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!

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 as 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
hose (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 other 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.

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 topalpation 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. 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 with 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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