendicitis). If there arekidney stones, they'll appear as a clump of small white dots ABOVE thepelvis (surrounded by black). If such stones appear, your action shouldbe REFERRAL (since urology is not the field you're in). If no stones arepresent, that's appendicitis! Click on OPERATE on the clipboard and exitthe patient's room. If you've just booted up, you'll be advised to checkin on the phone (the copy protection). Do that if you need to; thereceptionist should then inform you that they're waiting for you in OR.Head for the OR and here we go!
Part 2
On the upper right is the section of the patient's body with whichyou'll be working. Beneath the body is a message box (it may not appearinstantly) where words of encouragement, advice, and scorn will appearfrom your two assistants. Next to it is a small bottle representing thecurrent fluid connected to the patient's IV. At the left is the EKG andthe anesthetic machinery, and below that are a tray and two drawers(currently closed) with all the instruments you'll need to operate. Youcan see that the anesthetic is OFF and the breathing and heartbeat areregular. You'll want to learn to keep your ears tuned to that EKG; ifthe pitch changes or if the constant beeping stops, you'll have to turnyour attention to the problem. Although you have assistants who will becommenting 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 andBradycardia. With PVC, the EKG will drop in pitch and the line willplummet and bounce back (see the manual for a picture). The cure forthis is a quick injection of Lidocaine, already in a hypo in the bottomdrawer (marked with an "L"). PVC is easy to remember because it willlook like a "V" on the EKG. Bradycardia shows a relatively flat EKG, andthe beep will stop altogether; this requires an injection of Atropine,marked with an "A" and sitting next to the Lidocaine. Think of "A" goingwith "B" and you can easily recall Atropine going with Bradycardia.(These sorts of mnemonics are exactly what help most medical studentsget through school.) Once in a while, the patient's blood pressure will drop. This willhappen without fail if you don't start the patient on IV blood beforeyou begin cutting. If the heart rate does drop, put blood in the IV andquickly 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 ofAtropine and Dopamine. Since the patient's still awake, you're not likely to run into EITHERproblem! So let's get down to some slashing of an entirelynew kind. Open the bottom drawer (just click the fingertips on the end of thedrawer), and open the top drawer. From the top drawer: Click on soap towash; click on gloves. Click on the large bottle with the "A" on it(it's antiseptic). Holding the button down, move the antiseptic clothall over the skin; try not to leave any unwiped areas. The area will beshaded with black dots to show where you've wiped. Return the antisepticto the drawer, and pick up the sterile drape (the folded cloth on theleft). The cursor will change to a square; place this square all the wayto the upper left corner of the abdominal window so that the corner ofthe square fits neatly into the corner of the window (don't leave anyvisible area in between) and click. You should get a very thin, almostunnoticeable line around the abdomen -- virtually no drape at all. Thisis crucial since you'll need every available millimeter of space withwhich to operate. If the square cursor vanishes and is replaced by thehand, and the abdomen window flickers slightly, you've done it right. (Acomment 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 (itLOOKS like blood) from the drawer, and click it on the full bottle nextto the message window; that bottle should change to blood. This willprevent the patient's blood pressure from dropping as you make yourfirst 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 fromthe upper left corner of the abdomen to the lower right corner. Make theline as long as possible; this is also crucial because it determines thesize of the wound you're creating, and you need a BIG wound to get atthe 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 needto learn to cut as straight as possible while also cutting QUICKLY(which helps to keep the incision neat). Practice is the only solutionhere. Make that incision in the abdomen. Then drop the scalpel, pick up theforceps (lying horizontally above the scissors) and clamp a bleeder (thewidening circles of red that will appear along the incision). As youclamp, you should hear a "click" and you'll probably get a commentaffirming the action. Another forceps will have appeared; clamp all thebleeders. When all the bleeders have stopped spreading, pick up thecauterizer (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 3times on each, but eventually you'll have cauterized them all. Thenremove each clamp, one at a time, and using either sponge or suctionhose (S-shaped), remove the blood. Pick up the skin spreader (the butterfly-shaped mechanism at the bottomof the tray), and click it on the incision. The skin will peel away andreveal a layer of subcutaneous fat. Congratulations! Get somebody in theroom to wipe your forehead. All the while, of course, you'll be listening to the EKG and injectingthe proper fluid when necessary. Also keep your eye on that bottle; whenthe blood is about to run out (don't wait till the last moment), put ina 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, andwipe 