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LIFE & DEATH SOLVE
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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!

Operating
---------

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 yourforehead.

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.

Your new crop of patients will have one of three possible conditions:
arthritis, immature aneurysms, and mature aneurysms. The diagnosis is just
nearly as straightforward as in the previous part of the game. Carefully palpate all areas of each patient's abdomen. Be certain to palpate several times just below the navel. If the patient has pain all over the abdomen, take an X-RAY. You'll probably find that the spine is practically a solid white mass; this indicates arthritis and requires MEDICATION. If the patient's response to palpation under the navel is "That feels like a lump" or some mention of a lump, that's probably an aneurysm. Do an ULTRASOUND SCAN to determine its size. If it's less than "5 cm" in diameter (use the ruler up above the ultrascan screen to judge), it's immature and should not be operated upon. Check OBSERVE. If the aneurysm is 5 cm or larger (as it probably will be), you'll have to OPERATE!

Before you go into the OR, though, you'll want to readjust your staff. Be sure
to include Laurelee Menzies, the resident expert on aneurysms. Your other
assistant should be either Kim Brewer, Bev Kabes, or Ken Shepherd. Head into the OR. You'll note a few new items on the trays, but don't be intimidated. Next to conquering the appendix, this one's almost a cakewalk.

Open the bottom and top drawers. Use the soap and the gloves (in that order
please!). Apply the antiseptic (this time you have a whole abdomen to work
with). Put on the drape, and as before, you're going to leave as much room to
operate with as possible. Close the top drawer, turn on the gas, inject with the "B" hypo (there's a new one marked "H" for Heparin, which you'll need in a bit).

Hang a bottle of blood on the IV and pick up your scalpel.

This time you won't be making any McBurney's incisions. Cutting smoothly,
incise the abdomen straight down the middle from as far on top to as close to
the bottom as you can without touching the drape. There shouldn't be much drape
there, anyway...only a line or two on top and bottom. Work quickly to clamp all
the bleeders with the forceps. The cauterizer is gone; we now have a ligator --
a pretzel-shaped loop on the tray. Pick it up and center it over each bleeder;
click once to ligate each bleeder. When you've gotten them all, remove the
forceps and wipe the area clean. Separate the skin with the skin retractor. Do
the same with the rippling subcutaneous fat layer. Always be vigilant for
problems with the EKG; act quickly with Atropine, Lidocaine, and Dopamine when
necessary.

Now you're down to the muscle layer, the rectus abdominus. This one won't
bleed. Cut down the linea alba, the thick white portion at the center. Spread
using the retractor. You'll be looking at the preperitoneum, which is incised
the same way the peritoneum was: Click with the scalpel to scrape, elevate just
below with forceps, click again with scalpel to nick a hole, remove forceps and
snip all the way down with the scissors. Be cautious not to make your snips so
far apart that you appear to be making a separate incision; this will puncture
the intestines. But do try to make the incision straight...neatness counts.

After snipping the preperitoneum, spread it. Using your fingertips, click on
the bottom of the chest to push the intestines out of the way. In the top drawer you'll see a small bag (called the gut bag). Click the bag on the intestines at the top of the screen to keep them clean, tidy, and out of the way. Underneath the intestines is the postperitoneum, and underneath that, the murky shape of the aneurysm. Scrape, elevate, nick and snip the postperitoneum exactly as you did with the preperitoneum. Spread it and there's the aneurysm, the swelling just above where the two iliac arteries merge.

In the bottom drawer, take the Heparin and inject it before proceeding. This
prevents embolisms in 100% of my cases so far! I wouldn't know what to do if
there WAS an embolism. Click the fingertips at the base of the aneurysm and
rubber tubing will appear in place. The aneurysm is now immobilized and ready
for action!

Take a clamp (NOT a hemostat) and clamp either of the iliac arteries, then
clamp the other one. Put another clamp on the small vessel (mesenteric artery)
extending from the center of the aorta, close to where they come together. Then
put a clamp at the top of the aneurysm, right where it comes into view. Work
quickly at this point; you've cut off the blood supply to the legs!

Take the scalpel and nick the mesenteric artery just above the clamp (not
between the clamp and the aorta). A bleeder will appear; ligate it. You're going to incise the aorta with the scalpel. Don't start right at the top! Start about a quarter of the way down the aneurysm or the incision will be too long, and you'll have to abort the operation. Make the incision straight and clean; don't bring it quite all the way to the bottom. Use the skin retractor to expose the clot. Remove the clot with your fingertips; take the Y-shaped dacron graft from the bottom drawer and put it in place.

The graft has to be sutured into place. Take the needle and put three sutures
into each of the graft's three ends (nine sutures altogether). You should be
able to see each of the three sutures connecting the graft to the artery walls.
Put down the needle.

Before you can complete the suturing, you have to close the artery walls around the graft. With your fingertips, click at the junctures of the graft (the three ends) until the flaps of vessel tissue close around them. Then take the needle up and suture three times at each juncture again, for a total of six sutures in each of the three branches. Pick up the retractor and close the aorta around the graft. Suture the aortal incision with close stitches.

The next step is a test of your previous work. Remove one of the iliac clamps.
Then remove the next. Finally remove the clamp at the top, re-establishing the
flow of blood through the aorta. If no bleeders appear, you've made it! If
bleeders do appear, replace the three clamps, starting 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!

LIFE & DEATH is published by The Software Toolworks and distributed by
Electronic Arts.