life and death walkthrough
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!