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 bloodvessels and will not cause bleeders. Cut the oblique muscle layerexactly as in the last two layers, going from corner to corner andmaking a straight, neat incision. The next layer -- the transversusmuscle -- is striated in the other direction. Don't cut at the usualangle; cut "with the grain" from upper right to lower left. Keep makingthose incisions as long as possible. Retracting the transversus willreveal the peritoneum, through which you can vaguely see the end of thelarge intestine (which covers the appendix). The peritoneum calls for very delicate incising. Unless you haveversion 1.03 of the program (or better), forget what the manual tellsyou about incising the peritoneum and listen carefully. You're going tocut diagonally from upper left to lower right with the scissors. FIRST,pick the spot where you're going to start the incision. Pick up thescalpel and click once just at that point; you're scraping theperitoneum but not cutting it. Don't draw a line, just click once andlet go. Put the scalpel down and get the forceps; clamp the forceps justa 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 youscraped; a large black dot should appear. Drop the scalpel, remove theforceps, pick up the scissors and start clicking. Make each click alittle farther down and to the right of the last, but not too far or theprogram will think you've started a new incision. Don't make your firstsnip right on the black dot; make it a bit further down/right. Continueall 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, andclick it on the abdomen to get a fluid sample. Close the drawer and getthe suction tube; start to suction off the liquid, and it'll come rightup. Put down the hose. Click the fingertips at the bottom of the large intestine. Providedyou've made the incisions long enough, the cecum will flip up intosight. If the incisions aren't as large as they need to be, you won't beable to get at this area, and you'll have to abandon the operation. Butlet's hope for the best. Open the top drawer and get the roll of gauze. Click the gauze at thebase of the cecum, and the cecum becomes packed and immobilized. Closethe drawer. I assume you're still watching the IV and the EKG? Of courseyou are. Once again, click the fingertips at the base of the cecum to exposemore intestine. Click the fingertips at the base of this new intestine,and the appendix pops up, pointing to the right. Take a clamp, theL-shaped object in the center of the tray. Clamp the tip of theappendix, all the way to the right and just above the bottom edge. Ifyou clamp in the wrong spot, the appendix may rupture; in that case,take the drainer from the top drawer (the red bulb) and drain theappendix before continuing. If you've clamped the appendix correctly, itwill be lifted and the underside exposed. You're doing great if you'restill 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 andabout a fifth of the way up that red line. If you mess up, you'll knowit...and they'll show you in class the proper place to nick. Assumingyou've clicked in the right place, you'll get another big black dot witha small white dot in the center. Put down the scalpel and take theneedle and thread. Click once at the center of that dot to suture themesoappendix artery. Get the scalpel. To sever and remove the artery and membrane, you clickonce directly on that long red shadow, a pixel or so below the bottomedge of the clamp. The clamp appears spread; use the lower of the twoclamp ends as a reference point. Click just below that end, and themembrane vanishes. Now get another clamp and clamp the base of thatlong, red shadow; Danielson should confirm that the LOWER clamp is inplace. Get another clamp and clamp at about the middle of the shadow;Danielson will remark that the HIGHER clamp is in place. Get the needleand thread, click once between the two clamps, and a small "pursestring" suture should appear. Click the scalpel just above the suture,and off it goes. The appendix is gone. All the clamps except one willvanish. Remove that clamp and click the fingers on the cecum to tuck inthe wound. A small hole appears on the cecum; click the needle on thatonce to make a Z-string suture across the hole. Put away the needle, andclick the fingertips on the base of the cecum. That'll instantly removethe 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 tothe right of the window; it will be almost entirely off the screen.Click it once and the peritoneum closes. Put down the retractor, pick upthe needle, and place sutures along the closed incision. They don't haveto be touching, but they should be fairly close together. You'll need tomake a lot of them. Once you've finished suturing the peritoneum, take the spreader andclick it all the way on the right as you did just before. Thetransversus muscle layer closes; suture it the same way. Now close andsuture the oblique muscle layer and the subcutaneous fat layer. Closethe skin layer, but don't suture it. Secure it with the X-shaped skinclips in the upper left corner of the tray. Put them close enoughtogether 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 MedicalSchool if your performance was not perfect. If it was perfect, you'll becongratulated for having performed an appendectomy and sent to medicalschool anyway! But now you'll be promoted to deal with a different setof problems, and appendectomies will become a thing of the past.
Part 3
Your new crop of patients will have one of three possible conditions:arthritis, immature aneurysms, and mature aneurysms. The diagnosis isjust nearly as straightforward as in the previous part of the game.Carefully palpate all areas of each patient's abdomen. Be certain topalpate several times just below the navel. If the patient has pain allover the abdomen, take an X-RAY. You'll probably find that the spine ispractically a solid white mass; this indicates arthritis and requiresMEDICATION. If the patient's response topalpation under the navel is"That feels like a lump" or some mention of a lump, that's probably ananeurysm. 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 tojudge), it's immature and should not be operated upon. Check OBSERVE. Ifthe aneurysm is 5 cm or larger (as it probably will be), you'll have toOPERATE! 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 KenShepherd. Head into the. You'll note a few new items on the trays, butdon't be intimidated. Next to conquering the appendix, this one's almosta cakewalk. Open the bottom and top drawers. Use the soap and the gloves (in thatorder please!). Apply the antiseptic (this time you have a whole abdomento work with). Put on the drape, and as before, you're going to leave asmuch room to operate with as possible. Close the top drawer, turn on thegas, 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 pickup your scalpel. This time you won't be making any McBurney's incisions. Cuttingsmoothly, incise the abdomen straight down the middle from as far on topto as close to the bottom as you can without touching the drape. Thereshouldn't be much drape there, anyway...only a line or two on top andbottom. Work quickly to clamp all the bleeders with the forceps. Thecauterizer is gone; we now have a ligator -- a pretzel-shaped loop onthe tray. Pick it up and center it over each bleeder; click once toligate each bleeder. When you've gotten them all, remove the forceps andwipe the area clean. Separate the skin with the skin retractor. Do thesame with the rippling subcutaneous fat layer. Always be vigilant forproblems with the EKG; act quickly with Atropine, Lidocaine, andDopamine when necessary. Now you're down to the muscle layer, the rectus abdominus. This onewon't bleed. Cut down the linea alba, the thick white portion at thecenter. Spread using the retractor. You'll be looking at thepreperitoneum, which is incised the same way the peritoneum was: Clickwith the scalpel to scrape, elevate just below with forceps, click againwith scalpel to nick a hole, remove forceps and snip all the way downwith the scissors. Be cautious not to make your snips so far apart thatyou appear to be making a separate incision; this will puncture theintestines. 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 thebag 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, andunderneath that, the murky shape of the aneurysm. Scrape, elevate, nickand snip the postperitoneum exactly as you did with the preperitoneum.Spread it and there's the aneurysm, the swelling just above where thetwo 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 whatto do if there WAS an embolism. Click the fingertips at the base of theaneurysm and rubber tubing will appear in place. The aneurysm is nowimmobilized 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 towhere 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 cutoff 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 atthe top! Start about a quarter of the way down the aneurysm or theincision will be too long, and you'll have to abort the operation. Makethe incision straight and clean; don't bring it quite all the way to thebottom. Use the skin retractor to expose the clot. Remove the clot withyour fingertips; take the Y-shaped dacron graft from the bottom drawerand put it in place. The graft has to be sutured into place. Take the needle and put threesutures into each of the graft's three ends (nine sutures altogether).You should be able to see each of the three sutures connecting the graftto the artery walls. Put down the needle. Before you can complete the suturing, you have to close the arterywalls around the graft. With your fingertips, click at the junctures ofthe graft (the three ends) until the flaps of vessel tissue close aroundthem. Then take the needle up and suture three times at each junctureagain, for a total of six sutures in each of the three branches. Pick upthe retractor and close the aorta around the graft. Suture the aortalincision with close stitches. The next step is a test of your previous work. Remove one of the iliacclamps. Then remove the next. Finally remove the clamp at the top,re-establishing the flow of blood through the aorta. If no bleedersappear, you've made it! If bleeders do appear, replace the three clamps,starting with the two iliac clamps. Resuture the incision and try again. Once the aorta is repaired, remove the rubber tubing. Then un-retractthe postperitoneum. Suture it. Remove the gut bag and replace theintestines. Un-retract the preperitoneum and suture it. Un-retract thenext two layers (chest muscle and subcutaneous fat). After un-retractingthe skin, close it with skin clips instead of stitches. Turn off thegas, and pick up your diploma in the Chief of Surgery's office. You retire wealthy, and your name will vanish from the receptionist'sclipboard. Should you want to relive past glories, head into the Staffroom and click on the file cabinet. Again, hearty congratulations: I'llcatch you on the back 9!